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Urology Obstructive Uropathy

Placement of a ureteral stent in an unobstructed system will result in:
A) increase in ureteral contractility.
B) decrease in ureteral contractility.
C) atrophy of the ureteral mucosa.
D) atrophy of the ureteral smooth muscle.
E) decrease in intrapelvic pressure.

B
( decrease in ureteral contractility. A number of changes occur after placement of a ureteral stent including: hyperplasia and inflammation of the urothelium, smooth muscle hypertrophy, increased intrapelvic pressure, a decrease in ureteral contractility and vesicorenal reflux. Decreased ureteral contractility does contribute to vesicorenal reflex, which may have implications in infected systems in the setting of bladder outlet obstruction. Chew B, Denstedt J: Access, stents and urinary drainage, in Nakada S, Pearle M {eds}: ADVANCED ENDOUROLOGY. Totowa, NJ, Humana Press, 2006, chap 2, p 22. 2011 Adult Obstructive Uropathy )

The upper ureter is more susceptible to serious injury during endourological procedures because it:
A) is less distensible.
B) has thin suburothelium.
C) has thin muscularis.
D) has thin urothelium.
E) has variable blood supply.

C
( has thin muscularis. The ureteral wall consists of three different layers. However, the composition of these layers is not constant for the entire length of the ureter. The urothelium is four or five cell layers thick. Beneath the urothelium is a lamina propria with loose or dense connective tissue, but not a distinct structure. The muscularis varies in its composition over the course of the ureter. In the proximal ureter, it consists of a thin, poorly defined inner circular and an outer longitudinal layer. Both the mid and distal ureter have a muscularis which is distinctly composed of an inner longitudinal, middle circular, and outer longitudinal fibers. The deficiency in the muscularis of the upper ureter and the geometric arrangement of large areas of collagenous connective tissue interspacing the muscle bundles is thought to make the upper ureter more susceptible to serious ureteral injury. Anderson JK, Kabalin JN, Cadeddu JA: Surgical anatomy of the retroperitoneum, adrenals, kidneys, and ureters, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 1, chap 1, p 33. 2011 Adult Obstructive Uropathy )

The factor most responsible for ureteral dilation during pregnancy is:
A) mechanical compression by the uterus.
B) elevated estradiol levels.
C) elevated progestin levels.
D) placental hormones.
E) increased urine flow.

A
( mechanical compression by the uterus. Dilation of the ureter occurs commonly during pregnancy and is most prominent by the 22nd to 24th week. Although various experiments have suggested that estrogens, progestins, placental hormones and increased GFR may play a role in the dilation, mechanical compression is the most significant factor. Indeed, quadrupeds have a lower incidence of ureteral dilation during pregnancy than bipeds.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1219. 2011 Adult Obstructive Uropathy )

A 41-year-old woman with endometriosis has intermittent left flank pain, gross hematuria, dysuria, and urgency that coincides with her menstrual cycle. A CT scan reveals mild left ureteral obstruction and no stones. Cystoscopy and cytology are normal. The next step is:
A) tamoxifen.
B) gonadotropin-releasing hormone agonist.
C) flutamide.
D) ureterolysis.
E) bilateral salpingo-oophorectomy.

B
( gonadotropin-releasing hormone agonist. Endometriosis of the urinary tract involves the ureter, typically the distal third, in 15-20% of cases. Although most patients with ureteral obstruction associated with endometriosis are asymptomatic, signs and symptoms may occur cyclically and include flank pain, dysuria, urgency, hematuria and frequent urinary tract infections. A trial of hormonal therapy using gonadotropin-releasing hormone agonists {Lupron} or medroxyprogesterone {Danazol} should be initiated for mild symptomatic obstruction when there is good preservation of renal function. For more severe obstruction associated with significant periureteral fibrosis, surgical intervention to correct the obstruction, with or without hysterectomy and bilateral salpingo-oophorectomy, is advisable.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1221. 2011 Adult Obstructive Uropathy )

Hypertension secondary to acute unilateral urinary obstruction is most likely:
A) found in patients with a solitary kidney.
B) associated with transient hyperreninemia.
C) persistent after relieving the obstruction.
D) associated with a demonstrable renovascular lesion.
E) due to sodium and water retention.

B
( associated with transient hyperreninemia. Renin-mediated hypertension sometimes occurs in acute unilateral renal obstruction and may present a clinical picture suggestive of a renovascular etiology; however, angiographic studies do not show a vascular lesion. A transient hyperreninemia initiates the hypertension and the hypertension is probably sustained by complex volume-vasoconstricting abnormalities that are dependent on the duration of the obstruction and the presence of a contralateral normal kidney. The abnormalities are corrected by relieving the obstruction and the blood pressure in turn reverts to normal. This type of hypertension usually does not occur in a solitary hydronephrotic kidney or bilateral hydronephrosis because of compromised renal function with lowering of renin levels due to impairment of overall sodium and water excretion. Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, pp 1196-1197. 2010 Adult Obstructive Uropathy )

A 71-year-old man with a history of aortoiliac reconstruction has left flank pain. A noncontrast CT scan reveals obstruction of the left ureter at the pelvic brim. The most likely cause of the obstruction is:
A) compression from an anteriorly placed graft.
B) pseudoaneurysm formation.
C) retroperitoneal fibrosis.
D) ligation of the ureter.
E) ischemia of the ureter.

C
( retroperitoneal fibrosis. Ureteral obstruction is a recognized complication of reconstructive vascular procedures. The incidence of temporary, asymptomatic hydronephrosis is 12-30%, and mild or moderate permanent ureteral obstruction is seen in 2-14% of patients. Most patients develop ureteral obstruction within one year following the procedure; however, delays up to 14 years have been reported. Retroperitoneal fibrosis secondary to the surgical procedure is the most common cause of ureteral obstruction and is believed to be secondary to bleeding or excessive periureteral dissection. The other choices are all causes of obstruction, but not the most common.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1223. 2010 Adult Obstructive Uropathy )

The factor that most likely predicts stent failure in patients with ureteral obstruction due to extrinsic compression is:
A) pain.
B) bilateral obstruction.
C) malignant obstruction.
D) distal ureteral obstruction.
E) the presence of a vascular graft.

