PEDIATRIC UROLOGY

Evolution of Endoscopic Management of Ectopic Ureterocele: A New Approach
Kajbafzadeh A, Salmasi AH, Payabvash S, Arshadi H, Akbari HR, Moosavi S.
Department of Urology, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran
J Urol. 2007; 177: 1118-23; discussion 1123

• Purpose: We report the evolution of endoscopic treatment of ectopic ureteroceles from the unroofing technique to a novel approach using concomitant ureterocele double puncture and intraureterocele fulguration. We also compare the results of different endoscopic modalities at a single center.
• Materials and Methods: We reviewed the records of 46 children with ectopic ureteroceles who were treated endoscopically between 1995 and 2005. The patients were divided into 2 main groups. Group 1 included 17 patients who underwent common endoscopic treatments, including ureterocele incision (4 patients), single ureterocele puncture (4), and single puncture with insertion of a Double-J stent (9). Group 2 included 29 children who underwent ureterocele double puncture and fulguration of the anterior and posterior walls of the collapsed ureterocele after insertion of a Double-J stent into both punctured sites. We also managed concomitant vesicoureteral reflux by endoscopic injection of tricalcium phosphate ceramic into the subureteral region.
• Results: Total success rates in group 1 were 0%, 25% and 33% in patients who underwent ureterocele incision, single ureterocele puncture and single puncture with insertion of a stent, respectively. Total success rate in group 2 was 90% (p<0.05). New onset vesicoureteral reflux developed in 8 patients (47%) in group 1, of which 6 were in ureterocele moieties, and in 8 patients (28%) in group 2, with none in a ureterocele moiety (p<0.01). A total of 13 patients (76%) in group 1 required open surgical intervention, compared to 3 (10%) in group 2 (p<0.05).
• Conclusions: This new endoscopic approach is highly effective in the treatment of children with ectopic ureteroceles.
  
  
• Editorial Comment
  The treatment of ureteroceles has for the last decade and a half has swung towards endoscopic incision with subsequent management as necessary. Success rates vary significantly and there are articles such as Ben Meir et al. (1) suggesting that intravesical ureteroceles do very well with incision techniques while ectopic ureteroceles do not have such good results.
  I think this manuscript is remarkable in that only 10% of the patients with the new approach needed open surgery and the remainder of the ectopic ureteroceles could be managed endoscopically. Preoperative and postoperative reflux can be a problem. These authors successfully managed it with injection therapy in many patients. There is concern that the ureteroceles have poor muscular backing and that this procedure in the long-term may lead to bladder diverticula. One would expect with 8 years follow up in some of their patients that perhaps some of those would have been seen by now. Presumably, the longest term follow up patients were the ones with incisions were not the ones with the two incisions and the double-J stent placement.

Reference

1. Ben Meir D, Silva CJ, Rao P, Chiang D, Dewan PA: Does the endoscopic technique of ureterocele incision matter? J Urol. 2004; 172: 684-6.

Dr. Brent W. Snow
University of Utah Health Sci Ctr
Division of Urology
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu