Ureterocele is a defect of the ureter characterized by cystic expansion of its distal part and bulging into the bladder cavity. Pathology is accompanied by lower back pain, dysuric disorders, hematuria. Diagnosis includes ultrasound of the bladder and kidneys, excretory urography, cystography, cystoscopy. Treatment consists in dissecting the narrowed mouth of the ureter and removing the ureterocele, followed by ureteral reanastomosis; in some cases, partial or total nephrectomy is required.
Meaning
Ureterocele is an intravesical (ureterovesical) cyst of the distal ureter, in which the cyst–like expanded intravesical segment of the ureter prolapses into the bladder cavity. In practical urology, ureterocele occurs with a frequency of 2- 2.5%; at the same time, it is observed in girls 2-4 times more often than in boys. Usually the disease is diagnosed already in childhood, less often in adults. Pathology is often accompanied by doubling of the ureters.
Causes
In most cases, ureterocele is caused by congenital narrowing of the ureter’s mouth and elongation of its intramural segment due to a deficiency of muscle fibers in the distal ureter. According to researchers, this defect is associated with a violation of the innervation of the lower ureter and adjacent tissues. Acquired ureterocele develops more often due to infringement of the urinary stone in the intramural segment of the ureter.
Pathology is always accompanied by a violation of the outflow of urine from the ureter, an increase in hydrostatic pressure, overgrowth of the ureter wall and its bulging into the intravesical part of the urinary bladder. The ureterocele cavity is bounded by the walls of the ureter and the exfoliated wall of the bladder. Usually the cyst contains purulent urine, concretions; less often – watery or bloody contents.
Violation of the urinary process leads to stagnation of urine in the renal pelvis (hydronephrosis), microbial infection, the development of cystitis and pyelonephritis, the formation of urinary stones in the ureterocele, and subsequently to nephrosclerosis and loss of kidney function.
Classification
The ureterocele can be unilateral or bilateral (bilateral), located in both ureters. There are simple ureterocele (in a normally located ureter), prolapsing and ectopic. Prolapsing (falling out) ureterocele in girls can exit through the urethra to the outside in the form of a dark purple formation, often covered with ulcerated mucous membrane.
Prolapsing ureterovesical cyst in boys falls into the prostatic part of the urethra, causing acute urinary retention. Ectopic ureterocele is localized in an atypically located ureter that opens into the urethra, the vestibule of the vagina, the diverticulum of the bladder, etc. Sometimes there is a blindly ending ureterocele.
According to the etiology, the disease can be primary (congenital) or secondary (acquired). There are 3 degrees of congenital pathology. At grade 1, there is a slight expansion of the intravesical ureter, which does not lead to functional changes in the upper urinary tract. The ureterocele of the 2nd degree is large and leads to the development of ureterohydronephrosis. At grade 3, in addition to ureterohydronephrosis, there are significant violations of the function of the bladder.
Symptoms
The main manifestations of the disease are pain syndrome and violation of the nature of urination. A large-volume ureterocele can occupy a significant part of the bladder and limit its volume, accompanied by increased urination and urine excretion in small portions. In the case of overlapping with such a protrusion of the mouth of another ureter, a total violation of the outflow of urine from the kidneys develops – acute hydronephrosis, manifested by paroxysmal pains of the type of renal colic. In women, when the ureterocele is lowered into the urethra, complete urinary retention may develop.
Complications
A complication of the ureterocele in women may be its prolapse with an exit to the outside when trying to urinate. The loss of the ureterocele is intermittent and is corrected independently. In some cases, a fallen cyst may be pinched in the urethra and necrotic. Patients have persistent recurrent infections (chronic cystitis and pyelonephritis), accompanied by pyuria, fever, painful urination with foul-smelling urine, sometimes hematuria.
Diagnostics
Ureterocele is usually detected by a urologist during an extended urological examination for recurrent urinary tract infections. In general urine tests, as a rule, leukocytes, pus, and erythrocytes are detected. Bacteriological examination of urine reveals the microflora characteristic of urinary infections. Ultrasound of the bladder allows you to visualize the ureterocele in the form of a rounded thin-walled liquid formation bulging on the wall of the bladder. Ultrasound of the kidneys reveals a one- or two-sided hydronephrotic transformation of the organ.
With the help of radiation studies (cystography and intravenous urography), it is possible to obtain a clear X-ray picture of the ureterocele. Radiographs determine the presence of vesicoureteral reflux into the adjacent and opposite ureter, a defect in the filling of the bladder, a club-shaped expansion (sometimes ectopia) of the distal segment of the ureter. Reliable detection of ureterocele and examination is performed during cystoscopy. During endoscopic examination, the formation has the form of a cystic protrusion of the intravesical part of the ureter with a narrowed mouth.
Treatment
The treatment of pathology can only be surgical – reconstructive or oral. Before the operation, antimicrobial therapy is performed, aimed at relieving urinary tract infection. With a non-functioning kidney or part of it, nephrectomy or partial nephrectomy with excision of the ureterocele and reimplantation of the upper segment of the ureter into the pelvis, and the lower segment into the bladder (ureterocystoanastomosis) is indicated.
With preserved kidney functions, endoscopic dissection of the ureterocele is performed with the formation of the ureteral mouth according to the antireflux technique. Transurethral endoscopic dissection of the mouth leads only to the elimination of ureteral obstruction, but does not eliminate the ureterocele itself. Complications of surgical treatment are usually associated with the development of vesicoureteral reflux, bleeding, exacerbation of pyelonephritis, scarring of anastomoses.