retrocaval ureter

1. RETROCAVAL URETER –
Etiology, Diagnosis, Management
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.

3. Introduction
❑Circumcaval/ Retrocaval ureter/ Preureteric Vena Cava describes the abnormal
course of the proximal ureter surrounding along the posterior circumference of the
inferior vena cava (IVC) first (from normal lateral positioning to abnormal medial
positioning) and then gradually going back to normal lateral positioning in its later
course.
❑Hoechstetter first described it in 1893.
❑Retrocaval ureter is a rare entity where the course of the ureter becomes posterior
to the inferior vena cava at the level of L3–L4
❑It occurs as a result of the persistence of the subcardinal veins.(by Shulman in 1997)
❑aberration in the development of the inferior vena cava rather than ureter.

4. ❑The normal type of postrenal vena cava that is found in 97.6% of cadavers,
result of persistence of the right supracardinal vein.
❑Result of inferior vena cava developing from the subcardinal system (which lies anteriorly to
the ureter during the foetal life) instead of the supracardinal system (which lies posteriorly).
❑Anomalies arise from persistence of three other embryonic veins: right subcardinal, left
supracardinal, and left subcardinal.
❑Although it has been calculated that 15 possible patterns could result from combinations of
these three persistent veins
❑the only anomalies found in cadavers are persistence of the right subcardinal vein
(retrocaval ureter) and left supracardinal vein.

7. ❑Nearly all retrocaval ureters involve the right ureter, and left retrocaval ureter is
extremely rare (partial or complete situs inversus or duplication of the IVC)
❑Its prevalence is around 1:100 live births
❑incidence of circumcaval ureter is 1 in 1100
❑ is more common in males. (3:1)
❑presents in the third to fourth decades of life

8. Clinical presentation
❑About 80% of cases are symptomatic
❑Right flank pain being the most common symptom occurring in about 70% of cases
❑ haematuria, UTI, or urolithiasis

9. Associated congenital anomalies
Approximately 20% of the patients with retrocaval ureter may have accompanying
congenital abnormalities
❑solitary kidney, contralateral renal hypoplasia or ectopia, horseshoe kidney, aberrant
renal artery
❑Turner’s syndrome, Goldenhar syndrome
❑retroperitoneal fibrosis, polycystic disease of the kidneys, nutcracker symdrome
❑ureterocele, ureteropelvic junction obstruction
❑genital malformation (hypospadias)
❑duplicated IVC, situs inversus
❑ intestinal malrotation, cardiovascular anomalies (coarctation of the aorta,
pulmonary venous stenosis) and myelomeningocele

11. DIAGNOSIS
❑Ultrasound shows hydronephrosis along with proximal ureteric dilatation.
❑hydronephrosis may be due to- kinking of the ureter, a ureteric segment that is
adynamic or compression against the psoas muscle.
❑IVU usually does not demonstrate the middle and distal ureter requiring a
retrograde ureteropyelogram(RGP) to demonstrate the ureter and hence confirm the
diagnosis.
❑On EU or RP, an abrupt medial course of a right proximal ureter segment arriving at
a point medial to the ipsilateral lumber pedicle should raise the suspicion RCU.

12. ❑intravenous urogram (IVU) - ‘S Shaped’ or ‘sickle shaped’ curve of the ureter, with
the point of obstruction coinciding with the lateral margin of the inferior vena cava
Types : (1982, Bergman)
1) Moderate to severe hydronephrosis with ‘S’ or ‘fishhook’ deformity of the ureter
at the point of obstruction. The point of obstruction has some distance from the lateral
margin of the IVC. RCU goes behind the IVC at the third or fourth lumbar vertebral body
level(Low loop) – common
2) Mild hydronephrosis with ‘sickle‐shaped’ curve of the ureter at the point of
obstruction. The obstruction coincides with the lateral margin of the inferior vena cava.
RCU passes behind the IVC at the level of the renal pelvis(high loop)

14. EU at 10 min after contrast medium
administration shows delayed
opacification of the right urotract
with right hydronephrosis ( arrow) .
The right ureter is not opacified

15. EU at 30 min after contrast medium
administration shows opacification
of the dilated right renal collecting
system ( arrow) and right proximal
ureter ( arrowhead) . Note the right
proximal ureter has an abrupt
medial deviation course

16. right RP shows an abnormal course
( arrow ) of the most proximal part
of the right ureter before its
passage behind the inferior vena
cava (IVC).
The right proximal ureter then goes
medially abruptly and becomes
medial to the right pedicle at the L4
body level.

