Parenchymal Thinning Research Articles

Objective sonographic measurements of renal pelvic diameter and renal parenchymal thickness can identify renal hypofunction and poor drainage in patients with antenatally detected unilateral ureteropelvic junction obstruction

INTRODUCTIONHydronephrosis grading systems risk stratify patients with potential ureteropelvic junction obstruction, but only some criteria are measured objectively. Most notably, there is no consensus definition of renal parenchymal thinning. OBJECTIVESThe objective of this study was to assess the association between sonographic measures of renal length, renal pelvic diameter, and renal parenchymal thickness and the outcomes of a)renal hypofunction(differential renal function{DRF} <40%) and b)high-risk renal drainage(T1/2 >40 minutes). STUDY DESIGNAn institutional database of patients who had diuretic renograms(DR) for unilateral hydronephrosis was reviewed. Only infants with Society for Fetal Urology(SFU) grades 3/4 hydronephrosis without hydroureter on postnatal sonogram and had a DR within 120 days were included. The following measurement variables were analyzed: anterior posterior renal pelvic diameter(APRPD), renal length(RL), renal parenchymal thickness(PT), minimal renal parenchymal thickness(MPT=shortest distance from mid-pole calyx to parenchymal edge), and renal pyramidal thickness(PyrT). RL, PT, MPT, PyrT measurements were expressed as ratios (hydronephrotic kidney/contralateral kidney). Multivariate logistic regression was performed for each outcome by comparing three separate renal measurement models. Model 1: RLR, APRPD, MPTR; Model 2: RLR, APRPD, PTR, Model 3: RLR, APRPD, PyrTR. Individual performance of variables from the best performing model were assessed via ROC curve analysis. RESULTS196 patients were included (107 with SFU grade 3, 89 with SFU grade 4) hydronephrosis. Median patient age was 29[IQR 16,47.2] days. 10% had hypofunction, and 20% had T1/2 >40 minutes. 90% with hypofunction and 87% with high-risk drainage had SFU4 hydronephrosis. Model 1 exhibited the best performance, but on multivariate analysis, only APRPD and MPTR were independently associated with both outcomes. No other measure of parenchymal thickness reached statistical significance. The odds of hypofunction and high-risk drainage increase 10% per 1mm increase in APRPD(aOR 1.1 [CI 1.03-1.2], p=0.005; aOR 1.1 [CI 1.03-1.2], p=0.003). For every 0.1unit increase in MPTR the odds of hypofunction decrease by 40%(aOR 0.6 [CI 0.4-0.9], p=0.019); and the odds of high-risk drainage decrease by 30%(aOR 0.7 [CI 0.5-0.9], p=0.011). Optimal statistical cut-points of APRPD >16mm and/or MPTR <0.36 identified patients at risk for obstructive parameters on DR. DISCUSSION AND CONCLUSIONOf the sonographic hydronephrosis measurement variables analyzed, only APRPD and MPTR were independently associated with objective definitions of obstruction based on renal function and drainage categories. Patients who maintain APRPD <16mm and/or MPTR >0.36 can potentially be monitored with renal sonograms as there is >90% chance that they will not have DRF<40% or T1/2>40 minutes.

Long Term Follow-Up Of Patients With Nonrefluxing Hydronephrosis.

The aim of this study is to examine the long-term prognosis of children with ureteropelvic junction obstruction-like hydronephrosis (UPJO-like HN). The files of children with hydronephrosis (HN) were analyzed retrospectively. Patients with vesicoureteral reflux (VUR) and other genitourinary anomalies were excluded. The final status of the HN, the need for surgery, and urinary tract infection (UTI) frequency were evaluated. The study included 219 patients with 302 renal units (RU) with HN. Surgery rate was higher in RUs with larger kidney size and parenchymal thinning (p:<0.001 for both). Hydronephrosis resolved in 113 (40.2%) RUs, improved in 66 (23.3%), unchanged in 100 (35.5%) and worsened in 4 (1.4%). The frequency of recovery and improvement was found to be less in RUs with severe HN, large kidney size, and thin parenchyma. The UTI frequency was higher in severe HN group (12.2% vs 30.6% p:<0.001). Children with mild HN had an excellent prognosis. Although the majority of the patients with high-grade HN had also a good prognosis, it seems important to closely follow up patients with severe HN, increased kidney size, and accompanying parenchymal thinning. Clinicians should be aware of the increased frequency of UTIs in children with severe HN.

Tubulointerstitial nephritis and uveitis syndrome and SARS-CoV-2 infection in an adolescent: just a coincidence in time?

