Utility of F-15 diuretic MAG3 renography in assessment of paediatric hydronephrosis.

INTRODUCTION: Diuretic renography is crucial in evaluation of paediatric hydronephrosis. Furosemide is conventionally given 15-20 min after radiolabelled tracer (F+15/F+20 protocol), however this is equivocal in around 15% of patients. Giving furosemide 15 min prior to tracer (F-15 MAG3 protocol) has been suggested as an additional tool in the investigation of patients with suspected upper urinary tract obstruction. However, the role of this method in assessment and management of paediatric hydronephrosis is not widely reported. OBJECTIVE: To investigate utility of F-15 renograms in children with hydronephrosis being assessed for Pelvi-Ureteric Junction Obstruction (PUJO). STUDY DESIGN: Retrospective review of patients <16 years old undergoing F-15 MAG3 renogram between 2018 and 2021 in our tertiary paediatric surgical centre. Data collected included patient demographics, mode of presentation, investigations, management and outcomes. RESULTS: Eighteen patients were included. Median age at F-15 renogram was 7.3 years. Eleven patients presented with antenatal hydronephrosis, 5 with symptoms in childhood and 2 with incidental hydronephrosis on trauma imaging. Fourteen patients were symptomatic. Ten had a prior non-obstructed F+20 renogram but persisting symptoms suggestive of PUJO. Seven had previous equivocal F+20 renograms. One symptomatic patient directly underwent an F-15 renogram. A conclusive result was obtained in 16/18 (89%); 11 patients had obstructed curves and 5 non-obstructed. Two asymptomatic patients' scans were inconclusive. All symptomatic patients had conclusive scans. Of 11 patients with an obstructed F-15, 9 have undergone pyeloplasty to date. All have had post-operative resolution in symptoms and static or improved post-operative ultrasound. One patient with an inconclusive scan underwent pyeloplasty due to persisting hydronephrosis and parent preference. Three patients with non-obstructed F-15 renograms have been discharged. One symptomatic patient with a non-obstructive F-15 had a ureteric stent inserted due to persistent flank pain; 1 continues under surveillance. DISCUSSION: It is known that conventional F+20 MAG3 renograms can give equivocal results. Published experience suggests that F-15 renograms are conclusive in the majority of patients. Routine primary use is, however, discouraged as they can 'over diagnose' obstruction and limit the study of tracer transit under physiological flow rates. This study indicates that the F-15 renogram is a useful adjunct in the assessment of patients with symptoms suggestive of PUJO who have previously had an equivocal or a non-obstructed F+20 renogram. CONCLUSION: F-15 renogram was conclusive in 89% of patients. We recommend using F-15 renograms to aid surgical decision-making in children with equivocal F+20 renograms, especially in the presence of symptoms.

A consensus process to identify research priorities in paediatric urology in the United Kingdom.

INTRODUCTION: Paediatric urologists manage a spectrum of conditions, much of the evidence for relevant treatment pathways is of low quality. For many conditions treatment varies according to location and surgeon; children with the same condition might have surgery in one unit but watchful waiting in another. Underlying this variation are differences in opinion, and insufficient high-level evidence with few prospective randomized studies. Such studies may be challenging to design, fund and recruit into, and are more likely to succeed if there is a collaborative approach. Research prioritization is a tool to identify the research of most value. Delphi methodology is an interpretive technique aiming to gain the consensus view of interested parties. The British Association of Paediatric Urologists (BAPU) set out to ascertain consensus on what paediatric urologists, working in the UK, consider to be areas of priority for research. This paper describes the process used, and the resulting list of research questions. METHODS: A scoping survey of paediatric urologists in the UK was undertaken to identify an initial set of research questions. These were refined by the BAPU research committee (BAPU RC), then prioritized using a modified Delphi process. During Stage 1a multiple new research questions were submitted leading to Stage 1b, an interim process. All UK paediatric urologists were invited to take part in Stage 2 of the prioritization process. RESULTS: Sixty-five questions were submitted to the scoping survey by 24 paediatric urologists. The BAPU RC refined these to 60 questions, which were submitted to Stage 1a of the modified Delphi process. Sixty-seven people completed Stage 1a, at the same time submitting 224 additional research questions. The BAPU RC revised the entire question set, ensuring the key subject of the original question was not altered and novel questions were retained. The BAPU RC undertook interim scoring of the resultant 79 questions, the top scoring 25 questions plus 5 lower scoring 'wild card' questions (to ensure the breadth of the specialty was represented) were put forward to Stage 2. A total of 65 people completed Stage 2, including a lay representative. A list of 30 priority research questions was generated; the top 10 includes management of neuropathic bladder, posterior urethral valves, antibiotic prophylaxis, DSD & CAH, continence, male external genitalia, VUR and transition care (Table). CONCLUSION: This process has provided BAPU, paediatric urologists in the UK, and funders with areas of research considered a priority in the specialty.

