Modern management of and update on prune belly syndrome

Generation of induced pluripotent stem cell line, NCHi028-A, from a male child with Prune Belly Syndrome

Prune belly syndrome (PBS) is a rare, multi-system congenital myopathy mainly affecting males, whose genetic basis is still being explored. Phenotypically, its morbidity spans from mild to lethal, and PBS cases manifest three cardinal pathological features: wrinkled, flaccid ventral abdominal wall with skeletal muscle deficiency, urinary tract dilation with poorly contractile smooth muscle, and intra-abdominal undescended testes. NCHi028-A is an iPSC line derived from skin fibroblasts of a 1-month-old male with PBS using Sendai Virus reprogramming factors. This iPSC line shows typical iPSC morphology, has normal karyotype, expresses undifferentiated hPSC state markers, and can be differentiated into three germ layers.

Anatomic and Functional Reconstruction of the Abdominal Wall in Prune Belly Syndrome: A Case Report

Prune belly syndrome (PBS), or Eagle-Barrett syndrome, is a rare congenital disorder marked by abdominal wall muscle deficiency, urinary tract anomalies, and cryptorchidism, causing significant abdominal wall laxity and functional impairment. This case report discusses an innovative approach to abdominal wall reconstruction in a 19-year-old male patient with PBS and associated conditions, including chronic renal failure and spina bifida. Previously, he underwent distal ureterectomy and vesicoureteral reimplantation at the age of two years to correct urinary tract dilation and bilateral orchiopexy. Preoperative examination revealed a distended abdomen, hypoplastic anterior abdominal wall musculature with associated abdominal flaccidity, and the presence of a malformed umbilical remanent. Due to the extensive abdominal muscle deficiency, the surgical team combined abdominoplasty with bilateral rectus femoris and sartorius muscle transfers. This dynamic reconstruction aimed to enhance abdominal wall function and aesthetics. Postoperative complications included skin flap necrosis, effectively managed with debridement, an abdominal anchor device, and skin grafting. Over a 41-month follow-up, the patient showed marked improvement in abdominal strength, posture, and ambulation, with no recurrence of abdominal bulging. This case highlights the potential of combining fascial plication and muscle transfer for sustained functional and aesthetic benefits in PBS, supporting its consideration in similar complex cases.

Prune belly syndrome in a neonate with severe bilateral hydronephrosis: A rare case report from Somalia

INTRODUCTION AND IMPORTANCE

Prune belly syndrome (PBS), also known as Eagle-Barret syndrome, is a rare congenital disorder characterized by abdominal wall muscle underdevelopment, urinary system abnormalities, and cryptorchidism. This case report presents the clinical features, diagnosis, and management of PBS in a newborn. This is the first case report of prune belly syndrome in Somalia. The condition is estimated to occur in approximately 1 in 30,000 to 1 in 50,000 live births, making it a relatively uncommon presentation. Recognizing and managing this syndrome is crucial, as it can lead to significant morbidity and mortality if not addressed promptly.

CASE PRESENTATION

A term baby delivered without complications developed respiratory distress, jaundice, and urinary retention shortly after birth. Physical examination revealed abdominal distension, fluid in the abdomen, and bilateral undescended testes. Laboratory tests showed elevated bilirubin levels and abnormal blood counts. Ultrasound findings demonstrated bilateral hydroureteronephrosis and underdeveloped abdominal wall muscles. The limited resources and infrastructure in the healthcare setting in Somalia posed challenges in providing comprehensive care for this neonate.

CLINICAL DISCUSSION

PBS is a rare congenital syndrome with a higher prevalence in males. Its exact cause is not fully understood, but genetic factors may play a role. The management of PBS in resource-limited settings can be particularly challenging. The differential diagnosis included sepsis, neonatal jaundice, and posterior urethral valves. The key interventions included supportive care, such as maintaining fluid and electrolyte balance, treating infections, and addressing any urinary tract abnormalities. The limited access to specialized pediatric urology services and advanced diagnostic tools, such as magnetic resonance imaging (MRI), hindered the ability to fully characterize the extent of the urinary tract abnormalities and plan definitive surgical interventions.

