Ureter

Question 1

Define intrinsic UPJO

Answer 1

area of ureter lacking peristalsis secondary to collagen deposition or poor circular musculature; also could be due to mucosal folding

Question 2

Define extrinsic UPJO

Answer 2

aberrant, lower pole vessel crosses anteriorly to the ureter causing it to kink

Question 3

Tx of choice for UPJO in peds; adults?

Answer 3

Peds = pyeloplasty

Adults: endopyelotomy if etiology is not due to a lower pole vessel

Question 4

What factors determine success rate for endopyelotomy for UPJO in adults

Answer 4

No lower pole crossing vessel
Good renal function
Stricture segment < 2cm
Mild-moderate hydronephrosis

Question 5

If your surgery fails to correct the UPJO, what is the next step?

Answer 5

Endopyelotomy fails –> pyeloplasty or vice versa

If both fail, or pyeloplasty is failed with a long stricture, consider ureterocalicostomy

Question 6

What is Dietl’s Crisis?

Answer 6

Someone with UPJO has renal colic secondary to diuresis, such as alcohol ingestion

Question 7

What is a bifid ureter/ureter fissus?

Etiology?

Answer 7

It’s where 2 ureters insert the renal pelvis (duplex kidney) with a solitary, shared ureteral orifice

Due to partial division of ureteric bud prior to contacting the metaneprhogenic blastema

Question 8

What is a duplicated ureter?

Etiology?

Answer 8

2 ureters at the renal pelvis with 2 completely separate ureters with their own UO’s

Due to complete division of the ureteric bud prior to contact with the metanephrogenic blastema

Question 9

What is the Weigert-Meyer rule?

Answer 9

Upper pole ureter associated with ureterocele (obstructs), is ectopic, and the UO is inferior-medial

Lower pole ureter associated with VUR and UPJO, and the UO is superior-medial

Question 10

What imaging test can be done to determine function of each renal unit/segment in a duplicated system?

Answer 10

MAG3 scan

Question 11

In a duplicated system, what is the treatment if symptomatic obstruction and segment has minimal function?

Answer 11

Partial nephrectomy

Question 12

In a duplicated system, what is the treatment if symptomatic obstruction but kidney has function?

Answer 12

Treat the obstruction (ureterocele ablation or pyeloplasty for UPJO)

Question 13

In a duplicated system, what is the treatment if asymptomatic but kidney segment has minimal function?

Answer 13

Observe

Question 14

Define ectopic ureter:

Answer 14

UO not located within bladder trigone

Question 15

In females, an ectopic ureter will never directly insert into a _____ structure, but rather into associated ____ duct remnants.

Answer 15

promesoneprhos structure (Mullerian)

inserts into a mesonephos (Wolffian) structure

Question 16

How do females commonly present with ectopic ureter?

Answer 16

continuous incontinence, as ureter can be distal to the spincter/bladder neck, vagina, or rectum

Question 17

In males, where can ectopic ureters insert?

Answer 17

anywhere from bladder neck to the proximal extent of external sphincter

*males never have incontinence with ectopic ureters b/c it will always insert proximal to the external sphincter

Question 18

Treatment for ectopic ureter?

Would you ever separate a duplicated or bifid ectopic ureter?

Answer 18

Ureteral reimplantation (ureteroneocystostomy)

NEVER separate ureters, as this will injure ureteral vasculature

Question 19

Etiology of ureterocele?

Answer 19

Cystic dilation in a distal ectopic ureter due to persistent Chwalla’s membrane

Question 20

What is a cecoureterocele?

Answer 20

the portion of the ureterocele that extends into the urethra

- hard to diagnose and treat

Question 21

What study/test is required before surgically treating a ureterocele?

Answer 21

VCUG

Question 22

IVP or CT urogram or CT cystogram, what is the buzzword for the appearance of a ureterocele (contrast within the ureterocele and not contrast surround it)

Answer 22

Cobra-head appearance

Question 23

Study of choice to dx a ureterocele in pediatrics?

Answer 23

bladder ultrasound

- will have hydronephrosis (upper pole if duplex system)

Question 24

What are the various treatment options for a ureterocele?

What should one do to the patient prior to definitive treatment?

Answer 24

Transurethral incision
Excision of ureterocele with ureteral reimplantation
Upper pole nephroureterectomy if non-functioning
Ureteroureterostomy

Patient should be given prophylactic antibiotics

Question 25

Is a retrocaval ureter a problem with the urogenital development or problem with vascular development?

Answer 25

Vascular development (persistent cardinal veins)

Question 26

Define megaureter:

Answer 26

non-specific term for severely dilated ureter > 7-8mm

Question 27

Primary megaureter is due to what?

Treatment?

Answer 27

intrinsic ureteral abnormality leading to lack of peristalsis

Tx: majority resolve; check renal ultrasound at puberty

Question 28

If primary megaureter needs surgical fixation, how should it be fixed?

Answer 28

distal remodeling to allow a 5:1 tunnel length-to-diameter ratio to prevent reflux; plication for moderate hydronephrosis, excision tapering for severe hydro

Divide the medial umbilical ligament (obliterated umbilical artery) as it loops lateral to posterior the ureter, thus eliminating possible ureteral obstruction

Question 29

What is secondary megaureter?

Answer 29

megaureter due to severe VUR (grade 5), bladder outlet obstruction, neurogenic bladder

Question 30

What should be given to patients with megaureter?

Answer 30

antibiotic prophylaxis until resolved