Abstract: 1. Eric Balighian, MD* 2. Michael Burke, MD* 1. *St Agnes Hospital, Baltimore, MD * Abbreviations: AAP: : American Academy of Pediatrics CFU: : colony-forming unit DMSA: : dimercaptosuccinic acid IV: : intravenous UTI: : urinary tract infection VCUG: : voiding cystourethrogram WBC: : white blood cell Consideration of risk factors for urinary tract infections (UTIs) in young children with fever is critical for accurate diagnosis, as well as prevention of overtesting. The use of perineal bags to collect urine from young children should be limited to specific indications in the diagnosis of UTIs. Screening for and managing bowel and bladder dysfunction reduces the risk of UTIs in older children. After completing this article, readers should be able to: 1. Recognize the risk factors for urinary tract infections (UTIs) in children. 2. Review the interpretation of urinalysis and urine cultures. 3. Review antibiotic therapy choices for UTIs. 4. Describe which children need imaging after febrile UTIs. 5. Discuss prevention strategies to discuss with families. Charlotte is a 13-month-old girl with a history of 2 febrile urinary tract infections (UTIs) 4 and 6 months ago. She had normal renal and bladder ultrasonographic findings 6 months ago. She presents with a fever that began yesterday. She has no other new symptoms. Her 4-year-old brother had a self-limited febrile illness 1 week ago, which resolved. At examination, she is fussy but consolable and alert. She is non–toxic appearing. Her physical examination findings show tachycardia with a heart rate of 130 beats/min, without murmur. Her respiratory rate is 28 breaths/min, without distress or retractions. Her lungs are clear bilaterally. Her tympanic membranes appear normal. Her abdomen is soft and nontender. Her genital examination findings appear normal, without erythema or labial adhesions. Her temperature is 102.5°F (39.2°C). A bag is placed …

Abstract: Contrast-enhanced voiding urosonography (ceVUS) is widely used outside the United States to diagnose vesicoureteral reflux (VUR) in children and is highly sensitive while avoiding exposure to ionizing radiation. At the onset of this study, two ultrasound (US) contrast agents were available in the United States. Pediatric safety data for intravenous administration was published for one, Optison™. This study aimed to evaluate the diagnostic performance and safety of ceVUS using Optison™ and compare its diagnostic efficacy with voiding cystourethrogram (VCUG) for VUR detection and grading in children. The United States Food and Drug Administration and institutional Investigational New Drug authorizations were obtained to conduct a prospective comparative study of ceVUS with Optison™ and VCUG. CeVUS was performed with intravesical administration of 0.2% Optison™/normal saline solution. A standard VCUG followed. Safety assessment included physical examination, and heart rate, pulse oximetry and adverse reactions monitoring before, during and immediately after the examinations. A follow-up questionnaire was completed by telephone 48-h after the studies. Sixty-two pelviureteric units were studied in 30 patients with a mean age of 3.5 years (range: 0.1–17 years) including 21 girls and 9 boys. No severe adverse events occurred. All patients had normal heart rate and blood oxygenation saturation prior to, during and after the studies. At the 48-h follow-up, one patient (3.3%) reported transient dysuria. Taking the VCUG as the reference standard, ceVUS had a sensitivity of 91.7% (95%; confidence interval [CI]: 61.5%–99.8%) and specificity of 98% (95%; CI: 89.4%–99.9%). The concordance between ceVUS and VCUG for VUR detection and grading was 84.3% and 81.8%, respectively. VUR grades were discrepant in 4/11 refluxing pelviureteric units, with VCUG upgrading VUR in 2. Detection of VUR with Optison™ ceVUS was comparable to VCUG without exposure to ionizing radiation. CeVUS with Optison™ is a well-tolerated diagnostic procedure with a favorable safety profile.

Abstract: OBJECTIVES: Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use. METHODS: The survey was administered to a random sample of pediatricians through the American Medical Association’s Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization. RESULTS: A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly ( P n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux ( P CONCLUSIONS: Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.

