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Re: The Swedish Reflux Trial: Review of a Randomized, Controlled Trial in Children with Dilating Vesicoureteral Reflux
Urological Survey
Pediatric Urology Re: The Swedish Reflux Trial: Review of a Randomized, Controlled Trial in Children with Dilating Vesicoureteral Reflux P. Brandström, U. Jodal, U. Sillén and S. Hansson Pediatric Uro-Nephrologic Center, Queen Silvia Children’s Hospital, University of Gothenburg, Göteborg, Sweden J Pediatr Urol 2011; 7: 594 – 600.
Objectives: To evaluate prophylaxis and endoscopic injection for children with dilating vesicoureteral reflux (VUR) compared to surveillance, regarding urinary tract infection (UTI) recurrence, new renal damage, VUR outcome, and impact of lower urinary tract (LUT) dysfunction on these outcomes. Patients and Methods: 203 children (128 girls and 75 boys), aged 1 to ⬍2 years, with VUR grade III or IV were randomized to antibiotic prophylaxis (n ⫽ 69), endoscopic injection (n ⫽ 66) or surveillance (n ⫽ 68). Voiding cystourethrography, dimercaptosuccinic acid scintigraphy and optional LUT function assessment were performed before randomization and after 2 years. Results: There were 67 febrile UTIs in 42 girls and 8 in 7 boys (p ⫽ 0.0001). In girls, recurrence rate was 19% on prophylaxis, 23% with endoscopic treatment and 57% on surveillance (p ⫽ 0.0002). In boys, there was no difference between treatment groups. New damage was seen in 13 girls: 8 on surveillance, 5 in the endoscopic group and none on prophylaxis (p ⫽ 0.0155), and in 2 boys. In 13 children with no or non-dilating VUR after 1 injection, dilating VUR reappeared at the 2-year follow up. LUT dysfunction at follow up was associated with persistence of VUR. Conclusion: In girls, prophylaxis reduced the rate of UTI recurrence and new renal damage, and endoscopic injection the rate of UTI recurrence. Boys did not benefit from active treatment. Editorial Comment: In this study 203 children with dilating VUR were randomized to antibiotic prophylaxis, endoscopic injection or surveillance. The children were followed with dimercapto-succinic acid scintigraphy. Febrile urinary tract infections, new renal damage during the 2-year study period and reflux grade at study end were recorded for each group. This series is unusual because it focused exclusively on high volume VUR, and analyzed girls and boys separately. The authors found little evidence of recurrent urinary tract infection in boys regardless of therapy, suggesting that endoscopic treatment or antibiotic prophylaxis is unnecessary in boys older than 1 year. In girls endoscopic management and antibiotic prophylaxis were associated with longer times to first febrile recurrence than surveillance alone, suggesting that antibiotic prophylaxis or endoscopic treatment is beneficial for girls with dilating vesicoureteral reflux. Only 2 boys exhibited new renal damage. By comparison, 13 girls exhibited new renal damage (none in the prophylactic group, 5 in the endoscopic group and 8 in the surveillance group). There was no association between new renal damage and lower urinary tract dysfunction. Because of their findings, the authors suggest a new management strategy for children older than 1 year with dilating vesicoureteral reflux. They suggest that clinicians manage girls by either antibiotic prophylaxis or endoscopic treatment and those with recurrent infection cross over to either antibiotic prophylaxis or endoscopic treatment, depending on their initiating arm. Boys with dilating VUR can initially be monitored without therapy. Those who manifest recurrent UTI are managed by endoscopy or prophylaxis. 0022-5347/12/1882-0598/0 THE JOURNAL OF UROLOGY® © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
598
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2012.04.049 Vol. 188, 598-600, August 2012 Printed in U.S.A.
PEDIATRIC UROLOGY
599
I believe that my generation has been confused about which children with VUR require management and which can be monitored without therapy. Because most of our studies have lumped boys together with girls and nondilating reflux together with dilating reflux, we have had a difficult time discerning those at risk and the appropriate treatment to protect them. This study begins to help distinguish between the 2 groups. Douglas A. Canning, M.D.
Re: Management of Recurrent Urethral Strictures after Hypospadias Repair: Is there a Role for Repeat Dilation or Endoscopic Incision? P. C. Gargollo, A. W. Cai, J. G. Borer and A. B. Retik Department of Urology, Children’s Medical Center Dallas, UT Southwestern Medical School, Dallas, Texas J Pediatr Urol 2011; 7: 34 –38.
Objective: Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique. Methods: All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s). Results: Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P⫽0.03). Conclusion: Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation. Editorial Comment: The authors identified 73 boys with postoperative stricture following hypospadias repair in a series of 2,273 boys undergoing repair at Children’s Hospital Boston. In 88 post-hypospadias strictures open surgical correction was successful in 53%, while direct visual internal urethrotomy was successful in 38%. Of patients who underwent initial internal urethrotomy a recurrent stricture following internal urethrotomy was successfully treated in only 17%. The authors suggest that while an initial attempt at endoscopic correction can be successful, if that attempt fails the child is best served with a second open repair. Douglas A. Canning, M.D.
Re: Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial K. Rourke, S. McKinny and B. St. Martin Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Urology 2012; 79: 443– 447.
Objective: To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. Methods: A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open.
