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1256 TIMING OF RADIOLOGIC REFLUX ON VOIDING CYSTOURETHROGRAM PREDICTS HYDRODISTENTION GRADE BUT DOES NOT PREDICT SHORT TERM TREATMENT OUTCOMES
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THE JOURNAL OF UROLOGY姞
8 cm). Seventy-four patients had simple cysts while 25 had complex cysts (septations, irregular shaped, calcifications, thick walled cysts, or debris filled). Forty patients had 61 CT and 10 MRI scans ordered as part of evaluation and subsequent management. Size concordance (⫾ 3mm) between initial US and initial axial imaging was present in 29/40 (73%) cases. Cyst characteristics were concordant in 29/40 (73%) of cases; 22 showing simple cysts and 7 showing complex cysts. Of the 11 remaining patients, 7 patients had complex cysts on US and simple cyst by axial imaging while 4 patients had complex cyst on axial imaging and simple cyst on RUS. Twenty-eight patients had growth of their cyst during follow-up, while 22 patients did not have the cyst identified on subsequent imaging. Ten patients underwent surgical exploration, mostly for concern over cyst features, with all specimens revealing benign tissue. CONCLUSIONS: Solitary renal cysts are a benign clinical entity with no malignant elements noted on surgical specimens in our series. 22% of simple cysts identified in our series were not visible on subsequent imaging. Axial imaging has a reasonable concordance with US findings. Omitting CT scans performed to characterize simple solitary renal cysts in a pediatric population can limit radiation exposure while not compromising quality care. Source of Funding: None
1256 TIMING OF RADIOLOGIC REFLUX ON VOIDING CYSTOURETHROGRAM PREDICTS HYDRODISTENTION GRADE BUT DOES NOT PREDICT SHORT TERM TREATMENT OUTCOMES Justin Watson*, Jonathan Kaye, Hal Scherz, Andrew Kirsch, Atlanta, GA INTRODUCTION AND OBJECTIVES: Low pressure, early cycle reflux on VCUG is associated with a low chance of spontaneous resolution when compared to late filling or voiding reflux. We sought to determine if the timing of VUR on VCUG 1)correlates with ureteral hydrodistention (HD) grade and 2) predicts the outcome of endoscopic surgery. METHODS: The records of 115 patients consecutively treated by two surgeons by the HIT injection method for VUR were examined. Twenty-five patients were excluded due to lack of VCUG, leaving 90 patients with 132 refluxing ureters. All VCUGs were examined by a urologist and radiologist for grade and timing of reflux. Sixty three (48%) of refluxing ureters or 44/90 patients were studied with more than one VCUG prior to intervention. Fourteen patients underwent three or more preoperative VCUGs. Each preoperative VCUG was examined for timing of VUR. Intraoperative hydrodistention grades (HD) were recorded for each ureter and a three month postoperative VCUG was obtained on each patient. RESULTS: Average time between first VCUG and operative intervention was 328 days. The timing of reflux on both initial VCUG and immediately preoperative VCUG was statistically significantly correlated with HD grade intraoperatively. Severity of reflux on initial VCUG correlated with severity of HD grade (Somers’D 0.004) when classified by “early/ late/voiding” and (Somers’D 0.052)when classified by “filling, voiding”. Severity of reflux on immediately preop VCUG correlates with severity of HD grade (Somers’D 0.032) when classified by “early/late/voiding” but is not significant when classified by “filling/ voiding” (Somers’D 0.302). The success rate of endoscopic treatment per ureter for early filling reflux, late filling reflux and voiding reflux based upon initial VCUG was 90.9% (40/44), 82.8% (53/64) and 93.3% (14/15) respectively. These differences were not significant (Pearson’s Chi-square 0.539). Categorized by only filling or voiding reflux, these success rates are 86.1% (93/108) and 93.3% (14/15) (Pearson chisquare 0.726). CONCLUSIONS: A uniformly high surgical success was achieved despite the timing of reflux during the bladder cycle or degree of ureteral HD. Our data confirm the anatomic basis for low pressure,
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
early cycle reflux and delayed spontaneous resolution as abnormally high ureteral HD. These data support the need for standardized radiographic reporting. Source of Funding: None
