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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 4  |  Page : 277-279

Anatomical variations of ureter in central India: A cadaveric study


Department of Anatomy, Jawaharlal Nehru Medical College, DMIMS (DU), Wardha, Maharashtra, India

Date of Web Publication17-May-2018

Correspondence Address:
Dr. Brij Raj Singh
Department of Anatomy, Jawaharlal Nehru Medical College, DMIMS (DU), Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_73_17

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  Abstract 


Background: Duplication of ureter is a developmental anomaly of urogenital system. The possible embryological reasons for the formation of a duplicated ureter could be splitting of ureteric bud, resulting two ureters draining into single kidney. Prevalence occurs in approximately 1% of the population. It may be associated with or without other congenital defects. Aim: To study the major anatomical variations of the ureter in routine dissection method. Materials and Methods: The present study conducted in the Department of Anatomy on 156 formalin-fixed cadavers of both sex and focus on the ureteric anomaly in routine dissection method. The ureter was followed from the renal pelvis to the uretrovesical junction, an opening into the urinary bladder (UB). Out of them, we got in one cadaver that two ureters were draining a single kidney into the UB separately and were not associated with any other congenital anomaly. There was complete duplication of ureter on unilateral side (left). Right kidney and its ureter were entirely normal. Conclusion: The knowledge of abnormality in renal collecting system is necessary for effective endo-urological applications and intrarenal surgeries. The present study adds on to the literature and will be helpful and interesting for the radiologists and urologists as it describes the ureteric anomaly in the Central Indian population.

Keywords: Bifid ureter, kidney-ureter-bladder region, mesonephric duct, ureteral duplication, ureteric bud


How to cite this article:
Roy M, Singh BR, Gajbe UL, Thute P. Anatomical variations of ureter in central India: A cadaveric study. J Datta Meghe Inst Med Sci Univ 2017;12:277-9

How to cite this URL:
Roy M, Singh BR, Gajbe UL, Thute P. Anatomical variations of ureter in central India: A cadaveric study. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Aug 17];12:277-9. Available from: http://www.journaldmims.com/text.asp?2017/12/4/277/232585




  Introduction Top


Ureters are a pair of thick-walled cylindrical tubes, each measuring about 25 cm in length and 3 mm in average diameter, extending from the funnel-shaped renal pelvis to urinary bladder (UB), and convey urine from the corresponding kidney. Each ureter is developed from stalk of ureteric diverticulum that lies between the pelvis of kidney and the vesicourethral canal, which grows headwords from the caudal part of mesonephric duct around the 5th week of intrauterine life.[1] Anatomical variations of ureter and its relationship to surrounding structures are therefore important in academic as well as clinical perspective to preserve renal functions. Duplication of ureters results from early splitting of ureteric bud [2] into two or more either completely or incompletely (bifid ureter). Single kidney drained by double, triple, and quadruple ureters has been reported, and the double ureters (DUs) may be associated with double renal pelvis in single kidney or double kidney.[3]

Symptomatic patients usually have complete ureteric duplication, in which the ureters are prone to develop obstruction, reflux, and infection.[4] Duplications may be discovered in childhood less frequently, in later life often accompanied by various complications, or they may be occult and discovered at autopsy.[5],[6] In neonates, out of all congenital anomalies of the abdominal masses found, the urinary tract accounts for more than 50% and involve about 0.5% of all pregnancies. Malformations of the urinary system are common and comprise about 3% of live births.[7] From the study among Central Indian population, information regarding duplex system and DU is yet to accomplished. Hence, this study was performed to find out the ureteric anomalies in the Central Indian population, as the cadaveric study by simple dissection method has immense value, even in the modern era of imaging techniques.


