Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Vesicoureteral reflux by contrast ultrasound, comparison with voiding and retrograde urethrocystography: A prospective accuracy study

INTRODUCTION

Diagnosis of vesicoureteral reflux (VUR) plays an important role in the management and follow-up of children presenting with urinary tract infection. This study compared voiding uronosography (VUS) as a diagnostic method for the diagnosis of VUR with the "gold standard", voiding or micturating cystourethrography (MCU). The objective of the study is not only to compare the effectiveness of both methods, but also to assess the feasibility of implementing VUS technically and economically in a large tertiary radiology center in South America.

MATERIALS AND METHOD

This was a prospective accuracy study that include 41 patients (a total of 85 ureteral units) aged between 1 month and 16 years. VUS was performed in an alternative form as regular MCU, by injecting microbubble contrast solution (SonoVue©) into the bladder through an intermittent catheter and evaluating the presence of reflux with ultrasound. MCU was always performed immediately after VUS. One pediatric radiologist evaluated all VUS exams, while a second independent pediatric radiologist evaluated all MCU exams, with both blinded to each other's assessments.

RESULTS

Comparing VUS with MCU in the diagnosis of VUR, we observed a sensitivity of 92.3 % (95 % CI 74.9-99.1 %), specificity of 98.3 % (95 % CI 90.9-100 %), positive predictive value of 96.0 % (95 % CI 79.6-99.9 %), negative predictive value of 96.7 % (95 % CI 88.5-99.6 %) and a Kappa of 0.916 (0.822-1.000). When comparing the VUR grading between VUS and MCU the agreement between the two methods was high with a Kendall's Tau-b > 0.9. VUS failed to diagnose two grade 1 VUR reflux cases in teenagers while diagnosing one grade 4 VUR in a very dilated kidney-ureter unit, which was missed on MCU. VUS and MCU had similar costs when considering the price of the ultrasound contrast agent.

DISCUSSION

VUS is a reliable alternative method to MCU for the diagnosis of VUR with the advantages of not exposing the child to ionizing radiation and potentially being more accessible due to the greater availability of ultrasound equipment. Limitations to this study include the usage of a single ultrasound equipment, which limits its generalizability and not evaluating the interobserver variability.

CONCLUSION

Consideration should be given to implementing VUS for the diagnosis of VUR, particularly in centers without fluoroscopy equipment available, since the exam's performance and cost are comparable to those of the MCU.

Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys?

Introduction:

Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach.

Materials and Methods:

Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump.

Results:

Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78).

Conclusion:

Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.