Positioning irrigation of contrast cystography for diagnosis of occult vesicoureteric reflux: association with technetium-99m dimercaptosuccinic acid scans.

OBJECTIVE: Positioning irrigation of contrast (PIC) cystography identifies occult or PIC vesicoureteral reflux (PIC-VUR) in children with recurrent febrile urinary tract infections (UTI) but no vesicoureteric reflux (VUR) on standard voiding cystourethrogram (VCUG). We sought to identify the relationship between PIC-VUR and renal scarring in technetium-99m dimercaptosuccinic acid (DMSA) scans. PATIENTS AND METHODS: We retrospectively analysed PIC cystograms and DMSA scans for 154 kidneys in 81 children (65 girls; 16 boys; median age, 4.7 years; range, 0.9-15.2). Renal scarring was graded on a scale of 0-3. DMSA scans were pathologic in 66 patients (81%). Children had experienced mean 3.8 febrile UTI (range 1-25). Forty-seven (58%) children had a history of reflux, including 15 (19%) with previous anti-reflux operations. Indications for PIC cystography were recurrence of febrile UTI after either bilateral negative VCUG (66 children) or unilateral VUR (15 children) with contralateral/bilateral scarring or reflux that had changed sides in subsequent VCUGs. RESULTS: PIC-VUR was bilateral in 63, unilateral in 12, and absent in 6 children. Statistically significant associations between PIC-VUR grade and severity of renal scarring were identified in inter-individual (n = 77, p = 0.017) and intra-individual (refluxing vs. nonrefluxing kidney; n = 12, p = 0.008) analyses. After excluding patients with history of VUR, statistical significance was maintained in inter-individual analysis (n = 49; p = 0.018). CONCLUSION: The data suggest an association between PIC-VUR and severity of renal scarring, and legitimise the use of PIC cystography in children with renal scarring due to recurrent febrile UTI but negative findings on VCUG.

Long-term follow-up after botulinum toxin A (BTX-A) injection into the detrusor for treatment of neurogenic detrusor hyperactivity in children.

PURPOSE: To prove the long-term efficacy of BTX-A injection in the management of children with neurogenic detrusor hyperactivity. MATERIALS AND METHODS: 28 out of 145 children with neurogenic bladder (15 male and 13 female, mean age 10.7 years) who were treated between 2002 and 2010 and became non-responders to conservative treatment were included into the retrospective study. We injected 10-12 U/kg of BTX-A (Botox(®)) into the detrusor at 20-30 sites, sparing the trigone. The mean follow-up was 48 months (range 6-84 months). RESULTS: Group 1. 14 patients had a single injection of BTX-A. Five of them were successful. Mean bladder reflex volume increased (from 62.9 to 117.5 ml), maximum detrusor pressure decreased (from 59 to 37.5 cm H2O), detrusor compliance increased (from 4.8 to 9.5 ml/cm H2O), and leak-point-pressure decreased (from 46.5 to 24.2 cm H2O). Four patients did not respond and were treated by ileocystoplasty. Another five were lost to follow-up. Group 2. 14 patients had repeated (mean 2.5) injections of BTX-A with a mean interval of 13.7 months. In thirteen patients, urodynamic parameters of the first and last injection were similar to those obtained in Group 1, showing a good response. One patient received an ileocystoplasty. CONCLUSION: BTX-A is a safe alternative in the treatment of detrusor hyperactivity in children with myelomeningocele (MMC). The efficacy lasted a mean of 12 months and urodynamic response was unchanged even after several injections. In our series, 21.7% of children with severe low-compliance bladders were non-responders.

The role of the Lich-Gregoir procedure in refluxing duplicated collecting systems: experience from long-term follow up of 45 children.

OBJECTIVE: The need for surgical correction of vesicoureteral reflux (VUR) is increased in duplicated systems. The aim of this study was to evaluate the outcome of the Lich-Gregoir procedure (LG) with regard to VUR persistence, contralateral de-novo VUR, hydronephrosis, preservation of split renal function, urinary tract infections (UTI) and postoperative side effects. PATIENTS AND METHODS: Between 1993 and 2007, 45 children (mean age 3.2 years) underwent a unilateral common sheath LG. A combined number of at least 75 episodes of febrile UTI had occurred in 39 children prior to surgery. VUR grades I to V were present in two, nine, 16, 16 and two children, respectively. Hydronephrosis was present in 18 children. Mean split renal function was 44.03% (range 15-63%). Indications for surgery were febrile breakthrough UTI in 11 children and abscessing pyelonephritis in two. The remainder underwent surgery due to renal scars, reduced split renal function (<45%), VUR persistence and/or parental desire. RESULTS: Persistent ipsilateral and de-novo contralateral VUR were detected in three children (ipsilateral in one, contralateral in one, bilateral in one), resulting in a 4.4% rate of persistent ipsilateral VUR. One year post surgery, low-grade hydronephrosis persisted in six patients without impact on split renal function. Mean split renal function remained stable at 44.06% (range 15-68%). During follow up (mean 41 months), six febrile UTIs occurred in five girls (92.4% risk reduction, P<0.00000005). Neither urinary retention nor any other side effect was observed. CONCLUSION: Performed unilaterally, common sheath LG is a safe and effective technique to cure VUR, prevent febrile UTI and maintain split renal function in duplicated systems with otherwise uncomplicated anatomy.

