Orthotopic Ureterocele

A 67-year-old woman was admitted to the hospital with fever, chills, unilateral flank pain, dysuria, and urinary frequency and urgency. Her past medical history included several febrile relapses of infection.

Left costovertebral angle tenderness was noted. Laboratory findings included significant leukocytosis with a left shift. The urinalysis showed numerous leukocytes, bacteria, and protein. Drs Constantine Bouropoulos, Anna Bista, Chousam Dauacher, and Demetrios Papaioannides of Arta, Greece, diagnosed acute pyelonephritis.

No signs of urolithiasis were seen on an x-ray film of the kidneys, ureter, and bladder. Ultrasonography demonstrated a cystic mass in the bladder (A). Intravenous urography revealed the typical appearance of an intravesical ureterocele on a single ureter (B, arrow). The dilated ureterocele protruded into the urinary bladder but was separated from it by a thin radiolucent halo, the so-called cobra head or spring onion sign. There was no hydronephrosis.

Cystoscopic findings included a stenotic orifice in the normal location of the bladder trigone and cystic dilatation of the lower end of the ureter. The ureterocele expanded rhythmically consequent to its filling and shrinking as thin jets of urine drained through its small orifice in peristaltic waves. Soon after the diagnosis of an orthotopic ureterocele was made, an endoscopic incision was performed.

Ureterocele-a sacculation of the terminal portion of the ureter-has been attributed to a delayed or incomplete canalization of the ureteral bud before its absorption into the urogenital sinus. The cystic dilatation forms between the superficial and deep muscle layers of the trigone.

A ureterocele may be either intravesical or ectopic. Intravesical ureteroceles are associated most often with a single ureter. The orifice of ectopic ureteroceles is located at the bladder neck or in the urethra; usually, these ureteroceles involve the upper pole of duplicated ureters, and significant hydroureteronephrosis and a dysplastic segment of the upper pole of the kidney are present. They are 4 times more common in women than in men and occur almost exclusively in whites; approximately 10% are bilateral.

The choice of therapy is influenced by the size and location of the ureterocele, associated anomalies, and the patient's clinical symptoms. Treatment goals include control of infection, protection of ipsilateral renal structures, and maintenance of vesicoureteral continence. Endoscopic treatment has numerous advantages.

A transurethral transverse “smiling mouth” incision under the stenotic orifice is appropriate for small or medium-size ureteroceles in adults. This technique is simple to perform and does not lead to significant vesicoureteric reflux. Surgical procedures, which are usually performed in the youngest patients, include heminephrectomy and ureterectomy, excision of the ureterocele, vesical reconstruction, and ureteral reimplantation.

References:

FOR MORE INFORMATION:

• Schlussel RN, Retik AB. Anomalies of the ureter. In: Walsh PC, ed. Campbells' Urology. vol 2. Philadelphia: WB Saunders Company; 1998:1830.