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Year : 2004  |  Volume : 14  |  Issue : 4  |  Page : 355-360
Mobile calculi In retrocavalureter presenting as dietl's crisis - A case report

Radiologist and Sonologist, Sakthi Scans, Raghavi Hospital Mogappair, Chennai - 37, India

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Obstructive Hydroureteronephrosis due to impacted calculus is a common urological entity in our clinical practice. A congenital malformation presenting with dietl's crisis makes this case report interesting. The classical reverse 'J' /fish hook sign on intravenous urography helps in the diagnosis.

Keywords: Retrocavalureter, Dietl′s crisis

How to cite this article:
Gowrishankar P, Varadharajan S, Mani A C. Mobile calculi In retrocavalureter presenting as dietl's crisis - A case report. Indian J Radiol Imaging 2004;14:355-60

How to cite this URL:
Gowrishankar P, Varadharajan S, Mani A C. Mobile calculi In retrocavalureter presenting as dietl's crisis - A case report. Indian J Radiol Imaging [serial online] 2004 [cited 2020 Jul 10];14:355-60. Available from:

   Introduction Top

Retrocaval ureter is one of the rare congenital abnormalities in which the ureter passes behind the inferior venacava leading to varying degrees of ureteric compression. It was first described by Hochsteller in 1893.Incidence of retrocaval ureter is one in 1500 cadavers. The male to female ratio is 4:1.Most patients present with right lumbar pain and may have recurrent urinary infection or episodes of acute pyelonephritis. Occasionally calculus may form above the obstruction with unusual presentation as dietl's crisis seen in this patient is very rare.

   Case report Top

A 25 year old man presented with right flank pain which was on and off for the past three months and severe for the past two days associated with swelling in the right loin. The pain was dull to severe in intensity and was relieved after lying supine. Later he had mild polyuria after which he noticed that the pain and swelling had significantly reduced. He had no other urological complaints Examination revealed tenderness with fullness in the right lumbar area and the right renal angle. Urine examination revealed 10-12 pus cells but no RBC or casts. His hematological profile including serum creatinine was normal.

Preliminary ultrasound showed normal study of the left kidney. There was moderate hydroureteronephrosis of the right kidney with presence of two calculi measuring 12 and 10 mm seen to move freely within the dilated proximal ureter and renal pelvis on changing the patient position. The ureter was dilated and was seen traceable upto 8 cms from the P.U junction beyond which it had a kink and turned upwards and medially to give an typical s shape or fish hook sign. Preliminary diagnosis of retrocaval ureter was suggested and IVU examination was performed to confirm the diagnosis.

Intravenous urography showed hydroureteronephrosis on the right side, which had two freely mobile calculi within the dilated system. The ureter was dilated upto the level of L-4 transverse process ,which was then seen to ascend upwards medially showing classical reverse J sign.The right ureter was seen normal in calibre in it's lower part. The left kidney, left ureter and urinary bladder were normal.

   Discussion Top

Retrocavalureter is one of the rare congenital anomaly in which the ureter deviates medially and passes behind the inferior venacava, winding about and crossing behind of it.

Developmentally, the metanephros forms in the pelvis and rises through a ring of embryonic venous channels as it moves to a lumbar position. The major venous channels in the very young embryo are the posterior cardinal veins. The minor venous channels and the subcardinal veins are connected to the posterior cardinal veins by numerous prominent anastomotic vessels. Normally the posterior cardinal vein undergoes a complete regression caudal to the renal vein, allowing the ureter to assume a more normal position i.e. ventral to the inferior vena cava. The subcardinal vein remains as a tributary of the inferior vena cava. Persistence of the posterior cardinal vein as the major portion of the infrarenal inferior vena cava causes medial displacement and compression of the ureter after the lateral migration of the kidney. The ureter spirals from a dorsolateral position above, to a venteromedial position below around the developing inferior vena cava. Variants of the condition include duplication of the vena cava with the ureter lying beside, between or behind the vascular limbs.

Retrocaval ureter is classified into two types based on its radiographic appearance and the site of narrowing of ureter.

Type I

  • More common
  • Ureter crosses behind the inferior vena cava at the level of the third lumbar vertebra and has a fish hook shaped (S shaped) deformity of the ureter at the point of obstruction.
  • Marked hydronephrosis is seen in 50% of the patients.

Type II

  • Crossover occurs higher at the level of the renal pelvis.
  • Lesser degree of hydronephrosis or none at all.
  • Renal pelvis and upper ureter lie nearly horizontal before encircling the vena cava in a smooth curve (sickle shaped curve).

The various anomalies associated with retrocaval ureter are Double IVC, Horse shoe kidney and Left retrocaval ureter with Goldenhar syndrome. About 21% of cases of retrocaval ureter present with concomitant abnormalities mainly from the cardiovascular system and the genito urinary tract like glandular hypospadias and with supernumerary lumbar vertebra and syndactilia in both feet

This case is presented here as the imaging findings were diagnostic of this entity and also because of its unique clinical presentation with Dietl's crisis.[7]

   References Top

1.Richard N, Schlussel, Alan B Relik. Anomalies of upper urinary tract - Anomalies of ureteric position : Walsh PC, Retik AB, Vaughan ED Jr. (Eds): Campbell's Urology, 7th Edition, Philadelphia, WB Saunders, Philadelphia, 1998; 2 : 1850-57.  Back to cited text no. 1    
2.Resnick MI, Kurush ED. Extrinsic obstruction of the ureter, in Walsh P, Retik AB, Stamey TA, Vaughan ED Jr. (Eds) : Campbell's Urology, 6th Edition, Philadelphia, WB Saunders, 1992; I : 533-69   Back to cited text no. 2    
3.nii-reo abstract volume 33, issue 1 p-19-22 2002- university hospital of Patras, 26500 Rio,Patras,Greece  Back to cited text no. 3    
4.Ishitoya S, Arai Y, Okubo K, et al. Left retrocaval ureter associated with the Goldenhar Syndrome (brachial arch syndrome). J Urol 1997; 158 (2) : 572-3.  Back to cited text no. 4    
5.Helsin JE, Mamonas C. Retrocaval ureter. Report of four cases and review of literature. J Urol 1951; 65 : 212.  Back to cited text no. 5    
6.Bateson EM, Atkinson D. Circumcaval ureter, A new classification. Clinical radiol 1969; 20 : 173  Back to cited text no. 6  [PUBMED]  
7.Campbell's Urology 7th ed.WB.Saunder's Comp.Philadelphia.1998  Back to cited text no. 7    

Correspondence Address:
P Gowrishankar
Radiologist and Sonologist, Sakthi Scans, Raghavi Hospital Mogappair, Chennai - 37
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Source of Support: None, Conflict of Interest: None

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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14], [Figure - 15], [Figure - 16], [Figure - 17], [Figure - 18]


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