Preoperative Preparation and Planning
Most clinically significant cases of ureteroceles are associated with duplex systems. There are different schools of thought as to what the best form of definitive surgical management is in these patients. Some prefer an upper tract approach in which heminephrectomy is performed, but others prefer a lower tract approach in which excision of the ureterocele and reimplantation of the ureters is performed. Alternatively, upper or lower ureteroureterostomy can also be done. The presence or absence of reflux, as well determination of whether there is salvageable function of the upper pole segment that is associated with the ureterocele, can help determine which approach is most appropriate in individual patients. Regardless of whether one favors an upper or lower tract approach, most patients require initial endoscopic incision of the ureterocele to decompress the obstructed upper pole system. In some patients, endoscopic incision alone is definitive therapy with no further need for surgery. This is especially true in those with an intravesical ureterocele that is not associated with reflux. In other patients, additional upper or lower tract surgery will be needed after initial endoscopic incision.
Patient Positioning and Surgical Incision: Dorsal Lithotomy
Initial endoscopic inspection of the entire bladder and urethra should be done very carefully to determine numerous important anatomic factors: (1) the size of the ureterocele, (2) whether the ureterocele is entirely intravesical or whether there is an ectopic component in which there is extravesical extension into the urethra, and (3) the location of the ipsilateral lower pole orifice (in duplicated systems) and the contralateral orifice(s). The ureterocele should be inspected closely with various states of bladder filing because the ureterocele will decompress with the bladder full and will bulge and be more tense with the bladder empty. It is often much easier to see the associated ureteral orifices when the bladder is full with resultant decompression of the ureterocele.
Endoscopic decompression of the ureterocele can be accomplished with either a Bugbee electrode (puncture) or with a resectoscope peg (transverse incision). The location of the puncture or incision should be at the inferior and medial edge of the ureterocele ( Fig. 45.1 ). This gives one the best chance of avoiding subsequent reflux. It is best to perform the puncture or incision with the bladder mostly empty to allow the ureterocele wall to be tense. If the ureterocele is not bulging and tense, then the Bugbee electrode or resectoscope peg is more likely to slide off the wall of the ureterocele, which can increase the risk of making the incision in the wrong place or inadvertently injuring the contralateral orifice. Many ureteroceles are thick walled and require more than one pass with the Bugbee electrode or resectoscope peg to get entirely through the wall. Use of the cutting current with little to no cautery mix allows for a clean puncture or incision. One should observe full decompression of the ureterocele when the puncture or incision is adequate. If this does not occur, then the defect in the ureterocele wall needs to be further enlarged.
When the ureterocele is ectopic and has an extravesical component in which there is extension into the urethra, an additional puncture or incision needs to be made to prevent accumulation of urine in the urethral portion of the ureterocele, which can in turn cause secondary outflow obstruction ( Fig. 45.2 ). To accomplish this, a second puncture with the Bugbee electrode can be made in the most inferior portion of the urethral extension, or the resectoscope peg can be used to extend the ureterocele incision within the bladder longitudinally into the urethral extension with a T-configuration. A Crede maneuver should be performed afterwards to ensure that there is no outflow obstruction.