Importance of imaging in diagnosis
A precise diagnosis of urinary tract anomalies requires a multimodality imaging approach, with each technique providing distinct structural and functional insights.

Ultrasound is the first-line imaging tool due to its easy accessibility and non-invasive nature, identifying obvious anatomical abnormalities such as duplex moieties, dilated ureters with duplication and ureteroceles. Intravenous urography (IVU), has been particularly useful in detecting anomalies like Smith’s type two ureteral triplication. Micturating cystourethrogram (MCU) plays a key role in evaluating the lower urinary tract and diagnosing vesico-ureteric reflux (VUR), a frequent complication of ureteral anomalies. Renal scintigraphy provides functional assessment of the kidneys, helping to identify impairments in the collecting system and overall renal function¹.

MRU emerges as the gold standard for detailed anatomical and functional evaluation of the urinary system, offering superior and unparalleled visualization of complex urinary tract anomalies. MRI, due to its non-ionising nature, has proven valuable in detecting concurrent embryological and developmental conditions, particularly in the pediatric age group; highlighting its indispensable role in a comprehensive diagnostic workup^1,4. However, it does require patient cooperation and sometimes sedation in pediatric patients to minimize movement during the scan^2,6.

Discussion
Understanding the clinical significance of ureteral triplication is vital for proper management. While incontinence, recurrent urinary tract infections (UTIs) and abdominal pain are prominent presenting signs, the illness often manifests asymptomatically. In some cases, patients may develop complications such as obstruction, reflux and renal dysfunction, which necessitate prompt and appropriate intervention^1,6.

Management strategies for ureteral triplication depend on the severity of symptoms, the presence of complications and the overall functional status of the kidneys. Observation may be sufficient for asymptomatic patients, while those with recurrent UTIs require appropriate antibiotic management to prevent complications. Minimally invasive laparoscopic techniques are indicated for patients with ongoing obstruction or deteriorating renal function^1,2,4.

This 6-year-old girl with right renal triplication and a ureterocele is a complex and rare congenital anomaly which requires expeditious diagnosis. The integration of various imaging modalities, as demonstrated in this report, aligns with the findings of previous studies, highlighting the evolution of diagnostic techniques over time.

Ureteral duplication is the primary differential for triplication, as both anomalies involve multiple ureters draining a single kidney and share complications like reflux, obstruction and ureteroceles. However, distinguishing between them is critical for management. Ultrasound and IVU have limitations, often failing to detect an additional ureter due to poor resolution or contrast filling issues. MRU is the gold standard, offering high-resolution, multiplanar visualization, superior tissue contrast and functional assessment. MRU allows accurate differentiation between duplication and triplication, facilitating optimal treatment planning^1,6.

Another important differential diagnosis is renal dysplasia, a condition characterized by abnormal kidney development, leading to cyst formation and impaired renal function. Where modalities like USG and IVU fail, MRU plays a crucial role in differentiating renal dysplasia from triplication by identifying structural abnormalities and assessing the presence of multiple collecting systems^1,2.

Ureteral triplication often occurs alongside other congenital anomalies, further complicating their diagnosis and management. Contralateral duplication is the most frequently associated anomaly, reported in 37% of cases². Additionally, ureteral ectopia is observed in 28% of cases, while renal dysplasia is noted in 8%⁵. Another significant concern is vesicoureteral reflux (VUR), which can arise as a consequence of obstruction, particularly in the presence of a ureterocele². Recognizing these coexisting anomalies is essential for comprehensive evaluation, as they influence both clinical presentation and treatment strategies.

Conclusion
The discussion emphasizes how crucial it is to use a multidisciplinary approach when diagnosing and treating ureteral triplication, involving radiologists, urologists and pediatric surgeons. Using sophisticated imaging methods such as MRU, can provide comprehensive anatomical and functional data that is critical for informing therapy choices, thereby allowing medical practitioners to proficiently handle this uncommon condition and improving the well-being of those impacted.