Cases Of Vesicoureteral Reflux Research Articles

A pediatric patient case of vesicoureteral reflux: Successful healing using Yoga Prana Vidya protocols

Vesicoureteral reflux (VUR) is characterized by abnormal urine flow from the bladder back through the ureters, finally reaching the kidneys. The disease is usually symptomless and is diagnosed accidentally when patients suffer from febrile urinary tract infections. Many treatment guidelines are available ranging from medicine to surgery. However, management is a clinical art. Here, we present a pediatric case of VUR healed by Yoga Prana Vidya (YPV) therapies without surgery. The normal condition of the patient’s kidneys and bladder was achieved within 2½ months of the YPV healing intervention. This case shows that YPV protocols have successfully treated a pediatric VUR condition without the need for surgery. Further research using appropriate sample and methodology is recommended.

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.

Evaluation of screening with urine dipsticks and renal ultrasonography for 3-year-olds in Chiba City over 30years.

Urinary screening for 3-year-olds cannot adequately detect congenital anomalies of the kidney and urinary tract (CAKUT). Urinary screening for 3-year-olds was investigated over 30years. Dipsticks for proteinuria, hematuria, glycosuria, leukocyturia, and nitrite at first screening, and dipsticks, urinary sediments, and renal ultrasonography at second screening were performed. Screening results were evaluated. The positive rates of proteinuria, hematuria, leukocyturia, and nitrite relative to 218,831 children at the first screening were 1.0%, 4.6%, 2.3%, and 0.88%, respectively. Thirty-seven glomerular disease, 122 CAKUT, and 5 urological disease cases were found. We detected 6 stage 3-4 chronic kidney disease (CKD) and 3 end-stage kidney disease cases, including 3 CAKUT, comprising 2 bilateral renal hypoplasia and 1 vesicoureteral reflux (VUR), and 6 glomerular diseases, comprising 4 focal segmental glomerulosclerosis and 2 Alport syndrome. The positive rates relative to 218,831 children and CKD detection rates for each tentative diagnosis of mild hematuria, severe hematuria, proteinuria and hematuria, proteinuria, and suspected urinary tract infection were 1.4% and 0.67%, 0.11% and 3.7%, 0.01% and 28.6%, 0.02% and 45.0%, and 0.08% and 9.7%, respectively. Among 14 VUR cases with significant bacteriuria, 13 were found by leukocyturia, 12 had grade ≥IV VUR, and 10 had severe renal scars. Nine stage 3-5 CKD cases comprising 3 CAKUT and 6 glomerular disease were found by urinary screening of 3-year-olds among 218,831 children. The combination of urine dipsticks including leukocyturia at the first screening and ultrasonography at the second screening appeared useful.

Ionizing Radiation Exposure in Children with Vesicoureteral Reflux: Should We Be Alarmed?

Abstract Objectives Ionizing radiation imaging is commonly used for diagnosis and follow up in children with vesicoureteral reflux (VUR). We aim to measure the effective dose (mSv) in patients with VUR. Methods We reviewed our electronic database of patients under 8-years-old with VUR. Primary endpoint was to calculate the effective radiation dose (ED). Absolute frequencies and percentages were reported for global qualitative variables. This study conducted a logistic regression model to calculate the odds ratio for radiation exposure. Analysis was performed using STATA version 14.0 (StataCorp LLC, College Station, TX, EEUU). Results A total of 140 patients were found, 97 were assessed for eligibility. We included 59 patients in the final analysis. Mean age was 20 ± 17.9 months, 66% were females. Most cases of VUR were bilateral (44%) and high grade (93.4%). The lowest number of studies per patient was two, with a minimum radiation of 5.7 mSv. The highest radiation was estimated at 20.7 mSv corresponding to a total of five studies. Logistic regression showed that highest grades of VUR and age of first UTI episode were associated with higher ED (OR, 1.7; 95% CI, 0.87-3.31), (OR 1.02; 95% CI 0.97-1.07) respectively. A mean ED for children with VUR was estimated of 5.5 ± 3 mSv/year. Conclusion In our study, the children with VUR were exposed to 5.5 mSv/year without counting the natural background radiation, which is alarming, and we believe should raise awareness worldwide in how we are unnecessarily diagnosing indolent VUR cases and following patients.

Contrast-enhanced voiding urosonography for the diagnosis of vesicoureteral reflux and intrarenal reflux: a comparison of diagnostic performance with fluoroscopic voiding cystourethrography.

PurposeThis study evaluated the diagnostic performance of contrast-enhanced voiding urosonography (ce-VUS) using a second-generation ultrasound contrast agent for the diagnosis of vesicoureteral reflux (VUR) and intrarenal reflux (IRR), and compared it with that of standard fluoroscopic voiding cystourethrography (VCUG).MethodsThirty-two consecutive children from April to October 2019 were included in this study. ce-VUS and VCUG were performed simultaneously by two operators with intravesical infusion of a mixture of ultrasound contrast medium, iodinated contrast medium and water. Two pediatric radiologists independently reviewed the ce-VUS and VCUG images and reported the presence and degree of VUR (grades I-V), and the presence and type of IRR.ResultsTwenty-seven of 63 urinary systems showed VUR. Interobserver agreement for VUR grading was very good for both examinations (κ=0.87; 95% confidence interval [CI], 0.82 to 0.92 for ce-VUS and κ=0.92; 95% CI, 0.87 to 0.96 for VCUG). The detection rate of VUR showed no significant difference between the two examinations (P=0.370). Four cases of VUR were missed on ce-VUS, while one case of VUR was missed on VCUG. All four false-negative cases on ce-VUS were grade 1 VUR. The two examinations showed very good agreement regarding VUR grading (κ =0.89; 95% CI, 0.81 to 0.96). IRR was more frequently detected with ce-VUS than with VCUG (10 cases with ce-VUS vs. 3 cases with VCUG, P=0.016).Conclusionce-VUS showed very good agreement with VCUG for detecting grade 2 VUR and above, while grade 1 VUR was sometimes missed with ce-VUS. IRR was more frequently detected with ce-VUS than with VCUG.

Endoscopic treatment of symptomatic VUR disease after the renal transplantation: analysis of 49 cases.

To evaluate the outcome of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) disease in renal transplantation patients and to determine the factors that were associated with the success rate of the treatment. A total of 121 symptomatic VUR diseases diagnosed between 2014 and 2018 in 3560 renal transplant patients. The results of 49 VUR cases that presented with febrile urinary tract infection (UTI) and were hospitalized for antibiotic treatment were included in the study. Reflux was detected by voiding cystourethrogram and treatment was performed by endoscopic Deflux® injection. The result of endoscopic treatment was evaluated clinically by 3months periods. The mean time between transplantation and endoscopic treatment was 59.6 (5-132) months, and the mean follow-up period after the endoscopic treatment was 14 (6-48) months, respectively. The success rate after the first injection was 59.1% (n = 29) and 67.3% (n = 33) after the second injection. One patient developed anuria, one patient febrile UTI and four patients developed minimal macroscopic hematuria after the procedure. Endoscopic treatment of symptomatic VUR in transplanted kidney is a safe and feasible procedure. The amount of bulking agent or duration between the transplantation and diagnosis of VUR does not have any impact on the success of the treatment. However, the younger age of the patients and the female gender seem to have a positive effect on the outcome of the procedure.

Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation.

Introduction:Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR).Materials and Methods:We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test.Results:Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5–2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively.Conclusion:SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.

