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Watchful Waiting for Prenatally Detected Ureteroceles
Watchful Waiting for Prenatally Detected Ureteroceles Tania Direnna and Michael P. Leonard*,† From the Division of Pediatric Urology, Department of Surgery, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
Purpose: Ureteroceles are commonly detected by prenatal ultrasound. Although many require surgical intervention due to obstruction of more than one renal moiety or obstruction of the bladder neck, some may be carefully observed. The objective of this study was to assess the outcome of conservative management in select cases of prenatally detected ureteroceles at a tertiary care pediatric hospital. Materials and Methods: We retrospectively reviewed the charts of patients with ureteroceles detected on prenatal ultrasound who were treated nonsurgically between 1990 and 2001. Results: A total of 10 cases were detected in the course of the chart review, with 6 involving duplex system and 4 involving single system ureteroceles. Median followup was 5 years (range 1 to 11). Patients were followed with routine ultrasound at 3 to 6-month intervals for the first 2 years, and at 6-month to 2-year intervals thereafter. Voiding cystourethrogram and renal scans or IVPs were performed initially in all patients. Those with vesicoureteral reflux were followed with annual or biennial cystogram until reflux resolution. Antibiotic prophylaxis was routinely prescribed for an average duration of 1.5 years. Initial ultrasound revealed unilateral hydronephrosis in all patients, with complete resolution in 6 during a mean followup of 2 years. Voiding cystourethrogram demonstrated vesicoureteral reflux of grade III or less in 4 patients. Reflux resolved in 2 of these patients during a mean followup of 3 years. No patient required surgical intervention within the time frame of this study. Conclusions: There may be a role for watchful waiting in select cases of prenatally detected ureteroceles. Cases involving obstruction of more than one renal moiety, bladder neck obstruction or high grade vesicoureteral reflux were not selected among the population we followed, and would likely require initial surgical management. Patients without these complicating features may be safely followed on suppressive antibiotics, as based on our experience many of the associated problems may resolve without surgical intervention. Key Words: hydronephrosis, prenatal diagnosis, ureterocele, observation
here is considerable controversy regarding the treatment of prenatally detected ureteroceles. Many of the treatment strategies used are derived from experience with symptomatic patients who present postnatally.1,2 However, most neonates with fetal ultrasound detected urinary tract anomalies are asymptomatic and do not have clear indications for surgical intervention. Surgical intervention without knowledge of the natural history of a condition raises the question of the need for such invasive procedures. Our study attempts to address this question by examining the outcome of patients with prenatally detected ureteroceles who were treated with careful observation.
T
MATERIALS AND METHODS We retrospectively reviewed the charts of patients with prenatally detected ureteroceles who presented between 1990 and 2001. Patients had prenatally detected urinary tract
Submitted for publication February 12, 2005. Study received institutional review board approval. * Correspondence: Division of Pediatric Urology, Children’s Hospital of Eastern Ontario, 401 Smyth, Ottawa, Ontario, Canada K1H 8L1 (telephone: 613-737-7600, ext. 1353; FAX: 613-738-4271; e-mail: [email protected]). † Financial interest and/or other relationship with Q-Med Canada.
0022-5347/06/1754-1493/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
anomalies later confirmed as ureteroceles with postnatal ultrasound. All patients were treated initially with careful clinical observation—there was no initial intent for surgical intervention. Exclusion criteria used to select against initial observation included ipsilateral lower pole moiety obstruction, high grade (IV or V) vesicoureteral reflux and/or bladder outlet obstruction. We did not exclude children with demonstrable function in the renal unit associated with the ureterocele. However, there had to be adequate drainage documented for the affected unit. It should be emphasized that the patients selected for observation constituted a minority of all patients assessed with a prenatal diagnosis of ureterocele during this interval. Renal ultrasounds were performed at 3 to 6-month intervals for the first 2 years of followup, and at 6-month to 2-year intervals thereafter. The degree of hydronephrosis seen on ultrasound was graded according to SFU criteria. VCUG was routine in all patients and was repeated approximately every 1 to 2 years if reflux was found. Vesicoureteral reflux detected on VCUG was graded according to the ICS. In some patients nuclear cystogram was used for followup of reflux status. Static renal scans or IVPs were done to assess function and drainage of the affected unit, and in some cases furosemide renal scans were necessary to rule out obstruction. Outcome was assessed regarding degree of resolution of hydronephrosis and/or reflux, collapse of the ureterocele or
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Vol. 175, 1493-1495, April 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00676-2
1494
OBSERVATION OF URETEROCELES Clinical course of patients followed with prenatally detected ureteroceles
Pt No.—Sex
System
Ureterocele Type
1—M 2—M 3—F 4—M 5—F 6—F 7—F 8—F 9—M 10—F
Single Single Single Single Duplex Duplex Duplex Duplex Duplex Duplex
Orthotopic Orthotopic Orthotopic Orthotopic Ectopic Ectopic Ectopic Ectopic Ectopic Ectopic
Hydronephrosis Grade*
VUR Grade†
Initial
Final
Moiety Function
Moiety Obstruction
Initial
Final
Not accessible 3 3 1 2 2 2 2 2 1
0 0 2 1 0 0 1 0 2 0
No (MCDK) Yes Yes Yes Yes Yes Yes Yes Yes Yes
Not accessible No No‡ No‡ No‡ No No No No No
0 0 0 0 III III 0 III III 0
0 0 0 0 0 III 0 0 1 0
* Hydronephrosis was graded according to SFU criteria. † VUR was graded according to ICS criteria. ‡ Furosemide renal scan was performed to rule out obstruction.
