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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1169-1174
The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult


1 Institue of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, India
2 Shambu Nath Pandit Hospital, Kolkata, India

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Date of Web Publication8-Nov-2011
 

   Abstract 

Endoscopic incision is a good management option for orthotopic ureterocele. But most of the literature has shown its efficacy only in children. We have done this retrospective study to evaluate the safety and efficacy of endoscopic incision of orthotopic ureterocele in adults. From March 2004 to January 2008, at our center, 26 adults underwent transurethral, transverse incision of an ureterocele. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition in adults. Unilateral ureterocele was present in 24 patients and two patients had bilateral ureterocele. One patient had associated upper tract stones. Three patients had associated stones in ureterocele. Transurethral, transverse incision of ureterocele was given in all patients. The mean postoperative hospital stay was 50.5 h. Twenty-three patients were available for follow-up at three, six and 12 months. All patients were symptom free. At three months ultrasound and intravenous urography revealed no residual ureterocele but four patients showed residual hydronephrosis, but with a decrease in the grade indicating decompression. Micturating cystourethrography revealed vesico-ureteral reflux (VUR) in two patients and the reflux persisted in one patient even at 6 months. We conclude that in adults, management with endoscopic incision of orthotopic ureterocele is safe and effective. VUR may occur in a few cases.

How to cite this article:
Vijay MK, Vijay P, Dutta A, Gupta A, Tiwari P, Kumar S, Bera M K, Das R K, Kundu A K. The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult. Saudi J Kidney Dis Transpl 2011;22:1169-74

How to cite this URL:
Vijay MK, Vijay P, Dutta A, Gupta A, Tiwari P, Kumar S, Bera M K, Das R K, Kundu A K. The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 12];22:1169-74. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1169/87227

   Introduction Top


Ureterocele is cystic dilation of the terminal part of the ureter located within the bladder or the urethra or both. In the majority of cases, it is accompanied by a double-collecting system and in children, it affects females in a ratio 6:1. Single system intravesical ureterocele occurs most frequently in males and adults. The incidence of ureterocele at autopsy is estimated to be 1/500 to 1/4000. [1],[2] Urinary tract infection has been the most common clinical presentation. Ureterocele has been debated for many years, particularly regarding the treatment options. The goals of treating ureterocele are to prevent infection, preserve function, and maintain continence while preserving the possibility of a reconstructive procedure in the future as necessary. Many studies during the last two decades favored the endoscopic approach for intravesical, ectopic, and single and duplex systems. Some of these studies offered different methods to prevent postoperative vesicoureteral reflux (VUR) and bladder outlet obstruction, and suggested ways to facilitate optimal upper tract decompression. [3],[4],[5],[6],[7],[8],[9],[10],[11] But most of the literature has shown its efficacy in children. We evaluated the effectiveness of transurethral, transverse endoscopic incision of orthotopic ureterocele in adult. Outcomes included relief of obstruction, prevention of infection/reflux, and need for subsequent surgery.


   Materials and Methods Top


We reviewed the records of 26 adult patients (28 ureteroceles) who were treated with transurethral, transverse endoscopic incision of orthotopic ureterocele from March 2004 to January 2008. Follow-up ranged from six to 12 months (mean 8). Modes of presentation and radiographic studies were evaluated. Mode of presentation was defined as symptomatic if there was pain or infection. Single system ureterocele was confirmed by both ultrasound and intravenous urography. Associated VUR was documented with voiding cystourethrography. All patients were followed-up at three, six and 12 months; at three months with detailed clinical history, urine routine examination, urine culture and sensitivity, ultrasound, intravenous urography, and voiding cystourethrography; at six and 12 months with detailed clinical history, urine routine examination, urine culture, and sensitivity in all patients and ultrasound, intravenous urography in patients who had residual hydronephrosis and voiding cystourethrography in patients in whom postoperative reflux was present. We recorded the number of patients in whom the symptoms persisted, who had residual ureterocele and/or hydronephrosis and those in whom reflux developed after incision and those in whom postoperative reflux resolved spontaneously.

Incision was performed using an endoscope and Collins knife. Cutting current level was set high enough to ensure a clean incision. The bladder was maintained mild to moderately distended to comfortably incise ureterocele. It achieves ureterocele distention as much as possible, which in turn helps to ensure a low transverse (smiling) incision, preserving a better decompressed ureterocele flap valve.

The puncture was made low on the front ureterocele wall to establish an antireflux flap valve of the collapsed ureterocele. After the procedure, frusemide 40 mg IV was given to ensure visualization of urine efflux, confirming adequate drainage.


