title: Utility of retrograde ureterocelogram in management of complex ureterocele.
abstract: BACKGROUND
  Symptomatic pediatric ureterocele has diverse manifestations, making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureterocelogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. This study sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy, compared with renal ultrasound (US) and voiding cystourethrography (VCUG).
  
  
  METHODS
  Patients who underwent surgical management of ureterocele from 2003 to 2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included: demographics, pre-operative evaluation, surgical interventions, and outcomes. The RUC images were individually examined, and the anatomic impression compared with previous renal US and VCUG. Novel RUC findings not previously appreciated by the pre-operative evaluation were noted. The RUC was performed by cystoscopically inserting a needle into the ureterocele and injecting contrast retrograde. If indicated, simultaneous PIC (Positioning the Instillation of Contrast) cystography was performed.
  
  
  RESULTS
  Of the 43 patients that underwent surgery for suspected ureterocele, 28 underwent cystoscopy + RUC (10 M: 18 F) at a median age of 4.6 months and median follow-up of 37.0 months. All patients had prior US, 25 had prior VCUG, and 20 had prior radionuclide studies. Ureteroceles were either duplex system (n = 21) or single system (n = 7); 17 were ectopic into the bladder neck or urethra; seven were intravesical; and four were pseudoureteroceles. Fourteen patients underwent concomitant transurethral incision of the ureterocele (TUIU); two were deferred for surgery; and 11 received concomitant definitive surgery (e.g., nephrectomy). The RUC illuminated novel aspects of the anatomy in 20 of the 28 patients. No adverse events occurred. Notably, in nine of the 28 children, significant observations from RUC prompted change to the pre-operative surgical plan.
  
  
  CONCLUSIONS
  Retrograde ureterocelogram clearly revealed ureterocele ectopy, pseudoureterocele, ureterocele disproportion, and unsuspected duplex systems, making it a useful adjunct to standard US and VCUG studies. Retrograde ureterocelogram can also be used to fluoroscopically verify decompression of the ureterocele post incision, document severity of ureteral dilation, and teach residents about the great damage generated by ureterocele variations. Limitations of RUC included increasing radiation dose and overall cost. The study design was limited by its small size, retrospective approach, selection bias, and availability of RUC images.
  
  
  CONCLUSIONS
  While not indicated in routine ureterocele management, intraoperative RUC further defined ureterocele anatomy in nearly all cases and yielded changes to the original surgical plan frequently enough to merit greater use in complex patients.
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA. Electronic address: michelle.arevalo@utsouthwestern.edu.
authors.forename: M K
authors.initials: MK
authors.lastname: Arevalo
authors.affiliation: San Antonio Pediatric Surgery Associates, 4499 Medical Drive, Suite 360, San Antonio, TX 78229, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Prieto
authors.affiliation: Pediatric Urology, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA.
authors.forename: N
authors.initials: N
authors.lastname: Cost
authors.affiliation: Urology Associates of North Texas, 811 West Interstate 20, Suite G-22, Arlington, TX 76017, USA.
authors.forename: G
authors.initials: G
authors.lastname: Nuss
authors.affiliation: Gulf Coast Plastic Surgery, 543-A Fontaine Street, Pensacola, FL 32503, USA.
authors.forename: B J
authors.initials: BJ
authors.lastname: Brown
authors.affiliation: Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Pediatric Urology, Children's Health Dallas, 2350 N. Stemmons Freeway, Suite F4300, Dallas, TX 75207, USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Baker
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003558:Cystoscopy / Q000379:methods; D003952:Diagnostic Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014518:Ureterocele / Q000000981:diagnostic imaging* / Q000601:surgery*; D018666:Ureteroscopy / Q000379:methods; D013520:Urologic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D014718:Vesico-Ureteral Reflux / Q000000981:diagnostic imaging / Q000601:surgery*
keywords: Ectopic ureter; Fluoroscopy; Pseudoureterocele; Retrograde ureterocelogram; Ureterocele