Urological Survey PEDIATRIC UROLOGY Double-J Stent Insertion Across Vesicoureteral Junction—Is it a Valuable Initial Approach in Neonates and Infants With Severe Primary Nonrefluxing Megaureter? M. Castagnetti, M. Cimador, M. Sergio and E. De Grazia, Department of Paediatric Surgery, Istituto Materno Infantile, University of Palermo, Palermo, Italy Urology 2006; 68: 870 – 876. Objectives: To evaluate the role of double-J stent insertion in perinatally detected primary nonrefluxing megaureters as a method to temporize treatment in patients with impaired renal function or to prevent function loss in patients treated expectantly, but deemed at high risk of deterioration. Methods: Two neonates and 8 infants with a ureter greater than 10 mm and an obstructive excretion pattern, including 3 cases with renal function less than 40%, were selected to undergo double-J stent insertion for a 6-month period. Patients underwent surgery if the ureter redilated and the excretion pattern was obstructive at reassessment 3 months after stent removal. Results: Stents were placed at a median age of 3 months (range 1 to 6). Open insertion was necessary in 5 cases (50%). Seven patients (70%) developed stent-related complications (five breakthrough urinary infections) requiring early stent removal in 2 (20%). Five patients (50%) underwent surgery at a median age of 14 months (range 13 to 27), including the 3 patients with decreased renal function at presentation. None required ureteral tapering. None experienced any renal function loss with respect to the initial evaluation. Conclusions: Double-J stent insertion across the vesicoureteral junction allows for effective internal drainage of primary nonrefluxing megaureters, but at the cost of a 70% morbidity rate and various technical drawbacks. Therefore, stenting should be considered on a case-by-case basis. The procedure seems valuable to temporize surgery in patients with decreased renal function. However, given the associated morbidity, it seems impractical for patients with preserved function selected in accordance with currently available prognostic indicators. Editorial Comment: The indications for placing a Double-J® stent in a child with megaureter are limited. In children the most attractive time to try this approach is in the newborn period, when deciding what therapeutic option to begin with. However, this is the time when the morbidity should be the greatest. In the infant the ureteral orifice is small. In males it is difficult to traverse the infant urethra with an endoscope large enough to deliver a ureteral stent. Also, the relatively high pressure voiding pattern of the newborn male may theoretically drive vesicoureteral reflux and urinary tract infection. Most of us believe that truly obstructed megaureters are relatively rare. Many of these patients improve without treatment. With the 70% morbidity outlined in this study it becomes difficult to justify stenting. In the few infants with truly obstructed megaureter end cutaneous ureterostomy with subsequent reimplantation at 18 months, when the relative function is known, may be a better option. In infants with a solitary kidney, where diversion would leave the bladder empty, ureteral reimplantation without tapering may be a better option. Douglas A. Canning, M.D.
Renal Transplantation or Bladder Augmentation First? A Comparison of Complications and Outcomes in Children A. K. Taghizadeh, D. Desai, S. E. Ledermann, R. Shroff, S. D. Marks, G. Koffman, P. G. Duffy and P. M. Cuckow, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom BJU Int 2007; 100: 1365–1370. Objective: To identify whether the order of performing transplant and bladder reconstruction operations in children who need both operations affects outcome of either operation. Patients and Methods: A retrospective case note review was performed of children identified from our database, who had undergone both renal 0022-5347/08/1804-1502/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
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transplantation and bladder augmentation between 1990 and 2005. Results: In all, 18 renal transplants (eight live-related) were performed in 16 children with 10 transplants done after bladder augmentation and eight transplants done before augmentation. The median age at transplantation was 7.5 years and at augmentation was 7.0 years. The median interval between the operations was 33.5 months and the median follow-up was 58.4 months after transplantation. Outcomes were compared between the two groups of patients: those who received their transplantation before bladder augmentation, and those who were transplanted after bladder augmentation. There was no difference between these groups in: the pretransplant estimated glomerular filtration rate, inpatient stay after transplantation or after augmentation, and incidence of urinary tract infection in the 3 months after renal transplantation or after bladder augmentation. There was no statistical difference in renal allograft loss with one graft failure in the group who were augmented first, and four graft failures in the group who were transplanted first. However, it is of note that the single graft failure in the patient augmented first was due to renal artery thrombosis on the first day related to a double arterial anastomosis, whilst in the other group, three of the graft failures were in transplants that had initially been drained by ureterostomy. Three patients in the group transplanted first developed significant ureteric pathology, of which one developed graft failure. Conclusion: Bladder reconstruction can be performed safely before transplantation; it does not increase complications and might better protect the renal graft and specifically the transplant ureter. Editorial Comment: The authors compared children who underwent transplantation before bladder augmentation with those augmented before transplantation. They conclude that augmentation can safely be performed before renal transplantation, and suggest that performing augmentation first might be associated with a lower rate of complications, specifically to the ureter and to the graft itself. While this finding may apply in some children, in whom it is inevitable that augmentation be performed, our impression is that, at the time of transplant, it usually is difficult to predict which children will need augmentation. Our practice has been to transplant before augmentation, often to a bladder with a functioning vesicostomy. We have been surprised that when the vesicostomy is closed a number of these cases can be managed by intermittent daytime catheterization combined with continuous overnight catheter drainage, with little morbidity to the graft in the long term. Douglas A. Canning, M.D.
