Initial and long-term management of posterior urethral valves

Primary ablation versus urinary diversion in posterior urethral valve: Systematic review and meta-analysis

PURPOSE

To determine differences in long-term kidney and bladder outcomes in boys with posterior urethral valves (PUV) managed by a primary valve ablation or primary urinary diversion.

MATERIALS AND METHODS

A systematic search was performed in March 2021. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included kidney outcomes (chronic kidney disease, end-stage renal disease, kidney function) and bladder outcomes. Odds ratios (OR) and mean difference (MD) with 95% confidence interval (CI) were extrapolated from available data for quantitative synthesis. Random-effects meta-analysis and meta-regression were performed according to study design, and potential covariates were assessed with subgroup analysis. The systematic review was prospectively registered on PROSPERO (CRD42021243967).

RESULTS

Thirty unique studies describing 1547 boys with PUV were included in this synthesis. Overall effect estimates demonstrate that patients undergoing primary diversion have significantly increased odds of developing renal insufficiency [OR 0.60, 95% CI 0.44, 0.80; p < 0.001]. However, when adjusting for baseline kidney function between intervention groups, there was no significant difference in long term kidney outcomes [p = 0.09, 0.35], or the development of bladder dysfunction or requiring clean-intermittent catheterization with primary ablation rather than diversion [OR 0.89, 95% CI 0.49, 1.59; p = 0.68].

CONCLUSIONS

Current low-quality evidence suggests that medium-term kidney outcomes in children are similar between primary ablation and primary diversion after adjusting for baseline kidney function, while bladder outcomes are highly heterogenous. Further research with covariate control is warranted to investigate sources of heterogeneity.

LEVEL OF EVIDENCE

Level III.

Impact of surgical intervention on progression to end-stage renal disease in patients with posterior urethral valve

Background

Posterior urethral valve patients present with varied presentations at any age of life and have significant associated morbidity and require long-term follow-up and care.

Methods

This was a single-center ambispective cohort study carried out over a period of 2 years. Patient data regarding the symptoms, investigations, interventions, secondary complications were recorded and were followed up regularly during the study till either normalization of their creatinine level which was maintained up to one-year post-fulguration (non-CKD) or progression to end-stage renal disease (ESRD) requiring renal transplant. Various clinical factors were then compared between these groups.

Results

The age of presentation varies from 6 months antenatal period to a maximum of 34 years. Most common symptom was of lower urinary tract obstruction, followed by recurrent febrile UTI. The interval between disease presentation detection and PU valve fulguration ranged from 6 days to more than 5 years, median duration being 1 month. 85.7% patients had hydroureteronephrosis on initial USG. In VCUG, there was no significant difference found between the presence of reflux and poor renal outcome. Age of presentation greater than 2 years was seen in 52% of patients with CKD compared to only 10% patients in non-CKD group (significant, p value 0.02). Among patients who developed CKD, 60% of patients had PU valve fulguration after one month of disease presentation, while in contrast, among the non-CKD group, 80% of patients had it done within one month of disease presentation. (significant, p value 0.03).

Conclusions

Late age of presentation, delayed fulguration with high initial creatinine, and failure of serum creatinine to return to normal after one-month post-fulguration are important risk factors in the progression of the disease to ESRD. Symptomatic improvement after interventions does not correlate with progression to ESRD. The number of interventions also does not predict progression to ESRD. Interventions should be chosen wisely on case to restore near-normal physiology and delay progression to ESRD.

Gross Hematuria as a Presenting Feature of Posterior Urethral Valves in a Neonate with Normal Antenatal Sonograms

Background: Posterior urethral valves (PUVs) are usually suspected during antenatal sonograms or by postnatal evidence of bilateral hydronephrosis with enlarged bladder. Gross hematuria as an initial manifestation of PUV with a history of normal antenatal sonogram is very rare. Methods: This is a retrospective chart study. Results: We describe a nine-day-old male neonate who presented with gross hematuria and was later found to have a urinary tract infection (UTI) and severe acute kidney injury (AKI). The mother apparently had normal antenatal sonograms with no evidence of fetal hydronephrosis. The child did not have postnatal renal bladder sonogram done until gross hematuria occurred at Day 9 of life. Sonogram showed bilateral severe hydronephrosis and hydroureter with enlarged bladder. The patient underwent ablation of the PUVs after initial bladder decompression with indwelling urethral catheterization. His AKI resolved after prompt treatment of UTI and PUV ablation. Conclusions: This report emphasizes the importance of a high index of suspicion for obstructive uropathy in a newborn with gross hematuria irrespective of prenatal sonogram findings.

