Double ureter and duplex system: a cadaver and radiological study

PURPOSE

To study the prevalence of duplex system and double ureter in cadavers and intravenous pyelograms in Indian population.

MATERIALS AND METHODS

Fifty cadavers were dissected and 50 intravenous pyelograms were examined on both (right and left) sides for the presence of duplex system and double ureter.

RESULTS

One male cadaver aged 43 years showed complete double ureter and duplex system on the right side and incomplete double ureter and duplex system on the left side. Another male cadaver aged 56 years showed incomplete double ureter and duplex system only on the right side. An intravenous pyelogram of a 43-year-old man showed incomplete double ureter along with duplex system on the right side.

CONCLUSION

Developmental anomalies of the kidney, ureter, and urinary bladder should be kept in mind and promptly detected before the manifestations of aforementioned complications increase the morbidity of the affected individuals.

Clinical significance of renal pelvic dilatation on ultrasound in dogs and cats

Renal pelvic dilatation is often recognized sonographically in dogs and cats, but ranges of measurements expected with different urologic conditions remain unknown. Ultrasound images of 81 dogs and 66 cats with renal pelvic dilatation were reviewed, and six groups were formed based on medical records: (I) clinically normal renal function, and (II) clinically normal renal function with diuresis; (III) pyelonephritis; (IV) noninfectious renal insufficiency; (V) outflow obstruction; (VI) miscellaneous nonobstructive anomalies. Medians for maximal pelvic width (range) for group I was 2.0 mm (1.0-3.8) in 11 dogs, and 1.6 mm (0.8-3.2) in 10 cats; for group II, 2.5 mm (1.3-3.6) in 15 dogs, and 2.3mm (1.1-3.4) in 16 cats; for group III, 3.6 mm (1.9-12.0) in nine dogs, and 4.0 mm (1.7-12.4) in seven cats; for group IV, 3.1 mm (0.5-10.8) in 33 dogs, and 2.8 mm (1.2-7.3) in 13 cats; for group V, 15.1mm (5.1-76.2) in six dogs, and 6.8mm (1.2-39.1) in 17 cats; and for group VI, 3.8mm (1.2-7.6) in seven dogs, and 3.0 mm (1.3-7.5) in three cats. Pelvic width in group I was lower than in groups III-V (P = 0.0001), but did not significantly differ from group II. Pelvic width > or =13 mm always indicated obstruction. While the proportion of bilateral pelvic dilatation was not different among groups, the difference in pelvic width (maximal-minimal) was greater in group V vs. groups I, II, and IV (P = 0.0009). These results confirm that renal pelvic dilatation can be detected sonographically in dogs and cats with clinically normal renal function, and that it increases with renal insufficiency, pyelonephritis, or outflow obstruction. Nevertheless, renal pelvic width varies substantially within groups and should be interpreted with caution.

Urothelial carcinoma of the renal pelvis associated with cystic disease of the kidney

Primary tumors of the renal pelvis and ureter account for about 8% of all urinary tract tumors. More than 90% of them are urothelial carcinomas. On the other hand, unilateral multicystic renal disease is an uncommon pathologic condition that may be mistaken for unilateral autosomal dominant polycystic kidney disease, multilocular cystic nephroma or cystic neoplasm. We present the case of a 54-year-old male known with arterial hypertension, admitted in the Second Surgery Department of Emergency County Hospital, Constanta, with intense right flank and right lumbar pain. This symptom started one month before hospital admission. Based on clinical features and imaging evaluations we established a presumptive diagnosis of unilateral autosomal dominant polycystic kidney disease. For these reasons, total right nephrectomy was performed. Pathologic examination of the nephrectomy specimen revealed high-grade urothelial carcinoma of the renal pelvis associated with unilateral multicystic renal disease. The particularity of this case lies in the uncommon association between two rare renal pathological conditions diagnosed by pathological examination.

