Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is common in children. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment is a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term (several months to 2 years) antibiotics aimed at preventing recurrence. This is the third update of a review first published in 2001 and updated in 2006, and 2011.

OBJECTIVES

To assess whether long-term antibiotic prophylaxis was more effective than placebo/no treatment in preventing recurrence of UTI in children, and if so which antibiotic in clinical use was the most effective. We also assessed the harms of long-term antibiotic treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 30 July 2018 through contact with the Cochrane Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI in children.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information for the initial and previous updates. A random-effects model was used to estimate risk ratio (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

In this update sixteen studies (2036 children randomised, 1977 analysed) were included. Seven studies (612 children) compared two or more types of antibiotics, six (1088 children) compared antibiotics with placebo or no treatment, one four-armed study compared circumcision with and without antibiotic treatment, one study compared dose of antibiotic, and one three-armed study compared two different antibiotics as well as no treatment. Of the sixteen included studies only one study was judged to be at low risk of bias for all domains, with the majority judged to be at unclear risk of bias due to very poorly reported methodology. The number of studies judged to be a low risk of bias was: selection bias (7); performance bias (4); detection bias (1); attrition bias (6); reporting bias (7); and other bias (2). The number of studies judged to be at high risk of bias was: selection bias (0); performance bias (5); detection bias (1); attrition bias (4); reporting bias (6); and other bias (1).Compared to placebo/no treatment, antibiotics lead to a modest decrease in the number of repeat symptomatic UTI in children; however the estimate from combining all studies was not certain and the confidence interval indicates low precision indicating that antibiotics may make little or no difference to risk of repeat infection (RR 0.75, 95% CI 0.28 to 1.98). When we combined only the data from studies with concealed treatment allocation, there was a similar reduction in risk of repeat symptomatic UTI in children taking antibiotics (RR 0.68) and we have greater certainty in this estimate because of the more robust study designs, the confidence interval is smaller and it does not include the point of no effect (95% CI 0.48 to 0.95). The estimated reduction in risk of repeat symptomatic UTI for children taking antibiotics was similar in children with vesicoureteric reflux (VUR) (RR 0.65, 95% CI 0.39 to 1.07) compared to those without VUR (RR 0.56, 95% CI 0.15 to 2.12) however there was considerable uncertainty due to imprecision from fewer events in the smaller group of children with VUR. There was no consistency in occurrence of adverse events, with one study having more events in the placebo group and a second study having more events in the antibiotics group. Three studies reported data for antibiotic resistance with the analysis estimating the risk of a UTI caused by a bacteria resistant to the prophylactic antibiotic being almost 2.5 times greater in children on antibiotics than for children on placebo or no treatment (RR 2.40, 95% CI 0.62 to 9.26). However the confidence interval is wide, showing imprecision and there may be little or no difference between the two groups.Eight studies involving 659 children compared one antibiotic with another but few studies compared the same combination for the same outcome so little data could be pooled. Two studies reported microbial resistance data and analysis showed that treatment with nitrofurantoin may lead to a lower risk of a UTI caused by a bacteria resistant to the treatment drug compared to children given trimethoprim-sulphamethoxazole as their prophylactic treatment (RR 0.54, 95% CI 0.31 to 0.92).

AUTHORS' CONCLUSIONS

Long-term antibiotics may reduce the risk of repeat symptomatic UTI in children who have had one or more previous UTIs but the benefit may be small and must be considered together with the increased risk of microbial resistance.

Ureterocele fenestration with holmium laser in neonates

AIM

To evaluate the effectiveness of holmium-laser fenestration of intravesical ureteroceles in neonatal period.

MATERIAL AND METHOD

We retrospectively analyzed the results of the holmium-laser puncture in ten neonates with intravesical ureterocele, between September 2013 and September 2016. Laser probe was placed through the cystoscope to the lowest and medial portion of the ureterocele, near the bladder floor. Few punctures (4 to 8) were made, until ureterocele has been collapsed.

RESULTS

Mean duration of general anesthesia was 16 minutes (range, 10-24) and duration of hospitalization was 1-3 days (mean, 1.3 days). There weren't complications regarding endoscopic treatment. There was the need for retreatment in one (10%) patient. Obstruction was found in one (10%) patient on ultrasound after one month. After three months there was no obstruction on ultrasound in any patient. In patients in whom VCUG was performed, vesicoureteral reflux was not found three months after the surgery.

DISCUSSION

The relief of the obstruction, prevention of the vesicoureteral reflux and the urinary tract infection are the reasons for the immediate treatment in the neonatal period. In that way, the preservation of renal function is enabled. The reason for laser fenestration was better endoscopic control of the extensibility of the ablation. The moment of ureterocele collapsing can be visualized directly.

CONCLUSIONS

Holmium-laser fenestration is a minimally invasive, highly effective and safe kind of treatment for ureterocele in neonatal period with minimal complication rate. Further clinical studies with a greater number of patients will offer more reliable information regarding this procedure.

KEY WORDS

Fenestration, Holmium-laser, Neonates, Ureterocele.

[Antirreflux ureteral catheters.]

Double-J ureteral stents disposal is associated with the appearance of side effects in up to 90% of the patients. The main causes of these symptoms are related to stent's design and the materials they are manufactured from. Vesicoureteral reflux and bladder trigone irritation are the etiopathogenic causes of ureteral stents associated morbidity. Due to this, and in order to improve patients' quality of life, stents that avoid reflux have been developed. Among anti-reflux designs, the first was a double-J stent the bladder tip of which is provided with a polymeric membrane that prevents retrograde flow of urine through its internal drainage channel. This design showed satisfactory vesicaresults, although not statistically significant. Their use in renal transplantation has also been assessed not only to decrease morbidity and ascending infection but also to improve graft survival. Other designs try to thin the distal end and even change it to a surgical suture thread, with the aim of eliminating the internal drainage channel in order to cause the minimum interference with the UVJ. Recently, two prototypes were evaluated in animal models and have achieved reduction of VUR. The first consists of a valve attached to the distal end of a traditional double-J stent, acting as a backflow prevention device. The second design is an intra-ureteral stent that acts like a double-J stent, but without crossing the UVJ and therefore preventing reflux completely. Nowadays, the use of these devices is not implemented in hospitals due to the absence of scientific evidence supporting the superiority of these designs over conventional stents.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

[Long-term results of organo-safe operation in obstructive ureterohydronephrosis of terminal stage]

A comparative analysis of efficacy of two methods was the purpose of the research. Politano-Leadbetter technique was applied in 41 cases and nipple way was used in 13 cases. The investigation included 45 patients aged from 2 months till 17 years with congenital obstructive ureterohydronephrosis of terminal stage (the pathology was diagnosed from both sides in 15 children). A follow-up period was from 1 till 6 years. Recurrent intervention was required in 31 cases. An analysis of overall results allowed determining the outcome as positive in 26 cases after Politano-Leadbetter operation. There were a vesicoureteral reflux in 6 cases and signs of obstruction appeared in 9 cases. The application of nipple operation had positive results in 9 cases, at the same time, the complication such as vesicoureteral reflux was noted in 2 cases, the signs of obstruction were in 2 cases. The authors prefer using the nipple method of reimplantation in spite of identical results of two different methods.

Augmentation cystoplasty and simultaneous ureteral reimplantation reduce high-grade vesicoureteral reflux in children with neurogenic bladder

BACKGROUND

To compare the incidence of residual high-grade vesicoureteral reflux (HVUR) (≥Grade III) in neurogenic bladder patients receiving augmentation cystoplasty alone or with simultaneous ureteral reimplantation. Furthermore, we also tried to find the risk factors of residual VUR and febrile urinary tract infection.

METHODS

Between 1999 and 2009, urinary bladder augmentation was performed in 21 children with neurogenic bladder. Seventeen of these patients had VUR on preoperative voiding cystourethrography, of whom 11 patients (14 ureters) received augmentation alone (Group A) and 6 patients (8 ureters) received simultaneously ureteral reimplantation (Group B). Univariate logistic regression analysis and Fisher exact test were used for statistical analysis.

RESULTS

Six patients (8 ureters) had residual HVURs in Group A, but none in Group B. The incidences of residual HVUR were 57.14% and 0%, respectively. Seven patients had febrile UTIs after operation, 6 of them had residual HVURs. In risk factor analysis, postoperative follow-up duration less than 12 months and lack of anti-reflux operation were significant risk factors for residual HVUR; the residual HVUR was the significant risk factor for febrile urinary tract infection.

CONCLUSION

Simultaneous ureteral reimplantation reduces postop HVUR significantly. We recommend augmentation and simultaneous ureteral reimplantation in children with HVUR and neurogenic bladder if technically feasible.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is common in children. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment is a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence.

OBJECTIVES

To determine the efficacy and harms of long-term antibiotics to prevent recurrent UTI in children.

SEARCH STRATEGY

In November 2010 we searched without language restriction MEDLINE, EMBASE, CENTRAL (in the Cochrane Library), the Cochrane Renal Group's Specialised Register, reference lists of review articles and contacted content experts.

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information. A random-effects model was used to estimate risk ratio (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

Twelve studies (1557 children) were identified with six (five analysed, 1069 children) comparing antibiotics with placebo/no treatment. Duration of antibiotic prophylaxis varied from 10 weeks to 12 months. Compared to placebo/no treatment, when all studies were included, antibiotics did not appear to reduce the risk of symptomatic UTI (RR 0.75, 95% CI 0.36 to 1.53) however when we evaluated the effects of antibiotics in studies with low risk of bias, there was a statistically significant reduction (RR 0.68, 95% CI 0.48 to 0.95). The effect was similar in children with vesicoureteric reflux (VUR) (RR 0.65, 95% CI 0.39 to 1.07) compared to those without VUR (RR 0.56, 95% CI 0.15 to 2.12). There was no consistency in occurrence of adverse events. Three studies reported antibiotic resistance, showing a non-significant increased risk for resistance to the antibiotic in the active treatment groups (RR 2.4, 95% CI 0.62 to 9.26).Five studies (4 analysed, 367 children) compared one antibiotic with another but all compared different combinations or different outcomes and studies were not pooled. Two studies reported microbial resistance, nitrofurantoin having a significantly lower risk of resistance than cotrimoxazole (RR 0.54, 95% CI 0.31 to 0.92).One study compared alternate with every day cefadroxil treatment.

AUTHORS' CONCLUSIONS

Long-term antibiotics appear to reduce the risk of repeat symptomatic UTI in susceptible children but the benefit is small and must be considered together with the increased risk of microbial resistance.

[Does diagnostic and therapeutic management of urinary tract infections remain still controversial in children?]

The paper presents controversial issues in diagnosis and management of urinary tract infections (UTIs) in children, with respect to diagnosis and so called chronic antibiotic prophylaxis in children with UTI and coexisting vesicoureteral reflux. It should be remembered, that there is a risk of development of chronic kidney disease in adulthood in those who suffered UTIs in childhood.

Change of ureteral submucosal anti-reflux implantation into an intussuscepted ileal nipple valve as reflux protection in ureterosigmoidostomy

OBJECTIVES

After submucosal implantation of the ureters in ureterosigmoidostomy failed for different reasons, urologists are confronted with the task of creating a new form of urinary diversion. Therefore, the implantation site of the ureters must be removed because of the risk of secondary malignancy with the consequences of a large colonic defect.

TECHNICAL CONSIDERATIONS

Here we describe a technique for reimplantation of both ureters with an intussuscepted ileal nipple in ureterosigmoidostomy with three advantages for the patient in situations in which classical submucosal implantation failed after several years. We were able to avoid conversion into another form of incontinent or continent urinary diversion. To prevent the development of colonic tumors at the implantation site where urothelial meets colonic epithelium, we interposed an ileal segment which avoids this epithelial contact. We were also able to cover a large colonic defect which was mandatory to receive a negative surgical margin when the tumor was resected.

CONCLUSIONS

This technique of using an ileal nipple as reflux protection in ureterosigmoidostomy allows the patient to keep the form of urinary diversion he is used to live with, for many decades.

The development of the bladder trigone, the center of the anti-reflux mechanism

The urinary tract is an outflow system that conducts urine from the kidneys to the bladder via the ureters that propel urine to the bladder via peristalsis. Once in the bladder, the ureteral valve, a mechanism that is not well understood, prevents backflow of urine to the kidney that can cause severe damage and induce end-stage renal disease. The upper and lower urinary tract compartments form independently, connecting at mid-gestation when the ureters move from their primary insertion site in the Wolffian ducts to the trigone, a muscular structure comprising the bladder floor just above the urethra. Precise connections between the ureters and the trigone are crucial for proper function of the ureteral valve mechanism; however, the developmental events underlying these connections and trigone formation are not well understood. According to established models, the trigone develops independently of the bladder, from the ureters, Wolffian ducts or a combination of both; however, these models have not been tested experimentally. Using the Cre-lox recombination system in lineage studies in mice, we find, unexpectedly, that the trigone is formed mostly from bladder smooth muscle with a more minor contribution from the ureter, and that trigone formation depends at least in part on intercalation of ureteral and bladder muscle. These studies suggest that urinary tract development occurs differently than previously thought, providing new insights into the mechanisms underlying normal and abnormal development.

[A comparative analysis of antireflux and direct methods of ureteral implantation in intestinal continent urinary derivation]

Intestinal continent urinary derivation was made from 1997 to 2006 in three groups of patients. The following kinds of derivation were performed: ureterosygmostomy according to Maintz-Pouch and Abol-Enein modification (group 1, n=32); heterotopic replacement of the urinary bladder in various modifications (group 2, 50 patients); orthotopic replacement according to Hautmann, Studer, Abol-Enein, sygmocystoplasty, n=51). In group 1 ureterosygmoanastomosis was created only by antireflux methods: Goodwin and Hohenfellner submucous technique and Abol-Enein extramural implantation. In groups 2 and 3 uretero-intestinal anastomosis was created by Wallace direct implantation and antireflux--Abol-Enein extramural implantation. The patients were followed up from 6 months to 9 years. The results show that both methods are effective. The antireflux methods are preferable in detubulizing ureterosygmostomy, in extended atonic ureters in case of creation of continent heterotopic and orthotopic reservoirs. The problem of antireflux mechanisms in creation of neobladder needs further investigation.

Technique of kidney transplantation in mice with anti-reflux urinary reconstruction

Experimental models of organ transplantation play a crucial role in establishing the principles of transplantation immunobiology. Murine transplant models of vascularized organs are particularly useful for immunobiological studies because there are more immunological tools available. However, the technique of kidney transplant in mice is very challenging. A difficult aspect of this model is urinary reconstruction, which is frequently associated to complications. In this article, the technique of mouse kidney transplantation using an anti-reflux system (modified extravesical ureteroneocystostomy) is described and illustrated for the first time. Although technically demanding, this procedure is feasible and may reduce the incidence of urine leakage and reflux.

Evolution of Endoscopic Management of Ectopic Ureterocele: A New Approach

PURPOSE

We report the evolution of endoscopic treatment of ectopic ureteroceles from the unroofing technique to a novel approach using concomitant ureterocele double puncture and intraureterocele fulguration. We also compare the results of different endoscopic modalities at a single center.

MATERIALS AND METHODS

We reviewed the records of 46 children with ectopic ureteroceles who were treated endoscopically between 1995 and 2005. The patients were divided into 2 main groups. Group 1 included 17 patients who underwent common endoscopic treatments, including ureterocele incision (4 patients), single ureterocele puncture (4), and single puncture with insertion of a Double-J stent (9). Group 2 included 29 children who underwent ureterocele double puncture and fulguration of the anterior and posterior walls of the collapsed ureterocele after insertion of a Double-J stent into both punctured sites. We also managed concomitant vesicoureteral reflux by endoscopic injection of tricalcium phosphate ceramic into the subureteral region.

RESULTS

Total success rates in group 1 were 0%, 25% and 33% in patients who underwent ureterocele incision, single ureterocele puncture and single puncture with insertion of a stent, respectively. Total success rate in group 2 was 90% (p<0.05). New onset vesicoureteral reflux developed in 8 patients (47%) in group 1, of which 6 were in ureterocele moieties, and in 8 patients (28%) in group 2, with none in a ureterocele moiety (p<0.01). A total of 13 patients (76%) in group 1 required open surgical intervention, compared to 3 (10%) in group 2 (p<0.05).

CONCLUSIONS

This new endoscopic approach is highly effective in the treatment of children with ectopic ureteroceles.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Acute urinary tract infection (UTI) is common in children. By the age of seven 8.4% of girls and 1.7% of boys will have suffered at least one episode. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment consists of a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence.

OBJECTIVES

To determine the efficacy and harms of long-term antibiotics to prevent recurrent UTI in children.

SEARCH STRATEGY

We searched without language restriction MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, the Cochrane Renal Group's Specialised Register, reference lists of review articles and contacted content experts. Date of most recent search: January 2006

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information. A random-effects model was used to estimate relative risk (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

Eight studies (618 children) were identified, five (406) comparing antibiotics with placebo/no treatment. The duration of antibiotic prophylaxis treatment varied from 10 weeks to 12 months. Compared to placebo/no treatment, antibiotics reduced the risk of repeat positive urine culture (RR 0.44, 95% CI 0.19 to 1.00; RD -30%, 95% CI -56% to -4%) No side effects were reported. One study reported that nitrofurantoin was more effective than trimethoprim in preventing recurrent UTI over a six month period (RR 0.48, 95% CI 0.25 to 0.92; RD -18%, 95% CI -34% to -3%). However, patients receiving nitrofurantoin were more likely to discontinue the antibiotic due to side effects (mainly gastrointestinal) (RR 3.17, 95% CI 1.36 to 7.37; RD 22%, 95% CI 8% to 36%). The other study found cefixime was more effective in preventing recurrent UTI than nitrofurantoin (RR 0.74, 95% CI 0.13 to 4.10; RD -3%, 95% CI -17% to -12%). However, 62% of patients receiving cefixime experienced an adverse reaction during the first six months of treatment (18/29) while only 26% (8/31) of patients receiving nitrofurantoin reported an adverse reaction.

AUTHORS' CONCLUSIONS

Large, properly randomised, double blinded studies are needed to determine the efficacy of long-term antibiotics for the prevention of UTI in susceptible children.

[Vesicoureteral reflux in renal transplantation]

Frequency of vesicoureteral reflux (VUR) variants was studied with miction cystography in 40 patients with chronic renal insufficiency. In 8 (20%) patients VUR was in their kidneys. The kidney was transplanted in 30 patients. The rate of urological complications was compared in ureterocystostomy by our technique and other procedures. In patients operated by our technique VUR did not occur. In 3 of 10 patients operated by other methods VUR into the transplant was found. Own kidney on the side of the reflux was removed in 4 patients after kidney transplantation. Indication for removal of own kidneys after allotransplantation of the kidney is urinary infection, arterial hypertension, pain in the lumbar spine. The proposed technique of ureterocystostomy has advantages in prevention of VUR into the renal transplant.

New Serosal Lined Antireflux Ureteroileal Implantation Technique on a Gia Stapler Detubularised Ileal Neobladder: Technical Considerations and Results

OBJECTIVES

To evaluate the adaptability and the possible advantages of the antireflux mechanism of the serous lined extramural tunnel for ureter re-implantation on a gastrointestinal anastomosis (GIA) Stapler detubularised ileal neobladder

METHODS

From April 1998 to July 2002 43 male patients underwent radical cystectomy and the creation of a Camey II ileal neobladder using this antireflux technique. Follow-up in all cases included excretory urography or T.C. scan and a retrograde cystography at 6 months and a renal scintigraphy with DMSA at 1 year follow-up, besides serum creatinine, blood urea and serum electrolytes every three months and renal-neovesical ultrasound every six months.

RESULTS

Early and late complications were low. At follow-up 1 case of neovesico-ureteral reflux and 2 cases of ureteroileal anastomotic strictures were found. DMSA scintigraphy showed no further renal scars.

CONCLUSIONS

This preliminary experience was favourable due to overall reduced operating time (about 1 hour 45 minutes to create the orthotopic neobladder and the ureteroileal anastomosis), simplicity of execution and a low complication rate (6.9%) at a median follow-up of 38 months (range 12-52 months).

Double J Stent With Antireflux Device in the Prevention of Short-Term Urological Complications After Cadaveric Kidney Transplantation: Single-Center Prospective Randomized Study

The placement of a double J stent to protect a uretero-vesical anastomosis in a kidney transplant is a widespread procedure performed to reduce the incidence of fistula and stenosis at the anastomosis. However, the presence of a double J stent may cause vesicoureteral reflux (VUR), predisposing one to urinary tract infections (UTIs), which may be a significant source of morbidity for the graft. We evaluated whether a ureteral stent incorporating an antireflux device can reduce the incidence of ureteral reflux and UTIs. From January to December 2003, 44 kidney transplant recipients were randomized to receive a 14-cm 4.8-F double J stent with (group A) or without an anti-reflux device (group B). Primary end points were the reduction of the incidence of VUR and of UTIs. The secondary end point was the graft function, on the basis of mean serum creatinine level at 3, 6, and 12 months. We failed to observe statistically significant differences in terms of either the incidence of VUR and UTIs, or the short-term outcomes of the grafts. We concluded that the anti-reflux device does not have an impact on the incidence of stent-related side effects.

Vesicoureteral reflux – current treatment options

Vesicoureteral reflux has long been recognised as a major child and public health problem. Widespread recognition and screening of at-risk populations has the potential to significantly reduce long-term morbidity in both children and adults. Advances in pharmacotherapy, materials science and surgery, have caused many experts to reassess established dictums of treatment. Concern regarding the overuse of antibiotics and surgery has led to efforts to tailor therapy more narrowly for those who are at the highest risk from recurrent urinary tract infection and pyelonephritis. Children after a certain age, without underlying voiding dysfunction, might not require treatment at all. Newer surgical and anaesthetic techniques have the potential of transforming surgical correction from a painful experience to an ambulatory procedure, with a rapid return to daily activities. Both the promise and pitfalls of these newest advances will be discussed in this review.

Antireflux Uretero-Intestinal Anastomosis—Flap-and-Trough Technique—Applicable to Ileum: Early Clinical Experience

OBJECTIVE

To report our functional results of the "flap-and-trough" (FT) antireflux uretero-intestinal anastomosis (UIA) applied to various forms of urinary diversions.

PATIENTS AND METHODS

From April 1998 through March 2003, a total of 49 ureters were implanted in 28 patients into various types of urinary diversions. Forty-six ureters were implanted transluminally (32 separately, 14 conjointly by the double-barrelled method), 3 ureters extraluminally into preformed reservoirs during kidney transplantation. Forty-one ureters were implanted primarily, 8 ureters secondarily due to stricture of former UIA.

RESULTS

Median observation time was 26 months. The healing was uneventful in all cases. Late complications were not related to the UIA. Twenty-four patients could be evaluated. The upper urinary tract remained stable, no reflux and no stenosis at the site of UIA were detected. FT anastomoses were clearly seen and easily accessible at endoscopy.

CONCLUSION

In our hands the FT anastomosis has proved to be simple, safe and highly effective in terms of protecting the upper urinary tract against obstruction and reflux. Creation of antireflux UIA need not mean increased risk of obstruction in comparison with direct (reflux) ones. The FT technique could represent another alternative of nonrefluxing implantation of normal as well as dilated ureters into various types of urinary diversion.

Modern Management of Nonneurologic Pediatric Incontinence

Incontinence affects 20%-30% of children. Historically, evaluation of voiding problems in children has involved complete urodynamic studies and treatment based primarily on bladder findings and anticholinergic medications. Unfortunately, success with this approach has been poor. This article describes new advances in our understanding of the causes of nonneurologic pediatric incontinence and its associated problems and provides new treatment strategies to manage these patients. A strategy incorporating an escalating approach to evaluation and treatment is the cornerstone of this approach. Minimizing the routine use of invasive studies and medication is the result.

Prevention of vesicoureteral reflux at the time of complete primary repair of the exstrophy-epispadias complex

INTRODUCTION

With Mitchell's technique it is possible to perform bladder closure, reconstruction of epispadias and the bladder neck in one single procedure in an exstrophy patient. However the most common postoperative complication is pyelonephritis secondary to vesicouretral reflux. Reflux is closely linked to bladder exstrophy due to an abnormal anatomic development of the distal ureteral segment and to a pathologic bladder disposition. This problem is normally solved in subsequent surgical procedures.

TECHNICAL CONSIDERATIONS

We decided to apply the technique described by Gil-Vernet as a first step of a bladder exstrophy repair following the Mitchell's technique. This ureteral advancement by means of trigonoplasty is a simple surgical procedure for vesicouretral reflux that preserves the intrinsic and extrinsic periureteral musculature. It is quite a short procedure that has yielded rates of success over 90%.

CONCLUSIONS

The realization of this antireflux technique together with the primary closure could avoid later surgical correction in patients whose have had multiple operations.

Impact of early screening for reflux in siblings on the detection of renal damage

OBJECTIVE

To assess the impact of screening siblings after detecting significant vesico-ureteric reflux (VUR) and renal scarring, as such screening might identify patients with VUR before urinary tract infections develop, but might also detect clinically insignificant VUR.

PATIENTS AND METHODS

We used a previously reported screening protocol to assess the clinical characteristics of patients, including the incidence of renal scarring, and their siblings, and compared the results. In all, 123 children were screened and 44 (36%) had VUR on voiding cystography. The median (range) age at screening was 9 (1-90) months.

RESULTS

The grades of VUR detected were < III in 61% and > or = III in 39%; VUR was bilateral in 48%. In all, 37 siblings with VUR were assessed by ultrasonography; 70% were normal, including 12 (32%) children with VUR of grade > or = III. When used, renal scintigraphy was normal in 74% of siblings, vs 18% of index patients. However, when screened after 2 years old, siblings had twice the risk of already having renal damage on renal scintigraphy (P = 0.04).

CONCLUSION

Early screening (< or = 2 years) appears to be more protective for avoiding renal damage than screening older patients. Thus we propose early screening in asymptomatic siblings to detect VUR before it becomes clinically significant.

Long-term results of a prospective randomized study comparing two different antireflux techniques in orthotopic bladder substitution

PURPOSE

We compared the long-term functional results following two different reflux prevention techniques in orthotopic ileal bladder substitution in a prospective controlled randomized study.

METHODS

The study included 60 patients for whom orthotopic bladder replacement was indicated. The treated patients were prospectively randomized into two groups: group I (30 patients) underwent ileal W neobladder with serous lined extramural tunnel and group II (30 patients) received hemi-Kock pouch with intussuscepted nipple valve. Laboratory evaluation included estimation of serum creatinine while radiological studies included IVU and voiding studies. Urodynamic evaluation was an integral part of our investigation.

RESULTS

Patients and tumor characteristics were comparable between both groups. No operative or postoperative mortality were observed in either. Early complications were encountered in 5 (16.7%) and 4 (13.3%) patients in the two treated groups respectively (p=0.72) and most were treated conservatively. Twenty patients in group I and 19 in group II were evaluable. The mean follow up was 73.9+/-6.6 and 72.9+/-5.6 months in the treated groups respectively. Day and night time continence was comparable between both groups. Ascending studies demonstrated reflux in 3 (7.7%) of the reimplanted units in group I versus 2 (5.3%) in group II (p=0.81); IVU showed uretero-ileal anastomotic strictures in 2 renal units with both the serous lined extramural tunnel (5.1%) and the ileal nipple valve (5.3%) techniques (p=0.98). One patient in group I had pouch stone compared with 5 in group II (p=0.08). Urodynamic characteristics were also comparable in both groups.

CONCLUSION

The study provided evidence that the long-term functional results following serous lined extramural tunnel are as equal as the nipple valve. Furthermore, it spares the use of extra-bowel length, does not need staples and allows retrograde endoscopic procedures.

[Surgical treatment of the extrophy-epispadias complex. Review and current concepts]

Since earlier descriptions the surgical management of the bladder exstrophy and epispadias complex (BEEC) has experimented gradual changes in the search for good aesthetic and functional results. The initial urinary diversion and bladder plate removal has evolved under various authors either by improving or supplementing the above described advances, until reaching the staged functional closure and more recently the complete primary BEEC closure. These later techniques allow to obtain encouraging continence indexes and successful aesthetic results; the low incidence and complexity of this condition however, advises both in terms of early management and later complications that this should be managed in reference centres. Sharing on this spirit of technique combination in search for a satisfactory result for exstrophic newborns and inspired by Leadbetter's contribution to Young-Dees's procedure for vesicoureteral reflux (VUR) correction, we have added a new step to the complete primary BEEC closure known as the Mitchell's technique by performing Gil-Vernet's trigonoplasty to prevent VUR, closely associated to bladder exstrophy. We believe VUR can be prevented right from the first surgical approach in the exstrophic newborn.

Morphogenesis of the ureterovesical junction:a histologic and microanatomic study in the rat

OBJECTIVES

To investigate the development of the ureterovesical junction in rats.

METHODS

A total of 110 albino rats (50 prenatal and 60 newborn) with a gestation of 21 days were studied at the age of 17 days after conception until 5 days after birth. The lower urinary tract was microdissected. Microphotography (110 animals), histologic examination (44 animals), and scanning electron microscopy (66 animals) of the ureterovesical junction were performed. Urea and creatinine from the amniotic fluid of 20 fetuses and from the urine of 10 neonates were measured.

RESULTS

At day 17 after conception, separate penetration of the mesonephric duct and ureter into the wall of the urogenital sinus was observed. Continuity between the lumen of the ureter and the urogenital sinus was established on day 19 after conception. The straight passage of the intramural ureter into the urogenital sinus at day 17 after conception changed to the definitive L-shape with a vertical entry into the bladder on day 5 after birth. In the distal ureter, the change of the mesenchymal tissue into immature smooth muscle was first observed at birth, and the muscle became mature on the fifth postnatal day. At birth, Waldeyer's sheath was recognized. The creatinine and urea levels were stable prenatally (average 22.4 micromol/L and 6.88 mmol/L, respectively) and rose significantly postnatally (average 133 micromol/L and 32.65 mmol/L, respectively).

CONCLUSIONS

The attachment of the ureter to the urogenital sinus and later to the bladder, the modification of its passage, and its mobility within Waldeyer's sheath may be essential in preventing vesicoureteral reflux. The production of urine and its flow does not seem to be the trigger of ureteral smooth muscle formation.

Prophylactic antibiotics in children at risk for urinary tract infection

The outcome of using prophylactic antibiotics in children considered at risk for a urinary tract infection (UTI) was documented in 66 children during the period of suppressive antibiotics and for a follow-up period of 3.7+/-2.2 years (range 0.92-9.83 years). A breakthrough UTI occurred in 13 girls but none of the boys during the initial course of prophylactic antibiotics. During the follow-up period, 33 girls and 5 boys had no recurrence of infection, while 25 girls and 3 boys had UTIs. Statistical analysis of the data using chi-square and risk estimate relating factors for infection to the occurrence of a UTI showed that during the period of initial prophylactic antibiotic there was significant risk of infection among children with voiding dysfunction and abnormal kidneys and during the follow-up there was increased risk of infection among those with voiding dysfunction and vesicoureteric reflux (VUR) of grade 3 or greater severity. Lesser grades of VUR and constipation did not significantly increase the risk of UTI. These observations should be useful in developing a study to define the risks and benefits of prophylactic antibiotic in "at-risk" children.

De-serosalized muscle layer covering method for antireflux ureteroileostomy: a new operative technique and pressure study with ureterometry at the ureteroileal anastomotic site in dogs

PURPOSE

In pursuit of a more effective antireflux ureteroileostomy with a lower postoperative complication rate we performed a new operative technique and evaluated intraureteral pressure with ureterometry to examine the mechanism of antireflux function.

MATERIALS AND METHODS

A total of 11 beagle dogs were used in this study. A 3 x 2 cm. section of the ileal serosa was removed, the severed ureter was directly anastomosed to the de-serosalized area and 1 cm. of terminal ureter and the direct anastomotic site were covered with the de-serosalized ileal wall. The bladder was augmented with the ileum containing the ureter. Postoperative evaluations were performed monthly and ureterometry of the reimplanted ureter was done 6 months postoperatively.

RESULTS

Complete reflux prevention and a low stricture rate were achieved with this procedure. Direct ureteroileal anastomosis caused stricture in 1 of the 11 ureters but the covering procedure to prevent ureteral reflux caused no ureteral strictures. When the bladder was empty, ureteral closure pressure at the intramural portion of the ureter was low. At the phase of high intravesical pressure ureteral closure pressure at the intramural ureter was as high as intravesical pressure.

CONCLUSIONS

The de-serosalized muscle layer covering method prevented ureteral reflux completely with a low stricture rate. The antireflux function of this method seems to depend on the flexibility of the terminal ureter covered with the de-serosalized ileal wall. Reflux prevention in the low intravesical pressure phase seems to be due to extension of the ileal wall.

The use of the small caliber JJ stent with anti-reflux valve in double kidney transplant. Personal experience

BACKGROUND

In the experience of other authors, double kidney transplant have a higher complication rate (30%) if compared with single renal graft. In personal experience the use of small calibre ureteral stents with antireflux valve can reduce this complication rate.

METHODS

From November 1999 to April 2001, at the A.S.O. S. Giovanni Battista in Turin, we performed 29 double kidney transplantations with the application of small calibre stents in 20 male and 9 female patients, aged 50-74 years. The uretero-neocystostomies were carried out according to Lich-Gregoire technique, and the JJ stents used were pediatric ones, 12 cm long and 4.8 Ch, with antireflux valve.

RESULTS

We complained only 2 urological complications out of 58 anastomoses (distal unilateral ureteral necrosis in 1 case and total ureteral necrosis in the other).

CONCLUSIONS

Complication rate is lower than in the literature: the authors suggest that the use of small calibre JJ stents can keep the complication rate low in double kidney transplant.

Laser incision of ureterocele in the pediatric patient

PURPOSE

We evaluated the effectiveness of initial laser transurethral incision of ureterocele for relieving obstruction, prevention of infection and need for subsequent surgery.

MATERIALS AND METHODS

We reviewed the medical records and imaging studies of 30 children with ureterocele treated between 1995 and 2000. Of 30 children 14 underwent initial transurethral laser incision of the ureterocele. Records and images were evaluated for mode of presentation, ureterocele location, thickness, and decompression, and relief of obstruction. The incidence of urinary tract infection, new onset vesicoureteral reflux, upper segment renal function and need for subsequent surgery after incision was investigated.

RESULTS

There were 5 boys and 9 girls in our series. Mean patient age at presentation was 17.5 months. There were 12 patients who had ectopic and 2 orthotopic ureteroceles. Ureterocele was defined as thick if ultrasound measurement was 4 mm. or greater. Thick ureterocele was present in 4 (28%) patients. All patients had ultrasound evidence of decompression of the ureterocele and upper tract with 1 treatment. Urinary infection risk was 0.015 per month of followup after incision. Vesicoureteral reflux was present in 8 of 12 (67%) ectopic systems before incision and 9 of 10 (90%) after. None had resolved reflux during followup. Upper pole renal function was assessed by renal scan and/or renal ultrasound. Upper pole function or increased cortical thickness was documented in 9 of 11 (82%) patients. Endoscopic laser incision was the only treatment required in 4 of 14 (28%) patients, including 2 with orthotopic and 2 ectopic ureteroceles. Of 14 patients 5 (36%) had undergone definitive surgery and 5 were followed.

CONCLUSIONS

Endoscopic laser incision of ureterocele allows a precise incision and decompression of the ureterocele with 1 treatment. Laser incision of ureterocele should be considered as the initial treatment in most patients.

Ureteroileal anastomosis in orthotopic urinary diversion: how much or how little is necessary?

PURPOSE

An increasing number of patients with an orthotopic neobladder and their expanding life expectancy necessitate an effective antireflux protection of the upper urinary tract. During the evolution of urinary diversion in the 20th century, several techniques to perform an ureteroileal anastomosis have been introduced. Those techniques most commonly used for orthotopic neobladders are discussed.

MATERIALS AND METHODS

Vascularization of both the ureteral ends and the recipient bowel as well as a meticulous surgical technique are necessary to reduce the reported postoperative stricture rate, which ranges between 3% and 30%. Variations such as preservation of additional periureteral adventitial tissue and its use for coverage of the ureterointestinal suture line are described. High-pressure urinary reflux may lead to mechanical damage of the renal parenchyma, whereas low-pressure occasional reflux in conjunction with chronic bacteriuria will lead to pyelonephritic changes and eventually deterioration of renal function. An intraluminal valve mechanism with increasing efficiency during pouch filling is clearly the most physiological form of antireflux mechanism. Interposition of an afferent ileal limb in addition to the antireflux valve seems advantageous due to the favorable vascularization in the dissected midureter.

CONCLUSIONS

Increased life expectancy in patients with orthotopic neobladders will increase the number of cases where access to the upper urinary tract becomes necessary due to a benign or malignant disease. Any technique that simultaneously provides an efficient antireflux mechanism and facilitates retrograde manipulation of the ureters (via the pouch) will be greatly appreciated by both patients and treating physicians.

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE

To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms.

PATIENTS AND METHODS

From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years).

RESULTS

There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01).

CONCLUSION

Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.

Children's UTIs in the new millennium. Diagnosis, investigation, and treatment of childhood urinary tract infections in the year 2001

OBJECTIVE

To provide an effective approach for family physicians treating children presenting with urinary tract infections (UTIs).

QUALITY OF EVIDENCE

The information presented, and articles quoted, are drawn from both review of the literature and recent consensus guidelines. Data and recommendations come from prospective multicentre trials; retrospective reviews; expert consensus statements; and some smaller trials, commentaries, and editorials.

MAIN MESSAGE

Urinary tract infections are often seen in family practice. Diagnosis requires suspicion and a realization that children, especially those younger than 2 years, often have very few, nonspecific signs of infection. Obtaining a proper urine sample is vital, because true infections require radiographic studies. Antibiotic prophylaxis is promoted because of the link between vesicoureteral reflux, recurrent UTIs, and renal scarring and hypertension. We generally provide prophylaxis until children are 3 or 4 years, when risk of damage from reflux is lessened and timely urine samples are easier to obtain for prompt therapy. Surgical opinion is sought only when medical management has failed. Failure is defined as either recurrent infections and pyelonephritis or poor renal growth.

CONCLUSION

To diagnose UTIs in children, physicians must suspect them, obtain proper urine samples, order appropriate investigations to rule out underlying anatomic abnormalities, and treat with appropriate antibiotics considering both organism sensitivities and length of therapy.

Extravesical ureteroneocystostomy with and without internalized ureteric stents in pediatric renal transplantation

The use of ureteric double-J stents and the Lich-Gregoir (extravesical) technique of ureteroneocystotomy have both been shown to decrease the rate of urologic complications in adult kidney transplantation (Tx). There are, however, few studies of the systematic use of stents in pediatric renal Tx. Between 1991 and 1997, 32 consecutive pediatric renal transplant recipients routinely received a 6F-12 cm indwelling double-J stent and were studied prospectively. These patients were compared with 32 consecutive pediatric recipients in whom a stent was not used. The latter were transplanted between 1987 and 1991 and formed the control group. All patients had a Lich-Gregoir ureteroneocystotomy. Stents were removed under general-anesthetic cystoscopy 2 3 weeks after Tx. Immunosuppression for stented patients was polyclonal antibody induction, delayed (7-10 days) cyclosporin A, azathioprine, and prednisone. The control group received the same triple drug regimen but with no induction in 29 of the 32 patients. All patients were followed-up with at least one ultrasound evaluation in the first month, and a renal scan and repeat ultrasound were performed if there was any rise in serum creatinine. In the stented group there were two patients with urinary leak and no obstructions. In the non-stented group there were no leaks and one obstruction. There was no graft loss owing to urologic complications in either group. There were three cases of stent expulsion (all in girls) and one case of stent migration in the posterior urethra (a boy). The 1-yr graft survival rate was 90.6% in the stented group and 65.6% in the non-stented group. The prophylactic use of an indwelling ureteral stent in pediatric renal Tx did not reduce the risk of urinary leakage or obstruction. Stent migration is a common phenomenon and, while not a serious complication, is traumatic to children. Furthermore, removal of an internalized double-J stent requires a general anesthetic. We recommend using a stent for selected patients only.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Acute urinary tract infection (UTI) is common in children. By the age of seven years, 8.4% of girls and 1.7% of boys will have suffered at least one episode. Symptoms are systemic rather than localised in early childhood and consist of fever, lethargy, anorexia, and vomiting. UTI is caused by E. coli in over 80% of cases and treatment consists of a course of antibiotics. Due to the unpleasant acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence. However these medications may cause side effects and promote the development of resistant bacteria.

OBJECTIVES

To determine the efficacy and side effects of long-term antibiotics given to prevent recurrent UTI in children.

SEARCH STRATEGY

A search of MEDLINE (1966 to Jan 2001), EMBASE (1988 to Jan 2001) and the Cochrane Controlled Trials Register for relevant randomised controlled trials without language restriction; reference lists of review articles; contact with content experts.

SELECTION CRITERIA

Randomised comparisons of two or more antibiotics and placebo with one or more antibiotics to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed and extracted information. For each trial, information was collected on the methods of the trial, participants, interventions and outcomes. A random-effects model was used to estimate a summary relative risk (RR) and a summary risk difference (RD) for recurrent UTI. Heterogeneity tests and subgroup analyses were carried out based on a priori hypothesis of plausible effect modification.

MAIN RESULTS

There were three trials (n = 151) comparing antibiotics with placebo/no treatment. The duration of antibiotic prophylaxis treatment varied among the studies (10 weeks to 12 months). The method of allocation concealment in the three trials was inadequate, unclear and adequate. The overall rate of recurrent UTI in the placebo/no treatment group was 63% (48/76). Compared to placebo/no treatment, antibiotics reduced the risk of recurrent UTI (RR 0.36, 95% CI 0.16 to 0.77; RD -46%, 95% CI -59% to -33%). No side effects were described in any of these three trials. There was one double-blinded trial (n = 120) with unclear allocation concealment that compared two different types of antibiotics to prevent recurrent UTI. Nitrofurantoin was more effective than trimethoprim in preventing recurrent UTI over a six month period (RR 0.48, 95% CI 0.25 to 0.92; RD -18%, 95% CI -34% to -3%). However, patients receiving nitrofurantoin were more likely to discontinue the antibiotic due to side effects (mainly gastrointestinal) than patients receiving trimethoprim (RR 3.17, 95% CI 1.36 to 7.37; RD 22%, 95% CI 8% to 36%).

REVIEWER'S CONCLUSIONS

Most published studies to date have been poorly designed with biases known to overestimate the true treatment effect. Large, properly randomised, double blinded trials are needed to determine the efficacy of long-term antibiotics for the prevention of UTI in susceptible children.

[Postnatal followup of fetal pyelectasis: an unresolved problem]

Postnatal followup of fetal pyelectasis is a controversial topic in recent literature. Questions such as the definition of pyelectasis, whether these neonates should be selected for postnatal study in an attempt to prevent reflux nephropathy and urinary tract infections, which complementary investigations (postnatal ultrasonography, cystourethrography, isotopic studies) should be performed and when, and whether these neonates should be administered antibiotic prophylaxis are unresolved issues. In addition, the relationship between prenatal pyelectasis, vesicoureteral reflux and infections is not at present clear. In this article, we try to review and order the present controversies, and briefly introduce the role of genetic aspects in the origin of different forms of nephropathy and renal malformations.

Outcomes of primary valve ablation versus urinary tract diversion in patients with posterior urethral valves

OBJECTIVES

Although valve ablation is the treatment of choice for patients with posterior urethral valves, debate continues as to the role of urinary diversion. We sought to retrospectively compare the clinical and radiologic outcomes between valve ablation and urinary diversion for patients with posterior urethral valves.

METHODS

We retrospectively reviewed the records of 50 consecutive patients with posterior urethral valves since January 1995. On the basis of the initial renal function and radiologic findings, patients were divided into three groups: group 1, normal renal function and radiologically normal upper tracts; group 2, normal renal function with hydronephrosis and/or reflux; and group 3, azotemia with hydronephrosis or reflux.

RESULTS

All 22 patients in group 1 were treated with valve ablation. After a mean follow-up of 32 months, these children had normal renal function and no evidence of upper tract deterioration. All 13 patients in group 2 were also treated with valve ablation. The radiologic abnormalities (hydronephrosis, reflux) resolved in 50% of cases, with an average follow-up of 28 months. Of the 15 patients in group 3, 7 underwent valve ablation and 8 underwent urinary diversion. Urinary diversion was performed in patients with renal deterioration and severe hydronephrosis and/or high-grade reflux. Renal function returned to normal in all patients who underwent valve ablation except one; renal function returned to normal in only 3 of 8 patients who underwent urinary diversion. Radiologically, the severity of the hydronephrosis and reflux was downgraded in patients who underwent valve ablation but not in the diverted group.

CONCLUSIONS

Valve ablation is the mainstay of treatment for patients with posterior urethral valves. Prenatal and postnatal factors, such as renal dysplasia and urinary tract infection, respectively, rather than the posterior valve treatment dictate the long-term renal and radiologic outcomes.

Influence of ureterovesical anastomosis technique on the incidence of vesicoureteral reflux in renal transplant recipients

Urological complications of allogenic kidney transplantation include vesicoureteral reflux which can result in graft threatening urinary tract infection. To prevent this complication several ureterovesical anastomosis techniques have been developed. Authors present a comparison of three different techniques: extravesical without antireflux mechanism, extravesical Witzel-Lich with antireflux mechanism and intravesical Laedbetter-Politano with antireflux mechanism. 39 patients were selected randomly from a cohort of 420 allogenic kidney recipients (follow up time 10-147 months). All patients had voiding cystography and urine culture performed. The incidence of vesicoureteral reflux varied from 13.3% to 50%, depending on the anastomosis technique. No correlation between type of anastomosis and urinary tract infection was found.

