Secondary Vesicoureteral Reflux Research Articles

Urine Neutrophil Gelatinase Associated Lipocalin as a Predictor of Vesicoureteral Reflux and Renal Parenchymal Damage: A Systematic Review

Background: Vesicoureteral reflux (VUR) is the most common congenital urinary tract abnormality in children. Renal parenchymal damage is the most devastating complication of severe undiagnosed VUR. Different diagnostic biomarkers have been introduced as alternatives for radiologic evaluation in these patients. This review article aimed to increase the knowledge about the role of urine neutrophil gelatinase-associated lipocalin (uNGAL) in children affected by primary VUR and renal parenchymal damage. Methods: A systematic review of PubMed, Scopus, Web of Science, ProQuest, and Ovid was conducted in September 2022 to retrieve studies that investigated the correlation between uNGAL or uNGAL/Cr excretion and primary VUR in male/female patients younger than 18 years of age. Patients with secondary VUR, age older than 18 years, infectious or inflammatory disorders, obstructive uropathies, and acute or chronic kidney diseases were excluded. Two reviewers independently screened the titles and abstracts of the search results and then assessed the full texts selected from the pertinent studies. Results: Eighteen research articles with a total sample of 699 patients were found to measure uNGAL in VUR or renal scarring. UNGAL or uNGAL/Cr had increased excretion in the majority of children with primary VUR or RPD, with a positive or no correlation to the severity of VUR. Conclusions: Several studies addressed uNGAL and uNGAL/Cr as putative biomarkers for the prediction of VUR or reflux-associated RPD.

MP70-15 PRIMARY VESICOURETERAL REFLUX IN A MODERN COHORT: WHAT ARE THE RISK FACTORS FOR URINARY TRACT INFECTIONS?

You have accessJournal of UrologyCME1 Apr 2023MP70-15 PRIMARY VESICOURETERAL REFLUX IN A MODERN COHORT: WHAT ARE THE RISK FACTORS FOR URINARY TRACT INFECTIONS? Daniel Wilkinson, Matthew Buell, Kai Wen Cheng, Cayde Ritchie, Levi Miles, Jocelyn Huang, Ala’a Farkouh, David Chamberlin, and Joshua Chamberlin Daniel WilkinsonDaniel Wilkinson More articles by this author , Matthew BuellMatthew Buell More articles by this author , Kai Wen ChengKai Wen Cheng More articles by this author , Cayde RitchieCayde Ritchie More articles by this author , Levi MilesLevi Miles More articles by this author , Jocelyn HuangJocelyn Huang More articles by this author , Ala’a FarkouhAla’a Farkouh More articles by this author , David ChamberlinDavid Chamberlin More articles by this author , and Joshua ChamberlinJoshua Chamberlin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Children with vesicoureteral reflux (VUR) are known to be at increased risk of urinary tract infection (UTI). With a trend towards observational management of children with VUR, untreated VUR and subsequent UTI can lead to significant morbidity. The purpose of this study was to identify risk factors for development of UTI in a modern cohort of children with primary VUR. METHODS: We performed a review of a prospectively maintained clinical database of children with primary VUR at a single children’s hospital from July 2013 to June 2022. Children were included if they were diagnosed with primary VUR by voiding cystourethrography between the ages of 1 day to 18 years. Patients with secondary VUR were excluded. Demographic and clinical data were collected. The primary endpoint was development of a UTI defined by pyuria (>6 WBC/hpf or positive leukocyte esterase) on urinalysis and single-organism urine culture greater than 50,000 CFU/mL. Low-grade (LG) VUR was defined as International VUR grades 1-3 and high-grade (HG) VUR was defined as International VUR grades 4 and 5. Dilated ureter was defined as any ureteral dilation greater than 2 mm. Data were analyzed by performing univariate and multivariate Cox proportional hazards regressions as well as Chi Square tests. RESULTS: A total of 242 children had primary VUR, 116 (47.9%) male and 126 (52.1%) female. UTI occurred in 42 (17.3%) children with primary VUR, with an average follow-up time of 20.1 months [IQR of 6.2 - 45.0]. Female sex (HR: 2.39, 95% CI 1.22 - 4.67, p=0.011) and younger age at presentation of VUR (HR-1: 1.01, 95% CI 1.00 - 1.02, p=0.015) were found to be independent risk factors on multivariate analysis. Univariate analysis showed increased UTI rates in dilated ureter (14.6% non-dilated vs 30.5% dilated, p=0.024), HG VUR grade (13.2% in LG vs 23.7% in HG, p=0.038), and renal pelvis anterior-posterior diameter (APD) (16.9% ≤ 15 mm, 31.9% >15 mm p=0.032). Circumcision, degree of phimosis, constipation, voiding dysfunction, SFU grade of hydronephrosis, and prior febrile UTI were not found to be independent risk factors. CONCLUSIONS: Risk factors for UTI in children with primary VUR include female sex, age younger than 50 days old, dilated ureter, HG VUR, and hydronephrosis with APD greater than 15 mm. Treatment may be individualized to treat these higher risk patients. Further multi-institutional study of patients with primary VUR may help to further elucidate risk factors for UTI and improve the management of these patients. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1009 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Wilkinson More articles by this author Matthew Buell More articles by this author Kai Wen Cheng More articles by this author Cayde Ritchie More articles by this author Levi Miles More articles by this author Jocelyn Huang More articles by this author Ala’a Farkouh More articles by this author David Chamberlin More articles by this author Joshua Chamberlin More articles by this author Expand All Advertisement PDF downloadLoading ...

Overlooked Factors Causing Renal Damage in Vesicoureteric Reflux!

Vesicoureteric reflux (VUR), recurrent urinary tract infection (RUTI), febrile urinary tract infection (FUTI), renal scarring, and renal damage are intimately related. Key factors of renal damage in VUR are suspected to be RUTI and FUTI. Hence, conventional treatments are targeted toward the prevention of RUTI and FUTI. However, literatures have witnessed that control of infection is not sufficient enough. That means we are missing some hidden, enigmatic, or overlooked factors which are essentially responsible for renal damage. We know RUTI occurs from the stasis of urine in system and stasis might occur from obstruction somewhere in system. Moreover, obstruction builds up back pressure in the bladder and ureters, and ultimately in kidneys; that pressure is independently harmful to renal function. Pressure is further harmful if this joins together with infection. We know that RUTI and FUTI along with pressure in the urinary tract are harmful to renal parenchyma. Nevertheless, search for the nexus of obstruction, pressure, stasis, infection, and damage (OPSID) of renal function is not yet focused on in VUR research. In this retrospective study on secondary VUR, we would like to find the overlooked factors or nexus of OPSID associated with VUR causing renal damage. A total of 170 renal units of 135 patients with VUR resulted from the posterior urethral valve and from repaired bladder exstrophy, from March 2005 to April 2019, had adequate data regarding control/correction of obstruction and urodynamic studies. The mean patient's age was 2.8 years (range 1 day-14 years). The diagnosis of VURs was made with postnatal cystogram in patients of the posterior urethral valve and of repaired continent augmented bladder exstrophy. We do cystogram not micturating cystogram following ultrasonography if showing dilated ureter/s. If we find no residual in ureter/s after 30 min in cystogram, we label it as "rise and fall" VUR (raf_VUR), i.e., without obstruction. On the other hand, if there is post void residual in ureter/s for more than 30 min, we label it as "rise and stasis" VUR (ras_VUR) means combination of VUR with uretero vesical junction obstruction (UVJO). Along with this, all patients were followed up with albumin creatinine ratio, creatinine clearance, USG Renometry, DTPA renal scan, uroflowmetry, and urodynamic study (UDS). Repeat cystoscopy, if necessary, was done following UDS for secondary bladder neck incision (BNI) or for repeat BNI if necessary. Mean duration of follow-up was 7.2 years (range 3-14 years). Out of 170 renal units, 132 renal units had VUR without VUJO, i.e., raf_VUR and 38 renal units had ras_VUR. All patients of UVJO were relieved either with anticholinergics or with DJ stenting or by re-implantations. Twenty-nine patients out of 135 had high pressure on UDS, and they needed BNI. We were able to prevent upstaging of chronic kidney disease (USCKD) in all 135 patients. Our tangible goal of treatment in VUR is the prevention of USCKD. We differentiated raf_VUR from ras_VUR with cystogram. Patients with ras_VUR and patients with raf_VUR with high bladder pressure were actively treated. This particular subset VUR was treated with prophylactic antibiotic and surgical corrections. We prevented renal damage by eliminating obstruction and stasis which helped to prevent RUTI and FUTI. Possibly, similar management might also help to manage "primary VUR." Possibly those overlooked factors which are essentially responsible for renal damage are veiled in nexus OPSID of the kidney.

The accuracy of cystography under general anesthesia in children with vesicoureteral reflux.

To examine the accuracy of cystography under general anesthesia in children with vesicoureteral reflux (VUR). A prospective study of children who had VUR on cystography without general anesthesia (i.e., the gold-standard), and who are candidates for endoscopic VUR repair surgery. All children subsequently underwent a cystography under general anesthesia before injection using standardized method, which was compared to the gold-standard cystography. χ2 and Mann-Whitney U tests were used to compare proportions and medians between groups. Between 2017 and 2021, 126 renal units in 13 boys and 50 girls were included. Median age was 3.4 years (interquartile range[IQR] 1.5-6.5). Median time from cystography without to cystography with general anesthesia was 3.8 months (IQR 2.7-6). Of the 126 renal units, 96 had VUR on cystography without general anesthesia. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative and positive predictive values of cystography under general anesthesia were 47% (45/96), 87% (26/30), 34% (26/77) and 92% (45/49), respectively. Accuracy was 56.3%; Cohen's Kappa coefficient was 0.22, indicating poor agreement. In subgroup analysis, the sensitivity of cystography under general anesthesia was significantly lower in primary VUR (20% vs. 55% in secondary VUR, p = 0.01) and active VUR (14% vs. 52% in passive VUR, p = 0.008). Cystography under general anesthesia was poorly correlated to cystography performed while the child was awake or lightly sedated. Clinical decision relying on this cystography is questionable.

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results.

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

Introduction and objectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris

Introduction and ObjectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (p = 0.012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Bilateral Hydronephrosis as a Consequence of Vesicoureteral Reflux in a 6-Year-Old Male Patient

Vesicoureteral reflux (VUR) is the most common urologic pathology in the pediatric population. VUR is defined as primary when the intravesical portion of the ureters is short and produces an incompetent ureterovesical junction. Secondary VUR is caused by anatomical or functional obstruction to bladder emptying, which in turn increases the bladder internal pressure, therefore overcoming the ureterovesical junction and causing reflux.

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.

Can Spot Urinary Uric Acid/Creatinine Ratio Be Used as a Surrogate for Renal Scarring in Vesicoureteric Reflux?

Objective: Increased urinary excretion of uric acid has been shown to be associated with vesicoureteral reflux (VUR). The aim of this study is evaluate if urinary uric acid/creatinine ratio can be used as a surrogate for renal scarring in VUR. Method: Retrospective chart analysis was made to identify patients who were diagnosed with VUR. Those with secondary VUR, <3 years of age, and inadequate evaluation were excluded. Age, gender, VUR status, dimercaptosuccinic acid (DMSA) scintigraphy findings, presence of hypertension and microalbuminuria, and body mass index values were noted. Uric acid, calcium and creatinine levels for both urine and serum were measured. Urinary uric acid/creatinine and calcium/creatinine ratios were assessed for age. Backward logistic regression analysis was used for determining any predictors. Results: A total of 76 patients were eligible for the study. Mean age was 8.2±3.7 years. There were 49 females and 27 males. Fifty-one patients had renal scars while 25 had no scars. Microalbuminuria was present in 22 patients. Hypertension was detected in 5 patients. Hyperuricosuria was found in 23 patients (30.7%) while hypercalciuria was found only in 1 patient (1.3%). There was no correlation between urinary uric acid/creatinine and renal scarring, microalbuminuria and hypertension. Also, no correlation was found between urinary calcium/creatinine levels and aforementioned parameters (p values >0.05, for all). Conclusions: Our results indicate that urinary uric acid/creatinine ratio would not be used as surrogate for renal scarring in VUR.

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.

Utility of Urine Interleukines in Children with Vesicoureteral Reflux and Renal Parenchymal Damage.

Vesicoureteral reflux (VUR) is the most common risk factor of urinary tract infection in children. Currently, diagnosis of VUR depends on invasive imaging studies, with a high radiologic burden. Therefore, different biomarkers have been introduced for the evaluation of these patients. The objective of this study was to identify alteration of urinary interleukins (ILs) excretion in children with primary VUR and renal parenchymal damage, for further clinical application. Urinary concentrations of IL-1α, IL-1β, IL-6, and IL-8 were evaluated in 34 children with VUR (cases) and 36 without VUR (control), during 2018-2019. Urinary concentrations of IL-1, IL-1, IL-6 and IL-8 were measured, using polyclonal antibody ELISA kit, and standardized to urine creatinine (Cr). Patients with infectious or inflammatory disorders, urolithiasis, immune deficiency, acute or chronic kidney disease, and secondary VUR were excluded from the study. Mean age of cases (36.00 ± 27.66) had no significant difference with the control (32.86±29.31) group (p=0.44). The majority of patients had moderate VUR (58.8%), followed by severe (35.3%) and mild (5.9%) grades. Urinary concentration of all ILs/Cr were significantly higher in patients with VUR, compared with those without VUR. There was no significant correlation between urine ILs/Cr with age, gender, serum electrolytes, urine specific gravity, renal ultrasound, laterality or severity of VUR, and DMSA renal scan. All urine ILs/Cr had acceptable sensitivity and accuracy for workup of children with primary VUR. Urine IL-1α, IL-1β, IL-6 and IL-8/Cr were sensitive and accurate additionary screening biomarkers in children with primary VUR.

IJU this issue

This issue of International Journal of Urology contains one Guideline, three Review Articles, five Original Articles, two Urological Notes, five Editorial Comments and two Letters to the Editor. Miyakita et al. (Kanagawa, Japan) formulated and issued an algorithm to assist in the medical management of vesicoureteral reflux (VUR) consistent with clinical practice, and explained the epidemiology and the following elements: syndromes, diagnosis, treatment (medical and surgical), secondary VUR, long-term prognosis and reflux nephropathy. VUR is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. I am sure that the clinical algorithm for VUR should be helpful to your understanding and clinical practice. Akiyama et al. (Tokyo, Japan) reviewed recent evidence on interstitial cystitis/bladder pain syndrome (IC/BPS) categorization to describe the evolving taxonomy of IC/BPS, discussed the potential pathophysiologies and animal models, and suggested future strategies to achieve better clinical management and research progress of IC/BPS based on these emerging concepts. They emphasized the critical differences between IC/BPS with and without Hunner lesions, and suggested a tailored approach that targets Hunner lesions for better outcomes in clinical management and future research of IC/BPS. Ziegelmann et al. (Minnesota, USA) reviewed contemporary evaluation and management for Peyronie’s disease. Peyronie’s disease is a common, yet poorly understood, condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. However, its prevalence is low in Japan. As Shiraishi (Yamaguchi, Japan) described in the Editorial Comment, there are distinct differences in the prevalence and patients’ dissatisfaction with their condition, goal for treatment, and satisfaction after treatment between USA and Japanese Peyronie’s disease patients. It should be elucidated in further investigations. Tsuchiya et al. (Kyoto, Japan) summarized recent advances in circadian clock emergence during ontogenesis, and discussed possible associations with cellular differentiation and carcinogenesis. It is desirable that the relationships between cancer development and circadian clock dysregulation could lead to identification of unrecognized prognostic markers and therapeutic targets for specific cancers. In the Original Articles, Laucirica et al. (Barcelona, Spain) reported the surgical technique of “muscle-sparing” laparoscopic radical prostatectomy as a simple technical variation. Urinary incontinence is an important complication, as well as erectile dysfunction, after radical prostatectomy. Various surgical techniques are implemented to improve urinary continence, and the fundamental principle of them is to preserve the normal anatomy and function of pelvic structures. The continence rate outcomes were excellent, with comparable cancer control evaluated by the positive surgical margin rate. However, the rationale for the benefit and utility of laparoscopic radical prostatectomy in the robotic era requires debate. I am sure that many fine pictorial essays should be helpful to your understanding. In the Urological Notes, Ohtake et al. (Yokohama, Japan) examined the effectiveness of the N-composite gel kidney tumor model – a tool for practicing laparoscopic partial nephrectomy. They compared the face validity (the realism of the model), content validity (its utility as a training tool) and construct validity (the surgical objective parameters) between laparoscopic novices and laparoscopic experts. Surgical simulation is an important adjunct in surgical education. There is growing interest in and provision of cadaveric simulation courses worldwide. However, it is important to develop surgical models that feel like real organs, and can be used daily without the cost implications and the ethical issues. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of International Journal of Urology. None declared.

Guidelines for the medical management of pediatric vesicoureteral reflux.

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow‐up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long‐term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

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.

Validity of urine neutrophile gelatinase-associated lipocalin in children with primary vesicoureteral reflux.

Vesicoureteral reflux (VUR) is the most common congenital urinary tract abnormality in children. The objective of this study was to evaluate the diagnostic value of urine neutrophil gelatinase-associated lipocalin (NGAL) in children with primary vesicoureteral reflux (VUR). A total of 69 patients were evaluated in 2 groups with (32) and without (37) VUR. Patients with secondary VUR, infectious or inflammatory disorders, obstructive uropathies, and acute or chronic kidney disease were excluded. Urine NGAL level was measured by ELISA kit. Mean age of children with VUR was 36.84 ± 28.16, compared to those without VUR 32.32 ± 29.08, with no significant difference (p = 0.51). Mean urine NGAL (p = 0.012) and urine NGAL/Cr (p = 0.003) were higher in patients with VUR. In addition, urine NGAL/Cr increased significantly in patients with decreased parenchymal function, compared to those with normal DMSA scan. Using the cutoff value of 0.888, urine NGAL had 84% sensitivity and 81% specificity for diagnosis of VUR. Based on AUC (0.86), urine NGAL had acceptable diagnostic accuracy in children with VUR. The results of this study support the evidence that urine NGAL/Cr is a sensitive, specific and accurate biomarker for diagnosis of children with primary VUR.

Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients?

Neuropathic bladder, voiding dysfunction, and posterior urethral valves may cause a great challenge in children. Preserving the kidney function is the main aim in all of these patients which can be achieved by cutaneous vesicostomy. The objective of this study is to evaluate the long-term outcomes of patients who have undergone cutaneous vesicostomy in an 11-year period at the study center. In this retrospective study, the authors evaluated the long-term treatment results and complications of cutaneous vesicostomy on children with bilateral severe hydronephrosis, bilateral vesicoureteral reflux (VUR), and urosepsis who were operated at our center from 2007 to 2018. There were 64 (80%) boys and 16 (20%) girls. Their mean of age was 15.27 months old when they underwent vesicostomy. Twenty-three (28.75%) of them had neurogenic bladder and 17 (21.25%) of them had intact neuronal pathway defined as dysfunctional voiding. Twenty-five (31.25%) boys had posterior urethral valves. Fifteen (18.75%) of them were younger than six months old with primary bilateral high-grade VUR and urosepsis. Mean of follow-up time was 65.34±37.82 months (11.5 months-10.5 years). Cure rate was 95% in urinary tract infection, 80.7% in secondary VUR, and 40% in primary VUR. Creatinine level was significantly reduced after vesicostomy and during follow-up (P<0.001). Complications after vesicostomy were stoma stenosis (11.25%), mucosal prolapse (7.5%), dermatitis (3.75%), and febrile urinary tract infection (5%). In primary VUR after vesicostomy, 60% of the patients did not require an intervention to correct the reflux (Table). A number of 29 of 66 patients with closed vesicostomy needed another surgery: three modified Gil-Vernet antireflux surgeries, one ureteral reimplantation, two endoscopic Deflux injections, 13 valve ablations, six ileocystoplasties, and four Botox injections. The 37 (56.06%) remaining patients did not require any other surgery after closure of vesicostomy. Vesicostomy should be considered in children with neuropathic bladder or bladder outlet obstruction in case first-line therapies fail. This simple and reversible procedure can reduce febrile urinary tract infections, protect the upper urinary tract, and reduce the need for a major surgery without decreasing the bladder capacity.

Pattern of presentation and management of benign upper urinary tract obstruction in Sokoto Northwest Nigeria

Background: Upper urinary tract obstruction is a common cause of severe symptoms, recurrent urinary tract infection and deterioration or complete loss of renal function when intervention is not timely.Objective: To document the pattern of presentation and the management options for the benign upper urinary tract obstruction in our practice.Materials and Methods: The study retrospectively reviewed patients managed for benign upper urinary tract obstruction in our facility from February 2011 to February 2016. A total of 52 patients were treated during the study period. All the patients with benign upper urinary tract obstruction were included in the study. While Patients with lower urinary tract obstruction without secondary vesico-ureteric reflux (VUR), upper urinary tract obstruction from malignancy and those with incomplete records were excluded.Data was collected via a proforma and analysis was done using SPSS 20.0 versionResults: The mean age of patients in the study was 32.9±12.8 years and Male: female ratio was 3.3:1. The mode of presentations were flank pain in 47 patients (90.2%), haematuria in 36 patients (69.2%), childhood haematuria in 23 patients (44.2%) and urinary tract infection (UTI) in19 patients (36.5 %). The causes of upper tract obstruction were urolithiasis in 32 patients (61.6%), ureteric obstruction in 15 patients (28.8 %) and pelvi-ureteric junction obstruction in 5 patients (9.6 %). The definitive treatments were open in 27 patients (51.9 %), endoscopic in 14 patients (26.9%), and non-operative in 11 patients (21.2%).Conclusion: Urolithiasis, ureteric obstruction and pelvi-ureteric junction obstruction are the commonest cause of benign upper tract obstruction in our environment. Treatment can be open, endoscopic or medical.Keywords: Ureteric obstruction, urolithiasis, pelvi-ureteric junction obstruction

Aggressive diagnosis and treatment for posterior urethral valve as an etiology for vesicoureteral reflux or urge incontinence in children.

Vesicoureteral reflux (VUR) is one of the most common diseases in pediatric urology and classified into primary and secondary VUR. Although posterior urethral valve (PUV) is well known as a cause of the secondary VUR, it is controversial that minor urethral deformity recognized in voiding cystourethrography represents mild end of PUV spectrum and contributes to the secondary VUR. We have been studying for these ten years congenital urethral obstructive lesions with special attention to its urethrographic and endoscopic morphology as well as therapeutic response with transurethral incision. Our conclusion to date is that congenital obstructive lesion in the postero-membranous urethra is exclusively PUV (types 1 and 3) and that severity of obstruction depends on broad spectrum of morphological features recognized in PUV. Endoscopic diagnostic criteria for PUV are being consolidated.

The Decline of the Open Ureteral Reimplant in the United States: National Data From 2003 to 2013

To examine trends in the number of cases of primary vesicoureteral reflux managed by ureteral reimplantation nationally over the last decade. Substantial changes have occurred in management of vesicoureteral reflux (VUR) over time, but trends in use of ureteral reimplantation have yet to be investigated on a national scale with annualized data. Using the Premier Healthcare Database, we extracted hospital discharge data for pediatric patients (age ≤ 18 years) with a procedure code for ureteroneocystostomy (International Classification of Diseases, Ninth Revision, 56.74) between January 1, 2003 and December 31, 2013. We excluded patients with secondary VUR. The presence of a temporal trend in reimplantation was examined via regression using generalized estimating equations. In 4301 cases of primary VUR (23,602 weighted), there was a substantial decrease in the number of reimplantations performed, with an estimated decline in the rate of 0.239 cases per attending per year (P = .006). Average patient age declined 1.2 months in each year (P < .0001) due largely to a decline in reimplantation in those over age 2, which fell by 0.15 reimplantations per attending per year (P = .026). There was no difference between rates of decline in reimplantation for children with and without reflux nephropathy (P = .21) CONCLUSION: Nationally there has been a marked decrease in the incidence of ureteral reimplantation among children with primary VUR. The potential factors contributing to this are broad, including changes in diagnostic patterns, treatment recommendations, and the rise of endoscopic intervention.