Modified Y-V plasty based on MRU evaluation for iatrogenic bladder outlet obliteration: a multicentre experience in China.

PURPOSE: To compare the diagnostic ability of traditional radiographic urethrography and magnetic resonance urethrography (MRU) for iatrogenic bladder outlet obliteration (BOO), and explore the efficacy and complications of laparoscopic modified Y-V plasty for patients selected based on MRU evaluation. METHODS: 31 patients with obliteration segments ≤ 2 cm and no false passages or diverticula based on MRU evaluation from eight centers in China were included. Obliteration segments were measured preoperatively by MRU and conventional RUG/VCUG and compared with intra-operative measurements. Surgical effects were evaluated by uroflow rates, urethrography, or cystoscopy at 1, 3, 6, and 12 months post-operation and then every 12 months. Postoperative urinary continence was assessed by 24-h urine leakage (g/day). RESULTS: The results showed that MRU measured the length of obliteration more accurately than RUG/VCUG (MRU 0.91 ± 0.23 cm, RUG/VCUG 1.72 ± 1.08 cm, Actual length 0.96 ± 0.36 cm, p < 0.001), and clearly detected false passages and diverticula. Laparoscopic Y-V plasty was modified by incisions at 5 and 7 o'clock positions and double-layer suture with barbed sutures. All operations were successfully completed within a median time of 75 (62-192) minutes and without any complications. Urethral patency and urinary continence rates were 90.3% (28/31) and 87.1% (27/31), respectively. Three recurrences were cured by direct visual internal urethrotomy. Four patients had stress urinary incontinence after catheter removal 14 days post-operation, with urine leakage of 80-120 g/day, not relieved during follow-up. CONCLUSIONS: Laparoscopic modified Y-V plasty based on MRU evaluation is a promising approach for iatrogenic BOO, with a high patency rate and a low incontinence rate.

Preoperative fistula diagnostics in male anorectal malformations after colostomy: a single-center experience.

BACKGROUND: Accurate preoperative fistula diagnostics in male anorectal malformations (ARM) after colostomy are of great significance. We reviewed our institutional experiences and explored methods for improving the preoperative diagnostic accuracy of fistulas in males with ARMs after colostomy. METHODS: A retrospective analysis was performed on males with ARMs after colostomy admitted to our hospital from January 2015 to June 2022. All patients underwent magnetic resonance imaging (MRI) and high-pressure colostogram (HPC) before anorectal reconstruction. Patients with no fistula as diagnosed by both modalities underwent a voiding cystourethrogram (VCUG). General information, imaging results and surgical results were recorded. RESULTS: Sixty-nine males with ARMs after colostomy were included. Age at the time of examination was 52 ~ 213 days, and the median age was 89 days. The Krickenbeck classification according to surgical results included rectovesical fistula (n = 19), rectoprostatic fistula (n = 24), rectobulbar fistula (n = 19) and no fistula (n = 7). There was no significant difference in the diagnostic accuracy between MRI and HPC for different types of ARMs. For determining the location of the fistula, compared to surgery, HPC (76.8%, 53/69) performed significantly better than MRI (60.9%, 42/69) (p = 0.043). Sixteen patients diagnosed as having no fistula by MRI or HPC underwent a VCUG, and in 14 patients, the results were comfirmed. However, there were 2 cases of rectoprostatic fistula that were not correctly diagnosed. CONCLUSION: High-pressure colostogram has greater accuracy than MRI in the diagnosis of fistula type in males with ARMs after colostomy. For patients diagnosed with no fistula by both methods, VCUG reduces the risk of false-negative exclusion, and rectoprostatic fistula should be considered during the operation.

Utility of Positional Instillation of Contrast Cystography for Diagnosing Occult Vesicoureteral Reflux in Children: A Report of Two Cases.

