Frequency of urinary tract infection in children with antenatal diagnosis of urinary tract dilatation.

BACKGROUND: Neonates with congenital urinary tract dilatation (UTD) may have an increased risk of urinary tract infections (UTI). At present, the management of these patients is controversial and the utility of continuous antibiotic prophylaxis (CAP) remains uncertain as the literature presents contradicting evidence. The aim of this observational study was to assess UTI occurrence in children with prenatal diagnosis of urinary collecting system dilatation without antibiotic prophylaxis. METHODS: Between June 2012 and August 2016, we evaluated the incidence of UTI and the clinical and ultrasonography evolution in 407 children with a prenatally diagnosed UTD. All subjects underwent two prenatal ultrasounds scans (USs) at 20 weeks and 30 weeks of gestation and within 1 month of birth. Patients with a confirmed diagnosis of UTD underwent US follow-up at 6, 12 and 24 months of life. According to the UTD classification system stratify risk, after birth UTD were classified into three groups: UTD-P1 (low risk group), UTD-P2 (intermediate risk group), and UTD-P3 (high risk group). Voiding cystourethrogram was performed in all patients who presented a UTI and in those with UTD-P3. No patient underwent CAP. RESULTS: Postnatal US confirmed UTD in 278 out of 428 patients with the following rates: UTD-P1 (126), UTD-P2 (95) and UTD-P3 (57). During postnatal follow-up, 6.83% patients presented a UTI (19 out of 278). Eleven out of 19 had vesicoureteral reflux (VUR), and other four were diagnosed with obstructive uropathy and underwent surgical correction. Five patients presented a UTI reinfection. CONCLUSION: The occurrence of UTI in patients with urinary collecting system dilatation was low. The recent literature reports an increased selection of multirestistant germs in patients with VUR exposed to CAP. This study constitutes a strong hint that routine continuous antibiotic prophylaxis could be avoided in patients with UTD.

Primary vesicoureteral reflux; what have we learnt from the recently published randomized, controlled trials?

In recent years, progress has been made on understanding the relationship between vesicoureteral reflux (VUR) and urinary tract infection (UTI). The findings on recent prospective, randomized, controlled studies have questioned the conventional VUR clinical significance and, therefore, have challenged the traditional diagnostic and therapeutic recommendations. These new studies have redefined the pathogenic role of vesicoureteral reflux in UTI as well as have disputed the routine use of urinary antibiotic prophylaxis to prevent UTI and renal damage in VUR patients. The time to overinvestigate and treat the vast majority of otherwise healthy children who have an uncomplicated UTI with long-term antibiotic prophylaxis seems to be over. Is there a role of severe VUR in the development of chronic renal disease and renal failure? New ideas are needed to answer these questions with the goal to avoid repeating past mistakes when therapeutic choices were based on expert opinions rather than facts.

Common clinical markers predict end-stage renal disease in children with obstructive uropathy.

BACKGROUND: Obstructive uropathy (OU) is a common cause of end-stage renal disease (ESRD) in children. Children who escape the newborn period with mild-to-moderate chronic kidney disease (CKD) continue to be at increased risk. The predictive ability of clinically available markers throughout childhood is poorly defined. METHODS: Patients with OU were identified in the Chronic Kidney Disease in Children Study. The primary outcome of interest was renal replacement therapy (RRT) (cases). Controls were age matched and defined as patients within the OU cohort who did not require RRT during study follow-up. RESULTS: In total, 27 cases and 41 age-matched controls were identified. Median age at baseline and age at outcome measurement were 10 vs. 16 years, respectively. First available glomerular filtration rate (GFR) (36.9 vs. 53.5 mL/min per 1.73 m2), urine protein/creatinine (Cr) (0.40 vs. 0.22 mg/mg) and microalbumin/Cr (0.58 vs. 0.03 mg/mg), and serum CO2 (20 vs. 22 mmol/L) and hemoglobin (12.4 vs. 13.2 g/dL) differed significantly between cases and controls, respectively. GFR declined 3.07 mL/min per 1.73 m2/year faster in cases compared to that in controls (p < 0.0001). Urine protein/Cr and microalbumin/Cr increased by 0.16 and 0.11 per year more in cases compared to those in controls, respectively (p ≤ 0.001 for both). Serum phosphate increased by 0.11 mg/dL and serum albumin and hemoglobin decreased by 0.04 (g/dL) and 0.14 (g/dL) per year more for cases compared to those for controls, respectively (p < 0.05 for all). CONCLUSIONS: Age-specific baseline and longitudinal measures of readily available clinical measures predict progression to ESRD in children with mild-to-moderate CKD from OU.

