Hydronephrosis Research Articles

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.

Prenatal diagnostic and management of megacystis microcolon intestinal hypoperistalsis syndrome: A report on a rare case in Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a rare and the most severe form of functional intestinal obstruction in the newborn. The characteristic features of this congenital and fatal disease are abdominal distension, absent or decreased bowel peristalsis. Abdominal distension is a consequence of the distended, unobstructed urinary bladder with or without hydro nephrosis. Some previous reports have revealed that the typical antenatal sonographic findings are as follows: a greatly distended bladder, bilateral hydro nephrosis, and a normal amount of amniotic fluid; however, the antenatal diagnosis of this syndrome is occasionally difficult.

Laparoscopic ureteral reconstruction in infant with congenital mid ureteric valve

Congenital mid ureteric valve (MUV) stenosis is a very rare cause of ureteric obstruction and hydronephrosis (HN) in children. We describe how we manage laparoscopically one case of a patient with congenital MUV. We describe a 6-month-old boy born with antenatal left HN, with an anteroposterior diameter (APD) of 1,5cm. Follow-up renal ultrasound at 3 months of age showed an increase in left kidney HN, approximately 2.5cm below the PUJ associated with distal stenosis. Renal scintigraphy with DTPA showed an obstructive pattern. Urography scan showed an abrupt reduction in the caliber of the mid left ureter Based on a preoperative diagnosis of MUV stenosis, we performed a laparoscopic left ureteroplasty. Abrupt tapering of the left ureter at 3cm from the PUJ was identified. Proximal ureter repair was performed before the resection of the narrowing segment. The two edges of the ureter were spatulated and continuous anastomosis was performed without tension. An antegrade JJ stent was inserted after the posterior part of the anastomosis was done. Patient made an uneventful recovery and was discharged on the first postoperative day. Laparoscopic ureteroplasty is a complex but feasible option to treat patients with congenital MUV stenosis.

Critical analysis of the outcome of primary unilateral vesicoureteral reflux in a medium volume center

BackgroundVesicoureteral reflux (VUR) is a common finding in pediatric age group. Here in we explored the possible risk factors that affect the rate of resolution in patients with primary unilateral VUR under conservative treatment.MethodsBetween 2006 and 2014, we retrospectively evaluated all VUR patients and included only patients with primary unilateral VUR. Records were reviewed for patient age at diagnosis, antenatal history, patient gender, mode of presentation, side, and grade of VUR, associated hydronephrosis (HN) on renal ultrasound, presence of scarring and split function on dimercaptosuccinic acid (DMSA) scan. Clinical and radiological outcomes were assessed. Both univariate and multivariate analysis were conducted.ResultsA total of 68 patients with primary unilateral VUR were included (32 boys and 36 girls) with a mean age of 10 months (range 1–32). Antenatal HN was detected in 50% of patients. In 15 cases (22%), VUR was of high grade (IV–V). Associated HN was evident in 39 patients (57%). DMSA scans showed renal scarring in 16 patients (23%). After a mean follow-up of 7 years, VUR resolved in 49 patients (72%). Significant predictors for VUR resolution were VUR grade, DMSA split function and associated high-grade HN. High-grade HN with VUR was the only significant independent risk factor.ConclusionsThe rate of resolution in primary unilateral VUR under conservative treatment is significantly affected by VUR grade, DMSA split renal function and the presence of associated HN. Association of high-grade HN with VUR carries a low chance for spontaneous resolution.

Renal cortical transit time as a predictor for pyeloplasty in pediatric patients with unilateral hydronephrosis

Majority of patients with unilateral hydronephrosis (HN) detected on ultrasound do not require pyeloplasty. The measurement of the cortical transit time (CTT) has been demonstrated by several authors to predict the need for patients who may require pyeloplasty. The study aimed to assess if CTT would have predicted a drop in differential renal function (DRF) in patients with unilateral HN on the affected side and to assess whether CTT would differ on the first renogram between those patients who had a pyeloplasty and those who did not have a pyeloplasty. Sixty-eight patients with at least two renograms with unilateral HN with a normal contralateral kidney were observed retrospectively. The CTT was recorded for each kidney. Renograms were processed three times to measure the DRF. The mean of the three DRF measurements was used for analysis. The mean CTT of the left and right hydronephrotic kidneys was 6.0 min and 6.7 min, respectively. The relationship between CTT and DRF as well as CTT and anterior posterior diameter in the first renogram of those patients who did not have a pyeloplasty was statistically significant (P < 0.05). In the 20 patients who had a pyeloplasty, there was a drop of more than 10% in the DRF of three patients. No significant difference was found in CTT or DRF when comparing the group who had surgery against the group who did not have surgery. The current study was unable to demonstrate in our series of patients that CTT can predict a drop in DRF in those patients who would require pyeloplasty.

