34th ESPU Congress in Naples, Italy

S21: VUR

Moderators: Rafał Chrzan (Poland), Gundela Holmdahl (Sweden)

ESPU Meeting on Friday 19, April 2024, 17:05 - 17:55


17:05 - 17:08
S21-1 (OP)

★ IS A KIDNEY AND BLADDER ULTRASOUND (USKUB) NEEDED AFTER A FIRST PEDIATRIC FEVERISH UTI? A RANDOMISED PROSPECTIVE MULTICENTER TRIAL

Zeno ADRIAENSSENS 1, Lise VAN HOVE 2, Jolan KINT 2, Laura GIELEN 2, Nathalie SEGERS 3, Ann BAEL 3, Nele VANHAMEL 4, Denis LIBEERT 5, Wim VERGAUWEN 6, Geert VAN LOMMEN 7, Dominique HAENTJES 8, Loes LAMBRECHT 9, An HUYBRECHTS 10, Els VERLINDEN 11, Frederic DE MEULDER 12, Emmi VAN DAMME 13, Miet JAMERS 14, Karen DE BAETS 15, Gunter DE WIN 1 and Koenraad VAN HOECK 16
1) University Hospital Antwerp - University of Antwerp, Urology - Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM - 2) University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM - 3) ZNA Queen Paola Children Hospital, Pediatrics, Antwerp, BELGIUM - 4) AZ Klina, Pediatrics, Brasschaat, BELGIUM - 5) AZ Turnhout, Pediatrics, Turnhout, BELGIUM - 6) Sint-Dimpha Hospital Geel, Pediatrics, Geel, BELGIUM - 7) AZ Sint-Maarten, Pediatrics, Mechelen, BELGIUM - 8) AZ Monica, Pediatrics, Antwerp, BELGIUM - 9) AZ Herentals, Pediatrics, Herentals, BELGIUM - 10) Heilig Hart Hospital Lier, Pediatrics, Lier, BELGIUM - 11) GZA Hospital Sint-Augustinus, Pediatrics, Wilrijk, BELGIUM - 12) GZA Hospital Sint-Vincentius, Pediatrics, Antwerp, BELGIUM - 13) ZNA Jan-Palfijn, Pediatrics, Merksem, BELGIUM - 14) Maria Hospital North Limburg, Pediatrics, Pelt, BELGIUM - 15) University Hospital Antwerp - University of Antwerp, Urology, Wilrijk, BELGIUM - 16) University Hospital Antwerp - University of Antwerp, Pediatric Urology - Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM

PURPOSE

To investigate the value of a USKUB after a first febrile UTI for the prevention of recurrent UTI.

MATERIAL AND METHODS

Children (6m-16yrs) with a first low risk febrile UTI (based on NICE guidelines) were randomized in a prospective multi-centre trial with a non-inferiority design. Known risk factors for recurrence were assessed. In the intervention group, a kidney and bladder ultrasound (USKUB) was performed (with subsequent further management based on an agreed protocol). In the control group a USKUB was only performed in case of recurrent feverish UTI. Outcome was based on recurrence of a febrile UTI within the first year of follow up.

RESULTS

12 hospitals participated. One year follow-up was available for 242 children (29M/213F) with median age 1 year and range 6m - 10 yrs. 119 were assigned to the control group, 123 to the intervention group. There was no statistical difference in baseline demographic characteristics (age, sex and risk factors) between the two study arms. Recurrent UTI was seen in 42 patients (17%), with a recurrence of 13.8% (17) in the control group and 21.0% (25) in the intervention group. When stratified for age, sex and risk factors, no statistical difference was seen between both study groups. Based on a delayed USKUB in the control group, 3 high grade VUR and one trabeculated bladder were found.

CONCLUSIONS

Not performing a USKUB after a first low risk feverish UTI is safe and doesn't increase the risk of recurrence.


