Urethral Valves Research Articles

Posterior urethral valves: Role of prenatal diagnosis and long-term management of bladder function; a single center point of view and review of literature.

Posterior Urethral Valves (PUV) are the most common cause of lower urinary tract obstruction. More severe forms are detected early in pregnancy (mainly type I), while other forms are usually discovered later in childhood when investigating lower urinary tract symptoms. Bladder dysfunction is common and is associated with urinary incontinence in about 55% (0%-72%). Despite the removal of the obstruction by urethral valve ablation, pathological changes of the urinary tract can occur with progressive bladder dysfunction, which can cause deterioration of the upper urinary tract as well. For this reason, all children with PUV require long-term follow-up, always until puberty, and in many cases life-long. Therefore, management of PUV is not only limited to obstruction relief, but prevention and treatment of bladder dysfunction, based on urodynamic observations, is paramount. During time, urodynamic patterns may change from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure (valve bladder). In the past, an aggressive surgical approach was performed in all patients, and valve resection was considered an emergency procedure. With the development of fetal surgery, vesico-amniotic shunting has been performed as well. Due to improvements of prenatal ultrasound, the presence of PUV is usually already suspected during pregnancy, and subsequent treatment should be performed in high-volume centers, with a multidisciplinary, more conservative approach. This is considered to be more effective and safer. Primary valve ablation is performed after clinical stability and is no longer considered an emergency procedure after birth. During childhood, a multidisciplinary approach (pediatric urologist, nephrologist, urotherapist) is recommended as well in all patients, to improve toilet training, using an advanced urotherapy program with medical treatments and urodynamic evaluations. The aim of this paper is to present our single center experience over 30 years.

Congenital anomalies of the urethra

Congenital anomalies of the urethra are insufficiently covered in the literature, except for hypospadias and epispadias. Therefore, there is a significant gap in information on the diagnosis, classification and management of patients with such anomalies among practising physicians and researchers. Also, the urgency of studying this problem is due to the complexity of these malformations. This fact dictates the need for a very careful and correct approach to timely surgical treatment and subsequent rehabilitation, which will minimize the negative medical and social consequences of these anomalies. Taking these circumstances into account, key data on the most common congenital anomalies of the urethra were summarized in the form of a lecture material based on modern scientific advances. The following malformations of the urethra are considered as the main options: hypospadias; epispadias; urethral valves, obliterations, strictures, diverticula and cysts; Guerin's sinus; hypertrophy of verumontanum; agenesis of the urethra; urethral duplication; megalourethra; urethral fistulas; urethral polyp. Moreover, all types of anomalies are presented with illustrations of real clinical examples. The information from this study can be successfully used in the daily work for practising physicians of various profiles, scientific and pedagogical activities when teaching students at medical universities, residency training, postgraduate studies and in the courses of advanced training and professional retraining, as well as in conducting scientific research in this direction.

Urinary Ultrasound and Other Imaging for Ureteropelvic Junction Type Hydronephrosis (UPJHN).

Ultrasound is the main imaging study used to diagnose ureteropelvic junction (UPJ) obstruction. On ultrasound, abnormal dilatation of the pelvicalyceal system of varying degrees is seen, whereas the ureter is normal in caliber. A properly performed study provides essential information regarding laterality, renal size, thickness, and architecture of the renal cortex and degree of dilatation of the pelvicalyceal system. Doppler ultrasound may identify a crossing vessel, when present. This imaging method also has been used differentiating obstructive from non-obstructive hydronephrosis by renal arterial resistive index measurements. Abdominal radiographs may show soft tissue fullness, bulging of the flank, and displacement of bowel loops from the affected side. The voiding/micturating cystourethrogram helps exclude other causes of upper tract dilatation, including vesicoureteral reflux, urethral valves, and ureteroceles. Computerized Tomography angiography with multiplanar reformation and three-dimensional images may be used to depict suspected crossing vessels as a cause of UPJ obstruction in older children and adults. Magnetic Resonance Urography has progressed significantly in recent years due to the development of both hardware and software that are used to generate high-resolution images. This imaging technique currently allows for the detailed assessment of urinary tract anatomy, while also providing information regarding renal function, including differential renal function, and the presence or absence of obstructive uropathy.

Historia de la cirugía fetal

Los primeros procedimientos fetales considerados quirúrgicos fueron realizados en 1961, por Liley, al transfundir sangre a fetos con anemia por isoinmunización Rh. En 1974, se realizó la primera fetoscopia diagnóstica, en la Universidad de Yale, EE. UU. Un hito histórico sucede en 1981, cuando Harrison en la Universidad de California realizó por primera vez drenaje en un caso de mega vejiga causado por valva uretral; colocó, bajo control ecográfico, un catéter desde la vejiga a la cavidad amniótica. Por este hecho, se le reconoce como el ‘padre de la cirugía fetal’. En 1982, se reunieron especialistas de 5 países, vinculados a la cirugía fetal, y liderados por Harrison publicaron las primeras normas a regir en este campo nuevo de la medicina. Posteriormente, grupos colaborativos europeos revisaron las aplicaciones de esta cirugía, así como las normas éticas y de seguridad que debían ser prioritarias en estas técnicas. En el 2011, instituciones académicas y de ética de los EE. UU. reafirmaron los principios, ya reconocidos, en los que debían basarse los nuevos centros de alta calidad en cirugía fetal. En 2015, se establecieron las reglas para la innovación tecnológica y la investigación en este campo, remarcando la necesidad de crear los comités de ética. En el 2017, los especialistas involucrados, nuevamente convocados por organizaciones académicas de los EE. UU., emitieron opinión sobre el contexto global de esta cirugía, las obligaciones éticas, de infraestructura, implementación tecnológica, investigación conjunta y capacitación integral del equipo; remarcaron la necesidad de crear los comités de supervisión en estos centros. En América Latina, el desarrollo de la cirugía fetal se encuentra en una etapa intermedia, de acuerdo a los reportes actuales. En el Perú, se ha publicado artículos sobre los primeros casos de cirugía prenatal.

Management of Posterior Urethral Valves: An Outcome Analysis of Endoscopic Valve Fulguration

Posterior urethral valves (PUV) constitute the most common infra-vesical urinary obstruction in boys. PUV are often accompanied by severe consequences to the lower and upper urinary tract (LUT, UUT). They also represent a major urological cause for pediatric renal transplantations. Surgical options for primary management invariably aim at abolition of valves. However, temporary urinary diversion may sometimes be a viable alternative, especially in critically ill patients or preterm infants. It was a retrospective, descriptive study which was conducted at the Department of Pediatric Surgery, Rajshahi Medical College from January 2018 to December 2018. All stable patients with the diagnosis of posterior urethral valves were included in the study. Endoscopic valve fulguration was performed in all diagnosed patients using bugbee electrode and an adequate sized cystoscope. The procedure was performed under general anesthesia and the urinary bladder was drained with a suitable size Foley's or silicon catheter for 14days. Patients were discharged from the hospital 48-72 hours after the procedure on oral antibiotics and were advised to come to the outpatient department for follow up visits for a period of 6 months. A total of 84 patients were included in the study. All were males with a mean age of 6.5years ranging from 6 months to 12 years. Sixty five patients were without any diversion while 19 had vesicostomy or ureterostomy already done in our department or somewhere else. Stricture urethra was seen in 5 patients, incontinence of urine was seen in 7 patients, nocturnal enuresis in 15 patients and recurrent urinary tract infection in 19 patients. Chronic renal failure was seen in 4 patients while 16 patients lost the follow up.18 patients had an uneventful recovery. Urethral valve ablation is the definitive treatment of posterior urethral valves. Endoscopic urethral valve fulguration is safe, effective and definitive way of management for posterior urethral valves. Early treatment improves the quality of life and prevents the ongoing renal damage. Early presentation in fetal and neonatal life has worst prognosis due to associated renal dysplasia.
 TAJ 2018; 31(2): 68-72

