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Objective To analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries. Materials and Methods A retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P Results Postoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function. Conclusion Laparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Highlights • Ureterocele is rare especially with collecting system duplication in the nonorthotopic (extravesical) position in adult. • Ureterocele has a variety of clinical manifestations and complications. • Endoscopic treatment was performed to decompress hydroureteronephrosis. • In this case, laparoscopy heminephrectomy is needed due to dysfunctional uppers moiety. • Renal scintigraphy is a gold standard to assess function in the duplex kidney., Introduction Ureteroceles is a developmental anomaly with cystic dilation of the distal aspect of the ureter and are often associated with some urological anomaly such as a duplicated system or stenotic ureteric orifice. Presentation of case This study reports an ectopic ureterocele in duplication of collecting system associated with double ureters and ureteral ectopia in a woman aged 24 years with minor flank pain. Cystoscopy deroofing of the ureterocele performed and followed by secondary surgery laparoscopic heminephrectomy. Discussion Ureteroceles have various clinical manifestations and complications. Treatment for ureterocele depends on age, type of the ureterocele, obstruction to the draining system, and complications. No single method is sufficient for all cases, and management must be individualized. Endoscopic treatment has gradually broadened as a safe, minimally invasive, and effective procedure, but there is no consensus on its effectiveness for treating ectopic ureterocele. However, it is reported that 50–80% of cases after initial endoscopic treatment require secondary surgery. Conclusions Ureterocele is reported rarely in adults, especially with duplication of the collection system in the nonorthotopic (extravesical) position in women. Cystoscopy deroofing of the ureterocele can be performed to decompress the hydroureteronephrosis, and laparoscopic heminephrectomy can be performed due to dysfunctional uppers moiety. Long-term follow-up is required to monitor renal function, symptoms, and occurrence of vesicoureteric reflux.

Background Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. Case Report We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. Why Should an Emergency Physician Be Aware of This? Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.

Introduction The range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes. The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methods A retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. Technique We put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus. Results During the 1993–2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2–12). Successful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%). Discussion The anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of patients is small and there are few studies, hindering the agreement on the most appropriate technique. Conclusion Endoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Objective To evaluate the management and clinical outcomes of nonfunctioning upper pole moieties treated with either upper pole heminephrectomy or upper pole preservation with lower ureteral reconstruction at a single tertiary institution. Methods After Institutional Review Board (IRB) approval, patients with duplicated systems undergoing upper pole heminephrectomy, ureteroureterostomy, or common sheath ureteral reimplantation from 2012-2017 were identified. Only patients with a nonfunctioning upper pole moiety on ultrasound or renal scan were included. Patients undergoing upper pole heminephrectomy were compared to those undergoing upper pole preservation with respect to demographics, anatomic variations preoperatively, and postoperative outcomes. Results Twenty-seven (57%) patients underwent upper pole preservation with lower ureteral reconstruction; 20 (43%) patients underwent upper pole heminephrectomy. Patients undergoing lower ureteral reconstruction were older (1.63 vs 2.76 years, P = .018) and more commonly presented with lower pole vesicoureteral reflux (67% vs 25%, P = .008). No significant difference in postoperative complications was seen between the two groups. After ureteroureterostomy, one patient developed new onset symptomatic reflux to the upper pole requiring intravesical reimplantation. In the heminephrectomy group, 4 of 11 patients with ureteroceles had ureterocelectomy with concomitant lower pole reimplantation. After heminephrectomy, two additional patients required further interventions: ureterocele excision and transurethral polyp excision. Conclusion For patients with nonfunctional upper poles, lower tract reconstruction is a safe alternative to upper pole heminephrectomy. No significant difference in outcomes was seen. Considering that nearly 1 of 3 of patients with upper pole heminephrectomy required additional lower urinary tract procedures, pursuing upper pole preservation with lower urinary tract reconstruction may be favorable.

The management of UCs remain controversial, especially for UCs with duplex collecting systems that still represent a great challenge in paediatric urology. Several approaches have been used and a shared management is not yet validated.Aim of our study is to evaluate the results of the endoscopic treatment of UC comparing ortothopic single-system UC and ectopic duplex-system UC over a 10-year period in a single referral tertiary center. Success was defined as resolution of dilation, lack of urinary infections and preservation of renal function.We retrospectively reviewed medical records of children with a diagnosis of UC who underwent endoscopic puncture at our division from January 2009 to January 2019. Patients were divided in two groups: Group A composed of patients with ectopic UC associated with renal duplex system and Group B with orthotopic UC in single collecting system.We identified 48 paediatric patients treated with transurethral primary endoscopic incision. Groups result homogeneous for clinical and pathological characteristics. The only statistical significative difference between the two samples was the age at diagnosis (p value with Yates correction = 0.01).We considered as a therapeutic success infections control and the elimination of obstruction with preservation of global kidney function. Based on that, our success rate after single (77%) or double (92%) endoscopic treatment is higher than data reported in literature. Differently from previous studies, vescico-ureteral reflux without UTIs was not considered as a failure of the procedure. The present study has some limitations: it is a retrospective and monocentric serie and it lacked a longer follow-up; on the other hand, it has been conducted on a quite large sample size and it is one of the few studies that compares the endoscopic treatment between orthotopic and ectopic UC.Our data report primary endoscopic puncture of ureterocele as a simple, effective, and safe procedure also in long-term follow up. This technique avoids the need for additional surgery in the majority of the patients, also in the case of an ectopic UC associated to a duplex system.

Highlights • Ureterocele is a rare condition. One of its presentation is the presence of a stone, usually a solitary stone, inside the ureterocele. • Ureteroceles represent a clinical challenge in term of diagnosis and management due to their variable presentations and types. • Our patient ureterocele was complicated by a large calculus so we decided to proceed with endoscopic resection of the ureterocele along with stone removal., Introduction Ureterocele is a cystic dilatation of the lower part of the ureter. It is a congenital anomaly that is associated with other anomalies such as a duplicated system, and other diseases. It poses a great challenge owing to its numerous types and clinical presentations. Its incidence is 1 in every 4000 individuals. One of its presentations in the adult population is the presence of a stone, usually a solitary stone, inside the ureterocele. Case presentation We are reporting a case of an adult ureterocele complicated by a large calculus; managed endoscopically with transurethral deroofing of the ureterocele followed by cystolitholapaxy. A literature review was also conducted. Discussion The pathogenesis of ureteroceles is not well understood, however many proposed mechanisms exist with the incomplete dissolution of chwalla membrane being the most accepted one. The type of ureterocele and age at presentation will help guide the appropriate investigation and management, nevertheless certain goals of treatment should apply to all cases. Adult ureterocele is usually clinically silent but it may co-exist with other conditions such as a ureteral calculus and in these conditions it can be managed endoscopically. Conclusion Ureteroceles complicated by stones can be effectively managed with endoscopic resection or incision of the ureterocele coupled with stone removal, however long term follow up is required to monitor for hydronephrosis and iatrogenic vesicoureteric reflux.

