it may rarely lie parallel to the upper ureter when it can be confused with the latter .
we encountered one such case of long appendix running parallel to the ureter in retroperitoneum .
a 32-year - old female patient presented with right flank pain of 3 weeks duration .
intraoperatively , a double j ( dj ) stent was placed , which was removed 3 weeks later . following stent removal she had progressively increasing flank pain .
ultrasonography showed normal left kidney with hydronephrotic right kidney ( parenchymal thickness of 7 mm ) and 400 ml perinephric collection .
a right nephrostogram with the right retrograde ureteropyelogram ( rgp ) was done , which showed complete cut - off at the pelvi - ureteric junction with small intrarenal pelvis and ureter showed complete cut - off at l2 vertebral level [ figure 1a and b ] .
lower pole of the kidney could be mobilized only in the subcapsular plane and the pcn came out during the mobilization .
however , urinary bladder was not distended prior to stent placement ; hence , no attempt was made to see retrograde efflux of urine from side holes of cranial end of the stent .
post - operative x - ray showed a malpositioned lower end of stent [ figures 1c ] .
pcn was placed and nephrostogram was done , which showed that the contrast going into the cecum thereby establishing that the lower pole of the kidney was inadvertently anastomosed to tip of the appendix .
intravenous urography done 6 weeks following stent removal showed patent ureterocalyceal anastomosis with prompt drainage of contrast .
( a ) nephrostogram showing complete cut - off at the pelvi - ureteric junction with intrarenal pelvis .
( c ) x - ray kidney , ureter and bladder region showing malpositioned caudal end of double j ( dj ) stent .
( d ) retrograde ureterogram showing dj stent lateral to ureter ( a ) intraoperative picture showing appendix anastomosed to the lower pole of kidney and ureter lying separately .
however , in urological practice it is a useful substitute for the right as well as left ureter and for creating catheterizable stomas .
monks and blake examined 656 cadavers regarding variations in anatomy of appendix . in 4.4% cases ,
sometimes , it tracked upward behind caecum , passed over the anterior surface of the right kidney until its upper margin .
another variation was to find the appendix behind the peritoneum , under the caecum and extending to the lower border of the right kidney .
, the mesoappendix was attached to half - length of appendix at the base , tip remaining free . in certain cases mesoappendix
if a long appendix is positioned adjacent to ureter and the tip is free , it can be easily misidentified as ureter . in the index case ,
patient was previously operated and had developed perinephric collection in the post - operative period due to which there were dense perinephric adhesions with obliteration of normal anatomical planes rendering identification of ureter difficult .
intraoperatively , lower end of the dj stent went into the appendix without any resistance and coiled into the caecum . because of the ease of placement of stent no misadventure was suspected .
however , bladder was not distended prior to stent placement and hence no attempt was made to see efflux of urine from the side holes of cranial end of the stent after positioning it .
in retrospect , this complication could have been avoided by pre - placement of ureteric catheter to aid intraoperative identification of ureter . giving attention to finer details like partially distending the bladder prior to placement of the stent and to observe retrograde flow of urine from cranial end of stent
the position of the appendix is highly variable and it may lie adjacent to the right ureter where it can be confused with the latter . in urological surgeries , when dense fibrosis is expected , pre - placement of ureteral catheter may aid its intraoperative identification . though ease of placement usually suggests correct positioning of stent , it should always be confirmed by observing retrograde flow of urine from the bladder through side holes of the stent .
 anatomical structures with similar appearance may at times be confused for each other . 
 this situation can be compounded by lack of normal anatomical planes . 
 we did ureterocalicostomy on a 32-year - female with secondary pelvi - ureteral junction obstruction . 
 post - operatively , it was discovered that she had a long appendix running parallel to ureter in retroperitoneum , which was misidentified as ureter and anastomosed to the lower pole of the kidney . 
 she was re - explored , appendix was removed , ureter was identified and ureterocalicostomy was done . 
 patient is asymptomatic at 1 year follow - up . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION