Abstract: Background. In patients undergoing kidney transplantation with a small bladder, many surgeons are faced with technical difficulties about the implantation as well as about satisfactory bladder rehabilitation. The objective of this study was to clarify the clinical outcomes of patients with end-stage renal disease who had a bladder capacity of less than 100 mL on preoperative voiding cystourethrogram after renal transplantation using extravesical ureteroneocystostomy. Patients and Methods. We retrospectively studied 345 patients with end-stage renal disease who underwent renal transplantation between April 2002 and June 2006. These patients were classified into two groups according to their preoperatively estimated bladder capacity using a voiding cystourethrogram. Group A had a bladder capacity of less than 100 mL (n = 23; 6.7%) and group B had a capacity of 100 mL or more (n = 322; 93.3%). For each group, the clinical outcome, including serum creatinine level at 1 month and 1 year after transplantation, bladder capacity, surgical complications, and prevalence of urinary tract infection (UTI) requiring hospital admission were recorded and the graft survival rate calculated. Results. Compared with group B, group A had undergone a longer duration of dialysis and required cadaveric kidney transplantation more frequently (P <.05). Postoperative surgical complications occurred in nine cases. There was no difference in the frequency of surgical complications and UTI requiring hospital admission between group A and group B. At 1 year posttransplant, bladder capacity was 342.0 ± 43.8 mL (range, 300-400 mL) and 429.1 ± 75.9 mL (range, 200-500 mL), respectively (P =.015). There was no statistical difference between the groups in the serum creatinine level and the graft survival rate at 5 years after transplantation (100% vs 92.4%). Conclusions. Similar to patients with a normal bladder size, renal transplantation can be successfully achieved in patients with a small bladder. Attempts to increase the bladder capacity by programmed training of the bladder and bladder expansion by surgical intervention seem unnecessary.

Abstract: Voiding cystourethrogram (VCUG) and radionuclide scan is recommended for patients with solitary (secondary to aplasia or multicystic dysplasia), hypoplasic or single ectopic kidney, to detect associated anomalies (vesicoureteric reflux, obstructive uropathies). With the increase of occasional diagnosis, mainly by fetal ultrasound (US), the possibility of an unjustified extension of diagnostic work up must be prevented. Aim of this paper was to estimate the incidence of associated anomalies in asymptomatic cases without associated US signs of hydronephrosis. Among 158 Patients examined there were 81 solitary kidneys (26 multicystic dysplasia), 27 small kidneys, 50 single ectopic kidneys); prenatal diagnosis was recorded in 86%. Incidence of associated anomalies was compared with figures resulting when symptomatic cases or with hydronephrosis were excluded. Vesicoureteral reflux or obstruction were found in 17% of solitary kidneys, 70% of hypoplasic kidneys and 2% of single ectopic kidneys. Among those (120 cases) without infection or hydronephrosis, incidence decreased, respectively to 5, 60 and 0%. Associated anomalies are reported to affect up to 48% of solitary kidneys and about 30% of single ectopic; 80% of severe reflux are usually associated to small kidneys. In our series of solitary and ectopic kidneys incidence of abnormalities was significantly less and fell to negligible values when occasionally detected, undilated cases were considered. On this basis, indiscriminate urological screening simply based on the occasional pre or postnatal detection of undilated solitary or ectopic kidney appears to be unjustified. Small kidneys deserve special attention and VCUG is always indicated.

Abstract: Of the 363 Thai children upon whom a voiding cystouretrogram was performed, a vesicoureteral reflux was detected in 22.8% (17.1%-28.5%) of those for whom it was performed within 7 days (n = 215) of a urinary tract infection diagnosis and in 24.3% (17.4%-31.2%) of those for whom it was performed 7 days (n = 148) after diagnosis. There was no statistically significant difference in reflux prevalence between these two groups.

Abstract: Objectives: We described various types of congenital urethral anomalies seen in boys with LUTS such as refractory enuresis. Their urethrograpic and endoscopic finding were reviewed and the effect of trans-urethral incision (TUI) was analyzed. Patients and Methods: We evaluated 67 boys with lower urinary tract symptoms (LUTS, mean: 9 years old), in a period of three and a half years. A voiding cystourethrogram (VCUG) was performed in 37 patients and if we suspected a urethral abnormality, endoscopy was performed. Congenital urethral obstruction was diagnosed from VCUG and endoscopic findings and classified into Types 1, 3 and 4 posterior urethral valves (PUV) according to Douglas Stephens' description. Trans-urethral incision (TUI) was carried out for congenital urethral obstruction and the effect was judged three months later. Results: On VCUG, 17 patients (45.8%) had an abnormal urethral configuration. On endoscopy, nine patients (24.3%) were diagnosed as having PUV. The effect of TUI on PUV excluding Type 3 was 80%, while that on Type 3 was 25%. Discussions: The incidence of PUV compared to bulbar urethral narrowing was significantly different from that described in previous Japanese reports, but similar to other countries. The reason is thought to be the lack of standardized interpretations of VCUG images and endoscopic findings, resulting in the overestimation of the bulbar urethral lesion. Conclusion: The incidence of PUV in Japanese boys with LUTS was higher than had ever been described. The improvement rate by TUI was high in PUV excluding Type 3, but low in Type 3. The ring like strictures at the bulbar urethra may be less important than has previously been thought.

