Persistent Hydronephrosis Research Articles

Retrograde Endopyelotomy with Cutting Balloon™ for Treatment of Ureteropelvic Junction Obstruction in Infants.

The aim of this study is to analyze results of retrograde endopyelotomy with cutting balloon for treatment of ureteropelvic junction obstruction (UPJO) in infants. We routinely treat patients with UPJO under 18 months of age with retrograde high-pressure balloon dilatation of the pelviureteric junction (PUJ). During the procedure, in these cases where narrowing at the PUJ persists, endopyelotomy with cutting balloon is performed. Endopyelotomy is performed over guidewire with 5-mm Cutting Balloon™ under fluoroscopic control. Double-J stents is left in situ for 4 weeks. We retrospectively analyzed the postoperative, clinical, and radiological outcome infants treated with cutting balloon endopyelotomy between 2007 and 2015. Sixteen patients required cutting balloon endopyelotomy to achieve complete resolution of narrowing of the waist observed during high-pressure balloon dilatation of the PUJ. Mean operative time was 35 ± 21 min (mean ± SD) and hospital stay was <24 h in all patients. Complete resolution of the narrowing at the PUJ under fluoroscopy was achieved in all cases, with no perioperative complications. One patient presented with urinary tract infection, postoperatively (Clavien grade II). Preoperatively, all cases had grade IV SFU hydronephrosis with parenchymal thinning. During follow-up, resolution of the hydronephrosis was observed in 11 patients (grade I SFU). In four infants, there was an improvement of the hydronephrosis (grade II SFU) and the renogram curve. In one case, an open pyeloplasty was required due to persistent hydronephrosis and obstructive curve. We believe that endopyelotomy with cutting balloon could be a valid and safe option in minimally invasive management of UPJO in infants.

Evaluation of Mathisen's technique for ureteral reimplantation in children with primary vesicoureteral reflux

Although cross-trigonal ureteral reimplantation (Cohen) is a commonly used technique in children, it represents a non-physiological transfer of the ureteral orifices and may prove challenging with regard to endoscopic ureteral operations in later life. In 1964, Mathisen described an alternative method of ureteral reimplantation with lateralization of the neohiatus, creating an orthotopic course of the submucosal ureter. We have evaluated success and complication rates of both techniques that were applied sequentially at our departments. Forty-eight consecutive patients (83 ureters, 24 males/24 females) following Mathisen reimplantation were compared with 53 consecutive patients (98 ureters, 30 males/23 females) following Cohen reimplantation. Inclusion criteria were primary vesicoureteralreflux (VUR) and no previous intervention. Reflux grades (Mathisen 58 ureters/69.9% VUR ≥ III; Cohen 66 ureters/66.7% VUR ≥ III) and the occurence of other complicating factors (ureteroceles, megaureters, posterior urethral valves) in both groups were comparable. After Cohen's reimplantation there were no immediate complications requiring intervention; during follow-up (mean 28.2 months) three patients (5.6%) suffered febrile urinary tract infections (UTIs), of which one (1.8%) was diagnosed with a persisting VUR. Persistent hydronephroses (≥II SFU) were recorded in six patients (13.2%). After reimplantation using Mathisen's technique, two patients (4.1%) suffered significant intravesical bleeding; during follow-up (mean 23.06 months) four patients (8.3%) suffered febrile UTIs, and seven patients (14.5%) were diagnosed with persisting VUR after a mean follow-up of 10.8 months. The patients with persistent VUR had more commonly high-grade (IV and V) VUR initially, compared to the whole group. Two patients (4.1%) had persistent hydronephroses (≥II SFU). Mathisen's technique for ureteral reimplantation yielded a significantly (p=0.0256 patients, p=0.006 ureterorenal units) lower success rate (85.5% patients, 89.2% ureterorenal units) in comparison with Cohen's technique (98.2% patients, 99% ureterorenal units). Although there was no intervention for obstruction, persistent hydronephrosis was more common in the Cohen group (13.2% vs. 4.1%, n.s.). Despite the advantages of an orthotopic ureteral orifice close to the bladder neck, as achieved by Mathisen's reimplantation, cross-trigonal ureteral reimplantation proved more reliable for VUR correction. As regards optimizing the results, patient selection for either technique could prove essential. Nevertheless, as regards the difficulties with ectopic ureteral orifices in the Cohen technique in the long-term follow-up, the concept of anatomic, orthotopic ureteral reimplantation should be pursued and the technique should be further refined.

