obstructive megaureter

• 28 May 2020 12:22:12 PM
• |Pediatic Urology

Antenatal diagnosed Bilateral Hydronephrosis. Male child

Comments(19)

• 

  Rahul Kapoor

  28 May 2020 12:23:19 PM

  how will we proceed ?

  I will upload investigation as demanded 

• 

  Rahul Kapoor

  02 Jun 2020 07:05:25 PM

  I  am sharing immediate postnatal studies

  1. USG at 6 days

  2. USG at 4 months

  3. MCU and IVP at 5 months

  
  

  

• 

  Dr. Anil Takvani

  05 Jun 2020 12:57:59 PM

  USG, diuretic renal scan and IVU are suggestive of Left obstructive large(mega) ureter.

  I would have avoided IVU in this case.

  Child is 5 to 6 months old and bladder appears to have good size, unilateral ureteric reimplantation is likely to give an excellent outcome.

  My preference is open extravesical reimplantation after tailoring of last 5 to 7 cm of ureter.

  Thanks for very useful case for everyone in specific for trainees.
  

  
  

• 

  shriram joshi

  05 Jun 2020 05:41:38 PM

  Repair of obstructive megaureter requires excision of terminal aperistaltic segment & reimplant after tailoring of dilated ureter. What additional information did you get with Doppler study?

  My preference is intavesical surgery, for excision of terminal aperistaltic segment + remodell reimplant of ureter. I prefer politano-leadbetter technique.

  SSJ

• 

  Dr. Anil Takvani

  05 Jun 2020 07:49:26 PM

  @ SSJ Sir,

  Sir, any specific precautions while tailoring ureter?

  How much to tailor?

  In how many layers?

  Which side you prefer to excise?

  Suture material of your choice?

  Continuous or intermittent sutures for re-modelling?

  Sir, Please share your vast experience.

  Thanks

  
  

• 

  Ramesh Babu

  05 Jun 2020 08:32:15 PM

  I would wait until 1yr of age (with antibiotic prophylaxis) before reimplant as a good size bladder is crucial for a succesful reimplant). Prefer excisional tapering and intravesical modified politano leadbetter type reimplant (no crossing of UO)

  
  

  If urosepsis occurs before 1yr my options would be

  End ureterostomy left

  Stenting alone

  Recycle antibiotics

  Refluxing /mini reimplant

• 

  Rahul Kapoor

  05 Jun 2020 09:07:02 PM

  Thanks very much sir. 

  I was waiting for so many days after posting this case to get others views.

  Parents didnt agree for reimplantation ...

  
  

  
  

  Does any one plan wait and watch?

  What is the role of conservative treatment in obstructive megaureter?

  
  

  
  

• 

  Dr. Anil Takvani

  06 Jun 2020 08:43:54 AM

  @ Ramesh Babu,

  Thanks for posting various options.

  I agree if surgeon's filling is bladder not of adequate size for required tunneling should avoid reimplantation.

  Waiting for another six month and not doing any de-obstructing surgery in this case is not a good option looking at severe obstruction.

  Stenting for six months or above in such a small kid is also not a good option.

  Refluxing anastomosis is discussed very much in last couple of years but not so simpleto perform when there is huge dilatation and tortuosity. It is time consuming on table, technically also not easy and in most of the cases patients require additional reconstructuion in previously operated side( my personal experience of 2 cases in last 6 months).

  Yes ureterostomy is sim ple, easy and effective option.

  I think we have best oppertuniety to discuss large(mega) ureter through this case.

  Thanks

  
  

• 

  shriram joshi

  06 Jun 2020 09:01:13 AM

  I will try and answer. Tailoring should be enough to achieve 4:1tunnel ratio. Each ureter can have a) one large vessel with longitudinal anastomosis.

  B) this leaves a relatively avascular area on one side.c) pass 8/f nelaton catheter , push it towards longitudinal

  Main vessel and apply Babcoks at interval preventing catheter from any movement.d) excise the avascular segment. I prefer 5/0 vicryl, continuous suture only in half of ureter starting at top. Rest is interrupted but close. This is in case you want to excise redundant terminal ureter.e) proceed to reimplant.

  Dear Ramesh Babu I prefer a refluxing ureterostmy instead end uret

  erostmy. With this on CAP you can wait till 1 yr of age.

