ESPU Meeting on Friday 19, June 2026, 10:30 - 11:15
10:30 - 10:33
S21-1 (CP)
Jin Kyu (Justin) KIM 1, Rosalia MISSERI 1, Joshua ROTH 1, Konrad SZYMANSKI 1, Nikhil BATRA 1, Martin KAEFER 1, Mark CAIN 1, Richard RINK 1, Kirstan MELDRUM 1, Benjamin WHITTAM 1, Pankaj DANGLE 1, Shaobo ZHANG 2 and David HAINS 2
1) Riley Hospital for Children, Urology, Indianapolis, USA - 2) Riley Hospital for Children, Nephrology, Indianapolis, USA
PURPOSE
Recurrent urinary tract infections (UTIs) in children are most often caused by Escherichia coli, whereas non-E. coli pathogens are linked with greater morbidity and higher recurrence risk. Host and anatomic factors such as vesicoureteral reflux (VUR) and bladder and bowel dysfunction (BBD) are well established, but the role of genetic variation is incompletely understood. The DEFA1A3 locus encodes neutrophil α-defensins, antimicrobial peptides central to innate immunity at mucosal surfaces. Copy number variation (CNV) at DEFA1A3 has been implicated in infection susceptibility, with higher copy number hypothesized to alter peptide expression and microbial clearance. We sought to evaluate the role of DEFA1A3 CNV, DMBT1 CNV, and RANSE7 polymorphism (rs1263872) in children with and without VUR, using data from the RIVUR and CUTIE cohorts.
MATERIAL AND METHODS
We analyzed 303 RIVUR participants with available genetic data. Covariates included sex, age, BBD status, VUR grade (high vs. low), and genetic markers. Logistic regression identified independent predictors of non-E. coli UTI. Separately, 160 CUTIE children with genetic information were evaluated. Since CUTIE excluded VUR, regression included age, sex, BBD, and DEFA1A3 CNV. The outcome was pathogen type (E. coli vs. non-E. coli) at index UTI.
RESULTS
In RIVUR, 11.2% of children had a non-E. coli UTI. Multivariate regression identified significant predictors: female sex (OR 0.151, 95% CI 0.41–0.551, p=0.004), high-grade VUR (OR 2.487, 95% CI 1.116–5.544, p=0.026), and DEFA1A3 CNV ≥5 (OR 0.446, 95% CI 0.201–0.991, p=0.047). DMBT1 CNV and rs1263872 were not significant. In CUTIE, 8.75% presented with non-E. coli UTI. Regression showed no association between DEFA1A3 CNV and infection (OR 4.312, 95% CI 0.805–23.079, p=0.088) after adjusting for age (OR 1.066, 95% CI 1.019–1.114, p=0.005) and female sex (OR 0.137, 95% CI 0.030-0.625, p=0.021).
CONCLUSIONS
Higher DEFA1A3 copy number, a marker of innate immune defense, was significantly associated with non-E. coli UTI in children with VUR but not in those without reflux. These results suggest that the interaction between genetic predisposition and urinary tract anatomy modulates pathogen susceptibility. Integrating genetic markers with clinical features may enhance prediction of infection risk and inform tailored management strategies in pediatric UTI.
10:33 - 10:36
S21-2 (CP)
Jin Kyu (Justin) KIM, Lydia HERMANN, Zachary EARDLEY, Renee SHAVNORE, Konrad SZYMANSKI, Rosalia MISSERI, Nikhil BATRA, Martin KAEFER, Martin KAEFER, Richard RINK, Joshua ROTH, Kirstan MELDRUM, Benjamin WHITTAM and Pankaj DANGLE
Riley Hospital for Children, Urology, Indianapolis, USA
PURPOSE
Voiding cystourethrography (VCUG) is traditionally used to detect vesicoureteral reflux (VUR) following febrile urinary tract infection (UTI) in children. The 2011 American Academy of Pediatrics (AAP) guideline recommends against routine VCUG after the first febrile UTI, reserving it for cases with abnormal renal and bladder ultrasonography (RBUS), atypical clinical courses, or recurrent infections. However, identifying subgroups at higher risk for abnormal VCUG findings may optimize early detection and guide individualized imaging strategies.
MATERIAL AND METHODS
We retrospectively evaluated infants/children (2-24 months) who underwent a VCUG after a symptomatic, culture proven first UTI over 3-year period (2022-2024) who presented to outpatient urology clinic. We conducted a logistic regression analysis using a backward stepwise likelihood ratio approach to evaluate predictors of high grade VUR on VCUG. Candidate variables included sex/circumcision status, febrile presentation, infecting organism, hydronephrosis, prior antibiotic exposure (treatment or prophylaxis), any hospitalization within 30 days of UTI, constipation, prophylaxis, and demographic factors.
