VUR In Children Research Articles

Diagnostic accuracy of ureteric jet angle and location in children with vesicoureteric reflux: A retrospective study

AbstractBackgroundVesicoureteral reflux (VUR) is a common urological abnormality in children that can lead to urinary tract infections and renal scarring. Micturating cystourethrogram (MCU) is the gold standard for diagnosis but is invasive and involves radiation exposure. This study investigates the diagnostic accuracy of ureteric jet angle (UJA) and midline to ureteric orifice distance (MOD) measurements using colour Doppler ultrasonography as a non‐invasive alternative.ObjectivesTo determine the association between UJA and MOD with the presence and severity of VUR in children referred for MCU.MethodsThis retrospective diagnostic accuracy study in an Australian quaternary paediatric hospital included 42 children (68 renal units) referred for MCU to investigate suspected VUR. Colour Doppler ultrasonography was used identify the ureteric jets, permitting measurement of UJA and MOD, which were compared to MCU results (reference standard). Analysis included ROC curves, Mann–Whitney and Kruskal–Wallis tests.ResultsVUR was present in 25 of 68 units (36.8%). Thirty‐two males and 10 females included; mean age 10 months 18 days (range: 26 days to 8 years). Median UJA for VUR units 67.0° (IQR 46.0°) versus non‐VUR 51.0° (IQR 26.0°), p = 0.002. Median MOD for VUR units 8.9 mm (IQR 7.2 mm) versus non‐VUR 5.8 mm (IQR 4.2 mm), p = 0.006.Diagnostic AccuracyUJA: AUC 0.728 (95% CI: 0.590–0.866), optimal cut‐off 56.5°. MOD: AUC 0.701 (95% CI: 0.568–0.835), optimal cut‐off 6.7 mm.DiscussionUJA and MOD measurements show potential as non‐invasive indicators of VUR presence. However, they did not reliably differentiate between individual grades of VUR severity.RegistrationNot applicable.

History of endoscopic treatment of vesicoureteral reflux.

Since its first clinical application in 1984, the endoscopic subureteral injection of bulking agents has become an alternative to long-term antibiotic prophylaxis and open surgical intervention in the treatment of VUR in children. The 15min day care endoscopic procedure has gained worldwide popularity in the management of VUR in children. Over the years, multiple studies have demonstrated safety and long-term efficacy of this minimally invasive outpatient procedure. Nowadays almost 90% of the surgical treatment of VUR in Sweden is done by endoscopic procedure. In the current article, our aim was to review how the endoscopic treatment of VUR developed.

Color Doppler Ultrasound's Utility in Detecting Vesicoureteral Reflux Using the Ureteral Jet Angle.

This study hypothesizes using color Doppler ultrasound to measure ureteral jet angles (UJA) as a diagnostic screening tool for reflux. The present prospective cohort study included 122 patients and 238 renal unit pediatric patients suspected of VUR who presented to our hospital between 2019 and 2021. All patients underwent ultrasonography and VCUG, and the UJA was measured color Doppler evaluation of the ureteral jet. The UJA was compared with the VCUG findings in patients with and without reflux. SPSS 26 was used to analyze the data. A total of 96 patients and 139 renal units exhibited reflux. The mean ureteral jet angle in refluxing units was 60.47 + 16.66 degrees, whereas, it was 42.59 + 13.26 degrees in non-refluxing units, a significant difference between the two groups (P < .001). The mean ureteral jet angle was 42.59, 45.89, 60.32, 68.23, and 56.16, for reflux grading from 0 to 5 (except grade 1), respectively. The angle value in each reflux grade increased significantly except for grade 5. For reflux detection (grade I-V), a cut-off angle of 50 degrees was associated with sensitivity and specificity of 70 and 79, respectively. Grade IV/V reflux can be diagnosed with a sensitivity of 70% and specificity of 84% using a cut-off angle of 68 degrees or greater. UJA detection via color Doppler ultrasound demonstrates high accuracy, is non-invasive method can be utilized as an alternative primary diagnostic tool or in follow-up cases of VUR in children.

