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Calcified ureterocoele causing renal tract obstruction in an adult

We believe this is the first report of a calcified ureterocoele, containing no calculi, and causing significant renal tract obstruction in an adult.

 

Corresponding Author: Ashley Ridout, Croydon University Hospital, Department of Urology, Croydon, UK. Email: [email protected]

Abstract
 
The ureterocele is an intravesical cystic dilatation of the terminal ureter, often due to a congenital weakness in the lower ureteric wall.  Adult orthotopic ureterocoeles, although more common in women, remain a rare clinical entity. We believe this is the first report of a calcified ureterocoele, containing no calculi, and causing significant renal tract obstruction in an adult. We report the case of an elderly Caucasian female patient, presenting with a calcified, right sided, simple orthotopic ureterocoele, mimicking a right vesicoureteric junction (VUJ) calculus.

 

Case Report
 
An 84-year old female presented to the emergency department with a short history of worsening right-sided abdominal pain. Cognitive function was well preserved despite significant medical comorbidities, including a previous cerebrovascular accident with residual right hemiplegia, atrial fibrillation (for which she was taking warfarin), giant cell arteritis, ischaemic heart disease and congestive cardiac failure. On general examination, the patient appeared cushingoid and was drowsy, confused, tachycardic and hypotensive. Abdominal examination revealed tenderness in the right loin and right iliac fossa, with no evidence of peritonism. Blood tests revealed acute renal failure (Ur 14.2, Cr 145), raised inflammatory markers (CRP >250) and a raised serum lactate (6.7). The patient was also in fast atrial fibrillation, with rate-related ischaemia evident on ECG.
The patient responded well to appropriate fluid resuscitation and intravenous antibiotics. Ultrasound of the renal tract reported right hydronephrosis, with a calculus at the right vesicoureteric junction. Subsequent CT scan of the abdomen & pelvis reported a calculus at the right VUJ and moderate right hydronephrosis and hydroureter (Figure 1a/1b).

 

Figure 1a. CT scan 

 

Figure 1b. CT scan 

 

Although no calculus was identifiable on limited IVU, hydronephrosis and hydroureter in a single collecting system with obstruction at the level of the right VUJ was reported. The ‘cobra head’ sign pathognomic of a ureterocele was not evident.
Once clinically stable and fit for general anaesthetic, retrograde ureteric stenting was arranged. During the procedure, a ureterocoele was noted at the right ureteric orifice. The site and appearance of the left ureteric orifice was cystoscopically normal. Transurethral de-roofing of the right ureterocoele was performed. No calculus was present in the ureterocele, or at the vesicoureteric junction. A ureteric stent was inserted without complication, and the patient recovered well from the procedure. Renal function normalised (Creatinine 79, Urea 7) and the patient was discharged three days after the procedure. The stent was removed without incident 4 weeks post-procedure, and the patient remains well.

 

Discussion
 
The ureterocoele is a congenital abnormality, commonly now identified with antenatal screening. Ureterocoeles may be either intravesical or ectopic in location, and there is a great clinical spectrum of symptoms and functional consequences. The precise aetiology of ureteroceles is uncertain – it is most widely accepted that obstruction of the ureteral orifice during embryogenesis, with incomplete dissolution of the Chwalla membrane, predisposes to ureterocoele formation. Occasionally, ureterocoeles are discovered in adulthood – these are typically intravesical, and associated with a single collecting system[1]. Presentation may include flank/back pain, recurrent urinary tract infections, urosepsis, voiding difficulty or loin to groin pain. In addition, they may be detected incidentally at endoscopy, or radiologically[1-5].  Stones are known to form in ureterocoeles, thought to be secondary to ureteral atony and urinary stasis – it is reported that stone formation in ureterocoeles in more common in males than females [1,5].
In our patient, the decision for retrograde stenting instead of nephrostomy and antegrade stenting was based on availability of resources at the time for urgent intervention.  If antegrade stenting were performed, the ureterocoele may not have been identified and treated, as was the outcome in our patient. Endoscopic management is the gold standard therapy for management for symptomatic adult ureterocoele [2,6].  Timely diagnosis and endoscopic de-roofing of obstructing ureterocoeles may avert recurrent presentations with infection and obstruction, and thereby significantly reduce subsequent morbidity. This is especially important in patients such as ours, with multiple other co-morbidities, which may be exacerbated by episodes of sepsis.
Adult ureterocoele, although an uncommon clinical entity, should be considered in the differential diagnoses of patients presenting with urinary symptoms. Cystoscopic examination in those presenting with refractory and/or severe urinary symptoms may allow correct and timely recognition and management of previously unidentified ureterocoeles.

