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Video: Step-by-Step. Robotic assisted laparoscopic ureteral reimplantation – Extravesical approach

Robot-assisted laparoscopic ureteric reimplantation: extravesical technique

Pankaj P. Dangle 1,*,Anup Shah 2 and Mohan S. Gundeti 3,4

1 Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA

2 Pritzker School of Medicine, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA

3 Center for Pediatric Robotic and Minimal Invasive Surgery, Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA

4 Comer Children’s Hospital, Chicago, IL, USA

Objectives

To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation.

Patients and Methods

A total of 29 children, with high grade (III–V) vesico-ureteric reflux (VUR) underwent robot-assisted extravesical ureteric reimplantation between September 2010 and September 2013. Follow-up renal ultrasonography was performed at 1 month and 3 months and a voiding cysto-urethrogram (VCUG) was obtained at 4 months to assess VUR resolution.

Results

The mean (range) patient age at the time of surgery was 5.38 (3.0–10.0) years. Postoperative VCUG showed complete resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1–3) days.

Conclusions

In conclusion, robot-assisted extravesical ureteric reimplantation is technically feasible with acceptable resolution of VUR.

Primary small cell carcinoma of the ureter with hydronephrosis

We report a case of primary small cell carcinoma of the ureter with hydronephrosis.

Authors: Zhao Zhenhua (1), Wang Boyin (1), Yang Jianfeng (1), Wang Ning (2), Pan Shouhua (3)
1. Department of Radiology, Shaoxing People’s Hospital (Zhejiang University Shaoxing Hospital) Shaoxing, Zhejiang, China
2. Department of Pathology, Shaoxing People’s Hospital (Zhejiang University Shaoxing Hospital) Shaoxing, Zhejiang, China
3. Department of Urology, Shaoxing People’s Hospital (Zhejiang University Shaoxing Hospital) Shaoxing, Zhejiang, China

Corresponding Author: Yang Jianfeng Department of Radiology, Shaoxing People’s Hospital (Zhejiang University Shaoxing Hospital) 568 Zhongxing North Rd, Shaoxing, Zhejiang, China

 

Introduction
Small cell carcinoma (SCC) is usually found in the lungs, and its extrapulmonary counterpart is rarely encountered. Primary small cell carcinoma (PSCC) of the ureter with hydronephrosis is extremely rare. We report a 70-year-old woman who presented with left-sided flank pain. The clinical impression and diagnosis following renal ultrasound was of a calculus in the distal left ureter. Abdominal and pelvic CT indicated a mass near the distal ureter with pronounced hydronephrosis. The patient underwent left nephroureterectomy. Histological and immunohistochemical staining confirmed PSCC of the ureter. After 9 months, the patient was found to have massive metastases in the liver and lungs, lymphadenopathy in the retroperitoneum, and para-aortic region, and several implantation metastases in the bladder and left psoas major. Radiologists and clinicians should be aware of the possibility and severity of malignant PSCC of the ureter in patients with hydronephrosis.

Case report
A 70-year-old woman presented with left-sided flank pain without the symptoms of bladder irritation and gross hematuria. The pain was continuous with paroxysmal irritation radiating to the hypogastrium and groin. It was accompanied by nausea but no vomiting. Physical examination was unremarkable except for sensitivity to percussion in her left renal region and tenderness over the course of the left ureter. Urinalysis indicated leukocytes (+) in her urine specimen; her other laboratory data were within normal limits. Ultrasonography revealed one 6-mm diameter calculus in the distal left ureter with hydronephrosis. The pain did not improve after several days’ treatment with anti-inflammatory agents and analgesia. The patient then underwent intravenous urography (IVU), abdominal and pelvic computed tomography (CT), and chest radiography.

The IVU showed a left hydroureter (Fig. 1A). The CT indicated pronounced left hydronephrosis and thickened perirenal tissue within the wall of the left upper ureter. Abdominal multiplanar reconstruction (MPR) demonstrated a mass near the end of the ureter and the thickened, irregular wall of the upper ureter with pronounced hydronephrosis (Fig. 1B). We did not observe any lymphadenopathy in the pelvis, retroperitoneum, or para-aortic regions. A chest radiograph was reviewed, and no abnormality was seen.

The patient underwent left nephroureterectomy. Macroscopically, a 1.6 × 1.2 × 0.5–cm grayish white lesion was identified.. Histological examination revealed that the mass was composed of small cells with hyperchromatic nuclei, round to fusiform in shape, exhibiting a high level of mitotic activity but little cytoplasm and an absence of nucleoli [Fig. 2A]. Immunohistochemical staining of the specimen was positive for chromogranin A (CgA) [Fig. 2B], CD56, synaptophysin (Syn), neuron-specific enolase, and Ki-67 80%, confirming the neuroendocrine origin of the tumor.

The abdominal and pelvic CT and chest radiography performed 9 months after the operation indicated massive metastases in the liver and lungs [Fig. 3A], lymphadenopathy involving the retroperitoneum, and para-aortic regions, and some implantation metastases in the bladder and left psoas major [Fig. 3B]. This patient died 10 months after operation due to multiple organ failure.

