Prevalence and implications of perinephric fluid on renal point-of-care ultrasound in the emergency department.

BACKGROUND: Point-of-care ultrasound (PoCUS) is commonly utilized in the setting of renal colic. The presence of perinephric fluid may be an overlooked finding associated with ureteral obstruction. Our aims were to determine the prevalence of perinephric fluid on emergency physician-performed PoCUS and to determine whether perinephric fluid was associated with stone size or urologic intervention. METHODS: This was a 12-month cross-sectional study at an academic emergency department (ED) that took place from January 1, 2022, to December 31, 2022. All adult ED patients ≥18 years of age who had a renal PoCUS examination performed were included. Patients with missing or inadequate PoCUS images were excluded. Investigators blinded to PoCUS images and interpretations performed chart review for demographic data and outcome variables, while separate investigators blinded to clinical data reviewed PoCUS images to assess for perinephric fluid and hydronephrosis. A chi-square analysis was used to determine significance of association between perinephric fluid and outcome variables (stone size, urologic intervention). RESULTS: There were 442 patients screened; 18 were excluded due to inadequate images and 4 were repeat visits of which only the initial visit was analyzed. Of the remaining 420 patients included, the prevalence of perinephric fluid was 6.2% (n = 26). Most patients (23/26) with perinephric fluid had final diagnoses consistent with ureterolithiasis. Hydronephrosis was present in 115 of the 420 patients (27.4%) and of these, 22 (19.1%) had perinephric fluid which was significantly associated with a need for urologic intervention; odds ratio (OR) 10.38 (95% CI 2.70-39.85), p < 0.01. Among the 67 patients with confirmed ureterolithiasis on computed tomography, perinephric fluid was associated with stone size ≥5 mm; OR 4.00 (95% CI 1.01-15.85), p = 0.04. CONCLUSION: The prevalence of perinephric fluid on emergency physician-performed renal PoCUS was 6.2% of all studies and 19.1% of patients with hydronephrosis. In the setting of ureterolithiasis, perinephric fluid was associated with larger stone size and need for urologic intervention.

The role of circumcision in preventing urinary tract infections in children with antenatal hydronephrosis: Systematic review and meta-analysis.

INTRODUCTION: Circumcision has been reported to reduce the risk of urinary tract infections (UTIs) in boys with antenatal hydronephrosis (HN). Our aim was to compare the incidence of UTIs in circumcised vs. uncircumcised boys with antenatal HN by conducting a systematic review and meta-analysis. STUDY DESIGN: A comprehensive search was performed until December 2022. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included: UTIs, continuous antibiotic prophylaxis (CAP) use, renal outcomes, and circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed. RESULTS: Twenty-three studies describing 9093 boys with antenatal HN were identified, including 4677 uncircumcised and 4416 circumcised boys. Overall effect estimates demonstrate that circumcised boys have significantly reduced odds of developing any UTI [OR 0.26, 95%CI 0.21, 0.32; p < 0.001]]. In addition, there a significantly reduced odds of developing UTI when circumcised and on CAP [OR 0.19, 95% CI 0.13, 0.30; p < 0.001]. When stratifying by etiology, circumcision reduced the odds of UTI in boys with isolated HN [OR 0.33, 95% CI 0.16, 0.68; p = 0.003], vesicoureteral reflux [OR 0.23, 95% CI 0.13, 0.42; P < 0.00001], or with posterior urethral valves [OR 0.29, 95% CI 0.13, 0.64; p = 0.002]. DISCUSSION: Circumcision reduces the incidence of UTIs in boys with antenatal HN. This review is limited by the varied definitions of UTIs and inconsistent reporting on HN etiology, renal outcomes, and circumcision complications. CONCLUSIONS: Circumcision should be considered in boys with antenatal HN to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with HN.

Ketamine uropathy: Clinical experience in a high prevalence center.

