Overlooked Factors Causing Renal Damage in Vesicoureteric Reflux!

Introduction: Vesicoureteric reflux (VUR), recurrent urinary tract infection (RUTI), febrile urinary tract infection (FUTI), renal scarring, and renal damage are intimately related. Key factors of renal damage in VUR are suspected to be RUTI and FUTI. Hence, conventional treatments are targeted toward the prevention of RUTI and FUTI. However, literatures have witnessed that control of infection is not sufficient enough. That means we are missing some hidden, enigmatic, or overlooked factors which are essentially responsible for renal damage. We know RUTI occurs from the stasis of urine in system and stasis might occur from obstruction somewhere in system. Moreover, obstruction builds up back pressure in the bladder and ureters, and ultimately in kidneys; that pressure is independently harmful to renal function. Pressure is further harmful if this joins together with infection. We know that RUTI and FUTI along with pressure in the urinary tract are harmful to renal parenchyma. Nevertheless, search for the nexus of obstruction, pressure, stasis, infection, and damage (OPSID) of renal function is not yet focused on in VUR research. In this retrospective study on secondary VUR, we would like to find the overlooked factors or nexus of OPSID associated with VUR causing renal damage. Patients and Methods: A total of 170 renal units of 135 patients with VUR resulted from the posterior urethral valve and from repaired bladder exstrophy, from March 2005 to April 2019, had adequate data regarding control/correction of obstruction and urodynamic studies. The mean patient's age was 2.8 years (range 1 day-14 years). The diagnosis of VURs was made with postnatal cystogram in patients of the posterior urethral valve and of repaired continent augmented bladder exstrophy. We do cystogram not micturating cystogram following ultrasonography if showing dilated ureter/s. If we find no residual in ureter/s after 30 min in cystogram, we label it as "rise and fall" VUR (raf_VUR), i.e., without obstruction. On the other hand, if there is post void residual in ureter/s for more than 30 min, we label it as "rise and stasis" VUR (ras_VUR) means combination of VUR with uretero vesical junction obstruction (UVJO). Along with this, all patients were followed up with albumin creatinine ratio, creatinine clearance, USG Renometry, DTPA renal scan, uroflowmetry, and urodynamic study (UDS). Repeat cystoscopy, if necessary, was done following UDS for secondary bladder neck incision (BNI) or for repeat BNI if necessary. Results: Mean duration of follow-up was 7.2 years (range 3-14 years). Out of 170 renal units, 132 renal units had VUR without VUJO, i.e., raf_VUR and 38 renal units had ras_VUR. All patients of UVJO were relieved either with anticholinergics or with DJ stenting or by re-implantations. Twenty-nine patients out of 135 had high pressure on UDS, and they needed BNI. We were able to prevent upstaging of chronic kidney disease (USCKD) in all 135 patients. Conclusions: Our tangible goal of treatment in VUR is the prevention of USCKD. We differentiated raf_VUR from ras_VUR with cystogram. Patients with ras_VUR and patients with raf_VUR with high bladder pressure were actively treated. This particular subset VUR was treated with prophylactic antibiotic and surgical corrections. We prevented renal damage by eliminating obstruction and stasis which helped to prevent RUTI and FUTI. Possibly, similar management might also help to manage "primary VUR." Possibly those overlooked factors which are essentially responsible for renal damage are veiled in nexus OPSID of the kidney.

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.

Study the Possibility of Creating Mucosal Valve Mechanism at Ureteric Orifice without Obstructing the Urine Outflow but Preventing the Urine Backflow into the Ureters.

