小儿输尿管膨出症的治疗--附91例分析

目的 选用创伤小，疗效好的术式治疗输尿管膨出症，减法二次手术。方法 91例输尿管膨出症，男25例，女66例，其中70例（76.9%)并发于重肾双输尿管畸形，其中左上输尿管膨出症40例，右上27例，双上3例，影像学检查；双上肾积水4例，患侧上肾积水52例，患侧上下肾积水10例，患侧上，下及对侧都有肾积水4例。21例单一系统输尿管膨出症中，左侧5例，右侧11例，双侧5例。影像学检查；患侧肾积水10例，双侧肾积水5例，患肾功能严重受损5例。上尿路正常1例。结果 78例（85.7%)术后平均随访2年。重肾组；（1）上肾部切除48例52侧，治愈36例，失访7例，需加做输尿管残留切除3例，需再经尿道戳穿输尿管膨出2例；（2）切除输尿管膨出及输尿管膀胱再吻合6例，治愈5例。术后加做上肾部切除1例；（3）经尿道戳穿输尿管膨出15例，治愈9例，失访4例。需加做上肾部切除2例；（4）输尿管膨出自行缩小，症状消失1例。单一系统21例中15例经尿道戳穿输尿管膨出，治愈12例，失访2例，需加做输尿管膀胱再植1例，1例经输尿管膨出切除，输尿管膀胱再植治愈，发育不良肾切除5例。治愈2例，有尿失禁症状2例，仍时有尿路感染1例。全组1次手术治愈65例。结论 输尿管膨出症的治疗须根据患肾功能决定，如患肾功能严重受损，首选患肾或肾部切除，反之则经尿道做膨出部下缘戳孔术，对单一系统肾发育不良并发异位输尿管膨出的女性，其位置低至尿道远端，因该处尿道肌肉缺损造成失禁，须进一步治疗。     

Bladder surgery as first-line treatment of complete duplex system complicated with ureterocele

ObjectivesWe retrospectively analyzed our experience to determine the optimum management of complete duplex system complicated with ureterocele.Materials and methodsBetween 1994 and 2003, we reviewed 15 patients treated with bladder surgery for complete duplex system complicated with ureterocele. The associated anomalies were seven vesicoureteral reflux (VUR) of the lower pole ureter and one of both poles. All patients had ureterocele (11 intravesical, 4 extravesical) and a functioning upper moiety. Initial treatment was transurethral incision of ureterocele (TUI) (14) or common sheath reimplantation (1). The median follow-up was 30 (13–48) months.ResultsThere were no requirements for secondary procedures, with a significant improvement or conservation of ipsilateral renal function and no reflux, in 10 patients (67%). Five patients (33%) with ureterocele (1 intravesical, 4 extravesical) who initially underwent TUI required additional operative management due to moderate to severe VUR, recurrent urinary tract infection or decreased function of upper moiety. The secondary operation performed was lower pole nephrectomy with ureteral reimplantation (1), ureteroureterostomy with ureteral reimplantation (2) or common sheath reimplantation (2). One patient who underwent common sheath reimplantation as secondary operation needed a nephrectomy due to breakthrough febrile urinary tract infection and decreased renal function.ConclusionTUI is recommended as the first-line treatment of complete duplex system with intravesical ureterocele and well-conserved renal function.     

Ectopic ureterocele in nonduplicated collecting systems

Ectopic ureteroceles in nonduplicated collecting systems are rare; only 34 well-documented cases have been reported in the English-language literature. We report two cases of a single-system ectopic ureterocele associated with a nonfunctional ipsilateral kidney in two boys. Nephroureterectomy and excision of the ureterocele were performed. One of the patients had a ventricular septal defect and the other had Sotos' syndrome. An ectopic ureterocele in a nonduplicated collecting system differs from a simple ureterocele or an ectopic ureterocele of a duplicated collecting system because of its prevalence in males, the frequent presence of a nonfunctional ipsilateral kidney, and the high incidence of associated anomalies such as congenital heart disease, crossed renal ectopia, and vas deferens abnormalities. Offprint requests to: R. Gonzalez     

Incidence of urinary tract infection in neonates with antenatally diagnosed ureteroceles.

