Primer Obstrüktif Megaüreterde Cerrahi Tedavi; 22 Olgunun Değerlendirmesi

Öz

Amaç: Obstrüktif megaüreter prenatal hidronefroz saptanan olguların %10’nu oluşturur. Prenatal tanılı olguların artmasıyla birlikte obstrüktif megaüreterli olguların izlemi ve tedaviside son yirmi yılda değişiklikler görülmektedir. Kliniğimizde primer obstrüktif megaüreter tanısı ile cerrahi girişimde bulunulan olgular sunularak tedavi sonuçları literatür bilgileri ışığında tartışılacaktır.Gereç ve Yöntem: 2007-2011 yılları arasında primer obstrüktif megaüreter tanısı ile cerrahi girişimde bulunulan 22 olgu hastane kayıtlarından geriye dönük olarak değerlendirildi. Obstrüktif megaüreter tanısı ile izlenen olgularımızda artan renal pelvis çapı, azalan renal fonksiyon, tekrarlayan idrar yolu enfeksiyonu ve flank ağrısı cerrahi müdahale için aranan şartlar oldu.Bulgular: Sekiz kız, 14 erkek toplam 22 olgu geriye dönük olarak değerlendirmeye alındı. Olguların yaşları ortalama 2.23± 2.42 (1 ay–8 yaş) yıldı . Dört olguda sağ üreter, 17 olguda sol üreterde, bir olguda ise bilateral obstrüksiyon saptandı. 11 olgumuz prenatal saptanan hidronefroz nedeni ile araştırılırken tanı aldı. Soliter böbreği olan üç olgumuza bir yaş altında erken dönemde girişimde bulunuldu. Ürosepsiste olan bir olguya ise üreterokutaneostomi açıldı ve bir yaşından sonra definitif onarım yapıldı. 18 olgumuz açık cerrahi girişim ile üreter çapı azaltıldıktan sonra üreteroneosistostomi yapılarak, dört olgumuz da JJ kateter takılarak izlendi.Tartışma: Primer obstrüktif megaüreter ender karşılaşılan üriner sistem anomalisidir. Tedavisinde halen görüş birliği oluşmamıştır. Özellikle antenatal hidronefroz ile tanınan olgularda izlem tartışmalıdır. Endoskopik olarak JJ katerer takılarak izlenebileceği ifade edilse de serimizdeki olguların çoğunda endoskopik kateter yerleştirmek mümkün olmamıştır. Bu tür olgularda gerekli olduğunda geçici üreterokutaneostomi yapılırken bir yaşın üzerinde üreter çapını azaltarak üreteroneosistostomi yapılması uygun seçenektir. Özellikle soliter böbrekli olgularda erken dönemde açık cerrahi girişim yapılması gerekebilir.

Anahtar Kelimeler

• Obstrüktif megaüreter

OPERATIVE TREATMENT OF THE PRIMARY OBSTRUCTIVE MEGAURETER; EVALUATION OF 22 PATIENTS

Öz

Aim: Obstructive megaureter composes 10% of the prenatally diagnosed cases of hydronephrosis. During the recent 20 years, some changes have appeared in the follow-up and treatment of the cases with obstructive megaureter in conjunction to the increase in prenatally diagnosed cases. In this article, cases of obstructive megaureter operated in our clinic has been presented and results of treatment have been discussed on the basis of literature knowledge.Materials and methods: 22 cases operated for the diagnosis of obstructive megaureter between 2007 and 2011 were evaluated retrospectively by the hospital records. Increasing renal pelvis diameter, decreasing renal functions, recurrent urinary tract infection and flank pain were the parameters for indication of surgical intervention in these cases of obstructive megaureter.Results: Total of 22 cases (8 girls and 14 boys) with the mean age of 2.23± 2.42 years (age range: 1 month-8 years) were evaluated retrospectively. Obstruction was determined at the right ureter in 4 cases, at the left ureter in 17 cases, and bilateral in one case. Eleven cases were diagnosed during investigation for prenatally identified hydronephrosis. Early surgical intervention was performed in 3 cases with solitary kidney under the age of one. Ureterocutaneostomy was carried out for one case with urosepsis and definitive operation was conducted after one year of age. Ureteroneocystostomy was performed for 18 cases by reducing the diameter of the ureter, whereas 4 cases were followed up after a JJ catheter was placed. Discussion: Primary obstructive megaureter is a rare urinary system abnormalities. There is no consensus on the treatment of this disease, yet. Follow-up is controversial especially in cases recognized as antenatal hydronephrosis. Although these cases could be followed by endoscopically placing a JJ catheter; this has not been feasible in most of our cases. In such cases, a temporary ureterocutaneostomy can be performed when it is necessary. Furthermore, ureteroneocystostomy by reducing the diameter of the ureter has been a prefered option for cases over one year of age. Open surgery might be necessary especially in cases with solitary kidney at an early stage

