Nonfunctioning Renal Unit Research Articles

Native Ureter Ventriculo-Ureteral Shunt Placement for Management of Refractory Hydrocephalus in a Child With a History of Renal Transplant: Case Report and Technical Note

This report describes the case of a 5-year-old male with intractable hydrocephalus secondary to neonatal intraventricular hemorrhage who was ultimately managed with the placement of a ventriculo-ureteral (VU) shunt. He had previously failed numerous attempts at cerebrospinal fluid shunting, choroid plexus cauterization, and endoscopic third ventriculostomy. The patient had a history of end stage renal disease, and had previously undergone renal transplant. In an operation that involved Neurosurgeons, Pediatric Urologists, and Transplant surgeons, a Gibson incision was used to avoid the patient's multiple intra-abdominal adhesions, and his nonfunctioning renal unit was used to implant a VU shunt without early or late complications.

Ectopic Ureter: Surgical Management

The ectopic ureter is an uncommon presentation in the pediatric population, seen in approximately one in 2,000 live births with a female prevalence. However, observation and conservative management have a short-lived role as many of these children are incontinent or symptomatic from an obstructed system. Urgent decompression of an infected system may be required as a temporizing measure before definitive surgical management can be pursued. In this review, we discuss the surgical options available for the ectopic ureter. This includes heminephrectomy of the nonfunctioning renal unit and reconstructive measures such as ureteral reimplantation, ureteroureterostomy, and ureteropyelostomy. We also discuss the management of the remnant ureteral stump and concomitant vesicoureteral reflux. This review contains 1 figure and 35 references. Key words: cutaneous ureterostomy, ectopic ureter, renal duplication anomalies, heminephrectomy, ureteral reimplantation, ureteropyelostomy, ureteroureterostomy

PD40-05 EVALUATION OF LAPAROSCOPIC PYELOPLASTY AS AN ALTERNATIVE TO NEPHRECTOMY IN ADULTS WITH POORLY FUNCTIONING KIDNEYS DUE TO URETEROPELVIC OBSTRUCTION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion III1 Apr 2016PD40-05 EVALUATION OF LAPAROSCOPIC PYELOPLASTY AS AN ALTERNATIVE TO NEPHRECTOMY IN ADULTS WITH POORLY FUNCTIONING KIDNEYS DUE TO URETEROPELVIC OBSTRUCTION Bruno Nascimento, Eduardo Miranda, Victor Srougi, Marco Arap, Hiury Andrade, Anuar Mitre, Rodolfo Bandeira, Miguel Srougi, and Ricardo Duarte Bruno NascimentoBruno Nascimento More articles by this author , Eduardo MirandaEduardo Miranda More articles by this author , Victor SrougiVictor Srougi More articles by this author , Marco ArapMarco Arap More articles by this author , Hiury AndradeHiury Andrade More articles by this author , Anuar MitreAnuar Mitre More articles by this author , Rodolfo BandeiraRodolfo Bandeira More articles by this author , Miguel SrougiMiguel Srougi More articles by this author , and Ricardo DuarteRicardo Duarte More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1537AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoscopic pyeloplasty has been considered the gold-standard treatment for adults with ureteropelvic junction obstruction (UPJO). Likewise, it is well established in adults that a symptomatic non-functioning renal unit should be removed. This study aimed to evaluate safety, kidney function recovery and symptoms improvement after laparoscopic pyeloplasty in adults with poorly functioning kidneys due to UPJO. METHODS Retrospective data analysis from August 2008 to November 2015, from a prospectively maintained database, was performed. Patients with poorly functioning kidney who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty were included. In one patient, the retroperitoneal approach was preferred due to multiple previous abdominal surgeries. Poor function was defined as a split renal function of ≤ 15% in renal scintigraphy with Tc-99m DMSA. Pre and postoperative data were compared regarding differential renal function (DRF) and symptoms. Success was defined as split renal function stabilization (absolute variation of less than 5% in renal scintigraphy) and symptoms improvement. Outcome (renal function stabilization, intra and pos-op complications and symptoms) was further compared to a similar group of patients who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty in normal functioning renal units. RESULTS We identified 167 patients who underwent laparoscopic pyeloplasty in our service. From those, 14 patients had poor renal function, with a mean age of 37 years (23 - 60 years). No major intra or post-operative complications were seen. At a mean follow up of 21.2 months (4-53 m) all patients reported symptoms improvement, no cases of recurrent pyelonephritis or stone formation was seen. Until this date, no patient needed further surgical treatment as re-pyeloplasty, endoscopic treatment or nephrectomy. Complete symptom resolution was seen in 10 patients (71%). One patient, despite showing complete symptom resolution, had decreased postoperative DRF in renal scintigraphy. Overall success rate was 92.8% (13/14). Split renal function remained stable in 11 patients (78,6%), considerably decreased in 1 (7.1%) and considerably increased in 2 (14.3%) patients. Renal function stabilization, intra and post-operative complications were statically similar (p>0.05) when compared to patients with normal functioning renal units who underwent the same procedure. No patient with normal functions renal units showed improvement in DRF measured with Tc-99m DMSA. CONCLUSIONS Laparoscopic pyeloplasty is an alternative to nephrectomy in adults with poorly functioning kidneys due to UPJO, enabling good symptom control with possible considerable improvement in renal function. In this study, laparoscopic pyeloplasty in this of patients showed similar outcomes and success rates to those presented by patients with normal functioning renal units. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e937 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Bruno Nascimento More articles by this author Eduardo Miranda More articles by this author Victor Srougi More articles by this author Marco Arap More articles by this author Hiury Andrade More articles by this author Anuar Mitre More articles by this author Rodolfo Bandeira More articles by this author Miguel Srougi More articles by this author Ricardo Duarte More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Retaining the refluxing lower ureteral stump of a non-functioning kidney to preserve contralateral renal function

