脊髓脊膜膨出患儿尿动力学改变与上尿路损害的关系探讨

目的探讨脊髓脊膜膨出患儿尿动力学改变与上尿路损害的关系。方法对36例脊髓脊膜膨出患儿行泌尿系彩超、静脉肾盂造影及尿动力学检查,根据检查结果分析与上尿路损害密切相关的尿动力学危险因素。结果36例患儿中,泌尿系彩超检查提示15例存在上尿路损害,21例无上尿路损害。尿动力学检查提示上尿路损害组中逼尿肌漏尿点压（47．2±21．9）cm H3O,显著高于未损害组（15．7±9．6）cmH2O;逼尿肌漏尿点压〉40cmH2O的发生率为66．7％（10／15）,显著高于未损害组中发生率0．0％（0／21）;膀胱顺应性（4．5±2．4）mL／cmH2O,显著低于未损害组（12．8±13．2）mL／cmH2O;残余尿量（137．8±99．7）mL,显著高于未损害组（32．3±36．7）mL;残余尿量≥50mL的发生率为93．3％（14／15）,显著高于未损害组中的发生率19．0％（4／21）;排尿期逼尿肌反射低下或无反射的发生率为66．7％（10／15）,显著高于未损害组中的发生率14．1％（3／21）。差异均具有显著的统计学意义（P〈0．05）。结论膀胱漏尿点压升高、膀胱顺应性降低、排尿期逼尿肌反射低下或无收缩以及残余尿量增多与上尿路损害关系密切;逼尿肌漏尿点压〉40cmH2O、残余尿量〉150mL、排尿期反射低下或无反射的发生可有效提示上尿路损害。     

肾静态显像联合DWI对儿童上尿路感染的诊断价值

目的　评价99mTc-DMSA肾静态显像方法联合磁共振扩散加权成像（DWI）检查对儿童上尿路感染的诊断价值。 方法　收集2017年6月至2018年6月就诊于内蒙古医科大学附属医院儿科明确诊断为泌尿道感染的49例患儿的临床资料,所有患儿均进行99mTc-DMSA肾静态显像、B超及 DWI检查,对检查结果进行统计分析。结果 49例患儿中,男性患儿29例,女性患儿 20例,年龄3月龄至16岁,2岁以内的患儿15例（30.6%）。明确诊断泌尿道感染的49例患儿中经99mTc-DMSA肾静态显像检查,结果正常42 例（85.7%）,异常7例（14%）,共7个肾有肾脏损害, 其中6例（12%）6个肾呈急性肾盂肾炎改变, 1例（2%）1个肾有肾瘢痕形成; 49例患儿经DWI检查,结果46例（93.8%）正常,3例（6%）3个肾发现肾脏损害,均表现为肾炎改变。49例确诊为泌尿道感染患儿中,有1例（2%）经
B超检查发现肾脏病变。三种方法检测结果对比统计分析,DMSA及DMSA联合DWI检测方法检出率均明显高于B超的检出率（P均＜0.05）。99mTc-DMSA肾静态显像联合DWI检查共9例（18%）患儿为上尿路感染。 结论　99mTc-DMSA肾静态显像联合DWI检查可提高儿童上尿路感染的诊断率。DWI检查可作为上尿路感染的辅助检查方法。     

Reactive thrombocytosis in children with upper urinary tract infections

The relationship between reactive thrombocytosis and the level of urinary tract infections was studied in 48 children. Platelets were counted before, during and after treatment. Reactive thrombocytosis was noticed in 74% of children with upper and in 14% with lower urinary tract infections. A significant rise in the platelet count presented in another five children (15%) with upper urinary tract infections. Conclusion: Reactive thrombocytosis was found almost exclusively in the renal parenchymal infections, usually during the recovery phase.     

