Non-refluxing Megaureter Research Articles

Clinical case of complete duplication of the right kidney in combination with non-refluxing megaureter of the upper and hydronephrosis of the lower segments

Clinical case of complete duplication of the right kidney in combination with non-refluxing megaureter of the upper and hydronephrosis of the lower segments

Antenatally detected urinary tract dilatation: a pediatric nephrologist's point of view

Antenatally diagnosed urinary tract dilatation (UTD), previously referred to as antenatal hydronephrosis, is the most commonly detected abnormality by prenatal ultrasonography. Several grading systems have been developed for the classification of antenatal UTD using prenatal and postnatal ultrasonography. UTD comprises a wide variety of congenital abnormalities of the kidney and urinary tract ranging from transient UTD to more significant abnormalities such as vesicoureteral reflux, ureteropelvic junction obstruction, ureterocele, ureterovesical junction obstruction, posterior urethral valves, and non-refluxing megaureter. Optimizing the evaluation of antenatally detected UTD is essential to recognize children with important disorders while avoiding excessive investigations. Conservative approach with close follow-up is increasingly accepted as an appropriate treatment option for patients with asymptomatic vesicoureteral reflux and ureteropelvic junction obstruction in recent years. However, predicting permanent kidney damage in an unselected group of children with antenatal UTD is still challenging. The management and follow-up of children with UTD should be individualized based on recommendations from a pediatric nephrologist, a pediatric urologist, or both. Future research directed at predicting long-term outcomes of children diagnosed with UTD from mild findings to severe disease is needed to refine management for those at higher risk of kidney disease progression.

Cytokine Profile and Enzymes of Tubular Nephrothelium in the Urine of Children with Congenital Megaureter

The objective: to determine the concentration of transforming growth factor β1 (TGF-β1), interleukin 1β (IL-1β) and tumor necrosis factor-α (TNF-α), activity levels of tubular nephrothelium enzymes total N-acetyl-β-D-glucosaminidase (NAG), its thermostable NAG isoenzyme B (NAG-B), β-galactosidase (β-Gal), γ-glutamyl transpeptidase (GGT) and neutral α-glucosidase (Nα-Gl) as cytokine-enzymological risk criteria for the development of nephrofibrosis in the urine of children with congenital nonrefluxing megaureter (NRMU) and refluxing megaureter (RMU) with unilateral and bilateral localization of the pathological process. Materials and methods. 174 patients with congenital MU were examined, who were divided into two groups. Group 1 included 131 children with NRMU, group 2 – 43 children with RMU aged from 6 months to 15 years. The control group included 25 practically healthy children. There were 97 patients with unilateral NRMU (group 1a), with bilateral – 34 persons (group 1b); there were 16 patients with unilateral RMU (group 2a), with bilateral – 27 (group 2b). Cytokine and enzyme indicators were studied in the morning portion of urine before reconstructive treatment. The levels of cytokines were determined by the ELISA method. Enzyme activity of urine was determined by the colorimetric method. Statistical processing of data was performed after analyzing the conformity of their distribution to the norm parameters. Results. It was found that the levels of TGF-β1, IL-1β and TNF-α, as well as the activity levels of NAG, NAG-B, β-Gal, GGT and Nα-Gl in the urine of patients with both congenital NRMU and congenital RMU are significantly increased compared to similar indicators in the control group (p<0.001). In patients with congenital RMU, compared to similar average indicators of patients with congenital NRMU, there is a significant increase of all cytokine and enzyme parameters (р<0.05–0.001), which indicates the probability of ischemic-hypoxic, as well as fibrotic damages in the kidney parenchyma in children with MU, especially in patients with RMU. A significant increase in the cytokine levels and enzyme activity levels were established in patients with NRMU and RMU with a unilateral process compared to similar control data (p<0.001. A statistically significant increase of TNF-α, the activity of NAG-B and β-Gal in patients with bilateral NRMU, the concentration of IL-1β, TNF-α and activity levels of NAG, NAG-B, β-Gal, GGT and Nα-Gl in patients with bilateral RMU compared with similar data in groups of patients with unilateral process was found (p<0.05–0.001). Conclusions. Congenital MU (NRMU, RMU) negatively affects the function of the tubular nephrothelium, which is manifested by an increased level of profibrogenic cytokine TGF-β1 and pro-inflammatory cytokines IL-1β and TNF-α in the urine of children, as well as the activity levels of lysosomal enzymes NAG, NAG-B, β-Gal and brush border enzymes GGT and Nα-Gl, which have renal specific properties. This indicates a high probability of ischemic processes in the kidney parenchyma and the risk of nephrofibrosis development in these patients, especially in patients with RMU with bilateral localization of the pathological process.

