Ureteropelvic junction obstruction caused by metastatic cholangiocarcinoma

ABSTRACT We describe the rare case of a 61-year-old female with right ureteropelvic junction (UPJ) obstruction caused by metastatic cholangiocarcinoma. Her past medical history was notable for cholangiocarcinoma treated with neoadjuvant chemoradiation and two orthotopic liver transplants six years earlier. Urology was consulted when she presented with flank pain and urinary tract infection. Diagnostic workup demonstrated right UPJ obstruction. She was managed acutely with percutaneous nephrostomy. She subsequently underwent robotic pyeloplasty and intrinsic obstruction of the UPJ was discovered. Histological examination revealed adenocarcinoma, consistent with systemic recurrence of the patient's known cholangiocarcinoma.

Isolated low grade prenatally detected unilateral hydronephrosis: do we need long term follow-up?

ABSTRACT Purpose: To assess the need for postnatal evaluation and the medium term outcome in patients with isolated unilateral low grade prenatally detected hydronephrosis. Materials and Methods: We prospectively selected 424 patients (690 kidney units) with a prenatal diagnosis of urinary tract dilatation between 2010 and 2013. We included only those patients with isolated unilateral low-grade hydronephrosis who underwent at least 2 postnatal ultrasound examinations. The Society for Fetal Urology (SFU) grading system was utilized for assessment of the hydronephrosis. We excluded patients with bilateral dilation or other urological abnormalities. The fate of hydronephrosis including resolution, stability or worsening was documented. Results: A total of 66 infants (44 boys and 22 girls) with antenatally diagnosed unilateral urinary tract dilation (23 right and 43 left) were identified. Ultrasounds showed SFU grade 1 hydronephrosis in 32 patients (48%) and SFU grade 2 hydronephrosis in 34 (52%). After a mean follow-up period of 32 months (range 12 to 60), 37 patients (56%) had complete resolution of hydronephrosis while the remaining 29 were stable (44%). None of our patients developed UTIs during follow-up and none required surgical intervention. Conclusions: Prenatally detected, isolated unilateral low-grade hydronephrosis usually have a favorable prognosis. All cases in our cohort showed either stability or resolution of hydronephrosis without any harmful consequences. Based on our findings on medium-term in this category of patients, long-term follow-up is not warranted.

Homemade ultrasound phantom for simulation of hydronephrosis / Modelo feito em casa para simulação ultrassonográfica da hidronefrose

Abstract In this article, we describe the development of a simple and inexpensive simulation phantom as a surrogate of human hydronephrosis for the identification of urinary tract obstruction at bedside to be used in undergraduate training of medical students.

Resumo Neste artigo, descrevemos o desenvolvimento de um phantom de simulação, simples e barato, como modelo de hidronefrose humana para capacitar estudantes de graduação em medicina na identificação da obstrução do trato urinário à beira do leito.

99mTc-DTPA Diuretic Renography with 3 hours late output fraction in the evaluation of hydronephrosis in children

ABSTRACT Objective: Dynamic renal scintigraphy complemented by late gravity assisted postvoid images to 60 minutes is a frequently used diagnostic test in the evaluation of hydrone- phrosis. The objective of this study is to evaluate the effectiveness in acquiring images at 180 minutes to calculate the late output fraction (LOF) of 99mTc-DTPA in the diagno- sis of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective study of 177 patients (196 renal units) of sus- pected cases of clinical UPJO was conducted. The patients were submitted to at least two dynamic renal scintigraphies of 99mTc-DTPA, with the addition of furosemide (F0), with a mean age of 4.3±3.8 years for the first study, and a follow-up of 2.7±2.5 years. Results: For diagnosis based on renal curves, a 100% sensitivity, 82.2% specificity, positive predictive value (PPV) of 10.4% and negative predictive value (NPV) of 100% were estimated. For diagnosis based on LOF, a 100% sensitivity, 96.3% specificity, PPV of 35.7% and NPV of 100% were estimated. Conclusion: A LOF <10% is indicative of UPJO, and a LOF ≥15% is indicative of no UPJO. The data demonstrate that LOF presents equivalent sensitivity and NPV, and higher specificity and PPV in comparison to diagnosis based on renal curves, and is useful in the evaluation and follow-up of suspected cases of UPJO.

Point of care kidney ultrasonography and its role in the diagnosis of urinary obstruction: a case report / Ultrassonografia urinária "Point of Care" e o seu papel no diagnóstico da obstrução urinária: um relato de caso

Abstract Introduction: Ultrasonography (US) is a rapid, non-invasive and safe procedure that allows the nephrologist to obtain vital information to the bedside, as well as allows to guide the procedures for nephrology practice. Case report: Male patient, elderly with hypertension, diabetes mellitus and chronic kidney disease presents with infraumbilical protrusion that the Point of Care US (POCUS), performed by the nephrologist, proved to be a large bladder with a diverticulum. In addition, the US enabled the nephrologist to diagnose bilateral hydronephrosis, preservation of the cortico-medullary differentiation and echotexture of the right kidney, post-voiding urinary retention, urinary catheter placement and functional and morphological monitoring of the urinary tract after surgical correction of the infravesical obstruction. Conclusion: POCUS assessment of the renal tract may become the new standard of care among nephrologists by enabling the expansion of clinical information in a timely fashion, allowing faster resolution of cases and permitting the monitoring of the treatment done.

Resumo Introdução: A ultrassonografia (US) é um procedimento rápido, não invasivo e seguro que possibilita ao nefrologista obter informação vital à beira do leito, assim como permite guiar os procedimentos necessários à prática nefrológica. Relato do caso: Paciente masculino, idoso, com hipertensão arterial, diabetes mellitus e doença renal crônica apresenta-se com abaulamento infraumbilical que a Point of Care US (POCUS), realizada pelo nefrologista, mostrou ser um quadro de retenção urinária acompanhado de divertículo vesical. Adicionalmente, a POCUS possibilitou ao nefrologista diagnosticar hidronefrose bilateral, preservação da diferenciação córtico-medular e da ecotextura do rim direito, retenção urinária pós-miccional, correto posicionamento do cateter vesical pós-drenagem e acompanhar funcionalmente e morfologicamente as alterações do trato urinário após a correção da obstrução infravesical. Conclusão: A avaliação do trato urinário na ótica da POCUS eleva a prática nefrológica a um patamar mais alto, ao possibilitar a ampliação de informações clínicas imediatas e à beira do leito, proporcionar maior rapidez na resolução dos casos e permitir o monitoramento do tratamento instituído.

Retrocaval ureter and contra lateral renal agenesis – a case report and review of literature

ABSTRACT Associated congenital anomalies are seen in 21% of retrocaval ureter patients; among them, associated contralateral renal agenesis is a very rare entity. We report one such case of right circumcaval ureter with left renal agenesis, diagnosed after febrile UTI. Surgical correction with uretero-ureterostomy was successful. In literature very few such cases are reported and only one case with renal failure was reported. Unilateral renal agenesis cases complicated by associated such anomalies need definitive management and lifelong clinical monitoring to diagnose and prevent chronic kidney disease.

Involução espontânea da hidronefrose isolada / Spontaneous involution of hydronephrosis