Discussion
Primary small cell carcinoma of the ureter is an extremely malignant and rare disease; only several cases worldwide have been reported so far [1-4]. To our knowledge, PSCC with hydronephrosis has never been reported. The cause of SCC of the ureter may be related to smoking, but it remains unclear [2]. There are two hypotheses regarding the histopathogenesis of urinary tract small cell carcinoma. One indicates that it originates from intrinsic neuroendocrine cells within the normal genitourinary tract derived from the neural crest during embryogenesis [5], whereas the other hypothesis suggests that it results from a transformation of pluripotent epithelial reserve cells in the genitourinary tract that exhibit the ability to generate any cell type [6]. According to Kim Ts [2], SCC of the ureter combined with other components, such as transitional cell carcinoma, adenocarcinoma, squamous cell carcinoma, and carcinoma sarcomatodes, supports the second hypothesis. However, in this case, there are no other components; thus, it is compatible with the first hypothesis.
Because of high mitotic activity [1, 4, 7], small cell carcinoma of the ureter usually obstructs the ureter completely. The ureter above the obstruction or renal pelvis exhibits severe dilation. To our knowledge, severe and long-standing obstruction can give rise to the renal insufficiency or renal failure; the excretion of contrast medium is then not visualized on IVU or CT after contrast administration. In this patient, we did not find these changes. We presume that this was due to the following two reasons: the pressure in the left renal pelvis decreased after the development of the hydronephrosis, and secondly that the function of the right kidney improved to compensate.

The clinical features of PSCC of the ureter are mostly hematuria and flank pain [4]. Hematuria, usually gross, is due to vascular invasion, whereas pain is secondary to hydronephrosis after obstruction of the ureter. However, in this case, the patient only presented with left-sided flank pain and radiating pain in both the hypogastrium and groin. This clinical feature was similar to the presentation of a ureteric calculus. Ultrasonography is a commonly performed examination for urogenital diseases, but its resolution is inferior to CT. We can differentiate a calculus from a mass in the ureter by CT scanning, and demonstrate the development of hydronephrosis and its relationship with surrounding tissues through MPR.

Nephroureterectomy is the primary treatment in the majority of patients with PSCC of the ureter but usually cannot achieve adequate control of the disease; cisplatin-based chemotherapy has been frequently combined with surgery, but the overall outcome is poor [1]. The lymphatics, the lung, and the liver are common metastatic sites for small cell carcinoma of the ureter, and the majority of patients with small cell carcinoma die of the disease within a year [2]. This PSCC of the ureter caused hydronephrosis, and subsequently extensive metastases involving the liver and lungs and lymphadenopathy in the retroperitoneum, and para-aortic region. A the metastasis in the psoas major muscle also occurred 9 months following the surgical procedure.

Conclusion

Primary small cell carcinoma of the ureter is rare and often misdiagnosed as a ureteric calculus or other disease. CT assisted in identifying both the lesion and subsequent metastases, but the final diagnosis depended on pathological confirmation. During operation, surgeons must be mindful of the possibility of implantation metastasis in the perirenal tissue in patients with PSCC of the ureter with hydronephrosis. Radioactive implants may be considered to help prevent metastases. A patient with an early diagnosis and comprehensive therapy may achieve a long-term relative survival
.
Conflict of interest: There are no conflicts of interest in this study.

References
1. Kozyrakis D, Papadaniil P, Stefanakis S, et al. Small cell carcinoma of the urinary tract: a case report. Cases J. 2009;2:7743.
2. Kim TS, Seong DH, Ro JY. Small cell carcinoma of the ureter with squamous cell and transitional cell carcinomatous components associated with ureteral stone.J Korean Med Sci. 2001;16:796-800.
3. Ishikawa S, Koyama T, Kumagai A, Takeuchi I, Ogawa D. A case of small cell carcinoma of the ureter with SIADH-like symptoms. Nippon Hinyokika Gakkai Zasshi. 2004;95:725-8.
4. Kho VK, Chan PH. Primary small cell carcinoma of the upper urinary tract. J Chin Med Asso. 2010;73:173-6.
5. Fetissof F, Dubois MP, Lanson Y, Jobard P. Endocrine cells in renal pelvis and ureter: an immunohistochemical analysis. J Urol. 1986;135:420-1.
6. Christopher ME, Seftel AD, Sorenson K, Resnick MI. Small cell carcinoma of the genitourinary tract: an immunohistochemical, electron microscopic and clinicopathological study. J Urol.1991; 146:382-8.
7. Sved P, Gomez P, Manoharan M, Civantos F, Soloway MS. Small cell carcinoma of the bladder. BJU Int. 2004;94:12-7.

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Fig 1
The IVU shows the dilated ureter (arrow) [A]. The sagittal oblique reconstruction of the left ureter shows the lesion at the end of the ureter (arrow) and hydronephrosis (asterisk) [B]

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Fig 2
Light microscopy shows small cells that exhibit hyperchromatic nuclei, round to fusiform in shape, and high mitotic activity with little cytoplasm and an absence of nucleoli (H&E, 400×) [A]. The immunohistochemical staining of the specimen is positive for CgA (100×) [B]

Fig3a040Fig3b040

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig 3
Many metastases scatter over the liver [A] and one of implantation metastases are in the left psoas major (arrow) [B] 9 months postoperatively

Date added to bjui.org: 06/12/2012
DOI: 10.1002/BJUIw-2012-040-web

 

Inadvertent injury to an incidental ectopic ureter in a completely duplicated collecting system during open radical perineal prostatectomy

We present the diagnosis and management of a man with clinically localised prostate cancer and a complete duplication of the right collecting system associated with an asymptomatic upper pole ectopic ureter, that was inadvertently injured during open RPP.

