Ultrasonic evaluation of the obstructed duplex kidney

Ureterocele as differential diagnosis of hydrosalpinx-an interesting case from the clinical practice

Hydrosalpinx is a common condition in women of reproductive age that correlates with infertility. A ureterocele is a dilatation of the terminal ureter within the bladder and/or urethra that occurs seldomly in adults, but can sonographically be mistaken for a hydrosalpinx. We report of a 29-year-old patient (G2/P1) who was referred in our department with secondary infertility and suspicion of hydrosalpinx. Intraoperatively, no hydrosalpinx could be visualized. Postoperatively, an intravesical cystic mass was detected, alongside a second-degree urinary retention. Sonographically, a double kidney on the left side and an accentuated calyx system could be diagnosed. Ureteroceles seem to represent a rare but still possible differential diagnosis in suspected hydrosalpinx, given the similar sonographic presentation of both conditions.

The fate of lower pole hydronephrosis after transurethral incision of upper pole ureteroceles in children with duplex systems

PURPOSE

Duplex system is the most common upper urinary tract anomaly in childhood. The purpose of our study was to investigate the incidence, characteristics, and progression of lower pole hydronephrosis in children with duplex system who underwent transurethral incision (TUI) of upper pole ureterocele.

MATERIALS AND METHODS

Among children who underwent transurethral incision of ureteroceles between 2006 and 2018, 69 renal units with duplex systems were included after exclusion of preoperative lower pole vesicoureteral reflux and follow up loss. We retrospectively analyzed the postoperative progression of lower pole hydronephrosis and compared patient characteristics between two groups according to the presence of lower pole hydronephrosis.

RESULTS

The median age at operation and follow-up duration were 3.0 months (range 0-242 months) and 59 months, respectively. The median size of ureteroceles preoperatively was 14.5 mm. Thirty-five renal units (50.7%) demonstrated preoperative lower pole hydronephrosis of any grade (grade I in 13 [37.1%], II in 6 [17.1%], III in 10 [28.7%], and IV in 6 [17.1%]). In majority of cases, lower pole hydronephrosis drastically improved after transurethral incision, and 28 renal units (80%) demonstrated improvement of lower pole hydronephrosis to grade 0 or I. The preoperative diameter of upper pole ureter was significantly increased with lower pole hydronephrosis than without (11.30 ± 4.19 vs. 7.02 ± 4.94 mm, p < 0.01). Postoperative vesicoureteral reflux on upper pole was found in 16 (23%), five (7%) in lower pole. Eleven patients developed complications after TUI which required secondary surgeries. The differential renal function of affected renal units was decreased after TUI in group with preoperative lower pole hydronephrosis (46.77 ± 8.21 to 44.24 ± 8.55, p = 0.003), while it was maintained without significant difference in group without lower pole hydronephrosis (47.90 ± 6.39 to 46.24 ± 8.90, p = 0.091).

CONCLUSIONS

Lower pole hydronephrosis was found in a considerable number of renal units (50.7%), and the occurrence was related with the diameter of upper pole ureter. Most of renal units demonstrated significant improvement of lower pole hydronephrosis after transurethral incision of ureterocele. Given that differential renal function may be decreased even after improvement of hydronephrosis with TUI, a more careful monitoring on renal function is required in patients with hydronephrosis on lower pole.

Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter?

PURPOSE

Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes.

MATERIALS AND METHODS

All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes.

RESULTS

The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery.

CONCLUSION

Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.

Double collecting system with ectopic ureterocele masquerading as an ovarian torsion

OBJECTIVE

Ureterocele in a duplex system is rare and commonly presented with urinary tract infection at neonatal age, infant or childhood. Symptomatic ureterocele in reproductive-age is a diagnostic challenge and should be highly awarded to avoid miss-diagnosis.

CASE REPORT

An adolescent girl with right ectopic ureterocele presented as acute abdomen that mimicked ovarian torsion received emergent laparoscopic surgery. Right ureterocele was identified and excised. Computed tomography later showed bilateral renal duplications with visible renal parenchyma and upper ureters. Recurrent abdominal pain with pelvic abscess occurred 10 days after surgery. Laparoscopic right partial nephrectomy of the upper moiety and resection of the residual ureterocele was performed. Cystoscopy showed absence of intravesical ureterocele and her symptoms were completely resolved after surgery.

CONCLUSION

Infected ureterocele in a duplex system is a rare condition and should be kept in mind as differential diagnosis.

Prolapsed simple ureterocele: evaluation by transvaginal voiding sono-urethrography

Prolapsed ureterocele is a rare complication that may present with acute bladder outlet obstruction, generally in female infants. We present a case of prolapsed simple ureterocele in an adult woman, evaluated by transvaginal micturating sono-urethrography. High-frequency transvaginal sonography of the urethra performed during micturation revealed the relationship of the ureterocele with the urethral wall.

