Management Of Vesicoureteral Reflux Research Articles

Does the distal ureteral diameter ratio (UDR) matter in the surgical management of vesicoureteral reflux in children?

To evaluate UDR reliability, sensitivity, specificity and to identify the best treatment basing on UDR among single or double endoscopic injections and ureteral reimplantation. Data of patients affected by primary VUR and treated by endoscopic injection over a 10years period were retrospectively analyzed. Two radiologist attributed reflux grade and UDR on voiding cystourethrogram twice and blinded. Follow-up focused on resolution after 1 or 2 endoscopic injections. Relation between UDR, reflux grade and outcomes were analyzed. Patient enrolled were 198. Low grade VUR was present in 24.8%, grade 3 in 41.6%, grade 4-5 in 33.6%. Resolution after one injection was obtained in 88 patients; among 110 not resolved 104 cases had a second injection. Success after 2 injections was reported in 138 cases. UDR showed a higher reliability compared with reflux grade both in intra than inter-reader measurement (ICC > 90%). Success after 1 or 2 injections was reported for UDR < 0.33 and UDR < 0.47 respectively. UDR shows to be a more reliable measurement that allows for an objective estimation of VUR severity and prognosis. It represents a quantitative parameter that might be useful to identify patients who may benefit endoscopic or surgical treatment, avoiding unnecessary under or over-treatment.

How the 99mTc-DMSA scintigraphy findings are reflected in the adopted treatment of primary vesicoureteral reflux: One centre experience

Renal changes may have long-term sequalae and prevention is a main goal of management of primary vesicoureteral reflux (VUR). This study aims to reveal how much 99mTc-DMSA scintigraphy findings are reflected in the adopted surgical or non-surgical treatment in children with diagnosed primary VUR and to give the clinicians information regarding their final therapeutic decision. A total 207 children with primary VUR who underwent non-acute 99mTc-DMSA scan were retrospectively evaluated. The presence of renal changes, their grading, differential function asymmetry (<45%) and grade of VUR were compared with subsequent choice of therapy. Altogether 92 (44%) children had asymmetric differential function, 122 (59%) showed presence of renal changes, 79 (38%) had high-grade VUR (IV-V). Patients with renal changes had lower differential function (41%vs.48%) and higher grade of VUR. The incidence of high-grade changes (G3+G4B) afflicting more than one third of the kidney was significantly different between grade I-II, III and IV-V VUR (9%, 27%, 48%, respectively). Renal changes were detected in 76% of surgically and 48% of non-surgically treated patients, high-grade 99mTc-DMSA changes in 69% and 31%, respectively. In children with no scars/dysplasia (G0+G4A), non-surgical treatment prevailed in 77%. The independent predictors for surgical intervention were presence of renal changes and higher grade of VUR, but not functional asymmetry. Over the last 20 years, there has been a shift toward more non-surgical management of VUR. The long-term outcome of this approach should be thoroughly studied. This is the first study analysing renal status in VUR patients using 99mTc-DMSA scan and its grading regarding the adopted treatment. Renal changes in almost half of non-surgically treated children with VUR should be an indicator for earlier diagnosis and effective treatment of acute pyelonephritis and VUR. We recommend distinguishing grade III VUR, as a moderate-grade VUR, because it is linked to higher incidence of high-grade 99mTc-DMSA changes (G3+G4B); our findings of 65% of grade III VURs treated non-surgically should be cautionary. Grade III VUR does not mean a low-risk condition and should alert the clinician to evaluate the extent of renal changes and unmask high-risk cases. Our data strengthens the need to investigate the extent of renal changes in VUR patients regarding treatment decision. Performing 99mTc-DMSA scan individualizes the treatment of VUR patients; its grading can distinguish grade III-VUR as a separate risk entity because it differs significantly in terms of incidence of high-grade renal changes and chosen therapy.

