An Ectopic Ureter

Adam J. Singer, MD

Disclosures

November 28, 2001

Introduction

A 23-year-old Hispanic woman was referred to the urology service for long-standing right flank pain that occurred whenever she had to hold off voiding because a bathroom was not nearby and was relieved instantly when she voided. She was continent and had no obstructive or irritative voiding complaints. Two years earlier, she was treated empirically for simple cystitis by her family physician. Otherwise, her medical history was not contributory. Her complete blood count, serum electrolytes, blood urea nitrogen and creatinine levels, and urinalysis were normal.

Renal sonography demonstrated a bilateral collecting system duplication with a hydronephrotic right upper pole moiety (Figure 1). Excretory urography revealed that the ureter on the left had partial duplication; the duplication joined at the level of the transverse process of the second lumbar vertebrae and drained into the bladder (Figure 2a). On the right side, the lower pole moiety drained into the bladder, but the ipsilateral upper pole segment had severe hydronephrosis, with the dilated ureter coursing into an ill-defined area in the true pelvis (Figure 2b). The postvoid film showed emptying of all upper tract moieties with minimal residual urine in the bladder (Figure 2c). Interestingly, the patient experienced progressive colicky right flank pain during excretory urography; the pain subsided immediately after voiding.

A renal ultrasonogram of the right kidney shows duplication of the collecting system with a hydronephrotic upper pole moiety.

(A), An excretory urogram, 10 minutes after the administration of contrast, reveals left partial ureteral duplication with drainage into the bladder. On the right side, the lower pole moiety drains into the bladder, and the upper pole segment demonstrates severe hydronephrosis. (B), An excretory urogram, 30 minutes after the administration of contrast, faintly shows the hydronephrotic right upper pole ureter coursing into an ill-defined area in the true pelvis. (C), The excretory urogram postvoid film demonstrates emptying of all upper tract moieties, including the hydronephrotic right upper pole. There is minimal residual urine in the bladder.

(A), An excretory urogram, 10 minutes after the administration of contrast, reveals left partial ureteral duplication with drainage into the bladder. On the right side, the lower pole moiety drains into the bladder, and the upper pole segment demonstrates severe hydronephrosis. (B), An excretory urogram, 30 minutes after the administration of contrast, faintly shows the hydronephrotic right upper pole ureter coursing into an ill-defined area in the true pelvis. (C), The excretory urogram postvoid film demonstrates emptying of all upper tract moieties, including the hydronephrotic right upper pole. There is minimal residual urine in the bladder.

(A), An excretory urogram, 10 minutes after the administration of contrast, reveals left partial ureteral duplication with drainage into the bladder. On the right side, the lower pole moiety drains into the bladder, and the upper pole segment demonstrates severe hydronephrosis. (B), An excretory urogram, 30 minutes after the administration of contrast, faintly shows the hydronephrotic right upper pole ureter coursing into an ill-defined area in the true pelvis. (C), The excretory urogram postvoid film demonstrates emptying of all upper tract moieties, including the hydronephrotic right upper pole. There is minimal residual urine in the bladder.

Cystourethroscopy demonstrated a ureteral orifice located at the 7 o'clock position in the proximal urethra leading to the right upper pole moiety. The right ureteric orifice leading to the right lower pole moiety was appreciated in the bladder, but it was approximately 30% closer to the bladder neck than to the contralateral side (Figure 3). The left ureteric orifice was in its normal orthotopic position. A retrograde ureteropyelogram of the right upper pole ureter confirmed the cystourethroscopic findings of caudal ectopia with prompt drainage during micturition (Figures 4a and 4b). A cystogram showed no reflux. A diethylenetriamine pentaacetic acid (DTPA) renal scan revealed glomerular filtration rates of 38, 38, 7, and 39 mL/min of the left upper, left lower, right upper, and right lower renal moieties, respectively. Stasis of the right upper pole ureter cleared rapidly on voiding, without obstruction.

A retrograde ureteropyelogram of the right lower pole ureter is normal.

(A), A retrograde ureteropyelogram of the right upper pole ureter shows caudal ectopia into the proximal urethra. (B), Following the retrograde ureteropyelogram, there is prompt drainage of the right upper pole ureter after the patient has voided.

(A), A retrograde ureteropyelogram of the right upper pole ureter shows caudal ectopia into the proximal urethra. (B), Following the retrograde ureteropyelogram, there is prompt drainage of the right upper pole ureter after the patient has voided.

Which of the following is correct?

  1. The uterus is the most common site of entry of an ectopic ureter from a duplicated system in the female.

  2. In duplicated systems, the ureter from the lower pole moiety is more often ectopic than the ureter from the upper pole moiety.

  3. Ureteral ectopia is more common in females.

  4. The surgical management of systems with ectopic ureters only depends on the function of the involved kidney.

View the correct answer.

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