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Journal of Indian Association of Pediatric Surgeons
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Table of Contents   
CASE REPORT
Year : 2011  |  Volume : 16  |  Issue : 3  |  Page : 115-117
 

Magnetic resonance urography in duplex kidney with ectopic ureteral insertion


1 Department of Surgery, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
2 Department of Radiology, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Date of Web Publication4-Aug-2011

Correspondence Address:
Conjeevaram Rajendrarao Thambidorai
Department of Surgery, University Malaya Medical Centre, Kuala Lumpur
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.83500

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   Abstract 

This is a report on the use of magnetic resonance urography (MRU) in a 6-year-old girl who presented with urinary incontinence. She had a left duplex kidney with poorly functioning upper moiety and ectopic insertion of the dilated upper pole ureter. MRU has been shown to be superior to conventional imaging techniques in delineating poorly functioning moieties of duplex kidneys and ectopic ureters.


Keywords: Duplex kidney, ectopic ureter, magnetic resonance urography


How to cite this article:
Thambidorai CR, Anuar Z. Magnetic resonance urography in duplex kidney with ectopic ureteral insertion. J Indian Assoc Pediatr Surg 2011;16:115-7

How to cite this URL:
Thambidorai CR, Anuar Z. Magnetic resonance urography in duplex kidney with ectopic ureteral insertion. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2018 Oct 22];16:115-7. Available from: http://www.jiaps.com/text.asp?2011/16/3/115/83500



   Introduction Top


The anatomy of a duplex kidney and the site of insertion of its ureters are sometimes difficult to demonstrate preoperatively, particularly if the kidney moiety is poorly functioning. Magnetic resonance urography (MRU) has been found to be superior to conventional imaging techniques in delineating poorly functioning moieties of duplex kidneys and ureteral ectopia. [1],[2]


   Case Report Top


A 6-year-old girl was brought with history of dribbling of urine in between normal acts of micturition from early in life. The child was otherwise well and abdominal examination did not reveal any abnormality. Urine was dribbling in small amounts from the vulva. The urethral and vaginal orifices were normal on inspection. Urine examination, urine culture and blood parameters for renal function did not reveal any abnormality. Ultrasonogram (USG) of the renal tract showed left duplex with hydronephrosis of the upper moiety of the kidney and a normal lower moiety. The dilated and tortuous upper moiety ureter was seen behind the bladder with narrowing of its distal end [Figure 1].
Figure 1: Ultrasonogram showing dilated and tortuous distal left upper moiety ureter

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Intravenous urogram (IVU) also showed the duplex kidney on the left side. The lower moiety of the left kidney, its ureter and the whole of the right renal system appeared normal. The upper moiety of the left kidney was hydronephrotic and the proximal ureter of the upper moiety was seen mildly dilated near the renal hilum. The rest of the upper moiety ureter could not be demonstrated on IVU [Figure 2]. The degree of dilatation of the proximal ureter of the upper moiety as seen in IVU did not correspond to the massively dilated distal end of the lower ureter seen on USG.
Figure 2: Thirty-minute intravenous urogram fi lm showing the dilated proximal left upper moiety ureter

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MRU was performed using intravenous DTPA-Gadolinium contrast to delineate the anatomy of the left duplex better. MRU showed the dilated upper moiety of the left duplex. The lower pole ureter on the left side was of normal caliber and entered the urinary bladder [Figure 3]. The upper moiety ureter on the left side was dilated and tortuous was seen in its entire length. Its distal end was narrow and after coursing behind the bladder opened below the bladder neck [Figure 4], [Figure 5] and [Figure 6]. The right kidney and its ureter were normal. Upper pole nephroureterectomy was done with excision of the upper ureter to just above its terminal end.
Figure 3: Magnetic resonance urography T1 weighted image, 2 min after I.V. DTPA-Gadolinium contrast. The normal right kidney, right ureter, lower moiety, of left kidney and its ureter are seen. The partially filled hydronephrotic left upper moiety is also seen