subsequent need for surgical intervention. In our series the occurrence of a well documented urinary tract infection, on or off of prophylactic antibiotics, was an indication for surgical intervention. RESULTS All 10 patients (4 males, 6 females) were treated conservatively with a median followup of 5 years (range 1 to 11). Six patients (1 male, 5 females) had ectopic ureteroceles associated with duplex collecting systems, and the remaining 4 (3 males, 1 female) had intravesical ureteroceles associated with a single collecting system. One of the 4 patients with an intravesical ureterocele had an associated MCDK. Antibiotic prophylaxis was prescribed to all patients for a mean of 1.5 years (range 2 months to 4 years). Hydronephrosis. All patients had unilateral hydroureteronephrosis on prenatal ultrasound, which was categorized by SFU criteria. Two of 10 patients initially had SFU grade 1, 5 had grade 2 and 2 had grade 3 hydronephrosis. The patient with MCDK initially had significant ureteral dilatation but the degree of hydronephrosis by SFU criteria could not be accurately quantified. Hydronephrosis had completely resolved in 6 of the patients at a mean followup of 2 years (range 1 to 3). Of this cohort with resolution 2 patients had single system orthotopic ureteroceles (including the patient with MCDK) and 4 had duplex systems with ectopic ureteroceles. Hydronephrosis remained stable or decreased in the remaining 4 children. In 1 patient with a duplex collecting system the ectopic ureterocele had completely decompressed after 2 years of followup, and hydronephrosis had resolved completely. Vesicoureteral reflux. Initial VCUG showed grade III ipsilateral reflux in 4 patients. All of these patients had duplex collecting systems associated with ectopic ureteroceles, and the VUR was in the lower pole moieties. Two patients had contralateral low grade VUR, which resolved. Two cases of ipsilateral reflux had resolved at a mean followup of 3 years (range 1 to 7). The remaining 2 patients had stable (1) or downgraded (1) reflux throughout followup. Kidney function. Renal scans (5 patients) or IVP (1) in the 6 patients with duplex system ureteroceles revealed that all had detectable function in the upper pole moiety subtended by the ureterocele. Four patients had static renal scans that
demonstrated adequate drainage of the upper pole moiety, while 1 underwent a furosemide renal scan and 1 underwent IVP to document adequate drainage. Renal scans (2 furosemide) in the 3 patients with single system ureteroceles showed equitable relative renal function compared to the contralateral renal unit, and no evidence of obstruction. One patient had a nonfunctioning MCDK. Renal scans were not routinely repeated in patients during followup, but rather ultrasounds were performed to document that renal parenchymal integrity was maintained. Except for the patient with MCDK, in no patient did the renal parenchyma in the renal unit associated with the ureterocele deteriorate with followup. In no patient was surgical intervention necessary during the course of followup. A complete description of the clinical course of these patients is included in the table. DISCUSSION There may be a role for watchful waiting in select cases of prenatally detected ureteroceles, provided there is no bladder outlet obstruction or ipsilateral lower moiety obstruction, and ipsilateral lower moiety VUR is less than grade IV. The presence of function in the renal unit associated with the ureterocele does not exclude observation, as has been recommended by others,3 particularly if there is no evidence of obstruction of the unit. Hydronephrosis resolves or is stable in the vast majority of cases, and occasionally the ureterocele will completely decompress. Low grade (III or less) VUR also resolves or downgrades in most cases, and the use of antibiotic prophylaxis in any neonate with a ureterocele, for at least the first year of life, would seem prudent. Breakthrough urinary tract infection is an indication for surgical intervention. Our study did not examine children with more severe hydronephrosis or reflux (SFU grade 4, and ICS grade IV to V, respectively) because these cases were believed to mandate primary surgical management. Alternatives to a conservative approach in the asymptomatic neonate include endoscopic decompression, which may result in vesicoureteral reflux and usually requires further surgical correction.2,4 Other invasive procedures that provide more definitive treatment include heminephrectomy, ureteroureterostomy and ureterocele excision with ureteral reimplant, all of which are clearly accompanied by the risks of open surgery.
