Pattern of urinary tract infection in children with vesicoureteric reflux: Does breastfeeding reduce the occurrence of urinary tract infection?

Introduction: The protective factors against urinary tract infections (UTIs) in the setting of vesicoureteric reflux (VUR) remain poorly defined. Breastfeeding was suggested as a protective factor against UTI, but its role remains undetermined in this highly susceptible population. Objectives: The objective of the study was to identify the pattern and risk factors of UTI and investigate the effect of breastfeeding on UTI occurrence in VUR children. Materials and Methods: This was a mixed-method design, whereby the first part was a cross-sectional study that included children who were diagnosed with VUR and were assessed for their UTI pattern. The second part was a case-control study, which involved contacting the mothers of the children enrolled and questioning them about their breastfeeding pattern, and UTI development was assessed. Results: Our study included 62 children with a median age of 4.4 (interquartile range = 21) months at diagnosis. Of those, 37 (60%) were male and 25 (40%) were female. Most UTIs occurred in the first 3 months of life, and the first episodes were more frequent in males. Constipation was significantly associated with the occurrence of UTI (relative risk [RR] =1.750 [95% confidence interval (CI): 1.231-2.489], P = 0.003). Children with breakthrough UTIs were more likely to have been breastfed for <9 months (odds ratio [OR] = 4.091 [95% CI: 1.287-13.002], P = 0.015) and to have been exclusively breastfed for <2 months (OR = 4.600 [95% CI: 1.337-15.823], P = 0.012). Conclusion: Children with VUR are more susceptible to UTIs in their 1st year of life. Constipation is a major risk factor for UTI occurrence in VUR children and should be aggressively managed. Breastfeeding for longer durations showed promising protective features against breakthrough UTIs.

Intraoperative ultrasound-assisted endoscopic treatment of primary intermediate and high-grade vesicoureteral reflux in children in a long-term follow-up.

BACKGROUND: Endoscopic treatment of vesicoureteral reflux (VUR) is an important minimally invasive surgical approach in patients undergoing surgical treatment of VUR. In our past experience, we observed that a bulking agent mound sagittal diameter of 10 mm is the main predictor of effectiveness of the procedure. Moreover we noticed that the use of intraoperative ultrasound, allows the surgeon to better identify the site, volume and shape of the bulking agent injected, finally reducing operative time. OBJECTIVE: We aimed to evaluate if the intraoperative ultrasound assistance could definitively improve effectiveness of the endoscopic procedure. METHODS: We retrospectively compared two series treated with endoscopic procedures for intermediate and high grade primary VUR, respectively without (series A) and with (series B) intraoperative ultrasound (IO-US). In all patients VCUG was performed to assess VUR grade and to verify resolution or VUR downgrading during the follow-up. RESULTS: A total of 177 ureteric units were treated. Endoscopic procedures globally were effective in 68/96 ureters (70.8 %) in series A and in 68/81 ureters (83.9 %) in series B. No significant differences in effectiveness were observed comparing the series with regard to VUR grades, but a significant difference is shown (p < 0.05) when grouping grades III-V VUR. No significance in differences of volume injected were detected, but operative time was significantly lower in series B (27.5 min vs 19.6 min, p < 0.05). Mean sagittal mound diameter measured during cystoscopy in series B was 10.45 mm (range 8.5-14.2 mm). DISCUSSION: The intraoperative ultrasound assistance during endoscopic treatment of VUR could represent a valid tool for surgeons to better identify location, volume and shape of the bulking agent. Furthermore, the use of an objective parameter of evaluation of the implant can overcome the subjective intraoperative evaluation of the implant itself, improving results for experienced surgeons and reducing the learning-curve for inexperienced ones. CONCLUSIONS: Results of endoscopic injection of bulking-agent can be improved with intraoperative ultrasound, allowing at the same time a significant reduction of operative time.

Urinary tract infection in children: A narrative review of clinical practice guidelines.

