Ureteral duplicity with a left ureterocele: a case report.

An intravesical ureterocele is a rare condition in which a terminal ureter terminates in a cystic dilation of the bladder. We present the case of a 42-year-old female who presented with irritative lower urinary tract symptoms and left lower back pain. Computed tomography (CT) urography revealed ureteral duplication with a ureterocele complicated by upper tract obstruction. Treatment involved endoscopic ureterocelotomy, which successfully relieved symptoms and resolved renal obstruction.

[Ipsilateral ureteroureterostomy. A safe alternative in complete duplicated collecting system with associated pathology]. / Uretero-ureteroanastomosis distal ipsilateral. Una alternativa segura en doble sistema renal completo con patología asociada.

In patients with complete double renal system with the involvement of only one system, there are several surgical alternatives for its resolution. Uretero-ureteral anastomosis has been presented as a good alternative, even in cases with atrophy of the affected system. OBJECTIVE: To report our experience in patients with complete double renal system with only one system affected, with the surgical technique of uretero-ureteral anastomosis. PATIENTS AND METHOD: Retrospective study of patients with double renal system with involvement of one of the systems, treated with uretero-ureteral anastomosis technique between January 2015 and May 2022. The variables of age, specific pathology of the affected system, preoperative study, days of hospitalization, postoperative complications (leakage, obstruction, infection), and follow-up time were evaluated. RESULTS: We analyzed 26 procedures in 25 patients, mean age 36.8 months (range: 8-80); 53.8% had ectopic ureter, 23% ureterocele, 11.5% sphincteric ureterocele, and 11.5% VUR of the lower system. All were studied preoperatively with urethrocystography and 65% with scintigraphy. 50% of the operated systems showed signs of renal atrophy. The average hospital stay was 2.2 days (range: 1-7). In an average follow-up of 26.5 months (range: 3-77), one patient presented leakage, no patient presented signs suggestive of obstruction, and one patient presented febrile urinary tract infection with persistent lower-grade reflux. CONCLUSION: In our experience, the uretero-ureteral anastomosis technique proved to be an easy and safe alternative to reproduce, with a success rate of 96%, 11% of grade I complications, and 4% of grade II complications according to the Clavien-Dindo classification.

Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

OBJECTIVE: To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED). MATERIALS AND METHODS: This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups. RESULTS: Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections. CONCLUSIONS: SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes.

INTRODUCTION: Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure). OBJECTIVE: With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants. STUDY DESIGN: A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups. RESULTS: Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques. DISCUSSION: RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers. CONCLUSIONS: Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.

Clinical outcomes and risk factor analysis of early endoscopic puncture decompression for ureterocele associated with duplex kidney in children: a single-center retrospective study.

PURPOSE: The aims of this study were to analyze the clinical outcomes of treating duplex system ureteroceles with early endoscopic puncture decompression and to identify the risk factors related to outcomes to help guide future work. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of patients with ureteroceles with duplex kidney that were treated with early endoscopic puncture decompression. Charts were reviewed for demographics, preoperative imaging, surgical indications, and follow-up data. Recurrent febrile urinary tract infections (fUTIs), de novo vesicoureteral reflux (VUR), persistent high-grade VUR, unrelieved hydroureteronephrosis, and the need for further intervention were considered unfavorable outcomes. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), type of ureterocele, ipsilateral VUR diagnosed before surgery, simultaneously upper-pole moiety (UM) and lower-pole moiety (LM) obstruction, the width of ureter affiliated to UM, and maximum diameter of ureterocele were all considered potential risk factors. A binary logistic regression model was used to identify the risk factors of unfavorable outcomes. RESULTS: A total of 36 patients with ureteroceles related to duplex kidney underwent endoscopic holmium laser puncture from 2015 to 2023 at our institution. After a median follow-up of 21.6 months, unfavorable outcomes developed in 17 patients (47.2%). Three patients underwent ipsilateral common-sheath ureter reimplantation and one patient underwent laparoscopic ipsilateral upper to lower ureteroureterostomy combined with recipient ureter reimplantation. Three patients underwent laparoscopic upper-pole nephrectomy. Fifteen patients suffered from recurrent UTIs were treated with oral antibiotics and eight of them were diagnosed de novo VUR according to voiding cystourethrography (VCUG). In univariate analysis, patients with simultaneously UM and LM obstruction (P = 0.003), fUTIs before surgery (P = 0.044), and ectopic ureterocele (P = 0.031) were more likely to have unfavorable outcomes. Binary logistic regression analysis showed that ectopic ureterocele (OR = 10.793, 95% CI 1.248-93.312, P = 0.031) and simultaneously UM and LM obstruction (OR = 8.304, 95% CI 1.311-52.589, P = 0.025) were identified as independent factors for unfavorable outcomes. CONCLUSIONS: Our study suggested that early endoscopic puncture decompression is not a preferred but an available treatment option to release BOO or to cure refractory UTIs. It was easier to fail if the ureterocele was ectopic or simultaneously UM and LM obstruction existed. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), ipsilateral VUR diagnosed before surgery, the width of ureter affiliated to UM, and maximum diameter of ureterocele were not significantly related to the success rate of early endoscopic punctures.

