Vesicoureteral Reflux Grade Research Articles

Allograft Vesicoureteral Reflux after Kidney Transplantation.

Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient’s characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.

Evaluation of the Relationship of the Time of Vesicoureteral Reflux Between Renal Scar Development and Endoscopic Treatment Success in Early Childhood

INTRODUCTION: Vesicoureteral reflux (VUR) is an important cause of urinary tract infection and chronic renal disease. Voiding cystourethrography (VCUG) is the gold standard diagnostic test in the diagnosis of VUR. In recent years, new parameters related to VCUG have been more objectively studied to evaluate the clinical prognosis. It is aimed to evaluate the effect of reflux time in primary VUR in terms of predicting endoscopic treatment success and treatment timing in VUR management. METHOD: In our study, the records and imaging findings of children with primary VUR who underwent VCUG examination between 2012 and 2019, who were treated with endoscopic injections, were retrospectively reviewed. Forty one children (67 renal units) were included in our study. Patients with preoperative VCUG, urinary ultrasonography, dimercaptosuccinic acid (DMSA) renal scan, and post-operative control VCUG were included in this study. RESULTS: Patients with preoperative VUR grade 1-2 were divided into two groups as “low grade” and patients with stage 3-4-5 as “high grade”. In the general patient population, endoscopic success rates in terms of renal unit deficit were found to be 46.3% (31/67). When the subgroup was analyzed, the endoscopic treatment success rate was 72.2% (13/18) in the low-grade group, versus 36.7% (18/49) in the high-grade group (p = 0.010). In the multivariate logistic regression analysis performed to identify independent predictors of scarring, reflux degree and reflux time were found to be independent predictors of scarring. CONCLUSION: In our study, we found that in VCUG evaluated preoperatively, VUR time as well as VUR grade were effective on endoscopic success rate and scar development. Based on these results, it could be thought that VUR time may be effective in selecting the best candidates for surgery and in the management and timing of treatment of VUR patients.

Математический анализ индивидуальных профилей биомаркеров повреждения почек у детей с пузырно-мочеточниковым рефлюксом

Objective. To assess the severity of lesions to renal parenchyma in children with grade II–IV vesicoureteral reflux (VUR) using hierarchical clustering based on the analysis of individual profiles of urinary biomarkers. Patients and methods. In this study, we evaluated the excretion of urinary biomarkers of inflammation (IL-8, IL-18, MCP-1), angiogenesis (VEGF), and fibrogenesis (TGF-β1) and compared them with clinical and demographic parameters of 65 patients with grade II–IV VUR aged 1 to 17 years (mean age 4.9 ± 3.1 years) with a normal glomerular filtration rate (GFR). The control group comprised healthy children without kidney diseases (n = 25). We used hierarchical clustering (construction of dendrogram using the Ward's method) for all biomarkers. Results. All patients, regardless of their age, gender, and VUR severity demonstrated a pathological profile of urinary biomarkers excretion, including IL-8, IL-18, MCP-1, VEGF, TGF-β1 (p &gt; 0.05). Using cluster analysis, we divided all patients into three subgroups (clusters) depending on the similarity of their individual biomarker profiles. We identified three main patterns of biomarkers that were associated with different severity of tubulointerstitial nephritis (TIN). The first pattern (I) with low levels of excretion of all biomarkers (p &lt; 0.001) correlated with mild TIN and was observed in 61.5% of children. The second pattern (II) with average excretion of IL-8, IL-18, MCP-1, TGF-β1 (p &lt; 0.01) and high VEGF excretion (p &lt; 0.001) was associated with moderate TIN and was observed in 32.2% of patients. The third pattern (III) with elevated excretion of IL-8, IL-18, MCP-1 and VEGF (by 2.5–17 times compared to patterns I and II) (p &lt; 0.01) correlated with severe TIN and was found in 6.1% of patients. Patients with the same VUR grades demonstrated different biomarker patterns. Conclusion. Hierarchical clustering enables comparison of individual profiles of urinary biomarkers with identified patterns, as well as their stratification into groups according to tubulointerstitial nephritis severity, which often remains undiagnosed with visualization techniques alone. Key words: children, cluster analysis, urinary biomarkers, vesicoureteral reflux, reflux nephropathy, tubulointerstitial nephritis

Is there a relationship between renal scarring and neutrophil-to-lymphocyte ratio in patients with vesicoureteral reflux?

