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Rivera Pereira BMY, Landa Juárez S, Márquez González H. Laparoscopic Lich - Gregoir ureteroneocystostomy versus open surgery: Are there benefits from the minimally invasive procedure? J Pediatr Urol 2024:S1477-5131(24)00589-8. [PMID: 39580348 DOI: 10.1016/j.jpurol.2024.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 10/31/2024] [Accepted: 11/05/2024] [Indexed: 11/25/2024]
Abstract
BACKGROUND The optimal treatment of vesicoureteral reflux is controversial. When patients need surgery, the gold standard is open vesicoureteral reimplantation. Despite the more frequent use of laparoscopy when managing vesicoureteral reflux, we have found scarce comparative studies comparing the open versus the laparoscopic Lich-Gregoir reimplantation. OBJECTIVE The aim of this study is to compare the open Lich-Gregoir reimplantation technique versus the laparoscopic approach, in patients with primary vesicoureteral reflux in terms of complications and the procedure´s success, to document the benefits of minimal invasion. STUDY DESIGN This is a cross-sectional retrospective study of a single Institution, in which we collected the information of pediatric patients with primary vesicoureteral reflux from their clinical charts, in whom either an open or laparoscopic reimplantation following the Lich- Gregoir technique was performed, between January 1, 2013, and December 31, 2017. Patients with incomplete records were excluded. This was a non-probabilistic, consecutive case sample. The Chi-square test or Mann-Whitney´s U were used, as appropriate, to establish between-group differences. RESULTS Sixty-eight patients were included, 27 in the open Lich-Gregoir group (OLG), and 41 in the laparoscopic Lich- Gregoir group (LLG). We found no statistical differences in operative times and mean hospital stay. Post-operative complications in the OLG versus the LLG group were similar. The open procedure was successful in 85.2 % and in 90.2 % laparoscopic cases, with no statistically significant difference between groups. DISCUSSION We found no statistically significant differences between an open and a laparoscopic approach. The percentage of success was below the expected, this could be result of the large percentage of patients with high-grade reflux and the patients' complex anatomy in both groups. Our study is limited by the small number of patients and by its retrospective design. CONCLUSIONS The laparoscopic approach with the Lich-Gregoir technique yields similar results to the open technique. However, in this study, we were unable to demonstrate any additional benefits from the laparoscopic approach.
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Affiliation(s)
- Bárbara María Yolanda Rivera Pereira
- Pediatric Urologist at the Centro Médico Nacional Siglo XXI [National Medical Center "Siglo XXI"], High Specialty Medical Unit Pediatric Hospital "Silvestre Frenk Freund" Mexican Social Security Institute, Avenida Cuauhtémoc No.330, Colonia Doctores, Cuauhtémoc, P.C. 06720 Mexico City, Mexico.
| | - Sergio Landa Juárez
- Pediatric Urologist, Head of the Pediatric Urology Department at the Centro Médico Nacional Siglo XXI [National Medical Center "Siglo XXI"], High Specialty Medical Unit Pediatric Hospital "Silvestre Frenk Freund" Mexican Social Security Institute, Mexico.
| | - Horacio Márquez González
- National Investigator at the Centro Médico Nacional Siglo XXI [National Medical Center "Siglo XXI"], High Specialty Medical Unit Pediatric Hospital "Silvestre Frenk Freund" Mexican Social Security Institute, Mexico.
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Nascimben F, Molinaro F, Maffi M, Nino F, Lachkar A, Zislin M, Ogunleye M, Becmeur F, Messina M, Cobellis G, Lima M, Angotti R, Talon I. Endoscopic injection vs anti-reflux surgery for moderate- and high-grade vesicoureteral reflux in children: a cost-effectiveness international study. J Robot Surg 2024; 18:371. [PMID: 39412617 PMCID: PMC11485032 DOI: 10.1007/s11701-024-02103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 09/14/2024] [Indexed: 10/19/2024]
Abstract
Even if vesicoureteral reflux is a common condition in children, there are no guidelines about the best therapeutic approach. This study aims to compare the results of endoscopic injection and ureteral reimplantation in children with grade III, IV and V VUR. A multicenter retrospective study included children with grade III, IV and V VUR treated from 2003 to 2018 at three Departments of Pediatric Surgery. Patients were divided into Group A (endoscopic injections) and Group B (anti-reflux surgery), B1 (open, OUR), B2 (laparoscopic, LUR) and B3 (robot-assisted laparoscopic RALUR). Follow-up was at least 5 years. 400 patients were included, 232 (58%) in group A and 168 (42%) in group B. Mean age at surgery was 38.6 months [3.1-218.7]. Mean follow-up was 177.8 months [60-240]. Group A had shorter operative time than group B (P < 0.01); lower analgesic requirement (p < 0.05), shorter hospital stay (P < 0.05) and lower overall costs (p < 0.05), but higher postoperative PNPs (p < 0.01), lower success rate (p < 0.01) and higher redo-surgery percentage (p < 0.01). No differences in terms of postoperative complications, success rate and mean radiation exposure between the two groups. Endoscopy is associated with shorter operative time, shorter hospitalization and lower cost, also in case of multiple injections. Recurrence rate after surgery is lower meaning lower rate of re-hospitalization and radiation exposure for children.
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Affiliation(s)
- F Nascimben
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
- Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Viale Bracci 14, 53100, Siena, Italy.
| | - F Molinaro
- Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Viale Bracci 14, 53100, Siena, Italy
| | - M Maffi
- Pediatric Surgery Department, Istituti Di Ricovero E Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitraia Di Bologna, Bologna, Italy
| | - F Nino
- Pediatric Surgery, Salesi Children Hospital, Università Politecnica Delle Marche, Ancona, Italy
| | - A Lachkar
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - M Zislin
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - M Ogunleye
- Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Viale Bracci 14, 53100, Siena, Italy
- Pediatric Surgery Department, Istituti Di Ricovero E Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitraia Di Bologna, Bologna, Italy
| | - F Becmeur
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - M Messina
- Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Viale Bracci 14, 53100, Siena, Italy
| | - G Cobellis
- Pediatric Surgery, Salesi Children Hospital, Università Politecnica Delle Marche, Ancona, Italy
| | - M Lima
- Pediatric Surgery Department, Istituti Di Ricovero E Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitraia Di Bologna, Bologna, Italy
| | - R Angotti
- Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Viale Bracci 14, 53100, Siena, Italy
| | - I Talon
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Quiring ME, Son Y, Thaker R, Davidson N, Wu E, Fink BA, Thomas B, Gentry NB, Yossef A, DeMario VK, Earnshaw L, Weldekidan B, Dean G. Vesicoureteral reflux severity is not associated with unplanned urinary catheterization or length of hospital stay after ureteroneocystostomy. J Pediatr Urol 2024; 20:183-190. [PMID: 37770341 DOI: 10.1016/j.jpurol.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023]
Abstract
INTRODUCTION Vesicoureteral reflux (VUR) is a common urologic condition affecting approximately 1% of all children. Surgical success often depends on the grade of VUR, as patients with grades 4 or 5 have been have a greater risk for postoperative complications. Unplanned urinary catheter placement (UCP) postoperatively and prolonged length of hospital stay (LOS) are indicative of unexpected complications. The association between VUR severity and such metrics remain unclear. OBJECTIVE The study's objective is to determine if the severity of VUR is associated with higher rates of UCP or prolonged LOS after ureteroneocystostomy (UNC). STUDY DESIGN The 2020 National Surgical Quality Improvement Program Pediatric database was analyzed for patients with VUR. A total of 1742 patients were initially evaluated with 1373 meeting exclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed, and logistic regression was performed with both UCP and LOS as dependent variables. RESULTS Among the 1373 patients, 2.9% were included in Group A, 32.5% were in Group B, and 64.6% were in Group C. Significant differences were found among the groups for mean age, gender, inpatient status, rate of congenital malformation, ureteral stents, and ASA classification. Regarding surgical treatment, differences were also found comparing mean operative time, LOS, laterality and type of procedure, urine culture results, rates of UTI, surgical site infections, postoperative returns to the emergency department, and unplanned procedures and catheterization. Multivariate analysis demonstrated no significant association between the rate of UCP and VUR severity, while postoperative UTI and unplanned procedure were both independent factors associated with UCP postoperatively. Additionally, postoperative UTI, ASA classification, mean operation time, ureteral stent placement, unplanned procedure, and UCP were independent factors found to contribute to LOS. CONCLUSION Greater VUR severity does not appear to increase the need for catheterization or prolong hospital stay, while the development of a UTI postoperatively or having an additional unplanned procedure are associated with an increased likelihood of both. The postoperative course after UNC also appears to be influenced more so by other factors such as the operative approach and whether complications arise.
