Radiological seminal vesicle stones may actually be in the ureter.

Calculi in blind-ending ureters are uncommon. We describe a rare case of calculi in the diverticulum of a blind-ending ureter associated with ipsilateral renal agenesis, which masqueraded as seminal vesicle calculi.

INTRODUCTION

Calculi in blind-ending ureters are uncommon. We describe a rare case of calculi in the diverticulum of a blind-ending ureter associated with ipsilateral renal agenesis, which masqueraded as seminal vesicle calculi.

CASE REPORT

A 44-year-old man presented with gross painful hematuria and frequency. He did not have lithuria, hematospermia or previous urinary tract instrumentation. He had received antitubercular therapy 20 years back for pulmonary tuberculosis and again 1 year before presentation to us. His urine examination and serum biochemistry were normal. Intravenous urogram showed multiple radio-opaque densities in right hemipelvis, normal left kidney and nonvisualized right kidney [Figure 1]. Micturating cystourethrogram revealed calcific densities in right pelvis and grade 1 right vesicoureteral reflux. A diagnosis of right renal agenesis with seminal vesical calculi was made and confirmed with magnetic resonance imaging (MRI) of the pelvis [Figure 2].

Figure 1

(a) Plain X-ray showing radio-opacities in the right pelvis, (b) 15-minute IVU film showing reflux into right lower ureter, not outlining the calculi and (c) micturating cystogram film with dye in the bladder obscuring the calculi and right-sided ureteral reflux

Figure 2

(a and b) Saggital and axial MRI films showing mobile calculi in a cavity behind the bladder, (c and d) retrograde ureterogram with dye filling the diverticulum at the lower end of the ureter, no opacification of a pelvi-calyceal system and (e) removed calculi

He was planned for endoscopic removal of seminal vesical calculi. On cystoscopy, a small stone was seen at the right vesicoureteral junction. Retrograde ureterography revealed that the right ureter was blind ending and dye was seen filling a diverticulum at the lower end of ureter [Figures 2c, and d]. Endoscopic incision of the diverticulum orifice was made. It was full with multiple, tiny, smooth-surfaced calculi which were removed endoscopically.

DISCUSSION

The adult kidney develops from the metanephros while the ureter and collecting system develop from the mesonephric duct. Contact of the ureteric bud with the metapehric blastema and reciprocal molecular signaling between the two is responsible for differentiation along the normal pathway. Unilateral renal agenesis develops due to a fault in the development of the ureteral bud which fails to form or make contact with the developing metanephros.[1] In most cases, the ipsilateral ureter is completely absent.

Ureteral diverticulae are usually blind-ending bifid ureters. Owing to altered peristalsis and ureteroureteral reflux of urine, calculi may form in these diverticulae. An extensive search of the English literature on Pubmed did not produce any report on calculi in blind-ending single ureters associated with ipsilateral renal agenesis. Radiologically, these resembled seminal vesical caluli. This ureter had reflux and stasis of urine in the diverticulum could have led to stone formation in absence of kidney on that side.[2] The diagnosis could only be established on cystoscopy and retrograde pyelography.

CONCLUSIONS

In symptomatic patients with unilateral renal agenesis and associated anomalies of ureter, cystoscopy and retrograde pyelography should be performed to confirm the diagnosis and delineate the anatomy. Radiological findings may be misleading.