Vesicoureteral Reflux Grade Research Articles

Renal function damage in children with duplex kidneys

PurposeTo evaluate renal function damage in children with duplex kidneys.MethodsA total of 355 duplex kidneys, 110 urinary tract infection (UTI) kidneys without abnormalities, and 104 kidneys with primary unilateral vesicoureteral reflux (VUR) were reviewed. Clinical data including age at diagnosis, body weight, history of UTI, ureteroceles, ectopic ureteral opening, VUR grade, serum creatinine level, cystatin C level, renal scarring, split renal function in dimercaptosuccinic acid scans, and effective renal plasma flow (ERPF) were analyzed.ResultsDuplex kidneys had a higher grade of VUR and renal scarring. Split renal function in unilateral duplex kidneys (45.58 ± 12.85%) was much lower than that in contralateral duplex kidneys (56.33 ± 11.90%) and controls (50.00 ± 11.38%) (P < 0.001 and P = 0.014, respectively). Both left and right split renal functions in bilateral duplex kidneys were similar to those ipsilateral to the controls (P = 0.906 and P = 0.932, respectively). However, the total ERPFs in the left, right, and bilateral duplex kidneys were significantly lower than that in the control group (P = 0.003, P = 0.001, and P = 0.003, respectively). The total ERPFs in the left and right unilateral duplex kidneys were similar. ERPF in unilateral duplex kidneys (106.70 ± 48.05 mL/min/m2) was significantly lower than that in contralateral duplex kidneys (150.18 ± 49.01 mL/min/m2) or those ipsilateral to controls (145.98 ± 41.16 mL/min/m2) (P < 0.001 and P < 0.001, respectively).ConclusionDuplex kidneys are usually accompanied by a higher grade of VUR, more severe renal scarring, and renal function impairment. Split renal function in duplex kidneys often declines significantly. Notably, the evaluation of split renal function in bilateral duplex kidneys should be performed cautiously.

Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience

BackgroundThough common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation. MethodsWe retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time. ResultsAltogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26–3.52]) and surgical experience (Range OR: 8.88[7.16–11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32–0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN. ConclusionsIncidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR. Level of evidenceII

The Spectrum of Parenchymal Changes in Kidneys Affected by Intrarenal Reflux, Diagnosed by Contrast-Enhanced Voiding Urosonography and DMSA Scan.

PurposeTo describe the parenchymal defects in kidneys with intrarenal reflux (IRR) diagnosed using contrast-enhanced voiding urosonography (ceVUS) and 99mTc-DMSA scintigraphy (DMSA scan).Materials and MethodsA group of 186 uretero-renal units (URUs) was analyzed using ceVUS and DMSA scans: 47 without vesicoureteral reflux (VUR) (group A) and 139 with VURs, comprising 73 VURs without (group B), and 66 with IRR (group C). VURs included non-dilating (grades I–II), mildly non-dilating (grade III), and non-dilating (grades IV–V) grades. The parenchymal changes were analyzed using a DMSA scan.ResultsThe median age for VUR diagnosis was 16.5 months in girls, and 8.5 months in boys (Z = 3.9; p = 0.001). IRR occurred in 51.4% of boys and in 25.9% of girls (χ2 = 12.4; p < 0.001). The non-dilating VUR occurred in 44% of boys and 24.1% of girls (χ2 = 7.7; p = 0.005). IRRs characterized upper and lower renal segments (81.8 and 63.6%) and middle segments (33.3%). Both incidence and increase in IRR correlated with the grade of VUR (p < 0.001). The incidence of reduced DMSA signal was statistically different among groups A + B and C, but not between groups A and B (χ2 = 32.2; p < 0.001). No statistically significant relationship existed between the reduced DMSA signal and the grade of VUR in group C. The reduced DMSA signal appeared in 9.9% positions in kidneys from group A, 14% from group B, and 32% from group C. Out of all 118 IRRs, 38.1% had reduced and 61.9% had normal DMSA signal. Among 11 parenchymal scars found in all three groups, 2 belonged to group B, 9 to group C, while group A had no scars.ConclusionThe parenchymal changes are the most prominent in the group with IRR, but they do not significantly differ among kidneys with different grades of VUR. VURs of higher grades are associated with a higher incidence of IRR and early clinical presentation. Scars can also appear in lower-grade VURs accompanied by IRR. Boys with VUR have earlier clinical presentation than girls, as they have significantly higher grades of VUR with a higher proportion of IRRs. Therefore, we suggest a subdivision of VURs into those with IRR and abundant parenchymal damage, and those without IRR and less parenchymal damage.

