Isolated bilateral simplex ureteric ectopia: Bladder capacity as an indicator of continence outcome.
BACKGROUND
Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ureteric reimplantation alone does not accomplish continence in all. Identifying the patients needing additional procedures for continence early could prevent multiple operations.


OBJECTIVE
Potential preoperative indicators for postoperative continence are explored in eight BSEU girls without cloacal, anorectal, or spinal anomalies.


METHODS
With institutional approval, all patients with BSEU between 1985 and 2012 were retrospectively reviewed. Cystoscopy determined the site of ureteric ectopia (6 of 16 at the bladder neck [BN], 5 of 16 below the BN, and 5 of 16 in the distal urethra). Bladders were assessed by a combination of ultrasound, urodynamics, micturating cystourethrogram, cystoscopic, and intraoperative observations. Expected bladder capacity for age (EBCA) was calculated by 30 ml + (30 ml × age in years) or 38 ml + (2.5 ml × age in months) for children greater or less than 2 years, respectively. Continence outcomes were appraised at a minimum of 4 years. The small number of patients precludes credible statistical analysis and therefore raw data are presented.


RESULTS
Patients underwent cross-trigonal ureteric reimplantation at 1-5.5 years, in five without BN surgery and in three with a Young-Dees-Leadbetter BN tightening. Of those without BN surgery at reimplantation, four achieved satisfactory continence for their age, but one has had multiple procedures culminating in BN closure, ileocystoplasty, and Mitrofanoff. Among the BN-tightening group, one was in nappies at 4 years, one had residual stress incontinence after two further BN injections, and one proceeded to artificial urinary sphincter after two BN injections. Five patients had significant renal impairment.


CONCLUSIONS
Patients with satisfactory continence after reimplantation alone and those needing further procedures tended to differ in their preoperative observations of bladder capacity and apparent BN competence. This study suggests preoperative observations of an empty bladder on serial ultrasound and/or a wide-open BN with small or even moderate bladder capacity at cystoscopy to indicate the need for BN surgery. In contrast, children with bladder filling to at least 30% of expected bladder capacity for age on preoperative ultrasound or apposition of the BN at cystoscopy may achieve satisfactory continence after ureteric reimplantation alone. Bladder capacity as an indicator of BN competence can also be correlated to continence outcomes in previously published series. Polyuria associated with renal impairment can exacerbate the challenge for continence.


CONCLUSIONS
Preoperative bladder capacity appears to be an indicator of inherent BN function and a thorough assessment of the urinary tract by cystoscopy, ultrasound, micturating cystourethrogram, and functional imaging may guide the surgeon on the need for BN surgery at the time of ureteric reimplantation. Where continence remains elusive, patients should be counselled that a further BN injection is occasionally of value although more significant BN procedures are required for most.
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK.
Vasilis
V
Stavrinides
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
Paul
P
Charlesworth
Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK.
Dan
D
Wood
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK.
Divyesh
D
Desai
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK.
Abraham
A
Cherian
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
Imran
I
Mushtaq
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK.
Peter
P
Cuckow
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Departments of Paediatric and Adolescent Urology, University College London Hospitals NHS Foundation Trust, London, UK. Electronic address: naima.smeulders@gosh.nhs.uk.
Naima
N
Smeulders
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D002828:Choristoma / Q000000981:diagnostic imaging* / Q000601:surgery*; D015331:Cohort Studies; D000070621:Cystography / Q000379:methods; D003558:Cystoscopy / Q000379:methods; D016208:Databases, Factual; D005260:Female; D006801:Humans; D011237:Predictive Value of Tests; D011379:Prognosis; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome; D014513:Ureter; D001745:Urinary Bladder Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D014549:Urinary Incontinence / Q000453:epidemiology / Q000503:physiopathology / Q000517:prevention & control; D014563:Urodynamics; D014564:Urogenital Abnormalities / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery; D055815:Young Adult
Bilateral ectopia; Bladder neck reconstruction; Ectopic ureter; Simplex system; Urinary incontinence