Minimally Invasive Laser Treatment of Ureterocele

Abstract

Introduction: Ureterocelemay cause severe pyelo-ureteral obstruction with afebrile urinary tract infections in infants and children. Early decompressive treatment is advocated to reduce the risk of related renal and urinary tract damage. Endoscopic techniques of incision have been offered utilizing diathermic electrode. We adopted laser energy to release the obstruction of the ureterocele and reduce the need of further surgery. Our technique is described and results are presented, compared with a group of matched patients treated by diathermic energy. Materials and methods: Decompression was performed by endoscopic multiple punctures at the basis of the ureterocele. Holmium YAG Laser was utilized with 0.5–0.8 joule energy, through 8–9.8F cystoscope under general anesthesia. The control group received ureterocele incision by diathermic energy through pediatric resettoscope. Foley indwelling catheter was removed after 18–24 h. Renal ultrasound was performed at 1, 3, 6, and 12 months follow-up. Voiding cysto-urethrogram and radionuclide renal scan were done at 6–18 months in selected cases. Statistical analysis was utilized for data evaluation. Results: From January 2012 to December 2017, 64 endoscopic procedures were performed: 49 were ectopic and 15 orthotopicureteroceles. Fifty-three were in duplex systems, mostly ectopic. Mean age at endoscopy was 6.3 months (1–168). Immediate decompression of the ureterocele was obtained, but in five cases (8%) a second endoscopic puncture was necessary at 6–18 months follow-up for recurrent dilatation. Urinary tract infections and de novo refluxes occurred in 23.4 and 29.7% in the study group, compared to 38.5 and 61.5% in the 26 controls ( p < 0.05) . Further surgery was required in 12 patients (18%) at 1–5 years follow-up (10 in ectopic ureteroceles with duplex systems): seven ureteral reimplantation for reflux, five laparoscopic hemy-nephro-ureterectomy. Orthotopic ureteroceceles had better outcome. Secondary surgery was necessary in 13 patients (50.0%) of control group ( p < 0.05) . Conclusions: Early endoscopic decompression should be considered first line treatment of obstructing ureterocele in infants and children. Multiple punctures at the basis of the ureterocele, performed by low laser energy, is resulted a really minimally invasive treatment, providing immediate decompression of the upper urinary tract, and reducing the risk of further aggressive surgery.

De Novo Vesicoureteral Reflux Following Ureterocele Decompression in Children: A Systematic Review and Meta-Analysis Comparing Laser Puncture versus Electrosurgical Incision Techniques

“…Of these, 84 abstracts were excluded. Only six full-texts were considered relevant for eligibility [ 7 , 8 , 9 , 10 , 11 , 16 ]. One of these was further excluded as it consisted of adult patients [ 16 ].…”

“…One of these was further excluded as it consisted of adult patients [ 16 ]. Therefore, five studies were considered for systematic review [ 7 , 8 , 9 , 10 , 11 ], while four were included in the final meta-analysis [ 8 , 9 , 10 , 11 ]. The study by Haddad et al [ 7 ] was considered for the meta-analysis because it compared the watering-can method of LP of ureterocele versus all the conventional methods (including incision using cold-knife and ES incision).…”

“…Although the average age at surgery was non-uniform among the included studies, none of these studies demonstrated a significant difference in age at surgery among the two treatment groups. The type of collecting system was depicted by three studies [ 9 , 10 , 11 ], and the majority of the included subjects had a duplex system (in the renal unit subtending the ureterocele). The location of the ureterocele, whether intravesical or ectopic, was shown by all four studies [ 8 , 9 , 10 , 11 ].…”

“…However, the incidence of de novo VUR varies among these techniques. Ureteroceles managed via the LP technique are associated with a significantly lower incidence of de novo VUR as compared to those treated via ES [ 8 , 9 , 10 , 11 ]. Therefore, the use of the LP technique not only prevents UTIs by limiting vesicoureteral reflux in the ipsilateral renal unit but also provides a therapeutic advantage in terms of reducing the requirement of subsequent surgical procedures.…”

Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital

“…2,7 Modern treatment of ureteroceles, particularly ureteroceles in adults like present index case include minimally invasive endoscopic unroofing using resectoscopes or even endoscopic technique of multiple punctures at the base of ureterocele using Holmium laser. 2,8,9 Our centre is yet to have facilities for endoscopic intervention of ureterocele, hence we managed our case by open surgical repair. Open surgical repair of ureterocele has been previously studied.…”