 

Conclusion
 
We believe this is the first reported case of a ureterocoele mimicking a ureteric calculs. Our patient was admitted acutely unwell, with urinary sepsis and radiological findings suggestive of obstructing ureteric stone. The cystoscopic finding of a calcified ureterocoele, with no obstructing calculus, was unexpected. After definitive management of the ureterocoele, the patient recovered rapidly, and remains well.

 

References

 

1. Vasu TS, Elliot WC, Lai RS. Bilateral ureteroceles progressing to reversible acute renal failure in an adult.
Can J Urol. 2006 Feb;13(1):2993-6
2. Halachmi S, Pillar G. Congenital urological anomalies diagnosed in adulthood – management considerations.
J Pediatr Urol. 2008 Feb;4(1):2-7
3. Tomaszewski JJ, Turner RM 2nd, Ost MC. Stone Cobras: Adult bilateral single system ureteroceles presenting with multiple calculi.
Urology 2011 Feb 17 (Epub ahead of print)
4. Berger MB, Larson KA, DeLancey JO. An incidental finding: routing cystoscopy after pelvic floor reconstruction surgery revealed a bladder mass.
Am J Obstet Gynecol. 2010 Nov;203(5):518e1
5. Shamsa A, Asadpour AA, Abolbashari M, Hariri MK. Bilateral simple orthotopic ureteroceles with bilateral stones in an adult: a case report and review of literature.
Urol J. 2010 Summer;7(3):209-11
6. Singh I. Adult bilateral non-obstructing orthotopic ureteroceles with multiple calculi: endoscopic management with a review of literature.
Int Urol Nephrol. 2007;39(1):71-4

 

Date added to bjui.org: 17/10/2011 


DOI: 10.1002/BJUIw-2011-076-web

 

Vitamin D recommended intake

Vitamin D Recommended Intake

 

Most people should get some form of additional vitamin D. The bottom line is, if you spend a lot of time indoors or in an urban area, getting enough vitamin D is important for your overall health. Some people who spend a lot of time indoors and cannot get outside to get sunlight are supplementing with some type of D3 supplement, whether that be some of NuMedica’s vitamin D supplements or some other ones.


How Much Vitamin D Is Good?

 

Although the number one recommended daily allowance (RDA) for vitamin D is 200 IU per day, the RDA varies widely from country to country. If you’ve ever heard of the RDA, you’ve probably heard that a good RDA is 2,000 IU. Many adults in the United States would define a good dietary intake as at least 10,000 IU daily. According to the Institute of Medicine (IOM), the RDA is inadequate for more than 2 million American adults, which leaves many who do not meet the RDA low in the vitamin D column. If you don’t think your levels are adequate, then you may want to get an assessment done by an endocrinologist. That said, the basic formula of the RDA is based on the person’s weight and body fat to calculate total daily requirement. If you’re in the 7-9 range, then your average recommended RDA is around 1,300 IU for adults and 700 IU for children

 

Two Important Demographics That Need a Product with a Higher Requirement

 

This is especially true for children and pregnant women. While newborns are not yet active bodies, infants will start experiencing muscle mass loss and growth as they continue to grow.

 

Since only certain children or pregnant women are able to absorb enough vitamin D3, there are a variety of different types of D3 supplements available on the market to help make sure that you’re getting the right amount of Vitamin D3. 

 

It is often recommended that adults in the following age groups have 500 to 800 IU per day: Children from birth through 8 years and adults over 18 years of age. However, pregnant women often need more, so it would be advised to consult your doctor about your needed levels.

 

For more detailed information on how to measure your daily requirements of vitamin D, please see your physician.

 

 

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