Role of dexamethasone in controlling the proinflammatory cytokine cascade in the first episode of paediatric acute pyelonephritis.

AIM: Febrile urinary tract infection is a common bacterial infection in childhood. The kidney damage after acute pyelonephritis (APN) could be related to the stimulation of the proinflammatory response. We aimed to investigate the role of inflammatory cytokines and the effect of dexamethasone after a first episode of APN. METHODS: Subanalysis of the DEXCAR RCT in which children with confirmed APN (1 month-14 years) were randomly assigned to receive a 3 days course of either intravenous dexamethasone or placebo. Urinary cytokine levels at diagnosis and after 72 h of treatment were measured. RESULTS: Ninety-two patients were recruited. Younger patients, males and those with abnormalities in the ultrasound study or vesicoureteral reflux showed higher values of urinary cytokines. Patients with severe APN had higher Tumour Necrosis Factor (TNF)α levels (81.0 ± 75.8 vs. 33.6 ± 48.5 pg/mg creatinine, p = 0.015). Both intervention groups showed similar basal clinical characteristics, including urinary cytokine levels. Treatment reduced urinary cytokine levels irrespective of dexamethasone administration. Neither the intervention group nor the urinary cytokine levels modulated the development of kidney scars. CONCLUSION: Basal urinary cytokines were associated with age, abnormal ultrasound and vesicoureteral reflux. Patients with severe APN had higher TNFa urinary levels. Administration of dexamethasone in children with APN does not improve the control of the proinflammatory cytokine cascade.

Antibiotic Prophylaxis in Infants with Grade III, IV, or V Vesicoureteral Reflux.

BACKGROUND: The efficacy of continuous antibiotic prophylaxis in preventing urinary tract infection (UTI) in infants with grade III, IV, or V vesicoureteral reflux is controversial. METHODS: In this investigator-initiated, randomized, open-label trial performed in 39 European centers, we randomly assigned infants 1 to 5 months of age with grade III, IV, or V vesicoureteral reflux and no previous UTIs to receive continuous antibiotic prophylaxis (prophylaxis group) or no treatment (untreated group) for 24 months. The primary outcome was the occurrence of the first UTI during the trial period. Secondary outcomes included new kidney scarring and the estimated glomerular filtration rate (GFR) at 24 months. RESULTS: A total of 292 participants underwent randomization (146 per group). Approximately 75% of the participants were male; the median age was 3 months, and 235 participants (80.5%) had grade IV or V vesicoureteral reflux. In the intention-to-treat analysis, a first UTI occurred in 31 participants (21.2%) in the prophylaxis group and in 52 participants (35.6%) in the untreated group (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P = 0.008); the number needed to treat for 2 years to prevent one UTI was 7 children (95% CI, 4 to 29). Among untreated participants, 64.4% had no UTI during the trial. The incidence of new kidney scars and the estimated GFR at 24 months did not differ substantially between the two groups. Pseudomonas species, other non-Escherichia coli organisms, and antibiotic resistance were more common in UTI isolates obtained from participants in the prophylaxis group than in isolates obtained from those in the untreated group. Serious adverse events were similar in the two groups. CONCLUSIONS: In infants with grade III, IV, or V vesicoureteral reflux and no previous UTIs, continuous antibiotic prophylaxis provided a small but significant benefit in preventing a first UTI despite an increased occurrence of non-E. coli organisms and antibiotic resistance. (Funded by the Italian Ministry of Health and others; PREDICT ClinicalTrials.gov number, NCT02021006; EudraCT number, 2013-000309-21.).

Efficacy and safety of Hyadex for treatment of vesicoureteral reflux: a multicenter experience.

