Duplex kidney with calculus obstruction of lower moiety lessons learnt

Ganesh Lakshman, Sriram Krishnamoorthy, Natarajan Kumaresan

Sri Rama chandra Institute of Higher Education & Research, Chennai, Tamil nadu, India

ABSTRACT

Duplex kidneys are one of the commonest congenital malformations of the urogenital system that one comes across in urological practice. It can be complete or incomplete. Ureteral duplication is usually asymptomatic but can accompany by urinary infections, ureterocele, vesicoureteral reflux or other congenital complications. The presence of stone in one of the systems may sometimes pose a therapeutic challenge to the urologists, especially when they attempt to remove the ureteric stone endoscopically. We report a 33-year-female who presented with acute left ureteric colic. Axial imaging revealed a large distal ureteric calculus. During ureteroscopy, no calculi were seen in the entire course of ureter upto renal pelvis. Screening with an image intensifier revealed a stone adjacent to the line of ureteroscope, raising suspicion of a duplex system or radio-opaque shadow outside the lumen of ureter. On further evaluation, a mucosal elevation with oedema was seen above and lateral to the ureteric orifice, raising suspicion of complete duplication of the ureter with pseudo ureterocele. However, no other ureteric orifice was observed. Deroofing of the edematous mucosa revealed the underlying large ureteric calculus. Retrograde pyelogram confirmed a duplex system and two ureters with stone in the upper moiety. Our report highlights the unusual presentation and the hard lessons learnt. It is prudent to search for accessory ureteric orifice especially when stone is not seen during ureteroscopy but seen under image intensifier.

Keywords:

Duplex Kidney, Urolithiasis, Hydronephrosis, Ureterocele.