Purpose Treatment for vesicoureteral reflux remains controversial. Lacking an evidence-based treatment protocol, we offered the option of terminating prophylactic antibiotics in otherwise healthy ...patients with persistent vesicoureteral reflux at age 5 years or greater. We report outcomes with respect to the urinary tract infection incidence and to whether surgical intervention was eventually done. Materials and Methods We obtained institutional review board approval to retrospectively review the records of all children with vesicoureteral reflux from December 1999 to February 2009. Of this group we selected children 5 years old or older who had been taken off prophylactic antibiotics. We assessed children with primary vesicoureteral reflux in detail. Results The records of 1,217 that we reviewed showed that antibiotics were discontinued in 185 patients, including 160 girls (89%) and 25 boys (11%), at an average age of 6.2 years. Average followup was 2.0 years with recorded followup up to 8 years off prophylaxis. In 50 girls (91%) and 5 boys (9%), urinary tract infection developed after discontinuing prophylaxis. Correction was done in 57 patients, including open repair in 34 and endoscopic injection in 23. Two patients underwent intervention at parent request after an average of 0.7 years of uneventful observation. We identified no parameter predicting patients at risk for urinary tract infection. Conclusions Urinary tract infection develops in 29% of patients 5 years old or older with persistent vesicoureteral reflux within 2 years after the cessation of prophylaxis. Most of these cases are febrile. Discontinuing antibiotics is reasonable but a prospective, randomized, long-term, multi-institutional trial is required to determine whether this approach is beneficial.
Background
We have noted a recent increase in neurosurgical requests at our institution for urodynamics (UDS) prior to release of asymptomatic tethered cord. Our aim was to determine how preoperative ...UDS results are used in the clinical management of asymptomatic tethered cord.
Methods
A retrospective review was performed of 120 patients diagnosed with primary tethered cord from 2007 to 2010. Inclusion criteria included MRI diagnosis of tethered cord and UDS performed by three pediatric urologists. Excluded were any neurologic or urologic dysfunction or associated syndromes, as well as other significant comorbidities.
Results
Thirty-eight patients (female 26; male 12), mean age of 3 years (0.2–16.3) were diagnosed with an asymptomatic tethered cord. The majority of the patients had normal preoperative renal ultrasounds. Thirty-one (82 %) of the children had normal baseline UDS, yet twenty-one (68 %) of these patients still underwent neurosurgical intervention. Of the 27 patients untethered, 15 patients (55 %) had follow-up UDS performed. Three patients had improved UDS parameters and one had worsening UDS parameters, including high PVR and DSD. Of the seven patients with abnormal baseline UDS, all had normal renal ultrasound findings and had no other significant differences in presentation from the patients with normal UDS.
Conclusion
In children with asymptomatic tethered cord, abnormal preoperative UDS may prompt intervention, while normal UDS do not appear to prevent intervention. There is no significant correlation between abnormal preoperative UDS and abnormal preoperative imaging. Further study is needed to evaluate the utility of this procedure in the preoperative setting in this asymptomatic patient population.
Abstract Objective The evaluation and treatment of perinatal testicular torsion is controversial. We performed a survey to assess practice patterns among pediatric urologists regarding treatment of ...perinatal torsion. Methods An internet survey was administered to members of two pediatric urology societies. Cases of prenatal, postnatal and bilateral prenatal torsion were outlined. Respondents were asked about use of ultrasound, timing of surgery, incision, and management of the contralateral testicle. A case with a non-palpable testicle and blind ending vessels was also presented. Results We had 121 respondents. In a neonate with prenatal torsion, 34% percent would operate immediately, 26% urgently within 72 h, 28% electively and 12% would not explore; 93% would perform a contralateral orchiopexy. In a neonate with postnatal torsion, 93% would operate immediately, 5% urgently, 1% electively and 1% would not explore; 96% would perform a contralateral orchiopexy. In both cases, 75% would use a scrotal incision and 25% would use an inguinal incision. When presented with bilateral prenatal torsion, 90% would operate immediately, 1% urgently, 2% electively and 7% would not operate. In the case of a non-palpable testicle with blind ending vessels 28% would perform a contralateral orchiopexy, 12% would explore the ipsilateral canal for a “nubbin”, 56% would perform no intervention and 4% would perform some other form of management. Conclusion We documented variability of timing for intervention of prenatal torsion and confirmed that most view postnatal torsion as a surgical emergency. Most perform a contralateral orchiopexy for prenatal torsion despite the fact that most cases are extravaginal. The surgical approach via a scrotal incision appears to be preferred at this time.
