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Boswell TC. Advancements in Surgical Management of Megaureters. Curr Urol Rep 2024:10.1007/s11934-024-01214-8. [PMID: 38954357 DOI: 10.1007/s11934-024-01214-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To review and describe the recent evolution of surgery for the various types of pediatric megaureter. RECENT FINDINGS Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.
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Affiliation(s)
- Timothy C Boswell
- Department of Urology, Children's of Alabama and University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 318, Birmingham, AL, 35233, USA.
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Gnech M, 't Hoen L, Burgu B, Radmayr C. Reply to Ping Zhong, Xin Liu, and Limin Liao's Letter to the Editor re: Michele Gnech, Lisette 't Hoen, Alexandra Zachou, et al. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2023.12.005. Eur Urol 2024:S0302-2838(24)02355-8. [PMID: 38735821 DOI: 10.1016/j.eururo.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Lisette 't Hoen
- Department of Paediatric Urology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Berk Burgu
- Department of Paediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Christian Radmayr
- Paediatric Urology, Medical University of Innsbruck, Innsbruck, Austria
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Gnech M, 't Hoen L, Zachou A, Bogaert G, Castagnetti M, O'Kelly F, Quaedackers J, Rawashdeh YF, Silay MS, Kennedy U, Skott M, van Uitert A, Yuan Y, Radmayr C, Burgu B. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2024; 85:433-442. [PMID: 38182493 DOI: 10.1016/j.eururo.2023.12.005] [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] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVE The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.
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Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Lisette 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alexandra Zachou
- Department of HIV and Sexual Health, Chelsea & Westminster Hospital, London, UK
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Marco Castagnetti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital Dublin & University College Dublin, Ireland
| | - Josine Quaedackers
- Department of Urology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yazan F Rawashdeh
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Biruni University, Istanbul, Turkey
| | - Uchenna Kennedy
- Department of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Skott
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, London Health Science Centre, London, Ontario, Canada, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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Zhong P, Liu X, Liao L. Re: Michele Gnech, Lisette 't Hoen, Alexandra Zachou, et al. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2023.12.005. Eur Urol 2024:S0302-2838(24)02137-7. [PMID: 38614821 DOI: 10.1016/j.eururo.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 04/15/2024]
Affiliation(s)
- Ping Zhong
- Second Clinical Medical College, Shandong University, Jinan, China; University of Health and Rehabilitation Sciences, Qingdao, China; Department of Urology, China Rehabilitation Science Institute, Beijing, China; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Xin Liu
- Department of Urology, China Rehabilitation Science Institute, Beijing, China; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China; School of Rehabilitation, Capital Medical University, Beijing, China
| | - Limin Liao
- Second Clinical Medical College, Shandong University, Jinan, China; University of Health and Rehabilitation Sciences, Qingdao, China; Department of Urology, China Rehabilitation Science Institute, Beijing, China; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China; School of Rehabilitation, Capital Medical University, Beijing, China; Wenzhou Medical University, Wenzhou, China.
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Kruppa C, Wilke A, Hörz C, Kosk T, Hörz T, Fitze G, Schuchardt K. Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux. J Clin Med 2023; 12:5686. [PMID: 37685751 PMCID: PMC10488379 DOI: 10.3390/jcm12175686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/04/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations. METHODS Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course. RESULTS The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients). CONCLUSIONS For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.
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Affiliation(s)
- Christian Kruppa
- Department of Pediatric Surgery, University Hospital Dresden, Technical University Dresden, 01307 Dresden, Germany (G.F.)
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Chandrasekharam VVS, Ravula S, Janapareddy KK. Transvesicoscopic Ureteral Reimplantation for Primary Vesicoureteral Reflux in Children: Does Prior Failed Endoscopic Injection Impact Outcome? J Laparoendosc Adv Surg Tech A 2023; 33:417-421. [PMID: 36921282 DOI: 10.1089/lap.2022.0556] [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: 03/17/2023] Open
Abstract
Purpose: Transvesicoscopic ureteral reimplantation (TVUR) for vesicoureteral reflux (VUR) is a technically demanding operation. The technical difficulty is further increased by previous failed endoscopic injection, which causes intense fibrosis around the ureter. In this study, we compared primary TVUR with TVUR after previous failed endoscopic injection for VUR. Materials and Methods: The records of all children undergoing TVUR by a single surgeon over a 4-year period were analyzed. The children were divided into group 1 (primary TVUR, n = 50) and group 2 (TVUR after previous failed endoscopic treatment of Dextranomer/Hyaluronic Acid, n = 7). Demographic, clinical, radiologic, operative and follow-up data were compared between the two groups. The results were analyzed by statistical software; Mann-Whitney test and Fisher's exact test were used where appropriate, and P < .05 was considered significant. Results: Both the groups were comparable with respect to age and mean VUR grade. The mean VUR grade was significantly higher in group 1 and mean operative time per ureter was significantly more for group 2 than group 1. The postoperative hospital stay, success of TVUR, and complications were not significantly different between the groups. Conclusions: To our knowledge, this is the first report of its kind. TVUR after previous failed endoscopic injection could be done safely with good success, but with longer operative time than primary TVUR even in expert hands. Hence, previous failed endoscopic injection is not a contraindication to TVUR.
