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Complete Unilateral Triplication of the Ureter and Renal Pelvis1
COMPLETE UNILATERAL TRIPLICATION OF THE URETER AND RENAL PELVIS 1 STANLEY R. WOODRUFF From the Department of Urology, Bayonne Hospital, Bayonne, N. J.
Anomalies of the urinary tract are most frequent and often mystifying. The gyrations and hegiras of the ureter and kidney have been practically cleared up from the mysticisms of the past since the advent of excretion urography. It is only because of the extreme rarity of the condition, that the incidence of a living patient showing 3 complete ureters and renal pelves emptying normal kidney structures is shown. Complete triplication of the ureter and renal pelvis is about the rarest anomaly in urology and there is only 1 authentic description on record, that of Lau and Henline who found a patient having 3 ureteral orifices on 1 side in the bladder from which 3 ureters arose, 2 going to the separate normal pelves of a fused kidney and the third ending in the blind pouch of an a plastic kidney. In no text books prior to their publication in 1931 of this condition can even a mention of such a possibility be found, while later works on urology contain the notice of its record but no others. Jordan and Kindred's Text Book of Embryology in describing various anomalies of the kidney and ureter speak of double or triple ureter in these words: "This condition is caused by the development of more than 1 ureteric bud from the mesonephric duct. In such cases the more caudal ureter of the series developes normally." The literature develops the fact that embryologists differ somewhat on the actual type of origin of supernumerary ureters whether from budsplitting or extra budding but they are all united on the process of development of the ureteral orifice in the bladder. The patient herein described appears to have even a purer type of triplication than that of Lau and Henline because of the fact that the 3 ureters all go to normal pelves with a high funcrional output from each (fig. 1) while in their patient 1 ureter went to an aplastic kidney, evidently without function. There may be some difference of opinion about the manner of growth 1 Read at annual meeting, American Urological Association, at Colorado Springs, Colo., May 19, 1941. 376
TRIPLICATION OF URETER AND RENAL PELVIS
377
which is somewhat difficult to reconcile. Whether extra ureters anse from splitting and ultimate separation at some time in their growth or
FIG. l. (upper) Intravenous urogram showing 3 separate renal pelves on right side. b (lower left) Retrograde urogram showing 3 catheters in place. c (lower right) Retrograde urogram of left urinary tract and middle ureter and renal pelvis of right side.
whether they arise from separate ureteric buds coming off the primordial excretory or Wolffian duct is only of more or less academic interest to
378
STANLEY R. WOODRUFF
the urologist, with the exception that if their origin is from an accessory bud there is no question of an ureteral orifice in the bladder for each ureter, while if from an anlage splitting process such alteration must necessarily occur early or only one vesical orifice will be the result. The exact type of abnormal development in our patient would appear first of all to be the ordinary fused or double kidney with which we are familiar because the anatomical "hammer head" type of upper pelvis is well defined. If the lower pelvis is that of a true supernumerary kidney or is still a part of the upper kidney mass is difficult to verify in view of
FIG.
2. Cystoscopic appearance of bladder showing 3 orifices on right interureteric ridge
the fact that no surgical approach to the source of the renal pelves was indicated, so that the actual anatomical condition cannot be proven. Oblique and lateral roentgenographic exposures suggests complete fusion of all segments as they appear to be directly in line, therefore, one may surmise the presence of an ordinary fused kidney to which is attached a fused supernumerary kidney. Whatever the exact condition it must be conceded that the mesochyme attached to each ureteral anlage must have been in sufficient amounts because well functioning renal tissue appears to encompass each renal pelvis. The anomaly was discovered during the process of a preoperative
379
TRIPLICATION OF URETER AND RENAL PELVIS
examination of a patient suffering from prostatic hypertrophy and is a dividend from our rule of making an intravenous urogram on all our patients.
Case report. A. P., 74 years of age, was admitted to the urologic service complaining of acute retention. Subsequent examination revealed this condition to be due to an immense prostatic hypertrophy. After relief of the acute retention a routine excretion urogram was performed the next morning, and the result revealed a suspicion that 3 complete ureters existed. Cystoscopic examination showed such enormous intravesical prostatic intrusion that retrograde study was considered too difficult and dangerous for the patienL Subsequent to a successful 2-stage suprapubic prostatectomy and after healing had taken place, cystoscopic examination was repeated, and the condition verified. Three normal appearing, functioning ureteral orifices were noted on the extremity of the right interureteric ridge and 1 on the left (fig. 2). All 3 orifices were easily catheterized and retrograde urograms made using a 20 per cent solution of hippuran. The same procedure was carried out on the left urinary tract and the resulting urogram revealed the common type of bi:fid renal pelvis. Nothing of a pathologic nature being present, no treatment was indicated. 16 Enos Place, Jersey City, N. J. REFERENCES
J.
