A Case of Duane's Retraction Syndrome with Multiple Congenital Malformations

Duane's retraction syndrome is associated with various ocular and systemic abnormalities. We report a case with bilateral Duane's retraction syndrome type I accompanied by renal agenesis, vesico-ureteral reflux, patent ductus arteriosus, and external ear malpositioning. Because of disabling consequences, we recommend a thorough physical examination and screening for renal and cardiac abnormalities in all patients presenting with Duane's reaction syndrome.

[MODIFIED Politano-Leadbetter REIMPLANTATION FOR TREATMENT OF CONGENITAL MALFORMATION OF VESICOURETERAL JUNCTION IN CHILDREN]

Corresponding author: HUANG Lugang, E-mail: lugang992001@aliyun.com

OBJECTIVE

To explore the effectiveness of modified Politano-Leadbetter reimplantation for the treatment of congenital malformation of the vesicoureteral junction in children.

METHODS

A retrospective analysis was made on the clinical data of 53 patients with congenital malformation of the vesicoureteral junction treated with modified Politano-Leadbetter reimplantation between June 2000 and October 2014. Of 53 cases, there were 24 boys and 29 girls, aged from 8 months to 7 years (mean, 2.1 years); 23 had congenital vesicoureteral junction obstruction (14 left, 5 right, and 4 bilateral), and 30 had vesicoureteral reflux (12 unilateral, 18 bilateral), which were verified by voiding cystourethrography. The disease duration was from 1 month to 1 year (mean, 5 months).

RESULTS

All of the patients underwent modified Politano-Leadbetter reimplantation successfully. The mean operation time was 74 minutes (range, 65-85 minutes) for unilateral cases and 105 minutes (range, 98-130 minutes) for bilateral cases. There was no dysuria, infection of incision, or incision dehiscence after urinary catheter removal. The follow-up time was 6 months to 14 years (median, 28 months); all patients were free from complications of fistula, vesicoureteral reflux, vesicoureteral junction obstruction, or hypertension. The new ureteral orifices had good appearance at 1 month after operation. Urologic ultrasound showed that hydronephrosis relieved at 3 months after operation. Urinary tract infection rate was 13.2% (7/53) during 6 months after operation, which was cured by antibiotics. Voiding cystourethrography showed no vesicoureteral reflux in 32 cases at 6 months after operation.

CONCLUSION

The modified Politano-Leadbetter reimplantation simplifies he operation course, which has the longitudinal ureter after operation and is similar to physiological state. It is a safe and effective option for congenital malformation of vesicoureteral junction in children with few complications, especially for patients with unilateral megaloureter.

Large spectrum of complete urinary collecting system duplication exemplified by cases. Pictorial essay

Urinary collecting system duplication is a congenital anomaly and can associate various types of urinary tract pathologies. Authors will illustrate by cases some of associated anomalies such as ureterocele, extravesical ectopic ureter, vesicoureteral reflux or reflux nephropathy; one case presented an association between posterior urethral valve and bilateral collecting system duplication.

[Recent advances in the diagnosis of vesicoureteral reflux in children]

Primary vesicoureteral reflux is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal treatment, which necessitates identification of patients requiring early intervention. The aim of this review is to evidence the recent advances in the diagnosis of this congenital abnormality and to indicate the guidelines for its diagnostic management.

Single trocar retroperitoneoscopic assisted ipsilateral ureteroureterostomy for ureteral duplication

The aim of this study is to present the technique and early outcomes of single trocar retroperitoneoscopic assisted ureteroureterostomy for ureteral duplication. The patient was placed in a lateral decubitus position. A skin incision of 11 mm width was made above the iliac crest. The operation was performed through single trocar with operating laparoscope. The two ureters were encircled with a vessel loop and exteriorized outside the retroperitoneal space via trocar incision. The pathologic ureter was divided as low as possible. The recipient ureter was opened longitudinally. End-to-side ureteroureterostomy anastomosis was performed extracorporeally with two running 6/0 PDS sutures. From December 2010 to July 2011, nine patients were operated on using the same technique. Patient's ages ranged from 2 to 72 months. Mean operative time was 78 ± 21 min. There were no intra or postoperative complications. Postoperative stay was 2.6 ± 1.0 days. Follow-up revealed that two renal moieties preserved their functions in all patients. The diameter of involved ureters and pelvises was significantly reduced in all patients. Single trocar retroperitoneoscopic assisted ureteroureterostomy is safe and effective procedure for ureteral duplication.

Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?

PURPOSE

Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group.

MATERIALS AND METHODS

A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life.

RESULTS

No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status.

CONCLUSIONS

Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis.

Assessing urinary tract defects in mice: methods to detect the presence of vesicoureteric reflux and urinary tract obstruction

Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) encompass a spectrum of kidney and urinary tract disorders. Here, we describe two assays that can be used to determine if a mouse has vesicoureteric reflux (VUR) or urinary tract obstruction, two urinary tract defects observed in CAKUT. To test for VUR, dye is injected into the mouse bladder and then monitored to determine if it passes retrogradely from the bladder towards the kidneys, indicating the presence of VUR. To test for urinary tract obstruction, the renal pelvis is microinjected with dye and its passage along the urinary tract is monitored to determine if there is evidence of impaired flow along the tract. These methods will facilitate the analysis of CAKUT phenotypes in the mouse.

Anorectal and urinary anomalies and aberrant retinoic acid metabolism in cytochrome P450 oxidoreductase deficiency

CONTEXT

Cytochrome P450 oxidoreductase (POR) is an electron donor for all microsomal P450 enzymes including CYP26 involved in inactivation of all-trans retinoic acid (atRA). Although previous studies in Por knockout mice suggest that atRA accumulation is relevant to various posterior organ abnormalities, a systematic analysis has not been performed for anorectal and urinary anomalies in patients with POR deficiency (PORD).

OBJECTIVE

To report the frequencies of anorectal and urinary anomalies and plasma atRA values in PORD patients.

PATIENTS

We studied 37 Japanese patients with PORD, consisting of 15 homozygotes for R457H (group A), 15 compound heterozygotes for R457H and one apparently null mutation (group B), and seven patients with other combinations of mutations (group C). Since R457H is a severe hypomorphic mutation, the residual POR function is predicted to be higher in group A than in group B.

RESULTS

Imperforate anus was observed in four patients (10.8%) and vesicoureteral reflux was found in three patients (8.1%), with no significant difference in the frequencies of such anomalies between groups A and B. In addition, a complex urogenital malformation including penile agenesis was identified in one patient. Plasma atRA values were above the reference range in nine of 12 patients examined, and were similar between groups A and B and between patients with and without anomalies.

CONCLUSIONS

The results imply that aberrant atRA metabolism due to CYP26 deficiency underlies various anorectal and urinary anomalies in patients with PORD. Clinical phenotypes may be primarily determined by maternal oral retinol intake during pregnancy, and plasma atRA values may be largely influenced by the amount of postnatal oral retinol intake in such patients.

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.

[Ureter triplex with non-functioning upper pole due to ectopic ureterocele and refluxive third ureter bud : case report and review of the literature]

We present the case of an 8-month-old boy with ureter triplication on the left side with non-functional upper pole due to ectopic ureterocele and a refluxive third ureter bud. We performed an upper pole heminephroureterectomy with resection of the ureterocele and of the refluxive third ureter bud and reimplantation of the lower pole ureter using the psoas hitch technique.

Radiographic changes following excisional tapering and reimplantation of megaureters in childhood: long-term outcome in 46 renal units

PURPOSE

Despite the routine use of renal ultrasonography to document progressive improvement in hydronephrosis following ureteral tailoring and reimplantation of megaureters, there have been few reports characterizing the serial radiographic changes to be expected following this procedure. We evaluated the radiographic outcomes following surgical repair of megaureters at single institution, and assessed potential preoperative factors for predicting outcome.

MATERIALS AND METHODS

We conducted a retrospective analysis of all patients who underwent surgical correction of clinically significant megaureters at our center between 1996 and 2003. Demographic data, indications for surgery, and preoperative and postoperative radiographic imaging data were recorded.

RESULTS

A total of 46 megaureters (39 patients) were tapered and reimplanted. Average patient age at surgery was 4.0 years (range 5 months to 19 years). Indications for surgery included recurrent or breakthrough urinary tract infections, decreased renal function and increased hydroureteronephrosis. Mean followup was 3.9 years (range 4 months to 7 years). Postoperative voiding studies showed vesicoureteral reflux in 3 reimplanted ureters (7%). There was no evidence of obstruction on postoperative nuclear renal scans in any patient. Renal ultrasonography revealed improvement or resolution of hydroureteronephrosis in 29 reimplanted units (63%). In general, male patients, those operated on at a younger age and those with a lower preoperative grade of hydronephrosis were most likely to demonstrate improvement or resolution of hydronephrosis. The best results were seen in ectopic megaureters, followed in decreasing order by refluxing megaureters, megaureters associated with ureteroceles and primary obstructive megaureters.

CONCLUSIONS

Despite functional improvement on postoperative radiographic imaging, it is not uncommon to see persistent hydroureteronephrosis following excisional tapering and reimplantation of megaureters in childhood.

Is a complete urological evaluation necessary in all newborns with asymptomatic renal ectopia?

AIM

To evaluate if a complete urological screening is justified by potential urological anomalies in newborns or infants with asymptomatic renal ectopia (RE).

METHODS

The database records of 60 consecutive neonatal cases of RE diagnosed at the authors' hospital from 1990 to 2004 were retrospectively reviewed.

RESULTS

At diagnosis, mean patient age was 1.6 months. In 58 of 60 patients, the suspected diagnosis of RE was made during prenatal or postnatal screening ultrasonography, including two newborns with anorectal malformation. There were 24 patients with crossed RE (C-RE) and 36 patients with simple RE (S-RE). A solitary RE was present in two patients. The most frequent associated urological abnormality was vesico-ureteral reflux (37.5% of C-RE and 16.6% of S-RE). Hydronephrosis was detected in seven RE and five contralateral kidneys. An obstructive megaureter was present in one patient with C-RE. In 40% of S-RE and 92.9% of C-RE, the (99m)Tc DMSA documented reduction of function of RE. The longitudinal diameter of the ectopic kidney was significantly smaller than the contralateral one. Other non-renal diseases were present in 15% of patients, of which the most frequent was cryptorchidism (6.6%).

CONCLUSIONS

A complete urological evaluation is necessary in newborns with C-RE for the high incidence of associated urological anomalies, of which VUR is the most frequent. A complete urological evaluation is also reasonable in patients with S-RE who have a pelvic dilatation. No diagnosis or treatment of the associated urological diseases, in consideration of congenital decreased function of the ectopic kidney, might predispose these children to improvement of renal function impairment.

Growth curves of the fetal prostate based on three-dimensional reconstructions: a correlation with gestational age and maternal testosterone levels

OBJECTIVE

To create a nomogram of the fetal growth of the human prostate corresponding to gestational age, and to investigate the relationship between the expansive growth of the fetal prostate and the maternal testosterone surge during pregnancy.

MATERIALS AND METHODS

In all, 27 fetal prostates at 11-40 weeks of gestation, and seven neonatal specimens at 1-20 weeks after birth, were analysed. Serial sections of prostates were immunostained and examined using light microscopy. After modular image acquisition the volumes were calculated using three-dimensional reconstruction. The prostate volumes were correlated with gestational age, and related to reference testosterone levels during pregnancy.

RESULTS

There was exponential growth of the fetal prostate with gestational age. The increasing volume of the prostate during the fetal period corresponded with maternal testosterone levels. In the second trimester there was a significant increase in prostate volume in relation to the bladder. In infants, macroscopically there was an inverse proportion between bladder size and prostate volume.

CONCLUSIONS

Starting from the second trimester there is distinct growth of the fetal prostate, obviously triggered by the maternal testosterone surge. In neonates there is an inversion of the dimensions between bladder and prostate. These results indicating exponential growth of the fetal prostate provide evidence of a gender-related transient infravesical obstruction in human fetuses.

[Megalourethra in association with VACTER syndrome]

The megalourethra is an uncommon congenital anomally. It is a consecuence of the abnormal development of the corpus spongiosum and, occasionally, also the abnormal development of the corpora cavernosum. It is specially common in association with the Prune-Belly syndrome, and with upper tract abnormalities. We present a bizarre case because of its association with a VACTER syndrome.

Vesicoureteric reflux and renal malformations: a developmental problem

Vesicoureteric reflux (VUR) is a congenital urinary tract defect caused by the failure of the ureter to insert correctly into the bladder. It occurs in up to 1% of the general population and is associated with recurrent urinary tract infections and renal failure. Despite treatment of affected children for the past 40 years, the incidence of end-stage renal disease secondary to VUR has not decreased. Twin and family studies reveal that VUR has a genetic basis. Some of the gene candidates that have been identified regulate the position of ureteric budding, a critical step in both kidney and urinary tract development. Analysis of data from humans and mice suggests that some of the renal damage associated with VUR is congenital and is due to a kidney malformation. Therefore, in these cases, the association of VUR and renal failure may be caused by a genetic defect affecting the formation of the kidney and the urinary tract.

[Anesthetic management of an infant with Cornelia de Lange syndrome]

We report anesthetic management of an infant with Cornelia de Lange syndrome. A 12-month-old girl with Cornelia de Lange syndrome was scheduled for ureterocystoneostomy because of vesicoureteral reflux. Preoperative physical examination suggested difficult tracheal intubation. After induction of anesthesia with sevoflurane (5%) in nitrous oxide (70%) and oxygen, a laryngeal mask airway (# 1.5) was inserted. A guide wire was inserted in the trachea through a laryngeal mask airway under direct vision of a fiberoptic bronchoscope. A tube-exchanger stylet was inserted around the guide wire after the laryngeal mask airway and fiberoptic bronchoscope had been removed. An endotracheal tube (ID 4.0 mm) was easily intubated around the tube-exchanger stylet. During the surgery, anesthesia was maintained with sevoflurane (2-3%) in nitrous oxide (50%) and oxygen. There was no perioperative pulmonary complication.