OBSERVATION OF URETEROCELES We fully acknowledge that this series is limited in number and retrospective in scope. Our patients were carefully selected for conservative treatment based on the aforementioned selection criteria, and constituted a small percentage of patients with ureterocele seen in our practice. Also, due to the retrospective nature of the study, it is possible that patients who would have been candidates for observation were operated on during this interval. The series also included patients with duplex system/ectopic ureteroceles and single system/orthotopic ureteroceles, with the latter more commonly treated conservatively as a standard of practice. Furthermore, the series contained 1 patient among the single system cohort with MCDK. Coplen and Austin had previously reported that such patients do well with conservative treatment.5 These potential confounding issues do not diminish the importance of our observations in the duplex system/ectopic ureterocele cohort. A recent study presented by Han et al included a similar series of patients, and would seem to corroborate our observations.6 CONCLUSIONS This report is by no means a comparison between surgical and conservative approaches to ureteroceles. We can only draw conclusions based on our limited followup, since the consequences of nonoperative management of prenatally detected ureteroceles in adulthood would require lifelong surveillance. We use our positive experience with conservative management during a limited followup to suggest another possible clinical approach to the prenatally detected ureterocele in select circumstances. Data gathered from more patient series will be helpful in this regard, and careful followup of our conservatively treated cohort continues.
Abbreviations and Acronyms ICS IVP MCDK SFU VCUG VUR
⫽ ⫽ ⫽ ⫽ ⫽ ⫽
International Classification System excretory urography multicystic dysplastic kidney Society for Fetal Urology voiding cystourethrogram vesicoureteral reflux
REFERENCES 1. Decter, R. M., Roth, D. R. and Gonzales, E. T.: Individualized treatment of ureteroceles. J Urol, part 2, 142: 535, 1989
1495
2. Barthold, J. S.: Individualized approach to the prenatally diagnosed ureterocele. J Urol, 159: 1011, 1998 3. Shankar, K. R., Vishwanath, N. and Rickwood, A. M. K.: Outcome of patients with prenatally detected duplex system ureterocele; natural history of those managed expectantly. J Urol, 165: 1226, 2001 4. Jayanthi, V. R. and Koff, S. A.: Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems. J Urol, 162: 1077, 1999 5. Coplen, D. E. and Austin, P. F.: Outcome analysis of prenatally detected ureteroceles associated with multicystic dysplasia. J Urol, suppl., 172: 1637, 2004 6. Han, M. Y., Gibbons, D., Belman, A. B., Pohl, H. G., Majd, M. and Rushton, H. G.: Indications for nonoperative management of ureteroceles. J Urol, part 2, 174: 1652, 2005
EDITORIAL COMMENT The authors should be congratulated for attempting to identify a select subset of neonates with asymptomatic ureteroceles that could be successfully managed nonsurgically. The authors clearly admit the major shortcoming of this (or any) retrospective review, and freely state that some patients with the same criteria used for observation may have undergone surgical intervention during the study period. Therefore, we cannot determine what percentage of patients would be expected to have a good outcome with this approach. Patients with single system ureteroceles with no evidence of obstruction or reflux would not be considered surgical candidates by most pediatric urologists today. Therefore, the novel approach is limited to the 6 patients with duplex systems with minimal (SFU grade 2) hydronephrosis, especially the 4 patients with reflux who were treated successfully without intervention. I personally have difficulty in determining the absolute function and degree of obstruction in the upper pole in many newborns with ureteroceles and a duplex collecting system. Further prospective studies using the stated inclusion criteria with followup functional studies would confirm that observation in this select group of patients is safe, and does not lead to deterioration of renal function in the upper pole segment with time. Mark Cain Department of Urology Indiana University School of Medicine Indianapolis, Indiana
Purpose: Ureteroceles are commonly detected by prenatal ultrasound. Although many require surgical intervention due to obstruction of more than one renal moiety or obstruction of the bladder neck, some may be carefully observed. The objective of this study was to assess the outcome of conservative management in select cases of prenatally detected ureteroceles at a tertiary care pediatric hospital. Materials and Methods: We retrospectively reviewed the charts of patients with ureteroceles detected on prenatal ultrasound who were treated nonsurgically between 1990 and 2001. Results: A total of 10 cases were detected in the course of the chart review, with 6 involving duplex system and 4 involving single system ureteroceles. Median followup was 5 years (range 1 to 11). Patients were