ECTOPIC URETER DRAINING INTO THE SEMINAL VESICLE LEANDER W. RIBA, LT. CoL. (MC), CARL J. SCHMIDLAPP, CAPT. (MC) AND N. LEWIS BOSWORTH, CAPT. (MC) AUS From the Genito-Urinary Sub-section of the Surgical Service, Bushnell General Hospital, Brigham City, Utah
Since 1852 abnormal draining of a ureter into the male seminal tract has been recorded at least 36 times. Thirty-two (89 per cent) of these observations were noted during autopsies, and in four instances (11 per cent) the diagnosis was made clinically. AUTOPSY GROUP, 32 CASES
In 23 autopsies the ages of the subjects varied from 6 to 73 years; the average, 48.3 years. Four in this group were infants. Two were middle-aged, and in three the ages were not recorded. This anomaly was noted 21 times on the left side and 11 times on the right. In 26 cases (81 per cent) the ectopic ureter was single, and in six (19 per cent) there was reduplication (1 bilateral). In 14 cases the corresponding kidney was rudimentary and absent in ten. A double kidney was noted 3 times, fibrosis of the kidney 2 times, and cystic degeneration 2 times. In only 1 autopsy recording was the kidney found to be normal. The distribution of these aberrant ureteral openings are of interest. The ureters in 22 cases drained into the seminal vesicles (18 left, 4 right), and in 10 cases into the vas deferens or ejaculatory duct (7 right, 3 left) . In the case recorded by Rech with left double ureters, one opened into the left vas deferens and the other into the left ejaculatory duct. The embryologic etiology was briefly described by Campbell: "Between the fifth and sixth weeks of fetal life, a frontal fold, the urorectal septum, passes downward to separate the primitive cloaca into a dorsal rectal and a ventral urogenital segment. From the latter spring the ureteral buds which ultimately form the urinary collecting system. The Wolffian ducts open into this vesico-urethral anlagen. Later the ureteral orifice on each side shifts upward to open into the lateral angle of the trigone; failure to do so results in ureteral ectopy. From the ·wolffian ducts are formed the posterior urethra, vas deferens, epididymis, and by budding the seminal vesicles. This early anatomic relationship of ureteral buds and the Wolffian derivatives explains certain unusual types of ectopy of the ureteral orifice." Associated development defects as absence or rudimentary kidneys, infantile ureters, rectal fistulae, and imperforate ani are frequently noted. Culver also carefully discussed the embryological male genito-urinary development and causes resulting in ectopic ureters. CLINICAL CASE REPORTS
The opening of an ectopic ureter into the male seminal tract has been reported clinically 4 times: Day, 1932; Culver, 1937; Hamer et al, 1937; Minuzzi and Toressi, 1940. In two of these reports the ectopic ureter was a reduplicate and in two the ureter was single. One single and one reduplicate ectopic ureter 332
ECTOPIC URETER DRAINING INTO SEMINAL VESICLE
opened into the right seminal vesicle while the remaining two opened into the left seminal vesicle. In all four reported cases, pyuria was the outstanding finding, intermittent in two and constant in two. In addition, 3 patients had pain, frequency, terminal hematuria and fever. One patient remained asymptomatic. In 2 patients the 2 glass test of urine suggested seminal vesiculitis, i.e. a clear first glass and a cloudy second. In Day's patient, following nephroureterectomy, the left pelvic pouch was demonstrated by catheterizing the left ejaculatory duct and injecting opaque x-ray media. In Culver's case intravenous pyelography readily demonstrated the uretero-seminal vesicle connection. Hamer, following intravesical incision and drainage of the right subvesical cyst, demonstrated a rudimentary right ureter with a likely absence of the corresponding kidney. Minuzzi suspected a double ureter, one draining into the right seminal vesicle, before nephrectomy. At operation they noted that the upper pole was hydronephrotic but the blood supply precluded heminephrectomy. After a long series of postoperative treatments their patient became symptom free. In Day's case the wounds continued to drain, necessitating a combined abdomino-perineal operation to close the fistulae and clear the urine. This case summary is recorded because of the difficulty encountered in finding the source of the patient's pyuria. Following successful left heminephrectomy the pyuria continued even though the kidney urine remained normal. The first clew was the 2 glass test, showing a cloudy second glass. Seminal vesiculograms confirmed the clinical suspicion of seminal vesiculitis and operative removal of the anomalous pelvic pouch relieved the patient of his persistent pyuria. To the 4 cases previously reported another case of reduplication and ectopic left ureter is recorded in the male. The ureter draining the upper half of the kidney was ectopic and drained directly into the left seminal vesicle. The right seminal vesicle also appeared dilated. CASE REPORT
A private, aged 19, inducted 1943, had been in good health and his past history was non-contributory. On August 24, 1943, while boxing, he was struck in the left flank. He continued boxing but 2 hours later had a sudden severe and continuous pain in the left flank and was admitted to the station hospital. The urine contained 3 to 4 white blood cells and 1 to 5 red blood cells. Intravenous pyelograms were interpreted as normal. The pain continued and on August 26 an exploratory operation was performed through a high left transverse abdominal incision for the possibility of a ruptured spleen, Exploration was negative save for a notation that the peritoneum overlying the left kidney was edematous. The patient had an uneventful postoperative course but urinalyses continued to show pus cells. Further examination was not carried out and on September 14 the patient was returned to duty status. He performed duty asymptomatically until May 5, 1944, when he was admitted to Bushnell General Hospital with a diagnosis of Vincent's angina. He was treated with 2,200,000 units of penicillin and on May 22 was examined by the Urologic Service for a persistent pyuria. There were no urinary symptoms.
