Standardized protocol for voiding cystourethrogram: Are recommendations being followed?

BACKGROUND: Voiding cystourethrogram (VCUG) images the urethra and bladder during filling and emptying, as well as ureters and kidneys when vesicoureteral reflux (VUR) is present, providing detailed information about both anatomical and functional status of the urinary tract. Given the importance of information obtained, and the varying quality depending on VCUG technique and radiology reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016. OBJECTIVE: We compared VCUG reports from multiple institutions before and after publication of the protocol to determine adherence to recommendations. STUDY DESIGN: VCUG reports generated during two separate time periods were assessed - before and after publication - to evaluate impact of the protocol. Adherence to the reporting template was evaluated. Studies performed on patients >18 years of age and those obtained for trauma evaluation were excluded from study. RESULTS: A total of 3121 VCUG reports were analyzed, 989 (31.7%) were generated before and 2132 (68.3%) after protocol publication. Comparing cohorts, there was no difference in gender (62.6% female versus 61.4%; p = 0.53) though children in the post-cohort were slightly older (3.34 ± 3.82 versus 3.68 ± 4.19 years; p = 0.03). A significant increase in scout image reporting (91.5%) and cyclic studies (20.5%) were observed in the post-cohort, in comparison to 79.2% and 13.1%, respectively, in the pre-protocol cohort (p < 0.001) [Figure]. Measured PVR and recorded infused volume actually decreased between study periods (84.7% vs 72.8% and 97.2% vs 91.5%, p < 0.001). There was no statistically significant difference between VUR grade reporting (99.4 vs 98.5%, p = 0.25). Recorded volume in which reflux occurred increased between periods (0.6% vs 2.3%, p < 0.05), while reporting of filling vs voiding reflux decreased in the post-cohort (84.4% pre-vs 77.4% post-protocol, p < 0.008). DISCUSSION: The 2016 VCUG protocol recommended inclusion of various data points, however the volume at which reflux occurs remained vastly underreported. Timing of reflux has been shown to predict likelihood of spontaneous resolution and risk of breakthrough urinary tract infection; thus, its omission may limit the information used to counsel families and provide individualized care. CONCLUSION: Despite consensus on standard VCUG protocol to best perform and record data, reports remain inconsistent. While VUR grade is routinely reported, other important anatomic and functional findings which are known to impact resolution and breakthrough urinary tract infection rates, such as volume at which reflux occurs, are consistently underreported.

Magnetic resonance urography for diagnosis of pediatric ureteral stricture.

PURPOSE: Ureteral stricture is a rare cause of hydronephrosis in children and is often misdiagnosed on ultrasound (US) and diuretic renal scintigraphy (DRS), requiring intraoperative diagnosis. We evaluated ureteral strictures diagnosed by magnetic resonance urography (MRU) at our institution. MATERIALS AND METHODS: Children with ureteral stricture who underwent MRU were identified. Patient demographics, prior imaging, MRU findings, and management were assessed. The efficacy of MRU in diagnosis of stricture was compared with US and DRS. Patients with ureteropelvic or ureterovesical junction obstruction were excluded. RESULTS: Twenty-eight ureteral strictures diagnosed by MRU between 2003 and 2013 were identified; 22% of strictures were diagnosed by DRS ± US. The mean age at MRU diagnosis was 2.4 years (range 4 weeks-15 years). Hydronephrosis was the most common presentation, accounting for 20 (71%) cases. Other etiologies included pain (3), incontinence (2), and urinary tract infection, cystic kidney, and absent kidney, present in one case each. A mean of 2.7 imaging studies was obtained prior to MRU diagnosis. Twenty-one (75%) ureteral strictures required surgical intervention, with the approach dependent upon location. CONCLUSIONS: MRU provides excellent anatomic and functional detail of the collecting system, leading to accurate diagnosis and management of ureteral stricture in children.

Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux.

