Hydronephrosis Grade Research Articles

The Resonance and the Allium ureteral stents in the treatment of non-malignant refractory ureterostenosis

BackgroundRefractory non-malignant ureterostenosis is challenging to treat. The experience to treat the stenosis primarily cause by retroperitoneal fibrosis with the Resonance and Allium metallic stent is still limited. We aim to evaluate the efficacy and safety of these two stents and provide alternative treatment options.MethodsA retrospective study was conducted for patients with non-malignant ureterostenosis and treated with the Resonance and Allium stents from March 2011 to September 2020 in our department. The efficacy was evaluated by the change of serum creatinine, glomerular filtration rate (GFR), the proportion of GFR of the affected side and hydronephrosis grade. The safety was evaluated by postoperative presence of moderate or severe overactive bladder (OAB), recurrent urinary infection, pain, stent displacement, encrustation and re-obstruction.Results33 patients were eligible for the study, including 18 cases treated by the Resonance stents and 15 patients treated by the Allium stents. The patients of two groups had similar age and gender proportion. The cause of ureterostenosis was mainly retroperitoneal fibrosis in both groups but the Resonance group had more idiopathic cases. Follow-up time was significantly longer in the Resonance group than the Allium group (36.2 ± 24.0 vs 9.4 ± 5.0 months, p < 0.001). Both groups showed improvement or maintenance of serum creatinine level, GFR, the GFR proportion of the affected side and hydronephrosis grade after treatment. The Resonance group presented significant higher incidence of moderate or severe OAB, recurrent urinary infection and pain, while the Allium group showed significant more cases of re-obstruction.ConclusionBoth the Resonance and Allium stent can relieve the non-malignant refractory ureterostenosis effectively. The Resonance stent may cause more irritable symptoms while the Allium stent may have a higher rate of re-obstruction. The long term efficacy and safety of the Allium stent in treating non-malignant refractory ureterostenosis requires further study.

Incidence of Urinary Tract Infections in Newborns with Spina Bifida-Is Antibiotic Prophylaxis Necessary?

Urinary tract infections commonly occur in patients with spina bifida and pose a risk of renal scarring. Routine antibiotic prophylaxis has been utilized in newborns with spina bifida to prevent urinary tract infections. We hypothesized that prophylaxis can safely be withheld in newborns with spina bifida until clinical assessment allows for risk stratification. Newborns with myelomeningocele at 9 institutions were prospectively enrolled in the UMPIRE study and managed by a standardized protocol with a strict definition of urinary tract infection. Patient data were collected regarding details of reported urinary tract infection, baseline renal ultrasound findings, vesicoureteral reflux, use of clean intermittent catheterization and circumcision status in boys. Risk ratios and corresponding 95% confidence intervals were calculated using log-binomial models. From February 2015 through August 2019 data were available on 299 newborns (50.5% male). During the first 4 months of life, 48 newborns (16.1%) were treated for urinary tract infection with 23 (7.7%) having positive cultures; however, only 12 (4.0%) met the strict definition of urinary tract infection. Infants with grade 3-4 hydronephrosis had an increased risk of urinary tract infection compared to infants with no hydronephrosis (RR=10.1; 95% CI=2.8, 36.3). Infants on clean intermittent catheterization also had an increased risk of urinary tract infection (RR=3.3; 95% CI=1.0, 10.5). The incidence of a culture positive, symptomatic urinary tract infection among newborns with spina bifida in the first 4 months of life was low. Patients with high grades of hydronephrosis or those on clean intermittent catheterization had a significantly greater incidence of urinary tract infection. Our findings suggest that routine antibiotic prophylaxis may not be necessary for most newborns with spina bifida.