Benefit of F-15 protocols in equivocal F + 20 MAG3 renography in children with upper tract dilatation and symmetric split function: Results and outcomes

In children with upper tract dilatation, diuretic renography, which includes application of mercaptoacetyltriglicin-99mTc (MAG3), is the standard examination. Ordinarily, furosemide is applied 20min after tracer injection (F+20). In children with persistent hydronephrosis and preserved split function, this protocol may lead to further examinations with repeatedly equivocal washout curves. The present study evaluated the potential of MAG3 (F-15) scans in this subgroup of children to achieve a conclusive result avoiding additional equivocal MAG3 (F+20) scans. To evaluate whether the washout curve using the F-15 protocol is a helpful criterion with which to clarify results in patients with equivocal patterns in the F+20 protocol. 31 children (male/female 22/9, median age at time of examination 42 months, mean anterioposterior diameter 2.1cm, left/right 14/18) underwent MAG3 F-15 renography at the present department because of upper urinary tract dilatation and (repeatedly n≥2F+20=28) equivocal results in MAG3 F+20 examinations. In 10/31 children (32.2%), MAG3 F-15 revealed an obstructive pattern, indicating a pyeloplasty in 9/10 of them (90%). In 16/31 children (51%), the F-15 protocol showed a non-obstructive curve, leading to further uneventful follow-up in 15/16 of them (93.7%). In 5/31 children (16%), MAG3 F-15 led to equivocal results, resulting in no pyeloplasty and further uneventful follow-up in all the children (mean follow-up 1.46 years). In children with persistent high-grade hydronephrosis on ultrasound and preserved split function, multiple scans were prompted and further management was sometimes difficult. Although there was proven evidence that the F-15 protocol reduced the frequency of equivocal pattern, there was no indication for primary F-15 investigation, due to the risk of over diagnosis of obstruction. The F-15 scan was considered to be a stress test of the upper tract leading to a diuretic challenge without any opportunity to investigate normal washout curve. In these cases, partial obstruction could lead to false positive obstructive results. A stepwise approach, in which the traditional F+20 technique allows observation of the rate of washout of radiopharmaceuticals before forced diuresis followed by a F-15 protocol, could reduce the child's additional radiation burden and stress. After equivocal results in MAG3 F+20 protocols, performing a MAG3 F-15 exam lead to a conclusive result in 80.6% (25/31 patients) of the cases. Thus, performing a MAG3 (F-15) exam can be recommended in children with persistent hydronephrosis and preserved split function after equivocal results on MAG3 (F+20) scans.

Early mercaptoacetyltriglycine(MAG-3) diuretic renography results after pyeloplasty.

To describe the drainage and functional outcome of paediatric pyeloplasty, 1 week after stent removal 7-9 weeks after pyeloplasty using diuretic renography. Between 2009 and 2014, we assessed the functional and drainage outcomes according to mercaptoacetyltriglycine MAG-3 diuretic renograms from 66 children (69 kidneys) who underwent modified dismembered Anderson-Hynes pyeloplasty for pelvi-ureteric junction (PUJ) obstruction. Stents were left in place for 6-8 weeks and postoperative renal units were evaluated with MAG-3 renogram 1 week after stent removal. Surgical success was defined by improvement of drainage (half clearance time [T/2] < 20 min), stable or improved function on the postoperative MAG-3 renogram and by decreased pyelocaliceal dilatation on ultrasonography (US) at 1 year. Of the 69 kidneys with a preoperative median range T/2 of 33.4 (7.6-200) min, 60 (87%) had improved drainage curves, with a median (range) T/2 of 6.9 (1.6-19) min. Thirteen percent (9/69) had persistent impaired drainage, with a median (range) T/2 of 36 (24-108) min. Of these nine children, one girl was found to have a persistent obstructive pattern (T/2 = 30 min) associated with a decreased split renal function (SRF; from 42 to 33%) and persistent hydronephrosis (at 28 mm). Redo pyeloplasty was performed 2 months after the initial procedure (and 18 days after stent removal) and renal function recovered to 47%. The remaining eight patients were free of symptoms; hydronephrosis improved at 1 year (anteroposterior diameter decreased from 28 to 18.5 mm; P = 1.94) and SRF remained stable (44.5 vs 48.5% after repair; P = nonsignificant). In the 29% of kidneys (20/69) that had preoperative impaired SRF, postoperative renal function improved in 75% (from 27.5 to 43%; P < 0.001), remained unchanged in 2% and one kidney (0.2%) deteriorated. The median (range) postoperative follow-up was 18 (12-90) months. There is no agreement regarding the 'gold standard' investigation to use after pyeloplasty for PUJ obstruction. Improvement in hydronephrosis on US is slow and often takes > 12 months. Based on animal studies, it is possible that missed recurrent obstruction will cause irreversible loss of renal function after 6 weeks; therefore, early postoperative assessment is desirable, but there have been few reports on urinary drainage changes with early diuretic renography after pyeloplasty. Most of the renal units had improved drainage on diuretic renography 7 weeks after pyeloplasty and 1 week after stent removal. An early diuretic renogram is a reliable method of documenting surgical success after pyeloplasty.

Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2–4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

V10-05 ROBOTIC-ASSISTED LAPAROSCOPIC TRANSURETEROURETEROSTOMY

You have accessJournal of UrologyBladder Oncology/Robotics1 Apr 2014V10-05 ROBOTIC-ASSISTED LAPAROSCOPIC TRANSURETEROURETEROSTOMY Rebecca S. Zee, C.D. Anthony Herndon, L.I. Smith-Harrison, and Sean T. Corbett Rebecca S. ZeeRebecca S. Zee More articles by this author , C.D. Anthony HerndonC.D. Anthony Herndon More articles by this author , L.I. Smith-HarrisonL.I. Smith-Harrison More articles by this author , and Sean T. CorbettSean T. Corbett More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2454AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Developed in the 1930s, transureteroureterostomy (TUU) is a well-established procedure used for a variety of urologic disease processes. The utility of TUU becomes apparent when a shortened, irreparable, or damaged ureter precludes conventional repair. A novel approach to this procedure is a robotic-assisted approach. This teaching video will demonstrate positioning and operative technique for this procedure. METHODS This particular case involves a 28-year-old woman with a complex urologic history including bilateral ureterovesical junction obstructions at birth that were repaired in infancy with bilateral ureteral reimplants. She subsequently developed left ureterovesical junction obstruction and underwent a robotic-assisted laparoscopic left ureteral reimplantation with a psoas hitch. After a lengthy period of recurrent urinary tract infections (UTIs), abdominal pain, and persistent hydronephrosis, a robotic-assisted laparoscopic TUU was presented as a treatment option. RESULTS After placement of 3 laparoscopic ports the patient was positioned in steep Trendelenburg position. The robotic surgical system was then docked between the patient's legs. Both ureters were identified and mobilized from the retroperitoneum in the setting of significant scarring. The left ureter was transected distally, brought through a defect created in the sub-sigmoid mesentery and re-anastomosed end-to-side with the right ureter. She tolerated the procedure well. Her post-operative course was complicated by a UTI. At 3 months, a renal ultrasound revealed mild bilateral hydronephrosis that resolves with voiding. CONCLUSIONS The accompanying teaching video demonstrates positioning and operative technique for a robotic-assisted laparoscopic TUU. This innovative and minimally invasive technique is a safe and feasible approach to manage ureteral reflux and persistent hydronephrosis in a collecting system that is not amenable to ureteroneocystotomy. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e907-e908 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Rebecca S. Zee More articles by this author C.D. Anthony Herndon More articles by this author L.I. Smith-Harrison More articles by this author Sean T. Corbett More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of surgical outcomes and cosmetic results between standard and mini laparoscopic pyeloplasty in children younger than 1 year of age

ObjectiveTo evaluate safety, efficacy, and cosmetic results after mini laparoscopic (mL) pyeloplasty and standard (sL) pyeloplasty in children younger than 1 year of age with ureteropelvic junction obstruction (UPJO). Materials and methodsFrom August 2009 to March 2011, 20 sL pyeloplasties were performed in pediatric patients younger than 1 year of age; afterwards, 20 patients younger than 1 year of age underwent mini laparoscopic (mL) pyeloplasty from June 2011 to August 2012. The patients were followed by urine culture and ultrasonography at 3 and 6 months after surgery. Cosmetic appearance was assessed in all patients in both groups group 3 months after surgery using the Patient Scar Assessment Questionnaire. ResultsPeri and postoperative results revealed that operative time (total and anastomosis of ureteropelvic junction), hospital stay, and overall complication rate were significantly lower in mL than in sL. Persistent hydronephrosis in follow-up imaging and recurrence of obstruction was not observed in any cases. Mean appearance score and consciousness score showed significantly better results in the mL group. ConclusionWe believe that mL pyeloplasty in infant cases with UPJO is more cosmetically pleasing and less invasive than sL pyeloplasty and has similar functional outcomes.

