Voiding Cystourethrography Research Articles

Voiding Sistoüretrogram ile Tanı Konulan Vezikoüreteral Reflü'nün Saptanmasında Dinamik Böbrek Sintigrafisinin Rolü

Aims: This study aims to evaluate the role of standardized dynamic renal scintigraphy (DRS) in recognizing vesicoureteral reflux (VUR) in patients detected with VUR by voiding cystourethrography (VCUG). Methods: The data of all pediatric patients who underwent both VCUG and DRS [technetium-99m diethylenetriamine pentaacetic acid (Tc-99m DTPA) or technetium-99m mercaptoacetyltriglycine dynamic renal scintigraphy (Tc-99m MAG-3)] in our hospital between 2013 and 2022 were retrospectively reviewed. Tc-99m MAG-3 was used in infants and Tc-99m DTPA radiopharmaceutical in children over one year old. According to VCUG findings, VUR grades were grouped as grade I-II-III low-grade VUR and IV-V high-grade VUR. The role of DRS in detecting VUR in both low and high-VUR-grade groups was evaluated. Results: A total of 56 patients (and 69 renal units), 23 girls (%41.1), and 33 boys (%68.9) were included in this study. The median value of the time elapsed between the DRS and VCUG examinations was nine days. According to VCUG, VUR was grade I in five renal units, grade II in 19 renal units, grade III in six renal units, grade IV in six renal units, and grade V in 33 renal units. DRS detected VUR in two of 30 renal units (%6.7) in the low VUR grade group. On the other hand, VUR was observed with DRS in 27 of 39 renal units (%69.2) in the high VUR grade group. Conclusions: Standardized DRS shows very low sensitivity in recognizing low-grade VUR, and its performance in detecting high-grade VUR is comparatively better. Raising awareness among clinicians that VUR can be observed with standardized DRS will benefit the patient in terms of early detection of accompanying VUR pathologies.

Clinical Outcomes of Voiding Cystourethrogram and Antibiotic Prophylaxis.

Background Urinary tract infections (UTIs) are a prevalent and potentially serious bacterial infection observed among children. Presently, the primary use of diagnostic imaging for UTI is to pinpoint young patients who are at a high risk of developing renal scarring. The most significant procedure for pediatricurology fluoroscopic evaluation is voiding cystourethrogram (VCUG). VCUG-acquired UTIs continue to be an important concern and the purpose of this study is to assess the clinical outcomes of antibiotic prophylaxis on VCUG-associated UTIs. Methods This retrospective study included all patients who underwent VCUG procedures performed from the year 2014 to 2021. All data were retrieved from the medical registries and databases. Radiological and laboratory investigations related to the VCUG procedures were thoroughly reviewed. Patients were considered to have post-procedure UTI if urological symptoms including fever and dysuria along with positive urine culture were exhibited within four weeks after the VCUG study. Patients with incomplete medical records were excluded from the analysis. Results This study consisted of 147 participants. Continuous antibiotic prophylaxis (CAP) was observed in 57 (38.8%) participants of them 35 (23.8%) participants suffered from UTI while urine culture and sensitivity testing were performed among 142 (96.6%) participants before VCUG which came negative and only five (3.4%) had a positive result. Overall, the results of the Chi-square test of association revealed a significant association between sex and vesicoureteral reflux (VUR), indicating that the prevalence of VUR differs between males and females. However, no significant associations were observed between VUR and UTI, urine culture and sensitivity results, hydronephrosis, type of catheter, or choice of antibiotic. Conclusion In conclusion, this study contributes valuable insights into the clinical outcomes of antibiotic prophylaxis on VCUG-associated UTIs. Despite the prophylaxis rate of 38.8%, UTIs were still observed in a significant proportion of children undergoing VCUG. This calls for further research to identify additional risk factors, optimize prophylaxis strategies, and enhance the overall safety and efficacy of VCUG procedures in children.

