Venkata Sai

Pelvis/cortex ratio: An early marker of success following pyeloplasty in children

OBJECTIVES To document the change in anterio-posterior pelvic diameter (APPD), cortical thickness (CT) and pelvis/cortex ratio (P/C ratio) following pyeloplasty, and determine the usefulness of each of these parameters in assessing postoperative outcome. PATIENTS AND METHODS Twenty-four children with unilateral pelvi-ureteric junction obstruction who underwent standard dismembered pyeloplasty with stent were prospectively studied (median age 13 months; range 2 months-5 years). Maximum APPD, CT and P/C ratio values were compared pre- and postoperatively. RESULTS Mean APPD was 40.70 mm preoperatively, and 30.04 mm at 3 months and 12.75 mm at 1 year postoperatively. The reduction in size at 3 months was not significant (P = 0.34), but was significant at 1 year (P < 0.01). Mean CT was 4.41 mm preoperatively, 6.29 mm at 3 months and 9.45 mm at 1 year. The increase in CT was not significant at 3 months (P = 0.44), but was significant at 1 year (P < 0.01). The P/C ratio was 13.48 mm preoperatively, 5.73 mm at 3 months and 1.45 mm at 1 year. The reduction in P/C ratio was significant at 3 months (P < 0.01) as well as at 1 year (P < 0.01). Sonographic resolution rate did not correlate with outcomes on radionuclide scans. CONCLUSION P/C ratio could be used as an early marker of success following pyeloplasty. Improvement in other sonographic criteria or on radionuclide scans may be useful only in the long term.

Functional outcomes of early versus delayed pyeloplasty in prenatally diagnosed pelvi-ureteric junction obstruction

UNLABELLED Although initial conservative management is popular in the management of antenatally detected pelvi ureteric junction (PUJ) obstruction [1-3], several authors [4,5] have questioned this approach and expressed concern about failure to recover the function lost during expectant management following surgery. In this single center prospective study, we have compared the functional outcomes following early versus delayed pyeloplasty in SFU grade 3-4 PUJ obstruction. METHODS Among those children, who presented between 2004 and 2013, with prenatal diagnoses of unilateral PUJ obstruction (n = 886), those with SFU grade 1 or 2 hydronephrosis on USG (n = 533) were excluded. In the remaining 353 children with SFU grade 3 and 4 hydronephrosis, 243 had obstructive pattern on radionuclide scan. After excluding those with severely impaired or supranormal split renal function (SRF), palpable mass, single kidney status, bilateral disease and associated other urological anomalies a total of 126 children were included in the study group. Parents who were unwilling for a frequent follow-up underwent early pyeloplasty, (Group I: n = 62) while the remaining underwent initial conservative management, with 3 monthly USG and nuclear scans (Group II; n = 64). In this group pyeloplasty was performed whenever there was deterioration in SRF >10%, or urine infection or pain during the follow-up. A standard open dismembered pyeloplasty was performed by the same surgeon in all patients. Radionuclide scan was performed at 1 year, at the same center using the same protocol, to assess final SRF and drainage. The functional outcomes were compared using students t test and chi square test. RESULTS Group I comprised of 62 patients while Group II 64 patients. The mean age at pyeloplasty was 2.8 months in group I while 12.5 months in group II. There was no significant difference in the initial antero posterior diameter (APD) between the groups; 30.2 (±3.2) mm in group I and 29.6 (±3.7) mm in group II. At 1-year follow up after surgery, there was improvement in the APD, 16.8 (±4.2) mm in group I and 18.2 (±4.5) mm in group II, with no significant difference between them. In group I, the initial mean SRF was 34.1% (±6.4) and there was significant improvement (p = 0.01) in mean SRF to 37.2 (±7.1) at 1-year follow up after surgery. In group II, the mean SRF was 35.9 (5.7) initially and there was a deterioration to 32.6 (±5.5) before surgery (Figure). At 1-year follow up after surgery, there was a marginal improvement to 33.5 (5.6), however it was significantly lower compared to the initial SRF (p = 0.01). Compared to initial function, at 1-year follow up after pyeloplasty, SRF improved in significantly higher number of patients; 17/62 (27.4%) in group I while only 7/64 (10.9%) in group II (p = 0.03) (Table). There was significantly fewer patients with deterioration in final SRF at 8/62 (12.9%) in group I compared to 22/64 (34.4%) in group II (p = 0.03). DISCUSSION Although several publications [1-3] have reported functional recovery during initial conservative treatment of PUJ obstruction, in our study a large proportion of patients (80%) in Group II had loss of function during follow-up. This is probably because the study population included only SFU grade 3-4 with obstructive renogram. Several authors have expressed concern about irreversible loss of renal function during expectant management [4,5]. Findings of our study reveal that irrespective of initial SRF, early pyeloplasty in prenatally diagnosed SFU grade 3-4 PUJ obstruction leads to significant improvement of SRF, while delayed pyeloplasty leads to a marginal but, significant loss. This fact should be highlighted to parents so that informed decisions can be made regarding early versus delayed surgery.

