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CASE REPORT
Year : 2020  |  Volume : 47  |  Issue : 3  |  Page : 185-187

Giant ureterocele management in an adult male: A rare case report


1 Department of Urology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
2 Department of Radiology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
3 Department of Anaesthiology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
4 Department of Pulmonology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India

Date of Submission19-Apr-2020
Date of Acceptance12-Sep-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. G Ajay Kumar
Department of Urology, Sentini Hospitals, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_28_20

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  Abstract 


Ureterocele is dilatation of lower ureter at its entry into the urinary bladder. It is classified into the single or duplex system and acquired or congenital. Acquired type is rare and seen in adults. We report the case of a 23-year-old male presented with voiding lower urinary tract symptoms and intermittent flank pain. He had a history of frequent spontaneous stone passage with right colicky pain 2 years back. On ultrasonogram and magnetic resonance urogram, diagnosis was made as right renal hydronephrosis with hydroureter due to right side giant intravesical ureterocele. The patient was managed by endoscopic transurethral incision and excision of ureterocele. It is the first case ever reported in the literature, where in giant ureterocele was completely removed by total endoscopic approach.

Keywords: Bladder, ureterocele, voiding lower urinary tract symptoms


How to cite this article:
Kumar G A, Babu B S, Lavakumar A, Sindhuri A. Giant ureterocele management in an adult male: A rare case report. J Sci Soc 2020;47:185-7

How to cite this URL:
Kumar G A, Babu B S, Lavakumar A, Sindhuri A. Giant ureterocele management in an adult male: A rare case report. J Sci Soc [serial online] 2020 [cited 2021 Mar 7];47:185-7. Available from: https://www.jscisociety.com/text.asp?2020/47/3/185/307595




  Introduction Top


Ureteroceles may present both diagnostic and treatment challenges, particularly among urologists. The diagnosis of ureterocele may be obvious, but at times, it is less clear and is then only diagnosed with a high index of suspicion. The management of ureterocele varies according to its effects on obstruction, reflux, continence, and renal function. Therefore, it is imperative for the urologist to be aware of the variable clinical and radiological presentations and treatment options of ureterocele to yield the best possible results. Ureterocele is a cystic dilatation of the terminal portion of the ureter that is located inside the bladder or the urethra, or both. Its incidence at autopsy is 1:500; it affects women more than men, with a 6:1 ratio.[1],[2],[3] In our environment, it has a frequency of 7 out of every 10 million children under the age of 6 years.[4] It is a congenital pathology that has been attributed to the delayed rupture of the Chwalla membrane that divided the Wolffian duct from the urogenital sinus at the time the ureteral sac was forming during embryonic development.[5]

Acquired type is rare, seen in adults and associated with other lower ureteric pathologies. Endoscopic incision of ureterocele relieves the obstruction and preserve the renal function. Open surgery is reserved for failed cases.[6]


  Case Report Top


A 23-year-old male presented to our urology OPD services with chief complaints of severe obstructive symptoms, suprapubic discomfort, and right-sided loin pain. He had a history of frequent spontaneous stone passage with right colicky pain 2 years back. No other significant past history was noted. On examination, his vitals were stable; the abdomen was soft with no tenderness in the right renal angle, and external genitalia were normal. His laboratory investigations, including renal function tests, were within normal range. Uroflowmetry showed prolonged voiding and poor flow suggesting obstruction. Abdominal ultrasonogram and magnetic resonance (MR) urogram-coronal and sagittal views, showed bilateral single system with right hydroureteronephrosis, mid tortuous ureter, and delayed function with a balloon like large intravesical swelling (7 cm × 6 cm) at right vesicoureteric junction [Figure 1]a and [Figure 1]b. Left renal unit was normal functioning.
Figure 1: (a) Magnetic resonance urogram-coronal view, showing bilateral single system with right hydroureteronephrosis, mid tortuous ureter and delayed function with a balloon like large intravesical swelling (7 cm × 6 cm) at right vesicoureteric junction. (b) Magnetic resonance urogram-sagittal view, showing bilateral single system with right hydroureteronephrosis, mid tortuous ureter and delayed function with a balloon like large intravesical swelling (7 cm × 6 cm) at right vesicoureteric junction. (c) Cystoscopy showing intravesical right sided giant ureterocele obstructing the urinary bladder neck with stenotic opening. (d) Transeurethral endoscopic incision and excision. (e) Specimen showing intoto ureterocele

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Cystoscopy showed intravesical right-sided giant ureterocele obstructing the urinary bladder neck with stenotic opening [Figure 1c]. The patient was treated by transeurethral endoscopic incision and excision [Figure 1d] with removal of intoto ureterocele completely [Figure 1e] by endoscopy and discharged uneventfully. On follow-up at 1 year, the patient is asymptomatic with normal urinary flow and on radiologic imaging mild hydronephrosis with no vesicoureteral reflux.


