1
|
Sforza S, Marco BB, Haid B, Baydilli N, Donmez MI, Spinoit AF, Paraboschi I, Masieri L, Steinkellner L, Comez YI, Lammers RJM, 't Hoen LA, O'Kelly F, Bindi E, Kibar Y, Silay MS. A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux. J Pediatr Urol 2024; 20:283-291. [PMID: 38000950 DOI: 10.1016/j.jpurol.2023.11.006] [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: 04/04/2023] [Revised: 09/27/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. OBJECTIVE In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV + V) VUR in children. STUDY DESIGN A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. RESULTS Overall, 135 children who underwent either OUR (n = 68), or RALUR (n = 67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p < 0.01); the open cohort had a weight of 11 kg (IQR 9.9-16.6 kg) while the RALUR group had 19 kg (IQR 13-25 kg) (p < 0.01). No significant differences were found for intraoperative (1.5 % vs 7.5 %, p = 0.09) or for postoperative complication rates (7.4 % vs 9 %, p = 0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p < 0.01). The success rate was 94.0 % and 98.5 % in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. DISCUSSION This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. CONCLUSION RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.
Collapse
Affiliation(s)
- Simone Sforza
- Department of Pediatric Urology, University of Florence, Meyer Children Hospital, Florence, Italy.
| | - Beatriz Bañuelos Marco
- Department of Urology, Charité University Clinic, Division of Paediatric Urology, Berlin, Germany
| | - Bernhard Haid
- Department of Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Linz, Austria
| | - Numan Baydilli
- Department of Pediatric Urology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muhammet Irfan Donmez
- Division of Pediatric Urology, Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Anne-Françoise Spinoit
- Department Urology ERN Centre, Ghent University Hospital, Ghent University, 9000 Ghent, Belgium
| | - Irene Paraboschi
- Department of Pediatric Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Lorenzo Masieri
- Department of Pediatric Urology, University of Florence, Meyer Children Hospital, Florence, Italy
| | - Lukas Steinkellner
- Department of Pediatric Urology, Ordensklinikum Linz, Hospital of the Sisters of Charity, Linz, Austria
| | - Yusuf Ilker Comez
- Department of Urology, Biruni University, Division of Paediatric Urology, Istanbul, Turkey
| | - Rianne J M Lammers
- Department of Urology, University Medical Center Groningen, 9713 GZ Groningen, the Netherlands
| | - Lisette Aimée 't Hoen
- Department of Paediatric Urology, Sophia Children's Hospital, Erasmus University Medical Center, 3015 GD Rotterdam, the Netherlands
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital, DK18 AK68 Dublin, Ireland
| | - Edoardo Bindi
- Pediatric Surgery Unit, Salesi Children's Hospital, Ancona, Italy
| | - Yusuf Kibar
- Department of Urology, University, Koru Hospital, Ankara, Turkey
| | - Mesrur Selçuk Silay
- Department of Urology, Biruni University, Division of Paediatric Urology, Istanbul, Turkey
| |
Collapse
|
2
|
Bastos JM, Rondon AV, Machado MG, Zerati M, Nascimento RLP, Lima SVC, Calado ADA, Barroso U. Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice. Int Braz J Urol 2020; 46:523-537. [PMID: 32167732 PMCID: PMC7239285 DOI: 10.1590/s1677-5538.ibju.2019.0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR. Methods The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document. Results and Discussion Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.