Positional instillation of contrast (PIC) cystography is effective for detecting occult vesicoureteral reflux (VUR), which can not be revealed by standard voiding cystourethrography (VCUG). We experienced two cases of young female patients; one had repeated urinary tract infection with a negative VUR on standard VCUG, and the other had findings suggestive of reflux hydronephrosis and intolerance of standard VCUG. They underwent PIC cystography, and occult VUR was detected in both cases. Both were successfully treated with simultaneous endoscopic injection therapy with dextranomer/hyaluronic acid. PIC cystography is useful for detecting occult VUR in children with negative VUR findings on standard VCUG or who are unable to tolerate standard VCUG.

A new recommendation for febrile urinary tract infection in children aged 2-24 months: Tepecik UTI Guideline-2.

AIM: Urinary tract infections (UTIs) represent a common febrile illness in infancy. The study compared two UTI guidelines in terms of number of imaging studies, presence of parenchymal damage and radiation exposure in patients with the first febrile UTI between 2 and 24 months of age. METHOD: The results of Tepecik UTI Guideline-1 used until 2012 (Group 1, n = 105) were retrospectively compared with Tepecik UTI Guideline-2 (Group 2) used after 2013. In Group 1, urinary tract ultrasonography (US), dimercaptosuccinic acid (DMSA) and voiding cystourethrography (VCUG) were made in all patients. In Group 2, if the US result was abnormal, patients were evaluated with VCUG and DMSA. If the US was normal, only DMSA was performed. If the DMSA was abnormal, the VCUG was undergone (n: 43, 40.9%). RESULTS: The abnormal VCUG detection rate was 69.2% in Group 1 and 30.8% in Group 2 (p = 0.09). Sensitivity and specificity of US in the diagnosis of vesicoureteral reflux (VUR) was 15.9% and 96.7% in Group 1 and 61.5% and 70.5% in Group 2, respectively. Abnormal DMSA findings were observed among 33.3% (Groups 1) and 66.7% (Groups 2) subjects, respectively (p > 0.05). The median radiation exposure (500 mrem) of patients in Group 1 was statistically significantly higher than those in Group 2 (200 mrem) (p < 0.001). CONCLUSION: The VCUG should not be the first examination to be considered in such patients. We think that Tepecik UTI Guideline-2 reduces unnecessary invasive procedure and radiation exposure and not missed VUR in the management of children with UTI at 2-24 months. Needs prospective follow-up studies before considering this recommendation.

Bladder height width ratio on voiding cystourethrogram as a predictor of future valve bladder in children with posterior urethral valve.

BACKGROUND/AIMS: Prompt and early treatment of valve bladder is known to improve renal outcome in patients with PUV. We hypothesized that bladder height width ratio (HWR) measurement on voiding cystourethrogram (VCUG) could predict development of valve bladder. METHODS: All patients who underwent primary PUV ablation and evaluated later with urodynamics were included. Valve bladder was suspected when there were daytime wetting, persistent hydroureteronephrosis, and elevated detrusor pressures on urodynamics. VCUGs were analysed for HWR: maximum height/width of bladder. ROC curve analysis was performed to identify HWR that could predict development of urodynamic abnormality. RESULTS: Between 2012 and 2017, 102 patients were studied: median age at valve ablation 25 days (3-125 days); follow-up 5 years (3-7 years). The ROC curve comparing post-ablation HWR with occurrence of valve bladder showed a cut-off of 1.45 (AUC 0.93). HWR cut-off of 1.45 had a sensitivity of 89% and specificity of 84% in predicting future valve bladder. Detrusor overactivity was noticed on urodynamics in 41/55 (74%) of those with HWR > 1.45 compared 5/47 (11%) in those with HWR < 1.45 (p = 0.001). CONCLUSION: Bladder height width ratio on VCUG is a useful parameter to predict development of future valve bladder in children with PUV.

Is ultrasonography mandatory in all children at their first febrile urinary tract infection?