Abstract: We investigate the ability of physical exam to diagnose urethral diverticula with or without magnetic resonance imaging (MRI) and exclusive of invasive modalities. A retrospective chart review of all women undergoing urethral diverticulectomy at our institution since 1999 was performed. We identified 28 female patients with a mean age at diagnosis of 42.6 years (range 18–66). Common presenting symptoms included dyspareunia, urgency, and frequency. Physical exam revealed a suspected urethral diverticulum in 26 (92.9%) patients, which was confirmed postoperatively in 17 of the 20 (85%) women who underwent surgical resection. Noninvasive imaging modalities (MRI or CT) were available for review in 20 (71%) cases and made the correct diagnosis of urethral diverticulum (presence or absence) in 19 (95%) patients. In those patients with symptoms of stress or urge incontinence (11, 39%), voiding cystourethrogram (VCUG) was performed. Urethral diverticula are often easily diagnosed on physical exam. MRI can be a useful adjunct for defining diverticular extent in surgical planning, especially for proximal and complex diverticula, and should be the modality of choice if clinical suspicion is high based on patient symptoms and physical exam.

Abstract: Background: Voiding cystourethrogram is performed 3–6 weeks after urinary tract infection. This prolongs the interval of prophylactics, reducing the likelihood of having to perform the procedure. Objectives: To investigate the yield and potential risks/benefits of early compared to late performance of VCUG after UTI. Methods: We conducted a prospective study of 84 previously healthy children 10 days after UTI, and a historical control group C – 82 children in whom VCUG was performed > 4 weeks following UTI. Results: VCUG was performed in 48/48 (100%), 6/35 patients (17.1%) and 34/116 patients (29.3%), and vesicoureteral reflux was demonstrated in 38.8%, 37.9% and 39% in groups A, B and C respectively. No significant difference was found between these groups in terms of incidence of VUR and severity and grading of reflux within each group. One case of UTI secondary to VCUG occurred in a patient in whom the procedure was performed 4 months after the diagnosis. Conclusions: Performing VCUG early does not influence the detection rate, severity of the VUR, or risk of secondary infection; it shortens the period of prophylactic use and increases performance rate of VCUG, thereby minimizing the risk of failure to detect VUR. The traditional recommendation of performing VCUG 3–6 weeks after the diagnosis of UTI should be reevaluated.

Abstract: A 1-year-6-month-old Japanese girl with Hinman syndrome manifested urosepsis and severe obstructive nephropathy. Her voiding cystourethrogram (VCUG) revealed high-grade vesicoureteral reflux with hydronephrosis; urodynamic study was compatible with detrusor-sphincter dyssynergia. She was treated conservatively, including clean intermittent catheterization. At 3 years old, bladder function had not improved, and estimated creatinine clearance was in the subnormal range. Hinman syndrome is a potential cause of acute and chronic renal failure in infancy. Taking account of the possibility of this condition in any neonates or infants who present urinary tract infection (UTI) appears to be necessary, since early recognition and proper management of this syndrome may prevent serious complications.

Abstract: UNLABELLED Prenatal ultrasonography has revolutionized the detection and management of many urological abnormalities. Vesicoureteric reflux (VUR) which develops in 10% to 15% of cases of prenatal hydronephrosis, is difficult to predict prenatally. While all children with prenatal hydronephrosis should undergo ultrasonography within the first few weeks of life, there seems to be controversy regarding the role of voiding cystourethrogram (VCUG) in the assessment of these children. MATERIALS AND METHODS Neonates with antenatally diagnosed unilateral hydronephrosis were prospectively assessed with sonography on day 3-7, and VCUG and isotope imaging at three months. RESULTS Seven (16.6%) children of the 42 children with Society of Fetal Urology grade 0/I/II hydronephrosis on postnatal sonography had evidence of VUR on VCUG. 44.4% of the refluxing ureters identified involved high grade disease and two (28.5%) children required reimplantation. CONCLUSIONS Children with fetal reflux may be diagnosed prior to urinary tract infection and in whom further renal injury may be prevented. VCUG when performed properly is safe and presents with little risk of infectious and noninfectious complications. VCUG should be done in children in whom hydronephrosis is detected prenatally to restrict the use of VCUG to diagnose VUR. Two patients had infection.