1257 ULTRASOUND RENAL PARENCHYMAL AREA CORRELATES WITH REFLUX RESOLUTION IN CHILDREN WITHOUT URINARY TRACT INFECTION Ilene Wong*, Curtis Clark, Tin Ngo, Jen-Jane Liu, Hsi-Yang Wu, Linda Shortliffe, Stanford, CA INTRODUCTION AND OBJECTIVES: Age, reflux grade, gender and the presence of renal damage on dimercapto-succinic acid (DMSA) scan are reported to be prognosticators of spontaneous vesicoureteral reflux (VUR) resolution. Previously, we have shown ultrasound renal parenchymal area (US-RPA) to correlate with DMSA determined renal function in children with VUR. We examined whether US-RPA could predict reflux resolution in children with reflux without history of urinary tract infection (UTI). METHODS: With institutional review board approval, we retrospectively reviewed charts of children who had a VCUG performed from 2001-2008 with VUR and no history of UTI; those with other abnormalities such as neurogenic bladder and posterior urethral valves, cardiac anomalies, lack of follow-up VCUG, or history of febrile illnesses were excluded. Renal bladder ultrasound (RBUS) images for these patients were obtained. Static ultrasound images were captured in .bmp format and imported into imaging software for US-RPA measurement as previously described. Charts were reviewed to assess reflux resolution or persistence. Multiple regression controlling for age and grade of reflux was performed to compare the US-RPA of refluxing renal units in children with VUR resolution versus those without. RESULTS: 57 children were found to have VUR without history of UTI. Of these 7 were lost to follow-up and 5 did not have repeat VCUG. The 45 patients remaining had 74 refluxing renal units with an average reflux grade of 3.12 (median grade 3). Initial VCUG was performed for sibling reflux in 8, ear tag in 1, and antenatal hydronephrosis in 36. Children had urologic follow-up to an average of 2.9 years of age (20.1 months of mean follow-up after diagnosis), at which time 44 renal units showed spontaneous resolution of reflux, with 21 units progressing to surgery and 9 showing persistent reflux. Analyzed by grade of reflux, 0/4 (0%) of Grade V, 12/22 (55%) of Grade IV, 22/32 (69%) of Grade III and 10/16 (63%) of units with Grade I or II resolved. Multiple regression analysis showed grade of reflux (p⫽0.01), age (p⬍0.0001) and initial US-RPA (p⫽0.01) to be associated with reflux resolution. When Grade V refluxing units were removed from analysis, grade of reflux was not associated with reflux resolution (p⫽0.17) but correlation with initial US-RPA (p⫽0.04) and age (p⬍0.0001) remained. CONCLUSIONS: In this study limited to children with VUR without UTI, larger US-RPA was associated with reflux resolution. Further analysis with a greater number of children is needed to confirm a role for US-RPA as a prognostic factor in VUR resolution. Source of Funding: None
1258 IDENTIFICATION OF URINARY SUBSTANCE P LEVEL AS A BIOMARKER FOR BLADDER SPASMS FOLLOWING URETERAL REIMPLANTATION SURGERY Andres Silva Waissbluth*, Constance Houck, Petra Meier-Haran, Brenda Barton, Vanessa Young, Alan Retik, Hiep Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: Bladder spasms are acute spasmodic pains, which are common following bladder surgery. Recent studies have demonstrated that bladder hyperactivity triggered by C-fiber afferents may play a role in the etiology of this type of pain.
THE JOURNAL OF UROLOGY姞
8 cm). Seventy-four patients had simple cysts while 25 had complex cysts (septations, irregular shaped, calcifications, thick walled cysts, or debris filled). Forty patients had 61 CT and 10 MRI scans ordered as part of evaluation and subsequent management. Size concordance (⫾ 3mm) between initial US and initial axial imaging was present in 29/40 (73%) cases. Cyst characteristics were concordant in 29/40 (73%) of cases; 22 showing simple cysts and 7 showing complex cysts. Of the 11 remaining patients, 7 patients had complex cysts on US and simple cyst by axial imaging while 4 patients had complex cyst on axial imaging and simple cyst on RUS. Twenty-eight patients had growth of their cyst during follow-up, while 22 patients did not have the cyst identified on subsequent imaging. Ten patients underwent surgical exploration, mostly for concern over cyst features, with all specimens revealing benign tissue. CONCLUSIONS: Solitary renal cysts are a benign clinical entity with no malignant elements noted on surgical specimens in our series. 22% of simple cysts identified in our series were not visible on subsequent imaging. Axial imaging has a reasonable concordance with US findings. Omitting CT scans performed to characterize simple solitary renal cysts in a pediatric population can limit radiation exposure while not compromising quality care. Source of Funding: None
1256 TIMING OF RADIOLOGIC REFLUX ON VOIDING CYSTOURETHROGRAM PREDICTS HYDRODISTENTION GRADE BUT DOES NOT PREDICT SHORT TERM TREATMENT OUTCOMES Justin Watson*, Jonathan Kaye, Hal Scherz, Andrew Kirsch, Atlanta, GA INTRODUCTION AND OBJECTIVES: Low pressure, early cycle reflux on VCUG is associated with a low chance of spontaneous resolution when compared to late filling or voiding reflux. We sought to determine if the timing of VUR on VCUG 1)correlates with ureteral hydrodistention (HD) grade and 2) predicts the outcome of endoscopic surgery. METHODS: The records of 115 patients consecutively treated by two surgeons by the HIT injection method for VUR were examined. Twenty-five patients were excluded due to lack of VCUG, leaving 90 patients with 132 refluxing ureters. All VCUGs were examined by a urologist and radiologist for grade and timing of reflux. Sixty three (48%) of refluxing ureters or 44/90 patients were studied with more than one VCUG prior to intervention. Fourteen patients underwent