Bilateral complete ureteral duplication with calculi obstructing both limbs of left double ureter

Abstract

Introduction: A woman with bilateral complete ureteral duplication with stones simultaneously obstructing both limbs of the left double ureter is presented. A search of the English medical literature suggests that this is the first reported case. Based on the initial difficulty accessing the stones via ureteroscopy we make recommendations regarding how this rare problem should be approached if encountered.

Presentation of case: A 37-year old woman with left-sided flank pain was discovered on CT scan to have bilateral complete ureteral duplication and three stones obstructing both limbs of the left double ureter. Ureteroscopy was initially unsuccessful due to the very small calibre and unyielding nature of the ureters and both ureteral limbs were stented. Repeat ureteroscopy was easily achieved after pre-stenting and the impacted stones were completely cleared with intracorporeal laser lithotripsy.

Discussion: The smaller calibre of both double ureters and their presence in a common adventitial sheath distally, made initial attempts at ureteroscopy difficult. Stenting both limbs increased ureteral compliance, passively dilated both ureters and allowed for improved manoeuvrability and retrograde passage of the ureteroscope. Based on the experience with this first reported case it is recommended that pre-stenting should be routinely performed prior to any attempt at ureteroscopy in cases of stones complicating completely duplicated ureters.

Conclusion: We report the first recorded case of bilateral complete ureteral duplication with stones simultaneously obstructing both limbs of the double ureter and recommend that routine pre-stenting be done prior to ureteroscopy to allow easy uncomplicated retrograde passage of the ureteroscope.

Keywords: Calculus; Duplication; Obstruction; Stenting; Ureter; Ureteroscopy.

Fig. 1

Plain oblique CT scan image demonstrating 3 calculi at lumbar vertebral levels 3 and 4 on left side.

Fig. 2

Excretory phase of CT scan post contrast demonstrating bilaterally duplicated ureters and two of three stones on left with hydronephrotic moieties.

Fig. 3

Plain KUB film showing double-J stents in both limbs of the left double ureter with calculi in situ.

Fig. 4

KUB film taken after ureteroscopy and lithotripsy but prior to stent removal showing stone clearance.