Bilateral complete duplex system with right intravesical & left extravesical ureteroceles. A case report from tertiary care hospital

Bilateral complete duplex system with right intravesical & left extravesical ureteroceles. A case report from tertiary care hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bilateral complete duplex system with right intravesical & left extravesical ureteroceles. A case report from tertiary care hospital Yirgalem Gebreziher, Enderta Zeru, Hadush Negash, Zeamanuel Teshome This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5688436/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Bilateral duplex system with ureteroceles is one of the rarest entities in urology. Duplex collecting system is a common urologic anomaly with a wide range of clinical symptoms and a variety of associated urologic abnormalities such as an ectopic ureter, ureterocele, vesicoureteral reflux and ureteropelvic junction Presentation of case : We present a 12-year-old male adolescent presented with nocturnal enuresis since birth and right flank pain of 8 months duration. Clinical findings and investigations : There were no pertinent physical findings. A complete blood count, renal function test, urine analysis, ultrasound of the abdomen and pelvis, computed tomography urography, and cystoscopy were performed. Intervention and outcome : A single-setting right upper pole heminephroureterectomy and left ureteropyelostomy were performed. He is now asymptomatic and regularly followed up on an outpatient basis. Relevance and impact : This case report shows the safety of simultaneous open bilateral procedures for complete bilateral duplex systems in resource-limited settings. Case Report Bilateral Complete Duplex System Ureteroceles Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction 1.1. Background and rationale Bilateral complete duplication of the ureters is a rare condition. In a study of 5,196 excretory urograms conducted on both children and adults, duplex systems were found in 95 patients. The condition was bilateral in only 16 patients, while complete duplication was demonstrated in less than a third of the duplicated systems ( 1 ). We report the first case of simultaneous bilateral open procedures for a bilateral complete duplex system with right intravesical and left extravesical ureteroceles, to the best of our knowledge. 1.2. Guidelines: SCARE 2023 paper This case report has been reported in line with the SCARE Criteria ( 1 ). 1.3. Patient information: demographics and presentation A 12-year-old male adolescent presented with nocturnal enuresis since birth and right flank pain of 8 months duration. Otherwise no history of fever, burning during micturition and dysuria. He had a normal voiding pattern. 1.4. Past medical and surgical history He had no known history of TB, Hypertension; Diabetes Mellitus. He had no surgical interventions done in the past. 1.6. Drug and allergy history No history of long-term drug intake and no known allergies until date. 1.7. Family history He had no history of similar illness in the family. 1.8. Clinical findings The physical examination was unremarkable. 1.9. Diagnostic assessment and interpretation The laboratory investigations of complete blood count, creatinine, urinalysis, including renal function tests, were within normal limits. Ultrasound of the abdomen and pelvis revealed the presence of duplex collecting systems with double ureters on both sides. Additionally, a right intravesical ureterocele and a left extravesical ureterocele were observed. Voiding cystourethrography demonstrated a round intravesical-filling defect. No vesicoureteral reflux was present. Subsequently, cystoscopy revealed a ureterocele situated within the prostatic urethra as well as another intravesical ureterocele (Figure: 1). Computed tomography urography revealed bilateral complete ureteral duplication. The right upper moiety displayed severe hydronephrosis and thinned-out, non-excreting parenchyma, along with hydroureter and intravesical ureterocele. The right lower moiety exhibited moderate hydronephrosis and a dilated, normally inserted ureter. The left lower moiety appeared normal with a non-dilated ureter. The left upper moiety had moderate hydronephrosis and a dilated ureter draining below the bladder neck into the prostatic urethra (Figure: 2). A renal scan was not performed due to unavailability. 