What are the diagnostic and treatment options for issues related to the left ureter ostia?

Diagnostic and Treatment Options for Left Ureter Ostia Issues

The management of left ureter ostia issues should follow a systematic approach based on the specific condition, with imaging studies being the cornerstone of diagnosis and treatment decisions guided by the nature and severity of the pathology.

Diagnostic Approach

Initial Evaluation

• For suspected ureteral injury or pathology, contrast-enhanced CT scan with delayed urographic phase is the diagnostic procedure of choice in hemodynamically stable patients 1
• In penetrating trauma, contrast-enhanced CT with delayed phase is indicated in all hemodynamically stable or stabilized patients 1
• Intravenous urography may be useful in unstable patients during surgery when a kidney injury is found intraoperatively or when CT scanning is not available 1

Specific Imaging Techniques

• CT urography (CTU) is the preferred imaging modality for evaluating the upper urinary tract, including the left ureteral ostium 1
• Retrograde pyelography can provide detailed visualization of the ureter and its ostium when CT findings are equivocal 1
• For suspected ureteral ectopia, CT scan with delayed contrast has proven to be the most sensitive test for diagnosis 2
• On contrast-enhanced CT scans, the ureter can be identified in its posterior position relative to the renal vessels 3

Endoscopic Evaluation

• Cystoscopy with direct visualization of the ureteral ostia is essential for diagnosis of conditions like ureteral ectopia or strictures 1
• Ureteroscopy may be performed at 3-12 month intervals for follow-up if endoscopic resection is considered 1
• In cases of positive upper tract cytology but negative imaging, ureteroscopy with selective catheterization of the ureters may identify occult ureteral tumors 1

Treatment Options

For Ureteral Trauma

• Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable minor, moderate, and severe lesions 1
• During emergency laparotomy, direct inspection of the ureter should always be performed in patients with suspected ureteral injury 1
• Urinary drainage should be obtained as soon as possible in case of traumatic injury to the urinary tract 1

For Ureteral Tumors

• For resectable ureteral tumors, the primary management is surgery, with the specific procedure depending on tumor location and extent 1
• Tumors in the upper ureter are typically treated with nephroureterectomy with a cuff of bladder plus regional lymphadenectomy for high-grade tumors 1
• Distal ureteral tumors may be managed with distal ureterectomy and reimplantation of the ureter (preferred if clinically feasible), endoscopic resection, or nephroureterectomy with a cuff of bladder 1

For Ureteral Strictures or Obstruction

• Urethral endoscopic management (e.g., urethral dilation or direct visual internal urethrotomy) may be utilized for urgent management of urethral stricture 1
• For complete obliteration of ureteral ostium, a combined anterograde trans-nephrostomic and retrograde endoscopic approach can restore patency 4
• In cases of ectopic ureter causing incontinence, surgical correction is required 5, 2

For Lynch Syndrome Patients

• In patients with Lynch syndrome, frequent urinalysis with a threshold of 3 RBC/HPF or greater should be performed to pursue further testing for upper tract urothelial cancer 1
• More intensive screening of high-risk Lynch syndrome populations, particularly those with MSH2 mutation or family history of upper tract urothelial cancer, is recommended 1

Follow-up Recommendations

• For ureteral tumors, the final pathologic stage guides subsequent management 1
• No adjuvant therapy is advised for lesions that are pT1 or less, but serial follow-up of the urothelial tracts is recommended 1
• Follow-up should include upper-tract imaging studies such as IVP, retrograde pyelogram, or CT/MRI urography at 1-2 year intervals 1
• Patients with more extensive disease should consider systemic adjuvant treatment with chemotherapy 1

Special Considerations

• In trauma cases, understanding the posterior position of the ureter relative to renal vessels is crucial for surgical exploration and imaging interpretation 3
• For patients with Lynch syndrome, modification of CT protocols to include CTU can be requested when imaging is already being done for follow-up of colon cancer 1
• In cases of ureteral ectopia, the diagnosis may require multiple imaging modalities as initial tests are often negative 2

The management of left ureteral ostia issues requires careful diagnostic evaluation with appropriate imaging and endoscopic techniques, followed by targeted treatment based on the specific pathology identified.