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28
TH
CONGRESS OF THE ESPU
15:17–15:20
S17-6 (PP)
MICROSURGICAL-BLADED CUTTING-BALLOON
ENDOURETEROTOMY FOR PRIMARY OBSTRUCTIVE
MEGAURETER (POM) OBVIATES THE NEED FOR URETERIC
RE-IMPLANTATION
Naima SMEULDERS
1
, Pankaj MISHRA
1
and Abraham CHERIAN
2
1) Great Ormond Street Hospital NHS Foundation Trust, Department of Paediatric Urology, London, UNITED KINGDOM
- 2) Great Ormond Street Hospital NHS Foundation Trust, Deparftment of Paediatric Urology, London,
UNITED KINGDOM
PURPOSE
1/3-1/2 of children stented for primary obstructive megaureter (POM) will require subsequent
ureteric re-implantation. Can this be averted by endoscopic incision of the vesico-ureteric junction
(VUJ) using a microsurgical-bladed cutting-balloon?
MATERIAL AND METHODS
All patients presenting for cutting-balloon endoureterotomy of POM between April’11 and
April’16 were prospectively enrolled into the study and followed a set protocol of investigations
(serial ultrasound+MCUG+functional imaging), surgery and follow-up (serial ultrasound+functional
imaging).
RESULTS
Thirty-one children (25 male/6 female) presented after antenatally-detected hydronephrosis (24),
urosepsis (5), acute renal failure (1) and investigation of hypertension/proteinuria (1). POM was to
a solitary-functioning kidney (2), bilateral (2), co-existing with ipsilateral PUJO (7) or VUR (2-ipsi-
lateral, 1-contralateral). Intervention for POM was indicated for symptoms (9), reduced differential
function (DF; 6) and increasing hydro-ureteronephrosis(HUN; 15).
At age 3weeks-9yrs (median 5months), 33 POM were incised under image-guidance/cystoscopic-
vision using a 3-microsurgical-bladed small peripheral cutting-balloon (Boston Scientific 2.5mm-1,
3mm-31, 4mm-1) over a 0.014inx200cm Synchro-wire (Boston Scientific) followed by JJ-stenting
(32-Cook 4.7Fr8-20cm; 1-Cook 5Fr8cm) for 4-8 weeks in 28, and 5,5,7,9,9 months in the remain-
der. A migrated JJ-stent (2) or fractured Synchro-wire (1) were retrieved by ureteroscopy. No stent
change for sepsis was required.
Follow-up extends from 6-67months (median 24months) with reduced HUN in 27 (DF increased-6,
stable-21), stable HUN in 3 (DF increased-1, stable-2), increasing HUN in 3 (DF stable). In the
latter, redo-endoureterotomy (4mm-cutting-balloon) resulted in reduced HUN in 2 and clearance of
2mm calculi in the other. No residual/recurrent stenosis was found on balloon re-assessment in one
further patient with gross congenital hydronephrosis (APD>90mm) due to PUJO+VUJO.
CONCLUSIONS
Endoscopic deployment of microsurgical-bladed balloons allows precise incision of the VUJ in POM
obviating the need for prolonged JJ-stenting and ureteric re-implantation. A repeat endoscopic inci-
sion, required in 10% in this study for increasing HUN on follow-up, can tackle persistent/recurrent
stenosis.