A 60-year-old woman with a history of breast cancer presented with bilateral obstruction of bilaterally duplicated renal collecting systems secondary to extrinsic compression from metastatic pelvic lymphadenopathy. Bilateral JJ ureteric stents were inserted, resulting in some improvement of renal function but a failure to normalise completely. Repeat computed tomography demonstrated bilateral duplex collecting systems with persisting obstruction of the undrained moieties. Selective puncture was performed to decompress the obstructed renal moieties for bilateral nephrostomy catheter insertion. This allowed renal function to improve sufficiently for the patient to be discharged and commence chemotherapy. This is the first reported case of bilaterally obstructed partially duplicated collecting systems and it illustrates the importance of recognising anatomical variants to tailor treatment appropriately. It also highlights the important relationship between urology and interventional radiology in the management of such complex patients. KEYWORDSInterventional radiography -Kidney tubules -Collecting systems -Abnormalities -Urology Case historyA 60-year-old woman presented with abdominal pain and acute kidney injury. On admission, urea was recorded as 15mmol/l (normal: 2.5-7.8mmol/l) and creatinine as 243µmol/l (normal: 49-90µmol/l). Five years previously, the patient had been diagnosed with invasive ductal carcinoma of the left breast (grade 3, T3 N1 M0), and had undergone a mastectomy and axillary clearance (4/14 nodes positive) followed by adjuvant chemoradiotherapy. She was otherwise independent without significant co-morbidity.Ultrasonography identified bilateral hydronephrosis and computed tomography (CT) confirmed distal ureteric obstruction secondary to extrinsic compression by metastatic pelvic lymphadenopathy (Figs 1 and 2). CT also revealed lumbar spine metastatic disease, bilateral pleural effusions, ascites and peritoneal disease (Fig 2). Positron emission tomography CT demonstrated high uptake in the pelvic lymph nodes, consistent with local metastasis, thought to be the cause of her ureteric obstruction (Fig 3). Subsequently, bilateral JJ ureteric stents were inserted under general anaesthesia (Fig 4). During cystoscopy and retrograde ureterography, no anatomical abnormalities were identified, and the guidewires and stents passed without difficulty into the renal A B ONLINE CASE REPORT Ann R Coll Surg Engl 2016; 98: e55-e58

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