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Damasio MB, Donati F, Bruno C, Darge K, Mentzel HJ, Ključevšek D, Napolitano M, Ozcan HN, Riccabona M, Smets AM, Sofia C, Stafrace S, Petit P, Ording Müller LS. Update on imaging recommendations in paediatric uroradiology: the European Society of Paediatric Radiology workgroup session on voiding cystourethrography. Pediatr Radiol 2024; 54:606-619. [PMID: 38467874 DOI: 10.1007/s00247-024-05883-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/13/2024]
Abstract
Voiding cystourethrography (VCUG) is a fluoroscopic technique that allows the assessment of the urinary tract, including the urethra, bladder, and-if vesicoureteral reflux (VUR) is present-the ureters and the pelvicalyceal systems. The technique also allows for the assessment of bladder filling and emptying, providing information on anatomical and functional aspects. VCUG is, together with contrast-enhanced voiding urosonography (VUS), still the gold standard test to diagnose VUR and it is one of the most performed fluoroscopic examinations in pediatric radiology departments. VCUG is also considered a follow-up examination after urinary tract surgery, and one of the most sensitive techniques for studying anatomy of the lower genitourinary tract in suspected anatomical malformations. The international reflux study in 1985 published the first reflux-protocol and graded VUR into five classes; over the following years, other papers have been published on this topic. In 2008, the European Society of Paediatric Radiology (ESPR) Uroradiology Task Force published the first proposed VCUG Guidelines with internal scientific society agreement. The purpose of our work is to create a detailed overview of VCUG indications, procedural recommendations, and to provide a structured final report, with the aim of updating the 2008 VCUG paper proposed by the European Society of Paediatric Radiology (ESPR). We have also compared VCUG with contrast-enhanced VUS as an emergent alternative. As a result of this work, the ESPR Urogenital Task Force strongly recommends the use of contrast-enhanced VUS as a non-radiating imaging technique whenever indicated and possible.
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Affiliation(s)
- Maria Beatrice Damasio
- Pediatric Radiology Department, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.
| | - Francesco Donati
- Pediatric Surgery Department, University of Genova, Genoa, Italy
| | - Costanza Bruno
- Radiology Department, AOUI Verona (Azienda Ospedaliera Universitaria Integrata), Verona, Italy
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Department of Radiology, Universitätsklinikum Jena, Jena, Germany
| | - Damjana Ključevšek
- Department of Radiology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Marcello Napolitano
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital, Milan, Italy
| | - H Nursun Ozcan
- Department of Radiology/Division of Pediatric Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Anne M Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina, Italy
| | - Samuel Stafrace
- McMaster University and McMaster Children's Hospital, Hamilton, ON, Canada
| | - Philippe Petit
- Department of Pediatric Radiology, Hopital Timone Enfants, Aix Marseille-Université, Marseille, France
| | - Lil-Sofie Ording Müller
- Division of Radiology and Nuclear Medicine, Department of Paediatric Radiology, Oslo University Hospital, Oslo, Norway
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Arlen AM, Kirsch AJ. Armamentarium to treat primary vesicoureteral reflux in children. Semin Pediatr Surg 2021; 30:151086. [PMID: 34412883 DOI: 10.1016/j.sempedsurg.2021.151086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.
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Affiliation(s)
- Angela M Arlen
- Department of Urology, Yale University School of Medicine, New Haven, CT.
| | - Andrew J Kirsch
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA.
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Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Front Pediatr 2021; 9:650326. [PMID: 33869117 PMCID: PMC8044769 DOI: 10.3389/fped.2021.650326] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | | | - Tryggve Neveus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrew J Kirsch
- Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, United States
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Roupakias S, Sinopidis X, Spyridakis I, Tsikopoulos G, Karatza A, Varvarigou A. Endoscopic Injection Treatment of Vesicoureteral Reflux in Children: Meeting with the Factors Involved in the Success Rate. ACTA MEDICA (HRADEC KRALOVE) 2021; 64:193-199. [PMID: 35285440 DOI: 10.14712/18059694.2022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The challenges and controversies in vesicoureteral reflux intervention guidelines resulted in a more individualized treatment planning. Endoscopic injection therapy is now widely used and is considered preferable, but still remains less successful than ureteral reimplantation. Τhe endoscopic vesicoureteral reflux approach should be risk-adapted to current knowledge, so more experience and longer-term follow-up are needed. The precise of preoperative, intraoperative, and postoperative factors that affecting endoscopic injection therapy success rates and outcome have not yet been clearly determined. The aim of this study was to investigate these associated factors. Although the reflux grade is the most well-known factor that can affect the success of the procedure, there is no agreement on which factors are the most influential for the efficacy of endoscopic reflux treatment. So, we carried out a broad review of published papers on this topic, and we presented all the potential predictive variables of endoscopic reflux resolution in children.
