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BACKGROUND: Posterior urethral valves represent the most common cause of lower urinary tract obstruction in male infants (â¼1/4000 live births). Long-term kidney outcomes of posterior urethral valves remain uncertain. We aimed to determine the time-varying risk of major adverse kidney events (MAKE) following children with posterior urethral valves into adulthood. METHODS: A population-based retrospective cohort study of all males (<2 years) diagnosed with posterior urethral valves between 1991-2021 in Ontario, Canada. Comparator cohorts were: 1) male general population and 2) male pyeloplasty patients (both <2 years). The primary outcome was MAKE (death, long-term kidney replacement therapy [dialysis or kidney transplant], or chronic kidney disease). Time-to-MAKE was analyzed using multivariable-adjusted Cox proportional hazards models. We censored for provincial emigration, or administrative censoring (March 31, 2022). RESULTS: We included 727 children with posterior urethral valves, 855 pyeloplasty comparators, and 1,013,052 general population comparators. Median follow-up time was 16.6 years (Q1-3 8.6-24.5) overall. Throughout follow-up, 32% of children with posterior urethral valves developed MAKE vs. 1% of the general population and 6% of pyeloplasty comparators. Their adjusted hazard ratio for MAKE was 36.6 (95%CI 31.6-42.4) vs. the general population. The risk of developing MAKE declined over the first 5 years after posterior urethral valves diagnosis but remained elevated for >30-year follow-up. Children with posterior urethral valves were also at higher risk of death, chronic kidney disease, long-term kidney replacement therapy, hypertension, and acute kidney injury than general population or pyeloplasty comparators. CONCLUSIONS: Children with posterior urethral valves are at higher risk of adverse long-term kidney outcomes well into adulthood.
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PURPOSE: We describe long-term outcomes, including UTIs and need for reimplantation, after ureterovesicostomy (UV) as a lasting surgical procedure for children with primary obstructive megaureter (POM). MATERIALS AND METHODS: Children referred to our institution between 2016 and 2023 who underwent refluxing UV were analyzed. POM was defined as hydroureteronephrosis with distal ureteral dilatation > 7 mm and a negative workup for other etiologies of hydronephrosis. We assessed for surgical outcomes, complications, rate of UTI, and improvement in upper tract dilatation. Statistical analyses assessed for change in hydronephrosis metrics over follow-up. RESULTS: Among 183 patients diagnosed with POM, 47 (24%) underwent UV. Median age of presentation, surgery, and follow-up was 2, 9, and 43 months, respectively. A total of 7 patients developed 30-day complications: Clavien-Dindo grade 1 in 2 (transient urinary retention) and grade 2 in 5 (UTIs). During monitoring 14 (30%) developed UTIs and 7 (15%) required ureteral reimplant or UV takedown. After surgery there was a significant decrease in the proportion of patients with high-grade hydronephrosis, anteroposterior renal pelvis diameter, and maximum ureteral dilatation. CONCLUSIONS: Refluxing UV is a safe alternative to cutaneous diversion in POM. Most patients had improvement in upper tract dilatation with an acceptable short-term complication rate and need for reoperation (in comparison to routine later reimplantation). Our experience suggests that monitoring alone after UV is feasible, and that selective subsequent reconstruction is a reasonable strategy.
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Ureter , Obstrução Ureteral , Humanos , Masculino , Feminino , Obstrução Ureteral/cirurgia , Obstrução Ureteral/etiologia , Pré-Escolar , Lactente , Seguimentos , Estudos Retrospectivos , Ureter/cirurgia , Ureter/anormalidades , Ureter/diagnóstico por imagem , Resultado do Tratamento , Derivação Urinária/métodos , Derivação Urinária/efeitos adversos , Refluxo Vesicoureteral/cirurgia , Refluxo Vesicoureteral/etiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Hidronefrose/etiologia , Hidronefrose/cirurgia , Reimplante/métodos , Reimplante/efeitos adversos , Cistostomia/métodosRESUMO
INTRODUCTION: A nomogram for predicting the diagnosis of lower urinary tract obstruction (LUTO) based on an antenatal ultrasound index generated from a Bayesian Meta-regression analysis has been in development and noted with superior diagnostic accuracy compared to the keyhole sign (KHS). We aim to assess the accuracy of the nomogram in expanded diagnostic utilization to predict LUTO. METHODOLOGY: The validation of the nomogram for expanded diagnostic utilization was based on data from a prospective institutional antenatal clinic database between January 2020 and June 2022. Diagnostic accuracy indices were determined for confirmed postnatal diagnosis of LUTO or prune belly syndrome (PBS). Receiver operating characteristics (ROC) curves were generated to compare the area under the curve (AUC) of the nomogram versus KHS. RESULTS: Based on 84 male fetuses with antenatal ultrasound of moderate-severe hydronephrosis (PUV n = 15, PBS n = 4), the KHS had 26.3% (95%CI 9.1-51.2) sensitivity and 100% (95%CI 94.4%-100%) specificity, with 14 false-negatives. The nomogram showed a 84.2 (95%CI 60.4%-96.6%) sensitivity and 95.4 (95%CI 87.1%-99%) specificity with three false-positives. The nomogram also had a superior AUC compared to KHS (0.98 vs. 0.63). CONCLUSION: The nomogram can be used as a valuable tool to trigger further postnatal screening and provide individualized risk assessments to families during prenatal counseling.