three or more preoperative VCUGs. Each preoperative VCUG was examined for timing of VUR. Intraoperative hydrodistention grades (HD) were recorded for each ureter and a three month postoperative VCUG was obtained on each patient. RESULTS: Average time between first VCUG and operative intervention was 328 days. The timing of reflux on both initial VCUG and immediately preoperative VCUG was statistically significantly correlated with HD grade intraoperatively. Severity of reflux on initial VCUG correlated with severity of HD grade (Somers’D 0.004) when classified by “early/ late/voiding” and (Somers’D 0.052)when classified by “filling, voiding”. Severity of reflux on immediately preop VCUG correlates with severity of HD grade (Somers’D 0.032) when classified by “early/late/voiding” but is not significant when classified by “filling/ voiding” (Somers’D 0.302). The success rate of endoscopic treatment per ureter for early filling reflux, late filling reflux and voiding reflux based upon initial VCUG was 90.9% (40/44), 82.8% (53/64) and 93.3% (14/15) respectively. These differences were not significant (Pearson’s Chi-square 0.539). Categorized by only filling or voiding reflux, these success rates are 86.1% (93/108) and 93.3% (14/15) (Pearson chisquare 0.726). CONCLUSIONS: A uniformly high surgical success was achieved despite the timing of reflux during the bladder cycle or degree of ureteral HD. Our data confirm the anatomic basis for low pressure,
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
early cycle reflux and delayed spontaneous resolution as abnormally high ureteral HD. These data support the need for standardized radiographic reporting. Source of Funding: None
1257 ULTRASOUND RENAL PARENCHYMAL AREA CORRELATES WITH REFLUX RESOLUTION IN CHILDREN WITHOUT URINARY TRACT INFECTION Ilene Wong*, Curtis Clark, Tin Ngo, Jen-Jane Liu, Hsi-Yang Wu, Linda Shortliffe, Stanford, CA INTRODUCTION AND OBJECTIVES: Age, reflux grade, gender and the presence of renal damage on dimercapto-succinic acid (DMSA) scan are reported to be prognosticators of spontaneous vesicoureteral reflux (VUR) resolution. Previously, we have shown ultrasound renal parenchymal area (US-RPA) to correlate with DMSA determined renal function in children with VUR. We examined whether US-RPA could predict reflux resolution in children with reflux without history of urinary tract infection (UTI). METHODS: With institutional review board approval, we retrospectively reviewed charts of children who had a VCUG performed from 2001-2008 with VUR and no history of UTI; those with other abnormalities such as neurogenic bladder and posterior urethral valves, cardiac anomalies, lack of follow-up VCUG, or history of febrile illnesses were excluded. Renal bladder ultrasound (RBUS) images for these patients were obtained. Static ultrasound images were captured in .bmp format and imported into imaging software for US-RPA measurement as previously described. Charts were reviewed to assess reflux resolution or persistence. Multiple regression controlling for age and grade of reflux was performed to compare the US-RPA of refluxing renal units in children with VUR resolution versus those without. RESULTS: 57 children were found to have VUR without history of UTI. Of these 7 were lost to follow-up and 5 did not have repeat VCUG. The 45 patients remaining had 74 refluxing renal units with an average reflux grade of 3.12 (median grade 3). Initial VCUG was performed for sibling reflux in 8, ear tag in 1, and antenatal hydronephrosis in 36. Children had urologic follow-up to an average of 2.9 years of age (20.1 months of mean follow-up after diagnosis), at which time 44 renal units showed spontaneous resolution of reflux, with 21 units progressing to surgery and 9 showing persistent reflux. Analyzed by grade of reflux, 0/4 (0%) of Grade V, 12/22 (55%) of Grade IV, 22/32 (69%) of Grade III and 10/16 (63%) of units with Grade I or II resolved. Multiple regression analysis showed grade of reflux (p⫽0.01), age (p⬍0.0001) and initial US-RPA (p⫽0.01) to be associated with reflux resolution. When Grade V refluxing units were removed from analysis, grade of reflux was not associated with reflux resolution (p⫽0.17) but correlation with initial US-RPA (p⫽0.04) and age (p⬍0.0001) remained. CONCLUSIONS: In this study limited to children with VUR without UTI, larger US-RPA was associated with reflux resolution. Further analysis with a greater number of children is needed to confirm a role for US-RPA as a prognostic factor in VUR resolution. Source of Funding: None
1258 IDENTIFICATION OF URINARY SUBSTANCE P LEVEL AS A BIOMARKER FOR BLADDER SPASMS FOLLOWING URETERAL REIMPLANTATION SURGERY Andres Silva Waissbluth*, Constance Houck, Petra Meier-Haran, Brenda Barton, Vanessa Young, Alan Retik, Hiep Nguyen, Boston, MA INTRODUCTION AND OBJECTIVES: Bladder spasms are acute spasmodic pains, which are common following bladder surgery. Recent studies have demonstrated that bladder hyperactivity triggered by C-fiber afferents may play a role in the etiology of this type of pain.