[Prenatal diagnosis and management of two cases of bilateral ureteroceles on simplex ureters]

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.

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.

[Should morphology of the upper pole in renal duplication with preserved function and associated ureterocele be taken into account during treatment planning?]

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.

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.

Endoscopic Treatment of Vesicoureteral Reflux Associated With Ureterocele

PURPOSE

We determined the value of endoscopic treatment for vesicoureteral reflux associated with ureterocele.

MATERIALS AND METHODS

From 1984 to 2005, 109 children with a median age of 6 months underwent endoscopic ureterocele puncture. Ureterocele presented as a part of a duplex system in 97 of patients (89%) and as part of a single system in 12 (11%). Vesicoureteral reflux was seen to the lower ipsilateral moiety in 53 patients and in 32 contralateral kidneys (85 refluxing renal units). Puncture was performed with a 3Fr Bugbee electrode. High grade vesicoureteral reflux or breakthrough infection while on antibiotic prophylaxis served as the indication for the surgical correction of vesicoureteral reflux. Median followup after endoscopic correction was 10 years (range 1 to 21).

RESULTS

Spontaneous vesicoureteral reflux resolution following successful ureterocele puncture was seen in 36 of the 85 refluxing renal units (42%) and in 5 (6%) reflux was downgraded. The latter patients were withdrawn from antibiotic prophylaxis and they did well. A total of 33 refluxing renal units with vesicoureteral reflux into the lower moiety of the ureterocele kidney and 11 contralateral refluxing renal units underwent endoscopic correction. Reflux was corrected in 31 of the 44 refluxing renal units (70%) after a single injection and it resolved after a second injection in another 9 (21%). In 4 refluxing renal units (9%) endoscopic correction failed and open reimplantation was done. Of the 109 patients (13%) 14 had vesicoureteral reflux to the ureterocele moiety following endoscopic puncture. Of those patients endoscopic correction resolved reflux in 3, reflux resolved spontaneously in 5 and upper pole partial nephrectomy was performed in 4 due to a nonfunctioning moiety. The remaining 2 patients did well without antibiotic prophylaxis.

CONCLUSIONS

Our data show that endoscopic treatment of vesicoureteral reflux associated with ureterocele is a simple, long-term effective and safe procedure, avoiding the need for open surgery in the majority of patients following endoscopic puncture of ureterocele.

Adult bilateral non-obstructing orthotopic ureteroceles with multiple calculi: endoscopic management with review of literature

We describe and report two cases of bilateral symptomatic ureterocele with calculi in two young adult women. They were successfully managed endoscopically by a transverse meatotomy and stone extraction done bilaterally in a single operative session. The 6th month postoperative voiding cystourethrogram showed no reflux. The literature regarding the incidence, occurrence, diagnosis and management of this uncommon condition in adults has been reviewed and discussed.

Watchful Waiting for Prenatally Detected Ureteroceles

PURPOSE

Ureteroceles are commonly detected by prenatal ultrasound. Although many require surgical intervention due to obstruction of more than one renal moiety or obstruction of the bladder neck, some may be carefully observed. The objective of this study was to assess the outcome of conservative management in select cases of prenatally detected ureteroceles at a tertiary care pediatric hospital.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients with ureteroceles detected on prenatal ultrasound who were treated nonsurgically between 1990 and 2001.

RESULTS

A total of 10 cases were detected in the course of the chart review, with 6 involving duplex system and 4 involving single system ureteroceles. Median followup was 5 years (range 1 to 11). Patients were followed with routine ultrasound at 3 to 6-month intervals for the first 2 years, and at 6-month to 2-year intervals thereafter. Voiding cystourethrogram and renal scans or IVPs were performed initially in all patients. Those with vesicoureteral reflux were followed with annual or biennial cystogram until reflux resolution. Antibiotic prophylaxis was routinely prescribed for an average duration of 1.5 years. Initial ultrasound revealed unilateral hydronephrosis in all patients, with complete resolution in 6 during a mean followup of 2 years. Voiding cystourethrogram demonstrated vesicoureteral reflux of grade III or less in 4 patients. Reflux resolved in 2 of these patients during a mean followup of 3 years. No patient required surgical intervention within the time frame of this study.

