Obstructive Uropathy In Children Research Articles

Anterior urethral valve with diverticulum in an adolescent

Abstract The anterior urethral valve (AUV) is a rare cause of obstructive uropathy in children; they are much rarer than posterior urethral valves. A 13-year-old male presented with obstructive and irritative lower urinary tract symptoms (LUTS). On urethrocystoscopy, an AUV with a diverticulum was noted in the ventral surface of the urethra. It was ablated endoscopically using the holmium laser. Postoperatively, the patient voided successfully without any immediate complications. AUV with diverticulum may occur in adolescents. Endoscopic holmium laser ablation of the valve and the diverticulum is associated with good outcome.

IMMUNOHISTOPATHOLOGICAL CHARACTERISTICS OF OBSTRUCTIVE UROPATHY IN CHILDREN (LITERATURE REVIEW)

Despite advances in the early diagnosis of congenital obstructive uropathy, especially in prenatal diagnosis, and early surgical correction of this pathology, the problem of prognosis of obstructive uropathy in children currently comes out on top in terms of its relevance. In everyday clinical practice, the question constantly arises why, with the same type of uropathy in some children, kidney function recovers rather quickly after surgical treatment, while in others it continues to progressively decrease to the development of chronic renal failure.

Assessment of Cases of Congenital Obstructive Uropathy in Children

Background: The aim is to assess cases of congenital obstructive uropathy in children.Material & Methods:Sixty- five children in age ranged 5-12 years of either gender with congenital obstructive uropathy were recruited for the study. In all cases, ultrasonography was done in all cases. Growth of the child was monitored and height standard deviation score (Ht-SDS) was calculated annually. Glomerular filtration rate (ml/min/1.73 m2) was calculated.Results:Out of 65 patients, males were 40 and females were 25. Etiology found to be ureteropelvic junction obstruction (PUJO) in 12, posterior urethral valve (PUV) in 14, PUJO + PUV in 30 and obstructive megaureter in 9 cases. Symptoms were fever in 34, pain abdomen in 20, burning micturition in 45, poor urinary stream in 21 and flank pain in 15 cases. Treatment given was pyeloplasty in 14, nephrectomy in 20, PUV fulguration in 11, ureterocele decompression in 12 and ureteric reimplantation in 8 cases.Conclusions:Most common etiologies for congenital obstructive uropathy in children were congenital uretero-pelvic junction obstruction and posterior urethral valve. Male preponderance was seen with burning micturition.

Диагностика и лечение обструктивных уропатий у детей

Material and methods. The study is based on the results of diagnosis and treatment of 444 children with congenital obstructive diseases of the urinary tract. They were in the urology department of NRCMCH since August 2007. To differentiate organic and functional obstructive uropathy were conducted high-tech, informative and noninvasive imaging diagnostic methods. On the basis of which were provided a differentiated treatment. Results. Children with functional hydronephrosis and vesico-dependent version of urodynamic disorders in obstructive megauretera received conservative treatment. In ureteral type of the functional form of obstructive megauretera and 2-3 stage of vesicoureteral reflux were provided mini invasive endoscopic treatment. Effectiveness of endoscopic treatment of obstructive megauretera was - 85%, while the vesicoureteral reflux of 2nd stage - 100%, grade 3 - 80%. The use of mini lumbotomy frontside access for hydronephrosis, allowed towork locally in the area of ureteropelvic segment, to avoid injury of the kidneys and paranephritis. Conclusion. Thus, the use of an integrated approach to diagnosis using minimally invasive, highly informative methods made it possible to pathogenetically substantiate the choice of tactics for the treatment of obstructive uropathy in children and significantly improve the results of this complex category of patients.

Treatment of primary obstructive megaureter in children using minimally invasive technologies

Introduction. The final formation of the child's functional systems completed during postnatal ontogeny. To create optimal conditions for the functioning of the body is necessary either to decrease the level of functional requirements to the immature system, or the creation of new operating conditions under which the extended maturation time factor.
 Relevance. Currently, the most common treatment for obstructive uropathies is surgical treatment. To create optimal conditions for the functioning of the body, it is necessary either to reduce the level of requirements for an immature functional system, or to create new functioning conditions under which the ripening time factor is extended.
 Objective: Rationale and introduction of minimally invasive endoscopic draining techniques aimed at restoring urodynamics by using a PVC intraluminal drainage (stent).
 Materials and methods. The possibility of stenting with determination of the size of the ureteric orifice was investigated. The study involved 32 children aged from birth to three years. A retrospective analysis of previously treated 41 patients with obstructive ureterohydronephrosis was performed.
 Results. The study found that the optimal age for endoscopic correction of the intramural ureter is up to 3 months of life, when telescopic bougienage with dilation of the intramural compartment of the compromised ureter can be performed with calibration of the ureteric orifice and stent of the ureter with a corresponding stent.
 Retrospective analysis of previously treated patients allowed us to determine the same dependence. Thus, out of 41 patients with obstructive ureterohydronephrosis positive result was achieved in 29 children (70.73%) up to 1 year and 6 (14.63%) over 1 year. The impossibility of performing endoscopic correction of the orifice and stenting of the ureters in the age group up to 1 year was noted only in 1 patient (2.43%), whereas in the group from 1 year to 3 years - in 5 patients (12.19%).
 Conclusions. The proposed tactics of treatment of obstructive uropathy in children has advantages in terms of open surgical techniques in the technical simplicity, minimally invasive, maximum physiological, reducing the incidence of postoperative complications. It should be remembered that the effectiveness of endoscopic stenting of the lower parts of the ureter depends on the age of the child.

Таргетирование процессов гетерохронии в рациональном подходе к диагностике и лечению обструктивного уретерогидронефроза у детей

The final formation of the child’s functional systems completed during postnatal ontogeny. To create optimal conditions for the functioning of the body is necessary either to decrease the level of functional requirements to the immature system, or the creation of new operating conditions under which the extended maturation time factor. Currently, the most common treatment for obstructive uropathies is surgical treatment. A promising alternative to open surgical treatment of obstructive megaureter is endoscopic stenting of the ureter, based on an assessment of the phenomena of growth imbalances and dysfunction, tissue and maturation of the urinary system.Objective: rationale and introduction of minimally invasive endoscopic draining techniques aimed at restoring urodynamics by using a PVC intraluminal drainage (stent).Materials and methods. The possibility of stenting with determination of the size of the mouth of the ureter was investigated. The study involved 32 children aged from birth to three years. A retrospective analysis of previously treated 41 patients with obstructive ureterohydronephrosis was performed.Results. The study found that the optimal age for endoscopic correction of the intramural ureter is up to 3 months of life, when telescopic bougienage with dilation of the intramural compartment of the compromised ureter can be performed with calibration of the mouth and stent of the ureter with a corresponding stent.Retrospective analysis of previously treated patients allowed us to determine the same dependence. Thus, out of 41 patients with obstructive ureterohydronephrosis positive result was achieved in 29 children (70.73%) up to 1 year and 6 (14.63%) over 1 year. The impossibility of performing endoscopic correction of the orifice and stenting of the ureters in the age group up to 1 year was noted only in 1 patient (2.43%), whereas in the group from 1 year to 3 years – in 5 patients (12.19%).Conclusions. The proposed tactics of treatment of obstructive uropathy in children has advantages in terms of open surgical techniques in the technical simplicity, minimally invasive, maximum physiological, reducing the incidence of postoperative complications. It should be remembered that the effectiveness of endoscopic stenting of the lower parts of the ureter depends on the age of the child.The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies.

Bilateral Ureteral Obstruction Related to Pelvic Rhabdomyosarcoma Presenting with Acute Kidney Injury: A Case Report

Bilateral renal obstruction is a rare critical condition, requiring a prompt diagnostic approach and treatment to restore the renal function. The most commonly observed obstructive uropathy in children is congenital malformation, such as posterior urethral valves and bilateral ureteropelvic junction obstruction. Malignant pelvic masses obstructing the ureter are widely reported in adults but are rarely observed in children. The treatment of ureteral obstruction related to pelvic malignancy is a therapeutic challenge with a median survival duration of 3–7 months in adults; however, pediatric patients with pelvic malignancy leading to ureteral obstruction had better outcomes, with a reported 5-year mortality rate of 20%, than the adult patients. Here, we report a rare case of bilateral ureteral obstruction associated with pelvic rhabdomyosarcoma presenting with acute kidney injury treated by ureteral diversion with double J stent, and concommittent emergency hemodialysis, leading to restoration of good renal function. We suggest that bilateral ureteral obstruction should be released as soon as possible using surgical or interventional approach to minimize the obstruction period, and subsequential chemotherapy may contribute to improvement of survival and recovery of renal function. Key words: Urinary bladder neck obstruction, Acute kidney injury, Child, Pelvic Neoplasms, Prognosis

Clinical Profile and Outcome of Children with Congenital Obstructive Uropathy.

To study the etiology and clinical profile of congenital obstructive uropathy in children, renal status and growth at diagnosis and at follow-up and to determine the predictors for development of chronic kidney disease (CKD). An observational (retrospective-prospective) study was conducted at a tertiary care hospital in South India from September 2014 through September 2016. Sixty children diagnosed to have congenital obstructive uropathy with a minimum follow-up period of 5 y were included and followed up prospectively for 2 more years during the study period. The data of the children at admission and follow-up was obtained from the medical records and analyzed. Congenital uretero-pelvic junction obstruction followed by Posterior urethral valve were the most common etiologies identified. Male preponderance (88.3%) was observed with poor urinary stream being the most common presentation (36.6%). Forty percent of the population had elevated creatinine. Fifteen percent were hypertensive and 25% had growth failure at diagnosis. However, there was a reduction in the number of children with poor estimated glomerular filtration rate (eGFR), hypertension and growth faltering during follow-up. Among the risk factors, hypertension at diagnosis [O.R-12.8 (2.21-74.22) and p value <0.05] and frequent urinary tract infection (UTI) [O.R-14.06 (2.32-85.42) and p value <0.05] were the most important factors for CKD progression. Children with low eGFR (< 60ml/min/1.73m2) had more height faltering and hypertension at follow-up (p value <0.05). Hypertension and frequent UTI were observed to be strongly associated with progression of CKD. Estimated GFR was found to be significantly associated with faltering of height and hypertension. Preserving the renal function prevents growth faltering and development of hypertension at follow-up thereby ensuring a better quality of life.

Obstructive Uropathy in Children – An Update

Obstructive nephropathy is a structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction. Urinary tract obstruction can result from congenital (anatomic) lesion or can be caused by trauma, neoplasia, calculi, inflammation or surgical procedures, although most childhood obstructive lesions are congenital.The clinical features in most of the patients are due to consequences of the obstruction2. Obstruction of the urinary tract generally causeshydronephrosis, which is typically asymptomatic in its early phase. Renal USG gives information about urinary tract dilatation, renal cortical thickness, calyx size, diameter of pelvis, ureter, bladder thickness, tumor &amp; calculi and doppler USG for evaluation of aberrentvessles. Once obstructive nephropathy has been identified therapy focuses on the rapid restoration of normal urine flow either by medical or surgical intervention.Bangladesh J Child Health 2017; VOL 41 (2) :117-124

Врожденные обструктивные уропатии у детей: нефропротективная стратегия

Врожденные обструктивные уропатии у детей: нефропротективная стратегия

Рефлюкс-нефропатия у детей: ранняя диагностика и мониторинг

Vesicoureteral reflux (VUR) is the most common type of obstructive uropathy in children. Reflux nephropathy (RN) is one of the most common complications of VUR that inevitably leads to chronic kidney disease. Patients with end-stage kidney disease require costly treatment, and the only way to cure them is kidney transplantation. A timely institution of renoprotective therapy is a key factor helping to preserve the function of the native kidneys. Hence, it is necessary to devise new highly sensitive and minimally invasive methods for early diagnosis of RN. The purpose of this article is to review the molecular mechanisms of initiation and progression of kidney fibrosis and the opportunities of instrumental and non-instrumental methods for its diagnosis. Special attention is paid to highly specific and highly sensitive non-invasive methods for the detection of minimal changes in the renal parenchyma. The authors discuss the promising biomarkers for the diagnosis and prediction of RN.

Anterior urethral valve, a rare cause of bilateral vesicoureteral reflux in a two year old boy: A case report and a review of the literature

Anterior urethral valve (AUV) is a rare cause of obstructive uropathy in children. These are much rarer than posterior urethral valves. We report a case of a child with AUV and high grade bilateral vesicoureteric reflux. He was managed by transurethral laser ablation. The left sided reflux resolved after ablation. The right sided reflux persisted. The child is awaiting ureteric reimplantation.

Giant hydronephrosis mimicking as gross ascites in a 6-year-old boy

Giant hydronephrotic kidney is a rare form of obstructive uropathy in children and adolescents. The congenital ureteropelvic junction obstruction is the most frequent cause. The CT scan is very important for the diagnosis. We report a 6-year-old boy with progressively increasing abdominal distension since birth. There were no associated urinary or gastrointestinal symptoms. He had bilateral hydronephosis with giant hydronephrosis over right side. The cystic mass occupied the right retroperitoneal space and crossed the midline.

