ESPU Meeting on Thursday 20, April 2023, 12:40 - 13:25
12:40 - 12:43
S11-1 (OP)
Jin Kyu (Justin) KIM 1, Margarita CHANCY 1, Michael CHUA 1, Natasha BROWNRIGG 1, Joana DOS SANTOS 1, Juliane RICHTER 1, Tim VAN MIEGHEM 2, Armando LORENZO 1 and Mandy RICKARD 1
1) The Hospital for Sick Children, Division of Urology, Toronto, CANADA - 2) Mount Sinai Hospital, Obstetrics and Gynecology, Toronto, CANADA
PURPOSE
Some studies have reported that hydronephrosis may predispose children to urinary tract infections (UTIs). However, there is yet to be consensus on the use of continuous antibiotic prophylaxis (CAP) for patients with isolated hydronephrosis. Herein, we evaluate the risk of UTI using individualized patient data and time-varying exposure analysis.
MATERIAL AND METHODS
Our institutional hydronephrosis database was examined. Urinary tract infection was defined as fever >38.5, with positive urinalysis and culture from catheterized specimens. Only the UTIs within the first year of life were included. To adjust for time-varying exposure, patients were censored based on the maximum follow-up of 365 days and CAP discontinuation, UTI event, surgery (pyeloplasty), loss to follow-up, or hydronephrosis resolution. Survival analysis and incidence per 1000 person days were calculated.
RESULTS
A total of 578 patients were seen prior to their first UTI episode and segregated into two groups based on exposure to prophylaxis. Of these, 271 (46.8%) did not have exposure to CAP. There were similar numbers of bilateral hydronephrosis in each group (58/284, 20.0% vs. 73/325, 21.5%). There was a higher proportion of SFU grade ≥3 in the CAP group (88/284, 30.9% vs. 137/325, 42.5%). There were 2 UTI events in the no CAP group (incidence 0.025 per 1000-person-days) and 3 in the CAP exposure group (incidence 0.050 per 1000-person days). Kaplan-Meier survival curve, accounting for time-varying exposure censoring, showed no difference in time to UTI between the two groups (log-rank p=0.511).
CONCLUSIONS
The rates of UTIs in patients with isolated hydronephrosis are very low. Risk adjusted analysis of individualized patient data suggests that CAP does not seem to significantly reduce the likelihood of UTIs in patients with isolated hydronephrosis. This information is valuable for both pre- and postnatal recommendations and management.
12:43 - 12:46
S11-2 (OP)
Ermelinda MELE, Ludy LOPES, Del Prete LAURA, Michele INNOCENZI, Collura GIUSEPPE and Marco CASTAGNETTI
Bambino Gesù Children Hospital and Research Center, Pediatric Urology Unit, Rome, ITALY
PURPOSE
In some conditions, such as ureterocele, a history of fUTI before treatment has been suggested to be a risk factor for postoperative fUTI and therefore an argument in favor of early endoscopic decompression (Upadhyay et al, J Urol. 2002 Jun;167(6):2560).
We aimed to assess the prevalence of fUTI in patients with POM before and after EBD. Our hypothesis was that patients with an history of fUTI before EBD were at increased risk of fUTI also after EBD.
MATERIAL AND METHODS
Retrospective study of 123 consecutive patients with POM undergoing EBD between 2009 and 2021. Prevalence of fUTI before and after EBD was compared in patients with vs. without a history of fUTI before EBD. Prophylaxis was not routinely used in any of these patients and none was circumcised.
RESULTS
40/123 (32.5%) patients developed fUTI before EBD and 6/40 (15%) required hospital admission. EBD was performed at a median age (range) of 14 (4-240) months. During post-EBD follow-up, 7/123 (3%) patients developed fUTIs. All fUTIs occurred within 12 months of EBD and none required hospital admission. Post-EBD fUTIs occurred in 4/40 (10%) patients with a history of pre-EBD fUTIs vs. 3/83 (3.6%) of those without fUTI before EBD, p=0.1. Surgical reimplantation was required in 4/40 (10%) patients with pre-EBD fUTI (2 of which had also post-EBD fUTI) vs. 15/83 (18%) without pre-EBD fUTI (none had post-EBD fUTI), p=0.3.
CONCLUSIONS
fUTI occurred in 1/3 of our patients before EBD (none on prophylaxis), but the prevalence of fUTI and risk of reimplantation after EBD was not different in patients with vs. without a preoperative history of fUTI. These data do not support our hypothesis that pre-EBD fUTI increase the risk of fUTI after EBD, and therefore, that the risk of fUTI should be considered an argument in favor of early treatment in patients with POM.
