Abstract: BACKGROUND AND OBJECTIVE: Continuous antibiotic prophylaxis (CAP) is recommended to prevent urinary tract infections (UTIs) in newborns with antenatal hydronephrosis (HN). However, there is a paucity of high-level evidence supporting this practice. The goal of this study was to conduct a systematic evaluation to determine the value of CAP in reducing the rate of UTIs in this patient population. METHODS: Pertinent articles and abstracts from 4 electronic databases and gray literature, spanning publication dates between 1990 and 2010, were included. Eligibility criteria included studies of children <2 years old with antenatal HN, receiving either CAP or not, and reporting on development of UTIs, capturing information on voiding cystourethrogram (VCUG) result and HN grade. Full-text screening and quality appraisal were conducted by 2 independent reviewers. RESULTS: Of 1681 citations, 21 were included in the final analysis ( N = 3876 infants). Of these, 76% were of moderate or low quality. Pooled UTI rates in patients with low-grade HN were similar regardless of CAP status: 2.2% on prophylaxis versus 2.8% not receiving prophylaxis. In children with high-grade HN, patients receiving CAP had a significantly lower UTI rate versus those not receiving CAP (14.6% [95% confidence interval: 9.3–22.0] vs 28.9% [95% confidence interval: 24.6–33.6], P < .01). The estimated number needed to treat to prevent 1 UTI in patients with high-grade HN was 7. CONCLUSIONS: This systematic review suggests value in offering CAP to infants with high-grade HN, however the impact of important variables (eg, gender, reflux, circumcision status) could not be assessed. The overall level of evidence of available data is unfortunately moderate to low. * Abbreviations: APD — : anteroposterior diameter CAP — : continuous antibiotic prophylaxis CI — : confidence interval HN — : hydronephrosis OR — : odds ratio SFU — : Society for Fetal Urology UTI — : urinary tract infection VCUG — : voiding cystourethrogram VUR — : vesicoureteral reflux

Abstract: No universal guidelines exist for the management of patients with mild to moderate antenatal hydronephrosis (ANH). In this Review, the authors assess the data and present their own approach to postnatal risk stratification and management, including recommendations regarding serial ultrasonography schedule, prophylactic antibiotics, voiding cystourethrogram and renal scintigraphy. No universal guidelines exist for the management of patients with mild to moderate antenatal hydronephrosis (ANH). Unsurprisingly, practice patterns vary considerably with respect to recommendations for postnatal evaluation and follow-up imaging schedule. Although some clinical tools are available to specifically grade ANH and postnatal hydronephrosis, these are commonly used interchangeably with varying degrees of success. A universal classification system and nomenclature are needed to best identify patients at risk of renal deterioration, UTI and need for surgical intervention. We present our own approach to postnatal risk stratification and management, including recommendations regarding serial ultrasonography schedule, prophylactic antibiotics, voiding cystourethrogram and renal scintigraphy.

Abstract: Urinary tract infection (UTI) is a common infection in infants and children. During infancy, boys are more commonly affected than girls and thereafter, female preponderance is found. Presentation varies among different age groups. Clinical features in neonates and young infants are non-specific, manifest as septicemia where a high index of suspicion is needed. Older children typically present as simple or complicated UTI. Rapid diagnosis, institution of early treatment and further evaluation by imaging modalities are of utmost importance. The prevention of recurrent UTI and detection of congenital anomalies of kidney and urinary tract are major objectives in the management. Use of ultrasound is required to detect underlying congenital abnormalities, whereas voiding cystourethrogram and dimercaptosuccinic acid (DMSA) scan are useful in the diagnosis of obstructive uropathy and vesicoureteric reflux and renal scar, respectively. The children requiring surgical interventions are to be recognised early to prevent recurrent UTI. The treatment of vesicoureteric reflux by chemoprophylaxis in lower grades and surgical treatment in higher grades are important consideration in prevention of recurrent UTI. This is required to prevent renal parenchymal damage and scarring that can cause hypertension and progressive renal insufficiency in later life.

