Ureter ectopic

Simply stated, UI may occur only as a result of abnormalities of the urethra (including the bladder outlet and urinary sphincter) or the bladder, or from a combination of abnormalities of both structures. Abnormalities may result in either overfunction or underfunction of the bladder and/or urethra with the resulting development of UI. While this simple classification scheme excludes extremely rare causes of UI such as congenital ectopic ureters and urinary fistulas, it is useful in gaining a working understanding of the condition. 

Gynaecological disorders, such as ruptured ovarian cysts, ovarian torsion,ectopic pregnancy or pelvic inflammatory disease, can resemble acute diverticulitis in female patients, but often these patients are younger. Transvaginal sonography maybe helpful in obtaining an accurate diagnosis. Stone of the ureter on the left side may simulate diverticulitis. 

Fig. 1.1.1. US axial scan of the bladder in a 10-year-old girl. Dilated left upper pole ureter identified through a full bladder in a child with duplicated ureter and ectopic implantation of the upper pole ureter...

Fig. 1.1.4. Accidental introduction of the tube in the ectopic orifice of the upper pole ureter of a duplicated kidney. No consequence was observed. Catheter was withdrawn, then introduced again in the bladder. This type of accident illustrates the importance of sterility in any maneuver while performing VCU...

Fig. 5.31. VUR into an ectopic ureter inserting into the posterior urethra (patient with pelvic horseshoe kidney)...

Ureterocele (ucele) represents cystic dilatation of the intravesical segment of the ureter. It is more common with duplex kidneys. When it is associated with a single system, the ucele is commonly intravesical. An ectopic ucele may also be associated with a multicystic dysplastic kidney (Fig. 5.32). On US, the ucele appears as a cystic structure within the bladder that is connected with the ureter (Fig. 5.33) the upper urinary tract is not necessarily obstructed or dilated. On IVU, after injection, the ucele appears as a filling defect within the bladder, especially on early films, and it opacifies progressively (Fig. 5.34). 

Many complications may occur and involve any of the poles of the duplex kidney, sometimes both, such as dilatation of the upper or lower pole, pyonephrosis, VUR, ectopic ureter, or ucele. 

Abnormal duplex kidneys used to be and are still detected during the work-up of urinary tract infection or urinary dribbling in girls. They are more and more often demonstrated during fetal life. In utero, it is possible to differentiate between the two collecting systems particularly if one is dilated. It is even possible to differentiate between ectopic ureter and ucele in utero (Joseph et al. 1989 Avni et al. 1991 Abuhamad et al. 1996 Vergani et al. 1999 Caione et al. 1989 Jee et al. 1993). Other forms of presentation include interlabial mass in girls or bladder outlet obstruction. Both conditions are related to urethral prolapse of the ucele (Nussbaum 1983). 

The findings of obstetrical US have to be confirmed after birth by US first. US usually demonstrates the two renal poles and the ureterohydronephrosis involving one or both moieties. It displays easily intravesical uceles however, the technique cannot always demonstrate ectopic ureters. VCU is performed thereafter in order to detect VUR, including ectopic ureter reflux, and to evaluate the ucele. MR imaging is performed whenever anatomical information is needed on the morphology of the duplex system. The technique is able to provide all the anatomical details as well as some functional information after gadolinium enhancement. Isotope studies are mandatory to determine renal function that remains in the dilated and dysplastic renal moiety. This complete work up is mandatory in order to orient the best therapeutic approach (Avni et al. 2001, 2000). 

Typically, the ureter draining the upper pole develops caudal to the normal location and is often ectopic. 

Borer JG, Bauer SB, Peters CA et al (1998) A single system ectopic ureter draining an ectopic dysplastic kidney. Br J Urol 81 474- 478... 

Braveman RM, Lebowitz RL (1991) Occult ectopic ureter in girls diagnosis with CT. AJR 156 365-366 Bude RO, DiPietro MA, Platt JE et al (1992) Age dependency of the renal resistive index in healthy children. Radiology 184 469-473... 

Gharagoloo AM, Lebowitz RL (1995) Detection of a poorly functioning malpositioned kidney with single ectopic ureter. AJR 164 957-961... 

Nusshaum AR, Dorst JP, Jeffs RD et al (1986) Ectopic ureter and ureterocele their varied US appearance. Radiology 159 227-235... 

Wulfsohn MA (1980) Pyelocalyceal diverticula. J Urol 123 1-8 Wyly JB, Lebowitz RL (1984) Refluxing urethral ectopic ureters. AJR 142 1263-1267... 

Ectopic ureterocele develops at the lower end of the upper pole ureter of a duplicated kidney. It is a cyst-like thin-walled structure that is known to be mobile and variable in shape. During fetal life, the ureterocele can prolapse into the posterior urethra and create obstruction (Fig. 6.9). Bilateral hydronephrosis and megacystis can subsequently develop. Clinical diagnosis can be made at birth in girls with a perineal soft tissue mass, megacystis and bilateral urinary tract obstruction. Sonographic diagnosis can be difficult when the ectopic ureterocele has... 

Fig. 6.8. Sagittal US view of the bladder neck in a male neonate with left duplicated ureter. The echogenic mass visible in the bladder neck is a spontaneously ruptured ectopic ureterocele, draining the dysplastic upper pole of the duplicated left kidney. Urethral polyp is the main differential diagnosis...

Fig. 6.9. VCU in a female neonate with prenatal diagnosis of megacystis and hydronephrosis. Vesicoureteric reflux into the lower pole of a left duplicated kidney. Left upper pole ureter is obstructed by an ectopic ureterocele that is prolapsed in the urethra during micturition...

Rosenfeld DL, Lis E (1993) Gartner s duct cyst with single vaginal ectopic ureter and associated renal dysplasia or agnesis. J Ultrasound Med 12 775-778 Shozu M, Akasofu K, Harda T, Kubota Y (1991) A new cause of female pseudohermaphrodism placental aromatase deficiency. J Clin Endocrinol Metab 72 560-566 Siegel MJ (1995) Pediatric sonography, 2nd edn. Raven Press, New York, pp 441-442... 

Avni F, Matos C, Rypens F Schulman CC (1997) Ectopic vaginal insertion of an upper pole ureter Demonstration by special sequences of magnetic resonance imaging. J Urol 158 1931-1932... 

VUR into an ectopic ureter that opens into the urethra or near the bladder neck may be difficult to visualize during a conventional VCU (Fig. 11.25). Cyclic filling of the bladder helps to demonstrate this condition, which is usually, but not always, associated with a duplex collecting system (Wyly 1984). A single-system ectopic ureter is usually associated with a small dysplastic kidney. 

Wyly JB, Lebowitz RL (1984) Refluxing urethral ectopic ureters recognition by the cyclic VCU. AJR 142 1263-1267 Yeung CK, Godley ML, Dhillon HK et al (1997) The characteristics of primary VUR in male and female infants with prenatal hydronephrosis. Br J Urol 80 319-327 Yu TJ, Chen W, Chen HY (1997) Early versus late surgical management of fetal reflux nephropathy. J Urol 157 1416-1419... 

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