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Endoscopic Management of Primary Obstructive Megaureter: A Systematic Review
Alexander D Doudt1, Chad R Pusateri1, Matthew S Christman1
1Department of Urology, Naval Medical Center San Diego , San Diego, California.
Insights
Endoscopic management offers a minimally invasive option for primary obstructive megaureter (POM) in children over 12 months, with modest success. Infants may benefit from this as a temporary measure before potential reintervention.
Area of Science:
- Pediatric Urology
- Minimally Invasive Surgery
- Urologic Oncology
Background:
- Primary obstructive megaureter (POM) is a congenital condition affecting the ureter.
- Traditional treatment involves ureteral reimplantation, which can be invasive for infants.
- Endoscopic management presents a less invasive alternative.
Purpose of the Study:
- To systematically review the literature on endoscopic management of POM in pediatric patients.
- To evaluate the efficacy and outcomes of various endoscopic techniques.
- To compare endoscopic approaches with traditional open surgery.
Main Methods:
- Systematic literature search of multiple databases (MEDLINE/Ovid, PubMed, Embase, Web of Science).
- Inclusion of full-text English articles with more than one pediatric case.
- Independent data extraction and strength of evidence assessment by two authors.
Main Results:
- 12 studies (11 retrospective, 1 prospective) involving 222 patients were analyzed.
- Common endoscopic approaches included balloon dilation and ureterotomy with stenting.
- Overall anatomic and functional success rates were 79.3% and 76.7%, respectively.
- Higher success rates observed in children aged 12 months or older (82.3% anatomic success).
- 15.1% required endoscopic retreatment, and 36.7% needed surgical reintervention.
- Complications were generally mild, with 12 cases of vesicoureteral reflux.
Conclusions:
- Endoscopic management is a viable, minimally invasive alternative for POM in children over 12 months.
- In infants, endoscopic procedures may serve as a temporizing measure.
- A significant proportion of patients (approximately one-third) may require further surgical intervention.
Background:
The gold standard treatment for primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent infections is ureteral reimplantation with or without tapering. In infants, open surgery can be technically demanding and associated with significant morbidity. We conducted a systematic review of the literature with special interest in endoscopic management of POM and its outcomes.
Materials And Methods:
A search was conducted of the MEDLINE/Ovid, PubMed, Embase, and Web of Science databases. Only full-text articles written in the English language and involving greater than one reported pediatric case per publication were included. Two authors independently extracted data and assessed strength of evidence for each study.
Results:
We found 11 retrospective and 1 prospective, single institution case series that met selection criteria, describing 222 patients with 237 obstructed renal units. Mean age at time of surgery was 24.6 months. The most common endoscopic approaches were cystoscopy+high-pressure balloon dilation+Double-J ureteral stent placement (49.5%), cystoscopy+incisional ureterotomy+Double-J ureteral stent placement (27.8%), and cystoscopy+Double-J ureteral stent placement (18.9%). For all approaches and age groups, anatomic and functional success rates were 79.3% (146/184) and 76.7% (132/172), respectively. Anatomic success rates were highest in children ≥12 months of age (82.3%, 117/142). Endoscopic retreatment was performed in 15.1% of cases with a 36.7% overall surgical reintervention rate. Forty-one ureters progressed to ureteral reimplantation. Complications were generally mild (Clavien-Dindo Grades I-II), but 12 ureters did develop vesicoureteral reflux. Mean follow-up period was 3.2 years.
Conclusions:
Endoscopic management for persistent or progressive POM in children ≥12 months of age is a minimally invasive alternative to ureteral reimplantation with modest success rates. In infants, it may best be utilized as a temporizing procedure. Approximately one-third of patients require surgical reintervention.
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