Augmentation Cystoplasty in Children

Reappraisal of Tc-99m DMSA scintigraphy for follow up in children with vesicoureteral reflux

We reviewed Tc-99m DMSA scintigraphy in children with vesicoureteral reflux (VUR) in order to assess whether repeated Tc-99m DMSA scans are necessary for the follow up of these patients. Ninety-seven children who were followed up for more than one year (1-7.4 years, average 2.8 years) after the first DMSA scan were included in the study. Fifty-one patients had been diagnosed as primary VUR and 46 as secondary VUR. Age at the first examination ranged from 0 to 14 years (average 5.1 years). Planar images were taken 2 hours after injection. The % renal uptake per injected dose (%RU) was calculated from posterior images. Kidneys in 11 patients (11.3%) changed morphologically during the follow up. Of these, new photon deficient areas (PD) were detected in only 4 patients (4.1%). All of these 4 patients had neurogenic bladder and were managed with self-catheterization. Of the remaining 7 patients, cortical thinning progressed in 5 patients (5.2%) and PDs resolved in 3 patients (3.1%). In one of these 7 patients, PD resolved in one kidney and cortical thinning progressed in the contralateral kidney. Of 97 patients reviewed, % RU decreased more than 20% during the follow up in 6 patients (6.2%). All were diagnosed as secondary VUR due to neurogenic bladder. %RU decreased only in the contracted kidneys at the initial scan. Two of them underwent renal transplantation because of severe renal failure. In conclusion, new PD rarely developed and % RU decreased in only a few patients during the follow up of children with VUR. Repeated Tc-99m DMSA scintigraphy therefore seems to have little benefit in the follow up of children with VUR. It should be performed in selected patients with high risk of urinary tract infection or renal failure.

The relevance of urethral resistance in children with myelodysplasia: its impact on upper urinary tract deterioration and the outcome of conservative management

PURPOSE

Upper urinary tract deterioration, such as vesicoureteral reflux and hydronephrosis, affects the long-term prognosis in children with myelodysplasia. We retrospectively analyzed the relevance of urethral resistance to upper tract deterioration in untreated children with myelodysplasia as well as the outcome of conservative treatment based on urethral resistance.

MATERIALS AND METHODS

Included in our study were 32 boys and 29 girls with a mean age at presentation of 3.6 years and a mean followup of 9.2 years. The children were divided into group 1-31 with high and group 2-30 with low urethral resistance, as determined by leak point pressure or maximum urethral closing pressure. Clean intermittent catheterization with or without anticholinergics was instituted in all children in group 1 and those in group 2 with documented upper tract deterioration and/or problematic urinary incontinence after school age. We compared the incidence of upper tract deterioration at the initial evaluation and during followup as well as the final status of the upper tract in the 2 groups.

RESULTS

At the initial evaluation 17 of 31 group 1 (55%) and 4 of 30 group 2 (13%) patients had upper tract deterioration (p <0.01). Deterioration was refractory to conservative management in 5 group 1 children who required bladder augmentation. The incidence of de novo upper tract deterioration during followup was not statistically different in the 2 groups (10 and 7% in groups 1 and 2, respectively). At the final evaluation the upper tract was normal in 26 (84%), improved in 3 and stable in 2 group 1 patients, while it was normal in 26 (87%) in group 2.

CONCLUSIONS

Urethral resistance is relevant to upper tract deterioration in untreated children with myelodysplasia. Although bladder augmentation was necessary in some children with high urethral resistance, the outcome of conservative treatment was generally satisfactory with the preservation or normalization of the upper tract in more than 80% regardless of urethral resistance.