Primary lower urinary tract reconstruction for nonfunctioning renal moieties associated with obstructing ureteroceles
ABSTRACT 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.
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ABSTRACT: Objective: Although ureteroureterostomy (UU) is an established procedure for the treatment of duplex anomalies, there may be a reluctance to apply this approach to patients with poor upper pole function and/or marked degrees of ureteral dilation. 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. Results: A total of 41 patients (43 renal units) were identified. There were 35 females and six males with an average age at surgery of 2.3 years (range 55 days to 15.9 years) and an average follow up of 2.8 years. Diagnosis included ureterocele (17), ectopic duplex ureter (25) and ureteral triplication (1). Thirty-six patients underwent UU only and five underwent UU with simultaneous lower pole reimplantation. Twelve of the 41 patients (29%) underwent laparoscopic repair. Twelve of the 43 renal units (28%) required ureteral tapering, of which three were performed laparoscopically. Preoperative median upper pole function was 17% (0-35%). Six patients had no measurable function and ten had < 15%. No patient developed lower pole hydronephrosis in the follow-up period. There were two complications: one patient was found to have a post-operative ureterovesical junction (UVJ) stricture and the second had an anastomotic stricture. Conclusion: Ureteroureterostomy is a safe and effective technique for the reconstruction of duplex anomalies, even with a massively dilated and poorly functioning upper pole moiety.Journal of Pediatric Urology 08/2014; 10(4). DOI:10.1016/j.jpurol.2014.05.003 · 1.41 Impact Factor
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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-UreteroceleMonatsschrift Kinderheilkunde 12/2010; 158(12):1231-1240. DOI:10.1007/s00112-010-2248-7 · 0.28 Impact Factor
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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