THE JOURNAL OF UROLOGY
Vol. 63, No. 3, March 1950 Printed in U.S.A.
RETROCAVAL URETER: CASE REPORT 1 P.A. DUFF From Ashburn Veteran's Administration Hospital, McKinney, Texas
The congenital anomaly of circumcaval ureter, though relatively rare, is being discovered more frequently in late years by the urologist in his search for the cause of obstruction of the right upper ureter. Creevy found 37 cases in the literature and added one of his own. Since his report was submitted, McElhinney and Dorsey have reported a case, making a total of 39. Of these, 22 were discovered in the anatomical laboratory or at necropsy, 13 were discovered at operation and 4 were recognized preoperatively. Attempted surgical repair has been done in 9 cases with successful results reported in 7. CASI£ REPORT
W. K. W., a white man, aged 51, was admitted to the medical service of the hospital on May 28, 1946. His chief complaints were attacks of pain in the right flank accompanied by frequency and nocturia, burning on urination, and passage of slugs of mucus and pus in his urine for many years. His symptoms dated back to 1928, and during the intervening years he had been treated many times with prostatic massages, urinary antiseptics, cystoscopic examinations, and finally in 1944 a transurethral resection of the prostate gland was done. There had been no permanent relief of his main symptoms following any of his treatments. There were no significant physical findings. Blood pressure was 120/74. Laboratory findings showed 4,610,000 red blood cells, 8,700 white blood cells, hemoglobin 14.5 gm. and a normal differential white count. Urinalysis showed a trace of albumin and many white blood cells in the sediment. Urine cultures showed a heavy growth of Pseudomonas aeruginosa. A scout film of the abdomen showed no significant findings. The 20 minute excretory urogram (fig. 1, A) showed a small irregularly shaped kidney on the right side with moderate dilatation of the pelvis and the upper ureter. The ureter curved medially at the level of the third lumbar vertebral body and was not visualized in its midportion. The left kidney appeared normal in all respects. Cystoscopic examination revealed fine trabeculation of the bladder wall, mottling of the lmver portion of the trigone and irregular intrusion of prostatic tissue at both sides of the bladder neck. There was no residual urine. No. 6 F catheters were passed to each kidney pelvis without meeting obstruction. There was no residual urine in either pelvis. Intravenous phenolsulfonphthalein appeared in 5 minutes on the left and in 5½ minutes on the right. Microscopic examination of the right kidney urine showed many white blood cells, 1 Published with permission of the Chief Medical Director, Department of Medicine and Surgery, Veteran's Administration, who assumes no responsibility for the opinions expressed or conclusions drawn by the author.
FIG. 1. A, 20 minute excretory urogram, showing dilatation of upper right ureter and its eourse medially. B, retrograde right pyelo-ureterogram, showing course of right ureter over to midline and back.
FIG. 2. Vena cavogram, showing course of right ureter medial to vena cava 497
single and clumped. No pus cells were seen in the specimen from the left kidney. In a 10 minute collection of phenolsulfonphthalein,' 9 cc urine was collected from the right with 8 per cent of the dye and 8 cc from the left with 17 per cent of the dye. Retrograde pyelogram of the right side (fig. 1, B) showed the midportion of the ureter coursing over to the midline in a long curve and back to a normal position in its lower third. There were no particular deformities of the pelvis and calyces of the right kidney noted in this film. Culture of the right kidney urine revealed Pseudomonas aeruginosa. Urine from the left was sterile on culture. Diagnosis was made of retrocaval right ureter with mild obstruction of the right upper ureter and chronic pyelonephritis, right kidney. On June 15, 1946 a vena cavogram was made with an opaque ureteral catheter in place in the right ureter. This film (fig. 2) showed the midportion of the right ureter to be medial to the vena cava in that area on the anteroposterior
Fm. 3. A, external view of posterior aspect of kidney, showing destruction of poles. B, view of cut surface of posterior half of kidney.
view, and although not absolute proof of a retrocaval ureter, it was highly suggestive of same. The vena cavogram was made by O'Loughlin by technique previously described by him. An attempt was made on the medical service to eradicate the infection in the right kidney by repeated courses of different urinary antiseptics, including sulfa drugs, penicillin, mandelamine, calcium mandelate, and streptomycin. The pyuria and positive cultures of Pseudomonas aeruginosa persisted. The patient was reluctant to undergo surgery at this time and he was discharged home. He was re-admitted to the urological service 2 weeks later with the same complaints. The findings were the same as on the first admission except that there seemed to be more pus in the urine and there was tenderness in the right flank on pressure. The preoperative diagnosis was retrocaval right ureter with chronic pyelonephritis of right kidney.
On November 6, under general anesthesia, the right kidney area was exposed through the usual oblique loin incision and the kidney freed of its fatty capsule and exposed. The ureter ·was found to be of normal size and was traced downward and medially where it dipped behind the inferior vena cava approximately 6 cm. belo,v the level of the lower pole of the kidney. The vena cava was exposed on further down and the ureter found emerging from behind and medial to this great vessel approximately 7 cm. down from the point of disappearance behind the vessel. It curved around anteriorly on its way into the pelvis. The kidney was found to be partly destroyed with a massive depressed purple scarred area involving the entire lower pole and another similar area involving the upper pole. There was serious doubt in the operator's mind as to the feasibility of attempting a repair of the ureter and leaving a diseased kidney in place. Therefore a routine nephrectomy was done and no attempt was made to remove the ureter from behind the vena cava. The pathological report was chronic pyelonephritis ·with destruction of both poles (fig. 3). The patient made an uneventful recovery. The urine became free of pus cells and became sterile on culture. He was discharged from the hospital 1 month after operation. Subsequent follow-up has found the patient symptom free, with a clean sterile urine, and able to work full time at his usual occupation. COMMENT
This case is believed to be the fifth reported where the diagnosis was made preoperatively. It differs from the other recently reported cases in that the kidney lesion was not a hydronephrosis, but rather a destructive pyelonephritis of long standing. It is felt that a vena cavogram taken ·with an opaque ureteral catheter in place is helpful in establishing a diagnosis of circumcaval ureter, but not necessary. As already pointed out by Creevy, the course of the ureter in this condition is so typical that, once seen, is not easily forgotten. REFERENCES CREEVY, C. D.: J. Urol., 60: 26-30, 1948. GREENE, L. F. AND KEARNS, W. M.: J. Urol., 55: 52-59, 1946. GoYANNA, R., CooK, E. N. AND CouNSELLER, V. S.: Proc. Staff Meet. Mayo Clinic, 21: 356-360, 1946. HARRILL, H. C.: J. Urol., 44: 450-457, 1940. KIMBROUGH, J.C.: J. Urol., 33: 97-100, 1935. McELHINNEY, P. P. B. AND DoRSEY, J. W.: J. Urol., 59: 497-500, 1948. NouRsE, M. H. AND MoouY, H. C.: J. Urol., 56: 525-529, 1946. O'LouGHLIN, B. J.: Am. J. Roentgenol. & Rad. Therapy, 58: 617-619, 1947.