Paediatric urology · KIMS Secunderabad
Ureterocele — A Cystic Dilation at the End of the Ureter Causing Obstruction
A ureterocele is a cystic dilation (ballooning) of the distal segment of the ureter — the portion of the ureter that lies within the wall of the bladder. It forms when the ureteric orifice (the opening of the ureter into the bladder) is abnormally narrow or obstructed, causing the terminal ureter to balloon out into the bladder lumen. On cystoscopy or CT, a ureterocele appears as a smooth, thin-walled, fluid-filled cyst projecting into the bladder from one or both ureteric orifices — like a cobra head on IVU imaging.
Ureteroceles are classified as intravesical (the cyst lies entirely within the bladder) or ectopic (the cyst extends into the bladder neck or urethra — more common in girls). They may be associated with a duplex (duplicated) collecting system — a duplex kidney with two separate ureters, where the upper pole ureter inserts ectopically and develops a ureterocele. Ureteroceles occur in approximately 1 in 500 to 1 in 4,000 children and are more common in females. The clinical consequences are obstruction of the affected ureter (causing hydronephrosis and renal parenchymal damage) and recurrent urinary tract infections from stasis.
Classification and associated conditions
Simple intravesical ureterocele
The cystic dilation is confined within the bladder. Usually associated with a single (non-duplex) collecting system. May be asymptomatic and found incidentally, or may cause intermittent ureteric obstruction, UTIs, or — in large ureteroceles — bladder outlet obstruction (the ureterocele may prolapse into the urethra during voiding, causing intermittent obstruction to urinary outflow).
Ectopic ureterocele with duplex system — the more complex variant
The ureterocele is associated with a duplex kidney — a kidney with two separate collecting systems, each drained by a separate ureter. The upper pole ureter inserts ectopically (below and medial to the normal ureteric orifice, following the Weigert-Meyer rule) and develops a large ectopic ureterocele that may extend into the urethra. The upper pole kidney is typically hydronephrotic and poorly functioning from obstruction. The lower pole kidney is at risk for VUR (reflux into the lower pole ureter around the ureterocele). Complex cases require multidisciplinary planning between nephrology and urology.
Clinical presentation
Antenatal hydronephrosis — detected on routine foetal ultrasound. The dilated upper pole collecting system of a duplex kidney or a single system with ureterocele hydronephrosis is the most common mode of detection in the modern era.
Recurrent urinary tract infections — the obstructed, poorly draining ureteric segment above the ureterocele is prone to infection. UTIs in an infant or young child should prompt ultrasound to exclude ureterocele.
Haematuria — from infection within the ureterocele or from the mucosa of the ureterocele itself.
Urinary retention — in girls, a large ectopic ureterocele may prolapse through the urethra, appearing as a cystic mass at the urethral meatus — a dramatic but not dangerous presentation. The prolapsed ureterocele is easily visible on examination.
Incidental detection on adult imaging — simple intravesical ureteroceles are often detected incidentally on CT or ultrasound performed for other reasons in adults.
Diagnosis
Renal and bladder ultrasound
The first investigation — identifies a cystic intravesical mass at the ureteric orifice and the degree of associated hydronephrosis. The duplex collecting system (if present) may be visible as echogenic tissue separating the two halves of the kidney.
VCUG (voiding cystourethrogram)
Essential for assessing VUR — which is present in up to 50% of the contralateral ureter and the lower pole ureter in duplex systems with ureterocele. The ureterocele itself appears as a filling defect within the contrast-filled bladder — a smooth, round, negative shadow (the ureterocele wall excludes contrast from its lumen).
DMSA scan
Assesses the differential function of each renal unit — particularly the upper pole function in a duplex system (typically very low, 5 to 15%). Determines whether the upper pole is worth preserving (if above 15% function, upper pole-sparing endoscopic treatment is preferred; if below 15%, upper pole nephrectomy may be appropriate).
CT urogram or IVU
The classic 'cobra head' sign on IVU (or filling defect with enhancing rim on CT urogram) confirms the ureterocele. CT urogram also characterises the duplex system anatomy and guides surgical planning.
