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.

Evaluation and Management of Antenatal HydronephrosisEvaluation and Management of Antenatal Hydronephrosis

Antenatal hydronephrosis (ANH) is one of the most common abnormal findings detected on prenatal ultrasound (US), and it has been reported in 1-5% of all pregnancies. The likelihood of significant postnatal pathologic abnormality in the urinary tract correlates with the degree of anterior-posterior diameter (APD) according to the gestational age. Detection of urologic anomalies prenatally permits fetal interventions that avoid complications in rare cases of bladder outlet obstruction with oligohydramnios even though their final benefits still remain controversial. There is no clear consensus on the extent and mode of postnatal imaging after a diagnosis of ANH. US is the mainstay of the postnatal evaluation and helps guide further testing with voiding cystourethrography (VCUG) and diuretic renography. Although most algorithms continue to recommend generous VCUG for identification of lower urinary tract anomalies, VCUG may be safely reserved for high grade ANH cases or any grade of ANH with dilated distal ureter without increasing the risk of urinary tract infection (UTI). There are conflicting studies about efficacy of postnatal prophylactic antibiotics. It still seems reasonable to consider use of a prophylactic antibiotic to prevent infant UTIs in high-risk populations, such as females and uncircumcised males with high grades of hydronephrosis, hydroureteronephrosis, or vesicouretral reflux.

Evaluation and Management of Antenatal HydronephrosisEvaluation and Management of Antenatal Hydronephrosis

Antenatal hydronephrosis (ANH) is one of the most common abnormal findings detected on prenatal ultrasound (US), and it has been reported in 1-5% of all pregnancies. The likelihood of significant postnatal pathologic abnormality in the urinary tract correlates with the degree of anterior-posterior diameter (APD) according to the gestational age. Detection of urologic anomalies prenatally permits fetal interventions that avoid complications in rare cases of bladder outlet obstruction with oligohydramnios even though their final benefits still remain controversial. There is no clear consensus on the extent and mode of postnatal imaging after a diagnosis of ANH. US is the mainstay of the postnatal evaluation and helps guide further testing with voiding cystourethrography (VCUG) and diuretic renography. Although most algorithms continue to recommend generous VCUG for identification of lower urinary tract anomalies, VCUG may be safely reserved for high grade ANH cases or any grade of ANH with dilated distal ureter without increasing the risk of urinary tract infection (UTI). There are conflicting studies about efficacy of postnatal prophylactic antibiotics. It still seems reasonable to consider use of a prophylactic antibiotic to prevent infant UTIs in high-risk populations, such as females and uncircumcised males with high grades of hydronephrosis, hydroureteronephrosis, or vesicouretral reflux.

Validation of the inoue method for camera-based glomerular filtration rate determination in Filipinos

A study was conducted to validate the Inoue protocol in determining the glomerular filtration rate (GFR) of Filipinos. Dynamic posterior planar kidney images of 402 consecutive Filipino patients referred for in vitro GFR determination were reprocessed using the Inoue protocol. Regression and Bland-Altman analyses were done on surface area normalized glomerular filtration rates (GFRSAnorm) generated using the Inoue linear regression model of the sample, Gates' method, and original regression formula published by Inoue, using respective two-point plasma concentration (in vitro) GFRSAnorm values as reference standards. GFRSAnorm results from the three camera-based techniques had strong correlation with those obtained using the in vitro method (i.e. r values of 0.9349, 0.8922 and 0.9349, respectively). However, agreement analysis showed lack of both bias and precision in the results of the Inoue linear regression model of the sample, and presence of bias and lack of precision in the results of both the Gates' method and the original linear regression model published by Inoue when compared to their corresponding in vitro GFRSAnorm results (standard error of 0.6209, 0.8379 and 0.9473, respectively). Thus, the linear regression model of the Inoue protocol is superior to the Gates' method for camera-based GFR estimation, and is population-specific, but is not robust enough to be a replacement for the in vitro technique.