儿童泌尿系统梗阻畸形合并上尿路结石的术中内镜治疗

目的 探讨儿童泌尿系统梗阻畸形外科手术中联合内镜治疗儿童泌尿系统梗阻畸形合并上尿路结石的安全性和有效性.方法 回顾分析我院小儿外科2010年1月1日至2013年8月31日收治的17例儿童泌尿系统梗阻畸形合并上尿路结石的患儿临床资料.男13例,女4例,年龄3～12岁,平均年龄5.9岁,左侧14例,右侧3例.肾积水、UPJO合并肾脏结石11例,输尿管膀胱连接处狭窄合并肾盂内结石3例,输尿管膀胱连接处狭窄合并输尿管末端结石者2例,输尿管膀胱连接处狭窄合并肾输尿管多处结石1例,结石直径4～12 mm.结果 11例肾积水、UPJO(肾盂输尿管连接处狭窄)患儿均顺利行离断式肾盂输尿管成形术,术中均行经肾盂输尿管镜或膀胱镜检查肾盂内各盏,10例患儿成功取出结石,1例术中未见找到结石,术后辅助行体外震波碎石治疗(ESWL).6例输尿管膀胱连接处狭窄(UVJO)患儿均顺利行膀胱外输尿管膀胱再植术,术中4例顺利行输尿管硬镜检查术,2例顺利行输尿管软镜检查术,结石顺利取出4例,2例术中检查未能发现结石.结论 对于儿童泌尿系统梗阻畸形合并上尿路结石,在梗阻畸形外科手术治疗的同时联合内镜治疗上尿路结石是理想、安全、有效的.     

The correlation between bladder volume wall index and the pattern of uroflowmetry/external sphincter electromyography in children with lower urinary tract malfunction

ObjectiveTo evaluate the relationship between bladder volume wall index (BVWI) and the pattern of uroflowmetry in children with lower urinary tract malfunction.Patients &; methods91 children aged 4–15 years with history of bladder dysfunction and 59 age/sex-matched healthy children with negative urine culture in previous month were enrolled. Uroflowmetry and kidney and bladder sonography were performed in all children. BVWI was measured by dividing maximum bladder volume index by mean bladder thickness. It was expressed as percentage by dividing calculated BVWI by expected BVWI, and values between 70% and 130% were presumed normal. Urodynamic study was done in symptomatic cases.ResultsThe bladder was thick (<70%) in 39 (28 cases, 11 controls) and thin (>130%) in 35 (18 cases, 17 controls) (P > 0.05). Uroflowmetry was abnormal in 82 (61 cases, 21 controls) (P < 0.05). Severe sphincter dyssynergia was detected in 47% of cases compared with 20% of controls (P < 0.05).There was no relationship between BVWI and uroflowmetry in cases or in controls (P > 0.05). The median post-void residual urine was not statistically different between the groups (20 vs 12.3 ml) (P > 0.05). When both bladder sonography and uroflowmetry were abnormal, they had an association with abnormal urodynamics (P < 0.05).ConclusionAmong children with lower urinary tract dysfunction, the pattern of uroflowmetry could not be predicted from the BVWI, but in cases with combined abnormal bladder sonography and uroflowmetry results, there was a significant association with an abnormal urodynamic study.     

In vitro motility investigations and electron microscopic observations on children's upper urinary tract muscle wall.

This study was performed as a part of a longer research programme on urinary tract smooth muscle layer in children. All the children whose samples were investigated underwent surgery for urinary tract malformations. Specimens were taken from different segments of upper urinary tract during surgical intervention. Specimens were investigated by either in vitro motility tests or electron microscopy or both of them. Basic patterns of tissue strips were recorded after incubation of varying duration and then tested by administering neurotransmitter agents like noradrenaline and acetylcholine-bromide. Microstructure of samples were examined electron microscopically. Investigations were performed in order to find correlation between microarchitecture and motility patterns of urinary muscle wall. Factors influencing urinary muscle motility, characteristic features of impaired musculature and its possible regeneration are discussed too. Microhistological deteriorations inhibit spontaneous smooth muscle motility but muscle contractility proved by administering noradrenaline and acetylcholine-bromide remained in some extent. Taking into consideration that smooth muscle is able to regenerate and rebuild close contacts pediatric surgeon and urologist should spare kidney parenchyma as far as it is possible.     

