输尿管膨出的微创手术治疗

目的评价输尿管膨出的微创手术治疗方法及其疗效。方法回顾性总结22例输尿管膨出经尿道电切手术治疗输尿管膨出的临床资料。结果22例患者手术一次成功21例，术后定期B超、膀胱造影随诊，随诊时间6—60个月。1例异位输尿管膨出合并重复肾、输尿管畸形患者存在术后膀胱输尿管返流，再次行开放手术后痊愈。结论经尿道电切术是治疗输尿管膨出简单、有效、微创的治疗方法。     

内窥镜手术治疗输尿管膨出13例报告

目的:观察内窥镜手术切除输尿管膨出的治疗效果.方法:回顾性分析13例成人输尿管膨出患者采用内窥镜手术治疗的临床资料.结果:13例患者均经IVU、B超及膀胱镜检查确诊,采用电切镜或钬激光机行输尿管囊肿低位横行切开术5例,3例肾积水消失,2例肾积水改善;8例行输尿管膨出囊壁部分切除,积水全部消失.均一次手术成功,术后平均随访18个月,3例术后出现输尿管反流,2例2个月后自行缓解,1例于术后4个月行开放手术抗反流.结论:内窥镜手术切除输尿管膨出是一种安全、简单、有效的治疗方法,可以减少手术创伤及术后并发症,创伤小、恢复快.囊壁部分切除术效果更为理想.当输尿管反流不能自愈时,应行输尿管膀胱抗反流吻合术.     

开放手术治疗肾移植术后输尿管梗阻的技术探讨

目的探讨肾移植术后移植肾输尿管狭窄的开放手术技巧与效果。方法首都医科大学附属北京友谊医院泌尿外科于2019年1月—2020年1月共行166例单肾移植,共发生5例肾移植术后输尿管狭窄,根据梗阻部位的不同采用了不同的开放手术术式进行治疗,回顾性分析这组患者的临床资料及预后。结果5例患者中,男性3例,女性2例,平均年龄42.6岁。其中2例患者原发病为Ⅱ型糖尿病,3例患者为肾小球肾炎。输尿管梗阻确诊的平均时间为肾移植术后143.8 d,行开放手术平均时间为肾移植术后209.8 d,确诊梗阻时平均血肌酐水平为271.94μmol/L。所有患者均因出现移植肾积水合并血肌酐进行性升高经影像学检查确诊,首先采取内支架或经皮肾造瘘紧急挽救肾功能。待肾功能恢复稳定后,根据梗阻段位置,3例患者行移植输尿管-膀胱再吻合术,1例患者行原输尿管-移植肾输尿管端端吻合术,1例患者行膀胱皮瓣翻转代输尿管术。5例患者开放手术平均时间为2.6 h,术中平均出血量为32 ml。开放手术后,5例患者均预后良好,开放手术后平均血清肌酐恢复至111.5μmol/L,尿量正常,无外科并发症发生。随访半年后,5例患者均未再发生输尿管梗阻。结论移植肾输尿管梗阻是肾移植术后常见外科并发症之一,腔内治疗中远期效果有限,根据不同梗阻部位选择不同术式进行开放手术,是治疗移植肾输尿管狭窄的有效方案。     

输尿管膨出44例报告

目的 :探讨提高对输尿管膨出的诊断和治疗水平的方法。方法 :总结 16年收治的 4 4例患者临床资料。术前行B超、IVP、CT或膀胱镜检查。 2 4例行膨出部切除加膀胱输尿管再吻合术 ,其中 8例同时切除了同侧上肾和输尿管。 2 0例行经尿道内腔镜囊肿切开治疗。结果 :B超和IVP两种检查结合可明显提高诊断符合率 ,膀胱镜检的准确率可达 10 0 %。随访 1～ 16年 ,其中 1例患者有待接受第二次手术 ,所有患者术后症状改善 ,复查显示积水消失 ,无尿液反流。结论 :B超和IVP是理想而必要的检查 ,对手术方法的选择有指导意义。治疗以手术为主 ,并发有重复肾输尿管畸形或输尿管膨出部巨大 (直径 >3cm)的病例 ,宜行上肾及输尿管切除或 (和 )膨出部切除加输尿管膀胱再吻合术。成人单纯型输尿管膨出 ,可优先考虑内腔镜治疗     

膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理

目的：探讨膀胱全切原位回肠新膀胱术后输尿管肠吻合口良性狭窄的处理方法。方法：我科自2003年1月～2012年6月采用膀胱全切原位回肠新膀胱术治疗395例膀胱癌患者。术后发生输尿管肠吻合口良性狭窄10例,采用输尿管镜扩张、内镜下逆行／经皮穿刺顺行球囊扩张、内镜下狭窄段内切开、开放输尿管膀胱再植术,并留置双J管3～6个月。结果：本组10例中,1例（1处）因导丝不能通过狭窄段而改行开放手术,术后随访36个月,肾积水明显改善。其余9例（11处）采用腔内技术处理,其中3例（4处）采用输尿管镜扩张,2例（3处）采用内镜下狭窄段内切开,4例（4处）采用内镜下逆行／经皮穿刺顺行球囊扩张。术后随访9～72个月（中位25个月）。5例（7处）肾积水明显改善,2例（2处）肾积水长期随访无加重,2例（2处,狭窄段长分别为1．2cm、1．5cm）再发狭窄,遂采用开放手术,分别随访16及24个月,肾积水改善。结论：腔内技术操作简单,创伤小,可作为输尿管肠吻合口良性狭窄的首选治疗方案。开放手术仍然是治疗输尿管肠吻合口狭窄的金标准。对于狭窄段〉1cm的患者,应首先考虑开放手术。     

腹腔镜下与开放手术半肾切除治疗小儿重复肾的疗效比较

目的 比较腹腔镜下和开放手术半肾切除治疗小儿重复肾的疗效. 方法先天性重复肾患儿64例.平均年龄17个月.开放手术组36例,腹腔镜下手术组28例.开放组平均年龄18个月,男19例,女17例;输尿管异位开口15例、输尿管膨出18例、膀胱输尿管反流2例、肾盂输尿管连接处梗阻1例.腹腔镜组平均年龄16个月,男18例,女10例;输尿管异位开口9例、输尿管膨出16例、膀胱输尿管反流3例.2组患儿年龄、病种比较差异无统计学意义(P＞0.05). 结果 腹腔镜组术中转开放手术2例.2组患儿术中术后未发生外科并发症.开放组平均手术时间2.5 h,手术前后血红蛋白差均值2.64 g,术后引流量平均91.4 ml,引流天数平均4.2 d,住院天数平均19.3d;腹腔镜组分别为2.9 h、1.45 g、55.4 ml、3.4 d和14.3 d;2组比较差异均有统计学意义(P＜0.05).结论 腹腔镜下半肾切除术治疗小儿重复肾畸形半肾无功能安全有效,与开放手术比较手术创伤小、术中出血量少、术后疼痛和住院时间短.     

肾移植术后输尿管并发症17例临床分析

目的 总结肾移植术后输尿管并发症的诊治经验.方法 回顾分析济南军区总医院诊治的17例肾移植术后输尿管并发症患者的临床资料.结果 17例患者伴有不同程度的少尿和局部肿胀不适等症状,实验室检查血清肌酐（Scr）升高,彩色多普勒超声（彩超）检查示移植肾积水、移植肾输尿管扩张,经磁共振水成像或计算机断层摄影术（CT）尿路成像明确诊断.其中输尿管膀胱吻合口狭窄15例,输尿管坏死2例.治疗经过：14例行开放性手术,包括行移植肾输尿管膀胱重新吻合术12例,移植肾输尿管-自体输尿管吻合1例,移植肾输尿管游离、重新放置输尿管支架管1例.3例行非开放性手术治疗,包括输尿管皮肤造瘘1例、腔内球囊导管扩张术1例、软膀胱镜下逆行输尿管支架管插管治疗1例.疗效：14例开放手术治疗患者与1例输尿管皮肤造瘘患者的移植肾肾盂与膀胱的连接部恢复通畅,移植肾功能均明显改善.另2例非开放手术治疗患者,包括1例腔内球囊导管扩张术及1例行软膀胱镜下逆行输尿管支架管插管术患者术后复发,行开放手术治疗.结论 彩超及磁共振成像水成像或CT尿路成像等影像学检查是确诊移植肾输尿管并发症的主要方法.肾移植术后输尿管并发症应以预防为主,确诊后视具体情况行开放性手术或非开放性手术治疗,开放手术治疗的疗效较佳.     