[Transient pseudohypoaldosteronism in infants with vesicoureteral reflux]

BACKGROUND

Congenital urologic malformations occur with an incidence of 1:100 to 1: 200, leading to an increased risk of urinary tract infections. However, most patients remain without symptoms; serious electrolyte imbalance is rare.

MATERIAL AND METHODS

We report two infants who were admitted to hospital because of failure to thrive and poor weight gain. Both children had severe hyponatraemia and hyperkalaemia. Further work-up established pseudohypoaldosteronism secondary to dilated vesicoureteral reflux and urinary tract infection. Based on a literature search in PubMed, a short overview of this rare condition is presented.

RESULTS AND INTERPRETATION

Infants younger than 6 months of age with urologic malformations, and in most cases concomitant urinary tract infections, may develop secondary pseudohypoaldosteronism. The pathogenesis of this condition is probably a result of high intrarenal pressure, inflammation and immaturity of the tubular function leading to tubular resistance to aldosterone. The major symptoms are failure to thrive, poor weight gain, and signs of dehydration. Laboratory studies show hyponatraemia, hyperkalaemia and high levels of plasma renin activity and aldosterone. Treatment involves fluid resuscitation, sodium supplementation and antibiotic treatment of concomitant urinary tract infection. The most important differential diagnosis is the salt-losing form of congenital adrenal hyperplasia. A thorough endocrinologic and urological work-up, including abdominal ultrasound examination and urine analysis, may lead to correct diagnosis and treatment.

Voiding dysfunction: outcome in infants with congenital vesicoureteral reflux

OBJECTIVES

To assess the rate of development of voiding dysfunction as an outcome in patients with congenital vesicoureteral reflux.

METHODS

A computerized database was used to review the medical records of all patients with congenital reflux diagnosed before 6 months of age from 1988 to 2002. Only those infants with reflux who were followed up for at least 6 months past the age of toilet training were included. The parameters tabulated in this group included the presence of frequency, daytime wetting, urge incontinence, and infrequent voiding. The variables were summarized using contingency tables, and associations were evaluated using chi-square analysis and Fisher's exact test.

RESULTS

Of 342 patients (145 boys and 197 girls) with reflux, 67 (19.6%) developed voiding dysfunction (17.9% boys and 20.8% girls). No statistically significant difference was found between high grade (IV and V) and low grade (I and II) or grade III reflux, or between unilateral and bilateral reflux for the development of voiding dysfunction. Of the patients with reflux who had renal damage on dimercaptosuccinic acid scan, 24.3% of girls and 30.4% of boys developed voiding dysfunction, which was not significantly different from those without renal damage.

CONCLUSIONS

Approximately 20% of patients with vesicoureteral reflux diagnosed before 6 months of age demonstrated dysfunctional voiding after the age of toilet training. Voiding dysfunction occurred independent of sex, laterality, or severity of vesicoureteral reflux. Infants with renal damage on dimercaptosuccinic acid scan developed dysfunctional voiding only at a slightly greater, but not significantly different, rate than those with normal kidneys.

Should the presence of congenital para-ureteral diverticulum affect the management of vesicoureteral reflux?

PURPOSE

The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD.

MATERIALS AND METHODS

We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups.

RESULTS

Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution.

CONCLUSIONS

The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.

BOYS WITH POSTERIOR URETHRAL VALVES: OUTCOME CONCERNING RENAL FUNCTION, BLADDER FUNCTION AND PATERNITY AT AGES 31 TO 44 YEARS

PURPOSE

The short-term prognosis for boys with posterior urethral valves (PUV) has improved in recent decades, but the long-term prognosis in terms of renal and bladder function and fertility is still a matter of great concern. This study is a followup of boys with PUV and dilated upper urinary tract treated in 1956 to 1970 at the Children's Hospital in Göteborg, Sweden.

MATERIALS AND METHODS

The records of 54 boys treated for PUV were reviewed. Of 27 boys with PUV and upper urinary tract dilation, 5 boys (18%) died at an early age and 3 boys were lost to followup during adolescence, leaving 19 to be included in the followup. They all answered a questionnaire about renal and bladder function and paternity.

RESULTS

Of the 19 men 32% were uremic, 21% had moderate renal failure and 47% had not been checked since adolescence. There were signs of bladder dysfunction in 40% and all these subjects had bladder symptoms suggesting detrusor weakness as the cause. All the men were continent. The ability to father children was dependent on whether or not the man was uremic.

CONCLUSIONS

This long-term followup study emphasizes the importance of checking renal and bladder function throughout life in men born with PUV. Increasing attention to bladder dysfunction and its early treatment could probably improve the long-term prognosis.

Effect of ureteral reimplantation on prevention of urinary tract infection and renal growth in infants with primary vesicoureteral reflux

AIM

We retrospectively reviewed the results of ureteral reimplantation in infants with primary vesicoureteral reflux (VUR) to evaluate the effect on prevention of urinary tract infection (UTI) and renal growth.

MATERIALS AND METHODS

From July 1991 to December 2001, a total of 205 infants (180 boys and 25 girls) with primary VUR underwent ureteral reimplantation at the Department of Urology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan. Indications for surgery were high-grade reflux (grade IV-V), breakthrough UTI and non-compliance of medical treatment. Age at surgery raged from 1 to 11 months (mean, 6.4 months). Ureteral reimplantation was performed according to Cohen's method. Only two of 336 refluxing ureters required ureteral tailoring. Follow-up ranged from 12 to 110 months (mean, 64 months). Surgical outcome, frequency of UTI and individual renal growth measured by (99m)Tc-dimercaptosuccinic acid (DMSA) scintigraphy was evaluated.

RESULTS

Postoperative ultrasound and voiding cystourethrography showed neither residual reflux nor ureterovesical obstruction. Contralateral low grade reflux occurred in six of 74 patients (8.1%) who had unilateral reflux preoperatively. After reimplantation, 10 patients documented 13 febrile UTI. Eleven of the 13 episodes occurred early in the postoperative period (<6 months). Frequency of febrile UTI reduced from 0.23538 before surgery to 0.00894 and 0.00081 per patient per month at 6 and 12 months after surgery, respectively. No development of renal scarring was seen in postoperative DMSA scan. Changes of differential renal function was <0.05 in all patients.

CONCLUSION

The present results show ureteral reimplantation in infants is safe and very effective for the prevention of UTI. After surgical treatment in infancy, individual renal growth of children with primary VUR is stable.

