Treatment Of Vesicoureteral Reflux Research Articles

Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

ObjectiveTo assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED).Materials and methodsThis is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1–148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups.ResultsGroups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections.ConclusionsSS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Vezikoüreteral Reflüde İlk veya Sonraki Cerrahi Girişim Olarak Subüreterik Enjeksiyon veya Üreteroneosistostomi Tercihinin Sonuçları

The incidence of vesicoretral reflux (VUR) in childhood is 0.4-1.8%. Among the surgical treatment options, there are two different approaches: Subureteric injection (SUI) and ureteroneocystostomy (UNC). In this study, we evaluated the operation results of patients who underwent SUI and UNC for VUR. Patients who underwent surgical treatment for vesicoureteral reflux in a tertiary university hospital between 2010-2018 were retrospectively analyzed. The surgical techniques applied to the patients, whether the procedure was successful or not, and additional interventions needed afterwards were recorded. The success rates of the two different techniques applied were compared. Of the 274 patients included in the study, 219 received SUI as the first procedure, 57% of patients did not need additional intervention. After the first SUI, 13.1% of patients underwent UNC as the second procedure. A second SUI was given to 21.2% of patients. UNC was given to 5.5% of patients who received two injections, and 4% of patients were underwent a third SUI. 59.8% patients were treated with SUI alone. Reflux was treated in 65.6% of patients with a single procedure. In VUR patients, SUI should be the first treatment choice because of its high success rate, low complication risk and not preventing UNC.

What are the Effective Factors in Spontaneous Resolution Rate of Primary Vesicoureteral Reflux: A Meta-Analysis and Systematic Review.

This meta-analysis aimed to predict the rate of spontaneous resolution and identify influencing factors among pediatric patients with primary vesicoureteral reflux (VUR). The primary objective was to construct a nomogram to facilitate clinical decision-making in the treatment of primary VUR by assessing the rate of spontaneous resolution and its determinants. A systematic search was conducted up to September 2023, encompassing databases such as PubMed, Web of Science, Scopus, and the reference lists of relevant studies. Inclusion criteria comprised 33 studies with a total of 8540 pediatric patients. Data extraction was performed independently by two reviewers, with discrepancies resolved by a third reviewer. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Form. The analysis included the assessment of various outcomes, such as the rate of spontaneous resolution, and identification of influential factors, including gender, age, laterality, and VUR grade. The pooled spontaneous resolution rate among pediatric patients with primary VUR was 0.42 (95% CI: 0.38 to 0.47, Tau2 = 0.26), demonstrating high heterogeneity (Q = 429.9, df = 32, P < 0.001, I2 = 93%). Egger's regression test indicated no publication bias (p = 0.67). VUR grade emerged as the most significant determinant of spontaneous resolution, with varying rates for different grades: grade 1 (0.80, 95% CI: 0.72-0.86), grade 2 (0.67, 95% CI: 0.60-0.74), grade 3 (0.49, 95% CI: 0.42-0.56), and grade 4 (0.23, 95% CI: 0.18-0.30; Tau2 = 0.28, I2 = 0.49). While differences in gender and laterality were observed, statistical significance was not evident. This study provides valuable insights into the spontaneous resolution rate of primary vesicoureteral reflux in pediatric patients. The constructed nomogram, based on VUR grading, serves as a useful tool for clinicians in decision-making. Despite observed variations in gender and laterality, only VUR grading demonstrated statistical significance in influencing spontaneous resolution. Further research is recommended to explore additional factors within larger populations to enhance our understanding of primary VUR resolution dynamics.

The Effectiveness of Deflux® Treatment for Vesicoureteral Reflux Following Pediatric Renal Transplantation: A Single-Institution Challenging Experience

