Ureteral duplication and prostatic disease

U R E T E R A L D U P L I C A T I O N AND

PROSTATIC DISEASE ARJAN D. AMAR, M.B., M.S., F.R.C.S. (C) From the Depa~hnents of Urology, Kaiser-Permanente Medical Center, Walnut Creek, and University of California, San Francisco, California

ABSTRACT-The coincidence of ureteral duplication and prostatic disease often causes adverse interactions between the two conditions, creates diffwulties in diagnosis, complicates treatment, and lengthens postprostatectomy follow-up. A logical grouping of the characteristic problems is offered as an aid to their recognition and has been found useful in planning the management of the patient. In some patients, surgical treatment for ureteral duplication may be safely combined with prostatectomy.

Ureteral duplication, because it is the most common anomaly of the urinary tract, ~ coincides at times with prostatic disease, the most frequent cause of urinary tract symptoms in men older than fifty years. While the duplication per se does not affect the course of the prostatic disease, its complications add to the difficulties of diagnosis and management. Conversely, the occurrence of prostatic disease may draw attention to previously unrecognized disorders associated with ureteral duplication. Analysis of 58 cases of these combined events seen within the last twelve years has led to deftnition of a variety of characteristic problems. As a consequence of recent advances in diagnosis and management of urinary tract disease associated with ureteral duplication, solutions are available for many of these problems. Effects of Prostatic Disease on Ureteral Duplication

Obstruction Prostatic enlargement, either benign or malignant, adds the element of postvesical obstruction to whatever mechanical problems may be caused by ureteral duplication. The obstruction increases the probability that reflux will lead to ureteral dilatation and pyelonephritis. Early in the course of prostatic disease, an ectopic ureteral opening in the prostatic urethra may be olv strncted by the hypertrophied or carcinomatous prostate gland (Fig. 1B). The ipsilateral lower segment ureter, with its orifice in the trigone, may be obstructed late, or not at all. Silent prostatic obstruction frequently contributes to the destruction of renal parenchyma in a dup!i" cated ureterorenal system. By obstructing the bladder neck, prostatic disease frequently causes bladder diverticula which in turn often disturb the ureterovesical valvular function of one or both of the duplicated orifices, leading to reflux.

Reflux Vesicoureteral or urethroureteral reflux is a frequent concomitant of ureteral duplication. Although the re fluxing urine in the male is usually sterile, w h e n the prostate gland becomes infected, the bacteria may become established in the bladder urine and endanger the renal segm e n t attached to the refluxing ureter (Fig. 1A). Case 1 is an example of this.

428

latrogenic infection and trauma The instrumentation necessary for evaluati01~ Of prostatic disease may introduce infecti°n,/':'lll a previously sterile bladder. In cases in win+' the duplicated ureteral structure is conducive to reflux, bacteria may reach the kidney causing a first attack of acute pyelonephritis.

UROLOGY / APRIL1074 / VOLUMEIII'NUMBI~fld

D

Ficum~ 1. Schema of complete ureteral duplication on right: (A) Reflux into lower segment ureter and its renal pelvis. (B ) Obstruction of lower end of upper segment ureter which opens ectopically into prostatic urethra. (C ) Calculus impacted in ectopically opening upper segment ureter obstructs prostatic urethra and upper segment tJreter. (D) Ureterocele at lower end of upper segment ureter, which opens ectopicallgt into prostatic urethra. Ureterocele in this position ma~l obstruct its ipsilateral lower segment ureter, contralateral single ureter, or btadder neck.

The orifice of the upper segment ureter often opens into the prostatic urethra or bladder neck; here, it is likely to be injured during open or transurethral prostatic resection. Reflux or obstTuetion from fibrosis and scar tissue may then ~cur for the first time in that ureter and may n~cessitate secondary surgical correction. 8!/mptoms: diagnostic diJJiculty

Prostatic disease may cause the first symptoms of urinary tract disease due to ureteral duplication, thus leading to its discovery. However, the distortion in the area of the bladder neck and trigone caused by the prostatic disease may make it more difficult to visualize the orifices of the duplicated ureters than of single ureters. During investigation for prostatic disease, ureteral dulflieation may have to be differentiated from other disease of the urinary tract; for example, tUmor of the kidney, ureteral calculous disease, perinephrie abscess, tuberculosis, or other Si~ace-occupying lesions which cause displacement or distortion of the kidney or ureters.

