MR urography: the future gold standard in paediatric urogenital imaging?

Background. Examination of the paediatric urogenital tract is traditionally performed using methods that utilise ionising radiation, such as intravenous urography (IVU), computerised tomography (CT), voiding cystourethrography (VCU), and scintigraphy, in addition to ultrasound (US). Objective. To determine the potential and effectiveness of MR urography (MRU) in infants and children. Materials and methods. 44 MRU examinations were prospectively performed in 39 patients (21 infants, mean age 3.5 months, and 18 children, mean age 6 years 2 months) with known or suspected pathology of the urinary tract. Non-enhanced, fast spin-echo sequences (TSE) were performed in all patients. In 70 % of the patients a contrast-enhanced, fast gradient-echo sequence (TFE) was included. The dynamic sequence was prolonged and supplemented with furosemide provocation in some patients with suspected urinary-tract obstruction. Results. Nine percent of examinations were non-diagnostic or interrupted due to movement. MRU contributed additional information in 66 %. Nine patients with suspected urinary-tract obstruction were examined with both contrast-enhanced MRU and scintigraphy. Three MRU examinations were less informative and one equal to scintigraphy when obstruction was the diagnosis. When using a technique with a prolonged dynamic sequence, including frusemide provocation, four MRU examinations were equal and one was superior to scintigraphy. Conclusions. MRU has the potential to replace traditional diagnostic methods which use ionising radiation in paediatric patients. Further studies are needed before definite conclusions can be drawn. Received: 18 June 1998 Accepted: 9 March 1999     

Renal transplant nephrectomy in children: Can an aggressive approach be recommended?

BACKGROUND: A patient with a failed renal graft is generally approached conservatively, especially when graft failure occurs more than 1 month after transplantation. This approach was the cause of extensive morbidity in our institution and therefore we evaluated the correctness of our approach towards transplanted children. PATIENTS AND METHODS: Case histories of 182 renal transplants in 145 patients, performed between 1977 and 1999 were reviewed. Results: A total of 63 renal grafts failed: 19 between 0-1 month (group 1), 22 between 1 month and 1 yr (group 2) and 22 later than 1 yr after transplantation (group 3). Fifty-three grafts (84%) were removed: 100% of group 1, 86% of group 2 and 68% of group 3. The symptoms that indicated the need for graft removal were fever without a clear infection focus (n = 12), abdominal pain in the transplant area (n = 14), macroscopic hematuria (n = 10) and severe hypertension (n = 22). After transplant nephrectomy pain, fever and macroscopic hematuria completely resolved in all and hypertension resolved in 36% of patients. Transplant nephrectomy-associated morbidity was observed in 38% of the patients with 100% recovery. CONCLUSION: The clinical outcome confirmed the indications for transplant nephrectomy. Our future approach will be more aggressive: as soon as symptoms such as unexplained fever, local pain or macroscopic hematuria appear, graft removal will be performed without delay.     

Obstructive diseases of the urinary tract in children: lessons from the last 15 years

Imaging urinary tract obstruction is a common query in paediatric uroradiology. With the advent of a more conservative treatment approach, the task of imaging today is to distinguish as early as possible those kidneys that do not require surgery, from those that will deteriorate and lose function and/or growth potential and thus benefit from surgery. At present, in spite of significant advancements in imaging and the introduction of diuretic paediatric MR-urography, there is still no reliable a-priori pro-futuro assessment. Thus, repeated follow-up imaging is often necessary for monitoring. Imaging usually starts with US; the major additional complementary and more function-oriented tools are diuretic renal scintigraphy and MR-urography. The frequency and timing as well as the detailed protocol vary within institutions, partly because of differences in the criteria that are used for indicating surgery. Intra-venous urography (IVU) for obstruction has practically vanished apart from for a few exceptions, and the “Whitaker” test is today seldom performed, being reserved for complicated cases.     

Oesophageal atresia: what has changed in the last 3 decades?

The aim of the study was to analyse the outcomes of children born with oesophageal atresia over the last 3 decades. The records of 104 patients born between 1973 and 1999 were reviewed retrospectively. To evaluate changes over time, the analysis was done for three consecutive time periods: 1973–79, 1980–89, and 1990–99. Mean birth weight was 2553 g (SD 640), and mean gestational age was 39 weeks (SD 4). Forty-two newborns (40%) had one or more associated congenital malformations, and 30% had associated cardiac malformations. There was no change in incidence of associated anomalies over the three time periods studied. Mortality of patients decreased from 33% to 14% ( p =0.048). There was a significant association between the presence of a major cardiac malformation and survival (survival: 88% vs. 57%, p =0.004). Analysing the three different time periods separately reveals that cardiac disease was not a significant risk factor in the first period but became significant in the period from 1980–99 (relative risk: 6.76, 95% CI 1.44–31.77). Birth weight was significantly higher in infants who survived (2626 g, SD 642) compared with those who died (2290, SD 570, p =0.028). This effect, however, is mainly based on the difference during the first period and is lost later. Early and late postoperative complications occurred in 44/102 patients. Strictures developed in 33/91 patients who survived the first month of life (33%). The rate of symptomatic strictures decreased significantly over the three time periods, from 50% to 23% ( p =0.022). In summary, this study shows no significant change in patient characteristics over the last 3 decades, but mortality and postoperative complication rates decreased, and associated cardiac anomalies became the far most important risk factor for mortality.     

Laparoscopic pyeloplasty in children: Is the outcome different in children under 2 years of age?

PurposeTo report the outcomes of a series of children younger than 2 years with ureteropelvic junction obstruction (UPJO) who underwent laparoscopic pyeloplasty (LP), compared to children older than 2 years.Patients and methodsTwenty-three children (18 male) with UPJO underwent 24 Anderson–Hynes transperitoneal LPs between March 2003 and July 2007. The diagnosis of UPJO was confirmed on renal sonography and diuretic renogram. Nine children were younger than 2 years (Group 1) and 14 were older (Group 2). One child had bilateral UPJO and underwent two non-simultaneous procedures. All children were investigated with postoperative diuretic renogram and renal sonography, and the results were statistically analysed.ResultsLP was feasible without conversions or intraoperative complications in all 24 cases. Median age in Groups 1 and 2 was 11 months (4–24) and 74 months (27–204), respectively, (P < 0.00001). No differences were found between the groups regarding median operative time, complications, technical difficulties, discharge home and follow-up. All patients in both groups experienced resolution of symptoms or obstruction.ConclusionsThe LP in children younger than 2 years is highly successful with a low-rate of complications, and has the same outcomes as in older children.