Abstract: BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011 The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS) The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings METHODS: This was a quality improvement implementation study in a large academic medical center Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider A multidisciplinary team developed and tested interventions Impact was assessed with annotated run charts Statistical comparisons were made with χ2 analysis and Fisher’s exact test RESULTS: The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department Rates have been sustained for 12 months and 8 months, respectively Interventions using the electronic medical record and ordering system were most impactful CONCLUSIONS: Rapid adoption of evidence-based UTI care across multiple settings is achievable Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting * Abbreviations: AAP — : American Academy of Pediatrics CCHMC — : Cincinnati Children’s Hospital Medical Center ED — : emergency department EHR — : electronic health record H&P — : history and physical HM — : Hospital Medicine QI — : quality improvement RBUS — : renal and bladder ultrasound UTI — : urinary tract infection VCUG — : voiding cystourethrogram

Abstract: Purpose: Anterior urethral valves (AUV) is an unusual cause of congenital obstruction of the male urethra, being 15 to 30 times less common than posterior urethral valves (PUV). It has been suggested that patients with congenital anterior urethral obstruction have a better prognosis than those with PUV.The long term prognosis of anterior urethral valves is not clear in the literature. In this report we describe our experience and long-term follow up of patients with AUV. Materials and methods: We retrospectively identified 13 patients who presented with the diagnosis of AUV in our institutions between 1994 and 2012. From the 11 patients included, we evaluated the gestational age, ultrasound and voiding cystourethrogram findings, age upon valve ablation, micturition pattern, creatinine and clinical follow up. Results: Between 1994 and 2012 we evaluated 150 patients with the diagnosis of urethral valves, where 11 patients (7.3%) had AUV and an adequate follow up. Mean follow up is 6.3 years. 5 patients (45.4%) had pre-natal diagnosis of AUV. The most common prenatal ultrasonographic finding was bilateral hydronephrosis and distended bladder.The mean gestational age was 37.6 weeks. Postnatally, 90% had trabeculated bladder, 80% hydronephrosis and 40% renal dysplasia. The most common clinical presentation was urinary tract infection in 5 patients (45.4%).7 patients (63.6%) had primary transurethral valve resection or laser ablation and 3 patients (27.2%) had primary vesicostomies. One boy (9.1%) had urethrostomy with urethral diverticulum excision. 2 patients (18.2%) developed end-stage renal disease (ESRD). Conclusions: Early urinary tract obstruction resulted in ESRD in 18% of our patient population. In our series, the complication rate and the evolution to renal failure are high and similar to patients with PUV. In patients with AUV we recommend long-term follow up and close evaluation of patient’s bladder and renal function.

Abstract: Vesicoureteral reflux is a major problem in childhood affecting 1% of all children. There are various surgical methods for vesicoureteral reflux treatment. Current study evaluates effectiveness and success rate of the Lich-gregoir procedure in treatment of the vesicoureteral reflux. In a descriptive-analytical study, 32 children with 47 reflux unit underwent Lich-gregoir anti-reflux procedure in Imam Reza and Amir-al-Momenin Hospitals, Tabriz between March 2008 and August 2011. Surgery outcome and success rate, sonographic findings and complications rate were recorded in follow-up. Patients mean age was 5.85 +/- 3.81 years. 28.1% were male and 71.9% were female. Reflux was unilateral in 53.1% and bilateral in 46.9%. Vesicoureteral reflux grade I to V was in one, 1, 13, 22 and ten patients, respectively. Voiding Cystourethrogram (VCUG) findings were abnormal in all cases before operation. Surgery success rate in first 6 months was 95.7% and was 100% in 8 months after operation. Hydronephrosis disappeared after operation in all cases. Complication occurred in 2 cases (6.25%) with bilateral reflux including urinary intention and lymphocele. Lich-gregoir anti-reflux procedure technique is accompanied with higher success rate, low complication and hydronephrosis improvement and is an appropriate treatment for vesicoureteral reflux in children.

Abstract: Background/Aim: To evaluate the spontaneous resolution rate in infants and young children with vesicoureteral reflux (VUR). Patients and Methods: Paediatric patients with VUR treated in our hospital from January 2000 to December 2010 were retrospectively analyzed. Only patients with pretreatment and follow-up voiding cystourethrogram were included into the study. Treatment success was defined as complete VUR resolution. Results: The resolution rate for infants less than 1 year of age was 38.6% (17 of 44 renal units). Renal units with mild-moderate VUR (I-III) had a resolution rate of 40% (12 of 30 renal units) compared to 35.7% (5 of 14 renal units) with severe grade (IV-V) VUR. The resolution rate for children over 1 year of age was 39,1% (9 of 23 renal units). Renal units with mild-moderate VUR (I-III) had a resolution rate of 42.9% (9 of 21 renal units) compared to 0% (0 of 2 renal units) with severe grade (IV-V) VUR. Conclusion: Infants less than 1 year of age with nonsymptomatic, mild, moderate or severe VUR have a spontaneous resolution rate of more than 35% and therefore should receive a primary conservative therapy. Children over 1 year of age with nonsymptomatic mild-moderate VUR (I-III) have a spontaneous resolution rate of about 40% and should receive primary conservative treatment as well.

