Recovery from severe hydroureter and hydronephrosis after ureteral anastomosis in a dog

Progressive hydroureter and hydronephrosis were diagnosed in a dog after anastomosis of a crushed ureter. Nephrectomy was averted when partial resolution was noticed one month after the ureteral repair. The appearance of the kidney and ureter was nearly normal several months later. Conservative management should be considered in cases of partial unilateral ureteral obstruction.

[Percutaneous nephropyelostomy--indications, complications, and various aspects of clinical use]

During almost 3 years in 100 patients the percutaneous nephropyelostomy was used as method of the supravesical discharge of urine 109 times. The X-ray-aimed puncture was performed on the basis of the fine needle puncture technique by means of a puncture set which we developed ourselves. When a urinary retention is present, the number of targets is great (96%), the rate of complications small. In 12 systematically exposed kidneys limited subcapsular haematomas were found, once a small perirenal haematoma. In one case a breaking off of the wire occurred. In 2 cases a septicaemia appeared, 4 punctures failed. Following the PNS 3 kidneys had to be exposed due to tamponage of the renal pelvis (2) and perforation of the renal pelvis, respectively. The percutaneous nephropyelostomy is a measure for the temporary or permanent supravesical discharge of the urine which is little stressing for the patient and simply to be performed. It represents a secure and effective alternative for the operative nephrostomy in patients with obstruction of the urinary tract of every genesis.

[Complications following transcutaneous operations on the kidney]

Percutaneous nephrostomy was performed in 249 patients in regard to different indications since 1979. The following complications were found: technical difficulties 5/249/2%, bleeding 3/249/1% and pyelonephritis 25/229/11%. 124 patients with percutaneous nephrostomy are compared to 125 patients with nephrostomy followed by percutaneous nephrolithotripsy regarding the septic complication. No difference could be pointed out.

Intervention for fetal obstructive uropathy: has it been effective?

The best management of fetal hydronephrosis is controversial. Despite the lack of experimental evidence that prenatal drainage of the obstructed urinary tract substantially improves ultimate renal function, various forms of percutaneous intervention on the fetal bladder and kidney have been used. To evaluate the efficacy of intervention for suspected fetal obstructive uropathy, all published reports of drainage of the fetal urinary tract up to December, 1985, were reviewed. In the 57 reported cases, the most common type of intervention was placement of a vesicoamniotic shunt (37%). Complications occurred in 25 cases (44%), including inadequate shunt drainage or migration (19%), onset of premature labour within 48 h (12%), urinary ascites (7%), and chorioamnionitis (5%). Of 28 fetuses with associated oligohydramnios, only 6 (21%) survived. 2 of these survivors had vesicoamniotic shunts, 2 single or multiple bladder aspirations, 1 an external renal drainage catheter, and 1 in-utero vesicostomy. Because of the high complication rate and lack of evidence of improved survival from in-utero drainage procedures, a prospective, randomised trial is needed to compare survival with and without vesicoamniotic shunt placement.

Fetal surgery for obstructive uropathy: rational considerations

The widespread use of high resolution dynamic ultrasound imaging methods in obstetrics now permits recognition of structural and/or functional developmental anomalies of fetal genitourinary tract with some considerable accuracy. Detection of congenital obstructive uropathy in the human fetus may occur as early as 16 weeks gestation. In the fetal lamb model, experimental occlusion of the outflow tract results in progressive hydronephrosis, pulmonary hypoplasia, and oligohydramnios. The renal parenchymal changes vary with the fetal age at obstruction ranging from simple hydronephrosis with later obstruction to dysgenesis with earlier obstruction. The pulmonary damage, and to some extent the renal damage, may be halted or even reversed with release of obstruction. These advances in diagnosis and an understanding of the pathophysiology have prompted attempts at chronic in utero diversion therapy in the human fetus with obstructive uropathy yielding encouraging, but as of yet, unproven success. In this report, the methods for such therapy, the rationale for the therapy, and the results of the therapy is reviewed.

