Metachronous vesicoureteral reflux in a bilateral incomplete duplex system: A case report

Metachronous vesicoureteral reflux in a bilateral incomplete duplex system: A case reportDear Editor, Vesicoureteral reflux(VUR) is an anatomical and/or functional disorder in which urine flows from the bladder to the ureter. 1 Diagnosis is typically confirmed via cystography.During the follow-up of VUR, reflux may resolve spontaneously over time.Since urinary tract infections related to VUR can impact renal function, vesicoureteral reimplantation is often performed in patients with surgical indications.Generally, the reflux is corrected and the symptoms disappear postoperatively.Nevertheless, a few children with a history of unilateral vesicoureteral reimplantation will develop contralateral vesicoureteral reflux after surgery. 2 We report a case of metachronous VUR in a bilateral incomplete duplex system to enhance clinical understanding of this situation.A 7-year-old girl was admitted to our department with a history of recurrent fever persisting for over 2 months.Throughout this period, she experienced multiple febrile episodes, with temperatures consistently ranging between 39 and 40 degrees Celsius, without any respiratory symptoms.This patient underwent left ureteral reimplantation (Lich-Gregoir procedure) five years ago due to incomplete duplication of the left ureter with reflux (grade 2-3) (Fig. 1A).Ultrasonography of the urinary system at that time revealed bilateral renal pelvis abnormalities.Renal scintigraphy indicates decreased left kidney function, with possible formation of scar tissue at the lower pole periphery.Six months postoperatively, renal scintigraphy follow-up indicated stable kidney function and postoperative ultrasound did not show bilateral ureteral dilation.Otherwise, patient did not exhibit positive findings on physical examination.A routine urine analysis showed 2++ white blood cells in the urine, with a white blood cell count of 360/μL, and urine culture indicated the presence of Escherichia coli, which suggestive of UTI.The patient was administered oral nitrofurantoin to treat the infection.After obtaining a negative urine culture, cystography revealed right VUR (grade 2) (Fig. 1B), while left VUR was not observed.The renal scans revealed a 6% decrease in right renal function compared to previous assessments (Fig. 1C and D).During the cystoscopy examination, normal bladder morphology without trabeculation or diverticula was observed, but the right ureteral orifice was noted to be relatively lower compared to the contralateral side, closer to the bladder neck.Given the recent presentation of persistent febrile UTIs and a history of left ureteral reimplantation, VCUG confirmed new right-sided vesicoureteral reflux.Following a renal scan showing progressive deterioration of right renal function, a diagnosis of metachronous VUR was made.Then, the patient underwent right ureteral reimplantation (Cohen's procedure) and experienced a Contents lists available at