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Adhikari Pet al. International Journal of Medicine and Biomedical Sciences.2017; 2(2):1-5
International Journal of Medicine&Biomedical Sciences. 2017; 2(2):1-5www.intlmedbio.com 1
Copyright © 2017 International Journal of Medicine & Biomedical sciences. All right Reserved.
INTRODUCTION
The renal system anomalies are the most commonest
anomalies due to disorder in different stages of kidney
development during gestation[1]. The anomalies may be
complete or incomplete of which having double ureters of
incomplete nature is classified as bifid ureter[2]. The
urinary lithiasis, nephrolithiasis is the major risk factor of
the bifid ureter [3] The frequency of incomplete duplex
ureter is very low as compared to complete ureter
accounting for about 0.8% of random population [4]. The
duplexing of the ureter may be either bilaterally and
unilaterally present or both, having bilateral presence is a
rare condition. Urethral duplexing is more common in
females as compared to male with the ratio of 1.6:1[5].
Ureteral duplication may be genetically determined by an
autosomal dominant trait with incomplete penetrance [6].
Hydroureteronephrosis is the dilatation of the kidney and
ureter due to partial or complete blockage of ureter.
However, duplexing of ureters giving bifid rise with
calculus inducing hydroureteronephrosis is a rare clinical
entity. The anatomical variations are revealed during
various medical procedures such as autopsy, urological
surgery, radiology and routine anatomic dissections. The
renal duplex i.e. bifid ureter is the result of the certain
anomaly of renal system during intrauterine gestation of
4th to 5th week due to untimely and early division of
ureteric bud or diverticulum. The major structural parts of
kidneys such as ureter, renal pelvis, major and minor
calyces, including the millions of the nephrons are
originated from ureteric bud penetrating the meta-nephric
tissue [7]. However, the division of ureteric bud before
the penetration of meta-nephric tissue is the main crucial
factor for the development of the bifid ureter [2,3].
Calculus Induced Hydroureteronephrosis Obstructive Syndrome in a Patient with
Two Separate Pelvicalcyeal System in Right Side with Bifid Ureter: A Rare Clinical
Entity
Anil Gautam1, Bijay Subedi1, Mukesh Dhital2, Janak Awasthi3, Suman Adhikari4, *Purushottam
Adhikari5
2Demonstrator, Department of Pathology, Jawaharlal Nehru Institute of Medical Sciences, Imphal,
Manipur.
3Prof. & Head, Department of Microbiology, Jawaharlal Nehru Institute of Medical Sciences,
Imphal, Manipur.
4Prof.& Head of Microbiology, Nepalese Army Institute of Health Sciences, College of Medicine,
Kathmandu, Nepal.
ABSTRACT
Hydroureteronephrosis is a clinical condition where the dilatation of renal calyces and ureter occur jointly due to
obstruction. When two ureters arise from single kidney the situation is known as bifid ureter which may be complete or
incomplete. The present study examines a congenital anomaly of bifid ureter and rare clinical presentation of calculus
induced obstructive hydroureternephrosis in a adult male aged 38 by past 48 hours. The common symptoms of this
condition were extreme intolerable pain in the abdomen, flank pain moderate to severe radiate to loin to groin,
vomiting/nausea and haematuria. Diagnosis was done by injection of intravenous dye and computed tomography
intravenous pyleogram was performed along with lab findings. In this case we found two incomplete ureters i.e. bifid
nature arising from right kidney that unite as a single ureter before emptying into the urinary bladder. There was presence
of single large calculus measuring approximately 8.6*8mm right at the junction of bifid ureter at the level of L3 vertebra
inducing hydroureteronephrosis. Similarly marked upstream dilation of upper right ureter was found. The anomaly of
bifid ureter occurs due to the untimely division of ureteric diverticulum. Unless some complication of ureter occurs, the
duplication does not expose itself. Acute obstruction of ureter does not cause any significant alternation in renal function.
