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 ev olved from complicated major surgery to minimally invasive endoscopic treat ment. Because of the high rate of secondary surgery in some recently report ed series, an upper pole partial nephrectomy is again recommended as the pr ocedure 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 treat ed in our service with primary endoscopic puncture of a ureterocele. The me an age of the patients was 1.1 +/- 4.3 (mean a SD) years. Mean follow-up wa s 6.1 +/- 2.4 years. Antenatally ultrasound detected the ureterocele in 5 ( 14%) patients, fetal hydronephrosis leading to the postnatal diagnosis in 1 3 (38%), and 16 (48%) children presented with symptoms of urinary tract inf ection (UTI). The ureteroceles presented as part of renal duplication in 31 patients (91%), 3 (9%) in a single system and 1 child had bilateral ureter oceles of a duplex system. Twenty (58%) children had intravesical ureteroce les and the remaining 14 (42%) ectopic ureteroceles. Very poorly functionin g upper pole moiety presented in 26 (75%) of the cases and nonfunctioning u pper poles in 5 (14%). Twenty of 34 children (58%) had initial vesicoureter al reflux (VUR) to the lower moiety, either to the ipsi (60%) or contralate ral kidney (40%). A cold knife incision was carried out in 4 (11.7%), punct ure by a 3-french Bugbee elctrode in 20 (58%), and the stylet of a 3-french ureteral catheter was utilized to puncture the ureterocele in the remainin g 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 impro ved 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 recurren t UTI, required surgery. Three underwent ureteric reimplantation and anothe r 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 de veloped VUR to the upper moiety following the puncture of the ureterocele, 3 after cold knife incision and 3 after simple puncture. In 2, submucosal T eflon 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 p oles, 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 fol low-up, Copyright <(c)> 2001 S. Karger AG. Basel.