ORTHOTOPIC URETEROCELE MASQUERADING AS A BLADDER TUMOR IN A WOMAN WITH PELVIC PAIN
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DAVID D. THIEL, STEVEN P. PETROU, GREGORY A. BRODERICK

Department of Urology, Mayo Clinic Jacksonville, Jacksonville, Florida, USA

ABSTRACT

     Single system orthotopic ureteroceles often present in adulthood are associated with characteristic radiographic findings. We present the case of a 54 year old woman with 8 months of urgency/frequency and pelvic pain that has the cystoscopic appearance of a bladder tumor. Cystoscopic images, radiographs and intraoperative photos demonstrate the work-up, evaluation, and treatment of this unique single system orthotopic ureterocele containing a calculus. This patient demonstrates the need for cystoscopy accompanied by upper tract imaging in patients with new onset pelvic pain, urgency/frequency, and frequent urinary tract infections.

Key words: bladder; ureterocele; bladder neoplasms; ureteral calculi; pelvic pain
Int Braz J Urol. 2005; 31: 549-51

CASE REPORT

     A 54 year old white female was referred from her gynecologist for a bladder tumor. The patient had complained of worsening lower abdominal and pelvic pain accompanied by urinary urgency/frequency for the past 8 months. Treatment of four separate culture proven E. coli urinary tract infections with appropriate antibiotics failed to relieve the patient’s symptoms. Diagnostic cystoscopy was performed to evaluate the complaints and the patient sent to urologist for the finding of a bladder tumor.
     Past medical history was significant for osteoporosis and carpal tunnel repair. The patient was a hair dresser with a 30 pack-year smoking history. The patient denied any previous urologic history including calculi or hematuria. Physical exam revealed a physically fit female without costo-vertebral tenderness. Laboratory evaluation revealed only microscopic hematuria with negative urine cytology.
     In office cystoscopy was performed that revealed a papillary bladder tumor present at the right lower posterior portion of the bladder (Figure-1). The right ureteral orifice could not be identified. An excretory urogram was performed that revealed a non-obstructing, single system, distal right ureteral calculus surrounded by a radiolucent ring (Figure-1). Pelvic CT scan demonstrated what appeared to be a stone contained in a distal right ureterocele (Figure-2).





     The patient was taken to the operating room and cystoscopy performed. One ampoule of intravenous indigo carmine solution was given that eventually was secreted from the ureteral orifices. Once the opening of the right ureteral orifice was identified via secretion of the blue dye, a 5F open-ended catheter was placed inside the orifice into the kidney under fluoroscopic vision (Figure-2). The orifice was then sliced open utilizing endoscopic shears exposing a large stone (Figure-2). The stone was removed from the bladder and the ureteral stent removed.
     At the six month postoperative visit the patient noted complete resolution of her voiding symptoms and pelvic discomfort. She had no further documented urinary tract infections during that time. A voiding cystourethrogram performed at the 6 month postoperative visit failed to demonstrate vesico-ureteral reflux.

COMMENTS

     Single system (orthotopic) ureteroceles are usually discovered in adults and are almost always intravesical (1). Urinary stasis in the dilated distal segment often lends to urinary infection and stone formation; precluding the most common presenting symptoms of dysuria, urgency, and recurrent urinary infections.
     Diagnosis is often via excretory urography demonstration of the characteristic “cobra-head” sign (Figure-1). The radiolucent halo surrounding the dense filling area is a filling defect representing the ureterocele wall (1).
     Intravesical incision of the ureterocele is the treatment of choice in adults and has been described utilizing endoscopic shears and holmium laser technology (2). Vesico-ureter reflux is seldom a problem following incision (3).
     This patient demonstrates the necessity of cystoscopy accompanied by upper tract imaging in patients presenting with new onset urinary urgency/frequency or pelvic discomfort. The bullous edema surrounding an intravesical ureterocele containing calculus such as this case can mimic bladder tumors and confuse the less experienced cystoscopist.

CONFLICT OF INTEREST

     None declared.

REFERENCES

  1. Schlussel RN, Retik AB: Ectopic Ureter, Ureterocele, and other Anomalies of the Ureter. In: Walsh PC et al. (eds.), Campbell’s Urology, Philadelphia, WB Saunders. 2002; 8th ed., pp. 2022-34.
  2. Aron M, Costello AJ: Case report: holmium laser resection and lasertripsy for intravesical ureterocele with calculus. Lasers Surg Med. 2001; 29: 82-4.
  3. Rich MA, Keating MA, Snyder HM 3rd, Duckett JW: Low transurethral incision of single system intravesical ureteroceles in children. J Urol. 1990; 144: 120-1.
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Received: May 12, 2005
Accepted after revision: July 25, 2005

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Correspondence address:
Dr. David D. Thiel
3 East Urology - Davis Building
Mayo Clinic Jacksonville
4500 San Pablo Road
Jacksonville, Florida, 32224, USA
Fax: + 1 904-953-7330
E-mail: thiel.david@mayo.edu