BackgroundDespite recent well-established kidney tropism of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), usually presenting as acute kidney injury (AKI), there are few published cases with SARS-CoV-2-related tubulointerstitial nephritis (TIN). We report an adolescent with TIN and delayed association with uveitis (TINU syndrome), where SARS-CoV-2 spike protein was identified in kidney biopsy.Case-diagnosis/treatmentA 12-year-old girl was assessed for a mild elevation of serum creatinine detected during the evaluation of systemic manifestations including asthenia, anorexia, abdominal pain, vomiting, and weight loss. Data of incomplete proximal tubular dysfunction (hypophosphatemia and hypouricemia with inappropriate urinary losses, low molecular weight proteinuria, and glucosuria) were also associated. Symptoms had initiated after a febrile respiratory infection with no known infectious cause. After 8 weeks, the patient tested positive in PCR for SARS-CoV-2 (Omicron variant). A subsequent percutaneous kidney biopsy revealed TIN and immunofluorescence staining with confocal microscopy detected the presence of SARS-CoV-2 protein S within the kidney interstitium. Steroid therapy was started with gradual tapering. Ten months after onset of clinical manifestations, as serum creatinine remained slightly elevated and kidney ultrasound showed mild bilateral parenchymal cortical thinning, a second percutaneous kidney biopsy was performed, without demonstrating acute inflammation or chronic changes, but SARS-CoV-2 protein S within the kidney tissue was again detected. At that moment, simultaneous routine ophthalmological examination revealed an asymptomatic bilateral anterior uveitis.ConclusionsWe present a patient who was found to have SARS-CoV-2 in kidney tissue several weeks following onset of TINU syndrome. Although simultaneous infection by SARS-CoV-2 could not be demonstrated at onset of symptoms, since no other etiological cause was identified, we hypothesize that SARS-CoV-2 might have been involved in triggering the patient’s illness.

V04-07 ROBOTIC ASSISTED SIDE-TO-SIDE REFLUXING NON-DISMEMBERED URETEROCYSTOTOMY FOR MANAGEMENT OF AN OBSTRUCTED MEGAURETER

You have accessJournal of UrologyCME1 Apr 2023V04-07 ROBOTIC ASSISTED SIDE-TO-SIDE REFLUXING NON-DISMEMBERED URETEROCYSTOTOMY FOR MANAGEMENT OF AN OBSTRUCTED MEGAURETER Hailey Silverii, Xinyuan Zhang, and Nicolas Fernandez Hailey SilveriiHailey Silverii More articles by this author , Xinyuan ZhangXinyuan Zhang More articles by this author , and Nicolas FernandezNicolas Fernandez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Obstructed megaureters can often be safely observed; however, when there are associated changes in renal function or recurrent infections, surgical intervention is indicated. Surgical management options include: endoscopic intervention, diversion with cutaneous ureterostomy, non-refluxing ureteral reimplantation, or refluxing ureteral reimplantation with an end-to-side or side-to-side approach. Determining factors for management include the circumstance for which intervention is indicated, age and size of the patient, degree of ureteral dilation and obstruction, and bladder size. In this video, we present a robotic assisted side-to-side refluxing non-dismembered ureterocystotomy for an infant with a ureterovesical junction (UVJ) obstruction. METHODS: A 4-month-old, 6.6 kg male with a history of antenatally diagnosed hydroureteronephrosis presents with a 3 month interval renal ultrasound demonstrating worsened degree of right hydroureteronephrosis with debris and increased parenchymal thinning. He has no prior history of urinary tract infections. A MAG3 renal scan demonstrated normal differential function and an obstruction at the level of the right UVJ. Given the patient’s young age and small bladder capacity, a non-refluxing ureteral reimplantation was not felt to be a feasible option. A side-to-side ureterocystotomy was recommended to which the family consented. After further counseling, a robotic approach was agreed upon and completed with the assistance of the Da Vinci XI platform (Intuitive Surgical, Sunnyvale, CA). RESULTS: The case began with a cystoscopy and right retrograde pyelogram which confirmed the level of the obstruction at the UVJ. Three supraumbilical 8 mm ports were placed prior to docking the Da Vinci system. Console time was 60 minutes. The tension free side-to-side anastomosis was completed in an interrupted fashion between the bladder and the dilated distal ureter. Estimated blood loss was less than 5 cc. The patient was discharged on post-operative day one after Foley catheter removal and the patient is doing very well. CONCLUSIONS: In conclusion, a robotic approach to a refluxing non-dismembered ureterocystotomy can safely be employed in small infants with adaptations in port placement, dissection, and anastomosis given small working space and risk to injuring nearby structures. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e340 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hailey Silverii More articles by this author Xinyuan Zhang More articles by this author Nicolas Fernandez More articles by this author Expand All Advertisement PDF downloadLoading ...

Risk determination for upper urinary tract damage in children with neuropathic bladder.

