Teaching Case

30-year-old female patient with history of urinary incontinence from birth. Patient urine analysis report showed 1-2 W.B.C, 1 R.B.C and 10-12 Ep. Cells.

On ultrasound, left renal dilated upper moiety and gross left side hydro-ureter was detected. Intravenous pyelography (IVP) showed trifid ureter on the left and bifid collecting system on the right. This was accompanied by a gross hydro-ureter of the triplicate ureter. All three ureters unite and drain through a single orifice to the bladder in late images.

Ureter triplication has been very rarely described; Ureter triplication is a developmental abnormality of the ureter bud originating from the Wolffian duct at the 5th week of embryonic life. The ureter bud arises from the distal part of the wollfian duct after 4 weeks of fetal development. It grows dorsally at first and cranial later and makes contact with the metanephros and the distal end differentiates into the renal pelvis and the major and minor calyces during the 6th-8th weeks. In triplicate ureter, three ureter buds could arise independently from the mesonephric duct or from early fission of one or more ureter buds to join the metanephros.[1, 4, 2] Smith classified ureteral triplication into 4 types as follows: Complete ureteral triplication, incomplete triplication, trifid ureters, double ureter, and one bifurcated. [1, 4]
Presenting symptoms are renal colic, recurrent UTI and urinary incontinence. In addition, patients with triplication may suffer signs of reflux, obstruction, ureterocele or ectopia, similar to those with duplication anomalies. The most frequently encountered urological anomalies associated with ureteral triplication are: contralateral duplication (37%), ureteral ectopia (28%), renal dysplasia (8%) and reflux. [3, 4]
Intravenous pyelography (IVP) and CT-IVU are the methodology of choice.
Treatment is best tailored to individual cases and depends on the extent of the clinical problem i.e. presence of obstruction, extravesical ureteral ectopia, ureterocele or VUR. Transurethral incision of ureterocele effectively relieves the obstruction but may result in VUR necessitating ureteral reimplantation at a later stage. Other forms of surgical intervention require partial nephrectomy with aspiration of ureterocele in the first instance with re-implantation of ureter at a later stage. [4[
Due to lack of specific clinical signs, radiological examination remains the mainstay of diagnosis and can direct the best treatment strategy. This case emphasizes the importance of complete anatomic and functional evaluation of the urinary tract in the management of a patient with urinary symptoms. [4]