Abstract

A 28 year old man presented with right flank pain since three months, the pain was dull and intermittent, associated by frequent attacks of recurrent urinary tract infections proved by urine culture. No abnormality was found on general and abdominal physical examination. Apart from urinalysis which showed 12-13 pus cells and epithelial cells but no red cells, complete laboratory evaluation including complete blood picture, urea, creatinine and electrolytes were within normal limits. X-ray KUB showed a small radio-opaque shadow in the region of right kidney.On ultrasonography, moderate hydronephrosis and upper hydroureter with a stone in lower pole of right kidney was found. Intravenous pyelography revealed right-sided hydronephrosis and hydroureter upto mid region with "J deformity" along with a stone in the lower calyx. Lower right ureter, left kidney, left ureter and urinary bladder were normal. Reyerograde pyelography revealed normal lower part of the right ureter upto the point where the ureter cross behind the inferior vena cava (fig 1). A diagnosis of postcaval ureter was established and surgery was planned. The right kidney and ureter were approached by right sub costal lumbar incision. On exploration, right proximal ureter and pelvis were dilated. Dilated proximal ureter was curved medially then posterior to IVC. Finally curved anteromedial to IVC and took a downward course. Distal ureter was normal. Ureter was dissected and separated anteriorly from IVC and transected near the pelvis. The stone in the lower pole was removed and ureter was anteriorised and an oblique ureteroureteral anastomosis was done with 4/0 vicryl.A double J stent was placed inside the ureter across the anastomosis. Tube drain was placed and wound closed in layers. Drain was removed on fourth postoperative day. Patient recovered uneventfully. An IVU six weeks after surgery showed regression of hydronephrosis and hydroureter with no ureteric obstruction

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