D U P L I C A T I O N O F T H E U R E T E R 125

AN UNUSUAL VARIANT OF DUPLICATION OF THE URETER By JAMES A. ROSS, F.R.C.S.

UNILATERAL duplication of the ureter is frequently encountered, as it occurs in about 2-3 per cent of bodies according to Macalpine (1936) or 4 per cent according to Thomson- Walker (1936). There are two pelves which serve independent portions of the kidney. They are placed one above the other, never one in front of the other. The upper pelvis is the smaller and drains approximately a third of the kidney, the lower, obviously the larger, serving the remainder. These proportions are singularly constant. Exceptions have never- theless been known, the two divisions having been equal in size, whilst in one instance the upper was the larger ” (Macalpine, 1936).

The following case history, therefore, appears worthy of record, as it is an example of the rare variety in which the upper division is the larger, representing two-thirds of the kidney, and the lower is the smaller, representing one-third.

“ There is much constancy in the anatomical arrangements.

CASE REPORT J. H., a male patient aged 40, reported to Mr. R. L. Stewart’s wards at the Royal Infirmary,

Edinburgh, on Sept. 7, 1946 with two days’ history of hmnaturia, accompanied by the passage of clots, and some difficulty in micturition. A cystoscopic examination the same day revealed a small papilloma in the centre of the vault of the bladder which was bleeding freely : a considerable amount

FIG. 41.-Retrograde pyelograms showing FIG. 43.-Repeat pyelogram revealing the two normal left r nal pelvis and ureter. T h e right pelves ot the right kidney ; the lower pelvis corre- ureter bifurcafes at the level of the upper part of sponds to a normal lower major calix system, the the sacro-iliac joint, one division going to a upper pelvis corresponds to normal middle and small pelvis, the other being incompletely filled. upper major calices.

of clots required washing out before the papilloma could be seen. It was fulgurated. Three days later (September 10) a full urological examination was carried out, as in view of the unusual position of the papilloma in the bladder it was considered advisable to see the state of the renal pelves in case a primary renal papilloma were present. The appearances shown in Fig. 42 were found.

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126 T H E B R I T I S H J O U R N A L O F U R O L O G Y

These revealed a normal left renal pelvis and a very small right renal pelvis with a partial filling of a second ureter, the bifurcation of the main ureter being at the level of the upper part of the sacro- iliac joint. As the right kidney had not yet been completely demonstrated, a further examination was carried out on October 16. The patient’s hzmaturia had ceased and the condition of his bladder was now satisfactory. This revealed the ureter dividing into two at the level of the right sacro-iliac joint and demonstrated two pelves. The lower pelvis corresponded to a normal lower major calix and the upper pelvis corresponded to normal middle and upper major calices. Both had filled completely with the opaque medium (50 per cent uroselectan) and no abnormality apart from the anomalous division was shown. The ureter leading to the lower calix showed a moderate degree of dilatation.

The patient has continued well, reporting at regular intervals for check cystoscopies. He has complained of occasional mild pain in the right renal region. Repeat pyelograms on Feb. 11, 1948 showed no change since the first examination, and are those actually illustrated in this paper.

DISCUSSION

A pyelogram as shown in Fig. 43 was obtained.

This case illustrates, therefore, the phenomenon of a bifid renal pelvis with the Macalpine (1936) recorded that one

previous similar case had been described, but he has not seen such a condition himself (1948). Cabot (1936) illustrated a variety of anomalies of ureters and renal pelves, but did not show any example of the present variant.

The embryological aetiology of ure- teral anomalies has recently been sum- marized by Irvine Smith (1946) in dis- cussing triplicate ureter. A double ureter may arise either from a splitting of the original ureter bud into two parts, each of which forms its own pelvis, or two separate ureteral buds may arise independently from the primitive Wolffian duct. The reason why the upper pelvis should be small and the lower large in almost every case, and that the reverse should be so rare, is very obscure and I am unable to offer any ex- planation. I see no reasoD why, in an organ developed like the kidney and h c -

A B tionina as a series of separate units, such

lower pelvis the smaller and the upper the larger.

- FIG. 44.-A composite photograph showing, !,,the

upper third and lower two-thirdsand, 6, the present case,

an anomaly should not occasiondy occur. For purposes of comparison, a pyelo-

gram of the usual type of duplication of

usual type of duplication of the ureter and pelvis into

where the proportions are reversed.

the ureter and pelvis is shown alongside a pyelogram of t b present case in Fig. 4. This illustrates clearly the contrast between the two.

I am grateful to Mr. R. L. :tewart for permission to record these findings. REFERENCES

CABOT, H. (1936), Modern Urology, 3rd ed., 2,248. MACALPINE J. B. (1936), Cystoscopy and Urography 2nd ed., 357. -- (1948), personal communication. SMITH IRVINE (1946), Brit. 3. Surg., 34, 182. THOMSON-WALKER J. (1936), Surgical Diseases and Injuries of the Genito-urinary Organs, 2nd ed.,

London : Henry Kimpton. Bristol : John Wright & Sons.

London : Cassell & Co., Ltd.