What management is recommended for bilateral ureteroceles in a patient with a history of febrile Urinary Tract Infections (UTIs)?

Management of Bilateral Ureteroceles in a 62-Year-Old Woman with Febrile UTIs

Surgical intervention is recommended for bilateral ureteroceles in a 62-year-old woman with a history of febrile UTIs, as this represents a failure of conservative management and indicates the need for definitive treatment to prevent further infections and potential renal damage. 1

Assessment and Initial Management

• Diagnostic evaluation should include ultrasonography of the kidneys and bladder as the first-line imaging study to assess the ureteroceles, degree of hydronephrosis, and renal status 1
• Voiding cystourethrogram (VCUG) should be performed to evaluate for vesicoureteral reflux (VUR), which is commonly associated with ureteroceles 1
• Renal function assessment with serum creatinine and GFR measurement is essential to determine baseline kidney function 1
• DMSA scan should be considered to evaluate differential renal function and identify any cortical scarring from previous infections 1

Treatment Algorithm

Medical Management (Not Recommended as Primary Approach)

• Continuous antibiotic prophylaxis (CAP) alone is not recommended as the primary management for bilateral ureteroceles in an adult with recurrent febrile UTIs, as this represents failure of conservative management 1
• If surgical intervention must be delayed, temporary CAP with trimethoprim-sulfamethoxazole, amoxicillin, or nitrofurantoin at one-quarter to one-half the therapeutic dose can be considered 1

Surgical Management (Recommended)

1. First-line approach: Endoscopic decompression/incision of the ureteroceles

   • This is the least invasive option with shorter recovery time 2
   • Success rates for endoscopic treatment range from 50-92% 1
   • Particularly appropriate for intravesical ureteroceles 2

2. Second-line approach: Open surgical repair

   • Indicated if endoscopic treatment fails or is not appropriate due to complex anatomy 1
   • Options include ureterocele excision with ureteral reimplantation 3
   • Success rates for open surgical procedures approach 98% 1
   • More definitive but associated with higher morbidity 1

Post-Intervention Management

• Renal ultrasound should be performed following any surgical procedure to assess for obstruction 1
• Post-operative voiding cystography is recommended following endoscopic injection of bulking agents to confirm resolution of VUR 1
• Continued monitoring for recurrent UTIs is essential 2
• If VUR develops after endoscopic incision (occurs in approximately 41% of cases), it may be managed conservatively unless symptomatic UTIs occur 4

Special Considerations

• Bilateral ureteroceles are associated with higher risk of recurrent febrile UTIs compared to unilateral cases 1
• In adults, ureteroceles are more likely to present with complications such as recurrent UTIs, stones, or renal dysfunction 5
• The presence of febrile breakthrough UTIs despite prophylaxis is a clear indication for surgical intervention 1
• Caution is advised with bilateral surgical procedures due to the risk of transient urinary retention 1

Pitfalls to Avoid

• Delaying surgical intervention after multiple febrile UTIs can lead to irreversible renal damage 3
• Incomplete decompression of ureteroceles can result in persistent obstruction and recurrent infections 6
• Failure to address associated VUR may lead to ongoing infections even after ureterocele management 2
• Underestimating the complexity of bilateral cases, which require careful surgical planning 1

In summary, bilateral ureteroceles in a 62-year-old woman with a history of febrile UTIs require surgical intervention, with endoscopic decompression as the first-line approach, followed by open surgical repair if necessary. Conservative management with antibiotics alone is inadequate in this scenario and risks ongoing infections and renal damage.