  Discussion Top


The endoscopic transurethral approach is the minimally invasive method for treating ureterocele; its effectiveness in resolving impaired urinary flow is reportedly 76'–100', the occurrence of de novo? VUR in the punctured moiety is between 10'–75', and its effectiveness as a single-stage treatment is around 15'–90'.[7],[8],[9],[10],[11],[12],[13],[14] Such variability may be a result both of technical aspects of the procedure or patient selection. For the former, currently, it is well-established that the incision should be made at the junction between the ureterocele and the bladder wall to create a flap mechanism that avoids reflux after decompression. Creating a small opening seems to be another crucial factor to prevent reflux, but it also increases the risk of unsatisfactory ureteric decompression. The Bugbee electrode, ureteric catheter stylet wire, Collin knife and laser, either puncturing or incising the ureterocele have all been used.[7],[9],[13],[15],[16] We adopted the Collins knife to create a 2–4 mm wide low opening in the ureterocele. This allowed successful decompression in 98' of cases, whereas iatrogenic VUR appeared in 13 of 41 patients (32'). Notably, the same incision was used in both ectopic or intravesical ureteroceles, and the de novo reflux rate in the punctured moiety was no different in the two groups. In contrast to an initial report,[9] opening the ureterocele portion encroaching on or beyond the bladder neck is no longer advised.[11] Indeed, it only increases the risk of later reflux in the punctured moiety.

Transurethral endoscopic incisions of ureterocele relieve the obstruction and preserve the renal function in most cases. Decision regarding further treatment such as re-implantation for reflux and nephrectomy in case of dysplastic or nonfunctioning kidneys may require.[17],[18] In our case, renal function was intact and obstruction was removed, no further intervention was required. Because of rarity of the presentation and diagnosis of the condition, urologist needs to be aware of etiology and appearance. Treatment options depend on the extension of the ureterocele, obstruction to draining system and its complications.[19]


  Conclusion Top


Management of ureterocele by endoscopic incision is the standard approach in most of the cases. However, removing it completely by endoscopy is challenging in giant ureterocele without resection, as it needs a great expertise. Here, in our case, it was removed completely by endoscopic resection intoto, which is first of its kind reported in the literature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Churchill BM, Sheldon CA, McLorie GA. The ectopic ureterocele: A proposed practical classification based on renal unit jeopardy. J Pediatr Surg 1992;27:497-500.  Back to cited text no. 1
    
2.
Monfort G, Guys JM, Coquet M, Roth K, Louis C, Bocciardi A. Surgical management of duplex ureteroceles. J Pediatr Surg 1992;27:634-8.  Back to cited text no. 2
    
3.
Di Benedetto V, Morrison-Lacombe G, Bagnara V, Monfort G. Transurethral puncture of ureterocele associated with single collecting system in neonates. J Pediatr Surg 1997;32:1325-7.  Back to cited text no. 3
    
4.
Alvarado GR, Gallego GJ, Garcia AG. Ureterocele en niños. Cir Cir 2004;72:117-20.  Back to cited text no. 4
    
5.
Reyna-Pérez R, Almanza-González M, Castell-Cancino HR, et al. Ureterocele en el adulto. Rev Mex Urol 1994;54:40-4.  Back to cited text no. 5
    
6.
Coplen DE, Duckett JW. The modern approach to ureteroceles. J Urol 1995;153:166-71.  Back to cited text no. 6
    
7.
Blyth B, Passerini-Glazel G, Camuffo C, Snyder HM 3rd, Duckett JW. Endoscopic incision of ureteroceles: Intravesical versus ectopic. J Urol 1993;149:556-8.  Back to cited text no. 7
    
8.
Cooper CS, Passerini-Glazel G, Hutcheson JC, Iafrate M, Camuffo C, Milani H, et al. Long-term followup of endoscopic incision of ureteroceles: Intravesical versus ectopic. J Urol 2000;164:1097-9.  Back to cited text no. 8
    
9.
Jelloul J, Berger D, Frey P. Endoscopic management of ureterocele in children. Eur Urol 1997;32:321-4.  Back to cited text no. 9
    
10.
Jayanthi VR, Koff SA. Long-term outcome of transurethral puncture of ectopic ureteroceles: Initial success and late problems. J Urol 1999;162:1077-80.  Back to cited text no. 10
    
11.
Hagg MJ, Mourachov PV, Snyder HM, Canning DA, Kennedy WA, Zderic SA, et al. The modern endoscopic approach to ureterocele. J Urol 2000;163:940-3.  Back to cited text no. 11
    
12.
Chertin B, de Caluwé D, Puri P. Is primary endoscopic puncture of ureterocele a long-term effective procedure? J Pediatr Surg 2003;38:116-9.  Back to cited text no. 12
    
13.
Marr L, Skoog SJ. Laser incision of ureterocele in the pediatric patient. J Urol 2002;167:280-2.  Back to cited text no. 13
    
14.
Chertin B, Fridmans A, Hadas-Halpren I, Farkas A. Endoscopic puncture of ureterocele as a minimally invasive and effective long-term procedure in children. Eur Urol 2001;39:332-6.  Back to cited text no. 14
    
15.
Coplen DE, Duckett JW. The modern approach to ureteroceles. J Urol 1995;153:166-71.  Back to cited text no. 15
    
16.
Husmann D, Strand B, Ewalt D, Clement M, Kramer S, Allen T. Management of ectopic ureterocele associated with renal duplication: A comparison of partial nephrectomy and endoscopic decompression. J Urol 1999;162:1406-9.  Back to cited text no. 16
    
17.
Coplen DE, Duckett JW. The modern approach to ureteroceles. J Urol 1995;153:166-71.  Back to cited text no. 17
    
18.
Conlin MJ, Skoog SJ, Tank ES. Current management of ureteroceles. Urology 1995;45:357-62.  Back to cited text no. 18
    
19.
Byun E, Merguerian PA. A meta-analysis of surgical practice pattern in endoscopic management of ureteroceles. J Urol 2006;176:1871-7.  Back to cited text no. 19
    


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