Management of congenital hydronephrosis with ureteropelvic junction obstruction: The Vienna AKH experience 1986–2001

One of the most common causes of congenital hydronephrosis is obstruction of the ureteropelvic junction. The obstruction can be detected with prenatal ultrasonography screening and treated before renal function is reduced; the obstruction may also resolve spontaneously. Currently, there is no test for predicting the outcome of this obstruction. Management guidelines for neonates with asymptomatic obstruction of the ureteropelvic junction are based on expert opinions, but not on evidence-based data. In our retrospective study, we evaluated management and outcome of 26 renal units in 23 infants (15 boys, 8 girls) with congenital obstruction of the ureteropelvic junction treated in our institution between 1986 and 2001. These infants had isolated hydronephrosis on prenatal and postnatal sonography, showed an obstructive curve pattern in the postnatal diuretic nephrogram and had at least one follow-up nephrogram during a follow-up period of at least 1.5 years. Of these renal units, 16 demonstrated normal function (Group I), five moderate function (Group II) and five severely reduced function (Group III). In group I, 6 of 12 primarily conservatively managed kidneys resolved spontaneously and remained normal in function. In group II, all infants were operated and 83% improved their kidney function. In group III, all infants were operated but none demonstrated relevant improvement. These data support the current expert opinion of the Arbeitsgemeinschaft Pädiatrische Nephrologie (APN), that ureteropelvic junction obstruction in neonates with normal renal function can be managed primarily conservatively with close monitoring. In neonates with moderately--but not with severely--reduced renal function, early surgery is effective in the prevention of deterioration.

SPONTANEOUS RESOLUTION OF HIGH GRADE INFANTILE VESICOURETERAL REFLUX

PURPOSE

We studied the spontaneous resolution rate in a group of infants with high grade vesicoureteral reflux (VUR). The influence of gender, prenatal or postnatal diagnosis, recurrent urinary tract infections (UTIs) and bladder dysfunction on the resolution rate was also evaluated.

MATERIALS AND METHODS

This prospective study comprised 115 infants (80 boys and 35 girls) with high grade VUR (grades III to V). Bilateral reflux was seen in 70% of cases. The majority of patients (71%) were diagnosed after UTI during infancy and only 26% were prenatally diagnosed. Median age at diagnosis was 2.7 months. Patients were followed according to a program of repeat video cystometry and noninvasive 4-hour voiding observations. Median followup was 39 months.

RESULTS

The overall spontaneous resolution rate to grade II or less for all grades was 39% with no difference between boys and girls. However, when comparing the more severe grades IV and V, we found a significantly higher resolution rate in boys during the infant year. No difference in VUR disappearance could be detected when comparing the groups according to presentation, prenatal ultrasound or pyelonephritis. Breakthrough UTIs were seen in 47% of cases despite antibacterial prophylaxis and they significantly correlated with VUR nonresolution. Bladder dysfunction was found in 37% of patients and it also significantly correlated with nonresolution.

CONCLUSIONS

The spontaneous resolution rate for high grade (grades IV and V) congenital VUR was high in boys during the infant year (29%), whereas in girls and boys after the infant year the resolution rate was 9% yearly during followup. Negative prognostic factors for resolution were recurrent UTIs and bladder dysfunction.

[Urethral valves. Fate of the bladder and upper urinary tract]

Posterior urethral valve is a condition that leads to characteristic changes in the bladder and upper tracts. The bladder develops hypertrophic changes including muscular hypertrophy, dilatation of the prostatic urethra (keyhole appearance), and progressive hydroureteronephrosis. The voiding cystourethrogram confirms the diagnosis and documents vesicoureteral reflux and accompanying bladder changes. The follow-up of the serum creatinine level is a parameter for renal recovery. In our opinion, primary endoscopic ablation of the valves followed by a wait-and-see attitude is the most efficacious management of posterior urethral valves. The development of the bladder function is controlled by ultrasound and voiding cystourethrogram. Urodynamics provide a formal and objective means of assessing bladder function, but should be carefully applied in infants. Valve ablation in a neonate with significant reflux and a markedly trabeculated bladder can remodel itself remarkably within the 1st year of life. The persistence of hydronephrosis, bladder wall thickening and trabeculation, and persistent elevation of serum creatinine can all be harbingers that a degree of bladder outlet obstruction persists and one needs to rule out a persistent anatomic obstruction. At what point a functional obstruction occurs and which management is reasonable are still issues of debate and require the vigilance of a pediatric urologist to sort out. Dysfunctions of the bladder such as hyperreflexia, hypertonic, small capacity bladder, sphincter incompetence and/or myogenic failure should be adequately treated.

[Prenatal diagnosis of obstructive uropathies - positive predictive value and effect on postnatal therapy]

INTRODUCTION

Prenatal diagnosis of urological anomalies is a standard procedure nowadays. The aim of this study was first to define the frequency of urinary tract anomalies in the selected patients in a level III center for prenatal diagnostics and therapy. The second aim was to show the accuracy of prenatal diagnosis in the special groups of obstructive uropathies.

PATIENTS AND METHODS

Postnatal diagnoses were used for control of the prenatal findings. In the 12-year retrospective study, we analyzed 21 616 pregnancies scanned for fetal anomalies. In 1 574 fetuses pediatric surgical anomalies were diagnosed. Out of 1 077 follow-ups 618 patients with urinary tract anomalies were found.

RESULTS

It could be shown that prenatal ultrasound has a high sensitivity for the diagnosis of obstructive renal tract anomalies. The diagnosis of subpelvine obstruction and muticystic kidney dysplasia can be made with an accuracy of 97 and 98 %. The therapeutic relevance of the diagnosis "isolated hydronephrosis" increases up to 60 % when mild dilatation is neglected. False negative scans for urinary tract anomalies are low at 10 %.

CONCLUSION

Hence, prenatal ultrasound for urinary tract anomalies is a method of high sensitivity. The therapeutic relevance is rather high. The most important question is to find all those patients who need a postnatal therapeutic approach immediately.

Polydimethylsiloxane Injection Versus Open Surgery for the Treatment of Vesicoureteral Reflux in Complete Duplex Systems

PURPOSE

We compared the efficacy of subureteral polydimethylsiloxane injection (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) versus open surgery for correction of varying degrees of reflux in complete duplex systems.

MATERIALS AND METHODS

Between 1997 and 2000 polydimethylsiloxane injection was performed in 15 females (22 refluxing moieties). Mean patient age at presentation and at surgery was 54 and 94 months, respectively. Extravesical common sheath reimplantation (ECSR) was performed in 34 children (bilateral 10) with a mean age at presentation and at surgery of 31 and 57 months, respectively. Voiding cystourethrography and ultrasound were performed at 3 months. In cases of persistent reflux repeat voiding cystourethrography was performed at followup. We then analyzed the surgical outcome for both groups.

RESULTS

Mean followup for the injection and ECSR groups was 12 and 15 months, respectively. The success rate per moiety after injection was 68% at 3 months, which increased to 81.8% at 12 months. One patient had contralateral vesicoureteral reflux and none had de novo hydronephrosis, urinary tract infection or complications postoperatively. The success rate of ECSR was 95.5% at 3 months, which improved to 97.7% at an average of 15 months (p <0.04). After ECSR transient contralateral vesicoureteral reflux was seen in 4 renal units, de novo hydronephrosis was seen in 2 units and 4 patients had urinary tract infections.

CONCLUSIONS

Although endoscopic subureteral polydimethylsiloxane injection was simple and successful in more than 80% of patients with low grade vesicoureteral reflux in duplex systems, it is less effective than surgery with regard to elimination of reflux.

