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.

Displasia renal multiquística segmentaria asociada a ureterocele y quistes renales simples en un recién nacido / Multicystic segmentary renal displasia associated to ureterocele and simple renal cysts in a newborn

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Long-term bladder function after ureterocele decompression in children.

PURPOSE: There is limited knowledge of long-term bladder function after ureterocele decompression. We studied bladder function in patients who underwent surgery in childhood for duplex system ureteroceles. MATERIALS AND METHODS: Toilet trained children treated for duplex system ureteroceles between 1990 and 2010 were included in study. We evaluated voiding dysfunction by the valid DVSS questionnaire and noninvasive studies, including uroflowmetry, electromyogram and post-void residual urine measurement. Urodynamics were done only in patients with abnormal DVSS or abnormal noninvasive studies. Patients were divided into group 1-ureterocele decompression (endoscopic incision), upper pole partial nephrectomy and ureteropelvic anastomosis, and group 2-primary or secondary bladder surgery (ureterocelectomy, ureterovesical reimplantation and bladder floor reconstruction). RESULTS: Of 62 operated patients 17 were lost to followup and 45 were fully studied at a mean followup of 9.5 years (range 3 to 20). Initial surgery was done at mean age of 5.1 months (range 6 days to 48 months). In the 33 group 1 patients, of whom 70% underwent endoscopic incision, the mean DVSS score was 1.5 (range 0 to 6), 7 patients (22%) had abnormal uroflowmetry or significant post-void residual urine and none had abnormal DVSS results. In the 12 patients in group 2 the mean DVSS score was 4 (range 0 to 11), 8 patients (66%) had abnormal uroflowmetry and significant post-void residual urine, and 3 had abnormal DVSS findings (p = 0.036). All group 2 patients underwent bladder surgery after decompression, including endoscopic incision in 2 and upper pole partial nephrectomy in 1. Only 1 child needed clean intermittent catheterization at age 3 years for hypocontractile megacystis and repeat febrile urinary tract infections. CONCLUSIONS: Ureterocele decompression alone in early childhood does not lead to major bladder dysfunction at long-term evaluation. Even if secondary bladder surgery is needed, significant bladder dysfunction is rare.

Prolapsed single system ureterocele in a female adult: case report.

A 36 year old female teacher, presented with a bleeding mass in the introitus, difficult micturition, and dysuria of four months duration. She was a para 3+0, all spontaneous vertex deliveries, her last delivery was in 2001. She was first seen at a private mission hospital in March 2006 where an attempt to excise the mass was made but was abandoned due to bleeding. She was later discharged and re-admitted to a second mission hospital. On examination the mass was firm, round in shape about 2.5 cm in diameter, dark red in colour with a catgut stitch and areas of necrosis. The patient was investigated and a diagnosis of a prolapsing ureterocele was made and a transvesical excision was undertaken. A repeat IVP done six months later revealed no hydronephrosis and urea and electrolyte (U/E) were normal. This case is reported to highlight one of the differential diagnoses that should be considered when evaluating masses at the introitus in a female patient. The presentation, diagnosis, and management protocols are discussed. Thus far no local case reports have been established.

Ectopic ureteroceles in duplex systems: long-term follow up and 'treatment-free' status.

OBJECTIVE: Definitive treatment of ectopic ureterocele (EU) implies that no further surgery or prophylactic antibiotic is needed. The literature is unclear on which interventions render a child 'treatment free'. MATERIALS AND METHODS: Thirty (23 female, seven male) patients presented between 1984 and 2000. Follow up ranged from 5 to 15 years (mean: 7). Presenting reasons were: urinary tract infection in 18 (16 females, two males; age: 17<6 months, one 2 years), prenatal ultrasound in 11 (seven females, four males), and renal failure in one (male, aged 3 weeks). RESULTS: Treatment was as follows. No intervention, three (10%). Single procedure, eight (27%): five hemi-nephrectomy (HN), two transurethral incisions (TUI), one excision and re-implantation (E&R). Two procedures, 14 (47%): first procedure 10 TUI, 4 HN; second procedure 13 E&R, 1 TUI. Three procedures, three (10%): first 2 TUI, 1 HN; second 3 TUI; third 2 E&R, 1 HN. Four procedures, two (7%): first 2 TUI; second 1 HN, 1 TUI; third 2 TUI; fourth 2 E&R. Eight (27%) remained on prophylaxis: two had no intervention, in 4 the ectopic ureterocele was in situ after HN or TUI, and two had reflux after E&R. Twenty two (73%) came off prophylaxis (16 E&R, 4 HN, 1 TUI, 1 observation). Poorly or non-functioning upper pole moieties were left in place in 14/18 who underwent E&R. CONCLUSION: 'Treatment-free' status most often requires ureterocele excision. HN alone can be definitive, while TUI alone is so rarely. Poor or non-functioning upper pole segments can remain after E&R. Children with collapsed ureteroceles in situ often must remain on antibiotic prophylaxis. A staged approach with initial TUI, followed by E&R, was successful in definitively treating the majority.

