Diagnostic Ultrasound - Abdomen and Pelvis

Ureterocele
Diagnoses: Urinary Tract
Prolapsing Ureterocele: Vaginal Mass in Females
• Bladder diverticulum: Indistinguishable from everted
ureterocele
○ Sac formed by herniation of bladder mucosa, connects to
bladder cavity via neck
○ Does not return to intravesical position after micturition
• Gartner duct cyst: Cyst in vaginal wall
○ Transvaginal US defines origin
PATHOLOGY
General Features
• Etiology
○ Congenital anomaly
○ Simple type: Secondary to obstruction or stricture
(adults) at terminal ureter
• Associated abnormalities
○ Single system ectopic ureteroceles: Cardiac and genital
anomalies
○ Complete duplicated system: Commonly upper moiety
ureter associated with ureterocele
– Obstruction leading to hydronephrosis and
hydroureter
– Occasional dysplastic small upper pole moiety with
hydroureter
– Lower pole moiety ureter has orthotopic insertion
associated with hydronephrosis due to reflux
(Weigert-Meyer rule)
Staging, Grading, & Classification
• Orifice type: Stenotic, sphincteric, sphincterostenotic,
cecoureterocele
○ Sphincteric: Orifice distal to bladder neck
○ Cecoureterocele: Intravesical orifice; submucosal
extension to urethra
Gross Pathologic & Surgical Features
• Simple ureteroceles: Pinpoint orifices but no significant
obstruction
• Ectopic ureteroceles: Often obstructed, with dysplasia of
upper pole kidney
• Ureteric orifice, which is narrowed, usually opens at tip,
occasionally at base
• Sometimes portion of ureter extends distal to ureterocele
to open in ectopic position in bladder or urethra
Microscopic Features
• Thin wall: Covered by bladder mucosa and lined by ureteral
mucosa
• Less common: Mucosal layer only or mucosal and thin
muscularis layer
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Orthotopic: Usually asymptomatic; incidental finding
○ Ectopic ureteroceles: UTI, incontinence, vaginal mass
• Other signs/symptoms
○ Rarely, prolapse into bladder neck/urethra, causing
obstruction
• Clinical profile
○ Ectopic: Infant or child with UTI or sepsis
Demographics
• Age
○ Ectopic: Median age 3 months at diagnosis
– Often diagnosed with prenatal ultrasound
• Gender
○ Ectopic ureterocele with duplicated system M:F = 1:4
• Epidemiology
○ US: 1:12,000-1:5,000
Natural History & Prognosis
• Severe obstruction: Primarily ectopic ureteroceles
○ Dysplasia of obstructed upper pole moiety in complete
duplex system
Treatment
• Options, risks, complications
○ Obstructed ureteroceles may cause stasis and stone
formation
DIAGNOSTIC CHECKLIST
Consider
• Look for ureterocele in reasonably full bladder if duplex
renal system detected
• Big ureterocele may occupy the entire bladder mimicking
bladder itself, especially if bladder is empty
Image Interpretation Pearls
• Long axis of ectopic ureterocele points to side of origin
SELECTED REFERENCES
1. Adeb M et al: Magnetic resonance urography in evaluation of duplicated
renal collecting systems. Magn Reson Imaging Clin N Am. 21(4):717-30, 2013
2. Shebel HM et al: Cysts of the lower male genitourinary tract: embryologic
and anatomic considerations and differential diagnosis. Radiographics.
33(4):1125-43, 2013
3. Esfahani SA et al: Precise delineation of ureterocele anatomy: virtual
magnetic resonance cystoscopy. Abdom Imaging. 36(6):765-70, 2011
4. Taori K et al: Prolapsed simple ureterocele: evaluation by transvaginal
voiding sono-urethrography. J Clin Ultrasound. 39(9):544-7, 2011
5. Zougkas K et al: Assessment of obstruction in adult ureterocele by means of
color Doppler duplex sonography. Urol Int. 75(3):239-46, 2005
6. Bolduc S et al: The predictive value of diagnostic imaging for histological
lesions of the upper poles in duplex systems with ureteroceles. BJU Int.
91(7):678-82, 2003
7. do Nascimento H et al: Magnetic resonance in diagnosis of ureterocele. Int
Braz J Urol. 29(3):248-50, 2003
8. Shimoya K et al: Diagnosis of ureterocele with transvaginal sonography.
Gynecol Obstet Invest. 54(1):58-60, 2002
9. Madeb R et al: Evaluation of ureterocele with Doppler sonography. J Clin
Ultrasound. 28(8):425-9, 2000
10. Zerin JM et al: Single-system ureteroceles in infants and children: imaging
features. Pediatr Radiol. 30(3):139-46, 2000
11. Davidson AJ et al: Radiology of the kidney and genitourinary tract. 3rd ed.
Philadelphia, W.B. Saunders. 213-6, 1999
12. Abrahamsson K et al: Bladder dysfunction: an integral part of the ectopic
ureterocele complex. J Urol. 160(4):1468-70, 1998
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