RETROCAVAL URETER: CASE REPORT 1 P. P. B. McELHINNEY
JOHN W. DORSEY
Retrocaval ureter is an uncommon congenital anomaly that is primarily of vascular origin. It is of interest to the urologist because of its potentiality for producing obstruction involving the right upper urinary tract. Thirty-six cases have been reported in the medical literature. In 11 the condition -was discovered at the time of surgery; in only 2 cases ,ms the diagnosis established preoperatively (Harrill, 1940; Greene and Kearns, 1946) _ The remaining 23 ,vere discovered in the anatomical laboratory or at postmortem examinations. CASE REPORT
M. H., S 2/c, USNR, a ,vhite man aged 20, was admitted to the urological service of U. S. N. Base Hospital Ko. 18, Guam, M. L, on January 15, 1945. His chief complaint was constant, dull, localized right flank pain, chills, fever, and moderate dysuria. The symptoms were of 10 days' duration, becoming progressively more severe. During the past year he had noted recurrent attacks of right flank pain often accompanied by vomiting. One month prior to the present admission, he had been released from the hospital following what appeared to be an acute right pyelonephritis which had responded favorably to chemotherapy. The significant physical findings were marked tenderness on deep palpation of the right hypochrondrium and on percussion of the right costovertebral angle. Neither kidney was palpable. The temperature fluctuated from 99.6 to 102. Urinalysis showed 14,450 white blood cells, 4,100,000 red blood cells, and 78 per cent hemoglobin. An excretory urogram on January 16, 1945 showed in the 30 minute, upright film the characteristic sickle shaped deformity of a retrocaval ureter at the level of the third lumbar intervertebral space (fig. 1, A). There was a fusiform dilatation of the ureter and renal pelvis proximal to the site of ureteral angulation. A definite hydronephrotic change is present. On comparison with figure 1, B and C, there was no evidence of increased renal mobility. The point of ureteral obstruction was at the level of L-3. Cystoscopic examination revealed mild hyperemia of the trigone. The right ureteral orifice exhibited a sluggish peristaltic action. The left renal pelvis was catheterized without difficulty. An impassable obstruction was f:)ncountered in the right ureter at 20 cm. An x-ray (fig. 1, B) revealed a medial displacement of the right ureteral catheter almost to the midline. The retrograde pyelogram (fig. 1, C) revealed a normal upper left urinary tract, and incomplete visualization of a hydronephrotic right kidney. Repeated attempts to visualize the right ureter were unsuccessful due to reflux of the contrast medium. 1 Read at annual meeting, Western Section, American Urological Association, Yosemite Valley, Calif., May 21-23, 1947. 497
P. P. B. MCELHINNEY AND JOHN W. DORSEY
The preoperative diagnosis was infected right hydronephr03is and hydroureter, secondary to obstruction of the right ureter at the inferior border of L-3, pro:::Jably due to an aberrant renal blood vessel. On January 24, 1945, a low right curved lumbar incision was made, ed3nding from the costovertebral angle to the lateral border of the right rectus. The lower pole of the kidney was exposed and the dissection carried to the dilated pelvis and proximal ureter. At the site of ureteral angulation there were numerous adhesions. When these were freed it was found that the ureter disappeared behind the vena ca-, a, and the diagnosis was obvious. During the mobilizatio:i of the postcaval portion of the ureter, it was found to be hung on a lumbar caval tributary. (This condition has been postulated by Pick and Anson as a factor in producing obstruction. This is the first recorded instance of its having been found.) The dissection of the ureter to L-5 was completed without difficulty.
Fm. 1. A, Excretory urogram, 30 minute upright position. Hydronephrosis, hydro ureter, with characteristic "sickle shape" deformity. B, Illustrating medial displacement of right ureteral catheter. C, Retrograde pyelogram, showing incomplete visualization of right hydronephrosis.
The ureter was severed at its junction with the dilated segment, using an oblique incision, anatomical relationship being maintained by means of silk stay sutures. A small segment of constricted ureter located at the site of the acute angulation was excised. The now completely mobilized ureter ,vas brought to the antecaval position and anastomosis with the proximal segment completed, using 0000 interrupted chromic sutures. Two 5 F. splinting ureteral catheters were carried out through a pyelostomy incision. An 18 F. pyelostomy tube was placed well in the pelvis of the kidney. T,Yo Penrose drains were placed in the depths of the wound and the incision was closed in layers. The immediate postoperative course was uneventful, the incision healing by primary intention and drainage from the pyelostomy subsiding in a satisfactory manner. During the early convalescent period there were recurrent attacks of low grade fever and pyuria that responded to the use of an indwelling right ureteral catheter, chemotherapy and antibiotics (fig. 2, A). A 6 weeks' postoperative right retrograde urogram in the upright position revealed no ptosis and a decrease in the hydronephrosis (fig. 2, B). A film made 12 weeks' postoperative
RETROCAVAL URETER: CASE REPORT
showed a more marked return to normal in the configuration of the renal pelvis, major and minor calyces. There was a suggestion of narrowing at the site of the ureteral anastomosis. Having no ureteral catheters or bougies larger than 7 F., the patient was evacuated with the recommendation that further ureteral dilatation be carried on. Prior to evacuation he was afebrile, asymptomatic, and the urine repeatedly negative microscopically.
Fm. 2. A, Six weeks postoperative, showing marked decrease in hydronephrosis and hydroureter. B, Twelve weeks postoperative, showing continued improvement in configuration of major and minor calyces, with slight constriction at site of ureteral anastomosis.
SUMMARY AND COMMENT
To establish a preoperative diagnosis one must be cognizant of this anomaly and the associated diagnostic criteria. The medial displacement of the right ureter over the vertebral column is a very suggestive roentgenologic sign. The oblique or lateral roentgenogram demonstrating the impingement of the ureter on a vertebral body is of major diagnostic significance. The demonstration of the peculiar sickle shaped deformity as noted in the case reported, or the gentle "S" shaped deformity is almost diagnostic. Although not utilized in this case, we believe that nephrostomy provides more satisfactory drainage than pyelostomy. The lack of excessive renal mobility and the site of the obstruction eliminate the necessity for complete mobilization of the kidney with subsequent nephropexy. Section and anastomosis should be performed in the dilated portion well above the point of ureteral angulation, using an oblique incision to lessen the possibility of pelvic distortion and ureteral stricture. The presence of a lumbar caval tributary as a factor in the production of ob-
P. P. B. MCELHINNEY AND JOHN W. DORSEY
structive uropathy as postulated by Pick and Anson in 1940, was demonstrated for the first time. Infection was a definite factor in this case.
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