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Hari P, Meena J, Kumar M, Sinha A, Thergaonkar RW, Iyengar A, Khandelwal P, Ekambaram S, Pais P, Sharma J, Kanitkar M, Bagga A. Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux. Pediatr Nephrol 2024; 39:1639-1668. [PMID: 37897526 DOI: 10.1007/s00467-023-06173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/27/2023] [Accepted: 09/17/2023] [Indexed: 10/30/2023]
Abstract
We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.
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Affiliation(s)
- Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jitendra Meena
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Arpana Iyengar
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sudha Ekambaram
- Department of Pediatric Nephrology, Apollo Children's Hospital, Chennai, India
| | - Priya Pais
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Gnech M, 't Hoen L, Zachou A, Bogaert G, Castagnetti M, O'Kelly F, Quaedackers J, Rawashdeh YF, Silay MS, Kennedy U, Skott M, van Uitert A, Yuan Y, Radmayr C, Burgu B. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2024; 85:433-442. [PMID: 38182493 DOI: 10.1016/j.eururo.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVE The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.
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Affiliation(s)
- Michele Gnech
- Department of Paediatric Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Lisette 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alexandra Zachou
- Department of HIV and Sexual Health, Chelsea & Westminster Hospital, London, UK
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Marco Castagnetti
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital Dublin & University College Dublin, Ireland
| | - Josine Quaedackers
- Department of Urology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yazan F Rawashdeh
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Mesrur Selcuk Silay
- Division of Pediatric Urology, Department of Urology, Biruni University, Istanbul, Turkey
| | - Uchenna Kennedy
- Department of Pediatric Urology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Skott
- Department of Urology, Section of Pediatric Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, London Health Science Centre, London, Ontario, Canada, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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Passoni NM, Peters CA. Modern Management of Vesicoureteral Reflux: Envisioning a Future with Individualized Therapies. Eur Urol 2024; 85:443-444. [PMID: 38423919 DOI: 10.1016/j.eururo.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Niccolo M Passoni
- Department of Urology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
| | - Craig A Peters
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Meena J, Bagga A, Hari P. Management of Urinary Tract Infections and Vesicoureteric Reflux: Key Updates From Revised Indian Society of Pediatric Nephrology Guidelines 2023. Indian Pediatr 2024; 61:363-369. [PMID: 38419278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Non-specific symptoms and difficulty in collecting urine specimens make the diagnosis of urinary tract infection (UTI) challenging in children. However, timely diagnosis and initiation of therapy are essential to prevent complications. Children with recurrent UTIs require detailed evaluation and follow-up for optimal management. We report key updates from the revised evidence-based practice guidelines of the Indian Society of Pediatric Nephrology for UTIs and primary vesicoureteric reflux.
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Affiliation(s)
- Jitendra Meena
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi. Correspondence to: Prof. Pankaj Hari, Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi.
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Kabir S, Pippi Salle JL, Chowdhury MEH, Abbas TO. Quantification of vesicoureteral reflux using machine learning. J Pediatr Urol 2024; 20:257-264. [PMID: 37980211 DOI: 10.1016/j.jpurol.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION The radiographic grading of voiding cystourethrogram (VCUG) images is often used to determine the clinical course and appropriate treatment in patients with vesicoureteral reflux (VUR). However, image-based evaluation of VUR remains highly subjective, so we developed a supervised machine learning model to automatically and objectively grade VCUG data. STUDY DESIGN A total of 113 VCUG images were gathered from public sources to compile the dataset for this study. For each image, VUR severity was graded by four pediatric radiologists and three pediatric urologists (low severity scored 1-3; high severity 4-5). Ground truth for each image was assigned based on the grade diagnosed by a majority of the expert assessors. Nine features were extracted from each VCUG image, then six machine learning models were trained, validated, and tested using 'leave-one-out' cross-validation. All features were compared and contrasted, with the highest-ranked then being used to train the final models. RESULTS F1-score is a metric that is often used to indicate performance accuracy of machine learning models. When using the highest-ranked VCUG image features, F1-scores for the support vector machine (SVM) and multi-layer perceptron (MLP) classifiers were 90.27 % and 91.14 %, respectively, indicating a high level of accuracy. When using all features combined, F1 scores were 89.37 % for SVM and 90.27 % for MLP. DISCUSSION These findings indicate that a distorted pattern of renal calyces is an accurate predictor of high-grade VUR. Machine learning protocols can be enhanced in future to improve objective grading of VUR.
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Affiliation(s)
- Saidul Kabir
- Department of Electrical and Electronic Engineering, University of Dhaka, Dhaka, 1000, Bangladesh
| | | | | | - Tariq O Abbas
- Urology Division, Surgery Department, Sidra Medicine, Qatar.
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Mehta AJ, Bhargava M, Rao R. Evolution in Management of Vesicoureteral Reflux in Children. Indian Pediatr 2024; 61:285-287. [PMID: 38469847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Amar Jeet Mehta
- Department of Pediatric Nephrology, Rajasthan University of Health Sciences (RUHS) College of Medical Sciences, Jaipur, Rajasthan, India
| | - Maneesha Bhargava
- Department of Pediatric Nephrology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Ruchi Rao
- Department of Pediatric Nephrology, Rajasthan University of Health Sciences (RUHS) College of Medical Sciences, Jaipur, Rajasthan, India
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Muranaka I, Kyoda Y, Nofuji S, Shinkai N, Hashimoto K, Kobayashi K, Tanaka T, Masumori N. [A Case of Neuropathic Lower Urinary Tract Dysfunction Due to Spina Bifida Occulta Discovered at the Age of 19 Years and Successfully Treated with Multidisciplinary Therapy]. Hinyokika Kiyo 2024; 70:55-59. [PMID: 38447946 DOI: 10.14989/actauroljap_70_2_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
A 19-year-old man had been aware of dysuria and urinary incontinence since childhood but did not seek medical attention. He was diagnosed with acute pyelonephritis due to lower urinary tract dysfunction associated with spina bifida occulta and tethered cord syndrome (TCS) due to spinal cord lipoma. After placement of a urethral catheter and antibacterial chemotherapy, the patient was cured of acute pyelonephritis. He was treated with solifenacin and started clean self-intermittent catheterization (CIC). Shortly after the start of CIC, the acute pyelonephritis flared up again, and he was managed with a reinserted urethral catheter until an untethering operation. Preoperative video urodynamics showed that the bladder morphology was Ogawa classification grade III with vesicoureteral reflux (VUR) at 92 ml infusion. With the combination of an untethering operation and additional mirabegron, the functional bladder capacity was increased to 353 ml and VUR improved, allowing for safe urinary management of the CIC. TCS can be diagnosed at any age and requires appropriate urinary management and therapeutic intervention as early as possible after diagnosis.
