Abstract: Multicystic dysplastic kidney (MCDK) is the most common cause of cystic disease in children. It is characterized by multiple non-communicating cysts of varying sizes with no identifiable normal renal parenchyma. The incidence ranges from 1 in 1000 to 4300 live births, and it is one of the most commonly detected anomalies on prenatal ultrasound. MCDK has been shown to follow a benign course with relatively few sequelae and therefore should be managed conservatively. Currently, the key clinical questions revolve around the detection of anomalies in the contralateral kidney and follow-up imaging. The recent literature suggests that very limited radiographic evaluation of the MCDK is needed. The use of voiding cystourethrogram or nuclear medicine renal scans should be directed by any abnormalities on renal ultrasound or the development of urinary tract infections.

Abstract: Aims To report our data on initial urological presentation after in utero myelomeningocele (MMC) closure. Methods A prospective urological assessment at first presentation was designed for patients that had undergone in utero MMC closure and referred to our urological facility. The protocol consisted of detailed medical history, renal sonography, voiding cystourethrogram, and urodynamic evaluation. Results In utero MMC closure was performed in 19 patients at gestational age of 25.6 weeks 25–27. Birth occurred at a mean gestational age of 31.8 weeks 26–36. Hyperactive bladder was observed in 89.5% 17/19. Bladder compliance was normal in two cases (10.5%), was markedly reduced in 10 patients (52.6%) and not possible to be determined due to urinary leakage in 7 patients (36.8%). We observed normal bladder capacity in 8 patients (42.1%), reduced in 11 (57.9%), and detrusor-sphincter dyssynergia in 9 patients (47.4%). Underactive bladder was diagnosed in one case. Clean Intermittent Catheterization was initiated by 11 patients (57.9%) mostly in association with anticholinergics 10/11. Vesicoureteral reflux was found in 5 patients (26.3%) and 9 had pyelonephritis at a mean follow-up of 5.4 months 2–17. Conclusions Our data suggested that despite in utero MMC surgery, patients are at risk for bladder abnormal function and renal deterioration and should be aggressively treated, not differently from those operated in the post-natal term. This study has the merit of being a prospectively set evaluation performed by one investigator, including the urodynamic study. We acknowledge the need of long-term follow up. Neurourol. Urodynam. 34:461–464, 2015. © 2014 Wiley Periodicals, Inc.

Abstract: OBJECTIVE. The purpose of this study is to determine the performance of renal ultrasound for detecting vesicoureteral reflux (VUR) and obstructive uropathies in infants younger than 2 months with a febrile urinary tract infection (UTI). MATERIALS AND METHODS. We performed a retrospective cohort study of infants younger than 2 months with fever and culture-proven UTI presenting from July 1, 2008, through December 31, 2011, with renal ultrasound and voiding cystourethrogram (VCUG) performed within 30 days of UTI diagnosis. Two pediatric radiologists independently reviewed the renal ultrasound and VCUG findings. Results of the renal ultrasound were deemed abnormal if collecting system dilation, renal size asymmetry, collecting system duplication, urothelial thickening, ureteral dilation, or bladder anomalies were present. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of renal ultrasound were calculated using VCUG as reference standard. RESULTS. Of the 197 pati...

Abstract: Vesicoureteral reflux (VUR) is the most common congenital anomaly of the urinary tract. The gold standard for diagnosing VUR is a voiding cystourethrogram (VCUG). According to the International Reflux Grading Scheme, the severity of VUR is classified as grade I–V. It is diagnosed in 30–40 % of children with a urinary tract infection (UTI). VUR may be an isolated abnormality (primary VUR) or it may occur in association with other congenital anomalies of the kidney and urinary tract (CAKUT), including renal dysplasia and obstructive uropathy. VURmay also be noted secondary to bladder dysfunction such as neurogenic bladder or other obstructive anomalies (e.g., posterior urethral valves) (secondary VUR). An increasing number of children with VUR are being diagnosed during follow-up for antenatally diagnosed renal abnormalities and no preexisting history of UTI. Renal scarring associated with VUR is called reflux nephropathy (RN). RN is categorized as “congenital,” which is a result of abnormal renal development leading to focal renal dysplasia, or “acquired” as a result of pyelonephritis-induced renal injury. Complications of RN in pediatric patients include proteinuria, hypertension, and end-stage renal failure (ESRF). The management of VUR has been driven by the belief that the risk of VUR and UTIassociated renal injury is decreased by long-term antimicrobial prophylaxis or surgical correction of VUR. Over the years, many studies have assessed if one treatment modality is superior to another in preventing kidney injury, with most concluding that the long-term outcome with one intervention is no better than the other. Recently, surveillance with no intervention, particularly for low-grade VUR, has been proposed as another option, which has generated questions on the usefulness of routinely diagnosing VUR after UTI, particularly if the clinical presentation is typical and renal ultrasound is normal. This argument forms the basis of various recent recommendations on the management of children after first UTI.

