Persistent Vesicoureteral Reflux Research Articles

Clinical outcomes and risk factor analysis of early endoscopic puncture decompression for ureterocele associated with duplex kidney in children: a single-center retrospective study

PurposeThe aims of this study were to analyze the clinical outcomes of treating duplex system ureteroceles with early endoscopic puncture decompression and to identify the risk factors related to outcomes to help guide future work.Materials and methodsWe retrospectively reviewed the clinical records of patients with ureteroceles with duplex kidney that were treated with early endoscopic puncture decompression. Charts were reviewed for demographics, preoperative imaging, surgical indications, and follow-up data. Recurrent febrile urinary tract infections (fUTIs), de novo vesicoureteral reflux (VUR), persistent high-grade VUR, unrelieved hydroureteronephrosis, and the need for further intervention were considered unfavorable outcomes. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), type of ureterocele, ipsilateral VUR diagnosed before surgery, simultaneously upper-pole moiety (UM) and lower-pole moiety (LM) obstruction, the width of ureter affiliated to UM, and maximum diameter of ureterocele were all considered potential risk factors. A binary logistic regression model was used to identify the risk factors of unfavorable outcomes.ResultsA total of 36 patients with ureteroceles related to duplex kidney underwent endoscopic holmium laser puncture from 2015 to 2023 at our institution. After a median follow-up of 21.6 months, unfavorable outcomes developed in 17 patients (47.2%). Three patients underwent ipsilateral common-sheath ureter reimplantation and one patient underwent laparoscopic ipsilateral upper to lower ureteroureterostomy combined with recipient ureter reimplantation. Three patients underwent laparoscopic upper-pole nephrectomy. Fifteen patients suffered from recurrent UTIs were treated with oral antibiotics and eight of them were diagnosed de novo VUR according to voiding cystourethrography (VCUG). In univariate analysis, patients with simultaneously UM and LM obstruction (P = 0.003), fUTIs before surgery (P = 0.044), and ectopic ureterocele (P = 0.031) were more likely to have unfavorable outcomes. Binary logistic regression analysis showed that ectopic ureterocele (OR = 10.793, 95% CI 1.248–93.312, P = 0.031) and simultaneously UM and LM obstruction (OR = 8.304, 95% CI 1.311–52.589, P = 0.025) were identified as independent factors for unfavorable outcomes.ConclusionsOur study suggested that early endoscopic puncture decompression is not a preferred but an available treatment option to release BOO or to cure refractory UTIs. It was easier to fail if the ureterocele was ectopic or simultaneously UM and LM obstruction existed. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), ipsilateral VUR diagnosed before surgery, the width of ureter affiliated to UM, and maximum diameter of ureterocele were not significantly related to the success rate of early endoscopic punctures.

MP70-08 OUTCOMES AND SAFETY OF ROBOTIC-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION IN INFANTS LESS THAN 24 MONTHS OF AGE WITH PRIMARY VESICOURETERAL REFLUX

You have accessJournal of UrologyCME1 Apr 2023MP70-08 OUTCOMES AND SAFETY OF ROBOTIC-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION IN INFANTS LESS THAN 24 MONTHS OF AGE WITH PRIMARY VESICOURETERAL REFLUX Sahar Eftekharzadeh, Katherine Fischer, Aznive Aghababian, Sameer Mittal, John Weaver, Karl Godlewski, Christopher Long, Dana Weiss, Aseem Shukla, and Arun Srinivasan Sahar EftekharzadehSahar Eftekharzadeh More articles by this author , Katherine FischerKatherine Fischer More articles by this author , Aznive AghababianAznive Aghababian More articles by this author , Sameer MittalSameer Mittal More articles by this author , John WeaverJohn Weaver More articles by this author , Karl GodlewskiKarl Godlewski More articles by this author , Christopher LongChristopher Long More articles by this author , Dana WeissDana Weiss More articles by this author , Aseem ShuklaAseem Shukla More articles by this author , and Arun SrinivasanArun Srinivasan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While the use of robotic assisted laparoscopic ureteral reimplantation (RALUR) for management of vesicoureteral reflux (VUR) in the pediatric population has been well reported over the years, the use of RALUR in the infant cohort (<24 months of age) remains lower than older children likely due to perceived technical challenges including robotic arm collision in a small working space. We hypothesize that the safety and efficacy of performing RALUR on patients <24 months of age is comparable to an older cohort. METHODS: An IRB approved single-institutional registry was queried to retrospectively identify all patients under 18 years of age who underwent RALUR for primary VUR between 2012 - 2019. Patients undergoing concomitant procedures or with duplex renal collecting systems were excluded. We categorized patients into two groups: 1) <24 months of age 2). >24 months of age. Demographics, pre-operative imaging, operative details, and post-operative outcomes including 30-day complications, persistent VUR, incidence of febrile UTI (fUTI), dysfunctional voiding, and rate of reintervention was aggregated. RESULTS: Of 172 patients who underwent RALUR during the study period, 141 (82%) met inclusion criteria: 29 in the <24 months group, and 112 in the >24 months group (Table 1). There was a higher incidence of breakthrough UTIs in the <24 months group (p<0.001), occurring in 28/29 patients (97%) in this group. Patients <24 months old had a higher percentage of fUTIs within 30 days of surgery (Clavien-Dindo Grade II). There was no statistical difference in the length of surgery, use of straight catheterization, persistent VUR, dysfunctional voiding, fUTIs occurring >30 days after surgery, or need for further interventions between the two groups (Table 2). 7 patients from both groups required subsequent intervention. CONCLUSIONS: Outcomes of patients undergoing RALUR for primary VUR are favorable regardless of age. RALUR is technically feasible, safe, and efficacious for management of primary VUR in patients younger than 24 months. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1006 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sahar Eftekharzadeh More articles by this author Katherine Fischer More articles by this author Aznive Aghababian More articles by this author Sameer Mittal More articles by this author John Weaver More articles by this author Karl Godlewski More articles by this author Christopher Long More articles by this author Dana Weiss More articles by this author Aseem Shukla More articles by this author Arun Srinivasan More articles by this author Expand All Advertisement PDF downloadLoading ...

