Ureterovesical Junction Obstruction Research Articles

Long-Term Follow-Up after Ureteral Reimplantation in Children: A 12-Year Analysis

Abstract Background Ureteral reimplantation (UR) is a well-established procedure, yet there exists a notable absence of evidence-based guidelines for postoperative follow-up. Existing literature suggests that routine follow-up extending beyond one year may not yield significant advantages, particularly for asymptomatic children. However, it is crucial to acknowledge that many studies supporting this assertion rely on relatively short observation periods. Aims This study seeks to address the potential emergence of late-presenting complications post UR. Our objective is to comprehensively evaluate our patient cohort for the incidence of conditions warranting the establishment of standardized, long-term follow-up practices after UR. Methods Retrospective review of 137 medical records from children who underwent UR at our institution between January 2006 and June 2013. Inclusion criteria required a minimum 10-year postoperative follow-up. Results Fifty-three renal units in 34 children met inclusion criteria. Ureterovesical junction (UVJ) obstruction occurred in 7.5% of the units and was diagnosed within eight months after UR. Obstruction occurred exclusively after Politano-Leadbetter reimplantation and was silent in all cases. Postoperative UTIs occurred in 9 children. Notably, these were all singular events without signs for recurrent reflux. A decade after surgery, one child developed chronic kidney disease (CKD) due to preexisting reflux nephropathy (RN), while one child was newly diagnosed with RN during follow-up despite the timely surgical correction of vesicoureteral reflux (VUR). or hypertension linked to RN were recorded. Conclusion Children with uncomplicated postoperative recoveries within the first-year, devoid of evident UVJ obstruction, exhibit a low subsequent risk, suggesting limited benefit from repeated scheduled long-term follow-up. Nevertheless, we recommend that general practitioners conduct regular monitoring, considering individual risk factors, to enhance the detection of late-onset hypertension or proteinuria as potential indicators of RN during adolescence.

Antenatally detected urinary tract dilatation: a pediatric nephrologist's point of view

Antenatally diagnosed urinary tract dilatation (UTD), previously referred to as antenatal hydronephrosis, is the most commonly detected abnormality by prenatal ultrasonography. Several grading systems have been developed for the classification of antenatal UTD using prenatal and postnatal ultrasonography. UTD comprises a wide variety of congenital abnormalities of the kidney and urinary tract ranging from transient UTD to more significant abnormalities such as vesicoureteral reflux, ureteropelvic junction obstruction, ureterocele, ureterovesical junction obstruction, posterior urethral valves, and non-refluxing megaureter. Optimizing the evaluation of antenatally detected UTD is essential to recognize children with important disorders while avoiding excessive investigations. Conservative approach with close follow-up is increasingly accepted as an appropriate treatment option for patients with asymptomatic vesicoureteral reflux and ureteropelvic junction obstruction in recent years. However, predicting permanent kidney damage in an unselected group of children with antenatal UTD is still challenging. The management and follow-up of children with UTD should be individualized based on recommendations from a pediatric nephrologist, a pediatric urologist, or both. Future research directed at predicting long-term outcomes of children diagnosed with UTD from mild findings to severe disease is needed to refine management for those at higher risk of kidney disease progression.

Failure in Double-J stent inserting in laparoscopic pyeloplasty of ureteropelvic junction obstruction: the clinical features and outcomes

