Secondary obstructive giant megaureter leading to massive pyogenic urinary infection

Abstract is not required for Clinical Imagesis not required for Clinical Images (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 10, October 2017. ISSN: 0976-3198 Int J Case Rep Images 2017;8(10):684–686. www.ijcasereportsandimages.com Fonseca et al. 684 CASE REPORT OPEN ACCESS Secondary obstructive giant megaureter leading to massive pyogenic urinary infection João Fonseca, Maria Amparo Castellano, Manuel Veríssimo, Armando Carvalho


CLINICAL IMAGE PEER REVIEWED | OPEN ACCESS
therapy was instituted. The clinical condition of the patient declined progressively and had passed away after three days.

DISCUSSION
Giant megaureter is the name given to a massively dilated ureter. This pathological finding is rarely seen in clinical practice, especially in the geriatric age. The mechanism should be classified as obstructive, refluxing or non-obstructive non-refluxing [1]. We theorize that this case of obstructive megaureter was a late complication of a prior gynecological surgery, considering its absence in previous follow-up imaging exams. Almost half of the ureteral iatrogenic complications result from gynecological surgeries, of which hysterectomy is the main cause [2,3]. Its early diagnosis is crucial, as it can lead to kidney damage and urinary tract infections [2].
In these patients with impaired renal function, nonenhanced CT scan can be of great value. This characterizes the extent of urologic changes, and identifies the presence Figure 1: A cystic-like structure (9.5 cm in diameter) is easily identifiable in the right pararenal location, on the computed tomography scan axial cuts, corresponding to the right ureter. of calculi, compressive masses, and other anatomical abnormalities [4]. Magnetic resonance urography may also play an important role because it allows optimal noninvasive evaluation of many abnormalities of the urinary tract, including urinary tract obstruction [5]. Additionally, new gadolinium-based contrast agents associated with a few/unconfirmed cases of nephrogenic systemic fibrosis (like Gadobenate dimeglumine -MultiHance®), may be used safely even with severe renal dysfunction [6].
Due to the severe clinical condition of the patient, who met criteria for severe sepsis, after discussion of the case with the urology department, percutaneous nephrostomy was considered the safest option at the time. Other procedures, such as nephrectomy and resection of the ureter, were not considered because the patient and her family refused more invasive surgical interventions.
This case is interesting because it presents a rare image of an extremely aberrant dilation of ureteral architecture.

CONCLUSION
We presented a patient who exhibited a secondary giant megaureter complicated by a severe urinary tract infection. The obstructive lesion resulted probably from gynaecological surgery, which is the main cause of iatrogenic ureteral injury. Sometimes these complications are only detected after serious consequences.

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