Ureteropelvic junction obstruction and calyceal diverticulum in a child with Turner syndrome and horseshoe kidney

Laparoscopic dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction is considered to be a routine procedure in many pediatric surgical centers. UPJ obstruction is known to be associated with horseshoe kidney and several reports on successful laparoscopic repair in such cases exist. The case of a 9-month-old girl with Turner syndrome is reported. A horseshoe kidney with grade 4 hydronephrosis on the left side was diagnosed by ultrasound during the neonatal period. MAG3 diuretic renography and dynamic magnetic resonance imaging nephrography revealed a differential renal function of 31% and 69% on the left and right side, respectively. No drainage from the left renal pelvis could be demonstrated. Laparoscopy showed a combined UPJ obstruction and a calyceal diverticulum with a narrow infundibulum of the upper pole calices on the left side of the horseshoe kidney. Laparoscopic dismembered pyeloplasty and an additional infundibulopelvic anastomosis was performed. No intraoperative complications occurred. The immediate postoperative course was uneventful. Unobstructed drainage and stable differential renal function on the left side could be demonstrated on MAG3 diuretic renography 6 weeks postoperatively. In conclusion, laparoscopic repair of complex malformations of the upper urinary tract is feasible and leads to good functional outcome in selected cases.

Catheter-free methods for vesicoureteric reflux detection: our experience and a critical appraisal of existing data

In recent years, the exact role of vesicoureteric reflux (VUR) in general has become controversial, though in some groups of children the knowledge of the existence or non-existence of VUR is still a very important issue. The number of techniques available for the assessment of VUR is increasing, and a new classification taking into account their real characteristics (direct/indirect, catheter-using/catheter-free, radiation-giving/radiation-free) has been proposed. The purpose of the following review is to evaluate the currently available evidence supporting the use of various catheter-free methods for VUR detection. We believe that as the clinical role of VUR has been questioned, it is even more important for the method of its detection to be user-friendly as regards catheterisation, radiation and availability. There is still no evidence supporting the assertion that any of the catheter-free methods of VUR detection might be the optimal one for any child. However, there are some groups of children who would benefit from using them. New studies using new, catheter-free methods of VUR detection or a combination of two or more of the methods described may prove useful in improving sensitivity and providing additional data on this important issue.

[Informative value of radiodiagnosis methods of pyelo-ureteral strictures in kidney anomaly]

A total of 98 patients aged 18-67 years (mean age 42.5 +/- 10.3 years) suspected to have a pelviureteral stricture (PUS) were examined using ultrasound investigation in B-mode (BUI), excretory urography (EU), angiography, slice and multislice computed tomography (SCT, MSCT). This combined examination allowed to make diagnosis of hydronephrosis in 83 (84.7%) patients including PUS diagnosis in 48 (57.8%) patients. Basing on CT findings PUS was operated in 41 (85.4%) patients. Sensitivity, specificity and accuracy of BUI in detection of the level of the upper urinary tract obstruction was 92.8, 75.0, 89.3%, EU--94.5, 77.8, 92.2, SCT--100, 97, 98.1%, respectively. MSCT detected the level of the obstruction in all the cases. PUS was identified by BUI in 26.5, 89.3, 65.6, EU--in 81.3, 73.7, 79.1, by SCT in 90.5, 96.8, 94.2, MSCT--96.3, 100, 97.8% cases. Thus, MSCT is most effective in radiodiagnosis of PUS and can be recommended as a method of choice in PUS.

Ureter triplication with contra-lateral partial duplex system

Ureteral triplication is a rare congenital anomaly of the urinary tract. We report a case of ureteral triplication with contralateral partial kidney duplication in a patient with right loin pain. The development and types of ureteral triplication and the features of type 2 ureteral triplication on intravenous urography and magnetic resonance urography are described.

Late second trimester assessment of pyelectasis (SERP) to predict pediatric urological outcome is improved by checking additional features

OBJECTIVE

Counseling for pyelectasis in the late 2nd trimester is usually based only upon assessing the antero-posterior (AP) width of the renal pelvis. We hypothesized that checking additional features would better predict postnatal outcome.

STUDY DESIGN

Ultrasound (<24 weeks gestational age (GA)) and newborn outcome data collected prospectively since 1986 were analyzed retrospectively. We determined if outcome predictions in kidneys with a sonographically evident renal pelvis (SERP), which had evaluation of additional features (e.g., renal and bladder lengths, presence of a dilated ureter or dilated calyces) are more accurate than those that did not have these features.