Abstract: Background Posterior urethral valves (PUV) are a common cause of congenital obstructive nephropathy The outcome of patients with PUV at Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa, has not been documented previously Objectives To describe the outcome of patients diagnosed with PUV over a 29-year period from January 1985 to December 2013, and to analyse risk factors for chronic kidney disease Methods This was a retrospective record review of boys aged <14 years diagnosed with PUV at Chris Hani Baragwanath Academic Hospital PUV was diagnosed by a voiding cystourethrogram (VCUG) and/or at cystoscopy Valves were resected primarily or after vesicostomy The glomerular filtration rate was calculated using the Schwartz formula, and stratified as normal or decreased for age at presentation and at the final visit Results Records of 181 patients were analysed The diagnosis was made during the first year of life in 139 patients (768%) Clinical presentation included urinary tract infection (UTI) in 109 patients (602%), palpable bladder in 98 (541%), palpable kidney in 85 (469%), and poor urinary stream in 78 (431%) An ultrasound scan was reported normal in 109% Vesicostomy was performed in 80 patients (442%) and primary valve ablation in 101 (558%), with vesicostomy being more prevalent in the pre-2000 era The median duration of follow-up was 21 months (interquartile range 5 - 79) and renal outcome at last visit was normal in 117 patients (646%) The presence of bladder diverticula was associated with a favourable renal outcome Thirteen patients (72%) died, and 102 (563%) defaulted from follow-up Conclusions PUV frequently presents with UTI and palpable bladder and/or kidneys Findings on ultrasound were normal in 109% of our patients with PUV A VCUG is indicated in the presence of palpable kidneys or bladder even if the ultrasound scan is normal Bladder diverticula as a pressure-release mechanism are renoprotective Vesicostomy or primary valve ablation did not affect final renal outcome Chronic kidney disease occurred in 348% of patients after surgical correction Adherence to scheduled appointments is problematic in this population Long-term follow-up is mandatory

Abstract: Background: Pediatric urethral stricture and its treatment have functional implications in the growing child. Subjects and Methods: A retrospective study of records on urethral strictures encountered in our institution between January 2005 and May 2016 yielded 23 boys against a backdrop of 19,250 admissions during the same period; stenosis and strictures after hypospadias repair were not included in this study. Demographic data were collected from the charts, and the success of repair was assessed clinically by success of repair was assessed clinically by observing for presence or absence of symptoms such as dribbling, straining at voiding, adequacy of urinary stream and radiologicaly by assessing the micturition phase of voiding cystourethrogram. Success was defined as successful initiation, flow, and completion of voiding with radiological evidence of reestablishment of urethral continuity. Results: The most common cause of urethral stricture was perineal or pelvic trauma (56.5%). Three after surgery for anorectal malformation (13.04%) and 2 (8.6%) followed otherwise unspecified urethritis. Transperineal and transpubic anastomotic routes were used for surgery. Redo surgery was required in 47.8%. The overall success rate was 82%. A self-catheterizable mitrofanoff channel was created as part of the primary procedure in 63.6% (7/11) or after the failure of the first procedure in 36.3% (4/11). Conclusion: The majority of urethral strictures are long-segment strictures or those with complete disruption not amenable to endoscopic techniques. The aim of the surgery is to obtain end-to-end opposition of healthy proximal and distal urethra. The route – transperineal or transpubic – which will give the best access to the ends of the urethra is determined by the location and extent of the stricture and the alteration in anatomy as a consequence of the pelvic fracture. Even after the introduction of laser and endoscopic techniques, surgical repair is required to tackle the majority of urethral strictures in children.

Abstract: The aim of the current study was to describe a novel approach of urethral reconstruction through minimally invasive harvesting of the bladder graft via endoscopic sub-mucosal dissection of water-jet. The records of two patients were reviewed, who underwent transurethral endoscopic surgical bladder mucosa graft harvest by water-jet and urethral reconstruction with informed consent. Case 1 was a 35-year-old male with anterior urethral stricture; case 2 was a 22-year-old male with secondary anterior urethral stricture and hypospadias following a failed hypospadias surgery. The two male patients successfully underwent urethral reconstruction using bladder mucosa graft harvested via endoscopic assisted by water-jet; no perforation, cysthemorrhagia or any other postoperative bladder-related complication was observed. Voiding cystourethrogram of case 1 indicated that the reconstructed urethra was unobstructed, and no recrudescence was observed within 4 months of follow-up. In case 2, dysuria had disappeared completely within 1 month of follow-up, and the urethra plate was successfully reconstructed by first-stage. To the best of our knowledge, this is the first report to demonstrate urethral reconstruction using a bladder mucosa graft harvested by transurethral endoscopic sub-mucosal dissection, assisted by water-jet. Transurethral endoscopic surgery may provide a minimally invasive approach instead of the traditional open surgery for harvesting bladder mucosa graft. Urethral reconstruction conducted with bladder mucosa graft harvested via endoscopic sub-mucosal dissection assisted by water-jet is a feasible and safe method, and the short-term follow-up results are encouraging.

