- Email: [email protected]
Ureteral Diverticula
THE JOURNAL OF UROLOGY
Vol. 108, September Printed in U.S.A.
Copyright© 1972 by The Williams & Wilkins Co.
URETERAL DIVERTICULA ROY R. GETTEL, FRED LEE
AND
R. K. RATLIFF
From the Departments of Radiology and Urology, St. Joseph Mercy Hospital and University of Michigan Medical Center, Ann Arbor, Michigan
Ureteral diverticulum is one of the least common congenital abnormalities of the urinary tract. In 1947 Culp discussed 52 cases with reference to anatomic variation, criteria for diagnosis and etiology. Only 10 cases were deemed to qualify as true congenital diverticula. Five cases were termed true acquired diverticula. Since that time 10 articles on single or multiple diverticula, occurring unilaterally and bilaterally, have been published. Herein are described 4 cases, with 1 patient having the complication of diverticulitis.
cystourethrogram and a retrograde pyelogram (fig. 1). Bilateral pyelocaliectasis and a duplicated distal right ureter which was non-communicating and suggestive of a diverticulum were noted. No surgical treatment was instituted at this time. Case 2. K. A. G., a 5-year-old white girl, was admitted to the hospital with a history of 3 urinary tract infections in the past year. The last 2 episodes were associated with high fever. The urine was infected as evidenced by 30 plus white blood cells per high power field and more than 100,000 bacteria
Fm. 1. Case 1. A, IVP demonstrates duplication of distal portion of right ureter. B, voiding cystourethrogram shows bilateral reflux with fill of right ureteral diverticulum. CASE REPORTS
Case 1. K. A. D., a 4-year-old white girl, had had persistent urinary tract infection for 6 months prior to hospitalization. She had had 2 prior urinary tract infections, one when she was a year old, with fever, emesis, abdominal cramps and grossly infected urine. Cystoscopy showed moderate trabeculation of the bladder. Roentgenographic studies consisted of an excretory urogram (IVP), a voiding
Accepted for publication January 7, 1972.
on culture. Roentgenographic studies consisted of an IVP and a voiding cystourethrogram (fig. 2). Pyelocaliectasis, left hydroureter and a 3.5 cm. diverticulum from the left ureter were discovered. Surgical correction was deferred. Case 3. W. F. S., a 52-year-old white woman, had had diarrhea and mucous stools for the previous 3 to 4 years. She also had had stress incontinence on several occasions in the past as well as several urinary tract infections. On admission to the hospital urinalysis was negative. Roentgenographic
392
URETERAL DIVERTICULA
393
I I
Frn. 2. Case 2. A, IVP illustrates anomaly of left distal ureter. B, arrow indicates diverticulum enclosed in ureteral sheath.
Frn. 3. Case 3. A, ureter al diverticulum first noted on IVP. B, retrograde pyelogram confirms diverticulum
studies consisted of an IVP and a retrograde pyelogram (fig. 3). A diverticulum of the left lower ureter just proximal to the ureterovesical junction, extending superiorly for 3.5 cm., was discovered. No surgical correction was carried out at this time. Case 4. S. F. a 24-year-old white admitted to the with recurrent
tract infection. Urinalysis yielded 20 to 30 white blood cells per high power field and a moderate number of bacilli. Radiologic studies included an IVP and a retrograde pyelogram (fig. 4). Findings included a diverticulum of the right ureter, 2.5 cm. 3.5 by 3 cm. below the pelvis and measuring 6 A diverticulum of the left ureter was but
394
GETTEL, LEE AND RATLIFF
Fm. 4. Case 4. A, bilateral ureteral diverticula. B, right ureteral diverticulum in lateral view
Fm. 5. Case 4. Photomicrograph illustrates diverticular wall with transitional epithelium, fibrous lamina propria and underlying smooth muscle with inflammatory (polymorphonuclear and lymphocytic) infiltration. Diagnosis was diverticulitis.
less striking. Surgical correction consisted of a right diverticulectomy and ureteroplasty once the urinary tract infection had resolved. Microscopic sections revealed that the diverticulum contained all of the ureteral coats in the wall. There was some disruption of the mucosa! surface with definite inflammatory cellular elements confirming the diagnosis of diverticulitis (fig. 5). The patient did well and was discharged from the hospital 10 days postoperatively on gantenol.
