Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

OBJECTIVE: To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED). MATERIALS AND METHODS: This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups. RESULTS: Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections. CONCLUSIONS: SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Ureterocele with duplex collecting systems and febrile urinary tract infection risk.

PURPOSE: Ureterocele has been hypothesized to be the risk factor for febrile urinary tract infections (F-UTIs) in patients with duplex collecting systems, but this has not been proved, and our goal was to assess the relation between ureterocele with duplex collecting systems and F-UTIs. METHODS: We included individual-participant data from patients seen for complicated duplex collecting systems from 2010 to 2020 retrospectively followed. Those with using continuous low-dose antibiotic prophylaxis and incompletely duplicated systems were removed from the study. The participants were divided into two cohorts according to patients with or without ureterocele. The primary endpoint of this study was recurrent F-UTIs. RESULTS: We analyzed medical reports of 300 patients, of which 75% were female. Among the 300 patients, F-UTIs developed in 111/159 (69.8%) patients in the ureterocele group and in 69/141 (48.9%) patients in the no-ureterocele group. Univariate analysis found no discernible difference except in grade of hydronephrosis between ureterocele group and no-ureterocele group. Moreover, Cox proportional regression analysis revealed that patients of duplex system ureterocele might be intrinsically more prone to develop F-UTIs (adjusted hazard ratio 1.894; 95% CI 1.412-2.542; p  <  0.001). CONCLUSION: Among participants with duplex systems, the risk of recurrent F-UTIs in patients with ureterocele was higher than patients without it, and mini-invasive surgical correction should be considered at young age to reduce F-UTIs.

An alternative lower tract approach to ectopic duplex system ureteroceles feasible in young children.

INTRODUCTION: The best surgical approach to ectopic ureters and ureteroceles is yet to be determined. The objective of this study is to provide an alternative lower tract surgical approach to ectopic ureters and duplex system ureteroceles that can be safely performed in young children. METHODS: The "in-and-out" bladder approach was performed via an open intravesical incision. The upper and lower pole ureters were mobilized and brought into the bladder. The dilated ureter/ureterocele was cut open, and the distal part was deuroepithelialized. Subsequently, common sheath reimplantation was performed. The ureterocele wall was not involved during the whole procedure. We retrospectively reviewed all patients who underwent surgery for ureteroceles and ectopic ureters between January 1, 2004, and December 31, 2019. Patients with intravesical ureteroceles were excluded. Outcome parameters included the presence of hydronephrosis or reflux, split renal function on DMSA scan, incidence of urinary tract infection, and urinary incontinence. RESULTS: A total of 32 patients with ectopic duplex system ureterocele who underwent the "in-and-out" bladder approach between 2004 and 2019 were included in the retrospective study. The median age at operation was 7.8 months (range: 1.5 months-3.0 years). The median length of follow-up was 6.1 years (range: 1.0 years-14.3 years). Sixteen patients (55%) had ipsilateral vesicoureteral reflux. Five patients postoperatively developed a urinary tract infection within 1-3 years. No patients required further endoscopic treatment or surgeries. During long-term follow-up, two patients (6.3%) had intermittent day wetting at the ages of 4 and 5 years and were managed conservatively. The symptoms of intermittent day wetting subsided during follow-up. CONCLUSIONS: The "in-and-out bladder" approach can be performed in complex duplex system ureteroceles and enables early intervention; it is a single and simple operation with a satisfactory long-term continence rate.

Fetal surgery for obstructive ureterocele using an ultrasound-guided needle laser ablation technique: a case series.