[A case of urinary stone in ureterocele extracted transurethrally after ESWL]

A 66-year-old man was referred to our hospital with chief complaints of difficulty in urination and terminal micturition pain. Ureteroceles were identified bilaterally, and a ureteral stone (19 x 12 mm) existed in the right ureterocele. After crushing the stone by extra corporeal shock wave lithotripsy (ESWL), we removed the stone transurethrally with a small incision in the right ureterocele. The vesicoureteral reflux (VUR) was not detected postoperatively. Now, we recommend the combination of ESWL and a small transurethral incision of the urelerocele for the treatment of ureteral stones in a ureterocele in order to prevent postoperative VUR.

Ureteroenteric anastomosis in continent urinary diversion: long-term results and complications of direct versus nonrefluxing techniques

PURPOSE

Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion.

MATERIALS AND METHODS

Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months.

RESULTS

Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia.

CONCLUSIONS

Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.

Long-term efficacy of subureteral collagen injection for endoscopic treatment of vesicoureteral reflux in neurogenic bladder cases

PURPOSE

We evaluated the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of vesicoureteral reflux in patients with neurogenic bladder dysfunction due to meningomyelocele.

MATERIALS AND METHODS

We prospectively studied 12 women and 8 men (26 ureteral renal units) with a median age of 8 years (range 1 to 51) who had neurogenic bladder due to meningomyelocele. Reflux into single collecting systems was treated with subureteral collagen injection (GAX 35). Followup with video urodynamics included voiding cystography.

RESULTS

All patients performed intermittent catheterization to control the bladder. During the study all bladders were areflexic with normal compliance. Preoperative reflux according to the International Reflux Study Classification was grade I in 1, II in 9, III in 10, IV in 4 and V in 2 ureteral renal units. All patients were treated with subureteral collagen injection (mean volume 1.9 ml., range 0.7 to 3.5). Reflux resolved initially in all but 2 cases. Mean followup was 16 months (range 1 to 71). Reflux was still absent in only 15% of treated units after 24 months.

CONCLUSIONS

Our data suggest that endoscopic subureteral collagen injection in neurogenic bladder cases is not effective with long-term followup. New biocompatible and biodegradable materials should be tested to control vesicoureteral reflux.

[Management of ureteroceles with pyelo-ureteral duplication in children. Report of 64 cases]

Sixty four cases of ureteroceles in a context of pyeloureteric duplication were reviewed. They were detected antenatally in 69% of cases. Upper pole nephroureterectomy was performed as first-line procedure in 32 cases. In 37.5% of cases, this procedure was followed by lower tract reconstruction, essentially because of symptomatic reflux in the inferior renal pelvis. Complete renal and vesical reconstruction was performed as the first-line procedure in 6 cases. An ureteropelvic anastomosis allowed preservation of the superior renal pelvis in 4 cases, including one case with secondary lower tract reconstruction. Intravesical reimplantation of the two ureters was performed in 8 cases. Primary endoscopic opening of the ureterocele was performed in 10 cases and complementary surgery was required in 7 cases. Other procedures were used more rarely: temporary ureterostomy, nephrostomy, resection of the protruding dome of a cecoureterocele. Current management is usually neonatal. The first step consists of prevention of infection. The therapeutic approach depends on the quality of the superior renal pelvis assessed by DMSA renal scintigraphy. Immediate complete reconstruction of the kidney and bladder is now rarely indicated. When the superior renal pelvis is not functional, resection should be considered with aspiration of the ureterocele. A complementary bladder procedure is required in some cases (40% in our series) to treat symptomatic reflux in the inferior renal pelvis. When the superior renal pelvis is functional, ureteropelvic anastomosis is a good solution, especially when the superior ureter is very large and poorly functional, but endoscopic opening of the ureterocele can also be proposed, which may need to be followed be intravesical reconstruction.

A prospective randomized study comparing absorbable and nonabsorbable staples in constructing antireflux valves of urethral hemi-Kock pouches

OBJECTIVE

To determine the long-term complications associated with constructing an antireflux nipple valve using absorbable or nonabsorbable staples in the urethral hemi-Kock pouch.

PATIENTS AND METHODS

Fifty patients (all men, median age 47 years, range 28-73) undergoing construction of a urethral hemi-Kock pouch were randomized prospectively into two equal groups. In group 1, absorbable (polyglyconate) staples were used for the construction, and in group 2 nonabsorbable (metal) staples were used but omitting the staples applied at the tip of nipple valve. Assessment during the follow-up of 6-88 months comprised urine analysis, culture and sensitivity, measurement of serum creatinine, electrolytes and blood gases, and plain abdominal radiography, intravenous urography and micturating pouchography.

RESULTS

In group 1, 21 patients were evaluable; a pouch stone was detected in one, extussusception of the valve in one and valve stenosis in one. In group 2, 20 patients were evaluable; pouch stones were detected in six, extussusception of the valve in three and valve stenosis in one.

CONCLUSION

Compared with nonabsorbable (metal) staples, the use of absorbable (polyglyconate) staples significantly decreased the incidence of pouch stone formation and improved valve stability in patients with a urethral hemi-Kock pouch.

[Effect of transurethral collagen injection for vesicoureteral reflux in patients with spina bifida]

BACKGROUND

The effect of endoscopic injection of collagen was assessed in spina bifida patients with vesicoureteral reflux (VUR).

METHODS

Endoscopic collagen injection was carried out for grade II or worse VUR according to the international classification. Twenty-two ureters were studied in 6 boys and 8 girls (mean: 14.4 years) who were followed up over a period of at least 3 months (mean: 5 months) after surgery they all had a negative preoperative skin test for collagen and were investigated radiologically and urodynamically. Cystograpy was performed 1, 3 and 12 months after surgery and thereafter once a year to detect recurrence of VUR.

RESULTS

Anesthesia was not necessary in 4 patients. No adverse reactions occurred to the injection of collagen. VUR disappeared after 1 and 2 collagen injections in 17 (77%) and 2 (9%) ureters, respectively. The therapeutic effect of the single collagen injection showed no relationship to shape of the ureteral orifice, grade of VUR, compliance of the bladder, and presence of detrusor hyperreflexia.

CONCLUSIONS

Endoscopic treatment of VUR with collagen injection in spina bifida patients is a simple and less invasive method. We obtained satisfactory short-term results by this method. However, since the risk factor of recurrence remains unclear, sufficient investigation of long-term results is important to determine the role of this method in the treatment of VUR in patients with spina bifida.