Embryology, Treatment, and Outcomes of Ureteroceles in Children.

A ureterocele is a congenital cystic dilatation of the intravesical ureter that may affect either a single system kidney or the upper pole of a duplex system. The position of ureteral orifice correlates with function of associated renal moiety. Ureteroceles associated with good renal function and prompt drainage or ureteroceles associated with no renal function can be managed nonoperatively. Endoscopic puncture of ureteroceles addresses most cases; iatrogenic reflux may rarely require secondary surgery. Robot-assisted laparoscopic upper pole nephroureterectomy and ureteroureterostomy procedures are rarely associated with complications.

Ureterocele with duplex collecting systems and febrile urinary tract infection risk.

PURPOSE: Ureterocele has been hypothesized to be the risk factor for febrile urinary tract infections (F-UTIs) in patients with duplex collecting systems, but this has not been proved, and our goal was to assess the relation between ureterocele with duplex collecting systems and F-UTIs. METHODS: We included individual-participant data from patients seen for complicated duplex collecting systems from 2010 to 2020 retrospectively followed. Those with using continuous low-dose antibiotic prophylaxis and incompletely duplicated systems were removed from the study. The participants were divided into two cohorts according to patients with or without ureterocele. The primary endpoint of this study was recurrent F-UTIs. RESULTS: We analyzed medical reports of 300 patients, of which 75% were female. Among the 300 patients, F-UTIs developed in 111/159 (69.8%) patients in the ureterocele group and in 69/141 (48.9%) patients in the no-ureterocele group. Univariate analysis found no discernible difference except in grade of hydronephrosis between ureterocele group and no-ureterocele group. Moreover, Cox proportional regression analysis revealed that patients of duplex system ureterocele might be intrinsically more prone to develop F-UTIs (adjusted hazard ratio 1.894; 95% CI 1.412-2.542; p  <  0.001). CONCLUSION: Among participants with duplex systems, the risk of recurrent F-UTIs in patients with ureterocele was higher than patients without it, and mini-invasive surgical correction should be considered at young age to reduce F-UTIs.

Prevention of vesicoureteral reflux in neonatal patients with intravesical ureterocele using holmium-laser.

AIM: To evaluate the effectiveness of laser fenestration of intravesical ureterocele in prevention of vesicoureteral reflux. MATERIAL AND METHODS: The result of intravesical ureterocele holmium laser fenestration (LF) was retrospectively analyzed in 29 neonatal patients (mean age 8.1 days, range 3-28) in comparison with 38 neonates (mean age 9.6 days, range 5-28) treated with electrosurgical incision (ES). Patients' records were reviewed for preoperative findings, endoscopic procedure description and postoperative outcomes. RESULTS: Vesicoureteral reflux (VUR) was found in two patients (5.6%) in LF and in 25 patients (65.8%) in ES group after six months (P=0.000). The patients with VUR in LF group had reflux grade III. In ES group six patients (15.8%) had reflux grade III, ten (26.3%) grade IV and nine (23.7%) grade V. DISCUSSION: In our study we found that de novo VUR is several times more common in patients treated with electrosurgical incision. This is the main difference between two described endoscopic procedures. Although this is a relatively new surgical technique, and other authors had similar results, which implies the importance of laser fenestration in the prevention of VUR in neonates with ureterocele. CONCLUSION: The occurrence of VUR is significantly lower in neonatal patients treated with holmium-laser fenestration, compared to standard electrosurgical incision, although both techniques are highly effective in relieving the obstruction. Since the use of this technique reduces the incidence of VUR, the need for subsequent surgery is lower in patients treated with holmium-laser. KEY WORDS: Laser Reflux Prevention, Ureterocele.

