From: dmr@andromeda.rutgers.edu (Daniel Rosenblum)
Newsgroups: sci.med
Subject: Surgical options for ectopic ureterocele (long)
Summary: Curious about opinions on different surgical treatments
Keywords: common-sheath reimplantation, ureteroureterostomy, ectopic ureterocele
Date: 11 Sep 92 22:46:50 GMT
Organization: Rutgers University, Graduate School of Management, Newark, N.J.

Two weeks before our daughter was born, my wife had a sonogram to
ascertain the position of the placenta.  (It had been low-lying
throughout much of the pregnancy, and we wanted to rule out placenta
previa.  In fact, the ob/gyn was pretty certain that the placenta
was well away from the os, and much of the rationale for this
sonogram was to reassure my wife.  But it turned out to be rather
fortunate that it was done.)  The fetal bladder happened to be full
at the time, and some sort of membrane within the bladder was
clearly visible.  We were advised to have this checked out after she
was born.  So, when she was about two weeks old, she had a sonogram
which revealed duplication of the collection system of the right
kidney and an ectopic ureterocele (at the bladder end) of the upper
pole ureter.  (We learned that duplication of a collection system and
ectopic ureterocele commonly occur together.)  A subsequent voiding
cystourethrogram (VCU) showed no reflux.  At this point, the
pediatric urologist prescribed a renal scan to ascertain function of
the upper pole of the right kidney, drainage from which was
partially obstructed by the ureterocele.  The renal scan showed only
a slight loss of function of the upper pole of the right kidney, and
hence there was no indication for a partial nephrectomy, as would
have been necessary had that pole not been functioning.

At this point, the pediatric urologist, whom I will refer to as U1,
said that there were three surgical procedures that could be done
to correct this.  One was a common-sheath reimplantation, in which
the two right ureters are correctly implanted in the bladder.  This
is definitive for fixing the problem.  A second was a uretero-
ureterostomy, in which the upper pole ureter is cut, a hole is made
in the lower pole ureter, and the end of the upper pole ureter
coming from the kidney is attached to that hole, so that all the
drainage ultimately goes through the lower pole ureter.  The other
end of the upper pole ureter is cut as close to the bladder as
possible and removed, and the ureterocele is drained.  The third
was a transurethral procedure in which a cut is made in the
ureterocele.

The common-sheath reimplantation, U1 explained, could not be safely
done if the ureterocele was too low in the bladder, because it
carried the risks of harming the nerves in the neck of the bladder
and the urethra that provide bladder control.  The uretero-
ureterostomy involved attaching a dilated ureter to a normal one,
and carried with it perhaps a one-third chance of needing more
surgery later.  The transurethral procedure is quick, but it
exchanges a poorly draining system for a massively refluxing one,
and in his opinion should only be done as a temporizing procedure in
sick babies who cannot tolerate the stress of the more involved
surgery.  Hence U1's proposal was to do a cystoscopy to see if the
ureterocele was too low for the common-sheath reimplantation to be
done safely, then do either the common-sheath reimplantation or the
ureteroureterostomy accordingly.

Since we wanted to be well-informed and did not want to casually go
through extensive surgery on our daughter without knowing all the
options, we decided to get a second opinion from another pediatric
urologist, whom I will call U2.  U2, looking at the same data,
argued that the common-sheath reimplantation was too risky in terms
of bladder control and that it involved using a far too difficult
procedure for relieving something that could easily be remedied by
the transurethral incision in the ureterocele.  He argued that
results in such incisions, which could be done much more quickly
than a common-sheath reimplantation, might well differ among
different pediatric urologists because of differences in technique.
The reflux that would occur, he said, could be handled by long term
prophylactic antibiotics.  He ranked the ureteroureterostomy between
the other two procedures.  Since he knew we were now confronted with
two opposing views from highly recommended pediatric urologists, he
offered to show the data to two of his colleagues (whom we knew were
also highly regarded) whom he happened to be socializing with in
the next few days, and ask their opinion.  He later informed us that
both of them (I will call them U3 and U4) strongly supported the
transurethral incision, with U3 being particularly opposed to the
common-sheath reimplantation because of the risk of loss of bladder
control.

Since we were still stuck with two strongly divergent views, both
with apparently strong arguments to support them, we decided to get
one more opinion.  U5, as I will call him, favored either the
common-sheath reimplantation or the transurethral incision, leaning
slightly towards the latter, and did not like the ureteroureterostomy
very much, because of the difficulty in attaching the dilated ureter
to the normal one.  U5 also explained to us the details of how a
ureter is implanted in the bladder, and hence how the transurethral
incision would cause reflux.

At this point, we met again with U1, who persuaded us, with statistics
to back himself up, that his program was the best.  He also said that
he couldn't believe that U3 had opposed the common-sheath reimplanta-
tion, because he knew U3 quite well and knew him to be a rather
aggressive surgeon.  He also felt that anyone who would have misgivings
about doing a common-sheath reimplantation on a two-week old should not
be much more comfortable doing one on a two-year old, and that hence a
procedure that merely postponed the necessary major surgery had nothing
to recommend it.

One of the factors that we considered that prompted us to favor U1
was that he is at perhaps the preeminent pediatric hospital in the
area, part of a large and well-known tertiary teaching center.  We
felt that it was entirely likely that his willingness to perform the
more complicated procedure on an infant was the result of considerable
experience with the techniques at a place that provided top-notch
anesthesiologic and other support.  While the hospitals where U2
practices are fine tertiary and secondary hospitals, and would
undoubtedly have been more than adequate, especially for the far less
complex procedure that he favored, we felt more comfortable with our
daughter in U1's hospital, especially since my wife works there and
knows it very well.  (Of course, this was also a negative, because
she knows how things can go wrong too.  1/2 :-) )

So, when our daughter was seven weeks old, she had the surgery: the
cystoscopy showed that the ureterocele was indeed too low for a safe
common-sheath reimplantation, and she had the ureteroureterostomy.  A
followup intravenous pyelogram (IVP) showed good drainage through the
anastomosis (sp.?).  Finally, a followup VCU showed a small amount of
grade 2 reflux on both sides, the result, U1 explained, of the
weakening of the bladder wall's musculature around the (now drained)
ureterocele.  U1 hopes and expects the reflux to go away spontaneously,
since the bladder will grow more slowly at the site of the ureterocele
than elsewhere, and hence the ureter implantation sites will move away
from it.  Our daughter is now four months old, and will have another
VCU in about four months (six months after the surgery) to see if there
is still reflux.  She has been on prophylactic antibiotics since well
before the surgery -- amoxicillin until a month and a half after the
surgery, when she was about three months old, and the generic version
of Septra or Bactrim since -- and will continue to take them until
the reflux disappears.

It is obviously now a moot question, but I was wondering what
physicians and anyone else knowledgeable about this think about the
various options that we considered.  The results in our case were
pretty good, so we have no regrets.  But if you had heard this
story before we made the decision, what would you have suggested?
What criteria would you have advised us to use in deciding?  More
generally, how do patients choose when highly recommended, well-
qualified physicians differ in their assessments of the appropriate
treatment for a condition?
-- 
Daniel M. Rosenblum, Assistant Professor, Quantitative Studies Area,
   Graduate School of Management, Rutgers University (Newark Campus)
ROSENBLUM@DRACO.RUTGERS.EDU                      ROSENBLUM@ZODIAC.BITnet
dmr@andromeda.rutgers.edu          ...!rutgers!andromeda.rutgers.edu!dmr