DMSA Scan Research Articles

Vesico-ureteral reflux diagnosis after initial kidney abscess: Results from a Paediatric Tertiary Hospital.

Guidelines regarding voiding cystourethrogram (VCUG) indications following a paediatric kidney abscess are lacking. This study evaluates vesicoureteral reflux (VUR) prevalence and outcome after a first kidney abscess. This retrospective study included all children presenting to a tertiary paediatric reference centre with de-novo kidney abscesses from 2011 to 2022, diagnosed through imaging (ultrasonography or computed tomography). VCUG's clinical utility was assessed by exploring outcomes related to interventions. Among the 17 patients (median age 9 months, IQR; 6 months-6 years), VCUG identified VUR in 7 (41%; 95% CI: 18-65%), including two with grade IV-V. Median abscess size was 19 mm (IQR; 14-27). 7/8 (88%) children with DMSA scan presented scars, including 4 with hypofunctioning (20%-44%), and one with a non-functioning kidney. Scarring on the DMSA scan was similar regardless of identified VUR. Six children had subsequent pyelonephritis. Three of the remaining 11 had grade I-III and two IV-V VUR. Surgery was required in four children overall: three for recurrent pyelonephritis and one for high-grade VUR and scars. Among initial kidney abscess cases, 41% had VUR, similar to children experiencing their first uncomplicated pyelonephritis. VCUG results guided antibiotic prophylaxis but not surgical decisions. We suggest considering VCUG following recurrent pyelonephritis/kidney abscess and/or kidney scarring.

Simultaneous segmentation and classification of 99mTc-DMSA renal scintigraphic images with a deep learning approach.

99mTc-DMSA scan plays an important role in assessing functional abnormalities in kidneys. As a promising network for deep learning (DL), Mask R-CNN has the capability of simultaneously segmenting and classifying objects in images. In this study, we tested the feasibility and accuracy of Mask R-CNN in diagnosing acute pyelonephritis (APN) and segmenting kidneys in 99mTc-DMSA scintigraphic images. Two hundred and sixty patients with suspected APN were recruited for DMSA scan, of which 358 kidneys were diagnosed as APN. Of the recruited patients, 210 were randomly selected for training and validating Mask R-CNN, and the other 50 patients' images were used for model testing. Accuracy of the results was assessed by comparing against references from human experts. In the validation phase, the trained model provided segmentation masks with intersection over union (mask IoU, for segmentation accuracy) of 86.6%, and classifications with mean average precision at the bounding box IoU ≥ 50% (mAP50, for classification accuracy) of 86.2%. In testing with the 50 independent patients, mask IoU of the model's segmentation was 90.3%±2.2%, and in classifying the kidneys for APN, the trained model showed accuracy of 89.0%, sensitivity of 84.8% and specificity of 97.0%. In identifying patients with any APN kidney, 3 out of 50 patients were mis-diagnosed, achieving accuracy of 94.0%. Mask R-CNN, designed to perform both segmentation and classification for images, showed much promise in analyzing 99mTc-DMSA images for both accurate diagnosis of APN and kidney segmentation.

Congenital solitary functioning kidney: evaluations to do which, when, and how

Congenital solitary functioning kidney (CSFK) is characterized by an anatomical or functional absence of one kidney from birth. When suspected on perinatal ultrasonography (US), repeat US after birth should be performed for confirmation. Although postnatal 99mTc-dimercaptosuccinic acid scintigraphy (DMSA scan) is the gold standard for confirming CSFK, it carries the risk of radiation exposure; US alone is sufficient when performed by an experienced radiologist. One-third of patients with CSFK have additional congenital anomalies of the kidney and urinary tract at the solitary functioning kidney, the most common of which is vesicoureteral reflux. As evidence regarding vesicoureteral reflux with normal kidney US is correlated with significant urinary tract infection is lacking, voiding cystourethrogram may be considered in patients with CSFK with abnormal US findings. Furthermore, approximately 30% of patients with CSFK have extrarenal malformations. Moreover, up to 10% of them have syndromic features. In particular, examining for female genitalia malformations, which can have potential for complications from untreated obstructive malformations, is important. In conclusion, DMSA scan and voiding cystourethrogram are not necessary for all patients with CSFK, and the risk of each patient should be assessed to determine which test is needed during follow-up. The presence of extrarenal manifestations should also always be considered.

