How do I manage a patient with a ureterocele (a cystic dilation of the terminal ureter) diagnosed on ultrasound who is seeking fertility treatment?

Management of Ureterocele in a Patient Seeking Fertility Treatment

In an adult patient seeking fertility treatment with an incidentally discovered ureterocele on ultrasound, management depends entirely on whether the ureterocele is symptomatic or causing obstruction—asymptomatic ureteroceles require no intervention before fertility treatment, while symptomatic cases need endoscopic puncture or surgical correction first.

Initial Diagnostic Assessment

When a ureterocele is identified on ultrasound in a fertility patient, complete the following workup:

Essential Imaging and Studies

• Confirm ureterocele characteristics with transvaginal ultrasound, which can demonstrate the cystic dilation of the terminal ureter and assess for associated findings 1
• Perform voiding cystourethrography (VCUG) to detect vesicoureteral reflux (VUR), which occurs in 50% of cases in the ipsilateral lower pole and 25% in the contralateral kidney 2
• Obtain renal function assessment with 99m-technetium dimercaptosuccinic acid (DMSA) scan to evaluate differential kidney function 2
• Color Doppler sonography with spectral analysis can provide additional information about urinary flow dynamics and help determine if obstruction is present 3

Classification That Guides Management

• Intravesical ureterocele: Completely contained within the bladder—better prognosis with lower reoperation rates 2, 4
• Ectopic ureterocele: Extends to the urethra or bladder neck—more challenging management with higher reoperation rates (48-100%) 2
• Associated with duplex system in 91% of cases versus single system in 9% 4

Management Algorithm Based on Clinical Presentation

Asymptomatic Ureterocele (Incidental Finding)

No intervention is required before proceeding with fertility treatment if:

• No history of recurrent urinary tract infections 2, 5
• No evidence of obstruction on imaging 2
• Normal renal function bilaterally 2
• No vesicoureteral reflux detected 2

Proceed directly with fertility treatment while maintaining surveillance with:

• Annual renal ultrasound to monitor for changes 5
• Prompt evaluation if symptoms develop 6

Symptomatic Ureterocele Requiring Treatment

Endoscopic puncture is the first-line treatment for symptomatic ureteroceles before fertility treatment if the patient presents with:

• Recurrent febrile urinary tract infections (most common presentation) 2, 5
• Obstructive symptoms or hydronephrosis 2
• Abdominal/pelvic pain attributed to the ureterocele 6

Endoscopic puncture technique achieves complete decompression in 94% of cases with:

• Cold knife incision, Bugbee electrode puncture, or ureteral catheter stylet puncture 4
• Mean reoperation rate of 17.6% for intravesical ureteroceles versus 48-100% for ectopic ureteroceles 2, 4
• Preservation of renal function in all cases with potential for improvement 4

When Upper Pole Partial Nephrectomy Is Indicated

Consider upper pole partial nephrectomy as primary treatment only if:

• Ectopic ureterocele with nonfunctioning upper pole moiety (occurs in 14-75% of cases) 2, 4
• Recurrent symptomatic UTIs despite complete ureterocele decompression 4
• No preoperative vesicoureteral reflux (reoperation rate 15-20% versus 50-100% with VUR) 2

Critical Considerations for Fertility Treatment

Timing of Fertility Interventions

Complete urologic treatment before initiating fertility treatment if:

• Active urinary tract infection is present 2, 5
• Obstructive uropathy is causing progressive renal dysfunction 2
• Recurrent infections are occurring despite prophylactic antibiotics 4

Fertility treatment can proceed immediately after successful endoscopic puncture once:

• Ureterocele decompression is confirmed on follow-up ultrasound 4
• Urine culture is sterile 5
• Renal function is stable 4

Pregnancy Considerations

• Pregnancy itself does not worsen ureterocele but physiologic hydronephrosis of pregnancy may complicate imaging interpretation 1
• Maintain low threshold for treating UTIs during pregnancy given the underlying urologic abnormality 2
• Postpartum reassessment with ultrasound is recommended to evaluate for any changes 1

Common Pitfalls to Avoid

• Do not delay fertility treatment for asymptomatic, non-obstructing ureteroceles—these require no intervention 2, 4
• Do not perform upper pole nephrectomy as first-line treatment for intravesical ureteroceles—endoscopic puncture has 77-93% success rate 2, 4
• Do not assume all ureteroceles need surgery—many are incidental findings that remain asymptomatic throughout life 6
• Do not overlook contralateral kidney evaluation—25% have contralateral VUR requiring management 2
• Anticipate secondary bladder surgery (ureterocele excision with ureteral reimplantation) in 50-100% of ectopic ureteroceles with preoperative VUR 2

Specific Fertility Treatment Implications

Transvaginal ultrasound during fertility monitoring will continue to visualize the ureterocele, which should not be confused with ovarian pathology 1, 3

Hysterosalpingo-contrast sonography (HyCoSy) for tubal patency assessment can be performed safely in patients with treated ureteroceles 1

No contraindication exists for in vitro fertilization or other assisted reproductive techniques once symptomatic ureteroceles are treated and renal function is preserved 1