0022-5347/79/1214-0514$2.00/0 Vol. 121, April Printed in U.S.A.
THE JOURNAL OF UROWGY
Copyright © 1979 by The Williams & Wilkins Co.
RETROCAVAL URETER: REPORT OF 8 CASES AND THE SURGICAL MANAGEMENT H. CARRION, J. GATEWOOD, V. POLITANO, G. MORILLO
AND
C. LYNNE
From the Department of Urology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, Florida
ABSTRACT
We present 8 cases ofretrocaval ureter, one of which concerns a unique periureteral venous ring formed by the persistence of the right posterior cardinal vein along with a normal vena cava. Current radiographic concepts are reviewed and the importance of inferior venacavography in the preoperative evaluation for correction of the retrocaval ureter is emphasized. A retrocaval ureter is a congenital venous anomaly, in which the ureter passes behind and is compressed by the inferior vena cava. This condition was first described by Hochstetter in 1893. 1 Usually, the right ureter is involved and male subjects are ?.ffs..:ced more commonly. In 1935 Kimbrough performed the first successful surgical correction. 2 In 1940 Harrill was the first to diagnose the condition preoperatively. 3 Gladstone reported the condition bilaterally. 4 Since excretory urography (IVP) has become practical and common numerous accounts of this rare venous anomaly have been reported. We present our experience with 8 cases. CASE REPORTS
Case 1 . A 16-year-old white boy had acute right flank pain and gross hematuria. He had no prior urological history. The patient was afebrile and normotensive, and had costovertebral angle tenderness on the right side. Laboratory evaluation was unremarkable except for hematuria. An IVP demonstrated delayed excretion on the right side with pyelocaliectasis and ureterectasis of the upper third of the ureter on subsequent films. A combined retrograde pyelogram and venacavogram delineated the retrocaval ureter (fig. 1). The renal pelvis was transected completely above the ureteropelvic junction. The ureter was dissected free of the vena cava and brought around anteriorly. The pelvic anastomosis was then completed with 4-zero interrupted chromic sutures. Convalescence was uneventful. Case 2. A 9-year-old black boy was hospitalized with abdominal pain on the right side 2 months in duration. Other urological symptoms were denied. Physical examination was normal. Laboratory evaluation showed microscopic hematuria. An IVP suggested a right retrocaval ureter and this was confirmed by cystoscopy and retrograde pyelography (fig. 2). The portion of the ureter behind the vena cava was stenotic. The lower ureter was mobilized and the stenotic portion, together with a portion of the renal pelvis above the ureteropelvic junction, was excised. The lateral margin of the ureter was spatulated and sutured to the renal pelvis with interrupted 4-zero chromic catgut sutures. Convalescence was uneventful. An IVP 2 months later showed good function bilaterally and improvement in the dilatation seen preoperatively in the right pelviocaliceal system and pelvis. Case 3. A 23-year-old white man had severe right flank pain and gross hematuria. An IVP was consistent with a retrocaval ureter. Physical examination and laboratory diagnostic studies were within normal limits. After the ureter was excised at the ureteropelvic junction and relocated anterior to the vena cava the 5.0 cm. portion of the ureter behind the vena cava was excised. An end-to-end Accepted for publication July 21, 1978. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977.
anastomosis was made after both ends were spatulated with interrupted 4-zero chromic sutures. Because of prolonged flank drainage it was necessary to place a ureteral catheter into the right renal pelvis 10 days postoperatively. The flank was dry 8 days later. A followup IVP 21 months postoperatively showed a good result with only minimal dilatation remaining (fig. 3). Case 4. A 17-year-old white boy had acute, painless, gross hematuria. Physical examination and laboratory evaluation were unremarkable, except for gross hematuria. An IVP demonstrated pyelocaliectasis and ureterectasis throughout the upper third of the right ureter. Inferior venacavography showed that the right ureter passed through an unusual venous ring, formed by the persistent right posterior cardinal vein as the anterior portion of the ring. The normal caval derivative, the right supracardinal vein, formed the posterior portion of the ring (fig. 4). The corrective operation consisted simply of ligation and
Fm. 1. Case 1. Combined retrograde pyelogram and inferior venacavogram demonstrates retrocaval ureter.
