Unilateral Vesicoureteral Reflux Research Articles

Development and multi-institutional validation of a deep learning model for grading of vesicoureteral reflux on voiding cystourethrogram: a retrospective multicenter study

Voiding cystourethrography (VCUG) is the gold standard for the diagnosis and grading of vesicoureteral reflux (VUR). However, VUR grading from voiding cystourethrograms is highly subjective with low reliability. This study aimed to develop a deep learning model to improve reliability for VUR grading on VCUG and compare its performance to that of clinicians. In this retrospective study in China, VCUG images were collected between January 2019 and September 2022 from our institution as an internal dataset for training and 4 external data sets as external testing set for validation. Samples were divided into training (N=1000) and validation sets (N=500), internal testing set (N=168), and external testing set (N=280). An ensemble learning-based model, Deep-VCUG, using Res-Net 101 and the voting methods was developed to predict VUR grade. The grading performance was assessed using heatmaps, area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy, and F1 score in the internal and external testing set. The performances of four clinicians (2 pediatric urologists and 2 radiologists) with and without the Deep-VCUG assisted to predict VUR grade were explored in external testing sets. A total of 1948 VCUG images were collected (Internal dataset=1668; multi-center external dataset=280). For assessing unilateral VUR grading, the Deep-VCUG achieved AUCs of 0.962 (95% confidence interval [CI]: 0.943-0.978) and 0.944 (95% [CI]: 0.921-0.964) in the internal and external testing sets, respectively, for bilateral VUR grading, the Deep-VCUG also achieved high AUCs of 0.960 (95% [CI]: 0.922-0.983) and 0.924 (95% [CI]: 0.887-0.957). The Deep-VCUG model using voting method outperformed single model and clinician in terms of classification based on VCUG image. Moreover, Under the Dee-VCUG assisted, the classification ability of junior and senior clinicians was significantly improved. The Deep-VCUG model is a generalizable, objective, and accurate tool for vesicoureteral reflux grading based on VCUG imaging and had good assistance with clinicians to VUR grading applicability. This study was supported by Natural Science Foundation of China, "Fuqing Scholar" Student Scientific Research Program of Shanghai Medical College, Fudan University, and the Program of Greater Bay Area Institute of Precision Medicine (Guangzhou).

Evaluation of the results of urodynamic studies in patients with vesicoureteral reflux.

To investigate urodynamic abnormalities associated with vesicoureteral reflux (VUR) in toilet-trained children. The data of 157 children who were diagnosed with vesicoureteral reflux and referred to our hospital between 2013 and 2022 were retrospectively examined. The urodynamic parameters were analyzed and correlated with age, gender, lower urinary tract symptoms (LUTS), reflux severity, and laterality. Overall, 131 (83.4%) patients had abnormal urodynamic findings with a male-to-female ratio of 1:1.4. The most common pathological finding was detrusor overactivity (DO), identified in 101 (64.3%) patients, followed by dysfunctional voiding (DV) in 74 (50.3%) patients. Children with VUR grades II and III exhibited a greater percentage of abnormal urodynamic findings than children with grades IV and V. The prevalence of DO was higher in children younger than 10 years old with unilateral and lower-grade VURs. DV was more frequent in children older than 10 years, with bilateral VUR, and higher grade VUR. The prevalence of LUTS, bowel and bladder dysfunction (BBD), and urinary tract infection (UTI) was higher among children with abnormal urodynamic findings. Children with VUR have a high incidence of urodynamic disorders. Urodynamic dysfunction may contribute to the pathogenesis of VUR, especially in mild cases.

Posterior Urethral Valves, Unilateral Vesicoureteral Reflux, and Renal Dysplasia (VURD) Syndrome: Long-Term Longitudinal Evaluation of the Kidney Function.

