VAGINAL ECTOPIC URETER WITH GARTNER'S DUCT CYST

Abstract

In ureteral duplication anomalies a distal lower ectopic ureter usually will not require removal after heminephrectomy. We recently cared for a woman presenting with a purulent vaginal discharge. Retained secretions in an ectopic ureter draining into a Gartner’s duct cyst necessitated distal ureterectomy. The Gartner’s duct cyst was left in place in the vagina. CASE REPORT A 24-year-old woman presented with recurrent urinary tract infections and persistent purulent vaginal discharge. Evaluation of incontinence at age 5 years had revealed a duplicated collecting system on the right side, and right upper pole heminephrectomy was performed. The location of the upper pole ureteral orifice was never identified. At age 19 years further evaluation for the same symptoms revealed a ureteral orifice adjacent to the urethral meatus at the introitus. Left upper pole heminephrectomy was performed with resolution of incontinence. Excretory urography was performed for the recurrent symptoms and confirmed the bilateral heminephrectomies. Cystoscopy revealed normally placed ureteral orifices in the bladder. The left ectopic ureteral orifice could not be seen at the introitus or in the urethra. On vaginal examination a purulent discharge was seen coming from the area of a right Gartner’s duct cyst (fig. 1). Abdominal computerized tomography revealed a tubular, fluid filled structure running adjacent to the right ureter (fig. 2). Distal ureterectomy through a suprapubic approach was performed without removal of the vaginal component. The patient remains well 6 months following distal ureterectomy. The Gartner’s duct cyst remains palpable but no further treatment has been necessary. duplicated collecting system on the left side with an ectopic FIG, 1, speculum examination reveals Gartner,s duct cyst (large lateral to cervix DISCUSSION Embryologically, the ureteral bud arises from the mesonephric duct, separates from its origin and inserts into the urogenital sinus.’ The distal remnant of the mesonephric duct becomes the Gartner’s duct, which runs from the hymen to the uterine adnexae along the lateral vaginal wall. Failure of the ureteral bud to separate from the mesonephric duct leads to ureteral termination in the Gartner’s duct or Gartner’s duct cyst. Vaginoscopy or speculum examination may reveal the Gartner’s duct cyst lateral to the cervuf as Seen in this patient. While the urological literature descnbes ectopic ureteral entry into a Gartner’s duct cyst, documented case reports are rare due to the infrequency with which the distal ureter needs to be removed.z.3 Whether the Gartner’s duct cyst itself needs to be removed and with what morbidity are not well delineated in the urological literature. we elected not to remove the cyst to avoid entering the vawa but we would perform marsupialization of the cyst If the Patient were to become symptomatic.