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Affiliation(s)
- Stylianos Roupakias
- Department of Pediatric Surgery, University of Patras Medical School, Patra, Greece.
| | - Xenophon Sinopidis
- Department of Pediatric Surgery, University of Patras Medical School, Patra, Greece
| | - Ioannis Spyridakis
- Department of Pediatric Surgery, Aristotelian University of Thessaloniki Medical School, Thessaloniki, Greece
| | - George Tsikopoulos
- Department of Pediatric Surgery, Hippocrateion General Hospital, Thessaloniki, Greece
| | - Ageliki Karatza
- Department of Pediatrics, University of Patras Medical School, Patra, Greece
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Nakamura S, Tanabe K, Hyuga T, Kubo T, Inoguchi S, Kawai S, Nakai H. Mid-Term Safety and Efficacy of the Modified Double Hydrodistention Implantation Technique (HIT), Termed Systematic Multi-Site HIT (SMHIT), for Patients with Primary Vesicoureteral Reflux. Res Rep Urol 2020; 12:517-525. [PMID: 33150142 PMCID: PMC7604468 DOI: 10.2147/rru.s279240] [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: 08/28/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the treatment outcomes and postoperative complications associated with the systematic multi-site hydrodistention implantation technique (SMHIT) for primary vesicoureteral reflux (VUR) and to determine its mid-term efficacy and safety. Patients and Methods We retrospectively reviewed the data for 17 ureters from 12 consecutive children, aged ≥1 year, with grade II-IV reflux and a history of febrile urinary tract infections (FUTI), who underwent a single-session of SMHIT. The primary outcome was the absence of postoperative FUTI (clinical success). The secondary outcome was improvement in reflux to grade 0-I on postoperative voiding cystourethrography (radiographic success). Results Five and 7 children had bilateral and unilateral reflux, respectively. Reflux was categorized as grade II, III, and IV reflux in 2, 12, and 3 ureters, respectively. Seven of 10 (70%) toilet-trained children had bladder-bowel dysfunction (BBD) preoperatively. The SMHIT was performed for all patients, after which BBD improved. The mean postoperative follow-up period was 6 years and 9 months. The clinical success rate was 100%. Radiographic success was achieved in 16/17 ureters (94%) at 3-4 months, 17/17 (100%) ureters at 1 year, and 17/17 (100%) ureters at 3 years postoperatively. Major complications did not develop postoperatively. Conclusion When prioritizing treatment of concomitant BBD in children with primary VUR and avoiding dextranomer/hyaluronic acid injection therapy in contraindicated children according to the Food and Drug Administration recommendations, a single-session of SMHIT may be as effective and safe in the mid-term as performing open anti-reflux surgery.