CONCLUSIONS

There may be a role for watchful waiting in select cases of prenatally detected ureteroceles. Cases involving obstruction of more than one renal moiety, bladder neck obstruction or high grade vesicoureteral reflux were not selected among the population we followed, and would likely require initial surgical management. Patients without these complicating features may be safely followed on suppressive antibiotics, as based on our experience many of the associated problems may resolve without surgical intervention.

INDICATIONS FOR NONOPERATIVE MANAGEMENT OF URETEROCELES

PURPOSE

Ureteroceles have traditionally been managed surgically. We report our indications and outcomes of nonoperative management of ureteroceles in a select cohort.

MATERIALS AND METHODS

We identified prospectively for nonoperative management 11 females and 2 males with ureteroceles associated with hydronephrosis or multicystic dysplasia (MCD). Patients presented with either a febrile urinary tract infection (3) or prenatal hydronephrosis (10). All patients were evaluated with renal and bladder ultrasound, voiding cystourethrography and mercaptoacetyltriglycine-3 furosemide renography. Two subgroups were identified, consisting of 10 duplex system upper pole ureteroceles associated with nonobstructed functional systems and 3 ureteroceles associated with a completely nonfunctional single system (2) or duplex (1) kidneys with or without MCD. Median followup was 41 months (range 13 months to 8 years).

RESULTS

Of the 13 patients 9 required no surgical intervention. Of these 9 patients 3 had either a nonfunctional upper pole moiety (1) or MCD (2) that involuted, and 6 had good function of the upper pole segments relative to the lower pole without high grade obstruction on furosemide renography. Mean upper pole relative to lower pole differential function as determined by isotope renogram in these 6 patients was 40.8% (range 28% to 65%) and median drainage half-time was 5.3 minutes (4.5 to 19.3). On sonography, hydronephrosis improved in all 6 cases, with 5 (83%) decreasing to grade 0 (3) or I (2). Of these 6 cases of duplex system ureteroceles 5 had associated ipsilateral lower pole reflux of grade III (2) or IV (3). Reflux resolved in all cases. Surgery was necessary for progressive obstruction 1 patient and for breakthrough urinary tract infection in 3. The mean upper pole differential function in the operative group of 24.3% was lower than that of the nonoperative group. The initial median drainage half-time was 12.5 minutes (range 6.9 to 20). There was no significant difference between the nonoperative and operative groups in regard to hydronephrosis grade, reflux grade or ureterocele size.

CONCLUSIONS

Furosemide renography can identify a select subgroup of patients with ureteroceles who are candidates for nonoperative management. Ureteroceles with nonobstructed duplex systems have better preservation of renal function and a high rate of natural resolution of hydronephrosis and reflux. Ureteroceles associated with MCD or completely nonfunctioning upper pole moieties may never require surgical management.

Recent trends of genitourinary endoscopy in children

Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.

Obstructive uropathy: considerations for the nephrology nurse

Obstructive uropathy is the cause of renal failure in 16.2% of pediatric patients who undergo renal transplantation, 12.9% of those on dialysis, and 23.1% of those with chronic renal insufficiency, according to the annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Successfully caring for patients with obstructive uropathy requires an understanding of the various congenital anomalies that create obstructive uropathy, the urological interventions used to treat them, management of the patient, and the nursing care required.

Changing concepts in urological management of the congenital anomalies of kidney and urinary tract, CAKUT

Recent advancement in ultrasonographic evaluation has prompted early detection and diagnosis of congenital anomalies in the kidney and urinary tract (CAKUT) in the asymptomatic phase. Consequently, early surgical intervention has become possible in the asymptomatic phase for the purpose of controlling manifestations early, thereby avoiding renal functional deterioration. However, some lesions detected by ultrasonography have been shown to often resolve or disappear without intervention. Thus, it has become more important to identify and understand the natural history of CAKUT. For the precise evaluation of the results of surgical intervention, one must understand the maturational process of renal function during infancy. Without considering this process, we cannot differentiate the renal significance of the surgical management from the natural course of CAKUT. Recent advancement in the field of radioisotopic studies has also made a major contribution to the more precise assessment of renal function. Recent progress in the understanding of the pathophysiology and the natural history of CAKUT has helped rationalize its treatment and management. Improvement in the surgical techniques and tools, together with improvements in pediatric anesthesiology, have made an appreciably positive impact on the outcome. Herein, we present the emerging concepts in the urological management of CAKUT, specifically, multicystic dysplastic kidney, vesicoureteral reflux, congenital hydronephrosis, ectopic ureters and ureteroceles.

