Resolution Of Vesicoureteral Reflux Research Articles

Efficacy of Three Different Injection Techniques for the Endoscopic Treatment of Vesicoureteral Reflux (VUR) in Children: A Review of 10 Years of Experience.

To review our 10 years of experience with the endoscopic treatment of vesicoureteral reflux (VUR) in children, emphasizing the long-term efficacy of the "combined STING-HIT" technique. A retrospective study was performed including all children with symptomatic VUR undergoing the cystoscopic injection of bulking agents from January 2013 to December 2022 in our pediatric tertiary referral center. Three different endoscopic techniques were adopted: the "combined STING-HIT" technique, the STING technique, and the HIT technique. Treatment success was defined as symptom remission and VUR resolution on the voiding cystourethrogram (VCUG) performed at the 3-month follow-up. In the study period, 140 (F:M = 64:76) patients and 228 ureters were treated at a median patient age of 3 (2.0-6.0) years. After a single endoscopic treatment, VUR resolved in 203 (88%) ureters. The VUR resolution rate after a single endoscopic treatment was 95% (n=70/74) in case of I-II VUR, 88% (n=87/99) in case of III VUR; 83% (n=38/46) in case of IV VUR; 89% (n=8/9) in case of V VUR (p-value: 0.174). Overall, one or two endoscopic treatments succeeded in 219 (96%) ureters. The overall VUR resolution rate following one or two endoscopic treatments was 100% (74/74) in case of I-II VUR, 93% (n=92/99) in case of III VUR; 96% (n=44/46) in case of IV VUR; 100% (n=9/9) in case of V VUR (p-value: 0.083). Despite not being statistically significant, the VUR resolution rate was higher for the "combined STING-HIT" technique, both after one (92%: n=110/119; versus 85%; n=62/73 versus 86%; n=31/36; p-value: 0.225) or two (98%: n=116/119; versus 95%; n=69/73 versus 94%; n=34/36; p-value: 0.469) endoscopic treatments. The endoscopic approaches were highly successful for the treatment of VUR in children. The "combined STING-HIT" technique was a safe and effective procedure, being associated with the higher resolution rate.

Robot-assisted Foley Tie Ureteric Tapering and Reimplantation.

This study aimed to introduce and evaluate the feasibility and outcomes of a novel surgical technique, robot-assisted Foley tie ureteric tapering (RAFUT) and reimplantation, specifically designed for intravesical ureteral tapering during pediatric robotic-assisted ureteric reimplantation. A retrospective analysis was conducted on pediatric patients diagnosed with primary vesicoureteric reflux (VUR), who underwent RAFUT between January 2019 and July 2021. Patient records were reviewed to assess preoperative characteristics, operative details, and postoperative outcomes. RAFUT involved meticulous patient positioning, precise port placement with a 6 mm separation, and bladder anchoring to maintain pneumovesicum. Ureteric tapering was performed with the Foley tie technique to enhance surgical precision. The primary outcome measures included operative time, complications, and postoperative VUR resolution. All four patients underwent successful intravesical RAFUT without any intraoperative or postoperative complications. The age of the patients ranged from 3 to 12 years, with varying bladder capacities (range: 210-550 mL). The operating times ranged from 180 to 210 min, and the estimated blood loss was 35-50 mL. None of the patients required conversion to open surgery. Patients demonstrated resolution of VUR on postoperative imaging, and none experienced recurrent urinary tract infections during follow-up, which ranged from 1.5 to nearly 4 years. RAFUT represents a safe and effective surgical technique for intravesical ureteral tapering during pediatric robotic-assisted ureteric reimplantation. This innovative approach addresses the challenges posed by intravesical surgery for dilated ureters, maintains anatomical orientation, and offers precise excision and suturing capabilities.

Therapeutic Management of Children with Vesicoureteral Reflux.

