Samir Abdullazade, Serdar Tekgül, Önder Kara, Ali Kemal Uslubaş, Dilek Ertoy Baydar

AĞIR SKARLI BÖBREKLERİN ÜRETER ALT UÇ PATOLOJİK ÖZELLİKLERİ AZ SKARLI TARAFLA KARŞILAŞTIRILDIĞINDA BELİRGİN FARKLILIK GÖSTERMEKTEDİR

Amaç: Bu çalışma, üreterlerin distal ucunun patolojik özelliklerinin böbrekteki skar oluşum patternleri ile olan ilişkisini araştırmayı amaçlamaktadır. Yöntem: VUR tanısıyla takip edilen ve 2008-2010 yılları arası bilateral ve ünilateral üreteroneosistostomi (UNC) ameliyatı yapılan 83 çocuk hasta (49 erkek, 34 kız) değerlendirildi. UNC yapılan taraf üreter alt ucu rezeke edildi ve 83 hastanın toplam 110 adet üreter alt ucu spesimeni, mevcut klinik ve patolojik bulgularla beraber değerlendirildi. Hasta yaşı, klinik patterni, reflü derecesi, DMSA’ daki skar patterni üreter alt ucu histopatolojik yapısıyla birlikte değerlendirildi. Skar patternleri skarsız, diffüz skar, fokal skar olmak üzere ayırıldı. Histopatolojik değerlendirme sırasında inflamasyon Grade 1-3 olarak derecelendirildi. Ekstrasellüler matriks, düz kas oranı ve üreter çapı ve duvar kalınlığı değerlendirildi. Bulgular: Toplam 110 üreterorenal ünitenin otuz beşinde (%33) skar yoktu. Otuzunda (%27) diffüz skar ve 45 ünitede (%40) fokal skar tespit edildi. Skar oranları düşük dereceli reflü grubu (G1-2) ve yüksek dereceli reflü grubunda (G3-4-5) sırasıyla %39,5 ve %90,3 olarak bulundu. Skar oranları reflü derecesine (G1-2 düşük vs. G 3-5 yüksek) göre değerlendirildiğinde skar oranları sırasıyla %39,5 ve %90,3 olarak bulundu. İnflamasyonun en yüksek olarak değerlendirildiği grade 3 inflamasyon diffüz skar, fokal skar ve skarın olmadığı grupta sırasıyla %66, %28,9 ve %36,4 olarak bulundu (p

HEAVILY SCARRED REFLUXING RENAL UNITS HAVE SIGNIFICANTLY DIFFERENT PATHOLOGIC FEATURES AT THE DISTAL END OF THE RELATED URETER COMPARED TO THE URETERS OF LESS SCARRED RENAL UNITS

Objective: This study aims to describe the pathological features of the distal end of ureters and their correlation with scar formation patterns in thekidney.Methods: The study includes 83 children (49 male, 34 female), who underwent ureteroneocystostomy (UNC) operations from 2008-2010. The distalend of ureters (approximately 3-4 mm) were resected and 110 ureter specimens from 83 patients were available for pathological examination. Thepresentation age, clinical presentation pattern, reflux grade and scar patterns on dimercaptosuccinic acid (DMSA) scan were obtained from recordand correlation with histopathological findings were investigated. Scar patterns were defined as presence of no scar (NS), diffuse scar (DS) or focalcortical scars (FS). General structural changes were also investigated histopathologically including inflammatory changes graded for intensity (G1-G3), extracellular matrix and smooth muscle content, ureteric diameter and wall thickness.Results: Histological examination of the ureterorenal units showed that there were 35/110 (33%), 30/110 (27%) and 45/110 (40%) in the NS, DSand FS groups, respectively. When scar rates were investigated by grade of reflux (G1-2 low grade vs. G3-5 high grade reflux) the scar rates were39.5%and 90.3% respectively. High grade inflammation (G3) was found in 66%, 28.9% and 36.4% in kidneys in the DS, FS and NS scar groupsrespectively (p