[Ureterocele in adults complicated with calculi: diagnostic and therapeutic features. Report of 20 cases]

STUDY OBJECTIVE

The authors study the various diagnostic and therapeutic aspects of adult ureterocele and evaluate the place of endoscopic treatment.

MATERIALS AND METHODS

This retrospective study was based on 20 cases of ureterocele in adults complicated by stones and observed between January 1990 and December 2001. This series consisted of 8 men and 12 women with a mean age of 48.3 years (range: 24-75 years). The clinical features were dominated by low back pain. The diagnosis of ureterocele was based on intravenous urography in 19 patients and was discovered on endoscopy in one patient. The ureterocele affected a single ureter in 16 cases (80%) and a duplex ureter at the expense of the upper renal segment in 4 cases. All patients were treated by endoscopic horizontal meatotomy with stone fragmentation and extraction. The mean operating time was 27 min (range: 18-58 min).

RESULTS

The postoperative course was uneventful in 19 patients. One patient developed postoperative sepsis. All patients were reviewed clinically and radiologically at 3 months and at 6 months. Satisfactory results were obtained in every case with no residual stones and resolution of low back pain. Only one patient presented vesicoureteric reflux which had resolved on the follow-up urethrocystography performed at 6 months.

CONCLUSION

Adult ureterocele complicated by stones is a well tolerated, rare entity that can often be easily diagnosed. Endoscopic meatotomy is easy to perform and gives good results. The associated stones constitute an additional argument in favour of endoscopic treatment.

Ureterocele causing anhydramnios successfully treated with percutaneous decompression

BACKGROUND

Ureteroceles are congenital cystic dilatations of the submucosal segment of the distal ureter. We present a case of an intravesical ureterocele causing anhydramnios at 31 weeks' gestation.

CASE

A primiparous woman near 20 weeks' gestation had ultrasound evidence of a fetal duplicated right collecting system. At 31 weeks, an intravesical ureterocele was seen along with bilateral hydroureteronephrosis and anhydramnios. A single percutaneous needle decompression of the bladder and ureterocele successfully restored amniotic fluid volume.

CONCLUSION

Follow-up ultrasounds are indicated when either a duplicated renal collecting system or a ureterocele is identified. In utero treatment is indicated only when amniotic fluid is compromised. Needle decompression should be first-line treatment, with more invasive methods reserved for failures of decompression.

Outcome of patients with prenatally detected duplex system ureterocele; natural history of those managed expectantly

PURPOSE

We assessed the outcome of patients treated for prenatally detected duplex system ureterocele with particular reference to those treated expectantly.

MATERIALS AND METHODS

We reviewed the records of 52 consecutive patients treated between 1984 and 1999 with a median followup of 8 years (range 1 to 16.2).

RESULTS

Of the 38 patients who underwent surgical treatment 13 subsequently required unplanned secondary procedures. A total of 14 cases satisfying currently defined criteria, including less than 10% upper renal pole function, an unobstructed lower pole (absent nonrefluxing hydroureteronephrosis), lower pole vesicoureteral reflux not exceeding grade III and unobstructed bladder outflow, were managed expectantly with a median followup of 8 years (range 1.6 to 12.8). In this group of patients prophylactic antibiotics were routinely prescribed until the completion of toilet training or age 5 years in those with persistent reflux on repeat cystography. None has required surgery or had symptoms or urinary infection. In 6 cases followup ultrasonography showed substantial resolution of upper pole hydronephrosis with a collapsed ureterocele. Furthermore, 7 of the 38 patients who underwent surgical treatment early in our series would have been treated expectantly had the current criteria been applied.

CONCLUSIONS

In 14 of the 52 patients (approximately 27%) with prenatally detected duplex system ureterocele the natural history of the complaint is essentially benign within the currently available followup.

Ureterocele prolapse-rare presentation in an adolescent girl

Ureterocele prolapse is a rare presentation of single system ureteroceles and is usually found early in childhood. We present a rare case of recurrent prolapse of a single system ureterocele that did not present until the patient was 17 years of age.

Endoscopic puncture of ureterocele as a minimally invasive and effective long-term procedure in children

OBJECTIVES

Over the past years the surgical approach to ureterocele has evolved from complicated major surgery to minimally invasive endoscopic treatment. Because of the high rate of secondary surgery in some recently reported series, an upper pole partial nephrectomy is again recommended as the procedure of choice. We have retrospectively evaluated the long-term results of endoscopic puncture of a ureterocele and its long-term effectiveness and applicability in children.

