5th Joint Meeting of ESPU-SPU - Virtual

S7: LOWER URINARY TRACT

Moderators: Anju Goyal (UK)

ESPU-SPU Meeting on Friday 24, September 2021, 09:35 - 10:23


09:35 - 09:38
S7-1 (PP)

★ EFFECT OF CIRCUMCISION ON RISK OF FEBRILE URINARY TRACT INFECTION IN BOYS WITH POSTERIOR URETHRAL VALVES: RESULT OF THE CIRCUP STUDY

Luke HARPER 1, Thomas BLANCE 2, Matthieu PEYCELON 3, Marc-David LECLAIR 4, Sarah GARNIER 5, Valerie FLAUM 6, Alexis ARNAUD 7, Thierry MERROT 8, Eric DOBREMEZ 9, Alice FAURE 8, Laurent FOURCADE 10, Marie-Laurence POLI-MEROL 11, Yann CHAUSSY 12, Olivier DUNAND 13, Laetitia HUIART 14, Cyril FERDYNUS 15 and Frederique SAUVAT 16
1) CHU Pellegrin-Enfants, Pediatric Surgery, Bordeaux, FRANCE - 2) APHP, Hôpital Necker, Pediatric Surgery and Urology, Paris, FRANCE - 3) University Hospital Robert Debre, APHP, University of Paris, Centre de référence des maladies rares des voies urinaires (MARVU), Pediatric Urology, Paris, FRANCE - 4) Children's University Hospital, Nantes, France, Pediatric Surgery and Urology,, Nantes, FRANCE - 5) , Lapeyronie University Hospiotal, Montpellier, France, Pediatric Surgery and Urology, Montpellier, FRANCE - 6) Armand Trousseau Children's University Hospital, Paris, France., Pediatric Surgery, Paris, FRANCE - 7) Rennes University Hospital, Rennes, France., Pediatric Surgery., Rennes, FRANCE - 8) North and Timone Children's Hospital, Assistance Publique Hopitaux de Marseille, Aix-Marseille Université, France., Pediatric Surgery, Marseill, FRANCE - 9) Hopital Pellegrin-Enfants, Pediatric Surgery, Bordeaux, FRANCE - 10) University Hospital, Limoges, France., Pediatric Surgery, Limoges, FRANCE - 11) Reims University Hospital, Reims, France., Pediatric surgery, Reims, FRANCE - 12) Besançon University Hospital, Besançon, France, Pediatric Surgery, Besançon, FRANCE - 13) Hopital Bellepierre, CHU de La Réunion, Pediatric nephrology, Saint-Denis D Ela Reunion, FRANCE - 14) Hopital bellepierre, CHU de La Reunion, Research department, Saint-Denis De La Réunion, FRANCE - 15) Hopital Bellepierre, CHU de La Réunion, Research department, Saint-Denis De La Reunion, FRANCE - 16) Hopital Bellepierre, CHU de La Réunion, Pediatric surgery, Sainy-Denis De La Reunion, FRANCE

PURPOSE

Boys with posterior urethral valves (PUV) have increased risks of febrile urinary tract infection (fUTI) and ongoing renal damage. It has been suggested that circumcision reduces the risk of fUTI in boys with urinary tract malformations, but no randomized trial had confirmed this. We report the result of a prospective randomized trial comparing the risk of fUTI in boys with PUV randomized to neonatal circumcision + antibiotic prophylaxis (group 1) versus antibiotic prophylaxis alone (group 2).

MATERIAL AND METHODS

Boys with PUV were randomized either to neonatal circumcision + antibiotic prophylaxis or antibiotic prophylaxis alone. Circumcision was performed at the time of valve resection. Patients were followed for two years and the number of febrile UTIs in each group was compared. The diagnosis of febrile UTI was defined as fever (>38.5°) with evidence of pyuria and culture-proven infection on urinalysis obtained by urethral catheterization or suprapubic aspiration, and biological signs of inflammation. Episodes of suspected fUTI were validated by a scientific committee blind to the study arm. We estimated we would need 90 patients to identify a difference between both groups. Relative risk of presenting a fUTI was calculated using Cox’s model.

RESULTS

There were 49 patients in group1 and 41 in group 2, with a total of 19 patients who presented confirmed fUTI at the end of follow up (1 group 1 and 18 group 2). The relative risk of presenting a fUTI when not circumcised was RR:28.

CONCLUSIONS

Circumcision significantly decreases the risk of presenting a fUTI in boys with PUV even in presence of antibiotic prophylaxis.


09:38 - 09:41
S7-2 (PP)

IS THULIUM LASER EFFECTIVE AND SAFE TO TREAT POSTERIOR URETHRAL VALVES IN CHILDREN ?

Maria Luisa CAPITANUCCI, Antonio ZACCARA, Alberto LAIS and Giovanni MOSIELLO
Children's Hospital Bambino Gesu', Continence Surgery and NeuroUrology Unit, Dep. of Surgery, Rome, ITALY

PURPOSE

Use of thulium laser (ThL) ablation (ThLa) for posterior urethral valves (PUV) is not reported in literature.Since ThL evaporates tissue continuously without generating pressure waves and creates clean cuts by moving fiber tip across tissue,it could have advantages over holmium laser and electro-fulguration for tissue ablation in young babies.Aim of the present study is to evaluate effectiveness and safety of ThLa in PUV

MATERIAL AND METHODS

From 2014 to 2017, 20 PUV patients were randomly assigned to ThLa (group 1:10 cases) or electro-fulguration (group 2:10 cases).Since 2018, all PUV patients underwent ThLa.In all cases, cystoscopy and voiding cystourethrography (VCUG) were done at 6 and 12 months after treatment,respectively In all patients, operative time, catheterization period, need for re-treatment, immediate (bleeding, infection, retention) and long-term (urethral strictures, incontinence) complications were evaluated. Group 1 and group 2 were statistically compared (Student t test,Fisher exact test)

RESULTS

A total of 26 patients (average age:9.3±19 months;range:1-96 months) underwent ThLa:mean operative time was 25 (range:15-50) minutes;in all cases catheterization period was 1 day;at second look,14/26 patients were re-treated (ThLa) for residual valves; no patients had immediate or long-term complications.Comparing data between groups, group 2 showed longer catheterization period (p<0.002), higher requirement of re-treatment and higher rate of immediate (4 bleeding, 2 infection) and long-term (2 urethral strictures, 2 incontinence) complications (<0.05).Operative time did not significantly differ between the two groups (=0.2)

CONCLUSIONS

PUV ablation with ThL is effective and safe.Since ThL has fewer complication, it seems to be preferable to electro-fulguration, especially in newborns and young babies


09:41 - 09:44
S7-3 (PP)

POSTERIOR URETHRAL VALVES AND THE RISK OF NEURODEVELOPMENTAL DISORDERS

Niklas PAKKASJÄRVI 1, Veera HÖLTTÄ 2, Jukka HEIKKILÄ 1 and Seppo TASKINEN 1
1) New Children's Hospital, Helsinki University Hospital, Pediatric Urology, Helsinki, FINLAND - 2) New Children's Hospital, Helsinki University Hospital, Pediatric Neurology, Helsinki, FINLAND

PURPOSE

Congenital anomalies of the reproductive system have been linked to neurodevelopmental disorders in males (Butwicka A. et al J Child Psychol Psychiatry 2015;56:155-61, Rotem R. et al Am J Epidemiol 2018;187:656-663) . While rare associates, genes related to sex steroids, neural growth and delays in socioemotional development seem to connect with autistic traits and Asperger syndrome (Chakrabarti B et al. Autism Res. 2009;2:157-177). We sought to clarify whether patients with posterior urethral valves (PUV) are susceptible to neurodevelopmental disorders.

MATERIAL AND METHODS

Patients treated for PUV 1992-2013 in our hospital were analyzed in a register-based study. Later visits to neurological or psychiatric clinics were analyzed with regards to neurodevelopmental disorders. Serum creatinine levels at specific timepoints were collected (maximum, 6 months of age, first year nadir, five year). Statistical analyses comparing means between groups were done using standard methods.

RESULTS

Fifteen of 87 patients (17%) had neurodevelopmental disorders. Two (2.3%) fulfilled criteria of intellectual disability (F79.0), six (6.9%) had ADHD/ADD-spectrum diagnoses (F90.0) and two (2.3%) had learning disabilities (F83/D81.3). Problems with social interactions were detected among five patients. These were analyzed with regards to possible associations to gestational age, birth weight or p-creatinine levels. No difference in patients with or without neurodevelopmental disorders with regards to either gestational age, birth weight, highest crea, crea at 6months of age, or crea nadir during first year could be detected (p>0.1).

CONCLUSIONS

While this cohort is limited, it points toward a weak association between posterior urethral valves and neurodevelopmental disorders. Further studies are warranted on a larger scale to verify these findings.


09:44 - 09:53
Discussion
 

09:53 - 09:56
S7-4 (PP)

AGE- AND GENDER-SPECIFIC NOMOGRAMS OF POST-VOID RESIDUAL URINE IN HEALTHY CHILDREN AND ADOLESCENTS

Tze-Chen CHAO 1, Shang-Jen CHANG 2 and Stephen Shei-Dei YANG 3
1) Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Division of Urology, Department of Surgery,, New Taipei, TAIWAN - 2) Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Division of Urology, Department of Surgery, New Taipei, TAIWAN - 3) Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Division of Urology, Department of Surgery, Taipei, TAIWAN

PURPOSE

To expand the previously established age- and gender-specific nomograms of post-void

residual urine (PVR) from children to adolescents.

MATERIAL AND METHODS

Healthy children aged 2 to 16 years were enrolled for two sets of uroflowmetry and PVR. The first two consecutive PVRs of each child or adolescent with a voided volume >50 ml in participants >=6 years and >30mL in participants <=5 years were included for construction of PVR nomograms. Children with possible urinary tract infection or neurognenic lower urinary tract dysfunctions were excluded. All PVRs were assessed within 5 min after voiding with suprapubic ultrasound (Logiq Book1, GE Medical Systems, Milwaukee, WI), and estimated by the equation of height x width x depth x 0.52 ml. Bladder capacity (BC) was defined as voided volume + PVR.

RESULTS

Totally, 1663 children (841 boys and 822 girls) with a mean age of 9.9±3.9 years with 2752 PVRs were eligible for construction of PVR nomograms. The 95th percentile of PVR for all children was 32.6 ml, or 15.0% of bladder capacity (BC). The table showed the age and gender specific percentile of PVR and PVR/bladder capacity (PVR/BC) from age 2 to 16 years. The PVR and PVR/BC decreased as age increased before age of 12 years. The PVR increased after adolescence while PVR/BC remained stable at 10%. PVR was higher in boys than girls before age of 12 years. In adolescent, PVR was higher in girls.

CONCLUSIONS

Age, gender, and BC should be taken into considerations at interpretation of PVR tests in children and adolescents because of gender- and age- differences in bladder function development.


09:56 - 09:59
S7-5 (PP)

ACCURATE PREDICTION OF UROFLOW CURVES FROM CELL PHONE AUDIO RECORDING: A PROOF OF CONCEPT

Lauren ERDMAN 1, Slavka ZAHREBELNY 1, Daniel T. KEEFE 2, Marta SKRETA 1, Anna GOLDENBERG 1, Joana DOS SANTOS 2, Niraj MISTRY 3, Armando J. LORENZO 2 and Mandy RICKARD 2
1) The Hospital for Sick Children, Centre for Computational Medicine, Toronto, CANADA - 2) The Hospital for Sick Children, Urology, Toronto, CANADA - 3) The Hospital for Sick Children, Pediatrics, Toronto, CANADA

PURPOSE

Uroflowmetry is a diagnostic tool in urology employed in the diagnosis and monitoring of many conditions. In pediatrics, it relies on toilet trained children being able to provide on-demand samples in the artificial environment of the clinic in order to assess voiding patterns. Here we present a proof of concept strategy to generate a non-invasive flow curve outside of the clinic setting based on in vivo simulated uroflow from the clinic.

MATERIAL AND METHODS

We obtained samples from 1000 water pours and 20 healthy volunteers(30% male) in the clinic consisting of EMG-free uroflows (Laborie Medical Uroflow v15Rel10) and audio recording of the voiding phase using cell phone. WebPlotDigitizer was used to extract data points from uroflow curves. Curves were converted to spectrograms and concatenated with the time step value. Data was divided into training/validation (n=990 water pours) and held-out test (n=10 water pours, 20 volunteers). Training data was fed into a neural network, built using the pytorch python library. Divergence between predicted and true curve values was calculated using mean squared error (MSE). The final model was selected based on the minimal validation error in the validation set.

RESULTS

Minimal MSE of 22.18 was obtained in held-out test samples. Qualitatively, we see a similar curvature in the predicted versus true uroflow curve in both the human and water test samples. There appears to be a lag in the prediction however this doesn't appear to adversely impact the algorithm's diagnostic applicability.

CONCLUSIONS

Prediction of human uroflow from a model based on simulated water pour data is a feasible and promising option that will allow for more accurate models to be trained for this task. Ultimately, this technology will allow for easier, more efficient, and more frequent assessment of uroflow in a decentralized fashion since an audio recording of this kind can be generated anywhere.


09:59 - 10:05
Discussion
 

10:05 - 10:08
S7-6 (PP)

PRUNE BELLY MANAGEMENT: LESSONS LEARNED FROM THE LARGEST COHORT REPORTED TO DATE

Roberto LOPES, Gabriel SILVA, Daniel SUCUPIRA, Ricardo HAIDAR, Bruno CEZARINO and Francisco DÉNES
University of São Paulo Medical School, Urology, São Paulo, BRAZIL

PURPOSE

To report our experience with comprehensive surgical management of prune belly syndrome (PBS). 

MATERIAL AND METHODS

From 1987 to 2019, 74 children with PBS were evaluated: 64 patients were submitted to comprehensive surgical management, 9 are waiting surgery (7 submitted to early diversion) and one patient died of disease in the perinatal period (severe pulmonary hypoplasia).  According to individual needs, treatment aimed to correct the abdominal flaccidity, reconstruct the urinary tract, and perform bilateral orchiopexies and circumcision, which were performed in one procedure. Urinary tract reconstruction was indicated whenever pyelo-ureteral dilatation with evidence of significant stasis and/or vesicoureteral reflux was associated with recurrent urinary tract infections. 

RESULTS

Treatment for this cohort included: 59 abdominoplasties, 49 upper urinary tract reconstructions, 53 lower urinary tract reconstruction, 64 bilateral orchiopexies, 64 circumcisions and 5 urethroplasties. Median age at surgery was 20.8 months and median follow-up was 11.8 years. Abdominal appearance and tonus improved in 85% of the children after the primary surgery. Functional stabilization of the upper urinary tract was observed in 90% of the children, with progression to renal failure in 10%. Continence was observed in 80%, while some degree of incontinence was present in 20% and usually associated with polyuria. 88.2% of the testes were normal and topic after bilateral orchiopexies.

CONCLUSIONS

Optimal management should be tailored to each patient. The long-term results for reno-ureteral anatomy and function, bladder function, testicular size and location, as well as abdominal aspect and tonus, show that comprehensive surgery is an adequate method for managing children with PBS. 


10:08 - 10:11
S7-7 (PP)

REDUCING FOLEY CATHETER USAGE IN A PEDIATRIC HOSPITAL USING A BEHAVIORAL NUDGE

Daniel PELZMAN 1, Omar AYYASH 1, Marc COLACO 2, Janelle FOX 2, Rajeev CHAUDHRY 2, Francis SCHNECK 2 and Glenn CANNON 2
1) University of Pittsburgh Medical Center, Urology, Pittsburgh, USA - 2) Children's Hospital of Pittsburgh, Urology, Pittsburgh, USA

PURPOSE

Cather-associated urinary tract infections (CAUTI) prolong hospitalizations and increase healthcare costs. The rates of infection are closely monitored. Accordingly, many adult hospitals have instituted policies to reduce their CAUTI rate, but similar efforts have not been well-studied in pediatric hospitals. We sought to investigate whether behavioral modifications including catheter teaching and a daily rounding checklist could reduce unnecessary catheter usage in a tertiary-care pediatric hospital.