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Figure 4: Maximum intensity projection frontal image (T2 weighted) shows the left upper moiety and the full length of the dilated and tortuous left upper moiety ureter. The bladder is over-lying the distal ureter (s = spinal theca, b = bladder)

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Figure 5: Maximum intensity projection lateral T2 image in magnetic resonance urography shows the ectopic insertion of left upper moiety ureter

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Figure 6: Magnified view of the magnetic resonance urography lateral image showing the entry of the left upper moiety ureter below the bladder neck

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   Discussion Top


Magnetic resonance urography (MRU) has the advantage that in a single study, three-dimensional imaging of the entire urinary tract as well as assessment of renal function and urinary drainage can be done. It does not employ ionizing radiation and can be used in the presence of iodine-based contrast allergy or impaired renal function. [1],[2] Static fluid T2 weighted images in MRU are particularly useful to show large fluid-filled structures as in pelviureteric junction obstruction, cystic renal disease, complicated duplex renal anomalies including nonfunctioning moieties, large ureteroceles, and dilated ectopic ureters. [3],[4] Static fluid MRU does not require any contrast. Contrast-enhanced T1 images of (excretory) MRU delineate subtle anomalies such as nondilated duplex kidneys, small bladder diverticulae and ureterocoeles. [3],[4],[5] Very clear images of the urinary tract can be obtained by maximum intensity projection (MIP) on heavily T2 weighted images. MRU has about 99% sensitivity and greater than 90% specificity for the diagnosis of duplex renal system. [3] In the presence of poorly functioning renal moieties, MRU is more successful than IVU and computerized tomographic urography (CTU) in demonstrating the anatomy of complicated duplex anomalies. [3],[4],[5],[6]

Among the congenital urinary anomalies ectopic ureters often pose diagnostic and therapeutic challenges. [7] Demonstration of the anatomy of the ectopic ureter such as its course, relation to adjacent structures and site of insertion is sometimes difficult with conventional imaging and endoscopy. [1],[7] Single system ectopic ureter has been reported to be more common than ectopic ureters associated with duplex kidneys in India but requires further confirmation. [1] MRU is currently considered ideal for assessment of ectopic ureters, complicated duplex systems or when other complex abnormal anatomy of the urinary tract is suspected. [2],[5]

In our patient, cystourethroscopy and genitoscopy did not show the ectopic insertion of the left upper pole ureter, possibly because of the stenosis of its distal end. MRU clearly demonstrated the anatomy of the left duplex, particularly the entire extent of the dilated upper moiety ureter, its narrowed distal end and termination below the bladder.

With increasing availability of MRU in many centers, it may become the preferred imaging modality after an USG in duplex renal anomalies and ureteral ectopia. [4],[5],[6] MRU may also be used to clarify any discordant results of conventional imaging techniques.

 
   References Top

1.Krishnan A, Baskin LS. Identification of ectopic ureter in incontinent girls using magnetic resonance imaging. Urology 2005;65:1002.   Back to cited text no. 1
    
2.Riccabona M. Obstructive diseases of the urinary tract in children: Lessons from the last 15 years. Pediatr Radiol 2010;40:947-55.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Avni FE, Nicaise N, Hall M, Janssens F, Collier F, Matos C, et al. The role of MR imaging for the assessment of complicated duplex kidneys in children: Preliminary report. Pediatr Radiol 2001;31:215-23.   Back to cited text no. 3
[PUBMED]    
4.Darge K, Grattan-Smith JD, Riccabona M. Pediatric uroradiology: State of the art. Pediatr Radiol 2011;41:82-91.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Riccabona M, Ruppert-Kohlmayr A, Ring E, Maier C, Lusuradi L, Riccabona M. Potential impact of pediatric MR urography on the imaging algorithm in patients with a functional single kidney. Am J Roentgenol 2004;183:795-800.  Back to cited text no. 5
    
6.Leyendecker JR, Gianini JW. Magnetic resonance urography. Abdom Imaging 2009;34:527-40.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Choudhury SR, Chadha R, Bagga D, Puri A, Debnath PR. Spectrum of ectopic ureters in children. Pediatr Surg Int 2008;24:819-23.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

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