Subtle renal duplication as an unrecognized cause of childhood incontinence: diagnosis by magnetic resonance urography.

Department of Radiology, University of California San Francisco, 505 Parnassus Avenue, Box 0628, M-372, San Francisco, CA, USA.
Journal of pediatric urology (Impact Factor: 1.41). 11/2008; 4(5):398-400. DOI: 10.1016/j.jpurol.2008.01.213
Source: PubMed

ABSTRACT Urinary incontinence in young girls who have been toilet trained may be due to an ectopic ureter inserting below the urinary sphincter. This diagnosis is frequently delayed, is psychologically distressing, and may be missed at physical examination. Findings at ultrasound evaluation may be subtle and imaging with computed tomography or intravenous urography exposes young patients to ionizing radiation. We report two cases of girls with urinary incontinence where magnetic resonance (MR) urography revealed subtle renal duplication which implied the presence of an ectopic duplicated ureter with infrasphincteric insertion. These cases stress the importance of examining the kidneys, rather than the perineum, at MR, ultrasound and intravenous urogram evaluation, and show the value of MR urography as a safe alternative to computed tomography and intravenous urography for making this diagnosis.

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    ABSTRACT: Continuous urinary leakage, despite normal deliberate voiding, must suggest the diagnosis of ectopic ureter, more specifically in girls. Ectopic ureter is usually associated with duplex kidney and complete ureteral duplication. The strategy of investigations has changed over the past few years, due to MRI development in the analysis of urinary tract malformations. We report the case of a 4-year-old girl who presented with these symptoms and had a suspicion of left duplex kidney on the prenatal ultrasonography (US). Two US examinations during the first months of life were compatible with a left duplex kidney without any complication. Another US at the age of 4 years was reported as normal. We completed the investigation with MR urography, which revealed a left duplex kidney with a poorly functioning dysplastic upper pole, and the orifice of the ureter of this upper pole inserting in the vagina. The surgical treatment, realized by celioscopy, was partial nephrectomy of the upper pole, removing most of the ectopic ureter. US is the first exam to investigate urinary tract malformations. However, duplex kidney with small dysplastic pole and ectopic insertion of a nondilated ureter may be difficult to see, and a normal US should never end the investigations. Intravenous urography and renal scintigraphy used to be the reference complementary exams, but are now replaced by MR urography. Without using ionizing radiation, MR urography can visualize duplex kidney and ectopic ureteral insertion with high resolution, and evaluates renal function of each kidney and each pole. These morphological and functional data are essential to determine the surgical treatment.
    Archives de Pédiatrie 06/2013; 20(6):640–645. DOI:10.1016/j.arcped.2013.03.009 · 0.41 Impact Factor
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    ABSTRACT: Objective A simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper. Materials and methods Prospectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy. Results Median age was eight years (range 4 to 17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US. Conclusion Laparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.
    Journal of Pediatric Urology 05/2014; 10(6). DOI:10.1016/j.jpurol.2014.04.008 · 1.41 Impact Factor
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    ABSTRACT: Conventional imaging modalities are limited in the assessment of complex lower urinary tract anomalies including ectopic insertion of ureters. MR urography can be useful in these situations. To share our experience with MR urography in assessing lower urinary tract anomalies and to determine its accuracy in depicting ectopic ureters. We conducted a retrospective review of all MR urography examinations done between November 2007 and March 2013 to note the presence or absence of duplex kidneys and insertion of ureters. We reviewed patient charts, surgical findings and results of other investigations including cystoscopy with retrograde ureterogram in order to establish presence or absence of ectopic ureter. This served as a reference standard against which we compared MR urography results. Of 22 MR urography examinations (3 boys, 19 girls; age range 3-16 years, mean 9.2 years) performed during the study period, 19 were performed to rule out ectopic ureters, two to assess complex anatomy and one to rule out crossing vessel in ureteropelvic junction obstruction. MR urography showed ectopic ureter in 9/19 children; one proved to be a false-positive. MR urography correctly showed normal insertion in 7/19 children. In the remaining 3/19 children distal ureter could not be seen, hence insertion was indeterminate on MR urography. One of these children had an ectopic ureter on cystoscopy and surgery. Statistical analysis showed MR urography's sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) to be 88.8-100%, 70-90%, 75-88.8% and 90-100% for the detection of ectopic ureter. MR urography is highly accurate in the assessment of ectopic ureters. In incontinent girls, MR urography should be the method of choice for depicting or ruling out ectopic ureter.
    Pediatric Radiology 02/2014; 44(8). DOI:10.1007/s00247-014-2905-4 · 1.65 Impact Factor

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