Authors: Miguel Suhady (MS) Cabalag1, Henry Han-I (HH) Yao1, Gideon Adam (GA) Blecher1, Antonio (A) DeSousa1, Diana (D) Tran2

1 Department of Urology, Ballarat Base Hospital, Ballarat, Victoria, Australia
2 Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia

Corresponding Author: Richard (R) McMullin,  Consultant Urologist, Ballarat Base Hospital, Drummond Street North  Ballarat VIC 3350, Ballarat, Victoria, Australia E-mail: [email protected]

 

Abstract
 
It is rare for embryologic abnormalities of the urinary tract to present in adulthood, especially as an incidental finding post radical perineal prostatectomy (RPP). We present the incidental diagnosis and subsequent management of a 68 year old man with clinically localised prostate cancer and a complete duplication of the right collecting system associated with an asymptomatic upper pole ectopic ureter, that was inadvertently injured during open RPP.

 

Introduction
 
With the earlier detection of clinically localised prostate cancer using prostate specific antigen (PSA) testing, it has become routine not to perform extensive staging investigations to avoid unnecessary tests. This approach may lead to rare unforeseen post-operative complications in patients with asymptomatic congenital anomalies of the urinary tract. We report the case of a 68 year old man who presented with persistent urinary extravasation from his surgical wound following RPP. Subsequent CT intravenous urogram demonstrated an incidental complete duplication of the right collecting system and an injured right upper pole ectopic ureter. To our knowledge, there are only four cases reported in the literature of ectopic ureters found incidentally in men undergoing radical prostatectomy for prostate cancer (1-4), and we describe the first case reported during RPP.

 

Case Report
 
A 68 year old asymptomatic man initially presented with an incidental elevated PSA of 4.8 ng/ml (12% free) detected on routine testing. The patient otherwise had no significant past medical history. On digital rectal examination, the prostate was mildly enlarged and firm but with no palpable nodules bilaterally. Trans-rectal ultrasound (TRUS) of the prostate with concurrent 12 core guided biopsies, revealed no suspicious areas and an estimated prostate volume of 60 cm3. Histopathology showed a 2mm focus of Gleason 6 (3+3) prostate adenocarcinoma, which was only detected following further immunohistochemical staining. An active surveillance approach with six monthly PSA tests was initially adopted given the very low volume of malignancy. Over the next 18 months, the PSA gradually rose to 8.2 ng/ml whereby a repeat TRUS guided biopsy revealed prostate adenocarcinoma with Gleason 6 (3+3) in 33% of 1 core obtained from the right lateral prostate (clinical stage T1c).
Following patient counselling, a radical nerve-sparing perineal prostatectomy was performed using a previously described technique (5). A routine pre-operative rigid cystoscopy revealed a normal urethra and bladder with two appropriately located ureteric orifices. Surgery went as planned and a 16Fr two-way silicone indwelling catheter was inserted into the bladder intra-operatively. The urethral anastomosis was subsequently checked to ensure a watertight seal and a tube drain was also inserted through a separate stab incision into the perineum. Pelvic lymphadenectomy was not performed due to the patient’s low risk pathology. The final pathology demonstrated a Gleason 7 (3+4) adenocarcinoma, localised predominantly to the right lower zone involving approximately 15% of total prostatic volume. Lymphovascular invasion was absent and the surgical margins were clear.
Early post-operative recovery was uneventful and the drain tube was removed on post-operative day (POD) 2. A routine trial of void 2 weeks post surgery resulted in a persistent urine leak from the apex of his perineal wound, which was exacerbated by urination. Of note, the patient remained pain free and afebrile throughout the post-operative period. This was initially suggestive of an anastomotic leak and therefore the indwelling urinary catheter was re-inserted. However, a cystogram did not show any extravasation of contrast (Figure 1) and the leak persisted through the apex of the wound, so the re-introduced urinary catheter was removed.
Figure 1. Post-operative retrograde cystogram showing no anastomotic leakage

 

 

Subsequent computed tomography (CT) intravenous urogram demonstrated a complete duplication of the right collecting system with an ectopic right upper pole ureter (Figure 2a and 2b), the distal end of which could not be properly visualised.

 

Figure 2a.  Coronal view of the CT intravenous urogram showing the right lower pole ureter (LPU) and the right upper pole ectopic ureter (UPEU).

 

 

Figure 2b. 3D reconstruction of the coronal CT-intravenous urogram showing the orthotopic insertion of the right lower pole ureter (LPU) into the bladder (solid arrow), the tortuous right upper pole ectopic ureter (UPEU, dotted arrow). Note an indwelling urinary catheter is in situ.

 

 

There was also a fistulous tract originating from the ectopic ureter, draining into the perineum (Figure 3). The patient subsequently developed right-sided epididymo-orchitis, which was successfully treated with intravenous gentamicin and amoxicillin.