Background: Urinary tract infection (UTI) has been a major burden on the community and the health-care systems all over the globe. It is the most common cause of bacterial infection in the pediatric age group, with an annual incidence of 3%. The aim of this study is to review and summarize all available guidelines on the diagnosis and management of children with UTI. Materials and Methods: This is a narrative review of the management of children with a UTI. All biomedical databases were searched, and any guidelines published from 2000 to 2022 were retrieved, reviewed, and evaluated to be included in the summary statements. The sections of the articles were formulated according to the availability of information in the included guidelines. Results: UTI diagnoses are based on positive urine culture from a specimen of urine obtained through catheterization or suprapubic aspiration, and diagnoses cannot be established on the bases of urine collected from a bag. The criteria for diagnosing UTI are based on the presence of at least 50,000 colony-forming units per milliliter of a uropathogen. Upon confirmation of UTI, the clinician should instruct parents to seek rapid medical assessment (ideally within 48 h) of future febrile disease to ensure that frequent infections can be detected and treated immediately. The choice of therapy depends on several factors, including the age of the child, underlying medical problems, the severity of the disease, the ability to tolerate oral medications, and most importantly local patterns of uropathogens resistance. Initial antibiotic choice of treatment should be according to the sensitivity results or known pathogens patterns with comparable efficacy of oral and parenteral route, for 7 days to 14 days duration. Renal and bladder ultrasonography is the investigation of choice for febrile UTI, and voiding cystourethrography should not be performed routinely unless indicated. Conclusion: This review summarizes all the recommendations related to UTIs in the pediatric population. Due to the lack of appropriate data, further high-quality studies are required to improve the level and strength of recommendations in the future.

The Outcome of Multicystic Dysplastic Kidney Disease Patients at King Abdulaziz Medical City in Riyadh.

Background Multicystic dysplastic kidney (MCDK) is a type of kidney dysplasia consisting of many irregular, various-sized cysts divided by dysplastic renal tissue, which negatively impacts kidney function. MCDK is one of the most common renal congenital disorders seen in antenatal ultrasounds. The typical prognosis of MCDK is complete or partial involution that starts antenatally and continues postnatally. The aim of the study was to shed light on the overall outcome of patients with MCDK. Methods We retrospectively collected data on MCDK patients from 2016 until 2022 at King Abdulaziz Medical City, Ministry of National Guard Health Affairs in Saudi Arabia, Riyadh. The data included the recording of epidemiological data, radiological and laboratory reports, and the presence of urological or non-urologically associated anomalies. Results A total of 57 patients with MCDK were reviewed. Seven of them were excluded due to the diagnosis of bilateral MCDK, which was incompatible with life. Of the remaining 50 patients, the right kidney was affected in 52% of them. Most patients were diagnosed antenatally (98%). The mean duration of follow-up for the study was 48 months. Vesicoureteral reflux (VUR) was detected in 22% of the total sample. Overall, 90% of the patients underwent kidney involution. A small percentage had genitourinary anomalies (20%), while a larger percentage (48%) had extrarenal abnormalities. Conclusion Multicystic dysplastic kidney disease is relatively common in children. The prognosis is affected by the presence of genitourinary and non-genitourinary anomalies. Patients have an overall good prognosis with conservative management. Antenatal screening, diagnosis, and long-term nephrological follow-up are essential for the optimal management of patients.

Overlooked Factors Causing Renal Damage in Vesicoureteric Reflux!

