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Multiple Ureteral Diverticula
Vol. 105, Feb. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
MULTIPLE URETERAL DIVERTICULA HOMA YOUN KHONSARI
AND
JOHN A. OLIVER
From the Department of Urology, Royal Victoria Hospital and McGill University, Montreal, Canada
Multiple ureteral diverticula are rare. Review of the literature revealed 15 cases with adequate documentation to qualify as this entity. 1- 8 First described by Holly and Sumcad in 1957, 1 multiple diverticula are found throughout the entire length of the ureter, may be unilateral or bilateral 6 and are often associated with other defects of the urinary tract. 5 Patients range in age from 23 to 86 years but there is a marked preponderance for the fifth to seventh decades. Multiple diverticula are to be distinguished from a solitary diverticulum. The latter condition is much more common and cases were reported with great frequency until Culp defined the criteria for definite diagnosis in 1947. 9 Culp demonstrated that of 52 cases of single ureteral diverticulum reported only 15 fulfilled his criteria of diagnosis. The remaining cases were in fact hydronephrosis, ureteroceles, vesical diverticulum, blind-ending bifid ureters or segmental hydroureters. He stated that "a true ureteral diverticulum is one of any hollow structure whose lumen joins that of the ureter at a distinct angle, whose wall presents the same histologic coats as the ureter and whose length is more than twice its greatest diameter". As mentioned by Tynes and associates this presents some confusion of terminology regarding a blind-ending ureter and a true
ureteral diverticulum. 10 Since 1947 numerous cases have been reported. CASE REPORT
A 62-year-old man was admitted to the hospital with a scalp laceration. He had been treated for prostatitis on and off for the past 2 years. Two days after hospitalization pain developed on the left side and hematuria was noted. Physical examination was negative except for a 7 cm. scalp wound and hepatomegaly 4 cm. below the right costal margin. Urine cultures yielded more than 100,000 colonies of Enterococci and were negative for tuberculosis. Renal function and liver function tests were within normal limits. An excretory urogram was normal (fig. 1, A). At cystoscopy the bladder showed early trabeculation with evidence of prostatic obstruction. The left side was further studied by retrograde pyelography which revealed the presence of multiple ureteral diverticula (fig. 1, B). The patient responded well to conservative management and was discharged without further treatment.
Accepted for publication March 27, 1970. 1 Holly, L. E. and Sumcad, B.: Diverticular ureteral changes: report of 4 cases. Amer. J. Roentgen., 78: 1053, 1957. 2 Dolan, P.A. and Kirkpatrick, W. E.: Multiple ureteral diverticula. J. Urol., 83: 570, 1960. 3 Mims, 1\11. M.: Multiple acquired diverticulosis of the ureter. J. Urol., 84: 297, 1960. 4 Rank, W. B., Mellinger, G. T. and Spiro, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. 5 Baines, G. H.: Diverticulosis of the ureter. Brit. J. Urol., 34: 193, 1962. 6 Webber, M. M. and Kaufman, J. J.: Multiple ureteral diverticula. A case report. Amer. J. Roentgen., 90: 26, 1963. 7 Norman, C. H., Jr. and Dubowy, J.: Multiple ureteral diverticula. J. UroL, 96: 152, 1966. 8 Reggiani, A. and Torchi, B.: I diverticoli dell'uretere. Arch. Ital. Urol., 39: 207, 1967. 9 Culp, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 58: 309, 1947.
DISCUSSION
Experimental work on this subject was done as early as 1895 when Lindemann succeeded in producing solitary ureteral diverticula in young rabbits by ligation of the lower ends of the ureters.11 He postulated the etiology to be increased ureteral pressure together with exaggerated peristalsis. In 1933 Kretschmer claimed that these may be acquired segmental balloonings or outpouchings at various levels of the ureter usually proximal to an obstructing lesion. 12 10 Tynes, W. V., II, Devine, C. J., Jr., Buttarazzi, P. J., Devine, P. C., Fiveash, J. G., Jr. and Poutasse, E. F.: Ureteral embryology and resultant anomalies. Virginia Med. Monthly, 95:
395, 1968.
11 Lindemann, W.: Divertikel am Ureter bei Atresie des letzteren. Zbl. Allg. Path., 6; 801,
1895. 12 Kretschmer, H. L.: Duplication of the ureters at their distal ends, one pair ending blindly: socalled diverticula of the ureters. J. Urol., 30: 61,
1933. 183
184
KHONSARI AND OLIVER
. FIG: 1. A, IVP shows normal ureteral outline. B, left retrograde pyelogram shows multiple ureteral d1vert1cula.
FIG. 2. Diverticulosis of colon in area proximal to obstructive lesion.