Results of the treatment ofcongenital hydronephrosis

Results of the treatment ofcongenital hydronephrosis

Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction

The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA). The aim of this study is to assess the outcome of dehisced exstrophy, using a RAM flap assisted redo closure (without PBA) with concomitant or subsequent further reconstruction. This is a retrospective analysis of children who presented with dehisced exstrophy after repair in other institutions and who have undergone redo repair using RAM flap in two tertiary care centers from 2001 to 2019. The outcome of the redo closure and subsequent or concomitant further reconstruction as regards dryness, stability of the upper tracts and resolution of vesico ureteric reflux (VUR) was studied. Fifty five children (34 boys) underwent redo exstrophy repair for dehisced exstrophy using the RAM flap. Epispadias repair was performed concomitantly in 31 boys. In 26 children (group1) of mean age 12 months further surgery was deferred while in 29 children (group 2) of mean age 69 months underwent concomitant BA. Nine group 1 children underwent BA subsequently. Ureteric reimplantation was done at the time of BA in 54 ureters, 40 into the bladder plate and rest into the bowel segment of BA. 22 ureters were not reimplanted. Bladder neck surgery including 18 bladder neck closure and Mitrofanoff port for Clean Intermittent catheterization (CIC) were done along with BA. The RAM assisted bladder closure was event free and none needed redo operation. 35/38 augmented children are dry on Mitrofanoff CIC and one unaugmented boy voids normally. The upper tracts remain stable on ultrasound and VUR has resolved in 67/76 ureters. At current follow up, after a mean period of 53 months eGFR was normal in all except 3 who had initially presented with severe hydro uretero nephrosis. We present a simple and reliable method of repair of dehisced exstrophy using RAM flap with the feasibility of concomitant BA. Dryness was achieved with stable upper tracts in 36/39 children, 27 of them with a single reconstructive attempt.

Crossed fused renal ectopia: Diagnosis and prognosis as a single-center experience

BackgroundCrossed fused renal ectopia (CFRE) is a rare congenital malformation. Renal bladder ultrasound (RBUS) is a good tool for establishing the diagnosis, however, additional imaging with a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid scan (DMSA) might be required. We assessed the need for postnatal evaluation and the long-term consequences in patients with this diagnosis. MethodsA retrospective review of the records of all patients diagnosed with CFRE between 2004 and 2014 was done. We included all patients who underwent postnatal evaluation with RBUS, DMSA and VCUG. Long-term radiological and functional outcomes were assessed. ResultsA total of 29 patients with CFRE were identified. Majority of cases were detected antenatally (79%) and left to right crossed ectopia constituted the majority of cases (65%). RBUS revealed associated hydronephrosis (HN) in 11 patients (38%). DMSA scans confirmed the diagnosis in all patients and showed impaired renal function in 10 ectopic kidneys (34%). Vesicoureteral reflux was detected in 12 patients (41%); one third of them needed surgical intervention. Extra-urinary anomalies were present in 14 patients (48%) mainly of cardiac origin. After a mean follow-up of 4.5 years, 4 patients (14%) with extra-urinary anomalies developed chronic kidney disease and two of them died. ConclusionsCrossed fused renal ectopia is commonly associated with both urinary and extraurinary malformations. Postnatal RBUS is usually sufficient for diagnosis, however, additional imaging may aid for confirming the diagnosis and detection of associated urinary anomalies. Presence of extra-urinary malformations with crossed fused ectopia carries a higher risk of morbidity. Type of the StudyRetrospective study [diagnostic/prognostic study]. Level of EvidenceLevel IV.

The impact of post-procedural ureteric stent duration on the outcome of retrograde endopyelotomy for management of failed open pyeloplasty in children: a preliminary report.

