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Testicular vein syndrome
TESTICULAR
VEIN SYNDROME
Unusual
Cause of Hydronephrosis
RONALD
KRETKOWSKI,
NAVIN
SHAH,
M.D.
M.D.
From the Department of Urology, Leland Memorial Hospital, Riverdale,
Maryland
-A case of left hydronephrosis caused by thrombophlebitis of the left testicular vein is presented. Excision of the involved venous segment with ureterolysis relieved the hydronephrosis. A theory is suggested of a possible male counterpart of the ovarian vein syndrome. ABSTRACT
Ureteral obstruction due to calculous disease, tumor, stricture, abnormal vessels, retroperitoneal fibrosis, ovarian vein syndrome, and pressure from tumors and inflammatory disease of the adjacent organs usually causes hydronephrosis. Recently we encountered a rare cause of left hydronephrosis: left upper third ureteral obstruction due to thrombophlebitis of the left testicular vein causing pressure and inflammatory adhesions on and around the ureter. Case
Report
A healthy-looking twenty-year-old white male was admitted to Leland Memorial Hospital on November 9, 1975, with a history of an episode of total painless gross hematuria which occurred a month prior to admission. There were no other urinary symptoms. The hematuria cleared up in one day. Personal and family history was unremarkable. Results of clinical examination were normal except for mild left costovertebral Results of laboratory inangle tenderness. vestigations of urine, urine culture, blood count, chemistries, enzymes, and coagulation profile were within normal limits. Intravenous urography showed moderate hydronephrosis possibly due to abnormal vessels or ureteropelvic junction obstruction (Fig. 1). Cystourethroscopy showed a normal bladder and urethra. Left retrograde pyelogram with its drainage film suggested left ureteropelvic junction blockage.
UROLOGY
The patient underwent surgery on January 6, 1976. The left kidney and proximal half of the ureter were exposed through an eleventh rib bed incision. The renal pelvis and ureteropelvic junction appeared normal. The left testicular vein was large, tortuous, dilated, thrombosed,
/ SEPTEMBER1977
/ VOLUMEX,
NUMBER3
FIGURE 1. Intravenous urogram showed moderate hydronephrosis possibly due to abnormal vessels or ureteropelvic obstruction.
253
FIGURE 2. Microscopic examination of vein showed adventitial inflammatory reaction with collection of polymorphonuclear leukocytes. Diagnosis of thrombophlebitis was made.
and impinging on the upper third of the ureter, just distal to the ureteropelvic junction. In addition, there were fine adhesions between the vein and ureter. There was no evidence of retroperitoneal fibrosis or other abnormal pathology. Excision of about an &cm. segment of the involved vein along with complete ureterolysis of the proximal half of the ureter was carried out. Normal peristalsis was seen passing from the renal pelvis through the ureteropelvic junction to the ureter on completion of the operation. No other procedure was performed. Microscopic examination of the vein showed adventitial inflammatory reaction with collections of polymorphonuclear leukocytes. A diagnosis of thrombophlebitis was made (Fig. 2). Postoperative course was uneventful. For a week antibiotics were administered and anticoagulants were not used. Postoperative checkups of the patient did not reveal any subjective or objective positive findings. The patient never had a varicocele nor did one develop. Intravenous urography five months later exhibited marked regression of hydronephrosis and a normal-appearing ureteropelvic junction. Comment In spite of a very intimate anatomic relationship between left upper’ third of the ureter and the left testicular vein, no cases of testicular vein pathology causing ureteral obstruction are reported in the English literature.
