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 A Double-J catheter was positioned and withdrawn 2 months after the procedure.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.
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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
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ABSTRACT: Introduction It is well-known that the majority of congenital megaureters may be managed conservatively, but the indications and surgical options in patients requiring intervention are less well defined. Hence this topic was selected for discussion at the 2012 consensus meeting of the British Association of Paediatric Urologists (BAPU). Our aim was to establish current UK practice and derive a consensus management strategy. Methods An evidence-based literature review on a predefined set of questions on the management of the primary congenital megaureter was presented to a panel of 56 Consultant Surgeon members of the British Association of Paediatric Urologists (BAPU), and current opinion and practice established. Each question was discussed, and a show of hands determined whether the panel reached a consensus (two-thirds majority). Results The BAPU defined a ureteric diameter over 7 mm as abnormal. The recommendation was for newborns with prenatally diagnosed hydroureteronephrosis to receive antibiotic prophylaxis and be investigated with an ultrasound scan and micturating cystourethrogram, followed by a diuretic renogram once VUR and bladder outlet obstruction had been excluded. Initial management of primary megaureters is conservative. Indications for surgical intervention include symptoms such as febrile UTIs or pain, and in the asymptomatic patient, a DRF below 40% associated with massive or progressive hydronephrosis, or a drop in differential function on serial renograms. The BAPU recommended a ureteral reimplantation in patients over 1 year of age but recognized that the procedure may be challenging in infancy. Proposed alternatives were the insertion of a temporary JJ stent or a refluxing reimplantation. Conclusion A peer-reviewed consensus guideline for the management of the primary megaureter has been established. The guideline is based on current evidence and peer practice and the BAPU recognized that new techniques requiring further studies may have a role in future management.Journal of pediatric urology 02/2014; 10(1):26–33. DOI:10.1016/j.jpurol.2013.09.018 · 1.41 Impact Factor
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ABSTRACT: There is a growing interest in minimally invasive treatment of primary obstructive megaureter (POM) in children. However, the absence of long-term follow-up data, make it difficult to establish the indication for an endoscopic approach. The aim of our study is to determine long-term efficacy of endourologic high-pressure balloon dilation of the ureterovesical junction (VUJ) in children with POM that require surgical treatment. We retrospectively reviewed the clinical records from children with POM treated with endourologic high-pressure balloon dilatation of the VUJ from march 2003 to april 2010. To determine the long- term a cohort-study was conducted in November 2011. Endourological dilation of the VUJ was performed with semicompliant high-pressure balloon (2.7 FG) with a minimum size of 3 mm, followed by placement of double-J stent. We have treated 29 (32 renal units, left (n = 16), right (n = 10) and bilateral (n = 3)) children diagnosed of POM within this period of time. The median age at the time of the endourologic treatment was 4.04 months (range 1.6-39 months). In 26 children (29 renal units) a successful endourologic dilatation of the VUJ was achieved were followed with USS and MAG-3 lasix, that showed a progressive improvement of both the ureterohydronephrosis and drainage in the first 18 months in 20 patients (23 renal units) (69%). In two patients, treated with a 3 mm balloon, a further dilatation was required, with an excellent outcome. The cohort-study (at a median follow-up 47 months) showed that in all patients that had good outcome at 18th month follow-up after endourologic balloon dilatation remained asymptomatic with resolution of ureterohydronephrosis in the USS and good drainage on the renogram. Our study shows that children with POM treated with high-pressure ballon dilatation of the VUJ who have satisfactory appearance at 18 months maintain these results over time.Journal of endourology / Endourological Society 01/2014; 28(5). DOI:10.1089/end.2013.0210 · 2.10 Impact Factor