SUPERIORITY OF NEW URETEROCELE PUNCTURE TECHNIQUE LEADS TO DECREASED RATES OF DE NOVO VUR AND SUBSEQUENT SURGERY WITH LASTING RESULTS
Joseph A. Haddad, MD1, Nathan Rademaker, MD1, Hubert Greger, MD2, Bradley P. Kropp, MD1, Blake W. Palmer, MD1, Dominic Frimberger, MD1.
1University of Oklahoma, Oklahoma City, OK, USA, 2Department of Pediatric Surgery, Hospital of the Third Order, Germany.
It is now common practice to manage an obstructing ureterocele endoscopically. The goals of endoscopic ureterocele management are to relieve renal obstruction, prevent UTI, minimize surgical morbidity and avoid creating de novo vesicoureteral reflux (VUR). The classic incision achieves decompression but often results in de novo VUR. At our institution, we primarily use the ‘watering can’ puncture technique utilizing multiple small laser punctures instead of creating a single large incision in the ureterocele as classically described. Previously, in short follow up, this was shown to be equal to classic incision techniques with decompression of the obstructed system and superior in the incidence of de novo VUR and subsequent surgeries for VUR. Our objective is to assess if this technique’s outcomes were superior after the intial pilot testing phase and durable in long term follow up.
We retrospectively reviewed 57 consecutive endoscopic ureterocele procedures done at our institution since December 1999 by 3 pediatric fellowship trained surgeons. Ureterocele punctures were performed through a 9.5Fr pediatric offset cystoscope. A 275 µ holmium laser fiber was used to make 10 to 20 puncture holes in the intravesical portion of the ureterocele, creating a watering can appearance. Patients who underwent an endoscopic incision or watering can puncture procedure had their records reviewed for preoperative radiological and clinical data, operative description, and post-operative radiological and clinical outcomes. Follow up data was collected on infection, de novo VUR and the need for further treatment and surgery.
Of the 57 patients who underwent endoscopic ureterocele management, 34 underwent puncture versus 21 patients who underwent incision. The average age at endoscopic surgery was 5.7 months of age for the puncture group vs. 4.9 for the incision group. Median follow up was 3.31 years (0.19 - 7.46) in the puncture group vs. 5.09 years (1.1 - 13.2) in the incision group. Both groups had similar rates of ureterocele decompression (88% vs. 90%; p>0.05) and improvement in hydronephrosis (82% vs. 81%; p>0.05). The puncture group had a statistically significant decreased rate of de novo VUR (32% vs. 67%; p<0.05) and subsequent surgery due to de novo VUR (38% vs. 71%; p<0.05).
Our study shows that the endoscopic watering can procedure successfully decompresses the obstructing ureterocele and its associated hydronephrosis as good as the incision technique. However, compared to the incision, this puncture technique results in a decreased incidence of de novo VUR and ultimately in fewer invasive procedures for the patient. This update of our previous investigation demonstrates the superiority and lasting effects of this novel technique.
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