International Journal of Medical Research & Health Sciences Volume 2 Issue 2 April-June Coden: IJMRHS ISSN:

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1 International Journal of Medical Research & Health Sciences Volume 2 Issue 2 April-June Coden: IJMRHS ISSN: Received: 20 th Jan 2013 Revised: 22 nd Feb 2013 Accepted:28 th Feb 2013 Case report UNILATERAL BIFID URETER AND ITS CLINICAL SIGNIFIACANCE - A CASE REPORT *Ansari Mohammad Mujahid, Joshi DS, Rahman MA. Department of Anatomy, LSBRKM Government Medical College, Jagdalpur, Dist.Bastar Chhattisgarh, India. *Corresponding author mohammad_ansari2001@yahoo.com ABSTRACT DOI: /j Context: Congenital anomaly is commonly found in the urinary system in which collecting system is frequently encountered. Among other type bifid ureter is one of the common variations. Objective: To describe and analyze the clinical and the embryological significance of the unilateral bifid ureter. Design: The presence of unilateral bifid ureter was seen as an incidental finding during dissection of the anatomy of an adult male cadaver. The cause of such variation is a fusion of ureteric bud during intrauterine development. Outcome: The knowledge of such relationship is important for a surgeon during renal surgeries. This is one of the rare case reported with no other renal and collecting system congenital anomalies found with left sided bifid ureter. Conclusion: Surgeons and Nephrologists must keep the unilateral bifid ureter in their mind while making differential diagnosis of ureteric calculus. Surgery is nearly always required in the bifid ureter to cure the problem when associated with complication such as reimplantation surgery in vesicoureteric reflux, uretropyelostomy in saddle reflux bifid ureter. The unilateral bifid ureter may be similar to the collecting system obstruction in the form of ureteric stone and utmost care should be taken by Surgeons during renal and ureteric calculi surgeries. Keywords: Isolated bifid ureter, Reimplantation surgery, Congenital anomaly, Uretropyelostomy. INTRODUCTION Congenital anomalies of urinary and reproductive system are very common and around 10% of newly born baby are encountered with such anomalies. Enormous diseases are found in the urinary system of which 40% are related to congenital anatomical variation. Ureteric duplication may be partial or complete. Complete duplications are less common where two ureter drain one kidney and have separate orifices into the urinary bladder known as duplications of ureter and occurs 1 in 160 individuals 1. Incomplete duplication is known as bifid ureter. Various diseases are found in relation with bifid ureter congenitally of which gonadal dysgenesis 2 is one in which differentiation of kidney is abnormal and associated upper urinary tract anomalies are found which accounts around 88.8%. Patients with double ureter may be accompanied by other ureteral anomalies such as ectopic ureter and 312

2 have an increased risk of developing urinary tract infection, pain, hydronephrosis and stone formation3. Duplications of the ureter in adults are often symptomless, but in children the risk of infection is increased twentyfold 4. In the available literature, most authors have reported their experiences of single to few cases each. The finding of double ureters in members of the same family is a rare occurrence, but after a thorough investigation and detail studies of families of children with a duplex urinary tract, it was suggested that the inheritance of this anomaly was by an autosomal dominant gene 1. Duplication of pelvicalyceal system is among the common anomalies of the urinary tract, majority is unilateral. Bilateral duplication is less common than unilateral duplication and similarly lower urinary tract abnormalities are less common than upper pelvicalyceal system anomalies which occurs due to metanephric diverticulum abnormal development. 5 CASE REPORT The present case was found as bifid ureter during routine dissection on the left side of male cadaver approximately 60 years of age. The upper two separate limbs of bifid ureter were emerging out from the pelvis (hilus) of kidney as a separate entity. The bifid ureters were running lateral to the vasculatures of posterior abdominal wall (Fig.1).As the two limbs of bifid ureter descends down in the posterior abdominal wall it runs parallel to the main vasculature lower abdomen near pelvic cavity. After entry into the pelvic cavity near the opening of bifid ureter into the urinary bldder (2-3cm near to vesicoureteric junction) both the limbs of bifid ureter fuses and form a single ureter. No abnormality was seen near the opening of ureter into urinary bladder (Fig.2). In the pelvic cavity near the opening of ureter into the urinary bladder (Fig.3). The ureter on the right side was found to be normal (Fig.4). Testicular vessels Rt Ureter Ureter 1 Ureter 2 Fig:1. Bifid Ureter and relation with Abdominal Vasculaturess Fig 2. Right Single Ureter and Left Bifid Ureter Fusion of Ureterr 1 & 2 Opening of single ureter into urinary baldder Fig 3. Fusion of Ureter 1& &2 and opening of into Urinary Bladder Fig.4 Complete View of Right and Left Side Ureters Ansari et al., Int J Med Res Health Sci. 2013;2(2):

