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Neonatal urinary ascites of uncommon etiology
Rambha Rai, Sr., MBBS MS MRCSed FAMS, KL Narasimhan, Sr., MBBS, MS, Mch, FRCS, Suresh Chandran, Sr., MD FRCPCH FAMS, Harvey James Teo Eu Leong, Sr., MBBS FRCR, Yap Te-Lu, Sr., MBBS FRCS FAMS, Indra Ganeshan, Sr., MD MMed MRCPCH, Anette Sundfor Jacobsen, Sr., MBBS FRCS FAMS.
Singhealth, Singapore, Singapore.

BACKGROUND: Urinary ascites in neonates is a very rare condition. Two neonates with urinary ascites of unusual etiology are discussed.

METHODS: Two neonates presented to us with urinary ascites and were managed surgically. We present the challenges posed in the care of these patients.

Case 1:
A late prem male neonate presented with abdominal distension at birth associated with renal impairment and bilateral hydronephrosis to a hospital overseas. The child underwent a laparotomy (showing clear fluid in the abdomen) and a suprapubic cystostomy. The child was then airlifted to us with urine leaking from the main pfannensteil wound in the lower abdomen. The abdomen was reexplored, washed and drained. A rent in the bladder was identified by methylene blue instillation into the bladder. It was repaired and a vesicostomy was performed. The child recovered uneventfully. Six months later, a MCU was done through the vesicostomy and showed anterior urethal valves which were treated endoscopically. The vesicostomy was closed. The child is now 8 years old and both kidneys are normal.

Case 2: A full term, male neonate with Klinfelter Syndrome presented with a large urinary ascites during perinatal period along with a large cyst next to the suspected bladder detected on antenatal scans. He had renal agenesis on one side. He was managed with urgent peritoneal drainage and urethral catheterization at birth. He needed two weeks of ventilatory support due to gross abdominal distension and three weeks of peritoneal fluid drainage. After multiple modalities of imaging with ultrasonography, CT scan, MRI and MCU, it was found that the bladder outlet was obstructed at the bladder neck by a large utricular cyst. The cyst was not visualized in earlier post natal scans in the presence of ascitis and urethral catheter but it remanifested after the ascites resolved. The renal function also normalised gradually thereafter. He underwent a vesicostomy and is planned to be managed with excision of the cyst at a later date.

CONCLUSIONS: Neonatal urinary ascites is uncommon and usually presents as a clinical emergency. The diagnosis and treatment can be challenging if the cause of obstruction is rare. The management of these cases should be planned carefully based on the anatomical and functional status of the urinary system.
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Figure 1 : Prenatal MRI at 33 weeks gestational age demonstrates hyperintense, enlarged kidneys and minimal amniotic fluid, consistent with ARPKD.

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