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Does the Timing of a Micturating Cystourethrogram (Mcug) Following a Febrile Uti in Infants Affect Detection of Ureterovesical Reflux?
S30 TMPX/SMX 70.6%, and to AMP 40%*. There was no statistical difference between TMP and TMP/ SMX. There was no regional difference in the sensitivity pattern for TMP, SMX or TMP/SMX. * P < 0.05 when compared to TMP and TMP/ SMX.
ESPU Programme 2009 CONCLUSIONS In children with UTIs, the in-vitro sensitivity for TMP was comparable to that of TMP/ SMX and is significantly higher than that of SMX alone. This finding was similar in all geographic locations tested. The addition of SMX appears to be unnecessary
and may represent a risk to patients. TMP can be used as an alternative to TMP/ SMX without any compromise to antibacterial activity.
# S01-3 (O) OUTCOME OF ANTIBIOTIC PROPHYLAXIS CESSATION IN PATIENTS WITH PERSISTENT VESICO-URETERAL REFLUX WHO INITIALLY PRESENTED WITH A FEBRILE URINARY TRACT INFECTION Bruno LESLIE, Katherine MOORE, Darius BAGLI, Walid FARHAT, Antoine KHOURY, Joao PIPPI-SALLE and Armando LORENZO Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE Growing evidence suggests that antibiotic prophylaxis (ABP) may not prevent urinary tract infections (UTI). We report on the outcome of a specific cohort of patients assembled based on initial VUR diagnosis after a febrile UTI.
MATERIAL AND METHODS We retrospectively reviewed a prospectively collected database of patients with persistent VUR who discontinued ABP once toilet trained and with no evidence of dysfunctional voiding. End points included febrile UTIs,
abnormalities on follow-up renal ultrasound and need for further interventions.
RESULTS 72 girls and 24 boys were evaluated. Mean patient age at ABP cessation was 5.4 years (range 2.3-11.8), and mean subsequent follow-up was 28months (range 5-101). Reflux grade at presentation was I in 3%, II in 37%, III in 46%, IV in 8% and V in 4%; VUR was bilateral in 51 patients (53%). Febrile urinary tract infection developed in 9 girls and 1 boy (10% of the cohort, mean age ¼ 6 years), an average of 17.2 months (range 5 to 44 months) after ABP discontinuation. Findings consistent with new renal scarring on
ultrasound were identified in one patient who developed a febrile UTI and in one without infection. Upon comparison of the group who developed febrile UTI against those that did not a significant difference was found in number of high grade VUR (p 0.007) and the development of dysfunctional voiding (p ¼ 0.002).
CONCLUSIONS This data supports ABP discontinuation in the majority of patients with VUR who present with a febrile UTI. Development of dysfunctional elimination symptoms seems to be a preventable risk factor amenable to treatment.
# S01-4 (PP) DOES THE TIMING OF A MICTURATING CYSTOURETHROGRAM (MCUG) FOLLOWING A FEBRILE UTI IN INFANTS AFFECT DETECTION OF URETEROVESICAL REFLUX? Giampierro SOCCORSO1, Gail MOSS2, Julian ROBERTS1 and Prasad GODBOLE1 1 Sheffield Children’s Hospital, Paediatric Urology, Sheffield, UNITED KINGDOM, 2Sheffield Children’s Hospital, Paediatrics, Sheffield, UNITED KINGDOM
PURPOSE The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for ureterovesical reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after the UTI to avoid false positive results. We reviewed our 10 year experience to determine whether the timing of MCUG affected the detection of
ureterovesical reflux in this patient population.
MATERIAL AND METHODS Information on 427 infants under 1 year of age who had undergone MCUG following a first febrile UTI was reviewed. The infants were divided in two groups: Group A (117) with MCUG performed within 4 weeks from UTI diagnosis and Group B (310) with MCUG at least 8 weeks from diagnosis.
RESULTS Of the 427 children, there were 258 boys (60%) and 169 girls (40%) with a median age of 5.2 months (1-12). VUR was detected in 33% of those for whom MCUG was performed 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis (p ¼ 0.07). The grade of VUR in these two groups was not statistically significant (p ¼ 0.3)
ESPU Programme 2009 CONCLUSIONS Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is
S31 influenced by the timing of the MCUG. Following treatment of the acute episode and complete resolution of symptoms the
MCUG can be performed as soon as is convenient.
# S01-5 (PP) SURGICAL INTERVENTION IN CHILDREN WITH VESICOURETERIC REFLUX e ARE WE INTERVENING TOO LATE? Basem KHALIL1 and Alan DICKSON2 1
Birmingham, UNITED KINGDOM, 2Royal Manchester Children’s Hospital, Paediatric Urology, Manchester, UNITED KINGDOM
PURPOSE Vesicoureteric reflux is usually managed initially by medical treatment in our department. This study investigates if significant kidney damage has occurred during medical treatment prior to surgical intervention.