RESULTS
We identified 115 first UTIs (82 febrile) among children presenting between 2 to 24 months of age (18.4% male, 78.6% circumcised). Among them, 23.9% had high grade VUR. In the initial model, multiple variables were entered, but only three remained significant in the final step. Female sex was the strongest predictor of high grade VUR on VCUG (OR 21.6, 95% CI 2.5–188.5, p=0.005 [ref: uncircumcised males]). Infection with a non–E. coli organism was also independently associated with increased risk (OR 3.0, 95% CI 1.05–8.37, p=0.040). Hydronephrosis, already emphasized in the AAP guideline as abnormal finding on RBUS, was confirmed as a relevant independent predictor (OR 2.8, 95% CI 1.08–7.23, p=0.035). Other variables, including febrile presentation, race, prophylaxis, or hospitalization, were not significant after adjustment.
CONCLUSIONS
While the AAP guideline appropriately limits routine VCUG, presentation with non–E. coli UTI indicate an independent risk factor for high grade VUR. In this cohort, consideration of early VCUG may enhance timely identification of clinically significant VUR. These results support a more individualized, risk-based approach to imaging that integrates guideline recommendations.
10:36 - 10:39
S21-3 (CP)
Mandy RICKARD 1, Gillian HUNTER 2, Joana DOS SANTOS 1, Nithiakishna SELVATHESAN 3, Adree KHONDKER 1, Samer MAHER 1, Jin Kyu KIM 1, Michael CHUA 1, Ailish COBLENTZ 1 and Armando J. LORENZO 1
1) SickKids, Urology, Toronto, CANADA - 2) SickKids, Radiology, Toronto, CANADA - 3) SickKids, Nephrology, Toronto, CANADA
PURPOSE
In 2024, the Urology and Radiology departments at our Institution enforced triaging VCUG (voiding cystourethrogram) requests following standardized criteria, including confirmed febrile UTI (as defined by AAP and CPS guidelines) and hydroureteronephrosis. We evaluated whether this novel process reduced low-value testing while maintaining detection of clinically meaningful outcomes.
MATERIAL AND METHODS
Consecutive VCUG referrals from 2019 (historical), 2023–24 (pre-implementation), and 2024–25 (current) were reviewed. Patient demographics, VCUG indication, ultrasound findings and confirmatory evidence of UTI were captured. Definite indications (PUV, neurogenic bladder) were excluded. Outcomes included urology triage rate, test appropriateness, vesicoureteral VUR detection, and VUR surgery rates. Referring providers of declined VCUGs were advised to refer to urology.
RESULTS
A total of 721 VCUG requests (60% male; median age of 6 [6, 27] months) were included. Primary indications were UTI (69%), hydroureteronephrosis (16%) and hydronephrosis (15%). Urology triage increased from 42% (2019) and 50% (2023–24) to 80% in 2024–25 (p<0.01). The proportion undergoing VCUG fell from 100% to 84.3% (p<0.01), indicating prevention of avoidable studies. VCUGs meeting criteria improved from 53.1% (2019) to 72.2% (2024–25, p<0.01). VUR detection rose from 35.7% (2019) to 50.0% (2024–25, p<0.01), while VUR surgery rates remained stable (46.7% to 41.7%, NS).
| 2019 (n=258) (%) | 2023-24 (n=233) (%) | 2024-25 (n=230) (%) | p | |
| Sex (male) | 133 (52) | 152 (65) | 144 (63) | 0.04 |
| Age (median, IQR) | 8 (2, 36) | 4 (1, 16) | 6 (2, 33) | <0.01 |
|
Ordered by: - Community provider - Hospital Specialist |
140 (54) 118 (46) |
101 (43) 132 (57) |
98 (43) 132 (57) |
0.014 |
|
Indication: - UTI - HUN - HN |
161 (62) 32 (13) 65 (25) |
159 (68) 51 (22) 23 (10) |
180 (78) 33 (14) 17 (7) |
<0.01 |
| UTI confirmed | 107 (66) | 103 (44) | 135 (75) | <0.01 |
| Reviewed/ordered by Urology | 109 (42) | 117 (50) | 182 (80) | <0.01 |
| Meets criteria | 137 (53) | 155 (67) | 166 (72) | <0.01 |
| VCUG done | 258 (100) | 233 (100) | 193 (84) | <0.01 |
| VUR | 92 (36) | 101 (43) | 97 (50) | <0.01 |
| VUR surgery | 42 (46) | 45 (45) | 40 (42) | 0.85 |
CONCLUSIONS
Urology-led triage reduced invasive testing without reducing diagnostic or surgical yield. This stewardship model focuses on the reduction of radiation exposure, optimizes scenarios where VCUG results change management, and proposes a novel approach to specialized radiological testing.
