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Clinical note

Ureteral triplication without other associated malformations

Ramón Diz Rodríguez, Ignacio Arance Gil, Miguel Vírseda Chamorro, Pablo Quijano Barroso,
Carlos Alpuente Román, Domingo Sáenz Benito

Servicio de Urología. Hospital Central de la Defensa. Madrid. Spain.

ACTAS UROLÓGICAS ESPAÑOLAS 2009;33(3):330-331

Abstract
We report a case of type III ureteral triplication according to Smith's classification, without
associated anomalies of the urinary tract. The review of the literature indicates the rarity of this
malformacion and its frequent association with other urinary and extraurinary malformations.
The absence of associated malformations increases the exceptionality of this cases.
Key words: Ureter. Urinary maldformations. Ureteral triplication

Ureteral triplication is a rare malformation caused by an alteration in embryonal development.

Normally, a ureteric bud arises from each Wolfian duct and joins with the metanephric blastema
to form the kidney and with the urogenital sinus to form the bladder1. If several ureteric buds
arise, the Weigert-Meyer law indicates that the ureter draining the upper portion of the kidney
will finally lie more caudal and medial than the ureter draining the lower portion2. Displacement
of the upper ureter from its usual position makes it more likely to have an ectopic opening,
whereas the shorter development time of the lower ureter reduces its muscular layer and
facilitates the occurrence of vesicoureteric reflux. In ureteral triplication, these embryological
abnormalities are more marked and frequently associated with urinary tract anomalies3.
We conducted a review of the literature in the Medline database using the key words “ureter”
and “triplication”, obtaining 60 articles of clinical cases with this malformation.
The rarity of presentation of this malformation and the unusual absence of associated
alterations in our case justifies its publication.

CASE REPORT
A 31-year-old man who presented to the emergency department of our hospital with pain in the
left renal fossa radiating along the entire theoretical trajectory of the left ureter to the testicle,
compatible with an uncomplicated left renal-ureteral colic.
On physical examination, the patient was afebrile and normotensive, conscious and oriented,
and had good skin and mucous membrane color. The abdomen, with no laparotomic scars, was
soft and depressible, and no hernias, masses, organomegalies, tender points or signs of
peritoneal irritation were found. He had pain in the left renal fossa radiating to the genitals with a
positive kidney punch, whereas examination of the contralateral renal fossa was normal. The
patient did not show vesical globus. Genital examination revealed that both the penis and testes
were normal.
Blood and urine analyses showed slight leukocytosis with a left shift. Renal function was normal
and microhematuria was noted in the urine.
IV urography was performed (Figures 1 and 2), showing functional annulment of the left kidney
and complete ureteral triplicity of the right kidney. A double J-catheter was placed in the left
kidney and used to perform bladder cystoscopy, which revealed the presence of single eutopic
ureteral orifice in the right hemitrigone.
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FIGURE 1. IV urography showing three renal pelvises with their respective excretory
ducts in the right kidney. Functional annulment of the left kidney due to ureteral lithiasis.
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FIGURE 2. Ureteral triplication with a single uretral opening.

DISCUSSION
Ureteral triplication is a rare congenital malformation first described by Wrany in 18704. We
found 63 ureteral triplications in 60 Medline references, the first published in 19525 and the last
in 20046. Some authors state that the total number of ureteral triplications published is less than
100 cases4.
In a review of published cases, ureteral triplication was classified into four types by Smith7: type
I (three separate ureteral orifices), type II (a bifid ureter with two separate orifices), type III (a
trifid ureter with a single orifice), and type IV. The most frequent types are types I and II, and
type III is exceptional. Both the endoscopic and radiologic findings indicate that our case
involved a type-III triplication.
The presence of associated malformations of both the urinary and other organ systems is
frequent in this type of anomaly. In our review of the literature, we found that the most common
associated malformation was ureteral ectopia in 29% of cases, followed by ureterocele in 16%
and vesicoureteral reflux in 13%. The remaining associated malformations included from
dysplasia and upper urinary tract obstruction to digestive, facial and upper limb malformations.
In two cases, ureteral triplication was associated with contralateral duplication, and in only two
other cases was no associated malformation found.
In conclusion, ureteral triplication is a rare malformation of the urinary tract that is normally
associated with other types of malformations, mainly ureteral ectopia and ureterocele, and
therefore cystoscopy should be performed to rule out their presence.
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REFERENCES
1. Langman J. Embiología Médica. Interamericana 1969.
2. Meyer R. Normal and abnormal dedeveloppment of ureter in human embryo-mechanistic
sideration. Anat. Rec. 1946;96:355.
3. Zaontz MR, Maizels M. Type I ureteral triplication: an extension of the Weigert-Meyer law. J
Urol. 1985;134(5):949-950.
4. Li J, Hu T, Wang M, Chen S, Huang L. Ureteral triplication: the first report in China. J Pediatr
Surg. 2004;39(1):E38-9.
5. Gill RD. Triplication of the ureter and renal pelvis. J Urol. 1952;68(1):140-147.
6. Villanueva Pena A, De Diego Rodriguez E. Ureteral triplication, an unusual isolated
presentation. Actas Urol Esp. 2004;28(10):766-770.
7. Smith I: Triplicate ureter. Brit J Surg 1946;34:182.

Correspondence author: Dr. Miguel Vírseda Chamorro

Servicio de Urología. Hospital Central de la Defensa
Glorieta Ejército s/n - 28047 Madrid. Tel.: 914 228 186
Author e-mail: bgmeli@terra.es
Paper information: Clincal note
Manuscript received: june 2007
Manuscript accepted: july 2007