''Efficacy and Safety of Polyacrylate Polyalcohol Co-polymer (Vantris) Injection Material in the Endoscopic Treatment of VUR in Children: 3 Years of Prospective Follow Up

''Efficacy and Safety of Polyacrylate Polyalcohol Co-polymer (Vantris) Injection Material in the Endoscopic Treatment of VUR in Children: 3 Years of Prospective Follow Up

When does vesicoureteral reflux in pediatric kidney transplant patients need treatment?

The treatment of VUR in children with UTI has changed significantly, due to studies showing that antibiotic prophylaxis does not decrease renal scarring. As children with kidney transplants are at higher risk for UTI, we investigated if select patients with renal transplant VUR could be managed without surgery. A total of 18 patients with VUR into their renal grafts were identified, and 319 patients underwent transplantation from 2006 to 2016. The cause for the detection of the VUR, treatment, and graft function was reviewed. Six boys and 12 girls were identified, 13 of whom had grade 3 or 4 VUR into the renal graft. Nine patients presented with hydronephrosis or abnormal renal biopsy: eight were successfully managed with antibiotic prophylaxis and bladder training, one developed UTI and underwent Dx/HA subureteric injection. Nine patients presented with recurrent febrile UTI, only one was successfully managed without surgery. Only 2 of 9 (22%) patients who underwent Dx/HA injection had resolution of their reflux. Of the remaining seven, five required open ureteral reimplantation (two for obstruction), one lost the graft due to rejection, and one had significant hydronephrosis. eGFR was similar between the hydronephrosis, UTI, and abnormal renal biopsy groups at all times. Patients with transplant VUR and recurrent febrile UTI are more likely to require surgical therapy, but the complication and failure rate for Dx/HA injection is significant. Patients with transplant VUR without febrile UTI can be successfully managed with bladder training and temporary antibiotic prophylaxis.

Durasphere® EXP: a non-biodegradable agent for treatment of primary Vesico-Ureteral reflux in children

ABSTRACTIntroduction:Durasphere® EXP (DEXP) is a compound of biocompatible and non--biodegradable particles of zirconium oxide covered with pyrolytic carbon. The aim of this study is to evaluate the durability of off-label use of DEXP in the treatment of primary vesicoureteral reflux in children.Materials and Methods:Patients who underwent subureteric injection of DEXP for the correction of primary VUR were retrospectively reviewed. Patients aged >18 years as well as those who had grade-I or -V VUR, anatomic abnormalities (duplicated system, hutch diverticulum), neurogenic bladder or treatment refractory voiding dysfunction were excluded. Radiologic success was defined as the resolution of VUR at the 3rd month control. Success was radiographically evaluated at the end of the first year.Results:Thirty-eight patients (9 boys, 29 girls; mean age, 6.3±2.7 years) formed the study cohort. Forty-six renal units received DEXP (grade II: 22; grade III: 18; grade IV: 6). Mean volume per ureteric orifice to obtain the mound was 0.70±0.16mL. First con- trol VCUG was done after 3 months in all patients. After the first VCUG, 6 patients had VUR recurrence. Short-term radiologic success of DEXP was 84.2%. Rate of radiologic success at the end of the first year was 69.4% (25/32). Lower age (p:0.006) and lower amount of injected material (p:0.05) were associated with higher success rates at the end of 1 year.Conclusion:This is the first study to assess the outcomes of DEXP for treatment of primary VUR in children. After 1 year of follow-up, DEXP had a 69.4% success rate.