BACKGROUND: This study investigated whether performing kidney ultrasound (KUS) only in children presenting either a pathogen other than E. coli at their first febrile urinary tract infection (fUTI) or experiencing fUTI recurrence would increase missed diagnoses of kidney anomalies. METHODS: Patients aged 2-36 months with fUTI who underwent KUS evaluation from 2 January 2013 to 31 June 2018 were enrolled. Cystourethrography was performed after pathological KUS or recurring fUTIs. Thereafter, we retrospectively assessed the detection rate of kidney anomalies through performing KUS only in patients with atypical pathogen at first fUTI or with recurring fUTIs. RESULTS: In 263 patients included, the isolated pathogen was E. coli in 223 cases (84.8%) and atypical in 40 cases (15.2%). KUS detected kidney anomalies in 14/223 (6.3%) of fUTIs caused by E. coli and in 11/40 (27.5%) of fUTIs caused by an atypical pathogen (OR 5.5, 95%CI 2.5-14.5). Cystourethrography was performed in 40 patients and vesicoureteral reflux (VUR) found in 20 cases. None of the high grade VUR diagnoses or other kidney anomalies would have been lost through a different diagnostic protocol that required the presence of an atypical pathogen at the first fUTI or a fUTI recurrence to perform the KUS. CONCLUSIONS: A diagnostic protocol that requires presence of an atypical pathogen at the first fUTI or a second episode of fUTI to perform the KUS would allow a reduction in the number of negative ultrasounds with a negligible risk of missed diagnoses of kidney anomalies.

Antibiotic prophylaxis for prevention of urinary tract infections in the first year of life in children with vesicoureteral reflux diagnosed in the workup of antenatal hydronephrosis: a systematic review.

BACKGROUND: Children with antenatal hydronephrosis (ANH) diagnosed with postnatal asymptomatic vesicoureteral reflux (VUR) are thought to be at higher risk of urinary tract infection (UTI). As such, continuous antibiotic prophylaxis (CAP) is empirically recommended until age of toilet training; however, there are limited data to support this. The objective of this systematic review was to summarize the existing data and compare UTI rates in infants with asymptomatic VUR on CAP during the first year of life, to those not on CAP. Secondary objectives were to determine associated risk factors with UTI development. METHODS: A systematic search of all relevant studies and abstracts was conducted using 4 electronic databases by utilizing appropriate key words by an expert hospital librarian. Eligible studies included children with prenatal hydronephrosis, asymptomatic VUR with or without CAP, and reported on development of UTI in the first year. RESULTS: Of 6903 citations screened, 18 were selected, giving a total population of 829 (69.4% male, median age 57 days) who met the inclusion criteria. Most studies were retrospective and of low-quality evidence. Overall, 15.4% of patients developed at least one breakthrough UTI and females had a higher risk of UTI (odds ratio (OR) 2.3, 95% CI 1.1-4.7). Comparison with children not taking CAP was not readily reported, and meta-analysis could not be completed. CONCLUSIONS: Randomized controlled trials and standardized reporting of clinical variables are required to understand the protective effect of antibiotic prophylaxis in this cohort.

Necessity of performing voiding cystourethrography for children with unilateral multicystic dysplastic kidney.