INTRODUCTION: Obstructive ureterocele is an intravesical cystic dilation of the distal end of the ureter associated with anhidramnios and dilation of both renal pelvises. METHODS: This is a case-series of prenatally diagnosed ureterocele. Cases were selected at a third level reference hospital in Monterrey Mexico between 2010 and 2018. Eligible patients for fetal therapy were selected when bilateral hydronephrosis and severe oligohydramnios were found before 26+0 weeks of gestation. The fetal intervention comprised an ultrasound-guided needle laser technique for ureterocele ablation. RESULTS: There were six cases of prenatal diagnosed of ureterocele, two cases showed anhidramnios at 23 weeks of gestation and were considered obstructive ureterocele. For these two cases, fetal surgery was performed using laser ablation of the ureterocele through an ultrasound-guided needle. In both, the urinary tract was decompressed, and the volume of amniotic fluid improved allowing to carry both pregnancies until term, one of them vaginally and the other by cesarean section. In the postnatal follow-up of both cases, the first neonate died due to neonatal asphyxia at 48-hours, and the second neonate required removal of the abnormal collecting system. CONCLUSIONS: The use of ultrasound-guided laser ablation for the decompression of obstructive ureterocele is a safe and feasible technique in extremely premature fetuses that could allow survival of the affected fetus until term. Patients receiving an early prenatal diagnosis of obstructive ureterocele may benefit from fetal therapy to reduce the risk of lung hypoplasia and stillbirth.Established factsPrenatal mortality of bilateral obstructive ureterocele is up to 45%.Only a few techniques have been described for the management of prenatally bilateral obstructive ureterocele; among them, the puncturing of the ureterocele which may require more than one intervention during fetal, laser by fetoscopy which may increase the risk of postoperative complications, and ultrasound-guided laser fulguration which seems to be effective and safe.Novel insightsThe present is the first description of a case series on ureteroceles comprising two ultrasound-guided laser therapy as an effective treatment for bilateral obstructive ureterocele requiring a single intervention.The use of ultrasound-guided laser in obstructive cases avoids fatality and lung hypoplasia due to severe oligohydramnios. Still, the neonatal prognosis of the affected side at two years of age remains unchanged.

Acquired partial lower urinary tract obstruction caused by intravesical ureterocele in an adult dog.

Ureterocele is an uncommon condition in dogs characterised by a cystic dilation of the submucosal portion of the distal ureter. A 4-year-old intact male Siberian husky with a 4-month previous diagnosis of ureterocele was presented for pollakiuria. Abdominal ultrasound showed increased dimensions of the ureterocele, and a retrograde positive contrast urethrocystography detected a filling defect of the bladder neck lumen. The position of ureterocele was considered responsible for the partial urinary obstruction. This hypothesis is supported by the resolution of pollakiuria after surgical ureterocele resection. Based on a literature search, this is the first case of an intravesical ureterocele causing partial urinary obstruction in dogs. Ureterocele should be considered as a differential diagnosis in patients with pollakiuria.

Ureterocele as a cause of chronic intractable abdominal pain.

A ureterocele is a submucosal, cystic dilation of the terminal ureter, either congenital or acquired, as it enters the bladder. It is a rare clinical entity that can be entirely asymptomatic and present as an incidental finding or can manifest in the form of distressing symptoms such as unremitting abdominal pain, haematuria, obstructive uropathy, to name a few. The authors present a case of abdominal pain in a 43-year-old woman who was presumptively attributed to various clinical entities and was finally referred to the chronic pain clinic. The patient underwent numerous diagnostic tests, psychological evaluations and therapeutic interventions, including surgeries, over the years that failed to mitigate her symptoms until urologic imaging reported intravesical ureterocele as the underlying disorder. The case report entails the diagnostic challenge faced by the authors along with the clinical characteristics of ureterocele.

[Ectopic Ureterocele of Adult Male with Urination Difficulty : A Case Report].

