RESUMEN

The kidney is frequently injured in blunt abdominal trauma, accounting for 10 % of such cases and being the most commonly affected genitourinary organ in all traumas. Pelviureteric junction obstruction (PUJO) is typically a congenital and asymptomatic anatomical dilatation to the renal pelvis. This article reports on a 21-year-old male who ruptured a congenital PUJO following blunt abdominal trauma. He was managed with a retrograde ureteric stent and a staged pyeloplasty. This case highlights a rare case of urogenital injury due to blunt trauma and explores the impact of congenital anomalies can contribute to injury and lead to significant complications.

RESUMEN

Intraabdominal cystic lesions diagnosed during antenatal period are uncommon. They are found to have varying origins, with renal tract being the most common site. Rarely, a large unilateral cystic lesion of renal origin is caused by Pelviureteric junction obstruction, crossing the midline, leading to compression of the contralateral kidney. We present a case of a neonate who was diagnosed with a large abdominal cyst in the antenatal period. The cyst persisted and crossed the midline causing hydronephrosis on the contralateral side. This is an unusual presentation of a commonly occurring condition, usually such large cyst at birth origins from alimentary tract rather renal system. It is important to understand unusual presentations of intraabdominal lesions and the associated pathology. It is mandatory to rule out renal obstruction, if there is any decompression of renal function, it is mandatory to save renal function till the time of definitive surgery.

RESUMEN

CLINICAL PROBLEM: Congenital anomalies of the kidney and urinary tract (CAKUT) are very common findings in fetal diagnostics. Their effects range from variants without pathological significance to pronounced functional impairment with the need for renal replacement therapy in childhood. Sometimes the genital organs are also affected. The aim of the article is to provide an overview of embryology and examples of key findings. IMAGING PROCEDURES: In the fetal period, magnetic resonance imaging (MRI) is used, while postnatally, sonography with the option of contrast-enhanced micturition urosonography (MUS, ceVUS) dominates imaging in pediatric radiology, supplemented in individual cases by fluoroscopy (micturition cysturethrography) and MRI. Quantitative methods for assessing kidney function and excretion (MAG3 scintigraphy, functional MR urography) are essential when planning further therapeutic procedures, especially in obstructive uropathies. CONCLUSION: Imaging plays an essential role in the assessment of abnormalities of the kidneys and urinary tract both pre- and postnatally. Knowledge of embryology facilitates anatomical understanding and assessment of pathologies.

Asunto(s)

RESUMEN

Background: Pelviureteric junction obstruction (PUJO) is a common urological disorder that can present at any stage of life. The underlying etiology in children has been well studied; however, a gap exists in the literature for the adult population. Herein, we performed a systematic review of the literature to evaluate the current evidence on the underlying etiologies of adult patients presenting with PUJO. Materials and methods: Four electronic databases were searched for relevant studies assessing the underlying etiologies of pelviureteric junction obstruction in adults. Studies were assessed for eligibility based on predefined inclusion and exclusion criteria, and a critical appraisal of methodological quality and risk of bias was performed. Finally, qualitative and quantitative data analyses were performed. Results: Twelve studies comprising a total of 513 patients with radiologically confirmed PUJO met the inclusion criteria and were included in our analysis. The most common finding was crossing vessels, which were observed in 50.5% of patients, followed by intrinsic ureteral stenosis (27.1%), adhesions (15.3%), and high insertion of the ureter (10.1%). Conclusions: The underlying etiologies of PUJO in adults remain unclear. This study indicated that obstruction secondary to crossing vessels is the most common cause of obstruction in adults and occurs more frequently than in the pediatric population.

RESUMEN

INTRODUCTION: The medullary pyramid compresses during the early phases of severe hydronephrosis and represents a promising ultrasound metric for the diagnosis and surveillance of PUJ obstruction. The aim of this study was to define the optimal cut-off value and utility of medullary pyramid thickness (MPT) associated with the need for pyeloplasty in infants being followed up for hydronephrosis. METHODS: A retrospective review was performed over a five-year period to identify patients that were under surveillance for hydronephrosis during infancy and underwent a MAG3 to monitor the possible need for pyeloplasty. Ultrasound images were retrospectively reviewed to measure the MPT of the affected kidney in a blinded fashion. The primary outcome measure was subsequent requirement for pyeloplasty before three years of age. The Mann-Whitney U Test was used to determine statistically significant differences in the minimum MPT between the infant group requiring pyeloplasty and the non-operative group. Receiver operating characteristic analysis was performed to determine the optimal cut-off value associated with the requirement for pyeloplasty. RESULTS: A total of 63 patient cases were included, of which 45 underwent pyeloplasty (70%). A significant difference was found in the median MPT measurement between the pyeloplasty and non-operative groups (1.7 mm vs. 3.8 mm, p < 0.001). The optimal cut-off value of MPT associated with pyeloplasty was 3.4 mm. An MPT threshold of ≤3.4 mm conferred a sensitivity of 98%, specificity of 63%, positive predictive value of 86%, and negative predictive value of 92%. CONCLUSION: Thinning of the medullary pyramid is an important ultrasound sign of parenchymal deterioration in high-grade hydronephrosis. An optimal MPT cut-off value of ≤3.4 mm is associated with subsequent pyeloplasty in infants. MPT should be considered in future studies addressing the diagnosis and surveillance of PUJ obstruction.

