Is primary endoscopic puncture of ureterocele a long-term effective procedure?

Boris Chertin, Diane de Caluwé, Prem Puri

Presented at the 49th Annual Congress of the British Association of Paediatric Surgeons, Cambridge, England, July 23-26, 2002. 

Background/Purpose: For more than a decade, endoscopic puncture of ureterocele has been recommended as an initial and, in the majority of the patients, as a definitive procedure. This study evaluates the long-term effectiveness of primary endoscopic puncture of ureterocele.

Methods: Over the last 18 years (1984 through 2001), 52 patients (median age 3 months) underwent primary endoscopic puncture of ureterocele. The median follow-up was 9 years (6 months to 18 years). Antenatal ultrasound scan detected hydronephrosis and led to the postnatal diagnosis of ureterocele in 12 (23%) children, whereas in the remaining 40 (77%) children the diagnosis was made on investigation for urinary tract infection (UTI). The ureterocele presented as a part of renal duplication in 48 (92%) patients and a single system in 4 (8%). Forty-four (92%) of the patients with duplication presented with non- or poorly functioning upper poles. Vesicoureteric reflux (VUR) was seen in the lower moiety of the ipsilateral kidney in 31 and in 18 of the contralateral kidney comprising 49 renal refluxing units (RRU). Results: Complete decompression of the ureterocele was achieved in 48 (92%) patients after the first endoscopic puncture. Four (8%) patients required a second puncture of ureterocele. Nine (17%) of the 52 patients underwent nephrectomy for a nonfunctioning kidney. Ten (19%) patients required upper pole partial nephrectomy owing to nonfunctioning upper pole. Twenty-nine (59%) of the 49 RRU showed spontaneous resolution of VUR. Sixteen (33%) RRU underwent endoscopic correction of VUR. One required ureteric reimplantation. The remaining 4 (8%) are maintained on prophylactic antibiotics. Five (10%) patients had VUR in the upper pole moieties after ureterocele puncture. Conclusions: Our data suggest that primary endoscopic puncture of ureteroceles is a simple, long-term, effective, and safe procedure avoiding complete reconstruction in the majority of the patients. J Pediatr Surg 38:116-119. Copyright 2003, Elsevier Science (USA). All rights reserved.

Endoscopic puncture of ureterocele has become a well-established alternative in the treatment of patients with ureterocele.  However, some recent series reported a high rate of secondary surgery in the long-term follow-up advocating complete reconstruction in childhood, including upper pole surgery, ureterocele excision, and ipsilateral lower pole ureteral reimplantation. Reports have raised the questions of whether endoscopic puncture reduces the risk of pyelonephritis and facilitates upper urinary tract surgery. The aim of our study was to evaluate the long-term effectiveness of primary endoscopic puncture of ureterocele.

Materials and methods 

We reviewed retrospectively the medical records of all patients who underwent primary endoscopic puncture of ureterocele at our institution from 1984 to 2001. Fifty-two children (22 girls and 30 boys) underwent endoscopic puncture of ureterocele. The median age of the patients was 3 months (range, 1 month to 12 years). Antenatal ultrasound scan detected hydronephrosis leading to the postnatal diagnosis of ureterocele in 12 (23%) children, whereas in the remaining 40 (77%) the diagnosis was made on investigation of urinary tract infection (UTI). Preoperative evaluation and postoperative follow-up included renal and bladder ultrasound scan, micturating cystourethrogram (MCUG), and repeated renal scans either diethylenetriaminepentaacetic acid (DTPA) or mercaptoacetyltriglycine-3 (MAG-3) and technetium 99m dimercaptosuccinic acid (DMSA). DTPA or MAG-3 renal scans were performed to assess perfusion during the initial 2 minutes according to absolute counts. The isotope washout curve was recorded after bolus of a 1 mg/kg furosemide injection was given 10 minutes after injecting the radionuclide. Renal scintigraphy was taken 2 hours after intravenous injection of DMSA. One posterior, one anterior, and 2 posterior oblique images (250.000 counts) were acquired by a gamma camera, with the patient in a supine position. The fractional left and right renal activity was calculated for each kidney after background correction. A kidney uptake of 45% to 55% of the total renal activity was considered normal. The ureterocele presented as a part of renal duplication in 48 (92%) patients, and a single system in 4 (8%). Forty-four (92%) of the patients with duplication presented with non- or poorly functioning upper poles.