PURPOSE: To evaluate the incidence of neonatal urinary tract infection (UTI) in the presence of a ureterocele. PATIENTS AND METHODS: Fifteen successive patients with antenatally detected ureteroceles were reviewed between 1991 and 1996. Sixteen ureteroceles were treated (in one patient they were bilateral). Seven ureteroceles were intravesical, and nine were ectopic. Fourteen patients had a duplex upper tract associated with a ureterocele. One patient had one duplex upper tract and one simple upper tract, both associated with a ureterocele. RESULTS: Of the fifteen neonates with a ureterocele, eight already had a UTI on admission. Of these, three had had prophylactic antibiotics. Of the eight infected patients, seven were symptomatic (three with septicaemia). CONCLUSION: If diagnosed antenatally, obstruction has to be relieved as early as possible during the first week of life as antibiotic prophylaxis alone is not sufficient to avoid UTI in these patients. The authors point out the high frequency of UTI in patients with ureterocele.     

Ureteral triplication with a ureterocele

Ureteral triplication is a rare anomaly of the upper urinary tract. The occurrence of complete ureteral triplication with an associated ureterocele has only been reported once before. A case of this extremely rare association is described, and the embryology of this condition is discussed.     

Bladder neck obstruction caused by a large simple ureterocele in a young male

The most common clinical presentation of ureterocele is infection of the urinary tract. Much less common is obstruction of the bladder outlet by prolapse of the ureterocele into the urethra. Even less common is simple occlusion of the bladder outlet by a nonprolapsing ureterocele. We present such a case where a large, simple ureterocele in a young male led to such obstruction.     

Is an initial endoscopic treatment for all ureteroceles appropriate?

ObjectiveA systematic initial endoscopic approach has been locally adopted since 2002 for the treatment of ureterocele. Our aim was to compare outcomes for patients treated with this approach to those treated prior to this date.MethodsWe reviewed the charts of 145 children with ureteroceles treated surgically between 1992 and 2010. Patients were divided according to ureterocele position, year of treatment and type of initial intervention. Evaluation was completed by ultrasound, voiding cystourethrogram and nuclear renal scans.ResultsMean age at initial surgery was 18 months. Group 1 comprised 68 patients operated before 2002, and Group 2 66 patients operated after 2002. Group 1 patients showed a higher rate of preoperative vesicoureteral reflux. Mean follow-up was 43 and 25 months for group 1 and 2, respectively. Ureteroceles treated endoscopically underwent secondary procedures in 61% (group 1) and 42% (group 2) for ectopic and in 42% (group 1) and 10% (group 2) for orthotopic ureteroceles. Overall, there was more de novo upper moiety VUR in group 1 (48% vs 12%).ConclusionPrimary endoscopic ureterocele treatment seems to be an appropriate option for children with a clinically significant ureterocele. The rate of secondary procedures was higher for ectopic ureteroceles but acceptable compared to the upper tract approach.     

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.     

Development of the diagnosis and treatment of pyelo-ureteral duplication in children. Reflections on 179 cases

The method of diagnosis and therapeutic rules for pathological ureteral duplicity has been highly developed over the last few years. Recent advances in fetal ultrasonography sometimes allow an early diagnosis of renal or intravesical cystic structure to be appraised before complications (urinary tract infection or pyelonephritis, prolapsed ureterocele, recurrent orchitis, primary diurnal and nocturnal urinary incontinence with conserved micturation for a young girl). However, the basis of therapeutic rules remain unchanged, the superior pyelocaliceal system is not preserved in most cases of ureterocele with ureteral duplicity or ectopic ureter, because of major cystic dysplasia; although, in some cases when an earlier diagnosis is made, conservative treatment (primary endoscopy followed by a surgical intervention if necessary) can be proposed. Likewise, the endoscopic injection of Teflon causes the vesico-ureteral reflux to disappear in most cases (70%).     

Familial ureteroceles: an evidence for genetic background?