Developmental pathology of congenital kidney and urinary tract anomalies

Congenital anomalies of the kidneys or lower urinary tract (CAKUT) are the most common causes of renal failure in children and account for 25% of end-stage renal disease in adults. The spectrum of anomalies includes renal agenesis; hypoplasia; dysplasia; supernumerary, ectopic or fused kidneys; duplication; ureteropelvic junction obstruction; primary megaureter or ureterovesical junction obstruction; vesicoureteral reflux; ureterocele; and posterior urethral valves. CAKUT originates from developmental defects and can occur in isolation or as part of other syndromes. In recent decades, along with better understanding of the pathological features of the human congenital urinary tract defects, researchers using animal models have provided valuable insights into the pathogenesis of these diseases. However, the genetic causes and etiology of many CAKUT cases remain unknown, presenting challenges in finding effective treatment. Here we provide an overview of the critical steps of normal development of the urinary system, followed by a description of the pathological features of major types of CAKUT with respect to developmental mechanisms of their etiology.

All grown up: A transitional care perspective on the patient with posterior urethral valves

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Case: Anuria and acute renal failure post-endoscopic valve ablation and Foley catheter insertion in a newborn with a small-capacity, non-compliant bladder

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Posterior urethra: Anterior urethra ratio in the evaluation of success following PUV ablation

INTRODUCTION

There are conflicting reports on the criteria with which to determine success following posterior urethral valve (PUV) ablation. The aims of this study were to assess the value of the posterior urethra: anterior urethra ratio (PAR) in predicting successful PUV ablation.

MATERIALS AND METHODS

All neonates and infants with confirmed PUV on voiding cystourethrogram (VCUG) were included. Initial PAR was computed by dividing maximum posterior urethral diameter by anterior urethral diameter. Distances were measured by an on-screen distance measurement tool in the Radiology department, to avoid error. Only oblique images with good voiding phases were used for assessment. All patients underwent cystoscopy and PUV ablation using cold knife. Postoperative VCUG and cystoscopy were performed at 3 months follow-up. Success was defined as cystoscopic resolution of obstruction, in addition to biochemical and radiological improvement, and this was compared with PAR findings. An equal number of age-matched control patients who had a normal VCUG (as a part of evaluation of antenatal hydronephrosis) were also analyzed.

RESULTS

A total of 56 patients (median age 15 days, range 3-250 days) were analyzed between 2013 and 2016. The mean PAR was 1.5 (0.42) in controls and 3.42 (0.75) in those with PUV at diagnosis (P = 0.001). In those with successful PUV ablation (n = 51) the mean PAR was 1.8 (0.21), and in those with residual PUV/stricture (n = 5) the mean PAR was 3.16 (0.54). The difference between these two groups was statistically significant (P = 0.0001). Applying the value of mean + 2 SD of successful PUV ablation, an upper limit of PAR >2.2 was proposed to predict failure. Using this cut-off, 4/7 with PAR >2.2 had confirmed failure, while 48/49 with PAR <2.2 had successful resolution (P = 0.001) CONCLUSION: Whenever the posterior urethra is more than 2.2 times the diameter of the anterior urethra (PAR >2.2) on repeat VCUG following a PUV ablation, a cystoscopy check is essential to rule out residual PUV/stricture.

Posterior urethral valves: are neonatal imaging findings predictive of renal function during early childhood?

BACKGROUND

Obstructive renal dysplasia as observed on US is associated with posterior urethral valves and is regarded as predicting poor renal functional outcome.

OBJECTIVE

To investigate whether any characteristic of urinary tract imaging at birth is predictive of renal function in children with prenatally diagnosed posterior urethral valves.

MATERIALS AND METHODS

We reviewed clinical data including renal function (at birth and up to 3 years of age) and clinical outcome (urinary infection, dialysis, renal transplantation). Imaging data included US (dilatation of the urinary tract, renal cortical echogenicity, signs of cystic dysplasia, urinoma) and cystourethrography findings (vesicoureteral reflux, bladder anomalies, presence of valves) from imaging performed directly after birth.

