Duplex Renal System Research Articles

INTEGRATED CARE FOR URETEROCELE PROLAPSE

Ureteroceles are rare congenital anomalies, occurring in about 1 in 4000 individuals, with a higher incidence in females, particularly those with a duplex renal system. The etiology and clinical presentation of ureteroceles vary, often complicating diagnosis and management. Common symptoms include antenatal hydronephrosis, vesicoureteral reflux (VUR), and recurrent urinary tract infections (UTIs). In cases of ectopic ureteroceles, there is a risk of significant complications, such as hypertension and renal failure, requiring timely and precise intervention. Diagnostic methods include sonography and voiding cystourethrography (VCUG), while management approaches range from minimally invasive endoscopic incisions to more complex excision and reimplantation procedures, depending on the severity. We report the case of a 1.5-month-old female infant, born via LSCS, presenting with fever and a rapidly enlarging reddish mass descending from the urethra. Initially the size of a peanut, it grew to the size of a lemon, accompanied by symptoms of straining during urination and defecation. While prenatal scans showed hydro-ureteronephrosis, postnatal imaging appeared normal until the mass emerged. Clinical suspicion of a ureterocele was confirmed through imaging studies. This case highlights the unpredictable nature of ureteroceles, emphasizing the importance of prenatal and postnatal screening. Treatment strategies must be individualized, considering the rapid progression of the condition. While endoscopic incision is favored for its minimally invasive approach, reconstructive surgery may be necessary if complications such as reflux or a duplex renal system are present. Early detection remains key to preventing long-term morbidity and improving outcomes in infants with ureteroceles.

Bilateral Complete Ureteral Duplication with Obstructing Stones in Both Left Ureters: A Case Report and a Review of Literature

Congenital anomalies like duplex renal collecting systems are rare developmental conditions. Among these anomalies, ureteral duplication is rarely observed, with partial ureteral duplication comprising a majority of cases. Bilateral ureteral complete duplication, where fully duplicated ureters drain separately into the bladder via separate orifices, is extremely rare, making it a seldom-documented anomaly in the medical literature. A case of bilateral complete ureteral duplication complicated by calculi in both the upper and lower moieties of the left kidney presented to the urology outpatient department with complaints of left flank pain for one month. His computed tomography-urogram revealed complete duplication of bilateral collecting systems with bilateral double ureters with an 8.2×5.9 mm2 sized stone in the pelvi-ureteric junction of the left upper moiety and 11.9×5.6 mm2 sized stone in the proximal ureter of left lower moiety causing hydronephrosis of both upper and lower moiety pelvicalyceal system. Calculi in both the upper and lower moieties were cleared in a single setting using a Ureteroscopic Lithotripsy. Duplex renal systems, while often asymptomatic, are linked to a higher occurrence of treatable conditions like stones and renal reflux diseases. The duplicated structure may lead to stagnant urine, causing obstructions and consequently infections. Stones that obstruct the ureter for a prolonged period can cause renal impairment and require active intervention. Currently, flexible or semirigid ureteroscopy with laser lithotripsy is the standard procedure. Even in this case, both stones were effectively managed in a single session using a standard procedure.

Multiple vaginal stones secondary to an ectopic ureter in an adult female patient: a case report

Vaginal stone is a rare case with low incidence. Ectopic ureter insertion into the vagina is one of the congenital abnormalities that may lead to vaginal stone formation. True incontinence persisting until adulthood might indicate an ectopic ureter, often associated with a complete duplex renal system. We reported an adult female that came with a chief complaint of true incontinence since she was young. However, it was left untreated due to limited healthcare facilities in her area and low socioeconomic status. The computed tomography examination revealed a right complete duplex renal system, with upper moiety inserted into the vagina, and multiple vaginal stones. Thus, stone removal and ureteroneocystostomy procedure were performed. No further complaints or complications were recorded after the hospital discharge.

Bladder Dysfunction and Re-Absorbable Bulking Agent Affect Success Rate in Children Underwent Endoscopic Treatment for Vesicoureteral Reflux: A Long-Term Follow-Up Study.

