Endoscopic and minimal open surgical incision of ureteroceles

Ureterocele decompression by endoscopic or open incision was the primary treatment in 59 children with 63 ureteroceles. Of these, 18 were intravesical and 45 were ectopic. The endoscopic or open incision adequately decompressed all intravesical ureteroceles and 37 of 45 ectopic ureteroceles (82%). After incision, the secondary operation rate was 17% for intravesical and 62% for ectopic ureteroceles. In our opinion, endoscopic or open incision must be considered a definitive treatment in the large majority of intravesical ureteroceles and is also valid in ectopic ureteroceles. In these cases, the early decompression obtained by this approach produced significant functional recovery, fewer urinary tract infections, and facilitated subsequent surgery in those patients requiring complete surgical reconstruction. Accepted: 11 June 1997     

Renal function and vesicoureteric reflux in children with ureteroceles

A total of 215 ureteroceles were present in 41 children with single-system and 154 children with double-system ureteroceles. Males were predominant in the single-system group while the reverse was true in patients with double-system ureteroceles. Single-system ureteroceles occurred more commonly on the left side. In double-system ureteroceles there was minimal renal function in 74% of the ureterocele-bearing moieties, 26% of the ipsilateral lower moieties, and 3% of the contralateral kidneys. Vesicoureteric reflux (VUR) was present in 17% of the ureterocele-bearing ureters, 54% of the ipsilateral second ureters, and 28% of the contralateral ureters. In the single-system ureteroceles, 20% of the ipsilateral kidneys had minimal renal function and 9% of both the ipsilateral and contralateral ureters had VUR. Differences in laterality, VUR, and function of the subservient renal tissue suggest that single-system ureteroceles are a different disease entity from the double-system type and should be considered separately in any discussion of the management of ureteroceles.     

Endoscopic correction of primary vesicoureteric reflux by subureteric Teflon injection (STING): follow-up study in 123 patients

During a 4-year period 123 children (191 ureters) with primary vesicoureteric reflux (VUR) were treated endoscopically by subureteric Teflon injection (STING). They have now been followed up for periods ranging from 2 to 6 years. Sixty per cent of the ureters had grade III VUR and 36% had either grade IV or grade V. Reflux was corrected in 149 (78%) ureters after a single injection of polytef paste; 11 (6%) ureters showed improvement to grade I or II reflux after one injection and no further treatment was given; 24 (12%) ureters required two injections and 7 (4%) needed three to four subureteric injections for the correction of VUR. Of the 123 patients, 116 were discharged from the hospital on the day of the procedure. Of the 149 ureters corrected with one subureteric injection, 83% required less than 0.3 ml paste per ureter to stop reflux. At follow-up micturating cystography 91% of the ureters continue to show absence of reflux 2 to 6 years after endoscopic correction; 9% had recurrence of reflux, but more than one-half of the recurrences were only of grade I or grade II severity and required no further treatment. Seven ureters had recurrent grade III or IV reflux and were reinjected without any difficulty. There was no evidence of delayed appearance of vesicoureteric obstruction. Treatment of primary VUR by endoscopic subureteric injection of polytef paste was found simple, safe, and effective in correcting all grades of VUR.     

Surgical management of complete ureteric duplication abnormalities

In 2 decades (1974–1993), the senior author (S.A.) managed 148 patients with various abnormalities associated with complete ureteric duplication. Included were 72 patients with primary vesicoureteric reflux, 50 with ureteroceles, and 26 with upper-pole ectopic ureters. The majority of the patients were female, and the common clinical presentations included urinary tract infection (UTI), UTI with septicemia, and urinary incontinence. Ten cases were diagnosed after recognition of a renal abnormality on prenatal ultrasonography, an avenue that has provided new challenges, new opportunities, and new dilemmas. This review article is based on the authors' experience together with an analysis of current emphasis on early diagnosis, minimal surgery, and maximum preservation of renal function. Accepted: 15 October 1996     

Endoscopic injection therapy for treatment of vesicoureteric reflux: A 20-year perspective

OBJECTIVE:

To review the application and outcome of endoscopic injection therapy for vesicoureteric reflux in regard to its evolution over the past two decades.

DATA SOURCES:

Review articles, original reports and abstracts pertaining to endoscopic injection therapy were obtained through a PubMed search of English, German and French publications from 1981 to 2001.

DATA SELECTION:

A total of 46 studies were selected. Four were selected to support basic concepts in the management of vesicoureteric reflux, and the remainder pertained specifically to endoscopic injection therapy for vesicoureteric reflux.