RESULTS

We retrospectively studied 30 children. Three of the 30 (10%) were in renal failure by the age of 3 years. Twelve of 14 (85%) children with parenchymal anomalies (cortical hyperechogenicity or cystic changes) and 8/9 (89%) children with bilateral high-grade reflux had normal renal function at age 3 years. One child without cystic dysplasia or reflux had abnormal renal function from birth. None of the six children with urinoma developed renal failure by the age of 3 years.

CONCLUSION

Presence of cortical hyperechogenicity, cystic changes or bilateral reflux cannot be considered prognostic of renal failure by the age of 3 years.

Posterior Urethral Valves in Children: Pattern of Presentation and Outcome of Initial Treatment in Ile-Ife, Nigeria

Background:

The management of posterior urethral valves (PUV) and its sequelae is still a challenge to most pediatric surgeons in our environment due to late presentation and inadequate facilities for long-term evaluation and treatment. Despite initial successful treatment about 40% would develop chronic renal failure. The aim is to describe the presentation, management and outcome of the initial treatment in boys with PUV.

Materials and Methods:

It is a retrospective analysis of PUV in boys 8 years and below over a 17 years period. Demographic characteristics, clinical features, investigations, and treatment outcome were reviewed.

Results:

Thirty-seven cases were analyzed. The median age was 5 months (range from birth to 8 years). Three (8.1%) patients had prenatal ultrasound diagnosis. The most common presentation was voiding dysfunction 37 (100%). Part of the preoperative investigation included micturating cystourethrogram (n = 31: 83.8%) and abdomino-pelvic ultrasonography (n = 37:(100%). The mean serum creatinine value of those who presented within the first 30 days of life and those who presented afterwards were 325 (±251) µmol/L and 141 (±100) µmol/L respectively, P = 0.003. Surgical interventions included trans-vesical excision of valves (n = 9: 28.1%), valvotomy (n = 10: 31.3%), balloon avulsion (n = 8: 25.0%), vesicostomy (n = 4: 12.5%) and endoscopic valve avulsion (n = 1: 3.1%). Seventeen (56.7%) patients had serum creatinine >70.4 µmol/L after 1-month of valve excision. Five (13.5%) patients had postrelief complications and 5 (13.5%) died on admission. Ninety percentage (27/30) of patients had poor prognostic indices.

Conclusions:

The initial treatment outcome was good but most had poor prognostic factors.

Proteomic urinary biomarker approach in renal disease: from discovery to implementation

Biomarkers hold the promise of significantly improving health care by enabling prognosis and diagnosis with improved accuracy, and at earlier points in time. Previous results have indicated that single biomarkers are not suitable to describe complex diseases such as kidney disease. Here we provide an update on the progress of urinary proteomics-based studies and strategies to develop biomarker-based classifiers that tolerate instability and inconsistency of individual biomarkers. The examples focus on two major fields in nephrology: chronic kidney disease in the adult population and obstructive nephropathies in the pediatric population. When employed adequately, urinary proteomics demonstrates a clear value in kidney disease, indicating that the current status quo ruling for decades now could be changed by applying modern "omics" approaches. However, while research is able to deliver these useful tools for patient management, the issues associated with implementation are not yet solved. Active engagement of the relevant clinical professional societies, as well as patient's organizations, might help to implement these omics approaches that have shown a clear benefit for the patient.

Pre-transplant management of valve bladder: a critical literature review

OBJECTIVE

Indications, timing and problems related to augmentation cystoplasty (AC), in the context of posterior urethral valves (PUV) and renal transplantation (RT) are ill defined. Associated bladder dysfunction (BD) is not a stable condition and may cause the loss of the renal graft. Polyuria, accentuates BD and seems to improve after RT. The objective of this research is to critically review the available literature, aiming to rationalize the treatment of PUV with BD in the context of end stage renal disease (ESRD).

MATERIALS AND METHODS

A thorough literature review was performed. Pertinent papers were, critically analyzed and classified according to the level of evidence.

RESULTS

Data relating to PUV, RT and AC showed low levels of evidence. Results of RT in PUV cases with adequate management of BD were comparable to those suffering from other causes of ESRD. Bladder function can recover spontaneously after urinary undiversion. There were no established criteria to indicate AC in the context of ESRD and PUV or to define the ideal protocol to treat associated vesicoureteral reflux (VUR). Urinary tract infections (UTIs) were more frequent in transplanted PUV patients; this is possibly related to the inadequate control of BD, especially after AC. AC is feasible after RT with outcomes comparable to preemptive ones.

