Bladder Trabeculation Research Articles

Determinants of prolonged baseline blood pressure restoration following autonomic dysreflexia for individuals with spinal cord injuries

Objective This study aimed to identify the determinants affecting the time required for blood pressure (BP) restoration after autonomic dysreflexia (AD) and to propose a new method for BP measurement in individuals with cervical spinal cord injury (SCI) who experience AD. Methods In a prospective, single-center observational study, participants’ bladders were filled with body-temperature saline until reaching cystometric capacity, as confirmed by previous urodynamic studies. Restoration time (RT), defined as the time from the onset of voiding until BP returned to baseline, was measured during the morning voiding session. This session involved the use of a 10F hydrophilic transurethral catheter. Data were then compared with various clinical determinants including demographic, urodynamic, and cystographic variables. Results The study included 29 individuals with cervical SCI. Notable variations in RT were observed among individuals with differing levels of detrusor overactivity (DO) and bladder compliance. An inverse correlation was noted between RT and bladder compliance, whereas positive correlations were identified with maximal detrusor pressure, peak systolic BP (SBP), and the magnitude of BP changes. Factors associated with prolonged RT included injury completeness, bladder trabeculation, vesicoureteral reflux (VUR), DO, and changes in SBP. Conclusions A significant association was found between BP elevation and prolonged RT. Determinants such as the severity of the SCI, bladder trabeculation, VUR, and DO were correlated with prolonged RT, considering their importance in the assessment of baseline BP following AD.

Results of a defined surgical protocol for treating pediatric neurogenic bladder incontinence in a single institution

Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness. This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N=21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use. The mean age at surgery was 11.6 years (SD=6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2. Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure. Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.

External validation and reliability assessment of posterior urethral morphology on initial voiding cystourethrogram as a predictor for infants with posterior urethral valves

The morphology of the bladder and posterior urethra on initial voiding cystourethrogram (VCUG) in posterior urethral valve (PUV) has been proposed as a meaningful early metric for short- and long-term kidney outcomes. Here, we seek to externally validate the proposed association and assess the reliability of PUV morphology characteristics. We reviewed our institutional database for patients managed for PUV between 2000 and 2022 and included those treated with primary ablation with at least 1 year of follow-up for kidney function. Each VCUG was evaluated by three independent raters for the height-width ratio of the bladder (HW-B), height-width ratio of the posterior urethra (HW-PU), and posterior-anterior urethral ratio (PA-UR), and trabeculation (none, fine, or coarse). We assessed the reliability in these with intra-class coefficient and Fleiss kappa for continuous and categorical data, respectively. We performed univariate analysis with nadir creatinine and five-year follow-up glomerular filtration rate (GFR). In total, 98 patients met inclusion criteria. The median age at diagnosis and ablation was 10 and 21 days, respectively. Patients with nadir creatinine <0.8mg/dL had higher follow-up GFR (101 vs. 20ml/min/1.73m2, p=0.04), and lower risk of CKD (odds ratio 14.7, p=0.002). The median value for HW-B was 1.4, median HW-PU was 2.1, and median PA-U was 4.7, There was significant inter-class agreement between all three measures of 0.80, 0.51, and 0.70 (p<0.001). The inter-rater agreement for bladder trabeculation was fair (Fleiss K=0.40, p<0.001). There was no statistically significant correlation between HW-B, HW-PU, PU-A with nadir creatinine (p=0.07, 0.33, 0.91) or 5-year GFR (0.27, 0.45, 0.62), respectively. There is significant interest in determining prognostic factors and metrics in PUV. The morphological characteristics on VCUG are reliable and is available information for all boys diagnosed with PUV, resulting in an attractive metric. While we do not demonstrate correlation with kidney outcomes, VCUG features warrant further attention as prognostic factors in PUV. PUV morphology on initial VCUG is a reliable metric of lower urinary tract deformity but is not associated with 5-year kidney outcomes.

A grading system for evaluation of bladder trabeculation.

