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Khondker A, Kim JK, Chua ME, Kwong JCC, Chan JYH, Yadav P, Richter J, Santos JD, Brownrigg N, Lorenzo AJ, Rickard M. The effect of primary urinary diversion on kidney function in posterior urethral valve: A matched comparison. Urology 2023; 172:170-173. [PMID: 36450318 DOI: 10.1016/j.urology.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine long-term kidney outcomes in boys with posterior urethral valve (PUV) undergoing either primary valve ablation or urinary diversion with matched baseline kidney function. METHODS After retrospective review of patients managed for PUV at our institution, propensity score matched analysis was conducted using nadir serum creatinine with logistic regression analysis. Nearest neighbor matching was used to allocate boys to primary urinary diversion and primary ablation groups. Primary outcomes included kidney function by creatinine or estimated glomerular filtration rate, chronic kidney disease, and end-stage renal disease. Comparative statistics by odds ratio (OR) and hazard ratios on survival analysis were calculated. RESULTS A total of 21 boys undergoing primary diversion were matched with 42 boys undergoing ablation using nadir serum creatinine and follow-up time with a median follow-up of 4.8 years. After matching, there was no significant difference in last follow-up kidney function by creatinine (P = .99) or estimated glomerular filtration rate (P = .98). Primary diversion was not associated with increased likelihood of developing chronic kidney disease stage 3 (OR 1.33; P = .31) or end-stage renal disease (OR 1.88; P = .35 and hazard ratios 1.85; P = .30) compared to primary ablation. CONCLUSIONS Our propensity matched study suggests that long-term kidney function and kidney outcomes are similar between primary ablation and primary diversion after adjusting for baseline kidney function in boys with PUV.
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Affiliation(s)
- Adree Khondker
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jin K Kim
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Jethro C C Kwong
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Justin Y H Chan
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Priyank Yadav
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Juliane Richter
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joana Dos Santos
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Natasha Brownrigg
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada; Division of Urology, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Mandy Rickard
- Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada.
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Banerjee S, Kamath N, Antwi S, Bonilla-Felix M. Paediatric nephrology in under-resourced areas. Pediatr Nephrol 2022; 37:959-972. [PMID: 33839937 DOI: 10.1007/s00467-021-05059-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Nearly 50% of the world population and 60% of children aged 0 to 14 years live in low- or lower-middle-income countries. Paediatric nephrology (PN) in these countries is not a priority for allocation of limited health resources. This article explores advancements made and persisting limitations in providing optimal PN services to children in such under-resourced areas (URA). METHODS Medline, PubMed and Google Scholar online databases were searched for articles pertaining to PN disease epidemiology, outcome, availability of services and infrastructure in URA. The ISN and IPNA offices were contacted for data, and two online questionnaire surveys of IPNA membership performed. Regional IPNA members were contacted for further detailed information. RESULTS There is a scarcity of published data from URA; where available, prevalence of PN diseases, managements and outcomes are often reported to be different from high income regions. Deficiencies in human resources, fluoroscopy, nuclear imaging, immunofluorescence, electron microscopy and genetic studies were identified. Several drugs and maintenance kidney replacement therapy are inaccessible to the majority of patients. Despite these issues, regional efforts with support from international bodies have led to significant advances in PN services and infrastructure in many URA. CONCLUSIONS Equitable distribution and affordability of PN services remain major challenges in URA. The drive towards acquisition of regional data, advocacy to local government and non-government agencies and partnership with international support bodies needs to be continued. The aim is to optimise and achieve global parity in PN training, investigations and treatments, initially focusing on preventable and reversible conditions.
