title: Double obstruction of ureter: A diagnostic challenge.
abstract: BACKGROUND
  Isolated obstruction of the ureteropelvic junction and the vesico-ureteric junction are the two most common causes of hydronephrosis in a pediatric population.[1] They do not pose diagnostic difficulties when are present alone but when together can be difficult to diagnose. Here, we discuss the problems we faced when we encountered these two anomalies in the same ureter and the way in which we managed them.
  
  
  OBJECTIVE
  To assess the difficulties in diagnosis of pediatric patients who present with both ureteropelvic junction obstruction (UPJO) and vesico-ureteric junction obstruction (VUJO) in the ipsilateral ureter and their management protocol.
  
  
  METHODS
  This is a retrospective study. The study period is from 1 January 2004 to 31 December 2011. Out of 254 children who were diagnosed to have hydronephrosis due to UPJO in our institute, 5 patients (in the age range of 5 to 10 years) had both UPJO and VUJO in the ipsilateral ureter. The problems we faced in diagnosing the two conditions are mentioned with a literature review.
  
  
  RESULTS
  Operative intervention was used in four out of five patients; none of the patients had an accurate diagnosis before surgery. All patients were suspected of having double obstruction during pyeloplasty when appropriate size double J stent could not be negotiated through the vesicoureteric junction into the bladder. Postoperative nephrostogram confirmed the diagnosis in all patients.
  
  
  CONCLUSIONS
  Children with double obstruction of the ipsilateral ureter present as a diagnostic dilemma. Because of the rarity of this condition it can escape the eye of even an astute clinician. Early diagnosis can be made if this condition is kept in mind while treating any hydronephrosis due to UPJO or UVJO.
authors.affiliation: Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Halder
authors.affiliation: Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.
authors.forename: Ram Mohan
authors.initials: RM
authors.lastname: Shukla
authors.affiliation: Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.
authors.forename: Kartik Chandra
authors.initials: KC
authors.lastname: Mandal
authors.affiliation: Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.
authors.forename: Biswanath
authors.initials: B
authors.lastname: Mukhopadhyay
authors.affiliation: Department of Pediatric Surgery, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India.
authors.forename: Shibsankar
authors.initials: S
authors.lastname: Barman
keywords: Diagnosis; UPJO; VUJO; double obstruction of ureter; pediatric; treatment