DATA EXTRACTION:

The reports were analyzed with focus on the physical properties of the biomaterial injected, results of treatment in regard to the cure of vesicoureteric reflux, duration of cure, and possible adverse effects and clinical benefits engendered by the use of injectable materials.

DATA SYNTHESIS:

Endoscopic injection therapy successfully cures vesicoureteric reflux in 60% to 80% of cases. Success rates are higher with particulate materials (Teflon and Macroplastique) than with bovine collagen or autologous chondrocytes. Long term data regarding cure are scant. Although concerns about particulate migration and autoimmune disease exist, these have not been borne out of clinical experience. Endoscopic injection may be accomplished on an outpatient basis, with less morbidity than with open ureteroneocystostomy.

CONCLUSIONS:

Endoscopic injection therapy should be offered as an alternative treatment in patients with indications to consider ureteroneocystotomy, but should not change the indications for surgical intervention. The ideal biomaterial for injection has yet to be developed, but the field of autologous tissue engineering holds promise for future development.     

Management of duplex ureteroceles detected by prenatal ultrasound

During the last 13 years 110 children with duplex ureteroceles were treated. There was a 3 to 1 female-to-male predominance. The authors report their experience with a group of 25 patients with duplex ureteroceles diagnosed in utero. Endoscopic incision of the ureterocele was performed as the initial treatment in 18 (72%) of these patients; decompression of the upper pole of the ureterocele was achieved in 100% of cases. Preservation of the upper pole was possible in 8 patients (44%); vesicoureteral reflux was created at the level of the upper pole in 8 (44%). Reconstruction of the lower urinary tract was accomplished in 15 (83.3%) patients who had had endoscopic treatment. Our experience has led us to believe that endoscopic incision of the ureterocele deserves reconsideration and re-evaluation because, as our series has shown, this intervention offers the great advantage of allowing good functional recuperation of the obstructed moiety with a high rate of success in a totally asymptomatic group of patients diagnosed in utero.     

Endoscopic correction of vesicoureteric reflux in infants under 2 years of age

Forty-seven infants under the age of 2 years with vesicoureteric reflux were treated by subureteric injection of Polytef paste; 4 have completed sufficient follow-up to be analysed. The 41 patients had reflux into 60 single-system ureters and 12 duplex systems. Fifty-five single-system ureters have ceased refluxing and 4 of the remaining 5 have improved, whereas 7 of the 12 kidneys with reflux into one or both segments of a duplex system no longer reflux. Thirty-one patients had only single-system disease, and 26 (84%) are totally corrected. Of the 10 patients with 12 duplex systems that refluxed, 5 were completely corrected. Overall, 31 (76%) of the patients are free of reflux. Correspondence to: P. A. Dewan     

Long-term follow up of surgically treated primary vesicorenal reflux

It is well known that the most serious complication of primary vesicoureteric reflux is chronic atrophic pyelonephritis or reflux nephropathy. The main goal in the management of vesicorenal reflux (VRR) is the prevention of progressive renal damage.The elimination of reflux and the eradication of infection are fundamental in order to achieve this goal. The authors performed a retrospective study in 146 pediatric patients operated upon by ureteral reimplantation for primary VRR; 78 operations were unilateral and 68 bilateral, for a total of 214 reimplanted ureters. The mean age at the time of operation was 4.8 years; the mean age at the time of the study was 15.8 years, and the average postoperative observation period was 13.5 years.The study included pre- and postoperative urine analysis and determinations of blood pressure, renal scarring and parenchymal growth, and evolution of renal function.The study showed that: (1) urinary concentrating ability in bilateral high-degree VRR (64 patients) remained reduced in a relatively high percentage of patients; (2) there was significant improvement (from 40.7% to 17.9%) in proteinuria that was related to favorable evolution of renal function (z = 4.152; P <0.01); (3) the frequency of acute pyelonephritis decreased from 41.4 to 3.4%, and only 20% of the patients had episodes of afebrile pathologic bacteriuria in the postoperative period (z = 7.647; P <0.01); (4) more than 15% of the patients were hypertensive (10.3%) or at risk for hypertension, having a high peripheral plasma renin activity (5.2%); (5) some renal scarring developed despite successful antireflux surgery, and usually parenchymal growth resumed; in about 6% of the renal units a further decrease in renal size occurred; and (6) renal function generally improved after successful surgery (z = 4.115; P <0.01). This favorable evolution was much more evident in patients operated upon in the first 2–3 years of life (z = 3.885; P <0.01). However, when the renal function was already severely compromised, an antireflux operation had little or no effect on the inexorable decline in renal function. Correspondence to: G. Belloli     