Ectopic ureteroceles is sometimes noted in children as an incidental finding in antenatal ultrasonography results or because of symptoms related to a urinary tract infection. In contrast, it is rarely noted in adults, with only 18 cases in Japan presented in literature. We report here a 30-year-old adult male with an ectopic ureterocele discovered due to urination difficulty. The patient noted a poor urine stream and macroscopic hematuria after exercise, and over time needed manual compression on the lower abdomen for urination. Computed tomography results revealed a 35 mm right ureterocele containing a 7.0 mm stone. Cystoscopy showed the ureterocele protruding into the prostatic urethra, which was thought to be the cause of urination difficulty. Transurethral resection of the ureterocele and lithotripsy for the stone were performed. The right ureteral orifice was not visualized during the operation. Resection was performed from the bladder neck side so that the ureterocele wall did not interfere with urination and the calculus was crushed with a pneumatic lithotripter (LithoClast®). Urination difficulty was improved following the procedures. Urinary cystourethrography performed two weeks postoperatively confirmed no vesicoureteral reflux. No symptoms of dysuria or fever were noted at a follow-up visit two months after the operation.

[Ureterocele associated with simplex ureter in children: clinical and therapeutic features]. / Urétérocèle sur uretère simplex chez l'enfant: aspects cliniques et thérapeutiques.

Ureterocele is a pseudo-cyst dilation of the terminal submucosal ureter. It is a rare malformative uropathy, in particular associated with simplex ureter. We conducted a retrospective study over a period of 10 years. Twelve medical records of patients whose data were collected at the Department of Paediatric Surgery of Monastir between 2006 and 2016 were examined. The average age of patients was 2.7 years (ranging from 7 days to 11 years) with a sex ratio of 1. Patients´ clinical status was dominated by fever due to upper urinary tract infection. Diagnosis was mainly based on renal bladder ultrasound, intravenous urography (IVU) and retrograde urethrography and cystography. Ureterocele was unilateral in 10 cases and bilateral in 2 cases (on a total of 14 cases). It was associated with simplex ureter in all cases and all patients underwent endoscopic surgery. No perioperative adverse event was reported. The postoperative course was uneventful. Clinical and radiological improvements were reported in all cases. Ureterocele associated with simplex ureter is a very rare urinary abnormality. Early diagnosis is essential to avoid upper urinary tract involvement. Endoscopic treatment is a good alternative leading to satisfactory results.

Bladder leiomyoma masquerading as a ureterocele.

We present a unique case of bladder leiomyoma that was mistakenly diagnosed as a ureterocele. The delay in diagnosis meant ongoing significant voiding lower urinary tract symptoms, which could have been avoided. This was eventually successfully treated by transurethral resection. Leiomyoma is the most common benign bladder mass and should be considered in the differential diagnosis when a smooth mass with normal overlying mucosa is seen on cystoscopy or a homogeneous, low density bladder mass is seen on cross-sectional imaging. Despite the benign nature of the lesion, leiomyoma can convey significant morbidity to the patient.

[Cystoscopic-guided laser ablation for treatment of ectopic ureteroceles in 2 female dogs]. / Zystoskopiegeführte Laserablation zur Korrektur ektopischer Ureterozelen bei 2 Hündinnen.

Two female intact Labrador Retriever dogs (6 and 3 months of age, respectively) presented with a history of urinary incontinence. In both dogs, abdominal ultrasound revealed evidence of a unilateral ectopic ureterocele. Diagnosis of ureteral ectopia was established urethrocystoscopically by visualization of the ureteral orifice in the urethra, and an intramural course was confirmed via retrograde contrast fluoroscopy. Ectopic ureteral orifices were stenotic in both dogs. Cystoscopic- and fluoroscopic-guided laser ablation of the ectopic ureter were performed with a Hol:YAG laser. Following the procedure, both dogs were fully continent without any medical treatment. Cystoscopic- guided laser ablation of ureteroceles was effective and safe in these 2 dogs. Thus, this minimally invasive technique for the treatment of ectopic ureteroceles provides an alternative to surgical intervention.

18F-Fluciclovine Uptake in a Ureterocele.