Though the whole clinical presentation is rare itself, it further needs follow ups to avoid re-occurrence.
Keywords: Bifid Ureter, Calculus, ureter, Hydroureteronephrosis
*Correspondence: Purushottam Adhikari, Gandaki
Medical College Teaching Hospital and Research
Center, Prithvi Chowk, Pokhara, Nepal
Email: puru.ad12@gmail.com
CASE REPORT ISSN: 2467-9151OPEN ACCESS
Adhikari Pet al. International Journal of Medicine and Biomedical Sciences.2017; 2(2):1-5
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Copyright © 2017 International Journal of Medicine & Biomedical sciences. All right Reserved.
Individuals having congenital bifid ureter are detected
during autopsy, radiological, surgical and urological
procedures.
Case Presentation:
Here, we described the case of an adult male patient aged
38-years presented with pain in the right abdomen and
right renal colic with hydroureteronephrosis. It was due to
partial obstruction of right ureter at bifid junction
proximal to right kidney by single large calculus for two
days as shown in the Figure 1(b). It was associated with
wide spectrum of clinical manifestation and symptoms
that include right flank pain moderate to severe radiating
to loin to groin, with sudden onset increasing the
intensity, episodes of watery vomiting and non-bilious
fever with no any alteration in the bowel and bladder
habit. Blood pressure of 160/130 mmHg with acute
hypertension was observed. According to the patient, he
was living normal life without having any sign, symptoms
and medications. Similarly, there was no any family
history of such anomalies.
MATERIALS AND METHODS
This study was carried out at Gandaki Medical College
Teaching Hospital and Research Center after obtaining
ethical approval from institutional review board and
written consent from the patient. After observing the
patient's symptoms and performing physical examination
ultrasonography and X-ray was done along with
laboratory tests. However, seeing no any clear diagnostic
clue, case was revealed using intravenous pyleogram
along with computed tomography. Then the intravenous
pyleogram by injecting contrast medium ultravist of
concentration 1ml/kg body weight was given and CT
imaging films were taken along with that by letting the
patient on supine position. The biochemical assay for
renal function test and electrolyte was performed by
means of the autoanalyzer. The routine urine examination
was done in the microbiology laboratory. Furthermore,
the case was diagnosed by the evaluation of films
produced by the intravenous pyleogram and computed
tomography.
Similarly finding from the radiology was correlated with
the laboratory findings to reach the final diagnosis. The
calculus was removed by performing extracorporeal
shock wave lithotripsy.
RESULTS AND DISCUSSION
There are wide variations of the ureteric duplications but
in this case, we found two incomplete ureters arising from
right kidney that unite as a single ureter before emptying
into the urinary bladder. The presence of single large
calculus measuring approximately 8.6*8mm right at the
junction of bifid ureter at the level of L3 vertebra
inducing hydroureteronephrosis and marked upstream
dilation of upper right ureter was found as shown on
figure 1 (a) and (b). There was no any alteration regarding
the biochemical profile of renal function test and
electrolyte level. Based on the literature review, most of
the duplex renal ureters are associated with another
anomaly. Like that this anomaly was also characterized
by the presence of multiple calculi in the lumen of gall
bladder having size of gall bladder lumen 11mm*23mm
with air foci within some calculi forming Mercedes Benz
sign. No any malformations were seen regarding in other
parts of the body like thoracic, abdominal structure or
pelvic viscera. The case of isolated bifid ureter was
illustrated by some of the medical literature during
cadaveric dissection and imaging . Having this in mind
we do not found enough case report and recent literature
regarding the hydroureteronephrosis due to calculus in
bifid ureter. So, we can say the present case is rare. The
routine urine showed the plenty of RBC with haematuria.
Increased in neutrophil count i.e. 88%(normal range:40-
75%), and decreased in lymphocytes count i.e.
12%(normal range: 25-40%) was observed during routine
haemogram. The haemoglobin level was within the
normal range 14 gm/dl (normal range: 13.5-17.5 gm/dl).