 

Figure 3. Coronal view of the CT intravenous urogram demonstrating the right upper and lower pole renal moieties, as well as a fistulous tract (solid arrow) originating from the ectopic ureter into the perineum on the right side (dotted arrows). 

 

Management
 
The patient subsequently underwent a rigid cystoscopy and a right retrograde pyelogram, which demonstrated a non-dilated right ureter draining into a lower renal moiety, producing a ‘drooping lily’ type image of the right kidney (Figure 4).

 

Figure 4. Right retrograde pyelogram demonstrating the characteristic ‘drooping lily’ image of the lower renal moiety. 

 

 

After patient counselling, the decision was then made to perform an open right ureteric reimplantation. Intra-operatively, two ureters were identified in the retroperitoneum adjacent to the bifurcation of the right common iliac vessel. The lateral ureter was entered via a small stab incision and dye was injected. This dye was noted to be draining out of the indwelling catheter and therefore this was thought to be the normal ureter that was draining into the bladder. The medial ureter was also pierced and dye was injected, but the dye was not detected in the bladder. Thus, this was thought to be the ectopic ureter, most likely to have been injured during the RPP. Given the close proximity of the bladder to the ectopic ureter, a uretero-vesical anastomosis was performed. The distal ectopic ureter was spatulated and a cystotomy was made at a corresponding site. A 6Fr 26 cm ureteric stent was passed through the ectopic ureter over a guide wire up to the right kidney, and the distal end was placed through the cystotomy. Using four, 4-zero vicryl sutures in an interrupted fashion, the ureter was securely implanted onto the bladder with good mucosal apposition. A pelvic drain tube was placed adjacent to the newly formed uretero-vesical anastomosis. There were no peri-operative complications, the drain was removed on POD 4 and the patient was discharged home on POD 6. A flexible cystoscopy was performed approximately 4 weeks after to remove the ureteric stent. Repeat CT intravenous urogram performed 2 months post re-implantation demonstrated complete duplication of the right collecting system with double ureters in which contrast drained normally into the bladder. Importantly, it did not show any hydronephrosis bilaterally, no perineal collection nor any leak from the right renal tract (Figure 5).

 

Figure 5. Coronal view of the CT intravenous urogram post uretero-vesical anastomosis of the right upper pole ectopic ureter, showing resolution of the fistulous tract to the perineum.

 

 

Discussion
 
We report the case of a patient who was incidentally found to have a complete duplication of the right collecting system with an asymptomatic ectopic upper pole ureter that was inadvertently injured during a RPP. To our knowledge, this is the first case reported in the literature associated with such surgery.
A duplex system refers to a kidney with two pelvicalyceal systems within a single renal parenchyma, which may have either a single or bifid ureter (partial duplication), or two discrete ureters (complete duplication) (6).  Renal duplication is a relatively common congenital anomaly, with a reported prevalence of 0.3-6% (7). The majority of cases are detected during childhood, but up to 20% of patients remain asymptomatic into adulthood (8). In contrast, ectopic ureters are rare, with a reported incidence of 1 in 1900 (9). Ectopic ureters are more common in females and are usually associated with a duplicated collecting system, whereas they are typically associated with a single collecting system in men (10).The anatomic site of insertion of an ectopic ureter in a duplicated collecting system follows the Weigert-Meyer rule, whereby the upper pole ureter is more commonly ectopic and the lower pole ureter typically inserts into the trigone, or laterally and cranially to this structure. In 50-60% of patients, renal duplication is associated with vesicoureteric reflux, which may affect one or both ureters. Reflux is more common in the lower pole kidney (97%), while ureteroceles and ectopic ureters are commoner in the upper pole kidney (11).
The presentation of ectopic ureters depends on their site of insertion. Ectopic ureters inserting into the prostatic urethra typically present with urinary tract infections or lower urinary tract symptoms of urgency and frequency. Ectopic ureters inserting into a seminal vesicle, vas deferens or epididymis may present with epididymitis, chronic prostatitis, abdominal or pelvic pain, discomfort during ejaculation, constipation, or a large abdominal mass secondary to obstruction and hydronephrosis. Males with an ectopic ureter may also present with infertility (3).
In males, the majority of ectopic ureters (50%) insert into the prostatic urethra, and 33% into a seminal vesicle. The least common sites include the prostatic utricle and the vas deferens (12). Ectopic ureters in males almost never insert distal to the external sphincter, where it would present as urinary incontinence. One such case has been reported in the literature (13). Of note, this patient had no lower urinary tract symptoms prior to the RPP. It is likely that in this case, the upper pole ectopic ureter was transected during the bladder neck dissection at the level of the prostatic urethra.
There are multiple treatment options for the pathological ectopic ureter associated with a duplicated system, including ureteropyelostomy, heminphrectomy, ipsilateral ureteroureterostomy and common sheath reimplantation (14). An ureterovesical anastomosis was performed in this case due to the upper pole ectopic ureter being a distinct entity from the lower pole ureter, and because of its close proximity to the bladder.
Current guidelines do not recommend imaging of the prostate with CT or MRI for low risk disease prior to radical prostatectomy. Consequently, any asymptomatic congenital anomalies of the urinary tract will not be detected preoperatively. However, due to the rarity of such anomalies, as well as the expense and potential risk to patients, routine preoperative imaging to detect congenital abnormalities is not justifiable in this setting. In the retrospective study conducted by Costa et al, only 3 out of 254 (1.1%) surgical descriptions of nephroureterectomy samples showed anatomical variations of the collecting system, with all cases demonstrating ureteric duplications (15).
Of interest, given the established genetic association of duplex systems, the patient’s twin brother subsequently underwent a CT intravenous urogram, which did not demonstrate any evidence of a duplicated system or ectopic ureter.