Transvesicoscopic ureteral reimplantation and ureteroscopy for management of primary obstructed non-refluxing megaureter with ureteral calculus.

IntroductionPrimary obstructed non‐refluxing megaureter, a type of congenitally dilated ureter, often resolves spontaneously. Surgery may be indicated in symptomatic cases; however, there are no reports of transvesicoscopic ureteral implantation and ureteroscopy for ureteral stones. Therefore, we describe the treatment of primary obstructed non‐refluxing megaureter and ureteral calculi using this technique.Case presentationA 6‐year‐old Japanese girl was referred for abdominal pain and gross hematuria due to right megaureter with multiple stones in the renal lower‐pole calyces and ureter. She was diagnosed with primary obstructed non‐refluxing megaureter and ureterovesical junction obstruction. The stones were removed using mini‐percutaneous nephrolithotomy and transvesicoureteroscopic surgery, respectively. A narrow segment of the right ureter was cut, and transvesicoscopic ureteral plication and reimplantation were performed. The procedures were successful without postoperative complications.ConclusionTransvesicoscopic ureteral reimplantation with ureteroscopy may be a safe, effective and minimally invasive surgical option for ureterovesical junction obstruction with ureteral stones.

Does Early Upper Tract Diversion and Delayed Undiversion in Megaureters Secondary to Severe Posterior Urethral Valves Lead to Better Renal Outcomes?

Background:There are conflicting reports for the management of severe posterior urethral valve (PUV) after ablation. The primary objective was to assess the renal outcomes using the estimated glomerular filtration rate (eGFR) and secondary outcomes in severe PUVs who underwent early partially diverting reduction ureterostomy (PDRU) and a delayed undiversion protocol.Materials and Methods:This 10-year retrospective study reviewed the records of 1094 boys with PUV, where severe PUV cases were treated with early PDRU (324 surgeries). We then analyzed those patients who completed the early diversion and delayed undiversion protocol. The long-term renal outcomes using eGFR and antero-posterior diameter (APD) were compared at various time points using appropriate statistical methods.Results:Of the 171 severe PUV patients who underwent PDRU, 31 completed undiversion and 26 (47 renal units) were analyzed after exclusions. The mean age (standard deviation) at presentation was 1.46 ± 4.1 months. Thirty-two units were refluxing and 15 were nonrefluxing megaureters. PDRU was closed at a mean age of 3.9 years and had a mean duration of follow-up of 6.4 years. The mean eGFR increased from a minimum of 10.78 ± 10.25 at baseline and remained stable at 28.69 ± 18.89 after closure of both stoma. Similarly, mean APD decreased from 12.07 ± 6.79 at the diagnosis to 7.00 ± 6.20. Three patients (3 renal units) required revision of the stoma for stenosis and 1 patient had a parastomal hernia that was repaired at the time of undiversion.Conclusions:In severe PUVs, early PDRU with delayed undiversion is a reliable surgical option that may ensure better renal outcomes in the long-term. Nonrefluxing renal units recover better than the refluxing. APD measurements also are shown to improve favorably.

Febrile Urinary Tract Infections in Children with Primary Non-Refluxing Megaureter: A Systematic Review and Meta-Analysis.

Knowledge of the baseline risk of febrile urinary tract infections in patients with primary non-refluxing megaureter can help clinicians to make informed decisions for offering continuous antibiotic prophylaxis. The primary objective of this systematic review was to determine the pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter selected for primary non-surgical management independent of associated attributed risk factors at initial presentation in order to assess the value of continuous antibiotic prophylaxis. MEDLINE, EMBASE, and Cochrane Controlled Trials Register electronic databases were searched for eligible studies without language and time restriction. The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PROSPERO registration number CRD42018104752). Of 25 871 records, 16 studies (n=749 patients) were eligible for inclusion. The overall pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter was 14.35% (95% confidence interval: 8.8-22.6). The calculated number needed to treat for patients on continuous antibiotic prophylaxis to prevent one single febrile urinary tract infection over the course of 1-2 years would be 4.3. Based on the current available evidence the use of continuous antibiotic prophylaxis for children with PM selected for primary non-surgical treatment should be taken into consideration, at least in patients with urinary outflow impairment, higher grade of ureteral dilatation, and for children in the first months of life.