DISCUSSION
In 1949 Culp differentiated a true diverticulum from 14 cases of blind-ending branches of bifid ureters alleged to be ureteral diverticula by other authors. He conceded that both conditions probably resulted from premature cleavage of the ureteral bud. Patten pointed out that there is a tendency for the kidney to divide when a double ureter exists. The absence of renal deformity and the common origin of ureteral diverticula and bifid ureters would tend
395
URETERAL DIVERTICULA
to negate a distinction to be made between them. Rank concluded that ureteral diverticula and bifid ureters are one and the same. All authors cited have concluded that infection probably is an important factor in the development of acquired ureteral diverticula. None has elucidated the mechanism of this development. The second etiological factor might be calculi. These calculi upon obstructing the ureter tend to cause proximal sacculations, which may be concluded to be diverticula. None of the cases presented exhibited calculi. The third factor might be a congenital weakness within the ureteral wall itself causing, with the least amount of obstruction, proximal sacculation. The last etiological agent might be concluded to be trauma, leading to a stricture within the ureter and causing proximal dilatation and sacculation with the development of diverticula. Diagnostic procedures in the past consisted largely of retrograde pyelograms. In the 4 cases described herein the diverticula were found on IVP and later corroborated by a retrograde pyelogram. The only patient in our series who demanded definitive operative treatment had recurrent urinary tract infection not controlled by antibiotics. The procedure done at that time was a diverticulectomy with ureteral reconstruction. The other 3 patients have not, up to this point, experienced a course serious enough to warrant exploration and definitive treatment. Ureteral diverticula are associated with a high number of stone formations, urinary tract infections and a higher incidence of other urinary tract congenital lesions. Diverticulectomy has solved the problem of infection in one of our cases. This is the
!
i
only case of diverticulitis present in a ureteral diverticulum reported to date. SUMMARY Ureteral diverticula are rare abnormalities of the urinary tract. That these diverticula may be involved with diverticulitis has been demonstrated. REFERENCES Bowrn, C. W., GARVEY, F. K., BoYcE, W. H. AND PAUTLER, E. E.: Supernumerary urinary bladder and ureter, spiral deformity of the ureter, ureteral diverticulum, hypoplasia of the kidney and bicorna te uterus: a case report. J. U rol., 71 : 293, 1954. CuLP, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 68: 309, 1947. DoLAN, P. A. AND KIRKPATRICK, W. E.: Multiple uretocal diverticula. J. Urol., 83: 570, 1960. HARLIN, H. C. AND ATKINSON, H. D.: Ureteral diverticulum. Urol. & Cutan. Rev., 64: 526, 1950. HoLLY, L. F., III AND SuMCAD, B.: Diverticular ureteral changes. Amer. J. Roentgen., 78: 1053, 1957. MAYERS, M. M.: Diverticulum of the ureter. J. Urol., 61: 344, 1949. McGRAW, A. B. AND CuLP, 0. S.: Diverticulum of the ureter: report of another authentic case. J. Urol., 67: 262, 1952. MIMS, M. M.: Multiple acquired diverticulosis of the ureter. J. Urol., 84: 297, 1960. PATTEN, B. M.: Human Embryology, 2nd ed. New York: McGraw-Hill Book Co., Inc.; p. 568, 1953. RANK, w. B., MELLINGER, G. T. AND SPIRO, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. WEBBER, M. M. AND KAUFMAN, J. J.: Multiple ureteral diverticula. A case report. Amer. J. Roentgen., 90: 26, 1963. WILLIAMS, J. L. AND GooDWIN, W. E.: Congenital multiple diverticula of the ureter. Brit. J. Urol., 37: 299, 1965.
