Assessment of the Grades of Vesicoureteral Reflux in Stented Ureters: An Experimental Study.

INTRODUCTION: The aim of this experimental study is to assess, in a porcine model, the onset and grades of vesicoureteral reflux associated with ureteral stents. METHODS: Twenty-four female porcine models were used. A 4.7-Fr ureteral stent was placed in all right ureters and kept in place for 6 weeks. Follow-ups were performed on weeks 1, 3, 6, and 12. Ultrasonography, cystoscopy, and fluoroscopy were used to analyze grade of hydronephrosis, presence and grade of vesicoureteral reflux, bacteriuria, and macroscopic changes of the ureteral orifices. Vesicoureteral reflux was classified using a modification of the International Reflux Study Committee grades. RESULTS: 91.7% animals present vesicoureteral reflux, 89.5% grade IA, 3.5% grade IB, and 7% grade II. There is a significant increase in reflux during follow-ups at 3 and 6 weeks, whereas 6 weeks after removal, 26.3% of the ureters still present vesicoureteral reflux. Hydronephrosis and macroscopic changes of the ureteral orifice increase significantly with stenting, but there is no significant association between them and vesicoureteral reflux; the relationship between bacteriuria and the presence of vesicoureteral reflux is not significant either. CONCLUSION: Vesicoureteral reflux caused by ureteral stents in an animal model is mostly low grade and mainly affects the distal ureter.

Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting.

Background and Objectives: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods: Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results: Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion: With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.

Clinical Spectrum of Congenital Anomalies of Kidney and Urinary Tract in Children.

OBJECTIVES: To evaluate the clinical spectrum and patterns of clinical presentation in congenital anomalies of kidney and urinary tract. METHODS: We enrolled 307 consecutively presenting children with congenital anomalies of kidney and urinary tract at the pediatric nephrology clinic. Patients were evaluated clinically, with serum biochemistry, appropriate imaging and radionuclide scans. RESULTS: The most common anomaly was primary vesicoureteric reflux (VUR) (87, 27.3%), followed by pelviureteral junction obstruction (PUJO) (62,20.1%), multicystic dysplastic kidney (51 16.6%), non-obstructive hydronephrosis (32, 10.4%) and posterior urethral valves (PUV) (23, 7.4%). 247 (80.4%) anomalies had been identified during the antenatal period. Another 33 (10.7%) were diagnosed during evaluation of urinary tract infection, and 21 (6.8%) during evaluation for hypertension at presentation. Obstructive anomalies presented earlier than non-obstructive (7 (3, 22.5) vs 10 (4, 24) mo: (P=0.01)). The median (IQR) ages of presentation for children with PUV (n=23), VUR (n=87) and PUJO (n=62) were 4 (2, 14) mo, 10 (5, 27) mo, and 7 (3, 22.5) mo, respectively. Nine (2.9%) children had extrarenal manifestations. CONCLUSIONS: The median age at clinical presentation for various subgroups of anomalies indicates delayed referral. We emphasize the need for prompt referral in order to initiate appropriate therapeutic strategies in children with congenital anomalies of kidney and urinary tract.

Vesicoureteral refux detection in children: a comparison of the midline-to-orifice distance measurement by ultrasound and voiding urosonography.

BACKGROUND: Due to the questionable clinical role of vesicoureteral reflux (VUR) and the search for noninvasive, radiation-free procedures sufficiently reliable to detect VUR, we compared the correlation between the midline-to-orifice distance (MOD) measured by ultrasonography (US) and echo-enhanced voiding urosonography (VUS) for detecting VUR in children. The aim of the study was to determine whether measuring MOD by US could be a reliable predictor of VUR in children. METHODS: A total of 116 children, aged 0.25-84 months, with 232 potentially refluxing units were investigated simultaneously by measuring the MOD and performing VUS. Indications for cystography were urinary tract infection and follow-up of a previously detected VUR. VUS was performed after the MOD measurement. The results were analyzed with VUS as the reference method. RESULTS: The MOD was significantly larger in VUR grade III (10.7 mm; p = 0.003) and VUR grade II (9.9 mm; p = 0.001) refluxing units than in non-refluxing units (7.8 mm), even when controlling for the estimated volume/expected maximal capacity (Vest/Vmax) ratio. A MOD cutoff value of 7.4 mm was chosen as a predictor of either the presence or absence of VUR; the sensitivity and specificity of this cutoff measurement for VUR detection were found to be 89 and 24%, respectively. CONCLUSIONS: Despite the statistically significant difference between the MOD of refluxing versus non-refluxing units identified in our study, the MOD measurement needs further evaluation to determine its potential value as a diagnostic tool for the detection of VUR.