CYTOKINE-ENZYMATIC BIOMARKERS FOR RESTORATION OF THE FUNCTIONAL STATE OF RENAL PARENCHYMA IN CHILDREN AFTER RECONSTRACTIVE CORRECTION OF CONGENITAL DEFECTS OF THE URETERO-VESICAL SEGMENT

The aim of this study was to study the peculiarities of changes in cytokine excretion levels of transforming growth factor b1 (TGF-b1), tumor necrosis factor a (TNF-a), monocytic chemoattractant protein 1 (MCP-1) and urinary activity of conditionally renospecific enzymes g-glutamyltranspeptidase (GGT) and neutral a-gtlucosidase (NG) as biomarkers of restoration of the functional state of the kidney parenchyma in children at different times after reconstructive correction of congenital defects of the uretero-vesical segment (UVS). 
 Materials and Methods. Prior to reconstructive correction of congenital defects of UVS the comprehensive clinical and laboratory study was conducted in 45 children aged 4 to 15 years (22 boys, 23 girls) who were diagnosed with megaureter (MU) according to visualization methods: 18 patients with non-refluxing MU (NRMU) and 27 patients with refluxing MU (RMU). 3-4 patients were examined 3-4 weeks after the operation and 24 patients 4-6 months later. The study did not include children with neurogenic bladder dysfunction and pyelonephritis. All patients underwent transvesical ureterocystoneostomy. The reference group consisted of 25 healthy children with normal urinalysis and without an uronephrological pathology. Determination of TNF-a, TGF-b1 and MCP-1 was carried out in urine by the enzyme immunoassay. The results were expressed in units of mass of the substance in terms of unit volume of urine (pg/ml). The activity of GGT and NG was determined by a colorimetric method in our modification using reagent kits. The activity of enzymes in urine was expressed in relative units – in micromoles of reaction products formed after 1 hour of incubation 1 mmol of urine creatinine (µmol/hour/mmol creatinine). We also took into account the fluctuation limits of all investigated indicators. 
 Results. The comparative analysis of TGF-b1, TNF-a, GGT and NG in children with congenital UVS defects before reconstructive operations and the control group demonstrated the statistically reliable difference (p < 0.001). It was stated that in urine of the control group the levels of pro-inflammatory cytokine MCP-1 are not defined at all. The study of this cytokine as a diagnostic and prognostic index of the functional state of renal parenchyma, according to our results, is not advisable. It was also stated that in patients with RMU (baseline) there is an increase in both TGF-b1 and TNF-a levels and the levels of GGT and NG activity compared with the group of patients with congenital NRMU. 3-4 weeks after reconstructive surgery, the levels of TNF-a and the levels of activity GGT and NG urine did not decrease, levels of TGF-b1, on the contrary, even increased. A personalized analysis of the results 4 to 6 months after the transvesical reconstruction revealed that 33.3% of patients showed normalization of TGF-b1 levels (p < 0.001) and a significant decrease in TNF-a, the levels of GGT and urinary NG activity practically reach the range of control. In other cases, despite the recovery of upper urinary tract dynamics, the levels of TNF-a, TGF-b1 and the activity of GGT and NG continued to remain at a fairly high level. 
 Conclusions. The levels of TNF-a and TGF-b1 as well as the levels of activity of conditionally renospecific enzymes GGT and NG of urine in children with congenital malformations of UVS are diagnostically informative biomarkers about progression of pathological process in the kidney and negative influence of pronounced dysfunction of urinary bladder on the pro-inflammatory and pro-fibrotic processes of renal parenchyma in the postoperative period. Taking into account that in 66.7% of cases in children with congenital UVS defects after ureterocystoneostomy disorders in the function of the tubular apparatus of the renal parenchyma and signs of tubulointerstitial fibrosis persist, it is advisable to distinguish these patients into a separate group to avoid the risk for the development of nephrosclerotic disease and to start modern renoprotective therapy timely.

Urine Enzyme and Cytokine Levels in the Diagnosis of the Functional State of the Renal Parenchyma in Children with Pathology of the Ureterovesicular Segment After Ureterocystoneostomy

The objective: to study the dynamics of the levels of excretion of cytokines TNF-α and TGF-β11 and the activity of renospecific enzymes NAG and β-Gal in the urine of children with refluxing megaureter (MU) at different times after transfusion ureterocystoneostomy.Materials and methods. Before surgical treatment, 45 children aged 4 to 15 years (22 boys, 23 girls) were examined who were diagnosed with MU according to imaging assessment methods: 18 patients with non-refluxing MU, 27 patients with refluxing MU before and after reconstructive operations. Three to four weeks after the operation, 36 patients were examined, after 4–6 months, 24 patients. The reference group consisted of data obtained from 25 practically healthy children of similar age with normal urine tests (without protein, leukocyte, erythrocyte and crystalluria, mucus and bacteria).Results. The findings suggest that after reconstructive operations of the urinary tract in some patients there are signs of impaired renal function, followed by its deterioration. At the same time, it is known that a decrease in pressure in the ureter after urodynamic restoration with time leads to a certain normalization of some biomarkers of inflammation and proliferation in children with congenital malformations of the uretero-vesicular segment (UVS).Conclusion. Based on the obtained results, it can be argued that quantitative indicators of the content of proinflammatory cytokines TNF-α and profibrogenic cytokine TGF-β1 in the urine, as well as the activity levels of conditionally renospecific enzymes of NAG and β-galactosidase (β-Gal) urine in children with congenital malformations of UVS non-invasive and diagnostically informative biomarkers. We believe that it is advisable to allocate children with congenital malformations to a separate risk group for the development of nephrosclerosis, which requires timely renoprotective therapy.

The association of postnatal urinary tract dilation risk score with clinical outcomes

There are limited data on the predictive value of the consensus urinary tract dilation (UTD) score with respect to subsequent clinical diagnoses. We sought to define the relationship between postnatal UTD risk score and clinical outcomes during childhood. Complete ultrasound image sets from a random selection of infants aged 0-90 days undergoing initial ultrasound at a single institution for prenatal hydronephrosis between 2012 and 2014 were assigned a UTD score by 1 pediatric urologist and 1 pediatric radiologist. Urinary tract dilation risk score was analyzed for association with a composite outcome comprising urinary tract infection, vesicoureteral reflux (VUR), ureteropelvic junction obstruction, non-refluxing megaureter (NRM), ureterocele, bladder outlet obstruction (BOO), and chronic kidney disease. Surgical intervention and resolution of UTD were evaluated separately. Descriptive and survival analyses were performed. Urinary tract dilation scores for 494 subjects were P0 in 23.5%, P1 in 26.5%, P2 in 23.5%, and P3 in 26.5%. Seventy-four percent were male. Median age at initial imaging was 28 days; median follow-up was 19.8 months. The composite outcome occurred in 138 of 494 patients (27.9%) and varied significantly (p<0.001) by UTD score: 11.2% for P0, 10.7% for P1, 29.3% for P2, and 58.8% for P3. On survival analysis (Summary Figure), higher UTD grade was significantly associated with the composite outcome (hazard ratio for P3 vs. P0 was 7.4 [95% CI: 3.44-15.92, p<0.001]). Urinary tract infection and VUR diagnosis varied by UTD score (p=0.03 and p<0.001, respectively). Ureteropelvic junction obstruction was diagnosed (based on MAG3 results) in 6.3% of patients, 84% of whom were P3. Non-refluxing megaureter was diagnosed in 7.7%. Ureterocele and BOO were uncommon (1.4%, and 0.6%, respectively). Surgical intervention was also associated with UTD risk, with 46% of P3 undergoing surgery vs. 1% of P0, 1% of P1, and 6% of P2 (p<0.001). Resolution of UTD occurred in 41% (median 10.1 months) and varied significantly by UTD risk (p<0.001). Urinary tract dilation risk score is associated with clinical events, although ascertainment bias may influence some of the differences in outcomes, particularly for VUR, because VCUG utilization varied by the UTD group. The lack of any significant difference in outcomes between patients with UTD P0 versus P1 suggests that the P1 category could be eliminated as it does not meaningfully distinguish between outcome risk. Higher UTD risk scores are strongly associated with genitourinary diagnoses during the first two years of life.

Primary Non-refluxing Megaureter: Analysis of Risk Factors for Spontaneous Resolution and Surgical Intervention.

