Endoscopic Dilatation of Meatal Stenosis of Ureterocele in Adult Patients: An Easy and Innovative Technique with Literature Review.

This study presents initial experience in endoscopic meatal dilatation of obstructive ureterocele in adult patients. During cystourethroscopy, we tried to find the orifice of ureterocele, passed a guide wire and introduce an 8 Fr ureteroscope in to the ureterocele orifice, going up to the renal pelvis as under vision dilatation of ureterocele meatus. Two Double-J stent were inserted and remained for six weeks to keep the meatus dilated. Adverse effect of endoscopic management was decreased due to minimal anatomic changes. Patients' symptoms were relieved and no evidence of new onset vesico-ureteral reflux and obstruction were seen after up to one-year follow-up. Endoscopic meatal dilatation of stenotic ureterocele in adult patients is safe and effective thus, trying to find the orifice of ureterocele is suggested.

Active surveillance for antenatally detected ureteroceles: Predictors of success.

INTRODUCTION: Historically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles. OBJECTIVES: With data derived from a retrospective chart review of patients with ureteroceles that were detected antenatally, the current study aimed to determine which group of children would be at risk for failure on active surveillance. It was hypothesized that single system ureteroceles (SSU) and male patients with duplex system ureteroceles (DSU) would be ideal for observation. METHODS: Outcomes were assessed by descriptive statistics. Kaplan-Meier curves were utilized to estimate median duration on active surveillance in both single and duplex cohorts. Breakthrough febrile urinary tract infection (fUTI) and surgery were determined by Cox regression in the duplex system cohort. Surgery was considered surveillance failure. RESULTS: A total of 102 patients (64 females/38 males) met the criteria: 78 (76.5%) had DSU and 24 (23.5%) SSU. The overall median observation was 1.2 years (range 0.7-3.1). Follow-up ranged from 0.3 to 11.7 years for SSU, and from 0.02 to 17.3 years for DSU. The predictors of failure of active surveillance (AS) in DSU (surgical intervention) were male gender (HR 1.8, 1.0-3.3, P = 0.037), or fUTI (HR 3.1, 1.7-5.8, P = 0.002). Predictors of fUTI were contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter (OR 9.5, 1.2-71.7, P = 0.028). Interestingly, vesicoureteral reflux (VUR) was not a predictor of fUTI. The SSU patients were ideal for AS, while in DSU, surveillance was successful in 30% of patients who were primarily females without contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter. However, in contradiction to the hypothesis, males were at higher risk for surgical intervention in the DSU cohort. CONCLUSION: Active surveillance is an option for patients with antenatally detected ureteroceles, but careful long term follow up is mandatory. Parents should be advised that surgical intervention may still be necessary, particularly in males with DSU.

[Prenatal diagnosis and management of two cases of bilateral ureteroceles on simplex ureters]. / Diagnostic prénatal et prise en charge de deux cas d'urétérocèles bilatéraux sur uretères simplex.

Ureterocele is a rare urologic disorder characterized by pseudocystic dilatation of the terminal submucosal ureter. Most cases of ureteroceles are associated with complete ureteral duplicity and ureterohydronephrosis, whereas ureteroceles on simplex ureters are rarer. The authors report two cases of bilateral ureteroceles on simplex ureters diagnosed prenatally at 30 and 32weeks gestation. Fetal ultrasound had revealed bilateral ureterohydronephrosis. The delivery was made at term and renal function was normal at birth. Radiological and isotopic studies of the urinary tract confirmed the diagnosis of bilateral ureteroceles on simplex ureters that were obstructive in one case and not obstructive in the other case. Both cases had urinary antiseptic treatment and neither had urinary infection. Endoscopic puncture with electrocoagulation of ureteroceles was performed at 8 and 14months of age, respectively, with a simple postoperative course. Prenatal diagnosis of ureteroceles is essential to plan early multidisciplinary care to avoid long-term renal consequences.

Large bladder calculus masking a stone in single-system ureterocele.

Ureterocele in an elderly is a rare entity. The presence of stone within ureterocele along with a large bladder calculus is an even rarer presentation. This phenomenon has not been reported so far to the best of our knowledge. We present an unusual case of a large bladder calculus with a concomitant stone in the associated ureterocele. The diagnosis was missed in the first instance due to the masking effect by the larger bladder calculus. Herein, we discuss this case and its management.

Displasia renal multiquística segmentaria asociada a ureterocele y quistes renales simples en un recién nacido / Multicystic segmentary renal displasia associated to ureterocele and simple renal cysts in a newborn

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Evaluation of the Initial Treatment of Ureteroceles.

