THE JOURNAL OF UROLOGY
Vol. 82, No. 6, December 1959 Printed in U.S.A.
ANOMALY SIMULATING A RETROCAVAL URETER WILLIAM DREYFUSS From the Department of Urology, Huron Road Hospital, Cleveland 12, Ohio
\Vhen one studies the metamorphosis and meanderings of the ureter and the vascular system in the stage of the embryological development, one is surprised that not more anomalies occur. In ascending from the pelvis, the kidneys move medial of the postcardinal veins. They pass first medial and then lateral behind these vessels. There are innumerable anastomoses through which the ureter runs. Most of these connecting veins obliterate and only a few persist. Whether the ureter runs in front or in back of the caval vein is determined by which one of the supracardinal or posterior cardinal veins has persisted. Dufour and Sesboi.ie have illustrated this in a paper with marvelous colored schematic drawings. The most common known abnormality is the so-called postca val ureter. Since its first discovery by Hochstetter (in an autopsy) in 1893 there are less than 100 cases reported. V. C. Laughlin published the last one observed in this institution in 1954, which was the first one observed on a solitary kidney. CASE REPORT
Mr. J. K., aged 61, was first seen in Huron Road Hospital on February 8, 1956. The reason for his admission was gross, painless hematuria existing for 5 days. His family and personal history were noncontributory. His weight was 170 pounds. Blood pressure 180/100 but on later observation it leveled to 140 /90. Electrocardiogram was normal. Hemoglobin 13 gm.; hematocrit 44 per cent; sedimentation rate 19 mm./60 min. Blood chemistry: Blood sugar 120 mg. per cent, blood urea nitrogen 20 mg. per cent. Serology negative. Urinalysis: pH 6, specific gravity 1.022, albumin negative, sugar negative. l\Iicroscopic: calcium phosphates, moderate number of red blood cells. No growth on culture. Physical examination showed a well developed man in good nutritional condition. He appeared actually younger than he was. There was an Accepted for publication June 1, 1959. 630
impairment of his bearing. The general examination was otherwise negative. His prostate gland was moderately enlarged with a few soft nodules present. It was soft in consistency, mobile, fairly symmetrical with only a faint middle sulcus palpable. Chest x-ray was negative. The x-ray of the kidneys, ureters and bladder showed normal renal shadows with no conspicuous calcification. In the intravenous urogram, there was prompt bilateral excretion of dye. The left kidney and the left ureteral structures were normal. There was mild enlargement of the right renal pelvis and blunting of all calyces. The ureteropelvic juncture seemed to be posterior and the slightly dilated upper portion of the ureter made a sharp deviation to the midline at the level between L3 and L4. Cystoscopy (February 10): The urine obtained was clear. The anterior urethra was normal. The posterior urethra showed faint intrusion from the lateral lobes of the prostate gland and a median bar. A papillary tumor of cherry size was noted above the right ureteral orifice. It was well pedunculatecl. The rest of the bladder was negative. Indigo carmine made its appearance in good time and concentration, bilaterally. Ureteral catheters size 5 were easily inserted in both orifices for 26 cm. Specimens were collected for examination and culture. Retrograde pyelograms were made by injecting 5 cc skiodan and repeated as pyeloureterograms by means of the withdrawal technique, as well as in the upright position. Then the right pyelogram was repeated by means of the gravity technique using a Braasch bulb catheter size 10. The papillary tumor was then resected and the surrounding tissue fulgurated. Examination of the prostate gland with the indwelling cystoscope revealed nothing new. Retrograde pyclograms: The left kidney and the left ureter were normal. On the right side there was a dilatation of the kidney pelvis and the upper ureter, as previously described in the intravenous urogram. Then the ureter had a narrow portion and deviated to the midline and
SIMULA'l'lNG ItE'l'liOCA VAL URE'l'EH
from there it ,vas normal in size dowmvarcl to the bladder. ;\ retro ca val ureter ,,,-as suspected. Since the changes ,n·re minimal and the patient had no complaints nothing further was done at this admission. Pathological report of tlw tumor revealed a transitional cell grade 1, of tlw blackleL On .June 8 the patient ,, as admitted for a 8tleCk\ljJ, :vcN.c,r,r;,rnc f8fl:alcr] L\ (']ea,!1 8(:[tj' WhC'ft' the tumor ,v:rn previously lorntr cL Six months later the result was the same. the middle of ] 9.57 he complaining of occasional dull pain in bis right flank. No masses could be fdt and there ,rn~ no flank tenderness. On January 3, 1958 lie wa, admitted for his chedrnp ..At this time lie complained of more frequent dull pain on tlw right side', but still more annoying than disabling in drnradcr, ilt the blaclckr ,rns found to be normal \ pyelogram was dorn, and again re .. peatccl on the right sick as a pyelonretcrogram, The left kidney and ureter WC'rl' undiangecl, but on the right sick the previously described area of dilatation had increased in sizr:, The lom:r t,rnthircls of the ureter was normal There was a qlwstion of 11 racliolucent sbaclow in the; dilated portion of the upper ureter. The diagnosis at this time was possibility of a retrocava 1 ureter on the sick with progrcs0
