Commonly, the diagnosis of EU is made during childhood owing to recurrent urinary tract infections or urinary incontinence [3, 6]. However, a single-system ectopic ureter is a diagnostic challenge and is often delayed, especially when it is associated with a small dysplastic, poorly functioning, non-visualized kidney, which may be difficult to see even with conventional imaging studies and having a contralateral normal solitary kidney [1, 13]. Our patient came to visit the health facility during adulthood and the diagnosis was delayed because of improper evaluation. In males, an ectopic ureter is always inserted proximal to external urethral sphincter, and they are usually continent. In females, the ureteral opening may be located in the urethra, in the vagina, in the uterus, or in the fallopian tubes along the mullerian duct structures that bypass the urethral external sphincter . Twenty-five percent of ectopic ureter open into the vagina. So girls present with small volume of leakage or spotting but they have normal voiding patterns. Our patient presented with the same complaint since childhood. The diagnosis of EU in our patient was made clinically by a negative dye test and inspection of a small unilateral hole with spurting of urine in the right lateral vaginal wall, through which advancing an infant feeding tube is possible. It was confirmed by CT urography, which also showed atrophic ipsilateral pelvic kidney in addition to the EU. A single-system ectopic ureter (SSEU) is rare in females and commonly associated with other anomalies such as in this patient where it was associated with ipsilateral ectopic kidney . Surgery of an SSEU depends on the degree of renal function, associated anomalies, and the location of the EU . In single-system ectopic ureter, the affected kidney is usually small and poorly functional and the management is nephroureterectomy (removal of the kidney and ureter) . Preservation of the renal function in the affected kidney makes our case unique and increases the difficulty in decision-making of the management. If the renal function is good and the kidney is not dysplastic, the most important factor that affects the surgery is the location of the EU. An intramural ectopic ureter is found attached to the serosal surface of the bladder but fails to terminate and open into the bladder lumen at the trigone. Instead, it continues to tunnel through the trigone in the submucosa to open at a site distal to the bladder neck. In this case, UI may result not only from the ectopic position, but also from disruption of the smooth muscle of urethral sphincter mechanism by the submucosal ureteral tunnel. This is managed surgically by neoureterostomy and urethral-trigonal reconstruction. Whereas, repair of an extramural ectopic ureter is done by ureteral reimplantation (neoureterocystostomy). The goal of surgery is to restore the ureteral orifice to a position proximal to the urethral sphincter, thereby restoring urinary outflow control . In our case, the kidney was small, ectopic, and had good function. So, we preserved the kidney and re-implanted the ectopic ureter to the bladder wall at the bladder trigone. Grover et al. reported a case of right EU terminating into the right lateral wall of the vagina, with good function of the right kidney managed by right ureteric re-implantation (extravesical ureteroneocystostomy). In this case, follow-up of the patient after 3 months was uneventful . The management of this case is similar to our case. But, in our case, the ectopic pelvic kidney opening into the lateral vagina made a transvaginal surgical approach easier.
This surgery decreases the risk of recanalization of the distal segment because we mobilized the ureter at its most distal segment. This approach is also important in patients having ipsilateral ectopic kidney with good function because it decreases the postoperative morbidity and invasive abdominal or inguinal surgery.