9.4.1 Ureterocele

The management is controversial between endoscopic decompression, partial nephro-ureterectomy or complete primary reconstruction. The choice of a therapeutic modality depends on the following criteria: clinical status of the patient (e.g. urosepsis), age of the patient, renal function of the upper pole, presence or absence of reflux, obstruction of the ipsilateral ureter and pathology of the contralateral ureter.

Early diagnosis

1. In a clinically asymptomatic child with an ureterocele and non- or hypofunctional upper pole, without significant obstruction of the lower pole and without bladder outlet obstruction, a prophylactic antibiotic treatment is given for 3 months until surgery is performed.

2. In the presence of obstruction of the lower pole ureter or of the contralateral ureter, or urethral obstruction, an immediate endoscopic incision or punction is recommended in combination with prophylactic antibiotic treatment. After 3 months a re-evaluation is performed.

Re-evaluation: If decompression is effective and there is no reflux (approximately 25%), medical treatment is stopped and follow-up is based on urine cultures and ultrasound. If decompression is not effective or significant reflux is present or obstruction of the ipsi- or contralateral ureters and/or bladder neck obstruction, secondary surgery is necessary varying from partial nephrectomy to complete unilateral reconstruction (depending on upper pole function).

Late diagnosis

1. Non-functional upper pole, no further pathology: heminephro-ureterectomy is the method of choice.

1. Presence of significant reflux or obstruction: excision of the ureterocele and re-implantation of the ureter/ureters, heminephro-ureterectomy according to the function of the upper pole.

Bladder outlet obstruction caused by ureterocele: endoscopic incision might be an optional therapy, with awareness of secondary surgery in the majority of the patients.