Abstract: IMPORTANCE: No studies have systematically examined the accuracy of clinical, laboratory, and imaging variables in detecting renal scarring in children and adolescents with a first urinary tract infection. OBJECTIVES: To identify independent prognostic factors for the development of renal scarring and to combine these factors in prediction models that could be useful in clinical practice. DATA SOURCES: MEDLINE and EMBASE. STUDY SELECTION: We included patients aged 0 to 18 years with a first urinary tract infection who underwent follow-up renal scanning with technetium Tc 99m succimer at least 5 months later. DATA EXTRACTION AND SYNTHESIS: We pooled individual patient data from 9 cohort studies. MAIN OUTCOMES AND MEASURES: We examined the association between predictor variables assessed at the time of the first urinary tract infection and the development of renal scarring. Renal scarring was defined by the presence of photopenia on the renal scan. We assessed the following 3 models: clinical (demographic information, fever, and etiologic organism) and ultrasonographic findings (model 1); model 1 plus serum levels of inflammatory markers (model 2); and model 2 plus voiding cystourethrogram findings (model 3). RESULTS: Of the 1280 included participants, 199 (15.5%) had renal scarring. A temperature of at least 39°C, an etiologic organism other than Escherichia coli, an abnormal ultrasonographic finding, polymorphonuclear cell count of greater than 60%, C-reactive protein level of greater than 40 mg/L, and presence of vesicoureteral reflux were all associated with the development of renal scars (P ≤ .01 for all). Although the presence of grade IV or V vesicoureteral reflux was the strongest predictor of renal scarring, this degree of reflux was present in only 4.1% of patients. The overall predictive ability of model 1 with 3 variables (temperature, ultrasonographic findings, and etiologic organism) was only 3% to 5% less than the predictive ability of models requiring a blood draw and/or a voiding cystourethrogram. Patients with a model 1 score of 2 or more (21.7% of the sample) represent a particularly high-risk group in whom the risk for renal scarring was 30.7%. At this cutoff, model 1 identified 44.9% of patients with eventual renal scarring. CONCLUSIONS AND RELEVANCE: Children and adolescents with an abnormal renal ultrasonographic finding or with a combination of high fever (≥39°C) and an etiologic organism other than E coli are at high risk for the development of renal scarring.

Abstract: INTRODUCTION Traditionally, a voiding cystourethrogram (VCUG) has been obtained in patients diagnosed with multicystic dysplastic kidney (MCDK) because of published vesicoureteral reflux (VUR) rates between 10%-20%. However, with the diagnosis and treatment of low grade VUR undergoing significant changes, we questioned the utility of obtaining a VCUG in healthy patients with a MCDK. We reviewed our experience to see how many of the patients with documented VUR required surgical intervention. MATERIALS AND METHODS We performed a retrospective review of children diagnosed with unilateral MCDK from 2002 to 2012 who also underwent a VCUG. RESULTS A total of 133 patients met our inclusion criteria. VUR was identified in 23 (17.3%) children. Four patients underwent ureteral reimplant (3.0%). Indications for surgical therapy included breakthrough urinary tract infections (2 patients), evidence of dysplasia/scarring (1 patient) and non-resolving reflux (1 patient). All patients with a history of VUR who are toilet trained, regardless of the grade or treatment, are currently being followed off antibiotic prophylaxis. To date, none have had a febrile urinary tract infection (UTI) since cessation of prophylactic antibiotics. Hydronephrosis in the contralateral kidney was not predictive of VUR (p = 0.99). CONCLUSION Routine VCUG in healthy children diagnosed with unilateral MCDK may not be warranted given the low incidence of clinically significant VUR. If a more conservative strategy is preferred, routine VCUG may be withheld in those children without normal kidney hydronephrosis and considered in patients with normal kidney hydronephrosis. If a VCUG is not performed the family should be instructed in signs and symptoms of urinary tract infection.