Abstract: OBJECTIVE. This practice quality improvement study of pediatric voiding cystourethrogram (VCUG) investigated the adequacy of substituting last-image capture for digital-spot images and dose reduction when this substitution was implemented and determined correlations between dose-area products (DAPs), patient ages, and fluoroscopy times. MATERIALS AND METHODS. The study consisted of three phases: phase 1 documented baseline data and evaluated diagnostic accuracy between last-image capture and digital-spot images. Phase 2 documented the change in dose after substituting last-image capture for digital-spot images. Phase 3 measured doses 3 years later. Each phase-1 VCUG study was segregated into two image sets: last-image capture and digital-spot images. Three radiologists graded vesicoureteral reflux on each side using the international grading scale. Weighted kappa statistics assessed grading differences between image sets. Patient age, fluoroscopy time, and DAP were assessed with parametric and nonparametr...

Abstract: Introduction The objective of this study was to report on the use of vesicoscopy in the treatment of symptomatic congenital bladder diverticula (CBD) in children. Material and Methods In this study, 16 males, aged 4 to 12 years (median age, 6.25 years), were treated for symptomatic CBD; 3 patients presented double diverticulum and 13 presented single diverticulum. The presenting symptoms were recurrent urinary tract infection, hematuria, lower abdominal pain, and voiding dysfunctions as urgency, frequency alone, or in association. A first midline 5-mm trocar was introduced for a 0-degree telescope at the dome of the bladder, and two left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The bladder was then insufflated with carbon dioxide to 10 to 12 mm Hg pressure. The diverticula were inverted into the bladder and the mucosa around the neck was circumcised by using scissors and hook. The defect was sutured and the bladder was drained. Vesicoureteral reflux (VUR) of third grade or higher was treated endoscopically. Results Mean operative time was 90 minutes for procedures. At 6-month follow-up, ultrasound and voiding cystourethrogram (VCUG) showed the disappearance of the diverticulum in 15 out of the 16 patients. The patient, with huge double diverticulum and fourth grade right VUR, presented recurrence of a small left diverticulum. Patients with voiding disorders presented a gradual improvement of their urgency. VUR disappeared at VCUG in all patients. Conclusion Vesicoscopic diverticulectomy resulted a safe and effective procedure and can be considered a valid alternative to the open or laparoscopic procedures. In our opinion, routine use of vesicoscopy could become the gold standard for the treatment of CBD in children.

Abstract: Introduction: Vesicoureteral reflux (VUR) is a backward flow of urine from bladder to ureter or kidney. Potential reflux is harmful because of kidney being faced with the hemodynamic high-pressure during urination. This project was carried out for high prevalence of VUR and delay in growth of children with chronic diseases. In case of growth disorder in children with this disease and its difference with healthy person, treatment can be tried by treating the growth disorder. Objectives: The purpose of this study is survey of children with VUR about growth and developmental impairment. Patients and Methods: All patients who performed voiding cystourethrogram (VCUG)because of UTI, divided into 2 groups, healthy and sick. History and checklist filled, patients’ height and weight measured in a standard way and ASQ questionnaires adjusted to age, used for the studying development effect. The height and weight of children measured by standard meter and scale and used the curves adjusted to age and sex. Control group entered the study with the same characteristics of case group without VUR, however, their height and weight were recorded. The way of evolution studied according to Nelsons evolution table and ASQ questionnaire. Results: The both groups (total of 150 studied children) in the area of development of fine motor, gross motor and indicators of mean and percentile of height and weight and parents’ literacy, had a significant difference (P< 0.05). It is can be due to better assessment and follow, higher education levels and better socioeconomic situation. Conclusion: Children with VUR, in terms of height and weight growth and index of gross and fine movements and communicate were better than normal children.

