Sonographic Differentiation From Pseudoureterocele of Ectopic Ureter and Ureterocele in Pediatric Patients.

OBJECTIVES: Ectopic ureter and ureterocele need an adequate treatment plan and different surgical interventions. However, some cases appear as intravesical cystic lesions on ultrasound, with ectopic ureter sometimes reported as pseudoureterocele. This study aimed to describe the sonographic imaging findings of intravesical cystic lesions to differentiate between pseudoureterocele and ureterocele. METHODS: Nineteen patients with duplex collecting system and intravesical cystic lesions that were classified into pseudoureterocele and ureterocele based on the surgical findings were included. The ultrasound findings compared between the 2 groups were as follows: intravesical lesion with/without a covered muscular layer, presence/absence of notch sign within the lesion, and dynamic change in the appearance of intravesical cystic lesions using Fisher's exact test. RESULTS: The lesions in 3 patients were classified as pseudoureterocele due to ectopic ureter and the remaining 16 as ureterocele. Significant differences were observed in intravesical lesions with/without a muscular layer (pseudoureterocele versus ureterocele = 3/0 versus 3/13, P = .021) and the presence or absence of a notch sign within the vesical cystic lesion (pseudoureterocele versus ureterocele = 3/0 versus 3/13, P = .021) between the groups. Although there was a tendency for the dynamic change in the appearance of intravesical cystic lesions to be more detectable in cases with ureterocele than in pseudoureterocele, the difference was not significant (0/3 versus 11/5, P = .058). CONCLUSIONS: Sonographic findings, including bladder muscular layer location and the presence of a notch sign within the cystic lesion, were useful in differentiating pseudoureterocele and ureterocele in intravesical cystic lesions in pediatric patients with a duplex collecting system.

A rare variant of obstructed hemivagina and ipsilateral renal agenesis and its improvement of classification.

Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) is a rare congenital malformation of the female reproductive organs, including uterine dysplasia, blind hemivagina, and ipsilateral renal dysplasia. It has a serious impact on patients' quality of life and fertility. We report a rare case of OHVIRA with a complete septate uterus, ectopic dysplasia of the left kidney, left ectopic ureter, and three oblique vaginal septa. The dysplastic left kidney and the ectopic ureter were removed during laparoscopy. In addition, the two layers of vaginal septa, which were ignored in the past 10 years, were removed by hysteroscopy. As the detection rate of OHVIRA has gradually increased, manifestations that previous classification systems could not recapitulate have emerged. By retrieving the relevant cases, we have tried to propose a new classification system, which would allow clinicians to have a complete understanding of the manifestations of OHVIRA and would be helpful in the treatment of patients.

An ectopic ureter inserting into epididymis combined with ipsilateral duplex kidney in a boy diagnosed by MRI: report of a rare case.

We present the first case of a right ectopic ureter ending in epididymis combined with an ipsilateral complete duplex kidney, presenting with painless right scrotal mass and demonstrated by magnetic resonance imaging (MRI). The boy was initially diagnosed as right testicular teratoma by ultrasound, and then underwent surgical treatment. Because of recurrence of right scrotal swelling 1 year later, MR scan was performed. MR images with body coil displayed the entire ectopic ureter, and MR images with small surface coil clearly showed anatomic details of right ureteral ectopia into epididymis. Delayed-enhanced MRI showed contrast agent in the right dilated epididymis. The boy finally received the curative right upper pole nephronureterectomy.

Surgery of the Equine Urinary Tract.

Urinary surgery in the horse may be challenging. More straightforward procedures, such as urinary bladder or urachal defects, do not usually require specialized equipment or imaging, although laboratory work is helpful. Congenital or acquired conditions of the ureters or kidneys may necessitate advanced diagnostic work-ups including advanced imaging /or and minimally invasive procedures. Some surgery of the lower urinary tract is done in the sedated, standing adult horse. Surgery involving the kidney typically requires general anesthesia. Laparoscopy and associated tools are frequently used. Although many of the surgical procedures discussed are quite involved, they are becoming more commonplace.

Urinary Incontinence and Urinary Tract Infections.

Urinary incontinence results from disorders of the lower urinary tract or neurologic diseases either of the nerve supply to the bladder/urethra or within the central nervous system. Congenital causes include patent urachus and ectopic ureter. Coordination of lower urinary tract function involves the interaction of both the sympathetic and parasympathetic system as well as somatic branches of the central nervous system. Well-recognized causes of incontinence include equine herpes virus 1 myeloencephalopathy, polyneuritis equi (neuritis of the cauda equina), and sacral/coccygeal trauma. Idiopathic bladder paralysis is characterized by bladder paralysis and sabulous cystitis in the absence of overt neurologic deficits.