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Affiliation(s)
- Ippei Muranaka
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Yuki Kyoda
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Seisuke Nofuji
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Nobuo Shinkai
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Kohei Hashimoto
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Ko Kobayashi
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Toshiaki Tanaka
- The Department of Urology, Sapporo Medical University School of Medicine
| | - Naoya Masumori
- The Department of Urology, Sapporo Medical University School of Medicine
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Basiri A, Ziaeefar P, Khoshdel A, Fattahi P, Mafi Balani M, Tofighi Zavareh MA. What are the Effective Factors in Spontaneous Resolution Rate of Primary Vesicoureteral Reflux: A Meta-Analysis and Systematic Review. Urol J 2023; 20:385-396. [PMID: 38158632 DOI: 10.22037/uj.v20i06.8095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE This meta-analysis aimed to predict the rate of spontaneous resolution and identify influencing factors among pediatric patients with primary vesicoureteral reflux (VUR). The primary objective was to construct a nomogram to facilitate clinical decision-making in the treatment of primary VUR by assessing the rate of spontaneous resolution and its determinants. MATERIALS AND METHODS A systematic search was conducted up to September 2023, encompassing databases such as PubMed, Web of Science, Scopus, and the reference lists of relevant studies. Inclusion criteria comprised 33 studies with a total of 8540 pediatric patients. Data extraction was performed independently by two reviewers, with discrepancies resolved by a third reviewer. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Form. The analysis included the assessment of various outcomes, such as the rate of spontaneous resolution, and identification of influential factors, including gender, age, laterality, and VUR grade. RESULTS The pooled spontaneous resolution rate among pediatric patients with primary VUR was 0.42 (95% CI: 0.38 to 0.47, Tau2 = 0.26), demonstrating high heterogeneity (Q = 429.9, df = 32, P < 0.001, I2 = 93%). Egger's regression test indicated no publication bias (p = 0.67). VUR grade emerged as the most significant determinant of spontaneous resolution, with varying rates for different grades: grade 1 (0.80, 95% CI: 0.72-0.86), grade 2 (0.67, 95% CI: 0.60-0.74), grade 3 (0.49, 95% CI: 0.42-0.56), and grade 4 (0.23, 95% CI: 0.18-0.30; Tau2 = 0.28, I2 = 0.49). While differences in gender and laterality were observed, statistical significance was not evident. CONCLUSION This study provides valuable insights into the spontaneous resolution rate of primary vesicoureteral reflux in pediatric patients. The constructed nomogram, based on VUR grading, serves as a useful tool for clinicians in decision-making. Despite observed variations in gender and laterality, only VUR grading demonstrated statistical significance in influencing spontaneous resolution. Further research is recommended to explore additional factors within larger populations to enhance our understanding of primary VUR resolution dynamics.
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Affiliation(s)
- Abbas Basiri
- Urology and Nephrology Research Center (UNRC), Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran.
| | - Pardis Ziaeefar
- Urology and Nephrology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Alireza Khoshdel
- Department of Epidemiology, Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, tehran, Iran.
| | - Payam Fattahi
- Medical student, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.
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Chang CL, Yang SSD, Hsu CK, Chen CH, Chang SJ. Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis. BMJ Paediatr Open 2023; 7:e002096. [PMID: 37989356 PMCID: PMC10660918 DOI: 10.1136/bmjpo-2023-002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis. METHODS A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments. RESULTS A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment. CONCLUSION Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.
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Affiliation(s)
- Chia-Lun Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Stephen Shei-Dei Yang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Kai Hsu
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Hua Chen
- Department of Neurology, Taipei Municipal Wanfang hospital, Taipei, Taiwan
| | - Shang-Jen Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
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Pingree EW, Harper BD, Liu S, Neuman MI. National Trends in Voiding Cystourethrograms During Hospitalization for Young Infants With Urinary Tract Infections. Hosp Pediatr 2023; 13:904-911. [PMID: 37671444 DOI: 10.1542/hpeds.2022-007045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
OBJECTIVES The American Academy of Pediatrics published a guideline in 2011 recommending against the routine use of voiding cystourethrogram (VCUG) in infants aged 2 to 24 months with first febrile urinary tract infection (UTI); however, the rates of VCUG for infants aged <2 months are unknown. The objective of this study was to determine the trend in VCUG performance during index hospitalization among infants aged 0 to 2 months with UTI. METHODS This retrospective cohort study included infants aged birth to 2 months hospitalized with a UTI from 2008 to 2019 across 38 institutions in the Pediatric Health Information System. Outcome measures included recurrent UTI within 1 year, vesicoureteral reflux diagnosis within 1 year and antiurinary reflux procedure performed within 2 years. Trends over time were compared between preguideline (2008-2011) and postguideline periods (2012-2019) using piecewise mixed-effects logistic regression. RESULTS The odds of VCUG decreased by 21% per year in the preguideline period (adjusted odds ratio, 0.79; 95% confidence interval, 0.77-0.81; P < .001) versus 20% (adjusted odds ratio, 0.80; 95% confidence interval, 0.77-0.83; P < .001) in the postguideline period. The preguideline and postguideline difference was not statistically significant (P = .60). There was no difference in the postguideline odds of UTI within 1 year (P = .07), whereas the odds of vesicoureteral reflux diagnosis (P < .001) and antiurinary reflux procedure performance (P < .001) decreased. CONCLUSIONS VCUG performance during hospitalization has declined over the past decade among young infants hospitalized with UTI. Further work is needed to determine the optimal approach to imaging in these young infants.
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Affiliation(s)
| | | | - Shanshan Liu
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Cvitkovic Roic A, Turudic D, Milosevic D, Roic G. Intrarenal reflux with low-grade vesicoureteral reflux: an underestimated significance? J Ultrasound 2023; 26:743-744. [PMID: 36715964 PMCID: PMC10468460 DOI: 10.1007/s40477-022-00772-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/26/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Andrea Cvitkovic Roic
- Helena Clinic for Pediatric Medicine, Kneza Branimira 71, 10000, Zagreb, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000, Osijek, Croatia
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20/1, 10000, Zagreb, Croatia
| | - Daniel Turudic
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Danko Milosevic
- Department of Pediatrics, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210, Bracak, Croatia
- School of Medicine, University of Zagreb, Šalata 3, 10000, Zagreb, Croatia
| | - Goran Roic
- Department of Radiology, Children's Hospital Zagreb, Ul. Vjekoslava Klaića 16, 10000, Zagreb, Croatia
- Faculty of Medicine, University of Rijeka, Braće Branchetta 20/1, 10000, Zagreb, Croatia
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Zhou G, Jiang M, Liu X, Li S, Chen J. Risk factors associated with recurrent febrile urinary tract infection in children with neurogenic bladder who perform clean intermittent catheterization. Neurourol Urodyn 2023; 42:1485-1490. [PMID: 37421159 DOI: 10.1002/nau.25245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To identify the clinical and urodynamic risk factors associated with the development of recurrent febrile urinary tract infections (FUTIs) in children with neurogenic bladder (NB) who perform clean intermittent catheterization (CIC). METHODS Children with NB receiving CIC were prospectively enrolled from January to December 2019 and followed up prospectively for 2 years. All data were compared between occasional (0-1 FUTI) and recurrent FUTIs (≥2 FUTI) groups. In addition, the risk factors for recurrent FUTIs in children were evaluated. RESULTS Complete data from 321 children were analyzed. Occasional FUTIs occurred in 223 patients, and 98 patients experienced recurrent FUTIs. Univariate and multivariate analyses, showed late-initiation and low-frequency CIC, vesicoureteral reflux (VUR), small bladder capacity and low compliance, and detrusor overactivity were associated with an increased risk of recurrent FUTIs. Children with high-grade VUR (grades IV-V) had a higher risk of recurrent FUTIs than those with low-grade VUR (grades I-III) (odds ratio [OR]: 26.95 vs. OR: 4.78, p < 0.001). CONCLUSIONS Our study suggests that late-initiation and low-frequency CIC, VUR, small bladder capacity and low compliance, and detrusor overactivity were associated with recurrent FUTIs in patients with NB. In addition, high-grade VUR is a crucial risk factor for recurrent FUTIs.