Postnatal outcome of fetal hydronephrosis: implications for prenatal counselling.

Objectives: Hydronephrosis is commonly detected during antenatal scans. There are multiple conflicting prognostic factors in the literature with no clear focus on the postnatal outcome. The aim of the study is to assess the outcome of fetal hydronephrosis, based on antenatal sonography. Materials and Methods: Based on the third trimester fetal ultrasound findings, patients were divided into group I (unilateral hydronephrosis) and group II (bilateral hydronephrosis, ureteric dilatation, bladder thickening, etc). Postnatal evaluation and follow-up was performed by a single physician with uniform protocol. The outcomes, spontaneous resolution vs. surgical intervention, were compared between groups. Among group I, further analysis of outcome was done based on 32-week fetal pelvic antero posterior diameter (APD). Results: Among a total of 116 patients in the study group; group I had 78 patients, 7 (9%) required surgery; group II had 38 patients, 21(55%) required surgery. The difference in outcome between the groups was statistically significant (P = 0.002). Among those with unilateral hydronephrosis, none (0/55) with APD <15 mm required surgery, while all patients (4/4) with fetal APD> 30 mm required surgery. In those with APD between 15-30 mm, 3/19 required surgery and prolonged follow-up was required to arrive at the decision. The difference in outcome between the subgroups was statistically significant (P< 0.001, Chi-square test). Conclusions: The results of our study show that simple unilateral fetal hydronephrosis runs a benign course. In the presence hydronephrosis larger than 15 mm, bilateral disease, or bladder distension, detailed postnatal evaluation and regular follow-up is warranted to plan a timely intervention. The above data could be used in prenatal counselling of these parents. Further larger studies are warranted to through more evidence.

Pelvis/cortex ratio: A sonographic marker of pelvi ureteric junction obstruction in children.

Objectives The aim of the study is to document pelvis/cortex ratio (P/C ratio) in children presenting with antenatally detected hydronephrosis and determine whether it could be used as a sonographic marker of Pelvi ureteric junction (PUJ) obstruction. Materials and Methods: All the children presenting with unilateral fetal hydronephrosis (PUJ) between Jan 2007 and March 2008 were included. Ultrasonogram was performed by the same sonologist and P/C ratio was determined by dividing maximum anteroposterior pelvic diameter with maximum cortical thickness. Results: Among a total of 111 children, 87 (78%) improved on conservative management while 24 (22%) required pyeloplasty. The mean (± SD) P/C ratio was 2.7 ± 2.18 in those improved on conservative management while 13.5 ± 1.48 in those who required surgery (P < 0.01). All (22/22) children with P/C ratio of 12 or above required pyeloplasty, while 2/5 with P/C ratio 8-12 and none (0/84) with P/C ratio less than 8 required pyeloplasty (P<0.01). Conclusions: P/C ratio could be used as a marker of PUJ obstruction in children with hydronephrosis.

Voiding urosonography: Contrast-enhanced ultrasound cystography to diagnose vesico-ureteric reflux: A pilot study

We report two children with hydronephrosis, in whom we have utilized voiding urosonography (VUS) in the evaluation of vesico-ureteric reflux. With wider availability of ultrasound contrast agents and high-end ultrasound machines, VUS is likely to become a popular tool to diagnose or exclude VUR.