Diagnostic Criteria for Stomal Obstruction of Tubeless Cutaneous Ureterostomy by Use of 99mTc-Mercaptoacetyltriglycine Diuretic Renography

PURPOSE: To evaluate 99mTc-mercaptoacetyltriglycine diuretic renograms for diagnosing stomal obstruction in tubeless cutaneous ureterostomy. MATERIALS AND METHODS: Cutaneous ureterostomy was performed in 29 patients (56 renal units) with a minimum follow-up period of 12 months. Stomal obstruction was evaluated with 99mTc-mercaptoacetyltriglycine diuretic renography 3 months after surgery. Regions of interest were drawn that completely encircled and snugly fit the kidney, renal pelvis, and ureter. The data analyses were performed with half-times to tracer clearance following furosemide (0.5 mg/kg) administration. RESULTS: The mean half-times to tracer clearance were 6.90+/-6.30, 5.25+/-4.29, and 8.75+/-7.63 minutes in the total, ipsilateral, and contralateral kidneys, respectively, in side relationships between the ureter and the stoma. There were significant differences between the ipsilateral and contralateral kidneys in the mean half-time to tracer clearance (p=0.038). Forty-eight renal units (85.7%) had a half-time to tracer clearance of less than 15 minutes, and all 48 renal units had no hydronephrosis. On the other hand, 5 renal units (8.9%) had a half-time to tracer clearance of more than 20 minutes, and these 5 renal units required the insertion of stent catheters or became atrophic. CONCLUSIONS: 99mTc-mercaptoacetyltriglycine diuretic renography was very useful for diagnosing stomal obstruction of tubeless cutaneous ureterostomy. The upper limit of the half-time to tracer clearance for unobstructed systems was 15 minutes, which allowed for the confident exclusion of stomal obstruction in tubeless cutaneous ureterostomy.

Excretory urography and renal scintigraphy for chronic obstructed kidney: does nonopacity mean nonsalvageability?

<p><b>INTRODUCTION</b>This study aimed to ascertain whether nonopacified kidney on excretory urography (also known as intravenous urography [IVU]) indicates nonsalvageability.</p><p><b>METHODS</b>We retrospectively reviewed 45 adult patients with chronic unilateral urinary tract obstruction, in whom IVU revealed nonopacified kidney on one side but normal excretion on the contralateral side. Affected kidneys with split glomerular filtration rate (GFR) < 10 mL/min/1.73 m2 on 99mTc-diethylenetriaminepentaacetic acid diuretic renal scintigraphy were considered nonsalvageable. Non-function was defined based on cutoff points (< 15% and < 20%) to determine the sensitivity and specificity of differential renal function. Differences in IVU and renal scintigraphy findings, with respect to the duration of delayed filming on IVU, were analysed for significance.</p><p><b>RESULTS</b>The results of IVU and renal scintigraphy findings for 34 (75.6%) nonopacified kidneys matched, representing nonsalvageable kidneys. Sensitivity and specificity of differential renal function were 76% and 100%, respectively, when the cutoff point for non-function was set at < 15%. Sensitivity and specificity were 97% and 82%, respectively, when the cutoff point was < 20%. There was no significant difference between renal scintigraphy findings and IVU with 2-hour and > 2-hour delayed films (p = 0.96).</p><p><b>CONCLUSION</b>Although most nonopacified kidneys on IVU were nonsalvageable, a quarter of them were found to be salvageable on renal scintigraphy. Besides split GFR, differential function at cutoff point < 15% could be used to determine non-function of a chronic obstructed kidney when the contralateral kidney is normal. Delayed filming beyond two hours appears unnecessary in ensuring non-excretion on IVU.</p>

Nephrotoxicity of CDDP assessed estimating glomerular filtration rate with 99mTc-DTPA plasma sample method

To assess early nephrotoxicity of CDDP [Cis-diamminedichloroplatinum] manifested by a decline in the glomerular filtration rate [GFR] estimated by plasma two sample clearance method [PSC 2] after 99mTc.DTPA injection. Descriptive study. Department of Nuclear Medicine, Karachi Institute of Radiotherapy and Nuclear Medicine, Karachi, from September 2004 to January 2005. The renal function was assessed on 36 patients suffering from different types of cancer and receiving CDDP in doses of >/= 50 mg/m[2] before and after in each of six CDDP cycles. The GFR was determined by PSC 2 method after 99mTc-DTPA injection]. A paired sample t-test was used for comparison of the mean value with significance at p < 0.01. There were [28 males and 8 females; age range being 16-68 years]. The average decline in GFR baseline to the end of sixth cycles was 43.86 ml/min/1.73m[2] [p=0.000] as estimated by PSC 2 method. There was a significant fall of average 9.36 ml/min/1.73m[2] [p <0.01] in GFR as observed in each cycle of CDDP estimated by the PSC 2 method. In the initial four cycles, CDDP produced a major nephrotoxic effect of average 10.27 ml/min/1.73m[2] [p <0.01] fall in GFR. This then gradually declined to a plateau of an average decline in GFR of 7.76 and 7.31 ml/min/1.73m[2] [p=0.000] after the 5[th] and 6[th] cycle respectively. CDDP produced an early nephrotoxicity which was manifested by a significant decline in GFR in each cycle. Tc-99m PSC 2 method for GFR estimation should be used periodically for the early detection of nephrotoxicity induced by CDDP

Scintigraphic Assessment of Renal Function Using 99mTc-DTPA in Miniature Pigs with Unilateral Ureteral Obstruction / 한국실험동물학회지

This study was performed to investigate the proper method for evaluating renal function in miniature pigs with unilateral ureteral obstruction. Experimental unilateral renal damage was induced after ligation of unilateral right ureter in 3 miniature pigs. On the 3rd post-operative day, scintigraphic images were obtained after 12 mCi of 99mTc-diethylentriamene pertaacetate (DTPA) intravenous injection. Renography showed that radiopharmaceutical uptakes in the right kidney were lower than those of left kidney uptakes as early as at 3 days after surgical operation. The static images of 99mTc-DTPA enabled us to measure the relative renal function in miniature pigs with unilateral ureteral obstruction. In conclusion, renography using 99mTc-DTPA was the useful diagnostic method to evaluate the renal function in miniature pigs.

Renal parenchyma thickness: a rapid estimation of renal function on computed tomography

Purpose: To define the relationship between renal parenchyma thickness (RPT) on computed tomography and renal function on nuclear renography in chronically obstructed renal units (ORUs) and to define a minimal thickness ratio associated with adequate function. Materials and Methods: Twenty-eight consecutive patients undergoing both nuclear renography and CT during a six-month period between 2004 and 2006 were included. All patients that had a diagnosis of unilateral obstruction were included for analysis. RPT was measured in the following manner: The parenchyma thickness at three discrete levels of each kidney was measured using calipers on a CT workstation. The mean of these three measurements was defined as RPT. The renal parenchyma thickness ratio of the ORUs and non-obstructed renal unit (NORUs) was calculated and this was compared to the observed function on Mag-3 lasix Renogram. Results: A total of 28 patients were evaluated. Mean parenchyma thickness was 1.82 cm and 2.25 cm in the ORUs and NORUs, respectively. The mean relative renal function of ORUs was 39 percent. Linear regression analysis comparing renogram function to RPT ratio revealed a correlation coefficient of 0.48 (p < 0.001). The linear regression equation was computed as Renal Function = 0.48 + 0.80 * RPT ratio. A thickness ratio of 0.68 correlated with 20 percent renal function. Conclusion: RPT on computed tomography appears to be a powerful predictor of relative renal function in ORUs. Assessment of RPT is a useful and readily available clinical tool for surgical decision making (renal salvage therapy versus nephrectomy) in patients with ORUs.