Introduction: Vesicoureteric reflux (VUR), recurrent urinary tract infection (RUTI), febrile urinary tract infection (FUTI), renal scarring, and renal damage are intimately related. Key factors of renal damage in VUR are suspected to be RUTI and FUTI. Hence, conventional treatments are targeted toward the prevention of RUTI and FUTI. However, literatures have witnessed that control of infection is not sufficient enough. That means we are missing some hidden, enigmatic, or overlooked factors which are essentially responsible for renal damage. We know RUTI occurs from the stasis of urine in system and stasis might occur from obstruction somewhere in system. Moreover, obstruction builds up back pressure in the bladder and ureters, and ultimately in kidneys; that pressure is independently harmful to renal function. Pressure is further harmful if this joins together with infection. We know that RUTI and FUTI along with pressure in the urinary tract are harmful to renal parenchyma. Nevertheless, search for the nexus of obstruction, pressure, stasis, infection, and damage (OPSID) of renal function is not yet focused on in VUR research. In this retrospective study on secondary VUR, we would like to find the overlooked factors or nexus of OPSID associated with VUR causing renal damage. Patients and Methods: A total of 170 renal units of 135 patients with VUR resulted from the posterior urethral valve and from repaired bladder exstrophy, from March 2005 to April 2019, had adequate data regarding control/correction of obstruction and urodynamic studies. The mean patient's age was 2.8 years (range 1 day-14 years). The diagnosis of VURs was made with postnatal cystogram in patients of the posterior urethral valve and of repaired continent augmented bladder exstrophy. We do cystogram not micturating cystogram following ultrasonography if showing dilated ureter/s. If we find no residual in ureter/s after 30 min in cystogram, we label it as "rise and fall" VUR (raf_VUR), i.e., without obstruction. On the other hand, if there is post void residual in ureter/s for more than 30 min, we label it as "rise and stasis" VUR (ras_VUR) means combination of VUR with uretero vesical junction obstruction (UVJO). Along with this, all patients were followed up with albumin creatinine ratio, creatinine clearance, USG Renometry, DTPA renal scan, uroflowmetry, and urodynamic study (UDS). Repeat cystoscopy, if necessary, was done following UDS for secondary bladder neck incision (BNI) or for repeat BNI if necessary. Results: Mean duration of follow-up was 7.2 years (range 3-14 years). Out of 170 renal units, 132 renal units had VUR without VUJO, i.e., raf_VUR and 38 renal units had ras_VUR. All patients of UVJO were relieved either with anticholinergics or with DJ stenting or by re-implantations. Twenty-nine patients out of 135 had high pressure on UDS, and they needed BNI. We were able to prevent upstaging of chronic kidney disease (USCKD) in all 135 patients. Conclusions: Our tangible goal of treatment in VUR is the prevention of USCKD. We differentiated raf_VUR from ras_VUR with cystogram. Patients with ras_VUR and patients with raf_VUR with high bladder pressure were actively treated. This particular subset VUR was treated with prophylactic antibiotic and surgical corrections. We prevented renal damage by eliminating obstruction and stasis which helped to prevent RUTI and FUTI. Possibly, similar management might also help to manage "primary VUR." Possibly those overlooked factors which are essentially responsible for renal damage are veiled in nexus OPSID of the kidney.

Relationship Between Vesicoureteric Reflux and Nephrocalcinosis in Children: A Case-Control Study at a Tertiary Medical Center in Saudi Arabia.

BACKGROUND:  Vesicoureteral reflux (VUR), one of the most common pediatric congenital urogenital abnormalities, refers to the abnormal backflow of urine from the urinary bladder back into the ureter or to the kidney. This causes urinary tract infections. Nephrocalcinosis (NC) refers to abnormal deposits of calcium within the renal parenchyma and/or in the renal cortex. Patients with NC are mostly asymptomatic and severe disease may progress to renal failure. Early diagnosis through examinations such as radiography, computed tomography, and ultrasonography, is crucial for therapeutic treatment. Ultrasonography is the preferred method for scanning and grading nephrocalcinosis in children, primarily because it emits no radiation. This study aimed to increase the body of knowledge regarding VUR and nephrocalcinosis by determining its prevalence and assessing the relationship between VUR and nephrocalcinosis in children presenting at our institution. ​​​​Methods:A case-control study was conducted using data from the medical records of 632 children younger than 14 years in a tertiary medical center in Riyadh, Saudi Arabia. Eligible participants were assigned to two groups: Group 1 consisted of 316 patients with VUR, while Group 2 consisted of 316 sex- and age-matched patients without VUR. The difference in the prevalence of nephrocalcinosis between the two groups was assessed. Frequency and percentage were used to present the categorical variables; Pearson product-moment correlation was utilized to establish the association between VUR and nephrocalcinosis. Statistical significance was established at p<0.05. ​​​​​Result: Only two cases in Group 1 were positive for nephrocalcinosis (0.63%, one male and one female), while four cases in Group 2 were positive for the condition (1.26%, two males and two females). There was no significant difference in the incidence of nephrocalcinosis between the two groups (p=0.873), indicating no relationship between VUR and nephrocalcinosis in children. CONCLUSION: There is no relationship between VUR and nephrocalcinosis in children under the age of 14 years.