514
RETROCAVAL URETER
515
Fm. 2. Case 2. A, IVP demonstrates retrocaval ureter. B, retrog-rade pyelogram demonstrates retrocaval ureter
FIG. 4. Case 4. Combined retrograde pyelogram and inferior venacavogram demonstrates unique periureteral venous ring. Fm. 3. Case 3. IVP 21 months postoperatively reveals resolution of upper ureteral dilatation and hydronephrosis.
excision of the anterior ureter. A IVP caliceal dilatation. Case 5. A diabetic woman was treated for urinary retention and referred to the clic_ic, a_nd
urine was clear. An IVP done as an outpatient procedure demonstrated right ureteropelvic junction obstruction in association with findings suggestive of a retrocaval ureter. Diagnosis was confirmed with a simultaneous retrograde pyelogram and inferior venacavogram. The ureter was transected below the ureteropelvic junction and relocated anterior to the vena cava. The renal pelvis was transected above the stenotic w,,,~-~~nn junction, A disrn.ernbered v10.s done
516
CARRION AND ASSOCIATES
Fm. 5. Case 7. A and B, combined IVP and inferior venacavogram demonstrates retrocaval ureter. C, IVP 6 months postoperatively reveals resolution ofhydronephrosis and dilatation of upper ureteral segment.
Case 6. A 59-year-old white woman had had low grade back pain for several months. She denied any history of hematuria or stones. Physical examination and laboratory evaluation were unremarkable. An IVP was considered suggestive of a retrocaval ureter and this was confirmed by retrograd,e pyelography. Because of the patient's age, minimal symptomatology and the absence of significant right ureteral obstruction on the IVP the patient was followed. Case 7. A 24-year-old black man had intermittent abdominal pain on the right side 2 months in duration. Physical examination and routine laboratory studies were unremarkable. An IVP suggested a retrocaval ureter. Inferior venacavography was done in conjunction with simultaneous drip infusion pyelography to confirm the diagnosis (fig. 5, A andB). The right ureter was dissected free of the vena cava. The right renal pelvis was transected above the ureteropelvic junction and the ureter was relocated anteriorly to the vena cava. A dismembered pyeloplasty was then done. A followup IVP 6 months later showed a satisfactory result (fig. 5, C). Case 8. A 9-year-old white boy presented with long-term nocturnal enuresis and urinary frequency. Physical examination revealed meatal stenosis. The diagnosis of retrocaval ureter was made by an IVP and retrograde pyelography. The right ureter was dissected free of the vena cava. The renal pelvis was transected approximately 1 cm. proximal to the ureteropelvic junction. The ureter was relocated anterior to the vena cava and reanastomosed with interrupted 4-zero chromic sutures. Convalescence was uneventful. DISCUSSION
A retrocaval ureter is a rare congenital anomaly. According to Shown and Moore, > 150 cases of this condition have been reported since 1893. 5 Many investigators have discussed the embryological significance of the retrocaval ureter which, strictly speaking, is an anomaly affecting the vena cava and not the ureter.lHl In the majority of patients symptoms are owing to the ureteral obstruction and resulting hydronephrosis. Pain can resemble renal colic but can be intermittent, dull and aching. Hematuria, in varying degrees, is present frequently. The resulting hydronephrosis may be silent and is unmasked by
unrelated clinical events. 10 Many cases of retrocaval ureter were found incidentally on an IVP obtained for unrelated reasons. The diagnosis ofretrocaval ureter is made radiographically. Bateson and Atkinson analyzed 92 cases and found that they could classify 79 cases into 1 of 2 types on the basis of radiographic criteria. 11 Type I, the more common form of retrocaval ureter, has severe or moderate hydronephrosis with extreme medial deviation of the middle ureteral segment, usually medial to the pedicle or across the midline at the L3 level. An S or fish hook deformity is present at the point of obstruction. In type II retrocaval ureter there is mild hydronephrosis and less medial deviation of the ureter. The ureter is noted to be sickle-shaped at the level of the obstruction. A retrograde pyelogram in conjunction with an inferior venacavogram 12 is helpful in cases in which the diagnosis cannot be established from the IVP and retrograde pyelogram. If medial deviation of the middle ureteral segment is lateral to the pedicles, or above or below the L3 level, the possibility of a periureteral venous ring should be considered, as in case 4. SURGICAL CORRELATION
