The utility of ureteral jet angle sonography as initial screening tool for assessing vesico-ureteral reflux in the Philippines: A prospective, cross-sectional trial

INTRODUCTION: One of the common risk factors in urinary tract infection is vesico-ureteral reflux. According to some studies, it is seen in 30%-50% of children and 40%-50% present with febrile urinary tract infection. The presence of moderate to severe reflux is an important risk factor in terms of acute pyelonephritis and reflux nepropathy. Investigation of children with urinary tract infection has undergone change so as to detect those who will benefit from diagnosis and treatment at the same time avoid over investigation.OBJECTIVE: The present study aimed to determine the role of ureteral jet angle (UJA) in detecting vesicoureteral reflux (VUR) as compared to the gold standard of voiding cystourethrography (VCUG).METHODS: A total number of 152 kidneys from 76 patients (37 female and 39 males) ages from 2 months up to 11 years old were included in this study. These patients presented with recurrent urinary tract infection as confirmed via routine urinalysis and/or urine culture and sensitivity and assessed to have vesico-ureteral reflux disease as confirmed by voiding cystourethrogram (VCUG). They were included regardless of the grade of reflux (grade I-V). Patients with urinary tract infection but negative VCUG were also included. Excluded from the study were parents with no consent, patients with neurogenic bladder disorder as cause of recurrent urinary tract infection, patients who had postoperative correction of vesico-ureteral reflux prior to ureteral jet angle sonography, patients currently taking medication for urinary tract infection and patients currently symptomatic for recurrent urinary tract infection i.e. fever,chills,dysuria. All of the participants underwent kidney, urinary bladder ultrasound with ureteral jet angle sonography and all data were collected.RESULTS: Out of 152 kidneys, vesicoureteral reflux was seen in 91 of them (60%). Low grade reflux defined as grade I or grade II reflux was present in 32 kidneys (21%) and high grade reflux defined as grade III-V reflux was seen in 59 kidneys (39%). In both right and left kidneys, no significant difference was observed in bladder volume and expected bladder capacity (EBC) by VUR status. On the other hand, there was a significant difference observed in volume to reach reflux by VUR status of both right and left kidneys. No significant difference was observed in UJA volume, EBC, EBC% and UJA degrees by VUR status in the right kidneys. On the other hand, UJA volume, EBC and EBC% was significantly different by VUR status in the left kidneys. All AUCs were less than 0.7 even if EBC was considered. Therefore, UJA may have poor ability to classify patients correctly according to their VUR status.CONCLUSION: Doppler flow ultrasound measurement of ureteral jet angle may be a simple and real non invasive test in children of any age but it only showed poor correlation compared to voiding cystourethrography in detecting vesicoureteral reflux. The ureteral jet angle sonography may not be a good initial diagnostic test in assessing vesicoureteral reflux due to its low sensitivity and specificity in detecting the said disease.

Analysis of prognosticating factors at initial presentation of neurogenic bladder in patients with myelomeningocele

OBJECTIVE: Neurogenic bladder dysfunction (NBD) in myelomeningocele (MMC) remains a major cause of renal decline. We evaluate the initial presentation, ultrasonographic, urodynamic and VCUG findings in search of indicators that can guide in early decisions in treatment to avoid poor long-term outcomes. MATERIALS AND METHODS: From 1989 to 2013, 178 patients with neurogenic bladder due to MMC had records accessible for review. The median follow up was 10.4 years (0.9 - 25.0). Parameters reviewed were: patients' initial presentation; Ultrasonography: hydronephrosis grade and bilaterality, bladder wall thickness, and kidney size; Urodynamics: compliance, Detrusor Leak Point Pressure (DLPP), bladder activity and sphincter synergy; VCUG: grade of reflux, bladder pattern, and bladder neck appearance. Endpoints to which all parameters were compared were: 1. need for surgery, 2. continence 3. renal status, and 4. follow-up urodynamics RESULTS: Recurrent UTI at presentation was associated with 3.1 times [OR = 3.1 (95% CI: 1.3 - 8.5)] need for surgery and incontinence at presentation was 11 times [OR=11.0 (95% CI: 3.8 - 33.4)] more likely to be incontinent in the long term. Hydronephrosis was associated with 4.4 times [OR= 4.4 (95% CI: 1.3 - 19.0)] risk for renal deterioration and 6 times [OR = 6.3, (95% CI: 3.8- 14.7)] need for surgery. Those with thickened bladder were 6 times [0R=6.0 (95% CI: 2.9 - 12.5)] more likely to have needed surgery. Patients with urodynamic findings of low compliance are 2.7 times [OR 2.7(95% CI: 1.2 - 6.3)] more likely to have needed surgery and high DLLP on initial consultation are 5.6 times [OR=5.6 (95% CI: 1.2 - 51.6)] more likely to have renal deterioration and 2.1 times [OR 2.1(95% CI: 1.1 - 4.4)] more likely needing surgery. On VCUG, those with "Christmas tree" pattern of bladder have 90% [0R=0.9 (95% CI: 0.01 - 0.70)] more risk for renal deterioration, 5 [0R=5 (95% CI: 2.5 - 10.2)] times more likely to need surgery and 70% [0R=0.7 (95% CI: 0.1 - 0.9)] more likely to have urodynamic deterioration. Finally, reflux, specifically bilateral, was associated with 4 times [OR = 4.0 (95% CI: 1.2 - 14.3)] risk renal deterioration as compared to those with no reflux findings and 9.6 times [OR=9.6 (95% CI: 4.1 - 23.8)] more likely to need surgery, while high-grade reflux had 90% more risk [OR = 0.9 (95% CI: 0.1 - 0.8)] to have urodynamic deterioration. CONCLUSIONS: Prognostication early in the course of NBD in MMC is possible. It is recommended that patients with risk factors for deterioration be provided a more intensive regimen of treatment and follow-up to prevent further morbidity.