All that seems to be miliary mottling is not always due to tuberculosis: A case report

A 5-year-old child was presented to a general practitioner with cough and wheezing for a fortnight’s duration. He neither had a past history of wheezing nor a family history of bronchial asthma. There was no history of contact with tuberculosis. The only clinical findings were bilateral basal lung wheezing and crepitation. He did not improve with bronchodilator and antibiotic treatment. A chest radiograph revealed miliary mottling (Figure 1a). Blood parameters were normal, and the Mantoux test, gastric juice for acid fast bacilli and TB quantiferon test were negative. However since miliary mottling was seen, the child was treated empirically with anti-tuberculosis treatment but showed no improvement neither clinically nor radiologically. Further physical examination on review after 6 weeks revealed a 3 2 cm scalp swelling in the left parietal region. A skeletal survey then revealed two well-defined lytic lesions in the skull. (Figure 1b).The thoracic computed tomography (CT) showed randomly distributed nodular shadows in both lung fields (Figure 1c). Histopathological examination of the scalp swelling was suggestive of Langerhans’s cell histiocytosis (LCH). The only lesions found were those in the skull and the lungs. A lung biopsy was refused by his parents. The child was categorised as Group III LCH with high-risk organ involvement (Group III is single system and any risk organ involved; spleen, liver, hematopoietic system and lungs are classified as risk organs). He was started on Inj. Vinblastine and oral Prednisolone, and after 12 cycles the child showed healing radiologically. Currently, the child is on continuation phase with third weekly chemotherapy with Inj. Vinblastine, oral Prednisolone and daily 6 Mercaptopurine for 1 year. Since it is not an isolated pulmonary involvement and after 12 weeks of chemotherapy there is a reduction in the pulmonary lesion as seen in X-ray and CT films, a diagnosis of LCH with pulmonary involvement was made.

Correlation and Predictive Value of the FDG uptake within Primary Mass in Non-small Cell Lung Carcinoma and Incidence of Distal Metastases

Introduction: Identification of tumour anatomic and functional features may allow us a better understanding of cancer dissemination. Here, we investigated how 18-Fluorine -Fluoro-2-Deoxyglucose [FDG] uptake influences the incidence of distal metastases. Material and Methods: We retrospectively evaluated 18-Fluorine -Fluoro-2-Deoxyglucose Positron emission tomography integrated with computed tomography [FDG-PET/CT] of 35 patients with Non-Small cell carcinoma [NSCLC], who had come for pre-treatment staging of the disease. Results: The mean FDG uptake of the tumour was maximum Standardized Uptake value [SUV max] of 10.73. 21 of the 35 patients had metastases. Metastases to the bone was the most frequent. The Pearson correlation between the FDG uptake and incidence of metastases was 0.013, suggesting negligent linear correlation between the two. Conclusion: Non-small cell lung carcinoma tumour have a favoured spread to the bones. FDG uptake cannot be taken as an independent parameter to predict the incidence of metastases in NSCLC

Orphan disease: Cherubism, optic atrophy, and short stature

A 12-year-old female presented with complaints of progressive visual impairment in both her eyes. On clinical examination, she was short for her age and her ophthalmoscopic examination revealed bilateral optic atrophy. Computed tomography of the patient revealed multiple expansile lytic lesions of mandible suggesting cherubism. The optic atrophy was confirmed on magnetic resonance imaging, which additionally revealed bilateral retrocerebellar arachnoid cysts. This association of cherubism with optic atrophy and short stature was grouped as orphan disease by National Institutes of Health and only one case was reported in the literature so far.

Duodenal lymphangitis carcinomatosa: A rare case.

Duodenal lymphangitis carcinomatosa has been sporadically described, and little attention has been paid so far. To our knowledge, no data on radiological findings for this rare entity has been published. We report a case of duodenal lymphangitis carcinomatosa secondary to gallbladder mass in a 44-year-old Indian man to focus on the radiological diagnosis, which was further confirmed by endoscopic-guided biopsy and immunohistochemical analysis.