ureterocele

ureterocele

1. Ureteroceles
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2

3. Classification
•Ericsson
Simple
Ectopic
3Dept of Urology, GRH and KMC,
Chennai.

4. Simple
4Dept of Urology, GRH and KMC,
Chennai.

5. Ectopic
5Dept of Urology, GRH and KMC,
Chennai.

6. Classification
•Stephens
Stenotic
Sphincteric
Sphincterostenotic
Cecoureterocele
6Dept of Urology, GRH and KMC,
Chennai.

7. Stenotic
A stenotic ureterocele is one whose narrowed or pinpoint opening
is found inside the bladder
7Dept of Urology, GRH and KMC,
Chennai.

8. Sphincteric
If a ureterocele has an orifice distal to the bladder neck,
it is termed sphincteric
8Dept of Urology, GRH and KMC,
Chennai.

9. Sphinctero-stenotic
If a ureterocele has an orifice that was
both stenotic and distal to the bladder neck,
it is considered a sphincterostenotic ureterocele
9Dept of Urology, GRH and KMC,
Chennai.

10. Cecoureterocele
A cecoureterocele has an intravesical orifice and a
submucosal extension that dips into the urethra
10Dept of Urology, GRH and KMC,
Chennai.

11. Committee on Terminology,
Nomenclature and Classification of
the Section of Urology of the
American Academy of Pediatrics
11Dept of Urology, GRH and KMC,
Chennai.

12. Intravesical
Ectopic
Stenotic
Sphincteric
Sphincterostenotic
Cecoureterocele
Single
Duplex
12Dept of Urology, GRH and KMC,
Chennai.

13. Intravesical
13Dept of Urology, GRH and KMC,
Chennai.

14. Intravesical Single
14Dept of Urology, GRH and KMC,
Chennai.

15. Intravesical Single Stenotic
15Dept of Urology, GRH and KMC,
Chennai.

16. Ectopic Duplex Sphincterostenotic
16Dept of Urology, GRH and KMC,
Chennai.

17. Embryology
17Dept of Urology, GRH and KMC,
Chennai.

18. •A ureterocele is a cystic dilatation of the
terminal ureter.
•At 37 days' gestation, Chwalle's
membrane, a two-layered cell structure,
transiently divides the early ureteric bud
from the urogenital sinus
18Dept of Urology, GRH and KMC,
Chennai.

19. Theory I
•Incomplete dissolution of Chwalle's
membrane.
19Dept of Urology, GRH and KMC,
Chennai.

20. Theory II
•The affected intravesical ureter suffers
from abnormal muscular development;
without the appropriate muscular backing,
the distal ureter assumes a balloon
morphology
20Dept of Urology, GRH and KMC,
Chennai.

21. Theory III
•Developmental stimulus responsible for
bladder expansion acting simultaneously
on the intravesical ureter
21Dept of Urology, GRH and KMC,
Chennai.

22. Diagnosis
•Can be diagnosed by prenatal
ultrasound studies.
•Prenatal ultrasonography demonstrates
both the hydronephrosis and the
intravesical cystic dilatation.
22Dept of Urology, GRH and KMC,
Chennai.

23. •Fetal diagnosis of a ureterocele can be
accomplished with MRI.
•Although this is not the primary
modality for ureterocele diagnosis in
utero, MRI can overcome issues of
suboptimal fetal position, maternal
obesity, and oligohydramnios, which
may hinder obstetrical ultrasounds
23Dept of Urology, GRH and KMC,
Chennai.

24. Clinical Features
•Females : Males = 4 : 1
•10% are bilateral.
24Dept of Urology, GRH and KMC,
Chennai.

25. •Eighty percent of
all ureteroceles
arise from the
upper poles of
duplicated
systems.
25Dept of Urology, GRH and KMC,
Chennai.

26. •Single-system
ureteroceles are
sometimes called
simple ureteroceles and
are usually found in
adults.
•These single-system
ureteroceles are less
prone to the severe
obstruction and
dysplasia associated
with duplicated systems
26Dept of Urology, GRH and KMC,
Chennai.