Study the Possibility of Creating Mucosal Valve Mechanism at Ureteric Orifice without Obstructing the Urine Outflow but Preventing the Urine Backflow into the Ureters.

Objective: To study the possibility of creating mucosal valve mechanism at ureteric orifice without obstructing the urine outflow but preventing the urine backflow into the ureters. Materials and Methods: Ethical waiver was obtained from the institutional ethical committee. Prospective experimental study was conducted on the post-mortem specimen of intact bladder with urethra and bilateral ureters retrieved from the already slaughtered lamb available in the meat market. Feeding tube inserted via urethral opening into the bladder lumen and bladder inflated with saline demonstrated no reflux of urine via transverse cut opening of ureters. Bladder lumen opened, ureteric orifices incised backwards to eliminate the obliquity. After closing the bladder opening, saline inflation test demonstrated bilateral reflux of saline via cut openings of bilateral ureters. Bladder was re-opened. The upper limb of horizontal U started 10 mm lateral and 8 mm above the refluxing ureteric orifice. Distal most curvature of horizontal U was kept 5 mm medial to ureteric orifice continuing along the lower limb of horizontal U terminating 10 mm lateral and 8 mm below the refluxing ureteric orifice, mucosal flaps from superior and inferior incision mobilized and edges joined to cover the ureteric orifice creating a flap valve mechanism. Influx of saline via cut end of ureters demonstrated no obstruction. Bladder was closed. Saline inflation test and contrast study demonstrated abolition of reflux on flap side and persistence of reflux on another side. Results: Five such experiments were conducted. On the side where the valve was created, Vesicoureteral reflux was abolished in four but in one minimal reflux still persisted. Conclusion: Creating a mucosal flap valve around the ureteric orifice can prevent reflux in 80% of cases without obstruction and without the necessity of ureteric mobilization or creating submucosal tunnel.

Primary obstructive megaureter in children; 10 years' experience from a tertiary care center.

Introduction: Primary obstructive megaureter (POM) is a congenital dilatation of the ureter due to an adynamic segment of vesicoureteric junction obstruction. Surgical intervention is needed if nuclear scan shows obstructive curve. We analyzed our data and outcome of conservative and surgical treatment in such cases at our tertiary care hospital. Materials and Methods: We evaluated all cases of POMs during the study period. Investigations included ultrasonography (USG), voiding cystourethrogram, diethylene pentacetic acid (DTPA) scan, and dimercaptosuccinyle acid scan. In antenatal cases, any pelvic dilatation ≥12 mm after 6 weeks were subjected to reonography. Patients with anterior-posterior pelvic diameter (APPD) ≥12 mm had to undergo DTPA scan to look for DRF and drainage. Follow-up USG was done in all cases of mild-to-moderate hydroureteronephrosis, with APPD <12 at 3 months interval. Results: A total of 270 megaureters were registered and treated during the study period (2008-2019). The total number of patients included was 50 (64 ureters). The mean age of presentation in these 30 children was 21.78 ± 18.1 months (range 1-72 months) and the mean weeks of gestation in antenatal cases at presentation as megaureter was 24 ± 7 weeks (range 13-37 weeks). The mean weight of babies was 2.72 ± 0.7 g. The duration of follow-up ranged from 16 to 1W12 months. The mean APPD on the affected side was 19.99 ± 10.3 mm (range 11-43 mm). The mean ureteric diameter was 1.67 ± 0.33 mm (range 0.78-2.66 cm). The mean split function of patients with POM was 34.88% ± 11.5% on the affected side. Twenty patients (40%) had spontaneous resolution over a mean time period of 24.1 ± 11.1 months. Thirty patients underwent surgical procedures. In three children, HTN was observed over a mean follow-up period of 3 years. Conclusion: The babies with POM need a close follow-up. Surgery is indicated in prolonged t½/Tmax on renal scan, function <40% at the initial scan, or >5% split function deterioration in the subsequent renal scan.

