Systematic and meta-analysis of secondary procedures following an upper pole heminephrectomy or a ureterocele puncture as the initial treatment of ureterocele in a duplicated renal system
Sara Lobo, Post-CCT Fellow of Pediatric Urology, Jayaram Sivaraj, Senior House Officer, Wajid Jawaid, Specialist Registrar Pediatric Surgery, Peter Cuckow, Consultant Pediatric Urologist, Navroop Johal, Consultant Pediatric Urologist.
Great Ormond Street Hospital for Children NHS Foundation, London, United Kingdom.
Background: Management of duplex system ureteroceles (DSU) is variable and poses a challenge to pediatric urologists. Endoscopic ureterocele puncture is advocated by many surgeons as the primary treatment for all patients, regardless the type of ureterocele, presence of lower obstructive symptoms or upper moiety function. It remains unclear which primary approach is associated with higher reoperation rate. We assessed the need for secondary surgeries following primary endoscopic treatment (ET) of ureterocele or upper pole heminephrectomy (HN) in DSU. Methods:Pubmed articles were searched using the search terms: Upper pole heminephrectomy, Partial nephrectomy, Top-down, Bottom-up, Ureterocele treatment, Ureterocele puncture, Ureterocele incision, Duplex system, duplicated system. Titles and abstracts were reviewed and filtered by two authors independently according to PRISMA guidelines. Full texts of selected studies were obtained and the number of patients in both ET and HN groups were extracted. Secondary surgery was the primary outcome. Studies comparing HN with ET, as initial management reporting the primary outcome were included. Studies of ureteroceles in simplex systems were excluded. Non-comparative studies or studies reporting standard initial management for all patients as a default were excluded. Studies with missing data and those performed in adults were excluded. Markedly heterogeneous groups that precluded the comparison in terms of management of the ureterocele, for example a well-functioning upper moiety or the presence of a ceco-ureterocele, were also exclusion criteria. Meta-analysis was performed using a binary random-effects Der-Simonian and Laird model, generating overall odds-ratios, confidence intervals and heterogeneity. Results:Initial search identified 6943 studies from which 8 met all inclusion criteria. No RCTs were identified and all studies were observational and retrospective. Meta-analysis revealed that further surgery was 5 times more likely to be required in the group of patients treated with ET compared to HN (OR of 5.826, 95% CI 2.9 to 11.8, p <0.001) - see attached figure (Fig.1-Forest plot). Additional surgeries in the ET cohort included: repeat puncture, ureterocelectomy with ureteric reimplantation and upper poles heminephrectomies; for the HN group they were lower urinary tract reconstruction and ureteric reimplantation.
Conclusions:Our data strongly indicates that in DSU the need for additional surgery is significantly higher following primary ET compared to HN. To our knowledge this is the first meta-analysis in the literature comparing these two primary approaches with regards to the need for secondary surgeries. Limitations include that the meta-analysis is based solely on retrospective observational studies and this study is not designed to demonstrate the success of one technique over the other or to conclude which of the procedures should be adopted to treat DSU. It does however enhance the importance of a customized and pragmatic approach, not supporting a single universal initial management.
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