   Results Top


Over the past four years, 26 patients (16 female, 10 male) were treated in our series with primary endoscopic incision of an ureterocele. The mean age of the patients was 26.8 (mean) years. Unilateral single system ureterocele was present in 24 patients (92.31%) two patients had bilateral ureterocele (7.69%). Mean follow-up was eight months. Eighteen (69.23%) adults presented with symptoms of urinary tract infection (UTI) and eight (30.77%) presented with pain abdomen. Ultrasound [Figure 1] and intravenous urography [Figure 2] detected the ureterocele and mild to moderate grade hydroureteronephrosis in 26 patients. No patient revealed VUR in voiding cystourethrography. One (3.84%) patient had associated upper tract stones. Three (11.53%) patients had associated stones in ureterocele [Figure 2]. The mean operative time in ureterocele incision was seven min and in those with associated stones needing stone removal, the incision time was 16 min. The mean postoperative hospital stay was 50.5 h. Twenty-three patients with 25 treated ureteroceles were available for follow-up at three, six and 12 months. All patients were symptom free. At three months ultrasound and intravenous urography revealed no residual ureterocele but four kidneys with treated ureteroceles had residual hydronephrosis, but with a decrease in the grade indicating relief of obstruction, at least partial.

Voiding cystourethrography revealed vesicoureteral reflux in two patients. In one adult the reflux resolved spontaneously, and none of them presented with UTI, but reflux persisted in one patient in micturating cystourethrography at six months, which is found to be persisting also at 12 months [Table 1].
Figure 1: Ultrasound film showing ureterocele.

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Figure 2: Intravenous urography, single system with bilateral ureterocele, and filling defect (stone) in right ureterocele.

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Table 1: Demographic data and findings on various parameters.

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   Discussion Top


Ureterocele is a cystic dilatation of the intravesical ureter that is most commonly observed in females and children, and usually affects the upper moiety of complete pyeloureteral duplication. According to their position, ureteroceles are divided into intravesical (orthotopic), when the ureterocele is completely contained inside the bladder, and extravesical when part of the cyst extends to the urethra or bladder neck. [12] The goals of the endoscopic technique are to decompress the obstructive uropathy while minimizing the operative morbidity. Unroofing, puncture, laser incision, and Collins knife incision are methods used to decompress the ureterocele.

The decompression rate in our series of 100% compares favorably to others in which the rate varies from 76% to 100%. [3],[4],[10],[11],[13],[14] Many different endoscopic approaches have been described, which all aim to improve subsequent surgical success. However, there are no prospective randomized controlled studies and, thus, a precise statistical analysis of the difference between the methods is not possible. Also, comparison of studies is limited because the different ureterocele types were not categorized in all studies. However, it is reasonable to compare published results in 2 subsets, namely, intravesical and ectopic ureterocele associated with double collecting systems. [Table 2] lists the various ureterocele incision techniques, including puncture, using a cold knife, Bugbee electrode or laser incision, the site of ureterocele incision, and the effect on de novo vesicoureteral reflux and renal decompression. To prevent postoperative VUR some groups perform a transverse incision just above the base of the ureterocele. [3],[5],[15],[16] However, Cooper et al suggest that "a direct puncture with no lateral side movement using a 3Fr Bugbee electrode is currently recommended" to prevent reflux into the duplex segment. [10] Husmann et al used a 3Fr Bugbee electrode to make a low transverse incision or puncture in intravesical and ectopic ureteroceles. [11] Each group found their recommended treatment modality equally efficacious for all types of ureteroceles. A single system intravesical ureterocele is a completely different entity than a ureterocele associated with a duplex system or VUR. Patients with a single system ureterocele were much less likely to require an open procedure than those with an associated duplex system.

Theoretically, intravesical ureterocele are easier to decompress while preserving a flap valve than ectopic ureterocele. This observation may be due to the poor bladder support in ectopic ureterocele, which results in a higher incidence of reflux. [12] Accumulation of more data as well as progress in understanding trigonal anatomy in patients with ureterocele may help to clarify this issue. [4]
Table 2: Comparison of operative techniques for ureterocele management.

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With the use of modern endoscopic techniques, children with intravesical and single system ureterocele require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. [4],[10],[11],[14],[15] The rate of additional surgery after elective endoscopic puncture of an orthotopic ureterocele ranges from 4% to 23%. We have done our study in intravesical and single system ureterocele in adults which revealed good result and none of them required another operation.

The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureterocele require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles. [4]

Some surgeons advocate polytetrafluoroethylene injection into the bladder wall after puncture to prevent reflux. [17],[18] Orthotopic ureterocele has much different outcomes than ectopic ureterocele. The reflux rate of orthotopic after treatment is in the range of 4%-50% in other studies. [4],[5],[8] Our study revealed reflux rate 8% that persisted only in 4% of cases at six months.