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Affiliation(s)
- Guanglun Zhou
- Department of Urology and Laboratory of Pelvic Floor Muscle Function, Shenzhen Children's Hospital, Guangdong, China
| | - Man Jiang
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
- Department of Urology and Laboratory of Pelvic Floor Muscle Function, Shenzhen Children's Hospital, Shenzhen, China
- Department of Clinical Laboratory, Shenzhen Children's Hospital, Shenzhen, China
| | - Xiaodong Liu
- Department of Urology and Laboratory of Pelvic Floor Muscle Function, Shenzhen Children's Hospital, Guangdong, China
| | - Shoulin Li
- Department of Urology and Laboratory of Pelvic Floor Muscle Function, Shenzhen Children's Hospital, Guangdong, China
| | - Jinjun Chen
- Department of Urology and Laboratory of Pelvic Floor Muscle Function, Shenzhen Children's Hospital, Guangdong, China
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Abstract
Vesicoureteral reflux (VUR) is the commonest congenital anomaly of urinary tract in children. It is mostly diagnosed after a urinary tract infection or during evaluation for congenital anomalies of the kidney and urinary tract. High-grade VUR, recurrent pyelonephritis, and delayed initiation of antibiotic treatment are important risk factors for renal scarring. The management of VUR depends on multiple factors and may include surveillance only or antimicrobial prophylaxis; very few patients with VUR need surgical correction. Patients with renal scarring should be monitored for hypertension and those with significant scarring should also be monitored for proteinuria and chronic kidney disease.
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Affiliation(s)
- Tej K Mattoo
- Department of Pediatrics, Wayne State University School of Medicine, 400 Mack Avenue, Suite 1 East, Detroit, MI 48201, USA.
| | - Dunya Mohammad
- Pediatric Nephrology, University of South Alabama, 1601 Center Street, Suite 1271, Mobile, AL 36604, USA
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14
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Lorenzo AJ. Vesicoureteral Reflux, Renal Scars, and Urinary Tract Infections in Children: A New Way to Think About an Old Problem. Eur Urol 2021; 81:155-156. [PMID: 34635343 DOI: 10.1016/j.eururo.2021.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Armando J Lorenzo
- Department of Surgery, University of Toronto, Division of Urology, Hospital for Sick Children, Toronto, Canada.
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Kirsch AJ, Cooper CS, Läckgren G. Non-Animal Stabilized Hyaluronic Acid/Dextranomer Gel (NASHA/Dx, Deflux) for Endoscopic Treatment of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Urology 2021; 157:15-28. [PMID: 34411597 DOI: 10.1016/j.urology.2021.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 07/29/2021] [Indexed: 11/19/2022]
Abstract
Non-animal stabilized hyaluronic acid/dextranomer gel (Deflux; NASHA/Dx) was developed as a treatment for vesicoureteral reflux (VUR) in the 1990s. To mark 20 years since the US approval of this agent, we reviewed its properties, best practice for application, and the available clinical safety and efficacy data. Long-term or randomized, controlled studies of treatment with NASHA/Dx have reported VUR resolution rates of 59%-100% with low rates of febrile urinary tract infection post-treatment (4%-25%), indicating long-term protection of the kidneys. An individualized approach VUR management is advocated, and NASHA/Dx is a viable option for many patients requiring intervention.
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Affiliation(s)
- Andrew J Kirsch
- Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA.
| | | | - Göran Läckgren
- Section of Urology, University Children´s Hospital, Uppsala, SE
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Maruyama T, Mizuno K, Nishio H, Kato T, Hamakawa T, Ikegami Y, Yasui T, Hayashi Y. Antireflux endoscopic injection therapy in post-pubertal patients via techniques adopted for the dilated ureteral orifice: a retrospective single-center study. BMC Urol 2021; 21:70. [PMID: 33894751 PMCID: PMC8067324 DOI: 10.1186/s12894-021-00842-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To investigate the efficacy and safety of endoscopic injection therapy for vesicoureteral reflux in post-pubertal patients with dilated ureteral orifice via modified hydrodistension implantation techniques. METHODS We retrospectively reviewed medical records including operational procedure and clinical course of all consecutive patients over 12 years old with a history of injection therapy. Endoscopic injection of dextranomer/hyaluronic acid copolymer was performed under hydrodistension implantation technique with some modifications in order to inject through dilated ureteral orifice align with the intramural ureter. Technical selections were done according to hydrodistension grade of the ureteral orifice. Voiding cystourethrography was evaluated at 3 months postoperatively. Hydronephrosis was evaluated using ultrasonography preoperatively until 6 months postoperatively. RESULTS From 2016 to 2019, 12 patients (all female, 16 ureteral units; median age 32 [range 15-61] years) underwent endoscopic injection therapy at one of our institutions. We have identified grade II vesicoureteral reflux in 5 ureters, grade III in 8, and grade IV in 3 ureters. Grade 3 ureteral-orifice dilation were presented in 12 ureters (75%), grade 2 in 3 and grade 1 in 1 ureter in the present cases. Postoperatively, vesicoureteral reflux was diminished to grade 0 in 12 ureteral units (75%), decreased to grade I in 3 (9%), and remained grade III in 1 (6%). Three patients reported dull flank pain for several days postoperatively and there was 1 case of acute pyelonephritis. Temporary hydronephrosis was confirmed in 3 ureteral units (19%) at 1 month postoperatively. Median follow-up duration was 23 (range 13-63) months long. Although, 3 patients were experienced f-UTI 1-2 times, repeated VCUG showed no VUR recurrence. CONCLUSIONS According to hydrodistension grade of the ureteral orifice, endoscopic injection therapy via modified hydrodistension implantation technique is an effective and safe treatment for vesicoureteral reflux in post-pubertal female patients with dilated ureteral orifice. While ureteral deformities or a history of anti-reflux surgery may increase the risks, these can be managed with appropriate methods that ensure sufficient mound appearance and height.
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Affiliation(s)
- Tetsuji Maruyama
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Kentaro Mizuno
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hidenori Nishio
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Taiki Kato
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Takashi Hamakawa
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Yosuke Ikegami
- Department of Urology, Nagoya City East Medical Center, 2 Wakamizu-cho, Chikusa-ku, Nagoya, 464-8547, Japan
| | - Takahiro Yasui
- Department of Nephro-Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Yutaro Hayashi
- Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
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Ammenti A, Alberici I, Brugnara M, Chimenz R, Guarino S, La Manna A, La Scola C, Maringhini S, Marra G, Materassi M, Morello W, Nicolini G, Pennesi M, Pisanello L, Pugliese F, Scozzola F, Sica F, Toffolo A, Montini G. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr 2020; 109:236-247. [PMID: 31454101 PMCID: PMC7004047 DOI: 10.1111/apa.14988] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
AIM Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. METHODS The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. RESULTS Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. CONCLUSION These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
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Affiliation(s)
- Anita Ammenti
- Pediatric Polyspecialistic GroupPoliambulatorio Medi‐SaluserParmaItaly
| | - Irene Alberici
- Department of Woman and Child's HealthUniversity of PadovaPadovaItaly
| | | | - Roberto Chimenz
- Pediatric Nephrology and Dialysis UnitDepartment of PediatricsG. Martino HospitalUniversity of MessinaMessinaItaly
| | - Stefano Guarino
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Angela La Manna
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Claudio La Scola
- Nephrology and Dialysis UnitDepartment of PediatricsAzienda Ospedaliero Universitaria Sant'Orsola‐MalpighiBolognaItaly
| | | | - Giuseppina Marra
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - William Morello
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - Marco Pennesi
- Department of PediatricsInstitute for Child and Maternal HealthIRCCS Burlo GarofoloTriesteItaly
| | | | | | | | | | | | - Giovanni Montini
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
- Giuliana and Bernardo Caprotti Chair of PediatricsDepartment of Clinical Sciences and Community HealthUniversity of MilanoMilanoItaly
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Loardi C, Signorelli M, Gregorini M, Marella D, Torri F, Zambelloni CM, Omodei U, Odicino F. Moderate and severe fetal pyelectasis: Correlation between prenatal aspects and postnatal outcome. J Neonatal Perinatal Med 2020; 13:91-96. [PMID: 31609706 DOI: 10.3233/npm-180071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Renal pelvic dilatation (RPD) is a frequent finding in fetal ultrasound. The aim of the study is to correlate the prenatally detected moderate and severe pyelectasis with the postnatal outcome. METHODS A retrospective analysis involving 90 cases of prenatally detected moderate and severe RPD referred to our prenatal diagnosis centre with 18 months of urological follow-up. Prenatal ultrasound was correlated with postnatal renal function, assessed by plasmatic creatinine and/or renal scintigraphy performed before surgery. RESULTS Cases were divided between two groups according to postnatal management: group A including 35 newborns (38.9%) that needed surgical treatment and group B with 55 patients (61.1%) who were managed conservatively. The group A presented higher median RPD (18 mm, IQR 12-25 mm) compared to the group B (11 mm, IQR 10-14 mm). The most common anomaly detected within group A was pelvi-ureteric junction (PUI) obstruction (43%). Within group B 32 cases (58%) showed spontaneous resolution of hydronephrosis during postnatal follow up. In case of moderate pyelectasis the risk of postnatal surgery was 25% and raised to 60% for severe RPD. In our study, 29 newborns showed pathologic scintigraphies: 25 required surgery while 4 did not find indication for surgery due to ipsilateral renal function irreversible damage. 6 patients had high creatinine level (>0.6 mg/dl). 35 cases out of 90 (39%) developed monolateral irreversible renal function impairment. CONCLUSION Moderate and severe RPD are often correlated with postnatal renal damage, therefore a close multidisciplinary follow-up is required. Prenatal scanning is highly predictive of postnatal outcome and can address properly the prenatal counseling.