OBJECTIVE: This study was performed to evaluate the efficacy and safety of dextranomer/cross-linked hyaluronic acid (Hyadex) in patients with a clinical diagnosis of vesicoureteral reflux (VUR). METHODS: In this cross-sectional multicenter observational study, Hyadex was used in four different centers for the endoscopic treatment of VUR from 2020 to 2022. The study involved 74 patients (93 renal units) who were diagnosed with VUR according to voiding cystourethrography (VCUG) findings and were considered suitable for subureteric endoscopic treatment. The follow-up time (control VCUG time) was 3 months. RESULTS: In the VCUG evaluation, grade I VUR was found in 13 renal units, grade II in 23 renal units, grade III in 42 renal units, and grade IV in 12 renal units. The success rates of Hyadex treatment according to the degree of VUR were as follows: 84.6% for grade I, 82.6% for grade II, 71.4% for grade III, and 66.0% for grade IV. No major complications were observed. CONCLUSION: Endoscopic subureteric Hyadex injection had high success rates in appropriately selected patients with VUR and may be used as the first-line treatment for children with VUR.

Intravesical Botulinum toxin-A injection in pediatric overactive neurogenic bladder with Detrusor overactivity: Radiologic and clinical outcomes.

OBJECTIVE: The neurogenic bladder is one of the most serious and painful disorders seen in pediatric urology clinics. The upper urinary tract can be impaired by increased bladder pressure. Botulinum toxin-A (BTX-A) is one of the new therapeutic interventions for this disease. Thus, this research was designed to determine the clinical as well as radiological outcomes intravesical BTX-A injections in patients with overactive neurogenic bladder with Detrusor over activity. PATIENTS AND METHODS: From March 2012 to March 2019, this cohort study was conducted at Shahid Labbafinejad hospital in Tehran, Iran. Thirty-five pediatric patients with a neurogenic bladder and Detrusor overactivity who fulfilled the eligibility criteria received BTX-A injections. Demographic data, including spinal cord lesions or congenital malformations, upper and lower urinary tract nuclear scans, evidence of vesicoureteral reflux (VUR) and its severity, and hydronephrosis and 72 h voiding diary before and after intervention were all recorded. RESULTS: The mean ± standard deviation age of participants was 9.47 ± 4.61 years. After injection, nocturia and urination frequency as general symptoms of the overactive neurogenic bladder improved (p < 0.05). Also, the severity of hydronephrosis was decreased in 33% of patients following injection. In our study, 32 out of 35 patients had vesicoureteral reflux. Of those, there was complete resolution and downgrading of VUR in 17 (53.12%) and 13 (40.62%) respectively. CONCLUSION: In the evaluation of voiding cystourethrography (VCUG) before and after the injection, downgrading of VUR was seen in 53% of the cases. In the 99mTc-DMSA nuclear scan before and after the injection, the appearance of a new parenchymal scar and uptake reduction was not observed, which indicates the cessation of scar formation in all patients. Although Enuresis, Urgency, Frequency, Nocturia, and UUI significantly improved after injection.

[Effect of topical glucocorticoid in treating phimosis on urinary tract infection of vesicoureteral reflux in infants].

Objective: To evaluate the effect of topical glucocorticoid in treating phimosis on urinarytract infection(UTI) of vesicoureteral reflux(VUR) in infants. Methods: Clinical data of infants with UTI diagnosed as primary VUR admitted to our hospital from January 2016 to January 2021 were retrospectively analyzed. The children were divided into three groups:the effective group (topical glucocorticoid was effective in the treatment of phimosis), the ineffective group(topical glucocorticoid was ineffective in the treatment of phimosis), and the untreated group(phimosis was not treated). Age of onset, degree of reflux, side and other indicators were compared to understand the effectiveness of topical glucocorticoid in treating phimosis, and the clinical characteristics of repeated UTI with VUR in treated phimosis and untreated phimosis. Results: A total of 544 children were included. Among them, 59 cases were treated with topical glucocorticoid for phimosis, 48 cases in the effective group, and their age was (12.5±8.4) months;11 cases in the ineffective group,and their age was (11.2±8.9) months. There were 485 cases in the untreated group, and their age was (13.1±9.3) months.The effective rate of topical glucocorticoid in the treatment of phimosis was 81.36%. There were 12 cases(12/48) of recurrent UTI in the effective group and 213 cases (213/485)of recurrent UTI in the untreated group, and the difference between the two groups was statistically significant (P=0.008). Conclusion: Treatment of phimosis with topical glucocorticoid is an effective, easy to perform, and cost-effective method, and can effectively reduce the risk of recurrent UTI in infants with primary VUR.