CONCLUSION

Despite the constraints of the resource-limited setting, the supportive care and management strategies implemented led to an improvement in the baby's condition. This case highlights the importance of recognizing and managing Prune Belly Syndrome, even in environments with limited healthcare resources. Continued efforts to improve diagnostic capabilities and access to specialized care are crucial for optimizing the outcomes of patients with this rare and complex congenital disorder.

Practical Approach to Congenital Anomalies of the Kidneys: Focus on Anomalies With Insufficient or Abnormal Nephron Development: Renal Dysplasia, Renal Hypoplasia, and Renal Tubular Dysgenesis

Congenital anomalies of the kidney and urinary tract (CAKUT) accounts for up to 30% of antenatal congenital anomalies and is the main cause of kidney failure in children worldwide. This review focuses on practical approaches to CAKUT, particularly those with insufficient or abnormal nephron development, such as renal dysplasia, renal hypoplasia, and renal tubular dysgenesis. The review provides insights into the histological features, pathogenesis, mechanisms, etiologies, antenatal and postnatal presentation, management, and prognosis of these anomalies. Differential diagnoses are discussed as several syndromes may include CAKUT as a phenotypic component and renal dysplasia may occur in some ciliopathies, tumor predisposition syndromes, and inborn errors of metabolism. Diagnosis and genetic counseling for CAKUT are challenging, due to the extensive variability in presentation, genetic and phenotypic heterogeneity, and difficulties to assess postnatal lung and renal function on prenatal imaging. The review highlights the importance of perinatal autopsy and pathological findings in surgical specimens to establish the diagnosis and prognosis of CAKUT. The indications and the type of genetic testing are discussed. The aim is to provide essential insights into the practical approaches, diagnostic processes, and genetic considerations offering valuable guidance for pediatric and perinatal pathologists.

Novel minimally invasive abdominoplasty for selected cases of prune belly syndrome: Step-by-step technique description and clinical indications

BACKGROUND

Prune belly syndrome (PBS) is characterized by the triad of abdominal flaccidity, bilateral undescended testicles and genitourinary tract anomalies. A variable spectrum of abdominal wall laxity is observed in PBS. We present the first case of a novel technique using a minimally invasive abdominoplasty to specifically address patients with localized abdominal wall weakness in PBS.

CASE PRESENTATION

A two-years-old child with PBS presented with recurrent febrile urinary tract infections. Ultrasonography demonstrated a dysplastic right kidney associated with significant ipsilateral ureterohydronephrosis. Voiding urethrocystogram did not show vesicoureteral reflux and DMSA scan depicted a non-functioning right kidney. During laparoscopic right nephroureterectomy and first stage Fowler-Stephens bilateral orchiopexies, a significant right-sided lateral abdominal wall bulging was observed. A minimally invasive laparoscopic abdominoplasty was performed with a one-way running suture using an unabsorbable 2.0 prolene approximating the edges of the musculofascial defect. While undergoing the second-stage Fowler-Stephens orchiopexy, no bulging was observed.

CONCLUSION

A minimally invasive abdominoplasty to improve abdominal wall lateral bulging in PBS was feasible and presented good cosmetic result. We anticipate that this technique can be applied for children with PBS with primary lateral abdominal wall bulging, employing one or more suture lines depending on the fascial defect size.

Fertility prospects for the prune-belly patient: A scoping review

INTRODUCTION

With advances in medical care and assisted reproductive technologies (ART), fertility prospects for prune-belly syndrome (PBS) men may be changing. This review aims to identify the factors influencing fertility and optimization of reproductive health for PBS patients.

MATERIAL AND METHODS

A scoping review was performed on all records published over 70 years (1952-2022) analyzing fertility in PBS males. Records were summarized in a table and narrative describing cryptorchidism, orchiopexy, testicle histology; prostate characteristics; sex hormone function; semen analyses, ART, and conception ability. This review was registered on Open Science Framework (OSF) and conducted using PRISMA methodology.