Triplication of Ureter: A Rare Case.

Anatomical fusion abnormalities of the urinary system and ureters are not uncommon. However, triplication of the ureter is very rare. A boy with this abnormality is being presented in view of its rarity. The importance of a thorough preoperative evaluation is being projected that may help us to choose the best management avenue.

Bilateral Single-System Ectopic Ureter: When Can We Avoid Bladder Neck Reconstruction?

Bilateral single-system ectopic ureter (BSSEU) is often associated with underdeveloped incompetent bladder neck; hence, to achieve continence, bladder neck reconstruction (BNR) is usually advocated with ureteric reimplantation. Presented here is a 14-year-old girl with BSSEU who achieved continence without BNR. An attempt is made to look at factors that could identify patients in whom BNR could be avoided.

Embryology of the urogenital tract; a practical overview for urogynecologic surgeons.

INTRODUCTION AND HYPOTHESIS: Urinary tract anomalies are one of the most common birth defects. Nevertheless, they prove challenging to diagnose as a result of variable presenting symptoms. We aimed to perform a review of urogenital tract development, highlight common congenital upper urinary tract anomalies encountered by urogynecologists and tools to facilitate diagnosis. METHODS: Multiple searches were performed utilizing resources such as PubMed and the TriHealth library database to access publications related to embryology of the urinary tract and urinary tract anomalies. Each citation was reviewed. RESULTS: Congenital urinary tract anomalies account for up to 20% of all birth defects and occur more often in females. The true incidence of these malformations is unknown as some can remain clinically insignificant throughout life. In addition, patients may present with non-specific complaints such as urinary tract infections, nephrolithiasis or urinary incontinence. Therefore, unsuspected anomalies pose a risk of delayed diagnosis and potential injury during urogynecologic surgery. Imaging modalities such as computed tomography or magnetic resonance imaging are the most common diagnostic tests. Management and treatment options range from observation to surgical resection with the goal of optimizing long-term functionality and prevention of chronic sequelae. CONCLUSION: Patients with urinary tract anomalies can present with vague complaints often encountered by urogynecologists. It is crucial to understand the embryologic development of urinary tract anomalies to help facilitate diagnosis and guide care within the office and operating room setting.

Laparoscopic ligation of ectopic ureter in pediatric patients: a safe surgical option for the management of urinary incontinence due to ectopic ureters.

BACKGROUND: Ureteric ectopia is a pediatric urinary incontinence cause in girls. It is traditionally managed through hemi-nephrectomy or uretero-ureterostomy, which have the potential for complications including anastomotic stricture, leak, bleeding, and de-vascularization of the functioning renal moiety. Laparoscopic ureteric clipping has been shown to be a good alternative but has not been widely adopted yet. We provide our experience with this technique. METHODS: We retrospectively reviewed the data of 6 patients who underwent laparoscopic clipping of ectopic ureter between 2014 and 2019. We collected the following information: clinical presentation, preoperative and postoperative imaging, age at presentation, age at surgery, operative time, complications, length of stay, length of follow-up, as well as continence outcomes. RESULTS: Five patients were diagnosed with a duplex system associated with an ectopic upper pole ureter. One patient was noted to have a non-functional kidney associated with an ectopic ureter. Median age at presentation was 5 years (6 weeks-9 years), while at surgery was 8 years (2-13 years). Four patients were referred for incontinence, 1 was referred for antenatal hydronephrosis, 1 presented with urosepsis. The preoperative renal pelvis anteroposterior diameter (APD) was 8.60 cm (median) (6.80-8.70 cm). At the post-operative follow-up, the APD increased to median 9.1 cm (6.80-11.50 cm). Median operative time was 91 min (42-60 min). Complications were seen in only one patient who developed an immediate postoperative urinary tract infection (UTI). Five patients were discharged home the same day of the surgery, while the patient who developed UTI went home on post-operative day 3. Median follow-up was 33 months (22-72 months). Currently, all patients have achieved daytime urinary continence. No patient had UTI during the follow-up period. CONCLUSION: Laparoscopic ureteric clipping of the ectopic ureter appears to be a valid alternative to extirpative or reconstructive procedures. Follow-up shows an increase in hydronephrosis without any consequence for the patients. Further studies are necessary to reinforce these observations.

