Interactive case challenge: Surgical option in duplex kidney with single-pole VUR – cut or connect?

Duplex collecting systems are among the most common congenital anomalies of the upper urinary tract and may be complicated by vesicoureteral reflux (VUR), particularly in the lower-pole moiety. Surgical management becomes challenging when reflux is high-grade, urinary tract infections are recurrent, and the affected moiety retains potentially useful renal parenchyma. We present the case of a 2-year-old girl with a complete left duplex collecting system and grade IV VUR involving the lower-pole ureter. Despite endoscopic treatment with dextranomer/hyaluronic acid copolymer, high-grade reflux persisted. Renal scintigraphy demonstrated preserved overall left renal function, and the anatomy was considered favorable for reconstruction. Instead of heminephrectomy, distal ureteroureterostomy was performed, with exclusion of the refluxing distal ureter and an end-to-side anastomosis to the normal upper-pole ureter. A double-J stent was placed across the anastomosis. The postoperative course was uneventful, antibiotic prophylaxis was discontinued, and the patient remained free of recurrent urinary tract infections during follow-up. This case illustrates the contemporary dilemma between ablative and reconstructive surgery in duplex kidneys with single-moiety VUR. When useful renal parenchyma is preserved and the anatomy permits reconstruction, ureteroureterostomy may provide definitive treatment while avoiding loss of renal tissue. In selected patients, the answer to the question “cut or connect?” may therefore be connect.