Augmentation cystoplasty in children with stages III and IV chronic kidney disease secondary to neurogenic bladder.

Objective: This study examines the outcome of augmentation cystoplasty (AC) in children with stages III and IV chronic kidney disease (CKD) secondary to neurogenic bladder in which transplantation was not imminent. Methods: Hospital records of all children with CKD stages III and IV who underwent AC between 2008 and 2017 were retrieved to study outcome and complications including estimated glomerular filtration rate (eGFR, National Kidney Foundation Calculator), somatic growth (percentiles, compared with population data), and febrile urinary tract infections (fUTIs) requiring admission. Statistical analysis was performed using R. Results: AC was performed in 13 children with CKD stages III and IV (10 girls; median 8.0 years) with median follow-up of 51 months. Patients had incontinence (10/13), reflux (7/13), and hydronephrosis (13/13) despite antimuscarinics and intermittent catheterization. Bladder capacity was 74% of expected and median compliance was 5 mL/cm H20 (inter-quartile range 4 mL/cm H20). All underwent ileocystoplasty (25 cm bowel). One each had nephrectomy and mitrofanoff conduit. All had resolution of incontinence. One had acute kidney injury that recovered. Initial eGFR at presentation (24 mL/min/1.73 m2) improved with conservative management alone (52 mL/min/1.73 m2, p=0.004). This improved further 1 year following AC (61 mL/min/1.73 m2, p=0.036) with stable function at 7 years. There was improvement in somatic growth, hydronephrosis, and fUTI despite no ureteric re-implantation. Conclusion: AC carries acceptable morbidity in children with CKD stages III and IV secondary to neurogenic bladder. Surgery is effective with improvements in continence, eGFR, somatic growth, and propensity for fUTIs. Ureteric re-implantation might not be necessary.

The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans.

AIM: To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans. METHODS: A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit. RESULTS: At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%). CONCLUSION: Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.

Bladder Dysfunction and Re-Absorbable Bulking Agent Affect Success Rate in Children Underwent Endoscopic Treatment for Vesicoureteral Reflux: A Long-Term Follow-Up Study.

This paper is designed to evaluate the results (at long-term follow-up of) children affected by dilating VUR. Our attention was focused on how VUR grade, laterality, bladder dysfunction (BD), the double renal system, and the type of bulking substance may affect VUR resolution in the long-term period. The charts of 93 children with dilating VUR who underwent endoscopic treatment (ET) and with a minimum post-operative follow-up of 7 years were reviewed (mean follow-up time was 9.6 + 1.4). The majority of patients had severe and bilateral VUR. Polydimetilsiloxane or hyaluronic acid/dextranomer (PDS or Ha/Dx) were used as bulking agents. VUR persistence following endoscopic injection was independent with respect to grade, laterality, duplex renal system, and BD. However, the rate of VUR persistence was significantly higher in children with BD. Children treated with Ha/Dx had a higher rate of VUR persistence. This research demonstrated that ET of VUR is also effective at very long term follow up (and without the development of significant complications). We also showed that patients treated with absorbable bulking agents such as Ha/Dx may experience a higher recurrence rate at the long-term follow-up). We also confirm that the only preoperative condition affecting VUR recurrence was bladder dysfunction.

Dysfunctional elimination syndrome: a short review of the literature.

The combination of the functional disorders of urination and defecation constitutes the Dysfunctional Elimination Syndrome (DES). DES refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding, with no underlying anatomic or neurologic abnormalities. Essential precondition for a child to be subsumed under this entity is the exclusion of either anatomical or neurological causative factors. In the present review study the individual entities of dysfunctional filling, such as the unstable or lazy bladder, or dysfunctional urination, such as the detrusor sphincter dyssynergia and the functional constipation are being described comprehensively. Subsequently, the analysis of the pathophysiological effects of the dysfunctional elimination syndrome such as incontinence, urinary tract infections and the conservation or the deterioration of vesicoureteric reflux, is being accentuated. With the documentation of DES, the therapeutic strategy should aim at treating both the functional disorder of the vesicourethral unit and the functional constipation. The first part does not specify depending on the type of this disorder. Rarely, surgical treatment of functional urinary disorders may be required.