Double Urethral Valve: a Clinical Case

Introduction. Urethral valves (UVs) are congenital malformations of the urethra, leading to infravesical obstruction. The most common UV is the posterior urethral valve (PUV). The anterior urethral valve (AUV) is a somewhat rarer, but still well-known congenital anomaly. UVs can provoke significant obstruction of the proximal urinary system, which can later lead to disability of children and more frequent deaths.Materials and methods. The article presents a clinical example of a 32-year-old man with a congenital double urethral valve occuring in the anterior and posterior urethra, which led to the development of chronic urinary retention, urinary tract infection and chronic renal failure. The patient underwent a successful urethroplasty operation to remove the valve mechanism.Results. Six months following surgery, the patient noted the complete disappearance of symptoms, with renal function having returned to normal. No signs of recurrence of the disease or the formation of stricture of the urethra were detected by to the survey.Conclusion. A congenital variant of the double UV is an unusual extremely rare cause of infravesical obstruction. Early diagnosis and treatment of this anomaly is very important for preventing further irreversible damage to the urinary system. The presented clinical observation demonstrates the need to organise and conduct periodic preventive examinations of children of different age groups.

Paediatric urology: Emerging challenges

Medical advancements in paediatric urology are moving at a rapid pace, understanding natural history in congenital malformation of the urinary tract in infancy has changed our diagnostic as well therapeutic approach. Additionally more efficient diagnostic options have evolved our therapeutic in particular surgical approach toward minimally invasive options in children. Interdisciplinary teamwork are the needs of the moment applies above all to children with complex congenital malformations such as disorders of sexual development, urethral valves, cloacal extrophy or complex congenital deformities of the upper urinary tract. This short summary give insights into the current diagnostic discussion as well minimal invasive concepts of most important disease patterns in paediatric urology.

Progress of diagnosis and treatment of fetal and newborn lower urinary tract obstruction

Congenital lower urinary tract obstruction in the fetus and is rare in neonates, but it is identified increasingly in the era of prenatal sonography and resulted in substantial perinatal mortality with lifelong morbidity.Posterior urethral valves, urethral atresia, and prune-belly syndrome are the frequently reported causes of lower urinary tract obstruction.Despite the completion of a randomized trial, the benefit of prenatal intervention with vesicoamniotic shunt placement remains unclear.The management of these disease in fetus and newborns requires appropriate urinary tract decompression, subspecially support, and definitive diagnosis with endoscopy and radiography.Now, the recent progress of diagnosis and treatment of congenital lower urinary tract obstruction were reviewed. Key words: Fetus; Infant, newborn; Congenital lower urinary tract obstruction; Diagnosis; Treatment

Complications after bladder augmentation in children.

Bladder augmentation is an effective surgical procedure for increasing bladder capacity and reducing pressure on the urinary system. It is indicated for patients with anomalies such as spina bifida, myelomeningocele, urethral valve and bladder exstrophy, who progress with low tolerance of medication. This was a retrospective study conducted on pediatric patients submitted to bladder augmentation from 2000 to 2011. 34 patients aged 4 to 17 years were submitted to bladder augmentation, 30 of them with an ileal loop and 4 with a ureter.A continent urinary shunt was performed in 16 patients, the Mitrofanoff conduit was associated in 15, and the Macedo technique was used in one. Mean follow-up was 34.35 months (1 to 122 months). Mean creatinine was 1.5 ng/ml (0.4 to 7.5 ng/ml) preoperatively and 1.78 ng/ml postoperatively. Three patients required a renal transplant during follow-up. There was improvement or resolution of vesicoureteral reflux in 83.5% of the kidneys on the right and in 75% on the left. Bladder capacity increased, on average, from 152.5 ml to 410 ml. The main complications were vesical lithiasis in 3 patients and conduit perforation in one. Bladder augmentation showed good results in this series, preserving renal function in most of the patients.