Objective: To study the possibility of creating mucosal valve mechanism at ureteric orifice without obstructing the urine outflow but preventing the urine backflow into the ureters. Materials and Methods: Ethical waiver was obtained from the institutional ethical committee. Prospective experimental study was conducted on the post-mortem specimen of intact bladder with urethra and bilateral ureters retrieved from the already slaughtered lamb available in the meat market. Feeding tube inserted via urethral opening into the bladder lumen and bladder inflated with saline demonstrated no reflux of urine via transverse cut opening of ureters. Bladder lumen opened, ureteric orifices incised backwards to eliminate the obliquity. After closing the bladder opening, saline inflation test demonstrated bilateral reflux of saline via cut openings of bilateral ureters. Bladder was re-opened. The upper limb of horizontal U started 10 mm lateral and 8 mm above the refluxing ureteric orifice. Distal most curvature of horizontal U was kept 5 mm medial to ureteric orifice continuing along the lower limb of horizontal U terminating 10 mm lateral and 8 mm below the refluxing ureteric orifice, mucosal flaps from superior and inferior incision mobilized and edges joined to cover the ureteric orifice creating a flap valve mechanism. Influx of saline via cut end of ureters demonstrated no obstruction. Bladder was closed. Saline inflation test and contrast study demonstrated abolition of reflux on flap side and persistence of reflux on another side. Results: Five such experiments were conducted. On the side where the valve was created, Vesicoureteral reflux was abolished in four but in one minimal reflux still persisted. Conclusion: Creating a mucosal flap valve around the ureteric orifice can prevent reflux in 80% of cases without obstruction and without the necessity of ureteric mobilization or creating submucosal tunnel.

Swiss consensus recommendations on urinary tract infections in children.

The kidneys and the urinary tract are a common source of infection in children of all ages, especially infants and young children. The main risk factors for sequelae after urinary tract infections (UTI) are congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction. UTI should be considered in every child with fever without a source. The differentiation between upper and lower UTI is crucial for appropriate management. Method of urine collection should be based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. Treatment of UTI should be based on practical considerations regarding age and presentation with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing. All children, regardless of age, should have an ultrasound of the urinary tract performed after pyelonephritis. In general, antibiotic prophylaxis is not recommended.Conclusion: Based on recent data and in line with international guidelines, multidisciplinary Swiss consensus recommendations were developed by members of Swiss pediatric infectious diseases, nephrology, and urology societies giving the clinician clear recommendations in regard to diagnosis, type and duration of therapy, antimicrobial treatment options, indication for imaging, and antibiotic prophylaxis. What is Known: • Urinary tract infections (UTI) are a common and important clinical problem in childhood. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children less than 2 years of age. • Method of urine collection is based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. What is New: • Vesicoureteric reflux (VUR) remains a risk factor for UTI but per se is neither necessary nor sufficient for the development of renal scars. Congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction play a more important role as causes of long-term sequelae. In general, antibiotic prophylaxis is not recommended. • A switch to oral antibiotics should be considered already in young infants. Indications for invasive imaging are more restrictive and reserved for patients with abnormal renal ultrasound, complicated UTI, and infections with pathogens other than E. coli.

Dysfunctional elimination syndrome: a short review of the literature.

The combination of the functional disorders of urination and defecation constitutes the Dysfunctional Elimination Syndrome (DES). DES refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding, with no underlying anatomic or neurologic abnormalities. Essential precondition for a child to be subsumed under this entity is the exclusion of either anatomical or neurological causative factors. In the present review study the individual entities of dysfunctional filling, such as the unstable or lazy bladder, or dysfunctional urination, such as the detrusor sphincter dyssynergia and the functional constipation are being described comprehensively. Subsequently, the analysis of the pathophysiological effects of the dysfunctional elimination syndrome such as incontinence, urinary tract infections and the conservation or the deterioration of vesicoureteric reflux, is being accentuated. With the documentation of DES, the therapeutic strategy should aim at treating both the functional disorder of the vesicourethral unit and the functional constipation. The first part does not specify depending on the type of this disorder. Rarely, surgical treatment of functional urinary disorders may be required.

Voiding urosonography and voiding cystourethrography in primary vesicoureteral reflux associated with mild prenatal hydronephrosis: a comparative study.

BACKGROUND: Contrast-enhanced harmonic voiding urosonography has been introduced as a sensitive, radiation-free imaging method for the diagnosis of vesicoureteric reflux. OBJECTIVE: To evaluate the occurrence/severity of vesicoureteric reflux in infants with mild prenatal hydronephrosis comparing voiding cystourethrography and voiding urosonography. MATERIALS AND METHODS: Sixty infants with prenatal hydronephrosis were studied (anteriοposterior pelvic diameter 5-9 mm on ultrasound [US] at gestational weeks 21-30). Postnatal US was performed within the first month of life, as well as voiding cystourethrography and contrast-enhanced voiding urosonography at 1.5-2.5 months at the same session. RESULTS: Vesicoureteric reflux was diagnosed on at least one modality in 19/60 (32%) infants, and more often on contrast-enhanced voiding urosonography (18/60, 30%) than on voiding cystourethrography (8/60, 13%), P=0.046. Among girls, reflux was more often seen on contrast-enhanced voiding urosonography (6/16, 38%) than on voiding cystourethrography (1/16, 6%), P=0.03. Vesicoureteric reflux missed by voiding cystourethrography was more severe (Grades I, II and III in one, nine and four kidney-ureter-units, respectively), compared with a single case missed by contrast-enhanced voiding urosonography (Grade I in one kidney-ureter-unit). CONCLUSION: In the absence of a reference standard, our results imply that voiding cystourethrography might underdiagnose reflux, and/or contrast-enhanced voiding urosonography may overdiagnose reflux.