Surgical treatment should be directed toward relieving the obstruction and correcting the underlying anatomical abnormality. Crosse and associates followed 2 asymptomatic cases. 13 Patients with severe hydronephrosis and far advanced cortical atrophy with good function in the opposite kidney should be considered for nephrectomy. Division of the renal pelvis above the ureteropelvic junction with anastomosis after the ureter is relocated anterior to the vena cava was first done by Harrill. 3 The advantage of this approach is in the abundant vascular supply of the pelvis and proximal ureter, compared to the middle third of the ureter. Postoperative stricture at the anastomotic site is less likely. It is helpful to remember that the post-caval segment of ureter may be stenotic. If an SF catheter does not pass through this segment easily then the stenotic section of the ureter must be excised and a dismembered pyeloplasty should be done. Division of the ureter at the ureteropelvic junction, with subsequent ureteropelvic anastomosis, tends to yield a higher incidence of postoperative strictures. 14
517
RETROCAVAL URETER
If the proximal ureteral segment is not dilated and the ureter is impossible to free from the vena cava segmental resection may be indicated. The resultant anastomosis will have a smaller lumen and a greater chance of developing postoperative stricture. Ligation and section of the vena cava without reanastomosis were done successfully by Cathro. 15 Goodwin and associates divided and reanastomosed the vena cava after the ureter was relocated anteriorly . 16 The vascular approach is used if the post-caval portion of the ureter is free of stenosis. In our experience when the ureter assumed a devious course through a vena caval ring excision and ligation of the anterior portion of the ring freed the ureter. If an operation on the vena cava is contemplated preoperative inferior venacavography should be done. Preoperative venacavography might allow for simple excision of an unnecessary duplicated vessel. LePage and Baldwin believe that even superselective branch venography in evaluating ureteral venous anomalies might be useful. 17
Drs. William Chason Hayes, Richard L Fein and Fitzgerald contributed case material. REFERENCES
1. Hochstetter, F.: Beitriige zur Entwickelungsgeschichte des Ve-
2. 3. 4. 5.
5. 7.
nensystems der Amnioten. III. Sauger. Morphol. Jahrb., 20: 543, 1893. Kimbrough, J. C.: Surgical treatment of hydronephrosis. J. Urol., 33: 97, 1935. Harrill, H. C.: Retrocaval ureter: report of a case with operative correction of the defect. J. Urol., 44: 450, 1940. Gladstone, R. J.: Acardiac fetus (acephalus omphalositicus). J. Anat. Physiol., 40: 71, 1905. Shown, T. E. and Moore, C. A.: Retrocaval ureter: 4 cases. J. Urol., 105: 497, 1971. Gruenwald, P. and Surke, S. N.: Pre-ureteric vena cava and its embryological explanation. J. Urol., 49: 195, 1943. Pick, J. W. and Anson, B. J.: Retrocaval ureter: report of a case and discussion of its clinical significance. J. Urol., 43: 672, 1940.
8. Randall, A. and Campbell, E.W.: Anomalous relationship of the right ureter to the vena cava. J. Urol., 34: 565, 1935. 9. McClure, C. F. W. and Butler, E.G.: Development of the vena cava inferior in man. Amer. J. Anat., 35: 331, 1925. 10. Oshin, D. R.: Retrocaval ureter: an unusual complication associated with pregnancy. J. Urol., 91: 652, 1964. 11. Bateson, E. M. and Atkinson, D.: Circumcaval ureter: a new classification. Clin. Radio!., 20: 173, 1969. 12. Presman, D. and Firfir, R.: A diagnostic method of retrocaval ureter. Amer. J. Surg., 92: 628, 1956. 13. Crosse, J.E., Soderdahl, D. W., Teplick, S. K. and Clark, R. E.: Non-obstructive circumcaval (retrocaval) ureter. A report of 2 cases. Radiology, 116: 69, 1975. 14. Rowland, H. S., Jr., Bunts, C. R. and Iwano, J. H.: Operative
correction of retrocaval ureter: a report of four cases and review of the literature. J. Urol., 83: 820, 1960. 15. Cathro, A. J. McG.: Section of the inferior vena cava for retrocaval ureter: a new method of treatment. J. Urol., 67: 464, 1952. 16. Goodwin, W. E., Burke, D. E. and Muller, W. H.: Retrocaval ureter. Surg., Gynec. & Obst., 104: 337, 1957. 17. LePage, J. R. and Baldwin, G. N.: Obstructive periureteric venous ring. Radiology, 104: 313, 1972. EDITORIAL COMMENT The authors, because of an unusually large experience with a relatively rare condition, have had an opportunity to consider all methods of management. They correctly emphasize the importance of the combined venacavogram and retrograde pyelogram in clinching absolutely the diagnosis. 1 Particularly interesting is the case of a unique periureteral venous ring that was formed by the persistence of the right posterior cardinal vein along with the normal vena cava. This may be a unique experience. Most patients were treated by transection of the renal pelvis and reanast~mosis after the retrocaval ureter was placed into its normal position. This procedure, which the British call the Anderson-Hynes operation' and which many Americans call dismembered pyeloplasty, was first reported by Harrill in 1940 (reference 3 in the article). It is ironic that this procedure has come to be called the Anderson-Hynes operation when it was first done by Harrill. The authors correctly indicate that not every patient with a retrocaval ureter needs to be treated surgically. Although none of their patients was treated with an operation on the vena cava itself, instead of on the urinary tract, they mention that it is mandatory that preoperative venacavography should be done if that is planned. It is interesting that the surgical management of retrocaval ureter by division and reanastomosis of the vena cava has not caught on in this country, whereas in Japan it seems to be the favored treatment. Fujii and associates reported the fourth case managed that way in Japan in 1966. 3 These authors emphasize the main points: that diagnosis should be certain by radiographic means, treatment should be directed at removing the obstruction if necessary and that if the operation is to be on the urinary tract alone the dissection should be of the renal pelvis rather than of the ureter itself, as described by Harrill and later by Anderson and Hynes. Willard E. Goodwin Division of Urology UCLA School of Medicine Los Angeles, California 1. Kaufman, J. J., Burke, D. E. and Goodwin, W. E.: Abdominal
venography in urological diagnosis. J. Urol., 75: 160, 1956. 2. Anderson, J. C. and Hynes, W.: Retrocaval ureter: a case diagnosed pre-operatively and treated successfully by plastic operation. Brit. J. Urol., 21: 209, 1949. 3. Fujii, Y., Sasabe, S. and Araki, T.: Retrocaval ureter associated with polycystic disease of the kidneys: treated by division and reanastomosis of the vena cava. Acta Urol. Jap., 12: 1422, 1966.
THE JOURNAL OF UROWGY
Copyright © 1979 by The Williams & Wilkins Co.
RETROCAVAL URETER: REPORT OF 8 CASES AND THE SURGICAL MANAGEMENT H. CARRION, J. GATEWOOD, V. POLITANO, G. MORILLO
AND
C. LYNNE
From the Department of Urology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, Florida
ABSTRACT
We present 8 cases ofretrocaval ureter, one of which concerns a unique periureteral venous ring formed by the persistence of the right posterior cardinal vein along with a normal vena cava. Current radiographic concepts are reviewed and the importance of inferior venacavography in the preoperative evaluation for correction of the retrocaval ureter is emphasized. A retrocaval ureter is a congenital venous anomaly, in which the ureter passes behind and is compressed by the inferior vena cava. This condition was first described by Hochstetter in 1893. 1 Usually, the right ureter is involved and male subjects are ?.ffs..:ced more commonly. In 1935 Kimbrough performed the first successful surgical correction. 2 In 1940 Harrill was the first to diagnose the condition preoperatively. 3 Gladstone reported the condition bilaterally. 4 Since excretory urography (IVP) has become practical and common numerous accounts of this rare venous anomaly have been reported. We present our experience with 8 cases. CASE REPORTS
Case 1 . A 16-year-old white boy had acute right flank pain and gross hematuria. He had no prior urological history. The patient was afebrile and normotensive, and had costovertebral angle tenderness on the right side. Laboratory evaluation was unremarkable except for hematuria. An IVP demonstrated delayed excretion on the right side with pyelocaliectasis and ureterectasis of the upper third of the ureter on subsequent films. A combined retrograde pyelogram and venacavogram delineated the retrocaval ureter (fig. 1). The renal pelvis was transected completely above the ureteropelvic junction. The ureter was dissected free of the vena cava and brought around anteriorly. The pelvic anastomosis was then completed with 4-zero interrupted chromic sutures. Convalescence was uneventful. Case 2. A 9-year-old black boy was hospitalized with abdominal pain on the right side 2 months in duration. Other urological symptoms were denied. Physical examination was normal. Laboratory evaluation showed microscopic hematuria. An IVP suggested a right retrocaval ureter and this was confirmed by cystoscopy and retrograde pyelography (fig. 2). The portion of the ureter behind the vena cava was stenotic. The lower ureter was mobilized and the stenotic portion, together with a portion of the renal pelvis above the ureteropelvic junction, was excised. The lateral margin of the ureter was spatulated and sutured to the renal pelvis with interrupted 4-zero chromic catgut sutures. Convalescence was uneventful. An IVP 2 months later showed good function bilaterally and improvement in the dilatation seen preoperatively in the right pelviocaliceal system and pelvis. Case 3. A 23-year-old white man had severe right flank pain and gross hematuria. An IVP was consistent with a retrocaval ureter. Physical examination and laboratory diagnostic studies were within normal limits. After the ureter was excised at the ureteropelvic junction and relocated anterior to the vena cava the 5.0 cm. portion of the ureter behind the vena cava was excised. An end-to-end Accepted for publication July 21, 1978. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 27-31, 1977.