Objetivo: Estudar a involução espontânea do grau de gravidade da hidronefrose em 141 crianças com diagnóstico de hidronefrose isolada atendidos na Unidade de Nefrologia Pediátrica do Hospital das Clínicas da UFMG, entre 1999 e 2008. Métodos: Crianças com diagnóstico pré-natal hidronefrose foram acompanhadas com avaliação clínica e exames ultrassonograficos periódicos. O diâmetro anteroposterior da pelve renal (DAP), variável capaz de caracterizar o grau de hidronefrose dos pacientes, foi medido em três sucessivos momentos: antes do nascimento, imediatamente depois do nascimento e no final do periodo de acompanhamento. Os graus considerados são: normal (DAP < 5mm), leve (5mm ≤ DAP < 10mm), moderada (10mm ≤ DAP < 15mm), e grave (DAP > 15mm). A involução do grau de hidronefrose é a transição, no tempo, de um grau mais próximo de grave para outro mais próximo de normal. No primeiro estudo foi avaliado se a involução do grau de gravidade da hidronefrose ocorre com significância estatística. No segundo estudo foi avaliado se a ocorrência da involução pode ser associada com a lateralidade do rim ou com o sexo da criança. Resultados: Nas análises efetuadas, a hipótese de involução espontânea da dilatação foi comprovada com significância estatística. Constatou-se também que a involução ocorre em proporção mais acentuada nas unidades de lateralidade direita, e em pacientes do sexo feminino. Conclusão: Os resultados corroboram estudos de outros autores que demontram a involução espontânea do grau de gravidade) em pacientes com hidronefrose isolada, e que sugerem influência da lateralidade e do sexo na involução espontânea.(AU)

Objective: To study the spontaneous involution of the severity of hydronephrosis in 141 children diagnosed with isolated hydronephrosis treated in the Pediatric Nephrology Unit of Hospital das Clínicas ­ UFMG, between 1999 and 2008. Methods: Children diagnosed with prenatal hydronephrosis were followed with clinical evaluation and periodic ultrasound examinations. The anteroposterior diameter of the renal pelvis (APD), a variable capable of characterizing the degree of hydronephrosis of the patients, was measured in three successive stages: before birth, immediately after birth and at the end of follow-up period. The considered degree of hydronephrosis is: normal (APD < 5mm), light (5mm ≤ APD <10mm), moderate (10mm ≤ APD <15mm) or severe (APD > 15mm). The spontaneous regression of hydronephrosis gravity is the transition over time from a closer to severe level to a closer to normal level. Two studies were done. At first, we evaluated if the regression of hydronephrosis severity occurs with statistical significance. In the second study, we evaluated if the occurrence of involution may be associated with the laterality of the kidney or the sex of the child. Results: In the analysis, the spontaneous regression hypothesis of hydronephrosis was confirmed with statistical significance. Also, it was found that the regression is more pronounced in units on the right side, and in females.Conclusion: The results corroborate findings of other authors that demonstrate spontaneous involution of the degree of severity in patients with isolated hydronephrosis, and suggest the influence of laterality and sex on spontaneous involution.(AU)

Caracterização e avaliação quantitativa da variabilidade do diâmetro ântero posterior (DAP) da pelve renal / Characterization and quantitative evaluation of renal anteroposterior pelvis diameter (APD) variability

Objetivo: Avaliar a variabilidade em medidas do diâmetro ântero posterior da pelve renal (DAP) em 244 crianças com diagnóstico de hidronefrose isolada atendidos na Unidade de Nefrologia Pediátrica do Hospital das Clínicas da Universidade Federal de Minas Gerais, entre 1999 e 2008. Métodos: Os pacientes foram submetidos a acompanhamento clínico e a exames ultrassonográficos periódicos. As informações registradas ao longo do tempo nos prontuários foram transformadas em "séries de medidas", resultando em vinte e duas series de medidas para cada paciente (duas clínicas e dez ultrassonográficas para cada rim). A variabilidade dessas séries foi caracterizada em um índice que foi, na sequencia, avaliado para todas as series de medida. Os dados de variabilidade foram agrupados, conforme a variável medida e conforme a ocorrência ou não de evento cirúrgico. As médias dos grupos foram comparadas em análise estatística. Resultados: Os resultados mostraram que a variabilidade é muito pequena nas medidas clínicas (estatura e peso), relativamente pequena no comprimento e no volume renal e mais acentuada nas séries de DAP. Verificou-se que, nas series de medidas de comprimento e volume renal, há maior variabilidade em unidades submetidas a cirurgia. Nas medidas de DAP a variabilidade foi grande, independentemente de uropatia e/ou evento cirúrgico. Conclusão: Os resultados corroboram estudos de outros autores que mostram a ocorrência de variabilidade nas medidas do DAP, e colocam em evidência a necessidade de se levar em conta esta variabilidade nas situações em que o DAP serve de apoio a diagnóstico e na indicação de procedimento cirúrgico.(AU)