The presence of unilateral vesicoureteral reflux (VUR), and renal dysplasia associated with posterior urethral valves (PUV) (VURD syndrome) was believed to represent a pressure-released pop-off mechanism protecting kidney function. We aimed to investigate its role with respect to long-term kidney function in a cross-sectional and longitudinal analysis. We compared the iohexol glomerular filtration rate (GFR) measured at 5 (GFR5) and 10 (GFR10) years of age in children with (Group A) and without (Group B) VURD syndrome, who underwent PUV resection under 2 years of age. VURD syndrome was diagnosed in cases of unilateral loss of kidney function (<15% on nuclear medicine test) associated with ipsilateral grade IV-V VUR. VURD syndrome was diagnosed in 16 (12.8%) out of 125 patients who met the inclusion criteria. While the median GFR5 was similar in the 2 groups [Group A: 87.3 (74.7-101.2) mL/min/1.73 m2 vs. Group B: 99.6 (77-113) mL/min/1.73 m2, p-value: 0.181], the median GFR10 values were significantly lower in children with VURD syndrome [Group A: 75.7 (71.2-85.9) mL/min/1.73 m2 vs. Group B: 95.1 (81.2-114.2) mL/min/1.73 m2, p-value: 0.009]. Similar results were obtained in a longitudinal analysis of the children with GFR measurement available both at 5 and 10 years of age [GFR5 in Group A: 93.1 (76.9-103.5) mL/min/1.73 m2 vs. Group B: 97.5 (80-113) mL/min/1.73 m2, p-value: 0.460; GFR10: Group A: 71.9 (71.9-85.9) mL/min/1.73 m2 vs. Group B: 94.8 (81.5-110.6) mL/min/1.73 m2, p-value: 0.024]. In conclusion, VURD syndrome does not show a protective role in kidney function preservation. On the contrary, it seems to be associated with a deterioration of the kidney function on a long-term follow-up.

Posterior Urethral Valve: Factors Affecting the Renal Outcome

Background: Posterior urethral valve (PUV) is the most common cause of lower urinary tract obstruction in male children with associated sequlae. Different factors, such as age at presentation, initial and nadir serum creatinine, renal parenchymal echogenicity on initial USG, vesicoureteric reflux (VUR) , recurrent UTI, bladder dysfunction and the presence or absence of pop-off mechanism like VURD have significant impact on ultimate renal outcome. The main aim of the study was to observe the effects of different prognostic factors like age of presentation and preoperative VUR of the PUV respondents on postoperative long term renal outcome as well as changes of renal function status on the basis of initial and postoperative serum creatinine level in our settings. Material Methods: This was a quasi-experimental study and conducted in the Department of Pediatric urology of Bangladesh Shishu Hospital and Institute, Dhaka. We enrolled 58 male children of different ages having posterior urethral valve, who were admitted in the pediatric urology department from July,2018 to Dec,2021. Results: Total 58 patients included in our study. Among all patients 53.4% were aged between 1 month to 1 year, 39.7% of them were more than 1 year old and 6.9% of them were neonates. Among 31 respondents, 32.3 % had poor renal function 35.5 % of them also had moderately impaired renal function. Again, out of 23 respondents, 30.4% had poor renal function 6% had moderately impaired renal function. The relation between age category and postoperative renal function status (On the basis of postoperative eGFR) of the posterior urethral valve respondents were statistically not significant. Patients who had no VUR, 66.7% of them had normal renal function, 25% had moderately impaired renal function and 8.3% had poor renal function. Respondents who had bilateral VUR, 55% of them had poor renal function and 35% had moderately impaired renal function. Among respondents who had unilateral VUR, 28.6% of them had poor renal function and 28.6% had moderately impaired renal function but 42.9% had normal renal function. The relation between preoperative VCUG findings and postoperative long term renal function status of the PUV patients were statistically significant. 7 (100%) respondents who had preoperative abnormal renal function, more than 71.4% of them had returned to normal renal function after operative procedure. But abnormal renal function was present in 2 (28.6%) patients during follow up. In our study we found 29.3% of our patients had poor renal outcome and 29.3% patients had moderately impaired renal function within the mean follow up period of 19.33±12.38 months (ranges from 9months to 4 years). Conclusion: Our research highlights the significance of age at presentation, despite its statistically negligible effect on long-term renal outcomes. However, among the children with PUV following valve ablation and with a long-term follow-up, beginning serum creatinine and the presence of various types of VUR on initial VCUG had a significant effect (p.05) on postoperative renal function on the basis of serum creatinine.

