Initial Management of Ureterocele
The initial management of ureterocele should begin with renal ultrasound to assess upper tract anatomy and function, followed by voiding cystourethrography (VCUG) to detect vesicoureteral reflux, and then proceed with endoscopic puncture or incision as the primary therapeutic intervention for most cases. 1, 2
Diagnostic Workup
Essential Imaging Studies
Renal ultrasound is the first-line imaging modality to identify the ureterocele, assess for hydronephrosis, evaluate kidney structure (particularly in duplex systems where ureteroceles typically affect the upper moiety), and determine the presence of complete pyeloureteral duplication 1, 3
VCUG must be performed to detect vesicoureteral reflux, which occurs in approximately 50% of cases in the ipsilateral lower pole and 25% in the contralateral kidney 1
99m-technetium dimercaptosuccinic acid (DMSA) renal scan is mandatory to evaluate differential function of the upper and lower pole moieties in duplex systems, as 75% present with very poorly functioning upper poles and 14% with nonfunctioning upper poles 1, 2
Clinical Presentation to Assess
Look specifically for febrile urinary tract infection, which is the most common postnatal presentation 1
Assess for obstructive symptoms, as ureteroceles can rarely prolapse and acutely obstruct the bladder outlet 1
Obtain urine culture if infection is suspected, as this will guide antibiotic therapy before any intervention 4
Initial Therapeutic Approach
Endoscopic Puncture as First-Line Treatment
Endoscopic puncture or incision of the ureterocele should be performed as the initial therapeutic intervention for both emergency situations (infected or obstructing ureteroceles) and elective treatment, particularly for intravesical ureteroceles 1, 2
Complete decompression is achieved in 94% of cases with endoscopic puncture 2
The procedure can be performed using cold knife incision, 3-French Bugbee electrode puncture, or stylet of a 3-French ureteral catheter 2
This minimally invasive approach avoids major surgery in the majority of cases even with long-term follow-up (mean 6.1 years) 2
Stratification by Ureterocele Type
For intravesical ureteroceles:
- Endoscopic puncture is highly effective with reoperation rates of only 7-23% 1
- This should be the definitive initial treatment in most cases 1, 2
For ectopic ureteroceles:
- Endoscopic puncture remains appropriate as initial management, though reoperation rates are higher (48-100%) 1
- Anticipate potential need for secondary bladder-level surgery involving ureterocele removal and ureteral reimplantation, especially if vesicoureteral reflux is present 1, 5
Post-Intervention Monitoring
Expected Outcomes After Endoscopic Puncture
Spontaneous resolution of lower pole VUR occurs in 40% of patients following ureterocele puncture 2
New-onset VUR to the upper moiety develops in approximately 17.6% of cases after puncture 2
Upper pole function typically remains stable or improves; deterioration should not occur 2
Indications for Secondary Surgery
Secondary procedures are required when:
Persistent VUR to the lower pole with recurrent UTI occurs (30% of patients with initial VUR) - managed with ureteral reimplantation or submucosal injection 2
Nonfunctional upper pole with symptomatic UTI despite complete ureterocele collapse - requires partial nephrectomy 2
Bladder outlet obstruction from collapsed ureterocele wall persists - necessitates lower urinary tract reconstruction 5
Critical Pitfalls to Avoid
Do not perform upper pole partial nephrectomy as initial treatment unless dealing with a nonfunctioning upper pole in a single system with severe symptoms, as this frequently requires additional bladder-level surgery (reoperation rate 15-100% depending on presence of VUR) 1
Do not delay treatment in infected or obstructing ureteroceles, as endoscopic puncture provides rapid decompression and is appropriate for emergency management 1, 2
Do not assume simple puncture will be definitive for ectopic ureteroceles with preexisting VUR - counsel families that secondary bladder reconstruction should be anticipated in 50-100% of these cases 1, 5
Monitor for voiding dysfunction postoperatively, as bladder outlet pathology may persist and require lower urinary tract reconstruction 5