Significant Vesicoureteral Reflux Research Articles

All Children With UTI Need VCUG

Source: Kass EJ, Kernen KM, Carey JM. Paediatric urinary tract infection and the necessity of complete urological imaging. BJU Int. 2000;86:94–96.Recent studies have demonstrated that many children with pyelonephritis or renal scarring after infection do not have vesicoureteral reflux (VUR) and that there is a low incidence of VUR in children with normal renal scans.1,2 These findings have led some to conclude that a child with a normal ultrasound or scintigraphy after a UTI does not require a VCUG.2 The authors studied the incidence of reflux in children who have normal upper tract studies following UTI. Four hundred sixty-eight children were evaluated for documented UTI from 1996–1998 at William Beaumont Hospital, Royal Oak, Michigan, and were reviewed retrospectively. One hundred one children who had both normal DMSA scans and renal ultrasounds constituted the study group and included 89 girls and 12 boys. VCUG revealed reflux in 23 (23%). Fifteen of 20 girls and all of the boys (3/3) who had VUR were age 5 years or younger, the age group generally accepted to be more susceptible to renal scarring from UTI. Of the 23, 9 had unilateral reflux and 14 had bilateral reflux. Interestingly, 13 (57%) had grade III or higher VUR. The goal of evaluating children with UTI is to diagnose any abnormality that may predispose the child to recurrent infection. Since 23% of children with normal upper tract studies had VUR, the authors conclude that children who have normal kidneys on ultrasound or renal scan still need a VCUG.This is a retrospective study but it has the strength of large numbers of children evaluated in a consistent manner at a single institution in a relative short period of time. The authors do not give us information about the severity of the UTI or other patient history but instead chose to include all children with documented UTI. While some may argue that this is a wide net and that pyelonephritis is different than cystitis, it has been shown that clinical symptoms are unreliable in localizing the site of urinary infection.3 I would agree with the authors that urine culture documentation of UTI is the most reasonable indication for complete imaging of the urinary tract and that the modern radiographic VCUG offers the best initial imaging of the lower urinary tract. This study tells us that children with normal kidneys on the best available imaging studies following UTI frequently have significant vesicoureteral reflux. The knowledge that they have reflux should alter their subsequent care.

Paediatric urinary tract infection and the necessity of complete urological imaging.

To evaluate voiding cysto-urethrography (VCUG) in assessing children with urinary tract infection (UTI) when renal/bladder ultrasonography and renal scintigraphy show no abnormality. A total of 468 renal scintigrams taken in children for an indication of UTI between January 1996 and December 1998 were reviewed. The renal and bladder ultrasonograms of those children with a normal renal scan were then reviewed. Children with both normal renal scans and normal ultrasonography were then evaluated for the frequency and grade of vesico-ureteric reflux (VUR) on VCUG. Of the 468 patients, 453 (97%) had complete imaging studies; 152 of the children evaluated had normal renal scans, of whom 101 had a normal renal ultrasonogram. Twenty-three (23%) children with both a normal renal scan and renal/bladder ultrasonogram showed VUR on VCUG, of whom 14 had bilateral VUR and 13 grade III or higher VUR. This study indicates that about 23% of patients may have significant VUR despite both a normal renal scan and ultrasonogram. Therefore, VCUG remains important in evaluating and managing children with UTI.

Nonresponders: prolonged fever among infants with urinary tract infections.