Associations of ureteroceles location and system anatomy with outcomes of endoscopic treatment: A systematic review and meta-analysis.

INTRODUCTION: Ureteroceles are a congenital abnormality of the ureter that can cause significant complications. Endoscopic treatment is a commonly used treatment approach. The aim of this review is to assess the results of endoscopic treatment for ureteroceles with consideration to their location and system anatomy. METHODS: A meta-analysis was conducted by searching electronic databases for studies comparing outcomes of endoscopic treatment for ureteroceles. Newcastle-Ottawa Scale (NOS) was employed to evaluate the potential for bias. The primary outcome was the rate of secondary procedures required following endoscopic treatment. Secondary outcomes were inadequate drainage and post-operative vesicoureteral reflux (VUR) rates. A subgroup analysis was performed to investigate possible causes of heterogeneity in the primary outcome. The statistical analysis was conducted using Review Manager 5.4. RESULTS: There were 28 retrospective observational studies, published between 1993 and 2022, including 1044 patients with primary outcomes in this meta-analysis. The quantitative synthesis showed that ectopic and duplex system ureteroceles were significantly associated with higher rate of secondary operation compared to intravesical and single system ureteroceles, respectively (OR: 5.42, 95% CI: 3.93-7.47; and OR: 5.10, 95% CI: 3.31-7.87). The associations were still significant in subgroup analysis based on follow up duration, average age at surgery, and duplex system only. For secondary outcomes, incidence of inadequate drainage were significantly higher in ectopic (OR: 2,01, 95% CI: 1.18-3.43), but not in duplex system ureteroceles (OR: 1.94, 95% CI: 0,97-3.86). Post-operative VUR rates were higher in both ectopic (OR: 1.79, 95% CI: 1.29-2.47) and duplex system ureteroceles group (OR: 1.88, 95% CI: 1.15-3.08). CONCLUSION: Ectopic ureteroceles and duplex system ureteroceles were associated with worse outcomes following endoscopic treatment compared to intravesical and single system ureteroceles, respectively. It is recommended to carefully select patients, conduct pre-operative evaluations, and closely monitor patients with ectopic and duplex system ureteroceles.

Endourological treatment of ectopic ureterocele. Our experience in the last 15 years. / Tratamiento endourológico del ureterocele ectópico. Experiencia en los últimos 15 años.

OBJECTIVE: To assess the efficacy of the endourological treatment of ectopic ureterocele in children in a large series and with a long-term follow-up. MATERIALS AND METHODS: A retrospective, descriptive study of patients with ectopic ureterocele who had undergone surgery in our institution in the last 15 years was carried out. All patients were treated using an endourological approach, both for ureterocele and postoperative vesicoureteral reflux (VUR). RESULTS: 40 patients were treated -55% with left involvement and 5% with bilateral involvement. Mean age at diagnosis was 4.97 months, with diagnosis being established prenatally in 54.1% of cases. In all patients but one, endourological puncture of the ureterocele was conducted. Mean age at surgery was 6.96 months (0-1.11). Surgery was performed on an outpatient basis in 94.9% of patients. No perioperative complications were recorded. In the last 30 patients, preoperative voiding cystourethrography was not carried out. 72.5% of patients had postoperative VUR (44.8% into the upper pyelon, 10.3% into the lower pyelon, 17.2% into both, 6.9% into the contralateral system, and 20.7% into the bilateral system), but it was resolved with a single endoscopic procedure in 48.1% of cases (65% of patients were healed with two procedures). VUR was not endoscopically resolved in 3 patients who required ureteral re-implantation. 6 patients required heminephrectomy (n=3) or nephrectomy (n=3) as a result of functional impairment and infections. CONCLUSION: The endourological treatment of ectopic ureterocele is a little aggressive and little invasive technique that allows the obstruction to be resolved on an outpatient basis, which means bladder surgery -if required- can be performed outside the neonatal period.

