Opioid utilization is minimal after outpatient pediatric urologic surgery

INTRODUCTION

There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution.

MATERIALS AND METHODS

After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use.

RESULTS

Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups.

DISCUSSION AND CONCLUSIONS

Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness

INTRODUCTION

Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present.

OBJECTIVE

The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure).

STUDY DESIGN

Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region.

RESULTS

All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques.

CONCLUSIONS

The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

Is routine voiding cystourethrogram necessary following double hit for primary vesicoureteral reflux?

INTRODUCTION AND OBJECTIVE

Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG.

STUDY DESIGN

Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥ 3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade 4-5 VUR. Initially, all children underwent postoperative VCUG ("routine" group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study ("indicated" group). Clinical success was defined as no postoperative fUTI and radiographic success as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months.

RESULTS

Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were "routine" and 38 were "indicated" [Figure]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2-50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2-40). Nine children (4.1%) underwent additional procedures.

DISCUSSION

We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an "indicated" VCUG (i.e. those less than 2 years of age, grade 4-5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an "indicated" VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence "spontaneous resolution" is unknown.

CONCLUSION

Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method.

Vesicoureteral reflux index (VURx): a novel tool to predict primary reflux improvement and resolution in children less than 2 years of age

PURPOSE

Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution.

MATERIALS AND METHODS

Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance.

RESULTS

Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p<0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively.

CONCLUSIONS

Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.

Phantom urinary incontinence in children with bladder-bowel dysfunction

OBJECTIVE

To report a previously undescribed condition in which children present with the sensation of wetness because of presumed urinary incontinence when they are actually completely dry. We have termed this entity "phantom" urinary incontinence (PUI).

MATERIALS AND METHODS

Twenty children referred to our pediatric urology clinic were diagnosed with PUI between 2009 and 2013. Patient demographics, associated bladder and bowel symptoms, concomitant diagnoses, imaging, management, and treatment outcomes were evaluated.

RESULTS

Twenty children (18 females and 2 males) were diagnosed with PUI over a 5-year interval. Mean age at diagnosis was 6.9 ± 2.5 years (range, 4-12 years). Nineteen patients (95%) had concomitant lower urinary tract symptoms, and all were also diagnosed with constipation. Urgency (75%) and frequency (50%) were the most common associated bladder symptoms. Of the 18 girls, 13 (72%) had associated vaginitis. Fourteen children (70%) carried a parent-reported diagnosis of obsessive-compulsive disorder or obsessive-compulsive disorder personality traits. Patients were managed with timed voiding, dietary modifications, and a bowel regimen. Ninety percent children experienced improvement of bladder-bowel dysfunction and resolution of PUI at a mean follow-up of 14.4 months.

CONCLUSION

Children with PUI have a high incidence of obsessive-compulsive traits. Phantom incontinence as well as associated lower urinary tract symptoms resolve with adherence to a strict bladder-bowel regimen.

Emergency room visits and readmissions after pediatric urologic surgery

OBJECTIVE

Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution.

MATERIALS AND METHODS

Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed.

RESULTS

Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3-24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%.

CONCLUSIONS

The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux

OBJECTIVE

The objective of this study was to evaluate risk factors for new contralateral vesicoureteral reflux (NCVUR) and to investigate whether assessment of the non-refluxing contralateral ureter (NRCU) by hydrodistention and selective treatment can reduce the incidence of NCVUR.

MATERIALS AND METHODS

From 2001 to 2007, 339 of 841 patients (40%) were treated for unilateral VUR by endoscopic injection. While in the first 267 patients the NRCU was only assessed by hydrodistention but not injected (observation group), NRCUs of the subsequent 72 patients were prophylactically treated if deemed at high risk for NCVUR (H2 or H3) (prophylaxis group).

RESULTS

NCVUR occurred in 30 of 267 patients (11.2%) whose NRCUs were observed. No statistically significant risk factors for NCVUR were found in this group. In the subsequent 72 patients, whose H2 and H3 ureters were selectively injected (N = 56), no cases of NCVUR were seen.

CONCLUSIONS

Prophylactic endoscopic treatment of NRCU H2 and H3 ureters successfully prevented the occurrence of NCVUR.

Pediatric chronic orchalgia

INTRODUCTION

Chronic orchalgia, defined as testicular pain lasting > 3 months and interfering with normal activities, is neglected in the pediatric literature. We describe our experience with the evaluation and treatment of pediatric chronic orchalgia patients.

MATERIALS AND METHODS

Charts were screened to identify patients meeting the criteria for chronic orchalgia. Charts were further reviewed to record the history and physical exam, diagnostic tests, treatment and outcomes.

RESULTS

65/982 patients met the criteria for chronic orchalgia. Mean age was 13 and mean duration of pain was 8.6 months. Physical exam findings were normal in 46 patients (70%). 59 patients were managed conservatively with resolution (10/59, 17%) or a single visit (36/59, 61%) in 78%. 13/59 (22%) patients showed either minor improvement or no change in symptoms. 5 non-responding patients were managed by the anesthesia pain service; 4 received epidurals with or without additional oral pain medications with 3 experiencing significant pain improvement.

CONCLUSION

Conservative management of chronic orchalgia allowed symptoms to subside in the majority of cases. We recommend patients be treated with conservative measures for 1-2 months. If this fails, early involvement of the anesthesia pain service can offer treatment modalities such as epidural analgesia. Surgical management in the face of a normal physical exam does not seem to have a role.

Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux

PURPOSE

Follow-up of patients undergoing dextranomer/hyaluronic acid injection for vesico-ureteral reflux (VUR) is controversial. The purpose of our study was to test the hypothesis that patients undergoing the double hydrodistention-implantation technique (Double HIT) have a higher clinical and radiographic success rate.

MATERIALS AND METHODS

Patients undergoing Double HIT endoscopic injection for VUR were prospectively identified. Patients underwent an ultrasound at 6 weeks to assess the implants, and, if visible, prophylactic antibiotics were discontinued and patients were scheduled for a 1-year voiding cystourethrogram (VCUG). Radiographic success was defined as a negative VCUG and clinical success as no febrile urinary tract infections at 1 year.

