Computed tomographic peritoneography: CT manifestations in the investigation of leaks and abnormal collections in patients on CAPD.

Continuous ambulatory peritoneal dialysis (CAPD) is now a common form of treatment for patients with chronic renal failure. However, peritoneal leaks and abnormal intraperitoneal collections can be problematic in these patients, leading to poor dialysate returns, anterior abdominal wall oedema, and genital oedema. We report on a series of 62 computed tomographic peritoneograms performed using a standard protocol on 39 symptomatic patients over 6 years. Thirty-seven scans identified peritoneal leaks or abnormal collections, including leaks from the present dialysis catheter site and previous catheter sites, and collections in inguinal and abdominal herniae. Three patients had abnormalities at two sites each. Localization of leaks and collections is of direct use when surgical management of these patients is contemplated and this paper aims to illustrate the typical CT findings occurring in these patients.

Radiation disease of the urinary tract: histological features of 18 cases.

AIMS: To study the spectrum of histological changes in the urinary tract caused by pelvic irradiation. METHODS: Biopsy specimens of ureter and bladder and cystectomy specimens from 18 patients who had received pelvic irradiation were studied and the histological features were arbitrarily grouped into early and late changes. RESULTS: A wide range of histological changes were noted of which submucosal inflammation, fibrosis, and epithelial damage were the commonest. Other less common features were interstitial haemorrhage, ureteritis and cystitis cystica, squamous metaplasia of vaginal type and perineural inflammation. CONCLUSIONS: Although epithelial changes were most prominent in early cases and stromal changes in the late cases, there was a continuing spectrum of epithelial damage which persisted many years after initial radiation. Similarly, submucosal fibrosis was equally prominent in early and late phases.

The obstructive diuresis renogram: an appraisal of the significance.

We managed expectantly 23 patients with renal pelvic dilatation and unilaterally obstructive diuresis renograms. Serial renograms showed changes in ipsilateral relative renal function in 8 kidneys (4 deteriorated). Pressure-flow studies demonstrated low pressures on perfusion of 8 kidneys. Eight patients eventually required pyeloplasty, mostly for loin pain. Therefore, serially obstructive diuresis renograms can be associated with preserved renal function, with high pelviocaliceal compliance being a possible explanation.

Mixed mesonephric adenocarcinoma and transitional cell carcinoma of the bladder.

Mesonephric type adenocarcinoma is a very rare tumour in the bladder and bears a resemblance to nephrogenic adenoma. We report (to the best of our knowledge), the first case where the tumour was partly composed of mesonephric and partly of poorly differentiated transitional cell carcinoma. Staining for alpha 1-antitrypsin and carcino-embryonic antigen were positive in the mesonephric component but negative in the transitional cell carcinoma.

Effect of bladder filling on upper tract urodynamics in man.

A group of 21 patients with hydronephrosis but normal bladders had their upper urinary tract pressures monitored while perfusing the affected kidneys through a fine bore nephrostomy tube, initially with the bladder on free drainage and subsequently during bladder filling. In 7 patients the renal pelvic pressures were altered by bladder filling and loin pain was reproduced in 4. It was concluded that with high upper tract flow rates, vesical filling can affect upper tract dynamics and this should be considered when evaluating patients with loin pain or potential obstructive uropathy.

Compliance studies, pressure flow measurements and renal function assessment in patients with upper urinary tract dilatation.

The compliance index was determined in 38 hydronephrotic kidneys undergoing diagnostic pressure flow studies. A good correlation was found between this index and the result of the pressure flow study but no consistent relationship was observed between the index and relative renal function as assessed by renographic means. The ability of the compliance index to predict functional deterioration in patients with hydronephrosis must be questioned.

Bladder smooth muscle dysfunction in patients with irritable bowel syndrome.

Urodynamic studies were carried out on 30 patients with irritable bowel syndrome and 30 matched controls. Fifty per cent of the irritable bowel patients compared with only 13% of the control group had evidence of bladder dysfunction (p = 0.006). In the irritable bowel group detrusor instability was observed in 10 patients compared with only one control subject (p = 0.008). A steep cystometrogram occurred in five irritable bowel patients and three controls (NS). Detrusor instability was most common in patients with a bowel habit characterised by alternating constipation and diarrhoea. This is the first study to provide objective evidence that patients with irritable bowel syndrome may have a disorder of smooth muscle or its innervation that is not confined to the gastrointestinal system.