Abstract: Clinical problem We diagnosed 8 patients with late-stage posterior urethral valves (PUV) between 1 and 14 years of age. Five patients complained of symptoms related to voiding dysfunction. The other 3 patients required urethrocystoscopy for other reasons (hypospadias fistulae, difficulty with catheterisation and high-grade vesicoureteral reflux [VUR]). A second review of the first 2 patients’ medical history showed voiding dysfunction symptoms. All patients underwent preoperative ultrasonography: 3 patients had normal results and 5 had renal or vesical disorders. The diagnosis was reached through voiding cystourethrogram (VCUG), and 4 patients underwent urodynamic studies. The diagnosis was confirmed by urethrocystoscopy, performing valve electrofulguration. We performed urethrocystoscopy during the check-ups at 3–6 weeks and observed no stenosis. The symptoms disappeared for all patients after 20 months of follow-up. The patient with VUR was cured. The ultrasounds showed no progression of the renal involvement and showed improvement in the vesical involvement. The velocimetries during check-ups presented curves within normal ranges. Discussion Most children with PUV are diagnosed through ultrasound during the neonatal period. Some patients present PUV at later ages with diverse symptoms, which impedes its diagnosis. We should suspect PUV in male patients with symptoms of voiding dysfunction, either when they have normal or pathological results from ultrasounds or VCUG. We recommend performing urethrocystoscopy to rule out urethral obstruction.

Abstract: Background: Vesicoureteral reflux (VUR) is a common anomaly affecting 1–3% of all children and 30–50% of those with urinary tract infection (UTI). In the past febrile vesicoureteric reflux on chronic antibiotic prophylaxis were treated by open surgery. Now a day’s endoscopic injection of a bulking material has replaced open surgical procedure in cases of primary VUR. Our objective was to assess the efficacy of endoscopic treatment for primary vesico-ureteric reflux in children. Methods: This was a descriptive case series. One hundred and five patients with either unilateral or bilateral VUR (181ureters) underwent endoscopic treatment for primary VUR between January 2011 and January 2014. Children from 1 to 12 years of age with grade-II to IV reflux on preoperative voiding cystourethrogram (VCUG) were enrolled through consecutive non-probability sampling. Efficacy of treatment was evaluated at three months post injection by a standard VCUG. Ureters with no or grade-I reflux were considered successful treatment. Results: Out of 105 patients 76 had bilateral while 29 had unilateral reflux. Mean age was 5.7 years (SD±.7). Among 181 refluxing ureters, 116 (64%) were free of reflux, while 49 (27%) showed down gradation and 16 (8.8%) showed no response to treatment on postoperative VCUG. Conclusion: Endoscopic treatment for VUR is a viable option for patients with primary VUR and may be considered in management of such cases.

Abstract: Objectives: To share our experience regarding the handling of symptomatic or asymptomatic female urethral diverticula. Clinical presentation, diagnostic methods, and therapeutic strategies are reviewed. Methods: This was a retrospective analysis involving eight female patients with urethral diverticula who were followed up in our urology department between 2007 and 2015. Preoperative assessment included clinical examination and cystoscopy, voiding cystourethrogram, or magnetic resonance imaging. Postoperative follow-up visits were scheduled at 3, 6, and 12 months. Results: Diagnosis was based on anamnesis and physical examination, and then confirmed by complimentary exams such as voiding cystourethrogram and magnetic resonance imaging. All patients experienced symptomatic relief and improved esthetic outcome after surgery. Magnetic resonance imaging was instrumental in confirming the diagnosis and in planning the surgical approach. Surgical excision of the diverticulum and reconstruction resulted in good aesthetic and functional outcomes. There were no major postoperative complications. Conclusions: Previously unrecognized female urethral diverticula can now be more easily detected using magnetic resonance imaging. In our small series, surgical excision and reconstruction was associated with good clinical outcome.

