Evaluation of renal function and prediction of renal functional recovery in children with unilateral hydronephrosis using renal pelvic urine]

In 29 children with unilateral hydronephrosis who underwent surgery at the age from 2 months to 15 years (27 patients with ureteropelvic junction stenosis and 2 with obstructive megaureter), beta 2-microglobulin (beta 2-MG), alpha 1-microglobulin (alpha 1-MG), N-acetyl-beta-D-glucosaminidase (NAG) and albumin were determined in renal pelvic urine from the hydronephrotic kidney to evaluate renal dysfunction accompanying urinary tract obstruction. Moreover, it was also examined whether it is possible to predict functional recovery of the hydronephrotic kidney on the basis of relation between these indices and pre- and postoperative changes in renal dimercaptosuccinic acid (DMSA) uptake rate. The values of beta 2-MG, alpha 1-MG, NAG and albumin in urine from the renal pelvis were high in 48%, 50%, 75% and 83% of the patients, respectively. Among the patients of one year and up, those with low preoperative DMSA uptake rate tended to have high values of beta 2-MG, alpha 1-MG and NAG. On the contrary, albumin level was high in 78% of patients who had good preoperative DMSA uptake rate. With respect to the relation between pre- and postoperative changes in DMSA uptake rate and each index, beta 2-MG and alpha 1-MG were high in 73% and 62% of patients who exhibited a marked increase in postoperative DMSA uptake rate. In patients without a remarkable change in DMSA uptake rate before and after surgery, on the other hand, the values of these were high only in 25% and 36%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Renal function study by 99mTc-DMSA renal scintigraphy in each treatment of staghorn calculi

From 1976 through 1984, 94 staghorn calculi of 86 patients were treated in this department. Kidney function was assessed by Tc-DMSA renal scintigraphy consisting of renal cortical imaging and DMSA renal uptake rate, in 84 kidneys preoperatively and 43 kidneys pre- and postoperatively. There was an increase in the postoperative DMSA renal uptake in the operated kidney, in 3 out of 14 kidneys in which pyelolithotomy was performed and in one out of 10 kidneys in which nephrolithotomy was done. It was still impossible to answer the question of which mode of operation should be chosen only from consideration of kidney function study. But it was suggested by the statistical investigation that nephrectomy seemed to be selected in the case of severely decreased renal function. It was reasonable that pyelolithotomy was the best method from the point of predicting the postoperative recovery of renal function. But in the near future, advances in endoscopical stone surgery and extracorporeal procedures, might reduce the damage of the renal function caused by conventional stone surgery.     

Prediction of residual total renal function before nephron-sparing surgery using99mTc-DMSA renal scintigraphy

Background Although radical nephrectomy is the standard treatment for renal cell carcinoma, nephron-sparing surgery is the preferred treatment in patients with a single functioning kidney. It is important before surgery to evaluate the level of residual renal function likely after the operation. In this study, we investigated the prediction of residual renal function, using technetium Tc 99m dimercaptosuccinic acid (^99mTc-DMSA) renal scintigraphy, before nephron-sparing surgery for renal tumors. Methods Preoperative and postoperative evaluation of renal function was done in 11 patients with renal cell carcinoma or renal angiomyolipoma, using^99mTc-DMSA scintigraphy. Nine patients had renal cell carcinoma and 2 had renal angiomyolipoma. Partial nephrectomy was performed in 4 patients and surgical enucleation in 7 patients. Both the predicted total DMSA renal uptake rate prior to surgery and the actual postoperative total^99mTc-DMSA renal uptake rate were obtained. Endogenous creatinine clearance and serum creatinine levels were also obtained. Results There was a good relationship between the predicted and postoperative total^99mTc-DMSA renal uptake rates. The ratio of the postoperative total DMSA renal uptake rate to the predicted total^99mTc-DMSA renal uptake rate was 85% after partial nephrectomy, and 101% after surgical enucleation. There was also a significant correlation between the postoperative total^99mTc-DMSA renal uptake rate and creatinine clearance, and postoperative total^99mTc-DMSA renal uptake rate levels above 11.4% coincided with serum creatinine levels below 2.0 mg/dL. Conclusion Preoperative assessment with^99mTc-DMSA renal scintigraphy is clinically useful for predicting residual renal function after nephron-sparing surgery.     