Routine evaluation of vesico-ureteric reflux in children with anorectal malformation does not reduce the rate of urinary tract infection.

OBJECTIVE: Children with anorectal malformations (ARM) have a high rate of renal anomalies and increased risk of urinary tract infection (UTI). We aimed to determine whether using routine Micturating Cystourethrogram (MCUG) to detect VUR is effective in reducing the incidence of UTI or renal scarring in children with ARM. METHODS: A retrospective study of consecutive children diagnosed with ARM in two centres with a minimum of 3 years follow-up was performed, excluding those with cloaca or an MCUG prior to ARM repair. Univariate and multivariate logistic regression analysis was used to determine variables which were associated with VUR, UTI and renal scarring. Associations are described as Odd's Ratio (OR), 95% Confidence Interval. Significance was taken as p<0.05. RESULTS: 344 children were included with a median age of 8 years (IQR 5-11 years). 150 (44%) were female. 89 (26%) had renal anomalies and 101 (29%) had spine anomalies. 148 patients had routine MCUG and VUR was found in 62 (42%) of these children. Univariate analysis did not correlate any of the assessed variables with VUR or renal scarring. However, abnormal renal ultrasound - OR 6.18 (95% CI 2.99-13.07, p 0.0001) was associated with UTI whilst abnormal spine - OR 0.27 (95% CI 0.10-0.62, p 0.009), low ARM - OR 0.30 (CI 0.14-0.63, p 0.006) and intermediate ARM - OR 0.35 (CI 0.17-0.70, p 0.01) were associated with a reduced risk of UTI. On multivariate analysis, only abnormal renal USS retained a significant association with UTI (p<0.0001). CONCLUSIONS: VUR is common in patients with ARM. Children with an abnormal R-USS are at increased risk of UTI. Performing routine MCUG does not reduce the risk of UTI in children with ARM.

Variation in ureteric re-implantation for Australian children.

BACKGROUND: Management options for vesicoureteric reflux are numerous, increasingly diversifying and debated. There is longstanding anecdotal opinion of inexplicable regional variation in vesicoureteric reflux management in Australia. This study investigates temporal trends in ureteric re-implantation for children, and variation between states and territories. METHODS: Ureteric re-implantation data for children aged 0-14 years were retrieved from the Medicare Benefits Scheme item reports database for the 20-year period from 1998-2017. Claims data were population adjusted for each state then standardized for age using Australian Bureau of Statistics records. National and regional trends were calculated using joinpoint regression. Comparison between eastern (New South Wales, Victoria, Queensland, Tasmania, Australian Capital Territory) and western or central (Western Australia, South Australia) states was performed using the Mann-Whitney U-test. RESULTS: There were 4919 procedure rebate claims during the study period. A national decrease in claim rates of 6.3% per 100 000 children was identified (P < 0.001). This was derived from significant decreases observed in eastern states. There was a threefold higher claim rate in Western Australia and South Australia per annum compared to the remainder of the country (4.0 versus 12.6 per 100 000; P < 0.001). For the most recent 5 years of the study period, this difference increased to a sevenfold higher rate (1.6 versus 11.1; P < 0.001). CONCLUSION: There has been a dramatic nationwide decline in the rate of ureteric re-implantation procedure claims. Regional disparity between each side of the country is widening. Further research is required to determine if this degree of variation is warranted or unwarranted. The observed regional variation facilitates opportunity for a nationwide pragmatic clinical trial.

Swiss consensus recommendations on urinary tract infections in children.