Outcome analysis of Cohen’s cross trigonal ureteric reimplantation in paediatric age group

Introduction: Cohen’s cross trigonal ureteric reimplantation is the gold standard for surgical management of vesicoureteric reflux (VUR) in children with high success rate. The objective of this study was to evaluate and assess the outcome of open Cohen’s procedure in children with VUR.&#x0D; Methods: A retrospective review of all patients with VUR who underwent Cohen’s procedure between March 2010 and February 2020 was done. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome and complications.&#x0D; Results: The series consisted of 40 patients (25 girls and 15 boys) who underwent Cohen’s procedure with a mean age of 32 months (6 months to 8 years). Bilateral repairs were performed in 16 patients (40%) in the same setting and unilateral repair in 24 patients (60%). Twenty-two patients (55%) had grade IV VUR, 13 patients (32.5%) had grade V VUR and 05 patients (12.5%) had grade III VUR. Mean operative time for bilateral repairs was 249.4(200-290) minutes and 158.3(130-180) minutes for unilateral repair respectively. The mean length of hospital stay was 10.55 (7-15) days. Major complications included two persistent VURs, and one case of bladder hematoma. Postoperative ultrasound abdomen in all patients and micturating cystourethrogram in few patients was obtained, in which 38 patients (95%) had normal study.&#x0D; Conclusion: Cohen’s uretric reimplantation is a standard procedure in paediatric VUR. For better outcome, patient selection and refinement of operative technique should be pursued.

Giant foreign body granuloma after endoscopic management of vesicoureteric reflux: a case report

BackgroundDeflux®, a dextranomer/hyaluronic acid copolymer, is extensively used as an endoscopic bulking agent for management of vesicoureteric reflux (VUR). The complications following Deflux® treatment as described in the literature are clinically insignificant transient obstruction and infections of the urinary tract. We report a rare case of a giant Deflux® granuloma presenting as an intraoperative surprise while undergoing open ureteric reimplantation for the failure of prior endoscopic management.Case presentationA 2.5-year-old boy with a primary VUR needed Anderson Hyne’s pyeloplasty of the affected side for concomitant pelviureteric junction obstruction. During removal of the double “J “stent in the postoperative period, subureteric Deflux® was injected, hoping that a more invasive procedure could be avoided. At a later date, as VUR persisted, an open ureteric reimplantation, was performed. Intraoperatively, a large Deflux® granuloma was noted at the site of previously injected site.ConclusionsGiant Deflux® granuloma is a rare complication of this modality of VUR management. A focussed radiological assessment in such pateints during follow-up is required, especially those planned for surgical intervention in the vesicoureteric region later.

Diagnostic and therapeutic management of vesico-ureteral reflux in pediatric kidney transplantation-Results of an online survey on behalf of the European Society for Paediatric Nephrology.

Vesico-ureteral reflux (VUR) is considered to be a risk factor for recurrent febrile urinary tract infections and impaired renal transplant survival. An online survey supported by the European Society for Paediatric Nephrology was designed to evaluate current management strategies of VUR in native and transplanted kidneys of recipients aged <18 years. Seventy-three pediatric transplant centers from 32 countries contributed to the survey. All centers performed urological evaluation prior to pediatric kidney transplantation (KTx) with subsequent interdisciplinary discussion. Screening for VUR in native kidneys (30% in all, 70% in selected patients) led to surgical intervention in 78% (11% in all, 89% in selected patients) with a decided preference of endoscopic intervention over ureterocystoneostomy. Following KTx, continuous antibiotic prophylaxis was applied in 65% of the patients and screening for allograft VUR performed in 93% of selected patients. The main management strategies of symptomatic allograft VUR were continuous antibiotic prophylaxis (83%) and surgical treatment (74%) (endoscopic intervention 55%, redo ureterocystoneostomy 26%). This survey demonstrates the high variability in the management of VUR in pediatric KTx recipients, points to knowledge gaps, and might serve as a starting point for improving the care for patients with VUR in native and transplanted kidneys.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n=13), complete ureteral duplication (n=2), periureteral diverticulum (n=2), ectopic megaureter requiring dismembering (n=1). The median operative time was 155min for unilateral and 211.5min for bilateral repairs. The clinical+radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n=5, 8.7%), febrile urinary tract infection (UTI) (n=6, 10.5%) and gross hematuria (n=3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p=0.002] and bilateral repair [p=0.001] and post-operative urinary retention was more frequent in simple cases [p=0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p=0.001] (Table). This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Extravesical verses intravesical ureteral reimplantation in paediatric patients suffering from vesicoureteric reflux.

