Does prenatal diagnosis influence the morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety after endoscopic puncture of ureterocele?

PURPOSE: We compared long-term morbidity associated with left in situ nonfunctioning or poorly functioning renal moiety of a duplex system in children with prenatal vs postnatal diagnosis of ureterocele who underwent endoscopic puncture. MATERIALS AND METHODS: A total of 48 children underwent primary endoscopic puncture of duplex system ureterocele. Of the cases 35 (73%) were diagnosed prenatally (group 1) and 13 (27%) postnatally (group 2). Median age at time of puncture was 4 months in group 1 and 3.5 years in group 2. A total of 20 patients in group 1 (57%) and 8 in group 2 (62%) presented with intravesical ureterocele, while 15 in group 1 (43%) and 5 in group 2 (38%) had ectopic ureterocele. A total of 20 children in group 1 (57%) and 7 in group 2 (54%) had a nonfunctioning renal moiety, and 15 in group 1 (43%) and 6 in group 2 (46%) had a poorly functioning ureterocele moiety. Vesicoureteral reflux (VUR) was present in 23 children in group 1 (66%) comprising 30 renal refluxing units (RRUs), and in 12 in group 2 (92%) comprising 14 RRUs. Median followup was 9 years (range 1 to 15) for both groups. RESULTS: Preoperative urinary tract infection (UTI) was common in group 2 (92%) vs group 1 (20%). No patient in group 1 had development of UTI after puncture, while 23% of the children in group 2 presented with UTI. Four children (2 from each group) with ectopic ureterocele required secondary puncture resulting in satisfactory drainage. A total of 14 RRUs (47%) showed spontaneous resolution of VUR in group 1 compared to 3 (21%) in group 2. Four RRUs (13%) required endoscopic correction due to high grade VUR in group 1. Two RRUs (17%) were treated with endoscopic correction and 2 (17%) with ureteral reimplantation due to UTI in group 2. Only 1 patient in group 1 underwent nephrectomy due to nonfunctioning kidney, while 2 patients in group 2 required partial nephrectomy due to UTI. CONCLUSIONS: Our data reveal that prenatal diagnosis of duplex system ureterocele is associated with fewer UTIs, and early endoscopic management may decrease UTI and the need for additional surgery. Nonfunctioning or poorly functioning renal moieties left in situ following successful endoscopic decompression of ureterocele are not associated with additional morbidity and do not require partial nephrectomy in the majority of the cases.

[Ureterocele in children]. / Ureterocele en niños.

INTRODUCTION: Ureterocele is cystic dilation of the terminal part of the ureter located within the bladder of the urethra or both. In the majority of cases, it is accompanied by a double-collector system and affects 6:1 female child patients. MATERIALS AND METHODS: We conducted an observational, longitudinal, transverse, descriptive, retrospective, and open study. Files of pediatric patients with diagnosed ureterocele from January 1, 1990 through December 31, 2002 were reviewed. Age, sex, symptomatology, type of ureterocele, side effects, and laboratory and image studies were analyzed. RESULTS: There were 40 cases, 50% male, average age 20 months; first clinical manifestation was urinary tract infection in 87.5%. Ectopic type was found more frequently with 62.3% and orthotopic or simple, in 37.5%. First surgical intervention was reimplantation in 80% of ectopic and in 66.7% in orthotopic cases. DISCUSSION: Ureterocele treatment depends to a great degree on status of affected kidney and capacity of functionality of the contralateral kidney. The spectrum of therapeutic modalities range from transureteral incision of ureterocele to nephrectomy and vesical reconstruction. Indication to proceed with endoscopy would be considered only in a patient with intravesical ureterocele with a simple collector system. We prefer to proceed in the majority of cases with ureteral reimplantation and resection of ureterocele.

Obstructive ureterocele-an ongoing challenge.

Ureterocele is a cystic dilatation of the intravesical ureter that is most commonly observed in females and children, and usually affects the upper moiety of a complete pyeloureteral duplication. According to their position, ureteroceles are divided into intravesical, when the ureterocele is completely contained inside the bladder, and extravesical when part of the cyst extends to the urethra or bladder neck. Most ureteroceles are diagnosed in utero or immediately after birth during an echographic screening of renal malformations. Severe, febrile urinary tract infection is the most common postnatal presentation of ureteroceles, but they may, rarely, prolapse and acutely obstruct the bladder outlet. Once an ureterocele is identified sonographically, a voiding cystourethrogram to detect vesicoureteral reflux (VUR) and a 99m-technetium dimercapto-succinic acid renal scan to evaluate the function of the different portions of the kidney are mandatory. VUR in the lower pole is observed in 50% of cases and in the contralateral kidney in 25%. Simple endoscopic puncture of the ureterocele has recently been advocated as an emergency therapy for infected or obstructing ureteroceles and as an elective therapy for intravesical ureteroceles. The rate of additional surgery after elective endoscopic puncture of an orthotopic ureterocele ranges from 7 to 23%. Treatment of ectopic ureteroceles is more challenging and both endoscopic puncture and upper pole partial nephrectomy frequently require additional surgery at the bladder level. The reoperation rate after endoscopic treatment varies from 48 to 100%. It is 15 to 20% after upper pole partial nephrectomy if VUR was absent before the operation, but is as high as 50-100% when VUR was present. Thus, endoscopic incision is appropriate as an emergency treatment or when dealing with a completely intravesical ureterocele. Upper pole partial nephrectomy is the elective treatment for an ectopic ureterocele without preoperative VUR. In an ectopic ureterocele with VUR, no matter which type of primary therapy has been chosen, a secondary procedure at the bladder level, involving ureterocele removal and reimplantation of the ureter(s), should be anticipated.