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Síndrome do Abdome em Ameixa Seca , Sistema Urinário , Humanos , Masculino , Gravidez , Feminino , Nomogramas , Estudos Prospectivos , Teorema de Bayes , Ultrassonografia Pré-NatalRESUMO
Febrile ulceronecrotic Mucha-Habermann disease is a rare and severe variant of pityriasis lichenoides, characterized by sudden onset of generalized ulceronecrotic papules that rapidly coalesce into ulcers associated with high fever. Systemic manifestations such as intravascular disseminated coagulation and pulmonary, cardiac, gastrointestinal, and central nervous system involvement are common. Treatment is based on oral corticosteroids, immunosuppressive drugs such as methotrexate, and general supportive treatment. The present case describes a stepwise approach to a patient with Mucha-Habermann disease with insufficient response to methotrexate.
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Metotrexato , Pitiríase Liquenoide , Humanos , Febre/etiologia , Herpes Simples , Imunossupressores/uso terapêutico , Metotrexato/uso terapêutico , Pitiríase Liquenoide/patologia , Pitiríase Liquenoide/tratamento farmacológico , Úlcera Cutânea/etiologia , Úlcera Cutânea/tratamento farmacológico , Úlcera Cutânea/patologiaRESUMO
OBJECTIVE: To identify and critically appraise available clinical practice guidelines (CPGs) targeting male circumcision using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. STUDY DESIGN: A literature search was conducted using electronic databases, CPG databases, and national/international societies providing recommendations to guide clinical decision making for male circumcision. We selected pediatric-focused CPGs related to male circumcision published between January 2010 and December 2020. Non-English CPGs and publications involving narrative reviews, primary research, training manuals, patient and allied health professional guidelines, and technical guides were excluded from our search. Complete CPG documents (including full-text articles, supplemental documents, and associated information) were reviewed. Quality appraisal of CPGs was conducted in accordance with the AGREE II manual. RESULTS: A total of 163 CPGs were identified, of which 93 were screened and 13 were reviewed. All AGREE II domains demonstrated good to excellent interrater reliability, with intraclass correlation coefficients ranging from 0.82 (95% CI, 0.72-0.89) to 0.93 (95% CI, 0.90-0.95). Most CPGs performed satisfactorily in the clarity of presentation domain and performed poorly in the applicability and editorial independence domains. The top 3 CPGs identified were those of the American Academy of Pediatrics, Centers for Disease Control and Prevention, and Canadian Urological Association. Consistencies among the CPGs were demonstrated across most recommendations. CONCLUSIONS: Current CPGs are of variable quality, and our findings should be taken into consideration by clinicians and health care professionals when selecting appropriate guidelines for male circumcision.
