[Bradis anti-reflux ureterocysto-anastomosis in children with recurrent obstructive megaureter]

INTRODUCTION

Congenital ureterovesical junction (UVJ) obstructions quite rarely serve as an indication for ureteral reimplantation, and recurrent obstructions resulting from surgical treatment are even less frequent. Cases of acquired UVJ obstruction following endoscopy and ureteral reimplantation done for vesicoureteral reflux correction are fairly rare. The lack of known publications analyzing treatment of recurrent obstructive megaureter predetermines topicality of our research.

PURPOSE

Evaluate the efficiency and safety of extravesical anti-reflux uretero-cysto-anastomosis performed using Bradis technique for children with recurrent obstructive megaureter (OM).

MATERIALS AND METHODS

The work is based on the experience of surgical OM correction in 5 children aged 1 to 4 years, 4 boys and a girl with a recurrent UVJ obstruction following prior ureteral reimplantation for correction of UVJ obstruction (4 children) or vesicoureteral reflux (1 patient). Antenatal UVJ obstruction had been diagnosed in 2 patients. In all cases the examination included urine analysis, its culture study, ultrasonography of the kidneys and urinary tracts, dynamic renal scintigraphy, micturating cystography, and, where indicated, intravenous urography and SCT of the kidneys. All patients underwent Bradis extravesical reimplantation.

RESULTS

During postoperative care period, a considerable reduction of the dilatation of renal collecting system was accomplished in all five patients along with the differential renal function preserved on the pre-surgery level and a steady remission of urinary tract infection based on clinical manifestations and laboratory findings.

CONCLUSIONS

The simplicity of Bradis extravesical ureteral reimplantation represents its advantage over intravesical methods. Extravesical approach allows easy ureteral length and width correction. Limited experience of Bradis surgery in pediatric cases of recurrent OM requires confirmation with further randomized clinical trials.

[Renal abscess in children]

INTRODUCTION

Renal abscesses are relatively rare in children, but they can lead to prolonged hospital stay and life-threatening complications. Scrutiny of the literature over the past two decades indicates the absence of a unified tactic for the treatment of purulent-destructive forms of pyelonephritis in children, while more and more articles are appearing in terms of a low -key approach to the treatment of renal abscess in children.

MATERIALS AND METHODS

From 2005 to 2019, we treated 59 children with the renal abscess. Among the patients were 22 (37.3%) boys and 37 (62.3%) girls. The location of the abscess on the right was determined in 30 (50.8%) children, on the left, in 29 (49.2%). The average age of the patients was 109 months. The median size of kidney abscess among all patients was 29 [21; 42] mm (range from 12 to 69 mm).

RESULTS

The results of treatment were evaluated in the period from 3 months to 5 years. In 27 (45.8%) patients, conservative treatment gave a positive effect, while in 32 (54.2%) abscess puncture was performed under ultrasound guidance. The median hospitalization in patients after an abscess puncture was 15 [14; 18] days, against 13 [9; 17] days for children receiving only antibiotic therapy. The duration of hospital stay was significantly longer in the group of patients who underwent puncture (p=0.019). The effectiveness of conservative therapy was a lot lower in patients with a kidney abscess of more than 3 cm, 60% versus 31% (p=0.026). All 59 patients recovered completely, and none of them required an open surgery to drain a suppurative focus of a kidney or nephrectomy.

CONCLUSION

Conclusion. Our experience confirms the literature data, indicating the need to use a conservative approach to the treatment of patients with the renal abscess as a first-line therapy. Identification of an abscess with a diameter of more than 3 cm in patients considerably increases the likelihood of using an abscess puncture with the absence of the efficacy of a conservative approach.

[Comparison of functional magnetic resonance urography and dynamic renal scintigraphy in the functional assessment of ureteropelvic junction obstruction in children]

PURPOSE

In order to determine the role and significance of functional magnetic resonance urography (fMRU) in the diagnosis of ureteropelvic junction obstruction (UPJO), a comparative analysis of the results of fMRU and dynamic renal scintigraphy (DRS) was carried out.

