Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection.

OBJECTIVES: To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI). METHODS: We used retrospective data from a multicenter sample of infants younger than 3 months with bacteremic UTI, defined as the same pathogenic organism in blood and urine. Infants were excluded if they had any major comorbidities, known urologic abnormalities at time of presentation, required intensive unit care, or had no imaging performed. Imaging results as stated in the radiology reports were categorized by a pediatric urologist. RESULTS: Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had ≥1 RUS abnormalities. Thirty-four percent had ≥1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality. CONCLUSIONS: Although RUS and VCUG abnormalities were common in this cohort, the frequency and severity were similar to previous studies of infants with UTIs in general. Our findings do not support special consideration of bacteremia in imaging decisions for otherwise well-appearing young infants with UTI.

The foreskin advancement flap: an alternative technique for reconstruction of penile burns.

Penile burns are devastating injuries and are frequently associated with significant functional and psychological sequelae. The goals of penile reconstruction after burn injury include: 1) skin coverage, 2) preservation of penile length, sensation and erectile function, 3) esthetic integrity, and 4) permissive for penile growth in the pediatric patient. A multitude of different techniques have been proposed, including skin grafts, local, regional, and free flaps, each of which fail to address all goals of reconstruction. We introduce the foreskin advancement flap that, when available, successfully addresses these key challenges and as such provides for an ideal reconstruction.

Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection.

OBJECTIVES: To determine the impact of using an algorithm requiring selective rather than routine urinary tract imaging following a first febrile urinary tract infection (UTI) on imaging use, detection of vesicoureteral reflux (VUR), prophylactic antibiotic use, and UTI recurrence within 6 months. DESIGN: Retrospective review comparing outcomes during periods before algorithm use (September 1, 2006, to August 31, 2007) and after algorithm use (September 1, 2008, to August 31, 2009). The new algorithm, which adapted recommendations from the United Kingdom's National Institute for Health and Clinical Excellence 2007 guidelines, was implemented in 2008. The algorithm calls for renal ultrasonography in most cases and restricts voiding cystourethrography for use in patients with certain risk factors. SETTING: County health system. PARTICIPANTS: Children younger than 2 years with a first febrile UTI. INTERVENTION: Selective algorithm for urinary tract imaging. MAIN OUTCOME MEASURES: Urinary tract imaging use, detection of VUR, prophylactic antibiotic use, and UTI recurrence within 6 months. RESULTS: After introduction of the new algorithm, voiding cystourethrography and prophylactic antibiotic use decreased markedly. Rates of UTI recurrence within 6 months and detection of grades 4 and 5 VUR did not change, but detection of grades 1 to 3 VUR decreased substantially. Patients in the prealgorithm group with grades 1 to 3 VUR who would have been missed with selective screening underwent no interventions other than successive urinary tract imaging and prophylactic antibiotic use. CONCLUSIONS: By restricting urinary tract imaging after an initial febrile UTI, rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR. Clinicians can be more judicious in their use of urinary tract imaging.

Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation.

The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.

Fetal renal growth as assessed through renal parenchymal area derived from prenatal and perinatal ultrasonography.

PURPOSE: Few quantitative parameters allow for comparison of serial studies in children with prenatally detected genitourinary abnormalities. We establish the first ultrasonographically based fetal renal parenchymal growth curve that could serve as a standard for fetal renal growth assessment. MATERIALS AND METHODS: Longitudinal ultrasounds of 246 normal fetal kidneys from 16 to 38 weeks of gestation were scanned with renal parenchymal area calculated and growth curves plotted. Our previously determined nomogram from birth to adolescence was then combined with this fetal nomogram to produce a composite renal growth curve. Data were plotted as mean parenchymal area +/- 2 SD using lines determined by polynomial regression. RESULTS: Renal growth curves were constructed independently for the right and left fetal kidneys as well as the total fetal renal parenchymal area. The polynomial regression equation for the right renal parenchymal area was y = -0.0076x(2) + 0.7141x - 8.5344 (r(2) = 0.91). The polynomial regression equation for the left renal parenchymal area was y = -0.0036x(2) + 0.5161x - 6.2337 (r(2) = 0.96). The polynomial regression equation for the total fetal renal parenchymal area was y = -0.0113x(2) + 1.234x - 14.814 (r(2) = 0.95). CONCLUSIONS: We propose a new quantitative standard to evaluate appropriate fetal kidney size the prenatal renal parenchymal area growth curve. Renal parenchymal growth curves for the normal fetal kidney may serve as a valuable tool to assess fetal renal pathology.

