Endoscopic submucosal Teflon injection (STING): an alternative treatment of vesicoureteric reflux in children.

The authors present their results in treating vesicoureteric reflux with an endoscopic submucosal teflon injection (STING) of the refluxing ureter. One hundred refluxing units in 68 children were treated with a maximum follow-up of five years. Indications were high grade reflux (III-V), persistence or progression of reflux despite conservative therapy, breakthrough urinary infections despite antibiotic prophylaxis and finally bad antibiotic compliance. Treatment was performed on an outpatient basis and appeared to be free of complications. Reflux was cured with a success rate of 75% after a single injection and 96% after two injections. With respect to the grade of reflux, best results were obtained in low grade reflux (Grade I-II). A 60-70% success rate was obtained in high grade reflux (III-V). The main advantage over open reimplantations lies in its non invasiveness, simplicity and possibility of being repeated in case of failure.

How good is technetium-99m mercaptoacetyltriglycine indirect cystography?

The aim of the present study was to estimate the sensitivity of indirect radionuclide cystography (IRC) performed with technetium-99m mercaptoacetyl-triglycine (MAG3), in comparison with the micturition cystourethrography (MCUG) and direct radionuclide cystography (DRC), for the diagnosis of vesicoureteric reflux. Two groups of patients were selected: group I comprised 40 children who underwent IRC during the acute phase of urinary tract infection and an MCUG 6 weeks later; group II comprised 42 (other) children with known reflux, who underwent IRC and DRC during follow-up. Taking as the reference the total number of refluxing kidneys detected by means of any cystographic technique, 99mTc-MAG3 ICR missed two-thirds of the refluxing kidneys. Most of the small refluxes were missed, but so too were 50% of the major refluxes. Taking as the reference 99mTc dimercaptosuccinic acid (DMSA) scintigraphy, MCUG detected 91% of the patients with DMSA abnormalities on at least one kidney, DRC detected 95%, and IRC detected 46% and 43% respectively, in groups I and II. The use of 99mTc-MAG3 IRC as the sole technique for the detection of vesicoureteric reflux gives rise to an unacceptable number of false-negative results.

[Technetium 99m labeled dimercaptosuccinic acid (99m Tc-DMSA) scintigraphy in the diagnosis and follow-up of urinary infections in children]. / Apport de la scintigraphie à l'acide dimercaptosuccinique marqué au technétium 99m (99mTc-DMSA) dans le diagnostic et le suivi des infections urinaires de l'enfant.

BACKGROUND: The site of a urinary tract infection (UTI) is located by clinical findings plus imaging techniques. Renal imaging with technetium 99mTc-dimercaptosuccinic acid (99mTc-DMSA) has shown promise but its efficacy for detecting acute pyelonephritis is still debated as is its ability to differentiate between acute, potentially curable disease and scarring, definitive changes. PATIENTS AND METHODS: The files of all the 166 patients that underwent one or two (32 patients) 99mTc-DMSA imaging sessions for UTI in 1989 and 1990 in our department were analysed. The results of this technique were compared with the clinical and laboratory data and with those of other imaging techniques (ultrasonography and retrograde voiding cystourethrogram). The patients (92 girls and 74 boys, mean age: 5 years, range 15 days-17 years) were assigned to one of 3 categories: 1) acute pyelonephritis (27 patients), 2) low UTI (60 patients) and 3) uncertain UTI (79 patients), on the basis of the clinical and laboratory data. RESULTS: The first 99mTc-DMSA imaging was normal in 110 children; changes were unilateral in 45 and bilateral in 11 children. Images suggesting either acute or chronic changes were observed respectively in 19 and 48 children. 4 of the 7 acute changes were normalized on the second radioisotope scanning while 2 became worse; 19 of the 23 chronic changes were unchanged at the second scanning. Radioisotope scanning changes were seen in 81% of the patients classified as acute pyelonephritis and in only 27% of those with lower UTI. Reflux was detected in 56% of abnormal kidneys and in 36% of normal kidneys. The results of radioisotope scanning and ultrasound scan findings were not correlated in 24 patients (19 only abnormal radioisotope imaging, 5 only abnormal ultrasound scan). CONCLUSIONS: DMSA scans are useful for investigating and following UTI. They help to distinguish acute pyelonephritis and lower UTI. It is a reliable method of detecting structural abnormalities and identifying children at risk of progressive renal damage.

Renal function abnormalities after ifosfamide treatment in children.

Renal function was evaluated in 12 children (aged 2.5-17.5 years) who received ifosfamide as part of their chemotherapy for different malignancies. A blood and urine analysis evaluating renal glomerular and tubular function and an isotopic determination of glomerular filtration were carried out four months or later after treatment had been stopped. Three patients had several biochemical abnormalities suggesting a significant degree of proximal renal dysfunction (increased urinary excretion of calcium, glucose, beta 2-microglobulin, amino acids (three patients) and decreased tubular reabsorption of phosphate (one patient)). The tubular dysfunction in these patients was associated with a diminished glomerular filtration. These patients could be characterized by their younger age at treatment and a higher dose of ifosfamide received if calculated per kg body weight.

Replacing 99Tcm-DMSA for renal imaging?

We have tried to evaluate the usefulness of an early 99Tcm-MAG3 image, obtained during the second minute after injection of the tracer, in predicting the renal alterations seen on a 99Tcm-DMSA scintigraph, in children clinically suspected of pyelonephritis. It appears that the accuracy of the MAG3 image is population dependent: when, in most of the patients of a study group, DMSA scintigraphy is either normal or very abnormal, the MAG3 image will correctly reflect the DMSA scintigraph. However, when the DMSA alterations are less pronounced, the early MAG3 image will miss the lesions in about 50% of the cases.

