Introduction:-
There are two kidneys in the human body. Two tubes, known as ureters, connect the kidneys to the urinary bladder. These tubes or ureters are around eight to ten inches long and transport urine from the kidneys to the urinary bladder. The right ureter is shorter by one centimeter than the left one. Usually, each kidney is drained by one ureter that takes the urine to the bladder. Duplication of the ureter is the most common anomaly of the urinary system.
The part of the kidney from which they originate is called the renal pelvis. Bifid ureter (BU) is a condition in which the ureter is duplicated. It is a rare congenital abnormality where separate cavities of the kidney drain into separate ureters because of a doubling of the ureters. Still, they join before emptying the urinary bladder while opening through a single orifice. It is more common in females than in men. The anomaly commonly occurs in the right ureter.
What Are the Types of Duplicated Ureters?
The duplicate ureters can be divided into two types:-
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Complete - This happens when the ureters join separately at the urinary bladder.
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Incomplete - This happens when the ureters fuse during their course, commonly known as the bifid ureter.
Bifid ureters can be associated with other anomalies, like,
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Horseshoe Kidney - This is a condition where both kidneys are joined together, giving the appearance of a horseshoe.
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Goltz’s Syndrome- This is a multisystem anomaly involving the development of skin, hands, feet, and eyes.
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Renal Ectopia- This is the presence of a kidney at a site other than its original position.
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H Shaped Ureter.
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Ureterocele- This is the ballooning of the ureter end inside the urinary bladder.
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Megaureter- This is an anomaly involving one or both the ureters of the kid.
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Ureteropelvic Junction Obstruction and Dilatation- A condition in which there is a blockage in the place where the ureter joins with the kidney.
Bifid ureters are most commonly unilateral. The incidence of bifid ureter ranges from 0.6 to 0.8 percent occurring naturally in women.
What Causes Bifid Ureters?
During the ordinary course of embryonic development, the ureteric bud- a tube that arises from the mesonephric or Wolffian duct at the twenty-eighth day of gestation is formed. Wolffian ducts are a pair of embryonic structures from which the renal system in both males and females and male internal genitalia are developed.
The ureteric bud is the precursor for the renal collecting system and branches into the metanephric blastema- the embryological structures giving rise to the kidneys and ureteric bud.
The metanephric tissue forms the filtration structures of the developing kidney, and the ureteric bud becomes the ureter.
During abnormal embryogenesis, the ureteric bud may split into two branches. If the other branch reaches the metanephric blastema, then this forms one more ureter or complete duplication. If this additional branch fails to reach the metanephric blastema, then this forms an incomplete duplication or blind-ending bifid ureter.
What Are the Sign and Symptoms of Bifid Ureters?
In the absence of associated malformations, the bifid ureter is usually asymptomatic.
Malformations such as :
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Vesicoureteral reflux to the lower pole system.
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Ureteropelvic junction of the obstruction of the lower pole system.
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Ectopic ureteral orifice of the upper pole system.
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Ureteocele of the upper pole ureter.
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Hypoplastic and dysplastic renal parenchyma.
Bifid ureter associated with these malformations may cause-
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Hydronephrosis- It is the swelling of the kidneys due to urine build-up.
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Urinary Tract Infections.
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Fever.
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Abdominal Tumor.
How Are Bifid Ureters Diagnosed?
Bifid ureters are usually detected during childhood when the kid presents with urinary tract infections or urine incontinence. At times they are not detected until adulthood as they are generally asymptomatic.
The diagnostic tests that are performed to detect bifid ureters are:-
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Intravenous Urography - This is an X-ray examination of the urinary system.
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Retrograde Pyelography- This imaging technique uses X-rays to examine the bladder, kidneys, and ureters.
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Diagnostic Cystoscopy- This procedure uses a camera known as a cystoscope to look inside the bladder.
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Ultrasound- Ultrasound is an imaging technique that uses sound waves to produce images of internal organs. Ultrasound of the kidneys and bladder can show the presence of bifid ureters.
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Computed tomography (CT)- A CT scan uses a combination of X-ray images taken from different angles around the body and a computer to create images of the organs.
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Magnetic Resonance Imaging (MRI)- An imaging technique that uses a magnetic field and radio waves to create images of the internal organs. A contrast media or dye is inserted into the kidneys to get a clear image of the ureters.
How Are Bifid Ureters Treated?
Since bifid ureters are asymptomatic, no treatment is required. Treatment of the underlying malformations and symptoms can have a positive effect. The following treatment options should be considered in case of dire circumstances-
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Ureteroureterostomy- In this surgical procedure, the ureter is split near the bladder and then sutured into the normal ureter of the lower part of the kidney. This procedure allows the urine from the upper part of the kidney to drain normally.
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Nephrectomy- This procedure is rarely used. In this procedure, a part or whole of the kidney is surgically removed if they are not working correctly. This removes urine incontinence and decreases the risk of infection.
The recovery time after the surgery depends upon the type of procedure performed as well as the age of the patient. Kids require around two days in the hospital for recovery, are discharged, and are advised to rest for two weeks. During follow-up, a kidney ultrasound is done four to six weeks after the procedure. No problems are expected with the kidney function or sexual function of the individual after surgery.
Conclusion:-
Bifid ureters are not a life-threatening condition. They are usually asymptomatic, requiring treatment only when the underlying malformations become symptomatic. The bifid ureter is a rare congenital condition that can occur along with other related disorders of the urinary system. Bifid ureters detected in the womb should be followed up with an ultrasound examination in the third trimester of pregnancy to assess for other abnormalities. Connecting with the physician and correctly following the instructions can help manage the ureters effectively.