1.10. Intervention After thorough history and relevant investigations, diagnosis of bilateral complete duplication of ureter with right upper moiety severe hydroureteronephrosis & intravesical ureterocele, and left upper moiety hydroureteronephrosis with extravesical ureterocele was made. The patient was scheduled for single-setting upper tract procedures through bilateral anterior subcostal incisions, as there was no vesicoureteral reflux. For the right side, a right heminephroureterectomy was planned due to the nonfunctional upper moiety in the right kidney. For the left side, a ureteropyelostomy was planned. Intraoperative cystoscopy was performed to stent the lower pole ureters, but the orifices were difficult to visualize. On the right side, the renal parenchyma was thinned out, with a dilated upper moiety and dilated ureters. Consequently, a right heminephroureterectomy was performed (Figure: 3).The upper moiety ureter was excised as far distally as possible.The left upper moiety on the left side was dilated, along with its ureter. In contrast, the left lower moiety appeared normal, with a non-dilated ureter. A left ureteropyelostomy procedure was performed (Figure: 4). The upper moiety ureter was excised as distally as possible. Antegrade DJ stents were inserted intraoperatively for both kidneys, and perinephric drains were left in place. The operation was uneventful and blood loss was minimal. The patient was managed with Intravenous fluids, antibiotics, analgesics, antiemetic and antipyretic. Post-operative renal function tests were normal. Drains were removed on the second postoperative day. Postoperative period was uneventful and the patient had recovered well. Ureteric stents were removed after 6 weeks of surgery. 1.11. Outcome The patient has been monitored and seen in the outpatient clinic every month for the past six months and has had no complaints since. The ureteroceles disappeared (Figure: 5), the right lower moiety hydronephrosis decreased with an increase in cortical thickness, and there was significant improvement in left upper moiety hydronephrosis. His renal function tests are normal. Discussion Duplex collecting system is a congenital abnormality characterized by complete or incomplete duplication of the collecting system. This occurs due to incomplete fusion of the upper and lower pole moieties ( 3 ). Duplex kidney malformation has an estimated incidence of around 1.8%, and it occurs more frequently in women. This condition can be classified into two types: incomplete and complete. The complete ureteral deformity variant has an incidence of approximately 0.2% ( 4 ). Only 25% of these cases are reported to be bilateral ( 5 ). Duplication of the urinary collecting system can be associated with other deformities, such as ureterocele, ureteropelvic junction obstruction, vesicoureteral reflux, and ectopic ureter ( 6 ). Symptoms vary widely, with the majority of cases diagnosed in early childhood, though some patients remain asymptomatic. The most common symptoms relate to vesicoureteral reflux and urinary tract infections. Urinary incontinence is the primary presenting complaint for ectopic ureters in females, while ectopic ureters inserting at the verumontanum can cause bladder outlet obstruction in boys ( 3 , 7 , 8 ). Imaging is essential to confirm the diagnosis and identify associated abnormalities. ( 3 ). Ultrasound findings of asymmetrical renal lengths, dividing parenchymal tissue, or disproportionate pelvicalyceal dilation suggest an abnormal duplicated renal collecting system ( 9 ).Other Imaging studies, such as intravenous pyelogram, CT, MRI, and renal scintigraphy, can comprehensively evaluate the renal anatomy, function, and any complications associated with urinary tract duplication. These modalities are invaluable in differentiating complete from partial duplication, thereby guiding the most appropriate treatment approach. Furthermore, Micturating cystourethrogram can detect vesicoureteral reflux, while cystoscopy can identify anomalies like ectopic ureter ( 6 , 7 , 10 ). Management of duplex renal anomaly (DRA) is complex because of individual anatomic variation ( 10 ). The goals of treatment are control of infection, protection of normal ipsilateral and contralateral units, preservation of renal function, treatment of vesicoureteral reflux (VUR), minimization of surgical morbidity, facilitation of subsequent reconstructive procedures, and maintenance of continence ( 11 ). Evidence-based management for children with ureterocele and complete pyeloureteral duplication is not possible. Treatment should be individualized following consideration of renal function, severity of hydronephrosis and obstruction, drainage of the contralateral ureter and bladder outlet, and associated VUR and UTI ( 12 ). Optimal management of duplication anomalies may include an upper or lower tract surgical approach. When there is symptomatic non-functional upper pole moiety, heminephrectomy is historically favored. However, cases with preserved renal function in the upper pole are treated with ureteral reimplantation or ipsilateral upper to lower pole ureteroureterostomy ( 7 , 13 ). A right heminephrectomy was performed to address the non-functioning right upper pole, and a ureteropyelostomy was carried out for the functioning left kidney in our