Left Solitary Hydronephrotic kidney

• 12 Apr 2020 07:58:30 AM
• |Pediatic Urology

11 months male child with history of UTI, under treatment of paediatrician. 

Comments(18)

• 

  Venugopal P

  12 Apr 2020 11:38:38 AM

   

  Dear All,

  We are progressing backwards as how we were managing in the past as many investigations are not available during this crisis.

  In the case posted, it is mentioned that US has picked up only the left kidney which is hydronephrotic with mention that Ureter is not visualized which is more suggestive of PUJ Obstruction. What did the child present with is important. Is the child symptomatic?

  Anil has not mentioned the renal biochemical parameters as well as whether the child has UTI.

  US image provided appear as sufficiently large Pelvis with calyceal dilatation. I will not comment on the parenchymal thickness from the Image provided.

  There is an urgency to investigate further as the child has only solitary kidney and that too obstructed. Delay in decision making is going to be harmful. If the Child is asymptomatic and Renal function is well within acceptable limits, could be the child could be observed during the current situation. But there is need for further investigations prior to the decision of observation.

  If asymptomatic, a diuretic Challenge could on occasions reveal the obstructive nature in an asymptomatic child and a simultaneous US at that time, if showing more than 30% increase in renal pelvic size is a clear indication of obstruction warranting intervention.

  As Isotope scan is not available, it would be worthwhile to perform either IVU (if needed delayed pictures) or as modern pundits desire a CECT could be done. An IVU with delayed pictures to my mind is better at assessing the function than CECT and if delayed visualisation of the kidney is evident will require intervention without much delay.

  This would be the policy that I would adopt on this child in the present circumstances. I am open to criticisms.

  With warm Regards,

  Venu

   

• 

  Utsav Shah

  12 Apr 2020 01:06:28 PM

  Respected Anil sir,

  
  

  I have read about a historic test in a practical book by Dr Pratik Shah. 

  In these tough times due to non availability of radiotracer, instead of doing a DTPA/DMSA scan, Can we opt for ‘IVP/CT IVP WITH DIURETIC CHALLENGE’? This will need injection of a diuretic followed by delayed imaging. 

  That will be like a diuretic renogram except that curves won’t be seen. But we can have direct IVU images. 

  
  

  
  

• 

  Dr. Anil Takvani

  12 Apr 2020 02:18:12 PM

  Child presented with history of excessive crying.

  No UTI

  S.creatinine: 0.44Mg%

• 

  Gyanendra Sharma

  12 Apr 2020 04:23:08 PM

  Dear Anil

  You are testing us?

  Your first post mentioned 11 months old male child presenting with UTI

  Now you mention no UTI

  Left us assume both the scenarios

  Patient has UTI

  1. Urine for C/S
  2. Start Antibiotics
  3. Sr. Creat is Normal-- No need for emergency intervention
  4. Once C/s comes--start C/S antibiotics and see the clinical respone
  5. If patient is stable--afebrile-- I would repeat USG  looking at the AP diameter and diameter of calyces in supine & prone position and do a Diuretic IVU
  6. If patient has persistent fever despite culture specific antibiotics--DJ Stenting 

  Patient does not have UTI

  By this I presume that the Urine examination is Normal

  There are some internal echoes  seen in the USg film. I would confirm that with the sonologist and if start antibiotics  irrespective of the urine findings

  If there is No infection then USG as mentioned above & then Diuretic IVU

  The decision and need for intervention even if it is a solitary kidney will be based on the USG & Diuretic IVU findings

  I am attaching a link of an article comparing Diuretic IVU with Diuretic Renography

  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733295/
  

  
  
  

  
  

• 

  Dr. Anil Takvani

  12 Apr 2020 04:53:50 PM

  Dear Gyanendra, 

  My mistake. 

  Patient is under paediatrician treatment for UTI... 

