A simple Ureterocoele with multiple small stones is reported in young male child without any predisposing factors, IVP done as the investigation of choice and open surgical excision of the ureterocoele done.
A ureterocoele with multiple small stones is a
rare entity and not much of the reports have been published with such kind of presentation, as the case we are reporting. Fewer than 10 reports are available in English literature having ureterocoele with multiple small calculi without any predisposing factors.
Ureterocoele is a cystic dilatation of the intravesical submucosal ureter.
Types of Ureterocoele
Intravesical are entirely within the bladder.
Ectopic : Some portion of it is situated permanently at the bladder neck or urethra, regardless of position of orifice.
Simple is contained entirely with in the bladder.1
Ureterocoeles are seven times more common in girls than boys.2
Incidence of ureterocoele reported in 1951 by Campbell to be 1 in 4000 autopsies in children.
We report a case of 8 year old male child presented in emergency with retention of urine, with no past history of urinary complaints, haematuria, fever or abdominal pain.
Patient averagely built and nourished with normal vital parameters.
On palpation bladder was full with lower abdominal tenderness with a small meatal stone.
Blood investigations were normal along with calcium levels.
Plain radiograph of K.U.B revealed multiple small stones in right ureter, bladder and urethra.
Intravenous urogram revealed Rt. sided large simple ureterocoele with multiple small stones protruding within the bladder and few multiple small stones within the right kidney along with mild back pressure changes and early signs of right sided hydronephrosis.
Simple ureterocoele will appear as a typical cobra head deformity produced by opacified urine in the ureterocoele surrounded by a radiolucent Halo produced by the wall of ureterocoele.3 Multiple calculi in the ureterocoele, kidney and ureter.4
On admission meatal stone was milked out to relieve the obstruction and per urethral catheter passed to drain urine.
Patient operated under GA with midline suprapubic incision, bladder opened which revealed thin walled large Rt. ureterocoele filled with multiple small stones. Pinhead size ureteric opening seen which was getting obstructed by the stone. Stones removed and ureteric orifice dilated, after removing all stones from the ureterocoele, bladder and urethra a simple rubber catheter introduced proximally in the Rt. ureter till the pelvis and was flushed repeatedly to extract the retained stone [approx size of stones - .9 cm x .8 cm x .7 cm] Intraop K.U.B. X-ray done, was showing no stones. Urethral catheterisation performed. Bladder closed by 2-0 vicryl and corrugated rubberdrain placed. Abdomen closed in layers.
Chemical Analysis of Stone Revealedcalcium oxalate, Calcium phosphate, Calcium carbonate.
Stone formation in the urinary system requires the consideration of 4 factors. Urinary supersaturation, crystal growth inhibition, partical retention and matrix.5 Epidemiological data suggest that climate, geography, diet are important factors in the pathogenesis of urolithiasis. Primary hyperparathyroidism is the most common hypercalcaemic condition associated with urolithiasis and is responsible for stone formation.
Endoscopic surgeries for ureterocoele has been recommended, but open surgery with complete excision can also be done.6
Useful investigation is I.V.P in the case of ureterocoele.7
Endoscopic surgery of calculi in ureterocoele
Out of 366 patients with lower ureteral calculi operated upon by the author, 25 had a stone in Ureterocele.8 Operation is necessary as these stones cannot be passed spontaneously.
If endoscopic surgery is undertaken, the following must be taken in to account : The ureteral tone, size and number and types of ureterocoele. In all cases endoscopic smiling mouth incision associated in 6 cases used with lithotripty.
- Erricson - Ectopic ureterocoele in infants and children. Acta Chir Scand 1954; 197 : 1-93.
- Eklof, et al. 1978.
- Textbook of Genito Urinary Surgery, by HN Whitefield and W.F. Hendry Volume - 1.
- Fig. No. 582, 583, 584 in the Colour Atlas of Urology by RW Lloyd-Davies, JG Gow, DR Davies.
- Burn and Finlayson - 1983.
- Ashcarft and Hendren - 1979, Lasers Surg Med 2002; 31 (5) : 297-8.
- Berdonet, et al. 1968, Sherwood and Stevenson 1969, Williams et al -1972.
- Rodrigues JV. Eur Urol 1984; 10 : 36-9.