 

Conclusion
 
Preoperative imaging may help detect asymptomatic congenital abnormalities of the urinary tract, enabling appropriate intraoperative management. However, given the rarity of such anomalies and the expense of imaging, extensive investigations prior to radical prostatectomy for the sole purpose of screening for congenital abnormalities is not justifiable. However, this case highlights the need to consider congenital anomalies of the urinary tract as a possible differential in peri-operative complications post radical prostatectomy.

 

References
 
1. Funahashi Y, Kamihira O, Kasugai S, Kimura K, Fukatsu A, Matsuura O. [Radical prostatectomy for prostate carcinoma with ectopic ureter ; a case report]. Nihon Hinyokika Gakkai zasshi The japanese journal of urology. 2007 2007;98(3):580-2.
2. Ghazi A, Zimmermann R, Janetschek G. Delayed detection of injury to an ectopic ureter of a duplicated collecting system following laparoscopic radical prostatectomy for early organ-confined prostate cancer. Urologia internationalis.  2011 Feb (Epub 2010 Nov;86(1):121-4.
3. Marien TP, Shapiro E, Melamed J, Taouli B, Stifelman MD, Lepor H. Management of localized prostate cancer and an incidental ureteral duplication with upper pole ectopic ureter inserting into the prostatic urethra. Reviews in urology. 2008 2008;10(4):297-303.
4. Nakai Y, Tanaka M, Yoshikawa M, Tanaka N, Hirayama A, Fujimoto K, et al. [Prostate cancer and left ectopic ureter opening to seminal vesicle with left renal agenesis: a case report]. Hinyokika kiyo Acta urologica Japonica. 2009 2009;55(1):47-50.
5. Weiss JP, Schlecker BA, Wein AJ, Hanno PM. Preservation of periprostatic autonomic nerves during total perineal prostatectomy by intrafascial dissection. Urology. 1985 1985;26(2):160-3.
6. Glassberg KI, Braren V, Duckett JW, Jacobs EC, King LR, Lebowitz RL, et al. Suggested terminology for duplex systems, ectopic ureters and ureteroceles. The Journal of urology. 1984 1984;132(6):1153-4.
7. Hartman GW, Hodson CJ. The duplex kidney and related abnormalities. Clinical radiology. 1969;20(4):387-400.
8. Privett JT, Jeans WD, Roylance J. The incidence and importance of renal duplication. Clinical radiology. 1976 1976;27(4):521-30.
9. Campbell M, Harrison J. Anomalies of the Ureter. In: Campbell M, editor. Urology. 3rd ed. Philadelphia: WB Saunders; 1970.
10. Schlussel R, Retik A. Ectopic ureter, ureterocele, and other anomalies of the ureter. In: Wein A, Kavoussi L, Novick A, editors. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders Elsevier; 2008. p. 3383-422.
11. Jelloul L, Valayer J. Ureteroureteral anastomosis in the treatment of reflux associated with ureteral duplication. The Journal of urology. 1997 1997;157(5):1863-5.
12. Ellerker AG. The extravesical ectopic ureter. The British journal of surgery. 1958 1958;45(192):344-53.
13. Ejaz T, Malone PS. Male duplex urinary incontinence. The Journal of urology. 1995 1995;153(2):470-1.
14. Chacko JK, Koyle MA, Mingin GC, Furness PD, 3rd. Ipsilateral ureteroureterostomy in the surgical management of the severely dilated ureter in ureteral duplication. The Journal of urology. 2007 2007 Oct (Epub 2007 Aug;178(4 Pt 2):1689-92.
15. Costa HC, Moreira RJ, Fukunaga P, Fernandes RC, Boni RC, Matos AC. Anatomic variations in vascular and collecting systems of kidneys from deceased donors. Transplantation proceedings. 2011 2011;43(1):61-3.

 

Date added to bjui.org: 23/05/2012
DOI: 10.1002/BJUIw-2011-145-web

 

Right sided Bochdalek hernia causing ureteric obstruction

We report a case in a elderly female who presented with symptomatic BH causing obstruction of the right renal pelvis and ureter.

 

Authors: Vikram Balakrishnan, MBBS, BMedSc, Dip. Surg Anatomy; Gregory Neerhut MBBS, FRACS.

Urology Unit, Geelong Hospital, Victoria, Australia

 
Corresponding Author: Vikram Balakrishnan, Urology Unit, Geelong Hospital, Victoria, Australia.  T: +613 421 709 541  Email: [email protected]

 

Introduction
 
Bochdalek hernia (BH) is a congenital hernia of the diaphragm that occurs in 1 in every 2200 to 12,500 births with an overall prevalence in adults of between 0.17% and 10.5% [1-4]. It results from developmental failure of the posterolateral diaphragmatic foramina to fuse properly and most commonly presents during the neonatal period [5]. Adult patients presenting with symptomatic BH, especially on the right side, are exceedingly rare, and there have been less than 20 cases reported in the literature [6,7]. We report a case in a elderly female who presented with symptomatic BH causing obstruction of the right renal pelvis and ureter.