A 60-year-old man with prostate adenocarcinoma status post radical prostatectomy and bilateral pelvic lymph node dissection referred for restaging F-fluciclovine PET/CT due to rising serum prostate-specific antigen levels (1.1 ng/mL at that time of imaging). PET/CT images were obtained from the proximal thighs to the vertex of the skull approximately 3 to 5 minutes after the IV administration of 347.8 MBq (9.4 mCi) of F-fluciclovine. PET/CT imaging demonstrated a focus of abnormally increased F-fluciclovine uptake at the right ureterovesical junction. Subsequent MRI of the pelvis revealed that this focus corresponded to a benign ureterocele.

Signo cabeza de cobra: en relación con ureterocele y cálculo vesical / Cobra Head Sign: in relation to Ureterocele and vesical calculus

Imagen: Signo de la Cobra (flecha #1) hallazgo compatible con ureterocele, y en su interior imagen hiperecoica con sombra acústica posterior en relación con cálculo (flecha #2)...(AU)

The left ureterocele and stone of calyceal diverticulum in the patient with bilateral incomplete duplex kidneys managed by flexible ureteroscopy: a case report and literature review.

BACKGROUND: Duplex kidneys are one of the most common renal congenital abnormalities, mostly asymptomatic and of no clinical significance. There are little reports about the left ureterocele and stone of calyceal diverticulum in patients with bilateral incomplete duplex kidneys managed by flexible ureteroscopy. CASE PRESENTATION: A 69-year-old Chinese woman was presented with left waist pain for 1 month. A preoperative computed tomography (CT) scan and intravenous pyelogram revealed the left ureterocele which located in the left ureterovesical junction, and stone of calyceal diverticulum which located in the upper kidney of left incomplete duplex kidneys. The ureterocele was confirmed in view of ureteroscopy and the holmium laser was used for the resection of ureterocele. It took us a lot of efforts to find out the stone because of diverticular neck stenosis. Fortunately, when diverticular neck stenosis was incised internally by holmium laser, the stone was discovered clearly and removed using the holmium laser and nitinol stone basket through flexible ureteroscopy. A double-J ureteral stent was inserted and remained in place for 1 month. The symptom disappeared postoperatively and no complications were developed during the placement of the stent. There were no stone residents observed on CT scan before removing the ureteral stent 1 month later. CONCLUSIONS: Flexible ureteroscopy with holmium laser is feasible to manage the ureterocele and calyceal diverticulum stones in patients with bilateral incomplete duplex kidneys in one operation.

Computed tomographic and sonographic findings in a dog with duplex kidney, ureter duplex and ectopic ureterocele.

A 5-month-old, male French bulldog was presented with a history of urinary incontinence. Abdominal ultrasound showed changes compatible with a ureterocele and a bilobed right kidney. Excretory computed tomographic urography was consistent with right-sided duplex kidney, ureter duplex and ectopic ureterocele. To the authors' knowledge, this is the first description of a duplex kidney with an ectopic ureterocele diagnosed with ultrasound and contrast enhanced computed tomography in a dog. After the imaging diagnosis, a neoureterocystostomy was performed. In the follow-up examination the dog presented with mild incontinence which was treated medically using phenylpropanolamine.

Virtual Three-Dimensional Magnetic Resonance Fetal Cystoscopy: A Novel Modality for Precise in Utero Evaluation of Urinary Tract.

Urogenital anomalies are the most prevalent anomalies detected during pregnancy. Timely detection of these conditions could facilitate proper post-natal management and improve outcomes. In some cases, precise delineation of fetal urinary tract utilizing ultrasonography is not feasible. Moreover, sometimes the ultrasound study is technically limited. Magnetic resonance imaging could clarify the diagnosis in these situations. Prenatal ultrasonography indicated hydronephrosis and a 14 mm cystic lesion at right ureterovesical junction in a 25-week fetus. However, fetal magnetic resonance urography was not able to precisely clarify the condition and extension of ureterocele into the urethra. Fetal magnetic resonance virtual cystoscopy clearly demonstrated anatomy and extension of ureterocele. This modality provides three-dimensional cystoscopic-like view of urinary bladder and facilitates postnatal management.