Minimally-Invasive Ureteral Reconstruction for Ureteral Complications of Kidney Transplants

ObjectiveTo present the technique, feasibility and results of minimally-invasive reconstruction of the transplanted ureter using the native ipsilateral ureter in post-transplant ureteral strictures and vesicoureteral reflux (VUR) causing graft pyelonephritis. Ureteral complications after kidney transplantation represent a significant cause of morbidity potentially leading to graft dysfunction or loss. MethodsA prospective database from October 2011 to August 2018 identified renal transplant recipients who underwent minimally-invasive pyeloureterostomies or ureteroureterostomies using the ipsilateral ureter. Indications for either transplant ureteral stricture or VUR correction were assessed. Preoperative evaluation included a technetium-99m mercaptoacetyltriglycine renal scan to assess residual native renal function and either a video cysto-urethrogram or cystoscopy and retrograde pyelography. Postoperative patency was evaluated with either cystograms or antegrade nephrograms in conjunction with a technetium-99m mercaptoacetyltriglycine study. ResultsSeven patients were followed with a mean follow-up time of 20.9 months (range 4.7-64.8 months). Three cases of VUR causing graft pyelonephritis and 4 cases of transplant ureteral stricture were identified. Five minimally-invasive transplant-to-native pyeloureterostomies and 2 transplant-to-native ureteroureterostomies were performed. Six cases were performed robotically and 1 laparoscopically. No recurrent episodes of pyelonephritis were observed for patients treated for VUR causing graft pyelonephritis. Postoperative renal scans and contrast studies demonstrated no evidence of obstruction or urinary leaks in all cases. ConclusionMinimally-invasive reconstruction of the transplant ureter by pyeloureterostomy or ureteroureterostomy using the ipsilateral native ureter is feasible and can be safely performed with graft survival and acceptable complication rates.

Management of the Valves of the Posterior Urethra in Urology

Aim: Describe the clinical, radiological and management of patients with posterior urethral valves. Materials and Methods: This was a retrospective descriptive study over a period going from January 2011 to December 2016, reviewing 12 cases of patients treated for valves of the urethra posterior to the medical surgical center of urology in Cameroon at Douala. The variables studied were clinical, paraclinical, therapeutic and evolutionary. Results: In 5 years, we had diagnosed and treated 12 cases of posterior urethral valves, an average of 2.4 per year. The average age of patients was 41.6 months with extrems of 3 and 156 months. The reason for consultation was dominated by urinary tract infections. Urethrocystography and echography were performed in all patients and allowed to objectify a bilateral ureterohydronephrosis, a diverticular bladder in 9 cases and 4 cases of vesico-ureteral reflux, including a grade 4 according to the classification of Cendron, 8 patients suffered from acute urinary failure. Renal scintigraphyrealised on 3 patients had as objective in 1 patient the existence of a disfunctioning kidney. The treatment consisted of an endoscopic incision of the valves (n = 8), a vesicostomy (n = 3) and an iterative urethral dilatation with double J catheter placement (n = 1). The evolution was favorable (n = 7), and 5 cases of death were recorded. Conclusion: The endoscopic incision is the gold-standard of the treatment of the valves of the posterior urethra. The vesicostomy is an alternative in the absence of adequate technical platform. Despite adequate support, the prognosis remains burdened with significant mortality.

Endoscopic Treatment of Vesicoureteral Reflux in Infants. Can We Do It and Should We Do It?

To evaluate the outcomes of endoscopic treatment of vesicoureteral reflux (VUR) performed on infants, and to discuss the possible role of this approach in selected cases. A retrospective analysis was conducted on the patients who underwent endoscopic injection of a bulking substance for VUR in our institution, and a comparison was made with patients treated during infancy and those treated later in life. A total of 463 ureteral units were included (296 children), of whom 47 were patients less than 1 year of age (infants, INF group); the remaining 416 were included in a second group (children, CHL). In this study, the percentage of high-grade VUR and presence of reflux nephropathy were significantly higher in younger patients. Both early failure and recurrence rate were significantly higher in the INF group when compared with the CHL group. No complications were observed in the INF group. Endoscopic treatment of VUR is feasible in patients less than 1 year of age. The effectiveness is lower than when patients are treated at a later age but was still over 80% in our series. There were no complications reported related to the procedure itself or to the general anesthesia. Once it is known that endoscopic treatment of VUR can be performed, controversy arises about the indication of treating patients with VUR. Careful selection of VUR cases that are less likely to spontaneously resolve, presence of breakthrough infections, and parental preference, all play a role in the decision-making process.