Potential impact of pediatric MR urography on the imaging algorithm in patients with a functional single kidney.

OBJECTIVE: The purpose of this study was to evaluate the potential of MR urography in the assessment of children with a suspected "functional single kidney." SUBJECTS AND METHODS: Sixty patients (age range, 2.7 weeks to 15.7 years) who had been referred for assessment of a suspected functional single kidney underwent MR urography in addition to detailed sonography of the urinary tract and the currently indicated standard imaging. The results of the conventional imaging ((99m)Tc-dimer captosuccinic acid scintigraphy, voiding cystourethrography, and genitography) were compared with the results of sonography and MR urography; surgical findings served as the gold standard if available. RESULTS: Twenty-six patients had a single kidney. The other diagnoses were six contralateral multicystic dysplastic kidneys, two normal ectopic kidneys, one crossfused double system, and 25 ectopic or dysplastic renal buds. Scintigraphy detected all normal kidneys, two ectopic kidneys, and two dysplastic renal buds. Detailed sonography missed two ectopic kidneys and two orthotopic dysplastic renal buds, but one additional renal bud that could not be confirmed on other imaging techniques (accuracy, 91.7%; sensitivity, 88.2%; specificity, 96.2%) was suspected. MR urography results were correct in all patients and verified in all 13 with surgical correlation. CONCLUSION: MR urography allows a reliable assessment of renal and ureteral anatomy and of dysplastic or ectopic renal buds, even in non- or poorly functioning systems. MR urography therefore has the potential to replace the currently used excretory urography and scintigraphy. In patients with a suspected functional single kidney a detailed sonographic study and MR urography should be considered the diagnostic algorithm of choice.

Assessment and management of newborn hydronephrosis.

The incidence of asymptomatic hydronephrosis in newborns is high. Despite extensive clinical and scientific research much controversy still exists about the assessment and management of hydronephrosis during infancy. Postnatal management demands a detailed prenatal history. Initial workup in newborns with unilateral hydronephrosis starts with a physical examination and sonography of the urinary tract on day 3-5. Grades 3 and 4 hydronephrosis are further investigated with a voiding cystourethrogram (VCUG) and diuretic renogram between weeks 4 and 6. An infant with an asymptomatic unilateral hydronephrosis of any grade, without urinary infection and stable washout, and stable normal differential function on serial controls can be managed conservatively. The goal of all therapeutic strategies in the management of newborn hydronephrosis is to select all infants with severe obstructive dilatation during serial follow-ups and to perform surgical repair before irreversible deterioration and functional renal damage occurs. Interdisciplinary cooperation between experienced pediatric urologists, nephrologist and radiologists is the basis for optimal decision making.

Magnetic resonance urography: a new gold standard for the evaluation of solitary kidneys and renal buds?

PURPOSE: We evaluated the diagnostic potential of magnetic resonance urography (MRU) in pediatric patients with a solitary kidney and/or dysplastic orthotopic or ectopic renal buds. We present our evolving experience with this imaging procedure. MATERIALS AND METHODS: A total of 30 patients with a mean age of 43.8 months with a known or suspected solitary kidney with or without clinical symptoms underwent ultrasound of the urinary tract as well as voiding cystourethrogram, renal static dimercapto-succinic acid (DMSA) scintigraphy and MRU. The results of these diagnostic imaging studies were then compared with each other and set against the results of the final diagnosis established at surgery and by histology, if available. RESULTS: Dysplastic orthotopic or dystopic renal buds suspected on ultrasound in 11 of the 30 patients were confirmed in all 11 by MRU. While accompanying ectopic ureteral insertions were shown in only 3 patients by ultrasound, they were visualized in all 4 by MRU. The other 7 patients with dysplastic renal buds had orthotopic ureteral orifices. DMSA scintigraphy failed to detect 10 renal buds. CONCLUSIONS: The diagnostic value of MRU appears to be superior to that of other imaging tests, even to that of DMSA scintigraphy, which with voiding cystourethrography is currently considered the gold standard for evaluating sonographically suspected solitary kidneys with contralateral orthotopic or ectopic renal buds and ectopic ureteral insertion.

Botulinum-A toxin injection into the detrusor: a safe alternative in the treatment of children with myelomeningocele with detrusor hyperreflexia.

