Obstructive nephropathy and chronic kidney disease secondary to uterine leiomyomas

The relationship between muscle sympathetic nerve activity and systemic hemodynamics is altered in women with uterine fibroids

Women with uterine fibroids (UF), benign tumors of the myometrium, have a higher prevalence of hypertension than women without UF. The cause for this relationship is unclear. Muscle sympathetic nerve activity (MSNA) is a regulator of arterial blood pressure, and it is possible that variations in MSNA predispose women with UF to develop hypertension. The purpose of this study was to assess baseline blood pressure and MSNA and the relationships between MSNA and systemic hemodynamics in women with and without UF. We measured blood pressure (brachial intra-arterial line), MSNA (microneurography), and systemic hemodynamics (total peripheral resistance and cardiac output) at rest in 14 healthy, normotensive, premenopausal women with UF (42 ± 2 years old) and 9 healthy, normotensive, premenopausal women without UF (41 ± 2 years old). Baseline blood pressure and MSNA did not differ between groups (p > 0.05 for both). In women with UF, there was a positive correlation between MSNA and total peripheral resistance (r = 0.75, p = 0.02), as well as a negative correlation between MSNA and cardiac output (r = -0.73, p = 0.03). In contrast, these relationships were not seen in women without UF (p > 0.05 for both relationships). These data suggest that autonomic interactions with systemic hemodynamics, and thus blood pressure regulation, are different in healthy women with UF compared to healthy women without UF.

Percutaneous nephrostomy versus retrograde ureteral stenting for acute upper obstructive uropathy: a systematic review and meta-analysis

Acute obstructive uropathy is associated with significant morbidity among patients with any condition that leads to urinary tract obstruction. Immediate urinary diversion is necessary to prevent further damage to the kidneys. In many centres, the two main treatment options include percutaneous nephrostomy (PCN) and retrograde ureteral stenting (RUS). The purpose of this study if to compare the efficacy and safety of PCN and RUS for the treatment of acute obstructive uropathy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE, the World Health Organisation International Clinical Trials Registry Platform and ClinicalTrials.gov. We also searched the reference lists of included studies to identify any additional trials. We included randomised controlled trials and controlled clinical trials comparing the outcomes of clinical improvement (septic parameters), hospitalisation duration, quality of life, urinary-related symptoms, failure rates, post-procedural pain [measured using a visual analogue scale (VAS)] and analgesics use. We conducted statistical analyses using random effects models and expressed the results as risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). Seven trials were identified that included 667 patients. Meta-analysis of the data revealed no difference in the two methods in improvement of septic parameters, quality of life, failure rates, post-procedural pain (VAS), or analgesics use. Patients receiving PCN had lower rates of haematuria and dysuria post-operatively and longer hospitalisation duration than those receiving RUS. PCN and RUS are effective for the decompression of an obstructed urinary system, with no significant difference in most outcomes. However, PCN is preferable to RUS because of its reduced impact on the patient's post-operative quality of life due to haematuria and dysuria, although it is associated with slightly longer hospitalisation duration.

The value of surveying the kidneys during pelvic ultrasound examinations

INTRODUCTION

Pelvic ultrasounds are commonly performed for various clinical indications in female patients presenting to the hospital. A survey of the kidneys is routinely included as part of the examination, but there is limited justification for their inclusion in the assessment of every female presenting for a pelvic ultrasound.

METHOD

We examined the utility of surveying the kidney ultrasound during pelvic ultrasonography by reviewing the records of 1009 pelvic ultrasound examinations in 1000 women.

RESULTS

In total, 46 incidental findings were identified, but 91% of these were clinically inconsequential. Only four patients had incidental findings of high clinical priority requiring specialist treatment. Of these, two patients were symptomatic and had urinary tract obstruction due to stones. The other two patients harboured asymptomatic renal cell carcinomas. The overall incidence of renal incidental findings of high clinical priority in asymptomatic patients was two in 1009 examinations (1999 kidneys).

CONCLUSION

Indiscriminate uncritical screening of the kidneys in women presenting for pelvic ultrasound is not evidence-based and represents a low-yield examination with extremely low rate of incidental findings of clinical significance.