17:08 - 17:11
S21-2 (OP)

THE EXPERIENCE OF PARENTS OF CHILDREN WITH A FIRST FEVERISH UTI DURING THE DIAGNOSTIC PROCESS OF OUR RCT AND THE INFLUENCE ON THEIR PREFERRED STUDY GROUP

Zeno ADRIAENSSENS 1, Jolan KINT 2, Lise VAN HOVE 2, Laura GIELEN 2, Ann BAEL 3, Nathalie SEGERS 3, Nele VANHAMEL 4, Denis LIBEERT 5, Wim VERGAUWEN 6, Geert VAN LOMMEN 7, Dominique HAENTJES 8, Loes LAMBRECHT 9, An HUYBRECHTS 10, Els VERLINDEN 11, Frederic DE MEULDER 12, Emmi VAN DAMME 13, Miet JAMERS 14, Karen DE BAETS 15, Gunter DE WIN 15 and Koenraad VAN HOECK 16
1) University of Antwerp - University Hospital Antwerp, Faculty of Medicine and Health Sciences - Urology, Wilrijk, BELGIUM - 2) University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM - 3) ZNA Queen Paola Children Hospital, Pediatrics, Antwerp, BELGIUM - 4) AZ Klina, Pediatrics, Brasschaat, BELGIUM - 5) AZ Turnhout, Pediatrics, Turnhout, BELGIUM - 6) Sint-Dimpha Hospital Geel, Pediatrics, Geel, BELGIUM - 7) AZ Sint-Maarten Mechelen, Pediatrics, Mechelen, BELGIUM - 8) AZ Monica, Pediatrics, Deurne, BELGIUM - 9) AZ Herentals, Pediatrics, Herentals, BELGIUM - 10) Heilig Hart Hospital Lier, Pediatrics, Lier, BELGIUM - 11) GZA Sint-Augustinus, Pediatrics, Antwerp, BELGIUM - 12) GZA Sint-Vincentius, Pediatrics, Antwerp, BELGIUM - 13) AZ Jan-Palfijn Merksem, Pediatrics, Merksem, BELGIUM - 14) Maria Hospital North Limburg, Pediatrics, Pelt, BELGIUM - 15) University Hospital Antwerp - University of Antwerp, Urology - Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM - 16) University Hospital Antwerp - University of Antwerp, Pediatric Nephrology - Faculty of Medicine and Health Sciences, Wilrijk, BELGIUM

PURPOSE

To understand parent's perception and study-arm preferences when their children after a first feverish UTI were randomized.

MATERIAL AND METHODS

A prospective multi-centre trial was organized looking at the value of US KUB after a first febrile UTI. Children were randomized in an intervention group (in which a USKUB was performed) or a control group (where US KUB was only performed in case of disease recurrence) With a standardized questionnaire at the start and at one year follow up, parents'preferences were questioned. Semi-structured interviews until data saturation within four weeks of inclusion were performed for a more in depth analysis.

RESULTS

97 parents filled in the standardised questionnaire at the start, 141 after one year follow up. At the start, 57% of parents in the intervention group and 42% in the control group had a preference for a USKUB after the first feverish UTI. The remaining had no preference. None of the respondents (in both study groups) had a preference for the control group.
At one year, 38% of parents in the control group would have preferred a USKUB, and none of the parents of the intervention group would have preferred the control group.
Interviews were analysed across three themes (experiences before or during the study, and information provided). Parents look for reassurance about the situation of their child through imaging. Parents who are well-informed don't feel the need for extra investigations.

CONCLUSIONS

Reassuring and informing parents (rather then extra imaging) is the key for positive parents experiences after a first feverish UTI.


17:11 - 17:14
S21-3 (OP)

★ TRANSITIONAL OUTCOMES OF CHILDREN WHO HAVE UNDERGONE COHEN URETERONEOCYSTOSTOMY FOR THE TREATMENT OF VESICOURETERAL REFLUX TO ADULTHOOD

Tayfun OKTAR 1, İsmail SELVİ 2, M. İrfan DÖNMEZ 1, Mehmet GÜRCAN 1, Arda Tunç AYDINOĞLU 1 and Orhan ZİYLAN 1
1) İstanbul University, İstanbul Faculty of Medicine, Department of Urology, Division of Pediatric Urology, İstanbul, TURKEY - 2) İstanbul University/Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Istanbul, TURKEY

PURPOSE

We aimed to analyze the transitional outcomes of children who underwent Cohen ureteroneocystostomy (UNC) due to vesicoureteral reflux (VUR).

