Ureterocele is a cyst that forms when the ureter is covered by mucous membrane at the point where it enters the bladder. Usually there is a very small hole at the tip of this cyst, and although urine can slowly leak out, the obstruction is so severe that it causes ipsilateral urological dilatation (ureteral effusion, giant ureter, or even hydronephrosis). This malformation is more common in girls (male:female = 1:4), more common on the left side, but also affects both sides (10%). The majority (80%) of ureteral bulges originate in the upper half of the duplicated kidney. The (monosystemic) symptom finding without a heavy kidney may be delayed in the adult age group. Symptoms Today many of them are detected by prenatal ultrasound (about 30% or more). Ureteral bulge can lead to ipsilateral urinary obstruction, resulting in hydronephrosis and giant ureter. Those with prolapsed ureters can lead to urinary tamponade. The flow of water does not rot, and the household is not worm-eaten. Conversely, when the urinary system is not usual, urinary tract infections, even stones, and sepsis can occur. The child’s symptoms can be urinary urgency, incontinence, high fever, vomiting, or difficulty urinating. Physical examination can sometimes reveal a bulging ureteral prolapse (cecoureterocele) in girls. Painful pressure may be felt in the bladder and even in hydronephrosis or kidney abscesses. Some may cause urinary incontinence or urgency. The purpose of these tests is to determine whether there are duplicated kidneys, whether the urinary system is obstructed, and how much kidney function there is on each side. Only when these facts are known, together with the clinical symptoms (frequency of infection), can the pros and cons of the various factors be balanced and the right treatment plan be made. 1. Renal ultrasound can require a trained and experienced physician to show many malformations, ureteral bulges, duplicated kidneys, duplicated ureters, etc. There is no radiation. There is no radiation. 2. Magnetic resonance imaging (MRU) is becoming more and more common and can show very clear anatomy through 3D imaging. With the addition of a control agent (Gadolinium), it is possible to calculate the renal excretion function. The advantage of this test is that there is no radiation. The disadvantage is that it requires the child to lie still for 20 minutes. In many cases, sedation or light general anesthesia is required. 3. The nuclear scan (MAG3) not only further identifies duplicate kidneys, but also determines the function of each kidney in detail. This is important when deciding whether the upper half of the kidney should be removed for poor function. The radiography is actually lower than an X-ray. 4. CT scan + control agent. The procedure is quick, but there is greater radiation. Both intravenous pyelogram (intravenous pyelogram) and voiding cystourethrography (voiding cystouretherogram) can show filling defects. Personally, I believe that at least one of the MRI or nuclear scan should be added to the ultrasound to determine renal function. Treatment Babies with ureteral dilatation detected prenatally should be started on prophylactic antibiotics immediately after birth to reduce urinary tract infections. Difficulty in urination should be followed by immediate catheterization. Among pediatric urologists, there is still a debate between superior and inferior access methods of treatment (J Pediatr Urol. 2015 Feb;11(1):29.e1-6.). Because of this rarer malformation, it is more difficult to do prospective double-blind comparative studies of treatment outcomes. The superior approach advocates a one-time resection of the upper half of the kidney as well as its ureter (heminephroureterectomy) or an uretero-ureteral telangiectomy (trans-uretero-ureterotomy), which is a larger procedure. The inferior approach is advocated to incise the ureteral bulge first and then deal with the possible vesicoureteral reflux afterwards. Here I describe my personal, individualized approach from the bottom up. The most serious problem of ureteral bulge is urinary obstruction. By using a non-invasive cystoscope and cutting through the ureteral bulge with a cold knife, laser, or electrodesiccation, the urinary tract can be opened immediately and the chance of infection is greatly reduced (this ureteral bulge is traditionally an open bladder procedure). After surgery The child can be discharged immediately after surgery. This cystoscopic procedure is sometimes not easy to do. When I worked at Prince of Wales Hospital in Hong Kong, I saw the director, Professor Yeung Chung-kwong, use a minimally invasive method of removing the ureteral bulge with a clear view of the bladder, which is very safe (unpublished). About half of the children will have some vesicoureteral reflux after surgery. Much of this reflux will heal spontaneously. This practice is more popular in Australia and Hong Kong. Those children who still have an infection can be treated further on an individual basis, possibly when the child is older, on an elective basis. If the upper kidney in question still has some function, then a double barrel can be considered. If there is no function left, heminephroureterectomy may be considered. A Spanish pediatric urology team recently summarized their experience in the international journal “Urology” (Urology. 2015 Dec 7.) and my opinion is the same.