METHODS

Over the past 8 years, 34 patients (20 female, 14 male) were treated in our service with primary endoscopic puncture of a ureterocele. The mean age of the patients was 1.1 +/- 4.3 (mean +/- SD) years. Mean follow-up was 6.1 +/- 2.4 years. Antenatally ultrasound detected the ureterocele in 5 (14%) patients, fetal hydronephrosis leading to the postnatal diagnosis in 13 (38%), and 16 (48%) children presented with symptoms of urinary tract infection (UTI). The ureteroceles presented as part of renal duplication in 31 patients (91%), 3 (9%) in a single system and 1 child had bilateral ureteroceles of a duplex system. Twenty (58%) children had intravesical ureteroceles and the remaining 14 (42%) ectopic ureteroceles. Very poorly functioning upper pole moiety presented in 26 (75%) of the cases and nonfunctioning upper poles in 5 (14%). Twenty of 34 children (58%) had initial vesicoureteral reflux (VUR) to the lower moiety, either to the ipsi (60%) or contralateral kidney (40%). A cold knife incision was carried out in 4 (11.7%), puncture by a 3-french Bugbee electrode in 20 (58%), and the stylet of a 3-french ureteral catheter was utilized to puncture the ureterocele in the remaining 10 patients (30.3%).

RESULTS

Complete decompression of the ureterocele was observed in 32 of 34 children (94%). Two patients required secondary puncture 2 years following the primary procedure and are doing well. Upper pole moiety function improved postoperatively in 2 infants and remained stable in all 32 patients, no patient presented with deterioration of the renal function. Six of 20 (30%) patients who had initial VUR to the lower pole, accompanied with recurrent UTI, required surgery. Three underwent ureteric reimplantation and another 3 submucosal polytetrafluoroethylene paste (Teflon) injection. Eight (40%) patients presented with spontaneous resolution of VUR to the lower moiety following puncture of the ureterocele. An additional 6 (17.6%) patients developed VUR to the upper moiety following the puncture of the ureterocele, 3 after cold knife incision and 3 after simple puncture. In 2, submucosal Teflon injection solved the VUR and the remaining 4 patients were maintained on prophylactic antibiotics. In 1 child the reflux resolved spontaneously, and none of them presented with UTI. In 2 cases with nonfunctional upper poles, partial nephrectomy was performed due to symptomatic UTI in spite of complete collapse of the ureterocele 1 and 2 years, respectively, following the initial puncture. No difference was observed in the re-operation rate between the patients with ectopic versus intravesical ureterocele (p<0.05).

CONCLUSION

We found that endoscopic puncture of a ureterocele presents an easily performed procedure which allows the release of obstructive ureters and avoids major surgery in the majority of the cases even after a long follow-up.

Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems

PURPOSE

We studied the long-term outcome of transurethral puncture of ectopic ureteroceles specifically associated with duplex systems.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent transurethral puncture of an ectopic ureterocele. Study exclusion criteria were orthotopic, bilateral and prolapsing ureteroceles.

RESULTS

We identified 19 girls and 2 boys, of whom 11 presented with prenatal hydronephrosis and 10 presented with urinary tract infection. Mean age at puncture was 5 months (range 0.5 to 60). Preoperatively voiding cystourethrography revealed no reflux in 7 patients, isolated ipsilateral lower pole reflux in 8, and bilateral and/or contralateral reflux in 6. Postoperatively studies initially showed no reflux in 8 cases but in 4 of the 8 reflux recurred up to 4 years after puncture. In 10 patients (48%) reflux developed into the ureterocele and upper pole segment. Repeat puncture was required 1 to 13 months after the initial procedure in 4 patients for persistent or recurrent upper pole hydroureteronephrosis. Subsequent open surgery was required in 15 of the 21 cases (71%), including ureterocele excision with ureteral reimplantation in 14. Of the children 10 and 4 underwent open surgery for recurrent urinary tract infection and progressive reflux, respectively, while 1 underwent ureteroureterostomy for progressive upper pole reflux. No patient underwent upper pole nephrectomy. Of the remaining 6 patients 4 have low grade reflux.

