Ureteral duplication occurs in 0.3-0.8% of the population, but ureteral triplication has been very rarely described [1]. Ureteral triplication is a developmental abnormality of the ureteral bud originating from the Wolffian duct at the 5th week of embryological life. The ureteral bud arises from the distal part of the wollfian duct after 4 weeks of foetal development [2]. It grows dorsally at first and cranially later and makes contact with the metanephros and the distal end differentiates into the renal pelvis and the major and minor calyces during the 6th-8th weeks. In triplication of the ureter, three ureteral buds could arise independently from the mesonephric duct or from early fission of one or more ureteral buds to join the metanephros [2]. Smith [3] classified ureteral triplication into 4 types as follows: Complete ureteral triplication (35%), incomplete triplication (21%), trifid ureters (31%), double ureter, and one bifurcated (9%).
Our case was Smith type 2 triplication. Triplication is more common in females and on the left side [2]. Presenting symptoms are renal colic, recurrent UTI, and urinary incontinence [2, 4]. In addition, patients with triplication may encounter symptoms and signs of reflux, obstruction, ureterocele, or ectopia, similar to those with duplication anomalies [1]. The most frequently encountered urological anomalies associated with ureteral triplication are: contralateral duplication (37%), ureteral ectopia (28%), renal dysplasia (8%) and reflux [2]. Treatment is best tailored to individual cases and depends on the extent of the clinical problem i.e. presence of obstruction, extravesical ureteral ectopia, ureterocele or VUR. Transurethral incision of ureterocele effectively relieves the obstruction but may result in VUR necessitating ureteral re-implantation at a later stage. Other forms of surgical intervention require partial nephrectomy with aspiration of ureterocele in the first instance with re-implantation of ureter at a later stage [5].
Ureteral triplication is a rare congenital anomaly that requires high index of suspicion in order to diagnose. Due to lack of specific clinical signs, radiological examination remains the mainstay of diagnosis and can direct the best treatment strategy. This case emphasizes the importance of complete anatomic and functional evaluation of the urinary tract in the management of a child with urinary symptoms.