Cross-fused Ectopic Kidney in a Term Neonate

We report on a term neonate with a birthweight of 2300g antenatally suspected to have an absent left kidney. Postnatally the right kidney was palpable, and ultrasound confirmed an enlarged right kidney with obstruction at the pelvic-ureteric junction and multiple renal cysts. The left kidney had an unusual appearance with its upper pole cross-fused with the lower pole of the left kidney suggestive of a cross-fused kidney, with the ureter of the crossfused kidney joining the bladder on the left side. The cross-fused kidney also showed pelvicalyceal dilatation and cystic changes’ and DMSA scans confirmed the non-functioning of the crossfused kidney with a normally functioning right kidney. MCU was normal. The neonate remained hemodynamically stable throughout the NICU stay with normal blood pressure and renal function tests. He is currently 6 months old and on regular follow-up with normal growth development. We describe the approach and management of this rare condition of crossfused kidney.

Determining Split Renal Function in Children With Ureteropelvic Junction Stenosis: Technetium-99m Mercaptoacetyltriglycine (Tc-99m MAG-3) or Technetium-99m Dimercaptosuccinic Acid (Tc-99m DMSA)?

Background Ureteropelvic junction stenosis (UPJS) is the most common cause of clinically significant antenatal hydronephrosis. We compared separate renal function results obtained using technetium-99m-mercaptoacetyltriglycine (Tc-99m MAG-3) and technetium-99m-dimercaptosuccinic acid (Tc-99m DMSA) in pediatric patients with UPJS to evaluate the adequacy of Tc-99m MAG-3 scintigraphy and the necessity of additional Tc-99m DMSA scintigraphy during follow-up. Methodology Patients diagnosed with hydronephrosis in the Pediatric Nephrology Department of Pamukkale University Faculty of Medicine over a period of 10 years (2012-2022) were evaluated retrospectively. Patients who had been diagnosed with UPJS and underwent both Tc-99m MAG-3 and Tc-99m DMSA scintigraphy during follow-up were included in the study. Technetium-99m-labeled MAG-3 and DMSA scans were re-evaluated for all patients by the Department of Nuclear Medicine. Results The study included 52 children with unilateral UPJS (12 girls and 40 boys) with a mean age of 6.34 ± 4.81 years (range: 2.97-9.79 years). Thirty-six patients (69.2%) were diagnosed antenatally. Differential renal function in Tc-99m DMSA was 46.94 ± 10.64 and in Tc-99m MAG-3 was 43.08 ± 11.18; the functions were lower in Tc-99m MAG-3, but the values were within normal limits for both groups (p=0.0001, z=-3.893). When differential renal functions were compared between Tc-99m DMSA and Tc-99m MAG-3 results, a statistically significant positive and strong correlation was found in the kidney with ureteropelvic junction obstruction (UPJO) (p=0.0001, r=0.752). When classifying the Tc-99m MAG-3 and Tc-99m DMSA results in the kidney with UPJO (supranormal, normal, low function) for the determination of differential renal functions, there was a consistency of 76%, and it was correlated (p=0.0001, k=0.456). While two patients had supranormal function and 13 patients had low function in Tc-99m MAG-3, five patients had supranormal function, and eight patients had low function in Tc-99m DMSA. Conclusions Some studies in the literature have reported that Tc-99m MAG-3 causes supranormal function measurements in patients with UPJS; our results showed that Tc-99m DMSA resulted in a higher rate of supranormal values for affected kidneys. We believe that Tc-99m DMSA should not be performed in addition to Tc-99m MAG-3 scintigraphy in the follow-up of every patient with UPJS but can be utilized in select cases, such as patients with surgical indications and those suspected before surgery.

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.

Assessing asymmetrical kidney function in living donors: a retrospective cohort study on CT metrics

