Robert L. Lebowitz

International system of radiographic grading of vesicoureteric reflux

The classification of grading of vesicoureteric reflux (VUR) agreed to by the participants in the International Reflux Study in Children is described. It combines two earlier classifications and is based upon the extent of filling and dilatation by VUR of the ureter, the renal pelvis and the calyces. A standardised technique of voiding cystography is also described to ensure comparability of results.

Fate of 90 Children with Ileal Conduit Urinary Diversion a Decade Later: Analysis of Complications, Pyelography, Renal Function and Bacteriology

A study of the long-term results of ileal conduit urinary diversion for non-malignant disease in 90 children has shown that there were 75 survivors after 10 to 16 years. Stomal stenosis and ureteroileal or other intrinsic obstructions requiring ileal loop revisions occurred frequently and as late as 13 years postoperatively. Of 144 renal units 76 per cent improved or remained stable and 69.3 per cent of normal kidneys remained normal after more than a decade of urinary diversion. In order to obtain these results close lifetime followup and aggressive loop revisions have been required. Urine cultures were consistently negative in 70.5 per cent of all patients. Good results were obtained in terms of preservation of renal function in all categories. Creatinine clearance remained in the normal range after 10 years if the excretory urogram remained normal. Ileal conduit urinary diversion remains a major surgical undertaking but it also remains the standard of urinary diversion against which all other methods must be judged. The results in terms of renal preservation are impressive but so too are the significant number of long-term complications. Any other method of diversion (such as the sigmoid conduit) that can improve upon these results will be welcomed. All children with ileal conduit urinary diversion for reasons other than a neurogenic bladder must be considered candidates for urinary reconstruction.

Duplication of the Urethra

Ten patients with patent urethral duplication are presented. Nine patients had two independent patient channels originating from the bladder or the posterior urethra. Both voiding cystourethro and retrograde urethrography are necessary to completely evaluate this anomaly. In each instance the ventral channel, regardless of the position of its meatus, proved to be the more functional urethra. In those patients whose dorsal channel was in an epispadiac position, the symphysis pubis was abnormally wide. A functionally and anatomically accurate classification is proposed, and the embryology of these anomalies is discussed.

Cessation of Vesicoureteral Reflux For 5 Years in Infants and Children Allocated to Medical Treatment

A total of 401 children with severe vesicoureteral reflux (97 with grade III and 304 with grade IV) was entered into the European branch of the International Reflux Study in Children. Of these patients 37 with grade III and 43 with grade IV reflux were allocated to medical treatment as a sideline group because the reflux grade III or IV had improved to grade II or I, or it had disappeared during the preceding 2 to 6 months (median 4). Of the remaining 321 patients with persistent grade III or IV reflux 158 were randomly allocated to medical treatment of whom 3 switched to surgery. We report on 235 children treated medically (155 random medical and 80 sideline), of whom 88% had a complete 5-year followup with x-ray and/or isotope voiding cystourethrography at 6, 18, 30 and 54 months. Seven children dropped out of the study after a followup of 6 months or less, including 6 with persistent vesicoureteral reflux. Cessation of vesicoureteral reflux was observed significantly more often in children with unilateral (40 of 74, 54%) than with bilateral (18 of 154, 12%) reflux (p < 0.001). No significant difference between grades III and IV was noted. Vesicoureteral reflux ceased in 25 of 153 children (16%) from the random medical group and in 32 of 75 children (43%) in the sideline group. Of 194 children with vesicoureteral reflux detected for the first time at entry reflux resolved in 55 (28%). In only 2 of 34 children (6%) in whom vesicoureteral reflux was detected more than 1 year before entry did reflux resolve after 5 years. Among the children in whom vesicoureteral reflux either disappeared, diminished or remained unchanged the proportion with urinary tract infection recurrences was almost the same.

Suggested terminology for duplex systems, ectopic ureters and ureteroceles.

Recommendations are made for the standardization of nomenclature describing duplex systems, ectopic ureters and ureteroceles. The elimination of some terms and redefinition of others are proposed in the hope to eliminate the ambiguity and confusion that exist currently.

RATE AND PREDICTORS OF SPONTANEOUS RESOLUTION OF PRENATALLY DIAGNOSED PRIMARY NONREFLUXING MEGAURETER

PURPOSE We assessed clinical and ultrasound predictors of the spontaneous resolution of prenatally diagnosed, primary nonrefluxing megaureter. MATERIALS AND METHODS Primary nonrefluxing megaureter was prenatally diagnosed in 54 neonates from 1993 to 1998, including 15 in whom it was bilateral (69 megaureters). Median followup period from birth to the last radiology examination was 25.8 months (range 2.3 to 72). RESULTS Of the patients 10 underwent surgical repair for severe hydroureteronephrosis, including decreasing renal function on diuretic renography in 1, and an episode of bilateral obstruction and acute renal failure in 1. Hydroureteronephrosis resolved in 39 cases (72%) and persisted in 5 at 30 to 72 months of followup. Laterality, gender and retrovesical ureteral diameter had no significant effect on the resolution rate (p >0.05). Mean initial ureteral diameter in patients with resolution was less than in those without resolution and in those who underwent surgery (0.8 versus 1.15 and 1.32 cm., respectively). Presenting hydronephrosis grade was a significant predictor of the resolution rate (p = 0.03). Grades 1 to 3 hydronephrosis resolved at a median age of 12.9, 23.9 and 34.6 months, respectively (range 4.1 to 66). In patients in whom grades 4 and 5 hydronephrosis resolved the median age at resolution was 48.5 months. CONCLUSIONS Most cases of prenatally diagnosed, primary nonrefluxing megaureter resolve spontaneously. Grades 1 to 3 hydronephrosis tend to resolve between ages 12 and 36 months. For these grades followup intervals may be progressively elongated after a pattern of improving hydronephrosis has been established. In children with grade 4 or 5 hydronephrosis, or a retrovesical ureteral diameter of greater than 1 cm. the condition may resolve slowly and require surgery.