MATERIALS AND METHODS

From January 2017 to December 2019, fMRU and diuretic DRS were performed in 36 patients (mean age 89+/-63 months). Boys - 26 (72.2%), girls - 10 (27.8%). Left-sided hydronephrosis was detected in 23 (63.9%) children, right-sided in 12 (33.3%) patients, and bilateral lesions in 1 (2.8%) patient (2 renal units (RU)). Antenatal hydronephrosis was detected in 9 (25%) patients, and postnatally in 27 (75%) patients. According to ultrasound data, grade II hydronephrosis occurred in 11 (29.8%) RU, grade III - in 21 RU (56.7%), and grade IV - in 5 RU (13.5%) according to the SFU classification. A diuretic test was performed in 26 patients.

RESULTS

Median and quartiles of differential renal function (DRF) according to fMRU data on the affected side were 37% [29; 43], and according to DRS - 46% [40;49]. When performing fMRU, a positive diuretic test was detected in 20 patients, 5 patients - negative and 1 patient - doubtful, and according to the DRS data, 12 patients had a positive test, 10 patients - negative and 4 patients - doubtful. Differences in DRF between fMRU and DRS varied between 0.7-33%. The average value of differences in DRF on the affected side was 11.3+/-8.5%. When comparing the results of DRF on the affected side, a moderate correlation was found on the Cheddock scale (r=0.59, p<0.05) between fMRU and DRS data. In comparison of the DRF using the Wilcoxon test, statistically significant differences were revealed (p<0,05).

SUMMARY

Our experience demonstrates the high potential of fMRU in terms of replacing the classical methods of diagnosis of UPJO in children, taking into account the high correlation coefficients between the results of fMRU and DRS. Standardization of the fMRU protocol will increase the diagnostic relevance of information and in the future will make fMRU the only necessary study to determine management tactics for patients with UPJO.

[New coronavirus infection (COVID-19) associated with kidney infarction in a seventeen-year-old child]

In December 2019, a new SARS-CoV-2 virus, called COVID-19, was identified in the Wuhan province of China, the spread of which determined the development of a pandemic. The lack of publications with evidence-based clinical studies dictate the necessity to cover various, including rare, pathological effects of the virus on the human body and the subsequent effect on it. Nowadays, there is already evidence that the SARS-CoV-2 virus causes specific damage to the vessels (endothelium), myocardium, and kidneys. The pathophysiologic mechanisms leading to acute kidney injury during COVID-19 infection are unclear, but may be due to direct exposure of the kidney tubules and endothelial cells to the virus. We present a clinical case of a kidney infarction in a 17-year-old girl with a severe course of a new coronavirus infection. At the time of the description of this clinical case, there are no publications on COVID-19 associated with kidney infarction in children in the Russian and foreign literature which is available to us.

[The results of treatment of newborns with postrenal anuria due to upper urinary tract obstruction, caused by fungal bezoar]

AIM

To evaluate the results of different methods of urine derivation in patients with postrenal anuria due to upper urinary tract (UUT) obstruction, caused by fungal bezoar.

MATERIALS AND METHODS

The results of treatment of postrenal anuria in 8 patients without congenital obstructive anomalies of UUT in 5 clinics from 2004 to 2018 were analyzed. All patients from the birth received continuously two or more antibiotics for diseases not related to kidneys and the urinary tract. Median of gestational age was 32 weeks [31.5; 38.5]. There were 4 boys (50%), and 4 girls (50%). The duration of anuria at the time of hospitalization was 2 days [1.5; 5]. Creatinine level at admission was 218 mol/l [164.5; 392.5] and urea was 17.9 mmol/l [13.2; 24.95]. In all cases, candida albicans was revealed in urine. Postoperative complications were graded according to the Clavien-Dindo classification.

