January - March 2015 Volume 20 Issue 1

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51Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2015 / Vol 20 / Issue 1

Spontaneous resolution of antenatally diagnosed ureterocele

Sir,Ultrasound scan report in first week of life, in a full-term female neonate with antenatally diagnosed ureterocele (ADU), revealed left duplex kidney with upper moiety hydronephrosis, ureterocele of 5mm diameter in left bladder base and normal right kidney. The ureterocele wall was thick in ultrasound [Figure 1]. Voiding cystourethrogram (VCUG) showed no vesicoureteric reflux. Dimercaptosuccinic acid (DMSA) scan showed 45% left kidney function and nearly 20% function in upper moiety. The baby was managed conservatively.

Ultrasound three to six monthly showed stable hydronephrosis in early infancy and its reduction subsequently. Diuretic renogram (DR) showed good drainage and function in all renal moieties.

By three years, the left upper pole hydronephrosis disappeared with reduction in ureterocele size. By six years, both hydronephrosis and ureterocele were not seen. Cystoscopy (at various bladder volumes) did not show any ureterocele. Crescentic left upper pole ureteric orifice was seen supero-lateral to bladder neck with periodic urine efflux.

Periodic ultrasound scans till age of ten showed no hydronephrosis and ureterocele. VCUG was not repeated as the girl neared puberty.

Letters to the Editor

Only 39 patients with successful non-operative ureterocele management have been documented.[1-3] Poor function of involved renal moiety and associated multicystic kidney favor spontaneous ureterocele resolution (SUR). Progressive atrophy of renal moiety explains the SUR.[1-3]

Smooth muscle distribution in ureterocele wall varies.[4]

In our patient, the thick ureterocele rim on ultrasound suggests good muscle distribution. SUR with good function of renal moieties is known.[2,3] This may be explained by normal urine flow causing dilatation of ureterocele orifice. The dilatation is possibly facilitated by adequate muscle in ureterocele wall.

Investigation and management of ureterocele are tailored to the requirement of the individual patient.[1-3,5] Early DR helps to exclude obstruction in the renal moieties,[1,5] but requires consistently precise definition of regions of interest which is difficult in infants with duplex system.[5] Initial ultrasound and DMSA have been used for anatomical/functional assessment, respectively with serial ultrasound to monitor preservation of renal parenchyma.[2,3,5] In our patient, progressive hydronephrosis reduction with good function in all renal moieties shown by DMSA and subsequent DR ruled out obstruction.

In ADU managed conservatively, serial monitoring for at least 5 years after SUR is safe.[2,3,5]

Conjeevaram R Thambidorai, Tammy HQ Teoh, Zulfiqar M Annuar1

Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, 1Department of Radiology,

University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Figure 1: (Left half) Coronal ultrasound scan shows the dilated upper moiety (black arrows) and lower moiety (white arrows) of the left kidney. The right half marked-A shows the small intravesical ureterocele with a well-defi ned wall (white arrow)

Letters to the Editor

52 Journal of Indian Association of Pediatric Surgeons / Jan-Mar 2015 / Vol 20 / Issue 1

Address for correspondence: Conjeevaram R Thambidorai, Department of Surgery, Faculty of Medicine, University Malaya

Medical Centre, Kuala Lumpur, Malaysia.E-mail: thambidorai@gmail.com

REFERENCES

1. Han MY, Gibbons MD, Belman AB, Pohl HG, Majd M, Rushton HG. Indications for non-operative management of ureteroceles. J Urol 2005;174:1652-6.

2. Direnna T, Leonard MP. Watchful waiting for prenatally detected ureteroceles. J Urol 2006;175:1493-5.

3. Pohl HG. Recent advances in the management of ureteroceles in infants and children: Why less may be more. Curr Opin Urol 2011;21:322-7.

4. Stephens FD. Ureteroceles on duplex ureters. In, Stephens FD, Smith ED, Hutson JM, editors. Congenital anomalies of urinary and genital tract. 1st ed. Oxford: Isis Medical Media; 1996. p. 243-62.

5. Schlussel RN, Retik AB. Ectopic ureter, ureterocele and other anomalies of the ureter. In: Wein AJ, Kovoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 9th ed. Philadelphia: WB Saunders; 2007. p. 3383-422.

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DOIDOI: 10.4103/0971-9261.145558

Bile in various hepatobiliary disease states

Sir,We would like to discuss the report on “bile in various hepatobiliary disease states.”[1] Verma et al. concluded that the components of bile show a close correlation with various clinical and prognostic markers. There

is a very close correlation between these parameters and the clinical severity, disease progression and final outcome.[1] In fact, bile analysis is an old laboratory test in body fluid examination. Based on the report by Verma et al., the analysis might seem useful in clinical diagnosis. However, there are some concerns to be addressed. First, the bile component can be affected by several physiological and pathological conditions. For example, dehydration in children might concentrate the bile.[2] In addition, some underlying genetic diseases such as hemoglobinopathies might alter the component of the bile.[3] These factors have to be considered in bile analysis; however, it is not well assessed and mentioned in the report by Verma et al.[1]

Sim Sai Tin, Viroj Wiwanitkit1

Medical Science Unit, 1Visiting Professor in Tropical Medicine Unit, Hainan Medical University, China

Address for correspondence: Prof. Sim Sai Tin, Medical Center, Shantou, China.

E-mail: simsaitin@gmail.com

REFERENCES

1. Verma A, Bhatnagar V, Prakash S, Srivastava AK. Analysis of bile in various hepatobiliary disease states: A pilot study. J Indian Assoc Pediatr Surg 2014;19:151-5.

2. Devor AW, Marlow HW. Dehydration of cholic acid. J Am Chem Soc 1946;68:2101.

3. Barbi G, Annoni G. Thalassemia trait and the lithogenicity of bile. Minerva Med 1977;68:2997-3000.

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DOIDOI: 10.4103/0971-9261.145562

Reply

Sir, The issues raised in this letter are genuine. However, we have made it clear right from the title onwards that this is a pilot study. The purpose of this study was to highlight that bile composition can be different in various disease states and also within specific cohorts. We would be striving to work further on this subject but would be happy if more scientists take this work forwards and study the effect of various variables on the composition of bile.

A. Verma, V. BhatnagarDepartment of Pediatric Surgery, All India Institute of

Medical Sciences, New Delhi

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