This paper is designed to evaluate the results (at long-term follow-up of) children affected by dilating VUR. Our attention was focused on how VUR grade, laterality, bladder dysfunction (BD), the double renal system, and the type of bulking substance may affect VUR resolution in the long-term period. The charts of 93 children with dilating VUR who underwent endoscopic treatment (ET) and with a minimum post-operative follow-up of 7 years were reviewed (mean follow-up time was 9.6 + 1.4). The majority of patients had severe and bilateral VUR. Polydimetilsiloxane or hyaluronic acid/dextranomer (PDS or Ha/Dx) were used as bulking agents. VUR persistence following endoscopic injection was independent with respect to grade, laterality, duplex renal system, and BD. However, the rate of VUR persistence was significantly higher in children with BD. Children treated with Ha/Dx had a higher rate of VUR persistence. This research demonstrated that ET of VUR is also effective at very long term follow up (and without the development of significant complications). We also showed that patients treated with absorbable bulking agents such as Ha/Dx may experience a higher recurrence rate at the long-term follow-up). We also confirm that the only preoperative condition affecting VUR recurrence was bladder dysfunction.

Urinary incontinence in a dog with a duplex renal system and extramural ectopic ureter

A 1-year-old female spayed French Bulldog was referred to the Interventional Radiology and Endoscopy Service for evaluation of urinary incontinence with partial response to medical management (phenylpropanolamine). Cystourethroscopy and retrograde ureteropyelogram were performed and revealed multiple congenital abnormalities including; a duplex renal system of the left kidney with one normal ureter with an intravesicular ureteral orifice and one extramural ectopic ureter with an associated branching and ureteral diverticulum. A dual vagina was also noted. Left neoureterocystostomy of the extramural ectopic ureter was performed and a temporary ureteral stent was concurrently placed and removed cystoscopically one month later, leaving the patient with two patent left ureters. Thirty-four months later the patient is mildly incontinent with no other comorbidities.

Obstructed Right Upper Moiety in a Bilateral Partial Duplex Renal System in an Adult

Duplex renal system, a common congenital anomaly of the kidney and urinary tract, is preferably identified through screening. For obstructed symptomatic duplications, prompt relief of obstruction to forestall renal parenchymal loss is recommended. We present a case of neglected obstruction of the right upper moiety in an adult female with discordant bilateral renal duplex system. A 49-year-old female with a 10-year history of recurrent right flank pain and fever presented for clinical evaluation and treatment. She had no such symptoms in early childhood. A diagnosis was made of obstructed right upper renal moiety in bilateral discordant renal duplication with complete moiety parenchymal destruction. She had right renal exploration with complete excision of the hydronephrotic sac and the grossly dilated moiety ureter down to the obstruction at the fusion of both upper and lower moiety ureters. Her postoperative period was uneventful. She is symptomfree and her urinary tract is structurally intact. Hitherto asymptomatic renal duplication can become symptomatic in early adulthood from intrinsic moiety ureter obstruction, suggesting a need for lifetime monitoring of persons with duplex renal systems. Late presentation with neglected symptoms, and consequent renal moiety destruction as seen here, is a result of the absence of such monitoring.
 Keywords: Duplex renal system, Obstruction

Incomplete duplex renal system with severe obstruction at the uretero-ureteral junction and minor obstruction at the common stem-vesical junction: Challenging diagnosis and conclusive laparoscopic treatment

Twin obstructive megaureters associated with duplex renal system is a rare malformation, particularly when a giant ureter dilation is present. We report an original case, initially misinterpreted, of a right incomplete duplex renal system with huge disproportion between the upper pole giant megaureter and the lower pole moderate megaureter, with severe obstruction at the uretero-ureteral junction and minor obstruction at the uretero-vesical junction. Uromagnetic resonance imaging allowed conclusive diagnosis and the laparoscopic approach was effective for definitive, successful treatment.

OP33.08: Prenatal diagnosis of renal duplex systems. Ultrasonographic features and postnatal outcomes

To assess the accuracy of ultrasound diagnosis of duplex renal systems and to describe the natural history of prenatally diagnosed duplex systems. Observational retrospective study of cases with antenatal diagnosis of duplex system. The ultrasound features leading to the suspicion of duplex system included: a) identification of two separate renal poles, b) dilatation or cystic areas in an upper or lower pole, c) dilated ureter and d) cystic anechoic structure within the bladder suggesting ureterocele. Results of postnatal follow-up were obtained from hospital records. Of a total of 24 cases of suspected duplex systems 22 were followed until complete postnatal diagnosis. Duplex system was confirmed in 95.4% (21/22). Presence of two separate dilated renal poles was the most prevalent ultrasound feature followed by dilatation of a single pole in addition to ipsilateral dilated ureter and / or ureterocele. In half of the cases (47.6%) duplex systems had a benign course but in 38.1% urinary tract infection occurred and in 29% some kind of surgical procedure was needed. Duplex systems can be accurately diagnosed when there is even minimal pelvis dilatation. Antenatal diagnosis allows planning of postnatal care with a high accuracy. The natural history of prenatally diagnosed duplex systems seems to be essentially benign within the available follow up. Supporting information can be found in the online version of this abstract. Images of duplex systems, dilated ureter and ureterocele. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