BACKGROUND: The purpose of this study was to resolve the clinical question as to whether all patients with unilateral multicystic dysplastic kidney (MCDK) should receive voiding cystourethrography (VCUG). METHODS: This is a retrospective study using cross-sectional analysis. Seventy-five children with unilateral MCDK were enrolled, excluding patients with other genetic or chromosome abnormalities, spinal cord diseases, or anal atresia. We reviewed their records from medical charts and calculated risk factors for abnormal VCUG using multivariate logistic regression analysis. RESULTS: Abnormal VCUG findings were present in 24 of 75 patients (32.0%), specifically, vesicoureteral reflux (VUR) in 8 (10.6%), including high-grade VUR in 2 (2.7%), and only lower urinary tract or bladder disease in 16 (21.3%). In multivariate analysis, only abnormal findings by ultrasonography was an independent risk factor for abnormal VCUG findings with statistical significance in multivariate analysis (OR 6.57; 95% CI 1.99-26.26; P = 0.002). When we excluded five patients who showed similar findings by ultrasonography and VCUG, abnormal findings by ultrasonography were again calculated as an independent risk factor (OR 4.44; 95% CI 1.26-28.42; P = 0.02). Sensitivity, specificity, positive predictive value, and negative predictive value of abnormal findings by ultrasonography to predict urologic anomalies by VCUG in these children were 83%, 59%, 49%, and 88%, respectively. Two children required a third ultrasonography to detect abnormal findings. CONCLUSIONS: We can select, using only abnormal findings by ultrasonography, children with unilateral MCDK who should undergo VCUG. We would also like to emphasize that ultrasonography should be performed repeatedly to detect congenital anomalies of the urinary tract.

Diagnosis of congenital and acquired focal lesions in the neck, abdomen, and pelvis with contrast-enhanced ultrasound: a pictorial essay.

Contrast-enhanced ultrasound (CEUS) is a versatile imaging modality that improves the diagnostic potential of conventional ultrasound. It allows for portable imaging at the bedside. In this paper, we illustrate how CEUS can be used in evaluating several focal lesions in the pediatric population, including liver hemangioma, telangiectasias, splenic hamartomas, and bladder lesions. We describe the ultrasound findings and contrast enhancement patterns associated with these lesions. Findings are correlated with MRI, CT, and/or pathology when available. This paper demonstrates the value of CEUS in improving characterization of many focal lesions in the pediatric population. CONCLUSION: CEUS is a valuable bedside technique for use in the pediatric population to evaluate focal lesions in various organs, and will allow for safe, more efficient diagnostic imaging. What is Known: • CEUS offers many advantages over CT and MRI and is underutilized in the United States. • It is only FDA approved for vesicoureteral reflux and liver in the pediatric population. However, off label uses are well described. What is New: • This pictorial essay describes ultrasound findings and contrast enhancement patterns associated with liver hemangioma, liver telangiectasia, splenic hamartoma, hemorrhagic ovarian cyst, urachal remnant, spinning top urethras, and kaposiform hemangioendothelioma. • We demonstrate the utility of CEUS in expanding the diagnostic potential of conventional ultrasound.

Imaging in childhood urinary tract infection.

INTRODUCTION: Urinary tract infection (UTI) is a common query in pediatric radiology. Imaging for and after UTI is still a heavily debated topic with different approaches, as thorough evidence to decide upon a definite algorithm is scarce. CONTENT AND OBJECTIVE: This review article tries to address the clinical rational of the various approaches (general imaging, top-down or bottom-up, selected and individualized imaging concepts…), describes the available imaging modalities and the respective findings in imaging children with UTI, and proposes an imaging algorithm for the work-up of children during and after UTI discussing the "pros and cons" of the different attitudes. CONCLUSION: In summary, imaging by US is generally considered for all infants and children with a febrile or complicated (upper) UTI, particularly without previously known urinary tract anatomy. The further work-up (searching for renal scarring and assessment of vesico-ureteric reflux) is then decided according to these initial findings as well as the clinical presentation, course, and scenario.

Long-term functional outcomes following nonradiated vesicovaginal repair.

