A review of ninety-two obstructive megaureters in children

Objectives: The evolution of clinical presentation, age of surgery and ther apeutic approach of obstructive nonrefluxing megaureters (OMU) in children throughout the years has been retrospectively evaluated. Methods: 78 childr en with 92 stenotic ureterovesical junctions (UVJ) were reviewed. 66 underw ent surgery at a median age of 20 months, after a median of 10.5 months of conservative treatment with prophylactic antibiotics. 21 OMU were diagnosed prenatally, 71 because of symptoms at later age. 15 ureters (12 children) (24% in the prenatal, 14% in the second group) were treated in a conservati ve way for 2 years with antibiotics. In the prenatal group 33% needed a rei mplantation with tailoring and 10% without tailoring while in the other gro up the figures are reversed: 39% without and 21% with tailoring. 28% in the prenatal group and 17% of the second group were reimplanted at a mean of 1 5 months after a primary cutaneous ureterostomy. Three of 5 ureteroceles we re treated by endoscopic incision; 4 had an immediate nephroureterectomy. T he mean follow-up is >70 months. Results: By prenatal diagnosis the number of conservatively treated cases increased from 14 to 24%. Indications for s urgery remained unchanged: recurrent infection and poor kidney function. Bo th approaches resulted in stabilization of pretreatment renal function; nea rly half of the DMSA scans showed a R:L difference of > 20% at follow-up. U reterostomy for infected deteriorating kidneys rapidly ameliorated the func tion and resulted in shrinking of the ureteral diameter making tailoring at reimplantation unnecessary. One of the 3 endoscopically incised ureterocel es required later reintervention. Conclusions: Male:female (3:1), left:righ t (2:1) prevalence and high associated urological (30%) and nonurological ( 19%) pathology is found. Unsatisfactory reliability of tests for obstructio n diagnosis and a referral bias explains the larger number of conservativel y treated ureters in the prenatal group. Despite prenatal diagnosis, the ag e for surgery was not altered since the indications remained identical. Mos t OMU can be treated by a simple or tailored reimplantation of the ureter a fter resection of the stenotic segment. A temporary ureterostomy in small c hildren with refractory infections restores function and avoids the necessi ty for tailoring at final reconstruction. One of 3 endoscopically incised u reteroceles needed surgery at a later stage. DMSA shows stable function aft er reimplantation.