30th ESPU Congress - Lyon, France - 2019

S5: OBSTRUCTION & HYDRONEPHROSIS 1

Moderators: Martin Kaefer (USA), Marcel Drlík (Czech Republic)

ESPU Meeting on Thursday 25, April 2019, 08:52 - 09:40


08:52 - 08:57
S5-1 (LO)

★ A SUPERIORITY, PARALLEL, BLINDED RANDOMIZED PLACEBO CONTROLLED TRIAL OF CONTINUOUS ANTIBIOTIC PROPHYLAXIS FOR FEBRILE UTIS IN INFANTS WITH PRENATAL HYDRONEPHROSIS: THE ALPHA STUDY

Luis BRAGA 1, Melissa MCGRATH 2, Steven ARORA 3, Martha FULFORD 4, Armando J LORENZO 5, Lucy GIGLIA 3 and Forough FARROKHYAR 6
1) McMaster University - McMaster Children's Hospital, Department of Surgery / Urology, Hamilton, CANADA - 2) McMaster University - McMaster Children's Hospital, Surgery, Hamilton, CANADA - 3) McMaster University - McMaster Children's Hospital, Paediatrics, Hamilton, CANADA - 4) McMaster University - McMaster Children's Hospital, Paediatrics, Hamilton, CANADA - 5) The Hospital for Sick Children, Urology, Toronto, CANADA - 6) McMaster University - McMaster Children's Hospital, Clinical Epidemiology and Biostatistics, Hamilton, CANADA

PURPOSE

CAP to prevent fUTIs in infants with prenatal HN (PHN) remains controversial, contributing to a lack of consensus guidelines and diverse practice patterns. We aimed to determine whether CAP vs. placebo reduces fUTIs in prenatal HN patients within the first 18 months of life.

MATERIAL AND METHODS

Infants 0-7months with PHN were recruited. Inclusion criteria: SFU-grade III/IV with/without dilated ureter (>7mm) or UTD P2/P3, and VCUG to rule out VUR. Patients received equivalent volumes of Trimethoprim (TMP) or placebo (syrup) with a1:1 allocation ratio, using a computer-generated randomization sequence in random block sizes of 4,6and8.Trial participants were blinded, except the pharmacist. Primary outcome: catheter specimen fUTIs adjudicated by a 3-physician panel. Secondary outcome: bacterial resistance patterns. ITT analysis to estimate fUTI-free rate using KMcurves.  A subgroup analysis between UPJO-likevs non-refluxing primary megaureter (NRPM) was conducted.  

RESULTS

We screened 1435 infants, 1137 did not meet inclusion criteria; 48 refused and 150 were randomized: 75-placebo/75-TMP, 4 patients withdrew, leaving 146 for analysis. Baseline characteristics were equally distributed between groups. Overall fUTI  rate was 6%(9/146), with 8 events in the placebo vs.1(TMP resistant bacteria) in the intervention (11%vs.1.4%,p=0.03). 8 fUTIs occurred in uncircumcised males and 1 in a female. NRPM infants had a significantly higher fUTI rate vs.UPJO-like (14%vs.3%,p=0.02). Median time to fUTI=3 months. Multi drug resistance was higher in placebo vs.intervention patients (42%vs.22%,p=NS). Overall NNT=10; NNT for NRPM=4.

CONCLUSIONS

Patients with SFUIII/IV-PHN receiving placebo were 10x more likely to develop a fUTI than those on TMP. CAP should be offered to uncircumcised males and those with dilated ureters due to their higher risk of fUTI. 


08:57 - 09:02
S5-2 (LO)

★ EFFECT OF CAP IN CHILDREN WITH POST OPERATIVE JJ STENTS: A PROSPECTIVE RANDOMIZED STUDY

Perviz HAJIYEV 1, Aykut AKINCI 2, Cagri AKPINAR 2, Muammer BABAYIGIT 2, Utku BAKLACI 2, Murat KARABURUN 2, Tarkan SOYGUR 1 and Berk BURGU 1
1) Ankara University School of Medicine, Pediatric Urology, Ankara, TURKEY - 2) Ankara University School of Medicine, Urology, Ankara, TURKEY

PURPOSE

We aimed to investigate the effectiveness if continuous antibiotic prophylaxis (CAP) in patients with JJ stent and try to identify the group who could specifically benefit from CAP by a prospective randomized study.A total of 101 patients who underwent surgery with insertion of JJ stent (PNL, URS, pyeloplasty, UNC) were randomized in two group.