OBJECTIVES: Ketamine uropathy causes inflammatory changes to the urothelium, manifesting as significant lower urinary tract symptoms, small bladder capacity, and pelvic pain. Upper tract involvement and hydronephrosis can occur. Data from UK centers are limited, and no formal treatment guidelines exist. PATIENTS AND METHODS: All patients with ketamine uropathy presenting to our unit over an 11-year period were identified through operative and clinic lists, emergency presentations, and a prospectively collected local database. Demographic data, biochemical findings, imaging techniques, and both medical and surgical management were recorded. RESULTS: A total of 81 patients with ketamine uropathy were identified from 2011 to 2022; however, a large proportion presented from 2018 onwards. The average age at presentation was 26 years (interquartile range [IQR]: 27-34), 72.8% were male, and average follow-up time was 34 months (IQR: 8-46). Therapeutic interventions included anticholinergic medication, cystodistension, and intravesical sodium hyaluronate. Hydronephrosis was present in 20 (24.7%) patients and nephrostomy insertion was required in six. One patient underwent bladder augmentation surgery. Serum gamma-glutamyl transferase and length of follow-up were significantly higher in patients with hydronephrosis. Adherence to follow-up was poor. CONCLUSIONS: We present a large cohort of patients with ketamine uropathy from a small town in the UK which is unusual. The incidence appears to be rising, in-keeping with increasing recreational ketamine use and should be of concern to urologists. Abstinence is a key aspect of management, and a multi-disciplinary approach works best particularly as many patients are lost to follow-up. The development of formal guidance would be helpful.

Circumcision reduces urinary tract infection in children with antenatal hydronephrosis: Systematic review and meta-analysis.

INTRODUCTION: Urinary tract infection (UTI) is more prevalent in boys with antenatal hydronephrosis (ANH). Circumcision is known to lessen the risk of UTI. This study was performed to examine the associations between circumcision and UTI among patients with ANH. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed for conducting this systematic review and meta-analysis. PubMed, ScienceDirect, EMBASE, and Cochrane Library databases were searched through August 4th, 2022 to identify eligible studies. The risk of bias was measured using the Newcastle-Ottawa Scale (NOS). Review manager 5.4 was used for all analysis. RESULTS: A total of 21 studies involving 8,968 patients with ANH were included in the meta-analysis. The incidences of UTI were 18.1% in the uncircumcised group and 4.9% in the circumcised group. From analysis, circumcision had significant protective effect against UTI with pooled OR of 0.28 (95% CI 0.23-0.32). The significant protective effects were also found in subgroup analysis of hydronephrosis etiology, including vesicoureteral reflux (pooled OR of 0.24; 95% CI 0.17-0.32), obstructive hydronephrosis (pooled OR of 0.34; 95% CI 0.21-0.53), and posterior urethral valve (pooled OR of 0.28; 95% CI 0.16-0.52). CONCLUSION: Our meta-analysis showed that circumcision was associated with a decreased incidence of UTI in children with ANH. This benefit was consistent irrespective of the underlying cause of hydronephrosis.

Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux.

INTRODUCTION: With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. OBJECTIVE: In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. METHODS: An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. RESULTS: 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. DISCUSSION: The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study. CONCLUSIONS: De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.

Continuous antibiotic prophylaxis in isolated prenatal hydronephrosis.

BACKGROUND: Prenatal hydronephrosis (PNH) is one of the most common congenital anomalies and can increase the risk of developing a urinary tract infection (UTI) in the first two years of life. Continuous antibiotic prophylaxis (CAP) has been recommended empirically to prevent UTI in children with PNH, but its use has been controversial. OBJECTIVE: We describe the incidence of UTI in children with isolated PNH of the renal pelvis without ureteral dilation. Our objective was to compare patients receiving and not receiving CAP and determine whether CAP is beneficial at preventing UTI in children with isolated PNH. STUDY DESIGN: Children with confirmed PNH were enrolled between 2008 and 2020 into the Society for Fetal Urology Hydronephrosis Registry. Children with isolated dilation of the renal pelvis without ureteral or bladder abnormality were included. The primary outcome was development of a UTI, comparing patients who were prescribed and not prescribed CAP. RESULTS: In this cohort of 801 children, 76% were male, and 35% had high grade hydronephrosis (SFU grades 3-4). CAP was prescribed in 34% of children. The UTI rate among all children with isolated PNH was 4.2%. Independent predictors of UTI were female sex (HR = 13, 95% CI: 3.8-40, p = 0.0001), intact prepuce (HR = 5.1, 95% CI: 1.4-18, p = 0.01) and high grade hydronephrosis (HR = 2.0, 95% CI: 0.99-4.0, p = 0.05; Table) on multivariable analysis. For patients on CAP, the UTI rate was 4.0% compared to 4.3% without CAP (p = 0.76). The risk of UTI during follow-up was not significantly different between patients who received CAP and patients who were not exposed to CAP; adjusting for sex, circumcision status and hydronephrosis grade (HR = 0.72, 95% CI: 0.34-1.5, p = 0.38). In sub-group analysis of patients at higher risk of UTI (uncircumcised males, females and high grade hydronephrosis), CAP use was not associated with a statistically significant reduction in UTI. CONCLUSIONS: The overall UTI rate in children with isolated PNH is very low at 4.2%. In the overall population of patients with isolated PNH, CAP was not associated with reduction in UTI risk, although the limitations in our study make characterizing CAP effectiveness difficult. Clinicians should consider risk factors prior to placing all patients with isolated PNH on CAP.

