URETEROCELE

Ureterocele
Definition
A ureterocele is a cystic dilatation of the distal ureter as it drains into the bladder.

Incidence
Females are affected more than males (female:male ratio 4:1). They predominantly affect Caucasians. 80% are associated with the upper pole of a duplex system, although they can be found in single systems (more commonly in adults). 10% are bilateral.

Classification
- Intravesical: confined within the bladder
- Ectopic: if any part extends to the bladder neck or urethra
- Stenotic: intravesical ureterocele with a narrow opening
- Sphincteric: ectopic ureterocele with an orifice distal to the bladder neck
- Sphincterostenotic: orifice is both stenostic and distal to the bladder neck
- Cecoureterocele: ectopic ureterocele that extends into the urethra, but the orifice is in the bladder

Presentation
Infants commonly present with symptoms of UTI. Association with duplicated ureters increases the risk of reflux and reflux nephropathy. Ureteroceles can also cause obstruction and hydronephrosis, which may be identified on antenatal USS, or present in children with an abdominal mass or pain. A prolapsing ureterocele can present as a vaginal mass in girls.

Investigation
- USS shows a thin-walled cyst in the bladder often associated with a duplex system.
- IVU may demonstrate deviation of upper pole duplex kidney and delayed excretion of contrast signifying altered renal function. In single systems, contrast in the ureterocele gives the appearance of a cobra head.
- Micturating cystourethrogram can identify location, size, and associated reflux.
- Cystoscopy may reveal a defect near the trigone.
- 99mTc-DMSA assesses renal segment function.

Treatment
- Single-system ureterocele Initial management is usually endoscopic incision of the ureterocele, which can be followed by surgical ureteric re-implantation to preserve renal function and prevent reflux.
- Duplex-system ureterocele Treatment options vary with the individual and include: endoscopic incision; upper pole nephrectomy for a poorly functioning unit with ureterectomy or, where there is useful renal function, ureteropyelostomy can be performed.