Kidney transplant to vesicostomy: A safe strategy for children with end stage renal disease and lower urinary tract anomalies

INTRODUCTION

Resolution of underlying urinary tract anomalies prior to kidney transplantation in patients with end stage renal disease (ESRD) secondary to uropathy, has been historically supported under the argument that this would help prevent infectious complications and graft loss. We propose to perform earlier kidney transplantation with a transient vesicostomy, deferring resolution of the uropathy to the post-transplantation period. The aim of this study was to evaluate the outcomes of kidney transplantation in children with a vesicostomy.

MATERIAL AND METHODS

A retrospective, multicenter study was performed including all patients under 18 years of age who underwent kidney transplantation with a vesicostomy, between January 2005 and December 2020 and had at least one year of follow up. Data related with the indication and timing of vesicostomy, time until transplantation, post-transplantation complications, urinary tract infections (UTI) and graft survival rate were collected.

RESULTS

Of the 758 transplantations performed in the study period, 16 patients met the inclusion criteria. Mean age at transplantation was 58 months (range 20-151), and mean weight was 13.5 Kg (range 8.4-20). Mean time from vesicostomy to kidney transplantation was 30 months (range 0-70). There were 2 (12.5%) ureteral complications that required reoperation. Eighteen episodes of UTI were identified in 8 patients (50%), accounting for 0.4 UTIs per patient-year of follow-up. UTIs did not lead to graft loss in any of the cases. Urinary tract reconstruction was performed in 5 patients (31.3%) at an interval of 1-91 months post-transplantation. After a mean follow-up of 44.8 months (range 13-200) from transplantation, patients with vesicostomy had a mean creatinine clearance of 86.6 ml/min/1.73 m2, with a mean serum creatinine level of 0.6 mg/dl. Graft survival rate was 100%.

DISCUSSION

Early kidney transplantation into a vesicostomy permits a resolution of the ESRD, avoiding deleterious effects related to dialysis. With a low rate of UTIs, we found no graft loss due to infectious complications. This strategy permits careful planning and better timing for the urinary tract reconstruction without delaying kidney transplantation.

CONCLUSION

Kidney transplantation in pediatric patients with vesicostomy seems to be a safe and effective strategy. UTI rate was similar to that reported in the literature of patients with corrected urinary anomalies undergoing kidney transplantation without urinary diversion.

Clean Intermittent Catheterization in Children under 12 Years Does Not Have a Negative Impact on Long-Term Graft Survival following Pediatric Kidney Transplantation

BACKGROUND

Congenital anomalies of the kidneys and urinary tract (CAKUTs) are one of the most prevalent primary causes of end-stage renal disease (ESRD) in young children, and approximately one-third of these children present with lower urinary tract dysfunction (LUTD). Many children with LUTD require therapy with clean intermittent catheterization (CIC). CIC commonly leads to bacteriuria, and considerations have arisen regarding whether CIC in immunosuppressed children is safe or whether repeated febrile urinary tract infections (UTIs) may lead to the deterioration of kidney graft function.

MATERIAL AND METHODS

We retrospectively reviewed all cases of primary kidney transplantation performed in our center between 2001 and 2020 in recipients aged less than twelve years. The number of episodes of febrile UTIs as well as the long-term kidney graft survival of children undergoing CIC were compared to those of children with urological causes of ESRD not undergoing CIC, as well as to those of children with nonurological causes of ESRD.

RESULTS

Following successful kidney transplantation in 41 children, CIC was needed in 8 of these patients. These 8 children undergoing CIC had significantly more episodes of febrile UTIs than did the 18 children with a nonurological cause of ESRD (p = 0.04) but not the 15 children with a urological cause of ESRD who did not need to undergo CIC (p = 0.19). Despite being associated with a higher rate of febrile UTIs, CIC was not identified as a risk factor for long-term kidney graft survival, and long-term graft survival did not significantly differ between the three groups at a median follow-up of 124 months.

CONCLUSIONS

Our study demonstrates that, under regular medical care, CIC following pediatric transplantation is safe and is not associated with a higher rate of long-term graft loss.