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Affiliation(s)
- C Loardi
- Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - M Signorelli
- Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - M Gregorini
- Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - D Marella
- Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - F Torri
- Department of Pediatric Surgery, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - C Mario Zambelloni
- Department of Neonatology, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - U Omodei
- Department of Obstetrics and Gynecology, ASST Spedali Civili Brescia, University of Brescia, Italy
| | - F Odicino
- Department of Obstetrics and Gynecology, ASST Spedali Civili Brescia, University of Brescia, Italy
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Gutiérrez-Jiménez AA, Jiménez-López LA, Ricardez-Espinosa AA, Santos-Uscanga JP, Aguilar-Sandoval EG, Vega-Tepos IE, George-Micceli E. Endourological application of polydimetilsiloxane in patients with symptomatic vesicoureteral reflux in the kidney graft. Actas Urol Esp 2019; 43:262-268. [PMID: 30935761 DOI: 10.1016/j.acuro.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 01/13/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify the results of polydimethylsiloxane application in the endourological management of symptomatic vesicoureteral reflux to the kidney graft and to determine the factors associated with persistent symptoms and with vesicoureteral reflux. MATERIAL AND METHODS We included 23 patients diagnosed with symptomatic VUR in kidney graft, evaluated from January 2010 to August 2018 in the High Specialty Medical Unit # 14 in Veracruz. These patients received endourological application of polydimethylsiloxane. The descriptive analysis was carried out, and, if possible, the relative risk measures for clinical failure (CF) were determined with odds ratio (OR). RESULTS 18 (78.3%) patients presented clinical success (CS). There was a significant difference in the mean age (CS 30.61±9.7, CF 46.0±11.46; U Mann Whitney, P=.037), and in the number of episodes of AGPN prior to the application of PDMS (CS 2.27±1.27, CF 3.6±0.89, U Mann Whitney, P=.019). The most frequently identified pathogen was E. Coli, with 45.4%. VUR resolution was observed in 47.8% of the cases. There was a decreased degree of VUR in 73.9% of cases. A lower degree of VUR was determined as a protective factor for CF (OR: 0.031, 95% CI: 0.002-0.437, with P=.008). CONCLUSIONS The endourological application of PDMS proved to be useful in the management of patients with symptomatic VUR in kidney graft, as it decreased the VUR degree and allowed CS in most cases.
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Affiliation(s)
- A A Gutiérrez-Jiménez
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México; Facultad de Medicina Miguel Alemán Valdés, Universidad Veracruzana, Veracruz, México.
| | - L A Jiménez-López
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México
| | - A A Ricardez-Espinosa
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México; Facultad de Medicina Miguel Alemán Valdés, Universidad Veracruzana, Veracruz, México
| | - J P Santos-Uscanga
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México
| | - E G Aguilar-Sandoval
- Departamento de Trasplante, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México
| | - I E Vega-Tepos
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México
| | - E George-Micceli
- Departamento de Urología, Unidad Médica de Alta Especialidad, Hospital de Especialidades 14, Centro Médico Nacional Adolfo Ruiz Cortines, Instituto Mexicano del Seguro Social, Veracruz, México
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Gnech M, Lovatt CA, McGrath M, Rickard M, Sanger S, Lorenzo AJ, Braga LH. Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature: where do we stand? J Pediatr Urol 2019; 15:204-212. [PMID: 31060965 DOI: 10.1016/j.jpurol.2019.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/17/2018] [Accepted: 02/28/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND/INTRODUCTION Randomized controlled trials (RCTs) are considered the "gold standard" methodology for examining the effects of clinical interventions, yet only 1% of urology literature employs this design. The Consolidated Standards of Reporting Trials (CONSORT) statement contains a standardized checklist of 37 items to be included when reporting RCTs to ensure transparency and completeness of information [2]. Despite the robust design of RCTs, the number of events can greatly change the significance of the results, which can be represented by the fragility index (FI). OBJECTIVE The objective was to assess the quality of reporting of RCTs in the pediatric vesicoureteral reflux (VUR) literature using the 2010 CONSORT statement and, for studies with significant positive findings, to determine the FI as a measure of robustness of the results. STUDY DESIGN A comprehensive search was conducted through MEDLINE® and Embase® to identify RCTs in VUR literature from 2000 to 2016. Two reviewers independently selected articles, which were evaluated using the CONSORT checklist. An overall quality of reporting score (OQS) (%) was calculated by dividing the number of checklist items present in each study by the maximum possible score (34) and expressed as a percentage. Studies were classified as low (<40%), moderate (40-70%) and high quality (>70%) based on the modified assessing the methodological quality of systematic reviews (AMSTAR) checklist. Of the 2052 initial matches, 98% were excluded due to methodology or content, a further 28 studies were found not to meet inclusion criteria after full text review. The FI was calculated for the 7 studies that met inclusion criteria with significantly different results by manually adding events to the study groups until p>0.05. RESULTS Twenty-two studies met inclusion criteria. The mean OQS was 46+17% with 9 (41%) identified as low quality (score <40%), 11 (50%) as moderate (40-70%) and 2 (9%) as high quality (>70%). There was no significant difference in OQS between RCTs with a sample size > 100 (n=15) versus <100 patients (n=7) (45+17% vs. 47+17%, p=0.7). However, we noted a difference when we compared RCTs with biostatistician support (n=4) vs. those without (n=18) (59+20% vs. 43+15%, p<0.05). Seven studies reported significant positive results making calculation of FI possible. The mean FI was 5.8+5.1 indicating that most studies were fragile. There was no correlation between the OQS and FI. DISCUSSION AND CONCLUSION The mean OQS of VUR RCTs was suboptimal (46%), with most studies having low FI scores indicating the instability of the findings. The only variable that significantly impacted the OQS was biostatistician support. Implementation of the CONSORT checklist with a minimum of 50% inclusion as a prerequisite for submission of manuscripts may improve the quality and transparency of reporting. Calculation of the FI could provide readers with an objective measure of robustness for the published trials, allowing for appropriate interpretation of the results.
