Case Report: Bilateral Ectopic Ureters
Clinical Case Report
Buoy, an eight-month old intact female Labrador Retriever, presented to the Surgical Division of the Veterinary Referral Center on September 25, 2015 with a long history of urinary incontinence and urinary “accidents.” Medically Buoy was in excellent health. All routine complete bloodwork was within normal limits and no urinary tract infection was present. The patient was referred from the Banfield Pet Hospital of Gainesville where she had received excellent wellness care and had been started on Proin (phenylpropanolamine) to aid in urine control. The tentative diagnosis was ectopic ureter.
On presentation Buoy was a bright and alert young Lab with visible signs of some urinary leakage but no severe “wetness” in the rear. Historically, Buoy would go outside and urinate normally, but then have accidents in the house. The owner would find urine spots throughout the house but not consistently. The Proin did appear to help.
The differential diagnosis included: vaginal urine retention due to vaginal defect, inappropriate urinary flow and retention due to vulvar recession, incompetent bladder sphincter control and ectopic ureter. It was possible that more than one of these diagnoses was contributing to her health issues. Routine abdominal radiographs were normal and the bladder appeared to be in the correct location. With the help of Dr. Nichole Birnbaum of the Internal Medicine Division of the Veterinary Referral Center, vaginoscopy and cystoscopy were performed under general anesthesia. A vaginal webbing defect was found (see Image 1) as well as a left sided ectopic urethral opening. The urethra and bladder appeared to be normal but the bladder sphincter seemed lax.
An intravenous excretory pyelogram radiographic dye study (IVP) was performed to confirm the existence of an ectopic ureter (see Image 2). The IVP showed the presence of a right-sided ectopic ureter with the possibility of ureteral ectopia bilaterally. It was recommended at this time to explore the bladder and ureters and reconstruct the vulva. This was discussed with the owner and Buoy was taken to surgery.
Buoy was already under general anesthesia for the above diagnostic evaluations (the cystoscopy and the IVP) so she was prepped for abdominal and vaginal surgery. A midline, caudal abdominal surgical incision was made and the bladder and ureters were examined.
The bladder appeared normal but slightly small. Both ureters external to the bladder appear normal in size and shape both appeared to enter the bladder at the neck. Upon opening the bladder neck, it was determined that both ureters were ectopic and intramural (meaning tunneling through the wall of the bladder).
Small slits were then made over the path of both ureters and new ureteral openings (neoureterostomies) were made in the bladder. The new ureteral openings were sutured with 5-0 vicryl and both openings were cannulated with five French red rubber catheters to verify patency (see Image 3). Both openings were patent and the distal ureters were tied off. The bladder was then closed with 4-0 vicryl and the body wall and skin with prolene.
Buoy was then repositioned sternally with her rear-end tilted up and she was prepped for vulvaplasty, episiotomy, episioplasty, and episiostomy. The vulvar reconstruction surgery was performed to improve the flow of urine and avoid vaginal urine retention. A Foley retention catheter was then placed to collect her urine.
Postoperative Care and Evaluation
Buoy made an excellent recovery and was discharged from the hospital the following day. She was urinating with control but was still having accidents inside the house. It can be very difficult for several weeks to know if continence has been achieved. Because of the concern for the competency of the neck of the bladder and the small size of the bladder, we elected to keep Bouy on the Proin medication long term.
Over the next two weeks the owner noted that Buoy was now more continent and had only a few accidents. By the time the sutures were removed, Buoy had made a full recovery and was fully continent. The owner reported no accidents and Buoy had an excellent urinary volume and stream.
Ectopic ureter is the term given to a ureter coming from the bladder and as it approaches the bladder it does not enter the bladder at the normal location in the neck and therefore “bypasses” the control mechanism of the urethral sphincter.
This is a congenital anomaly in which one or both the ureters exit outside the bladder lumen. It is divided into those that tunnel through the wall of the bladder (intraluminal) or those that bypass the bladder completely (extraluminal).
Buoy had bilateral intraluminal ectopic ureters. The control of urine is in the neck of the bladder where there is a sphincter mechanism. If a ureter is ectopic the urine will leak out and the animal will be incontinent. Because this anomaly is a failure of precise embryogenesis of the urinary system, other abnormalities can coexist as with Buoy (vulvovaginal defects, urethral sphincter incompetence, bladder hypoplasia, and or ureteroceles).
It is suspected that Buoy had multiple other abnormalities excluding the ureterocele. Up to 80% of ectopic ureters are intraluminal as was Buoy’s which does make for easier surgical formation of a new ureteral opening (neoureterostomy) because the surgeon can “cut-down” over the tunneling ureter to make a new opening in the bladder. Otherwise with extraluminal ectopic ureters, the ureter is actually transplanted into the neck of the bladder, a more difficult procedure.
Many times an enlarged ureter (hydroureter) will form due to increased back pressure or chronic infection. If the hydroureter is severe enough, removal of the kidney and ureter may be necessary. Fortunately, that was not the case with Buoy.
Long-term incontinence is the greatest drawback to ectopic ureter surgery because of the intricacy of the condition and the other abnormalities that may be present. Accurate diagnosis is always a challenge and can require both cystoscopy and intravenous urography. Surgery should be considered as soon as possible to prevent hydronephrosis. At present this case appears to be a complete success but as they say “time will tell” and some reoccurrence of incontinence can occur.
(black and white arrows indicate red rubber catheters placed in right and left ureters to confirm patency, the bladder is between the two arrows)
Buoy Hanging Out and Relaxing After Surgery!