Abstract: Prune belly syndrome (PBS) is a rare congenital disorder affecting 2.5 to 3.8/100,000 live births worldwide. Our objective of this report is to describe clinical manifestation, laboratory, and radiological characteristics of PBS in our patients, to highlight the limitations to offering appropriate patient care due to parents demanding discharge against medical advice and the need to increase the awareness regarding this rare disease. We report three cases; all referred after birth with lax abdominal wall, congenital anomalies of kidney, and urinary tract. One of the patients had an absent right foot. They all had cryptorchidism, and in one, there was deranged renal function. The reported cases had both medical and radiological interventions to varying degrees. They all had an abdominal ultrasound which revealed varying degrees of hydronephrosis, hydroureters, and bladder changes. Voiding cystourethrogram showed vesicoureteric reflux in one of the reported cases. Urinary tract infections were appropriately treated with antibiotics based on sensitivity. PBS management in our setting remains a challenge because of strong cultural beliefs, and high rate of discharge against medical advice. Focus should be on parent education, early diagnosis, and multidisciplinary management approach.

Abstract: Karadeniz-Cerit K, Thomas DT, Ergun R, Yildiz N, Alpay H, Inanir S, Dagli ET, Tugtepe H. Positional installation of contrast (PIC) and Redo-PIC cystography for diagnosis of occult vesicoureteral reflux. Turk J Pediatr 2018; 60: 180-187. To evaluate the value of Positional Installation of Contrast (PIC) and Redo-PIC cystography in patients with febrile recurrent urinary tract infection (f-UTI) where voiding cystourethrogram (VCUG) was negative. Patients with recurrent f-UTI with no reflux on VCUG referred to the outpatient clinic of Pediatric Urology, between June 2011 and June 2016 were included in the study. A PIC cystography was performed in all patients. When reflux was found, subureteric injection was performed. Urinary cultures were used for follow-up. Patients that continued having f-UTI, received redo-PIC cystography. PIC cystography was performed on 42 patients. The average age of patients was 8.0±3.6 years. Vesicoureteral reflux (VUR) was detected in 41 patients. Average follow-up time after PIC cystography was 44.6 months. Thirty-three patients (80.5%) were free of f-UTI after PIC cystography and concurrent subureteric injection. Eight patients continued to have recurrent f-UTI. Six of these patients underwent redo-PIC cystography and PIC-VUR was demonstrated in all patients. After an average follow up of 30.9 months, no f-UTI was seen in these patients. The success rate of 80.5% (33/41) after 1st PIC cystography and subureteric injection increased to 95.1% (39/41) after redo-PIC cystography in six patients. Patients with recurrent f-UTIs without VUR on VCUG are an important challenge. PIC cystography is an important tool in demonstrating occult VUR in these patients. We advise that PIC cystography is performed in all patients with recurrent f-UTI with negative VCUG and redo-PIC cystography in patients who continue to have f-UTI after 1st PIC cystography and subureteric injection.

Abstract: • Current American Urological Association guidelines do not recommend ultrasound for the evaluation of undescended testicles. • Children with an undescended testicle should be referred to a pediatric urologist at approximately 6 months of age. • Infants with bilateral nonpalpable testicles should be evaluated for possible congenital adrenal hyperplasia. • Infants with hypospadias and unilateral or bilateral undescended testicles should be evaluated for disorder of sexual development. • Repair of hypospadias is recommended at between 6 months and 1 year of age. • Bladder exstrophy repairs are currently delayed to 3 months of age. • A voiding cystourethrogram should be performed in infants with high-grade hydronephrosis and bilateral hydronephrosis. • Most hydroceles in infants are noncommunicating, and infants should be referred to a urologist if they fluctuate in size suggesting a communicating hydrocele. • Vesicoureteral reflux is more common in male infants and has a high rate of resolution.

