eMedicine Specialties > Urology > Hydronephrosis and Ureter Disorders

Ureterocele: Treatment

Author: Eugene Minevich, MD, Assistant Professor, Department of Surgery, Division of Pediatric Urology, University of Cincinnati
Coauthor(s): Leslie Tackett, MD, Fellow, Departments of Surgery and Pediatrics, Division of Pediatric Urology, Children's Hospital Medical Center at Cincinnati
Contributor Information and Disclosures

Updated: Jan 27, 2008

Treatment

Medical Therapy

Observation alone is rarely a good option in symptomatic ureteroceles. The physician must rapidly initiate aggressive antibiotic therapy. Antibiotics should be instituted during the initial diagnostic evaluation and during surgical intervention for both pediatric and adult ureteroceles.

Surgical Therapy

Indications for surgical treatment for both pediatric and adult ureteroceles depend on the site of the ureterocele, the clinical situation, associated renal anomalies, and the size of the ureterocele.

Goals of treatment include the following:

• Control of UTI
• Preservation of renal function
• Protection of ipsilateral and contralateral renal units
• Maintenance of urinary continence

Surgical approach is selected based on the following:

• Age of the patient
• Size and location of ureterocele
• Degree of renal function
• Presence and degree of vesicoureteral reflux
• Comorbid conditions (risk of anesthesia)

Surgical therapy for both pediatric and adult ureteroceles may include endoscopic incision or transurethral unroofing of the ureterocele in the adult patient, upper pole heminephrectomy and partial ureterectomy with ureterocele decompression, ureteropyelostomy, excision of ureterocele and ureteral reimplantation, and nephroureterectomy.

Endoscopic incision is the least invasive method for decompressing the ureterocele. This is an ideal method for dealing with a neonate with ureterocele-induced obstructive uropathy and sepsis. It may also be performed safely in an adult female with symptomatic ureterocele. Other indications are a single system intravesical ureterocele with obstruction or a duplex system ureterocele with indeterminate function of the affected renal moiety. Performed via the cystoscope, a small puncture is created at the base of the ureterocele.

In addition to its therapeutic value, this technique may be used when the contribution of the associated renal moiety to overall renal function is indeterminate. Improvement in renal function after an incision indicates that reconstruction is favorable, if necessary, and poor function indicates that excision of the upper pole moiety is preferable.

This procedure also allows palliative decompression in children at high risk (secondary to concurrent medical illness), so that definitive reconstruction can be delayed until an adequate healing period has occurred. This is the definitive therapy in only 10-40% of patients with ectopic ureteroceles, compared to 90% of the patients with a single system intravesical ureterocele. This may also be used as the definitive therapy in adults with symptomatic ureteroceles.

Transurethral unroofing of a ureterocele in an adult reliably achieves decompression and allows effective treatment of infection and calculi in symptomatic ureteroceles. Low transverse incision of the ureterocele creates a "flap-valve" effect and minimizes the reflux. The actual incidence of reflux after endoscopic unroofing in ureteroceles in adults is not known since a large prospective adult series on ureteroceles is lacking. However, several case reports have alluded to the fact that the incidence of reflux appears to be proportional to the type of incision made.

When a transverse (ie, smiley face) incision has been made at the base of the ureterocele, as opposed to a vertical incision, the risk of reflux is minimized. Furthermore, vesicoureteral reflux in adults has not shown higher risk for renal insufficiency or pyelonephritis. Thus, vesicoureteral reflux in adults is not routinely treated with ureteral reimplantation. Rather, these patients are monitored expectantly, and the need for reimplantation is tailored to the individual. Data on the use of bulking agents for treatment of adult vesicoureteral reflux in these situations are lacking. The potential for vesicoureteral reflux limits the use of endoscopic unroofing in children.

Upper pole heminephrectomy and partial ureterectomy with ureterocele decompression involves removal of the upper pole of the kidney, as well as the affected proximal ureter to the level of iliac vessels. The remaining distal ureterocele is not excised but rather is decompressed. This is the definitive treatment in patients with an obstructed ectopic ureterocele and a dysplastic upper pole, but without associated vesicoureteral reflux. If reflux was present preoperatively, the distal ureterocele should be ligated rather than allowing it to remain decompressed. Upper pole heminephrectomy and partial ureterectomy with ureterocele decompression is a reasonable alternative for adults in whom transurethral ureterocele unroofing has failed due to technical or anatomical difficulties.