Current concepts of the etiology of multiple ureteral diverticula include 1) these may be multiple diverticula of the ureteral anlage, 2) compensatory bulges may occur following congenital
stenosis of the ureter and 3) acquired lesions may occur later in life following obstructive ureteral disease. Multiple ureteral diverticula have been considered as benign and have, therefore, received little histological study, leaving a void in the knowledge of their microscopic structure. No cases of diverticula have been reported in children with hydrometer, hydronephrosis, congenital strictures and other conditions found early in life producing increased intraureteral pressure. However, it is possible that multiple ureteral diverticula may be comparable to diverticulosis of the colon. This is an acquired disease, the diverticula (or pseudo or false diverticula) are of the pulsion type consisting of pouches of mucosa not covered by muscular tissue. These pouches tend to occur on the circumference of the large bowel where the blood vessels penetrate the muscular wall to form a point of potential weakness. The diverticula result from a persistently increased intracolonic pressure which is raised during peristalsis and this in turn may be associated with uncoordinated muscular activity in the colon (fig. 2). It is well known that diverticulosis of the colon is a disease of adult life and the incidence increases with age.
185
MULTIPLE URETERAL DIVERTICULA
The blood supply of the ureter is in the form of branches of the renal and testicular (ovarian in the female subject) arteries. In its lower segment it is supplied by the vesical and middle rectal arteries and on occasion direct branches from the common and internal iliac arteries. The vessels of the ureter penetrate first through the muscular layers where they form a in the deep aspect of the mucosa. The points of penetration of the muscular layers are thus potentially weak areas and in instances of infection associated with obstruction there occurs an alteration in the dynamics. This state may cause the formation of "diverticula" the walls of which are formed of mucosa only, at the sites of potential weakness (i.e. false diverticula rather than true variety).
SUMMARY
The literature on multiple ureteral diverticul:J, has been reviewed: 15 cases have been reported and a case is added. Multiple ureteral diverticula are more common in patients in the fifth to seventh decades. Diverticula may or may not be associated with outlet obstruction. There is usually associated infection. Most cases are discovered incidentally and are benign in nature. Multiple diverticula are demonstrated only by means of retrograde pyelography when the injecting pressure is high. The etiology of multiple diverticula has been discussed and a further theory of the pathogenesis is postulated. We believe that further light on this subject may be shed with reports of tissue histology in these cases.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
MULTIPLE URETERAL DIVERTICULA HOMA YOUN KHONSARI
AND
JOHN A. OLIVER
From the Department of Urology, Royal Victoria Hospital and McGill University, Montreal, Canada
Multiple ureteral diverticula are rare. Review of the literature revealed 15 cases with adequate documentation to qualify as this entity. 1- 8 First described by Holly and Sumcad in 1957, 1 multiple diverticula are found throughout the entire length of the ureter, may be unilateral or bilateral 6 and are often associated with other defects of the urinary tract. 5 Patients range in age from 23 to 86 years but there is a marked preponderance for the fifth to seventh decades. Multiple diverticula are to be distinguished from a solitary diverticulum. The latter condition is much more common and cases were reported with great frequency until Culp defined the criteria for definite diagnosis in 1947. 9 Culp demonstrated that of 52 cases of single ureteral diverticulum reported only 15 fulfilled his criteria of diagnosis. The remaining cases were in fact hydronephrosis, ureteroceles, vesical diverticulum, blind-ending bifid ureters or segmental hydroureters. He stated that "a true ureteral diverticulum is one of any hollow structure whose lumen joins that of the ureter at a distinct angle, whose wall presents the same histologic coats as the ureter and whose length is more than twice its greatest diameter". As mentioned by Tynes and associates this presents some confusion of terminology regarding a blind-ending ureter and a true
ureteral diverticulum. 10 Since 1947 numerous cases have been reported. CASE REPORT
A 62-year-old man was admitted to the hospital with a scalp laceration. He had been treated for prostatitis on and off for the past 2 years. Two days after hospitalization pain developed on the left side and hematuria was noted. Physical examination was negative except for a 7 cm. scalp wound and hepatomegaly 4 cm. below the right costal margin. Urine cultures yielded more than 100,000 colonies of Enterococci and were negative for tuberculosis. Renal function and liver function tests were within normal limits. An excretory urogram was normal (fig. 1, A). At cystoscopy the bladder showed early trabeculation with evidence of prostatic obstruction. The left side was further studied by retrograde pyelography which revealed the presence of multiple ureteral diverticula (fig. 1, B). The patient responded well to conservative management and was discharged without further treatment.