OBJECTIVE: To assess the results of the initial therapeutic approach to ureteroceles at our institution and the need for further interventions. PATIENTS AND METHODS: This is a retrospective study of all pediatric cases of ureterocele diagnosed at our center between January 2000 and December 2011. RESULTS: Forty-three patients were analyzed. Initial diagnoses were ureterohydronephrosis in 34 (33 prenatal), febrile urinary tract infection in 5, and prolapsed ureterocele in 3. Expectant management was decided upon in 6 patients (14%). Of these, 1 required surgery. The remaining 37 (86%) initially underwent surgery: transurethral puncture (18), heminephrectomy (14), nephrectomy (3), and reimplantation (2). Twelve (66.6%) of the 18 patients who underwent primary puncture progressed well and required no further intervention. New-onset vesicoureteral reflux to the upper pole appeared after puncture in 3 patients, but none required treatment. Only 6 patients (33.3%) underwent a second procedure. Mean follow-up was 8.5 years (standard deviation: 3.08). CONCLUSION: Early endoscopic puncture is useful for decompression and often the definitive treatment. Although new-onset vesicoureteral reflux into the punctured system is the most common complication, it often resolves spontaneously. Early heminephrectomy in patients with nonfunctioning upper moieties yields excellent results but may not be necessary. Some patients may not need transurethral puncture or any surgical intervention at all.

Fetoscopic laser surgery to decompress distal urethral obstruction caused by prolapsed ureterocele.

We report on the successful use of fetoscopic surgery to treat a case of prolapsed ureterocele in a female fetus. At 21 weeks' gestation, a double renal system with an intravesical ureterocele obstructing the bladder outlet was diagnosed, causing severe megacystis, bilateral hydronephrosis and progressive oligohydramnios. Ultrasound evaluation following referral to our center confirmed severe bilateral hydronephrosis with pelvic and calyceal dilatation, but amniotic fluid volume was normal and the ureterocele was not visualized in the bladder. Instead, a cystic mass within the external genitalia was observed, suggestive of a prolapsed ureterocele, causing intermittently severe obstruction of the urethra. The parents were counseled about the uncertain prognosis and fetal surgery to decompress the urinary system was proposed. The procedure involved firing a contact diode laser until perforation of the ureterocele was achieved. Following laser surgery, resolution of megacystis, reduction of hydronephrosis and normalization of amniotic fluid volume were observed. Our report demonstrates that fetoscopic decompression of a distal urethral obstruction is feasible in the rare event of congenital prolapsed ureterocele.

Ureterocele: antenatal diagnosis and management.

Ureteroceles are cystic dilations of the intravesical submucosal ureter. Most cases are associated with complete ureteral and renal duplication, and association with ureterohydronephrosis is frequent. The authors describe the 4 cases of fetal ureterocele diagnosed from March 2008 to March 2012. Mean gestational age at diagnosis was 23 weeks (16-34 weeks). One of 4 cases progressed to severe hydronephrosis with megacystis and was referred to a Fetal Medicine Center for fetoscopy and laser ureterocelotomy. The remaining 3 cases did not need fetal therapy. Mean gestational age at delivery was 37 weeks. One case abandoned follow-up; 2 children were submitted to cystoscopic ureterocele incision and the child submitted to fetal therapy needed heminephrectomy due to recurrent urinary tract infections. In those 3 cases renal function was preserved. When a fetal ureterocele is diagnosed, close sonographic surveillance should be offered to monitor the possible urinary tract obstruction and assess the need for prenatal intervention. Fetal diagnosis is important to program the timing of delivery and postnatal care.

Ureterocele ectópica em cão: relato de caso / Ectopic ureterocele in a dog: a case report

Relataram-se o quadro clínico, o diagnóstico, o tratamento e o acompanhamento de um cão com ureterocele ectópica e hidronefrose/hidroureter associados. Após as informações obtidas nos exames laboratoriais e de diagnóstico por imagem, o animal foi submetido à ureterocelectomia e à neoureterostomia. O cão apresentou evolução favorável após a conduta terapêutica. Apesar de pouco frequente, a ureterocele deve ser considerada como diagnóstico diferencial em animais jovens com histórico de incontinência urinária.

The clinical features, diagnosis, treatment and monitoring of a dog with an ectopic ureterocele and concomitant hydronephrosis/hydroureter were reported. After the information obtained in laboratory tests and imaging diagnosis, the animal was submitted to ureterocelectomy and neoureterostomy. The dog presented a favorable evolution after the therapy. Although infrequent, the ureterocele should be considered a differential diagnosis in young animals with history of urinary incontinence.

