PMC6450065_01
Ultrasound of the right kidney, demonstrating significant hydronephrosis with calyceal blunting and non-visualization of the right proximal ureter.
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F1
Ultrasound examination showed right hydronephrosis with an APD of 26 mm (Figure 1).
Diuretic renal scintigraphy with Tc 99m DTPA. Delayed images showed tracer retention by the hydronephrotic right kidney, with normal excretion by the left kidney. In addition, the proximal right ureter was dilated. The relative renal split function was 40% for the right kidney and 60% for the left kidney.
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F2
Diuretic renal scintigraphy with Tc 99m DTPA showed right renal pelvic dilatation with an obstructive pattern of radiotracer washout and a differential renal function of 40% (Figure 2).
Retrograde pyelography showing non-visualization of the right upper ureter with contrast pushed to the bladder upon application of higher pressure.
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F3
Routine intraoperative cystoscopy and right retrograde pyelography prior to pyeloplasty showed that the contrast was unable to pass beyond a proximal ureteric narrowing, with subsequent application of higher pressure resulting in reflux toward the urinary bladder (Figure 3).
Intra operative images in this patient. (A) A patent and wide pelviureteric junction (PUJ) was observed, along with a dilated right upper ureter with a demarcation point about 4 cm from the PUJ. (B) A transverse 2 mm ureterotomy just distal to the size discrepancy point, showing no free flow of urine.
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F4
The right pelvic-ureteric junction was wide and patent (Figure 4A). However, right ureteric focal narrowing was observed 4 cm from the pelviureteric junction, with distal ureterotomy showing no flow of urine through the right ureter (Figure 4B).
Histological evaluation of one side of the excised ureteric segment, showing a tongue-like fibrous fold derived from smooth muscle cells and extending toward the lumen (right upper side) of the ureter with a relative absence of epithelial lining (hematoxylin and eosin staining, x 10).
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F5
Histological examination of the excised ureteric segment showed normal urothelial lining, with no evidence of fibrosis or inflammation, and a valve-like membranous protrusion perpendicular to the wall of the ureter, which did not contain smooth muscles or an extensive urothelial covering (Figure 5).