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Affiliation(s)
- Shigeru Nakamura
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Kazuya Tanabe
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Taiju Hyuga
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan.,Department of Developmental Genetics, Institute of Advanced Medicine, Wakayama Medical University (WMU), Wakayama, Japan
| | - Taro Kubo
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Satoru Inoguchi
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Shina Kawai
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
| | - Hideo Nakai
- Department of Pediatric Urology, Jichi Medical University, Children's Medical Center Tochigi, Shimotsuke, Japan
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Leigh J, Rickard M, Sanger S, Petropoulos J, Braga LH, Chanchlani R. Antibiotic prophylaxis for prevention of urinary tract infections in the first year of life in children with vesicoureteral reflux diagnosed in the workup of antenatal hydronephrosis: a systematic review. Pediatr Nephrol 2020; 35:1639-1646. [PMID: 32350666 DOI: 10.1007/s00467-020-04568-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Children with antenatal hydronephrosis (ANH) diagnosed with postnatal asymptomatic vesicoureteral reflux (VUR) are thought to be at higher risk of urinary tract infection (UTI). As such, continuous antibiotic prophylaxis (CAP) is empirically recommended until age of toilet training; however, there are limited data to support this. The objective of this systematic review was to summarize the existing data and compare UTI rates in infants with asymptomatic VUR on CAP during the first year of life, to those not on CAP. Secondary objectives were to determine associated risk factors with UTI development. METHODS A systematic search of all relevant studies and abstracts was conducted using 4 electronic databases by utilizing appropriate key words by an expert hospital librarian. Eligible studies included children with prenatal hydronephrosis, asymptomatic VUR with or without CAP, and reported on development of UTI in the first year. RESULTS Of 6903 citations screened, 18 were selected, giving a total population of 829 (69.4% male, median age 57 days) who met the inclusion criteria. Most studies were retrospective and of low-quality evidence. Overall, 15.4% of patients developed at least one breakthrough UTI and females had a higher risk of UTI (odds ratio (OR) 2.3, 95% CI 1.1-4.7). Comparison with children not taking CAP was not readily reported, and meta-analysis could not be completed. CONCLUSIONS Randomized controlled trials and standardized reporting of clinical variables are required to understand the protective effect of antibiotic prophylaxis in this cohort.
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Affiliation(s)
- Jennifer Leigh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Mandy Rickard
- Division of Paediatric Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Luis H Braga
- Department of Pediatric Urology, McMaster Children's Hospital, Hamilton, Canada
| | - Rahul Chanchlani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Canada.
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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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Lorenzo AJ, Rickard M, Santos JD. The role of bladder function in the pathogenesis and treatment of urinary tract infections in toilet-trained children. Pediatr Nephrol 2020; 35:1395-1408. [PMID: 30671629 DOI: 10.1007/s00467-019-4193-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/21/2018] [Accepted: 01/08/2019] [Indexed: 02/03/2023]
Abstract
Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and search terms included recurrent UTI, VUR, bladder and bowel dysfunction (BBD), constipation, lower urinary tract symptoms, and voiding dysfunction. Common presenting symptoms of UTI in children include fever (> 38 °C) with or without "traditional" lower urinary tract symptoms (LUTS) such as dysuria, malodorous urine, frequency, urgency, and incontinence. However, many infections in older children are afebrile episodes-consisting primarily of LUTS-which may or may not be confirmed with biochemical and/or microbiological evidence. Therefore, when evaluating toilet-trained children with recurrent UTIs, it is paramount to consider dysfunctional elimination as an underlying cause, diagnose, and treat it prior to indicating surgical options, even in the presence of VUR or other anatomical abnormalities. Although the impact of bladder function on the risk of infections is important, so is the accurate diagnosis and initial evaluation. This review article will focus on an often overlooked yet critical factor: the impact of bladder function, particularly for toilet-trained children, as well as the importance of implementing bladder training strategies, aggressive management of constipation, and pharmacological management as necessary.
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Affiliation(s)
- Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
| | - Mandy Rickard
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Joana Dos Santos
- Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
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Lightfoot M, Bilgutay AN, Tollin N, Eisenberg S, Weiser J, Bryan L, Smith E, Elmore J, Scherz H, Kirsch AJ. Long-Term Clinical Outcomes and Parental Satisfaction After Dextranomer/Hyaluronic Acid (Dx/HA) Injection for Primary Vesicoureteral Reflux. Front Pediatr 2019; 7:392. [PMID: 31612121 PMCID: PMC6776605 DOI: 10.3389/fped.2019.00392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up. Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review. Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8-9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33-0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3-5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied. Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.
