Renal involvement in children with vesicoureteral reflux: are prenatal detection and surgical approaches preventive?

Objective. Surgical correction of vesicoureteral reflux (VUR) and prolonged administration of antibiotics seem to lead to similar renal outcomes. However, it is not known whether prenatal recognition and the position of VUR modify the outcome in different ways. The purpose of this study was to investigate the effects of prenatal detection and different treatment methods on the outcome of unilateral refluxing renal units. Patients and methods. This retrospective study enrolled 119 children (mean age 2.8+/-3.5 years) with primary VUR. Kidney growth and renal function were measured with ultrasound and scintigraphy, respectively. To compare the ultrasound readings among patients of different ages the comparative-length index or index was calculated, as a percentage of the ratio of unilateral and the sum of bilateral renal length. Results. In unilateral refluxing renal units there was a reduction in both index and function, whereas not-refluxing was increased. In the follow-up, unilateral refluxing renal units had a worse index, whereas not-refluxing was better. Unexpectedly, surgical therapy of the left-refluxing renal unit led to a reduction in the index, whereas its function always stayed low in diagnosis but stable. The outcome of severely refluxing renal units was similar after both interventions. Prenatal and postnatal diagnosis did not seem to modify the renal result. Conclusions. Surgery showed similar renal outcomes to medical treatment. A kidney growth defect from high-grade VUR was detected in the diagnosis. Therefore, a congenitally damaged kidney does not ameliorate after each treatment. Finally, prenatal detection of VUR does not seem to modify the outcome of the kidney significantly.     

Correction of vesicoureteral reflux: where do we stand?

PURPOSE OF REVIEW: Newer techniques of molecular biology allow us to gain a better understanding of the molecular mechanism of primary urinary reflux. In recent years, diagnostic tools and treatment options for vesicoureteric reflux have dramatically changed. In this review, we want to focus on genetics, molecular biology, histology, clinical findings, diagnostic tools and newer surgical techniques for the treatment of vesicoureteric reflux published between 2003 and March 2004. RECENT FINDINGS: Recent findings have demonstrated that the renin-angiotensin-aldosterone system does not seem to be responsible for the development of primary vesicoureteric reflux. Echo-enhanced ultrasound with contrast medium in the bladder, performed by an experienced investigator, could replace the voiding cystourethrogram in follow-up studies of patients treated conservatively for vesicoureteric reflux. The sensitivity and specificity of ultrasound is in the range of 70-100% in some studies compared with the standard voiding cystourethrogram. Endoscopic treatment of vesicoureteric reflux using Defux or Macroplastique has gained more and more popularity, with success rates ranging between 60 and 86%. The surgery is performed on an outpatient basis with minimal morbidity. Long-term results after open operative techniques have demonstrated cure of reflux in over 95% of cases. SUMMARY: In the coming years, echo-enhanced ultrasound may replace the standard voiding cystourethrogram during follow-up and it may be used as an initial test in females with normal voiding patterns. Endoscopic reflux correction must be judged on the re-treatment rates and long-term success.     

Which cystography in the diagnosis and grading of vesicoureteral reflux?

The gold standard procedure for the evaluation of vesicoureteral reflux (VUR) is the radiographic voiding cystourethrography (VCUG); direct radionuclide voiding cystography (DRVC) is an alternative method for detecting VUR. A new imaging procedure, voiding urosonography (VUS) with contrast medium, has recently been introduced. We have carried out a comparative study of these three techniques in 157 patients (aged 6 weeks–4.7 years). VUS showed the presence of VUR in 91 of 311 renal units; VCUG detected reflux in 64 of 233 renal units, and the DRVC in 23 of 78 renal units. VCUG and VUS were compared in 118 patients, and both procedures showed the same grade of reflux in 56 refluxing units (kappa value 0.92); in six cases the reflux grade was greater at VUS than at VCUG. Seven cases of reflux detected by VUS were not identified on VCUG. VCUG did not show a grade of VUR that was higher than in VUS in any patient. In the identification of 4°–5° grade reflux, the sensitivity of VUS reached 100%. VUS and DRVC were found to be equally effective in the detection of VUR (kappa value 0.85). In conclusion, we found that VUS is a useful method for the diagnosis and grading of patients with VUR.     