followed with routine ultrasound at 3 to 6-month intervals for the first 2 years, and at 6-month to 2-year intervals thereafter. Voiding cystourethrogram and renal scans or IVPs were performed initially in all patients. Those with vesicoureteral reflux were followed with annual or biennial cystogram until reflux resolution. Antibiotic prophylaxis was routinely prescribed for an average duration of 1.5 years. Initial ultrasound revealed unilateral hydronephrosis in all patients, with complete resolution in 6 during a mean followup of 2 years. Voiding cystourethrogram demonstrated vesicoureteral reflux of grade III or less in 4 patients. Reflux resolved in 2 of these patients during a mean followup of 3 years. No patient required surgical intervention within the time frame of this study. Conclusions: There may be a role for watchful waiting in select cases of prenatally detected ureteroceles. Cases involving obstruction of more than one renal moiety, bladder neck obstruction or high grade vesicoureteral reflux were not selected among the population we followed, and would likely require initial surgical management. Patients without these complicating features may be safely followed on suppressive antibiotics, as based on our experience many of the associated problems may resolve without surgical intervention. Key Words: hydronephrosis, prenatal diagnosis, ureterocele, observation
here is considerable controversy regarding the treatment of prenatally detected ureteroceles. Many of the treatment strategies used are derived from experience with symptomatic patients who present postnatally.1,2 However, most neonates with fetal ultrasound detected urinary tract anomalies are asymptomatic and do not have clear indications for surgical intervention. Surgical intervention without knowledge of the natural history of a condition raises the question of the need for such invasive procedures. Our study attempts to address this question by examining the outcome of patients with prenatally detected ureteroceles who were treated with careful observation.
T
MATERIALS AND METHODS We retrospectively reviewed the charts of patients with prenatally detected ureteroceles who presented between 1990 and 2001. Patients had prenatally detected urinary tract
Submitted for publication February 12, 2005. Study received institutional review board approval. * Correspondence: Division of Pediatric Urology, Children’s Hospital of Eastern Ontario, 401 Smyth, Ottawa, Ontario, Canada K1H 8L1 (telephone: 613-737-7600, ext. 1353; FAX: 613-738-4271; e-mail: [email protected]). † Financial interest and/or other relationship with Q-Med Canada.
0022-5347/06/1754-1493/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION
anomalies later confirmed as ureteroceles with postnatal ultrasound. All patients were treated initially with careful clinical observation—there was no initial intent for surgical intervention. Exclusion criteria used to select against initial observation included ipsilateral lower pole moiety obstruction, high grade (IV or V) vesicoureteral reflux and/or bladder outlet obstruction. We did not exclude children with demonstrable function in the renal unit associated with the ureterocele. However, there had to be adequate drainage documented for the affected unit. It should be emphasized that the patients selected for observation constituted a minority of all patients assessed with a prenatal diagnosis of ureterocele during this interval. Renal ultrasounds were performed at 3 to 6-month intervals for the first 2 years of followup, and at 6-month to 2-year intervals thereafter. The degree of hydronephrosis seen on ultrasound was graded according to SFU criteria. VCUG was routine in all patients and was repeated approximately every 1 to 2 years if reflux was found. Vesicoureteral reflux detected on VCUG was graded according to the ICS. In some patients nuclear cystogram was used for followup of reflux status. Static renal scans or IVPs were done to assess function and drainage of the affected unit, and in some cases furosemide renal scans were necessary to rule out obstruction. Outcome was assessed regarding degree of resolution of hydronephrosis and/or reflux, collapse of the ureterocele or
1493
Vol. 175, 1493-1495, April 2006 Printed in U.S.A. DOI:10.1016/S0022-5347(05)00676-2
1494
OBSERVATION OF URETEROCELES Clinical course of patients followed with prenatally detected ureteroceles
Pt No.—Sex
System
Ureterocele Type
1—M 2—M 3—F 4—M 5—F 6—F 7—F 8—F 9—M 10—F
Single Single Single Single Duplex Duplex Duplex Duplex Duplex Duplex
Orthotopic Orthotopic Orthotopic Orthotopic Ectopic Ectopic Ectopic Ectopic Ectopic Ectopic
Hydronephrosis Grade*
VUR Grade†
Initial
Final
Moiety Function
Moiety Obstruction
Initial
Final
Not accessible 3 3 1 2 2 2 2 2 1
0 0 2 1 0 0 1 0 2 0
No (MCDK) Yes Yes Yes Yes Yes Yes Yes Yes Yes
Not accessible No No‡ No‡ No‡ No No No No No
0 0 0 0 III III 0 III III 0
0 0 0 0 0 III 0 0 1 0
* Hydronephrosis was graded according to SFU criteria. † VUR was graded according to ICS criteria. ‡ Furosemide renal scan was performed to rule out obstruction.