CONCLUSIONS

Transurethral puncture of ectopic ureteroceles provides effective short-term correction of upper pole obstruction but it is not definitive therapy in the majority of cases. Most children still require open surgery. In patients without reflux after the puncture procedure new onset, recurrent or progressive reflux may later develop with extended followup. Repeat puncture may be required to ensure adequate decompression in a minority of cases, as in the 20% in our series.

[Treatment of ureterocele by endoscopic puncture]

Ureterocele is a congenital cystic dilatation of the intravesical segment of the ureter. As a consequence, the proximal ureter and renal pelvis become dilated and that results in renal-parenchymal pathological involvement. Management of this anomaly is still controversial. Among the therapeutical options there is a place for endoscopic punction. Our experience with 11 patients undergoing this treatment modality is reported. In all these cases endoscopic punction was the initial treatment. In 7 patients this technique was all that was needed. The technique of intravesical punction is described and its results are specified.

[Diagnostic and therapeutic retrograde ureterorenoscopy (URS)]

Presentation of results obtained in 50 procedures of retrograde ureterorenoscopy (URS), and discussion based on the literature and our results, on the current indications for URS with regard to extracorporeal lithofragmentation (ECL) for the treatment of pelvic ureteral lithiasis and the diagnosis and/or treatment of other conditions. Fifty URS were performed in 47 patients between February 1992 and March 1994: 35 were conducted to treat ureteral lithiasis, achieving a 97% success rate and a mean post-surgery hospital stay of 48 hours; and for diagnostic and/or therapeutic reasons. There were no major complications, and a description is made of minors cases. We prefer to use URS in those cases of distal ureteral lithiasis, as compared to ECL, because of its level of efficacy (higher than or equal to ECL), low cost/benefit ratio, low morbidity and shorter hospital stay involved. The paper emphasizes the major diagnostic and therapeutical indications for URS, and finally, it is noted that URS can avoid undertaking other more aggressive urinary by-passes, since it allows to catheterize the ureters where a false intramural route is conducted.

Transurethral puncture of ectopic ureteroceles in neonates and infants

Ten neonates and infants with 11 ectopic ureteroceles prospectively underwent transurethral puncture as the primary form of therapy. Of the 10 patients 6 had a prenatal diagnosis of uropathy and 4 presented postnatally with urinary tract infection. One patient had bilateral single system ectopic ureteroceles and 9 had a single ectopic ureterocele in a duplex system. Significant associated ipsilateral and/or contralateral urological pathology was noted in addition to the ectopic ureterocele in 7 patients. Transurethral puncture adequately decompressed 10 of the 11 ectopic ureteroceles (91%) and improved drainage of nonureterocele moieties in 3 cases. Iatrogenic reflux was found in 3 of the 11 ureterocele ureters. Urinary tract infection developed in 6 infants (4 with fever). Of the 10 patients 8 (80%) eventually required secondary surgical intervention because of recurrent urinary tract infections, persistent or iatrogenic reflux, or unresolving hydronephrosis. Although transurethral puncture rarely constitutes definitive treatment for ectopic ureterocele, there appears to be immediate benefit in cases of bilateral hydronephrosis or significant ipsilateral lower pole hydronephrosis. Decompression of the ureterocele is reliably obtained but it seldom obviates the need for more definitive reconstruction.

Experience with duplex system anomalies detected by prenatal ultrasonography

We reviewed 39 neonates with prenatally diagnosed duplex system anomalies. Principal diagnoses were ureterocele in 15 patients, ureteral ectopia in 15, lower polar vesicoureteral reflux in 6, lower pole ureteropelvic junction stasis in 2 and yo-yo reflux in an incompletely duplicated system in 1. Several patients had other ipsilateral and contralateral urinary anomalies. Ten patients (26%) had relevant physical signs and only 1 became symptomatic, with urosepsis, neonatally. At initial assessment, before any accounted urinary tract infection, renal polar function as judged by radionuclide examinations almost always was severely impaired in the presence of major ureteral ectopia or severe reflux. By contrast, function was usually well preserved when there was obstruction, or lesser degrees of ectopia or reflux. A total of 19 patients underwent surgery (14 electively and 5 after episodes of urosepsis), while 20 have been managed nonoperatively for 12 to 84 months (mean 34) during which time the appearances and function of the upper renal tracts have remained stable. We conclude that the natural history of these anomalies is often benign and that a policy of routine surgical intervention, developed when most cases presented symptomatically, may not be appropriate in patients who present antenatally.

