1
|
Wehbi EJ, Davis-Dao CA, Williamson SH, Herndon CDA, Chamberlin JD, Dudley AG, Cannon S, Lockwood GM, Kern NG, Zee RS, Braga LH, Welch V, Chuang KW, McGrath M, Stephany HA, Khoury AE. The conundrum of high-grade hydronephrosis with non-obstructive drainage on diuretic renography. J Pediatr Urol 2024; 20 Suppl 1:S11-S17. [PMID: 38906709 DOI: 10.1016/j.jpurol.2024.05.017] [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: 04/12/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Patients with high grade hydronephrosis (HN) and non-obstructive drainage on mercaptoacetyltriglycine (MAG-3) diuretic renography (renal scans) can pose a dilemma for clinicians. Some patients may progress and require pyeloplasty; however, more clarity is needed on outcomes among these patients. OBJECTIVE Our primary objective was to predict which patients with high-grade HN and non-obstructive renal scan, (defined as T ½ time <20 min) would experience resolution of HN. Our secondary objective was to determine predictors for surgical intervention. STUDY DESIGN Patients with prenatally detected HN were prospectively enrolled from 7 centers from 2007 to 2022. Included patients had a renal scan with T ½<20 min and Society for Fetal Urology (SFU) grade 3 or 4 at last ultrasound (RBUS) prior to renal scan. Primary outcome was resolution of HN defined as SFU grade 1 and anterior posterior diameter of the renal pelvis (APD) < 10 mm on follow-up RBUS. Secondary outcome was pyeloplasty, comparing patients undergoing pyeloplasty with patients followed with serial imaging without resolution. Multivariable logistic regression was used for analysis. RESULTS Of the total 2228 patients, 1311 had isolated HN, 338 patients had a renal scan and 129 met inclusion criteria. Median age at renal scan was 3.1 months, 77% were male and median follow-up was 35 months (IQR 20-49). We found that 22% (29/129) resolved, 42% of patients had pyeloplasty (54/129) and 36% had persistent HN that required follow-up (46/129). Univariate predictors of resolution were age≥3 months at time of renal scan (p = 0.05), T ½ time≤5 min (p = 0.09), SFU grade 3 (p = 0.0009), and APD<20 mm (p = 0.005). Upon multivariable analysis, SFU grade 3 (OR = 4.14, 95% CI: 1.30-13.4, p = 0.02) and APD<20 mm (OR = 6.62, 95% CI: 1.41-31.0, p = 0.02) were significant predictors of resolution. In the analysis of decision for pyeloplasty, SFU grade 4 (OR = 2.40, 95% CI: 1.01-5.71, p = 0.04) and T ½ time on subsequent renal scan of ≥20 min (OR = 5.14, 95% CI: 1.54-17.1, p = 0.008) were the significant predictors. CONCLUSIONS Patients with high grade HN and reassuring renal scan can pose a significant challenge to clinical management. Our results help identify a specific candidate for observation with little risk for progression: the patient with SFU grade 3, APD under 20 mm, T ½ of 5 min or less who was 3 months or older at the time of renal scan. However, many patients may progress to surgery or do not fully resolve and require continued follow-up.
Collapse
Affiliation(s)
- Elias J Wehbi
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA.