The association between the congenital heart diseases and congenital anomalies of the kidney and the urinary tract in nonsyndromic children.

Several congenital heart diseases (CHD) are present in children with congenital anomalies of the kidney and the urinary tract (CAKUT) in syndromic or nonsyndromic patterns. The purpose of this study was to identify nonsyndromic children with CAKUT who required echocardiographic evaluation and to find the prevalence of CHD in these patients. Retrospective chart review of nonsyndromic patients with CAKUT between 2012 and 2018 was conducted. Types of congenital anomalies of the kidney and urinary tract and echocardiogram reports of the patients, age, gender, prematurity, prenatal diagnosis of CAKUT, and family history were noted. Among 806 children with CAKUT, 135 patients underwent transthoracic echocardiographic evaluation and CHD was detected in 91 (11.2%). The most common type of CHD was secundum type atrial septal defect that was found in 73 (80.2%) patients. On the other hand, the most frequent types of congenital anomalies of the kidney and the urinary tract were isolated hydronephrosis and primary vesicoureteral reflux (61.4% and 12.8%, respectively). Our results showed that 75.8% of the patients with congenital heart diseases had isolated hydronephrosis. Finally, only 18 (2.2%) cases out of 806 patients that were evaluated via transthoracic echocardiography due to the clinical findings and family history had a CHD that required close (<6 months) follow-up. Congenital heart diseases that required close follow-up are rarely observed in nonsyndromic patients with CAKUT. Therefore, we suggest echocardiography should be performed in cases of clinical suspicion and family history rather than routinely in this patient group.

[Clinical analysis of ureteral endometriosis complicated with hydronephrosis:92 cases series].

Objective: To investigate the diagnosis, treatment and prognosis of ureteral endometriosis with hydronephrosis. Methods: A retrospective study was performed of 92 cases diagnosed as ureteral endometriosis with surgery confirmed in Peking University First Hospital from January 2000 to January 2021. Results: The incidence of ureteral endometriosis was 0.9% (92/10 222), with an average age of (40.0±6.0) years. Among 92 cases, urological symptoms and pelvic pain including dysmenorrheal, periodic abdominal pain were the main forms of clinical characteristics, while 11 patients (12%, 11/92) were asymptomatic. All patients with ureteral endometriosis had hydronephrosis and hydroureter before surgery, hydronephrosis were left sided in 48 (52%, 48/92) patients, right sided in 39 (42%, 39/92) patients, both sided in 5 (5%,5/92) patients. The distal and middle sections of ureteral obstructions existed in 73 (79%, 73/92) patients and 19 (21%, 19/92) patients, respectively. Out of the 92 ureteral lesions 71 (77%, 71/92) patients were extrinsic lesions, 21 (23%, 21/92) patients presented intrinsic lesions. Of the 38 cases who took preoperative radionuclide renal dynamic imaging examination, there were 6 (16%, 6/38) cases of mildly damaged, 7 (18%, 7/38) cases of moderately dameged, 14 (37%, 14/38) cases of severely damaged, and 11 (29%, 11/38) cases of normal renal function. Laparotomy was decided in 25 (27%, 25/92) patients, and laparoscopic surgery in 67 (73%, 67/92) patients. In cases of ureteral surgery, ureterolysis, partial ureteral resection and ureterocystoneostomy, partial ureteral resection and end-to-end ureteral anastomosis and nephroureterectomy were undertaken in 52 (57%, 52/92), 20 (22%, 20/92), 12 (13%, 12/92) and 8 (9%, 8/92) patients separately. The median follow up was 108 months (range: 6 to 240 months). During the follow-up period, 68 (87%, 68/78) patients took urinary ultrasound after surgery, and 60 (88%, 60/68) cases of hydronephrosis disappeared, and 8 (12%, 8/68) cases were better than before. Conclusion: Most of the patients with ureteral endometriosis are impaired with renal function, and early surgical treatment could effectively relieve urinary obstruction and promote the recovery of renal function.

Risk of urinary tract infection in patients with hydroureter: An analysis from the Society of Fetal Urology Prenatal Hydronephrosis Registry.