subsequent need for surgical intervention. In our series the occurrence of a well documented urinary tract infection, on or off of prophylactic antibiotics, was an indication for surgical intervention. RESULTS All 10 patients (4 males, 6 females) were treated conservatively with a median followup of 5 years (range 1 to 11). Six patients (1 male, 5 females) had ectopic ureteroceles associated with duplex collecting systems, and the remaining 4 (3 males, 1 female) had intravesical ureteroceles associated with a single collecting system. One of the 4 patients with an intravesical ureterocele had an associated MCDK. Antibiotic prophylaxis was prescribed to all patients for a mean of 1.5 years (range 2 months to 4 years). Hydronephrosis. All patients had unilateral hydroureteronephrosis on prenatal ultrasound, which was categorized by SFU criteria. Two of 10 patients initially had SFU grade 1, 5 had grade 2 and 2 had grade 3 hydronephrosis. The patient with MCDK initially had significant ureteral dilatation but the degree of hydronephrosis by SFU criteria could not be accurately quantified. Hydronephrosis had completely resolved in 6 of the patients at a mean followup of 2 years (range 1 to 3). Of this cohort with resolution 2 patients had single system orthotopic ureteroceles (including the patient with MCDK) and 4 had duplex systems with ectopic ureteroceles. Hydronephrosis remained stable or decreased in the remaining 4 children. In 1 patient with a duplex collecting system the ectopic ureterocele had completely decompressed after 2 years of followup, and hydronephrosis had resolved completely. Vesicoureteral reflux. Initial VCUG showed grade III ipsilateral reflux in 4 patients. All of these patients had duplex collecting systems associated with ectopic ureteroceles, and the VUR was in the lower pole moieties. Two patients had contralateral low grade VUR, which resolved. Two cases of ipsilateral reflux had resolved at a mean followup of 3 years (range 1 to 7). The remaining 2 patients had stable (1) or downgraded (1) reflux throughout followup. Kidney function. Renal scans (5 patients) or IVP (1) in the 6 patients with duplex system ureteroceles revealed that all had detectable function in the upper pole moiety subtended by the ureterocele. Four patients had static renal scans that
demonstrated adequate drainage of the upper pole moiety, while 1 underwent a furosemide renal scan and 1 underwent IVP to document adequate drainage. Renal scans (2 furosemide) in the 3 patients with single system ureteroceles showed equitable relative renal function compared to the contralateral renal unit, and no evidence of obstruction. One patient had a nonfunctioning MCDK. Renal scans were not routinely repeated in patients during followup, but rather ultrasounds were performed to document that renal parenchymal integrity was maintained. Except for the patient with MCDK, in no patient did the renal parenchyma in the renal unit associated with the ureterocele deteriorate with followup. In no patient was surgical intervention necessary during the course of followup. A complete description of the clinical course of these patients is included in the table. DISCUSSION There may be a role for watchful waiting in select cases of prenatally detected ureteroceles, provided there is no bladder outlet obstruction or ipsilateral lower moiety obstruction, and ipsilateral lower moiety VUR is less than grade IV. The presence of function in the renal unit associated with the ureterocele does not exclude observation, as has been recommended by others,3 particularly if there is no evidence of obstruction of the unit. Hydronephrosis resolves or is stable in the vast majority of cases, and occasionally the ureterocele will completely decompress. Low grade (III or less) VUR also resolves or downgrades in most cases, and the use of antibiotic prophylaxis in any neonate with a ureterocele, for at least the first year of life, would seem prudent. Breakthrough urinary tract infection is an indication for surgical intervention. Our study did not examine children with more severe hydronephrosis or reflux (SFU grade 4, and ICS grade IV to V, respectively) because these cases were believed to mandate primary surgical management. Alternatives to a conservative approach in the asymptomatic neonate include endoscopic decompression, which may result in vesicoureteral reflux and usually requires further surgical correction.2,4 Other invasive procedures that provide more definitive treatment include heminephrectomy, ureteroureterostomy and ureterocele excision with ureteral reimplant, all of which are clearly accompanied by the risks of open surgery.
