Vescico-ureteral Reflux Research Articles

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study.

Robot-assisted approach to UVJ is getting more and more used in pediatric patients. In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR). Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery. Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

Endoscopic treatment of ureterocele in children: Results of a single referral tertiary center over a 10 year-period

The management of UCs remain controversial, especially for UCs with duplex collecting systems that still represent a great challenge in paediatric urology. Several approaches have been used and a shared management is not yet validated. Aim of our study is to evaluate the results of the endoscopic treatment of UC comparing ortothopic single-system UC and ectopic duplex-system UC over a 10-year period in a single referral tertiary center. Success was defined as resolution of dilation, lack of urinary infections and preservation of renal function. We retrospectively reviewed medical records of children with a diagnosis of UC who underwent endoscopic puncture at our division from January 2009 to January 2019. Patients were divided in two groups: Group A composed of patients with ectopic UC associated with renal duplex system and Group B with orthotopic UC in single collecting system. We identified 48 paediatric patients treated with transurethral primary endoscopic incision. Groups result homogeneous for clinical and pathological characteristics. The only statistical significative difference between the two samples was the age at diagnosis (p value with Yates correction=0.01). We considered as a therapeutic success infections control and the elimination of obstruction with preservation of global kidney function. Based on that, our success rate after single (77%) or double (92%) endoscopic treatment is higher than data reported in literature. Differently from previous studies, vescico-ureteral reflux without UTIs was not considered as a failure of the procedure. The present study has some limitations: it is a retrospective and monocentric serie and it lacked a longer follow-up; on the other hand, it has been conducted on a quite large sample size and it is one of the few studies that compares the endoscopic treatment between orthotopic and ectopic UC. Our data report primary endoscopic puncture of ureterocele as a simple, effective, and safe procedure also in long-term follow up. This technique avoids the need for additional surgery in the majority of the patients, also in the case of an ectopic UC associated to a duplex system.

High-pressure balloon dilatation in children: our results in 30 patients with POM and the implications of the cystoscopic evaluation.

Primary Obstructive Megaureter (POM) is a common cause of hydronephrosis in children with spontaneous resolution in most cases. High-Pressure Balloon Dilatation (HPBD) has been proposed as a minimally invasive procedure for POM correction in selected patients. The aim of the paper is to review our experience with HPBD in patients with POM. We performed a retrospective study in a single Centre collecting data on patients' demographics, diagnostic modalities, surgical details, results and follow-up. In particular, the endoscopic aspect of the orifice permitted the identification of 3 patterns: adynamic ureteral segment, stenotic ureteric ring and pseudoureterocelic orifice. We performed HPBD in 30 patients over 6 years. We had 23 patients with adynamic distal ureteral segment (type 1), 4 with stenotic ring (type 2) and 3 with ureterocelic orifice (type 3). In 3 patients (10%) the guidewire did not easily pass into the ureter requiring ureteral stenting or papillotomy. Post-operative course was uneventful. Five patients (3 pseudoureterocelic) required open surgery during follow-up. HPBD for the treatment of POM is a safe and feasible procedure and it can be a definitive treatment of POM. Complications are mainly due to double J stent and none of our patients had symptoms related to vescico-ureteral reflux. The aspect of the orifice, identified during cystoscopy, seems to correlate with the efficacy of the dilatation: type 1 and 2 are associated with good and excellent results respectively; type 3 do not permit dilatation in almost all cases requiring papillotomy. HPBD can be performed in selected patients of all paediatric ages as first therapeutic line. The presence of a pseudoureterocelic orifice or long stenosis might interfere with the ureteral stenting and seems associated with worse outcomes.

Subtotal ureteral substitution with ileum for patients with multiple ureteral stenosis.

