Bilateral Reflux Research Articles

Comparison and clinical analysis of antibiotics and endoscopic injection for vesicoureteral reflux in children

PurposeThis study evaluated the outcome of pediatric patients with primary vesicoureteral reflux (VUR) and compared of the treatments between continued antibiotic prophylaxis (CAP) and endoscopic injection.MethodsThe clinical data of children diagnosed with primary vesicoureteral reflux from March 2015 to June 2020 who were treated with antibiotics or endoscopic injection were reviewed. Antibiotic was the first-chosen treatment after the diagnosis of VUR in children. Endoscopic treatment consisted of injection of dextran hyaluronic acid copolymer (DX/HA) into the ureteral opening under direct cystoscopy guidance.ResultsFifty-two children (35 males, 17 females) were included in this study, and for a total 90 ureters (14 unilateral, 38 bilateral) were diagnosed with vesicoureteral reflux by Voiding cystourethrography (VCUG). Twenty-two children were treated with antibiotics (8 unilateral, 14 bilateral), for a total of 36 ureters; thirty children were treated by endoscopic injection (6 unilateral, 24 bilateral), for a total of 54 ureters. The injection surgery took 36 ± 17 min including duration of general anesthesia and circumcision and the hospital stay was 2.3 ± 1.3 days. All male patients underwent circumcision simultaneously. There were no drug and allergic reactions in the antibiotic group, and no postoperative complications occurred in the injection group. With 23 months (13–63 months) of mean follow-up, the resolution rate, defined as radiological disappearance of VUR, was 36.1% (13/36) in the antibiotic group and 57.4% (31/54) in the injection group (P = 0.048).Two cases of bilateral reflux in the injection group required a second injection before resolution could be achieved. Thus, the overall success rate of injection was 64.8% (35/54). 9 cases (9/18, 50%) in the antibiotic group had renal scars on DMSA scans, while this was seen in 20 cases (20/23, 86.9%) in the injection group. There was a statistically significant difference between the two groups (P = 0.010).The positive rates of ultrasound between the antibiotic group and the injection group were 45.5% (10/22) and 80.0% (24/30), respectively. There was a statistically significant difference between the two groups in positive rates of ultrasound (P = 0.010).ConclusionsEndoscopic injection is easy to operate with short surgical time and hospital stay, so it is a safe and feasible treatment. For the treatment of primary vesicoureteral reflux in children, the radiological resolution rate of endoscopic injection is better than antibiotic therapy. In this study, the presence of kidney scars on DMSA and the dilated of the collecting system on ultrasound are the indications for endoscopic injection.

Comparison of voiding vesicoureteral urosonography with fluoroscopic voiding cystourethrography in children with vesicoureteral reflux.

To evaluate the value and compliance rate of voiding vesicoureteral urosonography in pediatric vesicoureteral reflux (VUR). This is a retrospective study. A total of 80 children with high-risk VUR admitted to Children's Hospital affiliated to Capital Medical University from December 2018 to December 2020 were selected. All patients underwent voiding urosonography (VUS) and fluoroscopic voiding cystourethrography (VCUG). The sensitivity and compliance of voiding vesicoureteral urosonography were compared, and its application value was evaluated. A total of 160 PUUs were examined, and all cases were normal. Among them, 56 PUUs had reflux (35.00%, 56/160), 46 PUUs had reflux under both examination methods (28.75%, 46/160), and 10 PUUs were only detected under VUS (6.25%, 10/160). Thirty-four cases of VUR (42.50%, 34/80) were diagnosed by VUS, among which 15 cases were bilateral reflux and 4 cases were unilateral reflux. Twenty-five cases (35.00%, 25/80) were diagnosed by VCUG, among which 10 cases were bilateral regurgitation and five cases were unilateral regurgitation. No significant difference was observed in the detection rate of reflux between the two methods (P=0.432). A total of 146 PUUs were found to be consistent between the two methods (91.25%, 160), including 2 Grade-I reflux, 6 Grade-II reflux, 14 Grade-III reflux, 12 Grade-IV reflux, eight Grade-V reflux, and 104 without reflux, demonstrating SATISFACTORY consistency between the two groups (Kappa=0.885). Voiding vesicoureteral urosonography has a high coincidence rate in the detection of vesicoureteral reflux in children.

MP70-12 THE WIDE URETER AND THE SMALL BLADDER, THE CUFF-NIPPLE REIMPLANTATION RATHER THAN URINARY DIVERSION

You have accessJournal of UrologyCME1 Apr 2023MP70-12 THE WIDE URETER AND THE SMALL BLADDER, THE CUFF-NIPPLE REIMPLANTATION RATHER THAN URINARY DIVERSION Moneer Hanna and Wael Abosena Moneer HannaMoneer Hanna More articles by this author and Wael AbosenaWael Abosena More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reimplantation of a dilated Ureter into an infantile small capacity bladder represents a surgical challenge. The surgical options for reflux megaureters who developed breakthrough urinary infections while on prophylaxis are temporary diversion (vesicostomy for bilateral and ureterostomy for unilateral megaureters). In cases of obstructed megaureter the options are ureterostomy and refluxing reimplantation. METHODS: Between 1995 and 2021, 46 infants aged 3 and 12 months were referred for surgical management following recurrent pyelonephritis while on prophylaxis (30 infants) and for worsening hydronephrosis (16 infants). There were 32 boys and 14 girls. The diagnosis was bilateral reflux megaureters in 18 and unilateral in 8 children. The other twenty children had bilateral obstructed megaureter in 9 and unilateral in 11 children. The radionuclide renal scan was performed in 43 children, and it showed reflux nephropathy in 35 kidneys with VUR and reduced function of more than 20% in 9/11 obstructed kidneys. A total of 73 megaureters were operated on. The ureteral tortuosity was straightened, and the caliber was reduced when indicated. Each ureter was reimplanted in a short (1 cm) submucosal tunnel, a cuff-nipple ureteral orifice was created in 62/73 ureters. Simple cuff-nipple without submucosal tunnelling in 11 ureters. RESULTS: The postoperative course was uneventful in all children and follow up US & VCUG were done at four months. Thereafter the follow-up continued by the pediatric nephrology service. The post operative US showed improved hydronephrosis in 59/73 kidneys and stable in 14 units. The VCUG showed no evidence of VUR in 58/62 (93%) of the group who had short tunnel and cuff-nipple reimplantation, in 4 ureters the VUR was downgraded to grade II. 10/11 (91%) of the ureters with the cuff-nipple without tunneling showed no evidence of VUR, and one ureter the VUR was grade II. 7 children had significant reflux nephropathy outgrew their renal function and underwent renal transplantation CONCLUSIONS: The time -tested Paquin dogma of tunnel length/width ratio of 5/1 was challenged by Lyons et.al, the latter contention was that the shape of the ureteral orifice (UO) is more important than the length of the tunnel for reflux prevention, (the cuff-nipple creates a volcano like UO). Recently Villaneuva et.al performed a parametric simulation study of ureteral collapse (LS-DYNA finite-element software). They confirmed Lyons observation. These observations would explain the high success rate which was achieved by the cuff-nipple technique. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1008 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moneer Hanna More articles by this author Wael Abosena More articles by this author Expand All Advertisement PDF downloadLoading ...

Problems in managing the outcome of posterior urethral valves at LRH Hospital

Aim: The goal of this study is to characterise the appearance of posterior urethral valves and evaluate the effectiveness of their treatment in settings with limited medical resources. Methods: The Department of Urology at lrh Peshawar performed a retrospective, descriptive research between Jan 2019 and Jan 2021. The presentation, duration of symptoms, complications, and treatment outcome were all considered. Results: There were 460 patients in total. Approximately three years old was the midpoint [02 days–10 years]. The average time from the onset of symptoms to diagnosis was [2.4 years]. 400 (90%) individuals reported urosepsis; 160 (34%) patients showed unilateral or bilateral reflux; 70 (16%) patients presented with big decompensated bladder, and 80 (18%) patients presented with substantial renal insufficiency. The radiological results verified the presumptive diagnosis of the posterior urethral valve. All patients underwent a cystoscopy and valve fulguration; some underwent further vesicostomy or ureterostomy procedures. Conclusion: According to the study, late presentation is common in our setting. High rates of illness and death are linked to this. The medical community must work toward greater awareness and earlier diagnosis to slow the epidemic.