Abstract: Objective: The aim was to study the outcome of posterior urethral valve (PUV) cases treated by stepladder protocol and the prognostic factors affecting the outcome. Materials and Methods: Hospital records of all PUV patients treated by stepladder protocol between January 1992 and December 2013 were reviewed. The studied parameters were: Age at presentation, serum creatinine, types of surgical intervention, vesicoureteral reflux (VUR) on initial voiding cystourethrogram (VCUG), renal cortical scars, plasma renin activity (PRA), and glomerular filtration rate (GFR). Results: Of 396 PUV patients treated during the study period, 152 satisfied study criteria. The age at presentation ranged from 2 days to 15 years (mean 31.3 months). The mean follow-up period was 5 years (range: 2-18 years). Primary endoscopic valve ablation was the most common initial procedure. Chronic renal failure was seen in 42.7% patients at the last follow-up. Serum creatinine at presentation, initial PRA levels, initial GFR, and PRA levels at last follow-up were significant predictors of final renal outcome. Age at presentation ( 1 year), presence/absence of VUR on initial VCUG and renal cortical scars had no significant correlation with ultimate renal function. Conclusion: Our study confirms the high prognostic significance of initial serum creatinine, PRA levels and GFR in cases with PUV. PRA also holds promise in long-term follow-up of these patients as a marker of progressive renal damage.

Abstract: Common pathogens of clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) are viruses, such as influenza virus. However, bacteria are rare pathogens for MERS. We report the first patient with MERS associated with febrile urinary tract infection. A 16-year-old lupus patient was admitted to our hospital. She had fever, headache, vomiting, and right back pain. Urinary analysis showed leukocyturia, and urinary culture identified Klebsiella pneumoniae. Cerebrospinal fluid examination and brain single-photon emission computed tomography showed no abnormalities. Therefore, she was diagnosed with febrile urinary tract infection. For further examinations, 99mTc-dimercaptosuccinic acid renal scintigraphy showed right cortical defects, and a voiding cystourethrogram demonstrated right vesicoureteral reflux (grade II). Therefore, she was diagnosed with right pyelonephritis. Although treatment with antibiotics administered intravenously improved the fever, laboratory findings, and right back pain, she had prolonged headaches, nausea, and vomiting. T2-weighted, diffusion-weighted, and fluid attenuated inversion recovery images in brain magnetic resonance imaging showed high intensity lesions in the splenium of the corpus callosum, which completely disappeared 1 week later. These results were compatible with MERS. To the best of our knowledge, our patient is the first patient who showed clinical features of MERS associated with febrile urinary tract infection. Conclusion: In patients with pyelonephritis and an atypical clinical course, such as prolonged headache, nausea, vomiting, and neurological disorders, the possibility of MERS should be considered.

Abstract: Vesicoureteral reflux, the retrograde flow of bladder urine into the ureter, is common in young children with urinary tract infections and is associated with renal scarring. Reflux is generally discovered when a voiding cystourethrogram is obtained after a urinary tract infection and is categorized as grade I (retrograde flow of urine into the ureter alone) to grade V (massive reflux into a distorted ureter and calyceal system). After an observational study by Edwards et al.1 showed that vesicoureteral reflux improved or resolved with long-term, low-dose antibiotic treatment to prevent infection, such treatment gained popularity. Nearly four decades later, we still . . .

Abstract: Objective Our aim was to describe laboratory findings and imaging results for neonatal patients diagnosed with urinary tract infection (UTI). Study Design Medical records were reviewed for infants diagnosed with UTI in a single neonatal intensive care unit (NICU) over a 13-year period. Results Of the 8,241 patients admitted to the NICU during the study period, 137 infants were diagnosed with UTI. Imaging was reviewed for 101 patients. Renal pelvis dilation was found in 34% of patients and vesicoureteral reflux was found in 21%. Renal pelvis dilation was not associated with reflux (OR: 0.53 [95% CI: 0.18–1.5]). The sensitivity of urinalysis to detect a positive culture was 76%, and the specificity was 41%. Tests of cure for bacterial infections were uniformly negative. Conclusion Renal pelvis dilation was common but not associated with reflux among NICU patients diagnosed with UTI. Diagnostic criteria in this population are not well defined, and guidelines are needed for diagnosis and management of UTIs in NICU patients.

Abstract: Few standards exist for reporting results of voiding cystourethrogram (VCUG). To assess the variation in reporting of VCUG findings from different facilities using a standardized assessment tool. VCUG reports were evaluated for demographic, technical, anatomical and functional information. Reports were categorized by age, gender, indication and vesicouretal reflux (VUR) status. Institutions were classified as a free-standing pediatric hospital (n = 3), pediatric hospital within a hospital (n = 11), or non-pediatric facility (n = 24) and reports were classified as having been read by a pediatric radiologist or not. Each category of outside reports (n = 152) was randomly matched with a twice-larger group of Hospital A reports from the same category (n = 304). Multivariate linear regression was used to analyze the association between the primary outcome (percentage of items described in dictated VCUG report) and the type of radiologist and institution. Of the 456 studies, 66% were in girls, 56% were in those <12 months old, and the indication was urinary tract infection (UTI) in 81%. The mean percentage of items reported was 67 ± 14% (74 ± 7% at free-standing pediatric hospitals, 61 ± 10% at pediatric hospitals within a hospital, and 48 ± 11% at non-pediatric facilities). In multivariate analysis, VCUG reports generated at non-pediatric facilities had 17% fewer items included (95% CI: 14.5–19.7%, P < 0.0001), and pediatric hospitals within a hospital had 9% fewer items included (5.9–12.5%, P < 0.0001) when compared to free-standing pediatric hospitals. Reports read by a pediatric radiologist had 12% more items included (9.1–15.3%, P < 0.0001) compared to those read by a non-pediatric radiologist. More complete VCUG reports were observed when generated at free-standing pediatric hospitals and when interpreted by a pediatric radiologist.