case. There have been a small number of reported cases involving the concurrent performance of bilateral renal procedures in pediatric patients ( 14 , 15 ). Kapoor et al described a minimally invasive approach of heminephrectomy and contralateral ureteroureterostomy to manage bilateral duplex systems in young children. This simultaneous bilateral robotic procedure demonstrated safety, with no intraoperative or postoperative complications reported ( 16 ). In our case, where minimally invasive surgery was unavailable and expertise lacking, we opted for a bilateral open approach. This allowed us to complete both the right heminephroureterectomy and the left ureteropyelostomy in a single operative session, sparing the patient a second surgery. Conclusion Bilateral complete duplication of the ureters is a rare condition. To the best of our knowledge, this is the first reported case of bilateral complete duplication of the ureters with a right intravesical ureterocele and a left extravesical ureterocele. The condition was managed with a single-setting right heminephroureterectomy and left pyeloureterostomy. This case report demonstrates the safety of simultaneous open bilateral procedures for complete bilateral duplex systems in resource limited settings. Declarations Ethical approval This type of study does not require any ethical approval by our institution. Sources of funding This case report hasn’t been funded by any person or any institutions. Declaration of Competing Interest There is no any conflicts of interest with this article. Consent Written informed consent was obtained from the patient’s mother for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this Journal on request. References Privett JTJ, Jeans WD, Roylance J (1976) The incidence and importance of renal duplication. Clin Radiol 27(4):521–530. 10.1016/s0009-9260(76)80121-3 Agha RA, Franchi T, Sohrabi C, Mathew G, Kerwan A, Thoma A et al (2020) The SCARE 2020 guideline: updating consensus surgical CAse REport (SCARE) guidelines. Int J Surg 84:226–230. https://doi.org/10.1016/j. ijsu.2020.10.034 Muhamad MS, Mousa MA, Oukan M, Razzok A (2022) Giant hydronephrosis secondary to an ectopic ureter associated with bilateral duplex collecting system: a case report, Oxford Medical Case Reports, Volume Issue 4, April 2022, omac034. https://doi.org/10.1093/omcr/omac034 Wu C, Ji F, Zhang H, Yao Z, Li L, Yan B (2022) Treatment for complete bilateral duplex kidneys with severe hydronephrosis and ureterectasis of the upper moiety in a child: A case report and literature review. Front Surg 9:1019161. 10.3389/fsurg.2022.1019161 Cassell AK, Traoré A, Jalloh M, Ndoye M, Diallo A, Labou I et al (2019) Bilateral Ureteral Duplication and Right Ectopic Ureter Presenting with Incontinence: A Case Report. Med Sur Urol 8:216. 10.35248/2168-9857.19.8.216 Mittal MK, Sureka B, Gupta P, Mittal A (2014) Bilateral duplex system with overlooked dysplastic moiety: A rare cause of incontinence. J Mahatma Gandhi Inst Med Sci 19:67–69 Singh S, Bhusal NP, Mishra S, Singh S, Rai K, Bista S, Amatya S, Kisee S Bilateral complete duplication of ureter with ectopic ureter presenting as persistent urinary dribbling with normal voiding pattern in 17-year-old female: Case report. Annals of Medicine & Surgery 84():, December 2022. | 10.1016/j.amsu.2022.104824 Docimo S (2018) The Kelalis–King–Belman Textbook of Clinical Pediatric Urology. 10.1201/9781315113982 Didier RA, Chow JS, Kwatra NS et al (2017) The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations. Pediatr Radiol 47:1526–1538. https://doi.org/10.1007/s00247-017-3904-z Yuri P, Utama ETP (2021) A complete duplicated collecting system with giant ureterocele in adult: case report. Int J Surg Case Rep 79:49–52. 10.1016/j.ijscr.2020.12.083 Herz D, Smith J, McLeod D, Schober M, Preece J, Merguerian P (2016) Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery. J Pediatr Urol 12(1):44 Epub 2015 Aug 17. PMID: 26443241. .e1-7 Timberlake MD, Corbett ST (2015) Minimally Invasive Techniques for Management of the Ureterocele and Ectopic Ureter. Urol Clin North Am 42(1):61–76. 10.1016/j.ucl.2014.09.006 Sahadev R, Rodriguez MV, Kawal T, Barashi N, Srinivasan AK, Gundeti M, Shukla AR (2022) Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches. J Robot Surg 16(6):1321–1328. 10.1007/s11701-022-01372-2 Epub 2022 Jan 25. PMID: 35079941 AZMY AF (1988) Simultaneous Bilateral Renal Surgery in Children. Br J Urol 62(2):191–192. 10.1111/j.1464-410x.1988.tb04313.x John A, Provet, Moneer K Hanna,Simultaneous repair of bilateral ureteropelvic junction obstruction, Urology,33, Issue 5,1989,Pages 390–394, ISSN 0090-4295, https://doi.org/10.1016/0090-4295(89)90032-0 Kapoor V, Elder JS (2015) Simultaneous bilateral robotic-assisted laparoscopic procedures in children. J Robotic Surg 9(4):285–290. 