Assessment of obstruction in adult ureterocele by means of color Doppler duplex sonography.

AIM: The purpose of this study is to present a method for identifying a ureteral obstruction in unilateral orthotopic ureterocele by means of conventional sonography and color Doppler duplex sonography. We focus on the measurement of the ureterocele dimensions, the degree of dilation it causes to the ipsilateral upper urinary tract, the registration of urine out-flow from the ureteral orifice into the bladder and its spectral analysis. MATERIAL AND METHOD: Over 2 years at our institutions, 8 adult patients (7 women, 1 man) were diagnosed as having a single system orthotopic ureterocele. Four of them presented with lumbar pain, dysuria and recurrent urinary tract infections, while the remainder were asymptomatic and diagnosed accidentally. The diagnosis was based on serial sonography of the upper and lower urinary tract confirmed by intravenous pyelography and cystoscopy. We also performed color Doppler duplex sonographic evaluation of the urine jets ejected from both ureteral orifices into the bladder. Using the flow spectral study we analyzed the waveforms and measured their duration and flow rate. The study was completed with a comparative analysis of the data obtained from both ureteral orifices. RESULTS: Cystic dilation of the lower ureteric extremity into the bladder was presented in all cases. Upper urinary tract dilation, of various grades, was present in 4 of 8 patients. Differences in urine jets between those derived from the ureterocele and those from the healthy contralateral ureteral orifice were significant in those patients with dilation of the upper urinary tract. The differences concerned mainly the frequency and symmetry of the jets as well as the pattern, duration and velocity of their waves. The 4 above-mentioned patients, with dilated upper urinary tracts and waveforms differentiated from the contralateral ones, were characterized as obstructive. On the other hand, the remaining 4 patients with subclinical ureterocele showed insignificant differences in urine jets and waveforms, and were found to be non-obstructive. CONCLUSION: Conventional sonography of the urinary tract in combination with color Doppler duplex sonography of the ureteral jets can be used in an attempt to diagnose and evaluate a unilateral orthotopic (single system) ureterocele and assess the necessity of intervention to identify the obstruction.

Contractile function of the smooth-muscle wall and its adrenergic regulation in megaureter.

We demonstrated disordered contractile capacity of megaureters formed against the background of reflux, organic or functional obstruction. The rhythmic and tonic contractions were suppressed in the megaureters with organic obstruction in comparison with megaureters caused by reflux. Norepinephrine stimulation induced pronounced pressor responses in obstructive megaureters. The state of the smooth-muscle walls of megaureters with functional obstruction was characterized by high tone, weak phase contractions, and increased capacity to pressor tonic reactions induced by norepinephrine.

[Giant orthotopic ureterocele. Diagnosis by ureteral jet detection with doppler color ultrasonography]. / Ureterocele gigante ortotópico. Diagnóstico por detección del jet ureteral mediante ecografía doppler color.

OBJECTIVE: To present an additional case of orthotopic ureterocele in a patient that consulted for hematuria and outlet obstruction, with special reference to the utility of non-invasive color doppler ultrasound in the diagnosis of this condition. METHODS/RESULTS: This condition was suspected on detecting a ureteral jet inside a cystic lesion of the bladder. The diagnosis was confirmed by IVP and cytoscopy. Treatment was by transurethral resection with good functional results. CONCLUSION: Color doppler ultrasound is useful for the diagnosis of ureteroceles, particularly in patients in whom contrast or ionizing radiation must be avoided.

Bladder dysfunction: an integral part of the ectopic ureterocele complex.