  So putting it again 

  11months male child 

  UTI 

  Excess crying 

  Culture negative 

  S.  Creatinine : 0.44mg%

  USG Image attached 

  
  

  Thanks 

• 

  Dr. Anil Takvani

  13 Apr 2020 08:19:09 AM

  Recommendations from ESPU for paediatric Urological Procedures

  Summary of Recommendations:

  • Any procedure should be deferred whenever delaying does not affect patient outcome (primarily survival), but efforts should be made to avoid patients to be lost to follow-up (e.g. telemedicine).

  • Non-surgical management should be considered, to begin with, including medical treatment (e.g. antibiotics for vesico-ureteral reflux associated urinary tract infections), endovascular embolization (e.g. for bleeding renal traumas), or urinary tract diversion (e.g. trans-urethral catheter positioning for posterior urethral valves or DJ stent placement for symptomatic upper tract dilatations).

  • Examples of procedures that should not be differed include, urogenital tumors where there is no space for additional chemo-/radio-therapy, unstable traumas, creation of access for dialysis, severe/symptomatic urinary tract obstructions not amenable to diversion, and scrotal exploration for testicular torsion.

  • Range of paediatric urology procedures performed and prioritization of such cases should be decided locally. Nevertheless, it is key the decision is made with a multidisciplinary input.

  • Multidisciplinary meetings should be held virtually.

  • Preoperatively, all surgical patients should be assessed for suspected symptoms, their temperature measured and, preferably, be tested for COVID-19 infection. During hospitalization all patients should wear surgical masks.

  • COVID operating rooms should be identified, if possible, and all non-tested patients should be managed as positive ones.

  • All the surgical team including surgeon, anesthetists, and nurses should wear personal protective equipment.

  • Standardized surgical techniques should be used, and the surgeries should be performed by surgeons beyond the learning curve.

  • During minimally-invasive procedures via a trans-peritoneal approach, and particularly if bowel handling is required (as virus makes its way through the faeces), efforts must be made to minimize the risk of virus diffusion with aerosol dispersal of the insufflation gas. Maneuvers include creation of small accesses to void gas leakage, use of filtration systems, lowering the pneumoperitoneum pressure, lowering electrocautery power setting, and favoring bipolar cautery over other sealing devices. All the surgical team should wear goggles, FFP2/3 masks, and body protective garb.

• 

  Venugopal P

  13 Apr 2020 09:35:30 AM

  Dear All,

  Anil has provided us the ESPU Recommendations for Paediatric Urology procedures during this COVID19 Pandemic. All recommendations made by any organization, though valuable, should be taken on its face value by understanding the local situations. This aspect has been mentioned in the ESPU Recommendations provided as well (Range of paediatric urology procedures performed and prioritization of such cases should be decided locally). This is the most important aspect that we all will have to consider. How long will this Pandemic persist is at present is anybody’s question. Hence undue delay in treatments, though may not affect in a short term, will have its implications when delayed extraordinarily.

  Anil has mentioned that this 11 month old child has a S. Creatinine of 0.44mg% and Urine Culture reported as having no growth. On the first look, it will appear that conservative management and delayed treatment can be applied. But it should be remembered that this child has solitary kidney and any undue delay (as how long being unpredictable) could result in Progressive renal functional deterioration which may not be evident for a while. As Gyanendra has suggested, close followup with US in Supine and Prone positions could be help. A Diuretic Challenge during US could be more reliable to denote the severity of obstruction and this simple test is of considerable importance especially as we are having a child with solitary kidney which is obstructed. No doubt Diuretic Renogram could be of more value (not universally accepted still), it cannot be performed at many centres as mentioned by Anil. Hence alternative methods as suggested by me in my earlier post stands to reason. I believe that a child with solitary obstructed kidney should not be left without being adequately investigated. The present generation may be of the opinion that IVU is dead as has been mentioned in an article a while ago in Indian J of Radiology and Imaging titled ‘Demise of IVU’. Contrast MRI could be a better investigation than CECT. From such MRI the functional status could be calculated if the needed software is available at the centre, but its availability and cost should be taken into consideration. In a country like India, IVU still has a place if properly performed and this statement applies to all investigations as well.

