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Hello everyone.

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Welcome to the tricky and Challenging Pediatric cases part two.

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So our first case is the continuation from the previous one,

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but I'm going to show you the nuclear medicine scan as well.

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So we had seen this case last time, but I'm going to go over it again.

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We had seen a case of duplicated collecting system where

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there is area of photo penia in the upper pole of the right kidney and

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some kind of, uh,

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reflux and increased uptake in the lower pole of the right kidney.

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This was consistent with duplicated collecting system.

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Now I'm going to share

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the ultrasound images on the same patient.

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You can see the ultrasound was performed which showed normal left kidney normal

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immunogenicity. The pelvic seal system is not dilated. However,

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on the right side as you scroll,

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you can see the dilated pelvic seal system.

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Further down just posterior to the bladder there is a dilated ureter

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and this is the upper pole of the right kidney.

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This is the lower pole of the right kidney.

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You can see there is a disproportionate dilation of the upper pole collecting

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system than the lower pole. Now,

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we had seen last time that the duplicated collecting systems,

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they follow Vigar Myer rule.

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That rule includes refluxing of the lower pole urator and

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obstruction of the upper pole ureter.

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The upper pole ureter can be obstructed either by uretal or by ectopic

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insertion of the ureter.

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Now here in the bladder we did not see any filling defect,

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which could suggest that there could be potential uretal.

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So we were asked to do the Mr.

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Urogram on this patient and we got very beautiful pictures.

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I would share the post contrast images on this patient.

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These are coronal post contrast,

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even weighted images where you see the disproportionate dilation of the upper

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pole cele system.

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There is some contrast to ation of the lower pole collecting system.

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Note that the upper pole collecting system inserts

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inferiorly than the expected location of the tric opening.

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This is severe dilation of the upper pole collecting system,

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which is opening into the urethral part of the

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urethral part of the collecting system or the, um,

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common collecting system.

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This is the ectopic insertion of the ureter from the upper pole

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collecting system, which is confirmed on multiple planes.

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And this is the refluxing

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Ureter where you can see the reflux part of the reflux into the lower pole

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collecting system. Again,

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the upper pole collecting system is not well opacified and is inserting into the

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urethra,

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inferior and medial to the insertion of the lower pole collecting

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system. Very complex case. However,

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we could confirm the ectopic region, uh, sorry,

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ectopic insertion of the upper pole uretal system,

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which caused to the co obstruction of the upper pole collecting system and the

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lower pole was consistent with refluxing type.

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So that was, uh, beautiful. Mr. Urogram.

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We did some post contrast OBL images, so to,

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uh, re retaliate the importance of collecting system opacification and delayed

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imaging. This is 20 minutes. Um, post delayed images,

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post contrast images, uh,

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where you see no opacification of the upper pole collecting system.

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Very good opacification of the lower pole collecting system and the ureter.

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Both the ureters are dilated. However,

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we could document using different techniques on m r I and different sequences

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to confirm that there are duplicated collecting system.

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Both the ureters are dilated and there is an ectopic insertion of the upper pole

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collecting system.

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So this is kind of a giveaway. So we will not, um,

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spend much time. Case one is of duplicated collecting system.

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Duplicated collecting system can be complete or incomplete if there is a

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complete duplication of the collecting system. As we said earlier,

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the lower pole collecting system will have reflux and the upper pole collecting

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system will have either ectopic insertion or ureteral.

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It is very common to cpel junction obstruction. On the contra lateral side,

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ectopic insertion is by default of the upper pole uretal.

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There can be other problems depending upon the sex of the patient.

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There could be, um,

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congenital anomalies in involving semial vesicles was deference,

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prostatic urethra, ejaculatory ducts in males. And, uh,

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the ectopic insertion with associated anomalies can be seen in vagina,

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urethra, euro, vaginal septum, and car's ducts In females, uh,

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if there is extra cycle insertion,

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there is a higher chance of renal dysplasia with cyst formation and

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usually the upper pole collecting system does not have that much of function as

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we saw on the nuclear medicine scan.