Prenatal imaging features and postnatal outcomes of isolated fetal duplex renal collecting system: A systematic review and meta-analysis.

OBJECTIVES: To perform a systematic review of studies reporting the outcome of fetuses with a prenatal diagnosis of isolated duplex collecting system (DCS). METHODS: Inclusion criteria were studies reporting the outcome of fetuses with a prenatal diagnosis of isolated DCS, defined as DCS not associated with other major structural anomalies at the time of diagnosis. The outcomes observed were: imaging features of DCS on prenatal ultrasound, associated anomalies detected exclusively at prenatal follow-up ultrasound and at birth, abnormal karyotype, symptoms at birth (including vesicoureteral reflux [VUR] and urinary tract infections [UTI]), need for and type of surgical approach, complications after surgery, and accuracy of prenatal ultrasound in correctly identifying this anomaly. RESULTS: Eleven studies (284 fetuses with a prenatal diagnosis of DCS) were included. On ultrasound, DCS was associated with ureterocele in 70.7% and with megaureter in 36.6% of cases. Worsening of pelvic/ureteric dilatation was reported to occur in 41.3% of fetuses. At birth, 4.3% of fetuses affected by DCS showed associated renal anomalies. After birth, VUR and UTI presented in 51.3% and 21.7% of children respectively, while 33.6% required surgery. Prenatal diagnosis of DCS was confirmed in 90.9% of included cases. CONCLUSION: DCS diagnosed prenatally is associated with a generally good outcome. Prenatal ultrasound has a good diagnostic accuracy, while detailed postnatal assessment is required in order to identify associated renal anomalies.

Pediatric laparo-endoscopic single site partial nephrectomy: feasibility in infants and small children for upper urinary tract duplication anomalies.

OBJECTIVE: To assess the feasibility and outcomes of laparo-endoscopic single site (LESS) partial nephrectomy (PN) in infants and small children for upper urinary tract duplication anomalies. MATERIALS AND METHODS: The medical records of all patients undergoing LESS PN at a single pediatric institution were retrospectively reviewed for patient demographics, perioperative details, and outcomes. A cystoscopy was initially performed to place an externalized catheter into the ureter of the ipsilateral normal renal moiety. An Olympus TriPort, an Olympus Endoeye flexible tip laparoscope, standard 3- or 5-mm instrumentation, and a LigaSure Blunt were utilized. RESULTS: Four children (two boys, two girls) underwent LESS PN. Three patients underwent upper pole PN and one underwent lower pole PN. All procedures were performed for poorly functioning obstructed renal moieties (one ureterocele, one ureteropelvic junction obstruction and vesicoureteral reflux, and two ectopic ureters). Median age was 6.2 months (range 2.5-16.4 months). Median weight was 7.7 kg (range 6.1-12.6 kg). Median operative time was 126 min (range 97-180 min). No patient received inpatient postoperative narcotics. Median follow-up was 9.9 months (range 6.2-19.1 months). No postoperative complications were noted. Postoperative renal ultrasound demonstrated successful resection in all patients. CONCLUSIONS: LESS PN is technically feasible, safe, and effective for upper urinary tract duplication anomalies in infants and small children.

Symptomatic ureteric triplex in a child.

We describe a case of a triplex system in a 4-year-old girl that was associated with a ureterocele and vesicoureteric reflux and causing symptomatic culture-proven urinary tract infections. Undetected on preoperative ultrasound imaging and micturating cystourethrogram, this was discovered at the time of a planned left heminephrectomy. The redundant system having been removed the patient is now asymptomatic.

Unusual presentation of bilateral ureteroceles with ureterolithiasis in a patient after robotic prostatectomy.

We present a unique case of incidentally discovered symptomatic, stone-laden ureteroceles after robotic prostatectomy at a high-volume institution. The 2-month postoperative timeline to presentation and laser unroofing management strategy for bilateral ureteroceles after robotic prostatectomy are described.

[Urinary tract duplication]. / Duplicaciones del tracto urinario.