[Pediatric renal abscesses: a diagnostic challenge]. / Absceso renal en Pediatría: un desafío diagnóstico.

Kidney abscess is an unusual entity in childhood with few studies about its clinical characteris tics. OBJECTIVE: To report the clinical presentation, diagnosis, and therapy used in a cohort of 20 children with kidney abscess. PATIENTS AND METHOD: retrospective study of cases of kidney abscess during a 10-year period at the Hospital Roberto del Río. The analysis of clinical, laboratory, and imaging characteristics were evaluated as well as the treatment usedfor this condition. RESULTS: 20 cases were reported among which 65% were women with a median age of 3.6 years. The most com mon clinical presentation was fever, vomit, and dysuria. Eighty percent of patients presented an increase of inflammatory parameters, 88% presented positive urine culture, and the most common organism identified was Escherichia Coli (77.8%). The diagnosis was mostly made through kidney ultrasound (75%) followed by an abdominal CT scan (35%). 93% of abscesses were unilateral. About 95% of the patients only required antibiotic treatment. Vesicoureteral reflux was diagno sed in 28% of the patients with no sphincter control, and only one of them presented high-grade reflux. In patients with sphincter control, bladder and bowel dysfunction (BBD) was diagnosed in 90% of the cases. Forty four percent of the patients with late DMSA renal scintigraphy presented renal scarring. CONCLUSIONS: In this series, pediatric kidney abscess appears with persistent fever despite the treatment, requiring prolonged antibiotic therapy and rarely surgical drains. We su ggest a study aimed at detecting modifiable factors, such as vesicoureteral reflux in patients with no sphincter control and BBD in patients with sphincter control, as well as identifying renal paren chymal sequels in all patients.

Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática / Influence in the outcome of neuropathic pediatric patients after early treatment

IntroducciónEl cateterismo limpio intermitente (CI) y el tratamiento anticolinérgico son la base del tratamiento conservador de la vejiga neuropática (VN); sin embargo, todavía no hay acuerdo sobre la edad a la que debería iniciarse dicha terapia.ObjetivoEl objetivo de nuestro estudio fue analizar la influencia del inicio precoz (primer año de vida) del tratamiento anticolinérgico y el CI en la evolución a largo plazo de la función renal y vesical. Nuestra hipótesis es que los niños que iniciaron el tratamiento conservador en el primer año de vida tienen mejor pronóstico en términos de función renal y vesical, así como menos necesidad de tratamiento quirúrgico que aquellos que iniciaron el tratamiento a edades más avanzadas.Pacientes y métodosEstudio retrospectivo de los pacientes con VN tratados en nuestro servicio (1995- 2005) dividiéndolos para su comparación en dos grupos: grupo 1 incluye a aquellos que iniciaron el tratamiento conservador en el primera año de vida, y grupo 2, a aquellos que lo iniciaron entre el primer y el quinto año. Se revisaron las historias clínicas recogiendo datos sobre: edad de inicio del CI y tratamiento anticolinérgico, presencia de reflujo vésico-ureteral (RVU) o ureterohidronefrosis (UHN), función renal, presencia de cicatrices renales, infección del tracto urinario (UTI), presencia de cicatrices renales, comportamiento vesical, necesidad de intervención quirúrgica y continencia urinaria.ResultadosSe incluyeron 61 pacientes: 25 en el grupo 1 y 36 en el grupo 2. Al inicio del estudio, la presencia de RVU e hiperactividad vesical eran más frecuentes en el grupo 2. En el grupo 1, un paciente con vejiga hiperactiva cambió a vejiga de baja acomodación, y en el grupo 2 un paciente con vejiga de acomodación normal y 4 con vejigas hiperactivas cambiaron a vejigas de baja

Background Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA

Dexamethasone to prevent kidney scarring in acute pyelonephritis: a randomized clinical trial.