BackgroundDouble-J (DJ) stent placement is an important procedure during laparoscopic pyeloplasty (LP). Failing to insert the DJ stent may indicate the patient was also complicated with uretero-vesical junction obstruction (UVJO), and surgeons have to change to another alternative drainage method. In the present study, we analyzed the risk factors of failure of DJ stent placement during the LP and reviewed the clinical outcomes of these challenging pyeloplasties.MethodsWe retrospectively analyzed the clinical data of patients with ureteropelvic junction obstruction (UPJO) who underwent LP in our department from January 2016 to September 2020. For patients who developed a difficult process of inserting the DJ stent, the externalized uretero-pyelostomy (EUP) stent was indwelled. Patients were finally divided into two groups: DJ group and EUP group. The primary outcomes were recurrent UPJO, postoperative uretero-vesical junction obstruction (UVJO) and complications.ResultsA total of 535 patients were included in the study, of which 37 patients (6.9%) failed to insert the DJ stent. Age was younger, and weight was lower (P < 0.05) in the EUP group. Within follow-up, recurrent UPJO occurred in ten (1.87%) patients, nine in the DJ group and one in the EUP group (P > 0.05). The incidence of postoperative UVJO in the EUP group was significantly higher than in the DJ group (10.8% vs. 0.2%, P < 0.01). 74 patients (13.8%) developed complications after surgery, 12 patients (32.4%) in the EUP group, significantly higher than that in the DJ group (32.4% vs. 12.4%, P < 0.01). Compared with the DJ group, the larger APD were observed in the EUP group at three months postoperatively (3.50 [3.02;4.58] vs. 2.20 [1.50;2.88], P < 0.05), but the difference vanished in further follow-up.ConclusionThe failure of DJ stent placement tends to occur in patients with younger age, lower weight, and larger preoperative APD. Failure may not increase the recurrent UPJO rate, but may indicate a higher probability of postoperative UVJO and may develop more postoperative complications and slower recovery.

Pilot Study on the Molecular Pathogenesis of Pyeloureteral Junction Obstruction: Underdevelopment or Fibrosis?

Background and Objectives: Congenital ureteral stenosis is one of the leading causes of impaired urinary drainage and subsequent dilatation of the urinary collecting system, known as hydronephrosis or ureterohydronephrosis. The mechanism that leads to obstruction is not clearly known. Multiple studies in rat models have shown increased angiotensin II and TGFβ levels in obstructed ureteral tissue. The aim of the study is to investigate the expression of fibrosis-related genes in obstructive and normal ureteral tissue. Material and Methods: It is a monocentric pilot study in which nineteen patients were selected prospectively. 17 patients underwent Hynes-Anderson pyeloplasty due to the PUJO; two patients underwent ureteroneocystostomy due to ureterovesical junction obstruction (UVJO); and six patients were chosen for the control group: five underwent nephrectomies due to the kidney tumor and one underwent upper pole heminephrectomy due to the duplex kidney with normal pyeloureteric junctions in all. Tissue RNA was chemically extracted after freezing the biopsy samples in liquid nitrogen, with cDNA synthesis performed immediately after nucleic acid isolation. qPCR was performed to evaluate the relative expression of Tgfb1, Mmp1, Timp1, Pai1, Ctgf, and Vegfa. Expression levels of the Gapdh and Gpi genes (geometric average) were used to calculate the relative expression of the investigated genes. Outliers were removed prior to calculating confidence intervals for the experimental groups, and a Wilcoxon rank-sum test was performed to determine the statistical significance of the differences. Results: Significant differences between healthy and stenotic tissue samples in Ctgf gene expression levels were observed, with the samples from afflicted tissue showing lower expression. No statistical difference in expression levels of Tgfb1, Timp1, Vegfa, Mmp1, and Pai1 was found. Conclusions: These findings suggest that tissue fibrosis, similar to other tissues and organs, is not the leading cause of stenosis, at least at the moment of surgery. Decreased CTGF expression is indicative of the developmental origin of obstruction.

Prenatal diagnosis and outcome of fetal urinomas in relation to the underlying etiology.

Evaluation of course and outcome of pregnancies with prenatally diagnosed fetal urinoma in a single center over a 20-year period. Retrospective study including all prenatally suspected or diagnosed fetal urinomas. Cases were analyzed by ultrasound findings during pregnancy, comparing urinomas caused by lower urinary tract obstruction (LUTO) and ureteropelvic or ureterovesical junction obstruction (UPJO/UVJO). Course of pregnancy and outcomes were compared according to the underlying etiology. 87 cases of fetal urinomas were identified between 2002 and 2022. The underlying etiology was LUTO in 56.3% and UPJO/UVJO in 43.7%. Complications mainly included oligo- or anhydramnios, thoracic hypoplasia as well as associated renal abnormalities. Postnatally, loss of function (LOF) in kidneys affected by urinomas was seen in 78.6% of children overall, but significantly more often in cases of UPJO/UVJO than in LUTO (86.2% vs. 70.2%, p<0.05). Association of prenatal urinoma and postnatal LOF of the affected kidney is high, especially in cases caused by UPJO/UVJO. In survivors with urinoma caused by UPJO/UVJO, the general prognosis is excellent if the contralateral kidney was normal. In survivors with urinomas caused by LUTO, long-term prognosis depends on postnatal renal and pulmonary function.

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 ...

Robotic Assisted Endoscopic Surgery Practices in Pediatric Surgery, Single Center Experience

Objective: While robot-assisted laparoscopic surgery (RALS) is spreading rapidly all over the world, In pediatric surgery, this spread is slower than in adult surgery for many reasons. In this study, we discuss our initial experiences with pediatric robotic surgical cases. Material and Methods: Robotic-assisted endoscopic surgery between November 2017 and April 2022 was retrospectively reviewed. The medical records of the patients were reviewed retrospectively for some demographical features, surgical details, and follow-up time. Results: Of the 48 children, 27 were male and 21 were female. The youngest of the cases was 10 months old, while the oldest was 17 years old (mean 7.72±5.6, median 7). The shortest follow-up period after surgery was 5 months, while the longest follow-up was 60 months. A total of 63 surgical procedures were performed on 48 pediatric patients. 17 pyeloplasty (left 10, right 7), 9 Lich Gregoir operations (right 6, left 3), 4 ureteral reimplantation and tapering procedures due to left ureterovesical junction obstruction (UJO), 3 Hemi nephrectomy, one appendicovesicostomy, One right ureteral reimplantation, 11 Nissen fundoplication, 10 gastrostomy and one gastrojejunostomy, two ovarian sparing surgeries for ovarian cyst were performed. One urachal remnant excision, one adrenal mass excision, and one thoracic outlet mass excision were performed. Conclusion: This is the first study that includes a wide range of pediatric robotic surgical procedures in our country. Robotic-assisted laparoscopic procedures in pediatric surgery can be safely performed for many surgical pathologies. We think at the beginning some simple surgical procedures and then turning to the more complex procedures after at least 15 cases will be more appropriate.

Overlooked Factors Causing Renal Damage in Vesicoureteric Reflux!

Vesicoureteric reflux (VUR), recurrent urinary tract infection (RUTI), febrile urinary tract infection (FUTI), renal scarring, and renal damage are intimately related. Key factors of renal damage in VUR are suspected to be RUTI and FUTI. Hence, conventional treatments are targeted toward the prevention of RUTI and FUTI. However, literatures have witnessed that control of infection is not sufficient enough. That means we are missing some hidden, enigmatic, or overlooked factors which are essentially responsible for renal damage. We know RUTI occurs from the stasis of urine in system and stasis might occur from obstruction somewhere in system. Moreover, obstruction builds up back pressure in the bladder and ureters, and ultimately in kidneys; that pressure is independently harmful to renal function. Pressure is further harmful if this joins together with infection. We know that RUTI and FUTI along with pressure in the urinary tract are harmful to renal parenchyma. Nevertheless, search for the nexus of obstruction, pressure, stasis, infection, and damage (OPSID) of renal function is not yet focused on in VUR research. In this retrospective study on secondary VUR, we would like to find the overlooked factors or nexus of OPSID associated with VUR causing renal damage. A total of 170 renal units of 135 patients with VUR resulted from the posterior urethral valve and from repaired bladder exstrophy, from March 2005 to April 2019, had adequate data regarding control/correction of obstruction and urodynamic studies. The mean patient's age was 2.8 years (range 1 day-14 years). The diagnosis of VURs was made with postnatal cystogram in patients of the posterior urethral valve and of repaired continent augmented bladder exstrophy. We do cystogram not micturating cystogram following ultrasonography if showing dilated ureter/s. If we find no residual in ureter/s after 30 min in cystogram, we label it as "rise and fall" VUR (raf_VUR), i.e., without obstruction. On the other hand, if there is post void residual in ureter/s for more than 30 min, we label it as "rise and stasis" VUR (ras_VUR) means combination of VUR with uretero vesical junction obstruction (UVJO). Along with this, all patients were followed up with albumin creatinine ratio, creatinine clearance, USG Renometry, DTPA renal scan, uroflowmetry, and urodynamic study (UDS). Repeat cystoscopy, if necessary, was done following UDS for secondary bladder neck incision (BNI) or for repeat BNI if necessary. Mean duration of follow-up was 7.2 years (range 3-14 years). Out of 170 renal units, 132 renal units had VUR without VUJO, i.e., raf_VUR and 38 renal units had ras_VUR. All patients of UVJO were relieved either with anticholinergics or with DJ stenting or by re-implantations. Twenty-nine patients out of 135 had high pressure on UDS, and they needed BNI. We were able to prevent upstaging of chronic kidney disease (USCKD) in all 135 patients. Our tangible goal of treatment in VUR is the prevention of USCKD. We differentiated raf_VUR from ras_VUR with cystogram. Patients with ras_VUR and patients with raf_VUR with high bladder pressure were actively treated. This particular subset VUR was treated with prophylactic antibiotic and surgical corrections. We prevented renal damage by eliminating obstruction and stasis which helped to prevent RUTI and FUTI. Possibly, similar management might also help to manage "primary VUR." Possibly those overlooked factors which are essentially responsible for renal damage are veiled in nexus OPSID of the kidney.

Genetic Basis of Congenital Anomalies of Kidney and Urinary Tract

Congenital anomalies of kidney and urinary tract (CAKUT) is a group of abnormalities affecting the kidneys or other structures of the urinary tract that include ureters, urinary bladder and urethra. CAKUT include renal agenesis or hypodysplasia, multicystic dysplastic kidney, ureteropelvic junction obstruction, duplication of the pelvis, ureter, and/or kidney, congenital megaureter, ureterovesical junction obstruction, vesicoureteral reflux and posterior urethral valves. Those results from abnormal development of the urinary system and is present from birth (congenital), although the abnormality may not become apparent until later in life. The clinical spectrum of CAKUT has significant impact on long-term patient survival. We observed that the causes of CAKUT are complex, usually combination of genetic and environmental factors contribute to the developmental abnormalities of kidney and urinary tract in foetus. The genetic factors involved in most cases of CAKUT are unknown; however, syndromic CAKUT is caused by changes in the genes associated with the particular syndrome. Variations in the same genes can also underlie some cases of isolated CAKUT. This review paper aims to discuss genetic basis of CAKUT, i.e., identifying different genes involved in syndromic and non-syndromic CAKUT. Modern genetic testing facilities can provide a precise diagnosis that can help individualize clinical care by screening for specific complications, facilitate medical decision making, and provide better genetic counseling.&#x0D; CBMJ 2022 January: vol. 11 no. 01 P: 69-74

Transvesicoscopic ureteral reimplantation and ureteroscopy for management of primary obstructed non-refluxing megaureter with ureteral calculus.

IntroductionPrimary obstructed non‐refluxing megaureter, a type of congenitally dilated ureter, often resolves spontaneously. Surgery may be indicated in symptomatic cases; however, there are no reports of transvesicoscopic ureteral implantation and ureteroscopy for ureteral stones. Therefore, we describe the treatment of primary obstructed non‐refluxing megaureter and ureteral calculi using this technique.Case presentationA 6‐year‐old Japanese girl was referred for abdominal pain and gross hematuria due to right megaureter with multiple stones in the renal lower‐pole calyces and ureter. She was diagnosed with primary obstructed non‐refluxing megaureter and ureterovesical junction obstruction. The stones were removed using mini‐percutaneous nephrolithotomy and transvesicoureteroscopic surgery, respectively. A narrow segment of the right ureter was cut, and transvesicoscopic ureteral plication and reimplantation were performed. The procedures were successful without postoperative complications.ConclusionTransvesicoscopic ureteral reimplantation with ureteroscopy may be a safe, effective and minimally invasive surgical option for ureterovesical junction obstruction with ureteral stones.

Serum and urine periostin and cytokeratin-18 in children with congenital obstructive nephropathy.

Congenital obstructive nephropathy (CON) is one of the most common causes of chronic kidney disease in children. The aim of the study was to investigate serum and urine periostin and cytokeratin-18 (CK-18) in children with CON in relation to CON etiology, treatment, and kidney injury. We evaluated 81 children with CON secondary to ureteropelvic junction obstruction (UPJO), ureterovesical junction obstruction (UVJO), posterior urethral valves (PUV) and 60 controls. Neither biomarker demonstrated any relation to CON etiology. However, all patients showed significantly higher urine periostin (uPeriostin) and uPeriostin/Cr levels than the controls. Also, UVJO patients showed higher sCK-18 and uCK-18/Cr levels, and PUV patients showed higher uCK-18/Cr levels than the controls. Neither biomarker was found to have any relation to CON treatment. However, conservatively treated children and those before and after surgery showed significantly higher uPeriostin and uPeriostin/Cr levels than the controls. uPeriostin strongly correlated with differential renal function (DRF) < 40%. The ROC analysis demonstrated the best area under the curve (AUC) for uPeriostin (0.831) and uPeriostin/Cr (0.768), and low for sPeriostin (0.656) and uCK-18 (0.615) for detecting renal injury. In conclusion, although serum and urine periostin and CK-18 did not display any relation to etiology or the type of CON treatment, uPeriostin seems to be a useful tool for detecting renal injury in children with CON, especially due to its strong negative correlation with DRF < 40%.

FACTORS ASSOCIATED WITH HAEMATURIA IN CHILDREN IN AGE GROUP OF 1 TO 14 YEARS

BACKGROUND: Haematuria is the most common urinary finding that bring children to the attention of the paediatric nephrologists. It can be caused by glomerular &amp; non-glomerular diseases. The main causes of Haematuria are urinary tract infections, trauma to abdomen, acute post streptococcal glomerulonephritis and congenital hydronephrosis.&#x0D; OBJECTIVE: The objective of this study was to identify the distribution of factors in children with haematuria in age group of 1 to 14 years&#x0D; METHODS: A total of 84 admitted patients of haematuria, who fulfill the inclusive criteria,were enrolled in this study after consent from their parents. Each patient was evaluated through history, examination and investigated. Urine sample of each patient was analyzed for a microscopic examination. Investigations / imaging were performed in clinical laboratory of LGH / PGMI, Lahore. The collected information was entered into SPSS version 20, and analyzed.&#x0D; RESULTS: There were 47(44.05%) male and 37(55.95%) female patients in this study. The mean age of patients was 8.69 ± 3.63 years.We found 14 patients (16.66%) has urological anomalies,6 boys have posterior urethral valves.2 girls and one boy has vesicoureteral reflux.One boy and one girl has ureterovesical junction obstruction,one boy has hypospadias and 2 girls , ureteropelvic junction obstruction.History of recent bladder catheterization was seen in 5(5.59%), urinary tract infection 17(20.23%) and 14 patients has urological anomalies(16.66%).&#x0D; CONCLUSION: According to this study ,most common factors causing haematuria was urinary tract infection 17(20.23%) , acute poststreptococcal glomerulonephritis 16(19.04%) and congenital urological anomalies 14(16.66%).Renal stones were found in 10(11.90%).

Late Presentation of Ureterovesical Junction Obstruction after Submucosal Transurethral Injection of Dextranomer/Hyaluronic Acid Copolymer for Vesicoureteral Reflux

Objective – We report a case of late-presenting symptomatic ureterovesical junction obstruction after endoscopic treatment of low grade vesicoureteral reflux. Case report – A two-year old girl, with no other underlying conditions, underwent endoscopic Submucosal Transurethral Injection of one ml dextranomer/hyaluronic acid copolymer for grade three VUR on the right side. She recovered uneventfully and remained asymptomatic for one year, when she presented with right-side flank pain. Renal ultrasound showed hydronephrosis with calyceal dilatation and hydroureter. Ureterovesical junction obstruction caused by the bulking agent was suspected on MR urography. A large 2×2 cm mass was found extravesically, clearly obstructing the ureter. After excision of the mass and reimplantation of the ureter, the hydronephrosis settled. Conclusion – However rare it is, ureterovesical obstruction may develop after endoscopic submucosal transurethral injection of dextranomer/hyaluronic acid copolymer. Long-term postoperative follow up may be necessary.

Hypertension as an atypical presentation of unilateral ureteral obstruction

Ureteral obstruction (ureteropelvic or ureterovesical junction obstruction) is frequently diagnosed during the workup investigation of an asymptomatic infant or child with upper urinary tract dilatation, commonly identified in a prenatal ultrasound. In older children, recurrent lumbar pain is a red flag for ureteral obstruction. Although less frequent, hypertension may be the initial and only manifestation of ureteral obstruction. The authors present two pediatric cases of unilateral ureteral obstruction with hypertension, in which the surgical treatment of the obstruction leads to blood pressure normalisation. In all pediatric age groups, a systematic investigation for secondary causes of hyperten‑ sion is of paramount importance. In some cases, especially those of an obstructive nature, early surgical management can be curative, with normalization of blood pressure levels and prevention of renal injury.

MP44-15 HIGH PRESSURE ENDOSCOPIC BALLOON DILATATION FOR TREATMENT OF URETEROVESICAL JUNCTION OBSTRUCTION IN CHILDREN

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-15 HIGH PRESSURE ENDOSCOPIC BALLOON DILATATION FOR TREATMENT OF URETEROVESICAL JUNCTION OBSTRUCTION IN CHILDREN Sergei Zorkin, and Dmitry Shakhnovskiy Sergei ZorkinSergei Zorkin More articles by this author , and Dmitry ShakhnovskiyDmitry Shakhnovskiy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Currently open ureteral reimplantation is considered to be the gold standard treatment for ureterovesical junction (UVJ) obstruction. The aim of this study was to assess long term effectiveness of high pressure endoscopic balloon dilatation for treatment of UVJ obstruction in children. METHODS: From 2015 to 2018 a total of 32 children with a median age of 10 months were treated with high-pressure balloon dilatation. Initial results were evaluated using ultrasonography (US), voiding cystourethrogram and MAG-3 renogram 6 months following the procedure. Then all patients were followed up with US examination annually for 3 years. Positive outcome we considered to be a decrease in pelvic and distal ureteral diameter and an improvement of drainage according to renogram. RESULTS: We observed no intraoperative complications. US pelvic diameter was decreased after balloon dilatation (delta, mm: -10,4±7,1. p<0.0001). MAG-3 renogram showed nonobstructive curve in all patients at 6 months follow up. Washout percentage showed an increase (delta, %: 25,3±13,5. p<0.0001). We observed also an increase in differential renal function after balloon dilatation (delta, %.: 4,3±1,5. p<0.0001). During a follow up period we found results of balloon dilatation to be stable according ultrasound pelvic and distal ureter diameter. CONCLUSIONS: Results of this study confirm that balloon dilatation proved its effectiveness for cases of UVJ obstruction, but further studies with bigger patient sample are needed to confirm long term positive results. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e798-e798 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sergei Zorkin More articles by this author Dmitry Shakhnovskiy More articles by this author Expand All Advertisement Loading ...