Dual-time [99m] TC-MAG3 diuretic renography and new criteria in the assessment of obstructive uropathy

Obstructive pattern within hydronephrotic non-obstructed kidney is frequently encountered during [99m] TCMAG3 diuretic renography. The aim of this study was to assess the value of applying new protocol and criteria on dual-time imaging in ruling out obstruction. We included 53 children [56 kidneys] in this study [28 boys and 25 girls with age range three weeks to 12 years]. All had hydronephrosis, which was bilateral in three children. Eighteen children had pyeloplasty, while 35 children had no previous surgical interventions. All children were referred for assessment of renal outflow obstruction and kidney function. All children underwent routine diuretic [99m]Tc MAG3 renal renography. All had obstructive patterns during diuretic [99m] TcMAG3 renography and underwent a second dynamic study 30 minutes later for 10 minutes. Non obstructive criteria were set as down sloping second time renogram with drop of kidney counts by 50% of peaked activity in first time renogram. Obstructive criteria on dual-time imaging were set as progressive rising second time renogram or flat second time renogram with drop of kidney counts by less than 30% compared to first time study. Equivocal criteria were set as flat renograms with drop of kidney activity by 3 0-50% or down sloping renogram with drop of kidney counts by<30% over 10 minutes. Non obstructive patterns were noticed in 16 kidneys 15 [patients], with down sloping curves during second time renograms in seven kidneys and flat second time renogram with drop of activity by> 50% in 9 kidneys. Obstructive patterns on dual time point [99m] TcMAG3 renography were noticed in 31 kidneys [29 patients]. Eleven kidneys [six patients] were false positive, since three patients had neurogenic bladder with no obstruction, two patients had long standing severe hydronephrosis with no obstruction and one patient had glomerulonephritis. Equivocal patterns were noticed in nine patients, four of them were turned to have significant obstruction, while five had no obstruction. Dual-time [99m] Tc-MAG3 diuretic renography can increase the efficiency in differentiating between obstructed and non-obstructed hydronephrosis compared to routine single time study

[Diagnostic value of power doppler sonography in acute pyelonephritis in children]

Urinary tract infection is common in pediatric age group and can result in serious complications such as chronic renal failure and hypertension if renal parenchyma is involved. Thus, definitive diagnosis of pyelonephritis in equivocal cases is of great importance. Comparing the diagnostic value of power color Doppler sonography and DMSA scan in acute pyelonephritis in children. This was a descriptive study carried out on 80 pediatric patients [160 renal units] suspected of having pyelonephritis. Two diagnostic methods [DMSA scan and power color Doppler sonography] were performed for all patients. Assuming DMSA scan as the gold standard method in diagnosis of acute pyelonephritis, the sensitivity, specificity, positive and negative predictive values and also the accuracy of power color Doppler sonography were calculated and analyzed, statistically. Power color Doppler sonography showed a sensitivity of 66.3%, specificity of 77.5%, positive predictive value of 78.7%, and negative predictive value of 64.7% with an accuracy of 71.3% in diagnosis of acute pyelonephritis in children. The agreement between the two diagnostic tests was shown to be around 43%. Based on our data, the power color Doppler sonography of kidneys has lower sensitivity and specificity compared to those obtained by DMSA scan in diagnosing acute pyelonephritis in children and is not considered as an ideal diagnostic technique for this particular clinical condition

Vesicoureteric reflux deterioration in monozygotic twins.

Primary vesicoureteric reflux (VUR) is the most common inherited structural urinary tract disorder, conforming closely to autosomal dominant transmission. A pair of monozygotic siblings is described exhibiting a remarkably parallel clinical course. VUR grade II was diagnosed in girl A during urinary tract infection at the age of 2 yr; screening of her asymptomatic sister (girl B) revealed the same. Renal cortical scintigraphy unveiled unilateral hypo-dysplasia in both the twins. Despite trimethoprime-sulfamethoxazole prophylaxis, infection recurred in girl A after 7 months, while girl B had a first episode 2 months later that prompted regimen switch to nitrofurantoin. Follow-up at the age of 4 depicted bilateral reflux deterioration; an urodynamics study that followed revealed functional bladder instability in both girls and the oral antispasmodic oxybutynin was initiated with good results. Evaluation for reflux should be prompt in infants with urinary infection. Patient siblings display a higher relative reflux risk, being highest in identical twins. Heredity issues, the impact of age and dysfunctional voiding in the clinical course, and the contribution of nuclear medicine in VUR management are discussed.