2!54
In 1964, Clark’ reported right hydronephrosis caused by ureteral obstruction due to dilated and tortuous ovarian vein on the right side at Diagnostic confirmation of the pelvic brim. ovarian vein syndrome is achieved by uterine phlebography, as described by Wegryn and Harron in 1960.* Dykhuizen and Roberts3 showed a cure by excision of the fibrous sheath between ureter and ovarian vein combined with resection of the ovarian vein. Derrick, Rosenblum, and Frensilli4 believed the cause of right ovarian vein syndrome to be embyrologic variance of the vascular formation of the said vein. Montalto et al. 5 reviewed all reported 17 cases of postpartum thrombophlebitis of ovarian veins and discussed the role played by stasis, infection, endothelial injury, and hypercoagulation state. Mellin and Madsen6 described a case of an enlarged right spermatic vein with an atypical course causing right hydroureteronephrosis. Excision of the said vein improved the condition. In the present case, no evidence of varicose veins, phlebitis, epididymitis, sepsis, stasis, endothelial injury, or hypercoagulation state is present. Clot culture was not performed, and hence a bacterial cause of thrombophlebitis could not be completely ruled out. Since excision of the involved vein and ureterolysis relieved the hydronephrosis, we endeavor to speculate and add one more entity in causation of the left hydronephrosis in male due to thrombophlebitis of the testicular vein at the upper third of ureter. Riverdale, Maryland 20840 (DR. KRETKOWSKI) ACKNOWLEDGMENT. To Dr. Lawrence Reese, pathologist, for help in surgical pathology, and to Dr. F. K. Mostofi, chief of GU pathology, A.F.I.P., for reviewing the slides. References 1. Clark JC: The right ovarian vein syndrome, in Emmett, JL: Clinical Urography, Philadelphia, W. B. Saunders & Co., 2nd. ed., 1964, pp. 1227-1236. 2. Wegryn SP, and Harron RA: Pelvic phlebography, Obstet. Gynecol. 15: 73 (1960). 3. Dykhuizen RF, and Roberts JA: The ovarian vein syndrome, Surg. Cynec. Obstet. 130: 443 (1970). 4. Derrick FC, Rosenblum R, and Frensilli FJ: Right ovarian vein syndrome, Urology 1: 383 (1973). 5. Montalto NJ, Bloch E, Malfetano JH, and Janelli DE: Postpartum thrombophlebitis of the ovarian vein, Obstet. Gynecol. 34: 867 (1969). 6. Mellin HE, and Madsen PO: Obstruction of ureter by abnormal right spermatic vein, Urology 6: 517 (1975).
UROLOGY
!
SEREMBER
1977
/
VOLUME X, NUMBER 3
VEIN SYNDROME
Unusual
Cause of Hydronephrosis
RONALD
KRETKOWSKI,
NAVIN
SHAH,
M.D.
M.D.
From the Department of Urology, Leland Memorial Hospital, Riverdale,
Maryland
-A case of left hydronephrosis caused by thrombophlebitis of the left testicular vein is presented. Excision of the involved venous segment with ureterolysis relieved the hydronephrosis. A theory is suggested of a possible male counterpart of the ovarian vein syndrome. ABSTRACT
Ureteral obstruction due to calculous disease, tumor, stricture, abnormal vessels, retroperitoneal fibrosis, ovarian vein syndrome, and pressure from tumors and inflammatory disease of the adjacent organs usually causes hydronephrosis. Recently we encountered a rare cause of left hydronephrosis: left upper third ureteral obstruction due to thrombophlebitis of the left testicular vein causing pressure and inflammatory adhesions on and around the ureter. Case
Report
A healthy-looking twenty-year-old white male was admitted to Leland Memorial Hospital on November 9, 1975, with a history of an episode of total painless gross hematuria which occurred a month prior to admission. There were no other urinary symptoms. The hematuria cleared up in one day. Personal and family history was unremarkable. Results of clinical examination were normal except for mild left costovertebral Results of laboratory inangle tenderness. vestigations of urine, urine culture, blood count, chemistries, enzymes, and coagulation profile were within normal limits. Intravenous urography showed moderate hydronephrosis possibly due to abnormal vessels or ureteropelvic junction obstruction (Fig. 1). Cystourethroscopy showed a normal bladder and urethra. Left retrograde pyelogram with its drainage film suggested left ureteropelvic junction blockage.
UROLOGY
The patient underwent surgery on January 6, 1976. The left kidney and proximal half of the ureter were exposed through an eleventh rib bed incision. The renal pelvis and ureteropelvic junction appeared normal. The left testicular vein was large, tortuous, dilated, thrombosed,
/ SEPTEMBER1977
/ VOLUMEX,
NUMBER3
FIGURE 1. Intravenous urogram showed moderate hydronephrosis possibly due to abnormal vessels or ureteropelvic obstruction.
