Sandra K. Fernbach

SURGERY VERSUS OBSERVATION FOR MANAGING OBSTRUCTIVE GRADE 3 TO 4 UNILATERAL HYDRONEPHROSIS: A REPORT FROM THE SOCIETY FOR FETAL UROLOGY

PURPOSEnThe Society for Fetal Urology has undertaken the first multicenter prospective randomized study of high grade obstructive unilateral hydronephrosis to evaluate the natural history of untreated obstruction and compare it to the benefits of pyeloplasty.nnnMATERIALS AND METHODSnSince 1991, infants with isolated unilateral Society for Fetal Urology grade 3 hydronephrosis and ipsilateral obstruction with greater than 40% differential renal function on well tempered renography were studied. Patients were randomly assigned to observation or pyeloplasty groups. Renal ultrasound and well tempered renography were performed biannually for 1 year and yearly thereafter. Crossover criteria for surgery included concurrent worsening of isotope washout and increasing grade of hydronephrosis or a greater than 10% point loss in percent differential renal function that was noted between studies. The end point of the study was the 3-year anniversary of randomization.nnnRESULTSnA total of 32 infants from 10 centers were randomized equally to 2 groups. The starting grade of hydronephrosis and percent differential renal function were similar between the 2 groups. At 6 months and 1 year the grade of hydronephrosis was significantly reduced (p < 0.02) and well tempered renography was significantly more likely to demonstrate no obstruction (p < 0.03) in the surgical group compared with the observation group. The mean percent differential renal function remained stable and similar in both groups. Reduced hydronephrosis and resolution of obstruction in the surgery group persisted as a trend at the 2 and 3-year anniversaries. In the observation group 4 patients (25%) showed enough renal deterioration to qualify for crossover to surgery.nnnCONCLUSIONSnInfant pyeloplasty significantly improved the grade of hydronephrosis and drainage pattern at 6 months and 1 year postoperatively, when compared with observation. Renal function stabilization was similar for either management approach. However, 25% of the patients satisfied objective criteria of status deterioration requiring pyeloplasty.

Grading nephroureteral dilatation detected in the first year of life: correlation with obstruction.

To understand better the significance of pediatric idiopathic nephroureteral dilatation the renal ultrasound images of patients less than 1 year old with hydronephrosis or hydroureteronephrosis were graded and compared to the radiological diagnosis of obstruction as determined by diuresis renography and/or urography. The study included 73 boys and 30 girls with hydronephrosis (76 patients) or hydroureteronephrosis (27). For hydronephrosis obstruction was diagnosed in 56 children (74%) and involved 61 of 97 kidneys (63%). For obstructed kidneys the mean grade of hydronephrosis (3.4 +/- 0.7 standard deviation) was statistically different from that of nonobstructed kidneys (1.6 +/- 0.8 standard deviation) (p less than 0.05). When the value to predict obstruction was set at grade 3 hydronephrosis or greater there was an 88% sensitivity and 95% specificity. For hydroureteronephrosis obstruction was diagnosed in 15 of 27 children (56%) and involved 17 of 34 kidneys (50%). The degree of dilatation was weighted as a score to assess the grades of hydronephrosis and ureteral dilatation, namely hydroureteronephrosis score equals grade of hydronephrosis plus grade of ureteral dilatation. In obstructed megaureters the mean hydroureteronephrosis score (5.8 +/- 1.0) was statistically different from that for nonobstructed megaureters (mean hydroureteronephrosis score 2.7 +/- 1.9) (p less than 0.001). When the value to predict obstruction was set at hydroureteronephrosis score of 5 or greater there was a 94% sensitivity and 80% specificity. Although ultrasound examination alone cannot be used to diagnose urinary obstruction, the radiological diagnosis of obstruction is linked with the grade of hydronephrosis or score of hydroureteronephrosis.

Clinical application of ultrasonography in the diagnosis of intussusception

Sixty-five consecutive patients seen in a pediatric emergency department, in whom the diagnosis of intussusception was considered, had an ultrasound examination of the abdomen before a barium enema. The mean age of the patients was 1.7 years (range 2 weeks to 5 years). Intussusception was detected by ultrasonography in all 20 cases proved by barium enema. There were three false-positive ultrasound results (sensitivity = 100%, confidence interval (Cl) = 86% to 100%; specificity = 93%, Cl = 86% to 96%). Normal findings on ultrasonography correlated with a negative barium enema results in 42 of 42 cases (negative predictive value = 100%, Cl = 94% to 100%). No intussusception was missed by ultrasonography. To determine which patients would most benefit from ultrasonography, we divided patients into either a high-risk group (81% with intussusception) or a low-risk group (14% with intussusception) on the basis of clinical symptoms (p less than 0.01). If each high-risk child had a barium enema and each low-risk child had an ultrasound study as their initial diagnostic test, 89% of the patients in this study would have undergone only one examination. We conclude that ultrasonography can be used as a rapid, sensitive screening procedure in the diagnosis or exclusion of childhood intussusception. Children considered at low risk of having intussusception on the basis of clinical symptoms should initially have an ultrasound examination; patients at high risk should have an immediate barium enema.