PURPOSE: We investigated the long-term impact on bladder and sexual symptoms in women with prior vesicovaginal fistula repair, particularly those previously treated before referral. MATERIALS AND METHODS: After receiving institutional review board approval we reviewed the charts of women who underwent nonradiated vesicovaginal fistula repair for demographics, surgical approach (vaginal or abdominal) and functional outcomes with a minimum 6-month followup. Patients lost to followup were reached by a structured phone interview and/or mailed validated lower urinary tract questionnaires, including the UDI-6 (Urogenital Distress Inventory-6), IIQ-7 (Incontinence Impact Questionnaire-7) and FSFI (Female Sexual Function Index). Three surgical groups were compared, including naïve-no prior repair, recurrent-1 prior repair and other-more than 2 repairs with the hypothesis of worse outcomes with more repairs. RESULTS: From 1996 to 2011 vesicovaginal fistula repair was performed in 66 patients, including in 42 as primary treatment (vaginal vs abdominal approach in 31 vs 11), in 14 as secondary treatment, and in 10 who underwent more than 2 repairs. Mean patient age was 45 years (range 24 to 87), mean body mass index was 29 kg/m(2) (range 19 to 43) and mean followup was 55 months (range 6 to 198). The overall repair success rate was 97%. There was no difference in functional outcomes in questionnaire responders among the 3 groups for lower urinary tract symptoms (62% on UDI-6/IIQ-7). However, for FSFI (33% of patients) there was female sexual dysfunction in patients who underwent transabdominal repair and in women with 2 repairs. CONCLUSIONS: Long-term followup of patients with vesicovaginal fistula repair indicated no differences in lower urinary tract outcomes at a mean 7-year followup between primary and recurrent repairs. There was a difference in sexual function, although it was not statistically significant. Sexual activity among responders was low.

New contralateral vesicoureteral reflux after unilateral ureteral reimplantation: predictive factors and clinical outcomes.

PURPOSE: Although unilateral ureteral reimplantation for vesicoureteral reflux is highly successful, new contralateral reflux will develop postoperatively in some patients. We examined predictors and clinical outcomes of postoperative contralateral vesicoureteral reflux. MATERIALS AND METHODS: We reviewed patients who underwent nontapered unilateral reimplantation for primary vesicoureteral reflux graded on a 3-point scale at our institution from January 1990 to December 2002, and identified those with subsequent contralateral vesicoureteral reflux. We analyzed the association of patient/procedure characteristics with incidence, and time to resolution of contralateral reflux and postoperative urinary tract infection. Multivariable models controlled for variables associated with incidence and time to resolution of contralateral reflux. RESULTS: A total of 395 patients (77.2% female, median age 5.3 years) underwent ureteral reimplantation for vesicoureteral reflux. Preoperative reflux was grade 1 in 2.8% of patients, grade 2 in 56.6% and grade 3 in 40.6%. Technical success was 95.4%. After reimplantation 39 patients (9.9%) had new contralateral reflux (grade 1 in 7, grade 2 in 27 and grade 3 in 5). Median followup was 51.8 months. On multivariate analysis younger age (less than 6 years, OR 3.7, p = 0.006) and low observed bladder capacity as percent of predicted bladder capacity (less than 50% of predicted capacity, OR 6.3, p = 0.02) were significant predictors of contralateral reflux. Contralateral reflux resolved in 21 of 27 patients (77.8%) on subsequent cystography at a median of 21.5 months. Two patients underwent reimplantation for persistent contralateral reflux. Four of 39 patients (10.3%) with contralateral reflux had postoperative febrile urinary tract infections at a median of 26 months, with spontaneous resolution of contralateral reflux in all. CONCLUSIONS: Younger patients and those with low observed vs predicted bladder capacity may be at increased risk for postoperative contralateral vesicoureteral reflux. A majority of contralateral reflux will resolve spontaneously, and the clinical course is typically benign.

Quantification of vesicoureteral reflux using machine learning.