Objective: To compare two different techniques for ureteric reimplantation for management of Vesicoureteric reflux in children. Study Design: Comparative study. Setting: Department of Pediatric surgery at D. G Khan Medical College Dera Ghazi Khan. Period: January 2010 to April 2021. Material &amp; Methods: Seventy four patients with vesicoureteric reflux were included. Extravesical reimplantation technique was performed in 35 children labeled as Group A , while intravesical reimplantation was performed in 39 children labeled as Group B. Parameters compared between two groups were length of the surgical procedure, average duration of hospital stay, postoperative bladder spasms, significant hematuria &gt;72 h, and long-term complications. Results: The mean age at operation was 6.5 years in Group A and 6.35years in Group B. The mean duration of surgery was significantly less in Group A .i.e 104 min with SD 18 min compared to Group B where mean duration was 128 min; SD 15 min. The mean postoperative stay was significantly lower (P value =0.032) at 4.5 (1.5) days in Group A compared to 6.5 (0.5) days in Group B. Postoperative bladder spasms were significantly lower (P = 0.003) at 1/35 in Group A compared to 35/39 in Group B. Postoperative hematuria was significantly lower (P =0.001) in Group A compared to Group B. Conclusion: Extravesical reimplantation technique has lower operative time, less postoperative discomfort and shorter hospital stay compared to intravesical reimplantation. Both techniques are equally effective in treating reflux.

Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences

Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR. We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5min. There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p=0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p=0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5min (p=0.039). In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.

MP17-20 THE NATURAL HISTORY OF CHILDREN WITH ANTENATAL HYDRONEPHROSIS AND ASYMPTOMATIC VESICOURETERAL REFLUX INCLUDING VCUG ORDERING PRACTICES