An innovative method for occluding the urethral meatus and accessing urethra strictures in retrograde urethrography in males

ObjectivesTo observe and evaluate the effectiveness and safety of using a sponge plug method to occlude the urethral meatus during retrograde urethrography (RUG) for accessing male urethral strictures.Methods40 male patients with a mean age of 51.4 years and a history of urethral injury were primarily diagnosed with urethral stricture using a urethrocystoscope. RUG was performed using a ureteral catheter with a sponge plug inserted into the external meatus. Iodixanol, a contrast medium, was injected into the urethra or bladder for performing RUG and voiding cystourethrography (VCUG). The patients were positioned obliquely to obtain urethrograms.ResultsAll X-ray radiologic procedures for performing urethrography were successful without any overflow of contrast liquid observed. In all cases, the sponge plugs became visible in the resulting images. The external meatuses were directly visualized in all cases on the obtained images, allowing identification of the number, location, and length of strictures as well as coexistent pathologies such as fistulas. In one case, the plug slipped off the meatus immediately after completing the procedure. The pain Visual Analogue Scale (VAS) was 0 to 2, mean 0.35. No instances of complication or adverse reactions was observed.ConclusionsThe sponge plug effectively occludes the external urethral meatus for retrograde urethrography, enabling visualization of the actual caliber of the entire urethra, including the strictures and external meatus, by filling it with contrast liquid. This technique is safe and well-tolerated by patients.

Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review

BackgroundA first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time.ObjectiveTo determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach.Materials and methodsA literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined.ResultsPediatricians advocated less imaging and intervention and were more inclined to adopt a “watchful-waiting” approach, confident that any significant abnormality, grades IV–V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results.ConclusionThere are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Non-refluxing Primary Megaureter in Children Resolves From Proximal to Distal

To evaluate a population of children with non-refluxing primary megaureter (NRPM), we investigated spontaneous resolution of ureteral dilation and the pattern (proximal to distal or distal to proximal) in which it occurs. From our prospectively collected prenatal hydronephrosis (HN) database (0-24months, 2008-2017), selecting those with NRPM (n=92). We excluded patients who underwent surgery (n=20), children with <6months follow-up (n=2) and without a voiding cystourethrogram (VCUG) (n=4). Images were segregated into 198 ureteric segments (proximal/mid/distal). We defined resolution as Society for Fetal Urology (SFU) (0/1), anteroposterior diameter (APD) <10mm, and ureteric dilatation <5mm. Descriptive statistics and Kaplan-Meier curves were created for time-to-resolution analyses. Of 66 patients and 198 ureteral segments, median age at presentation was 2months (0-12), 83% were male (33% circumcised). Mean APD at baseline was 11±4mm, and 79% had (SFU 3/4) HN. Mean dilatation of ureteral segments (mm) at baseline was: 9±2 proximal, 9±2 mid, and 11±3 distal. At a median follow-up time of 26 (7-83) months, dilation of 55 (83%) proximal, 48 (72%) mid, and 22 (33%) distal ureteric segments had resolved. Overall, HN resolution occurred in 76% of patients. Resolution rates were similar for proximal/mid-ureters (83% vs 72%; P=.20); however, they were significantly different from distal segments (83% proximal vs 33% distal; 72% mid vs 33% distal, P<.01). Our data suggest that spontaneous resolution of NRPM follows a proximal to distal progression. Distal ureteric dilatation takes up to 10months longer to resolve compared to that of proximal and mid-ureteric segments, as well as that of the renal pelvis.

Does preoperative screening VCUG affect the outcomes and complications of pyeloplasty in patients with ureteropelvic junction obstruction?