Congenital Posterior Urethral Diverticulum in a Male Child Case Report

Bladder neck and posterior urethra are common sites for obstructive uropathy in children. Diverticula of posterior urethra are rare cause of obstruction in children. A six year old boy presented with features of bladder outflow obstruction since birth. Ultrasound findings were suggestive of posterior urethral valve. Micturating cystourethrogram and endoscopic examinations revealed posterior urethral diverticulum which was placed dorsally. Diverticulectomy and reconstruction of urethra was performed by midline perineal incision. This report emphasizes that a posterior urethral diverticulum may be considered in those cases where features are suggestive of posterior urethral valve bladder outflow obstruction. DOI: http://dx.doi.org/10.3126/jnps.v32i3.5914 J. Nepal Paediatr. SocVol.32(3) 2012 257-258

Giant anterior urethral diverticulum with a calculus masquerading as left inguinal hernia: A missed diagnosis, a lesson to learn

Congenital anterior urethral diverticulum is an infrequent but important cause of infravesical obstructive uropathy in children. Clinical spectrum usually includes obstructive or irritative urinary symptoms or penile ballooning during the act of micturition. We share our experience in a case of giant anterior urethral diverticulum with a contained calculus presenting as a huge inguino-scrotal swelling and masquerading as left inguinal hernia. The fluctuation in the size of the swelling related to the act of micturition was mistaken for cough impulse. He was subjected to a left inguinal herniotomy, following which he developed urine leak from the surgery wound and was subsequently referred to our centre for further management. The importance of a detailed history, meticulous physical examination, and diagnostic imaging has been stressed. The surgical approach in such cases has also been highlighted.

Effect of Partial Ureteral Obstruction and Bacterial Virulence on the Occurrence of Renal Scarring in a Mouse Model

To evaluate the effect of the infection and the obstruction of urinary tract on renal parenchyma, we developed a model of ascending urinary infection in mice with partial unilateral obstructive uropathy. Six week-old CBA/J mice were operated on to perform a right partial ureteral obstruction and challenged transurethrally with Escherichia coli CFT073 (high virulent strain) or E. coli Mez (low virulent strain). Level of infection of urine and kidneys, score of inflammation and fibrosis of kidneys, and kidney weight ratio (KWR) in the short and long term were studied. At short-term (72 hours) experimentation, partial ureteral obstruction does not influence the level of kidney infection in terms of bacterial count, and the score of inflammation regardless of whether a virulent or low virulent strain was used. At long-term (42 days) experimentation, E. coli Mez was eliminated from all mice kidneys, but CFT073 persisted in almost all; obstruction did not influence the level of kidney infection with CFT073 but a significant difference of KWR and the inflammation and fibrosis score between obstructed and unobstructed kidneys was found (P = .0078; P = .036, respectively). Although the E. coli Mez strain did not persist in renal parenchyma, severe damage of the renal parenchyma was observed. The proposed model is similar to the obstructive uropathy in children in which ureteral obstruction is present before the onset of infection. The association of obstruction and urinary infection impairs kidney growth and favors the occurrence of renal damage.

Posterior Urethral Valves: Multivariate Analysis of Factors Affecting the Final Renal Outcome

Posterior urethral valves represent the most common obstructive uropathy in children with a broad spectrum of clinical severity. We evaluated prognostic variables affecting the outcome of renal function in such children. Between 1987 and 2004, 120 patients with a mean age of 2 years with posterior urethral valves were treated initially with valve ablation at our center. We studied certain parameters, including age at presentation, serum creatinine (initial and nadir), initial creatinine clearance, renal ultrasound findings (hydronephrosis and renal parenchymal echogenicity), vesicoureteral reflux on initial voiding cystourethrogram, bladder dysfunction and popoff mechanisms such as the syndrome of large vesical diverticulum, urinoma and ascites. Long-term renal outcome was assessed. Followup was 2 to 16 years (median 3.6). Renal insufficiency developed at the end of followup in 44 patients (36.5%). Serum creatinine at hospital admission, nadir serum creatinine, initial creatinine clearance and renal parenchymal echogenicity were significant predictors of the final renal outcome (p < 0.05). Patient age at diagnosis (2 or less vs greater than 2 years), upper tract dilatation, the presence or absence of vesicoureteral reflux, popoff mechanisms and bladder dysfunction had no significant impact on future renal function. On multivariate analysis nadir serum creatinine was the only independent prognostic factor. Our data confirm the high prognostic value of nadir creatinine after primary valve ablation. Also, initial serum creatinine, creatinine clearance and renal parenchymal echogenicity on initial renal ultrasound correlate significantly with long-term renal function in children with posterior urethral valves.

