Role of a Preoperative Catheter Regimen in Achieving Early Primary Endoscopic Valve Ablation in Neonates with Posterior Urethral Valves.

PURPOSE: Primary valve ablation is preferred to vesicostomy in the initial management of posterior urethral valves. However, some neonates have a prohibitively small urethra. We describe our experience with a preoperative urethral catheter regimen to enhance the likelihood of neonatal valve ablation. MATERIALS AND METHODS: We performed a retrospective review of 126 neonates with posterior urethral valves treated between 2003 and 2019 with valve ablation prior to 10 weeks of age. The preoperative indwelling catheter either was gradually upsized to an 8Fr (progressive urethral dilation), was not upsized (nondilated) or was initially larger bore (8Fr only). The primary outcome was the ability to perform primary ablation by neonatal resectoscope. The secondary objective was to establish the parameters for considering progressive urethral dilation as well as its associated risks. RESULTS: Overall 97% could be ablated. The progressive urethral dilation group had the lowest mean weight (p <0.001). Only a larger catheter at the time of ablation was significantly associated with feasible ablation (p <0.001) and not urethral dilation, the infant's weight or his gestational age. Progressive urethral dilation was associated with a longer duration of catheterization as well as double the rate of febrile urinary tract infections (8.5%) over the nondilated group (3.6%). CONCLUSIONS: A much higher rate of primary ablation is feasible (97%) than previously reported (82%). More important than the infant's weight is whether a 6Fr to 8Fr catheter is in place at ablation. If an initial 6Fr to 8Fr catheter cannot be placed, urethral dilation to 8Fr should be performed before attempting ablation. This is both a technique and preoperative assessment that is useful for operative planning.

Opioid utilization is minimal after outpatient pediatric urologic surgery.

INTRODUCTION: There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. MATERIALS AND METHODS: After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. RESULTS: Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. DISCUSSION AND CONCLUSIONS: Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Long-Term Clinical Outcomes and Parental Satisfaction After Dextranomer/Hyaluronic Acid (Dx/HA) Injection for Primary Vesicoureteral Reflux.

Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up. Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review. Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8-9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33-0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3-5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied. Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.

Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness.

INTRODUCTION: Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. OBJECTIVE: The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). STUDY DESIGN: Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. RESULTS: All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. CONCLUSIONS: The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

High GMS score hypospadias: Outcomes after one- and two-stage operations.

INTRODUCTION: Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other. OBJECTIVES: The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias. STUDY DESIGN: GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage). RESULTS: Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n = 48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n = 39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p = 0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p = 0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12). CONCLUSIONS: Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.

Is routine voiding cystourethrogram necessary following double hit for primary vesicoureteral reflux?

INTRODUCTION AND OBJECTIVE: Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. STUDY DESIGN: Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥ 3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade 4-5 VUR. Initially, all children underwent postoperative VCUG ("routine" group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study ("indicated" group). Clinical success was defined as no postoperative fUTI and radiographic success as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months. RESULTS: Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were "routine" and 38 were "indicated" [Figure]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2-50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2-40). Nine children (4.1%) underwent additional procedures. DISCUSSION: We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an "indicated" VCUG (i.e. those less than 2 years of age, grade 4-5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an "indicated" VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence "spontaneous resolution" is unknown. CONCLUSION: Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method.

Early effect of American Academy of Pediatrics Urinary Tract Infection Guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting.

PURPOSE: In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. MATERIALS AND METHODS: During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, voiding cystourethrogram and admission status were assessed. RESULTS: A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer voiding cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p <0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p <0.001). Of 55 voiding cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and voiding cystourethrogram positivity (p = 0.116). CONCLUSIONS: AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal voiding cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine voiding cystourethrogram results in increased morbidity is the subject of ongoing study.

Vesicoureteral reflux index (VURx): a novel tool to predict primary reflux improvement and resolution in children less than 2 years of age.

PURPOSE: Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. MATERIALS AND METHODS: Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. RESULTS: Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p<0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. CONCLUSIONS: Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.

Phantom urinary incontinence in children with bladder-bowel dysfunction.

OBJECTIVE: To report a previously undescribed condition in which children present with the sensation of wetness because of presumed urinary incontinence when they are actually completely dry. We have termed this entity "phantom" urinary incontinence (PUI). MATERIALS AND METHODS: Twenty children referred to our pediatric urology clinic were diagnosed with PUI between 2009 and 2013. Patient demographics, associated bladder and bowel symptoms, concomitant diagnoses, imaging, management, and treatment outcomes were evaluated. RESULTS: Twenty children (18 females and 2 males) were diagnosed with PUI over a 5-year interval. Mean age at diagnosis was 6.9 ± 2.5 years (range, 4-12 years). Nineteen patients (95%) had concomitant lower urinary tract symptoms, and all were also diagnosed with constipation. Urgency (75%) and frequency (50%) were the most common associated bladder symptoms. Of the 18 girls, 13 (72%) had associated vaginitis. Fourteen children (70%) carried a parent-reported diagnosis of obsessive-compulsive disorder or obsessive-compulsive disorder personality traits. Patients were managed with timed voiding, dietary modifications, and a bowel regimen. Ninety percent children experienced improvement of bladder-bowel dysfunction and resolution of PUI at a mean follow-up of 14.4 months. CONCLUSION: Children with PUI have a high incidence of obsessive-compulsive traits. Phantom incontinence as well as associated lower urinary tract symptoms resolve with adherence to a strict bladder-bowel regimen.