The role of voiding cystourethrogram (VCUG) in evaluating vesicoureteral reflux (VUR) in patients with known ureteropelvic junction obstruction (UPJO) remains unclear. While VCUG is frequently performed, the incidence of concomitant VUR and UPJO is low, and VUR is often low-grade with high rates of spontaneous regression. To analyze the clinical relevance of VCUG in patients with UPJO by determining its incidence and studying the difference in clinical outcomes between patients with known, unknown, and negative VUR. Retrospective review of patients with UPJO who underwent pyeloplasty from 2012 to 2020 with <18 years-old, unilateral UPJO, postoperative follow-up of ≥2 months and had at least 1 renal ultrasound (US) after pyeloplasty. Results were compared among 3 groups: patients who underwent VCUG before pyeloplasty and were found to have VUR (group 1), patients who underwent VCUG before pyeloplasty without VUR (group 2), and patients who did not have a VCUG before pyeloplasty (group 3). A total of 275 patients met the inclusion criteria, of which 21 patients were classified in group 1, 166 patients in group 2, and 88 patients in group 3 (Table). The age at preoperative VCUG was 14.7±32.9 months in group 1 and 15.17±35.8 months in group 2 (p=0.960). Overall, the incidence of concomitant UPJO and VUR was 11.2%. In group 1 the initial VUR grade was 5 in 2 patients, 4 in 3, 3 in 5, 2 in 7, and 1 in 4 patients. Of these, only 1 patient required ureteral reimplantation after pyeloplasty. Post-pyeloplasty, no significant differences were observed in complications (p=0.7436), length of follow up (p=0.3212), SFU grade 4 hydronephrosis (p=0.2247), postoperative UTIs (p=0.1047) and pyeloplasty success rate (p=0.4206) among the 3 groups. Despite the use of antibiotic prophylaxis being significantly different amongst the three groups (p<0.001), it was not associated with a lower incidence of postoperative UTIs (group 1 p=0.068, group 2 p=0.486, group 3 p=1). In patients with reflux, an increase in age was associated with a decrease in the rates of complications (p=0.019). We found no significant difference in the outcomes in patients who had a preoperative VCUG as compared to those who did not. The preoperative diagnosis of VUR by VCUG changed the management in less than 1% of the study population and thus its role in patients with UPJO should be reevaluated.

Preoperative fistula diagnostics in male anorectal malformations after colostomy: a single-center experience

BackgroundAccurate preoperative fistula diagnostics in male anorectal malformations (ARM) after colostomy are of great significance. We reviewed our institutional experiences and explored methods for improving the preoperative diagnostic accuracy of fistulas in males with ARMs after colostomy.MethodsA retrospective analysis was performed on males with ARMs after colostomy admitted to our hospital from January 2015 to June 2022. All patients underwent magnetic resonance imaging (MRI) and high-pressure colostogram (HPC) before anorectal reconstruction. Patients with no fistula as diagnosed by both modalities underwent a voiding cystourethrogram (VCUG). General information, imaging results and surgical results were recorded.ResultsSixty-nine males with ARMs after colostomy were included. Age at the time of examination was 52 ~ 213 days, and the median age was 89 days. The Krickenbeck classification according to surgical results included rectovesical fistula (n = 19), rectoprostatic fistula (n = 24), rectobulbar fistula (n = 19) and no fistula (n = 7). There was no significant difference in the diagnostic accuracy between MRI and HPC for different types of ARMs. For determining the location of the fistula, compared to surgery, HPC (76.8%, 53/69) performed significantly better than MRI (60.9%, 42/69) (p = 0.043). Sixteen patients diagnosed as having no fistula by MRI or HPC underwent a VCUG, and in 14 patients, the results were comfirmed. However, there were 2 cases of rectoprostatic fistula that were not correctly diagnosed.ConclusionHigh-pressure colostogram has greater accuracy than MRI in the diagnosis of fistula type in males with ARMs after colostomy. For patients diagnosed with no fistula by both methods, VCUG reduces the risk of false-negative exclusion, and rectoprostatic fistula should be considered during the operation.

National Trends in Voiding Cystourethrograms During Hospitalization for Young Infants With Urinary Tract Infections.

The American Academy of Pediatrics published a guideline in 2011 recommending against the routine use of voiding cystourethrogram (VCUG) in infants aged 2 to 24 months with first febrile urinary tract infection (UTI); however, the rates of VCUG for infants aged <2 months are unknown. The objective of this study was to determine the trend in VCUG performance during index hospitalization among infants aged 0 to 2 months with UTI. This retrospective cohort study included infants aged birth to 2 months hospitalized with a UTI from 2008 to 2019 across 38 institutions in the Pediatric Health Information System. Outcome measures included recurrent UTI within 1 year, vesicoureteral reflux diagnosis within 1 year and antiurinary reflux procedure performed within 2 years. Trends over time were compared between preguideline (2008-2011) and postguideline periods (2012-2019) using piecewise mixed-effects logistic regression. The odds of VCUG decreased by 21% per year in the preguideline period (adjusted odds ratio, 0.79; 95% confidence interval, 0.77-0.81; P < .001) versus 20% (adjusted odds ratio, 0.80; 95% confidence interval, 0.77-0.83; P < .001) in the postguideline period. The preguideline and postguideline difference was not statistically significant (P = .60). There was no difference in the postguideline odds of UTI within 1 year (P = .07), whereas the odds of vesicoureteral reflux diagnosis (P < .001) and antiurinary reflux procedure performance (P < .001) decreased. VCUG performance during hospitalization has declined over the past decade among young infants hospitalized with UTI. Further work is needed to determine the optimal approach to imaging in these young infants.