To analyse the outcomes of retroperitoneoscopic upper and lower moiety hemi-nephroureterectomy (HNU) and to assess the different variables that may have an impact on outcome; remnant moiety damage, morbidity and the need for secondary surgery.Prospectively recorded data of retroperitoneoscopic HNU's performed by a single surgeon from 2005 to 2018 were analysed. Patients were split into 2 groups according to moiety affected (UMHNU and LMHNU). Clinical presentation, underlying pathology, remnant moiety DRF on renal scintigraphy, and need for further surgery were recorded. Detailed operation notes were studied regards to renal vasculature, degree of dilatation, inflammatory changes and operative difficulties encountered. Renal loss was defined as remnant moiety DRF10% post-operatively. Change in DRF was assessed regards to the moiety, pathology and age at surgery (1 year, 1-2 years and ≥2 years). UMHNU group was further sub-divided into 3 subgroups: ureteroceles, ectopic ureters and 'other' pathology. Statistical analysis was performed using Fishers Exact test; findings were considered statistically significant at p 0.05.78 operations met the inclusion criteria on 75 patients (3 bilateral). There were no conversions to open, and 67% were performed as day-case procedures (53/78 patients). In 91.2% (71/78) patients the procedure was definitive in resolving pathology and symptoms. 7 patients needed further procedures after HNU, 5 for ureterocele/ureteric stump. Overall, there was remnant moiety renal loss in 5.1% (4/78) patients, all with UM surgery (3 ectopic ureters and 1 ureterocele). All 4 operations were recorded prospectively as 'difficult operations' due to grossly dilated UM ureter/pelvis measuring2 cm in diameter. 2 patients had a thinned out lower moiety (LM) sitting on top of the UM renal pelvis like a pancake with all vessels stretched over this dilated pelvis/ureter causing difficulty in accurate identification. There was intra-operative concern about some damage to LM vessels in 3 patients. Age1year was also related to increased renal loss (2/8 patients1 year, 1/25 patients 1-2 years, 1/45 patients ≥2 years of age P = 0.005).Retroperitoneoscopic LMHNU is a safe and definitive procedure with rapid recovery and minimal scarring. UMHNU has higher rates of remnant moiety loss due to more complex renal pathology, but remains a safe, successful operation on the majority of patients. Renal damage was also related to age1year (p = 0.005) and re-operation risk after UMHNU correlated to the presence of ureterocele (p = 0.003).

Duplication of renal system is one of the commonest renal anomalies. It is infrequently associated with renal calculus, ureterocele and vesico ureteric reflux. We report a 29-year male with right complete duplex system having upper moiety multiple ureteric calculi and lower moiety inferior renal calculus. Single sitting fURS was done and calculi in both systems were tackled one at a time. Calculi were dusted with holmium laser and double J stent placed in upper moiety ureter. Calculus management in anomalous kidney is challenging. Single sitting flexible ureterorenoscopy is feasible option in duplex renal system with low burden calculi.

To assess the outcomes of "watering can" ureterocele puncture (WCP), a technique previously associated with decreased incidence of de novo vesicoureteral reflux (VUR), as a durable option for management of ureteroceles and to determine the need for subsequent surgery for VUR following watering can puncture.We retrospectively reviewed records of 55 consecutive endoscopic ureterocele procedures performed at our institution from 1999 to 2015. The WCP was performed using a holmium laser fiber to make 10-20 puncture holes through the ureterocele. Follow-up data were collected on infection, de novo VUR in the affected renal moiety and the need for further treatment and surgery.Of 55 patients who underwent endoscopic ureterocele management, 34 underwent WCP and 21 patients underwent either incision or puncture. Median follow-up was 3.4 and 2.8 years in the incision and puncture groups, respectively. Both groups had similar rates of ureterocele decompression (88% vs 90%; P .05) and improvement in hydronephrosis (82% vs 81%; P .05). The WCP group had a significantly decreased rate of de novo VUR (32% vs 67%; P .05) and of subsequent surgery due to de novo VUR (38% vs 71%; P .05). The average grade of de novo VUR was lower in the WCP group (1.4 vs 2.8; P .05).Our study shows that the endoscopic WCP successfully decompresses the obstructing ureterocele and results in a decreased incidence of de novo VUR and ultimately in fewer invasive procedures for the patient. This update demonstrates the durable outcomes of this novel technique.

Objective To assess the results of the initial therapeutic approach to ureteroceles at our institution and the need for further interventions. Patients and Methods This is a retrospective study of all pediatric cases of ureterocele diagnosed at our center between January 2000 and December 2011. Results Forty-three patients were analyzed. Initial diagnoses were ureterohydronephrosis in 34 (33 prenatal), febrile urinary tract infection in 5, and prolapsed ureterocele in 3. Expectant management was decided upon in 6 patients (14%). Of these, 1 required surgery. The remaining 37 (86%) initially underwent surgery: transurethral puncture (18), heminephrectomy (14), nephrectomy (3), and reimplantation (2). Twelve (66.6%) of the 18 patients who underwent primary puncture progressed well and required no further intervention. New-onset vesicoureteral reflux to the upper pole appeared after puncture in 3 patients, but none required treatment. Only 6 patients (33.3%) underwent a second procedure. Mean follow-up was 8.5 years (standard deviation: 3.08). Conclusion Early endoscopic puncture is useful for decompression and often the definitive treatment. Although new-onset vesicoureteral reflux into the punctured system is the most common complication, it often resolves spontaneously. Early heminephrectomy in patients with nonfunctioning upper moieties yields excellent results but may not be necessary. Some patients may not need transurethral puncture or any surgical intervention at all.

Study Objective The objectives of this video are to demonstrate normal findings at the time of cystourethroscopy, show examples of common benign findings within the bladder and urethra, and to show lesions that warrant additional investigation. We hope to provide examples of common benign and malignant findings to gynecologic surgeons to assist with recognition if they incidentally found. Design N/A Setting Tertiary academic hospital with a high-volume gynecologic surgery practice Patients or Participants The images shown in the video are taken from a variety of patients undergoing cystoscopy by two urogynecologists. Interventions Images were obtained at the time of surgery for educational purposes Measurements and Main Results This video demonstrates the equipment and steps of performing cystourethroscopy. We review examples of the following benign anatomic variants: shaggy urethral fronds, squamous metaplasia, cystitis cystica, bladder trabeculations, ureterocele, bladder diverticula, bladder wall cysts, ureteral orifice cysts, hypervascularity, duplicated collecting systems, foreign bodies, and fistulas. We also review two examples of neoplastic findings, including urothelial papilloma and papillary urothelial carcinoma. Conclusion Cystoscopy can be a useful procedure in the office and operating room. Gynecologic surgeons should be familiar with normal cystoscopy findings. If abnormalities are found, it is the surgeon's responsibility to document and refer the patient for additional testing if indicated.

Summary Introduction Upper pole heminephrectomy (UHN) is performed for two main indications in children: ectopic ureterocele and duplication anomalies with upper pole ectopy, both in the context of a poorly functioning upper pole moiety. Current popular techniques for conducting UHN include laparoscopic (LPN) and robot-assisted laparoscopic (RAPN). Objective To evaluate outcomes following dorsal lumbotomy (DL), an open approach used historically for pyeloplasty and pyelolithotomy, and in which no clinical trials or exclusive case-series have been conducted for upper pole hemi-nephrectomy (UHN) in children. We ultimately aim to compare our outcomes following DL at our centre to that of published outcomes of minimally invasive approaches to UHN. Study design Institutional board review was obtained (H18-03716) for a retrospective review of 50 UHN performed in 49 consecutive pediatric patients using the DL approach by a single surgeon between 2001 and 2019. Clinical variables and indicators included age, sex, weight, skin-to-skin time, total operating room time, duration of hospital stay, post-operative complications, analgesic requirements, and post-operative ultrasound results. Results Of 50 UHN performed, 23 had a presurgical diagnosis of ectopic ureter, and 27 ureterocele. Mean weight of patients was 12.61 kg, and the mean age at surgery was 24.55 months. Mean (range) for time between skin incision and closure was 88.5 (62–132) minutes, and the mean (range) total operating room time was 138.5 (70–180) minutes. There were neither intraoperative complications nor transfusions. The mean (range) post-operative opioid delivered was 0.73 (0.00–2.00) mg/kg/day. Mean (range) post-operative ibuprofen delivered was 5.41 (0.00–37.73) mg/kg/day. Median length of hospital stay was 2 days. No patient received post-operative prescriptions for narcotics at discharge. There were no wound complications. One patient had secondary atrophy of the lower pole. Secondary lower tract surgery, unrelated to surgical approach, was performed in five patients. Ten patients experienced a urinary tract infection at some point after surgery. Conclusion DL is safe, feasible, and produces operative outcomes and times comparable to that of laparoscopic and robotic techniques. These findings as well as operative costs should be considered when selecting a surgical technique for UHN. Summary . Patients' demographics, operative and post-operative characteristics Age, months, mean ± SD (range) 24.55 ± 24.00 (5–132) Weight, kg, mean ± SD (range) 12.61 ± 5.35 (6.90–31.00) Time between skin incision and closure (skin-to-skin), min 88.51 ± 16.79 (62–132) Total operating room time, min 138.46 ± 24.60 (70–180) Length of hospital stay, days 2.55 ± 0.74 (2–5) Follow-up, months 22.25 ± 35.88 (1.70–179.03) Post-operative opioid (mg/kg/day) 0.73 ± 0.44 Post-operative acetaminophen (mg/kg/day) 66.51 ± 21.03 Post-operative ibuprofen (mg/kg/day) 5.41 ± 9.72 Values are described as “mean ± standard deviation (range, if applicable)”.