Split renal function in young children with unilateral pelvi-ureteric junction obstruction using [99m]Tc-DTPA or [99m]Tc-MAG[3]

Cases of unilateral hydronephrosis in pediatric patients are mostly due to pelvi-ureteric junction obstruction [PUJO] that causes hindrance in the drainage of urine outflow, leading to kidney function impairment The impaired excretory drainage is expected to have diminished or normal split renal function [SRF] on the affected side. However, in a significant number of patients with severe PUJO an elevated SRF can be found. The aim of this work was to estimate the frequency of various grades of SRF in children with PUJO. Secondly, to find out whether there is a difference between [99m]Tc-DTPA or[99m]Tc-MAG3 in assessing the SRF in these children. Fifty-eight children with unilateral PUJO referred for dynamic renography were included in this study on retrospective basis. Twenty-four patients underwent dynamic renography using [99m]Tc-DTPA while 34 were evaluated using [99m]Tc-MAG3. For both [99m]Tc-DTPA and [99m]Tc-MAG3, the dynamic renography started by perfusion phase [1 frame/ sec for 1 min] followed by 15-sec frames for 29 minutes. In all patients frusemide was given at a dose of 1mg/kg at 10 minutes post injection, In the DTPA and MAG3 studies, glomerular filtration rate [GFR] and renal plasma flow [ERPF] were estimated respectively and SRF was calculated from both figures. The normal range for SRF was considered 45% to 55%, In all patients, diagnostic ultrasound was done prior to isotopic renography. The mean age of the studied children was 18 +/- 10 months. The children in the DTPA and MAG3 groups were age and sex-matched. In the DTPA group 25% of the patients had a diminished SRF [< 45%], [46%] had normal SRF and 29% showed paradoxical SRF [> 55%]. In the MAG3 group, 32% of patients had diminished SRF, 41% had normal SRF and 26% showed paradoxical SRF of > 55%. There was no significant difference between DTPA and MAG3 in estimation of SRF in those with normal and suprnormal SRF [P value = 0.0865 and 0,094 respectively] however MGA3 tends to be superior to DTPA in cases of impaired renal function [P value < 0.05. The obstructive renogram patterns define the functional significance of the various grades of hydronephrosis detected by ultrasound. Both [99m]Tc-MAG3 and [99m]Tc-DTPA are comparable and can estimate the SRF in young children with unilateral PUJO, however, in cases of impaired renal function [99m]Tc-MAG3 tends to be better than [99m]Tc-DTPA. Impaired and Paradoxical supranormal split renal function are significantly present in young children with unilateral PUJO

Estimation of glomerular filtration rate by using tc-99m DTPA plasma I sample method, Gates method, Cockcroft-Gault method and predicted creatinine clearance method: a prospective comparative analysis with plasma 2 - sample clearance method

