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... ureter, PUJ Obstuction, Hydroureteronephrosis Retroiliac ureter is an extremely rare urological entity with fewer than 30 cases reported. The ureter passes deep to the iliac vessels. 1 Congenital causes are most often secondary to vascular variants including retrocaval ureter and retroiliac ureter. We report a case of retroiliac ureter masquerading as tubercular stricture. A 39 year old lady presented with one month history of right loin pain. Bilateral ureteric stenting and stent exchange twice for similar complaints in last one year and took anti tubercular therapy for six months. She had no comorbidities and clinical examination was unremarkable. Her hemoglobin was 12.4 g%, total leucocyte count was 7700/cmm and ESR was 10mm at 1 hour. Her renal function was normal (S. Creatinine: 0.9 mg/dL). CECT abdomen showed right gross hyrdonephrosis with proximal hydroureterosis (HUN), with abrupt narrowing of proximal ureter at the inferior margin of L3, suggesting stricture (Figure 1). Magnetic resonance urogram (MRU) showed right moderate HUN with grossly dilated ballooned out extrarenal pelvis with smooth narrowing of upper ureter probably secondary to upper ureteric stricture or low pelvic ureteric junction obstruction (PUJO) (Figure 2). Tc 99m Ethyl cysteine renogram showed enlarged hydronephrotic right kidney with moderate impaired function with pelvi calyceal and upper half of ureter dilatation and obstructed clearance (Figure 3) with 33% right and 67% left renal function. Intraoperatively, retrograde ureteropyelogram revealed suspicious right low PUJO. At exploration she was found to have retroiliac ureter (iliac vessels causing ureteral obstruction) (Figure 4), passing posterior to the iliac vessels approximately 3 to 5 cm distal to the aortic bifurcation. Ureteral division with anterior relocation and dismembered pyeloplasty was done. Double J stent was removed at 6 weeks. Patient is asymptomatic at one year follow up without recurrence. Several vascular abnormalities lead to ureteric obstruction. Retroiliac ureter is an infrequent congenital condition that causes ureteric obstruction with less than 30 cases reported. 2 Retroiliac ureter is considered to be of vascular origin. 1 Normally, the primitive ventral root of umbilical artery is replaced by development of a more dorsal branch between the aorta and distal umbilical artery. The persistence of this ventral root as the dorsal root fails to form, traps the ureter dorsally. 1 Retroiliac ureter is caused by the development of the iliac vessels from the anterior branch of the umbilical artery, instead of the normally dorsal branch. The ureter can be compressed by iliac vessels causing hydronephrosis. Obstruction occurs at the level of L5 or S1 as the ureter is compressed behind the artery. Coexisting anomalies are common, particularly vasal anomalies. 2,3 Nguyen et al reviewed the report of retroiliac ureters and found 24 cases, among which 4 cases were bilateral. 2 Preoperative radiologic diagnosis of retroiliac ureter usually complicated and depends on a high level of suspicion. Till date all reported cases have been shown during surgery or during indirect imaging finding on excretory urography and angiography without concurrent visualization of obstructed ureters and vessels. 3 Though it is a congenital anomaly our patient presented in the third decade of life with flank pain and features of ureteric obstruction. Treatment is surgical and involves division of ureter and anterior relocation and anastomosis. 1,2 In our case, since the renal pelvis was grossly dilated, anterior relocation and dismembered pyeloplasty was done. Retroiliac ureter creates a diagnostic dilemma. Anomalous vascular structures are often not diagnosed until surgical intervention for an obstruction of unknown etiology, unless vascular studies are considered. Most of these patients require surgical exploration to exclude tuberculous stricture or malignant ...

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... RIU is thought to originate as a result of embryologic defects: a defect in the mesonephric ureteral migration during arterial development, persistence of the embryologic primitive ventral root of the umbilical artery, between the aorta and distal umbilical artery, traps the ureter dorsally. The third hypothesis involves abnormal development of the iliac vessels from the anterior branch of the umbilical artery instead of the dorsal [30][31][32]. RIU is commonly located behind the common iliac artery, but other previously reported types have been described as a retro-common iliac vein, retro-external iliac artery/vein, and retrointernal iliac artery [30][31][32]. A bilateral RIU is a rare but possible variation ( Figure 6) [30]. ...
... The third hypothesis involves abnormal development of the iliac vessels from the anterior branch of the umbilical artery instead of the dorsal [30][31][32]. RIU is commonly located behind the common iliac artery, but other previously reported types have been described as a retro-common iliac vein, retro-external iliac artery/vein, and retrointernal iliac artery [30][31][32]. A bilateral RIU is a rare but possible variation ( Figure 6) [30]. ...
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Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.
... Much less commonly, secondary obstructive megaureter can be due to a retroiliac ureter wherein the ureter passes deep to the iliac artery. There have been a very small number (24) of documented retroiliac ureter cases reviewed to date [9]. Obstructive megaureter is associated with several anatomic variations including retro-common iliac artery (CIA) with lack of internal iliac artery (IIA), retro-IIA, and circumiliac ureter [7,10,11]. ...
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Introduction. A number of rare anatomical anomalies, including retroexternal iliac ureter, extrarenal calyces (ERCs), and vascular anomalies, were observed in a 96-year-old female cadaver during a routine dissection. Description. A markedly dilated left extrarenal pelvis (ERP) with a diameter of 3.15 cm was noticed. Three major calyces were found outside of the normal-sized left kidney. The abdominal aorta (AA), instead of normal bifurcation, branched to the right common, left external, and left internal iliac arteries. The median sacral artery was a direct branch from the right common iliac artery. No hydronephrosis was observed on the affected side, and no urinary tract anomalies were observed on the right side. Significance. The retroiliac megaureter is a rare congenital anomaly, with fewer than 25 cases reported to date. Additionally, the ERCs are amongst the rarest anomalies of the renal collecting system. Further, the current case is one of few reported cases where the particular branching pattern of the AA was observed. The combination of such anatomical anomalies is rare, and the relationship between them is unclear. Common clinical manifestations of retroiliac ureters are the results of ureteric obstruction, hydronephrosis, and secondary infection. Precise knowledge of anomalies of the kidney and urinary tract can help radiologists and surgeons make a definitive diagnosis and prevent inadvertent injury during surgery.
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Retroiliac ureter is a rare condition where the ureter passes behind the iliac vessels. The diagnosis is usually intra-operative and the reports of pre-operative imaging diagnosis are scarce. Herein, we report the CT appearance of a unique variant in which the right ureter partially encircles the right common iliac artery bifurcation; passing first in front of the common iliac artery and then medial to the artery and finally posterior to the external iliac artery, and then regains its normal course in the pelvis.