Background: The risk of febrile urinary tract infection (fUTI) in children with primary non-refluxing megaureter (PM) has been extensively studied in the literature, however, a paucity of information exists regarding risk factors for surgical intervention and spontaneous resolution. We sought to analyze data from our prospectively collected PM cohort to determine risk factors that would predict surgery and resolution in this population.Methods: Patients with PM were identified from our prospectively-collected prenatal hydronephrosis (HN) database from 2008 to 2017. Primary outcomes included surgical intervention and hydroureter resolution. Spontaneous resolution was defined as ureteral dilation <7 mm at last follow-up. Age at presentation, gender, development of fUTI, HN grade [low (SFU I/II) vs. high (SFU III/IV)], anteroposterior diameter (APD) measurements and ureteral diameter at baseline and last follow-up were recorded. Univariate and multivariable analyses (binary logistic and Cox regression) were performed.Results: Of 101 patients, 86 (85%) were male, and 80 (79%) had high grade HN. Median age at baseline and last follow-up were 2 (0–23) and 29 (2–107) months, respectively. Overall, 23 (23%) patients underwent surgery at a median age of 22 (3–35) months. Mean ureteral diameter was larger in surgical patients vs. those treated non-surgically (14 ± 4 vs.11 ± 3 mm; p < 0.01). Of the 78 (77%) non-surgical patients, 43(55%) showed resolution of their ureteral dilation at a median age of 24(4–56) months. Survival analysis demonstrated that 12 patients resolved by year 1, 22 by year 2, 30 by year 3, 40 by year 4, and 43 by year 5. However, when considering resolution as APD <10 mm, 62(79%) children resolved their HN by last follow-up (29 months). Univariate and multivariable analyses (Table 1) revealed that high-grade HN at baseline, development of fUTI, and ureteric dilation ≥14 mm were significant risk factors for surgical intervention. Cox regression (Figure 2) found that ureteral dilation <11 mm was the only independent risk factor significantly associated with PM resolution (Table 2).Conclusion: Patients with PM and high-grade HN, as well as individuals with ureteral dilation ≥14 mm and fUTI were more likely to undergo surgical intervention. Ureteral dilation <11 mm was the only independent risk factor significantly associated with spontaneous resolution of PM.

Side-to-Side Refluxing Nondismembered Ureterocystotomy: A Novel Strategy to Address Obstructed Megaureters in Children.

A nonrefluxing megaureter is a relatively common cause of antenatal hydronephrosis. Although nonoperative management is favored, surgical intervention is sometimes warranted. However, there is controversy regarding the best approach, particularly in young children. We describe our experience with nondismembered side-to-side refluxing ureterocystotomy as a simple option to address obstruction. Between January 2012 and January 2017, 32 patients underwent ureterocystotomy at 4 referral centers in North America. Demographics, surgical indications, complications, need for further interventions and change in hydronephrosis were captured. Patients were monitored clinically and with serial ultrasounds. Mean age at surgery was 3.7 months (range 0 to 33) and 25 (78%) patients were male. Unilateral procedures were performed in 29 patients. All patients were initially identified based on the presence of antenatal hydronephrosis and symptoms developed in 10. The procedure was conducted for primary nonrefluxing megaureter in 27 patients and to address secondary obstruction in the remainder. Mean followup was 34.3 months (range 6 to 58). At the most recent evaluation most children demonstrated significant improvement in dilation (86%). To date, 6 patients have undergone further procedures, including a circumcision and 2 ureteral reimplantations for recurrent infections. Our results suggest that side-to-side refluxing ureterocystotomy is a straightforward, minimally invasive alternative for the surgical management of nonrefluxing megaureter. Despite the trade-off of relieving obstruction and creating reflux, it can be considered a potentially definitive procedure in patients who remain infection-free, particularly circumcised boys. Extended followup with close monitoring is critical to document long-term results with this intervention.

Prenatal complicated duplex collecting system and ureterocele-Important risk factors for urinary tract infection.

To evaluate the risk of urinary tract infections (UTIs) in infants with prenatally detected complicated duplex collecting system (CDS) or ureterocele. All patients with prenatally detected CDS (n=34) or single system ureterocele (n=7) who were admitted to our institution between 2003 and 2013 were enrolled in this retrospective analysis. Duplex collecting systems with ureterocele (n=13), vesicoureteral reflux (VUR) (n=20) or nonrefluxing megaureter without ureterocele (n=7) were determined as complicated. Twenty-six (63%) patients were females. The prevalence of UTI was compared to 66 controls. The median follow-up time was 5.5 (1.7-12.2) years. Eighteen (44%) patients and 3 (5%) controls had at least one UTI (p<0.001) at the median age of 0.8 and 0.4years, respectively (p=0.481). Fifty-seven percent of the UTIs were breakthrough infections and 82% of those were non-Escherichia coli infections. UTIs occurred prior to any surgical intervention in 4/13 (31%) patients with ureterocele, in 2/14 (14%) patients with VUR, in 4/7 (57%) patients with both ureterocele and VUR, and in 3/7 (43%) patients with nonrefluxing megaureter without VUR or ureterocele (p-values 0.012, 0.209, 0.001 and 0.010, respectively, compared to controls). Postoperative UTIs were observed in 29% of the girls and in none of the 11 boys (p=0.072). The incidence of UTI after perforation of ureterocele was only 14%. Children with prenatally detected ureterocele or duplex collecting system associated with nonrefluxing megaureter are at high risk of UTI despite prophylactic antibiotics. In case of prenatally detected ureterocele we suggest to consider early endoscopic perforation. III.

