Rare case of ureteral endometriosis presenting as hydronephrotic kidney

A 29-year-old woman presented with unilateral loin pain because of severely hydro-nephrotic kidney due to deposits of pelvic endometriosis. Double J-stent was placed beyond the obstruction and she was started on hormone therapy. The stent was removed after three months when back pressure changes had resolved. This case is being presented along with a short relevant discussion, due to rarity of ureteral involvement by endometriosis.

Ureteral damage during appendicectomy

A case of right ureteric damage in a 7-year-old boy who underwent appendicectomy is described. Ultrasound, magnetic resonance urography, nephrostogram, and retrograde ureterogram were helpful in defining the nature and extent of the lesion. He underwent staged procedures of percutaneous nephrostomy, elective resection and reconstruction of midureteral segment, and subsequent removal of double J stent and made a smooth recovery. Ureteric injuries, although rare, have serious consequences. A high index of suspicion is essential for diagnosis. Management is influenced by site, type, extent, and mechanism of injury, as well as the timing of detection.

Abdominal cerebrospinal fluid (CSF) pseudocyst presented with inferior vena caval obstruction and hydronephrosis

PURPOSE

Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon complication of ventriculo-peritoneal shunt placement. A large pseudocyst may exert a significant pressure effect, but vascular or urological symptoms are extremely rare. We report an unusual case of a CSF pseudocyst causing inferior vena caval and ureteric obstruction.

CASE

A 14-year-old girl had previously undergone ventriculo-peritoneal shunting for congenital hydrocephalus. She developed bilateral ankle edema as the only presenting symptom of a large non-infected cerebrospinal CSF pseudocyst. The associated abdominal distension was initially attributed to obesity, and the patient was unable to communicate due to developmental delay. Imaging studies showed that the pseudocyst was causing inferior vena caval obstruction and bilateral hydronephrosis. The ankle edema and hydronephrosis resolved after aspiration of the pseudocyst and shunt revision.

CONCLUSION

Children who require CSF shunting may suffer from associated developmental delay and are frequently unable to communicate their symptomatic complaints. This case illustrated the importance of a heightened clinical suspicion in managing these patients in whom shunt failure may present with subtle and obscure signs of lower body venous congestion.

Pyeloureterostomy in the management of the lower pole pelvi-ureteric junction obstruction in incomplete duplicated systems

OBJECTIVES

To report our experience with the pyeloureterostomy (PU) for the treatment of the lower pole PUJO in incomplete duplex systems. The combination of the duplicated collecting system and pelviureteric junction obstruction (PUJO) is a rare association and infrequently reported. Surgical treatment can be challenging in such cases.

METHODS

We retrospectively reviewed the medical data of the patients who had surgery from 2001 to 2009, with a diagnosis of PUJO of the lower pole moiety in incomplete duplex system. Demographic, diagnostic, and procedural data were recorded.

RESULTS

Seven patients were identified with the lower pole PUJO associated with incomplete duplex systems. Their median age was 49 months (range 2-108 months). Prenatal hydronephrosis was detected in 3 patients, and 4 had a febrile urinary tract infection. PU was performed in 6 patients because of short ureteral length between the ureteropelvic junction and junction of lower and upper pole ureters. One patient was treated with the dismembered pyeloplasty because of sufficient ureteral length of the lower pole. No complications were detected during 14 months of follow-up.

CONCLUSIONS

The management of the lower pole PUJO in incomplete duplex systems should be individualized for every patient. PU is a good surgical option in the management of the lower pole PUJO associated with incomplete ureteral duplication.

Unilateral hydroureteronephrosis after a mesh procedure

Synthetic mesh has become a popular treatment of pelvic floor relaxation and pelvic organ prolapse, with low complication rates. We describe the case of a woman with unilateral hydroureteronephrosis after a mesh procedure (Gynecare Prolift; Ethicon Women's Health & Urology, Ethicon, Inc., Somerville, New Jersey) successfully treated by neoureterocystostomy. A 39-year-old woman with pelvic organ prolapse underwent the mesh procedure. Two months later, she had left flank pain, and hydroureteronephrosis was diagnosed on the same side despite cystoscopic confirmation of ureteral passage at the first operation. The arm of the mesh was removed surgically, and neoureterocystostomy was performed successfully. Mesh surgery is not without serious complications, and surgeons should bear in mind the possible complications associated with this surgical procedure.

