International Urology and Nephrology 24 (3), pp. 233--238 (1992)

Low Ureteral Obstruction Caused by Umbilical Ligament in a 37 Years Old Man: A Case Report R . GRIFONI, T. PIERANGEL1, A . GIOCACCHINI, S. CAPOBIANCO, P. MARCHI Urologic Center I.N.R.C.A., Ancona, Italy (Accepted July 15, 1991)

Arterial vascular anomalies rarely cause extrinsic ureteral obstruction and only 11 cases have been reported so far. This paper deals with a n unusual extrinsic obstruction of the left ureter caused by a residue of the umbilical artery in a 37 years old man. The patient had left flank pain due to serious hydronephrosis on the same side. At operation a fibrous cord, a residue of the left umbilical artery, partially obstructed the distal left ureter. Partial left terminal uretereetomy with ureteroneocystostomy was performed. In the differential diagnosis of low extrinsic ureteral obstructions also the u n c o m m o n vascular anomalies of the umbilical artery should be taken into consideration.

Introduction Arterial vascular anomalies rarely cause extrinsic ureteral obstruction. Although the obstructions may occur at any level, they are more frequent in the lower third o f the ureter [1 ]. The obstacle may be caused by normal vessels with aberrant course or by embryonic arteries that did not physiologically regress with birth. The arterial anomalies more often claimed to cause extrinsic low ureteral obstruction usually involve the obturator vessels [2], the common iliac arteries [3] and the umbilical artery [2]. Since 1929, when Hymas described for the first time an obstruction o f the lower ureter by aberrant blood vessels [4], only 11 cases have been reported. Such anomalies were observed mostly in children [2, 5] and rarely in adults [6]. We report an unusual extrinsic obstruction o f the left ureter 4 cm proximal to the ureterovesical junction caused by a residue of the umbilical artery in a 37 years old man.

Case report In September 1990, a 37-year-old man was admitted with left flank pain that was present for about one year but more marked in the last months. The histories of his relatives were negative, just like his physiologic and remote pathologic anamnesis, with the exception of a left orchiopexy which he underwent at 12 years o f age. VSP, Utrecht Akad~miai Kiad6, Budapest

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On examination we found a sharp and provoked left flank pain. Urinalysis as well as urinary cytology and urine culture were normal, blood urea nitrogen was 41 m g ~ and serum creatinine was 0.9 m g ~ . The patient underwent abdominal ultrasonography, IVP, scan of kidneys and computed tomography of the abdomen and pelvis. Finally we documented serious left hydronephrosis with considerable dilatation of the corresponding ureter, all being due to an obstacle of the left ureter in the proximity of the ureterovesical junction (Fig. 1). Endoscopic examination of the bladder did not show any serious change of the bladder surface even though the left ureteral orifice was a little smaller than the other side. The ureteroscope was advanced only for a few centimetres in the left ureter, since a blind-ending obstruction was seen and the ureteroscope might not advance beyond the obstruction. Subsequently a left retrograde pyelography was done, which showed near the ureterovesical junction a dilated, bent ureter similar to a " h o o k " and a very thin terminal tract of the same ureter (Fig. 2). Since the diagnostic results indicated a probable extrinsic ureteral compression, an exploratory operation was performed.

Fig. 1. Preoperative IVP: Serious left hydronephrosis and considerable dilatation of the ureter o n the same side International Urology and Nephrolopy 24, 1992

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Fig. 2. Left retrograde pyelography: Dilated " h o o k " - l i k e bent ureter near the ureterovesicaI junction

Fig. 3.1VP after 4 months: Reduction of the left ureteral and pyelocalyceal dilatation

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The left ureter was previously intersected at about 4 cm near to the ureterovesical junction, with a fibrous cord that came from above with a back-fore direction that went forward and - after reaching the abdominal wall - upwards. The fibrous cord leaned against the posterior abdominal wall, near the lateral margin o f the abdominal rectus muscle, to reach the umbilical zone. The ureter, in the crossing region, was similar to a siphon with a considerable dilatation above the stenosis. We tied and dissected the fibrous cord and performed a partial left terminal ureterectomy with ureteroneocystostomy. The patient did well postoperatively and was discharged from the hospital after 18 days. Table 1 Main causes of extrinsic ureteral obstruction 1. Diseases of the retroperitoneum Retroperitoneal fibrosis: idiopathic, secondary, radiation induced Abscesses. Haematomas Primary tumour: benign, malignant Lymphocele Pelvic lipomatosis 2. Diseases of the gastrointestinal tract Crohn's disease of the bowel Inflammatory disease of the appendix Diverticulitis Pancreatic lesions: pseudocyst, neoplasms 3. Diseases of the female reproductive system Pregnancy: normal, extrauterine Mass lesions of the uterus and ovary Pelvic inflammations Uterine prolapse Iatrogenic ureteral ligation during gynaecologic procedures 4. Vascular lesions (a) Venous Ovarian vein syndrome Post partum ovarian vein thrombophlebitis Retrocaval ureter (b) Arterial Abdominal aortic aneurysm Aneurysms of the internal and common lilac arteries Obstructive phenomena due to arterial repair Arterial anomalies: obturator, renal, umbilical and common lilac International Urology and Nephrolofly 24, 1992

