Ureterocele

URETEROCELE DAMON A. BROWN

Jackson Clinic, Madison, Wisconsin Received for publication September 9, 1926

Ureterocele, the subject of this paper, was considered a rarity in pre-cystoscopic days. Although it is now recognized as a not unusual condition, the subject is still obscured by failure of urologists to agree on a definite descriptive term. Among the terms employed to describe this condition are such names as intravesical dilatation of the ureter, prolapse of the ureter, intravesical and uretero-vesical cyst, hernia of the ureter, and ureterocele. Ureterocele should be preferred to all others, as it has the advantage of brevity and most accurately describes the condition. ETIOLOGY

Petillo has very satisfactorily explained the genesis of ureterocele as a sequel to functional disturbance of ureteral peristalsis. Impairment of the peripheral nervous elements controlling the muscular activity of the ureteral wall results in pronounced weakening or complete paralysis of the segment distal to the mJury. Such damage may be produced by an inflammatory process of the seminal vesicles of the male or the pelvic adnexa of the female. White and Gradwohl have shown the relationship of vesiculitis to ureteritis. The association of pelvic infection in the female with peri-ureteritis or ureteritis is also above conjecture. Moreover, the intramural portion of the ureter is weakened by division of the longitudinal fibers which go to form the inter-ureteral ridge and lateral limit of the trigone. This atony, which follows paralysis of ureteral function, plus a small ureteral orifice supply the two causative agents necessary to the production of a ureterocele. In practically every case of true ureterocele the orifice is only a punctiform opening 363

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which may not admit even the smallest size catheter. It should not be concluded, however, that a small opening is a pathologic condition contributing to the formation of ureterocele. Tiny orifices are seen every day in urologic practice and should be

FIG. 1. THE CYS'l'OSCOPIC APPE.HL\.NCE OF THE URETEROCELE, Nor DISTENDED During the ballooning stage the cyst filled the lower fourth of the bladder and bulged into the vesical orifice. The left orifice and ve3ical mucosa were normal.

regarde(simply as variations of the normal. But if there is also atony of the intramural segment of the ureter, the small orifice, which is composed of bladder tissue and does not possess con-

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tractile power, acts like a drawn noose on the bag of the ureterocele. The theory of the congenital nature of ureterocele may be .seriously questioned, as practically all cases reported occurred in adult persons, and the condition has developed gradually and progressively. The symptoms cover a period of from a few weeks to two or three years. This would lead one to believe that ureterocele could develop quite rapidly following ureteral injury with atony of the intramural segment. DIAGNOSIS

There would seem to be no symptom-complex pathognomonic of ureterocele Analysis of the cases reported reveals symptoms of pain, irritable bladder associated with frequent and at times painful urination, intermittent hematuria, and pain simulating renal colic. Urinary findings may or may not be completely negative, as the condition cou.ld occur with cystitis or infection of the renal pelvis, or independent of any such infection. The patient reported herein had been previously examined and advised to have immediate nephrectomy. In addition to severe bladder pain, this patient had pain along the course of the right ureter simulating colic, and whether nephrectomy was advised merely because of the symptoms or to correct the true condition I do not know. Cases have been reported in which nephrectomy was performed for ureterocele. Cystoscopic examination alone makes the diagnosis. The glistening cystic tumor located at one or the other ureteral orifice and ballooning and retracting according to the influx of urine could not be mistaken for any other condition, such as edematous papillae the result of an impacted calculus, ureteral prolapse, or hernia. The location of the orifice would determine whether or not catheterization could be accomplished. In the case reported it was so situated as to be at no time visible. TREATMENT

The following methods have been employed in the treatment of ureterocele: (I) suprapubic cystotomy with excision of the

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cyst, (2) delivery of the cyst through the urethra by means of traction forceps and amputation, (3) intravesical slitting, which has been entirely unsuccessful, and (4) fulguration. Fulguration is by far the simplest, most rational and completely successful of the procedures.

Fm.

2.

SLIGHTLY DILATED, PATULous OrnncE Two WEEKS AFTER FuLGU HATIO~

REPORT OF CASE

Mrs. L. T., aged forty-two years, came to the Jackson Clinic May 4, 1926, because of lower lumbar backache, attacks of moderately severe shooting pains in the lower right abdomen simulating renal colic, and pain in the suprapubic region radiating to the external genitalia. The condition developed the previous January and became progressively

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worse. At first the patient experienced pain only when she voided, but later pain occurred every fifteen to thirty minutes and lasted from a few seconds to about half a minute. Frequency of urination gradually increased so that she voided every half hour or hour during the day and two or more times at night. Recently there was severe burning on urination. An attack of hematuria, lasting one day, occurred three weeks before she entered the Clinic. A large cystic ovary had been removed in 1906. She menstruated every three or four weeks, but at the onset of this illness there was no other menstrual irregularity. There had been three normal pregnancies and no miscarriages. Physical examination was negative except for a lacerated cervix and tenderness on palpation in the lower right quadrant and suprapubic regions. The blood pressure was 120 systolic and 68 diastolic; the pulse rate and temperature were normal. The urine was negative for pus, blood and albumin. A blood count showed hemoglobin 80 per cent and leucocytes 9600. X-ray of the kidneys, ureters and bladder was negative. Cystoscopic examination revealed a ureterocele on the right side which, when distended with influx of urine, filled about one-fourth of the bladder. The pain oi which the patient complained occurred with each dilatation of the cyst. The membrane of the bladder appeared normal. The right ureteral orifice could not be seen. The left ureter was catheterized with a Garceau catheter and clear urine, at normal rate of flow, was obtained. With the Garceau catheter in position, the bladder was emptied and 1 cc. of phenolsulphonephthalein was injected intravenously. The dye appeared from the left side in three minutes and within fifteen minutes 15 per cent was recovered. The specimen of catheterized urine from the bladder also contained 15 per cent of dye which indicated a normally functioning kidney. The cyst was thoroughly fulgurated and four days later ruptured with sudden and complete relief of pain. Examination two weeks later showed that the cyst had been entirely destroyed, leaving a slightly dilated, patulous ureteral orifice with normally functioning, noninfected kidney. In July the patient appeared to be completely well, had gained in weight and felt better than she had for several years. REFERENCES PETILLO, D.: Ureterocele: Clinical significance and process of formation. Surg ., Gynecol. and Obstet., 1925, xl, 811- 818. WHITE, E . W., AND GRADWOHL, R. B . H.: Seminal vesiculitis: Symptoma, differential diagnosis, treatment and bacteriological studies in one thousand cases. Jour. Urol., 1921, vi, 303- 320. THE JOURNAL OF UROLOGY, VOL. XVI, NO. 5