Endoscopic balloon dilatation of primary obstructive megaureter: method standardization and predictive prognostic factors

Abstract

The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon dilatation (EHPBD) is indicated when symptoms, increasing dilatation and progressive renal damage are recorded, particularly in children younger than one year of age. We identified and described endoscopic prognostic factors predicting the success or failure of endoscopic dilatation. Thirty-eight patients (33 M;5 F) with POM from 2005-2018 were included. Diagnosis was based on US distal ureter dilatation (>7 mm), obstructive MAG-3 diuretic renogram and absence of vesicoureteral reflux (cystography). 24 patients were under 1 year of age. All patients underwent cystoscopy and high-pressure balloon dilatation with 3,5 Fr dilating balloon, after ascending pyelography. Median follow-up was of 6.5 years. We identified characteristics with poor prognosis: stenotic punctiform ureteral ostium and/or ostium located in a bladder diverticulum (9 pts) and stenotic tract longer than 1 cm (5 pts). The patients with a stenotic tract shorter than 1 cm (18 pts) were divided into two groups: <5 mm (5 pts) and between 5 and 10 mm (13 pts) showed a good response to dilatation. Endoscopic evaluation of ureteral ostium with pneumatic dilatation when possible is a useful diagnostic and therapeutic solution for POM treatment, especially under one year of age. EHPBD is effective in short stenotic tracts (<5 mm). It may also be repeated with good results in intermediate stenotic sections (5 mm-1 cm). According to our preliminary results, the procedure is more effective if performed earlier (3-7 months of life). Greater cohort and longer follow-up are needed to verify the stability of these results.

High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review

“…Out of 13 studies included, ten reported routinely using a double-J stent for three weeks to 3 months after HPBD [ 10 , 11 , 13 , 15 , 16 , 18 – 22 ]. Two authors [ 12 , 14 ] reported that a double-J was not inserted routinely. Faraj S et al [ 17 ] compared those with and without double-J after HPBD.…”

“…Out of the 13 studies, five [ 10 , 14 , 19 – 21 ] reported using a single perioperative antibiotics prophylaxis only, while five [ 13 , 15 , 17 , 18 , 22 ] reported continuing antibiotics as chemoprophylaxis after HPBD. Most used prophylaxis until the double- J stent was removed, while Casal Beloy et al [ 13 ] reported continuing antibiotics for only 5 days.…”

“…The average scores of the included studies ranged from 11 to 16. The study by Romero et al [ 21 ] had the minimum risk of bias and the study by Chiarenza et al [ 14 ] had the maximum risk of bias. The risk was high in eight studies [ 10 , 12 – 16 , 18 , 22 ] and moderate in the remaining five studies [ 11 , 17 , 19 – 21 ].…”

“…The commonest protocol seemed to be to screen those patients with postoperative UTIs after the stent removal. The rate of postoperative VUR was reported in 25/319 (7.8%) patients in 11 studies [ 10 – 12 , 14 – 17 , 19 – 22 ].…”

“…Most of the studies analysed here [ 10 , 11 , 13 , 15 , 16 , 18 – 22 ] reported routinely placing a double-J stent after balloon dilatation and keeping it in for three weeks to 3 months. Chiarenza et al and Capozza et al [ 12 , 14 ] reported that no double-J stents were placed after high pressure balloon dilatation. Interestingly, Faraj S et al [ 17 ] compared those with and without double-J stents after high-pressure balloon dilatations reports and showed similar success rates of balloon dilatation in those with double-J stent (75%) and those without (81%) but more complications in those with double-J stent.…”