Contrasting data refer to therapies for vesicoureteral reflux (VUR), such as surgical treatments and continuous antibiotic prophylaxis (CAP). This study evaluated the effectiveness of these approaches in children with VUR, analyzing the recurrence of febrile urinary tract infections (UTIs) and the resolution of VUR after the treatment. A total of 350 pediatric patients underwent contrast-enhanced voiding urosonography (ceVUS) to diagnose a VUR, whereas renal scintigraphy evaluated potential scars. After 12 months from the treatment, the VUR, the relapse of febrile UTIs, and reflux-related nephropathy were analyzed. Twenty-seven children had recurrent febrile UTIs after surgical therapy, with a greater rate of relapses observed in III and V VUR grades. Thirteen patients who underwent surgery had scars, independently of VUR grades and gender, with evidence of chronic renal failure at the end of the follow-up period. A total of 140 subjects were treated with CAP, and 30% of them continued to suffer from febrile UTIs. Ninety-five patients with VUR underwent ceVUS after 12 months, with persistent reflux in fifty-two patients. All of them had severe VUR, correlating with the age at diagnosis and gender. CAP therapy prevented scarring better than surgery, especially in children with III and V grades of VUR. A late onset of VUR or VUR involving neonatal patients is rarely a reversible process. This study identified predictors of success or failure of surgical or CAP therapies, evaluating the relapse of UTIs or persistent reflux after the treatment and giving prognostic information in children with VUR.

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

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

Voiding Cystourethrogram Before Pyeloplasty: To Do or Not To Do?

To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction(UPJO) and to identify factors that predict VUR. Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed.A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study.Demographic parameters,preoperative hydronephrosis grade,renal pelvis anteroposterior diameter(APD),renal parenchymal thickness(PT),split renal functions on MAG-3 scan and VUR status were noted.The patients were divided into two groups:Those with concomitant VUR(Group I, n:24, 8.9%) and those without VUR(Group II,n:246, 91.1%). Among 270 patients(205 boys,75.9%) with a median age of 4 months(2-98),197 (72.9%)had antenatal hydronephrosis.Median follow-up was 11 years(5-22).Among 24 patients with concurrent VUR,6(25%) had Grade II VUR,whereas Grade III-V VUR was detected in 18(75%).Of these,12(50%) had ipsilateral VUR,3(12.5%) had contralateral,and 9(37.5%) had bilateral VUR.In a median 137-month follow-up,spontaneous VUR resolution was observed in 6(25%) patients,whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3(12.5%) patients ureteroneocystostomy,respectively.Preoperative APD[35.5, IQR(27.6-36.0) vs. 26.5 IQR(25.0-35.0), p=0.004] were significantly higher in Group I,whereas Group I had significantly lower PT[3.7, IQR(3.4-6.4) vs. 5.8 IQR(4.4-6.1), p=0.026].Predictive factors for concomitant VUR were presentation with febrile UTI(OR:2.769,p=0.048), PT<3.95 mm(OR:1.367,p=0.043),and APD>28.8 mm (OR:1.035,p=0.001). Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty,while some type of surgical intervention for VUR was required in 75% of these patients.Thus,VCUG prior to pyeloplasty may be limited in those presenting with febrile UTI,having higher APD and lower PT on preoperative urinary ultrasonography.

Spontaneous vesicoureteral reflux resolution curves based on ureteral diameter ratio

Various factors influence the clinical course of vesicoureteral reflux (VUR) in the pediatric population. Distal ureteral diameter ratio (UDR) is an objective measure reflective of ureterovesical junction anatomy that has been shown to independently predict both spontaneous resolution and breakthrough febrile urinary tract infection (UTI) in children with primary reflux. UDR resolution curves were created, hypothesizing that a UDR value existed at which spontaneous resolution was unlikely to occur. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1-L3 vertebral bodies. Recursive partitioning with 10-fold cross validation methodology for time to event data, utilizing martingale residuals was used to create high and low risk groups based on UDR, and stratified by age at diagnosis and laterality. Three hundred and four patients (226 female, 78 male) were analyzed with a mean age at diagnosis of 1.55±1.98 years. Unilateral reflux (p=0.02), VUR grades 1-3 (p<0.001), and lower UDR (p<0.001) were associated with spontaneous resolution on univariate analysis. UDR values were categorized into risk groups based on recursive partitioning. Low risk patients (those with UDR <0.30) achieved VUR resolution faster and with a continuing rate compared to the high-risk group (≥0.30), which had persistent reflux after 3 years [Summary Figure]. When the 0.30 cutoff was applied randomly to patients in test group, the cutoff significantly discriminated between low and high-risk patients (log rank test p=0.02). Primary VUR is often a self-limiting diagnosis, with conservative management favored in low-risk children, UDR may be used to help distinguish those children who may benefit from intervention. Unlike traditional VUR grading where children with any grade of reflux may spontaneously resolve, there appears to be a consistent UDR cutoff whereby patients are very unlikely to spontaneously resolve, regardless of length of follow-up. Therefore, parents of children with a UDR above the 0.3 cutoff, regardless of VUR grade, may be counselled that VUR is very unlikely to resolve over time - thereby reducing the number of VCUGs and length of time these patients are on prophylactic antibiotic prior to surgical intervention. Children with primary VUR and a UDR of greater than 0.30 are significantly less likely to spontaneously resolve regardless of length of follow-up, and resolution after 3 years was rare. UDR provides objective prognostic information facilitating individualized patient management.