Combination of DMSA-scintigraphy and hippuran renography in unilateral obstructive nephropathy. Improved prediction of recovery after intervention

The renal handling of dimercaptosuccinic acid and hippuran differs. This might be used in unilateral obstructive nephropathy in order to predict potential functional recovery following intervention. The theory was evaluated on a retrospective basis in 17 patients, who primarily had a nephrostomy. If the DMSA-uptake rate in the diseased kidney was more than 10 per cent higher than that of hippuran, the uptake rate of hippuran increased following relief of obstruction. Use of the two radiopharmaceuticals, thus, may have great impact on the clinical decision, since in case of a difference some function may be saved by immediate intervention.

[One-stage operation of ureteropelvic junction and ureterovesical junction stricture]

One-stage surgical management for ureteropelvic (UP) and ureterovesical (UV) strictures is reported. A 3-year-old boy with UP and UV strictures on left side, underwent nephrostomy at 4 months old. The plastic operations which were Anderson-Hynes method for UP stricture and submucosal tunnel method with tailoring of dilated ureter for UV stricture were performed at the same time. The post-operative intravesical pyelogram and renal scintigraphy showed the improvement of hydronephrosis. Many authors have described two-stage operations for such cases. Our findings revealed that one-stage operation, carefully preserving the blood supply to the ureter, would be an alternative surgical management for UP and UV strictures.

The role of vesicostomy in the management of anterior urethral valves in neonates and infants

We performed vesicostomy as the initial form of management in 2 male newborns and 1 infant with anterior urethral valves associated with proximal urethral diverticula and bilateral hydronephrosis. Prompt improvement in the degree of hydronephrosis was noted after vesicostomy in all 3 patients along with improvement in renal function in 2 who had presented with renal insufficiency. Subsequently, 2 patients have undergone vesicostomy closure and transurethral valve fulguration, and 1 also required ureteral reimplantation for persistent vesicoureteral reflux. The use of vesicostomy in the newborn period rather than transurethral fulguration prevented the potential complications of urethral stricture and inadequate valve resection that can occur owing to the small size of the neonatal urethra. Furthermore, a period of vesicostomy drainage before eventual ureteral reimplantation for severe vesicoureteral reflux obviated the need for ureteral tailoring.

[Pathophysiology of primary renal pelvis outflow stenosis]

Ureteral peristalsis originates in the most proximal parts of the caliceal system. It is then conducted to the ureter by way of myogenic excitation conduction. In the pyeloureteral region, however, there seems to be some sort of physiological blockade and modulation of activity. It depends on the level of diuresis whether only a few or all contractions of the renal pelvis reach the ureter. Morphological and functional investigations show that the pathophysiological disturbance in cases of primary stenosis of the pyeloureteral junction seems to be a complete blockade of myogenic excitation conduction. The principle of open surgical corrections (dismembered pyeloureteroplasty) is not only to create a widely open connection between renal pelvis and ureter but also to remove the misfunctioning pyeloureteral segment and to substitute it by a region of improved myogenic excitation conduction.

[Percutaneous pyeloplasty. Indications, technic, results]

The indication for and technique of the percutaneous operation of strictures at the ureteropelvic junction in 117 patients are discussed. The results in 66 followed up cases are presented in detail. The new method was found superior to open surgery in cases of secondary (acquired) stenoses and a success rate of 89% can be expected. The results of its use for congenital stenoses are not as good (73%), however, if this simple and safe technique does fail, open plastic surgery can still be performed.

[The percutaneous approach to the pediatric kidney]

The percutaneous access also to the infantile kidney increasingly gains significance. It is reported on experience with 16 percutaneous interventions at the kidney in 14 children. Indication, technique and complications are demonstrated, compared with literature and discussed. The percutaneous access to the kidney allows the clarification of certain diagnostic problems, guarantees the protection of the kidney in congenital and acquired obstructions, septic renal diseases, postoperative complications. The drainage of urinomas, the dilation of stenoses of the ureter as well as nephrolitholapaxia and chemolitholysis are with certain restrictions possible also in childhood.