Abstract: Introduction Vesicoureteral reflux (VUR) is one of the most common ailments in children. Evidence-based guidelines recommend conservative treatment in children with VUR, followed by endoscopic surgery in those with breakthrough febrile urinary tract infections (UTIs). Despite this fact, the management of VUR is still controversial. Our objective is to evaluate the conservative strategy in children with primary VUR in terms of renal function and scarring, and identify factors associated with poor prognosis in those children. Material and methods A retrospective study was carried out in a tertiary center in children with primary VUR under conservative strategy treatment from 1989 to 2015. Data extracted included age of presentation, family and prenatal backgrounds, radiographic evaluation including ultrasound (US), dimercaptosuccinic acid (DMSA) scans and voiding cystourethrogram (VCUG). The SPSS program was used for statistical analysis. Results Two-hundred and five patients were diagnosed and followed a conservative therapy scheme (49.8% males, 50.2% females) after febrile UTI (73.17%) or prenatal diagnosis (26.83%). VCUG showed 53.20% of low-moderate VUR grade, 46.80% high VUR grade. Renal damage was present at diagnosis in 40.89%. Mean follow-up reakthrough recurrent febrile UTIs and underwent surgery. Conservative therapy was followed in 189 patients. Renal scarring or decreased kidney function were shown in 15.12% respectively. Renal damage was identified as a risk factor for poor prognosis (p-value <0.005) only for renal function deterioration. Patients with high-grade VUR required surgery in a significantly greater proportion (p <0.005) due to recurrent febrile UTIs. Conclusions Conservative strategy is a feasible treatment for primary VUR in children. The majority of cases could be managed conservatively with good outcomes after long-term follow-up. Decreased renal function is more frequent in patients with high-grade VUR. Renal damage at diagnosis increases the risk for surgical treatment.

Abstract: Objective To evaluate the utility of hydroureter (HU) to identify high-grade vesico-ureteric reflux (VUR) in patients with high-grade postnatal hydronephrosis (PH). Patients and methods We retrospectively reviewed patients’ charts that had antenatal hydronephrosis from 2008 to 2014. Patients were excluded if they presented with febrile urinary tract infection (fUTI), neurogenic bladder, posterior urethral valve, multi-cystic dysplastic kidney, and multiple congenital malformations. We reviewed postnatal ultrasonography images and patients with Society of Fetal Urology (SFU) Grades 3 and 4 hydronephrosis with a renal pelvic antero-posterior diameter of ≥10 mm were included. The ureter was assessed and considered dilated if the ureteric diameter was ≥4 mm. The voiding cystourethrogram (VCUG) studies, fUTI incidence, and surgical reports were reviewed. Results Of the 654 patients reviewed, we included 148 patients (164 renal units) of whom 113 (76.4%) were male and 35 (23.6%) female. SFU Grade 3 PH was identified in 49% of the renal units, with the remaining 51% being SFU Grade 4. HU was found in 50/164 renal units and was not detected in the remaining 114 units. VUR was diagnosed in four units (3.5%) without HU (low-grade VUR); whilst it was detected in 19 units (38%) with HU (72.7% were high-grade VUR) (P Conclusion Low-grade uncomplicated VUR was diagnosed in 3.5% of renal units without HU. Our results support limiting the use of VCUG to renal units with PH if associated with HU.

Abstract: Purpose The aim of this study was to report preliminary results of endoscopic treatment of vesicoureteral reflux in children with a single injection of a new bulking agent, cross-linked dextran and polymethylmethacrylate mixture. Materials and Methods We performed a single-center, single surgeon, prospective, off-label study using polymethylmethacrylate/dextranomer to treat vesicoureteral reflux. All patients underwent endoscopic injection, followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to identify de novo or worsening hydronephrosis and vesicoureteral reflux correction (to Grade 0 or I). Results Eighteen patients underwent injection of polymethylmethacrylate/dextranomer at our institution between April 2013 and December 2013. Ten were males and eight were females, with a median age of 58 months (range, 6 months to 5 years). Vesicoureteral reflux was unilateral in three patients and bilateral in 15, for a total of 33 renal refluxing units. Vesicoureteral reflux was Grade I in one renal refluxing unit, Grade II in 12, Grade III in 16, and Grade IV in four. Mean injected volume was 0.86 mL. Reflux was corrected in 23 renal refluxing units (69.7%) according to the 3-month voiding cystourethrogram. Complications included urinary retention in one patient. Mild pyelectasis was noted in one patient at 3 months, which spontaneously resolved 3 months later. Conclusions Our short-term data show that polymethylmethacrylate/dextranomer injection can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used and a low rate of complications. Long-term follow-up is required to confirm the usefulness of this material in treating vesicoureteral reflux.

