Pediatric ureterocele

　　One, Etiology

　　In terms of embryogenesis, ureterocele is caused by the delayed rupture of the Chwalla membrane. The Chwalla membrane exists in the normal embryo, located between the ureter and the urogenital sinus. The delayed rupture of this membrane leads to the dilation of the distal ureter, narrow opening, and is divided into simple and ectopic types according to the relationship between the position of the ureteral orifice and the ureterocele. The former, orthotopic ureterocele, is slightly deviated from the normal position and often smaller, with less impact, and is more common in adults, also known as adult type. Ectopic ureterocele is often larger and associated with double ureters of the heavier kidney, with the two ureters penetrating the bladder muscle layer at the usual location, the lower pole ureter opening at the bladder trigone, and the ureter with the ureterocele draining the upper pole, located in the submucosa, opening at the bladder neck or posterior urethra. Clinically, there are also cases between the two types.

　　Two, Pathogenesis

　　Ectopic ureterocele associated with double ureters of the heavier kidney occurs in the upper pole ureter of the heavier kidney. The upper pole is often dilated due to back pressure and often accompanied by pyelonephritis; it is very common for there to be renal dysplasia with fetal glomeruli, tortuous tubes, and small cysts, which is speculated to be due to severe urinary tract obstruction during fetal development, leading to underdevelopment of the upper pole. The contralateral lower pole kidney, according to the tension of the ureterocele, can have obstruction and reflux, causing hydroureter, and large ectopic ureterocele can occupy the bladder outlet and proximal urethra, thus affecting bladder emptying, and the child may have difficulty urinating, and contralateral renal hydroureter may also occur.

　　If pediatric ureteral prolapse is not treated in time, it can cause recurrent urinary tract infections in children, which may be complicated by calculus, ureteral reflux, or hydronephrosis. If the obstruction is not relieved, it will eventually lead to renal failure, leading to uremia. Therefore, it is necessary to treat it in time.

　　1. Ureteral ectopia is mainly manifested by urinary tract obstruction with concurrent infection, with symptoms such as recurrent fever, pyuria, and varying degrees of urinary difficulty, urinary line interruption, hematuria, and even calculus. In infants, there may be growth and development retardation or non-specific gastrointestinal symptoms, and abdominal masses can also be palpated. Since the ectopic ureteral ectopia is located at the neck of the bladder or and the posterior urethra, during urination in girls, part of the bulge can prolapse outside the urethral orifice. But it is also occasionally seen that the ureteral ectopia is strangulated to form a large hemorrhagic mass. If urinary tract obstruction is severe, bilateral kidneys are affected by back pressure and infection, and long-term urinary tract infection and obstruction are not released in time, it will lead to renal failure, which can lead to uremia. For infants and young children, especially females with recurrent urinary tract infections, urinary difficulty, or a recurrent small mass at the urethral orifice, this condition should be considered, and intravenous urography should be performed. If the renal function is good, intravenous urography should be performed.

　　2. It can be seen that there are round urinary tubular bulges filled with drugs in the bladder and thin bulge walls. When the upper pole of the upper kidney with double ureters associated with heavy kidney due to back pressure, hydronephrosis, infection, and malfunction does not show shadowing, the lower kidney with shadowing can be seen due to compression and downward displacement, and present maldevelopmental morphology. At the same time, a circular smooth filling defect can be seen at the neck of the bladder. Sometimes, the local wall of the bulge is too thin, and it is concave and seems to be lobulated. Cystoscopy is easy to identify the circular smooth urinary tubular bulge, semi-transparent, covered with normal bladder mucosa, but it is often too large to see the whole picture due to the bulge.

　　1. This condition belongs to congenital developmental abnormality, and there is no definite preventive measure (refer to the prevention methods of congenital diseases). In order to reduce the incidence of this condition, prevention should start from pre-pregnancy and extend to pre-natal period. Pre-marital physical examination plays a positive role in preventing birth defects, and the size of its role depends on the items and content of the examination, mainly including serological tests (such as hepatitis B virus, syphilis spirochete, HIV), reproductive system examination (such as cervical inflammation screening), general physical examination (such as blood pressure, electrocardiogram), and inquiries about family and personal medical history. Good genetic counseling work should be done, and pregnant women should try to avoid harmful factors, including staying away from smoke, alcohol, drugs, radiation, pesticides, noise, volatile harmful gases, and toxic and harmful heavy metals. During the process of prenatal health care during pregnancy, systematic screening for birth defects should be carried out, including regular ultrasound examination, serological screening, and chromosome examination when necessary.

　　2. Once an abnormal result occurs, it is necessary to determine whether to terminate the pregnancy; the safety of the fetus in the uterus; the presence of sequelae after birth, whether it can be treated, and the prognosis, etc., and take practical and feasible diagnostic and treatment measures.

　　When complicated with infection or calculus, hematuria may occur, with a significant increase in white blood cells, a significant increase in peripheral white blood cells, and possible signs of renal function damage such as increased blood creatinine. The diagnosis of ureteral cyst mainly relies on intravenous urography and B-ultrasound examination.

　　1. Urinary tract imaging:During urinary tract imaging, the bladder cysts with a single ureter can be seen as a snake head-like shadow at the distal ureter, and the surrounding annular shadow is the wall of the ureteral cyst. The upper half of the kidney caused by the merging of duplicated ureter and ectopic ureteral cyst is often not visible due to poor function. The visible lower kidney is displaced outward and downward, showing a hanging lily shadow. Smooth filling defects can be seen at the base of the bladder, and this shadow must be distinguished from bladder calculi, blood clots, and bladder tumors.

　　2. Ultrasound examination:The renal pelvis, ureteral hydronephrosis, cysts in the bladder or at the tail side of the bladder can be detected, and cysts with a diameter of more than 1 cm in the bladder can be detected.

　　3. Cystoscopy:Small cysts can be observed clearly, and large ectopic cysts with vascular distribution on thin cyst walls and rhythmic contraction and filling of cysts can be seen.

　　Dietary recommendations for pediatric ureteral prolapse patients mainly include the following points: 1. Mainly eat light food, pay attention to nutritional content, and pay attention to dietary regularity. 2. Eat rationally according to the doctor's advice.

　　1. Treatment

　　For small simple ureteral ectasia without urinary tract obstruction or clinical symptoms, treatment is not required. However, for ectopic ureteral ectasia with concurrent urinary tract obstruction, in addition to using antibiotics to control urinary tract infection, the surgical method is determined according to the condition of the affected kidney and ureter. If the upper half of the affected kidney function is poor, then nephrectomy of the upper half of the affected kidney should be performed; if there are still symptoms after surgery, the ureteral ectasia should be treated again. If the renal function of the affected side is good, then the ureteral ectasia resection and anti-reflux ureterovesical reanastomosis should be performed, or a hole should be opened at the bottom of the ureteral ectasia through the urethra.

　　2. Prognosis

　　If there is severe loss of renal function or developmental abnormalities, it will affect the prognosis. Mild cases may have no obvious symptoms and do not require treatment. After surgery to relieve obstruction, symptoms are often relieved.