Abstract: * Abbreviations: AAP — : American Academy of Pediatrics RBUS — : renal and bladder ultrasound UTI — : urinary tract infection VCUG — : voiding cystourethrogram VUR — : vesicoureteral reflux In this issue of Pediatrics , Nelson and colleagues present a retrospective cross-sectional study of children <60 months of age who underwent renal and bladder ultrasound (RBUS) and voiding cystourethrogram (VCUG).1 Like other studies of this topic,2–6 this is a retrospective analysis of data captured through routine care, but it is probably the largest and most well-conducted study of its kind. Their findings are consistent with most earlier work, and their conclusions valid: RBUS is a lousy screen for vesicoureteral reflux (VUR). Because the new American Academy of Pediatrics (AAP) guidelines7 recommend routine RBUS after the first febrile urinary tract infection (UTI), the authors make the point that a negative RBUS should not be interpreted as ruling out VUR or other conditions detectible on VCUG. This raises an important … Address correspondence to Stephen M. Downs, MD, MS, 410 West 10th St, HS1000, Indianapolis, IN 46202. E-mail: stmdowns{at}iu.edu

Abstract: Bladder diverticula are herniations of bladder mucosa through fibres of the detrusor muscle. We present the extravesical approach to a case of paraureteral bladder diverticulum in a six-year old boy who had a history of recurrent urinary infection. In case of recurrent urinary complaints, the possibility of presence of a bladder diverticulum should be kept in mind. Voiding cystourethrogram is helpful for the differential diagnosis of the bladder diverticulum. Excision by extravesical approach of the paraureteral bladder diverticulum is a good choice.

Abstract: Received March 2013 Accepted June 2013 Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India. A 10-year-old‎girl‎was‎ referred‎ for‎a‎voiding‎cystourethrogram‎(VCUG)‎with‎a‎history‎of‎ recurrent‎urinary‎ tract‎ infections.‎Examination‎including‎neurological‎evaluation‎was‎unremarkable.‎ Ultrasonography‎of‎the‎kidneys‎and‎bladder‎was‎normal.‎Voiding‎phase‎of‎VCUG‎was‎subsequently‎performed.‎Bladder‎ capacity‎and‎outline‎were‎normal‎(Figure‎1).‎There‎was‎marked‎dilatation‎of‎posterior‎urethra‎(Figure‎2)‎with‎smooth‎tapering‎towards‎ distal‎end‎resembling‎a‎“spinning‎top”.‎No‎vesicoureteral‎reflux‎or‎post-void‎residual‎urine‎was‎noted.‎Spinning‎top‎urethra‎(STU)‎ represents‎a‎widened‎posterior‎urethra‎seen‎mainly‎in‎girls.‎For‎a‎long‎time,‎it‎was‎considered‎a‎normal‎variation,‎due‎to‎contraction‎ of‎transverse‎fibers‎of‎urethral‎sphincter‎located‎in‎the‎distal‎urethra.(1)‎Proponents‎of‎STU‎as‎a‎pathological‎entity‎have‎attributed‎it‎ variably‎to‎meatal‎stenosis,‎urethral‎ring,‎distal‎sphincter‎dyssynergia,‎bladder‎instability‎and‎congenital‎wide‎bladder‎neck‎anomaly‎ (CWBNA).(2)‎‎Former‎three‎mechanisms‎were‎refuted‎by‎studies‎showing‎high‎urine‎flow‎rates‎in‎subjects‎with‎STU.‎For‎the‎latter‎two‎ mechanisms,‎controversy‎exists‎because‎majority‎of‎cases‎with‎instability‎and‎CWBNA‎do‎not‎show‎STU.‎Thus,‎one‎should‎consider‎ STU‎a‎normal‎variant,‎sometimes‎occurring‎in‎children‎with‎instability‎or‎CWBNA.‎Differential‎diagnosis‎includes‎Lyon1s‎(fibrous)‎ ring‎in‎girls‎and‎urethral‎valves‎in‎males.‎(3) PICTORIAL

Abstract: Voiding cystourethrogram (VCUG) is needed to ascertain the upper end of urethral stricture. Occasionally, a patient is unable to open the bladder neck with resultant failure of the test. Realizing the strong and prompt alpha antagonistic action of silodosin, we evaluated single 8 mg dose as a pharmacological adjunct prior to VCUG to overcome this problem.