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

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

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.

Usefulness of intraoperative voiding cystourethrogram as an indicator of success in the endoscopic treatment of vesicoureteral reflux.

Up until now, serial voiding cystourethrogram (SVCU) has been regarded as the gold standard technique in the diagnosis of vesicoureteral reflux (VUR). The aim of intraoperative SVCU during endoscopic treatment is to detect those patients eligible to receive more biosynthetic material as a result of persistent VUR. The objective of this study was to assess the usefulness of SVCU as a predictor of treatment success. An analytical, retrospective study of patient medical records was carried out. Patients included had undergone endoscopic VUR surgery from 2000 to 2019, and they were measured in ureteral units. VUR persistence at intraoperative SVCU following treatment was compared with SVCU results after 3 months. Of a total of 167 ureteral units undergoing surgery, persistent reflux immediately after surgery was observed in 17 cases (10% of the sample). Only 3 cases had other urological malformations. In the SVCU carried out after 3 months, reflux was found in 38% of the sample (64 cases). When comparing the results, intraoperative SVCU demonstrated a specificity of 92.6%, and a sensitivity of 15.6%. Given the low sensitivity (15.6%) of intraoperative SVCU to detect cases of persistent reflux in the mid-term, and considering the risks associated with radiation in the pediatric population - which is extremely sensitive to it -, intraoperative SVCU should be ruled out as a useful indicator of endoscopic treatment success.

Experience of Maharaj Nakorn Chiang Mai Hospital in extravesical ureteral reimplantation for vesicoureteral reflux in pediatric patients

Objective: The most commonly used technique for vesicoureteral reflux (VUR) treatment in pediatric patients in Maharaj Nakorn Chiang Mai Hospital is extravesical ureteral reimplantation (EUR). This report describes our experience of clinical outcomes of this technique. Materials and Methods: A total of 30 children underwent EUR for unilateral and bilateral VUR between July 2007 and June 2015. We retrospectively reviewed their medical records. Patient characteristics, operative time, duration of catheter drainage, length of postoperative hospital stay, and perioperative complications were evaluated. Results: Twenty-two boys and 8 girls with a mean age of 4.4 years (range, 0.5-14.6) were included in the study. Reflux was graded 1 to 5. Fourteen unilateral and 16 bilateral procedures were performed. A Pfannenstiel incision was implemented in the first 20 cases and inguinal incision in the last 10 cases. Mean operative time was 115.5 minutes. Mean duration of catheter insertion was 5.7 days. Mean length of postoperative hospital stay was 6.1 days and mean estimated blood loss was 28.7 ml. Overall success rate was 90%. One patient (3.3%), developed a post- operative urinary tract infection, while 3 cases had persistent VUR after surgery. Acute urinary retention occurred in 1 patient (3.3%) on postoperative day 4 but following catheterization the patient was able to urinate by day 7. Conclusion: EUR for the treatment of VUR is a simple, safe, and effective procedure. The prevalence of postoperative urinary retention in bilateral reimplantation is low and transient. The inguinal approach is a viable option and as effective as classical procedures.

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

Bilateral ureteral reimplantation at complete primary repair of exstrophy: Post-operative outcomes

The value of bilateral ureteral reimplant (BUR) at the time of complete primary repair of bladder exstrophy (CPRE) has been suggested, however, outcomes are poorly characterized in current medical literature. We hypothesize that BUR at time of CPRE will decrease the rate of recurrent pyelonephritis, post-operative vesicoureteral reflux (VUR), and the need for subsequent ureteral surgery. We analyzed 64 consecutive patients with a diagnosis of classic bladder exstrophy (BE) who underwent CPRE at three institutions from 2013 to 2019.15 patients underwent cephalotrigonal BUR-CPRE and 49 patients underwent CPRE alone. Our primary outcome was >1 episode of pyelonephritis as documented in the medical record. Secondary outcomes were persistent vesicoureteral reflux (VUR), with a sub-analysis of number of refluxing renal units and presence of dilating VUR, and the need for subsequent ureteral surgery. Descriptive statistics in addition to standard, two tailed univariate statistics, were used to compare the groups where appropriate. BUR-CPRE was associated with a significant decrease in the rates of post-operative VUR, number of refluxing renal units, and need for subsequent ureteral surgery (p=0.002, p=0.001, and p=0.048 respectively). There was a reduction in the rates of recurrent pyelonephritis and dilating reflux in patients undergoing BUR-CPRE, though it did not reach significance. Female gender was significantly associated with recurrent pyelonephritis regardless of BUR-CPRE status (p=0.005). There were no reports of distal ureteral obstruction or other complications following BUR-CPRE. The mean post-operative follow up for the BUR-CPRE group was 46.33 (10.26) months vs. 53.76 (26.05) months for CPRE (p=0.11). Recurrent pyelonephritis following bladder closure in patients with BE is a well-documented surgical complication, with centers performing CPRE reporting rates of post-operative pyelonephritis from 22 to 50%. Our series demonstrates similar efficacy of BUR-CPRE compared to other contemporary series and provides additional detail about need for subsequent ureteral surgeries and increased long term follow-up of these complex patients. Limitations of the study include male predominance of the cohort and lack of randomization of BUR-CPRE. BUR-CPRE decreases postoperative VUR and the need for additional ureteral surgery in select BE patients; it should be considered when technically feasible. While results continue to suggest a trend toward decreased recurrent pyelonephritis and dilating reflux, further longitudinal follow-up in our cohort will be needed.

A systematic review of outcomes of Deflux® treatment for vesicoureteral reflux following pediatric renal transplantation

Vesicoureteral reflux (VUR) after renal transplant in the pediatric population may be associated with an increased incidence of urinary tract infection (UTIs) leading to increased morbidity, including graft dysfunction and graft loss. The non-orthotopic location of the transplanted ureter, and lack of submucosal tunnel may pose challenges in correcting the VUR using endoscopic injection techniques. Herein we report the results of a systematic review evaluating the outcomes of endoscopic treatment of VUR using Deflux® in this population. Pubmed and Embase databases were searched from October 2001 to April 2019. Full-text English articles involving patients less than 18 years old at the time of transplant, with a diagnosis of VUR post-transplantation, who underwent Deflux® treatment were included. Figure1 outlines our PRISMA-compliant search strategy. We found 6 eligible studies describing Deflux® treatment outcomes in 67 pediatric patients with post-transplant VUR where voiding cystourethrogram (VCUG) confirmed the diagnosis and resolution of VUR. The mean success rate was 36.8%. Ureteral obstruction occurred in 7/67 cases (10.4%). In all these 7 cases of obstruction, ureteric stenting was the initial management, but was only successful in 1 patient. Open ureteroneocystostomy (UNC) was performed in 4/7 cases, while 2/7 were managed expectantly (unknown outcomes). Persistent VUR with UTI despite Deflux® were reported in 20 out of 67 cases. Of these, 7 were managed with prophylactic antibiotics, and 13 with UNC. Success rates were consistently low for UNC after failed Deflux® in comparison to redo UNC in transplant ureters without prior injection. Low success rates are seen following injection techniques for VUR after pediatric renal transplant. Although an appealing option, Deflux® may prove counterintuitive due to the high rate of obstruction and suboptimal results if open reimplantation is required. A multi-institutional prospective study with a larger population size may further elucidate these results.

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux

Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR). We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO). A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution. A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N=10) or symptomatic ureterovesical junction obstruction (UVJO, N=6). Mean console times were 102min (range 70-240min) for RALUR vs 128min (range 70-180min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction. RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

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.

CLINICAL EXPERIENCE OF TRANSURETHRAL INJECTION USING DEXTRANOMER-HYALURONIC ACID COPOLYMER (Deflux®) FOR CASES OF SECONDARY VESICOURETERAL REFLUX AFTER URETEROCYSTONEOSTOMY

(Objective) We reviewed the clinical efficacy of transurethral Deflux® injection therapy (Deflux® injection therapy) in patients with secondary vesicoureteral reflux (VUR) after ureterocystoneostomy. (Methods) We retrospectively evaluated data for Deflux® injection therapy in 4 patients after ureterocystoneostomy with secondary VUR due to lower urinary tract dysfunction treated at this hospital from 2010 through 2018. The indications for surgery were febrile urinary tract infection or new renal scarring, and the outcomes of treatment with Deflux® injection therapy were evaluated. (Results) There were 2 male and 2 female patients. Three patients had unexplained lower urinary tract dysfunction, all patients were using clean intermittent catherization, and 3 patients had operated by the Cohen method for VUR. Preoperative examinations revealed that all patients had unilateral VUR, and reflux was assessed as Grade III in 1 patient and Grade IV in 3 patients. The median age at initial surgery was 12.8 years, and Deflux® injection therapy was performed unilaterally in all patients. Deflux® injection therapy was performed by a combined HIT/STING technique in 2 patients and by the HIT technique alone in 2 patients, with a median injection volume of 2.4 ml. The therapeutic outcome for initial Deflux® injection therapy was resolution of VUR in 1 patient (25%) and persistence of VUR in 3 patients. Treatment was repeated for 2 of the 3 patients with persistent VUR, and resolution was reported for 1 of these patients. (Conclusion) The initial success rate for Deflux® injection therapy in VUR with bladder dysfunction was a low 25%, suggesting that caution is required in choosing this treatment option.

Impact of bilateral ureteral reimplantation at the time of complete primary repair of bladder exstrophy on reflux rates, renogram abnormalities and bladder capacity

Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity. An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity. A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p=0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p=0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p=0.016). After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation. BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient.

Girls and renal scarring as risk factors for febrile urinary tract infection after stopping antibiotic prophylaxis in children with vesicoureteral reflux.

To clarify the incidence of and risk factors for febrile urinary tract infection in children with persistent vesicoureteral reflux (VUR) after the discontinuation of continuous antibiotic prophylaxis (CAP), retrospective chart review was performed. Among children with primary VUR at 10years of age or younger at presentation, those who had persistent VUR despite conservative management with CAP and who were subsequently followed after discontinuation of CAP were included. Kaplan-Meier curve and Cox's proportional hazard regression model were used for evaluation of the incidence of and risk factors for febrile urinary tract infection (fUTI) after stopping CAP. Among 144 children (99 boys and 45 girls), fUTI developed in 34. The 5-year fUTI-free rate after discontinuation of CAP was 69.4%. On multivariate analyses, girls (p = 0.008) and abnormalities on nuclear renal scans (p = 0.0019), especially focal defect (p = 0.0471), were significant factors for fUTI. Although the fUTI-free rate was not different between children who had no or 1 risk factor, it was significantly lower in children with 2 risk factors than in those with no or 1 risk factor. The present study revealed that girls and abnormal renal scan, especially focal defect, are risk factors for fUTI. Active surveillance without CAP for persistent VUR seems to be a safe option for children with no or 1 risk factor. Prophylactic surgery or careful conservative follow-up may be an option for girls with abnormal renal scan results if VUR persists under CAP.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation.

Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR). We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system. A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort. Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

A scoring system for predicting downgrading and resolution of high-grade infant vesicoureteral reflux.

Aim of the study was to provide a scoring system for predicting downgrading and resolution of infantile high-grade vesicoureteral reflux (VUR). Eighty-nine infants (65 boys) with high-grade VUR (grade 4-5) diagnosed at median age 2.5months and followed to 39months had repeated investigations of VUR grade, renal damage/function and bladder function. Recurrent urinary tract infections (UTIs) were registered. Risk variables collected at 1year were analysed as independent factors for spontaneous resolution to grades ≤2 and 0, using univariable/multivariable logistic regression. A scoring system was built with a total of 14 points from four independent risk factors (sex, breakthrough UTI, type of renal damage and subnormal glomerular filtration rate). Children with persistent VUR (grade 3-5) had higher scores compared with the group with spontaneous resolution (grade 0-2) (mean 7.9 vs. 4.5, P<.0001). A score of ≥8 points indicated a low probability of VUR resolution (≤14%). The model was considered excellent based on area under the ROC curve (0.82) and showed satisfactory internal validity. This model provides a practical tool in the management of infants born with high-grade reflux. High scores at one year of age indicate a high risk of persistent dilated reflux.