Aim To evaluate the diverse presentations of Herlyn–Werner–Wunderlich (HWW) syndrome on magnetic resonance imaging (MRI) and its surgical correlations. Materials and methods From 2014 to 2019, a total of 40 patients with HWW syndrome underwent pelvic MRI. All MRI images were reviewed by two experienced radiologists in consensus. Uterine anomalies, obstruction sites, laterality and communications, urinary anomalies, and other abnormal findings were recorded. MRI findings were correlated with ultrasonography and surgical results. Results On MRI, the uterus was didelphic in 25 (62.5%), septate in nine (22.5%) and bicornuate in six cases (15%); an ipsilateral vaginal septum was found in 30 cases (75%), and ipsilateral cervical obstruction (obliterated cervical os) was found in 10 cases (25%). Twenty-seven patients underwent surgical treatment. MRI diagnoses of obstruction sites correlated completely with the surgical results. Although obstruction communications could not be found with ultrasonography, MRI identified nine cases of cervical communication, but failed to detect the five cases of surgically confirmed fistula on the vaginal septum. Moreover, MRI identified nine cases of ipsilateral ureteral remnants and/or paravaginal cystic structures, all with insertion into the obstructed vagina or cervix, and one case of ipsilateral ureterocele. Conclusions HWW syndrome can present as different combinations of uterine anomalies, unilateral cervico-vaginal obstruction, and ipsilateral renal anomalies; ipsilateral paravaginal cystic structures and/or ureter remnants inserting into the obstructed vagina or cervix can occasionally be seen. MRI can provide a comprehensive preoperative evaluation and better identification of obstruction sites, but seems insensitive for detecting vaginal communications in HWW syndrome.

Summary Introduction Duplex systems can be complicated by reflux, ureterocele, obstruction (most commonly PUJ in a lower moiety) and wetting secondary to an ectopic ureteric insertion in girls. The decision making algorithm for selection of surgical approach is complex and there is no consensus. The authors described the outcomes following an upper urinary tract approach in 2011(1) and now compare these results in a similar group of patients managed using a lower approach. Objectives To assess whether a top-down or bottom-up approach results in different likelihoods for further surgery. Study design A prospectively database was maintained for consecutive patients undergoing surgery for duplex systems by a single surgeon between 2003 and 2015. Patients were classified into 2 groups; Group 1 initial intention for upper urinary tract approach (heminephroureterectomy-HN) or Group 2 lower urinary tract approach (bladder reconstructive surgery-BRS). The requirement for further surgery was recorded-endoscopic incision (EI), bladder reconstructive surgery (BRS), endoscopic correction of reflux (ECR), heminephroureterectomy (HN). Indications for initial and subsequent surgery included urinary tract infection, VUJ obstruction and incontinence. Endoscopic incision was not performed for patients with an asymptomatic ureterocele. Statistical analysis consisted of Fisher's exact test with a 2 tail p value Results 79 patients underwent surgery for duplex systems. 39 patients had HN initially (Group 1) and 40 patients had BRS initially (Group 2). Further surgery was performed in 21% of patients from Group 1 (8 BRS) vs 5% of patients from Group 2 (1 redo BRS, 1 ECR). Significantly less additional surgical procedures were performed after BRS compared to HN (p = 0.048). The presence of both reflux and ureterocele increases the chances of further surgery in those patients who had HN initially compared to BRS (p = 0.01). No patients developed urinary retention or required intermittent catheterisation to improve bladder emptying. Conclusions Bladder reconstructive surgery (BRS) reduces the requirement for further surgery compared to heminephroureterectomy (HN) in symptomatic patients with a duplex kidney and either dilating vesicoureteric reflux or ureterocele. Summary Table . Group 1 –HN (Heminephroureterectomy) 2 –BRS (Bladder reconstructive surgery) Number of patients 39 40 Gender (Male: Female) M 10: F 29 M 8: F 32 Indication for initial surgery Infections 33 26 Incontinence (ectopic ureter) 2 4 Progressive hydronephrosis 4 10 Median age at surgery (years) 2.2 years (1.6–3.4) 3.4 years (1.9–6.4) Median duration of follow up (years) 11.9 (10.6–12.8) 5.6 years (4.2–7.1) Overall requirement for further surgery (%) 8 patients (21%)∗ 2 patients (5%)∗ Indication for redo surgery Infections 8 (stump infections 2, reflux to ipsilateral lower moiety 2, ureterocele dilatation 4) 1 (reflux) Incontinence 0 0 Progressive hydronephrosis 0 1 (VUJ stenosis) Nature of further surgery 21% (8 BRS) 5% (1 redo BRS, 1 ECR)

Objective To present our center's experience in single-port umbilical laparoendoscopic partial cystectomies, in both benign and malignant pathologies. Patient characteristics, perioperative aspects and the surgical techniques used are reviewed. Material and method Since May 2012, five patients have undergone a transumbilical single-port laparoendoscopic partial cystectomy with curved equipment through a reusable multichannel system and a 3.5 mm accessory trocar. Patients were three males and two females aged between 28 and 78 (median: 44 ± 42.5) years. The etiologies were endometriosis (in 2 cases), a tumor in the diverticulum, a congenital bladder diverticulum and ureterocele (1 case of each). Results Median surgery time was 273 ± 163.4 min, and intraoperative bleeding 250 ± 175 ml. None of the patients required transfusion. The postoperative period was uneventful, with good results and no complications. The hospital stay was 3 ± 1 days. With monitoring of 20 ± 17.5 months, morphological and functional recovery in the bladder and ureter was confirmed in all cases and the patient with neoplastic disease was disease-free more than 2 years after the surgery. Conclusions An umbilical laparoendoscopic partial cystectomy represents a viable surgical option and ensures that excellent surgical and cosmetic results are achieved.

