Should a Refluxing Internal Diversion Be Considered a Temporizing Procedure? Extended Follow-up and Outcomes After Side-to-Side Ureterovesicostomy for Primary Obstructive Megaureter in Young Children.

PURPOSE: We describe long-term outcomes, including UTIs and need for reimplantation, after ureterovesicostomy (UV) as a lasting surgical procedure for children with primary obstructive megaureter (POM). MATERIALS AND METHODS: Children referred to our institution between 2016 and 2023 who underwent refluxing UV were analyzed. POM was defined as hydroureteronephrosis with distal ureteral dilatation > 7 mm and a negative workup for other etiologies of hydronephrosis. We assessed for surgical outcomes, complications, rate of UTI, and improvement in upper tract dilatation. Statistical analyses assessed for change in hydronephrosis metrics over follow-up. RESULTS: Among 183 patients diagnosed with POM, 47 (24%) underwent UV. Median age of presentation, surgery, and follow-up was 2, 9, and 43 months, respectively. A total of 7 patients developed 30-day complications: Clavien-Dindo grade 1 in 2 (transient urinary retention) and grade 2 in 5 (UTIs). During monitoring 14 (30%) developed UTIs and 7 (15%) required ureteral reimplant or UV takedown. After surgery there was a significant decrease in the proportion of patients with high-grade hydronephrosis, anteroposterior renal pelvis diameter, and maximum ureteral dilatation. CONCLUSIONS: Refluxing UV is a safe alternative to cutaneous diversion in POM. Most patients had improvement in upper tract dilatation with an acceptable short-term complication rate and need for reoperation (in comparison to routine later reimplantation). Our experience suggests that monitoring alone after UV is feasible, and that selective subsequent reconstruction is a reasonable strategy.

Risk and protective factors for secondary procedures after endoscopic dilatation of primary obstructive megaureters.

PURPOSE: High-pressure balloon dilatation (HPBD) of the ureterovesical junction with double-J stenting is a minimally invasive alternative to ureteral reimplantation or cutaneous ureterostomy for first-line surgical treatment of primary obstructive megaureter (POM). The aim of our study was to identify the risk factors associated with the need for secondary procedures due to HPBD failure. METHODS: Prospective data were collected from patients who underwent HPBD for POM between 2007 and 2021 at a single institution. The collected data included patient demographics, diagnostic modalities, surgical details, results, and follow-up. Multivariate logistic regression analysis was performed. RESULTS: Fifty-five ureters underwent HPBD for POM in 50 children, with a median age of 6.4 months (IQR: 4.5-13.8). Nineteen patients (37.25%) underwent secondary ureteric reimplantation, with a median of 9.8 months after primary HBPD (95% CI 6.2-9.9). The median follow-up was 29.4 months (IQR: 17.4-71). Independent risk factors for redo-surgery in a multivariate logistic regression model were: progressive ureterohydronephrosis (OR = 7.8; 95% CI 0.77-78.6) and early removal of the double-J stent. A risk reduction of 7% (95% CI 2.2%-11.4%) was observed per extra-day of catheter maintenance. The optimal cut-off point is 55 days, ROC curve area: 0.77 (95% CI 0.62-0.92). Gender, distal ureteral diameter, pelvis diameter, dilatation balloon diameter and preoperative differential renal function did not affect the need for reimplantation. CONCLUSIONS: The use of a double-J stent for at least 55 days seems to avoid the need for a secondary procedure. Therefore, we recommend removing the double-J catheter at least 2 months after the HBPD.

Peristalsis prevents ureteral dilation.

