Transvesical Laparoscopic Surgery for a Stone in the Ureterocele

Abstract

Background: Ureteroceles containing stones present as a unique challenge to the urologist. When a calculus has to be removed from within the ureterocele, a large opening leads to de novo vesicoureteral reflux (VUR), which may result in recurrent infections and renal parenchymal damage.

Case Presentation: We present a case of a 13-mm stone in the ureterocele in an 11-year-old boy. He was asymptomatic but presented with abnormal urinalysis results and unilateral hydronephrosis. To avoid de novo VUR, we performed minimally invasive transvesical laparoscopic ureterolithotomy, which included partially suturing the incision at the roof of the ureterocele so that a small opening is maintained for drainage of urine. The surgery was performed with no complications and with normal postoperative urinalysis results. The patient's hydronephrosis resolved, and postoperative voiding cystourethrography showed no VUR.

Conclusion: Transvesical laparoscopic ureterolithotomy with partial suturing of the incision at the roof of the ureterocele is a good treatment option, particularly for asymptomatic patients.

Introduction and Background

Ureterocele is an abnormal dilation of the terminal portion of a single ureter, often associated with duplication of the ureter. The incidence of ureterocele is estimated to be 1 in 500–4000 newborns and is more common in girls. Ureteroceles can be found in the bladder (intravesical) or outside the bladder (ectopic). A duplicated ureteral system can be divided into two categories: complete and incomplete. The ureterocele may be associated with a single ureter in 15%–30% of cases. The grade of hydronephrosis and split renal function of the corresponding kidney varies widely. Voiding cystourethrography may reveal concurrence of vesicoureteral reflux (VUR). A wide range of treatment options is available because of the extreme diversity of the malformation. Surgical options for ureteroceles include simple aspiration for prolapse of the ectopic ureterocele, distal enlargement of the meatus, upper pole or total nephrectomy, ureteropelvic or uretero-ureteral anastomosis with segmental ureterectomy, ipsilateral ureterovesical reimplantation with total resection of the ureterocele, and total resection of the pathologic tract with parietal reconstruction/reimplantation.¹ Because of the extreme diversity of the malformation, physicians must design a unique treatment plan for each patient. De novo VUR, one of the complications of surgical treatment for ureteroceles,^1,2 can result in repeated urinary infections and renal parenchymal damage. Special care should be taken not to initiate reflux. If endoscopic unroofing of the ureterocele is performed, the opening should not be too large, as this may increase the risk of VUR. Secondary and tertiary operations may be required once VUR occurs, and these tend to be more invasive.¹

Urinary stones are a common urologic condition and are detected in 5%–40% of cases of ureterocele.³ However, stone formation in the ureterocele is rare in children, with only a few previous reports.⁴ There is no standard treatment for stones in the ureterocele in children. In this study, we report a case of a 13-mm stone in the ureterocele that was treated surgically.

Presentation of Case

An 11-year-old boy visited our institution for investigation of proteinuria identified at his school health screening. He was asymptomatic with no fever, macrohematuria, or abdominal pain. This was the first detection of proteinuria, and his parents denied any medical history, including urinary tract infection or childhood developmental issues.

The physical examination was unremarkable, and urinalysis revealed microscopic hematuria and proteinuria. A urine culture test was negative for infection. Ultrasonography revealed right hydronephrosis and a ureterocele with a calculus. A plain abdominal radiograph showed a 13 × 13 mm irregular radiopaque shadow in the pelvic area (Fig. 1, left). Both contrast CT and kidney, ureter, and bladder radiography, which was performed after contrast CT, revealed a stone within a duplex-system ureterocele (Fig. 1, right).

FIG. 1.

(Left) Radiograph showing a 13-mm calculus in the pelvis. (Right) The kidney, ureter, and bladder (KUB radiograph) after a contrast-enhanced CT scan show right duplex system and urolithiasis in the ureterocele.

