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previously visited BILATERAL DUPLEX RENAL COLLECTING SYSTEMS WITH ECTOPIC INSERTION OF UPPER POLE URETERS
Contributed by: Brenda Grabb, Radiologist, Radiology and Imaging Consultants, Colorado Springs, Colorado, USA.
Patient: 7 year old female
History: 7 year old female: patient presents to the ED with abdominal pain. Upon further questioning, patient admits to a long history of day and nighttime incontinence.
Images:[small]larger

Fig. 1: Coronal CT image demonstrates moderate to severe dilatation of the right upper pole pelvis with no surrounding renal parenchyma in the upper pole.

Fig. 2: Coronal CT image demonstrates dilatation of both upper pole moieties of the duplex systems.

Fig. 3: Coronal CT image demonstrates dilatation of the upper pole ureters.

Fig. 4: Coronal CT image demonstrates dilatation of the left upper pole ureter close to the bladder. However, it does not enter the bladder.

Fig. 5: Coronal CT image of the pelvis demonstrates the upper pole ureters passing below the bladder and posterior to it, toward the vagina.

Fig. 6: Coronal CT image of the pelvis again demonstrates the ectopic insertion of both upper pole ureters into the vagina.

Fig. 7: Axial CT image demonstrates the dilatation of the upper pole moiety collecting systems.

Fig. 8: Axial CT image of the pelvis demonstrates the dilated upper pole ureters close to the bladder but not entering the bladder.

Fig. 9: Axial CT image at the level of the UVJ's demonstrates the upper pole ureters to pass posterior to the bladder and not enter the bladder.

Fig. 10: Axial CT image at the level just above the vagina demonstrates the dilated right upper pole ureter just above its suspected insertion in the anterior vagina.

Fig. 11: Axial CT image at the level of the vagina demonstrates ectopic insertion of the left upper pole ureter into the anterior vagina.
Findings: CT images demonstrate bilateral duplex renal collecting systems. While there is no dilatation of the lower pole moeity collecting systems, there is moderate to severe dilatation of both upper pole moeity collecting systems. No renal parenchyma surrounds the right upper pole pelvis; thinned parenchyma surrounds the left upper pole pelvis.

The ureters of both upper systems insert ectopically. From the CT images, the ureters appear to insert into the anterior vagina although the insertions could be into the posterior urethra and have a similar appearance. Patient's clinical history of continual leakage of urine from the vagina would support the former.
Diagnosis: Bilateral duplex renal collecting systems with ectopic insertions of both upper pole ureters into the anterior vagina.
Discussion: Ureteropelvic duplication is the presence of two separate pelvicaliceal systems in one kidney. The two draining ureters may join above the bladder or may insert into the bladder separately. The ureter draining the cephalad portion of the kidney tends to insert more inferior and medial to the ureter draining the lower portion of the kidney (Weigert-Meyer rule). A corollary to the Weigert-Meyer rule is that the upper pole tends to obstruct and the lower pole tends to have vesiocureteral reflux. The upper pole ureter insertion is by definition ectopic within the bladder and may be associated with a ureterocele.

The upper pole ureter can insert even more ectopically, such as into the vagina in girls, into the prostate in boys, or into the posterior urethra in both. The more ectopic the insertion of the ureter, the more dysplastic will be the ipsilateral upper pole renal parenchyma.
References: STATdx. Ureteropelvic Duplication. Sara M. O'Hara
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Additional Details:

Case Number: 21235502Last Updated: 11-29-2008
Anatomy: Genitourinary (GU)   Pathology: Congenital
Modality: CTAccess Level: Readable by all users
Keywords: ectopic ureter; weigert meyer; pediatric; vagina

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