Ectopic ureterocele: clinical application of classification based on renal unit jeopardy.

PURPOSE: The Churchill classification system grades the ectopic ureterocele based on the number of renal units in jeopardy. We apply this system to our experience to help predict response to initial surgical intervention. MATERIALS AND METHODS: All cases of ectopic ureterocele diagnosed at our institution between 1990 and 2000 were retrospectively reviewed and categorized using the Churchill classification system. Initial surgical procedure and subsequent outcomes were analyzed. RESULTS: A total of 53 patients were identified, of whom 42% had only upper pole involvement (grade I), 40% ipsilateral upper and lower pole involvement (grade II) and 19% bilateral renal involvement (grade III). Endoscopic incision was definitive in 56% of grade I, 20% of grade II and no grade III ureteroceles. An upper tract approach was definitive in 85% of grade I, 45% of grade II and no grade III ureteroceles. An initial lower tract procedure was successful in 80% of grade II and 100% of grade III ureteroceles. Overall the initial surgical procedure was definitive in 73% of grade I, 48% of grade II and 20% of grade III ureteroceles. CONCLUSIONS: Our results confirm the findings of Churchill. In this series the majority of grade I ureteroceles were successfully managed with an upper tract procedure. However, high grade ureteroceles were more likely to require a secondary operation unless an initial lower tract reconstruction was performed.

Intravesical ureterocele with concurrent renal dysfunction in a dog: a case report and proposed classification system.

A unilateral intravesical ureterocele was diagnosed by ultrasonography in a 5-year-old female Pekingese that was referred for evaluation of increased hepatic enzymes. Ureteroceles are cystic dilatations of the submucosal portion of the distal ureter. They are frequently reported in humans but are uncommonly reported in dogs. This report describes surgical resection of the ureterocele and reduction of ipsilateral hydroureter in a dog that also had bilateral renal dysfunction and suffered progressive mild azotemia postoperatively. This report demonstrates that canine ureteroceles can occur concurrently with bilateral renal dysfunction and offers a classification system designed to encourage thorough urinary tract evaluation for determining prognosis.

Single-system ureteroceles in infants and children: imaging features.

PURPOSE: The purpose of this manuscript is to describe the clinical and imaging findings in children who have single-system ureteroceles. MATERIALS AND METHODS: We reviewed the urology records and imaging studies in 32 consecutive infants and children who were diagnosed in our department with single-system ureteroceles. RESULTS: There were 35 ureteroceles in the 32 patients-- 29 were unilateral (14 right-sided, 15 left-sided) and 3 were bilateral. Twenty-five patients were boys (78 %) and 7 girls. Mean age at presentation was 0.7 years (0-9.2 years). Prenatally detected hydronephrosis or cystic renal dysplasia was the most common presentation (24 patients). Four presented with urinary infection, 2 with abdominal mass, 1 had myelomeningocele, and 1 had hypospadias. Three patients also had multiple non-urologic, congenital anomalies. Thirty-three ureteroceles were intravesical, and 2 were ectopic to the bladder neck. Twenty-four ureteroceles were associated with ipsilateral hydroureteronephrosis and 10 with ipsilateral multicystic dysplastic kidney. One patient had a normal ipsilateral kidney and a contralateral multicystic dysplastic kidney. The ureterocele was identified on at least one imaging study in each patient. Sixteen ureteroceles (47%) everted at VCUG, mimicking paraureteral diverticula. Other variations included ureterocele prolapse and inadvertent ureterocele catheterization (1 each). CONCLUSIONS: Single-system ureterocele is an important, although uncommon cause of hydronephrosis and renal dysplasia in infants and children. Single-system ureterocele is distinguished clinically from the more common duplex-system ureterocele by its frequent occurrence in boys and its association with multicystic dysplastic kidney. Because these ureteroceles are frequently small and have a propensity to evert at VCUG, they can be mistaken for paraureteral diverticula.

[Classification and treatment of ureteroceles in the adult]. / Classification et traitement des urétérocèles de l'adulte.

Ureterocele or congenital pseudocystic dilatation of the terminal portion of the ureter due to persistence of Chwalla's membrane is frequent in female adults (17-35%) in its orthotopic form. It expands the short submucosal segment of the normally situated ureter and may be intravesical or extravesical. The diagnosis is primarily radiological based on intravenous urography (IVU) and endoscopy (urethrocystoscopy). Treatment depends on the site of the ureterocele, the clinical context, associated anomalies and especially the dimensions. Endoscopic treatment has numerous advantages and deserved to be more widely used.