Modified unilateral periureteral injection technique in the treatment of patients with high-grade vesicoureteral reflux: A study of primary findings

ObjectiveAlthough endoscopic treatment has been used by many pediatric urologists for the treatment of vesicoureteral reflux (VUR), it has no considerable success in high-grade VUR. We aimed to describe the primary outcomes of unilateral periureteral injection technique (PIT), as well as bilateral PIT in high-grade VUR. MethodsIn this prospective study, we examined 92 ureters in 45 boys and 40 girls from February 2010 to May 2018. Bilateral PIT and unilateral PIT were applied in 67 and 25 refluxing units, respectively. In the unilateral PIT, the subureteral injection site was only at the 5- or 7-o'clock position. However, in the bilateral PIT, the subureteral injection sites were at 5- and 7-o'clock position. Pre- and post-operative reflux grades were evaluated by voiding cystourethrography 6 months after surgery. ResultsSeven patients had bilateral reflux. Overall, 75 (81.5%) ureters showed Grade IV VUR, while 17 (18.5%) had primary Grade V VUR. The mean age of the subjects was 39.2 months. In unilateral PIT ureters, VUR was resolved in 23 (92.0%) refluxing units. It was downgraded to Grade III in one ureter (4.0%) and to Grade II in another ureter (4.0%). In addition, in bilateral PIT cases, VUR was resolved in 60 (89.6%) ureters; it downgraded to Grades II and III in 3 (4.5%) and 4 (6.0%) refluxing units, respectively. ConclusionUnilateral PIT can be highly effective in the treatment of selected ureters of high-grade VUR. However, further studies are needed to confirm our results.

Posterior urethral morphology on initial voiding cystourethrogram correlates to early renal outcomes in infants with posterior urethral valves

Posterior urethral valves (PUV) is a leading cause of chronic renal failure in childhood. Bladder and posterior urethral deformity in infants with PUV are highly variable on initial voiding cystourethrogram (VCUG). Some types of deformity may be more important than others in determining the severity of the condition. Identification of specific VCUG features may allow for a simple, early screening assessment for patients. Determine whether morphologic features on the initial VCUG correlate to renal outcomes as measured by the creatinine nadir in the first year after ablation. Children with PUV treated by primary valve ablation before 12 months old and followed >1 year were identified. Initial diagnostic VCUG was evaluated for the bladder height to width ratio (HW-B), posterior urethral height to width ratio (HW-PU), and posterior-anterior urethral ratio (PA-UR). A trabeculation grade was assigned by three pediatric urologists, and reflux was noted. Univariable analyses with chi-square and t-test were used to compare bladder and posterior urethral morphology factors among those who obtained a creatinine nadir <0.8 or ≥0.8mg/dL in the first year after ablation. Linear regression was performed to correlate morphology values with true creatinine nadir. A total of 120 boys were ablated at mean age of 40.5 days (range 0-342) and followed for 5.9 years (± 3.85). Among these, 21 (17.5%) had a creatinine nadir ≥0.8mg/dL. Mean overall HW-B and mean PA-UR were not significantly different between those with creatinine nadir <0.8 versus ≥0.8mg/dL. Bladder trabeculation grade was not associated with creatinine nadir. For the entire cohort, only the difference in HW-PU was statistically significant between creatinine nadir groups with a much higher ratio among those with a nadir ≥0.8 (p<0.001). Linear regression demonstrated a significant positive correlation between the HW-PU and creatinine nadir (R 2=0.097, p=0.002). The presence of bilateral reflux is significantly associated with creatinine nadir ≥0.8mg/dL (p=0.001). We investigate for the first time the association of morphology features on the initial VCUG with renal outcome in PUV patients. Posterior urethral deformity as quantified by a higher HW-PU ratio is significantly correlated with a higher creatinine nadir, whereas measured bladder morphology metrics are not. HW-PU may be an indirect measure of the severity of obstruction in posterior urethral valves. The HW-PU appears to be a meaningful early morphologic metric for renal outcome.

