Differential renal length index: useful measure in management of isolated unilateral hydronephrosis?

OBJECTIVE: To explore the usefulness of the 'differential renal length index' (iDRL) before and after pyeloplasty, as the anteroposterior diameter is commonly used to quantify hydronephrosis but inaccuracies arise due to interobserver variability, hydration status and pure intra-renal dilatation. PATIENTS AND METHODS: Prospectively collected data, from two centres, of all children undergoing pyeloplasty for isolated unilateral pelvi-ureteric junction obstruction (PUJO) (2015-2021) were analysed. Subgroup analysis was undertaken: Group A - differential renal function (DRF) ≥40%, Group B - subnormal DRF (20-39%), and Group C - symptomatic. Children with structural anomalies of upper and lower urinary tract, bilateral involvement, and subnormal DRF (<20%) were excluded. All the children had a pre- and postoperative ultrasound scan and Tc99m mercapto-acetyltriglycine (MAG3) renograms. The iDRL was calculated as follows: iDRL = ([a - b]/b) × 100, where 'a' is the length of hydronephrotic kidney (cm) and 'b' is the length of contralateral normal kidney (cm). The mean difference and standard error of mean (SEM) between the pre- and postoperative iDRL was evaluated using the paired Student's t-test, with P < 0.05 considered statistically significant. RESULTS: A total of 119 children with 1-year follow-up were included. For the entire cohort, the mean (SEM) preoperative iDRL was 27.7 (1.4) and postoperatively was 12.5 (1.1), with a mean (range) DRF improvement of 54% (44-66%) (P < 0.001). In Group A (n = 97), the mean (SEM) preoperative iDRL was 26.6 (1.5) and postoperatively was 13.1 (1.2), with a mean (range) DRF improvement of 50% (38-63%) (P < 0.001). In Group B (n = 22), the mean (SEM) preoperative iDRL was 32.6 (3.5) and postoperatively was 10.0 (2.8), with a mean (range) DRF improvement of 69% (49-89%) (P < 0.001). In Group C (n = 28), the mean (SEM) preoperative iDRL was 19.9 (2.3) and postoperatively was 7.7 (1.9), with a mean (range) DRF improvement of 61% (38-85%) (P < 0.001). CONCLUSION: Our study identifies the iDRL as a useful measure of improvement following successful pyeloplasty. In the subgroup with DRF of >39% minimum improvement was >37%. Similar minimum DRF improvement was also noted (>37%) in hypo-functioning kidneys and symptomatic PUJO.

Laparoscopy-Assisted Cutaneous Ureterostomy in Children: Early Experience.

OBJECTIVE: Laparoscopy-assisted cutaneous ureterostomy (LA-CU) is a minimally invasive approach for temporary urinary diversion in children. We describe the technique, its feasibility, potential advantages, and outcomes in 12 children treated for a variety of conditions. METHODS: Three trocars were used transperitoneally, one transumbilical, and another placed at the later stoma site. In the semilateral position, with a panoramic view, the ureter of interest is easily identified, mobilized, and exteriorized for stoma creation. We retrospectively reviewed our experience at two tertiary-care centers and included both refluxing and end ureterostomies. The study period was between October 2014 and February 2017. Renal function and growth curves were noted at follow-up. RESULTS: Twelve children underwent LA-CU: 3 end and 9 refluxing ureterostomy. Mean age was 18.75 ± 17.60 months. Mean operating time was 94.44 ± 34.86 minutes. Follow-up ranged from 10 to 38 months. No major postoperative complications occurred. Renal function and growth curves improved in the majority of children. CONCLUSIONS: Primary surgical correction of obstructive or refluxing uropathy is the gold standard; however, temporary urinary diversion is useful in specific scenarios. In these patients, laparoscopic assistance may offer better and direct visualization, achieves accurate and rapid identification of ureter, and provides adequate mobilization, tension-free exteriorization, and excision of redundant ureter in some to optimize drainage. One trocar at the eventual stoma site minimizes scarring.

Testicular asymmetry in healthy adolescent boys.

OBJECTIVES: To assess the presence of testicular asymmetry and the currently used threshold values in varicocoele management in a healthy adolescent population. SUBJECTS AND METHODS: We conducted an observational cross-sectional study from April 2015 until December 2016 in which we recruited 539 adolescent boys aged 11-16 years. A clinical examination including testicular size measurement by ultrasonography was performed. Testicular volume (TV) was calculated using the Lambert formula (length × width × height × 0.71). The Testicular Atrophy Index (TAI) was calculated using the formula [(TV right - TV left)/largest TV] × 100. The data for all statistical analyses were stratified for Tanner stage for genital development (TSG) and pubic hair (TSP). Non-parametric tests were used to assess the difference between right and left TV, and the prevalence of a smaller left testis for the entire population, and between each TSG and TSP. Parametric tests were used to determine the difference in mean TAI between each TSG and TSP, and to compare the mean TAI to a test value of 0. RESULTS: Of the 539 recruited boys, we excluded 194 due to a current or past pathology, including varicocoeles, influencing normal (testicular) growth or due to incomplete data. Most boys were in the second Tanner stage, followed by the third Tanner stage. The mean (sd) age of the entire population was 13.33 (1.25) years. Of the 345 included participants the mean (sd) left TV was 7.67 (5.63) mL and right TV was 7.97 (5.90) mL. The mean (sd) TAI was 2.85 (17.00)%. In all, 203 (58.84%) boys had a smaller left testis and 142 (41.16%) had a smaller right testis. In all, 51 boys (14.78%) had a TAI >20%, 45 (13.04%) had a TV difference (TVD) of >2 mL with a deficit in left TV, and 69 (20.00)% had a TAI >20% or a TVD of >2 mL with a deficit in left TV. Related-samples Wilcoxon signed-rank test showed a significant difference in mean left and right TV for the entire population, and more specifically for TSG3 (P < 0.001) and TSP3 (P = 0.004). A one-sample t-test showed a significant difference in the mean TAI vs the test value of 0 for the entire population (P = 0.002), and more specifically for TSG3 (P < 0.001) and TSP3 (P = 0.003). CONCLUSION: Testicular asymmetry, with a smaller left testis, was seen in a considerable number of healthy adolescents. One out of five adolescents had a smaller left testis and met one of the threshold values currently used in varicocoele management. Therefore, in left-sided unilateral inguinoscrotal pathology, a smaller ipsilateral testis in combination with a TAI of >20% and/or TVD of >2 mL requires careful interpretation and serial measurements of TV should always be performed. Furthermore, this study provides reference values for TV, TVD and TAI according to TSG and TSP for a healthy adolescent population.

