Obstructive uropathy due to prolapsed lower ureters and bladder in patients with severe procidentia: A report of two cases

INTRODUCTIONPelvic organ prolape is not uncommon in multi-parous or elderly women. It is one of the rare but important causes of obstructive uropathy. Herein, we report two cases of severe procidentia that were referred with obstructive uropathy due to prolapsed bladder and ureters.PRESENTATION OF CASEThe first case was a 78-year-old woman, with severe pelvic organ prolape and secondary bilateral hydroureteronephrosis and post-renal failure. She was treated successfully by bilateral nephrostomy insertion and then pessary insertion. The second case was a 75-year-old woman who referred with the same presentation, but treated surgically with burch colposuspention and synchronous bilateral ureteral stent insertion.DISCUSSIONPelvic organ prolapse is not uncommon in old women. In addition to physical problems of procidentia, it may cause acute renal failure (ARF), chronic renal failure (CRF), and finally end stage renal disease (ESRD) if undiagnosed.CONCLUSIONIn every aged female case with obstructive uropathy and/or bilateral hydroureteronephrosis with unknown causes, gynecologic examination should be performed for early detection of possible pelvic organ prolapse. Appropriate management is necessary to prevent renal failure from uterine prolapse (UP).     

Chronic arterial hypertension in children with corrected obstructive uropathy

Chronic hypertension in children with obstructive uropathy perhaps is an infrequent, but not unimportant condition. In patients with bilateral obstruction often accompanied by urinary tract infection, hypertension may develop in spite of restoration of urinary flow. Hypertension in these patients is caused by parenchymal damage of one or both kidneys resulting as a late sequela of obstruction even after normalisation of urinary flow. This report deals with three cases of this type of obstructive uropathy and severe hypertension. Hypertension developed up to 6 years after normalisation of urinary flow. In the two patients, in who serum renin examinations were performed, high renin levels were determined peripherally (6.2-7.9 ng/ml/h) and in both kidney veins (8.5-34.7 ng/ml/h). Early diagnosis and treatment of hypertension may have important implications for the outcome of these patients. In all patients glomerular filtration rate was diminished (31.6-67.8 ml/min X 1.73 m2), in two of them further deterioration during the observation period of 3-4 years could be avoided.     

Fetal serum beta2-microglobulin predicts postnatal renal function in bilateral uropathies

BACKGROUND: Predicting postnatal renal function is crucial for the prenatal evaluation of fetal bilateral uropathies. Prenatal ultrasound can identify intrauterine terminal renal failure, but is not sensitive enough to identify those infants who would survive with an impaired renal function. Because it reflects fetal glomerular filtration, fetal serum beta2-microglobulin is a potential predictor of postnatal renal function. METHODS: Fetal serum beta2-microglobulin (beta2m) was assayed in 61 cases of bilateral or low obstructive uropathy, 74 controls, and 17 cases of bilateral renal agenesis, and was correlated with renal function. RESULTS: Fetal serum beta2m was 3.2 mg/L (range 1.5 to 4.7) in controls (N = 74), 9.5 mg/L (range 6.7 to 11.3) in bilateral renal agenesis (N = 17), 7 mg/L (5.1 to 10.6) in uropathy in which terminal renal failure resulted in termination of pregnancy (N = 26), and 3.7 mg/L (range 2.3 to 11.2) in live births with uropathy (N = 35). In the latter subgroup, fetal serum beta2m was significantly and positively correlated (r2 = 0.91) with postnatal serum creatinine. All survivors with a postnatal serum creatinine < or =50 micromol/L ha a fetal serum beta2m lower than 5 mg/L. Four of 6 survivors with a postnatal serum creatinine> 50 micromol/L had a fetal serum beta2m greater than 5 mg/L. CONCLUSION: Fetal serum beta2-microglobulin is a marker for renal function and predicts postnatal serum creatinine in bilateral or low fetal obstructive uropathy.     

Clinical outcome of fetal uropathy. I. Predictive value of prenatal echography positive for obstructive uropathy

Clinical followup was performed in 73 neonates with a prenatal echographic suspicion of uropathy. Of 42 patients with a prenatal suspicion of unilateral hydronephrosis only 15 had pathological obstruction and 2 had multicystic dysplastic kidneys. Among 10 infants with a prenatal suspicion of bilateral hydronephrosis only 1 had true bilateral obstruction and 2 had unilateral obstruction. In 2 patients hydroureteronephrosis seen on prenatal echography was due to massive bilateral vesicoureteral reflux. In this group there was also a multicystic dysplastic kidney and 1 patient with bilateral cystic dysplasia. There was a prenatal suspicion of cystic disease in 8 infants. Postnatally, diagnosis was multicystic dysplastic kidney in 2 patients and a simple renal cyst in 4. The remaining 2 neonates had obstructive uropathy. Finally, of 13 neonates with a prenatal suspicion of anatomical-echo-structural abnormalities a definitive abnormality could be established in only 8. The predictive value of prenatal echography positive for obstructive uropathy was 34.6%.     