Outcomes of intrauterine interventions for the treatment in fetal urinary tract obstructions

Introduction: The leading cause of chronic renal failure in newborns, which occurs soon after birth is obstructive uropathies. Objectives: To prove the effectiveness of nephroamniotic shunting based on the evaluation of perinatal outcomes of this procedure, as well as a comparative analysis of the use of the stent manufactured by "Cook" (Ireland), 3.0 Fr/100 mm and the stent “SDE–MED”, 3.0 Fr/50 mm with the original shape of pigtails. Methods: After checking the safety of the stent “SDE-MED”, 3.0 Fr/50 mm developed by FGBU Mother and Child Care Research Institute with the original shape of pigtails in an animal experiment, the stent was used in clinical practice for intrauterine shunting in cases of unilateral or bilateral hydronephrosis of grade III to IV and posterior urethral valve disorder. In the final part of the study, a comparison of the outcomes of nephroamniotic shunting using two different stents was made. Results: The “SDE–MED” 3.0 Fr/50 mm stent provided more effective fixation in the fetal kidney cavity system in comparison to the stent manufactured by “Cook” (Ireland) 3.0 Fr/100 mm. Conclusion: Intrauterine shunting surgery of the upper urinary tract is a pathogenetically justified method of treating urinary tract obstructions and can be used to correct all types of fetal renal obstructions.

Analgesic refractory colic pain: Is prolonged conservative management appropriate?

To propose a clear definition and management pathway of patients with analgesic refractory colic pain (ARCP). Prospective cohort study from February 2018 to February 2019 including patients with ARCP defined as ongoing renal colic pain after one dose of IV NSAID, IV paracetamol, and a parenteral opioid, given sequentially in that order. Patients were observed in-hospital under full parenteral analgesic management for 8-12h, whenever patients had minimal or absent pain after conservative management (CM) they were discharged, and followed-up with new imaging within four weeks. If the pain was not controlled after CM, surgical management (double-J stent or ureteroscopy) was performed. We excluded patients with any other indication for urgent intervention or in cases where CM was deemed inappropriate (sepsis, acute renal failure, stones >10mm in size, suspected concomitant urinary tract infection, bilateral ureteral stones, pregnancy, patients with a single kidney, kidney transplant recipients, difficult access to medical care or refusal to undergo CM). Data from 60 patients was collected. The only variable associated with an increased risk of failed CM was a history of previous renal colic (OR 3.98 [95% CI 1.14-13.84], p=0.02). Neither gender, age, stone size, location, or hydronephrosis grade were able to predict CM failure. 41.6% of patients were successfully managed conservatively and only 8% of them required scheduled surgical management at follow-up. Our results show that a high proportion of patients with ARCP may be successfully managed conservatively with an extended observation period without complications at follow-up. These results should be replicated in a randomized controlled trial to confirm them.

Laparoscopic Upper-pole Heminephrectomy for the Management of Duplex Kidney: Outcomes of a Multicenter Cohort

ObjectiveTo analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries. Materials and MethodsA retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P <.05. ResultsPostoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function. ConclusionLaparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Optimal duration of preoperative antibiotic treatment prior to ureteroscopic lithotripsy to prevent postoperative systemic inflammatory response syndrome in patients presenting with urolithiasis-induced obstructive acute pyelonephritis.

PurposeThere is no consensus on the optimal duration of preoperative antibiotic treatment prior to ureteroscopic lithotripsy in patients presenting with urolithiasis-induced obstructive acute pyelonephritis (APN). We aimed to identify surgeon-modifiable, preoperative risk factors associated with postoperative systemic inflammatory response syndrome (SIRS) in these patients.Materials and MethodsThis multicenter retrospective study evaluated 115 patients who presented with urolithiasis-induced obstructive APN between January 2008 and December 2019. All patients were administered intravenous third-generation cephalosporin until culture sensitivity confirmation or until ureteroscopic lithotripsy. Data were collected for age, sex, diabetes mellitus, performance status, stone features, hydronephrosis grade, preoperative renal collecting system drainage, laboratory data, operative time, and duration of preoperative antibiotic treatment. Sensitivity analysis using Youden's index and logistic regression analysis were used to assess risk factors of postoperative SIRS.ResultsPostoperative SIRS was identified in 32 (27.8%) patients. The incidence of postoperative SIRS was higher in patients who received preoperative antibiotic treatment for fewer than 14 days (38.8% vs. 12.5%; p=0.001). Backward variable selection logistic regression analysis revealed maximal stone diameter ≥15 mm, duration of preoperative antibiotic treatment <14 days, and preoperative C-reactive protein (CRP) level ≥6.0 mg/L to be associated with higher risk of postoperative SIRS.ConclusionsPatients with urolithiasis-induced obstructive APN planned for ureteroscopic lithotripsy should be administered at least 14 days of preoperative antibiotic administration and achieve a serum CRP level ≤6.0 mg/L to minimize the risk of postoperative SIRS.

