DOI:10.2214/AJR.05.1431
AJR 2007; 189:W272-W274
© American Roentgen Ray Society
Duplicated Ectopic Ureter with Vaginal Insertion: 3D CT Urography with IV and Percutaneous Contrast Administration
Simona Croitoru1,
Michael Gross2 and
Elisha Barmeir1
1 Department of Radiology, Bnai Zion Medical Center, 47 Golomb St., Haifa,
Israel 34363.
2 Department of Urology, Bnai Zion Medical Center, Haifa, Israel.
Received August 16, 2005;
accepted after revision October 21, 2005.
WEB
This is a Web exclusive article.
Address correspondence to E. Barmeir
(barmar{at}zahav.net.il).
Keywords: congenital malformations • CT • genitourinary tract imaging • kidney • urinary tract
Introduction
Duplication of the ureters is a common congenital anomaly frequently
encountered in children. Complete duplication is most often associated with
vesicoureteral reflux, ectopic ureterocele, and ectopic ureteral insertion.
Because of poor function and anatomic variations, these anomalies are
sometimes difficult to detect on excretory urography, sonography, and voiding
cystourethrography (VCUG). Visualization of the course of duplicated ectopic
ureters and the insertion of the ureters is of utmost importance for treatment
and surgical planning.
We present the case of a woman with duplicated ectopic ureter with vaginal
insertion. Excretory urography, sonography, and VCUG had failed in
visualization of the anatomic course and insertion of the nonfunctioning
ectopic ureter. Percutaneous injection of iodinated contrast medium into the
dilated collecting system and IV contrast administration was performed during
CT examination of the abdomen and pelvis. Postprocessing that included
volume-rendered and maximum-intensity-projection reformatted 3D images clearly
showed the entire ectopic ureter in various planes. In addition to data about
the exact location of the extravesical drainage of the ureter, the study
provided information about the anatomic relations between the two ureters and
their tortuous intimate course.
Case Report
A 37-year-old woman was admitted to the department of urology with fever,
left flank pain, dysuria, urgency, and frequency that had started 3 days
before admission. The patient reported occasional vaginal discharge. She had a
history of recurrent urinary tract infections in childhood but recalled only a
single episode of urinary tract infection during adolescence. During that
episode, renal sonographic findings were normal, and VCUG showed no
vesicoureteral reflux.
During the admission described in this case, urine cultures were positive
for Escherichia coli, and IV treatment with cefuroxime was initiated.
Excretory urography showed no abnormality
(Fig. 1A). Despite adequate
antibiotic treatment, the patient's clinical condition had not improved after
5 days, and CT urography was performed with an MDCT system (LightSpeed 16 Pro,
GE Healthcare). Axial images (2.5-mm slice thickness reconstructed with a 1-mm
thickness) showed a dilated unenhanced moiety in the upper pole of the left
kidney that contained dense amorphous material, representing inspissated pus
(Fig. 1B). In the prone
position, an 18-gauge needle was inserted into the upper pole of the kidney.
After percutaneous drainage of 120 mL of pus, 30 mL of contrast medium
(ioxithalamate, Telebrix 30, Guerbet) was injected through the needle
(Fig. 1C). Reformatted 3D
images showed the entire collecting system. A duplicated system and dilated
ectopic ureter on the left side extended from the kidney to the point of
distal extravesical insertion into the vagina (Figs.
1D and
1E). After the procedure, the
patient became afebrile. Left heminephrectomy with hemiureterectomy was
performed.
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Fig. 1D —37-year-old woman with ectopic ureter. Reformatted 3D CT
urogram after IV and percutaneous introduction of contrast medium. Dilated
obstructed ectopic ureter is in close anatomic relation to tortuous normal
ureter on left.
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Fig. 1E —37-year-old woman with ectopic ureter. Reformatted 3D CT
urogram after segmentation of bone structures shows entire course of dilated
ectopic ureter. Ureter is obstructed at insertion into vagina.
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Discussion
Duplication of the ureters is the most common anomaly of the urinary tract,
commonly diagnosed in infancy and childhood. Ectopic ureters, however, are
rare, and 70% are associated with complete ureteral duplication
[1]. These anomalies can be
asymptomatic or be diagnosed when complications such as obstruction and
infection occur. In women, ectopic ureters can terminate at a level distal to
the bladder neck and external sphincter, resulting in incontinence
[2,
3]. When the ureter has an
ectopic orifice in the vagina or urethra, stenosis gradually prevents urine
from flowing freely; stasis occurs and infection follows. In pediatric
patients, ectopic ureters have an incidence of 1 case per 2,000–4,000
autopsies [4]. Detection in
adulthood is far less common.
The diagnosis of ureteral duplication is usually made with sonography and
VCUG. When it drains outside the urinary system, an ectopic ureter may not be
detected on excretory urography, despite acquisition of delayed images.
Sonography may show the nonfunctioning upper pole moiety that has to be
differentiated from complex renal cysts and calyceal diverticula. When the
proximal ureter is not dilated, sonographic differentiation can be difficult.
Sonography also is not effective for visualization of the entire dilated
tortuous ureter and its ectopic orifice. The ectopic insertion also may not be
visible on VCUG and cystoscopy. MRI urography has proved capable of displaying
dilated collecting systems, ectopic ureters, and ureteroceles and has been
described in the diagnosis of duplicated ectopic ureters
[5,
6]. This method is useful
mainly in the evaluation of associated anomalies of the spine
[1].
CT provides superb anatomic detail and diagnostic specificity
[7,
8]. The introduction of MDCT
has allowed fast scanning technique of the abdomen and pelvis with 3D
evaluation of the urinary tract
[9]. The advantages of MDCT
include short scanning time, thin collimation, and improved resolution of the
z-axis, resulting in multiplanar and 3D reformatted images of high
quality. CT also can depict the dilated upper pole moiety. When surgical
intervention is contemplated, however, detailed information about the exact
course of the ectopic and normal ureter and visualization of the ectopic
ureteral orifice are necessary. These features are not clearly depicted in the
axial plane because of the craniocaudal insertion. Contrast injection into a
dilated nonfunctioning system and the use of multiplanar reformatting, as in
this case, allow acquisition of images of the deep pelvic structures and
depiction of the anatomic detail in various planes. Direct contrast
administration was indicated because both excretory urography and axial CT
failed to depict the duplicated, obstructed kidney. Only enhanced 3D CT
combined with transrenal injection of contrast medium into the obstructed
upper renal moiety provided information about the anatomic course of both
ureters. The use of this method allows opacification of a nonfunctioning
system. The method is excellent for visualizing the anatomic relations between
the lower part ureter and the dilated nonfunctioning ectopic ureter.
In summary, we present a case in which a procedure combining invasive and
3D CT led to complete visualization of a nonfunctioning ectopic ureter. The
use of contrast-enhanced MDCT with simultaneous percutaneous injection of
contrast material into the obstructed system can provide morphologic data
about the course of the ureters and the location of the ectopic insertion.
These data are of utmost importance for planning surgery and are not readily
acquired with sonography, excretory urography, or VCUG.
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Introduction
Case Report