PurposeTo validate the effectiveness of Deflux® treatment for vesicoureteral reflux (VUR) following pediatric renal transplantation (RT), based on our single-institution experience. MethodA retrospective study was conducted using the medical records of pediatric patients who underwent Deflux® treatment for VUR after RT from April 2008 to March 2022. ResultsSixty-eight pediatric patients underwent RT. VUR was subsequently detected in 22 (32 %) of these patients. Seven of the 22 patients (32 %) underwent Deflux® treatment to avoid renal dysfunction due to urinary infection (UTI). The median age at the time of RT was 4 years (range:2–12). All 7 patients had urinary UTIs before Deflux® treatment. The median estimated glomerular filtration rate (eGFR) before Deflux® treatment was 67 ml/min/1.73 m2 (range:42–138 ml/min/1.73 m2). After Deflux® treatment, VUR was downgraded in three cases (43 %). Four patients (57 %) experienced postoperative UTI, two of who underwent a second Deflux® treatment, one underwent submuscular tunnel reconstruction, and the other one experienced UTI without VUR after 1st Deflux® treatment but did not reoccur. All seven patients continued prophylactic medication after Deflux® treatment, without any history of recurrent UTIs during the observation period after treatment (median 37 months [range 7–86 months]). Furthermore, the eGFRs did not significantly decrease after Deflux® treatment (median eGFR 58 ml/min/1.73 m2 [range:33–99 ml/min/1.73 m2], p > 0.1). ConclusionDeflux® treatment for VUR after RT is technically challenging because the new ureteral orifice is ventrally anastomosed at the bladder. We believe our results indicate the possibility of reducing the frequency of UTIs and contributing to preservation of the renal function after RT. Type of studyRetrospective Study. Level of evidenceLevel III.

Intraoperative ultrasound-assisted endoscopic treatment of primary intermediate and high-grade vesicoureteral reflux in children in a long-term follow-up

Endoscopic treatment of vesicoureteral reflux (VUR) is an important minimally invasive surgical approach in patients undergoing surgical treatment of VUR. In our past experience, we observed that a bulking agent mound sagittal diameter of 10mm is the main predictor of effectiveness of the procedure. Moreover we noticed that the use of intraoperative ultrasound, allows the surgeon to better identify the site, volume and shape of the bulking agent injected, finally reducing operative time. We aimed to evaluate if the intraoperative ultrasound assistance could definitively improve effectiveness of the endoscopic procedure. We retrospectively compared two series treated with endoscopic procedures for intermediate and high grade primary VUR, respectively without (series A) and with (series B) intraoperative ultrasound (IO-US). In all patients VCUG was performed to assess VUR grade and to verify resolution or VUR downgrading during the follow-up. A total of 177 ureteric units were treated. Endoscopic procedures globally were effective in 68/96 ureters (70.8%) in series A and in 68/81 ureters (83.9%) in series B. No significant differences in effectiveness were observed comparing the series with regard to VUR grades, but a significant difference is shown (p<0.05) when grouping grades III-V VUR. No significance in differences of volume injected were detected, but operative time was significantly lower in series B (27.5min vs 19.6min, p<0.05). Mean sagittal mound diameter measured during cystoscopy in series B was 10.45mm (range 8.5-14.2mm). The intraoperative ultrasound assistance during endoscopic treatment of VUR could represent a valid tool for surgeons to better identify location, volume and shape of the bulking agent. Furthermore, the use of an objective parameter of evaluation of the implant can overcome the subjective intraoperative evaluation of the implant itself, improving results for experienced surgeons and reducing the learning-curve for inexperienced ones. Results of endoscopic injection of bulking-agent can be improved with intraoperative ultrasound, allowing at the same time a significant reduction of operative time.

The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction

Early diagnosis and treatment of primary vesicoureteral reflux (VUR) are essential for preserving renal function. The study explored whether preoperative cystoscopic grading of refluxing ureteric orifices (UO) correlated with their shape in an institution with non-performance of hydrodistention of the UO in the diagnosis and grading of VUR. We also assessed the relationship between the UO shape and VUR grade with the effectiveness of endoscopic correction of primary VUR in children. This retrospective study included consecutive patients ≤15 years treated for primary VUR. The reflux grade was based on the results of preoperative voiding cystourethrography as mild, moderate, or severe. Fifty-one patients with 77 renal refluxing units (RRU) underwent endoscopic treatment with Deflux®. VUR was bilateral in 51% of patients. VUR was mild in 13%, moderate in 53%, and severe in 34% of cases. The patients with mild and moderate VUR had stadium-shaped UOs in 60% and 54% RRUs, respectively. Horseshoe-shaped UOs constituted 42% of UOs in patients with severe VUR, followed by 31% of golf-hole UOs. The reflux resolution rate after the first endoscopic injection was 84%. The preoperative VUR grade correlated with UOs shape (p<0.001). No significant correlation between UOs configuration and the outcome of endoscopic treatment was seen (p=0.452). The preoperative VUR grade negatively correlated with a favorable endoscopic treatment (p=0.043). Our data indicate ureteral orifice shapes are closely related to preoperative VUR grade. There was no correlation between the UO configuration and the success rate of endoscopic treatment of VUR, in contrast to the significant negative correlation between the VUR grade and the success rate of endoscopic treatment.

Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux.

The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations. Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course. The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients). For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.

Does previous endoscopic subureteric injection (STING) effect the outcomes of robot-assisted laparoscopic ureteral reimplantation surgery (RALUR) in children?

There is lack of evidence on the success of robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of vesicoureteral reflux (VUR) who had prior intervention. This study aimed to evaluate the effect of previous unsuccessful STING on the outcomes of RALUR in children. A total of 67 children treated with RALUR by a single surgeon for the treatment of VUR were scanned between February 2018 and April 2022. Two patients were excluded from the final data analysis due to the presence of a megaureter. Patients were divided into two groups: those with a history of STING (Group A - n:14) and those without STING (Group B - n:51). Patient characteristics, previous numbers of injections, console time, total operative time, perioperative and postoperative complications and clinical success data were collected. Clavien Dindo and Satava complication scales were used as the standard record of peri and postoperative complications. Radiographic success was defined as absence of reflux detected on postoperative voiding cystourethrography, whereas clinical success was defined as the absence of a febrile urinary tract infection during the follow-up. Mann-Whitney U and Chi-square tests and Fisher exact test were used where appropriate. A total of 36 (55.3%) female versus 29 (44.6%) male patients were operated for 96 refluxive ureters. Nearly half of the patients were with bilateral VUR (n=31). The mean follow-up was 20.2±15.4 months. The median age of patients was 59±31 (range: 28-132 months) versus 46±33.1 (range: 7-206 months) for groups A and B respectively (p=0.22). Gender, age, peri- and postoperative complication rates, and clinical success were comparable between the two groups. The median operative time and the console time was significantly higher in children with history of STING (op time: 142.5±27.4 versus 120±24.9min (p=0.008), console time: 117.5±28.2 versus 100±24.5min (p=0.011) for groups A and B, respectively. A total of six complications (9.2%) occurred with none of them were greater than Clavien grade 3b. The overall clinical success rate was 97%, with 2 cases of clinical failure. In both cases, VCUG demonstrated absence of VUR. The outcomes of our study provided that RALUR is effective with more than 95% success rates despite failed endoscopic injection procedures. The previous history of STING neither changes the success nor the complication rates of RALUR. However, this can lead to more challenging surgery by increasing the total operative times.

Outcomes after dextranomer/hyaluronic acid bladder neck injection in patients with urethral incontinence following bladder neck repair

Many patients who undergo surgery for bladder neck (BN) incompetence may still experience incontinence postoperatively. Dextranomer/hyaluronic acid (Dx/HA) is widely used for endoscopic treatment of vesicoureteral reflux in children; however, few studies have reported its use in treating incontinence after BN surgery. The aim of this study was to evaluate outcomes after Dx/HA bladder neck injection in patients with persistent outlet incompetency following BN Repair. We retrospectively reviewed patients at a single pediatric tertiary care center with history of prior bladder neck surgery and reported persistent incontinence who then underwent endoscopic bladder neck Dx/HA injection from 2013 to 2018 and had subsequent follow-up post-injection. We described primary outcomes of reported incontinence as "wet" (leakage similar to before injection), "improved" (wet but leakage improved), and "dry" (no leakage). Our secondary outcome was need for a secondary procedure after Dx/HA injection, including Dx/HA injection or bladder neck closure (BNC). At first follow-up (median 2.3 months post-op), 7/19 were wet, 6/19 were improved, and 6/19 were dry. At last follow-up (median of 34.7 months), only three patients (16%) were dry. Only one patient who received a single surgery for Dx/HA injection was "dry", though nearly 2/3rds (12) were initially "improved" in their continence. Overall, seven patients had another intervention or surgery after first injection. Five patients had multiple Dx/HA injections after first procedure, which resulted in dryness by last assessment in two of these. Four patients (21%) in the overall cohort required subsequent BNC. Longer-term follow-up in our study demonstrated that only one patient who received a single procedure of Dx/HA injection remained dry. Several studies had follow up for greater than 1 year after initial bladder neck Dx/HA injection; rates of dryness after a single surgery for injection were variable and reported between 20 and 40% over follow-up times ranging from 1.5 to 7 years (Alova et al., 2012; DaJusta et al., 2013; Lottmann et al., 2006a; Lottmann et al., 2006b; Kitchens et al., 2007). Our st udy does have inherent limitations. This study was performed at a single institution in a retrospective manner, with a single surgeon reviewing the medical record to determine operative techniques and continence outcomes. The patient population is small, although relatively comparable to other previously reported studies. Outcomes were based on documentation of patient reports and are therefore lacking in objectivity. In patients with prior unsuccessful BN repair, long-lasting dryness after single Dx/HA BN injection is unlikely, although one-third may demonstrate relatively durable improvement in incontinence.