What have we learned about traumatic diaphragmatic hernias in children?

BACKGROUND/PURPOSE: Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. The aim of this retrospective study was to identify pitfalls in the diagnosis and treatment of these injuries in children. METHODS: Data were collected from all patients admitted to the trauma service with traumatic diaphragmatic hernias for the period of January 1977 to August 1998. The authors evaluated 15 cases of traumatic diaphragmatic rupture (6 girls and 9 boys). RESULTS: Mean age was 7.5 years (range, 3 weeks to 15 years). Thirteen patients suffered from blunt trauma, and 2 patients suffered from penetrating trauma. The right and left hemidiaphragms were injured equally (7 patients each), with 1 additional patient suffering from bilateral injuries. All but 1 patient had laparotomies for trauma (n = 14). The diagnosis was made preoperatively in 8 patients (53%) with just a chest radiograph. Computed tomography (CT) scan, magnetic resonance imaging (MRI), and oral contrast studies were used as ancillary tests to diagnose traumatic diaphragmatic rupture. There were 3 missed injuries. Associated injuries included liver lacerations (47%), pelvic fractures (47%), major vessels tear (40%), bowel perforations (33%), long bone fractures (20%), renal lacerations (20%), splenic lacerations (13%), and closed head injuries (13%). The mean hospital stay was 20 days (range, 7 to 60 days). Complications were observed most commonly in those patients with multiple injuries and included postoperative ileus (40%), pneumonia (30%), pancreatitis (20%), wound infection (20%), intestinal obstruction (20%), cholestasis (10%), and renal failure (6%). Five deaths (33%) were caused by hemorrhagic shock, respiratory failure, coagulopathy, and refractory acidosis. CONCLUSIONS: Traumatic diaphragmatic hernias usually are associated with serious injuries in children. It is important to combine a high index of suspicion with radiological diagnostic tests in patients at risk. Palpation and/or visualization of both diaphragms at laparotomy is extremely important in detecting these injuries when they are not suspected preoperatively.     

Does deflux alter the paradigm for the management of children with vesicoureteral reflux?

The recent approval by the US Food and Drug Administration of Deflux (Q Med, Uppsala, Sweden), a particulate biodegradable polymer of dextran, has led to an understandable enthusiasm for treating children with vesicoureteral reflux by a routinely simple outpatient endoscopic procedure. However, Deflux is but one of a variety of particulate substances, both permanent and absorbable, that have been used to treat reflux in Europe for well over a decade with varying degrees of success. The purpose of this review is to place Deflux in this wider context to anticipate what can be expected realistically regarding the efficacy and potential hazards of this seductive technique and to make recommendations regarding its incorporation, in selected cases, in our therapeutic armamenftarium.     

New trends in voiding cystourethrography and vesicoureteral reflux: Who,when and how?

Vesicoureteral reflux, retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urological diagnoses in the pediatric population. Diagnosis and subsequent management of urinary reflux have become increasingly debated in the past decade, with divergent opinions over which patients should be evaluated for reflux, and when detected, which children should receive intervention. Although some argue that vesicoureteral reflux is a “phenotype” that often resolves without intervention, others contest that untreated reflux has the potential to cause irreversible renal damage over time. Voiding cystourethrogram images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when reflux is present, and is considered the gold standard for diagnosing vesicoureteral reflux. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without low‐dose antibiotic prophylaxis to a variety of operative interventions. Management should be based on a multitude of factors including patient age, risk of subsequent urinary tract infections, risk of renal parenchymal injury, a given child's projected clinical course and parental preference. Over the past two decades, investigators have elucidated many crucial voiding cystourethrogram findings in addition to grade that provide significant prognostic information and are useful in determining the best course of action for a child on a more individualized basis.     

The “incidental anesthetic” — an opportunity for the endoscopic correction of vesicoureteral reflux in children

Introduction:

The endoscopic management of vesicoureteral reflux (VUR) with subureteric injection (STING) has become more popular. The low morbidity associated with the STING procedure has led to some authors advocating its use as a first-line therapy. Many parents are uncomfortable with this procedure being performed in children because of the potential morbidity associated with general anesthesia. We present an alternative without added anesthetic morbidity: offering the parents a STING when their child is undergoing an anesthetic for another surgical indication.