Comparison of Urinary Tract Dilatation and Society of Fetal Urology systems in the detection of vesicourethral reflux and renal scar.

PurposeThe presence and degree of hydronephrosis is very important in the management of many diseases of the urinary tract. In this study, we aim to compare the sensitivity and specificity of 2 classification systems that are used for hydro-nephrosis grading in ultrasound, for reflux and scar detection. The classification systems were the Society of Fetal Urology (SFU) and Urinary Tract Dilatation (UTD).Material and methodsUltrasounds and dimercaptosuccinic acid scintigraphies (DMSA) of all patients who underwent voiding cystourethrogram (VCUG) due to urinary tract infection were examined retrospectively. DMSA was accepted for scar detection and VCUG for reflux detection as reference methods. SFU classification was used for hydronephrosis in ultrasound reports, and UTD classification was made over the reports. Sensitivity, specificity, and positive and negative predictive values of UTD and SFU classification systems for reflux and scar detection were calculated, and these 2 systems were compared.Results103 (39%) of the patients were male and 162 (61%) were female. Pathologies were detected in 192 (35%) of 530 kidneys in ultrasound. In 110 (42%) of the children, reflux was detected in VCUG. Scars in DMSA were detected in only 16% (44) of 266 kidneys. Sensitivity, positive and negative predictive values of the UTD classification system were statistically significantly higher than the SFU system for scar and reflux detection (p < 0.01).ConclusionsIf we use the UTD system in ultrasounds of patients with urinary tract infections, children reported as UTD 0 may not need VCUG, which reduces radiation exposure to children and the cost of the diagnostic interventions.

Factors Affecting Post Nephrostomy Removal Urinary Leakage after Percutaneous Nephrolithotomy (PCNL)

Background: Prolonged urinary leakage after nephrostomy tube removal leads to increased morbidity of PCNL and increased hospitalization. Objective: To evaluate factors affecting post nephrostomy removal urinary leakage after percutaneous nephrolithotomy. Patients and Methods: One hundred eight (108) patients older than 18 years who underwent PCNL were studied prospectively. The reasons that can affect urinary leakage postoperatively were divided into 4 categories according to individual factors including age, gender, and body mass index; Renal factors; including, previous operation, history of ESWL, parenchymal cortical thickness, and grades of hydronephrosis; stone factor (stone burden); and surgical factors including the number of tracts, presence of double J stent, nephrostomy tube diameter and stay duration. These data were compared for postoperative urine leak. Results: Urinary leakage was revealed in 76 of 108 patients (70.3%). There was no statistically significant relationship between individual factors and urinary leakage (P &gt;0.05). Among renal factors, just parenchymal cortical thickness and grade of hydronephrosis were strongly related to the urinary leakage (P &lt;0.001). The renal stone burden did not affect urinary leakage (P &gt;0.05). Among surgical factors, placing of ureteral double-J stent highly minimized the incidence of urinary leakage (P&lt;0.001), and the urinary leakage significantly correlated with the increased diameter of the nephrostomy tube and staying duration (P&lt;0.05). Conclusion: After PCNL surgery, some factors show to influence post-PCNL urinary leakage. however most of the urinary leakage was treated conservatively, but it increases morbidity and hospitalization. Keywords: Percutaneous nephrolithotomy; postsurgical complications; risk-factor; leaking of urine

Perioperative Indices Predicting Fever Following Percutaneus Nephrolithotomy.