BACKGROUND: Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children. METHODS: Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed. RESULTS: Ninety-one participants completed the follow-up and were finally included (dexamethasone n = 49 and placebo n = 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups, p = 0.907). Renal damage severity in the early DMSA (ß = 0.648, p = 0.023) and procalcitonin values (ß = 0.065 p = 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (ß = 0.545, p = 0.054), but dexamethasone treatment showed no effect. CONCLUSION: Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014. "A higher resolution version of the Graphical abstract is available as Supplementary information."

Selecting Children with Vesicoureteral Reflux Who are Most Likely to Benefit from Antibiotic Prophylaxis: Application of Machine Learning to RIVUR.

PURPOSE: Continuous antibiotic prophylaxis reduces the risk of recurrent urinary tract infection by 50% in children with vesicoureteral reflux. However, there may be subgroups in whom continuous antibiotic prophylaxis could be used more selectively. We sought to develop a machine learning model to identify such subgroups. MATERIALS AND METHODS: We used RIVUR data, randomly split into train/test in a 4:1 ratio. Two models were developed to predict recurrent urinary tract infection risk in scenario with and without continuous antibiotic prophylaxis. The test set was then used to validate recurrent urinary tract infection events and the effectiveness of continuous antibiotic prophylaxis. Predicted probabilities of recurrent urinary tract infection were generated from each model. Continuous antibiotic prophylaxis was assigned at various cutoffs of recurrent urinary tract infection risk reduction to evaluate continuous antibiotic prophylaxis effectiveness. RESULTS: A total of 607 patients (558 female/49 male, median age 12 months) were included. Predictors included vesicoureteral reflux grade, serum creatinine, race/gender, prior urinary tract infection symptoms (fever/dysuria) and weight percentiles. The AUC of the prediction model of recurrent urinary tract infection (continuous antibiotic prophylaxis/placebo) was 0.82 (95% CI 0.74-0.87). Using 10% recurrent urinary tract infection risk reduction cutoff, minimal recurrent urinary tract infection per population level can be achieved by giving continuous antibiotic prophylaxis to 40% of patients with vesicoureteral reflux instead of everyone. In a test set (121), 51 patients had continuous antibiotic prophylaxis randomization consistent with model recommendation (continuous antibiotic prophylaxis if recurrent urinary tract infection risk reduction >10%). Recurrent urinary tract infection incidence was significantly lower among this group compared to those whose continuous antibiotic prophylaxis assignment differed from model suggestion (7.5% vs 19.4%, p=0.037). CONCLUSIONS: Our predictive model identifies patients with vesicoureteral reflux who are more likely to benefit from continuous antibiotic prophylaxis, which would allow more selective, personalized use of continuous antibiotic prophylaxis with maximal benefit, while minimizing use in those with least need.

Impact of Long-Term Low Dose Antibiotic Prophylaxis on Gut Microbiota in Children.

PURPOSE: We evaluated the effect of long-term low dose antibiotic prophylaxis on children's gut microbiota. MATERIALS AND METHODS: We conducted 16S ribosomal RNA gene sequencing using stool samples from 35 patients younger than 3 years old (median age 5.2 months; male-to-female ratio 17:18) who underwent antibiotic treatment during the acute phase of febrile urinary tract infection. Samples were collected at 5 time points, ie before, during and at 1 to 2, 3 to 4, and 5 to 6 months after febrile urinary tract infection onset and antibiotic treatment. Continuous antibiotic prophylaxis using trimethoprim-sulfamethoxazole was initiated in 23 patients with grade III or higher vesicoureteral reflux and was not administered in 12 patients without reflux. RESULTS: Within 2 weeks after initiation of treatment for febrile urinary tract infection almost all enteric bacteria belonged to the order Lactobacillales, and gut microbiota diversity decreased compared to the pretreatment level (average Shannon index 2.9 before treatment, 1.4 during treatment). The diversity recovered within 1 to 2 months after febrile urinary tract infection onset in both groups. Diversity was maintained during the study period in both groups (p=0.43). A smaller proportion of gut microbiota component belonged to the order Enterobacteriales (p=0.002) in the antibiotic prophylaxis group. CONCLUSIONS: Our results revealed that patients receiving continuous antibiotic prophylaxis had normal gut microbiota diversity, indicating that the effect of trimethoprim-sulfamethoxazole on gut microbiota was insignificant. Furthermore, prophylaxis with trimethoprim-sulfamethoxazole might selectively suppress the growth of bacteria belonging to the order Enterobacteriales, such as Escherichia coli and Klebsiella species, which are the main causative bacteria of febrile urinary tract infections.

