Case Report
Urologia Internationalis
Received: September 15, 2014 Accepted after revision: November 12, 2014 Published online: January 24, 2015
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
Laparoscopic Ureteroureterostomy with the Intraoperative Retrograde Ureteroscopy-Assisted Technique for Inverted-Y Ureteral Duplication with a Blind-Ending Branch Zhi Chen Yao He Zheng-Yan Tang Wei He Xiang Chen Department of Urology, Xiangya Hospital, Central South University, Changsha, China
Abstract Inverted-Y ureteral duplications are an extremely rare variant of congenital ureteral malformation with few cases reported in the literature. We describe here a case of invertedY ureteral duplication with a blind-ending branch, which was managed by laparoscopic ureteroureterostomy with the intraoperative retrograde ureteroscopy-assisted technique. This is the first report that reveals that inverted-Y ureteral duplication was managed by ureteroureterostomy in a laparoscopic approach. © 2015 S. Karger AG, Basel
Introduction
Inverted-Y ureteral duplications are an extremely rare variant of congenital ureteral malformation with less than 40 cases previously reported [1–5]. This anomaly describes a partial ureteral duplication where two distal ureteral branches fuse before insertion into the renal pelvis [5]. Commonly, one of two distal ureteral branches results in ectopia [5], ureterocele [1], simple atresia [2] or atresia with calculi formation [4]. We describe here a case © 2015 S. Karger AG, Basel 0042–1138/15/0942–0163$39.50/0 E-Mail [email protected] www.karger.com/uin
of inverted-Y ureteral duplication with a blind-ending branch, which was managed by laparoscopic ureteroureterostomy with the intraoperative retrograde ureteroscopy-assisted technique. To our knowledge, this is the first report that reveals that inverted-Y ureteral duplication was managed by ureteroureterostomy in a laparoscopic approach.
Case Report A 31-year-old woman presented with a long history of vague, relapsing, right flank pain and recurrent urinary tract infections. Physical examination was unremarkable. Urine analysis and renal function tests were within the normal limits (she has been treated with amoxicillin by other institution). Her plain KUB X-ray depicted no positive findings. Both intravenous pyelography (IVU) and computed tomography urography (CTU) showed a supernumerary medial ureter and both its distal and proximal end seemed to join the right ureter, respectively. (fig. 1a and b) Voiding cystourethrography showed that there was not a vesico-ureteral-reflux. Cystoscopy showed only two normal ureter orifice in the bladder. Retrograde pyelography confirmed the presence of partial duplication of the right ureter, suggesting ‘erect’ -Y ureteral duplication with a blind-ending branch (fig. 1c). After thorough discussion, she consented for an exam under anesthesia, ureteroscopy and simultaneously laparoscopic exploration and excision versus ureteroureterostomy. Under general endotracheal anesthesia, patients were placed in a hyperextensive lithotomy position with the trunk in a 45° lateral decubitus posi-
Xiang Chen Department of Urology, Xiangya Hospital Central South University Changsha 10080 (PR China) E-Mail cxiang1007 @ 126.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
Key Words Ureteral duplication · Inverted-Y · Congenital · Laparoscopy
Color version available online
a
c
b
respectively. c Retrograde pyelography confirmed the presence of partial duplication of the right ureter, suggesting ‘erect’ -Y ureteral duplication with a blind-ending branch.