12:52 - 12:55
S11-3 (OP)
Lucas RABAUX 1, Mathilde GRAPIN 2, Eva MILE 1, Olivia BOYER 3, Nathalie BIEBUYCK-GOUGE 3, Henri LOTTMAN 1, Mathilde GLENISSON 1, Laurence HEIDET 3, Nathalie BOTTO 1, Guillaume DORVAL 3 and Thomas BLANC 1
1) Hôpital Necker-Enfants malades, Department of Paediatric Surgery, Paris, FRANCE - 2) Hôpital Necker-Enfants malades, Department of Paediatric Nephrology; Hôpital Necker-Enfants malades, Paris, FRANCE - 3) Hôpital Necker-Enfants malades, Department of Paediatric Nephrology, Paris, FRANCE
PURPOSE
Solitary kidney (SK) is associated with an increased risk of chronic kidney disease (CKD). Co-existing congenital anomalies of the kidney and urinary tract (CAKUT) is a known risk factor for developing CKD. We assessed long-term renal function in children with UPJO after pyeloplasty in the setting of a SK.
MATERIAL AND METHODS
We conducted a single-centre controlled retrospective cohort study between 1995 and 2020. Children with SK were divided into three groups: (1) without CAKUT (n=108); (2) with CAKUT other than UPJO (n=24); and (3) with UPJO (n=35). Serum creatinine, renal pelvis dilatation, blood pressure, height, weight and measured iohexol GFR (mGFR) were assessed pre-operatively and during follow-up. CKD was defined as a mGFR <90mL/min/1.73m2.
RESULTS
Indication for pyeloplasty was: renal failure in the neonatal period (n=21), prenatal hydronephrosis with increasing renal pelvis dilatation postnatally (n=10), flank pain (n=3) and UTIs (n=1). Median age at surgery was 15 months (1.2-30). Renal pelvis dilatation improved in all children. The median age at follow-up was 13 years. The risk of CKD was:
• 12% in group (1) (p = 0.0008).
• 37% in group (2) (p=0.9).
• 43% in group (3). The main risk factor was neonatal renal failure (OR 4,8 , p = 0.04). Three children out of 35 required kidney transplants.
CONCLUSIONS
UJPO in children with solitary kidney portends a high risk of developing CKD during childhood (43%). A large proportion of neonates will present with neonatal renal failure (60%). This is critical information to inform both prenatal counselling and long-term follow-up.
12:55 - 12:58
S11-4 (OP)
Laura DAL PRETE, Ana Ludy LOPES MENDES, Michele INNOCENZI, Ermelinda MELE, Giuseppe COLLURA and Marco CASTAGNETTI
Bambino Gesù Children Hospital and Research Center, Pediatric Urology Unit, Rome, ITALY
PURPOSE
One-trocar-assisted pyeloplasty (OTAP) is a minimally invasive technique for the treatment of PUJ obstruction. Aim of present study is to evaluate pre- or intra-operative risk factors for recurrent obstruction.
MATERIAL AND METHODS
Retrospective review of all consecutive children who underwent OTAP for PUJ obstruction between 01/2011 and 06/2021. Patients with incomplete data were excluded.
The following a priori chosen variables were assessed as risk factors for recurrent obstruction, define as need for reintervention (endoscopic or redo pyeloplasty): gender, anterior-posterior renal pelvic diameter >30 mm, age at surgery >24 months, surgery performed by an experience surgeon (>80 OTAPs), presence of crossing polar vessels, inability to place a JJ stent >3Fr JJ at surgery.
RESULTS
During the study period, 301 children (216 males) underwent a OTAP (194 on the left side); median age at surgery was 18 months (range 4 – 181 months); and 27/301 (9%) experienced recurrent obstruction after surgery requiring redo pyeloplasty or endoscopic procedures.
The inability to place a stent>3 Fr at OTAP proved the only predictor of pyeloplasty failure (Table).
|
RISK FACTORS |
OUTCOME (301 pts) |
OR (95% CI) |
p-value |
|
|
SUCCESS (n=274) |
FAILURE (n=27) |
|||
|
Male Gender |
197(72%) |
19(70%) |
1,07 (0,45–2,56) |
0,51 |
|
APD>30 mm |
95(35%) |
11(40%) |
1,29 (0,58–2,90) |
0,53 |
|
Age >24 months |
106(39%) |
10(37%) |
0,93 (0,41–2,11) |
0,52 |
|
Experienced surgeons |
172(63%) |
20(74%) |
0,59 (0,24–1,44) |
0,17 |
|
Crossing polar vessels |
16(6%) |
2(7%) |
1,29 (0,28–5,93) |
0,49 |
|
Stent 3 Fr |
19(7%) |
8(3%) |
5,65 (2,19–14,6) |
0,001 |
CONCLUSIONS
The inability to pass a stent >3Fr during the OTAP was, in our experience, the only predictor of pyeloplasty failure. We hypothesize that it could be a marker of a small size ureter that makes the pyelo-ureteral anastomosis more troublesome. Therefore, we recommend close postoperative follow up under these circumstances.
