CASE
OF A FRIENDLY CALCULUS AND A HELPING URETEROCELE !
TWO CASES OF POSTERIOR
URETHRAL VALVE & VUJ CALCULUS & URETEROCELE
Dr. PARAG MAHAJAN,Dr. (Mrs.) P.
S. PENDHARKAR, Prof. & Head,Dr. (Mrs.) B. D. SONAWANE, Asso.
Prof.
Dr. S. Z. SORTE, Asso. Prof.,Dr. R. R. KHANDELWAL, Hon. Asso.
Prof.,Dr. SURESH PHATAK, Hon. Asso. Prof.
Dr. DHANASHREE DANDE, Asst. Lect. DEPT. OF RADIOLOGY, INDIRA
GANDHI MEDICAL COLLEGE, NAGPUR.
CASE 1 :FILM1
MCU :
Dilated posterior urethra.
Changes of cystitis with sacculations
and irregularity of bladder wall.
Grade IV vesicoureteric reflux (VUR)
on left with gross hydroureteronephrosis.
Right VUJ calculus with Grade II VUR
on right with mild hydroureteronephrosis.
USG showed similar findings.
The cortical thickness of left kidney
was just 5 mm while that of right kidney was 14 mm.
The Right VUJ calculus has prevented
reflux on right side to some degree thus protecting the
function in right kidney as compared to the left one.
CASE 2 :FILM2
MCU :
Dilated posterior urethra
Changes of cystitis with sacculations
and irregularity of bladder wall.
Grade IV VUR on left with gross
hydroureteronephrosis.
Ureterocele on right seen as filling
defect on right.
Grade II VUR on right.
The ureterocele has prevented the VUR
on right to some extent thus decreasing the damage to right
kidney as compared to the left one.
DISCUSSION
Out of various investigations
available like USG, IVP, Renal scintigraphy and MCU (VCUG),
MCU is the procedure of choice to demonstrate PUV.
On voiding films, the posterior
urethra is markedly dilated and elongated.
Transition between dilated posterior
and anterior normal urethra is abrupt with thin stream.
The valves may be seen as two
radiolucent lines.
A posterior indentation or posterior
lip is often present at the level of bladder neck due to
bladder wall hypertrophy.
Secondary obstructive changes in
bladder, ureter and kidneys develop. Bladder hypertrophied,
trabeculated, develops saccules and diverticulae. In 50 % VUR
may be present. It commonly leads to renal infection and
consequent renal damage.
Ureters often dilated, elongated and
tortuous along with hydronephrosis.
Associated Renal Dysplasia common and
the affected kidney may be small. In our cases of PUV the VUJ
calculus and the ureterocele have prevented reflux on the
respective sides and thus protected the kidneys from damage
secondary to VUR. The other kidneys are damaged due to VUR
(and also back pressure changes due to PUV).
The VUR is more damaging than pure
obstruction because it carries infection to kidneys.
CONCLUSION
VUR associated with PUV contributes
to renal damage and end stage renal disease. It is more
damaging than pure obstruction because it carries infection
to kidneys. The damage secondary to VUR in cases of PUV may
be prevented or lessened by associated pathologies like
ureteric calculus or ureterocele.
TYPES OF POSTERIOR URETHRAL VALVE
GRADES OF VUR:
GRADE I :
Lower ureteral filling.
GRADE IIA :
Ureteral & pelviocalyceal filling
without other changes.
GRADE IIB :
Ureteral & pelviocalyceal filling
with mild calyceal blunting but without clubbing &
without dilatation of the pelvis or tortuosity of the ureter.
GRADE III :
Ureteral & pelviocalyceal
filling, calyceal clubbing & minimum to slight tortuosity
of the ureter.
GRADE IV :
Massive hydroureteronephrosis
–refluxing megaureter.