GEISINGER, Jos. F.: Supernumerary kidney. Urol., 38: 331-356, 1937. JORDAN AND KINDRED: Textbook of Embryology. LAu, F. T. AND HENLINE, R. B.: Ureteral Anomolies. J. A. M.A., 96: 587,
1931.
Anomalies of the urinary tract are most frequent and often mystifying. The gyrations and hegiras of the ureter and kidney have been practically cleared up from the mysticisms of the past since the advent of excretion urography. It is only because of the extreme rarity of the condition, that the incidence of a living patient showing 3 complete ureters and renal pelves emptying normal kidney structures is shown. Complete triplication of the ureter and renal pelvis is about the rarest anomaly in urology and there is only 1 authentic description on record, that of Lau and Henline who found a patient having 3 ureteral orifices on 1 side in the bladder from which 3 ureters arose, 2 going to the separate normal pelves of a fused kidney and the third ending in the blind pouch of an a plastic kidney. In no text books prior to their publication in 1931 of this condition can even a mention of such a possibility be found, while later works on urology contain the notice of its record but no others. Jordan and Kindred's Text Book of Embryology in describing various anomalies of the kidney and ureter speak of double or triple ureter in these words: "This condition is caused by the development of more than 1 ureteric bud from the mesonephric duct. In such cases the more caudal ureter of the series developes normally." The literature develops the fact that embryologists differ somewhat on the actual type of origin of supernumerary ureters whether from budsplitting or extra budding but they are all united on the process of development of the ureteral orifice in the bladder. The patient herein described appears to have even a purer type of triplication than that of Lau and Henline because of the fact that the 3 ureters all go to normal pelves with a high funcrional output from each (fig. 1) while in their patient 1 ureter went to an aplastic kidney, evidently without function. There may be some difference of opinion about the manner of growth 1 Read at annual meeting, American Urological Association, at Colorado Springs, Colo., May 19, 1941. 376
TRIPLICATION OF URETER AND RENAL PELVIS
377
which is somewhat difficult to reconcile. Whether extra ureters anse from splitting and ultimate separation at some time in their growth or
FIG. l. (upper) Intravenous urogram showing 3 separate renal pelves on right side. b (lower left) Retrograde urogram showing 3 catheters in place. c (lower right) Retrograde urogram of left urinary tract and middle ureter and renal pelvis of right side.
whether they arise from separate ureteric buds coming off the primordial excretory or Wolffian duct is only of more or less academic interest to
378
STANLEY R. WOODRUFF
the urologist, with the exception that if their origin is from an accessory bud there is no question of an ureteral orifice in the bladder for each ureter, while if from an anlage splitting process such alteration must necessarily occur early or only one vesical orifice will be the result. The exact type of abnormal development in our patient would appear first of all to be the ordinary fused or double kidney with which we are familiar because the anatomical "hammer head" type of upper pelvis is well defined. If the lower pelvis is that of a true supernumerary kidney or is still a part of the upper kidney mass is difficult to verify in view of
FIG.
2. Cystoscopic appearance of bladder showing 3 orifices on right interureteric ridge
the fact that no surgical approach to the source of the renal pelves was indicated, so that the actual anatomical condition cannot be proven. Oblique and lateral roentgenographic exposures suggests complete fusion of all segments as they appear to be directly in line, therefore, one may surmise the presence of an ordinary fused kidney to which is attached a fused supernumerary kidney. Whatever the exact condition it must be conceded that the mesochyme attached to each ureteral anlage must have been in sufficient amounts because well functioning renal tissue appears to encompass each renal pelvis. The anomaly was discovered during the process of a preoperative
379
TRIPLICATION OF URETER AND RENAL PELVIS
examination of a patient suffering from prostatic hypertrophy and is a dividend from our rule of making an intravenous urogram on all our patients.
Case report. A. P., 74 years of age, was admitted to the urologic service complaining of acute retention. Subsequent examination revealed this condition to be due to an immense prostatic hypertrophy. After relief of the acute retention a routine excretion urogram was performed the next morning, and the result revealed a suspicion that 3 complete ureters existed. Cystoscopic examination showed such enormous intravesical prostatic intrusion that retrograde study was considered too difficult and dangerous for the patienL Subsequent to a successful 2-stage suprapubic prostatectomy and after healing had taken place, cystoscopic examination was repeated, and the condition verified. Three normal appearing, functioning ureteral orifices were noted on the extremity of the right interureteric ridge and 1 on the left (fig. 2). All 3 orifices were easily catheterized and retrograde urograms made using a 20 per cent solution of hippuran. The same procedure was carried out on the left urinary tract and the resulting urogram revealed the common type of bi:fid renal pelvis. Nothing of a pathologic nature being present, no treatment was indicated. 16 Enos Place, Jersey City, N. J. REFERENCES
J.
GEISINGER, Jos. F.: Supernumerary kidney. Urol., 38: 331-356, 1937. JORDAN AND KINDRED: Textbook of Embryology. LAu, F. T. AND HENLINE, R. B.: Ureteral Anomolies. J. A. M.A., 96: 587,
1931.