Diagnostic Ultrasound - Abdomen and Pelvis

Ureteral Ectopia
Diagnoses: Urinary Tract
• Evidence of color Doppler flow
Fluid-Filled Bowel Loop
• Active peristalsis and change in configuration during realtime
scanning
Seminal Vesical Cyst
• Lateral to bladder base, superior to prostate
• Associated with ipsilateral renal agenesis
• May contain internal echoes from debris or hemorrhage
• EU may drain into seminal vesicle
Urachal Cyst or Diverticulum
• Midlineand supravesical
• Tubular or spherical and fluid filled
Müllerian, Ejaculatory Duct, and Utricular Cysts
• Midline, posterior and inferior to bladder, not tubular
PATHOLOGY
General Features
• Etiology
○ Congenital: Abnormal ureteral bud migration
– Failure of separation of ureteral bud from wolffian
duct
– EU is situated along path of wolffian duct
– Caudal to normal ureteral insertion
• Associated abnormalities
○ Hypoplasia or dysplasia of renal moiety drained by EU
– Degree of ureteral ectopia correlates with degree of
renal abnormality
○ Urethral duplication, hypospadias, cloacal abnormalities
○ VACTERL spectrum including imperforate anus,
tracheoesophageal fistula
Gross Pathologic & Surgical Features
• SSEU: Absent ipsilateral hemitrigone
• Distance from trigone correlates with degree of renal
dysplasia
Microscopic Features
• Muscularis of ectopic ureteral wall may have ultrastructural
abnormalities
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ 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
○ May be asymptomatic
Demographics
• Age
○ Age at diagnosis varies widely
○ Some cases not detected during life
○ Many cases diagnosed with prenatal ultrasound
• Gender
○ M:F = 1:6
○ Females: 80% of EUs are duplicated systems
○ Males: Majority associated with SSEU
○ SSEUs more common in males
• Epidemiology
○ Incidence: At least 1 in 1,900
○ True incidence uncertain since many cases asymptomatic
Natural History & Prognosis
• Most EUs drain single kidneys, which tend to be hypoplastic
or dysplastic or upper pole moieties with minimal function
Treatment
• Surgery depends on function and whether system is
duplicated
• EU with duplicated system: Partial upper pole nephrectomy
• SSEU: Nephrectomy if minimal function
• If renal function preserved or if diagnosis is made
prenatally: Ureteropyelostomy or common sheath ureteral
implantation
DIAGNOSTIC CHECKLIST
Consider
• EU in female with continuous dribbling urinary incontinence
Image Interpretation Pearls
• Dilated ureter extends beyond bladder trigone
• 70-80% associated with complete ureteral duplication
SELECTED REFERENCES
1. Figueroa VH et al: Utility of MR urography in children suspected of having
ectopic ureter. Pediatr Radiol. 44(8):956-62, 2014
2. Ehammer T et al: High resolution MR for evaluation of lower urogenital tract
malformations in infants and children: feasibility and preliminary
experiences. Eur J Radiol. 78(3):388-93, 2011
3. Roy Choudhury S et al: Spectrum of ectopic ureters in children. Pediatr Surg
Int. 24(7):819-23, 2008
4. Wille S et al: Magnetic resonance urography in pediatric urology. Scand J
Urol Nephrol. 37(1):16-21, 2003
5. Berrocal T et al: Anomalies of the distal ureter, bladder, and urethra in
children: embryologic, radiologic, and pathologic features. Radiographics.
22(5):1139-64, 2002
6. Damry N et al: Ectopic vaginal insertion of a duplicated ureter:
demonstration by magnetic resonance imaging (MRI). JBR-BTR. 84(6):270,
2001
7. Staatz G et al: Magnetic resonance urography in children: evaluation of
suspected ureteral ectopia in duplex systems. J Urol. 166(6):2346-50, 2001
8. Engin G et al: MR urography findings of a duplicated ectopic ureter in an
adult man. Eur Radiol. 10(8):1253-6, 2000
9. Gylys-Morin VM et al: Magnetic resonance imaging of the dysplastic renal
moiety and ectopic ureter. J Urol. 164(6):2034-9, 2000
10. Livingston L et al: Seminal vesicle cyst with ipsilateral renal agenesis. AJR Am
J Roentgenol. 175(1):177-80, 2000
11. Cabay JE et al: Ectopic ureter associated with renal dysplasia. JBR-BTR.
82(5):228-30, 1999
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