MATERIAL AND METHODS

Group A included 51 patients who received CAP during the presence of  JJ stent, and 50 patients Group B were controlled without CAP. Patients with external stents, nephrostomy tubes, indwelling long-term urethral catheters were excluded. History of preoperative use of CAP, lower urinary tract symptoms and presence of scars on DMSA if available were noted.

Trimethoprim/sulfamethoxazole (TMP/SMX) were used as initial choice whereas if there was a history of resistance in previous urinary cultures Nitrofurantoin administrated. Symptomatic febrile UTIs with positive urine culture (105 CFU on a clean catch or 103 with urethral catheterization) were compared between groups. Urinary cultures were obtained before surgery and before stent extraction. In the presence of fewer with stents after extraction JJ stents were sent to culture.

RESULTS

The median age of stent insertion was 4.8 years (2 months- 16 years). The mean duration of the stent was 15.3 days (6-42 days). Continuous antibiotic prophylaxis significantly reduced the incidence of febrile UTIs (19% vs. 3.9% p<0.01). Multivariate regression analysis revealed that a positive history for preop febrile UTI and/or LUTS a significantly higher association with the incidence of febrile UTIs.

CONCLUSIONS

CAP in presence of JJ stents reduces the incidence of febrile UTIs in a short time period, especially in children with the previous history of febrile UTIs and LUTS.


09:02 - 09:05
S5-3 (PP)

PEDIATRIC URETERAL STENT SYMPTOMS: PROSPECTIVE STUDY

Joshua CHAMBERLIN 1, Peter Zhan Tao WANG 2, Garen ABEDI 3, Ahmed ABDELHALIM 1, Amanda MACARAEG 1, Zayn SUHALE 1, Kai-Wen CHUANG 1, Heidi STEPHANY 1, Elias WEHBI 1, Irene MCALEER 1 and Antoine KHOURY 1
1) University of California Irvine, Children's Hospital of Orange County, Pediatric Urology, Orange, USA - 2) Western University, Pediatric Urology, London, CANADA - 3) University of California Irvine, Children's Hospital of Orange County, Department of Urology, Orange, USA

PURPOSE

Urinary symptoms and pain associated with ureteral stents are well characterized in the adult population, but is poorly understood in children. We prospectively evaluated ureteral stent pain and symptoms in children.

MATERIAL AND METHODS

Children ages 1 month to 18 years were eligible for prospective evaluation of urinary symptoms and pain associated with ureteric stents. Evaluations occurred during the first and fourth week of double-J ureteral stent insertion, and one month following the stent removal. Urinary symptoms and pain were evaluated with a modified Ureteral Stent Symptom Questionnaire (USSQ); the Face, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain assessment scale; and the Wong-Baker FACES Pain Scale (FPS).

RESULTS

From September 2016 to September 2018, 43 children with ureteral stents were evaluated after procedures including: pyeloplasty (18), ureteral balloon dilation (10), ureteroscopic stone treatment (7), ureteroureterostomy (4) and ureteroneocystostomy (2). Toilet trained children had dissatisfied urinary bother rate of 42.9% and 31.3% at 1 and 4 weeks with the stent, respectively.

Questionnaire scores at week 1, week 4 and after stent removal, respectively, include the following: urinary frequency at 28.6%/18.8%/7.7%; nocturia at 4.8%/0%/0%; urinary urgency at 23.8%/18.8%/23.1%; urge incontinence at 9.5%/6.3%/0%; unaware incontinence at 9.5%/0%/0%; dysuria at 28.6%/31.3%/21.4%; and hematuria at 47.0%/20.0%/7.1%. Higher pain scores and medication usage was seen in the first 2-3 days after stent placement (p<0.05).

CONCLUSIONS

Children tolerate ureteral stents better than adults, with a dissatisfied bother rate of 31.3%-42.9% in toilet-trained children compared to 58-78% in adults (Joshi et al. J Urol 2003;169: 1065-9). Significant pain requiring medication improves 3 days after ureteral stent surgery in children.


09:05 - 09:08
S5-4 (PP)

REVISITING RISK FACTORS FOR FEBRILE URINARY TRACT INFECTION IN INFANTS WITH PRENATAL HYDRONEPHROSIS

Smruthi RAMESH 1, Melissa MCGRATH 1, C.D. Anthony HERNDON 2 and Luis BRAGA 3
1) McMaster University - McMaster Children's Hospital, Surgery, Hamilton, CANADA - 2) Children's Hospital of Richmond at VCU, Urology, Richmond, USA - 3) McMaster University - McMaster Children's Hospital, Department of Surgery / Urology, Hamilton, CANADA

PURPOSE

Risk factors for febrile UTI(fUTI) in infants with prenatal hydronephrosis(HN) have been previously identified in small sample size series. Herein, we revisit this clinically important outcome using a large single center database to confirm or refute past findings.

MATERIAL AND METHODS

Since 2009, we have prospectively followed 876 consecutive prenatal HN infants <12months of age with the following conditions: UPJO-like, non-refluxing primary megaureter(NRPM) and VUR. Patients with <6months F/U were excluded. A priori collected variables HN-SFU grade(low-I/II vs. high-III/IV), HN etiology, CAP status, gender and circumcision status. Primary outcome was catheter specimen fUTI. Univariate and multivariable analyses were conducted. 

RESULTS

Of 848 included patients, 632(75%) were male and 36% were circumcised. 73 (9%) had a fUTI at a median age of 6 months(2-11). III-IV HN was seen in 467(55%) infants and CAP prescribed for 481(57%). VUR(68% grades IV-V) was detected in 168/572(29%) patients who had a VCUG. On multivariate analysis, NRPM, VUR, uncircumcised males, females, III-IV HN and lack of CAP were significantly associated with fUTI(Table 1).

OR (95%Cl) p value

Female

Uncircumcized Male

Circumcised Male

2.3 (1.1-4.9)

2.8 (1.3-6.3)

0.03

0.01

Hydronephrosis

(III-IV)

(I-II)

1.9(1.1-3.3) 0.03

Etiology 

NRPM

VUR

UPJO-like

4.4 (2.3-8.4

8.4(4.0-17.6)

<0.01

<0.01

CAP

No

Yes

0.3(0.15-0.5) <0.01

CONCLUSIONS

This study corroborates previous findings, establishing III-IV HN, NRPM, VUR, uncircumcised status and female gender as important risk factors for fUTI. According to our large sample size analysis, CAP should be offered to those high risk groups as it was shown to significantly reduce fUTI rates in this population. 


09:08 - 09:20
Discussion
 

09:20 - 09:23
S5-5 (PP)

DISTRIBUTION OF CAJAL CELLS IN URINARY TRACT: A PATHOPHYSIOLOGICAL PREDICTOR OF CONGENITAL ANOMALIES?

Eda TOKAT 1, Serhat GÜROCAK 1, Ipek Işık GÖNÜL 2 and Mustafa Özgür TAN 1
1) Gazi University School of medicine, Urology, Ankara, TURKEY - 2) Gazi University School of Medicine, Pathology, Ankara, TURKEY

PURPOSE

To determine the distribution of Cajal cells in congenital ureteropelvic junction obstruction(UPJO), ureterovesical junction obstruction(UVJO) and vesicoureteral reflux(VUR).

MATERIAL AND METHODS

The study group consisted of 77 renal units (41 renal units with UPJO,9 renal units with UVJO, 14 renal units with VUR and 13 renal units as control group) surgically treated by pyeloplasty and ureteroneocystostomy in our clinic between 2013-2018.Related UPJ and UVJO specimens from patients were immunohistochemically stained with CD117 (c-kit) antibody for  Cajal cells and compared to each other and controls.The control group consisted of UPJ tissues of patients with renal cortical tumors.

RESULTS

The mean age of the patients was 8,25±8,536 years. There was significant difference in the distribution of Cajal cells between UPJO and control group (p=0.011). However, no significant difference was determined between ureteral reimplantation(UVJ) specimens of patients either with VUR or UVJO and the control group (p=0.202, p=0.845 respectively) (Table). Comparison within anomaly groups yielded significant difference only between UPJ and VUR(p=0.000), UVJO(p=0.012).  

 

Groups

 

           n

 

Distribution of Cajal cells

(median, min-max)

 

P value

 

UPJO

 

          41

               

  6 (0-97)           

 

0.011(UPJO-control group)

 

VUR

 

          14

 

  42(10-131)

 

0.202(VUR-control group)

 

UVJO

 

           9

 

  35 (8-154)

 

0.845(UVJO-control group)

 

CONTROL

 

           13

 

  26(5-186)

 

CONCLUSIONS

Deficiency of Cajal cells might be the reason or result of pathophysiological mechanisms in UPJO.On the other hand, Cajal Cell distribution in urinary pathologies accompanied by ureteral abnormalities might represent a different pathophysiological mechanism.So,there is a need for studies with large number of cases in order to explain the increment of Cajal cells in cases with ureteral abnormalities.


09:23 - 09:26
S5-6 (PP)

PELVIC SHAPES AS AN ULTRASOUND MARKER IN FETAL GRADE III HYDRONEPHROSIS TO PREDICT POSTNATAL SURGERY FOR URETERO-PELVIC JUNCTION OBSTRUCTION

Sergei BONDARENKO
Clinical Hospital 7, Pediatric Urology, Volgograd, RUSSIAN FEDERATION

PURPOSE

Assess the role of the pelvic shape as a predictor for postnatal surgery in fetuses with grade III hydronephrosis (SFU grading system).

MATERIAL AND METHODS

Prospective study of 45 fetuses with grade III hydronephrosis at the third trimester was conducted. Cases with megaureter or posterior urethral valves were excluded from the study. The pelvic shapes were classified as funnel-shaped and ellipse-shaped. In ellipse-shaped pelvis the aspect ratio of the ellipse was calculated. Indications for surgery were an increase of the anteroposterior renal pelvis diameter and a decrease in kidney function. Statistical significance of continued variables was determined by t-test. Logistic multinomial and binary regressions were used for the prediction of neonatal hydronephrosis requiring surgery.

RESULTS

Of the 45 pelvises, 26 were classified as ellipse-shaped and 19 units as funnel-shaped. There was no difference in anteroposterior renal pelvis diameter between two groups (18.2±6.0 vs 16.4±4.8 mm, p=0.31). Postnatally, the anteroposterior renal pelvis diameter decreased in 17 funnel-shaped pelvises (89.5%) and in 7 (26.9%) ellipse-shaped pelvises. Nineteen patients (42.2%) underwent pyeloplasty, 17 of them with an ellipse-shaped pelvis with the aspect ratio ≥0.7 (89.5%).
Logistic regression showed that the elliptical shape of pelvis can predict the need for surgery with a probability of 0.75-0.95 (p=0.0001).

CONCLUSIONS

Estimation of pelvic shapes in fetuses with hydronephrosis is a significant and independent predictor for pyeloplasty.


09:26 - 09:31
S5-7 (VP)

★ URETERAL CLIPPING FOR THE TREATMENT OF A NON-FUNCTIONING UPPER KIDNEY MOIETY ASSOCIATED WITH A MASSIVE URETEROCELE: STEP-BY-STEP DESCRIPTION OF A NOVEL TECHNIQUE

Roberto LOPES 1, Marcos MELLO 1, Martin KOYLE 2 and Armando LORENZO 2
1) Hospital das Clínicas, Universidade de Sao Paulo, BR, Urology, São Paulo, BRAZIL - 2) The Hospital for Sick Children, University of Toronto, CA, Urology, Toronto, CANADA

PURPOSE

To illustrate the ureteral clipping for the treatment of massive ureteroceles associated with non-funtioning upper kidney moieties in duplex kidneys.

MATERIAL AND METHODS

A nine years-old boy presented with progressive lower urinary tract symptoms (weak urinary flow, dysuria and increased postvoid bladder residuals). Radiological work up depicted a duplex kidney on the left side with absence of function on the upper pole and huge ureterohydronephrosis with a massive ureterocele insinuating to the bladder.

Ureteral clipping after aspiration of the enlarged ureter was perfomed laparoscopicaly.

During follow up the patient remained completed asymptomatic.

RESULTS

A cohort of four patients with massive obstructing ureteroceles asssociated with a non functioning upper pole treated by ureteral clipping. All cases, complete decompression of the ureterocele with significant improvement on the ureterohydroneprosis was seen.  After a mean follow-up of 3 years, all remained asymptomatic and no postoperative complications were recorded to date.

CONCLUSIONS

Ureteral clipping is safe and feasible for the treatment of massive ureteroceles associated with non-funtioning upper kidney moieties in duplex kidneys. Advantages of this minimmaly invasive procedure is the small operative room time and early hospital discharge. The disadvantage is the need of regular clinical and ultrasonographic follow-up for the ligated upper pole.


09:31 - 09:40
Discussion