Mechanical Ablation of the Posterior Urethral Valve Omitting Thermal Energy: A Brief Report.

Management of the posterior urethral valve (PUV) is a clinical challenge in pediatric urology. We report the results of a modified valve ablation method without using a pediatric resectoscope and thermal energy. Patients were selected from children with PUV who were referred to the pediatric urology clinic of Shahid Labbafinejad Hospital, Tehran, Iran, and have undergone endoscopic valve ablation surgery between May 2019 to May 2021. Ten male patients with PUV underwent mechanical valve ablation without the use of the conventional pediatric resectoscope, and thermal energy was replaced by a 6F semi-rigid urethroscope and 3Fr ureteral catheter. Patients were assessed both pre-and postoperatively using serum creatinine, urinary tract ultrasound imaging, and voiding cystourethrography. The mean age was 23.88±30.13 months (range= 25 days to 8 years). Four out of 10 patients (40%) had elevated serum creatinine, and seven had unilateral or bilateral hydroureteronephrosis (70%). No major complications were reported according to Clavien-Dindo Classification System. The level of serum creatinine, the grade of hydroureteronephrosis, and the ratio of the prostatic urethra to anterior urethra diameter in postoperative voiding cystourethrography were decreased. A decrease in serum creatinine level occurred in patients after valve ablation, but this decrease was not statistically significant (P=0.059). The decrease in hydroureteronephrosis grade on the right (P=0.006) and left (P=0.022) was statistically significant. There was no evidence of urethral stenosis or need for repeating resection. It can be concluded that our mechanical valve ablation method might be a safe and effective technique for PUV ablation.

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

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

A quantitative analysis of voiding cystourethrogram features confirms the association between high-grade vesicoureteral reflux with male sex, younger age, and hydronephrosis.

Vesicoureteral reflux (VUR) is commonly diagnosed in the workup of urinary tract infections or hydronephrosis in children. Traditionally, VUR severity is graded subjectively based on voiding cystourethrogram (VCUG) imaging. Herein, we characterized the association between age, sex, and indication for VCUG, by employing standardized quantitative features. We included renal units with a high certainty in VUR grade (>80% consensus) from the qVUR model validation study at our institution between 2013 and 2019. We abstracted the following variables: age, sex, laterality, indication for VCUG, and qVUR parameters (tortuosity, ureter widths on VCUG). High-grade VUR was defined as grade 4 or 5 The association between each variable and VUR grade was assessed. A total of 443 patients (523 renal units) were included, consisting of a 48:52 male/female ratio. The median age at VCUG was 13 months. Younger age at VCUG (<6 months) was associated with greater odds of severe VUR (odds ratio [OR] 2.0), and there was a weak correlation between age and VUR grade (ρ=-0.17). Male sex was associated with increased odds of high-grade VUR (OR 2.7). VCUGs indicated for hydronephrosis were associated with high-grade VUR (OR 4.1) compared to those indicated for UTI only. Ureter tortuosity and width were significantly associated with each clinical variable and VUR severity. Male sex, younger age (<6 months), and history of hydronephrosis are associated with both high-grade VUR and standardized quantitative measures, including greater ureter tortuosity and increased ureteral width. This lends support to quantitative assessment to improve reliability in VUR grading.

A grading system for evaluation of bladder trabeculation.

