Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children

Mechanism of vesicoureteral reflux: High detrusor pressure versus low ureteral resistance A narrative review

The objective of this narrative review is to deepen the understanding of vesicoureteral reflux (VUR) by exploring its historical context, current treatments and their outcomes, as well as offering an alternative perspective on this condition. VUR was first identified in patients with neurogenic bladder following spinal cord injury; it has since been linked to urinary tract infections in newborns and children. The classical theory of primary VUR is that it is caused by the short submucosal ureteral tunnel which leads to low ureteral resistance, thus leading to the development of various surgical methods to increase the ureteral resistance. However, growing evidence indicates that secondary VUR, caused by elevated detrusor pressure, may be a more common cause. Hence, it is critical to identify low urinary tract obstruction during the voiding cystourethrogram or raised detrusor pressure as the cause of the VUR before attempting surgical correction. More studies are necessary to support this position and enhance the treatment outcomes for VUR patients.

Correlation not Causation: Looking Back at the History of VUR

Vesicoureteral reflux (VUR) is a medical condition where urine flows retrograde from the bladder superiorly, and has traditionally been considered a risk factor for kidney damage in children. However, over the past decade and a half, several randomized controlled trials have shown the risk of kidney damage in the presence of VUR is low, and any treatment for VUR does not change that risk. Here, we review the history of VUR as a pathologic condition, how the interpretation of that history led to possibly overestimating the danger, and how current findings should be seen in the context of that history.

Risk factors for new renal scarring in children with vesicoureteral reflux receiving continuous antibiotic prophylaxis

To investigate the risk factors for new renal scarring (NRS) in children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP). This was a single-center cohort study. The clinical data of 140 children with grade I-V VUR receiving CAP were analyzed. In this study, exposure variables were sex, younger age at the initial diagnosis of UTI ≤ 12 months, the occurrence of breakthrough urinary tract infection (BT-UTI), high-grade VUR, bilateral VUR, etiology, presence of renal scarring at the initial diagnosis and ultrasound abnormalities. The outcome was NRS. A total of 140 children were included in the risk factor analysis of NRS, 73 of whom experienced NRS, an incidence rate of 52.14%. Multivariate Cox regression suggested that the presence of renal function impairment after the initial diagnosis of UTI (OR 3.411, 95% CI 1.5751-6.646) and the occurrence of BT-UTI while receiving CAP (OR 1.995, 95% CI 1.089-2.958) were independent risk factors for NRS. Multivariate Cox regression showed that high-grade VUR had no significant effects on NRS (OR 0.940, 95% CI 0.462-1.912, P = 0.864). No significant difference was identified in multivariate Cox regression analysis in the IV-V group (vs I-III group) (OR 0.960, 95% CI 0.565-1.633, P = 0.960). Renal function impairment after the initial diagnosis of UTI and the occurrence of BT-UTI while receiving CAP were independent risk factors for NRS. Neither univariate analysis nor multivariate analysis found a correlation between VUR grade and NRS.

Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis

BACKGROUND

Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis.

METHODS

A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments.

RESULTS

A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment.

CONCLUSION

Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Modified unilateral periureteral injection technique in the treatment of patients with high-grade vesicoureteral reflux: A study of primary findings

Objective

Although endoscopic treatment has been used by many pediatric urologists for the treatment of vesicoureteral reflux (VUR), it has no considerable success in high-grade VUR. We aimed to describe the primary outcomes of unilateral periureteral injection technique (PIT), as well as bilateral PIT in high-grade VUR.

Methods

In this prospective study, we examined 92 ureters in 45 boys and 40 girls from February 2010 to May 2018. Bilateral PIT and unilateral PIT were applied in 67 and 25 refluxing units, respectively. In the unilateral PIT, the subureteral injection site was only at the 5- or 7-o'clock position. However, in the bilateral PIT, the subureteral injection sites were at 5- and 7-o'clock position. Pre- and post-operative reflux grades were evaluated by voiding cystourethrography 6 months after surgery.

Results

Seven patients had bilateral reflux. Overall, 75 (81.5%) ureters showed Grade IV VUR, while 17 (18.5%) had primary Grade V VUR. The mean age of the subjects was 39.2 months. In unilateral PIT ureters, VUR was resolved in 23 (92.0%) refluxing units. It was downgraded to Grade III in one ureter (4.0%) and to Grade II in another ureter (4.0%). In addition, in bilateral PIT cases, VUR was resolved in 60 (89.6%) ureters; it downgraded to Grades II and III in 3 (4.5%) and 4 (6.0%) refluxing units, respectively.

Conclusion

Unilateral PIT can be highly effective in the treatment of selected ureters of high-grade VUR. However, further studies are needed to confirm our results.

Risk factors for breakthrough urinary tract infection in children with vesicoureteral reflux receiving continuous antibiotic prophylaxis

BACKGROUND

To investigate the risk factors for breakthrough urinary tract infection (BT-UTI) in children with vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP).

METHODS

This was a single-centre cohort study (January 2016 to December 2019). The clinical data of 256 children with grade I-V VUR receiving CAP were analysed. In this study, exposure variables were sex, younger age at the initial diagnosis of UTI ≤12 months, high-grade VUR, bilateral VUR, aetiology, presence of renal scarring at the initial diagnosis, presence of renal function impairment at the initial diagnosis, ultrasound abnormalities, antibiotic used and bladder and bowel dysfunction (BBD). Outcome was BT-UTI.