To establish a parameter-based grading system for evaluating bladder trabeculation (BT). A retrospective analysis was conducted on children diagnosed with posterior urethral valve (PUV) or neurogenic bladder (NB) who underwent voiding cystourethrogram (VCUG), urodynamic testing, and urological ultrasonography between January 2016 and October 2022. Cases involving urologic surgery, secondary bladder pathology, and an interval of more than 12months between examinations were excluded. A parameter named Bladder Dispersion (BD) was calculated through fluoroscopic images, and the grading system was developed as follows: BD < 40 (Grade 0), 40 ≤ BD < 60 (Grade 1), 60 ≤ BD < 90 (Grade 2), BD ≥ 90 (Grade 3). Grades 0-1 were classified as low-risk group, while grades 2-3 were classified as high-risk group. Analysis of variance, Kruskal-Wallis test, and Chi-square test were performed to compare urodynamic results and complications across different grades and groups. A total of 74 patients were eligible to participate, which included 46 boys (62.2%) and 28 girls (37.8%), the mean age was 75.18 ± 48.39months. Among them, 11 (14.9%) were PUV, 50 (67.6%) were NB, and 13 (17.5%) were PUV and NB. Significant differences were observed in maximum detrusor pressure, post-void residual urine ratio, and compliance among grades 0-3. Severe hydronephrosis and histories of urinary tract infection were more prevalent in the high-risk group. A reliable grading system with objective standards was proposed which could aid in the assessment of BT severity.

Understanding factors influencing primary treatment with intradetrusor onabotulinumtoxinA versus augmentation cystoplasty in patients with spina bifida.

Surgical interventions in the urologic management of children with neurogenic bladder secondary to spina bifida aim to preserve upper tract function, prevent urinary tract infections, and optimize quality of life. However, since the introduction of intravesical onabotulinumtoxinA (Botox) in the management of these patients, the indications for choosing Botox over augmentation cystoplasty (AC) remain undefined. The objective of this study was to determine which factors lead patients to undergo Botox versus AC as a primary surgical treatment after failing medical management. We retrospectively reviewed the records of pediatric patients with myelomeningocele undergoing either primary Botox or primary AC at our institution between 2013 and 2018. We recorded demographic and clinical information. We identified 10 important clinical decision-making factors: bladder trabeculation, vesicoureteral reflux, or hydronephrosis on imaging; end-filling pressure (EFP) ≥40 cm H2O, detrusor overactivity, detrusor-sphincter dyssynergia, or reduced capacity on urodynamic studies; physician-perceived bladder hostility; and patient/family desire for continence and independence. The presence of these factors was compared between patients undergoing either primary Botox or primary AC. We identified 14 and 50 myelomeningocele patients who underwent primary AC and primary Botox, respectively. We found no significant differences in age, sex, race, or history of reconstructive surgery (antegrade continence enema or catheterizable channel). For the 10 decision-making factors, desire for independence/continence (p = <0.001) and reduced capacity (p = 0.002) were significantly associated with AC, while trabeculation (p = 0.006), EFP ≥40 cm H2O (p = 0.029), rising slope (p = 0.019), and physician-perceived hostility (p = 0.012) were significantly more common with Botox. At our institution, quality of life measures prompted AC over objective urodynamic or imaging findings before attempting Botox. These findings support a shared decision-making approach when considering surgical intervention for neurogenic bladder secondary to myelomeningocele.

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

In this interesting paper, the authors have studied the bladder height to width ratio (HW-B), posterior urethral height to width ratio (HW-PU), posterior-anterior urethral ratio (PA-UR) and bladder trabeculation grade on initial voiding cystourethrogram (VCUG) of children with posterior urethral valve (PUV) and found that only HW-PU significantly correlated with a higher nadir creatinine at one-year of age [1]. Niyogi [2] proposed that in children with PUV increasingly distorted bladder shape was associated with poor bladder dynamics and proposed shape, wall, reflux and diverticuli (SWRD) score.

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.