BACKGROUND: Prenatal hydronephrosis is one of the most common anomalies detected on prenatal ultrasonography. Patients with prenatal hydronephrosis and ureteral dilation are at increased risk of urinary tract infection (UTI) and continuous antibiotic prophylaxis (CAP) is recommended. However, current guidelines do not define the minimum ureteral diameter that would be considered a dilated ureter in these patients. OBJECTIVE: We evaluate the definition of clinically relevant hydroureter, its association with UTI, and the impact of CAP. STUDY DESIGN: Patients with prenatal hydronephrosis from seven centers were enrolled into the Society for Fetal Urology Prenatal Hydronephrosis Registry from 2008 to 2020. Patients with ureteral measurement on ultrasound were included. Patients with ureterocele, ectopic ureter, neurogenic bladder, posterior urethral valves, horseshoe or solitary kidney, known ureteropelvic junction obstruction, or follow-up less than one month were excluded. Primary outcome was UTI. Analyses were performed using Cox regression. RESULTS: Of the 1406 patients enrolled in the registry, 237 were included. Seventy-six percent were male, ureteral diameter ranged from 1 to 34 mm, and median follow-up was 2.2 years. Patients with ureters 7 mm or greater had nearly three times the risk of UTI adjusting for sex, circumcision status, antibiotic prophylaxis and hydronephrosis grade (HR = 2.7, 95% CI: 1.1-6.5, p = 0.03; Figure). In patients who underwent voiding cystourethrogram (VCUG; 200/237), ureteral dilation of 7 mm or more identified patients at increased UTI risk controlling for sex, circumcision status, vesicoureteral reflux and hydronephrosis grade (HR = 2.3, 95% CI: 0.97-5.6, p = 0.06). CAP was significantly protective against UTI (HR = 0.50 (95% CI: 0.28-0.87), p = 0.01). Among patients who underwent VCUG and did not have vesicoureteral reflux, ureteral dilation 7 mm or greater corresponded with higher UTI risk compared to ureteral diameter less than 7 mm on multivariable analysis (HR = 4.6, 95% CI: 1.1-19.5, p = 0.04). CONCLUSIONS: This is the first prospectively collected, multicenter study to demonstrate that hydroureter 7 mm or greater identifies a high-risk group for UTI who benefit from antibiotic prophylaxis. In contrast, patients with prenatal hydronephrosis and non-refluxing hydroureter less than 7 mm may be managed more conservatively.

Including Medical Management in the Urologic Approach to Idiopathic Retroperitoneal Fibrosis.

OBJECTIVE: To characterize the timing and effectiveness of medical management in resolving stent-dependent ureteral compression secondary to idiopathic retroperitoneal fibrosis (RPF), the long-term relevant outcomes, and the side effects of treatment. METHODS: A retrospective review of RPF patients diagnosed from 2002-2018 was performed. Patients with hydronephrosis due to ureteral involvement that were managed with medication and with temporary stenting as needed, but without initial ureterolysis, were included. Patient demographics and RPF management details were obtained, including the following subsequent events: ureterolysis, nephrectomy, recurrent upper tract obstruction, and medication side effects. RESULTS: Fifty-two patients met inclusion criteria. Resolution of ureteral obstruction with medical management and temporary renal drainage as needed occurred in 36 (69%) patients with a median stent duration of 16 months, and median clinical and radiographic follow up of 4.2 and 3.3 years, respectively. Recurrent obstruction after a stent-free period occurred in 9 (18%) patients. Ureterolysis was performed in 8 (15%) patients at a median of 2.2 years for medication intolerance, lack of radiographic response to medication, or persisting pain. Potential medication side effects occurred in 6 (12%) patients. CONCLUSIONS: Medical management supported successful resolution of ureteral obstruction in 69% of patients without the need for ureterolysis after temporary renal drainage using stents, with rare incidence of worsening renal dysfunction or medication side effect. To date, this is the largest reported series of systematically managed RPF patients with obstructive uropathy receiving initial medical therapy and serves to counsel patients and advise urologists and nephrologists of the expected course and advantages and disadvantages of medical versus surgical management.