Decreased Identification of Vesicoureteral Reflux: A Cautionary Tale.

To find the trend in patient's visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns. Data were extracted from electronic medical records for new and follow-up patients aged 0-18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied. Annually, Le Bonheur Children's Hospital and Nationwide Children's Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively. We conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children's hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that "undifferentiated UTI" referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.

Laparoscopic-Assisted Extravesical Ureteral Reimplantation and Extracorporeal Ureteral Tapering Repair for Primary Obstructive Megaureter in Children.

Open surgery is a preferred treatment for primary obstructive megaureter (POM) in cases where the conservative treatment fails, with reported success rates of 90%-96%. To describe our initial experience in the treatment of POM by laparoscopic-assisted extracorporeal ureteral tapering repair (EUTR) and laparoscopic ureteral extravesical reimplantation (LUER) by following Lich Gregoir technique as an alternative to open surgery. A total of 7 patients with POM underwent laparoscopic-assisted extracorporeal ureteral tapering repair and ureteral extravesical reimplantation by following Lich Gregoir technique between 2011 and 2014. Postoperative follow-up included the following: Renal and bladder ultrasound, voiding cystourethrogram (VCUG), and mercaptoacetyltriglycine (MAG3) renogram were done at 6 months. Outcome Measurements and Statistical Analysis: Statistical analysis was performed by using the SPSS software package (version 15.0; SPSS, Chicago, IL), and P < .05 was considered statistically significant. Paired tests and Wilcoxon test were performed to compare pre- and post-measures. LUER and EUTR were completed successfully in all patients without conversion. A postoperative MAG3 renogram showed nonobstructive pattern in all patients. Statistical analysis revealed significant differences before and after surgery in the average time of elimination on the MAG3 renogram (T½ 59.10 minutes versus 13.57 minutes, P < .0001). After medium-term follow-up, the overall POM resolution was 100%. One case of vesicoureteral reflux (VUR) was found during VCUG control. A total of 7 patients were asymptomatic without recurrence of POM. Laparoscopic-assisted extracorporeal ureteral tapering repair and ureteral extravesical reimplantation by following Lich Gregoir technique for POM constitutes a safe and good option when the first line of treatment fails, with a success rate similar to the open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

Extending indications of micropercutaneous nephrolithotomy: It is not just about cracking stones

ObjectiveTo describe our experience and results of using the MicroPerc™ micropercutaneous nephrolithotomy armamentarium (PolyDiagnost, Germany) for unusual indications unexplored using this modality. Patients and methodsWe used the MicroPerc™ system for stone clearance in three ureteric calculi, two bladder calculi, one case of urethral calculus, for antegrade biopsy in a case of upper tract urothelial carcinoma, for Deflux® (dextranomer/hyaluronic copolymer, Salix Pharmaceuticals, Uppsala, Sweden) injection in three cases of vesico-ureteric reflux (VUR), and three cases of posterior urethral valve (PUV) fulgurations. A 4.85-F ‘All-Seeing Needle®’ (PolyDiagnost) was used in most of the cases. An 8-F mini-micro sheath was used where stability was deemed necessary. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes were assessed. ResultsAll patients were successfully treated with complete stone clearance at 1month with no residual fragments. The antegrade biopsy confirmed a high-grade papillary neoplasm. There were no technical difficulties with injection of Deflux or PUV fulgurations. Follow-up at 1year revealed no stone recurrence, resolved reflux in all three cases, and all the children that had had PUVs were voiding well. The small sample and retrospective nature of the analysis are the limitations of this study. ConclusionMicroPerc™, besides its usual use for minimally invasive percutaneous nephrolithotomy, can also be feasibly used for ureteric, bladder and urethral stones, and for treating non-calculus diseases such as PUVs and VUR. True to its name, it may be an ‘All-Seeing Needle’ in reality with much more to offer and harvest from.