BackgroundLive donor kidney transplantation is the preferred kidney replacement therapy for eligible patients but requires thorough donor evaluation to minimise risks. Contemporary guidelines recommend split kidney function measurement in living donors only when there is a significant kidney size discrepancy, yet the evidence for this is poor, and practice varies nationally. This study evaluates the efficacy of CT-derived kidney metrics in detecting significant functional asymmetry.MethodsWe conducted a retrospective cohort analysis of 123 prospective living kidney donors at a regional transplant centre from June 2011 to October 2014, utilising CT to determine kidney and cortical volumes and lengths. Asymmetric kidney function (AKF), defined by > 10% function difference on DMSA scans, was correlated with CT measurements to calculate the diagnostic accuracy of current guidelines.ResultsAmong the prospective donors, the median age was 42 years, and 59.3% were female. The median split kidney function difference was 4%, with 25 individuals exhibiting > 10% AKF. Kidney length discrepancy proved to be a poor indicator of AKF (sensitivity: 28%, specificity: 84%). While negative predictive values for cortical and kidney volumes were high (96% and 93%, respectively), sensitivity was low, and specificity and positive predictive value did not meet satisfactory thresholds.ConclusionsCT-derived metrics of kidney length, cortical, and total volume show limited sensitivity and specificity in identifying significant AKF. These findings provide evidence to support revised guideline development in the assessment of living kidney donors.

The Intrarenal Reflux Diagnosed by Contrast-Enhanced Voiding Urosonography (ceVUS): A Reason for the Reclassification of Vesicoureteral Reflux and New Therapeutic Approach?

Vesicoureteral reflux (VUR) is defined as the urine backflow from the urinary bladder to the pyelo-caliceal system. In contrast, intrarenal reflux (IRR) is the backflow of urine from the renal calyces into the tubulointerstitial space. VURs, particularly those associated with IRR can result in reflux nephropathy when accompanied by urinary tract infection (UTI). The prevalence of IRR in patients with diagnosed VUR is 1-11% when using voiding cystourethrography (VCUG), while 11.9-61% when applying the contrast-enhanced voiding urosonography (ceVUS). The presence of IRR diagnosed by VCUG often correlates with parenchymal scars, when diagnosed by a 99mTc dimercaptosuccinic acid scan (DMSA scan), mostly in kidneys with high-grade VURs, and when diagnosed by ceVUS, it correlates with the wide spectrum of parenchymal changes on DMSA scan. The study performed by both ceVUS and DMSA scans showed IRRs associated with non-dilated VURs in 21% of all detected VURs. A significant difference regarding the existence of parenchymal damage was disclosed between the IRR-associated and IRR-non-associated VURs. A higher portion of parenchymal changes existed in the IRR-associated VURs, regardless of the VUR grade. That means that kidneys with IRR-associated VURs represent the high-risk group of VURs, which must be considered in the future classification of VURs. When using ceVUS, 62% of places where IRR was found were still unaffected by parenchymal changes. That was the basis for our recommendation of preventive use of long-term antibiotic prophylaxis until the IRR disappearance, regardless of the VUR grade. We propose a new classification of VURs using the ceVUS method, in which each VUR grade is subdivided based on the presence of an IRR.

Novel minimally invasive abdominoplasty for selected cases of prune belly syndrome: Step-by-step technique description and clinical indications

BackgroundPrune belly syndrome (PBS) is characterized by the triad of abdominal flaccidity, bilateral undescended testicles and genitourinary tract anomalies. A variable spectrum of abdominal wall laxity is observed in PBS. We present the first case of a novel technique using a minimally invasive abdominoplasty to specifically address patients with localized abdominal wall weakness in PBS. Case presentationA two-years-old child with PBS presented with recurrent febrile urinary tract infections. Ultrasonography demonstrated a dysplastic right kidney associated with significant ipsilateral ureterohydronephrosis. Voiding urethrocystogram did not show vesicoureteral reflux and DMSA scan depicted a non-functioning right kidney. During laparoscopic right nephroureterectomy and first stage Fowler-Stephens bilateral orchiopexies, a significant right-sided lateral abdominal wall bulging was observed. A minimally invasive laparoscopic abdominoplasty was performed with a one-way running suture using an unabsorbable 2.0 prolene approximating the edges of the musculofascial defect. While undergoing the second-stage Fowler-Stephens orchiopexy, no bulging was observed. ConclusionA minimally invasive abdominoplasty to improve abdominal wall lateral bulging in PBS was feasible and presented good cosmetic result. We anticipate that this technique can be applied for children with PBS with primary lateral abdominal wall bulging, employing one or more suture lines depending on the fascial defect size.

Comparison of absolute renal uptake by using Tc-99m MAG-3 and Tc-99m DMSA.

The purpose of this study is to compare the value of absolute renal uptake (ARU %) in patients by using Tc-99m MAG-3 and Tc-99m DMSA scan. Absolute renal uptake is calculated using Tc-99m MAG-3 and Tc-99m DMSA in renal scintigraphy, Itoh and Tauex kidney depth methods used, respectively. n = 40 adult patients of both genders were included. All patients underwent Tc-99m MAG-3 and Tc-99m DMSA, respectively. The values of ARU (%) were calculated separately in selected patients n = 40, (left = 17, right = 23 normal functioning kidneys) by MAG-3 and DMSA. Absolute renal uptake (%) of Tc-99m MAG-3 in left kidneys was found to be 15.2 ± 3.4, with spilt renal function 79.2 ± 14.7 and ARU (%) in right kidneys 16.2 ± 3.4 with spilt renal function 77.5 ± 19. Absolute renal uptake of Tc-99m DMSA in left kidneys was 17.5 ± 3.2 and in right kidneys 17.9 ± 4.5 with spilt renal function 81.8 ± 10.7 and 79.3 ± 13.8 for left and right kidney, respectively. Statistical analysis showed strong Pearson correlation. Absolute renal uptake % was found to be more reliable in cases of bilateral compromised kidneys. ARU (%) calculated by Tc-99m MAG-3 solely can be used as predictor of renal function. The use of Tc-99m MAG-3 has more advantages than Tc-99m DMSA alone in renal scintigraphy as dynamic scintigraphy gives less radiation burden to patient, more information regarding renal function, and shorter stay time at hospital in comparison to static renal imaging. SRF % is less reliable than ARU (%).

Appearance of the bladder on initial voiding cystogram in boys with PUV and its relation to pre and postnatal findings.

Bladder profile in boys with Posterior Urethral Valves can be very varied with a spectrum going from high pressure, unstable, hypocompliant small bladders to hypercompliant, large acontractile bladders, with some being near-normal. Our question was whether appearance, specifically of the bladder, on initial VCUG was correlated to prenatal features and whether it could predict early postnatal outcome. We used a prospectively gathered database of boys with prenatally suspected PUV. We analyzed whether the appearance, specifically of the bladder, was related to date of prenatal diagnosis, presence of a megacystis on prenatal ultrasound, presence of vesico-ureteral reflux (VUR), presence of abnormal DMSA scan, nadir creatinine or presence of febrile urinary tract infection (fUTI) during the first two years of life. The database comprised 90 cystograms. 15% of bladders were judged normal/regular, 54 % were small/diverticular and 31% were large/diverticular. Bladder appearance was not associated with presence of prenatal megacystis, abnormal DMSA scan, VUR, nor rate of fUTI. The only significant associations were normal/regular bladder and early prenatal diagnosis (p = 0.04) and normal/regular bladder and elevated nadir creatinine (>75µmol/l) (p = 0.01). We believe that when focusing solely on the appearance of the bladder, excluding information about the urethra and presence of reflux, the cystogram alone is insufficient to inform on future bladder function. This could be used as an argument in favor of performing early urodynamics in this population.

Characteristics and predictors of chronic kidney disease in children with myelomeningocele: a nationwide cohort study.

Myelomeningocele (MMC) is highly prevalent in developing countries, and MMC-related neurogenic bladder is an important cause of childhood chronic kidney disease (CKD). This nationwide study aimed to evaluate demographic and clinical features of pediatric patients with MMC in Turkey and risk factors associated with CKD stage 5. Data from children aged 0-19years old, living with MMC in 2022, were retrospectively collected from 27 pediatric nephrology centers. Patients > 1year of age without pre-existing kidneyabnormalities were divided into five groups according to eGFR; CKD stages 1-5. Patients on dialysis, kidney transplant recipients, and those with eGFR < 15ml/min/1.73 m2 but not on kidney replacement therapy at time of study constituted the CKD stage 5 group. A total of 911 (57.8% female) patients were enrolled, most of whom were expectantly managed. Stages 1-4 CKD were found in 34.3%, 4.2%, 4.1%, and 2.4%, respectively. CKD stage 5 was observed in 5.3% of patients at median 13years old (range 2-18years). Current age, age at first abnormal DMSA scan, moderate-to-severe trabeculated bladder on US and/or VCUG, and VUR history were independent risk factors for development of CKD stage 5 (OR 0.752; 95%; CI 0.658-0.859; p < 0.001; OR 1.187; 95% CI 1.031-1.367; p = 0.017; OR 10.031; 95% CI 2.210-45.544; p = 0.003; OR 2.722; 95% CI 1.215-6.102; p = 0.015, respectively). Only eight CKD stage 5 patients underwent surgery related to a hostile bladder between 1 and 15years old. MMC-related CKD is common in childhood in Turkey. A proactive approach to neurogenic bladder management and early protective surgery in selected cases where conservative treatment has failed should be implemented to prevent progressive kidney failure in the pediatric MMC population in our country.