Optimization of ultrasonographic ureteral jet detection and normal ureteral jet morphology in dogs.

Ureteral jets are visualized with ultrasound as echogenic streams extending from the ureterovesicular junction into the urinary bladder. In clinical practice, diuretics are sometimes administered to increase visibility of ureteral jets, however this has not been well described in the veterinary literature. The purpose of this prospective, crossover study was to describe the normal morphology of canine ureteral jets, determine an optimal protocol for diuretic administration to increase visibility of ureteral jets, and confirm in vitro the effect that differences in specific gravity and velocity have on visibility. Ultrasound of 10 normal dogs was performed at baseline and following 1 mg/kg furosemide administered intravenously or subcutaneously. Increased numbers of ureteral jets were seen post-furosemide administration compared to baseline, with an overall increased number of ureteral jets identified following intravenous administration when compared to subcutaneous administration. Time to first ureteral jet was significantly shorter with intravenous compared to subcutaneous administration. Urine specific gravity significantly decreased following furosemide administration. For the in vitro study, saline solutions of varying specific gravities were infused into a bath of hypertonic saline with specific gravity of 1.037. There was good visibility in vitro with infusion of solutions of specific gravities of 1.010-1.025. Infusion of saline solution with a specific gravity of 1.030 had reduced visibility, while infusion of saline with equivalent specific gravity (1.037) was not visible with B-mode ultrasonography. Both intravenous and subcutaneous furosemide administration significantly increase ureteral jet detection with ultrasound secondary to differences in specific gravity, confirming results of prior studies.

Four-dimensional CT excretory urography is an accurate technique for diagnosis of canine ureteral ectopia.

Computed tomographic (CT) excretory urography is commonly used to investigate canine ureteral ectopia (UE). Modern technology allows time-resolved CT imaging (four-dimensional CT excretory urography [4D-CTEU]) over a distance exceeding the detector collimation. Objectives of this prospective, observational, diagnostic accuracy study were to evaluate the diagnostic accuracy of CT excretory urography (CTEU) and 4D-CTEU for UE in dogs with lower urinary tract signs, assess the influence of pelvis positioning, and to determine the significance of the ureterovesical junction (UVJ) angle for UE diagnosis. Thirty-six dogs, with a total of 42 normotopic ureters, 27 intramural ectopic ureters, and three extramural ectopic ureters, underwent CTEU and 4D-CTEU with randomized pelvis positioning. Randomized CTEU and 4D-CTEU studies were scored by two observers for ureteral papilla location and murality on a grading scheme. Interobserver agreement, sensitivity, and specificity for ureter topia status and diagnosis were calculated. Computed tomographic excretory urography showed moderate interobserver agreement for the left ureter and perfect for the right ureter, whereas 4D-CTEU showed bilateral nearly perfect agreement between both observers. When comparing CTEU versus confirmed diagnosis, there was a sensitivity and specificity of 73% and 90.2%, respectively, whereas 4D-CTEU showed a sensitivity and specificity of 97% and 94.6%, respectively. An obtuse UVJ angle is significantly more commonly observed in ectopic intramural than normotopic ureters and is significantly associated with increased diagnostic confidence of UE. The use of a wedge to angle the pelvis did not increase the diagnostic confidence in determining ureteral opening position. Four-dimensional CT excretory urography is an accurate and reliable diagnostic technique to investigate UE as cause of urinary incontinence in dogs that is slightly superior to CTEU.

Computed tomographic excretory urography for diagnosing ectopic ureter in a female rhesus macaque (Macaca mulatta).

Ectopic ureter is a congenital abnormality where the ureter terminates at a site other than the urinary bladder. A five-year-old female rhesus monkey presented with a urine odor, a wet perineum, and persistent dribbling of urine. An ultrasound examination revealed a cyst-like structure (1 × 0.75 cm) on the left side of the bladder. Computed tomographic excretory urography (CTEU) imaging revealed a left unilateral extramural ectopic ureter, which was connected to the vagina. The perineum and wet hair were dried and disinfected with 0.4% chlorhexidine for perineal hygiene and skin care. The animal was closely monitored for potential moist dermatitis near the perineum and for urinary tract infection. The complete blood count (CBC) and blood chemistry results showed no signs of inflammation during the observation period. This is the first report of detailed diagnosis of ectopic ureter by ultrasound and CTEU in a female rhesus monkey.

Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients.

BACKGROUND: Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. CASE REPORT: We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.

UNILATERAL SINGLE VAGINAL ECTOPIC URETER WITH IPSILATERAL HYPOPLASTIC AND DEGENERATED KIDNEY ASSOCIATED WITH INFERTILITY IN IBERIAN IBEX (CAPRA PYRENAICA) DOES.

This article describes the urinogenital condition of three female Iberian ibexes (Capra pyrenaica-one infertile 3-yr-old adult and two prepubertal animals aged 1 (PP1) and 2 (PP2) yr, respectively, all raised in captivity. All showed constant urinal dribbling, leading to ulcerative dermatitis in the vulvar area. Housed in a stable with other females, the adult did not become pregnant after male contact in either of two consecutive mating seasons. Vaginoscopy and laparoscopic exploration performed on the prepubertal females revealed abnormalities of the vagina and urinary bladder. Ultrasound examination revealed atrophy of the left kidney in the adult female and PP1, and of the right kidney in PP2, with degeneration of the renal pelvis. A paraovarian cyst with hydrosalpinx was also detected in the left oviduct of the adult female. Postmortem analysis of the adult and PP2, which shared a mother, confirmed an extramural single ectopic ureter with vaginal insertion associated with atrophy of the ipsilateral kidney. Though PP1 was officially unrelated to the latter animals, all three might have had a common ancestor in their lineages.

Diagnosis and surgical outcomes of ectopic ureters in adults: A case series and literature review.

OBJECTIVES: To evaluate functional outcomes of surgery in patients with ectopic ureters diagnosed in adulthood; to review the world literature. PATIENTS AND METHODS: Patients were referred over 10 years. Data including surgical history, presenting symptoms, diagnostic modalities, interventions and functional outcomes were collected; and the world literature reviewed. RESULTS: 9 women and 1 man had a mean age of 37 (range 20-58). All women were referred with lifelong leakage. The man was referred with storage LUTS. Three women had heminephrectomy/nephrectomy with the distal ureter left in-situ prior to referral. MRI was the predominant diagnostic tool but often took senior review to confirm the diagnosis. Excision of the ectopic ureter was performed with bladder neck reconstruction in 6 women, with concomitant rectus fascial sling in one patient. 4 of 6 (67%) women were cured of their stress incontinence with the bladder neck reconstruction alone, whilst two required further intervention. Three women had nephroureterectomy alone as primary treatment of which two were cured. The single male had heminephrectomy and excision of seminal vesicle. CONCLUSIONS: Ectopic ureter is a rare diagnosis in adults but should be considered in patients who describe lifelong incontinence. Fine slice MRI is the imaging of choice. Excision of the ureter with bladder neck reconstruction alone was successful in two-thirds of patients, whilst further stress urinary incontinence surgery was required in one-third. Malignancy in ureteric remnants is described in 8% of the world literature. Patients should be counselled of this risk if the ureter is left in-situ.

Ectopic ureters in anorectal malformations.

PURPOSE: The literature about ectopic ureters in anorectal malformations is limited. Repair of an anorectal malformation may require dissection near the normal or abnormal insertion of the ureters. Knowledge of the presence and location of ectopic ureters may prevent intraoperative injury. We aim to describe the incidence and location of ectopic ureters in patients with anorectal malformations and to characterize associated renal anomalies. METHODS: This is an IRB-approved retrospective study of patients with anorectal malformations and ectopic ureters identified in our colorectal database. RESULTS: Of 2283 patients with anorectal malformation, 79 (3.5%) had ectopic ureter(s). Of those, 29% had bilateral ectopic ureters. Nearly all (87%) of bilateral ectopic ureters occurred in females. Ectopic ureters most commonly inserted into the bladder neck (33%), vagina (15%), or urethra (13%). Renal dysfunction was noted in a high proportion of patients. The majority (59%) of ectopic ureters were associated with dysfunction of the ipsilateral kidney. Interestingly, 29% of patients with unilateral ureteral ectopia had an abnormal contralateral kidney. Only 22 patients (28%) had two normal kidneys, and 5 (6%) had documented renal failure with 2 (2.5%) requiring renal transplant. This compares to a transplant rate of 0.6% among anorectal malformation patients without ectopic ureter. CONCLUSIONS: The incidence of ectopic ureter is 3.5% among anorectal malformation patients. Cloaca and recto-bladder neck fistula are the types of anorectal malformation with higher incidence. Ureteral ectopia seems to confer an increased risk of renal failure. Identifying ectopic ureters is important for surgical planning and monitoring renal function vigilantly.