Objective To analyze the outcomes of umbilical laparoendoscopic single-site (LESS) ureteral reimplantation using a reusable single-port platform. Materials and method The casuistic of LESS ureteral reimplantation in 5 patients is presented. The surgical technique using KeyPort system (reusable umbilical single-site platform) is described. Dissection, suctioning and suturing by minilaparoscopy through 3.5 mm accessory port in the iliac fossa are performed. Operative and postoperative outcomes are presented. The median follow-up at time of analysis was 11 ± 14 months. Results The median age of patients was 49 ± 34 years; male-female ratio was 1:1.15. Left surgery was carried out in all cases. In 4 patients, the etiology was secondary to stenosis (3 iatrogenic and 1 pelvic endometriosis). In the remaining case, the procedure was performed after excision of a symptomatic adult ureterocele. In all cases, bladder catheter and double-J ureteral catheter were inserted for 7 ± 3 and 30 ± 15 days and then removed. No conversion to convectional laparoscopic or open surgery occurred. The surgery time was 145 ± 60 min, and intraoperative bleeding was 100 ± 75 cc. Neither transfusion nor high analgesia was necessary. No postoperative complications, minor or major, have been reported. Hospital stay was 2 ± 0.5 days. In any patient, restenosis or worsening of renal function occurred. Conclusions In experimented centers, transumbilical laparoendoscopic single-site ureteroneocystostomy is a safe alternative with comparable results to conventional laparoscopy and an excellent cosmetic result at low cost thanks to device reuse.

The optimal management approach for children with ureterocele and complete pyeloureteral duplication, especially in the setting of high-grade ipsilateral vesicoureteral reflux, remains unclear. Trends in surgical management reflect a shift from single-stage open reconstruction toward conservative management and minimally invasive approaches. This article reviews lower tract approaches (endoscopic ureterocele incision and ipsilateral ureteroureterostomy), and upper tract approaches (ureterocele moiety heminephrectomy) in terms of selected operative techniques, patient selection, published outcomes, postoperative care, and follow-up. Current data support endoscopic puncture as a safe and effective treatment of symptomatic children with single-system intravesical ureteroceles.

Objective An obstructed megaureter can be managed using a number of techniques, with the primary goal being to minimize the potential for further injury to the affected kidney. Classically, these obstructed ureters have been treated using cutaneous ureterostomy. However, this technique has certain limitations including the potential for stenosis. We describe our experience with the refluxing ureteral reimplantation as a novel, yet technically simple, method for temporary internal diversion of the obstructed megaureter. Methods Treatment consists of transecting the ureter proximal to the obstruction and performing an end-to-side anastomosis with the bladder in a freely refluxing fashion. Patients are placed on antibiotic suppression following surgery. Subsequent open definitive surgery is performed through the same incision site once the child is older than 1 year of age. Results Sixteen patients identified with severe hydroureteronephrosis were found to have an obstructed megaureter(s) involving 19 ureteral moieties. Patients underwent internal diversion at an average age of 5 months. All patients demonstrated improved drainage of the affected kidney(s) following surgery. Three patients developed a febrile urinary tract infection. Definitive surgical treatment was undertaken in 18 of 19 ureters, and consisted of ureteral reimplantation with tapering or plication (13), ureteral reimplantation without tapering (3), and nephrectomy (2). One patient with multiple other congenital anomalies is not a candidate for further genitourinary reconstruction. Conclusions Refluxing ureteral reimplantation is a safe and easy method of temporary internal urinary diversion. Simple in principle, the concept of creating a refluxing ureteral reimplantation is no different from that of incising an obstructing ureterocele. This technique allows time for the child to mature, while preserving renal function and awaiting definitive repair.

Background The efficacy and utility of continuous antibiotic prophylaxis (CAP) in children with congenital antenatal hydronephrosis (ANH) is uncertain. The literature has both supportive and contradictory evidence. The growing trend not to place children with ANH on CAP has created varied clinical practice based on anecdotal individual case characteristics. Our goal was to compare individual infant characteristics between those children who were maintained on CAP to those that were not to try to determine predisposing risk factors to febrile. Methods All electronic medical records (EMRs) of children referred to our institution for congenital ANH over a period from 2001 to 2011 were examined. We excluded those referred for urinary tract infection (UTI) who had a history of congenital ANH. We also excluded those with incomplete records, or follow-up less than 2 years. Children were divided into two groups: those maintained on CAP (YCAP) and those not maintained on CAP (NCAP). Our primary endpoint was febrile UTI. Follow-up was at least 24 months. Demographic, perinatal and postnatal clinical data were recorded. Statistical analysis was performed using STATA Version 11.1. Results Of the 405 children fitting inclusion criteria, 278 (68.6%) children were maintained on CAP and 127 (31.4%) were not on CAP. The incidence of prematurity, oligohydramnios, perinatal respiratory complications, use of perinatal antibiotics, circumcision status, renal anomalies, associated medical diagnoses, and low birth weight did not differ between the two groups. Overall the incidence of febrile UTI during the follow-up period was 22.2%. The incidence of febrile UTI between the YCAP and NCAP groups was significant (YCAP = 7.9% and NCAP 18.7%, p = 0.021). Multivariate logistic regression using CAP as the dichotomous dependent variable revealed that ureteral dilation, high-grade vesicoureteral reflux (VUR), and ureterovesical junction (UVJ) obstruction were independent risk factors for febrile UTI. More specifically, children with ureteral dilation >11 mm NOT maintained on CAP had a 5.54 (OR = 5.54; CI = 3.15–7.42, p = 0.001) fold increased risk of febrile UTI compared to those maintained on CAP. Conclusions The presence of ureteral dilation, high grade VUR, and UVJ obstruction were independent risk factors for development of UTI in children with congenital ANH. Therefore CAP may have a significant role in reducing the risk of febrile UTI in children with ANH with those identifiable risk factors, but otherwise seems unnecessary.

Objective Urethral prolapse (UP) is a complete eversion of the distal urethral mucosa through the external meatus. UP must be distinguished by examination from trauma, prolapsed ureterocele, tumors or sexual abuse. Its management remains controversial. The aim of the study was to promote the benefits of primary surgical management for UP. Methods A retrospective multicenter review of children who received surgery for UP between 1991 and 2011 was carried out. Non-complicated UP was primarily treated conservatively. A total of 19 patients were referred for complicated UP and underwent resection of the prolapsed urethral mucosa. Results The mean delay in diagnosis was 2.2 days (range 1–6) and the most common symptoms were vaginal spotting and bleeding. No predisposing factor was found, but most patients had a mean weight, height and BMI greater than the 50th percentile. All patients underwent surgery successfully. One patient experienced a complication, i.e., dysuria. There was no case of recurrence after a mean 28 months of follow-up. Conclusion Early detection is based on bedside examination. The first-line treatment strategy for uncomplicated UP should be conservative management. Surgical resection is safe and effective for patients with significant symptoms.

Summary Objective The aim of this study is to evaluate the efficacy of primary cystoscopic transurethral incision (CTUI) in the management of paediatric ureteroceles. The secondary aim is to compare the efficacy of CTUI between simplex and duplex systems. Patients and methods This is a retrospective review of consecutive paediatric patients requiring surgical intervention for ureterocele. Data collected for analysis included demographics, diagnostic, pre-operative investigations, operative interventions and postoperative variables. Results Over a 19-year period, 79 consecutive cases were identified, and 42 were male (53.2%). The mean follow-up was 6.7 years. Seventy-three (92.4%) cases underwent primary CTUI; 50 of these cases (68.5%) required no further procedures during the study period. Sixty-one cases were treated by endoscopic intervention alone (77.2%). Forty-one (51.9%) cases had a simplex system, and 38 (48.1%), a duplex system. There was no statistically significant difference in the efficacy of primary CTUI in simplex vs duplex systems. Of the 20 patients who had pre-operative and postoperative micturating cystourethrograms performed, seven (35%) developed de-novo postoperative vesicoureteric reflux after CTUI. Conclusion Primary CTUI is a safe, minimally invasive procedure that is definitive in the majority of children presenting with a ureterocele that requires intervention. There was no difference in success of primary CTUI between simplex or duplex systems. Download : Download high-res image (302KB) Download : Download full-size image Summary Fig .