经尿道手术治疗输尿管膨出(附15例报告)

目的：探讨输尿管膨出患者行经尿道手术的治疗经验。方法：对15例输尿管输膨出患者采用经尿道手术治疗的资料进行总结。结果：15例均经IVU、B超、膀胱镜检查确诊,6例行经尿道囊肿低位横行切开术,4例积水消失,2例积水改善;9例行输尿管膨出囊壁部分切除术 ,积水全部消失。结论：输尿管膨出行经尿道手术治疗是一种简单而有效的治疗,经尿道囊壁部分切除术效果更为理想。     

腔内切开治疗移植肾输尿管膀胱吻合口梗阻

目的 探讨腔内切开处理移植肾输尿管膀胱吻合口梗阻的安全性与有效性. 方法 18例肾移植患者术后2～18个月出现尿量减少.实验室检查SCr 230～570/μmol/L.超声检查提示中重度肾积水.膀胱镜检查18例均无法逆行输尿管置管.经皮肾造瘘后行顺行造影显示输尿管膀胱吻合口梗阻,不完全梗阻14例、完全梗阻(闭锁)4例,梗阻长度0.5～1.3 cm.术中先经皮肾通道入镜,将斑马导丝顺行插过梗阻段达膀胱,再逆行经尿道将膀胱内导丝拉出尿道外,直视下用电刀或钬激光全层切开梗阻段;若斑马导丝无法通过梗阻段,则采用造影剂混合美蓝充盈膀胱,顺行入镜到达梗阻处,X线监视下用长针向膀胱内穿刺打通.术后留置2条双J管6～8周,定期行超声、肾图和肾功能检查. 结果 18例术中见吻合口黏膜苍白水肿,管壁僵硬、管腔狭窄、瘢痕组织增生明显,均成功将梗阻段切开,无手术并发症发生.术后夹闭肾造瘘管后排尿通畅,尿量正常.实验室复查SCr降至87～233μmol/L.超声检查提示肾血流正常,肾积水消失或仅轻度积水.随访4～90个月,平均51个月.8例1次治疗成功;5例因瘢痕组织切除不彻底经再次腔内切开(3例2次,2例3次)治疗后成功;5例拔管后梗阻复发无法逆行入镜,梗阻难以处理改开放手术治疗,其中4例治疗成功,1例仍需长期输尿管置管. 结论 肾移植术后输尿管膀胱吻合口梗阻采用腔内切开治疗安全、有效,梗阻复发者可考虑再次内切开或开放手术治疗.     

膀胱肌瓣输尿管成型术治疗输尿管中下段长段损伤17例报告

目的探讨膀胱瓣输尿管成形术治疗输尿管中下段长段病变的疗效。方法采用膀胱肌瓣输尿管吻合术治疗输尿管中下段长段狭窄或缺损17例,16例为医源性损伤,其中8例为妇产科手术、3例为普外科手术、2例为腔内泌尿外科手术、2例为输尿管下段开放取石术后、1例为输尿管吻合术后吻合口断裂;另外1例为先天性巨输尿管症。所有患者行膀胱肌瓣输尿管成形术。结果所有患者均吻合成功,13例患者术后随访3月～1年,全部尿路梗阻消除,未发生新的再狭窄,1例重度膀胱输尿管返流。结论膀胱肌瓣输尿管成形术治疗输尿管中下段长段损伤效果较满意。     

Impact of prenatal diagnosis on the morbidity associated with ureterocele management