1254 DYNAMIC FLUORODEOXYGLUCOSE -POSITRON EMISSION TOMOGRAPHY ACCURATELY IDENTIFIES AND LOCALISES ECTOPIC RENAL TISSUE IN GIRLS WITH CONSTANT URINARY DAMPNESS

You have accessJournal of UrologyPediatrics: Imaging Genital & Urinary Tract/Infections and Vesicoureteral Reflux/Andrology - Cryptorchidism & Varicoceles1 Apr 20101254 DYNAMIC FLUORODEOXYGLUCOSE -POSITRON EMISSION TOMOGRAPHY ACCURATELY IDENTIFIES AND LOCALISES ECTOPIC RENAL TISSUE IN GIRLS WITH CONSTANT URINARY DAMPNESS Chris Kimber, Rod Hicks, Neil McMullin, Yves Heloury, and Wei Cheng Chris KimberChris Kimber Hawthorn, Australia More articles by this author , Rod HicksRod Hicks Melbourne, Australia More articles by this author , Neil McMullinNeil McMullin Melbourne, Australia More articles by this author , Yves HelouryYves Heloury Melbourne, Australia More articles by this author , and Wei ChengWei Cheng Melbourne, Australia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.799AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ectopic ureters in girls can cause constant urinary dampness (CUD) and be difficult to detect and localise. Standard investigations (nuclear medicine, ultrasound, magnetic resonance urography) are usually negative. Laparoscopy may often identify and enable correction of the anatomical abnormality. We describe a novel imaging technique that enables accurate pre-operative diagnosis and localisation of the ectopic renal tissue, ureter and site of opening. METHODS 17 girls (aged 5-17) presented with CUD over a 12 year period (1997-2009) and all were ultimately found to have ectopic ureters. There were 3 clinical scenarios: 1) Solitary kidney (n= 9); 2) Previous multicystic kidney (n=3); 3) Unilateral duplex renal system (n = 5). Prior to 2007, 13 girls had undergone exploratory laparoscopy (n = 12) or open surgery (pelvic dissection n =1 or renal bed exploration n=1). All standard investigations including cystoscopies had failed to identify the abnormal ectopic ureters. Since 2007 we developed a dynamic fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan to identify these difficult renal abnormalities for girls with CUD. RESULTS The next 4 girls with CUD underwent dynamic FDG PET after all investigations including cystoscopy were negative. In all cases the scan SUCCESSFULLY identified the site, side and drainage route of the ectopic system. Vaginal filling was demonstrated in all 4 girls. Appropriate surgery (pelvic laparoscopy n=2, laparoscopic heminephrectomy n=1 and laparoscopic uretero-ureterostomy n=1) results in complete resolution of symptoms in all four cases. CONCLUSIONS Dynamic FDG PET allows accurate localisation and diagnosis of all cases. This investigation facilitates accurate surgical planning and avoids blind exploratory surgery. Further advanced isotopes are currently being introduced to improve the anatomical resolution. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e485 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chris Kimber Hawthorn, Australia More articles by this author Rod Hicks Melbourne, Australia More articles by this author Neil McMullin Melbourne, Australia More articles by this author Yves Heloury Melbourne, Australia More articles by this author Wei Cheng Melbourne, Australia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Role of magnetic resonance urography in diagnosis of duplex renal system: Our initial experience at a tertiary care institute

Aim:To determine diagnostic value of magnetic resonance urography in cases of duplex renal system.Method:Twenty cases between five month to nine years with suspected or known duplex renal system were evaluated by ultrasound (USG), micturating cystourethrography (MCU), intravenous urography (IVU) and magnetic resonance urography (MRU). The findings of these diagnostic imaging studies were then compared with each other and against the results of final diagnosis established at surgery.Results:Duplex renal system could be identified in two of these cases on USG, was diagnosed in four in IVU and could be diagnosed in all cases with MRU.Conclusion:MRU is superior and far accurate than IVU, MCU and USG in diagnosing duplex renal system.