The use of small bowel for ureteral substitution in patients with ureteral stenosis can, nowadays, be safely performed with a laparoscopic or robotic mini-invasive approach. To date, this technique required a complete substitution of the ureter with ileum. In this work we present our robotic intracorporeal sub-total ureteral substitution preserving the distal part of the ureter with the aim to reduce the risk of vescico-ureteral reflux. We report the case of a 65-years old male with a “functional” right single kidney and multiple recurrent stenosis. Our technique seems to be feasible and safe, no intra or postoperative complication were recorded. At 3 months of follow-up the trans-nephrostomic enhanced CT showed a completely opacification of ileal ureter, thus the nephrostomic tube was removed. At 6 and 12 months the patient was asymptomatic and with a level of serum creatinine 1.9 and 1.6 mg/dL, respectively. In conclusion the sub-total ureteral substitution with ileum can be a safety and effective procedure for patients who require a mandatory preservation of homolateral renal function.

Prenatal detection of megacystis: not always an adverse prognostic factor. Experience in 25 consecutive cases in a tertiary referral center, with complete neonatal outcome and follow-up

Megacystis is a condition of abnormal enlarged fetal bladder for gestational age, which is usually associated with urological malformations that may constitute a life-threatening condition for the baby. The purpose of this study was to assess the prognostic and etiological criteria of fetal megacystis and to describe the neonatal outcome in a large series collected in a single tertiary center. A retrospective observational study was conducted between 2008 and 2012. We reviewed all consecutive cases of fetal megacystis diagnosed during routine ultrasound (US) screening. The following data were collected and analyzed: maternal age, gestational age at diagnosis, prenatal ultrasonographic details of the urinary system, extra-urinary ultrasonographic anomalies, fetal karyotype, pregnancy outcome, postnatal diagnosis, and medical/surgical follow-up. Of the 25 fetuses included in this study, 76% were males. The mean gestational age (GA) at diagnosis was 23.1±7.5 weeks (range 12-34), among them only four (16%) were diagnosed during the first trimester. Associated urological malformations were detected in 92% (n=23) of the cases, while other malformations were detected in 36% (n=9). Oligohydramnios or anyhydramnios were observed in 52% (n=13) of the cases. Twelve (48%) fetuses were considered as having poor prognosis for renal function. Vesicocentesis with or without vesico-amniotic infusion were performed in 28% (n=7) of the cases. Pregnancy outcome was surprisingly good, with only one case of prenatal death and survival rate of 96% (n=24) of liveborn babies. Posterior urethral valve (PUV) (n=9, 36%) was the most common etiology of the fetal megacystis, followed by persistent urogenital sinus (n=2, 8%), Prune belly syndrome (n=2, 8%) and bilateral vescico-ureteral reflux (VUR) (n=2, 8%). Surgical or endoscopic procedures were performed in 75% (n=18) of the cases. Six (24%) newborns presented with moderate/severe respiratory distress that requested invasive assisted ventilation. Three cases (n=3, 12%) of perinatal death were observed due to severe impaired renal function. After a median follow-up of 29 months renal function was good in 79% (n=19) of the cases. Fetal megacystis may underline a wide range of associated pathologies with the highest prevalence of urinary malformation. Optimal counseling of the involved parents requires a multidisciplinary approach to allow the best management during the pregnancy and the perinatal period. Despite the high risk of renal failure, lung hypoplasia, and severe associated anomalies, the outcome of fetuses with megacystis could be improved thanks to an appropriate perinatal diagnosis and neonatal management.

Physiopathology of vesico-ureteral reflux.

Vescico-Ureteral Reflux (VUR) is a common condition in childhood, caused by a congenital anomaly at the Vescico-Ureteral Junction (VUJ) level. It seems that the main cause could be an abnormal embryological development occurred during the early stage of fetal life.Refluxing ureteral endings show structural and functional anomalies: previous studies have shown a significant decrease in alfa actin, miosin and desmin contents as well as an high rate of atrophy and muscular degeneration with disorganized muscular fibres. The roles played by Cajal cells and Connexin 43 in generating peristaltic waves appears to be fundamental for the physiological VUJ function and activity. Attention was focused also on the congenital muscular deficiency of the RUs, on regard to general morphology, smooth muscle cells architecture, inflammatory markers and the distribution of collagen composition.This review will discuss and investigate the importance of the modified configuration of Sarcoglycan (SG) sub complex (particularly the deficiency of the ε-SG and the increased expression of the α-SG), the role played by Cajal Cells, the intravescical tunnel length to ureteral diameter ratio as possible causes of the functional alterations in the refluxing ureteral ends leading towards the VUJ incompetence.