OBSERVATION OF URETEROCELES We fully acknowledge that this series is limited in number and retrospective in scope. Our patients were carefully selected for conservative treatment based on the aforementioned selection criteria, and constituted a small percentage of patients with ureterocele seen in our practice. Also, due to the retrospective nature of the study, it is possible that patients who would have been candidates for observation were operated on during this interval. The series also included patients with duplex system/ectopic ureteroceles and single system/orthotopic ureteroceles, with the latter more commonly treated conservatively as a standard of practice. Furthermore, the series contained 1 patient among the single system cohort with MCDK. Coplen and Austin had previously reported that such patients do well with conservative treatment.5 These potential confounding issues do not diminish the importance of our observations in the duplex system/ectopic ureterocele cohort. A recent study presented by Han et al included a similar series of patients, and would seem to corroborate our observations.6 CONCLUSIONS This report is by no means a comparison between surgical and conservative approaches to ureteroceles. We can only draw conclusions based on our limited followup, since the consequences of nonoperative management of prenatally detected ureteroceles in adulthood would require lifelong surveillance. We use our positive experience with conservative management during a limited followup to suggest another possible clinical approach to the prenatally detected ureterocele in select circumstances. Data gathered from more patient series will be helpful in this regard, and careful followup of our conservatively treated cohort continues.
Abbreviations and Acronyms ICS IVP MCDK SFU VCUG VUR
⫽ ⫽ ⫽ ⫽ ⫽ ⫽
International Classification System excretory urography multicystic dysplastic kidney Society for Fetal Urology voiding cystourethrogram vesicoureteral reflux
REFERENCES 1. Decter, R. M., Roth, D. R. and Gonzales, E. T.: Individualized treatment of ureteroceles. J Urol, part 2, 142: 535, 1989
1495
2. Barthold, J. S.: Individualized approach to the prenatally diagnosed ureterocele. J Urol, 159: 1011, 1998 3. Shankar, K. R., Vishwanath, N. and Rickwood, A. M. K.: Outcome of patients with prenatally detected duplex system ureterocele; natural history of those managed expectantly. J Urol, 165: 1226, 2001 4. Jayanthi, V. R. and Koff, S. A.: Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems. J Urol, 162: 1077, 1999 5. Coplen, D. E. and Austin, P. F.: Outcome analysis of prenatally detected ureteroceles associated with multicystic dysplasia. J Urol, suppl., 172: 1637, 2004 6. Han, M. Y., Gibbons, D., Belman, A. B., Pohl, H. G., Majd, M. and Rushton, H. G.: Indications for nonoperative management of ureteroceles. J Urol, part 2, 174: 1652, 2005
EDITORIAL COMMENT The authors should be congratulated for attempting to identify a select subset of neonates with asymptomatic ureteroceles that could be successfully managed nonsurgically. The authors clearly admit the major shortcoming of this (or any) retrospective review, and freely state that some patients with the same criteria used for observation may have undergone surgical intervention during the study period. Therefore, we cannot determine what percentage of patients would be expected to have a good outcome with this approach. Patients with single system ureteroceles with no evidence of obstruction or reflux would not be considered surgical candidates by most pediatric urologists today. Therefore, the novel approach is limited to the 6 patients with duplex systems with minimal (SFU grade 2) hydronephrosis, especially the 4 patients with reflux who were treated successfully without intervention. I personally have difficulty in determining the absolute function and degree of obstruction in the upper pole in many newborns with ureteroceles and a duplex collecting system. Further prospective studies using the stated inclusion criteria with followup functional studies would confirm that observation in this select group of patients is safe, and does not lead to deterioration of renal function in the upper pole segment with time. Mark Cain Department of Urology Indiana University School of Medicine Indianapolis, Indiana