C
( malignant obstruction. Extrinsic ureteral obstruction is associated with stent failure in nearly half of patients within a year. A recent study of 101 patients treated with indwelling stents revealed extrinsic obstruction due to cancer; renal insufficiency {serum creatinine > 1.3 mg/dl}; and obstruction following XRT or chemotherapy were predictors of stent failure. Patients with metastatic disease requiring systemic therapy may be best served with a percutaneous nephrostomy rather than a ureteral stent. Other alternatives, such as an extra-anatomic nephrovesical stent, can be considered as well. Chung SY, Stein RJ, Landsittel D, et al: A 15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J UROL 2004;172:592-595.Docimo SG, Dewolf WC: High failure rate of indwelling ureteral stents in patients with extrinsic obstruction: experience at 2 institutions. J UROL 1989;142:277-279. 2010 Adult Obstructive Uropathy )

A 37-year-old woman has had a prior hysterectomy now complains of pelvic pressure and intermittent left flank pain. An ultrasound demonstrates severe left hydronephrosis, however, an IVP obtained one week later reveals normal upper tracts bilaterally. This same scenario is repeated over the next several months. A CT scan reveals a 2 cm cystic mass in the left hemipelvis. The next step is:
A) excision of the left pelvic mass.
B) left ureteral reimplantation.
C) tamoxifen.
D) ureterolysis.
E) ureteral stent.

A
( excision of the left pelvic mass. This patient presents with a classic scenario of ovarian remnant syndrome. Residual ovarian tissue after oophorectomy will cyclically enlarge and result in symptomatology. This condition most commonly occurs after ovarian rupture during oophorectomy for endometriosis. Ureteral obstruction occurs in 5-10% of cases. Surgical excision of the mass should be curative while leuprolide depot can be effective in recurrent cases. Reimplantation and ureterolysis are not indicated for obstruction due to external compression by the ovarian remnant. Tamoxifen is not effective in controlling ovarian enlargement. Koch MO, Coussens D, Burnett L: The ovarian remnant syndrome and ureteral obstruction: Medical management. J UROL 1994;152, 158-160. 2009 Adult Obstructive Uropathy )

A 65-year-old man who underwent placement of an intraurethral stent for treatment of a recurrent bulbar urethral stricture has a markedly decreased urinary stream three months postoperatively. Urethroscopy demonstrates obstructive tissue protruding through the stent. The next step is:
A) balloon dilation.
B) replace stent.
C) urethroplasty.
D) suprapubic cystostomy.
E) endoscopic resection of tissue.

E
( endoscopic resection of tissue. Hyperplastic tissue can sometimes protrude through endoluminal stents postoperatively. Careful resection of this tissue is often effective, as this hyperplastic reaction usually subsides over time. Balloon dilation is unlikely to be effective in alleviating obstruction due to luminal occlusion; unlike vascular plaques, the scar tissue associated with strictures is not compressible. Stent replacement at three months will be extremely difficult; likewise urethroplasty will require excision of the stent, with a high likelihood for substitution urethral reconstruction. Suprapubic cystostomy is only a temporizing measure that is not indicated in the absence of urinary retention. Jordan GH: Urolume endoprosthesis for the treatment of recurrent bulbous urethral stricture. AUA UPDATE SERIES 1999, vol XIX, lesson 3, pp 18-23. Heisenberg ML, Elliott SP, McAninch JW: Management of restenosis after urethral stent placement. J UROL 2008;179:991-995. 2009 Adult Obstructive Uropathy )

A 55-year-old man has mild right flank pain eight weeks after an aorto-iliac vascular graft. Serum creatinine is 1.4 mg/dl, WBC 12,000/cu mm, and urine culture is sterile. Renal ultrasound shows moderate right hydronephrosis, and CT scan demonstrates the graft is posterior to the right ureter. The best treatment is:
A) percutaneous nephrostomy.
B) oral steroid therapy.
C) transureteroureterostomy.
D) nephrectomy.
E) ureterolysis.

B
( oral steroid therapy. Hydronephrosis occurs in 5% of ureters at risk following reconstructive vascular surgery. The cause of ureteral obstruction is anterior graft placement {30%} and localized retroperitoneal fibrosis {70%}. Grafts should be placed posterior to the ureter, as in this case. Early ureteral obstruction due to secondary retroperitoneal fibrosis occurring within six months of surgery can resolve with a four week course of oral steroid therapy. Percutaneous nephrostomy is not indicated with only mild flank pain and a normal serum creatinine. Transureteroureterostomy should be reserved for major loss of ureteral length and nephrectomy is not indicated. Ureterolysis would be reserved for failure of more conservative measures. Cangiano TG, deKernion JB: Urologic complications of vascular surgery. AUA UPDATE SERIES. 1998, vol 17, lesson 39, p 306. Huben RP, Schellhammer PF: Steroid therapy for ureteral obstruction after aortoiliac graft surgery. J UROL 1981;125:881-883. Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1223. 2009 Adult Obstructive Uropathy )

A 45-year-old African-American man has a one year history of progressive irritative voiding symptoms and general malaise. Urinalysis shows 15-20 WBC and 5 RBC/hpf. Urinary cytologies are negative. The serum creatinine is 4.5 mg/dl. Cystoscopy reveals an elongated urethra and inflammatory changes within the bladder. CT scan demonstrates bilateral hydronephrosis and encasement of the bladder, rectum, and both ureters by tissue that has negative Hounsfield units. The next step is:
A) high dose steroid therapy.
B) CIC.
C) ileal conduit.
D) ureterolysis.
E) bilateral nephrostomy tubes.