Association between the imaging characteristics of renal abscess and vesicoureteral reflux

IntroductionRenal abscesses are rare in pediatric populations. We aimed to highlight the differences in the computed tomography (CT) imaging characteristics of renal abscesses in patients with and without vesicoureteral reflux (VUR). Materials and methodsThirteen children with renal abscesses were included and categorized into those with and without VUR. Blood and urine culture results were recorded as positive or negative. Imaging characteristics were recorded: with/without subcapsular fluid collection, with/without upper/lower pole involvement, and with single/multiple lesions in kidneys. Fisher's exact test was used for intergroup comparisons of the rate of positive pathogens and imaging characteristics. ResultsNine patients had VUR (45.9%). Blood and urine culture were positive in two (15.4%) and seven cases (53.8%), respectively. There was no significant difference in the rate of pathogen-positive blood and urine cultures (blood culture positive/negative status with VUR vs. that without VUR = 2/7 vs. 0/4, p > 0.999, urine culture positive/negative status with VUR vs. that without VUR = 4/5 vs. 3/1, p = 0.559). The two groups differed significantly regarding subcapsular fluid collection presence (with/without subcapsular fluid collection with VUR vs. that without VUR = 9/0 vs 1/3, p = 0.014). There was no significant difference in upper/lower pole involvement (with/without involving upper/lower pole with VUR vs. that without VUR = 8/1 vs 2/2, p = 0.203). Patients with VUR were non-significantly more likely to have multiple lesions compared to those without VUR. ConclusionsVUR was associated with subcapsular fluid collection and possibly with multiple lesions, indicating the need for prompt detection of and specific treatment for VUR in cases with these findings.

Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux

Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury. This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR. Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated. Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143min for unilateral VUR and 194min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases. Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view. Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

How the 99mTc-DMSA scintigraphy findings are reflected in the adopted treatment of primary vesicoureteral reflux: One centre experience

Renal changes may have long-term sequalae and prevention is a main goal of management of primary vesicoureteral reflux (VUR). This study aims to reveal how much 99mTc-DMSA scintigraphy findings are reflected in the adopted surgical or non-surgical treatment in children with diagnosed primary VUR and to give the clinicians information regarding their final therapeutic decision. A total 207 children with primary VUR who underwent non-acute 99mTc-DMSA scan were retrospectively evaluated. The presence of renal changes, their grading, differential function asymmetry (<45%) and grade of VUR were compared with subsequent choice of therapy. Altogether 92 (44%) children had asymmetric differential function, 122 (59%) showed presence of renal changes, 79 (38%) had high-grade VUR (IV-V). Patients with renal changes had lower differential function (41%vs.48%) and higher grade of VUR. The incidence of high-grade changes (G3+G4B) afflicting more than one third of the kidney was significantly different between grade I-II, III and IV-V VUR (9%, 27%, 48%, respectively). Renal changes were detected in 76% of surgically and 48% of non-surgically treated patients, high-grade 99mTc-DMSA changes in 69% and 31%, respectively. In children with no scars/dysplasia (G0+G4A), non-surgical treatment prevailed in 77%. The independent predictors for surgical intervention were presence of renal changes and higher grade of VUR, but not functional asymmetry. Over the last 20 years, there has been a shift toward more non-surgical management of VUR. The long-term outcome of this approach should be thoroughly studied. This is the first study analysing renal status in VUR patients using 99mTc-DMSA scan and its grading regarding the adopted treatment. Renal changes in almost half of non-surgically treated children with VUR should be an indicator for earlier diagnosis and effective treatment of acute pyelonephritis and VUR. We recommend distinguishing grade III VUR, as a moderate-grade VUR, because it is linked to higher incidence of high-grade 99mTc-DMSA changes (G3+G4B); our findings of 65% of grade III VURs treated non-surgically should be cautionary. Grade III VUR does not mean a low-risk condition and should alert the clinician to evaluate the extent of renal changes and unmask high-risk cases. Our data strengthens the need to investigate the extent of renal changes in VUR patients regarding treatment decision. Performing 99mTc-DMSA scan individualizes the treatment of VUR patients; its grading can distinguish grade III-VUR as a separate risk entity because it differs significantly in terms of incidence of high-grade renal changes and chosen therapy.

