Case Report 524 CASE REPORT Endoscopic Dilatation of Meatal Stenosis of Ureterocele in Adult Patients: An Easy and Innovative Technique with Literature Review Abbas Basiri1,2*, Milad Bonakdar Hashemi1, Arsalan Aslani1 This study presents initial experience in endoscopic meatal dilatation of obstructive ureterocele in adult patients. During cystourethroscopy, we tried to find the orifice of ureterocele, passed a guide wire and introduce an 8 Fr ureteroscope in to the ureterocele orifice, going up to the renal pelvis as under vision dilatation of ureterocele me- atus. Two Double-J stent were inserted and remained for six weeks to keep the meatus dilated. Adverse effect of endoscopic management was decreased due to minimal anatomic changes. Patients’ symptoms were relieved and no evidence of new onset vesico-ureteral reflux and obstruction were seen after up to one-year follow-up. Endo- scopic meatal dilatation of stenotic ureterocele in adult patients is safe and effective thus, trying to find the orifice of ureterocele is suggested. Keywords: meatal dilatation; ureterocele; ureteroscope INTRODUCTION Ureterocele is a cystic dilation of the distal ureter. It is a congenital anomaly, associated with other anomalies such as a duplicated system and other diseases(1). There is no consensus on the management of ureterocele, type of presentation, and function of the affected kidney, and there are issues that should be considered in uret- erocele cases. Thus, individualized management is expectable (1). The ureterocele in an adult patient is rare and usually asymptomatic. The management of ureterocele mainly have focused on pediatric patients in the literature. Endoscopic approach has been accepted as a temporary technique and was introduced as a useful surgical man- agement with minimal postoperative morbidity(2). Ureteral re-implantation and/or bladder neck reconstruction is not necessary for all patients especially in adult patients(3). The successful management of ureterocele is associ- ated with relieving the obstruction, and prevention of de novo vesicoureteral reflux (VUR)(4). High incidence of acquired VUR (up to 35%) in endoscopic approach has been reported and it was associated with endoscopic tech- niques (transurethral incision (TUI), watering can technique) and ureterocele type(3,4). We present successful endoscopic meatal dilatation in adult obstructive ureterocele without adverse impact on outcomes. 1Urology nephrology research center (UNRC), Shahid Labbafinejad medical center, Shahid Beheshti university of medical sciences, Tehran, Iran 2Erfan hospital, Tehran, Iran *Correspondence: Urology nephrology research center (UNRC), Shahid Labbafinejad medical center, Shahid Beheshti university of medical sciences, Tehran, Iran. E mail: unrc.ir Received November 2019 & Accepted April 2020 Urology Journal/Vol 18 No. 2/ March-April 2021/ pp. 240-246. [DOI: 10.22037/uj.v0i0.5808] Figure1. Pre-operative Intravenous Urography (IVU). CASE PRESENTATION AND TECHNIQUE A) A forty-year-old man was referred to our clin- ic with the complaint of vague abdominal pain for years and hydroureteronephrosis on abdominopelvic ultra- sonography. The orthotopic single system ureterocele was obsereved in intravenous urography (IVU) (Fig- ure 1). During cystourethroscopy, the pinpoint orifice was found at the anterolateral of ureterocele with sharp urine jet through the orifice (Figure 2A). The safety wire was inserted, and with 8Fr ureteroscope via na- tive orifice we were able to enter into the ureter and continue up to the renal pelvis under vision dilatation procedure (Figure 2B). Then two Double-J stent were inserted to keep the meatus dilated (Figure 2C). After 6 weeks, both Double-J stents were removed. There was no evidence of de novo VUR and obstruction after 12 weeks of follow up (Figures 3,4). The urinary stasis after one year follow up was resolved. B) A forty-three-year-old man came to our clinic with left renal colic pain due to a one-centimeter ure- tero-vesical junction stone (Figure 5A). The patient was being prepared for transurethral lithotripsy. During cystoureteroscopy, ureterocele was found incidentally with a pinpoint orifice. 0.038 Fr guide wire was insert- ed, 8 Fr ureteroscope was passed through the uretero- cele orifice, the stone was extracted and removed with grasper and ureteroscopy was continued up to the renal pelvis (Figure 5B). After removing the ureteroscope, the ureterocele meatus remained dilated enough and urine jet was seen. Two Double-J stent were inserted to keep the meatus dilated. After 6 weeks, both Double-J stents were removed. The voiding cystourethrography (VCUG) was normal 12 weeks post-operation. There was no evidence of hydronephrosis on abdominopelvic ultrasonography in one-year follow-up. C) A thirty-year-old woman with a complaint Meatal dilatation of adult ureterocele-Basiri et al. Figure2. A. Intra-operation urine jet from pin point native orifice of ureterocele, before endoscopic dilatation. B. Intra-operation insertion of guide wire. C. Insertion of two Double-J. Figure 3. Post-operative DTPA Scan after 12. Case Report 241 Vol 18 No 2 March-April 2021 242 of recurrent urinary tract infection was referred to our clinic. The patient had a history of laparoscopic hem- inephrectomy due to non-functioning lower pole left kidney with complete double collecting system and also history of right side nephrectomy twenty years before referral due to non-functioning kidney with unknown etiology. Pre-operative evaluation consisted of serum creatinine (1.7 mg/dL) and normal ultrasound on the remaining part of the left kidney. On