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“THERAPEUTIC AND DIAGNOSTIC ALGORITHM FOR CONGENITAL
HYDRONEPHROSIS IN CHILDREN”
Ibragimov J.X.
Andijan State Medical Institute, Andijan, Republic of Uzbekistan
https://doi.org/10.5281/zenodo.13982092
Relevance.
Despite the rapid development and implementation of modern
high-tech methods, the problem of congenital hydronephrosis (CH) remains
relevant and is a relatively common condition of the urinary system. The
treatment outcomes for children with congenital hydronephrosis depend on
various factors, such as the timing of surgery or obstruction correction, the
degree of hydronephrosis, and the child's age. The longer the disease persists,
the more pronounced the hydronephrotic changes in the kidneys and the walls
of the renal parenchyma, leading to more severe postoperative conditions and a
higher likelihood of fatal outcomes.
Objective of the Study.
To improve the outcomes of surgical treatment in
children with congenital hydronephrosis by optimizing the treatment strategy
and the differentiated use of surgical methods.
Materials and Methods.
The study is based on the analysis of treatment
results of 691 children with congenital hydronephrosis aged 3 to 15 years,
treated in the urology departments of three medical institutions in the Ferghana
Valley: Andijan Regional Children's Multidisciplinary Medical Center (ARCMCC),
Namangan Regional Children's Multidisciplinary Medical Center (NRCMCC), and
Ferghana Regional Children's Multidisciplinary Medical Center of Urology from
2013 to 2022.
According to the objective, the patients were divided into two groups for
analysis: a comparison group of 337 (48.8%) children treated following
standard CH management protocols from 2013 to 2017, and the main group of
354 (51.2%) children treated from 2018 to 2022 using a developed tactical
therapeutic-diagnostic algorithm and a modified pyeloplasty method, taking into
account the timing of CH development and the possibilities of minimally invasive
surgery (laparoscopy).
Among the children included in the study, boys predominated (72.9%)
compared to girls (27.1%). The majority of patients (45.1%) were aged 8-15
years (school-age children). In the comparison group, 215 (63.7%) children
were admitted in satisfactory condition, 105 (31.1%) in moderate condition, and
17 (5.1%) in severe condition. In the main group, these indicators were 222
(62.7%), 109 (30.8%), and 23 (6.5%), respectively.
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Results of the Developed Therapeutic-Tactical Algorithm.
The
proposed
therapeutic-tactical
algorithm
for
managing
congenital
hydronephrosis in children is based on a multi-positional assessment of the
clinical situation and the application of a comprehensive approach to diagnostic
and therapeutic tactics, which ensures the maximum potential of qualified and
specialized medical care.
According to the proposed algorithm, upon admission of children with
congenital hydronephrosis to the emergency department, clinical-anamnestic
data were determined (complaints, disease and life history). Special attention
was paid to symptoms such as nausea, vomiting, hematuria, or signs of infection,
which indicated the onset of renal failure and the presence of concomitant
surgical and therapeutic pathologies.
The primary tactical decision for patients with congenital hydronephrosis is
to verify complete or partial ureteral obstruction and determine the location of
the obstruction using ultrasound or MSCT with excretory urography. To reduce
radiation exposure to the child, excretory urography is performed in conjunction
with multi-spiral computed tomography, which allows for diagnosis without the
need for numerous unnecessary diagnostic tests that are often poorly tolerated
by children and parents, potentially leading to refusal of manipulations and
surgery altogether.
When diagnosing bilateral hydronephrosis, it is advisable to include
additional methods such as general ultrasound and EchoCG to identify
accompanying diseases in cases of compensated forms of concurrent therapeutic
pathologies. Surgery in these patients is performed in stages, depending on the
severity of renal impairment. During this period, measures are taken to reduce
renal pressure, administer antibacterial therapy (second-generation
cephalosporins, uroseptics, or metronidazole at 500 mg IV, combined with
ceftriaxone at 1-2 g IV), antispasmodics, antifungals, and metabolic agents.
Pyeloplasty was considered indicated when hydronephrosis of II-III-IV
degree according to the SFU scale was detected. Children aged 6 months to 3
years were recommended lumbar mini-access surgery, from 4 to 7 years
transabdominal laparoscopic surgery or lumbar mini-access, and children aged
8 to 15 years predominantly underwent laparoscopic access. For long strictures
in the upper third of the ureter, patch pyeloplasty with tension-free anastomosis
and minimal de-vascularization of the ureteropelvic junction (UPJ) or
pyeloureteral anastomosis according to the clinic's method, with antegrade
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stenting of the anastomotic area and drainage of the intervention zone with a
Foley catheter for 2 days, was recommended.
Results and Discussion.
Based on the deficiencies and shortcomings in the
comparison group and the accumulated experience of using minimally invasive
surgical methods on the kidney (laparoscopy), the number of laparoscopic
approaches increased to 281 (79.3%) children, with conversion to a modified
posterior-lateral mini-access in only 1 (0.3% of 281) of them. Among these, 208
(58.7%) were boys and 73 (20.6%) were girls.
The duration of hospital stay after treatment differed significantly. In the
comparison group, after 316 (93.7%) traditional open surgeries, the minimum
hospitalization period was 12 days, with a maximum of 20-21 days, and the
average length of stay was 17.6 days (20.8±3.2 bed days). In the main group, the
minimum stay after surgery was 3 days, with a maximum of 6 days, and the
average length of stay was 4.5 days (± 0.26). After open surgery with mini-
access, the stay was 6.1±0.49 bed days, and after laparoscopic surgery, it was
5.1±0.23 bed days.
Conclusions.
The implementation of the developed therapeutic-tactical
algorithm for managing children with congenital hydronephrosis, based on a
multi-positional assessment of the situation and modern dominant approaches
to treating this pathology, allows for improved treatment outcomes in this
severe category of patients.
