Utility of Retrograde Ureteroceleogram in Management of Complex Ureterocele

INTRODUCTION: Symptomatic pediatric ureterocele manifests diversely making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureteroceleogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. We sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy compared to the routine preoperative ureterocele imaging studies: ultrasound and voiding cystourethrography (VCUG). METHODS: Patients who underwent surgical management of ureterocele between 2003-2015 were identified; those who received concomitant fluoroscopic RUC were selected for the case series. Data collected included demographics, preoperative evaluation, surgical interventions, and outcomes. RUC images were individually examined and the anatomic impression compared to previous renal US and VCUG. Novel RUC findings not previously appreciated by the preoperative evaluation were noted. RUC was performed by cystoscopically inserting a needle into the ureterocele and injecting contrast retrograde. If indicated, simultaneous cystography was performed to visualize the bladder and ipsilateral refluxing ureter. RESULTS: Of 43 patients that underwent surgery for suspected ureterocele, 28 underwent cystoscopy + RUC (10M: 18F) at a median age of 4.6 months and median follow-up of 37.0 months. 21 had images available for review. All patients had prior u/s, 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; 7 were intravesicular; 4 were pseudoureteroceles. 14 patients underwent concomitant transurethral ureterocele incision (TUIU); 2 were deferred for surgery; 11 received concomitant definitive surgery (e.g. nephrectomy). RUC illuminated novel aspects of the anatomy in 20 patients. No adverse events occurred. Notably, in 9 of 28 children, significant observations from RUC prompted change to the preoperative surgical plan. CONCLUSIONS: Intraoperative RUC further defines ureterocele anatomy in nearly all cases and yields changes to the original surgical plan with enough frequency to merit greater use in complex patients.