Postoperative evaluation of hydronephrosis due to the way of pyeloplasy (dismembered / non-dismembered).

Central European Journal of Urology106Cent European J Urol 2014; 67: 106-107 10.5173/ceju.2014.01.art25In recent years, we have seen rapid development of minimally invasive procedures in urologic oncology, but also in corrective surgery of congenital defects, including ureteropelvic junction obstruction (UPJO). After a period of testing the endoscopic treatment of UPJO, currently the majority of patients undergo laparoscopic or robotic surgery. Recently, single port laparoscopy (LESS) has become an optional technique in the urological armamentarium. Laparoscopic treat -ment of UPJO in adults has been established as the “gold standard” means of curing this quite common disease. Nowadays it draws much attention as it is one of the very few urological laparoscopic operations that can be done relatively easily by a laparoscopist with limited experience, and as such, resembles the case of cholecystectomy for general surgeons [1, 2]. Abundant literature offers much data about very good postoperative functional results of laparascopy: equal to open surgery and with the known advantage of min -imal invasiveness. In contrast, many authors contin-ue to commission research of functional supervision of patients after UPJO repair, since the disappearance of hydronephrosis observed in the ultrasound over a longer period of time may also result from the deterio -ration of renal function. However, it is surprising that the authors very seldomly give precise details about how long after the procedure the final outcome was evaluated and which diagnostic tools should be used. In the current issue of CEJU, Isoyama and co-oper-ators present a very interesting paper inspired by data coming from paediatric surgeons that the hy-dronephrosis after UPJO repair may subside very gradually, probably as the elastic properties of the renal pelvis may differ individually. According to the authors, this has two practical consequences. Firstly, provided that there are no remaining symptoms , the judgement of the result of surgery should be post-poned, as there is still time for improvement, even as long as two years after the operation. Secondly, serial ultrasound may be a valuable alternative to more invasive diagnostic tests, such as intravenous pyelography (IVP) or diuretic renogram, during the follow-up. It is worth noting that, in our opinion, the evaluation of the hydronephrosis stage changes should be sought for each patient individually, as a step in the laparoscopic partial resection of the en-larged renal pelvis. In some cases immediately af-ter surgery, with radical removal of the excess renal pelvis, the hydronephrosis is no longer observed [3]. The ultrasound evaluation of the functional effect of the surgery, by reducing the hydronephrosis, seems to be useful in the case of non-dismembered pyelo-plasy, since the treatment is limited only to the lon-gitudinal cut of UPJO and transverse suture without resection of the stenosed part of the renal pelvis [4].The study is small as it is based on the analysis of only 16 patients, but may give urologists some scientific sup-port for consultation of patients after UPJO surgery, who do not have symptoms, but are uncertain about the outcome, especially if there is some persistent hydro-nephrosis. From the Isoyama paper, we may conclude that the resolution of hydronephrosis may take even two years and may be followed very well by measure-ments from subsequent ultrasound evaluations, which are better that USG tests done separately. It can spare the patient unnecessary tests or maybe sometimes even prevent an unnecessary re-do operation. More-over, subsequent ultrasound measurements of the size of the renal pelvis in the improvement of kidney func-tion, after dismembered pyeloplasty of UPJO, in our opinion, provide an interesting noninvasive diagnostic option, but should be carried out individually, taking into account the extent of renal pelvis resection during surgery for each patient. If there are still any doubt as to the effect of the treatment, diuretic renogram and IVP remain the standard diagnostic procedures.Editorial referring to the paper published in this issue on pp. 101–105

Laparoscopic surgery to treat ureterosciatic herniation after ureteral stent failure

We report on a patient who presented with left flank pain for 6 months. Computed tomography and intravenous urography revealed left ureterosciatic herniation with severe hydronephrosis. Antegrade placement of the ureteral double-J stent was performed and her symptoms subsequently subsided. These symptoms recurred after the removal of the stent 1 year later with persistent hydronephrosis and herniation. We performed laparoscopic ureterolysis, ureteral fixation to psoas muscle, and sciatic hernia repair with hyaluronan-containing mesh. The result was encouraging and the follow-up image at 6 months showed no hydronephrosis and no ureteral herniation.