Vesicoureteral Reflux – Insights into Diagnosis and Management

Abstract Vesicoureteral reflux (VUR) is the most common congenital condition of the urinary tract. A plethora of imaging methods and treatment plans are described in literature and are used in clinical practice. The aim of this article is to analyze the available diagnostic tests and the pharmaceutical, endoscopic, and surgical options of our therapeutic armamentarium. A literature search on the PubMed database was conducted by two writers. Randomized controlled trials and meta-analyses were included, all published in PubMed and in the English language from 2011 to this day. After reviewing the full texts, we excluded duplicates, papers regarding secondary disease and those without a pediatric reference population. Regarding the mostly used imaging tests, voiding cystourethrography is considered the reference method for the diagnosis and grading of the disease, but it entails exposure of patients to ionizing radiation. Voiding urosonography has a similar sensitivity but is highly dependent on the operator’s experience. Renal scintigraphy with dimercaptosuccinic acid remains a useful test for detecting renal scars. As far as management is concerned, continuous antibiotic prophylaxis, though previously doubted, remains a valid therapeutic option, especially for lower grades of VUR. Open surgical techniques and their modern–laparoscopic and robotic–variations are useful for dealing with high-grade disease, while endoscopic methods have sufficient efficacy and are utilized more and more. The diagnosis and treatment of VUR are constantly evolving areas. New diagnostic methods are replacing the older ones, while the treatment algorithm is individualized.

Commentary to model for predicting high -grade vesicoureteral reflux in young children presenting with febrile urinary tract infection

The authors employ three well known imaging and clinical risk factors associated with vesicoureteral reflux (recurrent UTI, non-E. coli pathogen, abnormal renal and bladder ultrasound) to create a scoring system for limiting the use of a VCUG in all children who present with a febrile UTI. It is no surprise that the presence of any one of these factors alone identifies an appreciable number of children with high grade (III–V) reflux. The authors, along with the American Academy of Pediatrics and the British National Institute for Clinical Excellence, have striven to reduce the use of the VCUG and are content with missing some with reflux and renal scarring. These efforts are not without controversy. The cohort in this study has particular characteristics that affect the generalizability of the conclusions. The majority was uncircumcised males and this may explain why only 92 of 324 children with febrile UTI's had reflux. Since most were infants under the age of toilet training, bowel and bladder dysfunction could not be evaluated. A small number of children underwent DMSA scanning, so the authors are incapable of legitimately assessing the severity or clinical significance of the reflux in the remainder, independent of grade. Notably, of the small number of low grade reflux children who did undergo DMSA evaluation, 30% had scars. This is the group the authors are suggesting should not undergo a VCUG at presentation, as they argue that the consequences of reflux were “minimal.” Finally, it may be unrealistic to assume that a child with reflux who was not fully evaluated initially would reliably return for evaluation after a second or third UTI. A number of children in this cohort do not live near a center and in any case, follow up in many circumstances is often not perfect. As demonstrated by the data in this report, the use of this scoring system to withhold VCUG imaging will result in missing children with reflux and renal damage. Model for predicting high-grade vesicoureteral reflux in young children presenting with febrile urinary tract infectionJournal of Pediatric UrologyPreviewHigh-grade vesicoureteral reflux (VUR) is associated with long-term renal outcome, and can be missed if voiding cystourethrogram (VCUG) is not performed. The current febrile urinary tract infection (UTI) guidelines have narrowed down the indications for VCUG. This study aimed to determine the predictors and develop a model to predict high-grade VUR (grade III-V) in young children presenting with febrile UTI. Full-Text PDF Response to commentary re model for predicting high -grade vesicoureteral reflux in young children presenting with febrile urinary tract infectionJournal of Pediatric UrologyPreviewThank you so much for your comment. We do agree that voiding cystourethrography (VCUG) examination in young children with first febrile urinary tract infection (UTI) is still a controversial topic. Recently, a reduction in the use of the VCUG has occurred [1,2]. Concern regarding missing those with reflux and renal scarring is important and needs more long-term data analysis. Full-Text PDF

