1. URETEROCELURETEROCEL
EE
BYBY
AMR MOHAMED AHMEDAMR MOHAMED AHMED

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

3. INCIDENCEINCIDENCE
--Ureteroceles occur in about 1 in 500 to 1 inUreteroceles occur in about 1 in 500 to 1 in
4,000 people4,000 people..
-More in female than male-More in female than male
-bilateral in 10%-bilateral in 10%
--Ectopic ureteroceles are four times moreEctopic ureteroceles are four times more
common than those that are intravesicalcommon than those that are intravesical

4. EtiologyEtiology
--Ureterocele has been attributed to delayed orUreterocele has been attributed to delayed or
incomplete canalization of the ureteral bud leadingincomplete canalization of the ureteral bud leading
to an early prenatal obstruction and expansion ofto an early prenatal obstruction and expansion of
the ureteral bud prior to its absorption into thethe ureteral bud prior to its absorption into the
urogenital sinusurogenital sinus..
--The cystic dilation forms between the superficial andThe cystic dilation forms between the superficial and
deep muscle layers of the trigonedeep muscle layers of the trigone..
--Large ureteroceles may displace the other orifices, orLarge ureteroceles may displace the other orifices, or
even obstruct the bladder outleteven obstruct the bladder outlet..

5. CLASSIFICATIONCLASSIFICATION
EctopicEctopic
-Some part extends to the bladder-Some part extends to the bladder
neck or urethraneck or urethra
-associated often with duplicated-associated often with duplicated
ureterureter
IntravesicalIntravesical
-Confined within the bladder-Confined within the bladder
-associated often with single ureter-associated often with single ureter

6. 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

7. DiagnosticDiagnostic
ProceduresProcedures ))A) Laboratory StudiesA) Laboratory Studies
--UrinalysisUrinalysis
--Urine cultureUrine culture
--Complete blood cell countComplete blood cell count
--Serum chemistries, especially BUN and serumSerum chemistries, especially BUN and serum
creatininecreatinine
--Blood culturesBlood cultures
--Fungal cultures: obtained in infants who haveFungal cultures: obtained in infants who have
been on long-term antibiotic therapy or inbeen on long-term antibiotic therapy or in
immunocompromised patients with clinicalimmunocompromised patients with clinical
evidence of UTIevidence of UTI

8. ))B) Imaging StudiesB) Imaging Studies
Large ureteroceles are usually diagnosed earlierLarge ureteroceles are usually diagnosed earlier
than smaller ones. A ureterocele may bethan smaller ones. A ureterocele may be
discovered before the baby is born (during adiscovered before the baby is born (during a
pregnancy ultrasoundpregnancy ultrasound(.(.
Some people with ureteroceles do not know theySome people with ureteroceles do not know they
have the. Often, the diagnosis is made later inhave the. Often, the diagnosis is made later in
life due to kidney stoneslife due to kidney stones..

9. The following tests may be performed:The following tests may be performed:
1- Ultrasonography1- Ultrasonography
The cyst within a cyst is a pathognomonicThe cyst within a cyst is a pathognomonic
radiologic sign of ureteroceleradiologic sign of ureterocele..

10. 22--VoidingVoiding
cystourethrographcystourethrograph
yy
It may demonstrate reflux intoIt may demonstrate reflux into
the lower pole orthe lower pole or
contralateral uretercontralateral ureter..

11. 33--Intravenous urographyIntravenous urography
--Useful for delineating renal anatomy andUseful for delineating renal anatomy and
providing a subjective estimation of relativeproviding a subjective estimation of relative
renal functionrenal function
--The following may be seen on IVPThe following may be seen on IVP:-:-
• Hydronephrosis, revealing dilatation ofHydronephrosis, revealing dilatation of
collecting systemcollecting system
• Hydronephrotic upper pole displacing theHydronephrotic upper pole displacing the
lower pole moiety laterally and inferiorlylower pole moiety laterally and inferiorly
• Ureteral displacement by the hydroureterUreteral displacement by the hydroureter
• Cobra-headCobra-head extension of the distal ureterextension of the distal ureter
(ureterocele)(ureterocele)

13. 44--Magnetic resonance imagingMagnetic resonance imaging
Excellent anatomical study for evaluating rare casesExcellent anatomical study for evaluating rare cases
with suspected dysplastic, nonfunctioning, ectopicwith suspected dysplastic, nonfunctioning, ectopic
renal moieties and ectopic ureteral insertionrenal moieties and ectopic ureteral insertion
55--Nuclear renal scanNuclear renal scan
It is helpful for estimating renal functionIt is helpful for estimating renal function

14. 66--CT scanning of the abdomen andCT scanning of the abdomen and
pelvispelvis
-Used if U/S or IVU are equivocal-Used if U/S or IVU are equivocal
-Can reveal the presence of a duplicated collecting-Can reveal the presence of a duplicated collecting
system, hydronephrotic upper pole segmentsystem, hydronephrotic upper pole segment..
CT scan shows a right ureterocele within the bladder with contrast material filling the ureteroceleCT scan shows a right ureterocele within the bladder with contrast material filling the ureterocele.. TheThe
lucency on the left represents a Foley catheterlucency on the left represents a Foley catheter

15. 77--CystoscopyCystoscopy
--Allow direct inspection and examination of theAllow direct inspection and examination of the
lower urinary tractlower urinary tract
--Used for confirm diagnosis and treatmentUsed for confirm diagnosis and treatment

16. TreatmentTreatment
))A) Medical TherapyA) Medical Therapy
--Observation alone is rarely a good option inObservation alone is rarely a good option in
symptomatic ureterocelessymptomatic ureteroceles
--Must rapidly initiate aggressive antibioticMust rapidly initiate aggressive antibiotic
therapytherapy
--Antibiotics should be instituted during the initialAntibiotics should be instituted during the initial
diagnostic evaluation and during surgicaldiagnostic evaluation and during surgical
interventionintervention

17. ))B) Surgical TherapyB) Surgical Therapy
indicationsindications
--obstruction especially bladder neckobstruction especially bladder neck
--hydronephrosishydronephrosis
--loss of functionloss of function
--UTIUTI
****remember.....single system (non duplex) ureterocele is rareremember.....single system (non duplex) ureterocele is rare

18. Endoscopic incisionEndoscopic incision
--DefinitiveDefinitive
--Risk = inducedRisk = induced
refluxreflux

19. Upper pole nephrectomy
If no upper pole function

20. 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

21. 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

22. Heminephroureterectomy
No upper pole function, obstructing
ureterocele