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Affiliation(s)
- M Gnech
- Division of Urology, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Section of Paediatric Urology, Urology Unit, University Hospital of Padua, Padua, Italy
| | - C A Lovatt
- Department of Surgery/Urology, McMaster University, Hamilton, Ontario, Canada
| | - M McGrath
- Department of Surgery/Urology, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - M Rickard
- Division of Urology, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - S Sanger
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - A J Lorenzo
- University of Toronto, Division of Urology, The Hospital for Sick Children and Department of Surgery, 555 University Avenue, M5G 1X8, Toronto, Canada
| | - L H Braga
- Department of Surgery/Urology, McMaster University, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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21
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Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. This is an update of a review first published in 2004 and updated in 2007 and 2011. OBJECTIVES The aim of this review was to evaluate the available evidence for both benefits and harms of the currently available treatment options for primary VUR: operative, non-operative or no intervention. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 3 May 2018 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs in any language comparing any treatment of VUR and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model. MAIN RESULTS Thirty four studies involving 4001 children were included. Interventions included; long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin. Interventions were used alone and in combinations. The quality of conduct and reporting of these studies was variable, with many studies omitting crucial methodological information used to assess the risk of bias. Only four of the 34 studies were considered at low risk of bias across all fields of study quality. The majority of studies had many areas of uncertainty in the risk of bias fields, reflecting missing detail rather than stated poor design.Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI (9 studies, 1667 children: RR 0.77, 95% CI 0.54 to 1.09; low certainty evidence) and febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; low certainty evidence) at one to two years. At one to three years, antibiotic prophylaxis made little or no difference to the risk of new or progressive renal damage on DMSA scan (8 studies, 1503 children: RR 0.73, 95% CI 0.33 to 1.61; low certainty evidence). Adverse events were reported in four studies with little or no difference between treatment groups (1056 children: RR 0.94, 95% CI 0.81 to 1.08; ), but antibiotics increased the likelihood of bacterial drug resistance threefold (187 UTIs: RR 2.97, 95% CI 1.54 to 5.74; moderate certainty evidence).Seven studies compared long-term antibiotic prophylaxis alone with surgical reimplantation of ureters plus antibiotics, but only two reported the outcome febrile UTI (429 children). Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; moderate certainty evidence). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (4 studies, 572 children, RR 1.09, 95% CI 0.79 to 1.49; moderate certainty evidence)Four studies compared endoscopic injection with antibiotics alone and three reported the outcome febrile UTI. This analysis showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics (RR 0.74, 95% CI 0.31 to 1.78; low certainty evidence). Four studies involving 425 children compared two different materials for endoscopic injection under the ureters (polydimethylsiloxane (Macroplastique) versus dextranomer/hyaluronic acid polymer (Deflux), glutaraldehyde cross-linked (GAX) collagen (GAX) 35 versus GAX 65 and Deflux versus polyacrylate polyalcohol copolymer (VANTRIS)) but only one study (255 children, low certainty evidence) had the outcome of febrile UTI and it reported no difference between the materials. All four studies reported rates of resolution of VUR, and the two studies comparing Macroplastique with Deflux showed that Macroplastique was probably superior to dextranomer/hyaluronic acid polymer (3 months: RR 0.50, 95% CI 0.33 to 0.78; 12 months: RR 0.54 95% CI 0.35 to 0.83; low certainty evidence)Two studies compared probiotic treatment with antibiotics and showed little or no difference in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; low certainty evidence)Single studies compared circumcision with antibiotics, cranberry products with no treatment, oxybutynin with placebo, two different surgical techniques and endoscopic injection with no treatment. AUTHORS' CONCLUSIONS Compared with no treatment, the use of long-term, low-dose antibiotics may make little or no difference to the number of repeat symptomatic and febrile UTIs in children with VUR (low certainty evidence). Considerable variation in the study designs and subsequent findings prevented drawing firm conclusions on efficacy of antibiotic treatment.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear since few studies comparing the same treatment and with relevant clinical outcomes were available for analysis.
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Affiliation(s)
- Gabrielle Williams
- NSW Ministry of HealthAnalytics Assist73 Miller StNorth SydneyNSWAustralia2060
| | - Elisabeth M Hodson
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
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March-Villalba JA, Marzullo-Zucchet L, Hervás-Marín D, Polo Rodrigo A, Serrano Durbá A, Domínguez Hinarejos C, Boronat Tormo F, Boronat Tormo F. [Clinical usefulness of the non-invasive functional study of the lower urinary tract voiding phase as a predictor of resolution after the first endoscopic treatment of vesico-ureteral reflux in children older than 3 years.]. ARCH ESP UROL 2019; 72:36-44. [PMID: 30741651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine the usefulnessof voiding diary (VD), uroflowmetry with electromyography(UF-EMG), bladder wall thickness (before micturition)(VWTUS) and residual urine (PVR) (ultrasound measure)in predicting the outcome of the first endoscopic treatment(1ENDT) of vesicoureteral reflux (VUR) in children> 3 years. METHODS Cross-sectional ambispective study of 48children with vesicoureteral reflux. Those with previousendoscopic treatment, age or neurological abnormalities and a history of urethralor abdominal surgery were excluded. The outcomevariable was the correctness (by isotopic cystography)three months after 1ENDT. Univariate and multivariateanalyses were performed through a Multilayer Perceptronnetwork and a logistic regression model EmpiricalBayesian penalized type LASSO Elastic net. Diagnosticaccuracy were determined. RESULTS Mean age of the sample was 6.8 +/- 2.28years. The rate of VUR correction after 1ENDT was 77%.The variables selected by both methods were: VD-retentionist(OR 3.90), high PVR (OR 2.69), high VWTUS (OR4.44). Normal UF-EMG was a preventive variable (OR0.38). Diagnostic accuracy (pSp=48.7%), UF+EMG (Se=27.3%(Se=72.7% (AUC=0.8 cut point 20 ml),VWTUS (Se=81.8% (AUC=0.8 cut point4.6 mm). There were no statistical differences betweenPVR and VWTUS. Combined use of UF+EMG+PVR(Se=90.9%in predicting the persistence of VUR after 1ENDT inchildren > 3 years. After screening with a VD, UF-EMG+ RPM combination could be useful to detect these patientsand propose a treatment that improves bladdervoiding function prior to surgery.
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Affiliation(s)
- José Antonio March-Villalba
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Leopoldo Marzullo-Zucchet
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - David Hervás-Marín
- Unidad de Bioestadística. Instituto de Investigación Sanitaria Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Alba Polo Rodrigo
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Agustín Serrano Durbá
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Carlos Domínguez Hinarejos
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Francisco Boronat Tormo
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
| | - Francisco Boronat Tormo
- Sección de Urología Infantil. Servicio de Urología. Hospital Universitari i Politècnic La Fe. Valencia. España
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Rao KL, Menon P, Samujh R, Mahajan JK, Bawa M, Malik MA, Mittal BR. Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up. Indian Pediatr 2018; 55:1046-1049. [PMID: 30745475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance - Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction. DESIGN Retrospective analyses of case records. SETTING Pediatric Surgery department in a tertiary care government Institute. PARTICIPANTS 500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016). INTERVENTION Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans. MAIN OUTCOME MEASURE Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months. RESULTS Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR. CONCLUSIONS Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention.
