Retrograde incision from orifice technique for endoscopic incision of ureterocele: 15 years of outcomes
Lauren Corona, MD, Andrew Lai, MD, Theresa Meyer, MS, RN, Ilina Rosoklija, MPH, Dennis Liu, MD, Max Maizels, MD, Earl Cheng, MD, Bruce Lindgren, MD, David Chu, MD, MSCE, Emilie Johnson, MD, MPH, Edward Gong, MD.
Lurie Children's Hospital, Chicago, IL, USA.
Background: Management of obstructing ureterocele often includes endoscopic incisions that can be challenging secondary to uncertainty in anatomic landmarks and thus risk devastating complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele meatus and extends it retrograde to proximal to the bladder neck (Figure). With over 15 years of experience in performing our retrograde incision from orifice (RIO) technique, the aim of this study was to examine post-operative outcomes and the risk of failure after RIO compared to non-RIO transurethral incision (TUI) of ureterocele techniques.
Methods: A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007-2021 was conducted. Patients with no follow-up were excluded. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI techniques. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was the composite failure outcome of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups.
Results: Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Patients were 66% female, 60% non-Hispanic white, and 66% privately insured. Ureteroceles were
75% ectopic, 87% duplex, and incised for an indication of non-infectious obstruction 84% of the time. Median follow-up was 33 months (IQR 17-59). The RIO group had a shorter operative duration (27 vs 35 minutes, p=0.021). Incisions were performed by 11 surgeons, and the majority of incisions (81%) were performed by 5 surgeons that performed both RIO and non-RIO incisions. Only one operative note described lack of success with attempted RIO, and non-visualization of the orifice was described in 3 operative notes. Post-operative outcomes including primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p=0.27; composite failure 54% RIO vs 69% non-RIO, p=0.15) (Table). On multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.979, p=0.965) or composite failure (RIO aHR 0.801, p=0.458) between incisions.
Conclusions:In analyzing this 15-year experience of TUI ureterocele performed for obstructing ureterocele in infants, our RIO technique shows similar success to non-RIO endoscopic incisions. In addition, by using predictable anatomic landmarks, the RIO technique is attractive and simple to perform as evidenced by the short operative duration, broad applicability, and high uptake within our division. These findings suggest that, given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for ureterocele decompression.
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