Abstract
Case
A 22-year-old male smoker presented with intermittent right flank pain lasting over a year. He had a history of atrophied left kidney and gout. Physical exam revealed mild right renal angle tenderness.
Outcome
Initial imaging, pointed to a diagnosis of ureteropelvic junction stenosis. During surgery, a type two retrocaval ureter was discovered. Transposition pyelo-pyelostomy was performed to repair the ureter, and a double-J stent was inserted.
Conclusion
This case highlights the challenge of accurately diagnosing retrocaval ureter, especially type, based on initial radiological images.
1
Introduction
Retrocaval or circumcaval ureter, also known as pre-ureteral vena cava, is a rare congenital anomaly that almost always affects the right side and has a global incidence rate of 0.06–0.17 %. Men are three times more likely than women to have it. The infrarenal segment typically develops from the supracardinal vein; however, in the retrocaval ureter, the right posterior cardinal vein—located anteriorly and laterally to the ureter—develops the infrarenal IVC. Consequently, the proximal ureter becomes trapped behind the IVC. Often, this is asymptomatic; however, patients with retrocaval ureter may experience dull aches or intermittent flank or abdominal pain in their third and fourth decades of life due to ureteric obstruction and associated hydronephrosis. Ureter kinking or compression against the psoas muscle could be the cause of the hydronephrosis. Urinary tract infections (UTIs) can also occur in patients with retrocaval ureters. On intravenous urography (IVU), the ureter projects over or medial to the lumbar pedicles, taking an irregular course. In these cases, the ureter is surgically situated anterior to the IVC.
2
Case presentation
A 22-year-old single, smoker, male, presented to our specialized urology clinic, department of Urology at Al-Nadeem hospital in Jordan with intermittent right flank pain for more than 1 year. The pain was colicky in nature, intermittent, increased with intakes of fluids, and decreased by analgesia. There was no history of fever or vomiting. His past medical history is significant for atrophied left kidney, gout since 2016, and his father had PUJ stenosis. General physical examination showed mild right renal angle tenderness. Other systems were normal. The results of the laboratory tests are shown in Table 1 .
| Blood | |
|---|---|
| Red blood cells | 5.33 |
| Hemoglobin | 16.6 |
| Wight blood cells (WBC) | 9.47 |
| MCHC | 36.6 |
| MCH | 31.1 |
| MCV | 85.2 |
| PCV | 45.4 |
| Platelets | 158 |
| RDW-SD | 36.1 |
| RDW-CV | 11.7 |
| Serum | ||
|---|---|---|
| Creatinine | 74 | umol/L |
| Glucose | 4.48 | mmol/L |
| Urea | 3.3 | mmol/L |
| Chloride | 100.8 | mmol/L |
| Potassium | 4.37 | mmol/L |
| Sodium | 138 | mmol/L |
| Urine | |
|---|---|
| Glucose | NULL |
| protein | NULL |
| WBC | 1–3 |
| RBC | 0–2 |
| Bacteria | NULL |
| Ketones | NULL |
| Bilirubin | NULL |
| Urobilinogen | NULL |
| Color | Yellow |
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