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Mahyoub MA, Yousef BM, Ghaleb RA, Obad S, Mothanna A, Al-Yousofy F, Elhoumed M, Abbas M, Alnaggar M, Ren M, He S. Vesicoureteral reflux postoperative radical nephroureterectomy for upper urinary tract urothelial carcinoma: A case report. Heliyon 2024; 10:e30294. [PMID: 38707276 PMCID: PMC11066732 DOI: 10.1016/j.heliyon.2024.e30294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 04/21/2024] [Accepted: 04/23/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Primary Upper tract urothelial carcinoma (UTUC) is a rare subtype of urothelial carcinoma and has an unknown incidence and prevalence in Yemen. Radical nephroureterectomy (RNU) with bladder cuff removal is the standard treatment for UTUC. Case presentation We present a 67-year-old male patient who developed grade II vesicoureteral reflux (VUR) on the left side of the urinary tract after undergoing right-sided RNU for non-invasive UTUC. Follow-up examinations at one-, three-, and six-month post-surgery revealed no evidence of kidney diseases. The patient's recovery has been satisfactory, and ongoing regular follow-ups are being maintained. Conclusion Vigilant monitoring of VUR presence and effective management following RNU is crucial to minimize complications and preserve renal function. The underlying mechanisms linking VUR development and RNU remain unclear, necessitating further research.
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Affiliation(s)
- Mueataz A. Mahyoub
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Clinical Medical Research Center for Digestive Diseases (Oncology) of Shaanxi Province, Xi'an, China
- Department of Internal Medicine, Faculty of Medicine, Thamar University, Thamar, Yemen
| | | | - Radman A.M. Ghaleb
- Department of Urology, Faculty of Medicine, Taiz University, Taiz, Yemen
| | - Saleh Obad
- Department of Anesthesiology, Al- Ameen Typical Hospital, Ibb, Yemen
| | | | - Fayed Al-Yousofy
- Department of Pathology, Faculty of Medicine, Taiz University, Taiz, Yemen
| | - Mohamed Elhoumed
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, China
- National Institute of Public Health Research (INRSP), BP. 695, Nouakchott, Mauritania
| | - Mustafa Abbas
- Department of Internal Medicine, Faculty of Medicine, Thamar University, Thamar, Yemen
| | - Mohammed Alnaggar
- Department of Internal Medicine, Clinic Medical College, Hubei University of Science and Technology, Xianning, Hubei, China
- Department of Oncology, South Hubei Cancer Hospital, Xianning, Hubei, China
| | - Mudan Ren
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Clinical Medical Research Center for Digestive Diseases (Oncology) of Shaanxi Province, Xi'an, China
| | - Shuixiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Clinical Medical Research Center for Digestive Diseases (Oncology) of Shaanxi Province, Xi'an, China
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Pakkasjärvi N, Ripatti L, Läckgren G, Krishnan N, Anand S. PIC cystography in occult vesicoureteral reflux: A systematic review highlighting its utility in children with recurrent urinary tract infections and normal VCUG. J Pediatr Urol 2023; 19:804-811. [PMID: 37633825 DOI: 10.1016/j.jpurol.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) affects 1-2% of children, predisposing them to pyelonephritis, renal scarring, and reflux nephropathy. Treatment aims to prevent febrile urinary tract infections (f-UTI) and long-term sequelae. While guidelines differ, the current consensus proposes individual risk-stratification and subsequent management strategies. Here, we systematically analyzed the current literature on Positional Instillation of Contrast Cystography (PIC) for individualized diagnostics in patients with recurrent f-UTIs. OBJECTIVE We present a comprehensive qualitative and quantitative synthesis. Outcomes were: 1. the ability of PIC to predict VUR in patients with negative voiding cystographies (VCUG), 2. the ability of PIC to predict occult contralateral VUR, 3. the correlation of occult VUR in PIC with dimercaptosuccinic acid (DMSA) scan findings, and 4. the incidence of postoperative f-UTI in children treated for occult VUR picked up on PIC. STUDY DESIGN We conducted a systematic review following the PRISMA guidelines, applying the following inclusion criteria: Children with occult VUR in PIC with negative VCUG. RESULTS We included nine studies with 496 symptomatic patients with a mean age of 6.8 years, published between 2003 and 2021. PIC detected VUR in 73% of patients. Out of them, 81% had low-grade and 19% high-grade VUR. Occult contralateral VUR was present in 41% children. The presence of renal scars on DMSA scan was 1.39 times more likely with occult VUR on PIC. 85% of patients did not experience recurrent f-UTIs after PIC and subsequent treatment. DISCUSSION PIC can detect occult VUR in patients with recurrent f-UTIs in whom VCUG is negative. However, we recommend a cautious approach in the use of PIC in clinical practice until further prospective studies confirm the validity of our outcome measures. CONCLUSION Identification, risk stratification, and prompt action are central in managing VUR. PIC can be helpful in identifying VUR in patients with recurrent f-UTI.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland; Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland
| | - Göran Läckgren
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Nellai Krishnan
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.
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Esposito C, Masieri L, Fourcade L, Ballouhey Q, Varlet F, Scalabre A, Castagnetti M, El Ghoneimi A, Escolino M. Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience. J Pediatr Urol 2023; 19:136.e1-136.e7. [PMID: 36344364 DOI: 10.1016/j.jpurol.2022.10.024] [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: 04/08/2022] [Revised: 08/04/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. OBJECTIVE This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. STUDY DESIGN The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. RESULTS Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table). DISCUSSION This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. CONCLUSION REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.
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Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy.
| | - Lorenzo Masieri
- Division of Pediatric Urology, Meyer University Hospital, Florence, Italy
| | - Laurent Fourcade
- Division of Pediatric Surgery, CHU de Limoges, Hopital de la Mère et de l'Enfant, Limoges, France
| | - Quentin Ballouhey
- Division of Pediatric Surgery, CHU de Limoges, Hopital de la Mère et de l'Enfant, Limoges, France
| | - Francois Varlet
- Division of Pediatric Surgery, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Aurelien Scalabre
- Division of Pediatric Surgery, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Marco Castagnetti
- Division of Pediatric Urology, Bambino Gesù Children Hospital, Rome, Italy
| | - Alaa El Ghoneimi
- Department of Pediatric Surgery and Urology, University Hospital Robert Debrè, APHP, Paris, France
| | - Maria Escolino
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
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Tokat E, Gurocak S, Ozkan S, Dogan HS, Citamak B, Satar N, Izol V, Deger M, Sarikaya S, Bostanci Y, Gulsen M, Onal B, Altinay Kirli E, Burgu B, Soygur T, Haciyev P, Agras K, Karabulut B, Akbal C, Akin Sekerci C, Demirci D, Baydilli N, Tekgul S, Ozgur Tan M. Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study. Int J Clin Pract 2021; 75:e14339. [PMID: 33966353 DOI: 10.1111/ijcp.14339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/04/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country. MATERIALS AND METHODS The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR." RESULTS In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076). CONCLUSION Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.
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Affiliation(s)
- Eda Tokat
- Department of Urology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| | - Serhat Gurocak
- Department of Pediatric Urology, Gazi University School of Medicine, Ankara, Turkey
| | - Secil Ozkan
- Department of Public Health, Gazi University School of Medicine, Ankara, Turkey
| | - Hasan Serkan Dogan
- Department of Pediatric Urology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Burak Citamak
- Department of Pediatric Urology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Nihat Satar
- Department of Urology, Cukurova University School of Medicine, Adana, Turkey
| | - Volkan Izol
- Department of Urology, Cukurova University School of Medicine, Adana, Turkey
| | - Mutlu Deger
- Department of Urology, Cukurova University School of Medicine, Adana, Turkey
| | - Saban Sarikaya
- Department of Urology, Samsun Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Yakup Bostanci
- Department of Urology, Samsun Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Murat Gulsen
- Department of Urology, Samsun Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Bulent Onal
- Department of Pediatric Urology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Elif Altinay Kirli
- Department of Pediatric Urology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Tarkan Soygur
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Perviz Haciyev
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Koray Agras
- Department of Pediatric Urology, Gazi University School of Medicine, Ankara, Turkey
| | - Bilge Karabulut
- Department of Pediatric Urology, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Trainig and Research Hospital, Ankara, Turkey
| | - Cem Akbal
- Department of Urology, Acıbadem University School of Medicine, Istanbul, Turkey
| | - Cagri Akin Sekerci
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - Deniz Demirci
- Department of Urology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Numan Baydilli
- Department of Urology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Serdar Tekgul
- Department of Pediatric Urology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mustafa Ozgur Tan
- Department of Pediatric Urology, Gazi University School of Medicine, Ankara, Turkey
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Maruyama T, Mizuno K, Nishio H, Kato T, Hamakawa T, Ikegami Y, Yasui T, Hayashi Y. Antireflux endoscopic injection therapy in post-pubertal patients via techniques adopted for the dilated ureteral orifice: a retrospective single-center study. BMC Urol 2021; 21:70. [PMID: 33894751 PMCID: PMC8067324 DOI: 10.1186/s12894-021-00842-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To investigate the efficacy and safety of endoscopic injection therapy for vesicoureteral reflux in post-pubertal patients with dilated ureteral orifice via modified hydrodistension implantation techniques. METHODS We retrospectively reviewed medical records including operational procedure and clinical course of all consecutive patients over 12 years old with a history of injection therapy. Endoscopic injection of dextranomer/hyaluronic acid copolymer was performed under hydrodistension implantation technique with some modifications in order to inject through dilated ureteral orifice align with the intramural ureter. Technical selections were done according to hydrodistension grade of the ureteral orifice. Voiding cystourethrography was evaluated at 3 months postoperatively. Hydronephrosis was evaluated using ultrasonography preoperatively until 6 months postoperatively. RESULTS From 2016 to 2019, 12 patients (all female, 16 ureteral units; median age 32 [range 15-61] years) underwent endoscopic injection therapy at one of our institutions. We have identified grade II vesicoureteral reflux in 5 ureters, grade III in 8, and grade IV in 3 ureters. Grade 3 ureteral-orifice dilation were presented in 12 ureters (75%), grade 2 in 3 and grade 1 in 1 ureter in the present cases. Postoperatively, vesicoureteral reflux was diminished to grade 0 in 12 ureteral units (75%), decreased to grade I in 3 (9%), and remained grade III in 1 (6%). Three patients reported dull flank pain for several days postoperatively and there was 1 case of acute pyelonephritis. Temporary hydronephrosis was confirmed in 3 ureteral units (19%) at 1 month postoperatively. Median follow-up duration was 23 (range 13-63) months long. Although, 3 patients were experienced f-UTI 1-2 times, repeated VCUG showed no VUR recurrence. CONCLUSIONS According to hydrodistension grade of the ureteral orifice, endoscopic injection therapy via modified hydrodistension implantation technique is an effective and safe treatment for vesicoureteral reflux in post-pubertal female patients with dilated ureteral orifice. While ureteral deformities or a history of anti-reflux surgery may increase the risks, these can be managed with appropriate methods that ensure sufficient mound appearance and height.