Renal papillary necrosis in patients with sickle cell disease: How to recognize this 'forgotten' diagnosis.

INTRODUCTION: Renal papillary necrosis is not commonly seen in daily practice, but can have severe consequences when it is not diagnosed in time. It is known to be associated with sickle cell hemoglobinopathies; however a wide range of etiologies are possible, and it is therefore not the first diagnosis clinicians consider in patients with sickle cell disease who present with hematuria. METHODS: A literature search was performed to summarize the current knowledge about renal papillary necrosis associated with sickle cell disease. These findings are illustrated with a case of a 9-year old girl with sickle cell disease who was referred with painless gross hematuria. RESULTS: Typical radiologic signs for renal papillary necrosis are necrotic cavities that fill with contrast, small collections of contrast peripheral to the calyces in the papillary region (ball-on-tee sign), calcification of the papillary defect, filling defects, hydronephrosis, blunted papillary tip, clefts in the renal medulla filled with contrast, hyperattenuated medullary calcifications, non-enhanced lesions surrounded by rings of excreted contrast, and clubbed calyces. DISCUSSION: This study focuses on the pathophysiology of renal papillary necrosis associated with sickle cell disease, the possible symptoms, as well as the diagnostic steps, with a special interest in particular presentation on old (retrograde pyelography) and new (computed tomography) gold standard in radiologic imaging, and the management for this pathology. CONCLUSION: This study aims to remind clinicians of this "forgotten" diagnosis and what signs to look for in pediatric patients with sickle cell disease who present with hematuria. In pediatric cases radiation protection is important, therefore knowing what radiologic signs can be found on retrograde pyelography can lead to early identification of this pathology without having to proceed to computed tomography.

Emphysematous cystitis: report of an atypical case.

We report the atypical case of a nondiabetic 66-year old male with severe abdominal pain and vomiting who was found to have emphysematous cystitis. Of all gas-forming infections of the urinary tract emphysematous cystitis is the most common and the least severe. The major risk factors are diabetes mellitus and urinary tract obstruction. Most frequent causative pathogens are Escherichia coli and Klebsiella pneumoniae. The clinical presentation is nonspecific and ranges from asymptomatic urinary tract infection to urosepsis and septic shock. The diagnosis is made by abdominal imaging. Treatment consists of broad-spectrum antibiotics, bladder drainage, and management of the risk factors. Surgery is reserved for severe cases. Overall mortality rate of emphysematous cystitis is 7%. Immediate diagnosis and treatment is necessary because of the rapid progression to bladder necrosis, emphysematous pyelonephritis, urosepsis, and possibly fatal evolution.

Continent catheterizable vesicostomy in an adult population: success at high costs.

AIMS: To evaluate the long term outcome, to review the complication ratio and to analyze predicting factors of catheterizable continent vesicostomy in an adult population. To deduct a proper patient counseling policy. METHODS: We identified all patients that underwent a continent vesicostomy between 1998 and 2008. We did not consider patients that underwent orthotopic bladder reconstruction. Patient satisfaction, urinary leakage, catheterization problems were assessed by chart review or interview. Type of primary surgery, revisions (number and type), renal function and complications were assessed by chart review. RESULTS: Thirty-four patients underwent continent vesicostomy using an ileal segment (Monti or Spiral-Monti/Casale technique) or the appendix (Mitrofanoff). One patient underwent a detrusor wall flap. Twenty-one out of 35 patients underwent concomitant bladder augmentation and 2/35 patients bladder neck closure. Mean age at the time of the procedure was 44 years (range 21-80 years). Mean follow up is 60 months (range 6-117 months). Six out of 35 patients undergo surgical excision of the conduit because of untreatable problems. One patient has a permanent indwelling catheter. Two patients voided normal after sacral nerve stimulation. Ten out of 35 patients undergo stoma related revisions. Sixteen out of 35 patients undergo no stoma related revisions. Finally 26/35 patients were continent and had an easy catheterizable stoma. CONCLUSIONS: Continent urinary diversion in an adult population is associated with a high complication and revision rate. Although conversion rate to an ileal conduit is appreciable, the majority of patients (26/35) finally achieve full continence and unobstructed access to the bladder.