PURPOSE: The etiology of ureteral dilation in primary nonrefluxing, nonobstructing megaureters is still not well understood. Impaired ureteral peristalsis has been theorized as one of the contributing factors. However, ureteral peristalsis and its "normal" function is not well defined. In this study, using mathematical modeling techniques, we aim to better understand how ureteral peristalsis works. This is the first model to consider clinically observed, back-and-forth, cyclic wall longitudinal motion during peristalsis. We hypothesize that dysfunctional ureteral peristalsis, caused by insufficient peristaltic amplitudes (e.g., circular muscle dysfunction) and/or lack of ureteral wall longitudinal motion (e.g., longitudinal muscle dysfunction), promotes peristaltic reflux (i.e., retrograde flow of urine during an episode of peristalsis) and may result in urinary stasis, urine accumulation, and consequent dilation. METHODS: Based on lubrication theory in fluid mechanics, we developed a two-dimensional (planar) model of ureteral peristalsis. In doing so, we treated ureteral peristalsis as an infinite train of sinusoidal waves. We then analyzed antegrade and retrograde flows in the ureter under different bladder-kidney differential pressure and peristalsis conditions. RESULTS: There is a minimum peristaltic amplitude required to prevent peristaltic reflux. Ureteral wall longitudinal motion decreases this minimum required amplitude, increasing the nonrefluxing range of peristaltic amplitudes. As an example, for a normal bladder-kidney differential pressure of 5 cmH2 O, ureteral wall longitudinal motion increases nonrefluxing range of peristaltic amplitude by 65%. Additionally, ureteral wall longitudinal motion decreases refluxing volumetric flow rates. For a similar normal bladder pressure example of 5 cmH2 O, refluxing volumetric flow rate decreases by a factor of 18. Finally, elevated bladder pressure, not only increases the required peristaltic amplitude for reflux prevention but it increases maximum refluxing volumetric flow rates. For the case without wall longitudinal motion, as bladder-kidney differential pressure increases from 5 to 40 cmH2 O, minimum required peristaltic amplitude to prevent reflux increases by 40% while the maximum refluxing volumetric flow rate increases by approximately 100%. CONCLUSION: The results presented in this study show how abnormal ureteral peristalsis, caused by the absence of wall longitudinal motion and/or lack of sufficient peristaltic amplitudes, facilitates peristaltic reflux and retrograde flow. We theorize that this retrograde flow can lead to urinary stasis and urine accumulation in the ureters, resulting in ureteral dilation seen on imaging studies and elevated infection risk. Our results also show how chronically elevated bladder pressures are more susceptible to such refluxing conditions that could lead to ureteral dilation.

Primary non-refluxing megaureter: Natural history, follow-up and treatment.

Primary non-refluxing megaureter (PMU) is a congenital dilation of the ureter which is not related to vesicoureteral reflux, duplicated collecting systems, ureterocele, ectopic ureter, or posterior urethral valves and accounts for 5 to 10% of all prenatal hydronephrosis (HN) cases. The etiology is a dysfunction or stenosis of the distal ureter. Most often PMU remains asymptomatic with spontaneous resolution allowing for non-operative management. Nevertheless, in selective cases such as the development of febrile urinary tract infections, worsening of the ureteral dilatation, or reduction in relative renal function, surgery should be considered. CONCLUSION: Ureteral replantation with excision of the dysfunctional ureteral segment and often ureteral tapering is the gold-standard procedure for PMU, although endoscopic treatment has been shown to have a fair success rate in many studies. In this review, we discuss the natural history, follow-up, and treatment of PMU. WHAT IS KNOWN: • PMU is the result of an atonic or stenotic segment of the distal ureter, resulting in congenital dilation of the ureter, and is frequently diagnosed on routine antenatal ultrasound. WHAT IS NEW: • Most often, PMU remains asymptomatic and clinically stable, allowing for non-operative management. • Nevertheless, since symptoms can appear even after years of observation, long-term ultrasound follow-up is recommended, even up to young adulthood, if hydroureteronephrosis persists. • Ureteral replantation is the gold standard in case surgery is needed. In selected cases, however, HPBD could be a reasonable alternative.

Advancements in Surgical Management of Megaureters.

PURPOSE OF REVIEW: To review and describe the recent evolution of surgery for the various types of pediatric megaureter. RECENT FINDINGS: Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.

Endoscopic balloon dilation of primary obstructive megaureter: is fluoroscopic guidance necessary?