To compare diagnostic accuracy of predicted clearance method, Gates method. Cockcroft-Gault method and plasma 1-sample clearance method with plasma 2-samples clearance method with Tc-99m DTPA for the estimation of glomerular filtration rate[GFR]. This study included 91 consecutive patients who were referred for evaluation of renal function to the Nuclear Medicine section of Karachi Institute of Radiotherapy and Nuclear Medicine [KIRAN] from September 2004 to September 2005. The GFR was determined simultaneously by 5 methods including Plasma two-Sample Clearance method after Tc-99m DTPA injection [PSC 2]; Plasma one-Sample Clearance method after Tc-99 m DTPA injection [PSC I]; Gamma camera uptake method after Tc-99m DTPA injection [Gates method]; Predicted Creatinine Clearance by Modification of Diet and Renal Diseases [MDRD]: and Cockeroft-Gault's equation for GFR estimation [CG]. PSC 2 was chosen as a reference, Out of the 91 patients, 71 were males and 20 females with age ranging from 16-68 years. The regression equation of the PSC 1, Gates, MDRD and CC method against the NC 2 was Y = 1.884+0.970X [r=0.90, p<0.001, SEE value-10, 23 ml/min/1.73m2]. Y = - 9.944 + l.083X [r=0.82, p<0.001, SEE valuel=11.02 mI/min/1.73m2], Y=25.606+0.640X [r=0.71, <0.002, SEEvaIuc=15.56 ml/min/1.73m2], and Y=14.9811-0.714X [r=0.77, p=0.002, SEE value=14.44 mI/min/1.73m2] respectively. In comparison with the GFR by PSC 2, the PSC I and Gates tended to overestimate by 1% [p=0.359] and 2% [p=0.265] respectively, MDRD and CC tended to underestimate GER by 11% and 14% respectively [p<0.001] PSC I correlate well with PSC 2 and either can be substituted for the other as ideal GFR markers. The Gates method shows good correlation with PSC 2 however it is less precise than PSC I. MDRD and CG methods due to significant underestimation are not considered as ideal GFR marker

outcome of surgical interference in patients with acute obstructive renal failure

To evaluate some of the morphological, functional and clinical impacts of surgical management of acute obstructive renal failure. Thirty six clinically diagnosed patients as having acute obstructive renal failure [22 men 61.1% and 14 women 38.9% ranging in age between 28 and 62 years, mean 45 years] in the period from October 2005 to October 2008. All patients have been evaluated according to the protocol of obstructive uropathy. Clinically most patients presented by anuria 21[58.3%] patients, oliguria 12 [33.33%] patients, loin pain 16 [44.44%] patients, nausea and vomiting 23[63.9%] patients. 30 Patients underwent direct intervention and 6 patients were managed by temporary drainage until improvement of the general condition then definitive surgical procedure. There was a highly significant increase in the incidence of improvement among studied patients.100% [36 patients] out of 36 patients with acute obstructive renal failure showed improvement after surgical intervention. The syndrome of acute renal failure was reversed to a stable renal function that probably represents the preobstructive state of every patient. There was no morbidity or mortality rate in our series if compared with other series dealing with corrective surgery in obstructive renal failure. Surgical correction of acute obstructive renal failure show excellent results, so more efforts must be done for suspected obstruction in acute uremic patients to avoid the dialysis or kidney transplantation

outcome of surgical interference in patients with chronic obstructive renal failure