sive signs of dilatation in the kidnc)· ancl upper ureter; CJLH;stionahle radioluccnt stone (fig, J)' The discomfort increased and thl' finally wanted the condition corrected in "hich intention we encouraged him bccaus(-: of thn proven progress of the process, , the dilatation of the kidney pdvis ancl the umx,r third of the ureter, The patient was readmitted rviard1 2G. \nc,tber pydograrn showed basically the sam<, 11s on previous admissions, The combined of the kidney pelvis and ureter nwasured rn the gravity pyelograrn was 20 cc, The clescribccl questionable racliolucent :,tone shadmv mis absent, There was considnabl(· rn emptying of the right kidney. After 15 minutrs there was still a considerahle amount of m the kidney pelvis and in the upper ureter when the left side was long completely drained The laboratory work was within normal limits in regard to complete lJ!oocl count, bloorl chemistry, sedimentation rate, calcium ratios and uric acid. The preoperative: diagnosis was rett'ocaval meter. Operation (March 29): The kidney 1n1s found embedded in dense adbcsions which had to be s<·paratccl hy sharp dissection, The dilated of the upper ureter was now clearly seen and followed by separation from the dmniwarcl for about 7 cm. Thr:n, hmn:ver, it pcarcd behind the vcna can1 11·ithout winding;
around it. On this spot there was a small vein barely 2 cm. in length which came from the psoas muscle and drained into the vena cava. This little vessel was taut like a bowstring and compressed the ureter. The vein was severed between two ligatures and the ureter was freed. I ts course was followed running behind the vena cava and then it resumed normal position where it crossed the iliac vessels. There was no compression by the soft caval vein itself of the retrocaval portion of the ureter and, therefore, it was considered better to leave it where it was rather than to deprive it of nutritional vessels by freeing it. The kidney pelvis was opened by a small incision for two reasons: 1) to make certain there was no nonopaque stone, and 2) to pass a size 8 ureteral catheter down through the original area of obstruction. There was no intrinsic narrowing or scar formation. The condition was brought about by a) compression of the vessel, b) secondary dilatation of the ureter above it and c) final overhanging and riding phenomenon of the ureter over the vessel (fig. 2). The patient had a good recovery and was discharged on April 10. He was last seen in the office on April 28 in good condition with an entirely normal urinalysis and a blood pressure of 144/80. He returned to work on May 5. The pressure in his right flank disappeared.
these two features missing, the diagnosis was doubtful. Pick and his co-workers foresaw some such possibility as the one we described. They theorize that a ureter coursing retroeavally may be draped over a lumbar vein at the point of junction of the latter with the inferior vena cava and caught in the crotch formed by the great vessel and one of its segmental tributaries. This combination of anatomic arrangements-retrocaval ureter and lumbar caval tributary-has not so far as Pick knows been suggested heretofore as a cause of ureteropathy. But, it became fact in our case. They also emphasize the fact that angulation alone, like redundancy, does not necessarily lead to obstruction, as long as the ureter remains movable in the retroperitoneal tissues. But when excessive mobility exists with presence of an aberrant vessel, fibrous band or an adhesion and acute angulation at the point of ureteric crossing, it will undoubtedly result in obstruction. The case of Ubelhor comes close to ours. The obstructing vein was the spermatic. It was, however, more mobile than the one we found at the point of obstruction. In analyzing Ubelhor's findings, Harrill believes that most likely an additional anomaly-reduplication of the inferior caval vein-existed.
The vein which caused the anomaly was no doubt one of those connecting vessels previously mentioned which exists in the embryological period but which did not obliterate. One may note that we titled this paper, Anomaly Simulating a Retrocaval Ureter because not all prerequisites for such diagnosis are fulfilled. The signs suggesting a retrocaval ureter were: progressive hydronephrosis and ureterectasis of a large proximal segment; then medial dislocation of the ureter below L4, with a normal lumen below this point. In the oblique view the ureter was close to the spinal column. It did not, however, have the sudden turn ventrahrnrd which one generally sees in an oblique view at the spot of the obstruction, and it did not have a very pronounced S curve. With
A case is reported where a small collateral vein of the vena cava dislocated and partially obstructed a ureter suggesting a retrocaval ureter. Severing this vessel was sufficient to correct the condition.
13944 Euclid Ave., Cleveland 12, Ohio
REFERENCES HARRILL, H. C.: Retrocaval ureter. Report of a case with operative correction of the defect. J. Urol., 44: 450, 1944. LAUGHLlN, V. C.: Retrocaval (circumcaval) ureter associated with solitary kidney. J. Urol., 71: 195, 1954. DuFouR, A. AND SESBOUE, P.: L'uretere retrocave. J. d'urol., 58: 433, 1952. PrcK, J. W. AND ANSON, B. J.: Retrocaval ureter. Report of a case with discussion of its clinical .. significance. J. Urol., 43: 672, 1940. UBELHOR, R.: Hydronephrose bei Abnormalitat der unteren Hohlvene. Ztschr. f. Urol., 30: 769, 1936.