Retrograde ureteral catheterization under local anesthesia for emergency drainage in patients with infection and hydronephrosis secondary to ureteral calculi: Experience from a tertiary care hospital.

Objectives: The aim is to evaluate the safety and efficacy of retrograde ureteral catheterization under local anesthesia in patients with urinary tract infections complicated by hydronephrosis caused by ureteral stone obstruction. Materials and Methods: From October 2020 to September 2021, a retrospective analysis of patients' medical records was performed. Records of past history, physical examination, laboratory tests, and imaging investigations were reviewed. Retrograde ureteric stent (RUS) was performed under local anesthesia using cystoscopes and guided by portable fluoroscopy. Real-time fluoroscopy was used to verify the double-J stent position and confirm a smooth process. The postoperative recovery and length of admission were also recorded. Results: A total of 14 patients with ureteral stone obstruction with infective hydronephrosis received 15 total emergency RUS procedures (one bilateral). Intraoperative findings, operation times, and infection signs were recorded and analyzed. All patients met systemic infection criteria, with a mean body temperature of 38.7°C ± 1.7°C. Leukocytosis was noted in 8 (57.1%) patients. Elevated C-reactive protein (8.5 ± 6.3 mg/L) and procalcitonin (24.1 ± 22.0 ng/mL) were found in 13 (92.9%) and 9 (64.3%) patients, respectively. Mean stone size was 8.5 ± 6.3 mm, mostly localized to the upper ureter (upper: 12; middle: 0; lower: 3). Mean operation time was 14.1 ± 4.3 min. After emergency drainage, all patients improved and were discharged after infection was controlled. The average length of admission was 6.2 ± 2.2 days. Conclusion: RUS under local anesthesia is safe and effective for treating infective hydronephrosis due to ureteral stone obstruction. A randomized controlled trial with a large sample remains necessary to validate these findings.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report.

BACKGROUND: Ectopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions. CASE PRESENTATION: We report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient's condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic. CONCLUSION: We present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis.

BACKGROUND: Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis. METHODS: A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments. RESULTS: A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment. CONCLUSION: Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.

Mechanism of Social Stress-Related Erectile Dysfunction in Mice: Impaired Parasympathetic Neurotransmission and Ketamine.

This study aimed to investigate the mechanism underlying social stress (SS)-induced erectile dysfunction (ED) and evaluate the effects of a single subanesthetic dose of ketamine on SS-related ED. Male FVB mice were exposed to retired male C57BL/6 mice for 60 min daily over a 4-week period. In the third week, these FVB mice received intraperitoneal injections of either saline (SSS group) or ketamine (SSK group). Erectile function was assessed by measuring the intracavernosal pressure (ICP) during electrical stimulation of the major pelvic ganglia. Corpus cavernosum (CC) strips were utilized for wire myography to assess their reactivity. Both SSS and SSK mice exhibited significantly lower ICP in response to electrical stimulation than control mice. SS mice showed increased contractility of the CC induced by phenylephrine. Acetylcholine-induced relaxation was significantly reduced in SSS and SSK mice. Sodium nitroprusside-induced relaxation was higher in SSS mice compared to control and SSK mice. Nicotine-induced neurogenic and nitric oxide-dependent relaxation was significantly impaired in both SSS and SSK mice. An immunohistochemical analysis revealed co-localization of tyrosine hydroxylase and neuronal nitric oxide synthase-immunoreactive fibers in the CC. These findings highlight the complex nature of SS-related ED and suggest the limited efficacy of ketamine as a therapeutic intervention.

Methyl Palmitate Modulated NMDA-Induced Cerebral Hyperemia in Hypertensive Rats.

