[Renal development long after correction of primary non-refluxing forms of megaureter in children].

We studied the condition and development of 50 kidneys in 45 patients 10-30 years after surgical correction of megaureter. We made resection and neoimplantation of the ureter according to the antireflux technique. By x-ray findings, we estimated area of the kidney, renocortical index and compared them with visual assessment of the condition of the kidney and its pelvicocalicyal system. We have found that correction of the megaureter creates favourable conditions for development of the kidney as shown by good growth of the kidney (area increased 1.5-3.5 fold) in a stable renocortical index. This indicates stabilization of nephrosclerosis and large area of renal parenchyma. However, kidney growth was accompanied with developing nephrosclerosis in 7 cases, in 1 case nephrosclerosis terminated with secondary contraction and a decline of renal function. The condition of the kidney varied due to many factors such as the condition of the immune system, age of the patient, virulence of the microflora, etc., but the key role for the kidney belonged to condition of renal parenchyma before surgical intervention. The data of light optic (53 cases) and electron-microscopies (3 cases) examinations of renal biopsies demonstrated that renal lesions were characterized by congenital structural disorders such as low number of nephrons, the presence of canalicular and glomerular microcysts and other manifestations of hypoplastic dysplasia. Inflammatory infiltration of the cortical and medullary layer interstitium aggravated severity of renal lesion. Various correlation and severity of congenital and aquired lesions characterized condition of the kidney in each individual case. Thus it is necessary to conduct a long-term follow-up and update methods of therapy.

[Pyelonephritis in various types of obstructive uropathies in children]. / O pielonefrite pri nekotorykh vidakh obstruktivnykh uropatii u detii.

Kidney biopsies were examined in 73 children with some forms of obstructive uropathies: vesico-renal reflux and obstructive megaurether. In 59 patients (80%), chronic pyelonephritis was detected. The predominant morphological form of chronic pyelonephritis in patients with obstructive uropathies is a mixed form with a combination of tubulo-stromal-vascular changes. In most patients chronic pyelonephritis was extensive up to the development of nephrosclerosis, in 22% it developed against the background of renal dysplasia. The nature and intensity of pyelonephritis was shown to depend on the severity of congenital pathology of the urinary tracts and the age of the patients.

[Repeat operation to correct the ureteropelvic segment in hydronephrosis in children]. / Povtornaia operativnaia korrektsiia lokhanochno-mochetochnikovogo segmenta pri gidronefroze u detei.

The results of surgical correction of 487 ureteropelvic segments (UPS) were studied in 455 patients (age 4 months to 15 years). Good results were obtained in correction of 477 (98.0%) UPS including 12 after reoperation. Postoperative follow-up lasted for 1 to 25 years. Anastomosis obstruction observed in 12 patients had developed within several postoperative months. In 3 patients it appeared 2-14 years after an effective UPS correction. The obstruction resulted from cicatricial transformation of the ureter and aduject fat with or without obliteration of the anastomosis or ureteral transformation into a rigid connective tissue tube unable to carry the functional load. One of the reasons of connective tissue transformation of the ureter may be urine leakage of the anastomosis. An individual reaction to the suture material (catgut) followed by scar process is also possible. Development of destructive changes many years after successful correction of UPS may arise due to inflammatory process ending in sclerosis. Some moments in pathogenesis of scar transformation of the ureter remains unknown and need further studies. Repeated correction of UPS was effective in all 15 patients. This intervention should be performed at least after 5-6 months after the failure of the first operation. To prevent the scar process, the patients must be followed up for many years and therapeutic methods should be perfected.

[Principles of surgical correction of congenital developmental defects of pelvi-ureteral and vesico-ureteral segments in children]. / Printsipy operativnoi korrektsii vrozhdennykh porokov razvitiia lokhanochno-mochetochnikovogo i puzyrno-mochetochnikovogo segmentov u detei.