You have accessJournal of UrologyCME1 May 2022MP17-20 THE NATURAL HISTORY OF CHILDREN WITH ANTENATAL HYDRONEPHROSIS AND ASYMPTOMATIC VESICOURETERAL REFLUX INCLUDING VCUG ORDERING PRACTICES Jeremy Goodman, Walid Farhat, Fardod O'Kelly, Jennika Finup, Ryan McAdams, Kara Gill, and Matthew W. Harer Jeremy GoodmanJeremy Goodman More articles by this author , Walid FarhatWalid Farhat More articles by this author , Fardod O'KellyFardod O'Kelly More articles by this author , Jennika FinupJennika Finup More articles by this author , Ryan McAdamsRyan McAdams More articles by this author , Kara GillKara Gill More articles by this author , and Matthew W. HarerMatthew W. Harer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002550.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the last two decades, there has been a shift towards more conservative management of vesicoureteral reflux (VUR). Although there are multiple areas of consensus, the current literature is marked by controversy and divergent guidelines regarding VUR imaging, screening, and treatment. Furthermore, the practice of ordering voiding cystourethrograms (VCUG) continues to be common, particularly in infants with a history of antenatal hydronephrosis. Herein, we sought to examine inter-departmental VCUG ordering practices, and subsequent rates of VUR in infants with antenatal hydronephrosis (ANH) in a large US tertiary referral hospital. METHODS: A single academic center radiology database was used to identify all infants with documented ANH that underwent a VCUG within the first 6 months of life. Data relating to ANH, VCUG findings, VCUG requests, and ordering services were extracted from the electronic health record and analyzed. RESULTS: 627 infants with ANH (207 bilateral) had a VCUG performed between 2015-2019, of which 143 (23%) confirmed VUR (bilateral in 66; with 59.6% male, mean age 2.65 months and 40.4% female, mean age 2.8 months). Overall, pediatric urology was responsible for the highest number of VCUG requests (70%), followed by nephrology (10%), pediatrics (9%), neonatology (8%), and family medicine (2%). However, in infants with low grade hydronephrosis (SFU grades I/II), 60% of VCUGs were requested and obtained by pediatrics, 18% by pediatric urology, 12% by nephrology, and 10% by family medicine. Most infants with VUR (70%; 100/143) had a follow-up VCUG scan was performed, which was done at a mean of 6 months (Range: 1-4 years). In infants with confirmed VUR and a subsequent follow-up VCUG, 33% (30/100) had resolved spontaneously (mean follow-up interval and age of 6 months, and 4.2 years respectively), 21% (21/100) underwent operative interventions, and 46% (46/100) were managed without any surgical intervention. CONCLUSIONS: Most asymptomatic patients (77%) with a history of ANH do not have evidence of VUR on VCUG , however, VCUGs continue to be ordered in infants diagnosed with ANH irrespective of symptoms, with pediatricians more likely to order VCUG for lower grades of hydronephrosis. As VUR management has become more conservative, we recommend abstaining from requesting VCUGs in infants with asymptomatic ANH and to follow an informed, shared decision-making model based on intent to treat. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e294 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremy Goodman More articles by this author Walid Farhat More articles by this author Fardod O'Kelly More articles by this author Jennika Finup More articles by this author Ryan McAdams More articles by this author Kara Gill More articles by this author Matthew W. Harer More articles by this author Expand All Advertisement PDF DownloadLoading ...

Vesicoureteral reflux treatment following kidney transplantation potentially prevents graft function deterioration and allows long-term graft survival.

The impact of vesicoureteral reflux post-kidney transplantation on graft survival remains unclear, and guidelines on appropriate vesicoureteral reflux management post-kidney transplantation are lacking. For this reason, we conducted a retrospective study on the impact of vesicoureteral reflux and its treatment on graft survival. We evaluated 347 consecutive kidney transplantation recipients, who also underwent a ureteroneocystostomy, between 1996 and 2012. Vesicoureteral reflux was diagnosed in 55 cases (15.9%), with a median post-kidney transplantation duration of 50 months (range 0-172 months). Among these, 22 were monitored, 17 underwent transurethral collagen injections, and 16 received a ureteroneocystostomy. The 10-year graft survival rate was significantly lower in recipients with vesicoureteral reflux (68.9%) than in those without vesicoureteral reflux (84.4%) (P = 0.0165). Moreover, among the vesicoureteral reflux recipients, the 10-year graft survival rate was significantly higher in those whose vesicoureteral reflux was cured (80.1%) than in those whose vesicoureteral reflux persisted (53.6%) (P = 0.0062). Multivariate analysis showed that vesicoureteral reflux was significantly associated with both overall and death-censored graft loss (odds ratio 3.737 and 3.685; P = 0.0015 and P = 0.0052, respectively). Lastly, the incidence of interstitial fibrosis and tubular atrophy was higher in recipients with vesicoureteral reflux than in those without vesicoureteral reflux (P = 0.0009). Post-kidney transplantation vesicoureteral reflux has a negative impact on long-term graft survival, and that treatment prevents graft deterioration. From the perspective of maintaining long-term graft function in kidney recipients, vesicoureteral reflux may be one of the most important complications to be addressed.

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.

