What is the treatment for ureteroceles (ureteral duplication cysts)?

Treatment of Ureteroceles

Endoscopic puncture or incision of the ureterocele is the recommended first-line treatment for most ureteroceles, as it is minimally invasive, effective, and avoids major surgery in the majority of cases with good long-term outcomes. 1, 2

Initial Management Approach

Diagnostic Evaluation

• Complete evaluation should include ultrasound of the kidney and bladder, voiding cystourethrogram (VCUG) to detect vesicoureteral reflux (VUR), and renal scan to evaluate differential kidney function 3
• Assessment of ureterocele type (intravesical vs. ectopic) and presence of renal duplication is crucial for treatment planning 3

Primary Treatment Options

Endoscopic Management

• Endoscopic puncture/incision is the preferred initial treatment for most ureteroceles 1, 2
  • For intravesical ureteroceles: Complete decompression achieved in up to 94% of cases 1
  • For ectopic ureteroceles: Effective as emergency treatment or primary therapy, though secondary procedures may be needed more frequently 3
• Techniques include:
  • Cold knife incision 1
  • Bugbee electrode puncture 1
  • Stylet of ureteral catheter for puncture 1
  • Laser incision (holmium/thulium) 4

Surgical Management

• Upper pole heminephrectomy:

  • Indicated for non-functioning upper pole moiety with recurrent UTIs despite successful ureterocele decompression 1, 3
  • Should only be performed after functional evaluation following ureterocele incision 5

• Lower urinary tract reconstruction:

  • Indicated for persistent VUR, breakthrough UTIs, or bladder outlet obstruction due to collapsed cele wall 6
  • Includes ureterocele excision, bladder neck reconstruction, and ureteral reimplantation 5, 6
  • Particularly important for ectopic ureteroceles to correct reflux and bladder outlet pathology 6

Management Based on Ureterocele Type

Intravesical Ureteroceles

• Endoscopic incision is highly effective as definitive treatment 3
• Lower reoperation rate (7-23%) compared to ectopic ureteroceles 3
• Follow-up should include ultrasound and VCUG to assess for VUR 1

Ectopic Ureteroceles

• Endoscopic incision is appropriate as emergency treatment 3
• Higher reoperation rate (48-100%) compared to intravesical ureteroceles 3
• Upper pole partial nephrectomy is recommended for non-functioning upper pole without preoperative VUR 3
• Secondary procedures at the bladder level should be anticipated, especially with preexisting VUR 3

Post-Treatment Considerations

Management of Vesicoureteral Reflux

• Pre-existing VUR to lower pole moiety may resolve spontaneously after ureterocele decompression (40% of cases) 1
• De novo VUR to upper pole moiety can develop after puncture (17.6% of cases) 1
• Options for persistent symptomatic VUR include:
  • Ureteral reimplantation 1
  • Submucosal injection of bulking agents 1
  • Prophylactic antibiotics while awaiting spontaneous resolution 1

Follow-up Protocol

• Regular ultrasound evaluation to confirm ureterocele decompression 2
• VCUG to assess for VUR 2
• Renal scan to monitor differential renal function 2
• Low-dose antibiotic prophylaxis until VCUG shows no reflux 2

Special Considerations

Complications to Monitor

• Persistent or recurrent urinary tract infections 6
• Voiding dysfunction 6
• Incomplete decompression requiring secondary puncture 1
• Development of new VUR 1, 2

Pediatric Considerations

• Majority of ureteroceles are diagnosed in utero or immediately after birth 3
• Conservative approach with endoscopic incision as primary treatment is supported by long-term outcomes 5
• Preservation of functional renal tissue should be prioritized whenever possible 5