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Affiliation(s)
| | | | - Noah Tollin
- Department of Biology, University of Georgia, Athens, GA, United States
| | - Scott Eisenberg
- Department of Biology, University of Georgia, Athens, GA, United States
| | - Jake Weiser
- Department of Biology, University of Georgia, Athens, GA, United States
| | - Leah Bryan
- Department of Biostatistics, Emory University, Atlanta, GA, United States
| | - Edwin Smith
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - James Elmore
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Hal Scherz
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Andrew J Kirsch
- Children's Healthcare of Atlanta, Atlanta, GA, United States
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Johnin K, Kobayashi K, Tsuru T, Yoshida T, Kageyama S, Kawauchi A. Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children. Int J Urol 2018; 26:160-171. [PMID: 30569659 DOI: 10.1111/iju.13881] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 11/14/2018] [Indexed: 12/24/2022]
Abstract
Voiding cystourethrography is the most important fluoroscopic examination in pediatric urology for the investigation of lower urogenital tract diseases, such as vesicoureteral reflux or urethral stricture. However, this invasive procedure imposes a significant burden on children and their parents, and recently there has been a paradigm shift in the diagnosis and treatment of vesicoureteral reflux. In the 2011 revision, the American Academy of Pediatrics guidelines on urinary tract infection recommended abandoning routine voiding cystourethrography after the first febrile urinary tract infection. In 2014, the randomized intervention for children with vesicoureteral reflux study recommended discontinuation of routine continuous antibiotic prophylaxis for vesicoureteral reflux. The time is now ripe to radically reconsider indications for voiding cystourethrography and the procedure itself.
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Affiliation(s)
- Kazuyoshi Johnin
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kenichi Kobayashi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Teruhiko Tsuru
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tetsuya Yoshida
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Susumu Kageyama
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akihiro Kawauchi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Lau G, Anderson R, Cartwright P, Wallis MC, Schaeffer A, Oottamasathien S, Snow B. Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy. J Pediatr Urol 2018; 14:566.e1-566.e5. [PMID: 30126744 DOI: 10.1016/j.jpurol.2018.07.014] [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: 02/09/2018] [Accepted: 07/19/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. OBJECTIVE The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. STUDY DESIGN A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000 Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥ 101.5 F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. RESULTS A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P = 0.003), but this was not associated with a higher reoperation rate (P = 0.168). There were 11 total complications, with three grade 3 complications. DISCUSSION This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective design and the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. CONCLUSION Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.
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Affiliation(s)
- G Lau
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
| | - R Anderson
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA.
| | - P Cartwright
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
| | - M C Wallis
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
| | - A Schaeffer
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
| | - S Oottamasathien
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
| | - B Snow
- University of Utah/Primary Children's Hospital, 100 N Capecchi Dr #2200, Salt Lake City, UT, USA
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Wang PZT, Abdelhalim A, Walia A, Wehbi E, Dave S, Khoury A. Avoiding routine postoperative voiding cystourethrogram: Predicting radiologic success for endoscopically treated vesicoureteral reflux. Can Urol Assoc J 2018; 13:E119-E124. [PMID: 30407152 DOI: 10.5489/cuaj.5589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment. METHODS This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution. RESULTS A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with "other" morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively. CONCLUSIONS We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.
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Affiliation(s)
- Peter Zhan Tao Wang
- Department of Surgery, Division of Urology, London Health Sciences Centre, Western University, London, ON, Canada
| | - Ahmed Abdelhalim
- Department of Urology, Children's Hospital of Orange County, University of California, Irvine, CA, United States.,Department of Urology, Mansoura Urology and Nephrology Centre, Mansoura University, Egypt
| | - Arman Walia
- Children's Hospital of Orange County, University of California, Irvine, CA, United States
| | - Elias Wehbi
- Department of Urology, Children's Hospital of Orange County, University of California, Irvine, CA, United States
| | - Sumit Dave
- Department of Surgery, Division of Urology, London Health Sciences Centre, Western University, London, ON, Canada
| | - Antoine Khoury
- Department of Urology, Mansoura Urology and Nephrology Centre, Mansoura University, Egypt
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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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García-Aparicio L, Blázquez-Gómez E, Vila Santandreu A, Camacho Diaz J, Vila-Cots J, Ramos Cebrian M, de Haro I, Martin O, Tarrado X. Routine delayed voiding cystourethography after initial successful endoscopic treatment with Dextranomer/Hialuronic Acid Copolimer (Dx/HA) of vesicoureteral reflux (VUR). Is it necessary? Actas Urol Esp 2016; 40:635-639. [PMID: 27161091 DOI: 10.1016/j.acuro.2016.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Some guidelines recommend an early voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR), but there's no consensus if it's necessary a long-term follow-up in these patients. The aim of our study is analyze if it's necessary a delayed VCUG after initial successful treatment with Dx/HA. MATERIAL AND METHOD We have reviewed all medical charts of patients that underwent Dx/HA treatment from 2006 to 2010. We have selected patients with initial successful treatment and more than 3 years of radiological and clinical follow-up. We have analyzed late clinical and radiological outcomes. RESULTS One hundred and sixty children with 228 refluxing ureters underwent Dx/HA endoscopic treatment with a mean follow-up of 52.13 months. Early VCUG was performed in 215 ureters with an initial successful rate of 84.1%. The group of study was 94/215 ureters with more than 3 years of follow-up with a delayed VCUG. VUR was still resolved in 79,8% of the ureters. Clinical success rate was 91.7%. The incidence of febrile urinary tract infection in those patients with cured VUR and those with a relapsed VUR was 8 and 15%, respectively; but there were no significant differences. We have not found any variable related with relapsed VUR except those ureters that initially received 2 injections (P<.05). CONCLUSION If our objective in the treatment of VUR is to reduce the incidence of febrile urinary tract infection it is not necessary to perform a delayed VCUG even though the long-term radiological outcomes is worse than clinical outcome.