Vesicoureteral Reflux in Patients With Posterior Urethral Valves

PURPOSE

We reviewed our experience with posterior urethral valves to analyze the influence of reflux.

MATERIALS AND METHODS

We retrospectively analyzed the records of 73 consecutive patients with posterior urethral valves. Of the patients 35 boys had reflux at presentation, which was unilateral in 18 (severe in 17) and bilateral in 17 patients (severe unilateral reflux and low grade contralateral reflux to a better functioning kidney in 5). Followup ranged from 1 to 17 years (mean 5.6).

RESULTS

Reflux resolved after relief of obstruction in 11 of 44 (25%) evaluated renal units but only 5 of 35 (14%) units with high grade reflux. The reflux more often resolved in the bilateral than unilateral group (35% of units versus 11%) and usually did so on the initial study after obstruction relief. Neither the presence, grade, pattern of reflux nor type of initial treatment impacted the outcome in terms of overall renal function. The function of the involved kidney did affect the likelihood of resolution in that unit. Resolution occurred in 10% of refluxing units that provided less than 20% function versus 39% in units with better function.

CONCLUSIONS

Vesicoureteral reflux is common with posterior urethral valves and often persists, particularly to a poorly functioning kidney. Resolution, if it occurs, usually does so early after relief of obstruction. Reflux, no matter what the pattern, has not been a significant prognostic factor for renal function in this series.

Treatment of Vesicoureteral Reflux by Endoscopic Injection of Dextranomer/Hyaluronic Acid Copolymer: Preliminary Results

PURPOSE

Endoscopic subureteral injection of tissue augmenting substances has become an established alternative to long-term antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR) in children. Recently, dextranomer/hyaluronic acid copolymer (Deflux, Q-Med AB, Uppsala, Sweden) a biodegradable injectable material has been reported to be a promising alternative to other tissue augmenting substances. However, the experience with dextranomer/hyaluronic acid copolymer is limited. We prospectively evaluate the effectiveness of dextranomer/hyaluronic acid copolymer in the endoscopic treatment of VUR.

MATERIALS AND METHODS

A total of 32 males and 81 females with a median age of 1 year (range 3 months to 10 years) underwent endoscopic correction of primary VUR with dextranomer/hyaluronic acid copolymer. Reflux was unilateral in 58 cases and bilateral in 54, affecting 166 ureters. Reflux was grades II to V in 7 (4.2%) cases, 91 (54.8%), 63 (38%) and 5 (3%), respectively. All patients underwent endoscopic correction as a day procedure and have been followed for 3 months to 1 year.

RESULTS

The reflux was corrected in 143 (86%) of the 166 ureters after a single injection, and resolved after a second and third injection in 22 (13%) and 1 (1%) ureter, respectively. No untoward effects were seen in any of these patients with the use of dextranomer/hyaluronic acid copolymer as an injectable material.

CONCLUSIONS

Dextranomer/hyaluronic acid copolymer is an effective tissue augmenting substance in the endoscopic treatment of all grades of VUR.

Is Common Sheath Extravesical Reimplantation an Effective Technique to Correct Reflux in Duplicated Collecting Systems?

PURPOSE

We evaluate the outcome vesicoureteral reflux (VUR) in duplicated collecting systems compared to single collecting systems corrected using an extravesical detrusorrhaphy approach.

MATERIALS AND METHODS

We reviewed the records of 266 patients (422 ureters) treated for VUR using an extravesical approach between 1991 and 2001. Inclusion criteria were primary reflux in single (201 patients, 125 bilateral) or duplicated collecting systems (65, 31 bilateral) in patients not undergoing other concomitant surgery with at least 1 year of postoperative followup. The indication for surgical intervention was unresolved reflux (greater than 4 years) in more than 70% of patients. Postoperative evaluation included a voiding cystourethrogram at 3 months and 12 months if reflux was unresolved at 3 months. Also ultrasound was performed at 6 weeks or earlier if clinically indicated and 12 months.

RESULTS

Group 1 (duplicated collecting systems) and group 2 (single collecting systems) were comparable for age, sex distribution and reflux grade distribution. Overall success rate at 3 and 12 months was 94.7% and 98.9% for group 1, and 95.1% and 98.5% for group 2, respectively. The difference in success rate at 3 and 12 months was not statistically significant (p >0.05). Of note in both groups postoperative VUR was contralateral in more than 40% of cases. Postoperative hydronephrosis (Society for Fetal Urology grade 1, 2 or 1 increment in grade from preoperative status) was observed in 5.3% and 7.3% of ureteral units at 6 weeks in groups 1 and 2, respectively (p >0.05). At 12 months less than 1% of ureteral units exhibited low grade residual hydronephrosis. No high grade postoperative hydronephrosis was observed in either group, and there were no intraoperative complications. Postoperative urinary retention occurred in 4.7% and 4% of patients in groups 1 and 2, respectively (p >0.05).

CONCLUSIONS

Common sheath extravesical reimplantation is highly effective in treating VUR. The common sheath extravesical reimplantation for duplicated collecting systems is as effective in nonduplicated systems and is associated with minimal perioperative morbidity.

Endoscopic Treatment of Vesicoureteral Reflux With Dextranomer/Hyaluronic Acid Copolymer is Effective in Either Double Ureters or a Small Kidney

PURPOSE

Endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) copolymer is an increasingly established treatment for primary vesicoureteral reflux (VUR) in children. We performed a retrospective analysis to assess this treatment for VUR associated with either double ureters or a small kidney.

MATERIALS AND METHODS

The study included 68 children with duplex ureters and 40 with a small kidney (1 kidney contributing 10% to 35% of total renal function) who underwent endoscopic treatment with Dx/HA copolymer for VUR. Followup consisted of voiding cystourethrography 3 and 12 months after injection. Positive response was defined as reflux grade 0 or I. As many as 2 repeat injections were offered to nonresponders, and those with persistent reflux were referred for open surgery. Long-term clinical followup with renal function testing was continued for 4 to 9 years.

RESULTS

A positive response was observed in 63% of children with duplex ureters, with only 17 (25%) patients requiring open surgery. Among children with a small kidney the response rate was 70%, and open surgery was performed in 9 (23%). In both treatment groups a positive response to treatment was sustained throughout the followup period in all cases. The treatment was well tolerated, with no complications associated with the procedure.

CONCLUSIONS

Endoscopic treatment with Dx/HA copolymer appears to be an effective and well tolerated alternative to open surgery for first line treatment of VUR associated with double ureters or a small kidney.

Lower Urinary Tract Reconstruction for Duplicated Renal Units With Ureterocele. Is Excision of the Ureterocele With Reconstruction of the Bladder Base Necessary?

PURPOSE

Current practice in reconstruction of the lower urinary tract for duplicated renal systems with an associated ureterocele is excision of the ureterocele with reconstruction of the bladder and a common sheath ureteroneocystostomy. For a nonfunctioning upper pole treatment is partial nephroureterectomy. We postulate that lower urinary tract reconstruction can be performed successfully through an extravesical approach without excision of the ureterocele or reconstruction of the bladder base. We present our experience with that approach.