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Affiliation(s)
- Tetsuji Maruyama
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Kentaro Mizuno
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hidenori Nishio
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Taiki Kato
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Takashi Hamakawa
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Yosuke Ikegami
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Takahiro Yasui
- Department of Nephro-Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yutaro Hayashi
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
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Adherence and Acceptability of an Oral Antibiotic Used for the Prevention of Pediatric Urinary Tract Infection in Japan. Pharmaceutics 2021; 13:pharmaceutics13030345. [PMID: 33800757 PMCID: PMC8000562 DOI: 10.3390/pharmaceutics13030345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 11/17/2022] Open
Abstract
Urinary tract infection (UTI) is a common health care-associated adverse event and the leading nosocomial complication following pediatric urological surgery. While continuous antimicrobial prophylaxis effectively reduces the risk of UTI following such a surgery, non-adherence is common and represents a distinct clinical entity that is associated with renal scarring. Acceptability is likely to have a significant impact on patient adherence. Herein we used a validated data-driven approach-the ClinSearch acceptability score test (CAST)-to investigate the acceptability of cefaclor, an oral antibiotic widely used for the prevention of pediatric UTI in Japan. Standardized observer reports were collected for 58 intakes of cefaclor 10% fine granules in patients aged from 0 to 17 years. The medicine was classified as positively accepted on the acceptability reference framework. According to the percentage of the prescribed dose taken reported at the end of the treatment, patients exhibited good adherence to this well-accepted medicine. Nonetheless, requirements for greater dosing frequency or poor acceptability in certain patients could affect adherence. Acceptability should be established to ensure patient adherence to medicines used for long-term prophylaxis and consequently guarantee the safety and efficacy of the treatment.
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Al Qahtani W, Sarhan O, Al Otay A, El Helaly A, Al Kawai F. Primary Bilateral High-Grade Vesicoureteral Reflux in Children: Management Perspective. Cureus 2020; 12:e12266. [PMID: 33520484 PMCID: PMC7834586 DOI: 10.7759/cureus.12266] [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] [Indexed: 11/21/2022] Open
Abstract
Objective Vesicoureteral reflux (VUR) is a common finding in the pediatric population with the risk of repeated infections and renal damage. There is little is known about the natural history of primary bilateral high-grade reflux. Herein we present our experience in the management of primary high-grade bilateral VUR and the long-term outcome of renal function in this specific group of patients. Materials and methods We retrospectively evaluated all patients with congenital bilateral VUR between 2006 and 2014. Records were reviewed for patient age at diagnosis, antenatal history, clinical presentation, the grade of VUR on voiding cystourethrogram (VCUG), presence of scars on dimercaptosuccinic acid (DMSA) scan, indications for surgical intervention, and surgical approaches. Clinical and radiological outcomes of this subgroup of patients were assessed. Results A total of 67 patients with bilateral VUR were identified, of whom 31 (20 boys and 11 girls) had primary high-grade (grade IV and V) bilateral VUR. The mean age at diagnosis was seven months. DMSA scans showed renal scars in 19 patients (61%) and eight of them were bilateral. Surgical intervention was necessary for 81% of patients with a success rate of 58% after endoscopic correction and 100% after reimplantation. Chronic kidney disease (CKD) developed in 13 patients (42%) after a mean follow-up of eight years. Conclusions Primary bilateral high-grade VUR carries a high rate of surgical intervention. The endoscopic correction has an acceptable success rate and efficient long-term outcome. Nevertheless, a significant proportion of patients progresses to CKD even after VUR management.
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Affiliation(s)
| | - Osama Sarhan
- Urology, Mansoura Urology and Nephrology Center, Mansoura, EGY
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Sarhan O, El Helaly A, Al Otay A, Al Ghanbar M, Nakshabandi Z, Al Kawai F. Critical analysis of the outcome of primary unilateral vesicoureteral reflux in a medium volume center. AFRICAN JOURNAL OF UROLOGY 2020. [DOI: 10.1186/s12301-020-00058-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Vesicoureteral reflux (VUR) is a common finding in pediatric age group. Here in we explored the possible risk factors that affect the rate of resolution in patients with primary unilateral VUR under conservative treatment.
Methods
Between 2006 and 2014, we retrospectively evaluated all VUR patients and included only patients with primary unilateral VUR. Records were reviewed for patient age at diagnosis, antenatal history, patient gender, mode of presentation, side, and grade of VUR, associated hydronephrosis (HN) on renal ultrasound, presence of scarring and split function on dimercaptosuccinic acid (DMSA) scan. Clinical and radiological outcomes were assessed. Both univariate and multivariate analysis were conducted.
Results
A total of 68 patients with primary unilateral VUR were included (32 boys and 36 girls) with a mean age of 10 months (range 1–32). Antenatal HN was detected in 50% of patients. In 15 cases (22%), VUR was of high grade (IV–V). Associated HN was evident in 39 patients (57%). DMSA scans showed renal scarring in 16 patients (23%). After a mean follow-up of 7 years, VUR resolved in 49 patients (72%). Significant predictors for VUR resolution were VUR grade, DMSA split function and associated high-grade HN. High-grade HN with VUR was the only significant independent risk factor.
Conclusions
The rate of resolution in primary unilateral VUR under conservative treatment is significantly affected by VUR grade, DMSA split renal function and the presence of associated HN. Association of high-grade HN with VUR carries a low chance for spontaneous resolution.
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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: 0.5] [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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Ripatti L, Viljamaa HR, Kauko T, Kytö V, Rautava P, Sipilä J, Pakkasjärvi N. Trends in the surgical management of vesicoureteral reflux in Finland in 2004-2014. Scand J Urol 2020; 55:67-71. [PMID: 33241755 DOI: 10.1080/21681805.2020.1849387] [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: 10/22/2022]
Abstract
OBJECTIVES Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland. METHODS We analyzed national data from Finnish Care Register for Health Care on children (<16 years of age) surgically treated for VUR in 2004-2014. RESULTS Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p < 0.001, respectively). The median age at surgery for VUR was lower in those treated with open ureteral reimplantation than those with endoscopic injections of the ureteral orifices [3 and 4 years, respectively] (p = 0.0001). The length of hospital stay was significantly longer (median 9.9 days) with open ureteral reimplantation compared to that (median 1.3 days) with endoscopic injections (p < 0.0001) and did not change during the study period. Reoperations were significantly more common in patients who were primarily treated with endoscopic injections (n = 146/1072, 14%) than with ureteral reimplantation (n = 7/230, 3%) (p < 0.0001). CONCLUSIONS While the best treatment options for VUR remain debatable, operative treatment of VUR has become less common in Finland. HIGHLIGHTS Recent data on the trends of treatment of vesicoureteral reflux outside USA are scarce. Surgical treatment for vesicoureteral reflux decreased in Finland during the study period. The length of stay was longer but reoperations were needed less often with ureteral reimplantation compared to endoscopic injections.
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Affiliation(s)
- Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Turku, Finland
| | | | - Tommi Kauko
- Auria Clinical Informatics, Turku University Hospital, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland.,Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Jussi Sipilä
- Department of Neurology, Siunsote, North Karelia Central Hospital, Joensuu, Finland.,Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Department of Neurology, University of Turku, Turku, Finland
| | - Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Turku, Finland.,Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
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11
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Al Hindi S, Mubarak M, Al Aradi H. High-grade vesicoureteral reflux in infants: Our experience with endoscopic subureteric injections. Urologia 2020; 89:120-125. [PMID: 33063631 DOI: 10.1177/0391560320966187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is the most common urological anomaly in pediatric patients. Management options for VUR vary from continuous antibiotic prophylaxis (CAP) to surgery via either endoscopic subureteric injection of a bulking agent or open anti-reflux surgery. In this study, we assess the efficacy of subureteric injections of Dextranomer/Hyaluronic acid Copolymer (Deflux) in managing primary VUR in infant patients with high-grade VUR. METHODS From 2010 to 2015, children less than 1-year-old with primary high-grade VUR were observed prospectively following the administration of endoscopic subureteric injections of Dextranomer/Hyaluronic Acid Copolymer (Deflux). The diagnosis of VUR was based on MCUG, and all patients underwent a holistic clinical, laboratory, and radiological assessment before and after the intervention. Complete success was defined as the resolution of VUR on follow up 1 year post-operatively. RESULTS A total of 30 infants (50 renal units) with high-grade VUR (grades IV and V) were included in the study. The mean age at surgery was 6.3 ± 2.5 months. Most of the patients presented with a urinary tract infection (90%). Complete symptomatic relief was achieved in 27 patients (90%) at the first post-operative follow-up. Forty-four renal units received one injection, while six required a second injection as they did not meet our treatment success criteria. No patients required a third injection or referral for open surgery. CONCLUSION Endoscopic injection of Dextranomer/Hyaluronic acid Copolymer (Deflux) at the vesicoureteral junction is an effective minimally invasive intervention to treat high grades VUR (IV-V) infants.
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Affiliation(s)
- Saeed Al Hindi
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Mohamed Mubarak
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Husain Al Aradi
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
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12
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Johnston AW, Routh JC, Purves JT, Wiener JS, Sinani A, Holl EK. Immune Expression in Children With Vesicoureteral Reflux: A Pilot Study. Urology 2020; 148:254-259. [PMID: 33049235 DOI: 10.1016/j.urology.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To perform an exploratory, descriptive pilot study of the systemic and local immune environment in patients with vesicoureteral reflux (VUR) and bladder-bowel dysfunction (BBD). METHODS Consecutive children with VUR undergoing intravesical ureteral reimplantation were enrolled. Patients were assessed for presence of BBD by reported patient history and validated questionnaire. Fresh blood and bladder tissue, collected at the time of surgery, were immediately processed for analysis. Immune cell compositions were determined via flow cytometry. Immune cell activation was also defined at the time of analysis. LegendPlex assay analysis was utilized to define levels of circulating chemokines and cytokines. RESULTS A total of 7 patients were enrolled. Although percentages of circulating immune cells in the blood of those with VUR/BBD and VUR alone were similar, within bladder tissue, VUR/BBD demonstrated increased immune infiltrates compared to VUR alone. Bladder sample analysis showed that B cells, and Effector Memory and Naïve T cell percentages were significantly increased in VUR/BBD patients compared to VUR patients. T cell expression of PD1 was increased in bladder tissues of BBD/VUR. Additionally, analysis of circulating neutrophils displayed significantly increased upregulation of PDL-1 in patients with VUR/BBD vs those with VUR only. CONCLUSION These pilot data suggest an immune-rich microenvironment is present within VUR. Severity of inflammation appeared to correlate with presence of BBD. This implies that targeting pelvic inflammation may be a novel therapy for children with VUR- or non-VUR-related BBD. Follow-up studies are currently underway.
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Affiliation(s)
- Ashley W Johnston
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC.
| | - Jonathan C Routh
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - J Todd Purves
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - John S Wiener
- Division of Urologic Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Angela Sinani
- Dept of Chemical and Biomolecular Engineering, University of Delaware, Newark, DE
| | - Eda K Holl
- Division of Surgical Sciences, Department of Surgery, Duke University School of Medicine, Durham, NC
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13
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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: 2.8] [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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14
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Köse T, Özgür S, Coşgun E, Keskinoğlu A, Keskinoğlu P. Effect of Missing Data Imputation on Deep Learning Prediction Performance for Vesicoureteral Reflux and Recurrent Urinary Tract Infection Clinical Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1895076. [PMID: 32733929 PMCID: PMC7378600 DOI: 10.1155/2020/1895076] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/17/2022]
Abstract
Missing observations are always a challenging problem that we have to deal with in diseases that require follow-up. In hospital records for vesicoureteral reflux (VUR) and recurrent urinary tract infection (rUTI), the number of complete cases is very low on demographic and clinical characteristics, laboratory findings, and imaging data. On the other hand, deep learning (DL) approaches can be used for highly missing observation scenarios with its own missing ratio algorithm. In this study, the effects of multiple imputation techniques MICE and FAMD on the performance of DL in the differential diagnosis were compared. The data of a retrospective cross-sectional study including 611 pediatric patients were evaluated (425 with VUR, 186 with rUTI, 26.65% missing ratio) in this research. CNTK and R 3.6.3 have been used for evaluating different models for 34 features (physical, laboratory, and imaging findings). In the differential diagnosis of VUR and rUTI, the best performance was obtained by deep learning with MICE algorithm with its values, respectively, 64.05% accuracy, 64.59% sensitivity, and 62.62% specificity. FAMD algorithm performed with accuracy = 61.52, sensitivity = 60.20, and specificity was found out to be 61.00 with 3 principal components on missing imputation phase. DL-based approaches can evaluate datasets without doing preomit/impute missing values from datasets. Once DL method is used together with appropriate missing imputation techniques, it shows higher predictive performance.
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Affiliation(s)
- Timur Köse
- Ege University Faculty of Medicine, Department of Biostatistics and Medical Informatics, Turkey
| | - Su Özgür
- Ege University Faculty of Medicine, Department of Biostatistics and Medical Informatics, Turkey
| | - Erdal Coşgun
- Genomics Team, Microsoft Research, Redmond, WA, USA
| | - Ahmet Keskinoğlu
- Ege University Children's Hospital, Department of Pediatric Nephrology, Turkey
| | - Pembe Keskinoğlu
- Dokuz Eylul University Faculty of Medicine, Department of Biostatistics and Medical Informatics, Turkey
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15
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Cundy TP, Barker A, Borzi P, Khurana S. Variation in ureteric re-implantation for Australian children. ANZ J Surg 2020; 91:1011-1016. [PMID: 32419287 DOI: 10.1111/ans.15995] [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] [Received: 03/19/2020] [Revised: 04/18/2020] [Accepted: 05/03/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Management options for vesicoureteric reflux are numerous, increasingly diversifying and debated. There is longstanding anecdotal opinion of inexplicable regional variation in vesicoureteric reflux management in Australia. This study investigates temporal trends in ureteric re-implantation for children, and variation between states and territories. METHODS Ureteric re-implantation data for children aged 0-14 years were retrieved from the Medicare Benefits Scheme item reports database for the 20-year period from 1998-2017. Claims data were population adjusted for each state then standardized for age using Australian Bureau of Statistics records. National and regional trends were calculated using joinpoint regression. Comparison between eastern (New South Wales, Victoria, Queensland, Tasmania, Australian Capital Territory) and western or central (Western Australia, South Australia) states was performed using the Mann-Whitney U-test. RESULTS There were 4919 procedure rebate claims during the study period. A national decrease in claim rates of 6.3% per 100 000 children was identified (P < 0.001). This was derived from significant decreases observed in eastern states. There was a threefold higher claim rate in Western Australia and South Australia per annum compared to the remainder of the country (4.0 versus 12.6 per 100 000; P < 0.001). For the most recent 5 years of the study period, this difference increased to a sevenfold higher rate (1.6 versus 11.1; P < 0.001). CONCLUSION There has been a dramatic nationwide decline in the rate of ureteric re-implantation procedure claims. Regional disparity between each side of the country is widening. Further research is required to determine if this degree of variation is warranted or unwarranted. The observed regional variation facilitates opportunity for a nationwide pragmatic clinical trial.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Barker
- Department of Paediatric Surgery, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Peter Borzi
- Department of Paediatric Surgery, Queensland Children's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
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16
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17
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Gaither TW, Copp HL. Antimicrobial prophylaxis for urinary tract infections: implications for adherence assessment. J Pediatr Urol 2019; 15:387.e1-387.e8. [PMID: 31182400 DOI: 10.1016/j.jpurol.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Continuous antimicrobial prophylaxis (prophylaxis) is associated with a reduction in recurrent urinary tract infections in children with vesicoureteral reflux. However, adherence to daily medications has been shown to be poor. OBJECTIVE To determine patient/caregiver factors associated with non-adherence and to determine whether adherence alters the effect of prophylaxis on recurrent UTIs and renal scarring. STUDY DESIGN We conducted a secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux trial. We stratified adherence scores into quartiles to assess trends within the data. We assessed predictors of non-adherence using ordinal logistic regression. We then examined the efficacy of prophylaxis stratified by adherence quartiles. RESULTS Six hundred patients were included in the analysis. The quartiles of adherence were as follows: 1st quartile-0-70% adherence; 2nd quartile-71-91% adherence; 3rd quartile-92-96% adherence; and 4th quartile->96% adherence. Neither demographic factors nor disease severity was associated with non-adherence. In the subanalysis of patients who were toilet trained at baseline, increasing bladder and bowel dysfunction (BBD) symptom score was associated with non-adherence (adjusted odds ratio, aOR = 1.1, 95% confidence interval [CI] 1.0-1.2). Patients least adherent were 2.5 times more likely (95%CI 1.1-5.6) to have a recurrent UTI compared with patients most adherent. After controlling for treatment arm, age, sex, degree of reflux, BBD, and number of UTIs, patients least adherent (taking the study medication less than <70% of the time) were at highest risk for renal scarring (aOR = 24.2, 95%CI 3.0-197). In contrast, among the most adherent quartile, the probability of renal scarring was highest in those assigned prophylaxis (16.2% compared with 1.7% in those most adherent to placebo). CONCLUSIONS Adherence is distinctly related to clinical outcomes in children with VUR. Non-adherence is common and represents a distinct clinical entity that is associated with renal scarring. Adherence should be assessed in prophylaxis management algorithms.
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Affiliation(s)
- T W Gaither
- Department of Urology, University of California, San Francisco, USA
| | - H L Copp
- Department of Urology, University of California, San Francisco, USA.