Neuropathic bladder dysfunction (NBD) or neurogenic lower urinary tract dysfunction occurs as a result of a lesion at any level of central nervous system. The most common aetiology of NBD in children is abnormal development of spinal column. These defects cause neurogenic detrusor overactivity which contributes to detrusor-sphincter dysfunction and results in lower urinary tract symptoms such as incontinence. One of the more progressive and insidious, at the same time preventable result of neuropathic bladder is upper urinary tract deterioration. It is vital to aim reduction in bladder pressures and the minimisation of urine stasis in order to prevent or at least attenuate renal disease. Despite world-wide strategies for prevention of neural tube defects currently, we will still be involved in the care of spina bifida patients born every year with a neuropathic bladder and at risk of long-term renal damage. This study was planned for evaluation of results and detection of possible risk factors for upper urinary tract deterioration during routine visits of neuropathic bladder population. The electronic medical records of the patients who were followed up for at least 1 year with the diagnosis of neuropathic bladder in Pediatric Urology and Nephrology units of Adana City Training and Research Hospital were reviewed retrospectively. A total of 117 patients, whose blood, urine, imaging and urodynamic study required for the evaluation of nephrological and urological status were completed and included in the study. Patients under the age of one were excluded from the study. Demographic characteristics, medical history, laboratory and imaging results were recorded. All statistical analyses were analysed by SPSS version 21 software package and analysed by descriptive statistical. Of the 117 patients who participated in the study, 73 (62.4%) were female and 44 (37.6%) were male. Mean age of the patients was 6.7 ± 4.9 years. The leading cause of neuropathic bladder was neuro-spinal dysraphism with 103 (88.1%) patients. Urinary tract ultrasound imaging revealed hydronephrosis in 44 patients (35.9%), parenchymal thinning in 20 patients (17.1%), increased parenchymal echo in 20 patients (17.1%) and trabeculation or increase in wall thickness of the bladder in 51 patients (43.6%). Voiding cystogram revealed the presence of vesicoureteral reflux in a total of 37 patients (31.6%), with 28 patients being unilateral and 9 patients bilateral. More than half of the patients had abnormal bladder findings (52.1%). In the Tc 99 m DMSA scan of the patients, 24 patients (20.5%) had unilateral renal scars and 15 (12.8%) had bilateral. Loss of renal function was detected in 27 (23.1%) of the patients. Urodynamic study revealed decreased bladder capacity in 65 patients (55.6%) and increased detrusor leakage pressure was found in 60 patients (51.3%). The mean leak point pressure of the patients was 36 ± 26 cm H2 O, and the mean leakage volume was determined as 157 ± 118 mL. Findings obtained from imaging and urodynamic studies during routine investigation of neuropathic bladder patients can be a guide for the upper urinary tract. According to our results, age, bladder changes in ultrasound and voiding cystogram, high leak point pressure obtained during urodynamic studies are thought to have strong correlation with upper urinary tract damage. The prevalence of progressive chronic kidney disease in children and adults with spina bifida is remarkable and completely preventable. The strategies for prevention of renal disease in this patient population should be planned by coordinated work of urologist with nephrologist and requires family cooperation.

Bilateral nephrolithiasis and upper tract transitional cell carcinoma in horseshoe kidney.

Nephroureterectomy is currently the criterion-standard treatment for high-grade upper tract urothelial carcinoma (UTUC). Current guidelines and expert opinions propose some exceptions to this approach based on patient characteristics, disease status, and function of the contralateral kidney. We present a rare case of a patient with horseshoe kidney, bilateral large nephrolithiasis, high-grade UTUC in one moiety, and relative parenchymal thinning of the contralateral side. The patient was treated with a percutaneous, minimally invasive, nephron sparing approach. The patient also had intracollecting system instillations of gemcitabine and docetaxel. Minimally invasive percutaneous resection of high-grade UTUC is a safe procedure in select cases. Current guidelines may not apply to all patients; unique scenarios with UTUC may require personalized decision-making and treatment at specialized centers.

