Variation in Management of Duplex System Intravesical Ureteroceles: A Survey of Pediatric Urologists

Upper pole pathologies in duplex kidneys: an analysis of predictive factors for surgery and urinary tract infections from the Mid-Atlantic Pediatric Academic Consortium

BACKGROUND/OBJECTIVE

While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR).

METHODS

We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS.

RESULTS

Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p = 0.03/0.001 and p = 0.002 respectively). Ectopic ureter (p = 0.004), ureterocele (p = 0.02), and obstruction (p = 0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p = 0.03 and p = 0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p = 0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p = 0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR.

CONCLUSIONS

Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes.

Imaging of ureter: a primer for the emergency radiologist

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Management and outcomes of ureteroceles in children: An experience of 25 years

Introduction:

Ureterocele is a rare urogenital malformation. The treatment is variable and complicated as it depends on several factors. The aim of this study was to evaluate the management and outcomes of children with ureterocele and to compare single system and duplex system ureteroceles.

Materials and Methods:

A retrospective study was conducted and all patients with ureterocele operated from January 1992 to December 2018 were included. The records of those included were assessed, and a detailed case record sheet was filled. The outcome parameters assessed were the persistence of symptoms and additional surgical procedure performed.

Results:

Forty-seven patients (28 boys and 19 girls) with a median age of presentation of 21 months were included. Four patients had bilateral ureterocele. Overall, 51 renal units with ureterocele were studied. Twenty renal units of the 31 renal units with duplex system underwent cystoscopic decompression, and of these, 8 (40%) needed a second procedure. Fourteen renal units of the remaining 20 renal units with single system underwent cystoscopy and decompression, and of these, 1 (7%) required another procedure (P = 0.024). Sixteen renal units had ectopic ureterocele, of which 9 (56%) underwent heminephrectomy/nephrectomy. Intravesical ureterocele was present in 35 renal units, of which only 2 (5.7%) underwent nephrectomy or heminephrectomy (P < 0.001).

Conclusion:

Duplex system ureteroceles are more likely to require a second procedure following an endoscopic puncture. Units with ectopic ureterocele were more likely to need nephrectomy.

Laparoscopic Upper-pole Heminephrectomy for the Management of Duplex Kidney: Outcomes of a Multicenter Cohort

OBJECTIVE

To analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries.

MATERIALS AND METHODS

A retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P <.05.

RESULTS

Postoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function.

CONCLUSION

Laparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients

BACKGROUND

Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed.

CASE REPORT

We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.

Ureteroureterostomy in patients with duplex malformations: does a large diameter of the donor ureter affect the outcome?

INTRODUCTION

Ureteroureterostomy is a commonly adopted, minimally invasive approach in the management of duplex anomalies requiring diversion, e.g., ectopic upper pole ureters.

OBJECTIVE

The authors hypothesized that a large diameter of the donor ureter could affect the outcome of this procedure.

STUDY DESIGN

Forty-two patients from two centers were retrospectively reviewed. To compare patients with small (group 1) vs large donor ureters (group 2), they were split at the median of the sonographically measured diameter at the level of the future anastomosis (n = 20 < 1.2 cm, mean 0.71 cm vs n = 22 ≥ 1.2 cm, mean 1.75 cm; P < 0.001) Figure. Ureteroureterostomy was performed in an end-to-side fashion with the donor ureter being tapered if required.

RESULTS

There was no significant difference in operation time (127 vs 121 min; P = 0.59) or duration of hospital stay (4.15 vs 4.09 days; P = 0.89) or number of postoperative complications (3 febrile urinary tract infections [fUTIs] in group 1 and one fUTI in group 2, P = 0.33). Reoperations during follow-up (1 stump resection and 2 endoscopic vesicoureteral reflux procedures) occurred exclusively in group 1 (P = 0.22). The mean pre-operative hydronephrosis grade of the affected moiety was higher in group 2 compared with group 1 (mean 2.73 Society for Fetal Urology classification [SFU] vs 1.65, P < 0.001). During follow-up, the mean hydronephrosis grade in group 2 improved from 2.73 to 1.36 SFU (P = 0.0011). In patients from group 1, the mean hydronephrosis grade remained relatively unchanged, from 1.65 to 1.35 SFU (P = 0.4).