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Circuncisão Masculina , Canadá , Criança , Bases de Dados Factuais , Humanos , Masculino , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Lower urinary tract obstruction (LUTO) is a rare but critical fetal diagnosis. Different ultrasound markers have been reported with varying sensitivity and specificity. AIMS: The objective of this systematic review and meta-analysis was to identify the diagnostic accuracy of ultrasound markers for LUTO. MATERIALS AND METHODS: We performed a systematic literature review of studies reporting on fetuses with hydronephrosis or a prenatally suspected and/or postnatally confirmed diagnosis of LUTO. Bayesian bivariate random effects meta-analytic models were fitted, and we calculated posterior means and 95% credible intervals for the pooled diagnostic odds ratio (DOR). RESULTS: A total of 36,189 studies were identified; 636 studies were available for full text review and a total of 42 studies were included in the Bayesian meta-analysis. Among the ultrasound signs assessed, megacystis (DOR 49.15, [15.28, 177.44]), bilateral hydroureteronephrosis (DOR 41.33, [13.36,164.83]), bladder thickening (DOR 13.73, [1.23, 115.20]), bilateral hydronephrosis (DOR 8.36 [3.17, 21.91]), male sex (DOR 8.08 [3.05, 22.82]), oligo- or anhydramnios (DOR 7.75 [4.23, 14.46]), and urinoma (DOR 7.47 [1.14, 33.18]) were found to be predictive of LUTO (Table 1). The predictive sensitivities and specificities however are low and wide study heterogeneity existed. DISCUSSION: Classically, LUTO is suspected in the presence of prenatally detected megacystis with a dilated posterior urethra (i.e., the keyhole sign), and bilateral hydroureteronephrosis. However, keyhole sign has been found to have modest diagnostic performance in predicting the presence of LUTO in the literature which we confirmed in our analysis. The surprisingly low specificity may be influenced by several factors, including the degree of obstruction, and the diligence of the sonographer at searching for and documenting it during the scan. As a result, providers should consider this when establishing the differential for a fetus with hydronephrosis as the presence or absence of keyhole sign does not reliably rule in or rule out LUTO. CONCLUSIONS: Megacystis, bilateral hydroureteronephrosis and bladder wall thickening are the most accurate predictors of LUTO. Given the significant consequences of a missed LUTO diagnosis, clinicians providing counselling for prenatal hydronephrosis should maintain a low threshold for considering LUTO as part of the differential diagnosis.
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Ultrassonografia Pré-Natal/normas , Obstrução Uretral/diagnóstico por imagem , Adulto , Teorema de Bayes , Feminino , Idade Gestacional , Humanos , Gravidez , Ultrassonografia Pré-Natal/métodos , Uretra/anormalidades , Uretra/diagnóstico por imagemRESUMO
Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and search terms included recurrent UTI, VUR, bladder and bowel dysfunction (BBD), constipation, lower urinary tract symptoms, and voiding dysfunction. Common presenting symptoms of UTI in children include fever (> 38 °C) with or without "traditional" lower urinary tract symptoms (LUTS) such as dysuria, malodorous urine, frequency, urgency, and incontinence. However, many infections in older children are afebrile episodes-consisting primarily of LUTS-which may or may not be confirmed with biochemical and/or microbiological evidence. Therefore, when evaluating toilet-trained children with recurrent UTIs, it is paramount to consider dysfunctional elimination as an underlying cause, diagnose, and treat it prior to indicating surgical options, even in the presence of VUR or other anatomical abnormalities. Although the impact of bladder function on the risk of infections is important, so is the accurate diagnosis and initial evaluation. This review article will focus on an often overlooked yet critical factor: the impact of bladder function, particularly for toilet-trained children, as well as the importance of implementing bladder training strategies, aggressive management of constipation, and pharmacological management as necessary.
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Bexiga Urinária/fisiopatologia , Infecções Urinárias/diagnóstico , Criança , Pré-Escolar , Constipação Intestinal/complicações , Feminino , Humanos , Masculino , Exame Físico/métodos , Infecções Urinárias/etiologia , Infecções Urinárias/terapia , Refluxo Vesicoureteral/complicaçõesRESUMO
PURPOSE: We assessed achievement of competence in pediatric renal transplant by developing a learning curve model for consecutive operations performed by a single surgeon. MATERIALS AND METHODS: We retrospectively evaluated pediatric renal transplant cases performed by an index pediatric urologist during his first 15 years of being the primary transplant surgeon at our institution. Case characteristics, operative time and surgical complications within 30 days postoperatively were assessed and compared to those of a reference senior surgeon. To generate a learning curve plot, we performed a cumulative sum analysis to evaluate the evolution of operative times and surgical complications. RESULTS: During 15 years 55 pediatric renal transplants (17%) were performed by the index surgeon and 78 (24%) by the senior surgeon. Total operative time was shorter for the index surgeon (226 vs 252 minutes, p = 0.006), while ischemia time was longer (40 vs 30 minutes, p = 0.001). The 30-day surgical complication rates were similar (32.7% and 35.9%, p = 0.853). The learning curve showed that the complication rates and operative times did not increase following the 17th case. Ureteroureterostomy has been more commonly performed for ureteral anastomosis (p = 0.048) and longer warm ischemia time has been noted after reaching the peak of the learning curve (p = 0.003). CONCLUSIONS: We determined that technical skills for pediatric renal transplant can be achieved after the 17th case. We propose that a dedicated team with a pediatric urologist who has an interest in performing pediatric renal transplant secure more cases than the case volume determined in our study within the first few years of practice to maintain proficiency.
