Renogram Research Articles

Laparoscopic Resection and End-to-End Ureteroureterostomy for Midureteral Obstruction in Children.

Midureteral obstruction is an extremely rare condition. This retrospective study assessed the outcomes of laparoscopic ureteroureterostomy (UU) in 13 children with midureteral obstructions. Records of patients with midureteral obstruction who underwent laparoscopic end-to-end UU between July 2011 and August 2015 were reviewed. The medical records comprised patient demographic data, intraoperative details, postoperative outcomes, and related complications. Renal ultrasound, magnetic resonance urography, and radioisotope renography were used for pre- and postoperative assessment. Success was defined as removal of symptomatic obstruction or improvement of hydronephrosis. Thirteen patients from 3.0 months to 12 years old were identified: 6 patients presented with asymptomatic hydronephrosis (according to the renal ultrasonography), 3 with intermittent abdominal pain, and 2 with gross hematuria. The remaining 2 patients presented with urinary extravasation after inguinal hernia repair and the Soave procedure, respectively. All patients underwent laparoscopic end-to-end UU. Procedures were performed using either the laparoscopic transperitoneal approach or laparoscopic retroperitoneal approach. All surgeries were performed successfully except for one case that required open surgery because of difficult anastomosis. There were no intraoperative or immediate postoperative complications. The etiology of the midureteral obstruction included congenital midureteral stricture, ureteral polyp, retrocaval ureter, and iatrogenic injury. The mean surgical time was 148.4 min, and postoperative hospital stay was 4.0-9.0 d. Postoperative outcomes were successful in all 13 patients (100%); median follow-up was 19.1 months. Laparoscopic UU was found to be feasible and safe for the management of midureteral obstruction in children.

Ureterocele in newborns, infants and children: Ten year prospective study with primary endoscopic deroofing and double J (DJ) stenting

AimTo evaluate the success of endoscopic deroofing with double J (DJ) stenting as a primary treatment modality of uncomplicated ureterocele. Patients and methodsAll babies with uncomplicated ureterocele referred to us between 2005 and 2015 were to be prospectively recruited into the study without any exception. The preoperative management would include ultrasound KUB on a fixed protocol, micturating cystourethrogram, DTPA scan and MRU (magnetic resonance urography) or IVP (intravenous pyelography). Those who had non-obstructing ureterocele were to be followed conservatively. The indications for operative intervention were to be obstructed ureterocele, bladder outlet obstruction, recurrent UTI or progressive renal scarring. They were then to be taken for cystoscopy in diuretic phase for endoscopic deroofing and DJ stenting with 9F resectoscope. Four weeks later, the DJ stent was to be removed after examining the deroofing in each patient. They were then followed up for future development of symptoms and need for secondary surgery with anatomical and functional imaging as necessary. ResultsForty three consecutive patients (47 ureterocele units) with ureterocele were recruited into the study between 2005 and 2015. Thirty four patients were managed by endoscopic first approach with ureterocele deroofing and DJ stenting. Four babies were asymptomatic and did not show obstructed drainage pattern on DTPA and hence were managed conservatively and kept on follow-up. Four patients underwent primary open surgery and reconstruction because of presentation with complications. Ectopic ureteroceleThere were 17 patients with ectopic ureterocele. Thirteen underwent primary endoscopic deroofing. Three underwent open surgery and one underwent robotic bilateral ureterocele excision and ureteric reimplantation. Eight children out of thirteen are completely asymptomatic after the endoscopic incision. On ultrasound evaluation 8/13 have resolution of the hydronephrosis and 5/13 have stable hydronephrosis with no increase in dilatation. None of these 13 children have required a second endoscopic procedure for inadequate decompression of the ureterocele. None of the 13 patients have any voiding difficulty or incontinence. 2/13 cases with recurrent UTI and persistent symptoms, required secondary surgery. This constituted 15% secondary surgery in the ectopic ureterocele category. Orthotopic ureteroceleThere were 21 patients out of 22 with orthotopic ureterocele who underwent endoscopic deroofing. Six out of these 21 patients had episodes of UTI, of which three had resolution of the reflux and two had downgrading of reflux. One child continued to have recurrent UTI and needed a laparoscopic nephroureterectomy. Eighteen children are completely asymptomatic after the initial endoscopic deroofing. The rate of secondary surgery was 4.7% in orthotopic ureterocele group, where nearly 50% have more than five years follow-up. None of our patients who are more than five years, have had any urinary incontinence or voiding dysfunction. All patients remain on follow-up from 6months to 10years (median 5years). ConclusionAt this stage of our study with median follow-up of 5years (6months–10years), we suggest that primary endoscopic deroofing with DJ stenting for obstructing ureterocele is the best initial approach for adequate decompression and reducing the rate of secondary surgery.