To evaluate the variability in measures of anteroposterior diameter of renal pelvis (APD) in 244 children diagnosed with isolated hydronephrosis and treated at the Pediatric Nephrology Unit of Hospital das Clinicas ­ Federal University of Minas Gerais, between 1999 and 2008. Methods: All patients were subjected to clinical follow-up ultrasound exams and periodicals. The information collected over time in the medical records were turned into "series of measures", resulting in twenty-two series of measurements for each patient (two clinic and ten ultrasound related for each kidney). The variability of these series was synthesized on an index that was, in sequence, evaluated for all series of measures. The variability data was grouped according to the measured variable and to the occurrence of surgical events. Statistical analysis was performed to compare the means og the groups. Results: The results showed that the variability is very small in clinical measures (height and weight), relatively small in length and renal volume and more pronounced in the series of APD. It was found that, in the series of measurements of length and volume kidney, there is greater variability in units subjected to surgery. In APD measures the variability was large, regardless of uropathy and / or surgical event. Conclusion: The results corroborate findings of other authors that show the occurrence of variability in measures of APD, and make evident the need to take into account this variability in situations where the APD is used to support diagnosis and indication for surgery.

Vesicoureteral reflux in neonates with hydronephrosis; role of imaging tools

Neonatal Hydronephrosis is a common abnormality diagnosed ante- or postnatally. The aim of this study was to determine the prevalence and severity of vesicoureteral reflux [VUR] in neonates with antenatal or postnatal hydronephrosis and the value of ultrasonography as a noninvasive tool for VUR prediction. In a prospective study, 202 infants with neonatal hydronephrosis were studied. Two successive renal ultrasound examinations were performed at 1 and 4-6 weeks after birth in neonates with antenatal hydronephrosis or immediately after presentation. Voiding cystourethrography [VCUG] was performed in all infants. The incidence of VUR was 29.7%, of which 17.8% had severe [grade IV-V] reflux. 27% of 133 neonates with unilateral and 34.8% of 69 cases with bilateral hydronephrosis had VUR. Although a significant association was observed between severity of hydronephrosis and VUR, 5.9% of normal appearing and 7.8% of grade 1 hydronephrotic neonates had high-grade reflux. VUR was observed significantly in hydronephrotic neonates. A normal or mildly hydronephrotic urinary tract on ultrasound scan cannot exclude presence of severe VUR. We recommend performing VCUG in all hydronephrotic newborns

Evaluation of renal transit time [RTT] in children with MR urography

To evaluate use of dynamic contrast material-enhanced.magnetic resonance [MR] urdgraphy for measurement, of renal transit time [RTT of a contrast agent through the kidney and collecting system so as to identify obstructive uropathy in children. One hundred twenty-six children suspected of having hydronephrosis were hydrated prior to undergoing both conventional and dynamic contrast-enhanced MR urography of the kidneys and urinary tract. A three-dimensional sequence was used to track passage of contrast agent through the kidneys. Time between the appearance of contrast material in the kidney and its appearance in the ureter at or below the level of the lower pole of the kidney was defined as RTT. Bland-Altman plots were used to quantify intra- and interobserver performance. In 30 children, a nuclear medicine renogram was also obtained, and the half-life of renal signal decay after furosemide administration was derived and compared with the MR imaging RTT by using receiver operating characteristic curves. On the basis of RTT, kidneys were classified as normal [RTT RTT 490 seconds]. Receiver operating characteristic analysis for comparison of results of MR imaging and diuretic renal scintigraphy showed.good agreement between the modalities, with a mean area under the curve of 0.90. When used in conjunction with morphologic images obtained in the same, examination, RTT generally allowed normal kidneys to be differentiated from obstructed and partially obstructed kidneys

Comparative findings of ultrasongraphy and IVU in the diagnosis of hypernephrosis