The penis as a component of external genitalia, takes part in fertility, urinary and psychosexual structure of males with its complex character. We report a case of penis agenesis with associated left renal agenesis, left superior segment ureteral agenesis, prostate agenesis, left ureterocele, right vesicoureteral reflux and high urethrorectal communication above the rectal sphincter. The patient refused any surgical intervention because of his religious beliefs.

We report on the observation of a 30-month-old female newborn that was treated for a urinary infection. The medical imaging revealed the existence of a right double system ureterocele with vesicorenal reflux on the ureter of the upper pyelon and a bifid left ureter. The treatment consisted in an ureterocelectomy, a reimplantation of the two right ureters and a repair of the vesical floor. The external drainage of the upper pyelon allowed us to make sure of its functionality that was about 15% of the full renal function. The post-op follow-ups have been simple and thirteen months later, the newborn is doing well and does not present any sign of urinary infection.

Duplex renal collecting systems are common congenital anomalies of the upper urinary tract. In most cases they are incidental findings and not associated with additional pathologies. They demonstrate, however, higher incidences of hydroureteronephrosis, ureteroceles, and ectopic ureters. The most comprehensive morphologic and functional evaluation of duplex systems can be achieved using magnetic resonance urography. Functional magnetic resonance urography allows better separation of the renal poles, thus more accurate calculation of the differential renal functions compared with renal scintigraphy. Magnetic resonance urography is the study of choice when upper urinary tract anatomy is complex or when functional evaluation is needed.

Objective A systematic initial endoscopic approach has been locally adopted since 2002 for the treatment of ureterocele. Our aim was to compare outcomes for patients treated with this approach to those treated prior to this date. Methods We reviewed the charts of 145 children with ureteroceles treated surgically between 1992 and 2010. Patients were divided according to ureterocele position, year of treatment and type of initial intervention. Evaluation was completed by ultrasound, voiding cystourethrogram and nuclear renal scans. Results Mean age at initial surgery was 18 months. Group 1 comprised 68 patients operated before 2002, and Group 2 66 patients operated after 2002. Group 1 patients showed a higher rate of preoperative vesicoureteral reflux. Mean follow-up was 43 and 25 months for group 1 and 2, respectively. Ureteroceles treated endoscopically underwent secondary procedures in 61% (group 1) and 42% (group 2) for ectopic and in 42% (group 1) and 10% (group 2) for orthotopic ureteroceles. Overall, there was more de novo upper moiety VUR in group 1 (48% vs 12%). Conclusion Primary endoscopic ureterocele treatment seems to be an appropriate option for children with a clinically significant ureterocele. The rate of secondary procedures was higher for ectopic ureteroceles but acceptable compared to the upper tract approach.

Objective Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. Methods We analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6 mm high-pressure balloon after inserting a stent with guidewire of 0.014 in. to the ureterocele. Results There were no intraoperative or postoperative complications, surgical time being 24 ± 9 min. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatically after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. Conclusions High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.

To our knowledge, there are only few published cases of benign renal AML presenting with tumor thrombus in females. We present a new case of this uncommon complication of a benign renal tumor.Epithelioid angiomyolipoma is a recently described rare variant of renal angiomyolipoma.It can occur in patients with or without tuberous sclerosis, and may potentially bemalignant. Benign renal angiomyolipoma (AML) rarely presents with evidence of extension into the renal vein, inferior vena cava (IVC) or atrium. We report a case of a benign renal AML with a tumor thrombus extending into the IVC in a 46-year-old female who presented with right-sided flank pain associated with a right sided abdominal mass. Right Radical nephrectomy with IVC tumor thrombectomy was done. Patient is totally asymptomatic. At 1 month after surgery, an abdominal ultrasound showed no evidence of thrombus within the IVC. CT scan of the abdomen at 3 months post-operatively showed no evidence of recurrence. Surgical treatment of angiomyolipoma with IVC thrombus is warranted in view of risk of malignancy and to prevent tumor embolus to the heart or lungs.

Objective We report our initial experience, and describe our technique, in performing laparoscopic ipsilateral ureteroureterostomy (IUU) in the pediatric population. Materials and methods An IRB-approved, retrospective review of all patients undergoing laparoscopic IUU at our institution between 2006 and 2009 was performed. Demographic data, mode of presentation, underlying diagnosis, operative parameters, complications and follow-up data were analyzed. Cystoscopy, retrograde pyelograms and ureteral stent placement into the lower pole ureter were performed at the beginning of all cases. All were performed via a transperitoneal approach. An end-to-side ureteral anastamosis was carried out along the proximal lower pole ureter. No drains were left in place. Urethral catheters were left for 48 h. Results There were seven patients in the series. All were female with a mean age of 84 months (11舐190). Diagnosis was an ectopic ureter in six patients and a ureterocele in one patient. No patient required conversion to an open approach. Mean total operative time was 187 min (140舐252). Mean hospital stay was 2 days (1舐4) with a mean follow up of 8 months (1舐15). No complications occurred postoperatively. Follow-up studies demonstrate decreased or resolved hydronephrosis in all cases. Conclusions In our initial experience, laparoscopic IUU can be accomplished in a safe and effective manner with minimal complication.

Introducción: La duplicación del uréter y la pelvis renal es la anomalía más común del tracto urinario superior. La heminefrectomía polar superior es el tratamiento de elección cuando la anomalía se asocia con ectopia ureteral o ureterocele en un sistema no funcionante o infección crónica del riñón. Material y método: Se describe la heminefrectomía del polo renal superior por NOTES-híbrido en una mujer de 24 años de edad con infecciones urinarias recurrentes en un sistema superior con escasa función. El procedimiento se realizó con un trócar bariátrico a través de la vagina, y un trócar multicanal (Triport, Olympus Surgical) a través del ombligo. Se utiliza bisturí ultrasónico para la heminefrectomía. El espécimen se retira por la vagina. Resultados: El tiempo operatorio fue 150 minutos y el sangrado 50 cc. Después de una semana la paciente desarrolló un urinoma en el lecho quirúrgico, que precisó exploración por vía laparoscópica. El lecho de la heminefrectomía fue fulgurado y se colocó un drenaje. La paciente se recuperó sin eventualidad tras la reintervención. Conclusiones: Se describe la técnica de heminefrectomía transvaginal con técnica NOTES-híbrido. Este abordaje requiere mayor desarrollo, tanto de la instrumentación como de la técnica. La combinación de los abordajes umbilical y transvaginal restablece la triangulación y facilita la disección, pero se requiere más experiencia para determinar su seguridad, eficacia y reproducibilidad. Introduction: Duplication of the ureter and renal pelvis is the most common anomaly of the upper urinary tract. Upper pole heminephrectomy is a treatment option when duplication anomalies are associated with ureteral ectopia or ureterocele with an associated nonfunctioning or infected upper pole moiety. Material and method: We describe a NOTES hybrid transvaginal upper pole heminephrectomy in a 24 year old with recurrent infections in a poorly functioning right upper pole moiety. The procedure was performed with a bariatric trocar in the vagina, and a multichannel single-port device (Triport, Olympus Surgical) in the umbilicus. An ultrasonic scalpel was used for the heminephrectomy. The specimen was retrieved through the vagina. Results: Operative time was 150 minutes and blood loss 50 cc. One week later the patient developed urinoma at the surgical site and was re-explored laparoscopically. The cut edge of the heminephrectomy defect was fulgurated and a drain placed. The patient recovered uneventfully following re-exploration. Conclusions: We describe the technique for transvaginal Hybrid-NOTES heminephrectomy. This approach requires further development with respect to instrumentation, and surgical expertise. The combined umbilical and vaginal approached restored triangulation and facilitates dissection, but more experience is required to determine safety, efficacy and reproducibility.