Prenatal imaging features and postnatal outcomes of isolated fetal duplex renal collecting system: A systematic review and meta-analysis.

OBJECTIVES: To perform a systematic review of studies reporting the outcome of fetuses with a prenatal diagnosis of isolated duplex collecting system (DCS). METHODS: Inclusion criteria were studies reporting the outcome of fetuses with a prenatal diagnosis of isolated DCS, defined as DCS not associated with other major structural anomalies at the time of diagnosis. The outcomes observed were: imaging features of DCS on prenatal ultrasound, associated anomalies detected exclusively at prenatal follow-up ultrasound and at birth, abnormal karyotype, symptoms at birth (including vesicoureteral reflux [VUR] and urinary tract infections [UTI]), need for and type of surgical approach, complications after surgery, and accuracy of prenatal ultrasound in correctly identifying this anomaly. RESULTS: Eleven studies (284 fetuses with a prenatal diagnosis of DCS) were included. On ultrasound, DCS was associated with ureterocele in 70.7% and with megaureter in 36.6% of cases. Worsening of pelvic/ureteric dilatation was reported to occur in 41.3% of fetuses. At birth, 4.3% of fetuses affected by DCS showed associated renal anomalies. After birth, VUR and UTI presented in 51.3% and 21.7% of children respectively, while 33.6% required surgery. Prenatal diagnosis of DCS was confirmed in 90.9% of included cases. CONCLUSION: DCS diagnosed prenatally is associated with a generally good outcome. Prenatal ultrasound has a good diagnostic accuracy, while detailed postnatal assessment is required in order to identify associated renal anomalies.

Antenatally detected ureterocele: Associated anomalies and postnatal prognosis.

OBJECTIVE: We purposed to review prenatal diagnoses of ureterocele, to determine the sonographic findings and additional abnormalities, and to illustrate the pregnancy outcomes of these patients. MATERIAL AND METHODS: We reviewed the records of 24 patients with the diagnosis of ureterocele in our referral center between January 2010-March 2017. Prenatal sonographic findings, antenatal course, and postnatal follow-up were obtained. RESULTS: The mean gestational age at first US diagnosis was 24.5 ± 2.9 weeks. 13 (54.1%) of fetuses were female, and 11 (45.9%) were male. Ureterocele was associated with the duplex kidney in 17 (70.8%), MCDK in 5 (20.8%) and hydronephrosis with a single system in 1 (4.2%) and pelvic kidney in 1 (4.2%) fetuses. Postnatal follow-up was achieved in 22 of 24 (91.6%) cases, and mean follow-up interval was 56 ± 14.2. Months. The diagnosis of ureterocele was confirmed in 22 (91.6%) cases postnatally. 15 of 22 (68%) cases were classified as extravesical ureterocele, and 7 (32%) cases were intravesical ureterocele. Postnatal confirmation of duplex kidney achieved in 16 of 17 (94.1%) patients. 17 (77.2%) patients were required surgical intervention, and 5 (22.8%) cases were managed conservatively. 15 of 16 (93.7%) cases who were diagnosed duplex kidney underwent surgery however 2 of 5 (40%) cases which were confirmed MCDK required an operation. Cystoscopic ureterocele incision was the initial approach for the surgical management and performed all of the cases which required surgery. It was curative in 10 of 17 (58.8%) patients and 7 (41.2%) cases needed to further operations. Ureteroselectomy and common-sheath ureteroneocystostomy was performed in 5 (29.1%) cases and. 2 (%11.7%) cases underwent partial nephrectomy. CONCLUSION: Ureterocele can be accurately diagnosed by prenatal sonography, and it is a significant clue for the diagnosis of a duplex kidney. Postnatal prognosis depends on associated anomaly and presence of reflux and upper pole function.