Clinical outcome and follow-up of prenatal hydronephrosis

Between 1987 and 1991, 160 hydronephrotic kidneys were diagnosed prenatally and confirmed postnatally in 100 infants. The aim of the study was to describe the natural history and management of primary hydronephrosis detected prenatally. We devised a new classification of obstructive uropathy outcome using ultrasonography and the diethylenetriamine penta-acetic acid scan. Accordingly, we classified the patients as having mild, moderate or severe hydronephrosis. Nine patients had pyeloplasties and 5 had ureteric reimplantations. We conclude that in most cases there is no need for immediate surgery, and that the initial approach to the management of congenital hydronephrosis should be conservative. We suggest that anti-bacterial prophylaxis be conventionally given to infants with vesicoureteral reflux and for the first 6 months of life to infants demonstrating moderate to severe newborn primary hydronephrosis.Presented by A.B. in partial fulfillment of the requirements for the M.D. degree at the School of Medicine, Soroka Medical Center-Ben Gurion University of the Negev, Beer-sheva, Israel.     

Clinical outcome and follow-up of prenatal hydronephrosis

Hydronephrosis is probably the most common congenital abnormality detected prenatally by ultrasonography This study was performed to determine the cause and outcome of prenatal hydronephrosis in our hospital. A total of 45 infants, with 57 prenatally hydronephrotic renal units, were enrolled into this study. For the purpose of this study, the degree of hydronephrosis was defined as mild, moderate or severe. Postnatal ultrasonography was performed as soon as possible in those with bilateral hyronephrosis and 3-7 days after birth in those with unilateral hydronephrosis. Voiding cystourethrogram was performed in 6-8 weeks time. In the absence of vesicoureteral reflux (VUR), diethylenetriamene penta acetate scan was performed to exclude obstructive uropathy. There were 29 males and 16 females (male:female ratio 1.8:1), and unilateral and bilateral hydronephrosis were seen in 33 (73%) and 12 (27%) of the cases, respectively. Hydronephrosis was caused by ureteropelvic junction obstruction (UPJO) in 20 (44.5%), VUR in 10 (22.2%), ureterovesical junction obstruction in four (8.9 %), posteriorurethral valves in four (8.9 %), UPJO with VUR in two (4.4%) and non-VUR non-obstructive in one (2.2%). During follow-up, 16 patients (35.5%) required operative intervention while seven (15.5%) improved spontaneously. Fetal hydronephrosis needs close follow-up during both ante-natal and postnatal periods. In this study, the most common cause for hydronephrosis were UPJO and VUR. Also seen in this study is the noteworthy point that mild fetal hydronephrosis is relatively benign and does not require surgical intervention in most cases and surgery should be performed only if there is renal function compromise. Prenatal consultation with a pediatric nephrologist and urologist is useful in decreasing parental anxiety and facilitating postnatal management.     

Pouch Dilatation after Gastric Banding Causing Gastric Necrosis

Background: Early or late pouch dilatations account for a moderate complication rate after restrictive bariatric operations. Various strategies were developed to prevent or treat pouch dilatations. Methods: A case of necrosis of gastric wall in a concentric dilated pouch following laparoscopic adjustable gastric banding is reported as a severe complication of a conservative treatment attempt. Results: Emergency laparotomy resulted in band removal, partial gastric resection and prolonged hospital stay. Conclusion: Conservative strategies in the treatment of pouch dilatations bear the risk of complications, with both failure of the bariatric procedure and critical clinical course. Indication for early operative reintervention is recommended.     

Bilateral obstructive uropathy secondary to inguinoscrotal bladder hernia

Bladder hernia is present in an important number of cases of inguinal hernias. Massive inguinoscrotal bladder hernias are rarer. The association of massive bladder hernia and bilateral ureterohydronephrosis is not often found. According to our knowledge, there have been only seven cases documented in the last ten years. Therefore, we will present a case of renal failure secondary to inguinoscrotal bladder hernia with bilateral obstructive uropathy. Once we have analyzed a clinical case, we will give the diagnosis and treatment for those hernias.     