anastomosis was made after both ends were spatulated with interrupted 4-zero chromic sutures. Because of prolonged flank drainage it was necessary to place a ureteral catheter into the right renal pelvis 10 days postoperatively. The flank was dry 8 days later. A followup IVP 21 months postoperatively showed a good result with only minimal dilatation remaining (fig. 3). Case 4. A 17-year-old white boy had acute, painless, gross hematuria. Physical examination and laboratory evaluation were unremarkable, except for gross hematuria. An IVP demonstrated pyelocaliectasis and ureterectasis throughout the upper third of the right ureter. Inferior venacavography showed that the right ureter passed through an unusual venous ring, formed by the persistent right posterior cardinal vein as the anterior portion of the ring. The normal caval derivative, the right supracardinal vein, formed the posterior portion of the ring (fig. 4). The corrective operation consisted simply of ligation and
Fm. 1. Case 1. Combined retrograde pyelogram and inferior venacavogram demonstrates retrocaval ureter.
514
RETROCAVAL URETER
515
Fm. 2. Case 2. A, IVP demonstrates retrocaval ureter. B, retrog-rade pyelogram demonstrates retrocaval ureter
FIG. 4. Case 4. Combined retrograde pyelogram and inferior venacavogram demonstrates unique periureteral venous ring. Fm. 3. Case 3. IVP 21 months postoperatively reveals resolution of upper ureteral dilatation and hydronephrosis.
excision of the anterior ureter. A IVP caliceal dilatation. Case 5. A diabetic woman was treated for urinary retention and referred to the clic_ic, a_nd
urine was clear. An IVP done as an outpatient procedure demonstrated right ureteropelvic junction obstruction in association with findings suggestive of a retrocaval ureter. Diagnosis was confirmed with a simultaneous retrograde pyelogram and inferior venacavogram. The ureter was transected below the ureteropelvic junction and relocated anterior to the vena cava. The renal pelvis was transected above the stenotic w,,,~-~~nn junction, A disrn.ernbered v10.s done
516
CARRION AND ASSOCIATES
Fm. 5. Case 7. A and B, combined IVP and inferior venacavogram demonstrates retrocaval ureter. C, IVP 6 months postoperatively reveals resolution ofhydronephrosis and dilatation of upper ureteral segment.