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Affiliation(s)
| | | | - Sampson Antwi
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Hofmann A, Haider M, Cox A, Vauth F, Rösch WH. Is Vesicostomy Still a Contemporary Method of Managing Posterior Urethral Valves? CHILDREN 2022; 9:children9020138. [PMID: 35204859 PMCID: PMC8869788 DOI: 10.3390/children9020138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022]
Abstract
In boys with posterior urethral valves (PUVs) the main treatment aim is to preserve long-term bladder and renal function. To determine the effectiveness of secondary vesicostomy in boys with PUVs, the medical records of 21 patients with PUV (2010–2019), divided into two groups (group I: valve ablation; group II: secondary vesicostomy), were reviewed regarding the course of serum creatinine, renal ultrasound, voiding cystourethrogram, urodynamics, postoperative complications, need of further surgery, and long-term solution. The median age of all patients at first follow-up was 11 (9–13) months and at last follow-up 64.5 (39.5–102.5) months. Despite a significant difference of the SWDR score (shape, wall, reflux, and diverticula) (p = 0.014), both groups showed no significant differences preoperatively. Postoperatively, serum creatinine (p = 0.024), grade of vesicoureteral reflux (p = 0.003), side of upper tract dilatation (p = 0.006), side of megaureter (p = 0.004), and SWDR score (p = 0.002) were significantly decreased in group II. Postoperative urodynamic measurements showed comparable results in both groups. Stoma complications were found in three (20%) patients (group II). Eight (53.3%) patients already received a closure of the vesicostomy. Seven out of eight (87.5%) patients were able to micturate spontaneously. Vesicostomy remains a reliable treatment option for boys with PUV to improve bladder function and avoid further damage to the urinary tract.
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Affiliation(s)
- Aybike Hofmann
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, 93049 Regensburg, Germany; (A.C.); (F.V.); (W.H.R.)
- Correspondence:
| | | | - Alexander Cox
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, 93049 Regensburg, Germany; (A.C.); (F.V.); (W.H.R.)
- Department of Urology, University Hospital Bonn, 53127 Bonn, Germany
| | - Franziska Vauth
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, 93049 Regensburg, Germany; (A.C.); (F.V.); (W.H.R.)
| | - Wolfgang H. Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, 93049 Regensburg, Germany; (A.C.); (F.V.); (W.H.R.)
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Temporary vesicostomy in pediatrics: What are the potential predictors of functional and morphological improvement of the upper urinary tract? J Pediatr Urol 2021; 17:834.e1-834.e9. [PMID: 34602355 DOI: 10.1016/j.jpurol.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/14/2021] [Accepted: 09/16/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Vesicostomy is a simple, well-tolerated, and reversible procedure with few complications that safeguards upper urinary tract (UUT), decreases VUR grade, decreases UTI, and preserves renal function and should be considered in patients with PUV who have undergone prior valve ablation and bladder function not improved, and in myelodysplastic children that do not respond to catheter drainage [1-4]. OBJECTIVE We evaluated the temporary vesicostomy as a safeguard of the UUT in children with bladder outlet obstruction, bladder dysfunction, and high-grade VUR with sepsis and assessed the possible predictors of the UUT's morphological and functional improvement since these have been rarely explored in previous reviews. STUDY DESIGN We evaluated the outcome and complications of temporary vesicostomy who were operated on 69 children at our center from 2014 to 2019. RESULT There were 63 (91.3%) boys and 6 (8.7%) girls who underwent vesicostomy at a mean age of 15.38 ± 2.74 months old. Twenty-nine cases (42%) were diagnosed as primary VUR, 23 (33.3%) had posterior urethral valve (PUV), and 5 (7.2%) had voiding dysfunction, while 12 (17.4%) were neurogenic bladder. Twenty-five (36.2%) patients were diagnosed prenatally and the remainder (44, 63.8%) postnatally. All patients were evaluated at least one year postoperatively. UTI was diagnosed in all cases before vesicostomy; 47 (68.1%) had a single episode of UTI and 22 (31.9%) had recurrent episodes of UTI. Mean serum creatinine was 1.75 ± 0.13 (0.7-4.8) mg/dl. Serum creatinine and the rate of UTI significantly improved (p-value <0.01). Seven (10.1%) cases were complicated with prolapse, 8 (11.6%) with stenosis, and 10 (14.5%) with peristomal dermatitis, all of them were males. DISCUSSION About 75.4% of cases developed morphological improvement, while 24.6% of cases not improved (p-value = 0.0001). Improvement or stability of glomerular filtration rate (GFR) was seen in 84.1%, while 15.9% deteriorated GFR (p-value = 0.0001). This deterioration is associated with prenatal renal dysplasia. Age less than one year, abdominal swelling, severe HUN, grade V VUR and recurrent UTI before vesicostomy all independently affect functional improvement after vesicostomy. CONCLUSION Vesicostomy is a simple, reversible, and well-tolerated surgery with few complications that is indicated in children with bladder outlet obstruction, bladder dysfunction, and high-grade VUR to protect UUT, improve renal function, decrease VUR, hydronephrosis, and febrile UTI. Age less than one year, abdominal swelling, severe HUN, grade V VUR and recurrent UTI before vesicostomy all were predictors that independently affect morphological and functional outcomes after vesicostomy.