According to the recommendations of the Committee on Terminology of the Section on Urology of the American Academy of Pediatrics, all ureteroceles were classified into intravesical ureterocele, which was present in 38 (73%) patients and ectopic ureterocele, which was present in the remaining 14 (27%) children.11 Vesicoureteric reflux (VUR) was seen in the lower moiety of the ipsilateral kidney in 31 renal refluxing units (RRU) and in 18 RRU of contralateral kidney. According to the International Classification System12 (International Reflux Study Committee) 8 RRU had grade I VUR, 28 rru grade II, 11 rru grade III, and the remaining 2 rru grade IV VUR. An endoscopic puncture was carried out in all patients utilising a stylet of a 3F ureteric catheter. All patients underwent renal and bladder ultrasound scan 2 weeks after puncture. Those patients with VUR into lower moiety or into contralateral kidney who underwent endoscopic correction of VUR underwent MCUG 6 months after procedure, and, if negative, annual ultrasound scan was performed in long-term follow-up. In these patients with spontaneous resolution of VUR after puncture of ureterocele MCUG or ultrasound scan was performed in long-term follow-up if indicated. All patients received antibiotic prophylaxis after puncture until MCUG showed no reflux. Those patients who showed persistent reflux into the lower moiety of ipsilateral kidney or into contralateral kidney or iatrogenic reflux into the ureterocele moiety remained on antibiotic prophylaxis until either spontaneous resolution of reflux or definitive treatment cured the VUR. The blood pressure was recorded routinely in those patients who had poorly functioning kidney caused by vesicoureteric reflux or in those patients who had poorly functioning upper poles left in place.

Either nephrectomy or upper pole heminephrectomy was considered in patients with nonfunctioning kidney or nonfunctioning upper pole. The median follow-up was 9 years (range, 6 months to 18 years).

Results 

Complete decompression of ureterocele was achieved in 48 (92%) patients after the first endoscopic puncture. Four (8%) patients required second puncture of ureterocele. Renal function in the patients with poorly function upper moiety remained stable in all patients. None of the patients with normal or moderate function in the upper moiety before puncture had deterioration of renal function during long-term follow-up. Nine (17%) of the 52 patients underwent nephrectomy owing to nonfunctioning kidneys. Ten (19%) of the 52 patients required upper pole partial nephrectomy because of nonfunctioning upper pole. None of the remaining 25 patients with poorly functioning upper poles had acute pyelonephritis in the long-term follow-up. Twenty-nine (59%) of the 49 RRU showed spontaneous resolution of VUR (Table 1).

Table 1. Outcome of vesicoureteric reflux after endoscopic puncture of ureterocele in 49 renal refluxing units

VUR Outcome No of RRU
Spontaneous resolution 29

Endoscopic treatment

15

Ureteric reimplantation

1

Antibiotic prophylaxis

4

Sixteen (33%) RRU underwent endoscopic correction of VUR, and one of these patients failed to respond to endoscopic treatment and needed ureteric reimplantation. The remaining 4 (8%) are maintained on prophylactic antibiotics. Five (10%) patients had VUR into upper pole moieties after ureterocele puncture. One patient had grade I, vur, 3 grade II, and one grade III vur. VUR ceased after endoscopic treatment in the patient with grade III, 2 patients showed spontaneous resolution of VUR, and the remaining 2 patients are doing well without antibiotic prophylaxis. No patients suffered from incontinence after endoscopic puncture of ureterocele. None of the patients in the current series had hypertension in the long-term follow-up. No difference was observed in reoperation rate between the patients with intravesical versus ectopic ureterocele.

Discussion 

Currently, the most frequent presentation of ureteroceles is by antenatal ultrasound scan, although UTI continues to be a common presentation of ureteroceles after birth.1 The main goals in the treatment of ureterocele are control of infection, protection of normal ipsilateral and contralateral units, preservation of renal function, facilitation of subsequent surgery, and the maintenance of continence.