Abstract: Of 433 febrile children examined in the paediatric clinics of two university hospitals in Tehran, Iran, 39 (9%) children (27 girls and 12 boys) were diagnosed as having urinary tract infection in which Escherichia coli was the most frequently detected pathogen (84.6%). According to the voiding cystourethrogram, nine (75%) boys and 17 (63%) girls had urinary tract abnormalities. This result is slightly higher than seen in other reports from developing countries.

Abstract: PURPOSE: To assess the utility of intraoperative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux (VUR). METHODS: From September 2003 to June 2005, 24 children underwent injection of deflux for the treatment of VUR. A total of 38 ureters were treated. After deflux injection, our most recent 14 patients had a cystogram with simulated voiding phase to assess for the presence of VUR. All patients were scheduled for a voiding cystourethrogram (VCUG) three months postoperatively to assess for persistent reflux. The surgery was considered a success only if patients did not demonstrate reflux on their postoperative VCUG. RESULTS: Of the 24 patients undergoing deflux injection, 14 had complete resolution of their VUR. Eight patients had persistent VUR and 2 patients were lost to follow-up. A total of 38 ureters were injected. Twenty-seven ureters no longer refluxed, while 8 ureters continued to reflux and 3 ureters were lost to follow-up. Fourteen patients had an intra-operative cystogram with simulated voiding phase. The intra-operative cystogram with simulated voiding phase was negative in all patients except for one patient who demonstrated the presence of de novo contralateral VUR. There were 7 true negatives on intra-operative cystogram with a simulated voiding phase and 6 false negatives. CONCLUSIONS: Our results of endoscopic treatment of VUR compare well to the results reported by others in the literature. An intra-operative cystogram may demonstrate unsuspected contralateral reflux but does not appear to predict the success of deflux injections.

Abstract: A descriptive, microbiological and ultrasonic study was done on 100 patients with urinary tract infection under age of 10 years attending pediatric Department of Tikrit Teaching Hospital during the period from 1 st of February to the last of October 2007. The patients were divided into two groups (50 patients for each), the first group were with first attack of urinary tract infection and the second group were with recurrent urinary tract infection. Most of the patients in the first group (60%) were between the ages of 5-10 years, and most of them were males (58%)and they were from the urban areas (64%), while those with recurrent infections were at the ages range between 1-5 years (88%) , most of them were females (86%) and they were also from the urban areas (88%). The commonest presentation of patients with the first attack urinary tract infection was urgency (44%) while those in the second group present with failure to gain weight (98%). E.coli was the most commonly isolated microorganism in both groups with regard to age as well as for sex of patients ( 56% and 66% respectively). Cystitis was the commonest ultrasonic picture in patients with first attack of urinary tract infection (58%)while bladder wall thickening was the commonest picture in the recurrent attack group (66%). Introduction Urinary tract infection (UTI) is defined as the presence of bacteria in urine along with symptoms of infection. UTIs occur in as many as 5 percent of girls and 1 to 2 percent of boys. The kidneys filter and remove waste and water from the blood to produce urine. They get rid of about one and half to two quarts of urine per day an adults and less in children(1). Normal urine contains no bacteria (germs).Urinary tract infection usually occur as a consequence of colonization of the periurethral area by a virulent organism that subsequently gains access to the bladder(2) . Bacteria may, at times, get into the urinary tract and the urine from the skin around the rectum and genitals by traveling up the urethra into the bladder. When this happens, the bacteria can infect and inflame the bladder and cause swelling and pain in the lower abdomen and side. This bladder infection is called cystitis(3). If the bacteria travel up through the ureters to the kidneys, a kidney infection can develop. Kidney infections are much more serious than bladder infections. . During the first few months of life, uncircumcised male infants are at increased risk for UTIs, but thereafter UTIs predominate in females(1). Urinary tract infection (UTI) is common in pediatric practice and an important cause of morbidity and mortality in children. Infected urine stimulates an immunological and inflammatory response leading to renal injury and scarring, ultimately leading to end stage renal failure(4). Prompt diagnosis and management of UTI can reduce the incidence of morbidity and life threatening bacteraemia. Approximately 3-5% of the if undiagnosed leads to permanent renal damage causing hypertension or end stage renal disease. The diagnosis of UTI is difficult in the neonatal period because the signs and symptoms are non-specific in this age group(3). The incidence in the neonates is 0.01-1% and can also be as high as 10% in low birth weight and preterm babies(2). Checking a urine sample is the only way to diagnose a bladder infection, as there is usually no outward sign on the penis or vagina that indicates an infection. E coli usually causes a child's first infection, but other gram-negative bacilli and enterococci may also cause infection. The specimen for urinalysis and culture should be obtained by catheter or suprapubic aspiration in the infant or child unable to void on request . Additional tests may be recommended to check for abnormalities in the urinary tract. Repeated infections in abnormal urinary tracts may cause kidney damage(5). The kinds of tests ordered will depend on the child and the type of urinary infection. Because no single test can tell everything about the urinary tract that might be important, more than one of the following tests may be needed: Kidney and bladder ultrasound, Voiding cystourethrogram, Intravenous pyelogram, Nuclear scans, Computed tomography (CT) scans and magnetic resonance imaging (MRI) (3). Although intravenous urography has been a time-honored examination in the initial radiologic evaluation of UTI in children,ultrasonography has largely replaced intravenous urography as the initial screening examination.Ultrasonography alone is not generally adequate for investigation of UTI in children, as it is unreliable in detecting vesicoureteral reflux, renal scarring or inflammatory changes(6). If reflux or morphologic abnormalities are identified, renal scintigraphy and voiding cystourethrography are recommended to further search for renal scarring or urinary tract abnormalities(7). The way the antibiotic is given and the number of days that it must be taken depend in part on the type of infection and how severe it is(6). Materials and methods A descriptive , microbiological and ultrasonic study was done on children under 10 years with acute and recurrent UTIs attending the Pediatric Department in Tikrit Teaching Hospital during the period from 1 st of February to the last of October 2007. 1. Descriptive study: Each patient with acute or recurrent UTI is assessed by a prepared questionnaire including the name, age , sex, residence, frequency, urgency, painful micturition, fever, vomiting, diarrhea, loss of appetite and failure to gain weight.