1063 PREDICTIVE FACTOR FOR FEBRILE URINARY TRACT INFECTION AFTER URETEROSCOPIC PROCEDURES

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder (I)1 Apr 20131063 PREDICTIVE FACTOR FOR FEBRILE URINARY TRACT INFECTION AFTER URETEROSCOPIC PROCEDURES Masafumi Kita, Masaki Watanabe, Kazumi Hashizume, Tatsuya Iwata, Seiji Matsumoto, and Hidehiro Kakizaki Masafumi KitaMasafumi Kita Asahikawa, Japan More articles by this author , Masaki WatanabeMasaki Watanabe Asahikawa, Japan More articles by this author , Kazumi HashizumeKazumi Hashizume Asahikawa, Japan More articles by this author , Tatsuya IwataTatsuya Iwata Asahikawa, Japan More articles by this author , Seiji MatsumotoSeiji Matsumoto Asahikawa, Japan More articles by this author , and Hidehiro KakizakiHidehiro Kakizaki Asahikawa, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.649AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Febrile urinary tract infection (f-UTI) is a major complication associated with ureteroscopic procedures and, in some cases, leads to a life-threatening event. However there have been few reports investigating factors influencing the prevalence of f-UTI after diagnostic and therapeutic ureteroscopy. The aim of this study is to clarify predictive valuables of f-UTI related to ureteroscopic procedures. METHODS A retrospective review of the medical records of 215 consecutive patients undergoing ureteroscopic procedures was performed. These cases were divided into two groups: transurethral lithotripsy (TUL) group (112 cases, 66 males and 46 females, mean age 63.2±1.3 years) and ureteroscopic investigation (USI) group (103 cases, 56 males and 47 females, mean age 69.1±1.3 years). Risk factors for f-UTI were evaluated using univariate and multivariate analysis. RESULTS Mean operating time was 81.8±3.9 min in TUL group and 26.5±1.6 min in USI group. Prevalence of f-UTI was 11.6% in TUL group and 13.6% in USI group. Univariate analysis revealed that the presence of preoperative bacteriuria (p<0.001), renal stone (p=0.013), use of access sheath during lithotripsy (p=0.025), history of f-UTI (p=0.032) and operating time (p=0.008) had a significant relationship with f-UTI in TUL group. Multivariate logistic regression analysis revealed that operating time and preoperative bacteriuria were risk factors for f-UTI after TUL (Table1). In USI group, there was no single factor that had a significant relationship with f-UTI. However, among cases of USI group, those with both positive preoperative bacteriuria and persistent hydronephrosis after ureteroscopy had more than 2.5 times larger risk for f-UTI compared with other cases. CONCLUSIONS The reason why there were no significant risk factors for f-UTI in USI group might be explained by considerably short operating time compared to TUL group. When TUL is to be performed, reducing operating time is an important factor to prevent postoperative f-UTI especially in those cases with positive bacteriuria and renal stone. Table 1. univariate and multivariate analysis of factors elicitting f-UTI after transurethral lithotripsy univariate analysis univariate analysis multivariate analysis multivariate analysis OR P value OR P value age 1.03 .192 - - sex 0.56 .324 - - size of calculi 1.05 .141 - - preoperative ESWL 0.35 .328 - - preoperative bacteriuria 14.10 .001 16.70 .001 history of f-UTI 4.73 .012 - - ranal stone 0.22 .02 - - diabetes mellitus 0.43 .436 - - access seath 3.65 .032 - - perforation 0.67 .71 - - postoperative ureteral stenting 1.14 .872 - - operating time 1.02 .012 1.02 .018 ESWL: Extracorporeal shock wave lithotripsy, OR: odds ratio © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e436 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Masafumi Kita Asahikawa, Japan More articles by this author Masaki Watanabe Asahikawa, Japan More articles by this author Kazumi Hashizume Asahikawa, Japan More articles by this author Tatsuya Iwata Asahikawa, Japan More articles by this author Seiji Matsumoto Asahikawa, Japan More articles by this author Hidehiro Kakizaki Asahikawa, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Unusual stent after ureteral substitution. A first case