CONCLUSION

AC increases the risk of UTI after RT. Preemptive AC should be constructed only if the risks associated with increased bladder pressures exceed those associated with AC. Adequate management of BD is essential to improve bladder function and to minimize UTIs. AC is feasible after RT, with complication rates similar to the ones performed beforehand. Since a considerable number of PUV patients with high-pressure bladders eventually develop myogenic failure, it seems logical to postponing AC in this population, as long as they are under close surveillance.

Long-term follow-up after transurethral treatment of infravesical obstruction in boys

OBJECTIVE

To study whether boys who underwent transurethral treatment of (mild) infravesical obstruction during childhood have lower urinary tract symptoms and complications at young adult age.

MATERIALS AND METHODS

Young adult men who underwent transurethral treatment for infravesical obstruction as a child were contacted. The following measurements were done: International Prostate Symptom Score (IPSS), International Consultation on Incontinence Modular Questionnaire on Urinary Incontinence, frequency volume chart uroflowmetry, and postvoid residual. A group of 151 male students who completed IPSS and underwent uroflowmetry was used as reference group to compare with patients.

RESULTS

Of 135 traceable patients, 87 men (median age 21.9 years; interquartile range [IQR] 19.6-25.6) returned the questionnaires, and 71 underwent uroflowmetry. Median age at initial treatment was 7.9 years (IQR 1.0-10.8). Compared with men in the reference group, patients had similar IPSS and quality of life scores; median IPSS was 3, and IPSS-quality of life 1 (IQR 0.0-1.0). Urgency incontinence and postmicturition incontinence were reported in 2.4% and 8.5%, respectively. Frequency volume charts (n = 29) showed normal frequency and voided volumes. Uroflowmetry results were comparable with the reference group, although 16 (22.5%) patients voided volumes >600 mL. One patient had urethral stricturing, and one a significant postvoid residual.

CONCLUSION

Young adult men treated for (mild) urethral obstruction in childhood have few micturition symptoms and good uroflowmetry results, not different from a reference group. Some patients, however, report incontinence, and this group deserves close attention. Late complications were rare.

Clinical proteomics in obstetrics and neonatology

Clinical proteomics has been applied to the identification of biomarkers of obstetric and neonatal disease. We will discuss a number of encouraging studies that have led to potentially valid biomarkers in the context of Down's syndrome, preterm birth, amniotic infections, preeclampsia, intrauterine growth restriction and obstructive uropathies. Obtaining noninvasive biomarkers (e.g., from the maternal circulation, urine or cervicovaginal fluid) may be more feasible for obstetric diseases than for diseases of the fetus, for which invasive methods are required (e.g., amniotic fluid, fetal urine). However, studies providing validated proteomics-identified biomarkers are limited. Efforts should be made to save well-characterized samples of these invasive body fluids so that many valid biomarkers of pregnancy-related diseases will be identified in the coming years using proteomics based analysis upon adoption of 'clinical proteomics guidelines'.

Posterior urethral valves: creatinine velocity, a new early predictor of renal insufficiency

AIM

Antenatal screening has led to early detection of posterior urethral valves (PUV). However, despite early intervention, a proportion of children will develop chronic renal insufficiency. We studied the trend of serum creatinine following urinary tract decompression during the neonatal period in infants as a possible predictor of chronic renal insufficiency.

METHODS

Patients treated by endoscopic resection of posterior urethral valves between 1993 and 2004 were identified. From these, infants treated within the first 30 days of life were identified. Serum creatinine values taken within the first 5 days following initial drainage were recorded. A creatinine velocity for each patient was calculated by linear regression analysis. Creatinine was considered rising if velocity was >3 μmol/L/day, or falling if velocity was <-3 μmol/L/day. Chronic renal insufficiency was defined as CKD2 or higher.

RESULTS

Sixty-four neonates had decompression of the urinary tract. Of these, 16 had rising creatinine despite drainage, 10 had a plateau in creatinine level, and 36 had falling creatinine following drainage. Insufficient data were available in two to calculate creatinine velocity. Progression to renal insufficiency was significantly higher in patients with an initial rise in creatinine (62.5%) than in those with plateau creatinine (40%) or falling creatinine (8.6%) (P ≤ 0.0005 by Fisher exact test). Mean follow-up was 9.2 years.

CONCLUSIONS

Rising creatinine, even transiently, following urinary tract drainage in neonates with posterior urethral valves is significant and is a new and important indicator of long-term prognosis.