The kidneys and the urinary tract are a common source of infection in children of all ages, especially infants and young children. The main risk factors for sequelae after urinary tract infections (UTI) are congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction. UTI should be considered in every child with fever without a source. The differentiation between upper and lower UTI is crucial for appropriate management. Method of urine collection should be based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. Treatment of UTI should be based on practical considerations regarding age and presentation with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing. All children, regardless of age, should have an ultrasound of the urinary tract performed after pyelonephritis. In general, antibiotic prophylaxis is not recommended.Conclusion: Based on recent data and in line with international guidelines, multidisciplinary Swiss consensus recommendations were developed by members of Swiss pediatric infectious diseases, nephrology, and urology societies giving the clinician clear recommendations in regard to diagnosis, type and duration of therapy, antimicrobial treatment options, indication for imaging, and antibiotic prophylaxis. What is Known: • Urinary tract infections (UTI) are a common and important clinical problem in childhood. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children less than 2 years of age. • Method of urine collection is based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. What is New: • Vesicoureteric reflux (VUR) remains a risk factor for UTI but per se is neither necessary nor sufficient for the development of renal scars. Congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction play a more important role as causes of long-term sequelae. In general, antibiotic prophylaxis is not recommended. • A switch to oral antibiotics should be considered already in young infants. Indications for invasive imaging are more restrictive and reserved for patients with abnormal renal ultrasound, complicated UTI, and infections with pathogens other than E. coli.

The Outcome of Transurethral Electro-Endoscopic Resection of Orthotopic Single System Ureterocoeles in Adults Nigerians.

Background: Endoscopic transurethral electro-incision and resection are minimally invasive options for treating adult single system ureterocoele. Vesicoureteral (VU) reflux is frequently associated with ureterocoeles and can complicate the treatment. The literature on endoscopic management isscanty from sub-Saharan Africa. This study aimed to describe the technique and outcome of adult patients who had transurethral incision and or deroofing of orthotopic single system ureterocoele. Methodology: This was a prospective study on patients who presented with single system ureterocoeles. All were diagnosed either by computerized axial tomography urography or intravenous urography and were followed up and monitored for resolution of symptoms, development of urinary tract infection, and ureterovesical reflux. The patients' demographic information such as their age, sex, details of endoscopic treatments, complications on follow-up were entered into Excel and analyzed using SPSS version 21. Results: There were eighteen ureteric units managed in 10 patients with single system ureterocoeles. The male: female ratio was 3:2. The 30-39-year age group (four; 40%) and 60-69year age groups (four; 40%) had the highest frequency. Six (33.33%) had calculi, and 83.30% presented with lower urinary tract symptoms (LUTS). Nine (50%) of the ureteric systems had transurethral deroofing of ureterocoele (TUDU), while eight (44.4%) had transurethral incision of ureterocoele (TUIU). Urinary tract infection was the commonest complication. Ureterovesical reflux was present in two and two developed refluxes after TUDU. The patients with refluxes had antibiotics with the resolution of the ipsilateral symptoms. All had preserved renal function. Conclusion: VU reflux inpatients that underwent endoscopic incision or deroofing for single system ureterocoele is infrequent and can be managed conservatively. It is an effective treatment for single system ureterocoeles and has minimal complications.

The Spectrum of Renal Pathologies in Saudi Pediatrics Patients Using Ultrasound.

BACKGROUND AND OBJECTIVE: The Kingdom of Saudi Arabia (KSA) has a high population of children with hereditary renal infections whose factors are linked to the X chromosomes. This study aims to determine the spectrum of renal pathologies in Saudi pediatrics patients as well as to link the genetic aspect to the development of renal diseases in Saudi children by using ultrasound. MATERIALS AND METHODS: The study, hence sought to analyze the outcomes of a cross-sectional retrospective study report at the Radiology department of King Fahad Medical City (KFMC) within 12 months retrogressively. Data was collected using ultrasound machines with B-mode and Doppler modes used to generate results that were later filled in forms. RESULTS: Demographic characteristics showed that even though the study incorporated the children between the ages of 1-14 years, renal infection was most prevalent in children between the ages 4-7 years. The study revealed that male children were at a higher risk of getting a hereditary renal infection compared to their female counterparts. Indications for renal ultrasound examination of the study samples indicated that the ectopic renal disease affected 2% of the 50 sample size, while hydronephrosis affected 26% of the sample. CONCLUSION: The current study was able to successfully highlight the role of ultrasound in the detection of a wide range of renal diseases among Saudi children. Additionally, this study attempted to link the genetic aspect to the development of renal diseases in Saudi children, but the use of ultrasound alone was not very helpful in this.