The connection of hydronephrosis and microcirculation deterioration

Abstract In this study, we have analyzed the influence of hydronephrosis upon the microcirculation system, in situations of pyeloureteral junction obstruction. Herein, bulbar conjunctiva has been chosen as the object of this biomicroscopic study because of its simplicity and the method availability in clinic practice. In fulfilling this work, we ascertained the connections between extravascular, intravascular, vascular and general conjunctival indices of the patients before radical and paliatic correction of the pyeloureteral junction obstruction (i.e. by open and laparoscopic pyeloplasty, endopyelotomy, laser resection and balloon dilatation). We concluded that, apart from the proved deterioration of kidney function, systemic deteriorations of microcirculation may be observed in situations of clinically marked hydronephrosis, according to the results of radioisotope renography and excretory urography.

Arterial Clamping Increases Central Renal Cryoablation Efficacy: An Animal Study.

The minimally invasive treatment of small renal masses with cryoablation has become increasingly widespread during the past 15 years. Studies with long-term follow-up are beginning to emerge, showing good oncological control, however, tumors with a central and endophytic location seem to possess an increased risk of treatment failure. Such tumors are likely to be subjected to a high volume of blood giving thermal protection to the cancerous cells. Arterial clamping during freezing might reduce this effect but at the same time subject the kidney to ischemia. The aim of this study was to evaluate the effect of renal artery clamping during cryoablation in a porcine survival model. Ten Danish Landrace pigs (approximately 40 kg) underwent bilateral laparoscopic cryoablation with clamping of the right renal artery during freezing. The cryoablation consisted of a standard double-freeze cycle of 10-minute freeze followed by 8 minutes of thaw. Arterial clamping subjected the right kidney to 2 cycles of ischemia (10 minutes) with perfusion in between. After surgery, the animals were housed for 14 days prior to computed tomography perfusions scans, radioisotope renography, and bilateral nephrectomy. No perioperative or postoperative complications were experienced. Mean differential renal function was 44% (95% confidence interval: 42-46) in the clamped right kidney group and 56% (95% confidence interval: 54-58) in the nonclamped left kidney group, P < .05. The ±5% technical inaccuracy is not accounted for in the results. Mean maximum temperature between freeze cycles was 5.13°C (95% confidence interval: -0.1 to 10.3) in the clamped right kidney group and 22.7°C (95% confidence interval: -16.6 to 28.8) in the nonclamped left kidney group, P < .05. Mean cryolesion volume, estimated on computed tomography perfusion, was 12.4 mL (95% confidence interval: 10.35-14.4) in the clamped right kidney group and 6.85 mL (95% confidence interval: 5.57-8.14) in the nonclamped left kidney group, P < .05. Pathological examination shows a higher degree of vital cells in the intermediate zone of the cryolesions in the nonclamped left kidneys when compared with the clamped right kidneys. Arterial clamping increases cryolesion size by approximately 80%, and pathologic examinations suggest a decreased risk of vital cells in the intermediate zone. The clamped kidneys showed no sign of injury from the limited ischemic insult. This study was limited by being a nontumor model.

