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Pediatric – Ureterocele

Normally, we are born with a pair of ureters which connect the individual kidneys to the bladder for passing urine. However, there are times when the portion of the ureter nearest to the bladder becomes obstructed and affects the normal flow of urine. This condition is called as ‘Ureterocele’. Today, there are a large number of diagnostic methods and medical treatments useful for correcting this abnormality in the ureter.


What happens under normal conditions?

The kidneys are responsible for filtering out toxins and wastewater from the blood stream which is passed on to the bladder for expulsion from the body. The urine is passed from the kidney to the bladder through the ureters. Under normal conditions, a one-way flap valve controls the flow or urine from the kidney to the bladder and also prevents the urine from flowing back into the kidney (called ‘vesicoureteral reflux’). According to research studies, 1 out of every 125 persons has a couple of ureters that help to drain urine from the kidney one is attached to the upper portion while the other is attached to the lower portion of the kidney. As long as both ureters attached to the same kidney work without interruption the kidney filters and passes out the urine effectively. The ureter continues from the lower portion of the bladder to the urethral opening (penis in men and the vagina in women).


What is a Ureterocele?

Ureterocele is a congenital (birth) defect which affects the person’s bladder, ureter and kidney. Ureter causes the ureter part nearest to the bladder to swell up due to the abnormally small size of the ureter opening into the bladder, which in turn, affects normal flow of urine. Around 1 person in every 2,000 individuals is deemed to be affected by Ureterocele around the world. When the urine is not able to pass into the bladder, it reverses its flow in some cases. When there are two ureters serving a single kidney in women, around 90% of them suffer from an obstruction in the ureter connecting the upper portion of the kidney. In men, this condition is seen affecting almost half of such individuals.

Ureteroceles may be ‘ectopic’, with a portion protruding into the bladder opening or they may be ‘orthotopic’ where it remains inside the bladder only. Around 5-10% of Ureterocele cases are seen affecting both kidneys (bilateral). Mostly, Ureteroceles are diagnosed in children within the first two years after birth however it is also detected in older children and adults as well.


What are the complications of a Ureterocele?

Ureterocele puts the patient at risk of kidney infections. Reverse of urine flow (vesicoureteral reflux) is also seen in many cases, mostly when the patient has dual ureters connected to the kidney, as it affects the natural one-way valve of the ureter and bladder. Reflux of urine into the other kidney is also commonly seen in case of Ureterocele.

Rarely a Ureterocele may also make passing kidney stones troublesome. The Ureterocele can also grow to abnormally large size and obstruct the flow of urine completely from the bladder to the urethra. In some cases, women may suffer from Ureterocele which descends abnormally low and protrude from the opening of the urethra.


What are some symptoms of Ureterocele?

Normally, a Ureterocele may not exhibit any symptoms. Although, the patient may experience back pain or pain in the flanks along with urinary tract infection (UTI), painful urination, odorous urine, hematuria (blood in urine) apart from excessive urination and fever as well.


How is a Ureterocele diagnosed?

Ureteroceles are usually detected during a maternal ultrasound before child birth. However, it may also be diagnosed if the patient is being tested for urinary tract infection (UTI).

There are several imaging tests performed to determine the severity and location of the Ureterocele. Ultra-sonography, VCUG (Voiding Cystourethrogram) – type of x-ray imaging test of the bladder and lower urinary tract is also helpful in such cases. It is also essential to determine the level of function in the kidney in the person affected with Ureterocele which is mostly done with a renal scan.

Abdominal CT (Computerized Tomography) scans are also performed along with MRI (Magnetic Resonance Imaging) tests in this case.


What are some treatment options?

The exact treatment method is mainly based on several factors, such as the age of the patient, the level of functioning remaining in the affected kidney and if the flow of urine is reversed (development of vesicoureteral reflux). In certain cases, multiple treatment methods may be required however there are rare cases that do not require treatment at all.

As Ureterocele increases the risk of kidney infection, the doctor may prescribe antibiotics till the complications from the Ureterocele are treated effectively.

These are the treatment options recommended by doctor for treating Ureterocele:


Transurethral puncture

This is a minimally invasive surgical procedure which is useful for puncturing and decompressing the swollen part of the ureter using a cystoscope which is inserted through the urethra. This procedure is usually performed in 15 to 30 minutes and is mostly an outpatient procedure.

In case the Ureterocele wall is thick the treatment becomes difficult. This surgical treatment does not require making any incisions.
There are certain risks that are seen in some cases, such as inability to decompress the Ureterocele properly which may result in the urine to flow into the Ureterocele and need a surgical operation. Apart from this, there is also the risk of causing an obstruction to the flap valve which poses difficulties while urinating.


Upper pole Nephrectomy

In case the upper half portion of the kidney is affected by Ureterocele but there is no vesicoureteral reflux seen, the doctor may recommend removing the affected portion of that kidney. In such cases, the surgery is performed using a small incision under the rib cage. This is also done using minimally invasive laparoscopic method.


Nephrectomy

In case the kidney is affected completely and is not functioning optimally due to the Ureterocele, then the doctor will recommend removing the affected kidney entirely using a minimally invasive (laparoscopic) surgical procedure through the rib cage.


Removal of Ureterocele and Ureteral re-implantation

In case the doctor considers it vital to remove the Ureterocele completely then a conventional and comparatively longer surgical procedure is required. In this, the bladder is opened to remove the Ureterocele. Later on, the bladder floor and the bladder neck are reconstructed and the ureters are re-implanted in a manner which avoids reflux (back-flow) of urine between the ureters and the bladder. This surgery requires making a small incision in the lower abdominal region. This surgery carries a success rate of around 90 to 95%. Risks include obstruction or vesicoureteral reflux in rare cases.


Ureteropyelostomy or upper-to-lower ureteroureterostomy

In case the upper part of the ureter remains functional sufficiently the doctor may choose to connect the obstructed upper part of the ureter to the open lower part of the ureter or kidney. This surgical procedure is performed through a small incision in the lower abdomen and carries a success rate of around 95%.


Frequently asked questions

Is there any way to prevent this condition?

As this is a developmental defect which affects in the fetal stage there is no known preventive measure against it.


My baby was diagnosed with a Ureterocele on a prenatal ultrasound. She seems very healthy. Is it absolutely necessary for her to undergo treatment?

Usually, Ureterocele in small children are detected during a testing for kidney infection, which calls for hospitalization and administering antibiotics intravenously. However, there is a risk of urinary tract infection in case the Ureterocele is left untreated.


My doctor has recommended that my daughter take antibiotic prophylaxis because she has a Ureterocele and urinary reflux. Is it safe to take antibiotics every day?

Low dosage of daily antibiotics is recommended for children and adults to prevent urinary tract infections. This is a tried-and-tested method which has proven effective in the past on the condition that the dosage in 1/4th or ½ of the full dose. Although there are certain complications from using antibiotics regularly these are less risky than kidney infection.


My child was diagnosed with a Ureterocele and it was punctured through a small scope. Now there is reflux into the Ureterocele and the lower part of the kidney also. Will more surgery be necessary?

In cases where reflux to the ureter is seen in the lower part of the kidney and/or the Ureterocele itself, doctors usually recommend removing the Ureterocele and ureteral re-implantation is also essential in such cases.

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