Ureterocele in adult man

Clinical History

A 42-year-old man was admitted to first aid for onset of left flank pain for a few days.
The patient was not subjected to any illness or medical investigations in the past.
However, he complained of frequent urination (pollakiuria) since a long time.

Imaging Findings

The ecography showed a severe cortical thinning of the left kidney due to renal atrophy and a significant dilatation of the renal pelvis with ballooned calyces (clearly noticeable).
Moreover a well demarcated cyst-like mass (5 cm in size), bordered by very thin walls, was evident in the left postero-lateral portion of bladder. In the left flank we saw a tubular anecoic structure due to dilatation of the left ureter.
Subsequently, the patient underwent a CT that confirmed the severe thinning of the left renal parenchyma, the noticeable hydroureteronephrosis, and showed a partial double collecting system, both remarkably dilated and a bulging distal portion of the ureter, leading into the bladder lumen.
He did not excrete any contrast media in the delayed phase.
Based on this evidence, a diagnosis of utererocele was made and the urological consultation suggested a radical nephrectomy.

Discussion

The term ureterocoele refers to the congenital saccular dilatation of the terminal ureter induced from the persistence or incomplete dissolution of Chwalla's membrane with a resulting ureter meatal obstruction [1-4].
The anomaly can be detected at a very early stage by perinatal screening or, if the obstruction is minimal and without symptoms, it can be found in older children or adults.
The most common symptoms are: urinary tract infection, failure to thrive, abdominal pain, hematuria.
In adulthood, inflammation, kidney stones or cancer may cause an obstruction and dilatation of ureter, mimicking an ureterocel; this condition is named pseudoureterocele or acquired form [5].
The incidence of ureterocele is approximately 1 in every 4,000 children, prevalent in females and on the left side; however in 10% of cases it is bilateral and its size varies from a few mm to several cm [6].
According to the renal collecting system, associated (unique or dual) ureteroceles are classified in single or duplex, both can be intra or extravesical. Based on the normal or abnormal urethral insertion they are classified into orthotopic or ectopic [6].
Generally, ectopic ureterocele is associated with a duplex collecting system, while an orthotopic ureterocele is associated with a simplex collecting system, which is usually found in adults.
In our case an intravesical orthotopic simple ureterocele was associed with two ureters fused together to form a single ureteral orifice.
Imaging techniques are crucial to detect this condition and all imaging modalities are able to recognize it. Traditionally, urography was used to evaluate the urinary tract and to detect ureteral lesions. A ureterocele could be seen with a characteristic aspect (cobra-head sign or spring onion) caused by a radiolucent halo produced by the ureterocele’s wall inside the bladder filled with contrast media [7]. Because of technology progresses, urography has been largely replaced by CT and echography.
In echography, a ureterocele is seen as a cyst-like intravesical mass, near the margin of trigone and contiguous with a dilated ureter.
The wall of the ureterocele is thin and echogenic and its base is usually narrow.
Enhanced CT and MRI may be helpful to better delineate urinary tract anatomy, especially to identify duplicated renal systems, the degree of hydronephrosis, the cortical thickness and the functional ability of the kidneys to excrete contrast material [3].
Surgical intervention is required to relieve obstruction and preserve the renal function, to prevent infection or reflux.
Transurethral puncture/incision is often enough to solve simpler cases; open procedures are reserved for more complex types and include partial/total nephrectomy, ureterectomy and bladder recostruction [8-9].

Differential Diagnosis List

Final Diagnosis

Ureterocele in adult man

URL:	https://www.eurorad.org/case/14242
DOI:	10.1594/EURORAD/CASE.14242
ISSN:	1563-4086