Association of bladder trabeculation and neurogenic bladder with spinal cord injury

ObjectiveTo compare clinical findings and urodynamic parameters according to trabeculation grade and analyze their correlations with trabeculation severity in neurogenic bladder caused by suprasacral spinal cord injury (SCI).MethodsA retrospective chart review was performed of neurogenic bladder caused by SCI. Bladder trabeculation grade was compared with SCI-related clinical parameters and bladder-related urodynamic parameters.ResultsIn SCI patients, factors such as disease duration, bladder capacity, detrusor pressure, peak detrusor pressure values, and compliance were significantly different between different grades of bladder trabeculation, while neurological level of injury, completeness, and detrusor sphincter dyssynergia had no clear relationship with bladder trabeculation grade. In the correlation analysis, vesicoureteral reflux was moderately correlated with trabeculation grade (correlation coefficient 0.433), while the correlation coefficients of disease duration, involuntary detrusor contraction, and bladder filling volume were between 0.3 and 0.4.ConclusionBladder trabeculation with suprasacral-type neurogenic bladder was graded. Although disease duration was positively correlated with bladder trabeculation grade, differences in the neurological level of injury or American Spinal Injury Association Impairment Scale score were not observed. Bladder volume, peak detrusor pressure, compliance, reflex volume, and vesicoureteral reflux also showed significant differences according to trabeculation grade. Vesicoureteral reflux was moderately correlated with trabeculation grade.

Risk Factors for Recurrent Urinary Tract Infection in Children With Neurogenic Bladder Following Clean Intermittent Catheterization

ObjectiveTo investigate the risk factors for recurrent urinary tract infection (UTI) in children with a neurogenic bladder (NB) managed by clean intermittent catheterization. Materials and MethodsOver a 5-year period, we retrospectively assessed the risk factors for recurrent UTIs in children (age 9-151 months) who had clean intermittent catheterization. All patients were followed up for more than 12 months and had at least two clinic visits during the study period. Demographic, clinical, and urodynamic parameters were assessed. All data were compared between the recurrent UTI (>1.0 UTI/study-year) and episodic UTI (≤1.0 UTI/study-year) groups. ResultsOf 327 patients, 79 (24.2%) had recurrent UTIs and 248 (75.8%) had episodic UTIs. Univariate and multivariate analyses showed that older age, lumbar level lesions, long duration of NB, presence of vesicoureteral reflux, increased bladder wall thickness, and low bladder compliance were the significant factors for recurrent UTIs. Bladder trabeculation was associated with recurrent UTIs on univariate analysis, but not on multivariate analysis. During the follow-up period, chronic renal insufficiency was diagnosed in 31 (39.2%) and 29 patients (11.7%) in the recurrent and episodic UTI groups (P <.05), respectively. ConclusionThese results suggest that older age, high level of spinal cord lesions, long duration of NB, vesicoureteral reflux, increased bladder wall thickness, and low bladder compliance may be directly associated with recurrent UTIs in children with NB. Children with NB might have higher susceptibility to chronic renal insufficiency after recurrent UTIs.

Association between Urodynamic and Cystoscopic findings in Women with Bothersome Lower Urinary Tract Symptoms: A Prospective Observational Study

Introduction: Lower Urinary Tract Symptoms (LUTS) are responsible for negative impact on quality of life of women. Urodynamic Study (UDS) is gold standard objective investigation in evaluating bothersome LUTS. Cystoscopy is important where UDS is difficult or unavailable. Despite vital role and unique properties of UDS and cystoscopy, the role of UDS and cystoscopy in the assessment of bothersome LUTS in young females continues to be heavily debatable subject as there is limited study in this age group. Aim: To evaluate causes of LUTS in young female patients and associate them with urodynamic and cystoscopic findings. Materials and Methods: This was a prospective observational study conducted in IPGMER and SSKM Hospital, Kolkata, West Bengal, India, from July 2019 to December 2020. A total of 100 female patients from adulthood to menopause were evaluated having decreased quality of life due to LUTS called bothersome LUTS in the form of history taking, clinical examination, basic biochemical tests, ultrasonography followed by urodynamic and cystoscopic examination. Patients were classified according to their LUTS into three groups: storage dysfunction, urinary incontinence and bladder emptying dysfunction. Association of UDS parameters like Idiopathic Detrusor Overactivity (IDO), IDO with detrusor underactivity, Compensated Bladder Outlet Obstruction (CBOO) was made with cystoscopic findings like dilated veins with cystitis,lax urethra, bladder trabeculations,diverticula, urethral stricture. Results were analyzed using Microsoft Excel spreadsheet and International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 27.0. Results: In storage dysfunction group, frequency with nocturia (53.3%) and in urinary incontinence group, stress urinary incontinence (58.3%) was predominant bothersome symptom. In storage dysfunction group 73.3% patients had IDO and 26.7% patients had normal UDS findings. In these patients on cystoscopic examination, 83.3% patients had dilated veins with cystitis changes. In urinary incontinence group 70.8% patients had IDO and 29.2% patients had IDO with detrusor underactivity on UDS examination. In these patients cystoscopic examination 54.2% had lax urethra with cystitis changes. In bladder emptying dysfunction group on UDS examination, all patients had CBOO and 75% had urethral stricture on cystoscopy. Conclusion: Significant association exists between UDS and cystoscopic findings on evaluation of LUTS in young females patients. Storage dysfunction symptoms were the most common in young age group followed by urinary incontinence symptoms. Bladder emptying dysfunction symptoms were least common.