Ultrasound grade of hydronephrosis and severity of renal cortical damage on 99m technetium dimercaptosuccinic acid renal scan in infants with unilateral hydronephrosis during followup and after pyeloplasty

PURPOSE: We performed ultrasonography and (99m)technetium dimercaptosuccinic acid (DMSA) renal scan in infants with unilateral hydronephrosis during followup and after pyeloplasty to examine the correlation of ultrasound hydronephrosis grade with the severity of renal cortical damage and assess the recovery of renal function in the obstructed kidneys after surgery. MATERIALS AND METHODS: We studied 80 boys and 19 girls with unilateral hydronephrosis detected in the first year of life, including 75 (76%) in whom it was detected prenatally. Ultrasound images were graded according to the Society for Fetal Urology grading system. The severity of renal cortical damage was assessed by DMSA renal scan. Absolute function of the right and left kidneys was estimated by DMSA uptake and relative DMSA uptake was calculated by the formula, relative uptake = uptake in obstructed kidney/total uptake in right and left kidneys x 100%. RESULTS: On ultrasonography grades 1 to 4 hydronephrosis were diagnosed in 9, 21, 19 and 50 kidneys, respectively. On DMSA renal scan cortical damage was detected in 10 kidneys (53%) with grade 3 and 49 (98%) with grade 4 hydronephrosis but not in kidneys with grade 1 or 2 disease. Dysfunction in the obstructed kidney, defined as relative DMSA uptake less than 40%, was noted in 13 patients with grade 4 hydronephrosis. Relative DMSA uptake significantly increased after successful pyeloplasty compared with preoperative uptake (44% +/- 2% versus 40.1% +/- 2%, p <0.01). CONCLUSIONS: Ultrasound grading of hydronephrosis correlates with the severity of cortical damage or the decrease in renal function on DMSA renal scan. Differential renal function on DMSA renal scan may be a useful and less invasive tool for determining surgical indications and examining changes in renal function after surgery.     

Effect of extracorporeal piezoelectric lithotripsy shock waves on renal function measured by Tc-99m-DMSA using spect

Extracorporeal shock-wave lithotripsy has altered the therapeutic approach to urinary stone disease. Recently, a method was developed in which shock-wave generation is obtained piezoelectrically. To evaluate the effect of extracorporeal piezoelectric lithotripsy (EPL) on renal function, 20 patients were studied prior to and after EPL of renal calculi. Renal cortical function was evaluated by using a previously described and validated quantitative single photon emission computerized tomography (SPECT) method to measure individual absolute uptake of technetium-99m dimercaptosuccinic acid (Tc-99m-DMSA). Twenty kidneys were treated, and the 19 contralateral kidneys were without stone disease (1 patient had a single kidney). The absolute kidney uptake of Tc-DMSA in the normal kidneys was 21.4% +/- 6.2% before and 22.2% +/- 6.4% after EPL. For the treated kidneys the absolute update was 16.8% +/- 5.3% and 16.8% +/- 4.7% before and after, respectively. There was no statistical significant difference between pre- and post-treatment values. The absolute kidney uptake was significantly lower (p less than 0.01) in the treated than in the normal kidneys. This study indicates that the EPL procedure did not cause any damage to cortical function detectable by the DMSA uptake.     

Congenital renal anomaly: evaluation with 99mTc-dimercaptosuccinic acid renal scintigraphy

Technetium 99m-2,3, dimercaptosuccinic acid (99mTc-DMSA) preferentially accumulates in the renal cortex, demonstrating functioning cortical mass. We used 99mTc-DMSA renal scintigraphy in ten patients with horseshoe kidneys and five patients with unilateral fused kidneys. The results show that 99mTc-DMSA renal scintigraphy reliably establishes the diagnosis of horseshoe kidney and clearly shows the isthmus, which is very essential for proper management. The technique also aids in the definitive assessment of separate kidney function and of total radionuclide uptake is possible using 99mTc-DMSA scintigraphy.     