Case 6. A 59-year-old white woman had had low grade back pain for several months. She denied any history of hematuria or stones. Physical examination and laboratory evaluation were unremarkable. An IVP was considered suggestive of a retrocaval ureter and this was confirmed by retrograd,e pyelography. Because of the patient's age, minimal symptomatology and the absence of significant right ureteral obstruction on the IVP the patient was followed. Case 7. A 24-year-old black man had intermittent abdominal pain on the right side 2 months in duration. Physical examination and routine laboratory studies were unremarkable. An IVP suggested a retrocaval ureter. Inferior venacavography was done in conjunction with simultaneous drip infusion pyelography to confirm the diagnosis (fig. 5, A andB). The right ureter was dissected free of the vena cava. The right renal pelvis was transected above the ureteropelvic junction and the ureter was relocated anteriorly to the vena cava. A dismembered pyeloplasty was then done. A followup IVP 6 months later showed a satisfactory result (fig. 5, C). Case 8. A 9-year-old white boy presented with long-term nocturnal enuresis and urinary frequency. Physical examination revealed meatal stenosis. The diagnosis of retrocaval ureter was made by an IVP and retrograde pyelography. The right ureter was dissected free of the vena cava. The renal pelvis was transected approximately 1 cm. proximal to the ureteropelvic junction. The ureter was relocated anterior to the vena cava and reanastomosed with interrupted 4-zero chromic sutures. Convalescence was uneventful. DISCUSSION
A retrocaval ureter is a rare congenital anomaly. According to Shown and Moore, > 150 cases of this condition have been reported since 1893. 5 Many investigators have discussed the embryological significance of the retrocaval ureter which, strictly speaking, is an anomaly affecting the vena cava and not the ureter.lHl In the majority of patients symptoms are owing to the ureteral obstruction and resulting hydronephrosis. Pain can resemble renal colic but can be intermittent, dull and aching. Hematuria, in varying degrees, is present frequently. The resulting hydronephrosis may be silent and is unmasked by
unrelated clinical events. 10 Many cases of retrocaval ureter were found incidentally on an IVP obtained for unrelated reasons. The diagnosis ofretrocaval ureter is made radiographically. Bateson and Atkinson analyzed 92 cases and found that they could classify 79 cases into 1 of 2 types on the basis of radiographic criteria. 11 Type I, the more common form of retrocaval ureter, has severe or moderate hydronephrosis with extreme medial deviation of the middle ureteral segment, usually medial to the pedicle or across the midline at the L3 level. An S or fish hook deformity is present at the point of obstruction. In type II retrocaval ureter there is mild hydronephrosis and less medial deviation of the ureter. The ureter is noted to be sickle-shaped at the level of the obstruction. A retrograde pyelogram in conjunction with an inferior venacavogram 12 is helpful in cases in which the diagnosis cannot be established from the IVP and retrograde pyelogram. If medial deviation of the middle ureteral segment is lateral to the pedicles, or above or below the L3 level, the possibility of a periureteral venous ring should be considered, as in case 4. SURGICAL CORRELATION
Surgical treatment should be directed toward relieving the obstruction and correcting the underlying anatomical abnormality. Crosse and associates followed 2 asymptomatic cases. 13 Patients with severe hydronephrosis and far advanced cortical atrophy with good function in the opposite kidney should be considered for nephrectomy. Division of the renal pelvis above the ureteropelvic junction with anastomosis after the ureter is relocated anterior to the vena cava was first done by Harrill. 3 The advantage of this approach is in the abundant vascular supply of the pelvis and proximal ureter, compared to the middle third of the ureter. Postoperative stricture at the anastomotic site is less likely. It is helpful to remember that the post-caval segment of ureter may be stenotic. If an SF catheter does not pass through this segment easily then the stenotic section of the ureter must be excised and a dismembered pyeloplasty should be done. Division of the ureter at the ureteropelvic junction, with subsequent ureteropelvic anastomosis, tends to yield a higher incidence of postoperative strictures. 14
517
RETROCAVAL URETER
If the proximal ureteral segment is not dilated and the ureter is impossible to free from the vena cava segmental resection may be indicated. The resultant anastomosis will have a smaller lumen and a greater chance of developing postoperative stricture. Ligation and section of the vena cava without reanastomosis were done successfully by Cathro. 15 Goodwin and associates divided and reanastomosed the vena cava after the ureter was relocated anteriorly . 16 The vascular approach is used if the post-caval portion of the ureter is free of stenosis. In our experience when the ureter assumed a devious course through a vena caval ring excision and ligation of the anterior portion of the ring freed the ureter. If an operation on the vena cava is contemplated preoperative inferior venacavography should be done. Preoperative venacavography might allow for simple excision of an unnecessary duplicated vessel. LePage and Baldwin believe that even superselective branch venography in evaluating ureteral venous anomalies might be useful. 17
Drs. William Chason Hayes, Richard L Fein and Fitzgerald contributed case material. REFERENCES
1. Hochstetter, F.: Beitriige zur Entwickelungsgeschichte des Ve-
2. 3. 4. 5.
