IS case 501: Bilateral orthotopic ureteroceles with secondary hydroureteronephrosis

Daniel O'Connor, MD

University of Rochester

Imaging Sciences URMC 2010
Publication Date: 2010-09-10

History

A 20-year-old male presented with numerous stab wounds to the chest and abdomen. Abdominal CT demonstrated, among other findings, bilateral hydroureteronephrosis with what appear to be bilateral ureteroceles. Patient has no history of renal disease and serum creatinine is normal.

Findings

Initial CT of the abdomen was in the portal venous phase of contrast; findings of bilateral hydroureteronephrosis and probable ureteroceles were incidental. Further work-up was requested by the urology service. VCUG demonstrated no evidence of vesicoureteral reflux. IVP demonstrated impressive bilateral hydroureteronephrosis with retained contrast in the distal ureters post void and bulging of the ureterovesicular junctions (UVJs) into the bladder consistent with ureteroceles. MAG3 study demonstrated normal prompt renovascular and cortical distribution of radiotracer with only delayed clearance of radiotracer from the dilated collecting systems.

Diagnosis

Bilateral orthotopic ureteroceles with secondary hydroureteronephrosis

Discussion

Orthotopic ureteroceles, which insert at the normal position of the ureterovesicular junction in the bladder trigone, are usually asymptomatic, as in our patient. In contrast, ectopic ureteroceles are frequently associated with obstruction and/or reflux, duplication of the collecting systems, and other urogenital and cardiac abnormalities.

Classic appearance of the orthotopic ureterocele is that of the "spring onion" or "cobra-head" deformity, with the distal ureter bulging into the posterior bladder wall, outlined by a radiolucent halo of reflected bladder and ureteral wall, as seen in both the above CT and IVP exams. What is remarkable about our patient is that his bilateral ureteroceles have produced sufficient obstruction to cause significant bilateral hydroureteronephrosis without causing obstructive nephropathy. Obstruction is usually a symptom of ectopic ureteroceles and presents at a median age of 3 months. Our patient, despite evidence of obstruction, has survived to adulthood without loss of renal function, as demonstrated by both normal serum creatinine and GFR, and by MAG3 scan, which demonstrated normal cortical accumulation and excretion of administered radiotracer bilaterally.

References

1. Federle MP, Rosado-de-Christenson ML, Woodward PJ, et al. Diagnostic and Surgical Imaging Anatomy: Chest, Abdomen, Pelvis. Amirsys, 2006.
2. Dahnert WF. Radiology Review Manual, 6th ed. Lippincott Williams & Wilkins, 2007.