Umar Farouqi DNB Studenr Urology Hyderabad

1. Yashoda
Superspeciality
Hospital Malakpet
Hyderabad.
 Dr.B.Surya Prakash, HOD
Urology
 Dr. D.Kashinatham
 Dr. Umar Farouqi
 Dr.Majid ( SR
Pathology.)

2. • Ureter, Single or Duplex, that does not enter Trigonal area of the bladder.
Duplex system ectopic ureter - upper pole ureter
• Females
bladder neck to the
perineum and into the
vagina, uterus
rectum –
Classic symptoms is continuous wetting.
• Males
vas deferens,
seminal vesicles, or
ejaculatory duct.
No incontinence present
Single-system ectopic ureters similar fashion but with an apparently absent kidney

5. Ureteric Bud -- Mesonephric Duct .
Common Nephric Duct expands and is absorbed into the bladder where
the CND undergoes apoptosis. Ureteral cells merge with bladder epithelia
and undergo a second wave of Apoptosis, generating a new Ureteral
orifice, which in the Bladder Neck.
Growth and expansion of the bladder moves the ureteral orifice, which is
now inserted in the bladder epithelium, farther away from the
mesonephric duct to the final position.
Ectopic ureters can arise due to
 Abnormal timing or location of the primary ureteral budding from the mesonephric ducts,
 Abnormalities at the stage of ureter. would explain the occurrence of these defects with duplicated
systems, particularly the upper pole (later budding) ureter.

6.  Abnormal apoptosis maintain the connection between the Ureter and
the Wolffian duct and prevent incorporation of the Ureter and the UGS.
This defect would produce a ureter attached to the Wolffian remnants in
girls (Gartner duct) or to the vas deferens in boys.
 Abnormal timing of ureteral budding may be one cause of this
dysregulated apoptosis and would explain the occurrence of these
defects with Duplicated systems, particularly the upper pole (later
budding) ureter.
 A lesser defect, either by timing or completeness of the defect, might
explain the ectopic ureter to the urethra distal to the bladder neck in
girls.

10.  Incontinence.
 Vaginal Discharge.
 Flank Soarness.
 Pain .
 Reccurrent UTI.
YOUNG MALE NOT SEXUALLY ACTIVE WITH
EPIDIDOMO-ORCHITIS – RULE OUT ECTOPIC
URETERS.

11. 8 Perineal ectopic ureteral orifice (bottom Gartner duct cyst (bottom right arrow) in
arrow) cannulated with an angiocatheter, situated newborn with a left multicystic dysplastic
between the urethral orifice (top arrow) and the vagina, kidney. B, Injection of the cyst communicated
just to the left of midline. with the ureter and dysplastic kidney.

12. US image will usually provide the anatomic diagnosis Ultrasound image of bladder in a
and permit inference of functional assessment. The typical
findings are dilated upper pole with ureteral dilation or a
child with an ectopic ureter
dilated single system extending into the bladder.

13. Ectopic ureter –Dilated Ectopic Ureter opening
with Abnormal Insertion into Epididymal Cyst

15. Dimercaptosuccinic acid renal scan in a child with a ureterocele
Dimercaptosuccinic acid renal scan in a child with evidence of upper pole function after transurethral incision to
decompress the ureterocele. The upper pole was separately
with a left ureterocele demonstrating no assessed as contributing approximately 18% of total renal
function in the affected upper pole. function.

16. Endoscopic views of the bladder neck and the ectopic
ureteral orifice marked by the arrow. Bladder neck
ectopic ureteral orifices are often patulous but do not
Endoscopic images of the bladder
always reflux. neck orifices of an ectopic ureter

17. Preservation of renal function; elimination of infection, obstruction,
and reflux; and maintenance of urinary continence.
For both ectopic ureter and ureterocele associated with a duplicated
system, a primary concern is the preservation of functional renal
parenchyma.
Decision making for renal parenchymal preservation is largely
empirical, and there are few objective criteria to indicate how much
residual function is worth preserving.
For an ectopic ureter, this can mean common sheath reimplantation
or ureteroureterostomy, either low or proximal near the renal pelvis.

18.  Maintain the upper pole of a duplex system then the surgical approach
depends on the presence of reflux in the lower pole; if present, a common
sheath reimplantation or a lower pole reimplantation with distal upper to
lower pole ureteroureterostomy is performed.
 If there is no lower pole reflux, either proximal or distal
ureteroureterostomy is performed
 . If the degree of function is ambiguous, a temporary end ureterostomy can
be used to permit assessment out of the acute setting, particularly with a
massively dilated ureter
 Preference for removal of nonfunctioning, dysplastic tissue, an upper pole
nephrectomy is performed.
 For the single-system ectopic ureter, preservation or removal is also based
on degree of function and surgeon preference.

19.  Total no. of cases operated = FIVE.
 Ectopic ureters = 2.
 Uretero-Lithotomies=2.
 Nephrectomy Non Functional Kidney=1.

20. A 26yr old female presented with
 Cramping Left Flank Pain and Fever for one week.
 Repeated Urinary Tract Infection
 Intermittent left flank Soareness for several years.
Laboratory tests
 Normal renal function
 Numerous white and red blood cells in urine.
 Urine culture showed E. coli
Imaging
• A plain radiograph of abdomen discerned no radio opaque lesion.
• Left hydronephrosis was seen on renal sonography.

23.  Non Functional Nature of the Upper Moity led
to the decision of Upper Partial Nephrectomy.
 Laproscopic Upper Partial Nephrectomy was
done.
 Duration of Surgery : 189 minutes.

29.  Oral intake and ambulation were resumed on
postoperative day 1.
 Fever and pain subsided.
 The right subcostal drain was removed 15 days
after the operation when the daily output was
< 20 mL.
 Follow-up renal ultrasonography demonstrated no
urinoma.

31. Section of Abnormal Section of Abnormal
Pelvis Ureter

32. An Ectopic Ureter and Duplex Kidney are rarely presented in
adults.
In treating an adult with Recurrent Urinary Tract infections,
this condition should be included in the differential diagnosis.
Contrast enhanced CT abdomen provides an excellent
diagnosis modality being easily available and less time
consuming modality.
A Pure Trans-peritoneal Laparoscopic
Hemi-nephroureterectomy is a safe and Feasible Procedure.