ПРЕДИКТОРЫ УСПЕХА ЭНДОСКОПИЧЕСКОЙ КОРРЕКЦИИ ПУЗЫРНО-МОЧЕТОЧНИКОВОГО РЕФЛЮКСА У ДЕТЕЙ

Predicting the outcome of endoscopic correction of vesicoureteral reflux (VUR) is an urgent problem in pediatric urology because the identification of predictors for the effectiveness of endoscopic treatment of VUR will optimize the strategy for examination and treatment of the disease. The purpose of the research was to evaluate the statistical impact of various predictors on the success of endoscopic correction of VUR; to predict the clinical outcome by creating a mathematical model. Materials and methods used: a single-center experimental uncontrolled study was conducted in Sept. 2017 - Feb. 2022. The results of treatment of 150 pediatric patients (240 renal units) aged from 1 month till 7 years old who underwent endoscopic correction of VUR are presented. The following indicators were evaluated as predictors: gender, age of the disease manifestation, bilateral/unilateral VUR, grade of VUR, ureteral diameter ratio (UDR), cystography initial confirmation of VUR, expansion of the pelvicalyceal system and ureter according to ultrasound, the presence of urinary tract infection. Results: according to the data obtained, when comparing the grade of VUR, cystography initial confirmation of VUR, UDR, expansion of the pelvis and ureter depending on the result of treatment, the statistically significant differences have been found (p&lt;0.001). A prognostic model has been developed to determine the probability of the outcome of endoscopic correction of VUR using the binary logistic regression method. The area under the ROC curve was 0.985±0.007 with 95% CI: 0.967-1.000. The resulting regression model was statistically significant (p&lt;0.001). The sensitivity and specificity of the model were 96.4% and 95.3%, respectively. Conclusion: the results of the research show that UDR and the initial confirmation of VUR have greater predictive power for the success of the endoscopic urethroplasty compared to the grade of VUR alone. The use of the predictors and predictive modeling can help improving the selection of candidates for the endoscopic correction of VUR and developing personalized treatment tactics.

A comprehensive review on hydrogel materials in urology: Problems, methods, and new opportunities.

Hydrogel materials provide an extremely promising group of materials that can find an increasingly wide range of use in treating urinary system conditions due to their unique properties. The present review describes achievements to date in terms of the use and development prospects of hydrogel materials applications in the treatment and reconstruction of the urinary system organs, which among others include: hydrogel systems of intravesical drug delivery, ureteral stents design, treatment of vesicoureteral reflux, urinary bladder and urethral defects reconstruction, design of modern urinary catheters and also solutions applied in urinary incontinence therapy (Figure 4). In addition, hydrogel materials find increasingly growing applications in the construction of educational simulation models of organs and specific conditions of the urinary system, which enable the education of medical personnel. Numerous research efforts are underway to expand the existing treatment methods and reconstruction of the urinary system based on hydrogel materials. After conducting the further necessary research, many of the innovative solutions developed to date have high application potential.

Continence management in children with severe caudal regression syndrome: role of multidisciplinary team and long-term follow-up.