Clinical Course of Children and Adolescents with Primary Vesicoureteral Reflux: A retrospective study of 958 patients

Abstract Introduction. Vesicoureteral reflux (VUR) is the most common pediatric urologic abnormality and since it can predispose to urinary tract infection and resultant kidney scar it is an important issue in pediatric nephrourology. Methods. A retrospective chart review and follow-up of 958 patients with primary VUR was performed in the Children’s Medical Center, Tehran, Iran. Children with primary vesicoureteral reflux were included in the study and these parameters were studied: age, sex, clinical presentation, VUR grade, sonographic findings, DMSA changes, treatment modality (medical, surgical or endoscopic) and response to treatment, hypertension (presence/absence), urinary tract infection recurrence and development of new kidney scars in patients under medical treatment. Results. VUR was more prevalent in girls. Sonography was unable to detect VUR in many cases. Presence of renal scars was strongly associated with degree of reflux. Medical management was effective in a substantial percentage of patients and they experienced full resolution of reflux. This was especially true for lower degrees of VUR. 17.6% of patients developed new kidney scars on followup which was associated with higher degrees of VUR. Hypertension and breakthrough urinary tract infection was an uncommon finding in our patients. Conclusion. Medical management, which means using prophylactic antibiotics for prevention of urinary tract infection, is effective in many cases of VUR especially in cases with lower degrees of VUR. Surgical and endoscopic procedures must be reserved for patients with higher degrees of VUR unresponsive to conservative management or in whom new scars may develop.

The diagnosis and management of the urological complications of Renal Transplantation: a series of 1100 patients

Objective: To analyse the Urological Complications after Renal Transplantation and their management. Material and methods: -A retrospective analysis of 1150 consecutive live donor renal transplants was performed. The study period extended from December 1995 to December 2004. The surgical procedure for ureteral reimplantation was modified Lich anastomosis. Ultrasonography, renal scanning, antegrade pyelography, retrograde pyelography and cystography were the diagnostic tools. Results: -Overall, 68 primary urological complications (5.9%) were identified during the 15-year experience in 65 patients. The Urological Complications in our series included 35 ureteral obstruction (3.0%), 25 ureteral or bladder leaks (2.17%), 05 out flow obstruction, 02 cases of vesicoureteral reflux and 01 case of ureteral stone. Conclusion: The incidence of Urological Complications in our study is 5.9%. Early exploration of the ureteric leaks and timely intervention to obstructed kidney reduced the morbidity and improves graft su rvival. The causes of these complications and techniques for their prevention are discussed in this study.

Reliability of the Grading System for Voiding Cystourethrograms in the Management of Vesicoureteral Reflux: An Interrater Comparison.

Aim. Vesicoureteral reflux (VUR) is one of the most common conditions seen in pediatric urology. Fortunately, there are many treatment options for this disorder. The grading system for VUR varies among doctors, and the literature on its reliability is sparse. Here, we assessed the effectiveness of the current VUR grading system. Methods. A series of 40 voiding cystourethrogram (VCUG) studies were selected. Four pediatric urologists (PU) and four pediatric radiologists (PR) independently graded each VCUG and then agreed on a uniform interpretation. For statistical analysis the intraclass correlation coefficient (ICC) was applied to assess interrater agreement. Results. ICC values ranging from 0.82 to 0.88 reflected the strong reliability of VCUG for grading cases of VUR among pediatric urologists and radiologists as separate groups, and the reliability between the two groups was also good, as indicated by an ICC of 0.89. Despite the high ICC, disagreement existed between raters; the lowest agreement was associated with middle grades (III and IV). Conclusions. The interrater reliability of the international grading system for VUR was high but imperfect. Thus, grading differences at middle grades can profoundly influence the type of treatment pursued.

