While horseshoe configuration and PUJ obstruction are not uncommon findings, triplex kidney is an extremely rare entity 1, and seldom occurs alone 1,2. Our patient is type-III based on Smith's classification of triplex kidneys 2, having all three ureters united and draining into a single vesical orifice. The importance of reporting the triplex configuration is to beware that an undetected or residual third moiety may turn out to be a source of persistent symptoms, or an unfortunate indication for repeated surgery 1.
We note that while the MRI shows most of the findings, it is the CT that shows all of them and in detail, reminding that CT urogram is the gold standard of urinary tract imaging 3.
We also note that the left-sided PUJ obstruction producing severe hydronephrosis has remained silent and undetected hitherto, highlighting the silent-killer nature of PUJ obstructions 3.