Caudal regression syndrome (CRS) is a rare congenital abnormality including orthopedic deformities, urological, anorectal, and cardiac malformations. The clinical spectrum of CRS varies in severity, therefore multiple surgeries and complex medical care may be required with the efforts and support of a multidisciplinary team to ensure the most accurate treatment and the best outcome. The aim of our retrospective study was to evaluate the role of a multidisciplinary treatment and the long-term outcome in patients with severe CRS. Clinical, surgical and psychological data were collected for all patients with diagnosis of CRS, treated at our Pediatric Hospital from January 1995 to December 2020. Patients with a severe form of CRS according to Pang's classification were included in the study. All patients have been followed by a multidisciplinary team composed by urologists, neurosurgeons, neonatal and digestive surgeons, orthopedic surgeon, physiatrists and psychologists. On admission, patients were screened for CRS with sacrum, spine and legs X-ray, spine MRI, renal ultrasound, voiding cystography and urodynamic, and renography. Clinical data about bowel function were evaluated. During the study period, 55 patients with CRS were treated at our Institution. Six out of 55 (10.9%), presented with severe form of CRS (5 pts with type 1; 1 pt, with type 2) and represent our study group. Diagnosis of severe CRS was made at birth because of the typical deformities of the pelvis (fusion of the iliac wings), and of the lower extremities (undeveloped legs with flexion of the knees, clubfoot). All patients presented with neurogenic bladder, 4/6 (66.6%) with vesicoureteral reflux (VUR) and 2/6 (33.3%) with renal agenesia and contralateral ectopic hypoplastic kidney. Bowel symptoms occurred in 5/6 pts (83.3%). All patients were started with an earlier clean intermittent catheterization (CIC) regimen. In 3 patients oxybutynin has been effective or well tolerated, while in other 3 onabotulinumtoxin A has been used. Vesicoureteral reimplantation has been performed in 1 patient, 2 required endoscopic treatment of VUR. On long-term, 2 patients required bladder augmentation with ileum and appendicostomy (Mitrofanoff). Low adherences in CIC have been observed in three patients, mainly at puberty. Two patients presented with chronic renal failure. One patient reported suicide proposal. Regarding social life, only one is regularly performing sport activity. CRS is characterized by maldevelopment of the caudal half of the body with variable involvement of the gastrointestinal, genitourinary, skeletal, and nervous systems. Management of CRS includes a wide variety of interventions to address the full spectrum of possible anatomical abnormalities. Hence, a multidisciplinary team is also mandatory for a correct bladder and bowel management, in order to maintain continence and preserve renal function, improve quality of life and increase self-esteem.

Modified unilateral periureteral injection technique in the treatment of patients with high-grade vesicoureteral reflux: A study of primary findings

ObjectiveAlthough endoscopic treatment has been used by many pediatric urologists for the treatment of vesicoureteral reflux (VUR), it has no considerable success in high-grade VUR. We aimed to describe the primary outcomes of unilateral periureteral injection technique (PIT), as well as bilateral PIT in high-grade VUR. MethodsIn this prospective study, we examined 92 ureters in 45 boys and 40 girls from February 2010 to May 2018. Bilateral PIT and unilateral PIT were applied in 67 and 25 refluxing units, respectively. In the unilateral PIT, the subureteral injection site was only at the 5- or 7-o'clock position. However, in the bilateral PIT, the subureteral injection sites were at 5- and 7-o'clock position. Pre- and post-operative reflux grades were evaluated by voiding cystourethrography 6 months after surgery. ResultsSeven patients had bilateral reflux. Overall, 75 (81.5%) ureters showed Grade IV VUR, while 17 (18.5%) had primary Grade V VUR. The mean age of the subjects was 39.2 months. In unilateral PIT ureters, VUR was resolved in 23 (92.0%) refluxing units. It was downgraded to Grade III in one ureter (4.0%) and to Grade II in another ureter (4.0%). In addition, in bilateral PIT cases, VUR was resolved in 60 (89.6%) ureters; it downgraded to Grades II and III in 3 (4.5%) and 4 (6.0%) refluxing units, respectively. ConclusionUnilateral PIT can be highly effective in the treatment of selected ureters of high-grade VUR. However, further studies are needed to confirm our results.

Does pre-fellowship experience alter success rates of endoscopic treatment of vesicoureteral reflux during pediatric urology fellowship?