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Affiliation(s)
- Mark E Quiring
- University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX 76107, USA.
| | - Young Son
- Jefferson Health New Jersey, Department of Urology, 18 E Laurel Rd, Stratford, NJ 08084, USA.
| | - Ranel Thaker
- Lake Erie College of Osteopathic Medicine, 1858 W Grandview Blvd, Erie, PA 16509, USA.
| | - Noah Davidson
- Lake Erie College of Osteopathic Medicine, 1858 W Grandview Blvd, Erie, PA 16509, USA.
| | - Edward Wu
- Alabama College of Osteopathic Medicine, 445 Health Sciences Blvd, Dothan, AL 36303, USA.
| | - Benjamin A Fink
- Jefferson Health New Jersey, Department of Urology, 18 E Laurel Rd, Stratford, NJ 08084, USA; Rowan University, School of Osteopathic Medicine, 113 E Laurel Rd, Stratford, NJ 08084, USA.
| | - Brian Thomas
- Rowan University, School of Osteopathic Medicine, 113 E Laurel Rd, Stratford, NJ 08084, USA.
| | - Nathaniel B Gentry
- New York Institute of Technology College of Osteopathic Medicine, 2405 Aggie Rd, Jonesboro, AR 72401, USA.
| | - Angie Yossef
- Pacific Northwest University of Health Sciences College of Osteopathic Medicine, 200 University Parkway, Yakima, WA 98901, USA.
| | - Virgil K DeMario
- University of the Incarnate Word, School of Osteopathic Medicine, 7615 Kennedy Hill Dr, San Antonio, TX 78235, USA.
| | - Lance Earnshaw
- Jefferson Health New Jersey, Department of Urology, 18 E Laurel Rd, Stratford, NJ 08084, USA.
| | - Blen Weldekidan
- Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA.
| | - Gregory Dean
- Temple University, Department of Urology, 3401 N Broad St, Philadelphia, PA 19140, USA.
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Zvizdic Z, Catic A, Zivojevic S, Jonuzi A, Glamoclija U, Vranic S. The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction. J Pediatr Urol 2024; 20:295-301. [PMID: 37940510 DOI: 10.1016/j.jpurol.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Early diagnosis and treatment of primary vesicoureteral reflux (VUR) are essential for preserving renal function. OBJECTIVES The study explored whether preoperative cystoscopic grading of refluxing ureteric orifices (UO) correlated with their shape in an institution with non-performance of hydrodistention of the UO in the diagnosis and grading of VUR. We also assessed the relationship between the UO shape and VUR grade with the effectiveness of endoscopic correction of primary VUR in children. METHODS This retrospective study included consecutive patients ≤15 years treated for primary VUR. The reflux grade was based on the results of preoperative voiding cystourethrography as mild, moderate, or severe. RESULTS Fifty-one patients with 77 renal refluxing units (RRU) underwent endoscopic treatment with Deflux®. VUR was bilateral in 51 % of patients. VUR was mild in 13 %, moderate in 53 %, and severe in 34 % of cases. The patients with mild and moderate VUR had stadium-shaped UOs in 60 % and 54 % RRUs, respectively. Horseshoe-shaped UOs constituted 42 % of UOs in patients with severe VUR, followed by 31 % of golf-hole UOs. The reflux resolution rate after the first endoscopic injection was 84 %. The preoperative VUR grade correlated with UOs shape (p < 0.001). No significant correlation between UOs configuration and the outcome of endoscopic treatment was seen (p = 0.452). The preoperative VUR grade negatively correlated with a favorable endoscopic treatment (p = 0.043). DISCUSSION AND CONCLUSION Our data indicate ureteral orifice shapes are closely related to preoperative VUR grade. There was no correlation between the UO configuration and the success rate of endoscopic treatment of VUR, in contrast to the significant negative correlation between the VUR grade and the success rate of endoscopic treatment.
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Affiliation(s)
- Zlatan Zvizdic
- Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Adna Catic
- Department of Clinical Pathology, Cytology and Human Genetics, Clinical Center of the University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Selma Zivojevic
- Department of Anesthesiology and Reanimation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Asmir Jonuzi
- Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Una Glamoclija
- Scientific Research Unit, Bosnalijek d.d., Sarajevo, Sarajevo, Bosnia and Herzegovina; Department for Biochemistry and Clinical Analysis, Faculty of Pharmacy, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, Doha, Qatar.
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Hewitt IK, Roebuck DJ, Montini G. Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review. Pediatr Radiol 2023; 53:2651-2661. [PMID: 37776490 PMCID: PMC10698093 DOI: 10.1007/s00247-023-05771-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time. OBJECTIVE To 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 METHODS A 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. RESULTS Pediatricians 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. CONCLUSION There 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.
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Affiliation(s)
- Ian K Hewitt
- Department of Pediatric Nephrology, Perth Children's Hospital, Nedlands, 6009, Australia
| | - Derek J Roebuck
- Division of Pediatrics, Medical School, University of Western Australia, Crawley, 6009, Australia.
- Department of Medical Imaging, Perth Children's Hospital, Nedlands, 6009, Australia.
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda IRCCS, Policlinico di Milano, Milan, Italy
- Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
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Hou SW, Xing MH, Gundeti MS. Pediatric robotic urologic procedures: Indications and outcomes. Indian J Urol 2023; 39:107-120. [PMID: 37304986 PMCID: PMC10249524 DOI: 10.4103/iju.iju_276_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/10/2022] [Accepted: 03/09/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology. Methods We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included "Treatment Outcome" and "Robotic Surgical Procedures." Results Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care. Conclusions RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.
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Affiliation(s)
- Sean W. Hou
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Monica H. Xing
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Mohan S. Gundeti
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- Department of Surgery, Section of Urology, University of Chicago, Comer Children's Hospital, Chicago, IL, USA
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Reinke S, Snider Z. Vesicoureteral Reflux Diagnosis After Hospitalization for Acute Cystitis and Pyelonephritis. Cureus 2023; 15:e38216. [PMID: 37252605 PMCID: PMC10224773 DOI: 10.7759/cureus.38216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Children with recurrent fevers in a short period of time need to be worked up to identify the underlying cause. Fevers in children and infants can be from many different sources. Vesicoureteral reflux (VUR) is an anatomical and physiological anomaly in children that can lead to retrograde urine flow from the bladder back into the distal ureters. This retrograde flow can cause distention, scarring, and recurrent infections including urinary tract infections (UTIs) and pyelonephritis. Identification of multiple UTIs in a short period of time should raise suspicion for a more complex pathology such as VUR and requires a more thorough workup. This workup is needed for both diagnosis and treatment. The patient in this report was seen by physicians in the emergency department, pediatric intensive care unit, nephrology, and her pediatrician. If surgery is needed, a urologist would also be involved. This report will discuss the pathophysiology of VUR and associated pathologies, diagnostic approach, medical and surgical treatment modalities, as well as prognosis.
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Affiliation(s)
- Shay Reinke
- Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Zairha Snider
- Pediatrics, Edward Via College of Osteopathic Medicine, Blacksburg, USA
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Muacevic A, Adler JR, Miakhil SI, Makhija R. A Rare and Late Complication of Subureteric Teflon Injection With Non-Animal Stabilized Hyaluronic Acid/Dextranomer Gel. Cureus 2023; 15:e33238. [PMID: 36601359 PMCID: PMC9806547 DOI: 10.7759/cureus.33238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2023] [Indexed: 01/04/2023] Open
Abstract
Primary non-syndromic vesicoureteral reflux (VUR) is the commonest paediatric anomaly of the urinary tract. Complications of high-grade VUR include recurrent urinary tract infections, pyelonephritis, reflux nephropathy, and irreversible renal failure. The primary aim of its management centres on minimizing the number of urinary tract infections and renal scarring via surgical correction or continuous antibiotic prophylaxis. A rare complication of surgical treatment by subureteric Teflon injection with non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx) is ureteric obstruction. We report the case of a 38-year-old female who was diagnosed with ureteric obstruction secondary to subureteric injection with Deflux injection 30 years after endoscopic correction of VUR. She was successfully treated with ureteric reimplantation. Although considered efficient and safe, subureteric injection of bulking agent Deflux can be associated with delayed ureteric obstruction. This case highlights the need for long-term follow-up to allow timely detection and management of delayed ureteric obstruction. The possibility of late complication must also be addressed when obtaining pre-operative informed consent.
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Comparative study of open, laparoscopic and endoscopic treatments of intermediate grade vesicoureteral reflux in children. Surg Endosc 2022; 37:2682-2687. [PMID: 36414870 DOI: 10.1007/s00464-021-08985-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/31/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Low-grade vesicoureteral-reflux (VUR) are rather treated by endoscopic injection, whereas open or laparoscopic procedures are mainly performed for high-grade VURs. Management of intermediate grades is controversial and no study focused on grade III to date. This study aims to compare the results of open, laparoscopic, and endoscopic approaches in children with grade III VUR. METHODS A multicenter comparative retrospective study included children with grade III VUR operated for febrile urinary tract infections (UTIs) from 2007 to 2016. Children without UTI, with reflux of other grades, neurological bladder, duplex system, posterior urethral valves, and bladder exstrophy were excluded. Success was defined as no recurrence of febrile UTI and was presented as event-free survival curves. RESULTS Out of 806 children operated of VUR, 171 met the inclusion criteria (114 females). Seventy-seven children (45%) underwent an open Cohen procedure, 35 (21%) a laparoscopic Lich-Gregoir and 59 (34%) a submucosal endoscopic injection according to the centers' preference. The mean follow-up was 64 months (24-132). Groups were not different for age, sex, and circumcision status. Compared to Cohen procedure, recurrences of febrile UTI were more frequent after laparoscopic treatment (p = 0,02, 8/35) and endoscopic treatment (p = 0.001, 16/59). Redosurgery was also more frequent after laparoscopy (n = 2) and endoscopic injection (n = 14) than after open surgery (n = 0, p < 0.001). CONCLUSION Recurrent febrile UTIs and redosurgery are more frequent after endoscopic and laparoscopic procedures in grade III VUR than open reimplantation. Whether the lower morbidity of laparoscopic or endoscopic approaches balances the risk of recurrent febrile UTI remains to be determined for intermediate grade reflux.