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux.

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Scinтigraphy in Children with Urinary Tract Dilatation (Antenatally Detected Hydronephrosis)

The causes of Antenatal Hydronephrosis/Urinary Tract Dilatation (ANH/UTD) vary from transient benign conditions-transit hydronephrosis, (resolves by birth or during infancy) to conditions that can significantly affect renal function. The outcome of depends on the underlying etiology, so it is very important to determine these causes. The definition and grading of ANH is based on the Anteroposterior Pelvic Diameter (APD) of the fetal renal pelvis. Antenatal management includes antenatal ultrasound monitoring, which is usually repeated every 4-6 weeks. It is recommended that the assessment of the severity of postnatal hydronephrosis is based on the APD of the renal pelvis. Extensive postnatal investigation was proposed to be limited to those with moderate or severe dilatation. Voiding cystourethrography and scintigraphy are usually preserved for children with postnatal APD &lt;15 mm and/or abnormal kidney parenchyma, severe caliyx dilatation ureteral dilatation and bladder pathology. Diuretic renal scintigraphy is important in the postnatal evaluation of infants with ANH, particularly in distinguishing kidneys with poor drainage from nonobstructive hydronephrosis with good drainage. According to our diuretic renography results, we conclude that in the presence of partial or no drainage, the separate renal function may not be significantly impaired. The finding of poor renal emptying is significantly more common among children with increasing renal pelvis APD. Technetium 99m-dimercaptosuccinic acid renal scintigraphy (99mTc-DMSA) has been used in renal imaging to estimate the functional renal mass (damage to the kidney) and relative renal function, especially in pediatric patients. A statistically significant correlation between the degree of hydronephrosis (APD) and DMSA scan finding and between the degree of the VUR and DMSA scan finding was established. Other than VUR, CAKUT (pelvic ureteric junction obstruction, pyelon et ureter duplex, megaureter, posterior urethra valves) were not statistically correlated with pathological findings on the DMSA scan.

Urologic manifestations of hypotonia, ataxia, and delayed development syndrome (HADDS), a rare neurodevelopmental disorder

Early B-cell factor 3 (EBF3) is a transcription factor involved in neuronal differentiation and maturation. Pathogenic variants are associated with hypotonia, ataxia, and delayed development syndrome (HADDS) (MIM#617330). Urologic manifestations are common and may have implications regarding long term renal function. To review all known patients with pathogenic variants of the EBF3 gene resulting in HADDS with urologic manifestations. We hypothesize a high rate of bladder dysfunction secondary to the EBF3 variant's impact on relaxation of the urinary sphincter leading to detrusor sphincter dyssynergia (DSD). The PubMed database was queried for publications of the EBF3 mutation between January 2017 and January 2023. Search terms were "EBF3 mutation OR HADDS AND urology OR phenotype". Retrospective analysis of HADDS patients cared for in our institution was performed. Demographic and clinical information was collected. We identified 52 patients (33F:19M) through literature (28F:18M) and retrospective review (5F:1M). There was a high prevalence of genitourinary physical exam abnormalities, history of urinary tract infection, vesicoureteral reflux (VUR), and diagnosis of neurogenic bladder. Within the literature review cohort, 67% had a urologic diagnosis. Females were disproportionately affected with urologic manifestations. In our cohort, four of six children were diagnosed with VUR and severe voiding dysfunction consistent with neurogenic bladder (67%). These children were managed with a vesicostomy. Five children had bowel dysfunction requiring therapy. Urodynamics suggested a high prevalence of external sphincter dyssynergia. Less severe forms of DSD were felt to be implicated in the abnormal voiding parameters in children who presented later in life based on non-invasive flow studies. There is significant variability in the phenotypic presentation of patients with HADDS. While EBF3 plays a clear role in neurodevelopment, it also impacts muscle development and may impact muscle relaxation. The location of the genetic variant may impact the degree of DSD, with more severe forms leading to earlier presentations. Initial work-up should include a renal ultrasound (RUS) and post void residual (PVR). Consideration can be given to obtaining a VCUG, DMSA scan or urodynamic studies. Yearly screening should be pursued with an RUS and PVR in those with an initial unremarkable work-up given the variable timing and severity of presentation. Urologic manifestations of HADDS include high rates of bladder dysfunction secondary to DSD, vesicoureteral reflux, urinary tract infection, and cryptorchidism. These patients are at risk of renal deterioration if urinary abnormalities are not properly diagnosed and managed.