Incidence of urinary tract infections in infants with antenatally diagnosed hydronephrosis-A retrospective single center study.

OBJECTIVE: To evaluate the incidence of urinary tract infections (UTIs) in infants with antenatal hydronephrosis (AHN). MATERIALS AND METHODS: A cohort of AHN patients admitted to our institution between 2003 and 2013 were identified. Altogether 192 patients with nonrefluxing hydronephrosis (HN, n=135), nonrefluxing hydroureteronephrosis (HUN, n=21), or vesicoureteral reflux (VUR, n=36) were identified. Patients with complex anomalies or neonatal decompression of the urinary tract were excluded. Information about UTIs diagnosed among the AHN patients was collected and compared with data from 58 controls. RESULTS: During the median follow-up time of 2.6 (0.3-11.2) years, 24 (13%) patients (15 (10%) males and 9 (19%) females) and 2 (3%) controls experienced at least one UTI (p=0.033). Eighteen (69%) UTIs were febrile. The males had the first UTI at significantly younger age than the females (0.3, 0.0-1.7years vs. 1.0, 0.4-4.8years, p=0.010). UTI was detected in 15 (63%) patients with grade 4-5 VUR, in 8 (6%) patients with HN, and in one (5%) patient with HUN (p-values <0.001, 0.726 and >0.999 against the controls). None of the patients with grade≤3 VUR had UTI. Fifty-eight percent of the patients with UTI were on antimicrobial prophylaxis. In five (12%) cases UTI appeared within one week after voiding cystourethrography (VCUG). CONCLUSIONS: Infants with AHN and grade 4-5 VUR had the highest risk of UTI. UTIs tented to be more common in females than in males; however, males experienced UTI at younger age than females. VCUG caused UTI in 2.3% in our material. LEVEL OF EVIDENCE: III.

[Imaging strategy for children after a first episode of pyelonephritis]. / Explorations morphologiques après un premier épisode de pyélonéphrite chez l'enfant.

Pyelonephritis is a common bacterial disease in young children and is a serious infection because of its potential to produce renal scarring. One of the concerns of physicians is therefore the diagnosis of uropathy at risk for recurrence of pyelonephritis, especially high-grade reflux. There are no French recommendations on imaging evaluation after a first episode of pyelonephritis. Voiding cystography was systematically proposed years ago and recommended by the American Academy of Pediatrics until 1999. This systematic strategy exposed all children to a painful, irradiating exam, and exposed them to urinary tract infection. The American recommendations changed in 2011 and cystography is now only proposed to children with recurrence of pyelonephritis or with ultrasound abnormalities. A collaborative review of the literature involving the Pediatric Emergency, Nephrology and Surgery Departments at Necker-Enfants-Malades Hospital led us to propose an algorithm for imaging after the first episode of pyelonephritis in children. This algorithm was based on data from the past medical history (results of prenatal ultrasonography or recurrence of pyelonephritis), the results of the ultrasound exam at the time of diagnosis, and the procalcitonin concentration, to limit the indications for voiding cystography, limiting risk for delaying high-grade reflux diagnosis. Children with low risk for high-grade reflux can be followed up with an ultrasound exam 6 months after acute infection.

Misdiagnoses caused by use of indwelling urethral catheters in children with ureterovesical junction anomalies.

PURPOSE: Children commonly undergo vesicograms for diagnosing vesicoureteral reflux (VUR). This requires urethral catheterization with transurethral replacement. We report misdiagnosed or related complications due to indwelling urethral catheters unintentionally placed in the ureter. METHODS: From our computerized urology records over an 18-year period from January 1995 to May 2013, we retrospectively identified nine cases of 1850 vesicograms that had misdirection of a urethral catheter placed in a ureter. Foley catheters with inflating balloons were used to obtain the vesicograms. RESULTS: In all, 1850 vesicograms were performed (746 males, 1104 females; age 1 week to 14 years, mean age 3.8 years) using standard radiological techniques. Size 6-10 Fr indwelling urethral catheters were used, depending on the patient's age and gender. In nine cases (five females, four males), a misdirected urethral catheter was discovered in one of the ureters. The urethral catheter was in the left ureter in four patients and in the right ureter in five patients. Cystoscopic examination found ectopic ureteral openings in six patients: at the bladder neck in four and just below the bladder trigone in two. Three patients in this group with ectopic ureters were followed due a misdiagnosis of VUR. The remaining three patients had grade 3 or 4 VUR. In this group, the catheter passed into the ureter because of the enlarged ureterovesical junction. In one patient with VUR, intraparenchymal fluid leakage and transient hematuria occurred due to the rapid tension increase following the fast injection of contrast with liquid to one ureter. CONCLUSION: Although placing an indwelling urethral catheter is a relatively safe procedure, complications can occur, particularly in patients with ureterovesical anomalies, such as high-grade VUR or an ectopic ureter. Using catheters with inflating balloons can cause rapid increases in tension in the ureter, and related complications.

[MODIFIED Politano-Leadbetter REIMPLANTATION FOR TREATMENT OF CONGENITAL MALFORMATION OF VESICOURETERAL JUNCTION IN CHILDREN].

UNLABELLED: Corresponding author: HUANG Lugang, E-mail: lugang992001@aliyun.com OBJECTIVE: To explore the effectiveness of modified Politano-Leadbetter reimplantation for the treatment of congenital malformation of the vesicoureteral junction in children. METHODS: A retrospective analysis was made on the clinical data of 53 patients with congenital malformation of the vesicoureteral junction treated with modified Politano-Leadbetter reimplantation between June 2000 and October 2014. Of 53 cases, there were 24 boys and 29 girls, aged from 8 months to 7 years (mean, 2.1 years); 23 had congenital vesicoureteral junction obstruction (14 left, 5 right, and 4 bilateral), and 30 had vesicoureteral reflux (12 unilateral, 18 bilateral), which were verified by voiding cystourethrography. The disease duration was from 1 month to 1 year (mean, 5 months). RESULTS: All of the patients underwent modified Politano-Leadbetter reimplantation successfully. The mean operation time was 74 minutes (range, 65-85 minutes) for unilateral cases and 105 minutes (range, 98-130 minutes) for bilateral cases. There was no dysuria, infection of incision, or incision dehiscence after urinary catheter removal. The follow-up time was 6 months to 14 years (median, 28 months); all patients were free from complications of fistula, vesicoureteral reflux, vesicoureteral junction obstruction, or hypertension. The new ureteral orifices had good appearance at 1 month after operation. Urologic ultrasound showed that hydronephrosis relieved at 3 months after operation. Urinary tract infection rate was 13.2% (7/53) during 6 months after operation, which was cured by antibiotics. Voiding cystourethrography showed no vesicoureteral reflux in 32 cases at 6 months after operation. CONCLUSION: The modified Politano-Leadbetter reimplantation simplifies he operation course, which has the longitudinal ureter after operation and is similar to physiological state. It is a safe and effective option for congenital malformation of vesicoureteral junction in children with few complications, especially for patients with unilateral megaloureter.

Single trocar retroperitoneoscopic assisted ipsilateral ureteroureterostomy for ureteral duplication.