RESULTS

A total of 54 patients underwent endoscopic injection for VUR. Twenty-five (51%) were compliant with the 1 year follow-up; 18 non-compliant patients were contacted and their clinical status assessed. Thirty patients eventually completed the 1-year VCUG at a mean of 12.2 months (range 10-20). Among the 60% of patients with 1-year radiographic follow-up, 2 had persistent VUR for a radiologic success rate of 93%. All radiographic failures were infection-free. Of the 80% (43/54) of patients with available clinical data, 3 (7%) had afebrile UTI for a clinical success rate of 93%.

CONCLUSIONS

The Double HIT leads to a 93% clinical and 93% radiographic intermediate/long-term success rate. With this technique, better outcomes were achieved with fewer recurrences than previously reported. These favorable results challenge the need for postoperative VCUG in asymptomatic patients after the Double HIT.

Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: defining measures of success

OBJECTIVE

Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up.

METHODS

We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1-21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12-36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions.

RESULTS

In 2004-2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as 'radiographic cure and no clinical evidence of FUTIs' it was 82% (275/336).

CONCLUSIONS

It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.

Does compliance status predict clinical status in patients undergoing endoscopic management of vesico-ureteral reflux?

OBJECTIVE

Previous studies of endoscopic management of vesico-ureteral reflux (VUR) have had non-compliance rates around 50%. We examined success rates of patients non-compliant with a delayed follow up protocol after endoscopic injection for VUR.

MATERIALS AND METHODS

Patients undergoing Double HIT, dextranomer/hyaluronic acid copolymer endoscopic injection for VUR were enrolled in a 1-year, delayed voiding cysto-urethrogram (VCUG) study. All patients non-compliant with the VCUG were contacted and information on their clinical status was collected. Non-compliant patients were re-scheduled for a VCUG.

RESULTS

49/54 (91%) patients underwent endoscopic injection for VUR and completed the 6-week ultrasound. At 1-year 49% (24/49) were non-compliant with a VCUG; 75% (18/24) were contacted and provided clinical information. All but one patient agreed to the VCUG. Patients compliant with the 1-year VCUG showed 96% (24/25) clinical and 92% (23/25) radiologic success rates. Non-compliant patients had an 89% (16/18) clinical success rate; 5 (21%) non-compliant patients underwent VCUGs with a 100% success rate.

CONCLUSIONS

Long-term compliance remains an issue for patients treated endoscopically for VUR, but compliance does not predict clinical status as both groups have favorable clinical outcomes. The repeat VCUG is a barrier to long-term follow up as only 21% of patients underwent the study.

Is endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder?

OBJECTIVE

To assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB).

METHODS

A total of 41 patients with VUR and OAB underwent endoscopic injection of dextranomer/hyaluronic acid. At surgery, 13 patients had been successfully treated for their OAB (urgency with or without wetting) with behavior modification with or without anticholinergic therapy, and 28 had persistent OAB despite treatment. Voiding cystourethrogram was obtained 6-12 weeks postoperatively, and patients were followed up clinically for 1-5 years.

RESULTS

Negative voiding cystourethrogram findings after a single treatment were seen in 34 (82.9%) of 41 patients. The radiographic success rate in patients with well-controlled OAB was 76.9% (10 of 13) compared with 85.7% (24 of 28) of those with poorly controlled OAB. The overall clinical success rate, defined as no evidence of urinary tract infection in the setting of negative voiding cystourethrogram findings, reached 78.0% (32 of 41). After successful endoscopic treatment, an unanticipated return to normal voiding patterns without the need for postoperative anticholinergic therapy was seen in 4 of the children with well-controlled OAB (40.0%) and in 4 with poorly controlled OAB (16.7%).

CONCLUSION

Our data suggest that endoscopic injection is a viable treatment option for VUR in those with OAB, with postoperative rates of resolution comparable to those found in patients without OAB. Furthermore, 40.0% of children with well-controlled OAB no longer required therapy for OAB after resolution of their VUR.

Appearance of Deflux implants with magnetic resonance imaging after endoscopic treatment of vesicoureteral reflux in children

OBJECTIVE

With the increasing popularity of endoscopic treatment for vesicoureteral reflux (VUR) in children, dextranomer/hyaluronic acid copolymer (Deflux) implants are more frequently detected by magnetic resonance imaging (MRI). Such findings on MRI may be misinterpreted and lead to unnecessary intervention. The objective of this study was to characterize the appearance of Deflux implants on MRI.

MATERIALS AND METHODS

Between July 2001 and November 2007, hospital charts of patients with a history of Deflux injection for VUR were evaluated to identify those who had subsequent MRI studies. The indications were determined, and the appearance of Deflux implants analyzed and compared to findings on ultrasound, voiding cystourethrography and kidney ureter bladder radiography.

RESULTS

Of 893 patients who underwent endoscopic treatment for VUR, subsequently 16 patients (1.8%) had MRI scans. Twenty-seven Deflux implants were identified on MRI as bright structures on T2-weighted sequences only. Neither T1-weighted images nor excretory MR urography visualized the Deflux implants, which did not enhance with gadolinium. Deflux was not detected by kidney ureter bladder radiography; however, voiding cystourethrography and more reliably ultrasound could identify implants.

CONCLUSIONS

Deflux implants appear on MRI as bright structures on T2-weighted sequences. History of VUR/VUR treatment and the presence of a single urinary system should provide reassurance and prevent inappropriate intervention for misdiagnosed ureteroceles.

Endoscopic injection of dextranomer hyaluronic acid copolymer for the treatment of vesicoureteral reflux in duplex ureters

PURPOSE

Endoscopic injection of dextranomer hyaluronic acid copolymer (DxHA) has been increasingly utilized for the treatment of complex cases of vesicoureteral reflux (VUR). We present our 6-year experience with the use of DxHA for the treatment of VUR in duplex ureters.

MATERIALS AND METHODS

Between July 2001 and April 2007, 52 children were identified retrospectively who had been treated by endoscopic injection of DxHA for VUR into duplex ureters. Mean age was 3 years (range 9 months-10 years) with a mean maximum grade of reflux of III (range 2-5). The refluxing lower pole ureter was injected using a subureteric injection technique (STING) or intraureteric injection technique (utilizing the hydrodistention implantation technique). The endpoint in all cases was the loss of hydrodistention of the ureteral orifice. Voiding cystourethrograms was obtained at 6 weeks-3 months to evaluate for the presence of VUR. Cure was defined as complete resolution of reflux in the treated moiety.