Bilateral primary Non-Obstructive and Non-Refluxing Megaureter in Child: Diagnosis by Non-Radiation Imaging Modalities

Bilateral primary Non-Obstructive and Non-Refluxing Megaureter in Child: Diagnosis by Non-Radiation Imaging Modalities

Primary non-refluxive megaureter in children: single-center experience and follow-up of 212 patients.

Primary non-refluxing megaureter (pMU) is a multifaceted and challenging congenital pathology of the urinary tract. We report our 23-year experience with this anomaly in terms of presentation, diagnostic work-up and management. We retrospectively reviewed the medical records of 212 children diagnosed with pMU between 1986 and 2009 at our institution. Mean follow-up was 45.17 (0-192) months. Of the total, 168 (79%) children presented with upper urinary tract dilation on perinatal ultrasound screening. In 44 (21%) patients, the diagnosis was made following diagnostic work-up of a urinary tract infection (UTI, 18%) or flank pain (3%). In total, 203 of 254 pMUs (79.9%) were successfully treated conservatively during the 23-year observation period. Forty-eight children (23%) underwent ureteric reimplantation. UTIs occurred in 91 of 212 children (43%). Of these, 41 (45%) occurred despite antibacterial infection prophylaxis. Within the past three decades, there has been a marked shift from surgical toward conservative therapy at our institution. Neonatal renal ultrasound is the method of choice to timely identify children with pMU and, alongside dynamic renography, to monitor the clinical course. Nowadays, only a minor subset of children with asymptomatic course requires surgical correction. Antibacterial prophylaxis has the potential to reduce the risk of febrile UTIs. Prospective randomized studies are warranted to provide evidence of the beneficial effect of antibacterial prophylaxis.

Isolated low initial differential renal function in patients with primary non-refluxing megaureter should not be considered an indication for early surgery: A multicentric study

Low initial differential renal function (DRF) in patients with primary non-refluxing megaureter (PNRM) is considered an indication for surgery as are an increase of dilatation and symptoms. We hypothesized that low DRF is not necessarily a result of obstruction, but may be due to impaired development of the upper urinary tract. Thus, in the absence of symptoms, there is a low risk for further loss of renal function. This study aimed to assess whether initially low DRF is a reliable indicator of obstruction. We reviewed data from four university centers between 1995 and 2010. Patients under 12 months of age with unilateral primary non-refluxing megaureter (PNMR) and a DRF between 10% and 40%, and followed minimally 24 months, were included. Patients were placed in two groups based on management: group A, surgical; group B, conservative. The dynamics of DRF in relation to age and type of treatment was studied. In each patient we recorded the earliest (initial) DRF, the last known (final) DRF, the age when MAG-3 scans were performed and the type of treatment. From 25 patients, 16 were treated surgically (group A) and 9 followed conservatively (group B). The initial mean DRF in group A was 33.1% and in group B 34.5%, at a mean age 3.0 and 3.6 months, respectively. The final mean DRF in group A was 40.1% and in group B 43%, at a mean age 59.9 and 46.3 months, respectively. Using two-way repeated ANOVA (age [initial DRF, final DRF] vs. group [group A, group B]), we found non-significant difference between the groups in the DRF, F (1, 21)=0.96, p=0.338, while we observed statistically significant and similar increase from the initial to final DRF in both groups, F (1, 21)=16.66, p=0.001 (Figure). This is the first study focusing on the evolution of renal function in patients with PNRM and low initial DRF. Results suggest that the diagnosis of obstruction is inaccurate in most infants with unilateral PNRM if it is based on low initial DRF only. Renal deterioration rarely occurs in asymptomatic patients, and even profoundly impaired kidneys have potential for improvement. Limitations of our study include retrospective design and lack of standardization of treatment among the four centers. Low DRF in asymptomatic and anatomically stable patients with PNMR should not be considered an indication for early surgery. These findings challenge current practice and should be confirmed by a prospective study.

