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Duplex Kidneys Unraveled
Chris Driver Aberdeen
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Duplication Anomalies
0.8% population 40% bilateral Inheritance autosomal dominant incomplete penetrance 8% in siblings of index case
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Types of duplex complete incomplete 2 UO’s VERY rarely 2 kidneys
1 UO only divided outside bladder usually no clinical issues
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Embryology Ureteric Bud Induces Renal Differentiation
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Duplex ureters cross over
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Mackie Stephen’s Hypothesis J Urol 1975
↑distance from orthotopic site = ↑ dysplasia
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Duplex MOST DUPLEXES ARE CLINICALY IRRELEVANT Upper Moiety
Low / ectopic orifice Lower Moiety High Lateral orifice
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If the lower moiety is ectopic....
lateral UO VU reflux dysplasia
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Management of Reflux in Duplex
indication UTI progressive scarring less likely to resolve spontaneously STING or HIT En Bloc reimplantation lower pole hemi-nephroureterectomy
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If the upper moiety is ectopic.....
low UO obstruction, ureterocele extra-vesical ectopic
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C:\ Ureterocele
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Management of Duplex Ureterocele
indications obstruction especially bladder neck hydronephrosis loss of function UTI remember.....single system (non duplex) ureterocele is rare
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Endoscopic Puncture definitive (temporising) Risk = induced reflux
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Definitive management
No upper pole function - Upper pole nephrectomy
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Definitive management
Good upper pole function, big ureterocele - Uretero-ureterostomy
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Definitive management
Good upper pole function, small ureterocele – en bloc reimplantation
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Definitive management
No upper pole function, obstructing ureterocele - heminephroureterectomy
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Ectopic Ureter “she’s always wet, doctor.....”
primary continuous normal voiding pattern otherwise can be very wet....
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Extravesical Ectopic Ureter
females HN HU usually BUT may not be associated with dilatation small dysplastic upper moiety “CRYPTIC DUPLICATION”
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Investigation of Cryptic Duplication
USS- may miss small non-dilated IVU- may miss poor function, clues Retrograde Pyelogram....difficult ++ MRU new gold standard
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If so small, why so wet? DYSPLASTIC RENAL TISSUE GOOD RENAL TISSUE
GFR 1ml/min 60 mls/hour <50% reabsorption in tubules Urine output 30 mls per hour = 720mls/day = very wet! GOOD RENAL TISSUE GFR 100ml/min 6000 mls /hour 99.9% reabsorption in tubules Urine output 60 mls per hour
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Summary Duplex lower moiety: Reflux upper moiety: Obstruction
ectopic orifice: Incontinence
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