RESULTS

After initial treatment, 38/52 (73%) patients were cured. Of the 14 failures, nine children underwent repeat endoscopic treatment with a 67% (6/9) resolution rate for repeat injection. Seven of the initial failures failed to grade I VUR. Overall, 85% (44/52) were cured after one or two treatments, 98% (51/52) were improved and only one (1.9%) with grade V VUR required open surgery. The treatment was well tolerated and there were no associated complications.

CONCLUSION

Endoscopic injection of DxHA copolymer corrected VUR in 85% of children with VUR into duplex ureters. This minimally invasive approach should be considered as a viable alternative to open surgery or antibiotic prophylaxis for the treatment of VUR associated with duplex ureters.

Endoscopic treatment of vesicoureteral reflux using dextranomer hyaluronic acid copolymer

Vesicoureteral reflux (VUR) is a common urinary tract anomaly. Treatment is performed to minimize the risk of febrile urinary UTIs that may result in renal scarring. The endoscopic use of dextranomer hyaluronic acid copolymer has been gaining popularity as an alternative to the traditional methods of open surgery and chronic antibiotic prophylaxis. The aim of this educational review was to present the trends, latest perspectives and surgical techniques regarding this newer method of treatment of VUR. Evolving techniques are described that have resulted in VUR cure rates that rival that of open ureteral reimplantation with minimal associated morbidity. These have proven to be effective in complex cases that were previously considered as contraindications for endoscopic treatment, including voiding dysfunction, duplex ureters, high-grade VUR and paraureteral diverticuli. It is recommended that open reimplantation be reserved for those children with ectopic ureters, megaureters that require tapering or secondary grade V VUR, and those who have failed two endoscopic injections. Future advances promise to standardize the injection technique, ensuring optimum needle placement for consistently successful injections.

Incidence of urinary tract infections in children after successful ureteral reimplantation versus endoscopic dextranomer/hyaluronic acid implantation

PURPOSE

Endoscopic implantation of dextranomer/hyaluronic acid has proved to be an effective minimally invasive technique for correcting vesicoureteral reflux in children. There is some evidence suggesting that in addition to being less invasive, successful dextranomer/hyaluronic acid implantation compared to successful antireflux surgery is associated with fewer febrile and nonfebrile urinary tract infections. We review the clinical outcomes of 2 groups of children cured of reflux with open surgery and dextranomer/hyaluronic acid implantation to determine if a difference in clinical outcomes exists.

MATERIALS AND METHODS

We reviewed the charts of 43 patients who underwent dextranomer/hyaluronic acid implantation and 33 who underwent open surgery for vesicoureteral reflux. Data collected included age, gender, preoperative and postoperative grades of reflux, and urinalysis and urine culture results. Urinary tract infection was defined as any culture that grew more than 10(5) colonies of a single organism, with symptoms typical of cystitis (urgency, frequency, dysuria). A febrile urinary tract infection was defined as an infection accompanied by a temperature greater than 101.5F. Any hospitalizations for febrile episodes were also recorded.

RESULTS

The incidence of urinary tract infection after successful open surgery (38%) was significantly higher than that observed following successful dextranomer/hyaluronic acid treatment (15%, p = 0.03). Febrile urinary tract infections occurred in 24% of the children who underwent open surgery and in 5% of those who underwent dextranomer/hyaluronic acid implantation (p = 0.02). Hospital readmissions occurred only in the group undergoing open surgery.

CONCLUSIONS

Children successfully cured of vesicoureteral reflux with dextranomer/hyaluronic acid implantation have a lower incidence of febrile and nonfebrile urinary tract infections compared to those cured with open surgery. These findings suggest that dextranomer/hyaluronic acid implantation, when successful, may result in more favorable clinical outcomes.

Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children

PURPOSE

The goal of this review is to present current indications, injectable agents, techniques, success rates, complications, and potential future applications of endoscopic treatment for vesicoureteral reflux (VUR) in children.

MATERIALS AND METHODS

The endoscopic method currently achieving one of the highest success rates is the double hydrodistention-implantation technique (HIT). This method employs dextranomer/hyaluronic acid copolymer, which has been used in pediatric urology for over 10 years and may be at present the first choice injectable agent due to its safety and efficacy.

RESULTS

While most contemporary series report cure rates of greater than 85% for primary VUR, success rates of complicated cases of VUR may be, depending on the case, significantly lower. Endoscopic treatment offers major advantages to patients while avoiding potentially complicated open surgery. As the HIT method continues to be applied to complex cases of VUR and more outcome data become available, the indication for endoscopic treatment may exceed the scope of primary VUR.

CONCLUSIONS

Endoscopic injection is emerging as the treatment of choice for VUR in children.

Small Intestinal Submucosa for Corporeal Body Grafting in Severe Hypospadias Requiring Division of the Urethral Plate

PURPOSE

Severe chordee associated with proximal hypospadias is a challenging problem. Occasionally division of the urethral plate and corporeal body grafting are necessary to achieve a straight phallus. We report our experience with small intestinal submucosa for corporeal body grafting to correct severe chordee associated with proximal hypospadias.

MATERIALS AND METHODS

We reviewed the charts of all 28 patients who underwent small intestinal submucosa corporeal body grafting to correct severe chordee during stage 1 of planned 2-stage proximal hypospadias repair from January 2001 to June 2006. After mobilization and division of the urethral plate ventral horizontal corporotomies were performed at the site of maximum curvature. Four and 1 ply small intestinal submucosa in 21 and 7 cases, respectively, was then fashioned to size and secured into the defect. Preoperative, operative and postoperative clinic visit records were reviewed to assess outcomes.

RESULTS

Preoperatively the meatal position was penoscrotal in 18 patients, scrotal in 5 and perineal in 5. In all patients, who had a mean age of 16 months, the urethral plate was divided and the corporeal bodies were grafted during stage 1 surgery. Vascularized preputial flaps were rotated ventrally for subsequent urethroplasty in 25 patients and buccal mucosa was used for urethroplasty in the remaining 3. A total of 26 patients underwent stage 2 repair with a mean followup of 38 months (range 6 to 61). Overall there were 6 complications, including epidermal retention cysts in 2 cases, partial urethral dehiscence in 2 and urethral diverticulum requiring reduction urethroplasty in 1, while a perimeatal granuloma developed in 1 following stage 1 repair, which required excision. Except the possibility of this latter patient there were no complications related to the small intestinal submucosa graft and a straight phallus without fibrosis was achieved in all 26.

CONCLUSIONS

Our experience suggests that small intestinal submucosa is a suitable material for corporeal body grafting in 2-stage hypospadias repairs when there is associated severe chordee. In rare instances in which other maneuvers are inadequate to correct chordee small intestinal submucosa grafting is a reasonable option and a low complication rate can be anticipated.

Endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula in children

PURPOSE

Paraureteral or Hutch diverticula are congenital bladder diverticula that occur at or adjacent to the ureteral hiatus and are associated with vesicoureteral reflux in the majority of cases. Surgical treatment has traditionally been ureteral reimplantation with or without diverticulectomy. We present our experience with endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula.

MATERIALS AND METHODS

Of 745 patients undergoing endoscopic treatment for vesicoureteral reflux between 2002 and 2006, 17 (2.3%) had paraureteral diverticula located at the refluxing ureter. The hydrodistention implantation technique was used and dextranomer/hyaluronic acid copolymer was used as bulking material. Success was defined as vesicoureteral reflux grade 0 on postoperative voiding cystourethrogram at 1 to 3 months after a single treatment.

RESULTS

A total of 20 refluxing ureters with associated paraureteral diverticula were treated in 17 patients. Of the cases 14 were unilateral and 3 were bilateral. Reflux was grade I in 6 patients, grade II in 4, grade III in 8, grade IV in 1 and grade V in 1. A mean of 1.2 ml bulking agent was injected per ureter. Overall success was 81% (13 of 16 patients) after a single injection. Success per vesicoureteral reflux grade was 100% (6 of 6 patients) for grade I, 100% (3 of 3) for grade II, 63% (5 of 8) for grade III, 100% (1 of 1) for grade IV and 100% (1 of 1) for grade V. Endoscopic treatment failed in 3 patients. Multivariate analysis identified large diverticular size and high bulking agent volume as predictors of treatment failure. Age, reflux grade and the presence of unilateral vs bilateral paraureteral diverticula did not impact outcome.

CONCLUSIONS

Endoscopic injection of dextranomer/hyaluronic acid copolymer is an excellent choice for the treatment of vesicoureteral reflux associated with paraureteral diverticula because it has a high success rate and avoids open surgery.

Antegrade and Retrograde Endoscopic Dextranomer/Hyaluronic Acid Bladder Neck Bulking for Pediatric Incontinence

PURPOSE

Endoscopic bladder neck bulking techniques offer the potential for a relatively noninvasive cure for a difficult clinical problem. We review our experience using antegrade and retrograde approaches.

MATERIALS AND METHODS

A total of 34 children (18 boys and 16 girls, mean age 11.7 years) have been treated since March 2003. Of the patients 28 (82%) had neurogenic bladder and 6 had nonneurogenic sphincteric incontinence. Urodynamics confirmed low detrusor leak point pressures and adequate bladder capacity. Patients were treated with either a retrograde or an antegrade approach. In 82% of patients an antegrade approach was used and a posttreatment suprapubic tube was placed.

RESULTS

Mean followup was 11.7 months (range 3 to 31). Patients averaged 1.47 injections (range 1 to 5). Detailed followup of 19 patients revealed significant improvement in continence in 78% (mean 1.6 injections), with an average followup of approximately 1 year.

CONCLUSIONS

Our 31 months of experience with antegrade/retrograde bladder neck bulking demonstrates that it is a viable therapy for this group of children. While some patients have experienced prolonged success, re-treatment can be beneficial. The antegrade approach offers several advantages, including intraoperative leak point pressures, improved visualization and placement of a suprapubic tube to limit post-procedural remodeling.

Scrotal incision orchiopexy for undescended testes with or without a patent processus vaginalis

PURPOSE

Bianchi and Squire first described scrotal incision orchiopexy as an alternative to the traditional inguinal approach in the 1980s. The goal of this study was to review our series of scrotal orchiopexies to evaluate operative times, success rates and complications in patients with and without a patent processus vaginalis.

MATERIALS AND METHODS

A total of 121 scrotal incision orchiopexies were performed in 103 patients with palpable undescended testes between November 2002 and January 2006. This technique involves manipulation of the testis down to the scrotum so that it is secured between the thumb and index finger as fixation is performed. Charts were retrospectively reviewed to assess operative times as well as position and size of the testes at followup.

RESULTS

Patient age ranged from 6 months to 13 years (mean 4.5 years). The processus vaginalis was patent in 75 testes (62%). A total of 121 testes (100%) were successfully placed within the scrotum using a single incision. Operative times ranged from 7 to 36 minutes (mean 18.9). There were no cases of testicular atrophy or ascent, hernia or hydrocele formation with followup that ranged from 6 months to 1 year. The only complications were 4 wound infections (3.3%), which were successfully treated with antibiotics.

CONCLUSIONS

The scrotal incision technique is an underused method of orchiopexy regardless of patency of the processus vaginalis. Shorter operative times, comparable success and complication rates, and a more cosmetically appealing result compared to the traditional inguinal approach make scrotal orchiopexy an attractive alternative.

Long-term preservation of dextranomer/hyaluronic acid copolymer implants after endoscopic treatment of vesicoureteral reflux in children: a sonographic volumetric analysis

PURPOSE

We compared injected volume of dextranomer/hyaluronic acid with sonographic volumes obtained 2 weeks to 36 months postoperatively to evaluate the amount of volume retention with time and to correlate volume retention with voiding cystourethrogram results.

MATERIALS AND METHODS

We retrospectively reviewed sonographic volume measurements of dextranomer/hyaluronic acid implants in children at 2 weeks to 36 months postoperatively. Hydronephrosis and percentage of dextranomer/hyaluronic acid retained at each interval were recorded. Average change in volume at each interval was used to compare volume retention with time. The fraction of dextranomer/hyaluronic acid retained was compared to voiding cystourethrogram at 3 months.

RESULTS

No patient had new or worsened hydronephrosis. Volumetric data were available for 296, 150, 42, 23 and 20 ureters at 2, 3, 6 and 12 weeks, and 24 to 36 months postoperatively, respectively. Percentage of dextranomer/hyaluronic acid retained was 79% at 2, 74% at 3, 70% at 6 and 78% at 12 weeks, and 65% at 24 to 36 months (p >0.05). While there was no significant difference in mean volume retained between cures (74%) and treatment failures (67%), the 94% cure rate with mega-implants (greater than anticipated volume retention) was higher than that with micro-implants (75%) or nonvisualized implants (70%).

CONCLUSIONS

After the initial volume reduction at 2 weeks dextranomer/hyaluronic acid implants remained durable with insignificant volume reduction for up to 36 months postoperatively. Although overall mean volume retention did not correlate with cure, mega-implants were associated with high cure rates and may justify elimination of postoperative voiding cystourethrography.

Magnetic resonance urography in the evaluation of prenatally diagnosed hydronephrosis and renal dysgenesis

PURPOSE

We present our experience with dynamic contrast enhanced magnetic resonance urography for evaluation and treatment in infants born with prenatally recognized hydronephrosis. We determined the characteristics of renal dysgenesis in this population.

MATERIALS AND METHODS

We reviewed magnetic resonance urography images done within the first 6 months of life in 67 infants born with prenatally recognized hydronephrosis. High resolution imaging was used to establish a morphological diagnosis. Functional evaluation was used to assess obstruction and individual renal function. Voiding cystourethrography was performed in 62 patients.

RESULTS

Our study included 67 infants (87 renal units). There were 54 boys and 13 girls with a mean age of 2.8 months (range 0.9 to 4.6). Of these 87 renal units 30 (35%) had ureteropelvic junction obstruction, 18 (21%) had primary megaureters, 10 (11%) had nondilating vesicoureteral reflux, 10 (11%) had fetal folds, 8 (9%) had posterior urethral valves, 6 (7%) had ectopic ureters, 4 (5%) had multicystic dysplastic kidneys and 1 (1%) had a normal study. Magnetic resonance urography revealed renal dysgenesis in 24 renal units (28%), consisting of loss of corticomedullary differentiation, renal cystic changes distinct from multicystic dysplastic kidneys, solid renal dysplasia, hypoplasia and dysmorphic calyces.

CONCLUSIONS

Magnetic resonance urography is an excellent addition to our armamentarium for evaluating neonatal hydronephrosis and renal dysgenesis. Due to its comprehensiveness magnetic resonance urography has the potential to become the study of choice for evaluating infants with significant prenatally recognized hydronephrosis. However, further prospective, comparative studies in larger patient populations are needed to justify the cost and the need for sedation in infants.

Magnetic resonance urography for evaluating outcomes after pediatric pyeloplasty

PURPOSE

We report the role of magnetic resonance urography in children with ureteropelvic junction obstruction. Differential renal function, the single kidney glomerular filtration rate index, renal transit time, renal length and renal pelvis anteroposterior diameter were compared before and after pyeloplasty.

MATERIALS AND METHODS

Magnetic resonance urography was performed before and after pyeloplasty in 24 patients with a mean age of 1.9 years (range 3 months to 10 years). Renal length, renal transit time and renal pelvis anteroposterior diameter were determined by the radiologist. The volume of functioning renal tissue and descending aorta were segmented and the ratio of the volumes of functioning kidney tissue was used to calculate differential renal function. Rutland-Patlak plots were used to calculate single kidney glomerular filtration rate index, that is the Patlak score.

RESULTS

Mean renal pelvis renal pelvis anteroposterior diameter was 3.3 cm preoperatively and 2.5 cm postoperatively (p = 0.0003). There was no difference in average renal length (p = 0.22). Of the 24 cases 22 (92%) showed stable or improved differential renal function. Improvement in renal transit time was seen in 20 of 23 cases (87%). Of 15 patients with complete Patlak scores 14 (93%) showed postoperative improvement. Mean preoperative and postoperative differential renal function, renal transit time and Patlak score were 36% and 41% (p = 0.003), 16.2 and 8.6 minutes (p = 0.0005), and 6.6 and 11.9 ml per minute (p = 0.01), respectively.

CONCLUSIONS

Magnetic resonance urography provides superior anatomical and unprecedented functional information to fully define the preoperatively and postoperative status of corrected ureteropelvic junction obstruction. Magnetic resonance urography has the potential to become the imaging study of choice for evaluating pediatric hydronephrosis and obstructive uropathy.

Postoperative Ureteral Obstruction After Subureteral Injection of Dextranomer/Hyaluronic Acid Copolymer

PURPOSE

Subureteral injection of dextranomer/hyaluronic acid copolymer is widely accepted for the treatment of primary vesicoureteral reflux. Few studies document the incidence of surgically relevant postoperative obstruction or the characteristics of patients at risk.

MATERIALS AND METHODS

Four institutions had reported surgically relevant postoperative obstruction to representatives of Q-Med Scandinavia, the manufacturers of Deflux (dextranomer/hyaluronic acid). All children undergoing dextranomer/hyaluronic acid injection at these institutions were evaluated in this study. Patients requiring postoperative stenting were retrospectively reviewed for pertinent history, volume injected, technique of injection, duration of symptoms before intervention, duration of intervention and final outcome.

RESULTS

A total of 745 patients (1,155 ureters) underwent injection. Five patients (6 renal units, 7 ureters) required stenting for obstructive symptoms and hydronephrosis, of whom 4 immediately became symptomatic. All patients had been injected with up to 1 ml dextranomer/hyaluronic acid. Four patients (80%) had either a neurogenic bladder or dysfunctional voiding. All stents were placed and removed without complications, with complete resolution of symptoms in all patients. Length of stenting ranged from 2 to 6 weeks. No patient required open surgery. One of 2 patients undergoing postoperative voiding studies had development of recurrent vesicoureteral reflux.

CONCLUSIONS

Dextranomer/hyaluronic acid injection is associated with a small risk of postoperative ureteral obstruction requiring endoscopic intervention, with an overall incidence of less than 0.7% of patients injected. Patients with voiding dysfunction or neurogenic bladder may be at increased risk. Intervention with temporary ureteral stenting is effective, technically simple and curative.

Salvage Extravesical Ureteral Reimplantation After Failed Endoscopic Surgery for Vesicoureteral Reflux

PURPOSE

Open intravesical ureteral reimplantation has been reported to be uncomplicated following dextranomer/hyaluronic acid implantation. However, there are no known reports regarding extravesical ureteral reimplantation following dextranomer/hyaluronic acid failure. We reviewed our experience with extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure.

MATERIALS AND METHODS

We reviewed the charts of 30 patients who underwent extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. If reflux was initially bilateral and only a unilateral cure was achieved, the cured ureter was not reimplanted. Intraoperative complications, need for stenting or prolonged bladder catheterization, length of hospitalization and radiographic results were noted.

RESULTS

At cystoscopy the dextranomer/hyaluronic acid implants were not seen in half of the patients. In the remaining 15 patients the blebs had moved caudally and/or were seen extravesically at the ureteral hiatus or along Waldeyer's sheath. Unilateral extravesical ureteral reimplantation was performed without difficulty in all patients and there were no intraoperative complications. Stents were left indwelling only in those patients who had undergone dismembered ureteral reimplantation. No patient required prolonged bladder drainage. All patients except 2 who had undergone additional procedures were discharged home within 24 hours postoperatively. There was no evidence of obstruction on postoperative renal sonography, and extravesical ureteral reimplantation was confirmed to be successful in all 24 patients with postoperative voiding cystourethrograms.

CONCLUSIONS

Extravesical ureteral reimplantation can be performed without difficulty following dextranomer/hyaluronic acid implantation. Since extravesical ureteral reimplantation is less morbid and better tolerated than intravesical reimplantation, it is an excellent treatment option for patients with persistent unilateral vesicoureteral reflux following dextranomer/hyaluronic acid implantation. Furthermore, in cases in which vesicoureteral reflux is initially bilateral our data suggest that reimplantation of the successfully treated contralateral ureter can be avoided.

New Contralateral Vesicoureteral Reflux Following Dextranomer/Hyaluronic Acid Implantation: Incidence and Identification of a High Risk Group

PURPOSE

To our knowledge the incidence of NCVUR following the endoscopic treatment of VUR with Dx/HA has not been reported previously. We evaluated the outcomes in a group of patients to determine the incidence, and to attempt to identify risk factors.

MATERIALS AND METHODS

A total of 126 children with primary unilateral VUR underwent unilateral Dx/HA implantation at our institutions. The incidence of NCVUR was determined by postoperative VCUG. Indications for surgery, patient age and gender, preoperative grade of VUR and volume of Dx/HA injected were assessed as possible risk factors for NCVUR.

RESULTS

Of the patients 96 (76.2%) were female, and mean age was 4.8 years. The principal indications for Dx/HA implantation were persistent reflux in 56 patients (44.4%) and primary therapy in 51 (40.5%). At followup VCUG 17 patients (13.5%) had NCVUR. No variable independently appeared to influence the incidence of NCVUR. Statistical analysis suggests that females younger than 5 years have an increased incidence of NCVUR (13 of 62, or 21% vs 4 of 64, or 6.3% of the remaining patients, p = 0.016).

CONCLUSIONS

NCVUR occurred in approximately 13% of our patients. Patients with higher preoperative VUR grade or a lower number of preoperative VCUGs and those undergoing treatment as primary therapy did not have an increased incidence. Girls younger than 5 years had the highest incidence of NCVUR, and initial bilateral injection may be a consideration for this group. Further effort directed at identifying the etiology and risk factors for NCVUR is needed.

Dextranomer/hyaluronic acid for vesicoureteral reflux: success rates after initial treatment failure

PURPOSE

Following Food and Drug Administration approval of Dx/HA there has been increasing interest in the endoscopic management of VUR. Currently, there are few data regarding the success rates of repeat injection. We recently published our success rates for a group of children following initial Dx/HA treatment, and herein report the success rate of a subgroup of children undergoing repeat injection.

MATERIALS AND METHODS

We queried our database to identify all children undergoing a second Dx/HA injection for the treatment of VUR at our institution. VUR grades as determined by VCUG before and after the second treatment were specifically noted. Success was defined as the complete absence of VUR by VCUG.

RESULTS

A total of 42 children (37 girls and 5 boys) with a mean age of 5 years underwent a second Dx/HA treatment for VUR after initial treatment failure. Complete followup was available for 39 patients (53 ureters). Before the second injection 14 patients had bilateral and 25 had unilateral VUR, with a mean grade of 2.2. A second Dx/HA injection resolved VUR in 35 of 39 patients (90%) and in 47 of 53 ureters (89%). A second injection resolved reflux in 7 of 8 ureters (88%) with grade I, 24 of 26 (92%) with grade II and 16 of 19 (84%) with grade III VUR.

CONCLUSIONS

A second Dx/HA injection for the treatment of VUR persisting after initial endoscopic treatment has a high success rate. This information is useful when counseling parents after initial treatment failure.

ENDOSCOPIC TREATMENT WITH DEXTRANOMER/HYALURONIC ACID FOR COMPLEX CASES OF VESICOURETERAL REFLUX

PURPOSE

The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success decreases in more complex cases and often involves reoperation and increased morbidity. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in complex cases of vesicoureteral reflux in which open surgery would have been indicated.

MATERIALS AND METHODS

Between October 2001 and July 2003, 72 patients 9 months to 31 years old (mean age 5.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. A guidewire was used to manipulate the ureteral orifice and a retrograde ureterogram was used to delineate the anatomy in selected cases. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR.

RESULTS

A total of 93 ureters were treated in 55 girls and 17 boys. All cases were considered to be complex as 17 had persistent reflux after open surgery (7 megaureters repairs, 2 extravesical repairs, 7 intravesical reimplants and 1 blind ureter), 11 had persistent reflux and neurogenic bladder, 7 had ectopic ureters to bladder neck, 6 had bilateral Hutch diverticulum, 6 had persistent stump reflux, 5 had ureterocele after puncture or incision, 15 had duplications, 1 had the prune belly syndrome, 2 had posterior urethral valve following resection, 1 had epispadias and 1 had urogenital sinus. The average maximum reflux grade was IV. An average of 1.1 cc (range 0.4 to 2) was injected per ureter. Of the patients 69 had 3-month followup results. The overall success rate was 68% after 1 implantation (47 of 69).