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Competência Clínica , Transplante de Rim/educação , Curva de Aprendizado , Adolescente , Criança , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de TempoAssuntos
Obstrução Ureteral , Refluxo Vesicoureteral , Humanos , Obstrução Ureteral/cirurgia , Obstrução Ureteral/etiologia , Refluxo Vesicoureteral/cirurgia , Refluxo Vesicoureteral/etiologia , Derivação Urinária/métodos , Seguimentos , Resultado do Tratamento , Pré-Escolar , Ureter/cirurgia , Ureter/anormalidades , Lactente , Fatores de Tempo , Masculino , Feminino , CriançaRESUMO
INTRODUCTION: Urethral duplication is rare. Characterized by the presence of two urethral channels. This anomaly presents a great variety of clinical findings that depend on the type of duplication that often is associated with other anomalies. MATERIAL AND METHODS: We report thirteen boys with urethral duplication managed in our institution between 1988-2015. Clinical findings, associated anomalies, treatment of urethral duplication and our results are described. Patients were classified according to Effmann classification. RESULTS: Mean patient's age was 38.3±34.7 months (3-136 months). Mean follow-up was 7.7±3.4 years (3y8m-14y2m). Type II A2 was the most common pattern (8/13 patients, 61.5%), followed by type IA (3/13 patients, 23%) and IIA1 (2/13 patients, 15.3%). The most frequent clinical manifestations were urinary tract infections (UTI) observed in 11/13 patients (84.6%) and anal urinary leakage, found in 7/13 patients (53.8%). Associated anomalies were found in 9/13 patients (69.2%). Required surgeries were 3.53±2.84 procedures per patient. Considering groups: Type IIA2 4.25±3.28, type IIA1 4±1.41 and type IA 1.33±0.57 needed procedures per patient. Complications rate were 0% for type IA, 50% for type IIA1 and 75% for type IIA2. CONCLUSIONS: Patients with incomplete duplication (type I A or I B) can totally be asymptomatic, with no need of surgical correction. Type IIA2 is the most complex form of duplication to correct and multiple procedures might be required because of the very hypoplastic orthotopic dorsal urethral tissue. Surgical treatment should be individualized and parents should be advised on complications and need of multiple surgeries according to urethral duplication type.
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Uretra/anormalidades , Uretra/cirurgia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Reoperação , Estudos Retrospectivos , Procedimentos Cirúrgicos UrológicosRESUMO
INTRODUCTION: Congenital Anomalies of the Kidney and Urinary Tract (CAKUT) are structural disorders originating prenatally and present at birth. Affecting 4.2 to 1000 per 10,000 births globally, CAKUT includes conditions like posterior urethral valves, cloacal anomalies, and reflux nephropathy. These anomalies can lead to chronic kidney disease (CKD) or end-stage kidney disease (ESKD) in children, necessitating renal replacement therapy or transplantation. OBJECTIVES: This article aims to provide an updated perspective on pediatric kidney transplantation for children with CAKUT, emphasizing pre-transplant evaluation and management to optimize long-term outcomes. METHODS: A comprehensive urologic evaluation is essential for children with ESKD being considered for kidney transplantation. Key pre-transplant investigations include kidney/bladder ultrasound (US), voiding cystourethrogram (VCUG), uroflowmetry, and urodynamics (UDS)/video-urodynamics (VUDS). Non-operative interventions such as pharmacotherapy and clean intermittent catheterization (CIC) are also considered. Surgical interventions, like augmentation cystoplasty or continent catheterizable channels, are evaluated based on individual patient needs. RESULTS: Kidney/bladder US and VCUG provide essential anatomical information. UDS offers comprehensive functional data, identifying hostile bladders needing pre-transplant optimization. Non-surgical measures like anticholinergics and CIC improve bladder function, while surgical options enhance compliance and capacity. Concurrent interventions during transplantation are feasible but require careful consideration of risks and benefits. DISCUSSION: Children with CAKUT undergoing kidney transplantation exhibit comparable or better graft survival rates than those without CAKUT. However, those with lower urinary tract obstructions (LUTO) may have poorer long-term outcomes. UDS is crucial for evaluating bladder function pre-transplant, guiding the need for interventions. Long-term monitoring for urinary tract infections (UTIs) and bladder dysfunction is essential. CONCLUSION: Optimal outcomes in pediatric kidney transplantation for CAKUT patients require thorough pre-transplant evaluation and management, particularly for those with LUTO. Multidisciplinary approaches ensure careful monitoring and timely interventions, improving graft survival and quality of life for these patients.
