Arjan D. Amar

Congenital hydronephrosis of lower segment in duplex kidney

Congenital hydronephrosis of the lower segment in duplex kidney was treated in 12 patients. This uncommon abnormality carries the risk of calculous formation, chronic urinary tract infection, and functional failure of the involved segment. Diagnostic problems encountered included differentiation from tumor, obstruction by a calculus, and hydronephrosis due to reflux. Treatment was individualized according to severity of hydronephrosis and presence or absence of specific complications. Mild obstruction could be treated nonsurgically while the patient was closely observed for evidence of stone, infection, or worsening of obstruction. Available surgical procedures include end to side or side to side pyeloureteral anastomosis, plastic widening of a narrowed obstructive site, removal of calculus with relief of obstruction, and heminephrectomy.

Extravesical Ureteral Ectopia in Male Patients

In male patients with extravesical ureteral ectopia the ectopic orifice does not cause urinary incontinence and the diagnosis is often delayed. We describe our experience with 12 male patients who had extravesical ureteral ectopia. According to the embryologic phenomena leading to such anomalies we have classified them into mesonephric ductal ectopia and urogenital sinus ectopia. Distinctive clinical and radiologic features of these 2 types of ureteral ectopia are discussed. Guide lines to surgical therapy are based upon the type of ectopia, function of the affected kidney or renal segment and whether a single or duplicated ureteral system is affected.

Reflux in duplicated ureters: Treatment in children

Abstract Reflux is more common in duplicated than in nonduplicated ureters. Since reflux may cause recurrence or persistence of urinary infection and destruction of renal parenchyma, the surgical treatment of ureteral duplication with reflux may be the most important aspect of management of children with such a pathologic picture. Available surgical procedures include ureteral reimplantation, heminephroureterectomy, pyelopylostomy with removal of dilated distal ureter, primary nephro-ureterectomy of both segments, nephro-ureterectomy secondary to primary heminephrectomy, and removal of refluxing ureteral stump remaining from previous heminephrectomy. In 28 children treated surgically for refluxing duplicated ureters, the most frequently used technique was ureteral reimplantation (17 cases). Excellent results were obtained in the majority of the 28 patients.

Ureteral Strictures Following Ureterolithotomy

Ureteral strictures occurring after ureterolithotomy may not be recognized until obstruction or recurrent stone impaction occurs in the area. We describe our treatment of this problem in 9 patients. Management varied from conservative treatment in patients having no discernible renal function on the affected side to various forms of reconstruction or reimplantation, depending upon the situation and site of the stricture. All patients were followed for a minimum of 2 years without complications. The etiopathogenesis and other methods of treatment available for this problem are discussed.

Management of Urinary Calculous Disease in Patients with Ureterocele

Of 37 adult patients with ureteroceles, 13 also had calculous disease (35 per cent). Of these 13 cases 7 had single ureters and 6 had duplicated ones. None had a metabolic or urinary abnormality such as hypercalcemia, gout, hypercalciuria or hyperuricuria. Two of the patients were a mother and daugher--the first reported familial incidence of ureterocele with calculous disease. A surgical technique is described for removal of the calculus, excision of the ureterocele and reimplantation of the ureter. The procedure was used in 4 of the 7 patients with single ureters, while the stone passed spontaneously in 2 patients and was treated by ureterolithotomy in 1. A modification of the technique was used in 2 of the 6 patients with duplicated ureters but other surgical procedures were used in the remaining 4. Of 10 stones that were analyzed 2 were struvite and none contained cystine or uric acid. Long-term followup is a requisite to assure control of this clinical entity.

Vesicoureteral Reflux in Women with Primary Bladder Diverticulum

In 22 years we treated 271 adults, including 149 women, for vesicoureteral reflux. We describe our management of vesicoureteral reflux in 12 women between 18 and 58 years old who had an associated primary vesical diverticulum. A vesical diverticulum located near the ureteral orifice caused reflux by destroying the ureterovesical valve in 11 of these 12 patients. In 1 woman a bladder diverticulum distant from the ureteral orifice acted as a reservoir of chronic infection, which perpetuated reflux in a marginally competent ureterovesical junction. The reflux disappeared after excision of the diverticulum. Reflux was bilateral in 3 and unilateral in 9 cases. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were noted in 4. Urinary infection was controlled successfully by medical management in 4 patients. Ureteral reimplantation after excision of the bladder diverticulum and repair of the bladder wall was successful in eradicating reflux in 5 patients. Each patient was followed for 3 or more years.

Vesicoureteral Reflux in Patients With Obstructive Prostatic Disease

We present our experience during a 22-year period with the management of 53 patients in whom vesicoureteral reflux was associated with obstructive prostatic disease. There were 45 cases of benign prostatic hyperplasia and 8 cases of carcinoma of the prostate. After prostatectomy medical management of reflux was successful in controlling urinary infection in 34 patients and an operation was performed in 19. Each patient was followed for at least 1 year.

Delayed recurrence of reflux after initial success of antireflux operation.

Delayed recurrence of reflux was discovered in 4 children among 103 who were followed at least 5 years after ureteral reimplantation for treatment of vesicoureteral reflux. In each of the 103 children initial success in correction of reflux was proved by 2 cystographic series performed 3 months apart after the initial ureteral reimplantation. Reoperation was successful in correction of the recurrent reflux in 2 children, failed in 1 and has been attempted in 1. Prolonged postoperative followup (to at least 5 years) is recommended after ureteral reimplantation for treatment of vesicoureteral reflux.

The Practical Management of Vesicoureteral Reflux in Children: A Review of 12 Years' Experience with 236 Patients

Early recognition, adequate treatment, close observation, and systematic follow-up over a long period are essential to renal salvage in the child with vesicoureteral reflux. The decision whether and when to operate is made on a balance of factors by the pediatrician-urologist team. Among 236 patients with reflux diagnosed during childhood, reflux was stopped in 55 per cent of those treated medically and in 98 per cent of the more severe cases who were treated by ureteral reimplantation. Chronic pyelonephritis appeared or worsened during medical management in 12 per cent; no child showed new pyelonephritic scars or worsening of pyelonephritis after ureteral re implantation.

Improved radiographic visualization of calculus in distal ureter

Roentgenographic visualization of a calculus in the distal ureter is often made difficult by gas or bowel contents in the region of the pelvis. Filling the bladder with sterile water raises the bladder dome and displaces the bowel upward. Any calculus in the lower 4 to 5 cm. of the distal ureter is then clearly demonstrated on roentgenograms taken against the water-filled bladder instead of against the bowel filled with gas and feces. This maneuver also aids in differentiation of a calculus in the distal ureter from a phlebolith in the bladder wall, and has improved visualization of distal ureteral calculus in 50 patients during the last six years.