International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children.

The classification of grading of vesicoureteric reflux (VUR) agreed to by the participants in the International Reflux Study in Children is described. It combines two earlier classifications and is based upon the extent of filling and dilatation by VUR of the ureter, the renal pelvis and the calyces. A standardised technique of voiding cystography is also described to ensure comparability of results.

Pelviureteric obstruction in children: the effect of pyeloplasty on 99mTc-DTPA uptake and washout.

The renographies of 23 children, treated by means of dismembered pyeloplasty for unilateral pelviureteric obstruction, were analysed. Computerised 99mTc-DTPA renography was performed on each patient both preoperatively and on one or several occasions postoperatively. Of the 13 hydronephrotic kidneys, which had normal glomerular function preoperatively, 12 had also normal postoperative function. In a large proportion of those hydronephrotic kidneys which had reduced glomerular function preoperatively, the function improved after pelviureteroplasty. The improvement was most pronounced in the group of kidneys with severely reduced preoperative glomerular function. The effect of pelviureteroplasty on the washout of DTPA was examined in 13 patients who had diuretic renograms performed both preoperatively and postoperatively. Improved drainage of the hydronephrotic kidney after pyeloplasty was noticed in all these cases.

Pelviureteric obstruction in children: kidney parenchymal area and technetium-99m diethylenetriaminepentaacetic acid renography.

In 33 patients with pelviureteric obstruction the renal parenchymal area was measured from excretory urography films and split renal function determined with computerized 99mTc-DTPA-renography. All patients had pelviureteroplasty performed during childhood. For this study, excretory urographs and DTPA-renographs performed in 7 patients preoperatively and in all the 33 patients 10 months to 15 years postoperatively, were analyzed. The parenchymal area of both hydronephrotic and healthy contralateral kidneys showed good correlation with split DTPA clearance. The percentile parenchymal area of the hydronephrotic kidneys also had good correlation to their percentile split DTPA-clearance. The planimetric measurement of kidney parenchymal area and DTPA renography are useful alternative methods when evaluating split renal function, severity of hydronephrosis and the result of pelviureteroplasty.

Pelviureteric obstruction in children.

A series of 161 hydronephrotic kidneys from a 30-year period in 147 children is reported. The left kidney was affected more frequently than the right and the condition was more common in the male than in the female child. In infants, abdominal mass was a common mode of presentation. In older children, loin or abdominal pain, haematuria and urinary tract infection were typical findings. The principles of treatment have changed: during 3 decades there has been a definite shift from nephrectomy to dismembered pyeloplasty, mostly according to Anderson-Hynes technique or its modifications. The results of the dismembered pyeloplasties were good or excellent as contrasted with often unsatisfactory results of the non-dismembered pyeloplasties. There were 1 early and 1 late death in the series; both of these patients were uraemic already preoperatively. The key to good results is the dismembered pyeloplasty with postoperative nephrostomy drainage and applying a stent for the anastomosis, combined with strict control of postoperative pyelonephritis.

Bilateral Wilms' tumor and secondary malignancies.

A series of six patients with bilateral Wilms' tumor (nephroblastoma) is presented. Multimodal therapy yielded a survival rate of 83% at 2 yr of follow-up. However, at the end of a later follow-up period only two patients (33%) were alive. of the 4 patients who died. Only 1 died of Wilms' tumor. One died of complications of aggressive chemotherapy and two patients died after 12 and 16 yr following treatment of secondary malignant tumors arising in the irradiated region. Patients with bilateral tumor should be followed at regular intervals for the duration of life for the occurrence of secondary malignant tumors.

Posterior urethral obstruction: valvular or diaphragmatic? Endoscopic diagnosis and treatment.

Young's classification of posterior urethral valves has been criticized because clinically only type 1 valves have been observed. However, with a certain technique of postmortem examination the obstruction has been found to be caused by a fenestrated diaphragm. When reevaluating the photographs and motion pictures taken during endoscopies it was concluded that the obstructions were diaphragmatic. The earlier controversial conclusions can be attributed to questionable methods of examination and misinterpretation of the findings. On the basis of the anatomic structure of diaphragmatic obstruction, the endoscopic anterior resection used by the author can be considered a logical and effective method of treatment.