E
( bilateral nephrostomy tubes. This patient's clinical presentation is typical of pelvic lipomatosis and does not require tissue diagnosis. Treatment of the mass with radiotherapy or excision has not generally been successful. While there have been occasional reports of successful treatment with chronic antibacterial suppression, this in general has not been a successful approach. Steroid therapy has no role in pelvic lipomatosis. Supravesical diversion may be indicated as the ultimate treatment of choice in this man but the immediate therapy of his renal insufficiency can be accomplished by temporary nephrostomy drainage.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, pp 1218-1219. 2008 Adult Obstructive Uropathy )

A 32-year-old woman underwent a left PCNL three years ago for a staghorn calculus. Since then she has experienced intermittent left flank pain and episodes of pyelonephritis. An IVP shows a normal right kidney, marked hydronephrosis on the left with a nearly obliterated renal pelvis, and a 2 cm segment of proximal ureteral narrowing. A renogram shows a differential function of 65%25 of the right and 35%25 on the left. The best treatment for the left side is:
A) ureterocalicostomy.
B) retrograde endopyelotomy.
C) percutaneous endopyelotomy.
D) pyeloplasty.
E) nephrectomy.

A
( ureterocalicostomy. Although endopyelotomy {antegrade or retrograde} is generally a good choice for salvage of a failed pyeloplasty, incision through an obliterated or intrarenal pelvis may risk significant renal hemorrhage due to incision into renal parenchyma or hilar vessels. Furthermore, repeat open or laparoscopic pyeloplasty will likely be unsuccessful in the face of an intrarenal pelvis. In this case, ureterocalicostomy is the best choice for re-establishing adequate renal drainage.Hsu THS, Streem SB, Nakada SY: Management of upper urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 38, pp 1247-1249. 2008 Adult Obstructive Uropathy )

A 66-year-old man is scheduled for elective repair of a 7 cm abdominal aortic aneurysm. CT scan shows peri-aneurysmal fibrosis, a normal right kidney, and marked left hydronephrosis with cortical loss. Renogram demonstrates 25%25 function on the left, and a retrograde pyelogram reveals entrapment of a 6 cm segment of the mid-left ureter. The serum creatinine is 1.6 mg/dl. The next step is aneurysm repair and:
A) left ureterolysis.
B) delayed ureterolysis.
C) steroid therapy.
D) left nephrectomy.
E) balloon dilation.

D
( left nephrectomy. The management of ureteral obstruction in association with inflammatory abdominal aortic aneurysms is controversial. Peri-aneurysmal fibrosis has been reported to subside in some cases after aneurysm repair and there have been some who have recommended steroid treatment for this condition. Since the right kidney is functioning normally and there is a long ureteral stricture, left nephrectomy should be strongly considered. Ureterolysis concomitantly with aneurysm repair would likely to require an ileal ureter or autotransplantation which would be ill-advised in this setting.Hsu THS, Streem SB, Nakada SY: Management of upper urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 38, pp 1270-1273. Hafez KS, Wolf JS Jr: Update on minimally invasive management of ureteral strictures. J ENDOUROL 2003;17:453-464. 2008 Adult Obstructive Uropathy )

A 72-year-old woman undergoes an abdominal hysterectomy for uterine fibroids. In the recovery room, she is anuric for four hours despite several boluses of intravenous fluids. Her indwelling catheter is patent. Her blood pressure is 100/50 mmHg, pulse is 100. Estimated blood loss during the procedure was 1000 ml. The best explanation for her condition is:
A) acute tubular necrosis.
B) bilateral ureteral obstruction.
C) prerenal azotemia.
D) hypovolemic shock.
E) vesicovaginal fistula.

B
( bilateral ureteral obstruction. Anuria always implies complete ureteral obstruction until proven otherwise. The two most likely areas where the ureter can be occluded during hysterectomy are at the level of the broad ligaments and at the vaginal cuff and bladder trigone. Consequently, the most likely finding in this patient would be a ureteral obstruction at the level of the vaginal cuff. While hypovolemic shock and low urine outputs are commonly seen after all types of abdominal operations, the anuria in this case suggests an obstructive etiology. Acute tubular necrosis does not normally occur in a precipitous fashion as in this case. A vesicovaginal fistula should be obvious clinically. McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, pp 1288-1289. 2008 Adult Obstructive Uropathy )

In chronic ureteral obstruction, the glomerular filtrate exits the renal pelvis primarily by:
A) pyelosinus backflow.
B) pyelolymphatic backflow.
C) extravasation from the renal pelvis.
D) reabsorption from renal pelvis.
E) pyelovenous backflow.

E
( pyelovenous backflow. Following acute ureteral obstruction, the renal pelvic pressure is initially elevated but gradually returns to normal. Glomerular filtrate exits the renal pelvis by extravasation into the perirenal spaces, pyelolymphatic backflow and pyelovenous backflow. It is believed that 80-90 percent of the filtrate in chronic hydronephrosis is reabsorbed in the tubules and exits via the renal veins. Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1200. 2011 General Obstructive Uropathy )

A newborn boy with a history of left prenatal hydroureteronephrosis develops gram negative urosepsis despite prophylactic amoxicillin. VCUG is normal. Renal ultrasound and MAG-3 renal scan are shown. The differential renal function is 74/26(right/left). The next step is:
A) observation.
B) change prophylaxis to trimethoprim-sulfamethoxazole.
C) cutaneous pyelostomy.
D) distal cutaneous ureterostomy.
E) tapered ureteral reimplantation.

D
( distal cutaneous ureterostomy. Gram negative sepsis in a child less than three months of age has a mortality approaching 15-20%. In an infant less than three months of age with a gram negative UTI, there is a 30% chance of a recurrent UTI over the next six months. In this infant with an obstructing primary megaureter and ipsilateral decreased renal function, surgical intervention is indicated. A tapered ureteral reimplantation would be technically very difficult at this age and should be deferred until older than one year of age. The preferred treatment is a low end cutaneous ureterostomy. Altering prophylaxis to sulfamethoxazole trimethoprim should not be done in an infant due to the risk of kernicterus and hematopoietic dysfunction. Cordero L, Rau R, Taylor D, Ayers LW: Enteric gram-negative bacilli bloodstream infections: 17 years' experience in a neonatal intensive care unit. AM J INF CONTROL 2004;32:189-195.Biyikli NK, Alpay H, Ozek E, et al: Neonatal urinary tract infections: Analysis of the patients and recurrences. PED INTERN 2004;46:21-25. 2011 Pediatric Obstructive Uropathy )

A six-year-old boy has a history of a PUV treated with endoscopic resection. He now has worsening bilateral hydronephrosis and his serum creatinine has increased from 0.6 to 1.0 mg/dl over the past nine months. He is dry and has no voiding complaints. Videourodynamics reveal no reflux, near complete emptying without outflow obstruction and filling pressures of 20 cm H<sub>2</sub>O at 220 ml and 32 cm H<sub>2</sub>O at 280 ml. The initial plan should be:
A) voiding diary.
B) start oxybutynin.
C) start alpha-blocker.
D) nocturnal indwelling catheter.
E) initiate CIC every four hours.