Masked obstructive uropathy of the upper urinary tract in childhood

Congenital ureteropelvic junction obstruction is the most common site of urinary tract obstruction in children. In infants an abdominal mass, in older children loin or abdominal pain, especially after fluid intake, are commonly the presenting features. In some cases the only symptom is posttraumatic hematuria. Appropriate diagnostic procedures are suggested.     

Diagnostic imaging in children with urinary tract infection: the role of intravenous urography

Ninety children referred to hospital with urinary tract infection (UTI) were investigated by iv urography (IVU), ultrasonography (US) and ^99mTc dimercaptosuccinic acid scan (DMSA). Fifty-eight children also underwent micturating cystourethrography (MCUG). In 36 (40%) of the children, at least one result was abnormal. Abnormal findings were found in 29 children with IVU, in 10 with US and in 16 with DMSA. Six of the 58 children had vesicoureteric reflux (VUR) in 8 kidneys. In 16 children, IVU was the only examination with an abnormal result, and in 10 of these the findings were considered important for treatment or prognosis. IVU is an important supplement to US and DMSA in investigation programs for children with UTI. IVU should be performed in cases of renal scars, dilatations or in children with recurrent infections.     

Ultrasonographical aspects of urinary schistosomiasis: Assessment of morphological lesions in the upper and lower urinary tract

Ultrasonographic evaluation of 213 patients with urinary schistosomiasis in different age groups was performed in an endemic area of the Democratic Republic of Congo. The results were compared with 94 age matched controls without urinary schistosomiasis. In patients the bladder showed thickening of the wall, polypoid lesions of the mucosa and bladder wall, calcifications and urinary retention. Urinary tract obstruction, predominantly unilateral, was demonstrated. The lesions increased in severity with the intensity of infection, parallel to an increase in ova excretion. Children aged between 8 and 19 years were most severely affected. Pathological lesions of the upper urinary tract were rare in patients over 25 years of age. The combination of morphological abnormalities was interpreted as being specific for urinary schistosomiasis as they did not occur in the control group. It is suggested that real time ultrasonography may be used to identifiy morphological lesions in urinary schistosomiasis.     

Imaging the urinary tract in children with urinary tract infection

Aim: To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI). Methods: The reports on US and voiding cystourethrography (VCUG) were reviewed. Results: Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III–V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow‐up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow‐up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III–V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed. Conclusion: We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.     

Relationship of bladder dysfunction with upper urinary tract deterioration in cerebral palsy

Although lower urinary tract dysfunction (LUTD) in patients with cerebral palsy (CP) has been previously documented by clinical observations and urodynamic tests, its correlation with upper urinary tract deterioration (UUTD) has not been demonstrated. This paper documents symptoms and urodynamic findings of LUTD and their relationship with UUTD in 33 children with CP. By sonography, 4 of these children were found to have UUTD. Age was found to correlate with UUTD, but gender difference and mental or motor functions did not. When comparing urinary symptoms with UUTD, incontinence (n = 31) did not correlate, but on the other hand symptoms of detrusor sphincter dyssynergia (interrupted voiding, urinary retention, hesitancy; n = 5) and culture proven febrile urinary tract infections (n = 4) did. Abnormal urodynamics findings were not diagnostic. We conclude that, apart from incontinence, dysfunctional voiding symptoms and febrile urinary tract infections are valuable indicators of UUTD.     