MATERIAL AND METHODS

Files of patients who underwent UNC between January 2003 and December 2013 and had >10 years of follow-up were retrospectively reviewed.Demographic and clinical data before surgery were noted.Lower urinary tract dysfunction (LUTD) status was assessed via ICIQ M/F-LUTS,voiding diary and uroflowmetry in all patients. Renal functions,hypertension,proteinuria,febrile/afebrile urinary tract infections (UTIs),and complications associated with pregnancy were noted.

RESULTS

There were 241 patients (140 girls, 58.1%).Forty-five patients (18.7%) had bilateral,and 91 (37.8%) had unilateral renal scars.UNC was performed at median 6.5 years (3-14) of age (57.7% bilateral, 42.3% unilateral repair).Median follow-up was 15 years (range 10-20).Median patient age at the last clinic visit was 21 years (range 18-31) and LUTD was detected in 69(28.6%).Bilateral surgery, female gender,history of childhood LUTD,presence of renal scar, and older age (>7 years) at the time of surgery significantly increased the likelihood of LUTD in adulthood.

Median creatinine level at last clinic visit was 0.61 (0.42-1.21) mg/dl.Febrile UTI was detected in 7.9% (19/241) following surgery,whereas six needed subureteral injection due to persistent low-grade VUR.Further, 11(4.6%) patients developed hypertension and 7(2.9%) had proteinuria.Of 67 sexually active female patients, 10(14.9%) had febrile UTIs.Forty-nine women had pregnancy, 4(8.1%) had febrile UTIs, 7(14.2%) had afebrile UTIs and two(4.1%) had preeclampsia during pregnancy, but none had a miscarriage.Girls with renal scar and LUTD as well as bilateral disease were risk factors for these undesirable issues.

CONCLUSIONS

Despite VUR control,febrile UTIs were detected in 8% and preeclampsia in 4% during pregnancy.In addition,a quarter of patients face LUTD when they reach adulthood.Female patients with bilateral disease,renal scar,and previous LUTD have higher risks for these clinical problems.


17:14 - 17:17
S21-4 (OP)

MULTI-INSTITUTIONAL VARIATIONS IN RADIATION EXPOSURE DURING VOIDING CYSTOURETHROGRAM: CAN WE DO BETTER?

Suhaib ABDULFATTAH 1, Sahar EFTEKHARZADEH 1, Sameer MITTAL 1, Susan BACK 1, Hannah BACHTEL 2, Carly HANSEN 2, Caleb COOPER 3, Sonam SAXENA 1, Aznive AGHABABIAN 1, Mohamed ELSINGERGY 4, Eric BIH 5, Emily MARSHALL 6, Kate FEINSTEIN 6, Zheng FEN LU 6, John WEAVER 1, Katherine FISCHER 1, Karl GODLEWSKI 1, Dana WEISS 1, Arun SRINIVASAN 1, Chester KOH 2, Mohan GUNDETI 3 and Aseem SHUKLA 1
1) Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 2) Texas Children's Hospital, Urology, Houston, USA - 3) UChicago Medicine, Urology, Chicago, USA - 4) Children's Hospital of Philadelphia, Radiology, Philadelphia, USA - 5) Texas Children's Hospital, Radiology, Houston, USA - 6) UChicago Medicine, Radiology, Chicago, USA

PURPOSE

The purpose of this study is to investigate and quantify the substantial differentiations in fluoroscopy time during VCUG procedures across three high-volume pediatric centers.

MATERIAL AND METHODS

We identified all patients aged 6 months to 5 years who underwent VCUG imaging at one of three participating centers between January 2018 and December 2020. We retrospectively reviewed electronic health records to gather demographic and clinical information, as well as fluoroscopy data. Multivariate regression analysis was conducted to assess variations in fluoroscopy time and the requirement for multiple VCUG exams based on demographic factors, indication for imaging, and the imaging center.

