A 42-year-old woman (gravida 4, para 2) presented with pelvic pain, abnormal uterine bleeding, and presumed endometriosis. A preoperative computed tomography (CT) scan (right) and a pelvis ultrasound (left) showed dilatation of the distal left ureter without hydronephrosis. The patient subsequently underwent a laparoscopic total hysterectomy, lysis of adhesions, and resection of stage IV endometriosis. Preoperatively there was the suspicion that the dilatation of the left ureter could be related to constriction from infiltrative endometriosis. However, after completion of the ureterolysis, the left distal ureter remained visibly dilated, with the dilatation extending from the pelvic rim down to the trigonal area (middle). Cystoscopy was performed, which noted a normal-appearing left ureteral orifice. The patient was given intravenous indigo carmine, and good flow was seen on the right side and sluggish flow on the left side. An intraoperative urology consultation was obtained, resulting in a recommendation of no further management given her lack of symptoms and hydronephrosis, and some spillage from the left ureter. The presumptive diagnosis was a congenital megaureter.
The incidence of endometriosis is approximately 10% to 20% in women of reproductive age. The urinary tract is affected in 2% of cases, and the ratio of bladder to ureter to urethra involvement is 40:5:1.1 The rate of ureteral involvement is estimated by some authors to be 0.08% to 1%.2,3 Laparoscopic ureterolysis is an effective treatment option in most patients.2,3
Congenital anomalies of the kidneys and urinary tract can be detected in 1 of every 500 ultrasonographic fetal examinations.4 Despite worldwide availability of prenatal ultrasound, many patients with a congenital megaureter are not diagnosed until adulthood.5 Adult primary obstructive megaureter is usually a symptomatic condition and is related to high complication rates, including infections, stone formation, and renal failure. Spontaneous resolution is rare and prompt surgical management is advocated.5
This patient had nonobstructive megaureter and given her lack of symptoms and hydronephrosis, no further management was recommended. It is important for gynecologists to be aware of this rare condition. Distal dilatation of the ureter without hydronephrosis does not necessarily require specific treatment.
References
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