A novel endoscopic approach for management of hutch diverticulum concomitant vesicoureteral reflux with dextranomer/hyaluronic acid copolymer injection

There are various treatment options for symptomatic bladder diverticulum, including robotic-assisted laparoscopic bladder diverticulectomy, open and endoscopic techniques. But, to date, the optimal surgical technique remains unclear. To present the preliminary long-term follow-up results of a novel technique of dextranomer/hyaluronic acid copolymer (Deflux) plus autologous blood injection for correction of hutch diverticulum in patients with concomitant vesicoureteral reflux (VUR). We retrospectively reviewed four patients who had hutch diverticulum with concomitant VUR and had undergone submucosal Deflux following autologous blood injection. Patients with neurogenic bladder, posterior urethral valve, or voiding dysfunction were excluded from the study. Success was defined as the resolution of the diverticulum, hydronephrosis, and hydroureter on ultrasonography at a 3-month follow-up and long-term symptom-free period. Four patients with hutch diverticula were included. The median age at the time of surgery was 6.1 (range 3-8) years. Three of them had unilateral VUR, and one had bilateral VUR. During the procedure, a mean of 0.625ml Deflux plus a mean of 1.25ml autologous blood were injected submucosally for correction of VUR. Additionally, a mean of 1.62ml Deflux plus a mean of 1.75ml autologous blood were injected submucosally to occlude the diverticulum. The median follow-up was 4.6 (range 4-8) years. This method had excellent success in all patients in the current study with no postoperative complications such as febrile urinary tract infection, or diverticulum, hydroureter, or hydronephrosis in follow-up ultrasounds. Submucosal injection of Deflux plus autologous blood injection can be a successful endoscopic intervention for treatments of hutch diverticulum in patients with concomitant VUR. Deflux injection can be a simple and cost-effective technique.

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.

The impact of reflux pressure on renal scarring in children with sterile vesicoureteral reflux

Vesicoureteral reflux (VUR) is a complex disease as patient spectrum is variable. Some cases struggle with recurrent febrile urinary tract infections (UTI) and end-up with renal scars despite intervention. While others suffer no clinical problems and need no treatment. The detrimental effect of VUR on kidneys depends on many factors like grade of reflux, detrusor pressure, and presence of voiding dysfunction. The adverse effects of sterile VUR on kidneys is still under discussion. Thus, we assessed the impact of detrusor pressure at VUR onset on renal scarring in children with sterile reflux. We retrospectively reviewed the five years follow-up data of 38 children who had unilateral VUR without UTI under treatment. No febrile or afebrile UTIs were detected during the follow-up in any children. All children were assessed with annual video-urodynamics and renal scintigraphy for five consecutive years. The detrusor pressure at VUR onset, grade of VUR, presence of involuntary detrusor contractions, bladder capacity and the presence of renal scaring were recorded. All VURs were recorded during the voiding phase and children with VUR during the filling phase were excluded from the study. In the first line of video-urodynamic studies, the mean detrusor pressure at VUR onset was 24.3±14.8cm/H2O (median 34.5cm/H2O, min: 6 - max: 47). There was no relation between boys and girls regarding median detrusor pressure at VUR onset (p=0.356). Eventually, 22 (57.9%) children developed renal scars and ended up with surgery. There was no relation between scar development and age at first presentation (p=0.888) The cut-off value for detrusor pressure at VUR onset was noted as 26cm/H2O (AUC: 0.849 [p<0.01], Figure). In children who developed renal scars eventually, the median detrusor pressure at VUR onset was significantly higher (p<0.01). The detrimental effect of VUR on kidneys is associated with recurrent infections, bladder dysfunction, and detrusor pressure. Dispute over risk of renal scarring in patients with sterile VUR still continues. Children in whom VUR start at higher voiding pressures suffer more renal scars. The threshold of voiding detrusor pressure for risky patients is identified as 26cm/H2O. It is true that patients suffering recurrent febrile UTIs have higher risk of developing renal scarring. However, the impact of sterile reflux should not be underestimated, since renal scars due to sterile reflux may develop in patients under antibiotic prophylaxis.