A
( voiding diary. Children with correction of severe obstructive uropathy will sometimes demonstrate a persistent decrease in renal concentrating ability. This tends to worsen with growth and may lead to very high obligate urine output. This output can, at times, be so high that children cannot void frequently enough to maintain safe intravesical pressures; hydronephrosis and rising creatinine will ensue. This boy appears to void without obstruction. He does have reduced bladder compliance {as many valve patients do}, but his pressures only reach 32 cm H2O by 280 ml - which should be an average six-year-old bladder capacity. However, if his urine output is very high, then he will reach this capacity very quickly after voiding. While he may eventually need timed voiding, antimuscarinic medication, CIC, or use of a nocturnal indwelling catheter, none of them can be used in a logical way without first knowing more about the patient's daily urine output volume. An alpha-blocker is not indicated in this patient.Casale AJ: Posterior urethral valves and other urethral anomalies, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 122, pp 3586-3587. 2011 Pediatric Obstructive Uropathy )

An eight-year-old girl has urinary urgency, urge incontinence, and constant leakage of urine between voids. She is started on timed voiding and has improvement with the urge incontinence but still has constant urinary leakage. An ultrasound does not show any evidence of hydronephrosis or bladder wall thickening. The next study that will most definitively diagnose her problem is:
A) MRI scan of the abdomen.
B) MRI scan of the spine.
C) VCUG.
D) videourodynamics.
E) MAG-3 renal scan.

A
( MRI scan of the abdomen. The clinical history strongly suggests that this girl has an ectopic ureter even though the ultrasound does not show evidence of this. The absence of an abnormality on ultrasound does not rule out an ectopic ureter. Occasionally, the renal parenchyma from the upper pole of the kidney that is associated with the ectopic ureter is difficult to locate and may be identified only by alternative imaging studies. In cases in which an ectopic ureter is strongly suspected because of incontinence yet no definite evidence of the upper pole renal segment is found, magnetic resonance imaging {MRI or CT scanning} will likely demonstrate the small, poorly functioning upper pole segment and ureter. None of the other options will adequately visualize the ectopic ureter. Schlussel RN, Retik AB: Ectopic ureter, ureterocele, and other anomalies of the ureter, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 116, pp 3383, 3393. 2011 Pediatric Obstructive Uropathy )

A three-month-old boy underwent left dismembered pyeloplasty. An ultrasound nine months postoperatively demonstrates worsening hydronephrosis and severe cortical thinning. A renal scan demonstrates the left kidney to contribute 22%25 of total renal function, and T1/2 > 40 minutes. Retrograde pyelography demonstrates a 2 cm stricture at the anastomosis and an intrarenal pelvis. The next step is:
A) retrograde endopyelotomy.
B) antegrade endopyelotomy.
C) repeat dismembered pyeloplasty.
D) ureterocalicostomy.
E) nephrectomy.

D
( ureterocalicostomy. The infant has a failed pyeloplasty. In redo repairs, one must assess the anatomy carefully to determine whether a redo dismembered technique can be performed. When a long segment of stricture is present with an intrarenal pelvis, a repeat dismembered repair may not be technically feasible and/or will be at high risk for failure. Ureterocalicostomy is the most appropriate choice since it bypasses the need for an anastomosis to the pelvis. With this technique, it is important to remove as much parenchyma around the lower pole calyx as possible to allow a widely patent tension free anastomosis. If a large and redundant extrarenal pelvis were present, one could consider a spiral flap repair. Endoscopic manipulations in a one year old male infant with a long stricture is not efficacious. With 22% function nephrectomy is not appropriate. Carr MC, El-Ghoneimi A: Anomalies and surgery of the ureteropelvic junction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 115, p 3381.Ellsworth PI, Walker RD, Elder JS: Management of the failed pyeloplasty. AUA UPDATE SERIES 1997, volume 16, lesson 17, pp 130-135. 2011 Pediatric Obstructive Uropathy )

An eight-year-old boy has persistent urinary incontinence following newborn resection of a PUV. This is most likely due to:
A) detrusor instability.
B) vesicoureteral reflux.
C) non-compliant bladder.
D) incompetent bladder neck.
E) damaged external urethral sphincter.

A
( detrusor instability. Urinary incontinence following surgery for a PUV is common. Although in some instances this is secondary to the primary surgery in the urethra or bladder neck, the most common finding is bladder dysfunction. Three patterns of bladder dysfunction have been identified in boys with valves: myogenic failure, detrusor overactivity, and decreased compliance with a small bladder. In prepubertal boys with persistent incontinence, bladder instability from overactivity is the dominant pattern.Casale AJ: Posterior urethral valves and other urethral anomalies, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 122, p 3597. 2011 Pediatric Obstructive Uropathy )

A nine-year-old boy has urinary frequency and diurnal urinary incontinence without a history of urinary infection. Renal ultrasound is normal. An ultrasound of the bladder is shown. The next step is:
A) observation.
B) behavioral modification.
C) VCUG.
D) oxybutynin.
E) cystoscopy.

