5 Yaşında Yan Ağrısıyla Başvuran Erkek Olgu
Özet
Bu olgu sunumunda, antenatal dönemden itibaren takip edilen ve bebeklik döneminde sol böbreğinde hafif (SFU evre 1) genişleme saptanan erkek bir hastanın süreci ele alınmaktadır. İlk iki yılında stabil seyreden ve sonrasında takipten çıkan hasta, 5 yaşında şiddetli sol yan ağrısı, 39 derece ateş, bulantı ve kusma ile başvurmuştur. Yapılan incelemelerde, sol böbreğinde SFU evre 4 genişleme, parankimal incelme ve piyonefroz tespit edilmiştir. Hastaya ampirik antibiyotik başlanmış ve perkutan nefrostomi (PKN) ile piyonefroz drenajı sağlanmıştır. PKN sonrası ateşi düşen, klinik tablosu ve laboratuvar değerleri düzelen hastaya çekilen antegrad pyelografi ile üreteropelvik bileşke darlığı (UPD) kanıtlanmıştır. Enfeksiyon nedeniyle oluşan fibrozis göz önüne alınarak, PKN uygulamasından 4-6 hafta sonra definitif cerrahi planlanmıştır. Postoperatif takiplerinde Tc-99m MAG3 sintigrafisinde sol böbrekte uzamış boşalma ve %22 fonksiyon izlenen hasta, şu an 11 yaşında olup sol böbreğindeki evre 2 genişleme ile takip altında tutulmaktadır. Bu vaka, hafif hidronefroz olgularında bile yıllar sonra obstrüksiyon ve buna bağlı fonksiyon kaybı gelişebileceğini göstererek uzun süreli takibin ve ebeveyn eğitiminin önemini vurgulamaktadır.
This case report presents a male patient who was monitored starting from the antenatal period and detected with mild (SFU grade 1) left renal dilation during infancy. The patient, who remained stable during his first two years but was subsequently lost to follow-up, presented at age 5 with severe left flank pain, a 39-degree fever, nausea, and vomiting. Evaluations revealed SFU grade 4 dilation, parenchymal thinning, and pyonephrosis in the left kidney. Empirical antibiotics were initiated, and percutaneous nephrostomy (PCN) was performed to drain the pyonephrosis. Following PCN, the patient's fever subsided, clinical and laboratory findings improved, and an antegrade pyelography confirmed ureteropelvic junction obstruction (UPJO). Due to infection-related fibrosis, definitive surgery was scheduled 4 to 6 weeks after PCN placement. Postoperative follow-ups with Tc-99m MAG3 scintigraphy showed prolonged drainage and 22% function in the left kidney, and the patient, now 11 years old, remains under monitoring with persistent grade 2 dilation. This case highlights the vital importance of long-term monitoring and parental education, demonstrating that obstruction and subsequent loss of renal function can develop years later even in initially mild hydronephrosis cases.
Referanslar
Hwang J, Shin J, Lee Y, et al. Percutaneous nephrostomy placement in infants and young children. Diagn Interv Imaging. 2018;99(3):157-62.
Shellikeri S, Daulton R, Sertic M, et al. Pediatric percutaneous nephrostomy: a multicenter experience. J Vasc Interv Radiol. 2018;29(3):328-34.
Li AC, Regalado SP. Emergent percutaneous nephrostomy for the diagnosis and management of pyonephrosis. Seminars in interventional radiology; 2012: Thieme Medical Publishers.
Florido C, Herren JL, Pandhi MB, et al. Emergent percutaneous nephrostomy for pyonephrosis: a primer for the oncall interventional radiologist. Seminars in Interventional Radiology; 2020: Thieme Medical Publishers.
Ulman I, Jayanthi VR, Koff SA. The long-term followup of newborns with severe unilateral hydronephrosis initially treated nonoperatively. J Urol. 2000;164(3 Part 2):1101-5.
Bowen DK, Yerkes EB, Lindgren BW, et al. Delayed presentation of ureteropelvic junction obstruction and loss of renal function after initially mild (SFU Grade 1-2) hydronephrosis. Urology. 2015;86(1):168-70.
Ransley P, Dhillon H, Gordon I, et al. The postnatal management of hydronephrosis diagnosed by prenatal ultrasound. J Urol. 1990;144(2):584-7.
Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol. 2014;10(6):982-98.
Riccabona M, Avni FE, Blickman JG, et al. Imaging recommendations in paediatric uroradiology: minutes of the ESPR workgroup session on urinary tract infection, fetal hydronephrosis, urinary tract ultrasonography and voiding cystourethrography, Barcelona, Spain, June 2007. Pediatr Radiol. 2008;38(2):138-45.
Akhavan A, Shnorhavorian M, Garrison Jr LP, et al. Resource utilization and costs associated with the diagnostic evaluation of nonrefluxing primary hydronephrosis in infants. J Urol. 2014;192(3):919-24.
Gatti JM, Broecker BH, Scherz HC, et al. Antenatal hydronephrosis with postnatal resolution: how long are postnatal studies warranted? Urology. 2001;57(6):1178.
Matsui F, Shimada K, Matsumoto F, et al. Late recurrence of symptomatic hydronephrosis in patients with prenatally detected hydronephrosis and spontaneous improvement. J Urol. 2008;180(1):322-5.
Pabon-Ramos WM, Dariushnia SR, et al. Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol. 2016;27(3):410-4.
Lewis JM, Cheng EY, Campbell JB, et al. Complete excision or marsupialization of ureteroceles: does choice of surgical approach affect outcome? J Urol. 2008;180(4S):1819-23.
Ajib KM, Matta IF, Zgheib JT, et al. Non-angled intercostal percutaneous access under full expiration: safety is not an issue anymore. J Endourol. 2017;31(8):736-41.
Rana AM, Zaidi Z, El-Khalid S. Single-center review of fluoroscopy-guided percutaneous nephrostomy performed by urologic surgeons. J Endourol. 2007;21(7):688-91.