Ultrafast cadmium-zinc-telluride-based renal single-photon emission computed tomography: clinical validation

BackgroundOne of the main limitations of 99mtechnetium-dimercaptosuccinic acid (DMSA) scan is the long acquisition time.ObjectiveTo evaluate the feasibility of short DMSA scan acquisition times using a cadmium-zinc-telluride-based single-photon emission computed tomography (SPECT) system in children.Materials and methodsThe data of 27 children (median age: 4 years; 16 girls) who underwent DMSA SPECT were retrospectively analyzed. Both planar and SPECT DMSA were performed. SPECT images were analyzed using coronal-simulated planar two-dimensional images. A reduction in SPECT acquisition time was simulated to provide 4 series (SPECT-15 min, SPECT-10 min, SPECT-5 min and SPECT-2.5 min). A direct comparison of the planar and SPECT series was performed, including semi-quantification reproducibility, image quality (mean quality score on a scale of 0 to 2) and inter- and intra-observer reproducibility of the scintigraphic patterns.ResultsThe overall image quality score (± standard deviation) was 1.3 (± 0.6) for the planar data set, 1.6 (± 0.5) for the SPECT-15 min data set, 1.4 (± 0.5) for the SPECT-10 min data set, 1.0 (± 0.5) for the SPECT-5 min data set and 0.6 (± 0.6) for the SPECT-2.5 min data set. Median Kappa coefficients for inter-observer agreement between planar and SPECT images were greater than 0.83 for all series and all readers except one reader for the SPECT-2.5 min series (median Kappa coefficient = 0.77).ConclusionShortening SPECT acquisitions to 5 min is feasible with minimal impact on images in terms of quality and reproducibility.Graphical

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

Risk determination for upper urinary tract damage in children with neuropathic bladder.

Neuropathic bladder dysfunction (NBD) or neurogenic lower urinary tract dysfunction occurs as a result of a lesion at any level of central nervous system. The most common aetiology of NBD in children is abnormal development of spinal column. These defects cause neurogenic detrusor overactivity which contributes to detrusor-sphincter dysfunction and results in lower urinary tract symptoms such as incontinence. One of the more progressive and insidious, at the same time preventable result of neuropathic bladder is upper urinary tract deterioration. It is vital to aim reduction in bladder pressures and the minimisation of urine stasis in order to prevent or at least attenuate renal disease. Despite world-wide strategies for prevention of neural tube defects currently, we will still be involved in the care of spina bifida patients born every year with a neuropathic bladder and at risk of long-term renal damage. This study was planned for evaluation of results and detection of possible risk factors for upper urinary tract deterioration during routine visits of neuropathic bladder population. The electronic medical records of the patients who were followed up for at least 1 year with the diagnosis of neuropathic bladder in Pediatric Urology and Nephrology units of Adana City Training and Research Hospital were reviewed retrospectively. A total of 117 patients, whose blood, urine, imaging and urodynamic study required for the evaluation of nephrological and urological status were completed and included in the study. Patients under the age of one were excluded from the study. Demographic characteristics, medical history, laboratory and imaging results were recorded. All statistical analyses were analysed by SPSS version 21 software package and analysed by descriptive statistical. Of the 117 patients who participated in the study, 73 (62.4%) were female and 44 (37.6%) were male. Mean age of the patients was 6.7 ± 4.9 years. The leading cause of neuropathic bladder was neuro-spinal dysraphism with 103 (88.1%) patients. Urinary tract ultrasound imaging revealed hydronephrosis in 44 patients (35.9%), parenchymal thinning in 20 patients (17.1%), increased parenchymal echo in 20 patients (17.1%) and trabeculation or increase in wall thickness of the bladder in 51 patients (43.6%). Voiding cystogram revealed the presence of vesicoureteral reflux in a total of 37 patients (31.6%), with 28 patients being unilateral and 9 patients bilateral. More than half of the patients had abnormal bladder findings (52.1%). In the Tc 99 m DMSA scan of the patients, 24 patients (20.5%) had unilateral renal scars and 15 (12.8%) had bilateral. Loss of renal function was detected in 27 (23.1%) of the patients. Urodynamic study revealed decreased bladder capacity in 65 patients (55.6%) and increased detrusor leakage pressure was found in 60 patients (51.3%). The mean leak point pressure of the patients was 36 ± 26 cm H2 O, and the mean leakage volume was determined as 157 ± 118 mL. Findings obtained from imaging and urodynamic studies during routine investigation of neuropathic bladder patients can be a guide for the upper urinary tract. According to our results, age, bladder changes in ultrasound and voiding cystogram, high leak point pressure obtained during urodynamic studies are thought to have strong correlation with upper urinary tract damage. The prevalence of progressive chronic kidney disease in children and adults with spina bifida is remarkable and completely preventable. The strategies for prevention of renal disease in this patient population should be planned by coordinated work of urologist with nephrologist and requires family cooperation.