Asunto(s)

RESUMEN

Pelviureteric junction obstruction, also known as ureteropelvic junction obstruction, is a congenital narrowing of the urinary excretory tract at the junction between the renal pelvis and the ureter and is a common cause of congenital pelvicalyceal dilatation. The outcome is variable, from spontaneous resolution to renal parenchymal function loss in cases of untreated high-grade obstruction. Abnormalities in renal ascent, rotation and vascularity can be associated with pelviureteric junction obstruction and easily overlooked radiologically. In this pictorial review, we explore the anatomical, radiological and surgical correlations of pelviureteric junction obstruction in the context of a normal kidney and a spectrum of renal abnormalities, including hyper-rotation (also known as renal malrotation), failed renal ascent, fusion anomalies and accessory crossing renal vessels. For each scenario, we provide technical tips on how to identify the altered anatomy at the first ultrasound assessment and correlation with scintigraphic, cross-sectional and postoperative imaging where appropriate. A detailed ultrasound protocol specifically to assess and characterise pelviureteric junction obstruction in paediatric patients is also offered.

Asunto(s)

RESUMEN

Bilateral ectopic pelvic kidney is an exceptional finding and it may be associated rarely with other abnormalities of the kidney such as uretero-pelvic junction syndrome. We report a case of bilateral ectopic pelvic kidney revealed by left flanc pain with a left uretero-pelvic junction syndrome and a right ureteral duplication proved by computed tomography. A MAG3 renal scintigraphy was performed confirming the obstructive uretero-pelvic junction. An open left Anderson-Hynes pyeloplasty was performed without objectifying, preoperatively, any extrinsic compression without any postoperative complication. This case emphasizes on the possibility of the reconstructive management in such cases.

RESUMEN

Introduction: The etiopathogenesis of pelviureteric junction obstruction (PUJO) has been debated. Recently, the role of interstitial cells of Cajal-like cells (ICC-LC)has been studied and reported to be the cause of this functional obstruction. We studied the histopathology and ICC-LC density at PUJ and compared it with that of PUJ of the control group and distal ureteric margin of the study group. Methods: A prospective study was conducted which included PUJO patients in the study group and the renal tumor patients in the control group. Histopathological examination (muscle hypertrophy and fibrosis) and immunohistochemistry (ICC-LC density) were done. The muscle hypertrophy, fibrosis, and ICC-LC density at the PUJ in both the groups were compared. A similar comparison was performed between the findings at the PUJ and the distal margin in the study group. Results: The study and control groups included 37 PUJO patients and 13 Wilms tumor patients. The ICC-LC density at PUJ in the study group was significantly lower than that in the control group (P < 0.001) and that at the distal resected margin of the study group (P < 0.001). Significantly increased muscle hypertrophy (P < 0.001) and fibrosis (P = 0.002) were seen at PUJ in the study group compared to the control group. No significant association was noted between the ICC-LC density and muscle hypertrophy at PUJ and the distal resected margin in the study group. Conclusion: A significant decrease in the density of ICC-LC and increased fibrosis and muscle hypertrophy at PUJ in children with PUJO play a role in the etiopathogenesis of the disease.

RESUMEN

Aims: Pelviureteric junction obstruction (PUJO) due to aberrant lower polar artery is conventionally managed with pyeloplasty. We present our experience of managing PUJO due to "vascular" anomalies-aberrant lower polar artery and vascular adhesions with simpler surgical options. Subjects and Methods: This is a protocol based, retrospective study of PUJO. Preoperative investigations included ultrasonography (USG) and diuretic renogram. An intraoperative methylene blue test (MBT) assessed transit across the Pelviureteric junction (PUJ) after release of vascular compression. Surgical management included adhesiolysis for vascular adhesions and pyelopyelostomy anterior to the aberrant polar artery. Postoperative studies were repeated after 3 and 6 months. Results: Fourteen of 144 PUJO (9.7%) were "vascular" obstructions. Those with vascular adhesions (six) were largely infants with antenatal hydronephrosis. Children with aberrant lower polar artery (eight) were older, had fleeting symptoms, minimally increased pelvic diameter and subtle impairment on diuretic renogram. Majority were term males with urinary tract infection. The MBT showed normal transit across the PUJ in all. Postoperatively, there was progressive improvement on USG and diuretic renogram after 3 and 6 months. None had any complication or redosurgeries. At a mean follow-up of 41.2 months, all are asymptomatic. Conclusions: PUJO due to extrinsic vascular anomalies is rare. Intraoperative evaluation with the MBT ruled out associated intrinsic pathology. We describe two simple surgical alternatives preserving the normal PUJ - adhesiolysis for vascular adhesions and pyelopyelostomy for aberrant lower polar artery. The preliminary outcomes are comparable to conventional pyeloplasty.

RESUMEN

BACKGROUND: To find the impact of the obstructive index (OI) as a predictor of management in antenatal pelviureteric junction obstruction. METHODS: Records of 135 cases of antenatally detected unilateral pelviureteric junction obstruction, selected for initial observation were retrospectively analyzed. All patients who underwent pyeloplasty on follow up were assigned to Group A. Those patients who were still on conservative management were assigned to Group B. The pelvic anteroposterior diameters of the affected (PAPD[A]) and normal kidney (PAPD[N]) of the same patient, along with the cortical thickness of the affected kidneys (CT[A]) and normal kidneys (CT[N]) on postnatal ultrasound scan, the T1/2 of the affected (T1/2 [A]) and normal kidneys (T1/2 [N]), the differential renal function (DRF), and the shape of the curve on a diuretic renogram were noted for each patient at 6 weeks. The OI was defined as (PAPD[A] × T1/2 [A]) / (PAPD[N] × T1/2 [N]). RESULTS: The median duration of follow up was 55 months (36-110). Median age at surgery was 12 months (4-80). Group A had 30 patients with 105 in Group B. On multivariate analysis, OI and shape of curve predicted need for surgery with statistical significance. Median OI in Group A was 18.9 compared to 4.82 in Group B (P < 0.001, Mann-Whitney). Using receiver operating characteristic analysis, the area under curve for the OI was 0.95. A level of 12.2 could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%. CONCLUSIONS: The OI can reliably predict the need for surgery at a very early stage, thus avoiding repeated tests and saving time.

Asunto(s)

RESUMEN

Extrarenal calyces (ERC) is a rare renal anomaly where calyces lie outside the renal parenchyma and are connected to pelvis by draining infundibulum. Its presentation with pelviureteric junction obstruction presents a confusing intraoperative finding. We report two cases of ERC with pelviureteric junction obstruction in the ectopic kidney. Emphasis is laid on the defining the anatomy so that reader can identify the condition if he comes across similar situation. The two patients were managed by minimal access approach. Management of these cases and review of pediatric cases reported in literature are discussed.

RESUMEN

Cortical transit time (CTT) has recently been shown to be a useful parameter in the management of children with pelviureteric junction obstruction (PUJO). The aim of this study was to assess intraobserver and interobserver variations in the qualitative and quantitative assessment of CTT in children with PUJO. A retrospective study was performed, and 99mTc-MAG3 renogram images of all children with PUJO performed from January 2016 to December 2017 were retrieved. The images were assessed by three observers at two different time points. CTT was qualified as delayed if CTT was more than 3 min else; it was noted as normal. The intraobserver and interobserver variations in the results of the CTT of the normal kidney and affected kidney both before and after surgery were studied. The kappa statistic was used to compare the interobserver variation of qualitative interpretation of CTT. The Bland-Altman plot was used to evaluate the intraobserver and interobserver variations of the quantitative interpretation of CTT. A total of 57 99mTc-MAG3 renal scintigraphies were evaluated. Overall, 114 renal units were evaluated with 51 normal renal units and 63 renal units with PUJO. Of these, 63 renal units with PUJO, 31 renal units had been operated upon, whereas the remaining 32 renal units had no intervention at the time of the study. The kappa statistic in the normal, affected operated, and affected unoperated kidneys was interpreted as almost perfect, substantial to almost perfect, and moderate to substantial level of agreement, respectively. The Bland-Altman plot revealed a large mean difference and wide 95% limits of agreement in affected kidneys (both operated and unoperated). The study concludes that the qualitative CTT interpretation in the affected renal unit which is most commonly used in recent studies is a reliable and reproducible parameter in children with PUJO. The quantitative measurement had wide inter- and intraobserver variation for clinical use.

