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Paediatric Surgery
Ureteral Duplication and Duplex Systems
Built from Puri — Pediatric Surgery and Pediatric Urology
What’s inside
12 sections · 70 slides
Foundations
What a duplex system is and why it matters
- What does 'duplex' actually mean?
- Complete versus incomplete duplication
- How common are these anomalies?
- Why duplex systems draw attention
- Who develops a duplex system?
Embryology
How two ureters, and their problems, come to be
- The starting material: the ureteric bud
- Reciprocal induction: bud meets kidney tissue
- How a duplication is created
- The Meyer-Weigert law: which ureter ends up where
- Why the lower pole tends to reflux
- Stephen's hypothesis and upper-pole dysplasia
- Sex differences that decide the symptoms
- A useful anatomical footnote in boys
The Clinical Spectrum
A heterogeneous set of problems
- The list of problems a duplex system can cause
- Prenatal diagnosis has changed the game
- Why the evidence base is thin
Incomplete Duplex Systems
The milder, usually silent variant
- Three problems of an incomplete duplication
- How incomplete systems are treated
Complete Duplication: Reflux
The most common problem of all
- Reflux: the commonest problem, favouring the lower pole
- Presentation and the chance of spontaneous cure
Ectopia of the Upper-Pole Ureter
Obstruction, dysplasia, and wetting
- Ectopia and dysplasia go together
- Ectopic ureters in boys: always obstructed
- Ectopic ureters in girls: the constantly wet child
Investigations
Building up the anatomical and functional picture
- Ultrasound: the first-line map
- Ultrasound of a duplex kidney's dysplastic upper pole
- The MCUG: still the gold standard for reflux
- The drooping lily sign on an MCUG
- The DMSA scan: how much kidney is working
- DMSA scan showing a poorly functioning upper pole
- MR urography: anatomy and function together
- MR urogram demonstrating an ectopic ureter insertion
Principles of Treatment
Why every plan must be individualized
- Factors that shape the management plan
- The four aims of treatment
Treatment of Reflux
Medical, endoscopic, and open options
- Start conservatively, then escalate
- Endoscopic (injection) treatment
- Open anti-reflux surgery: reimplant both ureters
- Dealing with a very wide ureter
- When the lower pole is not worth keeping
Heminephrectomy
Removing a non-functioning pole
- When to remove an upper pole
- How the operation is done
- The problem of the retained ureteral stump
- Complications are uncommon
- Which access route?
- Minimal-access heminephrectomy series (2000-2014)
- What the heminephrectomy literature tells us
Kidney-Sparing Alternatives
Rethinking automatic removal
- Do we always need to remove the dysplastic pole?
- Ureteroureterostomy and pyeloureterostomy
- How well these salvage operations work
- Matching the problem to the operation
Wrap-Up
Consolidating the key ideas
- A toilet-trained girl voids normally but is constantly damp. What diagnosis must you exclude, and why not in boys?
- The essentials to remember
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- Pediatric Surgery and Pediatric Urology