不对称双侧先天性上睑下垂的分期手术治疗策略

目的 探讨不对称的先天性双侧上睑下垂进行分期手术的治疗策略。方法 对2011年至2013年的30例不对称双侧上睑下垂患者进行分期手术矫正。一期手术矫正较重侧(中~重度),行睑板部分切除联合上睑提肌缩短前徙术;3~6个月后再行较轻侧矫正,行睑板部分切除术或上睑提肌缩短术。术后随访3~24个月,术后评估内容包括矫正程度与双侧对称性。结果 全部30例患者60只眼,在矫正效果评估中,37(61.7%)只眼为充分矫正,23(38.3%)只眼为中等矫正,无矫正不足或过矫病例。对称性评估中,23(76.5%)例达到良好对称,7(23.5%)例达到中等对称,无对称不佳病例。结论 与我们以往的治疗经验相比,对于不对称的双侧先天性上睑下垂,分期手术治疗能够达到更好的对称效果。     

Topical application of mitomycin C in the treatment of esophageal and tracheobronchial stricture: a report of 2 cases

We present 2 cases of successful treatment of recurrent anastomotic strictures using a topical application of mitomycin C. In the first case, a 4-year-old boy had a cervical cyst excised, which appeared to be an ectopic gastric mucosa. He consequently presented severe stenosis at the origin of the cervical esophagus that needed repeated balloon dilatations. The second case is about a 12-year-old girl who presented a traumatic complete rupture of the right mainstem bronchus managed by primary repair, with subsequent anastomotic stricture. Both patients were successfully managed with topical application of mitomycin C (1 mg/mL), and needed no more dilatations.     

Outcome of isolated antenatal hydronephrosis: a prospective cohort study

The purpose of this study was to report the outcome of infants with antenatal hydronephrosis. Between May 1999 and June 2006, all patients diagnosed with isolated fetal renal pelvic dilatation (RPD) were prospectively followed. The events of interest were: presence of uropathy, need for surgical intervention, RPD resolution, urinary tract infection (UTI), and hypertension. RPD was classified as mild (5-9.9 mm), moderate (10-14.9 mm) or severe (>or=15 mm). A total of 192 patients was included in the analysis; 114 were assigned to the group of non-significant findings (59.4%) and 78 to the group of significant uropathy (40.6%). Of 89 patients with mild dilatation, 16 (18%) presented uropathy. Median follow-up time was 24 months. Twenty-seven patients (15%) required surgical intervention. During follow-up, UTI occurred in 27 (14%) children. Of 89 patients with mild dilatation, seven (7.8%) presented UTI during follow-up. Renal function, blood pressure, and somatic growth were within normal range at last visit. The majority of patients with mild fetal RPD have no significant findings during infancy. Nevertheless, our prospective study has shown that 18% of these patients presented uropathy and 7.8% had UTI during a medium-term follow-up time. Our findings suggested that, in contrast to patients with moderate/severe RPD, infants with mild RPD do not require invasive diagnostic procedures but need strict clinical surveillance for UTI and progression of RPD.     

Pneumothorax and transient pseudohypoaldosteronism in an infant with hydronephrosis

Pneumothorax and transient pseudohypoaldosteronism have been noted as complications of obstructive uropathy in infancy. However, they are rare complications, and there have been no reports of a patient with both pneumothorax and pseudohypoaldosteronism in obstructive uropathy. Here we describe a case of pneumothorax and transient pseudohypoaldosteronism in an infant with bilateral hydronephrosis due to ureteropelvic junction obstruction. Nephrostomy improved the patient's condition and laboratory findings rapidly. While the exact pathogenic mechanism of pneumothorax in patients with obstructive uropathy is unclear, some biochemical defects due to obstructive uropathy might impair fetal lung maturation, which results in pneumothorax.     

Outcome and prognostic factors in patients with advanced prostate cancer and obstructive uropathy.

In a series of 51 patients with prostate cancer and obstructive uropathy, unilateral or bilateral obstruction was identified in 22 (43%) and 29 (57%) respectively. This included a non-functioning kidney in 12 patients. In 86% of patients the T category was advanced. Bone metastases were present in 36 cases (71%); 19 patients (37%) had chronic retention. All patients with metastatic disease underwent hormonal manipulation and 43 underwent transurethral resection of the prostate. External beam radiotherapy, percutaneous nephrostomy and ureteric reimplantation were performed in 4, 5 and 1 patient respectively. Actuarial survival of all 51 patients was 57 and 25% at 2 and 5 years. Presentation with bilateral or non-function did not predict a worse prognosis in comparison with patients with unilateral hydroureteronephrosis. Raised alkaline phosphatase and prostatic acid phosphatase were of no prognostic value, while creatinine reached marginal significance. A positive bone scan and raised urea were strongly predictive of a poor outlook. It was concluded that prostate cancer and obstructive uropathy should not uniformly imply a terminal event, and interventional therapy is justified with a 25% 5-year survival rate.     