Vancouver Symptom Score for Dysfunctional Elimination Syndrome: Hindi translation and validation

BACKGROUND

Bladder and bowel dysfunction (BBD) is a common problem in school-aged children and is evaluated using questionnaires. Among available questionnaires, "Vancouver Symptom Score for Dysfunctional Elimination Syndrome" (VSSDES) is considered superior in validity and reliability. We translated VSSDES into Hindi and performed validity and reliability testing of Hindi-VSSDES in children aged 4-16 years with lower urinary tract dysfunction (LUTD).

METHODS

In this cross-sectional study, we followed Consensus-based Standards for the selection of health Measurement Instruments recommendation to develop Hindi-VSSDES. Forward-translation-harmonization-back-translation-expert committee review-prefinal version sequence of translation was followed by cognitive debriefing. One hundred and sixteen children with symptoms suggestive of LUTD and 106 healthy controls were recruited. Construct validity of Hindi-VSSDES was assessed via structural validity (factor analysis) and hypotheses testing. In addition, test-retest reliability and internal-consistency reliability were assessed.

RESULTS

Hindi-VSSDES had acceptable face validity. Factor analysis identified four factors representing three domains. All a priori hypotheses were met. The questionnaire displayed excellent convergent validity and discriminative ability (area under receiver operating characteristic curve 0.83). The cutoff scores for screening and diagnosis were 7 and 11, respectively. Scores were comparable whether children self-filled the questionnaire or parents were proxy. Scores in girls were significantly higher. It had an excellent test-retest reliability (intraclass correlation coefficient = 0.96) and Cronbach's ɑ was 0.62. The smallest detectable change was 4.1 points. Median time to complete the questionnaire was 7 min and majority (91%) rated it as easy.

CONCLUSIONS

Hindi-VSSDES is the first validated and reliable Hindi questionnaire for children with BBD. Clinimetric properties of responsiveness and interpretability are yet to be tested.

A 15-year retrospective review of urodynamic studies in children at Red Cross War Memorial Children's Hospital, Cape town, South Africa

Background

Despite the undeniable diagnostic benefits of urodynamic studies (UDS), their adoption into clinical practice in Africa has been slow. This study aimed to review the use of invasive UDS in children at a tertiary paediatric hospital in South Africa.

Methods

A retrospective analysis of 1108 UDS was conducted. Patient demographic characteristics, primary diagnosis, indication and urodynamic outcomes were reviewed. Presence of urodynamic high-risk features were documented, and a comparison was made between the first study and follow-up study.

Results

This study revealed increasing trends in the use of UDS from 2015. Referrals were from Urology (37.7%), Spinal defects clinic (34.4%), Nephrology (20.8%) and other departments (7.0%). The most common reason for referral was review of medical treatment (36.5%). Spinal dysraphism (58.3%) accounted for the majority of conditions seen. Majority (59.1%) of the patients were receiving more than one type of bladder treatment at the time of their first study, with clean intermittent catheterisation (46.5%) being the most common form of bladder management. 97.5% of studies were performed using transurethral bladder catheterization. Urodynamic diagnosis was neurogenic in 74.0%, anatomical (12.2%), functional (8.8%) and normal (5.0%). There was statistically significant improvement in bladder compliance, detrusor leak point pressure and detrusor sphincter dyssynergia between the first study and a subsequent study following therapeutic intervention.

Conclusions

The unique ability of UDS to demonstrate changes in detrusor pressures, which is a common reason for therapy failure, makes UDS an invaluable tool in the diagnosis and management of children with lower urinary tract dysfunction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03462-4.

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?

INTRODUCTION

If children do not experience satisfactory relief of lower urinary tract dysfunction (LUTD) complaints after standard urotherapy is provided, other treatment options need to be explored. To date, little is known about the clinical value of pelvic floor rehabilitation in the treatment of functional voiding disorders.

OBJECTIVE

Therefore, we compared pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE) to intensive urotherapy in the treatment of children with inadequate pelvic floor control and functional LUTD.

STUDY DESIGN

A retrospective chart study was conducted on children with functional incontinence and inadequate pelvic floor control. All children referred for both intensive inpatient urotherapy and pelvic floor rehabilitation between 2010 and 2018 were considered for inclusion. A total of 52 patients were eligible with 25 children in the group who received BABE before inpatient urotherapy, and 27 children in the group who received BABE subsequently to urotherapy. Main outcome measurement was treatment success according to International Children's Continence Society criteria measured after treatment rounds and follow-up.