RESULTS

All patients received systemic antifungal therapy; UUT drainage was performed in 7 (87.5%) cases. Ureteral catheter was placed bilaterally in 2 (28.6%) patients (4 renal units). There were 5 complications (Clavien-Dindo grade IIIb). Bilateral percutaneous nephrostomy was performed in 3 (42.8%) patients (6 renal units), and there were 2 complications (Clavien-Dindo grade IIIb and V). Open pyelostomy was performed in 2 (28.6%) patients (one bilateral, one on the right side; a total of 3 renal units). There was only one complication of Clavien-Dindo grade V. The average number of surgical procedures required to alleviate UUT obstruction per one renal unit was as following: 2.25 for ureteral catheterization; 1.17 for percutaneous nephrostomy; 1 for open pyelostomy. Regardless of the drainage method, diuresis tended to be normalized and azotemia decreased during the first postoperative day. In one case, the obstruction was eliminated by antifungal therapy without drainage of UUT. Mortality rate was 25% (n = 2).

CONCLUSION

Ureteral catheterization is a minimally invasive, safe method for decompression of UUT obstruction, caused by fungal bezoar, which is non-inferior to nephrostomy tube or open pyelostomy. Ureteral catheterization can be used as a primary method of urine derivation in children with UUT obstruction caused by candida bezoar.

[Paternity rates among men who have not undergone varicocelectomy in childhood or adolescence]

INTRODUCTION

Feasibility of prophylactic varicocelectomy in adolescents is under discussion, which determines the importance of studying the frequency of paternity among men who were actively monitored.

AIM

to evaluate a paternity rate in a group of adult men who have not undergone varicocelectomy in childhood or adolescence.

MATERIALS AND METHODS

The paternity rate was evaluated using a questionnaire-based survey carried out in 2018 among men who were actively monitored for unilateral varicocele with ipsilateral testicular hypotrophy during adolescence in 1999-2004. A total of 202 questionnaires were sent out checking whether the recipients were willing to have children. Median age at the time of the varicocele diagnosis was 15 years [Q1; Q3] (13-17). At the time of diagnosis, varicocele of grade III was found in 114 (93.4%) boys, and in 8 (6.6%) children, varicocele of grade II was seen.

RESULTS

A total of 142 respondents were enrolled. Median age of the participants was 31 (29; 34). 20 men were excluded from the survey, due to prophylactic varicocelectomy (n=8, 5.6%), other reproductive diseases (n=4, 2.8%), previous radiotherapy or chemotherapy (n=2, 1.4%) and reproductive pathologies in the spouses (n=6, 4.2%). 16 (13.1%) participants were not planning to have children. Among the remaining, 9 respondents (6.6%) had no children. Varicocelectomy was carried out in 17 (16.3%) patients due to infertility, and 14 (82.3%) subsequently became fathers. 83 (78.3%) patients had one or more children as a result of spontaneous pregnancy. Paternity frequency in the surveyed group was 91.5%.

CONCLUSION

Our results demonstrate high paternity frequency among men with asymptomatic left-sided varicocele accompanied by ipsilateral testicular hypotrophy during childhood and adolescence who were actively monitored without surgical treatment.

[Disorders of sexual differentiation in children: a critical look at open questions (part II)]

Surgical management of children with disorders of sexual differentiation (DSD) is one of the most difficult problems in pediatric urology. In the second part of the article we continue to discuss the controversies concerning the surgical management of patients with the classical form of congenital adrenal hyperplasia and 46, XX karyotype - feminizing genitoplasty and its different types.

[Disorders of sexual differentiation in children: a critical look at open questions (part I)]

Management of children with disorders of sexual differentiation (DSD) continues to cause questions and receive criticism. This review discusses some contradictions concerning the newly proposed terminology, nomenclature, and classification. Congenital adrenal hyperplasia (CAH) is the most common cause of DSD, and its management also remains controversial. Therefore, in this part of the article, we critically analyze available literature on gender identity, the need and timing of surgery in children with DSD and 46, XX karyotype.