[Management of ureteral obstruction : Value of percutaneous nephrostomy and ureteral stents]

Ureteral obstruction represents a heterogeneous disease pattern and is treated by ureteral stenting or percutaneous nephrostomy (PCN) depending on the necessity. The benefits of urinary diversion with ureteral stenting or PCN in malignant ureteral obstruction (MUO) for patient survival are only moderate. No differences have been found between ureteral stenting and PCN in MUO with regard to median patient survival and complication rates. In cases of MUO there is currently no evidence that urinary diversion improves the quality of life. Alternative concepts of ureteral stenting, such as tandem ureteral stents, metallic ureteral stents or metal mesh ureteral stents have not yet shown clear benefits. In benign ureteral obstruction, prospective randomized studies have demonstrated comparable quality of life after PCN or ureteral stenting. The method of choice for urinary diversion is influenced by the recommendations, personal experience of the clinician and the availability of the method.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

The relationship between uterine leiomyomata and pelvic floor symptoms

INTRODUCTION AND HYPOTHESIS

To compare pelvic floor symptoms in women with a leiomyomatous uterus ≤12 weeks and those >12 weeks in size and to evaluate the resolution of these symptoms after surgical intervention.

METHODS

The PFDI-20, PFIQ-7 and 3-day voiding diaries were administered prospectively to all subjects. Demographics and questionnaire responses were compared using a t test, Chi-squared test or Mann-Whitney U test as indicated.

RESULTS

One hundred and forty-five women completed the questionnaires and were included for analysis. There were 58 women with uterine size ≤12 weeks (group I) and 87 women with size >12 weeks (group II). Participants in group I reported more straining to defecate (p = 0.042), while group II reported increased feeling of incomplete bladder emptying (p = 0.007) and difficulty emptying their bladder (p = 0.008). Review of ultrasound images revealed no difference in pelvic floor symptoms when stratified by leiomyoma location. At 1-year follow-up, 69 women (48 %) responded, and 40 (58 %) had undergone surgical intervention. Surgery was shown to improve symptoms for all questions reviewed at 1-year follow-up.

CONCLUSIONS

A leiomyomatous uterus >12 weeks is associated with the symptom of incomplete bladder emptying, but does not appear to have an effect on other pelvic floor symptoms compared with women with a smaller leiomyomatous uterus. Surgical intervention for leiomyomata improves pelvic floor symptoms.

Resolution of hydronephrosis after uterine artery embolization for fibroids

PURPOSE

To determine the prevalence, predisposing factors, and resolution of hydronephrosis among patients undergoing uterine artery embolization (UAE) for fibroids.

MATERIALS AND METHODS

From October 2004 to May 2008, 1,114 patients underwent UAE at an academic medical center. Hydronephrosis was found on angiographic images in 101 patients. In 34 of these patients, 3-month ultrasound follow-up was available. The angiographic images were graded for hydronephrosis severity by three interventional radiologist reviewers. The degree of residual hydronephrosis was obtained from ultrasound images or reports in 3-month follow-up imaging. Descriptive statistics summarizing outcomes and interobserver agreement regarding hydronephrosis grade were calculated. In a parallel assessment, prospectively gathered baseline data available from 776 patients undergoing UAE were analyzed to identify predisposing factors to hydronephrosis.

RESULTS

Among the 34 patients with hydronephrosis and appropriate follow-up, resolution occurred in 28 of 34 (82%) patients. Among the entire study group, 9.0% (101 of 1,114) of patients had unilateral or bilateral hydronephrosis. Hydronephrosis was less frequent in left kidneys (4.5% [35 of 776]) than right kidneys (6.3% [49 of 776]; P = .013). The mean uterine volume in the group with hydronephrosis was greater than in the group without hydronephrosis (1,041 cm(3) vs 609 cm(3); P < .0001), and the mean dominant fibroid volume was also greater (233 cm(3) vs 147 cm(3); P < .0001).

CONCLUSIONS

These results suggest that UAE may result in resolution of hydronephrosis in a notable number of cases. Large uterine size and dominant fibroid size was associated with hydronephrosis.