The treatment of single system ureterocele is best accomplished by a single low puncture. This puncture should be directed to the lower front aspect of the ureterocele. One must be careful not to puncture too low with a resultant hole in the bladder wall below the ureterocele. This problem is avoided by remaining parallel to the bladder floor. Furthermore, when an ureterocele wall appears thickened and postoperative reflux develops, one should consider the missed diagnosis of pseudoureterocele, an ectopic ureter in which distal dilatation elevates the trigonal anatomy, perhaps mimicking ureterocele. [19]

In conclusion, endoscopic incision allows a precise incision and decompression of the ureterocele. It has also been shown to be a single treatment for the drainage of orthotopic systems in adults. In addition to these benefits, patients enjoy the advantage of all other endoscopic approaches and lower operative morbidity. VUR occurs in very few cases but in most of them it resolves spontaneously. Our results indicate that endoscopic puncture has a definite role in the management of ureterocele in adults, which is safe and effective.

In most cases the endoscopic approach completely eliminates the need for major open surgery. As operative technique improves, more patients should be able to attain a complete cure by this minimally invasive approach.

 
   References Top

1.Uson AC, Lattimer JK, Melicow MM. Ureteroceles in infants and children: a report based on 44 cases. Pediatrics 1961;27:971.  Back to cited text no. 1
    
2.Campbell M. Ureterocele; a study of 94 instances in 80 infants and children. Surg Gynecol Obstet 1951;93:705.  Back to cited text no. 2
    
3.Coplen DE. Neonatal ureterocele incision. J Urol 1998;159:1010.  Back to cited text no. 3
    
4.Haag MJ, Mourachov PV, Snyder HM, et al. The modern endoscopic approach to ureterocele. J Urol 2000;163:940.  Back to cited text no. 4
    
5.Shekarriz B, Upadhyay J, Fleming P, et al. Long-term outcome based on the initial surgical approach to ureterocele. J Urol 1999;162:1072.  Back to cited text no. 5
    
6.Tank ES. Experience with endoscopic incision and open unroofing of ureteroceles. J Urol 1986;136:241.  Back to cited text no. 6
    
7.Marr L, Skoog SJ. Laser incision of ureterocele in the pediatric patient. J Urol 2002;167:280.  Back to cited text no. 7
    
8.Jayanthi VR, Koff SA. Long-term outcome of transurethral puncture of ectopic ureterocele: Initial success and late problems. J Urol 1999; 162:1077.  Back to cited text no. 8
    
9.Singh SJ, Smith G. Effectiveness of primary endoscopic incision of ureteroceles. Pediatr Surg Int 2001;17:528.  Back to cited text no. 9
    
10.Cooper CS, Passerini-Glazel G, Hutcheson JC, et al. Long-term followup of endoscopic incision of ureteroceles: intravesical versus extravesical. J Urol 2000;164:1097.  Back to cited text no. 10
    
11.Husmann D, Strand B, Ewlat D, Clement M, Kramer S, Allen T. Management of ectopic ureterocele associated with renal duplication: a comparison of partial nephrectomy and endoscopic decompression. J Urol 1999;162:1406.  Back to cited text no. 11
    
12.Glassberg KI, Braren V, Duckett JW, et al. Suggested terminology for duplex systems, ectopic ureters and ureteroceles. Report of the Committee on Terminology, Nomenclature and Classification, American Academy of Pediatrics. J Urol 1984;132:1153.  Back to cited text no. 12
    
13.Pesce C, Musi L, Campobasso P, Belloli G. Endoscopic and minimal open surgical incision of ureteroceles. Pediatr Surg Int 1998;13:277.  Back to cited text no. 13
    
14.Pfister C, Ravasse P, Barret E, Petit T, Mitrofanoff P. The value of endoscopic treatment for ureteroceles during the neonatal period. J Urol 1998;159:1006.  Back to cited text no. 14
    
15.Di Benedetto V, Morrison-Lacombe G, Bagnara V, Monfort G. Transurethral puncture of ureterocele associated with single collecting system in neonates. J Pediatr Surg 1997;32:1325.  Back to cited text no. 15
    
16.Snyder HM 3 rd . Endoscopic treatment of ureteroceles. In: Smith AD,(ed.) Smith's Textbook on Endourology.: Quality Medical Pub., chapt. 87, 1996;1376-85.  Back to cited text no. 16
    
17.Yachia D. An entirely endoscopic treatment for simple ureteroceles in nonduplicated systems: a preliminary report. J Urol 1988;140:815.  Back to cited text no. 17
    
18.Viville C. Endoscopic treatment of ureterocele and antireflux injection with Teflon paste. Eur Urol 1990;17:321.  Back to cited text no. 18
    
19.Gill B. Ureteric ectopy in children. Br J Urol 1980;52:257.  Back to cited text no. 19
    

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Correspondence Address:
Mukesh Kumar Vijay
Assistant Professor, IPGME & R, Kolkata
India
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PMID: 22089776

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