right double inferior vena cava ( rdivc ) with retrocaval ureter is an extremely rare anomaly with only a few cases reported in the literature . preoperative identification of this ivc anomaly is essential before embarking on ureteric repair , else serious surgical mishap can occur . to the best of our knowledge , surgical repair of retrocaval ureter with rdivc by a single - incision laparoscopic technique has not yet been described in the literature . this case report highlights the embryological basis and the surgical technique of repair by using the single incision multiple port laparo - endoscpic ( simple ) technique . because one of the major hurdles in single - incision laparoscopic surgery is the limited maneuverability and difficult anastomotic suturing , we performed end - to - end ureteric anastomosis by using the santosh postgraduate institute ( pgi ) ureteric tacking fixation technique . a 23-year - old male presented in the urology department with complaints of dull aching right flank pain . he had no episodes of hematuria , graveluria , fever , or other urinary symptoms . preoperative urine analysis was unremarkable with ph of 6.5 , specific gravity of 1.010 , and no pus cells or red blood cells . ultrasound of the abdomen revealed right - sided hydroureteronephrosis involving the upper ureter with rdivc . because the patient had a prior history of contrast allergy , noncontrast magnetic resonance imaging was performed , which showed a dilated pelvicalyceal system . the upper ureter was dilated with medial deviation and coursed behind the lateral ivc at the level of the third lumbar vertebra with abrupt narrowing at that level . the results of a preoperative ethylene - dicysteine scan revealed a split function of 43% for the right kidney with significant tracer retention at the end of 3 hours of study . the diagnosis of symptomatic retrocaval ureter with significant obstruction and rdivc was supported , and the patient underwent single - incision multiport laparoendoscopic repair with the santosh pgi ureteric tacking fixation technique ( fig . a nearly 3-cm incision was made at the level of the umbilicus and three conventional laparoscopic ports were inserted : two 12-mm and one 5-mm ports . after soft tissue dissection , the rdivc was clearly seen with the ureter coursing in between the double ivc . following mobilization , the stenotic ureteric segment was excised and both ends were brought lateral to the ivc and spatulated . to make anastomotic suturing easier , both ureteric ends were brought close and their adventitia was tacked to the adjacent abdominal wall by using hemostatic clips . this maneuver stabilized both ureteric margins , and an end - to - end anastomosis was performed with vicryl 3 - 0 interrupted sutures followed by release of the clips . blood loss was minimal and the hospital stay was for 3 days . at the 8-month follow - up , the magnetic resonance urogram was repeated and showed preserved renal parenchyma with a normal - caliber ureter ( fig . the postoperative diuretic scan revealed split function of 45% for the right kidney with adequate tracer clearance by the end of 3 hours of study . first described by horchstetter in 1893 , retrocaval ureter is a rare anomaly that occurs in 1 out of 1,000 live births . ivc anomalies are a result of abnormal regression or persistence of three pairs of embryonic vessels , namely , the posterior cardinal , subcardinal , and supracardinal veins . infrarenal ivc anomalies were classified by chuang et al .   in 1974 into four types : persistent right posterior cardinal vein ( retrocaval ureter ) , persistent right supracardinal vein ( normal ivc ) , persistent left supracardinal vein ( left ivc ) , and persistent right and left supracardinal veins ( double ivc ) . ivc duplication is of two principal types : double - sided ( with one ivc on either side of the aorta ) or single - sided ( both ivc on one side of the aorta ) . the reported incidence of double - sided ivc is around 0.2% to 3% , whereas less than a dozen cases of right single - sided double ivc ( or rdivc ) have been documented in the literature . our patient is among the rarest of the cases that have been reported to have retrocaval ureter with rdivc . persistence of the right posterior cardinal with the supra- or subcardinal vein will result in rdivc with retrocaval ureter , whereas persistence of sub- and supracardinal veins with regression of the posterior cardinal vein will result in rdivc without a retrocaval ureter . small case series and reports exist describing transperitoneal and retroperitoneal approaches for laparoscopic repair of retrocaval ureter . the transperitoneal approach has the advantage of familiar anatomy , a larger working space , and easier suturing compared with the retroperitoneoscopic approach . this is the first reported case of retrocaval ureter with rdivc managed by the simple technique utilizing the santosh pgi ureteric tacking fixation technique . as published in a previous report , this technique is easily reproducible , is technically feasible , provides a good aesthetic outcome , utilizes conventional endoscopic ports , and has minimal morbidity when performed by expert laparoscopic surgeons . the simple technique also helps to reduce the cost burden on patients , because it does not require specialized single - incision port devices or special laparoscopic instruments . one of the limitations of single - incision laparoscopic surgery is the limited maneuverability of the instruments , thereby increasing the operating time . the santosh pgi ureteric tacking fixation technique helps in stabilizing and maintaining alignment of the two ends of the ureter and showed a reduction in mean operating time compared with other reports . the ureteric dissection is performed between the two ivc instead of between the ivc and the aorta . because the vessel walls of the ivc are thinner than the walls of the aorta , inadvertent injury can easily occur owing to mechanical tension or thermal damage by electrosurgical or harmonic shear devices leading to profuse bleeding . this ivc anomaly also highlights the importance of preoperative cross - sectional imaging instead of relying solely on intravenous urography or retrograde pyelography . major surgical mishaps can occur should the lateral component of the rdivc be confused for a dilated right ureter or the medial component be confused for the aorta during a laparoscopic upper urinary tract reconstruction or nephrectomy . in summary , preoperative identification can theoretically reduce the risk of intraoperative major surgical mishap during upper urinary tract surgery . to the best of our knowledge , this is the first case report of managing such a scenario with single - incision multiple - port laparoscopic surgery . the simple technique along with the santosh pgi ureteric tacking fixation technique , with its inherent advantages over conventional single - incision or multiple - incision laparoscopic surgery , is a feasible option for the management of such cases .
right double inferior vena cava with obstructed retrocaval ureter is an extremely rare anomaly with only a few reported cases in the literature . to the best of our knowledge , this is the first case report describing ureteric repair by use of a single - incision laparoscopic technique . 
 in addition , this report addresses the underlying surgical challenges of this repair and provides a brief review of the embryology of this anomaly . 
 the " santosh postgraduate institute ureteric tacking fixation technique " provides ease of end - to - end uretero - ureteric anastomosis in a single - incision laparoscopic surgery .