  In this child, I will not stop at just performing US periodically but would subject the child to an IVU study and decide on the further treatment based on the findings on IVU. This could be performed even during this period of Pandemic. I should complement Gyanaendra yet again for providing the article which I feel all must read. We should ‘cut the sleeves according to the material available’.

  I would not place this child, if symptomatic and showing even slight functional deterioration as evidenced by IVU, on conservative management or for that matter on Ureteric stenting or Nephrostomy, but would offer Pyeloplasty which I believe will be more humane for this child even during the period of this pandemic.

  With warm regards,

  Venu

   

• 

  shriram joshi

  14 Apr 2020 12:14:06 PM

  The USG picture is described in radiology text book as "Mickey mouse" appearance. It is almost diagnostic of puj obstruction. However all the above arguments put forth are correct. I would like to have the Dr g Sharma's opinion in a grossly hydronephrotic kidney with free communication between pelvis and calyx, his test of supine and prone USG will work, and how reliable?

  For the Puritans, ideal next investigation is a diuretic IVU. Mahesh Desai was routinely doing this as he had difficulty in getting a renal scan.

  Lastly I would not delay pyeloplasty for too long, taking all precaution mentioned in EUA guidelines.

• 

  Dr. Anil Takvani

  14 Apr 2020 11:45:30 PM

  As because of compulsive circumstances we are talking about diuretic IVU and I am absolutely agree with that.

  But as there is history of UTI, and there is hydronephrosis, I think I have to advise for VCUG in this child(experience + guidelines).

  In that case my question to PGs: 

  Which is first? VCUG or IVU? 

  Both can be done on same day?

• 

  Gyanendra Sharma

  15 Apr 2020 09:21:03 AM

  What Shyam Joshi Sir has asked is very relevant. Does the change in AP diameter in supine and prone position is relevant in grossly hydronephrotic kidneys

  The importance of calyceal dilatation has also been stressed by Duong et in 2014 who recommended Renogram only when the APD was > 30mm. Calyceal dilatation > 10mm or parenchymal thinning
  

  Since 2012--13 we look at not only the AP diameter of the pelvis but also look at the calyceal dilatation, Te largest diameter of the one or more calyxes are measured in supine and prone position. If the diamtere of both the pelvis and calyces decrease in prone position then we take it as good drainage. If both increase then it is poor draiange. If the AP diameter of renal pelvis decreases but the calyceal diameter increases then it is taken as poor drainage

  We have also seen that these changes are best seen when there is no infection

  When we look into our data of more than 175 cases of PUJ obstruction; there are many who have an APD of > 30mm & calyceal dilatation of > 10mm  who are doing well under observation

  
  

  In a solitary kidney things become tricky and the question arises as to can we rely only on USG.There is no doubt that functional imaging is a must

  Ideally a renogram is needed and if the Cortical transit is below 3 minutes then One may at times think of keeping the child under observation

  At present I have 2 such boys and both have not shown an increase in hydronephrosis in the last 3 years

  The dilemma is compounded when the CTT is around 3-4 minutes and for persons like me who do not rely on T 1/2  or draiange curves to confirm obstruction ( T1/2 < 10minutes rules out obstruction but > 20minutes does not confirm obstruction)

  It would be interesting to know what is the opinion of others

• 

  Dr. Anil Takvani

  15 Apr 2020 06:04:30 PM

  Posting MCU picture of this patient... 

  

• 

  Dr. Anil Takvani

  17 Apr 2020 08:10:55 AM

  Yesterday I posted MCU.  Now I am posting images of CT IVP. 

  Please go through images and discuss diagnosis and treatment of this case of 11months male child.... Thanks 

  

• 

  Venugopal P

  17 Apr 2020 06:08:46 PM

  Dear All,

  I have mentioned my views concerning this case posted by Anil Twice. This child needs detailed evaluation as mentioned earlier. I had mentioned that Diuretic Challenged US is one way to assess the severity of obstruction and of course Diuretic IVU as have been practiced by many in yester years is a good way of having the function also assessed (some could say crudely).

