Retrocaval ureter

This is 13 yrs old boy presented to us with rt loin pain of 7 days duration.

Usg shows..grade 2 HN with proximal ureter dilatation.image not available.
Ivp ..attached... Characteristic medial deviation upper ureter .rt
Any further investigation needed to work up this case?
How to manage this case...?
Kindly discuss

Retrocaval ureterRetrocaval ureter


  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    03 Mar 2020 07:32:53 PM

    Pain + HN + Characteristic apperance >> Anderson Hyne's Pyeloplasty

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Mar 2020 07:54:25 PM

    There is a typical appearance of involved ureter in provided IVU images.

    Question for trainees: What are these deformities in IVU? 

  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    03 Mar 2020 08:14:10 PM

    Fish hook appearance sir

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Mar 2020 08:23:53 PM


    Are there more  appearances describe?
    Like types and appearances...

  • Utsav Shah
    Utsav Shah
    03 Mar 2020 08:51:06 PM

    Hello sir. We recently operated upon a similar case. 

    There r 2 types of retrocaval ureter:
    Type 1 is low loop and has ‘Fish hook’ or ‘S shaped’ appearance. 
    Type 2 is high loop, has mild Hydronephrosis and has ‘Sickle curve’ like appearance 

    Hereby attaching the intraop lap image of the ureter being compressed by the abnormally developed IVC

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Mar 2020 09:04:46 PM

    Great replay Utsav.

    So, you mean to say problem is because of abnormal development of IVC?

  • Utsav Shah
    Utsav Shah
    03 Mar 2020 10:06:23 PM

    Ya sir it’s wrong to call it circumcaval ureter. It’s actually an anterior cava. The issue is with the persistence of posterior cardinal vein on the right side. Also, Goodwin proposed a technique where he cut the vena Cava after clamping and reanastomosed it behind the ureter citing that the problem is with actually the vena cava then why shud the ureter suffer! Sounds extremely courageous but that’s the truth!

  • Gyanendra Sharma
    Gyanendra Sharma
    04 Mar 2020 08:51:46 AM

    The diagnosis in this case is obvious --the question is should be operate

    The views  that I I am putting forth are my thoughts and are meant to stimulate a discussion
    1. Are these cases obstructed? Such cases are not common but whenever I have seen them I have never found the function to be compromised. There is dilatation on USG & IVU  but the concentration of the contrast is good on either sides &  it is only the excretion which seems to be delayed
    2. Atleast two cases which I have seen & followed up did not show deterioration of function during follow up. Diuretic IVU in these cases showed clearance of contrast
    3. When patient complains of right loin pain --is the pain definitely due to renal cause
    4. Why , very often these cases are seen in adults
    5. In this case also the concentration looks good on either side
    6. It would interesting to know the experience of seniors  who at times must have followed up these cases conervatively

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    05 Mar 2020 06:37:14 PM

     I think Preop diuretic Renogram is necessary.
    If normal,

    DJ stenting may be tried to exclude pain of renal origin.

  • Venugopal P
    Venugopal P
    06 Mar 2020 09:19:37 AM

    Dear All,

    I am happy that the post of Tikenjit Mazumdar on Retrocaval Ureter is having some discussion and the discussions are fruitful.

    For the trainees in the group (not those others are exempted), it is necessary for all to know the Embryological basis of Development of Retrocaval ureter. I would urge all to read ‘Hinman’s Atlas of Urological anatomy 2012 edited by Gregory T MacLennan’ if possible. For those not having access to the book, It would be advisable to read the article by Arianna Lesma* et al (2006).

    first reported by Hochstetter in 1893. Utsav has mentioned the two types as described by Bateson and Atkinson (1969). The generally accepted explanation that pressure by the inferior vena cava explains the second type, but not the first. In the first Type that is more commonly encountered than the second the point of obstruction is placed some distance from the lateral margin of the IVC. It may be to an associated anomaly in the development of the ureter where it crosses the lateral border of the psoas muscle. Some have mentioned the possibility of functional deficiency of the segment of ureter passing under the IVC but a smaller calibre of the ureter is not discerned when Retrograde studies are done. More often than not, the catheter can be passed up this segment into proximal ureter.

    Today we are in the era of Lap and Robot assisted procedures and Retrocaval ureters are no exception. However it is wise to remember Hemal when he stated that Robot assisted procedures give no added advantage in the operative intervention other than adding to the cost for the procedure. This may not be well taken by the protagonists for Robotic technology.

    Division of dilated pelvis with transposition and reanastomosis, initially described by Harril in 1940, is the most commonly practiced intervention in symptomatic patients. For this the part of ureter passing under the IVC needs to be mobilized. I prefer the technique described by Puigvert wherein he leaves the part behind the IVC untouched, dissecting the proximal ureter upto its point behind the IVC and the distal ureter over and medial to the IVC. The distal ureter is disconnected and brought laterally to the proximal ureter and then a decision is taken as to where the Uretero-ureteral anastomosis need be made. The part under the ureter is left untouched and left open. Most often the uretero-ureteral anastomosis will be Uretero-Pelvic.

    I have seen left sided Retrocaval ureter in a case of Duplicated IVC. I have also encountered this anomaly in a patient with RCC.

    With warm regards,



  • Dr. Roy Chally
    Dr. Roy Chally
    09 Mar 2020 08:14:34 PM

    Retrocaval ureter is congenital but are symptomatic usually in 2nd or 3rd decade. Any explanation? 

    Is the retrocaval segment of ureter abnormal in function or anatomy? When is  this pathology manifest. 
    What is the treatment for asymptomatic retrocaval ureter?
    Comments of experts will be helpful. 

  • JG Lalmalani
    JG Lalmalani
    18 Mar 2020 03:33:40 PM

    Retrocaval Ureter is always obstructive and in my mind always merits surgery.

    Standard treatment involves mobilisation; excising the part behind the IVC and anastomosing with ureter medial to the IVC.
    I have been mobilising the ureter as advised but cutting vertically in the dilated proximal Pelvis and pulling the entire medial ureter and lateral part of the pelvis from behind the ureter; and anastomosing the wide proximal pelvis with the wide pelvis pulled out from behind the IVC, anterior to the IVC - this forms a wide anastomosis and unlikely to stenose.
    Not regretted even once. 

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