PURPOSE: Follow-up of patients undergoing dextranomer/hyaluronic acid injection for vesico-ureteral reflux (VUR) is controversial. The purpose of our study was to test the hypothesis that patients undergoing the double hydrodistention-implantation technique (Double HIT) have a higher clinical and radiographic success rate. MATERIALS AND METHODS: Patients undergoing Double HIT endoscopic injection for VUR were prospectively identified. Patients underwent an ultrasound at 6 weeks to assess the implants, and, if visible, prophylactic antibiotics were discontinued and patients were scheduled for a 1-year voiding cystourethrogram (VCUG). Radiographic success was defined as a negative VCUG and clinical success as no febrile urinary tract infections at 1 year. RESULTS: A total of 54 patients underwent endoscopic injection for VUR. Twenty-five (51%) were compliant with the 1 year follow-up; 18 non-compliant patients were contacted and their clinical status assessed. Thirty patients eventually completed the 1-year VCUG at a mean of 12.2 months (range 10-20). Among the 60% of patients with 1-year radiographic follow-up, 2 had persistent VUR for a radiologic success rate of 93%. All radiographic failures were infection-free. Of the 80% (43/54) of patients with available clinical data, 3 (7%) had afebrile UTI for a clinical success rate of 93%. CONCLUSIONS: The Double HIT leads to a 93% clinical and 93% radiographic intermediate/long-term success rate. With this technique, better outcomes were achieved with fewer recurrences than previously reported. These favorable results challenge the need for postoperative VCUG in asymptomatic patients after the Double HIT.

Pediatric chronic orchalgia.

INTRODUCTION: Chronic orchalgia, defined as testicular pain lasting > 3 months and interfering with normal activities, is neglected in the pediatric literature. We describe our experience with the evaluation and treatment of pediatric chronic orchalgia patients. MATERIALS AND METHODS: Charts were screened to identify patients meeting the criteria for chronic orchalgia. Charts were further reviewed to record the history and physical exam, diagnostic tests, treatment and outcomes. RESULTS: 65/982 patients met the criteria for chronic orchalgia. Mean age was 13 and mean duration of pain was 8.6 months. Physical exam findings were normal in 46 patients (70%). 59 patients were managed conservatively with resolution (10/59, 17%) or a single visit (36/59, 61%) in 78%. 13/59 (22%) patients showed either minor improvement or no change in symptoms. 5 non-responding patients were managed by the anesthesia pain service; 4 received epidurals with or without additional oral pain medications with 3 experiencing significant pain improvement. CONCLUSION: Conservative management of chronic orchalgia allowed symptoms to subside in the majority of cases. We recommend patients be treated with conservative measures for 1-2 months. If this fails, early involvement of the anesthesia pain service can offer treatment modalities such as epidural analgesia. Surgical management in the face of a normal physical exam does not seem to have a role.

Does compliance status predict clinical status in patients undergoing endoscopic management of vesico-ureteral reflux?

OBJECTIVE: Previous studies of endoscopic management of vesico-ureteral reflux (VUR) have had non-compliance rates around 50%. We examined success rates of patients non-compliant with a delayed follow up protocol after endoscopic injection for VUR. MATERIALS AND METHODS: Patients undergoing Double HIT, dextranomer/hyaluronic acid copolymer endoscopic injection for VUR were enrolled in a 1-year, delayed voiding cysto-urethrogram (VCUG) study. All patients non-compliant with the VCUG were contacted and information on their clinical status was collected. Non-compliant patients were re-scheduled for a VCUG. RESULTS: 49/54 (91%) patients underwent endoscopic injection for VUR and completed the 6-week ultrasound. At 1-year 49% (24/49) were non-compliant with a VCUG; 75% (18/24) were contacted and provided clinical information. All but one patient agreed to the VCUG. Patients compliant with the 1-year VCUG showed 96% (24/25) clinical and 92% (23/25) radiologic success rates. Non-compliant patients had an 89% (16/18) clinical success rate; 5 (21%) non-compliant patients underwent VCUGs with a 100% success rate. CONCLUSIONS: Long-term compliance remains an issue for patients treated endoscopically for VUR, but compliance does not predict clinical status as both groups have favorable clinical outcomes. The repeat VCUG is a barrier to long-term follow up as only 21% of patients underwent the study.

Evolution of single practice trends in the surgical approach to the undescended testicle.