12:58 - 13:01
S11-5 (OP)
Tayfun OKTAR, Ismail SELVI, M. Irfan DÖNMEZ, Yaren ALAN, Enes DEĞİRMENCİ and Orhan ZİYLAN
İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, İstanbul, TURKEY
PURPOSE
To analyze the long-term clinical outcomes of children who underwent open dismembered pyeloplasty due to ureteropelvic junction obstruction.
MATERIAL AND METHODS
Files of patients between 2000 and 2012 were reviewed retrospectively.The changes in hydronephrosis grade,renal pelvis anteroposterior diameter(APD),renal parenchymal thickness,split renal functions on MAG-3 scan as well as development of hypertension and proteinuria were noted.Complete hydronephrosis resolution was defined when SFU grade was 0-1 or APD≤10mm or ≥50% APD decrease,the remaining were named as incomplete resolution.Then,patients were divided into two groups: Complete resolution (n:190,85.2%) and incomplete resolution, defined as persistent hydronephrosis with improved drainage and stable renal function,(n:33,14.8%). None of the cases required re-do pyeloplasty (only two patients required temporary ureteral stenting).
RESULTS
Overall,223 patients (161 boys) with a median age of 9 months (1-185) underwent unilateral pyeloplasty,whereas 14 patients (13 boys) with a median age of 4 months(2-39) underwent bilateral pyeloplasty.Of these,155(65.4%) had antenatal hydronephrosis.Median follow-up was 13 years (10-22).Regarding unilateral cases,postoperative changes in hydronephrosis and split renal function reached to a plateau at 60th and 12th months,respectively(p<0.05,all). Predictive factors for incomplete resolution were <52.5% reduction in APD at the postoperative 12th month (OR:5.518,p=0.008), APD>18.95 mm at the postoperative 12th month (OR:5.246,p<0.001), preoperative APD>35.1 mm (OR:4.109,p=0.045) and age at surgery>17.5 months (OR:1.008,p=0.028).
Further, hypertension developed after a median period of 12 years in 13(5.4%) of 237 patients and proteinuria developed after a median period of 11.5 years in 4(1.6%) patients. Predictive factors for development of hypertension and/or proteinuria were;<36.5% APD decrease at the postoperative 12th month (OR:5.253,p<0.001),APD>24.1 mm at the postoperative 12th month (OR:5.071,p<0.001),renal parenchymal thickness<4.55 mm at the postoperative 12th month (OR:4.253,p<0.001),<29.5% preoperative split renal function on MAG-3 (OR:4.189,p<0.001) and bilateral disease (OR:2.518,p=0.034).
CONCLUSIONS
Our results indicated that sonographic stability was achieved after the postoperative 60th month,whereas split renal function stabilized after the postoperative 12th month. The risk of developing hypertension and/or proteinuria is 2.5 times greater in bilateral cases.Incomplete resolution following pyeloplasty might be observed in 1 out of every 7 patients.
13:13 - 13:16
S11-6 (OP)
Ermelinda MELE, Francesca SILVESTRI, Ludy LOPES, Laura DEL PRETE, Michele INNOCENZI, Giuseppe COLLURA and Marco CASTAGNETTI
Bambino Gesù Children Hospital and Research Center, Pediatric Urology Unit, Rome, ITALY
PURPOSE
EBD is an alternative to ureteral reimplantation for the treatment of POM. Nevertheless, its role as definitive treatment and its long-term durability are still controversial. In the last 12 years, EBD has been our first-line approach in POM patients. Aim of present study was to report our experience with more than 100 patients and a maximum follow-up >10 years.
MATERIAL AND METHODS
Retrospective study of 123 consecutive patients undergoing EBD from 2009 to 2021. We describe characteristics, complications, and outcomes.