PD23-04 THE IMPACT OF PROSTATIC URETHRAL LIFT ON ALPHA-BLOCKER DISCONTINUATION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology IV (PD23)1 Sep 2021PD23-04 THE IMPACT OF PROSTATIC URETHRAL LIFT ON ALPHA-BLOCKER DISCONTINUATION Ankur Shah, Andrea Yeguez, Robert Zhang, and Robert Kovell Ankur ShahAnkur Shah More articles by this author , Andrea YeguezAndrea Yeguez More articles by this author , Robert ZhangRobert Zhang More articles by this author , and Robert KovellRobert Kovell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002016.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostatic urethral lift (PUL) is a widely utilized minimally invasive treatment for benign prostatic hypertrophy (BPH) indicated in men with prostates less than 80 grams who desire preservation of erectile and ejaculatory function. Like many chronic conditions, men with symptomatic BPH tend to have poor medication adherence rates, estimated around 30%. While the majority of evidence demonstrates that PUL is safe and durable at 5 years, these studies primarily evaluate postoperative changes in patients’ urinary and erectile symptom scores and maximum urinary flow rates. There is sparse evidence on the impact of PUL on AB therapy. We therefore sought to evaluate whether PUL reduced the need for AB use postoperatively. We hypothesized PUL would decrease AB utilization. METHODS: We performed a retrospective analysis of 88 patients on AB therapy who underwent PUL from 2018 to 2020 at a single institution. We collected patients’ baseline demographic data and preoperative American Urological Association Symptom Score (AUASS). We also recorded the presence of diabetes mellitus, degree of bladder trabeculation, presence of urethral stricture, prior benign prostatic intervention and history of urinary retention. We then determined whether patients were on AB before and after their surgery using electronic records. Logistic regression was used to examine predictors of post-procedural discontinuation of AB. Paired student’s t-test and chi square test were utilized to compare continuous and categorical variables, respectively. RESULTS: No patients had prior prostatic surgical intervention or urethral strictures. Fifty-three percent of patients were able to discontinue AB therapy postoperatively. Patients with diabetes mellitus were more likely to require AB postoperatively (p<0.01). Age, race, AUASS, degree of bladder trabeculation, and a history of urinary retention requiring catheterization were not predictors of postoperative discontinuation of AB (Figure 1). CONCLUSIONS: PUL allowed more than half of patients undergoing surgery to discontinue use of their AB treatment. While further investigation is necessary, the findings of this study suggest PUL may be an effective alternative for men who have difficulty with or seek to avoid long-term medication use. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e421-e421 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ankur Shah More articles by this author Andrea Yeguez More articles by this author Robert Zhang More articles by this author Robert Kovell More articles by this author Expand All Advertisement Loading ...

Detection of bladder trabeculation by voiding cystourethrography and sonography: observations in boys with posterior urethral valves

BackgroundAs trabeculated bladder wall is often referred to as a sign of chronically increased intravesical pressure, we investigated whether voiding cystourethrography (VCUG) or sonography reliably predicts bladder trabeculation on later...

Are Tubular Injury Markers NGAL and KIM-1 Useful in Pediatric Neurogenic Bladder?

The lack of early biomarkers of renal damage in children with neurogenic bladder (NB) prompts us to investigate the role of promising proteins: neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1). This prospective analysis was conducted on 58 children with NB and 25 healthy children. We assessed urinary levels of NGAL and KIM-1 in both groups. Age, sex, anthropometric measurements, activity assessment, renal function, and urodynamics parameters were analyzed. The differences between the median uNGAL and uKIM-1 in the NB group compared to control were recorded. However, only uNGAL levels were statistically significantly higher. Statistically significant correlation was found between gender, recurrent urinary tract infections, bladder trabeculation, its compliance, activity assessment, and uNGAL. To conclude, elevated levels of uNGAL may be considered a biomarker of tubular injury in children with NB due to MMC in contrast to uKIM-1.