Methods:

We reviewed the records of 10 children who underwent incidental dextranomer/hyaluronic acid copolymer (DHA) injection over a 2-year period.

Results:

We considered the treatment outcome after a single STING procedure to be successful in 8 (80%) patients and a failure in 2 (20%). Distribution of VUR grade, according to the highest grade per patient, was high in 5 (50%) patients, moderate in 3 (30%) and low in 2 (20%). We observed no complications.

Conclusion:

The idea of performing STING in children under incidental anesthetic introduces yet another possibility in the paradigm of VUR care. Though the long-term efficacy of DHA remains to be determined, this option reduces the potential morbidity of DHA as first-line therapy while favourably altering the cost benefit.     

Cochlear implants in children: What constitutes a complication?

The surgeon must ultimately accept the responsibility for any complications that occur as the result of a cochlear implant. Listening to the cochlear implant team members and responding to their needs may enhance the child’s progress. Surgical complications, (i.e., skinflap problems, infection, and facial paralysis) are indeed infrequent, but nonsurgical problems are not. Surgical and nonsurgical experiences were reviewed in 55 children. Ages ranged from 23 months to 18 years at the time of cochlear implantation, which occurred from 1984 to 1995. There were no surgical complications. However, the most common surgical obstacle was ossification, which was present in 40% and undetected by computed tomographic scanning in 16.3% of children. Ossification occurred at the round window and scala tympani in 32.7% and involved the cochlea more extensively in 7.3% of children. In only one child was the cochlea entirely ossified. There were, however, many nonsurgical problems that were viewed as complications in patient management. The single most important complication was device failure. This occurred in 10.9% (5/46) of children with the Cochlear Corporation multichannel implant. Head banging and other temper tantrums, parental interference with rehabilitation, socioeconomic factors, poor compliance by the family unit, equipment problems, educational deficiencies, and impatience with habilitative training were some of the other problems. (Otolaryngol Head Neck Surg 1997;117:243-7.)     

TGF-β1 gene polymorphisms and primary vesicoureteral reflux in childhood

The aim of this study was to assess the association between the transforming growth factor-β1 (TGF-β1) gene polymorphisms rs1800469 (commonly known as T-509C) and rs1982073 (commonly known as Leu ¹⁰→Pro) and primary vesicoureteral reflux (VUR) and renal scarring. Using a case–control approach, we examined 121 children with primary VUR and 169 controls. Genotyping of the TGF-β1 gene polymorphisms was performed by restriction fragment length polymorphism (RFLP) analysis. The ^99mTc-DMSA– or ^99mTc-unitiol–single photon emission computed tomography method was used to evaluate renal scars in 84 of 121 VUR children. Statistical analysis revealed differences in rs1800469 genotype frequencies between VUR patients and controls (p = 0.0021). Our data demonstrate that individuals homozygous for the TT genotype are at risk of primary VUR [odds ratio (95% confidence interval) = 2.7 (1.46–5.08)]. Distribution of the rs1982073 polymorphism was similar in VUR children and controls. In terms of renal scarring, patients were stratified into non-scar and scar subgroups, and no differences in the genotype frequencies of either polymorphism was found. Previous reports have shown that the TT genotype of the rs1800469 polymorphism is a risk factor for renal scarring in primary VUR, and the results of our study suggest that this same polymorphism is associated with susceptibility to this congenital uropathy.     

Endoscopic management of vesicoureteral reflux: does it stand the test of time?

Endoscopic subureteral injection of tissue-augmenting substances, a 15-minute outpatient procedure has become an alternative to long-term antibiotic prophylaxis and surgical intervention in the treatment of vesicoureteral reflux (VUR) in children. This paper reviews the long-term results of endoscopic treatment of reflux using various tissue-augmenting substances presently available. In terms of effectiveness and long-term successful results, polytetrafluoroethylene is still the most reliable injectable material for the endoscopic treatment of VUR.