Transvesical laparoscopic surgery was performed under general anesthesia with the patient in the lithotomy position. After an overall examination of the bladder, saline infusion was performed under transurethral cystoscopy to expand the bladder adequately. Simultaneous transabdominal ultrasonography was performed to identify suitable sites for trocar insertion to avoid entering the peritoneal cavity. We used three 5-mm short trocars (VersaOne; Covidien, Norwalk, CT): one for a laparoscope port and two for working ports (Fig. 2). Under transurethral cystoscopic guidance, two 2-0 nylon sutures were introduced into the bladder, and a 5-mm trocar was then inserted through an incision between the two sutures that were pulled up adequately to fix the bladder and abdominal walls. The two other trocars were placed in the same manner. After the bladder had been emptied, insufflation of CO₂ gas was started with a pneumovesicum of 8 mm Hg. The ureterocele mucosa was swelling, and an orifice was detected at the top (Fig. 3A). A careful incision, at a site other than the ureteral orifice, was made to unroof the ureterocele (Fig. 3B). The length of the incision was determined by the stone size to extract the stone without fracture. The stone was carefully removed from the ureterocele into the bladder using forceps (Fig. 3C). To avoid de novo VUR, the incision at the roof of the ureterocele was partially sutured, with a small space left to serve as an outlet for urine (Fig. 3D). The stone was segmented in the bladder using a holmium laser (0.8 J at 10 Hz) and extracted through a port and the urethra. There were no complications, and the patient was discharged on the day 5 postsurgery, after removal of the urethral catheter.

FIG. 2.

The center trocar (5 mm) for a laparoscope port and two lateral trocars (5 mm) for working ports.

FIG. 3.

(A) The ureterocele appears swollen and not smooth. The ureteral orifice (arrow) can be seen. (B) Incision of the upper wall of the ureterocele. (C) Calculus removal. (D) Partial suturing and repair of a large opening in the ureterocele.

Approximately 3 months after the operation, the patient underwent voiding cystourethrography, which detected no VUR (Fig. 4). Urine analysis showed no proteinuria or microhematuria, and ultrasonography revealed resolution of the hydronephrosis. The stone was composed of calcium oxalate. There was no recurrence of calculi in the ureterocele at 1 year postoperatively.

FIG. 4.

Voiding cystourethrography performed 3 months after the surgery shows no vesicoureteral reflux.

The procedures were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Discussion and Literature Review

Although transurethral incision of a ureterocele and removal of the stone within it is considered a simple option, the risk of VUR is increased relative to the width of the required incision for stone extraction. Although there exists no randomized control trial on treatment options for ureterocele and the risk of VUR, we found several reports that suggest that a large incision in the ureterocele might result in VUR, requiring an additional operation because of recurrent urinary tract infection.² Further, other reports have indicated that a small puncture, not a large incision, could prevent de novo VUR.¹ Furthermore, Deflux injection is a noninvasive treatment option for VUR, but it may be insufficient for the modification of a large opening in a ureterocele after the extraction of a 13-mm calculus.

Total resection of the ureterocele containing a stone and anastomosis of the ureter and bladder would have resolved the issue, but this procedure is highly invasive and is associated with risks, such as ureter stenosis. Particularly, in our case, reimplantation of ureters of the duplex system in one sheath may be required. The patient was asymptomatic, and we avoided a highly invasive operation.

Although the patient did not complain of any symptoms, he may have experienced urinary infection, abdominal pain, or macrohematuria as the stone size increased. Our evaluation showed the treatment indication for the patient. We considered a minimally invasive surgery that would achieve complete resection of the stone and allow us to prevent de novo VUR. We performed transvesical laparoscopic surgery to extract the stone without fragmentation and to repair the large opening of the ureterocele.

Although pneumovesicum surgery is currently a popular treatment option for VUR, we believe that this is the first report of application of the technique for ureteroceles containing stones. Careful follow-up is necessary for the patient and we should reveal the long-term outcomes and durability of the reported technique. As stones in ureterocele can recur, radical operations, such as total removal of the ureterocele and reimplantation of the ureter, may be required if the patient becomes symptomatic or suffers renal damage.

Conclusion

Herein, we present a case of a ureterocele containing a stone in an 11-year-old boy. Transvesical laparoscopic ureterolithotomy with partial suturing of the incision at the roof of the ureterocele is a good treatment option, particularly for asymptomatic patients.

Patient Consent

Consent for treatment and publication of this report was obtained from the patient and his parents.

Abbreviations Used

CT

computed tomography

VUR

vesicoureteral reflux

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Cite this article as: Satoji Y, Tobu S, Udo K Noguchi M (2020) Transvesical laparoscopic surgery for a stone in the ureterocele, Journal of Endourology Case Reports 6:4, 283–286, DOI: 10.1089/cren.2020.0003.