Abstract: Presence of posterior urethral valves (PUV) is the most common cause of urinary tract obstruction in the male neonate. Late presentation occurs in 10% of cases. We present a case of PUVs in an adult male who presented with history of obstructive lower urinary tract symptoms and hematuria. On evaluation, he was found to have raised serum creatinine level. A voiding cystourethrogram (VCUG) could not be completely performed because of narrowing in the posterior urethra. A rigid urethrocystoscopy was performed at which he was found to have type-I posterior urethral valve which were fulgurated. A repeat uroflowmetry revealed maximum flow rate of 12 ml/second. This case highlights that PUVs is not solely a disease of infancy but may also present late. VCUG is the radiological investigation of choice but the diagnosis may be missed. A urethrocystoscopy is advised if there is a high index of suspicion.

Abstract: A voiding cystourethrogram (VCUG) is one of the most commonly performed studies in pediatrics. A VCUG is a fluoroscopic study that can assess the structure and function of the bladder and the structure of the urethra. It is frequently used in the evaluation of children with urinary tract infections to determine the presence of vesicoureteral reflux (VUR), bladder diverticula, complete bladder emptying, and assess for possible bladder sphincter dyssynergia. It is also used in the evaluation of hydronephrosis, congenital renal anomalies, imperforate anus, cloacal abnormalities, disorders of sexual differentiation, trauma, and screening siblings for VUR. In addition, it provides information regarding the urethra and is used in diagnosing posterior urethral valves, urethral strictures, or suspicion of a duplicated urethra or other anomalies.

Abstract: © The Canadian Journal of UrologyTM; 21(5); October 2014 Address correspondence to Dr. Lane S. Palmer, Pediatric Urology, Cohen Children’s Medical Center of New York, 269-01 76th Avenue, New Hyde Park, NY 11040 USA Voiding cystourethrogram in multicystic dysplastic kidney: the pendulum has swung Ariella A. Friedman, MD, Lane S. Palmer, MD Cohen Children’s Medical Center, North Shore-Long Island Jewish Health System, New Hyde Park, New York, USA Referring to the article published on pp. 7510-7514 in this issue

Abstract: A retrospective study for data record of 106 patients subjected to voiding cystourethrogram test (VCUG), sonography test, and dimercaptosuccinic acid (DMSA) scintigraphy take place at King Abdulaziz University, radiology department to find out the possibilities of detecting vesicoureteral reflux (VUR) in infants and children. Hydronephrosis & Renal pelvis dilatation were the highest frequency reason for VUR scan study and represent 36% of the overall cases with 53% positive finding, while Recurrent UTI frequency was 22.6% with 83% positive finding, and patients who had history of VUR come at the third place with 15% frequency and 81% positive finding. VUR was found in 65 of 106 children representing 61%. Male children are more likely to diagnostic with VUR than female and they represented 69% while 31% for female. Among the children with VUR, 39 had high-grade reflux (grade IV or V), while 26 had low-grade reflux (grades I, II or III). When we classified VUR into low-grade and high-grade, we found the majority of children with high-grade VUR had an abnormal DMSA and represented 77.4%, while 13 children with low-grade VUR had normal study. These studies are agreed with the present study; most children with normal DMSA scan finding had low grade reflux. In this study, 48 of 65 children (74%) the DMSA scintigraphy shows abnormal findings during the period of UTI while the VCUG scan study shows VUR in 75% of the children during the period of UTI. Comparing results of ultrasound and VCUG scan, 59% of the ultrasound findings gave the same result as VCUG in detecting the VUR in children. Then we confirm it all with the urine culture results of the same children. We found the majority of children with VUR had abnormal US finding during the period of UTI and represented 83%.