Anahtar Kelimeler

• Obstructive megaureter

Kaynakça

1. Cussen LJ. Dimensions of the normal ureter in infancy and child- hood. Invest Urol 1967;5(2):164-78.
2. King LR Megaloureter: definition, diagnosis and management. J Urol 1980;123(2):222-3.
3. Liu HY, Dhillon HK, Yeung CK, Diamond DA, Duffy PG, Rans- ley PG. Clinical outcome and management of prenatally diagnosed primary megaureters. J Urol 1994; 152(2 Pt 2):614-7.
4. Shukla AR, Cooper J, Patel RP, Carr MC, Canning DA, Zderic SA, et al. Prenatally detected primary megaureter: a role for extended followup. J Urol 2005;173(4):1353-6.
5. Keating MA, Escala J, Snyder HM 3rd, Heyman S, Duckett JW. Changing concepts in management of primary obstructive megau- reter. J Urol 1989;142(2 Pt 2):636-40.
6. Baskin LS, Zderic SA, Snyder HM, Duckett JW. Primary dilated megaureter: long term followup. J Urol 1994;152(2 Pt 2):618-21.
7. Peters CA, Mandell J, Lebowitz RL, Colodny AH, Bauer SB, Hendren WH, et al. Congenital obstructed megaureters in early in- fancy: diagnosis and treatment. J Urol 1989;142(2 Pt 2):641-5.
8. McLellan DL, Retik AB, Bauer SB, Diamond DA, Atala A, Man- dell J, et al. Rate and predictors of spontaneous resolution of prenatally diagnosed primary nonrefluxing megaureter. J Urol 2002;168(5):2177-80.

9. Cozzi F, Madonna L, Maggi E, Piacenti S, Bonanni M, Roggini M, et al. Management of primary megaureter in infancy. J Pediatr Surg 1993;28(8):1031-3.
10. Gimpel C, Masioniene L, Djakovic N, Schenk JP, Haberkorn U, Tönshoff B, et al. Complications and long-term outcome of pri- mary obstructive megaureter in childhood. Pediatr Nephrol 2010;25(9):1679-86.
11. Calisti A, Oriolo L, Perrotta ML, Spagnol L, Fabbri R. The fate of prenatally diagnosed primary nonrefluxing megaureter: do we have reliable predictors for spontaneous resolution? Urology 2008;72(2):309-12.
12. Tanagho EA. Intrauterine fetal ureteral obstruction. J Urol 1973;109(2):196-203.
13. Cuchi JA, Chandran H. Congenital ureterric strictures; an uncom- mon cause of antenatally detected hydronephrosis. Pediatr Surg Int 2005;21(7):566-8.
14. Kannaiyan L, Karl S, Mathai J, Chacko J, Sen S. Congenital ureteric stenosis: a study of 17 children. Pediatr Surg Int 2009;25(6):513-7.
15. Nicotina PA, Romeo C, Arena F, Romeo G. Segmental up- egulation of transforming growth factor–beta in the pathogenesis of primary megaureter. An immunocytochemical study. Br J Urol 1997;80(6):946-9.
16. Farrugia MK, Steinbrecher HA, Malone PS. The utilizati- on of stents in the management of primary obstructive megau- reters requiring intervention before 1 year of age. J Pediatr Urol 2011;7(2):198-202.
17. Lipski BA, Mitchell ME, Burns MW. Voiding dysfuncti- on after bilateral extravesical ureteral reimplantation. J Urol 1998;159(3):1019-21.
18. Shenoy MU, Rance CH. Is there a place fort he insertion of a JJ stent as a temporizing procedure for symptomatic partial con- genital vesico-ureteric junction obstruction in infancy? BJU Int 1999;84(4):524-5.
19. Carroll D, Chadnan H, Joshi A, McCarthy LSL, Parashar K. En- doscopic placement of double-J ureteric stents in children as a treatment for primary obstructive megaureter. Urology Ann 2010;2(3):114-8.
20. Castagnetti M, Cimador M, Sergio M, De Grazia E. Double-J stent insertion across vesicoureteral junction-is it a valuable initial app- roach in neonates and infants with severe primary nonrefluxing megaureter? Urology 2006;68(4):870-6.
21. Barbancho DC, Fraile AG, Sanchez RT, Diaz ML, Fernandez MM, Vazquez FL, et al. Is effective the initial management of pri- mary nonrefluxing megaureter with double-J stent? Cir Pediatr 2008;21(1):32-6.
22. Kitchens DM, DeFoor W, Minevich E, Reddy P, Polsky E, McGre- gor A, et al. End cutaneous ureterostomy for the management of se- vere hydronephrosis. J Urology 2007;177(4):1501-4.
23. Lee SD, Akbal C, Kaefer M. Refluxing ureteral reimplant as tem- porary treatment of obstructive megaureter in neonate and infant. J Urol 2005;173(4):1357-160.
24. Fretz PC, Austin JC, Cooper CS, Hawtrey CE. Long-term outco- me analysis of starr plication for primary obstructive megaureters. J Urol 2004;172(2):703-5.
25. DeFoor W, Minevich E, Reddy P, Polsky E, McGregor A, Wacksman J, et al. Results of tapered ureteral reimplantation for primary mega- ureter: extravesical versus intravesical approach. J Urol 2004;172 (4Pt 2):1640-3.