Purpose Although rarely indicated, surgical treatment of severe megaureter can pose a formidable technical challenge, especially in the small infant. We present our experience and outcomes with end ...cutaneous ureterostomy as a temporizing adjunct to future ureteral reimplantation. Materials and Methods We performed a retrospective cohort study of patients who underwent end cutaneous ureterostomy between 1993 and 2005. Patient demographics, surgical details and outcomes were recorded. Results A total of 29 patients (22 males, 7 females) underwent diversion of 34 renal units. Primary megaureter was diagnosed in 15 patients (17 renal units). Secondary megaureter was found in 10 patients (12 renal units). Postoperative megaureter was diagnosed in 4 patients (5 renal units). Mean patient age at time of diversion was 3.2 months for those with primary megaureter and 1.4 years overall. Bilateral diversion or diversion of a solitary functioning kidney was performed in 14 patients (48%), of whom 4 had renal insufficiency. Nine patients (31%) had a febrile urinary tract infection while awaiting undiversion, with no evidence of renal scarring on followup. Undiversion was performed in 12 patients (13 renal units) with primary megaureter at a mean age of 18 months. Overall, undiversion was performed in 21 patients (23 renal units), and ureteral tailoring was required in only 5 renal units (22%). Mean followup after undiversion was 4.2 years for primary megaureter and 3.9 years overall. Conclusions End cutaneous ureterostomy is a safe and effective procedure to temporize massive hydronephrosis while awaiting definitive ureteral reimplantation.
The treatment of the newborn diagnosed with a ureteropelvic obstruction prenatally should follow a systematic approach. Although a majority of patients can be followed without surgical intervention, ...controversy exists concerning appropriate follow-up. Furthermore, a significant number of patients will manifest mild disease and thus deserve abbreviated follow-up. Herein, an appropriate algorithm and a review of the literature are discussed.
Purpose of Review
This review will address current literature on electrical nerve stimulation in the pediatric population for the treatment of non-neurogenic lower urinary tract symptoms. The ...following therapies will be discussed: parasacral transcutaneous electrical nerve stimulation (TENS), transcutaneous posterior tibial nerve stimulation (TCPTNS), and implantable sacral neuromodulation.
Recent Findings
Thus far, all studies have demonstrated safety similar to the adult population. Although few studies have been performed in children, TENS and TCPTNS have favorable enough results to justify offering as treatment for patients who would like to avoid lead implantation. Sacral neuromodulation has shown some promising results in recent large-cohort studies with quality-of-life assessments, particularly in patients with urinary incontinence, overactive bladder symptoms, and constipation. However, device malfunction and high reoperation rates remain problematic.
Summary
Electrical nerve stimulation in the carefully selected pediatric patient can be a safe and viable option. Family should be counseled on its off-label use and risks of complications that are unique to this population. Future studies should focus on standardizing preoperative assessment pathways, identifying predictors of postoperative success and exploring the durability of effects.
The efficacy of endoscopic injection of dextranomer/hyaluronic acid to correct primary vesicoureteral reflux is well documented. We present experience at 2 institutions with endoscopic treatment for ...vesicoureteral reflux after failed ureteroneocystostomy.
A retrospective review was performed of the records of all patients who underwent endoscopic dextranomer/hyaluronic acid injection to correct vesicoureteral reflux following ureteral reimplantation between April 2002 and July 2005. De novo ipsilateral vesicoureteral reflux was noted after repair of primary nonrefluxing megaureters or renal transplantation and persistent vesicoureteral reflux was noted following attempted vesicoureteral reflux repair. Injection was performed using the standard technique if the ureteral orifice was easily accessible, and percutaneously if access was difficult.
Nine male and 9 female patients were identified. Median age was 1.9 years at reimplantation and 6.5 years at injection, and median followup was 19 months. Ten patients underwent extravesical detrusorrhaphy and 8 underwent cross-trigonal reimplantation. Six patients underwent reimplantation for primary megaureter repair and all had resolution of vesicoureteral reflux with injection. Of the 20 renal units 16 (80%) and 15 of 18 patients (83%) had complete resolution of vesicoureteral reflux after 1 injection. One patient had improvement in vesicoureteral reflux and 2 had no improvement. There were no complications resulting from injections.
Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid following extravesical or cross-trigonal reimplantation is safe and efficacious, at least at short-term followup. Endoscopic injection should be considered first line treatment for this situation.
Purpose of Review
Transient urinary retention is a known complication of bilateral extravesical ureteral reimplantations. Recent studies have shown that the robotic-assisted bilateral extravesical ...reimplantation may have lower transient urinary retention rates than previously reported for the open approach. The purpose of this review is to compare urinary retention incidence in patients undergoing open versus robotic-assisted extravesical reimplantations.
Recent Findings
In some of the larger series, open bilateral extravesical ureteral reimplantation was noted to have a temporary urinary retention rate of 4–15%. In our recent experience with the open approach, we have noted a 2% incidence of transient urinary retention. In recent series of robotic-assisted bilateral extravesical reimplantations, transient retention was seen in 0–22%, with larger series favoring lower urinary retention rates.
Summary
The incidence of transient urinary retention following open or robotic-assisted approaches in recent series is 0–2%, which is almost negligible. Dysfunctional elimination syndrome symptoms and constipation need to be aggressively treated preoperatively. Families of patients who undergo bilateral extravesical ureteral reimplantations, regardless of whether it is performed via the open or robotic-assisted approach, should not only be counseled of the small risk of transient urinary retention but should also be told that this can also be seen with any other surgical approach for the repair of primary vesicoureteral reflux.
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