Surgical management of vesicoureteral reflux in adults

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the upper urinary tract with or without upper-tract dilatation. This diagnosis is commonly made in childhood, affecting 1% of all births. In adults, its prevalence and incidence are not known. Presentation in adults could be with loin pain associated with voiding or a full bladder, recurrent urinary tract infections, a diagnosis carried over from childhood or an incidental finding. Most of the works on VUR have been done in the paediatric population. There are limited publications addressing VUR in adults. Unsurprisingly, the management of VUR in adults is extrapolated from the knowledge that we have gained from paediatric urology. Herein, we recap on the pathophysiology and review the surgical management of VUR in adults as published over the years.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Assessment of distal ureteral and ureterovesical junction visualization on contrast-enhanced voiding urosonography.

Contrast-enhanced voiding urosonography (CEVUS) uses intravesically administered microbubble contrast to detect vesicoureteral reflux (VUR) and urethral anomalies with ultrasound. Multiple studies have suggested CEVUS can replace voiding cystourethrogram (VCUG) as a radiation-free alternative. Analysis of the ureterovesical junction and ureters on VCUG documenting the ureterovesical junction position, ureteral duplication, periureteral diverticula and ureteroceles is important as anatomical variations may affect management and surgical approach. Our purpose was to assess distal ureteral and ureterovesical junction region visualization in children with VUR detected on CEVUS. CEVUS studies performed between June 2018 and March 2019 with reported VUR were retrospectively reviewed by two pediatric radiologists to confirm VUR and to qualitatively assess the ureterovesical junction region for each renal moiety using a 3-point scale for clear, limited or absent visualization of the distal ureter, ureterovesical junction, ureteral duplication, periureteral diverticula and ureteroceles. Thirty-four studies with VUR on CEVUS were identified. Sixty-seven renal moieties were evaluated including a solitary kidney in one child. VUR was detected in 52 moieties by reader 1 and in 53 by reader 2. A single moiety with discrepancy between readers regarding VUR was excluded from statistical analysis. No diverticula were detected by either reader and one ureterocele was detected by both readers. Visualization of the ureterovesical junction was described as clear in 5/52, limited in 14/52 and absent in 33/52 refluxing renal moieties by reader 1 and as clear in 12/52, limited in 20/52 and absent in 20/52 by reader 2. The ureterovesical junction was clearly visualized in 5/52 (9.6%) by reader 1 and 12/52 (23.1%) by reader 2. The Kappa value of -0.29 (confidence interval [CI] -0.25, 0.21) reveals a lack of agreement between the readers for clear versus limited or absent ureterovesical junction visualization. Distal ureteral visualization was described as clear in 14/52, limited in 16/52 and absent in 22/52 refluxing renal moieties by reader 1 and as clear in 27/52, limited in 7/52 and absent in 18/52 by reader 2. The distal ureter was clearly visualized in 14/52 (26.9%) by reader 1 and 27/52 (51.9%) by reader 2. The Kappa of 0.43 (CI 0.22, 0.64) reveals moderate agreement between the readers for clear versus limited or absent distal ureteral visualization. Duplication of the renal collecting system was identified in 13/52 refluxing kidneys by reader 1 and 11/52 refluxing kidneys by reader 2. Visualization of ureteral duplication was described as clear in 9, limited in 4 and absent in 39 of 52 refluxing renal moieties by reader 1 and as clear in 9, limited in 2 and absent in 41 by reader 2. Ureteral duplication was clearly visualized in 9/52 (17.3%) by reader 1 and 9/52 (17.3%) by reader 2. Kappa of 0.87 (CI 0.68, 1) reveals high agreement between the readers for clear versus limited or absent identification of ureteral duplication. The distal ureter and ureterovesical junction region frequently are not clearly visualized in refluxing renal moieties on CEVUS. Awareness of this limitation is important as there may be implications when evaluating patients for surgical management of VUR.

Surgical indications for operative management of vesicoureteral reflux in children.