Estimated GFR (eGFR) by prediction equation in staging of chronic kidney disease compared to gamma camera GFR

Background: Glomerular filtration rate is an effective tool for diagnosis and staging of chronic kidney disease. The effect ofrenal insufficiency by different method of this tool among patients with CKD is controversial.Objective: The objec­tive of this study was to evaluate the performance of eGFR in staging of CKD compared to gamma camera based GFR.Methods: This cross sectional analytical study was conducted in the Department of Biochemistry Bangabandhu Sheikh Mujib Medical University (BSMMU) with the collaboration with National Institute of Nuclear Medicine and Allied Sciences, BSMMU during the period of January 2011 to December 2012. Gama camera based GFR was estimated from DTP A reno gram and eGFR was estimated by three prediction equations. Comparison was done by Bland Altman agree­ment test to see the agreement on the measurement of GFR between three equation based eGFR method and gama camera based GFR method. Staging comparison was done by Kappa analysis to see the agreement between the stages identified by those different methods.Results: Bland-Altman agreement analysis between GFR measured by gamma camera, CG equation ,CG equation corrected by BSA and MDRD equation shows statistically significant. CKD stages determined by CG GFR, CG GFR corrected by BSA , MDRD GFR and gamma camera based GFR was compared by Kappa statistical analysis .The kappa value was 0.66, 0.77 and 0.79 respectively.Conclusions: This study findings suggest that GFR estimation by MDRD equation in CKD patients shows good agreement with gamma camera based GFR and for staging of CKD patients, eGFR by MDRD formula may be used as very effective tool in Bangladeshi population.

Use of Contrasted Computerized Tomography as a Surrogate for Nuclear Medicine Renogram to Categorize Renal Function in the Setting of Ureteropelvic Junction Obstruction

To use basic measurements on contrasted computerized tomography (CT) to reliably determine whether a kidney with ureteropelvic junction obstruction (UPJO) is definitively functional (≥30% differential renal function [DRF]) or nonfunctional (≤10% DRF), obviating the need for nuclear medicine renogram (RG) to determine DRF. This is a single institution, retrospective cohort of patients diagnosed with UPJO who underwent either pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both preoperative mercaptoacetyltriglycine RG and contrasted CT within 180 days of each other. Patients with stents or nephrostomy tubes were excluded. A total of 49 patients were included. The strongest correlation between differential CT measurements and DRF on RG existed by multiplying the cortical area by the average cortical Hounsfield units (Pearson's r = 0.90, P < .001). Using an equation derived from linear regression and cutoff values generated by receiver operator curve (ROC) analysis, CT equation-estimated DRF values of ≥40% and ≤10% correlated with "definitively functional" RG values of ≥30% (100% specificity) and with "definitively nonfunctional" RG values of ≤10% (100% specificity), respectively. In 30 out of 49 cases, CT could have replaced RG. RG is the gold standard in determining quantitative DRF. However, the treatment algorithm for a kidney with symptomatic UPJO hinges on categorized function: "functional" (repair) or "nonfunctional" (remove). Appropriate measurements on contrasted CT can categorize definitively functional or nonfunctional kidneys with UPJO, negating the need for RG to obtain DRF in a majority of cases. This study design favors real-world application with potential to reduce medical expenditure and delay in definitive treatment.

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

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

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.

Role of open surgery in the management of staghorn calculus

Objective: To evaluate the role of open surgery in the management of staghorn calculi by comparing it with other available modalities of treatment i.e. percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) and assessing improvement in the renal function (parenchymal thickness & glomerular filteration rate (GFR) after stone removal. Design: Institutional- based prospective study. Place and Duration of study: This study was conducted at the department of Urology, Nishter hospital, Multan from January 2000 to February 2002 (2 years). Subjects & Methods: A total of fifty patients with staghorn calculi who underwent open surgery in the department & completed a three-month follow-up were included in the study. All patients had a complete blood examination (CBE), complete urine examination (CUE) (including culture & sensitivity (CIS), renal parameters (urea & creatinine), renal tract ultrasonography (USG) preoperatively & at first, second & third month of follow-up to assess the improvement in heamoglobin, control of urinary tract infection (UTI), parenchymal thickness & postoperative complications. Tc99m DTPA scan was employed before surgery & at third month of follow-up to evaluate the improvement in GFR for operated kidney. Results: The male to female ratio was 2.1:1, with a mean age of presentation of 42.70 years. Pain in the lumbar region (58%) was the most common presentation followed by lower urinary tract symptoms (LUTS 32%) & renal insufficiency (16%). Fever (36%) was the most common postoperative complication. The mean cortical thickness increased to 10.68 mm at third month of follow-up, compared to 9.26mm before surgery. The mean preoperative Hb was 10.84gm/dl. It fell to 10.21 gm at first month of follow-up but increased to 11.89 gm by the third month. . The mean GFR before surgery was 77.18ml/min, which increased to 81.56ml/min after surgery at third month of follow-up. The mean GFR of the kidney with stones was 32.46 ml/min before surgery, which increased to 39.84-ml/ min after surgery. Conclusion: Staghorn stones if left untreated lead to chronic UTI & renal insufficiency. Removal of the stone is the only way these consequences can be avoided. Nonavailability of resources, a poor health care system, the lack of PCNL & ESWL facilities &/or expertise, the cost & need for multiple sessions &/or ancillary procedures in these minimally invasive techniques & the vigorous follow-up required still make open surgery a viable & an applicable option in our socioeconomic setup.

The staging evaluation of ketamine associated urinary dysfunction based on a scoring system

Objective To establish the a staging system based on scoring of ketamine associated urinary dysfunction (KAUD) and evaluate its diagnosis performance and clinical value. Methods A retrospective analysis of 135 admitted KAUD patients from September 2009 to September 2015 was performed. All patients were classified into three stages according to bladder and upper urinary tract impairment, and treated with subsequent strategy. The behavioral modification and pharmacotherapy was performed in stage I which image investigation was normal. Hydrodistension and intravesical perfusion was used if pharmacotherapy failed in stage II patients who had bladder impairment in image or urodynamics. Augmentation cystoplasty or cystectomy with urinary diversion was optional if aforementioned treatment failed in stage III who had upper urinary tract involvement and abnormal renal function. The voided volume, micturition interval, and nocturnal void frequency as recorded in their 3-day bladder diary, PUF, ICPI and ICSI score after treatment in one month, were compared with their baseline data prior to treatment. Ketamine abusing history, renal and liver function, bladder and upper urinary tract changes, urodynamics and radioisotope renography correlation with stages were analyzed. A scoring system was established and the concordance between the clinical staging and model staging of each patient was compared. Receiver operating characteristic curve was employed to testify the sensitivity and specificity. Results There were 39, 80 and 16 patients included in each stage respectively. After subsequent strategy of treatment, voided volume, micturition interval, and nocturnal void frequency, PUF, ICPI and ICSI were improved significantly. Age (P=0.018), ketamine abusing history (P=0.006), eGFR (P=0.001), ALT (P=0.037), γ-GT (P<0.001), bladder (P=0.013) and ureteral changes (P<0.001), hydronephrosis (P<0.001) and radioisotope renography abnormality (P=0.01) were correlated with clinical stages. In total, 107 cases’ stages based on scoring were accordant with clinical stages (30, 65 and 12 cases in each stage respectively). AUC of the scoring model ROC was 0.922 on cut point between I and II stages and AUC of the scoring model ROC was 0.978 on cut point between II and III stages. Conclusions We presented a scoring staging system of KAUD based on ketamine abusing history, laboratory test results, and imaging findings. It might be helpful to evaluate the progression on bladder and upper urinary tract, and provide a reference for treatment. This staging system based on scoring still needs further validation and improvement. Key words: Ketamine; Urinary system; Clinical stage; Scoring system; Diagnostic value

PD14-08 CORRELATION BETWEEN CONTRASTED CT SCAN AND NUCLEAR MEDICINE IMAGING TO DETERMINE DIFFERENTIAL RENAL FUNCTION IN URETEROPELVIC OBSTRUCTION