 

Case Report
An 83 year old female presented to the emergency department with severe right flank pain on a background of a 12 month history of intermittent mild flank pain. Her past history included chronic renal impairment and right renal colic. Clinical examination revealed a frail elderly lady with normal vital signs. There was some mild flank tenderness on the right and respiratory examination was normal. Creatinine was chronically elevated at 192umol/L, eGFR was 23mL/min, white cell count was 12.0 10^9g/L (reference rage 4-11.0 x10^9 g/L) and the urine was sterile. Plain radiographs of the abdomen demonstrated degenerative changes of the lumbar spine consistent with osteoarthritis and there was no evidence of kidney stones. The patient was discharged with a presumptive diagnosis of chronic back pain.
At outpatient follow-up, the patient had ongoing flank pain and ultrasound demonstrated normally sized and positioned kidneys with hydronephrosis of the right collecting system and a renal pelvis measuring 6cm in diameter. A computerised tomography (CT) scan demonstrated a small BH of the posterior aspect of the right diaphragm. The dilated renal pelvis was drawn superiorly through the hernia into the thorax with the pelviureteric junction located superior to the remainder of the collecting system. The ureter then passed inferiorly through the neck of the Bochdalek hernia back into the abdomen. There was no dilatation of the ureter below the hernia (Figure 1 and 2).
 

Figure 1. Axial CT scan demonstrates dilated right renal pelvis drawn superiorly through the diaphragmatic hernia

 

 

Figure 2. Coronal CT scan demonstrates distended ureter and renal pelvis above the neck of the Bochdalek hernia and normal calibre ureter below

 

 

Rigid cystoscopy and a right retrograde pyelogram demonstrated superior and medial deviation of the proximal ureter with kinking of the ureter and proximal hydronephrosis (Figure 3).
 

Figure 3. Retrograde pyelogram pre and post double J stent placement

 

 

A guide-wire was passed to the renal pelvis without difficulty and a 6 French double J stent was placed. The patient’s pain resolved immediately, she made an uneventful recovery and was discharged home the following day. The stent is changed electively every six months and 12 months following presentation she remains pain free.

 

Discussion
Congenital diaphragmatic hernia was first described by Vincent Alexander Bochdalek in 1848 and results from incomplete closure between the pars lumbaris and pars costalis parts of the diaphragm during fetal development [5,8]. The majority of patients present during neonatal life with concomitant congenital pulmonary abnormalities and consequently have a poor prognosis [1]. Adult presentation with symptomatic BH is rare with approximately 100 cases reported in the literature. Whilst asymptomatic BH tend to occur equally on the right and left hand sides of the diaphragm [3,4], symptomatic BH tend to occur on the left with a ratio of 9:1 [1,2]. The contents of BH depend on the side of the hernia and have included liver, omentum, bowel, spleen, kidneys and stomach [1,10]. The presence of renal pelvis or ureter within a BH is exceedingly rare with only three cases reported in the literature [11-13].
The clinical presentation of BH in adults ranges from an incidental finding on imaging to strangulation of intra-abdominal contents with significant morbidity and mortality. Symptoms are often non-specific and include abdominal pain, dyspnea, chest pain and nausea and vomiting [10]. Of the three cases reported in the literature on BH containing ureter, one was asymptomatic and was discovered incidentally [11], one presented with right upper quadrant pain [12] and the other presented almost identically to our case with a 12 month history of intermittent flank pain [13]. Precipitating factors are sometimes identified and include any mechanism that increases intra-abdominal pressure, however, the patient in our study did not have any history of chronic cough or constipation.
Diagnosis is ultimately via imaging and CT provides the most accurate and reliable method [2,14]. Discontinuity of the posterior diaphragm is usually clearly identified and protrusion of intra-abdominal contents including ureter is clear [2,5,14]. Importantly, CT can identify associated complications of ureteric herniation including hydronephrosis and hydroureter, which is evidenced by dilatation above the hernia neck and a normal calibre ureter below. Of the three reported cases on BH containing ureter, two were associated with obstructive uropathy with similar CT findings to our case [12,13]. Ultrasound, whilst able to identify hydronephrosis in our case, was not able to identify the hernia or the site of obstruction.
The optimal treatment of BH causing obstructive uropathy is unclear. Despite kinking of the ureter we were able to successfully pass a double J stent to the renal pelvis which provided immediate relief of the patient’s symptoms. Similarly, Song et al [14] were able to successfully pass a retrograde stent with follow-up CT confirming resolution of hydronephrosis. Definitive surgical correction of BH is recommended because of the risk of herniation and strangulation of abdominal viscera and excellent outcomes have been described with no evidence of hernia recurrence [10]. In particular, laparoscopic repair with or without mesh appears to be reliable and confers all the benefits of minimally invasive surgery [15]. However, diaphragmatic surgery is not without complications and elderly patients in particular gain only a minimal benefit as the risk of further herniation over their remaining lifetime is low.
Our elderly frail patient was managed with a retrograde ureteric stent. Patients managed this way need to have their stent changed every 6 to 12 months because of the risk of stent encrustation causing obstruction. In addition, these patients should have regular imaging such as chest radiography because, as discussed, clinical symptoms and signs may not correlate with severity of disease. In a younger fitter patient we would recommend surgical correction of the hernia.