Autoaugmentation versus enterocystoplasty: Outcomes in myelodysplastic children with neurogenic bladder

OBJECTIVE: Bladder autoaugmentation with detrusorectomy is done to improve bladder capacity and compliance in neurogenic bladders, to achieve constant low bladder pressure, preventing sequelae such as renal failure. Some reports discourage its application however citing that effects are short term and failure rates are high. We compared the pre and post-operative urodynamic profile of high risk patients undergoing autoaugmentation or enterocystoplasty to determine if it can still be used as a treatment option for neurogenic bladders. MATERIALS AND METHODS: A retrospective study using the database of our spina bifida foundation was performed. Out of 382 patients, 45 underwent augmentation cystoplasty. Twenty seven (27) had followed evaluation protocol and were included in the study. The median age was 8.6 years at the time of surgery and the median years of follow up was 3.5 years. Urodynamic parameters, as well as symptom and bladder/sphincter profiles, pre- and post-operatively were compared between the two groups. RESULTS: In the autoaugmentation group there was a 42.45% mean increase in capacity, and mean increase in compliance of 181.1% versus a 190.3% increase in capacity, and 479% increase in compliance in the enterocystoplasty group. The difference is statistically significant. There was no difference in the end filling pressure, leak point pressures, reflux, number of postoperative UTIs and incontinence. One patient in the autoaugmentation needed redo with an enterocystoplasty. Complication rates were comparable in both groups. CONCLUSION: Autoaugmentation cystoplasty is still a viable option for surgical management of neurogenic bladders. Our data showed that in patients who underwent detrusorectomy, there was improvement of urodynamic parameters, bladder and upper tract profiles, UTIs and incontinence, which were comparable to the gold standard.

The effects of transcutaneous nerve stimulation on incontinence, constipation and urodynamic parameters in pediatric patients with myelomeningocele

OBJECTIVE: The purpose of this study was to determine the efficacy of transcutaneous nerve stimulation (TENS) in the treatment of neurogenic bladdder secondary to myelomeningocele (MMC). MATERIALS AND METHODS: A total of 14 children (7 boys and 7 girls) with neurogenic bladder secondary to MMC who were referred to our clinic between 2009 and 2011 were enrolled in the study. Urodynamic parameters including maximum bladder capacity (MBC) and detrusor leak point pressure (DLPP), maximum detrusor pressure (MDP) and bladder compliance (BC), daily incontinence score, constipation, and subjective improvement were recorded as outcome measures. After the first urodynamic session to get the baseline parameters, a 1 hour dose of TENS once a day for at least 3 months was applied at a certain dermatomal level. This was followed by another urodynamic session to assess its effects. RESULTS: Out of 14 subjects, 11 (78.5%) had improvement in continence profile and 8 (57%) had improvement in bowel movement. Thirteen out of 14 (92%) had subjective improvements such as higher catheterized and/or voided volume, lesser bedwetting episodes, spontaneous voiding, increased sensation to void, presence of urgency to void, and frequent voiding. One subject had no subjective improvement. The difference in DLLP, MBC, MDP, and BC pre and post treatment was not statistically significant. CONCLUSION: The efficacy of TENS in treating bladder dysfunction in patients with MMC remains uncertain. It did show slight improvement in urodynamic parameters specifically BC and MBC however, it was not statistically significant.