Temporal pattern of vesicoureteral reflux on voiding cystourethrogram correlates with dynamic endoscopic hydrodistention grade of ureteral orifice.

PURPOSE: The double hydrodistention implantation technique uses ureteral hydrodistention to visualize injection site(s) and determine required bulking agent volume. Along with grade, early vesicoureteral reflux on voiding cystourethrogram provides prognostic information regarding spontaneous resolution of reflux. We hypothesized that reflux timing is predictive of endoscopic hydrodistention grade. MATERIALS AND METHODS: We identified children undergoing the double hydrodistention implantation technique for primary vesicoureteral reflux between 2009 and 2012. Hydrodistention grade (0 to 3) was assigned prospectively, and compared to vesicoureteral reflux grade and timing on voiding cystourethrogram. RESULTS: A total of 196 children with a mean ± SD age of 3.94 ± 2.58 years underwent injection of 332 ureters. Mean ± SD vesicoureteral reflux grade was 2.8 ± 0.9. Of the ureters 52.4% demonstrated early to mid filling, 39.2% late filling and 8.4% voiding only reflux. Mean ± SD reflux grade was 3.1 ± 0.81 for early filling, 2.6 ± 0.81 for late filling and 2.1 ± 1.1 for voiding only (p <0.0001). Vesicoureteral reflux and hydrodistention grades correlated, with higher reflux grades associated with grade 3 hydrodistention (p <0.001). There was a significant relationship between reflux timing and hydrodistention grade (p <0.001), with a high percentage of ureters with grade 3 hydrodistention displaying early reflux compared to those with grade 1 disease. Significantly increased mean injected volume for ureters with grade 3 hydrodistention (1.6 ml) was observed compared to those with grade 1 or 2 disease (1.25 ml, p <0.001). CONCLUSIONS: Hydrodistention grade correlates with vesicoureteral reflux grade, timing of reflux and injected volume. Early to mid filling vesicoureteral reflux is associated with abnormal hydrodistention (grade 2 to 3). Temporal pattern of vesicoureteral reflux on voiding cystourethrogram may be used to predict ureteral orifice competency and thus aid in predicting resolution of reflux.

Emergency room visits and readmissions after pediatric urologic surgery.

OBJECTIVE: Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution. MATERIALS AND METHODS: Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed. RESULTS: Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3-24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%. CONCLUSIONS: The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux.

OBJECTIVE: The objective of this study was to evaluate risk factors for new contralateral vesicoureteral reflux (NCVUR) and to investigate whether assessment of the non-refluxing contralateral ureter (NRCU) by hydrodistention and selective treatment can reduce the incidence of NCVUR. MATERIALS AND METHODS: From 2001 to 2007, 339 of 841 patients (40%) were treated for unilateral VUR by endoscopic injection. While in the first 267 patients the NRCU was only assessed by hydrodistention but not injected (observation group), NRCUs of the subsequent 72 patients were prophylactically treated if deemed at high risk for NCVUR (H2 or H3) (prophylaxis group). RESULTS: NCVUR occurred in 30 of 267 patients (11.2%) whose NRCUs were observed. No statistically significant risk factors for NCVUR were found in this group. In the subsequent 72 patients, whose H2 and H3 ureters were selectively injected (N = 56), no cases of NCVUR were seen. CONCLUSIONS: Prophylactic endoscopic treatment of NRCU H2 and H3 ureters successfully prevented the occurrence of NCVUR.

Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: defining measures of success.

OBJECTIVE: Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up. METHODS: We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1-21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12-36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions. RESULTS: In 2004-2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as 'radiographic cure and no clinical evidence of FUTIs' it was 82% (275/336). CONCLUSIONS: It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.

Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux.

PURPOSE: Follow-up of patients undergoing dextranomer/hyaluronic acid injection for vesico-ureteral reflux (VUR) is controversial. The purpose of our study was to test the hypothesis that patients undergoing the double hydrodistention-implantation technique (Double HIT) have a higher clinical and radiographic success rate. MATERIALS AND METHODS: Patients undergoing Double HIT endoscopic injection for VUR were prospectively identified. Patients underwent an ultrasound at 6 weeks to assess the implants, and, if visible, prophylactic antibiotics were discontinued and patients were scheduled for a 1-year voiding cystourethrogram (VCUG). Radiographic success was defined as a negative VCUG and clinical success as no febrile urinary tract infections at 1 year. RESULTS: A total of 54 patients underwent endoscopic injection for VUR. Twenty-five (51%) were compliant with the 1 year follow-up; 18 non-compliant patients were contacted and their clinical status assessed. Thirty patients eventually completed the 1-year VCUG at a mean of 12.2 months (range 10-20). Among the 60% of patients with 1-year radiographic follow-up, 2 had persistent VUR for a radiologic success rate of 93%. All radiographic failures were infection-free. Of the 80% (43/54) of patients with available clinical data, 3 (7%) had afebrile UTI for a clinical success rate of 93%. CONCLUSIONS: The Double HIT leads to a 93% clinical and 93% radiographic intermediate/long-term success rate. With this technique, better outcomes were achieved with fewer recurrences than previously reported. These favorable results challenge the need for postoperative VCUG in asymptomatic patients after the Double HIT.