Study the Possibility of Creating Mucosal Valve Mechanism at Ureteric Orifice without Obstructing the Urine Outflow but Preventing the Urine Backflow into the Ureters.

Objective:To study the possibility of creating mucosal valve mechanism at ureteric orifice without obstructing the urine outflow but preventing the urine backflow into the ureters.Materials and Methods:Ethical waiver was obtained from the institutional ethical committee. Prospective experimental study was conducted on the post-mortem specimen of intact bladder with urethra and bilateral ureters retrieved from the already slaughtered lamb available in the meat market. Feeding tube inserted via urethral opening into the bladder lumen and bladder inflated with saline demonstrated no reflux of urine via transverse cut opening of ureters. Bladder lumen opened, ureteric orifices incised backwards to eliminate the obliquity. After closing the bladder opening, saline inflation test demonstrated bilateral reflux of saline via cut openings of bilateral ureters. Bladder was re-opened. The upper limb of horizontal U started 10 mm lateral and 8 mm above the refluxing ureteric orifice. Distal most curvature of horizontal U was kept 5 mm medial to ureteric orifice continuing along the lower limb of horizontal U terminating 10 mm lateral and 8 mm below the refluxing ureteric orifice, mucosal flaps from superior and inferior incision mobilized and edges joined to cover the ureteric orifice creating a flap valve mechanism. Influx of saline via cut end of ureters demonstrated no obstruction. Bladder was closed. Saline inflation test and contrast study demonstrated abolition of reflux on flap side and persistence of reflux on another side.Results:Five such experiments were conducted. On the side where the valve was created, Vesicoureteral reflux was abolished in four but in one minimal reflux still persisted.Conclusion:Creating a mucosal flap valve around the ureteric orifice can prevent reflux in 80% of cases without obstruction and without the necessity of ureteric mobilization or creating submucosal tunnel.

Pneumovesicoscopic Correction of Primary Vesicoureteral Reflux in Children: Our Initial Experience.

Purpose: The main objective of our prospective, descriptive, monocentric, longitudinal study is to demonstrate the feasibility of vesicoscopic cross-trigonal ureteral reimplantation under CO2 pneumovesicum in treatment on primary vesicoureteral reflux (VUR), analyze results, and specify the age limit of this approach. Materials and Methods: A total of 60 patients underwent transvesicoscopic ureteral reimplantation (33 boys, 27 girls) by the same surgeon from May 2011 to May 2015. All patients had primary VUR, and surgery was performed because of breakthrough urinary tract infection despite antibiotic prophylaxis and persistent high grade of VUR, especially in association with significant renal scarring, mean age at operation was 47.47 months (6 month-12 years). Of the 60 patients, 34 had bilateral reflux and 26 had unilateral reflux. The reflux grade in the total of 94 ureters was grade IV, V in 59.57%, grade III in 35.11%, and grade II in 5.32% in association with contralateral high-grade VUR. Results: The transvesicoscopic procedure was effectively completed in all patients without perioperative complication except one case of pneumoperitoneum that required exsufflation by open laparoscopy. The mean overall operative time decreased significantly with an average of 58.43 ± 11.26 minutes for unilateral reimplantation and 101.18 ± 26.5 minutes for bilateral reimplantation. The postoperative hospital stay was 3 days for all patients. The mean follow-up period was 3 years. Cystography was performed 3 months after surgery in all patients and showed the disappearance of VUR in 57/60 patients (95%) or 91/94 of ureters (97%). Persistent VUR was documented in 3 of 94 ureters and had resolved spontaneously at 12 months after reimplantation. Conclusion: Our preliminary results indicate that vesicoscopic ureteral reimplantation is safe and effective procedure with minimal morbidity when compared to traditional open method. It can be applied in children younger than 12 months.

