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Ureteral diverticulum is a rare anomaly and often gives rise to urinary complications. We report a case of a woman with bifid renal pelvis. She had a stone in the lower pelvis with cystic dilation of the upper ureter.
Sallami Satáa, Sami Ben Rhouma, Ali Horchani
Department of Urology, La Rabta Hospital-University, Tunis, Tunisia
Submitted: September 1, 2011
Accepted for Publication: October 4, 2011
KEYWORDS: Diverticulum; Ureter; Abnormalities; Stone
CORRESPONDENCE: Sallami Satáa, MD, Department of Urology, La Rabta Hospital-University, Tunis, Tunisia ().
CITATION: UroToday Int J. 2011 Feb;5(1):art 86. http://dx.doi.org/10.3834/uij.1944-5784.2012.02.04
True ureteral diverticulum is a rare anomaly and often gives rise to urinary complications .
Its etiology remains unknown, although many theories have been proposed. It may be congenital or acquired . Congenital diverticula of the ureter are exceptional and only a few cases were reported in the literature.
Herein we present a case with a view of surgical treatment and long-term results.
A 36-year-old woman, with no significant medical history, presented for chronic right lumbar pain. Her physical examination was unremarkable. The urinalysis was normal and so were the blood-count cells and plasma creatinine. The KUB film (Figure 1) and renal ultrasonography showed a stone on the right renal pelvis. On intravenous pyelography, the left kidney, pelvicalyceal system, and the bladder looked normal.
The right kidney had a duplex system. The lower pelvis contained a stone of 3 cm in size with mild hydronephrosis, and the ureter of the lower pelvis showed an outpouching (Figure 2).
The patient underwent a surgical diverticular resection with removal of the pelvic stone, and an end-to-end ureter anastomosis with the insertion of a double J catheter.
The pathological study concluded true ureteral diverticulum, with all the layers of a ureteral wall and with no sign of malignancy. The recovery period was uneventful. The double J catheter was removed 4 weeks later. By the 26-month follow-up, the pain completely disappeared and radiological investigations didn’t reveal any anomaly.
Duplicated and bifid ureters constitute the most common ureteral malformations, but ureteral diverticulosis is an uncommon urinary abnormality [1,3]. Their association on the same side is possible, but it remains extremely rare .
In 1808, Pepere described the first case of ureteral diverticula found at autopsy . Their etiology and their clinical significance are still debated. Barrett and Malek , through a series of 12 patients with ureteral diverticulum, showed that associated renal or ureteral diseases may potentiate the development of a diverticulum. Infection has been implicated in causing diverticular formation or, at least, in leading to its discovery . Lindeman, in 1895 , reported that obstructing a rabbit ureter might produce true diverticula, which supports this theory. Previous reports have described a positive association of vesicoureteral reflex, urolithiasis, fibroepithelial polyps, and trauma with diverticula . The most plausible view is considering the diverticulum as a secondary compensatory structure following a congenital stricture that formed either in utero or shortly after .
Although nephritic colic, hematuria, and upper urinary tract infections may be the presenting symptoms, ureteral diverticula are usually asymptomatic , as in our case. Our patient remained asymptomatic until adult age. Actually, this anomaly is accidentally discovered via radiological investigations in patients with lumbar pain or renal colic more and more. They are occasionally detected during urography or retrograde pyelography, they appear as small specula or as a saccade wall outpouching, they are singular or more often in multiples, and they are mostly limited to the upper third of the ureter .
Gray and Skandalakis had classified the diverticula of the ureter into 3 categories: 1) abortive ureteral duplications (blind-ending bifid ureters), 2) true congenital diverticula containing all tissue layers of the normal ureter, and 3) acquired diverticula representing mucosal herniations . Congenital diverticula possess the histological layers of the ureter (mucosa, muscularis, and adventitia), and they connect with the other ureter at an acute angle. Through these structural features, they are distinguished from acquired diverticula (post traumatic or infective), which have no ureteric wall proper . The histopathologic diagnosis in our case revealed these different layers, which are typically seen in congenital cases.
When diagnosed, treatment of the diverticulum depends on the clinical presentations . Treatment is indicated if the diverticulum is thought to be the cause of symptoms or if complications ensue. Infection is the most common complication, but several cases of stone formation in a diverticulum have been reported, as in our case , and other cases that include ureteral strictures. A case of transitional-cell carcinoma in a diverticulum of the lower ureter was described .
The principal aim of treatment is to release the obstruction of the collecting system and the creation of a patent ureter with ureteroscopic maneuvers or open surgery. A nephrectomy is rarely necessary and should only be applied to infected and nonfunctioning kidneys [2,4]. Our patient underwent a diverticular resection with extraction of the stone by open surgery. In all cases, operated or nonoperated patients, the radiological follow-up is mandatory to detect later complications, such as secondary ureteral stenosis.
Ureteral diverticulum is a very rare urinary abnormality associated with an increased risk of local complications. Diagnosis is made during radiological investigations, especially the intravenous pyelogram. The treatment, if indicated, is surgical.
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