PDF

___

1. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol 2000;30(9):587-93 doi: 10.1007/s002470000263.
2. Elder JS. Guidelines for consideration for surgical repair of vesicoureteral reflux. Curr Opin Urol 2000;10(6):579-85 doi: 10.1097/00042307-200011000-00008.
3. Arena S, Fazzari C, Arena F, et al. Altered 'active' antireflux mechanism in primary vesico-ureteric reflux: a morphological and manometric study. BJU Int 2007;100(2):407-12 doi: 10.1111/j.1464-410X.2007.06921.x.
4. Oswald J, Brenner E, Schwentner C, et al. The intravesical ureter in children with vesicoureteral reflux: a morphological and immunohistochemical characterization. J Urol 2003;170(6 Pt 1):2423-7 doi: 10.1097/01.ju.0000097146.26432.9a.
5. Sofikerim M, Sargon M, Oruc O, Dogan HS, Tekgul S. An electron microscopic examination of the intravesical ureter in children with primary vesico-ureteric reflux. BJU Int 2007;99(5):1127-31 doi: 10.1111/j.1464-410X.2007.06751.x.
6. Oswald J, Schwentner C, Brenner E, et al. Extracellular matrix degradation and reduced nerve supply in refluxing ureteral endings. J Urol 2004;172(3):1099-102 doi: 10.1097/01.ju.0000135673.28496.70.
7. Schwentner C, Oswald J, Lunacek A, et al. Structural changes of the intravesical ureter in children with vesicoureteral reflux-does ischemia have a role? J Urol 2006;176(5):2212-8 doi: 10.1016/j.juro.2006.07.062.
8. Schwentner C, Oswald J, Lunacek A, et al. Loss of interstitial cells of Cajal and gap junction protein connexin 43 at the vesicoureteral junction in children with vesicoureteral reflux. J Urol 2005;174(5):1981-6 doi: 10.1097/01.ju.0000176818.71501.93.
9. Schwentner C, Oswald J, Lunacek A, et al. Extracellular microenvironment and cytokine profile of the ureterovesical junction in children with vesicoureteral reflux. J Urol 2008;180(2):694-700 doi: 10.1016/j.juro.2008.04.048.
10. Pirker ME, Rolle U, Shinkai T, Shinkai M, Puri P. Prenatal and postnatal neuromuscular development of the ureterovesical junction. J Urol 2007;177(4):1546-51 doi: 10.1016/j.juro.2006.11.081.
11. SPOT Imaging Solutions. Secondary SPOT Imaging Solutions. http://www.spotimaging.com/.
12. Mohanan N, Colhoun E, Puri P. Renal parenchymal damage in intermediate and high grade infantile vesicoureteral reflux. J Urol 2008;180(4 Suppl):1635-8; discussion 38 doi: 10.1016/j.juro.2008.03.094.
13. Shaikh N, Craig JC, Rovers MM, et al. Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. JAMA Pediatr 2014;168(10):893-900 doi: 10.1001/jamapediatrics.2014.637.
14. Marra G, Barbieri G, Dell'Agnola CA, Caccamo ML, Castellani MR, Assael BM. Congenital renal damage associated with primary vesicoureteral reflux detected prenatally in male infants. J Pediatr 1994;124(5 Pt 1):726-30 doi: 10.1016/s0022-3476(05)81362-9.
15. Brandstrom P, Neveus T, Sixt R, Stokland E, Jodal U, Hansson S. The Swedish reflux trial in children: IV. Renal damage. J Urol 2010;184(1):292-7 doi: 10.1016/j.juro.2010.01.060.
16. Benador D, Benador N, Slosman DO, Nussle D, Mermillod B, Girardin E. Cortical scintigraphy in the evaluation of renal parenchymal changes in children with pyelonephritis. J Pediatr 1994;124(1):17-20 doi: 10.1016/s0022- 3476(94)70248-9.
17. Skoog SJ, Belman AB, Majd M. A nonsurgical approach to the management of primary vesicoureteral reflux. J Urol 1987;138(4 Pt 2):941-6 doi: 10.1016/s0022-5347(17)43465-3.
18. Hinchliffe SA, Chan YF, Jones H, Chan N, Kreczy A, van Velzen D. Renal hypoplasia and postnatally acquired cortical loss in children with vesicoureteral reflux. Pediatr Nephrol 1992;6(5):439-44 doi: 10.1007/bf00874007.
19. Lee BR, Silver RI, Partin AW, Epstein JI, Gearhart JP. A quantitative histologic analysis of collagen subtypes: the primary obstructed and refluxing megaureter of childhood. Urology 1998;51(5):820-3 doi: 10.1016/s0090- 4295(98)00013-2.
20. Radmayr C, Fritsch H, Schwentner C, et al. Fetal development of the vesico-ureteric junction, and immunohistochemistry of the ends of refluxing ureters. J Pediatr Urol 2005;1(2):53-9 doi: 10.1016/j.jpurol.2004.11.009.