An alternative lower tract approach to ectopic duplex system ureteroceles feasible in young children

The best surgical approach to ectopic ureters and ureteroceles is yet to be determined. The objective of this study is to provide an alternative lower tract surgical approach to ectopic ureters and duplex system ureteroceles that can be safely performed in young children. The "in-and-out" bladder approach was performed via an open intravesical incision. The upper and lower pole ureters were mobilized and brought into the bladder. The dilated ureter/ureterocele was cut open, and the distal part was deuroepithelialized. Subsequently, common sheath reimplantation was performed. The ureterocele wall was not involved during the whole procedure. We retrospectively reviewed all patients who underwent surgery for ureteroceles and ectopic ureters between January 1, 2004, and December 31, 2019. Patients with intravesical ureteroceles were excluded. Outcome parameters included the presence of hydronephrosis or reflux, split renal function on DMSA scan, incidence of urinary tract infection, and urinary incontinence. A total of 32 patients with ectopic duplex system ureterocele who underwent the "in-and-out" bladder approach between 2004 and 2019 were included in the retrospective study. The median age at operation was 7.8 months (range: 1.5 months-3.0 years). The median length of follow-up was 6.1 years (range: 1.0 years-14.3 years). Sixteen patients (55%) had ipsilateral vesicoureteral reflux. Five patients postoperatively developed a urinary tract infection within 1-3 years. No patients required further endoscopic treatment or surgeries. During long-term follow-up, two patients (6.3%) had intermittent day wetting at the ages of 4 and 5 years and were managed conservatively. The symptoms of intermittent day wetting subsided during follow-up. The "in-and-out bladder" approach can be performed in complex duplex system ureteroceles and enables early intervention; it is a single and simple operation with a satisfactory long-term continence rate.

Risk factors for febrile urinary tract infection in boys with posterior urethral valves.

ObjectiveBoys with posterior urethral valves (PUV) present an increased risk of febrile urinary tract infection (fUTI). Identifying specific risk factors could allow for tailoring UTI prevention. The aim of this study was to use the data from the CIRCUP randomized controlled trial data to identify patient characteristics associated with a higher risk of fUTI.Patients and methodsWe performed a secondary analysis of the data from the CIRCUP randomized trial which included boys with PUV, randomized to circumcision and antibiotic prophylaxis vs. antibiotic prophylaxis alone and followed for 2 years. There was only 1 episode of fUTI in the circumcision group vs. 17 in the uncircumcised group. We therefore only studied the antibiotic prophylaxis alone group and compared age at prenatal diagnosis, size and weight at birth, presence of dilating VUR at diagnosis, abnormal DMSA scan at 2 months, and nadir creatinine between children who presented a fUTI and those who did not, as well as age at first episode of fUTI.ResultsThe study group consisted of 42 patients of which 17 presented at least on fUTI. Presence of dilating VUR was significantly associated with risk of fUTI (p = 0.03), OR: 6 [CI 95% = (1.13–27.52)]. None of the other parameters were associated with increased risk of fUTI. We observed three distinct time periods for presenting a fUTI with a decrease in infection rate after the first 40 days of life, then at 240 days of life.ConclusionIn boys with PUV, presence of high-grade VUR is associated with a higher risk of presenting a fUTI. The rate of febrile UTIs seems to decrease after 9 months.