The ways of recovery of morphofunctional state of duplicated kidneys
Background. The number of children with duplicated kidney is constantly growing. Perinatal diagnosing facilitates early detection of complications and prevent the irreversible changes in kidneys. The purpose was to substantiate management tactics, treatment method and determine the benefits of using minimally invasive methods for the treatment of children with duplicated kidney anomaly. Materials and methods. A kidney and ureteral duplication is the most common anomaly of the urinary system, which occurs in one child per 150–160 new-borns. The children with complete duplication of kidneys along with other diseases (ectopic ureter, reflux, ureterocele, megaureter and obstructed ureteropelvic junction) need examination and timely treatment. According to the literature data, the frequency of ectopic ureters occurs up to 14 %. Duplicated kidney can also be combined with ureterocele (9–10 %), vesicoureteral reflux (30–35 %) and abnormalities of the internal genitalia up to 60 %. Vesicoureteral reflux (VUR) is more often observed in the lower half of the duplicated kidney, less often through both orifices of the kidney. The clinical manifestations of this pathology depend on the disease of the abnormal kidney. The most common complications of this pathology are hydronephrosis, pyelonephritis, urolithiasis, and renal hypertension. The examination of children includes ultrasound diagnostics, excretory urography, and micturating cystourethrogram. In some complicated cases, computer tomography, retrograde pyelography, and cystoscopy can be used. Results. In the Urology Department of the Regional Children’s Clinical Hospital, 119 patients aged from 0 to 18 years with a duplicated kidney were examined. Sixty-six patients from this group of patients were operated. Age characteristic was as following: up to 1 year — 26 patients; 1–3 years — 24; 3–6 years — 9; older than 6 years — 7. In 23 children, an abnormal kidney was diagnosed in utero. The rest children were admitted due to the urinary inflammation. Two girls complained of urinary incontinence; the examination revealed an extravesical ectopia of the ureteral orifice was revealed. Among the operated children, there were 48 girls (73.4 %); unilateral doubling was detected in 56 patients (85.6 %). The diagnostic examination revealed VUR in 39 children, ureterocele in 14 children, ureteric stricture of the upper half — in 11; ectopic ureteral orifice — in 2 patients. One of the serious complications in several children was pyonephrosis. The treatment of children with a duplicated kidney in diagnosed urodynamic disorders is only surgical. The choice of surgical procedure for a duplicated kidney depends on the severity of damage to the kidney parenchyma and the concomitant anomaly of the ureters. Impaired urodynamics in the pyeloureteral segment caused the resection of the ureteropelvic segment with the imposition of pyeloureterostomy at an early age in 14 children, and other children underwent ureteroureterostomy and removal of the altered ureter. In the presence of VUR, it is important to determine the correct treatment tactics. The use of anti-inflammatory and stimulating therapy for I–III degree VUR allowed obtain positive results in 25 % of cases. The effectiveness of the endoscopic method of treatment is higher, but with severe degrees of VUR only open surgery gives a positive result. In our clinic, 34 children with VUR underwent endoscopic plastic surgery of the ureterovesical segment. In 4 children, due to the non-effective repeated use of the endoscopic method of treatment, neocystoureteroneostomy was performed using Politano-Leadbetter technique with a single unit. The patients with complications of stone formation in the intramural segment of the duplication ureter (fissus) performed stone elimination and neocystureteroneostomy by Cohen with a single unit. At the first stage, we used endoscopic dissection of ureterocele in 12 children, cystostomy in 2 children and intraoperative dissection of ureterocele. These patients further underwent the corrective surgeries. Conclusions. Several multi-stage interventions are used for the treatment of duplicated kidney and ureter disease, which aimed at the restoration of urodynamics and reduction of the risk of complications. Correctly chosen treatment tactics reduced the number of heminephroureterectomies and nephrouretherectomies and also contributed to the restoration of kidney morphofunctional state.
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