OBJECTIVES: Review the clinical and radiological characteristics of the different kinds of urinary tract duplications, assessing the outcome of the cases and the incidence of renal parenchymal injury. MATERIAL AND METHODS: A retrospective study was performed including 301 children diagnosed of renal duplication by urological ultrasound, voiding cystourethrogram (VCUG) and 99-technetium renal scintigraphy (DMSA). RESULTS: They were classified in four groups. The first consisted of 166 (55.1%) cases that had complete ureteral duplication without an obstructive component (CD). The cases that had an upper system obstruction due to an ectopic ureter (EU), 19 (6.3%), or an ureterocele (UTC), 35 (11.6%), were divided into two different groups. The fourth group 81 (26.9%) had incomplete ureteral duplication. The nephro-urological study was performed in 181/301 after a urinary tract infection; in 100/301 after a prenatal finding of hydronephrosis. It was a casual diagnosis in 20/301. The percentage upper kidney dilation in the diagnostic ultrasound was significantly higher in those with EU 16/19 (84%) and in those with UTC 33/35 (94%), compared with the upper pole dilations found in the CD 35/166 (21%) and ID 21/81 (25%). Surgery was performed in 96/166 (41%) of the CD, 7/81 of the ID, 16/19 (84%) of the EU, and 34/35 (97%) of the UTC. Three cases with EU and 8 with UTC needed a second surgery, and 3 a third one. No scintigraphy changes were observed in 58% of the patients in the CD group, 87% in the ID group, 29% in the EU group, and 5% in the UTC group. As regards the renal duplications who did not have surgery, it was found that there were 98 refluxing units in the CD, and 74 in the ID. The spontaneous resolution of the vesicoureteral reflux (VUR) was 80% in the CD, and 90% in the ID (McNemar test P<.001). The average healing time ranged from 1 year to 5 years (Mean: 3 years and 3 months). CONCLUSION: The patients with higher risk of having renal injury are those who presented with a duplication with upper kidney obstruction due to ectopic insertion of the ureter, particularly due to an ureterocele.

Simplified upper pole nephrectomy: initial experience.

OBJECTIVE: To assess the results of an upper pole nephrectomy technique on 5 children. MATERIALS AND METHODS: Upper pole nephrectomy was performed on 5 children, including 4 females and 1 male. Age ranged from 3 to 6 years old. The technique was performed without initial dissection of the renal pedicle. The upper pole is incised and removed. Upon its complete dissection, the segment that drains the upper pole is easily identified, clamped and sectioned. RESULTS: Three children with ureterocele and 2 with ectopic ureter underwent this procedure. There was no intra- or postoperative complication with this technique. DSMA scintigraphy showed no decrease in renal function in the remaining kidney following the procedure. CONCLUSION: The polar nephrectomy technique is simple, and has the advantage of not approaching the renal hilum, which makes surgery less laborious and prevents risk of renal damage, hemorrhage and decreased function in the remaining renal portion.

Simplified upper pole nephrectomy: initial experience

OBJECTIVE: To assess the results of an upper pole nephrectomy technique on 5 children. MATERIALS AND METHODS: Upper pole nephrectomy was performed on 5 children, including 4 females and 1 male. Age ranged from 3 to 6 years old. The technique was performed without initial dissection of the renal pedicle. The upper pole is incised and removed. Upon its complete dissection, the segment that drains the upper pole is easily identified, clamped and sectioned. RESULTS: Three children with ureterocele and 2 with ectopic ureter underwent this procedure. There was no intra- or postoperative complication with this technique. DSMA scintigraphy showed no decrease in renal function in the remaining kidney following the procedure. CONCLUSION: The polar nephrectomy technique is simple, and has the advantage of not approaching the renal hilum, which makes surgery less laborious and prevents risk of renal damage, hemorrhage and decreased function in the remaining renal portion.

Obstructive ureterocele-an ongoing challenge.

