Eli Armando S. Rabelo

Multicystic dysplastic kidney detected by fetal sonography: conservative management and follow-up

Abstract The most common cystic lesion recognized antenatally is multicystic dysplastic kidney (MCDK). Recently, conservative management without nephrectomy has been advocated. The purpose of this study was to report our experience in the conservative management of unilateral MCDK. Between 1989 and 1997, 20 children with MCDK detected by prenatal ultrasonography (US) were prospectively followed. At birth, US confirmed the prenatal findings in all cases. All patients were submitted to radioisotope scans and a micturating cystogram. Follow-up US examinations were performed annually. Mean age at diagnosis during the prenatal period was 31 weeks of gestation (range 24–38). Median follow-up time was 33 months (range 7–91). Follow-up US was performed in 19 children; 13 (68%) showed partial involution, 4 (21%) complete involution, and 2 (11%) an increase in unit size. The mean age at complete or partial involution of the lesion was 18 months. No children developed hypertension or tumors, and all maintained normal growth. In conclusion, the natural history of MCDK is usually benign, and serial US examinations show that affected kidneys frequently show involution with time.

Predictive factors of ultrasonographic involution of prenatally detected multicystic dysplastic kidney

To evaluate possible predictive factors of involution on ultrasonography (US) or disappearance of a prenatally detected multicystic dysplastic kidney (MCDK).

Primary megaureter detected by prenatal ultrasonography: conservative management and prolonged follow-up.

With the widespread use of obstetric echography the incidence of fetal hydronephrosis has been reported more frequently. Consequently, many uropathies have been detected in asymptomatic neonates. The authors report their experience with prenatally detected primary non-refluxing megaureter. Newborns with fetal hydronephrosis were investigated by ultrasonography and micturating cystourethrogram after the beginning of chemoprophylaxis. If primary megaureter was identified, after 1 month the children underwent 99tm-DMSA, diuretic 99tm-DTPA, and intravenous urography. Eight infants with primary megaureter (bilateralin 3 cases) were identified, for a total of 11 renal units for study. All children were submitted to non-operative management. We performed ultrasonography and diuretic 99tm-DTPA during follow-up, which lasted on average 75 months. The mean cross-sectional diameter of the dilated ureter was 13.6 mm during neonatal period, and reached 8.4 mm atthe end of follow-up. The renal function and the diuretic renogram remained stable throughout follow-up. Two neonates presented transitory hypertension. Our results support the notion that conservative management is safe for primary megaureter detected in asymptomatic neonates, with most cases showing spontaneous regression during aprolonged follow-up.

Features of primary vesicoureteric reflux detected by investigation of foetal hydronephrosis

Primary vesicoureteric reflux (VUR) diagnosed on investigation of foetal hydronephrosis accounts for many antenatally detected uropathies. In order to study foetal VUR and its consequences, newborns with foetal hydronephrosis were investigated by ultrasound, micturating cystourethrogram and99mTechnetium-dimercaptosuccinic acid (DMSA), after beginning of chemoprophylaxis. Twenty-eight infants with VUR (bilateral in 15 cases) were identified giving a total 43 renal units for study. There was a predominance of males (86%), moderate/severe reflux (84%) and renal damage (51%). Presence of renal damage was correlated with the severity of reflux. VUR should be investigated in cases of foetal hydronephrosis and our results support that renal damage is frequently congenital and not secondary to urinary tract infection.

Outcome of apparent ureteropelvic junction obstruction identified by investigation of fetal hydronephrosis.

Objectives: The purpose of the study was toevaluate the outcome of prenatally detectedureteropelvic junction obstruction (UPJO)managed with a more conservative protocol.Methods: The records and imaging studies of 77consecutive neonates with UPJO identified by fetal hydronephrosis werereviewed. A nonoperative approach wasattempted in patients with mild/moderate pelvicdilatation, renal units with good functionas ascertained by DMSA scan and anon-obstructed pattern on DTPA. Otherwise, thepatients were managed surgically bypyeloplasty. Both groups were prospectivelyfollowed and the imaging studies were performedbefore and after the initial approachand at one-year intervals thereafter.Results: Of the 77 infants (85 units), 39 weresubmitted to surgery (33 pyeloplasty and 7 nephrectomy) and 38 were conservativelymanaged. During follow-up, 9 (24%) of 38 patients in the non-operative group presentedrenal function deterioration and 3 presented with urinary infections and were submitted topyeloplasty. Of the 39 patients surgically managed, 76% presented improvement ofhydronephrosis and 90% showed a non-obstructed pattern on diuretic renography. Thedifferential renal uptake, as measured by DMSA scan, remained stable in the three groupsanalyzed (conservative, initial pyeloplasty, and delayed pyeloplasty). Therewas a minimal improvement in those units submitted to pyeloplasty with impairedrenal function at baseline (< 40%). Mean renal uptake was 28.6% at admission and33.9% at the end of follow-up. Conclusion: There was a wide spectrum ofureteropelvic junction stenosis. Surgical intervention in a subgroup of patients withsevere hydronephrosis and impaired function may possibly improve or preserve renalparenchyma. Conversely, conservative management and clinical follow-up are safe anddesirable for the subgroup with mild/moderate pelvic dilatation and preservedrenal function.