27. Presentation
Stasis
Infection
Hydronephrosis
Calculi
Recurrent UTI
Insidious as failure to thrive
or as abdominal or pelvic pain
27Dept of Urology, GRH and KMC,
Chennai.

28. •The ureterocele, if ectopic, can prolapse
out of the urethra as a vaginal mass
28Dept of Urology, GRH and KMC,
Chennai.

29. •If the ureterocele
is large enough, it
can obstruct the
bladder neck or
even the
contralateral
ureteral orifice
and result in
hydronephrosis
of that collecting
system
29Dept of Urology, GRH and KMC,
Chennai.

30. •Ectopic ureteroceles can cause
incontinence by hindering the normal
sphincteric function at or distal to the
bladder neck.
30Dept of Urology, GRH and KMC,
Chennai.

31. •Patients with ureteroceles may have a
varied pattern of voiding dysfunction,
including urgency and incontinence.
31Dept of Urology, GRH and KMC,
Chennai.

32. Evaluation
32Dept of Urology, GRH and KMC,
Chennai.

33. Ultrasound
•Most
commonly,
the
ureterocele is
associated
with a
duplicated
collecting
system.
33Dept of Urology, GRH and KMC,
Chennai.

34. Ultrasound
•Most
commonly,
the
ureterocele is
associated
with a
duplicated
collecting
system.
34Dept of Urology, GRH and KMC,
Chennai.

35. Ultrasound
•Sonographically, two
separate renal pelves
surrounded by their
echogenic hila can be
seen.
•This duplex kidney is
larger than a kidney
associated with a single
collecting system.
35Dept of Urology, GRH and KMC,
Chennai.

36. Ultrasound
•A dilated ureter
emanates from a
hydronephrotic upper
pole
•This finding should
signal the examiner
to image the bladder
to determine whether
a ureterocele is
present.
36Dept of Urology, GRH and KMC,
Chennai.

37. If the lower pole is associated with reflux, or if the ureterocele has
caused delayed emptying from the ipsilateral lower pole, this lower
pole may likewise be hydronephrotic.
•Similarly, the ureterocele may impinge on the contralateral ureteral
orifice or obstruct the bladder neck and cause hydronephrosis in the
opposite kidney.
•The upper pole parenchyma drained by the ureterocele will exhibit
varying degrees of thickness and echogenicity. Increased
echogenicity correlates with dysplastic changes.
37Dept of Urology, GRH and KMC,
Chennai.

38. •The bladder
frequently
displays a thin-
walled cyst that is
the ureterocele
38Dept of Urology, GRH and KMC,
Chennai.

39. •The bladder
frequently
displays a thin-
walled cyst that is
the ureterocele
39Dept of Urology, GRH and KMC,
Chennai.

40. •There are several pitfalls in ultrasound diagnosis. If the bladder
is overdistended, the ureterocele may be effaced and go
unnoticed.
•At times the bladder may be empty, in which case it is difficult to
discriminate between the wall of the ureterocele and the wall of the
bladder. In such instances, the empty bladder with a ureterocele
may be interpreted as simply a partially filled bladder.
•The dilated ureter should be seen posterior to the bladder\On
occasion, a large ureterocele is associated with a diminutive ureter
and collecting system.
•The corresponding upper pole parenchyma can be so small as to be
nonvisualized. The diagnosis of ureterocele may be overlooked
because the duplicated collecting system cannot be identified. This
entity has been termed both nonobstructive ectopic ureterocele(
Bauer and Retik, 1978 ) and ureterocele disproportion
40Dept of Urology, GRH and KMC,
Chennai.

41. •On occasion, a dilated ectopicureter may be seen
immediately posterior to the bladder and may
impinge on the bladder wall, giving the appearance
that the dilated ureter is intravesical.
•This may give the false impression of a ureterocele, the
pseudoureterocele referred to previously
•The difference between the two entities is that a
ureterocele is separated from the bladder space by its
thin wall, whereas an ectopic ureter has the thicker
bladder wall separating it from the intravesical space.
•A mesonephric duct cyst that communicates with an
ectopic ureter can open into the bladder and mimic a
ureterocele on radiographic studies
41Dept of Urology, GRH and KMC,
Chennai.