Renal function damage in children with duplex kidneys

PurposeTo evaluate renal function damage in children with duplex kidneys.MethodsA total of 355 duplex kidneys, 110 urinary tract infection (UTI) kidneys without abnormalities, and 104 kidneys with primary unilateral vesicoureteral reflux (VUR) were reviewed. Clinical data including age at diagnosis, body weight, history of UTI, ureteroceles, ectopic ureteral opening, VUR grade, serum creatinine level, cystatin C level, renal scarring, split renal function in dimercaptosuccinic acid scans, and effective renal plasma flow (ERPF) were analyzed.ResultsDuplex kidneys had a higher grade of VUR and renal scarring. Split renal function in unilateral duplex kidneys (45.58 ± 12.85%) was much lower than that in contralateral duplex kidneys (56.33 ± 11.90%) and controls (50.00 ± 11.38%) (P < 0.001 and P = 0.014, respectively). Both left and right split renal functions in bilateral duplex kidneys were similar to those ipsilateral to the controls (P = 0.906 and P = 0.932, respectively). However, the total ERPFs in the left, right, and bilateral duplex kidneys were significantly lower than that in the control group (P = 0.003, P = 0.001, and P = 0.003, respectively). The total ERPFs in the left and right unilateral duplex kidneys were similar. ERPF in unilateral duplex kidneys (106.70 ± 48.05 mL/min/m2) was significantly lower than that in contralateral duplex kidneys (150.18 ± 49.01 mL/min/m2) or those ipsilateral to controls (145.98 ± 41.16 mL/min/m2) (P < 0.001 and P < 0.001, respectively).ConclusionDuplex kidneys are usually accompanied by a higher grade of VUR, more severe renal scarring, and renal function impairment. Split renal function in duplex kidneys often declines significantly. Notably, the evaluation of split renal function in bilateral duplex kidneys should be performed cautiously.

Framing the picture: Impact of radiographic imaging on parental vesicoureteral reflux management preferences

Given the variety of treatment options for vesicoureteral reflux (VUR), shared decision making between clinicians and parents is essential. Despite its importance, shared decision making is limited by the framing effect - people process the same information differently depending on how it is presented. Studies have also demonstrated that showing patients their radiology images can impact behaviors. In this pilot study, we sought to determine if showing parents radiographic images could serve as a framing tool that impacts the decision of whether to pursue surgery, endoscopic intervention, or conservative management for VUR. We designed a survey instrument which provided background on VUR and a hypothetical scenario of a 2-year-old child with VUR who had a breakthrough febrile urinary tract infection (UTI). Guideline-concordant management options were presented: (1) change antibiotics, (2) endoscopic management, or (3) open or laparoscopic surgery. All options were similarly presented regarding risks, benefits, and length of stay. Respondents were randomized into a group with no image accompanying the clinical scenario or a group which had a labeled image of a voiding cystourethrogram (VCUG) demonstrating unilateral VUR. Respondents also answered demographic and health experience questions. The instrument was published on Amazon's Mechanical Turk online work interface which provides reliable and validated results in VUR experiments. Parents aged 18-60 years old were eligible. Responses with failed attention questions, duplicate internet addresses, or submission times <1 or >30min were disqualified. Data were analyzed using t-test, chi-square, and multinomial logistic regression. Sensitivity analyses were performed after excluding all responses submitted under 2, 3, and 5min. There were a total of 914 responses, 426 met inclusion criteria. The presence or absence of a VCUG image did not result in a statically significant difference in the management decision (p=0.081). Multinomial logistic regression demonstrated that prior UTI experience influenced the management decision (p=0.027). Sensitivity analyses revealed a significant difference in the management decision when excluding responses <5min (p=0.039). In this analysis, there was no statistically significant framing effect by radiographic images on parental management decision for VUR. Multinomial analyses suggested that prior experience with UTI has an impact on VUR management decisions. These results need to be considered within the limitations of this pilot study - the respondents were given a hypothetical clinical scenario and the survey instrument cannot replace an in-office discussion. Further analyses on framing and its role in pre-operative counseling is warranted.

