RESUMEN
BACKGROUND: Most primary non-refluxing megaureters resolve spontaneously and the indications for surgery are not sufficiently well established. OBJECTIVES: To analyze the clinical features, treatment and outcome of asymptomatic primary non-refluxing megaureter. PATIENTS AND METHODS: We retrospectively studied 58 infants with primary non-refluxing megaureter. The diagnostic methods used were renal ultrasound, renal isotopic renogram, DMSA scan, and evaluation of renal function. RESULTS: The mean age at postnatal diagnosis was 24 days. The mean follow-up was 4 years. Sixty-nine percent of the patients were male. Fifty-seven percent were left megaureters and 22% were bilateral (71 affected renal units). Eleven percent of megaureters were grade I, 48% were grade II, and 41% were grade III. Only nine patients (15%) received surgical treatment. The indications for surgical treatment were severe megaureter (3/9 patients; 33%), prolonged T1/2 (3/9 patients; 33%), reduced function (1/9 patients; 11%), prolonged T1/2 plus reduced function (1/9 patients; 11%) and increased dilation (1/9 patients; 11%). The mean age at surgery was 7 months. Outcomes in the non-surgical group (85% of the patients; 60 renal units) were as follows: 90% of megaureters were corrected or improved on ultrasound scan and 10% showed no change. In the first renogram, function was low in 4/60 kidneys (7%) and T1/2 was prolonged in 3/60 (5%). Finally, all kidneys in the non-surgical group had normal function, except one, which was injured from the beginning. T1/2 was normal in all kidneys. Outcomes in the surgical group (10 megaureters) were as follows: 80% of megaureters were corrected or improved after surgical intervention and 20% showed no change. At diagnosis, 4/10 kidneys (40%) had reduced function. In the post-surgical renogram 2/10 kidneys (20%) continued to show reduced function, 1/10 kidney (10%) showed restored renal function, and 1/10 kidney (10%) was nephrectomized. Initial T1/2 was prolonged in 4/10 patients (40%), and after surgery T1/2 was normal in all patients. The final DMSA scan showed 5/71 kidneys (7%) with irreversible damage (one slightly injured, two moderately injured, and three severely injured). The remaining 66 kidneys were normal. Overall renal function and blood pressure were normal in all patients. CONCLUSIONS: Primary non-refluxing megaureter is usually a functional and benign congenital malformation that resolves during the first months of life. Although the malformation can persist, only a few patients require surgical treatment. Most authors agree that initial treatment should not be surgical and that surgery should be reserved for patients who develop ureteral dilation, a decrease in differential renal function, and/or severe symptoms during follow-up. In a few patients (7% of our series), the renal unit belonging to the megaureter shows irreversible congenital injury. In these patients, surgery is not useful.
Asunto(s)
Ultrasonografía Prenatal , Uréter/anomalías , Niño , Preescolar , Interpretación Estadística de Datos , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Pruebas de Función Renal , Masculino , Renografía por Radioisótopo , Radiofármacos , Estudios Retrospectivos , Ácido Dimercaptosuccínico de Tecnecio Tc 99m , Factores de Tiempo , Uréter/diagnóstico por imagen , Uréter/cirugía , Obstrucción Ureteral/diagnósticoRESUMEN
INTRODUCTION: Currently, consensus is lacking on the indications for surgery in primary congenital unilateral hydronephrosis. OBJECTIVES: To analyze the clinical characteristics, treatment and outcome of severe asymptomatic primary congenital unilateral hydronephrosis (grades 3 and 4). PATIENTS AND METHODS: We performed a retrospective study of 98 neonates with severe primary congenital unilateral hydronephrosis. Diagnostic techniques consisted of ultrasound, renogram, and DMSA scan. RESULTS: The mean age at diagnosis was 24 days. The mean length of follow-up was 4 years. Forty-eight percent of cases were grade 3 and the remaining cases were grade 4. Fifty-six percent of the patients received conservative treatment. Forty-four percent underwent surgery. Surgical indications consisted of prolonged T1/2, reduced differential renal function and/or very severe hydronephrosis. The mean age at surgery was 5.5 months. In 94 % of the patients who received conservative treatment, hydronephrosis resolved spontaneously. In this group, renal parenchyma and renal function were normal in all patients except two. In 97 % of the patients who received surgical treatment, hydronephrosis was corrected or improved after pyeloplasty. At diagnosis, 19 kidneys had reduced function. In the postsurgical renogram, although T1/2 had markedly improved, 8 kidneys showed reduced function. DMSA performed in 63 patients belonging to both groups, outside the active phase of hydronephrosis, revealed 8 atrophic kidneys, 4 with moderately reduced renal size and function and 4 with scarring and normal renal size and function. During the study period, overall function was maintained in all patients and none developed hypertension. CONCLUSIONS: Severe congenital unilateral hydronephrosis resolves spontaneously in most patients. Consequently, clinicians increasingly adopt a conservative approach. The available diagnostic techniques cannot identify patients who will benefit from pyeloplasty. In general, accepted surgical indications are an increase in hydronephrosis and/or worsening of renal function. In our series, 15 % of the patients with hydronephrosis had an irreversible lesion of variable severity, which in some patients seemed to have developed during embryogenesis. Kidneys at risk of presenting a lesion were those that had grade 4 hydronephrosis.
Asunto(s)
Hidronefrosis/congénito , Preescolar , Femenino , Humanos , Hidronefrosis/cirugía , Lactante , Recién Nacido , Masculino , Remisión Espontánea , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
After experimental verification of an excellent correlation between volume measurements by water displacement and echography we have checked that there were no differences among several renal measurements performed in children by the same person. In our normal population of 313 children we assumed that the best correlation between somatometric and renal measurements parameter was between weight and renal volume. We have developed volumetric growth charts for both kidneys. There were no significant difference between right and left kidney.