In the pediatric population, ureteroceles may present with different clinical pictures, and the severity of the renal damage is greater than in adults. Ureterocele, an anomaly of ureteric budding, is likely a component of a spectrum of anomalies including vesicoureteral reflux and ureteral duplications. Both have been confirmed to have a genetic and familial basis. We document the largest series of familial cases of ureteroceles, giving evidence for genetic background. We retrospectively reviewed the charts of patients with familial ureteroceles seen between 1992 and 2002. Coexisting ureteral anomalies and features of the cases were documented and compared to sporadic cases and all familial cases within the literature. This is the largest series of familial ureterocele patients in the literature. The review of the literature revealed seven publications with seven ureterocele families (15 affected patients) between 1936 and 2002. Comparing sex, ureterocele location, and single versus duplex systems, familial series are similar to other sporadic cases. Three of the families have twin siblings with ureteroceles. Familial cases, despite their rarity, raise the issue of the genetic origin of uretereoceles. Family members of ureterocele cases should be informed and followed carefully, especially twins. Increased reporting and genetic analysis of familial ureteroceles may prove to link the genetic mouse models of abnormal ureteric budding to the human conditions.     

Bilateral intravesical ureteroceles associated with hydroureteronephrosis and hyperechogenic spots in kidneys. Report of a neonatal case

Ureterocele is a cystic dilatation of the terminal ureter. In children it is most commonly ectopic and associated with the duplex collecting system, less frequently it is intravesical and associated with the single collecting system. We present the radiological and ultrasound findings in a male newborn with bilateral intravesical ureterocele associated with hydroureteronephrosis and hyperechogenic spots in both kidneys. In the literature this association has never been reported in neonatal age.     

Complications of pyelo-ureteral duplications in children and their surgical treatment. Apropos of 69 cases (78 pathogenic duplications)

The authors report their experience on the surgical treatment of 69 infants and children with pyelo-ureteral duplication. Urinary infection was the main revealing symptom (52 cases). Vesico-ureteral reflux was the major associated anomaly (39 cases) involving most often the lower pole ureter; the surgical correction of the reflux was performed according to the technique of Cohen with a favorable outcome in all cases. Because of poorly functioning and dysplastic upper renal segment, partial upper pole nephrectomy was performed in 8 among 12 cases of associated ectopic ureteral orifice and in 9 among 15 cases of associated ureterocele. A reimplantation of the ureter was made possible in 3 cases of ectopic ureteral orifice and in 5 cases of ureterocele with little corresponding renal lesions. With the experience of one neonate who died from septic shock following partial nephrectomy there were no other post-operative complications in this series.     

一期手术矫治肾输尿管重复畸形合并异位输尿管囊肿

目的 探讨分析完全性肾输尿管重复畸形合并同侧上输尿管异位囊肿的病人，治疗时是否需要同时切除病变肾和输尿管囊肿。方法 对近8年来我院收治的10名完全性肾输尿臂重复畸形合并同侧上输尿管异位囊肿的病例予以总结。结果 发现其中6名初期治疗中仅切除患侧上半肾输尿管的儿童，平均术后1年都因为膀胱内囊肿增大而再次接受了输尿管囊肿切除术。另3例病人一期同时施行了上半肾输尿管切除术、膀胱内输尿管囊肿切除术和下半肾输尿管再植术，术后随访疗效良好。结论 我们认为对类似疾病应该在切除肾输尿管的同时一并切除异位输尿管囊肿。     