Distinction of Degrees of Ischemic Kidney Parenchymal Injury in Children with Congenital Vesicoureteral Reflux (According to Enzymological Criteria)

The objective: to evaluate the possibility of determining the levels of activity of N-acetyl-β-D-glucosaminidase B (NAG B) in urine as an enzymological marker of differentiation of ischemic damage to the renal parenchyma in children with congenital vesicoureteral reflux (VUR). Materials and methods. 49 children aged 1 to 15 years with a verified diagnosis of unilateral VUR and 25 practically healthy children were examined. NAG B activity in urine was determined before reconstructive treatment. The limits of the reference intervals of the levels of enzyme activity in the urine of healthy children were calculated by the formula M±1.5σ. According to the personalized analysis the patientswere divided into 3 groups: group 1 – 13 patients (the levels of NAG activity in the urine are registered from 0.8 to 2.3 units); group 2 – 14 patients (the levels of NAG activity in the urine – 2.4 to 4.5 units); group 3 – 22 patients (the levels of NAG activity in urine – 4.6 to 10.5 units. Results. In the urine of healthy children, the activity of NAG B averages 1.56±0.096 units, σ=0.48, reference levels are recorded from 0.8 to 2.3 units. In the urine of the 1st group, the levels of NAG B activity are equal to 1.61±0.13 units correspond to the control values and are evaluated as zero degree of ischemic damage of a renal parenchyma; in the urine of the 2nd group – 3.97±0.17 units exceed the average control values by 1.6–2.9 times and are assessed as moderate or I degree of ischemic damage to the renal parenchyma; in the urine of the 3rd group – 7.50±0.39 units exceed the average control values by 3 times or more and are assessed as severe or II degree of ischemic damage to the renal parenchyma (p2,3-1&lt;0,001; p3-2&lt;0.001). Conclusions. The expediency of determining the activity levels of N-acetyl-β-D-glucosaminidase B in the urine of children with congenital vesicoureteral reflux, as an enzyme with pronounced renospecific properties and as enzyme marker for differentiating the degrees of ischemic damage (0, I, II) of the renal parenchyma was established. Activity levels of NAG B can be used as well for timely prevention of the development and progression severe complications through the timely appointment of the appropriate optimal corrective therapy.

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results.

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

Urinary neutrophil gelatinase-associated lipocalin might be an associated marker for anticipating scar formation in children with vesicoureteral reflux

Introduction: Vesicoureteral reflux (VUR) is considered as the most common urogenital abnormality occurring in children. There is no reliable and routine clinical test that is non-invasive and rapid for recognizing the renal scars from VUR. Objectives: Urine neutrophil gelatinase-associated lipocalin (uNGAL) can be the best indicator for early diagnosis of scar formation in children with VUR. Patients and Methods: Children with primary VUR admitted to Hamadan’s Besat hospital from March to December 2020 were included in this cross-sectional study. A dimercaptosuccinic acid (DMSA) scan was employed to assess all subjects in order to diagnose scar formation at least 180 days after the last episode of urinary tract infection (UTI). Additionally, uNGAL and its ratio to urine creatinine (uCr) levels were measured. Results: During the study, all 63 cases (male/female, 13.50) with VUR were included for further evaluation. The mean age of the patients was 59.1 ± 34.7 months (range 2 to 132 months). Twelve subjects suffered from unilateral VUR, while bilateral VUR inflicted 51. According to the disease severity, nine patients had mild, 35 had moderate, and 19 had a severe form of VUR. No significant difference was observed between patients with (n = 31) and without (n = 32) renal scars regarding mean levels of the uNGAL and uNGAL/uCR ratios (P&gt;0.05). Conclusion: We found no significant difference between the groups with and without the renal scar in terms of biomarker levels.

