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CASE REPORT
Year : 2013  |  Volume : 40  |  Issue : 3  |  Page : 177-179

A trifid pelvis in a patient with a solitary kidney with LUTS: An unusual presentation


Department of Urology, KLES Kidney Foundation, Belgaum, Karnataka, India

Date of Web Publication19-Oct-2013

Correspondence Address:
Rajendra B Nerli
Department of Urology, KLES Kidney Foundation, KLE University's JN Medical College, Belgaum-590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.120062

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  Abstract 

Trifid pelvis is one of the rarest congenital malformations of the upper urinary tract. Trifid pelvis in a solitary kidney is a very rare presentation. A young male adult presented to us with dysuria and white discharge per urethra since 1 year on and off. Urine examination showed few pus cells and white blood cells. Initial imaging by ultrasonography revealed a solitary right kidney. A computed tomography urogram showed a normal right kidney with a trifid pelvis and left ectopic hypoplastic kidney with focal thickening at the right posterolateral aspect of the vesicoureteric junction. Cystoscopy revealed normal anterior and posterior urethra, verumontanum extending until bladder neck, no ejaculatory duct openings noted, and right ureteric orifice placed slightly laterally, with the left ureteric orifice not visualized. Right RGP confirmed a trifid pelvis. A high index of suspicion is needed for the identification of this rare condition.

Keywords: Solitary kidney, trifid pelvis, urography


How to cite this article:
Kumar GA, Nerli RB, Devaraju S, Hiremath MB. A trifid pelvis in a patient with a solitary kidney with LUTS: An unusual presentation. J Sci Soc 2013;40:177-9

How to cite this URL:
Kumar GA, Nerli RB, Devaraju S, Hiremath MB. A trifid pelvis in a patient with a solitary kidney with LUTS: An unusual presentation. J Sci Soc [serial online] 2013 [cited 2019 May 26];40:177-9. Available from: http://www.jscisociety.com/text.asp?2013/40/3/177/120062


  Introduction Top


Trifid pelvis is a rare congenital anomaly of the kidney. The embryologic genesis of multiple pelvises is best described by one ureteral bud arising at the fifth week of embryological life from the mesonephric duct. This structure then divides into two or three before reaching the metanephrogenic blastema. [1],[2],[3] In such cases, it may be difficult to decide whether the kidney represents a trifid pelvis, purely a peduncular arrangement, or elongation of the major calyces in association with a rudimentary pelvis. Trifid pelvis in association with ureteropelvic junction obstruction (UPJO) may coexist, but this is also extremely rare, and, if associated, may present with pain. But diagnosis of a trifid pelvis without any abdominal symptoms is very rare and is not reported in the literature yet. We herein present a case of an adult male with a trifid pelvis presenting in a very different way, posing a diagnostic dilemma.


  Case Report Top


A 34-year-old man presented with dysuria and white discharge per urethra. A complete urological evaluation was performed. Laboratory data were as follows: hematocrit 38.2%, white blood cell count 9,400 K/μL, urea 26 mg/dL, and creatinine 1.21 mg/dL. Urine routine and microscopy showed few pus cells and white blood cells. Urine culture and sensitivity showed no organisms. An ultrasound examination of the KUB region revealed a solitary right kidney with nonvisualization of the left kidney. Computed tomography (CT) urography revealed a normal right kidney with a trifid pelvis and left ectopic hypoplastic kidney with focal thickening at the right posterolateral aspect of the vesicoureteric junction [Figure 1] and [Figure 2]. Cystoscopy revealed normal anterior and posterior urethra, verumontanum extending until the bladder neck [Figure 3], no ejaculatory duct openings, and right ureteric orifice placed slightly laterally, with the left ureteric orifice not visualized [Figure 4]. Right RGP confirmed the trifid pelvis [Figure 5].
Figure 1: CT urogram demonstrating a solitary right kidney

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Figure 2: CT reconstruction showing the right trifid pelvis

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Figure 3: Cystoscopy showing verumontanum extending until the bladder neck

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Figure 4: Cystoscopy showing the right ureteric orifice placed laterally