To investigate 18 independent peroperative parameters that may have an effect on fever after percutaneous nephrolithotomy (PCNL). A descriptive study. Departments of Urology, Nevşehir State Hospital, and Sultan Abdulhamid Han Education and Research Hospital, Turkey, from January 2016 to June 2019. Two hundred and seventy-six patients, who underwent PCNL between 2016 and 2019 in two institutions, were evaluated retrospectively. Patients were divided as Group I and II, according to the absence or presence of fever after PCNL, then peroperative parameters were compared. There was no statistically significant difference between Group I and II in terms of age, gender, side of stone, ipsilateral open stone surgery or PCNL history, presence of renal anatomic anomaly, preoperative hydronephrosis grade, stone size in computed tomography (CT), stone Houndsfield Unit (HU) value, skin stone distance, duration of operation, postoperative D-J insertion rate and postoperative blood transfusion requirement (p >0.05). Guy' s Stone Score (GSS), number of calyceal access and duration of achieving limpid urine coming out of the nephrostomy tube were significantly higher in Group II (p <0.05). The rate of postoperative fever was statistically significantly higher in patients with middle calyceal (mid-calyceal) access, than patients with inferior calyceal access (p=0.05). High GSS, mid-calyceal access, the increase in the amount of mid-calyceal access, the longer duration of achieving limpid urine coming out of the nephrostomy tube were found to be related with fever after PCNL. Key Words: PCNL, Post-PCNL fever, Nephrolithiasis, Guy's stone score.

Diagnostic Test Characteristics of Ultrasound Based Hydronephrosis in Identifying Low Kidney Function in Young Patients with Spina Bifida: A Retrospective Cohort Study.

Kidney dysfunction in spina bifida is usually detected by low estimated glomerular filtration rate or ultrasound based hydronephrosis. We assessed the diagnostic test characteristics of hydronephrosis for detecting low estimated glomerular filtration rate, hypothesizing that hydronephrosis has low sensitivity compared to cystatin C based estimated glomerular filtration rate. We conducted a single center, retrospective cohort study, including patients with spina bifida from 2012-2017 with 2 kidneys and complete data needed to calculate estimated glomerular filtration rate via multiple pediatric (age 1-17.9 years) or adult (age ≥18 years) estimating equations. We evaluated the association of hydronephrosis status (high grade, low grade or none) with estimated glomerular filtration rate, adjusting for small kidney size and scarring, and calculated diagnostic test characteristics of hydronephrosis for low estimated glomerular filtration rate. We analyzed 247 patients (176 children and 71 adults). Mean±SD age was 13.7±6.6 years, and 81% of patients had myelomeningocele. Hydronephrosis (77% low grade) was found in 35/176 children and 18/71 adults. Hydronephrosis was associated with low estimated glomerular filtration rate in stepwise fashion, independent of kidney size and scarring. However, across cystatin C based pediatric equations, any hydronephrosis (compared to none) had 23%-48% sensitivity, and high grade hydronephrosis (compared to none or low grade) had 4%-15% sensitivity for estimated glomerular filtration rate <90 ml/min/1.73 m2, which remained unchanged after excluding small kidneys and scarring. Across cystatin C based adult equations, any and high grade hydronephrosis had 55%-75% and 40%-100% sensitivity, respectively, for estimated glomerular filtration rate <90 ml/min/1.73 m2, although with wide confidence intervals. Specificity was higher with high grade vs any hydronephrosis. Sensitivities were higher for estimated glomerular filtration rate <60 ml/min/1.73 m2. Hydronephrosis was associated with low estimated glomerular filtration rate but had poor sensitivity for cystatin C based estimated glomerular filtration rate <90 ml/min/1.73 m2, especially among children with spina bifida.