Vesicoureteral reflux (VUR) exacerbates the risk of renal scarring by establishing a ground for pyelonephritis. It is known that the inflammatory process is more influential than the direct damage caused by bacterial infection in the development of renal scars after pyelonephritis. Therefore, the present study aims to investigate the relationship between renal scarring and systemic inflammatory markers in patients with VUR. Hundred and ninety-two patients (116 females, 76 males) diagnosed with VUR were divided into two groups based on the presence or absence of renal scarring and into three groups according to the grade of VUR (low, moderate and high). Neutrophil count, lymphocyte count, mean platelet volume (MPV) and neutrophil-to-lymphocyte ratio (NLR) were compared among the groups. Of the 192 patients, 102 had renal scarring. The age and gender distribution did not differ significantly between the groups with and without renal scarring (p > 0.05). However, the grade of reflux and lymphocyte count were significantly higher in the group with renal scarring (p < 0.05), and the NLR was significantly lower in the group with renal scarring (p < 0.05). The lymphocyte count was significantly higher (p < 0.05) and NLR was significantly lower in the high-grade VUR group (p < 0.05). However, MPV values did not differ significantly (p > 0.05) between the groups. NLR can be used to predict renal scarring in patients with VUR, especially in the period of 3-6 months after the first attack of infection, and may even serve as a candidate marker for treatment selection. However, larger series and prospective studies are needed.

Augmentation uretero-enterocystoplasty for refractory urinary tract dysfunction: a long-term retrospective study

ObjectivesTo report the long-term efficacy and complications of the augmentation uretero-enterocystoplasty (AUEC), including augmentation cystoplasty with simultaneous ureteroplasty and ureteral anti-reflux implantation in a single center.MethodsWe retrospectively reviewed clinical records, video-urodynamic data, and magnetic resonance urography of 210 patients who underwent the procedure for refractory lower urinary tract dysfunction (LUTD) from 2003 to 2019. International vesicoureteral reflux (VUR) and upper urinary tract dilatation (UUTD) grading systems were applied to assess upper urinary tract function, and post-operative complications were assessed.ResultsMean age was 28.1 years, with a mean follow-up time of 57.4 months. A total of 338 ureters were simultaneously re-implanted, and ureteroplasty was performed on all ureters. There was a significant postoperative improvement in the bladder capacity, intravesical pressure, and compliance (P < 0.05). VUR improvement rate was 97.7% and postoperative improvement of UUTD presented in 72.5% ureters. Mean serum creatinine (Scr) level was significantly improved compared to preoperative Scr values (226.0 ± 89.4 μmol/L vs. 217.5 ± 133.9 umol/L, P < 0.05). The 1.0% patients had unacceptably postoperative urinary incontinence and 85.4% preoperative megaureters were improved. Primary complications included metabolic acidosis (9.5%), vesicoureteral anastomosis stenosis (6.2%), persistent VUR (2.7%), urinary calculi (6.6%), and intestinal dysfunction requiring laparotomy (3.3%).ConclusionIn the study, a large series of patients treated with a complex surgical procedure was reported. It is novel, as this case series represents patients with aggressive surgical correction of VUR, ureteral tortuosity and upper tract dilation at the time of AC. AUEC was shown to have a positive role in treating patients with refractory LUTD associated with hydronephrosis and ureteral dilatation, stenosis or obstruction, with or without high- or low-pressure VUR. It was effective in improving renal function and protecting the UUT function from further deterioration in most patients with renal insufficiency.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

Effectiveness and safety of sacral neuromodulation on neurogenic bladder and bowel dysfunction in patients with spina bifida

To evaluate the effectiveness and safety of sacral neuromodulation (SNM) in the treatment of neurogenic bladder and bowel dysfunction in patients with spina bifida. The clinical data of 33 patients with neurogenic bladder and bowel dysfunction caused by spina bifida treated with SNM between July 2012 and May 2021 were retrospectively analyzed. There were 19 males and 14 females, with an average age of 26.0 years (range, 18.5-36.5 years). The disease duration ranged from 12 to 456 months, with an average of 195.8 months. The types of spina bifida included 8 cases of occult spina bifida and 25 cases of meningocele/myelomeningocele. Clinical symptoms included 19 cases of urgency-frequent urination, 18 cases of urinary incontinence, 27 cases of chronic urinary retention, and 29 cases of bowel dysfunction. Image urodynamics showed that 4 patients had detrusor overactivity (DO) and 29 patients had detrusor underactivity (DU). Vesicoureteral reflux (VUR) was found in 5 ureters (4 patients). SNM procedure was divided into experiential treatment and permanent implantation. Patients who were evaluated as successful or willing to be permanently implanted after experiential treatment would implant the permanent pulse generator. The duration of experiential treatment was 14-28 days, with an average of 19.2 days; there was no complication during this period, and the overall success rate was 69.69% (23/33). At the end of experiential treatment, the urination frequency in 24 hours, urine volume per time, urinary urgency score, and urine leakage of patients were significantly improved when compared with those before experiential treatment ( P<0.05); there was no significant difference in postvoid residual volume between before and after experiential treatment ( t=1.383, P=0.179). The success rate of patients with chronic urinary retention after experiential treatment (25.93%) was significantly lower than that of urgency-frequent urination (63.16%) and urinary incontinence (61.11%) ( χ 2=7.260, P=0.064). Compared with those before experiential treatment, the maximum cystometric capacity and compliance increased and the maximum detrusor pressure during filling decreased significantly ( P<0.05). Among the 4 patients with DO before experiential treatment, DO disappeared in 2 cases; 27 patients with DU before experiential treatment did not recover the normal contraction of detrusor during micturition. Among the 5 ureters with VUR before experiential treatment, 2 VUR disappeared at the end of experiential treatment, and the VUR grade or the bladder volume before VUR of the other 3 ureters were improved. At the end of experiential treatment, the neurogenic bowel dysfunction (NBD) score and the grade of bowel dysfunction significantly improved ( P<0.05). A total of 19 patients received permanent implantation, of which 11 patients needed to empty the bladder in combination with intermittent catheterization. SNM is effective for neurogenic bladder and bowel dysfunction in patients with spina bifida. At the same time, it can significantly improve the urodynamic parameters during urine storage and avoid upper urinary tract damage.

Posterior Urethral Valves Outcomes Prediction (PUVOP): a machine learning tool to predict clinically relevant outcomes in boys with posterior urethral valves

Early kidney and anatomic features may be predictive of future progression and need for additional procedures in patients with posterior urethral valve (PUV). The objective of this study was to use machine learning (ML) to predict clinically relevant outcomes in these patients. Patients diagnosed with PUV with kidney function measurements at our institution between 2000 and 2020 were included. Pertinent clinical measures were abstracted, including estimated glomerular filtration rate (eGFR) at each visit, initial vesicoureteral reflux grade, and renal dysplasia at presentation. ML models were developed to predict clinically relevant outcomes: progression in CKD stage, initiation of kidney replacement therapy (KRT), and need for clean-intermittent catheterization (CIC). Model performance was assessed by concordance index (c-index) and the model was externally validated. A total of 103 patients were included with a median follow-up of 5.7years. Of these patients, 26 (25%) had CKD progression, 18 (17%) required KRT, and 32 (31%) were prescribed CIC. Additionally, 22 patients were included for external validation. The ML model predicted CKD progression (c-index = 0.77; external C-index = 0.78), KRT (c-index = 0.95; external C-index = 0.89) and indicated CIC (c-index = 0.70; external C-index = 0.64), and all performed better than Cox proportional-hazards regression. The models have been packaged into a simple easy-to-use tool, available at https://share.streamlit.io/jcckwong/puvop/main/app.py CONCLUSION: ML-based approaches for predicting clinically relevant outcomes in PUV are feasible. Further validation is warranted, but this implementable model can act as a decision-making aid. A higher resolution version of the Graphical abstract is available as Supplementary information.

A machine learning-based approach for quantitative grading of vesicoureteral reflux from voiding cystourethrograms: Methods and proof of concept

The objectivity of vesicoureteral reflux (VUR) grading has come into question for low inter-rater reliability. Using quantitative image features to aid in VUR grading may make it more consistent. To develop a novel quantitative approach to the assignment of VUR from voiding cystourethrograms (VCUG) alone. An online dataset of VCUGs was abstracted and individual renal units were graded as low-grade (I-III) or high-grade (IV-V). We developed an image analysis and machine learning workflow to automatically calculate and normalize the ureteropelvic junction (UPJ) width, ureterovesical junction (UVJ) width, maximum ureter width, and tortuosity of the ureter based on three simple user annotations. A random forest classifier was trained to distinguish between low-vs high-grade VUR. An external validation cohort was generated from the institutional imaging repository. Discriminative capability was quantified using receiver-operating-characteristic and precision-recall curve analysis. We used Shapley Additive exPlanations to interpret the model's predictions. 41 renal units were abstracted from an online dataset, and 44 renal units were collected from the institutional imaging repository. Significant differences observed in UVJ width, UPJ width, maximum ureter width, and tortuosity between low- and high-grade VUR. A random-forest classifier performed favourably with an accuracy of 0.83, AUROC of 0.90 and AUPRC of 0.89 on leave-one-out cross-validation, and accuracy of 0.84, AUROC of 0.88 and AUPRC of 0.89 on external validation. Tortuosity had the highest feature importance, followed by maximum ureter width, UVJ width, and UPJ width. We deployed this tool as a web-application, qVUR (quantitative VUR), where users are able to upload any VCUG for automated grading using the model generated here (https://akhondker.shinyapps.io/qVUR/). This study provides the first step towards creating an automated and more objective standard for determining the significance of VUR features. Our findings suggest that tortuosity and ureter dilatation are predictors of high-grade VUR. Moreover, this proof-of-concept model was deployed in a simple-to-use web application. Grading of VUR using quantitative metrics is possible, even in non-standardized datasets of VCUG. Machine learning methods can be applied to objectively grade VUR in the future.

Obesity and febrile urinary tract infection in young children.

Obesity is a risk factor for infectious diseases. However, the relationship between obesity and febrile urinary tract infection (fUTI) is controversial. This study aimed to determine the relationship between obesity and fUTI in young children. We analyzed the medical records of children aged <2 years who were admitted to our hospital because of fever between April 2013 to March 2018. The children were categorized into three groups of non-obese, overweight, and obese according to the World Health Organization weight-for-length curves for children aged <2 years. A total of 600 patients were enrolled in this study, of whom 118 were diagnosed with first fUTI. Patients in the fUTI group were younger than those in the control group (patients who were diagnosed with other febrile diseases) (5 ± 5.11 vs 11 ± 6.53 months; P < 0.001). There were no significant differences in the populations of overweight and obese children between the fUTI and control groups. In the fUTI group, the duration of fever, types of pathogen, recurrent rate, the grades of vesicoureteral reflux, and renal scarring were not associated with obesity. The white blood cell count and C-reactive protein levels were not significantly different among the three weight-for-length categories. The same results were obtained when the fUTI group was compared with an age-matched control group (n = 192, 4 ± 2.55 months old; P = 0.261). Obesity is not a significant risk factor for fUTI in febrile hospitalized young children. Our study suggests that conducting urinalysis for febrile young children without obvious sources, irrespective of obesity, should be considered.

Risk of urinary tract infection in patients with hydroureter: An analysis from the Society of Fetal Urology Prenatal Hydronephrosis Registry

Prenatal hydronephrosis is one of the most common anomalies detected on prenatal ultrasonography. Patients with prenatal hydronephrosis and ureteral dilation are at increased risk of urinary tract infection (UTI) and continuous antibiotic prophylaxis (CAP) is recommended. However, current guidelines do not define the minimum ureteral diameter that would be considered a dilated ureter in these patients. We evaluate the definition of clinically relevant hydroureter, its association with UTI, and the impact of CAP. Patients with prenatal hydronephrosis from seven centers were enrolled into the Society for Fetal Urology Prenatal Hydronephrosis Registry from 2008 to 2020. Patients with ureteral measurement on ultrasound were included. Patients with ureterocele, ectopic ureter, neurogenic bladder, posterior urethral valves, horseshoe or solitary kidney, known ureteropelvic junction obstruction, or follow-up less than one month were excluded. Primary outcome was UTI. Analyses were performed using Cox regression. Of the 1406 patients enrolled in the registry, 237 were included. Seventy-six percent were male, ureteral diameter ranged from 1 to 34mm, and median follow-up was 2.2 years. Patients with ureters 7mm or greater had nearly three times the risk of UTI adjusting for sex, circumcision status, antibiotic prophylaxis and hydronephrosis grade (HR=2.7, 95% CI: 1.1-6.5, p=0.03; Figure). In patients who underwent voiding cystourethrogram (VCUG; 200/237), ureteral dilation of 7mm or more identified patients at increased UTI risk controlling for sex, circumcision status, vesicoureteral reflux and hydronephrosis grade (HR=2.3, 95% CI: 0.97-5.6, p=0.06). CAP was significantly protective against UTI (HR=0.50 (95% CI: 0.28-0.87), p=0.01). Among patients who underwent VCUG and did not have vesicoureteral reflux, ureteral dilation 7mm or greater corresponded with higher UTI risk compared to ureteral diameter less than 7mm on multivariable analysis (HR=4.6, 95% CI: 1.1-19.5, p=0.04). This is the first prospectively collected, multicenter study to demonstrate that hydroureter 7mm or greater identifies a high-risk group for UTI who benefit from antibiotic prophylaxis. In contrast, patients with prenatal hydronephrosis and non-refluxing hydroureter less than 7mm may be managed more conservatively.

MP44-06 ULTRASOUND CONTRAST-ENHANCED VOIDING CYSTOURETHROGRAM FOR DIAGNOSIS OF VESICOURETERAL REFLUX: SINGLE-INSTITUTION EXPERIENCE

You have accessJournal of UrologyPediatric Urology II (MP44)1 Sep 2021MP44-06 ULTRASOUND CONTRAST-ENHANCED VOIDING CYSTOURETHROGRAM FOR DIAGNOSIS OF VESICOURETERAL REFLUX: SINGLE-INSTITUTION EXPERIENCE Thomas Williams, Lane Palmer, John Amodio, and Jeffrey Palmer Thomas WilliamsThomas Williams More articles by this author , Lane PalmerLane Palmer More articles by this author , John AmodioJohn Amodio More articles by this author , and Jeffrey PalmerJeffrey Palmer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002065.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The current standard diagnostic method for vesicoureteral reflux (VUR) is fluoroscopic voiding cystography (VCUG). However, exposure to this inherent ionizing radiation may increase the risk of developing a malignancy in this vulnerable population. The development of stable and reproducible intravesical ultrasound contrast agents and techniques offer an opportunity to diagnose VUR without radiation exposure. This study highlights a large volume, single-institution’s experience of ultrasound contrast-enhanced VCUG and reported outcomes. METHODS: Retrospective chart review for 143 pediatric patients who underwent ultrasound contrast-enhanced VCUG at a single children’s hospital between 2018 and 2020. Technique involved several voiding and filling cycles with 1cc of Lumason® microbubbles, mixed with normal saline, and instilled via catheter gravity drip. Primary outcomes measured grade of VUR (International Reflux Grading System) as interpreted by a trained pediatric radiologist. Additionally, related anatomical findings, indications for exam, and clinical outcomes were reported. RESULTS: Mean age ranged from newborn to 14 years of age (18.7 ± 33.6 months, mean ± SD). The predominant indication for examination was prenatal hydronephrosis, 85 patients (59.4%) followed by history of urinary tract infection, 46 patients (32.2%). Overall, VUR was detected in 41 patients (28.7%) with total of 58 renal units. VUR was more commonly noted on the left side - 31 renal units (53.4%) but without difference in reflux grade (3.1 vs 3.0). Reflux grade breakdown was Grade I (0), Grade II (19), Grade III (23), Grade IV (9), and Grade V (7). There were no complications. CONCLUSIONS: Ultrasound contrast-enhanced VCUG is a safe and efficient alternative to the diagnosis of VUR without exposure to ionizing radiation. Future studies should continue to explore exam reproducibility and comparison between that of fluoroscopic VCUG. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e794-e795 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Williams More articles by this author Lane Palmer More articles by this author John Amodio More articles by this author Jeffrey Palmer More articles by this author Expand All Advertisement Loading ...

Diagnosis and grading of vesicoureteral reflux on voiding cystourethrography images in children using a deep hybrid model

Background and objectiveVesicoureteral reflux is the leakage of urine from the bladder into the ureter. As a result, urinary tract infections and kidney scarring can occur in children. Voiding cystourethrography is the primary radiological imaging method used to diagnose vesicoureteral reflux in children with a history of recurrent urinary tract infection. Besides the diagnosis of reflux, it is graded with voiding cystourethrography. In this study, we aimed to diagnose and grade vesicoureteral reflux in Voiding cystourethrography images using hybrid CNN in deep learning methods. MethodsImages of pediatric patients diagnosed with VUR between 2016 and 2021 in our hospital (Firat University Hospital) were graded according to the international vesicoureteral reflux radiographic grading system. VCUG images of 236 normal and 992 with vesicoureteral reflux pediatric patients were available. A total of 6 classes were created as normal and graded 1-5 patients. ResultsIn this study, a hybrid-based mRMR (Minimum Redundancy Maximum Relevance) using CNN (Convolutional Neural Networks) model is developed for the diagnosis and grading of vesicoureteral reflux on voiding cystourethrography images. Googlenet, MobilenetV2, and Densenet201 models are used as a part of the hybrid architecture. The obtained features from these architectures are examined in concatenating process. Then, these features are classified in machine learning classifiers after optimizing with the mRMR method. Among the models used in the study, the highest accuracy value was obtained in the proposed model with an accuracy rate of 96.9%. ConclusionsIt shows that the hybrid model developed according to the findings of our study can be used in the diagnosis and grading of vesicoureteral reflux in voiding cystourethrography images.

Integrated Ultrasound With Urodynamics Illustrates Effect of Bladder Volume on Upper Tract Dilation: Should we Trust Surveillance Ultrasounds?

ObjectiveTo evaluate if ultrasound during urodynamics (uUS) will show that traditional ultrasound (tUS) routinely underestimates the potential magnitude of upper tract dilation (UTD). MethodsProspective pilot study of 10 consecutive patients ≥ 5 years of age undergoing same day uUS and tUS. Using randomized images, the study pediatric radiologist determined anterior-posterior renal pelvic diameter (APD), bladder volume, vesicoureteral reflux (VUR) and UTD grades. A single pediatric urologist determined urodynamic bladder capacity and assigned either hostile, intermediate, abnormal but safe, or normal national spina bifida patient registry classification (NSBPR). ResultsBladder volume on tUS was significantly smaller than final bladder volume on uUS (180 vs 363 ml: P<.001). On average, patient reported maximum catheterized/voided volumes were also 82 ml greater than final bladder capacity on uUS. UTD was upgraded in 25% of kidneys and APD increased by 0.6 cm on uUS over that seen on tUS (P=.001). Units with VUR had greater increases in APD (1.2 P=.007 vs. 0.3 cm P=0.06). Changes in APD stratified by NSBPR revealed average increases of up to 1.3 cm. ConclusionDespite instructions to the contrary, patients come for tUS with a relatively empty bladder as compared to either their urodynamic or patient-reported capacity. This translates to a significant underestimation of UTD with tUS, most notably in those with VUR. Alternatives to traditional protocols include insisting patients wait until their bladder is truly full for tUS, retrograde filling their bladder, or performing uUS. Accurate assessment of UTD severity may help guide long term management.

The Role of Radiographic Imaging in Diagnosis and Follow-up of Vesicoureteral Reflux: Review Article

Background: Primary vesicoureteral reflux is a basic influencing for urinary tract infections in children. The basic technique for the diagnosis of vesicoureteral reflux is voiding cystourethrography, accompanied with cystoscintigraphy. Voiding cystourethrography has the benefit of only minor irradiation. However it does no longer permit the morphological assessment of bladder and vesicoureteral reflux grading. Colored-Doppler cystosonography with echocontrast is a currently delivered technique for imaging vesicoureteral reflux. The purpose of our study is to explore the role of Radiographic Imaging in diagnosis and follow‐up of vesicoureteral reflux.&#x0D; Method: A systematic review was carried out, (including PubMed, Google Scholar, and EBSCO) of imaging modalities used to detect or evaluate vesicoureteral reflux disease. The found articles were screened by titles, and abstracts. No software will be utilized to analyze the data. The review was performed by the group members and each verified by at least two, to ensure the validity and minimize the mistakes.&#x0D; Results and Conclusion: Colour-Doppler cystosonography, due to the nonexistence of ionizing radiations, has great benefits, mainly in cases requiring continued or prolonged monitoring. In spite of practices stated in the literature, this procedure has a role in the diagnosis of vesicoureteral reflux. Our group chooses colour-Doppler cystosonography for the follow-up of medium-severe grade vesicoureteral reflux previously diagnosed by radiology and/or scintigraphy. Cystoscintigraphy is used only to confirm cases resulting negative at ultrasonography.

The impact of our acquired experience on endoscopic injection treatment outcomes of vesicoureteral reflux during the first ten years of practice

Introduction: Endoscopic injection treatment (EIT) for vesicoureteral reflux (VUR) correction is widely accepted as an optimal method for more than thirty years. However, it is still in its infancy in many pediatric surgical centers. It presents variable cure rates, with many factors affecting its successfulness. Objectives: We aimed to identify how accumulated endoscopic experience affected the VUR resolution success rates, in association with a variety of characteristics, since the beginning of practicing the technique. We attempt to improve patient selection. Patients and Methods: The outcomes of 53 children, corresponding to 78 refluxing ureteral units (RUUs), treated with endoscopic injection during the first years of practice (2010-2016), and 26 children with 42 RUUs during the latest years (2017-2020), were compared. Characteristics such as age, gender, VUR grades, preoperative voiding cystogram and dimercaptosuccinic acid scintigraphy, side, laterality were analyzed in relation with outcome of the groups of the study population. Outcomes presenting statistically significant differences were considered related to experience. Results: Refluxing ureters of the second group presented significant improved endoscopic treatment success rates and also significant reduced need for open surgery. The second group of experienced performance presented significant improved success rates in younger children, in girls, in children with bilateral VUR or duplex ureteral system, and when reflux presented at the filling phase of voiding cystourethrogram. Furthermore, the second group of experienced performance presented significant improved success rates in ureteral units of a duplex system or with grade III and high grades IV-V VUR. Conclusion: Our initial experience with EIT has been promising. Boys, and children with bilateral VUR or duplex ureteral system should be treated by more experienced endoscopic surgeons. Furthermore, high grade VUR is a predisposing factor for endoscopic treatment failure, performing by less experienced surgeons. Pediatric surgeons must upgrade their learning curve, initiating their experience, and developing their surgical skills with more simple cases before expanding their practice to more complicated.

Clinical profile of children with primary vesicoureteric reflux and its association with renal parenchymal scarring

Context: Vesicoureteric reflux (VUR) has been implicated in renal injury before birth as well as in postnatal occurrence of urinary tract infection (UTI) and further renal damage. About 30–49% of children with primary VUR may develop renal scarring called reflux nephropathy. About 5–10% of children with reflux nephropathy may progress to chronic kidney disease in late childhood. Objectives: The objectives of the study were to study the clinical profile of children with primary VUR and to assess the relationship with grades of primary VUR and renal parenchymal scarring. Materials and Methods: Fifty children of age 1 month–5 years, diagnosed to have Primary VUR, were included in this prospective observational study. Detailed history was taken; examination was carried out as per the study protocol. Investigations included urine analysis, renal function tests, urine culture, renal ultrasonography, micturating cystourethrogram, and 99mTc dimercaptosuccinic acid (DMSA) scintigraphy. For those who had UTI, DMSA was carried out after a minimum period of 6 months after UTI episode. Results: Among the 50 children, 21 (42%) were male and 29 (58%) were female with male-to-female ratio of 0.72:1. Mean age at diagnosis was 9 months, ranging from 1 to 40 months. The number of children presented with UTI was 43 (86%), and 7 children (14%) were asymptomatic and were evaluated in view of abnormality in prenatal ultrasound scan. Unilateral VUR was found in 21 patients (42%), and 29 patients (58%) had bilateral VUR. Of all 79 refluxing units (21 unilateral plus 58 bilateral), 4% had VUR of Grade I severity, 30% of Grade II, 34% of Grade III, 28% of Grade IV, and 4% of Grade V severity. Renal parenchymal scarring on DMSA scan was detected in 42 (54%) of 79 refluxing units including 33% of Grade II, 55% of Grade III, 71% of Grade IV, and 100% of Grade V refluxing units. Prevalence of scarring in complicated, recurrent, and simple UTI was 100%, 93%, and 22%, respectively. Conclusion: Risk of renal scarring increased progressively with increasing severity of primary VUR. Complicated and recurrent UTI were found to be statistically significant risk factors for renal scarring. Renal scarring was also seen in absence of UTI in a small percentage of children with primary VUR.