Morphological and functional analysis of a cohort of patients undergoing orthotopic ileal neobladder.

This study was conducted between January 2001 and December 2013 to evaluate patient's outcomes after radical cystectomy and orthotopic ileal neobladder from a morphological and functional point of view at a median follow-up of 2 years. A total of 48 eligible patents were included. We first report our technical modifications to Studer's neobladder. Sequently, after a medium follow-up of two years, we assessed morphology of the reservoir and voiding functionality of this patients cohort, submitting them to specific questionnaires and to uroflowmetry. Early and late postoperative data are available for 36 patients. From the morphological follow-up, 2 years after surgery, six patients had hydroureteronephrosis for vescico-ureteral reflux in four cases (11% of total) and uretero-neobladder anastomosis stenosis in the other two (5.6% of total). Neobladder shape always remained spherical, with a relative right lateralization in eight cases (22.2%). Regarding the nine patients subjected to uroflowmetry, seven (77.7%) highlighted the lack of postvoid residual urine, with a maximum urinary flow rate within the normal range in six of them. Improvements in surgical technique may help to reduce complications rate. From uroflowmetry analysis, we can observe that the mean filling pressure following surgery was relatively stable and urinary flow rate was mostly satisfactory. In patients without postvoid residual urine, all referred absence of daily incontinence and good quality of life. From this morpho-functional evaluation, our orthotopic Studer-modified ileal neobladder seems an ideal solution for urinary diversion, presenting functional features similar to native bladder and assuming a well-defined morphology, not changing in time.

Excessive urinary tract dilatation and proteinuria in pregnancy: a common and overlooked association?

BackgroundProteinuria and dilatation of the urinary tract are both relatively common in pregnancy, the latter with a spectrum of symptoms, from none to severe pain and infection. Proteinuria is a rare occurrence in acute obstructive nephropathy; it has been reported in pregnancy, where it may pose a challenging differential diagnosis with pre-eclampsia.The aim of the present study is to report on the incidence of proteinuria (≥0.3; ≥0.5 g/day) in association with symptomatic-severe urinary tract dilatation in pregnancy.MethodsCase series. Setting: Nephrological-Obstetric Unit dedicated to pregnancy and kidney diseases (January 2000-April 2011). Source: database prospectively updated since the start of the Unit. Retrospective review of clinical charts identified as relevant on the database, by a nephrologist and an obstetrician.ResultsFrom January 2000 to April 2011, 262 pregnancies were referred. Urinary tract dilatation with or without infection was the main cause of referral in 26 cases (predominantly monolateral in 19 cases): 23 singletons, 1 lost to follow-up, 1 twin and 1 triplet. Patients were referred for urinary tract infection (15 cases) and/or renal pain (10 cases); 6 patients were treated by urologic interventions (“JJ” stenting). Among them, 11 singletons and 1 triple pregnancy developed proteinuria ≥0.3 g/day (46.1%). Proteinuria was ≥0.5 g/day in 6 singletons (23.1%). Proteinuria resolved after delivery in all cases. No patient developed hypertension; in none was an alternative cause of proteinuria evident. No significant demographic difference was observed in patients with renal dilatation who developed proteinuria versus those who did not. An association with the presence of “JJ” stenting was present (5/6 cases with proteinuria ≥0.5 g/day), which may reflect both severer obstruction and a role for vescico-ureteral reflux, induced by the stent.ConclusionsSymptomatic urinary tract dilatation may be associated with proteinuria in pregnancy. This association should be kept in mind in the differential diagnosis with other causes of proteinuria in pregnancy, including pre-eclampsia.