The clinical utility and safety of the endoscopic treatment of vesicoureteral reflux in patients with duplex ureters

OBJECTIVE

A systemic review of published literature on the use of bulking agents in the treatment of vesicoureteral reflux (VUR) in patients with duplex systems was performed in order to evaluate the diagnostic challenges; determine success rates, and compare with use in single systems; and evaluate safety, in particular of Deflux.

METHODS

A PubMed/Medline search was conducted for index articles discussing duplex ureters published in 1963-2007. All types of publications were included. A multiple linear regression analysis was performed.

RESULTS

Overall, 28 different treatment arms originating in 17 separate studies (19 publications) satisfied the inclusion criteria for linear regression efficacy analysis. Data were available on 2879 patients: 2400 with single and 479 with duplex systems. Ten publications provided information on the frequency of failure to diagnose duplex systems using specific techniques. An overall 18% failure rate to detect duplex systems was reported for combined techniques. For patients in whom favorable anatomic location of ureters allowed successful endoscopic injection of a bulking agent, correction of VUR was achieved in 53-100% of cases. A univariant analysis showed no difference in success rate between single and duplex systems with the use of Deflux, or other bulking agent. The predicted probability of success in a single system was 68% and in a duplex system 64%.

CONCLUSIONS

There is significant potential for failing to detect duplex systems prior to preparing an individual for either open or endoscopic treatment. From the studies available, endoscopic injection of bulking agents is highly successful in correcting mild-to-moderate VUR in duplex systems, with no reports of serious or clinically significant adverse effects. At a minimum, duplex systems would not seem to be a contraindication to the use of Deflux or any other bulking agent.

Ureterocele misdiagnosed as pelvic inflammatory disease in an adolescent

BACKGROUND

Acute pelvic pain in reproductive-aged women presents a diagnostic challenge. In the case that follows, we report the management of a patient initially misdiagnosed with pelvic inflammatory disease.

CASE

A 14-year-old nulligravida who presented with acute pelvic pain was diagnosed with pelvic inflammatory disease and possible tuboovarian abscess. Despite treatment with broad-spectrum parenteral antibiotics, the patient remained febrile with persistent pelvic pain. Com-puted tomography revealed a duplicated right collecting system with the upper pole of the kidney drained by a markedly dilated, tortuous ureter. An infected ureterocele was identified and incised during cystoscopy.

CONCLUSION

An infected ureterocele was misdiagnosed as pelvic inflammatory disease. In patients with acute pelvic pain who do not respond to appropriate interventions, it is important to consider alternative diagnoses.

Ultrasonographic appearance of orthotopic ureterocele in a dog

A three-year-old, intact male, Siberian husky was evaluated for a two day history of dysuria. Sonographically there was an anechoic cyst-like structure in the urinary bladder. The abnormality appeared to be a 'cyst within a cyst', which is a characteristic ultrasonographic feature of ureterocele in humans. Ultrasonography may be a useful means of establishing a diagnosis of ureterocele in dogs.

Acute nondilated anuric obstructive nephropathy on echography: difficult diagnosis in the intensive care unit

Renal echography (RE) is a well recognized, accurate, non-invasive imaging procedure for detecting urinary tract (UT) obstruction in Intensive Care Unit (ICU) patients: a dilated collecting system is usually present but a few cases of nondilated obstructive nephropathy have been previously described. We report the clinical, biological, imaging procedure data and outcome of 6 additional cases of anuric obstructive nephropathy without dilatation on one or more RE. All patients had previous and/or actual history suggestive of UT obstruction. Retrograde ureteropyelography (RUP) was performed in all of them: it provided the diagnosis of obstruction in 4 and was immediately followed by dramatic improvement of renal function in all, including the 2 patients with septic shock from proven or suspected UT origin. The cause of obstruction was a neoplastic retroperitoneal process in 4. We conclude that anuric nondilated obstructive renal failure is not uncommon and should be considered in anuric patients when UT obstruction is likely to occur. The sole visualization of a non-dilated collecting system on RE should lead to repeat RE, especially in hypovolemic anuric patients. RUP provided immediate diagnostic and therapeutic benefits in comparison with other imaging procedures in our series.

Imaging of ureteral duplication with a non-functioning component

31 patients of ureteral duplication were selected when one moiety of the duplex system was poorly visualised with either IVU or DTPA studies. Both ultrasound and IVU were performed in all cases. DTPA scans were performed in 17 cases and MCUs in 26 cases. The cases were divided into 2 groups. Group 1 (28 patients), with hydronephrosis and hydroureter, was further subdivided into 1 A (18 patients) where the ureter terminated in an ureterocoele and 1 B (10 patients) where the ureter was ectopic. Group 2 (3 patients) were cases where the non-functioning moiety was hypoplastic or dysplastic and was drained by a small or normal size ureter. The diagnostic value of IVU, Ultrasound, DTPA scan and MCU was reviewed in each group.