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Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux. J Pediatr Urol 2022; 18:517.e1-517.e5. [PMID: 35654725 DOI: 10.1016/j.jpurol.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. OBJECTIVE In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. METHODS An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. RESULTS 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. DISCUSSION The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study. CONCLUSIONS De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.
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Chalfant V, Riveros C, Stec AA. Open versus minimally invasive ureteroneocystostomy: trends and outcomes in a NSQIP-P cohort. J Robot Surg 2022; 17:487-493. [PMID: 35798942 DOI: 10.1007/s11701-022-01437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/06/2022] [Indexed: 10/17/2022]
Abstract
Although surgical intervention has commonly been performed using an open approach for vesicoureteral reflux (VUR), this is rapidly changing due to adoption of minimally invasive surgery (MIS). Success rates with MIS are similar to open for re-implantation (> 90%); however, open ureteral re-implantation is still widely considered the gold standard. Using national surgical quality improvement program-pediatric (NSQIP-P) data, this manuscript evaluates recent large population trends of open versus robotic-assisted and laparoscopic ureteroneocystostomy for complications and factors associated with worse outcomes. Cases were identified in the 2012-2019 NSQIP-P database using the ureteroneocystostomy operative codes and vesicoureteral reflux post-operative diagnosis codes. A 1:1 propensity score match (PSM) analysis was performed comparing surgical outcomes while matching patients with similar characteristics to reduce bias. A total of 4183 patients were included; 621 patients with MIS and 3562 with open approach. Patients in the MIS approach tended to be older (67 months vs. 53 months) and non-Caucasian (12.9% vs. 6.3%) with no differences in other demographics. After 1:1 PSM, 30-day complications after ureteroneocystostomy showed no significant differences in readmission, reoperation, or extended hospital stay. A multivariate analysis found patients with CNS structural abnormalities (such as spina bifida) had 4.5 times greater odds of experiencing a reoperation (p value < 0.05). Similarly, patients with an ASA above two had 2.0 times greater odds of an UTI (p value < 0.05). The cohorts undergoing open and MIS approaches are well matched overall, without profound differences in outcomes overall.
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Affiliation(s)
- Victor Chalfant
- Department of Urology, Creighton University School of Medicine, Omaha, NE, 68124, USA.
| | - Carlos Riveros
- Department of Urology, University of Florida, Jacksonville, FL, 32209, USA
| | - Andrew A Stec
- Division of Pediatric Urology, Nemours Children's Health, Jacksonville, FL, 32207, USA
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12
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Opfermann P, Zadrazil M, Tonnhofer U, Metzelder M, Marhofer P, Schmid W. Ultrasound-guided epidural anesthesia and sedation for open transvesical Cohen ureteric reimplantation surgery in 20 consecutive children: a prospective case series and proof-of-concept study. Minerva Anestesiol 2022; 88:564-572. [PMID: 35381834 DOI: 10.23736/s0375-9393.22.15904-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Epidural anesthesia is usually combined with general anesthesia (GA) for children undergoing sub-umbilical surgery and GA in children is associated with a potential for respiratory events. Aiming to reduce airway manipulation and the use of GA drugs, we designed a study of transvesical Cohen ureteteric reimplantion under epidural anesthesia in sedated, spontaneously breathing children. METHODS We enrolled 20 children (3-83 months, 6.3-25.0 kg) scheduled for open transvesical abdominal surgery with Pfannenstiel incision. Sedation was followed by ultrasound-guided epidural anesthesia. Increases in heart rate by > 15% and or patient movements upon skin incision were rated as block deficiencies. Intubation equipment for advanced airway management was kept on standby. The primary study endpoint was successful blockade, meaning that no sequential airway management was required for the spontaneous breathing patients during surgery. Secondary endpoints included any use of fentanyl/propofol intraoperatively and of postoperative analgesics in the recovery room. RESULTS All 20 blocks were successful, with no block deficiencies upon skin incision, no need for sequential airway management, and stable SpO2 levels (97-100%). Surgery took a median of 120.5 minutes (IQR: 89.3-136.5) and included one bolus of fentanyl in one patient 120 minutes into a protracted operation. No more systemic analgesia had to be provided in the recovery room. CONCLUSIONS Sedation and epidural anesthesia emerged as a useful alternative to GA from our consecutive case series.
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Affiliation(s)
- Philipp Opfermann
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Zadrazil
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Ursula Tonnhofer
- Department of Surgery, Division of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Metzelder
- Department of Surgery, Division of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
| | - Werner Schmid
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria -
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13
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Ceku G, Petrovski M, Memeti S, Hyseni N, Statovci S, Berisha B. Indications for operation and results from surgical treatment of vesicoureteral reflux. Arch Public Health 2021. [DOI: 10.3889/aph.2021.6009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR
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14
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Marschner CA, Schwarze V, Stredele R, Froelich MF, Rübenthaler J, Geyer T, Clevert DA. Safety assessment and diagnostic evaluation of patients undergoing contrast-enhanced urosonography in the setting of vesicoureteral reflux confirmation. Clin Hemorheol Microcirc 2021; 79:65-72. [PMID: 34487027 DOI: 10.3233/ch-219110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) represents a common pediatric anomaly in children with an upper urinary tract infection (UTI) and is defined as a retrograde flow of urine from the bladder into the upper urinary tract. There are many diagnostic options available, including voiding cystourethrography (VCUG) and contrasted-enhanced urosonography (ceVUS). ceVUS combines a diagnostic tool with a high sensitivity and specificity which, according to previous study results, was even shown to be superior to VCUG. Nevertheless, despite the recommendation of the EFSUMB, the ceVUS has not found a widespread use in clinical diagnostics in Europe yet. MATERIALS AND METHODS Between 2016 and 2020, 49 patients with a marked female dominance (n = 37) were included. The youngest patient had an age of 5 months, the oldest patient 60 years. The contrast agent used in ceVUS was SonoVue®, a second-generation blood-pool agent. All examinations were performed and interpreted by a single experienced radiologist (EFSUMB Level 3). RESULTS The 49 patients included in the study showed no adverse effects. 51% of patients (n = 26) were referred with the initial diagnosis of suspected VUR, while 49% of patients (n = 23) came for follow-up examination or to rule out recurrence of VUR. The vast majority had at least one febrile urinary tract infection in their recent medical history (n = 45; 91,8%). CONCLUSION ceVUS is an examination method with a low risk profile which represents with its high sensitivity and specificity an excellent diagnostic tool in the evaluation of vesicoureteral reflux, especially in consideration of a generally very young patient cohort.
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Affiliation(s)
| | - Vincent Schwarze
- Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Regina Stredele
- Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias F Froelich
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Germany
| | | | - Thomas Geyer
- Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dirk-André Clevert
- Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany
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15
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Arlen AM, Kirsch AJ. Armamentarium to treat primary vesicoureteral reflux in children. Semin Pediatr Surg 2021; 30:151086. [PMID: 34412883 DOI: 10.1016/j.sempedsurg.2021.151086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.
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Affiliation(s)
- Angela M Arlen
- Department of Urology, Yale University School of Medicine, New Haven, CT.
| | - Andrew J Kirsch
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA.
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16
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Eli N, Phan YC, Kujawa M. Surgical management of vesicoureteral reflux in adults. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/20514158211014052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the upper urinary tract with or without upper-tract dilatation. This diagnosis is commonly made in childhood, affecting 1% of all births. In adults, its prevalence and incidence are not known. Presentation in adults could be with loin pain associated with voiding or a full bladder, recurrent urinary tract infections, a diagnosis carried over from childhood or an incidental finding. Most of the works on VUR have been done in the paediatric population. There are limited publications addressing VUR in adults. Unsurprisingly, the management of VUR in adults is extrapolated from the knowledge that we have gained from paediatric urology. Herein, we recap on the pathophysiology and review the surgical management of VUR in adults as published over the years.
