In the present study, we found that the recurrent febrile UTIs-free rate after EI was 63.75% and that risk factors for recurrent febrile UTIs were duplex system and VUR on postoperative VCUG. In 29 children with recurrent febrile UTIs after EI, this occurred < 12 months in most children.
The management protocol for children with ureterocele is a controversial subject without a clear consensus on the therapeutic choices for pediatric urologists. Among the surgical interventions for the ureterocele treatment are endoscopic decompression, nephroureterectomy and complete reconstruction. However, advocates of heminephrectomy raise concerns about the possibility of secondary interventions, especially in DSU, along with higher iatrogenic injury risk to the lower pole vessels [13]. Theoretically, a complete reconstruction would be ideal in this situation, concerns regarding surgical complications have restricted its usage, despite no evidence that a complete reconstruction would increase urodynamic morbidity [14]. Hence, in the past few decades, EI of ureterocele was a well-established optimal treatment; however, it was not a definitive intervention in DSU for relieving obstruction without preserving the ureterovesical valve mechanism [15].
There are a few studies reported long-term effectiveness of EI in both SSU and DSU. EI treatment provides definitive treatment in most patients with SSU. In our series 94% of patients with SSU were not documented to have recurrent febrile UTIs after EI, comparable to the rate reported [8, 16]. In multiple studies it has been noted that the recurrent febrile UTIs rate is higher in patients with DSU comparing SSU [3, 17]. Furthermore, there was statistically significant difference in recurrent febrile UTIs after EI between DSU to SSU in our study. More recently most investigators did find a higher proportion of DSU presenting with recurrent UTIs postoperatively, and a higher proportion of these required secondary procedures compared with SSU [12, 18]. This is consistent with our results, which showed a significantly greater risk of postoperative recurrent febrile UTIs in patients with DSU compared to cases with SSU.
There have always been several studies reported that EI offers the great advantage for definitive means of intravesical ureteroceles and EI would likely result in subsequent surgery for ectopic ureteroceles [17, 19]. Although the role of endoscopic treatment has been established in the management of intravesical ureteroceles, there is no consensus on its effectiveness for treating ectopic ureteroceles [16]. It is noteworthy that series of studies have demonstrated that the location of the ureterocele does not affect the recurrent UTIs and reoperation rate in children with ectopic ureterocele [8, 13]. We analyzed the value of EI in intravesical and ectopic ureteroceles cases and found no significant difference in in the efficacy of primary EI for ectopic and intravesical cases.
There has always been general acceptance that the primary concern of EI is the possibility of new onset VUR, which may require further intervention [2, 16]. However, it is noteworthy that VUR after endoscopic puncture of ureterocele can resolve spontaneously in a subset of patients [20]. Recently, Hodhod et al detected new VUR in 23.3% of DSU patients [21]. Indeed, endoscopic decompression combined with endoscopic correction of symptomatic VUR to ureterocele moiety or either to ipsilateral or contralateral kidney and associated moieties appear to be long-term effective and safe approach [22]. According to our current study, 20 patients developed VUR and underwent additional surgery. Nevertheless, several studies have shown that antibiotic prophylaxis reduces the incidence of recurrent UTIs in patients with primary VUR [17, 23], however, there is no convincing evidence that antibiotic prophylaxis treatment can reduce the incidence of recurrent febrile UTIs in cases of ureterocele after EI [20]. Further studies are necessary to clarify the effectiveness of antibiotic prophylaxis in this situation, but it might be beneficial in preventing recurrent UTIs and renal scarring during the critical period for symptomatic UTIs identified after EI. In 7 of these 29 patients (24.1%), of whom all had a DSU, the patient did well with antibiotic prophylaxis.
Early decompression can potentially preserve some renal function, even though the possibility of a functioning renal parenchyma is low. An affected upper pole does not drastically alter the entire renal function. In fact, the quantifiable loss of function after upper pole partial nephrectomy was 1.25%, whereas the gain in function after EI was 2.25% on average [24]. Gomes and Mendes, for instance, do not recommend EI for enhancing renal function in renal segments with reduced function, unless the renal reserve is depleted, as in majority of the cases the affected renal segment tends to be hypodysplastic [2]. Nevertheless, we retrieved data on ipsilateral function from most of the analyzed patients. Based on our analysis, one of patients experienced loss of renal function after surgery. Contrary to the Chertin and Fridman study, there was no discernible enhancement of renal function after DSU decompression [3, 25]. Alternately, we showed a significant enhancement of renal function after EI. Given that the upper pole moiety is frequently dysplastic or exhibits post-obstructive or infectious scarring, preservation of the renal moiety may markedly elevate hypertension risk. Unfortunately, currently, there are limited data on the long-term morbidity of a non-eliminated dysplastic upper moiety. We speculate that ureterocele decompression leads to satisfactory drainage of the previously obstructed system. Based on Chertin’s survey, a decompressed upper pole segment, that shows poor function and no VUR, is not in need of further intervention and does not have increased morbidity [26].