[Pyonephrosis on account of an ectopic ureterocele]

A case of isolated pyonephrosis on account of an ectopic ureterocele in a thirteen-month-old boy without bacteriuria is presented. The importance of early diagnosis and treatment is emphasized.

Endoscopic treatment of ureterocele and antireflux injection with Teflon paste

By referring to two cases, the author demonstrates the possibility of managing certain ureteroceles exclusively by endoscopic treatment. On one hand, by incising or resecting the ureterocele and, on the other hand, by suppressing the reflux thus created with a Teflon injection under the gaping ureterocele. The best indication for this method is the orthotopic ureterocele on a nondivided ureter, i.e. the ureterocele normally found in adults. It also seems possible to treat the orthotopic ureterocele on a duplex kidney in this way. On the contrary, the worst indications for this method are probably ectopic ureteroceles.

Two unusual duplication anomalies of the urinary tract: use of percutaneous urography

We performed suprapubic percutaneous urography in two patients to diagnose unusual duplication anomalies of the urinary tract, since preoperative diagnosis was unclear after routine noninvasive studies. In both patients standard suprapubic puncture technique was employed. The procedure was used to confirm the diagnosis of duplication of the bladder in one case and to establish the site of origin of a ureterocele in the other. The technique employed in suprapubic cystography may be extended to the diagnosis of unusual cystic abnormalities in the pelvis that may be of urinary tract origin.

Single system ureteroceles in childhood

Fifteen patients with single system ureterocele are reviewed (three bilateral). There was an equal male: female incidence and the majority presented with a urinary tract infection. Whereas pathology was usually confined to the ureterocele-bearing renal unit, in three patients there were other major urological abnormalities. The ureteroceles were best demonstrated by ultrasonography or intravenous pyelography but the latter proved to be more sensitive, probably because there usually was sufficient function in the involved kidney. Surgical management consisted of excision of the ureterocele with ureteric reimplantation in 10 patients (12 ureteroceles) and nephro-ureterectomy in two. Four ureteroceles in three patients were managed non-operatively. Overall results of surgery were satisfactory.

An entirely endoscopic treatment for simple ureteroceles in nonduplicated systems: a preliminary report

A case is reported of a large ureterocele associated with a single collecting system. The ureterocele caused frequent urinary retention and it was treated successfully by a staged endoscopic procedure, consisting of complete transurethral resection of the ureterocele followed by perimeatal polytetrafluoroethylene (Teflon) paste injections to prevent subsequent vesicoureteral reflux. This new approach of a combination of 2 endoscopic techniques proved to be useful in this case.

Ureteroscopy of the abnormal ureter

We do not contend that all ureters are amenable to ureteroscopic manipulation; we only call attention to the vast and expanding armamentarium available to the practicing endourologist. The application of these techniques and instruments in certain cases, especially when the potential for morbidity with an open operation is significant, will no doubt result in ever-increasing numbers of challenging ureters being managed successfully by the integration of antegrade and retrograde endourologic techniques. However, it should be remembered that the procedure is invasive and therefore should be performed by experienced endourologists for the proper indications.

[Complete ureteric duplication associated with ureterocele: two cases report]

Herein we report two cases of complete ureteric duplication associated with ureterocele. A 4-month-old girl with non-visualizing left kidney was hospitalized with complaints of cloudy urine and fever. An antegrade left pyelogram revealed a completely duplicated collecting system; a duplex tortuous ureter, and round radiolucent filling defect in the bladder. Under the diagnosis of completely duplicated ureter associated with the upper pole ureterocele, ureterocystoneostomy was performed. A circumferential incision was made around the base of the ureterocele and the Politano-Leadbetter technique was employed. Her postoperative course was uneventful. However, an excretory urogram showed a mild hydronephrotic upper pole. A 1-year and 4-month-old girl with the history of repeated urinary tract infections and fever attacks was admitted. The excretory urogram showed a left hydronephrotic lower pole with a "drooping flower" and no opacification of the upper pole. A radiolucent filling defect was seen in the bladder. A left antegrade pyelogram demonstrated the massively dilated upper pole with a hydroureter terminating in the ureterocele. Left heminephrectomy with partial ureterectomy was performed and left hydronephrosis and hydroureter with an atrophic kidney were seen. The postoperative course was uneventful.