Vesicoureteral reflux (VUR) management has been steadily evolving over the last several years. There is not a definitive algorithm for operative intervention, but there are some recognized patterns to follow when caring for this patient base. It is extremely relevant to review the rationale behind practice patterns as both literature and clinical practice are dynamic. VUR is a common malady that is emotionally, physically, and financially draining for families. As new treatment options emerge with minimally invasive techniques and older methods are re-explored, it is imperative to re-evaluate care strategies. This article reviews the mainstays of treatment in addition to newer therapeutic modalities. The decision to operate on any patient, particularly pediatric patients, must be preceded by sound clinical judgment. Thoughtful planning must be utilized to ensure every patient receives individualized and up-to-date VUR management. This article reviews indications for surgical intervention to consider when managing these patients.

Conservative Management of Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is defined as the retrograde flow of urine from the bladder to the upper urinary tract (the ureters and kidneys), caused by ureterovesical junction dysfunction. VUR is the most common congenital urinary tract abnormality; nevertheless, the conservative treatment for VUR remains controversial. In addition, the limited data availability made it difficult to establish a widely accepted treatment protocol. This study aimed to review available treatment modalities and recommendations with regard to the conservative management for VUR. An online literature search was performed on PubMed, PubMed Central, and Google Scholar. Studies were compared with several available guidelines. Based on literature search, the conservative management of VUR involves a multimodality approach, including the bladder-bowel dysfunction management through bladder training, anticholinergics and alpha-blockers, continuous antibiotic prophylaxis, and circumcision in male patients. Operative and other invasive treatment modalities may be considered in treatment failure or breakthrough urinary tract infection and should not be used as a first-line treatment.

Primary Bilateral High-Grade Vesicoureteral Reflux in Children: Management Perspective.

ObjectiveVesicoureteral reflux (VUR) is a common finding in the pediatric population with the risk of repeated infections and renal damage. There is little is known about the natural history of primary bilateral high-grade reflux. Herein we present our experience in the management of primary high-grade bilateral VUR and the long-term outcome of renal function in this specific group of patients.Materials and methodsWe retrospectively evaluated all patients with congenital bilateral VUR between 2006 and 2014. Records were reviewed for patient age at diagnosis, antenatal history, clinical presentation, the grade of VUR on voiding cystourethrogram (VCUG), presence of scars on dimercaptosuccinic acid (DMSA) scan, indications for surgical intervention, and surgical approaches. Clinical and radiological outcomes of this subgroup of patients were assessed.ResultsA total of 67 patients with bilateral VUR were identified, of whom 31 (20 boys and 11 girls) had primary high-grade (grade IV and V) bilateral VUR. The mean age at diagnosis was seven months. DMSA scans showed renal scars in 19 patients (61%) and eight of them were bilateral. Surgical intervention was necessary for 81% of patients with a success rate of 58% after endoscopic correction and 100% after reimplantation. Chronic kidney disease (CKD) developed in 13 patients (42%) after a mean follow-up of eight years.ConclusionsPrimary bilateral high-grade VUR carries a high rate of surgical intervention. The endoscopic correction has an acceptable success rate and efficient long-term outcome. Nevertheless, a significant proportion of patients progresses to CKD even after VUR management.

Trends in the surgical management of vesicoureteral reflux in Finland in 2004–2014

Objectives Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland. Methods We analyzed national data from Finnish Care Register for Health Care on children (<16 years of age) surgically treated for VUR in 2004–2014. Results Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p < 0.001, respectively). The median age at surgery for VUR was lower in those treated with open ureteral reimplantation than those with endoscopic injections of the ureteral orifices [3 and 4 years, respectively] (p = 0.0001). The length of hospital stay was significantly longer (median 9.9 days) with open ureteral reimplantation compared to that (median 1.3 days) with endoscopic injections (p < 0.0001) and did not change during the study period. Reoperations were significantly more common in patients who were primarily treated with endoscopic injections (n = 146/1072, 14%) than with ureteral reimplantation (n = 7/230, 3%) (p < 0.0001). Conclusions While the best treatment options for VUR remain debatable, operative treatment of VUR has become less common in Finland. HIGHLIGHTS Recent data on the trends of treatment of vesicoureteral reflux outside USA are scarce. Surgical treatment for vesicoureteral reflux decreased in Finland during the study period. The length of stay was longer but reoperations were needed less often with ureteral reimplantation compared to endoscopic injections.