The ultrasonographic findings of urinary obstruction indicate the diagnosis of hydronephorsis. Hydrophrosis is a descriptive term referring to the presence of dilatation of pelvis and calyces and not to the cause of the ddilation IVU can provide functional and anatomical details while ultrasonography can only provide anatomical details There are some different ideas about diagnostic values of each method. The purpose of this study is to evaluate the ultrasonoyraphic sensitivity in detection of hydronephrosis [obstructive or nonobstructive] as compared to IVU. This prospective comparative study was done on 70 patients referring to the radiology department of Bahman 22[nd]and Arya Hospitals since April 2006 to October 2007. Kidney ultrasonography and IVU were administered for all the patients. Then, the accuracy rate of ultrasonography in diagnosing hydronephrosis was determined comparing with IVU as a gold standard method. Some variables such as age, sex, the size of kidney, kidney parenchymal echo, ureteral stone, bladder condition in IVU and stone in KUB were evaluated in all the patients. Among 70 patients, the mean age was 36 +/- 16.3 years ranging from 12 to 72 years. Comparing ultrasonography with IVU, the sensivity of ultrasonography for diagnosing hydronephrosis was 79.41%, the specificity rate of ultrasonography was 55%; the positive predictive value was 62% and the negative predictive value was 74%. Also, the accuracy rate of sonography in diagnosing hydronephrosis was 67%. The results of this study suggest that although ultrasonography is not a substitute for IVU, it can be used as a preliminary tool for detecting hydronephrosis and as a screening diagnostic method for urinary obstruction in azotemic patients. IVU is suggested for acute urinary obstructions and in patients with renal colic and normal sono-findings

Giant hydronephrosis in children: diagnosis and therapeutic aspects

To evaluate the clinical aspects, diagnostic and therapeutic problems of giant hydronephrosis in children managed at the Department of Urology of the University Hospital of Dakar, Senegal. In this retrospective -study all cases of giant hydronephrosis in children managed at the Department of Urology of Aristide Le Dantec Hospital, Dakar, between February 2000 and February 2007 were reviewed. The parameters studied were the epidemiological and clinical aspects, laboratory and imaging investigations and therapy, as well as the short, medium and long-term outcome. Our series included 7 patients with a mean age of 6.1 years [range 8 months - 12 years]. In 5 out of 7 cases, giant hydronephrosis was found on the left side. Ultrasonography was performed in all cases, and the giant hydronephrosis was first misdiagnosed as cystic renal disease in 6 cases. Intravenous urography revealed a non-functioning kidney in 4 cases. CT scan, performed in 6 cases, confirmed the diagnosis and provided further information about the remaining parenchyma. Nephrostomy was performed pre-operatively in 4 cases. Three patients underwent pyeloplasty, while nephrectomy was performed in 4 cases. At follow-up, a pelvi-ureteric stenosis associated with a colonic fistula was noted in one patient. Long-term follow up was uneventful in all patients. CT scan is the method of choice for the diagnosis of hydronephrosis. Nephrostomy allows an evaluation of the renal function and facilitates the extraperitoneal approach to the kidney

etiologies of hydronephrosis in neonates

Hydronephrosis is defined as abnormal dilation of pyelocaliceal system. There is a controversy about the etiologies and follow up in antenatal and neonatal hydronephrosis. This study was done to determine the etiologies of hydronephrosis in neonates who were born with this disorder. This study was carried out on all neonates who were referred to nephrology department and clinic of Amirkola children hospital, Babol Medical University from 1998 to 2004. In whom it was diagnosed hydronephrosis before or after birth; VCUG [voiding cystourethrography], IVP [Intravenous pyelography] and/or DTPA [diethylene triamine-pentaacetic acid] were used as needed. Then all data were evaluated according to their etiologies. Of 42 neonates, 38 [90%] were male and 4[10%] were female. Twenty-four [57%] and 17 [40%] patients had UPJO [ureteropelvic junction obstruction] and VUR [vesicouretral reflux], respectively. Twenty-six [62%] had been diagnosed before birth. The most common causes of admission were prenatal diagnosis [57%] and UTI [24%]. Among 54 hydronephrotic kidneys unites in 42 neonates, 30 [55.5%], 23 [42.5%] and 1 had VUR, UPJO and UVJO respectively. The most common cause of hydronephrosis in neonates was UPJO, It is needed to give more attention to male neonates who showed higher prevalence of hydronephrosis and also early prenatal sonographic diagnosis

