Upper pole heminephrectomy is the conventional treatment for severely compromised nonfunctioning renal units associated with ureteroceles due to the potential morbidity of leaving a nonfunctioning renal moiety in place. This approach often fails to address the pathological anatomical defect present at the bladder level, and during long-term followup the majority of patients require subsequent lower tract surgery due to persistent ureterocele, new or persistent vesicoureteral reflux, or recurrent infections. We determined the success of primary lower urinary tract reconstruction for nonfunctioning renal moieties and the morbidity associated with leaving nonfunctioning renal units in situ.
We present the collective experience of 2 institutions using definitive lower urinary tract reconstruction without upper tract ablative surgery in 16 patients with duplex collecting systems and an associated nonfunctioning renal moiety due to obstructing ureteroceles.
At a mean followup of 62 months upper tract dilatation was decreased or completely resolved in all patients, no loss of renal function was present and 15 of 16 patients (94%) had no evidence of persistent reflux. Postoperative complications in the form of a urinary tract infection occurred in 2 of 16 patients (13%). No patient was febrile. No patient had development of hypertension, proteinuria or tumor during followup.
We believe that primary, single stage, lower urinary tract reconstruction in children with severely compromised or nonfunctioning renal moieties damaged by ureteroceles is superior to upper urinary tract ablative surgery, successfully correcting the obstructive or refluxing pathology with minimal morbidity and risk during long-term followup.
"Even in patients where function was not identified on DMSA scan (15%), upper pole sparing UU was performed due to the simplicity of the procedure and the belief that there is less risk to the lower pole healthy moiety in trained hands. Prior studies have also shown a high need for reoperation in 50e84% of cases after upper pole heminephrectomy for duplex anomalies , which was not seen in the present study's UU experience. In fact, only one complication requiring major re-operation was encoutered after an anastomotic obstruction was identified in a poorly functioning upper pole segment. "
[Show abstract][Hide abstract] ABSTRACT: Methods An institutional review board (IRB)-approved retrospective analysis of all patients undergoing UU between 2006 and present was performed. All patients underwent an end-to-side anastomosis with a double-J stent left in the lower pole ureter. Laparoscopic repairs were done 'high' and open repairs were done 'low'. If the upper pole ureter remained massively dilated after transection, the ureter was partially closed to reduce the length of the anastomosis. Data collected included demographics, diagnosis, surgical interventions, imaging studies and outcomes.
[Show abstract][Hide abstract] ABSTRACT: Dilatative kongenitale Harntraktanomalien werden heute vielerorts bereits intrauterin oder im Rahmen eines neonatalen Screenings
erkannt. Am häufigsten sind ureteropelvine Stenosen (UPS), gefolgt von primären Megaureteren (pMU), Ureterozele, Ureterektopie
und Urethralklappen. Während der Nachweis von Urethralklappen unmittelbare therapeutische Konsequenzen hat, setzt die Operationsentscheidung
bei UPS oder pMU die Diagnose einer korrekturbedürftigen Obstruktion voraus. Zu den Beurteilungskriterien gehören dabei der
Grad der Nierenbeckenkelchdilatation, der Nuklidabfluss im Diureseszintigramm und die seitengetrennte Nierenfunktion mit ihrer
jeweiligen zeitlichen Dynamik bei Verlaufskontrollen. Die Therapieentscheidung sollte interdisziplinär getroffen werden. Es
ist zu hoffen, dass sie in Zukunft durch den Einsatz der dynamischen Magnetresonanztomographie, durch die Entwicklung von
Biomarkern („proteomics“) und durch die Ergebnisse neuer Therapiestudien erleichtert werden wird.
In many places, dilating connatal uropathies are detected by prenatal or neonatal sonographic screening, most often presenting
as ureteropelvic junction obstruction (UPJO), followed by primary megaureter (pMU), ureterocele, ureteral ectopia and urethral
valves. Whereas urethral valves require immediate intervention, the diagnosis of an obstruction in need of correction is a
prerequisite for surgical procedures in UPJO and pMU. Grade of pelvicaliceal dilatation, outflow of the isotope in the diuretic
scintigram and split renal function at the time of diagnosis as well as at follow-up investigations are the main evaluation
criteria for interdisciplinary therapeutic decisions. Hopefully, the introduction of dynamic MRI, the development of biomarkers
(“proteomics”) and the results of current prospective studies will facilitate decisions in the near future.
SchlüsselwörterObstruktive Uropathie-Megaureter-Ureteropelvine Stenose-Urethralklappen-Ureterozele
KeywordsUreteral obstruction-Urethral obstruction-Ureteropelvic junction obstruction-Urethral valves-Ureterocele
[Show abstract][Hide abstract] ABSTRACT: The diagnosis, evaluation and management of antenatal hydronephrosis has undergone a two stage paradigm shift since the advent of prenatal ultrasonography in the early 1980s. Initially the identification of a large number of asymptomatic infants appeared to afford the surgeon the opportunity for preemptive intervention. However, it has now become apparent that antenatal hydronephrosis (AH) is far more difficult to interpret than originally perceived. The initial enthusiasm for surgery has now been replaced by a much more conservative approach to ureteropelvic junction(UPJ) obstruction, multi-cystic dysplastic kidney(MCDK), vesicoureteral reflux and the non-refluxing megaureter. This review will highlight the postnatal evaluation of AH and include an overview of the Society for Fetal Urology grading system for hydronephrosis. The differential diagnosis and treatment options for UPJ obstruction, vesicoureteral reflux, MCDK, duplication anomalies, megaureter, and posterior urethral valves will be discussed.
The Scientific World Journal 02/2006; 6:2345-65. DOI:10.1100/tsw.2006.366 · 1.73 Impact Factor
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