RESULTS

BT-UTI occurred in 81 out of 256 children with grade I-V VUR who received CAP, an incidence of 31.64%. Univariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, renal scarring on the dimercaptosuccinic acid (DMSA) scan at the initial diagnosis of UTI and BBD were correlated with the occurrence of BT-UTI. Multivariate analysis showed that younger age at the initial diagnosis of UTI (≤12 months) [hazard ratio (HR): 4.629; 95% confidence interval (CI): 1.302-16.462], bilateral VUR (HR: 2.078; 95% CI: 1.084-4.022) and BBD (HR: 3.194; 95% CI: 1.243-8.206) were independent risk factors for the occurrence of BT-UTI.

CONCLUSIONS

For VUR children receiving CAP, younger age at the initial diagnosis of UTI (≤12 months), bilateral VUR, and BBD were independent risk factors for the occurrence of BT-UTI.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of  V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

Do Various Treatment Modalities of Vesicoureteral Reflux Have Any Adverse Effects in Pediatric Patients? A Meta-Analysis

PURPOSE

Vesicoureteral reflux (VUR) is a risk factor for various renal problems like recurrent urinary tract infections (UTIs), pyelonephritis, renal scarring, hypertension, and other renal parenchymal defects. The interventions followed by pediatricians include low-dose antibiotic treatment, surgical correction, and endoscopy. This meta-analysis aimed to assess the advantages and drawbacks of various primary VUR treatment options.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of journals, and abstracts from conference proceedings were all used to find randomized controlled trials. The articles were retrieved from 1985 till 2020. Twenty articles were used for the data analysis. Criteria for Selection: Surgery, long-term antibiotic prophylaxis, noninvasive techniques, and any mix of therapies are also options for treating VUR. Collection and Interpretation of Data: Two authors searched the literature separately, determining research qualifications, assessing accuracy, and extracting and entering results. The odds ratio (OR) of these studies was used to construct the forest plot. The random-effects model was used to pool the data. Also, the random-effects model was used with statistical significance at a p value < 0.05 to assess the difference in side effects after treatment of VUR using different modalities.

RESULTS

We found no statistically significant differences between surgery plus antibiotics and antibiotic alone-treated patients in terms of recurrent UTIs (OR = 0.581; 95% confidence interval [CI] 0.259-1.30), renal parenchymal defects (OR = 1.149; 95% CI 0.75-1.754), and renal scarring (OR = 1.042; 95% CI 0.72-1.50). However, the risk of developing pyelonephritis after surgical treatment of VUR was lesser than that in the conservative approach, that is, antibiotics (OR = 0.345; 95% CI 0.126-0.946.), positive urine culture (OR = 0.617; 95% CI 0.428-0.890), and recurrent UTIs were more common in the placebo group than in the antibiotic group (p < 0.05; OR = 0.639; 95% CI 0.436-0.936) which is statistically significant.

CONCLUSION

Based on current research, we recommend that a child with a UTI and significant VUR be treated conservatively at first, with surgical care reserved for children who have issues with antimicrobials or have clinically significant VUR that persists after several years of follow-up.

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).

Vesicoureteral reflux is it important to find?

Vesico-ureteral reflux (VUR) has long been recognized as associated with urinary tract infections (UTIs), renal scarring, and chronic kidney disease (CKD). The concept of "reflux nephropathy" was born, whereby the VUR was considered the culprit, predisposing to recurrent UTIs and providing a conduit whereby the infection could ascend to the kidneys resulting in scarring and destruction. The more severe grades of reflux were thought to place the young child at particular risk of CKD. The question being asked in this pro/con debate is whether VUR is indeed the culprit responsible for a significant proportion of children with CKD, a number of whom progress to end-stage kidney failure (ESKF), and is thus important to find and treat, or is it an innocent bystander associated with CKD and ESKF but not the cause. We believe the latter and will present convincing evidence supported by large scale prospective randomized controlled trials that VUR is not the ogre it was thought to be and is not important to find following a UTI (with some exceptions).

Comparison of Subureteral Endoscopic Injection of Dextranomer/Hyaluronic Acid and Lich-Gregoir Ureteral Reimplantation in the Treatment of Pediatric Primary Vesicoureteral Reflux: A Prospective Randomized Study

Background: The gold standard of surgical intervention of vesicoureteral reflux (VUR) is open ureteral reimplantation with high success and low complication rates. However, in recent years, endoscopic injection, dextranomer/hyaluronic acid (Dx/HA), has become an effective therapy for VUR. It is noted that limited prospective randomized trials compare the different surgical techniques of especially endoscopic injection versus open procedures. We aimed to compare the outcomes of endoscopic injection of Dx/HA and Lich-Gregoir open technique of ureteral reimplantation for grades III and IV primary VUR in pediatric patients. Materials and Methods: Between January 2016 and December 2018, 60 pediatric patients with grades III and IV primary VUR were included in a prospective randomized trial. Thirty cases with 45 refluxing ureters managed by endoscopic injection of Dx/HA comprised group A. Open Lich-Gregoir technique used in the other 30 cases with 48 refluxing ureters composed of group B. Renal ultrasound, voiding cystourethrography, and renal scintigraphy were used for follow-up. The surgical success rate, cost-effectiveness, and occurrence of complications were evaluated and compared in both groups. Results: Sixty pediatric patients with 93 refluxing ureters (41 females and 19 males) were included in the trial. The mean follow-up for all patients was 17.7 ± 7.1 months. Overall reflux resolution was 80% (36/45) of the ureters in group A after a single injection and 93.75% (45/48) of the ureters in group B. The difference between the two groups was not statistically significant concerning clinical or anatomical preoperative factors and surgical success rate. There was a statistically significant difference between the two groups in terms of operative time and hospital stay. Conclusion: This comparative study demonstrated a high success rate of open ureteral reimplantation (Lich-Gregoir) procedure over the endoscopic injection of Dx/HA therapy to manage primary VUR grades III-IV. Clinical Trial Number: NCT04798443.

Vitamin D deficiency as a risk factor for renal scarring in recurrent urinary tract infections

BACKGROUND

Renal scarring is a serious complication in recurrent urinary tract infections (UTIs). Vitamin D deficiency has also been reported to be a risk factor for UTIs although, to date, no association between vitamin D deficiency and renal scarring has yet been identified. In the present study, it was investigated whether vitamin D deficiency may be a risk factor for renal scarring in patients with recurrent UTIs.

METHODS

The study included patients between the ages of 1 and 18 years who were admitted to the pediatric nephrology department of the center between November 1, 2018 and November 1, 2019 and who were diagnosed with recurrent UTIs. The medical records of the patients were reviewed for the collection of demographic data, vitamin D levels, ultrasonography results and scintigraphic investigations with 99m-technetium dimercaptosuccinic acid (^99m Tc-DMSA). The patients were divided into two groups: those with and without renal scarring, diagnosed via ^99m Tc-DMSA. The vitamin D levels and other parameters of the two groups were compared.

RESULTS

Vitamin D deficiency (<20 ng/mL) was observed in 73.9% of the patients without renal scarring, and in 94.1% of those with renal scarring (P = 0.015). A logistic regression analysis revealed vitamin D deficiency to be an independent risk factor for renal scarring in patients with recurrent UTIs (OR = 0.796 [0.691-0.917]).

CONCLUSIONS

Vitamin D deficiency is found to be a risk factor for renal scarring in patients with recurrent UTIs. Vitamin D treatment may contribute to the prevention of renal scarring in patients with recurrent UTI.

Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice

Introduction

Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR.

Methods

The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document.

Results and Discussion

Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation

INTRODUCTION

Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR).

METHODS

We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system.

RESULTS

A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort.

CONCLUSIONS

Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

Interventions for primary vesicoureteric reflux

BACKGROUND

Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. This is an update of a review first published in 2004 and updated in 2007 and 2011.

OBJECTIVES

The aim of this review was to evaluate the available evidence for both benefits and harms of the currently available treatment options for primary VUR: operative, non-operative or no intervention.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register to 3 May 2018 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

RCTs in any language comparing any treatment of VUR and any combination of therapies.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model.

MAIN RESULTS

Thirty four studies involving 4001 children were included. Interventions included; long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin. Interventions were used alone and in combinations. The quality of conduct and reporting of these studies was variable, with many studies omitting crucial methodological information used to assess the risk of bias. Only four of the 34 studies were considered at low risk of bias across all fields of study quality. The majority of studies had many areas of uncertainty in the risk of bias fields, reflecting missing detail rather than stated poor design.Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI (9 studies, 1667 children: RR 0.77, 95% CI 0.54 to 1.09; low certainty evidence) and febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; low certainty evidence) at one to two years. At one to three years, antibiotic prophylaxis made little or no difference to the risk of new or progressive renal damage on DMSA scan (8 studies, 1503 children: RR 0.73, 95% CI 0.33 to 1.61; low certainty evidence). Adverse events were reported in four studies with little or no difference between treatment groups (1056 children: RR 0.94, 95% CI 0.81 to 1.08; ), but antibiotics increased the likelihood of bacterial drug resistance threefold (187 UTIs: RR 2.97, 95% CI 1.54 to 5.74; moderate certainty evidence).Seven studies compared long-term antibiotic prophylaxis alone with surgical reimplantation of ureters plus antibiotics, but only two reported the outcome febrile UTI (429 children). Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; moderate certainty evidence). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (4 studies, 572 children, RR 1.09, 95% CI 0.79 to 1.49; moderate certainty evidence)Four studies compared endoscopic injection with antibiotics alone and three reported the outcome febrile UTI. This analysis showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics (RR 0.74, 95% CI 0.31 to 1.78; low certainty evidence). Four studies involving 425 children compared two different materials for endoscopic injection under the ureters (polydimethylsiloxane (Macroplastique) versus dextranomer/hyaluronic acid polymer (Deflux), glutaraldehyde cross-linked (GAX) collagen (GAX) 35 versus GAX 65 and Deflux versus polyacrylate polyalcohol copolymer (VANTRIS)) but only one study (255 children, low certainty evidence) had the outcome of febrile UTI and it reported no difference between the materials. All four studies reported rates of resolution of VUR, and the two studies comparing Macroplastique with Deflux showed that Macroplastique was probably superior to dextranomer/hyaluronic acid polymer (3 months: RR 0.50, 95% CI 0.33 to 0.78; 12 months: RR 0.54 95% CI 0.35 to 0.83; low certainty evidence)Two studies compared probiotic treatment with antibiotics and showed little or no difference in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; low certainty evidence)Single studies compared circumcision with antibiotics, cranberry products with no treatment, oxybutynin with placebo, two different surgical techniques and endoscopic injection with no treatment.

AUTHORS' CONCLUSIONS

Compared with no treatment, the use of long-term, low-dose antibiotics may make little or no difference to the number of repeat symptomatic and febrile UTIs in children with VUR (low certainty evidence). Considerable variation in the study designs and subsequent findings prevented drawing firm conclusions on efficacy of antibiotic treatment.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear since few studies comparing the same treatment and with relevant clinical outcomes were available for analysis.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society

BACKGROUND

We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae.

METHODS

A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement.

RESULTS

BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented.