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18
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Tokat E, Gurocak S, Ure I, Acar C, Sınık Z, Tan MO. Did our current initial treatment practice change after EAU/ESPU vesicoureteral reflux risk grouping? J Pediatr Surg 2019; 54:1477-1480. [PMID: 29871762 DOI: 10.1016/j.jpedsurg.2018.05.004] [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: 03/23/2018] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND/PURPOSE The "European Association of Urology (EAU) Guidelines on Vesicoureteral Reflux (VUR) in Children (September 2012)" established risk classification by analyzing and defining risk factors for each patient. In this study we aimed to investigate how our initial treatment procedures were affected by EAU/ESPU guideline vesicoureteral reflux risk grouping and to compare the early clinical results of treatments performed before and after the risk classification in our patients with VUR. MATERIALS AND METHODS 334 renal units with regular clinical follow-up who were treated owing to VUR (vesicoureteral reflux) between years 2009 and 2017 were retrospectively reviewed. Preoperative clinical parameters such as grade and laterality of reflux, presence of renal scar, initial and follow-up treatments, findings of medical treatment and surgical procedures were analyzed. The initial medical and surgical methods were compared by categorizing patients according to risk groups before and after 2013. RESULTS Mean age and follow-up duration were 71.4(6-216) months and 47(4-141) months, respectively. Among the preoperative parameters, only high EAU risk group (p = 0.01) and treating lower urinary tract symptoms (p < 0.001) were determining the postoperative success rates significantly, while age, sex, and presence of renal scar at DMSA were not affecting the success of treatment significantly. While no significant difference in medical and surgical treatment rates is observed after risk grouping system in low risk group, the percentages of patients who are treated with surgical methods initially were significantly decreased in moderate and high risk groups (p = 0.002 and p = 0.012, respectively). We determined that VUR risk grouping did not change clinical success significantly in all risk groups. CONCLUSIONS Despite the fact that EAU/ESPU VUR risk classification changed our current practice in terms of initial treatment method, this different approach did not seem to affect early clinical success positively. There is still an absolute need for studies with larger sample size and long-term follow-up to reach more reliable results. TYPE OF STUDY Therapeutic. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Eda Tokat
- Gazi University School of Medicine, Department of Urology, Ankara, Turkey.
| | - Serhat Gurocak
- Gazi University School of Medicine, Department of Urology, Ankara, Turkey
| | - Iyimser Ure
- Osmangazi University School of Medicine, Department of Urology, Eskisehir, Turkey
| | | | | | - Mustafa Ozgur Tan
- Gazi University School of Medicine, Department of Urology, Ankara, Turkey
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Hout M, Aoun B, Atweh LA, Merhe A, El-Hout Y. Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern tertiary care center. Urol Ann 2019; 11:168-170. [PMID: 31040602 PMCID: PMC6476207 DOI: 10.4103/ua.ua_124_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.
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Affiliation(s)
- Mohammad Hout
- Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Bilal Aoun
- Division of Pediatric Nephrology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Lamya Ann Atweh
- Department of Radiology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Ali Merhe
- Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Yaser El-Hout
- Division of Urology, American University of Beirut-Medical Center, Beirut, Lebanon
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20
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Sahadev R, Spencer K, Srinivasan AK, Long CJ, Shukla AR. The Robot-Assisted Extravesical Anti-reflux Surgery: How We Overcame the Learning Curve. Front Pediatr 2019; 7:93. [PMID: 30984718 PMCID: PMC6450052 DOI: 10.3389/fped.2019.00093] [Citation(s) in RCA: 10] [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: 12/25/2018] [Accepted: 03/04/2019] [Indexed: 02/03/2023] Open
Abstract
Management of vesicoureteral reflux (VUR) has evolved over the past several decades, with a trend toward a decrease in surgical management. In spite of this, ureteral reimplantation remains a commonly performed procedure by pediatric urologists in selected cases. Although the basic tenets of the ureteral reimplant procedure remain the same, the extra- vs. intravesical approach, and the traditional open vs. minimally invasive approach remain the primary options to correct reflux. Considering the advantages conferred by the robotic surgery platform, many leading centers have preferentially adopted robot-assisted laparoscopic extravesical anti-reflux surgery, or in common surgical parlance, the robot-assisted laparoscopic ureteral reimplantation (RALUR), over pure laparoscopic or open approaches. Predicated on our experience of performing over 170 cases of RALUR, we have made technical modifications which we posit reduce the morbidity of the procedure while offering acceptable outcomes. This review highlights the evolution and establishment of RALUR as a standardization of care in the surgical management of VUR at our institution. In particular, we emphasize the technical nuances and specific challenges encountered through the learning curve in hopes of facilitating this process for others.
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Affiliation(s)
- Ravindra Sahadev
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katelyn Spencer
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Arun K Srinivasan
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher J Long
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Aseem Ravindra Shukla
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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21
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Li B, Chu D. Screening for and Management of Chronic Kidney Disease for Children with Congenital Abnormalities of the Kidney and Urinary Tract. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0180-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications. J Pediatr Urol 2018; 14:262.e1-262.e6. [PMID: 29503220 DOI: 10.1016/j.jpurol.2018.01.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. OBJECTIVE To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. DESIGN AND METHODS We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. RESULTS In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. DISCUSSION We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. CONCLUSIONS Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.
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Warchoł S, Krzemień G, Szmigielska A, Bombiński P, Toth K, Dudek-Warchoł T. Endoscopic correction of vesicoureteral reflux in children using polyacrylate-polyalcohol copolymer (Vantris): 5-years of prospective follow-up. Cent European J Urol 2017; 70:314-319. [PMID: 29104797 PMCID: PMC5656363 DOI: 10.5173/ceju.2017.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 07/21/2017] [Accepted: 07/23/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction The endoscopic correction of vesicoureteral reflux (VUR) in children is a currently well accepted therapy in many pediatric urology centers. Polyacrylate-polyalcohol copolymer (PPC), namely Vantris®, is one of the tissue-augmenting substances used for endoscopic reflux therapy. The aim of this study was to evaluate the results with PPC in children. Material and methods From 2012 to 2016, 125 children (73 girls and 52 boys) aged 0.6–17.9 years (mean 4.9 ±3.58) were treated with PPC. VUR was unilateral in 64 and bilateral in 61 patients, comprising 197 renal refluxing units (RRUs) grades: II in 72, III in 50, IV in 33 and V in 42. Of these primary reflux was present in 132 RRUs and 65 were complex cases. Voiding cystourethrogram (VCUG) was done 3 months after procedure. Results Follow-up was completed in 89.6% of patients (112 children), and 89.8% of RRUs (177 out of 197). Reflux resolved in 86.4% of RRUs after single injection, in 99.4% after second and in 100% after the third. The only significant, but serious complication observed was late ureteral obstruction after PPC injection correcting high grade reflux, which required ureteral re-implantation. This complication was found in 9 out of 112 children (8%), and in 11 out of 177 RRUs (6.2%), 1.1 -2.9 years (mean 2 ±0.7) after the PPC injection. The longest follow-up reaches 4.5 years. Conclusions Our data show that the PPC injection is an effective procedure for treating all grades of VUR with high success rate. However, because of the possibility of late ureteral obstruction, which requires ureteroneocystostomy, long-term follow-up is mandatory.
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Affiliation(s)
- Stanisław Warchoł
- Department of Pediatric Surgery and Urology, Medical University of Warsaw, Warsaw, Poland
| | - Grażyna Krzemień
- Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Szmigielska
- Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Bombiński
- Department of Paediatric Radiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Teresa Dudek-Warchoł
- Department of Pediatric Surgery and Urology, Medical University of Warsaw, Warsaw, Poland
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Cisek LJ. Holding Water: Congenital Anomalies of the Kidney and Urinary Tract, CKD, and the Ongoing Role of Excellence in Plumbing. Adv Chronic Kidney Dis 2017; 24:357-363. [PMID: 29229166 DOI: 10.1053/j.ackd.2017.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Congenital anomalies of the kidneys and urinary tracts can result in diminished natal kidney function, possibly through common embryologic pathway disruption or as a result of development taking place in the face of disordered 'post-renal' drainage. Impaired conduit and reservoir function present potential for an ongoing assault leading to further deterioration and progression of chronic kidney disease, a risk that extends to adults with these conditions, even after "correction". The drainage and storage aspects of the urinary system that can impact kidney function are reviewed with attention to correctable or manageable problems including: Bladder dysfunction wherein the low pressure storage of urine is compromised requiring the kidney to work against a pressure gradient, the classic post renal failure problem. The kidney in the aftermath of obstruction which may have lost concentrating capacity leading to a tendency to dehydration ('pre-renal' failure) and through polyuria which exacerbates bladder pressure problems. Further there is an added challenge in evaluation for ongoing or reemergent obstruction in a significantly dilated system where the capacious system leads to slow turnover of urine often requiring a ureteral stent or nephrostomy to clearly establish clinical significance of delayed drainage. Stasis where slow urine flow leads to buildup of debris (stone) or potentiates infection. Vessicoureteral reflux which allows for introduction of lower urinary tract bacteria to the kidney and can lead to pyelonephritis. Conditions which combine problems such as posterior urethral valves where the bladder outlet obstruction compromises kidney function potentially impairing concentrating ability, creates bladder compromise often reducing emptying efficiency or elevating bladder storage pressures, as well as dilating the system potentially promoting stasis. Cognizance of the potential for plumbing problems to further kidney deterioration as patients with congenital urinary tract anomalies, even after they have been repaired is incumbent on those caring for these patients as they age. Thoughtful evaluation of those patients in whom kidney compromise maybe aggravated by drainage and storage disorder will optimize native renal function.
