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Diverticulum of the Ureter: A Review of the Literature and a Report of Two Additional Cases
DIVERTIGCLUM OF THE URETER: A REVIEW OF THE LITERATURE AND A REPORT OF TWO ADDITIONAL CASES JOHN G. PRATT, HARRY Q. GAHAGAN
AND
J. L. FISCHMAN
From the Tulane Urological Service, Charity Hospital of Louisiana, New Orleans
Diverticulum of the ureter is a rare clinical finding. A survey of the literature revealed a total of 34 case reports on living subjects in which diverticula were demonstrated either by operation or by uretero-pyelography. To this group 2 additional cases are herewith included, thereby bringing the total number of case reports to 36. Perusal of case reports found in the literature disclosed 12 autopsy reports of ureteral diverticula and 9 cat'es of ureteroceles that were reported as diverticula. An ureteral diverticulum may be either congenital or acquired. Vormann states that true diverticulum is a developmental anomaly, while the acquired type is caused by inflammatory and pressure changes in the ureter; and that the congenital type has the form of a true ureter with its course from its origin parallel to the ureter and ending blindly. The acquired diverticulum is a sharply defined sacciform ballooning of the ureter. Kretschmer explains that one of the branches of a bifid ureter may fail to develop completely and end blindly. These last structures are tube-like blind sacs lying more or less parallel to the course of the ureter and communicating with it through a narrow lumen and are abortive attempts at duplication. Kretschmer stresses the fact that these are bifid ureters and not diverticula. This does not apply to segmental balloonings or pouchings -which are reported at various levels of the ureter usually proximal to some form of obstruction, such as congenital or acquired stricture, or stone, or both. These acquired diverticula are usually more or less globular in shape and associated with varying degrees of hydroureter and hydronephrosis. Brown, quoted by Richardson, recognizes three types of ureteral diverticula: I) A blow-out following inflammatory thickening of the ureteral wall; 2) ureterocele, which is a dilatation of the intramural segment just proximal to the ureteral orifice, which is constricted and a cystic mass projects into the bladder; 3) congenital diverticula occurring along the course of the ureter. The second type, ureterocele, is not classed as a diverticulum of the ureter by most authors. Dodson states that acquired diverticula are caused by a localized expansion of a weakened ureteral wall above an obstructive lesion. The authors believe that an acquired diverticulum can also result in the site of a scar from previous ureteral surgery. Case one developed a diverticulum at the site of a previous ureterolithotomy. Lindermann in 1895 succeeded in producing ureteral diverticula in young rabbits by ligating the lower ends of the ureters. He regarded increased intraureteral pressure together with exaggerated peristalsis as the causal factors. Hale and Von Geldern give 3 possibilities for the development of diverticula: 322
DIVERTICULUM OF THE URETER
323
1) There may be a secondary budding of the metanephric anlage. 2) A compensatory structure following congenital stenosis of the ureter. 3) An acquired structure occurring later in life, following an acquired stricture of the ureter. There were no characteristic symptoms in the cases reviewed except that pain in the side on which the diverticulum was located was present in most cases and that fever and pyuria were frequent findings. Several of the cases were associated with stone in the diverticulum. The diagnosis of this entity rests on pyelography and carefully made ureterograms, and is usually made while studying other uropathies. The treatment is primarily surgical with removal of the cause in the acquired type. The choice of procedure depends on the findings after careful study and individualization to suit the case. Excision of the diverticulum has been successfully performed by others and ,vas selected for case one. Resection of the sac and adjacent ureter with reimplantation of the ureter into the bladder or anastomosis has been reported several times. l'\ ephroureterectomy is the last choice. Bugbee succeeded in relieving one of his patients by dilating the ureter below the diverticulum and another by cutting a stenosed ureteral orifice followed by ureteral dilatation. Richardson in a most comprehensive paper reviewed the literature and reported on a total of 33 cases in living subjects and attempted to make diagrams of the findings. Dodson in 1944 reported the thirty-fourth case, and our 2 cases, reported herewith, makes the total 36 cases to date. CASE REPORTS
