Duplicated, Ectopic Ureter Inserting into the Prostatic Urethra During Robot-Assisted Radical Prostatectomy

Abstract

Introduction: Robot-assisted radical prostatectomy has been shown to be a valuable therapeutic option for patients with clinically localized prostate cancer. In the era of cost savings and avoiding unnecessary tests, patients with intermediate-risk prostate cancer have been recommended against preoperative cross-sectional imaging techniques such as CT or MRI. Ureteral duplication associated with ectopia is a rare finding in men and insertion of the ectopic ureter occurs above the external sphincter or pelvic floor. In the literature, this clinical presentation has been reported in five case reports.1–5 Materials and Methods: We present the case of an otherwise healthy 67-year-old male who was found to have an elevated prostate-specific antigen (PSA), which prompted a transrectal ultrasound-guided biopsy of the prostate demonstrating Gleason 3 + 4 adenocarcinoma in the left mid and base. A prostate examination showed an ∼90-g gland that was otherwise benign, therefore clinical stage T1c. He denied lower urinary tract symptoms, erectile dysfunction, or family history for prostate cancer. After weighing all treatment options, he proceeded to robot-assisted radical prostatectomy and pelvic lymph node dissection. From an anterior approach during anterior cystotomy, he was discovered to have left-sided complete ureteral duplication with the upper pole inserting into the prostatic urethra. The bladder neck was widened to ensure identification of ureteral orifices and confirmation of the anatomy. Results: Following confirmation of the above anatomy by dissecting out the ureters at the level of the pelvic brim and observing indigo carmine excretion from the ectopic ureter, we placed a Double-J ureteral stent to identify and protect the ureter while proceeding with our posterior cystotomy. Ultimately, we performed complex bladder neck reconstruction to displace the stented ectopic ureter posteriorly and laterally, while completing the vesicourethral anastomosis using the routine Van Velthoven technique. Final pathology revealed Gleason 3 + 4, pT2cN0 adenocarcinoma of the prostate with negative surgical margins. Conclusions: After a satisfactory cystogram demonstrating contrast refluxing through the stent to the upper pole and no contrast extravasation, the patient's catheter was removed at 3 weeks postoperatively. He returned 1 month later for ureteral stent removal through flexible cystoscopy. The first PSA recheck at 3 months returned as undetectable and the patient continued with routine prostate cancer surveillance. As shown in the above case, excellent oncologic outcomes can be obtained with complex bladder neck reconstruction when encountering a duplicated, ectopic ureter inserting into the prostatic urethra during robotic radical prostatectomy. If the ectopic ureteral orifice appears too distal to the bladder neck, we recommend performing ureteral reimplantation or ureteroureterostomy to maintain adequate cancer control. All authors have no competing financial interests. Presented at: 31st World Congress of Endourology & SWL, October 22nd–26th, 2013, New Orleans, LA. Runtime of video: 7 mins 58 secs