Ureterocele is a cystic dilatation of the intravesical ureter that is most commonly observed in females and children, and usually affects the upper moiety of a complete pyeloureteral duplication. According to their position, ureteroceles are divided into intravesical, when the ureterocele is completely contained inside the bladder, and extravesical when part of the cyst extends to the urethra or bladder neck. Most ureteroceles are diagnosed in utero or immediately after birth during an echographic screening of renal malformations. Severe, febrile urinary tract infection is the most common postnatal presentation of ureteroceles, but they may, rarely, prolapse and acutely obstruct the bladder outlet. Once an ureterocele is identified sonographically, a voiding cystourethrogram to detect vesicoureteral reflux (VUR) and a 99m-technetium dimercapto-succinic acid renal scan to evaluate the function of the different portions of the kidney are mandatory. VUR in the lower pole is observed in 50% of cases and in the contralateral kidney in 25%. Simple endoscopic puncture of the ureterocele has recently been advocated as an emergency therapy for infected or obstructing ureteroceles and as an elective therapy for intravesical ureteroceles. The rate of additional surgery after elective endoscopic puncture of an orthotopic ureterocele ranges from 7 to 23%. Treatment of ectopic ureteroceles is more challenging and both endoscopic puncture and upper pole partial nephrectomy frequently require additional surgery at the bladder level. The reoperation rate after endoscopic treatment varies from 48 to 100%. It is 15 to 20% after upper pole partial nephrectomy if VUR was absent before the operation, but is as high as 50-100% when VUR was present. Thus, endoscopic incision is appropriate as an emergency treatment or when dealing with a completely intravesical ureterocele. Upper pole partial nephrectomy is the elective treatment for an ectopic ureterocele without preoperative VUR. In an ectopic ureterocele with VUR, no matter which type of primary therapy has been chosen, a secondary procedure at the bladder level, involving ureterocele removal and reimplantation of the ureter(s), should be anticipated.

Endoscopic management of milk of calcium-filled ureterocele stump.

A 38-year-old woman with a duplicated right collecting system and a history of right upper-pole heminephrectomy was referred for persistent dysuria and right lower-quadrant abdominal discomfort. Imaging identified a remnant ureter and a ureterocele filled with what appeared to be a large homogenous stone. At cystoscopy, the ureterocele was incised with a holmium:YAG laser, releasing a large quantity of white milky fluid (milk of calcium). There was no evidence of any solid material. Endoscopic evaluation should be the first step in patients with stones in a ureteral stump because milk of calcium may be the etiology of what appears to be a large stone burden in an obstructed system.

Antenatal hydronephrosis: evaluation and outcome.

We present a comprehensive and current review of the etiology, evaluation, treatment, and outcome of antenatal hydronephrosis. When a diagnosis of antenatal hydronephrosis is made, many questions regarding pregnancy, prenatal care, intervention, and what may be expected after birth are raised. Debate and controversy exist on the diagnosis and subsequent evaluation and management of the child with antenatal hydronephrosis. A review of the literature and our own experience with antenatal hydronephrosis are presented in order to guide the physician who is caring for mother and child.

Extensive surgery on the trigone for complete ureteral duplication does not cause incontinence or voiding problems.

OBJECTIVES: To evaluate whether extensive trigonal surgery for duplicated kidneys is harmful for later bladder and urethral function. METHODS: Of 201 surgically treated children with kidney and ureteral duplication, 145 were followed up for at least 1 year. The mean follow-up was 5 years (range 1 to 15), and all patients were at least 7 years old at the date of their last follow-up visit. Trigone surgery was performed in 105 children; bilateral trigonal surgery in 26, unroofing in 25, and total excision in 5. On all later consultations, the presence of infection, voiding habits, continence pattern, and ultrasound findings for residual urine volume and kidney function were noted. Children with recurrent urinary tract infection or dysfunctional voiding for more than 2 years underwent a urodynamic examination. RESULTS: Nine children, of whom five were boys, had nocturnal enuresis only. Eight patients had day and nighttime wetting. Seven of the 8 patients had recurrent urinary infections; urodynamic evaluation revealed a high compliance (with residual urine) in three of these children and four had detrusor instability. One girl had an irregular bladder neck, with stress incontinence. All reflux, whether surgically or conservatively treated and also three of four occurring de novo, disappeared within 1 year after surgery. In the group without voiding dysfunctions, seven cystitis and five pyelonephritis attacks occurred. CONCLUSIONS: Neither extensive trigonal surgery nor pre-existing trigonal deformation by ureteroceles provokes later bladder dysfunction.

A review of ninety-two obstructive megaureters in children.