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Affiliation(s)
- Nnaemeka Eli
- Urology Department, University Hospital Coventry and Warwickshire, UK
| | - Yih Chyn Phan
- Urology Department, Queen Alexandra Hospital Portsmouth, UK
| | - Magda Kujawa
- Urology Department, Stockport NHS Foundation Trust, UK
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17
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Association between severity of prenatally diagnosed hydronephrosis and receipt of surgical intervention postnatally among patients seen at a fetal-maternal center. BMC Urol 2021; 21:54. [PMID: 33827528 PMCID: PMC8028200 DOI: 10.1186/s12894-021-00822-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/24/2021] [Indexed: 12/14/2022] Open
Abstract
Background Hydronephrosis (HN) is the most common abnormality detected on prenatal ultrasound. This study sought to stratify outcomes of patients by severity of prenatal HN with postnatal outcomes. Methods This was a retrospective review of patients referred to a tertiary care fetal-maternal clinic with diagnosis of prenatal HN from 2004 to 2019. HN severity was categorized as mild, moderate, or severe. Data were analyzed to determine the association between HN severity and surgical intervention. Decision for surgery was based on factors including history of multiple urinary tract infections, evidence of renal scarring, and/or reduced renal function. Surgery-free survival time was represented by the Kaplan–Meier method, and hazard ratios were calculated using the log-rank test. Results 131 kidneys among 101 infants were prenatally diagnosed with hydronephrosis; 35.9% had mild HN, 29.0% had moderate HN, and 35.1% had severe HN. 8.5% of patients with mild HN, 26.3% of patients with moderate HN, and 65.2% of patients with severe HN required surgery. Patients with severe HN were 12.2 (95% CI 6.1–24.4; p < 0.001) times more likely to undergo surgery for HN than patients with mild HN and 2.9 (95% CI 1.5–5.3; p = 0.003) times more likely to undergo surgery than patients with moderate HN. Patients with moderate HN were 4.3 times more likely to require surgery than patients with mild HN (95% CI 1.5–12.9; p = 0.01). Median age at surgery was 11.8 months among patients with mild HN (IQR 11.7–14.1 months), 6.6 months among patients with moderate HN (IQR 4.2–16.4 months), and 5.4 months among patients with severe HN (3.7–12.4 months). Conclusion Among this cohort of referrals from a fetal-maternal clinic, severity of HN correlated with increased likelihood of surgical intervention. Continued assessment of patients with prenatal HN should be evaluated to best determine the role of the pediatric urologist in cases of prenatal HN.
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18
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Abstract
PURPOSE OF REVIEW Vesicoureteral reflux (VUR) management has been steadily evolving over the last several years. There is not a definitive algorithm for operative intervention, but there are some recognized patterns to follow when caring for this patient base. It is extremely relevant to review the rationale behind practice patterns as both literature and clinical practice are dynamic. RECENT FINDINGS VUR is a common malady that is emotionally, physically, and financially draining for families. As new treatment options emerge with minimally invasive techniques and older methods are re-explored, it is imperative to re-evaluate care strategies. This article reviews the mainstays of treatment in addition to newer therapeutic modalities. SUMMARY The decision to operate on any patient, particularly pediatric patients, must be preceded by sound clinical judgment. Thoughtful planning must be utilized to ensure every patient receives individualized and up-to-date VUR management. This article reviews indications for surgical intervention to consider when managing these patients.
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Salih EM, Eldamanhory H, Selmy GI, Galal HA. Comparison of Subureteral Endoscopic Injection of Dextranomer/Hyaluronic Acid and Lich-Gregoir Ureteral Reimplantation in the Treatment of Pediatric Primary Vesicoureteral Reflux: A Prospective Randomized Study. J Laparoendosc Adv Surg Tech A 2021; 31:719-723. [PMID: 33751917 DOI: 10.1089/lap.2020.0973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The gold standard of surgical intervention of vesicoureteral reflux (VUR) is open ureteral reimplantation with high success and low complication rates. However, in recent years, endoscopic injection, dextranomer/hyaluronic acid (Dx/HA), has become an effective therapy for VUR. It is noted that limited prospective randomized trials compare the different surgical techniques of especially endoscopic injection versus open procedures. We aimed to compare the outcomes of endoscopic injection of Dx/HA and Lich-Gregoir open technique of ureteral reimplantation for grades III and IV primary VUR in pediatric patients. Materials and Methods: Between January 2016 and December 2018, 60 pediatric patients with grades III and IV primary VUR were included in a prospective randomized trial. Thirty cases with 45 refluxing ureters managed by endoscopic injection of Dx/HA comprised group A. Open Lich-Gregoir technique used in the other 30 cases with 48 refluxing ureters composed of group B. Renal ultrasound, voiding cystourethrography, and renal scintigraphy were used for follow-up. The surgical success rate, cost-effectiveness, and occurrence of complications were evaluated and compared in both groups. Results: Sixty pediatric patients with 93 refluxing ureters (41 females and 19 males) were included in the trial. The mean follow-up for all patients was 17.7 ± 7.1 months. Overall reflux resolution was 80% (36/45) of the ureters in group A after a single injection and 93.75% (45/48) of the ureters in group B. The difference between the two groups was not statistically significant concerning clinical or anatomical preoperative factors and surgical success rate. There was a statistically significant difference between the two groups in terms of operative time and hospital stay. Conclusion: This comparative study demonstrated a high success rate of open ureteral reimplantation (Lich-Gregoir) procedure over the endoscopic injection of Dx/HA therapy to manage primary VUR grades III-IV. Clinical Trial Number: NCT04798443.
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Affiliation(s)
| | - Hany Eldamanhory
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Gamal I Selmy
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hussein A Galal
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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20
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Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting. ACTA ACUST UNITED AC 2021; 57:medicina57010056. [PMID: 33435420 PMCID: PMC7826578 DOI: 10.3390/medicina57010056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 01/11/2023]
Abstract
Background and Objectives: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods: Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results: Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion: With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.
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21
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Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Front Pediatr 2021; 9:650326. [PMID: 33869117 PMCID: PMC8044769 DOI: 10.3389/fped.2021.650326] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | | | - Tryggve Neveus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrew J Kirsch
- Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, United States
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22
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Siregar S, Kurniawan A, Mustafa A. Conservative management of vesicoureteral reflux: A literature review. UROLOGICAL SCIENCE 2021. [DOI: 10.4103/uros.uros_132_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Ureterovesical junction deformation during urine storage in the bladder and the effect on vesicoureteral reflux. J Biomech 2020; 113:110123. [DOI: 10.1016/j.jbiomech.2020.110123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
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Bastos JM, Rondon AV, Machado MG, Zerati M, Nascimento RLP, Lima SVC, Calado ADA, Barroso U. Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice. Int Braz J Urol 2020; 46:523-537. [PMID: 32167732 PMCID: PMC7239285 DOI: 10.1590/s1677-5538.ibju.2019.0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR. Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document. Results and Discussion Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.
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Affiliation(s)
- José Murillo Bastos
- Universidade Federal de Juiz de Fora -UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e Saúde de Juiz de Fora - HMTJ-SUPREMA, Juiz de Fora, MG, Brasil
| | - Atila Victal Rondon
- Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil.,Hospital Federal Cardoso Fontes - HFCF, Rio de Janeiro, RJ, Brasil
| | | | - Miguel Zerati
- Instituto de Urologia e Nefrologia de São José do Rio Preto - IUN, S J do Rio Preto, SP, Brasil
| | | | | | - Adriano de Almeida Calado
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - HCFMRP-USP, Ribeirão Preto, SP, Brasil
| | - Ubirajara Barroso
- Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina - BAHIANA, Salvador, BA, Brasil
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Kalayeh K, Brian Fowlkes J, Schultz WW, Sack BS. The 5:1 rule overestimates the needed tunnel length during ureteral reimplantation. Neurourol Urodyn 2020; 40:85-94. [PMID: 33017072 DOI: 10.1002/nau.24526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
AIMS Paquin asserts that in order for ureterovesical junctions (UVJs) to prevent reflux, the ureteral tunnel length-to-diameter ratio needs to be 5:1. We hypothesize that the surgical implementation of this observation results in an overestimation of the needed length-to-diameter ratio to prevent vesicoureteral reflux. METHODS With finite elements, we model the urine storage phase of the bladder under nonlinear conditions. In the reference state, the bladder is assumed to be a sphere with an oblique straight elliptical hole as the UVJ. Broad parametric studies on different length-to-diameter ratios are performed as the bladder volume increases from 10% to 110% capacity. RESULTS The capability of the UVJ to prevent reflux during storage depends on its length-to-diameter ratio. UVJs with larger length-to-diameter ratios lengthen and narrow as the bladder volume increases, causing the closure of the UVJ and rise in its flow resistance. Our model shows that the UVJ length-to-diameter ratio decreases as the bladder volume increases. The 5:1 ratio implemented at 80% capacity-approximate volume or bladder wall stretch during ureteroneocystostomy (UNC)-corresponds to 7:1 at the reference state-used by Paquin. The 5:1 ratio implemented at the reference state corresponds to 3:1 at 80% capacity. CONCLUSIONS Our modeling results are consistent with Paquin's original observation on the significance of the UVJ length-to-diameter ratio in preventing reflux. They, however, indicate that the surgical implementation of this rule during UNC results in an overestimation of the requisite tunnel length-to-diameter ratio to prevent reflux. They also suggest that the UVJ closure is due to the bladder wall deformation rather than the pressure.
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Affiliation(s)
- Kourosh Kalayeh
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - William W Schultz
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan S Sack
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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26
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Kirsch AJ, Arlen AM. Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'? Int Braz J Urol 2020; 46:314-321. [PMID: 32167694 PMCID: PMC7088498 DOI: 10.1590/s1677-5538.ibju.2020.99.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/10/2020] [Indexed: 12/18/2022] Open
Abstract
Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.
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Affiliation(s)
- Andrew J Kirsch
- Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA 30328, USA
| | - Angela M Arlen
- Department of Urology, Yale University School of Medicine, New Haven, CT 06520, USA
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Current Management of Urinary Tract Infection and Vesicoureteral Reflux. Indian J Pediatr 2020; 87:625-632. [PMID: 31828601 DOI: 10.1007/s12098-019-03099-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4 d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.