BackgroundTo the best of our knowledge this is the first case where a Silastic drain is used in ureteral surgery instead of a common urological stent. Patients coming from other institutions, especially in peripheral areas, can be treated with non conventional devices and if traditional imaging is inconclusive, computed tomography (CT) can provide valuable information to make the right diagnosis.Case presentationWe present the unusual case of a 32F Silastic drain found inside the urinary tract in a female patient who had previously undergone ileal loop replacement of the left ureter for post-hysterectomy stricture at another Institution, and had subsequently repeated surgery due to persistent hydronephrosis. Radiological findings on plain abdominal X-ray were quite misleading, while CT allowed a correct assessment of the drain features.ConclusionWhile double J stents of different lengths, sizes and materials are used in ureteral surgery, the use of Silastic drains has not been previously reported. In light of the present experience we don’t suggest its routinely use.

Antegrade pressure measurement of urinary tract in children with persistent hydronephrosis

Dilation of urinary tract occurs without the presence of obstruction. Diagnostic methods that depend on renal function may elicit mistaken diagnosis. Whitaker (1973) proposed the evaluation of urinary tract pressure submitted to constant flow. Other investigators proposed perfusion of renal pelvis under controlled pressure, making the method more physiological and reproducible. The objective of the present study was to evaluate the results of the anterograde pressure measurement (APM) of the urinary tract of children with persistent hydronephrosis after surgery suspected to present persistent obstruction. Along 12 years, 26 renal units with persistent hydronephrosis after surgery (12 PUJ and 14 VUJ) were submitted to evaluation of the renal tract pressure in order to decide the form of treatment. Previous radionuclide scans with DTPA, intravenous pyelographies and ultrasounds were considered undetermined in relation to obstruction in 10 occasions and obstructive in 16. APM was performed under radioscopy through renal pelvis puncture or previous stoma. Saline with methylene blue + iodine contrast was infused under constant pressure of 40 cm H2O to fill the urinary system. The ureteral opening pressure was measured following the opening of the system and stabilization of the water column. Among the 10 cases with undetermined previous diagnosis, APM was considered non-obstructive in two and those were treated clinically and eight were considered obstructive and were submitted to surgery. Among the 16 cases previously classified as obstructive, nine confirmed obstruction and were submitted to surgery. Seven cases were considered non-obstructive, and were treated clinically, with stable DMSA and hydronephrosis. APM avoided unnecessary surgery in one third of the cases and was important to treatment decision in 100 %. We believe that this simple test is an excellent diagnostic tool when selectively applied mainly in the presence of functional deficit.

Urinary Diversion in Early Childhood: Indications and Outcomes in the Exstrophy Patients

To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE). Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied. In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation. The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

Use of renal resistive index and semi-rigid ureteroscopy for managing symptomatic persistent hydronephrosis during pregnancy

PurposeThe aim of this study was to evaluate the use of Doppler ultrasonography (DUS) and semi-rigid ureteroscopy (URS) for managing symptomatic persistent hydronephrosis during pregnancy. Materials and methodsThe study included 19 pregnant patients with unilateral symptomatic persistent hydronephrosis. All pregnant patients were assessed with conventional ultrasonography (US) followed by DUS for both kidneys. ResultsThe mean patient age was 26 years (range 19–40), and the gestational period was 24 weeks (range 16–33). There was a significantly higher mean resistive index in the kidneys with ureteral obstruction than in the contralateral normal kidneys. Spinal anesthesia was performed on 18 patients, while general anesthesia was performed on 1 patient. Endoscopically stones were found in 17 patients (89.5%), while no stone was found in 2 patients (10.5%). The stones were fragmented by holmium laser and retracted with forceps. After lithotripsy, a ureteral JJ stent was inserted in 8 of 17 (47%) patients with ureteral stones. Intraoperatively, there were no obstetric complications, while ureteral perforation was seen in one patient. Two patients are still pregnant at the time of this writing, and 17 babies were born normally. ConclusionsBoth RI and ΔRI increase in unilateral symptomatic persistent hydronephrosis during pregnancy. Semi-rigid URS can be used successfully for diagnosis and treatment in these patients.