CONCLUSIONS

This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Paediatric robotic surgery

A review of the current status of robotic surgery use in paediatrics.

Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of robot-assisted laparoscopic ureteral reimplantation (RALUR) and open ureteral reimplantation (OUR) in treating primary pediatric vesicoureteral reflux (VUR) based on published literature.

METHODS

A comprehensive literature search of PubMed, Embase, Cochrane Library, CBM, CNKI and VIP databases was conducted to identify studies comparing the outcomes of RALUR with OUR for treating primary pediatric VUR. The last search was in January 2017. Summarized mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the differences in outcomes between RALUR and OUR.

RESULTS

A total of six studies containing 7122 children with primary VUR were included in this analysis. Significantly longer operation time was needed for RALUR than OUR (MD 66.69 min, 95% CI 41.71-91.67, P < 0.00001), while the RALUR group had significantly fewer days of hospital stay (MD - 17.80 h, 95% CI - 21.18 to - 14.42, P < 0.00001) and postoperative Foley placement (MD - 0.32 days, 95% CI - 0.57 to - 0.07, P = 0.01). No significant differences were found in estimated blood loss during operation, success rate, complications, and postoperative analgesia usage between the two groups. In subgroup analyses, a significantly higher rate of short-term postoperative complications in RALUR was found compared with OUR (OR 3.17, 95% CI 1.72-5.85, P = 0.0002).

CONCLUSIONS

Our study indicates that compared with OUR, RALUR is also an effective surgical approach for primary pediatric VUR and could help patients return to society more quickly; however, short-term postoperative complications of RALUR should be considered cautiously.

Urinary albumin excretion and chronic kidney disease in children with vesicoureteral reflux

BACKGROUND

Albuminuria is a potential biomarker of chronic kidney disease (CKD) in various glomerular diseases. Vesicoureteral reflux (VUR) often progresses to CKD, and study is required of use of albuminuria as a biomarker for this condition. The aim of this study was to evaluate the association between albuminuria and glomerular filtration rate (GFR) or filtration fraction (FF) in children with VUR.

STUDY DESIGN

In this retrospective study, renal parameters of 141 children with VUR were investigated, using inulin clearance, FF, and albuminuria. The association between urinary albumin to creatinine ratio (ACR), GFR, and FF was analyzed in a continuous manner by calculating the β coefficient, and also in a binary manner by calculating the OR.

RESULTS

Using both continuous and binary analyses, ACR values were negatively and significantly associated to GFR values in patients with low, normal, or high FF values (Table). It was also positively and significantly associated with FF values in patients with low, normal or high GFR values (Table). No association was found between ACR and gender, VUR stages or laterality, number of urinary tract infection, presence of a single functional kidney, history of reflux surgery, or renal scars or hypertension.

DISCUSSION

ACR is associated with CKD in patients with VUR. In addition, increased urinary albumin excretion cannot be completely and solely explained by decreased GFR and/or increased FF values. The two main limitations of this study are the crude assessment of renal scarring, which prevented finer analysis between albuminuria and renal scarring surface area, and that the study cohort may not be representative of the true VUR population.

CONCLUSION

This study shows that albuminuria is associated with decreased renal function in patients with VUR and that it could be used to monitor renal function in this condition.

Urinary Tract Infections in Infants and Children

Urinary tract infections (UTI) are one of the most common infections in children and symptoms may be nonspecific. The risk of renal scarring is highest in children under 1 year of age with febrile UTI and high-grade vesicoureteral reflux (VUR). Although treatment of UTI is usually straightforward, given increased rates of antimicrobial resistance worldwide, the choice of treatment for pediatric UTI should be guided by community resistance patterns whenever feasible. The benefit of antimicrobial prophylaxis after first UTI and/or in the presence of VUR remains controversial, but a recent meta-analysis supports continuous antimicrobial prophylaxis in children with VUR, indicating a need for more research in this area.

Validation of the ureteral diameter ratio for predicting early spontaneous resolution of primary vesicoureteral reflux

INTRODUCTION AND OBJECTIVE

Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade currently constitutes an important prognostic factor. Previous reports have demonstrated that distal ureteral diameter ratio (UDR) may be more predictive of outcome than vesicoureteral reflux (VUR) grade. We performed an external validation study in young children, evaluating early spontaneous resolution rates relative to reflux grade and UDR.

STUDY DESIGN

Voiding cystourethrograms (VCUGs) were reviewed. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1 and L3 vertebral bodies (Figure). VUR grade and UDR were tested in univariate and multivariable analyses. Primary outcome was status of VUR at last clinical follow-up (i.e. resolution, persistence, or surgical intervention). Demographics, VUR timing, laterality, and imaging indication were also assessed.

RESULTS

One-hundred and forty-seven children (98 girls, 49 boys) were diagnosed with primary VUR at a mean age of 5.5 ± 4.7 months. Sixty-seven (45.6%) resolved spontaneously, 55 (37.4%) had persistent disease, and 25 (17%) were surgically corrected. Patients who spontaneously resolved had significantly lower VUR grade, refluxed later during bladder filling, and had significantly lower UDR. In a multivariable model, grade of VUR (p = 0.001), age <12 months (p = 0.008), ureteral diameter (p = 0.02), and UDR (p < 0.0001) achieved statistical significance. For every 0.1 unit increase in UDR, there was a 2.6 (95% CI 1.58-4.44) increased odds of persistent VUR, whereas a 1.6 (95% CI 0.9-3.0) increased odds was observed for every unit increase in grade.

