Management of localized prostate cancer and an incidental ureteral duplication with upper pole ectopic ureter inserting into the prostatic urethra

Abstract

Ectopic ureters are rare congenital malformations of the renal system that most commonly present in females. It is extremely rare to encounter an ectopic ureter in an older man undergoing radical prostatectomy. We report herein a case of a 66-year-old man with prostate cancer and a complete duplication of the left renal collecting system, with an upper pole ectopic ureter and associated normal functioning renal parenchyma entering into the prostatic urethra. This anomaly was incidentally discovered on preoperative magnetic resonance imaging of the prostate. Open radical retropubic prostatectomy and a left ureteroureterostomy were performed.

Keywords: Ectopic ureter; Prostate cancer; Prostatectomy; Prostatic urethra; Ureteroureterostomy.

Figure 1

Axial (A, B), sagittal (C, D), and coronal (E, F) T2-weighted images show ectopic insertion of a dilated left ureter inserting into the prostatic urethra. *Urinary bladder.

Figure 2

Renogram with injection of mercaptoacetyltriglycine (MAG-3) without lasix of the kidneys. The time to peak was 4 minutes bilaterally. The clearance half-time was 17.9 minutes on the left and 14.9 minutes on the right. The split function was 40.6% for the left and 59.4% for the right.

Figure 3

Three-dimensional volume rendered (A) and maximum intensity projection images obtained from the computed tomography urogram. The images showed partial duplication of the right pelviocalyceal system with a single right ureter and complete duplication of the left pelviocalyceal system with 2 left ureters (A). The lower pole left ureter is of normal course and caliber and enters the bladder orthotopically. There is fusiform dilatation of the distal portion of the upper pole left ureter as it terminates in the prostatic urethra (B).

Figure 4

(A) A probe is inserted into the ectopic ureter posterior to the left seminal vesicle and exits in the prostatic urethra. (B) A transverse slice of the prostate at its midportion demonstrates the anteriorly located ureter lumen, well demarcated by the blue ink that had been previously introduced when the ureter was cannulated (black arrow). Note that the ureter is anteriorly located and approaching near to the prostatic urethra (yellow arrow). The posteriorly located ejaculatory duct lumens provide orientation as to midline (white arrow). The peripherally located focus of cancer on the right is outlined in white. (C) Urothelial lined lumen (white arrow) of the ureter traverses through the fibromuscular stroma (black arrow) of the prostate without a distinct muscularis layer (hematoxylin and eosin [H&E] stain, 40×). Higher magnification (D) of ureter lining showing stratified epithelial layer with umbrella cells characteristic of urothelium (H&E stain, 200×).

Figure 5

Contrast was injected retrograde into the left ureteral stent and into the Foley catheter. There was no extravasation at the site of the ureteroureteral anastomosis (white arrow in A) and none at the site of the bladder urethral anastomosis (B).

Figure 6

Renal ultrasound of the left kidney following radical prostatectomy and left ureteroureterostomy demonstrating no hydronephrosis and normal renal parenchyma.