Color version available online
Fig. 1. a, b Intravenous pyelography (IVU) and computed tomography urography (CTU) showed a supernumerary medial ureter and both its distal and proximal end seemed to join the right ureter,
Fig. 2. a The orifice of one ureteral branch a
tion. The abdomen and pelvis were prepared separately. Ureteroscopy revealed that two ureteral branches fused distally in the first channel before insertion into bladder. The orifice of one ureteral branch was thinner and the ureteroscopy could not pass through (fig. 2a). Another ureteral branch had a blind end (fig. 2b). Laparoscopic exploration confirmed inverted-Y ureteral duplication with a blind-ending branch (fig. 3a and b). Finally, after the stricture segment of the branch that drained the renal pelvis and the blind end of the blind-ending branch was excised, the patient underwent laparoscopic ureteroureterostomy. A 6F Double-J ureteral stent was inserted in a retrograde manner. The ureter-ureteral anastomosis was closed with an interrupted suture. (fig. 3c) A closed suction drain was placed into pelvic cavity. The operative time was 106 min. The blood loss was approximately 40 ml. No major intraoperative or postoperative complication occurred. The patient was discharged on the third postoperative day. The drain and double-J stent were, respectively removed
164
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
b
at 2 day and 8 week postoperatively. At the 3-month follow-up, nuclear scan showed no evidence of obstruction of the right kidney and the patient also remained symptom-free.
Discussion
Inverted-Y ureteral duplication forms when two distal ureteral branches fuse to become a single ureter to drain the renal pelvis proximally. Commonly, classic invertedY ureteral duplication has an acute point angle open caudally. In the present case, the end of the blind-ending branch adhered to the right ureter, resulting in an inverted-Y ureteral duplication with an obtuse point angle open Chen/He/Tang/He/Chen
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
was thinner (arrow) and the ureteroscopy could not pass through. b Another ureteral branch had a blind end.
Color version available online
a
c
b
Fig. 3. a The presence of partial duplication of the right ureter was confirmed under laparoscopy. b The blind end was dissected from the right ureter and inverted-Y ureteral duplication was confirmed. c Ureteroureteral anastomosis was completed.
References
Laparoscopic Ureteroureterostomy for Inverted-Y Ureteral Duplication
localization of the stricture segment and the diagnosis of the blind end of the inverted-Y ureteral branches, with no change in the patient’s position. Our technique posed a new insight that such cases can be simultaneously determined from internal and external aspects of the ureters with the combination of ureteroscopy and laparoscopy, thus contributing to choose the reasonable treatment methods. Additionally, intraoperatively retrograde stenting placement under ureteroscopy could also be easily performed.
Acknowledgments Zhi Chen and Yao He contributed equally to this work.
Disclosure Statement None declared.
1 Regan TC, Dejter SW Jr: Inverted Y duplication of the ureter with associated ureterocele and bladder outlet obstruction. J Urol 1996; 155:642. 2 Britt DB, Borden TA, Woodhead DM: Inverted Y ureteral duplication with a blind-ending branch. J Urol 1972;108:387–388. 3 Mourad MS: Inverted Y ureteral duplication with a large ureterocele and draining a bifid renal pelvis in a man. J Urol 1997;157:1353.
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
4 Suzuki S, Tsujimura S, Sugiura H: Inverted Y ureteral duplication with a ureteral stone in atretic segment. J Urol 1977;117:248–250. 5 Upadhyay J, Zuckerman JM, Shekarriz B: Minimally invasive surgical approach to excision of symptomatic ectopic inverted-Y ureteral duplications. J Pediatr Urol 2013;9:e114–e116.