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Four months later a control excretory urogram showed reduction of the left ureteral and pyelocalyceal dilatation found before the operation (Fig. 3). At present he has no important subjective and objective symptoms; blood and urinalysis are also normal.

Discussion

There are multiple pathologic conditions that may be responsible for an extrinsic obstruction of the ureter. They may be assigned to four main disease groups (Table 1): 1. retroperitoneum; 2. gastrointestinal tract; 3. female reproductive system; 4. vascular lesions (arterial and venous), among which the anomalies represent a small percentage. In our clinical case there was a tract of the fibrous residue of the left umbilical artery that caused a distal ureteral obstruction on the same side near to the ureterovesical junction. During fetal life the umbilical arteries are ventral branches of the dorsal aorta running to the placenta carrying fetal blood for oxygenation. They describe on the lateral wall of the pelvic hole an arch in a forward and bottom direction until they reach the posterior abdominal wall to rise, in the lateral umbilical fold, towards the umbilicus from which they go out through the umbilical funiculus. At birth the two umbilical arteries get atrophied in most of their length and are transformed into fibrous cords: the umbilical ligaments. Only their starting tract remains, which is like a thin branch o f the anterior portion o f branching o f the hypogastric artery. From this thin branch arise the superior vesical arteries and in the male the seminal vesicular arteries, and in the female the uterine artery. In the light of these preliminary remarks on embryology, we think that the importance of this clinical case may be summarized in two main points: (1) In the differential diagnosis o f low extrinsic ureteral obstructions also the uncommon but possible vascular anomalies and in particular those o f the umbilical artery on the same side should be taken into consideration. (2) The cases o f low ureteral obstruction secondary to anomalies o f the umbilical artery up to now reported in the literature involved newborns or young patients, and only one case has been described of a 79 years old man [6]. In this last case, as well as in ours, the obstruction was unilateral, whereas in the others it was bilateral and that might explain the early diagnosis owing to the progressive seriousness o f the clinical picture. In addition, we point out the favourable result obtained by partial ureterectomy of the distal ureteral tract compressed by the fibrous residue of the left umbilical artery and ureteroneocystostomy, since also in the newborns a simple resection o f the aberrant vessel compressing the ureter is not sufficient to resolve the ureteral obstruction [7].

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Acknowledgement We wish to t h a n k Miss Natalie D u r a n t i for the secretarial work.

References 1. Persky, L., Kursh, E. D., Feldman, S., Resnick, M. I.: Extrinsic obstruction of the ureter. Campbell's Urology, 5th Ed. W. B. Saunders, Philadelphia 1986. 2. Javadpour, N., Solomon, T., Bush, I. M. : Obstruction of the lower ureter by aberrant vessels in children. J. Urol., 108, 340 (1972). 3. Mehl, R. L. 9 Retroiliac artery -- ureter. J. UroL, 102, 27 (1969). 4. Hyams, J. A. : A b e r r a n t blood vessels as a factor in lower ureteral obstruction. Surg. GynecoL Obstet., 48, 479 (1929). 5. Yamarnoto, Y., Yamashita, M., Sen, Y.: Bilateral lower ureteral obstruction caused by aberrant blood vessels (umbilical ligament): A case report. Nipp. Hinyokika gakkai zasshi, 77, 145 (1986). 6. Quattlebaum, R., Anderson, A.: Ureterat obstruction secondary to a patent umbilical artery in a 79-year-old m a n : A case report. J. UroL, 134, 347 (1985). 7. Young, J. D., Kiser, W. S.: Obstruction of the lower ureter by aberrant blood vessels. s UroL, 94, I0l (1965).

International Uroloqy and Nephrology 24, 1992

Low ureteral obstruction caused by umbilical ligament in a 37 year old man: a case report.

Arterial vascular anomalies rarely cause extrinsic ureteral obstruction and only 11 cases have been reported so far. This paper deals with an unusual ...
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