Rabley Andrew, Singh Danish, Rawlings Tanner, Bird Vincent, Yeung Lawrence
Department of Urology, University of Florida College of Medicine, Gainesville, Florida, USA.
University of Florida College of Medicine, Gainesville, Florida, USA.
J Endourol Case Rep. 2020 Dec 29;6(4):505-508. doi: 10.1089/cren.2020.0176. eCollection 2020.
Periureteral venous rings are a rare congenital anomaly involving the inferior vena cava (IVC) and the right ureter, where the ureter courses through a venous ring made by the duplication of the IVC during embryogenesis. This anatomic anomaly is also referred to as a transcaval ureter. Although most patients are asymptomatic and radiographic findings are incidental, some patients can be symptomatic. We present the first reported case of asymptomatic obstructive ureterolithiasis at the level of a periureteral venous ring that was effectively treated with endoscopic management. A 47-year-old woman was found to have right hydroureteronephrosis on MRI. Further CT imaging showed an obstructing ureteral stone at the level of a periureteral venous ring. After initial decompression with ureteral stenting, she underwent ureteroscopy that revealed the ureteral stone at the level of the venous anomaly. The stone was fragmented and removed with laser lithotripsy and stone basket manipulation. After a period of ureteral stenting and removal, she had improved hydroureteronephrosis, no symptoms of ureteral obstruction, and stable renal function. Given these findings, she elected for surveillance with imaging in lieu of any reconstructive procedure to transpose the ureter around the venous anomaly. We present the first reported case of obstructive ureterolithiasis at the level of a periureteral venous ring. Our experience suggests that, with preoperative ureteral stenting, obstructing ureteral stones in the setting of an IVC anomaly can be managed with retrograde flexible ureteroscopy. Conservative laser settings and minimal torqueing of the ureteroscope are advised given adjacent vascular anomaly. Cases wherein the affected ureteral segment is too constricted or tortuous to allow for stone passage or for ureteroscopy may require management by percutaneous antegrade intervention. Surgical reconstruction of the ureter should also be considered.
输尿管周围静脉环是一种罕见的先天性异常，累及下腔静脉（IVC）和右侧输尿管，输尿管在胚胎发育过程中穿过由IVC重复形成的静脉环。这种解剖异常也被称为腔静脉后输尿管。虽然大多数患者无症状，影像学检查结果为偶然发现，但有些患者可能有症状。我们报告了首例经内镜治疗有效的输尿管周围静脉环水平无症状性梗阻性输尿管结石病例。一名47岁女性在MRI检查中发现右肾输尿管积水。进一步的CT成像显示输尿管周围静脉环水平有梗阻性输尿管结石。在输尿管支架置入进行初始减压后，她接受了输尿管镜检查，发现静脉异常水平有输尿管结石。结石通过激光碎石和结石篮操作被击碎并取出。经过一段时间的输尿管支架置入和取出后，她的肾输尿管积水有所改善，无输尿管梗阻症状，肾功能稳定。鉴于这些发现，她选择通过影像学监测代替任何将输尿管绕过静脉异常的重建手术。我们报告了首例输尿管周围静脉环水平梗阻性输尿管结石病例。我们的经验表明，术前进行输尿管支架置入，IVC异常情况下的梗阻性输尿管结石可通过逆行软性输尿管镜治疗。鉴于存在相邻血管异常，建议采用保守的激光设置并尽量减少输尿管镜的扭转。如果受影响的输尿管段过于狭窄或迂曲，无法让结石通过或进行输尿管镜检查，则可能需要经皮顺行干预治疗。也应考虑输尿管的手术重建。