N-methyl-D-aspartate (NMDA) receptors were found to be dysfunctional in hypertensive rats. Methyl palmitate (MP) has been shown to diminish the nicotine-induced increase in blood flow in the brainstem. The aim of this study was to determine how MP modulated NMDA-induced increased regional cerebral blood flow (rCBF) in normotensive (WKY), spontaneously hypertensive (SHR), and renovascular hypertensive (RHR) rats. The increase in rCBF after the topical application of experimental drugs was measured using laser Doppler flowmetry. Topical NMDA application induced an MK-801-sensitive increase in rCBF in anesthetized WKY rats, which was inhibited by MP pretreatments. This inhibition was prevented by pretreatment with chelerythrine (a PKC inhibitor). The NMDA-induced increase in rCBF was also inhibited by the PKC activator in a concentration-dependent manner. Neither MP nor MK-801 affected the increase in rCBF induced by the topical application of acetylcholine or sodium nitroprusside. Topical application of MP to the parietal cortex of SHRs, on the other hand, increased basal rCBF slightly but significantly. MP enhanced the NMDA-induced increase in rCBF in SHRs and RHRs. These results suggested that MP had a dual effect on the modulation of rCBF. MP appears to play a significant physiological role in CBF regulation.

Large retroperitoneal extraskeletal Ewing's sarcoma with renal pedicle invasion: a case report.

BACKGROUND: Extraskeletal Ewing's sarcoma (EES) is a rare malignant tumor primarily found in children and young adults. Localized disease can present with nonspecific symptoms such as local mass, regional pain, and increased skin temperature. More severe cases may present with systemic symptoms such as malaise, weakness, fever, anemia, and weight loss. Among these lesions, retroperitoneal sarcomas are relatively uncommon and difficult to diagnose. Since they are usually asymptomatic until large enough to compress or invade the surrounding tissues, most are already advanced at first detection. Traditionally, the treatment of choice is complete surgical resection, sometimes combined with postoperative radiotherapy and chemotherapy. We report a case of EES with left renal artery invasion in the left retroperitoneal cavity successfully treated with transarterial embolization and surgery. CASE PRESENTATION: A 57-year-old woman with a negative family history of cancer presented at our Urology Department with a large left retroperitoneal tumor found by magnetic resonance imaging during the health exam. Physical examination showed a soft abdomen and no palpable mass or tenderness. Imaging studies showed that the tumor covered the entire left renal pedicle, but the left kidney, left adrenal gland, and pancreas appeared tumor free. Since the tumor tightly covered the entire renal pedicle, tumor excision with radical nephrectomy was advised. The patient underwent transarterial embolization of the left renal artery with 10 mg of Gelfoam pieces daily before surgical excision. Tumor excision and left radical nephrectomy were uneventful the day after embolization. Post-operatively, the patient recovered well and was discharged on day 10. The final histopathological analysis showed a round blue cell tumor consistent with an Ewing sarcoma, and the surgical margins were tumor free. CONCLUSIONS: Retroperitoneal malignancies are rare but usually severe conditions. Our case report showed that retroperitoneal EES with renal artery invasion could be treated safely with transarterial embolization and surgery.

Predictive factors for stone management timing after emergency percutaneous nephrostomy drainage in patients with infection and hydronephrosis secondary to ureteral calculi.

This study examined the interval between stone management and emergency percutaneous nephrostomy drainage in patients with infection and hydronephrosis secondary to ureteral calculi. A retrospective chart review was conducted for 88 patients treated for 94 stones enrolled in this study from 2005 to 2020. The mean age was 60.7 ± 15.2 years (range: 2-87 years). The average stone size was 1.51 ± 0.8 cm (range: 0.4-4 cm). The most common location was the upper ureter (n = 71, 75.5%), followed by the lower (n = 17, 18.1%) and middle (n = 6, 6.4%) ureter. The mean interval between percutaneous nephrostomy drainage and secondary stone management was 8.17 ± 11.6 days (range: 1-76 days). Most patients underwent operations within 1 week (n = 72, 81.8%). Abnormal white blood cell counts were found in most patients (58, 65.9%). Tachycardia was detected in 40 (45.5%) patients. Only 11 (12.5%) patients had fever upon emergency department arrival. Severe shock was reported in 6 (6.8%) patients. More than half of all patients (45, 51.1%) experienced acute kidney injury, and 37 (42%) patients had elevated C-reactive protein levels. Most patients (69, 73.4%) received ureteroscopic lithotripsy as stone management. Mean arterial pressure (MAP) was the only significant parameter (p = 0.016) affecting the operation interval, with MAP < 60 mmHg associated with longer operation intervals (16.2 days). The timing of stone surgery depends on clinician discretion and patient recovery.