Aplicación endourológica de polidimetilsiloxano en pacientes con reflujo vesicoureteral sintomático en injerto renal / Endourological application of polydimetilsiloxane in patients with symptomatic vesicoureteral reflux in the kidney graft

Objetivo: Identificar los resultados de la aplicación de polidimetilsiloxano en el manejo endourológico de reflujo vesicoureteral (RVU) sintomático al injerto renal y determinar factores asociados a la persistencia de los síntomas y del reflujo vesicoureteral. Material y métodos: Se incluyó a 23 pacientes con el diagnóstico de RVU sintomático en injerto renal evaluados de enero del 2010 a agosto del año 2018 en la Unidad Médica de Alta Especialidad # 14 de Veracruz, quienes recibieron aplicación endourológica de polidimetilsiloxano. Se realizó el análisis descriptivo, cuando fue posible se determinaron medidas de riesgo relativo para fracaso clínico (FC) con odds ratio (OR). Resultados: Del total de pacientes, 18 (78,3%) presentaron éxito clínico (EC). Se observó una diferencia significativa en la edad promedio (EC 30,61 ± 9,7, FC 46,0 ± 11,46; U de Mann-Whitney, p = 0,037) y en el número de episodios de pielonefritis aguda al injerto previos a la aplicación de PDMS (EC 2,27 ± 1,27, FC 3,6 ± 0,89; U de Mann-Whitney, p = 0,019). El patógeno más frecuente identificado fue la Escherichia coli, con un 45,4%. La resolución del RVU se observó en el 47,8% de los casos. Hubo una disminución del grado de RVU en el 73,9% de los casos. Se determinó como factor protector para FC la disminución del grado de RVU (OR: 0,031, IC del 95%: 0,002-0,437, con p = 0,008). Conclusiones: La aplicación endourológica de PDMS mostro ser útil en el manejo de los pacientes con RVU sintomático en injerto renal, disminuyendo el grado de RVU y permitiendo el EC en la mayoría de los casos

Objective: To identify the results of polydimethylsiloxane application in the endourological management of symptomatic vesicoureteral reflux to the kidney graft and to determine the factors associated with persistent symptoms and with vesicoureteral reflux. Material and methods: We included 23 patients diagnosed with symptomatic VUR in kidney graft, evaluated from January 2010 to August 2018 in the High Specialty Medical Unit # 14 in Veracruz. These patients received endourological application of polydimethylsiloxane. The descriptive analysis was carried out, and, if possible, the relative risk measures for clinical failure (CF) were determined with odds ratio (OR). Results: 18 (78.3%) patients presented clinical success (CS). There was a significant difference in the mean age (CS 30.61 ± 9.7, CF 46.0 ± 11.46; U Mann Whitney, P = .037), and in the number of episodes of AGPN prior to the application of PDMS (CS 2.27 ± 1.27, CF 3.6 ± 0.89, U Mann Whitney, P = .019). The most frequently identified pathogen was E. Coli, with 45.4%. VUR resolution was observed in 47.8% of the cases. There was a decreased degree of VUR in 73.9% of cases. A lower degree of VUR was determined as a protective factor for CF (OR: 0.031, 95% CI: 0.002-0.437, with P = .008). Conclusions: The endourological application of PDMS proved to be useful in the management of patients with symptomatic VUR in kidney graft, as it decreased the VUR degree and allowed CS in most cases

Susceptibility of the Index Urinary Tract Infection to Prophylactic Antibiotics Is a Predictive Factor of Breakthrough Urinary Tract Infection in Children with Primary Vesicoureteral Reflux Receiving Continuous Antibiotic Prophylaxis.