To evaluate some of the morphological, functional and clinical impacts of surgical management of chronic obstructive renal failure. We will try to assess some of the factors that may predict favorable outcomes. Sixty four clinically diagnosed patients as having chronic obstructive renal failure [41 men 64.1% and 23 women 35.9% ranging in age between 25 and 69 years, mean 47 years] in the period from October 2005 to October 2008. The patients on this study were divided according to past history of renal impairment and/or regular dialysis into two groups as follow: Group [A]: Patients with chronic renal failure with no regular dialysis [36 patients] Males: 26 [72.22%] Females: 10[27.78%]. Group [B]: Patients with chronic renal failure with regular dialysis [28 patients] Males: 18 [64.29%] Females: 10 [35.71%]. All patients have been evaluated according to the protocol of obstructive uropathy. Clinically most patients presented by anuria 17 [26.6%] patients [9 group A and 8 group B], oliguria 24 [37.5%] patients [14 group A and 10 group B], loin pain 42 [65.6%], patients [27 group A and 15 group B], nausea and vomiting 27 [42.2%] patients [8 group A and 19 group B]. 50 Patients underwent direct intervention and 14 patients were managed by temporary drainage until improvement of the general condition then definitive surgical procedure. In our series patients with chronic obstructive renal failure [group A], showed improvement in 31 patients [86.1%] and did not improve in 5 patients [13.9]. Out of the 5 patients who did not improve after management 1 patient [2.8%] remained unchanged and 4 patients [11.1%] continued to have progressive renal failure up to regular dialysis. In patients with chronic obstructive renal failure [group B], renal functions showed different degrees of improvement as follow: In 15 patients [53.6%] good improvement and subsequent complete weaning from dialysis occurred, while in 5 patients [17.8%] there was a decrease in weekly dialysis sessions from 3 to 2 sessions/week. In the remaining 8 patients [28.6%] there was no improvement and patients continued to have regular dialysis as preintervention. The overall complications in this series were [15.6%]. The incidence was much more in the chronic cases group B. The mortality rate in our series is [3.1%] which is not high if compared with other series dealing with corrective surgery in obstructive renal failure. The degree of improvement of renal function found to be correlated to preoperative residual parenchyma thickness, parenchymal echogenicity, corticomedullary differentiation, presenting hemoglobin value and radioisotope GFR. Finally there is evidence of reversibility of renal function after long standing obstruction which provides justification for efforts to identify and treat urinary tract obstruction even if a patient with an obstruction requires dialysis to avoid the dialysis or kidney transplantation or helping patients under dialysis for complete weaning form dialysis or decrease their number of weekly sessions

A Case of Crossed Fused Renal Ectopia with Multicystic Dysplasia

Crossed renal ectopia is a congenital malformation in which both kidneys lie on the same side of the spine, usually side by side longitudinally. More often on the right side. Fusion of the two renal units is eight times more common than nonfusion. Although crossed renal ectopia is uncommon, this unusual entity must be considered in an infant when cystic mass in the abdomen or pelvis paticularly if no kidney can be found on the opposite side. In many cases of crossed fused ectopia with multicystic dysplastic kidney(MCDK), the diagnosis can be strongly suspected from the sonogram, and no other studies may be necessary. However, both intravenous urography and isotope renography is useful to assess the function of the crossed kidney. Crossed renal ectopia and MCDKs are associated with a greater incidence of ureteropelvic junction obstruction and reflux. So, screening voiding cystourethrography should be performed. Very few studies of MCDK in the setting of crossed fused ectopia have been reported. We have experienced a 3-year-old boy with crossed fused renal ectopia with multicystic dysplasia.

Clinical follow-up of children with low differential function on diuretic renogram.

OBJECTIVE: One of the most challenging dilemmas in pediatric urology today is to determine the optimal management of children with hydronephrotic kidney secondary to suspected ureteropelvic junction obstruction. Some believe in early surgical management while others believe in conservative management. To better define these issues, the authors retrospectively reviewed 101 patients with hydronephrosis. MATERIAL AND METHOD: The present study was approved by The Children 's Hospital of Philadelphia 's institutional review board and waiver of informed consent for retrospective study. One hundred and one children (72 males and 29 females) of ages of 6 days to 19 years with hydronephrosis with suspected UPJ obstruction underwent diuretic renograms with 99mTc DTPA. The authors classified the differential renal function into three groups: Group I: 0-15%, Group II: 16-30%, and Group III: 31-46%. RESULTS: Forty-one patients with conservative management, 32% (5 in group I: 1 in group II and 7 in group III) showed improved differential renal function. Non-operative management patients from group I and II showed no deteriorating renal function and only one case from group III had deteriorating renal function. In operative management, 78% of group I, 41% of group II, and 25% of group III showed improvement in differential renal function. In the remaining operative cases, six showed deteriorated differential renal function [1 (4%) group I: 3 (18%) group II: 2 (10%) group III] whereas 24 remained stable or unchanged [Group 1: 4 (17%), Group II: 7 (41%), Group 111: 13 (65%)]. CONCLUSION: The authors recommended conservative management for children with differential renal function between 16-46%.

