Severe complications after endoscopic injection of polydimethylsiloxane for the treatment of vesicoureteral reflux in early childhood.

Endoscopic subureteral injection of bulking agents has become a widespread treatment for vesicoureteral reflux (VUR) in children. Various biological and plastic materials have been introduced for this purpose with different success and complication rates. Evaluations of this method in previous studies have focused on the success rate of eliminating VUR, whereas complications have been less frequently reported in detail. This report describes four children with VUR grade I to IV-V who experienced severe complications after endoscopic treatment with polydimethylsiloxane at the age of 5 months to 7 years. Three children developed urosepsis and two patients obstructive acute renal failure. These complications required repeated hospitalizations with extensive diagnostic and therapeutic procedures. Percutaneous nephrostomy was necessary in three patients and ureteroneocystostomy was eventually performed in all. These observations suggest that endoscopic treatment of VUR in childhood with polydimethylsiloxane can lead to severe postoperative complications and that a standardized follow-up should be an integral part of endoscopic procedures.

Polycythemia and increased erythropoietin in a patient with chronic kidney disease.

BACKGROUND: A 16-year-old white male with a history of obstructive uropathy presented to a pediatric outpatient clinic with a first syncope. At presentation, he had a hemoglobin level of 220 g/l, a serum erythropoietin level of 27.4 U/l and a serum creatinine level of 200.7 micromol/l (2.27 mg/dl). INVESTIGATIONS: Physical examination, serum laboratory analysis, renal ultrasound, MRI, and 99mTc-MAG3 scintigraphy of the kidneys. DIAGNOSIS: Chronic renal insufficiency caused by obstructive hydronephrosis and accompanied by increased erythropoietin levels of renal origin and polycythemia. MANAGEMENT: Serial phlebotomies and laparoscopic removal of the right hydronephrotic kidney.

Laparoscopic dismembered pyeloplasty--the method of choice in the presence of an enlarged renal pelvis and crossing vessels.

OBJECTIVE: Herein we report our experience of 49 consecutive pyeloplasties that were all laparoscopically performed with an intracorporeally sutured anastomosis. We describe the operative technique, complications and outcomes during a follow-up period of 1-53 months (mean 23.2 months). PATIENTS AND METHODS: Forty-nine patients (28 women and 21 men) with a mean age of 34 years (range 6-65 years) underwent a laparoscopic dismembered pyeloplasty because of primary ureteropelvic junction (UPJ) obstruction with hydronephrosis in each case. The preoperative evaluation included an evaluation for pain, an excretory urography (IVP), renal scan and sometimes CT angiography to evaluate for crossing vessels. Follow-up studies included an IVP, renal scan and renal ultrasound 4 weeks postoperatively and every 3 months thereafter. Success was considered as improvement of the pain score and IVP (less hydronephrosis, visible UPJ and/or normalization of drainage) or absence of an obstructive pattern during the washout phase of a renal scan. RESULTS: There was no conversion to open surgery. The mean operative time was 165 min (range 90-240 min). Blood loss was negligible. Crossing vessels were noted in 57.1% of the patients (28/49). Postoperative hospital stay was 3.7 days (range 3-6 days). One patient had a leakage of the anastomosis on postoperative day 1 and needed to undergo laparoscopic repair. The mean follow-up is 23.2 months (range 1-53 months). There was one single late failure. This patient later underwent an open revision of the laparoscopic pyeloplasty. In all other patients (48/49), the obstruction was resolved or significantly improved. The long-term success rate is 97.7%. CONCLUSIONS: The results of dismembered laparoscopic pyeloplasties compare favorably with those achieved by open pyeloplasties with less perioperative morbidity and discomfort. We do believe that laparoscopic dismembered pyeloplasty with an intracorporeal anastomosis is the method of choice in the treatment of the UPJ obstruction in the presence of an enlarged renal pelvis and crossing vessels.