The aim of this study is to present the technique and early outcomes of single trocar retroperitoneoscopic assisted ureteroureterostomy for ureteral duplication. The patient was placed in a lateral decubitus position. A skin incision of 11 mm width was made above the iliac crest. The operation was performed through single trocar with operating laparoscope. The two ureters were encircled with a vessel loop and exteriorized outside the retroperitoneal space via trocar incision. The pathologic ureter was divided as low as possible. The recipient ureter was opened longitudinally. End-to-side ureteroureterostomy anastomosis was performed extracorporeally with two running 6/0 PDS sutures. From December 2010 to July 2011, nine patients were operated on using the same technique. Patient's ages ranged from 2 to 72 months. Mean operative time was 78 ± 21 min. There were no intra or postoperative complications. Postoperative stay was 2.6 ± 1.0 days. Follow-up revealed that two renal moieties preserved their functions in all patients. The diameter of involved ureters and pelvises was significantly reduced in all patients. Single trocar retroperitoneoscopic assisted ureteroureterostomy is safe and effective procedure for ureteral duplication.

Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?

PURPOSE: Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group. MATERIALS AND METHODS: A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life. RESULTS: No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status. CONCLUSIONS: Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis.

Candidiasis caused by Candida kefyr in a neonate: case report.

BACKGROUND: Systemic Candidia infections are of major concern in neonates, especially in those with risk factors such as longer use of broad spectrum antibiotics. Recent studies showed that also term babies with underlying gastrointestinal or urinary tract abnormalities are much more prone to systemic Candida infection. We report a very rare case of candidiasis caused by Candida kefyr in a term neonate. CASE PRESENTATION: Renal agenesis on the left side was diagnosed antenatally and anal atresia postnatally. Moreover, a vesico-ureteral-reflux (VUR) grade V was detected by cystography. The first surgical procedure, creating a protective colostoma, was uneventful. Afterwards our patient developed urosepsis caused by Enterococcus faecalis and was treated with piperacillin. The child improved initially, but deteriorated again. A further urine analysis revealed Candida kefyr in a significant number. As antibiotic resistance data about this non-albicans Candida species are limited, we started liposomal amphotericin B (AMB), but later changed to fluconazole after receiving the antibiogram. Candiduria persisted and abdominal imaging showed a Candida pyelonephritis. Since high grade reflux was prevalent we instilled AMB into the child's bladder as a therapeutic approach. While undergoing surgery (creating a neo-rectum) a recto-vesical fistula could be shown and subsequently was resected. The child recovered completely under systemic fluconazole therapy over 3 months. CONCLUSIONS: Candidiasis is still of major concern in neonates with accompanying risk factors. As clinicians are confronted with an increasing number of non-albicans Candida species, knowledge about these pathogens and their sensitivities is of major importance.

Urinary tract anomalies associated with high grade primary vesicoureteral reflux.

BACKGROUND: Few studies have evaluated the significance of associated urological anomalies in vesicoureteral reflux (VUR). The aim of our study was to determine the incidence of associated urological anomalies in patients with high grade VUR and to assess their impact on renal parenchymal scarring. METHODS: We retrospectively reviewed the hospital records of 1,765 consecutive cases diagnosed with high grade VUR (Grade III-V) at our hospital between 1998 and 2010. The diagnosis of VUR was made by a voiding cystourethrogram (VCUG). Renal scarring was evaluated by dimercapto-succinic acid (DMSA) scintigraphy and classified into three groups: mild (focal defects in uptake between 40 and 45%), moderate (uptake of renal radionuclide between 20 and 40%), and severe (shrunken kidney with relative uptake <20%). All associated urological anomalies were diagnosed by ultrasound or VCUG or DMSA scan. RESULTS: Associated urological anomalies were present in 229 (13%) children. There were 87 boys and 142 girls. Duplex kidney was the main associated anomaly occurring in 148 (64.6%) of the 229 patients. Other anomalies were: bladder diverticulum in 29, solitary kidney in 12, ureterocele in 13, hypospadiasis in 11, pelviureteric junction obstruction in 9, malrotated kidney in 3, horseshoe kidney in 2, crossed fused ectopia in 1 and renal cyst in 1. DMSA scan revealed renal scarring in 105 (47.7%) of the 220 children who had a DMSA scan. 75 (50.7%) children with duplex kidneys showed renal scarring. CONCLUSION: Associated urological anomalies occur commonly in patients with high grade VUR. Our data shows that nearly half of the patients with VUR and associated urological anomalies have renal scarring. Early recognition and treatment of VUR patients with associated urological anomalies may decrease the risk of renal parenchymal damage.