MATERIALS AND METHODS

Between 1996 and 2001, 60 patients presented with the diagnosis of ureterocele and obstruction of the upper pole ureter. Partial nephrectomy was performed in 12 cases of which 4 had reflux to the lower pole moiety. Upper pole only dismembered ureteroneocystostomy was performed in 7 of 15 cases reconstructed using the extravesical approach.

RESULTS

Average postoperative stay was 3.7 days. The Foley catheter was removed within 24 to 48 hours. Postoperative ultrasound showed decompression of the obstructed system and the ureterocele. Reflux was corrected in all patients. Flow rate with measurement of post-void residual 6 weeks postoperatively in toilet trained children showed complete bladder emptying.

CONCLUSIONS

Lower urinary tract reconstruction for duplicated renal systems with obstruction of the upper pole can be accomplished safely with decreased morbidity through the extravesical approach without excision of the ureterocele or reconstruction of the bladder base. Moreover, in instances when there is no reflux to the lower pole moiety, upper pole only extravesical ureteroneocystostomy can be performed.

[Occurrence, diagnostics and therapeutic management of hydronephrosis in pediatric patients in Germany]

As urinary tract obstruction in children may impair renal function, the early detection and evaluation of the degree of obstruction using adequate diagnostic tools is necessary for the choice of the optimal therapeutic procedure. This study describes diagnostic and therapeutic standards in relation to the quality of management of pediatric hydronephrosis in Germany in the first 6 months of the year 2000. In our study 407 of 711 (57.2%) children with a hydronephrotic condition were detected by routine ultrasound. This, and the fact that 25% of the patients, who were prenatally detected, had a diagnosis of vesicoureteral reflux, underlines the importance of this routine procedure. Our study illustrates the panel of diagnostic and therapeutic procedures used in the management of pediatric hydronephrosis in Germany.

Mass screening for early detection of congenital kidney and urinary tract abnormalities in infancy

BACKGROUND

Recent widespread use of ultrasound has led to new efforts at screening for congenital kidney and urinary tract abnormalities. However, a standard screening methodology, criteria defining abnormalities, and follow-up procedures remain to be established. In order to establish screening criteria for these abnormalities, we performed a preliminary study in 800 1-month-old infants using provisional methods and criteria.

METHODS

Based on the results of preliminary study, we screened 2700 1-month-old infants in a prospective study using the criteria of renal size (longitudinal diameter <or=35 mm or >or=60 mm, or a difference between sides of >or=10 mm), and of pelvic dilatation (Society for Fetal Urology [SFU] grade 2 or higher) as positive at the first ultrasound screening. We used the SFU grading system instead of anteroposterior pelvic diameter measurements for pelvic dilatation.

RESULTS

One hundred and twelve (4.1%) of the 2700 infants had abnormalities at the first ultrasound screening, while 18 (0.67%) had congenital kidney and urinary tract abnormalities on further examination. Use of the SFU grading system enabled us to reduce the false-positive rate at first screening, while maintaining a high diagnostic rate. The abnormalities consisted of ureteropelvic junction obstruction in seven infants, megaureter in two, hypoplastic kidney in four, vesicoureteral reflux in six (three were accompanied by hypoplastic kidneys or multicystic dysplastic kidney), multicystic dysplastic kidney in one, and horseshoe kidney in one.

CONCLUSION

These results indicate that our screening methods and criteria are useful variables for detecting congenital kidney and urinary tract abnormalities.

[Some features of recovery of upper urinary tract urodynamics after surgical treatment of vesicoureteral dysplasia in children]

Urodynamics of the upper urinary tract (UUT) was examined in 327 children aged 1.5 months to 15 years with congenital vesicoureteral reflux (VUR) dysplasia treated surgically. 230 patients were followed up for 1 to 20 years. Staging of chronic disorders of UUT urodynamics is thought to be the key criterion of objective assessment of VUR effective surgical treatment. The better long-term treatment outcomes are the earlier the disease was diagnosed and corrected. Early defects of urodynamics in the absence of marked dilatation of the ureter are better corrected by Lich-Gregoir operation which is physiological, low traumatic, technically available and most effective (97% of favourable long-term outcomes). Ureterocystoneostomy by Politano-Leadbetter (in modification of the authors) is indicated in urodynamic disorders stage III and marked ureteral dilatation as providing improvement of urodynamics or stabilization in 93.7% patients.

Clinical characteristics of primary vesicoureteral reflux in infants: multicenter retrospective study in Japan

PURPOSE

We evaluate clinical characteristics of primary vesicoureteral reflux in infants in a multicenter study in Japan with special reference to the relation of renal parenchymal damage to urinary tract infection and gender.

MATERIALS AND METHODS

Infants younger than 1 year old with primary vesicoureteral reflux were recruited from 14 hospitals during the 3-year registration period beginning in January 1996 and ending in December 1998. Various clinical parameters as well as renal parenchymal lesion on dimercaptosuccinic acid scintigraphy were evaluated.

RESULTS

Of 356 infants enrolled 296 (83%) were male and 60 (17%) were female. In 85% of infants presenting symptom was febrile urinary tract infection. There were 204 bilateral (57%) and 152 unilateral (43%) cases. Reflux was bilateral in 56% of males versus 65% of females, and high grade (grades IV and V) in 58% of males versus 55% of females. Diffuse parenchymal lesion was similarly noted in infants with or without prior urinary tract infection (38% and 46%, respectively) and was more often noted in male than in female infants (42% versus 25%).

CONCLUSIONS

Despite the current use of screening prenatal ultrasound, many infants are still diagnosed as having vesicoureteral reflux only after the occurrence of urinary tract infection. The greater severity of renal parenchymal lesion in male infants combined with similar incidence of diffuse parenchymal lesion in those with or without prior infection suggests preexisting congenital abnormalities in the male refluxing kidney.

Ureteroneocystostomy in children with posterior urethral valves: indications and outcome

PURPOSE

Ureteroneocystostomy in children with posterior urethral valves represents a surgical challenge. We reviewed our experience with this procedure to assess its indications and outcome.

MATERIALS AND METHODS

Between 1996 and January 2000, 106 children with posterior urethral valves were treated of whom 20 (19%) underwent ureteroneocystostomy at a mean age plus or minus SD of 5 +/- 2.6 years. Indications for surgery were recurrent urinary infections despite adequate valve ablation in 14 patients of whom 7 had persistent reflux in 12 renal units and 7 had obstruction in 11 ureterovesical junctions. The remaining 6 patients were initially treated with high loop diversion and obstruction was confirmed in 9 ureterovesical junctions by the Whitaker test. Bladder function was assessed by videourodynamics before surgery. Transureteroureterostomy was performed in 7 ureters, and 25 ureters were tailored and reimplanted using the combined intravesical and extravesical approach, including a psoas hitch in 18 (72%).

