Pattern of clinical presentation of congenital anomalies of the kidney and urinary tract among infants and children

AIM

Congenital anomalies of the kidneys and urinary tract (CAKUT) comprise various entities of structural malformations that result from defects in morphogenesis of the kidney and/or urinary tract. These anomalies are the most commonly diagnosed malformations in the prenatal period and constitute the leading cause of end-+stage renal disease (ESRD) in children, worldwide. This prospective study was performed to report the patterns of clinical presentation and diagnosis of infants and children with such malformations.

METHODS

Patients with suggestive features of CAKUT, presenting to Cairo University Children Hospital over one year duration were investigated and categorized based on underlying renal structural/functional malformation and associated extra-renal anomalies.

RESULTS

One hundred and seven CAKUT children were enrolled in the study. Familial clustering was identified in 14% of the cohort and syndromic CAKUT accounted for 31.8% of cases. Different anomaly entities have been identified; posterior urethral valves (PUV) being the commonest detected abnormality (36.4%). Of note, 9.3% of cohort patients had ESRD at presentation, of which 60% had PUV as their primary renal disease. Obstructive cases were noted to present significantly earlier and attain advanced CKD stages rather than non-obstructive ones.

CONCLUSION

CAKUT is a clinically heterogeneous group of diseases with diverse clinical phenotypes. More efforts should be aimed at improving antenatal detection as well as classification with comprehensive reference to the clinical, genetic and molecular features of the diseases. The high frequency of familial and syndromic CAKUT among studied patients is seemingly a convincing reason to pursue the underlying genetic defect in future studies.

Effect of size and site on the outcome of extracorporeal shock wave lithotripsy of proximal urinary stones in children

OBJECTIVE

To determine the effect of location and size of stones on the outcome of extracorporeal shock wave lithotripsy (ESWL) in children.

PATIENTS AND METHODS

In 2008-2010, 150 children (median age 6.6 years) with radio-opaque ureteric and renal stones measuring ≤4 cm were treated. Exclusion criteria were coagulation disorders, pyelonephritis, distal obstruction, non-functioning kidney and hypertension. ESWL was performed under general anesthesia. Follow up period was 5-22 months.

RESULTS

186 stones were treated: 76 calyceal, 92 pelvic and 18 proximal ureteral. Mean stone size was 1.3 cm. A total of 312 sessions were performed (mean per stone = 1.67 sessions). The mean number of shock waves per session was 2423.68. Overall stone-free rate was 89.24%. Having a calyceal location did not significantly affect the stone-free rate (p = 0.133). The failure rate was significantly higher (66.7%) in stones >3 cm in size (p < 0.001). Complications were encountered in 18 patients; 2 underwent auxillary ureteroscopy and 4 uretrolithotomy for treatment of steinstrasse.

CONCLUSION

ESWL is a safe and effective method for treatment of stones up to 2 cm in children. Rate of auxillary procedures increases in stones >2 cm in size. About 80% of failures were associated with stone size >1.35 cm while 52.3% of completely cleared stones were associated with size <1.35 cm.

Assessment of recoverability of kidney function in children with obstructive calcular anuria: multicenter study

OBJECTIVE

Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions.

MATERIALS AND METHODS

This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0-14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed.

RESULTS

Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [P(cr)] improved 20-50% the eGFR and CC were doubled, and when improved 50-70% eGFR and CC tripled. Beyond 70% improvement in [P(cr)], eGFR and CC improved 7-8 times. Using Spearman's correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively).

CONCLUSION

Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.

Holmium laser enucleation of prostate for patients in urinary retention

OBJECTIVES

To evaluate holmium laser enucleation of the prostate in patients presenting in urinary retention secondary to benign prostatic hyperplasia.

METHODS

From May 2000 to May 2004, 169 patients, with a mean age of 74 years, who presented in urinary retention secondary to benign prostatic hyperplasia underwent holmium laser enucleation of the prostate. The mean urinary volume drained at catheterization was 670 mL (range 132 to 2000). All the patients were assessed preoperatively, 1, 3, 6, and 12 months postoperatively, and every year thereafter. All the patients were evaluated by physical examination, digital rectal examination, symptom evaluation using the International Prostate Symptom Score questionnaire, uroflowmetry (whenever possible), postvoid residual urine volume measurement, and prostate-specific antigen. The mean preoperative prostate volume estimated by transrectal ultrasonography was 101 cm3 (range 20 to 351).

RESULTS

The mean catheter time and hospital stay was 1.6 and 1.7 days, respectively. The peak urinary flow rate, postvoid residual urine volume, and International Prostate Symptom Score and quality-of-life score were significantly improved by 1 month after surgery and continued to improve during subsequent follow-up. Three patients (1.75%) were unable to void postoperatively; one required a suprapubic catheter and two used clean intermittent catheterization. Four patients (2.4%) were receiving anticoagulant therapy and required blood transfusion. Bladder neck contracture and urethral stricture developed in 1.7% and 1.2%, respectively.

CONCLUSIONS

Holmium laser enucleation of the prostate represents a safe and effective treatment for patients with benign prostatic hyperplasia presenting in urinary retention. It has low morbidity and provides immediate symptom and voiding improvement.

Holmium laser enucleation of the prostate: a size-independent new "gold standard"

We report our experience with holmium laser enucleation of the prostate (HoLEP) for treatment of 552 patients with symptomatic benign prostatic hyperplasia (BPH) and their long-term outcome. Between March 1998 and January 2005, a retrospective review was conducted at our institution of 552 cases in which patients underwent HoLEP. Patient characteristics, indications for surgery, preoperative and postoperative International Prostate Symptom Score (I-PSS), peak flow rate (Qmax), postvoid residual urine, operative data, catheterization time, hospital stay, and immediate and long-term complications were recorded. The mean age of patients was 73.7 +/- 7.9 years, and the mean follow-up time was 36 months. The mean preoperative prostate size was 83.7 +/- 49.7 cm3 (range, 20 to 351 cm3), the mean enucleation time was 86 minutes (range, 15 to 255 minutes), and the mean enucleated tissue weight was 52.1 +/- 43.7 g (range, 5 to 340 g). The voiding parameters were significantly improved, with a 200% increase in Qmax, as well as a 75% improvement in I-PSS at 1 year postoperatively, which continued to improve during subsequent follow-up. A total of 11 patients required blood transfusion; 8 of them were on anticoagulant therapy. Irritative symptoms were noted in 9.4% and transient stress incontinence in 4.2% of patients. Bladder neck contracture and urethral stricture each developed in 1.3% of patients. We conclude that HoLEP is a safe and effective procedure for treatment of symptomatic BPH, regardless of prostate size, with low morbidity and short hospital stay. HoLEP appears to be the modern alternative to transurethral resection of the prostate and open prostatectomy, and it may be considered a size-independent new "gold standard."