Causes of failure in primary hypospadias repair: A prospective single-surgeon cohort study

OBJECTIVE: To identify the possible causes of failure in hypospadias repair and to evaluate the authors' own results in this demanding surgery. MATERIALS AND METHODS: Seventy-five consecutive boys, 3 months-15 years age underwent tubularized incised plate urethroplasty  with the corpus spongiosum as 3rd layer. Patient-related and surgeon-related factors were recorded preoperatively, intra-operatively, and postoperatively. Complications were recorded prospectively, initially after one week follow up. RESULTS: Overall complication rate was 41%. Fistula rate was 22.67%. Among the patient-related factors, meatal location (P=0.001), degree of severity of scrotal transposition (P=0.002) and atrophic proximal skin length (P=0.040) were significantly contributing to the risk of failure. The more developed the corpus spongoisum is, the risk of fistula formation decreases by 2.78 times (OR=0.36 P=0.043). CONCLUSION: Only patient-related factors primarily meatal location, degree of severity of scrotal transposition and presence of atrophic proximal skin are significantly associated with failure. Their presence would increase the risk of complication from 1.13 times to 8.5 times. The association of surgeon-related factors to the outcome of surgery varies from protective to risk.

Rhabdoid tumor in a nine-year old boy: A rare tumor of the urinary bladder

A 9 year old boy presented with painless gross hematuria 1 month prior to admission. Ultrasound and CT scan of the whole abdomen with contrast showed a 2.6cm x 2.0cm papillary mass on the right posterolateral wall. Initial transurethral biopsy result showed negative for malignancy, fibrovascular tissue with mild chronic and acute inflammation. On repeat cystoscopy, a 4cm x 4cm pendunculated lobulated mass was located posterolateral encroaching on the right ureteral orifice. Subsequently a partial cystectomy with distal ureterectomy, right; right-to-left transureteroureterostomy with DJ stent insertion were done. Microscopic and immunostaining results support a diagnosis of rhabdoid tumor. Adjuvant chemotherapy and immunotherapy was given. On follow up, there was no evidence of recurrence. This case emphasizes the need to follow aggressively children with gross hematuria. Biopsy should include deep biopsies as rhabdoid tumors are infiltrating tumors. Coordination with the pathologist is of extreme importance since special stainings are needed for confirmation.

Cost-effectiveness of extracorporeal shock wave lithotripsy vs percutaneous nephrolithotomy in the management of lower pole nephrolithiasis: A study in local figures

OBJECTIVE: We determined the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy and compared its cost-effectiveness with percutaneous nephrolithotomy (PCNL) for the management of lower pole renal calculi with a size of 1.0cm to 2.0cm in widest dimension. MATERIALS AND METHODS: Using the cost estimate data available locally from patient billing charges and average professional fee, efficacy and complication rates data from the literature, the cost-effectiveness for the percutaneous nephrolithotomy and shock wave lithotripsy as primary therapy for lower pole stones were evaluated. We developed a decision analysis model in which a patient in whom primary therapy (either ESWL or PCNL failed was rendered stone-free with secondary ESWL using a trial version add-in software for Microsoft Excel from www.TreePlan.com with some modifications. RESULTS: The average cost over all outcomes from the decision to perform ESWL in patients with lower pole stones 1.0 to 2.0 cm is Php 53,801.07 and Php 127,019.27 for PCNL. For PCNL to be as cost effective, cost incurred should be lowered to Php 47,746.38 CONCLUSIONS: Extracoporeal shock wave lithotripsy, despite its considerable low efficacy as compared to PCNL as a primary treatment for lower pole stones 1.0 to 2.0 cm, is still more cost-effective.

A prospective study on the consistency and reproducibility of uroflowmetry studies and post void residual measurements at a bladder volume of 50-100% of estimated bladder capacity in children

OBJECTIVE: There are no standard ways and guidelines in uroflowmetry and post void residual (PVR) measurements in children. We assessed the repeatability and consistency of uroflowmetry and PVR determination in children at a bladder volume of 50-100% of the estimated bladder capacity (EBC).METHODS: Twenty-five children, ages 3-8 years, underwent uroflowmetry and post void urine measurements. Values were taken for 3 consecutive micturitions at a bladder volume of 50-1 00% ofthe EBC, as measured by transabdominal ultrasound. Uroflowmetry parameters and PVR were analyzed and recorded.RESULTS: There were no significant differences in the measurements across three trials for maximum flow rate (Qmax) and prevoid urine volume. There were significant differences in the measurements of PVR and uroflowmetry curves. PVR urine volumes were not related to prevoid urine volumes. Age, height and weight were related to the prevoid volumes.CONCLUSION: Uroflowmetry and PVR tests will give informative and reliable values at a volume of 50-100% of EBC. In cases of any abnormal flow pattern at this bladder capacity, a repeat examination is prude