Pressure changes in the dilated upper urinary tract on perfusion at varying flow rates.

The conventional Whitaker test assesses the pressure response to a constant perfusion rate of 10 ml/min. Twenty-eight kidneys were perfused at increasing flow rates up to 20 ml/min. Nine became obstructed at rates of 12 to 20 ml/min. The feasibility of such a high urine output has been tested and confirmed. The standard Whitaker test may therefore miss some cases with potentially obstructive hydronephrosis, the effects of which may be deleterious to renal function.

Acquired cystic disease of kidney with multiple renal and urothelial neoplasms.

Acquired polycystic disease with concurrent development of renal cell tumours is a well documented complication of long term haemodialysis. We present a case of acquired polycystic disease with renal cell tumours and multifocal urothelial tumours. Only two similar cases have been recorded.

A comparison of diuresis renography, the Whitaker test and renal pelvic morphology in idiopathic hydronephrosis.

Diuresis renography and the Whitaker test are established methods of diagnosing obstruction in dilated renal pelves. These techniques have been compared in 36 patients with radiologically demonstrated idiopathic hydronephrosis and evaluated, where possible, against renal pelvic morphological features. The agreement between the results of the tests was as follows: diuresis renography/Whitaker test 67%; diuresis renography/renal pelvic morphology 74%; Whitaker test/renal pelvic morphology 58%. Both diuresis renography and the Whitaker test are indicated in some cases of idiopathic hydronephrosis.

Diuresis renography and parenchymal transit times in the assessment of renal pelvic dilatation.

A comparison has been made between the results of diuresis renography and deconvolution analysis of the renogram in 36 patients (46 kidneys) with urographically demonstrated renal pelvic dilatation. The mean transit times obtained by deconvolution analysis of the parenchymal renograms of eight normal volunteers had a mean value of 2.8 + 0.6 (S.D.) min, and the upper limit of normal was thus established as 4 min. Twenty-two of 29 kidneys (76%) with nonobstructive diuresis renograms had parenchymal mean transit times of 4 min or below. Fourteen out of 17 kidneys (82%) with obstructive diuresis renograms had parenchymal mean transit times above 4 min. Both investigations may contribute to the noninvasive assessment of dilated renal pelves; the parenchymal retention function (quantified by mean transit time) assesses the effects of dilatation on tubular transit and renal function, whereas the diuresis renogram is a more specific test for evaluating impedance to flow.

Regional renography in segmental renal disease.

Twenty-nine patients with symptomatic segmental renal disorders were studied by regional renography. Twenty-three patients had duplex kidneys and 6 had other segmental disease. Abnormal gamma camera findings included ureteroureteric reflux, vesicoureteric reflux, impaired function, obstruction and non-obstructive dilatation. Comparison between renography and radiology in duplex kidneys showed agreement in 10 cases. In 7 kidneys the gamma camera provided additional information and in 6 cases the X-rays alone were abnormal. It is concluded that regional renography should be performed wherever possible to complement conventional radiology in the functional and urodynamic evaluation of segmental renal disease.

The dilated non-obstructed renal pelvis.

This paper discusses 28 patients with renal pelvic dilatation in whom obstruction was excluded by excretion urography and diuresis renography. The clinical presentation and progress of the patients over a follow-up period of 1 to 5 years are presented. One patient required pyeloplasty, one developed 2 asymptomatic pelvic calculi and one showed some deterioration in function on the affected side. The remaining 25 patients remain well and their follow-up renograms show satisfactory renal function and excretion. Before the advent of objective means of assessing renal function and urodynamics, these patients would probably have been subjected to pyeloplasty. The present study confirms that the correct management of the dilated non-obstructed renal pelvis is conservative.

Diuresis renography and the results of pyeloplasty for idiopathic hydronephrosis.

Eighty-six kidneys in 82 patients have been assessed by diuresis renography after pyeloplasty. A non-obstructed diuresis renogram was found in 64% of kidneys. Ninety per cent of patients were clinically improved by surgery and 51% of cases studied had improved urographic features. Thirty kidneys (29 patients) were assessed both before and after pyeloplasty. An improvement in the diuresis renogram was found in 89% of cases postoperatively. Standard renography demonstrated improved drainage in only 33% of kidneys. These findings are discussed in relation to the value of diuresis renography after pyeloplasty.