Management of urinary tract infections

Urinary tract infection (UTI) is common in childhood. It may result in long-term complications due to renal scaring. Younger children are at higher risk of renal scarring. The diagnosis of UTI is based on urine culture. The bacterial count for diagnosis of UTI depends on the method of urine collection. Urinalysis is useful for making a presumptive diagnosis of UTI and allows initiation of empirical treatment in high-risk patients, after urine culture has been obtained. The treatment of UTI is guided by the severity of illness and age of the patient. Following a UTI, investigation should be performed to identify an underlying urinary tract anomaly. Recurrence of UTI occurs in 30–50% children. Important predisposing factors include VUR, urinary tract obstruction, voiding dysfunction and constipation. Vesicoureteric reflux (VUR) is seen in 30–50% children with UTI. The cornerstone of management of VUR is long-term antibiotic prophylaxis, which has been found to be as effective as surgical reimplantation.     

Ureteric tunnel incision in the fetal pig: a model for non-obstructive prenatal vesicoureteric reflux

The understanding of vesicoureteric reflux (VUR) continues to improve, particularly as the renal tract can now be assessed prenatally. To further study the evolution of fetal renal changes, we studied two neonatal piglets that had undergone midgestation ureteric tunnel ablation. Dilatation of the pelvicalyceal system was seen radiologically and macroscopically in all three kidneys into which VUR had been created. Despite the study being marred by poor fetal survival, the results indicate that the model should be developed further to explore what appears to be an interrelationship between VUR and renal parenchymal changes in utero. Accepted: 4 November 1998     

Posterior urethral valves: incidence and progress of vesicoureteric reflux after primary fulguration

This is a prospective study of 20 cases of posterior urethral valves (PUV) presenting between the ages of 12 days and 5.5 years (median 15 months) in order to determine the incidence and progress of vesicoureteric reflux (VUR), hydronephrosis (HN), and renal functional status. The efficacy of fulguration as the sole modality of treatment for PUV was assessed in terms of improvement or disappearance of VUR over a 6-month follow-up period. VUR was present in 60% of the patients, being unilateral in 41.7%. Out of 19 renal units with VUR, reflux subsided in 31.5% by 3 months and 78.94% by 6 months. The blood urea and serum creatinine levels, which were raised in 50% of the patients at presentation, came down to normal by 6 months in all the cases. Improvement in glomerular filtration rates (GFR) was noted in all the children at each follow-up and was found to be statistically significant (p<0.01). HN was present in all the patients at presentation and was bilateral in 90%. It decreased significantly during the follow-up period, though its complete disappearance was seen only in one case. Vesicoureteric reflux dysplasia syndrome (VURD) was present in two cases. Our study showed that VUR disappeared in a majority of the cases by 6 months once adequate urethral patency was restored, although hydronephrosis persisted.     

Subureteral collagen injection versus antireflux surgery in primary vesico-ureteral reflux grade III

Endoscopic subureteral collagen injection (SCIN) was performed in 24 girls and 5 boys (mean/range: 3.2/0.7–12.2 years) with primary grade III vesicoureteral reflux. Clinical outcome was compared to 20 girls and 6 boys treated by antireflux surgery (mean/range: 3.0/0.2–9.4 years). Forty-one ureters were treated by endoscopy, 37 by surgery. Patients were followed for 12 months. SCIN was not associated with severe persistent complications. No reflux was detected immediately after SCIN. After 6 months recurrent grade II reflux was present in 1 (4%) surgically treated patient and in 12/29 (41%) patients treated by collagen injection. This corresponded to a recurrence rate of 1/37 (3%) of ureters following surgery and 15/41 (37%) following SCIN. 8/15 refluxing ureters after collagen showed decreased reflux grade (two grade I, six grade II). After 12 months 24/26 (92%) patients with antireflux surgery remained free of urinary tract infections as compared to 25/29 (86%) children following endoscopy. Following SCIN, 4/29 (14%) patients required secondary antireflux surgery because of recurrent urinary tract infections.Conclusion On the basis of this study endoscopic SCIN appears to be safe in children. It is less effective than surgery with regard to elimination of primary grade III reflux. However, clinical success rate is comparable to surgery with regard to the frequency of recurrent urinary tract infections after the procedure. This may be due to the reduction of refluxing urine volume in those patients who showed recurrence of reflux after collagen injection.     