42. Intravenous pyelography
•In majority of
the cases, the
upper pole
functions
poorly and
excretes
contrast agent
in a delayed
fashion or not
at all.
42Dept of Urology, GRH and KMC,
Chennai.

43. Intravenous
pyelography
•The upper pole is
deviated laterally from
the spine because of
its hydronephrosis.
•This same upper pole
hydronephrosis is
responsible for pushing
the lower pole laterally
and inferiorly
43Dept of Urology, GRH and KMC,
Chennai.

44. Because only the
lower pole calyces
are seen, the
number of calyces is
less than the
complement of a
normal kidney.
44Dept of Urology, GRH and KMC,
Chennai.

45. The upper pole ureter
is infrequently seen on
the intravenous
pyelogram because of
the lack of contrast
excretion, its presence
may be inferred from
its effect on the lower
pole ureter.
45Dept of Urology, GRH and KMC,
Chennai.

46. •The lower pole ureter
can be seen as
laterally deviated,
taking a serpiginous
course, and notched.
•These characteristics
all result from its
association with the
dilated, tortuous
upper pole ureter
46Dept of Urology, GRH and KMC,
Chennai.

47. Hydronephrosis may
be seen in the
contralateral kidney
as a result of
obstruction by the
ureterocele.
47Dept of Urology, GRH and KMC,
Chennai.

48. Voiding cystourethrography
•Demonstrate the size and location of
the ureterocele
•The presence or absence of vesicoureteral
reflux.
48Dept of Urology, GRH and KMC,
Chennai.

49. •Reflux into the
ipsilateral lower pole
is common
•Reflux may also be
seen in the
contralateral system
if the ureterocele is
large enough to
distort the trigone
and the opposite
ureteral submucosal
tunnel.
49Dept of Urology, GRH and KMC,
Chennai.

50. •Reflux into the ureterocele and its ureter
may be present but is uncommon and
should alert the physician to the possibility
of an ectopic ureterocele whose open
mouth in the urethra is allowing reflux.
50Dept of Urology, GRH and KMC,
Chennai.

51. Cystography
51Dept of Urology, GRH and KMC,
Chennai.

52. •Cystography
demonstrates
the ureterocele
in the bladder. It
appears as a
smooth, broad-
based filling
defect located
near the
trigone.
52Dept of Urology, GRH and KMC,
Chennai.

53. 53Dept of Urology, GRH and KMC,
Chennai.

54. •It is frequently
eccentrically
located, and the
superior portion of
the ureterocele
may be angled to
one side, thereby
giving a clue as to
which side the
ureterocele is
associated with
54Dept of Urology, GRH and KMC,
Chennai.

55. 55Dept of Urology, GRH and KMC,
Chennai.

56. •However, on cystography, the ureterocele
is often centrally placed, and it may not be
helpful in this regard. In such instances,
cystoscopy may shed light on the issue.
56Dept of Urology, GRH and KMC,
Chennai.

57. •If the cystoscopic
findings are
inconclusive, the
answer can be
obtained by injecting
contrast material into
the ureterocele; this
method should define
the side from which
the ureterocele
originated
57Dept of Urology, GRH and KMC,
Chennai.

58. •Injection of contrast
medium into the
ureterocele can verify
the diagnosis of
ureterocele
disproportion when
the upper tract
findings are difficult
to interpret. Such
information is
obviously necessary
in planning the
surgical approach.
58Dept of Urology, GRH and KMC,
Chennai.

59. •Nuclear scans with agents such as DMSA
and diethylenetriaminepentaacetic acid
(DTPA) or mercaptoacetyltriglycine
(MAG3) can give valuable estimates of
upper pole contribution to overall renal
function as well as degrees of obstruction
•This information is often helpful in
determining whether the upper pole moiety
is worth saving.
59Dept of Urology, GRH and KMC,
Chennai.

60. Management
60Dept of Urology, GRH and KMC,
Chennai.

61. •Before any surgical intervention, the
surgeon must obtain as much information
as possible regarding the patient's altered
anatomy and physiology. Only then can a
rational treatment plan be devised.
61Dept of Urology, GRH and KMC,
Chennai.