10.1007/s11701-015-0528-x Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5688436","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":393122852,"identity":"a950f92a-4f5d-4e59-bc36-e488a3011ece","order_by":0,"name":"Yirgalem Gebreziher","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACg8MgsgBEsDEc+ACi2InSYsDAwMPAxnhwBkgLMwEtkg0ILcyHeUAcQlr42Xkfv/hhYBNtz96WcNjm1zZ5PmYGxg8fc3BrYWNmN7PsMUjL7eE5duBwbt9twzZmBmbJmdvwaWFjM+AxOJzbI5HeACRvMwK1sDHzEtBi+Mfgf26P/POGw5Y9t+2J0cL8mMfgANAWtgOHGX7cTiTKFmYZg+TcnjNpCQd7G24ntzEzNuP3C/8x5o9vKuxy29uPGX/48ee27fz25oMfPuLRAtIlAWcytoHJBrzqgYD5A4L9h5DiUTAKRsEoGIkAAOSQTU2NCmgIAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0005-9474-9964","institution":"Mekelle University","correspondingAuthor":true,"prefix":"","firstName":"Yirgalem","middleName":"","lastName":"Gebreziher","suffix":""},{"id":393122853,"identity":"712f12ab-b072-4ecb-8f5e-efc93ff13c88","order_by":1,"name":"Enderta Zeru","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Enderta","middleName":"","lastName":"Zeru","suffix":""},{"id":393122854,"identity":"8960f4ea-b022-4c33-993c-08ef96a23e82","order_by":2,"name":"Hadush Negash","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Hadush","middleName":"","lastName":"Negash","suffix":""},{"id":393122855,"identity":"0591fc1e-f0c4-422b-88b4-897b1af6598d","order_by":3,"name":"Zeamanuel Teshome","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"prefix":"","firstName":"Zeamanuel","middleName":"","lastName":"Teshome","suffix":""}],"badges":[],"createdAt":"2024-12-21 07:50:09","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5688436/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5688436/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72277661,"identity":"be5080e9-8620-4531-8c83-1ac799bc168a","added_by":"auto","created_at":"2024-12-24 15:29:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":492827,"visible":true,"origin":"","legend":"\u003cp\u003ecystoscopy showing an intravesical ureterocele (star) (arrows indicate the bladder neck) (A) and another one in the posterior urethra (star – ureterocele, arrows –posterior urethra) (B)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/45fb0462755e930606f50f72.png"},{"id":72279209,"identity":"cc5942c1-9482-4c65-8db3-cf2b10a739d0","added_by":"auto","created_at":"2024-12-24 15:45:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":616637,"visible":true,"origin":"","legend":"\u003cp\u003eCT urography shows bilateral duplex systems with a non-excreting right upper moiety (black star) (A). Complete duplication of the ureters can be seen in the coronal and axial planes with contrast seen in the left lower moiety non-dilated ureter (arrowhead) (B, C, \u0026amp; E), right intravesical cystic filling defect (white star) (B), and left extravesical cystic dilatation (blue star) (C, D, \u0026amp; F).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/d9a1c9e63717cd71c44b8485.png"},{"id":72278373,"identity":"54eecb20-8d57-454b-a7b8-d9b5c6b5330b","added_by":"auto","created_at":"2024-12-24 15:37:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":973128,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images of the right kidney showing dilated two ureters (arrows ) (A), thinned-out right upper moiety (star) (B), and after completion of heminephrectomy (C).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/9d79c3dad6a3de3f8f47c94e.png"},{"id":72277709,"identity":"43fa7a93-6e59-48a3-bf82-97d19bd2ba32","added_by":"auto","created_at":"2024-12-24 15:29:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":898646,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images of the left kidney showing non-dilated lower moeity ureter (short black arrow) dilated upper ureter (white arrow) \u0026amp; lower moeity pelvis (long black arrow) (A). During ureteropyelostomy with stent in place (black arrow- opened pelvic, white arrow- opened upper ureter) (B).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/820412b297c8bcb993b3978f.png"},{"id":72277663,"identity":"2cf983db-07b6-4454-8ebe-6e1308e4bf2c","added_by":"auto","created_at":"2024-12-24 15:29:23","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":303950,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound done at the 6-month postoperative period showing a normal-appearing urinary bladder. The ureteroceles disappeared.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/ab02df3a93c192922a39aec6.png"},{"id":72279791,"identity":"393a7a85-e9ad-410d-95a8-e6c1865bec56","added_by":"auto","created_at":"2024-12-24 15:53:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4738273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5688436/v1/140cac74-1858-4229-878e-38837ff7a615.