Utilidad del Renograma Diurético tras la Pieloplastia en la Población Pediátrica. ¿Es Necesario de Rutina?

PURPOSE: The diuretic renal scan (MAG3) continues being the gold standard to test the improvement of the urinary drainage after pyeloplasty. Recent researches suggest that there are certain parameters of ultrasound (US) that may indicate an adequate urinary drainage during the follow-up. Our aim is to prove if the measurement of the anteroposterior diameter (APD) of renal pelvis by USS after the pyeloplasty may be a valid screening method to select those patients who also require a MAG3. METHODS: We retrospectively study the patients who underwent pyeloplasty between 2010 and 2019. The sample was divided in two groups depending of the increase or non-increase in the pelvic APD on postoperative US. The results of the MAG3 and the US of both groups were compared in relation to the presence or absence of obstruction and the need for repyeloplasty. RESULTS: We included a total of 124 pyeloplasty, with a median age of 6 months (IQR 4-36); 12 patients showed an increase in pelvic APD, of those 5 had an obstructive MAG3 and renal function >10%, requiring reoperation. Of the 112 patients in whom the pelvic APD did not increase, only one patient needed reoperation due to obstruction in the MAG3, showing the same pre and postoperative pelvic APD. The sensitivity (S) of the US was 83.33% and the specificity (E) was 94.07%. CONCLUSION: A decrease of the renal pelvic APD between US before and after surgery appears to be enough to exclude those patients who will not to develop a recurrence of ureteropelvic junction obstruction (UPJO). In the rest of the patients, it would be necessary study the urinary drainage using MAG3, avoiding its inherent drawbacks in all patients undergoing pyeloplasty.

[Pyeloplasty and vascular crossing detection: Surgical approach influence on pieloureteral junction stricture.] / Pieloplastia y detección de cruces vasculares: análisis de la influencia del abordaje quirúrgico en la evolución de la estenosis de la unión pieloureteral.

OBJECTIVE: Polar vessels are related with pyelo-ureteral stenosis (PUE) in 5-10% of the patients. In the 24% of these cases an intrinsic cause of stenosis can also be found. An increased incidence of polar vessels is found in laparoscopic surgery, compare to open procedures. Our study analyses this difference in our hospital, studying its influence in the aetiology of the disease.MATERIAL AND METHODS: Descriptive and retrospective study of patients operated in our hospital of pyeloplasty, because of PUE between 2009 and 2017. Patients have been divided in two groups: operated by laparoscopy (PL), or operated by conventional surgery (PA). All cases in which polar vessels were seen in TC where excluded. Each group included 47 patients. RESULTS: We found no statistical differences in the age of surgery of the two groups (36,1±41,3 months PL/31,8±37,2 months PA; p=0.527). Overall, 18 polar vessels were found, 15 in PL and 3 in PA. 6 patients of the PA group presented recurrence of the obstruction, and in 2 of them, polar vessels were found in the second surgery. All the 18th cases presented anomalies in the histological study related with inflammation or fibrosis. CONCLUSIONS: The laparoscopic approach allows a better vision of crossing vessels in the cases of extrinsic PUE. Dismembered pyeloplasty might be the best treatment, as an intrinsic cause of obstruction cannot be ruled out according to the observed histological alterations.

OBJETIVO: La incidencia de vasos polares como causa de estenosis pielo-ureteral (EPU) es del 5-10%. En un 24% de los casos asocia, además, una estenosis intrínseca. La aplicación de la laparoscopia para la realización de la pieloplastia ha aumentado significativamente la detección de cruces vasculares respecto a la cirugía abierta. El objetivo del estudio es analizar esta diferencia en nuestro centro, valorando su repercusión en el cuadro de obstrucción.MATERIAL Y MÉTODOS: Estudio descriptivo y retrospectivo de pacientes intervenidos mediante pieloplastia por EPU entre 2009 y 2017. Los pacientes se han dividido en dos grupos: intervenidos por vía laparoscópica (PL) o por cirugía abierta (PA), excluyéndose los casos diagnosticados previamente de vaso polar. La muestra incluyó un total de 94 pacientes, 47 en cada grupo. RESULTADOS: No se han encontrado diferencias estadísticamente significativas en la edad de intervención de ambos grupos (36,1±41,3 meses PL/31,8±37,2 meses PA; p=0,527). Se detectaron 18 vasos polares en total, 15 en PL y 3 en PA. 6 pacientes del grupo PA presentaron recidiva de la obstrucción y 2 de ellos presentaron cruces vasculares no detectados en la primera cirugía. En los 18 casos se encontraron alteraciones histológicas de tipo inflamatorio/fibrosis. CONCLUSIONES: La laparoscopia ofrece una visión mas detallada de la vascularización del riñón, permitiendo una mayor detección de vasos polares frente a la PA. La pieloplastia desmembrada constituye el tratamiento con mejores tasas de éxito, pues no se puede descartar un componente intrínseco obstructivo, además de la compresión vascular.

