Surgery of pelviureteric obstruction in the first year of life

To screen or not to screen for vesicoureteral reflux in children with ureteropelvic junction obstruction: a systematic review

Ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux (VUR) are the most common uropathies. The co-occurrence of both anomalies has led to the practice of screening for VUR in children with UPJO to prevent deterioration of kidney function due to renal scarring following urinary tract infections (UTIs). We determined the prevalence of VUR in children with UPJO for a critical assessment of VUR screening by voiding cystourethrography (VCUG). A systematic search strategy in MEDLINE, EMBASE, and CENTRAL was carried out for all articles that included VCUG, and renal scintigraphy or any other appropriate imaging technique for the diagnosis of UPJO. Twenty studies were eligible for inclusion. We found a pooled prevalence for VUR of 8.2 % (95 % CI = 3.6-12.7), about a threefold increase compared to the general pediatric population. VUR occurred bilateral or contralateral to the kidney with UPJO in 5.7 % (95 % CI = 3.0-8.5), equivalent to 75 % of all children with VUR. Considering the effect size of VUR treatment with antibiotics, about 207 and 278 children would need to undergo VCUG to prevent one febrile UTI and one case of renal scarring by 1-2 years, respectively.

CONCLUSION

Against this background, screening for VUR needs to be scrutinized and restricted to selected risk groups. What is known: • Screening of patients with ureteropelvic junction obstruction (UPJO) for vesicoureteral reflux (VUR) is recommended based on a small number of repeatedly cited studies. • The lack of conclusive evidence results in different treatment strategies and leads to difficulties when communicating diagnoses and treatment options to parents. What is new: • A robust prevalence for VUR in children with UPJO based on all published evidence and the resulting number needed to screen are given for decision-making in daily clinical practice. • The results may be a precursor for implementation into guidelines.

Pyeloplasty in infancy

OBJECTIVE

The advent of routine maternal ultrasound has increased the number of neonates diagnosed to have ureteropelvic junction obstruction. Though the debate concerning its ideal management continues, recent years have witnessed reports on pyeloplasty in infancy. This study presents the feasibility and outcome of pyeloplasty in neonates and infants from a single centre.

METHODS

The authors examined the records of 40 neonates and infants (46 renal units) who underwent pyeloplasty for ureteropelvic junction obstruction since 1988. Patient characteristics, clinical presentation, investigations, associated anomalies, age at surgery, operative technique and outcome were evaluated.

RESULT

The mean and median age at surgery was 3.5 and 2.5 months respectively, and mean postoperative hospital stay six days. Associated anomalies were found in 27% of infants and in some they influenced the outcome. In 72%, no stent or nephrostomy was used. However, all had a closed perinephric drain. There was no mortality in this series. Complications (8.7%) comprised anastomotic leak in three and anastomotic stricture in one unit. In 35 of 38 renal units, improved drainage and recovery of differential function was confirmed on postoperative renogram.

CONCLUSION

Where indicated, pyeloplasty in the neonate and infant will be readily adopted by specialists for the select few it would benefit. It is hoped that all those involved in the care of these infants will take cognisance of this fact to ensure early optimal management of ureteropelvic junction obstruction.

Trans-pyeloureteric anastomosis in the management of pelviureteric junction obstruction

BACKGROUND

The application of pyeloureteric anastomoses in the management of pelviureteric junction obstruction is described.

METHODS

Two patients, one requiring a ureterocystoplasty for bladder augmentation but with a coexistent contralateral pelviureteric junction (PUJ) obstruction and the other with gross hydronephrosis but an atretic ipsilateral ureter, underwent trans-pyeloureteric anastomosis to relieve the obstruction.

RESULTS

Both patients demonstrated satisfactory drainage of the upper tracts on postoperative imaging.

CONCLUSIONS

Transureteropyeloplasty represents a novel and valid technique of urinary tract reconstruction in complex cases of PUJ obstruction.

Pelviureteric obstruction in children: conventional pyeloplasty is superior to endo-urology

BACKGROUND

Hydronephrosis secondary to pelviureteric junction (PUJ) obstruction is common in infancy and childhood. Pyeloplasty has until recently been the accepted method of management, but alternative endo-urological techniques have evolved in the last decade.

METHODS

Published results of conventional pyeloplasty for primary PUJ obstruction in children were compared with published results of endo-urological procedures.

RESULTS

Sixty-six pyeloplasties were performed in 61 children in a 6-year period. During a similar period, 63 primary endo-urological procedures were reported in the literature. The success rate after pyeloplasty was 95.5% compared with 65% after endo-urology.