CONCLUSIONS

Submucosal intraureteral implantation with Dx/HA corrected complex vesicoureteral reflux in 68% of patients. In all of these patients open surgery would have potentially been difficult. The use of fluoroscopy and/or guidewires is a useful adjunct in these cases. We believe that this minimally invasive approach is warranted as an initial step in the management of complex cases of VUR before resorting to more difficult open surgical procedures.

The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter

PURPOSE

With the advent of tissue bulking agents, in particular dextranomer/hyaluronic acid copolymer (Dx/HA), for endoscopic implantation for vesicoureteral reflux (VUR), there has been a major shift in the surgical paradigm throughout Europe, and more recently, in the United States. We describe a modification of the technique used for implantation that has significantly improved our results.

MATERIALS AND METHODS

Between October 2001 and October 2003, 285 children 7 months to 15 years old (mean age 4.6 years) underwent endoscopic implantation of Dx/HA for VUR at our institutions. A modified STING (subureteral transurethral injection) procedure (implantation submucosally within the intramural ureter) was introduced during the last year of the study. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months flouroscopic voiding cystourethrograms were used to evaluate for the presence of VUR. A subset of 122 patients treated with STING (52) were compared to those treated with modified STING (70).

RESULTS

A total of 459 ureters in 231 girls and 54 boys were treated (174 bilateral cases). Mean maximum grade per patient was 2.5/5. Mean injected volume was 0.9 cc ureter. There were 181 patients with at least 3 months of followup. After 1 treatment 76% (137 of 181) of cases were cured (grade 0 reflux), while 54% (24 of 44) of the failures were improved. The overall cure rate was 94% for grade I, 85% for grade II, 78% for grade III and 71% for grade IV reflux. The patients treated with STING had a mean age of 4.8 years, mean maximum reflux grade was 2.5 and success rate was 71% (37 of 52; 86% grade I, 89% grade II, 70% grade III and 63% grade IV reflux). The patients treated with a modified STING had a mean age of 5.5 years, mean maximum grade was 2.8 and a success rate was 89% (62 of 70; 100% grade I, 92% grade II, 91% grade III and 90% grade IV reflux). Ureteral success rates were significantly (p <0.01) greater for the modified STING (92%) vs the standard STING (79%). There were no cases of hydronephrosis at 3 months postoperatively.

CONCLUSIONS

The majority of patients undergoing minimally invasive therapy for VUR with Dx/HA are cured after 1 treatment. The modified STING is our preferred method of implant injection for the correction of VUR and in our hands produces a resolution rate of 89% (92% of ureters). The technique optimizes ureteral coaptation, is easy to perform and is not associated with any significant short-term complications. Persistence of VUR in a minority of patients continues to be the only significant adverse effect of endoscopic implantation.

Urological Manifestations of Down Syndrome

PURPOSE

We identified the urological anomalies seen in patients with Down syndrome.

MATERIALS AND METHODS

We reviewed the literature on Down syndrome and its associated genitourinary pathology.

RESULTS

Associated defects have been reported throughout the genitourinary tract. The most common renal anomalies seen are renal hypoplasia, obstructive uropathy and glomerular microcysts. Decreased creatinine clearance has also been noted. Developmental anomalies, such as megaureter and vesicoureteral reflux, have been reported. Dysfunctional voiding and urinary retention have been found in these patients. Posterior urethral valves and hypospadias have also been seen. The testicular abnormalities most frequently reported are cryptorchidism, testicular cancer and infertility.

CONCLUSIONS

Improved understanding and identification of the various urological anomalies associated with Down syndrome will aid in the care of these patients. In addition, an awareness of perioperative issues will further facilitate a smooth clinical course.

Minimally invasive treatment of vesicoureteral reflux with endoscopic injection of dextranomer/hyaluronic acid copolymer: the Children's Hospitals of Atlanta experience

PURPOSE

Emerging data demonstrate that injection of dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux, Q-Med Scandinavia, Uppsala, Sweden) is a safe and effective treatment for most patients with vesicoureteral reflux (VUR). We sought to determine the efficacy and factors predictive of outcome in patients treated with Dx/HA.

MATERIALS AND METHODS

A total of 180 children 7 months to 15 years old (mean age 4.6 years) underwent subureteral injection of Dx/HA for VUR between October 2001 and February 2003. Dx/HA was injected submucosally within or beneath the intramural ureter. The average volume of injected material was measured for each ureter. At 2 weeks and 3 months postoperatively bladder ultrasounds were performed to measure the volume of Dx/HA (mm3) in the trigone using the volume of an ellipsoid (V = 4/3pir(1)r(2)r(3)). Renal sonography was performed to determine whether hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR.

RESULTS

A total of 292 ureters in 180 children were treated (112 bilateral cases). There were 141 girls and 39 boys. Mean maximum grade per patient was 2.6 (out of 5). Average injected volume per ureter was 0.83 +/- 0.03 ml (830 +/- 30 mm3). At 2 weeks the average measured volume was 663 +/- 70 mm3 (18% decrease from original volume), which decreased an additional 1% by 3 months to 656 +/- 103 mm3. There were no cases of hydronephrosis at up to 12 months postoperatively.There were 134 patients with at least 3 months of followup. After 1 treatment 72% (96) were cured (grade 0), while 55% of the failures (21 of 38) were improved. New contralateral VUR was seen in 6 patients (4.5%) who had neither a history of VUR nor an abnormal appearing ureteral orifice at cystoscopy. A lower success rate (60%) was seen in the first 20 patients compared with the last 20 patients (80%). The cure rate per grade was 90% for grade I, 82% for grade II, 73% for grade III and 65% for grade IV reflux. Local migration of material caudal to the ureteral orifice was seen in 61% of patients (11 of 18) at the time of reinjection of Dx/HA after initial treatment failure. There was no statistically significant difference in age, grade, volume injected, bilaterality or gender when successes were compared with failures.

CONCLUSIONS

The majority of patients (72%) undergoing minimally invasive treatment of VUR with Dx/HA are cured after 1 treatment. Contralateral treatment of nonrefluxing ureters should be considered in view of the increased incidence of new reflux (4.5%) and absence of morbidity with Dx/HA injection. There is a definite learning curve with injection therapy. The location of injected material and experience with the technique appear to correlate with the outcome of the procedure.