Similarly, the electrolyte level and results from renal
function test were within normal range with the absence
of post-renal azotemia which is shown on table no.1
below.
Adhikari Pet al. International Journal of Medicine and Biomedical Sciences.2017; 2(2):1-5
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Copyright © 2017 International Journal of Medicine & Biomedical sciences. All right Reserved.
Figure 1:
a) Intra Venous Pyelogram Imaging (IVP) showing bifid ureter inducing hydroureteronephrosis. The arrowindicates the bifid
ureter and junction. (Bonesubtracted image)
b) Computed Tomography Imaging showing Coronalview. Arrow in big circle indicates hydro nephrosisinduced by calculus,
while arrow in small circleshows obstruction
c) X-ray imaging (Arrow indicates temporary stenting)
Table 1: Biochemical Findings
Tests
Result
(Average)
Units
Normal
Range
Blood Urea
5.7
mmol/L
2.5-7.5
Serum Creatinine
101
µmol/L
40-110
Na
141.3
mEq/L
135-145
K
4.3
mEq/L
3.5-4.5
Adhikari Pet al. International Journal of Medicine and Biomedical Sciences.2017; 2(2):1-5
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Note: The figure 1(a) and 1(b) are the images taken from the CT films by the help of smart phone facing it towards light,
while figure 1(c) is the image taken from X-ray.
Recent genetic findings have revealed that, there is
association between the congenital anomalies of the
kidney and urinary tract with BMP4(Bone Morphogenetic
Protein) gene polymorphism [8]. The bifid ureter
congenital anomaly follows the autosomal dominance
pattern of inheritance [9]. Knowledge in medicine is ever
changing phenomenon and the patient in the present study
may possibly followed genetic changes during embryonic
development. The duplexing of renal system i.e. bifid
ureter can be both of medical and academic importance.
The bifid ureter can be the major risk factors for the
urolithiasis, hydro nephrosis, hydroureteronephrosis,
pyelonephritis, reflux and urinary tract infection [10]. In
fetus and adult, the congenital anomalies of kidney and
ureter play significant role for the cause of morbidity [11].
CONCLUSIONS
From the above study, we conclude that though the case
of bifid ureter is common and its occurrence with
hydroureteronephrosis is a rare phenomenon. Individuals
having bifid ureter may remain asymptomatic throughout
the life and remain largely undetected unless triggered by
some form of calculus and physiological condition. Just
having the acute renal obstruction by calculus does not
alter the renal function.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the Gandaki
Medical College and Research Center for granting ethical
approval for conducting this research. We would like to
acknowledge patient for giving the written consent for
conducting the study. We thank radiographer Mr. Qamrul
Haque Ansari from B.P Koirala Memorial Cancer
Hospital for his valuable suggestions and continuous
feedback.
AUTHOR’S AFFILIATION
1Pokhara University, Faculty of Health Science/Dr.
Koirala Research Institute for Biotechnology and
Biodiversity
2Nobel College, Pokhara University, Kathmandu
3Gandaki Medical College, Department of Anatomy
4Nepal Academy of Medical Sciences, Bir Hospital
5Gandaki Medical College Teaching Hospital and
Research Center.
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Adhikari Pet al. International Journal of Medicine and Biomedical Sciences.2017; 2(2):1-5
International Journal of Medicine&Biomedical Sciences. 2017; 2(2):1-5www.intlmedbio.com 5
Copyright © 2017 International Journal of Medicine & Biomedical sciences. All right Reserved.
11. Start O’Toole. Congenital Anomalies of the
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Article History:
Received: 15 April 2017
Accepted: 29 July 2017
Published online: 3 May 2017
For Citation:
Adhikari P et al.Calculus InducedHydroureteronephrosis Obstructive
Syndrome in a Patient with Two Separate Pelvicalcyeal System in
Right Side with Bifid Ureter: A Rare Clinical Entity.International
Journal of Medicine & Biomedical Sciences. 2017; 2(2):1-5
