International Urology and Nephrology 36: 21–22, 2004.© 2004 Kluwer Academic Publishers. Printed in the Netherlands.

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Case report: Minimally invasive treatment of an unusual obstructiveectopic upper pole ureter

George Lee, Kakahama Attar & Charles HuddDepartment of Urology, Wexham Park Hospital, UK

Abstract. An 18-year old man presented with left loin pain and recurrent urinary tract infections. Ultrasound andIVU revealed a duplex left kidney with hydronephrosis of the upper pole moiety. F-15 Mag-3 renography confirmedobstruction of the upper pole moiety. Cysto-urethroscopy identified the site of ectopic insertion to be adjacent tothe verumontanum in the prostatic fossa. Retrograde ureterography showed the level of obstruction and dilation ofthe stricture was carried out. Post operatively, the patient became asymptomatic and remains so at 5-year followup. This is an unusual case of obstructive upper pole ureter with an ectopic insertion into the prostatic fossa. Wealso demonstrated that dilatation of a stricture at this site can achieve good long term outcome.

Figure 1. Ultrasound of the urinary tract which revealed a dilatedupper moiety ureter to the level of the bladder and the thinning ofupper pole renal cortex.

An 18 year-old man first presented with recurrent leftloin pain and urinary tract infection. Multiple urinecultures confirmed bacterial infection. He underwentultrasound of the urinary tract which revealed a dilatedupper moiety ureter to the level of the bladder andthe thinning of the upper pole renal cortex (Figure 1).The lower moiety of the kidney was normal measuring8 cm. IVU also demonstrated a poorly functioningupper pole moiety of the left kidney with a dilatedureter (Figure 2). The bladder emptied completely.F-15 Mag-3 renography with diuresis showed 53%function of the left kidney. Thirty-five minutes afterinjection of isotope, accumulation of isotope in the

Figure 2. IVU also demonstrated a poorly functioning upper polemoiety of the left kidney with a dilated ureter.

area overlapping the upper pole of the left kidneywas demonstrated. Poor renal function and significantobstruction of the upper pole moiety was shown.

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Figure 3. Retrograde ureterography showing hydronephrosis ofthe upper pole ureter from the level of the verumontanum whichconfirmed the obstruction at the site of ureteric insertion.

The patient underwent cysto-urethroscopy whichshowed a normal bladder but identified the site ofectopic insertion to be adjacent to the verumontanumin the prostatic fossa. Retrograde ureterographyshowed hydronephrosis of the upper pole ureter fromthe level of the verumontanum and confirmed obstruc-tion at the site of ureteric insertion (Figure 3). Theectopic obstructed ureteric orifice was dilated with a7 F ureteric dilator.

One year after the procedure, the patient under-went Mag-3 renography which showed no significantchange compared to the pre-operative renogram. Hehas been followed up annually for 5 years and remainsasymptomatic with no loin pain.

Discussion

Duplication of the urinary tract is a common abnor-mality of the urinary system with an incidence of0.3–0.7%. This is less common in male patients, whohave ectopic ureteric sites of the posterior urethra in58%, seminal vesicle in 26%, vas and ejaculatory ductin 15% and rectum in less than 1% [1]. The majorityof the ectopic insertions are proximal to the externalsphincter and therefore the patients do not have urinaryincontinence and may remain asymptomatic [2].

In our case report, the patient was aympto-matic until aged eighteen, during when he sufferedfrom recurrent UTI’s and loin pain. The ectopicobstructed upper moiety ureter may be responsiblefor the infection and pain. Dilation of the obstructedureteric orifice with a ureteric dilator, during cysto-urethroscopy is an effective mean of treatment. Wehave demonstrated this minimally invasive interven-tion has a good long term outcome without the neces-sity of upper pole heminephroureterectomy.

References

1. Blundon KE, Lane JW. Diagnostic difficulties in uretericectopia. J Urol 1960; 84: 463.

2. Ejaz T, Malone PS. Male duplex urinary incontinence. J Urol1995; 153(2): 470–471.

Address for correspondence: Mr George Lee, 8 Marloes Road,London W8 5LJ, UK