DISCUSSION

After its first description in 1928, it took almost 40 years for ipsilateral ureteroureterostomy to become a widely adopted technique in the management of duplex malformations, especially for obstructive or ectopic upper pole moieties. Whereas it has been recently shown that the upper pole function does not seem to matter, there are still only narrative reports about the influence of the donor ureter diameter contributing to potential complications such as a de novo hydronephrosis of the receiving ureter with potential damage of the healthy moiety or the persistence of a pre-operatively marked hydronephrosis. While the study data are retrospective, the authors could demonstrate that a ureteral diameter of ≥1.2 cm is not factoring adversely into the occurrence of postoperative complications.

CONCLUSION

A donor ureter diameter ≥1.2 cm in ureteroureterostomy was not associated with a higher complication rate or worse outcome considering further fUTIs or reoperations. The postoperative reduction in hydronephrosis grade was more pronounced in patients with large donor ureters with disappearance of the pre-operative significant difference between the two groups.

Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter?

PURPOSE

Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes.

MATERIALS AND METHODS

All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes.

RESULTS

The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery.

CONCLUSION

Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.

Evaluating Outcomes of Differential Surgical Management of Nonfunctioning Upper Pole Renal Moieties in Duplex Collecting Systems

OBJECTIVE

To evaluate the management and clinical outcomes of nonfunctioning upper pole moieties treated with either upper pole heminephrectomy or upper pole preservation with lower ureteral reconstruction at a single tertiary institution.

METHODS

After Institutional Review Board (IRB) approval, patients with duplicated systems undergoing upper pole heminephrectomy, ureteroureterostomy, or common sheath ureteral reimplantation from 2012-2017 were identified. Only patients with a nonfunctioning upper pole moiety on ultrasound or renal scan were included. Patients undergoing upper pole heminephrectomy were compared to those undergoing upper pole preservation with respect to demographics, anatomic variations preoperatively, and postoperative outcomes.

RESULTS

Twenty-seven (57%) patients underwent upper pole preservation with lower ureteral reconstruction; 20 (43%) patients underwent upper pole heminephrectomy. Patients undergoing lower ureteral reconstruction were older (1.63 vs 2.76 years, P = .018) and more commonly presented with lower pole vesicoureteral reflux (67% vs 25%, P = .008). No significant difference in postoperative complications was seen between the two groups. After ureteroureterostomy, one patient developed new onset symptomatic reflux to the upper pole requiring intravesical reimplantation. In the heminephrectomy group, 4 of 11 patients with ureteroceles had ureterocelectomy with concomitant lower pole reimplantation. After heminephrectomy, two additional patients required further interventions: ureterocele excision and transurethral polyp excision.

CONCLUSION

For patients with nonfunctional upper poles, lower tract reconstruction is a safe alternative to upper pole heminephrectomy. No significant difference in outcomes was seen. Considering that nearly 1 of 3 of patients with upper pole heminephrectomy required additional lower urinary tract procedures, pursuing upper pole preservation with lower urinary tract reconstruction may be favorable.

Does endoscopic puncture of ureterocele provide not only an initial solution, but also a definitive treatment in all children? Over the 26 years of experience

PURPOSE

We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status.

METHODS

78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1-26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period.

RESULTS

Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p = 0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p = 0.716).

CONCLUSIONS

Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

CT Urography for Evaluation of the Ureter

Over the past decade, computed tomographic (CT) urography has emerged as the primary imaging modality for evaluating the urinary tract in various clinical settings, including the initial workup of hematuria. With the widespread implementation of CT urography, it is critical for radiologists to understand normal ureteral anatomy and the varied appearance of pathologic ureteral conditions at CT urography. Pathologic findings at CT urography include congenital abnormalities, filling defects, dilatation, narrowing, and deviations in course. These abnormalities are reviewed, along with the indications for CT urography, current imaging protocols with specific techniques for optimal evaluation of the ureter, and dose reduction strategies.