Incidence of Renal Tract Abnormalities on Ultrasonography in Patients with Spinal Cord Injury: A Retrospective Pilot Study of a Military Cohort Undergoing Long-Term Institutional Rehabilitation.

Study DesignRetrospective pilot study.PurposeTo assess the incidence of renal tract abnormalities using ultrasonography (US) in a military cohort with traumatic spinal cord injury (TSCI) at a tertiary level spinal cord injury center.Overview of LiteratureNeurogenic bladder in TSCI patients results in significant urological morbidity. There is lack of data for these patients during the first 18 months of long-term rehabilitation in an institutional setting.MethodsWe retrospectively reviewed patient records to collect data on demographic characteristics, injury level, injury severity, time since injury, bladder management methods (such as an indwelling catheter [IC], clean intermittent catheterization [CIC], or self-voiding [S]); we correlated these data with the findings of the renal tract US.ResultsThe study included 73 out of 81 male participants. The mean patient age was 29.99 years; the study group included 34.2% tetraplegics and 65.8% people with paraplegia. The time since injury was 6–12 months for 42.5% of the subjects and 12–18 months for 57.5% of the subjects. A normal US scan was recorded in 65.7% patients, and bladder trabeculation was the commonest finding in 15.1% of the subjects, followed by hydronephrosis (HDN) in 12.3%, and renal calculus and atrophy in 1.3% participants each. We found 22.22% of the IC group participants had higher US abnormalities than those in the reflex voiding group (statistically non-significant difference, p=0.7). Trabeculations (21.4%) and HDN (19%) were more common in those who had sustained the injury 12–18 months previously as compared to that in those who had injured themselves 6–12 months previously (p=0.04). The proportion of patients who had a normal US scan was higher in the group who sustained the injury 6–12 months previously versus those who had sustained the injury 12–18 months previously; the difference was statistically significant (p=0.02). There was no significant (p=0.72) correlation in the bladder management method, injury level, and renal tract abnormalities between the groups.ConclusionsThis retrospective study shows that 65% of TSCI participants had no renal tract abnormality on US scan and bladder trabeculation ruled out as the most common finding. Long-term supervised rehabilitation may help achieve good renal quality of life; however, further prospective trials are required on this subject.

Urinary tract imaging in infants with spina bifida: a selective approach to a baseline DMSA

There is no general agreement among paediatric urologists on how infants with spina bifida (SB) should be investigated after birth. Recently the EUA/ESPU guidelines have been published recommending a baseline DMSA scan in the first year of life and a Voiding Cystourethrogram (VCUG) or Videourodynamic (VUD) between the second and third month of life. The aim of this study was to evaluate the outcome of renal investigations in the first year of life in infants with SB to verify if an early DMSA scan is indicated in the management of this group of patients. All renal imaging, Renal and Bladder Ultrasound (RBUS), VCUGs, VUDs and DMSA were reviewed by two independent assessors to evaluate outcome. Seventy patients with spina bifida (40 girls) were enrolled between June 2015 and February 2020. An early VUD detected vesico-ureteral reflux (VUR) in 8/49 (16%) of patients. An early VUD also gave additional information on detrusor under or over activity, bladder trabeculation, end filling detrusor pressure (EFDP) and sphincteric incompetence. DMSA scan detected renal scarring in 4/68 (6%) patients. Three of these 4 patients had significant history of febrile UTIs while the fourth patient had grade 2 left sided VUR. The initial assessment of a newborn with myelodysplasia includes a Renal and Bladder Ultrasound during birth hospitalization. This study confirms the recently published EUA/ESPU guidelines on the management of neurogenic bladder in children and adolescents, which recommend a VUD or VCUG & Cystomanometry with Electromyogram (CMG) (if VUD not available) in the first 6-12 weeks of life. A selective approach to DMSA scan only in infants with SB who either had a febrile UTI or vesico-ureteric reflux would not have missed any scarring or dysplasia and would have saved 58 unnecessary nuclear scans.

