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Year : 2022  |  Volume : 27  |  Issue : 1  |  Page : 118-119
 

Everting ureterocele masquerading as paraureteric diverticulum in a child: Avoid the pitfall


1 Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission29-Jan-2021
Date of Decision23-May-2021
Date of Acceptance14-Sep-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Dr. Kushaljit Singh Sodh
Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_16_21

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How to cite this article:
Bhatia P, Malik MA, Saxena AK, Sodh KS. Everting ureterocele masquerading as paraureteric diverticulum in a child: Avoid the pitfall. J Indian Assoc Pediatr Surg 2022;27:118-9

How to cite this URL:
Bhatia P, Malik MA, Saxena AK, Sodh KS. Everting ureterocele masquerading as paraureteric diverticulum in a child: Avoid the pitfall. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Jan 20];27:118-9. Available from: https://www.jiaps.com/text.asp?2022/27/1/118/335554




Ureterocele is a congenital, cystic, localized dilatation of the distal most part of the ureter. These can be either intravesical in position (occur at the normal vesicoureteric junction position) or extravesical (when they occur ectopically medial and low, near bladder neck/urethra). Extravesical ureterocele is much more common than intravesical types. Everting ureterocele refers to a type of ureterocele that, during the active micturating phase of micturating cystourethrogram (MCU) appears to be a paraureteral diverticulum.[1],[2],[3]

On an MCU, ureteroceles typically present as bladder filling defects, which may, however, be obscured due to high-density contrast or suboptimal bladder distension (over or under distension).[1],[3] The presentation may vary, depending on the varying dynamics during micturition.[1] One of them is eversion of ureterocele due to raised intravesical pressure during voiding. Eversion of ureterocele may be intraluminal, where there is intussusception of thin-walled ureterocele into the proximal dilated ureter or it may be extraluminal through the lax ureteric orifice.[2],[3] The type of eversion depends on the hiatus size and its surrounding anatomy and the duplication of the collecting system. Intussuscepting type occurs more commonly in single system dilated ureters and large hiatus, whereas extravesical eversion occurs more in duplicated because of poor detrusor backing.[3] An everted ureterocele may closely simulate a bladder or a paraureteral bladder diverticulum, and the distinction between the two entities is imperative for timely and appropriate surgical intervention which goes a long way in preserving the renal functions. It is a standard practice to stop retrograde flow of fluid during cystoscopy for ureterocele to prevent its eversion. In addition, even if it is everted, intravenous fluid bolus with or without Lasix may be given to make it protrude into bladder to facilitate deroofing. MR urography can also be performed in cases where there is a diagnostic dilemma.[4] Magnetic resonance urography is more sensitive in the detection of ureterocele compared to intravenous urography and MCU studies, showing saccular bulge of distal ureter into bladder lumen. However, as voiding is not performed during MRU studies, the phenomenon of eversion may not be identified. The dilemma of differentiating everting ureterocele from paraureteric diverticulum can still be addressed as intravesical filling defects of ureteroceles are better visualized in MRU which may be missed in the filling phase of MCU.[5]

Here, we present a case of a 3-month-old male child who was antenatally diagnosed with right hydronephrosis and now presented with urinary tract infection. MCU showed a contrast-filled outpouching from the right posterior wall of urinary bladder [Figure 1]a and [Figure 1]b in paraureteric position that was seen only in the micturating phase. Filling stationary phase of MCU did not reveal any outpouching or filling defect in the bladder. Ultrasound revealed right hydroureteronephrosis with a cystic structure projecting into the bladder near the ureterovesical junction thus confirming the diagnosis of an everted ureterocele [Figure 2]. Tc99mEC renal scan revealed normal left kidney while right kidney showed hydroureteronephrosis with significant tracer retention. The child underwent cystoscopic-guided deroofing of right ureterocele, and follow-up Tc99mEC renal scan after 3 months revealed significant improvement in renal function and drainage. Postoperative follow-up MCU done after 3 months of surgery showed no residual ureterocele with Grade V vesicoureteric reflux on the right side.
Figure 1: Micturating cystourethrogram showing full bladder with no filling defect (a). Micturating cystourethrogram (voiding phase) showing contrast-filled outpouching from the right lateral wall of bladder (b)

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Figure 2: Ultrasound pelvis showing tubular cystic structure (distal most ureter) projecting into the bladder near the vesicoureteric junction

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To conclude, ureterocele is an important congenital anomaly in infants and children. As these ureteroceles are often small and have a tendency to evert at MCU, they can be mistaken for paraureteral diverticula.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zerin JM, Baker DR, Casale JA. Single-system ureteroceles in infants and children: Imaging features. Pediatr Radiol 2000;30:139-46.  Back to cited text no. 1
    
2.
Koyanagi T, Hisajima S, Goto T, Tokunaka S, Tsuji I. Everting ureteroceles: Radiographic and endoscopic observation, and surgical management. J Urol 1980;123:538-43.  Back to cited text no. 2
    
3.
Bellah RD, Long FR, Canning DA. Ureterocele eversion with vesicoureteral reflux in duplex kidneys: Findings at voiding cystourethrography. AJR Am J Roentgenol 1995;165:409-13.  Back to cited text no. 3
    
4.
Sharma A, Sodhi KS, Saxena AK, Bhatia A, Menon P, Rao KL, et al. Comparison of intravenous urography and magnetic resonance urography in preoperative evaluation of pelvi-ureteric junction obstruction in children. J Indian Assoc Pediatr Surg 2016;21:169-74.  Back to cited text no. 4
  [Full text]  
5.
Payabvash S, Kajbafzadeh AM, Saeedi P, Sadeghi Z, Elmi A, Mehdizadeh M. Application of magnetic resonance urography in diagnosis of congenital urogenital anomalies in children. Pediatr Surg Int 2008;24:979-86.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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