Emphysematous pyelonephritis: classification, management, and prognosis.

Urinary tract infections are commonly encountered and managed worldwide, and emphysematous pyelonephritis (EPN) is among the most serious types of urinary tract infections. EPN is an acute necrotizing infection of the kidney, often associated with high rates of renal loss and mortality. The symptoms of EPN infection can be nonspecific, but the clinical triad of fever, flank pain, and nausea represent the most common presentations. The diagnosis and classification are performed with the assistance of computed tomography (CT). The imaging-based classification system created by Huang and Tseng is widely used in clinical assessments. They defined EPN into four different class (1-4), with the higher number the more severe disease. Optimal EPN treatment is controversial, with emergent nephrectomy suggested during early studies, whereas more recent evidence favors more conservative approaches. Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis are most common pathogens. The initial use of broad-spectrum antibiotics such as Third-or fourth-generation cephalosporins and carbapenems are recommended. Diabetes, obstructive uropathy and hypertension are the most common risk factors and often need treatment together. Emergent drainage is indicated with a larger-sized drainage tube to achieve better drainage function. CT guidance has a better success rate than insertion under the guidance of ultrasonography. Nephrectomy should be reserved as the last resort for those who fail to respond to conservative therapy. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of this life-threatening urological infection.

Ketamine Inhalation Alters Behavior and Lower Urinary Tract Function in Mice.

We aimed to evaluate behavioral and lower urinary tract changes in mice using a novel ketamine inhalation model mimicking human ketamine abusers and compare the results to those obtained using a ketamine intraperitoneal injection model. C57BL/6N mice were placed in a transparent acrylic observation cage connected to an ultrasonic nebulizer producing ketamine (KI) or saline (SI) fog. The mice were given KI or SI fog twice a week for three months. In another experiment arm, the mice were given intraperitoneal ketamine injections (KP) or saline injections (SP) twice a week for three months. The presence of urine ketamine (>100 ng/mL) was determined using a quick test kit. Locomotor activity was recorded by video using the open field test. Lower urinary tract function was assessed using urine spots, cystometry and histology. KI and KP mice crossed the center more frequently and traveled farther than SI and SP mice. Only KI mice, however, demonstrated popcorn-like jumping, and frequent center crossing. Detrusor overactivity, reduced cystometric bladder capacity, and denuded mucosa were observed in both KI and KP mice. Ketamine inhalation induces behavioral and lower urinary tract changes in mice that are comparable to intraperitoneal ketamine injections.

Botulinum Toxin Injection for Medically Refractory Neurogenic Bladder in Children: A Systematic Review.

The objective was to evaluate the use of botulinum toxin A (BTX-A) injection in children with medically refractory neurogenic bladder. A systematic review of the literature was conducted using three databases (Medline via PubMed, Cochrane, and EMBASE). Articles evaluating BTX-A in children with neurogenic bladder were collected. The clinical and urodynamic parameters were reviewed for the safety and efficacy evaluation. Sixteen studies were selected into this study and a total of 455 children with medical refractory neurogenic bladder were evaluated. All of the patients had received traditional conservative medications such as antimuscarinics and intermittent catheterization as previous treatment. The duration of treatments ranged from 2 months to 5.7 years. Improvements in incontinence and vesicoureteral reflux were the most common clinical outcomes. The detrusor pressure, bladder capacity and bladder compliance improvement were the most common urodynamic parameters which had been reported. However, patient satisfaction with the procedure remained controversial. There was only a minimal risk of minor adverse effects. In all of the studies, BTX-A injection was well tolerated. In conclusion, BTX-A injection appears to be a safe and effective treatment in the management of medically unresponsive neurogenic bladder in children. There is currently no evidence that the use of BTX-A injection could be used as a first-line therapy for neurogenic bladder in children.