Long-Term fate of the upper urinary tract and ITS association with continence in exstrophy patients

Scarce data is available in literature about the upper urinary tract outcomes of patients with Exstrophy-Epispadias Complex (EEC). After bladder closure during childhood, EEC bladders can become hostile to the upper tracts after bladder by exposing them to high pressures, leading to hydronephrosis (HN) and kidney damage. Similarly, vesicoureteral reflux (VUR) may be present and increase the likelihood for pyelonephritis. We sought to assess long-term upper urinary tract outcomes by evaluating renal function, HN and VUR; and to assess if upper urinary tract outcomes are associated with continence status. A retrospective review of EEC patients having ≥1 surger(y) (ies) at our institution from 1990 until 2019 was performed. Renal function was assessed by evaluating last available estimated glomerular filtration rate (eGFR) and creatinine values. HN was assessed on ultrasound and classified according to the SFU-classification. Patients with recurrent febrile urinary tract infections (UTI) or pyelonephritis underwent a voiding-cystourethrogram (VCUG) assessing VUR, graded following the 'International system of radiographic grading of VUR'. Descriptive and comparative statistical analysis were performed to assess if upper tract outcomes are associated with continence status. Forty-eight patients (75% male) had a median (IQR) follow-up of 18 (10-21) years. The table shows upper tract outcomes for the entire group and stratified by continence status. The median creatinine was 0.6 (0.2-0.9) mg/dL and median eGFR was 108 (72-160) mL/min/1.73m [2]. In two patients (4.2%), HN (SFU-grade 2) was detected. Thirty-six patients (75%) underwent VCUG, revealing high-grade VUR (stage IV-V) in 8 patients (17%) and low-grade VUR (stage I-III) in 7 patients (15%). Continence was associated with a higher need for VCUG (p=0.02) and a higher presence of VUR (p=0.03). Renal function in EEC patients and non-EEC patients is comparable when age matched. Only 6% had low-grade HN which was asymptomatic. 17% had high-grade VUR, which is little compared to literature (40-70%). However, results in literature are described in patients with a 'one-stage' bladder closure, whereas some of our patients had a 'two-stage' procedure. A one-stage procedure creates higher bladder pressures resulting in higher VUR-rates. Statistical analysis has showed that continence is associated with a higher prevalence of recurrent febrile UTI's or pyelonephritis and of VUR. No statistically differences were found between continent and incontinent patients concerning creatinine and eGFR value (p=0.52 and p=0.29), nor in the prevalence of hydronephrosis (p=0.36). However, results of this study suggest that continent patients may portend a higher risk of upper tract deterioration with recurrent febrile UTI's and pyelonephritis due to VUR. Close monitoring of the upper tract status is therefore as important as focus on continence. Large-scale prospective studies defining renal function as well as pyelonephritis rates are needed to optimize the management of the upper tracts in EEC patients.

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

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

Assessment of the Grades of Vesicoureteral Reflux in Stented Ureters: An Experimental Study

Introduction: The aim of this experimental study is to assess, in a porcine model, the onset and grades of vesicoureteral reflux associated with ureteral stents. Methods: Twenty-four female porcine models were used. A 4.7-Fr ureteral stent was placed in all right ureters and kept in place for 6 weeks. Follow-ups were performed on weeks 1, 3, 6, and 12. Ultrasonography, cystoscopy, and fluoroscopy were used to analyze grade of hydronephrosis, presence and grade of vesicoureteral reflux, bacteriuria, and macroscopic changes of the ureteral orifices. Vesicoureteral reflux was classified using a modification of the International Reflux Study Committee grades. Results: 91.7% animals present vesicoureteral reflux, 89.5% grade IA, 3.5% grade IB, and 7% grade II. There is a significant increase in reflux during follow-ups at 3 and 6 weeks, whereas 6 weeks after removal, 26.3% of the ureters still present vesicoureteral reflux. Hydronephrosis and macroscopic changes of the ureteral orifice increase significantly with stenting, but there is no significant association between them and vesicoureteral reflux; the relationship between bacteriuria and the presence of vesicoureteral reflux is not significant either. Conclusion: Vesicoureteral reflux caused by ureteral stents in an animal model is mostly low grade and mainly affects the distal ureter.