OBJECTIVE: To compare the long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation under fluoroscopic guidance versus not using radioscopy during the procedure. PATIENTS AND METHODS: A comparative study between POM cases treated at our institution by endoscopic balloon dilation (EBD) under fluoroscopic guidance (FG) (n = 43) vs no fluoroscopic guidance (NFG) (n = 48) between the years 2004 and 2018 was conducted. The procedure in FG consisted of performing a retrograde pyelography before dilation. Then, a guidewire is introduced to the renal pelvis, and the dilation of the vesicoureteral junction is performed using high-pressure balloon catheters under fluoroscopic vision. Finally, a double-J stent is placed between the renal pelvis and bladder. The procedure in NFG was performed exclusively under cystoscopic vision without radiological exposure. Complications, outcomes, and success rates were analyzed using Spearman's correlation test. Mean follow-up was 12.5 ± 2.2 years in FG and 6.4 ± 1.3 years in NFG. RESULTS: MAG-3 showed significant differences in renal drainage before and after endoscopic treatment in both groups (p < 0.001 T-test). Statistical analysis did not reveal differences between groups in initial technical failure (r: - 0.035, p = 0.74), early postoperative complications (r: - 0.029, p = 0.79), secondary VUR (r: 0.033, p = 0.76), re-stenosis (r: 0.022, p = 0.84), long-term ureteral reimplantation (r: 0.065, p = 0.55), and final outcome (r: - 0.054, p = 0.61). The endoscopic approach of POM had a long-term success rate of 86.5% in FG VS 89.6% in NFG. CONCLUSIONS: Endoscopic balloon dilation of POM can be done with no radiation exposure with similar results, effectiveness, and outcomes.

Non-surgical management in children with non-refluxing primary megaureter: a systematic review and meta-analysis.

BACKGROUND: Children with non-refluxing primary megaureter are mostly managed by a watchful approach with close follow-up and serial imaging. OBJECTIVES: This systematic review and meta-analysis aimed to determine whether there is sufficient evidence to support the current non-surgical management strategy in these patients. DATA SOURCES: A comprehensive search including electronic literature databases, clinical trial registries, and conference proceedings was performed. DATA SYNTHESIS METHODS: Outcomes were estimated as pooled prevalence. If meta-analytical calculations were not appropriate, outcomes were provided in a descriptive manner. RESULTS: Data from 8 studies (290 patients/354 renal units) were included. For the primary outcome, differential renal function estimated by functional imaging, meta-analysis was impossible due to reported data not being precise. Pooled prevalence for secondary surgery was 13% (95% confidence interval: 8-19%) and for resolution 61% (95% confidence interval: 42-78%). The risk of bias was moderate or high in most studies. LIMITATIONS: This analysis was limited by the low number of eligible studies with few participants and high clinical heterogeneity, and the poor quality of the available data. CONCLUSIONS: The low pooled prevalence of secondary surgical intervention and high pooled prevalence of resolution may support the current non-surgical management in children with non-refluxing primary megaureter. However, these results should be interpreted cautiously due to the limited available body of evidence. Future studies should overcome existing limitations of imaging methods by using standardized, comparable criteria and report outcome parameters in a quantitative manner. This would allow more sufficient data synthesis to provide evidence-based recommendations for clinical decision-making and counseling. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered on PROSPERO under CRD42019134502.

[Balloon dilation treatment of primary obstructive megaureter in children].

PURPOSE: Investigation of the results of ureteral stricture single balloon dilation in children with primary obstructive megaureter. MATERIALS AND METHODS: Since 2012 to 2020 79 children (65 boys and 15 girls) with primary obstructive megaureter of II and III grades who had 92 affected ureters were operated on by method of ureteral stricture balloon dilation. Duration of postoperative stenting period was Me=68 [48; 91] days, bladder catheterization period - Me=15 [5; 61] days. Follow-up was from 1 to 10 years. RESULTS: There were no intraoperative complications in the group of investigation. Pyelonephritis exacerbation in the early postoperative period occurred in 15 cases (18,98%). Control comprehensive examination revealed that urodynamics of 63 children (79,74%) tended to normalization what persisted in the future. There was no positive dynamics in 16 cases (20,25%). Vesico-ureteral reflux was revealed in 4 cases. DISCUSSION: Assessment of impact of various predictors (passport, urodynamic, infectious, anatomic, operation and postoperative period characteristics) on the treatment results proved that the effectiveness of the procedure depends on the following factors: ureteral stricture length (M-U Test U=202,5 p=0,0002) and features of the stricture rapture during ballooning (Fisher exact p=0,0006). There was significant difference in results in the group of up to 10 mm inclusive stricture length and the longer stricture group (Fisher exact p=0,00001). High activity of pyelonephritis in postoperative period was the predictor of adverse outcome (Fisher exact p=0,00001). CONCLUSION: Practically 80% of children with primary obstructive megaureter may be reliably cured by the method of ureteral stricture balloon dilation. The risk of intervention failure is greatly increased in case of the stricture length is more than 10 mm and technical difficulties of ballooning indicating a high resistance of the narrowed portion of the ureter to dilation.