Vesico-ureteric reflux: using mouse models to understand a common congenital urinary tract defect.

Vesico-ureteric reflux (VUR) is a common congenital urinary tract defect in which urine flows retrogradely from the bladder to the kidneys because of an abnormally formed uretero-vesical junction. It is associated with recurrent urinary tract infections, renal hypo/dysplasia, reflux nephropathy, hypertension, and end-stage renal disease. In humans, VUR is genetically and phenotypically heterogeneous, encompassing diverse renal and urinary tract phenotypes. To understand the significance of these phenotypes, we and others have used the mouse as a model organism and this has led to the identification of new candidate genes. Through careful phenotypic analysis of these models, a new understanding of the genetics and biology of VUR is now underway.

Polydimethylsiloxane (macroplastique®) injection for vesicoureteral reflux in duplex ureters: a comparison with single renal systems.

OBJECTIVE: VUR in patients with a duplex system (DS) is often treated by open surgery. The aim of this study was to evaluate the efficacy of subureteric polydimethylsiloxane (Macroplastique(®)) injection (SMING) in the management of VUR in duplex and single (SS) renal systems. PATIENTS AND METHODS: Fifteen children (24 refluxing renal units) with VUR in DS underwent SMING. VUR was more frequent in the lower moiety. VUR was graded moderate/severe in 88% of renal units. There was a history of urinary tract infections in 40% of cases. The outcome for DS patients was compared with 44 children (60 refluxing renal units) with moderate/severe VUR in SS. RESULTS: The VUR resolution/improvement rate was 88% in DS and 95% in SS patients. Ureteric reimplantation was required because of recurrent VUR in 13% and 7% of DS and SS groups, respectively. Transient ureteral obstruction was observed in 1/15 and 5/44 patients. Two required double-J ureteric stenting for 3 months. CONCLUSION: SMING seems an effective treatment for VUR in both DS and SS patients, even in severe cases. The complication rate does not significantly differ between the two groups.

Vesicoureteral reflux associated renal damage: congenital reflux nephropathy and acquired renal scarring.

PURPOSE: The pathophysiology, evaluation, description and clinical implications of renal damage associated with vesicoureteral reflux remain controversial. We summarized the current understanding of this important aspect of clinical vesicoureteral reflux. MATERIALS AND METHODS: We performed a detailed review of the literature on clinical, pathological and experimental data related to congenital vesicoureteral reflux and bladder dynamics. We also reviewed the clinical context and imaging evaluation with underlying experimental data related to post-infectious reflux nephropathy. RESULTS: Congenital reflux nephropathy is a pattern of impaired renal function and development with renal dysplasia as the most severe but not the only form. Mechanisms of developmental disruption are potentially related to vesicoureteral reflux dynamics during gestation and associated bladder dynamics, which may continue into postnatal life. Acquired renal injury associated with infection is related to particular bacterial and host factors that determine infection virulence, host inflammatory response and tissue recovery. As best seen on dimercapto-succinic acid scan, acute changes may resolve but may also persist as permanent renal scarring. Specific risk factors for acute pyelonephritis and renal scarring in patients with vesicoureteral reflux include higher reflux grade, dysfunctional voiding/elimination, recurrent pyelonephritic episodes and delayed initiation of antibiotic therapy. Low pressure sterile reflux is not a cause of reflux nephropathy. CONCLUSIONS: Renal damage associated with vesicoureteral reflux may be congenital or acquired and the respective pathophysiological mechanisms are likely different. Congenital damage is often dysplasia, which may be a result of disordered renal development secondary to significant alterations in bladder dynamics. These processes may continue into the newborn period while kidney maturation continues. Recognizing the clinical potential for ongoing effects on renal function and the role of bladder development are important for clinical care. Post-pyelonephritic acquired damage is the result of a complex interaction of host and bacterial factors that leads to acute alterations in renal function, and may lead to permanent renal scarring. Strategies for timely intervention as well as prevention are essential to limit the risk of permanent renal injury, which may predispose to hypertension and renal insufficiency in some patients.