The role of height and weight growth in spontaneous resolution of vesicoureteral reflux.

The aim of this study was to investigate the role of height and weight growth in the resolution of primary vesicoureteral reflux (VUR). We retrospectively evaluated the data of 74 males and 135 females who were diagnosed with primary VUR. According to the vesicoureteral reflux resolution, patients were divided into two groups. Patients with complete or partial resolution of VUR were included in Group 1 and patients with no resolution of VUR were included in Group 2. Patients were evaluated for weight Z-score, height Z-score and body mass index at the diagnosis and in the follow-up. In addition, age, sex, grade of reflux and laterality were recorded. There were no significant differences between the two groups, according to height Z-score, weight Z-score and body mass index at the diagnosis, in the follow-up and also annual changes of these parameters. In addition, the same parameters did not significantly differ in Groups 1 and 2, between the initial and final evaluations. However, when we evaluate the patients older than 12 months old, weight Z-scores were significantly higher at the final evaluation than at the diagnosis, in Group 1. This significant difference was not detected in Group 2 at the same age. Although we could not detect the hectic pace of height growth as being important in the prediction of long-term outcomes of VUR, weight growth should be considered to predict the resolution of VUR.

MITOCHONDRIAL RESPIRATORY CHAIN DISORDERS WITH VESICOURETERAL REFLUX: A PEDIATRIC CASE REPORT

Mitochondrial respiratory chain disorders (MRCD) constitute a highly heterogeneous group both with regard to clinical manifestations and underlying genetic/biochemical defects. Management of urological complications such as vesicoureteral reflux (VUR) has not been discussed in cases with MRCD. We report a pediatric case of MRCD with recurrent urinary tract infections (UTI) due to primary and secondary VUR.A 6-month-old boy with multiple malformations and a history of aspiration pneumonia was referred to our department for febrile UTI (fUTI). Voiding cystourethrography showed high-grade left VUR and a normal bladder. As a spontaneous resolution of VUR was not observed, he underwent left ureteral reimplantation concomitant with left orchidopexy at the age of 1 year and 7 months. Although he had fUTI immediately after surgery, no recurrence of the UTI occurred after discharge. At the age of 3 years, he had septic shock and cardiac arrest caused by aspiration pneumonia, as well as, encephalopathy following cardiopulmonary resuscitation. At this event, the diagnosis of MRCD was achieved by liver biopsy. Since the age of 4 years, he has had repeated fUTI. VCUG confirmed the bladder deformity and right VUR. He underwent vesico-cutaneostomy at the age of 6 years. The postoperative course was uneventful. No recurrence of UTI was observed at the one-year follow-up.