  This child if left unattended could progress to functional deterioration sooner than later as the child has solitary kidney. Kidney function will not wait for COVID19. May be since the Kidney appears functioning well, some delay in planning appropriate treatment could be done but for how long is the question. From the news available to all, it is very unlikely that this COVID19 will leave us soon to live in peace. Hence we have to take a call on how long to wait prior to planning the appropriate treatment which in this case is Pyeloplasty. I will not recommend Ureteric Stenting as it may add infection and could do more harm than good. Wait for a while, Observe progress and perform the needed procedure at as early a date as possible.

  With warm regards,

  Venu

   

• 

  Dr. Anil Takvani

  17 Apr 2020 06:48:08 PM

  Sir, 

  CT IVP is suggestive of right dilated and tortuous ureter along with dilated pelvicalyceal system. 

  Are we dealing with obstructed megaureter? 

  Or 

  Obstruction at both level : UPJ and VUJ? 

  Or 

  Pujo only 

  I agree child needs operative correction of obstruction but let's us have clarity on diagnosis... 

  Thanks 

• 

  shriram joshi

  17 Apr 2020 08:35:26 PM

  I feel there is a persistent narrowing just below pujunction in bothe films besides dilated pelvis & calyces. If obstruction is not relieved soon, as 

  Venu has commented, waiting for too long will be harmful to kidney function. I would not agree to preop DJ stenting for fear of infection, but will advise a per opertive DJ stenting not larger than 3/F. The ureter is mildly tortuous but NO  VUJ

  Stents larger than 3/F may be difficult to negotiate antegrade. Surgery should be under antibiotics and all precaution in covid era should be strictly followed.

  SSJ

• 

  Gyanendra Sharma

  17 Apr 2020 09:42:40 PM

  Dear Anil

  Honestly I am not a great fan of CT IVU in children

  An IVU would have been my choice

  The concentrating ability would have been better appreciated  by me on IVU

  
  

  What is the reason of a dilated ureter?

  1. Megaureter -- as suggested by you
  2. VUR not picked up on MCU
  3.  Dilatation following infection  as endotoxins are known to cause ureteral atony and dilatation

  If there is a significant element of obstruction at UVJ then there should have been significant dilatation of the ureter which would have been picked up on sonography

  Also how common is to get obstructed Megaureter and PUJO?

  
  

  VUR not picked up by MCU --theoretically possible--but very very very unlikely in this case

  
  

  Ureteral dilatation following infection--possible but the ureter shows tortuosity which is unlikely  to be due to infection alone

  I would treat his infection. Repeat USG after 2 weeks and then take a call

  There are two aspects which crossed my mind

  1.  The ureter is so well seen in all images. Is it not bit unusual for a PUJ obstruction ( Though I would still appreciate it better on IVU)
  2.  The total number of calyces  are around 12--14. Megacalycosis ?? -- with the limited images available I presume it is bit of a wild guess work
     

• 

  Dr. Anil Takvani

  17 Apr 2020 09:56:43 PM

  I agree with all the experts who suggested for IVU/diuretic IVU.

  But that advise was not in my hand.

  Yes, I will post 2 more images of CT tomorrow for sure as now patient is with me.

  I am afraid as his USG was not done by my experienced and expert sonologist. And I am worried of tortuous ureter seen in CT images.

  Patient is on antibiotic as per culture sensitivity report.

  
  

  Thanks

• 

  Prabir Basu

  18 Apr 2020 01:04:20 PM

  Dr Takvani sir , what is the ureteral diameter on CT? Is it possible to distinguish between obstructed megaureter and those that are nonobstructed, nonrefluxing by whatever tests we have till now before committing to pyeloplasty.

  In the same thread , i request Prof Joshi sir  to opine whether it is feasible or relevant to do some sort of a retrograde dye washout study before putting a DJ .