PURPOSE: The surgical approach to palpable and nonpalpable testicles has changed with increasing use of a single scrotal incision and laparoscopy, respectively. We identified current trends in the surgical approach to undescended testicles in the practice of a single surgeon at our institution. MATERIALS AND METHODS: A total of 580 orchiopexies were performed in 554 patients by a single surgeon between January 2002 and July 2009. Study inclusion criteria were palpable and nonpalpable primary undescended testicles. Patients were stratified into groups based on the date of the initial procedure by year. A retrospective chart review was performed and the surgical approach in each patient was recorded as laparoscopic, transinguinal abdominal, inguinal or scrotal. RESULTS: During the 7-year period the percent of orchiopexies performed through a single scrotal incision increased from approximately 15% to a high of 63%. The overall percent of cases performed through a standard inguinal incision decreased from 65% to 17% and the percent performed through a transinguinal abdominal approach decreased from 15% to 0% in the 2 most recent years tabulated. The use of laparoscopy increased from 3% to 17%. CONCLUSIONS: Substantial trends were observed among the 3 groups. The percent of procedures performed through a scrotal incision increased during the 7-year period while the percent of inguinal and transinguinal abdominal procedures decreased concomitantly with no increase in morbidity. Selected use of scrotal approach orchiopexy is safe and effective for palpable undescended testicles.

Incidence and clinical significance of arterial injury in varicocele repair.

OBJECTIVE: • This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries. MATERIALS AND METHODS: • 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically. • The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications. RESULTS: • Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports. • Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome. CONCLUSION: • The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

A review of the urologic manifestations of Beckwith-Wiedemann syndrome.

OBJECTIVE: Beckwith-Wiedemann syndrome (BWS) is a constellation of congenital anomalies that classically presents with macroglossia, abdominal wall defects and gigantism. Although renal and adrenal pathology are the most commonly associated urologic findings of BWS, we report a case of a girl with BWS and symptomatic clitoromegaly, recurrent urinary tract infections and vesicoureteral reflux, followed by a review of the literature regarding urologic manifestations of BWS. MATERIALS AND METHODS: A comprehensive review of the literature for renal and non-renal urologic manifestations of BWS was conducted using a computer-based (PubMed) search. The reported renal and non-renal urologic findings are summarized. RESULTS: In addition to well-described renal manifestations, a variety of non-renal urologic findings have been reported in patients with BWS. CONCLUSIONS: Healthcare providers should carefully evaluate both patients and their family members for urologic manifestations of BWS. Early diagnosis and thorough evaluation allows for potential improved management and prognosis of BWS urologic sequelae, including tumors, cryptorchidism and urinary tract abnormalities.

Same setting laparoscopic antegrade continence enema and antegrade bladder neck injection for constipation and urinary incontinence in the spina bifida population.

PURPOSE: Fecal impaction and urinary incontinence and are among the most important problems in patients with spina bifida. We report our preliminary results with a minimally invasive approach to these 2 problems, that is same setting laparoscopic antegrade continence enema and antegrade bladder neck injection. MATERIALS AND METHODS: We reviewed the charts of all patients who underwent same setting laparoscopic antegrade continence enema and antegrade bladder neck injection between January 1, 2006 and August 1, 2008. Demographic data, surgical indications, operative details and results were recorded. Surgical steps were uniform in all cases. Diagnostic laparoscopy was performed. Two additional 5 mm trocars were placed. The appendix was mobilized to reach skin in the right lower quadrant. The antegrade continence enema channel was matured. A small percutaneous cystotomy was then created via the suprapubic port site. The cystoscope was passed suprapubically and dextranomer/hyaluronic acid was injected in the bladder neck. A suprapubic tube was placed. RESULTS: We performed a total of 10 same setting laparoscopic antegrade continence enemas with antegrade bladder neck injection in 4 males and 6 females with a mean age of 9.4 years (range 6 to 13). All patients had a smooth walled bladder on cystogram, and good capacity, good compliance and low leak point pressure on urodynamics. There were no intraoperative complications and all patients were discharged home within 24 hours. At an average 18-month followup (range 12 to 27) all 10 patients were continent of stool and reported marked improvement in daily care. No patient experienced stool or gas leakage via antegrade bladder neck injection. Seven of 10 patients (70%) were continent of urine and no longer wore diapers. CONCLUSIONS: Same setting laparoscopic antegrade continence enema with antegrade bladder neck injection is a safe, efficacious, reasonably simple minimally invasive approach to severe constipation and urinary incontinence in patients with spina bifida.

Sutureless and scalpel-free circumcision--more rapid, less expensive and better?