The ectopic kidney in the emergency department

Renal ectopia can present as abdominal pain and be a predisposing factor to several pathologies seen in the genitourinary system. We present the case of a 21-year-old man with intermittent right lower quadrant abdominal pain who was found to have a nonfunctioning pelvic kidney and underwent nephrectomy. Although specific findings on renal ectopia are often absent, associated congenital defects above the pelvic organs raise the suspicion for renal ectopia. Early detection and recognition of the ectopic kidney can prevent long-term complications.

[Viscus perforation as an unusual complication of Politano-Leadbetter ureteral reimplantation]

Unusual complications of the Politano-Leadbetter ureteral reimplantation technique are reported in four ureters in three children with primary vesicoureteral reflux (VUR). These ureters were found to pass through an adjacent intraperitoneal viscus including the sigmoid colon, ileum or broad ligament. This complication occurred in 0.48% of the Politano-Leadbetter antireflux operations for primary VUR. Viscus perforation occurred only in children with a relatively high grade VUR. The prognoses of the hydroureter after ureteric reimplantation or ureterolysis, were good in all cases. Although there are several advantages in the transvesical procedure of the original Politano-Leadbetter method, we should not hesitate to go extravesically if there are difficulties in mobilizing the ureter or inducing it into the vesical cavity.

Fetal hydronephrosis: selection and surgical repair

Newly developed diagnostic techniques allowed us to select a fetus with potentially reversible renal damage from the usually fatal group with bilateral hydronephrosis and severe oligohydramnios early in gestation. Fetal surgery to marsupialize the fetal bladder at 24 weeks gestation restored normal amniotic fluid dynamics and allowed sufficient pulmonary and renal development to insure survival after delivery near term.

Percutaneous nephrostomy in paediatrics

Percutaneous nephrostomy has been performed on 18 kidneys in 16 children with an age range of 1 day old to 14 years. The indications and techniques for percutaneous nephrostomy are described, the results are documented, and the effects of the procedure on the management of these patients are discussed. It is shown that percutaneous nephrostomy in paediatrics is a safe and reliable method for draining renal collecting systems in order to relieve obstruction, to assess renal function and to drain pyonephroses.

Pelviureteric obstruction in children: growth of kidney parenchymal area after pyeloplasty

The excretory urographies of 26 patients with unilateral pelviureteric obstruction were analysed retrospectively. All patients had had dismembered pyeloplasty performed at the age of 9 months to 15 years 2 months. Planimetric parenchymal area measurements of each kidney were made from urographies performed preoperatively and at different stages of the follow-up period, the latest follow-ups being effected 3 to 14 years postoperatively. The postoperative parenchymal growth of the hydronephrotic kidneys was very good, especially in patients operated on in early childhood. The mean parenchymal growth rate in per cent of the hydronephrotic kidney exceeded the mean parenchymal growth rate in per cent, of its mate during the first postoperative year. During the long-term follow-up there was no further parenchymal "catch-up" growth of the hydronephrotic kidney as compared to the contralateral kidney. Planimetric measurement of kidney parenchymal area is proposed as a useful quantitative method for the preoperative and postoperative evaluation of hydronephrosis in children.

[A case of giant hydronephrosis with renal pelvic calcification]

A 26-year-old man had asymptomatic macroscopic hematuria. A left hydronephrotic sac outlined with a thin curvilinear shadow of calcium deposition was found in a plain film and stenosis at the ureteropelvic junction (UPJ) in a retrograde pyelogram. Left nephrectomy was performed and the fluid content was 1330 ml. Histologic examination showed subepithelial calcification of the renal pelvis and fibrous proliferation at the UPJ.

Transurethral resection of the ureteral meatus invaded by carcinoma of the prostate: a new approach

We present herewith our surgical procedure for the management of bilateral hydronephrosis and renal failure due to distal ureter infiltration by cancer of the prostate: transurethral resection of the ureteral meatus and intramural ureter or even extravesical ureter invaded by the carcinoma and placement of a double J catheter. We have performed this technique in 3 patients with good results.