Sonographic evaluation of renal masses

Basic technique of evaluating renal mass lesions is presented. The analytic criteria of separating cystic from solid lesions are reviewed along with the differential points of the intermediate mass lesion that does not meet the classical hallmark of a simple cyst. Experience has shown that sonography could be the first evaluation step in a renal mass since it is not invasive, does not employ ionizing radiation, and is cost effective.

Two unusual duplication anomalies of the urinary tract: use of percutaneous urography

We performed suprapubic percutaneous urography in two patients to diagnose unusual duplication anomalies of the urinary tract, since preoperative diagnosis was unclear after routine noninvasive studies. In both patients standard suprapubic puncture technique was employed. The procedure was used to confirm the diagnosis of duplication of the bladder in one case and to establish the site of origin of a ureterocele in the other. The technique employed in suprapubic cystography may be extended to the diagnosis of unusual cystic abnormalities in the pelvis that may be of urinary tract origin.

A review of the ultrasonic appearances of posterior urethral valve and ureteroceles

Ultrasonographic studies of patients with posterior urethral valve and ectopic ureterocele vary in relation to the severity of obstruction and changes in the upper tracts. A broad review of these conditions, stressing sonography (including use of the perineal approach to the upper urethra) shows the great value of sonography but emphasizes the need to correlate with other imaging modalities (urography, cystourethrography, nuclear imaging).

Ultrasonographic anatomy and diagnosis of fetal uropathies affecting the upper urinary tract. I. Obstructive uropathies

The authors describe the ultrasonographic anatomy and semiology of allowing detection of the main types of fetal uropathies. The results of the author's personal experience in this domain are compared to data from the literature. Differential features of the uropathies are given and the limitations and practical significance of prenatal and postnatal ultrasonography are discussed.

Is renal ultrasound a reliable indicator of a nonobstructed duplication anomaly?

Twelve kidneys which had a non-obstructed duplication anomaly on excretory urography were studied sonographically. Ten of the twelve kidneys had a single central renal sinus echo complex; only two kidneys had a split sinus complex typical of duplication. Sonography is not a reliable technique to identify a nonobstructed duplication anomaly.

Fetal and neonatal hydronephrosis

Maternal ultrasonography makes it possible to easily detect hydronephrosis in the fetus, and therefore fetal "screening" should be part of every obstetrical ultrasonogram. However, the mere presence of fetal hydronephrosis virtually never means that either fetal intervention or early delivery is warranted. The importance of fetal case-finding is that it enables us to promptly (and electively) evaluate and treat the asymptomatic neonate before infection or other complications occur.

Incomplete renal duplication obscuring ipsilateral complete duplication

Renal duplication is not an uncommon anomaly of the urinary tract. However, we report a case in which the occurrence of incomplete duplication of a large lower pole, with an unusual side-by-side orientation of the lower pole segments, delayed recognition of the clinically troublesome ipsilateral upper pole duplication.

Sonographic identification of collecting system duplications

Sonography can replace urography in the search for a duplication anomaly of the collecting system. As a screening procedure, sonography is more cost effective and does not require ionizing radiation or an intravascular injection.

The diagnostic approach to ectopic ureterocele and the renal duplication complex

The child with ectopic ureterocele frequently presents a diagnostic challenge. The use of standard excretory urography combined with newer modalities, such as ultrasonography and radionuclide renal scanning, provides an orderly diagnostic approach to ectopic ureterocele. This integrated approach should ensure the highest yield in a diagnostic sense and aid in assessing upper tract function, thus, helping with the selection of the proper surgical management.

Sonography for diagnosis and follow-up of neonatal adrenal hemorrhage

Neonatal adrenal hemorrhage was diagnosed by ultrasound as an echo-free mass superior to downward displaced normal kidneys in three newborns. In one, the adrenal hemorrhage was bilateral. Fine needle aspiration was performed to confirm the diagnosis in one case. The babies were followed-up until adrenal calcifications were seen on ultrasound as linear echoes with posterior acoustic shadowing. These calcifications were confirmed by plain films. It is suggested that the diagnosis of neonatal adrenal hemorrhage should be based on ultrasound and on one initial intravenous urogram. Follow-up examinations should be restricted to ultrasound and plain films. In doubtful cases fine needle aspiration can be added for confirmation.

Unusual radiographic findings in ectopic ureterocele

A case of an ectopic ureterocele with a cystic dysplastic upper pole and atretic proximal ureter was studied. A four-month follow-up showed marked decrease in the size of the dysplastic upper pole which is explained on an embryologic and pathophysiologic basis.

Diagnosis of ectopic ureterocele using ultrasound

Three children with ectopic ureteroceles were examined with ultrasound, excretory urography, and voiding cystography. In all cases the ultrasound studies outlined the ectopic ureterocele within the bladder.

Ultrasound diagnosis of ectopic ureterocele

Three children with ectopic ureteroceles were examined with ultrasound, intravenous urography and cystography. In all cases the ultrasound studies outlined the ectopic ureterocele within the fluid-filled bladder and in one case added additional information regarding the non-functional portion of the duplication and its ureter.