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CASE REPORTS
URETEROCOELE : PRENATAL DIAGNOSIS AND ITS SIGNIFICANCE
SUMIT PRUTHI*, AMISHA SAWKAR*, SULEMAN A MERCHANT**, AJITA NAWALE***, ARUN THOMAS*, VINIT A GAWAND*
A case of antenatally detected ureterocoele associated with a duplicated pelvicalyceal system is reported. On antenatal ultrasound examination of the foetus it is very easy to miss this entity. On the other hand, prenatal diagnosis goes a long way in minimizing complications. Our patient was started on prophylactic antibiotics in early neonatal life on the basis of the antenatal diagnosis, thereby preventing urosepsis. Urinary obstruction was surgically relieved and renal function was maintained, all before the patient became clinically symptomatic. This importance of prenatal diagnosis is emphasized here.
Congenital ureterocoeles are usually associated with the upper moiety of a duplicated pelvicalyceal system. The orifice of the ureterocoele is usually stenotic and causes obstruction of the upper moiety of a duplicated system, resulting in renal dysplasia of the upper moiety, if the obstructive changes occur early in life. These ureterocoeles are prone to get infected due to stasis of urine, and obstruction predisposes to renal failure. Once antenatally detected, these complications can be prevented and morbidity can be reduced.CASE REPORT
A 24 year old gravida 2 para 1 came for an antenatal ultrasound examination at 32 weeks of gestation; after being referred from a peripheral hospital, where an ultrasound examination at 31 weeks showed evidence of right-sided hydronephrosis. Ultrasound examination revealed an enlarged right kidney, measuring 4.7 cm in length. A right-sided duplex pelvicalyceal system, with moderate dilatation of the upper moiety (measuring 2.3 cm) was detected. There was a crescentic embrane within the bladder, in relation to its right posterolateral wall, indicative of a ureterocoele. The amniotic fluid volume was normal. At 36 weeks of gestation a 2670 gm female infant was delivered by a caesarean section. The antenatal ultrasound findings were confirmed on a postnatal scan performed on day 2 of life. Prophylactic antibiotics were started on the base of this diagnosis. At 5 weeks of age a radionuclide scan was performed, which showed good function of the parenchyma of the upper moiety, of the duplicated system. A voiding cystourethrogram at six weeks of age did not show any evidence of reflux into the lower moiety. Subsequently a transurethral ureterocoele incision was performed thereby relieving the obstruction. The baby has not required intervention thereafter and is asymptomatic.
DISCUSSION
A ureterocoele is a congenital or acquired cystic dilatation of the terminal submucosal ureter.
Fig. 1 : Antenatal ultrasound : longitudinal scan of the foetal abdomen showing an enlarged right kidney (small white
arrows) with a duplex moiety. Obstruction of the upper moiety has resulted in its dilatation.
Fig. 2 : Antenatal ultrasound : longitudinal scan of the foetal pelvis. The larger cystic area represents the foetal
urinary bladder, the smaller cystic area within represents a ureterocoele (white arrows).
Ureterocoeles can occur in single or duplicated collecting systems. Simple (also called as adult or orthotopic) ureterocoeles drain into the bladder at the posterolateral angle of the trigone. The ureteral orifice is stenotic and the lesion may be bilateral. An ectopic (infantile) ureterocoele forms at the site of the ectopic ureteral orifice. However it may drain into the bladder neck or the proximal urethra. It is usually unilateral, more common on the left side and may cause renal failure from obstruction. Both simple and ectopic ureterocoel are more likely to be associated with duplicated systems. In fact, ectopic ureterocoeles nearly always involve the ureter draining the upper moiety of a duplicated system.1 The term ectopic ureterocoele has thus come to infer hydroureteronephrosis of the upper moiety of a duplex collecting system with the upper pole ureter ending in a ureterocoele. The affected upper moiety is obstructed and often there is an element of dysplasia with functional impairment as well.2 Lower pole reflux is twice as common when an ectopic ureterocoele associated with a duplicated system is present.3
Prenatal sonographic detection of hydronephrosis of the upper pole of a duplex collecting system decreases the proportion of neonates presenting
Fig. 3 : Postnatal ultrasound of the urinary bladder reveals a large ureterocoele projecting into its lumen (white arrows).
with urinary tract infection and urosepsis because of prophylactic antibiotics initiated at birth and continued until surgical correction.