To establish a parameter-based grading system for evaluating bladder trabeculation (BT). A retrospective analysis was conducted on children diagnosed with posterior urethral valve (PUV) or neurogenic bladder (NB) who underwent voiding cystourethrogram (VCUG), urodynamic testing, and urological ultrasonography between January 2016 and October 2022. Cases involving urologic surgery, secondary bladder pathology, and an interval of more than 12months between examinations were excluded. A parameter named Bladder Dispersion (BD) was calculated through fluoroscopic images, and the grading system was developed as follows: BD < 40 (Grade 0), 40 ≤ BD < 60 (Grade 1), 60 ≤ BD < 90 (Grade 2), BD ≥ 90 (Grade 3). Grades 0-1 were classified as low-risk group, while grades 2-3 were classified as high-risk group. Analysis of variance, Kruskal-Wallis test, and Chi-square test were performed to compare urodynamic results and complications across different grades and groups. A total of 74 patients were eligible to participate, which included 46 boys (62.2%) and 28 girls (37.8%), the mean age was 75.18 ± 48.39months. Among them, 11 (14.9%) were PUV, 50 (67.6%) were NB, and 13 (17.5%) were PUV and NB. Significant differences were observed in maximum detrusor pressure, post-void residual urine ratio, and compliance among grades 0-3. Severe hydronephrosis and histories of urinary tract infection were more prevalent in the high-risk group. A reliable grading system with objective standards was proposed which could aid in the assessment of BT severity.

Clinical outcomes and risk factor analysis of early endoscopic puncture decompression for ureterocele associated with duplex kidney in children: a single-center retrospective study

PurposeThe aims of this study were to analyze the clinical outcomes of treating duplex system ureteroceles with early endoscopic puncture decompression and to identify the risk factors related to outcomes to help guide future work.Materials and methodsWe retrospectively reviewed the clinical records of patients with ureteroceles with duplex kidney that were treated with early endoscopic puncture decompression. Charts were reviewed for demographics, preoperative imaging, surgical indications, and follow-up data. Recurrent febrile urinary tract infections (fUTIs), de novo vesicoureteral reflux (VUR), persistent high-grade VUR, unrelieved hydroureteronephrosis, and the need for further intervention were considered unfavorable outcomes. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), type of ureterocele, ipsilateral VUR diagnosed before surgery, simultaneously upper-pole moiety (UM) and lower-pole moiety (LM) obstruction, the width of ureter affiliated to UM, and maximum diameter of ureterocele were all considered potential risk factors. A binary logistic regression model was used to identify the risk factors of unfavorable outcomes.ResultsA total of 36 patients with ureteroceles related to duplex kidney underwent endoscopic holmium laser puncture from 2015 to 2023 at our institution. After a median follow-up of 21.6 months, unfavorable outcomes developed in 17 patients (47.2%). Three patients underwent ipsilateral common-sheath ureter reimplantation and one patient underwent laparoscopic ipsilateral upper to lower ureteroureterostomy combined with recipient ureter reimplantation. Three patients underwent laparoscopic upper-pole nephrectomy. Fifteen patients suffered from recurrent UTIs were treated with oral antibiotics and eight of them were diagnosed de novo VUR according to voiding cystourethrography (VCUG). In univariate analysis, patients with simultaneously UM and LM obstruction (P = 0.003), fUTIs before surgery (P = 0.044), and ectopic ureterocele (P = 0.031) were more likely to have unfavorable outcomes. Binary logistic regression analysis showed that ectopic ureterocele (OR = 10.793, 95% CI 1.248–93.312, P = 0.031) and simultaneously UM and LM obstruction (OR = 8.304, 95% CI 1.311–52.589, P = 0.025) were identified as independent factors for unfavorable outcomes.ConclusionsOur study suggested that early endoscopic puncture decompression is not a preferred but an available treatment option to release BOO or to cure refractory UTIs. It was easier to fail if the ureterocele was ectopic or simultaneously UM and LM obstruction existed. Gender, age at surgery, BMI, antenatal diagnosis, fUTIs, bladder outlet obstruction (BOO), ipsilateral VUR diagnosed before surgery, the width of ureter affiliated to UM, and maximum diameter of ureterocele were not significantly related to the success rate of early endoscopic punctures.