Abstract: Background: Hydronephrosis as a major health issue, has a significant contribution to the loss of kidney function and dialysis. Based on this the aim of this was to evaluate the probably etiology of hydronephrosis in neonates. Methods: We have evaluated 314 neonates with fetal hydronephrosis (by ultrasonography) as a study group. Cases were followed by voiding cystourethrogram 3 weeks after the start time. In addition, we took a Diethylenetriaminepentaacetic Acid scan at the end of 1st month of childbirth. At the end, we evaluated data based on the statistical analysis. Based on these examinations, etiology of hydronephrosis were examined and recorded. Results: In total 314 infants with hydronephrosis (55.7% male and 44.3% female) were included. Idiopathic cause (42%) as the most common etiology and vesicoureteric reflux as 2nd most common etiology of hydronephrosis have been evaluated (37.4%). Conclusions: Based on this finding, different causes can induce hydronephrosis as a different etiology; therefore, we can control and reduce hydronephrosis by checking vesicoureteric reflux as the most common possible etiology.

Abstract: • The presentation of urinary tract infections (UTIs) in neonates differs from that seen in older children. • The type and route of infection also differ in neonates, when compared with older children. • An appropriate urine sample for diagnosis is needed, but treatment should not be delayed. • A neonate in whom a UTI is suspected should be evaluated for sepsis, including invasive cultures. • After a documented neonatal UTI, a radiologic work-up is warranted to detect anatomic anomalies. • Vesicoureteral reflux (VUR) is diagnosed in 30%–50% of neonates with proven UTI. • Voiding cystourethrogram is the gold standard for the diagnosis of VUR and should be performed on high-risk neonates. • Treatment of VUR should be tailored to each patient's individual risk of UTI recurrence, with the goals of preventing future UTIs and renal scar formation.

Abstract: Background: Urinary tract infection in infants is associated with septicemia and genitourinary anomalies. This study was aimed at investigating the frequency, clinical signs, and anomalies in infants hospitalized for urinary tract infection. Methods: This cross-sectional study was conducted on all infants with urinary infection who were hospitalized in the neonatal ward of Be’sat Hospital from 2006 to 2015. Results: Of 79 infants with urinary infection, 62% were male and 87.3% were term infants. The mean age at admission was 16.62±7.17 days, and the mean weight was 3276±478.23 grams. The most frequent clinical sign and the most common pathogen reported were prolonged jaundice (62%) and Escherichia coli (69.6%), respectively. Of the samples, 93.7% were obtained by suprapubic aspiration, 23% had leukocytosis, and 2.5% had urosepsis. In urinalysis examination, 81% had pyuria and 19% had positive nitrate. Among 25.3% infants who had abnormal ultrasound findings, the most abnormal finding was mild bilateral hydronephrosis and 6.3% of the infants had abnormal voiding cystourethrogram (VCUG) in which vesicoureteral reflux was the most frequent finding. Conclusion: It showed that a prolonged jaundice in infants should be considered as a strong factor predicting urinary tract infection.

Abstract: Objective To determine outcomes after removal of two synthetic mid-urethral slings (MUS) at a tertiary care center. Methods Following IRB approval, a retrospective chart review of non-neurogenic, symptomatic women requiring re-operation after ≥2 MUS was performed. Data reviewed by a third party included: demographics, prior anti-incontinence surgery, complications, pelvic/urinary symptoms, subsequent investigations, surgical repair and outcomes (including UDI-6/IIQ-7 questionnaires) at a minimum 6 months follow-up. Cure was defined as being continent, no dyspareunia, and no additional surgical therapy. Results Between 2007 and 2014, 21 women met the inclusion criteria. Mean age was 57 years (range: 40–82) and mean follow-up was 30.2 months (range: 6–78). The majority of patients presented with one or more symptoms of voiding dysfunction (95%), urinary incontinence (86%), irritative voiding symptoms (62%), dyspareunia (57%), recurrent urinary tract infections (UTIs) (29%), vaginal extrusion (20%) and erosion involving the urinary tract (5%). Patients had a mean of 2 prior anti-incontinence procedures (range 2–3). Over two-thirds had a combination of retropubic and transobturator MUS. Mean number of pre-operative investigations was 3.5 (1–6) including voiding cystourethrogram, cystoscopy and urodynamics. Two patients had complete remission, 14 partial remission, and five failed. Mean postoperative total UDI-6 and IIQ-7 scores at last clinic visit were 10 (range: 0–16/SD 4.1) and 11 (range: 0–28/SD 10.3), respectively. Conclusion The management of women with suboptimal outcomes following two synthetic MUS from transvaginal excision results in modest symptomatic improvement but low permanent complete remission and frequent need for additional therapies.