CONCLUSIONS

Conventional pyeloplasty is superior to endo-urology and should remain the gold standard for the treatment of primary PUJ obstruction in children.

Non-intubated pyeloplasty for pelviureteric junction obstruction in children

Sixty-one consecutive patients undergoing pyeloplasty (5 bilateral) were reviewed retrospectively; 54 pyeloplasties were non-intubated (NIP) and 12 were intubated. NIPs were managed by an extrarenal wound drain, which was removed after 2-4 days in 44 repairs with minimal or no urinary leakage and after 6-8 days in 10 with significant leakage. Fifty-two were successful after the primary procedure. One patient who developed a urinoma after drain removal required a percutaneous nephrostomy followed by a revision pyeloplasty. A second revision pyeloplasty was necessary for persistent postoperative obstruction. The results of NIP compared favorably with series where intubation was used routinely and were superior to alternative methods of management such as endopyelotomy.

Vesico-ureteric reflux and surgically treated pelvi-ureteric junction obstruction in infants under the age of 12 months

BACKGROUND

Pelvi-ureteric junction obstruction has been increasingly diagnosed in infants, mostly as a consequence of antenatal ultrasound examinations.

METHODS

Of 55 infants below the age of 12 months who underwent dismembered pyeloplasty over a 7-year period, we aimed to determine the patterns and outcome of associated vesico-ureteric reflux that was present in 15 (28%) of the 53 infants in whom follow-up was available.

RESULTS

A total of eight infants had resolution of their reflux with conservative management and the median time to resolution was 15 months. Five infants proceeded to ureteroneocystotomy.

CONCLUSIONS

Given the association of vesico-ureteric reflux and pelvi-ureteric junction obstruction, routine cystography is recommended when the diagnosis of pelvi-ureteric junction obstruction is made.

Diagnosis and treatment of antenatal uropathies

Thirty-five patients with significant fetal hydronephrosis detected on antenatal ultrasound had postnatal investigations which included ultrasound, 99mtechnetium diethylenetriamine pentacetic acid (99mTcDTPA) renal scans and micturating cystourethrograms. Antenatal and postnatal ultrasound were unable to determine reliably the level of obstruction causing the hydronephrosis. The 99mTcDTPA renal scan was useful in determining the necessity and timing of surgery, but could not exclude vesico-ureteric reflux. Seven patients required surgery in the neonatal period and a further seven children had surgery because of deterioration of the scan appearance on follow-up studies performed at 3, 6 and 12 months of age and then at longer time intervals. Twenty patients (almost 60%) have been managed conservatively for a mean of 28 months (range: 12 months-7 years) with no deterioration in renal function.

Urological anomalies detected on antenatal ultrasound: a 9 year review

One hundred and forty-eight patients (107 male, 41 female), in whom a urological anomaly was detected on antenatal ultrasound examination, are reviewed. Postnatal imaging was done primarily by ultrasonography (US) which was often repeated. Depending upon the ultrasound findings, the patients had a renal nuclide scan (RNS) and/or micturating cysto-urethrogram (MCU), but intravenous urogram (IVU) was not usually considered necessary. A range of urological anomalies was encountered, but renal anomalies were most common. Over half the cases had anomalies which did not require surgery, with non-obstructive pelvicalyceal dilatation being frequent. Almost half the operated cases had features which should have allowed a clinical diagnosis without the knowledge of the antenatal findings. A fifth of the cases were occult in that they would not have been diagnosed early in life but for the antenatal detection. The majority had congenital pelviureteric junction obstruction and results of early reconstructive surgery were satisfactory.

Surgery of pelviureteric obstruction in 101 children over one year of age

One hundred and one children over 1 year of age have had surgery for pelviureteric obstruction over an 11 year period. The common clinical features were abdominal pain, urinary infection or haematuria, but a number presented as an incidental finding. Less commonly, the patients presented with an abdominal mass or with hypertension. The diagnosis was usually made on intravenous pyelography (IVP) but in the latter part of the series, renal nuclide scan (RNS) and ultrasonography (US) were preferred. Ninety-three patients had a unilateral pyeloplasty, three had bilateral pyeloplasty and five had nephrectomy or heminephrectomy. Whereas initially nephrostomy drainage was used in the majority of patients after pyeloplasty, a trend away from nephrostomy evolved in the latter part of the series. With experience, the incidence of postoperative complications was also reduced and there was a reduction in the period of hospitalization. Clinical results were consistently satisfactory. Postoperative assessment after pyeloplasty was made by IVP and/or RNS and also US. A review of these investigations showed that RNS provided more factual information of the result when compared with the IVP.