Experience of Maharaj Nakorn Chiang Mai Hospital in extravesical ureteral reimplantation for vesicoureteral reflux in pediatric patients

Objective: The most commonly used technique for vesicoureteral reflux (VUR) treatment in pediatric patients in Maharaj Nakorn Chiang Mai Hospital is extravesical ureteral reimplantation (EUR). This report describes our experience of clinical outcomes of this technique. Materials and Methods: A total of 30 children underwent EUR for unilateral and bilateral VUR between July 2007 and June 2015. We retrospectively reviewed their medical records. Patient characteristics, operative time, duration of catheter drainage, length of postoperative hospital stay, and perioperative complications were evaluated. Results: Twenty-two boys and 8 girls with a mean age of 4.4 years (range, 0.5-14.6) were included in the study. Reflux was graded 1 to 5. Fourteen unilateral and 16 bilateral procedures were performed. A Pfannenstiel incision was implemented in the first 20 cases and inguinal incision in the last 10 cases. Mean operative time was 115.5 minutes. Mean duration of catheter insertion was 5.7 days. Mean length of postoperative hospital stay was 6.1 days and mean estimated blood loss was 28.7 ml. Overall success rate was 90%. One patient (3.3%), developed a post- operative urinary tract infection, while 3 cases had persistent VUR after surgery. Acute urinary retention occurred in 1 patient (3.3%) on postoperative day 4 but following catheterization the patient was able to urinate by day 7. Conclusion: EUR for the treatment of VUR is a simple, safe, and effective procedure. The prevalence of postoperative urinary retention in bilateral reimplantation is low and transient. The inguinal approach is a viable option and as effective as classical procedures.

Treatment of vesicoureteric reflux in children

Aim. To study the efficacy of endoscopic correction of vesicoureteric reflux in children using bulk synthetic material.Material and methods. From 2016 to 2020, we studied the results of treatment of 63 children with vesicoureteric reflux. The children ranged in age from 6 months to 17 years. The degree of vesicoureteral reflux was as follows: grade I was observed in 2 (3.1%) patients, grade II in 16 (25.3%), grade III in 30 (47.6%), grade IV in 13 (21.98%), and grade V in 2 (3.1%). Among 63 patients with CKD, grade I was found in 26 (41.3%), grade II - in 16 (25.4%); grade III - in 13 (20.6%); grade V - in 2 (3.1%). - III stage - 13 (20,6%); IV stage - 8 (12,7%); IV stage - 4 (12,6%). - (12,7%), and there were no patients with V stage of CKD were absent. Unilateral vesicoureteric reflux was noted in 45 (71.4%) children, bilateral - in 18 (28.5%) children. Endoscopic intravesical correction of vesicoureteral reflux was performed by suburethral injection of “Dam+”.Results and discussion. Summarizing the results of our study, it should be noted that positive results were achieved concerning the relief of urinary tract infection, elimination of urine outflow from the upper urinary tract, improvement of renal function after PMR correction using “Dam+”. Positive results of VUR correction amounted to 75,01%.Conclusions. Endoscopic correction of VUR is one of the effective and low-traumatic methods of treatment. Application of the biocompatible synthetic material “Dam+” in the correction of vesicoureteric reflux contributes to positive results.

Clinical profile of children with primary vesicoureteric reflux and its association with renal parenchymal scarring