Importance of Renal Abnormalities First Identified in the Third Trimester After Normal Findings on a Detailed Second-Trimester Structural Fetal Survey

The purpose of this study was to evaluate the importance of renal abnormalities first identified in the third trimester of pregnancy after normal findings on a detailed second-trimester structural fetal survey. Between March 1, 2007, and August 1, 2009, all patients having a sonographic examination in the third trimester who previously had normal findings on a second-trimester detailed structural fetal survey were retrospectively identified. Fetal renal abnormalities first detected in the third trimester and not seen during the second-trimester survey were tabulated. Neonatal follow-up was obtained for those with sonographic abnormalities. Overall, 4170 patients had third-trimester scans after normal findings on a detailed second-trimester survey. A new renal abnormality was detected in 77 (1.8%) of these third-trimester scans. Detailed postnatal imaging follow-up was available in 49 of 77 (63.6%), of which 44 (89.8%) had prenatal hydronephosis. Of these, 9 of 44 (20.5%) had reflux; 14 of 44 (31.8%) had normal findings or had hydronephosis that resolved on follow-up sonography after birth; and the rest had hydronephosis (13 of 44 [29.5%]), ureterovesical junction obstruction (3 of 44 [6.8%]), or ureteropelvic junction obstruction (5 of 44 [11.4%]). The other 5 fetuses with nonhydronephrotic renal abnormalities had pelvic kidneys (3) and unilateral renal agenesis (2). Two of those with reflux (22.2%) required surgery, and 1 of those with ureterovesical junction obstruction (33.3%) required surgery. Most renal abnormalities first identified in the third trimester after normal findings on a detailed second-trimester structural fetal survey were hydronephrosis, of which approximately one-third resolved after birth. Among the remaining neonates with persistent hydronephrosis, almost one-third had reflux that was not detected on the second-trimester anatomy scan.

Hydronephrosis in Children With Abdominal and Pelvic Neoplasms: Outcome and Survival Analysis of a Single Center Pediatric Oncology Series

We ascertained the incidence and outcome of hydronephrosis related to abdominal or pelvic neoplasms and survival in pediatric patients. We retrospectively reviewed our institutional oncology database between January 1995 and November 2009. We reviewed the charts of all children with intra-abdominal (nonrenal) and pelvic neoplasms. Of the 366 patients whose charts were reviewed 66 (18%) had hydronephrosis at some point during treatment, including 12 with hydronephrosis that was not caused by the neoplasm and 1 who was lost to followup, leaving 53 with malignant obstruction. Of the remaining patients hydronephrosis resolved in 34 (64%) with treatment for the primary neoplasm alone while in 19 (36%) hydronephrosis persisted after primary oncological treatment. Univariate analysis revealed that patients with persistent hydronephrosis (p = 0.025), those with urological intervention (p = 0.05) and those with high stage disease (p <0.001) had statistically significantly worse overall survival. On Cox multivariate analysis only disease stage remained statistically significant (p = 0.004). Analysis of this group revealed that pediatric nonrenal abdominal and pelvic tumors are associated with hydronephrosis in about 20% of cases. Approximately 60% of these cases resolved with treatment for the primary tumor alone while 13% required specific urological intervention for urinary tract involvement or compression. Patients with pediatric malignant ureteral obstruction had a 20% 5-year mortality rate. The main predictive factor was primary disease stage.

Scrotal hernia of the ureter in association with posterior urethral valves

Posterior urethral valves are a common obstructive uropathy causing severe hydroureteronephrosis. Ureteral herniation is very rare and often misdiagnosed. We report a male infant with posterior urethral valves who had increased persistent hydronephrosis despite prior successful ablation. Further examination revealed a paraperitoneal inguinal ureter herniation to be responsible for the clinical status.

Occult ureteropelvic junction obstruction presenting as anuria and urinary ascites in an infant with antenatal, unilateral hydronephrosis

To discuss an unusual case of occult ureteropelvic junction obstruction. A premature male infant with severe, unilateral hydronephrosis presented to the emergency room with 20 h of dry diapers. Placement of urethral catheter did not return urine. Imaging revealed persistent hydronephrosis on the previously affected side and new-onset hydronephrosis with perirenal fluid on the contralateral side. Patient was taken to the operating room and forniceal rupture from occult ureteropelvic junction obstruction with urinary ascites was identified. The obstruction was surgically repaired at that time and his postoperative course was uncomplicated. While most agree on postnatal evaluation for some children with antenatal hydronephrosis, there is no consensus as to the timing and frequency of evaluation. The risk of significant obstruction in children with low grades of hydronephrosis is very low, and many are not followed. This is a rare case in which low-grade postnatal hydronephrosis resulted in significant clinical obstruction.

