Everting ectopic ureteroceles

Cystoscopy at the time of ureteral reimplantation for primary vesicoureteral reflux: is it necessary? Incidence of undetected anomalies and cost

OBJECTIVES

To evaluate the impact on the planned procedure and associated cost of cystoscopy performed immediately before the surgical repair of vesicoureteral reflux. Cystoscopy is commonly performed at the time of ureteroneocystostomy to rule out a previously unsuspected anomaly such as ureterocele or ureteral duplication.

METHODS

We retrospectively reviewed the results of preoperative voiding cystourethrograms and ultrasound studies performed on 128 patients who underwent ureteral reimplantation for primary vesicoureteral reflux between 1994 and 2000. Radiographic findings were compared with observations made at cystoscopy and reimplantation to determine the rate of unsuspected ureterocele or duplication in the presence of a radiologic evaluation considered adequate by the operating surgeon and/or radiologist. We then performed an itemized analysis to determine the cost cystoscopy contributed to the procedure.

RESULTS

Of the 128 patients, 1 (0.7%) was found to have a small, undiagnosed ureterocele at cystoscopy. A review of this patient's preoperative evaluation revealed that her ultrasound examination was incomplete, lacking views of the bladder. At our institution, cystoscopy increased the total direct and indirect operating room costs of this procedure by 16.2%, adding $123.77 to the original cost of $762.97.

CONCLUSIONS

Routine cystoscopic examination before ureteral reimplantation in the setting of an adequate preoperative radiologic evaluation yields little diagnostic information. In this series, it did not have an impact on the surgical procedure to be performed but did add significantly to the cost. Cystoscopy before ureteral reimplantation for primary reflux should only be considered in those children with suspicious or inadequate radiologic studies.

Prolapse of an ectopic ureterocele into both urethra and ipsilateral orthotopic ureter

Ectopic ureteroceles frequently prolapse into the urethra. Inversion of ureteroceles into their own ureters has also been described. This patient showed a ureterocele which not only prolapsed into the urethra but also into the ipsilateral orthotopic ureter. We have not seen nor found a description of prolapse of a ureterocele into the ipsilateral orthotopic ureter.

Misleading appearances in pediatric uroradiology

Certain misleading appearances are peculiar to pediatric uroradiology. The most frequently encountered pitfalls are related to the bladder, to vesicoureteral reflux, and to the duplicated collecting system. The bi-chambered nature of the child's bladder, and the rapid settling of contrast material to the most dependent portion causes many pitfalls in diagnosis. When the child is prone, normal ureters may seem to be ectopic, and ureteroceles may become invisible. When the child is supine, the volume of urine in the bladder may be grossly under-estimated. Reflux can mimic function at urography. The dynamic nature of reflux leads to under-estimation of its presence and degree on the IVP and static cystogram. Reflux into an already dilated system can lead to over-estimation of its degree. Aberrant micturition with rapid refilling of the bladder can simulate incomplete emptying. The diagnosis of "ectopic ureterocele" is based on indirect evidence. Any condition that affects the urinary apparatus in the same way will have a similar appearance. A hugh ureterocele may have a small ureter, and massive reflux into a lower pole ureter may make the diagnosis of duplication difficult. Ureteroicele "look-alikes", and effacement or intussusception of the ureterocele are cystographic pitfalls. Lower pole ureteropelvic junction obstruction and Wilms tumor in the lower portion of a kidney can have surprisingly similar appearances.

Ureteroceles in infants and children

Ureteroceles in childhood have a broad spectrum of presentation, anatomy and pathophysiology and, thus, treatment must be individualized. We evaluated 64 children with 72 ureteroceles who underwent operation. Their presentation, radiographic findings, operative management and postoperative results are discussed. Simple or orthotopic ureteroceles often require no operation unless they are large enough to obstruct the urinary tract. Then excision of the ureterocele and ureteral reimplantation are recommended. There are a number of options available for the management of ectopic ureteroceles. The procedure of choice is upper pole heminephrectomy and partial ureterectomy in the majority of ureteroceles associated with a poorly functioning upper renal segment. Specific indications for each of the other surgical techniques considered acceptable at present are discussed.

"The intraureteric diverticulum", a manifestation of ureterocoele intussusception

An ectopic ureterocoele may present as a diverticular-like structure at the bladder base appearing during voiding cystography. The radiological appearances are described and the mechanism of formation as seen in serial 70 mm film is discussed. The conventional intravesical filling defect of an ureterocoele may not be recognised when the bladder is filled by contrast medium. This sign of extra-vesical intra-ureteric invagination is only seen during voiding.

Unusual presentation of cecoureterocele

A three-year-old female had a nephroureterectomy for a hydronephrotic left kidney with a total duplicated collecting system. Postoperatively urinary retention developed which was found to be secondary to a previously nonobstructive cecoureterocele. A brief review of cecoureteroceles is given along with the possible cause of this unusual presentation.