Renal parenchymal fibrosis and atrophy are not correlated with upper tract dilatation: Long-term study of partial unilateral ureteral obstruction in neonatal mice

Purpose The mechanism underlying the evolution of congenital obstructive hydronephrosis is still unclear. In a previous study, we have shown that it is possible to create renal lesions in newborn mice specific to partial ureteral obstruction. We aimed to study the long-term results of such partial obstruction. Methods Mice were operated on the third day of life. We created 2 groups: partial unilateral obstruction and control. We studied antero-posterior pelvis diameter, kidney length and volume on magnetic resonance imaging at day 10 and 3 months. We assessed ureteric patency by injecting Patent Blue dye. Kidney weight and fibrosis were histologically assessed. Fibrosis was assessed using Sirius Red staining and morphometry. Results Imaging showed parenchymal atrophy in the partially obstructed kidney and compensatory hypertrophy of the contralateral kidney. Pelvis dilatation was detected at day 10 but remained stable without significant increase at 3 months. The patency test confirmed the absence of total obstruction in the long term. There was no correlation between the degree of dilatation and parenchymal atrophy or the contralateral hypertrophy. Pathological studies at 3 months revealed fibrosis in the parenchyma without significant correlation with pelvis dilatation. Conclusions Long-term results confirmed that partial ureteral obstruction in newborn mice produces fibrotic lesions of the renal parenchyma, which are not correlated with dilatation of the upper tract. These results could contribute to the clinical management of obstructive uropathy in children, emphasizing that follow up with simple evaluation of upper tract dilatation is insufficient to predict renal deterioration.

Anterior urethral valves and diverticulum

Anterior urethral valves with associated urethral diverticulum is a rare but important cause of infravesical obstructive uropathy in children. This condition can be a cause of significant morbidity and can even lead to end-stage renal disease. This rare condition should be included in the differential diagnosis while evaluating male infants with infravesical obstructive uropathy.

Role of urinary biomarkers in the diagnosis of congenital upper urinary tract obstruction

Background:Congenital obstructive uropathy constitutes a significant cause of morbidity in children. Currently, there is no reference standard for the diagnosis of renal obstruction in children. The noninvasive measurement of biomarkers in voided urine has considerable appeal as a potential application in children with congenital obstructive nephropathy. The aim of the present review is to explore the current role of biomarkers in the diagnosis and follow-up of obstructive uropathy in children.Materials and Methods:The literature database (PubMed) was searched from inception to May 2007 regarding the role of urinary biomarkers in the diagnosis and follow-up of children with congenital obstructive uropathy.Results:The review included 23 experimental and 33 prospective controlled clinical studies. Several cytokines, peptides, enzymes and microproteins were identified as major contributors to or ensuing from obstruction-induced renal fibrosis and apoptosis. The most important biomarkers were transforming growth factor-β1 (TGFβ1), epidermal growth factor (EGF), endothelin-1 (ET-1), urinary tubular enzymes [N-acetyl-β-D-glucosaminidase (NAG), γ-glutamyl transferase (GGT) and alkaline phosphatase (ALP)], and microproteins [β2-microglobulin (β2M), microalbumin (M. Alb) and micrototal protein (M.TP)]. All biomarkers showed different degrees of success but the most promising markers were TGFβ1, ET-1 and a panel of tubular enzymes. These biomarkers showed sensitivity of 74.3% to 100%, specificity of 80% to 90% and overall accuracy of 81.5% to 94% in the diagnosis of congenital obstructive uropathy in children. Moreover, some of the markers were valuable in differentiation between dilated non-obstructed kidneys in need of conservative management and obstructed kidneys in need of surgical correction. Some studies demonstrated that urinary biomarkers are helpful in the evaluation of success of treatment of children with congenital renal obstruction. Some limitations of the previous studies include lack of different types of controls and small sample size. Larger studies with variable controls are invited to confirm the clinical usefulness of biomarkers in the diagnosis and follow-up of children with congenital obstructive uropathy.Conclusion:Urinary biomarkers are a promising tool that could be used as a noninvasive assessment of congenital renal obstruction in children.