Case of Incomplete Ureteral Duplication Complicated with Lithiasis and Right Uretero-Hydronephrosis ()
1. Introduction
Ureteral duplication is defined by a kidney that has two excretory ducts with two ureteral orifices or meatuses [1] . Ureteral pyeloduplication is a malformative uropathy of the urinary tract. It becomes pathological in the event of abnormality of the junction therefore of drainage of one or both ureters. The frequency of this pathology is estimated between 0.6% to 0.8% of the general population [2] .
Classically, ureteral duplicities arise from an anomaly in the development of the ureteral bud: incomplete with a simple ureteral bud which divides before its fusion with the mesenchyme to form a bifid or complete ureter; to two ureteral buds which develop until they reach the renal mesenchyme [3] . Its early diagnosis is rare in our context because of fortuitous discovery [1] [3] [4] [5] . This ureteral duplication most often increases the frequency of urinary tract infections and low-noise complications [6] [7] [8] [9] . Our main objective is to prove the importance or the gravity of the morbidity linked to the late discovery of this malformative congenital uropathy. The purpose of this work is to report a case and to review the literature.
We report a clinical case of incomplete ureteral duplication complicated by lithiasis of the ureterovesical junction with moderate right uretero-hydronephrosis.
2. Observation
Mrs. FK, 26 years old, consulted on August 23, 2022 for more marked abdominal pain in the right flank. This is a pain that radiates into the pelvis, intermittent stabbing type accompanied by pollakiuria, burning while urinating; No hematuria or vomiting.
In his history, we noted an appendectomy performed in 2017, the postoperative course of which was simple and no history of schistosomiasis in childhood. She is the mother of two children (G2P2V2A0D0) and the menstrual cycles are regular with more or less frequent occurrences of leucorrhoea and urinary tract infections.
The clinical examination does not find organomegaly but abdominal pain localized in the right flank and in the pelvis which becomes diffuse during attacks with unquantified fever. She has a blood pressure of 120/80 mm Hg and a heart rate of 80 beats per minute. Elsewhere the rest of the clinical examination is unremarkable.
The abdomino-pelvic ultrasound concluded that there was lithiasis of the right uretero-vesical junction associated with moderate ureterohydronephrosis upstream and fluid effusion in the Douglas fir (adnexitis). Uro computed tomography shows a 6.3 mm lithiasis enclosed at the level of the right uretero-vesical junction responsible for moderate ipsilateral uretero-hydronephrosis associated with two bilateral renal micro-lithiasis.
The biology is unremarkable, a thick drop positive at 50 trophozoites/µl of blood.
Midline laparotomy under the umbilical under locoregional anesthesia with a retro-peritoneal approach to the right ureter found two dilated ureters (Figure 1 and Figure 2) with a lithiasis (Figure 3) wedged in the right uretero-vesical junction.
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Figure 2. Midline laparotomy under the umbilical.
We performed a right ureterolithotomy and a ureterovesical reimplantation of the two ureters with two ureteral drains and drainage of the right lateral retzius. Ureteral drains were removed on D3 and discharged on D4. The suites were simple. The ablation of the urinary catheter was performed on D10.
3. Discussion
The management was motivated by a complication of this ureteral duplication unknown until the day of the scheduled surgery despite the uro CT scan, whereas in the literature the management is done from the neonatal period or in childhood [3] [4] [5] [6] [10] .
According to the classification of SMITH in 1946, our case corresponds to type III (Three renal units), one of them drained by a simple ureter and the other two units by two ureters joining into one with a ureteral meatus as described by some authors [3] . Our two ureters united 1 to 2 centimeters to lead through a meatus.
The association of calculation is very frequent in a context of late discovery of the duplication according to the literature [2] [3] [6] . Repetitive urinary tract infections, pain like renal colic would be the motivating causes for the discovery of this ureteral duplication in the literature [2] [3] [5] [8] [9] [11] .
The diagnosis of duplicity is found intraoperatively, therefore a fortuitous discovery, as with many authors [2] [3] [6] [12] . Our course of action consisted of uretero-vesical reimplantation of the two ureters after uretero-lithotomy, as in many authors where conservative treatment was the most frequent option [3] [5] [6] . The suites were simple as described in the literature [3] [6] [7] [9] .
4. Conclusions
Ureteral duplications are sometimes incidentally discovered during exploration radiological or computed tomography therefore without apparent clinical urological signs. Peroperative discovery is frequent in the face of complications in our context.
Pathogenic ureteral duplications require medical and surgical management, most often conservative as long as we can, accompanied by long-term monitoring. Early management of congenital anomalies of the ureters helps preserve renal capital. Elsewhere, late discovery of the pathogenic form causes destruction of the renal parenchyma.
Acknowledgements
The authors would like to thank the patient who kindly gave their informed consent.