Background: To evaluate the outcome of retrograde endopyelotomy as a minimally invasive option for management of failed open pyeloplasty in children and assess how the duration of post-procedural stenting may affect the endopyelotomy outcome. Methods: A total of 15 patients with secondary UPJO (Ureteropelvic junction obstruction) underwent retrograde endopyelotomy. The procedure was done using low-energy monopolar electrocautery hook under direct vision of pediatric ureteroscope and control of fluoroscopy. Double J stent was placed after the operation in all cases. Stent was removed in another session, 8 weeks (Group A, n=7) vs. 12 weeks (Group B, n=8) after endopyelotomy. Patients in both Groups were followed one, six and twelve months after the stent removal, and the anteroposterior renal pelvis diameter (APD), renal cortical thickness (CT) and degree of hydronephrosis (HDN) were recorded using the repeated measure test. P-value less than 0.05 were significant. We analyzed the data using SPSS software, version 20. Results: The median interquartile range (IQR) age at time of surgery for group A and B were 24 (62) months and 12 (50) months respectively. Median (IQR) times between previous pyeloplasty and endopyelotomy were 6 (6) months and 12 (8.5) months in groups A and B, respectively. The success rate of endopyelotomy after 12 months was 57.1% in group A and 87.5% in group B. The resolution of HDN was more prominent in the 12 week stenting group compared to the 8 week group during the 12 months follow-up period (p=0.030). The APD and CT in group B compared to group A was improved during follow-up period. Conclusion: A higher one-year success rate of retrograde endopyelotomy in terms of improvements in the degree of HDN, APD and CT was observed when the double j stent was remained for 12-weeks rather than 8-weeks. This observation need to be validated in a large cohort study with a long term post procedural follow up.

Advance in re-do pyeloplasty for the management of recurrent ureteropelvic junction obstruction after surgery

Ureteropelvic junction obstruction (UPJO) is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney. Open pyeloplasty had been regarded as the standard management of UPJO for a long time. Laparoscopic pyeloplasty reports high success rates, for both retroperitoneal and transperitoneal approaches, which are comparable to those of open pyeloplasty. However, open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%. The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation, ureteral ischemia, and inadequate hemostasis. In addition, failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO. In addition, poor preoperative split renal function, hydronephrosis, presence of renal stones, patient age, diabetes, prior endopyelotomy history, and retrograde pyelography history were considered as predictors of pyeloplasty failure. The failure is usually defined by persistent pain, persistent radiographic obstruction (infection or stones), continued decline in split renal function, or a combination of the above. And the failure of pye-loplasty often occurs in the first 2 years after the surgery. The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy, re-do pyeloplasty, stent implantation, percutaneous nephrostomy, ureterocalicostomy, and nephrectomy. Re-do pyeloplasty has such merits as high successful rates and rare complications, compared with endopyelotomy or ureterocalicostomy. And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible. Open pyeloplasty can enlarge the operating field, facilitate the exposure of the ureteropelvic junction, reduce the difficulty of operation, and thus reduce the occurrence of complications. There are no significant differences among the success rates of re-do pyeloplasty under open approach, traditional laparoscopy and robot-assisted laparoscopy, according to previous reports. However, traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology, small trauma, less postoperative pain, speedy recovery and shorter hospitalization, fewer complications and lower recurrent rates. If the primary pyeloplasty is an open operation in retroperitoneal approach, the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair. The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.

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.

From infancy to adulthood: challenges in congenital nephrogenic diabetes insipidus.

Objectives Congenital nephrogenic diabetes insipidus (NDI) is a rare hereditary disorder which is characterized by unresponsiveness to arginine vasopressin (AVP) in collecting ducts and leads to polyuria and polydipsia. The wide clinical spectrum of congenital NDI can cause difficulties in early diagnosis. We aimed to evaluate clinical prognosis of children with congenital NDI in long-term period. Methods Nineteen children with congenital NDI followed up in Pediatric Nephrology Department were enrolled to the study. This study is a single-center retrospective study, which reports clinical follow-up and genetic results of children with congenital NDI. Results Presenting symptoms of patients were mostly dehydration and fever due to polyuria and polydipsia. Four male patients had bilateral nonobstructive hydroureteronephrosis (HUN) and neurogenic bladder which requires clean intermittent catheterization (CIC). One patient had intracranial calcification which is a rarely seen complication in congenital NDI due to recurrent hypernatremic dehydration and severe brain dehydration. The causative mutations were identified in all patients. The identified mutations in six of them (31.6%) were hemizygous mutations in AVPR2 gene and homozygous mutations of AQP2 gene in the rest 13 cases (68.4%). More than that, four of these mutations (two in AVPR2 and two in AQP2) were novel mutations. Noncompliance with the treatments is associated with high risk of morbidity due to neurogenic bladder and chronic kidney disease (CKD). Conclusions The prognosis of congenital NDI is good when diagnosis can be made early and treatment is started immediately. Genetic counseling and prenatal testing for hereditary diseases are recommended especially in regions with relatively higher rates of consanguineous marriages.