[Uretero-ureteral anastomosis (ureteropyeloanasto-mosis) for the duplicated upper urinary tract in children]

INTRODUCTION

The duplex kidney is one of the most common congenital abnormalities of the urinary tract, and various surgical procedures exist for the management of this condition. Depending on the surgeon preferences, patients with duplex kidney may undergo heminephrectomy with ureterectomy using open or laparoscopic approach, uretero-cysto-anastomosis of the ectopic ureter or two ureters in a single block. Recently, there have been reports of inter-ureter anastomoses. Here we report our multicenter experience in open and laparoscopic uretero-ureteral anastomosis (UUA). The study aimed to improve the treatment results in children with urodynamic dysfunction due to the duplicated upper urinary tract.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 64 children treated from 2007 to 2017. There were 22 (32.8%) boys and 43 (67.2%) girls with mean age 40.2 months at the time of surgery. All of them had duplex kidneys, including 27 (42.2%) right-sided and 37 (57.8%) left-sided. Of them, 15 (23.4%) children underwent distal UUA (DUAA), and 49 (76.6%) had proximal UUA (PUUA).

RESULTS

After surgery, acute pyelonephritis occurred in three patients. In the early postoperative period, a prolonged urinary leakage from surgical site drainage was observed in three (6.1%) patients after laparoscopic PUUA. One (4.2%) child developed a stumpitis. Thus, complications occurred in 7 (10.9%) children; one of them (1.6%) needed additional treatment.

CONCLUSION

Distal and proximal UUA is a safe and effective surgical treatment for urinary outflow disorders in patients with the duplicated upper urinary tract, minimizing the risk of the duplex kidney dysfunction.

[The volume of the contralateral testis in unilateral non-palpable cryptorchidism a diagnostic criterion to optimize surgical strategy]

AIM

Given the need to reduce the number of unnecessary laparoscopies, this study aimed to calculate the threshold values of contralateral testicular volume in unilateral non-palpable cryptorchidism to optimize diagnosis and surgical strategy.

MATERIALS AND METHODS

From 2010 to 2016, contralateral testicular volume was prospectively evaluated in 78 patients aged under nine years with unilateral non-palpable cryptorchidism. The volume of healthy testes was calculated by multiplying length * width * height * 0.71. The patients were divided into two groups. Group 1 comprised 41 (52.6%) children with inguinal or intra-abdominal testes, who underwent orchiopexy for undescended testis. The second group consisted of 37 (47.4%) patients with severely hypoplastic testes that needed to be removed, or with testicular aplasia. In both groups, we matched the age (in months) at the time of surgery and the volume of the contralateral testis. Logistic regression was used to develop the diagnostic model. For the model, the ROC-curve (Receiver Operating Characteristic) was constructed, and the threshold of the contralateral testicular volume was selected.

RESULTS

All patients with contralateral testicular volume greater than 2.25 ml had testicular aplasia, or hypoplasia (sensitivity 100.0%, specificity 73.0%). All patients with a contralateral testicular volume less than or equal to 1.04 ml had inguinal or intra-abdominal testes (specificity of 100%, the sensitivity of 34%). The area under the ROC curve calculated to assess the quality of the model was 92.6%, suggesting the high predictive power of the model.

CONCLUSION

Revision scrototomy is indicated in patients with testicular volume exceeding 2.26 ml, while diagnostic laparoscopy is the optimal primary intervention in patients with the contralateral testicular volume of less than or equal to 1.04 ml.

[Experience of 157 vesikoscopic operations in children]

AIM

Recent advances in the field of minimally invasive surgical technologies in children and adolescents have led to the development of vesicoscopic (transvesical, pneumoscopic) access (VA). Current limitations in using VA emphasize the need for further studies investigating surgical options for the management of various pathological conditions of the bladder and ureterovesical junction, the features of surgical techniques and the course of the early postoperative period when used in pediatric urological practice.

MATERIALS AND METHODS

From 2013 to 2017, 157 patients (79 girls and 78 boys) aged between 2 months and 18 years (mean age 4.9-8.7 years) underwent surgery using VD. Unilateral and bilateral vesicoscopic ureterocystoneoimplantation was performed in 110 (70%) and 44 (28%) patients, respectively. A total of 198 ureters was implanted. Three (1.9%) children underwent vesicoscopic excision of the bladder diverticulum. Transvesicoscopic Cohen ureteric reimplantation, pneumovesical Glenn-Anderson procedure, and Chumakov ureterocystoneoimplantation were performed in 151 (96.1%), 2 (1.3%) and 1 (0.6%) patients, respectively.