Ureteric Clipping for the Treatment of Urinary Incontinence in Girls With Ectopic Ureters: Predicting Who Is Going to Dilate and Does It Matter?

OBJECTIVE: To assess the effectiveness and midterm follow-up of laparoscopic upper pole ectopic ureteral clipping to treat urinary incontinence in girls with duplex kidneys and non/poorly functioning upper pole moieties. To see if preoperative characteristics increased the likelihood of significant postoperative dilatation and whether this dilation has clinical significance. METHODS: A database review identified children who had undergone ureteric clipping at our institution. Patient details assessed included: age at presentation, age at procedure, significant past medical history, preoperative investigations, operative time, length of stay, postoperative symptoms, postoperative renal tract ultrasound findings and the need for subsequent intervention. RESULTS: Six girls underwent clipping between March 2018 and May 2021. The mean age at presentation and surgery were 77months (39-186) and 86months (44-193), respectively. The mean operative time was 94 minutes (range 66-128 minutes). The median length of stay was 1 day (range 0-3days). All the girls were dry immediately after the procedure. During a mean follow-up of 51months (29-66) all children have remained symptom-free and required no further intervention. Two children have developed significant (>30 mm) but stable ureteric dilatation after clipping but have remained asymptomatic and therefore are continuing on conservative follow-up. Both these children had dilated ureters (>10 mm) preoperatively. CONCLUSION: Ureteric clipping is quick, safe, and effective option in dealing with incontinence due to ectopic upper pole ureters in girls. Children with preoperative ureteric dilation seem to be at increased risk of postoperative dilation. However, as they remain asymptomatic, the clinical significance of this dilatation is unclear.

Paediatric acute epididymo-orchitis temporally related to SARS-CoV-2 infection: A case series and review of the literature.

INTRODUCTION: Acute epididymo-orchitis (AEO) is becoming an increasingly common differential diagnosis in children with acute scrotal pain. It has been noted in adult men that SARS-CoV-2 has a propensity for involving the testis and epididymis, affecting sperm and testosterone production. Our literature search revealed only one case report of COVID-19 presenting with epididymo-orchitis in a child. We present three more children who presented with AEO, all recovering from PCR-confirmed SARS-CoV-2 infection. This article reviews the post-inflammatory aetiology of paediatric epididymo-orchitis, and the propensity SARS-CoV-2 has for the testis. PATIENTS AND METHODS: Two pre-pubertal ten-year-old patients presented to the emergency department with a 48-h history of gradual onset unilateral scrotal pain and increasing erythema of the ipsilateral scrotal skin. One fifteen-year-old boy was referred for ongoing symptoms four days following a diagnosis of AEO made by his General Practitioner. On further questioning, all three had PCR-confirmed COVID infection two weeks prior to the onset of their scrotal symptoms and had just ended their isolation period. A literature search was then performed using the keywords SARS-CoV-2, testes and paediatric acute epididymo-orchitis. DISCUSSION: The SARS-Cov-2 virus has a propensity for affecting the testis and epididymis. This puts patients at increased risk of acute epididymo-orchitis during COVID infections. The inflammation induced by the virus appears to affect the cells responsible for testosterone production and sperm quality. However, there is no evidence that viral transmission can happen via semen. CONCLUSION: SARS-Cov-2 infection can lead to acute epididymo-orchitis. Knowledge of this is clinically significant, firstly to avoid unnecessary surgical intervention due to a mistaken diagnosis of testicular torsion and secondly, due to the potential of the virus to affect sperm quality and testosterone production.

Emergency scrotal exploration in children: Following a change in mindset in the UK.