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Affiliation(s)
- V V S Chandrasekharam
- Pediatric Surgery, Pediatric Urology and MAS, FSPU, Ankura Hospitals for Women and Children, Little Star Children's Hospital, Hyderabad, Telangana, India
| | - Satyanarayana Ravula
- Department of Pediatric Surgery, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
| | - Khyati Kiran Janapareddy
- Department of Pediatric Surgery, Ankura Hospitals for Women and Children, Hyderabad, Telangana, India
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Law ZW, Ong CCP, Yap TL, Loh AHP, Joseph U, Sim SW, Ong LY, Low Y, Jacobsen AS, Chen Y. Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: A systematic review and meta-analysis. Front Pediatr 2022; 10:935082. [PMID: 36340705 PMCID: PMC9633941 DOI: 10.3389/fped.2022.935082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE This study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis. METHODS Literature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR. RESULTS Twelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) -22.91 min; 95% confidence interval (CI), -44.53 to -1.30, P = 0.04] and hospital stay (MD -2.09 days; 95% CI, -2.82 to -1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1%) compared to bilateral IVUR (1.7%) (OR = 4.40; 95% CI, 1.33-14.58, P = 0.02). No patient undergoing unilateral EVUR or IVUR experienced ARU. CONCLUSION Both EVUR and IVUR are equally effective in correcting primary VUR. Operative time and hospital stay are shorter after EVUR compared to IVUR. However, bilateral EVUR is associated with higher risk of postoperative ARU.
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Affiliation(s)
- Zhi Wei Law
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Caroline C P Ong
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Te-Lu Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Amos H P Loh
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Udayan Joseph
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Siam Wee Sim
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lin Yin Ong
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Anette S Jacobsen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Anand S, Kainth D. Fragility Index of Recently Published Meta-Analyses in Pediatric Urology: A Striking Observation. Cureus 2021; 13:e16225. [PMID: 34367825 PMCID: PMC8343562 DOI: 10.7759/cureus.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
Background and objective Fragility Index (FI) of meta-analyses determines their stability in terms of the level of confidence and strength behind the results depicted by them. The present study was conducted to estimate the FI of recently published meta-analyses in the Journal of Pediatric Urology (JPUrol). Method Twenty recently published articles on meta-analyses were screened to identify the eligible ones. The baseline data of each meta-analysis including the details of the author, number of included studies, total sample size, the total number of events, the status of the overall outcome (significant or non-significant), type of effect measure, type of method used for pooling the estimates, and type of effects model were recorded. FI was calculated by doing each single status modification. The 95% CI of the treatment effect was re-calculated until the statistical significance of the meta-analysis was reversed. Results A total of seven articles incorporating 22 meta-analyses were included. Seven (32%) of them had a statistically significant outcome prior to FI estimation. The risk ratio (17/22; 77%) was the most commonly used effect measure. The random-effects model (15/22; 68%) and the Mantel-Haenszel method (20/22; 91%) of pooling the estimates were utilized in the majority of meta-analyses. The median (Q1-Q3; range) FI of statistically significant, non-significant, and total meta-analyses were 5 (3-19.5; 2-39), 5 (3.5-6; 1-17), and 5 (3-13; 1-39) respectively. FI of ≤5 was noticed in four out of seven (57%), 9/15 (60%), and 13/22 (59%) of these meta-analyses respectively. Conclusion Based on our findings, the majority of the recently published meta-analyses in the field of pediatric urology are fragile and depend upon the event status of ≤5 participants.
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Affiliation(s)
- Sachit Anand
- Pediatric Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, IND.,Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Deepika Kainth
- Pediatrics, All India Institute of Medical Sciences, New Delhi, IND
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Zhu X, Wang J, Zhu H, Huang L, Chen C, Wang L, Dong J, Ge Z, Ma G, Guo Y, Huang S. Lich-Gregoir vesico-ureteral reimplantation for duplex kidney anomalies in the pediatric population: a retrospective cohort study between laparoscopic and open surgery. Transl Pediatr 2021; 10:26-32. [PMID: 33633934 PMCID: PMC7882287 DOI: 10.21037/tp-20-163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The aim of the study is to compare the Lich-Gregoir vesico-ureteral reimplantation in laparoscopy and open surgery. METHODS In this case control study, we enrolled pediatric patients who were diagnosed with unilateral duplex kidney and had underwent surgical treatment. The surgical treatments were either conventional open surgery or laparoscopic surgery. We collected the basic demographic data and extracted the operative-related statistics such as operation time, blood loss, length of hospital stay, pain level, and post-operative complications. The two groups were compared using Student's t-test. RESULTS A total of 90 subjects were enrolled. Of the enrolled subjects, 35 underwent open surgery and 55 underwent laparoscopic surgery. There were no observable difference in the basic demographics between two groups (P>0.05). The duration of operation in laparoscopic surgery group was significantly shorter than in the open surgery group (95.60±5.25 vs. 108.70±3.12 min, P=0.040). It was also noted that the amount of blood loss, length of hospital stay, drainage level, and the mean visual analog scale in laparoscopic group were significantly lower (P<0.05). The total incidence of complications in the laparoscopic and open surgery groups were 16.36% and 37.14%, respectively. CONCLUSIONS Laparoscopic Lich-Gregoir vesico-ureteral reimplantation surgery management can be successful, clinically effective, and safe for pediatric population with functional duplex kidneys, and is better than the open surgery techniques.
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Affiliation(s)
- Xiaojiang Zhu
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Wang
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Haobo Zhu
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Liqu Huang
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chenjun Chen
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lixia Wang
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jun Dong
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Ge
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Geng Ma
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yunfei Guo
- Department of Urology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Songming Huang
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
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