Role of Renal Ultrasonography in Predicting Vesicoureteral Reflux and Renal Scarring in Children Hospitalized with a First Febrile Urinary Tract Infection.

BACKGROUND: This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with a first febrile urinary tract infection (UTI). METHODS: Hospitalized children aged ≤ 2 years with a first febrile UTI were prospectively evaluated using imaging studies, including (99m)Tc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography. RESULTS: Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with Grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for Grades I-V VUR and 68.4% and 87.8%, respectively, for Grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow up of renal function). Nephromegaly on initial US and Grades III-V VUR were risk factors of RS. CONCLUSION: Abnormal US may carry a higher probability of Grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and Grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after a first febrile UTI and children with normal US may not require voiding cystourethrography.

Pattern of clinical presentation of congenital anomalies of the kidney and urinary tract among infants and children.

AIM: Congenital anomalies of the kidneys and urinary tract (CAKUT) comprise various entities of structural malformations that result from defects in morphogenesis of the kidney and/or urinary tract. These anomalies are the most commonly diagnosed malformations in the prenatal period and constitute the leading cause of end-+stage renal disease (ESRD) in children, worldwide. This prospective study was performed to report the patterns of clinical presentation and diagnosis of infants and children with such malformations. METHODS: Patients with suggestive features of CAKUT, presenting to Cairo University Children Hospital over one year duration were investigated and categorized based on underlying renal structural/functional malformation and associated extra-renal anomalies. RESULTS: One hundred and seven CAKUT children were enrolled in the study. Familial clustering was identified in 14% of the cohort and syndromic CAKUT accounted for 31.8% of cases. Different anomaly entities have been identified; posterior urethral valves (PUV) being the commonest detected abnormality (36.4%). Of note, 9.3% of cohort patients had ESRD at presentation, of which 60% had PUV as their primary renal disease. Obstructive cases were noted to present significantly earlier and attain advanced CKD stages rather than non-obstructive ones. CONCLUSION: CAKUT is a clinically heterogeneous group of diseases with diverse clinical phenotypes. More efforts should be aimed at improving antenatal detection as well as classification with comprehensive reference to the clinical, genetic and molecular features of the diseases. The high frequency of familial and syndromic CAKUT among studied patients is seemingly a convincing reason to pursue the underlying genetic defect in future studies.

Reliability assessment of international grading system for vesicoureteral reflux.

PURPOSE: The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux. MATERIALS AND METHODS: A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades. RESULTS: The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001). CONCLUSIONS: The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility.

Single center experience with endoscopic subureteral dextranomer/hyaluronic acid injection as first line treatment in 1,551 children with intermediate and high grade vesicoureteral reflux.

PURPOSE: In recent years the endoscopic injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis and the surgical management of vesicoureteral reflux. We determined the safety and effectiveness of the endoscopic injection of dextranomer/hyaluronic acid as first line treatment for high grade vesicoureteral reflux. MATERIALS AND METHODS: Between 2001 and 2010, 1,551 children (496 male, 1,055 female, median age 1.6 years) underwent endoscopic correction of intermediate and high grade vesicoureteral reflux using dextranomer/hyaluronic acid soon after the diagnosis of vesicoureteral reflux on initial voiding cystourethrogram. Vesicoureteral reflux was unilateral in 761 children and bilateral in 790. Renal scarring was detected in 369 (26.7%) of the 1,384 patients who underwent dimercapto-succinic acid imaging. Reflux grade in the 2,341 ureters was II in 98 (4.2%), III in 1,340 (57.3%), IV in 818 (34.9%) and V in 85 (3.6%). Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure, and renal ultrasound was performed annually thereafter. Patients were followed for 3 months to 10 years (median 5.6 years). RESULTS: Vesicoureteral reflux resolved after the first, second and third endoscopic injection of dextranomer/hyaluronic acid in 2,039 (87.1%), 264 (11.3%) and 38 (1.6%) ureters, respectively. Febrile urinary tract infections developed during followup in 69 (4.6%) patients. None of the patients in the series needed reimplantation of ureters or experienced any significant complications. CONCLUSIONS: Our results confirm the safety and efficacy of the endoscopic injection of dextranomer/hyaluronic acid in the eradication of high grade vesicoureteral reflux. We recommend this 15-minute outpatient procedure as the first line of treatment for high grade vesicoureteral reflux.

Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?

PURPOSE: Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group. MATERIALS AND METHODS: A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life. RESULTS: No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status. CONCLUSIONS: Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis.

Urinary proteome analysis to exclude severe vesicoureteral reflux.