Correlation of ureteric jet angle (UJA) with vesicoureteral reflux grade and its assessment as a noninvasive diagnostic parameter to detect vesicoureteral reflux

BackgroundVesicoureteral reflux (VUR) is an essential urogenital entity affecting infants and younger children. Many patients present late with recurrent urinary tract infections (UTIs), which lead to chronic pyelonephritis, renal scarring, and end-stage renal disease (ESRD). This progression in disease adds to significant morbidity and mortality in the paediatric age group. Voiding cystourethrography (VCUG) is the investigation of choice which is an invasive procedure and is related to the risk of ionizing radiation and iodinated contrast administration. Ureteric jet angle (UJA) is a Doppler parameter that can be obtained by measuring the angle between the horizontal axis of the floor of the optimally distended bladder and the Doppler ureteric jet at the ureteral opening into the bladder. The study aimed (1) to investigate the correlation of UJA with VUR grade and (2) to assess the utility of UJA as a noninvasive diagnostic indicator to diagnose VUR as an alternative to VCUG.MethodAll paediatric patients with urinary complaints were evaluated by voiding cystourethrography (VCUG) for assessment of grades of VUR, followed by colour Doppler evaluation of ureteric jets. VCUG interpretations were made.UJA was calculated as the angle between the long axis of the colour Doppler jet and the horizontal axis of the floor of the optimally distended urinary bladder on colour Doppler examination. Ureteric jet angles were recorded on both sides irrespective of the presence of VUR, and data were analysed using SPSS. The correlation coefficient (r) with p value was calculated. The diagnostic efficacy of UJA (58° or more) to detect VUR was assessed by calculating sensitivity, specificity, PPV, NPV, positive LR and negative LR. The AUC was calculated to evaluate the diagnostic efficacy of UJA 58° or more to detect VUR.ResultsIn total, 34 (68 renal units) children (8 months–12 years), including 20 males (M) and 14 females (F), examined. The mean age was 4.96 ± 2.87 years for the total population, including 4.60 ± 2.02 years for boys and 5.47 ± 2.75 years for girls. Twenty-one patients (10 girls and 11 boys) showed VUR on MCUG. Eight patients showed high grades (grade III–V), including seven boys and a girl. The range of UJA in VUR-negative patients was 27–60° with a median angle of 42.03°. VUR-positive patients showed an angle range of 32–71°with a median angle of 62.13°. High-grade VUR was seen in 8 patients with an angle range of 59–84° and a median angle of 76.31°. A positive correlation (r = 0.81) was noted between UJA and VUR grading. The sensitivity and specificity of angle > 58° to detect VUR were 0.66 and 0.92 with PPV 0.93 and NPV 0.63. Yuden’s J value was 58°. The value for the area under the curve was 0.7.ConclusionsPositive linear correlation was seen between UJA and VUR grades with high specificity and positive predictive value. The Diagnostic Utility of UJA 58° as a screening method to detect severe VUR was acceptable and can be further studied with a larger sample size.

Study of Tethered Spinal Cord Syndrome Diagnosis Following a Close Examination of Daytime Urinary Incontinence

Background: Tethered spinal cord syndrome refers to neurological disorders caused by the lower end of the spinal cord becoming entrapped in the caudal tissue. Dysuria is one of the most common symptoms and often appears at an early stage. In this study, we investigated cases of children with tethered spinal cord syndrome who were presented to the urology department with daytime urinary incontinence. Subjects and methods: Eighteen children with tethered spinal cord syndrome were diagnosed between March 2011 and October 2017 after a visit to the urology department with daytime urinary incontinence as the main complaint. The reasons for the diagnosis of tethered spinal cord syndrome and the changes in clinical symptoms before and after laminectomy were investigated. Results: Nine boys and nine girls were selected as the study subject. The mean age at the first examination was 6.3 years (range 4–9 years). All patients underwent urodynamics and voiding cystourethrogram (VCUG) for refractory daytime urinary incontinence. Spinal MRI was performed in all patients to investigate abnormal findings on VCUG and urodynamics. Only four patients had indications of tethered spinal cord syndrome on MRI. Eight patients had lipoma of the filum terminale, four patients had potential tethered spinal cord syndrome, four patients had low-lying conus, one patient with conus lipoma, and one patient had intrasacral meningeal cyst. The mean follow-up after laminectomy was 66.3 (22–116) months, 11 patients were asymptomatic, 4 patients had residual nocturia only, and 3 patients were managed with intermittent voiding. Conclusion: It is necessary to treat patients with daytime urinary incontinence is one of the symptoms of the tethered spinal cord syndrome. Bladder function assessed by urodynamics may provide a diagnostic sign for spinal cord compression.

