Diagnostic Ultrasound - Abdomen and Pelvis
Ureteral Duplication (Left) Longitudinal US demonstrates 2 renal pelves ſt, separated by intervening bridging renal tissue. (Right) Longitudinal US demonstrates 2 exiting ureters ſt compatible with duplication. The upper moiety is hydronephrotic and the lower moiety is also mildly dilated , secondary to vesicoureteral reflux. Diagnoses: Urinary Tract (Left) Longitudinal US demonstrates dysplastic cystic changes ſt of an obstructed upper moiety with loss of the normal corticomedullary differentiation and cortical thinning. (Right) Longitudinal US demonstrates marked dilatation ſt of a lower moiety renal pelvis, shown to be ureteropelvic junction obstruction. (Left) Transverse US demonstrates a round, thinwalled, anechoic structure ſt within the bladder compatible with an ureterocele. (Right) Voiding cystourethrogram demonstrates the drooping lily sign, with opacification of a lower moiety ureter and renal pelvis, with displacement of the normal axis ſt by an obstructed upper moiety. 439
Ureteral Ectopia Diagnoses: Urinary Tract TERMINOLOGY • Strict definition: Ureter that does not terminate at bladder trigone • Common usage: Ureter that terminates outside bladder IMAGING • Best diagnostic clue ○ 70-80% associated with complete ureteral duplication ○ Dilated ureter that extends beyond bladder • Extravesicular insertion ○ Males: Prostatic urethra most common insertion site ○ Females: Vestibule or urethra most common insertion site • Orifice commonly stenotic, leading to obstruction of renal moiety TOP DIFFERENTIAL DIAGNOSES • Bladder diverticulum • Hydrosalpinx KEY FACTS PATHOLOGY • Failure of separation of ureteral bud from wolffian duct results in caudal ectopia CLINICAL ISSUES • Recurrent or chronic urinary tract infections (UTIs) • Females: Continuous dribbling urinary incontinence (50%) due to insertion below external sphincter • Males: Chronic or recurrent epididymitis ○ No incontinence due to insertion above external sphincter • M:F = 1:6 • Females: 80% of ectopic ureters are duplicated systems • Males: Majority associated with single system ectopic ureter (SSEU) DIAGNOSTIC CHECKLIST • Consider diagnosis in female with continuous dribbling urinary incontinence (Left) Graphic shows a dilated upper moiety ureter of a left duplex kidney with extravesicular ectopic insertion into the prostatic urethra. (Right) Graphic shows intravesicular insertion of a ureter from a duplex left kidney with an associated ureterocele. (Left) Longitudinal oblique ultrasound of the left pelvis shows a dilated ureter . There is mild urothelial thickening ſt. (Right) Longitudinal ultrasound of the left kidney shows a fluid-filled thin-walled structure ſt representing the atrophic upper pole moiety of a duplicated system. The lower pole moiety appears normal st. 440
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Ureteral Duplication<br />
(Left) Longitudinal US<br />
demonstrates 2 renal pelves<br />
ſt, separated by intervening<br />
bridging renal tissue. (Right)<br />
Longitudinal US demonstrates<br />
2 exiting ureters ſt<br />
compatible with duplication.<br />
The upper moiety is<br />
hydronephrotic <strong>and</strong> the<br />
lower moiety is also mildly<br />
dilated , secondary to<br />
vesicoureteral reflux.<br />
Diagnoses: Urinary Tract<br />
(Left) Longitudinal US<br />
demonstrates dysplastic cystic<br />
changes ſt of an obstructed<br />
upper moiety with loss of the<br />
normal corticomedullary<br />
differentiation <strong>and</strong> cortical<br />
thinning. (Right) Longitudinal<br />
US demonstrates marked<br />
dilatation ſt of a lower<br />
moiety renal pelvis, shown to<br />
be ureteropelvic junction<br />
obstruction.<br />
(Left) Transverse US<br />
demonstrates a round, thinwalled,<br />
anechoic structure ſt<br />
within the bladder compatible<br />
with an ureterocele. (Right)<br />
Voiding cystourethrogram<br />
demonstrates the drooping lily<br />
sign, with opacification of a<br />
lower moiety ureter <strong>and</strong> renal<br />
pelvis, with displacement of<br />
the normal axis ſt by an<br />
obstructed upper moiety.<br />
439
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