MP44-12 STENTLESS ROBOTIC PYELOPLASTY: LESS OPERATIVE TIME AND NO INCREASE IN COMPLICATIONS

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-12 STENTLESS ROBOTIC PYELOPLASTY: LESS OPERATIVE TIME AND NO INCREASE IN COMPLICATIONS Campbell Grant, William DeFoor, Michael Daugherty, Andrew Strine, Pramod Reddy, and Paul Noh Campbell GrantCampbell Grant More articles by this author , William DeFoorWilliam DeFoor More articles by this author , Michael DaughertyMichael Daugherty More articles by this author , Andrew StrineAndrew Strine More articles by this author , Pramod ReddyPramod Reddy More articles by this author , and Paul NohPaul Noh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Children undergoing robotic pyeloplasty (RP) for ureteropelvic junction obstruction often have internal double J ureteral stents placed at the time of surgery to facilitate drainage and prevent complications. However, placement of a stent typically requires a second anesthetic for removal. Previous studies have shown that stentless pyeloplasties are a feasible option, but none have compared outcomes to stented patients. The goal of this study is to assess overall complication rates between stented and stentless pyeloplasties at a single institution. METHODS: A prospective cohort study was performed of all robotic pyeloplasties performed by four surgeons in our institution from 2015 to 2020. A historical cohort of stented pyeloplasties from 2009 to 2020 was used as a control group. Categorical variables were analyzed using a chi-square test and continuous variables were compared using a two-sided t-test. RESULTS: A total of 310 patients underwent RP and met inclusion criteria. 114 patients in the study group underwent pyeloplasty without a ureteral stent and 196 control patients had a stent placed at the time of surgery. Stentless patients were younger (median: 19 vs. 75 months, p<0.001) and weighed less (11 vs. 23 kg, p<0.001) than stented patients. The average operative time for stentless patients (192 minutes) was less than stented patients (211 minutes, p=0.002). The overall complication rate in the stentless group (7%) was comparable to the stented group (10%), although there was a higher incidence of Clavien level 3/4 complications in the stentless group (5.3% vs. 2%). One infant boy with worsening hydronephrosis developed urosepsis requiring a PICU admission 4 weeks post-operatively and underwent urgent stent placement. There was one confirmed urinary leak and two suspected urinary leaks due to abdominal distension and ileus that were treated with a ureteral stent. One concomitant unrecognized ureterovesical junction obstruction required a percutaneous nephrostomy. CONCLUSIONS: Stentless robotic pyeloplasty appears to be comparable to stented pyeloplasties from a safety and clinical outcomes standpoint with the benefits of a shorter operative time and the avoidance of a second procedure. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e797-e797 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Campbell Grant More articles by this author William DeFoor More articles by this author Michael Daugherty More articles by this author Andrew Strine More articles by this author Pramod Reddy More articles by this author Paul Noh More articles by this author Expand All Advertisement Loading ...

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux

Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR). We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO). A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution. A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N=10) or symptomatic ureterovesical junction obstruction (UVJO, N=6). Mean console times were 102min (range 70-240min) for RALUR vs 128min (range 70-180min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction. RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

URINARY BLADDER NECROSIS - AN EXTRAINTESTINAL MANIFESTATION OF INFLAMMATORY BOWEL DISEASE IN A PEDIATRIC PATIENT

Abstract Extraintestinal manifestations are common in inflammatory bowel disease (IBD), and genitourinary complications are known, including nephrolithiasis, fistulas, and ureteral obstruction. Bladder involvement is less common, and limited to cystitis including xanthogranulomatous cystitis. Bladder necrosis has not been previously described in association with IBD. Here, we describe an unusual case of IBD associated with total bladder necrosis at the time of initial diagnosis. An 8-year-old female with a history of chronic microcytic anemia presented with 1 week of hematochezia, hematuria, and fever with associated abdominal pain. Her exam was significant for mild lower quadrant abdominal tenderness including the suprapubic area, but was otherwise unremarkable. Blood work showed microcytic anemia and mild thrombocytopenia, elevated inflammatory markers, and hypoalbuminemia. Infectious workup was unremarkable. Upon admission, she developed oliguria and hypertension and rapidly progressed to renal failure requiring dialysis catheter placement and renal replacement therapy. A kidney biopsy revealed acute tubular injury but showed no glomerular involvement and had no evidence of hemolytic uremic syndrome or vasculitis. Imaging obtained including CT of her abdomen showed a thickened transverse colon and a thickened bladder wall with dilation of the renal collecting system, worse on the left. Bladder biopsy showed full-thickness necrosis of unclear etiology and had negative staining for microorganisms. She had bilateral nephrostomy tubes placed for drainage of her kidneys and her renal function subsequently returned to normal. MR imaging also revealed necrosis and confirmed complete bladder involvement. Her renal failure was presumed to be a secondary to ureterovesical junction obstruction from the bladder necrosis. She underwent esophagogastroduodenoscopy (EGD) and colonoscopy due to persistent hematochezia. The EGD was unremarkable. Her colonoscopy was grossly abnormal with evidence of colitis from the cecum to the rectum. Biopsies revealed both active and chronic inflammation with sparing of the terminal ileum, and immunohistochemical staining for infection was negative. Capsule endoscopy was largely unremarkable. She was diagnosed with ulcerative colitis and started on steroids and sulfasalazine. Her abdominal pain and stool consistency improved and her bloody stools resolved. Steroids were tapered and she continued sulfasalazine as maintenance therapy. This case presents a novel association of IBD and bladder necrosis. Vascular obstruction secondary to a hypercoagulable state might explain such an event, but this seems less likely given the diffuse nature of bladder involvement. A clinical index of suspicion for bladder involvement and/or necrosis is warranted in patients with IBD who present with obstructive urinary symptoms or hematuria.