RESULTS

There were 286 fetuses studied with pediatric follow-up of an average of 6.5 years. There were 338 exams providing 459 ultrasound images with SERP. Additional features were not assessed in 183 fetuses; however 103 fetuses did have evaluation of additional features. These features were categorized as abnormal (92) or as normal (11). Fetuses with SERP and abnormal additional features required extensive urological care or died 6.1 times more often than fetuses in which additional features were not examined (p < 0.001) and 12.9 times more often when additional features were normal (p < 0.001).

CONCLUSION

Fetal kidneys with SERP (<24 weeks GA) and an abnormal additional ultrasound feature had extensive pediatric care significantly more often than when such features were not evaluated or were normal.

[Comparison of the results of magnetic resonance urography and other examination methods in patients with iatrogenic injuries of the ureter and pelvis-ureteral segment]

MR urography was made in 25 patients (age 24-70, mean age 48.6 years, 20 females, 5 males) with iatrogenic injury of the upper urinary tract (UUT). A comparison group consisted of 15 patients without nephrostomic drainage who had no contraindications for intravenous contrast preparations. MR urography was performed in frontal and sagittal projections. The examination was made before and 20 min after intravenous injection of 20 mg diuretic. Five patients received additionally excretory MR urography with intravenous injection of magnevist (0.2 ml/kg, 3 ml/s just before the examination). Mean duration of urography was 21 (18-23) min. The results were compared to findings of ultrasound or x-ray investigations, diapevtic ureteroscopy or open surgical intervention. The results were similar to those of x-ray CT. In patients with ureteral obliteration MR urography was less informative than joint antegrade and retrograde ureteropyelography as the ureter could not be visualized beneath the injury. In 2 patients examined with intravenous urography and x-ray CT, definite length of ureteral stricture was obtained only with MR urography. In 5 patients with hydronephrotic transformation MR urography was much more informative than excretory urography. MR urography provided information sufficient for diagnosis. Sensitivity of MR urography and that with diuretic load was 86.8 and 92.3%, respectively. MR urography, even without contrast enhancement, provides images with high resolution sufficient for visualization of the ureter distally of the stricture and is a method of choice in patients with subnormal renal function, intolerance to iodine-containing contrast media, with hyperthyroidism and pregnant women after the first trimester.

Results of a practical protocol for management of prenatally detected hydronephrosis due to ureteropelvic junction obstruction

INTRODUCTION

Several algorithms exist for the management of prenatally diagnosed hydronephrosis due to ureteropelvic junction obstruction (UPJO). We utilize a conservative and practical approach emphasizing observation, with less frequent use of renal flow scans (RFS). We reviewed the results of 143 pediatric patients with congenital UPJO managed at our institution, focusing on surveillance and selective utilization of RFS, according to a standardized protocol.

MATERIALS AND METHODS

Charts of all infants with prenatally detected UPJO treated surgically or followed conservatively according to our protocol were reviewed. Patients were initially evaluated with ultrasound (US), voiding cystourethrogram, and RFS. Successive follow-up was with interval US. RFS was reserved for those with worsening hydronephrosis or that which failed to improve on US by 1 year. Radiographic studies and operative reports were examined. Gender, side of UPJO, degree of hydronephrosis, mode of management, and current status of the patients were noted.

RESULTS

The records of 143 patients and a total of 198 renal units (RU) were reviewed. The male:female ratio was 2.7. UPJO was unilateral in 88 (61%) patients and occurred more frequently on the left side (68%). Obstruction was bilateral in 55 (39%) patients. Initial US grade of hydronephrosis was Grade 1 in 56 RU (28%), Grade 2 in 51 RU (26%), Grade 3 in 50 RU (25%) and Grade 4 in 41 RU (21%). 178 RU (90%) were followed conservatively, while open dismembered pyeloplasty was the initial therapeutic approach in 20 RU (10%). The mean age at the time of surgery was 15.95+/-14.60 weeks (range 2-60). Indications included low differential renal function (DRF) (n=12), absence of tracer clearance from the renal pelvis (n=2), parental preference (n=3), and acute renal failure (n=3). Postoperative course was uneventful during 33.43+/-33.53 months (range 2-120) with favorable US and RFS results. In conservatively managed patients, mean follow-up time was 14.94+/-14.35 months (range 1.5-142). Spontaneous resolution of hydronephrosis was observed in 87 RU (49%), while 10 RU (5.6%) eventually required surgery for worsening appearance or function on US or RFS, respectively (n=8), symptom development (n=3), and/or parental preference due to persistently prolonged T1/2 (n=4). Seventy-two RU (40.4%) remain under surveillance with improvement (47.2%) or stable hydronephrosis (47.2%) in 94.4%. Decreased DRF occurred in 1 RU. Nine RU (5%) were lost to follow-up. With application of this algorithm, only 12% of patients underwent two or more RFS.

