PUNCTURE OF PROLAPSED URETEROCELE AT BEDSIDE WITHOUT ANESTHESIA OR SEDATION
Donald H. Nguyen, MD, FAAP, Christopher Brown, MD.
Dayton Children's Hospital and Nationwide Children's Hospital
Background: Prolapsed ureterocele presenting in the early age postnatally as an introital mass between the labia represents an emergent situation due to obstruction of the urethra and bladder neck. Classically, the bladder is drained with a catheter to bypass the ureterocele and surgical intervention is undertaken in an operative theater under general or spinal anesthesia. We report 3 cases of prolapsed ureterocele which underwent puncture at bedside without anesthesia or sedation with the babies in an awake state and reviewed their clinical courses.
Methods: The charts of 3 baby girls were reviewed to establish the diagnoses and clinical courses. All 3 girls were born with a prenatal diagnosis of a ureterocele associated with a duplex kidneys and ureters on the right (2) and on the left (1). All patients underwent evaluation with VCUG and renal US along with prophylaxis with oral Amoxicillin pre and post puncture.
Results: All 3 patients developed unexpectedly prolapse of the ureterocele at age 4 weeks (2) and 8 wks (1), as an inter-labial mass with the crescent shape urethral meatus anterior to the ureterocele. One pt had US evaluation of the mass to ensure that it was cystic in nature. Puncture was carried out with a hand held high temp cautery pen with the patients awake without anesthesia (general, spinal, or topical) or sedation. An exact location of puncture was chosen to ensure decompression and to ensure the puncture hole to be returned to the bladder at a most desirable position intravesically. Post puncture, all patients genitalia returned to normal anatomy within 2 weeks on exam. Prior to puncture, 2 pts had no VUR and 1 pt had grade 1 VUR on the side of the ureterocele. Post puncture, no pts developed VUR. One pt underwent upper pole heminephrectomy and ipsilateral lower pole UPJ repair as definitive treatment and 2 pts have not needed any further surgery along with evidence of ureterocele decompression and improvement in hydronephrosis, with follow up of 58, 54, and 9 months respectively.
Conclusion: Prolapsed ureterocele can be punctured easily, quickly, and safely with no anesthesia or sedation needed, which has not been reported previously. The ureterocele wall seems to lack any sensory innervation. A geometric determination of the puncture site is crucial to ensure the puncture hole to be in an ideal location when it returns to the bladder to avoid reflux and to achieve decompression of the ureterocele and hydronephrotic moiety.
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