PURPOSE: We postulated that prenatal detection of ureteroceles has a positive impact on the natural history and clinical outcome of ureteroceles in duplex system. MATERIALS AND METHODS: Between 1992 and 2000, 95 children underwent surgery for a ureterocele in a duplex system. We evaluated the impact of prenatal diagnosis in 40 cases versus postnatal diagnosis in 55 on morbidity, as measured by postoperative urinary tract infection and secondary procedures, while controlling for ureterocele type and the initial surgical approach. RESULTS: Mean followup in the 2 groups was 3.9 years. Preoperatively the reflux rate was 51% in the prenatal and 66% in the postnatal groups. Preoperatively urinary tract infections were less common in the prenatal group (12% versus 84%). Mean age at initial intervention in prenatally and postnatally diagnosed patients was 6 and 31 months, respectively. Postoperatively the urinary tract infection rate was double in postnatally diagnosed patients. Overall postoperatively reflux was similar in the 2 groups and grades III to V reflux with urinary tract infection accounted for 14 of the 21 secondary bladder procedures (67%). After initial endoscopic decompression none of the prenatally diagnosed patients with intravesical ureteroceles required reoperation, whereas 6 (50%) with extravesical ureteroceles required reoperation. All 10 prenatally diagnosed extravesical ureteroceles treated with partial nephrectomy were cured. Overall the secondary procedure rate in the postnatal group was higher than in the prenatal group (46% versus 20%, p = 0.02). Also, there was a difference in the reoperation rate in the endoscopic decompression group according to mode of presentation (p = 0.03) and a difference when comparing endoscopic treatment with partial nephrectomy in all patients (p = 0.02). CONCLUSIONS: Prenatal diagnosis decreases morbidity and potential adverse outcomes related to infection. Overall prenatal diagnosis is associated with a decreased rate of secondary procedures independent of the type of ureterocele. Prenatally diagnosed intravesical ureteroceles may be cured by endoscopic incision alone but for extravesical ureteroceles partial nephrectomy appears to be more definitive.     

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.     

The modern endoscopic approach to ureterocele

PURPOSE: During the last 20 years the surgical approach to ureterocele has evolved from major open surgery to minimally invasive endoscopic puncture. We believe that the endoscopic approach decreases the need for open surgical procedures. We identified specific factors that predict the need for repeat surgery. MATERIALS AND METHODS: We reviewed the charts of 60 new patients with ureterocele treated with primary endoscopic incision between 1991 and 1995. Followup ranged from 4 to 62 months (mean 20). Mode of presentation, ureterocele location, associated vesicoureteral reflux and association of the ureterocele with a duplex system were evaluated. Ureterocele wall thickness was assessed subjectively via radiographic and cystoscopic methods, and categorized as thin, intermediate and thick. RESULTS: All 9 patients with a single system ureterocele had an intravesical ureterocele. No patient had associated reflux nor did any require a secondary open procedure. In 3 cases new onset ipsilateral reflux into the ureterocele spontaneously resolved. Of the 51 patients with a duplex system and associated ureterocele 19 (37%) required a secondary open procedure. The ureterocele was intravesical and ectopic in 22 (43%) and 29 (57%) cases, respectively. Reflux was associated with the ureterocele in 27 patients (53%), and 12 (44%) required a secondary open procedure. A total of 11 patients underwent ureteral reimplantation of 15 refluxing renal units and only 2 renal units required ureteral tapering. Reflux is no longer present in 14 of the 15 renal units (93%). Patients with a thick walled ureterocele required repeat puncture more frequently than those with a nonthick ureterocele. CONCLUSIONS: With the use of modern endoscopic techniques children with intravesical and single system ureteroceles require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureteroceles require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles.     

