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Medical Student Radiology SYB

Medical Student Radiology SYB. Matt Kulzer, MSIV 12/4/2008. The Case. 2 wk old infant born at term via CS 2/2 maternal hypertension/GDM On prenatal ultrasound a “renal abnormality” was noted No other complications with pregnancy/delivery. Findings – Renal ultrasound.

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Medical Student Radiology SYB

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  1. Medical Student Radiology SYB Matt Kulzer, MSIV 12/4/2008

  2. The Case • 2 wk old infant born at term via CS 2/2 maternal hypertension/GDM • On prenatal ultrasound a “renal abnormality” was noted • No other complications with pregnancy/delivery

  3. Findings – Renal ultrasound • Normal right kidney without dilation • Left kidney with complete duplex system (small upper pole with dilated ureter) • Upper pole with ureterocele at the bladder base • Mild fullness of lower pole collecting system

  4. Findings - VCUG • Left sided grade 4/5 VUR • Right sided grade 2 VUR • Normal bladder/urethra

  5. Duplicated collecting system • Key points: • Weigert-Meyer rule: 85% of the time, an ectopic upper pole ureter will insert inferior and medial to the lower pole ureter; upper pole ureter will frequently obstruct • Drooping lily sign – seen on VCUG or IVP • Obstructed upper pole pelvis becomes hydronephrotic and compresses lower pole pelvis, pushing it down • Makes lower pole pelvis resemble a drooping flower

  6. Vesicoureteral Reflux (VUR) • What is it? • Retrograde passage of urine from the bladder into the upper urinary tract • Most common urologic abnormality affecting 1% of newborns and 30-45% of young children with a UTI • So What? • Popular thinking is that VUR predisposes patients to pyelonephritis which may lead to renal scarring and eventually to HTN, ESRD, etc. • However, this popularly held belief is coming into question (outcomes related more to the degree of reflux rather than number of infections)

  7. VUR Grading • Grade I — Reflux only fills the ureter without dilation. • Grade II — Reflux fills the ureter and the collecting system without dilation. • Grade III — Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces. • Grade IV — Reflux fills and grossly dilates the ureter and the collecting system with blunting of the calyces. Some tortuosity of the ureter is also present. • Grade V — Massive reflux grossly dilates the collecting system. All the calyces are blunted with a loss of papillary impression and intrarenal reflux may be present . There is significant ureteral dilation and tortuosity.

  8. Management • Medical • Daily prophylactic Abx (TMP-SMX, TMP alone, nitrofurantoin, amoxicillin or cephalosporins if under 2 mos of age) • Dose ½ to ¼ the usual therapeutic dose to treat • Surgical • Open vs. endoscopic reimplantation of the ureter • Similar outcomes for both • With age, intravesicularureter will lengthen and may improve reflux

  9. Prognosis • Prenatal Dx – J Pediatr 2006 Feb;148(2):222-227 • 43 pts followed prospectively for 2 years with VCUG before 6 mos, after 1 yr of age, and if VUR persisted after 2 yrs of age: • VUR resolved in 91% with grade I-III • VUR resolved in 2/11 with grade IV-V • Postnatal Dx – J Urol 1997 May;157(5):1846-1851 • Review of 26 studies (1987 pts) • Resolution dependent on severity of VUR, unilat vs. bilat • Grade V rarely resolved

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