Prenatal Diagnosis of Partial Trisomy 3p (3p21→pter) and Partial Monosomy 11q (11q23→qter) Associated with Abnormal Sonographic Findings of Holoprosencephaly, Orofacial Clefts, Pyelectasis and a Unilateral Duplex Renal System

Patients with partial trisomy 3p seldom present major dysmorphic features, and holoprosencephaly occurs in only 10% of the cases with partial trisomy 3p. It has been suggested that multiple genetic hits or environmental exposures are required for the clinical expression of holoprosencephaly. At 16 weeks of gestation, prenatal sonography identified a fetus with holoprosencephaly, orofacial clefts, pyelectasis, and a unilateral duplex renal system. Amniocentesis revealed the karyotype of 46,XX,der(11)t(3;11)(p21;q23)pat with partial trisomy 3p (3p21-->pter) and partial monosomy 11q (11q23-->qter). The pregnancy was subsequently terminated. Postnatally, the proband showed hypotelorism, a depressed nasal bridge, orofacial clefts and holoprosencephaly-premaxillary agenesis. The present case provides evidence that partial trisomy 3p/monosomy 11q can be a genetic cause of holoprosencephaly and del(11)(q23-->qter) is associated with a duplex renal system.

A Meta-Analysis of Surgical Practice Patterns in the Endoscopic Management of Ureteroceles

We examined the contribution of patient features on reoperation after transurethral incision or puncture in children with ureteroceles. A systematic review was accomplished using Medline and article bibliographies to obtain articles related to endoscopic management of ureteroceles in English, Spanish, Italian, French and Japanese. Exposures of interest were ureterocele position and anatomy, and preoperative reflux. The outcome was secondary operation. Meta-analysis was done using Mantel-Haenszel calculations. Meta-analysis of 10 studies demonstrated that ectopic ureteroceles are associated with significantly greater reoperation rates than intravesical ureteroceles in patients undergoing ureterocele incision. This remains true with longer followup and systematic ureterocele incision/puncture, in neonates and in patients with single and duplex collecting systems. In addition, a meta-analysis of 3 studies showed that patients with duplex system ureteroceles are more likely to require subsequent operation. A third meta-analysis of 7 studies showed that preoperative reflux increases the risk of reoperation after ureterocele incision. More than 1 risk factor did not appear to increase the risk of secondary operation. To our knowledge this is the first systematic review of endoscopic ureterocele management. It suggests that ectopic ureterocele location, duplex renal systems and preoperative reflux are proxies for trigonal anatomical distortion, rather than independent risk factors for a secondary operation after incision. Findings reinforce the importance of considering these variables when making management decision in children with ureteroceles.

Treatment of calculi in kidneys with congenital anomalies: an assessment of the efficacy of lithotripsy

We studied the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of stones in kidneys with congenital anomalies to determine factors that may affect the results. Patients found to have renal calculi in kidneys with different types of congenital anomalies were treated using ESWL. All patients were investigated by intravenous urography (IVU) to confirm the diagnosis. J stents were inserted prior to therapy in renal units with calculi exceeding 1.5 cm in diameter. Complications encountered and factors affecting success using this treatment modality were analysed. Twenty-five patients (18 males, 7 females) were studied between August 1988 and July 2005. There were nine patients with horseshoe kidneys, eight with ectopic kidneys, three with malrotated kidneys, two with duplex renal system, and one patient each with polycystic kidneys and hypoplastic kidney. The IVU showed 31 isolated calyceal or renal pelvic stones with mean stone burden of 1.44cc. All 25 patients were treated by lithotripsy. Twenty-four (77.4%) renal units (in 19 patients) were completely cleared of stones, 2 (6.5%) renal units (2 patients) were partially cleared of calculi and the procedures failed in 5 (16.1%) renal units (4 patients). Out of five renal units in which the procedures failed, open surgery was performed in three renal units and percutaneous nephrolithotomy (PCNL) was performed in two. None of the 25 patients developed any major complications. No significant adverse changes in renal function tests were observed at 3-month follow-up. The stone-free rate was influenced and reduced by stone size and location in the pelvi-calyceal system. Calculi in kidneys with congenital anomalies may be treated successfully by ESWL as a first-line therapy in the majority of patients. With position modifications, localization of stones may be facilitated and disintegrated. The outcome in patients so treated does not differ significantly from that in those with normal kidneys.