The aging effects on phenylephrine-induced relaxation of bladder in mice.

OBJECTIVE: We have demonstrated that phenylephrine (PE) activates the capsaicin-sensitive nerves, and then activates capsaicin-sensitive nerves to release an unknown substance that facilitates the release of norepinephrine (NE) from adrenergic nerves. Subsequently, NE stimulates ß-ARs in the detrusor muscle in mice, leading to neurogenic relaxation of the urinary bladder (UB). MATERIALS AND METHODS: We examined if there existed sensory-motor dysfunction in UB of aging mice. To investigate the change of PE-induced detrusor relaxation in aging male-C57BL/6 mice (12- vs. 24-month-old mice), UB strips from mice were isolated, cut into strips, and mounted in the organ bath. RESULTS: The UB strip contractility responding to various agents was estimated using tissue bath wire myography. Acetylcholine (ACh) and KCl-induced UB strips contraction was not significantly different between 24- and 12-month mice. NE-induced UB strips relaxation was significantly lower in 24-month than 12-month mice. Denuded bladder strips showed similar decreased relaxation response to NE. This NE-induced relaxation was inhibited by silodosin and lidocaine. PE did not induce contraction in UB strips of aging mice. In contrast, PE-induced relaxation was weaker in 24-month than 12-month mice. CONCLUSION: Our results suggested that the PE-induced relaxation was age related. Aging seemed to lead the sensory-motor dysfunction. More animal and human studies are required to prove this concept and its clinical usefulness in the future.

Role of Camellia brevistyla (Hayata) Coh. Stuart Seed Pomace Extract on Hypertension and Vascular Function in L-NAME-Treated Mice.

Camellia brevistyla (Hayata) Coh. Stuart seeds are used to produce edible oil. The seed pomace is an agricultural waste, containing approximately 8% saponin, which has antihypertensive effects. Nω -nitro-L-arginine methyl ester (L-NAME) can induce hypertension with no deficiency on mice. Here, we investigated the effects of ethanol extract from C. brevistyla seed pomace (CBPE) in L-NAME-induced hypertension mice. The results showed that all doses of CBPE significantly decreased systolic (117 ± 5-122 ± 5 mmHg) and diastolic (72 ± 16-77 ± 8 mmHg) blood pressure, aortic intima media thickness (48 ± 5-53 ± 5 µm), and also reduced the MDA adduct and protein carbonyl levels in the liver (101 ± 19-114 ± 17 ρmol/mL and 4.8 - 5.2 nmol/mg) compared to those observed in the L-NAME group (140 ± 3 and 95 ± 8 mmHg, 65 ± 10 µm, 145 ± 25 ρmol/mL, and 7.8 nmol/mg; P < 0.05). These results suggest that CBPE has profitable antihypertensive properties which are preventing aorta remodeling and reducing liver oxidative stress in hypertensive mice.

Capsaicin-Sensitive Sensory Nerves Indirectly Modulate Motor Function of the Urinary Bladder.