165
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
caudally. This unusual variant of ureteral duplication may be an addition to the inverted-Y ureteral duplication classification. The treatment methods for inverted-Y ureteral duplication changed according to the anatomical variant of ureteral duplication. Regan et al. [1] used electrocautery with the Colling’s knife to unroof the ureterocele for inverted-Y ureteral duplication with associated ureterocele and symptoms dramatically improved. Upadhyay et al. [5] excised the ectopic segment laparoscopically without complication in the outpatient setting for the inverted-Y ureteral duplication with an ectopic ureteral limb. In the present case, although there is no sign of obstruction of the right kidney on the X-ray examinations, suggesting that the branch that drained the renal pelvis was just thinner but not stenotic; ureteroureterostomy was selected to completely excise the blind-ending branch. The key point of our technique used in the case was the performance of the intraoperative retrograde ureteroscopy-assisted technique. Retrograde ureteroscopy was performed concurrently with laparoscopy for both precise
Urologia Internationalis
Received: September 15, 2014 Accepted after revision: November 12, 2014 Published online: January 24, 2015
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
Laparoscopic Ureteroureterostomy with the Intraoperative Retrograde Ureteroscopy-Assisted Technique for Inverted-Y Ureteral Duplication with a Blind-Ending Branch Zhi Chen Yao He Zheng-Yan Tang Wei He Xiang Chen Department of Urology, Xiangya Hospital, Central South University, Changsha, China
Abstract Inverted-Y ureteral duplications are an extremely rare variant of congenital ureteral malformation with few cases reported in the literature. We describe here a case of invertedY ureteral duplication with a blind-ending branch, which was managed by laparoscopic ureteroureterostomy with the intraoperative retrograde ureteroscopy-assisted technique. This is the first report that reveals that inverted-Y ureteral duplication was managed by ureteroureterostomy in a laparoscopic approach. © 2015 S. Karger AG, Basel
Introduction
Inverted-Y ureteral duplications are an extremely rare variant of congenital ureteral malformation with less than 40 cases previously reported [1–5]. This anomaly describes a partial ureteral duplication where two distal ureteral branches fuse before insertion into the renal pelvis [5]. Commonly, one of two distal ureteral branches results in ectopia [5], ureterocele [1], simple atresia [2] or atresia with calculi formation [4]. We describe here a case © 2015 S. Karger AG, Basel 0042–1138/15/0942–0163$39.50/0 E-Mail [email protected] www.karger.com/uin
of inverted-Y ureteral duplication with a blind-ending branch, which was managed by laparoscopic ureteroureterostomy with the intraoperative retrograde ureteroscopy-assisted technique. To our knowledge, this is the first report that reveals that inverted-Y ureteral duplication was managed by ureteroureterostomy in a laparoscopic approach.
Case Report A 31-year-old woman presented with a long history of vague, relapsing, right flank pain and recurrent urinary tract infections. Physical examination was unremarkable. Urine analysis and renal function tests were within the normal limits (she has been treated with amoxicillin by other institution). Her plain KUB X-ray depicted no positive findings. Both intravenous pyelography (IVU) and computed tomography urography (CTU) showed a supernumerary medial ureter and both its distal and proximal end seemed to join the right ureter, respectively. (fig. 1a and b) Voiding cystourethrography showed that there was not a vesico-ureteral-reflux. Cystoscopy showed only two normal ureter orifice in the bladder. Retrograde pyelography confirmed the presence of partial duplication of the right ureter, suggesting ‘erect’ -Y ureteral duplication with a blind-ending branch (fig. 1c). After thorough discussion, she consented for an exam under anesthesia, ureteroscopy and simultaneously laparoscopic exploration and excision versus ureteroureterostomy. Under general endotracheal anesthesia, patients were placed in a hyperextensive lithotomy position with the trunk in a 45° lateral decubitus posi-
Xiang Chen Department of Urology, Xiangya Hospital Central South University Changsha 10080 (PR China) E-Mail cxiang1007 @ 126.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
Key Words Ureteral duplication · Inverted-Y · Congenital · Laparoscopy
Color version available online
a
c
b
respectively. c Retrograde pyelography confirmed the presence of partial duplication of the right ureter, suggesting ‘erect’ -Y ureteral duplication with a blind-ending branch.
Color version available online
Fig. 1. a, b Intravenous pyelography (IVU) and computed tomography urography (CTU) showed a supernumerary medial ureter and both its distal and proximal end seemed to join the right ureter,
Fig. 2. a The orifice of one ureteral branch a
tion. The abdomen and pelvis were prepared separately. Ureteroscopy revealed that two ureteral branches fused distally in the first channel before insertion into bladder. The orifice of one ureteral branch was thinner and the ureteroscopy could not pass through (fig. 2a). Another ureteral branch had a blind end (fig. 2b). Laparoscopic exploration confirmed inverted-Y ureteral duplication with a blind-ending branch (fig. 3a and b). Finally, after the stricture segment of the branch that drained the renal pelvis and the blind end of the blind-ending branch was excised, the patient underwent laparoscopic ureteroureterostomy. A 6F Double-J ureteral stent was inserted in a retrograde manner. The ureter-ureteral anastomosis was closed with an interrupted suture. (fig. 3c) A closed suction drain was placed into pelvic cavity. The operative time was 106 min. The blood loss was approximately 40 ml. No major intraoperative or postoperative complication occurred. The patient was discharged on the third postoperative day. The drain and double-J stent were, respectively removed
164
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
b
at 2 day and 8 week postoperatively. At the 3-month follow-up, nuclear scan showed no evidence of obstruction of the right kidney and the patient also remained symptom-free.