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Sharifiaghdas F, Mirzaei M, Nikravesh N. Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients? J Pediatr Urol 2019; 15:379.e1-379.e8. [PMID: 31060966 DOI: 10.1016/j.jpurol.2019.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/26/2019] [Accepted: 03/29/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neuropathic bladder, voiding dysfunction, and posterior urethral valves may cause a great challenge in children. Preserving the kidney function is the main aim in all of these patients which can be achieved by cutaneous vesicostomy. OBJECTIVE The objective of this study is to evaluate the long-term outcomes of patients who have undergone cutaneous vesicostomy in an 11-year period at the study center. STUDY DESIGN In this retrospective study, the authors evaluated the long-term treatment results and complications of cutaneous vesicostomy on children with bilateral severe hydronephrosis, bilateral vesicoureteral reflux (VUR), and urosepsis who were operated at our center from 2007 to 2018. RESULTS There were 64 (80%) boys and 16 (20%) girls. Their mean of age was 15.27 months old when they underwent vesicostomy. Twenty-three (28.75%) of them had neurogenic bladder and 17 (21.25%) of them had intact neuronal pathway defined as dysfunctional voiding. Twenty-five (31.25%) boys had posterior urethral valves. Fifteen (18.75%) of them were younger than six months old with primary bilateral high-grade VUR and urosepsis. Mean of follow-up time was 65.34 ± 37.82 months (11.5 months-10.5 years). Cure rate was 95% in urinary tract infection, 80.7% in secondary VUR, and 40% in primary VUR. Creatinine level was significantly reduced after vesicostomy and during follow-up (P < 0.001). Complications after vesicostomy were stoma stenosis (11.25%), mucosal prolapse (7.5%), dermatitis (3.75%), and febrile urinary tract infection (5%). In primary VUR after vesicostomy, 60% of the patients did not require an intervention to correct the reflux (Table). DISCUSSION A number of 29 of 66 patients with closed vesicostomy needed another surgery: three modified Gil-Vernet antireflux surgeries, one ureteral reimplantation, two endoscopic Deflux injections, 13 valve ablations, six ileocystoplasties, and four Botox injections. The 37 (56.06%) remaining patients did not require any other surgery after closure of vesicostomy. CONCLUSION Vesicostomy should be considered in children with neuropathic bladder or bladder outlet obstruction in case first-line therapies fail. This simple and reversible procedure can reduce febrile urinary tract infections, protect the upper urinary tract, and reduce the need for a major surgery without decreasing the bladder capacity.
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Affiliation(s)
- F Sharifiaghdas
- Urology and Nephrology Research Center, Department of Urology, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Mirzaei
- Department of Urology, Kerman University of Medical Sciences, Kerman, Iran.
| | - N Nikravesh
- Urology and Nephrology Research Center, Department of Urology, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Deshpande AV. Current strategies to predict and manage sequelae of posterior urethral valves in children. Pediatr Nephrol 2018; 33:1651-1661. [PMID: 29159472 DOI: 10.1007/s00467-017-3815-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022]
Abstract
Posterior urethral valves (PUV) constitute a significant urological cause of chronic kidney disease (CKD) in children. The condition is characterised by the unique pathophysiology of the evolution of bladder dysfunction after relief of obstruction, which contributes to CKD. Improvements in prenatal diagnosis followed by selective foetal intervention have not yet produced improvement in long-term renal outcomes, although better patient selection may alter this in the future. Proactive management with surveillance, pharmacotherapy, timed voiding, double voiding, and/or assisted bladder-emptying, is being increasingly offered to those with severe bladder dysfunction and has the potential of reducing the burden of renal disease. Clinicians are currently able to counsel regarding the prognosis using serum creatinine and other emerging markers. However, much of this work remains to be validated. Satisfactory graft survival rates are now reported with aggressive management of bladder dysfunction in children who are candidates for renal transplantation. Knowledge gaps exist in identifying early markers of renal injury, risk stratification, and in understanding patient and carer perspectives in PUV.