Potential causes of insufficient bladder contrast opacification and premature microbubble destruction during contrast-enhanced voiding urosonography in children.

Contrast-enhanced voiding urosonography (ceVUS) has been recognized as a child-friendly examination with high diagnostic accuracy for vesicoureteric reflux detection. A single bolus and the infusion techniques of ceVUS are described. Insufficient bladder contrast opacification during the filling phase and premature destruction of SonoVue microbubbles might occur. Data regarding SonoVue's features, doses, bladder contrast opacification, US bladder parameters, urine catheter, antibiotic prophylaxis, and childrens behaviors were collected to discover the possible causes of the contrast vanishing observed during bladder filling in 10% of examinations and in the later phase of ceVUS in 5% of examinations. An updated ceVUS examination protocol is suggested.

Co-Existing Pediatric Ureteropelvic Junction Obstruction and Vesicoureteric Reflux: Prevalence and Implications.

PURPOSE: The purpose of this study is to ascertain the coexistence of ipsilateral vesicoureteric reflux (VUR) with ureteropelvic junction obstruction (UPJO) and to compare postpyeloplasty outcome in patients with and without associated VUR. MATERIALS AND METHODS: Prospective study from 2014 to 2016 of consecutive children (n = 135) undergoing pyeloplasty. Data of patients without (Group 1) and with (Group 2) associated ipsilateral VUR were compared. RESULTS: Thirty-five patients (25.9%) had ipsilateral VUR along with UPJO (Group 2). This group showed the following unique features: (1) Higher percentage of infants (31/35) compared to Group 1 (62/100) (P = 0.003) (2) VUR in the contralateral (normal) kidney in 21/35 (60%) cases and nil in Group 1 (3) Significantly less preoperative differential renal function in children above 1 year (P = 0.007) (4) Presence of renal scars (18 units) and pyelonephritic changes (6 units) in Group 2 at the 1-year follow-up dimercaptosuccinic acid renal scan. Both groups showed improvement in function 3 months after pyeloplasty with no statistically significant difference. Improvement in drainage on the renal scan was better in Group 1 at 3 months postoperative (P = 0.015) as well as between 3 months and 1-year follow-up (P = 0.052). CONCLUSION: The prevalence of VUR was 25.9% in this study and 33.3% in ≤1 year age group. There was a loss of function in delayed presenters with associated ipsilateral VUR. There was delayed drainage postpyeloplasty in patients with VUR. A preoperative voiding cystourethrogram should be done in children <1 year age before pyeloplasty so that associated VUR if detected can be concurrently managed along with pyeloplasty and preserve nephrons affected by the dual pathology.

Technique of Antireflux Procedure without Creating Submucosal Tunnel for Surgical Correction of Vesicoureteric Reflux during Bladder Closure in Exstrophy.

AIM: To report the clinical application of the new surgical technique of antireflux procedure without creating submucosal tunnel for surgical correction of vesicoureteric reflux during bladder closure in exstrophy. MATERIALS AND METHODS: Based on the report of published experimental technique, the procedure was clinically executed in seven patients of classic exstrophy bladder with small bladder plate with polyps, where the creation of submucosal tunnel was not possible, in last 18 months. Ureters were mobilized. A rectangular patch of bladder mucosa at trigone was removed exposing the detrusor. Mobilized urteres were advanced, crossed and anchored to exposed detrusor parallel to each other. Reconstruction included bladder and epispadias repair with abdominal wall closure. The outcome was measured with the assessment of complications, abolition of reflux on cystogram and upper tract status. RESULTS: At 3-month follow-up cystogram, reflux was absent in all. Follow-up ultrasound revealed mild dilatation of pelvis and ureter in one. CONCLUSIONS: The technique of extra-mucosal ureteric reimplantation without the creation of submucosal tunnel is simple to execute without risk and complications and effectively provides an antireflux mechanism for the preservation of upper tract in bladder exstrophy. With the use of this technique, reflux can be prevented since the very beginning of exstrophy reconstruction.