Moderate Hydronephrosis among Acute Ureteral Calculus on Ultrasonographic Imaging in a Tertiary Care Center in Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Ureteric calculi are lying at any point of ureter from the pelvic ureteric junction to the vesicoureteral junction. If left untreated, ureteropelvic junction obstruction can lead to hydronephrosis. With the improved availability of computed tomography and ultrasound scanning, hydronephrosis is being diagnosed more frequently. The main aim of this study is to find out the prevalence of moderate Hydronephrosis among ureteral calculus on ultrasonography imaging in a tertiary care center of Nepal. METHODS: A descriptive cross-sectional study was conducted among 110 acute ureteral calculus cases at Radiodiagnosis and Imaging Department of Chitwan Medical College and Teaching Hospital, Bharatpur from 15th August 2020 to 15th May 2021. The ethical approval was taken from the Institutional Review Committee of same institution. Convenient sampling technique was used to select the participant. The collected data was entered in excel 16 and analysed in Statistical Package for Social Sciences. Point estimate at 95% Confidence Interval was done and frequency and percentage were calculated. RESULTS: Out of the 110 cases of acute ureteral calculus, 31 (28.2%) (19.79-36.60 at 95% Confidence Interval) has moderate hydronephrosis in the ultrasonographic imaging. The mean age of participants was 31.61±8.51 years and male to female ratio was 1.97:1. Vesicoureteric junction was the most common site for ureteric calculus 39 (35.5%). CONCLUSIONS: The ultrasound is an easy method to be applied, and a fast one to help and diagnose obstructive hydronephrosis. The main causes of hydronephrosis are kidney stones, followed by ureteral stones, with a moderate degree of hydronephrosis.

The Increased Risk of Complicated Ureteral Stones in the Era of COVID-19 Pandemic.

Background: Ureteral stone disease may be an emergent condition if the appropriate management is not performed in a timely manner. As the coronavirus disease 2019 (COVID-19) continues to spread globally, isolation and restriction orders taken by the governments have become the cores to control the pandemic. In this study, we, therefore, aimed to investigate the ureteral stone presentations in a high-volume university hospital during the COVID-19 restriction order period. Materials and Methods: The data of 149 patients who were hospitalized due to ureteral stone both during the COVID-19 pandemic restriction period and the corresponding period (non-COVID-19) of the previous year were collected and analyzed retrospectively. Unpaired Student's t-test was used to compare continuous variables. The categorical data were assessed using Chi-square and Fisher's exact tests. Results: Of 149 patients, 35 were hospitalized in the COVID-19 restrictions period. While the mean age and the stone characteristics of the two groups did not differ significantly, serum creatinine levels (1.9 ± 1.85 vs 1.15 ± 0.64) and the white blood cell counts (12.45 ± 6.54 vs 8.21 ± 4.15) at hospital admission were significantly higher in the COVID-19 restrictions group (p = 0.034 and p = 0.005, respectively). According to the priority classification recommendations of the European Urology Guidelines Office Rapid Reaction Group for urolithiasis applicable during the COVID-19 pandemic, a significant difference was observed between the two periods (X2 = 9.907, p = 0.019). In particular, the rate of emergency cases was found more than threefold in the COVID-19 period. Although there was no significant difference in terms of the grade of hydronephrosis at hospital admission between the two groups, the rates of grade 3 and 4 hydronephrosis were higher in the COVID-period group (1.8- and 3.3-fold, respectively). Conclusion: The rate of complicated ureteral stone disease significantly increased during the COVID-19 restrictions period. Urologists should prioritize the patients most in need of urgent care during COVID-19-like biosocial crisis.

The Impact of Ureteral Access Sheath Use on the Development of Abnormal Postoperative Upper Tract Imaging after Ureteroscopy.

PURPOSE: Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sheath can cause ureteral wall ischemia and ureteral tears, potentially increasing the risk of postoperative ureteral stricture and obstruction. We studied the impact of ureteral access sheath use on postoperative imaging studies. Secondary objectives included studying the impact of other intraoperative parameters on postoperative imaging studies. MATERIALS AND METHODS: A retrospective chart review was conducted of cases that underwent ureteroscopy for nephroureterolithiasis across 2 high volume institutions between January 2012 and September 2016. Patient demographics, cumulative stone size, operative time, use of ureteral access sheath, laser lithotripsy, basket extraction, preoperative ureteral stent and postoperative ureteral stent placement were extracted from the electronic medical record. Findings of followup renal ultrasound, kidney-ureter-bladder x-ray and/or computerized tomography at approximately 8 weeks after surgery were recorded. RESULTS: A total of 1,332 ureteroscopies were performed with 1,060 cases (79.6%) returning for routine upper tract imaging after ureteroscopy. Postoperative hydronephrosis was noted following 127 cases (12.0%). Factors predicting presence of hydronephrosis after ureteroscopy include lower body mass index (p=0.0016), greater cumulative stone size (p=0.0003), increased operative time (p <0.0001), preoperative ureteral stent (OR 1.49, p=0.0299) and postoperative ureteral stent placement (OR 6.43, p=0.0031). Postoperative hydronephrosis was not associated with use of ureteral access sheath, age, laser lithotripsy or basket extraction. CONCLUSIONS: Use of ureteral access sheath did not have a significant impact on development of postoperative hydronephrosis, suggesting ureteral access sheath is safe for use during ureteroscopy. Ureteral strictures remain rare following ureteroscopy, seen in only 1.0% of our cohort. With an observed prevalence of hydronephrosis of 12.0% on followup imaging at 8 weeks, routine upper tract imaging after ureteroscopy remains a valuable prognostic tool.