PURPOSE: The urinary bladder (UB) is innervated by both sensory and autonomic nerves. Recent studies have shown that sensory neuropeptides induced contractions in the detrusor muscle. Therefore, in a mouse model, we investigated the presence of interactions between the submucosal sensory nerves and the autonomic nerves that regulate the motor function of the detrusor muscle. METHODS: UB samples from male C57BL/6 mice were isolated, cut into strips, and mounted in an organ bath. Dose-response curves to norepinephrine and phenylephrine were studied in UB strips with and without mucosa, and the effects of preincubation with a receptor antagonist and various drugs on relaxation were also studied using tissue bath myography. RESULTS: Phenylephrine-induced relaxation of the UB strips showed concentration-related effects. This relaxation appeared in both mucosa-intact and mucosa-denuded UB strips, and was significantly inhibited by lidocaine, silodosin, and guanethidine (an adrenergic neuronal blocker). Meanwhile, phenylephrine-induced relaxation was inhibited by pretreatment with propranolol and calcitonin gene-related peptide (CGRP)-depletory capsaicin in UB strips with and without mucosa. CONCLUSIONS: The present study suggests that phenylephrine activates the α-1A adrenergic receptor (AR) of the sensory nerve, and then activates capsaicin-sensitive sensory nerves to release an unknown substance that facilitates the release of norepinephrine from adrenergic nerves. Subsequently, norepinephrine stimulates ß-ARs in the detrusor muscle in mice, leading to neurogenic relaxation of the UB. Further animal and human studies are required to prove this concept and to validate its clinical usefulness.

The efficacy of acupuncture in managing patients with chronic prostatitis/chronic pelvic pain syndrome: A systemic review and meta-analysis.

OBJECTIVES: This study aimed to systemically review published randomized control trials that compared the efficacy of acupuncture with sham acupuncture or standard medical treatment as management for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS: A systemic search of the PubMED®, Embase, Airiti Library, and China Journal Net was done for all randomized controlled trials that compared the efficacy of acupuncture with sham acupuncture, alpha-blockers, antibiotics, or anti-inflammatory drugs in patients with CP/CPPS. Two investigators conducted the literature search, quality assessment, and data extraction. The data were then analyzed using the Cochrane Collaboration Review Manager (RevMan®, version 5.3). The study endpoints were response rate, the National Institute of Health-Chronic Prostatitis Index (NIH-CPSI), and the International Prostate symptom score (IPSS) reduction. RESULTS: Three and four randomized controlled trials compared acupuncture with sham acupuncture (n = 101 vs. 103) and medical treatment (n = 156 vs. 138), respectively. The results revealed that acupuncture was superior to sham acupuncture as regards response rate (OR: 5.15, 95%CI: 2.72-9.75; P < 0.01), NIH-CPSI (WMD: -6.09, 95%CI: -7.85 to -4.33), and IPSS (WMD: -2.44, 95%CI: -4.86 to -0.03; P = 0.05) reductions, therefore, excluding the placebo effect. Compared to standard medical treatments, acupuncture had a significantly higher response rate (OR: 3.57, 95%CI: 1.78-7.15; P < 0.01). CONCLUSIONS: Acupuncture has promising efficacy for patients with CP/CPPS. Compared to standard medical treatment, it has better efficacy. Thus, it may also serve as a standard treatment option when available. Neurourol. Urodynam. 36:474-481, 2017. © 2016 Wiley Periodicals, Inc.

Are Middle-Aged Men with Chronic Kidney Disease at Higher Risk of Having Nocturia than Age-Matched Controls.

OBJECTIVE: We compared the lower urinary tract symptoms between middle-aged men with and without chronic kidney disease (CKD) under 50 years of age. METHODS: Between October 2010 and July 2013, patients with CKD aged below 50 who received regular follow-ups at the nephrology outpatient clinics were enrolled. We also enrolled men aged below 50 years with estimated glomerular filtration rates (eGFR) higher than 60 mL/min per 1.73 m(2) and without history of kidney diseases from the health examination department as the control group. Clinical parameters and laboratory parameters were collected for analysis and comparison. The lower urinary tract symptoms were evaluated using the International Prostate Symptom Score (IPSS). Metabolic syndromes were defined according to the ATP III guidelines. RESULTS: Overall, 50 men with CKD and 187 age-matched men without CKD were enrolled in the study (age: 44.9 ± 6.9 vs. 43.7.0 ± 4.3, P = 0.11). When compared with the age-matched control group, the occurrences of lower urinary tract symptoms were fewer in CKD patients, though not statistically significant. CKD Patients had significantly higher scores of nocturia (1.3 vs. 0.8, P = 0.02) but had significantly less urinary frequency and relatively fewer urgency score. Nocturia was significantly associated with eGFR. Multivariate analysis showed that lower eGFR and overweight were the only two independent risk factors for nocturia (P < 0.01), but was not the case for metabolic syndromes. CONCLUSION: Middle-aged men with CKD had significantly more nocturia episodes than the age-matched control group, but had lower urinary frequency scores. Lower eGFR and overweight are independent risk factors for nocturia in middle-aged men.