RESULTS

Baseline characteristics demonstrate no major differences between the BABE and control group. There was a significant difference in improvement between BABE and inpatient urotherapy after the first and second round of treatment (round 1: BABE vs urotherapy; 12% vs 70%, respectively, round 2: urotherapy vs BABE; 92% vs 34%, respectively, both P < .001). In both cases, the urotherapy group obtained greater results (Fig. 1). When the additional effect of BABE on urotherapy treatment is assessed, no significant difference is found (P = .355) in the children who received BABE; 30 (58%) showed improvement on pelvic floor control.

DISCUSSION

Our findings imply that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. Intensive urotherapy contains biofeedback by real-time uroflowmetry; children receive direct feedback on their voiding behaviour. Attention offered to the child and achieving cognitive maturity with corresponding behaviour is of paramount importance. It is known that combining several kinds of biofeedback does not enhance the outcome. However, our results do not provide a conclusive answer to the effectiveness of pelvic floor physical therapy in the treatment of children with LUTD because we specifically investigated BABE.

CONCLUSION

In this study, we could not prove that pelvic floor rehabilitation by BABE has an additional effect on inpatient urotherapy on incontinence outcomes. Considering the invasive nature of BABE, the use of BABE to obtain continence should therefore be discouraged.

The overlooked association between lower urinary tract dysfunction and psychiatric disorders: a short screening test for clinical practice

INTRODUCTION

Lower urinary tract dysfunction (LUTD) often presents with other associated comorbidities such as urinary tract infections, constipation, fecal incontinence, and vesicoureteral reflux. However, the psychiatric conditions that can be associated with LUTD tend to go unnoticed. The evaluation, diagnosis, and treatment of LUTD and psychiatric disorders in children are difficult and time-consuming. Moreover, there is currently no accepted consensus on this subject.

OBJECTIVE

In this study, the authors aimed to investigate the relationship between the subgroups of both LUTD and psychiatric disorders.

STUDY DESIGN

LUTD were divided into 4 groups by using voiding dysfunction symptom score (VDSS), bladder diary, and uroflowmetry/electromyography (UF/EMG) test. A short screening test for psychological problems was used to detect psychiatric disorders accompanying each LUTD group. In terms of psychiatric disorders, the patients were divided into two groups: externalizing and internalizing disorders.

RESULTS

A total of 156 children were diagnosed with LUTD. Seventy-six patients had overactive bladder (OAB), 53 had dysfunctional voiding (DV), 14 had primary bladder neck dysfunction (PBND), and 13 had underactive bladder (UAB). Psychiatric disorder was detected in 46 children (29.4%). Of these, 32 had an externalizing and 14 had an internalizing disorder. In terms of age, externalizing disorders were more common in children aged between 6 and 11 years (87.5%), whereas internalizing disorders were seen equally in both age groups. Among these, attention deficit hyperactivity disorder (ADHD) was the most common psychiatric disorder (16.1%). The LUTD groups with the most frequent psychiatric disorders were UAB (53.8%), PBND (35.7%), and OAB (28.9%).

DISCUSSION

Most of the studies investigating the relationship between the lower urinary tract and psychiatric disorders so far have been concerned with the lower urinary tract symptom (LUTS) (such as nighttime or daytime incontinence) and ADHD. However, the present study was performed according to the LUTD classification, which is primarily based on VDSS, bladder diary, and UF/EMG tests. Furthermore, psychiatric disorders were classified into their subgroups. The results have shown that around a quarter of children with LUTD also had comorbid psychiatric disorders. The relationship between LUTD and psychiatric disorders constitutes a critical point. Identifying this association can contribute to the comprehensive diagnosis and treatment for these patients.

CONCLUSIONS

LUTD and psychiatric disorders can be seen together, and this can be detected by the short screening test for psychological problems. Therefore, the authors think that patients who applied with LUTS should undergo this short test along with the routine urinary system examination and tests.