Aerococcus viridans urinary tract infection in a pediatric patient with secondary pseudohypoaldosteronism.

Aerococcus viridans is a catalase-negative gram-positive bacterium rarely found as human pathogen. Some cases of urinary tract infection (UTI) have been described in immunocompromised adults. In this article we describe a UTI case caused by this agent in a child with severe obstructive uropathy, clinically presented with secondary pseudohypoaldosteronism (SPHA). Although A. viridans is rarely associated with child infection, it can be responsible for life threatening conditions/ situations. To our knowledge, A. viridans UTI has never been reported in pediatric patients.

Prevalence of duplex collecting systems in familial vesicoureteral reflux.

PURPOSE: Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood with a reported incidence of 0.8%. Familial nature of vesicoureteral reflux (VUR) is well recognized with a prevalence of 27-51% in siblings of children with VUR and 66% rate of VUR in offsprings of parents with previously diagnosed VUR. Although VUR is known to be the most common abnormality associated with renal duplex systems, the prevalence and significance of renal duplication in familial VUR is not known. The aim of this study was to determine the prevalence and significance of duplex collecting systems in familial VUR. METHODS: Between 1998 and 2009, the parents of 237 index patients with grade III-V VUR were asked permission to screen siblings younger than 6 years old for VUR. A total of 513 children in 237 families were identified to have VUR (237 index patients, 276 siblings). Families were divided into three groups: Group I, families with only boys affected Group II, families with only girls affected and Group III, families with boys and girls affected. RESULTS: In 39 families (16.5%) only boys had VUR (Group I), in 89 families (37.5%) only girls had VUR (Group II) and in 109 families (46%) boys and girls were affected (Group III). Duplex collecting systems were present in 39 (7.6%) patients. The prevalence of duplex systems was significantly higher in Group I (15%) compared to Group II (6%) and Group III (6.4%), (p < 0.01). Duplex systems were present in 15% of boys in Group I and only in 4% of boys in Group III (p < 0.01). Patients with duplex systems had a significantly higher grade of VUR than patients without duplex systems (p < 0.01). CONCLUSION: Families with exclusively boys affected with VUR have a higher rate of prevalence of duplex collecting systems. This has implications for genetic counseling and for modeling the inheritance of VUR.

Five cases of severe vesico-ureteric reflux in a family with an X-linked compatible trait.

Vesico-ureteric reflux (VUR) is one the most common inherited disorder in humans. Even though this defect is common among siblings and parents of index patients (27-40%), the mode of inheritance is not well defined. Parents and siblings (three female and two male) of a 13-year-old girl with end-stage renal failure (ESRF) due to reflux nephropathy were screened for VUR although they had not presented episodes of urinary tract infection. VUR was identified in the father (44 years old) and in all the three sisters (aged 15 years, 16 years and 18 years) while the two brothers (aged 5 years and 8 years) had normal renal ultrasonograms and cystograms. A technetium-99m di-mercapto-succinic acid ((99m)Tc-DMSA) scan demonstrated renal scars in the father and in two of the sisters with VUR. No episodes of urinary infection had been documented for any relatives. Haplotype analysis on the X-chromosome confirmed paternity. This is the first description of VUR compatible with an X-dominant trait. This mode of inheritance must be added to what is already known on familial VUR, and future studies should also consider this possibility.

[Postnatal investigation and outcome of isolated fetal renal pelvis dilatation]. / Exploration post-natale et devenir des pyélectasies foetales isolées.