MR imaging of kidneys: functional evaluation using F-15 perfusion imaging

BACKGROUND

Children with hydronephrosis are typically investigated by a combination of diuretic renal scintigraphy, ultrasound, and voiding cystourethrography. Unfortunately, there is no gold standard to assess obstruction.

PURPOSE

The purpose of our study was to evaluate the utility of dynamic contrast enhanced MR urography in the investigation of children with hydronephrosis to define urinary tract anatomy, to calculate differential renal function and to assess urinary tract obstruction.

MATERIALS AND METHODS

Dynamic contrast-enhanced MR imaging was performed in 40 children with unilateral hydronephrosis. There were 14 girls and 26 boys with an age range of 1 month to 14 years (mean 1.4 years). The information from traditional imaging modalities was compared to the information obtained from the single MR study.

RESULTS

The anatomic imaging with MR urography was superior to other modalities. The split renal function was estimated with MR urography by calculating the volume of enhancing renal parenchyma and was comparable to renal scintigraphy ( r=0.98). By using surgery versus non-surgery as the decision point, with MR urography the sensitivity was 100%, specificity 71%, positive predictive value 86%, negative predictive value 100%, and diagnostic efficiency 90%. For renal scintigraphy the sensitivity was 96%, the specificity 56%, positive predictive value 76%, negative predictive value 90%, and diagnostic efficiency 79%.

CONCLUSIONS

Dynamic contrast-enhanced MR urography provides superior anatomic and functional information when compared with ultrasound and diuretic renal scintigraphy. The information is gathered in a single study that does not use ionizing radiation. It is likely that MR urography will replace renal scintigraphy in the evaluation of hydronephrosis in children.

Antenatal hydronephrosis with postnatal resolution: how long are postnatal studies warranted?

We present 2 cases of antenatal hydronephrosis with initial normalization of postnatal studies. Both patients experienced late-onset (6 and 22 months) hydronephrosis secondary to ureteropelvic junction obstruction, necessitating surgical intervention. These cases raise questions about the need for late follow-up imaging in patients with apparent resolution of hydronephrosis diagnosed antenatally.

Increased incidence of hypospadias in small-for-gestational age infants in a neonatal intensive-care unit

OBJECTIVE

To identify the incidence of hypospadias in children born prematurely and small-for-gestational age (SGA), and to compare this subgroup with infants of similar age and weight without hypospadias.

PATIENTS AND METHODS

Records from the neonatal intensive-care unit (NICU) of a major metropolitan hospital active in labour and delivery were reviewed over a 3-year period, specifically examining newborns admitted with the diagnosis of SGA, defined as a birth weight of < 10th percentile for gestational age. In all, 154 patients were identified and their charts reviewed, recording the presence and severity of hypospadias, gestational age, birth weight, placental weight, cord length, cord vessels, maternal age, parity, multiple births, drug exposure and associated comorbidity. A control group of age- and weight-matched infants without hypospadias were also identified and compared.

RESULTS

Of the 154 patients, 17 (11%) had hypospadias; the hypospadias was distal in nine, mid-shaft in four and proximal in four. The severity of hypospadias did not correlate with the degree of prematurity or weight for gestational age. Placental weight, fetal weight, fetal to placental weight ratio and cord length were all lower in the hypospadias group than in the control group, but the differences were not statistically significant. The maternal age was evenly distributed (median 32 years, range 20-43). Most mothers were multiparous and births were multiple in five of 17 (30%). Cryptorchidism (three) and inguinal hernia (three) were present in four of the infants.

CONCLUSIONS

The incidence of hypospadias in SGA infants admitted to the NICU is > 10 times higher than that reported for the general population. There was a trend to lower placental and fetal weight in SGA infants with hypospadias than in the controls. This finding merits further evaluation using a larger population database and suggests that factors resulting in SGA infants occur at a critical point early in development, affecting both somatic and urethral development.

Laser tissue soldering for hypospadias repair: results of a controlled prospective clinical trial

PURPOSE

Laser tissue soldering has been shown to provide safe and effective tissue closure by creating an immediate leak-free anastomosis with minimal scar formation. We compared the results of laser tissue soldering and conventional suturing for hypospadias repair.

MATERIALS AND METHODS

A consecutive group of 138 boys 4 months to 8 years old (mean age 15 months) was divided into a standard suturing (84) and a sutureless laser (54) hypospadias repair group. Urethral repair was defined as simple (Thiersch-Duplay or Snodgrass) and complex (onlay island flap or tube) in 101 and 37 cases, respectively. Laser tissue soldering was performed with 50% human albumin solder doped with 2.5 mg./ml. indocyanine green dye using an 808 nm. diode laser at 0.5 W. In the laser group sutures were used for tissue alignment only. At surgery neourethral and penile length, operative time for neourethral construction and the number of sutures or throws were measured. Postoperatively patients were examined for complications of wound healing, stricture or fistula.

RESULTS

Mean patient age, urethral defect severity, type of repair, neourethral length and stenting time plus or minus standard error of mean were not significantly different in the 2 groups. Mean operative time was a fifth as long for laser tissue soldering in simple and complex hypospadias repair compared to controls (1.5 +/- 0.1 and 5.1 +/- 0.3 versus 8.5 +/- 0.8 and 26.7 +/- 1.7 minutes, respectively, p <0.001). The mean number of sutures used for tissue alignment in the laser group for simple and complex repair was significantly less than in controls (3.0 +/- 0.2 and 8.2 +/- 0.6 versus 8.5 +/- 0.8 and 23.2 +/- 1.5, respectively, p <0.001). All patients were followed a mean of 12 months (minimum 6, maximum 22). The complication rate was 4.7% in the laser group and 10.7% in controls with fistula in 2 of 54 cases, and fistula and meatal stenosis in 7 and 2 of 84, respectively.

CONCLUSIONS

These preliminary results indicate that laser tissue soldering for hypospadias repair may be performed in almost sutureless fashion and more rapidly than conventional suturing. The ease of the laser technique and the lower complication rate in the laser group indicate that laser tissue soldering is an acceptable means of tissue closure in hypospadias repair.