Cajal-like cells in the upper urinary tract: comparative study in various species

The interstitial cells of Cajal (ICC) play an important role in the control of gut motility. The recognition that the ICC cell membrane harbors the c-kit receptor (CD117) sparked rapid advancement in ICC research on the gut and certain pathologies using immunochemical and molecular methods. The question arises whether ICC exist in the upper urinary tract (UUT) and trigger motility. The present study analyzed the distribution of the c-kit receptor in the normal human UUT compared with various species. Immunohistochemistry (alkaline-phosphatase–anti-alkaline-phosphatase technique, immunofluorescence) was applied on serial sections using monoclonal and polyclonal antibodies recognizing the c-kit receptor. C-kit staining was compared with standard endothelial, epithelial, neurogenic, histiocytic, mast cell, and smooth muscle markers, as well as a negative control. Normal proximal, middle, and distal ureter segments were analyzed in rodents, carnivores, porcines, cow, and humans. In all species the c-kit receptor was detected in either round or spindle-shaped cells. Because of their antigenic profile, the round cells were identified as mast cells occurring in all layers of the ureteral wall except the urothelium and were more frequent in humans. In contrast, the population of spindle-shaped cells was marked only by anti-c-kit receptor antibodies, thus resembling ICC. These ICC-like cells were found among the inner and outer smooth muscle layers and in the lamina propria of all species. In humans, spindle-shaped cells were also found vertically oriented within the urothelium. Our morphological data present for the first time the distribution of ICC in the UUT of various species. The ubiquitous distribution in the entire pyeloureteral complex provides strong evidence that ICC generate electrical pacemaker activity within the UUT as an intrinsic system. Animal studies may help to understand the physiological importance of these ICC-like cells. The significance of these findings needs to be evaluated by functional studies and investigations of certain congenital pathologies with disturbance of the urinary outflow.     

RARE-MR-urography in the diagnosis of upper urinary tract abnormalities in children

RARE-MR-urography (RapidAcquisition withRelaxationEnhancement) is a fast MR imaging technique (6.4 s/acquisition) that selectively depicts fluid by heavy T2-weighting. From 9/1989 to 11/1990, RARE-MR urograms were prospectively evaluated in the diagnosis of upper urinary tract abnormalities in 55 children. The method is performed in several planes and combined with a coronal, T1-weighted spin-echo sequence. Forty out of 42 kidneys with dilated renal pelvis, and 21 out of 24 dilated ureters were identified, only the mildly dilated ones were missed. Even in non-functioning kidneys the urinary tract was clearly depicted by RARE-MR-urography. However, no differentiation could be made with this technique between vesicoureteral reflux and non-refluxing dilatation of ureter and/or renal pelvis. All 19 pelviureteric obstructions and all eight renal duplications with a dilated segment were identified. RARE-MR-urography is a new tool for diagnosing urinary tract abnormalities in children without having to employ ionizing radiation, contrast media, or general anesthesia. A dilated urinary tract can be shown in one image displaying the entire urinary system, similar to excretory urography. The technique is presently not able to provide the information of voiding cystourethrography or renal scintigraphy, nor is it as easy to perform as ultrasound. However, in certain cases it may replace excretory urography.     

Ordering of renal tract imaging by paediatricians after urinary tract infection

AIM: To describe paediatricians' reported ordering of renal tract imaging of children following urinary tract infection. METHODS: This is a piloted self-administered survey. A total of 354 randomly sampled practising paediatricians in Australia participated in the survey. The survey included 12 clinical scenarios that varied with age, gender and fever. Respondents indicated their likelihood of ordering renal ultrasound, micturating cystourethrogram (MCU) and dimercaptosuccinic acid scan (DMSA) from 0 to 100%. RESULTS: Response rate was 74.6% (264/354). For all clinical scenarios the median probability of ordering an ultrasound was 100% with little variability. For children aged 2 months, likelihood of ordering an MCU was 100%, with little variability, but was 70% for 3-year-olds with fever (45% without fever), and 5% for 6-year-olds with very large variability. Median likelihood of ordering a DMSA was 80% at 2 months, 60% at 3 years and 20% at 6 years (40%, 15%, 5% without fever, respectively). Variability was large for all scenarios and DMSA ordering. Child gender did not influence ordering practices. CONCLUSIONS: Renal tract imaging practice across paediatricians shows consistent, approximately 100% use of the least invasive modality, ultrasound. In contrast, there is considerable variation in the reported ordering of the more invasive tests MCU and DMSA. Doctors order these tests more in younger children and when fever is present.