Conservative management of multicystic dysplastic kidney: clinical course and ultrasound outcome

OBJECTIVE The aim of this study was to describe the clinical course and ultrasound outcome of prenatally detected multicystic dysplastic kidney. METHODS Fifty-three children with unilateral multicystic dysplastic kidney detected by prenatal ultrasound between 1989 and 2004 were included in the analysis. All children were submitted to conservative management with follow-up visits every six months. Follow-up ultrasound examinations were performed at six-month intervals during the first two years of life and yearly thereafter. The following clinical parameters were evaluated: blood pressure, urinary tract infection, renal function, and growth. The following ultrasound parameters were evaluated: involution of multicystic dysplastic kidney and contralateral renal growth. RESULTS The mean follow-up time was 68 months. Two children presented hypertension during follow-up and five had urinary tract infection (only one with recurrent episodes). There was no malignant degeneration of multicystic dysplastic kidney. A total of 334 ultrasound scans were analyzed. US scan demonstrated involution of the multicystic dysplastic kidney in 48 (90%) cases, including complete involution in nine (17%). The involution rate was faster in the first 30 months of life. There was progressive compensatory renal hypertrophy of the contralateral renal unit; the rate of growth was greater in the first 24 months of life. CONCLUSION The results of prolonged follow-up of children with conservatively managed multicystic dysplastic kidney suggest that clinical approach is safe, the incidence of complications is small, and that there is a clear tendency for multicystic dysplastic kidney to decrease in size. Our data also suggest that the involution rate of multicystic dysplastic kidney as well as the growth of the contralateral kidney is greater in the first 24 months of life.

Tratamento conservador do rim displásico multicístico: curso clínico e ultra-sonográfico

OBJECTIVE:The aim of this study was to describe the clinical course and ultrasound outcome of prenatally detected multicystic dysplastic kidney. METHODS: Fifty-three children with unilateral multicystic dysplastic kidney detected by prenatal ultrasound between 1989 and 2004 were included in the analysis. All children were submitted to conservative management with follow-up visits every six months. Follow-up ultrasound examinations were performed at six-month intervals during the first two years of life and yearly thereafter. The following clinical parameters were evaluated: blood pressure, urinary tract infection, renal function, and growth. The following ultrasound parameters were evaluated: involution of multicystic dysplastic kidney and contralateral renal growth. RESULTS: The mean follow-up time was 68 months. Two children presented hypertension during follow-up and five had urinary tract infection (only one with recurrent episodes). There was no malignant degeneration of multicystic dysplastic kidney. A total of 334 ultrasound scans were analyzed. US scan demonstrated involution of the multicystic dysplastic kidney in 48 (90%) cases, including complete involution in nine (17%). The involution rate was faster in the first 30 months of life. There was progressive compensatory renal hypertrophy of the contralateral renal unit; the rate of growth was greater in the first 24 months of life. CONCLUSION: The results of prolonged follow-up of children with conservatively managed multicystic dysplastic kidney suggest that clinical approach is safe, the incidence of complications is small, and that there is a clear tendency for multicystic dysplastic kidney to decrease in size. Our data also suggest that the involution rate of multicystic dysplastic kidney as well as the growth of the contralateral kidney is greater in the first 24 months of life.

CHOLESTEATOMA OF THE UPPER URINARY TRACT

We report the case of a 57-year old patient with complex cystic image in right kidney. Following radical nephrectomy, the pathological study established the diagnosis of renal cholesteatoma. We discuss the frequency, pathogenesis, clinical presentation, propedeutics, histological findings and proposes for intervention observed in the literature.