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Affiliation(s)
- K Ln Rao
- Department of Pediatric Surgery, PGIMER, Chandigarh, India
| | - Prema Menon
- Department of Pediatric Surgery, PGIMER, Chandigarh, India. Correspondence to: Dr Prema Menon, Department of Pediatric Surgery, Advanced Pediatrics Centre, PGIMER, Chandigarh 160012, India,
| | - R Samujh
- Department of Pediatric Surgery, PGIMER, Chandigarh, India
| | - J K Mahajan
- Department of Pediatric Surgery, PGIMER, Chandigarh, India
| | - M Bawa
- Department of Pediatric Surgery, PGIMER, Chandigarh, India
| | - M A Malik
- Department of Pediatric Surgery, PGIMER, Chandigarh, India
| | - B R Mittal
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
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Pandya VK, Sutariya HC. Unilateral multicystic renal dysplasia: Prenatal diagnosis on ultrasound. Saudi J Kidney Dis Transpl 2017; 28:916-920. [PMID: 28748898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Multicystic renal dysplasia (MCRD) is the most common cause of abnormally enlarged kidney, diagnosed on antenatal ultrasound examination. It is an abnormality of the embryonic development in which the renal parenchyma is substituted by nonfunctioning renal tissue made up of cysts which do not communicate with each other. Vesicoureteric reflux (VUR), pelviureteric junction obstruction, vesicoureteric junction obstruction, and ureterocele are the most commonly seen abnormalities in contralateral kidney. Here, we report a case of prenatal diagnosis of unilateral MCRD with VUR in contralateral kidney. In conclusion, we want to emphasize optimal use of ultrasound imaging to detect such abnormalities as early as possible to guide the proper management.
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Affiliation(s)
- Vaidehi K Pandya
- Department of Radio Diagnosis and Imaging, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
| | - Harsh C Sutariya
- Department of Radio Diagnosis and Imaging, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
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25
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Álvarez García N, Gracia Romero J. [Vesicoureteral reflux. Fundamentals of the current treatment]. Cir Pediatr 2017; 30:67-70. [PMID: 28857527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- N Álvarez García
- FEA de Cirugía Pediátrica. Hospital Universitario Miguel Servet. Zaragoza
| | - J Gracia Romero
- Jefe del Servicio de Cirugía Pediátrica. Hospital Universitario Miguel Servet. Zaragoza
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Janchevska A, Gucev Z, Tasevska-Rmus L, Tasic V. Congenital Anomalies of the Kidney and Urinary Tract in Children Born Small for Gestational Age. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017; 38:53-57. [PMID: 28593895 DOI: 10.1515/prilozi-2017-0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Congenital anomalies of the kidney and urinary tract (CAKUT) represent several types of malformations with occurrence of 1 in about 500 live births. OBJECTIVE Small for gestation age (SGA) may influence in prevalence of CAKUT and progression of chronic kidney disease (CKD) in children. The aim of this study was to elaborate our experiences with detected CAKUT in a cohort of SGA born children in Macedonia. METHODS Our cohort consisted of 100 SGA born children investigated for associated congenital anomalies of urinary tract. We analyzed anthropometric and clinical birth data in children with diagnosed CAKUT and estimated the stage and time of onset of CKD by biochemical and imaging technics. RESULTS We revealed 7 (7.0%) SGA born children with congenital anomalies of the urinary tract. Their mean birth weight was very low 1855 gr (-3.93 SDS) and the birth length 45.57cm (-2.17 SDS), as well. A significant growth failure with reduced weight and BMI were noticed at the time of diagnosis. A diagnosis of CAKUT in 4/7 was established in the first few months of life, but in others 3 later in early childhood. Three children revealed with unilateral kidney agenesis, 2 had hypo-dysplastic kidneys and in 2 children was found vesicoureteral reflux. Normal glomerular filtration rate was estimated in 2 children with CAKUT. Stage 2 CKD with GFR 60-90 ml/minx1.73m2 had 3 children, 1 patient was graded in stage 3 and one child needed kidney transplantation, stage 5 CKD. CONCLUSIONS We presented 7 SGA born children with CAKUT. An early recognition, assessment and treatment of these anomalies might improve their quality of life.
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Affiliation(s)
- Aleksandra Janchevska
- MD, PhD student Department of endocrinology and genetics University Children's Hospital Skopje, Medical Faculty Skopje, Macedonia, Mother Teresa 17, 1000 Skopje
| | - Zoran Gucev
- University Children's Hospital Skopje, Medical Faculty Skopje
| | - L Tasevska-Rmus
- University Children's Hospital Skopje, Medical Faculty Skopje
| | - Velibor Tasic
- University Children's Hospital Skopje, Medical Faculty Skopje
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Tejwani R, Wang HHS, Lloyd JC, Kokorowski PJ, Nelson CP, Routh JC. Utility Estimation for Pediatric Vesicoureteral Reflux: Methodological Considerations Using an Online Survey Platform. J Urol 2016; 197:805-810. [PMID: 27746280 DOI: 10.1016/j.juro.2016.09.119] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The advent of online task distribution has opened a new avenue for efficiently gathering community perspectives needed for utility estimation. Methodological consensus for estimating pediatric utilities is lacking, with disagreement over whom to sample, what perspective to use (patient vs parent) and whether instrument induced anchoring bias is significant. We evaluated what methodological factors potentially impact utility estimates for vesicoureteral reflux. MATERIALS AND METHODS Cross-sectional surveys using a time trade-off instrument were conducted via the Amazon Mechanical Turk® (https://www.mturk.com) online interface. Respondents were randomized to answer questions from child, parent or dyad perspectives on the utility of a vesicoureteral reflux health state and 1 of 3 "warm-up" scenarios (paralysis, common cold, none) before a vesicoureteral reflux scenario. Utility estimates and potential predictors were fitted to a generalized linear model to determine what factors most impacted utilities. RESULTS A total of 1,627 responses were obtained. Mean respondent age was 34.9 years. Of the respondents 48% were female, 38% were married and 44% had children. Utility values were uninfluenced by child/personal vesicoureteral reflux/urinary tract infection history, income or race. Utilities were affected by perspective and were higher in the child group (34% lower in parent vs child, p <0.001, and 13% lower in dyad vs child, p <0.001). Vesicoureteral reflux utility was not significantly affected by the presence or type of time trade-off warm-up scenario (p = 0.17). CONCLUSIONS Time trade-off perspective affects utilities when estimated via an online interface. However, utilities are unaffected by the presence, type or absence of warm-up scenarios. These findings could have significant methodological implications for future utility elicitations regarding other pediatric conditions.
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Affiliation(s)
- Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jessica C Lloyd
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Kokorowski
- Division of Pediatric Urology, Children's Hospital Los Angeles, Los Angeles, California
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina.
