Reflux Grade Research Articles

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.

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.

Robot-assisted laparoscopic extravesical versus conventional laparoscopic extravesical ureteric reimplantation for pediatric primary vesicoureteric reflux: a systematic review and meta-analysis.

To perform a systematic review and meta-analysis comparing the outcomes of robotic-assisted laparoscopic extravesical ureteric reimplantation (RALUR) with conventional laparoscopic extravesical ureteric reimplantation (LEVUR) for primary vesicoureteric reflux in children. We searched the databases to identify all papers of RALUR and LEVUR between 2001 and 2020. Systematic review was performed to identify patient data, age, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Heterogeneity was reported with I2 statistics and publication bias was assessed by Doi curve and Luis Furuya-Kanamori index. Pooled data from both groups were compared with Student's t test and Fisher's exact test, wherever appropriate. From a total of 43 articles screened, 28 articles were included (18 RALUR and 10 LEVUR). The I2 statistics for RALUR and LEVUR showed heterogeneity of 86% and 25%, respectively. Both groups had comparable minor publication bias. RALUR had higher proportion of grade 5 VUR (p < 0.001) and bilateral reimplantations (p < 0.001). The success rate of RALUR was significantly lower than that of LEVUR (97.6% vs. 93.4%, p = 0.0018). RALUR took a significantly longer duration for surgery compared to LEVUR, both for unilateral and bilateral cases (p < 0.001). The complication rate was not significantly different: 6.6% for RALUR and 5.35% for LEVUR (p = 0.32). The most common complication in both groups was post-operative urinary retention in bilateral cases. Articles on LEVUR reported more consistent success. RALUR series had higher proportion of grade 5 cases and bilateral reimplantations. RALUR reported longer operative time and lower success compared to LEVUR, with a complication rate comparable to LEVUR.

Evaluation of the role of reflux pattern in Color Doppler Ultrasound on spermogram improvement after varicocelectomy.

Many attempts are being made to find an association between varicocele characteristics and sperm parameters. In this study, we investigated the association between a newly introduced varicocele reflux grading pattern and sperm parameters, as well as its effect on spermogram improvement after varicocelectomy. In a prospective study, 73 patients with a clinical single-sided varicocele who underwent corrective varicocelectomy were included. Reflux pattern was determined on Color Doppler Ultrasound (CDUS) and categorized into four grades: grade 1 (retrograde), grade 2 (augmentation), grade 3 (enhancement), and grade 4 (stasis). The association of pre- and postoperative spermogram with the patients' reflux pattern was evaluated. A significant positive association was found between the venous diameter and reflux pattern. Higher grades of the reflux pattern were associated with the more severe hemodynamic pattern of the reflux (shunt type). A significant association was found between the reflux pattern and preoperative semen characteristics, and this association was more prominent in constant venous diameter. In this respect, the enhancing reflux type was associated with the most impaired preoperative sperm count, motility, and morphology. The enhancing type also revealed the most improvement in spermogram after varicocelectomy. Patients with a higher reflex grade, particularly enhancing pattern, will most benefit from the surgical correction of varicocele. These findings suggest reflux pattern as a promising prognostic factor for a favorable outcome after varicocelectomy.

Robotic Assisted Vesicoscopic Cohen's Reimplantation in Pediatric Patient: Nuances of Technique, Experience, and Outcome.

Aim: Vesicoscopic Cohen's reimplantation closely replicates the open procedure and is reported to have equally good results. Robotic assisted vesicoscopic reimplantation (RAVR) is a new procedure, and the information on technique of RAVR is sparse. We present our technique, experience, and early outcome with RAVR and review of literature. Patients and Methods: We retrospectively evaluated patients with vesicoureteric reflux grade II and above. These patients were subjected to RAVR. Selection criteria for this procedure were age >4 years, preserved renal function, and bladder capacity >250 mL. Patients with previous bladder surgery or urethral issues were excluded. Patients were operated by DaVinci Si system, and the technique is described in detail. Three ports were placed by use of bougie. The ureters were adequately mobilized before placing in submucosal tunnel. Results: Total of 5 ureters were reimplanted in 4 patients (2 females and 1 bilateral). Ureteral tapering was done in 1 patient. Mean port placement time was 25 minutes with 12 minutes of docking time. Mean console time was 70 minutes for unilateral cases and 100 minutes for the bilateral case. There was resolution of reflux in all patients. The mean follow-up duration is 9 months. Conclusions: Robotic assisted vesicoscopic reimplantation is a feasible and safe method of replicating Cohen's reimplantation. There is a learning curve with the procedure, and nuances related to the technique need to be learned by the surgeon. This is the third report on RAVR and provides the necessary technical details required by a robotic surgeon to replicate this procedure.

ENDOSCOPIC CORRECTION OF THE VESICOURETERAL REFLUX AFTER URETERAL REIMPLANTATION IN CHILDREN

Introduction. Vesicoureteral reflux (VUR) is seen in 2 - 60% of patients after ureteral reimplantation. The present study summarizes the experience of several centers where endoscopic correction of the postoperative reflux was done with bulking preparations. Material and methods. A retrospective study including 43 patients (24 boys and 19 girls) with reflux of grade III-IV after various transvesical and extravesical ureteral reimplantations for primary megaureter, reflux, or kidney transplantation was performed. Exclusion criteria were: neurogenic bladder, posterior urethral valve and ureterocele. Patients’ age varied from 9 months to 17 years (average 70.6 months). VUR was unilateral in 40 patients and bilateral in 3 patients: a total number of operated ureters was 46. The interval between ureter reimplantation and endoscopic surgery ranged from 3 months to 8 years (average 18.9 months). Different biodegradable and stable bulking preparations were used in the procedure. Results. VUR was successfully corrected in 19 ureters (41.3%) after a single injection. The repeated procedure was performed in 14 ureters in case of decreased reflux grade after the first injection. In 5 ureters (35.7%), the reflux resolved after the repeated procedure. With the two mentioned injections, the total effectiveness of endoscopic VUR correction was 52.2%. There were no any ureteral obstruction. The only statistically significant factor affecting the effectiveness of treatment was the reflux degree. The effectiveness level for reflux grade III was 68.2% and for reflux grade IV - 37.5%. Conclusion. Endoscopic correction prevents ureter reimplantation in half of patients with a high grade of postoperative vesicoureteral reflux.

Management of Vesicoureteral Reflux in a Patient With Recurrent Febrile Urinary Tract Infections, Neurogenic Bladder, and Ureteral Triplication

Ureteral triplication is a rare anomaly with about 100 total cases reported in the literature. In this case presentation, we present a case of ureteral triplication in a young female with a history of neurogenic bladder secondary to L5 lipomeningocele who presented with recurrent febrile urinary tract infections (UTIs) and vesicoureteral reflux despite antibiotic prophylaxis. Given her high grade reflux, she underwent ureteral reimplantation which ultimately led to resolution of her UTIs and reflux. Later in her clinical course, toilet training unmasked additional bladder dysfunction and she was successfully managed with clean intermittent catheterization and anticholinergics. To the best of our knowledge, this is the first case report to describe ureteral triplication, recurrent febrile UTIs and vesicoureteral reflux in the setting of a concomitant neurogenic bladder with a successful outcome.

Magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in idiopathic normal pressure hydrocephalus.

Disturbed clearance of toxic metabolites from the brain via cerebrospinal fluid is emerging as an important mechanism behind dementia and neurodegeneration. To this end, magnetic resonance imaging work-up of dementia diseases is largely focused on anatomical derangements of the brain. This study explores magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in patients with the dementia subtype idiopathic normal pressure hydrocephalus and a cohort of reference subjects. All study participants underwent multi-phase magnetic resonance imaging up to 48 h after intrathecal administration of the contrast agent gadobutrol (0.5 ml, 1 mmol/ml), serving as cerebrospinal fluid tracer. Imaging biomarkers of cerebrospinal fluid tracer dynamics (i.e. ventricular reflux grades 0–4 and clearance) were compared with anatomical magnetic resonance imaging biomarkers of cerebrospinal fluid space anatomy (Evans’ index, callosal angle and disproportional enlargement of subarachnoid spaces hydrocephalus) and neurodegeneration (Schelten’s medial temporal atrophy scores, Fazeka’s scores and entorhinal cortex thickness). The imaging scores were also related to a pulsatile intracranial pressure score indicative of intracranial compliance. In shunt-responsive idiopathic normal pressure hydrocephalus, the imaging biomarkers demonstrated significantly altered cerebrospinal fluid tracer dynamics (ventricular reflux grades 3–4 and reduced clearance of tracer), deranged cerebrospinal fluid space anatomy and pronounced neurodegeneration. The altered MRI biomarkers were accompanied by pressure indices of impaired intracranial compliance. In conclusion, we present novel magnetic resonance imaging biomarkers characterizing idiopathic normal pressure hydrocephalus pathophysiology, namely measures of cerebrospinal fluid molecular redistribution and clearance, which add information to traditional imaging scores of cerebrospinal fluid space anatomy and neurodegeneration.

