Surgical Treatment For Ureterocele With Special Reference To Lower Urinary Tract Reconstruction

Main Category: Urology / Nephrology
Article Date: 02 Mar 2008 - 0:00 PDT

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UroToday.com- Shimada, et al in the December 2007 of The International Journal of Urology evaluated the surgical treatment for ureterocele with special reference to bladder reconstruction. They reviewed the medical records of 91 children who were diagnosed with a ureterocele and treated. The 91 patients spanned over 14 years. The initial treatment was a transurethral incision of the ureterocele. Of the patients who were incised, persistent reflux breakthrough urinary tract infection (UTI) or signs of bladder outlet obstruction due to a collapsed ureterocele wall underwent lower urinary tract reconstruction irrespective of the renal function with the involved ureterocele. The average follow-up was 5 years, ranging from 1.5 year to14 years.

The group found that after transurethral incision of the ureterocele, a total of 59 patients (65%) required lower urinary tract reconstruction. Four children underwent nephroureterectomy which was done during the bladder level reconstruction. All of these patients had follow-up voiding cystourethrography. Only one girl showed reflux at that follow-up voiding cystourethrography which subsequently disappeared on the next voiding cystourethrography study. Overall they found that voiding dysfunction was suspected in 8 patients and postoperative urinary tract infections occurred in 12 patients (20%) of those diagnosed with an ectopic ureterocele.

The group concludes that the primary objective for patients with ureteroceles, especially those which are ectopic in origin is to reconstruct the original pathology of the lower urinary tract. This is performed because it may give rise to reflux obstruction or abnormalities of urination. They go on to state that surgery at the bladder level is challenging however, the lower urinary tract reconstruction successfully corrects the vesicoureteral reflux and bladder outlet pathology under a cosmetically acceptable incision.

This study is important because it seems that our current experience shows that after ureterocele incision only 10% of patients require anything done further. Some would even advocate that in the light of a nonfunctioning system associated with a ureterocele that incision of a nonfunctioning moity has little effect in the future. This topic has been debated many times. There seems to be no full consensus of who would benefit from a heminephroureterectomy as compared to just incision of ureterocele alone. It seems in my experience that no matter which approach you take, whether it is incision alone or a laparoscopic heminephroureterectomy, it still falls that 10% of patients require reconstruction overall either due to refluxing of the lower pole moity which becomes new after decompression of ureterocele or that reflux occurs into the ureterocele or lower pole moity after endoscopic incision. This 10% that I have found in our practice differs extensively with the 65% found in this study. The type of incision that is made in the ureterocele alone might play a role in seeing reflux into the ureterocele component. Reflux into the previously non effected lower pole moity truly is a sign of bladder floor weakness and trigonal instability. It is my opinion that these patients with trigonal instability and weakness would benefit from lower urinary tract reconstruction.

Shimada K, Matsumoto F, Matsui F
Int J Urol. 14(12):1063-1067, December 2007
Reported by UroToday.com Contributing Editor Pasquale Casale, M.D

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