[High-pressure balloon dilatation for treatment of orthotopic ureterocele]. / Dilatación con balón de alta presión como tratamiento del ureterocele ortotópico.

OBJECTIVE: Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. MATERIAL AND METHODS: We have analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014" to the ureterocele. RESULTS: There were no intraoperative or postoperative complications, surgical time being 24 ± 9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. CONCLUSIONS: High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.

Recent advances in the management of ureteroceles in infants and children: why less may be more.

PURPOSE OF REVIEW: Ureteroceles are an infrequently seen and challenging pediatric urological condition that in addition to causing obstruction, may also be associated with vesicoureteral reflux and/or obstruction of the bladder outlet. Past experience with the morbidity associated with ureteroceles presenting with urinary tract infection may have stimulated a particularly aggressive approach as evidenced by more historical reports describing total reconstruction. This article purposes to review the recent literature in support of less aggressive management of ureteroceles in children. RECENT FINDINGS: The widespread availability and reported high success rates with endoscopic puncture of ureteroceles, along with the recognition that vesicoureteral reflux associated with ureteroceles can be effectively managed nonoperatively, has shifted the paradigm towards an individualized approach with greater emphasis placed on nonoperative management or less aggressive surgical techniques. Cystic renal dysplasia associated with ureterocele, much like that seen in isolation, is likely to involute thus providing spontaneous 'decompression' of the ureterocele and avoiding the need for surgery when it is present. SUMMARY: Although total reconstruction of renal moieties associated with ureteroceles might be appealing as it can achieve a normal appearing urinary tract with a single procedure performed in infancy, a more individualized approach that relies on less aggressive surgical treatments and nonoperative management over time can achieve the same functional results.

[Should morphology of the upper pole in renal duplication with preserved function and associated ureterocele be taken into account during treatment planning?]. / Czy zmiany morfologiczne górnego bieguna zdwojonej nerki z zachowana jego czynnoscia i wspólistniejaca torbiela moczowodu maja wplyw na wybór sposobu leczenia?

INTRODUCTION: The aim of this study was to assess structural changes of the upper pole in renal duplication with coexisting ureterocele with regard to primary and/or secondary lesions. These changes might be of importance in treatment planning. MATERIAL AND METHODS: The material of this study consisted of clinical documentation and results of histopathology of 23 upper poles removed due to renal duplication with coexisting ureterocele. The qualification criterion was preserved function of the upper pole seen with 99mTc-DTPA (99mTechnetium diethylenetriaminepentaacetic acid)/99mTc-DMSA (99mTechnetium dimercaptosuccinic acid). Resection of the upper pole was indicated in patients with recurrent urinary tract infections and/or persistent vesicoureteral reflux to the lower pole following endoscopic surgery of the ureterocele and/or low function of the upper pole. Morphological lesions were classified as primary (dysplasia) or secondary lesions. The patients were operated at the Department of Pediatric and Oncologic Surgery, PMU, in 1990-2008. RESULTS: The study group consisted of 17 girls and 6 boys aged from 4 months to 9 years (mean 40 months). Recurrent urinary tract infections noted in 16 (70%) children were the most frequent indication for surgery. The preoperative mean function of the renal poles assessed with DTPA/DMSA represented 6% of the differential renal function. Dysplasia was identified in eight resected renal poles (34%) with coexisting secondary lesions in three of them. Secondary lesions only were seen in 15 poles (66%). There was no correlation between age and incidence of dysplasia during follow-up (Pearson's correlation coefficient r = 0.031). CONCLUSIONS: Secondary lesions are a quite frequent finding in resected upper poles. As 66% of the renal poles studied with histopathology revealed secondary lesions only, we believe that renal sparing treatment is justified in cases of urinary duplication with coexisting ureterocele.

Variation in management of duplex system intravesical ureteroceles: a survey of pediatric urologists.

