Delayed management of neonatal hydronephrosis

There is healthy debate over the management and timing of surgical reconstruction in the neonate with hydronephrosis. We have seen 23 neonates (35 renal units) with antenatal or neonatal hydronephrosis secondary to ureteropelvic junction obstruction or megaureter since 1984. All renal units with postnatally confirmed hydronephrosis (78 per cent) were studied initially and serially with diuretic 99mtechnetium-diethylenetriaminepentaacetic acid renography and entered into a delayed management protocol. A total of 23 renal units followed for an average of 7 months before any surgical procedures were done demonstrated maturation of renal function. Of these cases 9 obstructed renal units (half-time greater than 20 minutes) underwent delayed reconstruction (6 with ureteropelvic junction obstruction and 3 with megaureter) at an average patient age of 6 months. In this group there was no compromise in renal function nor were any complications encountered. Two units with initially obstructive patterns on renography demonstrated improved drainage and have not required an operation to date. Twelve renal units with indeterminant (half-time 10 to 20 minutes) and nonobstructive (half-time less than 10 minutes) half-times also showed stable, maturing renal function. Delayed reconstruction in the neonate with ureteropelvic junction or megaureter obstruction and normal diethylenetriaminepentaacetic acid function is safe. In addition, a period of observation may obviate the need for an operation in some cases when ureteropelvic junction stabilization results in improved drainage. These as well as the added benefits of diminished anesthetic risk, enhanced technical ease, noninterrupted maternal-infant bonding and lower operative complication rate make this approach desirable in properly selected patients.

The natural history of and therapy for perirenal fluid collections following renal transplantation

Fluid collections following renal transplantation are not rare and may be associated with serious complications. We studied the incidence, clinical features, pathology and treatment outcome of perirenal fluid collections after kidney transplantation. Between January 1977 and June 1985, 386 consecutive renal transplants were performed at our university. All allografts were studied with B-mode ultrasonography together with a renal scan in the immediate post-transplant period, at 6-month intervals or when clinically indicated. Symptomatic fluid collections, those associated with rejection episodes and those containing more than 50 to 100 ml. fluid were aspirated under sonographic control via aseptic techniques. There were 190 fluid collections (49 per cent) observed during followup (2 to 11 years). Of these collections 98 (51 per cent) were estimated to be less than 50 ml. in volume, were clinically insignificant and resulted in no morbidity. A total of 92 collections was aspirated with 1 aspiration being diagnostic and therapeutic in 57 instances (serous or serosanguinous fluid). The 35 collections remaining were revealed to be lymphoceles on biochemical grounds. Of 13 lymphoceles associated with rejection episodes 8 resolved on initial aspiration. Of the recurrent lymph collections 27 were treated with repeated aspiration, tetracycline sclerotherapy or an operation (10 were treated with marsupialization into the peritoneal cavity). No large collections of urine or blood were detected and 1 infected lymphocele required external drainage. No renal allograft was lost as a result of a fluid collection and over-all graft survival was not affected by the development of perirenal fluid collections. We conclude that perirenal fluid collections are detected commonly in the post-transplant period using B-mode ultrasonography. The majority of these collections are small and will require careful observation only or they will resolve with a single aspiration. Aggressive diagnostic and therapeutic measures are used only for those collections that are symptomatic or result in allograft dysfunction. A rational approach to the diagnosis and treatment of peritransplant fluid collections is described in the form of an algorithm.

Is percutaneous nephrostomy for hydronephrosis appropriate in patients with advanced cancer?

Twenty patients with advanced pelvic malignancy and secondary hydronephrosis underwent percutaneous nephrostomy between July 1982 and October 1986. Improvement in renal function occurred in 17 patients (85 percent), and survival ranged from 4 days to 2 years. Median survival was 13 weeks, and 55 percent of the patients required multiple hospitalizations for urosepsis. In addition, 55 percent required multiple tube changes. Thirty-five percent of the patients never left the hospital and an additional 35 percent spent less than 6 weeks at home before they died. Median survival for eight patients with primary cancers most frequently associated with carcinomatosis was 7 weeks, and 63 percent of these patients died during hospitalization. The factors of limited survival, significant morbidity, in-hospital mortality, and poor quality of life should be considered before recommending percutaneous nephrostomy in patients with advanced cancer.

[Obstructive nephropathy; kidney function and renal excretion of prostaglandin (E)2 and Thromboxane B(2) following percutaneous decompression nephropyelostomy]

In patients with chronic urinary obstruction the excretion of prostaglandin E(2) (PGE2) and thromboxane B(2) (TXB2) was measured. During obstruction signs of an increased vasoconstrictor (TXB2)- and a decreased vasodilator (PGE2) activity were found. After percutaneous nephropyelostomy a reverse pattern with decrease of the initially high (TXB2) excretion and increase of the PGE(2)excretion was observed. It is suggested that these changes of the arachidonic acid metabolism previously found in animals also take part in the pathophysiological changes in humans after relief of urinary obstruction having significant effect of renal blood flow, glomerular filtration rate and tubular function in obstructive nephropathy in humans.

