My Clinical Approach
Ureterocele requires individualized management: goals are renal function preservation, addressing obstruction, and preventing UTIs with minimally invasive therapy whenever possible.
According to EAU/ESPU Pediatric Urology Guidelines 2024 and AUA Pediatric Urology:
- Complete imaging workup: U/S + VCUG + DMSA ± MR urography.
- Screen for coexisting vesicoureteral reflux (50%).
- Transurethral endoscopic puncture with holmium laser as first-line.
- Upper pole heminephrouretrectomy only if non-functional upper pole (<10% function on DMSA).
- Full reconstruction in complex cases (large ureterocele + severe VUR).
- Prophylactic antibiotic coverage until definitive treatment.
What is a ureterocele
A ureterocele is a cystic dilation of the distal intravesical ureter due to congenital stenosis of its orifice. Incidence is estimated at 1:4,000 births. More common in girls (4:1) and Caucasian. Associated with complete duplex system in 80% of pediatric cases (Weigert-Meyer rule: upper pole ureter inserts more inferomedially and develops the ureterocele).
Important: In adults, most ureteroceles are orthotopic in single systems and discovered incidentally or due to lithiasis within the cystic structure.
Stephens classification (AAP 1984)
Orthotopic (Intravesical / Adult-type)
Entire ureterocele within the bladder. More common in single system, adults. Usually small, asymptomatic, or stone-forming.
Ectopic
Part of ureterocele extends below the bladder neck, into the urethra. Almost always in upper pole of duplex system, children. May prolapse externally.
Sphincteric / Sphincterostenotic
Ectopic with orifice within or beyond the urethral sphincter. Causes bladder neck obstruction or both ureters.
Cecoureterocele
Rare — extensive submucosal extension into the urethra. Distended ureteroceles can cause retention or incontinence.
Symptoms & clinical presentation
Newborns / Infants
Prenatal hydronephrosis (50%+), febrile UTI, urosepsis, palpable cystic suprapubic mass, failure to thrive.
Children
Recurrent UTIs, dysuria, incontinence or dribbling, psychomotor delay from chronic infection.
Adolescent girls
Prolapsing cystic mass from vagina/urethra — urgent urologic evaluation. Acute urinary retention, rare.
Adults
Usually orthotopic: stones within ureterocele, hematuria, recurrent cystitis, or incidental finding on CT.
Diagnosis (U/S, VCUG, DMSA)
Renal-bladder ultrasound
First line. Shows the characteristic "cobra head" cystic structure within the bladder + upper pole hydronephrosis in duplex system. Can assess parenchymal thickness.
Voiding cystourethrogram (VCUG)
Reveals: filling defect from the ureterocele, coexisting vesicoureteral reflux (50% in lower pole), pseudo-ureterocele, and bladder neck obstruction in ectopic cases.
DMSA scintigraphy
Assesses upper pole function. Function >10-15% argues for kidney-sparing therapy; <10% leads to upper pole heminephrectomy.
MR urography
Provides detailed anatomic imaging — duplication, orifice locations, ureteral dilation, renal dysplasia. No radiation — preferred in children.
Cystoscopy
Confirms diagnosis and allows simultaneous endoscopic treatment. Also rules out malignancy in adults.
Urodynamic study
In suspected bladder neck dysfunction or coexisting neurogenic bladder — not routine.
Treatment options
1. Transurethral endoscopic puncture
First line for most cases. Cystoscope + holmium laser or Bugbee electrode, with low horizontal incision at the ureterocele base ("watering can" technique). Immediate decompression. Complications: de novo VUR ~30%, often managed later with Deflux.
2. Upper pole heminephrouretrectomy
When upper pole has minimal function (DMSA <10%) and lower pole is normal. Laparoscopic or robotic approach. Lower pole preservation.
3. Total bladder reconstruction
Ureterocele excision + trigone reconstruction + ureteral reimplantation by Cohen or Politano-Leadbetter. Indicated in large ureterocele with severe lower pole VUR or failed endoscopic management.
4. Ipsilateral pyelo/uretero-ureterostomy
In duplex systems with functional upper pole, anastomosis of upper pole pelvis to lower pole ureter (pyelo-pyelostomy or uretero-ureterostomy). Preserves all function.
5. Emergency decompression
In urosepsis or ureterocele prolapse from urethra: immediate endoscopic puncture and IV antibiotic coverage (cephalosporin + aminoglycoside).