Abstract: To audit the extent of evaluation of neonates with antenatal hydronephrosis. Records of all neonates with antenatal hydronephrosis between January 2013 and December 2016 were audited to look for patient factors and investigation results. 290 records were evaluated, 93 (32%) of which had abnormalities detected on voiding cystourethrogram. In the presence of hydroureter, 65% had an abnormality while in the absence only 11% were abnormal. In the presence of pelvis ≥20 mm, 93% had abnormal diuretic renogram, while with pelvis <20 mm, only 1.5% were abnormal (P=0.001). Numbers needed to harm calculation revealed 1 in 2 patients would receive an unnecessary voiding cystourethrogram in the absence of hydroureter, and unnecessary diuretic renogram when pelvis <20 mm. While evaluating neonates with antenatal hydronephrosis invasive tests can be limited, if evaluation is guided by ultrasonographic criteria.

Abstract: Urethral catheterization is a common invasive procedure applied for several purposes on children. Voiding cystourethrogram (VCUG) is a diagnostic fluoroscopic procedure, which is commonly ...

Abstract: We present a case of a child with pancreatic insufficiency and facial defects typical of Johanson-Blizzard syndrome (JBS), along with the more facultative anomalies of the JBS, such as those of the urogenital system including persistent urogenital sinus, urethral duplication and dysplastic kidneys. Fetal ultrasound in a 21-year-old G1P1 woman revealed ambiguous genitalia. Examination at birth revealed a phallic structure with urethral meatus, non-palpable gonads, two orifices in close proximity in the perineum, with the anterior being a common urogenital channel and the posterior, the rectum. A voiding cystourethrogram/genitogram showed bilateral high-grade vesicoureteral reflux and a common urogenital sinus extending 1.5 cm before dividing into three channels: the native urethra, an accessory urethra directed anteriorly towards the clitoris and a septate vagina with uterus didelphys. JBS was suspected by clinical presentation and confirmed by UBR1 molecular testing (46,XX). At 16 months of age, she underwent feminising genitoplasty and posterior sagittal anorectoplasty.

Abstract: Introduction: Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment. Methods: This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/ hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution. Results: A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with “other” morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively. Conclusions: We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.

Abstract: Background: Recurrent urinary tract Infection (UTI) is a common problem in pediatric age group. Vesicoureteral reflux (VUR) is a common cause for recurrent UTI. Objectives: This study was conducted to determine the prevalence of VUR in children who presented with recurrent UTIs and to assess the effect of endoscopic treatment in patients with grade III-V VUR. Methods: This was a prospective study recruiting 1232 patients who presented with recurrent UTI during April 2008 and January 2012. We used voiding cystourethrogram to diagnose VUR, and treated grades III-V VUR by bulking agent. One to 2 sessions were performed and the participants were followed-up postoperatively at first, second, third, and 12th months postoperatively. Results: VUR was found in 437 (35.5%) of the patients. Amongst those, 197 (16%) patients were diagnosed with VUR grade I and II. Additionally, 240 (19.5%) cases were diagnosed with VUR III-V. Two sessions were required to correct the reflux in all patients with grade III. The success rate of correction of grade IV was 79% after the second session. The success rate was 71% in grade V. New contralateral reflux with low grade (I and II) de novo VUR was found in 28/240 (11.7%) cases. After successful correction of VUR, UTI occurred in 12/203 (5.9%) of the patients. Conclusions: VUR was common in children with recurrent UTI with a good prognosis after endoscopic correction. Further study is needed to follow-up the participants who did not respond to treatment.