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Pogorelić Z, Gudelj K, Budimir D, Todorić J, Jukić M, Furlan D, Košuljandić Đ, Saraga M. Comparison of dextranomer/hyaluronic acid based bulking agents in the treatment of vesicoureteral reflux in children: Deflux versus Vurdex. Can J Urol 2016; 23:8312-8317. [PMID: 27347628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The objective of this study was to compare the clinical efficacy of two similar tissue bulking agents, Deflux and Vurdex, used for a treatment of vesicoureteral reflux (VUR) in our institution. MATERIAL AND METHODS The case records of 104 children, treated endoscopically for primary VUR from January 2010 to January 2015, were retrospectively reviewed. Most of the patients were treated with Deflux until 2012, when use of Vurdex was started. Exclusion criteria were patients with secondary reflux due to neurogenic bladder, duplicated refluxing ureters, primarily operated patients and patients operated after first or second injection. RESULTS Endoscopic treatment of vesicoureteral reflux using Deflux was performed in 65 children (106 ureters). There were 24 patients with unilateral and 41 patients with bilateral VUR. After first injection of Deflux success was achieved in 74 ureters (69.8%), after second injection in 91 ureters (85.8%) and after third injection in 99 ureters (93.3%). The same procedure using Vurdex was performed in 39 children (58 ureters). There were 20 patients with unilateral and 19 patients with bilateral reflux. After first injection of Vurdex success was achieved in 43 ureters (74.1%), after second injection in 52 ureters (89.6%) and after third injection in 55 ureters (94.8%). CONCLUSIONS Overall success rate for patients treated with Deflux was 93.3% and for patients treated with Vurdex 94.8%. No significant difference in success rates between two groups was found (p = 0.714). However, Vurdex has an advantage because of the significantly lower price, but with same treatment results as Deflux.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, Split University Hospital, Split, Croatia
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Affiliation(s)
- H Olbing
- Department of Pediatric Nephrology, Essen, FRG
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Gusmano R, Perfumo F, Raspino M, Ginevri F, Verrina E, Ciardi MR. Natural history of reflux nephropathy in children. Contrib Nephrol 2015; 61:200-9. [PMID: 3359778 DOI: 10.1159/000415251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- R Gusmano
- Nephrology and Dialysis Department, G. Gaslini Institute, Genoa, Italy
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33
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Koff SA, Murtagh D. The uninhibited bladder in children: effect of treatment on vesicoureteral reflux resolution. Contrib Nephrol 2015; 39:211-20. [PMID: 6744872 DOI: 10.1159/000409250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
Vesicoureteric reflux is defined as the retrograde passage of urine from the bladder into one or both ureters and often up to the kidneys, and mainly affects babies and infants. In severe cases dilatation of the ureter, renal pelvis, and calyces might be seen. Traditionally it was thought that only a low percentage of children have vesicoureteric reflux, but studies have suggested as many as 25-40% are affected. Guidelines recommend that the number of investigations for vesicoureteric reflux in children who have had a febrile urinary tract infection be reduced, but this approach is controversial. The recommendations also suggest that prophylactic antibiotics and surgery should be avoided in children with non-severe vesicoureteric reflux. In this Seminar I present data on the management of children with vesicoureteric reflux and give suggestions on how to navigate this difficult area.
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Affiliation(s)
- Kjell Tullus
- Department of Nephrology, Great Ormond Street Hospital for Children, London, UK.
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35
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Şencan A, Yıldırım H, Özkan KU, Uçan B, Karkıner A, Hoşgör M. Late ureteral obstruction after endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer. Urology 2014; 84:1188-93. [PMID: 25443932 DOI: 10.1016/j.urology.2014.07.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/09/2014] [Accepted: 07/15/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the incidence and presentation of ureteral obstruction after endoscopic injection of polyacrylate polyalcohol copolymer (PPC) for the treatment of vesicoureteral reflux, and to analyze its possible causes, together with histopathologic assessment. PATIENTS AND METHODS The data of 189 patients who underwent endoscopic injection of PPC between May 2011 and December 2013 were retrospectively reviewed. After the injection, patients were followed up by urinalysis and ultrasonography monthly for 3 months. Control voiding cystouretrography was performed in the third postoperative month. Patients were then followed up by ultrasound every 3 months. If a new-onset hydroureteronephrosis (HUN) was observed, control ultrasound was performed monthly to follow the change in the degree of HUN. If a moderate or severe HUN was observed, technetium-99m mercaptoacetyltriglycine or dimercaptosuccinic acid scintigraphy was performed. For patients who needed open surgery, Cohen ureteroneocystostomy was performed. The distal 1 cm of the ureters was resected and examined histopathologically. RESULTS One hundred eighty-nine patients with 268 refluxing ureters underwent endoscopic injection of PPC. Ureteral obstruction was observed in 3 ureters (1.1%), in 3 female patients of whom the degrees of reflux were grade 4, 5, and 5, respectively. Obstruction showed late onset in all 3 patients. Manifestations of obstruction included pain in 2 patients and recurrent febrile urinary tract infection with loss of function in scintigraphy in 1. All 3 patients underwent open ureteroneocystostomy. CONCLUSION PPC may cause ureteral obstruction several months or even years after injection. Patients who undergo endoscopic treatment of PPC need long-term follow-up, despite reflux showing complete resolution.
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Affiliation(s)
- Arzu Şencan
- Department of Pediatric Surgery, Dr. Behçet Uz Children's Hospital, İzmir, Turkey.
| | - Hülya Yıldırım
- Department of Pathology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | | | - Başak Uçan
- Department of Pediatric Surgery, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Aytaç Karkıner
- Department of Pediatric Surgery, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Münevver Hoşgör
- Department of Pediatric Surgery, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
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Fan R, Cohen MD. Small incidental renal mass in young children. J Pediatr 2014; 164:1499-1499.e1. [PMID: 24704301 DOI: 10.1016/j.jpeds.2014.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/26/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Rong Fan
- Department of Pathology and Laboratory Medicine, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mervyn D Cohen
- Department of Radiology, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
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Palumbo E. [Recent advances in the diagnosis of vesicoureteral reflux in children]. Recenti Prog Med 2013; 104:585-589. [PMID: 24336621 DOI: 10.1701/1370.15229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Primary vesicoureteral reflux is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal treatment, which necessitates identification of patients requiring early intervention. The aim of this review is to evidence the recent advances in the diagnosis of this congenital abnormality and to indicate the guidelines for its diagnostic management.
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Vírseda M, Salinas J, Bolufer E, Esteban M, Méndez S. Prognostic factors of endoscopic treatment of vesicoureteral reflux in spinal cord injured patients. Actas Urol Esp 2013; 37:565-70. [PMID: 23602506 DOI: 10.1016/j.acuro.2013.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 02/08/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vesicoureteral reflux (VUR) is an important complication in patients with spinal cord injury due to its frequency and morbidity. One of the most extended therapeutic options is endoscopic injection of obliteration substances in the urethral meatus. OBJECTIVE To analyze the prognostic factors of VUR treatment using obliterative substances in patients with spinal cord injury. MATERIAL AND METHODS A prospective study was performed in a cohort of 76 patients (age 48.9±14.4 years), of both genders, with spinal cord injuries, who underwent endoscopic treatment of the VUR during the years 2008 to 2011. In all the patients, a clinical history was obtained and a pre-operative videourodynamic study was performed. Another study was carried out at 7.32 months (standard deviation: 6.28 months) of the intervention. Treatment consisted in endoscopic injection of dextranomer/hyaluronic acid copolymer (62 cases) and polydimethylsiloxane (14). The statistical tests applied were the Fisher's exact test and the Student's T test comparing the means. Bilateral significance level was established at 95%. RESULTS Resolution of VUR was achieved in 46 cases (61%). The statistically significant prognostic factors were age (younger aging cured patients), bilaterality and reflects great (greater grade in bilaterality in the cases with persistence of reflux) and presence of neurogenic detrusor overactivity (greater percentage in the cases of reflux persistence). Stress urinary incontinence (greater percentage in cured patients), contractile potency (lower percentage in cured patients) and urethral resistance (greater percentage in cured patients) were also statistically significant prognostic factors. CONCLUSIONS Among the prognostic factors that affected the endoscopic treatment results of the VUR in patients with neurogenic lower urinary tract dysfunction (NLUTD), anatomical as well as functional factors were found.
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Affiliation(s)
- M Vírseda
- Servicio de Urología, Hospital Nacional de Parapléjicos, Toledo, España.
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Abstract
Pyonephrosis is uncommon in adult and paediatric population and very rare in neonates. Neonatal candidal and staphylococcal pyonephrosis has been reported earlier, and this is the first reported case of MRSA pyonephrosis. A case of potentially lethal fulminating primary MRSA pyonephrosis with septic shock in a neonate in whom investigations showed refluxing and obstructing left megaureter requiring successful surgical correction has been reported.