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Affiliation(s)
- Aniruddh V Deshpande
- Department of Paediatric Urology and Surgery, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia. .,Priority Research Centre GrowupWell, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia.
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Pellegrino M, Visconti D, Catania VD, D'Oria L, Manzoni C, Grella MG, Caruso A, Masini L, Noia G. Prenatal detection of megacystis: not always an adverse prognostic factor. Experience in 25 consecutive cases in a tertiary referral center, with complete neonatal outcome and follow-up. J Pediatr Urol 2017; 13:486.e1-486.e10. [PMID: 28495235 DOI: 10.1016/j.jpurol.2017.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Megacystis is a condition of abnormal enlarged fetal bladder for gestational age, which is usually associated with urological malformations that may constitute a life-threatening condition for the baby. OBJECTIVE The purpose of this study was to assess the prognostic and etiological criteria of fetal megacystis and to describe the neonatal outcome in a large series collected in a single tertiary center. STUDY DESIGN A retrospective observational study was conducted between 2008 and 2012. We reviewed all consecutive cases of fetal megacystis diagnosed during routine ultrasound (US) screening. The following data were collected and analyzed: maternal age, gestational age at diagnosis, prenatal ultrasonographic details of the urinary system, extra-urinary ultrasonographic anomalies, fetal karyotype, pregnancy outcome, postnatal diagnosis, and medical/surgical follow-up. RESULTS Of the 25 fetuses included in this study, 76% were males. The mean gestational age (GA) at diagnosis was 23.1 ± 7.5 weeks (range 12-34), among them only four (16%) were diagnosed during the first trimester. Associated urological malformations were detected in 92% (n = 23) of the cases, while other malformations were detected in 36% (n = 9). Oligohydramnios or anyhydramnios were observed in 52% (n = 13) of the cases. Twelve (48%) fetuses were considered as having poor prognosis for renal function. Vesicocentesis with or without vesico-amniotic infusion were performed in 28% (n = 7) of the cases. Pregnancy outcome was surprisingly good, with only one case of prenatal death and survival rate of 96% (n = 24) of liveborn babies. Posterior urethral valve (PUV) (n = 9, 36%) was the most common etiology of the fetal megacystis, followed by persistent urogenital sinus (n = 2, 8%), Prune belly syndrome (n = 2, 8%) and bilateral vescico-ureteral reflux (VUR) (n = 2, 8%). Surgical or endoscopic procedures were performed in 75% (n = 18) of the cases. Six (24%) newborns presented with moderate/severe respiratory distress that requested invasive assisted ventilation. Three cases (n = 3, 12%) of perinatal death were observed due to severe impaired renal function. After a median follow-up of 29 months renal function was good in 79% (n = 19) of the cases. CONCLUSIONS Fetal megacystis may underline a wide range of associated pathologies with the highest prevalence of urinary malformation. Optimal counseling of the involved parents requires a multidisciplinary approach to allow the best management during the pregnancy and the perinatal period. Despite the high risk of renal failure, lung hypoplasia, and severe associated anomalies, the outcome of fetuses with megacystis could be improved thanks to an appropriate perinatal diagnosis and neonatal management.
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Affiliation(s)
- Marcella Pellegrino
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy.
| | - Daniela Visconti
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Vincenzo Davide Catania
- Department of Pediatric Surgery, Pediatric Urology, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Luisa D'Oria
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Carlo Manzoni
- Department of Pediatric Surgery, Pediatric Urology, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Maria Giovanna Grella
- Department of Pediatric Surgery, Pediatric Urology, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Alessandro Caruso
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Lucia Masini
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
| | - Giuseppe Noia
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Therapy Unit, Catholic University of Sacred Heart, Policlinico A. Gemelli Hospital, Rome, Italy
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