|
I./4.3.: Ureterocele
I./4.3.1.: Etiology
|
 |
A cystic enlargement of the ureter’s intravesical part that bulges into the urinary bladder is called ureterocele. It is a congenital malformation with unknown cause; it is frequently associated with other abnormities such as a stenosis of the ureter’s orifice or a vesicoureteral reflux (VUR). Normally the pressure generated in the bladder mainly during abdominal pressing or voiding is not transposed to the ureters. In VUR, however the above “valve” mechanism is not functioning and urine may get back from the bladder to the ureters and renal pelvis.
I./4.3.2.: Symptoms
|
 |
Ureterocele is usually asymptomatic, and it is detected by chance. However, when it is associated with a stenosis, lower back pain may occur. If also reflux (VUR) is present, the lower back pain is characteristically experienced during voiding or abdominal pressing. In case of stones or inflammation developing in consequence of the narrowing or VUR, lower back pain, fever and hematuria may occur, similarly to those discussed in the previous part.
I./4.3.3.: Diagnostics
|
 |
Ureterocele is often detected by chance during an imaging examination, mainly US or CT performed due to another cause. If the ureterocele is associated with a secondary stenosis, VUR, infection, or stone development, the earlier mentioned symptoms may call the attention to these. In patients with lower back pain, fever, dysuria and hematuria it is useful to perform US examination when the bladder is full. Then the US shows a protrusion on the base of the bladder, corresponding to the ureter’s orifice; it has a thin wall and clear fluid can be observed within it.
During examinations with contrast media, e.g. intravenous urography, cystography or CT mostly a lack of filling is characteristic which is observed corresponding to the ureter’s orifice. If concomitant vesicoureteral reflux (VUR) is suspected, it can be confirmed by a cystography with pressing. The bladder is filled with contrast agent through a catheter and an X-ray picture is made during abdominal pressing. In patients with VUR the contrast agent gets from the bladder up to the ureter(s) possibly also to the renal pelvis(es).
I./4.3.4.: Differential diagnosis
|
 |
An ureterocele should be differentiated mainly from other space-occupying processes occurring in the bladder, from primary papillary tumors of the urinary bladder which are sitting at the ureter’s orifice. Both may be associated with complaints of dysuria, hematuria, pain at the kidney’s region, so that the symptoms are not diagnostic. The US examination shows that, unlike to the ureterocele, the interior of the tumors is not cystic and shows a good circulation with Doppler examination; however this is not sufficient for a safe diagnosis. It is useful to inspect the lesion in the bladder by cystoscopy. If a pouch-like mass covered by intact mucosa is found, on which also the ureter’s orifice is visible, it is ureterocele; when foreign tissue showing papillary or solid structure is seen, its is a tumor.
I./4.3.5.: Therapy
|
|
An incidentally recognized ureterocele which causes no complaints, no stenosis and no VUR and leads to no sequels requires no therapy, only the patient should be followed up if the diagnosis is certain. In case of complaints, subsequent narrowing, or when a differentiation from a tumor is uncertain, transurethral resection may be performed under general or epidural anesthesia. In relation to this, precaution is required in order to avoid the development of reflux or a stricture of the ureteral orifice. If VUR is present, the therapy depends on its degree, the accompanying malformations, the renal function and the patient’s age. Mild cases may be treated conservatively (e.g.: administration of antibiotics), severe cases require surgery (e.g. neoimplantation: formation of a new orifice for the ureter into the bladder).
|
|