Lower Pole Reflux Research Articles

Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus. ResultsDuring the 1993–2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2–12). Successful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%). DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of patients is small and there are few studies, hindering the agreement on the most appropriate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus ResultsDuring the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Percutaneous Nephroscopic Removal of Obstructing Fungal Bezoars and Endopyelotomy in an Infant

A full-term neonate with right prenatal and postnatal hydronephrosis was found to have complete duplication of the right renal collecting system with upper pole ureteral ectopia and lower pole reflux. The patient was treated with daily amoxicillin. At age 2 months she presented with fever and candiduria. Renal sonography demonstrated a fungal bezoar in the left (nonduplex) renal pelvis with severe pyelocaliectasis (fig. 1). The patient was treated with intravenous amphotericin B for 4 weeks without sonographic or culture improvement. Nuclear renography revealed impaired drainage and function (23%). A nephrostomy catheter was placed, and an antegrade nephrostogram showed multiple filling defects and narrowing at the ureteropelvic junction (fig. 2). Two additional weeks of antifungals and nephrostomy drainage did not improve the sonographic appearance of the bezoars or the candiduria. Renal irrigation was not attempted due to the obstructive lesion. At age 4 months the patient underwent percutaneous endoscopic removal of the bezoars and correction of the obstruction. A 12Fr vascular peel away sheath was positioned into a middle calix. A 10.5Fr pediatric rigid cystoscope was used for nephroscopy, and multiple fungal balls were visualized and extracted with flexible grasping forceps. A 7.5Fr flexible pediatric endoscope was used to inspect the entire collecting system. The ureteropelvic junction was laterally incised with a holmium laser (200 .) placed through the rigid cystoscope. A nephrostomy tube and ureteral catheter were left indwelling. The patient was discharged on postoperative day 2. Ten days later the ureteral catheter was removed. An antegrade nephrostogram performed 2 days later demonstrated no filling defects, no extravasation and prompt contrast drainage into the distal ureter. At 1-year followup the patient was free of infection and without evidence of hydronephrosis or filling defect by excretory urography and sonography.

Lower pole reflux in children: uroradiologic appearances and pitfalls.

Fig. 1-3-year 7-month-old girl with left lower pole grade 2 reflux. Voiding cystourethrogram shows renal tissue medial to uppermost calyx to be thicker than expected for single-system kidney. Uppermost infundibulum is truncated. Axis of pelvicaliceal system is oblique and points toward ipsilateral shoulder. usually the larger. Duplex kidneys are present in 12% of people and may be bilateral [I]. Most duplex kidneys are normal. Because the lower pole is the developmental analogue of a “single-system” kidney, abnormalities of the lower pole occurjust as they do in a singlesystem kidney. The most common abnormality is reflux [2, 3]; the natural history of lower pole reflux is the same as that of reflux into a single-system kidney [4].

Ipsilateral Pyeloureterostomy for Managing Lower Pole Reflux with Associated Ureteropelvic Junction Obstruction in Duplex Systems

Ipsilateral Pyeloureterostomy for Managing Lower Pole Reflux with Associated Ureteropelvic Junction Obstruction in Duplex Systems

Segmental Multicystic Kidney and Ipsilateral Duplication Anomalies

Purpose We characterize segmental multicystic dysplasia, in which there is a duplex collecting system with multicystic changes in the upper pole. Materials and Methods Three neonates with an abdominal mass and/or prenatal diagnosis of a multicystic kidney were evaluated. Postnatal ultrasound showed a classic multicystic kidney and small ipsilateral orthotopic ureterocele in all cases. All patients had ipsilateral grade V lower pole reflux and a renal scan showed functioning lower pole systems. Results One patient underwent bilateral ureteroneocystostomy and another underwent upper pole nephrectomy. There has been reduction in the size of the segmental multicystic kidney in 2 patients and decrease in reflux grade in 2 (followup 2 to 5 years). Conclusions Newborns with an apparent multicystic kidney should undergo a voiding cystourethrogram and renal scan to confirm the diagnosis. Segmental multicystic kidney can be followed nonoperatively in most cases because the cysts tend to involute.

Ureterocele eversion with vesicoureteral reflux in duplex kidneys: findings at voiding cystourethrography.

Ureterocele eversion refers to the sudden appearance of a bladder diverticulum at the site of ureterocele compression during voiding cystourethrography (VCUG). The radiologic appearance closely resembles a congenital bladder (paraureteral) diverticulum. Distinguishing ureterocele eversion with vesicoureteral reflux in duplex kidneys from congenital bladder diverticula with reflux is important for preoperative planning. This study describes the findings of ureterocele eversion and lower pole vesicoureteral reflux in duplex kidneys on VCUG and demonstrates how its appearance can be misleading. Medical records, sonograms, and cystograms were reviewed retrospectively for 12 children who had VCUGs demonstrating bladder diverticula with vesicoureteral reflux and who, at surgery, had ureteroceles associated with duplex systems. Each case was assessed as to whether the finding of a diverticulum with reflux on VCUG had been correctly interpreted as ureterocele eversion with lower pole vesicoureteral reflux. Diagnosis of ureterocele eversion with lower pole reflux was uncertain or misinterpreted as congenital bladder diverticula with reflux in five patients in whom ureteroceles were not identifiable or in whom reflux occurred into what resembled single systems rather than lower poles of duplex systems. In two patients in whom ureteroceles were not initially identified, fluoroscopy recognized ureterocele eversion with lower pole reflux. Sonography confirmed ureterocele in one of these patients, and cystoscopy in the other. Ureterocele eversion with lower pole vesicoureteral reflux is readily diagnosed by VCUG when a ureterocele is initially identified or if the fluoroscopic appearance is typical. Ureterocele eversion with lower pole reflux can be mistaken for a congenital paraureteral diverticulum with reflux into a single collecting system if the ureterocele is small or not initially detected or if the refluxed system is not recognized as a lower pole moiety.

Importance of prenatal detection of hydronephrosis of the upper pole.

To determine the impact of prenatal detection on neonates with hydronephrosis of the upper pole of a duplex collecting system, we reviewed 40 such cases seen between June 1982 and April 1989. This six-per-year rate contrasts with fewer than one case per year that was seen at our hospital from 1947 to 1977. Nineteen patients had an ectopic ureterocele, and 21 had an ectopic ureter without a ureterocele. Thirty-three (83%) were girls. Thirty-three cases were discovered because of abnormal findings on a prenatal sonogram, and 20 of those infants were asymptomatic. In the 33 patients whose prenatal sonographic findings were abnormal, the sonogram was diagnostically precise for hydronephrosis of the upper pole of a duplex collecting system in only 39%. This imprecision did not adversely affect management or outcome. Postnatal sonography modified the prenatal diagnosis in 75% of these 33 patients. Voiding cystourethrography was the most sensitive and precise imaging technique for detecting both ureterocele and reflux. Lower pole reflux was almost twice as common when an ectopic ureterocele was present (63%) than when one was not (33%). Prenatal sonographic detection of hydronephrosis of the upper pole of a duplex collecting system decreased the proportion of neonates presenting with urinary tract infection and urosepsis because of prophylactic antibiotics initiated at birth and continued until surgical correction. Precise prenatal diagnosis was not needed for effective surgical treatment.