Collapse
Affiliation(s)
- José Murillo Bastos
- Universidade Federal de Juiz de Fora -UFJF, Juiz de Fora, MG, Brasil.,Hospital e Maternidade Therezinha de Jesus da Faculdade de Ciências Médicas e Saúde de Juiz de Fora - HMTJ-SUPREMA, Juiz de Fora, MG, Brasil
| | - Atila Victal Rondon
- Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil.,Hospital Federal Cardoso Fontes - HFCF, Rio de Janeiro, RJ, Brasil
| | | | - Miguel Zerati
- Instituto de Urologia e Nefrologia de São José do Rio Preto - IUN, S J do Rio Preto, SP, Brasil
| | | | | | - Adriano de Almeida Calado
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - HCFMRP-USP, Ribeirão Preto, SP, Brasil
| | - Ubirajara Barroso
- Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil.,Escola Bahiana de Medicina - BAHIANA, Salvador, BA, Brasil
| |
Collapse
|
3
|
Marzullo-Zucchet L, March-Villalba JA, Domínguez Hinarejos C, Polo Rodrigo A, Serrano-Durbá A, Boronat Tormo F. Usefulness of the classification of urinary dysfunction for the prognosis of the first endoscopic treatment of vesicoureteral reflux in children over the age of 3. Actas Urol Esp 2019; 43:212-219. [PMID: 30833101 DOI: 10.1016/j.acuro.2018.06.005] [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: 02/23/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the diagnostic performance of urinary dysfunction patterns associated with vesicoureteral reflux (VUR) in children over the age of 3 according to the result of the first endoscopic treatment (ENDT1), grouped into a classification designed by our group (CMD.URI-La Fe). Comparison with other current classifications such as that of Van Batavia et al. MATERIAL AND METHODS: Ambispective cross-cutting study of a sample of 50 children. EXCLUSION CRITERIA previous ENDT, age ≤ 3 years, anatomical or neurological anomalies and a history of ureteral or abdominopelvic surgery. Prior to the ENDT1, a bladder voiding function assessment by uroflowmetry+electromyography (UF-EMG) and post-mictional residue (ultrasound). Other variables from the bladder diary, pre-mictional bladder wall thickness and other clinical variables. The correction of VUR was assessed by isotope cystography 3 months after the treatment. Urinary patterns were classified according to the significant variables (URI-La Fe), and the diagnostic performance of this classification was assessed, comparing it to the classification of patients as proposed by Van Batavia et al. RESULTS: Mean age: 6.8±2.28 years. Males/females (44%/56%). Grades of VUR (mild/moderate/severe). ENDT1 VUR correction rate: 77% (n=38). Diagnostic performance (Van Batavia; URI-La Fe): correct prediction (37.5%; 75%), sensitivity (32.4%; 87.8%), specificity (54.5%; 46.6%), positive predictive value (70.6; 78.3%) and negative predictive value (19.4%; 63.6%). CONCLUSIONS Our results show the usefulness of the non-invasive test and the classification of urinary dysfunction in children aged over 3 years prior to the first endoscopic treatment of VUR.
Collapse
Affiliation(s)
- L Marzullo-Zucchet
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J A March-Villalba
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - C Domínguez Hinarejos
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - A Polo Rodrigo
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - A Serrano-Durbá
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - F Boronat Tormo
- Sección de Urología Infantil, Servicio de Urología, Hospital Universitari i Politècnic La Fe, Valencia, España
| |
Collapse
|
4
|
Nerli RB, Pujar S, Ghagane S, Hiremath M, Dixit N. Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux. JOURNAL OF THE SCIENTIFIC SOCIETY 2019. [DOI: 10.4103/jss.jss_18_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
5
|
Friedlander DA, Ludwig WW, Jayman JR, Akhavan A. The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs. J Pediatr Urol 2018. [PMID: 29534861 DOI: 10.1016/j.jpurol.2018.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. OBJECTIVE To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. STUDY DESIGN Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. RESULTS A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. DISCUSSION This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. CONCLUSION Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.
Collapse
Affiliation(s)
- D A Friedlander
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - W W Ludwig
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J R Jayman
- Division of Pediatric Urology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Akhavan
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
6
|
Straub J, Apfelbeck M, Karl A, Khoder W, Lellig K, Tritschler S, Stief C, Riccabona M. [Vesico-ureteral reflux: Diagnosis and treatment recommendations]. Urologe A 2016; 55:27-34. [PMID: 26676728 DOI: 10.1007/s00120-015-0003-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. OBJECTIVES Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. THERAPY The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. CONCLUSION Decisions on treatment should be made individually with parents taking into account all the findings available.