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INTRODUCTION: Advances in health care have improved outcomes for pediatric patients with congenital neurourological conditions, highlighting the need for an effective transition from pediatric to adult care. This study investigates Canada's transitional urologic care within its single-payer health care system, focusing on the active members of Pediatric Urologists of Canada and their practices, perceptions, and attitudes toward transitional urologic care. METHODS: A survey was distributed to 35 Pediatric Urologists of Canada members from July 2023 to January 2024, which collected data on transitional care practices and available transitional urology clinics. It also focused on a service overview, covering aspects such as the responder's geographic and institutional affiliations, clinical practice characteristics involving transitional care, perceived challenges, and strategies for care enhancement. RESULTS: Nationwide engagement emphasized a commitment to improving transitional care, with a significant proportion of respondents (64%) having over 10 years of practice, reflecting substantial experience in addressing transitional care challenges. The survey identified 4 dedicated transitional care clinics, 3 of which are active, pointing to concerted efforts toward specialized service provision. The major challenges identified include the lack of adult transitional care initiatives and governmental support. Recommendations for improvement should focus on standardizing transition protocols and boosting patient education. The survey also underscored the necessity of protocolized care for spina bifida-neurogenic bladder and complex urogenital conditions. CONCLUSIONS: This study highlights the active efforts and existing challenges within Canada's transitional urologic care system, particularly emphasizing operational transitional care clinics as a crucial step forward in catering to transitioning patients' needs.
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Atitude do Pessoal de Saúde , Sistema de Fonte Pagadora Única , Transição para Assistência do Adulto , Urologia , Humanos , Canadá , Criança , Adulto , Masculino , Pediatria , Feminino , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Posterior urethral valves (PUV) is a chronic condition that can adversely impact child and family health related quality of life (HRQOL). Surprisingly, to date, the impact of this condition on the QOL of children with PUV has not been studied. Thus, our aim is to evaluate this important aspect of care using validated questionnaires in our institutional PUV clinic. METHODS: From December 2022 to January 2024, the PedsQL Inventory and associated family impact module was distributed in our PUV clinic. Higher scores reflect better HRQoL and less impact on family. Children >8 years old completed the tool themselves, otherwise parents completed the tools on behalf of the child. We compared PUV scores against reported psychometric data from healthy children and other chronic illnesses. RESULTS: A total of 112 families completed the questionnaires. The total HRQoL score was 80 ± 13. Overall, we noted that the domains reflecting psychosocial impact were significantly lower than those of physical well-being (76 ± 16 vs. 89 ± 15 for psychosocial and physical impact, respectively; p < 0.01). There was a significant difference in the psychosocial emotional impact for children managed with clean intermittent catheterization (CIC) compared to those who were not (69 ± 21 vs. 81 ± 16; p = 0.005) (Table 2). In addition, we noted that children with PUV scored similar to healthy controls, but higher than children with other chronic illnesses. With respect to the impact on family, overall, parent, and family impacts were 76 ± 19, 78 ± 21, and 81 ± 21, respectively. DISCUSSION: Chronic illness has been associated with a negative impact on HRQoL in both adults and children. We noted similar findings the present study, particularly for young children and those who are maintained on CIC. To our knowledge, this is the first study to evaluate the impact of PUV on a child's HRQoL as well as the impact on the family, and to document a negative psychosocial impact of CIC in this population. However, there are some important limitations to be addressed including relying on families to complete questionnaires accurately during busy clinic visits and the lack of controls from the same environment. CONCLUSION: When compared to healthy controls, PUV patients score similarly in HRQoL assessment. In addition, children <3years of age report a negative impact on physical well being, and CIC negatively impacts the emotional well-being. These data can be used to advocate for better mental health supports and social work for these children.