Ifosfamide-induced Fanconi's syndrome with growth failure in a 2-year-old child.

Fanconi's syndrome with phosphopenic rickets is described in a 2-year-old girl who had been treated for an embryonal sarcoma with multiagent chemotherapy including high-dose ifosfamide. The radiological and biochemical signs of rickets disappeared after treatment with 25-OH vitamin D3 and phosphorus supplements. Monitoring of tubular function in children during and after treatment with ifosfamide is mandatory.

99mTc-DMSA scintigraphy in acute urinary tract infection in children.

24 children with symptomatic urinary tract infection (UTI) underwent systematically ultrasound studies (US) and 99mTc-DMSA renal scans. Among the 15 patients considered as acute pyelonephritis (APN) on clinical grounds, the scan was abnormal in 12 cases, in contrast with only 1 abnormal scan in the clinical subgroup of the lower UTI. Among the 10 abnormal scans that were repeated later on, 6 did completely normalize. US showed only once a parenchymal appearance suggestive for APN. Our findings suggest that the DMSA scan has to be considered at present as the most sensitive imaging technique for the detection of APN.

Antenatal diagnosis of urological disorders by ultrasound: a critical review.

The suspected diagnosis of urological disorders made on the basis of antenatal ultrasonography was compared with the final outcome in 23 cases. In 18 cases the initial diagnosis could be confirmed, whereas 5 showed no postnatal urological anomalies. Further efforts should be undertaken to improve prenatal diagnosis in order to facilitate treatment as early as possible.

Prospective management of neonates with pelviureteric junction stenosis. Therapeutic strategy based on 99m Tc-DPTA studies.

A prospective therapeutic strategy based on separate glomerular filtration rate (SGFR) was evaluated in 14 prenatally detected asymptomatic neonates, suspected of having pelviureteric junction obstruction. The patients with low SGFR were referred for pyeloplasty with the hope to improve the renal function. A marked improvement occurred in only one patient, although the drainage function (furosemide test) did improve in all cases. A conservative attitude was adopted for those children with normal SGFR. In 6 of them, a progressive increase of SGFR was noted, related to the normal maturation of the function, followed by a stabilization in the normal range. In 1 patient, a sudden decrease of SGFR was observed around 1 year and the patient was shifted into the surgical group. In this patient, an initial partial response of the kidney to a furosemide injection changed into a persistent non-response, whereas in the other non-operated patients, partial or good response was always recorded, although the responses were essentially variable on successive tests. On the basis of these data, the protocol was slightly modified, the patients with persistent non-response to furosemide after 6 months of life being shifted to the surgical group.

Radioisotopic transit parameters in obstruction of pelviureteral junction.

Cortical and whole kidney radionuclide transit parameters were studied in 16 patients who underwent a pyeloplasty for unilateral pelviureteral junction (PUJ) obstruction. As expected, the whole kidney mean transit time was found to be very sensitive but, due to the low specificity, not very helpful in the distinction between obstructed and nonobstructed kidneys. The cortical transit reflected, in some cases, the favorable surgical outcome. In other cases, however, it could not be considered as a reliable parameter of the clinical status, since it was found to be normal preoperatively and prolonged postoperatively in patients whose parenchymal function improved significantly after surgery and who had their clinical symptoms relieved.

Temocillin in the treatment of pyelonephritis in children.

Temocillin is a beta-lactamase-stable penicillin with a selective. Gram-negative spectrum of activity and a long half-life. Previous studies in adult patients have demonstrated its efficacy and safety in the treatment of Gram-negative infections. The aim of the study was to evaluate the clinical and bacteriological efficacy and safety of temocillin in children with complicated urinary tract infections. Twenty-two children, aged 3 months to 13 years (mean 5.8 years) were treated with temocillin i.v. at a dose of 25 mg/kg 12 hourly for a mean period of 5.9 days (range 3-12 days). Acute pyelonephritis was diagnosed in 21 patients (one case associated with septicaemia); one patient presented recurrent bacteriuria due to a multiresistant pathogen. Some 20/22 children presented an underlying condition complicating the urinary tract infection (UTl). The causative pathogens, isolated from the urine, were: E. coli (17), Proteus mirabilis (3), Enterobacter cloacae (1), enterococcus (1). The enterococcus and one Proteus mirabilis were found to be resistant to temocillin. Clinical improvement was obtained after 24-36 h in all children with temocillin-sensitive organisms. Bacteriological cure was obtained in all patients with temocillin-sensitive organisms. The two patients with temocillin-resistant pathogens were treated with another antibiotic. Follow-up treatment was given per os during +/- 2 weeks. No adverse reactions or abnormal laboratory values were noted. In the authors' limited experience temocillin proved to be effective and safe in the treatment of pyelonephritis often due to ampicillin-resistant strains in children.

99Tcm-DMSA uptake in obstructed kidneys. How inaccurate are the 5 h measurements?

Partial obstruction of the left ureter was created in 19 rats and a relative 99Tcm-DMSA uptake was obtained 5 and 24 h after intravenous injection of the tracer. A systematic and variable overestimation of the left to right uptake ratio was found at 5 h, with a mean error of 15.8% (S.D. = 12.2).

Puncture of unilateral renal cyst in utero.

Although most authors do not recommend prenatal puncture of a unilateral single cystic renal mass, in case the contralateral kidney is normal and there is sufficient amniotic fluid, this case report shows that the procedure, which can be done very carefully under ultrasonic guidance, can be helpful in establishing the presumed diagnosis.