Evaluation of the Patients with Antenatal Hydronephrosis Diagnosed Ureteropelvic Junction Obstruction with the Hydronephrosis Severity Score

Objective: Ureteropelvic junction obstruction is the main cause of obstructive antenatal hydronephrosis. Although surgery is the traditional treatment modality, there is still no consensus on surgical indications. We aimed to analyse the patients referred as antenatal hydronephrosis and diagnosed with ureteropelvic junction obstruction with Hydronehprosis Severity Score that has been developed by Babu at al. Method: The patients who were admitted with antenatal hydronephrosis in 2013-2018 and diagnosed as ureteropelvic junction obstruction and followed up in our clinic for at least one year were evaluated. The cases with unilateral hydronephrosis were included. Those with vesicoureteral reflux, horseshoe kidney, hydroureter, ureterovesical junction obstruction were excluded. Renal ultrasonography and nuclear scintigraphy results were re-evaluated. They were grouped as mild (0-4), moderate (5-8) and severe (9-12) based on scoring of three parameters; differantial renal function, drainage curve pattern and US grade. Clinical outcomes were also classified in three groups; resolution (grade 1-no hydronephrosis), persistance (grade 2-3 hydronephrosis) and surgical intervention. The relation between the scores and clinical outcomes were analysed. Results: A total of 57 patients were evaluated. 2 with horseshoe kidney, 4 with vesicoureteralreflux, 7 with bilateral hydronephrosis, 4 with ureteric outlet obstruction, 12 with incomplete records were excluded. Finally, 28 patients were included. Hydronephrosis was resolved in 4 (14.2%), persisted in 5 (17.8%) and surgical intervention was required in 19 (67.8%) patients. 1/5 patients with mild, 15/20 patients with moderate and 3/3 patients with severe HSS underwent surgery. 77.2% of the patients with a total score of ≥6 initially required surgical intervention at their follow-up. Conclusion: HSS may provide a significant predictive value for surgical intervention for the patients classified as “mild” or “severe” at the initial evaluation. In the “moderate” group, the risk increases in the patients with HSS≥6. Existing data should be evaluated with larger case series.

Obstructive Left Ureterovesical Junction Calculus Presenting With Left Loin and Groin Pain in a Male Child: The Ultrasonographic Findings and Case Report

Ureterovesical junction (UVJ) obstruction refers to a blockage to this area causing hindrance to flow of urine down to the bladder, leading to urine back up into and causing dilatation of the ureters and kidney (megaureter and hydronephrosis). This is a 5-year-old male child referred for abdominal, pelvic and scrotal ultrasonography on account of moderate to severe supra-pubic pain radiating to the left loin and scrotal region with associated vomiting, sweating, occasional hematuria, increased urinary frequency and urinary tract infection for almost a year duration. The abdominal and pelvic ultrasonogram showed an oval echogenic area with posterior acoustic shadow measuring about 10mm in mediolateral dimension impacted at the left UVJ with associated dilatation of the left ureter, left calyceal moieties and pelvis. There is associated enlargement of left kidney with a bipolar length of about 144mm. A diagnosis of an obstructed left UVJ by an impacted calculus with associated hydronephrosis was established. The patient had a successful cystoscopy with pneumatic lithotripsy for surgical removal of the calculus, he got better and discharged home afterwards. We present a case of UVJ obstruction in a 5-year-old child due to its peculiar presentation, and to review the ultrasonographic findings