RETROCAVAL URETER* S. L. GROSSMAN, M .D . AND J . U. FEHR, M .D. Harrisburg, Pennsylvania OCHSTEl-FER in 1893 was apparently the first to report the occurrence of retrocaval ureter in man . The anomaly was discovered on routine dissection in an infant several weeks old during the course of Hochstetter's research on the development of the venous system . Heslin and Mamonas, in reviewing the literature in 1951, reported forty cases of retrocaval ureter to which they added four . An analysis of these cases follows : (n) Twenty-two 'cases were discovered antemortem . Of this number, eight were diagnosed preoperatively and confirmed by operation and thirteen were discovered at operation . (2) One of the cases was diagnosed on pyclographic evidence alone but the patient refused operation . (3) There were nine successful plastic repairs . The remaining twenty-two cases were discovered either on postmortem examination or on routine anatomic dissection . Of the total number of cases reported the occurrence of this anomaly in males to females was in the ratio of 3 to 1, and in the operative cases in the ratio of 2 to n . Although an insufficient number of cases are on record to draw any definite conclusions, the above-mentioned ratios would seen to indicate that the anomaly is more common in men . Embryologically, retrocaval ureter is the result of an error in the development of the vena cant and not of the ureter, as one might suspect . The permanent kidney or metanephron develops i n the pelvis and ascends to the lumbar region, attaining its normal position about the twentieth week of life in utero . During its ascent the kidney passes through a circle of veins known as the perimetanephric or the periureteric ring . Dorsally this circle of veins is composed of the lumbar division of the supracardinal vein and subcardino-supracardinal anastomosis (after McClure and Butler 1925) or the sacrocardinal vein (after Gruenwald 1938) . Ventrally the ring is made up of the lumbar division of the postcardinal vein and ' From the Department of Urology, Harrisburg Hospital,
subcardino-postcardinal anastomosis and the sacrocardinal vein . Normally the postrenal portion of the inferior vena cava develops from the dorsal limb of the perimetanephric ring, and hence the ureter lies in an antecaval position . Persistence of the ventral limb with resolution of the dorsal limb or failure of development of the dorsal limb will result in retrocaval ureter . Persistence of both ventral and dorsal limbs will result in the ureter passing between the cavae . Four types of retrocaval ureter have been observed in man : (1) Bilateral retrocaval ureter which is due to bilateral persistence of the postcardinal vein . Gladstone's case, that of an acardiac monster, is the only example on record to date. (2) Right-sided postcaval ureter which is the commonest type . (3) Double vena cava on the right, with the ureter passing between, which is the result of persistence of the ventral and dorsal perimetanephric limbs . (1) Double vena cava, consisting of one on each side with the ureter passing retrocavally on the right . There is no definite gamut of symptoms and signs pathognomonic of postcaval ureter . The clinical picture may vary from no symptoms to that of marked involvement of the urinary tract . The symptomatology is dependent upon the development of obstructive phenomena on the basis of ureteral kinking, stricture, compression or a combination of these factors . Ordinarily the diagnosis can be made upon retrograde study'alone ; however, in the case to be presented it will be evident that both intravenous urography and retrograde pyelographic study were essential . The following roentgenographic features are peculiar to this anomaly . Anteroposterior views disclose hydronephrosis with a dilated and elongated proximal ureteral segment which then courses abruptly toward the midline or slightly beyond in the region of the third, Fourth or fifth lumbar vertebra . This is the point at which the ureter passes retrocavally . After emerging from behind the vena cava the
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Grossman, Fehr-Retrocaval Ureter CASE REPORT D . A . (Harrisburg Hospital No . 2826$A), a thirty year old, white woman, entered the Harrisburg Hospital on July 28, 1951, with a three-week history of intermittent, dull, right costovertebral angle pain which radiated to the right lower quadrant and was associated with nausea but no vomiting . Positive findings on physical examination were paralysis of a vocal cord, right lower quadrant tenderness on deep palpation with moderate muscle guarding and right costovertebral angle tenderness . The blood pressure was 120/70, the pulse 8o and the temperature 98 .6°F.
Fic . i . Right preoperative intravenous urograrn thirty minutes after injection of diodrast .
ureter assumes a normal caliber and course to the bladder. This imparts a so-called S curve or sickle-shaped appearance to the upper third of the ureter . In the lateral and oblique views the ureter embraces the vertebral column instead of falling away from it as it does normally . The treatment of retrocaval ureter is surgical . The surgical policy, whether radical or conservative, is dictated by the degree of renal damage . Division of the ureter, careful mobilization and disengagement from its retrocaval to an antecaval position, and anastomosis of the severed ends, with or without intubation, is the surgical technic employed to conserve renal function . Various sites of ureteral division have been advocated, namely, above the ureteropelvic junction (Harrill) ; at the ureteropelvic junction (Derkes and Dial) ; immediately below the ureteropelvic junction (Kimbrough) ; at the point where the ureter passes retrocavally with excision of the involved portion (Goyanna, Cook, and Counseller) ; and finally at the ureterovesical junction (Lowsley) . Cathroc recommends division of the inferior vena cava rather than ureteral division, particularly in cases where the opposite kidney is seriously damaged or destroyed .
