Teaching Case

consulted his physician with slight fever, pain in the right fossa radiating to the penis, dysuria and pollakiuria. Physical examination showed mild tenderness of the right flank without sign of peritonitis. Laboratory tests revealed a slight increase in leucocytosis and CRP. Ultrasonography was performed, followed by urography, abdominal CT scan, and urethrography.

A 30-year-old man consulted his physician with slight fever, pain in the right fossa radiating to the penis, dysuria and pollakiuria. Physical examination showed mild tenderness of the right flank without sign of peritonitis. Laboratory tests revealed a slight increase in leucocytosis and CRP. Ultrasonography was performed, followed by urography, abdominal CT scan, and urethrography. Radiological findings suggested a complete ureteropelvic duplication with ectopic ureter. Cystoscopy showed only one ureter orifice at the right trigonum. Exploratory laparotomy confirmed the presence of an ectopic urethral ending of the ureter of the upper pelvis. Microscopic examination of the resected specimen after partial nephro-ureterectomy showed chronic pyelonephritis and ureteritis as a result of chronic vesico-ureteral reflux.

An ectopic ureter is one that does not end at the angle of the vesical trigone. Ninety percent of the patients with an ectopic ending of the ureter are children. The male to female ratio is 1:12. In females eighty percent of ectopic orifices are associated with a duplicated collecting system, whereas in males the majority of ectopic ureters drain single systems. The ectopic ureter ends proximally to the external sphincter. According to the Weigert-Meyer law, an ectopic ureter develops when the ureteral bud arises more cephalad along the mesonephric duct during embryogenesis. As such, there is a lack of absorption of the distal ureter into the trigone, causing the ureteral orifice to be more caudal than normal after the ascent of the metanephros (kidney). In male individuals the orifice may end anywhere along the structures formed from the mesonephric duct (prostatic urethra, seminal vesicle, ejaculatory duct), and therefore it is always proximal to the external sphincter. In females the mesonephric duct lies close to the Müllerian duct and ectopic ureteral orifices may be found in the uterus, cervix or vagina. In males the ectopic ureter may remain asymptomatic for a long time, but as a consequence of obstruction or infection may present clinically by pyelonephritis, prostatism or epididymitis. Urgency and/or frequency are a result of the continuous trickle of urine in the posterior urethra. In females urinary incontinence occurs in half of the patients. Fluor vaginalis is the main complaint in case of concomitant chronic pyelonephritis. Associated anomalies are renal duplication (mostly in females) with hypoplasia or dysplasia of the upper pole segment and total renal maldevelopment resulting in a poor or non visualization on urography. Treatments consists of partial nephrectomy and ureterectomy in case of an associated duplication, heminephrectomy and uretero-neocystostomy in case of single ectopic ureter.