The Frequency of Familial Congenital Anomalies of the Kidney and Urinary Tract: Should We Screen Asymptomatic First-Degree Relatives Using Urinary Tract Ultrasonography?

INTRODUCTION: The objectives of this study were to determine the incidence of congenital anomalies of the kidney and urinary tract (CAKUT) in asymptomatic first-degree relatives of patients with a CAKUT diagnosis and to evaluate the benefits of such screening. METHODS: Files of patients who were followed up at Cerrahpasa Faculty of Medicine, Pediatric Nephrology Outpatient Clinic, Istanbul University-Cerrahpasa between 1998 and 2016 were examined retrospectively and those with CAKUT were identified. These patients, and their asymptomatic first-degree relatives, were invited to participate in this study. Ultrasonography of the urinary tract was performed in siblings and parents of 145 CAKUT patients (index cases) who could be reached by phone and agreed to participate. RESULTS: A total of 412 asymptomatic first-degree relatives of 145 index patients were screened by ultrasound. CAKUT was diagnosed in 23 individuals among the family members of 21 index subjects. Anomalies detected in asymptomatic first-degree relatives were renal agenesis (RA) and grade 3 hydronephrosis (n = 1), RA (n = 7), renal hypodysplasia (n = 7), grade 2 hydronephrosis (n = 1), and grade 1 hydronephrosis (n = 7). The frequency of familial CAKUT was 14.4%. Familial RA was found in 3 of the 5 families of index cases with RA. CONCLUSION: The ratio of familial CAKUT was 14.4%. The findings of the present study could not support a systematic family screening to all asymptomatic first-degree relatives; however, family screening with ultrasonography can be considered for children with RA.

Hydronephrosis Associated With Pelvic Organ Prolapse: A Systematic Review.

OBJECTIVES: The aim of this study was to report the prevalence of hydronephrosis associated with pelvic organ prolapse (POP). METHODS: We conducted a MEDLINE and PubMed search from 1996 to October 2016 using PRISMA guidelines. Eight studies met criteria for inclusion, including 3 prospective and 5 retrospective studies. RESULTS: The prevalence of hydronephrosis ranged from 3.5% to 30.6% in studies that included multiple stages of prolapse. Hydronephrosis correlated with prolapse severity in multiple studies, but serum creatinine did not consistently predict hydronephrosis. Two studies reported a significantly higher prevalence of hydronephrosis in patients with uterovaginal prolapse compared with vaginal vault prolapse. Complete resolution of hydronephrosis was described in 56% to 83% of patients after undergoing surgical treatment for advanced prolapse. CONCLUSIONS: Hydronephrosis among patients with POP is not rare, and we suggest consideration of upper tract evaluation in patients presenting with POP, particularly in those with advanced uterovaginal prolapse electing to proceed with expectant or conservative management.

Association of spontaneous expulsion with C-reactive protein and other clinico-demographic factors in patients with lower ureteric stone.

The purpose of our study is to analyze the definitive relation of C-reactive protein (CRP) and other factors with the spontaneous stone passage in patients with distal ureteric calculus of 5-10 mm and to calculate the risk of failure of expectant management in patients. 185 patients of ureteric colic, who were subjected to medical expulsive therapy (MET), were included prospectively from August 2016 to May 2018 and followed up for 4 weeks. Patients were divided into two groups. Group A included successful spontaneous passage patients and group B included failure in the same. The parameters analyzed were age, gender, longitudinal and transverse diameter of stone, CRP, total leucocyte count, ureteric diameter and hydroureteronephrosis (HUN). We performed univariate and multivariate analysis. Receiver operating characteristics curve was used to determine the cutoff value for significantly associated variables. 122 (65.90%) and 63 (34.10%) patients were included in group A and B, respectively. In univariate analysis, CRP, longitudinal and transverse diameter of stone, HUN, proximal and distal ureteric diameters were statistically significant. However, in multivariate analysis, only negative CRP (p = 0.002), smaller longitudinal diameter of stone (p < 0.001) and absence of HUN (p = 0.005) were significantly associated with successful expulsion. Cutoff for CRP was 0.41 mg/dl and longitudinal diameter was 6.7 mm. The success rate in the group of patients with no risk factor was 96.7% and with all three risk factors was 16.7%. Patients with a longitudinal diameter of stone > 6.7 mm, HUN, and CRP > 0.41 mg/dl should be considered for early intervention. The success rate of MET can be increased to 86% after exclusion of patients with all three risk factors.