Collapse
Affiliation(s)
- J Straub
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - M Apfelbeck
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - A Karl
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - W Khoder
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - K Lellig
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - C Stief
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - M Riccabona
- Urologische Klinik und Poliklinik der Ludwig-Maximilians-Universität München, LMU, Klinikum Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| |
Collapse
|
7
|
Choi H, Park JY, Bae JH. Initial experiences of laparoscopic intravesical detrusorraphy using the Politano-Leadbetter technique. J Pediatr Urol 2016; 12:110.e1-7. [PMID: 26750185 DOI: 10.1016/j.jpurol.2015.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 07/23/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Minimally invasive laparoscopic surgical procedures are increasingly being used for the management of vesicoureteral reflux. OBJECTIVE We present our experience of the laparoscopic Politano-Leadbetter technique performed under pneumovesicum conditions, which allows an orthotopic ureteral location after vesicoureteral reflux correction. Our procedure recreates the new ureteric orifice in a normal anatomical position with potential less morbidity and better cosmesis. STUDY DESIGN Our series comprises ten cases. The three 5 mm ports were introduced through bladder wall under cystoscopic vision. A 5-0 monofilament traction suture was used and dissection was carried out. After the ureteral mobilization, the location of the new hiatus was selected in a straight line superior to the original orifice. Dissection of the submucosal tunnel was started from the new hiatus and advanced to the original hiatus and the ureter was gently drawn passed through the tunnel. The ureter was rolled up and muscle fibers were incised until ureter could freely move from the base of the new hiatus. Finally, after spatulation of the terminal part of the ureter, ureterovesical anastomosis was performed with intracorporeal suturing using 5-0 monofilament sutures. RESULTS The average operative time was 125 min, with an average of 93 min for unilateral and 133 min for bilateral reimplantation. Blood loss was minimal and drains were used selectively. Removal of urethral catheter was decided empirically after hematuria stopped. Mean catheterization time was 5.1 days. The mean postoperative hospital stay was 6.2 days. DISCUSSION This study had limitations: the small number of cases, follow-up period is relatively short and data on the pre-operative bladder capacity, catheter-related morbidity, pain control and cosmesis are lacking. But most cases showed positive clinical results including acceptable operating time and good resolution rate with minimal complication. Our Politano-Leadbetter transvesicoscopic ureteric reimplantation is safe and useful in the resolution of VUR, even though the laparoscopic ureteric reimplantation is technically demanding even for experienced pediatric surgeons. Considering the main advantages of endoscopic surgery, our new vesicoscopic technique could be an optional treatment to the open reimplantation and has merits because whole the procedure are performed within the bladder, so there is no risk of intraperitoneal organ injury. CONCLUSION Though the role of this new technique in the treatment of VUR remains to be determined, the technique could be an optional treatment to replace other surgical methods as a less invasive and effective therapeutic method.
Collapse
Affiliation(s)
- H Choi
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, South Korea.
| | - J Y Park
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, South Korea.
| | - J H Bae
- Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, South Korea.
| |
Collapse
|
8
|
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
|
9
|
Kirsch AJ, Arlen AM, Leong T, Merriman LS, Herrel LA, Scherz HC, Smith EA, Srinivasan AK. Vesicoureteral reflux index (VURx): a novel tool to predict primary reflux improvement and resolution in children less than 2 years of age. J Pediatr Urol 2014; 10:1249-54. [PMID: 25511573 DOI: 10.1016/j.jpurol.2014.06.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 06/22/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. MATERIALS AND METHODS Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. RESULTS Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p<0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. CONCLUSIONS Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.