Follow-up & prognosis
- Renal-bladder U/S at 4-6 weeks, 3, 6, and 12 months postoperatively.
- VCUG or RNC 3-6 months after endoscopic puncture — check for de novo VUR.
- DMSA at 12 months — assess parenchymal scars.
- Annual blood pressure + creatinine + proteinuria check.
- Continuous antibiotic prophylaxis until negative VCUG.
In summary: Prognosis is excellent in >90% with timely diagnosis and individualized treatment. Lifelong urologic follow-up ensures preservation of renal function.
Frequently Asked Questions (FAQ)
What is a ureterocele?
A ureterocele is a congenital cystic dilation of the intravesical portion of the ureter, due to stenosis of its meatus into the bladder. More common in girls (4:1) and usually associated with complete duplex collecting system in 80% of cases.
How is it classified?
By Stephens (AAP 1984): orthotopic (intravesical) — entirely within the bladder, usually adult single system; ectopic — extends below the bladder neck, almost always associated with upper pole of duplex system in children.
What are the symptoms?
Many are asymptomatic and diagnosed prenatally (hydronephrosis on fetal U/S). In children: UTIs, fever, failure to thrive. Large ectopic: prolapse from urethra, acute retention, incontinence. Adults: stone formation within ureterocele, hematuria, infections.
How is it diagnosed?
Renal-bladder ultrasound (first-line — shows the cystic "cobra head" within bladder + upper pole hydronephrosis in duplex system). Voiding cystourethrogram (VCUG): reveals coexisting vesicoureteral reflux (50%) and pseudo-ureterocele. DMSA: assesses upper pole function. MR urography for full anatomy.
When is treatment needed?
Always when causing obstruction, UTIs, reflux, or stones. Asymptomatic small orthotopic in adults can be observed. Ectopic in children usually requires surgical intervention.
What are the surgical options?
Transurethral endoscopic puncture/incision: minimally invasive with cystoscope + holmium laser or Bugbee electrode — decompression + improved drainage; secondary VUR risk ~30%. Upper pole heminephrouretrectomy: if upper pole non-functional. Total bladder reconstruction (excision + reimplantation per Cohen/Politano-Leadbetter) in complex cases.
What is the role of prenatal diagnosis?
Over 50% are diagnosed prenatally (hydronephrosis/cystic mass on second trimester fetal U/S). Allows: immediate postnatal U/S confirmation within 48 hours, prophylactic antibiotics (amoxicillin), VCUG at 4-6 weeks, organized multidisciplinary care.
What is the prognosis?
Excellent with proper diagnosis and treatment. Renal function preserved in 90% with timely therapy. The most common long-term issue is persistent or de novo reflux after endoscopic puncture — requires VCUG/RNC follow-up. Lifelong renal function and blood pressure monitoring.
What other urologic conditions are associated?
Renal duplication (80%), vesicoureteral reflux (in lower pole 50%), ectopic ureter, lower pole hydronephrosis from compression, ureterocele stones. Rarely associated with VATER syndrome or renal dysplasia.
Related topics
Suspected ureterocele?
Contact us for full pediatric or adult urologic evaluation: U/S, VCUG, DMSA and personalized plan — from endoscopic laser puncture to total reconstruction.
Scientific literature
- EAU/ESPU Guidelines on Paediatric Urology — Ureterocele (2024) — uroweb.org
- Stephens FD. Caecoureterocele and concepts on the embryology and aetiology of ureteroceles. Aust N Z J Surg 1971;40(3):239-48 — pubmed.ncbi.nlm.nih.gov
- Coplen DE. Management of the neonatal ureterocele. Curr Urol Rep 2001;2(2):102-5 — pubmed.ncbi.nlm.nih.gov
- Byun E, Merguerian PA. A meta-analysis of surgical practice patterns in the endoscopic management of ureteroceles. J Urol 2006;176(4):1871-7 — pubmed.ncbi.nlm.nih.gov
- Chertin B, Mohanan N, Farkas A, Puri P. Endoscopic treatment of vesicoureteral reflux associated with ureterocele. J Urol 2007;178(4 Pt 2):1594-7 — pubmed.ncbi.nlm.nih.gov
Medical Editorship
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas treats ureteroceles in children and adults with modern approach: from endoscopic puncture with holmium laser to laparoscopic/robotic upper pole heminephrouretrectomy and total bladder reconstruction per EAU/ESPU 2024.
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