Context: Vesicoureteric reflux (VUR) has been implicated in renal injury before birth as well as in postnatal occurrence of urinary tract infection (UTI) and further renal damage. About 30–49% of children with primary VUR may develop renal scarring called reflux nephropathy. About 5–10% of children with reflux nephropathy may progress to chronic kidney disease in late childhood. Objectives: The objectives of the study were to study the clinical profile of children with primary VUR and to assess the relationship with grades of primary VUR and renal parenchymal scarring. Materials and Methods: Fifty children of age 1 month–5 years, diagnosed to have Primary VUR, were included in this prospective observational study. Detailed history was taken; examination was carried out as per the study protocol. Investigations included urine analysis, renal function tests, urine culture, renal ultrasonography, micturating cystourethrogram, and 99mTc dimercaptosuccinic acid (DMSA) scintigraphy. For those who had UTI, DMSA was carried out after a minimum period of 6 months after UTI episode. Results: Among the 50 children, 21 (42%) were male and 29 (58%) were female with male-to-female ratio of 0.72:1. Mean age at diagnosis was 9 months, ranging from 1 to 40 months. The number of children presented with UTI was 43 (86%), and 7 children (14%) were asymptomatic and were evaluated in view of abnormality in prenatal ultrasound scan. Unilateral VUR was found in 21 patients (42%), and 29 patients (58%) had bilateral VUR. Of all 79 refluxing units (21 unilateral plus 58 bilateral), 4% had VUR of Grade I severity, 30% of Grade II, 34% of Grade III, 28% of Grade IV, and 4% of Grade V severity. Renal parenchymal scarring on DMSA scan was detected in 42 (54%) of 79 refluxing units including 33% of Grade II, 55% of Grade III, 71% of Grade IV, and 100% of Grade V refluxing units. Prevalence of scarring in complicated, recurrent, and simple UTI was 100%, 93%, and 22%, respectively. Conclusion: Risk of renal scarring increased progressively with increasing severity of primary VUR. Complicated and recurrent UTI were found to be statistically significant risk factors for renal scarring. Renal scarring was also seen in absence of UTI in a small percentage of children with primary VUR.

CLINICAL EXPERIENCE OF TRANSURETHRAL INJECTION USING DEXTRANOMER-HYALURONIC ACID COPOLYMER (Deflux®) FOR CASES OF SECONDARY VESICOURETERAL REFLUX AFTER URETEROCYSTONEOSTOMY

(Objective) We reviewed the clinical efficacy of transurethral Deflux® injection therapy (Deflux® injection therapy) in patients with secondary vesicoureteral reflux (VUR) after ureterocystoneostomy. (Methods) We retrospectively evaluated data for Deflux® injection therapy in 4 patients after ureterocystoneostomy with secondary VUR due to lower urinary tract dysfunction treated at this hospital from 2010 through 2018. The indications for surgery were febrile urinary tract infection or new renal scarring, and the outcomes of treatment with Deflux® injection therapy were evaluated. (Results) There were 2 male and 2 female patients. Three patients had unexplained lower urinary tract dysfunction, all patients were using clean intermittent catherization, and 3 patients had operated by the Cohen method for VUR. Preoperative examinations revealed that all patients had unilateral VUR, and reflux was assessed as Grade III in 1 patient and Grade IV in 3 patients. The median age at initial surgery was 12.8 years, and Deflux® injection therapy was performed unilaterally in all patients. Deflux® injection therapy was performed by a combined HIT/STING technique in 2 patients and by the HIT technique alone in 2 patients, with a median injection volume of 2.4 ml. The therapeutic outcome for initial Deflux® injection therapy was resolution of VUR in 1 patient (25%) and persistence of VUR in 3 patients. Treatment was repeated for 2 of the 3 patients with persistent VUR, and resolution was reported for 1 of these patients. (Conclusion) The initial success rate for Deflux® injection therapy in VUR with bladder dysfunction was a low 25%, suggesting that caution is required in choosing this treatment option.

Evaluation of Procalcitonin Serum Levels in Children Younger than Five Years Old with Urinary Tract Infection

