Circumcaval Ureter

Abstract

This Paper Deals with an interesting anomaly of the inferior vena cava which has been variously called postcaval ureter, retrocaval ureter, circumcaval ureter, and preureteric vena cava. We prefer the designation circumcaval ureter, since it best describes the anomaly and since one of us (W.J.E.) has observed a case in which the ureter occupied a position posterior to the inferior vena cava yet reappeared laterally without circumscribing that vessel. Although reports of 55 cases of this anomaly were found (1–47), none of these has appeared in a roentgenologic journal. Because the preoperative diagnosis can be made only by roentgenology, a recently proved case of ours prompted a review of the literature with special attention to the x-ray studies. Of the 55 cases previously reported, 21 were discovered in dissecting room cadavers or at autopsy and 34 at surgery; 1 was diagnosed roentgenographically but the patient was not operated upon (47). The first correct preoperative diagnosis was made by Harrill (22) in 1940. Since then, 16 cases (Goyanna et al., 29; Greene and Kearns, 30; Creevy, 34; Corbus, 35; Schwartz and Irey, 36; Anderson and Hynes, 37; Lich and Grant, 38; Shearer, 39; Lyter and Meyer, 40; Olson and Austen, 41; Sabatini and Wessler, 42; Beard and Goodyear, 43; Jacobson, 44; Duff, 45; Heslin and Mamonas, 47), in addition to our case, have been diagnosed correctly by roentgen studies. In Table I are listed the reported cases with pertinent information concerning them. Case Report A 33-year-old white man was first seen at the Cleveland Clinic on Dec. 7, 1948, complaining of pain in the right loin, radiating at times into the right lower quadrant. The pain had been present intermittently for eleven years. It was somewhat relieved by physical activity or by lying on either side. The patient had never had chills or fever but had experienced occasional episodes of frequency of urination and dysuria, accompanied by “cloudy urine.” Gross hematuria had occurred on one day eleven years previously. For the past ten years cystoscopic examination with ureteral dilatation had been done at frequent intervals. Seven years previously the patient had undergone an appendectomy, without relief, for right lower quadrant pain. The past history and family history were non-contributory. Physical examination was negative except that the right kidney was questionably palpable. Urinalysis revealed no abnormal findings. Multiple urinary cultures were negative. Intravenous pyelography on Dec. 8, 1948, disclosed a normal left kidney and ureter. On the right there were severe hydronephrosis and hydroureterosis of the upper ureter. The pelvis and upper portion of the ureter were somewhat redundant and assumed an S-shaped configuration. At the end of one hour there was considerable retention of dye in the dilated right pelvis and ureter. On Jan. 17, 1949, cystoscopy and right ureteropyelography were performed.