The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans.

To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans. A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit. At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%). Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.

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.

Application of urodynamics combined with contrast-enhanced ultrasound in evaluation of the urinary tract in patients with low bladder compliance and vesicoureteric reflux who underwent bladder augmentation alone.

We assessed the use of common urodynamics (CUD) combined with contrast-enhanced ultrasound (CEUS) to investigate the efficacy and durability of sigmoid cystoplasty alone in patients with low bladder compliance associated with vesicoureteric reflux (VUR). In this study, we recruited 25 patients with low bladder compliance and VUR who underwent bladder augmentation without antireflux surgery at our institutions between June 2017 and June 2021. The bladder condition and VUR grade were assessed preoperatively and postoperatively via CUD combined with CEUS. The mean follow-up period was 2.6 years. CUD showed significant improvement in bladder capacity and compliance and a decrease in intravesical pressure after sigmoid cystoplasty. CEUS demonstrated resolution of VUR compared with preoperative assessment. Of the 25 patients who had various degrees of reflux, VUR was eliminated in 18 patients and reduced to a lower grade in the remaining seven patients. CUD combined with CEUS is accurate and safe. They are invaluable and reliable tools for morphological and functional evaluations of the entire urinary tract in patients with low bladder compliance and VUR.

A case of minimal change disease associated to Rubinstein Taybi syndrome

Introduction: Focal segmental glomerulosclerosis (FSGS) is the main glomerular nephropathy secondary to malformative uropathies. The latter can be included in the poly malformative syndromes in the pediatric population. However, other glomerular impairments may rarely be associated with some polymalformative syndromes as reported in this rare case of a minimal change disease (MCD) associated with Rubinstein Taybi syndrome (RSTS). Materials and methods: We report a case of pure nephrotic syndrome in a young male patient with RSTS. Case presentation: It is about a 27 year old young patient diagnosed since birth with a Rubinstein Taybi. In 1994, he was hospitalized in pediatrics for acute pyelonephritis. Retrograde urethrocystoscopy (RUC) showed bilateral vesicoureteral reflux (VUR) grade 3 with functional renal asymmetry on scintigraphy. The patient was admitted in nephrology department in 2019 for a pure and intense nephrotic syndrome with abrupt onset. The initial diagnosis retained was glomerular nephropathy particularly a FSGS secondary to his malformative uropathy. Subsequently, in view of the persistence of an intense nephrotic syndrome, the absence of VUR at the RUC, as well as the functional renal symmetry at the scintigraphy, it was decided to perform a renal biopsy. The biopsy showed an optically normal kidney with the presence of some meningial C3 deposits. MCD was then retained. The patient received corticosteroid therapy with a favorable clinical and biological response. Conclusion: Even if reflux nephropathy remains the most frequent cause of glomerulopathy secondary to malformative uropathy, we should not hesitate to perform a renal biopsy in front of an intense nephrotic syndrome with no functional renal impact of the VUR.

Impact of Third-Generation Cephalosporin Resistance on Recurrence in Children with Febrile Urinary Tract Infections.

Background: The purpose of this study was to investigate the association between third-generation cephalosporin resistance and urinary tract infection (UTI) recurrence in patients who underwent voiding cystourethrogram (VCUG). Methods: In this retrospective study, data were obtained from hospitalized pediatric patients who had a first febrile UTI episode and subsequently underwent VCUG. Information based on VCUG was mandatory to identify the presence of vesicoureteral reflux (VUR). A multivariable logistic model was used to identify the risk factors for recurrence. Recurrence was divided into early (90-day) and late (1-year), and sensitivity analyses were performed according to each definition. The estimates of all the statistical models were internally validated using bootstrap samples. Results: A total of 210 patients were included, and the overall recurrence rate of UTI was 26.2% (55 of 210). Third-generation cephalosporin resistance was a significant risk factor for early recurrence (odds ratio: 2.79 [1.08–7.20]) but not for late recurrence. Sensitivity analyses showed that third-generation cephalosporin resistance was a significant risk factor for 60-day recurrence but not for 180-day recurrence. A VUR grade ≥ 3 was identified as a consistent risk factor for both early and late recurrence. Conclusions: Third-generation cephalosporin resistance was a significant risk factor for the early recurrence of pediatric UTI in patients who underwent VCUG.

PD40-01 ACCURACY OF CYSTOGRAPHY IN CHILDREN UNDER GENERAL ANESTHESIA WITH SUSPECTED VESICOURETERAL REFLUX

You have accessJournal of UrologyCME1 May 2022PD40-01 ACCURACY OF CYSTOGRAPHY IN CHILDREN UNDER GENERAL ANESTHESIA WITH SUSPECTED VESICOURETERAL REFLUX Michael Frumer, Bezalel Sivan, Tal May, Roy Morag, Dmitry Khunovich, and David Ben Meir Michael FrumerMichael Frumer More articles by this author , Bezalel SivanBezalel Sivan More articles by this author , Tal MayTal May More articles by this author , Roy MoragRoy Morag More articles by this author , Dmitry KhunovichDmitry Khunovich More articles by this author , and David Ben MeirDavid Ben Meir More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002601.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystography under general anesthesia has proven a safe procedure in several studies. Some radiologists prefer to insert the catheter and perform examinations under anesthesia for their and the child's convenience. This study compares cystography under light sedation to cystography under general anesthesia. METHODS: A prospective study of children who had vesicoureteral reflux (VUR) on cystography without general anesthesia, and underwent endoscopic injection of bulking agent into the ureter. Pre-operative clinical and radiological data were recorded. All children subsequently underwent a cystography under general anesthesia prior to injection using standardized method, which included bladder filling to iliac crest level, and external abdominal pressure to look for active reflux. This cystography was compared to cystography performed without general anesthesia. Chi-square and Mann–Whitney U tests were used to compare proportions and medians between groups. RESULTS: Between October 2017 and January 2021, 92 renal units in 8 boys and 38 girls were evaluated. Median age was 3 years (IQR 1.5, 5). Median time from cystography without to cystography with general anesthesia was 3.7 months (IQR 2.6, 5.9). Of the 92 renal units, 73 had VUR on cystography without general anesthesia, considered as gold standard. VUR grades by the gold standard are presented in Table 1. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative predictive value and positive predictive value of cystography with general anesthesia were 41% (30/73), 79% (15/19), 26% (15/58), and 88% (30/34) (Table 2). Cohen’s Kappa coefficient between the two cystography was 0.11, indicating poor agreement. In subgroup analyses, the sensitivity of cystography with general anesthesia for filling phase VUR was 45% (29/64) vs. 11% (1/9) for voiding phase VUR (P=0.05). CONCLUSIONS: Cystography with general anesthesia was poorly correlated to cystography performed while the child was lightly sedated. Clinical decision relying on this cystography is questionable. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e683 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Frumer More articles by this author Bezalel Sivan More articles by this author Tal May More articles by this author Roy Morag More articles by this author Dmitry Khunovich More articles by this author David Ben Meir More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP17-02 PREDICTIVE FACTORS FOR IMPROVEMENT/RESOLUTION OF VESICOURETERAL REFLUX IN DUPLEX KIDNEYS

