28 - Duplication of the Left Ureter in a 78-year Old Caucasian Male Cadaver: A Unique Finding

Poster Board Number: 28
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Abstract Body : Introduction
Ureter duplication is a developmental anomaly of the urogenital system occurring in approximately 0.7% of the population, or 1 in every 500 people. The duplication of a single ureter can be due to embryological errors such as abnormal ureteric bud division or incomplete fusion of the upper and lower renal poles. As a result, the two ureters leaving a single kidney can merge before entering the bladder or enter the bladder separately. The aim of this case report is to explore the causation, prevalence, and clinical correlations of ureter duplication as it pertains to our findings.

Materials and Methods
A routine dissection of a 78-year-old Caucasian white male was performed at the Texas A&M Engineering Medicine (EnMed) program for Medical Gross Anatomy. The kidneys and posterior abdominal wall were dissected to reveal pertinent structures, including the renal and suprarenal arteries, veins, ureters, and urinary bladder. Upon discovery of two ureters exiting the left kidney, the surrounding field was cleaned for better visualization, and the kidney, ureters, and bladder were removed en bloc. Ureteric variations were documented through notes and photography, and an in-depth literature review was performed to explore the clinical implications and significance of our findings.

Results
Detailed dissection revealed one ureter originating in the superior pole and the other originating in the inferior pole. These structures were further cleaned and traced down the renal pelvis. At a junction ~20 cm superior to the bladder, the duplicated structures merged prior to entering the bladder. No congenital anomalies or ureteric duplication were present in the right kidney and ureter. This particular cadaveric finding represents an example of a unilateral incomplete ureteric duplication, in which the ureter was split along its course to its final destination into the metanephric blastema.

Discussion and Conclusions
While most patients with ureteric duplication remain asymptomatic, those who do develop symptoms often present with urinary tract infections, vesicoureteral reflux, hydronephrosis, and incontinence. Patients with duplicated ureters are also more susceptible to kidney calculi due to an additional point of constriction created where the two ureters meet. The angled point of union of the two ureters can obstruct normal flow in vivo and further complicate flow reversal and hydronephrosis. Anatomical variation amongst patients is always significant to take into account. In females, ureteric duplication is significant for gynecologists performing a hysterectomy, as there is an additional risk of accidental trauma to the ureter. Furthermore, radiologists and surgeons should note that duplex systems may not always be visible via urography and sonography. A method to diagnose duplex ureters and visualize the location of fusion is a CT Intravenous Urogram (IVU) of the kidney, ureters, and bladder. This method aids radiologists and surgeons working in the field.

Significance and Implications
The awareness of such variation is crucial for physicians working in the abdominal, retroperitoneal, and pelvic regions. Lack of knowledge regarding double ureters can lead to complications that may negatively affect patient mortality or morbidity. Such complications have already been referenced in literature due to their clinical impact. Therefore, this case report adds to the current field by highlighting the implications of ureteric duplication.