DUPLEX COLLECTING SYSTEM FOR DOCTORS .pptx

DUPLEX COLLECTING SYSTEM FOR DOCTORS POWER POINT

1. DUPLEX COLLECTING SYSTEM DR BAKARE 10/02/2014

2. OUTLINE INTRODUCTION EPIDEMIOLOGY PATHOLOGY CLASSIFICATION DRAINAGE CLINICAL FEATURES RADIOLOGICAL FEATURES TREATMENT

3. INTRODUCTION Duplex system is characterised by incomplete fusion of upper and lower pole moeities resulting in complete or incomplete duplication of the collecting system. It is one of the most common congenital tract anomalies

4. EPIDERMIOLOGY

5. PATHOLOGY Embryologically , duplication occurs when two seperate ureteric buds arise from a single Wolfian duct. WEIGERT-MEYER RULE – future lower pole ureter seperates from Wolffian duct earlier & thus migrates superiorly and laterally as urogenital sinus grows.

6. CLASSIFICATION Duplex collecting system or duplex kidney anomalies can be classified into the following categories depending on the level or lack of of fusion: duplex kidney - two separate pelvicalcyeal systems draining a single renal parenchyma duplex collecting system - a duplex kidney draining into:

7. single ureter - i.e. duplex kidney's duplication pelvicalcyeal systems uniting at the pevi-ureteric junction (PUJ) bifid ureter ( ureter fissus ) - two ureters that unite before emptying into the bladder double ureter (complete duplication) bifid collecting system - refers to a duplex kidney with the two separate pelvicalcyeal collecting systems uniting at the PUJ or as bifid ureters double/duplicated ureters (or collecting system ) - two ureters that drain separately into the bladder or genital tract

8. DRAINAGE Lower moeity drains orthotopically while upper moeity ureter drains ectopically In the bladder Urethra vagina

9. ASSOCIATED ANOMALIES URETEROCELE VUR PUJ STENOSIS YO-YO REFLUX

10. CLINICAL FEATURES Asymptomatic Uncomplicated duplex kidney is a variation of normality UTI Pain due to intermittent obstruction at PUJ level of lower moiety or due to yo-yo reflux Continous wetting Vaginal prolapse Bladder neck obstruction mimicing PUV

11. IMAGING MODALITIES EXCRETORY UROGRAPHY MICTURATING CYSTOURETHROGRAPHY ULTRASOUND CT/CTU MRU NUCLEAR MEDICINE ANGIOGRAPHY

12. EXCRETORY UROGRAPHY A patient's duplex kidney is usually longer than his/her nonduplex kidney. The calyces are asymmetric. Poorly functioning system may not excrete "drooping lily" sign N ubbin sign- atrophied lower pole moiety of a duplex kidney Anomalies of the ureter , such as partial or complete ureteral duplication, may be demonstrated. Demonstrates ureterocele

13. Excretory urography in a man shows a blind-ending ureteric bud on the left, arising from the bladder.

14. MICTURATING CYSTOURETHROGRAPHY Detects ureterocele as a filling defect with small volume of contrast VUR may be detected usually into the lower moeity

15. ULTRASOUND The duplex kidney appears as 2 central echo complexes with intervening renal parenchyma. Hydronephrosis at one pole is suggestive of a duplex kidney. Occasionally, 2 distinct collecting systems and ureters can be observed on ultrasonographic images. Preferred mthd for detecting & measuring ureterocele

16. CT/CTU CT/CTU is able to delineate essentially all abnormalities. In an unobstructed system, the diagnosis can be difficult. A duplicated renal collecting system can be suspected by identifying the so-called faceless kidney   It can also help to determine if the insertion of the duplex ureter is intravesical or extravesical

17. MRU MR urography may be used as a primary diagnostic method in assessing a duplex ectopic ureter and complications associated with duplex kidneys.

18. NUCLEAR MEDICINE 99mTc-MAG3 will assess function, drainage &/or reflux, especially with late images Non functional moeity is not visualized Can demonstrate yo-yo reflux

19. 99m Tc -DMSA scintigram in the posterior (prone) projection shows a normal right kidney; the left kidney shows decreased activity in the upper pole with a little abnormal activity on the superomedial aspect . (D) Left posterior oblique projection of the 99m Tc -DMSA scintigram showing to better advantage the defect in the upper pole of the left kidney.

20. ANGIOGRAPHY Arteriography is an invasive procedure and is no longer used to diagnose the presence of a duplex collecting system. Invariably, 2 separate arteries arise, mostly independently from the aorta. Hydronephrosis of a moiety appears as a filling defect that displaces arterial branches

21. TREATMENT Usually does not require any treatment however complications may necessitate intervention VUR into lower moeity Marked hydronephrosis of upper moeity may be infected or have mass effect