RESULTS

During the study, 2,195 VCUGs were performed on 1,942 patients, with 64% females and 36% males, aged 1.4 years, and weighing 11.9 kilograms. The majority (71%) of patients were identified as white.
Median fluoroscopy time was 1.03 minutes (IQR: 0.5, 1.57), and the median number of images obtained during fluoroscopy was 14 (IQR: 10, 20). Linear regression analysis revealed significant variation in both fluoroscopy time and the number of images obtained among the centers. Subgroup linear regression analysis confirmed that gender and ethnicity had significant impacts on radiation exposure surrogates. Logistic regression analysis indicated that females, older children, and patients requiring VCUG for post-operative evaluation or PUV were more likely to undergo multiple VCUGs during the study period compared to others.

CONCLUSIONS

Significant radiation exposure variations during VCUG are linked to gender, indication, ethnicity, and the performing center. Further research is essential to enhance standardization, reduce radiation risk, and provide better pre-VCUG counseling to families.


17:17 - 17:30
Discussion
 

17:30 - 17:33
S21-5 (OP)

SUCCESS OF COHEN AND LICH-GREGOIR TECHNIQUES FOR URETERAL REIMPLANTATION IN PRIMARY UNILATERAL HIGH GRADE VESICOURETERAL REFLUX IN CHILDREN: AN INTERNATIONAL MULTICENTER STUDY OF CLINICAL OUTCOMES.

Khadija ISMAIL 1, Mohamad MOUSSA 2, Christian KRUPPA 3, Anthony KALLAS CHEMALY 4, Bilal AOUN 5, Mohamad ABOU CHAKRA 6, Katrin SCHUCHARDT 3, Alexandra WILKE 3, Pascale SALAMEH 7 and Amal AL-HAJJE 8
1) Lebanese University, Doctoral School of Sciences and Technology, Lebanese University, Faculty of Pharmacy, Clinical and Epidemiological Research Laboratory, Beirut, LEBANON - 2) Al Zahraa Hospital University Medical Center, Lebanese University, Faculty of Medical Sciences, Urology, Beirut, LEBANON - 3) University Hospital Dresden, Technical University Dresden, Pediatric Surgery, Dresden, GERMANY - 4) Hôtel-Dieu de France University Hospital, Pediatric Urology, Boulevard Alfred Naccache, Achrafieh, Beirut, LEBANON - 5) American University of Beirut-Medical Center, Division of Pediatric Nephrology, Beirut, LEBANON - 6) Lebanese University, Faculty of Medical Sciences, Urology, Beirut, LEBANON - 7) Lebanese University, Faculty of Pharmacy, Clinical and Epidemiological Research Laboratory, INSPECT-LB (Institut National de Santé Publique, d'Epidémiologie Clinique et de Toxicologie-Liban), Primary Care and Population Health Department, University of Nicosia Medical School, Nicosia, Cyprus, Beirut, LEBANON - 8) Lebanese University, Faculty of Pharmacy, Clinical and Epidemiological Research Laboratory, INSPECT-LB (Institut National de Santé Publique, d'Epidémiologie Clinique et de Toxicologie-Liban), Beirut, LEBANON

PURPOSE

Open ureteral reimplantation using Cohen and Lich-Gregoir techniques effectively manages high-grade unilateral primary vesicoureteral reflux (VUR), achieving clinical success rates between 68 and 100%. The aim of our study is to assess success rate and complications using these techniques.

MATERIAL AND METHODS

This is a multicenter retrospective cohort study including 377 children who had recurrent urinary tract infections (UTIs), diagnosed with unilateral VUR grade III-V, and treated surgically either by open Cohen or Lich-Gregoir ureteral reimplantation between 2010 and 2022. The success rate was defined by the absence of postoperative UTIs, and the complication rates were compared in both groups. Data analyses were performed using bivariate tests, event-free survival curves, and Cox regression analysis.