Prenatal Evaluation and Postnatal Follow-Up of Ureteral Ectopic Insertion in Multicystic Dysplastic Kidneys.

OBJECTIVE: To emphasize the need for analyzing the pelvis when a unilateral multicystic dysplastic kidney (MCDK) is observed at prenatal ultrasonography (US) because of possible associated ectopic ureteral insertion. METHODS: We performed a retrospective study including prenatal US diagnosis of unilateral MCDK and retrovesical cyst. The following data were recorded: pre- and postnatal US, magnetic resonance imaging (MRI), and voiding cystourethrography (VCUG) findings. The shape of the pelvic cyst was analyzed as well as the visibility of the ureteral insertion into the cyst. RESULTS: Fourteen patients were included (7 females). At prenatal US, the cyst wall was smooth in 8 cases (6 females) and lobulated in 5 cases (4 males). In 1 case it protruded into the bladder. Ectopic ureteral insertion was observed in 2 cases. Prenatal MRI (n = 6) depicted ureteral insertion in 2 more cases. Postnatal US (n = 14) showed the same cyst patterns as prenatally, ectopic ureteral insertion (n = 8), and duplicated uterus (n = 4). Postnatal MRI (n = 7) always depicted the ureteral ectopic insertion into the cyst. VCUG (n = 5) showed indirect findings of ectopic ureteral insertion (n = 3). CONCLUSION: Unilateral MCDK should lead to search for a retrovesical cyst corresponding most commonly to a distended hemivagina or a seminal vesicle. Early diagnosis of this condition leads to better clinical management.

[Diagnostic search for causes for urinary holding in a uniform kidney girl].

Ectopic of the ureter into the cervix is a rare case in the clinical practice of pediatric urologists around the world. This paper presents an observation of congenital urinary incontinence in a 13-year-old girl who underwent an annual examination in a hospital at the place of residence.

Upper Pole Heminephrectomy Versus Lower Pole Ureteroureterostomy for Ectopic Upper Pole Ureters.

PURPOSE OF REVIEW: Ureteral duplication and ectopic upper pole ureters are commonly associated with renal pathology, including vesicoureteral reflux, obstruction, infection, and renal function loss. There remains no consensus on the most appropriate management of these complex patients. In this review, we sought to compare existing data on upper pole heminephrectomy with ipsilateral ureteroureterostomy. RECENT FINDINGS: Application of magnetic resonance imaging and minimally invasive techniques have led to changes in the diagnosis and treatment of ectopic upper pole ureters. Recent studies have highlighted the safety of laparoscopic and robot-assisted upper pole heminephrectomy and ureteroureterostomy. Minimally invasive approaches to ectopic upper pole ureters appear safe and effective, with complication rates remaining low. Minimally invasive upper pole heminephrectomy carries a higher risk of lower pole function loss. Both upper pole heminephrectomy and ureteroureterostomy carry a small risk of additional surgery on the bladder and remnant ureter.

Ectopic insertion of a duplicated ureter into prostatic urethra: Demonstration by 3D multi-detector computed tomography urography.

Ectopic insertion of the ureter in the genitourinary tract is a rare congenital disorder, usually associated with ureteral duplication. Identification of the insertion open is critical for ureteric re-implantation. However, the challenge in the diagnosis of ectopic insertion of the ureter usually is to identify its insertion, particularly when the affected ureter is not dilated. Multi-detector computed tomography (MDCT) urography with nonionic iodinated contrast media delineates the ureteric course in the normal functioning kidney in the excretory phase [1]. This report presented a young male patient with ectopic insertion of a duplicated ureter diagnosed by MDCT urography. Three-dimensional (3D) analysis technology, such as volume rendering (with a color display improving the visualization of complex anatomy and 3D relationships) and maximum intensity projection (similar in principle to projection angiography), is useful for the illustration of urinary tract anatomy [1]. Rotated volume rendering reconstruction images and continual thinner maximum intensity projection reformatted images can be viewed as videos, which provides detail delineation of the ectopic ureteral insertion and its associated ureteral duplication.In this study, we reported MDCT urography and 3D analysis technology as an appropriate diagnostic method for the ectopic ureteral insertion and its associated complications.