Examining trends in the treatment of ureterocele yields no definitive solution

INTRODUCTION

The surgical management of ureteroceles is extremely variable. Some have hypothesized that if these patients were treated with 'definitive' staged surgical intervention, the need for further revision surgery would be eliminated.

OBJECTIVE

The present study sought to determine if the rate of revision surgery differed among patients who have undergone different surgical approaches for the ureterocele complex.

STUDY DESIGN

A large retrospective chart review was conducted, identifying all patients having undergone ureterocele surgery at a single institution over the past 41 years. The cohort was divided into four groups based on surgical approach: upper tract approach (UTA), lower tract reconstruction (LTR), simultaneous upper and lower tract approach (ULTA), and staged lower tract reconstruction (SLTR). Demographics, the presence of preoperative/postoperative VUR, postoperative morbidity and the need for revision surgery were compared using the Chi- squared test, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test (Bonferroni correction), logistic regression modeling and survival analyses (Kaplan-Meier and Cox proportional Hazards regression with unplanned revision operation as the outcome event).

RESULTS

Between 1969 and 2010, 180 patients were identified as having undergone surgical management of ureteroceles, of which 120 had complete demographic data available for analysis. The median age at the time of initial surgical intervention was 5.8 months and the majority of patients (83.3%) were female. The median follow-up was 33.1 months. Surgical management was as follows: 18 (15.0%) patients underwent UTA, 47 (39.2%) underwent LTR, 23 (19.2%) underwent ULTA, and 32 (26.6%) underwent SLTR. Among these groups, the only difference in median age was between the LTR and SLTR groups (6.3 months vs 3.7 months, P=0.012). Additional revision surgery was required in: nine (50.0%) of UTA, ten (21.3%) of LTR, four (17.4%) of ULTA, and three (9.4%) of SLTR. The only statistically significant difference in unplanned revision surgery was noted in the UTA group versus each of the other groups with VUR as the predominant indication (88.9%). The likelihood of requiring revision surgery in comparison to the SLTR group was significantly increased in the UTA group (OR 9.67, CI 2.15-43.56), but not in the LTR (OR 2.61, CI 0.66-10.37) or the ULTA group (OR 2.04, CI 0.41-10.13). Obstruction, recurring UTIs and VUR were the main indications for revision surgery overall.

DISCUSSION

There is a large body of literature examining the surgical management of ureteroceles. It most recently primarily focuses on an endoscopic approach to the lower tract. The present retrospective review examined the need for re-operative intervention by comparing four different surgical approaches, and found that there is no panacea. Although heminephrectomy (UTA) was a definitive procedure in some patients without reflux at presentation, many who underwent heminephrectomy, went on to require later bladder surgery for either recurrent UTI or persistent reflux. The present study has multiple limitations. Although VUR was an indication for revision surgery in the early part of the series, the current treatment of VUR is not necessarily as stringent. In addition, no distinction was made between an orthotopic or ectopic ureterocele, although some authors have reported differing outcomes in these two groups. However, it is felt that given the large data set of a relatively uncommon condition, the lack of superiority of one approach is apparent.

CONCLUSION

There is no definitive surgical repair for the ureterocele complex. All groups except UTA had statistically similar rates of revision surgery. The widespread variability in current management echoes the lack of one superior approach found in this comprehensive series.

Noninvasive ureterocele puncture using pulsed focused ultrasound: an in vitro study

PURPOSE

To evaluate the feasibility of performing noninvasive puncture of pediatric ureteroceles with cavitation-based focused ultrasound (US) (histotripsy).

MATERIALS AND METHODS

A model for the ureterocele wall was developed from an excised bovine bladder wall. The model was exposed to focused US pulses in a water bath under three different US parameter sets for up to 300 seconds to create localized perforations in the wall. B-mode US imaging was used to monitor the treatment and assess potential imaging guidance and feedback.