OBJECTIVES: High-grade vesicoureteral reflux (VUR, grade IV or V) is a risk factor for renal scarring, impaired renal function, and arterial hypertension. Voiding cystourethrography is the gold standard for detecting the severity of VUR. High-grade VUR is present in the minority of children with urinary tract infection (UTI), thus exposing the majority to invasive diagnostics that have no surgical consequence. We therefore aimed at establishing a noninvasive test to identify children with high-grade VUR. METHODS: In a case-control study, a specific urinary proteome pattern was established by capillary electrophoresis coupled to mass spectrometry in 18 patients with primary VUR grade IV or V, distinguishing these from 19 patients without VUR after UTI. This proteome pattern was independently validated in a blinded cohort of 17 patients with VUR grade IV or V and 19 patients without VUR. RESULTS: Sensitivity in detecting VUR grade IV or V in the blinded study was 88%, specificity was 79%. The test's accuracy was independent of age, gender, and grade of VUR in the contralateral kidney. The odds ratio of suffering from VUR grade IV or V when tested positive was 28 (95% confidence interval: 4.5 to 176.0). CONCLUSIONS: This noninvasive test is ready for prospective validation in large cohorts with the aim of identifying those children with UTI and hydronephrosis in need of further invasive diagnostics, such as voiding cystourethrography, thus sparing most children without pathologic urinary proteome patterns from additional diagnostics.

Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review.

OBJECTIVE: Published success rates of dextranomer/hyaluronic acid (Dx/HA) injection for pediatric vesicoureteral reflux (VUR) vary widely. Our objective of this study was to assess whether underlying patient or study factors could explain the heterogeneity in reported Dx/HA success rates. METHODS: We searched the Cochrane Controlled Trials Register and Medline, Embase, and Scopus databases from 1990 to 2008 for reports in any language, along with a hand search of included study bibliographies. Articles were assessed and data abstracted in duplicate, and differences were resolved by consensus. Conflict of interest (COI) was determined by published disclosure. Meta-regression was performed to adjust for patient as well as study-level factors. RESULTS: We identified 1157 reports, 89 of which were reviewed in full with 47 included in the pooled analysis. Of 7303 ureters that were injected with Dx/HA, 5633 (77%) were successfully treated according to the authors' definition. Injection success seemed to vary primarily on the basis of the preoperative reflux grade. After adjustment for VUR grade, other factors, such as the presence or absence of COI disclosure, were not significant. Studies were markedly heterogeneous overall. CONCLUSIONS: The overall per-ureter Dx/HA success rate was 77% after 3 months, although success rates varied widely among studies. Increased VUR grade negatively affected success rates, whereas COI, patient age, and injected Dx/HA volume were not significantly associated with treatment outcome after adjustment for VUR grade. There is a significant need for improved reporting of VUR treatments, including comparative studies of Dx/HA and other VUR treatments.

[Long-term results after endoscopic subureteral injection for VUR using dextranomer/hyaluronic acid copolymer : a five years experience]. / Endoskopische Unterspritzung des vesikoureteralen Refluxes mit Dextranomer/Hyaluronsäure : 5-Jahres-Langzeitergebnisse.

BACKGROUND: A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present the long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux) for VUR grade I-IV in children. PATIENTS AND METHODS: Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux in 30 ureters as an outpatient procedure. Twelve children had a unilateral reflux (two duplicated systems) and nine had a bilateral reflux. The median age was 5 years (6 months to 14.9 years). Six weeks postoperatively a voiding cystourethrogram (VCUG) was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) as well as the quality of life (parents' questionnaire) during long-term follow-up. RESULTS: No intra- and postoperative complications were noticed. In 25 ureters (83%) VCUG showed no VUR 6 weeks postoperatively. In three children a second injection was done (two were successful). After a median follow-up of 2.5 years 27 ureters in 17 children (90%) had no UTI and VUR. The results of the questionnaire regarding quality of life were very good in the successfully treated children and the parents would choose the same treatment option again. CONCLUSION: Subureteral injection of Deflux for children with VUR is an effective treatment option for VUR with a low complication rate.

Dynamic hydrodistention of the ureteral orifice: a novel grading system with high interobserver concordance and correlation with vesicoureteral reflux grade.