Ureteroceles in Infants and Children

Ureteroceles in childhood have a broad spectrum of presentation, anatomy and pathophysiology and, thus, treatment must be individualized. We evaluated 64 children with 72 ureteroceles who underwent operation. Their presentation, radiographic findings, operative management and postoperative results are discussed. Simple or orthotopic ureteroceles often require no operation unless they are large enough to obstruct the urinary tract. Then excision of the ureterocele and ureteral reimplantation are recommended. There are a number of options available for the management of ectopic ureteroceles. The procedure of choice is upper pole heminephrectomy and partial ureterectomy in the majority of ureteroceles associated with a poorly functioning upper renal segment. Specific indications for each of the other surgical techniques considered acceptable at present are discussed.

CONGENITAL OBSTRUCTED MEGAURETERS IN EARLY INFANCY: DIAGNOSIS AND TREATMENT

Fetal screening during maternal ultrasonography has changed the mode and age of presentation of congenital uropathies, particularly congenital obstructed megaureter. We studied 47 infants less than 8 months old with primary obstructed megaureter. Surgical correction in 42 patients with moderate to severe obstruction was performed at a mean age of 1.8 months in those detected prenatally and 3.8 months in those presenting after birth. All infants showed functional and structural urographic improvement with a mean followup of 2.3 years. Reflux was seen postoperatively in 8 patients, which subsided spontaneously in 3, continues to be followed in 2 and resulted in repeat reimplantation in 3. Five infants had mild obstruction, which was managed nonoperatively and 2 showed progressive obstruction, which required repair at ages 20 and 28 months. Repair of obstructed megaureters in early infancy improves renal drainage and offers the potential for preventing renal damage before the development of symptoms or infection. With proper attention to detail, excellent results may be achieved.

Life-threatening anoxic spells caused by tracheal compression after repair of esophageal atresia: correction by surgery.

Three infants who developed anoxic spells 2, 5, and 20 mo following repair of esophageal atresia developed apneic spells during or within a few minutes of feeding. These episodes began with stridor and cyanosis; when severe, they progressed to apnea and loss of consciousness. Mouth-to-mouth resuscitation was often necessary. Investigations failed to detect esophageal obstruction and/or a recurrent tracheoesophageal fistula. No neurologic or cardiac abnormalities were found. The cause was compression of a 1- to 3-cm segment of trachea anteriorly by a vascular structure and posteriorly by a dilated esophagus that emptied slowly because of poor motility. Endoscopy confirmed the x-ray findings. The aortic arch and innominate artery were suspended to the sternum anteriorly, which relieved the apneic spells in all patients.

Pediatric radiation exposure and effective dose reduction during voiding cystourethrography.

PURPOSE To compare radiation exposure and effective dose in children who underwent voiding cystourethrography (VCUG) performed with grid-controlled variable-rate pulsed fluoroscopy (GCPFL) with radiation exposure and effective dose in children who underwent VCUG performed with continuous fluoroscopy (CFL) and to compare these effective doses with those estimated with radionuclide cystography (RNC). MATERIALS AND METHODS Institutional review board approval was obtained, and the informed consent requirement was waived for this HIPAA-compliant retrospective study. Radiation exposure and fluoroscopy time during VCUG were reviewed in 145 children (75 girls, 70 boys; age range, 3 days to 8 years) who underwent GCPFL or CFL between 2001 and 2002. Children were grouped on the basis of the fluoroscopy unit used and their supine anteroposterior abdominal diameter (group 1, 8.0-8.5-cm diameter; group 2, 10-11-cm diameter; group 3, 12-13-cm diameter). Analysis of variance was used to compare radiation exposure and fluoroscopy time between fluoroscopy units and patient diameter groups. Effective doses were calculated and compared for both fluoroscopes and for estimated RNC dose values. RESULTS GCPFL resulted in a significant reduction in total radiation exposure, which was at least eight times lower than that with CFL in all three groups (P < .001 for all). There was no significant difference in fluoroscopy time (P > .50). Effective radiation doses from GCPFL were approximately one order of magnitude lower than those from CFL but one order of magnitude higher than those from RNC. CONCLUSION In children, VCUG can be performed with a GCPFL unit that delivers radiation exposures that are at least eight times lower than those delivered by a conventional CFL unit. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/2492062066/DC1.