Assessent of deconvolution technique for diagnosis of hydrone-phrosis in infants [under 6 months]

Hydronephrosis is one of the major causes of referring infants for nuclear medicine investigation. Renal dynamic study is the most reliable investigation for such children. However direct evaluation of renogram leads to generation of parameters that have no physiological interpretation. The configuration of renogram is very much dependent upon the rate at which radiopharmaceutical enters the kidney. In order to decrease such effect, the radiopharmaceutical has to be injected in a small volume and very fast into the vein, which is not always possible, especially in the infants. Deconvolution is a method in which the injection quality does not have any effect upon renogram decreasing the diagnostic errors. The renal retention function [RRF] is independent of input function and derived parameters have physiological significance and clinical values. In this study 54 patients data were evaluated. All the patients were under 6 month of age, suspicious for hydronephrosis referred to our imaging center for 99mTc-DTPA renal dynamic studies. All data were transformed into interfile format. Full renal package software was developed in visual basic 6 to read and process the data. Deconvolution was performed using matrix algorithm. Background subtraction was performed using conventional and Ruthland-Patlack method. All transit time parameters were calculated in 6 different filtering conditions. Our results show that deconvolution is useful for evaluation of infant hydronephrosis. Mean transit time is the most useful parameter for estimation of renal function in infants

Ultrasonographic changes in experimental ureteric ligation

This experimental work was done to see the hydronephrotic changes in kidney of completely ligated ureter. Five young healthy mongrel dogs weighing 20-25 kg. were induced in this study. They were kept on standard diet and free access to water. Ultrasound of experimental and control kidney was done for the measurement of hydronephrosis and changes in control kidney. On day 1 there was fullness of pelvis and calyces in experimental kidney on day 3 minimal to mild degree of hydronephrotic changes observed on day 5th mild to moderate degree of hydronephrosis was found. At the end of one week hydronephrosis was marked to severe and contralateral kidney was hypertrophied. At the end of the experimental work dogs were sacrificed and bilateral nephrectomy was done to observe the gross and microscopic changes in both kidney

Ultrasound guided nephrostomy in children with hydronephrosis

This study was carried out with the aim of diagnosis and percutaneous ultrasound guided nephrostomy until the condition of the child is improved for final surgical management. Nineteen children with hydronephrosis were studied. All patients were examined physically, clinically, and laboratory investigations were done. Plain radiograph of the abdomen and urinary tract intravenous pyelography, prior to ultrasound and percutaneous guided ultrasound draining of hydronephrosis and pyonephrosis by nephrostomy were done. All cases with ectopic or any congenital, mobile kidneys and renal failure were excluded from this study. The success rate was 95.4%. 19 children with hydronephrosis on their ultrasound examinations were subjected to percutaneous nephrostomy, 60% of causes of the hydronephrosis were post inflammatory. Minor problems were encountered because the technique is relatively recent and has not been utilized in Egypt, so far it is explained in details, its values and significance as well as the positive predictive value are discussed. No major complications were met, percutaneous nephrostomy drainage should be attempted as first choice of treatment of all cases with hydronephrosis and drained

Ultrasonography in acute flank pain.

In 58 patients with acute recurrent or persistent flank pain, straight x-ray (kidney, ureter, bladder region) detected stones in the urinary tract in 50 cases (86.2%), whereas ultrasonography detected stones in the urinary tract in 55 patients (94.8%). Ultrasound also detected unilateral hydronephrosis in 20 patients (34.48%). The presence of calculus was subsequently proved by intravenous urography/surgery or spontaneous passage. Ultrasonography is safe, quick, reliable and most effective diagnostic tool in such cases in rural areas. Intravenous urogram should be reserved for cases which need surgical intervention.