Impact of weight on stone-free rate during percutaneous nephrolithotomy

BackgroundTo assess Impact of weight on stone-free rate during percutaneous nephrolithotomy.MethodsHundred and twenty-three PNL procedures were done between January 2016 and July 2017. The patients were divided into four groups according to the World Health Organization (WHO) classification of body mass index (BMI): < 25 ((group 1, average)), 25–29.9 (group 2, overweight), 30–39.9 (group 3, obese), and ≥ 40 kg/m2 (group 4, morbidly obese). All groups were compared as regarding preoperative variables, intra-operative procedure and postoperative results.ResultsThe non-obese groups were younger in age than obese and morbid obese groups (P = 0.005). The difference in BMI was statistically significant between non-obese and obese groups (P = 0.0001). Most of females gender were obese and morbid obese (P = 0.0001) and most of the obese patients had left-sided renal stone (P = 0.001). Most of overweight and obese groups had radiopaque stones (P = 0.02). There were no statistically significant differences between all groups as regarding co-morbidity, stone size, stone locations, and hydronephrosis grade. Operative time (P = 0.034), length of hospital stay (P value = 0.014) and fluoroscopy time (P = 0.0001) were statistically significant differences between all groups. Number of accesses, access site, postoperative hemoglobin drop, post- operative complications, fate of residual stones and stone-free rate were not statistically significant differences between all groups. BMI was correlated with mean fluoroscopy time and mean hospitalization duration in our study as the time of hospitalization and time of x-ray exposure increase with obesity.ConclusionPNL is a safe and effective procedure for obese patients. BMI do not predict clearance post PNL.

Appropriate timing of performing abdominal ultrasonography and termination of follow-up observation for antenatal grade 1\xa0or 2 hydronephrosis

BackgroundMost cases of antenatal the Society of Fetal Urology (SFU) grade 1or 2 hydronephrosis (HN) improve or resolve spontaneously with conservative treatment. However, there is no consensus on the duration of follow-up for cases of grade 1or 2 HN. The aim of this study was to determine the need for continuous follow-up period and new management of children with antenatal grade 1or 2 HN.MethodsSubjects underwent ultrasonographic assessment for HN according to the SFU classification. We retrospectively evaluated 112 patients with postnatal grade 1 HN and 69 with grade 2 HN using abdominal ultrasonography between January 2010 and December 2017. We examined the change in HN grade on repeat ultrasonography. Kaplan–Meier method was used to show the effect of HN grade on the rate of HN changes.ResultsThe mean follow-up duration was 44.9 ± 36.4 months (range 12–274). Initial SFU grade 1 HN disappeared in 47.0% of cases at 12 months, 66.4% at 24 months and 73.2% at 48 months. Initial SFU grade 2 HN showed improvement in grade in 74.7% of cases at 12 months, 88.3% at 24 months and 89.5% at 48 months. However, 14.6% of SFU grade 1 and 2.8% of SFU grade 2 cases increased in grade and of the 17 cases, 16 cases worsened within the first 6 months. No cases with increased grade required pyeloplasty. Initial disappearance and later reappearance of HN occurred in 40.5% of SFU grade 1 and 2 cases. The mean duration of later reappearance of HN was 39.1 ± 36.2 months (range 12–137). No cases showed reappearance of HN after more than 1 year.ConclusionsUltrasonography within the first 6 months was necessary for management of children with antenatal grade 1or 2 HN, because some patients showed worsening. After that, it is considered safe to spread the follow-up interval for stable cases. Most cases of grade 1or 2 HN resolved spontaneously, however a few cases reappeared within 1 year. Therefore, ultrasonography after 1 year was necessary in children with HN that spontaneously disappeared. The appropriate time to end the follow-up was considered to have been after 1 year or more has passed since the disappearance was confirmed.

Automatic Detection and Scoring of Kidney Stones on Noncontrast CT Images Using S.T.O.N.E. Nephrolithometry: Combined Deep Learning and Thresholding Methods.

