THE KIDNEYS AND URETERS 933
Fig. 30.11 (A) Main stem renal artery supplying the upper
births, most commonly a small lower pole artery (Fig. 30.11). The
presence of an accessory renal artery is of significance and should
be identified if certain surgical procedures are being considered
(partial nephrectomy, endoscopic pyeloplasty and live renal trans­
plantation). They are common in horseshoe and crossed fused
kidneys. Accessory renal veins occur in up to 1/8 live births and
are often retroaortic on the left.
Duplication abnormalities These are common, being found in
10% of the population. The most minor form of this condition is a
A B
Fig. 30.12 Duplex ureters on IVU: complete bilateral (A) and partial left-sided (B).
two-thirds of the kidney with (B) an accessory lower pole renal
artery demonstrated on angiography.
bifid renal pelvis, which is a normal variant. Otherwise duplica­
tion abnormalities (duplex kidneys) are characterised by two (on
rare occasions more than two, up to six having been reported)
ureters and renal pelves. The duplication of the ureter may be
incomplete (the ureters fusing at some point in their course and
having a common distal ureter and orifice) or complete (both
ureters having separate distal orifices). Incomplete duplication is
almost always of no clinical significance, although in a small pro­
portion of cases it may be associated with yo-yo reflux in which
urine from one ureter refluxes back up the other ureter. This may
lead to loin pain on micturition and urinary tract infection.
Completely duplicated ureters are associated with a number of
potential problems. They may be associated with pelviureteric junc­
tion obstruction. The lower renal moiety drains via the ureter with
the orthotopic insertion (i.e. inserts on the trigone in the anatomi-
934 A T E X T B O O K O F R A D I O L O G Y A N D I M A G I N G
cally correct site) but is often associated with vesicoureteric reflux.
The ureter draining the upper moiety is inserted ectopically and its
termination is always distal to the lower moiety insertion. This is
usually within the bladder on the trigone inferior and medial to the
orthotopic ureter but it may insert in a number of other sites. This is
mainly within the bladder on the neck. In the male, the insertion is
never inferior to the external sphincter and is therefore very rarely
associated with incontinence. In the female, ureteric insertion into
the urethra or vagina may occur and lead to continuous inconti­
nence and vulnerability to ascending infection. There is often steno­
sis of the ureteric orifice with a variable degree of obstruction. The
upper moiety ureter has a strong association with ureterocele for­
mation, which is present in up to one-third of cases. Vesicoureteric
reflux much less commonly affects the upper moiety.
An uncomplicated duplex kidney appears enlarged on all
imaging modalities. The two collecting systems are visualised on Fig. 30.13 Ultrasound of duplex kidney.
IVU (Fig. 30.12), while the sinus fat surrounding the collecting

Fig. 30.14 (A) Ultrasound of duplex kidney with upper pole moiety hydronephrosis; there has been virtually complete loss of cortex from the upper pole
moiety. Similar features seen on MRI in a different patient with a small, chronically hydronephrotic upper pole moiety (B).

Fig. 30.15 The classical

drooping lily sign on IVU (A).
The lower pole moiety has
been displaced inferolaterally
by an upper pole hydro­
nephrosis. This usually occurs
due to obstruction of the
upper pole moiety ureter at its
orifice associated with ectopic
insertion or a ureterocele. In
this case it is due to a calculus
in the upper pole moiety
ureter (B).