This operation has been noted to cause spontaneous resolution of ipsilateral vesicoureteral reflux and contralateral reflux and/or obstruction. Upper pole heminephrectomy and partial ureterectomy with ureterocele decompression has been reported to cause spontaneous resolution of grade I and II vesicoureteral reflux in 60% of cases, while higher grades of reflux necessitated bladder reconstruction in 96% of cases. While upper pole heminephrectomy provides effective decompression, the risk for subsequent bladder surgery may be significant, especially if reflux is already present.

Factors that may predict the likelihood of future surgical intervention include the following:

• High-grade reflux (grades III, IV, V)
• Complications resulting from remaining stump of upper ureter (eg, UTI, calculus)
• Poor detrusor backing behind the remaining ureterocele

Therefore, upper pole heminephrectomy is an excellent first-line procedure for the child with a ureterocele that affects only the ipsilateral upper pole. It is a good choice in the child with a ureterocele with only ipsilateral renal involvement (which may include upper pole obstruction and lower pole reflux, for example). In any case, the patient and family should be counseled about the potential need for further surgical procedures.

Ureteropyelostomy is an operation that joins the upper pole ureter to the lower pole renal pelvis. This is preferred if the affected renal unit demonstrates significant function. Alternatively, a high ureteroureterostomy may also be performed. This is true for both pediatric and adult populations.

Excision and ureteral reimplantation is indicated as a primary procedure if the patient has significant vesicoureteral reflux in the lower pole moiety and a well-functioning upper pole moiety and/or significant contralateral vesicoureteral reflux. Both ipsilateral ureters may be reimplanted within a common sheath or via ureteroureterostomy. Note that common sheath reimplantation has a distinct disadvantage of reimplanting a very dilated distal ureter into the small bladder of an infant. The decision whether to taper the ureters must be made on an individual basis. This operation is commonly delayed until the child is older (aged approximately 2 y). However, this operation should be performed before the child is toilet trained since it is rather extensive surgery. This operation is not commonly used in adults since most patients respond favorably to endoscopic unroofing of the ureterocele. Again, the necessity of this operation should be individualized.

In the pediatric population, the excision and reimplantation procedure commonly is used as a secondary procedure (after previous heminephrectomy or endoscopic incision of a ureterocele) because of UTI, voiding disturbance, persistent vesicoureteral reflux, or obstruction. Significant vesicoureteral reflux on initial VCUG usually indicates that lower-tract reconstruction will be necessary. Of note, if this procedure is selected as the first-line treatment in the appropriate patient, the rate of secondary surgery is low.

Nephroureterectomy is performed in patients with single system ureterocele and a nonfunctioning kidney. The traditional method of correcting an ectopic ureterocele in a duplex system has been to perform a total reconstruction. This involved a bladder surgery, followed by renal surgery. The bladder surgery required excision of a ureterocele, reconstruction of the detrusor, and reimplantation of the ipsilateral ureter. This was followed by a flank incision and upper pole heminephrectomy. Since most ureteroceles typically present in young children (often <1 y), total reconstruction was technically challenging, and complications were common.

Briefly, a functional classification of the ectopic ureterocele by Churchill et al can be used to guide therapeutic considerations in children:²

• Upper pole nonfunction 
  • One renal unit in jeopardy (grade I) - Only the upper pole drained by the ureterocele is affected (other renal units normal, may have grade I-II vesicoureteral reflux): Perform upper pole heminephrectomy.
  • Entire ipsilateral renal unit (grade II) or all renal units (grade III) in jeopardy - Ipsilateral and/or contralateral renal units affected by hydronephrosis or high-grade vesicoureteral reflux: Perform upper pole nephroureterectomy, ureterocele excision with ureteral reimplantation.
• Indeterminate function: Perform endoscopic incision and reassessment of function.
• Upper pole function present  
  • One renal unit in jeopardy (grade I): Perform ureteropyelostomy and ureterocele drainage.
  • Entire ipsilateral renal unit (grade II) or all renal units (grade III) in jeopardy: Perform ureteropyelostomy, ureterocele excision, and ureteral reimplantation.
  • Note: the endoscopic incision is also considered first in infants who are medically unstable because of sepsis or coexistent medical conditions.