Treatment of vesicoureteral reflux in children by endoscopic injection of Teflon

From November 1986 to April 1990, 326 refluxing ureters in 197 children were treated by endoscopic injection of Teflon paste. Complications were observed in only 3 cases: 1 child had immediate bilateral ureteral stenosis requiring surgery at 48 h. In 1 case it was impossible to probe 1 ureteral orifice after injection, and Cohen reimplantation was immediately performed; in a 3rd case ureteral dilatation occurred 1 year later without anatomic stenosis at surgery. Three hundred twenty-two ureters were examined after 1 month: reflux had disappeared in 286 (88.82%). The stability of these results after one injection was verified 1 year later for 179 ureters: recurrence of reflux was observed in 19 cases (10.60%); 21 non refluxing ureters were again examined 2 years later: reflux reappeared in 2 cases. Analysis of the midterm results showed that failure was observed in 17.31% of cases of primary reflux and 19.04% of malformative or secondary refluxes. It was more significant in grade IV or V (21.11%) than in grade I–III (16.85%) reflux. Of the 57 immediate or secondary residual refluxes, 10 were followed and 2 spontaneously disappeared, 24 underwent successful surgical reimplantation, and 23 had a repeat injection with 22 successes and only 1 failure that was secondarily cured by surgery. Overall, reflux disappeared after one or two injections in 165 children (83.25%). Offprint requests to: H. Dodat     

Transluminal endoscopic electrosurgical incision of fenestrated duodenal membranes

Duodenal fenestrated membranes are traditionally treated by side-to-side diamond-shaped duodenoduodenostomy, or duodenotomy and resection. We describe an alternative endoscopic approach for its resolution. A flexible panendoscopy reaching the duodenal membrane was performed. A balloon was inserted to dilate its orifice. Traction was applied to the balloon to differentiate the border of the membrane forming the duodenal wall. After visualizing the ampulla, the membrane was incised using a sphincterotome or needle knife on two sites opposite to the bile duct. From May 2001 to August 2007, ten patients with a fenestrated duodenal membrane underwent transluminal endoscopic electrosurgical incision (TEEI). Mean patient age was 3.4 years (range 1 month to 15 years). The endoscopic procedure lasted from 30 to 60 min. Oral intake began 24 h postsurgery in eight patients and at 48 h postsurgery in two patients. Hospital stay lasted for 2-5 days. After 1 year of follow-up, eight patients were asymptomatic and thriving at present, and one had a double membrane, required a second endoscopy with TEEI, and has experienced occasional vomiting. An additional asymptomatic patient was lost after 3 months of follow-up. TEEI of fenestrated duodenal membranes is a feasible and effective procedure in children.     

The role of DMSA scans in evaluation of the correlation between urinary tract infection, vesicoureteric reflux, and renal scarring

The correlation between urinary tract infection (UTI), vesicoureteric reflux (VUR) and renal scarring was studied in 89 patients (177 renal units; 1 solitary kidney) during the period 1997–2000. There were 63 males and 26 females; ages ranged from neonates to 14 years. UTI was diagnosed on the basis of a positive urine culture, VUR was diagnosed and graded by micturating cystourethrogram (MCU), and renal scarring was assessed by technetium 99 m Tc-dimercaptosuccinic acid (DMSA) scan. Ultrasonography (US) was done to evaluate renal tract dilatation and other structural abnormalities. A follow up DMSA scan was performed approximately 6 months after the initial scan. VUR was present in 106 of the 171 renal units in which it was studied and absent in 65 units. The majority of the VUR was grade V. Renal scars were seen in 90 of 177 renal units at presentation and in 72 of the 163 renal units studied at follow-up. Some information was lacking in 31 patients; hence, the correlation between UTI, VUR, and renal scarring was done in 58 patients. The majority of the suspected scars at presentation were not seen at follow-up, but most of the established scars persisted. Only 2 renal units showed scars for the first time on follow-up. On US, approximately 50% of normal kidneys showed either suspicious or established scars on DMSA scan, and patients with bilateral abnormality on US showed renal scars. Renal scars were seen in 15 of 23 children without VUR, 17 of 18 with unilateral VUR, and 16 of 17 with bilateral VUR. Thus, there is a cause-and-effect relationship between UTI and renal scarring that is made worse by VUR. DMSA scans have been shown to be the most reliable method of assessing renal scarring, and an abnormal US scan showing upper-tract dilatation or a structural abnormality may have a predictive value in the detection of renal scarring. Accepted: 18 April 2001