Abstract: The incidence of neonatal urinary tract infection (UTI) varies from 0.1 to 1% of all infants, and its frequency is inversely proportional to birth weight [1]. Neonatal UTI presents different features than those observed in other age groups for several reasons, including higher prevalence, male sex predominance, and most importantly higher risk of urosepsis [2]. As the symptoms of a UTI in a neonate, such as irritability, poor feeding and vomiting are generalized, the clinician should have a high index of suspicion. The best correlates of infection in infants with UTI were found to be a body temperature greater than 38 o C and uncircumcised males [3]. Escherichia coli is the most likely pathogen, but Klebsiella pneumoniae, Enterobacter spp., Enterococcus spp., Pseudomonas spp., Candida spp. and coagulase-negative staphylococci have to be considered in nosocomial UTI as well [1-3]. A positive blood culture is reported in 12.4% of cases, and nosocomial UTI is nearly twice likely to result in urosepsis compared with community-acquired UTI [2]. Bladder puncture or transurethral catheter is recommended for urine sampling in neonates to avoid urinary contamination. Parenteral antibiotic regimen, including a combination of a third-generation cephalosporin or aminoglycoside with ampicillin for a total of 7-14 days should be commenced urgently in the suspicion of pyelonephritis following urine sampling for culture. Vancomycin and an aminoglycoside should be considered for nosocomial UTI. In the light of the results of sensitivity testing, a single-antibiotic coverage, if possible, should be considered [1-3]. The presence of high-grade reflux, severe urinary obstruction, and recurrent pyelonephritis mandates antibacterial prophylaxis, however its efficiency has not yet been proven [2]. Radiological studies have to be undertaken once a diagnosis of UTI has been made. An abnormal renal ultrasound is reported in around one third of cases, and vesicoureteral reflux is observed in nearly one fourth during voiding cystourethrogram (VCUG). The urine should be sterile while performing a VCUG [2, 3]. Gram-negative antibiotic resistance is emerging worldwide and outbreaks have occurred in neonatal units due to multi-resistant gram-negative bacteria [4]. To overcome this problem in the case of a UTI, urine cultures should be appropriately obtained, and the treatment should be tailored based on sensitivity results; antibiotic prophylaxis should be spared to aforementioned high-risk groups, while emphasizing the importance of compliance; and pediatric-specific antibiograms should be used [5]. Finally, evidence-based guidelines for the diagnosis and management of UTI in febrile infants aged less than 2 months are lacking, and urgently required [2].

Abstract: Endoscopic treatment of vesicoureteral reflux (VUR) is feasible in pediatric patients. As endoscopic injection has a lower success rate than ureteral reimplantation, a postoperative voiding cystourethrogram (VCUG) is usually performed. The present study evaluated whether the presence of a nodule on noninvasive ultrasound could predict the resolution of VUR and replace invasive VCUG. Patients who received an injection of endoscopic bulking agent for VUR from January 2005 to December 2010 were evaluated retrospectively. It was evaluated whether a nodule, an echogenic mass lesion distinguished from the bladder at the ureteral orifice, was present on the ultrasound one month postoperatively. The success of the injection in the group with nodules was compared with that of the group without nodules by VCUG 3 months postoperatively. A total of 149 patients (220 ureters) met the inclusion criteria. The mean age at surgery was 3.5 years (range, 0.6–18 years). The overall success rate was 73.2%. A nodule was present in 152 cases (69.1%). The group with nodules had a higher success rate than the group without nodules (84.2%, 128/152 vs. 48.5%, 33/68, respectively; P<0.001). According to multivariate analysis, injection nodules were a predictive factor for the success of the endoscopic injection (odds ratio, 6.050; P<0.001). The failure rate increased with increasing injection volume. The sensitivity of sonographic injection nodules for predicting success was 79.5% and the specificity was 59.3%. To conclude, the presence of a postoperative nodule can predict the resolution of VUR.

Abstract: Congenital bladder diverticula (CBD) are an outpouching of the mucosa through the muscular wall of the bladder. Large CBD may be presented with a serious urological problem in childhood. A 6-year-old boy was admitted with the complaint of recurrent urinary tract infection and urinary retention. Voiding cystourethrogram revealed a bilateral large CBD. Cystoscopy was performed before surgery to rule out bladder neck pathology, for direct visualization of diverticula, and to see the opening of the ureters. Transvesical diverticulectomy is a reliable technique for surgical treatment, if necessary, and can effectively be combined with the management of associated other pathology.

Abstract: Background: Urethral polyps are rare benign pathologies seen in the male posterior urethra, more frequently originating from verumontanum. In this article, we aimed to discuss diagnosis and treatment of a urethral polyp causing hematuria and urinary infection in a 3-month-old male infant. This is the first case in the literature in which a urethral polyp is treated with Holmium yttrium-aluminum-garnet (YAG) laser. Case Presentation: The patient was a 3-month-old male infant, and complains were hematuria and crying during micturition. Ultrasonography and voiding cystourethrogram were used for diagnosis. Urethral polyp was observed on urethrocystoscopy. Ablation was performed with a newborn cystoscope. Conclusion: Urethral polyp can cause hematuria and urinary obstruction and should be considered in the differential diagnosis of pathologies such as posterior urethral valve and cecoureterocele that could cause infravesical obstruction. Holmium-YAG laser is a good choice of treatment with easy applic...