POS-222 PATTERN AND OUTCOME OF VESICO-URETERIC REFLUX AMONG CHILDREN ON FOLLOW UP AT RENAL CLINIC OF TIKUR ANBESSA SPECIALIZED HOSPITAL, ADDIS ABABA, ETHIOPIA

Vesico-ureteral reflux (VUR), a congenital anomaly characterized by either a unilateral or bilateral reflux of urine from the bladder to the kidney(s), has been long recognized as a major pediatric health problem. Reflux nephropathy (RN) is responsible for 12% to 21% of all children with CKD. Reflux nephropathy (RN) is the fourth most common cause of ESRF in children.The role of antimicrobial prophylaxis or surgical intervention in the prevention of recurrent UTI or renal scarring remains controversial.

Intravesical and extravesical ureteral reimplantation in children with bilateral refluxing megaureter: comparison of results

Introduction. Extravesical ureteral reimplantation is an accepted technique for the surgical treatment of high-grade vesicoureteral reflux. However, many surgeons continue to use an intravesical technique, including for the megaureter. We present our experience and outcomes with these techniques for primary bilateral refluxing megaureter.Purpose of the study. To improve the results of surgical treatment of refluxing megaureter in children.Materials and methods. A retrospective study was performed of 95 patients who underwent ureteral reimplantation between 2006 and 2019. The age of patients at the time of surgery was from 4 months to 13 years (median — 27.6 months), boys were 71 (74.7%), girls were 24 (25.3%). All patients are divided into 2 groups depending on the method of treatment. Group 1 consisted of 65 patients who underwent Cohen single-stage bilateral transvesical ureteral reimplantation. Group 2 included 30 children who underwent two-stage Barry extravesical ureteral reimplantation. The interval between operations was from 1 to 63 months (median — 5.2 months). Patient demographics, surgical technique and outcomes were recorded. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux.Results. Median follow-up period was 3.2 years. The overall success rate was 80% for patients and 88% for ureters. Postoperative grade III – IV reflux had 15 patients (15,8%) and 16 ureters (8,4%). Persistent ureterohydronephrosis had 4 children (4,2%) and 6 ureters (3,2%). The effectiveness of treatment for patients in the Cohen group was 77%, in the Barry group — 87% (p = 0.408), for ureters — 86% and 93%, respectively (p = 0.223). The difference was not significant despite the higher effectiveness extravesical technique.Conclusion. Extravesical and transvesical ureteral reimplantation are effective methods of treatment for bilateral refluxing megaureter in children.

The necessity of voiding cystourethrogram for the evaluation of recipient candidates in adult renal transplantation

Objective . While international guidelines necessitate Voiding Cystourethrogram (VCUG) for pediatric patients, it is unnecessary for the evaluation of adult patients without urological disorders as renal transplant candidates. The objective of this study was to evaluate the results of adult candidates who underwent VCUG before transplantation and to demonstrate the necessity for this imaging. Methods . A retrospective study of the data of 1265 adult candidates who underwent VCUG before transplantation at our center, was undertaken. VUR, the presence of Postvoiding residual urine (PVR) (>100 ml), Low bladder capacity (LBC) (<100 ml), and urethral pathologies were evaluated with VCUG. Results . The mean age was 42.3 ± 1.3. The mean dialysis period was 27.8 ± 4.2 months. According to the VCUG results, 19.2% of the patients had pathological findings. On the other hand, the rate of urological disorders was only 5.1%, according to end-stage renal disease (ESRD) etiologies. VCUG outcomes indicated bilateral high-grade reflux in native kidneys in 4.4% (n = 56) of the candidates, unilateral high-grade reflux in 4.1% (n = 52), bilateral low grade reflux in 2.1% (n = 26), unilateral low-grade reflux in 2.4% (n = 30), and reflux in rejected transplanted kidney in 2.3% (n = 29). In addition, significant LBC was noted in 4.8% (n = 61), significant PVR in 1.1% (n = 14), and urethral stricture in 0.5% (n = 6) of the candidates. Conclusion . VCUG should be considered as a part of routine evaluation in adult renal transplant recipient candidates as well as in pediatric candidates, even if their ESRD etiologies are not due to urological disorders.