RESULTS

Punctures were formed between 46-300 seconds, depending on the focused US exposure parameters and model wall thickness. Puncture diameter was controllable through choice of exposure parameters and could be varied between 0.8-2.8 mm mean diameter. US-induced cavitation was visible on B-mode imaging, which provided targeting and treatment feedback.

CONCLUSIONS

Cavitation-based focused US can create punctures in a model that mimics the tissue properties of a ureterocele wall, under guidance from US imaging.

Duplex system ureterocele in infants: should we reconsider the indications for secondary surgery after endoscopic puncture or partial nephrectomy?

OBJECTIVE

We assessed outcomes and need for secondary surgery after primary trans-urethral puncture (TUP) or upper pole partial nephrectomy (UPPN) in duplex system ureterocele (DSU) patients undergoing management that disregards vesicoureteral reflux and upper pole function.

SUBJECTS AND METHODS

Between 2003 and 2010, 41 DSU <1 year underwent TUP (n = 32) or UPPN (n = 9). Postoperatively, additional investigations and surgery were limited to cases showing persistent hydroureteronephrosis or developing recurrent febrile urinary tract infections (UTI). Outcome parameters included upper tract decompression, UTI after decompression, continence status, and secondary surgery rate. Preoperative variables were compared between patients who required secondary surgery and those who did not.

RESULTS

Additional surgery was required for persistent hydroureteronephrosis in 20% of cases after TUP vs none after UPPN. After decompression, 4 female patients developed recurrent febrile UTI and 2 required additional surgeries. No case suffered from urinary incontinence. After a median (range) follow-up of 46 (17-102) months, TUP or UPPN was the only surgery required in 32 (78%) cases irrespective of preoperative variables.

CONCLUSION

UPPN seems more effective than TUP in decompressing severely dilated urinary tracts. After decompression, disregarding VUR status and upper pole function, TUP or UPPN is the only procedure required in 80% of DSU cases, regardless of preoperative variables.

[High-pressure balloon dilatation for treatment of orthotopic ureterocele]

OBJECTIVE

Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele.

MATERIAL AND METHODS

We have analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014" to the ureterocele.

RESULTS

There were no intraoperative or postoperative complications, surgical time being 24 ± 9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment.

CONCLUSIONS

High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.

The Value of PIC Cystography in Detecting De Novo and Residual Vesicoureteral Reflux after Dextranomer/Hyaluronic Acid Copolymer Injection

The endoscopic injection of Dx/HA in the management of vesicoureteral reflux (VUR) has become an accepted alternative to open surgery. In the current study we evaluated the value of cystography to detect de novo contralateral VUR in unilateral cases of VUR at the time of Dx/HA injection and correlated the findings of immediate post-Dx/HA injection cystography during the same anesthesia to 2-month postoperative VCUG to evaluate its ability to predict successful surgical outcomes. The current study aimed to evaluate whether an intraoperatively performed cystogram could replace postoperative studies. But a negative intraoperative cystogram correlates with the postoperative study in only 80%. Considering the 75-80% success rate of Dx/HA implantation, the addition of intraoperative cystograms cannot replace postoperative studies. In patients treated with unilateral VUR, PIC cystography can detect occult VUR and prevent postoperative contralateral new onset of VUR.

[Hydronephrosis: urgency of interventions and recommended times for surgical correction]

The prevalence of malformations of the kidneys is quite high compared to other congenital malformations. In a study of the Association for Neonatology of Mecklenburg-West Pomerania examining 37,634 births, a hydronephrotic kidney was diagnosed in 16.7 of 10,000 children. Depending on the type and severity of the congenital malformation it might be difficult to find out when there is a risk for loss of renal function. Unfortunately, in 2010 health politicians (the Gemeinsame Bundesausschuss) voted against routine ultrasound screening for renal abnormalities in newborns despite an increasing number of pre- or postnatally diagnosed dilated kidneys in recent years. Will this lead to a decrease in the diagnosis of hydronephrosis with possible loss of renal function later on? According to Roth et al. the incidence of in utero dilatations of the urinary tract is about 1:100, but only 1:500 children have a clinically relevant problem. This raises the question of which of these young patients need an intervention and which might be monitored expectantly.