Anatrophic nephrolithotomy in the solitary kidney

A retrospective analysis was conducted on 30 patients who had undergone anatrophic nephrolithotomy for staghorn calculus disease in a solitary kidney. No statistically significant difference (p greater than 0.1) was found between the average preoperative and postoperative renal function values. Of 27 patients who were infected preoperatively 19 were rendered free of further urinary tract infection and 24 of 30 patients (80 per cent) had no further recurrence of renal calculi. Because of the predictable morbidity and mortality associated with the non-operative management of staghorn calculus disease these patients are managed best by the complete surgical removal of all calculi and intensive antimicrobial therapy.     

The value of quantitative 99M technetium dimercaptosuccinic acid renal scintigraphy for predicting postoperative renal insufficiency in patients undergoing nephrectomy

PURPOSE: Radical nephrectomy is a routine urological practice. However, little is known about the use of dimercapto-succinic acid (DMSA) scan to evaluate compensatory changes after surgery and its ability to identify patient at risk for postoperative chronic renal failure or insufficiency. We predicted remaining kidney function using DMSA scan and serum creatinine. MATERIALS AND METHODS: A total of 42 patients were enrolled in the study. All underwent DMSA scan before surgery and in 38 DMSA scan was done after unilateral nephrectomy. Serum creatinine was determined before and 1 year after surgery. The Student t test was used to determine statistical significance. Spearman rank core analysis was used to evaluate the association of calculated creatinine clearance time after surgery and renal absolute uptake before surgery. We performed 1-way ANOVA comparison of the means to determine the influence of age distribution on kidney hypertrophy and the increase in kidney uptake. RESULTS: Average patient age was 61.5 years. Baseline mean creatinine clearance time was 71.5 ml. per minute, which decreased to 58.6 ml. per minute after nephrectomy (p <0.0001). Before surgery DMSA scan of the remaining kidney demonstrated an absolute uptake of 4.2% higher than that in the resected kidney (13.5% versus 9.35%, p = 0.0008). After nephrectomy the remaining kidney had an average increase of 3.9% of mean absolute uptake (17.7% versus 13.8%, p = 0.0001). Spearman rank core analysis demonstrated an association of higher preoperative absolute uptake in the remaining kidney with postoperatively high creatinine clearance time (r = 0.458, p = 0.003). Furthermore, 75% of patients with postoperative creatinine clearance time less than 40 ml. per minute presented with a preoperative absolute uptake of lower than 11% in the remaining kidney. In contrast, 75% of those with a postoperative creatinine clearance time of higher than 40 ml. per minute had a preoperative absolute uptake of higher than 11%. CONCLUSIONS: A preoperative absolute uptake of lower than 11% in the remaining kidney was a significant risk factor for postoperative chronic renal insufficiency.     

Impact of arterial occlusion during partial nephrectomy on residual renal function: An evaluation with 99m technetium-dimercaptosuccinic acid scintigraphy

BACKGROUND: Partial nephrectomy (PNx) has been performed with temporary renal arterial occlusion and in situ renal hypothermia (conventional PNx). However, the impact of temporary renal arterial occlusion on residual renal function has not been well assessed. To address this question, we performed renal scintigraphy with (99m)technetium-dimercaptosuccinic acid (DMSA) for the quantitative measurement of postoperative residual renal function after conventional PNx and partial nephrectomy without arterial occlusion (non-clamping PNx). METHODS: Thirty-four patients underwent postoperative DMSA scintigraphy after PNx for renal cell carcinoma. No obvious difference in preoperative renal function between the diseased kidney and the contralateral kidney was found in any of the patients. Of these patients, 24 underwent conventional PNx, and 10 underwent non-clamping PNx. Residual renal function was evaluated using the relative DMSA uptake of the operated kidney. RESULTS: The relative DMSA uptake of the operated kidney was 39.9 +/- 7.3% (25.1-58.8) after conventional PNx compared to 34.8 +/- 8.9% (13.5-45.5) after non-clamping PNx. This difference was not statistically significant (P = 0.15). Total ischemic time during conventional PNx had no adverse influence on the residual renal function. In the analysis of the other determinant factors influencing residual renal function, tumor size was the only significant factor that inversely correlated with the relative DMSA uptake. CONCLUSION: Our results showed that arterial clamping during PNx has no negative impact on the functional residual capacity as long as insitu renal hypothermia is adequately performed.     

Aortoiliac surgery after renal transplantation. Authors' experience and review of the literature]

Eighteen patients who had undergone renal transplantation three months to 25 years earlier were operated on for treatment of complicated aortoiliac atherosclerosis: nine had aneurysms (of which one was leaking) and nine had stenotic or obstructive lesions. Except for the first patient, operated on in 1973, in whom the kidney was protected by general hypothermia, no special measure was used to protect the kidneys in the other 17 patients. A transient increase in creatininemia occurred in the majority of cases during postoperative period. All patients had regained renal function identical to the preoperative state in less than 10 days. Three patients had significant improvement of renal function which lasted in the long term follow-up. Such improvement was a result of correction of a lesion that was impairing renal blood flow. Results obtained in this series show that protection of the transplant during aortic surgery is not necessary, provided an adequate surgical technique is used. This technique is described: it avoids the complex methods employed in several previously reported cases and appears to be a safe procedure.     

Aortoiliac surgery in renal transplant patients

Fifteen patients who had undergone renal transplantation 3 months to 25 years earlier were operated on for treatment of complicated aortoiliac atherosclerosis; eight had aneurysms and seven had stenotic or obstructive lesions. Except for the first patient, operated on in 1973, in whom the kidney was protected by general hypothermia, no special measure was used to protect the kidneys. A transient increase in creatinemia occurred in 11 patients during the postoperative period, whereas creatinine values remained unchanged in the other four. All patients had regained renal function identical to the + preoperative state in less than 10 days; three of them had significant improvement as a result of correction of a lesion that was impairing renal blood flow. Results obtained in this series show that protection of the transplant during aortic surgery is not necessary, provided an adequate surgical technique is used. This technique avoids the complex methods employed in the majority of previously reported cases and appears to be a safe procedure.     

Long-term radiographic changes of the kidney following the ileal ureter operation.

A long-term retrospective evaluation was done on the preoperative and postoperative radiographic studies from patients who had undergone the ileal ureter operation. The comparative studies demonstrated decreased or stable pelviocaliceal dilatation, no measurable parenchymal loss, frequent high pressure vesico-ileac reflux and decreased number of renal calculi. Radiographically there was no evidence of renal morphological deterioration.     

A clinical study of 99mTechnetium dimercaptosuccinic acid uptake in obstructed kidneys: comparison with the creatinine clearance

We studied 17 hydronephrotic kidneys owing to stenosis of the pyeloureteral junction. Preoperative uptake of 99mtechnetium dimercaptosuccinic acid was compared to early postoperative unilateral creatinine clearance, measured by urine collection from the nephrostomy tube. An excellent correlation was found. Therefore, uptake of 99mtechnetium dimercaptosuccinic acid represents a reliable parameter of renal function even in the presence of severe urinary tract obstruction. However, 99mtechnetium dimercaptosuccinic acid uptake should be measured more than 24 hours after injection of the tracer.     

Diagnostic value of routine bone scintigraphy renal imaging in renal cell carcinoma

Technetium-99m-phosphate compounds used in bone scanning are excreted by the kidney, and excellent renal images can be obtained on routine bone scintigrams. The preoperative bone scans of 49 patients who underwent radical nephrectomy for renal cell carcinoma between 1981 and 1985 were reviewed for renal imaging. Ninety-four percent of the patients had abnormal bone scan renal images (82% had focal decreased uptake, and 12% had focal increased uptake). Six percent of the renal images were symmetrical bilaterally. When bone scans are employed in the postoperative follow-up of patients with renal cancer, they can be used to assess the status of the remaining kidney.     

Recurrence of infected calculi following postoperative renal irrigation with stone solvent.

Renacidin has been shown to dissolve small fragments of infected renal calculi in vitro. 34 patients with infected calculi have undergone pyelolithotomy and postoperative renal irrigation with Renacidin. 30 patients were women and Proteus was the commonest infecting organism. Renal irrigation appears to be safe if closely monitored and covered by antibiotic therapy. 24.4% of calculi had recurred at a mean follow-up of 42 months. The rate of recurrence or unilateral calculi was much less than that of bilateral calculi (15% vs. 40%). Persistent postoperative urinary tract infections later led to recurrent stone formation.     