V01-09 URETEROCALICOSTOMY IN TWO PATIENTS WITH MULTIPLE FAILED PYELOPLASTIES

You have accessJournal of UrologyCME1 May 2022V01-09 URETEROCALICOSTOMY IN TWO PATIENTS WITH MULTIPLE FAILED PYELOPLASTIES Michael Gross, Jason Scovell, and Robert Stein Michael GrossMichael Gross More articles by this author , Jason ScovellJason Scovell More articles by this author , and Robert SteinRobert Stein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002520.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Success rates for primary repair of a ureteropelvic junction obstruction (UPJO) are excellent, however recurrent strictures do occur in a subset of patients. Secondary UPJO presents complex and variable surgical challenges and there is no one-size-fits all solution. Ureterocalicostomy, where a healthy segment of ureter is anastomosed to a lower pole calyx, is a reasonable approach as shown in two recent patients. METHODS: Case one is a 25 year old female with a history of left UPJO who underwent primary laparoscopic pyeloplasly followed by endopyelotomy for recurrent UPJO. She additionally experienced severe gross hematuria necessitating embolization of a lower pole branch renal artery. The resulting area of ischemia and parenchymal thinning presented a particularly favorable location for ureterocalicostomy to circumvent her UPJO. This was also felt to be a more anatomic drainage pattern in an otherwise malrotated kidney. The second case is a 31 year old female with UPJO repaired with open pyeloplasty followed by robotic pyeloplasty 13 years later for secondary UPJO who presented with persistent pain and hydronephrosis. This patient was not initially planned for ureterocalicostomy, however the ureter was severely scarred to the lower pole and the more proximal tissue did not appear dissectible or suitable for a buccal mucosal graft and the decision to proceed with ureterocalicostomy was reached intraoperatively. RESULTS: Both patients recovered without complications and experienced symptomatic resolution. Beyond standard principles for dissecting the ureter in pyeloplasty, there is a role for ultrasound in these cases to identify the optimal location for the calicostomy. A nephropexy can also be utilized to reposition the kidney and decrease tension on the anastomosis. Meticulous suturing technique is necessary to ensure apposition of the mucosa to minimize scarring and failure of the repair. CONCLUSIONS: Ureterocalicostomy is a feasible option in select patients and may be an elegant solution to circumvent dense scar tissue and to take advantage of pathologic anatomy. Source of Funding: No source of funding © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e54 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Gross More articles by this author Jason Scovell More articles by this author Robert Stein More articles by this author Expand All Advertisement PDF DownloadLoading ...

Impact on clinical outcome of segmental vs diffuse parenchymal thinning in infants with prenatal urinary tract dilation

Objective: To determine the difference in renal function and rate of surgical intervention between neonates with diffuse and segmental parenchymal thinning. Materials and Methods: First postnatal ultrasonography images of neonates with prenatal urinary tract dilation were evaluated and measurements taken. Neonates with parenchymal thinning were categorised into segmental and diffuse parenchymal thinning groups using the medullary to intermedullary ratio. A statistical correlation of differential renal function and rate of surgical intervention between the two groups was calculated and evaluated using an independent t-test and Kaplan-Meier curve with Log-rank test, respectively. Results: Of the 20 neonates, 10 had segmental parenchymal thinning, while the other 10 had diffuse parenchymal thinning. Mean differential renal function was 49.3% in the segmental parenchymal thinning group compared to 45.8% in the diffuse group (p = 0.400). Five patients (50%) from the segmental parenchymal thinning group underwent pyeloplasty in comparison to seven patients (70%) from the diffuse group (p = 0.430) Conclusion: There were no significant differences in renal function or rate of surgical intervention between neonates with segmental parenchymal thinning and diffuse parenchymal thinning. Neonates with segmental parenchymal thinning need to be monitored as closely as those with diffuse parenchymal thinning for early detection of renal deterioration and to identify potential need for surgical intervention.

Quantitative assessment of renal perfusion in children with UPJO by contrast enhanced ultrasound: A pilot study

Contrast-enhanced ultrasound (CEUS) is a new potential modality for the quantitative evaluation of the microvascular perfusion of a parenchymal organ. To prospectively and quantitatively analyse the role of CEUS in evaluating renal perfusion for assessing renal function in children with ureteropelvic junction obstruction (UPJO). The study protocol was approved by the local ethics committee, and written informed consent was obtained from the patients' parents or guardians. Ultrasonography, CEUS, and radioisotope renography were performed for 51 children (42 boys, 9 girls; mean age, 6.75±4.14 years) with unilateral UPJO. The slope of the ascending curve (A), time to peak (TTP), peak intensity (PI), and area under the curve (AUC) were recorded during CEUS; quantitative data were calculated by QLab system (semiautomated border tracking, Philips Healthcare) software. Sensitivity and specificity values were determined for CEUS with respect to radioisotope renography. CEUS was used to evaluate 102 kidneys in 51 patients, for which the perfusion time-intensity curve (TIC) was determined. The TIC of renal cortical perfusion in all groups showed an asymmetrical single-peak curve, which could be clearly distinguished between the experimental group and the control group. Compared with the control group, the experimental group showed a markedly prolonged TTP but a significantly decreased A (P<0.05). There was no significant correlation between the AUC, PI and differential renal function (DRF), but the correlation coefficient between TTP, A and DRF remained significant (p<0.001).The receiver operating characteristic (ROC) curves drawn to differentiate DRF using the TTP value yielded an area under the ROC curve (AUROC) of 0.86. For a quantitative assessment of DRF less than 40% by CEUS, the sensitivity and specificity values were 92.86% and 76.14%, respectively. Unlike in previous studies, no significant difference in the AUC or PI was found between the control group and the experimental group in this study (P>0.05). Renal blood perfusion could not be evaluated overall by CEUS. Parenchymal thinning may be considered a limitation to CEUS. This preliminary experience represents the first report of evaluating the diagnostic value of CEUS in assessing renal function in children with UPJO. CEUS is a highly sensitive, rapid, and cost-effective diagnostic imaging modality for detecting and monitoring renal function noninvasively.