MATERIAL AND METHODS Case notes of all children treated with ureteric re-implantation for vesicoureteric reflux in a five year period were reviewed. Demographic details, radiological investigations, surgery and follow up were recorded. Indication for surgery was failure of medical treatment. Kidney damage was
defined as the presence of a scar on the DMSA scans and/or kidney function below 45% in one kidney.
RESULTS Forty two patients underwent ureteric reimplantation with 24 having a bilateral procedure resulting in a total of 66 renal units. Mean age at surgery was 7.4 years. Twenty nine kidneys (44%) showed reduced functions prior to medical treatment. Twenty four kidneys (36%) had detoriation of renal function associated with recurrent urinary tract infections during the course of medical treatment with the overall mean function of the worst affected kidney being 28%. Fifteen children had unilateral kidney
function below 25%. Thirty five patients (83%) demonstrated scarring on their kidneys on DMSA scan prior to surgery with 6 patients having bilateral scarring. Nine patients (21%) maintained normal function whilst 4 patients had no available DMSA figures.
CONCLUSIONS 1. The majority of patients having reimplants for reflux already have kidney damage. 2. Patients who require surgical treatment after a failed medical treatment have commonly suffered increased renal damage. 3. This renal detoriation may have been prevented if earlier surgical management had been utilized.
# S01-6 (O) TRANSVESICOSCOPIC COHEN URETERIC REIMPLANTATION FOR VESICO-URETERAL REFLUX IN CHILDREN: A SINGLE CENTRE 5-YEAR EXPERIENCE ´CULE ´E, H. STEYAERT and J.S. VALLA Stephen GRIFFIN, J. LAURON, A.L. FRAGOSO, P. ARNAUD, R. LE Fondation Lenval Hopital pour Enfants, Chirurgie Pediatrique, Winchester, UNITED KINGDOM
PURPOSE To evaluate our results with the method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children.
performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days post-operatively. Patients were followed up with clinical assessment, renal ultrasonography voiding cystourethrogram.
MATERIAL AND METHODS RESULTS Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO2 pneumovesicum. Ports were inserted suprapubically e 5 mm for the camera and two 3-5 mm working ports. Having mobilised the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation
Ninety % had VUR greater than or equal to grade 3. A total of 113 ureters were reimplanted. The mean operative time was 82 minutes for unilateral re-implantation, 130 minutes for bilateral. Four cases (6%) were converted. Three patients (4%) presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients (10%) had
post-operative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in 4 of these patients (8%). There was a trend towards increased persistent VUR and conversion in patients less than 2 years of age. In addition, failure was more common in patients with higher grades of reflux.
CONCLUSIONS Laparoscopic ureteric remplantation with CO2 pneumovesicum is technically feasible with a high success rate (92%). However, the role of this technique, in the treatment of VUR, remains to be determined.
ESPU Programme 2009 CONCLUSIONS In children with UTIs, the in-vitro sensitivity for TMP was comparable to that of TMP/ SMX and is significantly higher than that of SMX alone. This finding was similar in all geographic locations tested. The addition of SMX appears to be unnecessary
and may represent a risk to patients. TMP can be used as an alternative to TMP/ SMX without any compromise to antibacterial activity.
# S01-3 (O) OUTCOME OF ANTIBIOTIC PROPHYLAXIS CESSATION IN PATIENTS WITH PERSISTENT VESICO-URETERAL REFLUX WHO INITIALLY PRESENTED WITH A FEBRILE URINARY TRACT INFECTION Bruno LESLIE, Katherine MOORE, Darius BAGLI, Walid FARHAT, Antoine KHOURY, Joao PIPPI-SALLE and Armando LORENZO Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE Growing evidence suggests that antibiotic prophylaxis (ABP) may not prevent urinary tract infections (UTI). We report on the outcome of a specific cohort of patients assembled based on initial VUR diagnosis after a febrile UTI.
MATERIAL AND METHODS We retrospectively reviewed a prospectively collected database of patients with persistent VUR who discontinued ABP once toilet trained and with no evidence of dysfunctional voiding. End points included febrile UTIs,
abnormalities on follow-up renal ultrasound and need for further interventions.
RESULTS 72 girls and 24 boys were evaluated. Mean patient age at ABP cessation was 5.4 years (range 2.3-11.8), and mean subsequent follow-up was 28months (range 5-101). Reflux grade at presentation was I in 3%, II in 37%, III in 46%, IV in 8% and V in 4%; VUR was bilateral in 51 patients (53%). Febrile urinary tract infection developed in 9 girls and 1 boy (10% of the cohort, mean age ¼ 6 years), an average of 17.2 months (range 5 to 44 months) after ABP discontinuation. Findings consistent with new renal scarring on
ultrasound were identified in one patient who developed a febrile UTI and in one without infection. Upon comparison of the group who developed febrile UTI against those that did not a significant difference was found in number of high grade VUR (p 0.007) and the development of dysfunctional voiding (p ¼ 0.002).
CONCLUSIONS This data supports ABP discontinuation in the majority of patients with VUR who present with a febrile UTI. Development of dysfunctional elimination symptoms seems to be a preventable risk factor amenable to treatment.