Learning curve is a well-known factor that affects the success rate of endoscopic injection for vesicoureteral reflux (VUR). To our knowledge, the significance of pre-fellowship training has not been studied. In the present study, our aim was to investigate the effect of pre-fellowship training on the endoscopic treatment success rates of pediatric urology fellows. A total of 78 patients aged 2-16 years (132 renal units) who underwent subureteric injection for the treatment of primary VUR by four pediatric urology fellows between 2014 and 2020 were retrospectively evaluated. Fellows were grouped into two as experienced and non-experienced according to the presence of pre-fellowship experience (defined as a minimum of 20 procedures). Patients in both groups were divided into two subgroups as non-dilating (grade I-II) and dilating VUR (grade III-V). Also, the change in success rate throughout the fellowship was analyzed. HIT or Double HIT method was used in all interventions. Experienced fellows carried out subureteric injection in 54 (40.9%) renal units while non-experienced fellows performed in 78 (59.1%). There was no success rate difference between experienced and non-experienced fellow groups in non-dilating VUR (100% vs. 88%, respectively p=0.268), whereas the success rate of the experienced group was significantly higher in dilated VUR (78.9% vs. 50.9%, p=0.006). Moreover, the amount of material used in the treatment of non-dilating VUR were similar between two fellow groups (0.6ml vs. 0.6ml, p=0.500), while experienced group achieved higher success rates in dilating VUR by statistically significant less amount of injected volume (0.7ml vs. 0.9ml, p=0.026).Overall complete VUR resolution rates were similar throughout the fellowship period in the experienced fellows (81.5% vs. 88.9%, p=0.444), while it significantly increased in the non-experienced group implicating the completion of the learning curve (51.3% vs. 74.4%, p=0.035). There has been no published reports on the effect of pre-fellowship experience on subureteric injection success. While many researchers reported on the importance of learning curve, various studies assessed the effect of injected volume on success rate implicating contradictory results. Furthermore, others indicated that the ideal technique providing accurate needle placement and obtaining proper depth during injection which is associated with surgical experience is more important than the injected volume in achieving success. Our results implicate that similar success rates in non-dilating VUR can be achieved regardless of previous subureteric injection training. However, higher failure rates may be expected when the procedures are performed by non-experienced pediatric urology fellows at the beginning of their fellowship in dilating VUR.

MP17-20 THE NATURAL HISTORY OF CHILDREN WITH ANTENATAL HYDRONEPHROSIS AND ASYMPTOMATIC VESICOURETERAL REFLUX INCLUDING VCUG ORDERING PRACTICES

You have accessJournal of UrologyCME1 May 2022MP17-20 THE NATURAL HISTORY OF CHILDREN WITH ANTENATAL HYDRONEPHROSIS AND ASYMPTOMATIC VESICOURETERAL REFLUX INCLUDING VCUG ORDERING PRACTICES Jeremy Goodman, Walid Farhat, Fardod O'Kelly, Jennika Finup, Ryan McAdams, Kara Gill, and Matthew W. Harer Jeremy GoodmanJeremy Goodman More articles by this author , Walid FarhatWalid Farhat More articles by this author , Fardod O'KellyFardod O'Kelly More articles by this author , Jennika FinupJennika Finup More articles by this author , Ryan McAdamsRyan McAdams More articles by this author , Kara GillKara Gill More articles by this author , and Matthew W. HarerMatthew W. Harer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002550.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the last two decades, there has been a shift towards more conservative management of vesicoureteral reflux (VUR). Although there are multiple areas of consensus, the current literature is marked by controversy and divergent guidelines regarding VUR imaging, screening, and treatment. Furthermore, the practice of ordering voiding cystourethrograms (VCUG) continues to be common, particularly in infants with a history of antenatal hydronephrosis. Herein, we sought to examine inter-departmental VCUG ordering practices, and subsequent rates of VUR in infants with antenatal hydronephrosis (ANH) in a large US tertiary referral hospital. METHODS: A single academic center radiology database was used to identify all infants with documented ANH that underwent a VCUG within the first 6 months of life. Data relating to ANH, VCUG findings, VCUG requests, and ordering services were extracted from the electronic health record and analyzed. RESULTS: 627 infants with ANH (207 bilateral) had a VCUG performed between 2015-2019, of which 143 (23%) confirmed VUR (bilateral in 66; with 59.6% male, mean age 2.65 months and 40.4% female, mean age 2.8 months). Overall, pediatric urology was responsible for the highest number of VCUG requests (70%), followed by nephrology (10%), pediatrics (9%), neonatology (8%), and family medicine (2%). However, in infants with low grade hydronephrosis (SFU grades I/II), 60% of VCUGs were requested and obtained by pediatrics, 18% by pediatric urology, 12% by nephrology, and 10% by family medicine. Most infants with VUR (70%; 100/143) had a follow-up VCUG scan was performed, which was done at a mean of 6 months (Range: 1-4 years). In infants with confirmed VUR and a subsequent follow-up VCUG, 33% (30/100) had resolved spontaneously (mean follow-up interval and age of 6 months, and 4.2 years respectively), 21% (21/100) underwent operative interventions, and 46% (46/100) were managed without any surgical intervention. CONCLUSIONS: Most asymptomatic patients (77%) with a history of ANH do not have evidence of VUR on VCUG , however, VCUGs continue to be ordered in infants diagnosed with ANH irrespective of symptoms, with pediatricians more likely to order VCUG for lower grades of hydronephrosis. As VUR management has become more conservative, we recommend abstaining from requesting VCUGs in infants with asymptomatic ANH and to follow an informed, shared decision-making model based on intent to treat. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e294 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremy Goodman More articles by this author Walid Farhat More articles by this author Fardod O'Kelly More articles by this author Jennika Finup More articles by this author Ryan McAdams More articles by this author Kara Gill More articles by this author Matthew W. Harer More articles by this author Expand All Advertisement PDF DownloadLoading ...