253
FIGURE 2. Microscopic examination of vein showed adventitial inflammatory reaction with collection of polymorphonuclear leukocytes. Diagnosis of thrombophlebitis was made.
and impinging on the upper third of the ureter, just distal to the ureteropelvic junction. In addition, there were fine adhesions between the vein and ureter. There was no evidence of retroperitoneal fibrosis or other abnormal pathology. Excision of about an &cm. segment of the involved vein along with complete ureterolysis of the proximal half of the ureter was carried out. Normal peristalsis was seen passing from the renal pelvis through the ureteropelvic junction to the ureter on completion of the operation. No other procedure was performed. Microscopic examination of the vein showed adventitial inflammatory reaction with collections of polymorphonuclear leukocytes. A diagnosis of thrombophlebitis was made (Fig. 2). Postoperative course was uneventful. For a week antibiotics were administered and anticoagulants were not used. Postoperative checkups of the patient did not reveal any subjective or objective positive findings. The patient never had a varicocele nor did one develop. Intravenous urography five months later exhibited marked regression of hydronephrosis and a normal-appearing ureteropelvic junction. Comment In spite of a very intimate anatomic relationship between left upper’ third of the ureter and the left testicular vein, no cases of testicular vein pathology causing ureteral obstruction are reported in the English literature.
2!54
In 1964, Clark’ reported right hydronephrosis caused by ureteral obstruction due to dilated and tortuous ovarian vein on the right side at Diagnostic confirmation of the pelvic brim. ovarian vein syndrome is achieved by uterine phlebography, as described by Wegryn and Harron in 1960.* Dykhuizen and Roberts3 showed a cure by excision of the fibrous sheath between ureter and ovarian vein combined with resection of the ovarian vein. Derrick, Rosenblum, and Frensilli4 believed the cause of right ovarian vein syndrome to be embyrologic variance of the vascular formation of the said vein. Montalto et al. 5 reviewed all reported 17 cases of postpartum thrombophlebitis of ovarian veins and discussed the role played by stasis, infection, endothelial injury, and hypercoagulation state. Mellin and Madsen6 described a case of an enlarged right spermatic vein with an atypical course causing right hydroureteronephrosis. Excision of the said vein improved the condition. In the present case, no evidence of varicose veins, phlebitis, epididymitis, sepsis, stasis, endothelial injury, or hypercoagulation state is present. Clot culture was not performed, and hence a bacterial cause of thrombophlebitis could not be completely ruled out. Since excision of the involved vein and ureterolysis relieved the hydronephrosis, we endeavor to speculate and add one more entity in causation of the left hydronephrosis in male due to thrombophlebitis of the testicular vein at the upper third of ureter. Riverdale, Maryland 20840 (DR. KRETKOWSKI) ACKNOWLEDGMENT. To Dr. Lawrence Reese, pathologist, for help in surgical pathology, and to Dr. F. K. Mostofi, chief of GU pathology, A.F.I.P., for reviewing the slides. References 1. Clark JC: The right ovarian vein syndrome, in Emmett, JL: Clinical Urography, Philadelphia, W. B. Saunders & Co., 2nd. ed., 1964, pp. 1227-1236. 2. Wegryn SP, and Harron RA: Pelvic phlebography, Obstet. Gynecol. 15: 73 (1960). 3. Dykhuizen RF, and Roberts JA: The ovarian vein syndrome, Surg. Cynec. Obstet. 130: 443 (1970). 4. Derrick FC, Rosenblum R, and Frensilli FJ: Right ovarian vein syndrome, Urology 1: 383 (1973). 5. Montalto NJ, Bloch E, Malfetano JH, and Janelli DE: Postpartum thrombophlebitis of the ovarian vein, Obstet. Gynecol. 34: 867 (1969). 6. Mellin HE, and Madsen PO: Obstruction of ureter by abnormal right spermatic vein, Urology 6: 517 (1975).
UROLOGY
!
SEREMBER
1977
/
VOLUME X, NUMBER 3