A survey of 200 emergency scrotal explorations done over four paediatric surgical centres in the UK revealed that the incidence of finding testicular torsion (TT) was 24% and the preoperative utilisation of Doppler ultrasound (DUS) was 10% [1]. We changed our practice to include better preoperative utilisation of a clinical risk score (TWIST) and DUS. This led to a significant increase in the incidence of finding TT from 18% to 53%. Obtaining a DUS did not lead to an increase in our orchidectomy rate. Adopting this change is possible in an NHS setting and it has significant clinical and economic benefits.

Low yield from imaging after non-E. coli urine tract infections in children treated in primary care and emergency department.

BACKGROUND: Imaging is recommended for selected children following urinary tract infections (UTIs) to look for actionable structural abnormalities. Non-E. coli is considered high risk in many national guidelines, but evidence is mainly drawn from small cohorts from tertiary centres. OBJECTIVE: To ascertain imaging yield from infants and children <12 years diagnosed with their first confirmed UTI (pure single growth >100 000 cfu per ml) in primary care or an emergency department without admission stratified by bacteria type. DESIGN, SETTING, PATIENTS: Data were collected from an administrative database of a UK citywide direct access UTI service between 2000 and 2021. Imaging policy mandated renal tract ultrasound and Technetium-99m dimercaptosuccinic acid scans in all children, plus micturating cystourethrogram in infants <12 months. RESULTS: 7730 children (79% girls, 16% aged <1 year, 55% 1-4 years) underwent imaging after first UTI diagnosed by primary care (81%) or emergency department without admission (13%). E. coli UTI yielded abnormal kidney imaging in 8.9% (566/6384). Enterococcus and KPP (Klebsiella, Proteus, Pseudomonas) yielded 5.6% (42/749) and 5.0% (24/483) with relative risks 0.63 (95% CI 0.47 to 0.86) and 0.56 (0.38 to 0.83)), respectively. No difference was found when stratified by age banding or imaging modality. CONCLUSION: In this largest published group of infants and children diagnosed in primary and emergency care not requiring admission, non-E. coli UTI was not associated with a higher yield from renal tract imaging.

The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans.

AIM: To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans. METHODS: A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit. RESULTS: At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%). CONCLUSION: Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.

Globalization in Pediatric Surgical Training: The Benefit of an International Fellowship in a Low-to-Middle-Income Country Academic Hospital.

OBJECTIVE: A relative oversupply of pediatric surgeons led to increasing difficulties in surgical training in high-income countries (HIC), popularizing international fellowships in low-to-middle-income countries (LMIC). The aim of this study was to evaluate the benefit of an international fellowship in an LMIC for the training of pediatric surgery trainees from HICs. METHODS: We retrospectively reviewed and compared the prospectively maintained surgical logbooks of international pediatric surgical trainees who completed a fellowship at Chris Hani Baragwanath Academic Hospital in the last 10 years. We analyzed the number of surgeries, type of involvement, and level of supervision in the operations. Data are provided in mean differences between South Africa and the respective home country. RESULTS: Seven fellows were included. Operative experience was higher in South Africa in general (Δx̅ = 381; 95% confidence interval [CI]: 236-656; p < 0.0001) and index cases (Δx̅ = 178; 95% CI: 109-279; p < 0.0001). In South Africa, fellows performed more index cases unsupervised (Δx̅ = 71; 95% CI: 42-111; p < 0.0001), but a similar number under supervision (Δx̅ = -1; 95% CI: -25-24; p = 0.901). Fellows were exposed to more surgical procedures in each pediatric surgical subspecialty. CONCLUSION: An international fellowship in a high-volume subspecialized unit in an LMIC can be highly beneficial for HIC trainees, allowing exposure to higher caseload, opportunity to operate independently, and to receive a wider exposure to the different fields of pediatric surgery. The associated benefit for the local trainees is some reduction in their clinical responsibilities due to the additional workforce, providing them with the opportunity for protected academic and research time.

Emergency scrotal exploration in children: Is it time for a change in mindset in the UK?

INTRODUCTION: Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK. OBJECTIVE: We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis. PATIENTS AND METHODS: A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice. RESULTS: In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores. DISCUSSION: The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy.

Problem solving in clinical practice: the sick infant with low sodium and high potassium.

Many paediatricians will be faced with a sick infant who on investigation is found to have hyponatraemia and hyperkalaemia at some time in their career. The focus of initial management includes the treatment of potentially life-threatening hyperkalaemia with concurrent investigation aiming to elucidate whether the underlying cause reflects a primarily renal or endocrine pathology. We describe the presentation of two infants who each presented with one of the more common underlying diagnoses that led to this biochemical disturbance and discuss the approach to immediate treatment, diagnostic work-up and longer term management.