PURPOSE: We evaluate whether bladder dysfunction is common in patients with ectopic ureterocele and, if so, whether it is an integral part of the ectopic ureterocele complex or a result of surgery. MATERIALS AND METHODS: From 1986 to 1995, 34 patients with a mean age of 10 months were treated for large or medium ectopic ureteroceles at our institution and 32 participated in postoperative followup. Bladder function was investigated by a careful history and repeat uroflowmetry, and residual urine estimation was assessed by ultrasound and cystometry. RESULTS: Of the 32 patients 19 had infrequent voiding and 3 had incontinence. Cystometric bladder capacity was increased to greater than 150% of the normal value for age in 15 of 27 patients (55%). Uroflowmetry revealed greater than 5 ml. residual urine in 15 patients (56%). Postoperatively no radiological signs of bladder neck obstruction were found. Increased bladder capacity and residual urine did not correlate with ureterocele size or location, or surgical procedure. There was no progression of bladder dysfunction with age. CONCLUSIONS: Children with ectopic ureterocele are at high risk for a high capacity bladder with incomplete emptying. This bladder dysfunction associated with ectopic ureterocele does not seem to be the result of surgery but an integral part of the disorder.

Experience with transurethral incision of ureteroceles.

OBJECTIVES: The value of primary transurethral ureterocele incision was investigated in the treatment of ureteroceles in infants and children. METHODS: The charts and radiographic studies of 13 patients between the ages of 2 weeks and 8 years who underwent transurethral incision of 14 ureteroceles as primary surgical therapy at our institution were reviewed. RESULTS: 57% of the ureteroceles were intravesical and 43% extravesical. 64.3% were associated with the upper pole of a duplicated system. All 14 ureteroceles were associated with a functional renal moiety. Endoscopic incision achieved ureterocele decompression in 13 of 14 ureteroceles (93%). Preexisting hydronephrosis improved or resolved in 10 of 14 cases (71.4%). Renal function after decompression was not shown to be significantly altered or improved. 5 of 13 patients (38%) required definite surgical reconstruction for recurrent urinary tract infections, upper pole vesicoureteral reflux, hydronephrosis and lower pole vesicoureteral reflux within a mean follow-up period of 14 months. CONCLUSION: Transurethral incision has a limited role in the treatment of ureteroceles in children. In many or even most cases it cannot be expected to constitute long-term definite treatment for ureteroceles. It is mainly indicated in patients with urosepsis, prolapsing ureteroceles with functional bladder neck obstruction or massive reflux into other renal segments. In these settings it reliably achieves decompression and allows effective treatment of infection. The function of the previously obstructed renal segment can be reevaluated at later point in time to assess whether it should be saved. The delay permits interim growth that is likely to make bladder reconstruction easier.

Current management of duplex-system ureteroceles: experience with 41 patients.

Experience is described of 41 infants and children with duplex-system ureteroceles, 25 presenting clinically and 16 by prenatal ultrasonography. Bladder outflow obstruction was rare but lower polar vesicoureteric reflux (VUR), usually of lesser grades, was common. Upper polar function, as assessed by 99mTc-DMSA, was negligible in children with truly ectopic ureteroceles but well preserved in those where the lesion lay wholly intravesically. Lower polar function was good, even in the presence of secondary obstruction, except in 2 infants with major VUR. Twenty-three patients were treated by upper polar nephrectomy plus aspiration of the ureterocele; 2 subsequently required ureterocele excision. Histology of excised specimens indicated that a more conservative approach would not have been rewarded. Where upper polar function was good, conservation was maintained in 3 cases by pyelopyelostomy and in 5 more by excision of the ureterocele plus bipolar ureteric reimplantation. Other operative strategies were employed in 2 cases. Finally, a defined group of 8 children was managed expectantly without untoward results. It was concluded that the variable anatomy and function associated with duplex-system ureteroceles require a flexibile approach to treatment, including, possibly, no treatment at all.

[Endoscopic treatment of complicated ureteroceles in adults. Apropos of 2 cases]. / Le traitement endoscopique des urétérocèles compliquées de l'adulte. A propos de deux cas.

Usually diagnosed in childhood, ureterocele is a congenital malformation which is often revealed in adults because of a complication. Renal colic and dysuria were the clinical symptoms that led to discovery in the two patients reported here. These two women (aged 80 and 32 years) underwent transurethral meatotomy for complicated ureterocele. This procedure was sufficient for cure, with spontaneous evacuation of all stones in patient 2. There were no clinical or bacteriological (urine analyses) signs of reflux during the follow-up period (24 and 12 months). Endoscopic treatment of adult complicated ureterocele can thus be proposed as a first line procedure. Development of symptomatic secondary reflux is an indication for surgery.

Refluxing ureteroceles.

We report 4 cases of 3 different forms of ureteroceles to illustrate spontaneous reflux without any evidence of obstruction. The presence of reflux tends to support those concepts that ureterocele formation is not on an obstructive basis. The obstruction that is oftern associated with ureteroceles is probably caused by the same stimulus as that which created the ureterocele. Obstruction does not necessarily accompany every ureterocele and is not causative of its formation.