Impact of common functional polymorphisms in renin angiotensin system genes on the risk of renal parenchymal scarring following childhood urinary tract infection

Pathogenesis of renal parenchymal scarring (RPS) after acute pyelonephritis (APN) is unclear. The risk of RPS varies markedly among individuals, suggesting a genetic role. To investigate a possible role of common polymorphisms in renin angiotensin system genes in APN-associated RPS in children. This study included 104 APN children and 300 controls. APN was diagnosed by urine culture and typical findings on 99Tc-DMSA scans. Voiding cystourethrogram tested the presence of vesicoureteral reflux (VUR). Follow-up DMSA scans were performed 4-6 months later to identify new RPS. Angiotensin converting enzyme gene I/D, angiotensin II receptor type-1 A1166C and angiotensinogen M235T polymorphisms were genotyped. New RPS developed in 44.2% (46/104) of children with APN. VUR was diagnosed in 35.6% (37/104) of APN cases. RPS developed in 73% of cases of VUR. The D allele of ACE gene I/D polymorphism was significantly more common in APN cases with RPS (73.91%) than non-RPS (58.6%) and controls (54.5%) (p = 0.021, p = 0.002, respectively). The AGTR-1 A1166C A allele was significantly more common in VUR than the non-reflux children (91.9% versus 76.1%; p = 0.005). VUR, in contrast to the D allele (OR 6.1, 95% CI 0.878-19.7; p = 0.05), was an independent risk factor for RPS. ACE gene D allele is associated with a twofold increase in RPS risk, which could be a result of a functional effect to increase tissue levels and activity of ACE during APN. However, D allele failed to qualify as an independent risk and its RPS association could be dependent on other co-factors, such as TGFβ1 activation, or the D-allele might link with recently discovered functional polymorphisms at the 5' end of the ACE gene. Although VUR is an independent risk for RPS, it is not clear whether this is due to exposure of the kidneys to infected urine, or VUR-associated dysplasia. In contrast with published literature, we noted higher rates of RPS and high-grade VUR, suggesting a more aggressive VUR course or local unawareness of APN. Our study has its limitations; the small number of VUR children, and the clinical and ethical difficulties of testing VCUG and DMSA in controls. ACE gene D allele is associated with, but cannot independently predict, RPS in children. VUR is an independent risk for post-pyelonephritic scarring. AGTR-1 1166A/C polymorphism is associated with occurrence, but not progression, of VUR.

Hereditary Vesicoureteral Reflux: A Study of 66 Families

Purpose: We studied the inheritance pattern, clinical features and outcome in children with vesicoureteral reflux (VUR). Characteristics of known familial VUR cases were also compared with those of sporadic VUR. Material and Methods: 726 patients were treated for VUR between 1990-2004. The families were contacted by letter inquiring if other members of the family were affected. The phenotype of all cases (familial and non-familial) was characterized in terms of presenting symptoms, reflux grade, recurrent urinary tract infections, kidney damage, and the natural course of reflux. Results: The response rate was 79%. A total of 99 individuals (22%) reported relatives with VUR. Since some of the 99 index cases belonged to the same family, the total number of families was ultimately 66. The distribution of relatives with VUR was: 38 siblings, 20 parents (15 mothers), 19 cousins, 15 aunts/uncles and 12 grandparents. The phenotype of VUR did not differ between familial and non-familial cases. However, VUR among relatives was of milder grade than index and sporadic cases. Conclusions: The proportion of hereditary reflux in our material was lower than in other studies (22%). We found a strong overrepresentation of maternal transmission of reflux. Severity of the disease did not differ between familial and non-familial VUR.

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

ObjectiveWe report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence. Materials and methodsConsecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. ResultsThere were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet). ConclusionsUpper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.

Commentary to ‘Upper tract changes in patients with neurogenic bladder and sustained pressures >40 cm following bladder neck surgery without augmentation’

Abstract Objective We report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence. Materials Consecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study. Results Of 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection. Conclusions Despite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation.