Analysis of the Predictive Capacity of the Clinical Variables That Indicate the Performance of Voiding Urosonography in the Study of Vesicoureteral Reflux in Children.

INTRODUCTION: Voiding urosonography (VUS) is a dynamic imaging technique which evaluates the lower urinary tract by introducing sonographic contrast into the bladder, preferably used in the diagnosis of vesicoureteral reflux (VUR). Our goals were to describe the clinical indications for performing a VUS for VUR's diagnosis and analyse its diagnostic reliability. MATERIAL AND METHODS: Cross-sectional study carried on patients under 15 years old with a VUS taken between November 2013-2020. Sex, age, indications (lower urinary tract infection-LUTI; dilatated lower urinary tract-DLUT; duplex collecting system-DCS), results (presence/absence of VUR, score and side) and complications were analysed. U Mann-Whitney and Chi-squared tests were used and 2 predictive capacity models for the indications used to detect VUR were employed (logistic binomial regression and multilayer perceptron neural network). Statistical significance p < 0.05. RESULTS: 415 VUS were completed correctly (male 51.8%, median age 7.3 (3.1-15.3) months). Indications were: LUTI (67.5%), DLUT (33.5%) and DCS (10.2%); presenting 1, 2 and 3 indications in 86.5%, 12.8% and 0.7% respectively. VUR was diagnosed in 34.7% cases. A tendency towards statistically significance was showed related to male sex (p = 0.052) and the only significative clinical indication for VUR was DCS (p = 0.007). Patients with 2 simultaneous indications had higher probability of VUR (p = 0.012). DCS presence or male sex were the only predictive variables of VUR: DCS = OR 1.89 (1.54-6.52) (p = 0.006) and male sex = OR 1.56 (1.03-2.35) (p = 0.035). CONCLUSIONS: VUS is a thriving technique, radiation free and with a low complications rate. Presence of DCS, male sex or 2 simultaneous indications for VUS increase the probability of presenting VUR.

Enuresis: clinical evolution of patients attended at specialized unit of paediatric urology.

OBJECTIVE: To analyse the clinical evolution, the therapeutic strategies and the characteristics of the patients presenting enuresis attended at our outpatient clinic. MATERIAL AND METHODS: Retrospective study of patients <14 years old(yo) diagnosed of enuresis attended at our outpatient clinic (2011-2019) and completed their follow-up (remission or aged 15). Urotherapy was offered to all patients as initial management. The therapeutic strategies were classified as: first line (desmopressin or clock alarm), second line (desmo-pressin+alarm) and third line(anticholinergics). The remission rate during follow-up, the number of consultations needed until remission and the treatments used were calculated. Statistical tests used:Kaplan-Meier, actuarial survival. Multivariate analysis:Cox regression.Statistical significance:p<0.05. RESULTS: Data were collected from 125 patients (mean age: 8.6±2.45yo). Family history of enuresis was present in 38.9%. The mean follow-up was 2.37±1.55yo and the average number of consultations was 7.54±5.06. The remission rate (RE) was 84%(n=105), with a median remission interval:2.66 years (2.34-2.991[95%CI]). The average number of treatments required for remission was 2.74±1.27. RE with urotherapy alone was 20%(n=25); RE with first line:19.3%(n=17) and second line:16.7(n=11). In the remaining patients, a RE of 78.18%(n=43) was achieved by adding an anticholinergic. Patients aged > 8.7 years at the beginning of the follow-up required less time to achieve remission (p=.025). These patients had a higher RE (hazard ratio 1.15 (1.05-1.25))(p=.004). No other variables were significant. CONCLUSION: Staged therapeutic strategies are necessary to achieve remission. Only 25% remitted with urotherapy as single treatment. RE are higher when patients are >8.7 yo once they initiate their follow up.

Eighteen years of experience with pediatric nutcracker syndrome: the importance of the conservative approach.

INTRODUCTION: Nutcracker syndrome (NS) defines an entity generated by the compression of the left renal vein resulting in venous hypertension, which transmitted in a retrograde direction may cause hematuria, proteinuria, and varicocele. The literature concerning exclusively pediatric patients is very rare. OBJECTIVE: To report the authors' experience with pediatric NS in the last 18 years. STUDY DESIGN: This is a retrospective review of the patients followed up in the authors' center with diagnosis of NS based on clinical and imaging tests (ultrasound, computed tomography/magnetic resonance imaging, and phlebography). The primary outcome was the success of the conservative approach in the study patients. RESULTS AND DISCUSSION: A total of 21 patients were diagnosed with NS and followed up for a mean period of 52.3 months (37.1-67.5). The mean age at diagnosis was 11.7 years (9.9-13.4). The most frequent symptom of presentation was hematuria in 16 patients (76.2%), being macroscopic in 75% patients and related to physical exercise in 42.9% patients. Other symptoms were left varicocele in 7 patients (33%) and proteinuria in 6 patients (28.6%). Mild to moderate cases received conservative treatment (change of physical activity, postural hygiene), which achieved resolution of symptoms in 16 patients (76.2%). Five cases (23.8%) finally needed a more aggressive approach. Two (9.5%) of them required endovascular procedures (intravascular stent in the renal vein in 1 case and embolization of the spermatic vein in 1 case); in one (4.8%) of the patients, transposition of the left renal vein and kidney autotransplantation were performed, and 2 (9.5%) of the patients with mild cases required surgical correction of the varicocele. CONCLUSIONS: Hematuria, usually macroscopic and related to physical exercise, is the most frequent symptom in pediatric patients with NS. The authors advocate studying the aortomesenteric junction by abdominal ultrasound in patients with varicocele or with intermittent macroscopic hematuria. Diagnosis is based on non-invasive tests; phlebography should be reserved for severe cases that require an interventionist attitude. A long period of conservative treatment is the first approach for pediatric patients with NS.