the cystourethros- copy, there were two ureteral orifices on the left side of trigone (cephalad one for lower moiety and caudal one on the tip of ureterocele for upper moiety) (Figure 6A). A guide wire was inserted to the cephalad orifice to make sure that was for lower moiety with no connection to the upper moiety. The second safety guide wire was inserted into the ure- terocele orifice (Figure 6B) and 8 Fr ureteroscope was passed through the native orifice of the ureterocele up to the renal pelvis. After removing the ureteroscope, the ureterocele orifice was seen to be dilated enough and urine jet was seen. The Double-J stent was inserted (Figure 7) and removed after six weeks. On one-year follow-up, the patient was asymptomatic and the urine culture was negative. D) A thirty-five-year-old man was referred to our clinic with refractory irritative lower urinary tract symptoms. Abdomino-pelvic ultrasonography showed right side moderate hydroureteronephrosis without any apparent causes of obstruction. The single system ure- terocele was seen in IVU (Figure 8). The patient was scheduled for endoscopic management of ureterocele, during cystourethroscopy native meatus of ureterocele was apparent (Figure 9) and guide wire 0.038(Fr) was inserted and 8 Fr ureteroscope was passed through the native orifice of ureterocele over the guide wire and ureteroscopy continued up to the renal pelvis. After removing the ureteroscope, the ureterocele orifice was seen to be dilated enough and urine jet was seen. The Double-J stent was inserted. After limited follow-up (three months) hydroureteronephrosis was relieved in ultrasonography and IVU (Figure 10). Figure4. Post-operative VCUG after 12 weeks. Figure5. A. Pre-operative abdomino-pelvic CT-Scan without contrast. B. The large stone located in ureterocele. Meatal dilatation of adult ureterocele-Basiri et al. DISCUSSION Most adults ureteroceles are in single system, intravesi- cal, and located on the trigone of bladder. The therapeu- tic management of ureterocele is controversial, which is related to the type of presentation and postoperative morbidity. Short operation time and acceptable out- comes of endoscopic approach have made the endo- scopic procedure the first-line therapy at some centers (5), however according to previous studies, there is no consensus on any priority for the type of endoscopic techniques(6) (Table 1). The high incidence of VUR and the necessity of auxil- iary procedures in endoscopic approaches are consid- ered as disadvantages of transurethral incision (TUI) or puncturing(4,6). The goals of endoscopic techniques are to decompress the obstructed system while minimizing the incidence of postoperative reflux(7), therefore, less manipulation of anatomic integrity in ureterocele is an important technical point to reach these goals. We went through literature for treatment of adult ureter- ocele and summarize them in Table 1. Dutov and colleagues studied 51 patients with true ure- terocele in adult patients in which 26 patients under- went endoscopic incision wall of ureterocele. Incidence of de novo VUR was not reported(8). Also Sadiki and Figure 6. A. Insertion of guide wire to lower moiety remnant ureter. B. Intra-operation insertion of guide wire. Figure 7. Post operation KUB. Meatal dilatation of adult ureterocele-Basiri et al. Case Report 243 with ureterocele who underwent TUI and were followed by ultrasonography and micturating cystourethrography (MCU). MCU revealed grade-1 VUR in three patients and grade-2 VUR in one patient at 3-month follow-up. Repeated MCU at six months revealed complete reso- lution of VUR in these patients(6). Based on previous reports that were shown in Table 1, it seems that there is no consensus for the location, length, and instrument for ureterocele incision and sometimes there is no confidence to cut the full thickness of ure- terocele wall. It seems that our technique can offer a uniform procedure for every surgeon by details of the procedure and have the answer for above mentioned unanswered technical questions with acceptable out- comes. CONCLUSIONS We introduce our initial experience in the endoscopic management of adult ureterocele. It seems that meatal dilatation of stenotic ureterocele without changing an- atomic integrity is a safe, feasible, and effective endo- scopic technique for relieving obstruction and prevent- ing new-onset VUR. Figure 10. Post-operative Intravenous Urography. Author Year of Number of Endoscopic Secondary Incidence of. VUR Occurrence of post study patient technic intervention post op op. obstruction Rodriguez(10) 1984 25 Smiling mouth incision None 1 (4%) Not reported Gotoh (11) 2000 1 Small Incision None Nil Not reported Chtourou (12) 2001 20 endoscopic horizontal None 1 (5%) – resolved Not reported ureterocele incision after six months Aron (13) 2001 1 Holmium laser incision None Nil at 3 months Not reported Jones (14) 2002 2 Holmium laser incision None Not specified Not reported Lieb (15) 2003 1 Holmium laser incision None Not specified Not reported Dutov (8) 2004 51 Incision wall of ureterocele None Not specified Not reported Sadiki (9) 2005 14 Endoscopic meatotomy 1 (7%) resection of the 5 (35.7%) resolved after Not reported ureterocele and Hendren three months ureteric reimplantation 1 (7.14%) Persistent after six months Spatafora (16) 2006 15 Collins knife incision None 3 (20%) Not reported Singh (17) 2007 2 Transverse incision None Nil at 6 months Not reported Shah (6) 2008 16 Holmium laser incision None 4 (25%) resolved after Not reported six months Table 1. 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