Discussion
Inverted-Y ureteral duplication forms when two distal ureteral branches fuse to become a single ureter to drain the renal pelvis proximally. Commonly, classic invertedY ureteral duplication has an acute point angle open caudally. In the present case, the end of the blind-ending branch adhered to the right ureter, resulting in an inverted-Y ureteral duplication with an obtuse point angle open Chen/He/Tang/He/Chen
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
was thinner (arrow) and the ureteroscopy could not pass through. b Another ureteral branch had a blind end.
Color version available online
a
c
b
Fig. 3. a The presence of partial duplication of the right ureter was confirmed under laparoscopy. b The blind end was dissected from the right ureter and inverted-Y ureteral duplication was confirmed. c Ureteroureteral anastomosis was completed.
References
Laparoscopic Ureteroureterostomy for Inverted-Y Ureteral Duplication
localization of the stricture segment and the diagnosis of the blind end of the inverted-Y ureteral branches, with no change in the patient’s position. Our technique posed a new insight that such cases can be simultaneously determined from internal and external aspects of the ureters with the combination of ureteroscopy and laparoscopy, thus contributing to choose the reasonable treatment methods. Additionally, intraoperatively retrograde stenting placement under ureteroscopy could also be easily performed.
Acknowledgments Zhi Chen and Yao He contributed equally to this work.
Disclosure Statement None declared.
1 Regan TC, Dejter SW Jr: Inverted Y duplication of the ureter with associated ureterocele and bladder outlet obstruction. J Urol 1996; 155:642. 2 Britt DB, Borden TA, Woodhead DM: Inverted Y ureteral duplication with a blind-ending branch. J Urol 1972;108:387–388. 3 Mourad MS: Inverted Y ureteral duplication with a large ureterocele and draining a bifid renal pelvis in a man. J Urol 1997;157:1353.
Urol Int 2015;94:163–165 DOI: 10.1159/000369908
4 Suzuki S, Tsujimura S, Sugiura H: Inverted Y ureteral duplication with a ureteral stone in atretic segment. J Urol 1977;117:248–250. 5 Upadhyay J, Zuckerman JM, Shekarriz B: Minimally invasive surgical approach to excision of symptomatic ectopic inverted-Y ureteral duplications. J Pediatr Urol 2013;9:e114–e116.
165
Downloaded by: University of Tokyo 157.82.153.40 - 5/23/2015 10:03:42 PM
caudally. This unusual variant of ureteral duplication may be an addition to the inverted-Y ureteral duplication classification. The treatment methods for inverted-Y ureteral duplication changed according to the anatomical variant of ureteral duplication. Regan et al. [1] used electrocautery with the Colling’s knife to unroof the ureterocele for inverted-Y ureteral duplication with associated ureterocele and symptoms dramatically improved. Upadhyay et al. [5] excised the ectopic segment laparoscopically without complication in the outpatient setting for the inverted-Y ureteral duplication with an ectopic ureteral limb. In the present case, although there is no sign of obstruction of the right kidney on the X-ray examinations, suggesting that the branch that drained the renal pelvis was just thinner but not stenotic; ureteroureterostomy was selected to completely excise the blind-ending branch. The key point of our technique used in the case was the performance of the intraoperative retrograde ureteroscopy-assisted technique. Retrograde ureteroscopy was performed concurrently with laparoscopy for both precise