OBJETIVO: Evaluar la eficacia del tratamiento endourológico del ureterocele ectópico en niños en una serie amplia y con seguimiento a largo plazo. MATERIAL Y METODOS: Estudio retrospectivo descriptivo de los pacientes con ureterocele ectópico intervenidos en nuestro centro en los últimos 15 años. Todos los pacientes se tratan por vía endourológica, tanto el ureterocele como el reflujo vesicoureteral (RVU) postoperatorio. RESULTADOS: Se trataron 40 pacientes, 55% eran izquierdos y 5% bilaterales. La edad media al diagnóstico fue de 4,97 meses siendo de diagnóstico prenatal el 54,1%. En todos los pacientes menos uno se realizó una punción endourológica del ureterocele. La edad media en el momento de la cirugía era de 6,96 meses (0-1,11). La cirugía fue ambulante en un 94,9% de los pacientes. No se registraron complicaciones perioperatorias. En los últimos 30 pacientes no se realizó cistouretrografía miccional preoperatoria. Un 72,5% de los pacientes presentaron RVU postoperatorio (44,8% a pielón superior, 10,3% a pielón inferior, 17,2% a ambos, 6,9% al sistema contralateral y 20,7% bilateral), pero este se resolvió con un único procedimiento endoscópico en un 48,1% de los casos (curación del 65% de los pacientes con dos procedimientos). El RVU no se resolvió de forma endoscópica en 3 pacientes que requirieron un reimplante ureteral. Seis pacientes precisaron heminefrectomía (n= 3) o nefrectomía (n= 3) por anulación funcional e infecciones. CONCLUSION: El tratamiento endourológico del ureterocele ectópico es una técnica poco agresiva invasiva que consigue la resolución de la obstrucción de forma ambulante permitiendo diferir la cirugía vesical (si fuera necesaria) fuera del periodo neonatal.

Tratamiento endourológico del ureterocele ectópico. Experiencia en los últimos 15 años / Endourological treatment of ectopic ureterocele. Our experience in the last 15 years

Objetivo: Evaluar la eficacia del tratamiento endourológico delureterocele ectópico en niños en una serie amplia y con seguimientoa largo plazo. Material y métodos: Estudio retrospectivo descriptivo de los pacientes con ureterocele ectópico intervenidos en nuestro centro en losúltimos 15 años. Todos los pacientes se tratan por vía endourológica,tanto el ureterocele como el reflujo vesicoureteral (RVU) postoperatorio. Resultados: Se trataron 40 pacientes, 55% eran izquierdos y 5%bilaterales. La edad media al diagnóstico fue de 4,97 meses siendo dediagnóstico prenatal el 54,1%. En todos los pacientes menos uno serealizó una punción endourológica del ureterocele. La edad media enel momento de la cirugía era de 6,96 meses (0-1,11). La cirugía fue ambulante en un 94,9% de los pacientes. No se registraron complicacionesperioperatorias. En los últimos 30 pacientes no se realizó cistouretrografía miccional preoperatoria. Un 72,5% de los pacientes presentaron RVUpostoperatorio (44,8% a pielón superior, 10,3% a pielón inferior, 17,2%a ambos, 6,9% al sistema contralateral y 20,7% bilateral), pero este seresolvió con un único procedimiento endoscópico en un 48,1% de loscasos (curación del 65% de los pacientes con dos procedimientos). ElRVU no se resolvió de forma endoscópica en 3 pacientes que requirieronun reimplante ureteral. Seis pacientes precisaron heminefrectomía (n= 3)o nefrectomía (n= 3) por anulación funcional e infecciones. Conclusión: El tratamiento endourológico del ureterocele ectópicoes una técnica poco agresiva invasiva que consigue la resolución de laobstrucción de forma ambulante permitiendo diferir la cirugía vesical(si fuera necesaria) fuera del periodo neonatal.(AU)