The sensitivity of antenatal ultrasound for predicting renal tract surgery in early childhood

To establish the sensitivity of antenatal ultrasound for identifying the need for renal tract surgery in infancy and early childhood. A retrospective analysis of the surgical records in children under 5 years of age undergoing renal tract surgery in a regional pediatric urological surgery referral unit was carried out. All records between May 1997 and July 2002 were examined to assess the relationship between prenatal ultrasound findings and postnatal surgical pathology. A total of 106 operations had been performed. The detection rate of multicystic renal dysplasia was 100% (17/17). The equivalent detection rates for pelviureteral junction obstruction, duplex renal system and vesicoureteral reflux were 82.8, 67 and 26.1%, respectively. None of the babies with renal tumors had abnormal antenatal ultrasound findings. The diagnosis of postnatal renal surgical pathology was made on the basis of prenatal scan findings in 59.6% of cases, while recurrent urinary tract infection led to the diagnosis in 26.0%. Approximately 40% of children requiring surgery for renal tract pathology will have a normal antenatal ultrasound examination. The prevalence of abnormal antenatal ultrasound findings varies depending on the type of renal tract pathology. Despite these findings, the commonest indicator for surgery remains abnormal prenatal scan findings, followed by recurrent urinary tract infections.

Accuracy of prenatal ultrasonographic diagnosis of duplex renal system.

Duplex renal system is a rare congenital anomaly of the urinary tract that can be diagnosed in utero. The purpose of this study was to establish the optimal diagnostic criteria for fetal renal duplication in a population undergoing prenatal sonographic screening. Between January 1989 and June 1997 we found 11 cases of duplex renal system, 10 of which were correctly identified in utero at a median gestational age of 28 weeks (range, 20 to 38 weeks), and one of which was a false-negative diagnosis. Prenatal diagnosis of duplex renal system can be made in utero during the second half of pregnancy in the presence of two or more of the following signs: hydronephrosis limited to one pole in a kidney with two separate, noncommunicating renal pelves; ipsilateral megaureter; and ureterocele.

Ipsilateral Pyeloureterostomy for Managing Lower Pole Reflux with Associated Ureteropelvic Junction Obstruction in Duplex Systems

In duplex renal systems with a normal upper pole collecting system, and a lower pole collecting system with reflux and ureteropelvic junction obstruction or a kink at the ureteropelvic junction (that is reflux with trapping), treatment must address reflux and obstruction. We reviewed the results of ipsilateral pyeloureterostomy as a single corrective procedure. We retrospectively reviewed our experience with 10 children who had complete ureteral duplication with lower pole reflux (grades III to V) and associated lower pole ureteropelvic junction obstruction or a ureteral kink with trapping. All patients were treated with ipsilateral end-to-side pyeloureterostomy. Followup ranged from 1 to 14 years. All patients had a good postoperative result, there have been no immediate or long-term complications and no subsequent surgical procedure was needed. All patients had continued lower pole renal growth with good function, 9 had resolution or a marked decrease in pelvicaliceal dilatation and none had evidence of obstruction. Ipsilateral end-to-side pyeloureterostomy for treating reflux into the lower moiety of a duplicated collecting system with associated ureteropelvic junction obstruction or a kink appears to be a single, safe corrective procedure that simultaneously manages vesicoureteral reflux and relieves the proximal obstructive process.

Ureteropelvic junction obstruction in upper and lower moiety of duplex renal systems

Objectives To review our experience with ureteropelvic junction obstruction in a duplicated renal collecting system. Methods The records of 7 patients with ureteropelvic junction obstruction in a duplex collecting system were reviewed. In addition to routine demographics, each case was reviewed for presenting symptoms, site of obstruction, and type of surgical treatment. Results Three of the 7 cases involved obstruction of the upper pole moiety, and the remaining 4 involved the lower pole segment of a duplex system. Obstruction of the upper and lower pole segments was found in both incomplete and complete duplicated collecting systems. Conclusions Careful preoperative evaluation of patients with ureteropelvic junction obstruction will usually identify segmental obstruction in a duplicated system. Treatment should be individualized based on site of obstruction and degree of function remaining in the affected segment.

Venous architecture in a duplex renal system with crossed fused ectopia: A case report

AbstractThis report presents the renal venous architecture in a case of a duplex kidney with crossed fused ectopia. The renal venous anatomy as defined by venography and resin cast preparation is described. The internal venous flow pattern was demonstrated to be non‐lobar and non‐segmental. Renal vein valves were not observed. © 1994 Wiley‐Liss, Inc.

Family Screening for Duplex Kidneys

Family screening was offered to the relatives of 57 patients with duplex renal systems and this resulted in the detection of another 37 cases. A further 5 first degree relatives had abnormal intravenous urography, so that 25% of the screened relatives had significant renal abnormalities. It is suggested that there may be a place for screening the whole family if renal tract duplex is detected.