A comparison between voiding patterns of healthy infants and those with recurrent UTI

OBJECTIVE: The purpose of this study was to compare voiding patterns of healthy infants and those with recurrent UTI aged 1-24 months.METHODS: This was an analytical, cross sectional study of healthy infants and those with recurrent UTI, aged 1-24 months from March 1999 to March 2000 seen at University of Santo Tomas Hospital. The study included 100 subjects; Group I (50 subjects) healthy infants (neurologically intact with other anomalies ruled out by ultrasound and voiding cystourethrogram) Group 2 (50 subjects) are those with recurrent UTI. During the 24-hour period, all micturitions were recorded in terms of voiding frequency, volume and character of voiding. The observation was completed with three determination of residual urine volume using ultrasound by a single sonologist who did not know the diagnosis of each case. Voiding patterns in terms of mean voiding frequency, mean volume per voiding, mean functional bladder capacity and character of voiding were determined. Mean residual urine volume was also determined in milliliters. The two groups were compared using T test with a p value of 0.05 percent at 95 percent confidence interval.RESULTS: The mean voiding frequency was 17.03 (SD +/- 7.5) in-group 1 and 13.5 (SD +/- 4.9) in-group 2 (p value of 0.009) The mean volume per voiding was 33.88 (SD +/- 15.2) on group 1 and 40.12 (SD +/- 37.4) in Group 2 (p value of 0.27). The mean bladder capacity was 44.02 (SD +/- 29.5) in group 1 and 66.48 (SD +/- 29.4) in group 2 (p value 0.00). In group 1 subjects, twenty eight percent showed interrupted voiding pattern compared to none in group 2 (p value 0.00). The mean residual urine volume for group 1 was 7.97 (SD +/- 7.5) and 6.06 (SD +/- 6.6) in group 2 (p value 0.183).CONCLUSION: The voiding patterns of pediatric patients with recurrent UTI were significantly characterized by increased frequency, decreased functional bladder capacity, and interrupted voiding. Mean volume per voiding was also decreased in those with recurrent UTI but not to a significant degree. Determination of residual urine in those with recurrent UTI was not significantly different from healthy infants.

Genitourinary tract changes in neglected patients with myelomeningocoele

The objective of this paper was to describe the bladder and sphincter urodynamic profiles and the upper tract status of patients with myelomeningocoele. This was correlated with the patients age when initially evaluated. Patients from the Spina Bifida Support Group of the Philippines who underwent initial videourodynamics when first seen were included in the study. The procedure was performed using a Laborie Avanti 4.1 model urodynamic machine. The hostile profile included bladder-sphincter dyssynergia, dyssynergic bladder neck/sphincter or leak point pressure greater than 35 cm H2O. The non-hostile picture included areflexic bladder and sphincter, open or areflexic sphincter or leak point pressure less than 35 cm H2O. The upper tracts were also assessed for the presence of hydronephrosis or vesicoureteral reflux There were 83 myelomeningocoele patients who underwent screening videourodynamics. Their ages ranged from 2 months to 19 years. Fifty one patients presented with hostile bladder sphincter profile while 32 patients presented with non-hostile features. Among the patients with hostile features, 37 manifested with hydronephrosis and/or vesicoureteral reflux. Three patients already presented with renal failure. Beyond 2 years old, 34 patients showed hostile bladder sphincter profile. Sixteen patients already presented with hydronephrosis and/or reflux after the age of 5 years. Renal failure was manifested by older children, all exhibited hostile bladder sphincter features and upper tract deterioration. These data showed a positive correlation of age, hostile profile and upper tract changes in patients with myelomengocoele

Prospective trial on the effect of circumcision in boys less than 2 years with primary vesicoureteral reflux and recurrent urinary tract infection: A university medical center experience