Objective: To assess the efficacy of the endourological treatmentof ectopic ureterocele in children in a large series and with a long-termfollow-up. Materials and methods: A retrospective, descriptive study ofpatients with ectopic ureterocele who had undergone surgery in ourinstitution in the last 15 years was carried out. All patients were treatedusing an endourological approach, both for ureterocele and postoperativevesicoureteral reflux (VUR). Results: 40 patients were treated – 55% with left involvement and5% with bilateral involvement. Mean age at diagnosis was 4.97 months,with diagnosis being established prenatally in 54.1% of cases. In allpatients but one, endourological puncture of the ureterocele was conducted. Mean age at surgery was 6.96 months (0-1.11). Surgery wasperformed on an outpatient basis in 94.9% of patients. No perioperativecomplications were recorded. In the last 30 patients, preoperative voidingcystourethrography was not carried out. 72.5% of patients had postoper-ative VUR (44.8% into the upper pyelon, 10.3% into the lower pyelon,17.2% into both, 6.9% into the contralateral system, and 20.7% into thebilateral system), but it was resolved with a single endoscopic procedurein 48.1% of cases (65% of patients were healed with two procedures).VUR was not endoscopically resolved in 3 patients who required ureteral remplantation. 6 patients required heminephrectomy (n=3) ornephrectomy (n=3) as a result of functional impairment and infections. Conclusion: The endourological treatment of ectopic ureterocele isa little aggressive and little invasive technique that allows the obstructionto be resolved on an outpatient basis, which means bladder surgery – ifrequired – can be performed outside the neonatal period.(AU)

Factors of transurethral incision effectiveness for ureteroceles in pediatric patients: A 28-year, single-institution retrospective review.

BACKGROUND: As a congenital anomaly, ureteroceles occur in 1 in 4000 children, and are usually diagnosed prenatally. However, there remains a lack of definite consensus on the optimal management of congenital ureteroceles. OBJECTIVE: We evaluated factors associated with success of primary transurethral incision (TUI) in ureterocele pediatric patients. METHODS: Demographic and clinical information for 120 pediatric patients who were diagnosed with congenital ureterocele between 1993 and 2021 at our institution were obtained through retrospective chart review. Data were 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 effectiveness, defined by no need for further surgical intervention. RESULTS: Of the 120 patients (39 boys, 81 girls) with ureteroceles, 75 patients (22 boys, 53 girls) met our inclusion criteria of undergoing initial TUI ureterocele. Initial TUI was effective in 51/75 patients (68.0%). We analyzed possible correlative factors for TUI efficacy. Simplex system was a significant predictor of primary TUI efficacy (85% effective in simplex systems, 62% in duplex systems). Prior urinary tract infection, prenatal diagnosis, and electrocautery technique were all associated with an increased risk of needing additional surgeries after primary TUI. DISCUSSION: The most significant predictors of effective primary TUI were simplex system and the absence of preoperative vesicoureteral reflux. Prenatal diagnosis, preoperative febrile urinary tract infection, higher preoperative hydronephrosis grade, and the use of electrocautery were all associated with decreased primary TUI efficacy. Study limitations include that it was a retrospective chart review, and cohort size was limited by incomplete urology follow-up and operative records. CONCLUSIONS: Initial TUI was an effective 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 an effective first TUI than patients with duplex systems, as were patients without preoperative reflux. Although not statistically significant, our data suggest prior UTI, prenatal diagnosis, higher preoperative hydronephrosis grade, and the use of electrocautery may be associated with having additional surgeries.

Surgical management of complicated duplex kidney: A tertiary referral centre 10-year experience.