Bilateraler Reflux – Kontra intravesikale Techniken

In reflux surgery, decisions on surgical procedures can be made on an individual basis today. Almost all open surgical implantation techniques provide very good, sustainable results, and parents prefer less invasive techniques. Therefore, if intravesical techniques are used to correct bilateral reflux, it should be considered and discussed with the parents that these procedures are associated with increased invasiveness in terms of longer operation times, longer catheter dwell times, a longer inpatient stay and more complications such as macrohaematuria and bladder spams compared with extravesical techniques.

Primary vesicoureteric reflux in 72 children

Objective To summarize the treatment and prognosis of children with primary vesicoureteric reflux (PVUR) and the correlation between PVUR and urinary tract infections(UTI). Methods The children with PVUR (72 cases) who were hospitalized at the Department of Nephrology and Urology of Children′s Hospital Affiliated to Capital Institute of Pediatrics from June 2007 to April 2018 were selected, and the clinical manifestations were summarized. Results A total of 72 patients (52 boys, 20 girls) were involved, and the median age at diagnosis was 8 months, in which 44 cases (61.1%) were less than 1 year old.There were 55 cases with UTI onset (76.4%), 94.5%(52/55 cases) with recurrent UTI(twice or more than twice) and 2 cases (2.8%) ended with renal failure.Refluxes were unilateral in 34 patients and bilateral in 38 patients.There were 110 ureters, in which 74 reflux ureters (67.3%) were identified as low-grade (Ⅰ-Ⅲ) PVUR, and 36 reflux ureters(32.7%) were high-grade (Ⅳ-Ⅴ) PVUR.Forty patients received conservative treatment, and significant differences of the remission rate were observed between group Ⅰ-Ⅱ grade PVUR(72.2%, 13/18 cases) and group Ⅲ-Ⅴ grade PVUR(32.5%, 13/40 cases)(χ2=7.92, P=0.005). Twenty-two patients (35 reflux ureters) underwent surgical treatment, in which 31 ureters were cured, and the remission rate was 88.6%.Ten patients with refluxes grade Ⅲ or above had no improvement after medical treatment, but the reflux was completely relieved after surgical treatment. Conclusions Children with recurrent UTI, especially less than 1 year-old, should be considered with PVUR.The conservative treatment could be prior for the patients with Ⅰ-Ⅱ grade PVUR.The surgical treatment could be chosen for those patients who suffered from high-grade PVUR, bilateral reflux or failed conservative treatment, especially with recurrent UTI, and reflux nephropathy could be reduced then. Key words: Vesicoureteric reflux; Urinary tract infection; Child

Vesicoureteral antireflux surgery with Lich–Gregoir technique without vesical drainage: Long-term results

ObjectiveTo describe our long-term experience with patients with vesicoureteral reflux (VUR) who underwent conventional surgery without postoperative bladder drainage. Material and methodsRetrospective review of 45 patients surgically treated by extravesical Lich–Gregoir's ureterovesical reimplantation without postoperative bladder drainage between 2010 and 2013. Results37 women (82.2%) and 8 men (17.8%). 28 patients with unilateral reflux, and 17 patients with bilateral reflux with a total of 62 operated kidneys. The mean age at surgery was 6 years (2–11 years).The main cause of surgical indication was the persistence of reflux in patients older than 6 years (73.3%); with grade III VUR (75.6%) being the most frequent. The mean surgical time was 44min (35–70) for unilateral reimplantation, and 70min (53–98) for bilateral ones.All patients presented spontaneous urination in the immediate postoperative period, without pain, no hematuria, full incontinence, and without a bladder balloon. None required bladder catheter placement, and hospital discharge was indicated between 7 and 36h postoperatively (mean 11h).All continued with spontaneous micturitions, without postvoid residual or voiding dysfunction during the 5-year follow-up. ConclusionThe thorough selection of the patients, the detailed surgical gestures, the bladder emptying without instrumentation of the urethra, together with a correct use of analgesics and early ambulation allowed excellent outcomes obtained in these patients managed with a short hospital stay and without bladder drainage, also demonstrating the safety of the procedure at 5 years of follow-up.