C
( VCUG. Persistent voiding dysfunction with urgency, frequency, and diurnal urinary incontinence in this age group warrants screening with ultrasound. This image shows a diffusely thickened bladder with the bladder wall measuring > 5 mm {the upper limits of normal}. This is a warning sign for outlet obstruction due to either an anatomic abnormality, neurogenic or non-neurogenic cause. This finding cannot be ignored. Cystoscopy can provide evidence for anatomic obstruction but would not be the recommended next step. The child should undergo a VCUG to rule-out the presence of valves. Observation, behavioral modification, and oxybutynin could be considered first in patients with minimal to mild bladder wall thickening since some degree of bladder wall hypertrophy can result from dysfunctional elimination. However, the degree of bladder wall thickening in this patient is greater than one would expect from dysfunctional elimination alone. Williams CR, Perez LM, Joseph DB: Accuracy of renal-bladder ultrasonography as a screening method to suggest posterior urethral valves. J UROL 2001;165:2245-2247. 2010 Pediatric Obstructive Uropathy )

A four-year-old girl undergoes a left cross trigonal ureteroneocystostomy with ureteral tapering for grade 5 VUR. The preoperative VCUG and a left renal ultrasound six weeks following surgery are shown. The next steps are to continue prophylactic antibiotics and:
A) repeat ultrasound in four weeks.
B) MAG-3 renal scan.
C) percutaneous nephrostomy.
D) ureteral stent placement.
E) revise ureteroneocystostomy.

A
( repeat ultrasound in four weeks. There is considerable postoperative edema at the level of the bladder four to six weeks following a tapered ureteroneocystostomy. In addition, high grade VUR results in diminished compliance of the ureter and renal pelvis. Prior to surgery, it is common to see a normal upper tract on renal ultrasound or only minimal hydroureteronephrosis. After surgery the combination of the resistance from the ureteral tunnel and operative edema can unmask the poor compliance of the ureter and kidney resulting in the appearance of significant hydroureteronephrosis. This should not be interpreted as obstruction. When evaluating the immediate post operative ultrasound it is necessary to put it into perspective with the initial degree of ureteral and renal dilation noted on the VCUG and not directly compare it to the preoperative renal ultrasound. In general, there is no major concern for obstruction if the degree of hydronephrosis on the post operative ultrasound correlates with the degree of dilation of the collecting system seen on the preoperative VCUG. Increased dilation due to edema and a poorly compliant system will begin to improve after six weeks. If this dilation persists after several months, a MAG 3 renal scan should be performed to aid in determining if post operative obstruction exists. All of the other options would be too premature at this point in time. Khoury A, Bagli DJ: Reflux and megaureter, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 117, pp 3460-3461. 2010 Pediatric Obstructive Uropathy )

A five-year-old boy has an ectopic ureter associated with a nonfunctional, hydronephrotic, upper pole segment of a duplex system. He undergoes an upper pole partial nephrectomy. The key step in the surgical dissection is:
A) mobilization of the lower pole of the kidney.
B) mobilization of the adrenal gland.
C) reduction of the size of the renal pelvis.
D) complete removal of the distal ureter.
E) dissection of the ureter from the renal hilum.

E
( dissection of the ureter from the renal hilum. The critical step in patients undergoing upper pole, partial nephrectomy, to remove a non functional segment, is dissecting the abnormal ureter from the renal hilum so as not to cause vascular injury to the normal lower pole. The adrenal gland should be left in situ and not disturbed. The distal ureter especially in a male is rarely an issue if not completely removed. The lower pole of the kidney can be mobilized for exposure but is not typically necessary. Reduction of the renal pelvis is not an issue.Schlussel RN, Retik AB: Ectopic ureter, ureterocele, and other anomalies of the ureter, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 116, p 3394. 2010 Pediatric Obstructive Uropathy )

A five-day-old boy has vomiting and dehydration. His serum CO<sub>2</sub> is 12 mEq/l, K<sup>%2B</sup> 5.5 mEq/l, and creatinine 2.2 mg/dl. A VCUG demonstrates posterior urethral valves and bilateral Grade 4 vesicoureteral reflux. The next step is:
A) percutaneous cystostomy.
B) percutaneous nephrostomies.
C) valve ablation.
D) urethral catheter drainage.
E) cutaneous vesicostomy.

D
( urethral catheter drainage. The management of the infant with a PUV depends on the severity of the obstruction and the degree of any renal dysplasia present. The main problems arise in management of the infant with severe obstruction and compromised renal function with dehydration, acidosis, and sepsis. Initially, a small infant feeding tube, placed transurethrally, can provide bladder drainage. Once stabilized, valve ablation can be undertaken. Vesicostomy is reserved for infants who cannot undergo primary valve ablation because of the inadequate size of their urethra or for very small, unstable infants. If initial bladder level drainage does not result in satisfactory clinical improvement, temporary supravesical diversion may be considered, however the vast majority of these patients will be found to have renal dysplasia, not urethral vesical obstruction as the etiology the penile of the persistently elevated creatinine. Casale AJ: Posterior urethral valves and other urethral anomalies, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 122, pp 3591-3594. 2010 Pediatric Obstructive Uropathy )

An 18-year-old girl has primary amenorrhea and recurrent UTIs. Her pelvic ultrasound shows a large cystic lesion. CT imaging is shown in exhibit 1. The most frequent associated condition is:
A) renal agenesis.
B) primary megaureter.
C) ectopic ureter.
D) multicystic dysplastic kidney.
E) UPJ obstruction.