Rationale: Vesicoureteral reflux (VUR) occurs in 30-50 percent of children with urinary tract infection (UTI). Although it does not cause bacteriuria, it facilitates transport of bacteria from the bladder to the upper tract and increases risk both for UTI and scarring and its sequelae. Antibiotics remain as the mainstay of prevention, yet 40 percent breakthrough infections still occurObjectives: This study was done to determine whether circumcision prevents recurrent UTI in boys less than 2 years old diagnosed with primary vesicoureteral reflux who are on standard prophylactic antibiotic and likewise correlate age, laterality and severity of reflux with UTI recurrenceMethods: This is a prospective cohort of 57 subjects selected by non randomized purposive sampling allocated to either group A (circumcised) or group B (uncirResults: Of 57 males, 25 (44 percent) were circumcised and 32 (56 percent) were uncircumcised. The mean age was 16 months (1 month - 24 months). Twenty-nine had unilateral reflux and 28 had bilateral reflux. Recurrent UTI was observed in 12 subjects in group B (37 percent) while only 2 subjects in group A (8 percent). Chi square analysis showed a significant association between recurrence and circumcision status (x2Conclusion: The role of circumcision seems to protect boys with VUR for it decreases the recurrence of UTI. It maybe considered as part of UTI therapy. (Author)

Early experience in laparoscopic renal surgery for pediatric urology: Our thoughts for the future

Laparoscopic surgery is presently assuming an important role in pediatric urology. It offers minimally invasive surgery to benign real conditions. We report our experience with laparoscopic renal surgery in the pediatric age group and evaluate our series to establish the safety and efficacy of it. Between August 2003 and June 2004,4 girls with ages ranging from 8 months to 8 years old, averaging 44 months, underwent laparoscopic renal surgeries. Our series consistent of 1 Nephrectomy, 1 Nephroureterectomy (retroperitoneal approach) and 2 Heminephroureterectomies. Operating time ranged from 125 to 340 minutes averaging 185 minutes. Blood loss was minimal. No early or late postoperative complications were noted. Our series also showed that patients experience minimal postoperative discomfort, improved cosmesis and shorter hospital stay with the laparoscopic approach. As we gain more experience refinements in our surgical technique are expected and with the advent of new technology such as Ultrasonic SonoSurg, laparoscopy will be an important facet in the surgical armamentarium of pediatric urologists. (Author)

Retroperitoneal laparoscopic adrenalectomy: A documentation of the first case in the country

The initial experience in laparoscopic adrenalectomy has been performed transperitoneally. To further minimize the invasiveness, the concept of retroperitoneal laparoscopy was developed and is rapidly gaining grounds as the standard of care. Locally, surgeons have been reluctant in adopting this remarkable alternative due to lack of facilities, experience and support. Thus, only 4 cases of laparoscopic adrenalectomies, all via the transperitoneal approach, had been performed for the past 4 years. Considering the limited experience, inadequate facilities and instruments, still, it was successfully performed with some procedural innovations and technical modifications. It follows the principles of minimally invasive surgery that can avoid some of the physiologic and technical complications of transperitoneal laparoscopic adrenalectomy in the country. It proves the possibility of the procedure in the local setting. As an innovative addition to urological practice, retroperitoneal laparoscopic adrenalectomy can therefore serve as an alternative treatment procedure for benign adrenal pathologies. (Author)

The value of a voiding cystourethrogram: Single and isolated recurrent urinary tract infection

OBJECTIVE: This study is designed to determine the correlation between a voiding cystourethrogram in children and a single and isolated recurrent urinary tract infection, as well as the most frequent presenting symptom in children yielding a positive resultMATERIALS AND METHODS: One hundred ninety seven (197) children, ages 0-6 years old, diagnosed to have a urinary tract infection based on history, physical examination, urinalysis and urine culture. Group I included those with single and isolated urinary tract infection: Group II, those with recurrent urinary tract infection. All patients in both groups underwent a voiding cystourethrogramRESULTS: Of one hundred ninety-seven (197), sixty-seven (67) of them were assigned to Group I, while one hundred thirty (130) were assigned to Group II. Sixteen (16) out of sixty-seven (67) in Group I (23 percent) and forty-four (44) out of one hundred thirty (130) in Group 2 had a positive VCUG. High grade fever was the most common presenting symptomCONCLUSION: The frequency of a urinary tract infection did not significantly affect positivity with voiding cystourethrogram. However, the presence of high grade fever correlated better with a (+) VCUG. (Author)

Tubularized tunica vaginalis graft for male urethral reconstruction

Graft substances such as skin, bladder and buccal mucosa have been used for urethral replacement when local epithelial tissue is not available. However, these subtances have been associated with meatal prolapse, stricture and fistula formation. We tried tunica vaginalis as a urethral graft in rabbitsA graft of tunica vaginalis was placed in the excised portion of the urethra in five experimental rabbits. After 6 weeks retrograde urethrograms revealed no strictures and a fistula formation in one rabbit. The histopathologic examination revealed that the tunica vaginalis was covered by the transitional epithelium of the urethra. The tunica vaginalis could be used as a urethral graft in animals with a fistula formation as a complication. (Author)