MATERIAL AND METHODS

Prospectively collected data of urinary catheter utilization at a single pediatric-only hospital from 2015-2019 were analyzed. In May 2017, hospitalwide mandatory workshops were performed and a nursing-driven daily checklist to assess for catheter necessity was implemented. Pre- and post-intervention catheter utilization rates were compared using the standardized utilization ratio, which is a CDC-developed quality measure of catheter usage defined as total catheter days per total patient days. The intervention was implemented during a seven-month run-in period (May-Dec 2017), which was omitted from analysis.

RESULTS

A total of 365,246 patient-days were available for analysis between January 2015 and August 2019. Catheter-associated UTI rate decreased from 0.13/1000 patient-days to 0.05/1000 patient-days. Hospital-wide urethral catheter utilization decreased from 10.2% (95% CI 9.8% - 10.6%) pre-intervention to 3.9% (3.4% - 4.4%, p < 0.0001) post-intervention (Figure 1). These changes were most pronounced in critical care units where utilization dropped from 36.2% (33.6% – 38.8%) to 12.9% (11.8% - 14.0%, p < 0.0001). Standardized utilization ratios in the critical care units fell from 2.16 (2.00 – 2.32) to 0.76 (0.69 – 0.83, p <0.0001).

CONCLUSIONS

Catheter teaching and institution of a daily rounding checklist successfully reduced urethral catheter utilization as measured by catheter usage rates and standardized utilization ratio in a pediatric hospital. Widespread adoption of these protocols may decrease unnecessary catheter usage and catheter associated morbidity.


10:11 - 10:14
S7-8 (PP)

CHARACTERIZATION OF THE URINARY MICROBIOTA OF HEALTHY PREPUBERTAL CHILDREN.

Kristina THORSTEINSSON 1, Lea FREDSGAARD 2, Caspar BUNDGAARD-NIELSEN 2, Nadia AMMITZBØLL 2, Peter LEUTSCHER 2, Qing CHAI 3, Suzette SØRENSEN 2, Lia Mendes PEDERSEN 1, Søren HAGSTRØM 1 and Louise Thomsen Schmidt ARENHOLT 4
1) Aalborg University Hospital, Department of Pediatrics, Aalborg, DENMARK - 2) The North Denmark Regional Hospital, Centre for Clinical Research, Hjoerring, DENMARK - 3) The North Denmark Regional Hospital, Department of Pediatrics, Hjoerring, DENMARK - 4) The North Denmark Regional Hospital, Department of Obstetrics and Gynecology, Hjoerring, DENMARK

PURPOSE

In recent years, it has been established that the urine of a healthy adult bladder contains a microbiota, and that dysbiosis of this urinary microbiota may be involved in development of urinary tract diseases including urinary incontinence. The aim of this study is to characterize the urinary microbiota of healthy prepubertal children.

MATERIAL AND METHODS

Clean-catch midstream urine samples of 30 healthy prepubertal children with equal gender distribution were assessed using 16S rRNA gene sequencing of the bacterial region V4. All included children had normal bladder function, and urine samples were negative by standard urine culture test.

RESULTS

Bacterial DNA was detected in all urine samples. The urinary microbiota differed significantly between the prepubertal boys and girls in terms of operational taxonomic unit richness, Shannon Index, and relative abundances of bacterial genera. The urine of girls had a higher number of different bacterial genera with a more even distribution compared to the urine of boys. The urine of boys was dominated by the Porphyromonas genus and to a lesser extent by Ezakiella, Campylobacter, Prevotella, and Dialister. Prevotella was the genus with the highest relative abundance in girls followed by Porphyromonas, Ezakiella, Prevotella 6, and Dialister.

CONCLUSIONS

Clean-catch midstream urine samples of healthy prepubertal children are not sterile, and the composition of the urinary microbiota differs significantly between boys and girls. The most abundant genera of the midstream urine samples from children are different from those reported in similar urine samples from adults.


10:14 - 10:23
Discussion