3 Examination of other abdominal and pelvic viscera and other structure revealed no other morphological abnormality. DISCUSSION Complete duplications are less common where two ureter drain one kidney and have separate orifices into the urinary bladder known as duplication of the ureter. Duplication in the ureter is either complete or incomplete. This variation having an incidence around 3.0% 6. As far as gender prevalence were compared in females occurrence was 5 times more common than in males. 7 Incomplete duplication is the close association of the bifiid ureter with contra -lateral orthotopic quadrafid ureter. Goltz s 16 syndrome high cephalic kidney and duplication of the pelvis, unilateral pulmonary hypoplasia 17,18 had been stated by many research workers that above mentioned diseases and syndromes had a strong link with bifid ureter. In the present case report of unilateral bifid ureter we found on the right side without any gross and congenital abnormalities. Buslingers M 19 have reported the bifid ureter with complication such as frequent urinary tract infection, calculi, uretero ureteric reflux, ureteric stenosis,urinary lithiasis, pyelonephritis, nonfunctioning of kidney units but in our case no commonly known as bifid ureter whose gross surgical abnormality observed. Rege 20 et occurrence three times more common than a little al., have reported the incidence of bifid ureter rare variety of complete duplication 8.Right sided more common in Females but in my case report duplication ois more frequent than left sided 9.The the cadaver is a male human being. incidence of congenital anomalies of urinary Developmental basis: The occurrence of bifid system in newborn babies ranges from 8-10% 10 ureter has a very strong link with the defective and duplication of the upper urinary tract is one intrauterine development. The basic of the commoner anomalies and occurs in about developmental error is division of ureteric bud at 1 in 160 individuals 11.The reported incidence of penetration into the metanephric tissue which bifid ureter varies widely. It depends whether the give rise to the formation of either duplication of survey based on autopsy or clinical data. Two ureter or bifid ureter. Bifid ureter is a large autopsy series have provided data regarding symptomatic condition and usually observed partial or complete ureteral duplication by Nation during renal surgeries, autopsy or anatomical and Campbell, in 16,000 autopsies identified 230 dissection. It may be diagnosed when there are cases. The reported incidence in general is 1 in reflux symptoms irritates the patient and then 147 or 0.68% 11. Campbell in his personal series undergoes for thorough urinary tract of 51,880 autopsies 342 cases was identified. The investigation for, urinary calculi reported incidence in general is 1 in 152 or Giannokopoulos 21 et al., pyelonephritis and 0.66% 11.Combining Nation s and Campbell uretero- hydronephrosis Chalouhy 22 et al., autopsy series the projected incidence of present case the individual had lived through 50 duplication is 1 in 125 or 0.8 % 11. It has been to 60 years of life without a surgical intervention suggested by many researchers that bifid ureter is related to complication of bifid ureter. associated with genetic mutation of PAX2 gene which is responsible for development of kidney CONCLUSION and ureter 12. According to studies of Russell 13 et Usually the cases of bifid ureter may be detected al described the incidence of ureteral duplication 3% on routine urography. Angulo 14 during a routine investigation or an incidental et al., stated finding at autopsy and the majority of the cases the association of bifid ureter with one serious remain asymptomatic and if a complication congenital abnormality i.e. congenital hydronephrosis. Bhandarker 15 occurs surgical intervention becomes et al., contra lateral necessary.in the present case the individual is orthotopic quadrafid ureter, and noted they gave 314