PURPOSE: We evaluated the usefulness and interobserver concordance of a novel grading system for dynamic ureteral hydrodistention. MATERIALS AND METHODS: Between May 1, 2002 and July 1, 2008 the hydrodistention grade in 697 ureters was prospectively assigned and recorded, including H0-no hydrodistention, H1-ureteral orifice open but tunnel not evident, H2-tunnel seen only and H3-extravesical ureter visualized. Specifically 489 refluxing ureters (vesicoureteral reflux group) were compared to 100 normal control ureters (normal control group). Additionally, the posttreatment hydrodistention grade in 56 ureters in which surgery for reflux failed was compared to that in 52 ureters with successful surgery. Hydrodistention grades assigned to an additional 77 ureters by 3 blinded observers were compared to assess the interobserver concordance of this system. RESULTS: Vesicoureteral reflux and hydrodistention grades correlated significantly (p <0.001). Ureters with a higher reflux grade also showed a higher hydrodistention grade. The normal control group (mean +/- SEM hydrodistention grade 0.62 +/- 0.07) showed a statistically lower hydrodistention grade than the reflux groups (overall mean hydrodistention grade 2.26 +/- 0.01). Mean posttreatment hydrodistention grade in the failed reflux surgery group was statistically higher than that in the mean successful reflux surgery group (2.03 +/- 0.09 vs 1.33 +/- 0.08). By defining the degree of hydrodistention as normal (H0-H1) and abnormal (H2-H3) the concordance between observers was 95% and 96%. CONCLUSIONS: The dynamic hydrodistention classification is a reliable method of evaluating the presence or absence of vesicoureteral reflux as it correlates significantly with radiographic reflux grade. It has high interobserver concordance.

[Endoscopic treatment of complicated vesicoureteral reflux grades III-V in infants under the age of one year]. / Tratamiento endoscópico del reflujo vesico ureteral III-V complicado en lactantes menores de 1 año.

OBJECTIVES: Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritis and high grade (G) Vesicoureteral Reflux (VUR). INCLUSION CRITERIA: infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibiotic prophylaxis (AP). N = 27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: G II (control without AP); Persistence: III-V Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings. RESULTS: 34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6%), Improved 1, OS 3 (33.3%). Overall results: Solved: 24 U (70.58%), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery. CONCLUSIONS: ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.

Therapy for vesicoureteral reflux: antibiotic prophylaxis, urotherapy, open surgery, endoscopic injection, or observation?

Vesicoureteral reflux (VUR) refers to the retrograde flow of urine from the bladder into the ureter and renal pelvis. It generally results from congenital maldevelopment of the ureterovesical junction, although VUR may develop in individuals with abnormally high detrusor pressure. VUR increases a child's susceptibility to pyelonephritis and renal scarring. Treatment goals include the prevention of pyelonephritis, reflux nephropathy, and other complications of reflux. Treatment alternatives include antibiotic prophylaxis, urotherapy (correction of voiding dysfunction), and surgical correction (open, injection therapy, or laparoscopic). Recent studies have challenged the presumed benefit of prophylaxis in children with VUR, while long-term retrospective studies have documented a high rate of hypertension in adults with reflux nephropathy. In addition, the risk of persistent VUR in adulthood is unresolved. These reports have stimulated a reevaluation of the role of various treatment options in children with VUR.

The deflux procedure reduces the incidence of urinary tract infections in patients with vesicoureteral reflux.

PURPOSE: The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR). MATERIALS AND METHODS: After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis. RESULTS: The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection). CONCLUSIONS: We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

[Voiding dysfunction in children with vesicoureteral reflux]. / Zaburzenia funkcji pecherza moczowego u dzieci z odplywami pecherzowo-moczowodowymi.

UNLABELLED: The aim of the study was to assess the rate of development of voiding dysfunction (VD) in patients with reflux nephropathy. We investigated 150 pts with vesicoureteral reflux (VUR): 33 boys and 117 girls in mean age 9 +/- 3.3 years with normal renal function. In all pts we performed renal scintigraphy (DMSA) and ABPM. Renal scarring by DMSA scan was categorized into grades 1-4. In all pts we assessed high and laterality of VUR, renal function (clearance creatinine--Ccr) and occurency of hypertension (HT). RESULTS: Of 150 pts, 80 (53.3%) developed VD (54.5% boys and 52% girls). DMSA grade: 1--27 pts, 2--85 pts; 3--31 pts; 4--7 pts. No statistically significant difference was found depends of: sex, age, laterality of renal damage in DMSA, unilateral and bilateral reflux for the development of VD. The incidence 3-4 grade in DMSA scan was significantly higher in pts with IV-V grade of VUR in comparison to pts with lower grade of VUR in group with and without voiding dysfunction. IV-V grades of VUR were observed more frequently in pts with bladder/sphincter dysfunction. The occurency of HT in group with VD and without VD was 12 pts (15%) and 8 (11.4%) respectively (ns). Pts with VD have lower Ccr in comparison with pts without VD (129.1 vs 136.3 ml/min/1.73 m2; p<0.05). CONCLUSIONS: Approximately 50% of patients with VUR demonstrated VD. VD occurred independent of age. IV-V degrees VUR and more severe changes in DMSA scan were seen in pts with bladder/sphincter dysfunction.

