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Um, this infant is born with antenatal diagnosis of bilateral

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hydronephrosis.

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Let me show you the pictures. All right,

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so this patient had, um,

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repeated infections and uh,

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had antenatal diagnosis of hydronephrosis and

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uh, this is like a six month old baby.

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So let me walk you through this.

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So we are doing a renogram, it's a very complex renogram,

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so I will, uh, spend some time here. Here is the perfusion image.

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As we can see, there is aota,

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which is supplying the different organs, so perfusion of both the kidneys,

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tric, both the perfusion, uh,

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both sides are getting perfused very well as we look at the cortical stage,

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this is the cortical uptake stage.

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The left kidney looks pretty good and the right kidney shows some phototop penia

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in the upper wall.

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This kidney is again showing normal uptake and as we progress

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through the different stages of uptake, excretion and brain age,

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you can see there is area of phia,

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a persistent area of phia in the upper pole of the right kidney.

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The right ureter is seen

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throughout the drainage phase.

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The left ureter has already drained by that time.

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We confirmed the same findings on the graphical representation.

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This is the perfusion curve where you can see the left kidney is

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represented by this dotted curve and this is the right kidney.

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So the perfusion is almost symmetric in regards to the uptake.

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As you can see, this is the left kidney. It did take the,

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the cortical uptake was absolutely normal. It started to drain automatically,

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spontaneously. However, on the right side you see the zigzag curve.

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This is consistent with reflux in the collecting system of the,

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um, on the right side. On top of it, there is no good uptake

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and this is a later curve.

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This is the post Lasix curve and you have injected the Lasix at

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31st minute. As we can see,

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the left kidney was already spontaneously draining and it completely,

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almost, completely drained by the end of the 60 minutes.

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This is the right kidney. So after looking at this curve,

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um, there were two interpretations. The first one is,

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it is partly obstructed system,

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But, But it is also kind of refluxing.

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And also we had area of photo penia in the upper pole.

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So we went ahead and we then separated the uptake

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curves as well as uh,

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the brain age curves for both the upper and the lower pole collecting system.

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So this is the upper pole collecting system

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and this is the lower pole collecting system.

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So you can see the lower pole is actually refluxing lower pole

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refluxes, upper pole obstructs.

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That's a duplicated collecting system with the obstructed collecting system of

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the upper pole and refluxing lower pole.

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While the obstruction can be by two causes,

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the most common cause of obstruction of the upper pole duplicated collecting

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system is typically, um, uretal.

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Uretal is abnormal dilation of the dis. However,

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the other common condition is the ectopic insertion of the,

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so we can see there is area ofia and there is, um,

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good uptake as well as drainage from the lower pole. However,

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the lower pole keeps on refluxing.

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So I think I'm already giving a lot of information what this could potentially

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be for slx, you can see the right kidney,

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which is represented by actually because we don't have a proper,

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um, labeling technique for upper and or pole.

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We kept on saying left kidney or right kidney.

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Actually it's a separate upper and the lower pole.

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So postle right kidney and le uh, the right kidney,

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upper pole and lower pole.

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The upper pole shows persistent poor, uh, drainage.

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So that system is obstructed. So can we bring the poll question?

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So what is the most common, what is the most likely diagnosis

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That is correct.

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So what happened to the other side? What happened to the left side?

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So what happened when we did an ultrasound,

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we saw a cystic change in the upper pole of the left kidney.

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So the left kidney absolutely looked normal on the regram. However,

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it had a tiny atretic upper pole collecting system. Um,

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so both the sites were duplicated. Duplicated collecting system, um,

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is a known renal anomaly,

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especially the problem arises when there is ectopic insertion and when we

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did the mr actually, uh,

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there was representation of the ureter possibly going below the,

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uh, sphincter and opening below the level of the sphincter which caused

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persistent um, incontinence.

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So duplicated collecting system can be complete or incomplete. Complete,

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uh, duplicated system is, as I said earlier,

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is associated with lower pole refluxing and upper pole with ectopic insertion or

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uretal. If you have duplicated collecting system only on one side,

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then the lateral side has a higher, uh,

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incidence of tic junction obstruction.

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So you have to closely look at the other side of other side as well.

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Pelvic junction obstruction can also be seen in the lower pole duplicated

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system. Now the ectopic insertion can be, uh,

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different based on the gender of the patient.

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And as you see on the slide can be in semial vesicle, VA deference,

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prostatic urethra, ejaculatory ducts, uh, in males and vagina,

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urethra, urethra regina septum and gardener's ducts in females.

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Extra vesicle insertion is associated with renal dysplasia.

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So that is the theory we have for the left side,

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a collecting system which we did not see as a duplicated system on the regram

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because uh,

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it was already dysplastic and there was extra cycle insertion on the right side.

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So probably left side also was ectopic in, uh,

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location and got ecre from repeated, um, uh,

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repeated reflux and um, insult.