Megaureter and Other Congenital Ureteral Anomalies Workup

  • Author: Christopher S Cooper, MD, FACS, FAAP; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Sep 6, 2011
 

Laboratory Studies

  • Urinalysis and urine culture are important in evaluating any young child with an unexplained fever, and the diagnosis of UTI should prompt further radiological evaluation to identify urologic structural anomalies.
  • When identifying structural anomalies in the presence of febrile illness, it is essential to evaluate the patient for a UTI and to provide early treatment to minimize the risk of renal injury.
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Imaging Studies

Renal and bladder ultrasound is a first-line imaging study to evaluate the upper (eg, duplication, dilatation of collecting system, character or thickness of the renal parenchyma) and lower urinary tract (eg, bladder wall thickness, ureterocele, diverticulum, posterior urethral dilatation, degree of bladder emptying).

Voiding cystourethrogram (VCUG) permits evaluation of the bladder and urethra (eg, VUR, diverticulum, ureterocele, bladder trabeculation, bladder emptying, urethral anatomy during voiding) as well as assessment of the ureters if VUR is present.

Diuretic nuclear renography is an excellent study to objectively establish differential renal function, cortical scars, and to evaluate the drainage efficiency of the dilated collecting system (eg, washout times).

Intravenous pyelogram (IVP) is a useful study, although it has been largely replaced by ultrasound and nuclear renography. IVP delineates anatomy (eg, dilatation of collecting system, renal or ureteral displacement, bladder wall characteristics) and provides subjective estimation of relative renal function.

MR urography (MRU) provides excellent anatomic and functional evaluation of the renal parenchyma, collecting system and vasculature without exposure to radiation. However, MRU is sensitive to motion artifact and necessitates anesthetic sedation of young children.[2]

Intravenous urogram demonstrating left primary megIntravenous urogram demonstrating left primary megaureter in comparison to normal right collecting system. Ultrasound image of a normal right kidney in a chiUltrasound image of a normal right kidney in a child with a febrile urinary tract infection. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio. Ultrasound image of the same patient (in Picture 2Ultrasound image of the same patient (in Picture 2), demonstrating that the left kidney has a duplex collecting system. Note the lower-pole hydronephrosis. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio. Voiding cystourethrogram from the same patient (inVoiding cystourethrogram from the same patient (in Picture 2), demonstrating right vesicoureteral reflux into a single system and left vesicoureteral system into the lower pole of a duplicated system. Note the deficiency of upper-pole calyces on the left side and the "drooping lily" appearance of the left lower-pole system, which suggest the duplication anomaly in this case. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio. Voiding cystourethrogram that illustrates a right Voiding cystourethrogram that illustrates a right ureterocele characterized by the round filling defect at the right bladder base. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio.
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Other Tests

  • Urodynamic studies (eg, flow study, cystometrogram) assess voiding and bladder functional characteristics that are essential in the evaluation of a suspected NGB.
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Diagnostic Procedures

  • Cystoscopy, vaginoscopy, and retrograde pyelogram are endoscopic procedures that allow direct visualization of the genital and lower urinary tracts and may include radiographic visualization of the upper urinary tract (eg, retrograde pyelogram).
  • Pressure-perfusion studies (eg, Whitaker test) measure differential pressures of the renal pelvis and the bladder. This invasive study, which requires percutaneous renal access, may be useful in evaluating equivocal urinary tract obstruction but is seldom used in the modern era of nuclear renography.
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Histologic Findings

Ureteral ectopia

Single-system ureteral ectopia reveals widespread renal dysplasia in 90% of affected kidneys.

Duplicated-system ureteral ectopia reveals renal dysplasia in approximately 50% of affected renal moieties.

Megaureters

Light microscopy of megaureters demonstrates a predominance of circular smooth muscle; muscle fiber hypoplasia and atrophy, with collagen deposits separating the muscle cells; and mural fibrosis with scant muscle fibers.

Electron microscopy of megaureters demonstrates increased collagen deposition within the adynamic segment.

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Contributor Information and Disclosures
Author

Christopher S Cooper, MD, FACS, FAAP  Professor of Urology, Director of Pediatric Urology, University of Iowa, Children's Hospital of Iowa; Associate Dean for Student Affairs and Curriculum, University of Iowa Carver College of Medicine

Christopher S Cooper, MD, FACS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, International Children's Continence Society, Phi Beta Kappa, Society for Basic Urologic Research, Society for Fetal Urology, and Society for Pediatric Urology

Disclosure: Nothing to disclose.

Coauthor(s)

Angela M Arlen, MD  Chief Resident, Department of Urology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Angela M Arlen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Urological Association, and Society of Women in Urology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Jeffrey Noble, MD  Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwest Oncology Group

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS  Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Leslie Tackett McQuiston, MD, FAAP, and Eugene Minevich, MD, to the development and writing of this article.

References

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Intravenous urogram demonstrating left primary megaureter in comparison to normal right collecting system.
Ultrasound image of a normal right kidney in a child with a febrile urinary tract infection. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio.
Ultrasound image of the same patient (in Picture 2), demonstrating that the left kidney has a duplex collecting system. Note the lower-pole hydronephrosis. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio.
Voiding cystourethrogram from the same patient (in Picture 2), demonstrating right vesicoureteral reflux into a single system and left vesicoureteral system into the lower pole of a duplicated system. Note the deficiency of upper-pole calyces on the left side and the "drooping lily" appearance of the left lower-pole system, which suggest the duplication anomaly in this case. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio.
Voiding cystourethrogram that illustrates a right ureterocele characterized by the round filling defect at the right bladder base. Image courtesy of Steven Kraus, MD, Cincinnati, Ohio.
 
 
 
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