Ускладнення ендовезикальної корекції міхурово-сечовідного рефлюксу у дітей

Objective. To reduce the percentage of complications in children after intravesical correction of VUR. Material and methods. The clinical material covers 270 patients with uni- and bilateral VUR II-IV grades, aged from 9 months to 14 years. Patients with VUR were collected complaints and anamnesis, a clinical examination, general clinical laboratory examinations with an assessment of the functional status of the glomerular apparatus and the degree of nephrosclerosis, ultrasound of the urinary tract and bladder with Doppler effect, retrograde cystography, excretory urography, dynamic angiography and renography with 99mTc-DTPA, cystoscopy. At the stage of clinical and laboratory remission patients underwent intravesical restored urodynamics – STING (subureteric injection), HIT (hydrodistention implantation technique), Double HIT, and, if necessary, their combination. Results. In the early postoperative period 8 (2.96%) patients had a disorder of urodynamics with exacerbation of pyelonephritis, requiring more intensive and prolonged parenteral antibiotic therapy – more than 3 days. In 4 patients a dilatation of the ureter and pyelocaliceal system (PCS) with signs of urinary tract obstruction was revealed via the ultrasonography. These patients performed an intravesical internal stenting of ureter and PCS with JJ-stent for 1-3 months. In 2 patients in the late postoperative period an obstructive ureterohydronephrosis was diagnosed according to the urological X-ray examination, which required the ureterocystoneostomy. The clinical case of minimally invasive removal of concrement fragments from the left ureter after intravesical treatment of VUR III grade in both segments of the left double kidney in a 3-year-old patient, who was twice operated and the defect was successfully corrected. Obstructive uropathy after the injection of implant under the urethra orifice is the results of neuromuscular dysplasia of the urinary tract, which associated with fibrous tissue changes in the area of the uretero-vesical junction. Conclusions. The endoscopic method is the most optimal way of treating VUR in children and its complications. However, intravesical treatment of VUR, as well as other methods of surgical intervention, also has various complications.

Urinary tract infection and vesicoureteral reflux in children with mild antenatal hydronephrosis

ObjectiveThe postnatal management of mild antenatal hydronephrosis (ANH) remains controversial. The purpose of this study was to evaluate the incidence of UTI and VUR in children with mild ANH in order to determine the necessity of antibiotic prophylaxis (ABP) and VCUG. MethodThe data of 1511 patients with various grades of ANH who were referred to Department of Urology, Boston Children's Hospital between January 1998 and January 2010 were reviewed and 760 patients who had mild ANH were identified. The inclusion criteria were:1) A confirmed report of ANH or actual prenatal ultrasound (US) images.2) Postnatal evaluation and management conducted at the hospital.3) Persistent mild hydronephrosis on the first US done between two weeks and three months of age.4) No other US findings such as ureteral dilatation, duplication anomalies or bladder abnormalities.5) At least one three-month follow up.Univariate statistical analysis was performed using a Student's t test. ResultsOf the 760 patients who were identified, 608 (80%) were males, and 225 (30%) had bilateral mild hydronephrosis. Of these, 475 patients (63%) underwent an initial screening VCUG. VUR was identified in 13 patients (1.7%) with grades varying from 1 to 5. At follow up, hydronephrosis resolved in 67% of the renal units and worsened in 3.3%. Among the 692 patients with available follow-up data, 23 (3.3%) had a documented UTI. Twelve of these children had an initial screening VCUG that was negative for VUR. Of these 12 patients, seven underwent a subsequent RNC with none having VUR; five of the 12 patients did not undergo a repeat evaluation for VUR (four had a UTI after the screening VCUG and one had an afebrile UTI). Eleven of the 23 children with mild ANH did not have an initial screening VCUG, and all underwent a subsequent VCUG/RNC. Only two children were then found to have VUR Grade 4–5. ConclusionThe incidence of UTI and VUR in children with mild ANH is low. Consequently, routine VCUG screening for VUR and the use of long-term ABP is not necessary for all patients with asymptomatic mild AHN. Evaluation for VUR in children with mild ANH should be reserved for those who subsequently present with a UTI.

Endoscopic treatment of vesicoureteric reflux with dextranomer/hyaluronic acid copolymer (Deflux): Single-surgeon experience with 48 ureters

