Renal dysplasia with the ipsilateral ectopic ureter mimicking abscess of the prostate Renalna displazija sa ipsilateralnim ektopi nim ureterom koji oponaša apsces prostate

Introduction. In males the ectopic ureter usualy drains into the prostate (50%). During ureteric developement a thin membrane (Chawalla’s membrane) separates the lumen of the ureter and the urogenital sinus at the point where the ureter joins the urogenital sinus. This membrane ruptures allowing urin to drain from the ureter to the urogenital sinus. The authors reported a case of renal dysplasia associated with ipsilateral uretral ectopia mimicking prostatic abscess. Case report. A subfebrile (37.3°C), 23-year-old patient, otherwise healthy, presented with persistent ascending perineal pain non-responsive to antibiotics and analgetics. Digitorectal examination (DRE) showed asymmetric prostate with a soft, tender, buldging left lobe suggestive of prostatic abscess. The diagnosis was suspected using transrectal ultrasonography (TRUS), but the picture of the anechoic tubular structure in the left lobe of the prostate with a proximal undefined extraprostatic extension and a caudal intraprostatic blind end was incoclusive for the definitive diagnosis of prostatic abscess. Magnetic resonance imaging (MRI) was ordered and definitive diagnosis of renal dysplasia associated with the ipsilateral ectopic ureter filled with inflamed content mimicking prostatic abscess was made. Transurethral incision/minimal resection of the distal, blindly closed end of left ectopic ureter was done. Endoscopic surgical treatment was sufficient for relief of clinical symptoms. The patient’s recovery was uneventful. Conclusion. To the best of our knowledge, a case of renal dysplasia with the ipsilateral ectopic ureter mimicking prostate abscess has not been reported so far. Cystic pelvic malformations in males may result from too craniall sprouting of the ureteral bud, with delayed absorption and ectopic opening of the distal end of the ureter.


Introduction
Principles of ureter developement are little undestood.Ureters begin as a simple cuboidal epithelial tube with a formed lumen at 28 days of gestation.It is suggested that transient luminal obstruction occurs between the days 37 and 40 that recanalizes subsequently.The proces of recanalization starts in the mid ureter and extends cranially and caudally.Chawalla's membrane presents a two-cell thick layer over the ureteral oriffice.During ureteric developement a Chawalla's membrane separates the lumen of the ureter and the urogenital sinus.This membrane ruptures allowing urin to drain from the ureter to the urogenital sinus.In males, ectopic ureter usually drains into prostate (50%).

Case report
A subfebrile (37.3°C), 23-years-old patient, otherwise healthy, presented with persistent ascending perineal pain lasting for a week, non-responinsive to antibiotic and analgetics.His past history revealed 3 episodes of similar symptoms (although much less severe), with the first episode presented 4 years ago.In the past the patient would be typicaly treated like exacerbated chronic prostatitis [the diagnosis would be established based on anamnesis and laboratory tests -digitorectal examination (DRE) were not done at any time] by ciprofloxacin.The symptoms would disapeare on the standard antibiotic therapy.After anamnesis had been taken, physical examination was done.Physical examination of the abdomen and external genitalia as well as laboratory findings (urinalaysis, white blood cells -WBC, erythocyte sedimentation rate -SE) were unremarkable.Digitorectal examination showed the asymmetric prostate with a soft, tender, buldging left lobe mass with no discharge on massage.The diagnosis of possible prostate abscess was made and transrectal ultrasonography (TRUS) was done (Figure 1), but the defintive diagnosis was revealed by magnetic resonance imaging (MRI) (Figures 2).Urethrocystoscopy showed the asymmetric bladder trigone elevated on the left side (by the dilated distal part of the ectopic left ureter) with the missing left ureteral orifice.A paracolicular swelling on the left side (buldging of dilated, distal part of ectopic ureter) in the prostatic urethra (Figure 3a) was incised/minimaly resected, and was followed by turbid discharge from the ectopic ureter.A wide ectopic, dilated distal part of the left ureter was noticed (Figure 3b).Immidiately after incision/resection of the paracolicular area of the prostate, elevation of the bladder trigone disappeared.After the procedure, upon waking up from general anesthesia, the patient was absolutely pain-free, requiring no analgesia at all.The patient was discharged from the hospital on the first postoperative day and was prescribed ciprofloxacin per os for 5 days.One month after the procedure, control cystoscopy was done and the same picture of intraoperative finding -a widely open ectopic, dilated distal part of the left ureter was seen.Digitorectal examination, physical examination of external genitalia as well as laboratory findings (urinalysis, urineculture, WBC, SE) were unremarkable.

Disscusion
To the best of our knowledge, there has been no previous report on renal dysplasia with the ipsilateral ectopic ureter mimicking prostatic abscess.Endoscopic prostate interventions can cause early and late postoperative complica-tions such as: failure to void, urinary tract infections and transurethral resection syndrome 1,2 .Pelvic cystic malformations in males may result from a too cranial sprouting of the ureteral bud with delayed absorption and ectopic opening of the distal end of the ureter.The symptoms are usually related to bladder or cyst distention or secondary to the obstruction of mesonephric duct derivations 3,4 .The most probable embriological cause of blindly closed ureter is a persistent Chwalla membrane.It is physiologically seen between the weeks 37 and 39 of gestation, then it ruptures and allows normal drainage of urin 5,6 .

Conclusion
To the best of our knowledge, a case of renal dysplasia with the ipsilateral ectopic ureter mimicking prostate abscess has not been reported so far.Cystic pelvic malformations in males may result from too cranial sprouting of the ureteral bud, with delayed absorption and ectopic opening of the distal end of the ureter.A clinical algorythm consists of the history and physical exam, TRUS and MRI, and seems to be sufficient for the correct diagnosis.

Fig. 1 -
Fig. 1 -Transrectal ultrasound (TRUS) showing the anechoic tubular structure in the left lobe of the prostate with a proximal extraprostatic extension and a caudal intraprostatic blind end.

Fig. 2 -
Fig. 2 -Magnetic resonance imaging (MRI) showing the small dysplastic kidney (white arrow) in the left retroperitoneum and the distended and convoluted ectopic ureter (black arrow).