Background
Duplication of renal tracts is the most common congenital renal anomaly, estimated to have an incidence of 0.8 to 5% (Williams 2007). It is more common in women. Duplex ureters can be double (with no communication between each), bifid (with dual origins to single distal ureter) or abortive (with a single origin to dual distal ureters). While duplex ureters can cause vesicoureteic reflux, urinary tract infections, ureterocele and obstruction, patients are often asymptomatic.
Case
A 36-year-old woman underwent a total laparoscopic hysterectomy and bilateral salpingo-oopherectomy for endometrial hyperplasia with focal atypia and menorrhagia. She had a significant history of breast cancer. The operation was uncomplicated. A routine cystoscopy was performed and the patient received indigo carmine intravenously. Efflux was visualised from three orifices, with one on the right and two on the left, demonstrating a double ureter (as shown in cystoscopy footage with presentation). Previous ultrasound imaging noted normal appearing kidneys bilaterally and she had normal renal function.
Discussion
As in this patient, duplex ureters may be undiagnosed pre-operatively. Ureteral injury is a serious surgical complication with significant morbidity and mortality. Gynaecology surgery, in the literature, accounts for over 75% of iatrogenic ureteric injuries (Thompson 1997) and the rate of ureteral injury during laparoscopic gynaecological surgery has been estimated to be 0.1-2.5% (Park, Park et al. 2012). Anatomical variants, particularly if undiagnosed, increase the risk of ureteral damage (Park, Park et al. 2012). Awareness of this common but rarely seen anomaly is important in endoscopic surgery.