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Triplication and contralateral duplication of ureter
TRIPLICATION AND CONTRALATERAL DUPLICATION OF URETER KARL FRANS
DELAERE, DEBRUYNE,
M.D. M.D.
From the Department of Urology, St. Radboud Hospital, Nijmegen, The Netherlands
University
ABSTRACT - A patient with a triple kidney and a double ureter with 1 bijid on the left side, and a double kidney with 2 complete ureters on the contralateral side is described.
The phenomenon of 5 ureters occurring in a single patient is rare. To our knowledge, there have been only 4 previous reports of this unusual anomaly. l-4 Case Report A sixty-five-year-old woman was admitted to our hospital in April, 1978, with a history of recurrent cystitis after an anterior vaginal repair
several years before. Because of postoperative bladder outlet obstruction with urinary retention, a bladder neck resection was done elsewhere. During the last three months there were also intermittent episodes of pain in the right flank. The patient was well developed, and physical examination revealed no abnormalities except a mild sensitive right flank. Blood pressure was 170/110 mm. Hg. Results of routine laboratory
1.
(A)
zvp
rronstrates triple kidI withweteraltripliion on left and &cat&n on right with rlonephfitis in lower Gle. (B) Cystogram bows rej’ur in dilated ]weter and pelvis of right 3er pole.
302
UROLOGY
/
MARCH
1982
/
VOLUME
XIX,
NUMBER
3
studies were within normal limits. Urinalysis showed 20 to 30 white blood cells per highpower field, and urine culture revealed a urinary tract infection caused by Escher&a coli. An excretory urogram (IVP) demonstrated a triple kidney with ureteral triplication on the left and duplication on the right with pyelonephritic changes of the lower pole (Fig. 1A). A cystogram showed reflux in dilated ureter and pelvis corresponding to the lower segment on the right (Fig. 1B). Cystoscopy revealed 2 ureteral orifices on each side of the trigone; the most lateral orifice on the right gaped considerably. A partial lower right nephroureterectomy was performed successfully. Her recovery was uneventful.
The case herein reported represents Smith’s second type of triplication in which 3 ureters arise from the kidney and 2 ureters join before reaching the bladder. The embryologic genesis of multiple ureters is best explained by 2 or more separate ureteral buds which arise from the wolfhan duct, or by fission of 1 ureteral bud into 2 or 3 ureters. Our case is remarkable and exceptional because of the association of ureteral duplication and triplication in the same patient. Yet more unusual is the reported case of bilateral ureteral quadruplication’ and 6 kidneys with 6 separate ureters.’ Postbus 9101 6500 HB Nijmegen The Netherlands (DR. DELAERE)
Comment Ureteral duplication is a common condition and has been reported in 0.7 per cent of autopsies by Campbell and Harrison.5 However, ureteral triplication is a distinctly rare anomaly of which approximately 60 cases were reported prior to 1973.’ A classification of triplicate ureters was made bv Smith.’ He described 4 tvnes: 1. Complete triple ureter with&3 ureteral orifices, entering the bladder or ectopically. 2. Double ureter with 1 bifid: 2 ureters may unite, leaving only 2 orifices. 3. Trifid ureter: 3 ureters leave the kidney and all join to drain through a single orifice. 4. Double ureter with inverted Y-bifurcation: 2 ur.eters leave the kidney with a bifurcation of one of them before it reaches the bladder.
UROLOGY
!
MARCH
1932
!
VOLUME
XIX,
NUMBER
3
References 1. Burt JC, Lane CM, and Hamilton JL: An unusual anomaly of the upper urinary tract, J. Ural. 46: 235 (1941). 2. Peterson C Jr, and Silbiger ML: Five ureters: a case report, ibid. 100: 160 (1968). 3. Redman JF: Triplicate ureter with contralateral ureteral duplication, ibid. 116: 805 (1976). 4. Wolpowitz A, Evan P, and Botha PAC: Triplication of ureter on one side and duplication on the other, Br. J. Ural. 47: 622 (lQ75). 5. Campbell MF, and Harrison JH: Urology, ed. 3, Philadelphia, W. B. Saunders Co., lQ70, p. 1488. 6. Perkins PJ, Kroovand RL, and Evans AT: Ureteral triplication, Radiology 168: 533 (1973). 7. Smith I: Triplicate ureter, Br. J. Surg. 34: 182 (1916). 8. Scderdahl DW, Shiraki IW, and Schamber DT: Bilateral ureteral quadruphcation, J. Ural. 116: 225 (1976). 9. Begg RC: Sextuplicitas renum: a case of six functioning kidneys and ureters in an adult female, ibid. 70: 666 (1953).