It is crucial to preserve the renal parenchyma in a solitary renoureteric system, especially when associated with VUR and/or elevated bladder pressures. The present study examined the effect of retaining the refluxing lower ureteral stump of a non-functioning renal unit (during nephrectomy) as a stoma to preserve contralateral renal function. Twelve children with various uropathologies (six with PUV, three with primary VUR, and three with neurogenic bladder) and a solitary functioning kidney were retrospectively analysed. In each, besides the relevant investigations and specific management, nephrectomy was performed for a non-functioning kidney with recurrent UTI (10/12) or hypertension (2/12), and the ipsilateral distal ureteric stump was exteriorised as a refluxing stoma. Antimicrobial prophylaxis was given to those with VUR into the solitary kidney (9/12). All were on strict follow-up at a dedicated paediatric nephrourology clinic with serial clinical, biochemical and radiological surveillance. The mean age at presentation and surgery was 19.7 months (range 0.5-96) and 30.5 months (range 3-100), respectively. Recurrent UTI (10/12) and acute renal failure (8/12) were common presentations; 2/12 were hypertensive. The initial serum creatinine ranged from 0.3 to 7.2 (mean 2.3) mg/dl. Of the solitary functioning kidneys with VUR (9/12), seven had Grade 5 VUR and six had renal cortical scars. The stoma served as an intermittent vent (9/12), for CIC (4/12) or for both purposes (3/12). Although all were Grade 5 refluxing ureters, 3/12 stomas remained dry. At a mean follow-up of 30 months (12-48), 9/12 were well and 3/12 were in end-stage renal disease. None had a UTI after the procedure. VUR resolved in five ureters that sub-served the contralateral solitary kidney. Serial DMSA renal cortical scans showed no scarring in four children, non-progressive scars in three and new scars in two. At the last follow-up, four (one dry, three leaking) were being used for CIC, four (one dry, three leaking) had been closed and four (one dry, three leaking) were retained until resolution of contralateral reflux/non-progression of scarring (three) or for possible CIC in the future (one). Retaining the refluxing lower ureteral stump of a non-functioning kidney as a cutaneous stoma provided a vent and an alternative channel for CIC of the bladder (Figure). Subsequently, fewer UTI seemed to protect the contralateral solitary functioning kidney, particularly in those with associated VUR. In this preliminary study, the procedure was simple and the stoma was well accepted by patients and parents.

