The advent of detailed fetal scanning at 18-20 weeks gestation has significantly increased the detection rate of urinary tract abnormalities with no significant increase in pregnancy termination rates. The need for antenatal intervention is a rare event and most problems can be managed conservatively both pre- and postnatally.
Previous published data have shown the benefit of nutritional support delivered via a gastrostomy button (GB) for children on chronic dialysis. The use of the GB is suspended following renal transplantation (RT) in most children and it is usually removed 2-3 months later together with the chronic dialysis catheter when the child is on alternate-day steroids. We reviewed the outcome of gastrostomies following successful RT in children. The gastrostomies were created by an open technique (Stamm) with the child under general anaesthesia, usually at the time of insertion of a chronic dialysis catheter. Growth data and complications of the GB were collected in a prospective registry. Following RT, the GB was removed with the expectation that the tract would close spontaneously. Those in whom a gastrocutaneous fistula persisted underwent formal surgical closure. A total of 18 children have had gastrostomy buttons removed: 11 gastrostomies (61%) closed spontaneously, but 7 (39%) required operative closure at a median of 2 months (range 3 weeks-4 years) post-removal. The need for formal closure was significantly related to the duration that the gastrostomy had been in situ pre-transplant (non-parametric statistics, 0.05 > p > 0.01). Although nearly two-thirds of gastrostomies in this study closed spontaneously following RT, less than one-half of those that had been in situ for more than 1 year did so. We thus recommend formal closure of all gastrostomies that have been in situ for more than 1 year. This can be done at the same operation as the removal of the chronic dialysis catheter.
Four cases of diffuse xanthogranulomatous pyelonephritis (XPN) in young children are presented. In three patients the clinical picture was one of weight loss, anaemia and neutrophilia with a large renal mass. The fourth presented with haematuria. Ultrasound (US) and CT findings were almost identical in all four patients. US showed the affected kidney was massively enlarged but retained a reniform shape. Dilated fluid spaces containing calculi were present. CT confirmed the US findings and revealed peripheral enhancement without contrast excretion, with dilated calyceal spaces producing the "bear paw sign". Extrarenal extension into abdominal wall and psoas muscle is typical and was well demonstrated by CT. The affected kidneys were non-functioning and nephrectomy was required. Typical US and CT features allow a confident diagnosis of XPN and appropriate early treatment.
IndicationsPartial vesico-ureteric junction obstruction (VUJO) with hydroureteronephrosis is a relatively uncommon congenital anomaly compared with PUJ obstruction (PUJO) and in most cases can be managed conservatively. In a series of 105 000 consecutive pregnancies scanned over a 10-year period, there were only 16 babies with VUJO (two bilateral), compared with 52 with PUJO (six bilateral) [1]. We present two patients with severe recurrent UTIs, one with an episode of septicaemia, who responded well to the temporary insertion of a JJ stent.
Case 1An antenatal diagnosis of left hydronephrosis was made at 35 weeks of gestation. Postnatal ultrasonography showed a left hydroureteronephrosis; micturating cysturethrography (MCUG) showed no VUR. A MAG3 scan showed slow washout on the left side with tortuosity of the ureter and 37% function on the left side (Fig. 1a). The patient had suCered from recurrent UTIs despite antibiotic prophylaxis. A JJ stent (3 F, 8 cm, SOF-FLEX paediatric double pigtail stent, Cook Urological, UK) was inserted at 6 months of age by an open technique after dilating the narrowed ureteric opening. The stent was removed after 5 months because of bacteriuria (the maximum recommended period of time that the stent could be left in situ is 6 months). Repeat renography 4 months after removal of the stent showed slower drainage on the left, with a diCerential function of 41% on the left and 59% on the right (Fig. 1b). Ultrasonography showed an excellent cortex with residual hydronephrosis. A repeat MAG3 scan 2 years after the operation showed less hydronephrosis with a similar diCerential function as before. The patient was a b well and asymptomatic at 30 months of age.
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