ПРЕДИКТОРЫ ЭФФЕКТИВНОСТИ ЛЕЧЕНИЯ ПУЗЫРНО-МОЧЕТОЧНИКОВОГО РЕФЛЮКСА У ДЕТЕЙ

The article presents a modern view on the prognostic factors of spontaneous resolution and effectiveness of treatment of children with vesicoureteral reflux (VUR). The most frequently used predictors of successful treatment of VUR (grades of reflux, distal ureteral diameter ratio to the distance of the lumbar vertebrae, reflux induction phase on mictional cystourthrography), delayed removal of contrast from the upper urinary tract, gender, age, antenatal hydronephrosis). Methodology, statistical significance, advantages, disadvantages of the described prognostic factors are analyzed.

Vesicoureteral Reflux in Children with Urinary Tract Infections in the Inpatient Setting in Taiwan.

PurposeChildren with vesicoureteral reflux (VUR) are at an increased risk of recurrent urinary tract infections (UTIs). Early detection and treatment of VUR are important to prevent renal function impairment. Therefore, the aims of this study were to determine the epidemiology of VUR and to identify clinical factors associated with VUR in Taiwanese children with a first documented UTI.Patients and MethodsWe conducted this nationwide retrospective study using the Longitudinal Health Insurance Database 2010. Children ≤6 years of age who were admitted and received intravenous antibiotics for a newly diagnosed UTI were included. Multivariate logistic regression analysis was used to identify independent factors associated with VUR.ResultsOverall, 388 (10.2%) of the children had VUR. The median (interquartile range) age at diagnosis of VUR was 0.5 (0.3–1.3) years. Among the children with VUR, the age at first UTI and the age at diagnosis of VUR were significant lower in the males than in the females. Age ≤1 year at the first UTI (odds ratio (OR), 1.3; 95% confidence interval (CI): 1.0–1.7), renal agenesis and dysgenesis (OR, 4.1; 95% CI: 1.3–13.1), hydronephrosis (OR, 2.2; 95% CI: 1.7–2.9), duplex collecting system/ectopic kidney/ectopic ureter (OR, 13.0; 95% CI: 8.1–20.8), neuropathic bladder (OR, 4.7; 95% CI: 2.0–11.1) and spina bifida (OR, 5.9; 95% CI: 1.3–27.8) were independent factors for VUR.ConclusionThe children with VUR were more likely to have small kidneys and progression to end-stage renal disease. VUR was common in the children with a UTI and who were ≤1 year of age. Clinicians should arrange ultrasound to diagnose urinary tract anomalies. Infants with urinary tract anomalies, neuropathic bladder and spina bifida should receive further voiding cystourethrography to diagnose VUR early, as this may help to prevent renal damage.