Posterior urethral valves: long-term outcome

Posterior urethral valves represent the most common cause of bladder outlet obstruction in infancy that impairs renal and bladder function. Long-term outcome of patients with previous PUV is evaluated. Patients over 18 years of age, treated from 1982 to 1995 before the age of 3 years were considered. Previous surgery, renal function, bladder activity, urinary incontinence, and fertility/sexual activity were evaluated. Clinical interview, creatinine clearance, uroflowmetry with ultrasound post-void urine residue, and self-administered questionnaire were recorded. Out of 45 identified records, 24 patients (53.3%) accepted to be enrolled (age 18-34 years, mean 23 years). The mean follow-up was 19.5 years (16-30 years). Out of the 21 excluded patients, 20 did not reply to the clinical interview and 1 died at age of 6 years. All the 24 patients had early endoscopic section of PUV; nine also received transient ureterocutaneostomy or vesicostomy. Ureteroneocystostomy was performed in five patients and ureterocystoplasty with unilateral nephrectomy in two. At follow-up chronic renal failure was detected in 13 patients (54.1%) and 9 (37.5%) had arterial hypertension. End-stage renal disease developed in five patients (20.8%): three had successful renal transplantation and two were in dialysis. Lower urinary tract symptoms were present in seven patients (29.1%). No significant fertility deficit and sexual dysfunction were observed in 23 patients, while 1 patient was azoospermic. No paternity was reported so far. Long-term outcome of patients with previously treated PUV is mandatory. Kidney, bladder, and sexual functions should be monitored till adulthood to verify any modified behaviour.

CKD and bladder problems in children

Approximately 35% of children with CKD who require renal replacement therapy have a significant urological abnormality, including posterior urethral valves, a neuropathic bladder, prune belly syndrome, Hinman syndrome, or severe vesicoureteral reflux. In such children, abnormal bladder function can have a significant deleterious effect on the renal function. In children with bladder outlet obstruction, bladder compliance and capacity often are abnormal, and a sustained intravesical pressure of >40 cm H(2)O impedes drainage from the upper urinary tract. Consequently, in these conditions, regular evaluation with renal sonography, urodynamics, urine culture, and serum chemistry needs to be performed. Pediatric urological care needs to be coordinated with pediatric nephrologists. Many boys with posterior urethral valves have severe polyuria, resulting in chronic bladder overdistension, which is termed as valve bladder. In addition to behavioral modification during the day, such patients may benefit from overnight continuous bladder drainage, which has been shown to reduce hydronephrosis and stabilize or improve renal function in most cases. In children with a neuropathic bladder, detrusor-sphincter-dyssynergia is the most likely cause for upper tract deterioration due to secondary vesicoureteral reflux, hydronephrosis, and recurrent urinary tract infection (UTI). Pharmacologic bladder management and frequent intermittent catheterization are necessary. In some cases, augmentation cystoplasty is recommended; however, this procedure has many long-term risks, including UTI, metabolic acidosis, bladder calculi, spontaneous perforation, and malignancy. Nearly half of children with prune belly syndrome require renal replacement therapy. Hinman syndrome is a rare condition with severe detrusor-sphincter discoordination that results in urinary incontinence, encopresis, poor bladder emptying, and UTI, often resulting in renal impairment. Children undergoing evaluation for renal transplantation need a thorough evaluation of the lower urinary tract, mostly including a voiding cystourethrogram and urodynamic studies.

A review of urodynamic evaluation in children and its role in the management of boys with posterior urethral valves

Posterior urethral valves are the commonest cause of lower urinary tract outflow obstruction in male infants with an estimated incidence of 1:5000 male infants and 1:25,000 live births. Despite treatment with fulguration of the obstructing valves, bladder function is abnormal in up to 70% of older children and adolescents. Bladder dysfunction causes morbidity e.g. urinary incontinence and has been implicated in the late deterioration of renal function in this population. A poor understanding and inappropriate management of bladder dysfunction can result in unnecessary morbidity, which can handicap a child for life. Any method that measures function or dysfunction of the lower urinary tract constitutes a urodynamics investigation. Broadly, the investigations can be classified into simple or noninvasive urodynamics and invasive urodynamics. The objective of urodynamics assessments in children is to reproduce the patient's complaints or symptoms. Video urodynamics can provide additional information that may contribute to a further understanding of the problem under investigation. Urodynamics provides a useful tool to test the efficacy of treatment as well as determine any refinements necessary to improve the outcome of such treatment.