Accepted for publication March 27, 1970. 1 Holly, L. E. and Sumcad, B.: Diverticular ureteral changes: report of 4 cases. Amer. J. Roentgen., 78: 1053, 1957. 2 Dolan, P.A. and Kirkpatrick, W. E.: Multiple ureteral diverticula. J. Urol., 83: 570, 1960. 3 Mims, 1\11. M.: Multiple acquired diverticulosis of the ureter. J. Urol., 84: 297, 1960. 4 Rank, W. B., Mellinger, G. T. and Spiro, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. 5 Baines, G. H.: Diverticulosis of the ureter. Brit. J. Urol., 34: 193, 1962. 6 Webber, M. M. and Kaufman, J. J.: Multiple ureteral diverticula. A case report. Amer. J. Roentgen., 90: 26, 1963. 7 Norman, C. H., Jr. and Dubowy, J.: Multiple ureteral diverticula. J. UroL, 96: 152, 1966. 8 Reggiani, A. and Torchi, B.: I diverticoli dell'uretere. Arch. Ital. Urol., 39: 207, 1967. 9 Culp, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 58: 309, 1947.
DISCUSSION
Experimental work on this subject was done as early as 1895 when Lindemann succeeded in producing solitary ureteral diverticula in young rabbits by ligation of the lower ends of the ureters.11 He postulated the etiology to be increased ureteral pressure together with exaggerated peristalsis. In 1933 Kretschmer claimed that these may be acquired segmental balloonings or outpouchings at various levels of the ureter usually proximal to an obstructing lesion. 12 10 Tynes, W. V., II, Devine, C. J., Jr., Buttarazzi, P. J., Devine, P. C., Fiveash, J. G., Jr. and Poutasse, E. F.: Ureteral embryology and resultant anomalies. Virginia Med. Monthly, 95:
395, 1968.
11 Lindemann, W.: Divertikel am Ureter bei Atresie des letzteren. Zbl. Allg. Path., 6; 801,
1895. 12 Kretschmer, H. L.: Duplication of the ureters at their distal ends, one pair ending blindly: socalled diverticula of the ureters. J. Urol., 30: 61,
1933. 183
184
KHONSARI AND OLIVER
. FIG: 1. A, IVP shows normal ureteral outline. B, left retrograde pyelogram shows multiple ureteral d1vert1cula.
FIG. 2. Diverticulosis of colon in area proximal to obstructive lesion.
Current concepts of the etiology of multiple ureteral diverticula include 1) these may be multiple diverticula of the ureteral anlage, 2) compensatory bulges may occur following congenital
stenosis of the ureter and 3) acquired lesions may occur later in life following obstructive ureteral disease. Multiple ureteral diverticula have been considered as benign and have, therefore, received little histological study, leaving a void in the knowledge of their microscopic structure. No cases of diverticula have been reported in children with hydrometer, hydronephrosis, congenital strictures and other conditions found early in life producing increased intraureteral pressure. However, it is possible that multiple ureteral diverticula may be comparable to diverticulosis of the colon. This is an acquired disease, the diverticula (or pseudo or false diverticula) are of the pulsion type consisting of pouches of mucosa not covered by muscular tissue. These pouches tend to occur on the circumference of the large bowel where the blood vessels penetrate the muscular wall to form a point of potential weakness. The diverticula result from a persistently increased intracolonic pressure which is raised during peristalsis and this in turn may be associated with uncoordinated muscular activity in the colon (fig. 2). It is well known that diverticulosis of the colon is a disease of adult life and the incidence increases with age.
185
MULTIPLE URETERAL DIVERTICULA
The blood supply of the ureter is in the form of branches of the renal and testicular (ovarian in the female subject) arteries. In its lower segment it is supplied by the vesical and middle rectal arteries and on occasion direct branches from the common and internal iliac arteries. The vessels of the ureter penetrate first through the muscular layers where they form a in the deep aspect of the mucosa. The points of penetration of the muscular layers are thus potentially weak areas and in instances of infection associated with obstruction there occurs an alteration in the dynamics. This state may cause the formation of "diverticula" the walls of which are formed of mucosa only, at the sites of potential weakness (i.e. false diverticula rather than true variety).
SUMMARY
The literature on multiple ureteral diverticul:J, has been reviewed: 15 cases have been reported and a case is added. Multiple ureteral diverticula are more common in patients in the fifth to seventh decades. Diverticula may or may not be associated with outlet obstruction. There is usually associated infection. Most cases are discovered incidentally and are benign in nature. Multiple diverticula are demonstrated only by means of retrograde pyelography when the injecting pressure is high. The etiology of multiple diverticula has been discussed and a further theory of the pathogenesis is postulated. We believe that further light on this subject may be shed with reports of tissue histology in these cases.