Evaluation of the Pediatric Neurogenic Bladder Dysfunction of the Patients in the King Abdulaziz University Hospital, Jeddah, Saudi Arabia: Pediatric Neurogenic Bladder

A neurogenic bladder results from conditions that affect either the central or peripheral nervous system. This study reviewed all the pediatric neurogenic patients in the King Abdulaziz University Hospital from 2008 to 2018, using their medical records and histories. The patients’ ages were between one month and 16 years during their first diagnosis. Patients with more than 50% missing data were excluded. A total of 678 patients were diagnosed with neurogenic bladder during the study period. But only the data of 212 patients were processed for statistical analysis. The patients’ median age was 9 years. The causes of neurogenic bladder in these patients were 1) spina bifida in 110 patients (51.8% of the sample population), 2) non- neurogenic neurogenic bladder (Hinman syndrome) in 40 (18.8%) cases, 3) bilateral hydronephrosis in 72 (33.9%) patients, and 4) urine incontinence, which was the main complain in 132 (62%) patients. Sixty-four (30%) patients had urine retention and were dependent on catheter. Spina bifida was the main cause of neurogenic bladder in this study group. Upper tract status of the patients during their presentation had affected the complication rates and the decisions to administer surgical intervention.

Selected Metal Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases as Potential Biomarkers for Tubulointerstitial Fibrosis in Children with Unilateral Hydronephrosis.

Renal tubulointerstitial fibrosis caused by congenital ureteropelvic junction obstruction (UPJO) may lead to the development of obstructive nephropathy (ON) and the impairment of kidney function. Hence, the identification of early biomarkers of this condition might be of assistance in therapeutic decisions. This study evaluates serum and urinary metalloproteinases MMP-1, MMP-2, and MMP-9 and tissue inhibitors of metalloproteinases TIMP-1 and TIMP-2 as potential biomarkers of ON in children with congenital unilateral hydronephrosis (HN) caused by UPJO. Forty-five (45) children with congenital HN of different grades of severity and twenty-one (21) healthy controls were enrolled in the study. Urinary and serum concentrations of MMP-1, MMP-2, MMP-9, TIMP-1 and TIMP-2 were measured using specific ELISA kits. The urinary excretions were expressed as biomarker/creatinine (Cr) ratios. To evaluate the extracellular matrix remodelling process activity, the serum and urinary MMP-1, -2, -9/TIMP-1, -2 ratios were also calculated. In comparison with the controls, patients with HN, independent of the grade, showed significantly increased median serum MMP-9, TIMP-1, and TIMP-2, median urinary MMP-9/Cr, and TIMP-2/Cr ratios. Lower median values of serum MMP-2/TIMP-1, MMP-9/TIMP-1 in patients with HN were also revealed. Additionally, higher urinary MMP-2/Cr, lower urinary MMP-2/TIMP-2, and lower serum MMP-9/TIMP-2 ratios were observed in patients with HN grades 3 and 4. Patients with ON diagnosed by renal scintigraphy had a significantly higher median serum MMP-9 concentration and lower median serum MMP-9/TIMP-1, -2 ratios in comparison with those without this condition. Patients with nonglomerular proteinuria had a significantly higher median serum TIMP-1 concentration, a higher median urinary TIMP-2/Cr ratio, and a lower serum MMP-9/TIMP-1 ratio compared to those without this symptom. The relationship between the measured biomarkers and the relative function of the obstructed kidney showed no correlations. The ROC curve analysis showed a promising diagnostic profile for the detection of ON for serum MMP-9 and the serum MMP-9/TIMP-1 and MMP-9/TIMP-2 ratios. In conclusion, the results of this study suggest that patients with HN, particularly with grades 3 and 4, are at higher risk of renal tubulointerstitial fibrosis. The noninvasive markers of this condition considered are urinary MMP-2/Cr and MMP-9/Cr, serum MMP-9, serum and urinary MMP-2, MMP-9/TIMP-1, -2. Additionally, serum MMP-9 and MMP-9/TIMP-1, -2 may become promising markers of ON.

