Robert L. Lebowitz, M.D. Children' s Hospital, Harvard Medical School Boston, Massachusetts

This little boy presented with day and night wetting and asymptomatic bacteriuria. He was eventually found to have bilateral duplex kidneys with Grade II reflux into the right lower pole. However, initially, this right lower pole pelvicalyceal system resembled a single (non-duplex) collecting system. The ureter inserted into a bladder diverticulum. There was a bilobed ureterocele in the bladder.

On the left, there was a duplex kidney with upper pole hydroureteronephrosis. The left lower pole was normal. There was a large left bladder diverticulum. It was originally thought that the ureterocele was at the end of the left upper pole ureter, but an IVP (Fig. 1, Fig. 2) showed that the ureterocele remained filled with nonopaque urine and never filled with contrast material, as it would have had it been at the end of the left upper pole ureter. Therefore, it was suspected that there was right ureterocele disproportion, and that the ureterocele was at the end of a nondilated upper pole ureter on the right that drained a tiny dysplastic nonfunctioning upper pole. At the time of cystoscopy, just prior to the definitive operation, the ureterocele was injected (Fig. 3, Fig. 4). It was bilobed and was, in fact, at the end of a nondilated right upper pole ureter. He underwent bilateral diverticulectomies, ureterocele excision, and bilateral common-sheath reimplants with tapering of the left upper pole ureter. His postoperative IVP (Fig. 5) showed a normal right lower pole, no function in the right upper pole, and normal left upper and left lower poles.