INTRODUCTION: The radiographic grading of voiding cystourethrogram (VCUG) images is often used to determine the clinical course and appropriate treatment in patients with vesicoureteral reflux (VUR). However, image-based evaluation of VUR remains highly subjective, so we developed a supervised machine learning model to automatically and objectively grade VCUG data. STUDY DESIGN: A total of 113 VCUG images were gathered from public sources to compile the dataset for this study. For each image, VUR severity was graded by four pediatric radiologists and three pediatric urologists (low severity scored 1-3; high severity 4-5). Ground truth for each image was assigned based on the grade diagnosed by a majority of the expert assessors. Nine features were extracted from each VCUG image, then six machine learning models were trained, validated, and tested using 'leave-one-out' cross-validation. All features were compared and contrasted, with the highest-ranked then being used to train the final models. RESULTS: F1-score is a metric that is often used to indicate performance accuracy of machine learning models. When using the highest-ranked VCUG image features, F1-scores for the support vector machine (SVM) and multi-layer perceptron (MLP) classifiers were 90.27 % and 91.14 %, respectively, indicating a high level of accuracy. When using all features combined, F1 scores were 89.37 % for SVM and 90.27 % for MLP. DISCUSSION: These findings indicate that a distorted pattern of renal calyces is an accurate predictor of high-grade VUR. Machine learning protocols can be enhanced in future to improve objective grading of VUR.

High-grade Vesicoureteral Reflux in Patients With Anorectal Malformation From the ARM-Net Registry: Is Our Screening Sufficient?

BACKGROUND: Vesico-ureteral reflux (VUR) is a common associated urological anomaly in anorectal malformation (ARM)-patients. High-grade VUR requires antibiotic prophylaxis to prevent urinary tract infections (UTI's), renal scarring and -failure. The exact prevalence of high-grade VUR in ARM patients is unknown. Hence, the aim of this study was determining the incidence of high-grade VUR in ARM-patients, and its associated risk factors. METHODS: A multicenter retrospective cohort study was performed using the ARM-Net registry, including data from 34 centers. Patient characteristics, screening for and presence of renal anomalies and VUR, sacral and spinal anomalies, and sacral ratio were registered. Phenotypes of ARM were grouped according to their complexity in complex and less complex. Multivariable analyses were performed to detect independent risk factors for high-grade (grade III-V) VUR. RESULTS: This study included 2502 patients (50 % female). Renal screening was performed in 2250 patients (90 %), of whom 648 (29 %) had a renal anomaly documented. VUR-screening was performed in 789 patients (32 %), establishing high-grade VUR in 150 (19 %). In patients with a normal renal screening, high-grade VUR was still present in 10 % of patients. Independent risk factors for presence of high-grade VUR were a complex ARM (OR 2.6, 95 %CI 1.6-4.3), and any renal anomaly (OR 3.3, 95 %CI 2.1-5.3). CONCLUSIONS: Although renal screening is performed in the vast majority of patients, only 32 % underwent VUR-screening. Complex ARM and any renal anomaly were independent risk factors for high-grade VUR. Remarkably, 10 % had high-grade VUR despite normal renal screening. Therefore, VUR-screening seems indicated in all ARM patients regardless of renal screening results, to prevent sequelae such as UTI's, renal scarring and ultimately renal failure. TYPE OF STUDY: Observational Cohort-Study. LEVEL OF EVIDENCE: III.

Society for fetal urology recommendations for postnatal evaluation of prenatal hydronephrosis--will fewer voiding cystourethrograms lead to more urinary tract infections?

PURPOSE: There is no consensus on the extent and mode of postnatal imaging after a diagnosis of prenatal hydronephrosis. We validated the protocol of our practice, which parallels current Society for Fetal Urology (SFU) recommendations, in limiting voiding cystourethrogram, while examining its impact on the incidence of febrile urinary tract infections. A secondary goal was to examine predictors of postnatal intervention. MATERIALS AND METHODS: We evaluated a cohort of 117 infants with prenatal hydronephrosis and retrospectively reviewed outcomes. Excluded from study were 30 infants with anatomical abnormalities. Third trimester prenatal ultrasound was done to evaluate SFU grade, laterality and anteroposterior diameter. Cox proportional hazard model and chi-square analysis were used to assess predictors of resolution and surgical intervention. RESULTS: A total of 87 infants with a median followup of 33.5 months were included in analysis. Postnatal voiding cystourethrogram was done in 52 patients, of whom 7 had vesicoureteral reflux. In 6 infants (6.9%) a febrile urinary tract infection developed, which was diagnosed with a catheter specimen during followup. In 3 infants a urinary tract infection developed immediately after catheterization. Anteroposterior diameter 9 mm or greater and SFU grade 3 or greater independently predicted the need for postnatal intervention (p = 0.0014 and 0.001, respectively). CONCLUSIONS: With adherence to our protocol, voiding cystourethrogram was avoided in almost half of evaluated infants. No infant diagnosed with vesicoureteral reflux had a urinary tract infection. Catheterization was associated with a urinary tract infection in 50% of cases. An anteroposterior diameter of 9 mm or greater and a SFU grade of 3 or greater were associated with postnatal progression to surgery. Patients with a SFU grade of 4 progressed to surgical intervention at a faster rate than those with a grade of greater than 3.

