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in Women's Health
August 2003
Hamid H. Sheikh, MD
Case
A 34-year-old female has been my patient for several years. She
was initially referred to me for pelvic pain and infertility evaluation.
I performed a laparoscopic exploration and discovered filmy adhesions,
which were lysed, and she had temporary relief of her pain. However,
she started having more back and pelvic pain. She was evaluated
with ultrasound, urine cytology, and cultures. Hematological examination
was within normal limits. A laparoscopic examination proved negative.
Her
symptoms of pain were worse during her three pregnancies (all
three were born prematurely), while taking oral contraceptives
(OCs), and after consumption of excess fluids (more so with caffeine).
An intravenous pyelographic examination revealed partial duplication
of right collecting system (double renal pelvis and ureter with
the union at the level of sacroiliac joint; Figure). A consultation
was obtained with a urologist, who performed a cystoscopic examination
and found absence of urinary reflex and did not recommend any
surgical interference.
The patient was instructed to discontinue
her OCs, limit her caffeine intake, and limit the quantity of
fluid intake. These
measures,
use of urinary cultures, and antibiotics as needed relieved
her symptoms to a great extent. For that past 3 years, the patient
has been symptom free.
|
Click
to enlarge |
Figure
1. Hydronephrotic and hydroureteric
changes are visible in the duplicated right ureter and renal
pelvis. |
Discussion
Anomalies of the urinary tract, mostly found in females, can
cause recurrent urinary tract infections, chronic pain, and obstetrical
complications such as premature labor.1 Partial or complete ureteral
duplication is mostly unexpected. Complications from such an anomaly
prompts ultrasonography and/or pyelography resulting in definite
diagnosis.2
Djurhuus and colleagues published a similar case with
one exception. In their case, hydro-nephrotic changes were present,
which prompted
pressure studies and surgical excision of the hydronephrotic
component and anastomosis of the two pelvices.
In cases of complete duplication,
vesicoureteral reflex is almost always present and prompts surgical
intervention. In the author's
case, as duplication was incomplete, no vesicoureteral reflex was
noted and recurrent mild utererocele, no surgical intervention
was carried out.4 As there was insignificant
hydronephrotic changes and symptoms were medically manageable,
ipsilateral ureteroureterostomy
as recommended in literature was not considered in author's
case.5 Even in cases of complete duplication
with minimal symptoms, nonoperative management has been recommended.6
In partial supplication,
the lower pole may terminate orthotopically, resulting in varying
degrees of vesicoureteral reflex. Contrary
to this in the author's case, the united uterer joined the
bladder at a normal site, so no vesicoureteral reflex was noted.7
Hamid H. Sheikh, MD, is a
private practitioner, OB/GYN, in Lexington, Ky.
References
- Sen S, Ahmed S, Borghol M. Surgical
management of complete ureteric duplication abnormalities. Pediatr
Surg
Int. 1998;13(1):61-64.
- Walker RD 3rd. Complications of ureteral
surgery. Urol Clin North Am. 1983;10(3):423-431.
- Djurhuus JC, Nerstrom B, Hansen RI,
Rask-Andersen H. Incomplete ureteric duplication. Electromyelographic
and manometric investigations.
Scand J Urol Nephrol. 1976;10(2):111-114.
- Fernbach SK, Feinstein KA, Spencer
K, Lindstrom CA. Ureteral duplications and its complications.
Radiographics. 1997;17(1):109-127.
- Bieri M, Smith CK, Smith AY, Borden TA.
The ipsilateral ureteroureterostomy for single ureteral reflux
or obstruction in a duplicate system. J Urol. 1998;159(3):1016-1028.
- Peppas DS, Skoog SJ, Canning DA, Belman
AB. Nonsurgical management of primary vesicoureteral reflex in
complete ureteral duplication: is it justified? J
Urol. 1991;146(6):1594-1595.
- Mesrobian HG, Balcom AH, Sturbaum CW, Van
Savage JG. Ectopia of both moities of ureteral duplication anomalies.
Urology. 1998;51(2):317-319.
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