URETEROCELE – Classification and Management

DEFINITION 

Ureterocele is a congenital anomaly (present at birth) that affects girls more than boys. It is simply a swelling limited to the end of the ureter as it enters the bladder.

Ureterocele is saccular out-pouching of the distal ureter into the urinary bladder

It arise from abnormal embryogenesis with anomalous development of the intravesical ureter, the kidney, and the collecting system

Ureterocele may be asymptomatic or may cause a wide range of clinical signs and symptoms, from recurrent cystitis to bladder outlet obstruction

ETIOLOGY

Several theories exist, including:

  • Obstruction of the ureteral orifice
  • Incomplete muscularization of the intramural ureter
  • Excessive dilatation of the intramural ureter during the development of the bladder and trigone

Obstruction of the ureteral orifice during embryogenesis, with incomplete dissolution of the Chwalla membrane

  • The most commonly accepted theory behind ureterocele formation

Chwalla Membrane

  • Primitive thin membrane that separates the ureteral bud from the developing urogenital sinus
  • Failure to completely perforate during development of the ureteral orifice is thought to explain the occurrence of a ureterocele

CLASSIFICATION OF URETEROCELE

Types of ureteroceles classified by their association with the renal unit

  • Single-sytem ureteroceles
  • Associated with a single kidney, a single collecting system, and a solitary ureter
  • Duplex-system Ureteroceles
  • Associated with kidneys that have a completely duplicated collecting system and 2 ureters
  • Orthotopic Ureterocele
  • Orifice is located in a normal anatomic (orthotopic) position within the bladder
  • Usually arises from a single renal unit with one collecting system and is more common in adults
  • Ectopic Ureterocele
  • Orifices are located in an ectopic position, such as the bladder neck or urethra
  • Arise from the upper pole moiety of a duplicated collecting system and are more common in the pediatric population

CLINICAL MANIFESTATION

Urinary tract infection

Urosepsis

Obstructive voiding symptoms

Urinary retention

Failure to thrive

Hematuria

Cyclic abdominal pain

Ureteral calculus

URETEROCELES DIAGNOSIS

Before the advent of prenatal U/S, most diagnosed clinically

Most common presentation of UTI or urosepsis

Palpable abdominal mass

Ureterocele may prolapsed out of urethra

Ureterocele - Classification and Managment

COMPLICATIONS OF URETEROCELE

Infection – it is the most common presentation

Obstruction – Hydroureteronephrosis

Stone Formation – Hematuria

Incontinence of Urine – Ectopic ureterocele drain beyond the bladder neck. It is more common in females

Acute Bladder Neck Obstruction – Ectopic or prolapsing ureterocele

URETEROCELE TREATMENT

Single-system ureterocele:

Initial management is usually endoscopic incision of the ureterocele, which can be followed by surgical ureteric reimplantation to preserve renal function and prevent influx

Duplex-system ureterocele:

Treatment options vary with the individual and include endoscopic incision, upper pole nephrectomy for a poorly functioning unit with ureterectomy  (Heminephroureterectomy), or, when there is useful renal function, ureteropyelostomy can be performed.

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