Cutoff Value of Ureteral Diameter Ratio for Predicting Spontaneous Resolution of Vesicoureteral Reflux

Purpose: The five-grade international scale for vesicoureteral reflux (VUR) has been the mainstay for describing VUR severity. The concept of the distal ureteral diameter to the L1–L3 vertebral body distance ratio has been validated. We validated the ureteral diameter ratio (UDR) for predicting VUR outcomes and determined the cutoff value for spontaneous resolution. Materials and Methods: This retrospective review included children with primary VUR and detailed serial voiding cystourethrograms (VCUGs) between March 2005 and December 2016. Patient characteristics, VUR grade, laterality, UDR, laboratory data, and follow-up results were collected. UDR was estimated as the largest distal ureteral diameter within the pelvis divided by the distance of the L1–L3 vertebral bodies. The primary outcome was the prediction of spontaneous VUR resolution. The secondary outcome was the determination of the cutoff value of UDR in the present cohort. Results: We recruited 101 children (59 boys and 42 girls) diagnosed as having primary VUR based on VCUGs at a mean age of 23.48 months. VUR resolved spontaneously in 31 (30.7%) children, 40 (39.6%) children had persistent disease, and 30 (29.7%) received surgical correction. In univariate analysis, laterality, VUR grade, and UDR were significantly associated with spontaneous resolution (P = 0.017, P = 0.026, and P = 0.001, respectively). Multivariate analysis revealed UDR as the prognostic factor for spontaneous VUR resolution (odds ratio, 4.167; P = 0.023). The area under the curve of UDR indicates that the prediction accuracy was 0.74. The optimal cutoff value for UDR in this study was 0.264 (sensitivity, 0.81 and specificity, 0.63). Conclusion: UDR is superior to the VUR grade for predicting spontaneous VUR resolution. Our findings add significant prognostic value for children with primary VUR. A cutoff value of 0.264 may assist with clinical assessment and future management.

Intravesical Botulinum toxin-A injection in pediatric overactive neurogenic bladder with Detrusor overactivity: Radiologic and clinical outcomes.

The neurogenic bladder is one of the most serious and painful disorders seen in pediatric urology clinics. The upper urinary tract can be impaired by increased bladder pressure. Botulinum toxin-A (BTX-A) is one of the new therapeutic interventions for this disease. Thus, this research was designed to determine the clinical as well as radiological outcomes intravesical BTX-A injections in patients with overactive neurogenic bladder with Detrusor over activity. From March 2012 to March 2019, this cohort study was conducted at Shahid Labbafinejad hospital in Tehran, Iran. Thirty-five pediatric patients with a neurogenic bladder and Detrusor overactivity who fulfilled the eligibility criteria received BTX-A injections. Demographic data, including spinal cord lesions or congenital malformations, upper and lower urinary tract nuclear scans, evidence of vesicoureteral reflux (VUR) and its severity, and hydronephrosis and 72 h voiding diary before and after intervention were all recorded. The mean ± standard deviation age of participants was 9.47 ± 4.61 years. After injection, nocturia and urination frequency as general symptoms of the overactive neurogenic bladder improved (p < 0.05). Also, the severity of hydronephrosis was decreased in 33% of patients following injection. In our study, 32 out of 35 patients had vesicoureteral reflux. Of those, there was complete resolution and downgrading of VUR in 17 (53.12%) and 13 (40.62%) respectively. In the evaluation of voiding cystourethrography (VCUG) before and after the injection, downgrading of VUR was seen in 53% of the cases. In the 99mTc-DMSA nuclear scan before and after the injection, the appearance of a new parenchymal scar and uptake reduction was not observed, which indicates the cessation of scar formation in all patients. Although Enuresis, Urgency, Frequency, Nocturia, and UUI significantly improved after injection.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n=13), complete ureteral duplication (n=2), periureteral diverticulum (n=2), ectopic megaureter requiring dismembering (n=1). The median operative time was 155min for unilateral and 211.5min for bilateral repairs. The clinical+radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n=5, 8.7%), febrile urinary tract infection (UTI) (n=6, 10.5%) and gross hematuria (n=3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p=0.002] and bilateral repair [p=0.001] and post-operative urinary retention was more frequent in simple cases [p=0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p=0.001] (Table). This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience

BackgroundThough common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation. MethodsWe retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time. ResultsAltogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26–3.52]) and surgical experience (Range OR: 8.88[7.16–11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32–0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN. ConclusionsIncidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR. Level of evidenceII

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

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

Upper pole pathologies in duplex kidneys: an analysis of predictive factors for surgery and urinary tract infections from the Mid-Atlantic Pediatric Academic Consortium

While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR). We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS. Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p=0.03/0.001 and p=0.002 respectively). Ectopic ureter (p=0.004), ureterocele (p=0.02), and obstruction (p=0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p=0.03 and p=0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p=0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p=0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR. Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes.