In the last two decades, the traditional aggressive treatment in the management of ureterocele has changed to a more conservative approach by, endoscopic puncture.Recent reports indicated that these patients often require reintervention, such as ureteric reimplantation and upper pole partial nephrectomy owing to VUR either into the lower moiety of the ipsilateral kidney or into contralateral kidney or because of iatrogenic VUR into ureterocele moiety.6, 8 Husmann et al10 showed recently that neonatal endoscopic puncture of ureterocele offers no definitive advantage over antibiotic prophylaxis alone during the immediate neonatal period. Over the last 18 years we have performed endoscopic puncture as a primary step in the management of patients with ureterocele. Full decompression of the ureterocele was shown on the postoperative ultrasound scan and MCUG in all but 4 patients in our series after first endoscopic puncture. It has been reported that decompression of the ureterocele results in the restoration of normal trigonal anatomy and resolution of any accompanying ureteric reflux.1, 9 Our data support this. Twenty-nine (59%) of the 49 renal units with VUR showed spontaneous resolution of VUR after endoscopic puncture. In the remaining patients, VUR was resolved by endoscopic treatment. The crucial question is the need for secondary operation in patients with iatrogenic reflux into the ureterocele moiety after endoscopic puncture. Five (10%) of our 52 patients showed reflux into the ureterocele moiety after puncture. High-grade VUR (grade III) was shown in only one patient. We think that a low incidence of the iatrogenic reflux into the ureterocele moiety is because of puncture technique. We have used in all of our cases the stylet of the 3F ureteric catheter. A puncture hole of 3F size is adequate for drainage in most cases. The puncture hole is made high enough and lateral from the base of ureterocele. At the same time, the postpuncture flap has to be sufficient to preserve the flap-value mechanism and thus reduce the incidence of iatrogenic VUR. We also did not come across any difference in the outcome of treatment of intravesical versus ectopic ureterocele utilising this technique.

One of the main advantages of endoscopic treatment includes early decompression of the ureterocele and, therefore, a presumed reduction in the risk of pyelonephritis.6 None of our patients had a UTI after endoscopic puncture. In those patients who required either nephrectomy or upper pole partial heminephrectomy after endoscopic puncture, the nonfunctioning kidney or nonfunctioning upper pole was the only indication for surgery. None of the 25 patients with poorly functioning upper poles left in place had acute pyelonephritis and subsequently required heminephrectomy during long-term follow-up. There are not enough data available in relation to the long-term morbidity of leaving a poorly or nonfunctioning upper pole in place. In a previously reported series of 115 patients with renal duplication and ureterocele a single case of hypertension was related to renal scarring in the lower pole of the contralateral kidney rather than to the dysplastic upper moiety.

Our data show that primary endoscopic puncture of ureterocele is a simple, long-term, effective, and safe procedure avoiding complete reconstruction in the majority of the patients.

Discussion 

I. Aaronson (Charleston, SC): I compliment you studying a large numer of patients who had an endoscopic puncture of ureterocele. You conclude that this is an effective long-term procedure, yet, among your 52 patients, 17% underwent a nephrectormy, 19% an upper nephroureterectomy, and 25% had surgery for reflux. It seems the only way the question you pose can be answered is by studying a large number of children who had endoscopic puncture alone with no further treatment to see how many get into trouble. Your report, like almost all those previously published, describes what further surgery you did. Would you tell us what governed your decision regarding these further procedures?

B. Chertin (response): In the majority of cases you can sort out the problem with minimal invasive surgery, even if we take into account the operation rate. I did not mention this because the rate needs to be taken in the right proportion. The majority of our children required minimal invasive surgery, even if they had undergone surgery for reflux, it was solved endoscopically. With regard to the children who underwent nephrectomy and partial nephrectomy, none of these patients actually required an excision of ureterocele or ureter after partial nephrectomy, that is if the system is well drained after puncture of ureterocele.

Also we need to put into consideration if we need to do open major surgery in place of puncture. So far, the indications for upper pole nephrectomy are a nonfunctioning kidney. The question is whether we need to do upper pole nephrectomy or just do puncture of ureterocele and follow-up with the children.

I. Aaronson (Charleston, SC): I think it would be fair to compliment you from the scientific point of view that you did follow-up a large number of patients who had ongoing problems without antibiotic prophylaxis, and I think that is a valid conclusion.

C. Buyukinal (Istanbul, Turkey): The Previous comment was against the concept of "endoscopic management of ureterocele." Besides, nearly half of these patients may still have persisting VUR after the endoscopic puncture of ureterocele. But as you mentioned, the majority of these cases with persisting VUR may be treated endoscopically. Sixteen of your 20 patients with persisting VUR were treated successfully by endoscopic procedures. I think there is an important role for endoscopic procedures in the treatment of obstructive ureteroceles and its related complications.

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