Paediatric ¶Urologic Pathologies In Two Hospitals Of Reference In Cotonou (BENIN): ¶ ¦Etiologic¦ And Therapeutic Aspects ¶

Background. Urologic pathologies of children are dominated by congenital malformations of the kidneys and urinary tract. ¦¶Their management is often surgical.¶ Objective: The general objective of this survey was to study etiological ¦¦ and therapeutic aspects of urologic pathologies in children.Patients and methods: Data for aetiology, treatment and results in children hospitalized at the Paediatric Surgery services of two National Teaching Hospitals ¦in ¦Cotonou were retrospectively analyzed from January 2002 to December 2011.¶ ¶Results. A total of 257 patients with complete data were evaluated. Urologic pathologies represented 4.8% of the hospitalizations in paediatric surgery, with an incidence of 26 cases per year. ¶The mean age was 4.9 ± 3.2 years (age between one 1 week and 14 years). ¶The sex-ratio was equal to 14.14. Cryptorchidism, ¶ ¦hydrocele¦, ¦nephroblastoma¦, the posterior ¦urethral valves¦, ureteropelvic junction obstructions¦ ¦, post-circumcision haemorrhage and ¦hypospadias¦ were the most frequent pathologies. Congenital urologic malformations ¶¦represented 81.3 %, followed neoplastic pathologies (7.9 %), traumatic pathologies (6.1 %) and others (4.7 %). The disorders of male genitalia were more frequent and constituted 69.3 % of the cases. ¶The anomalies of the urinary tract were 30.7 % and intersex disorders 1.2%. ¶ The mean consultation’s duration of children with urologic pathologies was 8.85± 4.6 weeks. ¶The treatment was often surgical with a mortality of 2.8 %. ¶

S18 DIAGNOSTIC VALUES OF DETRUSOR WALL THICKNESS, POSTVOID RESIDUAL URINE AND PROSTATE VOLUME TO EVALUATE LOWER URINARY TRACT SYMPTOMS IN MEN

277 L ower urinary tract symptoms (LUTS) are common, affecting approximately 40% of older men (1). LUTS is a recent term for what used to be known as prostatism (2). However, obstructive disorders of the lower urinary tract may also be caused by other diseases, such as bladder neck contractures, urethral valves, or external sphincter dyssynergia. However, for the majority of cases in the male population, the etiology is benign prostatic hyperplasia (BPH). Various animal and human studies have revealed that a significant enlargement of the bladder wall is attributable to smooth muscle cell hypertrophy, fibrocyte hyperplasia, and collagen deposition in the detrusor (3, 4). From a clinical perspective, thickening of the bladder wall should be considered as a sign of significant subvesical obstruction (5). The best way to visualize this detrusor muscle hypertrophy in a noninvasive manner is to measure the detrusor wall thickness (DWT) by suprapubic ultrasonography. In 2006, Belal and Abrams (6) evaluated noninvasive methods used to diagnose bladder outlet obstruction (BOO) in a meta-analysis and observed that ultrasound measurements of the DWT and bladder weight were the only predictors of subvesical obstruction in LUTS patients. It is widely accepted that DWT decreases continuously while the bladder fills to 50% of its capacity and then remains constant until 100%. Therefore, the detrusor wall measurements are performed on patients when the bladder is filled to maximum capacity only (7). However, no study has been published that evaluates the diagnostic accuracy of DWT when the bladder is empty. In our study, we investigated the association between the LUTS severity and DWT. In addition, the parameter “DWT when the bladder was empty” was also evaluated as a noninvasive diagnostic tool to predict LUTS in men. An ideal assessment tool to detect LUTS must be noninvasive, quick, inexpensive, and reproducible with high diagnostic accuracy. Ultrasonography has all of these criteria with additional advantages (no contrast material and no ionizing radiation). In uro-radiology practice, conventional ultrasound-derived noninvasive tests for the evaluation of LUTS severity can achieve measurements of DWT, postvoid residual urine volume (PVR), and prostate and bladder volumes. Hence, our primary aim in this prospective, controlled clinical study was to analyze the diagnostic accuracy of these ultrasound-derived noninvasive tools (i.e., DWT when the bladder is full and empty, PVR, and bladder and prostate volumes) in healthy, mildly symptomatic, and moderately-toseverely symptomatic men, and compare the outcomes in each group. In addition, their correlation according to International Prostate Symptom Score (IPSS) and age groups as well as differences in DWT values were also investigated. Our hypothesis was that these tests would accurately discriminate symptomatic cases from healthy subjects and would ABDOMINAL IMAGING