RESULTS

The mean operative time when using VA was 126.8+/-46.7 min. In patients younger than one year, 1-3 years, 4-17 years, it was 136.0+/-43.8 min, 130.1+/-43.5 min and 122.4+/-65.8 min, respectively. The mean length of postoperative hospital stay was 6.2+/-2.3 days. In 3 (1.9%) cases we had to convert to open surgery. Gas migration into the abdominal cavity occurred in 6 (3.8%) patients. Fourteen (9%) patients had early postoperative complications. Transient obstruction of ureterovesical junction occurred in 6 (3.8%) patients. Acute complete obstruction of the distal ureter developed in 3 (1.9%) patients aged three months who did not undergo drainage of the upper urinary tract intraoperatively. A paravesical urine leak occurred in 1 (0.6%) patient. In one (0.6%) of the boys, the distal end of the urinary drainage inserted through the trocar into the ureter migrated in the bladder. The urine leakage from the trocar puncture occurred once (0.6%) and was stopped by indwelling urethral catheterization for seven days. In 2 (1.3%) patients, exacerbation of pyelonephritis required a modification in antibacterial therapy.

DISCUSSION

Despite the accumulated experience, vesicoscopic surgery remains a laborious and complicated surgical intervention, requiring long learning curves even for surgeons who have good manual skills in laparoscopic surgery.

CONCLUSION

In our opinion, vesicoscopic access allows the entire range of surgical interventions on the vesicoureteral junction and bladder in children to be performed. It is effective, significantly less traumatic than traditional open cystotomy access, and associated with an excellent cosmetic result.

[Laparoscopic heminephrureterectomy for duplex kidney in children]

INTRODUCTION

Duplication of the upper urinary tract is one of the most common congenital urological anomalies. In patients with critically decreased or lost function of one of the renal segments, heminephrureterectomy is usually the treatment of choice. Until recently, this was an open surgery; in cases of complete removal of the ureter, an additional incision in the iliac region was required. Currently, heminephrureterectomy is increasingly performed laparoscopically. We report the experience in laparoscopic heminephrureterectomy (LHNUE) in 10 clinics in Russia and Belarus. Some of them have already used this technique for 10 years.

AIM

The study aimed to to improve the treatment results in children with urodynamic dysfunction due to duplicated upper urinary tract.

MATERIALS AND METHODS

We retrospectively analyzed medical records of 111 children treated from 2007 to 2016. There were 26 (23.4%) boys and 85 (76.6%) girls with mean age 44.6 months (from 2 to 170) at the time of surgery. All children included in the study had complete duplex kidneys, including 51 (45.9%) right-sided and 60 (54.1%) left-sided. All the children underwent LHNUE for a critical decrease or absence of function of the upper or lower segment of the duplex kidney caused by the following pathology: obstruction of the ureterovesical junction with the development of the megaureter of the upper ureteral segment in 57 (51.4%) patients; ureterocele in 28 (25.2%); extra-vesical ectopic ureter with urinary incontinence in 10 (9.0%) girls; high-grade UVR in 16 (14.4%) patients.

RESULTS

There were no conversions in this series of patients. The mean operative time was 135 minutes (60-240 min.). All children included in the study were followed for 1 to 9 years after surgery. Complications occurred in 17 (15.3%) patients, of whom 12 (10.8%) required repeat surgery. In one patient with the loss of lower pole function, the treatment result was considered unsatisfactory.

CONCLUSION

LHNUE for duplex kidney is performed by a few clinics and is still at the stage of development and accumulation of experience. Nevertheless, LHNUE, though an effective treatment modality, carries the risk of reducing or losing the function of the retained segment.

[VARICOCELECTOMY IN ADOLESCENTS: WHO AND WHEN TO OPERATE]

In studying the problem of varicocele in children and adolescents, there was a consistency of objectives chosen by researchers both today and half a century ago. Nearly all researchers start with phrases about the absence of reliable evidence of a direct negative impact of varicocele on male reproductive function, but yet they express confidence in the need for prophylactic varicocelectomy in children and adolescents in some cases. This demonstrates the necessity of prognostic indicators that could be used for selection of adolescents requiring surgery in circumstances of the limited feasibility of investigating the reproductive function.