You have accessJournal of UrologyCME1 May 2022MP17-02 PREDICTIVE FACTORS FOR IMPROVEMENT/RESOLUTION OF VESICOURETERAL REFLUX IN DUPLEX KIDNEYS Clinton Yeaman, Kathryn Morgan, Fionna Sun, Sherry Ross, Jamie Michael, Rebecca Zee, Hans Pohl, Daniel Casella, Bruce Sprague, C.D. Anthony Herndon, and Nora Kern Clinton YeamanClinton Yeaman More articles by this author , Kathryn MorganKathryn Morgan More articles by this author , Fionna SunFionna Sun More articles by this author , Sherry RossSherry Ross More articles by this author , Jamie MichaelJamie Michael More articles by this author , Rebecca ZeeRebecca Zee More articles by this author , Hans PohlHans Pohl More articles by this author , Daniel CasellaDaniel Casella More articles by this author , Bruce SpragueBruce Sprague More articles by this author , C.D. Anthony HerndonC.D. Anthony Herndon More articles by this author , and Nora KernNora Kern More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002550.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most vesicoureteral reflux (VUR) improves spontaneously over childhood with resolution rates of 45-70% in simplex kidneys. Lower pole VUR in duplex kidneys has not been as well studied with a single 1991 study citing resolution rates of 85% for grades 1-2 and 36% for grade 3 VUR. We aimed to describe the occurrence of VUR in duplex systems as well as predictive factors for resolution/improvement. METHODS: Patients were retrospectively reviewed between 2015-2020 treated at 4 institutions in the Mid-Atlantic. Inclusion criteria included patients with a duplex kidney with any grade of lower pole VUR. Multivariate logistic regression was used to identify predictors of VUR resolution based upon demographic and clinical characteristics. Successful improvement/resolution was defined as downgrading to grade 3 VUR or lower, and failure was defined as persistent grade 4-5 VUR. Descriptive statistics and regression modeling were performed using SAS. RESULTS: Of a cohort of 223 patients, 93 patients (41.7%) had lower pole VUR into 98 renal units. 68 patients (75%) were female. 22 patients (24%) underwent surgical procedures for VUR in the duplex moieties. 10 renal units (10.8%) had grade 1, 10 (10.8%) had grade 2, 24 (25.8%) had grade 3, 16 (17.2%) had grade 4, and 33 (35.5%) had grade 5 VUR. Infants were diagnosed at a mean age of 6 months and underwent repeat exam at a mean age 2.8 years (SD 2). 20 patients (21.5%) did not have repeat VCUG performed. On follow-up, VUR resolved/downgraded in 43 patients (55.1%), persisted at low grade in 7 patients (8.9%) and persisted at high-grade in 28 (35%). VUR resolved in 74% of those with grades 1-3 and in 17.5% of those with grades 4-5 (Table 1A). On univariate analysis (Table 1B), the only predictive factor for resolution of VUR was VUR grade (p=0.001) and was not affected by gender, grade of hydronephrosis or upper pole pathology. On multivariate analysis, low grade VUR remained a significant predictive factor (p=0.006). CONCLUSIONS: 55% of cases of lower pole VUR in duplex kidneys resolve spontaneously /downgrade to low grade. Spontaneous resolution seems to be affected by low grade VUR status alone. 83% of high grade VUR remained high grade at follow up. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e284 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clinton Yeaman More articles by this author Kathryn Morgan More articles by this author Fionna Sun More articles by this author Sherry Ross More articles by this author Jamie Michael More articles by this author Rebecca Zee More articles by this author Hans Pohl More articles by this author Daniel Casella More articles by this author Bruce Sprague More articles by this author C.D. Anthony Herndon More articles by this author Nora Kern More articles by this author Expand All Advertisement PDF DownloadLoading ...

Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children.

Objective To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups. Results The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001). Conclusion Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.

Value of sufficient clean intermittent catheterization in urinary tract infection and upper urinary tract protection in children with neurogenic bladder

Clean intermittent catheterization (CIC) is a mainstay in the management of neurogenic bladder. To assess the effect of CIC on urinary tract infection and upper renal tract function in pediatric patients with neurogenic bladder, and the influence of duration of CIC on these variables. A retrospective study was performed in 67 pediatric patients with neurogenic bladder who started CIC between 2014 and 2019at our institution. The febrile urinary tract infection (fUTI) rate, renal pelvis diameter (measured by antero-posterior renal pelvis diameter, APPD), bladder wall thickness (BWT) on ultrasound, and creatinine level at 6 months and 12 months of CIC were compared with baseline in all patients. The grade of vesicoureteral reflux (VUR) at 12 months of CIC were also compared with baseline. There were no significant differences compared with baseline after 6 months of CIC in the rate of fUTI, APPD, and BWT (p>0.05); however, all of these parameters significantly improved after 12 months of CIC (p<0.05). The VUR grade was significantly reduced after 12 months of CIC(p=0.03). There was no significant change in serum creatinine level with any duration of CIC (both p>0.05). Continuing CIC for more than 6 months had a beneficial influence on protecting the upper urinary tract. Complications of CIC, such as recurrent fUTI and lower urinary tract trauma, are more likely to occur in the early stage of CIC due to poor technique by the caregivers and poor patient compliance underscoring the importance of caregiver education. Study limitations include the retrospective nature and small sample size. CIC for less than 6 months may have limited influence on renal protection; however, a longer duration of CIC (12 months) resulted in significant improvement in outcomes. This study demonstrates the importance of proper caregiver education to establish standardized CIC techniques and to improve CIC quality.

ПРЕДИКТОРЫ ЭФФЕКТИВНОСТИ ЛЕЧЕНИЯ ПУЗЫРНО-МОЧЕТОЧНИКОВОГО РЕФЛЮКСА У ДЕТЕЙ

The article presents a modern view on the prognostic factors of spontaneous resolution and effectiveness of treatment of children with vesicoureteral reflux (VUR). The most frequently used predictors of successful treatment of VUR (grades of reflux, distal ureteral diameter ratio to the distance of the lumbar vertebrae, reflux induction phase on mictional cystourthrography), delayed removal of contrast from the upper urinary tract, gender, age, antenatal hydronephrosis). Methodology, statistical significance, advantages, disadvantages of the described prognostic factors are analyzed.

Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux

With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim etal. in an earlier study. De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.

Ureteral reimplantation during augmentation cystoplasty is not needed for vesicoureteral reflux in patients with neurogenic bladder: a long-term retrospective study

BackgroundTo investigate the need for ureteral reimplantation for vesicoureteral reflux (VUR) during augmentation cystoplasty (AC) in the long term.MethodsA total of 19 patients with a median age at surgery of 14 years (3–38 years) who underwent AC for neurogenic bladder with VUR between 1983 and 2016 were included in this study. The changes in VUR grade and urodynamic findings were retrospectively evaluated. We evaluated the renal function by periodic inspection of serum creatinine level and estimated glomerular filtration rate; eGFR.ResultsThe median follow-up period from AC was 14.8 years (5.7–30 years). VUR was detected in 19 patients, involving 27 ureters. Reflux grade was V in 6, IV in 9, III in 5, II in 6, and I in 1. Ureteral reimplantation was not performed in 18 patients (26 ureters), whereas it was done for 1 patient (1 ureter) in the early era of our experience. Postoperative videourodynamics showed that the reflux was radiologically not verifiable in 23 ureters (85%), was downgraded in 3 ureters (11%), and was unchanged in 1 ureter (3%). There were no cases of deterioration of VUR.ConclusionsUreteral reimplantation is not necessary for VUR during augmentation cystoplasty.