DISCUSSION

Both grade of reflux and UDR were statistically significant in a multivariable model; however, UDR had a higher likelihood ratio and was more predictive of early spontaneous resolution than grade alone. Furthermore, unlike traditional VUR grading where children with grade 1-5 may outgrow reflux depending on other factors, there appears to be a consistent UDR cutoff whereby patients are unlikely to resolve. In the present study, no child with a UDR greater than 0.43 experienced early spontaneous resolution, and only three (4.5%) of those with spontaneous resolution had a UDR above 0.35.

CONCLUSIONS

UDR correlates with reflux grade, and is predictive of early resolution in children with primary VUR. UDR is an objective measurement of VUR, and provides valuable prognostic information about spontaneous resolution, facilitating more individualized patient care.

Distal Ureteral Diameter Ratio is Predictive of Breakthrough Febrile Urinary Tract Infection

PURPOSE

Distal ureteral diameter ratio is an objective measure that is prognostic of spontaneous resolution of vesicoureteral reflux. Along with likelihood of resolution, improved identification of children at risk for recurrent febrile urinary tract infections may impact management decisions. We evaluated the usefulness of ureteral diameter ratio as a predictive factor for breakthrough febrile urinary tract infections.

MATERIALS AND METHODS

Children with primary vesicoureteral reflux and detailed voiding cystourethrogram were identified. Ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 and L3 vertebral bodies. Demographics, vesicoureteral reflux grade, laterality, presence/absence of bladder-bowel dysfunction, and ureteral diameter ratio were tested in univariate and multivariable analyses. Primary outcome was breakthrough febrile urinary tract infections.

RESULTS

We analyzed 112 girls and 28 boys with a mean ± SD age of 2.5 ± 2.3 years at diagnosis. Vesicoureteral reflux was grade 1 to 2 in 64 patients (45.7%), grade 3 in 50 (35.7%), grade 4 in 16 (11.4%) and grade 5 in 10 (7.2%). Mean ± SD followup was 3.2 ± 2.7 years. A total of 40 children (28.6%) experienced breakthrough febrile urinary tract infections. Ureteral diameter ratio was significantly greater in children with (0.36) vs without (0.25) breakthrough febrile infections (p = 0.004). Controlling for vesicoureteral reflux grade, every 0.1 U increase in ureteral diameter ratio resulted in 1.7 times increased odds of breakthrough infection (95% CI 1.24 to 2.26, p <0.0001).

CONCLUSIONS

Children with increased distal ureteral diameter ratio are at greater risk for breakthrough febrile urinary tract infections independent of reflux grade. Ureteral diameter ratio provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making.

Critical appraisal of the top-down approach for vesicoureteral reflux

Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.

Do Routine Preoperative and Intraoperative Urine Cultures Benefit Pediatric Vesicoureteral Reflux Surgery?

Objective. To determine if routine preoperative and intraoperative urine cultures (UCx) are necessary in pediatric vesicoureteral (VUR) reflux surgery by identifying their association with each other, preoperative symptoms, and surgical outcomes. Materials and Methods. A retrospective review of patients undergoing ureteral reimplant(s) for primary VUR at a tertiary academic medical center between years 2000 and 2014 was done. Preoperative UCx were defined as those within 30 days before surgery. A positive culture was defined as >50,000 colony forming units of a single organism. Results. A total of 185 patients were identified and 87/185 (47.0%) met inclusion criteria. Of those, 39/87 (45%) completed a preoperative UCx. Only 3/39 (8%) preoperative cultures returned positive, and all of those patients were preoperatively symptomatic. No preoperatively asymptomatic patients had positive preoperative cultures. Intraoperative cultures were obtained in 21/87 (24.1%) patients; all were negative. No associations were found between preoperative culture results and intraoperative cultures or between culture result and postoperative complications. Conclusions. In asymptomatic patients, no associations were found between the completion of a preoperative or intraoperative UCx and surgical outcomes, suggesting that not all patients may require preoperative screening. Children presenting with symptoms of urinary tract infection (UTI) prior to ureteral reimplantation may benefit from preoperative UCx.

A novel approach to evaluating the benefit of post-urinary tract infection renal ultrasonography, using decision curve analysis

BACKGROUND

The benefit of post-urinary tract infection (UTI) sonography to detect clinically significant renal abnormalities remains a subject open to debate. Decision curve analysis (DCA) is a novel method for evaluating the clinical usefulness of diagnostic tests. Our objective was to determine, using DCA, the benefit of post-UTI sonography and of post-UTI sonography with biological markers of inflammation to predict the risk of recurrence of febrile UTI in children aged 2 to 24 months without known uropathy.

METHODS

We retrospectively analyzed all children aged 2 to 24 months, without known uropathy, who presented with a first episode of febrile UTI between 2009 and 2012 and followed them for 30 months. We then used DCA to estimate the benefit of post-UTI sonography or post-UTI sonography + biological markers of inflammation for detecting the risk of recurrence.

RESULTS

A total of 318 children [144 boys (45.3 %) and 174 girls (54.7 %)], with a mean age of 6.9 ± 5.6 months, were identified. Of these, 210 children presented with a significant inflammation [66.2 %; 95 % confidence interval (CI) 61.0-71.4], and 30 (9.4 %; 95 % CI 6.2-12.6) presented with abnormal post-UTI sonographic findings. Eighteen (5.7 %; 95 % CI 3.1-8.2) children presented with recurrent UTI at 30 months.

CONCLUSIONS

There were significantly more recurrences in those children who presented with abnormal sonographic findings than in those who did not (relative risk 7.68; 95 % CI 3.03-19.46). However, taking into account the effect of false-positives and false negatives, the DCA revealed that for threshold probabilities of >30 %, at which patients/doctors are concerned about unnecessary interventions (whether tests or treatments), neither post-UTI sonography nor post-UTI sonography + biological markers of inflammation have sufficient value to improve care.

Controversies in the Management of Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the upper urinary tract. Diagnosis and subsequent management of VUR have become increasingly controversial, with differing opinions over which children should be evaluated for reflux, and when detected, who should undergo treatment. Management goals include prevention of recurrent febrile urinary tract infection (fUTI) and renal injury while minimizing the morbidity of treatment and follow-up. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Management should be individualized and based on patient age, health, risk of subsequent renal injury, clinical course, renal function, and parental preference.

High success rate with new modified endoscopic treatment for high-grade VUR: A pilot study with preliminary report

PURPOSE

Despite the benefits of the minimally invasive endoscopic treatment for vesicoureteral reflux (VUR) it has a major drawback which is low success rate in high grade VUR. For overcoming this problem, we introduce a new modified technique of endoscopic treatment called periureteral injection technique (PIT).

MATERIALS AND METHODS

In a prospective study a total of 37 ureters in 19 boys and 14 girls were treated, including 3 bilateral cases. Of 37 units, 30 (81.1%) had grade IV and 7 (18.9%) had grade V primary VUR (18 right, 13 left and 3 bilateral units). Subureteral injection of Vantris(®) was done at the 5-o'clock and 7-o'clock positions in which the direction of injecting needles were almost parallel. Pre- and post-operative evaluation included urinalysis, urinary tract ultrasonography, voiding cystourethrography (VCUG), dimercaptosuccinic acid scan and urodynamic studies.

RESULTS

The median age was 38 months (range 8-125). At 6 months follow up period confirmed with VCUG, the VUR has been disappeared in 34 (91.8%) units and 3 units [2 (5.4%) grade II and 1 (2.7%) had grade III)] had downgraded VUR. Complications included early fever due to urinary tract infection in 1 children, transient dysuria in 2 patients and low back pain in one patient (Summary Table).

CONCLUSION

The success rate of PIT for treatment of high grade VUR is high. However, further studies with more patients and longer follow up periods are needed to draw final conclusion.

Antireflux surgery does not change ongoing renal functional deterioration

AIM

Treatment modalities of vesicoureteral reflux (VUR) consist of antimicrobial prophylaxis and antireflux surgery. In this study, we aimed to determine if antireflux surgery changes the course of renal functional deterioration in children with VUR and urinary tract infections (UTI).

METHODS

Medical files of patients with VUR diagnosed during evaluation for UTI were evaluated retrospectively for gender, age, follow-up period, and renal ultrasonography (US) and serial 99mTc-dimercaptosuccinic acid (99mTc-DMSA) scintigraphy findings. Estimated glomerular filtration rate and urinary protein levels were determined at the initial and last visits, and before the operation in children who had antireflux surgery. The patients were divided into two groups as solely medically treated (Group 1) and both medically and surgically treated (Group 2). Group 2 was further divided as those with stable renal function (Group 2a) and with progressive renal injury (Group 2b).

RESULTS

There were 140 patients (77 female; mean age 51.6 ± 51.9 months). Group 1 and Group 2 included 82 and 58 patients, respectively. In Group 2, the number of patients with the abnormal US, DMSA scintigraphy, and renal function was higher than in Group 1. Recurrent UTI rate was similar, but progressive scarring was more prominent in the antireflux surgery group. In Group 2, 31 patients had a stable renal function (Group 2a) while 27 had progressive deterioration of renal functions (Group 2b). These subgroups were not different with respect to the rate of high-grade VUR, the presence of a renal scar in DMSA, and UTI recurrence. However, the bilateral renal scar was more common in Group 2b.

CONCLUSION

Antireflux surgery does not change the course of ongoing renal injury and renal functional deterioration.

Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI

OBJECTIVES

2011 American Academy of Pediatrics guidelines recommended renal-bladder ultrasound (RBUS) as the only evaluation after febrile urinary tract infection (FUTI) in infants aged 2-24 months. We determined the sensitivity, specificity, and false negative rate of RBUS to identify DMSA-detected renal damage in this age group as well as in older children.

METHODS

Consecutive patients referred to pediatric urology with a history of FUTI underwent DMSA ≥ 3 months after FUTI. Abnormal RBUS was defined as: Society of Fetal Urology hydronephrosis grades I-IV; hydroureter ≥ 7 mm; renal scar defined as focal parenchymal thinning; and/or size discrepancy ≥ 1 cm between kidneys. Abnormal DMSA was presence of any focal uptake defects and/or split renal function < 44%. We calculated sensitivity, specificity, positive and negative predictive values, and false negative rates of RBUS compared to DMSA.

RESULTS

618 patients (79% female), median age 3.4 years, were referred for FUTIs. Of the 512 (83%) with normal RBUS, 99 (19%) had abnormal DMSA. Children with normal RBUS after their first FUTI had abnormal DMSA in 15/151 (10%) aged ≤ 24 months and 23/119 (19%) aged > 24 months. RBUS had poor sensitivity (34%) and low positive predictive value (47%) to identify patients with renal damage. 99/149 (66%) children with renal damage on DMSA had normal RBUS.

CONCLUSION

After FUTI, 66% of children with reduced renal function and/or renal cortical defects found by DMSA scintigraphy had a normal RBUS. Since abnormal DMSA may correlate with increased risk for VUR, recurrent FUTI and renal damage, our data suggest RBUS alone will fail to detect a significant proportion of patients at risk. The data suggest that imaging after FUTI should include acute RBUS and delayed DMSA, reserving VCUG for patients with abnormal DMSA and/or recurrent FUTI.

Ultrasonography and C-reactive protein can predict the outcomes of voiding cystography after the first urinary tract infection

AIM

This study evaluated whether sex, clinical variables, laboratory variables or ultrasonography predicted the presence of vesicoureteric reflux during the first episode of urinary tract infection in paediatric patients. We also aimed to define the criteria that indicated the need for voiding cystography testing.

METHODS

We used voiding cystography to investigate 200 patients who experienced their first urinary tract infection at our institution between 2004 and 2013 and retrospectively analysed the data by reviewing their medical records.

RESULTS

Sex (p = 0.001), peak blood C-reactive protein levels (p < 0.001), the duration of fever after antibiotic administration (p = 0.007) and the ultrasonography findings grade (p < 0.001) were significantly different between patients with and without vesicoureteric reflux. Grade IV-V ultrasonography findings and C-reactive protein levels of ≥80 mg/L predicted vesicoureteric reflux with a sensitivity, specificity and odds ratio of 47.8%, 87.8% and 6.59 (95% confidence interval = 3.26-13.33), respectively (p < 0.001).

CONCLUSION

Voiding cystography should be performed for patients with C-reactive protein levels of ≥80 mg/L and grade IV-V ultrasonography findings, but is not necessary in patients with C-reactive protein levels of <80 mg/L and grade I-III ultrasonography findings.

Evaluation and management of recurrent urinary tract infections in children: state of the art

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Antibiotic prophylaxis and reflux: critical review and assessment

The use of continuous antibiotic prophylaxis (CAP) was critical in the evolution of vesicoureteral reflux (VUR) from a condition in which surgery was the standard of treatment to its becoming a medically managed condition. The efficacy of antibiotic prophylaxis in the management of VUR has been challenged in recent years, and significant confusion exists as to its clinical value. This review summarizes the critical factors in the history, use, and investigation of antibiotic prophylaxis in VUR. This review provides suggestions for assessing the potential clinical utility of prophylaxis.

Overdiagnosis: how our compulsion for diagnosis may be harming children

Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue. However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection. Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence.

Vesicoureteral Reflux in Pediatric Age: Where are we Today?

Although the diagnosis of vesicoureteral reflux and of reflux nephropathy is a well-established and shared procedure, its treatment nowadays is still very controversial. New developments on the knowledge of pathophysiology of renal damage associated to reflux opened the way towards a different diagnostic work-up and different therapeutic approaches.

Recently, the “top-down” diagnostic approach has gained wider interest, versus the “down-top” protocol. The attention has recently focused on the renal parenchyma damage and less interest has been given to the presence and the radiological degree of vesicoureteral reflux.

The review criteria were based on an in-depth search of references conducted on PubMed, using the terms “vesicoureteral reflux”, “children”, “incidence”, “etiology”, “diagnosis”, “treatment” and “outcomes”. The selection of the papers cited in this review was influenced by the content and the relevance to the points focused in the article.

Conservative approaches include no treatment option with watchful waiting, long-term antibiotic prophylaxis and bladder rehabilitation. The operative treatment consists of endoscopic, open, laparoscopic and robotic procedures to stop the refluxing ureter.

No final consensus has been achieved in literature yet, and further studies are necessary in order to better define the subset of children at risk of developing progression of renal damage.

This review aims to clarify the diagnostic management and the urological-nephrological treatment of reflux in pediatric age, on the basis of a review of the best-published evidence.

Relevance of current guidelines in the management of VUR

In recent years, there have been fundamental changes in the understanding of vesicoureteral reflux (VUR). This is reflected by current international guidelines that cover diagnosis, screening, and treatment of VUR. However, literature is still lacking and many questions are unsolved. In this article, we shortly review the important aspects of the current guidelines. Due to the lack of high-powered randomized controlled trials, guidelines often are based on an expert's opinion rather than evidence. In this review article, we address the controversies in the management of VUR; siblings and children with antenatally diagnosed hydronephrosis and the management of a patient with VUR.

CONCLUSION

With an individualized approach and patient risk stratification, the goal today must be to address the clinical problem, avoid unnecessary tests, and provide good quality of life for the patient and parents.

Evaluation of new Deflux administration techniques: intraureteric HIT and Double HIT for the endoscopic correction of vesicoureteral reflux

Vesicoureteral reflux (VUR) is one of the most common urologic diagnoses affecting children, and optimal treatment requires an individualized approach that considers potential risks. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Endoscopic correction of VUR is an outpatient procedure associated with decreased morbidity compared with ureteral reimplantation. The concept of ureteral hydrodistention and intraluminal submucosal injection (Hydrodistention Implantation Technique [HIT]) has led to improved success rates in eliminating VUR compared with the subureteral transurethral injection technique. Further modifications now include use of proximal and distal intraluminal injections (Double HIT) that result in coaptation of both the ureteral tunnel and orifice. Endoscopic injection of dextranomer/hyaluronic acid copolymer, via the HIT and Double HIT, has emerged as a highly successful, minimally invasive alternative to open surgical correction, with minimal associated morbidity.