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Qualidade de Vida , Humanos , Criança , Masculino , Estudos Prospectivos , Inquéritos e Questionários , Uretra/anormalidades , Feminino , Adolescente , Pré-Escolar , Equipe de Assistência ao PacienteRESUMO
BACKGROUND: Little is known about alpha blocker use in young children, particularly in those with lower urinary tract obstruction (LUTO). Therefore, we aimed to assess the safety and tolerability of selective alpha-blockers in children under 3 years of age with LUTO. METHODS: A prospectively-collected database captured 93 patients born between 12/2005 and 01/2023. Assessed data included baseline characteristics, ultrasound features, blood pressure (BP), side effects and creatinine values. Primary outcome was side effects or discontinuation of alpha-blockers. Secondary outcomes were BP parameters, growth, and kidney function. Data are shown as median with interquartile range (IQR), Odds Ratio (OR) with 95% CI and mean value with standard deviation (SD). RESULTS: A total of 33 patients less than 3 years of age were started on alpha-blockers at 16.8 ± 11.8 months and followed for 48.9 ± 40.5 months. At last follow-up, no significant effect on systolic/diastolic BP percentiles (p > 0.9 and p > 0.9), creatinine levels (p > 0.9). Weight percentiles increased to the last follow-up (37.8 ± 33.2 vs. 53.6 ± 32.9, p = 0.0133) while height percentiles increased from 28 to 100 days to last follow-up (12.9 ± 18.3 vs. 39.6 ± 35.2, p=0.001). Four patients discontinued alpha-blockers; however, no side-effects were reported during the study period. CONCLUSIONS: No severe clinical or systemic side effects were observed, demonstrating safety and tolerability in young children with LUTO. Although alpha-blockers did not significantly improve kidney function in short term follow-up, and failure to thrive was not observed in these children. Additional studies with more patients are required to assess the optimal dosing and timing leading to maximal benefits for these infants.
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Antagonistas de Receptores Adrenérgicos alfa 1 , Humanos , Lactente , Masculino , Feminino , Pré-Escolar , Estudos Prospectivos , Antagonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Antagonistas de Receptores Adrenérgicos alfa 1/administração & dosagem , Antagonistas de Receptores Adrenérgicos alfa 1/uso terapêutico , Resultado do Tratamento , Seguimentos , Obstrução UretralRESUMO
INTRODUCTION: Neonates with lower urinary tract obstruction (LUTO) experience high morbidity and mortality associated with the development of chronic kidney disease. The prenatal detection rate for LUTO is less than 50%, with late or missed diagnosis leading to delayed management and long-term sequelae in the remainder. We aimed to explore the trends in prenatal detection and management at a high-risk fetal center and determine if similar trends of postnatal presentations were noted for the same period. METHODS: Prenatal and postnatal LUTO databases from a tertiary fetal center and its associated pediatric center between 2009 and 2021 were reviewed, capturing maternal age, gestational age (GA) at diagnosis, and rates of termination of pregnancy (TOP). Time series analysis using autocorrelation was performed to investigate time trend changes for prenatally suspected and postnatally confirmed LUTO cases. RESULTS: A total of 161 fetuses with prenatally suspected LUTO were identified, including 78 terminations. No significant time trend was found when evaluating the correlation between time periods, prenatal suspicion, and postnatal confirmation of LUTO cases (Durbin-Watson [DW] = 1.99, p = 0.3641 and DW = 2.86, p = 0.9113, respectively). GA at referral was 20.0 weeks (interquartile range [IQR] 12, 35) and 22.0 weeks (IQR 13, 37) for TOP and continued pregnancies (p < 0.0001). GA at initial ultrasound was earlier in terminated fetuses compared to continued (20.0 [IQR 12, 35] weeks vs. 22.5 [IQR 13, 39] weeks, p < 0.0001). While prenatal LUTO suspicion remained consistently higher than postnatal presentations, the rates of postnatal presentations and terminations remained stable during the study years (p = 0.7913 and 0.2338), as were GA at TOP and maternal age at diagnosis (p = 0.1710 and 0.1921). CONCLUSION: This study demonstrated that more severe cases of LUTO are referred earlier and are more likely to undergo TOP. No significant trend was detected between time and prenatally suspected or postnatally confirmed LUTO, highlighting the need for further studies to better delineate factors that can increase prenatal detection.
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Doenças Fetais , Sistema Urinário , Gravidez , Recém-Nascido , Feminino , Criança , Humanos , Doenças Fetais/diagnóstico por imagem , Doenças Fetais/cirurgia , Estudos Retrospectivos , Cuidado Pré-Natal , FetoRESUMO
INTRODUCTION: There is debate regarding the effect of VURD syndrome, consisting of vesicoureteral reflux (VUR) and ipsilateral kidney dysplasia, on long-term outcomes in boys with posterior urethral valve (PUV). Here, we assessed whether VURD syndrome played a "protective" role on long-term bladder outcomes and voiding efficiency in boys with PUV. MATERIALS AND METHOD: A retrospective chart review was conducted for toilet-trained children with PUV managed at our institution between 2000 and 2022, only excluding cases without recorded uroflowmetry studies. Patients were stratified by VUR status and by the presence of VURD syndrome (high-grade VUR + ipsilateral kidney dysplasia). Outcomes included initial and final uroflowmetry parameters, and initiation of clean-intermittent catheterization (CIC). RESULTS: We identified a total of 101 patients who met study inclusion criteria, with an overall median follow-up of 114 months (IQR 67, 169). The median age of first and last uroflowmetry was 57 months (IQR 48, 82) and 120 months (IQR 89, 160), respectively. Patients with VURD syndrome had similar flow velocity, post-void residuals, and bladder voiding efficiency to other PUV patients at last follow-up uroflowmetry. On survival analysis, patients with VURD syndrome had no significant difference in risk of requiring CIC compared to patients without pop-offs (p = 0.06). DISCUSSION: Like more contemporary studies on pressure pop-offs, we show that this population is not at higher risk of poorer voiding and intermittent catheterization than others. VURD syndrome does not confer protection against poorer bladder function. Instead, our study suggests an independent association between kidney dysplasia and bladder outcomes which requires further attention. CONCLUSIONS: Among boys with PUV, VURD syndrome was not associated with significantly different uroflowmetry findings or rates of CIC by last follow-up.
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Obstrução Uretral , Sistema Urinário , Refluxo Vesicoureteral , Criança , Masculino , Humanos , Estudos Retrospectivos , Bexiga Urinária , Refluxo Vesicoureteral/complicações , Micção , Síndrome , UretraRESUMO
INTRODUCTION: Circumcision has been reported to reduce the risk of urinary tract infections (UTIs) in boys with antenatal hydronephrosis (HN). Our aim was to compare the incidence of UTIs in circumcised vs. uncircumcised boys with antenatal HN by conducting a systematic review and meta-analysis. STUDY DESIGN: A comprehensive search was performed until December 2022. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included: UTIs, continuous antibiotic prophylaxis (CAP) use, renal outcomes, and circumcision complications. Odds ratios (OR) and mean difference with 95% confidence interval (CI) were extrapolated from available data. Random-effects meta-analysis were performed. RESULTS: Twenty-three studies describing 9093 boys with antenatal HN were identified, including 4677 uncircumcised and 4416 circumcised boys. Overall effect estimates demonstrate that circumcised boys have significantly reduced odds of developing any UTI [OR 0.26, 95%CI 0.21, 0.32; p < 0.001]]. In addition, there a significantly reduced odds of developing UTI when circumcised and on CAP [OR 0.19, 95% CI 0.13, 0.30; p < 0.001]. When stratifying by etiology, circumcision reduced the odds of UTI in boys with isolated HN [OR 0.33, 95% CI 0.16, 0.68; p = 0.003], vesicoureteral reflux [OR 0.23, 95% CI 0.13, 0.42; P < 0.00001], or with posterior urethral valves [OR 0.29, 95% CI 0.13, 0.64; p = 0.002]. DISCUSSION: Circumcision reduces the incidence of UTIs in boys with antenatal HN. This review is limited by the varied definitions of UTIs and inconsistent reporting on HN etiology, renal outcomes, and circumcision complications. CONCLUSIONS: Circumcision should be considered in boys with antenatal HN to prevent the risk of developing UTI. Further research is warranted to individualize the prophylactic role of circumcision for patients with HN.