Idiopathic urethral stricture in adolescents: A case series presentation and review of the literature

Objective: To present our case series of idiopathic urethral stricture in adolescents, analyzing the treatments applied and the results obtained. Methods: A retrospective study of 7 patients with idiopathic urethral stricture treated at our center between 2000 and 2021 was performed. Results: The average age at the moment of surgery was 14.7 years. In 85% of cases the main symptom was voiding difficulty. The diagnosis was by voiding cystourethrography (VCUG) in five patients and by cystoscopy in two, locating the stricture in the anterior urethra in all cases. Six patients were treated with endoscopic urethrotomy and one with balloon dilation. Two patients recurred. The subsequent treatment in both cases was a second endoscopic urethrotomy and one of them required a posterior urethroplasty. Currently 6 out of 7 patients are asymptomatic and the patient who underwent urethroplasty is undergoing regular dilations. Limitations: The number of patients is limited due to the shortage of this pathology in childhood. Value: The available literature is quite limited. It is usually secondary to trauma or surgical interventions such as hypospadias repair. Idiopathic etiology represents less than a third of urethral strictures in adolescents and it causes the greatest controversy regarding its management. Conclusions: We should suspect idiopathic urethral stricture in childhood when symptoms appear, such as voiding difficulty in patients without previous pathologies. VCUG can help diagnosis, but a cystoscopy allows diagnosis and treatment at the same time. Endoscopic urethrotomy should be the treatment of choice for idiopathic strictures smaller than 1 cm, since the success rate is greater than 85%.

Comparison of voiding vesicoureteral urosonography with fluoroscopic voiding cystourethrography in children with vesicoureteral reflux.

To evaluate the value and compliance rate of voiding vesicoureteral urosonography in pediatric vesicoureteral reflux (VUR). This is a retrospective study. A total of 80 children with high-risk VUR admitted to Children's Hospital affiliated to Capital Medical University from December 2018 to December 2020 were selected. All patients underwent voiding urosonography (VUS) and fluoroscopic voiding cystourethrography (VCUG). The sensitivity and compliance of voiding vesicoureteral urosonography were compared, and its application value was evaluated. A total of 160 PUUs were examined, and all cases were normal. Among them, 56 PUUs had reflux (35.00%, 56/160), 46 PUUs had reflux under both examination methods (28.75%, 46/160), and 10 PUUs were only detected under VUS (6.25%, 10/160). Thirty-four cases of VUR (42.50%, 34/80) were diagnosed by VUS, among which 15 cases were bilateral reflux and 4 cases were unilateral reflux. Twenty-five cases (35.00%, 25/80) were diagnosed by VCUG, among which 10 cases were bilateral regurgitation and five cases were unilateral regurgitation. No significant difference was observed in the detection rate of reflux between the two methods (P=0.432). A total of 146 PUUs were found to be consistent between the two methods (91.25%, 160), including 2 Grade-I reflux, 6 Grade-II reflux, 14 Grade-III reflux, 12 Grade-IV reflux, eight Grade-V reflux, and 104 without reflux, demonstrating SATISFACTORY consistency between the two groups (Kappa=0.885). Voiding vesicoureteral urosonography has a high coincidence rate in the detection of vesicoureteral reflux in children.

Four-Point Injection Technique of Polyacrylate/Polyalcohol Copolymer in Vesicoureteral Reflux After Kidney Transplant.