BACKGROUND: Few studies have reported on breakthrough urinary tract infection (UTI) associated with the susceptibility of index UTI to prophylactic antibiotics in children with primary vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP). We assessed the impact of the susceptibility of index UTI to prophylactic antibiotics in breakthrough UTIs in children with primary VUR receiving CAP. METHODS: We retrospectively reviewed the medical records of 81 children with primary VUR who were diagnosed after febrile or symptomatic UTI and subsequently received trimethoprim-sulfamethoxazole (TMP-SMX) as CAP between January 2010 and December 2013. We allocated children to a susceptible group or a resistant group based on the susceptibility of index UTI to TMP-SMX. We evaluated patient demographics and clinical outcomes after CAP according to the susceptibility of index UTI to TMP-SMX. Multivariate analysis was used to identify the predictive factors for breakthrough UTI. RESULTS: Of the 81 children, 42 were classified into the susceptible group and 39 into the resistant group. The proportion of breakthrough UTI was 31.0% (13/42) in the susceptible group and 53.8% (21/39) in the resistant group (P = 0.037). Progression of renal scarring was observed in 0% of children in the susceptible group and 15% in the resistant group (P = 0.053). Multivariate analysis showed that TMP-SMX resistance and initial renal scarring were significant predictors of breakthrough UTI. CONCLUSION: Susceptibility of index UTI to prophylactic antibiotics is a risk factor of breakthrough UTI and is associated with poor clinical outcomes in children with primary VUR receiving CAP.

Bilateral duplex collecting system with bilateral vesicoureteral reflux: a case report.

BACKGROUND: A bilateral duplex collecting system is an unusual renal tract abnormality. Vesicoureteral reflux may be associated. We describe a rare case of bilateral duplex collecting system with bilateral vesicoureteral reflux in which the refluxing ureter on the left side drains the upper pole moiety contrary to what is often found. CASE PRESENTATION: A 24-year-old married Arab woman presented with ascending left-sided flank pain during micturition. She complained of recurrent urinary tract infections. A physical examination and laboratory tests were normal. Voiding cystourethrography and computed tomography scan detected bilateral duplex collecting system, grade IV vesicoureteral reflux on the left side, and grade I vesicoureteral reflux on the right. She underwent left heminephrectomy and dextranomer/hyaluronic acid injections on the right side. After a year of follow-up, a clinical examination and imaging findings were unremarkable. CONCLUSIONS: A bilateral duplex collecting system with refluxing upper pole moiety ureter is a very rare entity. The diagnosis should be suspected when exploring any flank pain with recurrent urinary tract infections to avoid subsequent renal impairment. Furthermore, this case shows how some common symptoms may lead to finding an unexpected urinary tract abnormality.

Retrospective Analysis to Determine the Optimal Timing to Discontinue Continuous Antibiotic Prophylaxis in Patients with Primary Vesicoureteral Reflux.

BACKGROUND: The management of febrile urinary tract infection (fUTI) in patients with vesicoureteral reflux (VUR) is crucial to prevent renal scarring. Continuous antibiotic prophylaxis (CAP) is the most widely used initial treatment for VUR. However, the optimal duration of CAP is still unclear. We aimed to clarify an appropriate patient population and the optimal timing to discontinue CAP. METHODS: We reviewed the records of 247 patients with primary VUR between January 2000 and December 2015. Seventy-two patients who discontinued CAP despite persistent VUR were enrolled. Kaplan-Meier method and Cox proportional hazard model was used in statistical analysis. RESULTS: Following the discontinuation of CAP, fUTI developed in 25 patients after a median of 9 months (range 0-81). VUR resolved spontaneously in 9 out of 47 patients without recurrence during follow-up. Multivariate analysis showed bilateral VUR and duration of CAP of less than 1 year after the last fUTI were significant risk factors for recurrence. CONCLUSION: Among the risk factors examined, patients administered CAP for less than 1 year after the last fUTI and those with bilateral VUR had significantly more frequent recurrence. Our study suggests that the administration of CAP for more than 1 year after the last fUTI is beneficial in avoiding recurrent fUTI.

