Diagnosis and management of ureteral fibroepithelial polyps in children: a new treatment algorithm.

INTRODUCTION: Fibroepithelial polyps are benign mesenchymal tumors arising from the urinary tract. With the advent of endoscopy in the pediatric population, more reports of endoscopic diagnosis and treatment have appeared. OBJECTIVE: The present study reports experience with the diagnosis and treatment of fibroepithelial polyps of the upper urinary tract in the pediatric population. Incorporating past experience from literature, we propose an algorithm to guide the clinical diagnosis and treatment plan. STUDY DESIGN: Four pediatric patients undergoing pyeloplasty for ureteropelvic junction (UPJ) obstruction were diagnosed with ureteral polyps. Their demographics, radiologic, surgical and pathologic information were reviewed. In addition, a comprehensive literature search using the MEDLINE database yielded 37 reports containing 126 cases of ureteral polyps, including 5 series with 57 cases and 9 cases of synchronous bilateral ureteral polyps. RESULTS: Of 123 pediatric patients undergoing pyeloplasty from 2008 to 2013, four (3.3%) were found to have fibroepithelial polyps of the upper urinary tract. All patients were male and the mean age of presentation was 12 years. Ureteral polyps predominantly occurred unilaterally in the left ureter (75%) and one case of bilateral ureteral polyps was encountered. Along with three other recent case series [1-3], the combined incidence of ureteral polyps in patients undergoing evaluation for ureteral obstruction was 5.2%. Intraoperative retrograde pyelogram was used to identify filling defects in 4 of 5 affected ureters (see Figure). Ureterorenoscopy was performed in all three patients with filling defects for polyp mapping along the ureter and evaluation of the macroscopic polyp appearance. Based on ureteroscopic findings, Holmium laser polypectomy was performed in two patients with single, pedunculated polyps. Anderson-Hynes dismembered pyeloplasty was performed in three patients with broad based, multilobulated polyps too large for endoscopic treatment and in one patient for undiagnosed polyp prior to pyeloplasty. DISCUSSION: The present study finds that the 5.2% combined incidence of ureteral polyps in contemporary reports may be higher than previously described [4]. Retrograde pyelogram was an effective tool in diagnosing ureteral polyp and ureteroscopy can be employed if ureteral polyps are suspected for both diagnostic and therapeutic purposes. Although clinical experience is limited, endoscopic laser treatment seems to be effective for the single, pedunculated ureteral polyps, while dismembered pyeloplasty is required for the broad based, multilobulated polyps. The study was limited by the rarity of ureteral polyps. Future multi-institutional collaborative studies are required to validate the diagnostic and treatment algorithm proposed. CONCLUSION: Ureteral polyps cause approximately 5% of UPJ obstruction in the pediatric population. Diagnosis can be made in certain cases by intraoperative retrograde pyelogram. If a filling defect is encountered, ureteroscopy is indicated for polyp mapping. The treatment modality is dictated by the endoscopic appearance of the ureteral polyp.

Retroperitoneal laparoscopic nephrectomy in children.

PURPOSE: We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique. MATERIALS AND METHODS: Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally. RESULTS: Average operative time was 1 hour 42 minutes. The most recent cases were performed in less than 1 hour and in 3 nephrectomy only required 30 minutes. All but 1 procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10). A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively. CONCLUSIONS: As confirmed by parent questionnaire, patient satisfaction was excellent.

Retrospective analysis of urologic complications in male patients with spinal cord injury managed with and without indwelling urinary catheters.

OBJECTIVES: To compare, in a retrospective fashion, the long-term urologic complications in male patients with spinal cord injury managed with and without indwelling urinary catheters. METHODS: The records of 142 consecutive male patients with traumatic spinal cord injuries sustained between 1975 and 1985 (inclusive) were reviewed. Fifty-six patients were managed with indwelling urinary catheters, and 86 were managed without an indwelling catheter. Urinary complications were recorded for each patient under the following general subheadings: renal, urinary tract infection, stones, urethral, and other. RESULTS: In all, there were 95 complications in the noncatheterized group versus 202 in the catheterized group (P = 0.007). The catheterized group experienced significantly more problems with renal damage, recurrent urinary tract infection, stones, and urethral complications. CONCLUSIONS: Our study shows that elimination of indwelling urinary catheters in patients with spinal cord injury will significantly reduce the incidence of urinary tract complications and lead to better preservation of renal function.