Vol. 114, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
Pediatric Articles VASCULAR DISTAL URETERAL OBSTRUCTION BISHOP P. READ
AND
PATRICK C. DEVINE
From the Department of Urologv, Eastern Virginia Medical School, Norfolk, Virginia
ABSTRACT
The diagnosis, treatment and results of 6 patients with 7 obstructed distal ureters secondary to vascular compression are presented. Three ureters were treated by transection of the offending vessels and the remaining 4 required additional ureteroneocystostomy. Vascular compression causing partial obstruction of the distal ureter results in proximal ureteropyelocaliectasis. Since 1929, 12 cases of this condition have been reported in the English literature. 1· 7 We have treated 6 patients with vascular compression of the distal ureter during the last 8 years and add these to the 12 previously reported cases. REVIEW OF CASES
All 6 patients were children between 6 months and 6 years old, and 5 were boys. The left ureter was obstructed in 4 patients, the right ureter in 1 and both ureters in 1. Gross, painless hematuria was the presenting complaint in 4 of 6 patients. In all patients cystoscopy was normal and cystograms demonstrated absence of reflux. Excretory urograms (IVPs) showed distal ureteral obstruction with proximal ureteropyelocaliectasis. Cine tapes demonstrated peristalsis of the proximal dilated ureter down to the point of obstruction with churning of urine in the area of obstruction and intermittent spurts of urine into the bladder. Exploration of each of the 7 obstructed ureters in our 6 patients indicated that 4 were obstructed by aberrant umbilical arteries and the remaining 3 by vesical arteries. Division of the obstructing vessel was the only treatment required in 3 ureters but reimplantation was necessary in the remaining 4 when the proximal dilated ureter failed to completely empty following division of the vessel. Histologic examination of the obstructed segment of the 4 reimplanted ureters revealed fibrosis with a deficiency of musculature in 3 and hypertrophic changes in 1 (fig_ 1). IVPs, 2 months to 8 Accepted for publication May 2, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs. Virginia, October 24-26, 197 4. 762
years postoperatively, demonstrated relief of obstruction in all 6 patients and gross hematuria has not recurred in any of the 4 patients who presented with this sign. DISCUSSION
Hyams first described vascular compression of the distal ureter and illustrated the various anomalous routes of the umbilical and vesical arteries. 4 The umbilical artery, after originating from the hypogastric artery, gives off vesical branches, continues laterally and superiorly with no attachment to the bladder and follows the peritoneum to the umbilicus (fig. 2, A). An aberrant umbilical artery attaches to the dome of the bladder and then follows the urachus to its termination at the umbilicus (fig. 2, B). As the bladder distends, the aberrant umbilical artery is stretched owing to fixation at its origin from the hypogastric artery and its attachment to the bladder dome causing compression and obstruction of the distal ureter (fig. 2, C). Photographs taken at the time of operation clearly demonstrate attachment of the aberrant umbilical artery to the bladder dome (fig. 3) and compression of the distal ureter (fig. 4). Of the 7 obstructed ureters in our 6 patients 3 required only division of the obstructing vessel and the remaining 4 required additional ureteroneocystostomy because the dilated proximal ureter failed to empty following division of the vessel. The histologic picture of the ureter at the site of obstruction is consistent with the fibrosis produced experimentally by compressing the ureter against a pulsatile vessel causing partial ureteral obstruction. 8 These findings are similar to those seen when ureteropelvic junction obstruction is associated with an accessory renal artery. Vascular compression should be considered in any patient with distal ureteral obstruction. 5 • 7
763
VASCULAR DISTAL URETERAL OBSTRl;CT!ON
F1G. L Cross section of ureter demonstrates submucosal fibrosis. Reduced from xJ:"i
FIG. 2. Lateral view of obliterated umbilical arterv. artery and · obliterated umbilical
empty.
764
READ AND DEVINE
FIG. 4. Aberrant obliterated umbilical artery obstructing distal ureter
When an aberrant vessel is found, it should be divided and the ureter should be reimplanted into the bladder if secondary stenosis has developed. REFERENCES 1. Campbell, M. F.: Vascular obstruction of the ureter in juveniles. Amer. J. Surg., 22: 527, 1933.
2. Campbell, M. F.: Vascular obstruction of the ureter in children. J. Urol., 36: 366, 1936. 3. Greene, L. F., Priestley, J. T., Simon, H. B. and Hempstead, R.H.: Obstruction of the lower third of the ureter by anomalous blood vessels. J. Urol., 71: 544, 1954. 4. Hyams, J. A.: Aberrant blood vessels as a factor in
5. 6. 7. 8.