Histology of upper pole is unaffected by prenatal diagnosis in duplex system ureteroceles

PURPOSE: We determined whether the histology of upper pole nephrectomy specimens vary with prenatal detection or ureterocele position. MATERIALS AND METHODS: Between 1992 and 2000, 95 patients with ureteroceles associated with a duplex system underwent surgical interventions, including upper pole nephrectomy in 60. A total of 55 specimens, of which 25 and 30 involved a prenatal and postnatal diagnosis, and 18 and 37 involved an intravesical and extravesical location, respectively, were available for independent review by a single pathologist. Histological lesions were classified into the 5 categories of chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Each category was divided into moderate/severe histological lesions (greater than 25% involvement) and minimal/mild lesions (25% or less involvement). RESULTS: A moderate/severe histological lesion was identified in 38 patients (69%) and a minimal/mild lesion was detected in 17 (31%), while dysplasia was present in 35 (64%). There was no significant difference in histological lesions and mode of presentation. In contrast to intravesical ureteroceles, extravesical ureteroceles were associated with severe fibrosis and tubular atrophy (p <0.05). Chronic interstitial inflammation, fibrosis, tubular atrophy and glomerulosclerosis in each specimen were graded moderate/severe (greater than 25% involved) in 55%, 67%, 66% and 53%, respectively. CONCLUSIONS: Prenatally diagnosed ureteroceles were not associated with less severe upper pole histological lesions. We noted pathological differences when comparing specimens according to ureterocele position, but chronic inflammation and dysplasia were similar in intravesical and extravesical ureterocele cases. It appears that the histological lesions observed are not progressive or reversible. Therefore, the goals of clinical management should focus on providing adequate drainage, antibiotic prophylaxis coverage and followup of reflux rather than the preservation or enhancement of upper pole function.     

Is endoscopic decompression of the neonatal extravesical upper pole ureterocele necessary for prevention of urinary tract infections or bladder neck obstruction?

PURPOSE: It has been hypothesized that endoscopic decompression of the duplex extravesical ureterocele is necessary to prevent the complications of urinary tract infections and progressive hydronephrosis. This study was performed to test this premise. MATERIALS AND METHODS: Infants younger than 2 weeks with an extravesical ureterocele associated with a duplex upper pole moiety were assigned to immediate endoscopic puncture of the ureterocele followed by antibiotic prophylaxis or antibiotic prophylaxis with plans for delayed surgical intervention. Radiographic studies and catheterized urine cultures were obtained at ages 3 and 6 months and for fever greater than 38.5C. All patients included in this study were followed through 6 months of life. RESULTS: Of the patients 32 underwent endoscopic puncture of the ureterocele. Median patient age at endoscopy was 5 days (range 3 to 13). During the first 6 months of life complications developed in 4 (12%), including febrile urinary tract infections in 3 (9%) and with progressive hydronephrosis due to incomplete puncture of the ureterocele in 1 (3%). The remaining 40 patients were treated with antibiotic prophylaxis and delayed open surgery. Median time to open surgery was 3 months (range 2 to 6). During the first 6 months of life complications developed in 5 (13%), including 3 (8%) febrile urinary tract infections and progressive hydronephrosis in 2 (5%). No statistical difference was noted between the 2 treatment groups. CONCLUSIONS: In patients with extravesical duplex ureteroceles neonatal complications of urinary tract infection and progressive hydronephrosis are not significantly different between those treated with immediate endoscopic decompression versus delayed open surgical intervention.     

Transurethral incision of duplex system ureteroceles in neonates: does it increase the need for secondary surgery in intravesical and ectopic cases?