[Characteristics of hydronephrosis due to obstruction of the pyeloureteral segment combined with dorsal rotation of the kidney]

Rotation of the kidney is caused by its dystopia and abnormal blood circulation. Dorsal rotation of the kidney in normal position is a rare anomaly. We studied a clinical course, evidence obtained at renosonography, excretory urography, computed tomography, radionuclide investigation, anatomic variants of pyeloureteral segment obstruction in female patients with right-side hydronephrosis in the presence of dorsal rotation of the kidney before and after pyeloplasty. We made pyeloplasty for obstruction of the pyeloureteral segment in 266 patients in 2001-2009. Hydronephrosis was accompanied with dorsal rotation of the kidney in 21 (7.9%) cases. Surgical approaches to the pelviureteral segment are characterized. The dorsal approach is a good alternative to standard subcostal approach, provides good visualization in creation of anastomosis, significantly reduces distance from the skin cut to pyeloureteral segment and offers the best cosmetic result. In subcostal approach mobilization of the pelvis and pyeloureteral segment is preferable on the posterior surface of the kidney. A laparoscopic transperitoneal approach is not justified as it implies wide mobilization of the kidney, the anastomosis is created in extremely limited space.

[Microbial contamination of penile tissues as a risk factor for complications in the treatment of hypospadia]

Biopsy of the skin, fascia and urethra was performed in 29 cases of urethroplasty for hypospadia in children and adults. The patients were divided into two groups: group 1 (n=14) with primary plastic urethra and group 2 (n=15) with secondary urethroplasty of hypospadia with complication. Tissue samples were examined microbiologically and morphologically. Focal infection of penile skin was found after iodopiron sterilization as well as contamination of the skin, fascia and urethra in all the patients of group 2. Nonclostridial anaerobes dominated among the bacteria. Microbiological investigations in groups 1 and 2 proved a great role of Bacteriodes fragilic in the development of penile tissue inflammation.

[Classification of urethroplasty complications in hypospadias]

The article presents the data on surgical treatment of 126 patients with hypospadias (a total of 343 operations). This experience gave rise to classification of complicated forms of hypospadias proposed by the authors.

[Transposition of the "conflict" vessel in obstruction of the pyeloureteral segment in children]

We studied effectiveness of the "conflict" vessel transposition in operations for hydronephrosis due to a vasoureteral conflict in children. For 1999-2007 we operated 323 children with unilateral hydronephrosis in obstruction of the pyeloureteral segment (PUS). The "conflict" vessels (CV) as a cause of the obstruction were detected in 67 patients who were divided into two groups. In group 1 (n = 33; 49.3%) we made PUS resection and created antevasal pyeloureteroanastomosis. In group 2 (n = 34; 50.7%) we made CV transposition using a graft from adventitium of the anterior pelvic wall. The degree of postoperative reduction of the calycopelvic system was the same in both groups, but in group 2 dilation decreased more rapidly and reached maximum in the first postoperative month. Simplicity of CV transposition as a method of hydronephrosis surgical treatment, its high effectiveness allow us to recommend this method for study in randomized prospective trials.

[Original experience in plastic surgery of pelviureteral segment in hydronephrosis in children]

The study of postoperative urodynamics of the upper urinary tract was made in 339 patients with obstruction of the pyeloureteral segment and on experimental animals (morphological tests). This study revealed factors deteriorating functional capacity of anastomosis in early postoperative period. The findings allow the surgeons to update the technique of the pyeloureteral segment resection and uretero-pyeloanastomosis, to determine indications for applying nonsteroid anti-inflammatory drugs in the postoperative period, to reveal advantages and establish indications for drainage-free pyeloplasty. Thus, use of drainage-free modified technique of pyeloplasty in certain indications is a safe and less traumatic method of the patients' management which increases efficacy of Anderson-Hines operation.