Vol. 108, September Printed in U.S.A.
Copyright© 1972 by The Williams & Wilkins Co.
URETERAL DIVERTICULA ROY R. GETTEL, FRED LEE
AND
R. K. RATLIFF
From the Departments of Radiology and Urology, St. Joseph Mercy Hospital and University of Michigan Medical Center, Ann Arbor, Michigan
Ureteral diverticulum is one of the least common congenital abnormalities of the urinary tract. In 1947 Culp discussed 52 cases with reference to anatomic variation, criteria for diagnosis and etiology. Only 10 cases were deemed to qualify as true congenital diverticula. Five cases were termed true acquired diverticula. Since that time 10 articles on single or multiple diverticula, occurring unilaterally and bilaterally, have been published. Herein are described 4 cases, with 1 patient having the complication of diverticulitis.
cystourethrogram and a retrograde pyelogram (fig. 1). Bilateral pyelocaliectasis and a duplicated distal right ureter which was non-communicating and suggestive of a diverticulum were noted. No surgical treatment was instituted at this time. Case 2. K. A. G., a 5-year-old white girl, was admitted to the hospital with a history of 3 urinary tract infections in the past year. The last 2 episodes were associated with high fever. The urine was infected as evidenced by 30 plus white blood cells per high power field and more than 100,000 bacteria
Fm. 1. Case 1. A, IVP demonstrates duplication of distal portion of right ureter. B, voiding cystourethrogram shows bilateral reflux with fill of right ureteral diverticulum. CASE REPORTS
Case 1. K. A. D., a 4-year-old white girl, had had persistent urinary tract infection for 6 months prior to hospitalization. She had had 2 prior urinary tract infections, one when she was a year old, with fever, emesis, abdominal cramps and grossly infected urine. Cystoscopy showed moderate trabeculation of the bladder. Roentgenographic studies consisted of an excretory urogram (IVP), a voiding
Accepted for publication January 7, 1972.
on culture. Roentgenographic studies consisted of an IVP and a voiding cystourethrogram (fig. 2). Pyelocaliectasis, left hydroureter and a 3.5 cm. diverticulum from the left ureter were discovered. Surgical correction was deferred. Case 3. W. F. S., a 52-year-old white woman, had had diarrhea and mucous stools for the previous 3 to 4 years. She also had had stress incontinence on several occasions in the past as well as several urinary tract infections. On admission to the hospital urinalysis was negative. Roentgenographic
392
URETERAL DIVERTICULA
393
I I
Frn. 2. Case 2. A, IVP illustrates anomaly of left distal ureter. B, arrow indicates diverticulum enclosed in ureteral sheath.
Frn. 3. Case 3. A, ureter al diverticulum first noted on IVP. B, retrograde pyelogram confirms diverticulum
studies consisted of an IVP and a retrograde pyelogram (fig. 3). A diverticulum of the left lower ureter just proximal to the ureterovesical junction, extending superiorly for 3.5 cm., was discovered. No surgical correction was carried out at this time. Case 4. S. F. a 24-year-old white admitted to the with recurrent
tract infection. Urinalysis yielded 20 to 30 white blood cells per high power field and a moderate number of bacilli. Radiologic studies included an IVP and a retrograde pyelogram (fig. 4). Findings included a diverticulum of the right ureter, 2.5 cm. 3.5 by 3 cm. below the pelvis and measuring 6 A diverticulum of the left ureter was but
394
GETTEL, LEE AND RATLIFF
Fm. 4. Case 4. A, bilateral ureteral diverticula. B, right ureteral diverticulum in lateral view
Fm. 5. Case 4. Photomicrograph illustrates diverticular wall with transitional epithelium, fibrous lamina propria and underlying smooth muscle with inflammatory (polymorphonuclear and lymphocytic) infiltration. Diagnosis was diverticulitis.
less striking. Surgical correction consisted of a right diverticulectomy and ureteroplasty once the urinary tract infection had resolved. Microscopic sections revealed that the diverticulum contained all of the ureteral coats in the wall. There was some disruption of the mucosa! surface with definite inflammatory cellular elements confirming the diagnosis of diverticulitis (fig. 5). The patient did well and was discharged from the hospital 10 days postoperatively on gantenol.
