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|Year : 1986 | Volume
| Issue : 4 | Page : 233-5
Blind ending bifid ureter (a case report).
Rege VM, Deshmukh SS, Borwankar SS, Gandhi RK
|How to cite this article:|
Rege V M, Deshmukh S S, Borwankar S S, Gandhi R K. Blind ending bifid ureter (a case report). J Postgrad Med 1986;32:233
A bifid ureter with a blind-ending branch is a rare form of partial duplication of ureter. Less than 70 of these have been reported till now, although they occur considerably less infrequently than the published data indicates. These duplications may be familial and the position of the ureteral orifice often indicates a possible dysplasia in an upper segment. It is seldom that ureteral duplications end blindly. Sometimes they are short, without the presence of reflux and are minimally symptomatic. However, patients with long blind ending duplications can present with severe infection and reflux, hence they require extensive surgery.
These blind ending ureteric duplications have to be differentiated from ureteral diverticula by the criteria laid down by Culp. These congenital anomalies are diagnosed three times more frequently in women than in men and twice as common on the right side.
The following is a case report of a left-sided blind-ending bifid ureter which was diagnosed pre-operatively and subsequently excised, in a 9 year old boy.
A 9 year old boy weighing 24 kg presented to us with the complaint of hematuria for the past 3 months only. He did not have any history of dysuria, pyuria or burning micturition. Hematuria began 3 months prior to presentation, and he would pass red coloured urine in the early morning, after which the urine colour would clear up by itself. There was no history of passage of stones in the urine or clots at any time. nor any trauma to the abdomen or loin in the recent past. He had not lost weight or appetite during these 3 months, nor had any puffiness of the face.
The general and systemic examination did not reveal any significant positive finding.
The routine investigations were also normal and the plain X-ray KUB did not show anything positive. An intravenous pyelogram was done which showed prompt excretion and good concentration of dye on both sides. Both the kidneys were normal in shape, size, position and axis. The left upper pole showed an increased parenchymal thickness. On the right side the pelvi-calyceal system and ureter were normal, but on the left side, the ureter was seen to be duplicated upto the left ischial spine where the two joined again [Fig. 1]. The upper third of the double ureter was not demonstrated; the contrast was present in the distal part of this ureter due to the uretero-ureteral reflux (yo-yo phenomenon). The other plates were normal. Thinking in terms of a left-sided duplication a cystoscopy was done on this patient, and we found a hypertrophied bladder neck with the presence of edema and turbid urine within the bladder. There was a single left-sided ureteric orifice which was catheterised following which we did a retrograde pyelography [Fig. 2]. This showed a blind ending ureter with a slight dilatation at. the tip like a bulb.
The patient was explored under general anaesthesia in a right lateral position through a left-sided oblique muscle cutting retroperitoneal approach about 4 cm above the left. anterior superior, iliac spine extending upto the iliac fossa. After identifying the lower: pole of the left kidney and the psoas muscle, the two left-sided ureters were identified which were seen to be lying side by side, having a common blood supply and within a common sheath. The upper end of the ureter ending blindly was identified and dissected from the second normal ureter by removing the sheath and preserving the blood supply to the normal meter. The blind ureter was dissected upto close to the bladder where it was ligated, and then cut and removed. The stump was closed with interrupted 4/0 catgut sutures. After keeping a drain, the wound was closed. The post-operative course was uneventful and the patient was discharged after 8 days.
On gross examination, the specimen of the h1ind ureter was 10 cm long, thin and had a smooth surface with bulb like expansion at the upper end. Histopathological Sections from the blind, thin ureter showed flat transitional mucosal lining and a few smooth muscle fibres in the wall. There was no significant inflammation, and them vas an absence of any nephrogenic tissue. The vesical end of the ureter however showed mild inflammation.
A bifid ureter with a blind-ending branch is an uncommon form of partial duplication of the ureter. Till 1986. only 70 cases of this anomaly have been reported and detailed sufficiently to fit the criteria recommended by Culp which are: "any blind ending hollow structure whose lumen join,, that of the ureter at a distinct angle, whose wall presents the same histologic coats as the ureter, and whose length is more than twice its greatest diameter''.
Embryologically, it would appear that double ureteral orifice represents a dual ureteral bud. When there is a single ureteral orifice and a long bifid ureter is present, a ureteral bud-branching defect is implicated. For reasons that are not cleat there is no union of the blind ureteral bud with the metanephric blastoma in utero. Although the X junction in the bifid type may be at any level, most are found in the mid or distal ureter (like in the present case). Blind ending ureters are diagnosed three times more frequently in women than in men, and are twice as common on the right side.
Many of these blind segments cause no problems, and are asymptomatic. Symptomatic patients mostly complain of vague abdominal pain or flank pain, at times complicated by infection or calculi or both. Majority of cases are not diagnosed till the third or fourth decade of life. As the blind segment does not always fill on excretory urography, retrograde pyelography may be required for diagnosis. At times, however, urinary stasis from disturbed persistalsis (uretero-ureteral reflux) may be demonstrated, with secondary dilatation of the branch and this is felt by some to be the cause of the pain.
Anatomically, the blind ends tend to have a bulbous dilatation. Most of these blind segments are not surrounded by am abortive renal tissue, but in a few, there is a fibrous stalk extending into a dysplastic renal segment. The blind limb varies from few cm to one extending all the way into the renal fossa. The area of union between the two limbs is invested in a common sheath that may be attenuated proximally. Devascularisation of the remaining ureter is always a concern to the surgeon. Rather than dividing totally the common ureteral sheath, one can incise distally the common sheath on its lateral surface and by careful dissection, pull the blind ending ureter through this hole in the common sheath, preserving much of the common sheath of the two ureters. Reflux often occurs with ureteral duplication and long blind ending duplications appear to have a high incidence of reflux.
When surgery is required, excision of the blind segment is indicated; and since the ensheathment is less dense at the upper or proximal end, the dissection should start there and care should be taken to denude only the blind segment and not enter the normal ureter.
We thank the Dean, K.E.M. Hospital and Seth G. S. Medical College, Bombay 400 012 for allowing us to publish the data.
|1.||Albers, D. D., Geyer, J. R. and Barnes, S. E.: Blind ending branch of bifid ureter: report of 3 cases. J. Urol., 99: 160-164, 1968. |
|2.||Albers, D. D., Geyer, J. R. and Barnes, S. E.: Blind ending branch of bifid ureter: report of 3 more cases. J. Urol., 105: 634-637, 1971. |
|3.||Culp, O. S.: Ureteral diverticulum: classification of the literature and report of an authentic case. J. Urol., 58: 309-321, 1947. |
|4.||Langhan, D.: Bifid ureters in children: anatomical, physiological and clinical study. J. Urol., 87: 808-817, 1962. |
|5.||Marshall, F. F. and McLoughlin, M. G.: Long blind ending ureteral duplications. J. Urol., 120: 626-630, 1978. |
|6.||Perlmuttor, A. D., Retic, A. B. and Bauer, S. B.: Anomalies of the upper urinary tract. In "Campbell's Urology." Vol. 2, 5th edition. Editors: P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey, W. B. Saunders Company, Philadelphia, 1986, pp, 1723-1724. |