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Year : 2001  |  Volume : 11  |  Issue : 2  |  Page : 83-84
Images : Spiral Ct evaluation of circumcaval ureter (retrocaval ureter)


Department of Radiology, IG Medical College, Shimla, HP, India

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Keywords: spiral CT, circumcaval ureter, retrocaval ureter, IVC

How to cite this article:
Singh D D, Sanjeev P, Sharma R K. Images : Spiral Ct evaluation of circumcaval ureter (retrocaval ureter). Indian J Radiol Imaging 2001;11:83-4

How to cite this URL:
Singh D D, Sanjeev P, Sharma R K. Images : Spiral Ct evaluation of circumcaval ureter (retrocaval ureter). Indian J Radiol Imaging [serial online] 2001 [cited 2019 Aug 18];11:83-4. Available from: http://www.ijri.org/text.asp?2001/11/2/83/28380

   Case Report Top


A thirty-two-years old man presented with complaints of fullness and diffuse pain in the right flank off and on. Patient complained of increase in severity of symptoms after consuming lots of liquid or beer. Though clinical examination revealed no abnormality, US of the abdomen was done. It showed marked hydronephrosis of the right kidney and dilated ureter in the upper one-third without any evidence of calculus. Plain radiograph KUB did not show any radio-opaque shadow. Intravenous urography (IVU) showed hydronephrosis of the right kidney and dilated ureter upto the level of the L3 vertebra with a reverse-J deformity at this level with non-visualization of the distal ureter [Figure - 1]. Spiral CT examination confirmed the presence of a type I retrocaval ureter [Figure - 2],[Figure - 3]

On exploration, the ureter was dilated upto the lateral edge of the IVC. The retrocaval part of the ureter was found to be stenotic and showed failure of peristaltic transmission. The stenotic ureter was resected, the ureter relocated and end-to-end anastomosis was done after confirmation of distal ureteric patency. The post-operative IVU was satisfactory and the patient remains asymptomatic


   Discussion Top


Circumcaval ureter has a reported autopsy prevalence of about 0.9 in 1000 with a male to female ratio of 2.8:1[4]. It results from anomalous development of the infra-renal vena cava and not from anomalous development of the ureter. In a circumcaval ureter, the ureters cross posterior to the IVC and then travel medially and anteriorly to partially circumscribe the IVC [2]. Symptoms when present are related to ureteral obstruction, which is frequent but not an inevitable complication of a circumcaval ureter [5]

Two types of retrocaval ureter are frequently encountered - Type 1 & Type II [6]. In type I, the ureter crosses behind the inferior vena cava at the level of the third lumbar vertebra and it has an 'S' or fish hook type shape at the point of obstruction. Marked hydronephrosis is seen in 50% of patients. In the less common Type II, the crossover occurs higher at the level of the renal pelvis. Mild hydronephrosis is usually seen in the majority of these. Both types are frequently detected in the 2nd, 3rd and 4th decades of life. Calculi occasionally co-exist with a circumcaval ureter.

Abeshouse and Tawkin (1952), Muller and Engel (1952), Goodwin et.al (1957) and Rowland et.al (1960) have described the radiological features of circumcaval ureter. The most important changes are hydronephrosis of the upper part of the right ureter with medial displacement and an 'S' or sickle shaped deformity at the level of displacement [2] [Figure - 2] and [Figure - 3]

The findings on IVU while suggestive of circumcaval ureter, are not diagnostic. Medial deviation of the ureter in the lumbar region may be caused by retroperitoneal fibrosis, a retroperitoneal mass, previous surgery as well as by circumcaval ureter [3]. A retrograde pyelography done in conjunction with an inferior vena cavogram has been advocated in the past for making the diagnosis.

In the present case, the spiral CT delineation of the ureter and its course in relation to the IVC and location of IVC lateral to the right pedicle of the L3 vertebra were diagnostic of circumcaval ureter [Figure - 2].[Figure - 3]. The cumbersome interventional vena cavogram was avoided. Whereas only 6% of normal individuals have an IVC lateral to the right pedicle of L-3 vertebra, all the reported cases of circumcaval ureter in the literature have an IVC lateral to the pedicle.

The anomalous development of the IVC leading to a circumcaval ureter explains the lateral position of the IVC in these cases [Figure - 2],[Figure - 3]. The IVC normally develops from the posterior cardinal, subcardinal and supracardinal veins, which undergo sequential development, anastomosis and regression to become the inferior vena cava and azygos venous system. Normally the right subcardinal vein forms the pre-renal IVC, the subcardinal-supracardinal anastomosis forms the renal segment and the right supracardinal vein forms the post-renal IVC. In a circumcaval ureter there is anomalous development of the infrarenal IVC from the right posterior cardinal vein that is embryologically more medial. The location of the IVC lateral to right pedicle of the L3 vertebra was clearly demonstrated in our patient [Figure ],[Figure - 3].

Spiral CT, having the capability of simultaneously outlining the ureter and IVC free of respiratory misregistration and motion artifacts with the production of overlapping images is probably the diagnostic modality of choice, avoiding the possible complications and expense of an invasive procedure.

 
   References Top

1.Martin IR, Elroy DK. Extrinsic obstruction of the ureter. In: Patric CW, Alan BR, Vaughan ED Jr., Alan JW, eds. Campbell's Urology, 7th ed. Philadelphia: WB Saunders, 1998:394-395.  Back to cited text no. 1    
2.Bateson EM, Atkinson D. Circumcaval ureter. A new classification. Clin Radiol 1969; 20: 173-177   Back to cited text no. 2    
3.Leutin EM, Haramati N et al. CT Diagnosis of circumcaval ureter, AJR 1988; 150: 591-594.  Back to cited text no. 3    
4.Johansson NT, Nilsson SV, Scherston T, Schvarz W, Weiland PO. Retrocaval ureter: a report of a case and short review of the literature. Scand J Nephrol 1969; 3: 53-58.   Back to cited text no. 4    
5.Crosse JEW, Sodendahi DW, Teplick SK, Clark RE. Non obstructive circumcaval (Retrocaval) ureter. Radiology 1975; 116: 69-71   Back to cited text no. 5    
6.Kenawi MM, Williamus DI, Circumcaval ureter: A report of new classification. Br J Urology 1976; 48:183-192.  Back to cited text no. 6    

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Correspondence Address:
D D Singh
I G Medical College, Shimla 171 001
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

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