Adult Ureterocele Presenting with Ureteral Obstruction and Urosepsis during Pregnancy.

Abstract

CASE REPORT Adult Ureterocele Presenting with Ureteral Obstruction and Urosepsis during Pregnancy Catherine R Harris, 1 Amjad Alwaal, 1,2 * Glen Yang, 1 Michael L Eisenberg, 1 Benjamin N Breyer 1 Keywords: pregnancy; ureterocele; adult; female; hydronephrosis; pathology. INTRODUCTION reteroceles are cystic dilatations of the distal ureter that occur due to congenital ureteric wall weakness. (1) They can be orthotopic, occurring in normal ureteric locations and most commonly seen in adults. On the other hand, heterotopic ureteroceles are located in ectopic ureters or in ectopic duplex renal systems, and are more common in children. (2) Ureterocele causing obstruction in adults is less commonly reported. There are few case reports and small case series in the adult population that describe ureteral obstruction from ureteroceles, (3-5) and only one published report of a ureterocele presenting as prolapsed mass containing stones during pregnancy. (6) We describe a report of an adult presenting with an obstructing ureterocele and urosepsis during pregnancy. The ureter- ocele was successfully extirpated cystoscopically without radiation exposure to mother or fetus. We also review the varied presentations and management of obstructing ureteroceles in adults who have presented at our institution. U CASE REPORT A 35 year-old woman gravida 5 para 2 at 22 weeks gestation presented to the emergency room with fevers and right flank pain. She was febrile to 39.0oC, tachycardic at 120/min, with stable blood pressure. On physical examination she had right costovertebral angle tenderness. Laboratory results revealed a leukocytosis of 19 × 10 9 /L and creati- nine of 0.5 mg/dL. Her urinalysis with microscopy was positive for pyuria and bacteriuria. Renal-bladder ultra- sound showed moderate right hydroureter (grade 3) proximal and distal to the gravid uterus as well as a ureterocele at the ureterovesical junction (Figure 1). The patient was otherwise healthy, with a history of a single urinary tract infection 2 years ago while not pregnant. Surgical Technique The patient was taken emergently to the operating room for endoscopic ureteral decompression. Cystoscopy was performed which showed a 3 cm right ureterocele. A ureteral orifice was not apparent, and a guidewire was unable to be passed into the ureter. Urine efflux was not visualized. An attempt to puncture the thick walled ureterocele with the Bugbee electrode (Medline Industries, Mundelein, IL, USA) was unsuccessful. A Collins knife (STORZ, Tuttlingen, Germany) was then used to incise the ureterocele. After extirpation with the Collins knife, we were able to visualize what appeared to be a ureteral orifice at the lateral extend of the ureterocele (Figure 2). A guidewire and 5-French ureteral exchange catheter passed through the ureteral orifice easily. We placed then a temporary Table. San Francisco general hospital experience with adult ureteroceles 1996-2015. Age (years) Sex Presenting Symptom Diagnostic Laterality Type of Imaging System Associated Stone Surgical Technique 35 F Pyelonephritis Ultrasound Right Single, orthotopic No Incision M Pyelonephritis CT, IVP Bilateral F Flank pain CT, DMSA Left Single, orthotopic Yes Excision, laser lithotripsy, stent Duplicated, ectopic No Heminephrectomy 26 F Recurrent UTI Ultrasound Left Single, orthotopic No Incision 68 F Recurrent UTI CT Left Single, orthotopic No Incision M Recurrent UTI CT Left Single, orthotopic No Open excision, ureteral reim plantation Abbreviations: M, male; F, female; CT, computed tomography; IVP, intravenous pyelography; DMSA, dimercaptosuccinic acid; UTI, urinary tract infection. Department of Urology, University of California, San Francisco, USA. Department of Urology, King Abdul Aziz University, Jeddah, Saudi Arabia. *Correspondence: 400 Parnassus Avenue A633, San Francisco, CA 94143-0738, USA. Tel: +1 415 206 8805. Fax: +1 415 206 5153. E-mail: amjadwal@yahoo.com. Received February 2015 & Accepted June 2015 Case Report 2285