  Materials and Methods Top


The anatomical study of ureteric anomaly was conducted in 156 properly embalmed and formalin-fixed cadavers of both sexes to teach 1st-year MBBS and BDS students in the Department of Anatomy, JNMC, Sawangi (Meghe), Wardha, Maharashtra, from August 2012 to March 2017. Out of 156 cadavers, 122 were males and 34 were females. Using conventional dissection techniques, following Cunningham's practical manual, the abdomen and pelvis region of all 156 cadavers were dissected. Skin incision was followed by superficial fascia, muscles of anterior abdominal wall and peritoneum to reach up to abdominal cavity. Intra-abdominal organs were removed as the kidneys are located in the posterior abdominal wall behind the peritoneum to expose kidney-ureter-bladder (KUB) region and the dissection of kidney and ureter was carried out. Each cadaver was examined on both (right and left) sides for the presence of duplex system or DU and the one showing variation was recorded, photographed, and described.


  Observation and Results Top


In the present study, as shown in [Table 1], out of 156 specimens, ureteral duplication was found in one cadaver (0.64%) only. The female cadaver had unilateral complete duplication of ureter which was present on the left side. The right kidney was drained by single ureter and opened into the UB at a single orifice. In left kidney (LK), there were DUs descended from the left renal pelvis originated from the hilum of the LK and opening separately into the bladder. None of those ureters had the presence of macroscopic lesions or any other major abnormalities. In all 156 specimens, kidneys of both sides were normal in relation to size and shape [Figure 1], [Figure 2], [Figure 3].
Table 1: An incidence of duplicated ureter among Central Indian population specimens expressed in percentage

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Figure 1: Anterior view of the left kidney showing double ureters originating from the pelvis

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Figure 2: Anterior view of left kidney showing complete duplicated ureters opening separately into the bladder

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Figure 3: Unilateral complete duplicated ureter of left kidney, while right kidney showing normal single ureter. (RK: Right Kidney, LK: Left kidney, SU: Single ureter, DU: Double ureter, UB: Urinary bladder)

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[Table 1] shows an incidence of duplicated ureter among Central Indian population specimens expressed in percentage.


  Discussion Top


There are various congenital anomalies involving KUB region, and the authors observed them during their study they have attempted but discuss few of them in their literature. The anatomical variations of ureter such as incomplete or complete duplications are some reported anomalies that have been known since ages. We conducted this study to document the presence of any major anatomical variations of ureter and its incidence in Central Indian population. The findings include the presence of unilateral complete duplication of ureter with an incidence of 0.64%.

The study conducted by Kulkarni et al. revealed that duplication in the ureter occurs in an incidence of 0.5% and ranges from 0.5% to 3.0% and it is two to five times more common in females, common in Caucasian race.[8] Literature also suggested that, the incidence of duplicated ureter is more common on the right side, which is just opposite in our case.

In 1989, Asakawa et al. reported five cases of double pelvis and ureter among 340 cadavers (1.47%, 1.8% R, 0.3% L).[9] In our study, the prevalence of left-sided complete bifid ureter was 0.64% which was almost similar.

Duplex systems are the most commonly encountered congenital abnormality of the renal tract, with a reported incidence of 0.8% by Privett et al.[10] However, Standring [11] has described the incidence of unilateral bifid ureter as 1 in 125. Choudhary et al.[12] observed that out of 32 cadavers, two showed unilateral duplication (6.25%, 3.12% R, 3.12% L). Lowsly and Kirwori revealed that out of 4215 cadavers studied, 18 showed duplication of ureter. Among those 18 specimens, 8 were unilateral complete duplication,[13] i.e., 0.19% and almost similar to our findings.

A cadaveric study by Deka and Saikia revealed out of 60 specimens, 56 (93.3%) cadaver with normal ureter and renal pelvis, whereas 4 (6.7%) specimens presented with variations of the renal pelvis and ureter. Out of these, 2 (3.3%) specimens presented with unilateral variations of ureter.[14]

As per the study of Moore and Persuad, the duplicated ureters may join together before reaching the bladder or remain separate while entering the bladder at two distinct points.[15] The variation we found in one cadaver is the complete duplication of ureter till their separate openings into the bladder.


