DOI: 10.55522/jmpas.V11I2.2335 ISSN NO.

2320–7418

Research article
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.

INTRODUCTION
Duplex kidneys are congenital malformations of the week. She also had nausea for 1 week but no febrile episodes. On
urogenital system. The incidence is reported to be approximately 1– examination, the left renal angle was tender. Renal parameters,
[1].
3% Duplex kidneys can be classified as complete or incomplete absolute leukocyte counts were normal. Urine microscopy revealed
[2].
according to ureteral morphology Meanwhile, such duplications micro-hematuria of 8 to 10 RBCs in each high power. Computed
also can be unilateral or bilateral. Bilateral duplex systems are tomography (CT) scan demonstrated a 2 cm giant calculus in the left
[3].
reported in 0.3% by excretory urography distal ureter (Figure 1a).
The cause of duplication is an incomplete fusion of the two Patient was planned for ureteroscopy and stone
[4]. [5].
poles Females are more commonly affected Ureteral fragmentation using Holmium Laser. Cystoscopy showed large
duplications are asymptomatic and identified accidentally but can mucosal protrusion in and around the left ureteric orifice (Figure 1b).
accompany by urinary infections, stone, ureterocele, vesicoureteral However, during ureteroscopy, no stone was seen (Figure 1c).
reflux or other congenital complications. Partial urinary stasis causes Imaging with an image intensifier revealed a big radio-
occurrence of stones, but different irrelevant factors to ureteral opaque shadow adjacent to the ureteroscope (Figure 2a), suggesting a
duplication may also influence it. duplicated system with stone in the adjacent moiety. Repeat
Junction and an upper moiety that is dysplastic and pseudo Cystoscopy did not reveal the second orifice, but demonstrated only a
ureterocele around both orifices that were treated by ureterocele large mucosal protrusion, suggesting a pseudo-ureterocele. De-
excision/deroofing and ureteroreno scopy and laser lithotripsy of roofing of the pseudo-ureterocele demonstrated the large stone in left
giant calculi. vesico ureteric junction, suggesting a complete duplication of left
CASE PRESENTATION system. Retrograde ureterogram (RGU) confirmed the duplex system,
A 33-year-old woman was suffering from left loin pain for
with a dysplastic upper portion of kidney and a stone in lower moiety
more than three weeks. The pain was colicky and aggravated for a
ureter (Figure 2b).

Journal of medical pharmaceutical and allied sciences, Volume 11 – Issue 2, 2335, March – April 2022, Page – 4718 – 4720 4718
DOI: 10.55522/jmpas.V11I2.2335 ISSN NO. 2320–7418
Figure 1: CT and endoscopic vision of stone in left ureter. CT scan (KUB region) showing the large left distal ureteric calculus (1a). The pseudo-ureterocele is marked
with yellow arrows (1b) and stone not seen during ureteroscopy (1c).

We report a unilateral complete left ureteral duplication with ureter of upper moiety opens below and medial to that from the one
[11].
obstructing giant calculi in lower moiety at the vesicoureteric that drains the lower moiety This knowledge is of paramount
Figure 2: Intra-operative fluoro images. Fluoroscopic image showing the importance especially when one performs ureteroscopy in duplex
guidewire in upper moiety while the stone adjacent to it (2a). RGU image
showing the attenuated upper moiety and the hydroureteronephrosis of lower systems.
moiety (2b).
The clinical presentations of ureteral duplication are
various and age-related. Most patients with duplex kidneys have no
[12].
significant symptoms, but complications are relatively frequent
The most common clinical presentation of ureteral duplication is
recurrent UTI in children and VUR, ureterocele and obstruction in
adults. Stone formation is a potential complication in such patients.
Ultrasound can, many a time, miss a complete ureteral duplication
without obstruction. Unequal hydronephrosis strongly raises
suspicion of complete duplication. Excretory urogram (EU) is very
helpful in differentiating the types of duplications. EU gives an
indirect assessment of renal function too but spiral CT urogram and
magnetic resonance imaging (MRI) much better can reveal the
locations of ureteral orifices.

The stone was levered out from the ureter into the bladder As patients with the stone disease are taken up for a

and removed in toto after laser lithotripsy. Double J stent was left in definitive procedure after a non-enhanced CT scan, a pre-operative

the lower moiety and removed after 14 days. diagnosis of this congenital anomaly is missed out more often. In

RESULTS AND DISCUSSION most instances, a duplex system is diagnosed on the table. During
Duplex kidneys are anatomical malformations where the ureteroscopy, when the stone is not identifiable during routine
renal units are made up of two distinct and discreet pelvicalyceal ureteroscopy, it is prudent to look for another ureter harboring the
systems [6]. The renal vasculature, collecting and draining systems are stone.
separate. The overall occurrence of duplicate kidney and ureter is Our report illustrates a rare unilateral left complete ureteral
[7].
about 1~3% Duplications occurring on one side has been reported duplication with the large stone obstructing lower moiety drainage.
at 0.8% in American autopsies. Bilateral occurrences are rare and The call for for a thorough knowledge of this congenital anatomical
[8].
seen in 20–40% of all ureteral duplications anomaly and a proper judgment of manifestations of a duplex system
Duplex kidneys are classified into complete and while performing ureteroscopy are the lessons to be learnt by every
incomplete. Complete duplex systems involve two distinctive aspiring urologist and trainee while performing endo-urological
pelvicalyceal systems that arise from separate ureteric buds of the procedures. Moreover, as most centers perform ureteroscopy after an
[9].
wolfian duct The resulting two separate ureters fuse to the unenhanced Computed Tomography scan, such congenital anomalies
adjoining mesenchyme and cause isolated and independent drainage may be overlooked, posing a challenge intra-operatively. Surgeons
of the ipsilateral kidney. These two ureters were identified as lower and urologists should bear in mind such congenital anomalies,
or upper moiety ureters according to their corresponding locations. especially when they come across large volume stones. In such
[10]
The locations of ureteric orifices follow Weigert–Meyer law . The instances, it is sensible to do a contrast-enhanced CT scan to

Journal of medical pharmaceutical and allied sciences, Volume 11 – Issue 2, 2335, March – April 2022, Page – 4718 – 4720 4719
DOI: 10.55522/jmpas.V11I2.2335 ISSN NO. 2320–7418
circumvent such intra-operative surprises. 5. Aiken WD, Johnson PB, Mayhew RG, 2015. Bilateral complete
CONCLUSIONS ureteral duplication with calculi obstructing both limbs of left
Duplex systems are common anomalies observed in double ureter. Int J Surg Case Rep. ;6C:23-5.
6. Hartman GW, Hodson CJ,1969. The duplex kidney and related
urology practice. Stones obstructing the duplicated ureter are not so
abnormalities. ClinRadiol. ;20(4):387-400.
uncommon. One should show a constant vigil to make an intra- 7. Privett JT, Jeans WD, Roylance J, 1976. The incidence and
operative diagnosis of such congenital anomalies. It is practical to importance of renal duplication. ClinRadiol. ;27(4):521-30.
8. Scantling D, Ross C, Altman H, 2013. A 52-year-old male with
suspect a duplex kidney, especially when large distal ureteric calculi
bilaterally duplicated collecting systems with obstructing
are identified under image intensifier but stones are not visualized ureteral stones: a case report. Curr Urol. ;7(2):104-6.
during ureteroscopy. 9. Whitten SM, Wilcox DT, 2001. Duplex systems. PrenatDiagn.
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