Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial.

BACKGROUND: Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this. OBJECTIVE: To determine the effect of circumcision on the risk of fUTIs in boys with PUVs. DESIGN, SETTING, AND PARTICIPANTS: A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision. INTERVENTION: Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method. RESULTS AND LIMITATIONS: In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age. CONCLUSIONS: Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs. PATIENT SUMMARY: In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

The fallow mitrofanoff.

BACKGROUND: Treatment of severe congenital dysfunctional bladders often requires bladder drainage to maintain low bladder pressure, thus preserving renal function. Although clean intermittent catheterization is the ideal choice, this can be especially challenging in the younger pediatric population or in children with neurological impairment. Alternatives such as incontinent vesicostomy, long-term suprapubic catheterization, or button cystostomy exist, but these are rarely very long-term options. OBJECTIVE: The objective of this study is to report the authors' experience with children who underwent a 'fallow' Mitrofanoff, meaning an appendicovesicostomy in which an indwelling catheter was placed for several months or years, allowing for bladder emptying several times a day, until the child was ready for clean intermittent catheterization (CIC). STUDY DESIGN: All patients who underwent a Mitrofanoff appendicovesicostomy with or without concomitant bladder augmentation, for whom there was a significant delay (≥6 months) between surgery and implementation of CIC, were reviewed. In all these cases, the child showed obvious opposition to CIC. An indwelling catheter was left in place, with a stopper allowing for bladder emptying 5-6 times a day as would happen with CIC. The catheter was changed once a week until CIC was implemented. Complications including febrile urinary tract infections (fUTIs) during the fallow period and complications including leakage or stenosis during the CIC period were noted. RESULTS: The series includes 10 patients (7 boys and 3 girls), aged a median 41 ± 34 months (range: 23-144) at the time of the appendicovesicostomy (6 posterior urethral valves and 4 non-neurogenic neurogenic bladders). All underwent classic appendicovesicostomies. The delay before full implementation of CIC was a median 29.5 ± 24 months (range: 6-72). During the fallow period, 3 patients presented fUTIs. The catheter was closed, allowing for bladder drainage 4-6 times a day. There were no episodes of leakage from the Mitrofanoff or stomal stenosis during the fallow period or CIC period. Mean follow-up since the appendicovesicostomy is 66 ± 33 months and since initiation of CIC is 26 ± 26 months (range: 4-94). DISCUSSION: For children who require bladder drainage, an appendicovesicostomy can be performed even if CIC is not initiated immediately and be used as a suprapubic catheter or button cystostomy. When the child is ready, CIC can be initiated without need for further surgery and without risk for the conduit. The limitations of this study include its retrospective nature and the low number of patients. CONCLUSION: A Mitrofanoff appendicovesicostomy can be performed in a child requiring long-term bladder drainage and in whom classic CIC is not possible, even if CIC is not initiated immediately.

Cortical transit time as a predictive marker of the need for surgery in children with pelvi-ureteric junction stenosis: preliminary study.

INTRODUCTION: Postnatal management of prenatally detected hydronephrosis remains controversial. It has been suggested that cortical transit time (CTT) could successfully predict deterioration in children with pelvi-ureteric junction (PUJ) obstruction. We decided to conduct a retrospective study in our hydronephrosis population to evaluate whether initial CTT was significantly correlated with the need for surgery. PATIENTS AND METHOD: We reviewed the charts of all our patients managed for significant PUJ obstruction (>12 mm) between 2007 and 2010 and determined CTT retrospectively, on the first diuretic scan of each of these patients. We then determined the relationship between initial CTT and the need for surgery. RESULTS: We identified 37 patients with hydronephrosis (pelvic size >12 mm) of which 26 were diagnosed prenatally. Out of 22 patients with an initial abnormal CTT, 20 underwent surgery. Out of 15 children with a normal initial CTT, 4 underwent surgery (OR 27.5 (IC95%: 4.3-174.9)). CONCLUSION: Initial CTT could be a reliable prognostic factor for future evolution of renal function in children with hydronephrosis. CTT is easy to determine on diuretic renal scan. A prospective trial is being devised to confirm what role it could have in the management of children with hydronephrosis.

[Stop of antibiotic prophylaxis in mild/moderate grade vesico-ureteral reflux]. / Arrêt de l'antibioprophylaxie urinaire dans les reflux vésico-urétéraux de grade I, II ou III.

UNLABELLED: Vesicoureteric reflux (VUR) is found in about 30 % of children with pyelonephritis (PN). It has been identified as a risk factor for the development of urinary tract infections, renal scars, hypertension and chronic renal failure but this risk is considerably smaller than previously assumed. Currently the therapeutic option was to use an antibiotic prophylaxis in order to keep the urinary tract sterile in order to prevent pyelonephritis and new renal scars. The review of the available data has shown that the antibiotic prophylaxis therapy is subject to discussion. The aim of this study was to evaluate the follow up of children with low-grade reflux before and after stopping the urinary antibiotic prophylaxis as soon as they became toilet-trained. METHODS: Fifty-eight children with low-grade reflux (grade I, II, III) were enrolled in this study. The follow up ranged from October 2002 till February 2007. The children who have not attained bladder control received antibiotic prophylaxis. This treatment was stopped as soon as they became toilet-trained. The presence of urinary tract infection (UTI) was considered in case of unexplained fever and urinalysis and urine culture were performed. RESULTS: VUR, mainly grade II, was discovered at a median age of 16 months. The prophylaxis was stopped at a median age of 40 months. The follow up after stopping the antibacterial prophylaxis was 27 months. Under treatment 2 pyelonephritis occurred, without treatment 2 pyelonephritis and 3 cystitis were diagnosed. At the end of the follow up, the grade of reflux decreased in half of the cases and disappeared in 3 cases. CONCLUSION: By stopping the urinary antibiotic prophylaxis in children with mild/moderate grade VUR when they became toilet-trained, there is no increase of the incidence of UTI, pyelonephritis. This study does not support the role for urinary antibiotic prophylaxis in preventing the recurrence of pyelonephritis.