A voided specimen of urine revealed many pus cells and epithelial cells, 3 to 4 red blood cells high power field, a trace of albumin, a specific gravity of 1 .020, and an acid reaction . A complete blood count showed 3,320,000 red blood cells, with a hemoglobin of 58 per cent and a white blood count of 3,050, with 68 per cent polymorphonuclears and 32 per cent lymphocytes . The blood urea nitrogen was 18 mg . per cent . Intravenous urogram disclosed prompt excretion of radiopaque material from both kidneys . The left kidney was normal, but the right kidney showed marked hydronephrosis of the pelvis and calyces with kinking of the right ureter just below the ureteropelvic junction with mesial displacement . (Fig . i .) On cystoscopic examination the bladder was normal. Both ureteral orifices were small with the suggestion of a right ureterocele . A No . 5 ureteral catheter was passed up the right ureter to a point corresponding to the inferior margin of the body of the third lumbar vertebra where impassable obstruction was encountered . Bladder and right kidney urine specimens were clear, microscopic analyses were negative, and cultures were sterile in forty-eight hours . Right retrograde pyeloureterography revealed hydronephrosis, with poor visualization of the upper third of the right ureter . The distal two thirds of the ureter was normal in caliber and course . A diagnosis of ureteral obstruction due to an aberrant vessel or band at the ureteropelvic junction was made and the patient was subjected to surgery following correction of anemia. The right kidney was exposed through the conventional lumbar approach . Without unAmerican Journal of Surgery
Grossman, Fehr-Retrocaval Ureter
Fic . 2. Artist's concept of findings at operation .
duly mobilizing the kidney a large, dilated extrarenal pelvis and an elongated, tortuous and dilated proximal ureter were found. The ureter coursed somewhat cephalad and passed behind the vena cava. Further visualization of the ureter through the lumbar approach being unsatisfactory, the superior angle of the wound was closed and the patient placed in the supine position . The incision was then extended anteriorly, affording better exposure and the ureter, upon emerging from behind the vena cava, assumed a normal caliber and course to the bladder . After mobilizing the ureter carefully it was divided and placed anterior to the vena cava . A thickened and strictured portion measuring 2 cm . corresponding to the point of compression by the vena cava was excised . End-to-end anastomosis was accomplished over a No . 6 ureteral catheter using five interrupted sutures of No . ooooo chromic catgut . (Fig. 2 .) The catheter was passed to the bladder distally and brought out through the renal pelvis proximally, hence splinting the entire ureter . Pyelostomy drainage was established using a mushroom catheter . The patient's postoperative course was uneventful and the ureteral splint was removed on the twentieth postoperative day . Upon clamping the pyelostomy tube the patient May, 1953
Fie . 3 . Postoperat position.
ureteropyelogram, right oblique
complained of pain and discomfort in the right costovertebral region . Introduction of radiopaque material through the pyelostomy catheter on the twenty-second postoperative day showed marked dilatation of the pelvis and calyces and there was no evidence of dye in the ureter . On the twenty-ninth postoperative day a No . 6 ureteral catheter was passed with ease to the right renal pelvis following a right ureteral mcatotomy . Retrograde pyelography at this time showed a marked diminution of the previously described hydronephrosis . The ureter was patent. (Fig . 3 .) The apparent lack of ureteral patency one week previously was explained on the basis of the mushroom catheter blocking the urcteropelvic junction . The patient was discharged from the hospital on the thirtieth postoperative day with instructions to clamp the drainage tube for increasing periods of time providing no untoward symptoms developed . Her convalescence at home was uneventful and she experienced no discomfort upon clamping the drainage tube for periods of five to six hours . Two weeks later the patient re-entered the hospital for retrograde studies which revealed moderate hydronephrosis and patency of the
Grossman, Fehr-Retrocaval Ureter
right ureter. The drainage tube was removed on the following day, with prompt closure of the sinus tract . Periodic ureteral dilatations were carried out at three- to six-week intervals with the ureter accommodating a No . ioF bulb easily throughout its entire length . Five months postoperatively the patient, symptom-free, was readmitted to the hospital for evaluation . Retrograde ureteropyelography revealed minimal hydronephrotic changes of the right kidney and patency of the ureter . Microscopic examination of the urine showed three to four pus cells and occasional squamous and renal epithelial cells . Cultures from the bladder and right kidney were sterile in fortyeight hours . SUMMARY
A brief resume of the history, embryologic considerations, statistical incidence, diagnostic features and treatment essentials of postcaval ureter has been presented . An additional case, diagnosed at operation, with a successful plastic repair followed over an eight-month period is added to the series . Transection of the ureter where it passes postcavally and excision of the postcaval seg-
ment with end-to-end anastomosis antecavally is advocated as the surgical treatment of choice . REFERENCES DECARLO, J . Postcaval ureter . J. Urol ., 45 : 827-831, 1941 . GRAVES, R . C . and DAVIDOFF, L. M . Anomalous
relationship of the right ureter to the inferior vents cava . J. Urol ., 8 : 75 -79 . 1 922 . GREENE, L . F. and KEARNS, W. M . Circumcaval ureter : report of a case with a consideration of the preoperative diagnosis and successful plastic repair . J . Uro1., 55 : 52-59. 1946 HARRILL, H . C . Retrocaval ureter . J . Urol ., 45 : 827831, 1 941 . LICK, R ., JR . and GRANT, o. Retrocaval ureter . Arch. Surg ., 59 : 84 1, 1949 . LowsLEV, 0 . S . Postcaval ureter, with description of a
new operation for its correction . Surg ., Gynec . o Obst., 82 : 549-556, 1946. MIDDLETON, A. W . Postcaval ureter . Rocky Mountain M . J ., 48 : t86-Too, 195 I . SCHMIDT, C . R ., H VERERT, D. W . and I3EAZELI ., J . M. Retrocaval ureter . Arch . Surg., 62 : 299-302, 1951 . SHIR, 11 . E . Postcaval ureter . J. Urol., 38 : 61-66, 1937. CATr1RO, A . J . NIcG . Section of the inferior vena cava for retrocaval ureter : A new method of treatment
J. Urol., 67-4 : 464-475, 1952 . IIESLIN, J . E . and MAMONAS, C .
Retrocaval ureter : Report of Four cases and review of literature .
J. Urol .,
65-2 : 212-222, 1951 .