Long-term followup of maximum concentrating ability and glomerular filtration rate in adult obstructed kidneys after pyeloplasty

We investigated 34 patients with obstructed kidneys preoperatively and 8 to 10 years postoperatively concerning the separate glomerular filtration rate and maximum concentration ability. The mean glomerular filtration rate for the obstructed kidneys was approximately 10 per cent lower compared to that for the contralateral kidneys preoperatively and at followup. Although the mean value for obstructed kidneys was not improved at followup, kidneys with a decreased glomerular filtration rate preoperatively improved significantly after pyeloplasty. The maximum concentration ability was low preoperatively for the obstructed kidneys compared to the contralateral kidneys. The lowest maximum concentration ability was found in patients with a history of repeated upper urinary tract infections. At followup marked improvement was noted, which was most obvious for kidneys with severely reduced concentration ability preoperatively. However, the restoration was not total. There was a positive correlation between the improvement in glomerular filtration rate and improvement in maximum concentration ability.

[Use of suspended catheters (stents) during surgery of hydronephrosis in children]

The application of hanging catheters (stents) in operations for hydronephrosis in children has considerable advantages over classical (open) methods of drainage. Bacteriological investigations of analyses of urea performed in open and closed closed systems of drainage have shown less incidence of infection of the upper urinary tracts with intrahospital gram-negative flora after operation on patients operated upon with using stents, which gave less amount of postoperative complications.

Prenatal diagnosis and management of bilateral hydronephrosis

This report reviews the management of the fetus with congenital hydronephrosis (CH), a challenging diagnostic and therapeutic problem. Experimental models of obstructive uropathy have produced histologic changes similar to those seen in kidneys of human neonates with congenital hydronephrosis. Relief of obstruction in utero in these models has been shown to prevent some of the dysplastic changes caused by obstruction. These studies have formed the theoretical basis for in utero decompression to restore amniotic fluid dynamics to prevent death from pulmonary hypoplasia, and reverse or arrest dysplastic morphogenesis. The development of prognostic criteria has greatly aided in selection of appropriate fetuses for intervention. These criteria include: (1) Na less than 100 mEq/l; (2) Cl less than 90 mEq/l; (3) osmolarity less than 210 mosmol; (4) sonographic appearance of the fetal kidneys; (5) amniotic fluid status; (6) urine output at fetal bladder catheterization. All fetuses should have ultrasonography to exclude other anomalies, and karyotype analysis to exclude chromosomal abnormality. If amniotic fluid volume is normal, the pregnancy is followed with serial ultrasound examinations. If oligohydramnios develops, a prognostic evaluation is performed, including fetal bladder catheterization. If the fetus has poor residual renal function, on the basis of prognostic criteria, appropriate counseling may be given. If the fetus has good residual renal function, depending on lung maturity, it can be delivered early for corrective surgery. If diagnosed prior to lung maturity in utero, decompression by either vesicoamniotic shunting or open fetal surgery may be attempted in the highly selected case.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of ureteropelvic junction obstruction in neonate

Fetal hydronephrosis demonstrated by maternal ultrasonography should lead to early investigation during the neonatal period. Postnatal confirmation of the diagnosis of ureteropelvic junction obstruction usually can be established by combining the radiologic modalities of ultrasound, diuretic isotope renal scan, and voiding cystourethrography. Rarely should intravenous urography, antegrade pyelography, or cystoscopy and retrograde pyelography be necessary. Findings of high-grade obstruction and/or significantly diminished function on the affected side(s) should prompt early neonatal reconstruction. Pyeloplasty was performed within the first month of life in 17 infants (20 kidneys) diagnosed as having significant ureteropelvic junction obstruction. Early reconstruction in the neonatal period can be performed successfully with minimal complications and a relatively brief period of hospitalization. This may ultimately achieve maximal preservation of renal function.

[Double kidney and vesico-ureteral reflux in children]

Our clinical material has shown that results of organ-preserving operations on patients with doubling of the kidneys and vesicoureteral reflux are dependent on a number of factors. The leading factors are: degree of pathomorphofunctional alterations of the calyceal-pelvic system and parenchyma of the kidneys, the presence of pyelonephritis. After operations all the patients should be followed-up at dispenseries.