Prospective study using a new bulking agent for the treatment of vesicoureteral reflux: polyacrylamide hydrogel.

PURPOSE: Vesicoureteral reflux is frequently diagnosed in the pediatric population. Endoscopic treatment has become a popular form of first-line therapy. Available products offer good short-term success rates. However, the cost of these injected implants is an issue. We evaluated the success of endoscopic treatment for vesicoureteral reflux using polyacrylamide hydrogel. MATERIALS AND METHODS: We performed a single center, single surgeon, prospective, off-label study using polyacrylamide hydrogel to treat vesicoureteral reflux. All patients underwent endoscopic subureteral double hydrodistention implantation technique injection followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to confirm the absence of de novo hydronephrosis and correction of vesicoureteral reflux (grade 0). RESULTS: A total of 40 patients (69 refluxing ureters) underwent polyacrylamide hydrogel injection. Median age at surgery was 50 months. Bilateral reflux was identified in 29 patients (73%). Nine patients had duplex systems, 2 with reflux into both moieties. Reflux was graded using the International Reflux Study in Children grading system, with grade I seen in 9 ureters, II in 17, III in 20, IV in 18 and V in 5. Mean volume injected was 1.1 ml. Success rate for grade I to III vesicoureteral reflux at 3 months after a single treatment was 87%, and the overall success for all grades was 81.2%. CONCLUSIONS: Off-label use of polyacrylamide hydrogel injection therapy for primarily low grade vesicoureteral reflux demonstrates that the technique and short-term success rates are comparable to the most popular bulking agent, dextranomer/hyaluronic acid. These results suggest that further trials comparing polyacrylamide hydrogel and dextranomer/hyaluronic acid would be worthwhile.

Cost-effectiveness of risk stratified followup after urethral reconstruction: a decision analysis.

PURPOSE: We propose a novel risk stratified followup protocol for use after urethroplasty and explore potential cost savings. MATERIALS AND METHODS: Decision analysis was performed comparing a symptom based, risk stratified protocol for patients undergoing excision and primary anastomosis urethroplasty vs a standard regimen of close followup for urethroplasty. Model assumptions included that excision and primary anastomosis has a 94% success rate, 11% of patients with successful urethroplasty had persistent lower urinary tract symptoms requiring cystoscopic evaluation, patients in whom treatment failed undergo urethrotomy and patients with recurrence on symptom based surveillance have a delayed diagnosis requiring suprapubic tube drainage. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethroplasties performed per year in the United States. Costs were obtained based on Medicare reimbursement rates. RESULTS: The 5-year cost of a symptom based, risk stratified followup protocol is $430 per patient vs $2,827 per patient using standard close followup practice. An estimated 7,761 urethroplasties were performed in the United States in 2010. Assuming that 60% were excision and primary anastomosis, and with more than 5 years of followup, the risk stratified protocol was projected to yield an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk stratified followup protocol was far more cost-effective than standard close followup in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk stratified followup protocol. CONCLUSIONS: A risk stratified, symptom based approach to urethroplasty followup would produce a significant reduction in health care costs while decreasing unnecessary followup visits, invasive testing and radiation exposure.