Abstract: Background: Retrograde urethrogram and voiding cystourethrogram are used to define length and location of urethral stricture prior to surgery We used a single dose of silodosin prior to VCUG to relax the bladder neck and achieve visualization of posterior urethra Objectives: To evaluate the efficacy of silodosin in visualization of posterior urethra during VCUG, and to compare the findings with a control group Patients and Methods: Patients were divided into two groups A and B containing 20 and 15 patients, respectively Patients in group A were given a single dose of silodosin prior to radiological studies Results: In group A 19 out of 20 patients were able to achieve satisfactory bladder neck opening while in group B 10 out of 15 patients were able to achieve bladder neck opening Conclusions: Silodosin use prior to VCUG confers a statistically significant increase in bladder neck opening and visualization of posterior urethra

Abstract: I am indeed privileged to serve as Guest Editor to this special issue of the Open Urology and Nephrology Journal on pediatric nephrology. I am also appreciative to the distinguished panel of authors for their contribution and for presenting the most recent clinical advances in various aspects of the specialty. Pediatric nephrology is rapidly evolving. Over the last few decades we have witnessed a rapid change in nosology, etiology, pathogenesis and treatment of renal disease. We have seen advances in renal and urinary tract imaging as well as more precise use of novel urinary biomarkers to define the type and degree of renal injury, both acute and chronic. We now have better understanding of factors contributing to normal and abnormal renal development, particularly the progenitors of renal development and regeneration, delivery of progenitor cell therapeutics, and the role of epigenetics [1]. Multi center pan-national and international clinical studies have helped to put together clinical guidelines to diagnose and manage renal disease. In this issue, we will discuss few, but important recent clinical developments in pediatric nephrology. While performing renal ultrasound and voiding cystourethrogram (VCUG) was once a routine, the American Academy of Pediatrics (AAP) and the National Institute for Health and Clinical Excellence (NICE) are now recommending a marked reduction in the imaging of children under age 2-3 with febrile urinary tract infection (UTI) [2]. Both AAP and NICE also agree that prophylactic antibiotic treatment should not be routinely used in these children even those with major vesicoureteral reflux (VUR). Presently, the AAP recommends that infants (2-24 months of age) with a febrile UTI undergo renal and bladder ultrasonography as a routine screen, and reserve VCUG for patients with recurrent UTI or with evidence of anatomic abnormality on ultrasound. In 2014, and only three years after this recommendation, the results of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study was published [3]. According to this study, antibiotic prophylaxis does indeed prevent UTI recurrence in young children with VUR, but at the cost of increased antibiotic resistance, and with unclear benefits in preventing 뀀ഀȠ

Abstract: A 3 year old male was transferred to pediatric emergency room because of acute urinary retention from one day ago. He had no history of similar problem until now. Physical exam revealed only full bladder. BUN and Creatinine were increased. After urinary catheter insertion, the bladder was decompressed. Kidney ultrasound showed bilateral hydroureteronephrosis. Voiding cystourethrogram (VCUG), TC99m DTPA scan and 99mTc dimercaptosuccinic acid DMSA scan was done after improvement of renal function (Fig. 1,2) and urodynamic study was performed for better evaluation of the bladder (Fig. 3).

Abstract: Background In 2011, the American Academy of Pediatrics revised practice parameters regarding febrile urinary tract infection (fUTI) in children aged 2–24 months. The Section on Urology opposed the omission of voiding cystourethrogram (VCUG), and expressed concern that potential untoward consequences of deferring VCUG may be most felt by children on Medicaid. Objective We ascertained imaging and characteristics of children presenting to the Emergency Department (ED) with initial fUTI to determine the impact of patient demographics on admissions for pyelonephritis. Methods Children aged 2–24 months presenting to the ED with initial fUTI were identified. Demographics, insurance status, laboratory studies, renal-bladder ultrasound (RBUS), VCUG, and hospital admission status were evaluated. Results Three-hundred fifty patients met inclusion criteria; 88 (25.1%) were admitted. Admitted patients were significantly ( p p p p Conclusions Abnormal ultrasound, non-Hispanic race, and public insurance were strongly associated with hospital admission in children presenting to the ED with initial febrile urinary tract infection.