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eBilateral complete duplex system with right intravesical \u0026amp; left extravesical ureteroceles. A case report from tertiary care hospital\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e1.1. \u003cstrong\u003eBackground and rationale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBilateral complete duplication of the ureters is a rare condition. In a study of 5,196 excretory urograms conducted on both children and adults, duplex systems were found in 95 patients. The condition was bilateral in only 16 patients, while complete duplication was demonstrated in less than a third of the duplicated systems (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWe report the first case of simultaneous bilateral open procedures for a bilateral complete duplex system with right intravesical and left extravesical ureteroceles, to the best of our knowledge.\u003c/p\u003e\n\u003ch3\u003e1.2. Guidelines: SCARE 2023 paper\u003c/h3\u003e\n\u003cp\u003eThis case report has been reported in line with the SCARE Criteria (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e1.3. Patient information: demographics and presentation\u003c/h2\u003e\n\u003cp\u003eA 12-year-old male adolescent presented with nocturnal enuresis since birth and right flank pain of 8 months duration. Otherwise no history of fever, burning during micturition and dysuria. He had a normal voiding pattern.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e1.4. Past medical and surgical history\u003c/h3\u003e\n\u003cp\u003eHe had no known history of TB, Hypertension; Diabetes Mellitus. He had no surgical interventions done in the past.\u003c/p\u003e\n\u003ch3\u003e1.6. Drug and allergy history\u003c/h3\u003e\n\u003cp\u003eNo history of long-term drug intake and no known allergies until date.\u003c/p\u003e\n\u003ch3\u003e1.7. Family history\u003c/h3\u003e\n\u003cp\u003eHe had no history of similar illness in the family.\u003c/p\u003e\n\u003ch3\u003e1.8. Clinical findings\u003c/h3\u003e\n\u003cp\u003eThe physical examination was unremarkable.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003e1.9. Diagnostic assessment and interpretation\u003c/h2\u003e\n\u003cp\u003eThe laboratory investigations of complete blood count, creatinine, urinalysis, including renal function tests, were within normal limits. Ultrasound of the abdomen and pelvis revealed the presence of duplex collecting systems with double ureters on both sides. Additionally, a right intravesical ureterocele and a left extravesical ureterocele were observed.\u003c/p\u003e\n\u003cp\u003eVoiding cystourethrography demonstrated a round intravesical-filling defect. No vesicoureteral reflux was present. Subsequently, cystoscopy revealed a ureterocele situated within the prostatic urethra as well as another intravesical ureterocele (Figure: 1).\u003c/p\u003e\n\u003cp\u003eComputed tomography urography revealed bilateral complete ureteral duplication. The right upper moiety displayed severe hydronephrosis and thinned-out, non-excreting parenchyma, along with hydroureter and intravesical ureterocele. The right lower moiety exhibited moderate hydronephrosis and a dilated, normally inserted ureter. The left lower moiety appeared normal with a non-dilated ureter. The left upper moiety had moderate hydronephrosis and a dilated ureter draining below the bladder neck into the prostatic urethra (Figure: 2). A renal scan was not performed due to unavailability.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003e1.10. Intervention\u003c/h3\u003e\n\u003cp\u003eAfter thorough history and relevant investigations, diagnosis of bilateral complete duplication of ureter with right upper moiety severe hydroureteronephrosis \u0026amp; intravesical ureterocele, and left upper moiety hydroureteronephrosis with extravesical ureterocele was made.\u003c/p\u003e\n\u003cp\u003eThe patient was scheduled for single-setting upper tract procedures through bilateral anterior subcostal incisions, as there was no vesicoureteral reflux. For the right side, a right heminephroureterectomy was planned due to the nonfunctional upper moiety in the right kidney. For the left side, a ureteropyelostomy was planned.\u003c/p\u003e\n\u003cp\u003eIntraoperative cystoscopy was performed to stent the lower pole ureters, but the orifices were difficult to visualize. On the right side, the renal parenchyma was thinned out, with a dilated upper moiety and dilated ureters. Consequently, a right heminephroureterectomy was performed (Figure: 3).The upper moiety ureter was excised as far distally as possible.The left upper moiety on the left side was dilated, along with its ureter. In contrast, the left lower moiety appeared normal, with a non-dilated ureter. A left ureteropyelostomy procedure was performed (Figure: 4). The upper moiety ureter was excised as distally as possible.