Application of urodynamics combined with contrast-enhanced ultrasound in evaluation of the urinary tract in patients with low bladder compliance and vesicoureteric reflux who underwent bladder augmentation alone.

We assessed the use of common urodynamics (CUD) combined with contrast-enhanced ultrasound (CEUS) to investigate the efficacy and durability of sigmoid cystoplasty alone in patients with low bladder compliance associated with vesicoureteric reflux (VUR). In this study, we recruited 25 patients with low bladder compliance and VUR who underwent bladder augmentation without antireflux surgery at our institutions between June 2017 and June 2021. The bladder condition and VUR grade were assessed preoperatively and postoperatively via CUD combined with CEUS. The mean follow-up period was 2.6 years. CUD showed significant improvement in bladder capacity and compliance and a decrease in intravesical pressure after sigmoid cystoplasty. CEUS demonstrated resolution of VUR compared with preoperative assessment. Of the 25 patients who had various degrees of reflux, VUR was eliminated in 18 patients and reduced to a lower grade in the remaining seven patients. CUD combined with CEUS is accurate and safe. They are invaluable and reliable tools for morphological and functional evaluations of the entire urinary tract in patients with low bladder compliance and VUR.

MP17-02 PREDICTIVE FACTORS FOR IMPROVEMENT/RESOLUTION OF VESICOURETERAL REFLUX IN DUPLEX KIDNEYS

You have accessJournal of UrologyCME1 May 2022MP17-02 PREDICTIVE FACTORS FOR IMPROVEMENT/RESOLUTION OF VESICOURETERAL REFLUX IN DUPLEX KIDNEYS Clinton Yeaman, Kathryn Morgan, Fionna Sun, Sherry Ross, Jamie Michael, Rebecca Zee, Hans Pohl, Daniel Casella, Bruce Sprague, C.D. Anthony Herndon, and Nora Kern Clinton YeamanClinton Yeaman More articles by this author , Kathryn MorganKathryn Morgan More articles by this author , Fionna SunFionna Sun More articles by this author , Sherry RossSherry Ross More articles by this author , Jamie MichaelJamie Michael More articles by this author , Rebecca ZeeRebecca Zee More articles by this author , Hans PohlHans Pohl More articles by this author , Daniel CasellaDaniel Casella More articles by this author , Bruce SpragueBruce Sprague More articles by this author , C.D. Anthony HerndonC.D. Anthony Herndon More articles by this author , and Nora KernNora Kern More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002550.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most vesicoureteral reflux (VUR) improves spontaneously over childhood with resolution rates of 45-70% in simplex kidneys. Lower pole VUR in duplex kidneys has not been as well studied with a single 1991 study citing resolution rates of 85% for grades 1-2 and 36% for grade 3 VUR. We aimed to describe the occurrence of VUR in duplex systems as well as predictive factors for resolution/improvement. METHODS: Patients were retrospectively reviewed between 2015-2020 treated at 4 institutions in the Mid-Atlantic. Inclusion criteria included patients with a duplex kidney with any grade of lower pole VUR. Multivariate logistic regression was used to identify predictors of VUR resolution based upon demographic and clinical characteristics. Successful improvement/resolution was defined as downgrading to grade 3 VUR or lower, and failure was defined as persistent grade 4-5 VUR. Descriptive statistics and regression modeling were performed using SAS. RESULTS: Of a cohort of 223 patients, 93 patients (41.7%) had lower pole VUR into 98 renal units. 68 patients (75%) were female. 22 patients (24%) underwent surgical procedures for VUR in the duplex moieties. 10 renal units (10.8%) had grade 1, 10 (10.8%) had grade 2, 24 (25.8%) had grade 3, 16 (17.2%) had grade 4, and 33 (35.5%) had grade 5 VUR. Infants were diagnosed at a mean age of 6 months and underwent repeat exam at a mean age 2.8 years (SD 2). 20 patients (21.5%) did not have repeat VCUG performed. On follow-up, VUR resolved/downgraded in 43 patients (55.1%), persisted at low grade in 7 patients (8.9%) and persisted at high-grade in 28 (35%). VUR resolved in 74% of those with grades 1-3 and in 17.5% of those with grades 4-5 (Table 1A). On univariate analysis (Table 1B), the only predictive factor for resolution of VUR was VUR grade (p=0.001) and was not affected by gender, grade of hydronephrosis or upper pole pathology. On multivariate analysis, low grade VUR remained a significant predictive factor (p=0.006). CONCLUSIONS: 55% of cases of lower pole VUR in duplex kidneys resolve spontaneously /downgrade to low grade. Spontaneous resolution seems to be affected by low grade VUR status alone. 83% of high grade VUR remained high grade at follow up. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e284 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clinton Yeaman More articles by this author Kathryn Morgan More articles by this author Fionna Sun More articles by this author Sherry Ross More articles by this author Jamie Michael More articles by this author Rebecca Zee More articles by this author Hans Pohl More articles by this author Daniel Casella More articles by this author Bruce Sprague More articles by this author C.D. Anthony Herndon More articles by this author Nora Kern More articles by this author Expand All Advertisement PDF DownloadLoading ...