TRANSIENT PSEUDOHYPOALDOSTERONISM SECONDARY TO URINARY TRACT INFECTION IN A MALE INFANT WITH UNILATERAL HYDRONEPHROSIS DUE TO PRIMARY OBSTRUCTIVE MEGAURETER: A CASE REPORT.

We present a case of transient form of type 1 pseudohypoaldosteronism (S-PHA) in a 1.5-month-old male infant who presented with lethargy, failure to thrive, severe hyponatremia (Na=118 mmol/L), hypochloremia (Cl=93 mmol/L) and fever due to urinary tract infection. Potassium levels were normal. Markedly elevated serum aldosterone level and elevated serum renin confirmed the diagnosis of pseudohypoaldosteronism. Renal ultrasound showed grade III hydronephrosis on the left kidney while contrast-enhanced voiding urosonography excluded the existence of vesicoureteral reflux, which raised suspicion of obstructive uropathy at the level of vesicoureteral junction. Serum sodium normalized after several days of intravenous fluids and antibiotic therapy, after which oral supplementation of sodium was introduced. The levels of 17-hydroxyprogesterone, adrenocorticotropic hormone, cortisol and thyroid-stimulating hormone were normal. Functional magnetic resonance urography conducted at the age of 3 months confirmed the diagnosis of primary congenital obstructive megaureter and the infant was referred to a pediatric surgeon. Although a rare occurrence, S-PHA can be a potentially life-threatening condition in infants if not recognized and treated appropriately. Therefore, serum concentrations of electrolytes should be obtained in every child diagnosed with obstructive anomaly of the urinary tract and/or acute cystopyelonephritis. On the other hand, every child diagnosed with S-PHA should be evaluated for obstructive anomaly of the urinary tract.

[Bradis anti-reflux ureterocysto-anastomosis in children with recurrent obstructive megaureter].

INTRODUCTION: Congenital ureterovesical junction (UVJ) obstructions quite rarely serve as an indication for ureteral reimplantation, and recurrent obstructions resulting from surgical treatment are even less frequent. Cases of acquired UVJ obstruction following endoscopy and ureteral reimplantation done for vesicoureteral reflux correction are fairly rare. The lack of known publications analyzing treatment of recurrent obstructive megaureter predetermines topicality of our research. PURPOSE: Evaluate the efficiency and safety of extravesical anti-reflux uretero-cysto-anastomosis performed using Bradis technique for children with recurrent obstructive megaureter (OM). MATERIALS AND METHODS: The work is based on the experience of surgical OM correction in 5 children aged 1 to 4 years, 4 boys and a girl with a recurrent UVJ obstruction following prior ureteral reimplantation for correction of UVJ obstruction (4 children) or vesicoureteral reflux (1 patient). Antenatal UVJ obstruction had been diagnosed in 2 patients. In all cases the examination included urine analysis, its culture study, ultrasonography of the kidneys and urinary tracts, dynamic renal scintigraphy, micturating cystography, and, where indicated, intravenous urography and SCT of the kidneys. All patients underwent Bradis extravesical reimplantation. RESULTS: During postoperative care period, a considerable reduction of the dilatation of renal collecting system was accomplished in all five patients along with the differential renal function preserved on the pre-surgery level and a steady remission of urinary tract infection based on clinical manifestations and laboratory findings. CONCLUSIONS: The simplicity of Bradis extravesical ureteral reimplantation represents its advantage over intravesical methods. Extravesical approach allows easy ureteral length and width correction. Limited experience of Bradis surgery in pediatric cases of recurrent OM requires confirmation with further randomized clinical trials.

