4. Genitourinary (Ureters)

Question 1

Normal anatomy (3)

Answer 1

Ureters run anterior to psoas muscle.
Empty at lateral angles of the bladder trigone.
3 layers, inner layer being transitional epithelium

Question 2

Congenital (primary) megaureter (6)

Answer 2

Generic term for enlarged ureter not due to distal obstruction.
Causes
- Distal adynamic segment (analogous to achalasia)
- reflux at UVJ
- Idiopathic.
Distal adynamic type “Obstructing primary megaureter” can have hydronephrosis. Otherwise absence of hydro differentiates this from obstruction.
Usually unilateral (usually left) and usually distal 1/3.

Question 3

Retrocaval ureter (circumcaval) (3)

Answer 3

Developmental anomaly of the IVC.
Mostly asymptomatic, but can cause partial obstruction and recurrent UTI.
IVP will show “reverse J” or “fishhook” appearance of ureter

Question 4

Duplicated system (3)

Answer 4

Weigert-Meyer Rule: upper pole inserts inferior and medially.
Upper pole is prone to uretercele formation and obstruction.
Lower pole is prone to reflux.

Question 5

Ureterocele (4)

Answer 5

cystic dilation of intravesicular ureter, due to obstruction at ureteral orifice.
IVP: Cobra Head sign, contrast surrounded by a lucent rim, protruding from the contrast filled bladder.
Associated with duplicated system (specifically upper pole).
Best demonstrated during early filling phase of VCUG.

Question 6

Pseudoureterocele (3)

Answer 6

acquired dilatation of submucosal portion of distal ureter.
Loss of normal lucent line around the “cobra head” suggests pseudoureterocele.
Causes: Impacted stone, recently passed stone, bladder malignancy.

Question 7

Ectopic ureter (2)

Answer 7

Ureter inserts distal to external sphincter in the vestibule.
more common in females, associated with incontinence in women.

Question 8

Vesicoureteric reflux (3)

Answer 8

Retrograde flow of urine.
Course of ureter is too short as it crosses the bladder, messing with ureteral valve mechanism.
Usually seen in kids.

Question 9

Congenital UPJ obstruction (5)

Answer 9

Most common congenital GU abnormality in neonates.
20% bilateral
Most caused by intrinsic defects in circular muscle bundle of renal pelvis.
Rx: Pyeloplasty.
Associated with vessels crossing the UPJ can change management (early branching lower pole vessels compress the ureter).
Associated with Multicystic Dysplastic Kidney on other side.

Question 10

Prominent extrarenal pelvis vs congenital UPJ obstruction

Answer 10

Whittaker test: Urodynamics study combined with antegrade pyelogram

Question 11

Ureteric calculi

Answer 11

Tend to lodge in 3 spots: UPJ, UVJ, Pelvic brim

Question 12

Ureteric wall calcification (2)

Answer 12

2 main causes
- TB
- Schistosomiasis

Question 13

Ureteritis cystica (3)

Answer 13

Numerous tiny subepithelial fluid filled cysts within the wall of the ureter.
Due to chronic inflammation (stones, infection).
Seen in diabetics with recurrent UTI. May be increased risk of cancer

Question 14

Ureteral pseudodiverticulitis (3)

Answer 14

Similar to ureteritis cystica, both due to chronic inflammation.
Multiple small outpouchings.
75% bilateral, favouring upper and middle third.
Associated with malignancy

Question 15

Leukoplakia (4)

Answer 15

Squamous metaplasia secondary to chronic inflammation.
Bladder more commonly involved than ureter.
Imaging shows mural filling defects.
Considered premalignant to squamous cell cancer (NOT TCC)

Question 16

Malacoplakia (7)

Answer 16

Inflammatory condition in setting of chronic UTI. Associated with E.Coli.
Often in female, immunocompromised patients.
Plaque-like or nodular intramural lesions, where pathogens are incompletely digested.
Usually manifests as a mucosal mass involving the ureter or bladder, so commonly causes obstruction.
buzzword “Michaelis-Gutmann Bodies”
Bladder more commonly affected than ureter.
NOT premalignant, will improve with antibiotics.

Question 17

Retroperitoneal fibrosis (6)

Answer 17

Proliferation of aberrant fibro-inflammatory tissue, usually surrounds aorta, IVC, iliac vessels and frequently the ureters, causing obstruction.
Idiopathic in 75% (Ormond Disease).
Other causes
- Prior radiation
- Medications (methyldopa, ergotamine, methylsergide)
- Inflammatory (pancreatitis, pyelonephritis, inflammatory aneurysms)
- Malignancy (desmoplastic reaction, lymphoma)

Question 18

Retroperitoneal Fibrosis - trivia (6)

Answer 18

Associated with IgG4 disorders (autoimmune pancreattis, reidels thyroid, inflammatory pseudotumour).
Classically medial deviation of ureters.
More common in men.
Malignancy associated retroperitoneal fibrosis occurs about 10% of cancers.
Fibrosis is Gallium avid, PET hot in early stages and cold in late stages.
Metabolically active disease will show increased FDG and Gallium uptake, regardless of benign or malignant underlying cause.

Question 19

Transitional cell carcinoma - basics (2)

Answer 19

90% of collecting system cancer.
“Goblet” or “Champagne glass sign” on CT IVP.

Question 20

TCC - risk factors (8)

Answer 20

Smoking
Azo dyes
Cyclophosphamide
Aristolochic Acid (Balkan Nephropathy)
Horseshoe kidney
Stones
Ureteral pseudodiverticulitis
HNPCC (type 2)

Question 21

TCC - trivia (7)

Answer 21

Ureter is least common location of urinary tract TCC
TCC of renal pelvis us 2-3x more common than ureter
TCC of bladder is 100x more common than ureter
75% of TCC in ureter is in bottom 1/3
Upper tract TCC confers 40% chance of developing bladder TCC
Bladder TCC confers 4% chance of developing renal pelvis or ureteral TCC.
5% of Ureteral TCC is bilateral

Question 22

Balkan Nephropathy (3)

Answer 22

Degenerative neuropathy endemic to Balkan regions.
Has high association with renal pelvis and upper ureter TCC.
Secondary to eating Aristolochic Acid in seeds of Aristolochia Clematitis plant

Question 23

Squamous cell Ca (2)

Answer 23

Much less common than TCC in the West.
Major predisposing factor us Schistosomiasis

Question 24

Haematogenous mets (2)

Answer 24

Mets to ureters are rare, but occur (GI, prostate, renal, breast).
Typically infiltrate the periureteral soft tissues and demonstrate transmural involvement.

Question 25

Fibroepithelial polyp (2)

Answer 25

Benign, usually located in proximal ureter.
Produces smooth, oblong, mobile defect on urography.

Question 26

Medial deviation vs Lateral deviation of ureters (7)

Answer 26

Medial:
- aka waisting of ureters
- Retroperitoneal fibrosis
- Retrocaval ureter (right)
- Pelvic lipomatosis
- Psoas hypertrophy (distal ureter)
Lateral:
- Retroperitoneal adenopathy.
- Aortic aneurysm
- Psoas hypertrophy (proximal ureter)