Point-of-care ultrasound is an accurate, time-saving, and cost-effective modality for post-operative imaging after pyeloplasty

Dismembered pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). Although the frequency and timing of follow up imaging after pyeloplasty is variable, renal ultrasound (RUS) is commonly utilized. With minimal training, point-of-care ultrasound (POCUS) can be easily performed by a urologist during a post-operative visit. Our hypothesis is that POCUS is an accurate, time-saving, and cost-effective alternative to a complete retroperitoneal ultrasound (CRUS) performed by the Radiology Department after pyeloplasty. The clinical records of all children who underwent pyeloplasty (by any method) over a 12 month period at our institution were retrospectively reviewed. The exact timing and method (POCUS vs. CRUS) of follow up imaging was surgeon-dependent. Statistical analysis was performed to compare the time and cost of POCUS vs. CRUS. The clinical course of each patient who had each type of imaging was assessed. A total 45 patients were included in this analysis. Over a mean follow up period of 29 months, a total of 73 CRUS and 67 POCUS were performed. Each CRUS on average added 2h to each patient's healthcare encounter. Had the 73 CRUS been performed as POCUS instead, this would have corresponded to $83,751 less charges to payers. There was no difference in the rate of the detection of worsening, stable, or improved hydronephrosis (HN) between either modality (p>0.05). The recommended follow up time for observed HN was no different between CRUS and POCUS (p>0.05). Children with worsening HN on POCUS underwent functional studies without confirmatory CRUS. Interestingly, two patients had metachronous, contralateral UPJO discovered during post-operative imaging. These were both discovered by POCUS. Nineteen (42%) patients who had attended at least one post-operative visit were eventually loss to follow-up. This occurred exclusively in those who did not have worsening ultrasound (p<0.01). There was no difference in the loss to follow-up after POCUS (8) or CRUS (12) (p>0.05). POCUS performed by a urologist is an accurate assessment of HN after pyeloplasty with time and cost savings to compared to a CRUS performed by a radiologist. POCUS is not associated with any difference in rate of detection of worsening HN or rate of loss to follow up.

MP29-04 ANNUAL RENAL ULTRASOUND IS ADEQUATE SURVEILLANCE TO SCREEN FOR NEW OBSTRUCTIVE UROPATHY IN ADULT PATIENTS WITH CONGENITAL ANOMALIES OF THE BLADDER

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I (MP29)1 Apr 2020MP29-04 ANNUAL RENAL ULTRASOUND IS ADEQUATE SURVEILLANCE TO SCREEN FOR NEW OBSTRUCTIVE UROPATHY IN ADULT PATIENTS WITH CONGENITAL ANOMALIES OF THE BLADDER Madeline Cancian*, Charlotte Wu, Lindsey Hartsell, Edwin Smith, K. Jeff Carney, and Niall Galloway Madeline Cancian*Madeline Cancian* More articles by this author , Charlotte WuCharlotte Wu More articles by this author , Lindsey HartsellLindsey Hartsell More articles by this author , Edwin SmithEdwin Smith More articles by this author , K. Jeff CarneyK. Jeff Carney More articles by this author , and Niall GallowayNiall Galloway More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000868.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with congenital bladder anomalies are surviving into adulthood and transitioning to adult urologic care. Urologists represent a hugely important gate keeper, as traditionally the leading cause of death in patients with spina bifida over 16 years old was renal failure secondary to complications of the urinary tract. Unfortunately, there are no standard guidelines for choosing an appropriate surveillance protocol. The goal of our study was to describe our surveillance patterns and examine renal outcomes in this population. METHODS: We performed retrospective chart review of patients with spina bifida (SB), posterior urethral valves (PUV) and bladder exstrophy (BE) seen from 2008 - 2019 at our institution, a single tertiary referral academic center. We excluded patients who had chronic kidney disease or clinically significant hydronephrosis (HN) upon referral. RESULTS: We identified 103 subjects (83% SB, 1% PUV, 16% BE). [Table 1] Our surveillance protocol involved annual renal ultrasonography. Routine bloodwork or urodynamics was not completed unless prompted by worsening HN. Six (6%) patients developed new or worsening HN during follow up. No patient developed worsening renal function, as measured by creatinine, in the absence of new or worsening HN, and only one patient had a concomitant rise in creatinine. Of the 6 patients, 2 patients were observed for physiologic HN, 3 patients required surgery for obstruction at the level of the stoma (1) or ureter (2), and one patient required transplant. While two (50%) cases of new obstructive uropathy were due to failed urinary diversion, one case was related to poor patient compliance, and the final case resulted from obstruction secondary to metastatic adenocarcinoma of the augmented bladder. CONCLUSIONS: In our patients with congenital bladder anomalies, annual renal ultrasound detected de novo or worsening HN in 6 (6%) patients. As adults, these patients did not develop new kidney failure in the absence of HN. Among those with clinically significant HN, the majority was from an iatrogenic cause and required operative intervention in the form of surgical revision or transplant. Annual renal ultrasonography appears to be an adequate and useful screening protocol in these patients. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e430-e430 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Madeline Cancian* More articles by this author Charlotte Wu More articles by this author Lindsey Hartsell More articles by this author Edwin Smith More articles by this author K. Jeff Carney More articles by this author Niall Galloway More articles by this author Expand All Advertisement PDF downloadLoading ...