Abstract: Background: The purpose of the study is to present the author's experience with congenital bladder diverticula in seven pediatric patients at a developing world tertiary care center. Materials and Methods: Records of seven patients diagnosed and treated as congenital bladder diverticulum, from January 1998 to December 2009 were retrospectively reviewed for age, sex, clinical symptoms, investigative work-up, operative notes, and postoperative follow-up. Results: All patients were males. Age at presentation ranged from six months to six years (mean three years and six months). All were manifested postnatally by urinary tract infection in four cases, bladder retention in three cases and abdominal pain in two cases. Diagnosis was suggested by ultrasound and confirmed by voiding cystourethrography (VCUG) in all cases and urethrocystoscopy in three cases. Open surgical excision of diverticulum was done in all the patients associated with ureteral reimplantation in four patients with VCUG-documented high-grade vesicoureteral reflux (VUR). Average follow-up was four years; there is a resolution of symptoms and no diverticulum recurrence at the defined mean follow-up. Conclusion: Recurrent urinary tract infections and voiding dysfunction in pediatric population should always be evaluated for congenital bladder diverticulum. Investigations such as abdominal ultrasound, VCUG and nuclear renal scanning, form an important part of preoperative diagnostic work-up and postoperative follow up. Diverticulectomy with ureteral reimplantation in case of high-grade reflux, provides good results without recurrence.

Abstract: ; C-reactive protein, 2.3 mg/dL. Urinalysis demons-trated microscopic pyuria (50-75 white blood cells/high power field). Transabdominal ultrasonography disclosed a complex cystic mass on the base of the urinary bladder. Voiding cystourethrogram showed contrast material filling the urethral diverticulum (UD) that encircled the urethral lumen (Figure-1). Coronal and axial T2-weighted MR images demons-trated a circumferential high-signal intensity, fluid--filled lesion with fluid-debris level and confirmed the diagnosis of UD (Figure-2). Cystourethroscopy showed two orifices of the UD (Figure-3). Transvagi-nal diverticulectomy was performed and postopera-tive course was uneventful. A UD is a focal outpouching of the urethra and usually occurs in women in the 3rd-7th decade of life, with an estimated prevalence of 0.6-6% (1). The vast majority of UDs are from acquired causes, with the most widely accepted theory involving rup-ture of a chronically obstructed and infected periu-rethral gland into the urethral lumen. Risk factors for acquired UDs include repeated infection of the pe-riurethral glands, vaginal birth trauma, trauma from the prior vaginal or urethral procedures (1). The classic presentation of UD has been des-cribed historically as the “three Ds”: dysuria, dys-pareunia, and dribbling (post-void). The most useful imaging modality for UDs is MRI (2). MRI plays an important role in the diagnosis of UDs and ideally provides the surgeon with preoperative information regarding location, number, size, configuration, and communication of the UDs. Although MRI is the best preoperative diagnostic tool for evaluating the UDs, the old standby double balloon pressure urethrogra-phy (adding sky-blue or brilliant green as staining agent) is of great value of intraoperative identifica-tion of these compound diverticular sacks and facili-tating their resection (3). Complications associated with UDs include recurrent infection, urinary incontinence, calculus formation, and development of intradiverticular neoplasm. Clinicians should be aware of the possibility of a UD in women with unexplained

Abstract: Purpose The American Academy of Pediatrics recently recommended against routine voiding cystourethrograms (VCUGs) in children 2 to 24 months with initial febrile UTI, raising concern for delayed diagnosis and increased risk of UTI-related renal damage from vesicoureteral reflux (VUR). We assessed factors potentially associated with higher likelihood of abnormal VCUG, including UTI recurrence, which could allow for more judicious test utilization.

Abstract: Introduction: Vesicoureteral reflux (VUR) is a risk factor for kidney scarring, hypertension and declining renal function. Standard diagnostic methods are invasive and can cause exposure to radiation and urinary tract infections (UTIs). We aimed to investigate urine albumin and interleukin-8 levels as markers of ongoing VUR and renal damage in children without UTIs. Methods: Random urine samples were collected from 51 children, including 16 children with VUR (group A), 17 children with resolved VUR (group B) and 18 normal children (group C). The diagnosis of VUR or resolved VUR was confirmed by voiding cystourethrogram (VCUG) or direct radionuclide cystography (DRNC). All children had normal kidney function and had no evidence of UTI in the preceding three months. Random urine specimens were assayed for albumin (Alb), creatinine (Cr) and interleukin-8 (IL-8) and mean values were compared by one way ANOVA. Results: In groups A and B, the mean age at first UTI was 31.7 ± 2.4 and 27 ± 2.0 months respectively. In group A, the mean duration between VUR diagnosis and study entrance was 30 ± 9.1 months. In group B, the mean duration between VUR diagnosis and recovery was 19.9 ± 1.3 months. Overall, 76.4% of affected children had bilateral VUR and 41.2% had severe VUR. There were no significant differences in urinary Alb, IL-8, Alb/Cr and IL-8/Cr between the three groups.

Abstract: A 19-year-old male patient was admitted with flank pain, which had lasted intermittently for four years. In X-ray, there was a radiopacity with a dimension of 6 × 4 cm on the left pelvic bone. Intravenous pyelography revealed a huge left megaureter with a stone in the lower end and grade V hydronephrosis. A left ureterolithotomy, left nipple ureteroneocystostomy, and psoas hitch operation was performed. A voiding cystourethrogram taken three months after the operation showed no reflux, and in IVP there was reduced dilatation of the collecting system when compared to the ureter before the operation.

Abstract: An 18-year-old man born with aphallia had undergone phallic reconstruction in childhood followed by total urethral reconstruction with a buccal mucosal graft and groin-based pedicle (Singapore) flap urethroplasty at 13 years of age. The patient presented with obstructive voiding symptoms lasting 6 months followed by acute urinary retention. The results of a voiding cystourethrogram showed a filling defect in the distal urethra that had been reconstructed by use of the skin flap. On urethroscopy, a 3 cm×2 cm sized tricholithobezoar was seen in the distal urethra. Pneumatic lithotripsy followed by bulbar urethrolithotomy was performed in the same operation to extract the bezoar. The remaining hairs were mechanically epilated. The patient has been doing well for 6 months of follow-up.

Abstract: A 7-year-old girl presented with recurrent lower respiratory tract infections, coughing episodes associated with liquids and recurrent abdominal distension. There was maternal polyhydramnios and absent gastric bubble on antenatal anomaly scan with an antenatal diagnosis of pure oesophageal atresia (OA). There was no family history of OA for three generations on maternal or paternal side. At birth she had babygram showing arrested orogastric tube in the upper blind pouch and gasless abdomen, no vertebral anomalies and spinal ultrasound, echocardiogram and renal ultrasound were all normal. Voiding cystourethrogram with distal loopogram demonstrated bilateral vesicoureteral reflux (VUR). The chromosomal studies revealed normal 46XX karyotype and the patient had genetic counselling. She was born with partial …

Abstract: Congenital obstruction of the male urethra is usually caused by posterior urethral valves. Anterior urethral valves (AUV) represent a rare anomaly with a wide spectrum of presentation varying from mild voiding difficulties to end-stage renal disease. Prompt diagnosis and appropriate treatment is essential to prevent renal impairment. We report the case of a 13 month-old boy who presented with deterioration of kidney function caused by unrecognized AUV disorder. Temporary cutaneous vesicostomy was necessary to protect the upper urinary tract from further damage and to stabilize renal function. Even though a voiding cystourethrogram (VCUG) demonstrated obstruction of distal urethra, AUV were initially overlooked but finally diagnosed on additional VCUG followed by urethroscopy.

Abstract: The most commonly used treatment modality for urethral strictures is the direct visual internal urethrotomy (DVUI) method according to Sachse. It is an effective short-term treatment, but the long-term success rate is low. A number of factors influence the outcome of DVUI including stricture location, spongiofibrosis and previous endoscopic stricture treatment. Multiple urethrotomy has a negative impact on the success rate of subsequent urethroplasty. A thorough preoperative diagnostic work-up including combined retrograde urethrogram/voiding cystourethrogram (RUG/VCUG) and urethrocystoscopy is, therefore, mandatory to allow for patient counselling regarding the risk of stricture recurrence and other treatment options. After a failed primary DVUI, subsequent urethrotomy cannot be expected to be curative.