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“Definitive” Is Not the Word – Rate of Revision In the Surgical Management of Ureteroceles: A Large Single Institutional Study

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Seth A. Cohen, M.D., Timothy Juwono, Kerrin L. Palazzi, M.P.H, Oren F. Miller, M.D., Nicholas M. Holmes, M.D., George W. Kaplan, M.D. and George Chiang, M.D., Urology, Rady Children's Hospital, University of California, San Diego, San Diego, CA

Purpose: The surgical management of ureteroceles is extremely variable; some have hypothesized that if these patients were treated with “definitive” staged surgical intervention, this would eliminate the need for further revision surgery.  We sought to determine if the rate of revision surgery was truly decreased among patients who have undergone staged surgical management.

Methods: A large retrospective chart review was conducted, identifying all patients having undergone ureterocele surgery at a single institution over the last 41 years.  The cohort was divided into four groups based on surgical approach: upper tract approach (UTA), lower tract reconstruction (LTR), simultaneous upper and lower tract approach (STA), and staged upper and lower tract reconstruction (SGTR).  Demographics, the presence of pre/post-op VUR, post-op morbidity, and the need for revision surgery were compared using Chitest, Fisher’s exact test, Kruskal-Wallis test, Mann-Whitney U test (Bonferroni correction), and logistic regression analyses.

Results: Between 1969 and 2010, 180 patients were identified as having undergone surgical management of ureteroceles, of which 120 had complete demographic data available for analysis.  Median age at time of time of initial surgical intervention was 5.8 months, (inter-quartile range (IQR), 2.6-13.5) and the majority (83.3%) were female.  Median follow up was 33.1 months (IQR, 16.5-57.9).   Surgical management was as follows: 18 (15%) patients underwent UTA, 47 (39.2%) underwent LTR, 23 (19.2%) underwent STA, and 32 (26.7%) underwent SGTR.  Amongst these groups, the only difference in median age was between the LTR and SGTR groups (6.3 months vs 3.7 months, p=0.012).  Otherwise, all the groups were similar in proportion of patients <6 months of age at time of initial surgery (p=0.733), sex (p=0.210), laterality of ureterocele (0.235), and presence of duplex systems (p=0.760).  Additional revision surgery was required in: 9 (50%) of UTA, 10 (21.3%) of LTR, 4 (17.4%) of STA, and 3 (9.4%) of SGTR; the only statistically significant difference in required revision surgery was noted in the UTA group versus each of the other groups.  The likelihood of requiring revision surgery in comparison to the SGTR group was significantly increased in the UTA group (OR 9.67, CI 2.15-43.56), but not the LTR (OR 2.61, CI 0.66-10.37) or the STA group (OR 2.04, CI 0.41-10.13). 

Conclusion: There is no definitive surgical repair for the ureterocele complex; all, with exclusion of the UTA group, had similar rates of revision surgery.  The widespread variability in current management echoes the lack of one superior approach found in this comprehensive series.