RESUMEN

INTRODUCTION: Antero-posterior trans pelvic diameter (APD) and renal scintigraphy play a significant role in the diagnosis of pelvi-ureteric junction (PUJ) obstruction and postoperative follow-up following pyeloplasty. However, the APD varies irrespective of improvement, deterioration, or preserved function in a hydronephrotic kidney and is not a reliable parameter due to various factors (hydration status, compliance, and reduction pyeloplasty). Calyx to Parenchymal Ratio (CPR) is the ratio of the depth of the calyx and parenchymal thickness measured on ultrasound (USG) in coronal image. We assessed the utility of CPR in the follow up of pyeloplasty and compared it with the commonly used APD of the pelvis and renal scintigraphy. MATERIAL AND METHODS: A prospective cohort study was done from July 2016 to October 2017. During this period 73 pyeloplasties were done, and 62 cases meeting the inclusion criteria were enrolled. All the children underwent ultrasound and Technetium-99 m Ethylene dicysteine isotope renogram (EC) scan before and after pyeloplasty. APD and CPR values were measured on USG and compared with isotope renogram outcomes in these children in the preoperative versus postoperative period. Two defined objective variables ΔAPD, percent ΔAPD and ΔCPR, percent ΔCPR were compared with categorical variables that would predict the surgical outcome as - failed, successful or equivocal. Multinomial logistic regression analysis and receiver operating curve (ROC) analysis was used to identify predictive accuracy. RESULTS: The mean (range) APD value recorded in the preoperative period was 3.67 cm (1.40-8.00 cm), which decreased to 1.67 cm (0.40-6.50) postoperatively, which was 54.2% lower (P=<0.001). The mean (range) CPR value decreased from 5.96 (1.20-20.00) in the preoperative period to 2.57 (0.43-10.90) postoperatively, which was 56.8% lower (P=<0.001). On multinomial logistic regression analysis, ΔCPR was found to be a significant predictor of outcome with an overall accuracy of 95.1%, change in CPR was a better predictor of success after pyeloplasty as compared to change in APD, which had an overall accuracy of 85.2% (p = 0.01). Further, on ROC curve analysis, we observed that ΔCPR and %ΔCPR can strongly predict successful pyeloplasty with a sensitivity of each with 96% and 98% respectively and AUC of 0.897 and 0.799 respectively. DISCUSSION: USG (APD) and renogram are the most widely used investigation in follow-up of pyeloplasty; however, APD has its own limitations like operator variability and slower improvement. CPR has the advantages that neither calyceal depth nor parenchymal thickness is directly altered during the surgery, and early resolution of calyceal dilatation and rapid parenchymal growth following pyeloplasty and thus a surgeon independent parameter. Our results have shown that ΔCPR can identify successful pyeloplasty with strong prediction than ΔAPD and thus renal scans can be avoided if there is visible improvement in CPR on follow-up. CONCLUSIONS: Our study identified a change in CPR, i.e., ΔCPR as a strong predictor of surgical outcome, as it is not influenced by extent of pelvis reduction during pyeloplasty and early to change. Using this parameter, we can avoid unnecessary repeated nuclear scans based on persistent high APD values and optimize resource utilization. We recommend the use of CPR in routine practice in the preoperative and postoperative follow-up of PUJ obstruction following pyeloplasty.

Asunto(s)

RESUMEN

INTRODUCTION: Delayed cortical transit time (CTT) has been recently studied and proposed as a parameter that can predict the need for surgery in children with pelviureteric junction obstruction (PUJO). AIM: The aim of this study was to study the change in CTT, after surgery, in children with PUJO and to correlate CTT with intrapelvic pressure of the kidney. MATERIAL AND METHODS: A prospective study was performed, and all children who underwent pyeloplasty from January 2016 to December 2017 were included. Pre-operative and postoperative renal ultrasonography and Technetium-99m mercaptoacetyltriglycerine Tc-MAG3 renal scintigraphy were performed. Cortical transit time was measured by a visual method by two different observers. The renal intrapelvic pressure of the kidney was also measured during surgery after giving a diuretic to replicate the diuresis induced during the renal scan. The correlation was studied between the pre-operative CTT and intrapelvic pressures and between the pre-operative CTT and the renal function of the affected kidney. RESULTS: Thirty-one children were included in the study. The median age of children who underwent surgery was 50 months (2-168). In 71% of patients, the CTT was prolonged before surgery, whereas only 22.5% had delayed CTT after surgery. The mean CTT before surgery was 226.1 ± 74.8 s and decreased to 165.4 ± 55.9 s after surgery (p= <0.001). The mean intrapelvic pressure was 21 ± 7.5 cm H2O. There was no correlation noted between the intrapelvic pressure and the CTT. A significant negative correlation was noted between the CTT and the different renal function of the kidney. DISCUSSION: This is the first prospective study that studies the changes in CTT after surgery. Only retrospective studies had been conducted to date which concluded that CTT was delayed in most of the patients who had been operated. It has been proposed that the prolonged CTT is due to raised pressure in the kidney secondary to obstruction. This study did not find any correlation between the pressure and CTT. The significant negative correlation between CTT and renal function also emphasizes the need to take the renal function into consideration before interpreting and using the absolute value of CTT for guiding treatment. CONCLUSION: Cortical transit time assessment by the visual method is a useful parameter in the management of children with PUJO. There is a significant improvement in CTT after surgery.