Relative renal function with MAG-3 and DMSA in children with unilateral hydronephrosis

AIM

Tc-99m DMSA renal cortical scan is a reference method for determining relative renal function (RRF). Tc-99m MAG-3 is also recommended for the estimation of RRF, particularly in young children. The aims of this study were to compare MAG-3 and DMSA RRF estimations and to assess the reproducibility of these estimations in children with unilateral hydronephrosis.

METHODS

We reviewed MAG-3 and DMSA scans of 19 children with unilateral hydronephrosis and a normal contralateral unit. All were imaged with 2 agents within 3 months. MAG-3 RRF was calculated using 2 different time intervals (1-2 and 2-3 min) and perirenal C-type region of background activity. No background correction method was used in the calculation of DMSA RRF. All data were processed twice by two independent operators.

RESULTS

In the repeated estimates of MAG-3 RRF, the maximum mean intra-observer and inter-observer differences were 0.9% (SD 1.7%) and 1.4% (SD 3.3%), respectively. Intra-method analysis showed statistically significant agreement between repeated measures of RRF for two agents as well as for two operators (intra-class cross-correlation coefficients of early and later phase of MAG-3 and DMSA RRF values were 0.979, 0.993 and 0.996 for operator 1, and 0.986, 0.973 and 0.995 for operator 2, respectively; p < 0.001). There were statistically significant correlations between the MAG-3 and DMSA RRF estimations (r = 0.763/0.766 at 1-2 min, 0.835/0.825 at 2-3 min for the repeated measures of RRF for operator 1, and 0.812/0.793 and 0.83/0.89 for operator 2, respectively; p < 0.01, Pearson). Each scan classified as normal or abnormal according to RRF values inter-method analysis showed statistically significant agreement between MAG-3 and DMSA RRF estimations (Kappa statistics). However, there was a slight disagreement between the methods especially in infants and cases with higher grade of hydronephrosis, when 5% difference in estimations and supranormal estimates of RRF were taken into consideration.

CONCLUSION

Although DMSA and MAG-3 RRF estimations demonstrated a statistically significant correlation with good reproducibility in children with unilateral hydronephrosis, overall the finding of surprising estimates of kidney function with MAG-3 calls attention to the existence of some problems especially in infants and in those with higher grades of hydronephrotic kidneys.

Retroperitoneal approach for laparoscopic nephrectomy is feasible in a child with difficult access due to severe scoliosis

Retroperitoneal minimal access surgery has been widely described and practiced in many paediatric urology units. However, retroperitoneal laparoscopic nephrectomy performed in the presence of severe scoliosis has not been described in the literature before. We report a challenging case of a 13-year-old girl with severe scoliosis requiring a nephrectomy. The feasibility of performing a retroperitoneal laparoscopic nephrectomy in paediatric patients with severe scoliosis is discussed.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Post transplant ureteric stenosis causing allograft hydronephrosis and calyceal rupture: salvage side to side ureteroneocystostomy

A 26-year-old lady with end stage renal disease who received a cadaveric renal transplant, presented with ureteral stenosis as well as calyceal rupture due to hydronephrosis that was unresponsive to balloon dilation and the allograft was salvaged by a side to side ureteroneocystostomy. The symptoms and renal function improved and patency of the side to side uretroneocystostomy was confirmed post operatively and also at seventeen month follow-up. It may be reasonable to treat post-transplant ureteral stenosis resistant to balloon dilation with this technique. However, long-term follow-up is required to evaluate the efficacy of this treatment.