Aim: The management of a complicated duplex kidney remains a challenge for paediatric urologists. The aim of this study is to report a 10-year experience of the surgical management of complicated duplex kidney in a single tertiary care paediatric referring hospital. Materials and Methods: Clinical records of all children who undergone a surgical procedure for complicated duplex systems between January 2009 and March 2019 at our institution were retrospectively reviewed. Clinical manifestations, surgical procedures, complications and follow-up were collected and analysed. Logistic regression was performed to explore if any patient's characteristic or underlying associated comorbidity (ureterocoele, ectopic ureter, obstruction, etc.,) could be positively linked to the chance to develop recurrent urinary tract infections (UTIs). Results: We have identified 95 children who received a surgical treatment for 102 complicated duplex kidneys. The presence of an ureterocoele was recorded in 41 (43.2%) patients, an ectopic ureter in 25 (26.3%), a vesicoureteral reflux (VUR) in 40 (42.1%), a vesicoureteric junction obstruction in 24 (25.3%) and an ureteropelvic junction obstruction in 3 (3.2%). An invasive approach such as an heminephrectomy (71.6%) was required in the majority of cases. Higher risk of developing a UTI has been demonstrated in children diagnosed postnatally (P < 0.001) and in those with an associated obstruction (P < 0.05). Conclusions: No standardised management could be recommended for the surgical treatment of complicated duplex kidney. Children without antenatal diagnosis and with either an upper tract obstruction or VUR are at greater risk to develop UTI and need to be looked after more closely.

An alternative lower tract approach to ectopic duplex system ureteroceles feasible in young children.

INTRODUCTION: The best surgical approach to ectopic ureters and ureteroceles is yet to be determined. The objective of this study is to provide an alternative lower tract surgical approach to ectopic ureters and duplex system ureteroceles that can be safely performed in young children. METHODS: The "in-and-out" bladder approach was performed via an open intravesical incision. The upper and lower pole ureters were mobilized and brought into the bladder. The dilated ureter/ureterocele was cut open, and the distal part was deuroepithelialized. Subsequently, common sheath reimplantation was performed. The ureterocele wall was not involved during the whole procedure. We retrospectively reviewed all patients who underwent surgery for ureteroceles and ectopic ureters between January 1, 2004, and December 31, 2019. Patients with intravesical ureteroceles were excluded. Outcome parameters included the presence of hydronephrosis or reflux, split renal function on DMSA scan, incidence of urinary tract infection, and urinary incontinence. RESULTS: A total of 32 patients with ectopic duplex system ureterocele who underwent the "in-and-out" bladder approach between 2004 and 2019 were included in the retrospective study. The median age at operation was 7.8 months (range: 1.5 months-3.0 years). The median length of follow-up was 6.1 years (range: 1.0 years-14.3 years). Sixteen patients (55%) had ipsilateral vesicoureteral reflux. Five patients postoperatively developed a urinary tract infection within 1-3 years. No patients required further endoscopic treatment or surgeries. During long-term follow-up, two patients (6.3%) had intermittent day wetting at the ages of 4 and 5 years and were managed conservatively. The symptoms of intermittent day wetting subsided during follow-up. CONCLUSIONS: The "in-and-out bladder" approach can be performed in complex duplex system ureteroceles and enables early intervention; it is a single and simple operation with a satisfactory long-term continence rate.

Risk factors for postoperative adverse outcomes and secondary surgery in pediatric patients with unilateral ectopic ureterocele associated with the duplex system.

INTRODUCTION: Ectopic ureterocele management in children remains a controversial subject without a clear consensus. The purpose of this study was to explore the risk factors for adverse outcomes and secondary surgery in pediatric patients with unilateral ectopic duplex system ureterocele, a complex urinary system deformity with controversial treatment. MATERIALS AND METHODS: We retrospectively reviewed 75 patients with unilateral ectopic duplex system ureterocele who underwent surgery at the Shengjing Hospital of China Medical University between January 1, 2008, and September 31, 2020. Demographic characteristics, preoperative data, surgical procedures, postoperative adverse outcomes, and secondary surgery were recorded. Adverse outcomes were defined as new-onset VUR and BOO after surgery. The risks of adverse outcomes and secondary surgery were evaluated using multivariate binary logistic regression and expressed as adjusted odds ratios with 95% confidence intervals. RESULTS: Adverse outcomes occurred in 25 (33.3%) patients, including 24 (32.0%) with new-onset vesicoureteral reflux and 1 (1.3%) with bladder outlet obstruction. Seven (9.3%) patients required secondary surgery. The independent risk factors for adverse outcomes were transurethral endoscopic incision and transurethral endoscopic puncture (transurethral endoscopic incision vs. upper pole partial nephrectomy: OR = 11.049, P = 0.004; transurethral endoscopic puncture vs. upper pole partial nephrectomy: OR = 33.222, P = 0.002). DISCUSSION: The definitive treatment for duplex system ureterocele remains controversial. We found that transurethral endoscopic incision or puncture was an independent risk factor for adverse outcomes. The main limitation of this study would be its retrospective nature and relatively short follow-up period. Furthermore, 30 children were younger than 5 years at last follow up, and thus, we could not efficiently evaluate their voiding function. CONCLUSIONS: Transurethral endoscopic incision or puncture is effective for decompressing the obstruction of the upper urinary tract in acute urosepsis in ectopic duplex system ureterocele. Although more than half of patients with unilateral ectopic duplex system ureterocele suffered from new-onset vesicoureteral reflux after transurethral endoscopic incision or puncture, few of them required secondary surgery.