Long-term follow-up and late complications following treatment of pediatric urologic disorders

Many pediatric urologic disorders have sequelae that may affect patients well into adulthood. Despite adequate treatment, many patients are at risk for progressive urologic deterioration years after surgical reconstruction. While many pediatric urologists follow their patients years after surgery, screening for late complications is a shared responsibility with primary care providers. This article discusses potential late complications and appropriate follow-up for patients who have a history of ureteral reimplantation, pyeloplasty, hypospadias repair, posterior urethral valve ablation, and intestinal interposition.

Mohan's valvotome for the ablation of posterior urethral valves

INTRODUCTION

Treatment of posterior urethral valves (PUV) is now most commonly by endoscopic valve ablation, but this is not readily available in our environment. We describe our experience with Mohan's valvotome for the ablation of PUV.

MATERIALS AND METHODS

All patients with PUV who underwent Mohan's valvotomy over a 28-month period from June 2006 were reviewed.

RESULTS

There were 35 patients. The median age was 1.5 years (mean age 3.0 years, range 11 days to 14 years). Eleven (31.4%) and 24 (68.6%) patients received the treatment under local and general anaesthesia, respectively. Adequate relief of obstruction was achieved in all patients with marked improvement in the urinary stream. Complications were recorded in two (5.7%) patients; one was re-operated because of recurrent urinary retention, and the other had urinary incontinence which resolved after 3 months. At follow-up of 1-28 months (median 14 months), three (8.6%) patients had died from sepsis and malnutrition. The 32 (91.4%) surviving have good urinary stream, normal renal function (serum creatinine level <1.5mg/dl) and resolution of hydronephrosis as demonstrated on ultrasound. There was no mortality resulting directly from the use of Mohan's valvotomy.

CONCLUSION

Mohan's valvotome is an effective instrument for the ablation of PUV. It is invaluable in the developing world where paediatric endoscopes are not readily available.

Validation of initial serum creatinine as a predictive factor for development of end stage renal disease in posterior urethral valves

OBJECTIVE

The aim of this study was to determine the value of initial serum creatinine in prediction of End-stage renal disease (ESRD) in children with posterior urethral valves PUV.

METHODS

In this retrospective study, patients diagnosed with PUV admitted in Aliasghar Children's Hospital in Tehran, Iran from 1991 through 2001 were studied. Based on the development of ESRD (need for dialysis) they were classified in two groups and their demographics, initial presentations, laboratory data, imaging findings and outcomes were reviewed and compared.

RESULTS

Thirty six male patients with PUV, treated with valve ablation (13), vesicostomy (13), or high ureterostomy (10) were followed for developing ESRD. Sixteen of the 36 patients developed ESRD at their last follow-up. There was no significant difference in age at initial presentation, presence of urinary tract infections, incidence of vesicoureteral reflux, renal dysplasia or type of primary surgical intervention between the patients with or without ESRD. Patients who progressed to ESRD had serum creatinine concentration > 1.0 mg/dl at diagnosis as compared to those without ESRD (P = 0.001).

CONCLUSION

Initial serum creatinine is a valuable factor for prediction of renal outcome in patients with PUV.

Voiding urosonography as first step in the diagnosis of vesicoureteral reflux in children: a clinical experience

BACKGROUND

Contrast-enhanced voiding urosonography (VUS) is becoming more widely used for the diagnosis of vesicoureteric reflux (VUR), but until now its use has only been accepted for first diagnosis in females and in the follow-up of children, including boys, who have already undergone voiding cystourethrography (VCUG).

OBJECTIVE

To describe our 6-year experience with VUS used as a first step in the diagnosis of VUR.

MATERIALS AND METHODS

A total of 610 children (334 boys, 276 girls; mean age 22 months), underwent VUS as the first step in the diagnosis of VUR. In selected children, VCUG was also performed.

RESULTS

VUR was detected in 199 of 610 VUS examinations, and 265 refluxing kidney-ureter units were found. Children with VUR underwent antibiotic prophylaxis or surgery. Children without VUR underwent clinical follow-up. Just 60 children underwent VCUG. The criteria for VCUG were: high-grade VUR after consultation with a urologist, onset of urinary tract infection while receiving prophylaxis, nondiagnostic VUS, and other malformations with or without clinical signs.

CONCLUSION

Our experience suggests that we can use VUS as the first step in the diagnosis of VUR in children, boys and girls, with a significant reduction in radiation exposure.