Late diagnosis of posterior urethral valves: a case report and the literature review

Posterior urethral valves (PUV) are the most common cause of lower urinary tract obstruction in boys. They are usually suspected antenatally or soon after the birth as the cause of severe hydronephrosis, oligohydramnios, renal hypodysplasia, and kidney failure. In milder forms of PUV, the uncharacteristic symptoms occur later in childhood, adolescence, or even adulthood and cause diagnostic problems. The final diagnosis and causative treatment of PUV are possible due to cystourethroscopy. Nevertheless, as a consequence of the defect, valve bladder syndrome (VBS) occurs and requires long-term treatment. The authors present a case of a 14-year-old boy with a late diagnosis of PUV at the age of 7. Recurrent pyelonephritis and nonspecific voiding dysfunction were the first symptoms. Ultrasounds(US) were initially normal while videocystometry(VCM) showed the 3rd-grade right-sided vesicoureteral reflux (VUR), bladder diverticulum as well as discrete detrusor overactivity, and reduced bladder capacity without any signs of bladder obstruction. Bilateral post-inflammatory nephropathy completed the clinical picture. In urethrocystoscopy surprisingly PUV were found and incised. Due to recurrent urinary tract infections (UTIs) one year later the STING procedure was performed which resulted in the resolution of VUR. Despite this, the features of bladder dysfunction, requiring regular urodynamic evaluation and pharmacotherapy, persisted. Recurrent UTIs in boys may suggest urinary tract obstruction and PUV should be considered regardless of the patient's age. Early diagnosis and appropriate management may improve the prognosis.

Efficacy of Bladder Ultrasound in Prediction of Resolution of Vesicoureteral Reflux After Endoscopic Subureteral Hyaluronic Acid/Dextranomer (Deflux) Injection

ObjectiveTo evaluate the efficacy of bladder ultrasound (US) in predicting the resolution of vesicoureteral reflux (VUR) after subureteral endoscopic Deflux injection in low-grade vs high-grade VUR patients. Materials and MethodsBetween 2014 and 2020, 160 children (220 ureters) were administered subureteral Deflux injection for treatment of primary VUR. The mean age at surgery was 72 months. Low-grade reflux (grades II-III) was observed in 190 ureters and high-grade reflux (grades IV-V) was observed in 30 ureters. Bilateral surgery was performed in 60 patients. All patients had follow-up using bladder US and voiding cystourethrography (VCUG) at 3 months and 12 months. Outcome included identification of Deflux mounds by bladder US and correlation of Deflux mounds identified with radiographic success rates of VUR on VCUG. ResultsSingle Deflux injection showed radiographic success rates in 98% of low grade reflux patients and 26.7% of high grade reflux patients at last follow-up. Bladder US was able to detect Deflux mounds in 89% of low grade reflux and 43.3% of high grade reflux patients at last follow up. Our study demonstrated higher sensitivity, Positive predictive value and accuracy in Deflux detection by bladder US in low grade reflux vs high grade reflux patients. ConclusionBladder-US was highly sensitive for detection of Deflux implants. Bladder-US could be adjusted in follow-up of patients with low-grade reflux treated by Deflux injection, while VCUG could be preserved for follow-up of high-grade reflux, this will lead to reduction of unnecessary radiation exposure during VCUG for children with low grade reflux.