\u003c/p\u003e\n\u003cp\u003eAntegrade DJ stents were inserted intraoperatively for both kidneys, and perinephric drains were left in place. The operation was uneventful and blood loss was minimal. The patient was managed with Intravenous fluids, antibiotics, analgesics, antiemetic and antipyretic. Post-operative renal function tests were normal. Drains were removed on the second postoperative day. Postoperative period was uneventful and the patient had recovered well.\u003c/p\u003e\n\u003cp\u003eUreteric stents were removed after 6 weeks of surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e1.11. Outcome\u003c/h3\u003e\n\u003cp\u003eThe patient has been monitored and seen in the outpatient clinic every month for the past six months and has had no complaints since. The ureteroceles disappeared (Figure: 5), the right lower moiety hydronephrosis decreased with an increase in cortical thickness, and there was significant improvement in left upper moiety hydronephrosis. His renal function tests are normal.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u0026nbsp;\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuplex collecting system is a congenital abnormality characterized by complete or incomplete duplication of the collecting system. This occurs due to incomplete fusion of the upper and lower pole moieties (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Duplex kidney malformation has an estimated incidence of around 1.8%, and it occurs more frequently in women. This condition can be classified into two types: incomplete and complete. The complete ureteral deformity variant has an incidence of approximately 0.2% (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Only 25% of these cases are reported to be bilateral (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDuplication of the urinary collecting system can be associated with other deformities, such as ureterocele, ureteropelvic junction obstruction, vesicoureteral reflux, and ectopic ureter (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Symptoms vary widely, with the majority of cases diagnosed in early childhood, though some patients remain asymptomatic. The most common symptoms relate to vesicoureteral reflux and urinary tract infections. Urinary incontinence is the primary presenting complaint for ectopic ureters in females, while ectopic ureters inserting at the verumontanum can cause bladder outlet obstruction in boys (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eImaging is essential to confirm the diagnosis and identify associated abnormalities. (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Ultrasound findings of asymmetrical renal lengths, dividing parenchymal tissue, or disproportionate pelvicalyceal dilation suggest an abnormal duplicated renal collecting system (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).Other Imaging studies, such as intravenous pyelogram, CT, MRI, and renal scintigraphy, can comprehensively evaluate the renal anatomy, function, and any complications associated with urinary tract duplication. These modalities are invaluable in differentiating complete from partial duplication, thereby guiding the most appropriate treatment approach. Furthermore, Micturating cystourethrogram can detect vesicoureteral reflux, while cystoscopy can identify anomalies like ectopic ureter (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eManagement of duplex renal anomaly (DRA) is complex because of individual anatomic variation (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). The goals of treatment are control of infection, protection of normal ipsilateral and contralateral units, preservation of renal function, treatment of vesicoureteral reflux (VUR), minimization of surgical morbidity, facilitation of subsequent reconstructive procedures, and maintenance of continence (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eEvidence-based management for children with ureterocele and complete pyeloureteral duplication is not possible. Treatment should be individualized\u003c/p\u003e\n\u003cp\u003efollowing consideration of renal function, severity of hydronephrosis and obstruction, drainage of the contralateral ureter and bladder outlet, and associated VUR and UTI (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOptimal management of duplication anomalies may include an upper or lower tract surgical approach. When there is symptomatic non-functional upper pole moiety, heminephrectomy is historically favored. However, cases with preserved renal function in the upper pole are treated with ureteral reimplantation or ipsilateral upper to lower pole ureteroureterostomy (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). A right heminephrectomy was performed to address the non-functioning right upper pole, and a ureteropyelostomy was carried out for the functioning left kidney in our case.