Pediatric Urology Re: The Swedish Reflux Trial: Review of a Randomized, Controlled Trial in Children with Dilating Vesicoureteral Reflux P. Brandström, U. Jodal, U. Sillén and S. Hansson Pediatric Uro-Nephrologic Center, Queen Silvia Children’s Hospital, University of Gothenburg, Göteborg, Sweden J Pediatr Urol 2011; 7: 594 – 600.
Objectives: To evaluate prophylaxis and endoscopic injection for children with dilating vesicoureteral reflux (VUR) compared to surveillance, regarding urinary tract infection (UTI) recurrence, new renal damage, VUR outcome, and impact of lower urinary tract (LUT) dysfunction on these outcomes. Patients and Methods: 203 children (128 girls and 75 boys), aged 1 to ⬍2 years, with VUR grade III or IV were randomized to antibiotic prophylaxis (n ⫽ 69), endoscopic injection (n ⫽ 66) or surveillance (n ⫽ 68). Voiding cystourethrography, dimercaptosuccinic acid scintigraphy and optional LUT function assessment were performed before randomization and after 2 years. Results: There were 67 febrile UTIs in 42 girls and 8 in 7 boys (p ⫽ 0.0001). In girls, recurrence rate was 19% on prophylaxis, 23% with endoscopic treatment and 57% on surveillance (p ⫽ 0.0002). In boys, there was no difference between treatment groups. New damage was seen in 13 girls: 8 on surveillance, 5 in the endoscopic group and none on prophylaxis (p ⫽ 0.0155), and in 2 boys. In 13 children with no or non-dilating VUR after 1 injection, dilating VUR reappeared at the 2-year follow up. LUT dysfunction at follow up was associated with persistence of VUR. Conclusion: In girls, prophylaxis reduced the rate of UTI recurrence and new renal damage, and endoscopic injection the rate of UTI recurrence. Boys did not benefit from active treatment. Editorial Comment: In this study 203 children with dilating VUR were randomized to antibiotic prophylaxis, endoscopic injection or surveillance. The children were followed with dimercapto-succinic acid scintigraphy. Febrile urinary tract infections, new renal damage during the 2-year study period and reflux grade at study end were recorded for each group. This series is unusual because it focused exclusively on high volume VUR, and analyzed girls and boys separately. The authors found little evidence of recurrent urinary tract infection in boys regardless of therapy, suggesting that endoscopic treatment or antibiotic prophylaxis is unnecessary in boys older than 1 year. In girls endoscopic management and antibiotic prophylaxis were associated with longer times to first febrile recurrence than surveillance alone, suggesting that antibiotic prophylaxis or endoscopic treatment is beneficial for girls with dilating vesicoureteral reflux. Only 2 boys exhibited new renal damage. By comparison, 13 girls exhibited new renal damage (none in the prophylactic group, 5 in the endoscopic group and 8 in the surveillance group). There was no association between new renal damage and lower urinary tract dysfunction. Because of their findings, the authors suggest a new management strategy for children older than 1 year with dilating vesicoureteral reflux. They suggest that clinicians manage girls by either antibiotic prophylaxis or endoscopic treatment and those with recurrent infection cross over to either antibiotic prophylaxis or endoscopic treatment, depending on their initiating arm. Boys with dilating VUR can initially be monitored without therapy. Those who manifest recurrent UTI are managed by endoscopy or prophylaxis. 0022-5347/12/1882-0598/0 THE JOURNAL OF UROLOGY® © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
598
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2012.04.049 Vol. 188, 598-600, August 2012 Printed in U.S.A.
PEDIATRIC UROLOGY
599
I believe that my generation has been confused about which children with VUR require management and which can be monitored without therapy. Because most of our studies have lumped boys together with girls and nondilating reflux together with dilating reflux, we have had a difficult time discerning those at risk and the appropriate treatment to protect them. This study begins to help distinguish between the 2 groups. Douglas A. Canning, M.D.
Re: Management of Recurrent Urethral Strictures after Hypospadias Repair: Is there a Role for Repeat Dilation or Endoscopic Incision? P. C. Gargollo, A. W. Cai, J. G. Borer and A. B. Retik Department of Urology, Children’s Medical Center Dallas, UT Southwestern Medical School, Dallas, Texas J Pediatr Urol 2011; 7: 34 –38.
Objective: Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique. Methods: All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s). Results: Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P⫽0.03). Conclusion: Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation. Editorial Comment: The authors identified 73 boys with postoperative stricture following hypospadias repair in a series of 2,273 boys undergoing repair at Children’s Hospital Boston. In 88 post-hypospadias strictures open surgical correction was successful in 53%, while direct visual internal urethrotomy was successful in 38%. Of patients who underwent initial internal urethrotomy a recurrent stricture following internal urethrotomy was successfully treated in only 17%. The authors suggest that while an initial attempt at endoscopic correction can be successful, if that attempt fails the child is best served with a second open repair. Douglas A. Canning, M.D.
Re: Effect of Wound Closure on Buccal Mucosal Graft Harvest Site Morbidity: Results of a Randomized Prospective Trial K. Rourke, S. McKinny and B. St. Martin Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Urology 2012; 79: 443– 447.
Objective: To determine the effect of closure versus nonclosure of the buccal mucosal graft harvest site in men undergoing bulbar urethroplasty in a randomized prospective study. The optimal postoperative management of the buccal mucosal graft donor site remains unknown. Methods: A total of 50 consecutive patients were randomized to either donor site closure or leaving the donor site open.