VESCICO-URETERAL REFLUX: ENDOSCOPIC TREATMENT, MANAGEMENT AND LONG-TERM FOLLOW-UP

Introduction. Vescicoureteral reflux (VUR) is a dynamic event in which there is a retrograde passage of urine from the bladder to the ureters. It is the most common urological disease in the childhood and it manifests with recurrent urinary tract infections (UTI). The therapeutic strategy provides an antibiotic prophylaxis, invasive surgery (Cohen reimplantation) and minimally invasive surgery (endoscopic subureteral injection). Recently, Endoscopic Subureteral Injection with Deflux became the treat- ment of choice. The purpose of this work was to conduce a retrospective study of our patients with VUR to evaluate the role of endoscopic technique (Deflux and Macroplastique) in the treatment. Materials and Methods. Forty two patients with VUR were treated by us in 65 refluxing units. Twenty were males (47.6%) and 22 (52.4%) females. Sex, age of infiltration, presence of associated diseases, unilaterality and bilaterality, side of pres- entation of VUR and substance used for injection were considered. The follow-up study included urine cultures and periodic renal ultrasound. The mintional cistouretrography was performed after 12 months. The results were statistically evaluated with the Wilcoxson test”, comparing data of patients treated with Deflux and Macroplastique. results. Refluxing ureters underwent endoscopic treatment by submeatal injection were 65, 4.6% with VUR grade I, 12.3% grade II, 43% grade III, 29.23% grade IV and 10.87% gradeV. In 19 patients, amounting to 45.2%, this was a unilateral VUR (84.2% left, 15.78% right) and in 23 patients, equal to 54.76%, a bilateral VUR. Thirdy eight per cent of these patients had associated diseases. At the first follow-up, the cure rate was 81.53%. At the second follow-up, the cure rate, including the 9 children re-infiltrated, was 89.23%. Four patients underwent a further infiltration, so as at the third follow-up, the overall cure rate was 93.84%. In only one patient with bilateral VUR grade IV, it was necessary to perform Cohen ureteral reimplan- tation due to the persistence of VUR after 2 endoscopic infiltration. In another one, due to the clinical severity and the per- sisting of VUR after two endoscopic infiltration, we decided to plan the bilateral reimplant according to Cohen. We have not been demonstrated significant differences based on gender, age of infiltration and the substance used, were not observed. Conclusions. At the moment, ours patients have a regular weight-height growth and they don’t have urinary tract infection or vescicoureteral reflux. The sub-meatal infiltration is a simple, repeatable and reliable techinique whereby results are imme- diate and safe in most cases. For this reason, we conclude that the submeatal infiltration represents the first-line treatment in patients with vescicoureteral reflux.

VESCICO-URETERAL REFLUX: ENDOSCOPIC TREATMENT, MANAGEMENT AND LONG-TERM FOLLOW-UP

Introduction. Vescicoureteral reflux (VUR) is a dynamic event in which there is a retrograde passage of urine from the bladder to the ureters. It is the most common urological disease in the childhood and it manifests with recurrent urinary tract infections (UTI). The therapeutic strategy provides an antibiotic prophylaxis, invasive surgery (Cohen reimplantation) and minimally invasive surgery (endoscopic subureteral injection). Recently, Endoscopic Subureteral Injection with Deflux became the treat- ment of choice. The purpose of this work was to conduce a retrospective study of our patients with VUR to evaluate the role of endoscopic technique (Deflux and Macroplastique) in the treatment. Materials and Methods. Forty two patients with VUR were treated by us in 65 refluxing units. Twenty were males (47.6%) and 22 (52.4%) females. Sex, age of infiltration, presence of associated diseases, unilaterality and bilaterality, side of pres- entation of VUR and substance used for injection were considered. The follow-up study included urine cultures and periodic renal ultrasound. The mintional cistouretrography was performed after 12 months. The results were statistically evaluated with the "Wilcoxson test”, comparing data of patients treated with Deflux and Macroplastique. results. Refluxing ureters underwent endoscopic treatment by submeatal injection were 65, 4.6% with VUR grade I, 12.3% grade II, 43% grade III, 29.23% grade IV and 10.87% gradeV. In 19 patients, amounting to 45.2%, this was a unilateral VUR (84.2% left, 15.78% right) and in 23 patients, equal to 54.76%, a bilateral VUR. Thirdy eight per cent of these patients had associated diseases. At the first follow-up, the cure rate was 81.53%. At the second follow-up, the cure rate, including the 9 children re-infiltrated, was 89.23%. Four patients underwent a further infiltration, so as at the third follow-up, the overall cure rate was 93.84%. In only one patient with bilateral VUR grade IV, it was necessary to perform Cohen ureteral reimplan- tation due to the persistence of VUR after 2 endoscopic infiltration. In another one, due to the clinical severity and the per- sisting of VUR after two endoscopic infiltration, we decided to plan the bilateral reimplant according to Cohen. We have not been demonstrated significant differences based on gender, age of infiltration and the substance used, were not observed. Conclusions. At the moment, ours patients have a regular weight-height growth and they don’t have urinary tract infection or vescicoureteral reflux. The sub-meatal infiltration is a simple, repeatable and reliable techinique whereby results are imme- diate and safe in most cases. For this reason, we conclude that the submeatal infiltration represents the first-line treatment in patients with vescicoureteral reflux.