Case 1. E. M., T-46-215209, a white male, aged 34 years, was admitted to the Charity Hospital of Louisiana on April 27, 1946 with the complaint of severe pain in the right lower quadrant associated with nausea and vomiting. These symptoms had begun suddenly only 12 hours prior to admission. The pain was described as sharp, colicky in nature and originated about 2 inches above the right inguinal ligament and radiated into the right testis and right thigh. The severity of the pain prevented the patient from extending his right thigh. No history of chills was obtained but fever had been present. There had been frequency of urination for 24 hours but there had been no dysuria, hematuria, or stone passage. No change in bowel habits had been noted. The past history revealed that the patient had suffered similar episodes previously. The first attack occurred in August 1944 and at that time an appendectomy was performed. The patient was hospitalized elsewhere in May 1945 and the following diagnosis was made: "Ureteral calculus, right; ureterocele, right, moderate; hydronephrosis, right, secondary infection, secondary to ureteral calculus." Cystoscopy with fulguration of the ureterocele was performed on May 30, 1945. On June 13, 1945, a right ureterolithotomy was clone. The patient had been asymptomatic until the present attack. The remainder of the past history, the family history, and the social history were non-contributory. On admission, physical examination revealed a -well developed, well nourished,
324
J. G. PRA'l'T, H. Q. GAHAGAN A:,,D J. L. FISCHMAN
adult male, about the stated age, who was in obvious distress and who appeared quite ill. The pulse rate was 120, respirations 32 per minute, temperature 102 degrees and the blood preesure 138/84. The head, neck, and thorax presented normal physical findings. Examination of the abdomen revealed 2 well healed incisional scars in the right lower quadrant parallel to the inguinal ligament. Tenderness on deep palpation ,vas elicited over this area. There was no rigidity present and no rebound tenderness was noted. The liver, spleen and kidneys were not palpable and tenderness was absent over these organs. There was no abdominal distention and the peristaltic sounds were normal. On digital examination of the rectum, the prcstate, seminal vesicles and base of the bladder ,Ycre found to be normal. Howe\·er, in the region of the
Frn. 1. Preoperative films showing diverticulum of lower right ureter that contains a large calculus.
lower right ureter a hard, exquisitely tender mass about one by three centimeters could be palpated. The clinical impression at this time was right ureterolithiasis with ureteral colic. Cystoscopy revealed an edematous right ureteral orifice. Catheterization of the right kidney pelvis disclosed a 55 cc stasis of cloudy urine which contained innumerable pus cells and gram positive cocci. Indigo carmine appeared in 5 minutes and was excreted in good concentration. There were normal findings on the left side. Urine culture from the right renal pelvis was reported staphylococcus albus pyogenes. Other laboratory findings were within normal limits. The roentgenograms ,vere interesting (fig. 1). They were interpreted as revealing a right ureteral cliverticulum containing a large calculus. On May 1, 1946, the calculus was removed (fig. 2) and a diverticulectomy was clone. The postoperative couree was smooth.
DIVERTICULUM OF THE URE'l'ER
325
The 8 month follow-up studies disclosed a 15 cc stasis in the right renal pelvis. No organisms were revealed by culture from this urine. Roentgenograms (fig. 3) revealed a satisfactory regression of the hydronephrosis and hydrometer and although there was evidence of recurrence of the diverticulum there was no evidence of recurrence of calculi. The patient was asymptomatic at this time.
. I
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Fm. 2. Calculus removed from diverticulum at operation
Fm. 3. Postoperative films
In reviewing the records of Charity Hospital of Louisiana, only one other case of ureteral diverticulum was found. Case 2. R. B., T-37-8068, a white male, 28 years old, was admitted August 22, 1937 for a check-up of pleural effusion and possible left pyonephrosis. He deserted the hospital before a satisfactory study could be accomplished. However, the roentgenograms were reported as follows: "Pyelograms show the pelvis of the right kidney dilated and the ureteral catheter coiled in a diverticulum on the left side of the bladder at or near the ureteral opening. A cystogram, antero-posterior and left oblique, showed a smoothly contoured bladder in which no filling defects or diverticula were made out. There was a spina
326'
J. G. PRATT, H. Q. GAHAGAN AND J. L. FISCHMAN
befida occulta of the fifth lumbar vertebra." Unfortunately, these films were either lost or destroyed and could not be found. SUMMARY
Including the above 2 cases, there have been 36 case reports of ureteral diverticulum to date. There are no characteristic symptoms and the diagnosis is made by carefully done pyelography and ureterography in the study of uropathies. The treatment usually is surgical. REFERENCES BROWN, A.: Trans. West. Surg. Assn., 45: 382, 1935. DODSON, A. I.: J. Urol., 52: 526, 1944. HALE, N. G. AND VoN GELDERN, C. E.: Calif. State Med. J., 19: 284, 1921. KRETSCHMER, H. L.: J. Urol., 30: 61, 1933. LINDERMANN, W.: Zentralb. f. allg. Path. u. path. Anat., 6: 801, 1895~ RICHARDSON, E. H.: J. Urol., 47: 535, 1942. VoRMANN, B.: Ztschr. f. Urol., 23: 124, 1929.