A male infant presenting with acute urinary retention

A 3-month-old male infant was admitted to the emergency department for acute urinary retention. A voiding cystourethrogram was performed because urethral valves were suspected. After bladder catheterization, the plain radio - graph prior to filling of the bladder showed an abnormal course of the urinary catheter tip together with focal absence and displacement of bowel gas out of the pelvis. Early contrast opacification of the bladder (Fig. A) demonstrated an abnormal cranial position of the lumen and an extrinsic impression on the bladder base, which became obscured after further distension of the bladder (Fig. B). These findings suggested presence of a pelvic mass, which was confirmed sonographically. CT and MRI were performed for better tumor delineation and tissue characterization. Both demonstrated a sharply delineated presacral soft tissue mass with homogeneous enhancement and DWI showed diffusion restriction. Sagittal T2-weighted image (Fig. C) nicely exhibits upward elevation of the bladder caused by a homogeneous presacral mass. Serum analysis showed increased neuron specific enolase and increased catecholamine metabolites were found in the urine. Tru-cut biopsy specimens confirmed neuroblastoma. CT and MIBG scan revealed no distant sites outside the pelvis while a bone scinti - graphy ruled out bone metastases. The tumor was macroscopically completely removed by means of a median laparotomy, and the infant recovered well after therapy.

Nephrolithiasis as an extra-intestinal presentation of pediatric inflammatory bowel disease unclassified

Urolithiasis is quite rare in pediatric inflammatory bowel disease (IBD) compared with the incidence at 9–18% in adult cases. The diagnosis and treatment of pediatric IBD is challenging. Indeterminate colitis (IC), originally proposed as a subgroup of fulminant IBD, has also been used for patients when the diagnosis of either UC or CD cannot be made with certainty. Such patients should be diagnosed as having “IBD unclassified” based on evidence including mucosal biopsy samples. We report herewith a 9-year-old boy with isolated colitis that reached a diagnosis of IBD unclassified. Infliximab therapy led to a successful remission after the refractory course. However, urolithiases were impacted in the urethral valves and vesico-ureteral junction. Microhematuria was noticed from the onset of colitis. Renal calculi were detected on the X-ray films during the first line treatment. Transurethrally crushed stones consisted of calcium oxalate. Renal calculi are more closely associated with CD than ulcerative colitis in adult patients for the ileal involvement. The oxalate stones and treatment response indicated a CD-like pathophysiology. Nephrolithiasis might be a rare but noticeable extra-intestinal presentation of pediatric IBD. Infliximab therapy could be an option in pediatric refractory colitis to change the critical steroid dependency.

The Utility of Serous Lined Extramural (SLEM) Conduit Implantation in Pediatric Augmentation Cystoplasty with Continent Diversion

Purpose During Ileocystoplasty with continent diversion, inherent anatomical and pathological abnormalities involving the bladder template, available conduit length, compression spinal deformities and obesity can preclude the effective construction of an adequate vesical submucosal antireflux mechanism and/or hinder putting an easily accessible abdominal stoma for the child. We present an extrapolation of Abol-Einein & Ghoneim's SLEM antireflux principle utilized in adult orthotopic bladder substitution to conduit implantation in select group of candidate children in an attempt to overcome these difficulties. Material and Methods Nineteen patients (8 boys and 11 girls, age range 5-16 years, median 9) with bladder exstrophy (9/19), myelodysplasia (7/19), urethral valves (2/19), and post repair of persistent cloaca (1/19) underwent ileocystoplasty with utilization of either the appendix (10/19) or a Monti (9/19) as a Mitrofanoff channel. The latter was received into the intestinal portion of the augment in a SLEM tunnel with its stomal end brought through the abdominal wall at an easily accessible site for the child. Results Median follow up was 24 months (13-47). The stoma was positioned at a neo-umbilicus in all exstrophy patients, in the epigastrium in 3 obese patients with spinal deformities, in the left iliac fossa in 2 left-handed patients and at the umbilicus in 5. Easy catheterization with adequate emptying was initially achieved in 14/19 (74%). Stomal stenosis developed in 5/19 (26%) of which 2/5 responded to dilatation and 3/5 to a skin level revision. None developed a stricture at the conduit trunk nor at its proximal end. Eighteen patients (95%) were CIC continent by end of followup. Conclusions The SLEM principle creates an effective and durable antireflux mechanism. Its versatility allows overcoming the problem of an inadequate or hostile bladder template, meanwhile, the conduit length sparing effect provides more liberty in placing easily accessible stomata in myelodysplastic patients with severe spinal deformities and obesity.