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Abstract
Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.
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Affiliation(s)
- Michael L Garcia-Roig
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
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Abstract
Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the upper urinary tract. Diagnosis and subsequent management of VUR have become increasingly controversial, with differing opinions over which children should be evaluated for reflux, and when detected, who should undergo treatment. Management goals include prevention of recurrent febrile urinary tract infection (fUTI) and renal injury while minimizing the morbidity of treatment and follow-up. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Management should be individualized and based on patient age, health, risk of subsequent renal injury, clinical course, renal function, and parental preference.
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Affiliation(s)
- Angela M Arlen
- Departments of Urology and Pediatrics, The University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242-1089, USA,
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Johnston DL, Qureshi AH, Irvine RW, Giel DW, Hains DS. Contemporary Management of Vesicoureteral Reflux. ACTA ACUST UNITED AC 2016; 2:82-93. [PMID: 27570729 DOI: 10.1007/s40746-016-0045-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The past 30 years have seen broad changes in the diagnosis and management of vesicoureteral reflux (VUR). Recently, a clinical debate has generated an open discussion in academic circles. New evidence has shifted treatment patterns away from widespread surgical management and recently brought into question some pharmacologic treatments. VUR is usually not hazardous by itself but is a significant risk factor for urinary tract infection (UTI) and less commonly, renal scarring and insufficiency. Given the costs and morbidity of UTI as well as the potential for significant renal injury, our approach remains conservative. Careful follow-up, parental education about pathophysiology and management of VUR and UTI, and management of bowel and bladder dysfunction (BBD) when present, are the foundation of treatment. Additionally, though we recognize the limitation of continuous antibiotic prophylaxis (CAP), we believe the benefits outweigh the risks and costs for many patients. Careful observation can be considered in patients with a single medical home, parental understanding of what UTI signs and symptoms are, low grade VUR, no history of complicated UTIs and close follow-up. Surgical management remains a relevant option for select patients who fail conservative measures with breakthrough UTIs or failure to resolve. Minimally invasive surgical options are available with acceptable outcomes though open ureteroneocystostomy still carries the highest success rate.
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Affiliation(s)
- Derrick L Johnston
- Division of Pediatric Urology, Department of Surgery, University of Tennessee Health Science Center
| | - Aslam H Qureshi
- Division of Pediatric Nephrology, Department of Pediatrics, University of Tennessee Health Science Center
| | - Rhys W Irvine
- Division of Pediatric Urology, Department of Surgery, University of Tennessee Health Science Center
| | - Dana W Giel
- Division of Pediatric Urology, Department of Surgery, University of Tennessee Health Science Center
| | - David S Hains
- Division of Pediatric Nephrology, Department of Pediatrics, University of Tennessee Health Science Center
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Endoscopic correction of vesicoureteral reflux in children with solitary functioning kidney: insertion of a double-J stent to avoid transient ureteral obstruction. Int Urol Nephrol 2016; 48:313-8. [DOI: 10.1007/s11255-015-1196-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 12/19/2015] [Indexed: 02/04/2023]
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