Pieloplastia y detección de cruces vasculares: análisis de la influencia del abordaje quirúrgico en la evolución de la estenosis de la unión pieloureteral / Pyeloplasty and vascular crossing detection: Surgical approach influence on pieloureteral junction stricture

OBJETIVO: La incidencia de vasos polares como causa de estenosis pielo-ureteral (EPU) es del 5-10%. En un 24% de los casos asocia, además, una estenosis intrínseca. La aplicación de la laparoscopia para la realización de la pieloplastia ha aumentado significativamente la detección de cruces vasculares respecto a la cirugía abierta. El objetivo del estudio es analizar esta diferencia en nuestro centro, valorando su repercusión en el cuadro de obstrucción. MATERIAL Y MÉTODOS: Estudio descriptivo y retrospectivo de pacientes intervenidos mediante pieloplastia por EPU entre 2009 y 2017. Los pacientes se han dividido en dos grupos: intervenidos por vía laparoscópica (PL) o por cirugía abierta (PA), excluyéndose los casos diagnosticados previamente de vaso polar. La muestra incluyó un total de 94 pacientes, 47 en cada grupo. RESULTADOS: No se han encontrado diferencias estadísticamente significativas en la edad de intervención de ambos grupos (36,1±41,3 meses PL/31,8±37,2 meses PA; p = 0,527). Se detectaron 18 vasos polares en total, 15 en PL y 3 en PA. 6 pacientes del grupo PA presentaron recidiva de la obstrucción y 2 de ellos presentaron cruces vasculares no detectados en la primera cirugía. En los 18 casos se encontraron alteraciones histológicas de tipo inflamatorio/fibrosis. CONCLUSIONES: La laparoscopia ofrece una visión mas detallada de la vascularización del riñón, permitiendo una mayor detección de vasos polares frente a la PA. La pieloplastia desmembrada constituye el tratamiento con mejores tasas de éxito, pues no se puede descartar un componente intrínseco obstructivo, además de la compresión vascular

OBJECTIVE: Polar vessels are related with pyelo-ureteral stenosis (PUE) in 5-10% of the patients. In the 24% of these cases an intrinsic cause of stenosis can also be found. An increased incidence of polar vessels is found in laparoscopic surgery, compare to open procedures. Our study analyses this difference in our hospital, studying its influence in the aetiology of the disease. MATERIAL AND METHODS: Descriptive and retrospective study of patients operated in our hospital of pyeloplasty, because of PUE between 2009 and 2017. Patients have been divided in two groups: operated by laparoscopy (PL), or operated by conventional surgery (PA). All cases in which polar vessels were seen in TC where excluded. Each group included 47 patients. RESULTS: We found no statistical differences in the age of surgery of the two groups (36,1±41,3 months PL/31,8±37,2 months PA; p = 0.527). Overall, 18 polar vessels were found, 15 in PL and 3 in PA. 6 patients of the PA group presented recurrence of the obstruction, and in 2 of them, polar vessels were found in the second surgery. All the 18th cases presented anomalies in the histological study related with inflammation or fibrosis. CONCLUSIONS: The laparoscopic approach allows a better vision of crossing vessels in the cases of extrinsic PUE. Dismembered pyeloplasty might be the best treatment, as an intrinsic cause of obstruction cannot be ruled out according to the observed histological alterations

[How do renal function and dilation change after pieloplasty surgery in children?] / ¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica?

OBJECTIVE: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. METHODS: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (<20%), diminished (20-40%), normal (40-55%) and supranormal (>55%). RESULTS: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (<20%) (mean 9.2+/-8.9) or supranormal (>55%) (mean -8.7+/-8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6+/-2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6+/-2.2) (p<0.0001), except in cases presenting complications. CONCLUSIONS: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty.

OBJETIVO: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros.MÉTODOS: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (<20%), regular (20-40%), normal (40-55%) y supranormal (>55%). RESULTADOS: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala <20% (media 9,2 +/-8,9) o cuando es supranormal >55% (media -8,7+/-8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6+/-2,2). La dilatación renal presentó cambios significativos (p<0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/-1,2), excepto cuando se habían producido complicaciones. CONCLUSIONES: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia.

¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica? / How do renal function and dilation change after pieloplasty surgery in children?

Objetivo: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros. Métodos: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (< 20%), regular (20-40%), normal (40-55%) y supranormal (> 55%). Resultados: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala < 20% (media 9,2 +/-8,9) o cuando es supranormal > 55% (media -8,7 +/- 8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6 +/- 2,2). La dilatación renal presentó cambios significativos (p < 0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/- 1,2), excepto cuando se habían producido complicaciones. Conclusiones: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia

Objective: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. Methods: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (< 20%), diminished (20-40%), normal (40-55%) and supranormal (> 55%). Results: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (< 20%) (mean 9.2 +/- 8.9) or supranormal (> 55%) (mean -8.7 +/- 8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6 +/- 2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6 +/- 2.2) (p < 0.0001), except in cases presenting complications. Conclusions: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty

[Endoscopically treated vesicoureteral reflux: Evolution of the recurrences.] / Evolución de los casos de recidiva del reflujo vesico ureteral resuelto endoscópicamente.

OBJECTIVES: In recent years, different studies have mentioned the recurrence of vesicoureteral reflux (VUR) endoscopically resolved, an exceptional event after open surgery. The aim of this study is to describe the evolution of the cases of recurrence identified in our center to assess the importance of this event. METHOD: We have identified the cases of VUR that recurred after successful endoscopic treatment in our anesdepartment. We have analyzed diagnostic tests, management and final outcome. RESULTS: In our series, we have a 19.5% incidence of VUR recurrence after endoscopic correction. Out of these patients, 66.2% were asymptomatic. Ultrasound (US) showed modifications only in two of the cases. Five of them had worsen differential renal function in the Tc- 99 dimercapto succinyl choline acid scan (DMSA). We performed a new endoscopic procedure in 49 ureteral units with a success rate of 75.5%. CONCLUSIONS: Most patients with VUR recurrence were asymptomatic, with no alterations in US or DMSA scan. Both endoscopic treatment or surveillance might be appropriate in this setting. These data lead us to reckon that the systematic search for VUR relapse in the asymptomatic patient might not be necessary. Similarly, ultrasound or DMSA monitoring should be aimed to the assessment of established reflux nephropathy, regardless of the possibility of recurrence.

Evolución de los casos de recidiva del reflujo vesico ureteral resuelto endoscópicamente / Endoscopically treated vesicoureteral reflux: Evolution of the recurrences

OBJETIVOS: Cada vez más estudios mencionan la incidencia de recidiva del reflujo vesicoureteral (RVU) tratado endoscópicamente, evento excepcional tras cirugía abierta. El objetivo de este trabajo es describir la evolución posterior de los casos identificados en nuestro centro para valorar la importancia de este evento. MÉTODO: Se han analizado los casos de RVU recidivado tras tratamiento endoscópico con éxito en nuestro departamento. Se han revisado pruebas complementarias, manejo posterior y evolución final. RESULTADOS: En nuestra serie, tenemos una incidencia de recidiva del RVU resuelto endoscópicamente del 19,5%. De ellas, 66,2% estaban asintomáticos. La ecografía de control presentaba alteraciones solo en dos de los casos. En cinco de ellos había deterioro de la función renal en el estudio gammagráfico realizado con ácido Tc-99 dimercaptosuccínico (DMSA). Se realizó de nuevo tratamiento endoscópico en 49 unidades con una tasa de éxito del 75,5%. CONCLUSIONES: La mayor parte de los pacientes que presentaron recidiva del RVU se encontraban asintomáticos, sin clínica ni alteraciones en ecografía o DMSA. El tratamiento endoscópico o la observación pueden ser alternativas válidas en estos pacientes. Estos datos nos llevan a replantearnos la búsqueda sistemática de la recidiva en el paciente asintomático. Asimismo, la realización de ecografía o DMSA en el seguimiento es de interés fundamental para la valoración de la nefropatía cicatricial (NC) ya establecida, independientemente de la recidiva