17. ➢CT Urography is now the method of choice for diagnosis;
➢it is the most efficacious and least invasive method of confirming the diagnosis,
➢ it allows the differential diagnosis of ureteral obstructions due to an acquired
retroperitoneal pathology, especially malignant tumors and retroperitoneal fibrosis.
➢Compared to CT Scan, MRI is equally good, has no radiation risk, and does not
require an iodinated contrast. (preureteric venacaval course)
➢MAG3 renogram confirms the degree of obstruction.
➢Renal scan can assess the degree of obstruction (DTPA), as well as the renal function
(DMSA), and may be used for the follow up of asymptomatic patients with retrocaval
ureter

18. A) CT image shows the right proximal
ureter ( arrow ) coursing from a medial
position to a posterior position of the
inferior vena cava (IVC). There is a right
renal calyceal stone ( arrowhead ).
B) 0.5 cm caudal to Fig. A, shows the
most proximal segment of the right ureter
( arrow ) located medial to the IVC and
another segment ( arrowhead) going
from posterior to posteromedial position
relative to the IVC.
C) shows the right proximal ureter ( arrow
) coursing from the posteromedial to
medial side of the IVC. There is dilatation
of right calyces ( arrowhead) .
D) at the pelvic cavity shows a right
middle ureteral stone ( arrow ),
accounting for right urotract obstruction.

21. MANAGEMENT
➢The first successful open dismembered pyeloplasty, published by Anderson and
Hynes in 1949, was performed on a retrocaval ureter.
➢ In 1994, Baba et al. were the first to report a successful laparoscopic pyeloplasty for
a retrocaval ureter

22. patients with persistent symptoms of obstruction, or with radiological evidence of renal
damage need intervention.
Includes:
1. Resection of the ureter with re-anastomosis.
2. Resection of the ureter with excision of the postcaval section – which may be stenotic –
and re-anastomosis.
3. Division of the vena cava with subsequent reanastomosis after release of the retrocaval
ureter
4. Renal transplantation.

23. Pyeloureterostomy or ureteroureterostomy can be done and the approach may be
open, laparoscopic transabdominal/ retroperitoneoscopic/robotic.
The classical treatment for retrocaval ureter consists of,
❑division of the ureter and repositioning it anterior to the inferior vena cava
❑ anastomosis between the renal pelvis and the ureter or a uretero-ureteric
anastomosis over a double-J stent.
❑ The segment behind the inferior vena cava which may be aperistaltic is either
excised or left in situ

24. Laparoscopic repair
❑ advantages - is less blood loss during surgery, shorter hospital stay, less
postoperative pain and superior esthetic results.
❑Intracorporeal anastomosis of the ureter remains the main limiting factor
Intracorporeal anastomosis of the ureter remains the main limiting factor.

25. ❑10-mm camera port was placed at the umbilicus level on the lateral rectus border.
❑A 10 mm working port was placed 1 cm below the costal border on the midclavicular line
❑a 5 mm port at a point on the lateral one-third of the line between the anterior superior iliac
spine and the umbilicus.
❑ 5-mm fourth trocar was placed for traction on midaxillary line at the level of the umbilicus
❑ incision of the Toldt line
❑Separate dilated proximal renal pelvis and ureter from the adjacent tissue by a blunt and sharp
dissection
❑Traction of the proximal ureter by a stich of the renal pelvis through the abdominal wall,
❑release of the ureteral segment beneath the inferior vena cava
❑Transect dilated renal pelvis at the ureteropelvic junction
❑Separate the ureter from the inferior vena cava and position anterior to it.
❑anastamose dilated renal pelvis (pyelopyelostomy) with 4-0 vicryl intracorporeal sutures
inserted in a continuous manner posteriorly and interrupted sutures anteriorly after the
introduction of the proximal curve of the double J stent inserted before the surgery.

28. whether to resect or preserve the retrocaval segment of the
ureter ?
➢radiologic findings and intraoperative appearance of the ureter are useful
➢preserve, if segment has normal appearance, without considerable kinking
➢with each ureteral peristalsis, the upper ureter should not dilate further
➢ peristaltic movement should be seen throughout the entire length of the retrocaval
segment.
➢ In such cases, it is preferred to transect the ureter at the lower part of the dilated
ureter, lateral to the IVC.
➢This makes the anastomosis to have ample blood supply and decreases the
probability of stricture formation
➢If doubtful, transect the ureter medial to the IVC and resect the upper stump until a
non-kinking dilated ureter and urine flow are clearly detected.

29. ➢approximately 1-cm spatulation of the lower ureteral stump and, in selected cases,
of the upper ureteral stump is recommended
➢Transperitoneal approach: larger operation field, more familiar approach
➢Retroperitoneal approach: safer, more direct approach to the urinary tract and the
shorter time, less chance of urine leaking into the peritoneum
Robotic-assisted laparoscopic surgery:
➢eases the dissection and intracorporeal suturing and knotting.
➢superior ergonomics, 3-dimensional optical magnification of the operative field

30. Operative time reduction
❖ running sutures for anastomosis (eliminating much intracorporeal knot tying)
❖ intraoperative placement of a Double-J® stent (thus, forgoing preliminary
cystoscopy, guide wire or stent placement and patient repositioning) contributed
significantly to a shorter operative time

31. THANK YOU…