Vesicoureteral reflux after kidney transplant is mostly asymptomatic, but recurrent urinary tract infections can cause graft rejection. Although the gold standard treatment is open surgical repair, we believe that endoscopic treatment can be further improved. Here, we investigated the long-term outcomes of 4-point endoscopic injection of polyacrylate/polyalcohol copolymer in patients with vesicoureteral reflux after kidney transplant. Patients who had undergone 4-point endoscopic injection of polyacrylate/polyalcohol copolymer for symptomatic vesicoureteral reflux after kidney transplant and were followed for at least 3 years were included. Patients with dysfunctional and/or obstructive voiding patterns, unsuccessful primary endoscopic treatment, concomitant injection of native kidney reflux, and incomplete follow-up were excluded. We evaluated patient characteristics, perioperative data, and clinical and radiological outcomes. Urine culture, serum creatinine, and renal ultrasonography were assessed every 3 months. Voiding cystourethrography was performed at month 3 and when recurrence was suspected. Clinical success was defined as absence of febrile urinary tract infection during follow-up, and radiological success was defined as absence of vesicoureteral reflux in the voiding cystourethrography. Of 21 study patients, 14 (66.6%) were female and 7 (33.3%) were male patients. Average age was 37.1 years (range, 12-62 years). According to preoperative voiding cystourethrography, 3 patients (14.2%) had grade II, 13 patients (61.9%) had grade III, and 5 patients (23.8%) had grade IV vesicoureteral reflux. Eighteen patients (85.7%) had clinical success with the first injection, and 20 patients (95.2%) had success with the second injection. Eleven patients (52.3%) demonstrated radiological success. The reflux degree of all patients, except 2, had partially or completely regressed. Ureteral balloon dilatation and double J stent implantation was performed in 1 patient (4.7%) due to ureteral obstruction. The 4-point injection of polyacrylate/ - polyalcohol copolymer provided long-term permanent success for symptomatic vesicoureteral reflux after kidney transplant.

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

V04-08 VIDEO ABSTRACT: NOVEL TREATMENT APPROACH OF A NEONATAL URETHRAL POLYP

You have accessJournal of UrologyCME1 Apr 2023V04-08 VIDEO ABSTRACT: NOVEL TREATMENT APPROACH OF A NEONATAL URETHRAL POLYP Kieran Moore, Rodrigo Romao, Daniel Keefe, and Dawn Maclellan Kieran MooreKieran Moore More articles by this author , Rodrigo RomaoRodrigo Romao More articles by this author , Daniel KeefeDaniel Keefe More articles by this author , and Dawn MaclellanDawn Maclellan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethral polyps are a rare entity, and typically present in male patients being investigated for dysuria, hematuria, or urinary retention. The etiology of these benign tumours remains unclear; however, they are likely to arise from the verumontanum (mesonephric duct), or a remnant from the sinus tubercule (paramesonephric duct). We describe a novel surgical approach to a urethral polyp causing urinary retention in a newborn. METHODS: A term baby (3815 g) admitted to the neonatal intensive care unit with congenital diaphragmatic hernia and respiratory distress was found to be in urinary retention post operatively. Comorbidities included pulmonary hypertension, bilateral hydroceles, and ear dysmorphism with normal microarray and spinal ultrasound (US). A formal US demonstrated an avascular mass in the urethra, suspicious for a polyp with a distended bladder and no hydronephrosis. Voiding cystourethrogram (VCUG) revealed a well-defined pedunculated polyp protruding into the urethra with voiding, and no evidence of reflux. Surgical options that have been described include resection with cold knife, fulguration and more recently, laser ablation. Additionally, larger polyps not amendable to endoscopic removal may require a trans-vesical approach. RESULTS: In the operating room, the ureteric orifices were orthotopic. The polyp was identified using a 6-French cystoscope just proximal of the verumontanum, with a well-defined stalk. Debris within the bladder suggested incomplete emptying. Given its large size and thin stalk, the polyp was resected in its entirety using a zero-tip loop-snare. Hemostasis was achieved with a monopolar fulgurating electrode. Pathology confirmed a benign urethral polyp. The baby was voiding well without urinary tract infections at follow up 6 weeks later, with no residual polyp or hydronephrosis on US. With this complete resection, prognosis remains excellent with recurrence unlikely. CONCLUSIONS: When suspected, the diagnosis of urethral polyps is achieved with VCUG and US, with ultimate endoscopic resection. We describe the successful endoscopic resection of a urethral polyp in a neonatal child with a loop snare, the first approach to our knowledge. This approach uses instruments readily available to the pediatric urologist and avoids the use of a resectoscope, and thus, the need for urethral dilatation in the newborn. Source of Funding: No funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e340 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kieran Moore More articles by this author Rodrigo Romao More articles by this author Daniel Keefe More articles by this author Dawn Maclellan More articles by this author Expand All Advertisement PDF downloadLoading ...