62. •Because ureteroceles have a broad
spectrum of presentation, anatomy, and
pathophysiology, each patient must be
treated individually.
•No single method of surgical repair
suffices for all cases.
62Dept of Urology, GRH and KMC,
Chennai.

63. Goals of therapy
1.Preservation of renal function
2.Elimination of infection, obstruction
and reflux
3.Maintenance of urinary continence
4.Minimizing surgical morbidity
63Dept of Urology, GRH and KMC,
Chennai.

64. Permutations and Combinations
•Ipsilateral and contralateral Reflux
•Ipsilateral and contralateral Obstruction
•Varying degrees of salvagable function
•Infection
•Age of patient
64Dept of Urology, GRH and KMC,
Chennai.

65. Prenatal Therapy
•Ureteroceles can cause bladder outlet
obstruction resulting in
hydronephrosis and oligohydramnios.
•Prenatal decompression of the ureterocele
(via laser incision or needle disruption) or
vesicoamniotic shunting has been
described in case reports as treatment for
fetal bladder outlet obstruction
65Dept of Urology, GRH and KMC,
Chennai.

66. •Although one might reason that a prenatal
diagnosis could lead to earlier relief of
obstruction and presumably a greater chance of
recovery of upper pole function, the evidence in
the literature seems to show that loss of function
of the upper pole occurs equally in those
diagnosed prenatally and postnatally
•In most instances, the upper pole contributes
little, if at all, to overall renal function
66Dept of Urology, GRH and KMC,
Chennai.

67. •Approximately one third of their patients
had preservation of function of the upper
pole
•Preservation rate was the same for
Intravesical versus ectopic ureteroceles
and also for
Antenatal versus postnatal diagnosis
67Dept of Urology, GRH and KMC,
Chennai.

68. Modalities
•Upper Tract Approach
•Combined Approach
•Endoscopic Incision
68Dept of Urology, GRH and KMC,
Chennai.

69. Upper Tract Approach
•Upper pole Nephrectomy and partial
Ureterectomy
•Ureteropyelostomy
69Dept of Urology, GRH and KMC,
Chennai.

70. Rationale
•Ureterocele Decompresses
•Trigone returns to Normal Configuration
•Resolution of ipsilateral lower pole reflux
occurs
70Dept of Urology, GRH and KMC,
Chennai.

71. Advantages
•The advantages of this approach are
avoidance of the morbidity of a second
surgical procedure
•Elimination of a potentially difficult bladder
neck and urethral dissection.
71Dept of Urology, GRH and KMC,
Chennai.

72. Disadvantages
•Indications for Reoperation
–Persistant lower pole reflux
–Reflux into the Ureteral Stump
–Failure of ureterocele decompression
72Dept of Urology, GRH and KMC,
Chennai.

73. Unsuitable for upper tract
procedures
•Patients having high-grade reflux into the
ipsilateral lower pole ureter
•Lower pole reflux associated with a large
everting ureterocele and a poorly
functioning upper pole
73Dept of Urology, GRH and KMC,
Chennai.

74. Combined Approach
•The combined approach uses two
incisions to achieve
1.upper pole heminephrectomy
2.partial ureterectomy
3.intravesical excision and marsupialization of
the ureterocele
4.correction of reflux when present
74Dept of Urology, GRH and KMC,
Chennai.

75. Rationale
•Upper Tract approach Only-Reoperation
75Dept of Urology, GRH and KMC,
Chennai.

76. Advantages
•Less incidence of Reflux
•Lower reoperative rate
76Dept of Urology, GRH and KMC,
Chennai.

77. Disadvantage
•Bladder surgery has the added morbidity
of hematuria, bladder spasm, and several
days of bladder drainage with a catheter.
•The dissection of the ureterocele bed may
be a difficult and has the potential
problems of bladder neck injury.
77Dept of Urology, GRH and KMC,
Chennai.

78. Endoscopic treatment of
ureteroceles
•Although transurethral resection was
satisfactory in achieving decompression, it
often led to massive reflux of the involved
system
78Dept of Urology, GRH and KMC,
Chennai.