Effectiveness of primary endoscopic incision of ureteroceles

Endoscopic incision of a ureterocele (EIU) is simple when compared to an open procedure such as ureterocele excision with or without an upper-pole nephrectomy. It has, however, the potential to induce vesicoureteric reflux (VUR), which traditionally requires further surgical intervention. The natural history of the VUR that develops following EIU is not known. We have treated asymptomatic VUR that developed following EIU conservatively and have surgically intervened only in cases with recurrent urinary tract infections (UTI). This is a review from a single surgeon's practice involving 29 consecutive cases of ureterocele spread over a period of 4 years. The range of follow up was 4–54 months (median 32). Of the 24 children who underwent primary EIU, 6 required a second procedure, 3 a reincision and 3 an open procedure. Of the 3 who had a reincision, 2 required a further open procedure. The indication for reincision was failure of decompression of the upper tract and the indication for an open procedure was recurrent UTI following EIU. Thus, overall success was achieved in 19 of 24 cases of primary EIU (79.2%). VUR following EIU appeared in 10 cases (41%); UTI developed in only 5 (50%) of these 10 cases. Overall, UTI developed in 6 of the 24 (25%) cases of primary EIU. Eight children had an open procedure (3 as a primary procedure and 5 after EIU); 2 (25%) from this group had UTI following the procedure, and interestingly, neither had VUR. Ureterocele incision is thus a good alternative to upper-pole nephrectomy or excision of the ureterocele, especially in infancy. There is an inherent risk of producing VUR in the postincision period, however, the majority of cases can be managed conservatively. All patients need to be monitored for hypertension and UTI following EIU. Accepted: 17 October 2000     

Experience with a novel approach to upper-pole nephrectomy and partial ureterectomy

The upper-pole moiety of a renal duplication anomaly associated with an ectopic ureter or ureterocele is often hydronephrotic and non-functioning. Thus, the treatment of choice is frequently upper-pole nephrectomy and partial ureterectomy. Previous surgical techniques have emphasized the initial removal of the upper pole followed by partial ureterectomy. The approach described here begins by identifying and dissecting the obstructed upper-pole ureter, dividing it distally, and performing the partial nephrectomy last. We have performed this procedure on 12 consecutive nonfunctioning and obstructed upper-pole moieties of duplicated kidneys. In 10 patients the obstructed upper pole was associated with an ectopic ureter or an ectopic ureterocele (bilateral in 1) and in 1 with uretero-pelvic junction obstruction of the upper-pole moiety. This anatomic approach has resulted in preservation of function in all 12 remaining lower renal and ureteral units as assessed by postoperative intravenous urography. Only 1 patient required an intraoperative blood transfusion. We believe that this safe and easy-to-teach approach should be included in the urologic armamentarium.     

Does endoscopic puncture of ureterocele provide not only an initial solution,but also a definitive treatment in all children? Over the 26 years of experience

Purpose

We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status.

Methods

78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1–26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period.

Results

Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p?=?0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p?=?0.716).

Conclusions

Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.

     

Nephrocalcinosis in a child with autosomal dominant polycystic kidney disease and a prolapsing ectopic ureterocele

Although autosomal dominant polycystic kidney disease commonly presents in adults, it can occur in children. Usually, renal calcification in patients with autosomal dominant polycystic kidney disease is manifested as calculi or as hemorrhage into a renal cyst. An ectopic ureterocele is a well-known finding in patients with renal duplication. To our knowledge, this is the first case report of a child who had combined findings of autosomal dominant polycystic kidney disease, nephrocalcinosis, and an obstructing ectopic ureterocele.     

Pediatric Ureteroceles: Diagnosis,Management and Treatment Options

Objective

The aim of the study was to evaluate clinical characteristics of ureteroceles particularly for diagnostic and treatment challenges.

Methods

Data about patients treated for ureterocele in the two hospital clinics during 1996- 2009 are retrospectively evaluated.

Findings

There were 12 girls and 7 boys. Symptomatic urinary tract infection was found in twelve cases. Ureterocele was associated with duplex systems in eleven cases. Vesicoureteral reflux was detected in 4 patients. Bladder diverticulum complicated with ureterocele in 1 patient. Ultrasonography diagnosed ureterocele in 12 patients. Renal scarring was detected in 6 patients at the side of ureterocele. Fifteen patients showed varying degrees of hydro-ureteronephrosis. Surgical therapy included upper pole nephrectomy in 3 cases. Bladder level reconstruction was performed in 11 cases. Five patients were treated only by endoscopic incision. In the follow up period 4 patients showed long term urinary tract infections whereas 3 of them were treated endoscopically. Postoperative reflux was still present in two patients who were treated by endoscopic incision.

Conclusion

Ureterocele diagnosis and treatment show challenges. Urinary tract infection is important marker for urinary system evaluation. Preoperative management generally depends on a combination of diagnostic methods. Endoscopic incision needs serious follow up for postoperative problems.