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Surgical Management of Meatal Stenosis with Meatoplasty
Published on: November 30, 2010
British Association of Paediatric Urologists consensus statement on the management of the primary obstructive
Marie-Klaire Farrugia1, Rowena Hitchcock2, Anna Radford3
1Department of Paediatric Surgery and Urology, Chelsea and Westminster Hospital, London, UK.
Insights
Congenital megaureter management is primarily conservative. Surgical intervention is indicated for symptomatic cases or asymptomatic patients with declining differential renal function and significant hydronephrosis.
Area of Science:
- Pediatric Urology
- Congenital Abnormalities
- Surgical Management
Background:
- Congenital megaureters often managed conservatively, but intervention indications are unclear.
- British Association of Paediatric Urologists (BAPU) convened to define management strategies.
- Established current UK practice and consensus for primary megaureter management.
Framework:
- Evidence-based literature review presented to 56 BAPU Consultant Surgeons.
- Consensus reached via two-thirds majority vote on predefined questions.
- Defined abnormal ureteric diameter as >7 mm.
Implementation:
- Newborns with prenatal hydroureteronephrosis: antibiotic prophylaxis, ultrasound, MCUG, then diuretic renogram.
- Conservative initial management for primary megaureters.
- Surgical indications: febrile UTIs, pain, or asymptomatic with DRF <40% and hydronephrosis/worsening function.
Implications:
- Recommended ureteral reimplantation for patients >1 year old.
- Acknowledged challenges of infant surgery; proposed temporary JJ stent or refluxing reimplantation as alternatives.
- Established peer-reviewed consensus guidelines for primary megaureter management.
Introduction:
It is well-known that the majority of congenital megaureters may be managed conservatively, but the indications and surgical options in patients requiring intervention are less well defined. Hence this topic was selected for discussion at the 2012 consensus meeting of the British Association of Paediatric Urologists (BAPU). Our aim was to establish current UK practice and derive a consensus management strategy.
Methods:
An evidence-based literature review on a predefined set of questions on the management of the primary congenital megaureter was presented to a panel of 56 Consultant Surgeon members of the British Association of Paediatric Urologists (BAPU), and current opinion and practice established. Each question was discussed, and a show of hands determined whether the panel reached a consensus (two-thirds majority).
Results:
The BAPU defined a ureteric diameter over 7 mm as abnormal. The recommendation was for newborns with prenatally diagnosed hydroureteronephrosis to receive antibiotic prophylaxis and be investigated with an ultrasound scan and micturating cystourethrogram, followed by a diuretic renogram once VUR and bladder outlet obstruction had been excluded. Initial management of primary megaureters is conservative. Indications for surgical intervention include symptoms such as febrile UTIs or pain, and in the asymptomatic patient, a DRF below 40% associated with massive or progressive hydronephrosis, or a drop in differential function on serial renograms. The BAPU recommended a ureteral reimplantation in patients over 1 year of age but recognized that the procedure may be challenging in infancy. Proposed alternatives were the insertion of a temporary JJ stent or a refluxing reimplantation.
Conclusion:
A peer-reviewed consensus guideline for the management of the primary megaureter has been established. The guideline is based on current evidence and peer practice and the BAPU recognized that new techniques requiring further studies may have a role in future management.
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