Renal Cyst after Heminephrectomy in a Pediatric Patient: Complication or Normality?

Introduction: In this work, we present two cases of heminephrectomies with postoperative findings of cystic lesions in the bed of the excised renal segment. Material and Methods: Description of the clinical cases, therapeutic management and description of the ultrasound findings. A review of the published cases was carried out. Results: We present a case of open heminephrectomy due to atrophy of the upper hemirrenal in a case of ureterocele, and another case with bilateral lower heminephrectomy in a case of vesicoureteral reflux disease. In the first case, the cystic lesion disappeared during follow-up, while in the second, the cysts remained stable. In none of the cases published in the literature was it necessary to perform any intervention to resolve the cysts. Conclusions: The appearance of cystic lesions in the heminephrectomy bed in pediatric patients is a radiological finding that occurs frequently. Due to its favorable evolution, without the need for additional procedures for its resolution, we do not consider the presence of these lesions as a complication after heminephrectomy (AU)

Objetivos: En este trabajo presentamos dos casos deheminefrectomías con hallazgos en el postoperatorio de lesiones quísticas en el lecho del segmento renal extirpado.Material y Métodos: Descripción de los casos clínicos, manejo terapéutico y descripción de los hallazgosecográficos. Se realizó una revisión de los casos publicados.Resultados: Presentamos un caso de heminefrectomía abierta por atrofia de hemirriñón superior en un casode ureterocele, y otro caso con heminefrectomía inferior bilateral en un caso de enfermedad por reflujo vesicoureteral.En el primer caso, la lesión quística desapareció duranteel seguimiento, mientras que en segundo, los quistes permanecieron estables. En ninguno de los casos publicadosen la literatura se precisó realizar ninguna intervención pararesolución de los quistes.Conclusiones: La aparición de lesiones quísticas enel lecho de la heminefrectomía en pacientes pediátricos esun hallazgo radiológico que sucede con frecuencia. Debidoa su evolución favorable, sin necesidad de procedimientosadicionales para su resolución, no consideramos la presencia de estas lesiones como una complicación tras la heminefrectomía. (AU)

Papillary Urothelial Carcinoma Arising from Ureterocele: Is it a Rare Occurrence?

Various hydronephrotic, dysplastic or clinical pathologies can accompany ureterocele, which is a cystic dilatation of the intravesical part of the submucosal ureter. However, the development of cancer in the ureterocele is highly unusual. Hematuria is the most common sign, although imaging can also indicate alterations in the wall of the ureterocele. Unfortunately, there is no current guideline for the management of papillary urothelial carcinoma arising from ureterocele. Non-muscle-invasive bladder cancer treatment and follow-up protocols are classically applied. However, the anatomical structure of the ureterocele differs from that of normal bladder tissue. It is unclear whether this difference represents a risk in terms of deep tissue tumour invasion. In addition, tumour cells may migrate to the upper urinary tract due to urinary reflux developing following tumour resection. The management of papillary urothelial carcinoma arising from ureterocele must therefore be specific to that condition. However, this depends on an increase in the number of patients reported in the literature. Our review of the literature revealed very few reports. The present study is therefore particularly valuable from that perspective and describes the clinical management of a patient developing papillary urothelial carcinoma in ureterocele. Key Words: Ureterocele, Bladder, Hematuria, Urothelial carcinoma.