Hodhod A, Jednak R, Khriguian J, El-Sherbiny M
Department of Pediatric Surgery, Urology, McGill University, Montreal, Quebec, Canada; Department of Urology, Faculty of Medicine, Menoufia University, Al Minufya, Egypt.
Department of Pediatric Surgery, Urology, McGill University, Montreal, Quebec, Canada.
J Pediatr Urol. 2017 Oct;13(5):501.e1-501.e6. doi: 10.1016/j.jpurol.2017.02.016. Epub 2017 Mar 18.
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.
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.
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.
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.
输尿管囊肿的治疗一直是小儿泌尿外科领域备受关注的争议之一。尽管有些人认为经尿道输尿管囊肿切开术（TUI）只是一种临时治疗方法，但也有人报告称其作为一种确定性治疗方法取得了良好效果。本研究评估了TUI作为确定性治疗方法的可行性。此外，还研究了发病情况对治疗结果的影响。
回顾性分析1995年至2015年期间患有输尿管囊肿患者的病历。纳入接受初次TUI治疗的患者。记录其初次发病情况和时间。回顾所有TUI术前及术后的超声、排尿性膀胱尿道造影（VCUG）和二巯基丁二酸扫描（DMSA）结果。此外，记录发热性尿路感染（FUTI）的发生情况以及任何二次手术干预情况。结果（图A）：共纳入51例患者的53个输尿管囊肿。其中，51%在产前发病，其他患者在发病时患有FUTI。39个输尿管囊肿与重复肾输尿管囊肿（DSU）相关，其余为单系统输尿管囊肿（SSU）。中位随访时间为44个月。新发反流至输尿管囊肿的发生率在SSU中为44%，在DSU中为23%（P = 0.22）。TUI术后反流至输尿管囊肿（4例SSU和7例DSU）的患者进行手术干预的风险较高（SSU中3/4，DSU中6/7）。DSU和SSU患者中64%的肾积水情况得到改善。51%的DSU患者和35.7%的SSU患者接受了二次手术。12例（67%）产后发病的DSU患者在切开术后接受了后续干预，而产前发病患者的这一比例为38%（8例）。DSU患者中26%的肾功能通过DMSA得到改善，其余患者肾功能稳定。
所有输尿管囊肿发病延迟的患者均患有FUTI，而1/3产前发病的患者在随访期间患有FUTI。值得注意的是，尽管发病年龄不同，但后续干预的年龄明显相同。研究局限性包括回顾性病历分析。此外，大多数但并非所有患者都有术前和术后的检查结果，如实验室和影像学结果，并进行了回顾。
三分之二的SSU患者和大约一半的DSU患者在TUI术后无需手术干预。然而，产前发病的患者发生FUTI的风险较低，再次手术的可能性较小。无论系统是否重复，反流至输尿管囊肿的患者再次手术率较高。输尿管囊肿切开术后，26%的DSU患者肾功能得到改善。
