Recurrent febrile UTI with left duplex system

18 months child presented with recent history of febrile UTI and admission for iv antibiotics before 15 days. History of similar 3 episodes in last one year. 

Weight,  height and BP normal. 
Urinary stream is good. 
History of constipation. 
Rft: normal 
Culture: E. Coli sensitive to Amoxycillin. 
Posting USG,  VCUG and DMSA scan for review...
Please discuss;
Any need of other investigations, 
Treatment options 

Recurrent febrile UTI with left duplex system Recurrent febrile UTI with left duplex system Recurrent febrile UTI with left duplex system


  • Ravindra Sabnis
    Ravindra Sabnis
    01 Jul 2021 10:09:07 PM

    Interesting x-ray. I feel significant finding on MCU is persistent dye in PCS in post void plate. 

    He needs chemoprophylaxis, circumcision - (evidence of phimosis on MCU). 
    However, refluxing & obstructing kidney should be kept in mind. 

  • Venugopal P
    Venugopal P
    03 Jul 2021 11:03:48 AM

    Dear All,

    Anil has posted a rather Unusual Case. Not many such cases are reported. I am not going into the details of Ureteral Duplications be it Complete or Incomplete. In the case presented, the VCUG pictures are suggestive of Incomplete Duplication but a Cystoscopy is needed to ascertain this. In many instances, in a complete Duplication, the lower end could have an overlap and for clarification, an oblique picture would be necessary. Another aspect of Importance in Incomplete Duplication is where the two Ureters join each other. On many occasions, Incomplete Ureteral Duplications are asymptomatic and seen on evaluation and such cases warrant no treatment.

    Dahnert et al (2007) conducted a study on urograms and found that the prevalence of incomplete duplication of the ureter was three times commoner than complete duplication of the ureters.

    Hema Nagpal* and Renu Chauhan (2017) suggested that clinicians should be aware of existence of partial or complete duplication of ureter when a patient is presenting with complains of recurrent urinary tract infections or urinary reflux disorders.

    Reflux associated with Complete Duplicated system is more often seen in the Lower Moiety Ureter with Upper Moiety Ureter being obstructive.

    Min Ji Park, Min Hyun Cho* et al (2019) opined that VUR is more often found in association with Complete ureteral duplication than in Incomplete Duplication. They also opined that Low grade VUR can be managed with antibiotics and careful observation, but high-grade VUR requires more intensive management.

    The case presented being High Grade Reflux in Incomplete Duplication with DMSA scan showing functional deterioration with scars, the decision favours surgical correction of the Left system.

    What is important to know when intervention is being contemplated is where the joining of the Duplicated Ureters is ie, how close to the UVJ, the joining is. If it is very close to the UVJ, then a proper length of Ureter for Tunnelling may not be obtainable and one may have to resort to common sheath reimplantation. Though many have suggested, Common Sheath reimplantation without separating the Ureters, this procedure is not without its own problems. An alterative that is suggested is Uretero-ureteral anastomosis at a higher level. It could be anywhere higher up with but some have preferred Uretero-Pyelostomy. Few aspects have to be given consideration when Uretero-ureteral anastomosis is being contemplated. First and foremost, the Ureter draining the Lower Moity should be utilised for Reimplantation and not Vice versa. Another aspect that will have to be taken into consideration is the fact that there will be a rotation of the ureters at the junction of joining. One has to be taken care of so that the lower moity ureter is reimplanted. If the Joining of Ureters are at a higher level from UVJ, such problems as mentioned will not be there.

    I am sure Anil will share with us the way he managed this case. I honestly feel there is very little role for conservatism in this case. I would appreciate those with more experience share their views.

    With warm Regards,



  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Jul 2021 11:20:09 AM

    Thank you very much Sir. 

    As you advised cystoscopy was done.
    Posting images for review...

  • Dr. Anil Takvani
    Dr. Anil Takvani
    03 Jul 2021 11:43:06 AM

    Bladder was large capacity in compare to age of child. 

    Right ureteric orifice was normal. 
    Left was single ureteric opening,  placed laterally and gaping,  allowing 7f cystoscope to enter easily. After 2 to 3 cm. two dilated ureteric  lumen seen of incomplete duplex system...

  • Venugopal P
    Venugopal P
    04 Jul 2021 10:42:03 AM

    Dear All,

    I have placed my thoughts on the post of Anil. Now that Anil has provided us the Cystoscopic and Ureteroscopic Views, I consider placing few thoughts with this new information would be worthwhile, even though there could be some overlap from my previous write up.

    The joining of the two Ureters is reported as 2 – 3 cms from the Left UVJ which by itself is laterally placed. This Segment of single Ureter which is extremely short cannot be used by itself for reimplantation as it will not provide adequate length to form the tunnel. As the Ureters proximal to Fusion are dilated and to some extent Tortuous can be used as a Common Tunnel with both ureters opening separately into the bladder. This is what has been recommended by some in the field. The bulkiness of the Ureter will necessitate a wider tunnel which by itself will hinder the success of Reimplantation. The other alternative that is mentioned (alluded in the previous write up as well) is to disconnect the Upper Moiety Ureter and perform a uretero-ureteral anastomosis more proximally and bring down the lower moiety ureter for Tunnel Reimplantation. Though this looks attractive, some have mentioned that this may not give satisfactory outcome.  Arjan K Amar as early as 1969 suggested Uretero-Pyelostomy in such cases with the Upper Moity Ureter Anastomosed to Renal Pelvis. But this will need often additional incision and exposure.

    One should primarily expose the Ureter Extravesically and then depending on the situation observed, plan the appropriate procedure.

    With warm regards,



  • Dr. Aadil Farooq
    Dr. Aadil Farooq
    06 Jul 2021 11:15:09 PM

    Respected Venugopal Sir, 

    You have very beautifully summarised the management of Duplex kidneys with very short common sheath.
     I have often seen dilemma in managing such types of Duplex systems in our groups.
    Overwhelmed Sir, for teaching us with such rare guidelines. 
    Thank you so much Sir. 
    Thank you Anil Sir for posting this outstanding unusual case.
    Sincere Regards. 

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