Purpose:VUR is a common urologic problem in children. Cystoscopic injection of bulking agents (most commonly Deflux) has gained popularity as the first line treatment in the west. However, primarily due to cost factors, it has not gained much popularity in our country. We present our initial experience with cystoscopic Deflux injection for VUR.Materials and Methods:We reviewed our 3-yr experience with the use of Dx/HA (Deflux) for correction of VUR in children and adolescents. All children were evaluated with Ultrasound, MCUG and DMSA renal cortical scan. The indications for surgical correction of VUR included breakthrough infections while on antibiotic prophylaxis, persistent high-grade VUR beyond 3 yrs of age, and presence of significant renal damage on DMSA at diagnosis (in those children presenting with UTI). All children underwent cystoscopic Deflux injection using the standard technique of subureteral injection (0.4-1 ml per ureter). All children received antibiotic prophylaxis for 3-6 months after the injection. USG was done at 1 month and MCUG at 3-6 months after the injection.Results:33 patients (48 ureters) underwent cystoscopic Deflux injection for correction of VUR. Mean age was 4.5 yrs (1-17 yrs); there were 12 boys and 21 girls. Thirteen children had antenatally diagnosed HDN, while 20 children presented with febrile UTI. All children had primary VUR except one child with persistent VUR 4 yrs after PUV fulguration. The VUR was grade 1-2 in 8, grade 3-4 in 37, and grade 5 in 3 ureters. Every child had at least one ureter with dilating reflux (grades 3,4 or 5). When present, low grade VUR (grade 1or 2) was always on the contralateral side. Only one child received a 2nd injection after 6 months. Follow-up MCUG was done in 28 children (41 ureters). Complete reflux resolution was achieved in 27 ureters (65%), and the reflux was downgraded in 2 (5%). There were no complications of Deflux injection.Conclusions:Endoscopic correction of VUR in children is a safe and effective minimally invasive treatment for VUR. It stops or downgrades VUR in 70% of ureters. At present, we recommend it as a first-line treatment for grades 1-4 VUR requiring surgical management. Cost is the major factor limiting its use in our country.

The influence of ureteral orifice configuration on the success rate of endoscopic treatment of vesicoureteral reflux

Background:To investigate the effect of polyacrylate polyalcohol copolymer (Vantris) injection for the correction of VUR in children according to ureteral orifice shape and VUR grade.Materials and Methods:Forty children (29 girls and 11 boys) with 61 renal refluxing units (RRU) and primary VUR underwent endoscopic correction of their reflux, using Vantris. Under general anesthesia, routine cystoscopy was performed and ureteral orifice configuration and dynamic hydro distention grade were determined. The injection technique was STING, HIT or a combination of them. Ultrasound scan was performed one and 3 months after injection and radionuclide cystography (RNC) was performed 3 months after the operation.Results:The mean volume of injected Vantris was 0.62 cc. Reflux was corrected in 52 (85.2%) of the 61 RRU after single injection and this equates reflux correction in 37 of the 40 patients. No significant correlation was observed between ureteral orifice shape and VUR correction rate.Conclusions:Our results showed that there was no correlation between the ureteral orifice configuration and the success rate of endoscopic surgery for VUR in short term.

Graft Vesicureteral Reflux in Children

PURPOSE Few reports have been published on the incidence of VUR in children after kidney transplantation. We analyze our graft VUR incidence and its clinical relevance. MATERIAL AND METHODS We report 140 kidney transplantations that were done during 1996-2006 (mean follow-up 4 yrs). A modified Lich-Gregoir antireflux procedure was used in all. We analyzed etiology of ESRD, native and graft VUR, bladder dysfunction and residual diuresis, rejection and acute pyelonephritis (APN). A routine VCUG was made 1 year after transplant. RESULTS Mean age at renal transplantation was 7 yrs (1-16) and 44% were less than 6 yrs old. Reflux was present in 35% of grafts, (13% also the native kidney), and reflux was present in the native kidneys alone in 17%. ESRD was due to PUV in 23% and half of these had graft VUR. Bladders were dysfunctional in 16% of the patients and without diuresis in 24%. Graft reflux was present in 42% of the former and in 50% of the patients with non-diuretic bladders. Four patients with graft VUR had a previous bladder augmentation. APN was related with graft VUR in 37% of patients, increasing to 70% in those with graft and native VUR. No patients without VUR had APN. Graft function and rejection episodes were similar in those with or without VUR. Five grafts were lost, 2 to primary failure and 3 to chronic allograft nephropathy. CONCLUSIONS The incidence of graft VUR is elevated and was associated with an increased risk of APN. However, it does not seem to negatively affect graft survival.