4 male with left sided bifid ureter (bifid ureter more common in females and occurrence more on the right side) around 60 years of age found without surgical intervention related to the complication of bifid ureter is rare variety of unilateral bifid ureter. ACKNOWLEDGEMENT I am thankful to Dr. Saleem Basha Tamboli (Associate Professor and Head of Department of Pharmacology, Dr. Shankarrao Chavan Govt. Medical College Nanded) for critical evaluation and proof reading of the manuscript. REFERENCES 1. Atwell JD, Cook PL, Howell CJ. Familial incidence of bifid and double ureter. Archives of Disease in Childhood. 1974; 49: Haider M Al Attia ; Cephalad Renal Ectopia, Duplication of Pelvicalyceal System and Patent Ductus Arteriosus in an Adult Female. Scand J Urol Nephrol. 1999; 33: Yamamoto K. Duplication of the renal pelvis and ureter: associated anomalies and pathological conditions. Radiat Med 1983; 1: Das's, Dhar P, Mehra RD, Unilateral Isolated bifid ureter J Anat Soc India.2001;50(1) Kulkarni V, Ramesh BR, Prakash BS. Bilateral bifid ureter with accessory renal artery. Indian Journal of basic Medical Sciences.2002;3(3): Setsuko Tohno, Cho Azuma, Yoshiyki Tohno. A case of double renal pelvis and ureters associated with double Superior venacavae. J Nara Med Assoc. 2008;59(5): George S Bisset III, Janet LS. The Duplex collecting system in girls with urinary tract infection ; Prevalence and Significance. AJR. March 1987; 148: Ray Dyer, Stephen Miller, Bonnie L Anderson, James E Drake, John SS. The Segmental Nephrogram. AJR. August 1985; 145: Khin PP, Srigit Das, Israa MS, Azian Latiff, Norzana Ghafar, Farihah Haji Suhaimi. Accessory renal vessels at the upper and lower pole of the kidney: A cadaveric study with clinical implications. Morphological study. Bratisl lek listy. 2010; 111(5): Burkland CE. The significance of genetic and environmental factors in urogenital disease. Journal of Urology.1958;79: Campbell s Urology. Volume 3, 8 th edition : Choi KL, McNoe LA, French MC. Absence of PAX2 gene mutations in patients with primary familial vesicoureteric reflux. J Med Genet. 1998; 35: Russell RCG, Williams NS. Bulstrode, CJK, Bailey and Love s Short practice of Surgery. Arnold Publishers, New York. 2000, 24 th Edition : Angulo CJ, Unda Urzaiz M, Florescorral N. Blind ending bifid ureter associated with adult congenital. Archives Esp Urology. 1991;44: Bhandarkar AD, Rahu AM, Rao MS.Single Unilateral ectopic bifid ureter with contralateral orthotopic quadrafid ureter A rare combination. Journal of Postgraduate medicine.1997; 43: Gunduz K, Gunalp, Erden. Bifid ureter in Goltz s syndrome.ophth- Genetics.1997;18: Al Attia HM. Cephalad Renal Ectopia duplication of pelvi-calyceal system and patent ductus arteriosus in an adult female. Scandevenian Journal of Urology & nephrology. 1990; 33; Prasad R, Mukerji PK, Kant S, Singh AK, and NarianVS. Indian Journal of Chest Diseases & allied sciences 1996;38: Busslinger M, Kaiser G. Surgical significance of duplex kidney with bifid ureter. European journal of Paediatric Surgery.1992;2:

5 20. Rege VM, Deshmukh SS, Borwankar SS, Gandhi RK. Blind Ending Bifid Ureter. Journal of Postgraduate Medicine.1986; 32 : Giannokopoulos X, Chambilomatis P, Thirothoulakis M, Seferiadis G. The blind ending bifid uretr. Urology & Nephrology. 1994; 26 : Chalouhy E, Harram R, Ezzo G. Various aspects of Uretero-Ureteral reflux in incomplete ureteral duplication. Journal of Medicine Libnan,1992; 40 :