The Fate of Primary Nonrefluxing Megaureter: A Prospective Outcome Analysis of the Rate of Urinary Tract Infections, Surgical Indications and Time to Resolution

We examined data on a cohort of patients with primary nonrefluxing megaureter to determine risk factors for febrile urinary tract infection, indications for surgery and time to resolution. The records of patients younger than 24 months with primary nonrefluxing megaureter were prospectively captured from 2008 to 2015. Six a priori defined variables were studied, including gender, circumcision status, hydronephrosis SFU (Society for Fetal Urology) grade (low--1 and 2 vs high--3 and 4), continuous antibiotic prophylaxis use, ureteral dilatation (greater than 11 mm) and tortuosity. Univariate analyses and Cox hazard regression were done for febrile urinary tract infection risk factors. Resolution trends were analyzed using Kaplan-Meier curves. Mean ± SD age at the first clinic visit was 3.7 ± 4 months and mean followup was 26.3 ± 16.6 months. Of 80 patients with primary megaureter 66 (83%) had high grade hydronephrosis, 72 (90%) were male, 21 (26%) were circumcised and 40 (50%) had ureteral dilatation greater than 11 mm at baseline. Overall continuous antibiotic prophylaxis was prescribed to 34 patients (43%) and febrile urinary tract developed infection in 27 (34%) at a mean age of 5.8 months (median 3, range 1 to 24). Cox regression identified uncircumcised male gender (HR 3.4, 95% CI 1.1-10.7, p = 0.04) and lack of continuous antibiotic prophylaxis (HR 4.1, 95% CI 1.3-12.7, p = 0.01) as independent risk factors for febrile urinary tract infection. The 19 surgical patients (24%) had a larger mean ureteral diameter immediately preoperatively than those who did not require surgery (17 ± 5 vs 12 ± 4 mm, p <0.01). Kaplan-Meier curves showed that 85% of primary nonrefluxing megaureters that did not require surgery resolved in a median of 17 months. Febrile urinary tract infection developed in 34% of patients with primary nonrefluxing megaureter within the first 6 months of life. Circumcision and continuous antibiotic prophylaxis significantly decreased febrile urinary tract infection rates in those infants. Ureteral diameter 17 mm or greater was significantly associated with a higher rate of surgical intervention. Overall 76% of megaureters resolved during a median followup of 19 months.

Conservative management of primary non-refluxing megaureter during the first year of life: A longitudinal observational study

There is a lack of prospective studies that include a selected population of patients with primary non-refluxing megaureter (PM). Thus, a longitudinal observational study was designed to follow from birth a selected population of children with PM; all were antenatally diagnosed. In this paper, the outcomes observed in the first year of life are presented. The primary aim was to follow the natural history of PM. The secondary aim was to monitor the onset of any potential complications such as urinary tract infections (UTIs), need for hospitalization and need for surgical correction. All children with antenatally diagnosed PM, born between January 2007 and December 2013, were prospectively followed with observational management: renal ultrasonography and clinical evaluation on a 3-month basis; urinalysis and culture in case of symptoms; and mercaptoacetyltriglycine (MAG3) nuclear scan once older than 1 month. Children presenting at birth with mild urinary tract dilatation were included in Group A; those with moderate-to-severe dilatation were included in Group B. Continuous antibiotic prophylaxis (CAP) was administered to Group B. Forty-seven children (44 males, three females) with 58 PM were included in the study. The participants and their corresponding outcomes are shown in the summary Table. The presence of obstruction at renogram was a significant predictor of UTIs and hospitalization. The strengths of this study were its prospective nature and its very consistent population. A limitation was the lack of control groups. The results regarding the negligible incidence of complications in Group A and the residual incidence of febrile UTIs (20%) and hospitalization (17%) in Group B, even with CAP, are in line with previous literature. In contrast, there was a higher risk of UTIs observed in children aged older than 6 months. Resolution or improvement is expected in all cases of PM with mild postnatal dilatation, and close to 60% of those with moderate or severe dilatation. Surgery is rarely performed on children younger than 1 year of age. It is safe to observe children with mild urinary tract dilatation without CAP, because the incidence of UTIs is negligible. In those presenting with moderate or severe urinary tract dilatation, despite CAP, a residual incidence of UTIs is seen, and symptomatic patients often require hospitalization. However, UTIs are well tolerated and do not seem to modify outcome. Cases showing obstruction on the MAG3 scan seemto be at higher risk of UTIs and hospitalization.