PURPOSE: We prospectively evaluated the efficacy and durability of botulinum-A toxin in the treatment of detrusor hyperreflexia in children with myelomeningocele (MMC). MATERIALS AND METHODS: This study involved 15 patients with MMC (10 male and 5 female, mean age 5.8 years), all nonresponders to orally and intravesically administered anticholinergic medication and all on clean intermittent catheterization. Pretreatment assessment included a videourodynamic evaluation, an incontinence score and a mercaptoacetyltriglycine-3 renal scan. We injected 10 U/kg to a maximum of 360 U of botulinum-A toxin into the detrusor at 25 to 40 sites, sparing the trigone. Followup lasted between 12 and 30 months. All children underwent a urodynamic reevaluation, an assessment of the bladder capacity and an incontinence score at 3, 9 and 12 months after the first injection. A second intravesical injection was administered after 12 months and followup repeated as in the first year. RESULTS: After the first injection treatment mean bladder reflex volume increased from 72.00 +/- 28.12 ml to 298 +/- 32.45 ml (mean +/- SD, p <0.001). Maximum detrusor pressure decreased from 78.76 +/- 23.14 cm H2O to 42.76 +/- 24.34 cm H2O (p <0.001). Maximum bladder capacity increased from 136.34 +/- 45.71 ml to 297.02 +/- 87.17 ml (p <0.001). Detrusor compliance increased from 18.29 +/- 27.19 ml/cm H2O to 51.17 +/- 38.17 ml/cm H2O (p <0.001). Of the 15 patients 13 became completely dry with CIC. The remaining 2 patients improved from score 3 to 1. Results after 9 months were similar to those obtained after 3 months. Mean durability of the effect of the drug was 10.5 months after the first as well as after the second intravesical injection. CONCLUSIONS: Botulinum-A toxin is a safe alternative in the management of detrusor hyperreflexia in children with MMC. The preliminary results regarding urodynamic parameters and continence have been promising.

Comprehensive analysis of six years experience in tubularised incised plate urethroplasty and its extended application in primary and secondary hypospadias repair.

OBJECTIVE: We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results. METHODS: In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure. RESULTS: The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002. CONCLUSION: In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair--irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.

Optimizing the operative treatment of boys with varicocele: sequential comparison of 4 techniques.

PURPOSE: We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation. MATERIALS AND METHODS: In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months. RESULTS: In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient. CONCLUSIONS: Comparison of all 4 groups revealed significant differences in varicocele recurrence (p = 0.038) and hydrocele formation (p = 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p = 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age.

Urinary tract infections in children.

PURPOSE OF REVIEW: To gain new insights into the epidemiology, imaging and conservative management of urinary tract infections based on the peer-reviewed literature of the last year. RECENT FINDINGS: It has been estimated that 3% of prepubertal girls and 1% of prepubertal boys are diagnosed with urinary tract infections. Breastfeeding has been shown to offer significant protection against urinary tract infection in infants. Any young child with an acute pyelonephritis should be evaluated by dimercaptosuccinic acid renal scan to confirm or rule out renal scarring. The voiding cystourethrogram can be performed within the first 7 days of diagnosis. Amoxicillin, trimethoprim-sulfamethoxazole and cephalosporin are the first-line antibiotics to treat children with uncomplicated urinary tract infection. SUMMARY: The incidence of urinary tract infections during infancy and childhood is high and influenced by the age and sex of the patient. Voiding cystourethrogram and dimercaptosuccinic acid renal scan are required for imaging. Short-course treatment is sufficient for children with acute uncomplicated lower urinary tract infections.

Voiding cystourethrography using the suprapubic versus transurethral route in infants and children: results of a prospective pain scale oriented study.

PURPOSE: We determined the advantages and disadvantages of different types of contrast medium injection into the bladder for imaging children during evaluation for urinary tract infection in regard to child behavior and distress during urethral catheterization or suprapubic puncture. MATERIALS AND METHODS: From December 2000 to September 2001 we prospectively compared transurethral catheter and suprapubic voiding cystourethrography in children with a history of urinary tract infection. A total of 65 children with a mean age of 33.8 months were entered into the study, of whom 32 underwent transurethral catheterization and 33 underwent suprapubic puncture with topical anesthesia. Each child was evaluated, particularly in regard to discomfort and pain using an objective pain score that measures stress and pain during a medical procedure. RESULTS: Objective pain score recording showed a mean pain score plus or minus SD of 4.25 +/- 1.3 in the transurethral catheterization and 3.03 +/- 1.21 in the suprapubic puncture groups. Correlation studies of age in the 2 groups also showed a significant impact of age on the objective pain score. In the transurethral group the score increased with age (p <0.001), whereas in the suprapubic group it decreased with age (p <0.001). CONCLUSIONS: The current study shows that the suprapubic puncture technique with topical anesthesia was well tolerated and associated with a low pain score independent of patient age. Transurethral catheterization was also tolerated but it was associated with a low pain score only in the younger age group. Thus, we recommend that voiding cystourethrography in children older than 24 months should be done via the suprapubic route.