Telocytes, c-Kit positive cells, Smooth muscles, and collagen in the ureter of pediatric patients with congenital primary obstructive megaureter: elucidation of etiopathology.

Congenital primary obstructive megaureter (POM) is an uncommon pediatric anomaly that is due to obstructive distal ureter leading to the loss of peristalsis with consequent ureterohydronephrosis causing loss of kidney function. The objectives are to elucidate the etiology of POM by demonstrating the presence of interstitial cells of Cajal (ICC), telocytes, smooth muscles, and collage in the obstructive and dilated ureteral segments. The study was carried out on 15 surgical specimens of congenital POM in pediatric patients, age range was 4 to 24 months, they were operated upon by excision of the obstructed segment, tailoring the dilated ureter, and anastomosing it to the bladder. Specimens included the obstructed ureteral segment and part of the dilated ureter. Specimens were examined with hematoxylin and eosin (H&E) stain, Modified Gomori trichrome stain, immunohistochemistry (IHC) with α-muscle actin, and c-kit (CD117), and transmission electron microscopy (TEM). Obstructed segment showed excess collagen intervening between smooth muscles, excess c-Kit positive cells, and presence of telocytes. The dilated segment of the ureteral wall is formed of smooth muscle bundles with scanty collagen. Staining with c-Kit did not demonstrate positive cells. TEM showed myofibroblasts and close adherence of smooth muscle cells to each other with absence of telocytes. The pathophysiology of POM is multifactorial. Loss of interstitial cells and rarity of collagen result in loss of elasticity of dilated segment leading to massive dilatation. While the obstructed segment had no muscle conductivity due to excess collagen irrespective of presence of telocytes.

[Extravesical reimplantation of heavily-dilated ureters according to Bradi technique].

INTRODUCTION: Surgery of the ureterovesical anastomoses lesions in case of weakly-dilated ureters is well developed by the Cohen and Lich-Grgoire techniques. However, there are no generally accepted approaches for heavily-dilated ureters. The experience of creating ureterocystoneoanastomosis according to the Bradi technique (1975) for the first time in the literature is presented. MATERIALS AND METHODS: The authors modification of the Bradi technique was used in 12 patients of both sexes with a dilated ureters diameter of more than 10 mm. Two cases of refluxogenic and 10 cases of obstructive megaureter were operated on 2010-2019. The follow-up period was 1-10 years. All patients underwent resection of the ureter in width. RESULTS: No intraoperative complications were noted. One case of acute pyelonephritis with acute urinary retention was noted as postoperative complications. All patients showed a decrease in dilatation of the pyelocaliceal system and ureter according to multispiral computed tomography after 6 months of follow-up. Two patients had vesicoureteral reflux of the first degree. Glomerular filtration rates decreased in 41.7% of cases after 12 months of follow-up. No recurrence of urinary tract infection and stenosis of the anastomosis was detected for 1-10 years monitoring. CONCLUSION: The Bradi technique along with the Hodgsons ureter reconstruction provides superior results for heavily-dilated ureters in adults.

[The opportunities of pneumovesicoscopic approach for correction of disorders of vesicoureteral junction in children].