Obstructive anuria in children. Apropos of 22 cases

The authors report twenty two cases of obstructive anuria observed in children. Causes are diverse: 6 cases were observed during the course of tumors, 4 cases were secondary to bilateral renal stones (or unilateral in a single kidney), 3 cases were observed before surgical correction of latent or well tolerated congenital uropathy, and 9 cases in the immediate postoperative period (including 8 after antireflux surgery). In the emergency situation, treatment of obstructive anuria is based on urinary diversion ideally by percutaneous nephrostomy under ultrasonic control. But prevention is the best treatment of anuria: treatment of urinary tract infections resulting in renal stones, in case of tumor, ultrasonographic survey of chronic upper tract dilatation: rigorous atraumatic operative technique avoiding any oedema.     

Bilateral hydroureter and hydronephrosis causing renal failure due to a procidentia uteri: a case report

We report a case of complete uterine prolapse that resulted in bilateral hydroureter, hydronephrosis, and renal dysfunction. The nonoperative reduction of the prolapse with a vaginal pessary reversed the obstructive uropathy and ameliorated renal function. The lower urinary tract should be imaged in patients with complete uterine prolapse. If present, obstructive uropathy should be relieved by the reduction of the prolapse before irreversible renal damage occurs.     

A clinicopathological study on intrahepatic cholesterol gallstones

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.     

A clinicopatholgoical study on intrahepatic cholesterol gallstones

In order to clarify the pathogenesis and process of the formation of intrahepatic cholesterol gallstones, we examined the clinical features, cholangiograms and pathological findings of eight patients with intrahepatic cholesterol gallstones. When examining the clinical features, one patient was found to have developed intrahepatic cholesterol gallstones 3 years after a complete lithotomy. The cholangiograms of two patients revealed small gallstones in the peripheral bile ducts of the lateral segment of the liver, and these bile ducts showed localized cystic dilatation and were tightly filled with gallstones. Conversely, their other bile ducts which contained no gallstones showed an entirely normal cholangiogram. Pathologically, these two cases showed mild chronic cholangitis, and cholesterol crystals in the peripheral bile ducts. The other six cases showed moderate or severe dilatation of the bile duct and severe chronic proliferative cholangitis. From the above results, we proposed the following theory to explain the pathogenesis and process of the formation of intrahepatic cholesterol stones: The cholesterol crystals in the peripheral intrahepatic bile ducts may be a primitive form of intrahepatic cholesterol gallstones, and the formation of intrahepatic cholesterol gallstones may precede and cause such deformities of the bile ducts as strictures or dilatations.     

Bilateral chronic ureteritis associated with Serratia marcescens.

To our knowledge this is the first case of bilateral obstructive uropathy caused by nonspecific chronic ureteritis to be reported. Prior to operation the bilateral involvement was throught to be due to a tuberculous infection or retroperitoneal fibrosis. The diagnostic difficulties were similar to those previously reported in the unilateral involvement. The focus of the infective organism found was Serratia marcescens which originated in the right kindey.     

Role of percutaneous urinary diversion in malignant and benign obstructive uropathy

OBJECTIVES: We evaluated the feasibility and effectiveness of percutaneous urinary diversion in patients with obstructive uropathy. PATIENTS AND METHODS: A total of 206 percutaneous nephrostomies (PCNs) (right-sided in 54, left in 56, and bilateral in 48) were performed in 102 male and 57 female patients 18 to 94 years old. In 125 patients, malignancy was the underlying cause of the obstruction and in 30, benign disease. In four patients, the cause remained unknown. In most patients (N = 154), the access was guided with both ultrasound and fluoroscopy. RESULTS: Percutaneous nephrostomy was successful in 158 patients (99%). Antegrade ureteral stenting was attempted in 48 patients with a success rate of 81%. Fifteen days postprocedure, the mean urea and creatinine concentrations had declined from 160.8 mg/mL to 63 mg/mL and from 6.9 mg/dL to 2.2 mg/dL, respectively. In 66% of the patients, renal function returned to normal. In 28%, it improved with no need for hemodialysis, while in 6%, there was no improvement. Advanced age and prostate cancer were negative predictive factors for the improvement of renal function, whereas the BUN and creatinine concentrations before the procedure and performance of unilateral v bilateral nephrostomies were not. We did not have severe complications. Three patients received transfusions, and in one patient, a urinoma was drained percutaneously. Patients with malignancy had a median survival of 227 days. CONCLUSION: Percutaneous urinary diversion under radiologic guidance is a safe and effective procedure for patients with obstructive uropathy.     

Management of multiple stones in a single session using minimally invasive methods in infants with renal failure: renal salvage

The goal in the treatment of stone disease causing infantile obstructive uropathy is to obtain a quick resolution of the obstruction using the least invasive treatment modality available and rendering the patient stone-free, if possible. Two infants with bilateral kidney stones, the first of whom also had ureteral stone, were referred to our clinic with acute renal failure and were treated successfully in a single session using minimally invasive methods. In this report, we discuss the management of these two cases, aged 9 and 26 months, which resulted in favorable outcomes.