RESULTS

827 articles were identified and 83 were selected for data extraction. Before 2000, there were 0.85 publications/year whereas after 2000 there were 1.95 publications/year. Orchiopexy successfully relocated 86 % of PBS testicles into the scrotum. Testicular histology demonstrated 50 % of patients had no spermatogonia, while 47.2 % and 2.7 % had reduced or normal numbers respectively. Leydig hyperplasia and Sertoli only histology were found in 19.4 % of patients. Prostatic hypoplasia and prostatic urethral dilation were found in 93.6 % and 91.4 % of patients respectively. Testosterone, Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH) were normal in 93.9 %, 87.7 % and 77.9 % of patients respectively. Azoospermia and oligospermia was found in 75.7 % and 21.6 % of patients respectively while 60.7 % had antegrade ejaculation. ART successfully extracted sperm in 6 instances and resulted in 4 conceptions, while natural conception was reported twice.

CONCLUSIONS

Data analysis indicates increased attention to fertility prospects for PBS males with evaluation of PBS patient's hormonal function, semen analyses, ART, and conception ability. The reviewed data suggest that PBS males may father biological offspring with contemporary management and also demonstrate the need for consistent reproductive management approaches to maximize their fertility prospects.

The challenging diagnosis and management of the prune belly syndrome: A case report

Prune belly syndrome is a rare disorder that occurs mainly in men. It is characterized by the triad of deficient abdominal wall muscles, the dilated urinary collecting system, bilateral cryptorchidism, and infertility. It mainly affects the genitourinary system, which involves the prognosis. We present the case of a preterm neonate male whose diagnosis of a prune belly was suspected in antenatal ultrasound. He had a urinary tract abnormality starting at 22 weeks of gestation. At birth, a clinical examination revealed a distended abdomen within a wrinkled and flaccid abdominal wall, a macropenis, and bilateral cryptorchidism. A urinary tract ultrasound revealed a right pyelocaliciel dilatation and a right megaureter with a megacystis. The neonate ultimately died due to severe renal failures. Prune Belly syndrome is a complex disease with a high mortality rate. Early antenatal ultrasound may ameliorate the prognosis.

Kidney function and transplants in prune belly syndrome: a scoping review

BACKGROUND

Children with prune belly syndrome (PBS) are at higher risk of developing kidney dysfunction and requiring kidney replacement therapy (KRT). While studies have described surgical and survival outcomes in these populations, there has yet to be a focused synthesis of evidence regarding kidney outcomes in this population. Here, the focus of this scoping review was to highlight knowledge gaps and report standards on kidney outcomes in PBS of all ages.

METHODS

Following scoping review methodology, EMBASE, MEDLINE, and Scopus were searched for peer-reviewed literature that describe kidney outcomes in PBS. All studies with a broad set of kidney outcomes (such as kidney function measures, chronic kidney disease (CKD), KRT and associated outcomes) were included. Findings were summarized and qualitatively synthesized.

RESULTS

Of the 436 unique records identified, 25 were included for synthesis. A total of 17 studies (441 patients) reported on kidney insufficiency outcomes, with an estimated prevalence of CKD ranging from 8 to 66%. A total of 15 studies (314 patients) described KRT, primary kidney transplant, and outcomes. Of these, the age for KRT ranged from 4 to 21 years, and graft survival ranged from 22 to 87% by last follow-up (range 1.3-27 years).

CONCLUSIONS

There is significant variability in studies reporting kidney outcomes in PBS which limits meaningful synthesis. There is a need for future studies with comprehensive reporting of confounders and drivers for kidney insufficiency in PBS.