Holmium: Yttrium-aluminum-garnet laser for endoscopic decompression of ureterocele in the first months of life: A comparison with electrosurgery.

Introduction:Few case series report the use of holmium: yttrium-aluminum-garnet (Ho:YAG) laser to decompress ureterocele (UC) in pediatric population, and only two studies compared its outcomes with electrosurgery. This study aims to compare outcomes of Ho:YAG laser transurethral endoscopic puncture (TUP) versus electrosurgery TUP of UC in the 1st month of life, analyzing incidence of secondary surgery, redo TUP, and iatrogenic vesicoureteral reflux (VUR).Patients and Methods:A retrospective study of patients treated by TUP of UC from 2008 to 2017 was performed. Those undergoing Ho:YAG laser TUP were included in Group A, those undergoing electrocautery TUP were included in Group B. Data were compared using Fisher's exact test.Results:Group A included seven patients (mean follow-up 4 years). Two required a redo TUP. Two had preoperative VUR, which resolved after TUP. Two developed VUR after TUP, which resolved spontaneously. No secondary surgery was required. Group B included nine patients (mean follow-up: 9.5 years). One required a redo TUP. Preoperative VUR was detected in 4/9 and persisted after TUP in 2. Three developed post-TUP VUR, which persisted. Five required further surgery because of persistent and symptomatic VUR. Secondary surgery was significantly lower after Ho:YAG laser compared to electrocautery TUP (P < 0.05). The incidences of both redo TUP and postoperative VUR were not significantly different between the two groups (P = ns).Conclusion:Ho:YAG laser TUP seems to be safe and effective in the decompression of obstructive UCs and maybe advantageous over electrocautery puncture. However, further studies with larger cohort are needed to corroborate our preliminary results.

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

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

Renal scarring is the most significant predictor of breakthrough febrile urinary tract infection in patients with simplex and duplex primary vesico-ureteral reflux

The association of high-grade vesico-ureteral reflux (VUR) with renal dysplasia and/or scarring is well-established, and the combination of these factors has been shown to decrease the likelihood of VUR resolution. Other VUR parameters have similarly been shown to be associated with VUR non-resolution, including VUR grade and timing at cystography, associated urinary tract anatomical abnormalities, and bladder dysfunction. To establish independent risk factors that can predict symptomatic persistence of VUR. This was a single-centre study (2011-2017) including consecutive prospectively collected patients with primary VUR on voiding cystourethrogram (VCUG). Patients with dilating VUR also underwent renography (dimercaptosuccinic acid [DMSA] or 99m-technetium mercaptoacetyltriglycine [99mTc-MAG3]). All patients were initially managed medically with antibiotic prophylaxis. Primary outcome was febrile culture-positive breakthrough urinary tract infection (BT-UTI). Demographic parameters, as well as VUR grade, VUR timing at cystography, presence of ureteral anomaly, VUR index (VURx), and differential renal function (DRF) or scarring were analysed to determine independent predictors. A total of 61 patients (41 male, of whom 7 circumcised at presentation) were studied. VUR was diagnosed following investigation of prenatal hydronephrosis in 37 patients (62%) and following a febrile UTI in 22 (37%). Median [range] follow-up period was 38 [12-84]months. Data from a total of 77 refluxing renal units (RUs) were used for analysis. Analysis of VCUG data demonstrated that high VURx might be a potential significant predictor of breakthrough UTI (RR: 1.7, 95% CI: 1.1-2.7, p<0.05 vs low VURx) but this was not the case for individual VURx components. Renography data showed increased risk of breakthrough UTI in patients with renal scarring (relative risk (RR): 5.1, 95% confidence interval (CI: 2.0-10.7, p<0.0001 vs no renal scarring), but not in patients with reduced DRF. Multivariate regression analysis revealed that renal scarring was the only significant risk factor for breakthrough UTI. VUR patients with renal scarring were three times more likely to develop breakthrough UTI (odds ratio (OR): 3.3, 95% CI: 1.4-7.4, p<0.01). Multiple factors have been shown to be significant predictors of radiological VUR resolution. Univariate analysis of these factors suggests that only scarring on DMSA and VURx are significant predictors of symptomatic non-resolution. On multivariate analysis, scarring on DMSA was the only significant predictive variable. This information will be useful in targeting investigation and treatment in susceptible patients and when counselling families. Renal scarring is the most significant risk factor for breakthrough UTI in primary VUR patients and could be used to determine those at risk of symptomatic VUR persistence.