Background: Children with vesicoureteral reflux (VUR) are posed to the danger of recurrent pyelonephritis, kidney scar and renal failure. Nowadays, the evaluation of VUR is carried out using different imaging methods that are accompanied with different limitations. Pediatricians usually look for other evaluation methods that are feasible, easy to implement and carries the least amount of danger to the patient. &#x0D; Objectives: The aim of this study was to investigate the level of serum Procalcitonin (PCT) as a predictor of VUR instead of the voiding cystourethrogram (VCUG).&#x0D; Methods: This case-control study was conducted from 2013 to 2014. One hundred and ten children younger than five years old were divided into two groups: (i) the case group with 76 children diagnosed with urinary tract infection (UTI) using urine culture test, and (ii) the control group with 34 healthy children. Serum levels of PCT were measured by a commercial kit. Demographic data were collected using a questionnaire and analyzed by software SPSS.&#x0D; Results: Of the samples, 69.1% of them had no VUR, 20% and 10.9% of the samples suffered from severe unilateral VUR and severe bilateral VUR, respectively. With regard to the level of serum PCT, 61.8% of the samples were positive. One-half of those samples (38 people) who was diagnosed to be healthy had a normal level of serum PCT. However, 30 people (88.2%) of the samples diagnosed to be healthy using VCUG had increased level of serum PCT. The positive and negative predictive values of the level of serum PCT were 44% and 90%, respectively. In this respect, 50% of the samples diagnosed by using level of serum PCT were false positive and 11.8% were false negative. The kappa score for the level of serum PCT was 0.3 (P &lt; 0.0001). The positive predictive value of the serum level of PCT for the female and male samples were 43% and 50% respectively.&#x0D; Conclusions: There was no statistically significant relationship between VUR and the serum level of PCT.

Critical analysis of the outcome of primary unilateral vesicoureteral reflux in a medium volume center

BackgroundVesicoureteral reflux (VUR) is a common finding in pediatric age group. Here in we explored the possible risk factors that affect the rate of resolution in patients with primary unilateral VUR under conservative treatment.MethodsBetween 2006 and 2014, we retrospectively evaluated all VUR patients and included only patients with primary unilateral VUR. Records were reviewed for patient age at diagnosis, antenatal history, patient gender, mode of presentation, side, and grade of VUR, associated hydronephrosis (HN) on renal ultrasound, presence of scarring and split function on dimercaptosuccinic acid (DMSA) scan. Clinical and radiological outcomes were assessed. Both univariate and multivariate analysis were conducted.ResultsA total of 68 patients with primary unilateral VUR were included (32 boys and 36 girls) with a mean age of 10 months (range 1–32). Antenatal HN was detected in 50% of patients. In 15 cases (22%), VUR was of high grade (IV–V). Associated HN was evident in 39 patients (57%). DMSA scans showed renal scarring in 16 patients (23%). After a mean follow-up of 7 years, VUR resolved in 49 patients (72%). Significant predictors for VUR resolution were VUR grade, DMSA split function and associated high-grade HN. High-grade HN with VUR was the only significant independent risk factor.ConclusionsThe rate of resolution in primary unilateral VUR under conservative treatment is significantly affected by VUR grade, DMSA split renal function and the presence of associated HN. Association of high-grade HN with VUR carries a low chance for spontaneous resolution.

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

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

Could the Implantation of Dextranomer/Hyaluronic Acid Cause the Elevation of Neuron-Specific Enolase in Children Treated for Vesicoureteral Reflux?

Background: Dextranomer/hyaluronic acid copolymer (Dx/HA) has been the most widely used bulking agent for the endoscopic treatment of vesicoureteral reflux. Case presentation: Here we report on a case of an 18-month-old male who underwent endoscopic treatment with Dx/HA for persistent high-grade unilateral vesicoureteral reflux (VUR). Three months later, due to the reappearance of contralateral VUR and indicated endoscopic treatment, a second cystoscopy was performed. A submucosal, well-vascularized mass localized on the left trigone and anteromedially to the left orifice was noted. Since it differed from the other similar implants previously detected on cystoscopy, it was misdiagnosed with a bladder tumor, indicating further evaluation. Extensive laboratory and imaging studies revealed normal findings, apart from high levels of neuron-specific enolase (NSE). A hypothesis made at that point was that the elevated level of NSE is due to the implantation of the Dx/HA. To test the hypothesis, two other healthy children previously treated with a Dx/HA implant were identified and their NSE levels measured. In both cases, the levels of NSE were elevated. Conclusion: The presented cases revealed that elevated levels of NSE are most likely due to a previous implantation of Dx/HA. This observation should be taken into consideration whenever there is a tentative diagnosis of bladder tumor following the endoscopic treatment of VUR with Dx/HA in a child.