Robotic Ureteral Reimplantation: Nonrefluxing Intravesical and Extravesical Techniques

Introduction: Nonrefluxing ureteral reimplantation is the gold standard surgical management of patients with symptomatic vesicoureteral reflux (VUR).1,2 Intravesical and extravesical ureteral reimplantation were traditionally performed with an open approach through the Cohen, Lich-Gregoir, Glen-Anderson, and Politano-Leadbetter techniques.3 However, there has been recent adoption of minimally invasive approaches including the use of robotic assistance.1 Moreover, these nonrefluxing ureteral reimplantation techniques have been primarily described in the pediatric population rather than in adults.2 We demonstrate our techniques and describe outcomes of adult patients undergoing nonrefluxing intravesical and extravesical robotic ureteral reimplantation (RUR). Materials and Methods: We reviewed our institution's own robotic ureteral reconstruction database to identify consecutive adult patients with a history of VUR who underwent nonrefluxing intravesical or extravesical RUR between September 2016 and November 2020. Indications for surgery included patients with symptoms of flank pain and/or recurrent infections secondary to VUR. Our primary outcome was surgical success, which we defined as the absence of postoperative flank pain and radiographic absence of VUR on voiding cystourethrogram or obstruction on diuretic renal scan. Before beginning the procedure, all patients underwent cystoscopy, cystogram, and/or retrograde pyelogram. Robotic ports are placed similarly for both techniques through the standard prostatectomy configuration without a fourth robotic port or the right lateral 12 mm assistant port. A 5 or 12 mm assistant port is placed between the camera and the right robotic port. Meticulous dissection of the distal ureter to preserve its fragile blood supply is performed for both techniques. In the robotic intravesical technique, adapted from the Politano-Leadbetter technique, the ureter is redirected through a new supratrigonal hiatus and submucosal tunnel created in a 5:1 ratio.4 The neoureteral orifice (UO) is relocated distally (subtrigonometry) and medial to the orthotopic UO. In the robotic extravesical technique, adapted from the Lich-Gregoir technique, a mucosa sparing extravesical tunnel is created according to the Paquin guidelines with a 5:1 length to diameter ratio.5,6 In patients who have a previous ureteroneocystostomy complicated by reflux symptoms, the existing reimplant site can be left intact and revised with an extravesical tunnel to prevent reflux. Results: Three patients met inclusion criteria. Two patients underwent nonrefluxing extravesical RUR and one patient underwent intravesical RUR. The patient who underwent an extravesical RUR had a history of reimplantation that was complicated by severe reflux-related symptoms. Intraoperatively, the mean estimated blood loss was 50 mL and mean robotic console time was 162 minutes. Postoperatively, none of the patients experienced major (Clavien >2) complications. With regard to surgical success, at a mean follow-up of 20.5 months, all patients were free of urinary tract infections and obstructive flank pain symptoms. In addition, all patients achieved complete resolution of VUR on postoperative voiding cystourethrogram or renal scan. Conclusions: Nonrefluxing intravesical and extravesical RUR may be safely and effectively utilized for surgical management of adult patients with symptomatic VUR. Moreover, the nonrefluxing extravesical RUR can be used to revise select patients with prior reimplantation complicated by symptomatic reflux. S.K., C.O., and M.L. have no competing financial interests. D.D.E. reports a relationship with Intuitive Surgical that includes consulting or advisory and speaking and lecture fees. D.D.E. reports a relationship with Melzi Corp that includes board membership. D.D.E. reports a relationship with Johnson and Johnson that includes consulting or advisory. Accepted for presentation at Mid-Atlantic AUA 2021. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: Music (Gentle Wave by Ketsa) is not copyrighted material and was obtained from a royalty-free source. Runtime of video: 7 mins 14 secs

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

Introduction and objectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.