To develop and validate a deep learning and thresholding-based model for automatic kidney stone detection and scoring according to S.T.O.N.E. nephrolithometry. Abdominal noncontrast computed tomography (NCCT) images were retrospectively archived from February 2018 to April 2019 for three parts: a segmentation dataset (n = 167), a hydronephrosis classification dataset (n = 282), and test dataset (n = 117). The model consisted of four steps. First, the 3D U-Nets for kidney and renal sinus segmentation were developed. Second, the deep 3D dual-path networks for hydronephrosis grading were developed. Third, the thresholding methods were used to detect and segment stones in the renal sinus region. The stone size, CT attenuation, and tract length were calculated from the segmented stone region. Fourth, the stone's location was determined. The stone detection performance was estimated with sensitivity and positive predictive value (PPV). The hydronephrosis grading and stone size, tract length, number of involved calyces, and essence grading were estimated with the area under the curve (AUC) method and linear-weighted κ statistics, respectively. The stone detection algorithm reached a sensitivity of 95.9% (236/246) and a PPV of 98.7% (236/239). The hydronephrosis classification algorithm achieved an AUC of 0.97. The scoring model results showed good agreement with radiologist results for the stone size, tract length, number of involved calyces, and essence grading (κ = 0.95, 95% confidence interval [CI]: 0.92, 0.98; κ = 0.97, 95% CI: 0.95, 1.00; κ = 0.95, 95% CI: 0.92, 0.98; and κ = 0.97, 95% CI: 0.94, 1.00), respectively. The scoring model was constructed that can automatically detect and score stones in NCCT images.

The effect of shock wave lithotripsy and retrograde intrarenal surgery on health-related quality of life in 10-20mm renal stones: a prospective randomized pilot study.

The effects of treatment modalities such as retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) on health-related quality of life (HRQoL) were determined in patients with renal stones between 10 and 20mm. A total of 120 patients were included in the study and prospectively randomized to RIRS or SWL group. A total of 39 patients experienced treatment failure and finally 81 patients (45 patients in the RIRS group, 36 patients in the SWL group) were analyzed for HRQoL. SF-36 survey was used to determine HRQoL pre-operatively, post-operative day 1 and 1month. The patient and stone characteristics such as age, gender, stone size, grade of hydronephrosis and body mass index were similar between the two groups. At post-operative day 1, the RIRS group was associated with lower scores of role functioning/physical (p = 0.008), role functioning/emotional (p = 0.047) energy/fatigue (p = 0.011), social functioning (p = 0.003) and pain (p = 0.003) when compared to the SWL group. At post-operative 1month, only pain and emotional well-being scores (p = 0.012 and p = 0.011, respectively) in the RIRS group were statistically lower according to the SWL group. In our study, patients in the SWL group showed more favorable HRQoL scores when compared to the patients in the RIRS group in short-term follow-up.

Non-invasive evaluation of obstruction after ureteroscopic stone removal: Role of renal resistive index assessment

The aim of this study is to evaluate prediction of postoperative ureteral obstruction needing ureteral stent insertion by evaluating the resistive index (RI) values and the grade of hydronephrosis. A total of 66 adult patients undergoing stentless endoscopic ureteral stone treatment (URS) between January 2018 and January 2019 were included in this prospective study. Preoperative patient and stone characteristics were noted. All patients were evaluated with renal Doppler ultrasonography study to assess degree of hydronephrosis and RI values. A renal Doppler ultrasonography was repeated at postoperative 1st, 3rd and 7th days. Changes in both RI and hydronephrosis levels before and after the procedures were noted. On the postoperative 7th day, patients were divided into two groups including obstructive and non-obstructive cases according to RI values assessed where a RI value of 0.7 was accepted as the cut-off for obstruction. The preoperative and perioperative characteristics of both groups were evaluated in a comparative manner. The mean patient age was 43.6 ± 1.72 years. Significant improvements were noted in RI and grade of hydronephrosis after the operation. The grade of hydronephrosis and RI values were found to improve more significantly on postoperative 3rd day when compared to the postoperative 7th day (p < 0.01 and p < 0.01). A significant correlation was detected between the grade of hydronephrosis (>grade 2) and obstructive RI values (> 0.7) in each postoperative visits (p: 0.001). RI values (> 0.7) at postoperative seventh days were correlated with larger mean stone size, increased ureteral wall thickness, increased diameter of the ureter proximal to the stone, and longer duration of the operation. Preoperative high-grade hydronephrosis indicated obstructive RI values at postoperative seventh day (p = 0.001) Conclusion: Changes in RI values on Doppler sonography and the grade of hydronephrosis may be a guiding parameter in assessing postoperative ureteral obstruction.

