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Ureteral Diverticulum
Vol. 109, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
URETERAL DIVERTICULUM DAVID T. MININBERG
AND
BRUCE GILLERS
From the Department of Urology, New York Medical College, New York, New York
Ureteral diverticulum is a rare clinical finding, most often occurring at the level of the ureterovesical junction. 1 We recently encountered the third case of a ureteral diverticulum at the level of the renal pelvis.
all ureteral layers, its length is more than twice its greatest diameter. Of his 52 collected cases, only 10 meet the definition of true congenital diverticulum. Kretschmer stated that all embryonic outpouchings of the ureter resulting from premature cleavage of the ureteral bud or multiple budding of the wolffian duct should be regarded as blindly ending bifid ureter regardless of their shape. 3 Rank and associates expanded on Kretschmer's thesis that so-called diverticula are merely bifid ureters that become over-extended.• In this way, the difference in configuration of a bifid ureter is
CASE REPORT
D. A., MHC 50 30 15, a 12-year-old girl, presented with puffy eyelids and swollen legs 5 days in duration. The patient had gained 7 pounds. Blood pressure was 150/106 and there was 1 plus pretibial edema. The remainder of the physical examination was normal. Laboratory diagnostic study was normal except for a blood urea nitrogen of 23 mg. per cent. Urinalysis revealed a specific gravity of 1.025, pH 5, protein 1 plus and 10 to 19 red and 6 to 12 white blood cells per high power field. The Addis count was 25,000,000 red and 2,080,000 white blood cells. Excretory urography (IVP) with tomography showed prompt bilateral excretion from 2 normalappearing kidneys. The right kidney was slightly larger than the left one and a diverticulum was noted along the superior border of the right renal pelvis at the area of the ureteropelvic junction (see figure). The diverticulum emptied promptly and there was no radiographic evidence of pyelonephritis in the kidney. Clinical diagnosis was acute glomerulonephritis. The patient was treated conservatively with prompt resolution of hypertension and edema. She is being treated for nephritis as an outpatient. Prognosis is good. With this highly placed branching of the ureter, we do not anticipate infection. However, pyelonephritis or loss of renal function may make surgical intervention useful.
IVP shows diverticulum of right ureter at level of renal pelvis.
influenced by concurrent disease processes and, in fact, differentiation of diverticulum from bifid ureter, on morphological grounds, is artificial. Youngen and Persky presented the first case of diverticulum of the ureter at the level of the renal pelvis.• Ours is the third case reported of this anomaly at the level of the ureteropelvic junction. Richardson found in 17 of 30 collected cases that the ostium was within 5 cm. of the bladder, 7 were found from 5 to 10 cm. above the bladder and 6 were near the level of the ureteropelvic junction. 1
DISCUSSION
Culp defined congenital ureteral diverticulum as an ovoid or round extraureteral sac which contains all the ureteral layers, communicates with the ureteral lumen through a distinct stoma and is congenital in origin. 2 He clearly distinguishes a diverticulum from the blind-ending branch of bifid ureters, which are hollow tube-like structures whose lumen meets that of the ureter at an acute angle. Although a diverticulum contains
'Kretschmer, H. L.: Duplication of the ureters at their distal ends, one pair ending blindly, so-called diverticula of the ureters. J. Urol., 30: 61, 1933. 4 Rank, W. B., Mellinger, G. T. and Spiro, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. 'Y oungen, R. and Persky, L.: Diverticulum of the renal pelvis. J. Urol., 94: 40, 1965.
Accepted for publication August 4, 1972. 1 Richardson, E. H.: Diverticulum of the ureter: a collective review with report of an unique example. J. Urol., 47: 535, 1942. 2 Culp, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 58: 309, 1947. 716
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
URETERAL DIVERTICULUM DAVID T. MININBERG
AND
BRUCE GILLERS
From the Department of Urology, New York Medical College, New York, New York
Ureteral diverticulum is a rare clinical finding, most often occurring at the level of the ureterovesical junction. 1 We recently encountered the third case of a ureteral diverticulum at the level of the renal pelvis.
all ureteral layers, its length is more than twice its greatest diameter. Of his 52 collected cases, only 10 meet the definition of true congenital diverticulum. Kretschmer stated that all embryonic outpouchings of the ureter resulting from premature cleavage of the ureteral bud or multiple budding of the wolffian duct should be regarded as blindly ending bifid ureter regardless of their shape. 3 Rank and associates expanded on Kretschmer's thesis that so-called diverticula are merely bifid ureters that become over-extended.• In this way, the difference in configuration of a bifid ureter is
CASE REPORT
D. A., MHC 50 30 15, a 12-year-old girl, presented with puffy eyelids and swollen legs 5 days in duration. The patient had gained 7 pounds. Blood pressure was 150/106 and there was 1 plus pretibial edema. The remainder of the physical examination was normal. Laboratory diagnostic study was normal except for a blood urea nitrogen of 23 mg. per cent. Urinalysis revealed a specific gravity of 1.025, pH 5, protein 1 plus and 10 to 19 red and 6 to 12 white blood cells per high power field. The Addis count was 25,000,000 red and 2,080,000 white blood cells. Excretory urography (IVP) with tomography showed prompt bilateral excretion from 2 normalappearing kidneys. The right kidney was slightly larger than the left one and a diverticulum was noted along the superior border of the right renal pelvis at the area of the ureteropelvic junction (see figure). The diverticulum emptied promptly and there was no radiographic evidence of pyelonephritis in the kidney. Clinical diagnosis was acute glomerulonephritis. The patient was treated conservatively with prompt resolution of hypertension and edema. She is being treated for nephritis as an outpatient. Prognosis is good. With this highly placed branching of the ureter, we do not anticipate infection. However, pyelonephritis or loss of renal function may make surgical intervention useful.
IVP shows diverticulum of right ureter at level of renal pelvis.
influenced by concurrent disease processes and, in fact, differentiation of diverticulum from bifid ureter, on morphological grounds, is artificial. Youngen and Persky presented the first case of diverticulum of the ureter at the level of the renal pelvis.• Ours is the third case reported of this anomaly at the level of the ureteropelvic junction. Richardson found in 17 of 30 collected cases that the ostium was within 5 cm. of the bladder, 7 were found from 5 to 10 cm. above the bladder and 6 were near the level of the ureteropelvic junction. 1
DISCUSSION
Culp defined congenital ureteral diverticulum as an ovoid or round extraureteral sac which contains all the ureteral layers, communicates with the ureteral lumen through a distinct stoma and is congenital in origin. 2 He clearly distinguishes a diverticulum from the blind-ending branch of bifid ureters, which are hollow tube-like structures whose lumen meets that of the ureter at an acute angle. Although a diverticulum contains
'Kretschmer, H. L.: Duplication of the ureters at their distal ends, one pair ending blindly, so-called diverticula of the ureters. J. Urol., 30: 61, 1933. 4 Rank, W. B., Mellinger, G. T. and Spiro, E.: Ureteral diverticula: etiologic considerations. J. Urol., 83: 566, 1960. 'Y oungen, R. and Persky, L.: Diverticulum of the renal pelvis. J. Urol., 94: 40, 1965.
Accepted for publication August 4, 1972. 1 Richardson, E. H.: Diverticulum of the ureter: a collective review with report of an unique example. J. Urol., 47: 535, 1942. 2 Culp, 0. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 58: 309, 1947. 716