Endocrine disruptor bisphenol A is implicated in urinary voiding dysfunction in male mice

Estrogens, acting synergistically with androgens, are known from animal experiments to be important in lower urinary tract symptoms (LUTS) and benign prostate enlargement. Human exposure to environmental estrogens occurs throughout the life span, but the urologic health risks in men are largely unknown. Bisphenol A (BPA) is an endocrine disruptor implicated in male urogenital malformations. Given the role of estrogens in male LUTS, we studied the effects of BPA administered in combination with testosterone (T) on the urinary voiding behavior of adult male mice. Adult male mice underwent subcutaneous implantation with slow-release pellets of 25 mg BPA or 2.5 mg estradiol-17β (E2), plus 25 mg T, and were compared with untreated (UNT) mice that underwent sham surgery. We studied urinary voiding behavior noninvasively for 1 mo before treatment and for 4 mo after treatment. After euthanasia, we evaluated bladder volume and mass. Mice treated with T+BPA had increased bladder volume ( P < 0.05) and mass ( P < 0.01) compared with UNT mice. After 4 mo of treatment with T+BPA, three of five mice developed voiding dysfunction in the form of droplet voiding or an intermediate pattern of voiding different from both UNT and T+E2-treated mice. Treatment of male mice with BPA or estradiol induces voiding dysfunction that manifests at later time points, implicating the endocrine disruptor, BPA, as a contributor to male LUTS.

Video Voiding Device for Diagnosing Lower Urinary Tract Dysfunction in Men

We introduce a novel diagnostic Visual Voiding Device (VVD), which has the ability to visually document urinary voiding events and calculate key voiding parameters such as instantaneous flow rate. The observation of the urinary voiding process along with the instantaneous flow rate can be used to diagnose symptoms of Lower Urinary Tract Dysfunction (LUTD) and improve evaluation of LUTD treatments by providing subsequent follow-up documentations of voiding events after treatments. The VVD enables a patient to have a urinary voiding event in privacy while a urologist monitors, processes, and documents the event from a distance. The VVD consists of two orthogonal cameras which are used to visualize urine leakage from the urethral meatus, urine stream trajectory, and its break-up into droplets. A third, lower back camera monitors a funnel topped cylinder where urine accumulates that contains a floater for accurate readings regardless of the urine color. Software then processes the change in level of accumulating urine in the cylinder and the visual flow properties to calculate urological parameters. Video playback allows for reexamination of the voiding process. The proposed device was tested by integrating a mass flowmeter into the setup and simultaneously measuring the instantaneous flow rate of a predetermined voided volume in order to verify the accuracy of VVD compared to the mass flowmeter. The VVD and mass flowmeter were found to have an accuracy of ±2 and ±3% relative to full scale, respectively. A VVD clinical trial was conducted on 16 healthy male volunteers ages 23-65.

Concised Form for Lower Urinary Tract Dysfunction Symptom Scale in Children

INTRODUCTION

Symptom Scales (SS) are questionnaires for evaluating and following up of special illnesses. SS used for the diagnosis and follow-up of Lower Urinary Tract Dysfunction (LUTD) in children is called LUTD Symptom Scale (LUTDSS).

AIM

Aim of the present study was to identify the questions which are more important for the diagnosis of LUTD in children and create a simpler SS.

MATERIALS AND METHODS

From January 2005 to March 2015, 631 children between the age 5 and 15 were enrolled in this study. Eleven children with active urinary tract infections were excluded from the study. Two hundred sixty three children from the nursery and secondary school saying that they have no urinary complaints and having LUTDSS <9 were designed as control group. Three hundred fifty seven children with LUTDSS score ≥9 were thought as having LUTD and diagnoses were verified with 3-day bladder diaries and 2-time Uroflow-EMG-PVR tests. The answered questions of LUTDSS in patient and control group were compared.

RESULTS

Children with daytime incontinence (first question of questionnaire) were 47.7 (4.8-510) times (p=0.01), children with enuresis (third question) were 59.53 (6.2-961) times (p=0.001), children with pause while urinating (eighth question) were 28.7 (4.4-2090) times (p=0.001), children with urgency (tenth question) were 54.7 (29.3-604) times (p=0.039) more likely to have LUTD than the children not having these complaints. The area under ROC curve created by using 1,3,8, and 10 questions was calculated 86.4%.

CONCLUSION

The diagnosis and control of LUTD can be made by using only 1., 3., 8. and 10. questions, and these 4 questions could form simpler SS for LUTD in children.

Relationship between urodynamic findings and sexual function in multiple sclerosis patients with lower urinary tract dysfunction

BACKGROUND AND PURPOSE

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients. Our aim was to determine the relationship between urodynamic findings and SD in a cohort of MS patients with LUTD.

