Implantation au niveau de l’urèthre prostatique d’un uretère ectopique. Découverte inhabituelle chez l’adulte : Un nouveau cas

Satâa SALLAMI |

La tunisie chirurgicale - ; Vol

Resumé

Les auteurs rapportent le cas d’un patient âgé de 47 ans qui s’est présenté pour des infections urinaires à répétition. Les explorations radiologiques ont montré un système urinaire double à gauche avec un rénicule polaire supérieur gauche détruit. L’uretère du rénicule supérieur s’abouchait au niveau de l’urèthre prostatique. Une héminéphrectomie polaire supérieure gauche a été réalisée. Les auteurs discutent la physiopathologie de cette anomalie et les modalités thérapeutiques.

Mots Clés

Uretère - urethre - prostate - duplicité

Introduction :

Renal duplication and associated ectopic ureter is a very rare urinary malformation almost diagnosed at paediatric age. Only some cases were reported in adults. We present an unusual case of duplex kidney associated to an ectopic ureter in adult man who was diagnosed because of renal cyst. We discuss the origins and nature of renal duplication and associated ectopic ureter that commonly accompany them. Imaging findings at excretory urography and voiding cystourethrography, as well as ultrasound (US), computed tomography (CT) are illustrated and discussed.

Article

Case report A 47-year old man, father of four children, presented with recurrent urinary infections and pyuria. Neither hematuria nor urinary incontinence was reported. The physical examination was normal especially without any appearing genital anomalies. The urinalysis was negative.

Abdominal ultrasonography identified a left upper pole renal cyst of 15 cm. Hydatid serology was normal. CT Scan suggested a single collecting system at the right side and a complete ureteral duplication at the left side with hydronephrosis of the upper pole (Fig. 1). Voiding cystourethrography revealed a normal urinary bladder and urethra without any vesicoureteral reflux. Percutaneous antegrade pyelography with CT Scan confirmed the diagnosis of ectopic ureter terminating on the prostatic urethra. The urodynamic examination was found to be normal. On cystoscopy, a single right ureteral orifice at the normal location at the angle of the trigone was visualized ; the left ureteral orifice was ectopic on the sus-montanal segment of the urethra. Retrograde catheterization failed with a complete stenosis of the ureteral opening. The history, physical examination, and radiographic findings were suggestive of a non-functioning left upper pole ectopic ureter on the prostatic urethra. The surgical exploration concluded to a complete ureteric duplication of the left side with hydronephrosis of the upper renal segment. The lower 4 cm of the left ectopic upper pole ureter was stenotic with an ectopic orifice in the sus-montanal segment of the urethra, but the ureter was dilated proximally. The patient underwent a left upper pole nephrectomy. Peroperative antegrade catheterization of the ureteral orifice was again impossible suggesting a complete stenosis of the ectopic meatus. Pathological study concluded to a chronic and xanthogranulomateous pyelonephritis. The postoperative course was uncomplicated, and the patient had satisfactory urinary continence. With a 24 months follow-up, he was completely asymptomatic and the IVP shows mild dilatation of the lower pole systems.

Discussion

Duplication of the ureters, frequently called renal duplication, is the most common anomaly of the urinary tract (1). It may be either complete or incomplete. Duplications may be discovered in childhood or, less frequently, in later life often accompanied by various complications, or they may be occult and discovered at autopsy (2). The most common complications of complete duplication are vesicoureteral reflux, ectopic ureterocele and ectopic ureteral insertion (3). The true incidence of ectopic ureteral insertion is unknown, as many cause no symptoms (4). This anomaly occurs more frequently in females than in males, with a ratio of 6 :1 (4,5). The basic defect results from a ureteral bud arising more cephalic than normal from the mesonephric duct. Rather than being normally incorporated into the bladder, it moves caudally with the mesonephric duct and inserts ectopically, either in or out of the bladder (6). In the male the extravesical ectopic orifice is always suprasphincteric and enters the prostatic urethra (47%), ejaculatory duct (5%), seminal vesicle (33%), or the vas deferens (5%) (4,7). Only one case of bilateral ureteral prostatic ectopia on the verumontanum causing urinary incontinence was reported (8). The ureters arise from the wollfian ducts. The ureter of the lower renal pole arisesinferiorly and isincorporated into the developing bladder first. It ascends during bladder growth and inserts superiorly and laterally to the ureter of the upper renal pole according to Weigert-Meyer rule (3). Commonly, the ureter of the upper pole renal moiety has a stenotic orifice, dilated ipsilateral upper urinary tract, dysplasia of the renal parenchyma and even a complete renal agenesis considered the most extreme form of dysplasia. Vesicoureteral reflux affects almost the lower pole (3,6). Extravesical insertion of the ureter is associated with significant renal poor function of the affected segment. This may hamper detection of the segment both clinically and radiologically unless the ureter and calices dilate secondary to distal ureteral obstruction (3). Ectopic ureters may be asymptomatic in childhood and remain undiagnosed until adulthood. The most common presenting symptoms are urinary tract infection and incontinence (7). All extravesical insertions in male are suprasphinctenic, above the verumontanum, and produce signs of infection, inflammation, or mass. (3). Therefore, recurrent epididymitis, onchitis or a seminal vesicle mass are common signs at presentation (3). Enunesis would not be an expected symptom in boys. Only one case of incontinence secondary to an ectopic ureter has been reported in a male (8). The 6 cases of ureteral prostatic ectopia reported by Mathews et al have caused urinary obstructive signs (9). The anatomical assessment may be incomplete if one moiety is markedly dilated or if there is little poorly functioning renal parenchyma (5). In fact, the demonstration of upper pole moiety and ectopic ureteral termination by conventional radiological methods is not always easy.Thus, there is frequently a long delay in the diagnosis of an ectopic ureter, especially when it drains a nonfunctioning, nonhydronephrotic dysplastic renal unit with no ureteral dilatation. Ultrasound can be useful in identifying a hydronephrotic collecting system and dilated ureter at the level of the bladder. In most instances, as in our case, the diagnosis of an ectopic ureter is suspected by CT San. When suspicion of ectopic insertion is high and routine studies have proved negative, pyelography, CT or MR imaging may provide the information necessary for a surgical cure (3). Because most ectopic ureters are always associated with poorly functioning renal parenchyma, an upper pole nephrectomy with partial or total ureterectomy is recommended (6,7). Removing the distal part of the ectopic ureter during heminephrectomy is debated. Plaire et al. showed that a secondary removal of the ureteral stump was necessary in only 12% of patients who underwent heminephrectomy (10). In our case, the distal part of the ectopic ureter was not removed because of the high risk of post-operative incontinence.

Conclusion

Although, ectopic ureter is commonly diagnosed in young girls, it should be considered even in adult men with ureteral duplication and recurrent urinary tract infections. The appropriate imaging studies should be obtained and carefully interpreted. If an ectopic ureter is found, surgical reconstruction should be planned depending on the degree of renal function and the presence of complications.

Références

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