Comparing the efficacy and safety between robotic-assisted versus open pyeloplasty in children: a systemic review and meta-analysis.

OBJECTIVE: This manuscript is mainly to systemically review the published reports that compared the efficacy and safety of robotic-assisted (RP) versus open pyeloplasty (OP) in children with ureteropelvic junction obstruction (UPJO). METHODS: We did a systemic search in the PubMed(®) for all randomized controlled trials or comparative studies that compared the surgical results of robotic versus open pyeloplasty in children with UPJO. Two of the authors (Hsu and Chang) independently did the literature search, quality assessment, and data extraction. The obtained data were analyzed with Cochrane Collaboration Review Manager (RevMan(®), version 5.3). The end points of the analysis and review included age, operative time, hospital stay, costs, complications, and success rate. RESULTS: In total, seven comparative trials and three studies using national database met the criteria that comprised 20,691 (RP:OP = 1956:18,735) patients in the meta-analysis. Most studies reported median value of patient age, operative time, and hospital stay. Only a small proportion of studies could be included for meta-analysis. The enrolled trials revealed that RP was more frequently performed in older children, required longer operative time, and shorter hospital stay. The postoperative success rate was comparable (RR = 0.99, 95 CI 0.94-1.04). Comparing with OP, there was a significant higher complication rate (RR = 1.29, 95 CI 1.10-1.51) and higher costs in the RP group. CONCLUSION: Robotic-assisted pyeloplasty may be a promising alternative minimal invasive surgery for UPJO in children if the higher complication rates and higher costs in the RP can be overcome in the near future.

Elevated postvoid residual urine volume predicting recurrence of urinary tract infections in toilet-trained children.

BACKGROUND: The aim of this study was to examine whether toilet-trained children with a history of febrile urinary tract infection (fUTI) and elevated postvoid residual (PVR) urine volume according to a recently published PVR nomogram were at greater risk of UTI recurrence. MATERIALS AND METHODS: One month after recovery from febrile UTI, constipation was diagnosed according to the Rome III criteria, and lower urinary tract (LUT) function was evaluated with two sets of uroflowmetry and PVR by ultrasonography. For children aged ≦ 6 and ≧ 7 years, elevated PVR is defined as >20 and >10 ml, respectively. Cox proportion hazards regression was used to evaluate the risk factors for recurrence of UTI. RESULTS: Between 2005 and 2011, 60 children aged 6.5 ± 2.5 years (boy:girl ratio 27:33) were enrolled for analysis. Univariate analysis showed that recurrent febrile UTI was more commonly observed in children with elevated PVR [repetitive elevated PVR: hazard ratio (HR) 5.75, 95% confidence interval (CI) 1.41-23.4; one elevated PVR: HR 4.53, 95% CI 1.01-20.2] and high-grade vesicoureteral reflux (VUR; HR 4.53, 95% CI 1.46-14.07). Multivariate analysis showed that younger age (HR 1.37, 95% CI 1.03-1.82, p < 0.01) and elevated PVR (HR 2.88, 95% CI 1.44-5.73, p = 0.01) were significant, independent risk factors for recurrent febrile UTI--but not gender, presence of high-grade VUR and constipation. CONCLUSION: Elevated PVR defined by the new PVR nomogram predicted recurrent UTI in children with history of febrile UTI. Care should be taken to manage children with elevated PVR.