Dorsal lumbotomy incision in paediatric pyeloplasty.

BACKGROUND: The purpose of the present study was to comprehensively assess the results of surgical management of pelvi-ureteric junction (PUJ) obstruction using lumbotomy as the surgical approach. METHODS: Records of 36 consecutive patients with unilateral PUJ obstruction who underwent pyeloplasty in the last 5 years were reviewed retrospectively. The investigations included renal function tests, ultrasound and serial renal diuretic scans. A micturating cystourethrogram was also done whenever indicated. A dismembered pyeloplasty via lumbotomy was the only surgical approach considered. Thirteen patients had a right pyeloplasty while 23 had a left pyeloplasty. Mean age at diagnosis was 57 months in 31 patients while five were antenatally diagnosed (range 1 month-12 years). Age at surgery ranged from 1 month to 12 years with a mean of 59.9 months. Nine children underwent surgery in infancy. Six patients had a preoperative percutaneous nephrostomy (PCN) placement, five for poorly functioning kidneys (less than 10% split renal function) and one for oliguria. Records were reviewed for age at diagnosis, age at surgery, duration of surgery, preoperative and postoperative split renal function. RESULTS: The follow-up period in the present study ranged from 9 months to 68 months with a mean of 44.9 months. Mean duration of surgery was 78 min of the group as a whole but in PCN patients it was significantly more (100 min vs 71.3 min). Fourteen patients had an improvement in split renal function noticed at 3 and 6 months postoperatively, 17 patients had no change while one patient had a deterioration of split renal function. Four patients had a solitary functioning kidney and in all of these glomerular filtration rate improved postoperatively. Hospital stay was on the average 7.45 days with a range of 6-10 days. However, when a double-J (D-J) stent was used across the anastomosis and the uretero-vesical junction (transrenal D-J stenting), the mean stay was reduced to 3 days. All patients returned to full oral feeds by postoperative day 1. No incidences of wound related problems were encountered. CONCLUSIONS: Pyeloplasty results in predictably good outcome in paediatric PUJ obstruction whenever indicated. The lumbotomy approach avoids muscle cutting, thereby minimizing complications related to wound and assisting with faster recovery. Keeping a double-J (D-J) stent across the anastomosis and the uretero-vesical junction (transrenal D-J stenting) reduces hospital stay.

Have cranio-vertebral junction anomalies been overlooked as a cause of vertebro-basilar insufficiency?

STUDY DESIGN: A prospective controlled study using single photon emission computed tomography (SPECT) to assess cerebellar perfusion in a cohort of 19 patients with congenital cranio-vertebral junction (CVJ) anomalies, with or without vertebro-basilar insufficiency (VBI). OBJECTIVE: To correlate symptoms of VBI with the presence of posterior circulation ischemia in patients with congenital CVJ anomalies, using technetium 99m ethylene cystine dimer SPECT. SUMMARY OF BACKGROUND DATA: Patients with VBI are rarely investigated for CVJ anomalies, despite the fact that a significant number of patients with congenital CVJ anomalies has VBI. There are also no studies quantifying outcome of surgical interventions, such as like occipito-cervical fusion, in patients with VBI and CVJ anomalies. METHODS: There were 19 consecutive patients with congenital CVJ anomalies who were scheduled for combined transoral odontoidectomy and occipito-cervical fusion were included in the study. Technetium 99m ethylene cystine dimer brain SPECT and clinical assessment of all patients was performed in the preoperative period and at 4 weeks after surgery. Before surgery, patients were divided into 2 groups depending on the clinical findings: (1) symptomatic group, consisting of 12 patients having features suggestive of VBI (drop attacks, episodic vertigo, visual disturbances and dysarthria); and (2) control group, consisting of 7 patients without symptoms of VBI. RESULTS: SPECT showed decreased cerebellar perfusion in 75% (n = 9) of patients in the symptomatic group compared to 14% (n = 1) in the control group before surgery (Fisher exact 2-tailed test, P = 0.019). Following surgery, 8 patients (88.9%) in the symptomatic group and none in the control group had improvement in cerebellar perfusion. Two patients in the symptomatic group who had meningitis develop during the postoperative period had a decrease in cerebellar perfusion on follow-up SPECT. Clinically, all patients with improvement in cerebellar perfusion had improvement in the symptoms of VBI at 1 month of follow-up. CONCLUSIONS: A significant number of patients with congenital CVJ anomalies who have symptoms of VBI develop have decreased cerebellar perfusion shown by SPECT. Rigid internal fixation of the CVJ may alleviate symptoms and improve posterior circulation in some of these patients.

Role of plasma renin activity in the management of primary vesicoureteric reflux: a preliminary report.

BACKGROUND: Nonoperative management is the choice of therapy in most patients with primary vesicoureteric reflux (VUR). Such patients are regularly monitored for breakthrough urinary tract infection, deterioration of renal function, and progression/ appearance of new scars as the indicators for switching over to surgical intervention. In this descriptive study, we report our additional observations on serial measurement of plasma renin activity (PRA) in a group of such children followed prospectively. METHODS: Twenty-six children (16 males and 10 females) with various grades (grades I to V) of primary VUR were enrolled. Besides the conventional investigations, we also monitored PRA. Ureteric reimplantation was performed based on established international criteria. PRA levels were correlated with the need for surgical intervention retrospectively. RESULTS: Mean age at presentation was 39.3 months (range, 12 to 120 months). Nineteen children (73%) were subjected to ureteric reimplantation. The mean PRA in this group (N = 19) was 6.97 ng/mL/hour versus 3.28 ng/mL/hour in patients who were continued on nonoperative management (N = 7). Postoperatively, the PRA reduced and stabilized in all 18 patients at a mean value of 5.4 ng/mL/hour. CONCLUSION: The currently accepted end points of medical management are inconsistent. On the other hand, 94.7% of children in the surgical group had shown an activation and a progressive increase in PRA. Postoperatively, the PRA was reduced and stabilized in all these patients. Our preliminary observations suggest that high PRA is a more sensitive indicator for surgical intervention as compared to the existing criteria.