Treatment at KIMS
Endoscopic incision (transurethral puncture) — the primary treatment
Under cystoscopy, a fine incision is made in the ureterocele wall using a laser or electrocautery hook, decompressing the cystic dilation and relieving the ureteric obstruction. Performed as a day-care procedure under general anaesthetic. Success rate for decompressing the obstruction and resolving hydronephrosis: 80 to 90%. Post-incision VUR into the ureterocele ureter (from the incised orifice) occurs in 30 to 50% — may require subsequent Deflux injection or ureteric reimplantation. Endoscopic incision is the preferred first-line treatment for most ureteroceles at KIMS.
Upper pole heminephrectomy — for non-functioning upper pole
If the upper pole of a duplex kidney contributes less than 10% of total renal function on DMSA and is irreversibly damaged, laparoscopic or robotic heminephrectomy (removing only the upper pole while preserving the lower pole) is performed — eliminating the source of infection and obstruction while preserving the functional lower pole. The ureterocele deflates after the upper pole is removed.
Ureteric reimplantation — for associated VUR
If significant VUR develops after endoscopic incision and does not resolve spontaneously, ureteric reimplantation (Cohen or Politano-Leadbetter technique) creates a new antireflux tunnel. At KIMS, this is deferred until the child is older (above 18 to 24 months) and the VUR severity is assessed.
Book a Paediatric Urology Assessment for Ureterocele at KIMS. Call 040-4488-5000
Frequently Asked Questions — Ureterocele
Not always — the decision depends on the clinical significance of the ureterocele. A small, asymptomatic intravesical ureterocele in an adult, found incidentally on CT, with no associated hydronephrosis, no VUR, and no recurrent UTIs, may be observed without intervention. Large ureteroceles causing hydronephrosis, recurrent UTIs, or bladder outlet obstruction require treatment. In children, any ureterocele causing significant obstruction (reduced differential function on DMSA) or recurrent pyelonephritis is treated promptly to prevent further kidney damage.
A duplex kidney (duplex collecting system) is a kidney with two separate collecting systems — two separate renal pelvices and two separate ureters — rather than the normal single system. It is a common congenital variant, occurring in approximately 1% of the population. In its mildest form (partial duplication — the two ureters join before entering the bladder), a duplex system is an incidental finding requiring no treatment. In complete duplication (two separate ureters entering the bladder separately), the risk of ureterocele (in the upper pole ureter) and VUR (in the lower pole ureter) is higher. A duplex kidney itself is not serious — it is the associated ureterocele or VUR that may cause kidney damage and require treatment.
Yes — in girls with large ectopic ureteroceles that extend into the urethra or vagina, continuous urinary dribbling (incontinence) occurs because the ectopic ureteral orifice opens below the urethral sphincter. The girl appears to have both normal voiding and a continuous urinary leak — because her normal ureteral system fills the bladder normally, but the ectopically inserting ureter drains directly into the vaginal vestibule or urethra below the sphincter. This presentation — a girl with constant dampness who also appears to void normally — is classic for ectopic ureterocele or ectopic ureter and should prompt immediate ultrasound and CT urogram.
Endoscopic ureterocele incision is typically performed as a day-care or overnight-stay procedure at KIMS — the child is admitted in the morning, has the procedure under general anaesthesia, recovers for a few hours in the paediatric ward, and goes home the same day or the next morning. Upper pole heminephrectomy (laparoscopic) requires 1 to 2 nights in hospital. Ureteric reimplantation (for associated VUR) requires 2 to 3 nights. All procedures at KIMS Paediatric Urology are minimally invasive where possible, minimising hospital stay and recovery time.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology KEM Mumbai, Member SIU, Paediatric Urology), renal ultrasound, VCUG, DMSA for upper pole function, endoscopic ureterocele incision, laparoscopic heminephrectomy for non-functioning upper pole, Deflux injection for post-incision VUR, ureteric reimplantation where indicated. NABH and NABL accredited. Call 040-4488-5000.