Prospective development of a patient-reported outcomes instrument for desmoid tumors or aggressive fibromatosis.

BACKGROUND: Desmoid tumors (or aggressive fibromatosis) are locally infiltrative connective-tissue tumors that can arise in any anatomic location; they can be asymptomatic, or they can result in pain, deformity, swelling, and loss of mobility and/or threaten visceral organs with bowel perforation, hydronephrosis, neurovascular damage, and other complications. Existing clinical trial endpoints such as the Response Evaluation Criteria in Solid Tumors (version 1.1) and progression-free survival are inadequate in capturing treatment efficacy. This study was designed to develop a novel clinical trial endpoint by capturing patient-reported outcomes (PROs). METHODS: Following best practices in qualitative methodology, this study used concept elicitation (CE) interviews to explore desmoid patients' perspectives on key disease-related symptoms and impacts. Qualitative analysis was performed to determine the relative frequency and disturbance of symptoms and impacts as well as other characteristics of these concepts. A draft PRO scale was then developed and tested with cognitive interviewing. Information from the interviews was subsequently incorporated into the refined PRO scale. RESULTS: CE interviews with desmoid patients (n = 31) helped to identify salient concepts and led to a draft scale that included symptom and impact scales. Cognitive interviews were completed with additional patients (n = 15) across 3 phases. Patient input was used to refine instructions, revise and/or remove items, and modify the response scale. This resulted in an 11-item symptom scale and a 17-item impact scale. CONCLUSIONS: This is the first disease-specific PRO instrument developed for desmoid tumors. The instrument is available as an exploratory endpoint in clinical trials. This study highlights the feasibility and challenges of developing PRO instruments for rare diseases.

A Comparative Analysis of Bladder Pattern of Patients who Underwent In Utero Versus Postnatal Myelomeningocele Repair.

PURPOSE: In utero myelomeningocele closure is a valid alternative to postnatal repair with unclear benefits to bladder function. We compared bladder status in patients who underwent fetal myelomeningocele surgery versus postnatal repair. MATERIALS AND METHODS: We retrospectively reviewed our database, with group 1 consisting of in utero surgery and group 2 consisting of postnatal repair. Group 3 was a subgroup of group 2, including patients initially presenting at age less than 12 months. We recorded medical history, radiological investigation with renal ultrasonography, voiding cystourethrography, urodynamic evaluation and clinical outcome of the bladder pattern after treatment. RESULTS: We identified 88 patients in group 1, 86 in group 2 and 38 in group 3. The incidence of urinary tract infection was higher in the postnatal period (45% vs 20%). Hydronephrosis occurred in 20.7%, 22.6% and 28.9% of patients in groups 1, 2 and 3, respectively. Vesicoureteral reflux was diagnosed in 15% in all groups. Urodynamic data showed a higher prevalence of detrusor overactivity in group 1 and no difference in other urodynamic parameters. The high risk bladder pattern at initial evaluation occurred in 56%, 50% and 46% of patients in groups 1, 2 and 3, respectively. There was a trend to decrease the percentages of the high risk bladder pattern and to increase the normal pattern after treatment in all groups. CONCLUSIONS: In utero repair did not improve urological parameters compared to repair in the postnatal period.