RESULTS

Among the children, 183 (48.5%) underwent the Cohen technique, and 194 (51.5%) received Lich-Gregoir ureteral reimplantation. VUR grade V, IV and III were seen in 59.4%, 31.3% and 9.3% of the patients respectively. Preoperative renal scars were observed in 18.3% of all cases, with a higher prevalence in the Cohen group (35.7%) compared to Lich-Gregoir (2.1%). Postoperative UTI rates showed no significant difference between the two techniques, with an unadjusted 1-year UTI-free rate of 76% for Cohen and 65% for the Lich-Gregoir (p=0.106), and this held even after controlling for demographic and clinical variables. Acute complications such as pain and hematuria were more common in the Cohen group (54.1% vs 27.8%, p<0.001, 47% vs 15.5%, p<0.001 respectively). Ureteral obstruction as long-term complication was higher in the Lich-Gregoir group (7.7% vs 1.1%, p=0.002), necessitating re-operation.

CONCLUSIONS

In high unilateral primary VUR, the open Cohen and Lich-Gregoir techniques achieved the same success rate. The Cohen technique was associated with decreased long-term morbidity, highlighting its true efficiency.


17:33 - 17:36
S21-6 (OP)

DIFFERENTIAL RENAL VOLUME MEASURED BY ULTRASOUND AS A PREDICTOR OF DIFFERENTIAL RENAL FUNCTION IN PATIENTS WITH UNILATERAL VESICOURETERAL REFLUX

Leopoldo TAPIA MORAL 1, Oriol MARTÍN-SOLÉ 1, Ainhoa LOMBARDERO HIDALGO 1, Blanca CAPDEVILA VILARÓ 1, Paula SALCEDO ARROYO 1, Sonia PÉREZ-BERTÓLEZ 1, Xavier TARRADO CASTELLARNAU 2 and Luis GARCÍA-APARICIO 1
1) Hospital Sant Joan de Déu (Barcelona), Pediatric Urology Unit, Pediatric Surgery Department, Barcelona, SPAIN - 2) Hospital Sant Joan de Déu (Barcelona), Pediatric Surgery Department, Barcelona, SPAIN

PURPOSE

Renal scintigraphy is routinely used to study renal impairment in patients with vesicoureteral reflux (VUR), but it is invasive and requires radiation exposure. The aim was to analyze whether differential renal volume (DRV) measured with ultrasound (US) was a good predictor of differential renal function (DRF) measured with DMSA scan.

MATERIAL AND METHODS

A retrospective review of all patients with VUR diagnosed in our hospital between January 2008 and May 2023. We registered: gender, VUR grade, laterality, comorbidities, US renal volume (measured as an ellipsoid volume), US differential renal volume (US-DRV) and DMSA-DRF. We excluded patients with bilateral reflux or comorbidities. The correlation between US-DRV and DMSA-DRF was studied.

RESULTS

A total of 921 patients were reviewed, of whom 147 had unilateral primary VUR and no comorbidities (83 females and 64 males): 81 were low grade (I-III) and 66 high grade (IV-V). The mean of DMSA-DRF was 32.9% (SD: 13.2) and the mean of US-DRV was 34.4 (SD: 13.1). US-DRV strongly correlated with DMSA-DRF, with an Intraclass Correlation Coefficient (ICC) of 0.94 (95%CI: 0.92-0.96), p<0.001. US-DRV overestimated DMSA-DRF by only 1.5% (95%CI: -10.4 to 13.5). The efficacy of US-DRV in predicting a DMSA-DRF<40% had an area under the ROC curve of 0.94 (95%CI: 0.90-0.97), with a sensitivity of 89.3% and a specificity of 89% using a cutoff point of US-DRV≤39.7%.

CONCLUSIONS

In patients with unilateral primary VUR, US-DRV seems to be a good predictor of DMSA-DRF. In this group of patients, US-DRV could be enough to predict the DRF, reserving DMSA scan for doubtful cases.


17:36 - 17:39
S21-7 (OP)

VISUAL ASSESSMENT OF ENDOSCOPIC VUR TREATMENT FAIL TO PREDICT OUTCOMES

Ömer Baris YÜCEL 1, Ali TEKIN 1, Sibel TIRYAKI 1, Denizay AVCI 2, Yigit OZEL 3 and Ibrahim ULMAN 1
1) Ege University, Department of Pediatric Surgery, Division of Pediatric Urology, İzmir, TURKEY - 2) Ege University, Department of Pediatric Surgery, Izmir, TURKEY - 3) Ege University, Department of Child Health and Diseases, Izmir, TURKEY

PURPOSE

The guidelines lack clarity on follow-up criteria after endoscopic therapy(ET) of VUR, especially regarding the need for VCUG. Risk-based approaches that consider patient characteristics, disease severity or factors related to the surgery itself, such as mound appearance or surgeon's experience could reduce the use of VCUG and the associated radiation exposure, but a satisfactory predictive model has not yet been established.Therefore, this study aims to evaluate if experts assessing surgical videos and other risk factors can predict treatment outcomes, potentially reducing the need for VCUG.