Childhood vesicoureteral reflux studies: registries and repositories sources and nosology

Despite several recent studies, the advisability of antimicrobial prophylaxis and certain imaging studies for urinary tract infections (UTIs) remains controversial. The role of vesicoureteral reflux (VUR) on the severity and re-infection rates for UTIs is also difficult to assess. Registries and repositories of data and biomaterials from clinical studies in children with VUR are valuable. Disease registries are collections of secondary data related to patients with a specific diagnosis, condition or procedure. Registries differ from indices in that they contain more extensive data. A research repository is an entity that receives, stores, processes and/or disseminates specimens (or other materials) as needed. It encompasses the physical location as well as the full range of activities associated with its operation. It may also be referred to as a biorepository. This report provides information about some current registries and repositories that include data and samples from children with VUR. It also describes the heterogeneous nature of the subjects, as some registries and repositories include only data or samples from patients with primary reflux while others also include those from patients with syndromic or secondary reflux.

Vesico-ureteric reflux (VUR) management and screening patterns: are paediatric urologists following the 2010 American Urological Association (AUA) guidelines?

OBJECTIVE

To evaluate the current practice patterns of vesico-ureteric reflux (VUR) management and screening among paediatric urologists and their relationship with the current American Urological Association (AUA) guidelines in managing and treating VUR.

SUBJECTS AND METHODS

A 17-question survey was sent out to 476 paediatric urologists who are members of the Society for Pediatric Urology (SPU). In all, 133 respondents answered the survey and results were included for all questions.

RESULTS

Paediatric urologists who were surveyed were consistent with the 2010 AUA guidelines in the initial evaluation of children with VUR, continuous antibiotic prophylaxis for the child aged < or >1 year, and follow-up evaluation in children with VUR. Most paediatric urologists do not obtain a serum creatinine on initial screening of children with VUR. The new guidelines address screening of siblings of patients with VUR and most paediatric urologists were consistent with these recommendations. Almost one third of responders screened all neonates diagnosed with prenatal hydronephrosis regardless of clinical history or findings on imaging despite the recommendations of the new guidelines.

CONCLUSION

We conclude that based on our present sample, most paediatric urologists follow the 2010 AUA guidelines on VUR management.

Current medical diagnosis and management of vesicoureteral reflux in children

Vesico-ureteral reflux (VUR) is presented in approximately %1 of children and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and morbidity, many aspects of VUR diagnosis and treatment are controversial. We objectively assessed the published data; the data base for many current diagnoses and treatment patterns of VUR is limited. Recent studies have focused on developed determination of VUR-related renal morbidity, improved stratification tools that children would benefit most from which VUR treatment option, and improved reporting of the long-term outcomes of VUR treatments in children who are at risk for VUR. In this review, the advances in the diagnosis and treatment of VUR will be accompanied by the current guidelines.

The incidence of urinary tract infection after open anti-reflux surgery for primary vesicoureteral reflux: early and long-term follow up

OBJECTIVES

Controversy exists regarding the benefit of open anti-reflux surgery (OS) in reducing the incidence of urinary tract infection (UTI). We, therefore, reviewed our short and long term data in children who have undergone OS.

METHODS

153 children (131F, 22M; ages 2-16 yrs, mean 8 yrs) underwent OS from 1990 to 2008. Reasons for presentation were UTI-131; sibling survey-19; prenatal hydronephrosis-3. Major reasons for OS were: breakthrough UTI-74 (48%), high grade (IV or V)-49 (32%), poor compliance with prophylaxis-15 (10%). Of 153 pre-operative DMSA scans, 60 (39%) had defects. Post-operative studies were performed 6 months after surgery and 151 (99%) had negative voiding cystourethrograms (VCUG's). All underwent urine cultures 6 months post-op and prophylaxis was stopped. 56 (37%) were later contacted at an average 7 yrs post-op (range: 2-13 yrs).

RESULTS

23 (15% of 153 followed short term, 40% of 56 followed long term)-20F, 3M-had non-febrile UTI's (nfUTI's) and one girl (0.6%) had a febrile UTI (fUTI). Of those who had nfUTI's 7 (30%) had high grade reflux and 16 (70%) had pre-op breakthrough UTI's. 11 (48%) had DMSA scans with defects. 2 had UTI's within 1 year after a negative VCUG and 21 had UTI's later (1-8 yrs). 1 girl had a fUTI 1 month after a negative VCUG.

CONCLUSIONS

Successful OS effectively eliminates fUTI. Families should be counseled that nfUTI may occur many years after surgery, especially in girls with a history of breakthrough UTI and renal scarring.

A modified technique for ureteral reimplantation: intravesical detrusorrhaphy

PURPOSE

To describe the surgical procedure of intravesical detrusorrhaphy, a modified technique of ureteral reimplantation, and report our initial experience.

METHODS

From October 2007 to March 2012, 55 children with vesicoureteral reflux (VUR) and 13 children with obstructive megaureter (OM) underwent intravesical detrusorrhaphy. All surgical procedures were performed via an open intravesical approach. The ureter was mobilized, and the bladder mucosa was separated from the detrusor in a cephalad direction. The separated detrusor was incised vertically and repaired underneath the mobilized ureter to create the submucosal tunnel. The ureteral orifice was anastomosed to its orthotopic position.

RESULTS

Of 31 patients treated with bilateral intravesical detrusorrhaphy, no patient had postoperative urinary retention. Follow-up voiding cystourethrography was performed in 45 patients with 72 reimplanted ureters. VUR was resolved in 41 patients (91.1%) with 68 ureters (94.4%). Among 13 patients with 14 ureters treated for OM, hydroureteronephorosis improved in 11 patients (84.6%) with 12 ureters (85.7%).

CONCLUSIONS

Intravesical detrusorrhaphy is modified technique of ureteral reimplantation, which recreates the neo-ureteric orifice in the orthotopic position and does not produce postoperative urinary retention in bilateral cases. Intravesical detrusorrhaphy is safe and effective in treating patients with VUR or OM.