lower ureteral obstruction. Surg., Gynec. & Obst., 48: 474, 1929. Javadpour, N., Solomon, T. and Bush, I. M.: Obstruction of the lower ureter by aberrant vessels in children. J. Urol., 108: 340, 1972. Trackler, R. T. and McAlister, W. H.: Obstruction of the lower ureter by the distal hypogastric (umbilical) artery. Amer. J. Roentgen., 98: 160, 1966. Young, J. D., Jr. and Kiser, W. S.: Obstruction of the lower ureter by aberrant blood vessels. J. Urol., 94: 101, 1965. Cockett, A. T. K., Nakamura, R. M. and Rein, B. I.: The role of arterial pulsation in experimental hydronephrosis. Invest. Urol., 2: 548, 1965.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
Pediatric Articles VASCULAR DISTAL URETERAL OBSTRUCTION BISHOP P. READ
AND
PATRICK C. DEVINE
From the Department of Urologv, Eastern Virginia Medical School, Norfolk, Virginia
ABSTRACT
The diagnosis, treatment and results of 6 patients with 7 obstructed distal ureters secondary to vascular compression are presented. Three ureters were treated by transection of the offending vessels and the remaining 4 required additional ureteroneocystostomy. Vascular compression causing partial obstruction of the distal ureter results in proximal ureteropyelocaliectasis. Since 1929, 12 cases of this condition have been reported in the English literature. 1· 7 We have treated 6 patients with vascular compression of the distal ureter during the last 8 years and add these to the 12 previously reported cases. REVIEW OF CASES
All 6 patients were children between 6 months and 6 years old, and 5 were boys. The left ureter was obstructed in 4 patients, the right ureter in 1 and both ureters in 1. Gross, painless hematuria was the presenting complaint in 4 of 6 patients. In all patients cystoscopy was normal and cystograms demonstrated absence of reflux. Excretory urograms (IVPs) showed distal ureteral obstruction with proximal ureteropyelocaliectasis. Cine tapes demonstrated peristalsis of the proximal dilated ureter down to the point of obstruction with churning of urine in the area of obstruction and intermittent spurts of urine into the bladder. Exploration of each of the 7 obstructed ureters in our 6 patients indicated that 4 were obstructed by aberrant umbilical arteries and the remaining 3 by vesical arteries. Division of the obstructing vessel was the only treatment required in 3 ureters but reimplantation was necessary in the remaining 4 when the proximal dilated ureter failed to completely empty following division of the vessel. Histologic examination of the obstructed segment of the 4 reimplanted ureters revealed fibrosis with a deficiency of musculature in 3 and hypertrophic changes in 1 (fig_ 1). IVPs, 2 months to 8 Accepted for publication May 2, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs. Virginia, October 24-26, 197 4. 762
years postoperatively, demonstrated relief of obstruction in all 6 patients and gross hematuria has not recurred in any of the 4 patients who presented with this sign. DISCUSSION
Hyams first described vascular compression of the distal ureter and illustrated the various anomalous routes of the umbilical and vesical arteries. 4 The umbilical artery, after originating from the hypogastric artery, gives off vesical branches, continues laterally and superiorly with no attachment to the bladder and follows the peritoneum to the umbilicus (fig. 2, A). An aberrant umbilical artery attaches to the dome of the bladder and then follows the urachus to its termination at the umbilicus (fig. 2, B). As the bladder distends, the aberrant umbilical artery is stretched owing to fixation at its origin from the hypogastric artery and its attachment to the bladder dome causing compression and obstruction of the distal ureter (fig. 2, C). Photographs taken at the time of operation clearly demonstrate attachment of the aberrant umbilical artery to the bladder dome (fig. 3) and compression of the distal ureter (fig. 4). Of the 7 obstructed ureters in our 6 patients 3 required only division of the obstructing vessel and the remaining 4 required additional ureteroneocystostomy because the dilated proximal ureter failed to empty following division of the vessel. The histologic picture of the ureter at the site of obstruction is consistent with the fibrosis produced experimentally by compressing the ureter against a pulsatile vessel causing partial ureteral obstruction. 8 These findings are similar to those seen when ureteropelvic junction obstruction is associated with an accessory renal artery. Vascular compression should be considered in any patient with distal ureteral obstruction. 5 • 7
763
VASCULAR DISTAL URETERAL OBSTRl;CT!ON
F1G. L Cross section of ureter demonstrates submucosal fibrosis. Reduced from xJ:"i
FIG. 2. Lateral view of obliterated umbilical arterv. artery and · obliterated umbilical
empty.
764
READ AND DEVINE
FIG. 4. Aberrant obliterated umbilical artery obstructing distal ureter
When an aberrant vessel is found, it should be divided and the ureter should be reimplanted into the bladder if secondary stenosis has developed. REFERENCES 1. Campbell, M. F.: Vascular obstruction of the ureter in juveniles. Amer. J. Surg., 22: 527, 1933.
2. Campbell, M. F.: Vascular obstruction of the ureter in children. J. Urol., 36: 366, 1936. 3. Greene, L. F., Priestley, J. T., Simon, H. B. and Hempstead, R.H.: Obstruction of the lower third of the ureter by anomalous blood vessels. J. Urol., 71: 544, 1954. 4. Hyams, J. A.: Aberrant blood vessels as a factor in
5. 6. 7. 8.
lower ureteral obstruction. Surg., Gynec. & Obst., 48: 474, 1929. Javadpour, N., Solomon, T. and Bush, I. M.: Obstruction of the lower ureter by aberrant vessels in children. J. Urol., 108: 340, 1972. Trackler, R. T. and McAlister, W. H.: Obstruction of the lower ureter by the distal hypogastric (umbilical) artery. Amer. J. Roentgen., 98: 160, 1966. Young, J. D., Jr. and Kiser, W. S.: Obstruction of the lower ureter by aberrant blood vessels. J. Urol., 94: 101, 1965. Cockett, A. T. K., Nakamura, R. M. and Rein, B. I.: The role of arterial pulsation in experimental hydronephrosis. Invest. Urol., 2: 548, 1965.