PIEZO1 loss-of-function compound heterozygous mutations in the rare congenital human disorder Prune Belly Syndrome

Prune belly syndrome (PBS), also known as Eagle-Barret syndrome, is a rare, multi-system congenital myopathy primarily affecting males. Phenotypically, PBS cases manifest three cardinal pathological features: urinary tract dilation with poorly contractile smooth muscle, wrinkled flaccid ventral abdominal wall with skeletal muscle deficiency, and intra-abdominal undescended testes. Genetically, PBS is poorly understood. After performing whole exome sequencing in PBS patients, we identify one compound heterozygous variant in the PIEZO1 gene. PIEZO1 is a cation-selective channel activated by various mechanical forces and widely expressed throughout the lower urinary tract. Here we conduct an extensive functional analysis of the PIEZO1 PBS variants that reveal loss-of-function characteristics in the pressure-induced normalized open probability (NPo) of the channel, while no change is observed in single-channel currents. Furthermore, Yoda1, a PIEZO1 activator, can rescue the NPo defect of the PBS mutant channels. Thus, PIEZO1 mutations may be causal for PBS and the in vitro cellular pathophysiological phenotype could be rescued by the small molecule, Yoda1. Activation of PIEZO1 might provide a promising means of treating PBS and other related bladder dysfunctional states.

Troubleshooting Tips for Diagnosing Complex Fetal Genitourinary Malformations

Fetal genitourinary anomalies can present a diagnostic challenge for the radiologist. The absence of a normally located kidney may represent agenesis or be secondary to a fusion or migration abnormality. A dilated renal pelvis should prompt evaluation for a specific cause, including ureteropelvic junction obstruction, reflux, or an obstructed duplicated system. Cystic parenchymal changes are characteristic of a multicystic dysplastic kidney but may also be seen in obstructive cystic dysplasia. There are numerous causes of megacystis including chromosomal (trisomy 18 syndrome), obstruction (posterior urethral valves, urethral atresia), or muscular dysfunction (prune belly syndrome, megacystis microcolon intestinal hypoperistalsis syndrome). Important mimics of a large bladder include hydrocolpos and urogenital sinus or cloacal malformation. Complications of genitourinary malformations are common and include oligohydramnios, urinary ascites, and urinoma. Making an accurate diagnosis often requires additional US views beyond those obtained in the standard fetal survey and occasionally performing fetal MRI. The appropriate use of orthogonal T2-weighted sequences, in conjunction with diffusion-weighted images for evaluation of the kidneys and gradient-recalled-echo sequences for evaluation of T1-hyperintense meconium in the colon, can play an integral role in diagnosis. Accurate diagnosis of fetal genitourinary malformations is vital to direct patient counseling and pregnancy management as outcomes are highly variable. Some conditions can be surgically corrected quite simply, some require multiple complex procedures, and some are lethal. The authors offer troubleshooting tips to narrow the differential diagnosis for four observations: unilateral absent kidney, dilated renal pelvis, cystic renal parenchyma, and megacystis and its mimics. ©RSNA, 2023 Test Your Knowledge questions are available in the Online Learning Center.

Prune Belly Syndrome in a Female Newborn following In Vitro Fertilization-Induced Pregnancy: A Case Report and Literature Review

Prune belly syndrome (PBS) is a rare congenital anomaly characterized by a triad of abdominal flaccidity, varying degrees of urinary system involvement, and cryptorchidism. The exact cause of PBS is unknown. Clinical symptoms can range from stillbirth to significant renal and respiratory abnormalities to almost normal children. Treatment typically involves surgical repair of the abdominal wall defect and urinary tract abnormalities, early orchiopexy, and supportive management of related problems. We report the first case of a female newborn with PBS following in vitro fertilization-induced pregnancy with a comprehensive systematic review of all relevant cases.

Megacystis Associated With an Underlying ACTA2 Variant and Diagnosis of Multisystemic Smooth Muscle Dysfunction Syndrome: A Case Report

Fetal megacystis, or an enlarged fetal bladder, is most often attributed to embryological defects, occurring early in gestation. Recent investigations have demonstrated that the underlying etiology of megacystis may be more myriad than originally thought. We present the third reported patient with megacystis due to an ACTA2 Arg179 substitution variant causing Multisystemic Smooth Muscle Dysfunction Syndrome. We also provide a description of pediatric evaluation and follow up. The growing number of cases in which this ACTA2 variant has been identified in fetal megacystis suggests that molecular sequencing is an appropriate consideration, particularly prenatally, when other features of Multisystemic Smooth Muscle Dysfunction Syndrome cannot be detected.