Hydroureteronephrosis in a male infant

A 7-month-old boy was diagnosed with his first febrile urinary tract infection (UTI) when a catheterized urine sample revealed pyuria with significant growth of Klebsiella pneumoniae in culture. In addition, no fetal pelvicalyceal dilatation was observed. His urinary stream was also reportedly normal. Renal ultrasound done post-UTI showed bilateral hydroureteronephrosis (renal pelvis, left 23 mm; right 13 mm) and a trabeculated bladder with thickened wall of 3.3 mm. Additionally, he underwent a voiding cystourethrogram (VCUG) showing left grade V vesicoureteral reflux (VUR) and proximal dilatation of the posterior urethra (Fig. 1). Cystoscopy confirmed the diagnosis of a posterior urethral valve (PUV) which was successfully fulgurated. A dimercaptosuccinic acid radioisotope renal scan performed 3 months later showed equal cortical uptake with no photopenic defects. Infants diagnosed with UTI should undergo renal sonographic evaluation even though antenatal scans had been normal, since this could be the first occurrence of congenital structural renal abnormality. Patients found to have hydroureteronephrosis on sonography should undergo further examination with VCUG for the identification of VUR or bladder and urethral abnormalities. The presence of a dilated posterior urethra, bladder neck hypertrophy, bladder trabeculation, and secondary VUR on VCUG would strongly indicate the diagnosis of PUV.1Berrocal T. López-Pereira P. Arjonilla A. Gutiérrez J. Anomalies of the distal ureter, bladder, and urethra in children: embryologic, radiologic, and pathologic features.Radiographics. 2002; 22: 1139-1164Crossref PubMed Scopus (166) Google Scholar PUV is the most common cause of congenital bladder outlet obstruction in males, affecting 0.02% of live male births. Most cases are detected antenatally or early postnatally, with poor urinary stream or recurrent UTIs. Milder cases may also occur at a later stage in childhood with voiding difficulties.2Hodges S.J. Patel B. McLorie G. Atala A. Posterior urethral valves.ScientificWorldJournal. 2009; 9: 1119-1126Crossref PubMed Scopus (63) Google Scholar,3Lopez Pereira P. Martinez Urrutia M.J. Espinosa L. Jaureguizar E. Long-term consequences of posterior urethral valves.J Pediatr Urol. 2013; 9: 590-596Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Importantly, PUV can lead to progressive renal disease, the pathogenesis of which includes obstructive uropathy and underlying renal dysplasia associated with abnormal nephrogenesis. Mainstay treatment of PUV is surgical relief of obstruction, usually by valve ablation; upper urinary tract diversion can also be done as a temporary measure or if urinary tract dilatation is persistent. Although surgical correction can relieve obstructive uropathy and prevent recurrent UTIs, renal dysplasia is not reversible. Since the degree of underlying renal dysplasia may lead to poor renal function, the longitudinal follow-up of all patients with PUV is important for serial monitoring of renal function, even after surgical correction.3Lopez Pereira P. Martinez Urrutia M.J. Espinosa L. Jaureguizar E. Long-term consequences of posterior urethral valves.J Pediatr Urol. 2013; 9: 590-596Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar

Video Atlas of Cystourethroscopy Findings

Study Objective The objectives of this video are to demonstrate normal findings at the time of cystourethroscopy, show examples of common benign findings within the bladder and urethra, and to show lesions that warrant additional investigation. We hope to provide examples of common benign and malignant findings to gynecologic surgeons to assist with recognition if they incidentally found. Design N/A Setting Tertiary academic hospital with a high-volume gynecologic surgery practice Patients or Participants The images shown in the video are taken from a variety of patients undergoing cystoscopy by two urogynecologists. Interventions Images were obtained at the time of surgery for educational purposes Measurements and Main Results This video demonstrates the equipment and steps of performing cystourethroscopy. We review examples of the following benign anatomic variants: shaggy urethral fronds, squamous metaplasia, cystitis cystica, bladder trabeculations, ureterocele, bladder diverticula, bladder wall cysts, ureteral orifice cysts, hypervascularity, duplicated collecting systems, foreign bodies, and fistulas. We also review two examples of neoplastic findings, including urothelial papilloma and papillary urothelial carcinoma. Conclusion Cystoscopy can be a useful procedure in the office and operating room. Gynecologic surgeons should be familiar with normal cystoscopy findings. If abnormalities are found, it is the surgeon's responsibility to document and refer the patient for additional testing if indicated.

A simple screening tool for an unfavorable bladder in children with myelomeningocele: Is the height to width ratio of the cystogram useful to predict high-pressure bladder?

Videourodynamics is the key follow-up examination of children with myelomeningocele. However, it has been performed in specific institutions focused on the urological management of children due to the difficulty in its interpretation. Although a neurogenic bladder frequently appears elongated vertically and trabeculated, no objective study has clearly shown the relationship between bladder shape on the cystogram and urodynamic parameters in children with myelomeningocele. The aim of this study was to investigate the usefulness of the height to width ratio of cystogram (HWR) as a screening tool for finding high-pressure bladder in children with myelomeningocele.Study design the medical records of children with myelomeningocele aged less than 13 years who underwent videourodynamics were reviewed. Maximum detrusor pressure (MDP) was defined as the maximum detrusor pressure at end-filling or at leak. HWR was calculated by the maximum height/maximum width of the cystogram appearance at maximum cystometric capacity (Figure) The children were categorized into two groups: children with high-pressure bladder (MDP≥40 cmH2O) and low-pressure bladder (MDP<40cmH2O). Age, sex, videourodynamics variables, and HWR were compared between the 2 groups. Using the results of the above, receiver-operating characteristic (ROC) curves were constructed. A total of 81 children who were on clean intermittent catheterization met the study criteria. All children were on CIC, and their median age was 81 months (IQR 54-128 months). The HWR was significantly higher for high-pressure bladders than for low-pressure bladders (median 1.50 vs 1.37, p=0.004). The sensitivity and specificity of the HWR for discriminating children with high-pressure bladder from all children were 87% and 56.9%, respectively. The area under the curve (AUC) was 0.71 with a cutoff score of 1.40. Bladder deformity was objectively evaluated by the HWR, and measurement of the HWR was straightforward. The main drawback of this evaluation method for bladder shape is to disregard the presence or absence of bladder trabeculation, which has been considered a key finding of an unfavorable bladder in this population. Based on the HWR ROC curves, the AUC was 0.71, which meant that the HWR would be considered to be fair at screening for high-pressure bladder. The height to width ratio of the cystogram was a useful tool for objectively evaluating bladder shape in children with myelomeningocele, and a cut-off point of 1.40 could be used as a simple screening tool for high-pressure bladder in this population.

Estimation of renal scarring in children with lower urinary tract dysfunction by utilizing resampling technique and machine learning algorithms

Aim: Classical database methods may be inadequate for large data sets accumulating continuously. Machine learning (ML), one of the main subsets of artificial intelligence, may solve this problem and find the best solution for future problems by gaining experience from the present data in medical studies. A method that may show the correlation between clinical findings and renal scarring (RS) with high accuracy in patients with lower urinary tract dysfunction (LUTD) is needed. In this study, the aim is to establish a model for the prediction of RS in children with LUTD by using ML. Methods: Patients older than three years of age (n=114) who needed urodynamic study were included in the study. There were 47 variables in the data set. Variables such as symptomatic urinary tract infection, vesicoureteral reflux, bladder trabeculation, bladder wall thickness, abnormal DMSA scintigraphy, and the use of clean intermittent catheterization were recorded. Several ML techniques (MLT) were applied to estimate RS. Results: As a result of the comparisons, the highest accuracy rate according to the confusion matrix was obtained by the Extreme Gradient Boosting (XGB) algorithm (91.30%). In the balanced (SMOTE) data set, the highest accuracy rate was obtained by the Artificial Neural Network (ANN) algorithm (90.63%). According to the Receiver Operating Characteristic (ROC), the highest success rate was obtained by the ANN algorithm in the balanced (SMOTE) data set (90.78%). Conclusion: High accuracy rates obtained by MLT may suggest that MLT might provide a faster and accurate evaluation process in the estimation of RS in patients with LUTD.

Development and validation of a bladder trabeculation grading system in pediatric neurogenic bladder

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p<0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p<0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p<0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB.