Significant Vesicoureteral Reflux Research Articles

Surgical Challenges of Bilateral Duplex Kidney with Ectopic Ureters

Abstract The bilateral duplex system is extremely uncommon, and only a few cases have been documented in the literature. It may manifest as a bifid renal pelvis and partial or complete ureteric duplication, with or without ectopic insertion of the ureter. An ectopic ureter is more problematic when there is significant vesicoureteral reflux, incontinence, and/or blockage. The optimal course of treatment is considered to be ureteral reimplantation rather than heminephrectomy. We describe the management strategy for a case of bilateral duplex kidneys with bilateral ectopic ureters in a growing female child.

Contemporary Management of Urinary Tract Infections in Children.

Purpose of ReviewUrinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice.Recent FindingsWith recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs.SummaryThe American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.

Do Various Treatment Modalities of Vesicoureteral Reflux Have Any Adverse Effects in Pediatric Patients? A Meta-Analysis

Purpose: Vesicoureteral reflux (VUR) is a risk factor for various renal problems like recurrent urinary tract infections (UTIs), pyelonephritis, renal scarring, hypertension, and other renal parenchymal defects. The interventions followed by pediatricians include low-dose antibiotic treatment, surgical correction, and endoscopy. This meta-analysis aimed to assess the advantages and drawbacks of various primary VUR treatment options. Search Strategy: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of journals, and abstracts from conference proceedings were all used to find randomized controlled trials. The articles were retrieved from 1985 till 2020. Twenty articles were used for the data analysis. Criteria for Selection: Surgery, long-term antibiotic prophylaxis, noninvasive techniques, and any mix of therapies are also options for treating VUR. Collection and Interpretation of Data: Two authors searched the literature separately, determining research qualifications, assessing accuracy, and extracting and entering results. The odds ratio (OR) of these studies was used to construct the forest plot. The random-effects model was used to pool the data. Also, the random-effects model was used with statistical significance at a p value < 0.05 to assess the difference in side effects after treatment of VUR using different modalities. Results: We found no statistically significant differences between surgery plus antibiotics and antibiotic alone-treated patients in terms of recurrent UTIs (OR = 0.581; 95% confidence interval [CI] 0.259–1.30), renal parenchymal defects (OR = 1.149; 95% CI 0.75–1.754), and renal scarring (OR = 1.042; 95% CI 0.72–1.50). However, the risk of developing pyelonephritis after surgical treatment of VUR was lesser than that in the conservative approach, that is, antibiotics (OR = 0.345; 95% CI 0.126–0.946.), positive urine culture (OR = 0.617; 95% CI 0.428–0.890), and recurrent UTIs were more common in the placebo group than in the antibiotic group (p < 0.05; OR = 0.639; 95% CI 0.436–0.936) which is statistically significant. Conclusion: Based on current research, we recommend that a child with a UTI and significant VUR be treated conservatively at first, with surgical care reserved for children who have issues with antimicrobials or have clinically significant VUR that persists after several years of follow-up.

Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines.

Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity. Urinary culture-confirmed first-time AP patients (aged 0-14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4-6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS). 17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III-V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III-V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III-V (75%) compared with AAP (56%). Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy.

Outcome of infants with antenatally diagnosed multicystic dysplastic kidney

Objective: The study was performed to evaluate the clinical course and renal outcome of patients with multicystic dysplastic kidney (MCDK). Methods: We retrospectively reviewed the medical records of 44 infants born at and followed up at King Abdul-Aziz Medical City, Riyadh, KSA, between January 2010 and December 2015. Available clinical and radiological records were reviewed. Outcomes of simple and complex, right- and left-sided MCDK were compared using paired sample t-test and Chi-Square tests as appropriate. Results: MCDK was found in the left side 22 infants (50%). There were other associated renal abnormalities in 63.6%; however; only 6.8% of the infants had other associated extrarenal abnormalities. Vesicoureteric reflux (VUR) was diagnosed in 7 infants (16%) of the study population. The median duration of follow-up was 36 range (12–84) months. At follow-up, urinary tract infections were diagnosed in 7 (16%) and 3 (6.8%) patients had hypertension requiring medical treatment. Follow-up renal ultrasound scans confirmed compensatory hypertrophy of the contralateral kidney in 31 (71%) of patients. Complete involution of the dysplastic kidney was seen in 10 (27.7%) of patients whereas partial involution of the dysplastic kidney was seen in 20 (45.5%) patients at follow-up. In 14 patients (31.8%), there were no changes in the size of the dysplastic kidney at follow-up. There were 28 infants with complex MSDK (associated with other renal abnormalities). Compared to infants with simple MSDK, there were born at an earlier gestation (36.5 vs. 38.8 weeks, P = 0.018). At follow-up, infants with simple MCDK, suffered more episodes of UTI (31% vs. 7%, P = 0.039). Maximum urea (7.2 vs. 4.8, P = 0.041) and creatinine (110 vs. 69, P = 0.045) were significantly higher in infants with complex MCDK. Conclusion: Children with unilateral MCDK suffer long-term morbidities regardless of the associated other renal abnormalities. In addition, given the low incidence of clinically significant VUR and the risks associated with Voiding cystourethrogram (VCUG) screening, routine VCUG is not advocated in patients with MCDK.

Yield of Imaging Performed as per Indian Society of Pediatric Nephrology Guidelines in Children with Urinary Tract Infection.

To assess yield of imaging performed as per Indian Society of Pediatric Nephrology (ISPN) urinary tract infection (UTI) guideline. Ultrasonography (USG), voiding cystourethrography (VCUG) and dimercaptosuccinic-acid (DMSA) scintigraphy were performed in 183 children (age 0-5y) with first episode (age 0-1y) of UTI or recurrent (age <5y) UTI, as per ISPN recommendations. Significant abnormalities were detected in 110 (63%), with vesicoureteric reflux (VUR) grades 3-5 in 31% and renal scars in 43%. Combined USG and DMSA had a negative predictive value of 94% for significant VUR. ISPN guideline resulted in a high yield of detection of significant abnormalities.

Critical appraisal of the top-down approach for vesicoureteral reflux.

Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.

Evaluation of the VANRIS Injection Success Rate in Vesicoureteral Reflux (VUR) Treatment in Children

Background: Vesicoureteral reflux (VUR) is a common condition among children. Although, subureteral injection is a minimally invasive new method for VUR treatment, ideal bulking agent in endoscopic treatment still remains controversial. We aimed to evaluate VANTRIS subureteral injection efficacy in VUR treatment in pediatric patients. Materials and Methods: All patients who referred to Imam Khomeini hospital in Urmia-Iran, Urology ward with VUR diagnosis that had indications for open surgery, enrolled study (during Mar 2013 to Mar 2015). Prior to intervention, VUR severity, urinary tract infection (UTI) and subsequent complications determined using urine analysis and imaging. Subsequently, single injection of the VANTRIS performed for all patients and patients underwent six-month follow up including several clinical and paraclinical evaluations. Results: 31 patients with VUR diagnosis participated; of 31 patients, 18 (58.06%) children with primary UTI who had surgery indication enrolled study; of 18 patients, seven patients (38.88%) were boy and eleven patients (61.12%) were girl with mean age of 6.88 ± 2.61 years, and out of 29 refluxing rental units (RRU), 13 (44.8%) were right and 16 (55.2%) were left kidney. In current study, patients divided to two subgroups regarding their age older than five or younger than five years old and there was no significant difference between the resolution rates following VANTRIS injection in two groups (P>0.05). Eleven (38.88%) RRU detected in boy patients, nonetheless VUR resolved in all of them, postoperatively. On the other hand, of 18 RRU in female patients, complete VUR resolution observed in 16 kidneys (88.8 %), but only 2 (11.11%) kidneys had incomplete, but significant VUR resolution, where no significant difference observed. The prevalence of reflux in patients with UTI was 30% and in patients without UTI was 17%. Conclusion: The current study indicated that in all age groups of patients, the subureteral injection of the VANTRIS was an accurate and effective treatment modality for VUR

REFLUXO VESICOURETERAL EM CRIANÇAS: ARTIGO DE REVISÃO

O Refluxo Vésico-Ureteral é definido como a entidade clínica em que ocorre fluxo retrógrado de urina da bexiga em direção aos ureteres. Conforme o grau do refluxo de urina e a severidade das alterações ocasionadas no sistema coletor renal demonstrado por uretrocistografia miccional, a doença é graduada de I a V, da menor para a maior gravidade. O diagnóstico pré-natal de RVU pode ser presumido através da evidência ultrassonográfica de hidronefrose fetal, enquanto que o diagnóstico pós-natal de RVU geralmente é feito após a ocorrência de infecção de trato urinário ou durante o rastreamento de crianças descendentes de famílias com altas taxas de RVU. A maioria dos pacientes apresentará resolução espontânea do RVU, alguns porém evoluem com infecções de trato urinário de repetição e formações de cicatrizes renais. O tratamento do refluxo vésico-ureteral em crianças é bastante controverso na literatura, variando desde conduta conservadora, com antibioticoprofilaxia de longo prazo, até procedimentos cirúrgicos abertos ou endoscópicos. O objetivo deste trabalho é revisar os principais aspectos relacionados à graduação, manifestações clínicas, diagnóstico, evolução e tratamento de pacientes pediátricos com refluxo vésico-ureteral

Evaluation of children with urinary tract infection – Impact of the 2011 AAP guidelines on the diagnosis of vesicoureteral reflux using a historical series

ObjectiveTo clarify the impact of the updated American Academy of Pediatrics guidelines for the evaluation of children presenting with initial febrile urinary tract infection (UTI) on the diagnosis of vesicoureteral reflux (VUR) in children with normal renal sonograms. Materials and methodsChildren with VUR followed between 2002 and 2004 were evaluated using criteria specified in the AAP guidelines. A total of 49 children (42 girls) who were 2–24 months of age at diagnosis of VUR made following initial febrile UTI were included. Results40.8% of ultrasounds were abnormal. While children with abnormal ultrasounds were more likely to have scintigraphic evidence of renal damage than children with normal ultrasounds (50% vs 17%, p = 0.026), one third of the children with abnormal renal scans had normal RBUS. There was no statistically significant difference in diagnosis of grade 3 or higher VUR between groups (p = 0.136). ConclusionsMost children in this series would not have been diagnosed with VUR after initial febrile UTI. More worrisome, 17.2% of children with normal ultrasound had renal injury identified on renal scanning, and 62.1% had grade 3 or higher VUR. These findings reinforce concerns that the new guidelines may miss or delay diagnosis of clinically significant VUR.

Utility of Screening Ultrasound After First Febrile UTI Among Patients With Clinically Significant Vesicoureteral Reflux

To assess the sensitivity and negative predictive value (NPV) of screening renal and bladder ultrasound (RBUS) after initial febrile urinary tract infection (UTI) among patients with clinically significant vesicoureteral reflux (VUR). A retrospective review was performed of all children<2 years of age who presented with a febrile UTI between 2004 and 2011. The sensitivity and NPV of initial RBUS was calculated among patients who were found to have high-grade (IV-V) VUR. Additionally, initial RBUS among patients with evidence of photopenia on dimercaptosuccinic acid (DMSA) scan or who underwent surgical intervention were reviewed. One hundred forty-four patients with febrile UTI were identified; available RBUS, voiding cystourethrogram (VCUG), and DMSA results for each kidney were reviewed. One hundred fifty-eight kidneys had evidence of VUR on VCUG, and initial RBUS demonstrated abnormality in 25 (sensitivity 0.17). Forty-five kidneys had high-grade VUR and RBUS revealed abnormality in 16 (sensitivity 0.36). One hundred seventy-eight kidneys had no evidence of abnormality on initial RBUS, and 136 (76%) were found to have VUR (NPV 0.24), of which 31 had high-grade VUR (NPV 0.83). Seven kidneys had scarring on DMSA and initial RBUS was normal in 4 (57%). Twelve of 19 patients (63%) who eventually underwent surgical intervention had a normal initial RBUS. RBUS has poor sensitivity and NPV for detecting high-grade VUR in patients<2 years who present with a febrile UTI. A significant number of patients who were diagnosed with high-grade VUR, renal scarring, or underwent surgical correction of VUR had a negative screening RBUS.

Clinical Outcomes and Long-Term Resolution in Patients with Persistent Vesicoureteral Reflux After Open Ureteral Reimplantation

Success rates of ureteral reimplantation for primary vesicoureteral reflux are high. Few studies document the natural history of children with persistent vesicoureteral reflux. We reviewed their clinical outcomes and long-term resolution. We performed a retrospective review of all children with persistent vesicoureteral reflux (grade 1 or greater) into the reimplanted ureter(s) on initial cystogram after reimplantation for primary vesicoureteral reflux at our institution from January 1990 to December 2002. We evaluated subsequent cystograms (graded on the 3-point radionuclide cystogram scale), surgery and urinary tract infection. We performed survival analyses of time to resolution of persistent (grade 1 or greater) and clinically significant (grade 2 or greater) vesicoureteral reflux in patients with more than 1 postoperative cystogram. Of 965 patients 59 (94 ureters) had persistent vesicoureteral reflux (6.1%), including 19 grade 1/3, 29 grade 2/3 and 11 grade 3/3. Median patient age at reimplantation was 1.9 years (range 0.8 to 5.1) and 62.7% were female. Preoperative vesicoureteral reflux grade was 2/3 in 42.4% and 3/3 in 57.6%, and 30.5% of patients had ureteral tapering. Median followup was 47.1 months (IQR 19.3-650.3). Reflux was resolved in 26 of 36 (72.2%) patients and median time to resolution was 20.4 months. Grade 2 or greater reflux on postoperative cystogram resolved in 21 of 32 (65.6%) patients and median time to resolution was 20.4 months. There were 10 patients with persistent vesicoureteral reflux at last cystogram, grade 1 or 2 in 9 and 3/3 in 1 patient. One patient underwent repeat reimplantation for persistent vesicoureteral reflux and 7 (13%) had postoperative febrile urinary tract infection at a median of 37 months postoperatively (IQR 1.7-64.4). Persistent vesicoureteral reflux after reimplantation resolves spontaneously in most children and can be managed nonoperatively with good long-term outcomes.

449 CAN WE ELIMINATE THE SCREENING VOIDING CYSTOURETHROGRAM IN CHILDREN WITH MULTICYSTIC DYSPLASTIC KIDNEY?

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Kidney & Ureter1 Apr 2012449 CAN WE ELIMINATE THE SCREENING VOIDING CYSTOURETHROGRAM IN CHILDREN WITH MULTICYSTIC DYSPLASTIC KIDNEY? Beth Drzewiecki, Douglass Clayton, John Thomas, John Pope, Mark Adams, John Brock, and Stacy Tanaka Beth DrzewieckiBeth Drzewiecki Nashville, TN More articles by this author , Douglass ClaytonDouglass Clayton Nashville, TN More articles by this author , John ThomasJohn Thomas Nashville, TN More articles by this author , John PopeJohn Pope Nashville, TN More articles by this author , Mark AdamsMark Adams Nashville, TN More articles by this author , John BrockJohn Brock Nashville, TN More articles by this author , and Stacy TanakaStacy Tanaka Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.517AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Our understanding of both multicystic dysplastic kidney(MCDK) and vesicoureteral reflux(VUR) has increased significantly over the years and therefore management continues to evolve. While reflux nephropathy in a solitary kidney can be devastating, the natural history of VUR in MCDK is primarily that of resolution. The current guidelines regarding VUR do not address children with a solitary kidney. We sought to determine role of screening VCUG in patients diagnosed with MCDK. METHODS We retrospectively reviewed the charts of all patients with a diagnosis of MCDK (ICD9 753.19) between January 1, 2000 and July 31, 2010. 210 patients were identified as having a diagnosis of MCDK and only 2 did not have a screening VCUG. Information including gender, screening VCUG, grade of reflux, location of reflux (contralateral vs ipsilateral), febrile UTI, resolution of VUR or surgical intervention, and indication for surgery was obtained. Kaplan-Meier survival analysis was performed to evaluate outcomes of contralateral reflux over time. RESULTS A total of 208 children (54% male and 46% female) included in the analysis. Documented VUR on either side was found in 51 (25%) of patients. Contralateral VUR was found in 37 (18%) of children with MCDK, of whom 8 had bilateral VUR. Median follow up of patients with contralateral VUR was 30.1 months (range 6.2-97.7). Clinically significant VUR was seen in 3 patients (1.4%) as noted by nephropathy (1) and febrile UTI (2). Nine patients underwent surgical correction for contralateral VUR, one of whom had endoscopic correction only. Indications for surgery included nephropathy (1), febrile UTIs (2), and concern for reflux in solitary kidney (6). Resolution in the children observed was documented by radiologic study in 18, of whom 12 had high grade VUR(grade III-V). Median time to resolution was 16.5 months (range 10.6 to 53). On Kaplan-Meier analysis, there is an 80% likelihood of children not requiring surgical intervention for contralateral VUR at 48 months. CONCLUSIONS Overall, 208 VCUGs were performed to detect clinically significant VUR in 1.4% of patients. Children with MCDK and contralateral VUR have a low likelihood of febrile UTI and excellent chance of resolution of even high grade VUR. Abnormal post natal ultrasound should still warrant investigation for VUR. Parents should be cautioned on the risks of UTIs in a solitary kidney and that any febrile illness should warrant urinary evaluation for infection. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e184 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Beth Drzewiecki Nashville, TN More articles by this author Douglass Clayton Nashville, TN More articles by this author John Thomas Nashville, TN More articles by this author John Pope Nashville, TN More articles by this author Mark Adams Nashville, TN More articles by this author John Brock Nashville, TN More articles by this author Stacy Tanaka Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vesicoureteral reflux in children with urachal anomalies

Objective We report the largest known series of vesicoureteral reflux (VUR) in children with urachal anomalies (UA). Methods Two institutions’ records were reviewed for children with UA (1951‒2007). Results Of 30 girls and 36 boys with UA (34 urachal cysts, 14 patent urachus, 10 urachal diverticula, 7 urachal sinuses, and 1 unknown), 57 (86%) underwent surgical resection or drainage. A voiding cystourethrogram was obtained in 22 (33%). VUR was demonstrated in 14 of the 22 children (64%), and rates were similar among the various types of UA. The median age with versus without VUR was not different (1.3 vs 1.7 years, P = 0.97). Of 24 refluxing renal units, classification was grade ≤ 3 in 71%, 4‒5 in 12%, and unspecified in 17%. Four children (26%) underwent ureteroneocystostomy and 10 observed patients resolved spontaneously. Conclusion To our knowledge, this is the first series of VUR associated with UA. The increased incidence of VUR (64%) in this small subset of patients warrants prospective studies to determine if there is a positive correlation with UA. We believe thorough genitourinary and family histories are important when evaluating children with UA to help detect clinically significant VUR.

Predictive Factors for Vesicoureteral Reflux and Prenatally Diagnosed Renal Pelvic Dilatation

We sought to identify predictive factors for primary vesicoureteral reflux among infants with prenatally detected renal pelvic dilatation. A total of 250 neonates were diagnosed with isolated renal pelvic dilatation between 1999 and 2008, and followed prospectively. The main event of interest was presence of moderate to severe reflux (grade III to V). Diagnostic odds ratio, sensitivity, specificity, and diagnostic accuracy (assessed by AUC) of fetal and postnatal renal pelvic dilatation were determined. Severity of dilatation was classified by Society for Fetal Urology grade. Binary logistic regression was performed to identify variables significantly associated with vesicoureteral reflux. A total of 23 patients (9.2%) had primary vesicoureteral reflux, of whom 16 had grade III to V disease. Diagnostic accuracy was 0.70 (95% CI 0.63 to 0.75) for fetal and 0.65 (95% CI 0.59 to 0.71) for postnatal renal pelvic dilatation. Combined results of fetal and postnatal renal pelvic dilatation were also assessed. When both tests less than 10 mm were considered negative indicators of moderate to severe vesicoureteral reflux sensitivity increased to 97% and diagnostic odds ratio to 19.1. After adjustment by logistic regression only Society for Fetal Urology grade greater than I and ureteral dilatation were variables independently associated with grade III to V reflux. Fetal and postnatal renal pelvic dilatation was a poor predictor of vesicoureteral reflux. Nevertheless, diagnostic accuracy regarding clinically significant vesicoureteral reflux improved when fetal and postnatal renal pelvic dilatation less than 10 mm was considered a negative indicator of reflux.

Imaging studies for first urinary tract infection in infants less than 6 months old: can they be more selective?

This retrospective study aimed to evaluate the applicability of the selective approach of imaging infants < 6 months old with urinary tract infection (UTI) according to the UTI guidelines of the National Institute for Health and Clinical Excellence (NICE) 2007. Infants < 6 months old with their first UTI from January 2001 to December 2006 having undergone an ultrasound examination of the urinary tract, a micturating cystourethrogram, and a late di-mercaptosuccinic acid (DMSA) scan, were included. Their condition was evaluated against a set of risk features according to the UTI guidelines. Those having any one of these were classified as atypical and those having none as typical. There were 134 infants reviewed, with a typical (98 infants) to atypical (36 infants) ratio of 2.7 to 1. Girls were found to be relatively more represented in the atypical group [male (M):female (F) = 1.3:1] than in the typical group (M:F = 4.4:1) (P < 0.004). There were significantly more infants with abnormal micturating voiding cystourethrograms (MCUGs) (P = 0.007), more refluxing ureters (P < 0.001) and more significant vesico-ureteral reflux (VUR) (>/= grade III) (P = 0.013) in the atypical group than in the typical group; while there was no significant difference in ultrasound (US) and DMSA scan findings between the two groups. In the atypical group there was no difference in imaging studies (and, thus, the results) between the conventional practice and the NICE UTI recommendation. In the typical group, if the recommendations of the guidelines had been followed (i.e. only those with abnormal US would have been further investigated), 25 refluxing ureters and 22 scarred kidneys would have been left undiagnosed. In conclusion, application of the suggested selective imaging approach would leave a significant number of VUR and renal scars undiagnosed, and it may not be an optimal practice for infants less than 6 months old with their first UTI. The best approach remains to be clarified.

Meta-analysis of vesicoureteral reflux and urinary tract infection in children

We evaluated the efficacy of medical and surgical treatment of vesicoureteral reflux (VUR) in children by means of a meta-analysis, using the recurrence of urinary tract infections (UTIs), renal growth and renal scarring as endpoints. We performed a MEDLINE search for articles published in the English language between 1966 and 2002. Of 639 relevant articles found, 139 were chosen for a close review and the main database was supplemented with some additional articles derived from the references of these reviewed articles. Five studies were found acceptable for a meta-analysis. We reviewed all articles independently. All reviewers had to approve the accepted articles and data that were used in this meta-analysis. Operative treatment of VUR was better than medical treatment in terms of abolishing reflux (OR = 0.033; 95% CI 0.010-0.107). We found no statistically significant differences between surgically and medically treated patients in terms of kidney growth (OR = 2.46; 95% CI 0.74-8.16), scarring (OR = 1.05; 95% CI 0.71-1.55) or recurrence of UTIs (OR = 0.80; 95% CI 0.49-1.29). We could not evaluate possible differences in the parameters monitored between boys and girls because of a lack of data. Although surgical treatment of VUR is a common pediatric urologic procedure, the data relating to it are scanty. We found no clinically significant differences between surgical and medical treatment for VUR other than in the resolution of VUR itself. On the basis of present evidence we suggest that a child with UTI and significant VUR should be treated conservatively at first and that surgical treatment should be reserved for children who experience problems with antimicrobials or persistent clinically significant VUR after several years of follow-up.

THE ROLE OF ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX: A 17-YEAR EXPERIENCE

During the last 20 years endoscopic treatment of vesicoureteral reflux (VUR) has gained popularity in European countries. We performed a retrospective analysis of our 17-year experience with more than 1,000 patients treated to assess whether technique, indications or results of endoscopic treatment of VUR have changed over time. From January 1986 to June 2002, 1,244 patients underwent endoscopic treatment for grades II to IV VUR. Polytetrafluoroethylene was injected as the bulking material in the first 14 cases, after 1989 bovine cross-linked collagen was used in 442 and since 1995 dextranomer/hyaluronic acid copolymer was used in 788. Urinary tract ultrasound was performed 1 and 6 months, and micturition cystourethrogram was done 3 and 12 months after endoscopic treatment. All patients included in the study completed a minimum 12-month followup. Endoscopic treatment was always performed in 1 day. Complications were observed in 0.5% of cases. After 1 or 2 injections the micturition cystourethrogram showed no significant VUR (absent or grade I) in 77% of cases. The success rate was 88%, 75% and 52% for grades II, III and IV VUR, respectively. With increasing experience not only primary VUR, but also secondary reflux was considered eligible for endoscopic treatment, and the number of grade IV VUR cases treated by endoscopy also increased. The presence of voiding dysfunction was identified as a limiting factor in the success of endoscopic treatment. The short hospital stay, acceptable success rate and absence of significant complications prompt us to consider endoscopic treatment as first choice treatment of VUR rather than long-term prophylaxis and open surgery. Even grade IV VUR and VUR in complex anatomical situations can be successfully treated by endoscopy. Patients with voiding dysfunction should be identified and adequately treated before any endoscopic attempt.

Isolated minimal renal pelvic dilatation detected antenatally in a non-tertiary setting is an uncommon predictor of significant vesicoureteric reflux.

To study in a non-tertiary centre the prevalence and grade of vesicoureteric reflux detected postnatally in infants already identified antenatally with isolated minimal renal pelvic dilatation. Retrospective review over the years 1998-2000 inclusive of a central computerized database in the single paediatric practice within Albury Wodonga. Ninety-three (65 male) infants detected antenatally with isolated renal pelvic dilatation (>or=3 mm at 18 weeks gestation, >or=5 mm at 32 weeks gestation,<10 mm dilatation at any gestation) had a Micturating Cystourethrogram result. Thirteen infants (seven male) had vesicoureteric reflux detected, with a total of 18 refluxing renal units. Of these 13 infants five had bilateral vesicoureteric reflux (two male), and eight had unilateral vesicoureteric reflux. The median reflux grade was 2.0, with significant vesicoureteric reflux (greater than grade II) occurring in 5.4% (5/93). Significant vesicoureteric reflux (greater than grade II) occurred in only 5.4% (5/93) of infants. It is concluded that isolated minimal renal pelvic dilatation detected antenatally is a poor screening test for clinically significant vesicoureteric reflux.

Neonatal renal ultrasound – a 5‐year review in an obstetric hospital

Aim: To review a consecutive series of neonatal renal scans presenting to the imaging department in an obstetric hospital, record the abnormalities seen and assess the accuracy of the antenatal diagnosis with subsequent outcome.Material and methods: In the 5 years (1996–2000), there were 788 neonates referred for renal ultrasound scans. Many of the infants had a micturating cystourethrogram (MCU) at the time of presentation. The commonest indication in 92% of neonates was fetal pyelectasis reported on the antenatal scan. The hospital records of these infants were reviewed with further details obtained from clinicians and surgeons and subsequent investigations.Results: The results were classified according to the findings. There were a total of 788 neonates who had a renal scan. There were 592 (75%) in whom the scan was considered normal and of these 49 had an MCU and 17 had associated vesico‐ureteric reflux (VUR) grades 1–4. There were 125 (16%) infants with persisting mild‐moderate pyelectasis/hydronephrosis and of these 61 resolved or were lost to follow up and 64 persisted at follow up scans variably timed 3–15 months later. Most of these had an MCU and 26 had associated VUR grade 1–5, not always on the side of the pyelectasis. Miscellaneous abnormalities were seen in 71 (9%) neonates, multicysticdysplastic kidney 25, pelviureteric junction obstruction (PUJ) 7, solitary kidney 6, crossed renal ectopia 5, uncomplicated duplex kidney 5, ureterocoele 5, two with posterior urethral valves and one with vesico‐ureteric junction obstruction (VUJ). There were four infants with significant VUR, three with thinned renal parenchyma and one with a small kidney. There were three with autosomal recessive polycystic kidney disease (Potter's type II), one with small dysplastic kidneys.Conclusion: In this review, there were 113 neonates (14%) found to have significant renal anomaly or VUR. Many of the miscellaneous fetal renal abnormalities have a characteristic and identifying appearance on the antenatal ultrasound. The majority of neonatal renal scans are referred because of mild/moderate fetal pyelectasis and many of these resolve over a variable time. Persisting moderate pyelocaliectasis is not a sensitive sign of VUR, nor in differentiating early PUJ obstruction from the normal variant that subsequently resolves. Follow up ultrasound may confirm resolution or increasing hydronephrosis. Nuclear medicine studies will compare function and drainage of the systems in patients with PUJ obstruction.