MP71-17 POINT OF CARE ULTRASOUND IS AN ACCURATE, TIME-SAVING, AND COST-EFFECTIVE MODALITY FOR POSTOPERATIVE IMAGING AFTER PYELOPLASTY

INTRODUCTION AND OBJECTIVE: Dismembered pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). Although the frequency and timing of follow up imaging after pyeloplasty is variable, ultrasound (US) is commonly utilized. With minimal training, point of care ultrasound (POCUS) can be easily performed by a urologist during a postoperative visit. Our hypothesis is that POCUS is an accurate, time-saving, and cost-effective alternative to a complete retroperitoneal ultrasound (CRUS) performed by a radiologist after pyeloplasty. METHODS: The clinical records of all children who underwent pyeloplasty (by any method) over a 12 month period at our institution were retrospectively reviewed. The exact timing and method (POCUS vs. CRUS) of follow up imaging was surgeon-dependent. Statistical analysis was performed to compare the time and cost of POCUS vs. CRUS. The clinical course of each patient who had each type of imaging was assessed. RESULTS: A total of 45 patients were included in this analysis. 33 were performed laparoscopically with robotic assistance and 12 were performed with open surgery. Over a mean follow up period of 29 months, a total of 71 CRUS and 70 POCUS were performed. Despite an average increased cost of $618 (total $43,878) and an increased wait time 119 minutes (total 8449 min) of CRUS over POCUS, there was no difference in the rate of the detection of worsening hydronephrosis (HN) between either modality (p > 0.05). The recommended follow up time for observed HN was no different between CRUS and POCUS (p > 0.05). Children with worsening HN on POCUS underwent functional studies without confirmatory CRUS. Interestingly, two patients had metachronous contralateral UPJOs discovered during postoperative imaging with POCUS. 20 (43%) patients who had attended at least one postoperative visit were eventually lost to follow up. This occurred exclusively in those who did not have worsening ultrasound (p <0.01). There was no difference in the loss to follow up after a follow up POCUS (8) or CRUS (12) (p > 0.05). There were 2 (4%) failed procedures which required eventual reoperative pyeloplasty. 1 of these postoperative failures was detected by POCUS. In this patient, MAG3 showed no deterioration in function (40/60 preoperative to 42/58 prior to salvage pyeloplasty). CONCLUSIONS: POCUS performed by a urologist is an accurate assessment of HN after pyeloplasty with time and cost savings compared to a CRUS performed by a radiologist. POCUS is not associated with any difference in rate of detection of worsening HN or rate of loss to follow up. Source of Funding: None

