U J 02 - Spring 2012 - All 008- without adv.pdf 527Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Keywords: ureter, embryology, vena cava, ureteral neoplasms INTRODUCTION T The clinical and surgical implications. CASE REPORT A 75-year-old man presented to the emergency ward with recurrent macroscopic hematuria and irritative voiding symptoms. In our diagnostic process, urinalysis, urine cytology, intravenous urography, and cystoscopy were employed. A tumor in the bladder and another one in the distal ureter were diagnosed. Tran- surethral resection of the bladder tumor was initially performed and the pathology was subsequently performed for tumor staging, which incidentally revealed a left The urologic history of the patient started 5 years earlier when an urothelial pT1 grade IIB tumor of the bladder was diagnosed. The treatment included transure- - cal instillations. The upper urinary tract had been examined that time with ultra- Diomidis Kozyrakis,1 Ioannis Prombonas,1 Vasilios Kyrikos,1 Alkiviadis Grigorakis,1 Georgios Pliotas,2 Dimitrios Malovrouvas1 Left Retrocaval Ureter Associated With Urothelial Malignancy Presentation of a Rare Case Corresponding Author: Diomidis Kozyrakis, MD Sofokli Venizelou 77 St., Halandri, 15232, Athens, Greece Tel: +30 210 681 9942 Fax: +30 210 681 1795 E-mail: dkozirakis@yahoo. gr. Received April 2010 Accepted October 2010 Case Report 1Department of Urology, “Evagelismos” General Hospital of Athens, Athens, Greece 2Department of Urology, Western Attica Hospital, Athens, Greece 528 | Left nephroureterectomy and radical cystoprosta- tectomy were performed for the treatment of his urothelial malignancy. The nephroureterectomy was a laborious procedure, and accidently, an opening to the IVC was made, which was imme- radical cystoprostatectomy was uncomplicated. The frozen section of the right ureteral margin was positive for urothelial malignancy and right distal ureterectomy with ileal loop diversion was performed. The postoperative recovery was uneventful. One and a half year after the operation, no signs of tu- mor recurrence, distant metastasis, or renal dys- DISCUSSION In cases of a retrocaval ureter, the subcardinal vein generates the IVC, which results in a course of the ureter dorsally to this vein. The term preureteral for the vascular origin of the abnormality to be emphasized. If the subcardinal vein persists at encountered. Reviewing the international litera- ture, only 6 cases have been reported so far. Recurrent abdominal pain, lumbar pain, hydro- nephrosis, and nephrolithiasis are the present- ing symptoms of LPUVC. Traditionally, the combination of retrograde urog- raphy with cavography can identify the PUVC. The spiral computed tomography can substantially contribute towards the correct diagnosis. Should the use of intravenous radiopaque agents is con- traindicated, magnetic resonance imaging can be performed instead. The left IVC and PUVC may be misdiagnosed as a retroperitoneal lymphadenopathy or a primary tu- mor of the retroperitoneal space. They also pose a threat for vascular or tissue damage during op- erations to the retroperitoneum, particularly when they are associated with situs inversus. The left re- nal vein has a brief course, which does not cross the aorta and subsequently, in cases of nephrecto- my, living renal donor surgery, and reno-vascular dissected from the surrounding tissues. The treatment of PUVC is ureterotomy and relo- cation of the ureter anteriorly to the IVC. This operation is usually an open surgical procedure, but nowadays it can be performed laparoscopi- Figure 1. Computed tomography of the abdomen with adminis- tration of contrast agent. A left inferior vena cava (asterisk) and a retrocaval course of the left ureter (arrow) can be diagnosed. Figure 2. Abnormal course of the left ureter, dorsally to the left inferior vena cava. The proximal ureter is grasped with a forceps. The big black arrow shows the inferior vena cava, while the small black one indicates the course of the ureter dorsally to the vein. The opening on the inferior vena cava was corrected (white arrow). Case Report 529Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L cally. Apart from hematuria, no other symptoms were de- scribed by our patient. Considering that his initial showed normal renal units and collecting systems bilaterally, it is estimated that the urothelial malig- nancy and not the LPUVC generated a clinical evi- dent obstruction of the left urinary tract. To the best PUVC is associated with urothelial malignancy. Despite the pre-operative diagnosis, the left IVC and the abnormal ureteral course obscured the re- troperitoneal structures. In our patient, an opening to the IVC was made. The surgeon must have a high index of suspicion and attention, and must be extremely meticulous during renal and ureteral dis- section for any damage to the retroperitoneal or- gans to be avoided and a source of intra-operative complications to be prevented. CONFLICT OF INTEREST None declared. Left Retrocaval Ureter Associated With Urothelial Malignancy | Kozyrakis et al REFERENCES 1. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH, Jr. Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. Radiographics. 2. Hyams BB, Schneiderman C, Mayman AB. Retrocaval ureter. 3. Pais VM, Strandhoy JW, Assimos DG. Pathophysiology of Urinary Tract Obstruction. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. Vol 4. Rubinstein I, Cavalcanti AG, Canalini AF, Freitas MA, Accioly PM. Left retrocaval ureter associated with inferior vena 5. Pierro JA, Soleimanpour M, Bory JL. 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