CONCLUSION

Pyeloplasty may be performed safely in infants when indicated; however, the majority of children with UPJO can be managed conservatively. Spontaneous resolution of hydronephrosis and/or favorable prognosis was encountered in 87% of conservatively managed RU. The use of a standard US grading system, selective utilization of follow-up renal function testing, and parental compliance are important factors in successful management.

Hydronephrosis index: a better physiological reference in antenatal ultrasound for assessment of fetal hydronephrosis

OBJECTIVE

To establish a nomogram of fetal hydronephrosis index (HI) (anteroposterior diameter of renal pelvis divided by urinary bladder volume) at different gestational ages, to serve as a new reference for antenatal ultrasound examination, and to avoid overestimation of fetal hydronephrosis due to transient effect of a distended fetal bladder.

STUDY DESIGN

504 uncomplicated singleton pregnancies from 20 to 38 weeks' gestation were included. In each fetus, the maximum anteroposterior diameters of both renal pelves were measured on transverse view of fetal kidneys. Urinary bladder volume was calculated using the ovoid volume formula. HI was derived accordingly.

RESULTS

Values of HI vary significantly at different trimesters of pregnancy. HI was much higher (mean = 0.1543) from 20 to 27 weeks' gestation, and its value decreased significantly (mean = 0.0253) from 28 to 38 weeks' gestation (P < .05, independent-sample t test). As gestational age increased, HI decreased (R(2) = 0.5921).

CONCLUSIONS

HI is easy to be measured and can be used as a new physiological reference for assessment of fetal hydronephrosis by eliminating the confounding effect of a full fetal bladder. The change in values of HI throughout gestation supports the clinical importance of a nomogram for this new index.

[Predictive value of antenatal ultrasound for the neonatal diagnostic of renal and ureteral anomaly]

Pyelectasis is a dilatation of the renal pelvis. It must be differentiated from hydronephrosis which is a dilation of the renal pelvis and of the renal calyces. In this retrospective study, we focused on the treatment and follow up of 31 newborns in whom a pyelectasis had been diagnosed in utero. At the end of the study, 20 babies showed no sign of an urologic disorder whereas 11 babies did. Our study suggests that it is crucial to search for an urologic disorder in the neonatal period when a fetal pyelectasis has been diagnosed.

Lower polar aberrant renal vein-renal pelvis fistula: a rare cause of haematuria

BACKGROUND

Non traumatic fistula between a lower polar aberrant renal vein and renal pelvis is a very rare condition, which to our knowledge has not been previously reported in the English literature.

OBJECTIVE

To report a rare case of non-traumatic fistula between an aberrant lower polar renal vein and renal pelvis.

CASE REPORT

An 80-year old man presented with six-week history of intermittent haematuria. He was fully assessed clinically in addition to having an intervenous urography, ultrasonography, ureteropyelogram and selective right renal angiography and the venography which confirmed the presence of a fistula between the right renal pelvis and an aberrant tortuous lower polar right renal vein just above the level of the pelviureteric junction. There was no communication with an artery. The fistula was successfully treated by selective angiographic (venographic) embolization using a coil. Immediately after the emboliza-tion the haematuria settled.

CONCLUSION

In our opinion renal veno-pelvis fistulae should be managed in the first place by selective angiography to confirm the diagnosis and then by embolization at the same sitting. If embolization fails, then surgical closure of the fistula may be achieved either through laparoscopic or open surgical approach and the vessel may be ligated or occluded.

Reproducibility of fetal renal pelvis volume measurement using three-dimensional ultrasound

OBJECTIVE

To assess the reproducibility of fetal renal pelvis volume measurement in hydronephrotic kidneys using transabdominal three-dimensional (3D) ultrasound.