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Stenbäck A, Olafsdottir T, Sköldenberg E, Barker G, Stenberg A, Läckgren G. Proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx) for endoscopic treatment of grade IV vesicoureteral reflux: Long-term observational study. J Pediatr Urol 2020; 16:328.e1-328.e9. [PMID: 32414615 DOI: 10.1016/j.jpurol.2020.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since 1993, children aged >1 year with persistent grade III-V vesicoureteral reflux (VUR) and febrile urinary tract infections (UTIs) attending Uppsala University Hospital have undergone endoscopic injection with proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx; Deflux®). OBJECTIVE Investigate long-term incidence of UTI, bladder dysfunction, ureteral reimplantation and overall clinical findings following endoscopic injection of NASHA/Dx. STUDY DESIGN Children with grade IV VUR diagnosed by voiding cystourethrogram (VCUG) and dilating VUR persisting for >1 year were included in this study. 15-25 years after endoscopic treatment, patients' hospital charts were studied. Information on bladder function and UTIs was obtained via questionnaire, 8-18 years after endoscopic treatment. RESULTS 185 patients (69 boys, 116 girls) were included in the study; 237 grade IV VUR ureters were treated. All study patients were diagnosed with VUR after a febrile UTI (i.e. pyelonephritis). According to the last voiding cystourethrogram, 69% of ureters showed a positive response (VUR grade 0-I), 7% had VUR grade II and 23% had VUR grade ≥ III. 46 patients (25%) required ureteral reimplantation during follow-up. Among patients treated during the second 5-year period compared with the first (1998-2003 versus 1993-1998), there was a significant decrease in the rate of ureteral reimplantation (31% vs 16%; p = 0.0365). This difference may be attributable to developments over time in the injection technique. UTIs occurred in 30 patients (21% of the evaluable population): 28 females and 2 males. Febrile UTIs were reported in 14 patients (10%), all females. Forty-nine patients (34%) had bladder problems (e.g. underactivity, overactivity, incontinence). Five patients underwent ureteral reimplantation 'late', 6-10 years after the last endoscopic injection. In one male patient, calcification around the NASHA/Dx implantation site was observed during routine examination 2 years after endoscopic treatment; no intervention was required. No safety issues were observed in the remaining 97% of the study population. CONCLUSIONS This study represents the longest published follow-up of Grade IV VUR patients undergoing endoscopic treatment. Three-quarters of patients did not need ureteral reimplantation. Optimal injection technique and higher injection volume were associated with a reduced ureteral reimplantation rate. Treatment with NASHA/Dx was durable and well tolerated: long-term risks of UTI, bladder dysfunction and recurrent VUR were low.
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Affiliation(s)
- Anders Stenbäck
- Section of Urology, University Children's Hospital, Uppsala, Sweden.
| | | | - Erik Sköldenberg
- Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Gillian Barker
- Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Arne Stenberg
- Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Göran Läckgren
- Section of Urology, University Children's Hospital, Uppsala, Sweden
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Jacob TJK, James Sam C, Jacob Kurian J, Karl IS, Kisku SMC, Sen S. Transureteroureterostomy as an adjunctive antireflux procedure in children undergoing bladder augmentation for neurogenic bladder with major reflux. J Pediatr Urol 2020; 16:190.e1-190.e6. [PMID: 31932241 DOI: 10.1016/j.jpurol.2019.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Transureteroureterostomy (TUU) provides urinary drainage of both renal systems to the bladder via a single ureter and is useful in selected situations of complex urological reconstructions. Herein we discuss its use, advantages and complications in children with neurogenic bladders and high-grade (4/5) reflux who have undergone augmentation cystoplasty. PATIENTS AND METHODS Children with neurogenic bladder complicated by unilateral or bilateral high-grade vesicoureteric reflux (VUR), who underwent TUU along with augmentation cystoplasty (BA), were selected from two institutions. Eighteen children with an average age of 5 years at presentation were identified from a retrospective chart review. RESULTS All had bilateral hydroureteronephrosis (HUN) of which there were 30 refluxing megaureters. While BA reduced bladder pressure, VUR was managed by refluxing to non-refluxing TUU in six cases with unilateral VUR and unilateral reimplantation with TUU to the reimplanted ureter in 12 cases of bilateral VUR, thus minimizing reimplantation to 12 of 30 ureters. The average time of follow-up was 51 months. Follow-up cystograms showed complete resolution of VUR in all. HUN improved/stabilized in all but one child. Serum creatinine remained normal in all but two cases. Other advantages of TUU include the use of the distal ureter as a catheterizable channel and ease of undiversion when the ureter has been diverted as a ureterostomy. An unusual complication of a TUU site stricture is discussed and the innovative technique of using a cecal patch to salvage the anastomosis is detailed. CONCLUSION We conclude that a TUU is a safe and useful adjunctive procedure in children undergoing BA for neurogenic bladder with high-grade VUR, minimizing the need for ureteric reimplant in an unhealthy bladder.
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Affiliation(s)
- Tarun John K Jacob
- Department of Paediatric Surgery, Christian Medical College, Vellore, India.
| | - Cenita James Sam
- Department of Paediatric Surgery, PSG Medical College and Hospital, Coimbatore, India
| | - Jujju Jacob Kurian
- Department of Paediatric Surgery, Christian Medical College, Vellore, India
| | | | - Sundeep M C Kisku
- Department of Paediatric Surgery, Christian Medical College, Vellore, India
| | - Sudipta Sen
- Department of Paediatric Surgery, Christian Medical College, Vellore, India; Department of Paediatric Surgery, PSG Medical College and Hospital, Coimbatore, India
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Friedmacher F, Puri P. Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux: Does the Type of Injected Bulking Agent Matter? Curr Urol Rep 2019; 20:49. [DOI: 10.1007/s11934-019-0913-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sakalis VI, Oliver R, Guy PJ, Davies MC. Macroplastique and Botox are superior to Macroplastique alone in the management of neurogenic vesicoureteric reflux in spinal cord injury population with presumed healthy bladders. J Spinal Cord Med 2019; 42:478-484. [PMID: 29412074 PMCID: PMC6718137 DOI: 10.1080/10790268.2018.1433266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
CONTEXT/OBJECTIVE Vesico-ureteric reflux(VUR) is a known complication of neuropathic bladder in spinal cord injury(SCI) population. Bulking agents such as Macroplastique are new minimally-invasive treatment option for VUR with good results. The aim of this study is to assess the efficacy of Macroplastique alone or in combination with Botox(BTX-A), in managing VUR in SCI population with presumed healthy bladders and correlate the pre-and post-injection urodynamic findings with the outcome. DESIGN Retrospective comparative study. PARTICIPANTS SCI patients with VUR and presumed health bladders (normo-compliant, low filling pressures), treated with macroplastique alone or in combination with BTX-A, who had pre and post-intervention Video-urodynamics (VUDS) and followed up for at least 12 months. INTERVENTIONS Macroplastique and BTX-A injections, VUDS. OUTCOME MEASURES The primary end point was the overall treatment rate of VUR at 3 months and the secondary outcomes were the success rate (treated + improved) and the comparison of urodynamic parameters (pre-and post-injection). RESULTS We studied 34 intervention-naïve SCI patients. 19 had only Macroplastique (Group 1) and 15 had Macroplastique and BTX-A (Group 2). The overall treatment rate was 65.4% for group 1 and 88.9% for group 2 (P = 0.029). The overall success rate (treated + improved) was 80.8% and 94.4% respectively (P = 0.123). The comparison of follow up VUDS parameters showed a statistically significant rise in the detrusor pressure of group 1 (34.04cmH2O vs.19.2cmH2O, P = 0.008) and a drop in compliance (19.8mls/cmH2O vs.26.3mls/cmH2O, P = 0.018) as compared to baseline. CONCLUSION The combination of BTX-A and Macroplastique is more effective that Macroplastique alone in the management of secondary VUR in SCI patients with presumed healthy bladders.
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Affiliation(s)
- Vasileios I. Sakalis
- Department of Urology, Salisbury NHS Foundation Trust, Salisbury, UK,Correspondence to: Vasileios I. Sakalis, MSc, FEBU, FRCS(Eng), Department of Urology, Salisbury NHS Foundation Trust, Salisbury, UK.
| | - Rachel Oliver
- Department of Urology, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Peter J. Guy
- Department of Urology, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Melissa C. Davies
- Department of Urology, Salisbury NHS Foundation Trust, Salisbury, UK
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Nerli RB, Pujar S, Ghagane S, Hiremath M, Dixit N. Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux. JOURNAL OF THE SCIENTIFIC SOCIETY 2019. [DOI: 10.4103/jss.jss_18_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children. Curr Opin Urol 2018; 27:20-26. [PMID: 27764016 DOI: 10.1097/mou.0000000000000357] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases. RECENT FINDINGS Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant. SUMMARY Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.