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Wang HHS, Tejwani R, Wolf S, Wiener JS, Routh JC. Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures. J Pediatr Urol 2017; 13:507.e1-507.e7. [PMID: 28434635 PMCID: PMC5632086 DOI: 10.1016/j.jpurol.2017.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION/BACKGROUND The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. OBJECTIVE To compare postoperative outcomes of EI vs UNC. STUDY DESIGN This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. RESULTS The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P < 0.001), male (30 vs 20%, P < 0.001), and publicly insured (34 vs 29%, P < 0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P < 0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR = 4.45; 2.69 in 30 days; 90 days, P < 0.001) and to have postoperative ER visits (OR = 3.33; 2.26 in 30 days; 90 days, P < 0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR = 7.12, P < 0.001). DISCUSSIONS Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. CONCLUSIONS Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.
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Affiliation(s)
- Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | | | - Steven Wolf
- Department of Statistics, Duke University, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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Srinivasan AK, Maass D, Shrivastava D, Long CJ, Shukla AR. Is robot-assisted laparoscopic bilateral extravesical ureteral reimplantation associated with greater morbidity than unilateral surgery? A comparative analysis. J Pediatr Urol 2017; 13:494.e1-494.e7. [PMID: 28319025 DOI: 10.1016/j.jpurol.2017.01.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 01/23/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Voiding dysfunction after bilateral extravesical ureteral reimplantation for vesicoureteral reflux has long remained a concern. Robotic approach with improved visualization that enables focused and minimal dissection may help with this concern. OBJECTIVES To compare postoperative outcomes after bilateral robot-assisted laparoscopic ureteral reimplantation to unilateral robot-assisted laparoscopic ureteral reimplantation. STUDY DESIGN This was a retrospective study using data abstracted from an institutional review board-approved registry prospectively maintained at our institution since 2012. Patient demographics, preoperative characteristics, and postoperative outcomes were analyzed. Patients with postoperative febrile urinary tract infection (UTI) underwent voiding cystourethrogram (VCUG). Surgical success is defined as absence of febrile UTI or febrile UTI with negative VCUG. RESULTS 92 patients with a median follow-up of 14 (25th and 75th IQR 5, 28) months. Median operative time (150 vs. 178 min, p = 0.01) and median hospital stay (33 vs. 37 h, p = 0.01) were longer in the bilateral cohort. Weight-adjusted morphine equivalents requirement was also higher in the bilateral group (0.45 vs. 0.59, p = 0.019). DISCUSSION Early postoperative voiding dysfunction is influenced by anesthesia, postoperative pain, analgesics, age, surgical dissection, and preoperative voiding issues. Effective preoperative management of voiding dysfunction, minimizing surgical dissection and cautery, and minimizing opiate use will aid improving outcomes after surgery and enable bilateral surgeries on uretero-vesical junction. A robotic approach to facilitate such strategies could help outcomes after bilateral ureteral reimplantation. Limitations of this study include its retrospective design, the absence of routine postoperative VCUG after ureteral reimplantation, and unknown confounding variables. CONCLUSION Robot-assisted laparoscopic bilateral extravesical ureteral reimplantation is not associated with an increased risk of postoperative morbidity compared with unilateral surgery.
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Affiliation(s)
| | - Daniel Maass
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aseem R Shukla
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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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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Boysen WR, Ellison JS, Kim C, Koh CJ, Noh P, Whittam B, Palmer B, Shukla A, Kirsch A, Gundeti MS. Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children. J Urol 2017; 197:1555-1561. [DOI: 10.1016/j.juro.2017.01.062] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 12/28/2022]
Affiliation(s)
| | | | - Christina Kim
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | | | - Paul Noh
- Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | | | - Aseem Shukla
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Koyle MA, Butt H, Lorenzo A, Mingin GC, Elder JS, Smith GHH. Prolonged urinary retention can and does occur after any type of ureteral reimplantantion. Pediatr Surg Int 2017; 33:623-626. [PMID: 28108784 DOI: 10.1007/s00383-017-4058-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6 weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred. MATERIALS AND METHODS We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons. RESULTS During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1 years. Eventually 7/10 patients were able to void normally, with periods ranging from 6 weeks to 8 years. The remaining three patients are still unable to void more than 5 years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal. CONCLUSION PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.
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Hall G, Routh JC, Gbadegesin RA. Urinary Anomalies in 22q11.2 Deletion (DiGeorge syndrome): From Copy Number Variations to Single-Gene Determinants of Phenotype. Am J Kidney Dis 2017; 70:8-10. [PMID: 28456345 DOI: 10.1053/j.ajkd.2017.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Gentzon Hall
- Duke University School of Medicine and Duke University Medical Center, Durham, North Carolina
| | - Jonathan C Routh
- Duke University School of Medicine and Duke University Medical Center, Durham, North Carolina
| | - Rasheed A Gbadegesin
- Duke University School of Medicine and Duke University Medical Center, Durham, North Carolina.
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Nordenström J, Sjöström S, Sillén U, Sixt R, Brandström P. The Swedish infant high-grade reflux trial: UTI and renal damage. J Pediatr Urol 2017; 13:146-154. [PMID: 28215835 DOI: 10.1016/j.jpurol.2016.12.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/23/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION High-grade vesicoureteral reflux (VUR) in children is associated with recurrent urinary tract infection (UTI) and renal damage. Breakthrough UTI despite continuous antibiotic prophylaxis (CAP) during the first years of life is a matter of concern and evokes early intervention. We investigated whether early endoscopic treatment (ET) of VUR grade 4-5 can reduce the risk of UTI recurrence and renal scarring. MATERIALS AND METHODS This prospective, randomized, controlled, multicentre, 1-year follow-up trial comprised 77 infants, <8 months of age with VUR grade 4-5 (Table) randomized to CAP (n = 39) or ET (with prophylaxis until resolution) (n = 38). Voiding cystourethrogram, ultrasound, renal scintigraphy, and free voiding observation were performed at study entry and after 1 year. Parenchymal defects were seen in 67 (87%) children at entry, 39 (34 boys, 5 girls) of them characterized as generalized. At follow-up, renal deterioration (new scars or progress in old damaged area) and symptomatic UTIs were reported. RESULTS There were 27 recurrent febrile UTIs in 6 (16%) children in the ET group and in 10 (26%) in the CAP group (p = 0.43), in eight (36%) girls and eight (15%) boys (p = 0.039). Successful VUR outcome (VUR 0-2) was seen in 22 (59%) in the ET and eight (21%) in the CAP group (p = 0.0014). Multiple recurrences were only seen in patients with persistent dilating reflux at follow-up (p = 0.019). Deterioration on scintigraphy was seen in eight children (9 kidneys) with no difference between treatment groups (p = 0.48) or sex (p = 0.17). Renal deterioration was associated with high bladder capacity (BC) and large residual volume (PVR) at 1 year (p = 0.0092 and p = 0.041). Six of the eight children with renal deterioration had a recurrent UTI (p = 0.0032). Seven of nine renal units with deterioration were seen in children with persistent VUR 3-5 at follow-up. Univariable logistic regression identified female sex and high PVR as positive predictors for recurrent UTI (p = 0.039 and 0.034) and high PVR tended to predict renal deterioration (p = 0.053). DISCUSSION No differences between the treatment groups regarding recurrent UTI and renal deterioration could be found. Increased PVR and female sex were positive predictors for UTI recurrences. VUR grade at follow-up was correlated to UTI recurrence and renal deterioration. CONCLUSION This study did not show any difference between ET and CAP in reducing the risk of UTI recurrence or renal deterioration. The rate of VUR resolution was higher in the ET group and VUR grade at follow-up correlated with both UTI recurrence and renal deterioration.
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Affiliation(s)
- Josefin Nordenström
- Department of Paediatric Surgery, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Sofia Sjöström
- Department of Paediatric Surgery, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ulla Sillén
- Department of Paediatric Surgery, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Rune Sixt
- Department of Paediatric Clinical Physiology, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Per Brandström
- Department of Paediatrics, Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
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Tejwani R, Wang HHS, Lloyd JC, Kokorowski PJ, Nelson CP, Routh JC. Utility Estimation for Pediatric Vesicoureteral Reflux: Methodological Considerations Using an Online Survey Platform. J Urol 2017; 197:805-810. [PMID: 27746280 PMCID: PMC5315661 DOI: 10.1016/j.juro.2016.09.119] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux. MATERIALS AND METHODS Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® (https://www.mturk.com) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 "warm-up" scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities. RESULTS A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17). CONCLUSIONS Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions.
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Affiliation(s)
- Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jessica C Lloyd
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Kokorowski
- Division of Pediatric Urology, Children's Hospital Los Angeles, Los Angeles, California
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina.
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Zaitouna M, Alsaid B, Lebacle C, Timoh KN, Benoît G, Bessede T. Origin and nature of pelvic ureter innervation. Neurourol Urodyn 2017; 36:271-279. [PMID: 28235166 DOI: 10.1002/nau.22919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/09/2015] [Indexed: 12/15/2022]
Abstract
AIMS Innervation of the pelvic ureter traditionally comes from the pelvic plexus. This innervation is independent: adrenergic and cholinergic. The purpose of this study was to describe more precisely the origin and nature of its innervation (adrenergic, cholinergic, nitrergic, and somatic). METHODS Six specimens of normal human fetal pelvis (four male and two female) from 20 to 30 weeks gestation were studied. The sections of these fetuses, carried out every 5 µm without interval, were treated with Hematoxylin Eosin (HE), with Masson's trichrome (TriM), immunolabeling of smooth muscle cells with smooth anti-actin, of nerves with anti-S100 protein, anti-tyrosine hydroxylase, anti-VAChT, anti-nNOS, and with anti- peripheral myelin protein 22 (PMP 22). The slides were scanned and two-dimensional images reconstructed in 3D, and analyzed. RESULTS The terminal pelvic ureter travels above and inside the inferior hypogastric plexus (IHP). The nerve fibers that innervate the ureterovesical junction come mainly from the superior hypogastric plexus (SHP) which gives off the hypogastric nerves and pelvic branches of the sacral plexus that form the IHP. Most nerve fibers meet below the ureter, behind the bladder to form an ascending bundle, which innervates the pelvic ureter. Immunohistochemical analysis shows that the nerves of the pelvic ureter consist of adrenergic, cholinergic, and nitrergic fibers. CONCLUSION The innervation of the distal ureter depends mainly on the SHP. This innervation is adrenergic, cholinergic, and nitrergic. It innervates the pelvic ureter in an ascending manner. This anatomical information can change rectal resection and ureteral reimplantation techniques and drug treatments for pelvic ureter stones. Neurourol. Urodynam. 36:271-279, 2017. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Mazen Zaitouna
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Laboratory of Anatomy, Faculty of Medicine, University of Damascus, Damascus, Syria.,Urology Department, G.H. Paris Sud, APHP, Paris Sud University, Le Kremlin Bicêtre, France
| | - Bayan Alsaid
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Laboratory of Anatomy, Faculty of Medicine, University of Damascus, Damascus, Syria
| | - Cédric Lebacle
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Krystel Nyangoh Timoh
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Gérard Benoît
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Thomas Bessede
- U1195, University Paris-Sud, INSERM, University Paris-Saclay, Le Kremlin Bicêtre, France.,Urology Department, G.H. Paris Sud, APHP, Paris Sud University, Le Kremlin Bicêtre, France
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Probabilities of Dilating Vesicoureteral Reflux in Children with First Time Simple Febrile Urinary Tract Infection, and Normal Renal and Bladder Ultrasound. J Urol 2016; 196:1541-1545. [DOI: 10.1016/j.juro.2016.05.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2016] [Indexed: 11/17/2022]
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Zieger B. [Imaging in urinary tract infections in childhood]. Radiologe 2016; 56:997-1012. [PMID: 27770147 DOI: 10.1007/s00117-016-0133-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diagnostic strategies for extended morphological and functional clarification after symptomatic urinary tract infections in children are changing. Improved knowledge of the causes for development of renal scarring and a changing view on the importance of vesicoureteral reflux have led to a change in paradigm in recent years. The purpose of this article is to present the ongoing discussions of the causes and outcome of childhood urinary tract infections, competing diagnostic imaging methods and different diagnostic algorithms.
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Affiliation(s)
- B Zieger
- Abteilung für Radiologie und Nuklearmedizin, Schwarzwald-Baar-Klinikum, Klinikstraße 11, 78050, Villingen‑Schwenningen, Deutschland.
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Liu W, Du G, Guo F, Ma R, Wu R. Modified ureteral orthotopic reimplantation method for managing infant primary obstructive megaureter: a preliminary study. Int Urol Nephrol 2016; 48:1937-1941. [PMID: 27590133 DOI: 10.1007/s11255-016-1409-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/23/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe a modified ureteral orthotopic reimplantation method in infant with primary obstructive megaureter (POM) and report our initial experience. METHODS Thirteen children with POM (range 1-7 months) underwent modified transvesical ureteral implantation surgery. Treatment consists of transecting the ureter proximal to the obstruction and performing orthotopic reimplantation in end freely fashion with distal ureter protruding into the bladder, providing dilated ureteral diameter: ureteral exposure length in bladder ratio of 1:1.5-2. All patients underwent repeat ultrasound, radionuclide imaging and voiding cystourethrography. Cystoscopy was conducted in patients at 6 months after surgery. RESULTS The mean operating time was 40 min. There were one redo this procedure for recurrent obstruction and one Cohen reimplantation for Grade 5 vesico-ureteral reflux in one bilateral POM. Hydroureteronephrosis improved in other 11 patients, and the ureter diameter was significantly reduced from preoperative measurements. At the time of cystoscopy, thick and large volcanic-shaped ureteral orifice was found and urine ejected intermittently. CONCLUSIONS The proposed 'modified ureteral orthotopic reimplantation' with no tapering or advancement for POM in infants is a simple, feasible and less invasive procedure that had good success rates in this small series. Further, larger studies are required to support or negate the usefulness of this technique.
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Affiliation(s)
- Wei Liu
- Department of Pediatric Surgery, Provincial Hospital Affiliated To Shandong University, Jinan, 250021, China
| | - Guoqiang Du
- Department of Pediatric Surgery, The People's Hospital of Linyi City, Linyi, 276003, China
| | - Feng Guo
- Department of Pediatric Surgery, Provincial Hospital Affiliated To Shandong University, Jinan, 250021, China
| | - Rui Ma
- Shandong Medical Imaging Research Institute, Jinan, 250021, China.
| | - Rongde Wu
- Department of Pediatric Surgery, Provincial Hospital Affiliated To Shandong University, Jinan, 250021, China.
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Woźniak MM, Scholbach TM, Scholbach J, Pawelec A, Nachulewicz P, Wieczorek AP, Brodzisz A, Zajączkowska MM, Borzęcka H. Color Doppler dynamic tissue perfusion measurement: a novel tool in the assessment of renal parenchymal perfusion in children with vesicoureteral reflux. Arch Med Sci 2016; 12:621-8. [PMID: 27279857 PMCID: PMC4889678 DOI: 10.5114/aoms.2015.51698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/25/2014] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Vesicoureteral reflux (VUR) occurs in 20-50% of children suffering from recurrent urinary tract infections (UTIs) and is associated with an increased risk of renal scarring and impaired renal function. Early detection of renal perfusion deterioration would allow for the implementation of more aggressive treatment and potentially prevent further damage to the renal parenchyma. The aim of the study was to assess renal parenchymal perfusions in children with recurrent UTIs with and without coexisting VUR, and compare the findings with the results of healthy patients. MATERIAL AND METHODS Color Doppler sonographic dynamic renal parenchymal perfusion measurements were performed with PixelFlux (Chameleon-Software, Germany) software in 77 children with recurrent UTIs and coexisting VUR and in 30 children with UTIs without VUR. The findings were compared with the results of 53 healthy children. RESULTS Cortical parenchymal perfusion of children suffering from UTIs and VUR was significantly reduced when compared to the control group. Statistically significant differences (p < 0.05) were found in all perfusion parameters (i.e. mean velocity (v mix ), mean perfused area (A mix ), mean perfusion intensity (I mix ), tissue pulsatility index (TPI), and tissue resistance index (TRI)) between the control group and children suffering from UTIs and VUR, particularly VUR grades III and IV. There were no significant differences between the UTI group and the control group. No differences were found between the controls and VUR grade II. CONCLUSIONS Renal parenchymal perfusion decreases significantly with higher grades of VUR.
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Affiliation(s)
| | | | | | - Agata Pawelec
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - Paweł Nachulewicz
- Department of Pediatric Surgery and Traumatology, Medical University of Lublin, Lublin, Poland
| | | | - Agnieszka Brodzisz
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | | | - Halina Borzęcka
- Department of Pediatric Nephrology, Medical University of Lublin, Lublin, Poland
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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: 1.0] [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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Nelson CP, Routh JC, Logvinenko T, Rosoklija I, Kokorowski PJ, Prosser LA, Schuster MA. Utility scores for vesicoureteral reflux and anti-reflux surgery. J Pediatr Urol 2015; 11:177-82. [PMID: 25975732 PMCID: PMC4540632 DOI: 10.1016/j.jpurol.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Management of vesicoureteral reflux (VUR) continues to be controversial. In conditions of uncertainty, decision analytic techniques such as cost-utility analysis (CUA) can help to structure the decision-making process. However, CUA analyses require a "utility," a value between 0 (death) and 1 (perfect health) corresponding to the quality of life associated with a health state. Ideally, utility values are elicited directly from representative community samples, but utilities have not been rigorously measured for pediatric urology conditions. OBJECTIVES To elicit utility scores for VUR and open anti-reflux surgery (ARS) from a representative, well-characterized community sample of adults who have been parents. METHODS Cross-sectional survey of nationally representative adults who had ever been parents. Each respondent saw one of four descriptions of VUR, with or without continuous antibiotic prophylaxis (CAP) and occurrence of febrile urinary tract infection (UTI). A 6-week postoperative health state following ARS was also assessed. We used the time trade-off (TTO) method to elicit utility scores. Factors associated with utility score were assessed with a multivariate linear regression model. RESULTS The survey was completed by 1200 individuals. Data were weighted to adjust for demographic differences between responders and non-responders. Mean age was 52 ± 15 years, 44% were male, and 68% were White. In terms of education, 29% had a college degree or higher. The mean utility score for VUR overall was 0.82 ± 0.28. VUR utility scores did not differ significantly based on inclusion of CAP or UTI in the health state description (p = 0.21). The 6-week postoperative period garnered a utility of 0.71 ± 0.43. DISCUSSION Our results showed that VUR has a mean utility score of 0.82, which indicates that the community perceives this condition to be a substantial burden. For comparison, conditions with similar utility scores include compensated hepatitis B-related cirrhosis (0.80) and glaucoma (0.82); conditions with higher utilities include neonatal jaundice (0.99) and transient neonatal neurological symptoms (0.95); and conditions with lower utility scores include severe depression (0.43) and major stroke (0.30). Our results suggest that parents consider the burden associated with VUR to be significant, and that the impact of the condition on families and children is substantial. CONCLUSIONS VUR is perceived as having a substantial impact on health-related quality of life, with a utility value of 0.82. However, use of CAP and occurrence of UTI do not seem to affect significantly the community perspective on HRQOL associated with living with VUR.
