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Ureterocele
Ureterocele
TERMINOLOGY • Congenital cystic dilation of distal submucosal portion of 1 or both ureters within urinary bladder • Categorized according to ureterocele insertion ○ Orthotopic (simple): Orifice located in normal anatomic position in bladder trigone ○ Ectopic: Orifice located anywhere else • Categorized according to type of kidney drained ○ Single system vs. duplicated system with 2 ureters – 1 ureter of duplicated system must be ectopic • Weigert-Meyer rule: Ureter from upper pole (UP) moiety of duplicated kidney inserts inferior & medial to normal lower pole (LP) moiety insertion site at trigone
IMAGING • Round/ovoid filling defect in urinary bladder ○ Thin-walled & cystic-appearing on US, MRU – Wall appears thicker, collapsed after surgery • ± visualization of associated dilated distal ureter
• In duplicated system, UP moiety (associated with ureterocele) typically obstructs & LP moiety typically refluxes ○ Varying degrees of hydronephrosis & parenchymal dysplasia of UP moiety ○ Vesicoureteral reflux into LP moiety classically shows drooping lily sign – Due to rotation of LP system by obstructed UP
Genitourinary
KEY FACTS
CLINICAL ISSUES • Prenatal detection: Hydronephrosis typical • Postnatal presentation: Febrile UTI most common • Ectopic, extravesical variety > orthotopic, simple, intravesical variety by 3:1 ratio • Typical treatment: Endoscopic incision of ureterocele, especially if infected or obstructed in neonate • Prognosis: Excellent if nonobstructing & nonrefluxing; variable if prolonged obstruction or high-grade vesicoureteral reflux has compromised renal function
(Left) Longitudinal ultrasound of the urinary bladder in an 18 day old with prenatally detected hydronephrosis shows a large thin-walled cyst filling much of the bladder lumen, typical of a ureterocele. The cyst connects to a dilated distal left ureter . (Right) Longitudinal ultrasound of the duplicated left kidney in the same patient shows severe pelvocaliectasis & parenchymal thinning of the left upper pole (UP) moiety . The lower pole (LP) moiety shows mild pelvocaliectasis with more normal-appearing renal parenchyma .
(Left) Frontal early filling image from a VCUG in the same patient shows the ureterocele as a large ovoid filling defect ſt partially outlined by contrast in the urinary bladder. (Right) Postvoid VCUG in the same patient shows grade II-III vesicoureteral reflux into the LP collecting system . The drooping lily configuration of contrast within the LP strongly suggests obstruction of an UP moiety (as confirmed on the ultrasound). The UP ureterocele ſt remains visible in the contrast-filled bladder.
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TERMINOLOGY • Congenital cystic dilation of distal submucosal portion of 1 or both ureters within urinary bladder • Categorized according to ureterocele insertion ○ Orthotopic (simple): Orifice located in normal anatomic position in bladder trigone ○ Ectopic: Orifice located anywhere else • Categorized according to type of kidney drained ○ Single system vs. duplicated system with 2 ureters – 1 ureter of duplicated system must be ectopic • Weigert-Meyer rule: Ureter from upper pole (UP) moiety of duplicated kidney inserts inferior & medial to normal lower pole (LP) moiety insertion site at trigone
IMAGING • Round/ovoid filling defect in urinary bladder ○ Thin-walled & cystic-appearing on US, MRU – Wall appears thicker, collapsed after surgery • ± visualization of associated dilated distal ureter
• In duplicated system, UP moiety (associated with ureterocele) typically obstructs & LP moiety typically refluxes ○ Varying degrees of hydronephrosis & parenchymal dysplasia of UP moiety ○ Vesicoureteral reflux into LP moiety classically shows drooping lily sign – Due to rotation of LP system by obstructed UP
Genitourinary
KEY FACTS
CLINICAL ISSUES • Prenatal detection: Hydronephrosis typical • Postnatal presentation: Febrile UTI most common • Ectopic, extravesical variety > orthotopic, simple, intravesical variety by 3:1 ratio • Typical treatment: Endoscopic incision of ureterocele, especially if infected or obstructed in neonate • Prognosis: Excellent if nonobstructing & nonrefluxing; variable if prolonged obstruction or high-grade vesicoureteral reflux has compromised renal function
(Left) Longitudinal ultrasound of the urinary bladder in an 18 day old with prenatally detected hydronephrosis shows a large thin-walled cyst filling much of the bladder lumen, typical of a ureterocele. The cyst connects to a dilated distal left ureter . (Right) Longitudinal ultrasound of the duplicated left kidney in the same patient shows severe pelvocaliectasis & parenchymal thinning of the left upper pole (UP) moiety . The lower pole (LP) moiety shows mild pelvocaliectasis with more normal-appearing renal parenchyma .
(Left) Frontal early filling image from a VCUG in the same patient shows the ureterocele as a large ovoid filling defect ſt partially outlined by contrast in the urinary bladder. (Right) Postvoid VCUG in the same patient shows grade II-III vesicoureteral reflux into the LP collecting system . The drooping lily configuration of contrast within the LP strongly suggests obstruction of an UP moiety (as confirmed on the ultrasound). The UP ureterocele ſt remains visible in the contrast-filled bladder.
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