The interrelationship between paraureteric diverticula, vesicoureteric reflux and duplication of the pelvicaliceal collecting system: a family study

Diverticulocystoplasty with bilateral ureteric reimplantation: management in a rare case of combined congenital large paraureteric diverticulum with bilateral obstructive megaureter

A large congenital paraureteric diverticulum has not been reported earlier in combination with bilateral obstructed megaureter. We present one such case in an adolescent male with decreased bladder capacity and renal failure. A single sitting surgical procedure included diverticulocystoplasty with bilateral ureteric reimplantation. The left ureter was implanted into the diverticular wall, which was used as a patch to augment the bladder. Reimplantation into the wall of the diverticulum has also not been reported earlier.

Prevalence of duplex collecting systems in familial vesicoureteral reflux

PURPOSE

Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood with a reported incidence of 0.8%. Familial nature of vesicoureteral reflux (VUR) is well recognized with a prevalence of 27-51% in siblings of children with VUR and 66% rate of VUR in offsprings of parents with previously diagnosed VUR. Although VUR is known to be the most common abnormality associated with renal duplex systems, the prevalence and significance of renal duplication in familial VUR is not known. The aim of this study was to determine the prevalence and significance of duplex collecting systems in familial VUR.

METHODS

Between 1998 and 2009, the parents of 237 index patients with grade III-V VUR were asked permission to screen siblings younger than 6 years old for VUR. A total of 513 children in 237 families were identified to have VUR (237 index patients, 276 siblings). Families were divided into three groups: Group I, families with only boys affected Group II, families with only girls affected and Group III, families with boys and girls affected.

RESULTS

In 39 families (16.5%) only boys had VUR (Group I), in 89 families (37.5%) only girls had VUR (Group II) and in 109 families (46%) boys and girls were affected (Group III). Duplex collecting systems were present in 39 (7.6%) patients. The prevalence of duplex systems was significantly higher in Group I (15%) compared to Group II (6%) and Group III (6.4%), (p < 0.01). Duplex systems were present in 15% of boys in Group I and only in 4% of boys in Group III (p < 0.01). Patients with duplex systems had a significantly higher grade of VUR than patients without duplex systems (p < 0.01).

CONCLUSION

Families with exclusively boys affected with VUR have a higher rate of prevalence of duplex collecting systems. This has implications for genetic counseling and for modeling the inheritance of VUR.

Familial Vesicoureteral Reflux: Influence of Sex on Prevalence and Expression

PURPOSE

Familial clustering of vesicoureteral reflux implies that genetic factors have an important role in the pathogenesis of vesicoureteral reflux. We investigated the impact of sex on familial vesicoureteral reflux.

MATERIALS AND METHODS

Between 1998 and 2003 we identified 159 white families with at least 2 children (range 2 to 5) with vesicoureteral reflux confirmed by a voiding cystourethrogram. Families were divided into 3 groups, including group 1 with only boys affected (29 or 18%), group 2 with only girls affected (57 or 36%) and group 3 with boys and girls affected (73 or 46%). Clinical characteristics, reflux grade and associated renal anomalies in these 3 groups were compared using the Mann-Whitney U and chi-square tests for statistical analysis.

RESULTS

Sisters of index female patients were at significantly higher risk for vesicoureteral reflux than brothers (p <0.01). Boys in group 1 had a significantly higher grade of vesicoureteral reflux than boys in group 3, and girls in groups 3 and 2 (p = 0.018, <0.001 and <0.0001, respectively). Severe renal scarring was present in 7% of boys in group 1, 6.6% of boys in group 3, 1.3% of girls in group 3 and 1.9% of girls in group 2. Duplex kidneys were present in 15.3% of boys in group 1 but only in 2.3% of boys in group 3 (p <0.01), 5.7% of girls in group 3 and 5.8% of girls in group 2. Age at diagnosis was not significantly different among boys in groups 1 and 3, and girls in group 2 (median 0.9, 0.6 and 1.9 years, respectively).

CONCLUSIONS

The risk and severity of vesicoureteral reflux in siblings depends on the sex of the affected child. Brothers of index male patients have higher grade of reflux and higher rate of associated duplex systems. This has implications for genetic counseling and for modeling the inheritance of vesicoureteral reflux.

Extravesical diverticuloplasty for repair of a paraureteral diverticulum and the associated refluxing ureter

PURPOSE

Extravesical diverticuloplasty for repairing a paraureteral (Hutch) diverticulum and the related refluxing ureter is presented.

MATERIALS AND METHODS

Of the 16 children in this study 10 had bilateral paraureteral diverticula with associated bilateral vesicoureteral reflux, 2 had bilateral paraureteral diverticula with a bilateral duplicated ureter, unilateral duplex refluxing ureters and contralateral lower moiety vesicoureteral reflux, and 4 had a unilateral paraureteral diverticulum with an ipsilateral refluxing ureter. The anatomical relationship of the ureteral orifice and diverticulum was identified by cystourethroscopy preoperatively and confirmed during the extravesical operation. The surgical technique differed depending on the size of the diverticulum and the position of the ureteral opening when the bladder was completely distended. The larger prolapsed diverticular mucosa served as a backing for the detrusor muscle, which was closed over the ureter, and the smaller diverticulum was repaired as a dilated ureter. Overall 30 renal units with grades II to IV vesicoureteral reflux were corrected by this method.

