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Apostel HJCL, Duval ELIM, De Dooy J, Jorens PG, Schepens T. Respiratory support in the absence of abdominal muscles: A case study of ventilatory management in prune belly syndrome. Paediatr Respir Rev 2021; 37:44-47. [PMID: 33349558 DOI: 10.1016/j.prrv.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
Prune belly syndrome (PBS) results in a total lack of abdominal musculature. Abdominal muscles have an important function during inspiration and expiration. This puts the patient at risk for respiratory complications since they have a very limited ability to cough up secretions. Patients in an intensive care unit (ICU) with PBS who receive mechanical ventilation are at even greater risk for respiratory complications. We review the function of the abdominal muscles in breathing and delineate why they are important in the ICU. We include an illustrative case of a long-term ventilated patient with PBS and offer respiratory management options.
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Affiliation(s)
- Heleen J C L Apostel
- Departement of Anesthesiology and Pain Management, Maastricht Universitair Medisch Centrm, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.
| | - Els L I M Duval
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Jozef De Dooy
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Philippe G Jorens
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Tom Schepens
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
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Wiener JS, Huck N, Blais AS, Rickard M, Lorenzo A, Di Carlo HNM, Mueller MG, Stein R. Challenges in pediatric urologic practice: a lifelong view. World J Urol 2020; 39:981-991. [PMID: 32328778 DOI: 10.1007/s00345-020-03203-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.
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Affiliation(s)
- John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Nina Huck
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne-Sophie Blais
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Mandy Rickard
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Armando Lorenzo
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Heather N McCaffrey Di Carlo
- The James Buchanan Brady Urologic Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret G Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics & Gynecology and Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Cornel A, Duicu C, Delean D, Bulata B, Starcea M. Long term follow-up in a patient with prune-belly syndrome - a care compliant case report. Medicine (Baltimore) 2019; 98:e16745. [PMID: 31415370 PMCID: PMC6831394 DOI: 10.1097/md.0000000000016745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Malformative uropathies represent a major cause of Chronic Kidney Disease (CKD) in children. Genitourinary system is the most frequent and sever affected in Prune-Belly syndrome cases. That is why the findings of early diagnosis and vigilant monitoring for these situations remain a major challenge for the medical team. PATIENT CONCERNS We present the clinical course of a 10 years old child with diagnosis of Prune-Belly syndrome. A urinary tract abnormality was suspected starting 25 weeks of gestation, when a routine ultrasound showed oligohydramnios, increased size urinary bladder, bilateral hydronephrosis and megaureters, thin abdominal wall. DIAGNOSIS Prenatal suspicion of Prune-Belly syndrome plays a deciding role in renal disease progression. A detailed clinical exam at birth established the diagnosis of Prune-Belly syndrome. Renal ultrasound confirmed bilateral grade III hydronephrosis and megaureters, with empty bladder, suggesting an obstruction at this level. A persistent urachus was confirmed by catheterization. Later it was used for imaging study that showed bilateral high grade reflux. INTERVENTIONS The main goal of any treatment is to preserve kidney function. Treatment options depend on the clinical picture. The pregnancy was closely monitorized, but fetal distress appeared so early labor was induced at 32 weeks. At beginning a temporary catheter was placed into the urachus which expressed urine. The urachus drain was left in place until the age of 6 weeks, when a bilateral ureterostomy was performed. Skeletal and genital malformations were present too; the child has undergone several surgeries to solve these abnormalities. OUTCOMES At the age of 10 years, he is a well-adapted child. He has had fewer than 3 urinary tract infections per year. Long term follow-up showed a relatively slow decline in the estimated Glomerular Filtration Rate in our child (62 ml/1.73m/min). LESSONS This case suggests that induced early labor could prove beneficial for early upper urinary tract decompression through earlier access to surgery. This is an option especially in situations or region where vesicoureteric or vesicoamniotic shunt placement is not available.
