Presence Of Vesicoureteral Reflux Research Articles

Multi-Institutional Bladder Exstrophy Consortium After 8 Years: The Short- and Intermediate-Term Outcomes.

Bladder exstrophy (BE) poses challenges both during the surgical repair and throughout follow-up. In 2013, a multi-institutional BE consortium was initiated, which included utilization of unified surgical principles for the complete primary repair of exstrophy (CPRE), real-time coaching, ongoing video capture and review of video footage, prospective data collection, and routine patient data analysis, with the goal of optimizing the surgical procedure to minimize devastating complications such as glans ischemia and bladder dehiscence while maximizing the rate of volitional voiding with continence and long-term protection of the upper tracts. This study reports on our short-term complications and intermediate-term continence outcomes. A single prospective database for all patients undergoing surgery with a BE epispadias complex diagnosis at 3 institutions since February 2013 was used. For this study, data for children with a diagnosis of classic BE who underwent primary CPRE from February 2013 to February 2021 were collected. Data recorded included sex, age at CPRE, adjunct surgeries including ureteral reimplantations and hernia repairs at the time of CPRE, osteotomies, and immobilization techniques, and subsequent surgeries. Data on short-term postoperative outcomes, defined as those occurring within the first 90 days after surgery, were abstracted. In addition, intermediate-term outcomes were obtained for patients operated on between February 2013 and February 2017 to maintain a minimum follow-up of 4 years. Outcomes included upper tract dilation on renal and bladder ultrasound, presence of vesicoureteral reflux, cortical defects on nuclear scintigraphy, and continence status. Bladder emptying was assessed with respect to spontaneous voiding ability, need for clean intermittent catheterization, and duration of dry intervals. All operating room encounters that occurred subsequent to initial CPRE were recorded. CPRE was performed in 92 classic BE patients in the first 8 years of the collaboration (62 boys), including 46 (29 boys) during the first 4 years. In the complete cohort, the median (interquartile range) age at CPRE was 79 (50.3) days. Bilateral iliac osteotomies were performed in 89 (97%) patients (42 anterior and 47 posterior). Of those undergoing osteotomies 84 were immobilized in a spica cast (including the 3 patients who did not have an osteotomy), 6 in modified Bryant's traction, and 2 in external fixation with Buck's traction. Sixteen (17%) patients underwent bilateral ureteral reimplantations at the time of CPRE. Nineteen (21%) underwent hernia repair at the time of CPRE, 6 of which were associated with orchiopexy. Short-term complications within 90 days occurred in 31 (34%), and there were 13 subsequent surgeries within the first 90 days. Intermediate-term outcomes were available for 40 of the 46 patients, who have between 4 and 8 years of follow-up, at a median of 5.7 year old. Thirty-three patients void volitionally, with variable dry intervals. Cumulative efforts of prospective data collection have provided granular data for evaluation. Short-term outcomes demonstrate no devastating complications, that is, penile injury or bladder dehiscence, but there were other significant complications requiring further surgeries. Intermediate-term data show that boys in particular show encouraging spontaneous voiding and continence status post CPRE, while girls have required modification of the surgical technique over time to address concerns with urinary retention. Overall, 40% of children with at least 4 years of follow-up are voiding with dry intervals of > 1 hour.

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

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

The Utility of Urodynamic Studies in Neuro-Urological Patients

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review. For this narrative review, a PubMed® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used. Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities. Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

PD37-05 USE OF CONTRAST ENHANCED ULTRASONOGRAPHY WITH URODYNAMICS: A COMPARISON STUDY TO FLUOROSCOPY

You have accessJournal of UrologyCME1 Apr 2023PD37-05 USE OF CONTRAST ENHANCED ULTRASONOGRAPHY WITH URODYNAMICS: A COMPARISON STUDY TO FLUOROSCOPY Emmett H. Kennady, Sean T. Corbett, Susan Leroy, Kathryn Morgan, Reza Daugherty, Nicole Kapral, and Nora G. Kern Emmett H. KennadyEmmett H. Kennady More articles by this author , Sean T. CorbettSean T. Corbett More articles by this author , Susan LeroySusan Leroy More articles by this author , Kathryn MorganKathryn Morgan More articles by this author , Reza DaughertyReza Daugherty More articles by this author , Nicole KapralNicole Kapral More articles by this author , and Nora G. KernNora G. Kern More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003335.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Video urodynamics (UDS) has classically been performed using fluoroscopy (fluoro). Contrast enhanced voiding ultrasonography (CeVUS) has been in use to evaluate for genitourinary anomalies but has not been known to be used in conjunction with UDS. We evaluated the ability, quality of using CeVUS UDS and compared the results with fluoro UDS. METHODS: Children ages 0-18 were enrolled for CeVUS UDS who previously underwent fluoro UDS. Demographic data, imaging data for CeVUS and fluoro UDS, time in between studies, and clinical data between studies were recorded. Changes in clinical status between the 2 studies included changes in catheterization, urine leakage between, anticholinergic medications, urinary tract infections, hydronephrosis and neurologic changes. Comparison testing was performed using McNemar’s Chi-Squared and Wilcoxon matched-pairs signed rank test. RESULTS: 53 children were recruited with none declining the study. Table 1 contains demographics and clinical changes between studies. Median time between studies was 1.3 years (IQR 0.9 - 2.9). 53 CeVUS UDS studies were completed with adequate data; none were aborted due to technical reasons. In 4 cases, the bladder neck could not be visualized accurately due to non-mixing and layering of the microbubble contrast against urine (Table 1). Benefits to CeVUS included ability to visualize the exact moment the bladder neck opened. There were no significant differences in bladder shape, presence of vesicoureteral reflux, bladder neck or urethral changes in the cohort at differing time points. Following exclusion of patients with significant changes in medication regimen, catheterization, neuro procedures, hydronephrosis, and UTIs that could lead to changes in UDS imaging findings, a subgroup analysis of 25 patients demonstrated no significant differences in parameters between the 2 studies. CONCLUSIONS: CeVUS can be used adequately in conjunction with urodynamics. Slight limitations to CeVUS include more granular imaging for bladder shape compared to fluoro and inability to visualize bladder neck if residual urine is in the bladder, mitigated by bladder emptying. Benefits include ability to visualize the dynamic activity of the bladder neck due to constant imaging with CeVUS. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e987 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emmett H. Kennady More articles by this author Sean T. Corbett More articles by this author Susan Leroy More articles by this author Kathryn Morgan More articles by this author Reza Daugherty More articles by this author Nicole Kapral More articles by this author Nora G. Kern More articles by this author Expand All Advertisement PDF downloadLoading ...

Vesicoureteral Reflux and Innate Immune System: Physiology, Physiopathology, and Clinical Aspects.

Vesicoureteral reflux represents one of the most concerning topics in pediatric nephrology due to its frequency, clinical expression with the potential to evolve into chronic kidney disease, and last but not least, its socio-economic implications. The presence of vesicoureteral reflux, the occurrence of urinary tract infections, and the development of reflux nephropathy, hypertension, chronic kidney disease, and finally, end-stage renal disease represent a progressive spectrum of a single physiopathological condition. For the proper management of these patients with the best clinical outcomes, and in an attempt to prevent the spread of uropathogens' resistance to antibacterial therapy, we must better understand the physiopathology of urinary tract infections in patients with vesicoureteral reflux, and at the same time, we should acknowledge the implication and response of the innate immune system in this progressive pathological condition. The present paper focuses on theoretical aspects regarding the physiopathology of vesicoureteral reflux and the interconditionality between urinary tract infections and the innate immune system. In addition, we detailed aspects regarding cytokines, interleukins, antimicrobial peptides, and proteins involved in the innate immune response as well as their implications in the physiopathology of reflux nephropathy. New directions of study should focus on using these innate immune system effectors as diagnostic and therapeutic tools in renal pathology.

Vesicoureteral Reflux Grading using Different Imaging Techniques (MCUG, NM, and US): A Comparative Study

The aim of this study was to compare the different imaging procedures (micturating cystourethrogram [MCUG], nuclear medicine [NM], and ultrasound [US]) in the evaluation of vesicoureteral reflux (VUR). Methods and Results: A retrospective study was conducted to compare different radiological investigations in the characterization and grading of VUR. In total, 93 patients (53 boys and 40 girls) with a mean age of 2.2 years were referred to the radiology department for exclusion or diagnosis of VUR. Age, sex, the pathway of obstruction, presence of VUR, degree of obstruction with VUR, presence of hydronephrosis, calcification, and grading according to MCUG were the main variables collected for US, NM, and MCUG. Our results show that according to the frequency distribution, MCUG showed a higher sensitivity for detecting VUR and the degree of obstruction than the other imaging tools. US showed a higher sensitivity for the presence of hydronephrosis. The grading of VUR was more effectively detected by MCUG than by US and NM grading. We revealed a statistical association between VUR grades and the gender of a study's population, with a higher frequency of grade 5 in boys than in girls (P=0.037). Grades 3-5 showed higher frequencies in MCUG, in which the younger patients (0–50 weeks old) were more affected by obstruction and VUR than the other age groups. Moderate hydronephrosis was higher in boys than in girls (P=0.006). Conclusion: The grading of VUR is more effectively detected by MCUG than by US and NM grading.

Clinical Profile and Outcome of Children who Underwent Micturating Cystourethrogram : A Tertiary Hospital Experience

Introduction: Micturating cystourethrogram (MCUG) is the gold standard test for the diagnosis of vesicoureteric reflux (VUR). The study aims to establish the association between the presence of VUR and renal outcomes. Methods: A cross-sectional retrospective study was conducted in children who were referred for MCUG at a tertiary centre over a 10-year period. Baseline characteristic data and the results of renal ultrasound, MCUG, with renal function were compiled and analysed. Fisher Exact test was used to compare between the grade of VUR and renal outcomes. Simple and multiple logistic regressions were used to examine the risk factors that may contribute to the development of VUR. Results: There were 136 children included in total. Forty-five had VUR, (31 [68%] high-grade, 14 [32%] low-grade, respectively). One third (33.3%) were surgically treated, 29 (64.4%) developed chronic kidney disease (CKD), and 18 (40%) developed renal scarring. Children with urinary tract infection (UTI) and hydroureter have 4.19 and 3.40 times the odds of developing VUR, respectively. Conclusion: The presence of hydroureter from ultrasound is a strong indicator of underlying VUR and justifies the rationale of requesting for MCUG, especially for those with recurrent UTI. However, this study failed to demonstrate significant association between the presence of VUR and complications of renal scarring and CKD.

Evaluation of Pediatric Patients with a Diagnosis of Ureterocele.

The presence and clinical importance of vesicoureteric reflux in patients with a double collecting system are being questioned. Therefore, the role of voiding cystourethrography in the management of patients with ureterocele is unclear. This study aimed to evaluate patients with a ureterocele in terms of urinary tract infection (UTI) and vesicoureteral reflux (VUR). The cases who were admitted to the Pediatric Nephrology Clinic of Health Sciences University Tepecik Training and Research Hospital between 2012 and 2022 and were diagnosed with ureterocele were evaluated retrospectively. Demographic, clinical, and laboratory data were obtained from file records. All patients diagnosed with ureterocele and voiding cystourethrography (VCUG) were evaluated. A total of 24 (female 13 (54.2%)) children were included. The reasons for admission were antenatal hydronephrosis in 13 (54.2%) patients, UTI in 9 (37.5%) patients, and incidentally diagnosed ureterocele in 2 (8.3%) patients. Urinary tract infection was observed in 20 patients at admission, recurrent UTI in 21 patients at follow-up, preoperative pyelonephritis in 12 patients. VUR was found in 11 patients, and severe VUR (≥stage 3) was found in 9 patients. Ten patients had ipsilateral hydronephrosis, and 14 patients had a double collecting system. The presence of VUR was found to be associated with female gender, UTI at admission, and recurrent UTI at follow-up (p < 0.05). However, there was no difference between groups with or without VUR in terms of ipsilateral hydronephrosis, scar formation, and the need for surgery (p > 0.05). We could not demonstrate any criteria to select patients to receive VCUG; on the other hand, VUR did not cause more kidney damage. Our study supports the need for more scientific data to determine management in patients with ureterocele.

Can Impaired Distal Ureteral Contraction Detected by Urinary Ultrasonography Indicate Presence of VUR?

Objective: The aim of this study was to determine if impaired distal ureteral contraction detected by urinary ultrasonography (US) could predict presence of vesicoureteral reflux (VUR). Materials and Methods: A Retrospective analysis of patients’ files between November 2016 and September 2020 was performed. A total of 248 children with demonstrated VUR on voiding cystourethrogram (VCUG) and who underwent urinary US within one week of the VCUG examination were included in the study. The degree of hydronephrosis was classified as per Society for Fetal Urology grading system and grading of VUR was done by the International Reflux Study Group grading system. The impaired distal ureteral contraction was defined as the reduced movement of the distal ureter as well as the deficiency of urine discharge into the bladder. Results: There was a significant correlation between the grade of VUR and the grade of hydronephrosis (p=0.0028). Also, the presence of distal ureteral dilation was related to increasing grades of VUR (p=0.001). The impaired distal ureteral contraction was present only in children with dilating VUR (grades III IV V) while its relationship between VUR grade was significantly high for grades IV and V VUR (p=0.001). Conclusion: In children, the impaired distal ureter contraction as well as the increase of grades of hydronephrosis, and the presence of distal ureteral dilation may aid decision-making in terms of requesting VCUG to detect dilating VUR.

Imaging characteristics predicting elevated detrusor pressures in patients with spina bifida

Patients with spina bifida require urologic follow up with assessments of bladder and renal function. The ideal screening protocol for bladder compliance remains controversial. This study assessed associations between bladder end filling pressure (EFP) and detrusor leak point pressure (DLPP) on urodynamic studies (UDS) and findings from renal bladder ultrasounds (RBUS) and voiding cystourethrograms (VCUG). Pediatric spina bifida patients who underwent RBUS and/or VCUG within six months of UDS at a single institution from 2015 to 2021 were retrospectively reviewed. Demographics, VCUG and RBUS results, and UDS EFP and DLPP were recorded. Multiple linear regression analyses and Pearson chi-square tests were conducted to correlate RBUS and VCUG findings with DLPP/EFP. 129 patients were included. In adjusted analyses, moderate to severe hydronephrosis on RBUS was significantly associated with elevations in mean DLPP/EFP (p=0.006). Patients with round bladders had significantly lower mean DLPP/EFP than patients with elongated or conical bladders (p<0.0001). The presence of trabeculations was associated with increased mean DLPP/EFP (p<0.0001) and increases in severity of trabeculations were associated with higher DLPP/EFP (p<0.0001). The presence of vesicoureteral reflux (VUR) on VCUG was not associated with significant differences in mean DLPP/EFP (p=0.20). Abnormal bladder shape and trabeculations on VCUGs in spina bifida patients had significant associations with increased mean bladder pressures on UDS. Assessment of bladder shape and contour by VCUG may be a valuable screening tool in conjunction with routine RBUS in determining the need for further assessment of bladder pressures in patients with spina bifida.

A study of the 20-year evolution of antimicrobial resistance patterns of pediatric urinary tract infections in a single center.

Febrile urinary tract infections (UTIs) are important bacterial infections in children but increasingly difficult to treat due to antimicrobial resistance. We performed a retrospective analysis of the prevalence of uropathogens in hospitalized children with a febrile UTI between 2000 and 2019 in our university hospital to get more insight into trend and determinants of antimicrobial resistance over time. There were 1010 hospitalizations in children with a median age of 1.1years. Thirty-six percent had an abnormal ultrasound and/or the presence of vesico-ureteral reflux, defined as CAKUT. Escherichia coli was the most prevalent pathogen (76%). However, there was an increasing prevalence towards other gram-negative organisms over time, and these pathogens were more common in children with congenital anomalies of kidney and urinary tract (CAKUT) (OR 4.26 (3.14-5.78), p < 0.001). E. coli strains demonstrated an increase in resistance against amoxicillin clavulanic acid (AMC) over time from 16% (2000-2004) to 36% (2015-2019) with an average increase of 2.0%/year; this was + 1.1%/year for third-generation cephalosporin. Multivariate analysis demonstrated that prior antibiotic use was an additional risk factor for antimicrobial resistance in E. coli. Nevertheless, increasing resistance was also observed in children without reported previous antibiotic treatment (+ 1.9%/year, p = 0.04). Conclusion: We observed a significant pattern of increasing antimicrobial resistance of E. coli within a relatively short period of time, making it increasingly difficult to treat pediatric UTIs. This pattern was also seen in children without underlying risk factors (recent antibiotic treatment or structural urological disease). This is indicative for a larger problem in the general population and an important threat to our current standard of health care. What is Known: •Escherichia coli is the most frequent pathogen in pediatric urinary tract infections. •There is an increasing antimicrobial resistance against commonly used antibiotics in urinary tract infections. What is New: •The first 20-year retrospective, longitudinal study on characteristics of the microorganisms of pediatric urinary tract infections in a single center. •A 1-2% yearly increase in antimicrobial resistance, not only in children with congenital anomalies of the kidneys or recent antibiotic treatment but also in children without risk factors.