AND
J. L. FISCHMAN
From the Tulane Urological Service, Charity Hospital of Louisiana, New Orleans
Diverticulum of the ureter is a rare clinical finding. A survey of the literature revealed a total of 34 case reports on living subjects in which diverticula were demonstrated either by operation or by uretero-pyelography. To this group 2 additional cases are herewith included, thereby bringing the total number of case reports to 36. Perusal of case reports found in the literature disclosed 12 autopsy reports of ureteral diverticula and 9 cat'es of ureteroceles that were reported as diverticula. An ureteral diverticulum may be either congenital or acquired. Vormann states that true diverticulum is a developmental anomaly, while the acquired type is caused by inflammatory and pressure changes in the ureter; and that the congenital type has the form of a true ureter with its course from its origin parallel to the ureter and ending blindly. The acquired diverticulum is a sharply defined sacciform ballooning of the ureter. Kretschmer explains that one of the branches of a bifid ureter may fail to develop completely and end blindly. These last structures are tube-like blind sacs lying more or less parallel to the course of the ureter and communicating with it through a narrow lumen and are abortive attempts at duplication. Kretschmer stresses the fact that these are bifid ureters and not diverticula. This does not apply to segmental balloonings or pouchings -which are reported at various levels of the ureter usually proximal to some form of obstruction, such as congenital or acquired stricture, or stone, or both. These acquired diverticula are usually more or less globular in shape and associated with varying degrees of hydroureter and hydronephrosis. Brown, quoted by Richardson, recognizes three types of ureteral diverticula: I) A blow-out following inflammatory thickening of the ureteral wall; 2) ureterocele, which is a dilatation of the intramural segment just proximal to the ureteral orifice, which is constricted and a cystic mass projects into the bladder; 3) congenital diverticula occurring along the course of the ureter. The second type, ureterocele, is not classed as a diverticulum of the ureter by most authors. Dodson states that acquired diverticula are caused by a localized expansion of a weakened ureteral wall above an obstructive lesion. The authors believe that an acquired diverticulum can also result in the site of a scar from previous ureteral surgery. Case one developed a diverticulum at the site of a previous ureterolithotomy. Lindermann in 1895 succeeded in producing ureteral diverticula in young rabbits by ligating the lower ends of the ureters. He regarded increased intraureteral pressure together with exaggerated peristalsis as the causal factors. Hale and Von Geldern give 3 possibilities for the development of diverticula: 322
DIVERTICULUM OF THE URETER
323
1) There may be a secondary budding of the metanephric anlage. 2) A compensatory structure following congenital stenosis of the ureter. 3) An acquired structure occurring later in life, following an acquired stricture of the ureter. There were no characteristic symptoms in the cases reviewed except that pain in the side on which the diverticulum was located was present in most cases and that fever and pyuria were frequent findings. Several of the cases were associated with stone in the diverticulum. The diagnosis of this entity rests on pyelography and carefully made ureterograms, and is usually made while studying other uropathies. The treatment is primarily surgical with removal of the cause in the acquired type. The choice of procedure depends on the findings after careful study and individualization to suit the case. Excision of the diverticulum has been successfully performed by others and ,vas selected for case one. Resection of the sac and adjacent ureter with reimplantation of the ureter into the bladder or anastomosis has been reported several times. l'\ ephroureterectomy is the last choice. Bugbee succeeded in relieving one of his patients by dilating the ureter below the diverticulum and another by cutting a stenosed ureteral orifice followed by ureteral dilatation. Richardson in a most comprehensive paper reviewed the literature and reported on a total of 33 cases in living subjects and attempted to make diagrams of the findings. Dodson in 1944 reported the thirty-fourth case, and our 2 cases, reported herewith, makes the total 36 cases to date. CASE REPORTS