Asunto(s)

RESUMEN

Hydronephrosis is diagnosed more often with the increased availability of computed tomography and ultrasound scanning. Hydronephrosis is an important consideration in patients with abdominal or pelvic pathology as progressive dilation of the upper urinary tract can lead to acute kidney injury and, if not corrected, permanent nephron loss. This article explores how to approach an adult patient with hydronephrosis, encompassing aetiology, clinical presentation, diagnosis and management.

Asunto(s)

RESUMEN

Crossed renal ectopia with fusion is an extremely rare congenital anomaly with few reported cases of pelviureteric junction obstruction, which often involves the crossed-over kidney. To our knowledge, we describe the second case in literature to report an uncrossed kidney with pelviureteric junction obstruction and giant hydronephrosis, which obstructs the pelviureteric junction of the crossed-over kidney. The grossly hydronephrotic kidney was found to be poorly functioning and an aberrant crossing vessel was considered to be potentially involved, raising both diagnostic and management challenges. By reporting this case, we aim to stress the importance of adequate mapping collecting systems, drainage patterns and vascular supply in such crossed fused anomalies.

RESUMEN

BACKGROUND: Horseshoe kidney (HSK) is a common renal fusion anomaly. We undertook this study to discuss various anomalies associated with HSKs. The objective of the study is to study various anomalies associated with HSKs and to assess the need for surgical intervention in patients with these anomalies. PATIENTS AND METHODS: This is a retrospective cohort study of twenty patients who presented to our institute with the diagnosis of HSKs. The data were analysed with regard to age at presentation, symptoms, associated anomalies, investigations and surgical intervention. RESULTS: Twenty patients were included in this study. They were referred either with a diagnosis of HSK or were diagnosed during investigations for symptoms and during workup for associated anomalies. Eleven patients were incidentally diagnosed and were asymptomatic, and there were no associated anomalies diagnosed in these patients. Nine patients were symptomatic and were diagnosed with various associated anomalies. Our results concur with recent literature review which suggests that nearly half of the patients with HSKs have associated anomalies. In the present series, all symptomatic patients with associated anomalies required surgical intervention. CONCLUSION: HSKs being a common fusion anomaly, necessitates a prompt and thorough search of the search for any associated anomalies. Many of these anomalies may require surgical intervention.

Asunto(s)

Asunto(s)

RESUMEN

ABSTRACT Objectives To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. Materials and Methods A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. Results Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. Conclusions Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

Asunto(s)

RESUMEN

OBJECTIVES: To investigate a possible causal relationship for stone formation in pelviureteric junction obstruction and to outline management options. MATERIALS AND METHODS: A literature search and evidence synthesis was conducted via electronic databases in the English language using the key words pelviureteric junction obstruction; urolithiasis; hyperoxaluria; laparoscopic pyeloplasty; flexible nephroscopy; percutaneous nephrolithotomy, alone or in combination. Relevant articles were analysed to extract conclusions. RESULTS: Concomitant pelviureteric junction obstruction (PUJO) and renal lithiasis has been reported only scarcely in the literature. Although PUJO has been extensively studied throughout the years, the presence of calculi in such a patient has not received equal attention and there is still doubt surrounding the pathophysiology and global management. CONCLUSIONS: Metabolic risk factors appear to play an important role, enough to justify metabolic evaluation in these patients. Urinary stasis and infection are well known factors predisposing to lithiasis and contribute to some extent. The choice for treatment is not always straightforward. Management should be tailored according to degree of obstruction, renal function, patient symptoms and stone size. Simultaneous treatment is feasible with the aid of minimally invasive operative techniques and laparoscopy in particular.

Asunto(s)