Clinical Significance of Deviations of the Pelvic Ureter

Vol. 96, Aug. Printed in U.S.A.

TI-IE .JOURNAL OF UROLOGY

Copyright © 1966 by The Williams & Wilkins Co.

CLINICAL SIGNIFICANCE OF DEVIATIONS OF THE PELVIC URETER RICHARD M. FRIEDENBERG, CHARLES NEY, FILEMON A. LOPEZ AND ROBERT A. STACHENFELD From the Departments of Radiology and Urology of The Bronx-Lebanon Hospital Center, Bronx, New York

A survey of numerous examinations of the lower genitourinary tract revealed a number oJ consistent ureteral deviations which tend to suggest a specific diagnosis. The pelvic uret:r has a fairly characteristic curvature parallelm~ the pelvic inlet in close proximity to numerous mtraperitoneal organs and retroperitoneal nodes, and often reflects changes in either the intraperitoneal or retroperitoneal space. FiO'ure 1 illustrates the more specific ureteral devi:tions encountered in the lower third of the ureter. Catheter No. 1 represents the usual lateral deviation of the distal third of the ureter secondary to centrally placed pelvic masses, usually intraperitoneal, such as fibroids or ovarian cys~s. Catheter No. 2 illustrates the sharp medial angulation of the ureter just above the ureterovesical orifice typical of the deviation produced by a diverticulum of the bladder arising adjacent to the ureteral orifice. Catheter No. 3 illustrates the gradual medial deviation of the ureter over the mid sacral segments following abdominal perineal surgery for carcinoma of the sig1:"10id. A similar deviation occurs secondary to diffuse pelvic carcinoma, most commonly carcinoma of the sigmoid which has extended outside the confines of the colon. Catheter No. 4 demonstrates the appearance of a tortuous, redundant ureter secondary to low pelvic obstruction, such as a calculus at or just above the ureterovesical junction. The ureter usually presents a localized lateral deviation just below the ureteropelvic junction and a gradual medial swing over the sacral region. Catheter No. 5 illustrates the localized medial deviation of the distal third of the ureter with loss of its normal convexity associated with a retroperitoneal mass lateral to the ureter. This mass usually represents enlarged pelvic retroperitoneal nodes secondary to metastases or inflammation, the former usually from carcinoma of the bladder, uterus or prostate. Accepted for publication September 21, 1~65. Read at annual meeting of America:i :t:Jrolog1cal Association, Inc., New Orleans, Louisiana, May 10-13, 1965.

ILLUSTRATIVE CASES

Lateral deviation of one or both pelvic ureters is commonly seen secondary to an intraperitoneal mass, most frequently uterine or ovarian. The less well-known significant medial deviations are illustrated in this paper. Marked medial displacement of the distal segment of the ureter just proximal to the intramural ureter, frequently "hooklike" in character, usually signifies a bladder diverticulum. In figure 2, the solitary diverticulum (arrow) is partially filled with contrast medium while in figure 3, A the marked medial ureteral deviation extending to the intramural ureter (short arrow) is clearly demonstrated prior to the filling of the diverticulum in figure 3, B. Bilateral medial deviation of the ureters over the upper and mid sacral segments may occur following abdominal perineal surgery for carcinoma of the sigmoid or in pelvic carcinomatosis. In figure 4 a calcified mucus-producing adenocarcinoma of the sigmoid (arrow) caused minimal medial deviation of both ureters over the second and third sacral segments (retouched) in a patient who had urinary symptoms. Figures 5 and 6 illustrate bilateral medial deviation without proximal obstruction following a Miles abdominal perineal resection for carcinoma of the sigmoid. In figure 7, A a similar deviation is present 2 years after abdominal perineal resection but the retrograde study (fig. 7, B) demonstrated proximal obstruction on the left side indicating recurrence of tumor. The patient was asymptomatic at this time. If obstruction is demonstrated proximal to the medial deviation occurring after abdominal perineal resection, recurrent tumor is probably present. Perhaps the most useful pelvic deviation is the demonstration of enlarged retroperitoneal nodes. In such cases there is a loss of the normal convexity of the pelvic ureter more proximal and less marked than the deviation of a bladder diverticulum. The ureterovesical junction is usually not involved. In figure 8, A there is a papil-

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CLINICAL SIGNIFICANCE OF DEVIATIONS OF PELVIC URETER

FIG. 1

Fm. 3

Fm. 2

lary carcinoma in the right side of the bladder with loss of the normal convexity of the right pelvic ureter (arrow) indicating enlarged retroperitoneal nodes which contained metastatic carcinoma. In figure 8, B a similar deviation is present on the left side (arrow) in a patient presenting with symptoms suggesting prostatic

