Significant improvement in hydronephrosis with pyeloplasty prior to 3 months of age in patients with antenatal severe hydronephrosis.

INTRODUCTION: Pyeloplasty is the definitive management of ureteropelvic junction obstruction (UPJO). One of the challenging questions is when to perform pyeloplasty. We studied if improvement post-pyeloplasty in the first 3 months of life could show greater improvement in hydronephrosis than surgery at an older age. PATIENTS AND METHODS: Patients with postnatally diagnosed UPJO and underwent pyeloplasty in the first year of life were retrospectively reviewed. We excluded patients with concomitant vesicoureteral reflux, and patients who had pyeloplasty because of UTI or missed follow-up. Patients were divided into two groups, according to the age at pyeloplasty, before and after the age of 3 months. We collected patients' demographics, anteroposterior diameter of the renal pelvis (APD), SFU grade, renogram data, perioperative data (surgery duration, hospital stay, and ureteral stent duration) and postoperative ultrasound changes. The percentage of change of APD (Δ%APD) was calculatedusing the formula: Δ%APD = [ (initial APD-last APD)/initial APD] *100. RESULTS: We included 90 patients (93 renal units). 36 patients had pyeloplasty during the first 3 months of life and 57 patients at 3 -12 months. Patients' characteristics were similar in both groups except APD which was higher when pyeloplasty was done < 3 months of age (p = 0.02). Both groups had comparable perioperative parameters. After almost similar follow-up period of both groups. The Δ%APD was 58% when pyeloplasty was done < 3 months compared to 33% when was performed > 3 months (p = 0.009). Using Kaplan-Meier analysis, APD significantly improved when pyeloplasty was performed before the age of 3 months (p = 0.001). CONCLUSION: Early pyeloplasty, in the first 3 months of life, showed a significant improvement of APD postoperatively than those had surgery later. It is unclear if this will relate to less loss of renal function yet certainly this would be suspected and feel this finding provides some evidence for early intervention.

Can we improve the usefulness of the diuretic renogram in the diagnosis of ureteropelvic junction obstruction (UPJO) in children? Introduction of mercaptoacetyltriglycine-suspected obstruction scoring system (MAG-SOS).

INTRODUCTION: Mercaptoacetyltriglycine (MAG-3) renogram is one of the gold standard diagnostic tools of ureteropelvic junction obstruction (UPJO); however, there is no widely agreed indications of pyeloplasty based on MAG-3 findings. In this study, we introduce a renogram scoring system that can help improve the prognostic value of MAG-3 renogram and in the decision making of pyeloplasty. PATIENTS AND METHODS: We retrospectively reviewed consecutive pyeloplasties for antenatal hydronephrosis from 2010 to 2020. A control group was included of non-operatively managed SFU grade 3 and 4. The initial renal ultrasound and preoperative MAG-3 Lasix renogram were reviewed for differential renal function (DRF), type of renogram curve and tracer washout half-time (T1/2). A ROC curve was used to evaluate the cut-off points that can be associated with obstruction. A multivariate linear regression model was used to assess the best renogram parameter that can predict surgical intervention. RESULTS: We included 188 patients with 209 renal units. The median age for pyeloplasty was 5.4 months. The mercaptoacetyltriglycine-Suspected Obstruction Scoring System (MAG-SOS) was associated with pyeloplasty (AUC = 0.97, P < 0.001) (Figure A). A score of 5 is 100% specific for obstruction. 78% of units required surgical intervention had a MAG-SOS score of≥5 while all units of the control group had a range of score 0-4. Using the multivariate analysis, the MAG-SOS system showed to the only independent predictor for pyeloplasty (HR = 0.03, p < 0.001). DISCUSSION: This study has some limitations. Firstly, the retrospective nature of the cohort; however, all patients were reviewed by one investigator who was blinded to the line of management. This is a single institutional study; therefor, this MAG-SOS should be evaluated by other centers to ensure its efficiency. Lastly, the pyeloplasty decision was taken by 3 different urologists; nevertheless, all of them adopt the same indications which are similar to those of the Society for Pediatric Urology and the Canadian Urological Association guidelines. CONCLUSION: The MAG-SOS system showed to be a useful tool that can predict pyeloplasty. A score of 5 has 100% specificity for patients having a pyeloplasty performed. Prospective studies are required to confirm the usefulness of this novel tool.

Incidence of bleeding in children undergoing circumcision with ketorolac administration.

INTRODUCTION: Circumcision is the most common surgical procedure performed by pediatric urologists. Ketorolac has been shown to have an efficacy similar to morphine in multimodal analgesic regimens without the commonly associated adverse effects. Concerns with perioperative bleeding limit the use of ketorolac as an adjunct for pain control in surgical patients. As such, we sought to evaluate our institutional outcomes with respect to ketorolac and postoperative bleeding. METHODS: We retrospectively reviewed all pediatric patients undergoing circumcision from January 1, 2014 to December 31, 2015 at the Alberta Children's Hospital. Demographics, perioperative analgesic regimens, and return to emergency department or clinic for bleeding were gathered through chart review. RESULTS: A total of 475 patients undergoing circumcisions were studied, including 150 (32%) who received perioperative ketorolac and 325 (68%) who received standard analgesia. Patients receiving ketorolac were more likely to return to the emergency department or clinic for bleeding (ketorolac group 19/150 [13%], non-ketorolac group 16/325 [5.0%]; p=0.005). Patients receiving ketorolac were more likely to have postoperative sanguineous drainage (ketorolac group 96/150 [64%], non-ketorolac group 150/325 [46%]; p<0.001). There was no significant difference in the number of patients requiring postoperative admission or further medical intervention. CONCLUSIONS: Although a promising analgesic, ketorolac requires additional investigation for safe usage in circumcisions due to possible increased risk of bleeding.