Pediatric chronic orchalgia.

INTRODUCTION: Chronic orchalgia, defined as testicular pain lasting > 3 months and interfering with normal activities, is neglected in the pediatric literature. We describe our experience with the evaluation and treatment of pediatric chronic orchalgia patients. MATERIALS AND METHODS: Charts were screened to identify patients meeting the criteria for chronic orchalgia. Charts were further reviewed to record the history and physical exam, diagnostic tests, treatment and outcomes. RESULTS: 65/982 patients met the criteria for chronic orchalgia. Mean age was 13 and mean duration of pain was 8.6 months. Physical exam findings were normal in 46 patients (70%). 59 patients were managed conservatively with resolution (10/59, 17%) or a single visit (36/59, 61%) in 78%. 13/59 (22%) patients showed either minor improvement or no change in symptoms. 5 non-responding patients were managed by the anesthesia pain service; 4 received epidurals with or without additional oral pain medications with 3 experiencing significant pain improvement. CONCLUSION: Conservative management of chronic orchalgia allowed symptoms to subside in the majority of cases. We recommend patients be treated with conservative measures for 1-2 months. If this fails, early involvement of the anesthesia pain service can offer treatment modalities such as epidural analgesia. Surgical management in the face of a normal physical exam does not seem to have a role.

Comparison of ultrasound and magnetic resonance urography for evaluation of contralateral kidney in patients with multicystic dysplastic kidney disease.

PURPOSE: The contralateral kidney is abnormal in up to 25% of patients with multicystic dysplastic kidney. Traditionally, anatomical and functional evaluation of the contralateral kidney has been performed with ultrasound and dimercapto-succinic acid renal scintigraphy, as indicated. Recently magnetic resonance urography has been used to evaluate renal anatomy and function in other urological abnormalities. We compared the results of magnetic resonance urography and ultrasound for evaluating the contralateral kidney in patients with multicystic dysplastic kidney and we describe the range of findings detected. MATERIALS AND METHODS: Patients with multicystic dysplastic kidney who underwent magnetic resonance urography were identified. Anatomical findings on magnetic resonance urography were analyzed and compared to those on renal ultrasound. Additional functional information derived from magnetic resonance urography was also recorded. RESULTS: We retrospectively identified 58 patients with a unilateral multicystic dysplastic kidney who had undergone magnetic resonance urography, of whom 54 also underwent ultrasound. Of the patients 19 (32.8%) had a contralateral abnormality. A discrepancy between magnetic resonance urography and ultrasound was seen in 9 patients (16.7%). Of these patients only 1 had a completely normal contralateral kidney by ultrasound on retrospective review. The incidence and range of parenchymal abnormalities was wider than previously reported. CONCLUSIONS: Contralateral abnormalities in children with multicystic dysplastic kidney are common and more definitively evaluated with magnetic resonance urography vs ultrasound. Renal ultrasound remains the most appropriate modality for the initial evaluation of children with multicystic dysplastic kidney, and magnetic resonance urography is recommended when a functional study is required either to confirm the diagnosis of multicystic dysplastic kidney or to evaluate suspected abnormalities of the contralateral kidney.

Is endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder?

OBJECTIVE: To assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB). METHODS: A total of 41 patients with VUR and OAB underwent endoscopic injection of dextranomer/hyaluronic acid. At surgery, 13 patients had been successfully treated for their OAB (urgency with or without wetting) with behavior modification with or without anticholinergic therapy, and 28 had persistent OAB despite treatment. Voiding cystourethrogram was obtained 6-12 weeks postoperatively, and patients were followed up clinically for 1-5 years. RESULTS: Negative voiding cystourethrogram findings after a single treatment were seen in 34 (82.9%) of 41 patients. The radiographic success rate in patients with well-controlled OAB was 76.9% (10 of 13) compared with 85.7% (24 of 28) of those with poorly controlled OAB. The overall clinical success rate, defined as no evidence of urinary tract infection in the setting of negative voiding cystourethrogram findings, reached 78.0% (32 of 41). After successful endoscopic treatment, an unanticipated return to normal voiding patterns without the need for postoperative anticholinergic therapy was seen in 4 of the children with well-controlled OAB (40.0%) and in 4 with poorly controlled OAB (16.7%). CONCLUSION: Our data suggest that endoscopic injection is a viable treatment option for VUR in those with OAB, with postoperative rates of resolution comparable to those found in patients without OAB. Furthermore, 40.0% of children with well-controlled OAB no longer required therapy for OAB after resolution of their VUR.