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Figure 5: Retrograde pyelogram showing the right trifid pelvis

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  Discussion Top


The embryologic genesis of multiple pelvises is best described by one ureteral bud arising at the fifth week of embryological life from the mesonephric duct. This structure then divides into two or three before reaching the metanephrogenic blastema. [3],[4],[5],[6] In such cases, it may be difficult to decide whether the kidney represents a trifid pelvis, purely a peduncular arrangement or elongation of the major calyces in association with a rudimentary pelvis. In our case, the appearance of three major draining systems resembles renal pelvises rather than elongated major calyces. Until and unless a trifid pelvis is not associated with UPJO, it cannot be diagnosed as it is an embryological anomaly. Previously, a trifid pelvis was diagnosed intraoperatively on the exploration of left UPJO, where the left kidney with thin parenchyma, markedly dilated left renal pelvis, and narrowing at the level of UPJ were observed. Trifid pelvis without any abdominal symptoms is a difficult way to diagnose.

Akkoη et al. [1] reported, a 54-year-old man who was admitted to the Department of Urology with left flank pain for 6 months and frequent urinary infection. Urine analysis revealed an infection due to E. coli. A complete urological evaluation was performed. Laboratory data were as follows: hematocrit 38.2%, white blood cell count 14,400 K/μL, urea 39 mg/dL, and creatinine 1.41 mg/dL. Urinary system radiography showed a few radioopacities of 4-5 mm diameter on the left side of the L3 vertebra. Delayed intravenous urography (IVU) revealed probable left UPJO and a dilated left pelvic system. CT urography revealed left UPJO and a severely dilated left pelvic system; the right kidney was completely normal. Scintigraphy revealed 63% renal fixation at the right kidney and a moderate reaction to treatment with a diuretic. Low-level perfusion and concentration functions of the left kidney were observed with 37% renal fixation, prolonged extraction time, and an atrophic left kidney. Due to the radiologic left UPJO, open left pyeloplasty was scheduled. The left kidney and pelvis were explored through a left-flank incision, and three renal pelvises joined to a common pelvis form with UPJO were observed. The condition was denoted as trifid pelvis and intraoperative ureteropelvic junction obstruction. The left ureter, atrophic left kidney, thin parenchyma, markedly dilated left renal pelvis, and a 0.4-cm segment of left ureter narrowing at the level of ureteropelvic junction were observed. After excising the narrow segment, open Anderson - Hynes dismembered pyeloplasty was performed. Left nephrectomy was not considered because renal fixation characterized 37% of the left kidney. The postoperative course was uneventful.


  Conclusion Top


Due to the rare nature of this condition, a high index of suspicion is necessary for diagnosis. A CT urogram demonstrated a trifid pevis which is confirmed by retrograde pyelography. Cystitis might not be related to the trifid pelvis. Simple antimicrobial prophylaxis relieved cystitis in our case.

 
  References Top

1.Akkoc A, Yaðlý OF, Metin A, Eroðlu M, Kandýralý E. A case of trifid pelvis with ureteropelvic junction obstruction. Turkish J Urol 2011;37:272-4.  Back to cited text no. 1
    
2.Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: A critical analysis of result. Eur Urol 2007;52:983-9.  Back to cited text no. 2
    
3.Grasso M, Caruso RP, Phillips CK. Ureteropelvic junction obstruction in the adult population: Are crossing vessels significant? Rev Urol 2001;3:42-51.  Back to cited text no. 3
    
4.Sapin E, Kurzenne JY, Bargy F, Mayer M, Bienaymé J. Trifid pelvis and controlateral bifid ureter with bilateral ureteropelvic junction obstruction. Eur Urol 1988;15:144-5.  Back to cited text no. 4
    
5.Marc J, Drouillard J, Bruneton N, Tavernier J. Triple ureter. One case. Diagnostic problem and review of the literature (author's transl). J Radiol Electrol Med Nucl 1977;58:427-39.  Back to cited text no. 5
    
6.Cromie WJ, Engelstein MS, Duckett JW. Nodular renal blastema, renal dysplasia and duplicated collecting systems. J Urol 1980;123:100-2.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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