METHODS

The fetal renal pelvis volume was measured using 3D ultrasound in one kidney in each of 15 fetuses with hydronephrosis in the second or third trimester of pregnancy. Hydronephrosis was diagnosed when the fetus had an anteroposterior renal pelvis diameter > or = 5 mm. After volume acquisition by one of the observers, the repeatability of volume calculation with manual delineation of the fetal renal pelvis was assessed by six different observers using the Virtual Organ Computer-aided AnaLysis (VOCAL(trade mark)) imaging program. The intraclass correlation coefficients (ICC), coefficient of variation (CV) and within- and between-observer repeatability coefficient (r) were calculated and Bland-Altman plots were constructed.

RESULTS

Both intra- and interobserver reliability of the fetal renal pelvis volume measurements were considered to be very good. For intraobserver reliability, the ICC was 0.996 and the CV was 10.8%. For the overall interobserver reliability, the ICC was 0.998 and the CV was 15.7%; the interobserver reliability between pairs of observers had ICCs between 0.994 and 0.999, and CVs between 19.5% and 7.6% for inexperienced and experienced observers, respectively.

CONCLUSION

With 3D ultrasound using the VOCAL imaging program, it is technically feasible to reproduce fetal renal pelvis volume measurements. Further research to establish the clinical applications of this technology is warranted.

Case report: laparoscopic pyeloplasty for ureteropelvic junction obstruction of lower moiety in duplex system

BACKGROUND AND PURPOSE

Ureteropelvic junction (UPJ) obstruction can be associated with renal anomalies. We report a case of laparoscopic dismembered pyeloplasty in a lower moiety of a complete duplex system.

CASE REPORT

A 40-year-old woman presented with right flank pain. Intravenous urography revealed a typical UPJ obstruction on the right side, and a diuretic renal scan showed 35% uptake of the tracer and a glomerular filtration rate of 57 mL/min with delayed excretion (T1/2 28 minutes). Transperitoneal laparoscopic dismembered pyeloplasty was performed. The operative time was 140 minutes with a blood loss of 30 mL. Diclofenac sodium (total requirement 150 mg) was used for analgesia. A diuretic renal scan at 3 months showed 41% uptake and a glomerular filtration rate of 66 mL/min, with prompt drainage without obstruction of the right kidney (T(1/2) 18 minutes). At 6 months' follow-up, the patient was symptom free.

CONCLUSION

To our knowledge, our report is the third where laparoscopic pyeloplasty for a duplex system was carried out. Prior placement of Double-J stent made identification of the ureter draining the lower moiety during laparoscopic surgery much easier. The principles of open surgery could be duplicated.

Sonographic measurement of renal pelvis wall thickness as diagnostic criterion for acute pyelonephritis in adults

PURPOSE

Inflammatory processes may increase the urothelial thickness of the renal pyelon. Purpose of the study was to assess sonographic measurement of pyelon wall thickness (PWT) in adult patients with acute pyelonephritis, chronic urinary tract infection (UTI) and indwelling ureteral stents.

MATERIALS AND METHODS

Four study groups (acute pyelonephritis n=50, chronic UTI n=10, indwelling ureteral stents n=10, controls n=25) underwent renal ultrasonography (Acuson Seqouia, Mountain View, CA; 6 MHz Transducer). The renal pyelon was imaged in transverse and longitudinal planes. PWT measurements of patients with acute pyelonephritis were repeated after successful antibiotic treatment.

RESULTS

Mean PWT in healthy controls was 1.0 mm+/-0.19. In patients with acute pyelonephritis, PWT was significantly increased to 2.9 mm+/-0.89 (p<0.001). PWT decreased significantly after antibiotic treatment to 1.4 mm+/-0.47 (p<0.001). Kidneys with indwelling stents presented with a PWT of 2.7 mm+/-0.68, kidneys with chronic UTI demonstrated a PWT of 2.8 mm+/-0.62. PWT in these patient groups was significantly greater than PWT in healthy volunteers (p<0.001). The interobserver agreement was excellent (p<0.001).

CONCLUSION

PWT is a reproducible diagnostic criterion for acute pyelonephritis. Based upon our experience, we suggest a cut-off value of 2.0 mm to distinguish healthy kidneys from those with urothelium thickened by inflammation. PWT cannot be used to distinguish acute pyelonephritis from chronic inflammation of the urothelium.