MR urography in children. Part 1: how we do the F0 technique

MR urography (MRU) has been widely accepted as a substitute to intravenous urography for investigating children with a dilated urinary tract after preliminary assessment by US and voiding cystourethrography. Hydronephrosis is by far the main indication for MRU because upper tract dilatation is a frequent condition in infants and children. Recent advances in technology have allowed MR to go beyond morphology and to assess renal function parameters such as split renal function and drainage. In this article we report our routine practice of the F0 MRU technique. The main advantages of our protocol are no requirement for general anaesthesia, no bladder catheterization, use of low-dose gadolinium-based contrast agent (0.05-0.1 mmol/kg) and total acquisition time of 30 min or less.

The endless differential diagnosis of acute obstructive renal failure: unusual challenges for the sharp-sighted clinician

Obstruction of urine outflow can result from mechanical blockade as well as from functional defects. In adults, urinary tract obstruction is due mainly to acquired defects, such as pelvic tumors, calculi, and urethral stricture. In childhood it is mostly due to congenital malformations. In this article we present two rare cases of acute obstructive renal failure that presented with hydronephrosis. These cases underline the wide range of causes that may lead to this clinical feature.

Primary bladder amyloidosis--case report of a patient with delayed upper urinary tract obstruction 3 years after the diagnosis

Primary bladder amyloidosis is a rare disease. There are approximately 100 reported cases. The lesions can be confused with bladder neoplasm and are characterised histologically by the classical apple green birefringence under polarised light. In this article, we report a 51-year-old lady with known history of primary bladder amyloidosis presenting with gross hydronephrosis 3 years after the first diagnosis. Laparoscopic ileal replacement of bilateral ureters was performed. There was no recurrent ureteric obstruction 2 years after surgery. This case demonstrates the progressive nature of primary amyloidosis of bladder. The diagnosis of primary bladder amyloidosis warrants long-term surveillance of upper urinary tract.

[Bilateral ureteroceles with bilateral secondary hydronephrosis and pelvic ureteral calculi. Case report]

Bilateral ureterocele is a rare congenital condition that is usually diagnosed antenatally or in childhood. We present the case of a 64 year-old woman who was admitted for incidentally discovered microscopic hematuria. A bilateral ureterocele and secondary pelvic ureteral calculi were diagnosed by clinical examination (vaginal touch), ultrasound, plain radiography and intravenous urography. A transurethral incision of the ureterocele and extraction of calculi was performed by endoscopic approach. The postoperative recovery was uneventfull. Considering the risk for development of vesicoureteral reflux or recurrence of obstruction at the ureterovesical junction, a close long-term follow-up is required.

Retroperitoneal fibrosis and obstructive uropathy due to actinomycosis: case report of a treatment approach

An actinomycotic retroperitoneal infection usually occurs in the presence of an intrauterine device (IUD). It can result in pelvic inflammatory disease and diffuse retroperitoneal fibrosis. A 39-year-old patient was admitted to the emergency unit with left flank pain. A computed tomography scan of the abdomen showed bilateral hydroureteronephrosis and a retroperitoneal malignant mass. Other tumors were excluded with a colonoscopy and an upper gastrointestinal endoscopy. Results of a fine needle aspiration biopsy showed fibrosis compatible with retroperitoneal mesenteritis. Double-J stents were placed in both ureters, and immunosuppressive therapy was started. The patient had clinical and radiologic responses to the therapy. A bilateral ureterolysis and sigmoid colon resection were done. The pathology report showed fibrosis and Actinomyces israelii infection. Parenteral and oral penicillins were administered. The probability of an Actinomyces infection in patients with retroperitoneal fibrosis should be kept in mind, especially in cases in which the patient has an intrauterine device.

Megacalycosis: a rare condition

Megacalycosis is an extremely rare condition. We report our experience with two cases and discuss its pathogenesis, diagnosis and management in children. Our two patients had presented a prior diagnosis of congenital hydronephrosis. An increased number of calyces with a significant disproportion between the degree of calyceal dilatation and a mildly dilated renal pelvis were found in each case. Megacalycosis must be considered in the differential diagnosis of congenital hydronephrosis, polycalycosis, and infundibular stenosis. The diagnosis is suggested by ultrasound and confirmed by diuretic renography, intravenous pyelography or magnetic resonance urography. Voiding cystourethrography should be performed to rule out vesicoureteral reflux. A high index of suspicion is needed for the diagnosis of this condition.