PURPOSE: We previously reported our success with sutureless circumcision using 2-octyl cyanoacrylate in 267 patients. We have since modified our technique by making incisions with electrocautery. We report our results with this novel technique. We also performed a cost analysis. MATERIALS AND METHODS: We compiled data on all patients 6 months to 12 years old who underwent primary circumcision and circumcision revision in a 39-month period, as done by 3 surgeons. Study exclusion criteria were complexity beyond phimosis and Gomco clamp use. The technique included 1) a circumferential inner incision using electrocautery on cutting current, 2) a circumferential outer incision using electrocautery, 3) foreskin removal, 4) hemostasis with electrocautery, 5) skin edge approximation with 2-octyl cyanoacrylate or 6-zero suture and 6) antibiotic ointment application. We also determined the cost of all procedures based on anesthesia and operating room facility fees, and material costs. RESULTS: Between July 1, 2006 and October 1, 2009 we performed 493 primary circumcisions and 248 revisions using 2-octyl cyanoacrylate, and 152 primary circumcisions and 115 revisions using 6-zero sutures. Mean operative time for primary circumcision and revision using 2-octyl cyanoacrylate was 8 minutes (range 6 to 18), and for sutured primary circumcision and revision it was 27 minutes (range 18 to 48). At a mean 18-month followup (range 1 to 39) 3 patients treated with 2-octyl cyanoacrylate and 2 treated with sutures were rehospitalized for bleeding. When done with electrocautery, the cost of the 2-octyl cyanoacrylate technique was $743.55 less than the sutured technique as long as the 2-octyl cyanoacrylate procedures required less than 15 minutes and the sutured procedures required more than 15 minutes. CONCLUSIONS: Combined electrocautery and 2-octyl cyanoacrylate for circumcision is a safe, efficient, financially beneficial, cosmetically appealing alternative to traditional circumcision done with scalpel and sutures.

Case report: Endoscopic laser lithotripsy of seminal-vesicle stones.

A 25-year-old man presented with painful ejaculation, an ejaculate volume of 0.75, and complaints of passing "granules" in the semen. Transrectal ultrasonography showed bilateral seminal vesicle enlargement. The patient underwent transurethral resection of the ejaculatory duct. The entry point of duct was resected using pure cutting current, resulting in the passage of multiple proteinaceous-appearing stones. Approximately 10 months later, the patient reported recurrent painful ejaculation and passage of granules in his semen. At cystoscopy, the ejaculatory duct openings were intubated with a cone-tipped catheter to perform bilateral seminal vesiculograms, which showed numerous mobile filling defects and a Steinstrasse appearance at the ejaculatory ducts. A 7F semirigid ureteroscope entered the lumen without difficulty over a guidewire, and the stones were fragmented with a 270-microm holmium laser fiber. The ejaculatory ducts were balloon dilated to 18F. To our knowledge, this is the first reported case where a ureteroscope was utilized to treat seminal-vesicle stones. The seminal vesiculogram proved to be extremely valuable in the diagnosis.

Collecting duct carcinoma arising from multicystic dysplastic kidney disease.

Malignancy arising from a multicystic dysplastic kidney (MCDK) is rare. Most reports are of Wilms' tumor and clear-cell renal cell carcinoma arising from a previously unrecognized MCDK. To our knowledge, no reports have described collecting duct carcinoma arising from MCDK.

Nonoperative management of a patent urachus.

Patent urachus accounts for 10% to 15% of all reported urachal abnormalities in the literature. Treatment in the past has relied on immediate surgery. Conservative therapy with bladder catheter drainage, resulting in spontaneous closure, has not been described. We report a case of patent urachus in a 6-day-old infant who presented with urine drainage from the umbilicus. Radiographic studies confirmed a patent urachus. One week of urethral catheterization resulted in spontaneous closure of the patent urachus. This case suggests that initial treatment should consist of urethral catheterization for 1 to 2 weeks, followed by repeat voiding cystourethrogram. If the patent urachus still persists, one should proceed to surgical correction.

Reduction of proteinuria after gastric bypass surgery: Case presentation and management.

Obesity is increasing in prevalence across the United States. The surgical therapy for obesity is effective at reducing weight; however, the benefits to renal function are not well described. We report an obese patient with nonnephrotic-range proteinuria that resolved after Roux-en-Y gastric bypass. Evidence suggests that obesity-related renal dysfunction is multifactorial and may be a result of hyperfiltration or increased intra-abdominal pressure. The use of gastric bypass as a permanent solution to obesity may confer a similar benefit to obesity-related renal dysfunction.