 

Conclusion
 
We described the case of an 83 year old female presenting with a right sided BH containing the right renal pelvis and ureter causing pain, hydronephrosis and hydroureter. Symptomatic BH in adult patients is rare and there have been only three cases of BH containing ureter in the literature. Ureteric stent offers a safer alternative to surgical repair of the hernia and may be a more appropriate treatment in elderly patients.

 

References
1. Gedik E, Tuncer MC, Onat S, Avci A, Tacyildiz I, Bac B. A review of Morgagni and Bochdalek hernias in adults. Folia Morphol (Warsz). 2011 Feb;70(1):5-12.
2. Wilbur AC, Gorodetsky A, Hibbeln JF. Imaging findings of adult Bochdalek hernias. Clin Imaging. 1994 Jul-Sep;18(3):224-9.
3. Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol. 2001 Aug;177(2):363-6.
4. Temizöz O, Gençhellaç H, Yekeler E, Umit H, Unlü E, Ozdemir H, Demir MK. Prevalence and MDCT characteristics of asymptomatic Bochdalek hernia in adult population. Diagn Interv Radiol. 2010 Mar;16(1):52-5. Epub 2009 Dec 28.
5. Sandstrom CK, Stern EJ. Diaphragmatic hernias: a spectrum of radiographic appearances. Curr Probl Diagn Radiol. 2011 May-Jun;40(3):95-115.
6. Rout S, Foo FJ, Hayden JD, Guthrie A, Smith AM. Right-sided Bochdalek hernia obstructing in an adult: case report and review of the literature. Hernia. 2007 Aug;11(4):359-62. Epub 2007 Mar 7.
7. Agrafiotis AC, Kotzampassakis N, Boudaka W. Complicated right-sided Bochdalek hernia in an adult. Acta Chir Belg. 2011 May-Jun;111(3):171-3.
8. Haller JA Jr. Professor Bochdalek and his hernia: then and now. Prog Pediatr Surg. 1986;20:252-5.
9. Bujanda L, Larrucea I, Ramos F, Muñoz C, Sánchez A, Fernández I. Bochdalek’s hernia in adults. J Clin Gastroenterol. 2001 Feb;32(2):155-7.
10. Brown SR, Horton JD, Trivette E, Hofmann LJ, Johnson JM. Bochdalek hernia in the adult: demographics, presentation, and surgical management. Hernia. 2011 Feb;15(1):23-30. Epub 2010 Jul 8.
11. Chawla K, Mond DJ. Progressive Bochdalek hernia with unusual ureteral herniation. Comput Med Imaging Graph. 1994 Jan-Feb;18(1):53-8.
12. Song YS, Hassani C, Nardi PM. Bochdalek hernia with obstructive uropathy. Urology. 2011 Jun;77(6):1338. Epub 2010 Jul 1.
13. Paterson IS, Lupton EW. Pelviureteric junction obstruction secondary to renal pelvic incarceration in a congenital diaphragmatic hernia. Br J Urol. 1989 Nov;64(5):548-9.
14. Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Chest. 1987 Dec;92(6):1098-101.
15. Palanivelu C, Rangarajan M, Rajapandian S, Amar V, Parthasarathi R. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: a retrospective study. Surg Endosc. 2009 May;23(5):978-85. Epub 2009 Mar 14.

 

Date added to bjui.org: 03/12/2011


DOI: 10.1002/BJUIw-2011-104-web

 

Blind-ending complete ureteric duplication with reflux and ectopia

We report a rare case of complete blind-ending refluxing ectopic ureteric duplication.

 

Authors: Dr. Abdelmoniem  Hassan  Koko FRCS(Ed), Dr. Khaled Ezzeddin  MD,PhD, Dr.Hussien Al Ghahtani FACHARTS, Dr. Khaled Al Gammal MD

Armed Forces Hospital, King Abduaziz Air Base ,Dhahran
P.O.BOX 4192, Al Khobar, 31952
Saudi Arabia

Corresponding Author: Dr. Abdelmoniem  Hassan  Koko FRCS(Ed), Armed Forces Hospital, King Abduaziz Air Base, Dhahran P.O.BOX 4192, Al Khobar, 31952 Saudi Arabia.  E-mail: [email protected]

 

Introduction
Blind-ending ureteric duplication is a rare developmental anomaly of the ureter. Embryologically, it was postulated that the affected ureteric bud is abortive and fails to make contact with the mesonephros. Histologically, it contains all the ureteric layers; it tends to have bulbous dilatation (1). Sometimes they are short without reflux and are minimally symptomatic. However, patients with long blind-ending duplications can present with severe infection and reflux, requiring extensive surgery (2). Here we report a rare case of complete blind-ending refluxing ectopic ureteric duplication.

 

Case report
A 20 year old female was admitted to the hospital with right sided abdominal pain, lower urinary tract symptoms and fever. She gave a history of recurrent febrile urinary tract infections since childhood, with multiple hospital admissions.  On examination she was febrile, and there was tenderness and guarding on the right side of the abdomen. Urine culture grew E coli and renal profile was normal. Ultrasound showed mild dilatation of the right pelvicalyceal system, with a cystic area above and medial to the upper pole of the right kidney, and a cystic area on the right side of the pelvis, representing  the dilated right ureter (Fig 1).

