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Retroiliac ureter presenting as right upper ureteric obstruction - Report of a rare case

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Honderabalu Prasad
Honderabalu Prasad
Honderabalu Prasad
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Vilvapathy Senguttuvan Karthikeyan at Apollo Hospitals
Vilvapathy Senguttuvan Karthikeyan
Maregowda Shivalingaiah
Maregowda Shivalingaiah
Maregowda Shivalingaiah
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Chandrashekar Ratkal
Chandrashekar Ratkal
Chandrashekar Ratkal
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International Journal of Research in Medical Sciences | August 2015 | Vol 3 | Issue 8 Page 2143
International Journal of Research in Medical Sciences
Prasad HL et al. Int J Res Med Sci. 2015 Aug;3(8):2143-2144
www.msjonline.org
pISSN 2320-6071 | eISSN 2320-6012
Case Report
Retroiliac ureter presenting as right upper ureteric
obstruction – report of a rare case
Honderabalu Lingaraju Prasad, Vilvapathy Senguttuvan Karthikeyan*,
Maregowda Shivalingaiah, Chandrashekar S. Ratkal
INTRODUCTION
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.
CASE REPORT
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). Tc99m
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.
ABSTRACT
Retroiliac ureter is an extremely rare urological entity in which the ureter passes deep to the iliac vessels. Congenital
causes are most often secondary to vascular variants. A 39 year old lady presented with one month history of right
loin pain. CECT showed right gross HUN till L3 and EC renogram showed 33% function in right kidney with
obstructive pattern. RGP revealed Right Pelvic Ureteric Junction Obstruction (PUJO) obstruction, but at exploration
was found to have retroiliac ureter. Ureteral division with anterior relocation and dismembered pyeloplasty was done.
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
tubercular stricture or malignant process.
Keywords: Retroiliac ureter, PUJ Obstuction, Hydroureteronephrosis
Department of Urology, Institute of Nephrourology, Victoria Hospital Campus, Bangalore -560002, India
Received: 30 May 2015
Accepted: 26 June 2015
*Correspondence:
Dr. Vilvapathy Senguttuvan Karthikeyan,
E-mail: sengkarthik@yahoo.co.in
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20150345
Prasad HL et al. Int J Res Med Sci. 2015 Aug;3(8):2143-2144
International Journal of Research in Medical Sciences | August 2015 | Vol 3 | Issue 8 Page 2144
Figure 1: CECT abdomen showed right gross
hydroureteronephrosis (HUN) with abrupt narrowing
of proximal ureter upto L3 inferior margin suggesting
stricture.
Figure 2: Magnetic resonance urogram 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 PUJO.
Figure 3: Tc99m Ethyl cysteine renogram enlarged
hydronephrotic right kidney with moderate impaired
function with pelvicalyceal and upper half of ureter
dilatation and obstructed clearance.
Figure 4: Intraoperative picture showing retroiliac
ureter causing upper ureteric obstruction.
DISCUSSION
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.
CONCLUSION
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 process.
REFERENCES
1. Wein AJ. Ectopic ureter, ureterocele and ureteral
anomalies. Campbell - Walsh Urology, 10th edition.,
Philadelphia: Elsevier Saunders 2011:3265.
2. Nguyen DH, Koleilat N, Gonzalez R. Retroiliac
ureter in a male newborn with multiple
genitourinary anomalies case report and review of
literature. J Urol. 1989;141(6):1400-3.
3. Ameur A, Lezrek M, Jira H, Menfaa M, Boumdin H,
Beddouch A. Retro-iliac ureter associated with
ipsilateral megaureter. Prog Urol. 2002;12(6):1291-3.
Cite this article as: Prasad HL, Karthikeyan VS,
Shivalingaiah M, Ratkal CS. Retroiliac ureter
presenting as right upper ureteric obstruction – report
of a rare case. Int J Res Med Sci 2015;3(8):xxx-xx.
... 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.
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... 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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CT Imaging Appearance of a Unique Variant of Retroiliac Ureter
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  • Nov 2015
  • UROLOGY
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.
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Retroiliac Ureter in a Male Newborn with Multiple Genitourinary Anomalies: Case Report and Review of the Literature
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We report a case of a male newborn with unilateral retroiliac ureter, ectopic left vas deferens, ectopic ureters and imperforate anus. A review of the urological literature has revealed only 2 other instances of an association of anomalies similar to that in our patient.
View
[Retro-iliac ureter associated with ipsilateral megaureter]
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  • Jan 2003
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Retro-iliac ureter is a rare congenital abnormality. The authors report a case of retro-iliac ureter associated with ipsilateral megaureter in a 38-year-old patient treated by section of the ureter at the ureterovesical junction, and dissection as far as the iliac pedicle and anterior repositioning of this pedicle, followed by ureterovesical reimplantation. Based on a review of the literature, this appears to be the first published case of this pathological association.
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Ectopic ureter, ureterocele and ureteral anomalies
  • Jan 2011
  • 3265
  • A J Wein
Wein AJ. Ectopic ureter, ureterocele and ureteral anomalies. Campbell -Walsh Urology, 10 th edition., Philadelphia: Elsevier Saunders 2011:3265.
Retro-iliac ureter associated with ipsilateral megaureter Cite this article as Retroiliac ureter presenting as right upper ureteric obstruction – report of a rare case
  • Jan 2002
  • 1291-3
  • A Ameur
  • M Lezrek
  • H Jira
  • M Menfaa
  • H Boumdin
  • A Beddouch
  • Hl Prasad
  • Vs Karthikeyan
  • M Shivalingaiah
  • Cs Ratkal
Ameur A, Lezrek M, Jira H, Menfaa M, Boumdin H, Beddouch A. Retro-iliac ureter associated with ipsilateral megaureter. Prog Urol. 2002;12(6):1291-3. Cite this article as: Prasad HL, Karthikeyan VS, Shivalingaiah M, Ratkal CS. Retroiliac ureter presenting as right upper ureteric obstruction – report of a rare case. Int J Res Med Sci 2015;3(8):xxx-xx.