Abdominoperineal Pull-through with Simultaneous Extravesical Detrussoraphy: An Alternative Surgical Technique for Congenital Pouch Colon with High-grade Vesicoureteric Reflux.

Congenital pouch colon (CPC) is frequently associated with vesicoureteric reflux (VUR). These patients require long-term antibiotic prophylaxis and/or an additional surgical intervention for the management of the refluxing system. We propose a single-stage alternative approach in these patients. Two patients diagnosed to have CPC underwent pouch excision and an end colostomy at birth. Further evaluation revealed high-grade reflux in both the patients. At 6 months of age, definitive abdominoperineal pull-through (APPT) surgery along with extravesical detrusorrhaphy was performed. In the follow-up at 1 year, they are thriving well with no urinary complaints. Micturating cystourethrogram revealed complete resolution of VUR. This approach takes the advantage of the anesthesia for APPT and offers a relatively simple and quick solution for the refluxing system, thus, enabling the stoppage of antibiotic prophylaxis and obviating the need for a future endoscopy/surgery.

Estimation of Renal Functional Reserve in Children with Different Grades of Vesicoureteric Reflux.

BACKGROUND: Vesicoureteric reflux (VUR) is one of the most common anomalies encountered in pediatric urology. The concept of renal functional reserve (RFR) as the ability of the kidney to increase glomerular filtration rate (GFR) following a protein load was introduced in the 1980s. AIM: This study aims to evaluate RFR using 99Tc diethylenetriamine pentaacetic acid (DTPA) as the filtration agent for GFR estimation in children with VUR. MATERIALS AND METHODS: RFR was estimated in 53 children, of which 31 patients had unilateral VUR (Group I) and 22 patients had bilateral VUR (Group II), by subtracting baseline GFR from stimulated GFR following an intravenous protein load. GFR was determined by double compartment-2 sample method using 99Tc DTPA radioisotope as the filtration agent. Both the groups were further subgrouped into low-grade (IA, IIA) and high-grade VUR (IB, IIB). RESULTS: The RFR was significantly lower in unilateral high-grade VUR (Group IB) as compared to unilateral low-grade VUR (Group IA) (P = 0.024). RFR was significantly lower in bilateral high-grade VUR patients (IIB) as compared to unilateral low-grade VUR group (IA) (P = 0.0226). Furthermore, the stimulated GFR shows very strong correlation to baseline GFR in both major groups (r = 0.9659 and P = 0.001 in Group I and r = 0.9856 and P = 0.001 in Group II) concluding that the baseline GFR and the stimulated GFR increase or decrease in tandem in both the groups. CONCLUSION: The RFR is impaired in children with both unilateral high-grade VUR and bilateral high-grade VUR while it is relatively preserved in unilateral low-grade VUR and bilateral low-grade VUR.

Residual intravesical iodinated contrast: a potential cause of false-negative reflux study at contrast-enhanced voiding urosonography.

A 9-month-old girl underwent conventional cyclic voiding cystourethrography (VCUG) followed immediately by cyclic contrast-enhanced voiding urosonography (ceVUS). Although the VCUG showed unilateral grade II reflux, the ceVUS showed no reflux. Images from the ceVUS showed posterior dependent layering of the denser iodinated contrast in the bladder. This layering likely prevented reflux of US microbubbles resulting in a false-negative ceVUS. To our knowledge, this potential pitfall has not yet been reported.

[Vesicoureteric reflux in children: many questions still unanswered]. / Vezikoureterální reflux u detí: stále mnoho nezodpovezených otázek.

Vesicoureteric reflux (VUR) is the most common congenital anomaly of the uropoetic system. The gold standard for its diagnosis is the voiding cystourethrogram. Sonographic cystourethrography is an alternative method for reflux detection, but it is still not used routinely. Static scintigraphy enables us to diagnose renal scarring reflux nephropathy (RN). While congenital RN is a result of prenatal kidney injury, acquired RN results from pyelonephritis-induced renal damage.Risk factors for RN include VUR, recurrent APN, lower urinary tract dysfunction and delay in treatment of febrile urinary tract infection. Management of children after APN with VUR consists of antibiotic prophylaxy, surgery or surveillance only. The conclusions of performed studies are controversial, thus unified guidelines for the management of patients with VUR are not available.