Urinary incontinence in girls.

Girls with incontinence may have minor irritative conditions or undiagnosed anatomic abnormalities that may require surgery. These abnormalities can be identified during a comprehensive history and physical examination that focuses on voiding signs and symptoms. Urinary tract infection and constipation if present should be identified. Most girls with daytime wetting will respond to conservative therapy using timed voiding, dietary changes, and anticholinergic medication. Uroflowmetry with a postvoid residual urine measurement can identify girls who may benefit from biofeedback to treat pelvic floor dysfunction. Formal urodynamics and spinal magnetic resonance imaging should be done in girls refractory to treatment. Instruments and tools to quantify dysfunctional voiding symptoms are being developed. Because most dysfunctional voiding will be treated clinically, these validated tools will be useful in documenting severity of symptoms and clinical outcomes.

Serial followup of the contralateral renal size in children with multicystic dysplastic kidney.

PURPOSE: Multicystic dysplastic kidneys have negligible renal function and the contralateral kidney (solitary kidney) frequently exhibits abnormalities that may affect growth. We previously showed that nomograms related to renal size constructed from digitalized ultrasonographic measurements of renal parenchymal area are a sensitive measure of renal growth and correlate with functional mass. We assess the age-dependent characteristics of compensatory renal growth in infants and children with multicystic dysplastic kidneys by construction of a growth curve for the contralateral kidney, assess these characteristics in comparison to normal renal growth of right and left kidneys, analyze the extent of compensatory renal growth and evaluate abnormal growth in solitary kidneys in infants and children. MATERIALS AND METHODS: From 1988 to 2000 we reviewed 152 serial sonograms from 48 patients with a diagnosis of multicystic dysplastic kidneys. We also reviewed 209 renal sonograms in patients whose studies, done for other purposes, showed normal bilateral kidneys. Using computer planimetry, parenchymal area and pelvicaliceal area were determined after digitalization of ultrasound images. Parenchymal area was calculated by parenchymal area minus pelvicaliceal area and expressed as a mean of 3 measurements. A parenchymal area growth curve was generated for the contralateral kidney in the multicystic dysplastic kidney group from birth to 216 months, and for right and left normal kidneys from birth to 338 months. Data were plotted as mean parenchymal area +/- 2 SD on a nomogram generated by linear regression. Differences in parenchymal area between normal right and left kidneys, between normal kidneys and the contralateral to multicystic dysplastic kidney were analyzed by unpaired Student t test. RESULTS: Of the 48 patients with multicystic dysplastic kidneys 36 had contralateral normal kidneys and 12 (25%) had a contralateral abnormality. Of the 12 cases 4 and an additional 5 without an identified abnormality (9 of 48) or 18.7% had solitary kidneys 2 SD below the normal growth curve for total parenchymal area, indicating a smaller than expected increase in compensatory renal growth. Conversely, 8 of 12 including 1 with grade V reflux into a solitary kidney exhibited normative compensatory renal growth. Left normal kidneys demonstrated a small but statistically significantly larger parenchymal area throughout growth. Solitary kidneys did not demonstrate growth differences associated with side. Solitary kidneys showed accelerated growth from 0 to 22 months while normal kidneys showed accelerated growth from 0 to 15 months. CONCLUSIONS: Nomograms constructed from ultrasonographic measurements of renal parenchymal area may be useful for assessing abnormal renal growth in solitary kidneys. Patients with solitary kidneys identified by conventional ultrasonographic measurement as normal may not exhibit expected growth. Clinical decision making may be improved by identification of solitary kidneys at risk for poor growth.