The majority of young children with fever and urinary tract infections (UTIs) have evidence of pyelonephritis based on renal scans. Resolution of fever during treatment is 1 clinical marker of adequate treatment. Theoretically, prolonged fever may be a clue to complications, such as urinary obstruction or renal abscess. Describe the pattern of fever in febrile children undergoing treatment of a UTI. Compare the clinical characteristics of those patients with prolonged fever to those who respond faster to therapy. An urban pediatric hospital. Medical record review. All children </=2 years old admitted to the pediatric service with a primary discharge diagnosis of pyelonephritis or UTI were reviewed for 65 consecutive months. Patients with previous UTI, known urologic problems, or immunodeficiency were excluded. Only patients with an admitting temperature >/=38 degrees C and those who met standard culture criteria were studied. Temperatures are not recorded hourly on the inpatient unit; therefore, they were assigned to blocks of time. Nonresponders were defined as those above the 90th percentile for the time to defervesce. Nonresponders were then compared with the balance of the study patients, termed responders. Of 288 patients studied, the median age was 5.6 months (interquartile range: 1.3-7.9 months old). Median admission temperature was 39.3 degrees C (interquartile range: 38.5 degrees C-40.1 degrees C). Median time to defervesce ranged in the time block 13 to 16 hours. Sixty-eight percent were afebrile by 24 hours and 89% by 48 hours. Thirty-one patients had fever >48 hours (nonresponders). Nonresponders were older than responders (9.4 vs 4.1 months old) but had similar initial temperatures (39.8 vs 39.2 degrees C), white blood cell counts (18.4 vs 17.1 x 1000/mm(3)), and band counts (1.4 vs 1.2 x 1000/mm(3)). Nonresponders had similar urinalyses with regard to leukocyte esterase positive (23/29 vs 211/246), nitrite-positive (8/28 vs 88/221], and the number of patients with "too numerous to count" white blood cell counts per high power field (12/28 vs 77/220). Nonresponders were as likely as responders to have bacteremia (3/31 vs 21/256), hydronephrosis by renal ultrasound (1/31 vs 12/232), and significant vesicoureteral reflux (more than or equal to grade 3; 5/26 vs 30/219). Eschericia coli was the pathogen in cultures of 28 of 31 (nonresponders) and 225 of 257 (responders) cultures. The number of cultures with >/=100 colony-forming units/mL was similar (25/31 nonresponders vs 206/257 responders). Repeat urine cultures were performed in 93% of patients during the admission; all culture results were negative. No renal abscesses or pyo-hydronephrosis was diagnosed. Eighty-nine percent of young children with febrile UTIs were afebrile within 48 hours of initiating parenteral antibiotics. The patients who took longer than 48 hours to defervesce were clinically similar to those whose fevers responded faster to therapy. If antibiotic sensitivities are known, additional diagnostic studies or prolonged hospitalizations may not be justified solely based on persistent fever beyond 48 hours of therapy.

SURGICAL COMPLICATIONS OF PEDIATRIC KIDNEY TRANSPLANTATION: A SINGLE CENTER EXPERIENCE WITH THE EXTRAPERITONEAL TECHNIQUE

Purpose The complex nature of pediatric renal transplantation and the often fragile condition of children with end stage renal disease create the potential for a number of complications. To decrease surgical complications we have performed renal transplantation via the extraperitoneal approach at our institution even in children who weigh less than 20 kg. We retrospectively evaluated whether renal transplantation via the extraperitoneal approach decreases surgical complications in pediatric kidney transplant recipients. Materials and Methods From February 1983 to December 1996, 1,115 patients underwent renal transplantation at our institution, including 60 boys and 47 girls with a mean age of 11.9 years who comprise the study group. Mean weight was 30 kg. at transplantation, and 32 and 75 patients weighed less than 20 and 20 or more kg., respectively. All 107 patients were treated with cyclosporine or tacrolimus based immunosuppression, including methylprednisolone and azathioprine or mizoribine. Living related and cadaveric renal transplantation was performed in 92 and 15 cases, respectively. The extraperitoneal technique was performed in all recipients, even in low weight children. The aorta and inferior vena cava, common iliac artery and vein or hypogastric artery and external vein were used for vascular anastomosis depending on recipient size. The ureter was anastomosed to the bladder via a modification of Paquin's method or an extravesical technique. Results During observation 7 surgical complications (6.5%) developed, including ureteral stricture, ureteral necrosis, renal artery stenosis, lymphocele, subcapsular hematoma, bladder leakage and significant vesicoureteral reflux to the graft in 1 patient each. There were no gastrointestinal complications. One patient with ureteral necrosis and 1 with subcapsular hematoma required surgical repair, and 1 underwent laparoscopic fenestration of a lymphocele. One patient with ureteral stricture and 1 with bladder leakage were treated conservatively, while another underwent ureteroneocystostomy. Overall only 1 graft (1%) was lost to a surgical complication (renal artery stenosis). Conclusions The incidence of surgical complications of the extraperitoneal technique in pediatric renal transplant patients was low (6.5%) and seems to be acceptable. The extraperitoneal technique did not cause any gastrointestinal complications, which seems to be its greatest advantage. The extraperitoneal technique may be used safely even in low weight children.

Diagnostic significance of 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy in urinary tract infection.

A total of 106 children with symptomatic urinary tract infection (73 girls and 33 boys, 0-15.9 years of age) were studied by means of a dimercaptosuccinic acid (DMSA) scan, renal ultrasound, and a desmopressin test during infection and at follow up approximately two months later. At follow up they were also investigated by means of intravenous urography (IVU) and micturition cystourethrography (MCU). During infection 23 children had a normal DMSA scan while 83 children had an abnormal one. The median C reactive protein and SD score for renal concentration capacity in the former group were 15 (range < 10-178) mg/l and -1.0 SD score (range -2.4 to 1.8), respectively, and in the latter group 98 (range < 10-320) mg/l and -3.1 SD score (range -5.7 to 1.1), respectively. In the former group there was no significant finding in any child on ultrasound or IVU and only one had significant vesicoureteric reflux (VUR) (grade 3). At follow up 51 children had a normal DMSA scan while 55 children showed persistent changes. The median SD score for renal concentration capacity in the former group was -0.9 SD score (range -3.2 to 1.4) and in the latter group -1.6 SD score (range -4.6 to 2.5). No significant changes were found in the former group on ultrasound or IVU and only two children had significant VUR (grade 3). In the latter group 20 children showed changes on ultrasound, 15 showed changes on IVU, and 23 had VUR. These results suggest that a normal DMSA scan during or approximately two months after urinary tract infection in children indicates a low risk of finding significant pathology of the urinary tract.

Evaluation of Acute Urinary Tract Infection in Children by Dimercaptosuccinic Acid Scintigraphy: A Prospective Study

A prospective study examining the incidence of dimercaptosuccinic acid (DMSA) abnormalities in children at the time of acute urinary tract infection, the progression of these abnormalities following treatment and their correlation with the presence of vesicoureteral reflux is reported. DMSA scans performed within 72 hours of presentation in 65 previously healthy children with acute urinary tract infection were abnormal in 34 (52%). The scan appearances of 30 of 36 (83%) initially abnormal kidneys improved or became normal on the repeat DMSA study performed at 3 to 6 months after the acute urinary tract infection. A cystogram demonstrated significant vesicoureteral reflux in 11 of 45 cases (24%). Of these 11 cases 10 had abnormal DMSA studies and 1 had dilated upper tracts on ultrasound.Several conclusions may be drawn from our study. The incidence of DMSA abnormalities at the time of acute urinary tract infection is high but these abnormalities tend to resolve with time. An abnormal DMSA study at the time of urinary tract infection identifies most children with significant vesicoureteral reflux, and in our series a combination of ultrasound and DMSA identified all cases. This study may have major implications for the clinical investigation of children with urinary tract infection.

Vesicoureteral reflux in children with and without a history of urinary tract infection: A comparative analysis

Eighty-eight children who were discovered to have vesicoureteral reflux were prospectively studied over a two-year period. Two groups were compared: 49 who presented with a urinary tract infection and 39 who were identified through prospective screening. Based on the distribution of grade and the presence of parenchymal scarring, the severity of vesicoureteral reflux was comparable in the two groups. Of note, more males with reflux were identified in the noninfected group, whereas sex distribution was almost equal in the infected group. Ultrasound alone was found to be highly inaccurate in identifying reflux or parenchymal changes. In conclusion, screening of at-risk groups of children without a history of urinary tract infection may identify patients with clinically significant vesicoureteral reflux.

Bladder Augmentation in Patients with Neurogenic Bladder and Vesicoureteral Reflux

Current treatment of noncompliant neurogenic bladder associated with significant vesicoureteral reflux that is refractory to intermittent self-catheterization and anticholinergic therapy includes bladder augmentation coupled with a procedure to eliminate reflux. Antireflux surgery is often difficult in such a clinical setting. The diseased and thickened detrusor makes reimplantation into the bladder difficult, and successful reimplantation into the intestinal component is tricky and time-consuming.Augmentation alone was done in 14 patients with significant vesicoureteral reflux in the face of a noncompliant, high pressure neurogenic bladder. No effort was made to correct reflux surgically because, in theory, reflux is secondary to abnormal bladder pressure. Of the 13 patients who have had adequate evaluation with postoperative cystograms 12 no longer have reflux. The reflux in the remaining patient has improved from grade IV to grade II. Postoperative cystometric examination in 12 patients demonstrated low pressure and adequate volume. Correction of bladder dynamics alone reversed the reflux. Conversely, persistence of reflux postoperatively is an indication that augmentation has not successfully returned the bladder to a low pressure reservoir. Our experience indicates that antireflux procedures are not routinely needed in this group of patients.

Detection of significant vesico-ureteric reflux by ultrasound in infants and children

Detection of significant vesico-ureteric reflux by ultrasound in infants and children

Detection of Significant Vesico-Ureteric Reflux by Ultrasound in Infants and Children

We evaluated real-time ultrasonography in the diagnosis of vesico-ureteric reflux by comparing its findings to those of dynamic micturition cystourethrography. The study material comprised 124 consecutive infants and children referred to uroradiological workup, usually because of a relapsing febrile urinary tract infection. Both examinations were done during the same session. Consistent findings were obtained on 232 ureters, of which 37 displayed II. and 19 III. + reflux. II. reflux was found in 12 ureters by cystography only; thus one-fourth of low-grade refluxes escaped the diagnosis by ultrasound. The false negative findings of ultrasound examination included also two ureters showing III. reflux in cystography. As calculated for therapy-requiring (grade III or higher) reflux, the sensitivity of ultrasound was 90 per cent and its specificity 100 per cent. We conclude that ultrasound can be used as a primary diagnostic technique for girls, and in the follow-up of both boys and girls.

A Prospective Study of Children with First Acute Symptomatic E. coliUrinary Tract Infection Early 99mTechnetium Dimercaptosuccinic Acid Scan Appearances

Between 1985 and 1987 102 children, age 0-14 years, presented with a first acute symptomatic E. coli urinary tract infection. Investigations included early 99mtechnetium dimercaptosuccinic acid (DMSA) scan (which was performed at a median of 27 days), ultrasonography, micturating cysto-urethrography and indirect voiding radionuclide cystography using 99mTc DTPA. Follow-up DMSA scan was carried out after 6 months. Twenty-one of 102 of initial DMSA studies showed diminished uptake of radionuclide and 12 showed cortical scarring. Twenty-nine patients had significant vesicoureteral reflux (VUR). The finding of diminished uptake on the initial scan was significantly associated with fever, systemic upset, length of symptoms and a peripheral blood leucocytosis, (p less than 0.05). In addition the finding was associated with fever and loin pain in the older child. Both diminished uptake and scarring were more common in refluxing kidney units. We propose that, in children with UTI, diminished uptake on early DMSA scan localises infection in the renal parenchyma.

The Management of Vesicoureteric Reflux

An increasingly large volume of data is being accumulated regarding the effects of vesicoureteric reflux on the kidney, data that influence clinical management. Although concrete guidelines cannot be drawn that will apply to all patients, important considerations include the following: All children with documented urinary infections should have a voiding cystourethrogram. The voiding cystourethrogram may correlate with probability of spontaneous resolution of vesicoureteric reflux. Younger patients have a higher chance of spontaneous resolution of vesicoureteric reflux. There is a definite familial tendency to vesicoureteric reflux, and patients with significant vesicoureteric reflux and scarring are more likely to have affected siblings. DMSA renal scanning is highly sensitive in the detection of scarring. Cystoscopy may play a role in the evaluation of the refluxing ureterovesical junction, but does not have as much prognostic significance as the voiding cystourethrogram. Urodynamic investigation may be important in evaluating children with urinary infections, reflux, and symptoms of voiding dysfunction. High-grade vesicoureteric reflux is associated with an increased incidence of renal scarring, and the answer to optimal management is not yet available. Most scarring occurs in infancy or childhood. Nonoperative management, especially in moderate degrees of reflux, can achieve a high rate of success. Nonoperative management requires continuous antibiotic prophylaxis. Breakthrough infections or lack of compliance with nonsurgical management have a high complication rate and must be managed aggressively. Antireflux surgery can be performed with a minimal complication rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Ureterocele in adults. A follow-up study of 28 adult patients treated with transurethral diathermy incision.

During an 18-year period, 28 adults with ureterocele were admitted to hospital with uncertain urological or abdominal symptoms. All of the ureteroceles were treated with transurethral diathermy incision. At follow-up examination after a mean observation time of 7 years, 16 of 20 patients were free from symptoms and the other 4 had only minor loin pain or dysuria. Significant vesico-ureteric reflux or depression of the renal filtration rate did not develop in any case. It is concluded that simple transurethral incision is adequate for treatment of small or medium-sized ureteroceles in adults.

The lack of correlation between upper tract changes on excretory urography and significant vesicoureteral reflux: A. W. Middleton, Jr and G. W. Nixon J Urol 123: 227–228, (February), 1980

The lack of correlation between upper tract changes on excretory urography and significant vesicoureteral reflux: A. W. Middleton, Jr and G. W. Nixon J Urol 123: 227–228, (February), 1980

Occurrence of reflux in children with ureteral jets.

The urograms of 186 boys and 145 girls were scrutinized in order to reveal the incidence of ureteral jets demonstable during intravenous pyelography (IVP). In this series a unilateral jet was observed in 26 cases and a bilateral jet in 6 cases. Ureteral jets were almost three times as common in patients with normal urograms compared with those revealing urinary abnormalities. The incidence of a positive jet sign, usually unilateral, varies with the employed technique of examination, but the highest incidence in routine IVP seems to be about 30%. Although infrequent, significant ipsilateral vesico-ureteral reflux (VUR) may occur. This fact together with the reported low rate of bilateral jets restricts the value or Unilateral jets being used as an indicator of absence of gross VUR. The need for micturition cysto-urethography (MCU) at the uro-radiological work-up remains unchallenged.