Abstract: INTRODUCTION : Controversy continues to exist regarding when and how a child with urinary tract infection should be evaluated. Urinary tract infections are common at the extremes of age - in children and elderly. Symptoms of urinary tract infections are vague and generalized1. Recognition and evaluation of urinary tract infection and genitourinary anomalies associated with the infection and subsequent management prevents long term complications of progressive parenchymal and functional loss. In infants UTI is the most common cause of parenchymal loss. 5% to 10% of children with UTI have obstructive urinary tract infection and an additional 21% to 57% have vesicoureteric reflux2. Children with voiding dysfunction, neurogenic bladder, bowel dysfunction have associated urinary tract infections3,4. Hence evaluation of the index infection may be worth evaluating to detect anomalies in the urinary tract and helps in prevention of morbidity of recurrent infections and renal damage. AIMS : 1. To detect the abnormalities of the urinary tract associated with urinary tract infection in children. 2. To find out the most common organism associated with urinary tract infection. 3. To find out the most useful drug in treating UTI. 4. To evaluate the yield of the various diagnostic modalities. MATERIALS AND METHODS : After approval from the Ethical committee and permission from the collaborating departments of this institution, the prospective study on evaluation of urinary tract infection in children was conducted at Coimbatore Medical College Hospital. Period of study : The period of study was from March 2006 to March 2008. The study was carried out at the Department of Paediatric Surgery in collaboration with Departments of Microbiology and Radiodiagnosis. Study design : The children who reported at or were referred to our out patient department with symptoms and signs of urinary tract infection were evaluated with urine culture. Children with positive urine culture were included in the study and further evaluated with ultrasonogram (USG) of kidney and bladder. The urinary tract infection is treated with appropriate antibiotics as dictated by antibiogram. Once the urine culture became negative, these children were subjected to voiding cystourethrogram with antibiotic prophylaxis. Cystocopy, renal scintigrapy, urodynamic study and other relevant investigations were performed based on the individual merits of the condition. The results were compiled and analysed. CONCLUSION : 1. Twenty nine percent of the UTIs are associated with genitourinary anomalies hence it is worth evaluating the child with UTI. 2. Vesicoureteic reflux is the commonest anomaly associated with UTI. 3. E.coli is the commonest organism causing UTI. 4. Voiding cystourethrogram is the tool for the diagnosis of VUR and PUV. 5. It is reasonable to approach a UTI with VCUG and if it is necessary an USG to rule out other anomalies. 6. Amikacin may be useful for empirical treatment for UTI in our children. 7. Since the study is conducted on a select and small population it needs further study.