[Vesicoureteral reflux grades III-IV: factors involved in the efficacy of endoscopic treatment in pediatric patients]. / Reflujo vesicoureteral grados III-IV: factores implicados en la efectividad del tratamiento endoscópico en pacientes pediátricos.

OBJECTIVES: Vesicoureteral reflux (VUR) is detected in 30-50% of pediatric patients diagnosed of urinary tract infection (UTI). Multiple clinical trials have compared the results of conservative management against surgical therapy. The introduction of a third alternative in 1984 (endoscopic approach) has dramatically modified the management of VUR. The objective of our work is to analyze the factors influencing the favourable outcome of the endoscopic treatment of VUR. METHODS: Retrospective and prospective cohort study analyzing 90 patients with grades III and IV VUR treated endoscopically over the last eight years. 184 patients undergoing endoscopic management were selected from a group of 550 patients (735 VUR renal units) with the diagnosis of VUR over the study period. All patients underwent VCUG or galactose-based sonocystography to obtain the diagnosis. DMSA scintigram was used to evaluate renal damage. Data about gender, age, UTI, bilateralism, renal damage, voiding dysfunction, outcomes, complications, and recurrences were registered. A new factor was defined: ureteral dilation independent from the international classification. This factor was evaluated by a single pediatric urologist blinded for the international classification results. Data analysis was performed using the chi square test and Fischer exact test; a multiple logistic regression analysis was also performed. Statistical significance was established at p < 0.05. SPSS 11.0 software was employed for data analysis. RESULTS: Boys/girls ratio was 2.91. Bilateral VUR appeared in 44.4% of the cases. UTI was the presenting diagnosis in 64 cases; the diagnosis was prenatal in 21 cases (with a male predominance 5.2:1). We found a strong correlation between renal scarring at the time of diagnosis and voiding dysfunction (p< 0.01). Cure rate after first injection was 64%. Although univariate analysis showed a strong correlation between cure and first injection, biloterality, voiding dysfunction, initial nephropathy, and ureteral dilation grade, on multivariate logistic regression the only significant factor to predict treatment response was the existence of severe ureteral dilation in comparison with mild dilation (p < 0.001; odds ratio 0.045, 95% confidence interval 0.01-0.16). Renal damage progression was specially detected in those patients with voiding dysfunction (p = 0.053), bilaterality (p = 0.034) and severe ureteral dilation (p < 0.001). CONCLUSIONS: A direct relation between cure rate after endoscopic treatment of grade III and IV reflux and severity of ureteral dilation was demonstrated. Other relevant factors implied in the endoscopic resolution of VUR include the existence of voiding dysfunction, bilateral reflux and renal damage determined by DMSA at the time of initial diagnosis. Gender, age, and number of infections during follow up have no influence in the probability of cure of grade III and IV VU reflux treated with subureteral injection of biocompatible substances.

Subureteral dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux in transplant candidates.

BACKGROUND AND PURPOSE: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR). Several injectable materials have been tried for this purpose. In this study, we tried to determine the efficacy of dextranomer/hyaluronic acid copolymer (Dx/HA) injection for the treatment of VUR in renal-transplant candidates. PATIENTS AND METHODS: A total of 21 transplant candidates (29 ureteral units; 13 females, 8 males) with a mean age of 20.2 years (range 14-26 years) underwent endoscopic correction of VUR with Dx/HA. Diagnosis of VUR was made by voiding cystourethrography. The efficacy of the treatment was assessed with voiding cystourethrography at 3 months and 1 year postoperatively. Renal transplantation with living related donor organs was performed in 11 of the 21 patients. RESULTS: Endoscopic treatment was performed without complication in all cases. Higher success rates were obtained in patients with low-grade reflux, the overall success rate in the series being 82.7%. The mean follow- up after renal transplantation was 21.8 months (range 5-45 months). In one patient, reflux recurred after renal transplantation and was treated successfully by a repeat Dx/HA injection. The urine cultures of all patients remained sterile. CONCLUSION: Transplant candidates with VUR can be treated with Dx/HA, which cured the majority of our patients after one or two treatments with few low side effects. Endoscopic subureteral injection of Dx/HA has become an alternative treatment for VUR in transplant candidates. Long-term results are needed before making a final statement about its value.