UROLOGy / APRIL 1974 / VOLUME III, N U M B E B 4

Effect of Complete Ureteral Duplication on Prostatic Disease Direct and indirect

Prostatic disease in a patient with duplicate ureters may not differ from that in a patient with single ureters. Duplication causes or aggravates urinary tract disease, however, in about 40 per cent of patients;" if a significant amount of kidney tissue is destroyed as a result, renal reserve may be diminished. When the upper segment ureter opens into the prostatic urethra or seminal vesicle, acute or chronic prostatitis with epididymitis may result. Ureteral duplication with associated urinary calculous disease has been reported recently.3 If a stone forms in the ureter which opens into the prostatic urethra, its presence may increase the obstruction caused by prostatic disease (Fig. 1C). Case 2 is an example of this. A ureteroeele, often present at the lower end of the upper segment ureter, may aggravate the obstruction from prostatic disease by blocking

429

its own ureter, the ipsilateral lower segment ureter, the contralateral (usually single) ureter, and even the bladder neck (Fig. 1D). Investigation and treatment

The preoperative work-up for prostatic disease is of necessity more extensive in patients with duplicate ureters than in those with single ureters. Complications of duplication may necessitate postponement of surgical procedures for prostatic disease, or dictate a change in the type of procedure performed. Urinary tract infection associated with refux in a duplicated ureter increases the hazards of surgical treatment for prostatic disease.

reflux into the right lower segment ureter and its renal pelvis. The acute attack of pyelonel)hritis was considered to have been initiated by the prostatitis; the infected bladder urine reached the lower renal segment through the refluxing ureter (Fig. 2B). Case 2

In a fifty-five-year-old man benign prostatic hyperplasia only partially obstructed the prostatic urethra, and would not of itself have caused acute urinary retention (Fig. 3). A strategically located calculus in the ectopically opening upper segment ureter converted this partial obstruction into complete occlusion. The patient was seen in acute urinary retention.

Case Reports

Diagnosis

A forty-two-year-old man had symptoms of acute prostatitis which subsided only partially with treatment. Three weeks later acute pyelonephritis caused fever and right flank pain. Excretory urograms disclosed bilateral complete ureteral duplication with pyelonephritie atrophy of the lower renal segment on the right (Fig. 2A). Findings on voiding cystogram revealed

We perform excretory urography before any open or transurethral surgical procedure on the prostate gland. Ureteral duplication may not be suspected when the patient is first seen. Once it is recognized, we seek to minimize surgical injury to one or both duplicated orifices by aster-: taining the following points before operating for prostatic disease: (1) status of duplication (complete or incomplete); (2) functional reserve of

Case 1

FlCoI~ 2. Case 1. (A) Excre" tonj urogram showing bilateral ureteral duplication with chronic pyelonephritic atroph~ of lower segment on right; (1~) voiding cystogram showing re2 flux into ureter and pelvis oJ right lower renal segment.

430

UROLOCY / APRILI974 / VOLUMEIII, NIJMI31"I~4

FIGI/I~ 3. Case 2. (A) Excretory urogram showing complete duplication on right. Lower renal segment pelvis and ureter are seen on left; upper renal segment is faintly visualized. Three calculi are noted in region of bladder and prostate. (B) Retrograde injection of contrast medium into ureter and pelvis of upper renal segment on left. Lowest of these calculi obstructed lower end of left upper segment ureter and prostatic urethra, resulting in acute urinary retention. (Courtesy of Charles Beach, M.D.)

duplicated renal segments; (3) status of contralateral kidney and ureter; and (4) location of both duplicated ureteral orifices. We then determine w h e t h e r or not reflux is present in either or both of the duplicated ureters preoperatively. If the patient has acute pyelonephritis or fever postoperatively, the cause may be the preexisting reflux. In some eases the lower renal segment does not excrete enough contrast medium to b e demonstrated on standard excretory urographic films; this segment and its ureter may then appear for the first time on delayed films. This may b e the clue to reflux in a ureter attached to a poorly functioning or nonfunctioning lower renal segment (Fig. 4). 4 Findings on the postvoiding cystographic film sometimes disclose unsuspected duplication by showing reflux into a ureter with an ectopic opening into the bladder neck or urethra. 5 The indigo carmine test performed during cystoscopic examination may indicate which of two ureters is refluxing, especially in cases in which cystography has shown only that the reflux is in the distal segment. 5'6 The presence or absence of ureterocele is determined before prostatectomy because it may be feasible to treat the ureterocele surgically at the prostatic operative procedure. Treatment Every effort is made to avoid injury to the ureters while operating on the prostate gland. In certain situations other surgical procedures are

UROLOC,Y / APRILI974 / VOLUMEIII, NUMBER4

I

FIGURE4. Schematic representation of improved visualization of late films, revealing previously undiscovered reflux. (A ) Hydronephrosis and hydroureter of lower renal segment ureter on right; these structures will visualize faintly or not at all on films made in early phase of excretory urography. Left kidney and ureter appear normal; bladder is empty. (B) Late phase: normally functioning structures have emptied their content of contrast medium into bladder. Contrast medium has entered right lower renal segment ureter and pelvis by reflux; structures are clearly outlined.

