Photomedicine and Laser Surgery Volume 33, Number 6, 2015 ª Mary Ann Liebert, Inc. Pp. 326–329 DOI: 10.1089/pho.2015.3889

Efficacy and Safety of Transurethral Photoselective Greenlight Laser Vaporization for the Treatment of Orthotopic Ureteroceles in Adults Cuilong Liu, MD,* Weihao Chen, MS,* Changliang Xie, BS, Weimin Guan, BS, Yubo Zhao, MD, Yun Ouyang, MS, Yansheng Xu, MS, Yiguang Wu, MD, Xiyou Wang, MD, Yi Wang, MD, and Xinyu Zhang, MD

Abstract

Objective: This study aimed to retrospectively evaluate the safety and efficacy of transurethral photoselective Greenlight laser vaporization in adult patients with orthotopic ureterocele. Materials and methods: Thirty adult patients diagnosed with orthotopic urecterocele were recruited at our center. Transurethral photoselective Greenlight laser vaporization was used as the exclusive technique for endoscopic management during the study period. Information, including age, gender, mode of presentation, ureterocele size, vesicoureteral reflux, hydronephrosis status, and incidence of reoperation, were collected for evaluation. Results: Our series included 12 men and 18 women. The mean patient age at presentation was 30.5 years (range, 18–62 years). The mean size of ureterocele was 18 mm (range, 10–41 mm). All patients successfully underwent transurethral photoselective Greenlight laser to vaporize the ureterocele. The operation ranged from 13 min to 38 min (mean 19.6 min). The average blood loss was < 10 mL. No patient had intraoperative complications. The average postoperative hospital stay was 18.3 h. All patients were voided after postoperative catheter removal. None of the patients demonstrated any residual ureterocele and/or hydronephrosis when evaluated with ultrasonography after 3 months. Only one patient with a duplex collecting system presented asymptomatic low-grade reflux at 3 months, which was spontaneously resolved after 6 months of follow-up. All patients were free of any symptoms. No reoperative procedures were required at a mean follow-up of 14.2 months (range, 8–16). Conclusions: Transurethral photoselective Greenlight laser vaporization is safe, effective, and efficient for the management of orthotopic urecteroceles in adults. Therefore, this technique should be considered as the initial treatment in most patients. Introduction

U

reteroceles are cystic dilations located in the bladder neck or urethra that are associated with a single or duplex collecting system. Ureteroceles are classified based on their position: intravesical (orthotopic), when the ureterocele is completely located inside the bladder; and extravesical (ectopic), and when part of the cyst extends to the urethra or bladder neck.1 The mode of presentation can be symptomatic (pain or urinary tract infection [UTI]) or asymptomatic (hydronephrosis). Vesicoureteral reflux (VUR) may also occur in any moiety or combination of moieties. The optimal approach of ureterocele management aims to decompress the cyst, relieve obstruction, avoid VUR, prevent UTI, and minimize the invasiveness of operative interventions. Endoscopic decompression has become a popular method because it decreases the incidence of complications and reoperation. Different methods of endoscopic incision, such as

electrocautery, puncture with a stylet, and cold-knife incision, have also been used.2 Transurethral photoselective green laser vaporization has been proposed as an effective treatment option, particularly for single-system ureteroceles and intravesical ureteroceles. This technique is relatively easy, minimally invasive, and does not require secondary surgery. We evaluated the safety and efficacy of transurethral photoselective Greenlight laser vaporization for the treatment of orthotopic ureteroceles in adults. Postoperative outcomes included relief of clinical symptoms, improvement in hydronephrosis, no reflux, prevention of UTI, and need for subsequent surgery. Materials and Methods Participants

We retrospectively reviewed the medical records of all adult patients who underwent transurethral photoselective

Department of Urology, General Hospital of the Navy, Beijing, China. *The first two authors contributed equally.

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Greenlight laser vaporization for ureteroceles at our institution from August 2004 to February 2014. Patients with ectopic ureterocele were excluded from the study. All cases were diagnosed via ultrasonography, intravenous urography (IVU), and cystoscopic examination before operation. Clinical parameters, including age at presentation, gender, and mode of presentation, size of the ureterocele, VUR and hydronephrosis status, were obtained from each patient. The method was considered curative if patients demonstrated improved hydronephrosis and did not present clinical symptoms and reflux postoperatively. The following symptoms were observed from the patients: recurrent UTI (14 patients), flank pain and/or dysuria (9 patients), hematuria (2 patients), and calculi in the ureterocele (2 patients). Three patients were asymptomatic at presentation. Moreover, 28 patients presented unilateral ureteroceles, and 2 patients were diagnosed with bilateral ureteroceles. The ureterocele was associated with a single system in 27 patients and with a duplex system in 3 patients. Procedure