OBJECTIVES To report our experience with the endoscopic treatment of ectopic ureterocele to demonstrate its long-term effectiveness. Endoscopic treatment is often recommended as the initial and definitive treatment in patients with ureterocele. METHODS A total of 46 children with ectopic ureterocele in a duplex system underwent primary endoscopic incision from January 1998 to January 2006. The mean follow-up was 3.8 years. Of the 46 children, 35 had been diagnosed prenatally and 11 had been diagnosed after birth because of a urinary tract infection. Low-dose antibiotic prophylaxis was administered to all children and was maintained until voiding cystourethrography showed no reflux. The pre- and postoperative evaluation included clinical assessment, ultrasound evaluation, diethylenetriaminepentacetic acid renography, and cyclic voiding cystourethrography. RESULTS Ureterocele decompression was achieved in 43 patients (93%). Three patients required additional surgery for persistent ureterocele (1 underwent ureteroureterostomy and 2 ureteropyelostomy). None of our patients showed deterioration of renal function after the procedures. Vesicoureteral reflux was seen in the lower moiety of the ipsilateral kidney in 14 patients (30%). Of the 14 patients with vesicoureteral reflux, 10 had spontaneous resolution. The remaining 4 underwent endoscopic correction. Five patients (10%) developed de novo vesicoureteral reflux in the ipsilateral ureterocele moiety. Of these 5 patients, 3 were treated with endoscopic injection and 2 had spontaneous resolution after 6 months of follow-up. CONCLUSIONS Our data have shown that primary endoscopic puncture of a ureterocele is a simple, long-term, effective, and safe procedure, avoiding complete reconstruction in most patients.

Summary Introduction Historically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles. Objectives With data derived from a retrospective chart review of patients with ureteroceles that were detected antenatally, the current study aimed to determine which group of children would be at risk for failure on active surveillance. It was hypothesized that single system ureteroceles (SSU) and male patients with duplex system ureteroceles (DSU) would be ideal for observation. Methods Outcomes were assessed by descriptive statistics. Kaplan–Meier curves were utilized to estimate median duration on active surveillance in both single and duplex cohorts. Breakthrough febrile urinary tract infection (fUTI) and surgery were determined by Cox regression in the duplex system cohort. Surgery was considered surveillance failure. Results A total of 102 patients (64 females/38 males) met the criteria: 78 (76.5%) had DSU and 24 (23.5%) SSU. The overall median observation was 1.2 years (range 0.7–3.1). Follow-up ranged from 0.3 to 11.7 years for SSU, and from 0.02 to 17.3 years for DSU. The predictors of failure of active surveillance (AS) in DSU (surgical intervention) were male gender (HR 1.8, 1.0–3.3, P = 0.037), or fUTI (HR 3.1, 1.7–5.8, P = 0.002). Predictors of fUTI were contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter (OR 9.5, 1.2–71.7, P = 0.028). Interestingly, vesicoureteral reflux (VUR) was not a predictor of fUTI. The SSU patients were ideal for AS, while in DSU, surveillance was successful in 30% of patients who were primarily females without contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter. However, in contradiction to the hypothesis, males were at higher risk for surgical intervention in the DSU cohort. Conclusion Active surveillance is an option for patients with antenatally detected ureteroceles, but careful long term follow up is mandatory. Parents should be advised that surgical intervention may still be necessary, particularly in males with DSU. Summary table . Patient characteristics Total, n = 102 SSU, n = 24 DSU, n = 78 Gender Female 6 58 Male 18 20 Circumcision Yes 5 4 No 11 13 Not reported 2 3 Interval on AS 252 days to 3.1 years 100 days to 11.2 years 7 days to 17.2 years Hydronephrosis of the lower moiety (ipsilateral to ureterocele) No N/A 11 Hydronephrosis only N/A 47 Hydroureteronephrosis N/A 20 Ipsilateral reflux (any grade) 4 34 Surgery Male 5 17 Female 0 36 AS, active surveillance; SSU, single system ureterocele; DSU, duplex system ureterocele; N/A, not available.

Introduction Laparoscopy may have a place in the treatment of vesicoureteral reflux (VUR). We report our initial experience in the treatment of VUR by laparoscopic extravesical transperitoneal approach (LETA) following the Lich-Gregoir technique to describe the evolution and to evaluate the results and benefits of this technique for these patients. Materials and Methods Between August 2007 and May 2009, 43 renal units in 30 children (23 female and 7 male) with VUR and deterioration of renal function on isotope renography (17 unilateral and 13 bilateral) were treated with LETA. The mean age was 52 (range, 15-183) months. Nine patients had a double total collector system associated with VUR in a lower system. Two of them had a ureterocele with adequate upper polar rein function, and another had a ureterocele with complete deterioration of upper polar rein function. Results The mean surgical time was 70 (38-120) minutes in unilateral and 124 (100-180) minutes in bilateral VUR. All procedures were successfully completed laparoscopically, and the reflux was corrected in all patients. At the same time, 1 heminephrectomy and 2 ureterocele were removed by laparoscopy and endoscopy, respectively. We had 1 ureter leakage 15 days postoperation that underwent a redo reimplantation. In cases of bilateral VUR, 1 patient presented postoperative bladder emptying difficulty and required temporary urethral catheterization postoperatively. The mean hospital stay was 24 hours. A cystogram was performed systematically in all patients at 45 days postoperation; none of them presented recurrence of VUR. The follow-up was 11 (range, 2-24) months, without recurrence of VUR. Conclusion Laparoscopic extravesical transperitoneal approach in the treatment of VUR is a safe and effective approach even in unilateral, bilateral simultaneous, and double total collector system. The technique results in a shorter hospital stay, less postoperative discomfort, and reduced recovery period, with a low morbidity to resolve the VUR and with success rates similar to the open technique.

Resume Introduction L’ureterocele est une malformation congenitale rarement diagnostiquee chez l’adulte. Son traitement, indique dans les formes compliquees ou symptomatiques, n’est pas univoque. Notre but a ete d’evaluer les resultats de la meatotomie endoscopique par incision semi-circulaire. Materiel et methode Etude retrospective de 26 dossiers de patients adultes ayant un ureterocele, traites entre janvier 1987 et decembre 2004. Resultats L’âge moyen de notre population etait de 41 ans. Le sexe ratio etait de 1,7/3. Trente-deux ureteroceles intravesicales ont ete diagnostiquees dont six etaient bilaterales. Dix-huit ureteroceles etaient compliquees de calcul in situ, neuf etaient compliquees de dilatation moderee en amont et trois avaient les deux complications. Deux ureteroceles etaient asymptomatiques et non compliquees, justifiant l’abstention therapeutique. Le traitement endoscopique a ete realise dans 30 cas consistant en une meatotomie en “bouche souriante” avec traitement d’eventuel calcul associe. Aucun incident operatoire n’a ete note. Les suites operatoires etaient simples. Une amelioration clinique et radiologique a ete obtenue chez 23 patients controles. Deux patients, parmi 12 controles par une urethrocystographie retrograde, ont eu un reflux vesico-ureteral grade I qui a disparu a 6 mois. Aucune stenose meatique n’a ete notee. Conclusion La meatotomie endoscopique apparait comme le traitement de choix des ureteroceles compliquees ou symptomatiques de l’adulte. C’est une technique mini invasive, facile, reproductible et efficace.

