Summary
Introduction
Management of obstructing ureterocele often includes endoscopic transurethral incision
(TUI) that can be challenging secondary to uncertainty in anatomic landmarks with
risk of serious complications. To this end, we innovated a technique using predictable
landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde
proximal to the bladder neck (Figure).
Objective
With over 15 years of experience in performing this retrograde incision from orifice
(RIO) technique, we aimed to examine post-operative outcomes and risk of surgical
failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized
that clinical outcomes after RIO would be superior to traditional endoscopic approaches
to decompression of obstructing ureterocele in infants.
Study design
A retrospective study of patients ≤12 months old who underwent TUI ureterocele at
our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative
characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary
outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome
was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional
hazard models were fitted to compare the time-to-event risk of primary and secondary
outcomes between groups.
Results
Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up
from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min,
p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29%
RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15).
In multivariable Cox proportional hazard models, there was no significant difference
in risk of fUTI (RIO aHR 0.98, 95% CI 0.38–2.54, p = 0.97) or composite failure (RIO
aHR 0.80, 95% CI 0.45–1.44, p = 0.46) between TUI techniques.
Discussion
RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic
landmarks making it simple to perform. In analyzing this 15-year institutional experience
of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This
study is a retrospective, non-randomized, single-institutional study over 15 years
and is therefore subject to change in surgeon practice over time and variable practices
between providers.
Conclusions
Graphical AbstractRetrograde incision from orifice (RIO) technique for endoscopic ureterocele-otomy.
a. Diagram depiction of ectopic urethral ureterocele with orifice (exaggerated) b.
Identification of predictable anatomic landmarks: orifice is visualized in urethra
c. Orifice is engaged by peg electrode and roof of ureterocele is cut in a retrograde
fashion via multiple short incisions until just proximal to the bladder neck, opening
the obstructing segment to promote upper tract drainage.
Keywords
Abbreviations:
RIO (retrograde incision from orifice), TUI (transurethral incision), fUTI (febrile urinary tract infection), EMR (Electronic Medical Record), BOO (bladder outlet obstruction), VUR (vesicoureteral reflux), CAP (continuous antibiotic prophylaxis), BBD (bowel bladder dysfunction), CIC (clean intermittent catheterization), aHR (adjusted Hazard Ratio), CI (Confidence Interval), IQR (Interquartile Range)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 10, 2022
Accepted:
September 29,
2022
Received in revised form:
September 23,
2022
Received:
June 30,
2022
Identification
Copyright
© 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