This Month in Pediatric Urology

No AccessJournal of UrologyThis Month in Pediatric Urology1 Sep 2013This Month in Pediatric Urology Laurence S. Baskin Laurence S. BaskinLaurence S. Baskin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.06.005AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Pediatric Urology." The Journal of Urology, 190(3), pp. 827–828 References 1 : Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction. J Urol2013; 190: 1028. Link, Google Scholar 2 : Long-term followup of primary nonrefluxing megaureter. J Urol2013; 190: 1021. Link, Google Scholar 3 : Long-term outcomes for males with disorders of sex development. J Urol2013; 190: 1038. Link, Google Scholar 4 : Uroflowmetry nomograms for healthy children 5 to 15 years old. J Urol2013; 190: 1008. Link, Google Scholar 5 : Prospective study using a new bulking agent for the treatment of vesicoureteral reflux: polyacrylamide hydrogel. J Urol2013; 190: 1034. Link, Google Scholar 6 : Dysfunctional elimination syndromes—how closely linked are constipation and encopresis with specific lower urinary tract conditions?. J Urol2013; 190: 1015. Link, Google Scholar © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 190Issue 3September 2013Page: 827-828 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laurence S. Baskin More articles by this author Expand All Advertisement PDF DownloadLoading ...

Long-Term Followup of Primary Nonrefluxing Megaureter

We evaluated outcomes of nonoperative management of primary nonrefluxing megaureter at long-term followup to identify clinical predictors of spontaneous resolution. A total of 75 patients (88 primary megaureters) were diagnosed between 1990 and 2005 and followed for more than 6 months. Of the patients 63 (74 primary megaureters) were included in the main study population. Indications for surgery were obstructive hydroureteronephrosis, functional impairment and persistent symptoms. Of the 74 primary megaureters 20 (27%) required surgery up to 7 years after diagnosis. Surgery was not indicated in 82% of primary megaureters with grade I or II hydronephrosis vs 62.9% of those with grade III or higher hydronephrosis (difference not significant), nor in 76.5% of types I and II primary megaureters vs 33.3% of type III primary megaureters (p = 0.040), 78.7% of renal units with differential function 40% or greater vs 0% with differential function less than 40% (p = 0.027), 80% of primary megaureters with a nonobstructive washout pattern vs 44.4% with an intermediate/obstructive pattern (p = 0.032), 67.9% of patients with perinatal presentation vs 25% with postneonatal presentation (p = 0.008) or 63.2% of patients presenting with symptoms vs 76.4% of those who were asymptomatic (difference not significant). On multivariate analysis age at presentation and washout pattern were significant predictors of spontaneous resolution. Most cases of primary megaureter resolve spontaneously or improve without loss of function or development of symptoms. Careful observation allows surgery to be delayed beyond the neonatal period in most patients. Long-term followup is recommended because symptoms can develop years later. Washout pattern and age at presentation are statistically significant predictors of spontaneous resolution.

Resolution of primary non-refluxing megaureter: An observational study

AimA prospective review of conservative management of primary non-refluxing megaureters (PM) was performed to determine the time taken for resolution (TTR) and complications. Material and MethodsPatient details were obtained from a prospectively maintained database from January 1, 2003, to December 31, 2011. The clinical features of USS and MAG3 findings were analyzed. All had annual USS and MAG 3 scans two yearly (and whenever necessary). ResultsFifty ureteric units (UU) in forty-four patients (six bilateral) were studied. There were thirty-three (75%) males. In the unilateral PM, 22/38 were left-sided. Children were classified according to the lower ureteric diameter (UD) into two groups: Group A (Gp A) UD <10mm (n=25, 26 UU), and Group B (Gp B) UD ≥10mm (n=19, 24 UU). Antenatal diagnosis was achieved in 21 (84%) UU in Gp A and 11 UU (58%) in Gp B.In Grp A, the median presenting UD was 6 (range 4–9)mm, and 76% resolved completely over a median duration of 60 (18–204)months. In Grp B, the median UD was 15 (10–27)mm, and 17% resolved completely over a median duration of 102 (42–210)months. Two developed ureteric calculi (removed ureteroscopically). Three with complications (obstructive drainage pattern in MAG 3 with decreasing function and debilitating infections) underwent ureteric tapering and reimplantation. An obstructed megaureter resolved after endoscopic dilatation. Another underwent temporary ureterostomy on developing hypertension. ConclusionThe exclusively conservative management of PM seems highly successful within Group A (i.e. UD <10mm). Complications (stones, decreasing renal function) were more common with higher UD. TTR seems to take over five years in both groups.