METHODS

From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent a first urodynamic examination, according to the International Continence Society criteria. Neurological impairment was assessed using the Expanded Disability Status Scale and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15). Multivariate logistic regression analysis was performed to identify predictors of female SD (FSFI < 26.55) or moderate-severe erectile dysfunction (ED) (IIEF-EF ≤ 16), after adjusting for confounding factors including urodynamic findings.

RESULTS

Subjects with maximum detrusor pressure during involuntary detrusor contraction (PdetmaxIDC) ≥20.0 cmH2 O had lower IIEF-EF, IIEF overall satisfaction (IIEF-OS), FSFI-Arousal, FSFI-Lubrication and FSFI-Orgasm. Subjects with maximum cystometric capacity (MCC) ≥135 ml had higher IIEF-EF, intercourse satisfaction (IIEF-IS), orgasmic function (IIEF-OF), sexual desire (IIEF-SD), FSFI-Arousal, FSFI-Lubrication, FSFI-Orgasm, FSFI-Satisfaction and FSFI-Pain. On multivariate logistic regression analysis, PdetmaxIDC ≥20 cmH2 O [odds ratio (OR) 6.7; P < 0.05] and MCC <135 ml (OR 6.80; P < 0.05) were predictors of moderate-severe ED. In a model including all previous variables, compliance ≤3 ml/cmH2 O was an independent predictor of moderate-severe ED (OR 14.49; P < 0.01). No relationship was found between the previous variables and FSFI <26.55.

CONCLUSIONS

Neurogenic bladder is associated with SD in MS patients. The presence of PdetmaxIDC ≥20 cmH2 O, MCC <135 ml and compliance ≤3 ml/cmH2 O may significantly predict the presence of moderate-severe ED.

Determinants of sexual impairment in multiple sclerosis in male and female patients with lower urinary tract dysfunction: results from an Italian cross-sectional study

INTRODUCTION

Sexual dysfunction (SD) is prevalent in multiple sclerosis (MS) patients and affects quality of life. Furthermore, lower urinary tract dysfunction (LUTD) is common in MS patients.

AIMS

This study aims to evaluate the relationship between SD, neurological disability, depression, anxiety, and urodynamic alterations in patients with MS and LUTD.

METHODS

From January 2011 to September 2013, 135 consecutive patients with MS in remission phase and LUTD underwent first urodynamic examination, according to the International Continence Society criteria. Depression and anxiety were evaluated with the Hamilton Depression Scale (HAM-D) and the Hamilton Anxiety Scale (HAM-A), neurological impairment was assessed using the Expanded Disability Status Scale (EDSS), and SD was investigated with the Female Sexual Function Index (FSFI) or the International Index of Erectile Function (IIEF-15).

MAIN OUTCOME MEASURES

Multivariate logistic regression analyses were carried out to identify variables for predicting female sexual dysfunction (FSD) (FSFI < 26.55), male SD (IIEF-15 < 60), or moderate-severe erectile dysfunction (IIEF-EF ≤ 16), after adjusting for confounding factors.

RESULTS

Total IIEF-15 and all subdomains (all P < 0.01), total FSFI, FSFI-arousal, FSFI-lubrication, and FSFI-orgasm (all P < 0.05) were lower in subjects with EDSS ≥ 4.5. We found inverse relationship between IIEF-15 and relative subdomains with EDSS (all P < 0.01) and between FSFI and relative subdomains with EDSS (all P < 0.01), HAM-D (all P < 0.01), and HAM-A (all P < 0.01). Continuous EDSS (odds ratio [OR] = 1.54; P = 0.03) and categorical EDSS (≥4.5) (OR = 6.0; P = 0.03), HAM-D (OR = 4.74; P = 0.03), and HAM-A (OR = 4.10; P = 0.02) were significantly associated with FSD (FSFI < 26.55). Detrusor overactivity (DO) was an independent predictor of moderate-severe ED (IIEF-EF ≤ 16) (OR = 2.03; P < 0.01), and of FSD (OR = 9.73; P = 0.04).

CONCLUSIONS

Neurological disability, depression and DO are significantly predictive of SD in MS patients, irrespective of gender. An EDSS ≥ 4.5 may significantly predict the presence of SD.