[Preliminary results of a program for the early management of children with congenital hydronephrosis]

Antenatal hydronephrosis is one of the most frequently diagnosed congenital abnormalities in the fetus. The aim of the study is to present the preliminary results of a newly launched Pommeranian Program for Early Management of CAKUT in Children.

MATERIAL AND METHODS

105 neonates and infants with hydronephrosis were assessed between Jan and Dec 2007 (27 girls and 78 boys). All patients had postnatal ultrasound performed. Static and dynamic scyntigraphy and cystography were performed according to set indications. Therapeutic decisions were made following a team meeting between pediatric nephrologists and urologists.

RESULTS

56.2% of children with hydronephrosis had documented prenatal findings: 61%--pyelectasis, 15.3% renal cysts, 5.1% unspecified renal pathology, in 18.6% no renal pathology. 82.6% of newborns had term births but perinatal complications were observed in 30.5%. Initial postnatal diagnosis was performed by neonatal wards in 22.8% newborns and by the children's pediatrician in 31.4% of infants. Following referral to nephro-urology centre cystography was performed in 22.9% of infants and scintigraphy in 36.2%. 21.9% of infants were qualified for surgical intervention at an average age of 24 + 13 weeks.

CONCLUSIONS

1. Only half of the children with congenital hydronephrosis are to nephro-urology care following prenatal diagnosis. 2. A large number of perinatal complications are observed in newborns with prenatally diagnosed hydronephrosis. 3. The management of newborn hydronephrosis requires better cooperation between obstetricians, neonatologists, pediatric nephrologists and urologists.

[Program of early nephro-urologic management of children with congenital hydronephrosis]

Congenital anomalies of kidney and urinary tract (CAKUT) are the main cause of end stage renal disease in childhood. Early prenatal detection with planned postnatal diagnosis and therapy are the mainstay of management of neonates with CAKUT which is aimed at the conservation of renal tissue. The above assumptions led to the establishment of the Pommeranian Program for Management of Children with CAKUT. The strategy of the program is to coordinate prenatal diagnosis performed by obstetricians, postnatal care by neonatologists and early management by pediatric nephrologists and urologists. It will involve approximately 200 neonates annually. The basic concept of the program includes the following: 1. Delivery of a child with congenital hydronephrosis detected prenatal should take place in a center with specialist neonatal care. 2. Child with a congenital hydronephrosis should remain under specialist nephro-urologic care immediately after delivery. 3. Child with a congenital hydronephrosis should be qualified to scheduled urologic surgery after results of diagnostic tests and according to general status. 4. Model of integrated care on a child with congenital hydronephrosis should consist in close cooperation between obstetricians, neonatologists, pediatric nephrologists, and urologists.

The predictive values of urinalysis in intravenous urogram. Is intravenous urography really necessary in mild hydronephrotic patient?

BACKGROUND AND AIMS

Many patients who presented to Universiti Kebangsaan Malaysia Medical Centre (UKMMC) with signs and symptoms of urolithiasis had mild hydronephrosis with non visualization of calculus on ultrasound examination. These patients underwent an intravenous urogram (IVU) in order to determine the presence of urolithiasis and most of them had normal IVU. The main aim of this study was to determine the predictive value of urinalysis in this group of patients in determining the need for IVU examinations.

MATERIALS AND METHODS

Retrospectively the ultrasound, urinalysis and intravenous urography reports of 53 patients were reviewed and evaluated.

RESULTS

The positive predictive and negative predictive value of urinalysis was found to be 68% and 96.4%, respectively. CONCLUSIONS; The results indicate that the urinalysis was an excellent negative predictor for IVU. In view of high radiation dose, risk of contrast reaction and contrast induced nephropathy of IVU, we suggest that it should not be performed in patient with non visualization of calculus mild hydronephrosis when the urinalysis is negative for blood.