RESULTS

All patients were followed with ultrasound and voiding cystourethrography 3 and 9 months postoperatively. The diverticula with associated refluxing ureters were successfully cured. Neither postoperative recurrence nor ureteral obstruction were noted.

CONCLUSIONS

Extravesical diverticuloplasty can be performed for many sizes of paraureteral diverticula and concomitantly for the associated refluxing ureter, including refluxing duplex ureters.

Absence of PAX2 gene mutations in patients with primary familial vesicoureteric reflux

Vesicoureteric reflux (VUR) is a common childhood condition characterised by regurgitation of urine from the bladder to the kidney. It is the commonest cause of end stage renal failure in children and an important cause in adults. Primary VUR is often familial, suggesting that genetic factors play an important role in its aetiology. Recently, VUR was observed as part of a syndrome, involving optic nerve colobomas and renal anomalies, caused by mutations of the PAX2 gene. PAX2 is a member of the paired box family of genes and is expressed in the ureteric bud and differentiating nephrogenic mesenchyme of the developing kidney. PAX2 has been shown to play a critical role in the development of both the kidney and the ureter. The occurrence of VUR in one family with the PAX2 mutation, and the expression pattern of PAX2 in developing ureteric bud, strongly suggested that PAX2 could be the cause of primary familial VUR. Single strand conformational polymorphism (SSCP) analysis of 23 affected subjects in eight families with primary familial VUR showed no alterations in exons 2-5 of the PAX2 gene. In addition, a polymorphic dinucleotide repeat marker located within the PAX2 gene segregated independently of the disease trait in one large family who primarily had VUR or reflux nephropathy. These results suggest that PAX2 is not a major cause of primary familial reflux.

HLA linkage with familial vesicoureteral reflux and familial pelvi-ureteric junction obstruction

The inheritance of HLA haplotypes has been looked at in a family with pelvi-ureteric junction obstruction (PUJO) and two families with vesicoureteric reflux (VUR). The data have been combined with those of other reported families and lod scores calculated for both these urinary tract anomalies. There seems no doubt that VUR is linked to HLA whilst the case for PUJO is equivocal.

In-office ultrasonography to image the kidneys and bladder of children

We present the first experience with in-office ultrasonography to further the office evaluation of children with urological problems. Since February 1986 we imaged prospectively the kidneys and bladders of 172 children (100 boys and 72 girls, mean age 6 years) who presented for office evaluation using a portable 5 MHz. real-time linear array scanner. Initially, we gained familiarity with in-office ultrasonography by examining 38 children who presented for evaluation of problems not recognized to be associated with renal malformations (that is undescended testis). In-office ultrasonography showed hydronephrosis in 1 boy with a buried penis that was found later to be owing to ureteropelvic junction obstruction requiring pyeloplasty. Then, in-office ultrasonography was used to supplement the office evaluation of children with a history of urine infection, voiding problems or known malformations of the kidney and/or bladder. The test showed that 12 of 24 children (50 per cent) with a history of urine infection had a thickened detrusor, large bladder capacity with or without residual urine or reduced sensation to void. In-office ultrasonography also showed that 24 of 74 children (32 per cent) with voiding problems had a thickened detrusor, large bladder capacity with or without residual urine, fecal impaction, suspected bladder neck obstruction (which later required internal urethrotomy) or small bladder capacity. In 35 children with known malformations of the urinary tract in-office ultrasonography was useful to assess the progress of hydronephrosis (29) or to clarify the etiology of the hydronephrosis (4). The diagnostic value of this test was evaluated in 98 children in whom enough data were available to compare the results to those of subsequent urography or clinical outcome. In-office ultrasonography had a 98 per cent sensitivity and an 82 per cent specificity rate. We conclude that in-office ultrasonography is a reliable means to identify incomplete bladder emptying in children with urine infection related to dysfunctional voiding, identify detrusor thickening related to the unstable bladder and indicate the likely etiology of hydronephrosis.

Lower extremity cyanosis: an unusual presentation of congenital paraureteral diverticula

Congenital bladder diverticula are an uncommon cause of urinary retention in children. We report on a male infant with bilateral congenital bladder diverticula that compressed the posterior urethra causing urinary retention and also compressed the venous return from the lower extremities producing cyanosis.

Familial pelviureteric junction hydronephrosis and its association with a duplex pelvicaliceal system and vesicoureteric reflux. A family study

The incidence of pelviureteric junction (PUJ) hydronephrosis and a bifid pelvicaliceal collecting system was determined in the parents and siblings of 19 patients with PUJ hydronephrosis. The high incidence of hydronephrosis in first degree relatives supports the hypothesis that PUJ hydronephrosis is inherited by an autosomal dominant gene of variable penetrance. There is a genetic inter-relationship between PUJ hydronephrosis and a bifid pelvicaliceal system and therefore indirectly between vesico-ureteric reflux and paraureteric diverticula. Ultrasound screening of the children of adults with PUJ hydronephrosis may lead to earlier diagnosis and treatment, thus preventing renal damage.

Vesicoureteral Reflux in Triplets

During an investigation for urinary tract infections in 3-month-old triplets similar patterns of vesicoureteral reflux were noted. To our knowledge, this is the first report of vesicoureteral reflux in triplets. The patterns of inheritance in vesicoureteral reflux and the need for sibling evaluation are discussed.