BACKGROUND: pneumovesicoscopic approach gives new possibilities for endovideosurgical correction of congenital ureteral and bladder pathology. AIM: To increase the efficiency of ureteral reimplantation in patients with vesicoureteral reflux (VUR), obstructive megaureter and bladder pathology by using pneumovesicoscopic access. MATERIALS AND METHODS: For the period 2014 - 2020 a total of 52 children aged from 10 months up to 15 years (median 2.5 years) were treated. In all patients, pneumovesicoscopic ureteral reimplantation according to the Cohen technique was performed, and in six cases bilateral procedure was done. 30 patients with obstructive megaureter (32 ureters) were treated, and intravesical suturing with ureteral plication was performed in 9 patients. Reimplantation for grade 3-5 VUR was performed in 22 patients (26 ureters), in combination with excision of the bladder diverticulum was done in 3 patients, while 3 children were undergone to simultaneous excision of the ureterocele. An original technique for fixation of the mobilized dilated ureter with a ligature to the bladder neck is proposed to simplify its intravesical suturing according to the Starr technique. RESULTS: The mean operation time was 142 (83-235 minutes). Conversion to open surgery was required in 1 (1.9%) child during the learning curve. The length of stay was 5-6 days, with an average of 5.21 days. According to ultrasound data, after 1, 3, 6 months there was a decrease in the size of the collecting system and ureter in all cases. At cystography after 6-12 months, VUR was detected in 3 (5.7%) children: in 2 (9%) patients with grade 3-5 VUR and in 1 (3.3%) patient with obstructive megaureter and ureteral suturing. CONCLUSION: Pneumovesicoscopic access for ureteral reimplantation in patients with VUR, obstructive megaureter, bladder diverticulum and ureterocele has proven its efficiency and reliability with a minimal complication rate (5.7%). Our proposed method of fixing the mobilized ureter with a ligature to the bladder neck helps to simplify the suturing of the ureter and to shorten the operation time.

Long-term safety and efficacy of psoas bladder hitch in infants aged <12 months with unilateral obstructive megaureter.

OBJECTIVE: To determine the long-term safety and efficacy of ureteric reimplantation with psoas bladder hitch (PBH) in patients aged <12 months with unilateral obstructive megaureter (OM). PATIENTS AND METHODS: We retrospectively compared a group of patients aged <12 months (study group) with an group of patients aged ≥12 months (comparison group), who underwent PBH for OM between September 2007 and April 2017, in terms of preoperative patient characteristics, intra- and peri-operative results, and postoperative results. RESULTS: The study group comprised seven infants, five boys and two girls. The median (range) age at the time of PBH was 3 (2-8) months; OM was detected by ultrasonography during the fetal period. The left side was affected in four infants and the right side in three. Four infants had primary OM (POM). In all three infants who had ectopic OM in the complete double renal pelvis and ureter, the OM involved the ureter from the upper half of the kidney. The median (range) follow-up period after PBH was 45 (33-129) months. Comparison of the two groups showed no significant difference in terms of surgical time (P = 0.948) and length of hospital stay (P = 0.125). In both groups, hydroureteronephrosis improved postoperatively in all patients. There was no significant difference between the two groups in terms of postoperative complications, such as vesico-ureteric reflux, febrile urinary tract infection and deterioration of ipsilateral renal function. Notably, no patient underwent reoperation in either group. CONCLUSION: Psoas bladder hitch for unilateral OM including POM appears to be safe and effective in the long term for patients aged <12 months and for those aged ≥12 months. Although not routinely recommended, PBH appears to be a viable option for selected infants with POM.

Prolonged urinary retention can and does occur after any type of ureteral reimplantantion.

OBJECTIVE: Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6 weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred. MATERIALS AND METHODS: We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons. RESULTS: During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1 years. Eventually 7/10 patients were able to void normally, with periods ranging from 6 weeks to 8 years. The remaining three patients are still unable to void more than 5 years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal. CONCLUSION: PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.

Ipsilateral Renal Agenesis With Megaureter, Blind End Proximal Ureter And Ureterocele In An Adult.

We reporting unilateral renal agenesis with ipsilateral ureterocoele, mega ureter and blind end proximal ureter in same patient first time as case report and has not been so far reported in local or international literature. Ultrasound, CT scan and intravenous pyelography performed which confirm the case. Patient presented with left lumber and pelvic pain on and off and history of recurrent urinary tract infection.

[Therapeutic mega-ureter primitive before one year of life, retrospective study of 20years]. / Stratégie thérapeutique des méga-uretères primitifs avant 1 an de vie, étude rétrospective de 20 ans.