Hydronephrosis in Infants and Children: Natural History and Risk Factors for Persistence in Children Followed by a Medical Service

Infants with neonatal hydronephrosis and a normal voiding cystourethrogram (VCUG) are presumed to have ureteropelvic junction obstruction (UPJO). There is little current information about the natural history of children with hydronephrosis or clinical factors that predict resolution of the radiological abnormality. To determine the time course until spontaneous resolution of neonatal hydronephrosis and define risk factors for persistence of the abnormality. This retrospective single center review examined infants and children <5 years of age with hydronephrosis who were followed for at least 12 months. 136 children were identified (96 male:40 female). The mean age at diagnosis of hydronephrosis was 3.3 ± 9.7 months and 76% of the patients were diagnosed at birth. The hydronephrosis was unilateral in 98 (72%) of cases, and hydronephrosis was at least moderate in severity in 22% of affected kidneys. At last follow-up at 30 ± 10 months, the abnormality had resolved in 77 out of 115 (67%) available patients, 30 (26%) had been referred to urology, and 12 (10%) had persistent hydronephrosis. Severity of hydronephrosis was the only clinical feature that predicted persistence of the abnormality (P < 0.001). There was an association between detection at birth and lack of resolution of hydronephrosis. Children with hydronephrosis and presumed UPJO and normal kidney parenchyma can be followed for at least 2 years to allow for spontaneous resolution before referral to urology. Serial sonography can be performed at 6 month intervals in uncomplicated cases. More severe hydronephrosis and presence of the lesion at birth may predict infants and children requiring closer observation and referral for possible surgical correction of the hydronephrosis.

Vesicoureteral Reflux and Urinary Tract Infection in Children With a History of Prenatal Hydronephrosis—Should Voiding Cystourethrography be Performed in Cases of Postnatally Persistent Grade II Hydronephrosis?

The clinical relevance of prenatal hydronephrosis is not well-defined. We determined the risk of febrile urinary tract infection in the absence of screening for vesicoureteral reflux, and whether postnatal voiding cystourethrography should be performed in patients with a history of prenatal hydronephrosis and postnatally persistent Society for Fetal Urology grade II hydronephrosis. From a longitudinal database of patients with prenatal hydronephrosis maintained since 1998 we identified those with postnatally persistent grade II hydronephrosis. This cohort was divided into patients who were and were not screened with an initial voiding cystourethrogram. The rates of vesicoureteral reflux and development of febrile urinary tract infection were determined. Of 2,076 patients with prenatal hydronephrosis 1,514 had grade II hydronephrosis. Of the patients 76% underwent an initial voiding cystourethrogram and vesicoureteral reflux was found in 28%. There was no relation between laterality of hydronephrosis and incidence of vesicoureteral reflux. There was no difference between nonscreened and screened patients with respect to gender and laterality of hydronephrosis. Urinary tract infection developed in 1.3% of the patients who were screened and did not have vesicoureteral reflux and, therefore, were not receiving antibiotics. Of the screened patients with vesicoureteral reflux who were receiving prophylactic antibiotics urinary tract infection developed in 1.6% at a mean age of 9.4 months. In 363 patients who did not undergo an initial voiding cystourethrogram we estimated (based on the screened population) that 101 would have vesicoureteral reflux and 5 would have a urinary tract infection. However, a febrile urinary tract infection developed in 16 patients (4.4% overall, p <0.0001) at a mean age of 9.3 months. Voiding cystourethrogram performed in these 16 patients revealed vesicoureteral reflux in 12. Of all the patients with a urinary tract infection who were ultimately observed to have vesicoureteral reflux (including those initially screened and those discovered to have reflux after a urinary tract infection) the laterality of hydronephrosis, grade of reflux and laterality of reflux were comparable. In patients with a history of prenatal hydronephrosis who are observed to have postnatally persistent grade II hydronephrosis identification of vesicoureteral reflux and use of prophylactic antibiotics significantly reduce the risk of febrile urinary tract infection. Therefore, we recommend that patients with a history of prenatal hydronephrosis and postnatally persistent hydronephrosis be screened with voiding cystourethrography early in life, and be placed on prophylactic antibiotics until the screening results are known.