Evaluation of Constipation by Abdominal Radiographs Correlated With Treatment Outcome in Children With Dysfunctional Elimination H. A. Allen, J. C. Austin, M. A. Boyt, C. E. Hawtrey and C. S. Cooper, Division of Pediatric Urology, Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa Urology 2007; 69: 966 –969. Objectives: To analyze the utility of assessing degree of constipation by abdominal radiograph (KUB) in relation to symptoms and urodynamic data in children with dysfunctional elimination. Methods: A retrospective review of children with concomitant constipation and daytime incontinence was performed. Inclusion required at least two consecutive visits with KUB and noninvasive uroflowmetry. Patients were excluded for anticholinergic medication use or neurogenic or anatomic abnormalities. Rectal fecal quantification and presence of stool throughout the colon was assessed on KUB and categorized as “empty,” “normal amount of stool,” or “fecal distention of rectum (FDR).” Results: Twenty-six patients met inclusion requirements (6 boys, 20 girls; average age, 7.7 ⫹/⫺ 2.2 years). The average time between the initial and subsequent visit was 12.5 ⫹/⫺ 7.8 weeks. Initial KUB revealed FDR in 17. No statistical significance was found between FDR on initial or final KUB and outcome of wetting symptoms, nor could a relationship between FDR uroflow parameters at either visit be demonstrated. Conclusions: No correlation between any uroflowmetry parameter and the presence of FDR at the initial or final visits could be demonstrated. Similarly, no statistical significance between FDR on final or initial KUB and outcome of wetting symptoms was established.
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Initial Trial of Timed Voiding is Warranted for All Children With Daytime Incontinence H. A. Allen, J. C. Austin, M. A. Boyt, C. E. Hawtrey and C. S. Cooper, Division of Pediatric Urology, Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa Urology 2007; 69: 962–965. Objectives: To analyze the relationship between potential prognostic factors and early success after treatment of childhood daytime urinary incontinence without anticholinergic medication. Methods: A total of 63 patients with daytime urinary incontinence met the inclusion criteria for a retrospective review of the effect of a timed voiding regimen. The severity, duration, and frequency of wetting, along with age, sex, and uroflow parameters, were recorded. Statistical analysis was used to determine the factors predictive of improvement in wetting without anticholinergic treatment. Results: Of 315 children evaluated with daytime incontinence, only 24% were treated with nonanticholinergic methods. At the first follow-up visit, 6.3% of patients treated without anticholinergics became dry, 38.1% showed significant improvement, 36.5% were slightly improved, and 19.0% were unchanged. Age, sex, duration or severity of wetting, constipation, bladder capacity, and uroflow pattern and parameters were not predictive of early improvement with timed voiding. Patients with good compliance with timed voiding were significantly more likely to improve than those with poor compliance (P ⫽ 0.014). Conclusions: The results of our study have indicated that anticholinergic therapy appears to be overused as a first-line treatment for children with daytime urinary incontinence in our clinic population. The lack of reliable predictive factors regarding the response to nonanticholinergic treatment suggests a trial of timed voiding should be used as an initial treatment for all children with daytime urinary incontinence. Almost 45% of our patients had significant improvement in the frequency of wetting within 4 months without anticholinergics. Editorial Comment: These are 2 good studies by a group that has analyzed the components of dysfunctional voiding and are systematically reviewing some of the concepts that we have always believed were important in the treatment of dysfunctional voiding. In their retrospective review on constipation the authors report no identifiable association between the presence of stool in the colon and maximum urinary flow, mean flow or post-void residual. To me this finding is not altogether surprising. We tend to use plain abdominal films as a teaching tool for parents, and to identify not only the presence of stool, but also the character of the stool within the intestine. Stool is nearly always present in the descending colon. Rectal distention may occur in the presence of soft or firm stool. It may be that the presence of firm pellet-like stool identifiable in the rectum is a better discriminator than the presence of stool alone. The authors rightly state in their comments that constipation is not a diagnosis that can be made with a KUB alone. In their study on timed voiding the authors demonstrate what most of us have believed for quite some time—that behavioral management for a large percentage of children with daytime wetting can be effective as initial therapy. I was surprised that nearly 60% of 315 children who presented to the Iowa Clinics had already been prescribed oxybutynin. This report supports my belief that the majority of children with daytime wetting can be treated initially with behavior management alone. Douglas A. Canning, M.D.
