Obstruction/reflux Flashcards
international reflux study committee grading of reflux
grade 1 reflux into ureter only
grade 2 reflux into renal pelvis
grade 3 mild dilatation of ureter and pc system
grade 4 - moderate dilatation, tortuous ureter, blunting fornices but papillary impression remain
grade 5 - severe dilataion, tortuous, loss of fornices and papillary impressions
incidence of PUV
1 in 4000
initial management of PUV
US on day 2 with creatinine – when creatinine not reflective of maternal
Then divide into two groups
Normal creatinine, passing urine, HUN mild – can give trimethoprim 2mg/kg orally at night, MCUG as OP, review result referral to local paed urology department
If plasma create raised, markedly abnormal US, not passing urine, trimethoprim 2mg/kg at night, catheterise urethral or SPC, monitor post ob diuresis can be up to 8-10/kg/hr
If abnormal creatinine measured bicarb as become acidotic and may require oral bicarb
Abnormal renal function involve paed nephrologist
initial management of PUV
US on day 2 with creatinine – when creatinine not reflective of maternal
Then divide into two groups
Normal creatinine, passing urine, HUN mild – can give trimethoprim 2mg/kg orally at night, MCUG as OP, review result referral to local paed urology department
If plasma create raised, markedly abnormal US, not passing urine, trimethoprim 2mg/kg at night, catheterise urethral or SPC, monitor post ob diuresis can be up to 8-10/kg/hr
If abnormal creatinine measured bicarb as become acidotic and may require oral bicarb
Abnormal renal function involve paed nephrologist
then MCUG
then cystoscopy and fulguration of valves
Repeat cystoscopy at 6 weeks to 3 months postop
4 types megaureter
reflux - VUR management
obstructing - conservative, stent +/- dilatation, refluxing implant, ureterostomy, reimplant
obstructing and refluxing - reimplant
non reflux non obstructive
definition mega ureter
> 7mm on 3rd trimester US
invesitgations megaureter
US check bladder
MCUG any reflux?
MAG3 - obstruction and differential function
cystoscopy and retrograde in selected cases
causes secondary megaureter
PUV, urinary stones, bladder dysfunction, ureterocele, ectopic ureter, diabetes insipidus
indications surgery in megaureter
how many require intervention
10-30%, usually in first 2 years life majority need no intervention esp if below 10mm give abx to all when born impaired function DRF <40% serial drop renal function evidence increasing HN on US scans infection episodes
surgery options megaureter
stent temporary with vuj dilatation +/- cutting can cure in 50% cases
then refluxing reimplant temporary, can do ureterostomy
then non refluxing reimplant - ureteroneocystotomy which will need end tapering
don;t forget circumcision if infections!
causes antenatal hydronephrosis based main post natal diagnosis
watson paper 50% non specific dilatation 11% PUJO 12% VUR 6% MCDK 4% duplex ureterocele 2% VUJO 1% PUV
definition AN hydro
7 or more mm in third trimester UK NHS foetal anomaly screening
measured AP at renal hilum
SFU grading AN hydro
1= prominent pelvis
2 = dilated pelvis, some calyces visible
3 - dilated pelvis and calyces all seen
4= greater pelvic and calyceal dilatation, cortical thinning
who needs post natal ix of AN HN (4)
unilateral RPD >10mm at 32 weeks
bilateral RPD with APD >6mm at any gestational age
RPD in solitary kidney
RPD with ureteric dilatation
which AN will resolve
APD <12mm 98% will resolve stabilised or improved on FU
managment post natal HN
first scan between 48 hours and 4 weeks
OPD US in 2-6 weeks no prophylaxis, confirm measurement, decide if any further investigation
if 2cm need MAG 3 for drainage and function
bilateral dilatation need earlier US and MCUG (PUV) also check baby’s back
MAG3 with diurectic can be in a few months
which AN HN are higher risk (5)
bladder abnormal HN in solitary bilateral severe HN abnormal parenchyma palpable kidney or bladder, poor stream
indications for pyeloplasty(3)
split differential less than 40 serial function decline 10-15% massive HN flank mass symptoms pain haematuriai UTI
US features MCDK (3)
check CL kidney
higher incidence VUR (20%), PUJO, VUJO, dysplasia
cysts with wall in between, non communicating
atresia ureter/pelvis
no renal parenchyma
natural history of MCDK
half will involute
same size 2-37%
enlarge 1-18%
follow up of MCDK
us at 2 year, 5 years and 10 years
monitor hypertension, proteinuria
see if involutes with compensatory hypertrophy
DMSA confirm no function at 6-12 months
how many AN HN is physiological or transient?
85%
what is sig AN HN?
1-2 cm in third trimester
monitoring of PUJO
until age 10, scan every 2 years
PUJO and big palpable kidney
can do nephrostomy
check function MAG3 if borderline can do DMSA
can do nephrostogram confirm dx
can see if nephrostomy improves function
if 10% or more can do pyelplasty fuction may improve if MAG3 and DMSA confirm less than 10% function and normal CL kidney then nephrectomy
sepsis with VUJO management
24-48 hours antibiotics if doesn't settle stent -difficult in small child nephrostomy or cutaneous ureterostomy alternative is a refluxing ureterostomy - side to end anastomosis just above VUJ
sting vs HIT
STING inject 6 oclock into bladder mucosa
to lift up ureteric orifice as make mound
HIT - hydrodistension with scope into distal ureter and inject into wall of distal ureter
whittaker test
nephrostomy and catheter in bladder saline with contrast at 10ml/min pressure in kidneyu and bladder if <15cm water then system not obstructed if more than 22 then obstructed 15-22 are equivocal
Dhillon GOSH natural history study
17% need surgery
56% stable
27% resolved
gross HN
AP diameter more than 5cm treatd
20-50mm not clear cut
> 30m, 55% will be treated
post operative pyeloplasty procedure
twoc next day
clamp 48 hours
nephro stent removed 7 days
