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Partial Nephrectomy versus Lower Urinary Tract Reconstruction for management of ureterocele in duplicated collecting systems : A Decision Tree Analysis.
Elizabeth B. Johnson, MD1, Joseph E. Tanenbaum, n/a2, Paul A. Merguerian, MD3.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2Dartmouth College, Hanover, NH, USA, 3Seattle Children's Hospital, Seattle, WA, USA.

Background:
Management of ureteroceles is controversial. If conservative management or puncture fail, options include lower urinary tract reconstruction (LUTR) or upper pole partial nephrectomy (UPPN). The rarity of this condition precludes a randomized trial. Decision analysis based on published data may help address this controversy.
Methods:
A comprehensive literature review was performed to evaluate the complication rates of UPPN and LUTR. Success was defined as not requiring further surgery. A decision tree with Monte Carlo simulation was designed for the index infant with a duplicated collecting system after failed puncture (TreeAge Software). Utilities were assigned based on the literature. Outcome measurements were quality adjusted life years.
Results:
14 of 721 screened articles were included. 218 patients underwent LUTR and 385 underwent UPPN. Successful treatment not requiring further surgery was achieved in 174/218 (79.8%) of LUTR and in 165/385 (42.9%) UPPN. With successful LUTR and UPPN , a complication rate of 19.5% (30 minor , 4 major) and 7.3% (7minor, 4 major) was observed respectively. Decision analysis favored LUTR with higher success rate and lower complications. A minor complications rate of below 40% would favor UPPN.
Conclusion:
Based on our decision analysis, LUTR has higher success and lower complication rates. Limitations of the study include lack of adequately conducted randomized trials specifically designed to answer these questions and lack of utilities in pediatric urology.


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