Diuretic radionuclide renography in assessing Anderson-Hynes pyeloplasty in unilateral pelvi-ureteric junction obstruction

To analyze the functional outcome of unilateral Anderson Hynes [AH] Pyeloplasty using DTPA renography in patients with symptomatic pelvi- ureteric junction [PUJ] obstruction. This study included 48 patients with PUJ-obstruction who underwent stentless AH pyeloplasty. Their record was analyzed for age, clinical presentation, pre and postoperative IVU and preoperative and postoperative DTPA renography finding. The out come of the pyeloplasty was evaluated by comparing preoperative and postoperative symptomatic improvement and DTPA renography split function result. The age range from 3yrs 25yrs with mean age 19.68 yrs. The were 35 [72.9%] male and 13[27.1%] female. The left side was involved in 31[64.58%], right side in 10[20.83%] and 7 [14.58%] patients had bilateral PUJ -obstruction. The predominant clinical presentation was pain in 36[75%], urinary tract infection in 4[8.33%], haematuria in 2[4.16%], while in 8[16.66%] patients it was an incidental finding. The patients were divided into 3 groups based on the renography split function. Group A: 20-30% function, 16 [33.33%] patients; Group B: 31-40% function, 12[25%] patients and Group C: >40% function, 20 [41.66%] patients. Post pyeloplasty scan revealed stable renal function in 19[39.58%] patients, while improvement was noticed in 21[43.75%] patients. The remaining 8[16.66%] had deterioration in renal function. Anderson-Hynes Pyeloplasty is an effective treatment for PUJ-obstruction. 99mT-DTPA renal scan is an important investigation in diagnosing PUJ-obstruction and evaluating the outcome of surgical intervention

Postoperative Outcome of the Upper Pole Kidney with a Complete Ureteral Duplication and Complicated with Ureterocele or Ectopic Ureter after Pyeloureterostomy / 대한비뇨기과학회지

PURPOSE: Non conservative treatment such as heminephrectomy is considered the treatment of choice when the upper pole kidney in children with a complete ureteral duplication complicated with ureterocele or ectopic ureter is nonfunctional. The postoperative outcome of the upper pole kidney with a complete ureteral duplication after pyeloureterostomy was evaluated, and we focused on those children with undetected functions on the upper pole kidney before surgery. MATERIALS AND METHODS: Between May 2002 and March 2006, we evaluated 28 children, 10 boys and 18 girls, who had undergone pyeloureterostomy for a complete ureteral duplication that was complicated with ureterocele or ectoplic ureter. Their mean age was 12.3 months. Ultrasound, 99mTc-dimercaptosuccinic acid(DMSA) scanning and voiding cystourethrography(VCUG) were performed preoperatively. The clinical courses were followed up with ultrasound at 1, 3, 6 and 12 months, and DMSA scanning was done between 6 and 12 months after surgery. The median follow-up period was 21.5 months. RESULTS: Among the 12 children with cortical thinning seen on ultrasound, 10 showed thickening of the renal cortex within 12 months. All 16 children with Grade III or less hydronephrosis on the upper pole kidney were downgraded, and 10 out of them showed complete resolution or Grade I hydronephrosis within 6 months. 4 cases with no visible photon uptake at the upper pole kidney preoperatively showed hot uptakes at the defective spot between 6 to 12 months after pyeloureterostomy. 5 out of 28 children had urinary tract infection(UTI) within 3 months after surgery; however, this was easily controlled with oral antibiotics. CONCLUSIONS: The function of the upper pole kidney is recovered within 1 year after pyeloureterostomy in most of the cases with a complete ureteral duplication, regardless of the severity of hydronephrosis at the upper pole kidney. Pyeloureterostomy can be an alternative treatment modality for treating a complete ureteral duplication that's complicated with ureterocele or ectopic ureter due to pyeloureterostomy's lower morbidity compared to non-conservative surgery such as heminephrecotmy.