OBJECTIVE: To evaluate the relevance of ureterocele ectopia and associated reflux on the outcome of duplex system ureteroceles (DSU) after neonatal transurethral incision (TUI). PATIENTS AND METHODS: The study included 41 neonates with a diagnosis of DSU; the ureterocele was ectopic in 24 (58%). Before TUI, vesico-ureteric reflux (VUR) was present in 13 lower moieties (32%) and seven contralateral ureters (17%). TUI was always performed within the first month of life. The follow-up and management were tailored for each patient from the findings at ultrasonography, voiding cysto-urethrography and renal scintigraphy. Results of intravesical and ectopic DSU were compared using Fisher's exact test. RESULTS: TUI was effective in allowing ureteric decompression in all but one patient (2.4%). After TUI, VUR ceased in six lower ipsilateral moieties and in two contralateral ureters, while new VUR occurred in three contralateral kidneys. De novo VUR in the punctured moiety appeared in 13 cases (32%). Nine upper poles were not functioning. Twenty-one patients (51%) required secondary surgery. Ureteric reimplantation was indicated exclusively for reflux in the punctured moiety in only in two cases (5%), while in a further two iatrogenic reflux in a nonfunctioning upper moiety required total heminephro-ureterectomy. There was no significant difference between intravesical and ectopic ureteroceles in the occurrence of VUR in the punctured moiety, rate of nonfunctioning upper poles or need for secondary surgery. CONCLUSIONS: About half of the patients with a DSU need secondary surgery, but this is rarely indicated for de novo reflux in the punctured moiety only. The need for secondary surgery was greater whenever there was associated reflux before endoscopic incision. There was no difference in the outcome of intravesical and ectopic ureteroceles and such distinction seems no longer to be of clinical relevance.     

Is bladder dysfunction and incontinence associated with ureteroceles congenital or acquired?

PURPOSE: Bladder dysfunction (a disorder often characterized by incontinence, urgency, patterns of dysfunctional voiding, incomplete emptying and so forth) in association with ureteroceles has been attributed to surgical intervention. A previous study suggested that patients with ectopic ureteroceles may have bladder dysfunction as part of this disorder regardless of the type of surgical intervention. We reviewed all types of ureteroceles (ectopic versus intravesical, simple versus duplex) to characterize the patterns of bladder dysfunction and its association with prior surgical treatments. MATERIALS AND METHODS: A retrospective review of medical records was performed as part of a multi-institutional study. From 1986 to 2000, 616 patients were identified with ureteroceles. Bladder dysfunction was determined by detailed history (that is, voiding diary) plus urodynamic evaluation when deemed appropriate. RESULTS: Based on initial history, 39 of 616 (6.3%) patients had some form of bladder dysfunction and 34 of the 39 underwent urodynamics. All patients had ectopic ureteroceles of duplex systems. The most common symptoms of bladder dysfunction were urinary urgency and incontinence. Infrequent voiding, less than 4 voids daily, occurred in 13% (5 of 39) of the patients. Of the 33 incontinent patients 7% (2) had undergone endoscopic surgery, 12% (4) open lower tract surgery, 45% (15) a combination of upper and lower tract surgery and 36% (12) open upper tract surgery alone. Bilateral ureteroceles did not seem to increase the risk of bladder dysfunction. The majority (35 of 39) of patients with bladder dysfunction responded to behavioral modifications and medical therapy. CONCLUSIONS: Bladder dysfunction associated with ureteroceles occurs in approximately 6% of patients regardless of surgical therapy. The fact that patients treated with upper tract surgery alone have similar rates of incontinence suggests that bladder dysfunction is congenital as opposed to surgically acquired.     

Estudio comparativo de diferentes técnicas quirúrgicas para el manejo del uréter distal durante la nefroureterectomía laparoscópica

ObjectivesTo compare the oncological outcomes between two open surgical techniques and two endoscopic approaches for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU).Material and methodsRetrospective review of 152 patients submitted to LRNU for the management of upper urinary tract tumors between 2007-2014. We analyzed the potential impact of two different open surgical (extravesical vs intravesical) and two endoscopic (resection of ureteral orifice and fragment removal vs endoscopic bladder cuff) techniques on the development of bladder recurrence, distant/local recurrence and cancer-specific survival (CSS).ResultsA total of 152 patients with a mean age of 69.9 years (±10.1) underwent LRNU. We reported 62 pTa-T1 (41%), 35 pT2 (23%) and 55 pT3-4 (36%). Thirty-two were low grade (21.1%) and 120 high grade (78.9%). An endoscopic approach was performed in 89 cases (58.5%), 32 with resection (36%) and 57 with bladder cuff (64%), and open approach in 63 (41.5%), 42 intravesical (66.7%) and 21 extravesical (33.3%). Within a median follow-up of 32 months (3-120), 38 patients (25%) developed bladder recurrence, 42 distant/local recurrence (27.6%) and 34 died of tumor (22.4%). In the univariate analysis, the type of endoscopic technique was not related to bladder recurrence (P = .961), distant/local recurrence (P = .955) nor CSS (P = .802). The open extravesical approach was not related to bladder recurrence (P = .12) but increased distant/local recurrence (P = .045) and decreased CSS (P = .034) compared to intravesical approach.ConclusionsLRNU outcomes are not dependant on the type of endoscopic approach performed. The open extravesical approach is a more difficult technique and could worsen the oncological outcomes when compared to the intravesical.     