Hybrid Transvaginal Nephrectomy: Development of Our Technique

To evaluate the development of natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy and present the initial experience. Thirty-eight female patients were submitted to hybrid NOTES transvaginal nephrectomy for tumor (n=23) and nonfunctioning renal unit (n=15) in 2 academic medical centers. Patients underwent surgery from July 2010 to June 2012 and none of them were candidates for partial nephrectomy (clinical stage T1b or higher). The procedure was performed by the use of multi-instrument ports or flexible cannulas inserted through umbilical and vaginal incisions. A 30° lens extra-long camera and combinations of conventional laparoscopic and prebent instruments were used. Specially designed extra-long, prebent straight instruments were found to be particularly useful for transvaginal manipulations. Prospective data regarding patient demographics, intraoperative and postoperative course of the patients, and pathology results were collected. Average tumor diameter was 6 cm (range, 4.9-7.5 cm). Average operative time was 114.1 minutes (range, 90-190 minutes). Estimated blood loss ranged between 50 and 150 mL (average, 80 mL). Intraoperatively, 2 bladder perforations occurred and were treated by suturing. Postoperatively, 2 patients suffered from fever of unknown origin and 2 patients required transfusions due to bleeding. Average hospital stay was 3.3 days (range, 3-5 days). Positive surgical margins were not detected. Hybrid NOTES transvaginal nephrectomy is a feasible and safe alternative to standard laparoscopic nephrectomy in selected patients. Difficulties arising from limitations in current instrumentation have been addressed by the use of specially designed instruments. Further clinical studies are required to ascertain this approaches' place among nephrectomy techniques.

PRIMARY LOWER URINARY TRACT RECONSTRUCTION FOR NONFUNCTIONING RENAL MOIETIES ASSOCIATED WITH OBSTRUCTING URETEROCELES

Upper pole heminephrectomy is the conventional treatment for severely compromised nonfunctioning renal units associated with ureteroceles due to the potential morbidity of leaving a nonfunctioning renal moiety in place. This approach often fails to address the pathological anatomical defect present at the bladder level, and during long-term followup the majority of patients require subsequent lower tract surgery due to persistent ureterocele, new or persistent vesicoureteral reflux, or recurrent infections. We determined the success of primary lower urinary tract reconstruction for nonfunctioning renal moieties and the morbidity associated with leaving nonfunctioning renal units in situ. We present the collective experience of 2 institutions using definitive lower urinary tract reconstruction without upper tract ablative surgery in 16 patients with duplex collecting systems and an associated nonfunctioning renal moiety due to obstructing ureteroceles. At a mean followup of 62 months upper tract dilatation was decreased or completely resolved in all patients, no loss of renal function was present and 15 of 16 patients (94%) had no evidence of persistent reflux. Postoperative complications in the form of a urinary tract infection occurred in 2 of 16 patients (13%). No patient was febrile. No patient had development of hypertension, proteinuria or tumor during followup. We believe that primary, single stage, lower urinary tract reconstruction in children with severely compromised or nonfunctioning renal moieties damaged by ureteroceles is superior to upper urinary tract ablative surgery, successfully correcting the obstructive or refluxing pathology with minimal morbidity and risk during long-term followup.