Primary squamous cell carcinoma of renal pelvis and kidney- Sole diagnosis by histopathology

Primary Squamous cell carcinoma of the renal pelvis is rare and accounts to only 0.5- 0.8 % of malignant renal tumours having poor prognosis. Chronic irritation, inflammation and infection induce the pathogenesis of this malignancy. A 53 year old male patient, presented with left flank pain since one month. On radiological investigation, his CT revealed atrophic shrunken left kidney measuring 7.9x5.2cms showing significant parenchymal thinning and complete loss of corticomedullary differentiation. A left upper ureteric calculus is seen measuring 7.5 mm with significant left renal hydronephrosis.Clinically, it was diagnosed as Xanthogranulomatous Pyelonephritis. Grossly the radical nephrectomy specimen measures 10.5x5.5x3.5cm. External surface is irregular &amp; bosselated. On Cut surface renal architecture is effaced by necrotic mass measuring 9.5x5.0x3.0 cm involving pelvic ureter and most of renal parenchyma.Hematoxylin and eosin stained tissue revealed characteristic feature such as keratin pearls and intracellular bridges seen, rendering the diagnosis of well-differentiated keratinising squmaous cell carcinoma seen with 40% tumour necrosis associated with Keratinizing Squamous Dysplasia. In the present case, obstructive uropathy has triggered the event of malignancy. The radiologic differential diagnosis includes primary and secondary renal neoplasms and xanthogranulomatous pyelonephritis associated with renal calculi. XGP is commonly associated with lithiasis however, rarely causes keratinizing squamous metaplasia and its manifestations closely mimic renal neoplasm, leading to misdiagnosis of malignancy.The prognosis is dismal with a 5-year survival rate of &amp;#60;10%. CT and MRI play a crucial role in diagnosis and staging of these tumors, though histology always remains confirmatory and diagnostic.

V11-12 BILATERAL NEPHROLITHIASIS AND UPPER TRACT TCC IN HORSESHOE KIDNEY

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-12 BILATERAL NEPHROLITHIASIS AND UPPER TRACT TCC IN HORSESHOE KIDNEY Tareq Aro, Arun Rai, David Hoenig, Arthur Smith, and Zeph Okeke Tareq AroTareq Aro More articles by this author , Arun RaiArun Rai More articles by this author , David HoenigDavid Hoenig More articles by this author , Arthur SmithArthur Smith More articles by this author , and Zeph OkekeZeph Okeke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephroureterectomy is the gold-standard treatment for High grade Upper tract urothelial carcinoma to date. Current guidelines and expert opinions offer some exceptions to this based on patient characteristics, disease status, and the contralateral kidney. METHODS: We present a rare case of a patient with horseshoe kidney, bilateral large nephrolithiasis, high-grade upper tract urothelial carcinoma in one moiety, and relative parenchymal thinning of the contralateral side. The patient was treated in a percutaneous minimally invasive, nephron sparing approach. Computed Tomography (CT) and Fluoroscopy images are provided, as well as live video of all procedures. RESULTS: Videos of multiple procedures are provided to demonstrate percutaneous resection of the tumor, stone lithotripsy, and repeat biopsies. The patient also had Intra collecting system instillations of gemcitabine and docetaxel, and video of post-installation percutaneous flexible nephroscopy is provided. CONCLUSIONS: Minimally invasive percutaneous resection of high-grade upper tract urothelial carcinoma is a safe procedure in select cases. Current guidelines may not apply to all patients; unique scenarios with upper tract urothelial carcinoma may require personalized decision making and treatment at specialized centers. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e861-e861 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tareq Aro More articles by this author Arun Rai More articles by this author David Hoenig More articles by this author Arthur Smith More articles by this author Zeph Okeke More articles by this author Expand All Advertisement Loading ...