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Affiliation(s)
- Caleb P Nelson
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Tanya Logvinenko
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Ilina Rosoklija
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul J Kokorowski
- Division of Urology, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Lisa A Prosser
- CHEAR Unit, General Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Grimsby GM, Dwyer ME, Jacobs MA, Ost MC, Schneck FX, Cannon GM, Gargollo PC. Multi-Institutional Review of Outcomes of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation. J Urol 2015; 193:1791-5. [DOI: 10.1016/j.juro.2014.07.128] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Gwen M. Grimsby
- Division of Pediatric Urology, Department of Urology, University of Texas Southwestern Medical Center and Children’s Medical Center, Dallas, Texas
| | - Moira E. Dwyer
- Department of Urology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Micah A. Jacobs
- Division of Pediatric Urology, Department of Urology, University of Texas Southwestern Medical Center and Children’s Medical Center, Dallas, Texas
| | - Michael C. Ost
- Department of Urology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Francis X. Schneck
- Department of Urology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Glenn M. Cannon
- Department of Urology, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Lima SVC, de Oliveira Rangel AE, de Melo Lira MM, Pinto FCM, Campos Júnior O, Sampaio FJB, de Andrade Aguiar JL. The Biocompatibility of a Cellulose Exopolysaccharide Implant in the Rabbit Bladder When Compared With Dextranomer Microspheres Plus Hyaluronic Acid. Urology 2015; 85:1520.e1-6. [PMID: 25872698 DOI: 10.1016/j.urology.2015.02.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/19/2015] [Accepted: 02/23/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate biocompatibility of a cellulosic exopolysaccharide (CEC) as bulking agent in rabbit urinary bladder. MATERIALS AND METHODS The experimental study was developed at the Nucleus for Experimental Surgery or UFPE. The new agent was injected into the bladder of the adult rabbits using a small abdominal incision. Animals were injected with 0.2 mL of dextranomer microspheres (Dx) plus hyaluronic acid and CEC. The animals were studied after 3 days (G1), 90 days (G2), and 11 months (G3). The biocompatibility was evaluated according to the histologic parameters (presence of blood vessels, inflammatory reaction, and collagen deposition) by a quantitative analysis. The Student paired t test was used for continuous variables, and the scores were compared through the chi-square test. RESULTS Both materials were structurally homogeneous and free from inflammatory cells or blood vessels (G1). In 3-month samples (G2), CEC areas were densely invaded by fibroblasts and blood vessels. Dx areas were fragmented but still homogeneous and free from cells or blood vessels. Samples from 3 and 11 months showed a significant difference in favor of CEC especially concerning preservation of material in the implant site, as well as the presence of neovascularization. This experimental study represents a positive outcome in terms of reflux resolution in the long term. Further studies may be necessary to confirm its efficacy when in clinical use. CONCLUSION The CEC exhibited low inflammatory response and integrated with the host tissue better than Dx in the long-term follow-up.
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Affiliation(s)
- Salvador Vilar Correia Lima
- Department of Surgery, Center for Health Sciences, Urology Service at the Clinical Hospital, Federal University of Pernambuco, UFPE, Recife, Brazil.
| | - Artur Eduardo de Oliveira Rangel
- Department of Surgery, Center for Health Sciences, Urology Service at the Clinical Hospital, Federal University of Pernambuco, UFPE, Recife, Brazil
| | | | - Flávia Cristina Morone Pinto
- Nucleus for Experimental Surgery, Department of Surgery, Center for Health Sciences, Federal University of Pernambuco, UFPE, Recife, Brazil
| | - Olávio Campos Júnior
- Nucleus for Experimental Surgery, Department of Surgery, Center for Health Sciences, Federal University of Pernambuco, UFPE, Recife, Brazil
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Lloyd JC, Yen T, Pietrobon R, Wiener JS, Ross SS, Kokorowski PJ, Nelson CP, Routh JC. Estimating utility values for vesicoureteral reflux in the general public using an online tool. J Pediatr Urol 2014; 10:1026-31. [PMID: 24766856 PMCID: PMC4185270 DOI: 10.1016/j.jpurol.2014.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/02/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cost-utility analyses are useful to study conditions without a widely accepted treatment algorithm; in pediatric urology, one such condition is vesicoureteral reflux (VUR). A necessary component of cost-utility analyses is to accurately calculate the "utility", a numerical surrogate of quality of life, for various health states. Our aims were to determine utility values for representative VUR health states and to verify the feasibility of a novel online platform for utility elicitation in order to reduce the time and expense of such analyses. METHODS A cross-sectional survey of American adults was conducted using the time-trade-off (TTO) method. Respondents were recruited from an online work interface, Amazon's Mechanical Turk (MTurk). Four annualized VUR health states were assessed: VUR treated with/without continuous antibiotic prophylaxis (CAP) and with/without associated febrile urinary tract infection (UTI). A 6-week post-operative scenario following open ureteroneocystostomy was also assessed. RESULTS We received 278 survey responses (70% response rate). The respondents were largely between the ages of 25 and 44 (59%), female (60%), and Caucasian (76%). Thirty-seven percent had a college degree, and 44% were parents. Compared with a perfect health state of 1.0, we found mean utilities of 0.87 for VUR, regardless of whether CAP was used or whether UTI was present (p=0.9). The immediate post-operative period following ureteroneocystostomy garnered an annualized utility of 0.94. CONCLUSIONS Our data suggest that MTurk-based utility assessment is feasible, and that subjects view the VUR health state as only slightly inferior to perfect health. This includes VUR health states incorporating CAP and febrile UTI.
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Affiliation(s)
- Jessica C Lloyd
- Division of Urologic Surgery, Duke University Medical Center, DUMC 3831, Durham, NC 27710, USA
| | - Talitha Yen
- Research on Research Group, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ricardo Pietrobon
- Research on Research Group, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, DUMC 3831, Durham, NC 27710, USA
| | - Sherry S Ross
- Division of Urologic Surgery, Duke University Medical Center, DUMC 3831, Durham, NC 27710, USA
| | - Paul J Kokorowski
- Department of Urology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Caleb P Nelson
- Department of Urology, Children's Hospital of Boston, Boston, MA, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, DUMC 3831, Durham, NC 27710, USA.
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Roupakias S, Sinopidis X, Karatza A, Varvarigou A. Predictive risk factors in childhood urinary tract infection, vesicoureteral reflux, and renal scarring management. Clin Pediatr (Phila) 2014; 53:1119-33. [PMID: 24366998 DOI: 10.1177/0009922813515744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Approaches to the management of children with urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scars have been challenged and have become controversial over the past decade. It is difficult to determine when, how, and which patients will benefit from the diagnosis and management of this condition. Therefore, the issues of diagnostic imaging, observation, follow-up, and intervention tend to be decided more on a case-by-case basis, rather than by using an algorithm. Over the past few years, there have been advances in the identification of risk factors that predispose patients with UTI to present with VUR, to develop recurrent UTIs and renal scars, to have deteriorating renal function, to show VUR improvement and/or spontaneous resolution, and to be candidates for and benefit from early surgical intervention.
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Affiliation(s)
- Stylianos Roupakias
- Department of Pediatric Surgery, University of Patras Medical School, Patras, Greece
| | - Xenophon Sinopidis
- Department of Pediatric Surgery, University of Patras Medical School, Patras, Greece
| | - Ageliki Karatza
- Department of Pediatrics, University of Patras Medical School, Patras, Greece
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Wang HHS, Gbadegesin RA, Foreman JW, Nagaraj SK, Wigfall DR, Wiener JS, Routh JC. Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: systematic review and meta-analysis. J Urol 2014; 193:963-9. [PMID: 25196653 DOI: 10.1016/j.juro.2014.08.112] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE Controversy exists regarding the use of continuous antibiotic prophylaxis vs observation in the management of children with vesicoureteral reflux. The reported effectiveness of continuous antibiotic prophylaxis in children with reflux varies widely. We determined whether the aggregated evidence supports use of continuous antibiotic prophylaxis in children with vesicoureteral reflux. MATERIALS AND METHODS We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE(®), EMBASE(®), Google Scholar and recently presented meeting abstracts for reports in any language. Bibliographies of included studies were then hand searched for any missed articles. The study protocol was prospectively registered at PROSPERO (No. CRD42014009639). Reports were assessed and data abstracted in duplicate, with differences resolved by consensus. Risk of bias was assessed using standardized instruments. RESULTS We identified 1,547 studies, of which 8 are included in the meta-analysis. Pooled results demonstrated that continuous antibiotic prophylaxis significantly reduced the risk of recurrent febrile or symptomatic urinary tract infection (pooled OR 0.63, 95% CI 0.42-0.96) but, if urinary tract infection occurred, increased the risk of antibiotic resistant organism (pooled OR 8.75, 95% CI 3.52-21.73). A decrease in new renal scarring was not associated with continuous antibiotic prophylaxis use. Adverse events were similar between the 2 groups. Significant heterogeneity existed between studies (I(2) 50%, p = 0.03), specifically between those trials with significant risk of bias (eg unclear protocol descriptions and/or lack of blinding). CONCLUSIONS Compared to no treatment, continuous antibiotic prophylaxis significantly reduced the risk of febrile and symptomatic urinary tract infections in children with vesicoureteral reflux, although it increased the risk of infection due to antibiotic resistant bacteria. Continuous antibiotic prophylaxis did not significantly impact the occurrence of new renal scarring or reported adverse events.
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Affiliation(s)
- Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Rasheed A Gbadegesin
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, North Carolina
| | - John W Foreman
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Shashi K Nagaraj
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, North Carolina
| | - Delbert R Wigfall
- Division of Pediatric Nephrology, Duke University Medical Center, Durham, North Carolina
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina.