DISCUSSION
In 1949 Culp differentiated a true diverticulum from 14 cases of blind-ending branches of bifid ureters alleged to be ureteral diverticula by other authors. He conceded that both conditions probably resulted from premature cleavage of the ureteral bud. Patten pointed out that there is a tendency for the kidney to divide when a double ureter exists. The absence of renal deformity and the common origin of ureteral diverticula and bifid ureters would tend
395
URETERAL DIVERTICULA
to negate a distinction to be made between them. Rank concluded that ureteral diverticula and bifid ureters are one and the same. All authors cited have concluded that infection probably is an important factor in the development of acquired ureteral diverticula. None has elucidated the mechanism of this development. The second etiological factor might be calculi. These calculi upon obstructing the ureter tend to cause proximal sacculations, which may be concluded to be diverticula. None of the cases presented exhibited calculi. The third factor might be a congenital weakness within the ureteral wall itself causing, with the least amount of obstruction, proximal sacculation. The last etiological agent might be concluded to be trauma, leading to a stricture within the ureter and causing proximal dilatation and sacculation with the development of diverticula. Diagnostic procedures in the past consisted largely of retrograde pyelograms. In the 4 cases described herein the diverticula were found on IVP and later corroborated by a retrograde pyelogram. The only patient in our series who demanded definitive operative treatment had recurrent urinary tract infection not controlled by antibiotics. The procedure done at that time was a diverticulectomy with ureteral reconstruction. The other 3 patients have not, up to this point, experienced a course serious enough to warrant exploration and definitive treatment. Ureteral diverticula are associated with a high number of stone formations, urinary tract infections and a higher incidence of other urinary tract congenital lesions. Diverticulectomy has solved the problem of infection in one of our cases. This is the
!
i
only case of diverticulitis present in a ureteral diverticulum reported to date. SUMMARY Ureteral diverticula are rare abnormalities of the urinary tract. That these diverticula may be involved with diverticulitis has been demonstrated. REFERENCES Bowrn, C. W., GARVEY, F. K., BoYcE, W. H. AND PAUTLER, E. E.: Supernumerary urinary bladder and ureter, spiral deformity of the ureter, ureteral diverticulum, hypoplasia of the kidney and bicorna te uterus: a case report. J. U rol., 71 : 293, 1954. CuLP, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 68: 309, 1947. DoLAN, P. A. AND KIRKPATRICK, W. E.: Multiple uretocal diverticula. J. Urol., 83: 570, 1960. HARLIN, H. C. AND ATKINSON, H. D.: Ureteral diverticulum. Urol. & Cutan. Rev., 64: 526, 1950. HoLLY, L. F., III AND SuMCAD, B.: Diverticular ureteral changes. Amer. J. Roentgen., 78: 1053, 1957. MAYERS, M. M.: Diverticulum of the ureter. J. Urol., 61: 344, 1949. McGRAW, A. B. AND CuLP, 0. S.: Diverticulum of the ureter: report of another authentic case. J. Urol., 67: 262, 1952. MIMS, M. M.: Multiple acquired diverticulosis of the ureter. J. Urol., 84: 297, 1960. PATTEN, B. M.: Human Embryology, 2nd ed. New York: McGraw-Hill Book Co., Inc.; p. 568, 1953. RANK, w. B., MELLINGER, G. T. AND SPIRO, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. WEBBER, M. M. AND KAUFMAN, J. J.: Multiple ureteral diverticula. A case report. Amer. J. Roentgen., 90: 26, 1963. WILLIAMS, J. L. AND GooDWIN, W. E.: Congenital multiple diverticula of the ureter. Brit. J. Urol., 37: 299, 1965.