Urethralduplikatur

Urethral duplication is a rare anomaly that can occur in various forms. Urethral duplication must be diagnosed and adequately treated. Only if clinical complaints develop should surgical management be considered. The aim of this study was to retrospectively analyze patients with congenital urethral duplication: age at the time of diagnosis, type of urethral duplication, diagnostic and therapeutic measures as well as clinical aftercare were evaluated. This homogeneous and selected cohort included nine male children. The average follow-up was 6.2 years. Seven children were symptomatic (77.7%). We found a double urethra with epispadias in four boys and with hypospadias in three boys and urethral duplication with perineal/anal meatus in one patient and normotopia in another patient. In two children without symptoms, the urethral duplication was an incidental finding during diagnostic work-up for other anomalies. Seven children had additional urological anomalies: one fusiform megalourethra, three urethral valves with hypospadias, and two epispadias. Two children without symptoms were managed conservatively. An open operation joining the urethras was performed in three children, and four boys underwent endoscopic treatment of the urethral duplication. Long-term results revealed normal continence in all of the children. One child exhibited recurrent urinary tract infections and late stricture, which was opened endoscopically in a second session. A surgical approach is only indicated in the presence of clinical complaints. There is no surgical gold standard. The decision is ultimately reached on an individual basis depending on the findings and anatomy in view of the rarity and variability of the clinical picture. The functional result is of foremost importance for the urethra that requires reconstruction, but the cosmetic aspect should be respected to the same extent. We present the results of our experience in treating children with this urological condition. At the same time larger (multicenter) studies are needed, which will make it possible to formulate guidelines for this rare anomaly.

Peritoneal dialysis in children under two years of age

Although results of peritoneal dialysis (PD) in small children have improved during recent years, the youngest children have poorer growth, more infections and higher mortality than do older children. In this retrospective study, we analysed patient records of all children under age 2 treated with continuous peritoneal dialysis (CPD) between 1995 and 2000 in Finland. Diagnoses leading to renal failure in these 23 children were congenital nephrotic syndrome of the Finnish type (13), polycystic kidney disease (4), a urethral valve (3), renal insufficiency due to neonatal asphyxia (2) and Prune-Belly syndrome (1). Of these 23, 17 (74%) were anuric. The mean age at the onset of PD was 0.4 years and the mean time on dialysis 1.4 years. Hernias were diagnosed in 57%. The peritonitis rate was 1:14.5 patient-months, and 30% were peritonitis-free. Hypertension was common, and 70% had at least one period on antihypertensive medication. None of the patients had pulmonary oedema or dialysis-related seizures. The mean height standard deviation score (hSDS) at the start of PD (n = 16) was -2.0 and after 9 months -1.6. Catch-up growth was documented in 64% of the patients during dialysis. Hospitalization time was 124 days/patient-year. Two patients (9%) died. Our results are reassuring. Mortality was low, laboratory parameters were acceptable and growth was good. Peritonitis rate was comparable to that in older children. Correction of inguinal hernia should be routinely performed; high blood pressure is still a problem.