All patients were administered prophylactic antibiotics, which were continued postoperatively. All cases were performed by a single surgeon (Cuilong Liu). After the patients were placed in the lithotomy position, an initial cystoscopic evaluation of the bladder was performed using epidural anesthesia. Physiological sodium solution (0.9%) was irrigated, and a video camera was used as a guide during all procedures. The Greenlight laser system (Laserscope, San Jose, CA) was used during the surgery, and laser energy was set at 60 W. A transverse incision was performed at the base, below the ureterocele, and close to the bladder. The roof of the ureterocele established an anti-reflux flap valve (Fig. 1). Urine efflux was visualized after the procedure, and the ureteroscope was passed through the dilated lower ureter to confirm adequate incision.3 The small calculi in the ureterocele could easily descend into the bladder, and evacuated or removed using lithotomy forceps after incision of the ureterocele. A urethral catheter was not used postoperatively, and a 6F double-J stent was placed in the ureter. Follow-up

All patients were followed up every 3 months for the first year and then every 6 months thereafter. During follow-up, a detailed history with clinical evaluation, urine routine examination, ultrasonography, IVU, or micturating cystoure-

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thrography (MCU) were performed to assess the curative effect. Results

A total of 30 adult patients (12 men and 18 women) with orthotopic ureterocele successfully underwent transurethral photoselective greenlight laser vaporization from August 2004 to February 2014. The median age of the patients was 30.5 years (range, 18–62 years). The mean size of the ureterocele was 18 mm (range, 10–41 mm). The duration of the operation ranged from 13 to 38 min (mean, 19.6 min). The size of ureterocele stones in the two patients was 8 mm and 10 mm. The average blood loss was < 10 mL. No intraoperative complications were observed in all patients. All patients were voided after postoperative catheter removal, and the mean postoperative hospital stay was 18.3 h (range, 15–26 h). All patients retained a stent after the procedure for 2–4 weeks. Two patients with associated calculi were free of stones after the procedure. The mean follow-up period was 14.2 months (range, 8–16). No patient had ultrasonography and/or IVU evidence of residual ureterocele and/or hydronephrosis. One patient was diagnosed with asymptomatic grade I VUR via MCU at 3-month follow-up. Repeated MCU revealed complete resolution of VUR at 6-month follow-up. All patients were free of any symptoms. No reoperative procedures were required for any patient during follow-up. Discussion

Ureteroceles are cystic dilations of the terminal part of the ureter into the bladder, and their etiology remains unclear. Ureteroceles are clinical entities commonly observed in neonates or children, and mostly accompanied with a duplex collecting system and ectopic orifice in the urethra; nevertheless, such abnormalities have also been detected in adults. Intravesical ureteroceles are frequently observed in adults and are mostly combined with a single system; in this type, the function of the moiety is normal or slightly impaired. Treatments for the management of ureteroceles primarily aim to prevent urinary infection, preserve renal function, eliminate obstruction and reflux, and minimize surgical complications with a minimal number of procedures. Endoscopic decompression has been suggested as the first line of management of ureteroceles at some centers, particularly for adults with single-system ureteroceles and intravesical ureteroceles. This technique presents minimal operative morbidity, easy procedure, and low reoperation rates.

FIG. 1. Photoselective vaporization of the ureterocele with Greenlight laser. (A) The ureterocele; (B and C) vaporizing the ureterocele; (D) final appearance; the roof of the ureterocele would persist as an anti-reflux flap valve.