\u003c/p\u003e\n\u003cp\u003eThere have been a small number of reported cases involving the concurrent performance of bilateral renal procedures in pediatric patients (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Kapoor et al described a minimally invasive approach of heminephrectomy and contralateral ureteroureterostomy to manage bilateral duplex systems in young children. This simultaneous bilateral robotic procedure demonstrated safety, with no intraoperative or postoperative complications reported (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn our case, where minimally invasive surgery was unavailable and expertise lacking, we opted for a bilateral open approach. This allowed us to complete both the right heminephroureterectomy and the left ureteropyelostomy in a single operative session, sparing the patient a second surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBilateral complete duplication of the ureters is a rare condition. To the best of our knowledge, this is the first reported case of bilateral complete duplication of the ureters with a right intravesical ureterocele and a left extravesical ureterocele. The condition was managed with a single-setting right heminephroureterectomy and left pyeloureterostomy. This case report demonstrates the safety of simultaneous open bilateral procedures for complete bilateral duplex systems in resource limited settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis type of study does not require any ethical approval by our institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report hasn\u0026rsquo;t been funded by any person or any institutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no any conflicts of interest with this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s mother for\u003c/p\u003e\n\u003cp\u003epublication of this case report and accompanying images. A copy of the\u003c/p\u003e\n\u003cp\u003ewritten consent is available for review by the Editor-in-Chief of this\u003c/p\u003e\n\u003cp\u003eJournal on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePrivett JTJ, Jeans WD, Roylance J (1976) The incidence and importance of renal duplication. Clin Radiol 27(4):521\u0026ndash;530. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0009-9260(76)80121-3\u003c/span\u003e\u003cspan address=\"10.1016/s0009-9260(76)80121-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgha RA, Franchi T, Sohrabi C, Mathew G, Kerwan A, Thoma A et al (2020) The SCARE 2020 guideline: updating consensus surgical CAse REport (SCARE) guidelines. Int J Surg 84:226\u0026ndash;230. https://doi.org/10.1016/j. ijsu.2020.10.034\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhamad MS, Mousa MA, Oukan M, Razzok A (2022) Giant hydronephrosis secondary to an ectopic ureter associated with bilateral duplex collecting system: a case report, Oxford Medical Case Reports, Volume Issue 4, April 2022, omac034. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/omcr/omac034\u003c/span\u003e\u003cspan address=\"10.1093/omcr/omac034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu C, Ji F, Zhang H, Yao Z, Li L, Yan B (2022) Treatment for complete bilateral duplex kidneys with severe hydronephrosis and ureterectasis of the upper moiety in a child: A case report and literature review. Front Surg 9:1019161. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2022.1019161\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2022.1019161\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassell AK, Traor\u0026eacute; A, Jalloh M, Ndoye M, Diallo A, Labou I et al (2019) Bilateral Ureteral Duplication and Right Ectopic Ureter Presenting with Incontinence: A Case Report. Med Sur Urol 8:216. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.35248/2168-9857.19.8.216\u003c/span\u003e\u003cspan address=\"10.35248/2168-9857.19.8.216\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMittal MK, Sureka B, Gupta P, Mittal A (2014) Bilateral duplex system with overlooked dysplastic moiety: A rare cause of incontinence. J Mahatma Gandhi Inst Med Sci 19:67\u0026ndash;69\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh S, Bhusal NP, Mishra S, Singh S, Rai K, Bista S, Amatya S, Kisee S Bilateral complete duplication of ureter with ectopic ureter presenting as persistent urinary dribbling with normal voiding pattern in 17-year-old female: Case report. Annals of Medicine \u0026amp; Surgery 84():, December 2022. | \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amsu.2022.104824\u003c/span\u003e\u003cspan address=\"10.1016/j.amsu.2022.104824\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDocimo S (2018) The Kelalis\u0026ndash;King\u0026ndash;Belman Textbook of Clinical Pediatric Urology. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1201/9781315113982\u003c/span\u003e\u003cspan address=\"10.1201/9781315113982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDidier RA, Chow JS, Kwatra NS et al (2017) The duplicated collecting system of the urinary tract: embryology, imaging appearances and clinical considerations. Pediatr Radiol 47:1526\u0026ndash;1538. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00247-017-3904-z\u003c/span\u003e\u003cspan address=\"10.1007/s00247-017-3904-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuri P, Utama ETP (2021) A complete duplicated collecting system with giant ureterocele in adult: case report. Int J Surg Case Rep 79:49\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2020.12.083\u003c/span\u003e\u003cspan address=\"10.1016/j.ijscr.2020.12.083\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerz D, Smith J, McLeod D, Schober M, Preece J, Merguerian P (2016) Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery. J Pediatr Urol 12(1):44 Epub 2015 Aug 17. PMID: 26443241. .e1-7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimberlake MD, Corbett ST (2015) Minimally Invasive Techniques for Management of the Ureterocele and Ectopic Ureter. Urol Clin North Am 42(1):61\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ucl.2014.09.006\u003c/span\u003e\u003cspan address=\"10.1016/j.ucl.2014.09.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahadev R, Rodriguez MV, Kawal T, Barashi N, Srinivasan AK, Gundeti M, Shukla AR (2022) Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches. J Robot Surg 16(6):1321\u0026ndash;1328. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-022-01372-2\u003c/span\u003e\u003cspan address=\"10.1007/s11701-022-01372-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2022 Jan 25. PMID: 35079941\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAZMY AF (1988) Simultaneous Bilateral Renal Surgery in Children. Br J Urol 62(2):191\u0026ndash;192. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410x.1988.tb04313.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410x.1988.tb04313.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn A, Provet, Moneer K Hanna,Simultaneous repair of bilateral ureteropelvic junction obstruction, Urology,33, Issue 5,1989,Pages 390\u0026ndash;394, ISSN 0090-4295, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0090-4295(89)90032-0\u003c/span\u003e\u003cspan address=\"10.1016/0090-4295(89)90032-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapoor V, Elder JS (2015) Simultaneous bilateral robotic-assisted laparoscopic procedures in children. J Robotic Surg 9(4):285\u0026ndash;290. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-015-0528-x\u003c/span\u003e\u003cspan address=\"10.1007/s11701-015-0528-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Mekelle University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Case Report, Bilateral, Complete Duplex System, Ureteroceles","lastPublishedDoi":"10.21203/rs.3.rs-5688436/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5688436/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Bilateral duplex system with ureteroceles is one of the rarest entities in urology. Duplex collecting system is a common urologic anomaly with a wide range of clinical symptoms and a variety of associated urologic abnormalities such as an ectopic ureter, ureterocele, vesicoureteral reflux and ureteropelvic junction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresentation of case\u003c/strong\u003e: We present a 12-year-old male adolescent presented with nocturnal enuresis since birth and right flank pain of 8 months duration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical findings and investigations\u003c/strong\u003e: There were no pertinent physical findings. A complete blood count, renal function test, urine analysis, ultrasound of the abdomen and pelvis, computed tomography urography, and cystoscopy were performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention and outcome\u003c/strong\u003e: A single-setting right upper pole heminephroureterectomy and left ureteropyelostomy were performed. He is now asymptomatic and regularly followed up on an outpatient basis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelevance and impact\u003c/strong\u003e: This case report shows the safety of simultaneous open bilateral procedures for complete bilateral duplex systems in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Bilateral complete duplex system with right intravesical \u0026amp; left extravesical ureteroceles. A case report from tertiary care hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 15:29:17","doi":"10.21203/rs.3.rs-5688436/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f12019d-8a64-4655-b1d8-6f7f88c6f667","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-24T15:29:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-24 15:29:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5688436","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5688436","identity":"rs-5688436","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}