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Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis. World J Urol 2018; 36:819-828. [PMID: 29374841 DOI: 10.1007/s00345-018-2194-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/19/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of robot-assisted laparoscopic ureteral reimplantation (RALUR) and open ureteral reimplantation (OUR) in treating primary pediatric vesicoureteral reflux (VUR) based on published literature. METHODS A comprehensive literature search of PubMed, Embase, Cochrane Library, CBM, CNKI and VIP databases was conducted to identify studies comparing the outcomes of RALUR with OUR for treating primary pediatric VUR. The last search was in January 2017. Summarized mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the differences in outcomes between RALUR and OUR. RESULTS A total of six studies containing 7122 children with primary VUR were included in this analysis. Significantly longer operation time was needed for RALUR than OUR (MD 66.69 min, 95% CI 41.71-91.67, P < 0.00001), while the RALUR group had significantly fewer days of hospital stay (MD - 17.80 h, 95% CI - 21.18 to - 14.42, P < 0.00001) and postoperative Foley placement (MD - 0.32 days, 95% CI - 0.57 to - 0.07, P = 0.01). No significant differences were found in estimated blood loss during operation, success rate, complications, and postoperative analgesia usage between the two groups. In subgroup analyses, a significantly higher rate of short-term postoperative complications in RALUR was found compared with OUR (OR 3.17, 95% CI 1.72-5.85, P = 0.0002). CONCLUSIONS Our study indicates that compared with OUR, RALUR is also an effective surgical approach for primary pediatric VUR and could help patients return to society more quickly; however, short-term postoperative complications of RALUR should be considered cautiously.
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Horasanli K, Bayar G, Acinikli H, Kutsal C, Kirecci SL, Dalkilic A. Lower urinary tract dysfunction in pediatric patients after ureteroneocystostomy due to vesicoureteral reflux: Long-term follow-up. Low Urin Tract Symptoms 2018; 11:O48-O52. [PMID: 29322636 DOI: 10.1111/luts.12213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/26/2017] [Accepted: 11/14/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate long-term lower urinary tract dysfunction (LUTD) in pediatric patients who underwent ureteroneocystostomy due to vesicoureteral reflux. METHODS The present retrospective study was performed on 61 patients. Patients were divided into 3 groups: Group 1 (n = 26), did not have LUTD; Group 2 (n = 23), had LUTD; and Group 3 (n = 12), was not toilet trained preoperatively. Patients were reassessed regarding de novo LUTD or the persistence of LUTD at least 7 years after the ureteroneocystostomy. RESULTS Mean patient age was 7 years (range 1-15) when ureteroneocystostomy was performed and the surgery was associated with a 92% success rate. The mean follow-up period was 10 years (range 7-12 years). Postoperative LUTD was present in 6 (23%), 12 (52%), and 1 (8.3%) patients in Groups 1, 2, and 3, respectively. The presence of LUTD before surgery and bilateral repair in the same setting were predictive risk factors for the presence of LUTD during the long-term follow-up. LUTD occurred at higher rate in Group 2 than in Groups 1 and 3 (52% vs. 23% and 8.3%, respectively; P = .015). The presence of de novo LUTD was significant in Group 1 compared with the presence of preoperative and postoperative LUTD (P = .031, Wilcoxon analysis). CONCLUSIONS LUTD may not resolve after a ureteroneocystostomy, and additional therapy could be necessary. Due to the probability of damage to the ureterovesical nerve and/or disturbed bladder dynamics, de novo LUTD may occur in patients with bilateral high-grade reflux without LUTD before a ureteroneocystostomy.
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Affiliation(s)
- Kaya Horasanli
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Göksel Bayar
- Urology Department, Idil State Hospital, Sirnak, Turkey
| | | | - Cemil Kutsal
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Sinan L Kirecci
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ayhan Dalkilic
- Urology Department, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
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Bustangi N, Kallas Chemaly A, Scalabre A, Khelif K, Luyckx S, Steyaert H, Varlet F, Lopez M. Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy. Front Pediatr 2018; 6:388. [PMID: 30619786 PMCID: PMC6305429 DOI: 10.3389/fped.2018.00388] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: The aim is to compare the outcome of open versus laparoscopic Lich-Gregoir technique in patients with vesicoureteral reflux. We report a retrospective multicenter comparative study between open and laparoscopic extra-vesical ureteral reimplantation (EVUR) following Lich-Gregoir (LG) technique for the correction of Vesico-Ureteral Reflux (VUR). Materials and Methods: Between January 2007 and December 2015, 96 patients with VUR (69 females and 27 males) and deterioration of the renal function, underwent EVUR following LG technique. Fifty patients (16 males and 34 females) were operated by open surgery (group A). The mean age was 4.22 years-old, (14-147 months). Laparoscopic approach (group B) was performed in 46 patients (11 males and 35 females). The mean age was 4.19 years-old (15-110 months). We compared the results in relation to degree of VUR, operative time, hospital stay, post-operative pain medications, recovery time, complications, successful rate, recurrence, and follow-up. Statistical analysis was done used Chi square test for categorical variables and the Student t-test for continuous variables. P < 0.05 was considered significant. Results: In both groups no correlation was identified between age or weight and operative time, length of stay or total analgesia used. The mean operative time for group A was 63.2 and 125.4 min for unilateral and bilateral VUR, respectively, and for the group B was 127.90 and 184.5 min, respectively. There was no conversion in the laparoscopic group. Perioperative mucosal perforation of the bladder occurred in 6 patients of group A and 4 patients of group B and was immediately repaired. One patient had to be reoperated for leakage in group B. The mean duration of Morphine, IV and PO analgesia was shorter in group B. The mean hospital stay was 5.46 days for group A and 1.54 days for Group B. The success rate was 98% in group A and 97, 8% in group B. The mean follow-up was 3.67 years for the open and 1.54 years for the laparoscopic group. Transitory voiding dysfunction occurred in bilateral EVUR in one case in each group. Conclusion: Laparoscopic or Open approach for the correction of VUR following Lich-Gregoir technique is effective in unilateral and bilateral VUR with similar results. Laparoscopic approach reduces significantly (p < 0.05 in each item) post-operative pain medication, hospital stay, and allows for a faster return to normal activity.
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Affiliation(s)
- Nasir Bustangi
- Department of Pediatric Surgery and Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Anthony Kallas Chemaly
- Department of Pediatric Surgery and Urology, Faculty of Medicine, Hôtel-Dieu de France, Beirut, Lebanon
| | - Aurelien Scalabre
- Department of Pediatric Surgery and Urology, Faculty of medicine, Hôtel-Dieu de France Hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Karim Khelif
- Queen Fabiola Children's University Hospital, Bruxelles, Belgium
| | - Stéphane Luyckx
- Queen Fabiola Children's University Hospital, Bruxelles, Belgium
| | - Henri Steyaert
- Queen Fabiola Children's University Hospital, Bruxelles, Belgium
| | - Francois Varlet
- Department of Pediatric Surgery and Urology, Faculty of medicine, Hôtel-Dieu de France Hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Manuel Lopez
- Department of Pediatric Surgery and Urology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,University Hospital of Saint Etienne, France
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Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey. World J Urol 2017; 36:481-488. [PMID: 29248949 DOI: 10.1007/s00345-017-2155-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/10/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This multicentric international retrospective study aimed to report the outcome of robot-assisted extravesical ureteral reimplantation (REVUR) in patients with unilateral vesico-ureteral reflux (VUR). METHODS The medical records of 55 patients (35 girls, 20 boys) underwent REVUR in four international centers of pediatric robotic surgery for primary unilateral VUR were retrospectively reviewed. Patients' average age was 4.9 years. The preoperative grade of reflux was III in 12.7%, IV in 47.3% and V in 40%. Twenty-six patients (47.3%) presented a loss of renal function preoperatively and 10 (18.1%) had a duplex system. RESULTS Average robot docking time was 16.2 min (range 5-30). Average total operative time was 92.2 min (range 50-170). No conversions or intra-operative complications were recorded. All patients had a bladder Foley catheter for 24 h post-operatively. Average hospital stay was 2 days (range 1-3). Average follow-up length was 28 months (range 9-60). We recorded three (5.4%) postoperative complications: 1 small urinoma resolved spontaneously (II Clavien) and 2 persistent reflux, only one requiring redo-surgery using endoscopic injection (IIIb Clavien). CONCLUSION REVUR is a safe and effective technique for treatment of primary unilateral VUR. The procedure is easy and fast to perform thanks to the 6° of freedom of robotic arms. The learning curve is short and it is useful to begin the robotics experience with a surgeon expert in robotic surgery as proctor on the 2nd robot console. The high cost and the diameter of instruments remain the main challenges of robotics applications in pediatric urology.
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Hajiyev P, Burgu B. Contemporary Management of Vesicoureteral Reflux. Eur Urol Focus 2017; 3:181-188. [PMID: 28918954 DOI: 10.1016/j.euf.2017.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 02/08/2023]
Abstract
CONTEXT Vesicoureteral reflux (VUR) remains the most interesting topic of pediatric urology due to the dynamic nature of recent controversial publications. Starting from the need for a diagnosis to the necessity and effectiveness of treatment in preventing scars, VUR remains in the mist. Although recent strong evidence helped as fog lights in this blurriness, more data are required for achieving crystal clearance. This article aims to summarize and discuss the current state of the evidence regarding VUR management. OBJECTIVE To provide a comprehensive synthesis of the main evidence in the literature on the current and contemporary management of VUR in children; to discuss conservative management with continuous antibiotic prophylaxis (CAP), especially its effectiveness and safety; and to review the current evidence regarding contemporary surgical techniques. EVIDENCE ACQUISITION We conducted a nonsystematic review of the literature using the recent guidelines and PubMed database regarding surveillance, CAP, endoscopic, open, laparoscopic, and robot-assisted ureteral surgical treatment. EVIDENCE SYNTHESIS Despite the striking results of previous studies revealing the ineffectiveness of CAP, more recent studies and their two fresh meta-analyses revealed a positive role for CAP in the contemporary management of VUR. One of the most interesting findings is the redundant rising of endoscopic correction and its final settlement to real indicated cases. Patient individualization in the contemporary management of VUR seems to be the keyword. The evidence in the literature showed a safe and effective use of laparoscopic and robot-assisted laparoscopic reimplantations. CONCLUSIONS The goal of VUR treatment is to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma. The approach should be risk adapted and individualized according to current knowledge. Individual risk is influenced by the presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status. PATIENT SUMMARY Vesicoureteral reflux is a nonphysiological reflux of urine from the bladder through the ureters to the kidney. Treatment depends on the presentation of the vesicoureteral reflux (VUR). Therapeutic options range from watchful waiting to open surgery. This article aims to summarize and discuss the current state of the evidence regarding VUR management.
