
Dr. Anil Takvani
Recent Posts

Infra Vesical outflo...
04 Dec 2024 12:58:30 PM
Spot the diagnosis a...
27 Nov 2024 04:25:15 PM
Qatar International ...
26 Nov 2024 09:16:33 PM
Asymptomatic high gr...
25 Nov 2024 07:11:42 AM
We are resuming disc...
24 Nov 2024 01:27:43 PMSpot the diagnosis and discuss further management
Dear All,
A 2-month-old boy developed febrile UTI, with a positive urine culture for E. coli. He was hospitalized and received IV antibiotics a year ago.
Pre-natal findings:
Ultrasound was suggestive of right HUN, with the right kidney being smaller in size compared to the left. The left kidney, bladder, and post-void residual (PVR) were normal.
Clinical details:
• Serum creatinine: 0.34 mg/dL at 2 months of age.
• VCUG was performed after infection control, and the patient was started on antibiotic prophylaxis.
I am attaching the VCUG images for your review.
Kindly provide your diagnosis and share your thoughts on further management.
Thank you.

Comments(18)
-
Yaqoub jafar
27 Nov 2024 08:49:54 PMHi Anil it’s really interesting case .
I have some question , did the child had ultrasound spine?The VCUG look high grade VUR but the bladder is trabeculated mildly .Would you consider cystoscopy to role out PUV in this child ?I may consider it to be honest , and I will for sure do circumcision for the child .For me it’s not obstructing refluxing megaureter as the concentration of the contrast is similar in the kidney and the bladder . -
Dr. Anil Takvani
27 Nov 2024 09:21:30 PMSpine is normal in USG and X ray
Bladder reported normalNo significant PVRParents have no complaints regarding urinary streamI am trying to attach first photo of first post natal USGRegarding diagnosis and further management let others to share their thoughtsThanks -
Dr. Aadil Farooq
27 Nov 2024 11:26:11 PMSir,
Thank you for sharing intersting cases.We are dealing with a good number of such cases at our Pediatric Urology centre and doing good.These cases require confidence,faith and patience on the part of treating doctor and parents.Here it's a High pressure bladder with High grade VUR.I would ask parents to see and record the voiding pattern of child if normal or stressful.Posterior Urethra is elongated and dilated.I will do circumcision and Cystoscopy then catheter placement.Continue antibiotic prophylaxis and keep urine sterile.Support the child to grow along with the kidneys.Once there is no more obstruction distally, bladder will begin to behave normally,no more deterioration in compliance.Meticulous follow up is necessary.Diversion is done only in case of Pyonephrosis.Sincere Regards,Dr. Aadil Farooq.Consultant,Pediatric Urology. -
Dr. Anil Takvani
28 Nov 2024 08:11:17 AMThis is most probably a refluxing an obstructing megaureter if you see the drainage image the bladder drains well, but not the ureter or the collecting system.
I would go ahead and a cuteneostomy ( ureteric diversion) and undivert in a year with right reimplant of ureter.From Prof. Serdar Tekgul, Turkey -
Dr. Anil Takvani
29 Nov 2024 08:48:30 AMPatient kept on AB prophylaxis
I am attaching the DMSA scan of this patient done almost at 12 weeks of agePlease discuss -
Yaqoub jafar
29 Nov 2024 11:43:36 AMGood morning Anil ,
Thank you for the amazing work ,After seeing the DMSA scan , it look for me as it’s pop off effect , with this finding , I have to scope the child . To make sure it’s not of the PUV as some PUV type the don’t have all classical finding . My DDX is either PUV or obstructing refluxing megaureter . The refluxing obstructing megaureter can be due to hypertrophied bladder detrosral muscular due to BOO as it was published by sick kid team . I would scope the child and if the child had no PUV or one of its variant I will circumcise him and can .CIC is option .If all the measure fails I would consider ureterostomy .With kind regards , -
Dr. Anil Takvani
29 Nov 2024 11:54:40 AMBladder not thick
Bladder neck not elevatedNo PVR on USG and VCUGUrinary stream is good as per parentsMost of the refluxed contrast stays in upper track even in post micturation film of VCUGThanks -
Abdulhakim alotay
29 Nov 2024 02:44:33 PMThanks Anil for update,
I am still with my first comment as this is a case of obstructing refluxing megaureter .With such DMSA and acceptable function ,and this boy is still 2 months age , I will continue abx and observe him if he develop break through infection or worsening hydro. I will proceed for cystoscope and diversion, otherwise , I will give chance for spontaneous resolution as this is the fate of most megaureter cases .Regards ???? -
Dr. Anil Takvani
29 Nov 2024 04:24:45 PMGreat responses
What type of diversion you will prefer in this patient?I concur with your comments and pathwayThanks -
Abdulhakim alotay
29 Nov 2024 04:33:11 PMThank Anil ,
I prefer as prof. Serdar recommended . Cutaneous ureterostomy ,, although many recent reports about JJ stenting promising with good result ( as internal drainage ) , but as long term and unilateral , cutaneous urterostomy more safe and efficientRegards -
Dr. Anil Takvani
29 Nov 2024 04:42:24 PMEnd Ureterostomy or low loop ureterostomy?
Please share your reasons for selecting the type of diversion.I agree with ureteric diversionThanks -
-
Dr. Anil Takvani
29 Nov 2024 04:56:06 PMI did the same when patient was almost of 3 months age.
They wanted circumcission, we did that along with low cutaneous loop ureterostomy.My reason is, it is very easy to perform and it is effective in serving the purpose.But I know few will prefer low end ureterostomy in this case.We will try to get few more expert comments on thatThanks -
-
Dr.Sneh shah
29 Nov 2024 06:06:41 PMSo as I understand this boy is 14 month of age right now and had febrile culture positive uti a year ago when he was 2 month of age..all these investigation posted are when he was 2 month old. Is MCU is when he was 2 month or recent?
So what's current history?any breakthrough Uti after starting prophylactic antibiotics? -
Dr. Anil Takvani
29 Nov 2024 06:58:08 PMDear All,
Posting time line of this case:Present age: 14 monthsPrenatal diagnosis of right HUN during 3rd trimesterFebrile UTI-2 months of age, hospitalization, iv antibioticsUSG done during that episode, attaching the report as pictures are not availableWas kept on AB prophylaxisVCUG was done, picture is already providedHad one episode of breakthrough infectionHe presented to me at around 3 months ageDMSA scan was advised by me, photo of DMSA already providedAt around 3 month I did low cutaneous uretrostomy on right side as a diversion as my diagnosis was an obstructive, refluxing dilated ureter with recurrent PN ( / infected HN )Child had one episode of febrile UTI within 3 to 4 weeks of ureterostomy, upper limb of uretrostomy was found to be blocked by pus flakes. He was treated. Since then no issues, grown well. Present weight is 11 Kg -
Serdar Tekgul
30 Nov 2024 01:03:18 AMHi An?l
Sorry being late to login but thank you for sharing my reply to you.I believe the wall of the bladder is so smooth and the emptying is also well, I think these are enough findings to exclude PUVBut the right system is not draining well and already lost some functionJj stents have not shown to be a reliable management as the infections keep continuing in about 70%Cutenoestomy is a great choice as it helps drainage keeps infection away and more importantly helps in improving ureter size for a much easier reimplant laterI would do loop if there is reflux to the contra?eral ureter and the bladder is problematic ( like in valve bl or neurogenic bladder) refluxing stoma will help the drainage of the bladderFor this case I eould end cutonestomy
Abdulhakim alotay
27 Nov 2024 08:23:07 PMInteresting case