Collapse
Affiliation(s)
- Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Angela M Arlen
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura S Merriman
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Lindsey A Herrel
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Hal C Scherz
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Arun K Srinivasan
- Department of Pediatric Urology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| |
Collapse
|
10
|
Arlen AM, Broderick KM, Huen KH, Leong T, Scherz HC, Kirsch AJ. Temporal Pattern of Vesicoureteral Reflux on Voiding Cystourethrogram Correlates with Dynamic Endoscopic Hydrodistention Grade of Ureteral Orifice. J Urol 2014; 192:1503-7. [DOI: 10.1016/j.juro.2014.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Angela M. Arlen
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| | - Kristin M. Broderick
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| | - Kathy H. Huen
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| | - Traci Leong
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| | - Hal C. Scherz
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| | - Andrew J. Kirsch
- Department of Pediatric Urology, Children’s Healthcare of Atlanta, and Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine (TL), Atlanta, Georgia
| |
Collapse
|
11
|
Kocherov S, Arafeh WA, Zeldin A, Ostrovsky IA, Ioscovich A, Farkas A, Chertin B. Downgrading of high-grade vesicoureteral reflux is a reliable option in the treatment of children with grade IV‒V reflux accompanied by breakthrough infections. J Pediatr Urol 2013; 9:212-6. [PMID: 22391110 DOI: 10.1016/j.jpurol.2012.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 02/08/2012] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate incidence of urinary tract infection (UTI) and natural history of downgraded vesicoureteral reflux (VUR) in children with high-grade VUR following endoscopic correction. MATERIALS AND METHODS We retrospectively studied 54 children (13 males and 41 females) with a mean age of 1.8 years who underwent endoscopic correction of Grade IV‒V VUR due to breakthrough infections while on antibiotic prophylaxis. Reflux was Grade IV in 40 (74%) and V in 14 (26%) patients comprising 95 renal refluxing units (RRU). Reflux was corrected in 72 (76%) RRU. 18 (34%) patients/23 (24%) RRU demonstrated downgrading of VUR. 21 of the 23 RRU showed Grade II and 2 Grade III VUR, and were taken off antibiotic prophylaxis and allocated to observation. Patients were followed for 2-22 years (median 14 years). RESULTS Technetium 99m dimercaptosuccinic acid renal scan demonstrated preoperative renal scarring in 21 (78%) of the 23 RRU with downgraded VUR. None of the children developed febrile UTI after surgery. 1 RRU showed renal function deterioration. 8 (44%) of the 18 patients underwent follow-up voiding cystourethrogram, and in 7 (88%) there was either spontaneous resolution of VUR or downgrade to Grade I VUR. CONCLUSIONS Downgrading of VUR is a reasonable option in patients with high-grade VUR suffering from breakthrough infections while on antibiotic prophylaxis. It leads to the cessation of febrile UTIs, further spontaneous resolution of VUR and may potentially avoid renal damage.
Collapse
Affiliation(s)
- Stanislav Kocherov
- Department of Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel
| | | | | | | | | | | | | |
Collapse
|
12
|
Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, Stein R, Dogan HS. EAU Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2012; 62:534-42. [DOI: 10.1016/j.eururo.2012.05.059] [Citation(s) in RCA: 205] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 05/25/2012] [Indexed: 11/28/2022]
|
13
|
Cooper CS. Individualizing management of vesicoureteral reflux. Nephrourol Mon 2012; 4:530-4. [PMID: 23573480 PMCID: PMC3614288 DOI: 10.5812/numonthly.1866] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 08/01/2011] [Accepted: 08/12/2011] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Approaches to the management of vesicoureteral reflux (VUR) in children have changed rapidly in recent years. Multiple studies published over the last decade have contributed to these changes by challenging the dogma that all children with reflux require and benefit from continuous antibiotic prophylaxis. The advent and wide acceptance of endoscopic treatment for VUR has also contributed to these changes. Although new guidelines for VUR management have recently been proposed, they are broad and relatively non-specific. Many physicians and parents remain unsure which children are at risk from their VUR, and which would benefit from antibiotic prophylaxis or surgical intervention. MATERIALS AND METHODS A literature search, followed by an additional search based on bibliographies, was performed for articles reporting on VUR and the utility of antibiotic prophylaxis for its treatment, as well as the chance of spontaneous resolution. RESULTS Articles selected for review included those that provided information to assist physicians in determining if a child with VUR is at increased risk of pyelonephritis or persistent VUR, and would benefit from intervention. Particular emphasis was placed on recent prospective, randomized trials in children with VUR. CONCLUSIONS Because of the multiple factors affecting risk in a child with VUR, specific guidelines for intervention cannot be provided. However, an accurate understanding of these risk factors will help the physician and parents to develop a more individualized management plan for a child with VUR.
