We report a case of giant hydroureter of an upper moiety presenting as abdominal lump.
Authors: Javali, Tarun; Gupta, Narmada
Corresponding Author: Tarun Javali, A.I.I.M.S., Urology department, New Delhi, India. Email: [email protected]
Most patients with duplex kidneys are asymptomatic, with genitourinary abnormalities being detected incidentally on imaging performed for some other reasons. In complete duplication, the upper pole ureter usually drains caudal and medial to the lower pole ureter (Weigert Meyer rule). Ectopic insertion of the upper pole ureter may cause hydronephrosis as a consequence of stenosis of the ureteric orifice. However massive dilatation of just the upper pole ureter (with a small and atrophic upper pole renal moiety) is rare. Here we report a case of giant hydroureter of an upper moiety presenting as abdominal lump.
A 31 year old male presented with dull ache in his right flank and progressively increasing abdominal swelling for the previous 8 months. There was no history of fever or lower urinary tract symptoms. The patient also gave a history of constipation for the past month. Examination revealed an ill-defined abdominal mass, soft in consistency, and occupying the right flank and right hypochondrium, extending into the right iliac fossa and umbilical regions.
On rectal examination, a soft cystic mass was palpable anterior to the rectum and causing extrinsic rectal compression.
Routine blood and urine tests were within normal limits. A contrast enhanced CT scan of the kidneys, ureters and bladder [Fig. 1] and an MR urogram [Fig. 2] were performed.
Figure 1. CT scan of the kidneys, ureters and bladder
Figure 2. MR urogram
A voiding cystogram showed no evidence of vesicoureteric reflux. On cystoscopic examination, the ectopic orifice of the right upper moiety ureter could not be identified. The right lower moiety ureter was stented. Transperitoneal laparoscopic upper pole nephroureterectomy was performed [Fig.3].
Figure 3. Transperitoneal laparoscopic upper pole nephroureterectomy
After ligating the upper pole renal vessel, the abnormal ureter was dissected close to its wall. The giant hydroureter contained 8 litres of turbid urine. The ectopic ureter was found opening into the posterior urethra. A 3cm Gibson incision was performed for specimen removal [Fig.4].
Figure 4. A 3cm Gibson incision was performed for specimen removal
This case has been reported to highlight the extent to which a ureter can dilate. There are only a few cases of duplex kidney/ectopic ureter reported in the literature in which the ureter has assumed such massive proportions, completely overshadowing the renal pelvis and parenchyma. Uson et al reported a case of a giant ectopic ureter presenting as an abdominal mass in a newborn infant . Mahajan et al reported a case of an adult woman who had unilateral upper-pole giant hydroureter in a duplex kidney which was incidentally detected during cesarean section . Heminephrectomy was performed, and the hydroureter was found to contain 2 litres of fluid. Whitmore et al reported a case of giant hydronephrosis of a duplex system associated with ureteral ectopia .
In the present case, the ectopic ureter of upper moiety of the right kidney was dilated to such an extent, that it presented as an abdominal mass and also caused constipation due to extrinsic rectal compression. Laparoscopic upper pole nephroureterectomy was successfully carried out and the patient’s symptoms were relieved after surgery.
1. Uson AC, Womack CE, Berdon WE. Giant ectopic ureter presenting as an abdominal mass in a newborn infant. The Journal of Pediatrics. 1972; 80:473-76.
2. Mahajan NN, Sahay S, Kale A, Nasre M. Unilateral upper-pole giant hydroureter in a duplex renal system: an incidental finding in cesarean section. Arch Gynecol Obstet. 2008; 278:149-51.
3. Whitmore RB, Schellhammer PF. Giant hydronephrosis of a duplex system associated with ureteral ectopia. J Urol. 1989; 141:1186-8.
Date added to bjui.org: 29/09/2011