Ureterocystoplasty with preservation of ipsilateral renal function

Recently the ureter has been used for bladder augmentation in selected patients with abnormal bladders and dilated upper tracts. The ureter has several advantages over other forms of bladder augmentation because it alleviates electrolyte disturbances, mucous production, and the disruption of the gastrointestinal tract. Initial reports emphasized the use of the entire ureter and renal pelvis in patients with an ipsilateral dilated nonfunctioning renal unit. Herein the authors report five cases of ureterocystoplasties performed since July 1993, in which the ipsilateral renal unit was preserved. All patients underwent preoperative videourodynamic studies, which showed small-for-age bladder capacity and poor compliance. Three patients underwent unilateral uretorocystoplasty, and two had bilateral ureterocystoplasty. Transureteroureterostomy (TUU) was performed in all patients, and most of the ipsilateral dilated ureter was used for augmentation. In two patients who had partial unilateral duplication, ipsilateral upper-to-lower ureteropy-elostomy was done in addition to the TUU to maximize the amount of ureter available for augmentation. The follow-up period ranges from 6 to 24 months. All patients are continent and free of vesicoureteral reflux. All show stabilization or improvement of their upper tracts. Pressure-specific bladder capacity (bladder capacity at 30 cm of water pressure) increased by 350% (from a mean 142 mL to 500 mL). The ureter is an excellent choice for augmentation cystoplasty in selected patients. An ipsilateral functioning renal unit is not a contraindication for ureterocystoplasty.

Bilateral ureteric obstruction from pelvic endometriosis

Endometriosis is an uncommon cause of ureteric obstruction. When it occurs, unilateral involvement predominates. We report a case characterized by the unusual presentation of acute hypertensive retinopathy and renal failure. The patient was treated surgically by ureterolysis with omental wrapping, total hysterectomy and salpingo-oophorectomy. Nephrectomy was not performed on the non-functioning renal unit as the obstruction had been relieved. Patients who have previously been treated with conservative surgery for pelvic endometriosis are at risk of recurrent symptomatic disease, and require long-term follow-up with particular consideration being given to monitoring of the upper tracts by renal ultrasound.

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction: H. N. Noe, O. S. Spivey, Jr., and G. R. Jerkins. Urology 23:144–147 (February), 1984

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction: H. N. Noe, O. S. Spivey, Jr., and G. R. Jerkins. Urology 23:144–147 (February), 1984

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction

If following posterior urethral valve fulguration a unilateral nonfunctioning or poorly functioning kidney remains, nephroureterectomy is the customary method of management. The distal ureter of such renal units can serve as a means of salvage for complications resulting from surgery on the ureter serving the remaining solitary functioning renal unit. We present 2 cases of posterior urethral valves where planned preservation of the distal ureter of a nonfunctioning kidney allowed salvage of such complications. We advocate preserving the ureter of a nonfunctioning renal unit if possible until the fate of the solitary functioning kidney and ureter is clear. This approach can be applied to other aspects of pediatric urologic reconstructive surgery.

Accuracy of Ultrasound in the Diagnosis of Nonfunctioning Kidneys

The accuracy and reliability of ultrasound were assessed in 246 patients with 338 radiologically nonfunctioning renal units. The causes of nonfunction included hydronephrosis, pyonephrosis, renal parenchymal disease, renal agenesis, renal neoplasm and polycystic disease. Obstruction was proved in 158 patients, with an accuracy of 98.1 per cent. Retrograde pyelography was avoided.The diagnosis of a small end stage kidney was correct in 42 patients. In 9 patients with a unilateral nonfunctioning kidney less than 9cm. long a thin coarsely textured cortex with dilatation of 1 or more calices was found. To our knowledge the presence of dilated calices in a small kidney, suggestive of chronic pyelonephritic changes, has not been described previously by ultrasound. Nonvisualization occurred in 16 cases (4.7 per cent) despite the anatomical presence of a kidney. An advanced degree of pyonephrosis with thick inspissated pus sometimes may mimic the ultrasonic appearance of a renal neoplasm.