A total of 426 children with hydronephrosis, 410 with fourth-degree reflux (506 ureters), and 233 with primary megaureter (307 ureters) were operated on. By the moment of surgery the patients' ages varied from 4 months to 14 years. The results of correction of the pelviureteral segment were studied in all patients in periods of 1-25 years and of vesicoureteral segment in periods of 1-29 years postoperation. The studies and analysis of remote results of surgical treatment indicate that irreversible structural changes in the ureter wall, mainly congenital (developmental defect), play a decisive role in the pathogenesis of urodynamic disorders at various levels of the ureter. Qualitative characteristics of these changes are identical at different levels of the ureter and in different types of dysplasia. The pattern of developmental defect was determined by quantitative ratios of structural involvement of the muscular, connective tissue, and elastic elements of ureteral wall. All this gave grounds for performing similar operations whose basic element was resection of the defective ureteral segment and its replacement by a morphologically and functionally full-value fragment. Such operations were resection of the pelviureteral segment with Anderson-Hynes-Kucera's anastomosis plasty in hydronephrosis and resection of the distal compartment of the ureter with its neoimplantation into the bladder by the antireflux method in dysplasia of the distal part of the ureter. In correction of hydronephrosis good results were attained in 97.8% cases, in fourth-degree reflux in 98% cases, and in primary megaureter in 90.2% cases. High efficiency of resection methods confirms that these operations were pathogenetically justified.

[Surgical correction of hydronephrosis in the retrocaval ureter]. / Operativnaia korrektsiia hidronefroza pri retrokaval'nom raspolozhenii mochetochnika.

The authors operated on 2 patients aged 12 and 13 years who had hydronephrosis and retrocaval ureter. Ureteropelvic segment resection with anastomotic plastic repair were antecavally made by the Anderson-Hynes-Kucera procedure in both patients. Good results were obtained. The follow-ups lasted 1 and 3 years. Histological studies of the ureteropelvic segments resected revealed structural changes in the wall, they were mainly of inborn genesis. The signs of malformations were ureteral wall sclerosis mainly located in the tunica submucosa; impaired myoarchitectonics as hypoplasia and disorganized muscle fascicles. The amount of agrophilic and elastic fibers was decreased. The findings led to the conclusion that the cause of hydronephrosis in the retrocaval ureter is ureteral wall structural abnormalities mainly of inborn genesis rather than the abnormal position of the ureter. These data show it necessary to resect the destructively changed segment to form a pyeloureteral anastomosis by using morphofunctionally normal tissues. The good outcomes of surgical correction of hydronephrosis with antecaval transposition of the anastomosis provide evidence for its pathogenetic rationale.

[Surgical correction of primary nonrefluxing megaureter in children and its remote results]. / Operativnaia korrektsiia pervichnykh nerefliuksiruiushchikh form megauretera u detei i ee otdalennye rezul'taty.

Correction of primary non-reflux megaureter (153 ureters) was made in 136 patients aged 3 months to 14 years. Bilateral disease was in 17 patients. Non-reflux non-obstructive megaureter was in 113 cases, obstructive in 40 cases including association with ureterocele in 23 cases. Resection of distal ureter with its neoimplantation into the urinary bladder according to the antireflux technique was made in 146 patients, endovesical electroperforation and resection of ureterocele were made in 5 and 2 patients, respectively. Good results were obtained in 88.3% (135 ureters), satisfactory in 2.6% (4 ureters), unsatisfactory in 9.1% (14 ureters). After effective correction of megaureter, the treatment should be focused on adequate therapy of pyelonephritis present in 90% examinees, on improvement of urodynamics and stabilization of sclerotic process in renal parenchyma. The patients need long-term follow-up and more effective treatment.

[Status and development of the kidney after surgical treatment of hydronephrosis in children]. / Sostoianie i razvitie pochek posle operativnogo lecheniia gidronefroza u detei.

Development of the kidneys after correction of hydronephrosis was studied in 40 patients operated at the age of 8 months-12 years. Follow-up lasted 10-25 years. X-ray control showed efficiency of correction of the uretheropelvic segment (UPS). Roentgenoplanimetric study demonstrated a uniform 50-100% increase in renal area and its parenchyma in 28 patients (32 kidneys). In 9 patients parenchyma increased 2.5-4-fold, renal area by 50-100%. In three cases parenchyma diminished by 3-10% in growth of the kidney by 24-80%. This evidenced of nephrosclerosis progress. UPS correction favoured renal growth and development. There were only few cases when correction of UPS was positive but nephrosclerosis aggravated. Development of the kidney may depend on many factors such as preoperative condition of the kidney, severity of UPS obstruction, the patient's age, duration and severity of pyelonephritis, dysplasia and age-related immaturity of renal parenchyma, immune status of the organism, microorganism virulence, etc. But decisive was the condition of renal parenchyma before the operation. In 3 patients with progressive nephrosclerosis renal parenchyma affection was additionally characterized by advanced sclerosis and inflammatory infiltration of the intertitium which ended in a poor outcome. The above observations suggest the necessity of long-term postoperative follow-up of the patients to design effective measures aimed at the treatment and prevention of nephrosclerosis.

[Anti-reflux operations in children with primary vesico-renal reflux]. / Antirefliuksnye operatsii u detei s pervichnym veziko-renal'nym refliuksom

Antireflux operations after the Grégoir-Lich technic was performed in 50 children on 72 ureters; resection of the distal ureteral portion with neoimplantation after the Politano-Leadbetter technic was accomplished in 31 patients on 46 ureters; nephroureterectomy-in 4 patients due to destruction of the organ. Morphological studies of 50 by the defect in development of muscles of the distal ureteral portion (diffuse, hyperplasia of muscle bundles, focal or segmental underdevelopment of muscles, etc). In insignificant muscle hypoplasia chronic inflammation resulting in sclerosis is of major importance for pathogenesis of insufficiency of the uretero-vesical segment. The changes described are manifested in the clinico-roentgenological picture of the disease. In reflux, grade III-IV, according to the R. A. Bridge and C. W. Roe classification resection and neoimplantation of the ureter after the Politano-Leadbetter technic seem to be indicated; in grade II antireflux Grégoir-Lich surgery may be performed.

[Organ-preserving surgery in closed injuries of the kidneys in children]. / Organosokhraniaiushchie operatsii pri zakrytykh povrezhdeniiakh pochek u detei.

Fourteen organ-preserving operations were fulfilled for deep ruptures of kidneys in children aged from 2.5 to 14. The examination including echography and dynamic scintigraphy in addition to traditional methods has shown good reestablishment of functioning the damaged kidney. The authors believe the operative organ-preserving treatment to be expedient for deep ruptures of the kidney.

[X-ray control of the kidneys and their development in the long-term period after surgical correction of hydronephrosis in children]. / Rentgenologicheskii kontrol' za sostoianiem i razvitiem pochek v otdalennye sroki posle operativnoi korrektsii gidronefroza u detei.

After surgical correction of hydronephrosis, the development of the kidneys was studied in 40 patients (44 hydronephroses) operated on at the age of 8 months to 12 years. Postoperative follow-ups lasted at least 10 and 25 years. X-ray planimetric studies made it possible to quantitatively characterize the growth of the kidney, the increase or decrease in its parenchymal area, the appearance or progression of prior nephrosclerosis. X-ray studies could yield an objective assessment of the trend in renal development. By supplementing the data of excretory urography, radiological techniques and ultrasonography provided additional data on the kidney and its parenchyma. Analysis of the results of the X-ray planimetric studies have indicated that 28 patients (32 kidneys) had a uniform increase in the areas of the kidney and its parenchyma by 50-100%; in 9 patients, the parenchyma increased by 2.5-4 times, the area of the kidney became only 50-100% larger. There was progression of nephrosclerosis with a 3-10% decrease in the area of parenchyma along with a 24-80% growth of the organ only in 3 cases after a quite satisfactory growth in the organ. These data show it necessary to perform long-term follow-ups of patients under the control of X-ray study as the most objective radiation diagnostic technique.

[Reconstructive surgeries for children with fused kidney hydronephrosis]. / Rekonstruktivnye operatsii pri gidronefroze podkovoobraznoi pochki u detei.