Ultrasound Measurement of Kidney Dimensions in Premature Neonates

Background Ultrasonography is a non-invasive and accurate diagnostic method to evaluate urinary system and its anomalies in the neonates. Kidney sonographic measurement can be used as an alternative method to estimate gestational age. The aim of this study was to measure kidney size in preterm neonates and to provide a guide reference for gestational age. Materials and Methods: Four hundred kidneys (in both sides) of 200 preterm neonates born with gestational age less than 37 weeks were evaluated in the present cross sectional study. Newborns with intrauterine growth retardation (IUGR), asphyxia, high grade hydronephrosis, single kidney, polycystic kidney, duplex kidney, dysplastic kidney and hydroureteronephrosis were excluded. Ultrasound investigations were performed in supine and lateral decubitus positions. Birth weight, gestational age, height and sex were recorded. Data were analyzed using SPSS software version 16.0. Results: The mean gestational age of patients was 33.8±2.2 weeks. Mean kidney length, width, and thickness were 38.8±3.8 mm, 18.9±2.6 mm, and 21.3±2.6 mm, respectively. In addition, the kidney volume was 84037±2533.4 mm3. Mean diameter of the kidney and its volume were significantly higher in male neonates (p <0.05). Kidneys length and volume had a strong correlation with neonatal birth weight (r =0.608, p <0.001, r =0.663, p <0.001, respectively). Conclusion A significant positive correlation was observed between renal dimensions and birth weight, gestational age, and height of patients. The results of this study showed that the trend of kidney growth can be used as a reference guide for gestational age in premature neonates.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation.

Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR). We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system. A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort. Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

Clinical and computed tomography factors associated with sepsis in women with clinically uncomplicated pyelonephritis.

Sepsis is major determinants of prognosis in acute pyelonephritis (APN). This study aimed to assess factors associated with the development of sepsis among patients with clinically uncomplicated APN. We examined 463 patients presenting to our hospital without complications. We assessed clinical factors including demographic and laboratory features. Renal and extrarenal features on computed tomography (CT) were also analyzed. Risk factors of sepsis are assessed. The study included 361 patients without (78.0%) and 102 patients with sepsis (22.0%). Crude and attributable mortality rates were 3.9% and 2.0% versus 1.4% and 0.6%, respectively, among patients with and without sepsis. Clinical risk factors for sepsis were age >65years (odds ratio [OR] 1.79, P=0.02), absence of flank pain (OR 1.59, P=0.04), absence of costovertebral tenderness (OR 1.89, P=0.03), diabetes mellitus (OR 2.25, P=0.02), bacteremia (OR 2.8, P=0.01), C-reactive protein level >100mg/L (OR 1.42, P=0.02), and lack of previous APN history (OR 1.76, P=0.04). APN grade IV (OR 3.16, P=0.01), high grade hydronephrosis (OR 1.50, P=0.03), diffuse peritoneal thickening (OR 4.12, P=0.01), and acute interstitial pulmonary edema (OR 3.73, P=0.01) were the CT features predictive of septic shock. Although uncomplicated APN was largely non-fatal, several clinical and CT features could lead to sepsis. Our findings may be useful for predicting sepsis risk and deciding whether intravenous antibiotic treatment and intensive management should be initiated for uncomplicated APN.