Endoscopic puncture of ureterocele as a minimally invasive and effective long-term procedure in children

OBJECTIVES: Over the past years the surgical approach to ureterocele has evolved from complicated major surgery to minimally invasive endoscopic treatment. Because of the high rate of secondary surgery in some recently reported series, an upper pole partial nephrectomy is again recommended as the procedure of choice. We have retrospectively evaluated the long-term results of endoscopic puncture of a ureterocele and its long-term effectiveness and applicability in children. METHODS: Over the past 8 years, 34 patients (20 female, 14 male) were treated in our service with primary endoscopic puncture of a ureterocele. The mean age of the patients was 1.1 +/- 4.3 (mean +/- SD) years. Mean follow-up was 6.1 +/- 2.4 years. Antenatally ultrasound detected the ureterocele in 5 (14%) patients, fetal hydronephrosis leading to the postnatal diagnosis in 13 (38%), and 16 (48%) children presented with symptoms of urinary tract infection (UTI). The ureteroceles presented as part of renal duplication in 31 patients (91%), 3 (9%) in a single system and 1 child had bilateral ureteroceles of a duplex system. Twenty (58%) children had intravesical ureteroceles and the remaining 14 (42%) ectopic ureteroceles. Very poorly functioning upper pole moiety presented in 26 (75%) of the cases and nonfunctioning upper poles in 5 (14%). Twenty of 34 children (58%) had initial vesicoureteral reflux (VUR) to the lower moiety, either to the ipsi (60%) or contralateral kidney (40%). A cold knife incision was carried out in 4 (11.7%), puncture by a 3-french Bugbee electrode in 20 (58%), and the stylet of a 3-french ureteral catheter was utilized to puncture the ureterocele in the remaining 10 patients (30.3%). RESULTS: Complete decompression of the ureterocele was observed in 32 of 34 children (94%). Two patients required secondary puncture 2 years following the primary procedure and are doing well. Upper pole moiety function improved postoperatively in 2 infants and remained stable in all 32 patients, no patient presented with deterioration of the renal function. Six of 20 (30%) patients who had initial VUR to the lower pole, accompanied with recurrent UTI, required surgery. Three underwent ureteric reimplantation and another 3 submucosal polytetrafluoroethylene paste (Teflon) injection. Eight (40%) patients presented with spontaneous resolution of VUR to the lower moiety following puncture of the ureterocele. An additional 6 (17.6%) patients developed VUR to the upper moiety following the puncture of the ureterocele, 3 after cold knife incision and 3 after simple puncture. In 2, submucosal Teflon injection solved the VUR and the remaining 4 patients were maintained on prophylactic antibiotics. In 1 child the reflux resolved spontaneously, and none of them presented with UTI. In 2 cases with nonfunctional upper poles, partial nephrectomy was performed due to symptomatic UTI in spite of complete collapse of the ureterocele 1 and 2 years, respectively, following the initial puncture. No difference was observed in the re-operation rate between the patients with ectopic versus intravesical ureterocele (p<0.05). CONCLUSION: We found that endoscopic puncture of a ureterocele presents an easily performed procedure which allows the release of obstructive ureters and avoids major surgery in the majority of the cases even after a long follow-up.     

A one-stage surgical approach to ectopic ureterocele.

Whenever a ureterectomy for treatment of ectopic ureterocele is appropriate total extravesical excision avoiding a ureteral stump is the preferred approach to avoid a pyoureter or alternating diverticulum and possible surgical complications from an intravesical procedure in small infants and children with large and distorting ectopic ureteroceles.