INTRODUCTION AND OBJECTIVES: Nuclear medicine renogram (RG) is the gold standard in determining differential renal function. However, the treatment decision for symptomatic ureteropelvic junction obstruction (UPJO) hinges on a dichotomous decision regarding the affected kidney: functional vs. nonfunctional. We predict that basic measurements taken from a contrasted CT scan can be used to reliably determine whether a kidney with UPJO is definitively functional or nonfunctional, thus obviating the need for a RG in many cases. METHODS: This is a single institution, retrospective cohort of patients with UPJO who either underwent pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both a pre-operative contrasted CT and a RG within 180 days of each other. Patients were excluded if a stent or nephrostomy tube was present at the time of the images. A single observer performed renal measurements on contrasted CT scans to predict the results obtained from RGs. RESULTS: 56 patients were included in the study. By using renal measurements with default imaging software to calculate the average cortical area and average cortical Hounsfield units, there exists a strong correlation between differential CT measurements and differential renal function on RG (Pearsons r 1⁄4 0.92, p < 0.00001). Using an equation generated by linear regression, CT measurements predicting 39% and 10% function correlated with RG values of 30% (100% specificity) and 10% (100% specificity), respectively, on ROC analysis. Using these cut-off values, over half (30/56) of the RGs would be considered unnecessary for determination of differential renal function. CONCLUSIONS: Contrasted CT in UPJO patients may be utilized to identify definitively functional or definitively nonfunctional kidneys, negating the need for RG prior to appropriate operative intervention in many cases. Our study is the largest homogenous UPJO cohort to evaluate the correlation between CT and RG, does not require additional imaging software, and maintains 100% specificity for determining clearly functional and nonfunctional kidneys when using appropriate cut-offs. The study design favors real-world application, and these findings show great potential in reducing medical cost and time to treatment without sacrificing quality or confidence in medical care.

MP29-09 RENO-PROTECTIVE EFFECT OF LOCAL SILDENAFIL ADMINISTRATION IN CANINE MODEL OF RENAL ISCHEMIA REPERFUSION INJURY

INTRODUCTION AND OBJECTIVES: The reno-protective effect of systemic Sildenafil administration in renal ischemia reperfusion injury (IR) animal models has been proved. Nevertheless, the local effect of Sildenafil on IRhas not been established yet. Therefore, we designed a new canine model of IR injury to investigate the effect of local Sildenafil administration during renal ischemia. METHODS: One hundred and twenty male mongrel dogs were classified into 5 groups (each consists of 24 dogs): sham (underwent right nephrectomy without ischemia), oral control (underwent right nephrectomy and left ischemia for 60 min), oral Sildenafil (OS) group (as control with oral Sildenafil 1mg/kg 60 min before ischemia), local control (local perfusion of ischemic left kidney with saline and heparinfor 5min) and local Sildenafil (LS) group (the same as local control with addition of Sildenafil 0.5 mg/kg to the perfusion solution). Serum creatinine (SCr), blood urea nitrogen (BUN) and radioisotope renography were measured at 1, 3, 7 and 14 days. Histopathological examination of the inner cortex and outer medulla was performed by non-informed pathologist. In kidney tissues, mRNA ofantioxidants glutathione reductase (GSH), sodium dismutase (SOD), and endothelial nitric oxide synthase (eNOS) were measured. Oxidative stress markers e.g. malondialdehyde (MDA), and angiogenesis markers e.g. vascular endothelial growth factor (VEGF) were assessed. Similarly, markers of inflammation e.g. Tumor necrosis factor-a (TNF-a), interleukin1s (IL1s), and intracellular adhesion molecule (ICAM-1) were assessed. The expression of cleaved caspase-3 was assessed by immunohistochemical staining. RESULTS: Serum creatinine, BUN and GFR improved significantly in Sildenafil-treated groups in comparison to their control groups with LS had better improvement than OS (p<0.05) (Fig. 1). LS showed significant attenuation of cortical and outer medullary damage scores and less neutrophil infiltration than other groups. Sildenafil-treated groups showed higher expression of antioxidant markers than control groups while LS has higher antioxidant markers than OS (p<0.05). Sildenafil-treated groups showed lower expression of oxidative stress, angiogenesis and inflammatory markers than control groups (p<0.05). LS had lower expression of these markers as well as apoptotic markers than OS (p<0.05). CONCLUSIONS: Sildenafil has a reno-protective effect via its anti-apoptotic, anti-inflammatory, and antioxidant effects. Local administration of Sildenafil seems to be more effective than systemic administration. These results may provide a base for its application in the process of renal transplantation in human during renal perfusion.

Initially Asymmetrical Function on MAG3 Renography Increases Incidence of Adverse Outcomes

To discriminate pathological from physiological hydronephrosis (99m)Tc-mercaptoacetyltriglycine (MAG3) diuretic renography is a fundamental imaging modality. Initial asymmetrical differential function or decreasing function on serial MAG3 scans is a classic surgical indication. However, prognostic evidence supporting this is limited. Therefore, we examined the association between initial function and outcomes. We hypothesized that patients with initially asymmetrical function would have higher odds of functional decline, and experience symptoms and surgical intervention compared to patients with initially symmetrical scans. We retrospectively reviewed the charts of 1,124 pediatric patients with hydronephrosis seen at Stollery Children's Hospital from 2000 to 2014. A total of 387 cases of unilateral ureteropelvic junction obstruction were grouped by initial postnatal differential function with asymmetrical defined as a greater than 10% difference in relative function. Postnatal surveillance, followup MAG3 results, pyeloplasty rates and post-pyeloplasty outcomes were compared. Of 387 patients 143 (37%) had initially asymmetrical function. Of those undergoing MAG3 scan surveillance 17% experienced a 10% or greater decline in ipsilateral differential function vs a 6% rate of function loss in the initially symmetrical group (OR 3.2, 95% CI 1.6-6.4, p = 0.0008). The overall pyeloplasty rate in patients with asymmetrical and symmetrical function was 27% and 16%, respectively (OR 1.9, 95% CI 1.1-3.2, p = 0.013). Patients with initially asymmetrical function had an increased rate of pyeloplasty secondary to symptoms compared to those with initially symmetrical function (16% vs 8%, OR 2.1, 95% CI 1.1-4.0, p = 0.019). Mean time to functional decline and pyeloplasty was 19and 17 months, respectively. Patients with initially asymmetrical differential function had increased ORs for subsequent renal decline, symptom onset and pyeloplasty.

Clearance of technetium-99m-DTPA in pulmonary sarcoidosis

The aim of this study was to explore the possible association of the lung clearance of 99mTc-DTPA scan with HRCT lung abnormalities and with the pulmonary function tests [PFTs] in patients with sarcoidosis. We studied prospectively 15 patients [5 males, 10 females] of median age 46yr [range 27-67] with histologically proved sarcoidosis. HRCT scoring included the sum of the severity and extent of lymph node enlargement and parenchymal involvement. The mean DTPA clearance half-time [tau 1/ <40 min] was found [mean [SD]] 38.3+/-4.5min. The lymph node enlargement was found 34% and the parenchymal involvement 12%. DTPA clearance was negatively correlated with the parenchymal involvement [r= -0.651, p=0.0091]. The HRCT parenchymal abnormalities were found significantly correlated with PFTs [FVC [r= -0.65, p=0.008] and TLCO [r= -0.76, p=0.02]. Our data suggest a moderate association between 99mTc-DTPA scan and HRCT in pulmonary sarcoidosis. However, further studies in large scale of sarcoid patients are needed to clarify the role of this novel methodology in the evaluation and follow-up of this disorder.

Role of renal cortical scintigraphy with Tc99m-DMSA in diagnosing renal scarring in patients undergoing staged reconstruction of classical urinary bladder exstrophy

Objectives: The purpose of this study was to find out incidence of renal cortical scintigraphy done with Technetium-99m (Tc-99m) dimercaptosuccinic acid III (DMSA-III), scan to diagnose cortical scarring in patients undergoing staged reconstruction of exstrophy bladder. Patients and Methods: We retrospectively reviewed 29 post operative patients who were referred to our department for Tc99m-DMSA scan to look for renal cortical scarring from January 2012 to April 2016. Tc-99m DMSA(III) scan was done in all 29 patients (58 kidneys). Tc-99m DTPA and Tc-99m L, L-EC scans were done in 9 (18 kidneys) and 2 (4 kidneys) patients respectively. Results: Out of 29 patients male comprised 69% of cases (n = 20) and female comprised 31% of cases (n = 09).The mean age of the presentation of patients with exstrophy bladder was 7.8 years. Tc-99m DMSA(III) scan was done in 29 patients (58 kidneys).Scarring was noted in 28/58 kidneys (48.27%) on Tc-99m DMSA(III) scan. Tc-99m DTPA scan was done in 9 patients (18 kidneys). In Tc-99m DTPA scan mean GFR (standardized Gates gamma camera method) was 71.91ml/min. Micturating cystouretherography(MCU) was done in 10 patients which revealed vesicoureteric reflux(VUR) in all the patients. DRCG was done in 1 patient which showed unilateral high grade VUR. Ultrasonography (USG) was done in 29 patients. Eighteen patients were found to have normal USG findings. Four patients had bilateral hydroureteronephrosis (HDUN) and one had unilateral HDUN. Three had mild hydronephrosis (HDN) and 3 had gross HDN. Conclusion: Preservation of renal function is one of the major goals of staged reconstruction of bladder exstrophy. Renal cortical scintigraphy with Tc-99m DMSA-III has become the “the gold standard” for renal cortical scarring imaging. Hence Tc-99m DMSA scan offers a significant diagnostic advantage over other diagnostic modalities to diagnose and follow up renal cortical scarring in patients with exstrophy bladder thus help in management.

Clinical study of robot-assisted laparoscopic surgery for the treatment of complex nephrolithiasis

Objective To investigate the clinical efficacy and safety of robot-assisted laparoscopic surgery for the treatment of complex nephrolithiasis. Methods The retrospective analysis of 31 cases of robot-assisted laparoscopic surgery for the treatment of complex nephrolithiasis was carried out. 20 of these patients were male, while the others were female. The average age of these patients was 47 years, ranged from 26-73. Sixteen patients had calculi located both in subrenal calyx and ureter, 7 cases of them had ureteropelvic junction obstruction while the subrenal calyx calculus were far away from ureteropelvic junction. Out of the total 31 cases, 9 were multiple renal calculi, 3 were staghorn calculi, 3 were congenital renal malformation with staghorn calculi. The average diameter of calculi was 33 mm, ranged from 15 to 78. 19 cases had obvious pelvic separation presented by pre-operative ultrasonography, average 33 mm, ranged from 12 to 62 mm. All the cases were performed by robot-assisted laparoscopic surgery transperitoneally. Results All operations were successful without converting to laparoscopy or open surgery. The average operative time (robotic console time) was 64 min, ranged from 45 to 128 min. The average estimated blood loss during operation was 80 ml, ranged from 10-400 ml. The length of post-operative hospital stay were 4-11 days, average 6 days. The average removal time of drainage was 4 days, ranged from 2 to 7 days. There was no severe complications after operation. The diuretic renogram showed that the obstruction in patients with UPJO was cured or significantly improved. The average follow-up time was 7 months(ranged from 2 to 27 months). Post-operative KUB X-ray showed no residual calculi in 29 patients. The average value of serum creatinine (Cr) was 96.5 μmol/L (ranged from 88.4 to 126.5 μmol/L) in one month post-operative follow-up. The glomerular filtration rates of affected side recovered to 36.5-45.7 ml/min, average 41.3 ml/min, in those 3 patients who had staghorn calculi. Conclusion Robot-assisted laparoscopic surgery may provide an excellent alternative option in the treatment of complex nephrolithiasis. Key words: Complex nephrolithiasis; Robot-assisted laparoscopic surgery; Staghorn calculi

Is a Reassuring MAG-3 Diuretic Renal Scan Really Reassuring?

Objective: The mercaptoacetyltriglycine-3 (MAG-3) diuretic renal scan is frequently used to diagnose obstruction in children with hydronephrosis. However, it remains unclear whether a reassuring MAG-3 diuretic scan in the presence of high-grade hydronephrosis accurately predicts the absence of obstruction. We sought to determine if a reassuring nuclear scan can accurately identify patients with high-grade hydronephrosis that can be safely observed. Materials and Methods: We retrospectively reviewed the course of 22 children (25 renal units) ages 0-3 months with significant hydronephrosis (Society of Fetal Urology grade 3-4) detected prenatally. All patients underwent a MAG-3 diuretic nuclear renal scan. Results: Twenty-two patients with 25 renal units were included, 19 with grade 3 and 6 with grade 4 hydronephrosis on ultrasound. Sixteen renal units had a reassuring nuclear scan (T ½ < 10 minutes, average 5.9, range 2-9). Nine renal units had indeterminate scans (T ½ 10-20 minutes, average 12.8, range 10-17). Fifteen of 16 (94%) kidneys with a reassuring nuclear scan had complete resolution of their hydronephrosis. One patient with an initially reassuring nuclear scan underwent pyeloplasty after persistent grade 4 hydronephrosis one year later prompted a repeat MAG-3 indicating obstruction. Eight of 9 (89%) patients with an indeterminate T ½ of 10-20 minutes had complete resolution of their hydronephrosis. One patient was lost to follow up. Average length of follow up and time to resolution was 23.6 months (range 4-61 months). Conclusion: In pediatric patients with persistent antenatally detected hydronephrosis, a reassuring MAG-3 can allow for safe observation in the vast majority. Only one of 24 renal units with follow-up progressed to obstruction. All patients treated without surgery had complete resolution of their hydronephrosis. Observation with serial ultrasounds may be an appropriate alternative to operative management, even in patients with moderate to severe hydronephrosis in the presence of a reassuring or indeterminate MAG-3 diuretic scan.

Renal perfusion phase curve analysis in DTPA renal scintigraphy – significance &amp; utility

Aims and Objectives: The retrospective study of renal scans aims at analysing the renal perfusion phase curve in the DTPA scan. Four different types of perfusion phase curves for non-transplant kidney are defined and validated by comparing them with the Hilson perfusion index and Kirchner’s K/A ratio.Materials and Methods: This study consists of 36 patients comprising of 26 males with mean age of 26.17 ± 18.65 and 10 females with the mean age of 33.20 ± 11.69. Renal scans were done using Siemens dual head gamma camera. 3-5mCi 99m Tc DTPA was used and injected intravenously, images were processed to obtain the renal curve using the icon software utilizing the Gate’s formula. The perfusion curves, which form the part of renographic curves are taken for scrutiny, are classified into different types and perfusion index was calculated.Results: The perfusion phase curves were scrutinised and categorised in 4 types. These curves have been validated by using Hilson index and Kirchner’s K/A ratio. Hilson perfusion index and Kirchner’s K/A ratio shows a good correlation with the uptake phase of conventional renal curve. We observed 47.22% of Type I, 22.22% of Type II, 16.67% of Type III and 13.89% of Type IV.Conclusion: This study highlights the utility of renal perfusion phase curve analysis in the non-transplant kidney. This can also serve as a better prognostic tool in the chronic kidney disease patient.Asian Journal of Medical Sciences Vol.7(2) 2015 44-48

Comparison of Renal Scintigraphy and Computed Tomographic Renal Volumetry for Determining Split Renal Function and Estimating Post-Transplant Renal Function

BackgroundIn living donor kidney transplantation, the decision regarding which donor kidney to transplant is based on characteristics such as vascular anatomy and split renal function (SRF). Computed tomography (CT) was used to assess vascular anatomy and renal scintigraphy was used to evaluate SRF. The ability of split renal volume (SRV) calculated from volumetric examination of CT scans and that of SRF of renal scintigrams derived from Tc-99m mercaptoacetyltriglycine-3 (MAG3) renography to predict donor residual single kidney function after donor nephrectomy were compared. Material and MethodsCT images and renal scintigrams from 35 live kidney donors who had at least 1 year post-donation renal function follow-up were analyzed. ResultsPredonation GFR was 99.1 ± 17.2 mL/min/1.73 m2. The average right and left kidney volumes were 138.8 ± 29.4 mL and 136.1 ± 29.2 mL, respectively. SRV was strongly and significantly correlated with SRF-MAG3 (r = 0.714). The residual renal functions predicted from calculating SRV and SRF-MAG3 were 46.2 ± 8.3 mL/min/1.73 m2 and 46.0 ± 9.2 mL/min/1.73 m2, respectively. Both SRV (r = 0.708) and SRF-MAG3 (r = 0.634) showed significant linear correlations with residual renal function after 1 year, with SRV showing a stronger correlation. ConclusionCalculating SRV from predonation CT examination is a valid method to estimate postdonation renal function after 1 year. CT volumetry may become a standard method in the near future.

Kidney Paired Donation Protocol for Participating Donors 2014.

Kidney Paired Donation Protocol for Participating Donors 2014.