Çocuklarda Üreteropelvik Bileşke Darlığı: Tek Merkez Deneyim

Amaç:Üreteropelvik bileşke darlığı (UPD) çocuklarda görülen böbrek hasarının en temel nedenlerinden biridir. Yüksek dereceli obstrüksiyonu olan hastalarda cerrahi tedavi için en uygun zamanı belirlemek oldukça zordur. Diüretik Tc-99m-dietilentriaminpentaasetik asit (DTPA) sintigrafi, UPD'nin tanı ve izleminde en yaygın olarak kullanılan metottur. Bizim çalışmamızda UPD olan çocuklarda DTPA sintigrafi bulgularının değerlendirilmesi amaçlanmıştır.Gereç ve Yöntem: Çalışmamızda 2000-2010 yılları arasında UPD tanısı ile izlenen çocuklar retrospektif olarak değerlendirildi. Böbrek pelvis önarka çapı >40 mm olan, bölünmüş böbrek fonksiyonu %40'ın altında olan, hidronefroz derecesinde anlamlı artışı olan hastalara pyeloplasti uygulandı. Cerrahi girişimden sonraki 3. ve 6. ayda bütün hastalara ultrasonografi ve Tc-99m-DTPA sintigrafi yapıldı. Bulgular: Çalışmamızda UPD tanılı 48 çocuk değerlendirildi. Pelvis ön-arka çapı, pyeloplasti yapılan hastalarda cerrahi girişim yapılmayan hastalardan daha yüksek bulundu (p=0.0001). Cerrahi girişim uygulanan 15 hastanın 14'ünde (%93.3) pelvis ön-arka çapı tedaviden sonra gerileme gösterdi (Sırası ile 30.5±11.7 mm, 15.4±10.4 mm, p=0.0001). Pelvis ön-arka çapının gerileme oranı %56.44 olarak belirlendi. Ortalama gerileme zamanı 10.23±6.02 aydı. DTPA sintigrafide ölçülen T1/2 değeri pyeloplasti yapılan hastalarda olmayan hastalara göre daha yüksekti. Ancak böbrek yüzde fonksiyonu her iki grup arasında benzerdi (Sırası ile p=0.038, p>0.05). Pyeloplasti yapılan hastalarda, cerrahi girişimden sonra T1/2 değerinde anlamlı oranda gerileme (Sırası ile 22.3±3.4 dakika, 14.0±0.9 dakika, p=0.011), böbreğin yüzde fonksiyonunda ise anlamlı artış olduğu saptandı (Sırası ile %39.2±2.5, %43.4±1.4, p=0.012). Sonuç: T1/2 süresi üreteropelvik darlığı olan çocuklarda cerrahi girişim gerekliliğini belirlemede ve hastaların izleminde kullanılabilecek yararlı bir belirteçtir. Ayrıca böbreğin bölünmüş fonksiyonu, cerrahi girişimin zamanlamasını belirlemekten çok girişimden sonra darlık bulunan böbreğin fonksiyonunun takibinde yararlı bir gösterge olabilir.

Ureteropelvic Junction Obstruction in Children: Single-Center Experience

Objective: Ureteropelvic junction obstruction (UPJO) is one of the most principal cause of renal damage in children. It is very difficult to determine the most suitable time for surgery in patients with high grade obstruction. Diuretic Tc-99m diethylenetriamine pentaacetic acid (DTPA) scintigraphy is the most widely used method for diagnosis and follow up of UPJO. The aim of our study was to evaluate DTPA scintigraphy parameters in children with UPJO. Material and Method: The children which were followed up with UPJO during the period 2000-2010 retrospectively were evaluated. Diuretic Tc99m-DTPA scintigraphy was performed on all patients. Patients who have bilateral disease, renal pelvic antero-posterior (AP) diameter >40 mm, split renal function less than 40% significantly increasing hydronephrosis, significantly decreasing split function and clinical symptoms were treated with surgery. All patients were followed with serially renal ultrasonography and 99mTc-DTPA renography at 3 and 6 months after the operation. Results: In our study, 48 cases with UPJO were evaluated. Pelvis AP diameters were higher in patients selected for pyeloplasty than in the patients with no operation (p=0.0001). AP diameters of operated patients [14 (93.3%) of 15] were regressed after operation (30.5±11.7 mm vs. 15.4±10.4 mm, p=0.0001). Regression ratios of AP diameters were 56.44% in these patients. Mean regression time were 10.23±6.02 months. T1/2 in DTPA were higher in operated patients than those of non-operated patients but baseline RF were similar in these groups (p=0.038 and p>0.05, respectively). After pyeloplasty, DTPA T1/2 time were improved (22.3±3.4, 14.0±0.9 respectively, p=0.011). RF were also increased after surgical treatment (Renal function 39.2% ± 2.5 / 43.4±1.4, p=0.012). Conclusion: T1/2 time is a useful marker that can be used in the follow-up and in determining the indication for surgery in children with UPJO. Also, split renal function could be used after the surgery in follow-up rather than in determining the optimal time for surgery in children with UPJO.