Collapse
Affiliation(s)
- Christopher S. Cooper
- Department of Urology, University of Iowa Department of Urology, Iowa, United States
- Corresponding author: Christopher S. Cooper, Department of Urology, University of Iowa, 200 Hawkins Dr., 3 RCP, IA 52242-1089, Iowa City, United States. Tel.: +1-3193848299, Fax: +1-3193563900, E-mail:
| |
Collapse
|
14
|
Wadie GM, Moriarty KP. The impact of vesicoureteral reflux treatment on the incidence of urinary tract infection. Pediatr Nephrol 2012; 27:529-38. [PMID: 21380627 DOI: 10.1007/s00467-011-1809-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 01/24/2011] [Accepted: 02/02/2011] [Indexed: 12/01/2022]
Abstract
Vesicoureteral reflux (VUR) is a heterogeneous disease and its management remains one of the most controversial topics in pediatrics. Management options include surveillance, antibiotics, and surgery. The approval of dextranomer/hyaluronic acid (DHA) as a bulking agent by the Food and Drug Administration was followed by wide acceptance of endoscopic techniques as a major tool in the management of reflux. Pyelonephritis rather than VUR is the most common cause of kidney damage in children. It should be emphasized that the primary goal of diagnosing and treating VUR should be preventing this complication. There are no sufficient data in the literature to address the impact of the different treatment modalities on the incidence of febrile urinary tract infections (feb-UTIs) denoting pyelonephritis, with very few studies evaluating endoscopic treatment in light of this clear and well-defined outcome. The fact that we can correct the anatomy at the vesicoureteral junction with a simple and relatively safe outpatient procedure does not justify offering it to all patients. In this review, we attempt to critically evaluate the available literature pertaining to the impact of different treatment modalities on reducing the incidence of febrile UTIs and kidney damage, with a special emphasis on endoscopic treatment.
Collapse
Affiliation(s)
- George M Wadie
- Pediatric Surgery, Sacred Heart Medical Center, 3377 Riverbend Drive, Springfield, OR 97477, USA.
| | | |
Collapse
|
15
|
Sung J, Skoog S. Surgical management of vesicoureteral reflux in children. Pediatr Nephrol 2012; 27:551-61. [PMID: 21695451 PMCID: PMC3288369 DOI: 10.1007/s00467-011-1933-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/18/2011] [Accepted: 05/20/2011] [Indexed: 10/27/2022]
Abstract
Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0-21%, new renal damage in 9-12%, and recurrent reflux in 17-47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.
Collapse
Affiliation(s)
- Jennifer Sung
- Surgery, OHSU, 3303 SW Bond Ave Mail code CH10U, Portland, OR 97239 USA
| | - Steven Skoog
- Surgery, OHSU, 3303 SW Bond Ave Mail code CH10U, Portland, OR 97239 USA
| |
Collapse
|
16
|
|
17
|
Bibliography. Female urology. Current world literature. Curr Opin Urol 2011; 21:343-6. [PMID: 21654401 DOI: 10.1097/mou.0b013e3283486a38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|