Development of Nocturnal Urinary Control in Chinese Children Younger Than 8 Years Old J. G. Wen, Q. W. Wang, J. J. Wen, J. Su, Y. Chen, K. Liu and H. Y. Yang, Department of Pediatric Surgery, Pediatric Urodynamic Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou City, Henan, China Urology 2006; 68: 1103–1108. Objectives: To estimate the development of nocturnal urinary control (NUC) with age in Chinese children younger than 8 years of age using cross-sectional and retrospective surveys. Methods: We used a crosssectional survey of 4754 children (1 to 8 years old), a retrospective investigation of 2745 children younger than 9 years old, and an anonymous questionnaire of 8222 children 9 to 18 years old . The children without NUC were subdivided into infant (1 to 3 years old), preschool age (4 to 6 years old), and primary school (7 to 8 years old) groups. Results: The response rate to the cross-sectional and retrospective surveys was 90% and 89%, respectively. In the cross-sectional survey, the prevalence of children attaining NUC was 52% for those younger than 2 years of age, 76% for those aged 2 to 3 years, and 93% at age 8. Girls were more likely than boys to acquire NUC earlier. In the retrospective survey, the prevalence of children attaining NUC before age 2 was 17% and was 72% for those aged 2 to 3 years, and 98% by age 8. The proportion of
ADRENAL AND RENAL PHYSIOLOGY, AND MEDICAL RENAL DISEASE nonmonosymptomatic bedwettings in children without NUC was 14%. Arousal difficulty and a positive family history were found in 67% and 11% of children with nocturnal wetting, respectively. The severity of bedwetting and arousal difficulty was significantly greater in infants than in preschool and school-age children. Conclusions: The results from the cross-sectional and retrospective surveys showed that the most important period of attaining NUC is 2 to 3 years of age. Nearly 90% of children attained NUC by the age of 5. Editorial Comment: This is a fascinating study that suggests a large number of Chinese children obtain nighttime dryness before age 2 years. In the United States 20% of children are still wet at age 5 years and 5% are still wet at 10 years. Since many infants in China sleep in bed with their parents, a sudden movement of the arm, leg or body during sleep triggers the mother or father to awaken and help the child to void. Although I do not believe a similar study has been done in young children from Western countries, it appears that the approach to nocturnal enuresis practiced in China as described here may be effective. It may be that sleeping in the same bed with the parent is as effective as a wetting alarm, even in young children. Douglas A. Canning, M.D.
ADRENAL AND RENAL PHYSIOLOGY, AND MEDICAL RENAL DISEASE Risk of Hypertension in Primary Vesicoureteral Reflux A. C. Simoes e Silva, J. M. Silva, J. S. Diniz, S. V. Pinheiro, E. M. Lima, M. A. Vasconcelos, M. R. Pimenta and E. A. Oliveira, Pediatric Nephrourology Unit, Hospital das Clinicas, Federal University of Minas Gerais, Belo Horizonte, Brazil Pediatr Nephrol 2007; 22: 459 – 462. The aim of this report was to estimate the risk of hypertension in children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR at a single tertiary renal unit. Of 735 patients, 664 (90%) were systematically followed and had multiple measurements of blood pressure. Hypertension was defined as values persistently above 95th for age, sex, and height in three consecutive visits. Risk of hypertension was analyzed by the Kaplan-Meier method. Of 664 patients followed, 20 (3%) developed hypertension. The estimated probability of hypertension was 2% (95%CI, 0.5%–3%), 6% (95%CI, 2%–10%), 15% (95%CI, 11%–20%) at 10, 15, and 21 years of age, respectively. The prevalence of hypertension has increased with age: it was 1.7% for patients with 1 yr–9.9 yr, 1.8% for adolescents with 10 yr–14.9 yr, 4.7% for patients with 15–19.9 yr, and 35% for patients⬎20 years at the end of the follow-up (P⬍0.001). It was estimated by survival analysis that 50% of patients with unilateral and bilateral renal damage would have sustained hypertension at about 30 and 22 years of age, respectively. Hypertension increased with age and was strongly associated with renal damage at entry in an unselected population of primary VUR. Editorial Comment: This is a large study in which the development of hypertension was quantitated in children with reflux. The take home message is that the risk of hypertension is related to the presence of previous renal damage and the severity of renal damage (determined by dimercapto-succinic acid scan), and depends on whether the reflux is unilateral or bilateral. Patients at greatest risk are those with bilateral reflux and significant scarring, approximately 50% of whom will have hypertension as they reach young adulthood. W. Scott McDougal, M.D.
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