A change in the type of neurogenic dysfunction as a result of treatment of children with neurogenic bladder subject to surgery for a spinal hernia during the newborn period

The most severe consequence of a spinal hernia, affecting the entire life of a person, is a spinal neurogenic bladder. Its symptoms limit the child’s socialization, and the problem of urination needs constant use of various aids. At the same time, despite many studies in neurology, there are no significant shifts in the possibility of restoring the function of urination in spinal patients.Purpose. The aim of study is to analyze the long-term results of correction of neurogenic bladder in children treated depending on the type of dysfunction with a history of surgery for spinal hernia.Characteristics of children and research methods. 100 patients with spinal neurogenic bladder aged 1–15 years were examined, urodynamic studies were used. Depending on the state of the detrusor and sphincter, groups of patients were identified, in each of which treatment lasting at least a year was selected.Results. With a differentiated approach to the choice of therapeutic tactics, depending on the type of neurogenic bladder, the presence of vesicoureteral reflux, urinary tract infection, it was possible to reduce the level of detrusor hypertension, if any, or activate the function of the atonic bladder. Individual options for urinary diversion were developed. With long-term therapy that stabilizes detrusor, a change in the type of neurogenic dysfunction occurred within a year in 98 patients, which required repeated urodynamic examination to change treatment tactics.Conclusion. Clinical manifestations of spinal neurogenic bladder do not always accurately indicate the type of dysfunction. During the growth of the child, as well as under the influence of treatment, there is a change in the type of neurogenic bladder. Urodynamic examination makes it possible to determine the state of the detrusor and sphincter — and to select a pathogenetically justified treatment option. In case of impaired urination, neurogenic bladder should be corrected with customized self-catheterization. Urodynamics should be controlled in spinal patients at least once a year to correct treatment.

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.

Sonographic differential diagnosis of duplex kidneys.

Duplex kidneys have two renal pelvises and two ureters, which can join on the way to the urinary bladder but can also enter the bladder separately. A distinction must be made between normal and pathological duplex kidneys. In normal duplex kidneys, both renal pelvises are normal in width, and the upper and lower poles are approximately the same size. Furthermore, ureters are not dilated, and the upper and lower poles of the kidneys are not cystically altered. In contrast, pathological duplex kidneys, occurring in about 50 % of cases, are characterized by dilation of one or both renal pelvises. Additionally, one or both ureters may be dilated. Megaureters may be obstructive or refluxive. If a megaureter is present, a ureterocele must be ruled out, as well as an ectopically opening ureter. A pathological duplex kidney must always be assumed if one pole of the kidney is hypoplastic. Hypoplasia of the upper renal pole is often associated with an obstructive megaureter. Vesicoureteral reflux into the lower pyelon is common in hypoplasia of the lower pole. In the presence of vesicoureteral reflux, the associated (lower) pyelon is dilated when the bladder is full or during micturition. In addition, there is a dilated ureter. On the other hand, the pyelon can have a normal width when the bladder is empty. In rare cases, one pole may be cystically altered in pathological duplex kidneys. In this instance, segmental multicystic dysplastic duplex kidney must be differentiated from segmental multicystic nephroma.

Prevalence of reflux nephropathy in Iranian children with solitary kidney: results of a multi-center study

BackgroundGiven the importance of the function of the remnant kidney in children with unilateral renal agenesis and the significance of timely diagnosis and treatment of reflux nephropathy to prevent further damage to the remaining kidney, we aimed to determine the prevalence of reflux nephropathy in this subgroup of pediatric patients.MethodsIn general, 274 children referred to pediatric nephrologists in different parts of Iran were evaluated, of whom 199 had solitary kidney and were included in this cross-sectional study. The reasons for referral included urinary tract infection (UTI), abnormal renal ultrasonography, being symptomatic, and incidental screening. Demographic characteristics, including age and gender were recorded. History of UTI and presence of vesicoureteral reflux (VUR) were evaluated.ResultsOf the 274 children evaluated in this study with the mean age (SD) of 4.71 (4.24) years, 199 (72.6%) had solitary kidney. Among these, 118 (59.3%) were male and 81 (60.7%) were female, 21.1% had a history of UTI, and VUR was present in 23.1%. The most common cause of referral was abnormal renal ultrasonography (40.2%), followed by incidental screening (21.1%), being symptomatic (14.1%), and UTI (5.5%). In 116 children (58.3%), the right kidneys and in 83 (41.7%) the left kidneys were absent. Besides, 14.6% of the participants had consanguineous parents and 3% had a family history of solitary kidney. Upon DMSA scan, the single kidney was scarred in 13.1%, of which only 7.5% were associated with VUR. In addition, proteinuria and hematuria were observed in 6.5% and 1.5% of children, respectively.ConclusionsThe prevalence of reflux nephropathy was 7.5% in children with solitary kidney with a male predominance. Given the relatively high prevalence of reflux nephropathy in these children, screening for VUR in the remnant kidney appears to be essential in this population.

Prediction of Recurrent Urinary Tract Infection in Paediatric Patients by Deep Learning Analysis of 99mTc-DMSA Renal Scan.

Purpose: Tc-99m dimercaptosuccinic acid (99mTc-DMSA) renal scan is an important tool for the assessment of childhood urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scarring. We evaluated whether a deep learning (DL) analysis of 99mTc-DMSA renal scans could predict the recurrence of UTI better than conventional clinical factors. Methods: the subjects were 180 paediatric patients diagnosed with UTI, who underwent immediate post-therapeutic 99mTc-DMSA renal scans. The primary outcome was the recurrence of UTI during the follow-up period. For the DL analysis, a convolutional neural network (CNN) model was used. Age, sex, the presence of VUR, the presence of cortical defects on the 99mTc-DMSA renal scan, split renal function (SRF), and DL prediction results were used as independent factors for predicting recurrent UTI. The diagnostic accuracy for predicting recurrent UTI was statistically compared between independent factors. Results: The sensitivity, specificity and accuracy for predicting recurrent UTI were 44.4%, 88.9%, and 82.2% by the presence of VUR; 44.4%, 76.5%, and 71.7% by the presence of cortical defect; 74.1%, 80.4%, and 79.4% by SRF (optimal cut-off = 45.93%); and 70.4%, 94.8%, and 91.1% by the DL prediction results. There were no significant differences in sensitivity between all independent factors (p > 0.05, for all). The specificity and accuracy of the DL prediction results were significantly higher than those of the other factors. Conclusion: DL analysis of 99mTc-DMSA renal scans may be useful for predicting recurrent UTI in paediatric patients. It is an efficient supportive tool to predict poor prognosis without visually demonstrable cortical defects in 99mTc-DMSA renal scans.

Risk Factors for Recurrent Urinary Tract Infection in Children With Neurogenic Bladder Following Clean Intermittent Catheterization

ObjectiveTo investigate the risk factors for recurrent urinary tract infection (UTI) in children with a neurogenic bladder (NB) managed by clean intermittent catheterization. Materials and MethodsOver a 5-year period, we retrospectively assessed the risk factors for recurrent UTIs in children (age 9-151 months) who had clean intermittent catheterization. All patients were followed up for more than 12 months and had at least two clinic visits during the study period. Demographic, clinical, and urodynamic parameters were assessed. All data were compared between the recurrent UTI (>1.0 UTI/study-year) and episodic UTI (≤1.0 UTI/study-year) groups. ResultsOf 327 patients, 79 (24.2%) had recurrent UTIs and 248 (75.8%) had episodic UTIs. Univariate and multivariate analyses showed that older age, lumbar level lesions, long duration of NB, presence of vesicoureteral reflux, increased bladder wall thickness, and low bladder compliance were the significant factors for recurrent UTIs. Bladder trabeculation was associated with recurrent UTIs on univariate analysis, but not on multivariate analysis. During the follow-up period, chronic renal insufficiency was diagnosed in 31 (39.2%) and 29 patients (11.7%) in the recurrent and episodic UTI groups (P <.05), respectively. ConclusionThese results suggest that older age, high level of spinal cord lesions, long duration of NB, vesicoureteral reflux, increased bladder wall thickness, and low bladder compliance may be directly associated with recurrent UTIs in children with NB. Children with NB might have higher susceptibility to chronic renal insufficiency after recurrent UTIs.

Influence in the outcome of neuropathic pediatric patients after early treatment

BackgroundClean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995–2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática

BackgroundClean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

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

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