MATERIAL AND METHODS

Clinical data of 50 patients (75 renal units) from 2015-2021 were analyzed. Detailed medical history(including DMSA,USG,VCUG reports,voiding symptoms,presence of febrile UTI, etc.) and video records of the procedure were submitted to 5 expert surgeons with experience in over 1000 reflux cases. Experts rated the injection volume(IV), needle placement site (NPS), and the mound appearance (MA) on a 1-5 Likert scale and predicted the operation's obstruction and success(yes/no).

RESULTS

Consistent responses were observed for NPS (p<0.01), but not for IV and MA (p=0.055, p=0.077, respectively, Friedman test). The scores provided by all evaluators for NPS, IV, MA were consistent with their predictions for success (p>0.05 for all). However, none of the scores given by the evaluators for the three parameters were consistent with success (p> 0.05 for all). Using the Cohen's Kappa score, it was observed that none of the evaluators could predict success or obstruction (p> 0.05 for all).

CONCLUSIONS

Visual assessment of the operation, even with a comprehensive medical history,does not aid in predicting outcomes and cannot replace VCUG.Our study highlights the need for better criteria to be able to recommend individualized management strategies following ET of VUR to reduce the use of VCUG and the associated radiation exposure.


17:39 - 17:42
S21-8 (OP)

RISK OF UTI AFTER CYSTOGRAPHY IN A CONTEMPORARY PEDIATRIC POPULATION

Peter CAI 1, Tanya LOGVINENKO 2, Caitlynn FENG 2, Katelyn RALSTON 2, Caleb NELSON 2 and Julia FINKELSTEIN 2
1) Boston Children's Hospital, Paediatric urology, Boston, USA - 2) Boston Children's Hospital, Urology, Boston, USA

PURPOSE

Voiding cystourethrogram (VCUG), radionuclide cystogram (RNC) and contrast-enhanced voiding urosonography (CEUS) are associated with post-cystography urinary tract infection (PCUTI). We sought to determine the incidence of and risk factors for PCUTI in a contemporary population.

MATERIAL AND METHODS

A retrospective review of 1656 unique patients who underwent VCUG/RNC/CEUS at our institution (02/01/2021 – 08/15/2022) was performed. We excluded charts without access to regional primary provider records (n=681) and patients with at least 50,000 CFU/mL on urine culture from catheterization at time of cystography (n=60). PCUTI was defined as strict (fever + pyuria on urinalysis + at least 50,000 CFU/mL on urine culture) or pragmatic (included patients with high clinical suspicion for PCUTI prompting treatment) within 30 days of cystography. Clinical data were tabulated based on pragmatic definition of PCUTI and associations analyzed using chi-square and Fisher’s exact test.

RESULTS

Analysis included 913 patients with median age of 1.42 years (IQR 0.2 to 4.3). Seventeen patients (1.9%) met strict definition for PCUTI and 33 (3.6%) met the pragmatic definition. Patient with PCUTI were more likely to have parenchymal abnormalities on pre-cystography ultrasound (41.4% vs 22.4%, p=0.017) and have vesicoureteral reflux (VUR) but not be on continuous antibiotic prophylaxis (CAP) at the time of cystography (33.3% vs. 19.1%, p=0.035).

CONCLUSIONS

PCUTI occurs in 3.6% of patients within 30 days of undergoing cystography. Parenchymal abnormalities on prior ultrasound and having VUR but not being on CAP is associated with developing PCUTI. Identifying these risk factors will allow for improvement in our counseling and management of patients undergoing cystogram.


17:42 - 17:55
Discussion