5. 7.
nensystems der Amnioten. III. Sauger. Morphol. Jahrb., 20: 543, 1893. Kimbrough, J. C.: Surgical treatment of hydronephrosis. J. Urol., 33: 97, 1935. Harrill, H. C.: Retrocaval ureter: report of a case with operative correction of the defect. J. Urol., 44: 450, 1940. Gladstone, R. J.: Acardiac fetus (acephalus omphalositicus). J. Anat. Physiol., 40: 71, 1905. Shown, T. E. and Moore, C. A.: Retrocaval ureter: 4 cases. J. Urol., 105: 497, 1971. Gruenwald, P. and Surke, S. N.: Pre-ureteric vena cava and its embryological explanation. J. Urol., 49: 195, 1943. Pick, J. W. and Anson, B. J.: Retrocaval ureter: report of a case and discussion of its clinical significance. J. Urol., 43: 672, 1940.
8. Randall, A. and Campbell, E.W.: Anomalous relationship of the right ureter to the vena cava. J. Urol., 34: 565, 1935. 9. McClure, C. F. W. and Butler, E.G.: Development of the vena cava inferior in man. Amer. J. Anat., 35: 331, 1925. 10. Oshin, D. R.: Retrocaval ureter: an unusual complication associated with pregnancy. J. Urol., 91: 652, 1964. 11. Bateson, E. M. and Atkinson, D.: Circumcaval ureter: a new classification. Clin. Radio!., 20: 173, 1969. 12. Presman, D. and Firfir, R.: A diagnostic method of retrocaval ureter. Amer. J. Surg., 92: 628, 1956. 13. Crosse, J.E., Soderdahl, D. W., Teplick, S. K. and Clark, R. E.: Non-obstructive circumcaval (retrocaval) ureter. A report of 2 cases. Radiology, 116: 69, 1975. 14. Rowland, H. S., Jr., Bunts, C. R. and Iwano, J. H.: Operative
correction of retrocaval ureter: a report of four cases and review of the literature. J. Urol., 83: 820, 1960. 15. Cathro, A. J. McG.: Section of the inferior vena cava for retrocaval ureter: a new method of treatment. J. Urol., 67: 464, 1952. 16. Goodwin, W. E., Burke, D. E. and Muller, W. H.: Retrocaval ureter. Surg., Gynec. & Obst., 104: 337, 1957. 17. LePage, J. R. and Baldwin, G. N.: Obstructive periureteric venous ring. Radiology, 104: 313, 1972. EDITORIAL COMMENT The authors, because of an unusually large experience with a relatively rare condition, have had an opportunity to consider all methods of management. They correctly emphasize the importance of the combined venacavogram and retrograde pyelogram in clinching absolutely the diagnosis. 1 Particularly interesting is the case of a unique periureteral venous ring that was formed by the persistence of the right posterior cardinal vein along with the normal vena cava. This may be a unique experience. Most patients were treated by transection of the renal pelvis and reanast~mosis after the retrocaval ureter was placed into its normal position. This procedure, which the British call the Anderson-Hynes operation' and which many Americans call dismembered pyeloplasty, was first reported by Harrill in 1940 (reference 3 in the article). It is ironic that this procedure has come to be called the Anderson-Hynes operation when it was first done by Harrill. The authors correctly indicate that not every patient with a retrocaval ureter needs to be treated surgically. Although none of their patients was treated with an operation on the vena cava itself, instead of on the urinary tract, they mention that it is mandatory that preoperative venacavography should be done if that is planned. It is interesting that the surgical management of retrocaval ureter by division and reanastomosis of the vena cava has not caught on in this country, whereas in Japan it seems to be the favored treatment. Fujii and associates reported the fourth case managed that way in Japan in 1966. 3 These authors emphasize the main points: that diagnosis should be certain by radiographic means, treatment should be directed at removing the obstruction if necessary and that if the operation is to be on the urinary tract alone the dissection should be of the renal pelvis rather than of the ureter itself, as described by Harrill and later by Anderson and Hynes. Willard E. Goodwin Division of Urology UCLA School of Medicine Los Angeles, California 1. Kaufman, J. J., Burke, D. E. and Goodwin, W. E.: Abdominal
venography in urological diagnosis. J. Urol., 75: 160, 1956. 2. Anderson, J. C. and Hynes, W.: Retrocaval ureter: a case diagnosed pre-operatively and treated successfully by plastic operation. Brit. J. Urol., 21: 209, 1949. 3. Fujii, Y., Sasabe, S. and Araki, T.: Retrocaval ureter associated with polycystic disease of the kidneys: treated by division and reanastomosis of the vena cava. Acta Urol. Jap., 12: 1422, 1966.
