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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 5  |  Page : 984-987
Ureterocele containing a stone in a duplex system

Pediatric Surgery Service, Habib Thameur Medical Center and the Faculty of Medicine, Tunis, Tunisia

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Date of Web Publication12-Sep-2013


The formation of calcified stone in the ureterocele, a frequent event in adults, is very uncommon in a pediatric age. We present a case of a ureterocele containing a calcified stone in an 8-year-old girl. The diagnosis was made with radiological investigations (intravenous pyelogram, ultrasonography and, eventually, voiding cystourethrogram). Meatostomy and calculus extraction, or open surgery in more complicated cases, are the treatments of choice.

How to cite this article:
Gharbi Y, Gargah T, Boukesra T, Hellal Y, Sayed S. Ureterocele containing a stone in a duplex system . Saudi J Kidney Dis Transpl 2013;24:984-7

How to cite this URL:
Gharbi Y, Gargah T, Boukesra T, Hellal Y, Sayed S. Ureterocele containing a stone in a duplex system . Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jan 27];24:984-7. Available from: http://www.sjkdt.org/text.asp?2013/24/5/984/118097

   Introduction Top

Ureterocele is an abnormal congenital dilatation of the terminal portion of a single or, more frequently (70-85%), the upper part of a duplex urinary tract, with normal or ectopic implantation. [1],[2] This abnormality is generally obstructive and more frequent in females (sex ratio 0.5 to 0.2), and is seen in 1/500 to 1/4000 newborns. [1],[3] It can determine many complications, from urinary tract infection to destruc­tion of the kidney and its upper pole (in the case of duplex system). [4]

We report a case of a ureterocele complicated with a calculus in an 8-year-old girl and discuss the etiology and the therapeutic procedure of this exceptional pathology.

   Case Report Top

An 8-year-old girl presented with right pyelonephritis at our hospital in August 2004, and she did not have any previous history of urinary tract infection, bleeding or abdominal pain. The clinical examination showed right lumbar tenderness and high-grade fever (39.3°C). Abdominal plain film showed a calcified density of the right side of the bladder and ultrasound disclosed a right hydroureteronephrosis. Intravenous urogram (IVU) revealed a right duplex system with a ureterocele including a calculus. There was no reflux at voiding cystourethrogram (VCUG) [Figure 1]. After surgical ureterocele excision and stone removal, the two right ureters underwent Cohen re-implantation [Figure 2] and [Figure 3]. Examination of a urine specimen, collected from the ureterocele, showed pyuria, microscopic hematuria, alkaline pH: 8 and struvite crystals. Uroculture was positive and identified Proteus mirabilis. Infrared spectrophotometric analysis confirmed the struvite composition of the stone. The IVU and VCUG, 12 months after intervention, were without abnormalities; particularly, there was no vesicoureteral reflux. At four years post-operatively, the patient remained asymptomatic and was doing well.
Figure 1. Urolithiasis and no VUR at voiding uretrocystography

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Figure 2. Open surgery shows a voluminous ureterocele

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Figure 3. Ureterocele containing stone (arrow).

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   Discussion Top

Ureteroceles can be diagnosed in utero with morphological sonography, which shows a unilateral and rarely bilateral dilatation of the urinary tract. [1],[2],[4] After birth, in the majority of children, it is made in front of the flank or back pain, with biological symptoms of urinary tract infection and on findings of the radiological investigations (ultrasonography, IVU and, eventually, VCUG) if an associated reflux is suspected. [5] Obstruction, stasis and infection are important factors in the genesis of stones in the ureterocele ("native stone"), but this phenomenon occurs generally after many years of evolution, and ureterocele can be complicated in adults by calcified stone in 15-40% of the cases. [4],[5],[6],[7],[8] In infancy and childhood, this eventuality is extremely rare. To the best of our knowledge, only two cases were previously reported in the literature [Table 1]. [9],[10] The originality of our case is that the symptomatology appeared eight years after birth, without any previous history of recurrent urinary tract infection, lumbar pain or bleeding. The urolithiasis was found fortuitously following the systematic radiological investigation of this inaugural right pyelonephritis. The ureterocele and the duplicity were revealed at the same time. The upper and lower poles of the right kidney were functional at IVU because the ureterocele was not completely obstructive, but the stasis resulted in the formation of a struvite stone in the ureterocele.
Table 1. Clinical and radiological presentation, treatment and outcome of the three cases reported (including ours).

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In adults, many authors proposed the transurethral incision (TUI) of the ureterocele and extraction of the calculus. [8] This minimally invasive and easy technique is better than the endoscopic resection and is more comfortable than the open surgery, but it is controversial in the pediatric population, especially if an associated vesico-ureteral reflux is suspected. Moreover, it may increase the risk of reflux in the upper pole ureter; [11] in adults, this risk seems lower than in infants. In our case, the size of the stone (1.7 cm) necessitated a meatotomy that could induce massive reflux and a long fragmentation time, with the associated anesthetic risks and bleeding. For these reasons, we eventuality preferred the open alternative, with re-implantation of the two right ureters.

   References Top

1.Sauvage P, Becmeur F, Moog R, Kauffman I. Is one-stage ureterocele repair possible in children? Eur Urol 2002;42:607-13.  Back to cited text no. 1
2.Sadiki R, Sadiq A, Tazi K, Koutani A, Hachimi M, Lakrissa A. Ureterocele in adult. Report of 14 cases. Prog Urol 2005;15:231-7.  Back to cited text no. 2
3.Bruezière J. Ureteroceles - Ann Urol (Paris). 1992;26(4):202-11  Back to cited text no. 3
4.Chtourou M, Sallami S, Rekik H, Binous MY, Kbaier I, Horchani A. Adult ureterocele complicated of calculi: Diagnosis and therapeutic aspects. Report of 20 cases. Prog Urol 2002; 12:1213-20.  Back to cited text no. 4
5.Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood. Management considerations. J Paediatr Urol 2008;4:2-7.  Back to cited text no. 5
6.Jha A, Fathi H. Ureterocele management. Evaluation in Jazan Region of Saudi Arabia with transurethral inverted Y-V decrofing. Urology 2000;74:52-65.  Back to cited text no. 6
7.Saussine C, Lechevallier E, Traxer O. Urolithiasis and congenital renoureteral malformations. Prog Urol 2008;18:967-99.  Back to cited text no. 7
8.Mizuno K, Kamisawa H, Hamamoto S, Okamura T, Kohri K. Bilateral single-system ureteroceles with multiple calculi in an adult woman. Urology 2008;72:294-5.  Back to cited text no. 8
9.Moskowitz B, Bolkier M, Levin DR. Ureterocele containing calcified stone. J Paediatr Surg 1987;11:1047-8.  Back to cited text no. 9
10.Gilbert WB, Hernanz-Schulman M, Pope JC 4th. Development of small calculi in an infant with bilateral single system ureterocele. J Urol 2001;166:880-1.  Back to cited text no. 10
11.Yoo E, Kim H, Chung S. Bladder surgery as first-line treatment of complete duplex system complicated with ureterocele. J Paediatr Urol 2007;3:291-4.  Back to cited text no. 11

Correspondence Address:
Youssef Gharbi
Pediatric Surgery Service, Habib Thameur Medical Center and the Faculty of Medicine, Tunis
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DOI: 10.4103/1319-2442.118097

PMID: 24029266

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