10:39 - 10:42
S21-4 (CP)
Emelie WIDHE 1, Mette HAMBRAEUS 2, Erik HEDSTRÖM 3, Anna BÖRJESSON 2 and Martin Jonathan SALO 2
1) Departemet of Pediatric Surgery, Skåne University Hospital, Lund, Swedennt, Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden, Lund, SWEDEN - 2) Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden, Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden, Lund, SWEDEN - 3) Department of Radiology, Skåne University Hospital, Lund, Sweden, Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Sweden, Lund, SWEDEN
PURPOSE
Voiding cystourethrography (VCUG) is a very common investigation for children with anatomical or functional conditions in the urogenital tract. Urinary tract infection (UTI) is the most common and significant complication after VCUG but the reported incidence in children varies highly. Therefore, the aim of this study was to evaluate the rate and possible risk factors for post VCUG UTI.
MATERIAL AND METHODS
Ethical approval was obtained. A multicenter retrospective cohort study of children < 15 years of age undergoing VCUG in five hospitals between 2017-2022 was conducted. All VCUGs were evaluated by a pediatric radiologist. Primary outcome was lower UTI (cystitis) and febrile UTI (pyelonephritis) within 14 days of the VCUG, and they were defined by clinical assessment and a positive urinary culture. Independent variables were age, sex, underlying known urogenital malformation or other condition, presence of any type of bladder drainage before the examination such as an urinary or suprapubic catheter, constipation, previous febrile UTI, continuous antibiotic prophylaxis (CAP) and type, pre-VUCG antibiotic prophylaxis and type, VCUG findings. Risk factors were assessed with multiple regression analyses.
RESULTS
Overall, 1 001 examinations were included (median age 1 year, 52% boys). Previous febrile UTI was present in 58 %. Pathology on VCUG was found in 47% of children of which 83% had vesicoureteral reflux (VUR). Post VCUG UTI occurred in 34 (3.4%) children within 14 days, of which 60% were within 7 days, and 88% were febrile. A post VCUG UTI was only seen in 5 (0.01%) examinations in children without pre-existing conditions or absence of VUR. Pre-procedural antibiotics did not lower the risk of UTI. Only dilating VUR (grade III-V) increased the risk for post VCUG UTI (adjusted odds ratio 5.4 [2.6 - 8.7] p<0.001).
CONCLUSIONS
There was a low overall rate of post VCUG UTIs. Dilated VUR was the only significant risk factor identified. Since these children is at risk for chronic kidney injury, targeted interventions after VCUG could possibly lower additional UTIs in this group.
10:57 - 11:00
S21-5 (CP)
Onur Can OZKAN 1, Türker ALTUNTAŞ 2, Mehmet ÇETİN 2, Çağrı Akın ŞEKERCİ 1, Kamil ÇAM 2, Tufan TARCAN 3 and Selçuk YÜCEL 1
1) Marmara University School of Medicine, Department of Urology, Division of Pediatric Urology, İstanbul, TÜRKIYE - 2) Marmara University School of Medicine, Department of Urology, Istanbul, TÜRKIYE - 3) Marmara University School of Medicine, Koç University School of Medicine, Department of Urology, Istanbul, TÜRKIYE
PURPOSE
This study aimed to compare the findings of PIC (Positioning the Instillation of Contrast) cystography performed during endoscopic procedures with VCUG results in children who underwent VCUG (Voiding cystourethrography) for urinary tract infection (UTI) or other indications, as well as in a control group of children who did not require VCUG.
MATERIAL AND METHODS
Between January 2024 and January 2025, PIC cystography was prospectively performed during endoscopic surgery in children with and without prior VCUG. The procedure was performed in a standardized manner by a physician blinded to the VCUG results. Using a 9 Fr pediatric cystoscope placed near each ureteral orifice, contrast medium was instilled by gravity from a height of 1 meter under fluoroscopic monitoring, and the presence of VUR was recorded. Reflux detected by VCUG and PIC cystography was classified as low-grade (Grade 1–3) or high-grade (Grade 4–5). The diagnostic performance of VCUG and PIC cystography was compared.