431

FIGURE 5. Patient with urinary retention with benign prostatic hypertrophy. (A) Excretory urogram showing single right kidney and ureter, left duplication with marked dilatation of lower renal pelvis. (B) Cystogram showing reflux into lower segment ureter and renal pelvis on left. (C) Diagram of ureteroureterostomy near bladder.

%--j FIGURE 6. Schematic representation of(A) complete ureteral duplication with ureterocele at the lower end of the upper segment ureter; (B) situation after ureterocele has been excised and both ureters reimplanted. (Courtesy, Appleton-Century-Crofts.)

432

readily combined with the prostatectomy; in others the second procedure is more safely postponed either because it must be performed at or near the prostatectomy site or because one must await the outcome of prostatectomy to determine w h e t h e r or not the ureteral anomaly requires surgical intervention. Reflux in one of the duplicated ureters in which the ipsilateral ureter is free of reflux and obstruction may be treated by ureteroureteral anastomosis above the bladder at the time of suprapubic or retropubic prostatectomy. I have recently used this simple, safe operative procedure in 2 patients (Fig. 5). It did not interfere with the prostatectomy and appears to have saved the renal segment of the refluxing ureter from future pyelonephritis; hydronephrosis and hydroureter were promptly reduced. Reflux in b0tll ureters of the duplicated pair is treated by the technique recently described ~ or by any other standard antireflux procedure. If one of the duplicated ureters opens into the prostatic urethra, it is treated by ipsilateral ttrc" teroureterostomy at the time ofprostatectomy" I~ some cases heminephroureterectomy may have to be performed at a later date. A small ureterocele causing minimal or no obstruction is left alone. A medium-sized ureter°" cele can be repaired at the time of prostatectOna)'

UROLOGY / APRIL 1974 / VOLUME Ill, NUMBI';II(

i by Boatwright's 8 or Mason's 9 technique. A large ureterocele is excised, and both of the duplicated ureters are reimplanted (Fig. 6), 1° If this is not feasible at the time of prostatectomy, the ureterocele is excised, the defect in the bladder wall closed, and the lower end of the involved ureter brought to the skin (Fig. 7A and B). 1°'11 Later, the involved ureter and its renal segment are excised, and the remaining ureter of the duplicate pair is reimplanted by an antireflux technique (Fig. 7C). Prostatic disease in a patient with duplicate ureters often warrants closer, longer follow-up than that in a patient with single ureters. The urinary tract problem may not cease even after successful treatment for the prostatic disease. Infection or symptoms involving the urinary tract may recur and d e m a n d surgical treatment for the ureteral anomaly. 1515 Newell Avenue Walnut Creek, California 94596 (DR. AMAR)

t!ROLOcy

/ APRIL 1974 I VOLUMEIII, NUMBER4

FIGURE 7. Schematic representation of (A) ureteral duplication with ureterocele at lower end of upper renal segment ureter. (B) Ureterocele excised; lower end of ureter belonging to upper renal segment anastomosed to skin. (C) Upper renal segment and its ureter excised; lower segment ureter reimplanted into bladder. (Courtesy, Appleton-CenturyCrofts.)

References 1. AMAR, A. D., and HUTCH, J. A.: Anomalies of the ureter, in Alken, C. E., et al., Ed.: Encyclopedia of Urology, vol. 7, New York, Springer-Verlag, 1968, p. 98. 9.. THOMPSON,I. M., and AMAR,A.D.: Clinical importance of ureteral duplication and ectopia, J.A.M.A. 168:881

(1958). 3. AMAP,,A.D.: The management of urinary calculous disease in patients with duplicated ureters, Br. J. Urol. 44: 541 (1972). 4. IDF.M.: Vesicoureteral reflux causing improved visualization on the delayed excretory urogram, Radiology 101: 1 (1971). 5. IDF.M.: Reflux in duplicated ureters, Br. J. Urol. 40:385

(1968). 6. IDEM.: Demonstration of vesicoureteral reflux without radiation exposure, J. Urol. 92:286 (1964). 7. IDEM.: Reimplantation of completely duplicated ureters, ibid. 107:230 (1972). 8. BOATWRIGHT,D. C.: Ureterocele: surgical treatment, ibid. 106:48 (1971). 9. MASON, T.: Simple operative repair of ureterocele (ureterocelorrhaphy), ibid. 106:52 (1971). 10. HUTCH, J. A., and AMAR, A. D.: Vesicoureteral Reflux and Pyelonephritis, New York, Appleton-Century-Crofts, 1972, chap. 4. 11. WILLIAMS,V. I., and WOODARD,J.R.: Problems in management of ectopic ureteroceles, J. Urol. 92:635 (1964).

433