303
DELAERE, DEBRUYNE,
M.D. M.D.
From the Department of Urology, St. Radboud Hospital, Nijmegen, The Netherlands
University
ABSTRACT - A patient with a triple kidney and a double ureter with 1 bijid on the left side, and a double kidney with 2 complete ureters on the contralateral side is described.
The phenomenon of 5 ureters occurring in a single patient is rare. To our knowledge, there have been only 4 previous reports of this unusual anomaly. l-4 Case Report A sixty-five-year-old woman was admitted to our hospital in April, 1978, with a history of recurrent cystitis after an anterior vaginal repair
several years before. Because of postoperative bladder outlet obstruction with urinary retention, a bladder neck resection was done elsewhere. During the last three months there were also intermittent episodes of pain in the right flank. The patient was well developed, and physical examination revealed no abnormalities except a mild sensitive right flank. Blood pressure was 170/110 mm. Hg. Results of routine laboratory
1.
(A)
zvp
rronstrates triple kidI withweteraltripliion on left and &cat&n on right with rlonephfitis in lower Gle. (B) Cystogram bows rej’ur in dilated ]weter and pelvis of right 3er pole.
302
UROLOGY
/
MARCH
1982
/
VOLUME
XIX,
NUMBER
3
studies were within normal limits. Urinalysis showed 20 to 30 white blood cells per highpower field, and urine culture revealed a urinary tract infection caused by Escher&a coli. An excretory urogram (IVP) demonstrated a triple kidney with ureteral triplication on the left and duplication on the right with pyelonephritic changes of the lower pole (Fig. 1A). A cystogram showed reflux in dilated ureter and pelvis corresponding to the lower segment on the right (Fig. 1B). Cystoscopy revealed 2 ureteral orifices on each side of the trigone; the most lateral orifice on the right gaped considerably. A partial lower right nephroureterectomy was performed successfully. Her recovery was uneventful.
The case herein reported represents Smith’s second type of triplication in which 3 ureters arise from the kidney and 2 ureters join before reaching the bladder. The embryologic genesis of multiple ureters is best explained by 2 or more separate ureteral buds which arise from the wolfhan duct, or by fission of 1 ureteral bud into 2 or 3 ureters. Our case is remarkable and exceptional because of the association of ureteral duplication and triplication in the same patient. Yet more unusual is the reported case of bilateral ureteral quadruplication’ and 6 kidneys with 6 separate ureters.’ Postbus 9101 6500 HB Nijmegen The Netherlands (DR. DELAERE)
Comment Ureteral duplication is a common condition and has been reported in 0.7 per cent of autopsies by Campbell and Harrison.5 However, ureteral triplication is a distinctly rare anomaly of which approximately 60 cases were reported prior to 1973.’ A classification of triplicate ureters was made bv Smith.’ He described 4 tvnes: 1. Complete triple ureter with&3 ureteral orifices, entering the bladder or ectopically. 2. Double ureter with 1 bifid: 2 ureters may unite, leaving only 2 orifices. 3. Trifid ureter: 3 ureters leave the kidney and all join to drain through a single orifice. 4. Double ureter with inverted Y-bifurcation: 2 ur.eters leave the kidney with a bifurcation of one of them before it reaches the bladder.
UROLOGY
!
MARCH
1932
!
VOLUME
XIX,
NUMBER
3
References 1. Burt JC, Lane CM, and Hamilton JL: An unusual anomaly of the upper urinary tract, J. Ural. 46: 235 (1941). 2. Peterson C Jr, and Silbiger ML: Five ureters: a case report, ibid. 100: 160 (1968). 3. Redman JF: Triplicate ureter with contralateral ureteral duplication, ibid. 116: 805 (1976). 4. Wolpowitz A, Evan P, and Botha PAC: Triplication of ureter on one side and duplication on the other, Br. J. Ural. 47: 622 (lQ75). 5. Campbell MF, and Harrison JH: Urology, ed. 3, Philadelphia, W. B. Saunders Co., lQ70, p. 1488. 6. Perkins PJ, Kroovand RL, and Evans AT: Ureteral triplication, Radiology 168: 533 (1973). 7. Smith I: Triplicate ureter, Br. J. Surg. 34: 182 (1916). 8. Scderdahl DW, Shiraki IW, and Schamber DT: Bilateral ureteral quadruphcation, J. Ural. 116: 225 (1976). 9. Begg RC: Sextuplicitas renum: a case of six functioning kidneys and ureters in an adult female, ibid. 70: 666 (1953).
303