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Minimally invasive management of a bilateral duplex collecting system with periurethral ectopic upper pole ureters and a right cecoureterocele in an infant
Alexis Steinmetz, MD and Jimena Cubillos, MD
University of Rochester Medical Center, Department of Urology, Rochester, NY

Case
A newborn female was initially referred to urology for prenatal bilateral hydronephrosis and a possible right ureterocele. Subsequent postnatal workup revealed a bilateral duplicated collecting system without vesicoureteral reflux. The left kidney was found to have severe upper and lower hydroureteronephrosis with a possible lower pole ureteropelvic junction obstruction and an upper pole ectopically located in the perineal region next to the urethral opening (from which purulent material was easily expressible by pushing on the abdomen). The right kidney had a hydronephrotic upper pole without any other discernable anatomic abnormalities. She was planned for a robotic-assisted laparoscopic left lower pole pyeloplasty and a left upper-to-lower ureteropyelostomy. However, at the time of surgery a cecoureterocele with an ectopic right ureteral orifice just proximal to the meatal opening was discovered. It was also determined that the left ureteropelvic junction was actually patent, although a little tortuous. Fluoroscopic images taken during cystoscopy demonstrate dilated tortuous ureters bilaterally and bilateral hydronephrosis. After and intra-operative discussion, the decision was made to proceed with bilateral ureteroureterostomies to be done simultaneously. The patient's post-operative course was uncomplicated, and she continues to do well.
Conclusion
We present a case of bilateral duplications with obstructed megaureters of different etiologies and an associated cecoureterocele managed successfully with robot-assisted laparoscopic bilateral ureteroureterostomies performed under a single anesthetic. Despite the complexity of delineating the patient's anatomy and the difficulty of the dissection due to chronic inflammation, this case was safely performed in a 10-month-old infant.


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