Assuntos
Circuncisão Masculina , Hidronefrose , Infecções Urinárias , Masculino , Criança , Humanos , Feminino , Gravidez , Circuncisão Masculina/efeitos adversos , Hidronefrose/complicações , Hidronefrose/epidemiologia , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Infecções Urinárias/prevenção & controle , Rim , Fatores de RiscoRESUMO
OBJECTIVE: To determine long-term kidney outcomes in boys with posterior urethral valve (PUV) undergoing either primary valve ablation or urinary diversion with matched baseline kidney function. METHODS: After retrospective review of patients managed for PUV at our institution, propensity score matched analysis was conducted using nadir serum creatinine with logistic regression analysis. Nearest neighbor matching was used to allocate boys to primary urinary diversion and primary ablation groups. Primary outcomes included kidney function by creatinine or estimated glomerular filtration rate, chronic kidney disease, and end-stage renal disease. Comparative statistics by odds ratio (OR) and hazard ratios on survival analysis were calculated. RESULTS: A total of 21 boys undergoing primary diversion were matched with 42 boys undergoing ablation using nadir serum creatinine and follow-up time with a median follow-up of 4.8 years. After matching, there was no significant difference in last follow-up kidney function by creatinine (P = .99) or estimated glomerular filtration rate (P = .98). Primary diversion was not associated with increased likelihood of developing chronic kidney disease stage 3 (OR 1.33; P = .31) or end-stage renal disease (OR 1.88; P = .35 and hazard ratios 1.85; P = .30) compared to primary ablation. CONCLUSIONS: Our propensity matched study suggests that long-term kidney function and kidney outcomes are similar between primary ablation and primary diversion after adjusting for baseline kidney function in boys with PUV.
Assuntos
Falência Renal Crônica , Insuficiência Renal Crônica , Obstrução Uretral , Derivação Urinária , Masculino , Humanos , Uretra/cirurgia , Creatinina , Derivação Urinária/efeitos adversos , Rim/cirurgia , Insuficiência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Estudos RetrospectivosRESUMO
PURPOSE: To determine differences in long-term kidney and bladder outcomes in boys with posterior urethral valves (PUV) managed by a primary valve ablation or primary urinary diversion. MATERIALS AND METHODS: A systematic search was performed in March 2021. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed measures included kidney outcomes (chronic kidney disease, end-stage renal disease, kidney function) and bladder outcomes. Odds ratios (OR) and mean difference (MD) with 95% confidence interval (CI) were extrapolated from available data for quantitative synthesis. Random-effects meta-analysis and meta-regression were performed according to study design, and potential covariates were assessed with subgroup analysis. The systematic review was prospectively registered on PROSPERO (CRD42021243967). RESULTS: Thirty unique studies describing 1547 boys with PUV were included in this synthesis. Overall effect estimates demonstrate that patients undergoing primary diversion have significantly increased odds of developing renal insufficiency [OR 0.60, 95% CI 0.44, 0.80; p < 0.001]. However, when adjusting for baseline kidney function between intervention groups, there was no significant difference in long term kidney outcomes [p = 0.09, 0.35], or the development of bladder dysfunction or requiring clean-intermittent catheterization with primary ablation rather than diversion [OR 0.89, 95% CI 0.49, 1.59; p = 0.68]. CONCLUSIONS: Current low-quality evidence suggests that medium-term kidney outcomes in children are similar between primary ablation and primary diversion after adjusting for baseline kidney function, while bladder outcomes are highly heterogenous. Further research with covariate control is warranted to investigate sources of heterogeneity. LEVEL OF EVIDENCE: Level III.
Assuntos
Obstrução Uretral , Derivação Urinária , Criança , Masculino , Humanos , Uretra/cirurgia , Estudos Retrospectivos , Obstrução Uretral/cirurgia , Bexiga UrináriaRESUMO
Neonatal circumcision is one of the most commonly performed surgical procedures in the world. As with all surgeries, it carries risks, including rare, but devastating complications, such as glans, and/or penile shaft amputation. Complete glans amputation with successful replantation has been previously reported. Herein we report a case of complete amputation at the penile midshaft in a 28-day-old neonate with a unique approach to postoperative care including the use of leech therapy, topical heparin, and caudal analgesia following successful microvascular replantation.