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© 2010 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 29:145-147 • 0278-4297

Just Images

Simultaneous Obstruction of Both Limbs of a Bifid Ureter by Calculi

Sonographic Evaluation

Stylianos Megremis, MD, PhD, Maria Chatziioannou, MD and Ioanna Tritou, MD

Department of Radiology, Venizelio General Hospital, Iraklio, Crete, Greece.

Address correspondence to Stylianos Megremis, MD, PhD, 23 Arsinois St, 71303 Iraklio, Crete, Greece. E-mail: efstel{at}med.uoc.gr

Abbreviations: ESWL, extracorporeal shock wave lithotripsy

Although it is not standard practice for emergency physicians to use renal sonography to identify calculi, some do perform it to exclude hydronephrosis, especially when a patient presents with abdominal or flank pain consistent with renal colic. A recent series indeed brought back the matter of the calculi detection rate with sonography, with competitive results for noncontrast helical computed tomography.1

A 41-year-old man with a history of right lateral abdominal pain and gross hematuria presented to the emergency department with acute right flank pain and dysuria. He had sharp pain radiating to the right groin and testicles with a burning sensation. The symptoms had started several weeks earlier, with periodic pain in the hypogastrium, which was more intense on the right side. The patient then used oral analgesics for pain relief and never sought medical assistance until this time. Physical examination showed moderate tenderness in the right lower abdominal quadrant, and a dipstick test confirmed blood in the urine.

On kidney-ureter-bladder radiography, several small round opacities were observed in the anatomic region of the right kidney. Abdominal sonography confirmed the presence of multiple renal stones on the right side and also revealed a duplex renal collecting system connected to a mildly dilated double upper ureter. Bowel gas overshadowed, continuity permitting only a single ureteral stone to be faintly seen (Figure 1, A and BGo). The compression technique that followed revealed the presence of "kissing stones" obstructing both proximal ureters (Figure 1CGo). The left kidney had a cortical cyst in the upper pole and a stone in the lower calyceal system without dilatation. The urinary bladder was empty. The sonographic differential diagnosis was between a double (complete duplication) and a bifid (incomplete duplication) ureter. Note the fact that the patient was unaware of his abnormality, and he had never been examined for this condition before. One week later, intravenous urography revealed a duplicated collecting system with incomplete ureteric duplication, similar to the sonographic findings (Figure 2Go).


Figure 1
Figure 1
Figure 1
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  		Figure 1. Abdominal sonograms. A, Right duplex renal collecting system (asterisks) with calyceal stones (arrows). B, A stone is shown in the proximal part of the lower-pole ureter (arrow), whereas the upper-pole ureter is faintly shown (asterisk). C, With the compression technique, an appearance of kissing stones is shown in the proximal part of each ureter (arrows).

 

Figure 2
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  		Figure 2. Right duplicated collecting system (asterisks) with incomplete ureteric duplication on intravenous urography. The arrow indicates the junction point.

 
Ten days after the acute incident, the patient underwent extracorporeal shockwave lithotripsy (ESWL), and tamsulosin was prescribed to improve the urine flow and relax the bladder muscle tone. One week after ESWL, sonography showed a stone-free right upper pyelocalyceal system with no dilatation, whereas the lower system was still obstructed by 2 stones remaining in the lower-pole ureter, producing the characteristic "twinkling sign" on color Doppler sonography (Figure 3Go). No stones were found in the urinary bladder, and the ureteral jets were shown on both sides.


Figure 3
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  		Figure 3. Abdominal sonograms after ESWL. A, Remaining lower-pole obstruction (asterisk). B, Two calculi obstructing the lower-pole ureter (arrows). C, In the absence of a definite acoustic shadow, the twinkling sign on color Doppler sonography confirms the origin of the echogenic foci as stones (arrow).

 
Our case can serve as a representative example of the usefulness of sonography in the investigation of urolithiasis complicating a common urologic anomaly. Renal collecting system duplication is the most common congenital abnormality of the urinary tract, with 4% incidence for incomplete ureter duplication and a bifid renal pelvis in the North American population.2 To the best of our knowledge, there are no data in the literature presenting analogous sonograms, such as double ureteropelvic dilatation due to the simultaneous presence of stones in both limbs of a bifid ureter.3 We may also speculate that when we see an appearance of kissing stones in a duplicated upper ureter, we should think of a bifid rather than a double ureter because the junction point actually represents native "stenosis."

Footnotes

Received September 3, 2009, from the First Department of Radiology, Venizelio General Hospital, Iraklio, Crete, Greece. Revision requested September 8, 2009. Revised manuscript accepted for publication September 12, 2009.

References

  1. Park SJ, Yi BH, Lee HK, Kim YH, Kim GJ, Kim HC. Evaluation of patients with suspected ureteral calculi using sonography as an initial diagnostic tool: how can we improve diagnostic accuracy? J Ultrasound Med 2008; 27:1441–1450.[Abstract/Free Full Text]
  2. Chu WC, Chan KW, Metreweli C. Scintigraphic detection of "yo-yo" phenomenon in incomplete ureteric duplication. Pediatr Radiol 2003; 33:59–61.[Medline]
  3. Bhatia V, Biyani CS. Calculus disease in duplex system: role of extracorporeal shockwave lithotripsy. Urol Int 1993; 50:164–169.[Medline]




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