Another consideration, in addition to the functional classification, is patient age. In the neonate or infant, transurethral puncture of the ureterocele or an upper tract approach (eg, heminephrectomy) would be the most feasible options, while excision of the ureterocele with bladder reconstruction or total reconstruction, including heminephrectomy, may be added to the therapeutic armamentarium in the older child (>2 y). In the adult, transurethral unroofing of the ureterocele is a reasonable first-line approach, because the development of postoperative vesicoureteral reflux is less problematic than in the child.

Preoperative Details

The goals of the preoperative evaluation of the ureterocele are as follows:

• Detailed delineation of upper and lower urinary tract anatomy
• Estimation of differential function of all renal moieties
• Determination of the presence of obstruction (anatomic or functional) or vesicoureteric reflux

Intraoperative Details

When an upper tract approach is planned, preoperative function of the involved moiety and appearance of the renal parenchyma intraoperatively contribute to the decision whether to perform heminephrectomy or renal-sparing surgery (eg, ureteroureterostomy or ureteropyelostomy).

The principles of successful ureteral reimplantation, with or without ureteral remodeling and bladder reconstruction, are as follows:

• Protection of contralateral ureteral orifice
• Adequate ureteral exposure and mobilization
• Gentle handling of the tissue and meticulous preservation of blood supply
• Creation of a valvular mechanism with a submucosal tunnel with a length to ureteral diameter ratio of 5:1, in case of ureteral reimplantation

Endoscopic incision of ureterocele

This is the least invasive technique. The patient is placed in dorsolithotomy position. Incision of the ureterocele is performed via the cystoscope. Using a small Bugbee electrode (3F) and a cutting current, create a small puncture at the lowest point just above the base of the ureterocele.

Upper pole heminephrectomy, partial ureterectomy with ureterocele decompression

Place the patient in a flank position. Insert a Foley catheter. Make a flank incision off the 12th rib. Mobilize the kidney and the proximal ureter. There is no need to dissect out the renal hilum. Remove the upper pole of the kidney. Manual compression of the kidney provides adequate vascular control. Next, excise the upper pole ureter to the level of the iliac vessels. Dissect on the upper pole ureter to avoid injury to the lower pole ureter. Use a catheter to decompress the distal ureterocele. If there is no reflux into the ureterocele, the stump is left open. If reflux is present, the ureterocele should be ligated. Irrigate the wound and leave a small drain in the pelvis.

Ureteropyelostomy

Place the patient in a supine position. Insert a Foley catheter. Make an anterior subcostal incision. Stay extraperitoneal. Dissect out both ureters. Incise the upper pole ureter laterally and incise the lower pole renal pelvis medially. Anastomose the upper pole ureter to lower pole renal pelvis. Insertion of a double J stent or a feeding tube is optional.

Excision of ureterocele with ureteral reimplantation

Place a patient in a supine position. Make a transverse lower abdominal incision. Open the bladder and identify the ureteral orifice and the ureterocele. Intubate both ureteral orifices with an infant feeding tube. Circumscribe out the distal ureterocele as for ureteroneocystostomy. Close the defect in the detrusor. Amputate the ureterocele. Ureters may be reimplanted within the common sheath or via ureteroureterostomy, with or without tapering of the ureter.

Nephroureterectomy

Postoperative Details

Intravenous antibiotics are continued until the patient is discharged from the hospital. Urethral catheters are removed when urine is clear. Depending on the operation, hospital stay ranges 1-4 days. If an internal stent has been placed, it is removed 3-6 weeks after surgery. Postoperative imaging studies such as renal ultrasonography and VCUG are usually obtained at 3-4 months after surgery or sooner as dictated by individual clinical scenario or postoperative complications.

Follow-up

Follow-up care consists of serial monitoring of renal function, periodic evaluation of voiding symptoms and bladder function, and interval radiologic studies to assess renal growth, hydroureteronephrosis, and vesicoureteral reflux.

Complications

• Endoscopic incision of ureterocele
  • Iatrogenic VUR occurs in 40-50% of pediatric patients.
  • This is infrequently definitive therapy, except in cases of a single system intravesical ureterocele.
• Upper pole heminephrectomy
  • Highest risk of -intraoperative blood loss
  • Vascular compromise of lower pole with potential loss of renal function
  • Need for further lower tract reconstruction due to persistent reflux, infection, or failure to decompress the ureterocele
• Excision of ureterocele and ureteral reimplantation
  • Problematic hematuria and/or bladder spasms
  • Damage to bladder neck or continence mechanism
  • Injury to the contralateral ureteral orifice
  • Compromise of blood supply to the lower pole ureter

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