Grading of Hydronephrosis: An Ongoing Challenge

The crucial point for prompt diagnostics, ideal therapeutic approach, and follow-up of hydronephrosis associated with UPJ anomalies in children is the severity of hydronephrosis. Such many hydronephrosis grading systems as AP diameter, SFU, radiology, UTD, and Onen have been developed to evaluate hydronephrosis severity in infants. Unfortunately, it is still an ongoing challenge and there is no consensus between different disciplines. AP diameter is a very dynamic parameter and is affected by many factors (hydration, bladder filling, position, respiration). More importantly, its measurement is very variable and misleading due to different renal pelvic configurations. The radiology grading system has the same grades 1, 2, and 3 as the SFU grading system with addition of the AP diameter for the first 3 grades. This grading system divides parenchymal loss into two different grades. Grade 4 represents mild parenchymal loss while grade 5 suggests severe parenchymal loss. However, it is operator dependent, is not decisive, and does not differentiate grades 4 and 5 clearly. All grades of SFU are very variable between operators and clinicians. UTD classification aims to put all significant abnormal urinary findings together including the kidney, ureter, and bladder and thus determines the risk level for infants with any urinary disease. Different renal deterioration risks occur depending on the mechanism of hydronephrosis. Therefore, SFU and UTD classification may result in significant confusion and misleading in determining the severity of hydronephrosis. SFU-4 and UTD-P3 represent a considerable range of severity of hydronephrosis. Both represent minimal thinning of the medullary parenchyma and severe thinning of the cortical parenchyma (cyst-like hydronephrotic kidneys) at the same grade. The wide definition of SFU-4 and UTD-P3 fails to indicate accurately the severity of hydronephrosis and thus significantly misleads from a prompt treatment. They do not suggest who need surgical treatment and who can safely be followed non-operatively. The anatomy and physiology of the 4 suborgans of the kidney (renal pelvis, calices, medulla, and cortex) are completely different from each other. Therefore, each part of the kidney affect and behave differently as a response to UPJ-type hydronephrosis (UPJHN) depending on the severity of hydronephrosis. The upgraded Onen hydronephrosis grading system has been developed based on this basic evidence both for prenatal and post-natal periods. The Onen grading system determines specific detailed findings of significant renal damage, which clearly show and suggest who can safely be followed conservatively from who will need surgical intervention for UPJHN. Neither AP diameter nor radiology, SFU, or UTD classification is the gold standard in determining the severity of hydronephrosis. All these grading systems are based on subjective parameters and are affected by many factors. They do not determine the exact severity of UPJHN and thus cause permanent renal damage due to a delay in surgical decision in some infants while they may cause an unnecessary surgery in others. The Onen grading system has resolved all disadvantages of other grading systems and promises a safer follow-up and a prompt treatment for UPJHN. It is an accurate and easily reproducible grading that has high sensitivity and specificity.

Utilization of Radiographic Imaging for Infant Hydronephrosis over the First 12 Months of Life.

Purpose The workup and surveillance strategies for infant hydronephrosis (HN) vary, although this could be due to grade-dependent differences in imaging intensity. We aimed to describe the frequency of imaging studies for HN within the first year of life, stratified by initial HN grade, within a large regional healthcare system. Study Design and Data Source. Retrospective cohort using Intermountain Healthcare Data Warehouse. Inclusion criteria: (1) birth between 1/1/2005 and 12/31/2013, (2) CPT code for HN, and (3) ultrasound (U/S) confirmed HN within four months of birth. Data Collection. Grade of HN on initial postnatal U/S; number of HN-associated radiologic studies (renal U/Ss, voiding cystourethrograms (VCUGs), and diuretic renal scans); demographic and medical variables. Primary Outcome. Sum of radiologic studies within the first year of life or prior to pyeloplasty. Statistical Analysis. Multivariate poisson regression to analyze association between the primary outcome and the initial HN grade. Results Of 1,380 subjects (993 males and 387 females), 990 (72%), 230 (17%), and 160 (12%) had mild, moderate, and severe HN, respectively. Compared with those with mild HN, patients with moderate (RR: 1.57; 95% CI: 1.42–1.73) and severe (RR: 2.09; 95% CI: 1.88–2.32) HN had a significantly higher rate of imaging use over 12 months (or prior to surgery) after controlling for potential confounders. Conclusions In a large regional healthcare system, imaging use for HN is proportional to its initial grade. This suggests that within our system, clinicians treating this condition are using a risk-stratified approach to imaging.