RIBA, SCHMIDLAPP AND BOSWORTH
The centrifuged second glass urine specimen showed 3-5 white blood cells per high pmver field and the urine culture a non-hemolytic Staphylococcus albus. A tentative diagnosis of possible upper left urinary tract infection was made. On May 26 an intravenous pyelogram revealed a mass involving the upper pole of the left kidney, probably an upp,er pole cyst. The left kidney was depressed, rotated and pushed laterally (fig. 1). On June 2, 1944 cystoscopy revealed a, large caliber 21 F. anterior ureteral stricture, but examination of the bladder was unrevealing save for elevation of the left side of the bladder with a high
FIG. 1. A, Preoperative intravenous left urogram revealed depression, rotation and lateral displacement of left kidney. B, 6 weeks postoperative intravenous urogram showed mild pyelectasis with good function.
left ureteral meatus. Right and left kidney urines contained no pus cells and the cultures were sterile. Retrograde pyelograms confirmed the previous x-ray findings. The phthalein output ranged from 40 to 50 per cent in 2 hours. The dilution concentration test gave values ranging from 1.007 to 1.020. The blood non-protein nitrogen was 33 mg. per cent. On July 5, 1944, under spinal anesthesia, a left lumbo-abdominal incision was made and the kidney exposed. A reduplication of the kidney and ureter with a cystic hydronephrosis of the upper portion with a hydro-ureter was found. Ex-
ECTOPIC URETER DRAINING IKTO SEMINAL VESICLE
cision of the cystic upper pole of the kidney was carried out including the upper two thirds of the hydro-ureter. Culture of the cystic content revealed no growth on cultures. The wound was closed with drains. Histologic diagnosis revealed chronic inflammation, fibrosis and cystic atrophy in the tissues from the left kidney. Postoperatively the patient ran a septic course. Pneumonitis developed on the second postoperative day. Penicillin ,vas begun, 20,000 i.m. units every 3 houn;. On the sixth postoperative day the lungs were clear but the patient was still febrile with a temperature of 100.8 F. At this time urine cultures showed aerobacter, diphtheroids, and hemolytic Staphylococcus aureus, coagulase positive. On the ninth postoperative day penicillin was discontinued and patient was cegun on sulfadiazine. Two days later he complained of pain in the left lmrnr quadrant. On the sixteenth postoperative day because the patient con-tinucd to run a low grade febrile course, penicillin ,rns reinitiated. Three days later patient became afebrile but complained of nausea, and the urine showed 8-10 "bite blood cells per high power field. On the t,venty-sixth postoperative day, the r:atient complained of an acute attack of pain in the left lower quadrant and at this time a soft left pelvic mass was palpated per rectum. A diagnosis of extraperitoneal al::sccrn was made. Patient refused operation until August 3, 1944 "hen explcraticn cf the left retroperitoneal space ,rns carried out. "'.'Jo abscess was found. Follm,ing this exploration, the patient continued to nm a low grade fever and persistent pyuria in spite of penicillin and sulfa drugs. Twelve days later the sharp severe left lower quadrant pain returned. On August 21 cystoscopy revealed that the bladder urine ,,as cloudy and its urine cultures shmn:d Beta hemolytic streptococci, aerobacter and non-hemolytic staphyloccccus aureus. A diagnosis of veRical pyuria "as made because the urinary findings from the right and lei t kidneys remai:ied normal. Following cystoscopy, prostatic examinations revealed a mild prostatitis, and after each prostatic massage there was an intensification of the pyuria. On October 23 it was noted that the second glass of urine ,ms more clouc1y than the firnt and a diagnosis of seminal vesiculitis ,rns made. Cathete1i~r"tion of tl:ie ejaculatory ducts and seminal vesiculograms revealed the preYious excised ectopic left ureter connected to the left seminal vesicle (fig. 2). Urine cultures continued to show streptococcus B. and hemolytic staphylococcus aureus. The patient was asymptomatic save for pyuria and was granted a 30 day furlough. On January 10, 1945 excision of the lower third of the aberrant ectopic left ureter was carried out. This cystic dilation was found posterior to the remaining ureter of the left kidney which appeared normal. The excision of this pouch was very difficult due to marked fibrous adhesions. The lowest portion was attached in region of the left ejaculatory duct and the upper portion tapered off into a narrower tube above the true pelvis (fig. 3). During this procedure a small opening was made into the bladder which was extremely thin in this region. Histologic diagnosis ,rns chronic inflammation of an aberrant ureter. On the sixth postoperative day the urine became clear and patient was asymptomatic. On the nineteenth postoperative day the urine became cloudy and cultures again revealed staphylococcus aureus. On February 6, 1945 a left extrap2ritoneal
RIBA, SCHMIDLAPP AND BOSWORTH
abscess was suspected and incision and drainage released 8 ounces of pus. Six days later the urines again became clear and patient was returned to duty status. The urethral strictures now cause intermittent shreds and few pus cells in the first glass of urine which are controlled by periodic dilatation.
Frn. 2. Right and left seminal vesiculograms. All ejaculatory duct catheters entered right seminal vesicle only. Left pelvic pouch was injected with 150 cc 20 per cent skiodan solution.
Frn. 3. Removed left pelvic pouch, which on microscopic sections showed a thickened aberrant left pelvic ureter. SUMMARY
A young male patient with a double left ureter, one ectopic draining into the left seminal vesicle, is presented. The source of the pyuria remained obscure for
ECTOPIC URE'l'ER DRAINING INTO SEMINAL VESlCLJ;;
several months, The cloudy second glass of urine suggested disease of the seminal vesicle. Further x-ray films after catheterization of the ejaculatory ducts simplified the diagnosis. Complete excision of this anomalous left uretero-seminal vesicle cleared the urine permanently. Chemotherapy, including penicillin, failed to remove the chronic infection,
720 N. 2vfichigan Ave., Chicago, Ill. REFERENCES TO AUTOPSY REPORTS BACHRACH, R.: Uber kongenitale Bildungsfehler des Harnapparates. (Concerning congenital developmental anomalies of the urinary system). Ztschr. f. Urol. 3: 921-926. 1909. , . BARGE, P.: Anurie datant de dix jours. Echec du traitement medical. Decapsulation du rein droit percu. Amelioration. Mort au vingt-sixieme jour de nephrite aigue. Autopsie: absence congenitale du rein gauche. La portion pelvienne de l'uretere gauche seule existe et debouche dans la vesicule seminale de ce cote. Bull. Soc. franc. d'urol., pp. 184-189, April 27, 1936. BosTROEM, E. L.: l!'reiburg! 1884, _contrib~tions to the pathological anatomy of the kidneys. (Schwartz: Beitr. z. klm. Chrr., Tubmgen, 16: 1, 159-244, 1895.) CAMPBELL, MEREDITH F.: Ectopic ureteral orifice. Surg., Gynec. & Obst., 64: 22-29, 1937. DRECHSEL, J.: Jahrb. Univ. Sofia, Med. Fae., 11: 121-130, 1932. (From Gloor: Not read in the original.) ECKARD'!', C. T.: Ueber die compensatorische Hypertrophie und das physiologische Wachsthum der Niere. Arch. f. path. Anat., etc., Berl., 114: 217-245, 1888. ENGEL, DESIDER: Ueber eine seltenere Form der Urogenitalmiszbildung. (Concerning a, rarer form of urogenital malformation.) Ziegler's Beitr. z. path. Anat., 67: .549-554, 1920. EPPINGER, H.: Ueber Agenesie der Nieren. (On agenesis of the kidneys.) Kleb's