Functional outcome after neonatal pyeloplasty in antenatally diagnosed uretero-pelvic junction obstruction

BackgroundWith routine antenatal ultrasonography, fetal hydronephrosis is commonly diagnosed. This leads to early detection of postnatal uretero-pelvic junction obstruction which may require surgical intervention. But, there is no clear consensus in the benefits of operating these patients in the neonatal age.MethodsAim—To study the functional outcome after pyeloplasty in neonates with antenatally diagnosed unilateral uretero-pelvic junction obstruction (UPJO). Records of all neonates (N = 48) who presented between 2016 and 2018 with prenatal diagnosis of unilateral UPJO and underwent a Anderson-Hyne’s Pyeloplasty were retrospectively analyzed. Indications for surgery were SFU grade 3 or 4, a split renal function (SRF) < 40% on a diuretic renal scan and antero-posterior renal pelvic diameter (APD) > 2.5 cm with parenchymal thinning. Parenchymal thickness (PT) and APD measured by ultrasonography, and SRF measured by 99 m Tc-EC renal scan were compared before and after surgery.ResultsOur study comprised of 48 patients with 79.2% males (n = 38). UPJO affected the left side more (n = 30, 62.5%). The mean age at pyeloplasty was 28 days (range 26–30). The outcome was considered successful in 46 (95.84%) patients. The APD decreased from a mean of 3.5 cm APD preoperatively to 1.38 cm 1 year later which was statistically significant (p < 0.001). The PT increased from 3.95 to 7.1 mm 1 year postoperatively which was significant (p < 0.001). The drainage pattern and SRF improved in 46 (95.84%) patients. The SRF improved from a mean of 35.48–44.7% 1 year postoperatively which was significant (p < 0.001).ConclusionPyeloplasty done in the neonatal age for prenatally diagnosed UPJO, having SFU grade 3–4 UPJO, leads to significant improvement of SRF and PT with minimal complications. Neonatal Pyeloplasty for significant UPJO is a safe procedure which provides the kidney maximum opportunity to improve function.

Huge encrusted ureteral stent forgotten for over 25 years: A case report

BACKGROUNDUreteral stent insertion is a relatively non-invasive procedure commonly used in the field of urology to resolve urinary obstruction. However, they are sometimes forgotten and the risk of complications increases with time.CASE SUMMARYA 43-year-old woman with a history of recurrent urinary tract infections visited our hospital for evaluation of persistent left flank pain, and lower urinary tract symptoms despite anti-biotic treatment. She had received urological surgery in her teens but did not know the details of her surgery. Kidney, ureter, and bladder X-ray and abdominopelvic computed tomography revealed a forgotten left ureteral stent with huge encrustation at both ends and a severely dilated left kidney with parenchymal thinning. In order to remove the ureteral stent, a laparoscopic nephroureterectomy was planned. The ureteral stent was successfully removed, and she was discharged after recovery. The patient was followed up for two years after surgery and did not show any signs of long-term complications. CONCLUSIONLong indwelling stents can cause dire complications requiring radical interventions. Stent registry systems, novel stent material development, and proper patient education is important for complication prevention.

Case report series: management of complete ureteral avulsion with review of the relevant literature

BackgroundEndoscopic operations and ureteroscopy have become the first choice for ureteral calculi and ureter-related operations. The ratios of the complications, which are mostly iatrogenic, range between 9 and 11%. Total ureteral avulsion during URS is quite rare with a prevalence of 0–0.3%. We present three total ureteral avulsions we experienced in our clinic during the last 2 years and their treatment.Case presentationDuring the last 2 years, we experienced three total ureteral avulsions: one of these occurred in our clinic and the other two occurred in an external center and were referred to us. In two cases, the omental flap was rotated after ureteral reimplantation and the ureter was completely wrapped inside the omental flap. In the third case, boari flap was formed from the bladder. Due to the presence of extrarenal wide renal pelvis, anastomosis was made with boari flap after a y–v flap was rotated on the renal pelvis. D-J stents of the patients were removed at the end of 3 months. Although there was mild hydronephrosis, parenchymal thinning and a significant decrease in functions were not observed. Ureteral avulsion of the patients was successfully managed without the need for nephrectomy.ConclusionUreteral avulsion management is an extremely difficult condition for both the surgeon and the patient. So, the most important thing is to prevent ureteral avulsion. Ureteroplasty and omental flap treatment are applicable methods with quite successful results for complete ureteral avulsions.

The different elements of the Urinary Tract Dilation (UTD) Classification System and their capacity to predict findings on mercaptoacetyltriglycine (MAG3) diuretic renography