Ultrasonography and C-reactive protein can predict the outcomes of voiding cystography after the first urinary tract infection.

AIM: This study evaluated whether sex, clinical variables, laboratory variables or ultrasonography predicted the presence of vesicoureteric reflux during the first episode of urinary tract infection in paediatric patients. We also aimed to define the criteria that indicated the need for voiding cystography testing. METHODS: We used voiding cystography to investigate 200 patients who experienced their first urinary tract infection at our institution between 2004 and 2013 and retrospectively analysed the data by reviewing their medical records. RESULTS: Sex (p = 0.001), peak blood C-reactive protein levels (p < 0.001), the duration of fever after antibiotic administration (p = 0.007) and the ultrasonography findings grade (p < 0.001) were significantly different between patients with and without vesicoureteric reflux. Grade IV-V ultrasonography findings and C-reactive protein levels of ≥80 mg/L predicted vesicoureteric reflux with a sensitivity, specificity and odds ratio of 47.8%, 87.8% and 6.59 (95% confidence interval = 3.26-13.33), respectively (p < 0.001). CONCLUSION: Voiding cystography should be performed for patients with C-reactive protein levels of ≥80 mg/L and grade IV-V ultrasonography findings, but is not necessary in patients with C-reactive protein levels of <80 mg/L and grade I-III ultrasonography findings.

Creation of effective antireflux mechanism without creation of submucosal tunnel in surgical correction of vesicoureteric reflux: Myth or reality?-An experimental study.

OBJECTIVE: To evaluate the possibility of creating an effective antireflux mechanism without the need to create submucosal tunnel in surgical correction of vesicoureteric reflux. MATERIALS AND METHODS: Ethical clearance was obtained from the institute ethical committee. The prospective experimental study was conducted on fresh postmortem specimens comprising of intact ureter-bladder-urethra of slaughtered lamb. Through perurethral tube, bladder distension revealed intact antireflux mechanism which disappeared following a cephalad slit of ureteric orifice. After intravesical advancement, mobilized ureters were anchored to the hiatus and the exposed detrusor along the proposed submucosal tunnel after stripping the bladder mucosa. Limited nonobstructed narrowing of the advanced ureteric ends was fashioned. After closure, bladder was distended and reflux was observed through proximal transected ureteric orifices with check cystogram. In second part of experiment, in a rectal reservoir, two intestinal segments as dilated ureters were implanted without creating submucosal tunnel, but anchoring the intrarectal segment to exposed submucosa. Intraluminal end of one segment was narrowed, while other left as such. Reservoir distension test was done to notice the status of reflux. In 24 months, 12 experiments were conducted. RESULTS: In first part of experiment, successful antireflux mechanism was created in 11 ureters. In second part of experiment, reflux persisted in the ureteral segment implanted with obliquity but without distal nonobstructed narrowing, while there was no reflux in the ureteral segment with both obliquity and narrowing. CONCLUSION: Advancement and anchoring of the ureteral segment to the exposed detrusor with creation of nonobstructive and limited narrowing can create effective antireflux mechanism without the need to create submucosal tunnel.

Intraoperative ultrasound-assisted endoscopic treatment of primary intermediate and high-grade vesicoureteral reflux in children in a long-term follow-up.