# S01-4 (PP) DOES THE TIMING OF A MICTURATING CYSTOURETHROGRAM (MCUG) FOLLOWING A FEBRILE UTI IN INFANTS AFFECT DETECTION OF URETEROVESICAL REFLUX? Giampierro SOCCORSO1, Gail MOSS2, Julian ROBERTS1 and Prasad GODBOLE1 1 Sheffield Children’s Hospital, Paediatric Urology, Sheffield, UNITED KINGDOM, 2Sheffield Children’s Hospital, Paediatrics, Sheffield, UNITED KINGDOM
PURPOSE The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for ureterovesical reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after the UTI to avoid false positive results. We reviewed our 10 year experience to determine whether the timing of MCUG affected the detection of
ureterovesical reflux in this patient population.
MATERIAL AND METHODS Information on 427 infants under 1 year of age who had undergone MCUG following a first febrile UTI was reviewed. The infants were divided in two groups: Group A (117) with MCUG performed within 4 weeks from UTI diagnosis and Group B (310) with MCUG at least 8 weeks from diagnosis.
RESULTS Of the 427 children, there were 258 boys (60%) and 169 girls (40%) with a median age of 5.2 months (1-12). VUR was detected in 33% of those for whom MCUG was performed 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis (p ¼ 0.07). The grade of VUR in these two groups was not statistically significant (p ¼ 0.3)
ESPU Programme 2009 CONCLUSIONS Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is
S31 influenced by the timing of the MCUG. Following treatment of the acute episode and complete resolution of symptoms the
MCUG can be performed as soon as is convenient.
# S01-5 (PP) SURGICAL INTERVENTION IN CHILDREN WITH VESICOURETERIC REFLUX e ARE WE INTERVENING TOO LATE? Basem KHALIL1 and Alan DICKSON2 1
Birmingham, UNITED KINGDOM, 2Royal Manchester Children’s Hospital, Paediatric Urology, Manchester, UNITED KINGDOM
PURPOSE Vesicoureteric reflux is usually managed initially by medical treatment in our department. This study investigates if significant kidney damage has occurred during medical treatment prior to surgical intervention.
MATERIAL AND METHODS Case notes of all children treated with ureteric re-implantation for vesicoureteric reflux in a five year period were reviewed. Demographic details, radiological investigations, surgery and follow up were recorded. Indication for surgery was failure of medical treatment. Kidney damage was
defined as the presence of a scar on the DMSA scans and/or kidney function below 45% in one kidney.
RESULTS Forty two patients underwent ureteric reimplantation with 24 having a bilateral procedure resulting in a total of 66 renal units. Mean age at surgery was 7.4 years. Twenty nine kidneys (44%) showed reduced functions prior to medical treatment. Twenty four kidneys (36%) had detoriation of renal function associated with recurrent urinary tract infections during the course of medical treatment with the overall mean function of the worst affected kidney being 28%. Fifteen children had unilateral kidney
function below 25%. Thirty five patients (83%) demonstrated scarring on their kidneys on DMSA scan prior to surgery with 6 patients having bilateral scarring. Nine patients (21%) maintained normal function whilst 4 patients had no available DMSA figures.
CONCLUSIONS 1. The majority of patients having reimplants for reflux already have kidney damage. 2. Patients who require surgical treatment after a failed medical treatment have commonly suffered increased renal damage. 3. This renal detoriation may have been prevented if earlier surgical management had been utilized.
# S01-6 (O) TRANSVESICOSCOPIC COHEN URETERIC REIMPLANTATION FOR VESICO-URETERAL REFLUX IN CHILDREN: A SINGLE CENTRE 5-YEAR EXPERIENCE ´CULE ´E, H. STEYAERT and J.S. VALLA Stephen GRIFFIN, J. LAURON, A.L. FRAGOSO, P. ARNAUD, R. LE Fondation Lenval Hopital pour Enfants, Chirurgie Pediatrique, Winchester, UNITED KINGDOM
PURPOSE To evaluate our results with the method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children.
performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days post-operatively. Patients were followed up with clinical assessment, renal ultrasonography voiding cystourethrogram.
MATERIAL AND METHODS RESULTS Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO2 pneumovesicum. Ports were inserted suprapubically e 5 mm for the camera and two 3-5 mm working ports. Having mobilised the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation
Ninety % had VUR greater than or equal to grade 3. A total of 113 ureters were reimplanted. The mean operative time was 82 minutes for unilateral re-implantation, 130 minutes for bilateral. Four cases (6%) were converted. Three patients (4%) presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients (10%) had
post-operative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in 4 of these patients (8%). There was a trend towards increased persistent VUR and conversion in patients less than 2 years of age. In addition, failure was more common in patients with higher grades of reflux.
CONCLUSIONS Laparoscopic ureteric remplantation with CO2 pneumovesicum is technically feasible with a high success rate (92%). However, the role of this technique, in the treatment of VUR, remains to be determined.