INTRODUCTION: What is the proper way to manage complicated primary mega-ureter in infants under the age of one. This has already been discussed in the literature but the controversy remains. OBJECTIVE: Evaluate the long-term results of the management of mega-ureter based support under the age of one. MATERIAL AND METHODS: Single-center retrospective study from 1990 to 2010. All children under one year found were evaluated including clinical examination, ultrasound, scintigraphy and cystography. They were divided into two groups: group 1: children operated on before the age of one year, group 2 non-operated or operated children after the age of one year. We analyzed the long-term evolution of these children on the following criteria: reflux, pyelonephritis, changes in dilation, renal function, need for surgical revision or secondary surgery, and impact on bladder function. RESULTS: In total, 54 patients were included in group 1 and 56 patients in group 2. In a median follow-up of 12 years. A total of 101 boys and 9 girls (sex-ratio 11.22). There were 57 left MUP (52%), 22 right (20%) and 31 bilateral (28%). A total of 71% of antenatal diagnosis. No difference on the emergence of complications: 25 (group 1) versus 31 (group 2) OR=0.69; 95% (0.307; 1.574); P=0.44. No difference between secondary surgery and revision surgery: group 1=12, group 2=22, OR=0.45; 95% CI (0.17, 1.09); P=0.06. No difference for daytime incontinence: OR=1.04; 95% CI (0.14; 7.64); P=0.67. Seventy-six children (69%) were finally made, 12 children operated twice (10.9%) and 34 children (31%) never made. CONCLUSION: The main challenge of the MUP of management is the preservation of renal function. Sixty-nine percent of our children received surgery due to impaired renal function lower than 30% of urethral dilatation greater than 10mm associated with reflux or recurrent pyelonephritis. Clinical monitoring, regular ultrasound and isotopic testing are necessary and should be extended to adulthood. LEVEL OF EVIDENCE: 5.

High pressure balloon dilatation of the ureterovesical junction in primary obstructive megaureter: Infectious morbidity.

INTRODUCTION: The objective of this study is to investigate the infectious morbidity associated with high-pressure balloon dilatation (HPBD) and an indwelling double J stent, in primary obstructive megaureter. METHODS: We reviewed the cases of 12 patients undergoing endoscopic treatment for primary obstructive megaureter from January 2012 to January 2015. The characteristics of the infection and data concerning the patient and the intervention were analyzed. RESULTS: The frequency of preoperative urinary tract infection (UTI) was 58%. The procedure was feasible in 100% of cases. Two patients required a second dilatation. One patient underwent Cohen's ureteral reimplantation after failure of the second dilatation. The frequency of postoperative UTI was 25%. All these infections occurred in patients with a double J stent. None of the patients had UTI after stent removal. None of the patients developed postoperative vesicoureteral reflux (VUR) after HPBD. CONCLUSION: Endoscopic balloon dilatation has been shown to have good short- mid- and long-term outcomes. In our experience, the morbidity of this procedure mostly results from infections, exclusively related to the use of a double J stent. The placement of a double J stent has a significant medical and economic impact. A definitive decision about the utility of double J stents will require studies of further dilatation without the placement of a double J stent. LEVEL OF EVIDENCE: 4.

Postoperative vesicoureteral reflux after high-pressure balloon dilation of the ureterovesical junction in primary obstructive megaureter. Incidence, management and predisposing factors.

OBJECTIVE: To describe the incidence, predisposing factors and management of postoperative vesicoureteral reflux (VUR) after high-pressure balloon dilation to treat primary obstructive megaureter (POM). MATERIALS AND METHODS: We have reviewed patients that underwent endoscopic treatment for POM from May 2008 to November 2013. All patients were evaluated with renal ultrasound, voiding cystourethrography and diuretic renogram. Endoscopic treatment was done with high-pressure balloon dilation of the ureterovesical junction under general anesthesia; a double-J stenting was done in all patients. Follow-up was performed with ultrasonography, voiding cystourethrography and a diuretic renogram in all patients. RESULTS: Fifteen boys and five girls with a mean age of 14.18 months (3-103) were reviewed. A total of 22 ureters underwent HPBD to treat POM. Ureterohydronephrosis improves in 19 ureters. After endoscopic treatment, six ureters developed VUR. Four ureters were managed surgically, and in the other two, VUR disappeared in a second cystogram. The presence of parameatal diverticulum in the preoperative cystography and those patients with bilateral POM are factors related to postoperative VUR (p < 0.05). Urinary tract infection after HPBD was observed in four patients, but only one of them was affected with VUR.