An alternative lower tract approach to ectopic duplex system ureteroceles feasible in young children

  • Cynthia Sze-Ya Ting
    Department of Pediatric Surgery, Chang Gung Children's Hospital, Chang Gung University, School of Medicine, No.5, Fuxing St., Guishan Dist., Taoyuan City 33305, Taiwan
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  • Pei-Yeh Chang
    Correspondence to: Pei-Yeh Chang, Department of Pediatric Surgery, Chang Gung General Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan No.5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan. Tel.: +886 3 3281200x8227; fax: +886 3 3285056
    Department of Pediatric Surgery, Chang Gung Children's Hospital, Chang Gung University, School of Medicine, No.5, Fuxing St., Guishan Dist., Taoyuan City 33305, Taiwan
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Published:October 11, 2022DOI:



      The best surgical approach to ectopic ureters and ureteroceles is yet to be determined. The objective of this study is to provide an alternative lower tract surgical approach to ectopic ureters and duplex system ureteroceles that can be safely performed in young children.


      The “in-and-out” bladder approach was performed via an open intravesical incision. The upper and lower pole ureters were mobilized and brought into the bladder. The dilated ureter/ureterocele was cut open, and the distal part was deuroepithelialized. Subsequently, common sheath reimplantation was performed. The ureterocele wall was not involved during the whole procedure. We retrospectively reviewed all patients who underwent surgery for ureteroceles and ectopic ureters between January 1, 2004, and December 31, 2019. Patients with intravesical ureteroceles were excluded. Outcome parameters included the presence of hydronephrosis or reflux, split renal function on DMSA scan, incidence of urinary tract infection, and urinary incontinence.


      A total of 32 patients with ectopic duplex system ureterocele who underwent the “in-and-out” bladder approach between 2004 and 2019 were included in the retrospective study. The median age at operation was 7.8 months (range: 1.5 months–3.0 years). The median length of follow-up was 6.1 years (range: 1.0 years–14.3 years). Sixteen patients (55%) had ipsilateral vesicoureteral reflux. Five patients postoperatively developed a urinary tract infection within 1–3 years. No patients required further endoscopic treatment or surgeries. During long-term follow-up, two patients (6.3%) had intermittent day wetting at the ages of 4 and 5 years and were managed conservatively. The symptoms of intermittent day wetting subsided during follow-up.


      Summary Figure
      Graphical AbstractProcedure of the “in-and-out bladder” approach to surgically treating ectopic ureterocele. (a) A mucosal incision was made along the lower edge of the orifice of the lower pole ureter. (b) A 7-0 polydioxanone stay suture was performed on the orifice of the ipsilateral lower pole ureter to facilitate the dissection. The lower pole ureter was then dissected out and cut open. (c) The mucosal layer of the distal stump/ureterocele was detached as distally as possible and ligated intramurally. (d) Common sheath reimplantation was performed through a submucosal tunnel.


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