Primary obstructive megaureter: Initial experience with endoscopic dilatation
ABSTRACT Primary obstructive megaureter (POM) without vesicoureteral reflux has classically been managed by open surgery with ureteral reimplantation. We present seven patients with POM who were treated endoscopically with balloon dilatation of the distal ureter.
Six boys and one girl with POM were treated from June 2000 through July 2004. Six of the cases were diagnosed prenatally when ectasia of the urinary tract was seen on ultrasound scans. The postnatal diagnosis was also achieved by ultrasonography, along with a diuretic isotopic renogram with MAG-3, intravenous urography, and filling cystography. The age at surgery was 1 to 3 years. In all cases, a compact 10F infant cystoscope with a 5F working channel was used. Dilatation of the stenotic area was performed under fluoroscopic monitoring. A 4F dilating balloon was used, which was insufflated to between 12 and 14 atm for 3 to 5 minutes, and disappearance of the narrowed ring was verified. A Double-J catheter was positioned and withdrawn 2 months after the procedure. Clinical, analytical, and imaging follow-up was carried out with ultrasonography and MAG-3 renography.
The mean follow-up of the patients is 31 months (range 12-56 months). Their clinical progress was highly satisfactory. Five patients exhibited reduced obstruction at MAG-3. One patient needed a second dilatation, and the obstructive curve improved after this additional procedure. One of the patients presented with a febrile urinary infection after the dilatation, but there were no other complications.
Endoscopic management of POM by balloon dilatation has yielded very good results in the short term. Longer follow-up will enable us to determine the final indications for this treatment.
SourceAvailable from: Luis Garcia-Aparicio[Show abstract] [Hide abstract]
ABSTRACT: To describe the incidence, predisposing factors and management of postoperative vesicoureteral reflux (VUR) after high-pressure balloon dilation to treat primary obstructive megaureter (POM). 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. 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.World Journal of Urology 04/2015; DOI:10.1007/s00345-015-1565-9 · 3.42 Impact Factor
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ABSTRACT: Ureteral tapering and reimplantation is an established treatment for persistent or progressive primary obstructive megaureter (POM) but may result in complications and morbidity. Use of a less invasive technique involving endoscopic balloon dilation appears very interesting. The objective of this report is to determine if endoscopic balloon dilation for POM is effective in the long term as well as to assess complications of the procedure. A retrospective review was done on 19 patients and 20 ureters treated with the endoscopic balloon dilation by POM from June 2000 to February 2010. Surgery was performed solely in those cases in which there was persistence of obstruction in the renogram along with one or all of the following conditions: impairment of the differential renal function <40%, worsening of the renal pelvic dilation, febrile UTI in spite of antibiotic prophylaxis or renal calculi. The patients comprised 16 boys and 3 girls with a mean age at surgery of 17 months (range 1-44 months). Ten cases were left sided, eight right sided, and one bilateral. Under endoscopic and fluoroscopic guidance, a 3-5 Fr dilating balloon was inflated to 12-14 atm, or until disappearance of the stenotic obstructive area. A double J stent was positioned and withdrawn 2 months later. Follow-up recorded the presence of symptoms, number of reintervention procedures registered, and included renal ultrasound and MAG-3 renogram. There were no perioperative complications. Eighteen ureters showed a non-obstructive pattern on MAG-3 renogram after the first endoscopic dilation, representing a 90% success rate. One case required a second dilation, which proved successful and two cases of recurrent lithiasis required ureterotomy without instances of obstruction. 2 patients had a febrile UTI and a vesicoureteral reflux was diagnosed in one. Renal function was preserved in 95% of patients. The mean follow-up was 6.9 years (range 3.9-13.3 years). One patient was lost after the procedure. In an era of minimally invasive techniques, the search for less invasive procedures for treatment of POM has resulted in a variety of surgical options. Angulo et al., in 1998 and our group described the first POM treatment with endoscopic balloon dilation, which is believed to be a definitive, less invasive, and safe treatment. Furthermore, should an endoscopic approach fail, reimplant surgery can be performed. Few publications have reported short series with good results in the short and medium term. Torino et al. presented five cases in children aged less than 1 year, none of these showed evidence of obstruction. García-Aparicio et al. presented a series of 13 patients treated with a success rate of 84.6%. Christman et al. added laser incision in cases of narrowed ureteral segment 2-3 cm long and used double stenting. Good outcomes were presented in 71%. Romero et al. reported improvement of drainage within the first 18 months after treatment in 69% of patients. The potential de novo onset of vesicoureteral reflux may be the source of some controversy. We consider that dilation does not significantly alter the antireflux mechanism. In VCUG is not systematically performed because it is an invasive test. This restricts the conclusions that can be drawn from our findings. Nevertheless, some groups continue to systematically perform VCUG. Endoscopic balloon dilation for POM is a safe, feasible, and less invasive procedure that shows good outcomes on long-term follow-up. However, multicenter studies and prospective trials should be encouraged to provide more definitive evidence on its benefits. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.Journal of Pediatric Urology 02/2015; DOI:10.1016/j.jpurol.2014.09.005 · 1.41 Impact Factor
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ABSTRACT: The management of primary obstructive megaureter (POM) is usually conservative, at least in the first year of life. Nevertheless, in high grade POMs with increasing dilation, obstructive patterns found at renography or cases involving decreased renal function there is a clear indication for surgery. From January 2009 to March 2013, 12 patients, aged between 6 to and 12 months of age(mean age 8 months), were treated endoscopically for POM. At the procedure, a clear stenotic ring was identified in 10 out of 12 and a simple endoscopic high-pressure balloon dilation (EHPBD) was successful in 7. In the 3 cases with persistent ring, a cutting balloon ureterotomy (CBU) was then performed, resulting in the immediate and complete disappearance of the stenosis. In 2 cases, no ring could be seen at the procedure and they showed no improvement at the follow-up. The mean follow-up was 21 months. Considering the whole series of patients treated endoscopically, the overall success rate of EHPBD + CBU was 83 %. Patients with POM Severe POM, in patients under 1 year of age, can be treated endoscopically. In the case of a persistent ring that is unresponsive to EHPBD, cutting-balloon ureterotomy seems to provide a valid, definitive treatment of primary obstructive megaureter.Journal of endourology / Endourological Society 03/2014; 29(1). DOI:10.1089/end.2013.0665 · 2.10 Impact Factor