PURPOSE: Controversy exists in ureterocele management and the literature lacks clear management guidelines. We surveyed pediatric urologists to understand practice patterns and perceptions of managing duplicated system intravesical ureterocele. MATERIALS AND METHODS: The survey consisted of 3 case scenarios, including upper pole obstruction without reflux, ureterocele without hydronephrosis and reflux after incision. The survey evaluated management at patient age 3 months and used a Likert scale to evaluate management strategies later in life. RESULTS: We analyzed 233 responses. There was agreement in prophylactic antibiotic use and diagnostic evaluation. When managing a duplicated system intravesical ureterocele with poor upper pole function, 50.6% of respondents advocated puncture at age 3 months. However, when followed conservatively for 18 months, the preference changed to surgical management with partial nephrectomy preferred by 61.8% of respondents. When managing the condition without hydronephrosis, watchful waiting was preferred by 47.2% of respondents while 35.6% chose puncture and another 16.3% chose partial nephrectomy. Most respondents advocated ureteral reimplantation to manage reflux to the upper pole after puncture while some preferred endoscopic Deflux® injection. Continued nonoperative management while off prophylaxis was not preferred. Most respondents viewed the risks of surgery and anesthesia as important factors when weighing options in children younger than 3 months. Preventing symptoms and preserving function of the renal units were significant factors guiding surgical intervention. CONCLUSIONS: We found significant variation in management of duplicated system intravesical ureterocele. Most pediatric urologists see fewer than 10 cases per year, stressing the need for multi-institutional, randomized, controlled studies to evaluate management and long-term outcomes.

Transurethral puncture for ureterocele-which factors dictate outcomes?

PURPOSE: We evaluated which clinical factors influence the outcome of primary transurethral puncture for ureterocele. MATERIALS AND METHODS: A total of 45 patients (47 ureteroceles) underwent primary transurethral incision between 1994 and 2008 at 2 institutions. Age at and mode of presentation, upper tract status, ureterocele site, preoperative vesicoureteral reflux and the corresponding upper pole or kidney function were analyzed to identify which factors influenced the need for secondary surgery. RESULTS: Transurethral puncture was the only treatment in 24 of 45 patients (53%) while 21 (47%) required further surgery. After transurethral puncture secondary surgery was required in 56% of patients who presented prenatally vs 27% of those who presented postnatally (p = 0.165), in 18% with a single system vs 58% with a duplex system (p = 0.036), in 30% with intravesical vs 63% with ectopic ureterocele (p = 0.039) and in 61% vs 37% with ureterocele units with vs without preoperative vesicoureteral reflux (p = 0.148). Fisher's 2-tailed exact test revealed an inconsistent distribution of negative prognostic factors, including duplex systems, ectopic ureterocele and vesicoureteral reflux at presentation, in prenatally vs postnatally and in asymptomatically vs symptomatically presenting subgroups. CONCLUSIONS: Upper tract status and ureterocele site influence the outcome of primary transurethral puncture as a definitive procedure. After puncture secondary surgery is least likely in patients with a single system and intravesical ureterocele.

Prolapsed bilateral ureteroceles leading to intermittent outflow obstruction.

A ureterocele refers to a cystic dilatation of the distal ureter. It may be unilateral or bilateral and may be associated with a duplex system in some cases. We present an unusual case where a young patient was found to have large bilateral ureteroceles which prolapsed into the urethra, causing intermittent incontinence and obstruction. We discuss the case and review the literature concerning this rare anomaly.

Management of duplex system ureteroceles in neonates and infants.

Ureteroceles associated with the upper pole of a complete ureteral duplication are known as duplex system ureteroceles (DSUs). A limited knowledge of the natural history of this condition makes its management in neonates and infants controversial. Asymptomatic neonates diagnosed antenatally in the absence of severe hydroureteronephrosis (HUN) are at low risk of developing urinary tract infections during the first months of life. These patients might, therefore, begin antibiotic prophylaxis and undergo comprehensive assessment by 3-6 months. Subsequently, conservative management can be viable in patients without severe HUN or high-grade vesicoureteral reflux (VUR). Cases of DSUs with severe HUN but no VUR can be treated by an upper urinary tract approach or by endoscopic decompression depending on upper pole function. Patients with preoperative VUR represent the most challenging cases. If VUR cure is considered necessary, lower urinary tract reconstruction is recommended. Endoscopic decompression allows for a definitive treatment in at least 50% of cases and, in the remaining cases, can be combined with conservative management or endoscopic treatment of VUR. Nonfunctioning or poorly functioning upper poles can be left in situ both in lower urinary tract reconstruction and after endoscopic decompression. Parental preferences should also be taken into account in the decision-making process.

Benign masses of the female periurethral tissues and anterior vaginal wall.

Due to their rarity, benign masses of the periurethral tissues and anterior vaginal wall are poorly understood. Arriving at the proper evaluation and treatment is challenging because many of these masses have similar presenting signs and symptoms, as well as overlapping differential diagnoses. The literature regarding these lesions mainly consists of level III evidence, mostly involving case reports and series. Clinical management has traditionally been based on established surgical principles and expert opinion. This review presents the pertinent embryologic and anatomic background for these benign masses, as well as other pertinent etiological processes. Furthermore, the most current evidence is reviewed regarding the differential diagnosis, evaluation, and treatment for each mass.