A case of prune belly syndrome: Experience from a regional hospital in Togo

INTRODUCTION AND IMPORTANCE

Prune Belly syndrome is a rare congenital condition first reported in 1939. It is a malformative disease associated with high mortality. We report a neonatal case in a regional hospital in Togo.

PRESENTATION OF CASE

A 4-month-old male infant was brought to the hospital by his uncle because of a "deformity of the abdomen and absence of testicles". The examination revealed hypoplasia of the abdominal wall associated with bilateral cryptorchidism. Abdominal and urinary tract ultrasound revealed a left pyelocaliceal dilatation and a right megaureter. All these data allowed the diagnosis of Prune Belly syndrome.

CONCLUSION

Prune Belly syndrome is a rare and complex disease with a high mortality rate.

MEDIUM AND LONG-TERM CLINICAL OUTCOMES OF KIDNEY TRANSPLANTATION IN PATIENTS WITH PRUNE BELLY SYNDROME: A SINGLE-CENTRE EXPERIENCE

OBJECTIVES

To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT).

METHODS

Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analysed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of non-urological causes.

RESULTS

The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pre-transplant urological operations in preparation for kidney transplantation, while four patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10 and 15 years were 90.9%, 57.7% and 38.5%, respectively. Graft survival for control cohort at 5, 10 and 15 years were 89.9%, 80% and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (p=0.449, p=0.134, respectively).

CONCLUSION

This single-centre study showed that the medium term graft survival rates in patients with PBS are encouraging and comparible to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multi-centre international collaboration will be needed.

Survival of children with rare structural congenital anomalies: a multi-registry cohort study

BACKGROUND

Congenital anomalies are the leading cause of perinatal, neonatal and infant mortality in developed countries. Large long-term follow-up studies investigating survival beyond the first year of life in children with rare congenital anomalies are costly and sufficiently large standardized cohorts are difficult to obtain due to the rarity of some anomalies. This study aimed to investigate the survival up to 10 years of age of children born with a rare structural congenital anomaly in the period 1995-2014 in Western Europe.

METHODS

Live births from thirteen EUROCAT (European network for the epidemiological surveillance of congenital anomalies) population-based registries were linked to mortality records. Survival for 12,685 live births with one of the 31 investigated rare structural congenital anomalies (CAs) was estimated at 1 week, 4 weeks and 1, 5 and 10 years of age within each registry and combined across Europe using random effects meta-analyses. Differences between registries were evaluated for the eight rare CAs with at least 500 live births.

RESULTS

Amongst the investigated CAs, arhinencephaly/holoprosencephaly had the lowest survival at all ages (58.1%, 95% Confidence Interval (CI): 44.3-76.2% at 1 week; 47.4%, CI: 36.4-61.6% at 1 year; 35.6%, CI: 22.2-56.9% at 10 years). Overall, children with rare CAs of the digestive system had the highest survival (> 95% at 1 week, > 84% at 10 years). Most deaths occurred within the first four weeks of life, resulting in a 10-year survival conditional on surviving 4 weeks of over 95% for 17 out of 31 rare CAs. A moderate variability in survival between participating registries was observed for the eight selected rare CAs.

CONCLUSIONS

Pooling standardised data across 13 European CA registries and the linkage to mortality data enabled reliable survival estimates to be obtained at five ages up to ten years. Such estimates are useful for clinical practice and parental counselling.

Bladder Cancer in a Long-term Survivor of the Prune Belly Syndrome

Prune belly syndrome (PBS) is a rare but morbid complexity of congenital anomalies that consists of abdominal wall defect, bilateral cryptorchidism, and urinary tract dilation. With the recent advances in perinatal care, the life expectancy of patients with PBS has improved. Although renal and sexual outcomes are frequently discussed in the literature, little is known about urinary tract malignancies in adulthood. Herein, we present a case of advanced bladder cancer in a 38-year-old man with PBS. To the best of our knowledge, a malignant tumor arising in a nondefunctionalized or nonaugmented bladder in patients with PBS has not been reported previously.