CASE 8187 Published on 23.02.2010
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Bilateral double renal pelvis with partial ureteral duplication complicated with unilateral ureteral and renal lithiasis

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Carmen Salvan 1,2,3, Paul Lazar 2, Doru Munteanu 2, Silviu Draghici 2, Andrei Lebovici 2, Elena Nastasa1,3 , Daniel Dreptate 2,3, Rodica Suciu 3, Anca George2
1) Praxis Medical SRL, 2) Hiperdia SA, 3) Spitalul Judetean de Urgenta, Bistrita, Romania.

Connected authors
Patient

41 years, female

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Clinical History
A 41 year old female presented for a routine abdominal ultrasound, having no complaints.
Imaging Findings
The female patient presented 8 years ago lumbar pain, without pathological findings at ultrasound and radiography. At the time being, ultrasound revealed a deep cortical band in the right kidney, suggesting a double pelvis. The upper part of the left kidney had a normal appearance (normal parenchymal index). However, the middle and the lower part presented a grade 3 hydronephrosis (Fig. 1a), with dilatation of the proximal ureter (lumbar part) (Fig. 1b) as well as an echogenic focus of 22 mm with shadow in the lower calyces suggesting renal lithiasis (Fig. 1a), but also a similar focus of 16 mm in the lumbar ureter, concluding as ureteral lithiasis (Fig. 1b). Subsequently, a simple renal radiography was done; just the ureteral lithiasis was proven (Fig. 2). CT urography (with native (Fig. 3), secretory (Fig. 4) and excretory phase (Fig. 5)) for detecting lithiasis and for opacification of the collecting system was performed for preoperatory functional renal status and revealed a normal left upper renal pole (Fig. 3a, b, 4 a, d), bilateral double pelvis (Fig. 5a,b), bilateral partial ureteral duplication (Fig. 5a-h), and confirmed the ultrasound results regarding the lithiasis (Fig. 3c-e, 4c, 5c), the hydronephrosis (Fig. 3b-e, 4 b-d) and the presumed double the renal pelvis (Fig. 5 a, b), and showed the maintained excretory function of both (whole) kidneys (Fig. 5a-c).
Discussion
Bilateral renoureteral malformations are rare entities, especially in woman, being first mentioned in anatomical dissections [1], found in the operating room and later proven in IV urography examinations as well as on CT urography [2- 7]. Double renal pelvis predispose to complications, mainly hydronephrosis and urolithiasis (3,5). Associations with partial ureteral duplication are increasing the risk for nephrolithiasis and ureteral lithiasis as well as for pionephrosis, with impaired outcome for the patient [7-9]. Ultrasound is a good initial diagnostic tool in patients with suspected lithiasis, including ureteral lithiasis, but has a limited role in characterizing certain anatomical abnormalities [4, 10, 11]. And cannot evaluate the functional status of the kidneys. Subsequently, IV urography has this potential, but CT urography is better demonstrating all types of lithiasis, location, size measurements, characteristics, and secretory as well as excretory function, urinary flow dynamics of the kidneys, degree of obstruction, with implications in selecting the best treatment option [2, 6, 10]. Finally, the radiologist should answer 3 questions regarding the presence of lithiasis, the necessity of treatment and the best treatment strategy [2, 12].
Differential Diagnosis List
Bilateral double renal pelvis. Partial ureteral duplication. Unilateral reno-ureteral lithiasis
Final Diagnosis
Bilateral double renal pelvis. Partial ureteral duplication. Unilateral reno-ureteral lithiasis
Case information
URL: https://www.eurorad.org/case/8187
DOI: 10.1594/EURORAD/CASE.8187
ISSN: 1563-4086
Figure 1

Ultrasound of the kidney

Ultrasound of the kidney
Renal lithiasis with hydronephrosis
Ultrasound of the kidney
Ureteral lithiasis with dilatation of the proximal ureter
Figure 2

Simple renal radiography

Simple renal radiography
Left paravertebral radiodense opacity suggesting the ureteral lithiasis seen in ultrasound
Figure 3

Native CT

Native CT
Bilateral normal upper pole kidney
Native CT
Hydronephrosis on the left
Native CT
Left renal lithiasis and ureteral lithiasis, with hydroureter
Native CT
Left renal lithiasis
Native CT
Left ureteral lithiasis and hydronephrosis
Figure 4

CT urography - secretory phase

CT urography - secretory phase
Preserved, normal secretory function for the upper pole of the left kidney
CT urography - secretory phase
Grade 3 hydronephrosis of the left kidney
CT urography - secretory phase
Preserved secretory function of the left kidney. Hydronephrosis. Ureteral and renal lithiasis.
CT urography - secretory phase
Normal secretory function for the upper pole of the left kidney, but grade 3 hydronephrosis with preserved secretory function for the rest of the kidney.
Figure 5

CT urography - excretory phase

CT urography - excretory phase
Bilateral double renal pelvis, with preserved excretory function of both kidneys
CT urography - excretory phase
Bilateral duplication of the lumbar ureter
CT urography - excretory phase
Partial duplication of the left ureter
CT urography - excretory phase
Partial duplication of the left ureter with joining point
CT urography - excretory phase
Duplication of the left lumbar part of the ureter with dilatation of one
CT urography - excretory phase
Duplication of the left lumbar part of the ureter with dilatation of one
CT urography - excretory phase
Partial duplication of the left ureter with joining point
CT urography - excretory phase
Just one ureter is seen on the left, on the right side the duplication is still present, the joining point being lower (not shown)