Radiology reporting of micturating cystourethrograms (MCUGs): What the paediatric urologists want to know.

BACKGROUND: Micturating cystourethrograms (MCUGs) are commonly requested to exclude vesicoureteric reflux (VUR) and bladder outlet obstruction (BOO). Useful additional information including timing and bladder volume at the start of reflux, urethral anomalies and post-void drainage can be obtained from the cystograms, but are not routinely reported by radiologists. OBJECTIVE: The study aim was to retrospectively review MCUG reports against a proposed reporting proforma, and then re-analyse the effect of the proforma on report quality. STUDY DESIGN: A retrospective analysis of paediatric MCUG reports was undertaken from two patient cohorts. Cohorts A (41 reports) and B (51 reports) comprised reports written before (2011-12) and following (2016-17) distribution of the standardised reporting proforma, respectively. Reports were assessed with respect to the parameters outlined on the standardised MCUG reporting proforma, including presence, grade and timing of VUR amongst others. Findings from both cohorts were compared and statistically analysed (p < 0.05 significant) to establish if the proforma influenced the content of reports. RESULTS: Statistically significant improvements were demonstrated in the reporting of: bladder outline normal/abnormal - reported in 92% after the proforma vs 56% before (p < 0.001); urethra normal/abnormal - 87% vs 68% (p = 0.033); contrast volume instilled - 84% vs 61% (p = 0.011); bladder emptying - 69% vs 17% (p < 0.001). In patients with VUR, reporting of VUR timing - 96% vs 33% (p < 0.001) and VUR grade - 91% vs 40% (p = 0.002) were also significantly improved. CONCLUSION: Implementation of a standardised MCUG reporting proforma produced substantial improvements in report quality and consistency, with statistically significant improvements noted in six of seven key features.

Voiding urosonography and voiding cystourethrography in primary vesicoureteral reflux associated with mild prenatal hydronephrosis: a comparative study.

BACKGROUND: Contrast-enhanced harmonic voiding urosonography has been introduced as a sensitive, radiation-free imaging method for the diagnosis of vesicoureteric reflux. OBJECTIVE: To evaluate the occurrence/severity of vesicoureteric reflux in infants with mild prenatal hydronephrosis comparing voiding cystourethrography and voiding urosonography. MATERIALS AND METHODS: Sixty infants with prenatal hydronephrosis were studied (anteriοposterior pelvic diameter 5-9 mm on ultrasound [US] at gestational weeks 21-30). Postnatal US was performed within the first month of life, as well as voiding cystourethrography and contrast-enhanced voiding urosonography at 1.5-2.5 months at the same session. RESULTS: Vesicoureteric reflux was diagnosed on at least one modality in 19/60 (32%) infants, and more often on contrast-enhanced voiding urosonography (18/60, 30%) than on voiding cystourethrography (8/60, 13%), P=0.046. Among girls, reflux was more often seen on contrast-enhanced voiding urosonography (6/16, 38%) than on voiding cystourethrography (1/16, 6%), P=0.03. Vesicoureteric reflux missed by voiding cystourethrography was more severe (Grades I, II and III in one, nine and four kidney-ureter-units, respectively), compared with a single case missed by contrast-enhanced voiding urosonography (Grade I in one kidney-ureter-unit). CONCLUSION: In the absence of a reference standard, our results imply that voiding cystourethrography might underdiagnose reflux, and/or contrast-enhanced voiding urosonography may overdiagnose reflux.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool.

OBJECTIVES: Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG). METHODS: Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients. RESULTS: Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p < 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%. CONCLUSIONS: The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.