  SSJ

• 

  shriram joshi

  06 Jun 2020 10:54:13 AM

  Please read original article by M.keifer on refluxing ureterostmy.

  The suturing in ureter is one layer.

  A stent or dj stent is necessary

  SSJ

• 

  Dr. Anil Takvani

  06 Jun 2020 11:25:41 AM

  https://pubmed.ncbi.nlm.nih.gov/24850437/

  Abstract of the article mentioned by Prof. S S Joshi Sir in his previous post.

  This is very attractive option in compare to cutaneous ureterostomy.

  But in my experience of two cases in last six month, it is not that simple to cut the ureter distal to obstruction and just anastomosis with bladder in single layer in refluxing fashion.

  When ureter is very much dilated and tortuous it is very difficult to anastomose it with bladder ignoring tortuosity. Also single layer anastomosis appears bit risky for urinary leak point of view. So, it takes significant more time in compare to cutaneous ureterostomy. My last patient was of 3 months, weak and sick child, it took significant more time, child required to shieft to ICU, tube was kept for long and was kept on oxygen support. By evening recovered well, now child is 7 months, asymptomatic. I will post pre and post refluxing reimplant investigations soon.

• 

  Lalit Shah

  06 Jun 2020 12:17:14 PM

  Agree with most of things mentioned above,

  Would not like to wait for one year,

  Bladder doesn’t look too small.

  However final decision on bladder capacity evaluation.

• 

  Dr. Isteaq Shameem

  06 Jun 2020 06:49:51 PM

  Isteaq Shameem

  Bladder doesn’t seem to be small capacity,since it is an obstructive megaureter surgery should be planned as early as possible. With huge dilated and tortuous ureter tailoring and reimplantation should be planned, extravesical 

  or  intravesical may be surgeon’s choice. My preference is extravesical. Since parents did not agree Dr Rahul might have more information to share. Are all investigations of Nov 2018?

  Thanks and regards to all

• 

  Rahul Kapoor

  07 Jun 2020 09:17:00 AM

  This child continued follow up USG at 3 months.

  I am attaching all USG and an repeat EC scan.

  
  

  I suggested surgery at 4 months but another opinion was continue conservative treatment. 

  As repeat EC scan showed slightly improved relative function, parents advised to continue conservative treatment.

  
  

  

• 

  Dr. Anil Takvani

  07 Jun 2020 10:39:11 AM

  Split renal function of left side is obvious over estimation because of gross HUN.

  @Rahul, Please post sequential images of diuretic renal scan along with post micturation/post erect posture or delayed images of renal scan.

  Thanks

• 

  Rahul Kapoor

  07 Jun 2020 11:27:27 AM

  Sir their are no other photos. 

  Child is around 2 years old. Sequential usg has shown that ureteric dilatation is increasing. 

  The increased renal function in repeat scan is probably due to hydronephrotic enlarged kidney. 

  1. Shall we continue waiting or proceed with surgical correction?

  2. Which are the cases where we can continue observation in obstructive megaureter?

• 

  Rahul Kapoor

  07 Jun 2020 11:48:19 AM

  These are followup USG at 7,10,14 and 18 months.

  
  

• 

  Dr. Anil Takvani

  07 Jun 2020 03:27:57 PM

  Very interesting Rahul, I failed to notice you posted serial USGs done 3 to 4 months apart.

  Renal and ureteric dilatation is increasing, at the cost of though little but definite increase in cortical thinning.

  Child is lucky did not developed infection or infected HUN.

  If this child is under your treatment , please operate as early as possible.

  His ureter will require major re-modelling and good tunnelled reimplantation.

  Thanks

  You can observe the cases with AB prophylaxis:

  1> No UTI or breakthrough UTI

  2> No increasing dilatation on sequential USGs

  3> Split renal function is not deteriorated or do not show increasing deterioration of slit renal function in second scan( poor indicator in compare to sequential USGs)

  4> Asymptomatic child

  
  

  
  

• 

  Rahul Kapoor

  07 Jun 2020 11:07:36 PM

  Thanks very much sir for guiding me. 

  This child is asymptomatic with no episodes of FUTI. 

  I feel child should undergo surgery. 

  Thanks for discussing when to do conservative treatment in POM. 

  I was always under the impression that obstructed system should be treated.