Predictive Factors of Transurethral Incision Definitiveness for Ureteroceles in Pediatric Patients: A Retrospective Review
Brian R. Smith, MS, Courtney J. Smith, BS, Kritika Sharma, BS, Kunj R. Sheth, MD.
Stanford University School of Medicine, Stanford, CA, USA.
BACKGROUND: As a congenital anomaly, ureteroceles occur in 1 in 4000 children, and are usually diagnosed prenatally. Initial management options include early transurethral incision (TUI) of ureterocele versus observation with the option for lower urinary tract reconstruction once the patient is older. Given the lack of definite consensus on the optimal management of congenital ureteroceles, we sought to evaluate the management and outcomes of ureterocele patients undergoing initial treatment with TUI in our institution's database.
METHODS: We retrospectively evaluated 120 pediatric patients who were diagnosed with congenital ureterocele between 1993-2021 at our institution. Demographic and clinical information were obtained through chart review. Data was analyzed using Fisher's exact tests, t-tests, and logistic regression with a significance threshold of p≤0.05. The primary outcome of ureterocele management was TUI definitiveness, defined by no further need for surgical intervention.
RESULTS: Of the 120 patients (39 boys, 81 girls) with ureteroceles, 75 patients met our inclusion criteria of undergoing initial TUI ureterocele. Post-TUI follow-up lasted a median of 3.13 years (range 0 - 15.3 years). Patient outcomes are summarized in Figure 1. Surgery was definitive in 51/75 patients (68%) with no further surgical interventions. Only 2/51 (4%) developed postsurgical complications, with one patient developing new daytime incontinence and another experiencing new recurrent urinary tract infections. The rate of post-TUI de novo vesicoureteral reflux was 6/75 (8%). Rate of ever developing a febrile urinary tract infection after initial TUI was 25/75 (33%). 96% of patients were on prophylactic antibiotics during the first year after initial TUI.
24 patients required additional surgeries after initial TUI. 11/24 (46%) were managed with repeat TUI and did not require more invasive open or laparoscopic surgery. 12/24 (50%) had a post-TUI ureteral reimplantation and 1/24 (4%) underwent a post-TUI heminephrectomy. These second procedures were definitive for 21/24 patients (87.5%). Of the 3 patients who required a third procedure, TUI was performed in 2/3 (67%) and ureteral reimplant in 1/3 (33%).
We performed Fisher's exact tests to measure possible correlative factors for initial TUI definitiveness, which are summarized in Table 1. Simplex system was a significant predictor of TUI definitiveness. Prior urinary tract infection and electrocautery technique were both associated with increased risk for needing additional surgeries after TUI.
CONCLUSIONS: Initial TUI was a definitive procedure for the majority of our pediatric ureterocele patients, a higher success rate compared to other cohorts. Patients with a simplex system were more likely to have a definitive first TUI than patients with duplex systems (85% vs 62% definitive, respectively). Although not statistically significant, our data suggest prior UTI and the use of electrocautery are both associated with needing additional surgeries.
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