RESULTS
A total of 67 children (mean age 8.9 ± 4.59 years; 36 boys, 53.7%; 31 girls, 46.3%) were included. Among 49 children who underwent VCUG for UTI or other reasons, VUR was detected in 42 of 98 renal units (42.85%) (34 low-grade, 8 high-grade). PIC cystography detected VUR in 38 renal units (38.77%). In 11 units without VUR on VCUG, VUR was demonstrated by PIC cystography, while 15 units with VUR on VCUG showed no reflux on PIC cystography. Of the 11 units with VUR detected only by PIC cystography, 2 had renal scarring and 5 had hydronephrosis. Correlation analysis of both methods across all renal units showed a kappa score of 0.347. Of the units with VUR identified only on PIC cystography, 8 were low-grade; renal scarring was present in 2 and hydronephrosis in 2 (p = 0.077). There was no significant difference between the two methods in detecting low-versus high-grade VUR (p = 0.557) (Table 1). No reflux was detected by PIC cystography in the 18 children who did not require VCUG.
Table 1. Number of Renal Units Diagnosed with VUR by VCUG and PIC Cystography
| PIC Cystography | ||||
| VCUG | Absent | Present | Overall | |
| Absent | 45 | 11 | 56 | |
| Present | 15 | 27 | 42 | |
| Overall | 60 | 38 | 98 | |
| p=0.557 | ||||
CONCLUSIONS
PIC cystography and VCUG findings showed low correlation. The fact that 35.4% of refluxes detected by VCUG were not identified by PIC cystography limits its reliability. Although PIC cystography revealed reflux in 19.6% of renal units where VCUG was negative, the majority (8/11) were low-grade, suggesting that the clinical utility of this technique may be limited.
11:00 - 11:03
S21-6 (CP)
Phani AARE 1, Chandrasekharam VVS 1 and Ramesh BABU 2
1) Ankura Hospitals for women and children, Paediatric Surgery, Paediatric Urology and Minimal Access Surgery, Hyderabad, INDIA - 2) SRIHER, Pediatric urology, Chennai, INDIA
PURPOSE
Children with renal cortical scarring and negative voiding cystourethrography (VCUG) represent a diagnostic challenge. While some manage these conservatively with prophylactic antibiotics alone some favor positional instillation of contrast (PIC) cystography followed by endoscopic treatment (ET). We hypothesized that early detection and intervention would reduce breakthrough infections and prevent progressive renal damage.
MATERIAL AND METHODS
This retrospective comparative study was conducted at two tertiary pediatric surgical centers (2018-2022) with institutional review board approval. Sixty-one children (age 1.3-9 years; 42 females, 19 males) with recurrent febrile urinary tract infections (fUTIs) and renal scarring on dimercaptosuccinic acid (DMSA) scan but no vesicoureteral reflux (VUR) on VCUG were included. Patients were stratified based on parental preference: Group A (n equal to 31) conservative treatment: only antibiotic prophylaxis; Group B (n equal to 30) active intervention: PIC cystography with immediate dextranomer/hyaluronic acid (Dx/HA) injection if VUR detected. Groups were comparable in age, sex, prior fUTI frequency, and DMSA scar grade. PIC cystography was performed under general anesthesia using pediatric rigid cystoscopy with targeted contrast instillation, Trendelenburg positioning (15-20 degrees), and hydrostatic pressure (100 cm elevation). Primary outcomes were fUTI recurrence and new renal scars on follow-up DMSA (median follow-up 24 months, range 12-36).
RESULTS
PIC cystography identified VUR in 26/30 (86%) Group B patients (Grades I-III; all unilateral).
During follow-up, 13/31 (41.9%) children in Group A developed fUTIs; PIC subsequently revealed VUR in all, and each received Dx/HA. In Group B, 1/30 (3.3%) developed an fUTI after PIC plus or minus Dx/HA (p equal to 0.001).
The absolute risk reduction (ARR) was 38.6%, number needed to treat (NNT) equal to 2.6 (95% CI: 1.8-5.0) .
Overall, 39 children ultimately received Dx/HA (26 initial plus 13 cross-overs). Of these, 38/39 (97.4%, 95% CI 86.8-99.6%) remained infection-free after treatment, and no new renal scars developed in any treated child (0/39). Minor complications included transient haematuria (15.4%) and temporary urinary retention (5.1%); no major complications occurred.
CONCLUSIONS
PIC cystography demonstrates good sensitivity for detecting occult VUR in children with unexplained renal scarring. Early identification and endoscopic treatment significantly reduce fUTI recurrence compared to antibiotic prophylaxis (NNT equal to 2.6) and prevents progressive renal damage. These findings support incorporating PIC cystography into diagnostic algorithms for high-risk children with DMSA-positive, VCUG-negative findings.