OBJECTIVES: The evolution of clinical presentation, age of surgery and therapeutic approach of obstructive nonrefluxing megaureters (OMU) in children throughout the years has been retrospectively evaluated. METHODS: 78 children with 92 stenotic ureterovesical junctions (UVJ) were reviewed. 66 underwent surgery at a median age of 20 months, after a median of 10.5 months of conservative treatment with prophylactic antibiotics. 21 OMU were diagnosed prenatally, 71 because of symptoms at later age. 15 ureters (12 children) (24% in the prenatal, 14% in the second group) were treated in a conservative way for 2 years with antibiotics. In the prenatal group 33% needed a reimplantation with tailoring and 10% without tailoring while in the other group the figures are reversed: 39% without and 21% with tailoring. 28% in the prenatal group and 17% of the second group were reimplanted at a mean of 15 months after a primary cutaneous ureterostomy. Three of 5 ureteroceles were treated by endoscopic incision; 4 had an immediate nephroureterectomy. The mean follow-up is >70 months. RESULTS: By prenatal diagnosis the number of conservatively treated cases increased from 14 to 24%. Indications for surgery remained unchanged: recurrent infection and poor kidney function. Both approaches resulted in stabilization of pretreatment renal function; nearly half of the DMSA scans showed a R:L difference of >20% at follow-up. Ureterostomy for infected deteriorating kidneys rapidly ameliorated the function and resulted in shrinking of the ureteral diameter making tailoring at reimplantation unnecessary. One of the 3 endoscopically incised ureteroceles required later reintervention. CONCLUSIONS: Male:female (3:1), left:right (2:1) prevalence and high associated urological (30%) and nonurological (19%) pathology is found. Unsatisfactory reliability of tests for obstruction diagnosis and a referral bias explains the larger number of conservatively treated ureters in the prenatal group. Despite prenatal diagnosis, the age for surgery was not altered since the indications remained identical. Most OMU can be treated by a simple or tailored reimplantation of the ureter after resection of the stenotic segment. A temporary ureterostomy in small children with refractory infections restores function and avoids the necessity for tailoring at final reconstruction. One of 3 endoscopically incised ureteroceles needed surgery at a later stage. DMSA shows stable function after reimplantation.

Surgical management of complete ureteric duplication abnormalities.

In 2 decades (1974-1993), the senior author (S.A.) managed 148 patients with various abnormalities associated with complete ureteric duplication. Included were 72 patients with primary vesicoureteric reflux, 50 with ureteroceles, and 26 with upper-pole ectopic ureters. The majority of the patients were female, and the common clinical presentations included urinary tract infection (UTI), UTI with septicemia, and urinary incontinence. Ten cases were diagnosed after recognition of a renal abnormality on prenatal ultrasonography, an avenue that has provided new challenges, new opportunities, and new dilemmas. This review article is based on the authors' experience together with an analysis of current emphasis on early diagnosis, minimal surgery, and maximum preservation of renal function.

Ureteral duplication and its complications.

Duplication of the ureters is a common anomaly and is frequently encountered by radiologists. Duplication may be either complete or incomplete and is often accompanied by various complications. Incomplete duplication is most often associated with ureteroureteral reflux or ureteropelvic junction obstruction of the lower pole of the kidney. Complete duplication is most often associated with vesicoureteral reflux, ectopic ureterocele, or ectopic ureteral insertion, all of which are more common in girls than in boys. Vesicoureteral reflux affects the lower pole and can be outgrown, as in nonduplicated systems. Ectopic ureterocele and ectopic ureteral insertion affect the upper pole. The ectopic ureterocele produces a filling defect of variable size in the bladder; it can be identified with contrast material studies or ultrasound. Ectopic ureters may function poorly, be difficult to detect, and cause enuresis in girls. A fourth complication, ureteropelvic junction obstruction, occurs only in the lower pole and is seen in more boys than girls. Anatomic variants or anomalies as well as suboptimal imaging techniques can either simulate or obscure duplication, making diagnosis difficult. However, familiarity with the embryology of duplication and an awareness of the potential pitfalls of excretory urography and voiding cystourethrography will foster an understanding of the varied appearances and associated complications of both incomplete and complete duplication.