BACKGROUND: Endoscopic treatment of vesicoureteral reflux (VUR) is an important minimally invasive surgical approach in patients undergoing surgical treatment of VUR. In our past experience, we observed that a bulking agent mound sagittal diameter of 10 mm is the main predictor of effectiveness of the procedure. Moreover we noticed that the use of intraoperative ultrasound, allows the surgeon to better identify the site, volume and shape of the bulking agent injected, finally reducing operative time. OBJECTIVE: We aimed to evaluate if the intraoperative ultrasound assistance could definitively improve effectiveness of the endoscopic procedure. METHODS: We retrospectively compared two series treated with endoscopic procedures for intermediate and high grade primary VUR, respectively without (series A) and with (series B) intraoperative ultrasound (IO-US). In all patients VCUG was performed to assess VUR grade and to verify resolution or VUR downgrading during the follow-up. RESULTS: A total of 177 ureteric units were treated. Endoscopic procedures globally were effective in 68/96 ureters (70.8 %) in series A and in 68/81 ureters (83.9 %) in series B. No significant differences in effectiveness were observed comparing the series with regard to VUR grades, but a significant difference is shown (p < 0.05) when grouping grades III-V VUR. No significance in differences of volume injected were detected, but operative time was significantly lower in series B (27.5 min vs 19.6 min, p < 0.05). Mean sagittal mound diameter measured during cystoscopy in series B was 10.45 mm (range 8.5-14.2 mm). DISCUSSION: The intraoperative ultrasound assistance during endoscopic treatment of VUR could represent a valid tool for surgeons to better identify location, volume and shape of the bulking agent. Furthermore, the use of an objective parameter of evaluation of the implant can overcome the subjective intraoperative evaluation of the implant itself, improving results for experienced surgeons and reducing the learning-curve for inexperienced ones. CONCLUSIONS: Results of endoscopic injection of bulking-agent can be improved with intraoperative ultrasound, allowing at the same time a significant reduction of operative time.

Pattern of urinary tract infection in children with vesicoureteric reflux: Does breastfeeding reduce the occurrence of urinary tract infection?

Introduction: The protective factors against urinary tract infections (UTIs) in the setting of vesicoureteric reflux (VUR) remain poorly defined. Breastfeeding was suggested as a protective factor against UTI, but its role remains undetermined in this highly susceptible population. Objectives: The objective of the study was to identify the pattern and risk factors of UTI and investigate the effect of breastfeeding on UTI occurrence in VUR children. Materials and Methods: This was a mixed-method design, whereby the first part was a cross-sectional study that included children who were diagnosed with VUR and were assessed for their UTI pattern. The second part was a case-control study, which involved contacting the mothers of the children enrolled and questioning them about their breastfeeding pattern, and UTI development was assessed. Results: Our study included 62 children with a median age of 4.4 (interquartile range = 21) months at diagnosis. Of those, 37 (60%) were male and 25 (40%) were female. Most UTIs occurred in the first 3 months of life, and the first episodes were more frequent in males. Constipation was significantly associated with the occurrence of UTI (relative risk [RR] =1.750 [95% confidence interval (CI): 1.231-2.489], P = 0.003). Children with breakthrough UTIs were more likely to have been breastfed for <9 months (odds ratio [OR] = 4.091 [95% CI: 1.287-13.002], P = 0.015) and to have been exclusively breastfed for <2 months (OR = 4.600 [95% CI: 1.337-15.823], P = 0.012). Conclusion: Children with VUR are more susceptible to UTIs in their 1st year of life. Constipation is a major risk factor for UTI occurrence in VUR children and should be aggressively managed. Breastfeeding for longer durations showed promising protective features against breakthrough UTIs.

Endoscopic treatment of vesicoureteric reflux with dextranomer/hyaluronic acid copolymer (Deflux): Single-surgeon experience with 48 ureters.

PURPOSE: VUR is a common urologic problem in children. Cystoscopic injection of bulking agents (most commonly Deflux) has gained popularity as the first line treatment in the west. However, primarily due to cost factors, it has not gained much popularity in our country. We present our initial experience with cystoscopic Deflux injection for VUR. MATERIALS AND METHODS: We reviewed our 3-yr experience with the use of Dx/HA (Deflux) for correction of VUR in children and adolescents. All children were evaluated with Ultrasound, MCUG and DMSA renal cortical scan. The indications for surgical correction of VUR included breakthrough infections while on antibiotic prophylaxis, persistent high-grade VUR beyond 3 yrs of age, and presence of significant renal damage on DMSA at diagnosis (in those children presenting with UTI). All children underwent cystoscopic Deflux injection using the standard technique of subureteral injection (0.4-1 ml per ureter). All children received antibiotic prophylaxis for 3-6 months after the injection. USG was done at 1 month and MCUG at 3-6 months after the injection. RESULTS: 33 patients (48 ureters) underwent cystoscopic Deflux injection for correction of VUR. Mean age was 4.5 yrs (1-17 yrs); there were 12 boys and 21 girls. Thirteen children had antenatally diagnosed HDN, while 20 children presented with febrile UTI. All children had primary VUR except one child with persistent VUR 4 yrs after PUV fulguration. The VUR was grade 1-2 in 8, grade 3-4 in 37, and grade 5 in 3 ureters. Every child had at least one ureter with dilating reflux (grades 3,4 or 5). When present, low grade VUR (grade 1or 2) was always on the contralateral side. Only one child received a 2(nd) injection after 6 months. Follow-up MCUG was done in 28 children (41 ureters). Complete reflux resolution was achieved in 27 ureters (65%), and the reflux was downgraded in 2 (5%). There were no complications of Deflux injection. CONCLUSIONS: Endoscopic correction of VUR in children is a safe and effective minimally invasive treatment for VUR. It stops or downgrades VUR in 70% of ureters. At present, we recommend it as a first-line treatment for grades 1-4 VUR requiring surgical management. Cost is the major factor limiting its use in our country.