Urological anomalies detected on antenatal ultrasound: a 9 year review

One hundred and forty-eight patients (107 male, 41 female), in whom a urological anomaly was detected on antenatal ultrasound examination, are reviewed. Postnatal imaging was done primarily by ultrasonography (US) which was often repeated. Depending upon the ultrasound findings, the patients had a renal nuclide scan (RNS) and/or micturating cysto-urethrogram (MCU), but intravenous urogram (IVU) was not usually considered necessary. A range of urological anomalies was encountered, but renal anomalies were most common. Over half the cases had anomalies which did not require surgery, with non-obstructive pelvicalyceal dilatation being frequent. Almost half the operated cases had features which should have allowed a clinical diagnosis without the knowledge of the antenatal findings. A fifth of the cases were occult in that they would not have been diagnosed early in life but for the antenatal detection. The majority had congenital pelviureteric junction obstruction and results of early reconstructive surgery were satisfactory.

Percutaneous nephrostomy for treatment of hydronephrosis of pregnancy

Hydronephrosis of pregnancy is a common phenomenon that rarely requires invasive intervention. We describe a young woman with markedly obstructive hydronephrosis of pregnancy causing forniceal extravasation who was treated successfully by percutaneous nephrostomy. The rationale of such intervention and its advantages over retrograde ureteral catheterization or stenting are discussed.

Kidney function in adults born with unilateral renal agenesis or nephrectomized in childhood

We have evaluated the long-term prognosis in an unselected group of adult patients either uni-nephrectomized in childhood because of hydronephrosis or born with unilateral renal agenesis. Thirty-six patients aged 7-47 years were followed for 7-40 years. In 23 control subjects aged 20-47 years the glomerular filtration rate (GFR) and the p-aminohippuric acid clearance (CPAH) did not change significantly with age. In patients with a single kidney the size of that kidney was larger and GFR and CPAH were higher than single kidney values in control subjects. However, in patients with a single kidney since childhood the GFR and the CPAH declined slowly but significantly during the follow-up period. Significant microalbuminuria occurred in 47% of the patients with a single kidney and was more frequent with a longer follow-up period. No patient had renal insufficiency or a marked increase in arterial blood pressure. We conclude that in patients with a single kidney since childhood the long-term prognosis is good, but the late decrease in GFR and increase in albumin excretion may indicate a moderate risk for premature renal damage.

Vascular integrity of the distal ureter following combined tapering and cross trigonal reimplantation

Massive unilateral hydroureteronephrosis was created in 20 female dogs by ligating the urographically normal prevesical ureter. Over a 14-day period the obstructed ureter dilated to an average of 15.3 mm. A ureteral tapering procedure was performed by lateral darting and posterior folding of the resultant flap, followed by a cross-trigonal reimplantation. One anastomotic stricture resulted; in the remaining 19 animals, ureteral peristalsis was restored, the ureteral diameter was reduced 61.9 per cent and hydronephrosis was resolved. Histological studies on the tapered segments of these 19 animals showed that the subadventitial blood supply was preserved with fibrotic occlusion of the folded flaps. These results demonstrate that no significant vascular compromise after ureteral tapering and cross-trigonal reimplantation occurs. Success rates comparable to those of conventional ureteral tailoring can be achieved by this technically simplified form of reconstructive surgery.

Management of ureteropelvic junction obstruction in infants and neonates

From June 1980 to October 1985 we performed 22 ureteropyeloplasties on 20 infants and neonates with ureteropelvic junction obstruction. All patients were males less than 2 years old; 12 were less than 1-month-old. The diagnosis was suspected on the basis of maternal ultrasonography in 10 patients (50%), a palpable abdominal mass was the presenting symptom in 7 (35%), and obstruction was detected during evaluation of congenital heart disease in 3 (15%). This change in mode of presentation is expected to become even more pronounced as the use of fetal ultrasonography increases. All patients in whom the diagnosis was suspected antenatally underwent ultrasonography after birth to confirm the presence of hydronephrosis. All 22 obstructed kidneys were repaired by a dismembered technique under optical magnification. There were no operative mortalities. Of 21 postoperative intravenous pyelograms available, 3 demonstrated marked improvement, 17 showed improvement with residual hydronephrosis, and 1 showed deterioration. The methods used to diagnose, treat and evaluate ureteropelvic junction obstruction in 20 infants and neonates are presented. Given the existing clinical and experimental data we advocate early postnatal surgical correction of ureteropelvic junction obstruction to achieve a maximum recovery of renal function.

Preoperative symptomatology and diagnostic findings in relation to outcome of pyeloplasty in patients with primary hydronephrosis

Sixty-seven patients, aged 3-71 years, with primary hydronephrosis were operated at our department during a 5-year period. All patients had Anderson-Hynes pyeloplasty. The primary clinical result of surgery was excellent in 63 patients (94%). Of the patients with reduced renographic uptake fraction preoperatively, 38% had a significant gain 6 months after reconstruction, while only 1 patient had a reduction. There was no correlation between the outcome of reconstruction and preoperative history, degree of hydronephrosis on IVP, preoperative functional share on renography or the peroperative finding of aberrant vessels compressing the ureter. It was concluded that surgery should be undertaken on rather wide indications as reconstruction leads to stable or improved renal function regardless of preoperative symptoms or diagnostic findings.