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Woźniak MM, Pawelec A, Wieczorek AP, Zajączkowska MM, Borzęcka H, Nachulewicz P. 2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and monitoring of treatment of vesicoureteral reflux in children - can it replace voiding cystourethrography? J Ultrason 2013; 13:394-407. [PMID: 26674600 PMCID: PMC4579665 DOI: 10.15557/jou.2013.0042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 11/22/2013] [Accepted: 11/27/2013] [Indexed: 12/21/2022] Open
Abstract
Introduction Vesicoureteral reflux appears in 20–50% of pediatric patients with recurrent urinary tract infections. The most common method of diagnosing this disease is voiding cystourethrography. However, contemporary pediatric radiology does not favor this method due to exposure to X-radiation. Aim The aim of this study was to assess the usefulness of 2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and treatment monitoring of vesicoureteral reflux in children and the possibility of using contrast-enhanced voiding urosonography to replace voiding cystourethrography. Material and methods Voiding cystourethrography and contrast-enhanced voiding urosonography were conducted in 80 pediatric patients in order to assess sensitivity, specificity, positive and negative predictive values as well as the number of vesicoureteral refluxes detected by each of the two methods. The second stage of the study involved performing voiding urosonography in an extended protocol in 58 children in order to determine the usefulness of three-dimensional (3D/4D) examinations in the assessment of vesicoureteral reflux and the ability to assess the urethra. Results The concordance between the two methods was 86.95%. The sensitivity of voiding urosonography was 84.51%, specificity – 90.99%, positive predictive value – 85.71% and negative predictive value – 90.17%. A 3D/4D assessment of the urinary bladder and transperineal 2D morphological assessment of the urethra were possible in all patients (100%). Assessment of the urethra during micturition with the use of 2D/3D/4D techniques was possible in all patients in whom voiding was elicited (95.83%), and 3D/4D assessment of vesicoureteral reflux was possible in all patients with reflux (100%). Although the application of 3D/4D techniques allowed accurate specification of the grade of reflux in all cases (100%), it appeared particularly useful in differentiating between grades II and III (70.97%). Conclusions Contrast-enhanced voiding urosonography allows the diagnosis and monitoring of treatment of vesicoureteral reflux in pediatric patients as well as assessment of the urethra in both girls and boys. The method is characterized by high sensitivity and specificity. Moreover, it is safe, relatively inexpensive and can replace voiding cystourethrography.
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Affiliation(s)
| | - Agata Pawelec
- Zakład Radiologii Dziecięcej, Uniwersytet Medyczny w Lublinie, Lublin, Polska
| | | | | | - Halina Borzęcka
- Klinika Nefrologii Dziecięcej II Katedry Pediatrii, Uniwersytet Medyczny w Lublinie, Lublin, Polska
| | - Paweł Nachulewicz
- Katedra i Klinika Chirurgii i Traumatologii Dziecięcej, Uniwersytet Medyczny w Lublinie, Lublin, Polska
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Weitz M, Licht C, Müller M, Haber P. Renal ultrasound volume in children with primary vesicoureteral reflux allows functional assessment. J Pediatr Urol 2013; 9:1077-83. [PMID: 23639632 DOI: 10.1016/j.jpurol.2013.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 03/14/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Renal scintigraphy represents the current diagnostic standard to assess split kidney function. We tested the hypothesis that the relative renal volume assessed by ultrasound provides an equally reliable but less invasive tool for assessment of kidney function as compared to renal scintigraphy in patients with primary vesicoureteral reflux. METHODS Renal ultrasound and renal scintigraphy were performed in 85 patients (median age 4.5 years, range 0.25-7.7) and repeated in 74 patients after 2-13 months (mean 7) of the primary investigation. Renal size was measured by ultrasound, and relative renal volume was calculated for each kidney by using the formula of a prolate ellipsoid. Renal function was estimated for each side (split renal function) by scintigraphy with (99m)Tc MAG3. RESULTS The mean difference between relative renal volume measured by ultrasound and split renal function determined by renal scintigraphy was 2.8% (standard deviation ± 4.1%; 95% confidence interval 10.8/-5.2%). There was a statistically significant correlation between relative renal volume estimated by ultrasound and split renal function estimated by renal scintigraphy at first examination (r = 0.98; p < 0.001) and at follow-up (r = 0.91; p < 0.001). CONCLUSION We conclude that ultrasound measurement of relative renal volume is capable of assessing split renal function in children with primary vesicoureteral reflux and, thus, should be considered instead of the more invasive MAG3 scintigraphy.
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Affiliation(s)
- Marcus Weitz
- University of Tuebingen, Department of Pediatrics, Hoppe-Seyler-Strasse 1, 72076 Tübingen, Germany.
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Huang WY, Chen YF, Chang HC, Yang TK, Hsieh JT, Huang KH. The frequency of vesicoureteral reflux diagnosis is correlated with urbanization level of residence in pediatric population: a nationwide study in Taiwan. J Pediatr Urol 2013; 9:546-50. [PMID: 23619352 DOI: 10.1016/j.jpurol.2013.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 02/27/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the frequency and characteristics of newly diagnosed vesicoureteral reflux (VUR) in children younger than 18 years based on a nationwide database in Taiwan. METHODS The present study utilizes a subset of the Taiwan's National Health Insurance Research Database, known as the Longitudinal Health Insurance Database 2005, which contains the data of all paid medical benefit claims over 1997-2007 for a subset of 1,000,000 beneficiaries randomly drawn from the population of 22.72 million individuals during any part of the 2005 calendar year. Our analysis includes the data of all pediatric patients with the diagnosis of VUR. RESULTS A total of 738 subjects with VUR diagnosis were identified, including 412 (55.8%) boys and 326 (44.2%) girls. The peak age of VUR occurrence was the first year for males and 1-4 years for females. Approximately 49.7% of all subjects presented with urinary tract infection (UTI); moreover, there were significant differences between genders concerning the presence of UTI (RR = 0.8; p = 0.002). The occurrence rate of VUR in the pediatric population ranged from 2.63 in 1998 to 3.94 in 2003 per 10,000 children during 1998-2005. The frequency of newly-diagnosed VUR in the pediatric population was significantly correlated with urbanization levels of residence. CONCLUSION The nationwide, population-based study of pediatric VUR shows there were gender differences in age distribution and presence of UTI. Further studies are warranted to clarify the correlations between urbanization level of residence and occurrence of VUR.
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Affiliation(s)
- Wei-Yi Huang
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
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Patel C, Modgil V, Luscombe C, Liu S. A unique presentation, and management, of acute urinary retention in a young boy with underlying vesicoureteral reflux. J Surg Case Rep 2013; 2013:rjt047. [PMID: 24963900 PMCID: PMC3813490 DOI: 10.1093/jscr/rjt047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Vesicoureteral reflux (VUR) affects ∼1% of children. We present an unusual case of urinary retention secondary to an obstructing urethral stone, underlying reflux, and its management. A 7-year-old boy presenting with acute urinary retention had a palpable penile shaft swelling and patent urethral meatus on examination. Cysto-urethroscopy with a 6.6Fr ureteroscope, due to unavailability of paediatric instruments, revealed an obstructing calculus impacted in the navicular fossa. This was laser fragmented and extracted. Cystoscopy revealed multiple bladder calculi with a patulous right ureteric orifice. Post-operative investigations revealed a small, scarred right kidney (ultrasound), bilateral ureteric reflux (micturating-cystourethrogram), 4 cm by 0.8 cm right ureteric calculus (CT-KUB) and 4% right split renal function (DMSA). Right laparoscopic nephroureterectomy was subsequently performed. Our case highlights the variety with which VUR can present and the effectiveness of a ureteroscope in an emergency setting as an alternative to a paediatric cystoscope to visualize the urethra and the bladder.
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Affiliation(s)
- Chirag Patel
- Department of Urology, City General Hospital, UHNS NHS Trust, Stoke-on-Trent, UK
| | - Vaibhav Modgil
- Department of Urology, City General Hospital, UHNS NHS Trust, Stoke-on-Trent, UK
| | - Christopher Luscombe
- Department of Urology, City General Hospital, UHNS NHS Trust, Stoke-on-Trent, UK
| | - Samson Liu
- Department of Urology, City General Hospital, UHNS NHS Trust, Stoke-on-Trent, UK
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A modified technique for ureteral reimplantation: intravesical detrusorrhaphy. J Pediatr Surg 2013; 48:1813-8. [PMID: 23932628 DOI: 10.1016/j.jpedsurg.2013.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 04/23/2013] [Accepted: 05/14/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the surgical procedure of intravesical detrusorrhaphy, a modified technique of ureteral reimplantation, and report our initial experience. METHODS From October 2007 to March 2012, 55 children with vesicoureteral reflux (VUR) and 13 children with obstructive megaureter (OM) underwent intravesical detrusorrhaphy. All surgical procedures were performed via an open intravesical approach. The ureter was mobilized, and the bladder mucosa was separated from the detrusor in a cephalad direction. The separated detrusor was incised vertically and repaired underneath the mobilized ureter to create the submucosal tunnel. The ureteral orifice was anastomosed to its orthotopic position. RESULTS Of 31 patients treated with bilateral intravesical detrusorrhaphy, no patient had postoperative urinary retention. Follow-up voiding cystourethrography was performed in 45 patients with 72 reimplanted ureters. VUR was resolved in 41 patients (91.1%) with 68 ureters (94.4%). Among 13 patients with 14 ureters treated for OM, hydroureteronephorosis improved in 11 patients (84.6%) with 12 ureters (85.7%). CONCLUSIONS Intravesical detrusorrhaphy is modified technique of ureteral reimplantation, which recreates the neo-ureteric orifice in the orthotopic position and does not produce postoperative urinary retention in bilateral cases. Intravesical detrusorrhaphy is safe and effective in treating patients with VUR or OM.
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