RESULTS

Mean followup plus or minus SD was 2.3 +/- 1 years. Obstruction and reflux occurred in 1 (4%) and 9 (36%) ureteroneocystostomies, respectively. Obstruction was successfully managed by repeat surgery. Patients with reflux were maintained on chemoprophylaxis. No patient required repeat surgery and reflux did not resolve spontaneously in any. Reflux occurred in all ureteroneocystostomies without a psoas hitch (100%) and in 2 with a hitch (10%) (p <0.004). Dilatation of the upper tracts persisted in all patients. In 2 patients end stage renal disease developed. The remaining 18 patients had serial sterile urine cultures and with a mean serum creatinine plus or minus SD of 0.8 +/- 0.3 mg.%.

CONCLUSIONS

Ureteroneocystostomy is indicated for patients with persistent obstruction after high diversion or those with persistent reflux or obstruction and recurrent infections despite adequate valve ablation and a stable bladder. However, the procedure is associated with a high rate of postoperative reflux. Psoas hitch has a significant role in prevention of reflux.

Vesicoureteral reflux and clinical outcomes in infants with prenatally detected hydronephrosis

PURPOSE

We evaluate the incidence of vesicoureteral reflux and urinary tract infections in infants with prenatally detected hydronephrosis.

MATERIALS AND METHODS

We retrospectively reviewed the charts of children referred to our hospital for evaluation of prenatally detected hydronephrosis between 1992 and 1998. Measured variables included ultrasound and voiding cystourethrogram findings, and infectious and clinical reflux outcomes.

RESULTS

Vesicoureteral reflux was identified in 40 of 234 infants (21%), including 24% of males and 13% of females. A significant correlation was found between the degree of hydronephrosis and incidence of reflux. Urinary tract infections were uncommon and identified in 7.5% of children on prevention for reflux and 4% with normal voiding cystourethrogram. In the majority (58%) of cases reflux resolved with medical management.

CONCLUSIONS

The incidence of reflux increases with greater degrees of sonographic dilatation but a normal ultrasound does not exclude reflux and, therefore, voiding cystourethrogram is recommended in all children with prenatally detected hydronephrosis. Since urinary tract infections are uncommon with prevention, antibiotics should be continued until reflux resolves and/or hydronephrosis significantly improves.

Detection of posterior urethral valves with voiding cystourethrosonography with echo contrast

PURPOSE

Cystosonography with echo contrast is an imaging modality developed to avoid x-ray exposure during detection of vesicoureteral reflux. The main role of cystosonography has been limited to screening for reflux in the female and for followup of both sexes. In males the radiographic voiding cystourethrogram is still considered the gold standard for urethral evaluation. We determined whether cystosonography during the voiding phase (voiding cystourethrosonography) can adequately visualize the male urethra and differentiate the normal from the obstructed urethra.

MATERIALS AND METHODS

100 males underwent cystosonography with echo contrast to detect vesicoureteral reflux. During the voiding phase the urethra was studied with ultrasound. The transperineal sagittal approach was chosen because the bladder neck and proximal part of the urethra were better visualized with the probe maintained coaxial to these structures. In every case in which ultrasound urethral imaging was considered abnormal a radiographic voiding cystourethrogram was performed for comparison, and the urethra was directly observed with cystourethroscopy. All patients with normal urethral imaging have been followed for 12 to 54 months (mean 32).

RESULTS

Voiding cystourethrosonography visualized the voiding phase in all patients studied with the transperineal ultrasound approach. Of the 100 boys 8 were correctly diagnosed with posterior urethral valves. None of those with normal ultrasound imaging showed clinical signs suggestive of urethral obstruction and remained asymptomatic.

CONCLUSIONS

The male posterior urethra can be effectively visualized with voiding cystourethrosonography, which can differentiate normal from the pathological obstructive urethral findings. This new approach can be recommended as the primary imaging modality to detect vesicoureteral reflux for both sexes, limiting the role of conventional fluoroscopic voiding cystourethrogram only to confirmation of a pathological finding in the male patient with a suspected obstructed urethra.

Renal parenchymal damage in male infants with high grade vesicoureteral reflux diagnosed after the first urinary tract infection

PURPOSE

Vesicoureteral reflux during infancy is found mainly in males, and it is of high grade and often bilateral. The higher predominance of male infants is reported in series when the reflux is diagnosed prenatally and when it is detected after urinary tract infection. Renal parenchymal damage may already be present at birth before any episode of urinary tract infection or acquired after a febrile urinary tract infection. We evaluate the incidence of renal damage in a large series of male infants with high grade vesicoureteral reflux diagnosed after the first urinary tract infection.

MATERIALS AND METHODS

We reviewed the medical and radiological records of 141 consecutive male infants 3 weeks to 1 year old (mean age 5.8 months) who were diagnosed with high grade (III to V) vesicoureteral reflux on voiding cystourethrography during 1984 to 2000 following hospitalization for the first febrile urinary tract infection. A total of 127 (90%) patients underwent technetium dimercapto-succinic acid scan to evaluate renal damage 3 to 6 months after the initial infection.

RESULTS

Vesicoureteral reflux was unilateral in 46 infants and bilateral in the remaining 95, comprising 236 ureters. Reflux was grade III in 79 ureters, IV in 114 and V in 43. Renal parenchymal damage was detected in 56 (44%) of the 127 infants on dimercapto-succinic acid scan, and was bilateral in 18 and unilateral in the 38, representing 74 renal refluxing units. Renal damage was mild (greater than 40% uptake) in 47 units, moderate (less than 40% and greater than 20% uptake) in 22 U and severe (less than 20% uptake) in 5 U.

CONCLUSIONS

This study shows that nearly half of the male infants with high grade reflux who present with the first febrile urinary tract infection have renal parenchymal damage. This high incidence of renal damage may be explained by the coexistence of the 3 risk factors of gender, urinary tract infection and high grade vesicoureteral reflux.

[Vesico-ureteral reflux, reflux nephropathy and terminal renal failure]

Vesicoureteric reflux is subcategorized into primary and secondary. Secondary vesicoureteric reflux results from increased bladder pressure duo to anatomic outlet obstruction or neuropathic disturbances. Primary vesicoureteric reflux was felt to result from a congenitally short mucosal tunnel length but this concept has been thrown into question. Recent studies suggest an association between lower urinary tract dysfunction and primary vesicoureteric reflux. Primary vesicoureteric reflux is often associated with kidney damage. It has been traditionally assumed that in children with primary vesicoureteric reflux kidney damage results from reflux of infected urine into the renal tissue. While there is unarguable proof that kidney damage can be acquired by the reflux of infected urine, the extent of reflux nephropathy explained by this mechanism has been overemphasized. Recent observations indicate that there are two categories of primary reflux disorder: a mild reflux associated with an acquired renal scarring secondary to infections which affects most females and a proportion of males; and a prenatal high-grade vesicoureteric reflux with a congenital nephropathy characterized by generalized hypodysplastic features which almost exclusively affects boys. Treatment options of primary vesicoureteric reflux range from surgical ureteric reimplantation to antimicrobial prophylaxis. Findings from comparative trials of prophylactic antibiotics and surgical management of children with high-grade vesicoureteric reflux do not show difference in renal growth and acquisition of new scars or renal function for 10 years. The factors accounting for the outcome in the mentioned studies are that most damage occurs at a very early stage and that severely damaged kidneys will either remain stable or progress to end-stage kidney disease, despite all efforts to cure the reflux.