A
( renal agenesis. This patient has a hematocolpos due to vaginal obstruction, the Mayer-Rokatanski-Kuster-Hauser syndrome which occurs in 1:4000 female births. This syndrome is composed of vaginal agenesis or absence with a rudimentary uterus, normal ovaries, and normal external genitalia. Absence or agenesis of the vagina is a developmental error of the ureterovaginal canal or the vaginal plate with failure of mullerian duct fusion. Renal anomalies are common with over one third of patients noted to have renal agenesis, ectopia or fusion abnormalities. Skeletal anomalies have been reported in 12% of girls and usually involve the spine, limbs or ribs. Diagnosis of this condition is made most often at the time of puberty in association with amenorrhea. Occasionally, it is noted in the neonatal period when evaluating a pelvic mass.Hensle TW: Genital anomalies, in Gillenwater JY, Grayhack JT, Howards SS, Mitchell ME {eds}: ADULT AND PEDIATRIC UROLOGY, ed 4. Philadelphia, Lippincott, Williams and Wilkins, 2002, chap 52A, pp 2487-2500. 2009 Pediatric Obstructive Uropathy )

A nine-year-old girl has sepsis and vomiting two years after bilateral ureteroneocystostomy for VUR. The BUN is 80 mg/dl, serum creatinine 2.9 mg/dl, CO<sub>2</sub> 12 mEq/l, and K 6.5 mEq/l. Her renal ultrasound shows severe bilateral hydroureteronephrosis. VCUG is normal. The next step is:
A) cystoscopy and ureteral catheterization.
B) diuretic renal scan.
C) bilateral percutaneous nephrostomies.
D) cutaneous vesicostomy.
E) bilateral loop cutaneous ureterostomies.

C
( bilateral percutaneous nephrostomies. This girl is likely to have post-operative ureteral stenosis with azotemia. Decompression will be necessary to medically stabilize her before reconstruction. This is most reliably accomplished by percutaneous nephrostomies which will not interfere with ultimate surgical revision of the ureterovesical anastomosis. Cystoscopy and ureteral catheterization is an option but can be technically challenging in the setting of post reimplant obstruction, especially when the previous reimplantation was performed in a cross-trigonal fashion. A diuretic renal scan may further confirm the diagnosis of obstruction but will not change the need for immediate relief of the obstruction in this septic patient. In addition, the renal scan may be less accurate in the setting of azotemia. Cutaneous vesicostomy will not address the ureteral obstruction and loop ureterostomies will complicate future surgery to correct the ureteral obstruction.Brock III J, Dimarco R: Surgery for vesicoureteral reflux, in Docimo SG, Canning DA, Koury AE {eds}: CLINICAL PEDIATRIC UROLOGY, ed 5. London, Informa Healthcare, 2007, p 683. 2009 Pediatric Obstructive Uropathy )

A one-year-old girl is evaluated for pyelonephritis. A VCUG is shown in exhibit 1, an ultrasound of the left kidney in exhibit 2, and a furosemide renogram in exhibit 3. The next step is:
A) antibiotic prophylaxis.
B) upper pole nephrectomy.
C) ureteroureterostomy.
D) subureteric injection of implant.
E) cutaneous ureterostomy.

C
( ureteroureterostomy. This patient has an ectopic ureter to the bladder neck. Substantial left upper pole parenchyma is seen on ultrasound, and upper pole function is documented on renal scan. Chemoprophylaxis is not a good long-term solution. It may prevent infection in the short-term but will not address the congenital abnormal ureteral insertion. Upper pole nephrectomy is not indicated since function in the upper pole is acceptable. The least morbid solution is a low uretero-ureterostomy that does not require manipulation of the bladder either intravesically or extravesically. Schlussel RN, Retik AB: Ectopic ureter, ureterocele, and other anomalies of the ureter, in Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ {eds}: CAMPBELL'S UROLOGY, ed 8. Philadelphia, WB Saunders Co, 2002, vol 3, chap 58, p 2007. 2009 Pediatric Obstructive Uropathy )

A nine-month-old girl is brought to the operating room for repair of a right UPJ obstruction. Renal ultrasound shows moderately severe hydronephrosis with a large extrarenal pelvis and no thinning of the parenchyma. During the UPJ repair, the ureter is found to be narrow for 2.5 cm immediately below the UPJ. A tension-free dismembered pyeloplasty is not possible after renal mobilization. The next step is:
A) cutaneous pyelostomy.
B) spiral flap pyeloplasty.
C) ureterocalycostomy.
D) appendix interposition.
E) Monti ileal ureter interposition.

B
( spiral flap pyeloplasty. When a long segment of strictured proximal ureter is encountered at the time of a planned repair for UPJ obstruction, a tension free anastomosis may not be possible with a standard dismembered pyeloplasty. When adequate renal pelvic tissue is present, the next best option is a spiral flap procedure, especially when the UPJ is already in a dependent position. The other options are viable alternatives but should only be considered when renal pelvis tissue is not available for use since they are more technically challenging and/or have a higher associated complication rate.Carr MC, El-Ghoneimi A: Anomalies and surgery of the ureteropelvic junction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 115, p 3370. 2009 Pediatric Obstructive Uropathy )

A twelve-year-old girl has had intermittent abdominal pain for the last six months. She has not menstruated. Pelvic MRI scan is shown in the exhibit. The diagnosis is:
A) vaginal agenesis.
B) imperforate hymen.
C) androgen insensitivity syndrome.
D) ovarian tumor.
E) anterior myelomeningocele.

A
( vaginal agenesis. The MRI scan shows a dilated uterus with no evidence of the vaginal canal consistent with vaginal agenesis. In patients with an imperforate hymen the vaginal canal would be dilated. Androgen insensitivity syndrome would show an absent uterus. The MRI scan does not show an ovarian mass or cyst. Anterior myelomeningocele would not effect menstruation and the spine is normal on this patient's MRI scan. Reconstruction can be complex in complete vaginal agenesis especially when the cervix is also absent.Rink R, Kaefer M: Surgical management of intersexuality, cloacal malformation, and other abnormalities of the genitalia in girls, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 129, pp 3832-3835. 2008 Pediatric Obstructive Uropathy )

A 32-week-male fetus has bilateral hydroureteronephrosis and a thick-walled bladder on ultrasound. The most important information needed to determine further prenatal care is:
A) renal parenchymal echogenicity.
B) presence and timing of onset of oligohydramnios.
C) degree of bladder dilation and thickening.
D) urine electrolytes and beta-2 microglobulin levels.
E) presence of a perinephric urinoma.