MP71-09 COMPARISON OF FRAGILITY METRICS BETWEEN 2 COMMON PEDIATRIC UROLOGY BODIES OF LITERATURE

You have accessJournal of UrologyPediatrics: Upper Urinary Tract Disorders and Fetal Urology (MP71)1 Apr 2020MP71-09 COMPARISON OF FRAGILITY METRICS BETWEEN 2 COMMON PEDIATRIC UROLOGY BODIES OF LITERATURE Mandy Rickard, Jessica Hannick*, Daniel T Keefe, Erik Drysdale, Lauren Erdman, Joana Dos Santos, and Armando J Lorenzo Mandy RickardMandy Rickard More articles by this author , Jessica Hannick*Jessica Hannick* More articles by this author , Daniel T KeefeDaniel T Keefe More articles by this author , Erik DrysdaleErik Drysdale More articles by this author , Lauren ErdmanLauren Erdman More articles by this author , Joana Dos SantosJoana Dos Santos More articles by this author , and Armando J LorenzoArmando J Lorenzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000951.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fragility index (FI) is a metric recently introduced to provide an objective measure of strength of study results. One proposed reason for poor study robustness is sparse well designed randomized controlled trials (RCTs). Different topics in Pediatric Urology literature include studies with varying quality of design. In particular, bowel and bladder dysfunction (BBD) studies are more likely to be higher quality versus other topics. To assess this hypothesis, we compared measures of robustness (FI and fragility quotient [FQ]) in our BBD and hydronephrosis (HN) literature databases. METHODS: A direct comparison of FI and FQ data from previously analyzed BBD and HN literature was performed. We gathered study design data and contrasted FI and FQ data stratified by study design. Search strategy, inclusion and exclusion criteria, data extraction and analyses were identical in both groups. RESULTS: 125 BBD and 130 HN papers published between 1971 and 2019 were included. The mean h index was 16 +15, median citation count was 14 (0-252), FI was 3(0-116), and 34% of the studies were RCTs. Significantly more BBD studies (42%) were categorized as RCTs relative to HN studies 25% (p<0.01). Despite the higher proportion of RCTs in BBD papers, we noted no significant difference between FI (3 vs. 2; p=0.08) or citation counts (15 vs.14) for BBD and HN papers respectively (p=0.09) (Figure 1). CONCLUSIONS: Despite the higher number of RCTs in BBD literature, the overall robustness of findings remains similar and consistent with other Pediatric Urology topics. This finding suggests that study design alone is not a factor likely to address limitations in our literature. Source of Funding: NA © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1067-e1067 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mandy Rickard More articles by this author Jessica Hannick* More articles by this author Daniel T Keefe More articles by this author Erik Drysdale More articles by this author Lauren Erdman More articles by this author Joana Dos Santos More articles by this author Armando J Lorenzo More articles by this author Expand All Advertisement PDF downloadLoading ...

Analysis of risk factors for postoperative stenosis with single ureteral calculi treated with ureteroscopic holmium laser listhotripsy

Objective To explore the risk factors of stricture after ureteroscopic holmium laser lithotripsy (URSL) in patients with single ureteral calculi, and to provide reference for the treatment of patients. Methods Retrospective analysis of 230 patients with single ureteral calculi who underwent URSL between November 2017 and November 2018 was performed. According to the postoperative follow-up results, 26 patients with ureteral stricture were treated as observation group, and ureteral non-stenosis patients were 204 patients as a control group. The risk factors for stenosis after surgery were analyzed. Results The risk factors of postoperative stenosis showed that the diameter of calculus≥2 cm, severe hydronephrosis, stone incarceration, and long course of disease were the risk factors for postoperative stenosis. The difference between the two groups was statistically significant(P<0.05). Multivariate logistic regression analysis of ureteral stricture showed that large stones, severe hydronephrosis, incarcerated stones and long-term disease were independent risk factors for ureteral stricture after URSL, and the difference was statistically significant(P<0.05). Conclusions Severe hydronephrosis, large stones, stone incarceration and long course of disease are high risk factors for postoperative ureteral stricture. Therefore, patients should be kept away from the high risk factors causing ureteral stricture in patients during treatment for better therapeutic efficiency. Key words: Ureteral Calculi; Lithotripsy, Laser; Urethral Stricture

A case report of duplex kidney and ureter abnormality accompanied with lower giant hydronephrosis

Duplex kidney and ureter abnormality are one of the most common malformation in urinary system, with most of patients present no apparent symptom, and only a few patients being complicated by ureter obstruction and serious hydronephrosis, which is difficult to differentiate with renal cyst. Therefore a case with duplex kidney and ureter abnormality was reported to provide information for clinical practice. Key words: Ureteral disease; Duplex kidney and ureter abnormality; Hydronephrosis