Macroplastique and Botox are superior to Macroplastique alone in the management of neurogenic vesicoureteric reflux in spinal cord injury population with presumed healthy bladders.

CONTEXT/OBJECTIVE: Vesico-ureteric reflux(VUR) is a known complication of neuropathic bladder in spinal cord injury(SCI) population. Bulking agents such as Macroplastique are new minimally-invasive treatment option for VUR with good results. The aim of this study is to assess the efficacy of Macroplastique alone or in combination with Botox(BTX-A), in managing VUR in SCI population with presumed healthy bladders and correlate the pre-and post-injection urodynamic findings with the outcome. DESIGN: Retrospective comparative study. PARTICIPANTS: SCI patients with VUR and presumed health bladders (normo-compliant, low filling pressures), treated with macroplastique alone or in combination with BTX-A, who had pre and post-intervention Video-urodynamics (VUDS) and followed up for at least 12 months. INTERVENTIONS: Macroplastique and BTX-A injections, VUDS. OUTCOME MEASURES: The primary end point was the overall treatment rate of VUR at 3 months and the secondary outcomes were the success rate (treated + improved) and the comparison of urodynamic parameters (pre-and post-injection). RESULTS: We studied 34 intervention-naïve SCI patients. 19 had only Macroplastique (Group 1) and 15 had Macroplastique and BTX-A (Group 2). The overall treatment rate was 65.4% for group 1 and 88.9% for group 2 (P = 0.029). The overall success rate (treated + improved) was 80.8% and 94.4% respectively (P = 0.123). The comparison of follow up VUDS parameters showed a statistically significant rise in the detrusor pressure of group 1 (34.04cmH2O vs.19.2cmH2O, P = 0.008) and a drop in compliance (19.8mls/cmH2O vs.26.3mls/cmH2O, P = 0.018) as compared to baseline. CONCLUSION: The combination of BTX-A and Macroplastique is more effective that Macroplastique alone in the management of secondary VUR in SCI patients with presumed healthy bladders.

Dextranomer-Hyaluronic Acid and Polyacrylate-Polyalcohol Copolymer are Equally Efficient for Endoscopic Treatment of Vesicoureteral Reflux in Children.

PURPOSE: To compare the efficacy of two bulking agents, Dextranomer-Hyaluronic Acid (DxHA) and Polyacrylate-Polyalcohol Copolymer (PPC) used for endoscopic treatment of vesicoureteral reflux (VUR). MATERIALS AND METHODS: We endoscopically treated 125 patients (89 girls and 36 boys) diagnosed with VUR grades I-V, comprising a total of 174 refluxing ureters (RUs). Patients were categorized into two groups, 99 (56,9%) RUs were treated with DxHA (Group 1) and 75 (43,1%) RUs with PPC (Group 2). RUs treated with both bulking agents were excluded. The success of treatment was evaluated with postoperative VCUG at 3- and 12-months after the endoscopic procedure, only complete resolution of VUR was considered as treatment success. Data was collected and analyzed retrospectively. Statistical calculations were performed using the Chi-square test. RESULTS: After a single injection 80,0% (60/75) and 68,7% (68/99 RUs) of RUs resolved completely when treated with PPC and DxHA, respectively (P = .094). A second injection of PPC healed another 10 RUs (total 93,3%), whereas DxHA resolved additional 16 RUs (total 84,8%) (P = .097). A third injection was needed for 1 RU, treated with PPC and another 3 RUs with DxHA. Twelve months post-operatively, we achieved a total resolution rate of 94,7% (71/75 RUs) with PPC, while DxHA successfully treated 87,9% (87/99) of RUs (P = .125). CONCLUSIONS: DxHA and PPC showed no statistically significant differences neither in the number of injections needed nor in the total success rate after 12 months of follow-up.