Case 1. E. M., T-46-215209, a white male, aged 34 years, was admitted to the Charity Hospital of Louisiana on April 27, 1946 with the complaint of severe pain in the right lower quadrant associated with nausea and vomiting. These symptoms had begun suddenly only 12 hours prior to admission. The pain was described as sharp, colicky in nature and originated about 2 inches above the right inguinal ligament and radiated into the right testis and right thigh. The severity of the pain prevented the patient from extending his right thigh. No history of chills was obtained but fever had been present. There had been frequency of urination for 24 hours but there had been no dysuria, hematuria, or stone passage. No change in bowel habits had been noted. The past history revealed that the patient had suffered similar episodes previously. The first attack occurred in August 1944 and at that time an appendectomy was performed. The patient was hospitalized elsewhere in May 1945 and the following diagnosis was made: "Ureteral calculus, right; ureterocele, right, moderate; hydronephrosis, right, secondary infection, secondary to ureteral calculus." Cystoscopy with fulguration of the ureterocele was performed on May 30, 1945. On June 13, 1945, a right ureterolithotomy was clone. The patient had been asymptomatic until the present attack. The remainder of the past history, the family history, and the social history were non-contributory. On admission, physical examination revealed a -well developed, well nourished,
324
J. G. PRA'l'T, H. Q. GAHAGAN A:,,D J. L. FISCHMAN
adult male, about the stated age, who was in obvious distress and who appeared quite ill. The pulse rate was 120, respirations 32 per minute, temperature 102 degrees and the blood preesure 138/84. The head, neck, and thorax presented normal physical findings. Examination of the abdomen revealed 2 well healed incisional scars in the right lower quadrant parallel to the inguinal ligament. Tenderness on deep palpation ,vas elicited over this area. There was no rigidity present and no rebound tenderness was noted. The liver, spleen and kidneys were not palpable and tenderness was absent over these organs. There was no abdominal distention and the peristaltic sounds were normal. On digital examination of the rectum, the prcstate, seminal vesicles and base of the bladder ,Ycre found to be normal. Howe\·er, in the region of the
Frn. 1. Preoperative films showing diverticulum of lower right ureter that contains a large calculus.
lower right ureter a hard, exquisitely tender mass about one by three centimeters could be palpated. The clinical impression at this time was right ureterolithiasis with ureteral colic. Cystoscopy revealed an edematous right ureteral orifice. Catheterization of the right kidney pelvis disclosed a 55 cc stasis of cloudy urine which contained innumerable pus cells and gram positive cocci. Indigo carmine appeared in 5 minutes and was excreted in good concentration. There were normal findings on the left side. Urine culture from the right renal pelvis was reported staphylococcus albus pyogenes. Other laboratory findings were within normal limits. The roentgenograms ,vere interesting (fig. 1). They were interpreted as revealing a right ureteral cliverticulum containing a large calculus. On May 1, 1946, the calculus was removed (fig. 2) and a diverticulectomy was clone. The postoperative couree was smooth.
DIVERTICULUM OF THE URE'l'ER
325
The 8 month follow-up studies disclosed a 15 cc stasis in the right renal pelvis. No organisms were revealed by culture from this urine. Roentgenograms (fig. 3) revealed a satisfactory regression of the hydronephrosis and hydrometer and although there was evidence of recurrence of the diverticulum there was no evidence of recurrence of calculi. The patient was asymptomatic at this time.
. I
. .
.. 'I
·1111111 . ~··,}P I.JI !-r.' 1 f . I . INCHES'··: . ••
.•
:
·-· _.. '
• .::.,J
Fm. 2. Calculus removed from diverticulum at operation
Fm. 3. Postoperative films
In reviewing the records of Charity Hospital of Louisiana, only one other case of ureteral diverticulum was found. Case 2. R. B., T-37-8068, a white male, 28 years old, was admitted August 22, 1937 for a check-up of pleural effusion and possible left pyonephrosis. He deserted the hospital before a satisfactory study could be accomplished. However, the roentgenograms were reported as follows: "Pyelograms show the pelvis of the right kidney dilated and the ureteral catheter coiled in a diverticulum on the left side of the bladder at or near the ureteral opening. A cystogram, antero-posterior and left oblique, showed a smoothly contoured bladder in which no filling defects or diverticula were made out. There was a spina
326'
J. G. PRATT, H. Q. GAHAGAN AND J. L. FISCHMAN
befida occulta of the fifth lumbar vertebra." Unfortunately, these films were either lost or destroyed and could not be found. SUMMARY
Including the above 2 cases, there have been 36 case reports of ureteral diverticulum to date. There are no characteristic symptoms and the diagnosis is made by carefully done pyelography and ureterography in the study of uropathies. The treatment usually is surgical. REFERENCES BROWN, A.: Trans. West. Surg. Assn., 45: 382, 1935. DODSON, A. I.: J. Urol., 52: 526, 1944. HALE, N. G. AND VoN GELDERN, C. E.: Calif. State Med. J., 19: 284, 1921. KRETSCHMER, H. L.: J. Urol., 30: 61, 1933. LINDERMANN, W.: Zentralb. f. allg. Path. u. path. Anat., 6: 801, 1895~ RICHARDSON, E. H.: J. Urol., 47: 535, 1942. VoRMANN, B.: Ztschr. f. Urol., 23: 124, 1929.