Sonography has shown to be an important imaging modality in the diagnosis of a duplex kidney associated with an ectopic ureterocoele. Equally important, it shows the status of the contralateral renal collecting system and ipsilateral lower moiety.4
On sonography, ureterocoeles appear as echolucent thin-walled cyst-like structures within the bladder. Although duplex systems with upper pole hydronephrosis and a ureterocoele have been diagnosed antenatally by sonography, this degree of diagnostic precision is probably the exception rather than the rule.1 The most common reported finding is simply either hydronephrosis or hydroureteronephrosis (61%).3 Hydronephrosis affecting the upper pole of a duplicated system is the next common finding (30%), with ureterocoeles being seen rarely (5%).5 The difficulties in antenatal diagnosis include the ureterocoele being mistaken for the bladder, if the bladder is empty and a full bladder
effacing the ureterocoele.
Identification of duplex systems antenatally may not be easy at all times. Precise antenatal diagnosis of a duplex system with a ureterocoele may not necessarily change the postnatal surgical management as the decision about which standard surgical approach needs to be adopted is based on the results of postnatal uroradiologic studies which include voiding cystourethrography, excretory urography and radionuclide scintigraphy. The significance of prenatal diagnosis however, lies in the fact that prophylactic antibiotics started on the basis of that diagnosis considerably alters the prognosis by the prevention/treatment of urosepsis associated with a ureterocoele. Generally the upper pole moiety functions poorly and currently the most popular approach to this problem is upper pole heminephrectomy and partial ureterectomy. When a renal scan suggests adequate upper pole function, consideration is given to a parenchymal sparing procedure such as ureteropyelostomy with partial ureterectomy, or a common sheath re-implant. If the ureterocoele is accompanied by high-grade vesicoureteral reflux in the neonate, then a transurethral incision followed by vesical reconstruction is done, whereas an older child with a similar presentation is subjected to a total reconstruction.6 Most patients with a ureterocoele are relieved of all symptoms by the definitive surgery, with long term follow-up studies showing no evidence of obstruction, reflux, urinary tract infection or renal function deficit. These excellent results are not, however, universal and depend upona prompt diagnosis of the ureterocoele, antibiotic prevention/treatment of infections and an appropriate choice of surgical procedure.1 Antenatal sonography can play a vital role in such early detection. Careful antenatal sonographic screening along with an increase in the awareness about the difficulties in diagnosing ureterocoeles will go a long way in ensuring such prompt diagnosis.
REFERENCES
1. Malisch WT, Jaenty P. Ureterocoele, ectopic. Malisch www.The Fetus.net.
2. Share CJ, Lebowitz LR. Ectopic ureterocoele without ureteral dilatation. (ureterocoele disproportion) : Findings
on urography and sonography. AJR 1989; 152 : 567-71.
3. Winters DW, Lebowitz RL. Importance of prenatal detection of hydronephrosis of the upper pole. AJR 1990; 155 : 125- 29.
4. Nussbaum RA, Dorst PJ, Jeffes DR, Gearhart PJ, Sanders CR. Ectopic ureter and ureterocoele : Their Varied Sonographic Manifestations. Radiology 1986; 159 : 227-35.
5. Lebowitz LR, Griscom TN. Neonatal Hydronephrosis. Radiologic Clinics of North America 1977; XV (1) : 51-59.
6. Decter MR, Roth RD, Gonzales TE. Individualised treatment of ureterocoeles. J Urol 1989; 142 : 535-37.
CARDIAC TROPONINS AND AMYLOIDOSIS
‘Raised values of serum cardiac troponins surpass both symptomatic congestive heart failure and
two-dimensional echocardiography as predictors of survival (of patients with primary systemic amyloidosis)’
They noted that cardiac troponins are indeed good predictors of survival, and that although many laboratories and hospitals use troponin I assays, troponin T proved to be a better indicator. The researchers concluded that measurement of cardiac troponins could be a useful source of information for clinicians, and could help standardise risk comparisons. Lancet, Neurology, 2003; 1787.