1-19-year follow-up results of plastic surgery for fused kidney hydronephrosis (FKH) in 12 children aged 3-14.5 years (a total of 15 hydronephroses, 3 cases of bilateral disease) were estimated as good. Correction of FKH is performed by resection of the affected ureteropelvic segment with bypass plastic reconstruction according to Andersen-Hynes-Kucera, compulsory total resection of the renal isthmus. Isthmotomy can be conducted only in the presence of connective tissue bridge between the renal poles. Often, renal isthmus consisting of parenchyma is to be removed together with resection of the renal pole (in joint circulation). In addition, for good outcome it is necessary to reconstruct pelvis and (or) perform nephropexy with muscular graft. The operated patients need long-term follow-up, control examinations of the kidney, updated treatment following elimination of the obstruction.

[The correction of primary megaureter in children. The late results]. / Korrektsiia pervichnogo megauretera u detei. Otdalennye rezul'taty.

The surgical intervention on 261 ureterovesicular segments was performed in 202 patients aged 3 months-14 years. All the patients presented with megaureter varying in forms: refluxing megaureter (147 cases), nonrefluxing megaureter (94 cases), megaureter with ureterocele (20 cases). Histological investigations demonstrated congenital structural changes of the same type to be a morphological basis of diverse megaureter forms. These structural changes involved muscular and connective tissue elements of the ureteral wall. Being qualitatively continual, the components varied in quantity thus producing different maldevelopments. Urodynamic dysfunctions depended on ureteral dysplasia severity and form. Clear-cut outlines in the x-ray image of the refluxing, nonrefluxing and megaureter with ureterocele resulted from the condition and structure of the ostium ureteris and its submucosal segment. The same pathogenetic origin of megaureter forms gave grounds for conducting operations of the same type, resection of the defective ureter along with the ostium and its replacement for a morphofunctionally competent segment with formation of another ostium. The response to the surgery was assessed in 196 patients (249 ureters). The follow-up lasted from 1.5 to 22 years. Good responses were achieved in 90%, satisfactory in 3.2%, poor in 6.8% of the surgical patients. High efficacy of the operation says in favour of its pathogenetic validity. The megaureter correction created favourable conditions for renal growth and development. However, in 7 cases the improvement has changed for progressive nephrosclerosis with decline in the organ function or arterial hypertension. The ureter in such cases was in stable good condition. The above observations suggest the necessity of further investigations of this problem and continuation of the patients' follow-up.

[Organ-preserving reconstructive operations in reflux into duplicated ureters in children]. / Organosokhraniaiushchie rekonstruktivnye operatsii pri refliukse v udvoennye mochetochniki u detei.

A total of 54 children, aged 9 mos--14 yrs were operated on for reflux in double ureters. Out of them 38 patients were with ureter duplex and 16 with ureter fissus in prevesical or intramural area. The surgery was indicated by the reflux, stages III-IV, into a single or both ureters or reflux, stage II, in the patients whose a one-year conservative treatment turned to be a failure. Both segments of morphologically competent kidney were preserved during the reconstructive surgery in 27 patients. Unsatisfactory results of resection and neoimplantation of the both ureters according to Politano-Leadbetter as a "united block" as well as of distal ureteroureteral anastomosis made surgeons abandon the techniques. For the recent 10 yrs the authors have used the Politano-Leadbetter technique of ureteropyelo- or pyelopyelo-anastomosis with the cutting out of the upper segment of the ureter, resection of the distal part of the ureteral low segment and its neoimplantation into the urinary bladder. 20 patients were operated on: 7 with ureter duplex and 13 with prevesical or intramural ureter fissus. Unitype surgery was performed: the resection and implantation of a lower ureter segment: in patients with ureter duplex 7 cm of the distal area was resected, in those with ureter fissus a 2-3-cm resection was made proximately to the site of splitting. The outcomes were followed up for the period of 1 to 9 postsurgical years. The operation turned to be beneficial in 17 patients (85 per cent). In 3 patients nephroureterectomy was performed for the complications arisen: renal hemorrhages (1); the obstruction of vesicoureteral anastomosis (1) and apostematous nephritis (1).(ABSTRACT TRUNCATED AT 250 WORDS)