RESULTS
Of 123 patients, 94 were males, 85 were diagnosed prenatally, and 40 were symptomatic. POM was on the left side in 77 and bilateral in 8. Median(range) age at EBD was 14(4-240) months. In 1 patient, the procedure was converted to open reimplantation due to a ureteral perforation with the wire. Additional 18 patients required ureteral reimplantation (all but 1 within 12 months of EBD), including 7 cases where no vesico-ureteral junction narrowing (ring) was visualized during balloon inflation and 11 with persistent/recurrent obstruction after an apparently successful ring dilatation (2 with post-EBD infections). Therefore, after a median(range) follow-up of 38(9-142) months, the procedure was successful in 104/123(84.5%) patients. Febrile urinary tract infections developed in 7 such patients (all in the first year post-EBD), but no VUR was detected and subsequent management was conservative in 5; post-operative ultrasound showed significant improvement in median(range) ureteral diameter, from 15(4-27)mm to 8(0-27)mm, p<0.05, and median differential renal function remained stable, 48.5%(22%-55%) postoperatively vs. 48%(15%-56%) preoperatively, p>0.05. No new symptoms or worsening dilatation were observed in any of the 66 patients with a follow-up longer than 5 years.
CONCLUSIONS
In our experience, EBD proved a durable first-line minimally invasive treatment of POM with minimal complication rate and a success rate of 84.5%. To our knowledge, this is the largest series available with EBD and can contribute to define the benchmark for this approach.
13:16 - 13:19
S11-7 (OP)
Mele ERMELINDA 1, Filippo GHIDINI 2, Collura GIUSEPPE 3, Michele INNOCENZI 3, Del Prete LAURA 3, Ludy LOPES 3 and Marco CASTAGNETTI 3
1) Bambino Gesù Children Hospital and Research Centerino, Pediatric Urology Unit, Rome, ITALY - 2) Azienda Ospedaliera di Modena, Pediatric Surgery, Modean, ITALY - 3) Bambino Gesù Children Hospital and Research Center, Pediatric Urology Unit, Rome, ITALY
PURPOSE
Reportedly, EBD has a success rate of around 85% in the treatment of POM. In present study, we aimed to assess potential risk factors for failure of EBD which could help for patient selection or counselling.
MATERIAL AND METHODS
Retrospective study of 123 consecutive patients with POM undergoing EBD between 2009 and 2021. The following a priori chosen variables were assessed as risk factors for failure of EBD: antenatal diagnosis, male gender, left side POM, presence of symptoms, ureteral dilatation >15mm, high-grade hydronephrosis (APD>20mm or SFU>3), DRF<40%, age at EBD<1year, absence of a ring at EBD, and dilatation time>5min. End point to define failure was the need for ureteral reimplantation.
Odds ratios (95%CI), and p values were calculated by MedCalc Software Ltd.
RESULTS
19/123(15.4%) patients required ureteral reimplantation (failures OF EBD) after a median (range) follow-up of 38(9-142) months.
Only the absence of a ring at EBD proved significant risk factor for failure of treatment (Table).
|
Risk facto for failure of EBD |
Outcome |
OR (95% CI) |
p-value |
|
|
Success |
Failure |
|||
|
Antenatal diagnosis |
13/16(81%) |
59/85(69%) |
1.91 (0.50-7.27) |
0.34 |
|
Male gender |
15/19(79%) |
79/104(76%) |
1.19 (0.36-3.91) |
0.78 |
|
Left side POM |
12/18(67%) |
65/97(67%) |
0.98 (0.34-2.86) |
0.98 |
|
Symptoms before EBD |
4/18(22%) |
36/82(44%) |
0.37 (0.11-1.20) |
0.1 |
|
Ureteral dilatation>15mm before EBD |
13/19(68%) |
52/104(50%) |
2.17 (0.77-6.14) |
0.14 |
|
Hydronephrosis (APD>20mm or SFU>3) before EBD |
7/12(58%) |
20/67(30%) |
3.29 (0.93-11.61) |
0.06 |
|
DRF < 40% before EBD |
0/19(0%) |
1/94(1.1%) |
1.60 (0.06-40.71) |
0.78 |
|
Age at EBD >1year |
8/19(42%) |
61/104(59%) |
0.51 (0.19-1.38) |
0.19 |
|
No Ring at EBD |
7/19(37%) |
2/104(1.9%) |
29.75 (5.54-159.9) |
<0.0001 |
|
Dilatation time >5min |
3/18(13%) |
13/101(13%) |
1.35 (0.34-5.33) |
0.66 |
CONCLUSIONS
No preoperative factor proved relayble for the selection of patients where EBD was more likely to be effective. The absence of a ring during EBD was the only significant risk factor for the failure of EBD.