Outcome of nonspecific hydronephrosis in the infant: a report from the Registry of the Society for Fetal Urology.

Abstract Since 1988 the Society for Fetal Urology has worked to evaluate if there is consensus on management of infants with nonspecific hydronephrosis. Initially, multicenter agreement on the criteria to grade hydronephrosis and method of diuretic renography were developed to promote similarities in how infant kidneys with nonspecific hydronephrosis were profiled for grade (0 to 4), per cent differential function by diuretic renography and drainage response by diuretic renography (obstructed, not obstructed or indeterminate). Between 1989 and 1992 a total of 33 pediatric urologists from 21 cities registered 464 cases (582 kidneys) of hydronephrosis. Of the cases 275 (59%) were managed by observation and 189 (41%) were treated surgically. The operated kidneys showed profiles (hydronephrosis grade 3 or greater and diuretic renography obstructed) that were significantly different from the profiles of observed kidneys (hydronephrosis grade 2 or less and diuretic renography no obstruction) (p

Urinoma formation in posterior urethral valves: Relationship to later renal function

A retrospective analysis of radiologically determined individual renal function was performed in five boys who presented in the neonatal period with posterior urethral valves, vesicoureteral reflux and documented urinoma formation. Renal function was evaluated with scintigraphy. There was reflux in eight of ten ureters. Six of these ureters had an associated urinoma and compromised renal function in the neonatal period. In two of the boys the kidney with urinoma functioned better than the contralateral kidney with reflux alone. In two other boys with unilateral urinoma the contralateral ureter did not reflux and the affected kidney functioned less well. In follow up (20 to 36 months) seven of the ten kidneys have a near normal appearance or function. Those kidneys which are now abnormal were noted to be abnormal in the neonatal period.

Peritoneal fluid in children with intussusception: its sonographic detection and relationship to successful reduction.

A retrospective review of the abdominal/pelvic ultrasound (US) examinations in 21 consecutive children with intussusception proven on barium enema was performed to determine what is the incidence of US detected peritoneal fluid in this population and to see if the rate of reduction was different in this subset. Twelve of the 21 children (57%) had free fluid demonstrated with US. Eight of these 12 (67%) had successful reduction. Six of the nine children (67%) without free fluid were also successfully reduced.

Axial torsion of Meckel's diverticulum presenting as a pelvic mass

Abstract. Meckels diverticulum is the most common congenital gastrointestinal anomaly. Axial torsion of the diverticulum is rare and may produce nonspecific abdominal signs and symptoms. We describe a case of torsion of a Meckels diverticulum that was noted as a pelvic mass on CT images.

Lower Extremity Cyanosis: An Unusual Presentation of Congenital Paraureteral Diverticula

Congenital bladder diverticula are an uncommon cause of urinary retention in children. We report on a male infant with bilateral congenital bladder diverticula that compressed the posterior urethra causing urinary retention and also compressed the venous return from the lower extremities producing cyanosis.

Computed tomography of primary intrathecal wilms tumor with diastematomyelia

A 2-year-old girl evaluated for diastematomyelia proved to have nearly complete block from an associated primary intraarachnoid Wilms tumor (nephroblastoma) situated immediately caudal to the bone spur and dorsal to the reunited hemicords and conus medullaris. No second focus of Wilms tumor could be detected. The computed tomographic appearance of the tumor and a possible embryological explanation for its relationship to the spinal cord are presented.

The Abnormal Renal Axis in Children with Spina Bifida and Gibbus Deformity—The Pseudohorseshoe Kidney

The axes of the kidneys in children with a thoracolumbar gibbus deformity may be distorted to simulate a horseshoe kidney. Measurements of the angle of the gibbus and the angle of intersection of the renal axes were made in 68 children with thoracolumbar meningomyelocele. Thirty-eight children with a gibbus deformity and thoracolumbar meningomyelocele had an abnormality of the renal axis on supine urography, including 19 (28 per cent) in whom a horseshoe kidney was suggested. Three additional children with a gibbus deformity and thoracolumbar meningomyelocele had a normal renal axis. Regression analysis of these data indicated a linear relationship between the angle of the gibbus and the amount of deviation of the renal axis for the values studied. Nuclear scintigraphy, ultrasound studies and clinical records were reviewed in all 41 children with a gibbus deformity. In none were the kidneys fused. There were 21 children with thoracolumbar myelomeningocele who had no gibbus deformity and a normal renal axis. Six other children will be described in detail, 2 of whom were excluded because of severe scoliosis and 4 with congenital renal anomalies.