| | - Carol A Davis-Dao
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Sarah H Williamson
- Children's Hospital of the King's Daughters, Division of Urology, Norfolk, VA, USA
| | - C D Anthony Herndon
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | | | - Anne G Dudley
- Division of Urology, Department of Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Shannon Cannon
- Department of Urology, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Gina M Lockwood
- Department of Urology, The University of Iowa, Iowa City, IA, USA
| | - Nora G Kern
- University of Virginia, Charlottesville, VA, USA
| | - Rebecca S Zee
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | - Luis H Braga
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Valre Welch
- Children's Hospital of Richmond at Virginia Commonwealth University, Department of Urology, Richmond, VA, USA
| | - Kai-Wen Chuang
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Melissa McGrath
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Heidi A Stephany
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| | - Antoine E Khoury
- Children's Hospital of Orange County, Division of Pediatric Urology, Orange, CA, USA; University of California, Irvine, Department of Urology, Irvine, CA, USA
| |
Collapse
|
2
|
Torres A, Horodeńska M, Woźniakowska E, Borowik J. Anxiety Connected with Pelvic Ultrasound in Adolescents and Their Caregivers: Comparison of Transabdominal and Transrectal Approaches. J Pediatr Adolesc Gynecol 2023; 36:284-290. [PMID: 36764510 DOI: 10.1016/j.jpag.2023.01.216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
STUDY OBJECTIVE Transabdominal ultrasound (TAUS) is usually the first approach for diagnosis of reproductive tract complaints in all adolescents. However, there are instances when transrectal ultrasound (TRUS) is more feasible. Although TRUS is considered more invasive and distressing, evidence-based data are lacking. The aim of this study was to evaluate the level of anxiety in adolescents subjected to TAUS and TRUS and in their caregivers. METHODS In this cross-sectional study, data were prospectively gathered using 2 instruments: the adult or child version of the State and Trait Anxiety Inventory (STAI or STAIC) and a self-developed survey. RESULTS TAUS and TRUS are connected with high-level anxiety in patients and moderate anxiety in caregivers, as measured by the STAI/STAIC questionnaires. TRUS-related anxiety, fear, discomfort, and pain in adolescents are significantly higher compared with TAUS. The TRUS-related anxiety of caregivers, as well as the parent-estimated fear, discomfort, and pain of adolescents, is significantly higher compared with TAUS. Anticipated pain connected to TRUS is significantly higher than the post-exam, actually experienced pain. Pain and shame are the main reasons for adolescent anxiety connected with TRUS, whereas shame and unknown experience contribute to TAUS-related anxiety. CONCLUSION Given the high level of anxiety associated with both exams, additional support should be provided to patients scheduled for any pelvic ultrasound exam. Given the even higher level of adolescent anxiety related to TRUS, specialists should be encouraged to train in TAUS and make efforts to begin with this approach. Because increased caregiver anxiety could adversely affect a child's reactions, anxiety-reducing interventions should be oriented toward the caregivers as well as the patients.
Collapse
Affiliation(s)
- Anna Torres
- Department of Pediatric and Adolescent Gynecology, Medical University of Lublin, Lublin, Poland.
| | - Magdalena Horodeńska
- Department of Didactics and Medical Simulation, Medical University of Lublin, Lublin, Poland
| | - Ewa Woźniakowska
- Department of Pediatric and Adolescent Gynecology, Medical University of Lublin, Lublin, Poland
| | - Joanna Borowik
- Department of Pediatric and Adolescent Gynecology, Medical University of Lublin, Lublin, Poland
| |
Collapse
|
3
|
Murugapoopathy V, Gupta IR. Editorial with respect to "Corticosteroids to prevent kidney scarring in children with a febrile urinary tract infection-a randomized trial". Pediatr Nephrol 2021; 36:2967-2969. [PMID: 33961105 DOI: 10.1007/s00467-021-05051-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Affiliation(s)
| | - Indra R Gupta
- Department of Human Genetics, McGill University, Montreal, Canada. .,Department of Pediatric , McGill University , Montreal, Canada.
| |
Collapse
|
4
|
Gernhold C, Kundtner N, Steinmair M, Henkel M, Oswald J, Haid B. Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit. CHILDREN-BASEL 2021; 8:children8050424. [PMID: 34065386 PMCID: PMC8160837 DOI: 10.3390/children8050424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/17/2022]
Abstract
Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.
Collapse
Affiliation(s)
- Christa Gernhold
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
- Correspondence:
| | - Nina Kundtner
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Martin Steinmair
- Department of Nuclear Medicine, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria;
| | - Martin Henkel
- Department of Paediatrics, Hospital of the Sisters of Charity Seilerstätte 4, 4020 Linz, Austria;
| | - Josef Oswald
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| | - Bernhard Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria; (N.K.); (J.O.); (B.H.)
