URETEROCELURETEROCELEE

BYBY

AMR MOHAMED AHMEDAMR MOHAMED AHMED

DEFINITIONDEFINITION

--A ureterocele is a sacculation of the terminal A ureterocele is a sacculation of the terminal portion of the ureter.portion of the ureter.-A ureterocele is a birth defect-A ureterocele is a birth defect..

INCIDENCEINCIDENCE--Ureteroceles occur in about 1 in 500 to 1 in Ureteroceles occur in about 1 in 500 to 1 in

4,000 people 4,000 people..-More in female than male-More in female than male-bilateral in 10%-bilateral in 10%

--Ectopic ureteroceles are four times more Ectopic ureteroceles are four times more common than those that are common than those that are intravesicalintravesical

EtiologyEtiology --Ureterocele has been attributed to delayed or Ureterocele has been attributed to delayed or

incomplete canalization of the ureteral incomplete canalization of the ureteral bud leading to an early prenatal obstruction bud leading to an early prenatal obstruction and expansion of the ureteral bud prior to and expansion of the ureteral bud prior to its absorption into the urogenital sinusits absorption into the urogenital sinus . .

--The cystic dilation forms between the The cystic dilation forms between the superficial and deep muscle layers of the superficial and deep muscle layers of the trigonetrigone . .

--Large ureteroceles may displace the other Large ureteroceles may displace the other orifices, or even obstruct the bladder outletorifices, or even obstruct the bladder outlet..

CLASSIFICATIONCLASSIFICATION

EctopicEctopic-Some part extends to the -Some part extends to the bladder neck or urethrabladder neck or urethra-associated often with -associated often with duplicated ureterduplicated ureter

IntravesicalIntravesical-Confined within the bladder-Confined within the bladder-associated often with single -associated often with single ureterureter

CLINICAL PICTURECLINICAL PICTURE

11--Urinary tract infectionUrinary tract infection

22 - -Lump (mass) in the abdomen that can be feltLump (mass) in the abdomen that can be felt

33--prolapsing from urethraprolapsing from urethra

44--urinary incontinenceurinary incontinence

55--urinary obstructionurinary obstruction

66--Abdominal painAbdominal pain

77 - -HematuriaHematuria

88--Frequent and urgent urinationFrequent and urgent urination

99 - -Ureteral calculusUreteral calculus

Diagnostic Diagnostic ProceduresProcedures

((AA ) )Laboratory StudiesLaboratory Studies--UrinalysisUrinalysis

--Urine cultureUrine culture--Complete blood cell countComplete blood cell count

--Serum chemistries, especially BUN and Serum chemistries, especially BUN and serum creatinineserum creatinine

--Blood culturesBlood cultures--Fungal cultures: obtained in infants who Fungal cultures: obtained in infants who

have been on long-term antibiotic have been on long-term antibiotic therapy or in immunocompromised therapy or in immunocompromised

patients with clinical evidence of UTIpatients with clinical evidence of UTI

((BB ) )Imaging StudiesImaging Studies

Large ureteroceles are usually diagnosed Large ureteroceles are usually diagnosed earlier than smaller ones. A ureterocele earlier than smaller ones. A ureterocele may be discovered before the baby is born may be discovered before the baby is born (during a pregnancy ultrasound)(during a pregnancy ultrasound)..

Some people with ureteroceles do not know Some people with ureteroceles do not know they have the. Often, the diagnosis is they have the. Often, the diagnosis is made later in life due to kidney stonesmade later in life due to kidney stones..

The following tests may be performed:The following tests may be performed:1- Ultrasonography1- Ultrasonography

The cyst within a cyst is a pathognomonic The cyst within a cyst is a pathognomonic radiologic sign of ureterocele radiologic sign of ureterocele..

22 - -Voiding Voiding cystourethrograpcystourethrographyhyIt may demonstrate reflux It may demonstrate reflux into the lower pole or into the lower pole or contralateral uretercontralateral ureter..

33 - -Intravenous urographyIntravenous urography --Useful for delineating renal anatomy and Useful for delineating renal anatomy and

providing a subjective estimation of providing a subjective estimation of relative renal functionrelative renal function

--The following may be seen on IVPThe following may be seen on IVP-:-:• Hydronephrosis, revealing dilatation of Hydronephrosis, revealing dilatation of

collecting system collecting system • Hydronephrotic upper pole displacing Hydronephrotic upper pole displacing

the lower pole moiety laterally and the lower pole moiety laterally and inferiorlyinferiorly

• Ureteral displacement by the Ureteral displacement by the hydroureter hydroureter

• Cobra-headCobra-head extension of the distal extension of the distal ureter (ureterocele)ureter (ureterocele)

44--Magnetic resonance imagingMagnetic resonance imagingExcellent anatomical study for evaluating rare Excellent anatomical study for evaluating rare cases with suspected dysplastic, cases with suspected dysplastic, nonfunctioning, ectopic renal moieties and nonfunctioning, ectopic renal moieties and ectopic ureteral insertionectopic ureteral insertion

55--Nuclear renal scanNuclear renal scanIt is helpful for estimating renal functionIt is helpful for estimating renal function

66 - -CT scanning of the abdomen CT scanning of the abdomen and pelvisand pelvis-Used if U/S or IVU are equivocal -Used if U/S or IVU are equivocal -Can reveal the presence of a duplicated -Can reveal the presence of a duplicated collecting system, hydronephrotic upper pole collecting system, hydronephrotic upper pole segmentsegment..

CT scan shows a right ureterocele within the bladder with contrast material filling the CT scan shows a right ureterocele within the bladder with contrast material filling the ureteroceleureterocele. . The lucency on the left represents a Foley catheterThe lucency on the left represents a Foley catheter

77 - -CystoscopyCystoscopy--Allow direct inspection and examination of Allow direct inspection and examination of

the lower urinary tractthe lower urinary tract

--Used for confirm diagnosis and treatmentUsed for confirm diagnosis and treatment

TreatmentTreatment((AA ) )Medical TherapyMedical Therapy

--Observation alone is rarely a good option Observation alone is rarely a good option in symptomatic ureterocelesin symptomatic ureteroceles

--Must rapidly initiate aggressive antibiotic Must rapidly initiate aggressive antibiotic therapy therapy

--Antibiotics should be instituted during the Antibiotics should be instituted during the initial diagnostic evaluation and during initial diagnostic evaluation and during surgical intervention surgical intervention

((BB ) )Surgical TherapySurgical Therapy

indicationsindications--obstruction especially bladder neckobstruction especially bladder neck

--hydronephrosishydronephrosis

--loss of functionloss of function

--UTIUTI

****remember.....single system (non remember.....single system (non duplex) ureterocele is rareduplex) ureterocele is rare

Endoscopic incisionEndoscopic incision

--DefinitiveDefinitive

--Risk = induced Risk = induced refluxreflux

Upper pole nephrectomy

If no upper pole function

Uretero-ureterostomy-an end-to-end anastomosis of the segments of the same ureter, with excision of the intervening injured or scarred ureter- Good upper pole function, big ureterocele

En bloc reimplantation

-Good upper pole function, small ureterocele-if the patient has significant vesicoureteral reflux in the lower pole- Both ipsilateral ureters may be reimplanted within a common sheath

HeminephroureterectomyNo upper pole function, obstructing ureterocele