Resultados a largo plazo de cirugía antirreflujo vesicoureteral con técnica de Lich-Gregoir sin drenaje vesical

ObjectiveTo describe our long-term experience with patients with vesicoureteral reflux (VUR) who underwent conventional surgery without postoperative bladder drainage. Material and methodsRetrospective review of 45 patients surgically treated by extravesical Lich-Gregoir's ureterovesical reimplantation without postoperative bladder drainage between 2010 and 2013. Results37 women (82.2%) and 8 men (17.8%). 28 patients with unilateral reflux, and 17 patients with bilateral reflux with a total of 62 operated kidneys. The mean age at surgery was 6 years (2 to 11 years).The main cause of surgical indication was the persistence of reflux in patients older than 6 years (73.3%); with grade III VUR (75.6%) being the most frequent. The mean surgical time was 44minutes (35-70) for unilateral reimplantation, and 70minutes (53-98) for bilateral ones.All patients presented spontaneous urination in the immediate postoperative period, without pain, no hematuria, full incontinence, and without a bladder balloon. None required bladder catheter placement, and hospital discharge was indicated between 7 and 36hours postoperatively (mean 11h).All continued with spontaneous micturitions, without postvoid residual or voiding dysfunction during the 5-year follow-up. ConclusionThe thorough selection of the patients, the detailed surgical gestures, the bladder emptying without instrumentation of the urethra, together with a correct use of analgesics and early ambulation allowed excellent outcomes obtained in these patients managed with a short hospital stay and without bladder drainage, also demonstrating the safety of the procedure at 5 years of follow-up.

Management and Outcome of Vesicoureteral Reflux: A 14-Year Experience

Objectives: Vesicoureteral reflux is a common problem in young children. The increased risk of urinary tract infection in these patients is the main cause of renal parenchymal damage. The main managements are prophylactic antibiotics and different surgical interventions. In this study, we evaluate the results of surgical intervention in VUR patients. Methods: This is a cross sectional retrospective study of all our patients with primary reflux who have been managed surgically between 2002 and 2016. Results: Of 420 patients with VUR, 207 were managed surgically. Eighteen (8.7) patients with bilateral reflux before intervention and persistent reflux (grade II or III) after intervention, progressed to end stage renal disease (ESRD). There was no significant relation between the grade of reflux, the serum level of the creatinine or frequency of positive urine culture, and progression to ESRD, while a significant relation existed between grade of post-operative VUR and post-operative positive urine culture with ESRD (P = 0.000). Conclusions: It seems that surgery cannot prevent renal damage in some cases of VUR. Close follow up after surgical intervention particularly in those with persistent reflux (of any grade) for prevention of renal damage is recommended. © 2018, Iranian Journal of Pediatrics.