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Affiliation(s)
- Perviz Hajiyev
- Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey.
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Cebeci Children's Hospital, Ankara, Turkey
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Endoscopic Treatment of Vesicoureteral Reflux. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0431-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Phillips B, Holzmer S, Turco L, Mirzaie M, Mause E, Mause A, Person A, Leslie SW, Cornell DL, Wagner M, Bertellotti R, Asensio JA. Trauma to the bladder and ureter: a review of diagnosis, management, and prognosis. Eur J Trauma Emerg Surg 2017; 43:763-773. [PMID: 28730297 DOI: 10.1007/s00068-017-0817-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Injuries to the ureter or bladder are relatively rare. Therefore, a high level of clinical suspicion and knowledge of operative anatomy is of utmost importance for their management. Herein, a review of the literature related to the modern diagnosis, management, and prognosis for bladder and ureteral injuries is presented. METHODS A literature search was conducted through PubMed. A thorough search of the world's literature published in English was completed. Search terms included "injury, diagnosis, prognosis, and management for ureter and bladder". All years, both genders, as well as penetrating, blunt, and iatrogenic mechanisms were evaluated for inclusion. Following PRISMA guidelines, studies were selected based on relevance and then categorized. RESULTS 172 potentially relevant studies were identified. Given our focus on modern diagnosis and treatment, we then narrowed the studies in each category to those published within the last 30 years, resulting in a total of 26 studies largely consisting of Level IV retrospective case series. Our review found that bladder ruptures occur from penetrating, blunt, or iatrogenic mechanisms, and most are extraperitoneal (63%). Ureteral injuries are incurred from penetrating mechanisms in 77% of cases. The overall mortality rates for bladder rupture and ureteral injury were 8 and 7%, respectively. LIMITATIONS Limitations of this article are similar to all PRISMA-guided review articles: the dependence on previously published research and availability of references. CONCLUSION The bladder is injured far more often than the ureter but ureteral injuries have higher injury severity. Both of these organs can be damaged by penetrating, blunt, or iatrogenic mechanisms and surgical intervention is often required for severe ureter or bladder injuries. Since symptoms of these injuries may not always be apparent, a high level of suspicion is required for appropriate diagnosis and treatment.
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Affiliation(s)
- B Phillips
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA. .,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA. .,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA. .,Vice Chair of Surgery, Surgical Research, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, 601 North 30th Street, Suite 3701, Omaha, 68131-2137, NE, USA.
| | - S Holzmer
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - L Turco
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - M Mirzaie
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - E Mause
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - A Mause
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - A Person
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - S W Leslie
- Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - D L Cornell
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - M Wagner
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - R Bertellotti
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
| | - J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Urology, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA.,Division of Trauma Surgery and Surgical Critical Care, Department of Clinical and Translational Science, Creighton University Medical Center, Creighton University School of Medicine, Omaha, NE, USA
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Do Routine Preoperative and Intraoperative Urine Cultures Benefit Pediatric Vesicoureteral Reflux Surgery? Adv Urol 2017; 2017:3197869. [PMID: 28487733 PMCID: PMC5405361 DOI: 10.1155/2017/3197869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/17/2016] [Accepted: 03/09/2017] [Indexed: 11/18/2022] Open
Abstract
Objective. To determine if routine preoperative and intraoperative urine cultures (UCx) are necessary in pediatric vesicoureteral (VUR) reflux surgery by identifying their association with each other, preoperative symptoms, and surgical outcomes. Materials and Methods. A retrospective review of patients undergoing ureteral reimplant(s) for primary VUR at a tertiary academic medical center between years 2000 and 2014 was done. Preoperative UCx were defined as those within 30 days before surgery. A positive culture was defined as >50,000 colony forming units of a single organism. Results. A total of 185 patients were identified and 87/185 (47.0%) met inclusion criteria. Of those, 39/87 (45%) completed a preoperative UCx. Only 3/39 (8%) preoperative cultures returned positive, and all of those patients were preoperatively symptomatic. No preoperatively asymptomatic patients had positive preoperative cultures. Intraoperative cultures were obtained in 21/87 (24.1%) patients; all were negative. No associations were found between preoperative culture results and intraoperative cultures or between culture result and postoperative complications. Conclusions. In asymptomatic patients, no associations were found between the completion of a preoperative or intraoperative UCx and surgical outcomes, suggesting that not all patients may require preoperative screening. Children presenting with symptoms of urinary tract infection (UTI) prior to ureteral reimplantation may benefit from preoperative UCx.
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Lee JN, Lee SM, Ha YS, Kim BS, Kim HT, Kim TH, Yoo ES, Kwon TG, Chung SK. VUR timing on VCUG as a predictive factor of VUR resolution after endoscopic therapy. J Pediatr Urol 2016; 12:255.e1-6. [PMID: 27220472 DOI: 10.1016/j.jpurol.2016.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The timing of reflux onset on VCUG (VUR timing) has been considered a predictive factor of spontaneous resolution in VUR children. While the voiding reflux is associated with a greater rate of spontaneous resolution, the filling reflux is more likely to require surgical intervention. However, the VUR timing in children with primary VUR has not been evaluated with regard to the prognostic value of endoscopic therapy. The aim of this study was to evaluate the effect of VUR timing on the surgical outcome after endoscopic therapy for primary VUR. METHOD We retrospectively reviewed the medical records of 94 primary VUR patients who underwent endoscopic injection for their initial surgical management. Radiologic success was defined as grade I or less on VCUG at 3-6 months following endoscopic therapy. We allocated patients to a filling reflux group or a voiding reflux group on the basis of their most recent preoperative VCUG. We evaluated the patients' demographics and outcomes after endoscopic therapy according to VUR timing. Predictive factors for radiologic success were analyzed using a multivariate logistic regression model. RESULTS Of the 94 children (136 ureters), 68 (101 ureters) were classified as the filling reflux group and 26 (35 ureters) were placed in the voiding reflux group. The preoperative VUR grade in the filling reflux group was significantly higher than that in the voiding reflux group (p = 0.001). Radiologic success was observed in 56.44% (57/101 ureters) in the filling reflux group and in 88.57% (31/35 ureters) in the voiding reflux group (p = 0.001). Multivariate analysis showed that VUR grade and VUR timing on VCUG were predictive factors of radiologic success after endoscopic therapy (p = 0.001 and p = 0.005). CONCLUSIONS Despite the clinical importance of VUR timing, no studies have investigated the prognostic value of VUR timing for endoscopic therapy in primary VUR children. In this study, multivariate analysis revealed that the VUR grade and VUR timing on preoperative VCUG were significant predictors of success after endoscopic injection. Although the VUR grade is the most well-known factor that can affect the success of the procedure, VUR timing was a newly identified predictive factor. While patients with a filling reflux have lower success rates, patients with a voiding reflux were observed to show higher resolution rates after endoscopic injection. VUR timing on preoperative VCUG was found to be an independent predictive factor of VUR resolution after endoscopic therapy.
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Affiliation(s)
- Jun Nyung Lee
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - So Mi Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yun-Sok Ha
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Bum Soo Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyun Tae Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
| | - Tae-Hwan Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Eun Sang Yoo
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Tae Gyun Kwon
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sung Kwang Chung
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
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Kordi Tamandani DM, Naeimi N, Ghasemi A, Baranzahi T, Sadeghi-Bojd S. Analysis of the IL-10, IL-12, and TNF-α Gene Polymorphisms in Patients With Vesicoureteral Reflux Among the Southeast Iranian Population. Nephrourol Mon 2016; 8:e34061. [PMID: 27247930 PMCID: PMC4884403 DOI: 10.5812/numonthly.34061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/05/2016] [Accepted: 01/20/2016] [Indexed: 12/13/2022] Open
Abstract
Background Vesicoureteral reflux (VUR) is a common childhood disorder that is characterized by the abnormal movement of urine from the bladder into the ureters or kidneys. Objectives The aim of this study was to determine whether the genetic polymorphisms of the IL-10, IL-12, and TNF-α genes are involved in the development of VUR. Patients and Methods The tetra amplification mutation refractory system-polymerase chain reaction (Tetra-ARMS PCR) was applied to analyze the four polymorphic sites of the IL-10AG-1082, IL-10CA597, IL-12CA1188, and TNF308GA genes in 124 VUR children and 110 healthy controls. Results A significant, highly increased risk of VUR disease was found for the CA, AA, and combined genotypes of IL-10CA597 (OR = 5.2, 95% CL: 1.80 - 18.25; P = 0.0006, OR = 9.1, 95% CL: 1.11 - 122.75; P = 0.02, OR = 5.3, 95% CL: 1.82 - 18.61; P = 0.00052, respectively); the AG, GG, and AG + GG genotypes of IL-10AG-1082 (OR = 12.8, 95% CL; 2.9 - 113.9; P = 0.00003, OR = 12.62, 95% CL: 2.93 - 114.53; P = 0.00003, respectively); and the AA genotype of IL-12 (AA, OR = 0.19, 95% CL: 0.5 - 0.55; P = 0.0006). The frequency of the C allele in both IL-10CA and IL-12CA was greater in patients with VUR than in the healthy controls. No association was found between TNF308GA and the risk of VUR. Conclusions The results demonstrated significant associations between the IL-10 (AG-1089, IL-10CA) and IL-12 (AA) gene polymorphisms and a highly increased risk of VUR.