The UTD Classification System risk stratifies postnatal UTD into three groups: low risk (UTD P1), intermediate risk (UTD P2), and high risk (UTD P3). In the original consensus document, a functional scan is not recommended for UTD P1 and is left to the discretion of the clinician for UTD P2 and P3. This study aims to understand which patients with postnatal urinary tract dilation would benefit from a functional study. We investigated how different elements of the UTD classification system predict differential renal function (DRF) and diuretic half-life (T½) on MAG3 scan in infants undergoing evaluation for prenatally detected UTD. This is a multicenter retrospective chart review of infants 6 months of age or younger evaluated for prenatal UTD, correlating their first MAG3 scan and first postnatal renal ultrasound (RUS). Multivariable logistic regression was used to find UTD elements predictive of DRF<40% and/or T½>20min. A total of 517 patients met study criteria. Median age at time of RUS and MAG3 renal scan was 48 days (IGR 31-81) and 63 days (IQR 45-98), respectively. DRF<40% was found in 6% of kidneys with UTD P2 and 35% of kidneys with UTD P3. T½>20min was found in 31% of kidneys with UTD P2 and 79% of kidneys with UTD P3. An abnormal ureter (OR 2.7, 95% CI 1.2-6.0) and parenchymal thinning (OR 16, 95% CI 5.8-41.4) were significant at predicting DRF<40%. Parenchymal thinning (OR 3.0, 95% CI 1.5-6.1) also predicted T½>20min, as did each cm increase in the anterior-posterior renal pelvic diameter (APRPD) (OR 4.8, 95% CI 3.0-7.7). The UTD system discriminates well and correlates with the likelihood of finding adverse features on diuretic renography. Patients in the UTD P3 high-risk category had a significantly higher incidence of decreased differential renal function and delayed drainage than those in UTD P1 and P2. Of the individual components of the UTD Classification system, the presence of parenchymal thinning was the most important factor in predicting both decreased differential renal function and delayed drainage. Given the high incidence of poor function and delayed drainage seen in the UTD P3 group, we believe a functional study should be recommended in the evaluation of these patients. Our findings support leaving the performance of a functional study at the discretion of the physician for UTD P2.

Course of Urological Problems in Children with Spinal Dysraphism: Long-Term Follow-Up Results

Background/Aims: We aimed to evaluate the course of urinary problems in children with spinal dysraphism. Methods: This multicenter study evaluated data on pediatric patients diagnosed with spinal dysraphism between 2010 and 2019. The neurological and urological conditions of the patients were examined retrospectively. This study focused on the course of urological problems. Urodynamic examinations including urodynamic bladder capacity, bladder pressure in maximal capacity, compliance, detrusor hyperactivity, uroflowmetry, and residual urine amount were evaluated. All patients underwent urinary system ultrasonography, urinalysis, hemogram and biochemical tests, and urodynamics at admission and follow-ups. Results: A total 62 patients (35 males, 27 females) with a mean age of 7.50 ± 4.01 years and age range of 1–16 years were included in the study. Ultrasonographic evaluation revealed normal results in 32 patients and abnormal findings, including moderate-to-severe calyceal dilatation, parenchymal thinning, and residual urine, in 30 patients. At the time of diagnosis, culture-positive urinary tract infection was detected in 22 patients, and leukocyte and/or bacterial positivity was detected in 18 patients. The differences between bladder capacity, bladder pressure at maximal capacity, compliance, and detrusor hyperactivity at first admission and post-treatment were statistically significant (p < 0.05). Vesicoureteral reflux was also detected in 25 patients. Thirty patients underwent oral anticholinergic and antibiotic prophylaxis, while 17 additionally underwent clean intermittent catheterization. Five patients underwent intravesical Botox injection, clean intermittent catheterization, and medical treatment, and 10 patients underwent augmentation cystoplasty. Conclusion: The prevalence of urinary tract problems is high in patients with spinal dysraphism for whom early diagnosis is very important for both urologic and neurosurgical considerations. Early follow-up of urodynamics should be performed, and treatment should be carried out if necessary. Regular follow-up and appropriate treatment have positive effects on the quality of life of these patients and may also prevent the occurrence of severe renal dysfunction.

Renal Replacement Lipomatosis—A Rare but Often Underdiagnosed Cause of Progressive Renal Damage in Calculus Disease

Renal replacement lipomatosis is a rare condition characterized by extensive fat deposition in hilum with parenchymal thinning and progressive detoriation of function.1-4 Though uncommon, it should be considered as a possibility in patients with history of intervention for stone disease.5,6 Correct diagnosis can be easily established by cross sectional imaging and is helpful to counsel patients about the possibility of progressive functional detoriation and poor salvageability of the affected kidneys.7-10 Here, we present 2 patients with previous history of intervention for calculus disease who had developed progressive renal damage due to RRL with one patient ultimately needing nephrectomy.

CLINICAL COURSE OF FETAL PELVI-CALYCEAL DILATATION DIAGNOSED ON EARLY SECOND TRIMESTER ULTRASOUND.