Beitr. z. path. Anat., 1880, 2: ll8, 1880. ERLANGER: (Bostroem, D.: Contributions to the pathological anatomy of the kidneys. Beitr. z. !din. Chir., 15: 159-244, 1895.) F1scHER, P.: (Thom, Bruno-Harnleiter- und Nierenverdoppelung mit besonderer Beri.ichtsichtigung der extravesikalen Harnleitermundungcn. (Ureteral and renal duplication with particular attention to extravesical ureteral orifices.) Ztschr. f. Urol., 22: 417-468, 1928. FRIEDLAKD, F.: U eber einen Fall von accessorischen N ebennieren in den beiden Samen strangen bei gleichzeitigem Conflux des Ureters und des vas deferens der rechten Seite. Prag. med. Wschr., 20: 145-147, 1895. GRUBER: Anatomische Notizen. Arch. f. path. Anat., etc., 68: 272, 1876. HoFFMAN, C. E. E.: Zwei Fiillc von Umwandlung der Samenblasen in Harnleiter. (Two cases of transformation of the seminal vesicles into ureters.) Arch. cl. He ilk., 13: 532-· 544. 1872. HOFFMAN, C. E. E.: Zwci Fiille von Tiefer Mi.indung des Ureters. Corr. BJ. f. Schweiz. Aerzte, 1: 147, 1871. INSBRUCH: Gruber: Anatomische ~ otizen. Arch f. path. Anat., etc., 68: 272, 1876. LACASSE: Thom, Bruno-Harnleiter und Nierenverdoppelung mit besonderer Beri.lchtsichtigung der extravcsikalcn Harnleitermundungen. Ztschr. f. Urol., 22: 417-468, 1928, JYicKrnnIE, J\1. AND PoLKJ;;Y, H. J.: Extravesical ureteral opening into seminal vesicle. J. Urol., 37: 706-71-+, 1937. P.\Li\LI., P.: Zur pathologischen Anatomie der Bildunganomalie im uropoietischen Systems. Prag. med. Wchnschr., 16: 32, 33,367,379, 1891. PAPIN, E. AND VERLIAC, H.: Aplasie renale gauche congenitale avec abouchemcnt de l'uretcre dans la vesicule seminalc. J. d'urol., 9: 431-433, 1920. RECH, W.: Ueber eine eigen thi.imliche pornbinierte Missbildung des miinnlichen Uro · genitalapparates und ihr formale Genese. Ztschr. f. urol. Chir., 11: 6, 1923. . RELIQGET: Pcrsistance du canal de Mi.tiler; hydronephrose de rem et de l'uretcre drort; pyclonephrite calculeuse du rein gauche tres hypertrophie. Progres med., Par., 1887, 5: 2.s.; 205-230, 1887. Ro-r-r T.: Ein Fall von ::\1angel der rcchten Niere nebst einer scltsamen Missbildung des rlarn- und Samen-leiters der gleichen Seite. Verh. d. phys. med. Gesellsch, in Wurzb. 13 n.s.: 125-142, 1879. SANKOTT, A.: Ein Fall von Agenesie der linken ;\;iere mit Dystopie des l\icrenrudimentes und Communication des cystenartig endigenden Ureters mit der Samenblase. Deut. Arch. f. !din. Med., 58: 463-.1,74, 1897.
RIBA, SCHMIDLAPP AND BOSWORTH
SCHMIDT, E.: Ueber einseitigen Nierenmangel bei Uebergang des Ureter in die Samenblase. Ziegler's Beitr. z. path. Anat., 42: 516-630, 1907. THIERSCH, C.: Bildungsfehler der Harn- und Geschlechtswerkzeuge des Mannes. Illus. Med. Ztschr., 1852, vol. 2. WEIGERT, C.: Zwei Falle von Missbildung einen Ureteren einen Samenblase. Arch. f. path. Anat., etc., 104: 4, 1886; 70: 575, 1878. WHITEFORD, C. Hamilton: Malformations of the kidney and ureter. Brit. Med. J., 2: 896, 1898. ZIMMERMANN, H.: Einseitige Nierenhypoplasie mit JVhindung des Ureters in die Samenblase. (Unilateral hypoplasia of the kidney, with ureter emptying into the seminal vesicle.) Zentralbl. f. allg. Path. u. path. Anat., 32: 1-13, 1921. REFERENCES TO CLINICAL CASE REPORTS ClcLVER, HARRY: Extravesical ureteral opening into the genital tract in a male. Tr. Am. Assn. Genito-Urin. Surg., 30: 295-300, 1937. DAY, R. V. : Ectopic opening of the ureter in the male; with report of case. .J. U rol., 11: 239-258. 1924. HAMER, H. C., MERTZ, H. 0. AND WISHARD, W. :'>I., Jr.: Ureter opening into seminal vesicle; case diagnosed clinically. Tr. Am. A. Genito-Urin. Surg., 30: 301-307, 1937. Mrnuzzr, P. G. AND ToRRESI, S.: Complete double kidney with hydronephrosis of upper pelvis and with ureter possibly ending in seminal vesicle; case. Rev. argent. de urol., 9: 334-342, 1940.