Single-Center Experience in Double Kidney Transplantation

Use of organs from marginal donors for transplantation is a current strategy to expand the organ donor pool. Its efficacy is universally accepted among data from multicenter studies. Herein, we have reviewed outcomes of double kidney transplantation (DKT) over an 9-year experience in our center. The aim of this study was to evaluate possible important differences between a monocenter versus multicenter studies. Between 1999 and 2008, we performed 59 DKT. Recipient mean age was 63 ± 5 years. Mean HLA-A, -B, and -DR mismatches were 3.69 ± 0.922. Donor mean age was 69 ± 7 years and mean creatinine clearance was 69.8 ± 30.8 mL/min. Proteinuria was detected in three donors (5%). Mean cold ischemia and warm ischemia times were 1130 ± 216 and 48 ± 11 minutes, respectively. The right and left kidney scores were 4.18 ± 2 and 4.21 ± 2, respectively. Thirty patients (51%) displayed good postoperative renal function; 22 (37%), acute tubular necrosis with postoperative dialysis; 3 (5%), acute rejection episodes; 4 (7%), single-graft transplantectomy due to vascular thrombosis; 1 (2%), a retransplantation; 5 (8%), a lymphocele; 3 (5%) vescicoureteral reflux or stenosis requiring surgical correction. Cytomegalovirus infection was detected in five patients (8%). In three patients (5%) displayed de novo neoplasia. Three patients showed chronic rejection (5%), whereas we observed a cyclosporine-related toxicity in 7 (12%). Nine patients (15%) developed iatrogenic diabetes. Patient and graft survivals after 3 years from DKT were 93% and 86.3%, respectively. In this study, we applied successfully a widespread score to allocate organs to single kidney transplantation or DKT. In our experience, the score is suitable for the organ allocation but it may be overprotective, excluding potentially suitable organs for a single transplantation.

High Grade Vescicoureteral Reflux in Children Presenting with Urinary Incontinence Without a History of Urinary Tract Infection

Purpose Urinary Tract Infection(UTI)is the most common clinical presentation of vesicoureteral reflux(VUR).However,VUR has also been reported in children with voiding disorders with or without history of UTI.The aim of this study was to determine the prevalence of VUR in children presenting with urinary incontinence without a history of UTI among a large group of patients with intermediate and high grade VUR. Material and Methods The medical records of 1432 children diagnosed with intermediate and high grade VUR(Grade III to V)during 1998 to 2008 were reviewed. VUR was diagnosed in all patients by voiding cystourethrogram(VCUG).Renal parenchymal scarring was evaluated by DMSA scans and classified into three groups:mild with relative uptake between 40%and45%,moderate with relative uptake between 20%and40% and severe with relative uptake Results Of the 36patients with urinary incontinence,11children had day and night incontinence,6 had only daytime wetting and 19 had only bedwetting at night.There were 19boys and 17girls and their ages ranged from 4years to 12.1years(median age 6.5years).24children had unilateral VUR and 12 bilateral with a total of 48 refluxing units.VUR was grade II in 2ureters,grade III in 30ureters,grade IV in 15 and grade V in 1.Both patients with grade II VUR had a higher grade VUR on the contralateral side.11(30.5%) patients demonstrated renal scarring on DMSA scans.Scarring was mild in 5 patients,moderate in 5 and severe in 1patient. Conclusions Our large series of intermediate and high grade VUR has identified a small but definite subgroup of patients whose sole presenting symptom is urinary incontinence.We recommend VCUG in all children beyond the age of toilet training who present with urinary incontinence without UTI but sonographic evidence of pelvicalyceal and ureteral dilatation.