The Outcome of Multicystic Dysplastic Kidney Disease Patients at King Abdulaziz Medical City in Riyadh.

Background Multicystic dysplastic kidney (MCDK) is a type of kidney dysplasia consisting of many irregular, various-sized cysts divided by dysplastic renal tissue, which negatively impacts kidney function. MCDK is one of the most common renal congenital disorders seen in antenatal ultrasounds. The typical prognosis of MCDK is complete or partial involution that starts antenatally and continues postnatally. The aim of the study was to shed light on the overall outcome of patients with MCDK. Methods We retrospectively collected data on MCDK patients from 2016 until 2022 at King Abdulaziz Medical City, Ministry of National Guard Health Affairs in Saudi Arabia, Riyadh. The data included the recording of epidemiological data, radiological and laboratory reports, and the presence of urological or non-urologically associated anomalies. Results A total of 57 patients with MCDK were reviewed. Seven of them were excluded due to the diagnosis of bilateral MCDK, which was incompatible with life. Of the remaining 50 patients, the right kidney was affected in 52% of them. Most patients were diagnosed antenatally (98%). The mean duration of follow-up for the study was 48 months. Vesicoureteral reflux (VUR) was detected in 22% of the total sample. Overall, 90% of the patients underwent kidney involution. A small percentage had genitourinary anomalies (20%), while a larger percentage (48%) had extrarenal abnormalities. Conclusion Multicystic dysplastic kidney disease is relatively common in children. The prognosis is affected by the presence of genitourinary and non-genitourinary anomalies. Patients have an overall good prognosis with conservative management. Antenatal screening, diagnosis, and long-term nephrological follow-up are essential for the optimal management of patients.

Urinary tract infection in children: A narrative review of clinical practice guidelines.

Background: Urinary tract infection (UTI) has been a major burden on the community and the health-care systems all over the globe. It is the most common cause of bacterial infection in the pediatric age group, with an annual incidence of 3%. The aim of this study is to review and summarize all available guidelines on the diagnosis and management of children with UTI. Materials and Methods: This is a narrative review of the management of children with a UTI. All biomedical databases were searched, and any guidelines published from 2000 to 2022 were retrieved, reviewed, and evaluated to be included in the summary statements. The sections of the articles were formulated according to the availability of information in the included guidelines. Results: UTI diagnoses are based on positive urine culture from a specimen of urine obtained through catheterization or suprapubic aspiration, and diagnoses cannot be established on the bases of urine collected from a bag. The criteria for diagnosing UTI are based on the presence of at least 50,000 colony-forming units per milliliter of a uropathogen. Upon confirmation of UTI, the clinician should instruct parents to seek rapid medical assessment (ideally within 48 h) of future febrile disease to ensure that frequent infections can be detected and treated immediately. The choice of therapy depends on several factors, including the age of the child, underlying medical problems, the severity of the disease, the ability to tolerate oral medications, and most importantly local patterns of uropathogens resistance. Initial antibiotic choice of treatment should be according to the sensitivity results or known pathogens patterns with comparable efficacy of oral and parenteral route, for 7 days to 14 days duration. Renal and bladder ultrasonography is the investigation of choice for febrile UTI, and voiding cystourethrography should not be performed routinely unless indicated. Conclusion: This review summarizes all the recommendations related to UTIs in the pediatric population. Due to the lack of appropriate data, further high-quality studies are required to improve the level and strength of recommendations in the future.