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Aydin O, Karademir S, Bülbül M. Evaluating the requirement of ultrasonography for children with their first urinary tract infection. J Pediatr Urol 2024; 20:504-512. [PMID: 37932198 DOI: 10.1016/j.jpurol.2023.10.026] [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: 06/26/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Management of urinary tract infection (UTI) in children remains important. It may be the first sign for a possible underlying congenital abnormalities for the kidney and urinary tract (CAKUT). This study examined whether performing renal and bladder ultrasonography (RBUS) only for children who have a pathogen other than E. coli during their first urinary tract infection (UTI), or who experience UTI recurrence, would result in more missed diagnoses of kidney anomalies. METHODS Patients aged between 2 months and 2 years who were seen in a tertiary pediatric hospital during a 2-year period and diagnosed with UTI were included. RBUS and voiding cystourethrography (VCUG) were performed according to American Academy of Pediatrics (AAP) guidelines. Afterwards, we looked back and evaluated how often we found kidney problems when we only did a RBUS on patients who had an atypical cause of their first UTI or who had multiple UTIs. RESULTS One hundred and seventy-eight patients who were followed up with UTI were included in this study. The isolated pathogen was E. coli in 104 cases (58.4 %) and atypical in 74 cases (41.6 %). VCUG was conducted on 40 patients, and vesicoureteral reflux (VUR) was discovered in 16 cases and ureteropelvic junction obstruction (UPJO) was discovered in 1 case. A different diagnostic approach that required the presence of an atypical pathogen at the first UTI or a fUTI recurrence to perform the RBUS would have missed just two severe kidney anomalies. It was observed that there could be a decrease of 40.4 % in RBUS and at least 20 % in VCUG. CONCLUSIONS A diagnostic approach that necessitates the presence of an abnormal pathogen during the initial UTI or a second UTI episode for the RBUS to be carried out would lead to fewer negative ultrasounds with minimal risk of overlooking kidney anomalies.
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Affiliation(s)
- Orkun Aydin
- Department of Pediatrics, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Selmin Karademir
- Department of Pediatric Cardiology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Mehmet Bülbül
- Department of Pediatric Nephrology and Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
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Hari P, Meena J, Kumar M, Sinha A, Thergaonkar RW, Iyengar A, Khandelwal P, Ekambaram S, Pais P, Sharma J, Kanitkar M, Bagga A. Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux. Pediatr Nephrol 2024; 39:1639-1668. [PMID: 37897526 DOI: 10.1007/s00467-023-06173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/27/2023] [Accepted: 09/17/2023] [Indexed: 10/30/2023]
Abstract
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.
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Affiliation(s)
- Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jitendra Meena
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Arpana Iyengar
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sudha Ekambaram
- Department of Pediatric Nephrology, Apollo Children's Hospital, Chennai, India
| | - Priya Pais
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Pakkasjärvi N, Ripatti L, Läckgren G, Krishnan N, Anand S. PIC cystography in occult vesicoureteral reflux: A systematic review highlighting its utility in children with recurrent urinary tract infections and normal VCUG. J Pediatr Urol 2023; 19:804-811. [PMID: 37633825 DOI: 10.1016/j.jpurol.2023.08.008] [Citation(s) in RCA: 1] [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: 02/20/2023] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) affects 1-2% of children, predisposing them to pyelonephritis, renal scarring, and reflux nephropathy. Treatment aims to prevent febrile urinary tract infections (f-UTI) and long-term sequelae. While guidelines differ, the current consensus proposes individual risk-stratification and subsequent management strategies. Here, we systematically analyzed the current literature on Positional Instillation of Contrast Cystography (PIC) for individualized diagnostics in patients with recurrent f-UTIs. OBJECTIVE We present a comprehensive qualitative and quantitative synthesis. Outcomes were: 1. the ability of PIC to predict VUR in patients with negative voiding cystographies (VCUG), 2. the ability of PIC to predict occult contralateral VUR, 3. the correlation of occult VUR in PIC with dimercaptosuccinic acid (DMSA) scan findings, and 4. the incidence of postoperative f-UTI in children treated for occult VUR picked up on PIC. STUDY DESIGN We conducted a systematic review following the PRISMA guidelines, applying the following inclusion criteria: Children with occult VUR in PIC with negative VCUG. RESULTS We included nine studies with 496 symptomatic patients with a mean age of 6.8 years, published between 2003 and 2021. PIC detected VUR in 73% of patients. Out of them, 81% had low-grade and 19% high-grade VUR. Occult contralateral VUR was present in 41% children. The presence of renal scars on DMSA scan was 1.39 times more likely with occult VUR on PIC. 85% of patients did not experience recurrent f-UTIs after PIC and subsequent treatment. DISCUSSION PIC can detect occult VUR in patients with recurrent f-UTIs in whom VCUG is negative. However, we recommend a cautious approach in the use of PIC in clinical practice until further prospective studies confirm the validity of our outcome measures. CONCLUSION Identification, risk stratification, and prompt action are central in managing VUR. PIC can be helpful in identifying VUR in patients with recurrent f-UTI.
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Affiliation(s)
- Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland; Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Turku 20521, Finland
| | - Göran Läckgren
- Department of Pediatric Surgery, Section of Urology, University Children's Hospital, Uppsala, Sweden
| | - Nellai Krishnan
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi 110029, India.
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Daza J, Ahmad A, Shabir U, Jing Z, Shiekh M, Kauffman E, Guru KA, Hussein AA. Does testosterone replacement therapy increase the risk of conversion to treatment in patients with prostate cancer on active surveillance? Urol Oncol 2023; 41:429.e1-429.e7. [PMID: 37423815 DOI: 10.1016/j.urolonc.2023.06.002] [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: 04/27/2023] [Revised: 05/25/2023] [Accepted: 06/13/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE We aimed to evaluate the impact of testosterone replacement therapy (TRT) in patients with localized prostate cancer (CaP) who elected active surveillance (AS). METHODS A retrospective review of our CaP database was performed. Patients who received TRT while on AS were identified and were matched to a cohort of patient on AS while not on TRT (1:3) using propensity score matching. Treatment-free survival (TFS) was computed using Kaplan Meier method. Multivariable Cox regression model was used to evaluate variables associated with treatment. RESULTS Twenty-four patients in the TRT group were matched to 72 patients without TRT. Median follow-up was 5.82 years (IQR 3.27-9.30). There was no significant difference in conversion to treatment (24% vs. 21%, P = 1.00) There was no significant difference in TFS (log rank P = 0.87). Prostate specific antigen (PSA) density was the only variable associated TFS (HR 1.08, 95%CI 1.03-1.13, P = 0.001). CONCLUSION TRT was not associated with conversion to treatment in this matched analysis among patients with localized prostate cancer on AS.
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Affiliation(s)
- Jorge Daza
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Ali Ahmad
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Usma Shabir
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Zhe Jing
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Mohsin Shiekh
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Eric Kauffman
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Khurshid A Guru
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY
| | - Ahmed A Hussein
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY.
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Lee T, Finney E, Jha A, Dorste A, Lee R. Approaches and Barriers to Biomarker Discovery. Urol Clin North Am 2023; 50:1-17. [DOI: 10.1016/j.ucl.2022.09.005] [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]
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Pennesi M, Amoroso S, Pennesi G, Giangreco M, Cattaruzzi E, Pesce M, Busetti M, Barbi E, Conversano E. Is ultrasonography mandatory in all children at their first febrile urinary tract infection? Pediatr Nephrol 2021; 36:1809-1816. [PMID: 33481100 DOI: 10.1007/s00467-020-04909-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/29/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study investigated whether performing kidney ultrasound (KUS) only in children presenting either a pathogen other than E. coli at their first febrile urinary tract infection (fUTI) or experiencing fUTI recurrence would increase missed diagnoses of kidney anomalies. METHODS Patients aged 2-36 months with fUTI who underwent KUS evaluation from 2 January 2013 to 31 June 2018 were enrolled. Cystourethrography was performed after pathological KUS or recurring fUTIs. Thereafter, we retrospectively assessed the detection rate of kidney anomalies through performing KUS only in patients with atypical pathogen at first fUTI or with recurring fUTIs. RESULTS In 263 patients included, the isolated pathogen was E. coli in 223 cases (84.8%) and atypical in 40 cases (15.2%). KUS detected kidney anomalies in 14/223 (6.3%) of fUTIs caused by E. coli and in 11/40 (27.5%) of fUTIs caused by an atypical pathogen (OR 5.5, 95%CI 2.5-14.5). Cystourethrography was performed in 40 patients and vesicoureteral reflux (VUR) found in 20 cases. None of the high grade VUR diagnoses or other kidney anomalies would have been lost through a different diagnostic protocol that required the presence of an atypical pathogen at the first fUTI or a fUTI recurrence to perform the KUS. CONCLUSIONS A diagnostic protocol that requires presence of an atypical pathogen at the first fUTI or a second episode of fUTI to perform the KUS would allow a reduction in the number of negative ultrasounds with a negligible risk of missed diagnoses of kidney anomalies.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Stefano Amoroso
- University of Trieste, Piazzale Europa 1, 34127, Trieste, Italy.
| | | | - Manuela Giangreco
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Marco Pesce
- University of Trieste, Piazzale Europa 1, 34127, Trieste, Italy
| | - Marina Busetti
- Microbiology Unit, University Hospital ASUITS, Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy.,University of Trieste, Piazzale Europa 1, 34127, Trieste, Italy
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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.
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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.)
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Burki T, Howeiti MS, Almadhi MK, Al Modhen FM, Alhazmi H, Vallasciani SA, Alhams AE, Mehmood SW, Al Shammari AM. Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation. Urol Ann 2019; 12:49-53. [PMID: 32015617 PMCID: PMC6978971 DOI: 10.4103/ua.ua_58_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/13/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR). Materials and Methods We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test. Results Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5-2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively. Conclusion SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.
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Affiliation(s)
- Tariq Burki
- Pediatric Urology Division, King Abdullah Specialized Children Hospital, King Abdul Aziz Medical City, National Guard Health Affair, Riyadh, KSA
| | - Muhammad S Howeiti
- Pediatric Urology Division, King Abdullah Specialized Children Hospital, King Abdul Aziz Medical City, National Guard Health Affair, Riyadh, KSA
| | - Maha K Almadhi
- Division of Pediatric Urology, Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
| | - Fayez M Al Modhen
- Pediatric Urology Division, King Abdullah Specialized Children Hospital, King Abdul Aziz Medical City, National Guard Health Affair, Riyadh, KSA
| | - Hamdan Alhazmi
- Division of Urology, Department of Surgery, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, KSA
| | - Santiago A Vallasciani
- Division of Pediatric Urology, Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA.,Alfaisal University, School of Medicine, Riyadh, KSA
| | - Abdulwahab E Alhams
- Pediatric Urology Division, King Abdullah Specialized Children Hospital, King Abdul Aziz Medical City, National Guard Health Affair, Riyadh, KSA
| | - Shahbaz W Mehmood
- Department of Urology, King Faisal Specialist Hospital and Research Center Riyadh, KSA
| | - Ahmed M Al Shammari
- Pediatric Urology Division, King Abdullah Specialized Children Hospital, King Abdul Aziz Medical City, National Guard Health Affair, Riyadh, KSA
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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.
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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
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Affiliation(s)
- Yong Seung Lee
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Won Han
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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