Fm. 4

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FRIEDENBERG, NEY, LOPEZ AND STACHENFELD

hypertrophy. Again, this represented metastases to the retroperitoneal nodes from a prostatic carcinoma. Similar findings have been present in pelvic abscesses, following inflanmiatory nodal enlargement, and secondary to aneurysms, or aneurysmal dilatation of the hypogastric artery. In the latter instance vascular calcification is frequently apparent adjacent to the deviation. Following prolonged partial obstruction of the pelvic ureter, the ureter frequently becomes redundant. In such instances the pelvic ureter tends to swing medially over the sacrum following the normal concavity of the skeletal structures in this area together with lateral kinking of the proximal ureter. These changes are demonstrated in figure 9 where a calculus (arrow) is partially obstructing the pelvic ureter producing the typical configuration of redundancy with a medial sweep over the sacrum and lateral angulation of the proximal ureter. DISCUSSION

FIG. 5

Anatomically the pelvic ureter is loosely adherent to the peritoneum. After the ureter crmses the iliac vessels it courses in an outward, back-

FIG. 6

CLINICAL SlG-""'TFICANCE OF DEVIATIONS OF PELVIC VHETEH

Fw. 7

ward and lateral direction follmving 1iw course of the hypogastric vessels in immediai f' proximity to the walls 0£ the bony pelvis. AL the ischial spines the ureters are at their most separated point and then proceed medially towards the bladder. The course of the pelvic urrte1 is more predictable and cornta11t than tha1. of the proximal ureter, tbereby lending more signi!i cance to deviations. Bilateral medial deviation of the un"tt:rn occurs 1) most frequently follmYing abclomi1tnl perinea] surgery without evidence of recurrfmt tumor ,vithin the pelvis (in ~urh cases therr; is moderate to marked medial cleYiation of the ureters over the mid ~acral segments withon1, proximal obstruction); 2) less commonly, [ollow-ing abdominal perinea] resection with recurrnut carcinoma in the pelvis where a similar deviatiun is encountered, usually associated with obstruction; and 3) least commonly in exten,i n; pelvic carcinornatosis (usually sigmoid) withoiil preyious surgery in which ease' the deviatio11 associated with considerable proximal obstruc · tion. Spillane and assoeiates 1 origi11ally desc:rifwd

FIG. 8

1 Spillane, R ..J., Kaiser, T. F. and Prather, G. C. · Medial deviation of the 11reters eornµli eating carcinoma of the rectum and sigmoid and

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FRIEDENBERG, NEY, LOPEZ AND STACHENFELD

FIG. 9

medial bowing of both ureters at the level of the mid rncrum or promontory following a Miles perineal resection. During this procedure the distal sigmoid and rectum are freed down to the sacrococcygeal articulation nece:,sitating opening of the peritoneum, which is subsequently reestablished. The major factors accounting for deviation may be either mechanical or secondary to the surgical technique. The mechanical factor accounts for deviation following extension of the malignant process to the retroperitoneal lymph nodes or throughout the pelvic area producing pressure on the lateral aspects of the pelvic ureters together with :,earring and contraction. The surgical factor consists of inadequate reconstruction of the pelvic floor following removal of the rectum and sigmoid and opening of the posterior pelvic peritoneum. This medial deviation is quite similar to that described in idiopathic retroperitoneal fibrosis. In both instances the deviation is usually bilateral, without evidence of mass impinging upon the ureters. However, in retroperitoneal fibrosis, the deviation usually occurs at a higher level, between IA and Sl, while folluwproctosigmoidectomy. Surg., Gynec. & Obst., 93: 273-282, 1951.

ing abdominal perineal surgery the deviation occurs between Sl and S3. The remaining characteristic deviations illustrated are primarily unilateral and medial in direction. In most instances the deviation depends simply on the presence of a mass in a predidable location. Solitary bladder diverticula usually occur on the JJOsterior lateral wall of the bladder adjacent to the ureteral orifice and displace the extreme distal end of the ureter medially producing a relatively sharp "hook-like" deviation. Unilateral medial deviation of the midpelvic ureter signifies a mass in the lateral retroperitoneal area. This is usually secondary to enlarged retroperitoneal nodes, most commonly metastatic from the bladder, prostate or uterus or secondary to a localized inflammatory process. Aneurysmal dilatation of the iliac artery will frequently impress the lateral surface of the pelvic ureter similarly to retroperitoneal nodes. The presence of vascular calcification lateral to the ureter and frequently a slightly more cephalad position of the deviation may suggest the diagnosis. Defore assuming significance to medial devia-

CLINICAL SIGNIFICANCE OF DEVIATIONS OF PELVIC URETER

tion of the ureter, the examiner must ascertain that the deviation is present on multiple films, especially those obtained in the supine rather than the prone position where the pelvic ureteral convexity is often less pronounced. If sharp acute angulation is present, localized adhesions may be the causative factor. If obstructive uropathy has produced severe ureterectasis, the medial bowing may simply represent redundancy of the ureter which frequently presents medially over the sacral segments following the medial skeletal slope of this region together with lateral angulation of the proximal ureter. Such devia-

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tions are occasionally bilateral, produced by chronic outlet obstruction with proximal hydronephrosis. CONCLUSION

We have presented a series of deviations of the pelvic ureter which in our experience are specific enough to suggest the nature of the lesion. Variations in ureteral contour and position may occur but careful attention to the course of the ureter will often assist the radiologist or urologist to correctly suggest a previously unsuspected diagnosis.