Orthotopic ureterocele masquerading as a bladder tumor in a woman with pelvic pain

Abstract

Single system orthotopic ureteroceles often present in adulthood are associated with characteristic radiographic findings. We present the case of a 54 year old woman with 8 months of urgency/ frequency and pelvic pain that has the cystoscopic appearance of a bladder tumor. Cystoscopic images, radiographs and intraoperative photos demonstrate the work-up, evaluation, and treatment of this unique single system orthotopic ureterocele containing a calculus. This patient demonstrates the need for cystoscopy accompanied by upper tract imaging in patients with new onset pelvic pain, urgency/frequency, and frequent urinary tract infections. CASE REPORTA 54 year old white female was referred from her gynecologist for a bladder tumor. The patient had complained of worsening lower abdominal and pelvic pain accompanied by urinary urgency/frequency for the past 8 months. Treatment of four separate culture proven E. coli urinary tract infections with appropriate antibiotics failed to relieve the patient's symptoms. Diagnostic cystoscopy was performed to evaluate the complaints and the patient sent to urologist for the finding of a bladder tumor.Past medical history was significant for osteoporosis and carpal tunnel repair. The patient was a hair dresser with a 30 pack-year smoking history. The patient denied any previous urologic history including calculi or hematuria. Physical exam revealed a physically fit female without costo-vertebral tenderness. Laboratory evaluation revealed only microscopic hematuria with negative urine cytology.In office cystoscopy was performed that revealed a papillary bladder tumor present at the right lower posterior portion of the bladder (Figure-1). The right ureteral orifice could not be identified. An excretory urogram was performed that revealed a nonobstructing, single system, distal right ureteral calculus surrounded by a radiolucent ring (Figure-1). Pelvic CT scan demonstrated what appeared to be a stone contained in a distal right ureterocele (Figure-2).The patient was taken to the operating room and cystoscopy performed. One ampoule of intravenous indigo carmine solution was given that eventually was secreted from the ureteral orifices. Once the opening of the right ureteral orifice was identified via secretion of the blue dye, a 5F open-ended catheter was placed inside the orifice into the kidney under fluoroscopic vision (Figure-2). The orifice was then sliced open utilizing endoscopic shears exposing a large stone (Figure-2). The stone was removed from the bladder and the ureteral stent removed.At the six month postoperative visit the patient noted complete resolution of her voiding symptoms and pelvic discomfort. She had no further documented urinary tract infections during that time. A

Zinner′s Syndrome

“…It may also contain a stenotic portion which would cause the ureterocele to look like a “cobra head” on an urogram. [6] In the CT pelvis, the mass does indeed seem like an ureterocele since it is round inside the bladder wall and is unilateral. The position of insertion matches where the ureter would have inserted.…”

Minimally-invasive treatment of complicated ureteroceles in adults avoiding vesico-ureteric reflux

“…In the literature there are cases of sliding ureteroceles causing bladder outlet obstruction accompanied by sharp, intermittent flank pain [13]. Another case report told about a woman with worsening lower abdominal and pelvic pain accompanied by urinary urgency/frequency for over eight months where an orthotopic ureterocele masquerading as a bladder tumor was found by cystoscopy and upper tract imaging and where a calculus in the distal intravesical portion of the ureter also was present [14]. The urinary stasis in the dilated distal "Cobra-head" shaped part of the ureter often favors the development of stones.…”