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Affiliation(s)
- Ramnik Patel
- The Department of Paediatric Urology, Children's Hospital, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Infirmary Road, Leicester, LE1 5WW, UK
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40
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Demède D. [Vesicoureteral reflux in children]. Soins Pediatr Pueric 2013:23-24. [PMID: 23789174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Vesicoureteral reflux is the most frequent uropathy in children and can have serious consequences if left untreated, including impaired kidney function.As urinary infection is the main element leading to its diagnosis, it is important not to ignore such an infection and to act quickly to treat it and prevent any recurrence.
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El-Ghoneimi A. [Advances in pediatric urology]. Soins Pediatr Pueric 2013:14-16. [PMID: 23789171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Urogenital disorders in children include congenital malformations affecting the urinary system and the genital organs, as well as disorders acquired during childhood. They require medical and surgical treatment by a dedicated team, notably a paediatric urologist, nurse and psychologist. Significant advances have been made in this discipline over the last ten years.
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Affiliation(s)
- Alaa El-Ghoneimi
- Université de Paris VII, Hôpital Robert-Debré, AP-HP, Paris Cedex, France.
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Barone JG. Editorial comment. Urology 2013; 81:1045-6; discussion 1046. [PMID: 23608427 DOI: 10.1016/j.urology.2013.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
PURPOSE After endoscopic correction of vesicoureteral reflux, we correlated the appearance of the Deflux® mound with the outcome. MATERIAL AND METHODS We created an online survey based on 11 primary vesicoureteral reflux cases, including 6 failed and 9 successful procedures in a total of 15 renal units. Cases were selected randomly from our video library. All cases were performed by a single surgeon using the double hydrodistention implantation technique until a satisfactory mound was achieved and corrected. An online survey questionnaire was e-mailed to 234 members of the Society for Pediatric Urology. Each survey question contained a preoperative voiding cystourethrogram image as well as images of the ureteral orifice before and after injection. Respondents were asked to predict whether they thought that the appearance of the Deflux mound would be associated with successful reflux resolution on voiding cystourethrogram 3 months postoperatively. We analyzed the percent of correctly answered questions as well as the sensitivity, specificity and predictive value of the ability of experts to predict the outcome. RESULTS A total of 104 pediatric urologists responded to the survey. Overall, 66.4% of respondents predicted reflux resolution based on mound appearance, including 66% and 67% who correctly predicted success and failure, respectively. Mean outcome predictability per respondent was 66% (range 26% to 86%). CONCLUSIONS The appearance of the Deflux mound and lack of hydrodistention at the completion of the procedure are not reliable predictors of outcome. Based on this experience, postoperative voiding cystourethrogram is still required to truly determine reflux resolution.
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Affiliation(s)
- Guy Hidas
- Urology Department, University of California-Irvine, Orange, California 92868, USA
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Affiliation(s)
- Saul P Greenfield
- Department of Pediatric Urology, Women and Children's Hospital of Buffalo, Buffalo, New York, USA
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Puri P, Kutasy B, Colhoun E, Hunziker M. Single center experience with endoscopic subureteral dextranomer/hyaluronic acid injection as first line treatment in 1,551 children with intermediate and high grade vesicoureteral reflux. J Urol 2012; 188:1485-9. [PMID: 22906657 DOI: 10.1016/j.juro.2012.02.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE In recent years the endoscopic injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis and the surgical management of vesicoureteral reflux. We determined the safety and effectiveness of the endoscopic injection of dextranomer/hyaluronic acid as first line treatment for high grade vesicoureteral reflux. MATERIALS AND METHODS Between 2001 and 2010, 1,551 children (496 male, 1,055 female, median age 1.6 years) underwent endoscopic correction of intermediate and high grade vesicoureteral reflux using dextranomer/hyaluronic acid soon after the diagnosis of vesicoureteral reflux on initial voiding cystourethrogram. Vesicoureteral reflux was unilateral in 761 children and bilateral in 790. Renal scarring was detected in 369 (26.7%) of the 1,384 patients who underwent dimercapto-succinic acid imaging. Reflux grade in the 2,341 ureters was II in 98 (4.2%), III in 1,340 (57.3%), IV in 818 (34.9%) and V in 85 (3.6%). Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure, and renal ultrasound was performed annually thereafter. Patients were followed for 3 months to 10 years (median 5.6 years). RESULTS Vesicoureteral reflux resolved after the first, second and third endoscopic injection of dextranomer/hyaluronic acid in 2,039 (87.1%), 264 (11.3%) and 38 (1.6%) ureters, respectively. Febrile urinary tract infections developed during followup in 69 (4.6%) patients. None of the patients in the series needed reimplantation of ureters or experienced any significant complications. CONCLUSIONS Our results confirm the safety and efficacy of the endoscopic injection of dextranomer/hyaluronic acid in the eradication of high grade vesicoureteral reflux. We recommend this 15-minute outpatient procedure as the first line of treatment for high grade vesicoureteral reflux.
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Affiliation(s)
- Prem Puri
- National Children's Research Centre, Dublin, Ireland; National Children's Hospital, Dublin, Ireland.
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Keren R. Management of primary vesicoureteral reflux in children: editorial commentary. Pediatr Clin North Am 2012; 59:835-8. [PMID: 22857831 DOI: 10.1016/j.pcl.2012.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Decisions are needed about the clinical management of children with vesicoureteral reflux (VUR) and a standardized risk-specific treatment approach is needed. Clinicians and researchers must begin to think creatively about VUR. Clinicians are beginning to understand that there are a variety of abnormalities in specific host defenses that might predispose some children to recurrent urinary tract infection, and that knowledge of these deficiencies may lead to therapies designed to compensate for them. There is also much to be learned about host inflammatory response to kidney infection.
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Akyol I. Intermediate to long-term follow-up indicates low risk of recurrence after double HIT endoscopic treatment for primary vesico-ureteral reflux. J Pediatr Urol 2012; 8:449. [PMID: 22056310 DOI: 10.1016/j.jpurol.2011.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 09/21/2011] [Indexed: 11/18/2022]
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Fujimoto T, Suwa T, Ishii N. Modified STING procedure for high-grade vesicoureteral reflux in children: intraureteral injection with ureteral orifice reposition technique. Pediatr Surg Int 2012; 28:847-50. [PMID: 22885807 DOI: 10.1007/s00383-012-3135-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2012] [Indexed: 11/26/2022]
Abstract
We describe a modified endoscopic injection technique for the treatment of vesicoureteral reflux (VUR). Our modification combines the STING and proximal HIT injection techniques and results in higher success rates in the resolution in VUR.
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Affiliation(s)
- Takao Fujimoto
- Department of Paediatric Surgery and Urology, Aiiku Maternal and Children's Medical Center, 5-6-8 Minami-Azabu, Minato-ku, Tokyo, 106-8580, Japan.
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Kirsch AJ, Kalisvaart JF. Response to commentary by P.H. Noh. J Pediatr Urol 2012; 8:448. [PMID: 22079676 DOI: 10.1016/j.jpurol.2011.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 10/19/2011] [Indexed: 11/19/2022]
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Abstract
The management of vesicoureteral reflux (VUR) is varied and remains controversial, which is likely because children with VUR have different risks for urinary tract infection or renal injury. Consequently, the treatment of VUR needs to be individualized based on the patient's characteristics. In this article, the authors review the medical and surgical management options for VUR in the pediatric population. The authors hope to provide a systematic approach to determine which treatment is optimal for a specific patient.
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Affiliation(s)
- Fernando F Fonseca
- Department of Urology, Children's Hospital, Boston Harvard Medical School, Boston, MA 02115, USA
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