Objectives We retrospectively analyzed our experience to determine the optimum management of complete duplex system complicated with ureterocele. Materials and methods Between 1994 and 2003, we reviewed 15 patients treated with bladder surgery for complete duplex system complicated with ureterocele. The associated anomalies were seven vesicoureteral reflux (VUR) of the lower pole ureter and one of both poles. All patients had ureterocele (11 intravesical, 4 extravesical) and a functioning upper moiety. Initial treatment was transurethral incision of ureterocele (TUI) (14) or common sheath reimplantation (1). The median follow-up was 30 (13–48) months. Results There were no requirements for secondary procedures, with a significant improvement or conservation of ipsilateral renal function and no reflux, in 10 patients (67%). Five patients (33%) with ureterocele (1 intravesical, 4 extravesical) who initially underwent TUI required additional operative management due to moderate to severe VUR, recurrent urinary tract infection or decreased function of upper moiety. The secondary operation performed was lower pole nephrectomy with ureteral reimplantation (1), ureteroureterostomy with ureteral reimplantation (2) or common sheath reimplantation (2). One patient who underwent common sheath reimplantation as secondary operation needed a nephrectomy due to breakthrough febrile urinary tract infection and decreased renal function. Conclusion TUI is recommended as the first-line treatment of complete duplex system with intravesical ureterocele and well-conserved renal function.

Hydronephrosis is the most common genitourinary tract anomaly identified on prenatal ultrasound studies. Ureteropelvic junction obstruction accounts for approximately 50% of the cases of prenatally detected hydronephrosis. Postnatal evaluation allows for the identification of the cause and further management. Rarely, in utero intervention may be performed for severe oligohydramnios associated with hydronephrosis. Prenatal consultation with a pediatric urologist is useful in decreasing parental anxiety and facilitating postnatal management.

Background Congenital disorders of the genitourinary system can be unpredictable. There are both medical and surgical interventions that can help manage symptoms. Case A 10-year-old girl was evaluated 6 months post-menarche with dysuria and pelvic pain. Her symptoms were not relieved with menstrual suppression. Evaluation revealed a probable ectopic ureter versus ureterocele and uterine didelphys with suspicion for obstructed hemivagina and hematocolpos. Surgical exploration revealed an obstructed hemivagina with a high vaginal septum. When resection failed, she ultimately underwent a robot-assisted hemihysterectomy, with resolution of her symptoms. Summary and Conclusions In this case presentation, a surgical approach was necessary to adequately make a diagnosis. When vaginal septum resection failed, robot-assisted laparoscopic hemi-hysterectomy and resection of a vaginal pouch led to symptom resolution in this pediatric patient with a complex anomaly.

Background/Purpose: For more than a decade, endoscopic puncture of ureterocele has been recommended as an initial and, in the majority of the patients, as a definitive procedure. This study evaluates the long-term effectiveness of primary endoscopic puncture of ureterocele. Methods: Over the last 18 years (1984 through 2001), 52 patients (median age 3 months) underwent primary endoscopic puncture of ureterocele. The median follow-up was 9 years (6 months to 18 years). Antenatal ultrasound scan detected hydronephrosis and led to the postnatal diagnosis of ureterocele in 12 (23%) children, whereas in the remaining 40 (77%) children the diagnosis was made on investigation for urinary tract infection (UTI). The ureterocele presented as a part of renal duplication in 48 (92%) patients and a single system in 4 (8%). Forty-four (92%) of the patients with duplication presented with non- or poorly functioning upper poles. Vesicoureteric reflux (VUR) was seen in the lower moiety of the ipsilateral kidney in 31 and in 18 of the contralateral kidney comprising 49 renal refluxing units (RRU). Results: Complete decompression of the ureterocele was achieved in 48 (92%) patients after the first endoscopic puncture. Four (8%) patients required a second puncture of ureterocele. Nine (17%) of the 52 patients underwent nephrectomy for a nonfunctioning kidney. Ten (19%) patients required upper pole partial nephrectomy owing to nonfunctioning upper pole. Twenty-nine (59%) of the 49 RRU showed spontaneous resolution of VUR. Sixteen (33%) RRU underwent endoscopic correction of VUR. One required ureteric reimplantation. The remaining 4 (8%) are maintained on prophylactic antibiotics. Five (10%) patients had VUR in the upper pole moieties after ureterocele puncture. Conclusions: Our data suggest that primary endoscopic puncture of ureteroceles is a simple, long-term, effective, and safe procedure avoiding complete reconstruction in the majority of the patients. J Pediatr Surg 38:116-119. Copyright 2003, Elsevier Science (USA). All rights reserved .

Resume Les ureteroceles sont des malformations complexes de l'appareil urinaire correspondant a une dilatation pseudo-kystique de la portion sous-muqueuse du trajet terminal de l'uretere. Elles peuvent etre developpees aux depens de l'uretere du pole superieur d'une duplicite ou sur une voie urinaire unique. Le diagnostic peut en etre effectue en antenatal par l'apparition d'une dilatation des voies urinaires superieures associees a un aspect de «kystea dans la vessie. Le diagnostic d'ureterocele antenatale necessite une appreciation echographique du parenchyme renal, d'evaluer la presence de malformations associees. La prise en charge postnatale vise a confirmer le diagnostic, a permettre la prise en charge la plus adaptee en fonction du type d'ureterocele, l'existence d'une atteinte renale uni- ou bilaterale. Le traitement en est complexe allant de l'abstention therapeutique, de la ponction endoscopique, a la nephrectomie polaire superieure ou au traitement radical correspondant a l'ablation de l'ureterocele, la reconstruction du bas-appareil urinaire plus ou moins associee a une nephrectomie polaire superieure. Les indications dependent du type d'ureterocele et de la qualite du parenchyme renal.

Objective: Despite renewed interest in either endoscopic decompression or complete reconstruction as primary approaches in ectopic ureterocele's (EU's) treatment, we advocate that a simplified upper tract approach is an optimal choice in a large subset of these patients. We review our surgical results to evaluate the effectiveness of different surgical procedures used in the treatment of EU, based on an individualised approach. Patients and Methods: We retrospectively analysed all patients with EU and without previous treatment ( n 59) operated in this centre between the years 1991 and 2000. This disorder was bilateral in three patients (62 EU) and associated with duplex ureters in 60 cases. Vesicoureteral reflux (VUR) was diagnosed pre-operatively in 49.1% of patients. Treatment and choice of procedure was based on patients' age, clinical manifestations, associated abnormalities and function of the ureterocele-bearing moiety. Patients were divided in three separate groups according to the initial surgical approach. Group 1–11 patients submitted to endoscopic puncture (six urgent ureterocele decompression, four infants with obstruction of a functional ureterocele-bearing moiety and another with both lower pole ureter and mild bladder outflow obstruction). Group 2–30 patients (31 EU) submitted to a simplified upper tract approach—pyeloureterostomy (1), heminephrectomy (29) and nephrectomy (1) (all patients but one with non-viable renal segments; VUR, grade≤III, present in six cases). Group 3–18 patients (20 EU) submitted to complete primary reconstruction (all patients with high-grade and/or contralateral reflux, with or without function of the ureterocele-bearing moiety). Success (clinically asymptomatic patients, without obstruction or VUR) and complication rates from the different approaches were analysed. For statistical evaluation, we used Fisher's exact test with p ≤0.05 considered significant. Results: The success rate of endoscopic treatment, simplified upper tract approach and complete reconstruction were 18.2%, 80% and 83.3%, respectively. Major complications occurred in two patients from group 3. Conclusion: Endoscopic puncture is our first option when immediate ureterocele decompression is required, although it seldom affords definitive treatment. Complete primary reconstruction is necessary in complex cases. Cure rates are high but there is a potential risk for serious complications. A simplified upper tract approach is curative in most patients without associated reflux. Heminephrectomy remains our first choice in a large subset of patients with non-viable or hypofunctional renal segments and without high-grade reflux.