B
( presence and timing of onset of oligohydramnios. The most likely diagnosis in this fetus is posterior urethral valves based upon male sex, bilateral hydronephrosis, and a thick walled bladder. The clinical outcome of a child with severe posterior urethral valves is most specifically predicted by the presence or absence of oligohydramnios and when the onset of oligohydramnios was noted to occur. Increased renal echogenicity alone is not predictive, although in the setting of oligohydramnios, it is a poor prognostic indicator. Bladder dilation is not a good prognostic indicator. Urinary electrolytes have been shown to be useful as an indicator of renal salvageability only in the setting of oligohydramnios and in early gestation {18 to 24 weeks}. A perinephric urinoma does not predict a poor outcome.Peters CA: Perinatal urology, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 109, p 3186. 2008 Pediatric Obstructive Uropathy )

A one-month-old girl has massive right hydronephrosis secondary to UPJ obstruction. The left kidney appears normal. Isotope renography shows relative renal function of 85%25 on the left and 15%25 on the right. The next step is:
A) right nephrectomy.
B) right percutaneous nephrostomy.
C) repeat renography in three months.
D) right pyeloplasty.
E) right cutaneous pyelostomy.

D
( right pyeloplasty. The immediate repair of a UPJ obstruction is advised in this child because the function in the right kidney is significantly decreased. Neither delay nor removal of this kidney is appropriate since the functional capacity may improve after relief of obstruction, particularly in this age group. Temporary nonintubated cutaneous diversion may provide an acceptable alternative in the very ill or septic infant {not the case here}. Prolonged nephrostomy drainage is not recommended in young infants. Carr MC, El-Ghoneimi A: Anomalies and surgery of the ureteropelvic junction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 115, pp 3365-3369. 2008 Pediatric Obstructive Uropathy )

Fetal UPJ obstruction is most difficult to distinguish from:
A) multicystic dysplastic kidney.
B) polycystic kidney.
C) ectopic ureterocele.
D) posterior urethral valves.
E) refluxing megaureter.

A
( multicystic dysplastic kidney. The most frequent error in the diagnosis of fetal uropathy is in distinguishing UPJ obstruction from multicystic dysplastic kidney {MCDK}. Since UPJ obstruction and MCDK are a spectrum, all patients with suspected MCDK need to have a confirmatory renal scan to document absence of function. The most sensitive scan is DMSA however a MAG-3 Lasix renogram will also confirm lack of function. Autosomal polycystic kidney disease is characterized by large kidneys greater than two standard deviations above the mean. Ectopic ureterocele is characterized by an upper pole dilated ureter and ureterocele in the bladder. Posterior urethral valves are characterized by a distended bladder and keyhole sign. Finally, on ultrasound a refluxing megaureter has a dilated ureter that is not present in UPJ obstruction.Peters CA: Perinatal urology, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 109, pp 3191-3194. 2008 Pediatric Obstructive Uropathy )

A 48-year-old woman has abnormal retention of isotope in the left renal collecting system on a bone scan that was performed during staging for breast cancer. The next step to evaluate the left kidney is:
A) serial creatinine measurements.
B) diuretic renogram.
C) cystoscopy and retrograde pyelogram.
D) antegrade pyelogram.
E) renal ultrasound.

B
( diuretic renogram. Radionuclide bone scans may reveal delayed concentration of tracer in the kidney due to a generous collecting system or due to true obstruction. This finding should be confirmed by a functional study such as an contrast CT scan or nuclear renogram, which should help determine whether or not this represents a functionally significant obstruction. More invasive procedures such as cystoscopy and retrograde pyelogram, or an antegrade pyelogram are not indicated at this point. Serial creatinine measurements will help follow overall renal function but will not determine functional obstruction. Renal ultrasound is an anatomic study and may show hydronephrosis but will not determine if it is functional.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1210. 2012 Adult Obstructive Uropathy, Laparoscopy/Robotics )

The most accurate method to determine the length of a graft needed for repair of an anterior urethral stricture is:
A) urethroscopy.
B) ultrasound.
C) VCUG.
D) retrograde urethrogram.
E) CT imaging.

B
( ultrasound. Prior to harvesting a Buccal graft or other graft for repair of an anterior urethral stricture, ultrasound can easily identify the area of stricture as well as the area of scarred urethra which must be resected to adequately restore urethral continuity using an onlay graft. Sonourethrography has been shown to be a useful adjunct to standard radiographic imaging of bulbar urethral strictures. Although it can aid in the visualization of the corpus spongiosum including vascular structures, calcifications, and periurethral fibrosis, incorporation of this information into surgical decision making algorithms has not followed. The primary benefit of ultrasound imaging is the lack of distortion created by the oblique position during retrograde urethrogram {RUG}. Thus the sonogram will more accurately measure the length of the stricture. In bulbar urethral strictures of intermediate length, RUG will underestimate the true length of the stricture by up to 13 mm. VCUG can delineate the urethra proximal to the stricture unless the patient is unable to void, in which case sonography may allow visualization of the posterior urethra by vigorous suprapubic pressure under anesthesia. Urethroscopy will not demonstrate underlying spongiofibrosis, while VCUG and retrograde urethrography are subject to distortion and measurement error. CT urethrograms have only been used to identify acute injuries of the urethra. Choudhary S, Singh P, Sundar E, et al: A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures. CLIN RAD 2004;59:736-742. Gallentine ML, Morey AF: Imaging of the male urethra for stricture disease. UROL CLIN N AM 2002;29:361-372. 2012 Adult Obstructive Uropathy, Laparoscopy/Robotics )

A 65-year-old man has lethargy, malaise, and a markedly diminished urinary stream. After urethral catheterization, he experiences a postobstructive diuresis that is managed by appropriate fluid replacement. Urine output is 1,500 ml daily. Serum creatinine and BUN are 6.8 mg/dl and 95 mg/dl respectively, and unchanged three days later. The next step is:
A) continued observation.
B) retrograde pyelography.
C) dialysis.
D) renal ultrasound.
E) increased fluid replacement.