Incidencias de las malformaciones congénitas renales fetales diagnosticadas por ultrasonografía bidimensional / Incidents of fetal renal congenital malformations diagnosed by two-dimensional ultrasonography

Introducción: Las malformaciones congénitas, como defectos estructurales primarios de un órgano, parte de él o de zonas más extensas del organismo, resultan de una alteración inherente en el desarrollo, que se hace evidente al examen físico del feto y del recién nacido, antes o posterior al nacimiento, cuando se hace patente el defecto funcional de un órgano interno afectado anatómicamente. Objetivo: Caracterizar las malformaciones congénitas renales fetales diagnosticadas por ultrasonografía bidimensional, atendidas durante 2015 y 2016. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo en el Centro Provincial de Genética Médica de Santiago de Cuba. Se seleccionó la muestra por el método aleatorio simple para un total de 59 gestantes (34 de 2015 y 25 de 2016), a las que se les diagnosticó algún tipo de malformación congénita renal embriofetal. Resultados: La malformación congénita renal que predominó fue la hidronefrosis, seguida de riñón poliquístico. En los hallazgos morfológicos por ecosonografía predominaron las afecciones del parénquima renal. El sexo fetal de mayor incidencia fue el masculino. La edad gestacional donde incidieron las afecciones renales en gestantes fue de 25 y más semanas, con edad materna entre 20 y 35 años, sin reportar factores genéticos. Los factores de riesgo externos de origen materno que más incidieron fueron la hipertensión arterial, el hábito de fumar y la diabetes. Conclusiones: Se mostraron los principales hallazgos morfológicos ultrasonográficos de los diferentes tipos de malformaciones congénitas renales encontradas, así como se identificaron los diferentes factores de riesgo presentes en las embarazadas. Se observó un predominio de las gestantes a temprana edad con hidronefrosis como el tipo de malformación congénita más frecuente(AU)

Introduction: Congenital malformations, as primary structural defects of an organ, part of it or larger areas of the organism, result from an inherent alteration in development, which is evident from the physical examination of the fetus and the newborn, before or after birth, when the functional defect of an anatomically affected internal organ becomes apparent. Objective: To characterize fetal renal congenital malformations diagnosed by two-dimensional ultrasonography during 2015 and 2016. Methods: A descriptive, longitudinal and prospective study was conducted at the Provincial Center of Medical Genetics in Santiago de Cuba. The sample was selected by simple random method for a total of 59 pregnant women (34 from 2015 and 25 from 2016). They were diagnosed with some type of embryo-fetal renal congenital malformation. Results: The congenital renal malformation that predominated was hydronephrosis, followed by polycystic kidney. In the morphological findings by echocardiography, renal parenchymal conditions predominated. Male fetal sex had the highest incidence. The gestational age where renal conditions affected pregnant women was 25 weeks and more, with maternal age ranging 20 and 35 years, without reporting genetic factors. Smoking and diabetes were the external risk factors of maternal origin that most affected high blood pressure. Conclusions: The main ultrasonographic morphological findings of the different types of congenital renal malformations found were shown, as well as the different risk factors present in pregnant women. A predominance of pregnant women at early age with hydronephrosis was observed as the most common type of congenital malformation(AU)

Significance of third trimester ultrasound in detecting congenital abnormalities of kidney and urinary tract-a prospective study.

INTRODUCTION: Antenatal hydronephrosis is defined as dilatation of the renal pelvis with or without dilatation of calyces in the developing fetus. Although second trimester scan is more sensitive in detecting congenital abnormalities of kidney and urinary tract (CAKUT), it has been suggested that the third trimester scan is more predictive of postnatal outcome. OBJECTIVES: This study aims to determine the incidence of antenatal hydronephrosis at our institution and the significance of third trimester scan in detecting CAKUT postnatally. STUDY DESIGN: It is a prospective observational study. During the 3-year study period from June 2013 to May 2016, all cases of antenatal hydronephrosis, defined as renal pelvic diameter (RPD) ≥4 mm in the second trimester and ≥7 mm in the third trimester scan, diagnosed in the fetal medicine unit of our hospital, were included and were followed up postnatally for 6 months. RESULTS: In the fetal medicine unit, 32,443 women were screened for anomalies, and hydronephrosis was detected in 269 cases. Incidence of antenatal hydronephrosis was observed to be 0.83% in our institution. In second trimester scan, of 80 cases with the left hydronephrosis, only 22 (27.5%) had postnatal CAKUT and of 70 cases with the right hydronephrosis, 18 (25.7%) had CAKUT. In the third trimester scan, it was observed that with RPD >10 mm, on the left side hydronephrosis, 87% had CAKUT on postnatal scan, and 85% with the right hydronephrosis had CAKUT. CONCLUSION: Sixty percent cases of hydronephrosis detected in the second trimester scan resolve in utero. In the third trimester scan with RPD <10 mm, the possibility of postnatal CAKUT is 23%, whereas if RPD is > 10 mm, then the possibility of postnatal CAKUT is 86%.