[Ureterocele in children]. / Ureterotsele u detei.

Types and variants of ureterocele are specified basing on 115 clinical cases and literature data. Three types of this anomaly exist: intravesical, cervicosphincteral and extravesical. Intravesical ureterocele can be orthopedic and ectopic. The latter has three variants: of accessory ureter, of partially double ureter, of non-double ureter. Ureterocele is frequently associated with low ectopy of ostium ureteric, double ureter. Ureterocele occurs neither in the ureter itself nor in high ectopy of the ostium ureteric. Extravesical ureterocele has many variants which differ in males and females. All ureterocele types and variants occur as unilateral or bilateral. The new diagnostic method is proposed: endovesical ureterocelegraphy.

[Value of endoscopic incisions in the treatment of ureteroceles in children]. / Intérêt de l'incision endoscopique dans le traitement des urétérocèles de l'enfant.

Endoscopic incision is a simple method to provide decompression of the urinary tract above ureteroceles. This technique has been used in most cases of ureterocele seen since 1987. In 6 cases of ureterocele in a single system good results were achieved in all cases. In 13 cases of ureterocele in a duplex system, incision was the only procedure in 5 patients. Seven patients required further surgery : upper pole partial nephrectomy when dilatation persisted, ureteral reimplantation and ureterocele excision in cases of upper pole reflux, secondary to the endoscopic incision, or in cases of persistent reflux in the lower pole ureter. Endoscopic incision is a safe treatment in cases of intravesical ureterocele (single system or duplex system) but in the cases of ectopic ureteroceles, it generally provides only temporary benefit. In these cases, it facilitates delayed lower urinary tract surgery.

The ectopic ureterocele: a proposed practical classification based on renal unit jeopardy.

A classification system for ectopic ureteroceles based on renal unit jeopardy is presented. This system has been found to be predictive of response to surgical reconstruction and is thus helpful in selecting the initial reconstructive approach. Specific guidelines for the selection of an appropriate surgical strategy are provided.

[Ureteroceles]. / Urétérocèles.

Four types of ureteroceles are described: A) ureterocele with single ureter (10%); B) ureterocele with total duplication and intra-vesical development (10%); C) ureterocele with total duplication and extra-vesical development (62%); D) ureterocele with ectopic ureter (3%). Most ureteroceles are now detected by antenatal ultrasonography, allowing early management. The treatment of types A and B is simple depending on the status of the above kidney and ureter: abstention, meatomy, ureterocelectomy with ureteral reimplantation, nephrectomy. In type C, the upper kidney is always destroyed. Two treatments are proposed: upper pole nephrectomy with ureterocelectomy which is a difficult but safe procedure, upper pole nephrectomy with aspiration of the ureterocele which is called the "simplified technique" but requires reoperation in 40% cases. The complicated forms may require either meatotomy for decompression, or diversion by percutaneous nephrostomy. Strangulation of the ureterocele constitutes an emergency.

[Ectopic ureterocele]. / Ektopicheskoe ureterotsele.

An analysis of 43 clinical observations helped to establish three variants of ectopic ureterocele: ectopic ureterocele of the accessory ureter, ectopic ureterocele of the doubled ureter. Ectopic ureterocele always brings about obstruction of the ureter. Ectopic ureterocele of the accessory ureter was treated by making anastomosis between the accessory ureter and the main ureter with a removal of all the accessory ureter and dissection of ureterocele. The operation of heminephrureterectomy or dissection of ureterocele with resection of the paracystic part of the ureter were performed with antireflux utererocystoanastomosis.

Noncrossed renal ectopia with fusion associated with single ectopic ureterocele.

We report a case of noncrossed renal ectopia with fusion associated with a single ectopic ureterocele. This association is rare, and it is extremely rare that an ectopic ureterocele is not a part of the duplicated urinary collecting system. Some problems about classification of renal fusion and ectopia are presented, and a new classification is introduced.

Surgical management of ureteroceles in children: strategy based on the classification of ureteral hiatus and the eversion of ureteroceles.

Experience in the surgical management of ureteroceles in children is reported. Six patients with intravesical and 16 with ectopic ureteroceles are included. In the case of intravesical ureterocele of noneverting type. Transurethral distal incision of the ureterocele was performed without reflux. In the case of everting ureterocele, excision with reimplantation of the ureter was performed, thus avoiding reflux inevitably induced by transurethral incision. In the patient with an ectopic ureterocele, a one-stage operation with complete excision of the ureterocele and ureteral stump was attempted. Our choice of operative procedure was decided after the assessment of the following features: cystography and cystoscopy to assess eversion, type of ureteral hiatus (common or separate), whether there was reflux or not to the ipsilateral ureter, and renal function by scintigraphy. Accordingly, hemi-nephroureterectomy or twin ureteroneocystostomy were most commonly performed. When based on these thorough preoperative evaluations, our results were quite favorable.