 

Fig 1. Ultrasound showed mild clayceal dilatation and cystic mass at the medial aspect of the upper pole of the right kidney.

 

 

Intravenous pyelography showed right sided calyectasia; the renal pelvis was not dilated and there was lateral displacement of the right kidney. The left kidney and urinary bladder were normal (Fig 2).

 

Fig 2. IVU showing lateral displacement of the right kidney, calyceal dilatation, renal pelvis and ureter not dilated.

 

 

After controlling the infection, she was scheduled for micturating cystourethrogram (MCUG). She developed severe intolerable pain when the Foley’s catheter was inserted. The radiologist found the catheter in the right ureter so it was removed immediately and the procedure was aborted. Indirect radioisotope MCUG demonstrated right sided vesicoureteric reflux (Fig 3).

 

Fig 3. Indirect micturating cystourethrogram with radioactive tracer in the dilated distal right ureter indicating vesicoureteric reflux.

 

 

She was scheduled for cystography and cystoscopy under anaesthesia. The Foley’s catheter was found again in the right ureter, which was dilated, tortuous and blind-ending (Fig 4).

 

Fig 4A. Preferential passage of the urethral catheter into the right ureter.

 

 

Fig 4B. Retrograde study showing blind ending tortuous dilated ureter as well as the collecting system on the right side.

 

 

Fig 4C, D. CT scan with  contrast material through ureteric catheter showing the blind ending duplication, and it’s relation to the right kidney.

 

 

Urethroscopy showed the opening of the ectopic right ureter just below the bladder neck (Fig 5).

 

Fig 5. Urethroscopy with guide wire in the ectopic ureteric orifice in the urethra.

 

 

Surgical exploration and excision of the blind ending right ureter was done (Figs 6A, B, C).

 

Fig 6. Duplication of the ureters on the right side.

 

 

Fig 6B. Upper pole right kidney after complete excision of the blind ending ureter.

 

 

Fig 6C. Surgical specimen.

 

 

The post operative recovery and subsequent follow up for four years was uneventful.

 

Discussion
Blind ending ureteric duplication is a rare anomaly of the ureter. Most of the cases reported were involving one limb of a bifid system; it is more common in females than in males, and present twice as often on the right side. The majority of the identified cases are diagnosed in the third or fourth decade of life. Embryologically, it was postulated that the affected ureteric bud is abortive and fails to make contact with the mesonephros. Histologically, it contains all the ureteral layers; it shares a common sheath and blood supply with the normal ureter (1). Our patient had recurrent severe febrile urinary tract infections, which led to frequent hospitalizations.
The only reported similar case found in the English literature described ureteric ectopia with preferential passage of the Foley’s catheter into an ectopic blind- ending ureter in the prostatic urethra, in a 67 year old man (3).
Surgical dissection of the lower segment of the blind ending ureter may compromise the vascularisation of the remaining ureter on that side.  This can be prevented by conserving the common ureteric sheath or re-implanting the normal ureter.  Since the ensheathment is less dense at the proximal end, the dissection should start there and care is taken not to denude or injure the normal ureter (1, 4, and 5). Careful and systematic steps must be adhered to in diagnosis and management of children presenting with febrile urinary tract infections. If the correct diagnosis was made initially, our patient could have been saved from unnecessary morbidity.

 

Conclusions
Blind-ending complete ureteral duplication is a rare developmental anomaly of the ureter. Careful and systematic steps must be followed in diagnosis and management of children presenting with febrile urinary tract infections.

 

References
 
1. Schulussel RN, Retik AB. Ectopic ureter, ureterocele, and other anomalies of the ureter. Chapter 58. Walsh PC (ed). Campbell’s Urology, 8th Edition. Philadelphia: Saunders; 2002; 2007 – 52.
2. Marshall FF, McLoughlin MG. Long blind ending ureteral duplications. J Urol. 1978; 120(5): 626-630.
3. Chai TC, Ohl DA. Difficult urethral catherterization due to ectopic ureter: an unusual presentation of ureteral ectopia in a man. J Urol. 1995; 153(6): 1899-900.
4. V.DE BOE, J. BRAECKMAN and F. KEUPPENS, A rare duplication anomaly of the upper urinary tract: a blind-ending uretic duplication with ectopic and refluxing ureterocele  BJU International (1999). 84(1): 173 – 174.
5. Rege VM, Deshumukh SS, Borwankar SS, Gandhi RK. Blind ending bifid ureter (a case report).
J Postgrad Med 1983; 32(4): 233-5.

 

Date added to bjui.org: 27/11/2011


DOI: 10.1002/BJUIw-2010-083-web

 

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

 

An Unusual Case of Duplex kidney: Giant Hydroureter of Upper Moiety presenting as abdominal lump

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]

Introduction
 
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.

 

Case report
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

 


 
Figure 5. 

 


 
Discussion
 
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 [1]. 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 [2]. 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 [3].
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.

 

References
 
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 


DOI: 10.1002/BJUIw-2011-073-web

 

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