UNLABELLED: The purpose of this study was to evaluate the prognosis of fetal renal pelvis dilatation in relation to the degree of prenatal dilatation and the postnatal ultrasonography assessment. Based on these results, an algorithm is proposed for the choice of postnatal investigations and follow-up in children with fetal renal pelvis dilatation. MATERIAL AND METHODS: The study was conducted prospectively among 10,677 newborns in Avignon over a nearly 5-year period. Infants with an anteroposterior pelvic diameter (APPD) 5mm or greater in the second trimester were enrolled with a threshold for the normal renal pelvis dimensions increasing with advancing gestation. Prenatal ultrasound was correlated with the results of postnatal investigation and frequency of surgical uropathy was established. RESULTS: Pyelectasis was found in 1% of pregnancies and among 100 infants whose cases were followed, 23 (23%) had uropathies (seven isolated pelviureteric junction obstruction [PUJ], nine isolated vesicoureteral reflux [VUR], three VUR+PUJ, two duplicity, one obstructive megaureter, and one multicystic dysplastic kidney). The largest group of fetuses (66/100) had minor fetal pyelectasis of less than 10mm: in this group, 90% of the infants had no uropathy and there was no surgery. Six of 34 (17%) in the moderate (APPD> or =10 and<15mm) and severe (APPD> or =15mm) fetal pyelectasis groups required surgery, especially those with progressive PUJ obstructions. When postnatal ultrasound was normal in 64 infants (64%), there were only three mild or moderate (grades I-III), asymptomatic, and spontaneously resolving VUR. When pyelectasis was isolated and 10mm< or =APPD<15mm, cystourethrography was normal in 70% of the cases and only four cases of spontaneously resolving VUR were found. Among 23 infants with uropathies, six of 23 required surgery (26%), especially PUJ stenosis (5/6) with APPD greater than 15mm. In the total population of fetal pyelectasis, postnatal ultrasound predicted renal abnormalities with a sensitivity of 87% and a negative predictive value of 95%. CONCLUSION: Normal neonatal ultrasound rarely coexists with significant abnormal findings and there seems to be no need for additional investigations when postnatal echography is normal. Cystourethrography can be delayed when pyelectasis is isolated with 10mm< or =APPD<15mm. Isolated and uninfected cases of VUR do not require surgery and all mild and moderate cases of VUR spontaneously resolved. All PUJ stenoses with APPD greater than 15mm required surgery.

Longitudinal development of renal damage and renal function in infants with high grade vesicoureteral reflux.

PURPOSE: We sought to study renal abnormality and renal function through time in infants with high grade vesicoureteral reflux. MATERIALS AND METHODS: This prospective observational study included 115 infants (80 boys and 35 girls) younger than 1 year with grade III to V vesicoureteral reflux. The diagnosis was made after prenatal ultrasound in 26% of the patients and after urinary tract infection in 71%. Patients were followed by renal scintigraphy, 51chromium edetic acid clearance and video cystometry. Median followup was 62 months. RESULTS: Renal abnormality, which was found in 90% of the children at followup, was generalized in 71% and focal in 29%. The abnormality was bilateral in 28% of the affected patients. Total glomerular filtration rate was less than 80% of expected in 30% of the patients. Single kidney function was less than 40% of expected total glomerular filtration rate in 71% of the patients. Renal status (parenchymal abnormality and function) remained unchanged through time in 84 of 108 available cases (78%), improved in 5 (5%) and deteriorated in 19 (18%). Predictive factors for deterioration were recurrent febrile urinary tract infection, bilateral abnormality and reduced total glomerular filtration rate. Deteriorated renal status was more common in cases diagnosed prenatally than in those detected after urinary tract infection. CONCLUSIONS: Among these infants with high grade vesicoureteral reflux renal abnormality was frequent and was associated with subnormal filtration of one of the kidneys. Decreased total glomerular filtration rate was seen in about a third of the patients. Overall deterioration of renal status was seen in only a fifth of the patients. Infection control seems to be an important factor to minimize the risk.

[Ureter triplex with non-functioning upper pole due to ectopic ureterocele and refluxive third ureter bud : case report and review of the literature]. / Ureter triplex mit afunktionellem Oberpol bei ektoper Ureterozele und refluxiver dritter Ureterknospe : Fallbericht und Literaturübersicht.

We present the case of an 8-month-old boy with ureter triplication on the left side with non-functional upper pole due to ectopic ureterocele and a refluxive third ureter bud. We performed an upper pole heminephroureterectomy with resection of the ureterocele and of the refluxive third ureter bud and reimplantation of the lower pole ureter using the psoas hitch technique.