Abstract: Objective: To evaluate the treatment outcome of single session endoscopic treatment using Polyacrylate Polyalcohol Copolymer (PPC) (Vantris ®) compared with conservative Continuous Antibiotic Prophylaxis (CAP) and open surgical treatment among children with Vesico-Ureteral Reflux (VUR). Methods: A retrospective cohort was undertaken in a single institution to evaluate children diagnosed with primary VUR grade 2-4 from 2006-2012 treated by a single urologist with different treatment modalities- conservative continuous antibiotic prophylaxis, endoscopic correction with PPC and open ureteral re-implantation with Cohen technique. Included patients for the study were only those who had 1-3 months and >1 year post-treatment follow- up study with Voiding Cystourethrogram (VCUG), kidney ultrasound, Dimercaptosuccinic Acid (DMSA) renal scan, and urine culture. Comparative analysis was made to evaluate the rate of VUR resolution, reflux recurrence, renal scaring and VUR treatment related hospital stay. Results: Twenty-five children (12 girl and 13 boys) with a mean age of 3 ± 1.4 years were included. Twelve children had bilateral VUR and thirteen had unilateral VUR, a total of thirty-seven Refluxing Renal Units (RRU) were being analyzed (12 CAP, 11 endoscopic corrections and 14 open re-implantation surgery). On initial 3 months post-treatment follow-up, RRU VUR resolution observed for CAP, PPC and open surgery were 33% (4/12), 91% (10/11) and 100% (14/14), respectively. At >1 year post treatment follow-up, VUR resolution were noted in 50% (6/12) treated with CAP. For PPC treated group, 27% (3/11) had reflux recurrence or persistence and 14% (2/14) of open surgery group had ureteral obstruction with hydronephrosis. Renal scarring detected among CAP, PPC and surgery group at >1 year follow-up were 42% (5/12), 18% (2/11) and 14% (2/14), respectively. VUR treatment related mean hospital day per year was highest among the CAP group (6.25 ± 2.6 days/year) and lowest among PPC group (3.27 ± 1.2 days/year). Conclusion: Endoscopic correction of VUR with PPC resulted to better treatment outcome when compared to CAP and was comparable to open surgical management with shorter treatment related hospital stay.

Abstract: Background: Vesicovaginal fistula (VVF) is the most common acquired fistula of the urinary system. Different surgical techniques exist, but having several advantages make laparoscopy as a favorable method. According to the recent data, we have performed the first laparoscopic repair of VVF in Iran. Case report: A 19-year-old (G1P1) woman, referred to our center, complaining from continuous urinary incontinence from 7 months ago. She developed continuous wetting after her first cesarean section, performed 7 months ago. Methylene blue dye test, was positive for VVF and voiding cystourethrogram (VCUG) confirmed the diagnosis. Cystoscopy revealed the exact location of fistula in the bladder wall. Patient underwent laparoscopic VVF repair using transperitoneal transvesical approach in the supine position. Patient did not have any urinary leakage during hospitalization and discharged with urethral indwelling catheter at fourth day after the operation. Voiding cystourethrogram was done after 2 weeks, and it was normal without any extravasations. Discussion: Dense pelvic adhesions and/or inflammation from prior abdominal surgery can make this approach less desirable in some patients. Furthermore, intracorporeal laparoscopic suturing requirement for VVF repair is an advanced skill many surgeons lack. We used transabdominally transvesical laparos copic method and, according to the literature review, this is the first case of VVF laparoscopic surgery performed in Iran.

Abstract: Recent studies have resulted in major changes in the management of urinary tract infections (UTIs) in children. The present statement focuses on the diagnosis and management of infants and children >2 months of age with an acute UTI and no known underlying urinary tract pathology or risk factors for a neurogenic bladder. UTI should be ruled out in preverbal children with unexplained fever and in older children with symptoms suggestive of UTI (dysuria, urinary frequency, hematuria, abdominal pain, back pain or new daytime incontinence). A midstream urine sample should be collected for urinalysis and culture in toilet-trained children; others should have urine collected by catheter or by suprapubic aspirate. UTI is unlikely if the urinalysis is completely normal. A bagged urine sample may be used for urinalysis but should not be used for urine culture. Antibiotic treatment for seven to 10 days is recommended for febrile UTI. Oral antibiotics may be offered as initial treatment when the child is not seriously ill and is likely to receive and tolerate every dose. Children <2 years of age should be investigated after their first febrile UTI with a renal/bladder ultrasound to identify any significant renal abnormalities. A voiding cystourethrogram is not required for children with a first UTI unless the renal/bladder ultrasound reveals findings suggestive of vesicoureteral reflux, selected renal anomalies or obstructive uropathy.