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Shaikh N, Hoberman A, Keren R, Ivanova A, Ziessman HA, Cui G, Mattoo TK, Bhatnagar S, Nadkarni MD, Moxey-Mims M, Primack WA. Utility of sedation for young children undergoing dimercaptosuccinic acid renal scans. Pediatr Radiol 2016; 46:1573-8. [PMID: 27287454 PMCID: PMC5039057 DOI: 10.1007/s00247-016-3649-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/11/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND No studies have examined whether use of sedation during a Tc-99 m dimercaptosuccinic acid (DMSA) renal scan reduces patient discomfort. OBJECTIVE To compare discomfort level during a DMSA scan to the discomfort level during other frequently performed uroradiologic tests, and to determine whether use of sedation during a DMSA scan modifies the level of discomfort. MATERIALS AND METHODS We examined the discomfort level in 798 children enrolled in the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) and Careful Urinary Tract Infection Evaluation (CUTIE) studies by asking parents to rate their child's discomfort level with each procedure on a scale from 0 to 10. We compared discomfort during the DMSA scan and the DMSA image quality between centers in which sedation was used >90% of the time (sedation centers), centers in which sedation was used <10% of the time (non-sedation centers), and centers in which sedation was used on a case-by-case basis (selective centers). RESULTS Mean discomfort level was highest for voiding cystourethrogram (6.4), followed by DMSA (4.0), followed by ultrasound (2.4; P<0.0001). Mean discomfort level during the DMSA scan was significantly higher at non-sedation centers than at selective centers (P<0.001). No difference was apparent in discomfort level during the DMSA scan between sedation centers and selective centers (P=0.12), or between the sedation centers and non-sedation centers (P=0.80). There were no differences in the proportion with uninterpretable DMSA scans according to sedation use. CONCLUSION Selective use of sedation in children 12-36 months of age can reduce the discomfort level experienced during a DMSA scan.
Collapse
Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gang Cui
- Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tej K. Mattoo
- Division of Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University School of medicine, Detroit, MI, USA
| | - Sonika Bhatnagar
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Milan D. Nadkarni
- Pediatric Emergency Department, Brenner Children's Hospital, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | | |
Collapse
|
8
|
Arlen AM. Editorial Comment. J Urol 2016; 195:1882. [DOI: 10.1016/j.juro.2016.01.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Angela M. Arlen
- Departments of Urology and Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
9
|
Early Effect of American Academy of Pediatrics Urinary Tract Infection Guidelines on Radiographic Imaging and Diagnosis of Vesicoureteral Reflux in the Emergency Room Setting. J Urol 2015; 193:1760-5. [DOI: 10.1016/j.juro.2014.06.100] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 11/23/2022]
|
10
|
Arlen AM, Scherz HC, Filimon E, Leong T, Kirsch AJ. Is routine voiding cystourethrogram necessary following double hit for primary vesicoureteral reflux? J Pediatr Urol 2015; 11:40.e1-5. [PMID: 25725613 DOI: 10.1016/j.jpurol.2014.11.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 11/22/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVE Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. STUDY DESIGN Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥ 3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade 4-5 VUR. Initially, all children underwent postoperative VCUG ("routine" group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study ("indicated" group). Clinical success was defined as no postoperative fUTI and radiographic success as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months. RESULTS Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were "routine" and 38 were "indicated" [Figure]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2-50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2-40). Nine children (4.1%) underwent additional procedures. DISCUSSION We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an "indicated" VCUG (i.e. those less than 2 years of age, grade 4-5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an "indicated" VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence "spontaneous resolution" is unknown. CONCLUSION Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method.
Collapse
Affiliation(s)
- Angela M Arlen
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
| | - Hal C Scherz
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
| | - Eleonora Filimon
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health and Emory University School of Medicine, Atlanta, GA, USA.
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
| |
Collapse
|
11
|
Editorial Comment. Urology 2014; 84:1209-10. [DOI: 10.1016/j.urology.2014.06.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
12
|
Botta S, Copp HL. To V(CUG) or not to V(CUG) in infants with prenatal hydronephrosis? J Urol 2014; 192:640-1. [PMID: 24951850 DOI: 10.1016/j.juro.2014.06.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Sisir Botta
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Hillary L Copp
- Department of Urology, University of California, San Francisco, San Francisco, California
| |
Collapse
|