D
( renal ultrasound. In patients with urinary obstruction and impaired renal function, postobstructive diuresis is not unusual. Typically, urinary catheter drainage produces improvement in the blood levels of creatinine, BUN, and electrolytes to normal levels. If significant improvement does not occur, consideration must be given to inadequate drainage of the upper urinary tract because the bladder is poorly drained {poorly functioning catheter} or because of supravesical obstruction. The latter should be evaluated using renal ultrasound which is less invasive than retrograde pyelography. Since creatinine and BUN have not improved, continued observation is inappropriate until upper tract obstruction is ruled out. No data to suggest the need for immediate dialysis in this patient is provided. There is no evidence the patient is dehydrated, therefore increased fluid replacement is not indicated.Pais VM Jr, Strandhoy JW, Assimos DG: Pathophysiology of urinary tract obstruction, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 37, p 1214. 2012 Adult Obstructive Uropathy, Laparoscopy/Robotics )

Ureteral peristalsis originates from:
A) preganglionic sympathetic input from T8 through L1.
B) postganglionic fibers arising from the celiac and aorticorenal plexuses.
C) parasympathetic input from the S2 through S4 spinal segments.
D) parasympathetic input from the vagus nerve.
E) intrinsic smooth muscle pacemaker sites in the minor calyces.

E
( intrinsic smooth muscle pacemaker sites in the minor calyces. Ureteral peristalsis does not require autonomic input. It originates and is propagated from the intrinsic smooth muscle pacemaker sites in the minor calyces of the collecting system. The kidneys do receive preganglionic sympathetic input from T8 to L1 and postganglionic fibers from the celiac and aorticorenal ganglia, as well as parasympathetic input from the vagus nerves, however the role of ureteral autonomic input is unclear. This explains why denervated or transplanted kidneys maintain ureteral peristalsis.Cybulski PA, Joo H, D'A, Honey J: Ureteroscopy: Anesthetic considerations. UROL CLIN N AM 2004;31:43-47. 2012 General Obstructive Uropathy, Laparoscopy/Robotics )

A 12-year-old boy undergoes a dismembered pyeloplasty with nephrostomy drainage for symptomatic UPJ obstruction. A nephrostogram performed two weeks later shows no drainage across the UPJ. The next step is:
A) repeat nephrostogram in two weeks.
B) MR urography.
C) antegrade renal perfusion study(Whitaker test).
D) convert the nephrostomy to a nephroureteral stent.
E) retrograde pyelography and ureteral stent placement.

A
( repeat nephrostogram in two weeks. After a successful dismembered pyeloplasty, it is not uncommon for a delayed opening of the anastomosis when using nephrostomy drainage. As long as the patient is doing well clinically, the best management during the early post-operative period is patience and repeat assessment to allow the anastomotic edema to subside further. Repeat nephrostogram in two weeks is the appropriate next step. Some have advocated a simple clamping trial of the nephrostomy tube and check the residual amount afterward. MR urography and a Whitaker study are unwarranted during the early post-operative period, as are the retrograde pyelography/stent placement and conversion of the nephrostomy tube to a nephroureteral stent. Stent placement could also damage the anastomosis. Carr MC, El-Ghoneimi A: Anomalies and surgery of the ureteropelvic junction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 115, p 3380. 2012 Pediatric Obstructive Uropathy, Laparoscopy/Robotics )

A four-year-old uncircumcised boy has a two-week history of foreskin swelling with urination. The retained urine under the foreskin drains slowly following completion of voiding. There is no dysuria or hematuria. Physical exam reveals mild erythema of the distal foreskin and a phimotic ring. The meatus cannot be visualized. The next step is:
A) observation.
B) sitz baths.
C) topical steroid ointment.
D) dorsal slit.
E) circumcision.

C
( topical steroid ointment. The patient has pathologic phimosis that does not allow adequate urinary drainage. Observation is only appropriate in the setting of physiologic phimosis in which the foreskin is not retractable due to normal physiologic adhesions, as opposed to pathologic phimosis, which is development of a dense fibrotic ring from chronic inflammation. Treatment of pathologic phimosis with a topical steroid ointment {0.05% betamethasone} is effective in up to 90% of cases in relieving the phimosis and allowing adequate retraction of the foreskin. If the patient had more acute problems such as severe balanitis or more obstructive voiding symptoms then surgical intervention with a dorsal slit or circumcision may be appropriate. Sitz baths alone are unlikely to rectify the problem. Orsola A, Caffaratti J, Garat JM: Conservative treatment of phimosis in children using a topical steroid. UROL 2000;56:307-310. Shortliffe LMD: Infection and inflammation of the pediatric genitourinary tract, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 112, p 3238. 2012 Pediatric Obstructive Uropathy, Laparoscopy/Robotics )

A 38-week-gestation newborn with a PUV has a serum creatinine of 1.1 mg/dl on day two of life. This child's serum creatinine value:
A) will not change with a rapid rise in GFR.
B) is a predictor of future poor renal function.
C) will decrease with completion of nephrogenesis.
D) is not reflective of the degree of renal function impairment.
E) will result in increased active sodium absorption from the descending limb of the loop of Henle.

D
( is not reflective of the degree of renal function impairment. The creatinine in a newborn is reflective of maternal renal function and is not necessarily representative of the degree of renal impairment. In usual circumstances, serum creatinine will reflect the child's renal function by day 7-10. Long term renal function in children with PUV is best predicted by the nadir creatinine at one year of age. If the nadir creatinine is less than 0.8 mg/dl at one year of life, this is a good prognostic sign for retained renal function that will be able to be maintained into adulthood. By 34 weeks gestational age, nephrogenesis is complete and will not affect the level of the creatinine. Sodium reabsorption issues cannot be predicted until the degree of true renal functional impairment is better defined. Chevalier RL, Roth JA: Renal function in the fetus, neonate and child, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 107, p 3153.Casale AJ: Posterior urethral valves and other urethral anomalies, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 122, p 3599.Haycock G: Perinatal nephrourology, in Gearhart JP, Rink RC, Mouriquand PDE {eds}: PEDIATRIC UROLOGY. Philadelphia, WB Saunders Co, 2001, chap 2, pp 14-26. 2012 Pediatric Obstructive Uropathy, Laparoscopy/Robotics )

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