Resumen Objetivos Evaluar las posibilidades diagnosticas de la TAC helicoidal en la ectopia renal cruzada (ERC) a la vez que se realiza una revision de 36 casos publicados en Espana, incluyendo nuestros 3 nuevos pacientes. Casos Clinicos Presentamos 2 mujeres y 1 varon con edades comprendidas entre 54 y 82 anos, que fueron diagnosticados de ERC izquierda. Uno de ellos mostraba asociadamente un ureterocele ipsilateral y otro presentaba un angiosarcoma esplenico. Discusion Las principales teorias embriogenicas, presentacion clinica, anomalias asociadas y distintos medios radiologicos en el diagnostico de esta infrecuente malformacion congenita son evaluados.

Resume Les auteurs rapportent cinq cas d'ureteroceles colliges sur une periode de six ans. L'âge moyen des patients etait de 34,2 ± 11,1 ans. Il s'agissait de quatre femmes et d'un sujet de sexe masculin. La symptomatologie douloureuse a type de douleur (n=3) et la dysurie ont ete les principaux motifs de consultation. Le diagnostic a ete evoque dans trois cas sur quatre a l'echographie, dans trois cas sur quatre a l'urographie intraveineuse (UIV). L'ureterocele etait bilaterale dans quatre cas et unilaterale dans un cas survenant toujours sur un uretere simplex. Chez deux patients, il existait une lithiase unilaterale enclavee dans l'ureterocele. Seuls quatre patients ont ete traites chirurgicalement, un patient ayant refuse l'intervention chirurgicale. Le traitement chirurgical a consiste en une ureterocelectomie suivie de reimplantation ureterovesicale avec antireflux type Cohen. Avec un recul moyen de 10,6 ± 4,7 mois il n'a ete note aucune complication et les resultats ont ete stables.

Objectives Ureterocele management is considered to be one of the famous debates in pediatric urology. Despite some considering transurethral ureterocele incision (TUI) as a temporary line of treatment, others have reported good results in terms of being a definitive treatment. The present study evaluated the feasibility of TUI as a definitive line of management. Moreover, it studied the impact of presentation on the outcomes. Patients and methods The charts of patients who had ureteroceles from 1995 to 2015 were retrospectively reviewed. Patients who had undergone initial TUI were included. The initial presentation and timing were recorded. All ultrasounds, voiding cystourethrograms (VCUG) and dimercaptosuccinic acid scans (DMSA) pre-TUI and post-TUI were reviewed. Moreover, the occurrence of febrile urinary tract infections (FUTI) and any secondary surgical intervention were recorded. Results (Fig. A) A total of 51 patients with 53 ureteroceles were included. Of these, 51% presented antenatally, while others had FUTI at the time of presentation. Thirty-nine ureteroceles were associated with duplex system ureterocele (DSU), while the remaining ones had single system ureterocele (SSU). The median follow-up was 44 months. The incidence of de-novo reflux into ureterocele was 44% of SSU and 23% of DSU (P = 0.22). Reflux into ureterocele after TUI (four SSU and seven DSU) carried a high risk of surgical interventions (3/4 SSU and 6/7 DSU). Hydronephrosis was improved in 64% of both DSU and SSU patients. Secondary surgery was performed in 51% of DSU and 35.7% of SSU. Twelve patients (67%) presented postnatally with DSU and had subsequent interventions after incision in comparison with 38% (eight patients) of those who presented antenatally. The DSU had improved renal function (by DMSA) in 26%, while the remaining had stable renal function. Discussion All patients with delayed ureterocele presentation had FUTI, while 1/3 of antenatally presenting patients had FUTI during follow-up. Notably, the age at subsequent interventions was apparently the same despite different ages at presentation. Study limitations included the retrospective chart review. Additionally, the pre-operative and postoperative investigations, such as laboratory and radiological results, were present and reviewed in most, but not all, patients. Conclusion Two thirds of SSU and approximately half DSU patients had no surgical intervention after TUI. However, those who presented antenatally had a lower risk of FUTI and lesser probability of being re-operated. VUR into ureterocele, regardless the system duplicity, had a high re-operation rate. After ureterocele incision, 26% of DSU patients had renal function improvement. Summary Fig. A. Rate for second surgical interventions, in relation to time of presentation and renal system duplicity. SSU, single system ureterocele; DSU, duplex system ureterocele. Figure options Download full-size image Download high-quality image (313 K) Download as PowerPoint slide

Over the past years the surgical approach to ureterocele has evolved from complicated major surgery to minimally invasive endoscopic treatment. Because of the high rate of secondary surgery in some recently reported series, an upper pole partial nephrectomy is again recommended as the procedure of choice. We have retrospectively evaluated the long-term results of endoscopic puncture of a ureterocele and its long-term effectiveness and applicability in children.Over the past 8 years, 34 patients (20 female, 14 male) were treated in our service with primary endoscopic puncture of a ureterocele. The mean age of the patients was 1.1 +/- 4.3 (mean +/- SD) years. Mean follow-up was 6.1 +/- 2.4 years. Antenatally ultrasound detected the ureterocele in 5 (14%) patients, fetal hydronephrosis leading to the postnatal diagnosis in 13 (38%), and 16 (48%) children presented with symptoms of urinary tract infection (UTI). The ureteroceles presented as part of renal duplication in 31 patients (91%), 3 (9%) in a single system and 1 child had bilateral ureteroceles of a duplex system. Twenty (58%) children had intravesical ureteroceles and the remaining 14 (42%) ectopic ureteroceles. Very poorly functioning upper pole moiety presented in 26 (75%) of the cases and nonfunctioning upper poles in 5 (14%). Twenty of 34 children (58%) had initial vesicoureteral reflux (VUR) to the lower moiety, either to the ipsi (60%) or contralateral kidney (40%). A cold knife incision was carried out in 4 (11.7%), puncture by a 3-french Bugbee electrode in 20 (58%), and the stylet of a 3-french ureteral catheter was utilized to puncture the ureterocele in the remaining 10 patients (30.3%).Complete decompression of the ureterocele was observed in 32 of 34 children (94%). Two patients required secondary puncture 2 years following the primary procedure and are doing well. Upper pole moiety function improved postoperatively in 2 infants and remained stable in all 32 patients, no patient presented with deterioration of the renal function. Six of 20 (30%) patients who had initial VUR to the lower pole, accompanied with recurrent UTI, required surgery. Three underwent ureteric reimplantation and another 3 submucosal polytetrafluoroethylene paste (Teflon) injection. Eight (40%) patients presented with spontaneous resolution of VUR to the lower moiety following puncture of the ureterocele. An additional 6 (17.6%) patients developed VUR to the upper moiety following the puncture of the ureterocele, 3 after cold knife incision and 3 after simple puncture. In 2, submucosal Teflon injection solved the VUR and the remaining 4 patients were maintained on prophylactic antibiotics. In 1 child the reflux resolved spontaneously, and none of them presented with UTI. In 2 cases with nonfunctional upper poles, partial nephrectomy was performed due to symptomatic UTI in spite of complete collapse of the ureterocele 1 and 2 years, respectively, following the initial puncture. No difference was observed in the re-operation rate between the patients with ectopic versus intravesical ureterocele (p0.05).We found that endoscopic puncture of a ureterocele presents an easily performed procedure which allows the release of obstructive ureters and avoids major surgery in the majority of the cases even after a long follow-up.