Advertisement

Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes

  • Lauren E. Corona
    Correspondence
    Correspondence to: Lauren E. Corona, Ann & Robert H. Lurie Children’s Hospital of Chicago, Division of Urology 225 East Chicago Avenue, Box 24 Chicago, IL 60611-2605, USA. Tel.: +1 312 227-6340; fax: +1 312 227-9560
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Andrew Lai
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, University of Illinois at Chicago, Chicago, IL, 60612 USA
    Search for articles by this author
  • Theresa Meyer
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA
    Search for articles by this author
  • Ilina Rosoklija
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA
    Search for articles by this author
  • Rachel Berkowitz
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA
    Search for articles by this author
  • Dennis Liu
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Max Maizels
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Earl Y. Cheng
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Bruce W. Lindgren
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • David I. Chu
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Emilie K. Johnson
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
  • Edward M. Gong
    Affiliations
    Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA

    Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA
    Search for articles by this author
Published:October 10, 2022DOI:https://doi.org/10.1016/j.jpurol.2022.09.024

      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

      Summary Figure
      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

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rich M.A.
        • Keating M.A.
        • Snyder 3rd, H.M.
        • Duckett J.W.
        Low transurethral incision of single system intravesical ureteroceles in children.
        J Urol. 1990; 144: 120-121https://doi.org/10.1016/s0022-5347(17)39387-4
        • Palmer B.W.
        • Greger H.
        • Mannas D.B.
        • Kropp B.P.
        • Frimberger D.
        Comparison of endoscopic ureterocele decompression techniques. Preliminary experience--is the watering can puncture superior?.
        J Urol. 2011; 186: 1700-1703https://doi.org/10.1016/j.juro.2011.04.007
        • Smith C.
        • Gosalbez R.
        • Parrott T.S.
        • Woodard J.R.
        • Broecker B.
        • Massad C.
        Transurethral puncture of ectopic ureteroceles in neonates and infants.
        J Urol. 1994; 152: 2110-2112https://doi.org/10.1016/s0022-5347(17)32332-7
        • Nabavizadeh B.
        • Nabavizadeh R.
        • Kajbafzadeh A.M.
        A step-by-step guide to double-puncture technique for endoscopic management of ureterocele.
        Urol J. 2020; https://doi.org/10.22037/uj.v16i7.6028
        • Kajbafzadeh A.
        • Salmasi A.H.
        • Payabvash S.
        • Arshadi H.
        • Akbari H.R.
        • Moosavi S.
        Evolution of endoscopic management of ectopic ureterocele: a new approach.
        J Urol. 2007; 177: 1118-1123https://doi.org/10.1016/j.juro.2006.11.001
        • Marr L.
        • Skoog S.J.
        Laser incision of ureterocele in the pediatric patient.
        J Urol. 2002; 167: 280-282
        • Adam A.
        • Farnsworth R.
        Catastrophic haemorrhage from ureterocele incision in an infant: beware of an associated iliac arteriovenous malformation.
        ANZ J Surg. 2016; 86: 942-944https://doi.org/10.1111/ans.12785
        • Maizels M.
        • Liu D.
        • Gong E.M.
        • Kaplan W.E.
        • Cheng E.Y.
        Endoscopic ureterocele-otomy - retrograde incision from orifice (RIO) of urethral segment of ureterocele and extending to bladder neck is a feasible and simple procedure.
        J Pediatr Urol. 2016; 12: 137-138https://doi.org/10.1016/j.jpurol.2016.05.010
        • Park J.S.
        • Lee Y.S.
        • Lee C.N.
        • Kim S.H.
        • Kim S.W.
        • Lee H.
        • et al.
        Transurethral incision as initial option in treatment guidelines for ectopic ureteroceles associated with duplex systems.
        World J Urol. 2019; 37: 2237-2244https://doi.org/10.1007/s00345-018-2607-x
        • Moriya K.
        • Nakamura M.
        • Nishimura Y.
        • Kanno Y.
        • Kitta T.
        • Kon M.
        • et al.
        Prevalence of and risk factors for symptomatic urinary tract infection after endoscopic incision for the treatment of ureterocele in children.
        BJU Int. 2017; 120: 409-415https://doi.org/10.1111/bju.13884
        • Jain V.
        • Agarwala S.
        • Dhua A.
        • Mitra A.
        • Mittal D.
        • Murali D.
        • et al.
        Management and outcomes of ureteroceles in children: an experience of 25 years.
        Indian J Urol. 2021; 37: 163-168https://doi.org/10.4103/iju.IJU_522_20
        • Haddad J.
        • Meenakshi-Sundaram B.
        • Rademaker N.
        • Greger H.
        • Aston C.
        • Palmer B.W.
        • et al.
        Watering can" ureterocele puncture technique leads to decreased rates of de novo vesicoureteral reflux and subsequent surgery with durable results.
        Urology. 2017; 108: 161-165https://doi.org/10.1016/j.urology.2017.06.008
        • Nabavizadeh B.
        • Nabavizadeh R.
        • Kajbafzadeh A.M.
        A novel approach for an old debate in management of ureterocele: long-term outcomes of double-puncture technique.
        J Pediatr Urol. 2019; 15 (389e): 1-5https://doi.org/10.1016/j.jpurol.2019.04.022
        • Castagnetti M.
        • Vidal E.
        • Burei M.
        • Zucchetta P.
        • Murer L.
        • Rigamonti W.
        Duplex system ureterocele in infants: should we reconsider the indications for secondary surgery after endoscopic puncture or partial nephrectomy?.
        J Pediatr Urol. 2013; 9: 11-16https://doi.org/10.1016/j.jpurol.2012.06.016
        • Adorisio O.
        • Elia A.
        • Landi L.
        • Taverna M.
        • Malvasio V.
        • Danti A.D.
        Effectiveness of primary endoscopic incision in treatment of ectopic ureterocele associated with duplex system.
        Urology. 2011; 77: 191-194https://doi.org/10.1016/j.urology.2010.02.061
        • Jesus L.E.
        • Farhat W.A.
        • Amarante A.C.
        • Dini R.B.
        • Leslie B.
        • Bägli D.J.
        • et al.
        Clinical evolution of vesicoureteral reflux following endoscopic puncture in children with duplex system ureteroceles.
        J Urol. 2011; 186: 1455-1458https://doi.org/10.1016/j.juro.2011.05.057
        • Chertin B.
        • Mohanan N.
        • Farkas A.
        • Puri P.
        Endoscopic treatment of vesicoureteral reflux associated with ureterocele.
        J Urol. 2007; 178: 1594-1597https://doi.org/10.1159/000052463