What is the recommended treatment for a patient with a urocele?

Management of Ureterocele

Endoscopic puncture is the recommended first-line treatment for ureteroceles, especially for intravesical ureteroceles and as emergency treatment for infected or obstructing ureteroceles. 1

Diagnosis and Assessment

• Ureterocele is a cystic dilatation of the intravesical ureter, most commonly observed in females and children

• Classification:

  • Intravesical: completely contained inside the bladder
  • Extravesical/ectopic: part of the cyst extends to the urethra or bladder neck

• Initial diagnostic workup should include:

  • Ultrasound: primary screening tool for identification
  • Voiding cystourethrogram (VCUG): to detect vesicoureteral reflux (VUR)
  • 99m-technetium dimercapto-succinic acid renal scan: to evaluate function of different portions of the kidney 1

Treatment Algorithm

1. Emergency Situations

• For infected or obstructing ureteroceles: Endoscopic puncture as emergency therapy 1
• For ureteroceles causing bladder outlet obstruction: Immediate decompression via endoscopic approach

2. Elective Management Based on Type

Intravesical Ureteroceles

• First-line treatment: Endoscopic puncture/incision
  • Success rate: 77-93% without need for additional surgery 1, 2
  • Techniques: Cold knife incision, Bugbee electrode puncture, or stylet of ureteral catheter 2
• Follow-up: Monitor for VUR development (occurs in approximately 17.6% of cases) 2

Ectopic Ureteroceles

• First-line approach: Endoscopic puncture
  • Note: Higher reoperation rate (48-100%) compared to intravesical type 1
• Secondary procedures often needed:
  • Upper pole partial nephrectomy: For non-functioning upper pole moiety
  • Lower urinary tract reconstruction: For persistent VUR, breakthrough UTIs, or bladder outlet obstruction 3

3. Management Based on Associated Conditions

With Vesicoureteral Reflux (VUR)

• Pre-existing VUR to lower pole (occurs in ~50% of cases) 1
  • Monitor after endoscopic puncture as 40% resolve spontaneously 2
  • For persistent symptomatic VUR: Ureteric reimplantation or submucosal injection 2

With Duplex Collecting System (91% of cases)

• Assess upper pole function:
  • Functioning upper pole: Consider preservation
  • Non-functioning upper pole with recurrent UTIs: Consider partial nephrectomy 2

With Urinary Tract Infection

• Antibiotic prophylaxis for patients with persistent VUR
• Surgical intervention for breakthrough infections 3

Follow-up Protocol

• Regular ultrasound to assess decompression of ureterocele
• VCUG to monitor for new or persistent VUR
• Urine cultures for patients with history of UTIs
• Long-term follow-up recommended (mean follow-up in studies: 5-6 years) 2, 3

Outcomes and Complications

• Complete decompression achieved in 94% of cases after endoscopic puncture 2
• Potential complications:
  • Development of VUR to upper moiety (17.6% of cases)
  • Recurrent UTIs (20% in patients with ectopic ureterocele) 3
  • Voiding dysfunction (reported in some patients)

Special Considerations

• Adult ureteroceles are typically intravesical with single ureter system
• Treatment for adults often involves ureterocelectomy with ureteral reimplantation 4
• Bilateral ureteroceles require careful planning of surgical approach

The management of ureteroceles has evolved toward less invasive approaches, with endoscopic techniques showing good long-term results, particularly for intravesical ureteroceles. However, ectopic ureteroceles often require more complex management with higher rates of secondary procedures.