Diagnosing and treating occult vesicoureteric reflux using PIC cystography: Is it influenced by abnormalities on DMSA?

BACKGROUND: Positioning the Instillation of Contrast cystography (PICc) is used to identify occult vesicoureteric reflux (VUR) in patients with recurrent urinary tract infections (UTI) despite optimized bladder and bowel function and without VUR demonstrated on conventional imaging. AIM: To determine the incidence of finding occult VUR in such patients usingPICc and the benefit, if any, of treating it. We also assessed if this was influenced by abnormalities on the pre-operative DMSA. PATIENTS AND METHODS: This was a retrospective review of PICc in our hospital between 2016 and 2018 and involved three paediatric urologists. The primary indication for PICc was two or more culture proven UTIs despite optimized bladder and bowel function and no reflux on voiding cystourethrography (VCUG) or indirect radionuclide cystography (I-RNC). All children had a preoperative DMSA scan to document any abnormalities. PICc was performed in a standardized way to each ureteric orifice. If occult reflux was found, it was treated concomitantly by cystoscopic injection of Deflux®. To assess the influence of the pre-operative DMSA status, the cohort was subdivided into two groups based on the DMSA scan: Group 1-abnormal DMSA, Group 2-normal DMSA. The median follow-up was 26 months (range 3-39 months). RESULTS: PICc was performed in 25 patients [23 females and 2 males; median age: 7 years (range 2-16 years; IQR = 4)]; 17 from Group 1 and 8 from Group 2. Occult VUR was identified in 22 patients (88%); 15/17 (88.2%) in Group 1 and 7/8 (87.5%) in Group 2 (p = 0.9). After cystoscopic treatment, 21/25 (84%) became infection free and this was not influenced by the preoperative DMSA status (p = 0.6). Fig 1. DISCUSSION: In this challenging group of patients, looking for and treating occult reflux appears to be clinically useful and beneficial. The ability to test and treat at the same sitting is an added advantage of PICc. The DMSA results did not influence the diagnostic or therapeutic aspect of the process. Our results concur with other published literature. CONCLUSION: There is a high incidence of finding occult reflux using PICc in this cohort of patients. Concomitant cystoscopic treatment led to 84% of children becoming infection free on follow up. Abnormalities on DMSA did not influence either the likelihood of finding occult reflux or the likelihood of successful treatment.

Save the foreskin: Outcomes of preputioplasty in the treatment of childhood phimosis.

BACKGROUND: Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods like preputioplasty. We sought to examine outcomes of preputioplasty for the treatment of non-scarred pathological phimosis in two UK paediatric surgery tertiary centres. METHODS: Retrospective case series selecting cases performed in both departments over a 4 year period (January 2012-December 2015). INCLUSION CRITERIA: non-scarred pathological phimosis treated with preputioplasty. EXCLUSION CRITERIA: diffuse scarring of foreskin or presence of balanitis xerotica obliterans (BXO), preputioplasty performed as part of hypospadias repair. Outcome measure was treatment success as evidenced by fully retractile prepuce at follow up. Follow up occurred between 3 and 24 months. RESULTS: We identified 126 patients, 6 were excluded due to the above criteria. Median age was 13.4 years (range 10 months-18 years). Median follow up was 13 months (range 3-24 months). 115 patients (96%) had successful treatment as evidenced by satisfactory post-operative cosmesis and complete resolution of phimosis at follow up. Recurrence of phimosis occurred in 5 patients (4%). Mean time of recurrence was 6 months, with a median age of recurrence of 15.3 years (range 10.7-16.7 years). All patients with recurrence were successfully treated with circumcision. CONCLUSION: Foreskin conserving methods like preputioplasty are a valid option in the treatment of non-scarred pathological phimosis.

Bladder injury in a child during laparoscopic surgery.

Injury to intra-abdominal organs occurs in approximately 0.2% of adult laparoscopic general surgery cases. This risk is increased in the paediatric population due to the comparatively smaller operative field. Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children. Placement of a suprapubic working port is common; this is associated with a risk of bladder injury. We present our experience of managing a 6-year-old boy who sustained an extra-peritoneal bladder injury during port placement for a laparoscopic appendicectomy. We will also review the relevant current literature.