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Affiliation(s)
- Aldea Cornel
- Department of Nephrology and Dyalisis Children, 2nd Pediatric Clinic, Emergency Hospital for Children, Cluj-Napoca
| | - Carmen Duicu
- 1st Pediatric Department, University of Medicine, Pharmacy, Science and Technology, Tîrgu Mureş
| | - Dan Delean
- Department of Nephrology and Dyalisis Children, 2nd Pediatric Clinic, Emergency Hospital for Children, Cluj-Napoca
| | - Bogdan Bulata
- Department of Nephrology and Dyalisis Children, 2nd Pediatric Clinic, Emergency Hospital for Children, Cluj-Napoca
| | - Magdalena Starcea
- 4th Pediatric Clinic, Department of Nephrology and Dialysis Children, Emergency Hospital for Children Iaşi, Romania
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White JT, Sheth KR, Bilgutay AN, Roth DR, Austin PF, Gonzales ET, Janzen NK, Tu DD, Mittal AG, Koh CJ, Ryan SL, Jorgez C, Seth A. Vesicoamniotic Shunting Improves Outcomes in a Subset of Prune Belly Syndrome Patients at a Single Tertiary Center. Front Pediatr 2018; 6:180. [PMID: 30018947 PMCID: PMC6038357 DOI: 10.3389/fped.2018.00180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/01/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: Review outcomes of Prune Belly Syndrome (PBS) with the hypothesis that contemporary management improves mortality. Methods: A retrospective chart review of inpatient and outpatient PBS patients referred between 2000 and 2018 was conducted to assess outcomes at our institution. Data collected included age at diagnosis, concomitant medical conditions, imaging, operative management, length of follow-up, and renal function. Results: Forty-five PBS patients presented during these 18 years. Prenatal diagnoses were made in 17 (39%); 65% of these patients underwent prenatal intervention. The remaining patients were diagnosed in the infant period (20, 44%) or after 1 year of age (8, 18%). Twelve patients died from cardiopulmonary complications in the neonatal period; the neonatal mortality rate was 27%. The mean follow-up among patients surviving the neonatal period was 84 months. Forty-two patients had at least one renal ultrasound (RUS); of the 30 patients with NICU RUSs, 26 (89%) had hydronephrosis and/or ureterectasis. Of the 39 patients who underwent voiding cystourethrogram (VCUG), 28 (62%) demonstrated VUR. Fifty-nine percent had respiratory distress. Nine patients (20%) were oxygen-dependent by completion of follow up. Thirty-eight patients (84%) had other congenital malformations including genitourinary (GU) 67%, gastrointestinal (GI) 52%, and cardiac 48%. Sixteen patients (36%) had chronic kidney disease (CKD) of at least stage 3; three patients (7%) had received renal transplants. Eighty-four percent of patients had at least one surgery (mean 3.4, range 0-6). The most common was orchiopexy (71%). The next most common surgeries were vesicostomy (39%), ureteral reimplants (32%), abdominoplasty (29%), nephrectomy (25%), and appendicovesicostomy (21%). After stratifying patients according to Woodard classification, a trend for 12% improvement in mortality after VAS was noted in the Woodard Classification 1 cohort. Conclusions: PBS patients frequently have multiple congenital anomalies. Pulmonary complications are prevalent in the neonate while CKD (36%) is prevalent during late childhood. The risk of CKD increased significantly with the presence of other congenital anomalies in our cohort. Mortality in childhood is most common in infancy and may be as low as 27%. Contemporary management of PBS, including prenatal interventions, reduced the neonatal mortality rate in a subset of our cohort.
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Affiliation(s)
- Jeffrey T White
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Kunj R Sheth
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Aylin N Bilgutay
- Department of Urology, Emory University School of Medicine, Atlanta, GA, United States
| | - David R Roth
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Paul F Austin
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Edmond T Gonzales
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Nicolette K Janzen
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Duong D Tu
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Angela G Mittal
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Chester J Koh
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Sheila L Ryan
- Memorial Hermann Health System, Houston, TX, United States
| | - Carolina Jorgez
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States
| | - Abhishek Seth
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.,Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
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