Incidence of abnormal imaging and recurrent pyelonephritis after first febrile urinary tract infection in children 2 to 24 months old.

PURPOSE: The AAP (American Academy of Pediatrics) no longer recommends voiding cystourethrogram in children 2 to 24 months old who present with a first urinary tract infection if renal-bladder ultrasound is normal. We identified factors associated with abnormal imaging and recurrent pyelonephritis in this population. MATERIALS AND METHODS: We retrospectively evaluated children diagnosed with a first episode of pyelonephritis at age 2 to 24 months using de-identified electronic medical record data from an institutional database. Data included age at first urinary tract infection, gender, race/ethnicity, need for hospitalization, intravenous antibiotic use, history of abnormal prenatal ultrasound, renal-bladder ultrasound and voiding cystourethrogram results, urinary tract infection recurrence and surgical intervention. Risk factors for abnormal imaging and urinary tract infection recurrence were analyzed by univariate logistic regression, the chi-square test and survival analysis. RESULTS: We identified 174 patients. Of the 154 renal-bladder ultrasounds performed 59 (38%) were abnormal. Abnormal prenatal ultrasound (p = 0.01) and the need for hospitalization (p = 0.02) predicted abnormal renal-bladder ultrasound. Of the 95 patients with normal renal-bladder ultrasound 84 underwent voiding cystourethrogram. Vesicoureteral reflux was more likely in patients who were white (p = 0.003), female (p = 0.02) and older (p = 0.04). Despite normal renal-bladder ultrasound, 23 of 84 patients (24%) had dilating vesicoureteral reflux. Of the 95 patients with normal renal-bladder ultrasound 14 (15%) had recurrent pyelonephritis and 7 (7%) went on to surgical intervention. CONCLUSIONS: Despite normal renal-bladder ultrasound after a first pyelonephritis episode, a child may still have vesicoureteral reflux, recurrent pyelonephritis and the need for surgical intervention. If voiding cystourethrogram is deferred, parents should be counseled on these risks.

Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction.

PURPOSE: There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition. MATERIALS AND METHODS: Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics. RESULTS: Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%). CONCLUSIONS: Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

Prevalence of urinary tract infection and vesicoureteral reflux in children with lower urinary tract dysfunction.

PURPOSE: Lower urinary tract dysfunction is a common pediatric urological problem that is often associated with urinary tract infection. We determined the prevalence of a urinary tract infection history in children with lower urinary tract dysfunction and its association, if any, with gender, bowel dysfunction, vesicoureteral reflux and specific lower urinary tract conditions. MATERIALS AND METHODS: We retrospectively reviewed the charts of children diagnosed with and treated for lower urinary tract dysfunction, noting a history of urinary tract infection with or without fever, gender, bowel dysfunction and vesicoureteral reflux in association with specific lower urinary tract conditions. RESULTS: Of the 257 boys and 366 girls with a mean age of 9.1 years 207 (33%) had a urinary tract infection history, including 88 with at least 1 febrile infection. A total of 64 patients underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 44 (69%). In 119 of the 207 patients all infections were afebrile and 18 underwent voiding cystourethrogram/videourodynamics, which revealed reflux in 5 (28%). A urinary tract infection history was noted in 53% of girls but only 5% of boys (p <0.001). Patients with detrusor underutilization disorder were statistically more likely to present with an infection history than patients with idiopathic detrusor overactivity disorder or primary bladder neck dysfunction (each p <0.01). CONCLUSIONS: Females with lower urinary tract dysfunction have a much higher urinary tract infection incidence than males. This association was most often noted for lower urinary tract conditions in which urinary stasis occurs, including detrusor underutilization disorder and dysfunctional voiding. Reflux was found in most girls with a history of febrile infections. Since reflux was identified in more than a quarter of girls with only afebrile infections who were evaluated for reflux, it may be reasonable to perform voiding cystourethrogram or videourodynamics in some of them to identify reflux.