Aims and Objectives: Incidental finding of fetal pelvi-calyceal dilatation is common finding on early second trimester anomaly scan. [18 to 23 weeks] It causes significant parental anxiety. The present study aims to apply stringent criteria for accurate assessment. It also studies the natural course of such findings, pathological cause for such findings and its postnatal outcomes.&#x0D; Study Design: This study includes 9500 cases that underwent anomaly at 18 to 23 weeks gestation period.&#x0D; &#x0D; The fetal pelvi-calyceal dilatation [PCD] was diagnosed and categorized according to criteria set by European Society for Pediatric Radiology [ 1]. PCD 0 – renal calyces and pelvis not or hardly visible. PCD 1 – renal calyces not visible and axial renal pelvis diameter is less than 7 mm. PCD 2 – some calices are visible but with normal forniceal and papillary shape, axial renal pelvis less than 10 mm. PCD 3 - marked dilatation of calices and pelvis. Pelvic axial width usually more than 10 mm with flattened papilla and rounded fornices but without parenchymal thinning. PCD 4- gross dilatation of entire collecting system and thinning of renal parenchyma. PCD 5- Only thin membrane like residual renal parenchymal rim.&#x0D; &#x0D; Result: Among 9500 women who underwent routine anomaly scan at 18 to 23 weeks gestation, total 390 had PCD findings [4.1 %] Single kidney taken as one case while bilateral findings were taken as 2 cases.&#x0D; 98 [25.1 %] pregnancies had bilateral PCD findings and rest 292[74.9%] had unilateral PCD changes. These findings correlate well with as shown by S Sairam et al, Livera et al, Gunn et al [2, 3, 4] &#x0D; PCD 1 findings were noted in 317 cases, PCD2 findings were noted in 38 cases, PCD3 findings in 23 cases and PCD4 findings in 12 cases. All these fetuses were followed till either PCD findings resolved naturally or till 2 years of their life. These findings also compare well with S Sairam et al, and Persutte et al [ 2, 5]&#x0D; About 00 cases of PCD1, 3 cases of PCD2 and 2 cases of PCD3 were lost for follow up for various reasons.&#x0D; Two cases of PCD1 were lost due to additional diagnosis of Down syndrome in one case and multiple anomalies in other cases. Both were excluded from the present study.&#x0D; Rest of them [383] were studied and analyzed for this paper.&#x0D; Out of 315 PCD1 cases, all turned out to be normal&#x0D; Out of 35 PCD2 cases, 19 were resolved, 12 remain unchanged at second year of child age rest were&#x0D; 4 worsened&#x0D; Out of 21 PCD 3, 2 cases resolved spontaneously, 5 remain unchanged and 14 cases worsened&#x0D; Out of 12 PCD 4 cases, all needed and underwent surgical intervention. 04 kidneys were saved and rest 8 had nephrectomies.

Luckenschadel Associated with Chiari Type II Malformation: An Autopsy Case Report

Background Luckenschadel is commonly associated with Chiari II malformation and myelomeningocele. The aim of this case report was to revisit this entity. Case report: Antenatal imaging performed at 32 weeks gestation showed severe hydrocephalus with brain parenchymal thinning, cerebellar hypoplasia and lumbar myelomeningocele, suggestive of Chiari type II malformation. Stillbirth occurred before the pregnancy termination. X-rays showed a characteristic honeycomb appearance of the skull. The female 34-week-old stillborn was severely macerated and presented with thin and fenestrated skull, ruptured lumber myelomeningocele and diastematomyelia. Hydrocephalus could not be confirmed because of cerebral maceration. Histological examination did not reveal any significant visceral alteration. Conclusion: This case report highlights two key points. Luckenschadel should be kept in mind when Chiari II malformation is diagnosed. Autopsy with radiographic assessment is very useful in revealing this congenital defect which may escape prenatal detection.

Can Freehand Elastosonography Be an Alternative to Renal Scintigraphy in Pediatric Vesicoureteral Reflux Cases?

Detecting renal scar is important in pediatric patients with vesicoureteral reflux (VUR) for deciding on treatment option. The aim of this study is to detect whether freehand elastosonography technique could be an alternative to dimercaptosuccinic acid (DMSA) scan in determining renal scar formation. Between November 2015 and April 2016, 25 VUR patients, age ranging from 3 to 17 years admitted to our clinic, had urinary ultrasound and elastosonography, and data of approximately 147 renal region were recorded. Data were upper, middle, and lower pole renal parenchymal thickness and echogenicities obtained by ultrasound and these poles strain target (ST), strain reference (SR), and strain index (SI) values obtained by freehand elastosonography. DMSA scan data (differential function and upper, middle, and lower pole parenchymal scar formation) were recorded. Scar formation and more than 10% reduction in differential function in renal scan were statistically higher in renal regions in which parenchymal thinning and echogenicity increase was detected by ultrasound. There was no elastosonographic data difference between renal units with and without differential function decrease. Also, there was no elastosonographic data difference between renal units with and without scar formation. In this study, we could not find any significant difference in term of tissue tension values (ST and SI) measured by freehand elastosonography between renal units with and without scar formation in renal scan.