肾盂切开钬激光碎石取石术治疗孤立肾巨大鹿角形结石的疗效观察

目的：探讨和评价经肾盂切开钬激光碎石取石术治疗孤立肾巨大鹿角形结石的安全性和疗效。方法：回顾性分析接受经肾盂切开配合钬激光碎石取石术治疗的7例孤立肾巨大鹿角形结石患者的临床资料。结果：7例患者均手术顺利．术中出血量80～250ml,平均150ml、随访6～21个月,肾功能4例恢复正常．3例接近正常值范围．复查B超无结石残留。结论：该术式具有术中出血少、手术安全、对肾功能无明显影响、结石取净率高等优点,是一种处理孤立肾巨大鹿角形结石的较好方法。     

后腹腔镜下肾盂切开取石术联合输尿管镜治疗多发性肾结石

目的探讨在多发性肾结石的治疗中，后腹腔镜下肾盂切开取石术联合输尿管镜的可行性和安全性。 方法回顾性分析2014年3月至2017年3月我院收治的多发性肾结石患者10例为研究对象，行后腹腔镜肾盂切开联合输尿管镜碎石取石术，观察患者的手术情况、手术时间、术中出血量、肾功能变化、术后住院时间及结石清除率等。 结果10例手术均成功，一期结石清除率为100%，平均手术时间（143±23）min，平均术中出血量（98±39）ml，术后平均住院时间（6.5±1.0）d。10例患者术前和术后6 h肌酐改变差异无统计学意义（P>0.05）。围手术期有1例患者发生尿瘘，保守治疗无效后于术后1个月再次行输尿管镜下双J管置入术，现已痊愈。所有患者术后复查腹平片未见结石残留，术后平均随访（10±5）个月，未发现吻合口狭窄，无继发性肾结石形成。 结论在选择性病例中，后腹腔镜联合输尿管镜碎石取石术是安全可行的。     

Abdominal aortic aneurysmectomy in renal transplant patients.

Five patients who had undergone renal transplantation 3 months to 23 years ago were operated on successfully for an abdominal aortic aneurysm. In the first case, dating from 1973, the kidney was protected by general hypothermia. In the remaining patients, no measure was used to protect the kidney. Only one patient showed a moderate increase of blood creatinine in the postoperative period; renal function returned to normal in 15 days. All five patients have normal renal function 6 months to 11 years after aortic repair. Results obtained in this series show that protection of the transplant during aortic surgery is not necessary, provided adequate surgical technique is used. Such a technique is described in detail. Its use simplifies surgical treatment of such lesions and avoids the complex procedures employed in the seven previously published cases.     

Renal artery revascularisation can restore kidney function with absent radiotracer uptake

Background

Children with renovascular hypertension often present with severe hypertension. Some children have severe obstruction of their renal arteries resulting in <10% relative function on [^99mTc]dimercaptosuccinic acid (DMSA) scan. Conventional treatment of these children has been nephrectomy of the poorly functioning kidney to normalise their blood pressure (BP).

Case-Diagnosis/treatment

We describe three children aged 20 months to 9 years with severe renal artery stenosis and severe hypertension who had radionucleotide uptake of 0% in one kidney. In one case, no renal perfusion was demonstrated by duplex ultrasound scan. Significant recovery of relative renal function of 18 to 52% was achieved after revascularisation by percutaneous angioplasty or open surgery of the obstructed renal artery.

Conclusion

These cases illustrate that scintigraphy alone cannot be used to predict salvageable function in children with renovascular disease.     

后腹腔镜肾盂输尿管切开取石术的疗效观察

目的:探讨后腹腔镜肾盂输尿管切开取石术的技术与临床价值。方法:采用后腹腔镜技术行肾盂输尿管切开取石术24例,术前未行其他治疗。结果:24例均取石成功,其中1例5岁患儿改开放手术留置输尿管支架外引流管;手术时间55～210min,平均103min;术中出血量5～30ml,平均17.5ml。术后肠功能恢复时间12～24h,漏尿时间0～3d,日漏尿量0～50ml。术后4d拔除腹膜后引流管;术后住院5～7d;20例获随访2～12个月,患者肾功能均得到改善,无肾盂输尿管狭窄发生。结论:后腹腔镜肾盂输尿管切开取石术具有创伤小、患者康复快、疼痛轻等优点,是微创治疗上尿路结石可选择的方法,对于较大的肾外型肾盂、输尿管上段结石可作为首选的治疗方法。