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  • 1. Benfield MR, McDonald RA, Bartosh S, Ho PL, Harmon W. Changing trends in pediatric transplantation: 2001 Annual Report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Transplant 2003; 7: 321-35.
  • 2. Koff SA. Neonatal management of unilateral hydronephrosis. Role for delayed intervention. Urol Clin North Am 1998; 25: 181-6.
  • 3. Chang CP, McDill BW, Neilson JR et al. Calcineurin is required in urinary tract mesenchyme for the development of the pyeloureteral peristaltic machinery. J Clin Invest 2004; 113: 1051- 8.
  • 4. Huang WY, Peters CA, Zurakowski D, et al. Renal biopsy in congenital ureteropelvic junction obstruction: evidence for parenchymal maldevelopment. Kidney Int 2006; 69: 137- 43.
  • 5. Matsumoto F, Shimada K, Harada Y, Naitoh Y. Split renal function does not change after successful treatment in children with primary vesico-ureteric reflux. BJU Int 2003; 92: 1006-8.
  • 6. Duckett JW, When to operate on neonatal hydronephrosis. Urology 1993; 42: 617-9.
  • 7. Woodard JR. Hydronephrosis in the neonate. Urology 1993; 42: 620-1.
  • 8. Hyun IY, Lee DS, Lee KH, et al. Improvement of diagnostic accuracy by standardization in diuretic renal scan. Korean J Nucl Med 1995; 29: 497-503.
  • 9. Dubovsky EV, Russell CD. Advances in radionuclide evaluation of urinary tract obstruction. Abdom Imaging 1998; 23: 17-26.
  • 10. Choong KK, Gruenewald SM, Hodson EM, Antico VF, Farlow DC, Cohen RC. Volume expanded diuretic renography in the postnatal assessment of suspected uretero-pelvic junction obstruction. J Nucl Med 1992; 33: 2094- 8.
  • 11. Koff SA. Neonatal management of unilateral hydronephrosis. Role for delayed intervention. Urol Clin North Am 1998; 25: 181-6.
  • 12. Tubre RW, Gatti JM. Surgical approaches to pediatric ureteropelvic junction obstruction 2015; 16: 72.
  • 13. Persky L, Krause JR, Boltuch RL. Initial complications and late results in dismembered pyeloplasty. J Urol 1977; 118: 162-4.
  • 14. Kim YS, Cho CK, Han SW. Comparison between unilateral pyeloplasty and conservative treatment in bilateral ureteropelvic junction obstruction of children. Korean J Urol 1998; 39: 1248-53.
  • 15. Homsy YL, Saad F, Laberge I, Williot P, Pison C. Transitional hydronephrosis of the newborn and infant. J Urol 1990; 140: 579- 83.
  • 16. Homsy YL, Koff SA. Problems in the diagnosis of obstruction in the neonate. In: King LR, editor. Urologic Surgery in Neonates and Young Infants. 1st ed. Philadelphia: Saunders; 1988: 77-94.
  • 17. Dhillon HK. Prenatally diagnosed hydronephrosis: the Great Ormond Street experience. Br J Urol 1998; 81: 39-44.
  • 18. Han SW, Lee SE, Kim JH, Jeong HJ, Rha KH, Choi SK. Does delayed operation for pediatric ureteropelvic junction obstruction cause histopathological changes? J Urol 1998; 160: 984- 8.
  • 19. Park S, Ji YH, Park YS, Kim KS. Change of hydronephrosis after pyeloplasty in children with unilateral ureteropelvic junction obstruction. Korean J Urol 2005; 46: 586-92.
  • 20. Dubovsky EV, Russell CD. Advances in radionuclide evaluation of urinary tract obstruction. Abdom Imaging 1998; 23: 17-26.
  • 21. Choong KK, Gruenewald SM, Hodson EM, Antico VF, Farlow DC, Cohen RC. Volume expanded diuretic renography in the postnatal assessment of suspected uretero-pelvic junction obstruction. J Nucl Med 1992; 33: 2094- 8.
  • 22. Chertin B, Pollack A, Koulikov D, et al. Does renal function remain stable after puberty in children with prenatal hydronephrosis and improved renal function after pyeloplasty? J Urol 2009; 182: 1845-8.
  • 23. Singh V, Garg M, Sharma P, Sinha RJ, Kumar M. Mini incision open pyeloplasty - Improvement in patient outcome. Int Braz J Urol 2015; 41: 927-34.
  • 24. Cost NG, Prieto JC, Wilcox DT. Screening ultrasound in follow-up after pediatric pyeloplasty. Urology 2010; 76: 175.
  • 25. Liu M, Fu Z, Li Q, et al. Delayed renal tissue tracer transit in Tc-99m-DTPA renography correlates with postoperative renal function improvement in UPJO patients. Nucl Med Commun 2015; 36: 833-8.
  • 26. Öktem F. Çocuk ürolojide ve nefrolojide görüntüleme teknikleri. Tıp Araştırmaları Dergisi 2005; 3: 33-8.
  • 27. Schlotmann A, Clorius JH, Rohrschneider WK, Clorius SN, Amelung F, Becker K. Diuretic renography in hydronephrosis: delayed tissue tracer transit accompanies both functional decline and tissue reorganization. J Nucl Med 2008; 49: 1196-203.