Ağır Skarlı Böbreklerin Üreter Alt Uç Patolojik Özellikleri Az Skarlı Tarafla Karşılaştırıldığında Belirgin Farklılık Göstermektedir

Objective: This study aims to describe the pathological features of the distal end of ureters and their correlation with scar formation patterns in the kidney. Methods: The study includes 83 children (49 male, 34 female), who underwent ureteroneocystostomy (UNC) operations from 2008-2010. The distal end of ureters (approximately 3-4 mm) were resected and 110 ureter specimens from 83 patients were available for pathological examination. The presentation age, clinical presentation pattern, reflux grade and scar patterns on dimercaptosuccinic acid (DMSA) scan were obtained from record and correlation with histopathological findings were investigated. Scar patterns were defined as presence of no scar (NS), diffuse scar (DS) or focal cortical scars (FS). General structural changes were also investigated histopathologically including inflammatory changes graded for intensity (G1-G3), extracellular matrix and smooth muscle content, ureteric diameter and wall thickness. Results: Histological examination of the ureterorenal units showed that there were 35/110 (33%), 30/110 (27%) and 45/110 (40%) in the NS, DS and FS groups, respectively. When scar rates were investigated by grade of reflux (G1-2 low grade vs. G3-5 high grade reflux) the scar rates were 39.5%and 90.3% respectively. High grade inflammation (G3) was found in 66%, 28.9% and 36.4% in kidneys in the DS, FS and NS scar groups respectively (p&amp;lt;0.05). Conclusion: This investigation shows that there are significant differences of histologic structure of the distal end of the ureters when they are classified by kidney scarring. There is more intense inflammation, more collagen deposition, less ssmooth muscle content and increased ureteric wall thickness in the ureters of the kidneys with diffuse scar when compared to others with less or no scar.

Risk factors for obstructive complications after endoscopic correction of vesico-ureteral reflux using polyacrylate polyalcohol copolymer

Use of polyacrylate-polyalcohol copolymer (PPC) after endoscopic correction (EC) of vesico-ureteral reflux (VUR) is highly effective but is associated with a higher risk of obstructive complications (OC) compared with other implants. We undertook a STROBE compliant retrospective investigation and studied the OC risk factors to increase the practical safety of PPC.Overall, 798 patients (464 [58.1%] girls and 334 [41.9%]) boys) from 5 hospitals in whom PPC was routinely used were evaluated retrospectively. The patients were subdivided into 2 groups. Group I consisted of 754 (94.5%) children (449 [59.5%] girls and 305 [40.5%] boys) without OC. Median age was 41 months [Q1: 18.0; Q3: 81.0]. Group II comprised 44 (5.5%) patients (29 [65.9%] boys and 15 [34.1%] girls) experiencing OC, and their median age was 21.5 months [Q1: 12.0; Q3: 43.0]. Clinical and renal ultrasound examinations were carried out 1 day and 1 month after EC, and then every 6 months after EC. At the follow-up examination approximately 6 months after EC, voiding cysto-urethrography (VCUG) was performed. All patients with OC underwent diuretic renography.OC occurred in 44 (5.5%) of 798 children, in some cases as late as 60 months after endoscopic injection of the bulking agent PPC for correction of VUR. Univariate analysis revealed that younger age (P < .001), higher grade of VUR (P < .001), male gender (P < .001), second injection (P = .003), and EC injection using hydrodistension implantation technique (HIT; P < .001) represented significant risk factors. At multivariate analysis, only male gender (P = .0078), younger age (P = .0044), HIT technique (P < .0001), and second injection (P = .04) represented significant risk factors for the occurrence of OC.We identified young age, male gender, high reflux grade, HIT technique, and second endoscopic injections as factors associated with the risk of OC after EC of VUR using PPC as a bulking agent. Thus, patients who have undergone EC with PPC must be monitored sonographically for occurrence of OC for at least 60 months after the intervention.

Kidney triplication with ectopic ureterocele: a case report

BackgroundKidney triplication is a rare urological abnormality. Association of triplex kidney and ureterocele is out of ordinary. Treatment of such patients usually implies heminephrureterectomy of the upper moiety. We report a case of a saved function of the upper moiety after minimal invasive surgical procedure.Case presentations5-year old girl complained for continuous wetting. Examination revealed 3 - segmented left kidney with pelvi-ureteric dilation of the upper moiety, IV grade vesicoureteral reflux in the upper moiety, cervical ectopic ureteral orifice of the upper moiety and a commune ureteral orifice of the lower segments.An endoscopic laser dissection of ureterocele was performed. Drainage of the upper moiety of triplex kidney was restored. Examination 18 months later showed no wetting and infection symptoms. Pelvi-ureteric dilation of the upper moiety and cavity of ureterocele decreased to minimal. Grade of vesicoureteral reflux decreased to I.ConclusionMinimal invasive elimination of obstruction of the upper moiety of triplex kidney was successful and led to regress of vesicoureteral reflux, urinary incontinence and let to avoid heminephrectomy.

The necessity of voiding cystourethrogram for the evaluation of recipient candidates in adult renal transplantation

Objective . While international guidelines necessitate Voiding Cystourethrogram (VCUG) for pediatric patients, it is unnecessary for the evaluation of adult patients without urological disorders as renal transplant candidates. The objective of this study was to evaluate the results of adult candidates who underwent VCUG before transplantation and to demonstrate the necessity for this imaging. Methods . A retrospective study of the data of 1265 adult candidates who underwent VCUG before transplantation at our center, was undertaken. VUR, the presence of Postvoiding residual urine (PVR) (>100 ml), Low bladder capacity (LBC) (<100 ml), and urethral pathologies were evaluated with VCUG. Results . The mean age was 42.3 ± 1.3. The mean dialysis period was 27.8 ± 4.2 months. According to the VCUG results, 19.2% of the patients had pathological findings. On the other hand, the rate of urological disorders was only 5.1%, according to end-stage renal disease (ESRD) etiologies. VCUG outcomes indicated bilateral high-grade reflux in native kidneys in 4.4% (n = 56) of the candidates, unilateral high-grade reflux in 4.1% (n = 52), bilateral low grade reflux in 2.1% (n = 26), unilateral low-grade reflux in 2.4% (n = 30), and reflux in rejected transplanted kidney in 2.3% (n = 29). In addition, significant LBC was noted in 4.8% (n = 61), significant PVR in 1.1% (n = 14), and urethral stricture in 0.5% (n = 6) of the candidates. Conclusion . VCUG should be considered as a part of routine evaluation in adult renal transplant recipient candidates as well as in pediatric candidates, even if their ESRD etiologies are not due to urological disorders.

Vesicoureteral reflux is it important to find?

Vesico-ureteral reflux (VUR) has long been recognized as associated with urinary tract infections (UTIs), renal scarring, and chronic kidney disease (CKD). The concept of "reflux nephropathy" was born, whereby the VUR was considered the culprit, predisposing to recurrent UTIs and providing a conduit whereby the infection could ascend to the kidneys resulting in scarring and destruction. The more severe grades of reflux were thought to place the young child at particular risk of CKD. The question being asked in this pro/con debate is whether VUR is indeed the culprit responsible for a significant proportion of children with CKD, a number of whom progress to end-stage kidney failure (ESKF), and is thus important to find and treat, or is it an innocent bystander associated with CKD and ESKF but not the cause. We believe the latter and will present convincing evidence supported by large scale prospective randomized controlled trials that VUR is not the ogre it was thought to be and is not important to find following a UTI (with some exceptions).

Minimally Invasive Treatment of Vesico-ureteral Reflux Using Endoscopic Injection of Polyacrylate-Polyalcohol Copolymer (Vantris) in Patients After Kidney Transplantation

BackgroundUrinary tract infections (UTIs) are the most common infectious complications among kidney recipients. They occur due to the lack of an effective antireflux mechanism in the majority of techniques used during kidney transplantation. Subureteral injection of tissue bulking substance is a feasible alternative to open ureteral reimplantation. This paper, to the best of the authors’ knowledge, is the first to evaluate the application of polyacrylate/polyalcohol copolymer (Vantris) as the agent for minimally invasive VUR treatment. Materials and MethodsBetween January 2018 and February 2019, 7 patients presenting with recurrent UTIs and the diagnosis of VUR (vesico-ureteric reflux) after kidney transplantation were enrolled in the study. Patients qualified for the study underwent cystoscopy and, if possible, minimally invasive, endoscopic subureteral application of 1 mL of polyacrylate/polyalcohol copolymer according to the subureteral transurethral injection (STING) technique. ResultsEndoscopic subureteral injection of tissue bulking substance (polyacrylate/polyalcohol copolymer) was successfully performed in 6 patients. In 1 patient it could not be completed because of an inconvenient location of the neo-orifice. In 4 patients (57%) no reduction of the reflux grade was observed in follow-up imaging. The number of UTIs in the follow-up was significantly reduced in 6 of 7 patients (86%) after polyacrylate/polyalcohol copolymer subureteral injection. ConclusionsEndoscopic treatment of VUR with polyacrylate/polyalcohol copolymer is an effective and safe method as a first-line treatment for patients with recurrent UTIs after kidney transplantation. To obtain clear conclusions, however, it is necessary to study a larger number of patients with a longer follow-up period after surgery.

Predicting Breakthrough Urinary Tract Infection: Comparative Analysis of Vesicoureteral Reflux Index, Reflux Grade and Ureteral Diameter Ratio.

The vesicoureteral reflux index is a simple, validated tool for predicting resolution of reflux. Along with likelihood of spontaneous resolution identification of children at risk for febrile urinary tract infection impacts management. We evaluated the usefulness of the vesicoureteral reflux index as a predictive factor for breakthrough febrile urinary tract infection compared to reflux grade and distal ureteral diameter ratio. Children with primary vesicoureteral reflux and detailed voiding cystourethrogram data were identified. A 1 to 6-point index was assigned, and ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 to L3 vertebral bodies. Random forest modeling and logistic multivariable regression were employed to estimate the predictive ability of grade, ureteral diameter ratio and vesicoureteral reflux index with regard to breakthrough febrile urinary tract infection. We analyzed 94 girls and 45 boys with a mean±SD age of 5.4±4.7 months at diagnosis. Mean±SD length of followup was 32.1±24.5 months. A total of 13 children (9.4%) experienced breakthrough febrile urinary tract infection. On univariate analysis ureteral diameter ratio (p=0.01) and vesicoureteral reflux index (p=0.0005) were associated with breakthrough urinary tract infection, while grade (p=0.09) did not reach significance. Area under the curve was generated as a measure of accuracy for each variable and was 0.77 for the vesicoureteral reflux index, 0.71 for ureteral diameter ratio and 0.68 for grade, indicating superiority of the vesicoureteral reflux index for predicting breakthrough febrile urinary tract infection. Children with higher vesicoureteral reflux index are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. The vesicoureteral reflux index provides valuable prognostic information about infection risk, facilitating improved clinical decision making.

Contrast reflux into the inferior vena cava on computer tomographic pulmonary angiography is a predictor of 24-hour and 30-day mortality in patients with acute pulmonary embolism.

Acute pulmonary embolism (PE) is a common disease with a high mortality. Computed tomographic pulmonary angiography (CTPA) represents the current gold standard for the evaluation of patients with suspected PE. To search possible CTPA predictors of 24-h and 30-day mortality in PE. Overall, 224 patients with PE (46.4% women, mean age 64.7 ± 16.7 years) were acquired. CTPA was performed on a multi-slice CT scanner. The following radiological parameters were estimated: thrombotic obstruction index; diameter of the pulmonary trunk (mm); short axis ratio of right ventricle/left ventricle; diameter of the azygos vein (mm); diameter of the superior and inferior vena cava (mm); and reflux of contrast medium into the inferior vena cava (IVC). Patients who died within the first 24 h after admission (n = 32, 14.3%) showed a reflux grade 3 into IVC more often than survivors (odds ratio [OR] 7.6, 95% confidence interval [CI] 3.3-17.7; P < 0.001). Other relevant CTPA parameters were diameter of IVC (OR 1.1, 95% CI 1.01-1.21; P = 0.034) and diameter of the pulmonary trunk (OR 0.91, 95% CI 0.82-1.01, P = 0.074), whereas the Mastora score showed nearly no influence (OR 1.01, 95% CI 0.99-1.02, P = 0.406). Furthermore, 61 (27.2%) patients died within the first 30 days after admission. These patients showed a reflux grade 3 into IVC more often than survivors (OR 3.4, 95% CI 1.7-7.0; P = 0.001). Other CTPA parameters, such as diameter of IVC (OR 1.04, 95% CI 0.97-1.12; P = 0.277) and diameter of the pulmonary trunk (OR 0.96, 95% CI 0.89-1.04; P = 0.291), seem to have no relevant influence, whereas Mastora score did (OR 0.99, 95% CI 0.976-0.999, P = 0.045). Subhepatic contrast reflux into IVC is a strong predictor of 24-h and 30-day mortality in patients with acute PE.

Comparison of Cohen and Lich-Gregoir ureteral reimplantation in the surgical management of primary unilateral vesicoureteral reflux in children.

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Various intravesical and extravesical techniques have been described for the surgical correction of VUR. The aim of our study was to compare the results of open intravesical and extravesical procedures for unilateral primary VUR in children. Between January 2012 and August 2018, 38 children with primary VUR who underwent open ureteral reimplantation surgery were retrospectively reviewed. The Cohen (intravesical) and the Lich-Gregoir (extravesical) approach were grouped as groups A and B, respectively. The groups were compared for age, gender, preoperative reflux grade, presence of lower urinary tract symptoms, operation time, discomfort and pain, analgesic requirements, duration of hematuria, postoperative complications, and hospital stay. All the parameters were statistically compared. There were 38 patients in this study. Group A had 18 patients, and group B had 20 patients. The mean operative time was significantly shorter in group B than in group A. The mean hospital stay was also shorter in group B. The urethral foley stay period was 4.7±0.9 days 2±0 days (p = 0.000*), respectively, for group A and B. Macroscopic hematuria was seen in group A. The objective pain scale was worse after intravesical surgery. Analgesic requirements were higher in group A (p =0.131). Intravesical and extravesical ureteroneocystostomy methods are equally successful and feasible in the treatment of primary unilateral VUR. The Cohen technique is associated with a longer and more painful hospital stay, gross hematuria, and longer operative time, compared to the Lich-Gregoir technique.

Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter.

Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

SUN-469 Dimercaptosuccinic Acid Scan as a Alternative Diagnostic Approach in Vesicoureteric Reflux Disease

In vesicoureteral refluxurine passage from bladder into kidney and induce hydronephrosis. Current diagnostic methods are voiding cystourethrography and cystogram radionuclide, Dimercaptosuccinic acid scan is not routinely used in vesicoureteral reflux disease. Based on mentioned section aim of this study was evaluation diagnostic efficacy of dimercaptosuccinic acid scanas a alternative dignostic approach for vesicoureteral reflux diagnosis. This is a case series study who was conducted on children with lower than 6 years of age with varying degrees of vesicoureteral reflux or by vesicoureteral reflux indication review and referring to Amir Kabir Hospital. Vesicoureteral reflux was diagnosed by voiding cystourethrograms and pediatrician confirmation, in following Dimercaptosuccinic acid scans has done for renal parenchyma evaluation. At the end, grade of vesicoureteral reflux in voiding cystourethrograms was campared to dimercaptosuccinic acid scan results. Dimercaptosuccinic acid scan and voiding cystourethrograms were correlated in high grades of vesicoureteral reflux (p=0.0001). But in low grade there is not this significant correlation between two tests(p=0.4). Dimercaptosuccinic acid scan is an appropriate dignostic approach with lower complications in the diagnosis of high graded vesicoureteral reflux, renal scar and pyolonephrit.

Ultrasound as A Viable Option in the Diagnosis of Pelvic Congestion Syndrome

The Pelvic Congestion Syndrome is a disease that manifests usually with chronic pelvic pain, impairments in daily activity due to pain severity, dyspareunia, and dysmenorrhea. It affects mainly women in premenopausal stages. The gold-standard procedure for diagnosis is venography, which has an invasive character. This syndrome is underdiagnosed, partly because women tend not to report symptoms to their doctors, but also because of the tendency to delay or deny invasive procedures until there is a severe alteration in the quality of life. Transabdominal and transvaginal ultrasound examination can detect pelvic vein insufficiency, which is the main cause of pelvic congestion syndrome. Vein diameter, the grade of reflux, velocity, and extension of affected vessels are among the parameters that can be assessed. Implementing a diagnosis scheme using only ultrasound parameters could lead to an increase in the number of diagnosed patients.