Additional VCUG-related parameters for predicting the success of endoscopic injection in children with primary vesicoureteral reflux

Prediction of vesicoureteral reflux (VUR) prognosis and decision for treatment are usually made according to the reflux grading classification. But the management of VUR is still controversial since there are difficulties in distinguishing reflux grade due to inter- and intra-observer variations. Previous studies have demonstrated that the distal ureteral diameter ratio (UDR) on voiding cystourethrography (VCUG) may be more predictive for clinical prognosis than reflux grade. We aimed to predict the success of endoscopic injection in primary VUR by creating new models that include other additional parameters (timing of reflux, delayed post-voiding contrast drainage of the upper urinary tract) as well as UDR. A total of 200 patients aged 2-15 years with primary VUR undergoing endoscopic injection were retrospectively evaluated. Demographic and clinical data for a total of 248 renal units were recorded. Besides reflux grade and laterality, distal ureteral diameter, UDR, timing of reflux [early filling, late filling or voiding] and presence of contrast delay in upper tract drainage were also assessed on VCUG. According to the complete resolution of VUR on the control VCUG at the postoperative 3rd month, the renal units were divided into two main groups: successful (n=171, 68.9%) and unresolved (n=77, 31.1%) RESULTS: The failure rate of endoscopic injection was found to be 4.068 times greater with early filling reflux on VCUG, 3.076 times greater with UDR>0.24, 2.745 times greater with delayed contrast drainage of the upper urinary tract, 2.666 times greater with the presence of scar in DMSA, 2.493 times greater with bladder-bowel dysfunction and 2.341 times greater with febrile urinary tract infection. We also observed that a model in which all VCUG-related parameters were combined provided a better estimation of endoscopic injection outcomes compared to only the reflux grade (AUC: 0.903 vs. 0.604, respectively). Distal ureteral dilatation is considered to be a more decisive factor for clinical outcomes of primary VUR rather than upper urinary tract dilatation since ureterovesical junction anatomy plays a more important role in primary VUR pathophysiology. Studies investigating new prediction models on this topic have recently become more popular. However, a consensus has not yet been achieved. We consider that UDR level, the timing of reflux and delayed upper tract drainage on VCUG may be more predictive parameters of endoscopic injection success compared with reflux grade, and could facilitate selecting the best candidates for surgery.

Endoscopic management of vesicoureteral reflux secondary to myelomeningocele in children: a single-center experience

Vesicoureteral reflux (VUR) is present in up to 24% of children with neurogenic bladder secondary to meningomyelocele. Endoscopic management of VUR has been an emerging approach, especially since the continuous development of this technique has translated in comparatively high success rates. In this study, we assess the efficacy of subureteric injections of dextranomer/hyaluronic acid copolymer in managing VUR secondary to meningomyelocele in pediatric patients. All patients aged less than 12 years who underwent endoscopic management for secondary VUR of grades III–V due to meningomyelocele were observed. The diagnosis and classification of VUR was done via a MCUG. All patients underwent clinical assessment, renal function tests, urine microscopy with culture, KUB ultrasound, and dimercaptosuccinic acid (DMSA) scan before and after the intervention. A total of 19 children (38 renal units) were evaluated and followed up. The mean age at presentation and intervention was 44 ± 34.6 months and 45.7 ± 35.2 months. The most common grade of reflux at presentation was grade IV (42.1%) followed by V (26.3%). A complete symptomatic relief and treatment success was achieved in 29 renal units (76.3%) following a single injection. A second injection was sufficient to achieve symptomatic relief in the remaining nine renal units (23.6%). None of the patients required a third injection or open surgery. The endoscopic treatment of secondary VUR grades III, IV, and V due to meningomyelocele with dextranomer/hyaluronic copolymer paste in children younger than 12 years is safe and effective alternative minimally invasive surgery with low morbidity.