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Affiliation(s)
- Dor Mohammad Kordi Tamandani
- Department of Biology, University of Sistan and Baluchestan, Zahedan, IR Iran
- Corresponding author: Dor Mohammad Kordi Tamandani, Department of Biology, University of Sistan and Baluchestan, Zahedan, IR Iran. Tel: +98-5412452335, Fax: +98-5412446565, E-mail: dor_kordi @yahoo.com
| | - Nasim Naeimi
- Department of Biology, University of Sistan and Baluchestan, Zahedan, IR Iran
| | - Ali Ghasemi
- Department of Biology, University of Sistan and Baluchestan, Zahedan, IR Iran
| | - Taybe Baranzahi
- Children and Adolescent Health Research Center Zahedan, University of Medical Sciences, Zahedan, IR Iran
| | - Simin Sadeghi-Bojd
- Children and Adolescent Health Research Center Zahedan, University of Medical Sciences, Zahedan, IR Iran
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Arlen AM, Broderick KM, Travers C, Smith EA, Elmore JM, Kirsch AJ. Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population. J Pediatr Urol 2016; 12:169.e1-6. [PMID: 26747012 DOI: 10.1016/j.jpurol.2015.11.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVE While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair. STUDY DESIGN Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum. RESULTS Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6 ± 6.5 months. The RALUR children were significantly older (9.3 ± 3.7 years) than the OUR patients (3.1 ± 2.7 years; P < 0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3 ± 0.7 days; P = 0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P = 1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P = 1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux. DISCUSSION Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure. CONCLUSION Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.
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Affiliation(s)
- Angela M Arlen
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Kristin M Broderick
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Curtis Travers
- Department of Pediatrics, Division of Biostatistics, Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30322, USA
| | - Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - James M Elmore
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA.
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Abstract
Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the upper urinary tract. Diagnosis and subsequent management of VUR have become increasingly controversial, with differing opinions over which children should be evaluated for reflux, and when detected, who should undergo treatment. Management goals include prevention of recurrent febrile urinary tract infection (fUTI) and renal injury while minimizing the morbidity of treatment and follow-up. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Management should be individualized and based on patient age, health, risk of subsequent renal injury, clinical course, renal function, and parental preference.
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Affiliation(s)
- Angela M Arlen
- Departments of Urology and Pediatrics, The University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242-1089, USA,
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Nabavizadeh B, Keihani S, Hosseini Sharifi SH, Kajbafzadeh AM. Insertion of a single double-J stent for bilateral open ureteral reimplantation: introducing a novel technique and assessment of feasibility. Int Urol Nephrol 2016; 48:1015-9. [PMID: 27043029 DOI: 10.1007/s11255-016-1279-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/21/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To propose a novel technique for bilateral placement of a single double-J stent during bilateral open ureteral reimplantation in order to reduce the intravesical length of stent and potentially minimize the irritative symptoms. METHODS A retrospective chart review was performed to find patients who underwent bilateral open ureteral reimplantation. According to the patient's age, an appropriate single double-J stent is used for stenting both ureters after open reimplantation using the Politano-Leadbetter technique. The stent is fixed to the bladder wall with a 4-0 chromic absorbable suture in the midline, superior to the intertrigonal ridge. A non-absorbable suture is also fixed to the stent in the midline as an extraction string. RESULTS From June 2009 to July 2013, 20 patients underwent bilateral ureteric surgery. Twelve (60 %) were female. Patients' age ranged from 3 months to 2 years. Double-J stents were successfully removed within 2 weeks postoperatively in all patients. CONCLUSIONS This technique might reduce the stent-related symptoms after open bladder surgery for bilateral ureteral surgery. Using this technique will reduce the redundant mass of ureteral stents in bladder and potentially minimize the trigonal irritation and subsequent pain and discomfort.
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Affiliation(s)
- Behnam Nabavizadeh
- Pediatric Urology Research Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box 1419733151, Tehran, Iran (IR)
| | - Sorena Keihani
- Pediatric Urology Research Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box 1419733151, Tehran, Iran (IR)
| | - Seyed Hossein Hosseini Sharifi
- Pediatric Urology Research Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box 1419733151, Tehran, Iran (IR)
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology Research Center, Pediatric Center of Excellence, Tehran University of Medical Sciences, No.62, Dr. Gharib's Street, Keshavarz Boulevard, P.O. Box 1419733151, Tehran, Iran (IR).
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Arlen AM, Kirsch AJ. Recent Developments in the Use of Robotic Technology in Pediatric Urology. Expert Rev Med Devices 2016; 13:171-8. [DOI: 10.1586/17434440.2016.1136211] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Insignificant impact of VUR on the progression of CKD in children with CAKUT. Pediatr Nephrol 2016; 31:105-12. [PMID: 26404649 DOI: 10.1007/s00467-015-3196-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is associated with an increased risk of kidney disorders. It is unclear whether VUR is associated with progression from chronic kidney disease (CKD) to end-stage kidney disease (ESKD) in children with congenital anomalies of the kidney and urinary tract (CAKUT). METHODS We conducted a 3-year follow-up survey of a cohort of 447 children with CKD (stage 3-5). Rates of and risk factors for progression to ESKD were determined using the Kaplan-Meier method and Cox regression respectively. RESULTS Congenital anomaly of the kidney and urinary tract was the primary etiology in 278 out of 447 children; 118 (42.4 %) had a history of VUR at the start of the cohort study. There were significantly more boys than girls with VUR, whereas the proportions were similar in children without VUR. The types of urinary anomalies/complications of the two groups were significantly different. Three-year renal survival rates of the groups were not significantly different, irrespective of CKD stage. Age < 2 years and age after puberty, stage 4 or 5 CKD, and heavy proteinuria, but not history of VUR, were significantly associated with progression to ESKD. CONCLUSIONS History of VUR at the start of follow-up was not associated with the progression of stage 3-5 CKD in children with CAKUT.
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Kang M, Lee JK, Im YJ, Choi H, Park K. Predictive Factors of Chronic Kidney Disease in Patients with Vesicoureteral Reflux Treated Surgically and Followed after Puberty. J Urol 2015; 195:1100-6. [PMID: 26555955 DOI: 10.1016/j.juro.2015.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE We delineated clinical features and determined predictors of chronic kidney disease during long-term postpubertal followup in patients with vesicoureteral reflux treated surgically. MATERIALS AND METHODS We analyzed the data of 101 patients who were surgically treated for vesicoureteral reflux and had gone through puberty. Patients underwent preoperative and postoperative voiding cystourethrography to assess reflux status, and dimercaptosuccinic acid scan to assess renal cortical defects. We compared several variables preoperatively and postpubertally, including body mass index; blood urea nitrogen, creatinine and uric acid levels; estimated glomerular filtration rate; microalbuminuria; blood pressure; renal function and renal scarring. Kaplan-Meier analysis was used to predict chronic kidney disease-free survival rates throughout the followup periods. Cox regression model was adopted to identify independent predictors of chronic kidney disease. We defined chronic kidney disease as estimated glomerular filtration rate less than 60 ml/minute/1.73 m(2). RESULTS Median followup was 100.0 months (IQR 69.0 to 136.5). Median age was 16 years at last followup (IQR 14 to 18). A total of 11 patients (10.9%) were diagnosed with de novo chronic kidney disease during postpubertal followup. It is noteworthy that serum uric acid levels (HR 1.96) and presence of high grade reflux (HR 7.40) were significant predictors of chronic kidney disease on multivariate analysis. CONCLUSIONS In children who were treated surgically for vesicoureteral reflux preoperative uric acid levels and high grade reflux were independent predictors of de novo chronic kidney disease during postpubertal followup. Our results offer valuable information for predicting long-term renal outcomes in patients with vesicoureteral reflux treated surgically.
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Affiliation(s)
- Minyong Kang
- Department of Urology, College of Medicine, Seoul National University, Seoul, Korea
| | - Jung Keun Lee
- Department of Urology, College of Medicine, Seoul National University, Seoul, Korea
| | - Young Jae Im
- Department of Urology, College of Medicine, Seoul National University, Seoul, Korea
| | - Hwang Choi
- Department of Urology, College of Medicine, Seoul National University, Seoul, Korea
| | - Kwanjin Park
- Department of Urology, College of Medicine, Seoul National University, Seoul, Korea.
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Bryskin RB, Londergan B, Wheatley R, Heng R, Lewis M, Barraza M, Mercer E, Ye G. Transversus Abdominis Plane Block Versus Caudal Epidural for Lower Abdominal Surgery in Children. Anesth Analg 2015; 121:471-8. [DOI: 10.1213/ane.0000000000000779] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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