Case 1

A middle-aged female presented with a suspected right renal mass on an

intravenous pyelogram
What study is this ?
What does the arrows and arrow heads
Indicate ?
What logical diagnosis to be suspected. ?
In this patient with complete duplication, the IVU shows an ill-defi ned mass in the
upper pole of the right kidney ( arrows ) deviating the remainder of the kidney's collecting system
inferiorly. This represents an obstructed upper pole moiety. The lower moiety ureter is deviated
laterally ( arrowheads ) by the dilated right upper ureter, which is not opacifi ed.
This is from IVU series’
Arrows indicate soft tissue mass near upper pole of right kidney.
Arrow head – displaced right ureter.
Complete duplication with obstructed upper moiety
Ureteral duplication occurs more commonly in females and is most often unilateral. Ectopic insertions
in females may be below the external urethral sphincter, but in males, insertion is above the
sphincter (most commonly into the posterior urethra). In females, most ectopic ureters are associated
with duplications, whereas a single kidney and ureter are more commonly found in males with
ectopic ureteral insertions.

Clinical Findings Duplications are often discovered during the work-up of urinary tract infection (UTI) symptoms.
Vesicoureteral refl ux is a common complication of the lower moiety ureter. Obstruction is seen with
the upper moiety ureter due to its abnormal insertion into the bladder (or due to ureterocele) presenting
with pain or UTI.
In a young girl who should be old enough to be continent, the history of being continually wet
should result in a work-up for an ectopic ureteral insertion below the external sphincter.
In incomplete duplication, a bifi d renal pelvis forms where upper and lower poles
drain to separate collecting systems that fuse at the ureteropelvic junction (UPJ) level or lower to
form one ureter that drains into the bladder. In complete duplication , two separate renal units (i.e.,
upper and lower moieties) will drain into separate ureters that have separate bladder insertions.
Using the Weigert-Meyer rule, the upper moiety will drain into the bladder lower and medial when
compared with the lower moiety. The upper moiety is prone to distal ureteral obstruction, whereas
the lower moiety’s ureter is prone to vesicoureteral refl ux and UPJ obstruction. The upper moiety
ureteral insertions may be ectopic and/or associated with ureterocele
 CT at this level shows a normal
lower moiety and the medially placed dilated upper
A) Obstructed atrophic upper moiety with
moiety’s ureter(asterisk).
cortical thinning (arrowhead).
CT at this level shows the dilated upper moiety’s ureter
(asterisk) displacing the lower moiety’s ureter laterally
(arrow).
Imaging Findings
RADIOGRAPHY
• An upper pole renal mass should enhance more than that seen in this case, and there should be
some excretion from an upper pole renal mass.
• An adrenal mass may present with these fi ndings; thus, cross-sectional imaging is indicated.
• Deviation of the lower moiety of a complete duplication is seen due to the mass effect from the
obstructed upper moiety
• As the upper moiety’s ureter is dilated, it produces mass effect on the adjacent lower moiety’s
ureter, deviating it laterally
• The complete duplication is not always apparent on the IVP; computed tomography (CT)-IVP
should be performed even if the IVP is negative if symptoms, such as continual urine leak in a
young female, suggest complete duplication.
The classic sign on IVP of a duplicated collecting system with obstruction is the “drooping lily” sign
. This results from the obstructed, poorly functioning upper moiety with mass effect on the
lower moiety, which is normally functioning. Excretion into the lower moiety’s collecting system
shows the contrast-fi lled calyces to be bunched together and to resemble the drooping petals of a
lily. Even though the obstructed upper moiety may not excrete, the nephrogram phase will show the
kidney to be larger than what is being drained by the lower moiety’s collecting system
COMPUTED TOMOGRAPHY
• CT-IVP is an excellent modality to show all of the
features associated with an obstructed duplicated
kidney
Abdominal radiograph from the excretory phase of an
intravenous pyelogram. Lower pole calyces (arrowheads)
are displaced downward to form the “drooping lily” sign.
Note the lateral displacement of the lower moiety’s ureter
(arrows).
Coronal reconstruction of a CT-IVP in the excretory phase at two levels (A and B). (A) Right
upper moiety hydronephrosis (up) with deviation of lower moiety’s ureter laterally (arrows). C, distal
ureter. (B) Upper moiety hydronephrosis (up) and hydroureter (u
Complete duplication on a renal sonogram. (A) Sagittal image of the right kidney shows the dilated upper collecting
system (up) out of proportion to the lower collecting system. This mismatch suggests complete duplication with
obstruction. The lower moiety collecting system is also somewhat prominent, most likely from refl ux. (B) Sagittal bladder images show the dilated upper
moiety’s ureter (U) ending in a ureterocele (uc), the cause for the obstruction.

ULTRASOUND
• Observing hydronephrosis and hydroureter localized to an upper pole (as in Fig. 1.5 A ) should raise
suspicion of a duplicated system with obstruction. This can, however, be confused with renal or
parapelvic cysts.
• Evaluation of the bladder may show the dilated ureter near the expected trigone ( Fig. 1.5 B ).
• An ectopic ureter may cause a fl uid-fi lled bulge in the lateral bladder wall, or the ectopic ureter
may end in a ureterocele (