Is Vesicostomy Still a Contemporary Method of Managing Posterior Urethral Valves?

In boys with posterior urethral valves (PUVs) the main treatment aim is to preserve long-term bladder and renal function. To determine the effectiveness of secondary vesicostomy in boys with PUVs, the medical records of 21 patients with PUV (2010–2019), divided into two groups (group I: valve ablation; group II: secondary vesicostomy), were reviewed regarding the course of serum creatinine, renal ultrasound, voiding cystourethrogram, urodynamics, postoperative complications, need of further surgery, and long-term solution. The median age of all patients at first follow-up was 11 (9–13) months and at last follow-up 64.5 (39.5–102.5) months. Despite a significant difference of the SWDR score (shape, wall, reflux, and diverticula) (p = 0.014), both groups showed no significant differences preoperatively. Postoperatively, serum creatinine (p = 0.024), grade of vesicoureteral reflux (p = 0.003), side of upper tract dilatation (p = 0.006), side of megaureter (p = 0.004), and SWDR score (p = 0.002) were significantly decreased in group II. Postoperative urodynamic measurements showed comparable results in both groups. Stoma complications were found in three (20%) patients (group II). Eight (53.3%) patients already received a closure of the vesicostomy. Seven out of eight (87.5%) patients were able to micturate spontaneously. Vesicostomy remains a reliable treatment option for boys with PUV to improve bladder function and avoid further damage to the urinary tract.

Dexamethasone to prevent kidney scarring in acute pyelonephritis: a randomized clinical trial

BackgroundUrinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children.MethodsMulticenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed.ResultsNinety-one participants completed the follow-up and were finally included (dexamethasone n = 49 and placebo n = 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups, p = 0.907). Renal damage severity in the early DMSA (β = 0.648, p = 0.023) and procalcitonin values (β = 0.065 p = 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (β = 0.545, p = 0.054), but dexamethasone treatment showed no effect.ConclusionDexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation.Trial registrationClinicaltrials.gov, NCT02034851. Registered in January 14, 2014.Graphical abstract“A higher resolution version of the Graphical abstract is available as Supplementary information.”

Long-term results of endoscopic treatment in vesicoureteral reflux after kidney transplantation.

To assess the long-term clinical outcomes and identify factors predicting success of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) after kidney transplantation. A retrospective chart review of all patients who had a symptomatic VUR after renal transplantation at our centre between January 2000 and December 2020 was performed. VUR was documented by retrograde cystography and was determined by at least one episode of acute graft pyelonephritis (AGPN). Endoscopic injections of polydimethylsiloxane (MacroPlastique™) or dextranomer/hyaluronic acid copolymer (Deflux™) were performed by expert urologists via rigid cystoscopy with a bevelled needle system. The results of endoscopic treatment were evaluated by cystography at three months. The primary endpoint was clinical efficacy as defined by the absence of AGPN during follow-up. Radiological success was defined by the absence of VUR at the three months follow-up cystography. Out of 2135 kidney transplantations, a total of 117 (5.5%) patients had symptomatic VUR: 100 (85.5%) underwent Deflux™ and 17 (14.5%) MacroPlastique™. Preoperative high-grade VUR was recorded in 71% of patients. One postoperative complication was observed, Clavien > II. After a median follow-up of 11.2years (IQR 6.5-14.4), clinical success was achieved in 73 patients (62.4%). Radiological success was obtained in 42 patients (36%). Multivariable analysis failed to identify predictors of endoscopic treatment success, which was independent of the preoperative grade of VUR and the type of bulking agent used. Endoscopic treatment of VUR is a simple and well-tolerated procedure with long-term clinical efficacy.