Renal Transplantation in Children With Lower Urinary Tract Dysfunction of Different Origin: A Single-Center Experience

Introduction Renal transplantation in patients with lower urinary tract dysfunction (LUTD) of various origins is a challenging issue in the field of pediatric transplantation. We report our single-center experience to evaluate patient and graft survivals as well as the risks of the surgery and immunosuppressive therapy. Patients and methods Among 70 pediatric transplant patients, 11 displayed severe LUTD. Videourodynamic tests were performed on all patients preoperatively as well as postoperatively if required. The cause of urologic disorders were neurogenic bladder ( n = 5) and urethral valves ( n = 6). Clean intermittent catheterization (CIC) was needed in six patients to empty the bladder. To achieve a low-pressure reservoir with adequate capacity pretransplantation augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient. Three of the patients received kidneys from cadaveric and eight from living donors. All patients were treated with calcineurin-based immunosuppressive therapy. Results The mean age at transplantation was 15 ± 4.7 years. The median follow-up after transplantation was 36 months (6 to 62 months). At their last visit the median creatinine level was 0.95 mg/dL (0.8 to 2.4 mg/dL). Three patients had recurrent symptomatic urinary tract infections who had augmented bladder on CIC. One patient with ileocystoplasty who developed urinary leak and ureteral stricture in the early postoperative period was treated by an antegrade J stent. Conclusion Severe LUTD carried high risks for the grafted kidney. However, our data suggested that renal transplantation is a safe and effective treatment modality, if the underlying urologic diseases properly managed during the transplantation course. Since surgery and follow-up is more complicated, patient compliance and experience of transplantation team have significant impacts on outcomes.

Acute focal bacterial nephritis in 25 children

Acute focal bacterial nephritis (AFBN), formerly known as lobar nephronia, is a rare form of interstitial bacterial nephritis. Most often described in adults with diabetes, there is only limited knowledge of AFBN in children. Ultrasound shows circular hypoechogenic, hypoperfused parenchyma lesions, which may be misdiagnosed as a renal abscess or tumor. From 1984 to 2005, AFBN was diagnosed in 30 children at the University Hospital Münster and the General Hospital Celle, Germany. Data of 25 cases (14 girls, 11 boys) were available for retrospective evaluation. Twenty-five children with AFBN, mean age 4.5 years (range: 0.25-17.5 years), were followed up on average 4.2 years (range: 0.5-11 years). All children were admitted to hospital due to fever and rapid deterioration of clinical condition, initially suspected of having meningitis (four patients), urinary tract infections (five patients), renal tumor (three patients), pneumonia (two patients), appendicitis (one patient), or with only unspecific symptoms (ten patients). AFBN was diagnosed by ultrasound on average 3 days (range: 1-10 days) after onset of symptoms. Pyuria was found in 18/25 children, bacteriuria in 20/25 children, and hematuria in one patient. Blood cultures were negative in all but one patient. Urinary tract abnormalities were found in 12 children, including vesicoureteral reflux (8), megaureter (1), urethral valves (1), unilateral renal hypoplasia (1), and one patient with megacystis, megaureter, caudal dystopic left kidney combined with hypoplasia and dysplasia of the right kidney. High-resolution ultrasound showed AFBN lesions to have resolved completely within 12 weeks after onset of intravenous antibiotic therapy in 20/25 children. Renal parenchymal cysts remained in three cases and focal scarring in two. Blood pressure and renal function was normal in 24/25 cases. AFBN should be suspected in children with fever and rapid deterioration of clinical condition. Residual lesions such as cysts or scarring of renal parenchyma could remain.

The Effect of Oxybutynin on Structural Changes of the Obstructed Guinea Pig Bladder