  Conclusion Top


The ureteric variation found during our study may be significant in clinical cases, especially to urologists and radiologists. Knowledge of developmental anomaly of the urinary system is of great importance as it can affect both the disease conditions and the interventional methods. In urogenital surgeries including renal transplant or gynecological surgeries and in laparoscopic procedures, this information is also very useful for early detection through radiological examinations. Recognition of such variants before renal surgeries can decrease unnecessary complications and decrease the morbidity and mortality significantly.

Concluding with the note, the developmental anomaly of the kidney, ureter, and UB should be kept in clinician's mind while treating as most of these ureteric abnormality cases are asymptomatic.

Acknowledgment

Our sincere thanks to Head of the Department of Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra, for her wholehearted support to further carry out this work. We would like to thank all the faculties of the Department of Anatomy for their support. We are also grateful to authors/editors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Datta AK. Essentials of Human Anatomy (Thorax and Abdomen). 9th ed. Kolkata: Current Books International; 2014.  Back to cited text no. 1
    
2.
Sadler TW. Langman's Medical Embryology. 9th ed. Baltimore, Maryland, USA: Lippincott Williams & Wilkins; 2004.  Back to cited text no. 2
    
3.
Mugunthan N, Felicia C, Anbalagan J. Bifid ureter and multiple renal arteries: Clinical and embryological significance. Indian J Basic Appl Med Res 2016;5:203-9.  Back to cited text no. 3
    
4.
Sailaja TK, Rajasree TK. A rare anomaly of ureter and its developmental aspect – A case report. MRIMS J Health Sci 2014;2:102-4.  Back to cited text no. 4
    
5.
Amitai M, Hertz M, Jonas P, Apter S, Heyman Z. Ectopic ureterocele in adults with a comparison of the anomaly in children. Urol Radiol 1992;13:181-6.  Back to cited text no. 5
    
6.
Cronan JJ, Amis ES, Zeman RK, Dorfman GS. Obstruction of the upper-pole moiety in renal duplication in adults: CT evaluation. Radiology 1986;161:17-21.  Back to cited text no. 6
    
7.
Rahul GA, Gune RP, Patil AD, Pote AJ, Nikam VR. Unilateral incomplete bifid ureter presenting with calculus in right kidney with hydronephrosis: A rare case report. Int J Sci Study 2015;3:201-3.  Back to cited text no. 7
    
8.
Kulkarni V, Ramesh BR, Prakash BS. Bilateral bifid ureter with accessory renal artery: A case report. Int J Basic Med Sci 2012;3:67-70.  Back to cited text no. 8
    
9.
Asakawa M, Kubodera T, Okamura Y, Habara K, Ito H. Five cases of the double renal pelvis and ureter. Kaibogaku Zasshi 1989;64:206-9.  Back to cited text no. 9
    
10.
Privett JT, Jeans WD, Roylance J. The incidence and importance of renal duplication. Clin Radiol 1976;27:521-30.  Back to cited text no. 10
    
11.
Standring S. Gray's Anatomy. 40th ed. Churchill Livingstone, Elsevier; 2012.  Back to cited text no. 11
    
12.
Choudhary U, Kumar S, Jee K, Singh A, Bharti P. A cadaveric study on anatomical variations of kidney and ureter in India. Int J Res Med Sci 2017;5:2358-61.  Back to cited text no. 12
    
13.
Lowsly OS, Kirwori TJ. Clinical Urology. USA: The Williams and Wilkins Company; 1956.  Back to cited text no. 13
    
14.
Deka B, Saikia R. A study of human cadaveric ureter by simple dissection method. Int J Anat Res 2016;4:3005-8.  Back to cited text no. 14
    
15.
Moore KL, Persuad TV. The Developing Human Clinically Oriented Embryology. 8th ed. Saunders, Elsevier; 2009.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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