OBJECTIVES: In recent years, different studies have mentioned the recurrence of vesicoureteral reflux (VUR) endoscopically resolved, an exceptional event after open surgery. The aim of this study is to describe the evolution of the cases of recurrence identified in our center to assess the importance of this event. METHOD: We have identified the cases of VUR thatrecurred after successful endoscopic treatment in our department. We have analyzed diagnostic tests, management and final outcome. RESULTS: In our series, we have a 19.5% incidence of VUR recurrence after endoscopic correction. Out of these patients, 66.2% were asymptomatic. Ultrasound (US) showed modifications only in two of the cases. Five of them had worsen differential renal function in the Tc- 99 dimercapto succinyl choline acid scan (DMSA). We performed a new endoscopic procedure in 49 ureteral units with a success rate of 75.5%. CONCLUSIONS: Most patients with VUR recurrence were asymptomatic, with no alterations in US or DMSA scan. Both endoscopic treatment or surveillance might be appropriate in this setting. These data lead us to reckon that the systematic search for VUR relapse in the asymptomatic patient might not be necessary. Similarly, ultrasound or DMSA monitoring should be aimed to the assessment of established reflux nephropathy, regardless of the possibility of recurrence

Laparoendoscopic single-site nephrectomy in children: Is it a good alternative to conventional laparoscopic approach?

BACKGROUND: Minimally invasive surgery is considered to be the gold standard treatment for nephrectomy in children. In recent decades it has been proposed that laparoendoscopic single-site (LESS) surgery is a feasible alternative to perform laparoscopic nephrectomies. OBJECTIVE: The aim of our study was to compare the safety and efficacy of LESS against conventional laparoscopic (CL) nephrectomy. STUDY DESIGN: From March 2010 to November 2012 charts of pediatric patients who underwent laparoscopic nephrectomy at our tertiary center were revised. The data from 23 nephrectomies performed by either LESS or conventional laparoscopic approach were analyzed retrospectively. A transperitoneal approach was selected for both modalities. Indications for surgery included multicystic dysplastic kidneys (MCDK), hydronephrosis, vesicoureteral reflux (VUR), and renal dysplasia. Malignancy and previous abdominal interventions were exclusion criteria. Differences with a p value less than 0.05 were considered to be statistically significant. RESULTS: Twenty-three laparoscopic nephrectomies were performed, 13 by CL (53.5%) and 10 by LESS (46.5%). The mean age of patients was 3.29 ± 3.5 years. There were no significant differences in age, gender, laterality of pathology, size of the kidneys, and surgical indications between the groups (p = 0.067, 0.431, 0.94, 0.644, and 0.078, respectively). The mean operative times were 120 min for LESS and 132.7 min for CL (p = 0.334). No procedures required conversion to open surgery or to standard laparoscopy. There was one intraoperative complication in each group (p = 0.845). The mean length of stay (LOS), narcotic usages, and postoperative complications were similar in both groups. DISCUSSION: To overcome technical difficulties of the LESS approach, articulated tools have been developed. However, they may be not suitable for use with younger children. Although we performed LESS nephrectomies with conventional laparoscopic instruments, in our study, LESS and CL approach were comparable in terms of operative time, analgesic therapy, LOS, and complications. CONCLUSIONS: LESS nephrectomy for benign kidney diseases performed by skilled laparoscopic surgeons is safe and comparable with CL technique in pediatric patients. However, although minimally invasive development pushes towards "a scar-free surgery" (see Figure), these approaches have been performed in only a few centers in the world. Prospective studies comparing both approaches are necessary to verify the advantages of LESS nephrectomy in children.

Endoscopic Treatment of Vesicoureteral Reflux in Infants. Can We Do It and Should We Do It?

OBJECTIVE: To evaluate the outcomes of endoscopic treatment of vesicoureteral reflux (VUR) performed on infants, and to discuss the possible role of this approach in selected cases. MATERIAL AND METHODS: A retrospective analysis was conducted on the patients who underwent endoscopic injection of a bulking substance for VUR in our institution, and a comparison was made with patients treated during infancy and those treated later in life. RESULTS: A total of 463 ureteral units were included (296 children), of whom 47 were patients less than 1 year of age (infants, INF group); the remaining 416 were included in a second group (children, CHL). In this study, the percentage of high-grade VUR and presence of reflux nephropathy were significantly higher in younger patients. Both early failure and recurrence rate were significantly higher in the INF group when compared with the CHL group. No complications were observed in the INF group. CONCLUSION: Endoscopic treatment of VUR is feasible in patients less than 1 year of age. The effectiveness is lower than when patients are treated at a later age but was still over 80% in our series. There were no complications reported related to the procedure itself or to the general anesthesia. Once it is known that endoscopic treatment of VUR can be performed, controversy arises about the indication of treating patients with VUR. Careful selection of VUR cases that are less likely to spontaneously resolve, presence of breakthrough infections, and parental preference, all play a role in the decision-making process.