A 6-year-old child with Fryns syndrome: Further delineation of the natural history of the condition in survivors

Fryns syndrome (FS) is a rare early lethal autosomal recessive disorder. The diagnosis is clinical since the underlying molecular defect is currently unknown. We report on a 6-year-old male child displaying an association of congenital diaphragmatic hernia (CDH), lung hypoplasia, corneal clouding and coarse face in the absence of distal digital/nail hypoplasia. Based on the recently published diagnostic guidelines, our patient fits the narrow definition of FS. Only a minority of FS patients surviving the neonatal period have been reported, thus limiting the recognition of the infantile phenotype. We compared the features observed in our proband with those of 10 published survivors. Neurological impairment ranging from mild to severe was present in all patients, while seizures manifested in one third of them, often in association with central nervous system malformations. Other characteristic features included central-paracentral corneal clouding, coarsening of the facial traits, gastroesophageal reflux, Hirschsprung disease, intestinal malrotation, hydronephrosis and vescico-ureteral reflux. These manifestations are representative of the natural history of this condition and should also be searched for in FS survivors.

Urinary endothelin-1 excretion according to morpho-functional damage lateralization in reflux nephropathy.

Reflux nephropathy (RN) is a pathophysiological human model of reduced nephron reserve, due to loss of renal mass, but little information exists about the role of urinary endothelin-1 (uET-1) in this disease. The aim of this study was to assess the presence of uET-1-like-immunoreactivity (uET-1L) in RN patients, particularly if lateralized renal damage existed. Thirty patients with vescico-ureteral reflux (VUR) and consequent RN, were studied. The presence of VUR was established by voiding cysto-urethrography. RN was assessed and graded by 99mTc-dimercapto-succinic acid scan (DMSA). Renal plasma flow (ERPF) was evaluated by (123)I-Hippuran renal sequential scintigraphy, and glomerular filtration rate (GFR) by creatinine clearance. Forty-five healthy subjects were selected as a control group. uET-1L excretion, in both affected and control groups, was assayed. Mann-Whitney U test showed a significant difference between control and patient groups in both GFR and uET-1L. A good correlation between DMSA grading, single kidney clearance and VUR grade was shown. A significant relationship was also shown between uET-1L and both ERPF and GFR. Patients with RN were divided into two subgroups according to functional damage lateralization. Between the two groups, a significant difference was found only for uET-1L when GFR was applied as a covariate in ANCOVA analysis. Our preliminary results confirmed the increase of urinary ET-1L excretion in RN, especially when renal functional injury was lateralized.

Retroperitoneal urinoma complicating Burch colposuspension

Burch colposuspension is an accepted and effective technique for correcting genuine stress incontinence w1x. Major complications are rare, but kinking of the ureter can occur in such a procedure especially in patients who have previously undergone hysterectomy w2x. Ureteral kinking can lead to a subtotal ureteral occlusion and hydronephrosis that may result in a rupture of the renal cavities and urinary extravasation. A 61-year-old woman presented with a history of urodynamically proven type II stress incontinence. In February 1989, at another institution, she had undergone transabdominal hysterectomy for uterine fibromatosis complicated by a vescicoureterovaginal fistula; in May 1989 she had the fistula repaired and the left ureter reimplanted; and in February 1990 she again underwent left ureteric reimplantation for symptomatic vescicoureteral reflux. In June 2000 the patient underwent standard Burch colposuspension w3x in our unit. At surgery it was difficult to free the bladder from the pubis and to expose the bladder neck and the anterior vaginal wall. After surgery the patient had a postvoiding residual that decreased to less than