Oxybutynin is used clinically to lower intravesical pressure and detrusor overactivity. In vitro it inhibits stretch induced bladder smooth muscle cell proliferation. We tested whether oxybutynin also prevents hypertrophic bladder changes in vivo in a model of partial bladder obstruction. Subvesical obstruction was induced in immature guinea pigs by a silver ring around the urethra. Eight animals received 0.4 mg oxybutynin per kg body weight per day in 2 doses. Control groups were obstructed without oxybutynin treatment or sham operated. Urodynamic pressure flow studies were performed at 1-week intervals for 10 weeks in all animals under anesthesia with ketamine/xylazine. After 10 weeks the animals were sacrificed and the bladder was removed for structural analysis with periodic acid-Schiff stain, in which the number of glycogen granules was also scored as a measure of previous ischemia. Compared to the sham treated group obstructed animals had significantly higher intravesical pressure and detrusor overactivity, lower compliance and increased contractility. Obstructed animals that received oxybutynin retained normal intravesical pressure, detrusor overactivity and compliance. Their bladder contractility increased as in obstructed animals. The oxybutynin group showed less collagen infiltration in the detrusor and fewer glycogen granules compared to those in obstructed animals. Our results demonstrate that oxybutynin has a protective effect on bladder function and structure. Prevention of hypertrophic and ischemic bladder changes is an argument for an early start of oxybutynin treatment in children with inborn neurogenic bladder dysfunction, such as spina bifida, or in patients with urethral valves.

Dysfunctional Elimination Syndrome Is a Negative Predictor for VUR

Urology| June 01 2007 Dysfunctional Elimination Syndrome Is a Negative Predictor for VUR AAP Grand Rounds (2007) 17 (6): 69–70. https://doi.org/10.1542/gr.17-6-69 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dysfunctional Elimination Syndrome Is a Negative Predictor for VUR. AAP Grand Rounds June 2007; 17 (6): 69–70. https://doi.org/10.1542/gr.17-6-69 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: dysfunctional elimination syndrome, urinary tract infections Source: Colen J, Docimo SG, Stanitski K, et al. Dysfunctional elimination syndrome is a negative predictor for vesicoureteral reflux. J Pediatr Urol. 2006;2:312–315; doi:10.1016/j.jpurol.2006.01.013 Researchers from the Children’s Hospital of Pittsburgh conducted a retrospective review to examine the rates of vesicoureteral reflux (VUR) in patients being evaluated for urinary tract infection (UTI) that was accompanied by fever (>38.0°C) and/or dysfunctional elimination syndrome (DES). DES was defined as the presence of one or more of the following: posturing, daytime wetting, urgency, constipation, encopresis, or a previous diagnosis of DES. The medical records of all patients who underwent voiding cystourethrograms (VCUG) for the diagnosis of UTI from 1997–2000 were evaluated. Patients without a documented infection and those with other reasons for UTI or VUR including urolithiasis, neurogenic bladder, urethral valves, ureteroceles, or complex anomalies were excluded. Children less than two years of age were assessed separately due to the difficulty of diagnosing DES in this population. One hundred thirty-two patients (122 girls; 112 white, 8 black, 18 unknown) met the criteria. VUR was identified in 48% (64/132): 54% (7/13) of patients who were afebrile and DES negative; 35% (12/34) of those who were afebrile and DES positive; 68% (23/34) of the febrile without DES group; and 43% (22/51) of those who were febrile and DES positive. Patients who were afebrile and diagnosed with DES were less likely to have VUR than patients who were febrile without DES (P=.02); among the febrile patients, those with DES were less likely than those without DES to have VUR (P=.01). Dilating VUR (grades III–V) was most common in febrile patients without DES (11/34). The authors note that the detection rate for VUR is higher in this study than in a previous series1 and attribute this to selection bias. One-third of VCUGs in this review were ordered by the urology department with the remainder ordered by primary care physicians. Some of the patients had VCUGs performed at other hospitals and it was presumed that most patients with VUR were referred to the urology department for management while those with normal studies were not, increasing the VUR population. The authors conclude that DES appears to be a negative predictor for VUR. Dr. McMahon has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/device. The association of dysfunctional voiding and constipation with urinary tract infection was noted in the last decade. The term DES was introduced in 19982 and at that time it was suggested that reflux is often secondary to the abnormal bladder dynamics found in patients with DES. A dysfunctional voiding symptom score3 was developed and studies demonstrated that improvement in the score was associated with resolution of VUR while worsening of the score was associated with breakthrough UTI and even increasing reflux.4 The authors of the current... You do not currently have access to this content.