79. Indications
•Intravesical ureterocele,
•Ureterocele associated with a functioning
upper pole
•Single-system ureterocele.
79Dept of Urology, GRH and KMC,
Chennai.

80. •When used for Ectopic ureteroceles –
Reoperation rates –up to 50 %
•However, when analyzing their data further, they
concluded that intravesical ureteroceles fared
better than ectopic ureteroceles with regard to
decompression (93% vs. 75%), preservation of
upper pole function (96% vs. 47%), newly
created reflux (18% vs. 47%), and need for
secondary procedures (7% vs. 50%).
80Dept of Urology, GRH and KMC,
Chennai.

81. 81Dept of Urology, GRH and KMC,
Chennai.

82. Single-System Ureteroceles
•Usually manifests in adults
•Rarely in children
82Dept of Urology, GRH and KMC,
Chennai.

83. •The ureterocele
in these cases is
almost always
intravesicaland
occupies the
proper trigonal
position.
83Dept of Urology, GRH and KMC,
Chennai.

84. •Although most
single-system
ureteroceles
have
obstructing
pinpoint
orifices,
unobstructed
ureteroceles do
exist.
84Dept of Urology, GRH and KMC,
Chennai.

85. •The degree of obstruction is probably not
significant in most adult cases and
likewise tends to be less severe than the
obstruction seen in duplicated systems in
children
85Dept of Urology, GRH and KMC,
Chennai.

86. Clinical Features
Stasis
Recurrent Urinary Infection
Calculi
86Dept of Urology, GRH and KMC,
Chennai.

87. •Excretory urography
often demonstrates
the characteristic
cobra-head (or
spring-onion)
deformity, an area of
increased density
similar to the head of
a cobra with a halo or
less dense shadow
around it
87Dept of Urology, GRH and KMC,
Chennai.

88. •The halo represents a
filling defect, which is the
ureterocele wall, and the
oval density is contrast
medium excreted into the
ureterocele from the
functioning kidney.
•The upper urinary tract
changes associated with
a simple ureterocele are
usually not as severe as
those associated with an
ectopic ureterocele.
88Dept of Urology, GRH and KMC,
Chennai.

89. •At cystoscopy, the ureterocele usually
expands rhythmically with each peristaltic
wave that fills it and then shrinks as a thin
jet of urine drains, usually continuously,
through the small orifice.
89Dept of Urology, GRH and KMC,
Chennai.

90. •Single-system ureteroceles more readily
lend themselves to transvesical excision
and reimplantation, with any muscular
defect corrected as necessary.
•These ureteroceles are also more
amenable to endoscopic incision and are
less likely to exhibit postoperative reflux
into the incised ureterocele.
90Dept of Urology, GRH and KMC,
Chennai.

91. Prolapsing Ureteroceles
91Dept of Urology, GRH and KMC,
Chennai.

92. •A ureterocele that extends through the
bladder neck and the urethra and presents
as a vaginal mass in girls is termed a
prolapsing ureterocele
92Dept of Urology, GRH and KMC,
Chennai.

93. Differential Diagnosis
•Rhabdomyosarcoma
•Urethral prolapse
•Hydrometrocolpos
•Periurethral cysts
93Dept of Urology, GRH and KMC,
Chennai.

94. •The prolapse may cause vesical
obstruction and, consequently, bilateral
renal obstruction.
•The patient may have varying degrees of
hydronephrosis and azotemia and may be
septic.
94Dept of Urology, GRH and KMC,
Chennai.

95. •The short-term goal is to decompress the
ureterocele.
95Dept of Urology, GRH and KMC,
Chennai.

96. Manually reduction
Transverse incision in the ureterocele at the level of the vagina.
Endoscopic incision of the ureterocele in its intravesical portion
Open surgical unroofing or marsupialization of the ureterocele is indicated
96Dept of Urology, GRH and KMC,
Chennai.

97. •Common sheath ureteral reimplantation to
correct the ensuing reflux can be carried
out on an elective basis when the child is
older.
97Dept of Urology, GRH and KMC,
Chennai.