PROFILE OF BOYS WITH POSTERIOR URETHRAL VALVES FROM A TERTIARY CARE CENTER IN A DEVELOPING COUNTRY

Introduction: Posterior urethral valves (PUVs) are the most common cause of obstructive uropathy in boys. While most patients&nbsp;in developed countries are diagnosed in the antenatal period, our patients often present late which adversely affects their outcome.&nbsp;This retrospective study was aimed to study the clinical profile of boys with PUV at follow-up. Methods: Records of 45 boys&nbsp;&nbsp;with PUV who were in follow-up for at least 1-year were retrieved between February and December 2015. Age of presentation,&nbsp;signs and symptoms, anthropometry, radiological findings, surgical interventions, and biochemical investigations were recordedin a pre-structured pro forma. The data were later analyzed on an Excel spreadsheet. Results: The mean age at the diagnosis&nbsp;of PUV was 16±2.8 months, and the mean age at enrollment was 70.6±53.5 months. The condition was detected antenatally in&nbsp;5 (10.9%) subjects only. At the time of data collection, the mean height and weight standard deviation scores were ?1.7 and ?1.5,&nbsp;respectively. Hypertension was present in 29% of patients. 44.5% of subjects had moderate-to-severe malnutrition and 42.2% had&nbsp;short stature. Mean GFR of the subjects was 66.3 ml/min/1.73m². Bilateral hydronephrosis was present on ultrasound in 26 (57.8%)&nbsp;subjects. Mean anteroposterior diameter on ultrasound was 22.1 mm for the right kidney and 20.8 mm for the left kidney. Significant&nbsp;post-void residue was detected in 54.6% of patients. Bilateral reflux was seen in 21.7% of subjects on micturating cystourethrogram.&nbsp;Urodynamic studies were available for 16 patients, and 31.3% had significant post-void residual urine. Detrusor instability was&nbsp;present in 18.8% of subjects. 35.6% of subjects underwent valve fulguration alone as the surgical procedure while 19 (42.2%) had&nbsp;a diversion procedure&nbsp; (vesicostomy/ureterostomy) along with valve fulguration. Conclusions: Most of the patients with PUV arestill diagnosed postnatally and have significant renal damage at presentation. Urinary diversion procedures are required in almost&nbsp;half of these patients. All these contribute to a poor long-term outcome.

Complete duplication of bladder, urethra, clitoris and vagina associated with bilateral ureteral reflux in an old female patient: unique case.

Complete duplication of the bladder, urethra, vaginal and clitoris is an extreme- ly rare congenital anomaly that is usually diagnosed at pediatric age. We report an unusu- al case of a complete bladder, vaginal, clitoris and urethra duplication occurred in an old female patient (81 years old). This case highlighted the fact that an anatomical anomaly should be considered in all patients with persistent urinary tract problems, especially in old women, due to patients' reluctance to consult physicians for this kind of problem. (Urologia 2009; 76: 258-9)

Metanephric adenofibroma in a child with impaired renal function

A 5-year-old girl presented with a history of bilateral reflux nephropathy and a left kidney mass, suspicious of Wilms tumor on imaging studies. She underwent radical nephrectomy according to the National Wilms Tumor Study protocol. The pathology report was consistent with metanephric adenofibroma (MAF), for which radical nephrectomy was considered curative. MAF is a benign, uncommon tumor, which is frequently confused with Wilms tumor on diagnostic imaging; histopathologic studies reveal the diagnosis. The diagnostic and management approach to MAF is discussed.

Outcome of isolated cases of antenatal hydronephrosis and its correlation with urinary tract anomalies

Introduction: Hydronephrosis is the most common congenital disorder diagnosed by prenatal ultrasonography. Objectives: The aim of this study was to evaluate the outcome of neonates with prenatal hydronephrosis and to determine its correlation with urinary tract anomalies. Patients and Methods: This cross-sectional study was conducted on 1453 neonates with prenatal hydronephrosis. The sonography was conducted on the third day after birth. In emergency conditions, it was conducted on first day to evaluate the possible anomalies. In severely positive cases, voiding cystourethrogram (VCUG) and technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) scan was requested too. Accordingly in cases who hydronephrosis after birth was not existed, a sonography was repeated on the sixth week after birth. Results: The mean anteroposterior pelvic diameter (APPD) was 17.66 ± 11.2 mm. The vesicoureteral reflux (VUR) was not observed in 74.2% of 1453 case of prenatal hydronephrosis. Around, 13.8% had unilateral and 12% had bilateral reflux. In DTPA scan, 92.9% % of cases had no obstruction, while 7.1% of cases had some degree of obstruction. Ureteropelvic junction obstruction (UPJO) was seen in 72.9%, and ureterovesical junction (UVJ) obstruction was presented in 22.4% of cases. Conclusion: Antenatal diagnosis of urinary tract anomalies allowed immediate application of prophylactic antibiotics, and decreased the risk of future complications as observed in this study. Management of congenital hydronephrosis is a clinical challenge. The natural history of hydronephrosis reveals that most cases resolve spontaneously but non-operative management with close follow-up is recommended.