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Over the last 20 years, different endoscopic approaches/ techniques (e.g., unroofing, puncture, and incision) were used to decompress ureteroceles with different instruments, including the Collins knife, electrocautery, and laser.4 Monfort et al.5 described the use of transurethral incision for obstructive ureteroceles in 1985. They found that a small incision was unlikely to cause reflux compared with previous endoscopic management using ureterocele unroofing. Ureterocele puncture was introduced in 1994. This technique involves supplanted incision similar to initial endoscopy, and exhibits reoperation rates ranging from 0% to 100%.5 However, Ben Meir et al.6 reported no significant differences in terms of outcome between ureterocele endoscopic puncture and incision. The use of different energy sources, including the Collins knife and electrode, also yielded similar results. All endoscopic approaches aim to improve subsequent surgical success, but an optimal endoscopic technique for ureteroceles has not been established because of insufficient prospective randomized controlled trials and difficulty in comparison with different approaches.7 In adults, ureteroceles are amenable to endoscopic management. Ureterocele unroofing is also no longer recommended. Simple endoscopic puncture has been advocated as an emergent therapy for infected or obstructed ureteroceles, but the number of cases requiring second surgery after endoscopic puncture of orthotopic ureteroceles ranges from 7% to 23%.8 Hence, we postulated that puncture may be inadequate in adult patients because of ureterocele size and thickness, as well as the possibility that the site may re-seal and require repeated punctures.9 The advent of the Greenlight laser system revolutionized the field of endourology over the past 10 years. This system has been widely used in photoselective vaporization of the prostate because of its safety and efficacy with long-term follow-up.10,11 Although the Holmium:Yttrium-AluminiumGarnet (Ho:YAG) laser is also used in urological practice, its application is limited because of the long learning curve.12 The Greenlight laser can be created by passing a 1064 nm Neodymium-doped Yttrium-Aluminium-Garnet (Nd:YAG) laser beam through a potassium-titanyl-phosphate (KTP) crystal to produce a light beam with a wavelength of 532 nm, and this beam is strongly absorbed by hemoglobin, not by water.13 This type of laser exhibits several advantages compared with other lasers. Specifically, this laser demonstrates excellent cutting and tissue vaporization effects, as well as superior hemostatic properties. In addition, the penetration depth of the Greenlight laser ranges from 1 to 2 mm only. This laser does not produce thermal effects beyond the point of incision compared with the Bugbee electrode or Collins knife, thereby protecting the surrounding tissues. The coagulation properties of the Greenlight laser also minimize bleeding complications even in patients undergoing anticoagulation or platelet inhibition treatment.14 Thus, this technique allows precise and safe incision of ureteroceles and results in low postoperative stenosis. Ureteroceles in adults are larger than those in pediatric patients; hence, the position and accuracy of the incision may be important. Spatafora et al.9 noted that performing an accurate incision using standard endoscopic techniques is difficult because the ureterocele wall easily collapses. Therefore, they developed combined percutaneous transurethral incision for the management of ureteroceles in adults. The percutaneous

LIU ET AL.

route enables a firm grasp of the ureterocele wall by the forceps during surgery to ensure an accurate incision. A similar technique was also used by Ben Meir et al.6 to treat 12 children with ureteroceles. These studies indicated that percutaneous cystoscopic incision of the ureterocele enables better vision of the ureterocele wall when held in a stretched position. In our series, all patients successfully underwent transurethral photoselective Greenlight laser vaporization of ureteroceles. No intraoperative complications were observed during surgery. The ureteroceles were adequately decompressed in all patients. During the procedure, 0.9% physiological saline solution was irrigated to maintain a moderately distended bladder and achieve ureterocele distention, thereby ensuring a comfortable and accurate incision. Furthermore, this technique could prevent additional damage compared with the percutaneous pathways. We performed a transverse horizontal incision in the most medial and distal part of the ureterocele as close to the bladder floor as possible. With this approach, the overhanging hood functions as an anti-reflux flap valve to diminish the occurrence of VUR. Moreover, the opening lies in a position as physiologically normal as possible (facing the contralateral meatus), and the ureteral and trigonal structures are preserved. All patients showed excellent decompression with relief from flank pain and hydronephrosis. Only one patient with a duplex collecting system demonstrated asymptomatic low-grade reflux that spontaneously resolved after 6 months of follow-up. Reoperation rates have been used as a primary outcome measure to evaluate the success of an endoscopic management. Numerous studies showed that reoperation rates are higher in patients with a duplex collecting system than in those with a single collecting system, and are also higher in patients with ectopic ureteroceles than in those with orthotopic ureteroceles.5,15–17 In the present series, no patients required a second procedure during follow-up. This result could be attributed to the use of the Greenlight laser. The laser can provide accurate and adequate tissue vaporization effects, and produce minimal damage to the surrounding tissues, resulting in a low risk of re-sealing. Moreover, the degree of obstruction is insignificant and less severe than that observed in duplex systems in children. Limitations

With the increase in newer lasers being applied in urology, a limitation of our study was lack of comparison with other techniques of ureterocele treatment, such as the Ho:YAG laser, and its retrospective nature. The need for specialized Greenlight laser equipment and its associated cost are other limitations of this technique. Conclusions

In summary, the Greenlight laser can be used to perform a bloodless operation with less thermal tissue damage, precise incision and decompression of the ureterocele, and minimal complications. Therefore, this laser is safe and effective for the treatment of ureteroceles in adults. Author Disclosure Statement

No competing financial interests exist.

GREENLIGHT LASER TREATMENT OF ADULT ORTHOTOPIC URETEROCELES References

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Address correspondence to: Cuilong Liu Department of Urology, General Hospital of the Navy Fucheng Road No.6 Haidian District Beijing China,100048 E-mail: [email protected]