Outcome of primary vesicoureteric reflux detected following fetal renal pelvic dilatation

OBJECTIVE

Postnatal investigation of mild degrees of fetal hydronephrosis has allowed subsequent detection of infants with vesicoureteric reflux (VUR). This study was designed to provide short to medium term information on such infants who had primary VUR, the rates of renal damage and progression over time, the risk factors for such damage and to compare the characteristics of those who had mild dilatation of the fetal renal pelvis (4-9 mm) with those who had moderate-severe dilatation (> or = 10 mm).

METHODOLOGY

Since June 1989, infants whose antenatal sonography had identified a fetal renal pelvis with an anteroposterior diameter of > 4 mm were investigated postnatally with renal ultrasonography and micturating cystourethrogram (MCU), and placed on antimicrobial prophylaxis. Those with VUR received 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. Infants were followed until discharge based on resolution of VUR, surgery, or low grade VUR. A 5.5 year cohort between June 1989 and December 1994 formed the study population. A review of notes and clinical review (if still under follow up) was undertaken. Vesicoureteric reflux on MCU was regraded according to the International Classification, and reflux nephropathy on DMSA scans was regraded according to criteria proposed by Goldraich. Regression analysis was used to assess risk factors for renal damage.

RESULTS

There were 69 infants (37 girls, 32 boys) who were identified with primary VUR, with 37/69 having bilateral reflux. Eight had a urinary tract infection during the follow-up period. There was a broad distribution of grades of reflux detected (Grades I-3, Grades II-23, Grades III-19, Grades IV - 17, Grades V-7). 99m-Tc-dimercaptosuccinic acid scans on 57/69 (83%) demonstrated renal damage in eight infants (14%). This was predominantly global contraction of function. No progression of renal damage was seen over 2-7 years. Regression analysis showed a strong association between Grades IV, V reflux and the presence of renal damage (P < 0.001). Review of the degrees of fetal renal pelvic dilatation showed that 60/69 infants were detected because of mild (4-9 mm) dilatation. The majority (43/60) had lower grades of reflux (Grades I, II, 3), but there was no obvious cut-off between 4 and 9 mm that could predict high grade VUR (Grades IV, V).

CONCLUSIONS

The use of 4 mm to define an abnormal fetal renal pelvis allows a much larger group of infants with high grade primary VUR to be detected than if a higher cut-off measurement is used. Although it also detects many more infants with low grade primary VUR, there is no obvious cut-off point at which this effect predominates. Progressive renal damage was not seen in follow up of up to 7 years of age. Renal damage on DMSA scanning in this group is almost exclusively a pattern of global contraction of function. The presence of high-grade VUR appears to be the only important factor in predicting the presence of renal damage.

The relationship between dysfunctional voiding and congenital vesicoureteral reflux

Voiding dysfunction may play an etiological role in congenital vesicoureteral reflux in otherwise normal children. There is increasing evidence to suggest that in some infants and older children, vesicoureteral reflux is associated with congenital structural deficiency of the trigonal ureterovesical junction valve mechanism as well as aberrant lower urinary tract function. In the youngest infants this abnormal function can be present at birth, whereas in older children it may be acquired and learned during the toilet training years, if it is not already present. Voiding dysfunction may spontaneously improve or require additional therapy. Increased rates of breakthrough infection, renal scarring and surgical failure have been associated with undiagnosed and untreated lower urinary tract dysfunction, emphasizing the importance of its recognition. Controversy remains regarding the role of invasive urodynamics and anticholinergic medication, and further large-scale prospective studies are necessary before either modality becomes routine when assessing and treating these children.

Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux

In women with reflux nephropathy, we investigated whether pre-existing hypertension and impaired renal function influence the rates of preeclampsia, renal function deterioration and preterm birth. The infants were investigated for vesico-ureteric reflux (VUR). A prospective audit of 54 pregnancies in 46 women with reflux nephropathy was performed. Preeclampsia complicated 24% of pregnancies and was increased in women with pre-existing hypertension (42%) compared with normotensive women (14%), (RR 3.0 (95% CI 1.1-7.8)). Nine (18%) women experienced deterioration in renal function during pregnancy Women with mild or moderate renal impairment were at increased risk of renal function deterioration (RR 12.7 (95% CI 1.6-98.5); RR 19.8 (95% CI 2.6-155)), respectively A third of infants were delivered preterm. The risk of preterm birth was increased if the mother had pre-existing hypertension (p = 0.01) or moderate renal impairment (p = 0.002). Seventeen (43%) of the 40 infants who underwent micturating cystourethrography had VUR, consistent with autosomal dominant inheritance with reduced penetrance. In reflux nephropathy, pre-existing hypertension was associated with an increased risk of preeclampsia and pre-existing renal impairment with deterioration in renal function. Infants of women with reflux nephropathy should be screened for VUR.

High incidence of a generally small kidney and primary vesicoureteral reflux

PURPOSE

We distinguished the scintigraphy pattern of congenital reflux nephropathy from that of acquired scarring in children with primary vesicoureteral reflux.

MATERIALS AND METHODS

We retrospectively evaluated the frequency and pattern of renal scintigraphy abnormalities in 41 patients with prenatally detected primary vesicoureteral reflux and in 322 with a mean age plus or minus standard deviation of 3.6 + or - 1 years in whom primary reflux was detected after urinary tract infection. Dimercapto-succinic acid scintigraphy was performed 4 to 6 and 1 to 4 months after reflux was diagnosed and/or the infection was cured in patients with urinary tract infection and prenatal detection, respectively.

RESULTS

We identified 3 patterns of renal damage, including overall decreased uptake of renal radionuclide that was 20% to 40% of relative uptake, focal defects in uptake and shrunken kidney with relative uptake less than 20%. Scintigraphy revealed renal damage in 12 prenatally detected cases of vesicoureteral reflux, including overall decreased uptake in 58% and shrunken kidney in 42%, and in 111 cases of reflux detected at urinary tract infection, including overall decreased uptake in 50%, uptake focal defects in 37% and shrunken kidney in 13%. In the urinary tract infection group overall decreased uptake was present in 25 of 90 boys and in 40 of 232 girls (p = 0.05). Of these children 15% of the girls had uptake focal defects and 17% had overall decreased uptake. Overall decreased uptake and uptake focal defects were significantly more common in kidney-ureter units with reflux grade 4 or greater than in those with grade 3 or less (p = 0. 00001 and 0.027, respectively).

CONCLUSIONS

When assuming that overall decreased radionuclide uptake indicates congenital reflux nephropathy and uptake focal defects indicate postnatal acquired scarring, congenital reflux nephropathy appears to be an important cause of renal damage in children with primary vesicoureteral reflux even beyond the neonatal age and even in girls. This finding is of interest because postnatally acquired scarring may but congenital reflux nephropathy may not be prevented.