Hasan Serkan Dogan

EAU Guidelines on Vesicoureteral Reflux in Children

CONTEXT Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention. OBJECTIVE To present a management approach for VUR based on early risk assessment. EVIDENCE ACQUISITION A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come. EVIDENCE SYNTHESIS There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques. CONCLUSIONS While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.

Prognostic Significance of Bladder Tumor History and Tumor Location in Upper Tract Transitional Cell Carcinoma

PURPOSE We studied prognostic factors for 5-year disease specific and recurrence-free survival in patients treated for upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS Since July 1987, 72 patients with a mean age of 58.9 years have undergone nephroureterectomy with bladder cuff excision. Median followup was 62.2 months (range 6 to 192). Patient age, sex, detection duration and mode, bladder tumor history, smoking habit, stone disease history, and tumor stage, grade and location were evaluated as prognostic factors. RESULTS Overall 5-year disease specific and recurrence-free survival rates were 74.9% and 67.8%, respectively. Univariate analysis revealed anemia, positive bladder tumor history, T stage, grade and tumor location in the upper tract as significant prognostic factors. On multivariate analysis T stage, grade and tumor location in the urothelium were the only significant variables for the 5-year disease specific and recurrence-free survival rates. CONCLUSIONS High tumor stage and grade, and ureteral location were significantly associated with worse disease specific and recurrence-free survival in patients with upper urinary tract transitional cell carcinoma. Our results may help define the patient groups that need adjuvant therapy and they may form a basis for further controlled studies.

Urinary tract infections in children: EAU/ESPU guidelines

CONTEXT In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract. OBJECTIVE To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI. EVIDENCE ACQUISITION The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low. EVIDENCE SYNTHESIS UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded. CONCLUSIONS The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage. PATIENT SUMMARY In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

Factors Affecting Complication Rates of Ureteroscopic Lithotripsy in Children: Results of Multi-Institutional Retrospective Analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSE We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate. CONCLUSIONS Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Percutaneous renal surgery in children with complex stones.

OBJECTIVE We report our experience with percutaneous nephrolithotomy (PNL) therapy for staghorn or complex pediatric renal calculi. PATIENTS AND METHODS We retrospectively analyzed the case records of 105 patients younger than 17 years who underwent PNL. The cases included 53 complex calculi analyzed in 51 patients. We defined complex calculi as either staghorn or those with a stone bulk larger than 300 mm(2), involving more than one calix, the upper ureter or stone in anomalous kidney. RESULTS Mean age of patients with complex calculi was 9.7+/-0.7 years and stone burden was 654+/-92.4mm(2). The median duration of PNL was 90+/-4.7 (30-220) min. Complete clearance was achieved in 39 patients (73.6%). Of these, 32 (60.4%) required a single tract, while 21 (39.6%) required multiple tracts. With subsequent shock wave lithotripsy and PNL, the clearance rate increased to 86.8%. The average hemoglobin drop was 1.6+/-0.16 g/dL. Assessing the factors affecting the hemoglobin drop, the number of tracts (P=0.01) and size of tracts (P=0.002) were found to be significant. The mean change in serum creatinine concentration between preoperative and postoperative measurements was -0.01+/-0.02 mg/dL, for both patients with a single tract and those with multiple tracts. CONCLUSIONS PNL is safe and effective in the management of staghorn and complex renal calculi in children. Tract dilatation and number of tracts are important factors in reducing blood loss.

Use of the holmium:YAG laser for ureterolithotripsy in children

To review our experience with rigid ureteroscopy and holmium:YAG laser for treating ureteric calculi in children.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

PURPOSE We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Treatment of Retrocaval Ureter by Pure Laparoscopic Pyelopyelostomy: Experience on 4 Patients

OBJECTIVES To present our experience and the feasibility of pure laparoscopic pyelopyelostomy for treatment of retrocaval ureter (RCU). METHODS RCU was detected in 4 male (ages: 4, 16, 36, 48) patients, with complaints of flank pain. In all the patients, Type 1 RCU was present and the right ureter was involved. All patients underwent intraoperative retrograde pyelography before laparoscopy. The patients were operated upon using the transperitoneal approach in the lateral decubitis position, with two 10 mm and two 5 mm ports. After the ureter was released from the superior and inferior parts of the inferior vena cava, the dilated renal pelvis was transected and the ureter was brought in an anterolateral position to the vena cava. After the completion of the posterior wall anastomosis of pyelopyelostomy with 4-0 polyglactin sutures in a continuous manner, a double-J-stent was placed and the anterior wall was anastomosed in a watertight manner. A drain was placed in the operative area and the operation was completed. RESULTS Mean operation time was 210 minutes. No intraoperative complications occurred. In one patient, antegrade double-J-stent placement failed, and the stent was therefore placed in the retrograde way without any complications. Postsurgery, the urethral catheter was removed on the first day, and the drain on the second. All patients were discharged 48 hours after surgery. The third month postoperative follow-up confirmed that the anastomoses were patent and patients were symptom-free. CONCLUSIONS Pure laparoscopic pyelopyelostomy seems technically feasible and reliable for RCU treatment. Our experience showed that laparoscopy should be the standard treatment option for such patients.

Association of vitamin D receptor gene Taq I polymorphism with recurrent urolithiasis in children

Objective:  Urolithiasis has a strong familial component. However, to date, no specific genetic abnormality has been identified. It has been reported that allelic variation in the vitamin D receptor (VDR) gene may affect calcium absorption and excretion. Urolithiasis is a multifactorial disease in which both genetic and environmental factors have an effect on onset and severity of disease. In the present study, the role of Taq I polymorphism of vitamin D receptor gene in urolithiasis was studied.

Significance of age-specific creatinine levels at presentation in posterior urethral valve patients

OBJECTIVE Determination of prognostic factors is of great importance in decision making on therapies and informing parents about the probable outcome of disease. The present study aims to evaluate and assess the prognostic factors in posterior urethral valve (PUV) patients. MATERIALS AND METHODS The data of 68 patients treated between 1996 and 2004 were evaluated retrospectively. The mean age at diagnosis was 36.4 months. The serum creatinine levels were standardized using the age-specific creatinine reference (ASCR) levels. The age at diagnosis, clinical presentation, initial serum creatinine, method of treatment, presence of vesicoureteral reflux (VUR) and hydroureteronephrosis (HUN), all of which may effect the prognosis, were evaluated. RESULTS The analysis revealed that, of the 36 patients whose initial serum creatinine levels were within ASCR, only one (2.8%) had a final serum creatinine higher than ASCR values. In contrast, of the 32 patients whose initial serum creatinine levels were not within ASCR, 19 (59.4%) had final serum creatinine levels higher than ASCR (P<0.001). The distribution of final serum creatinine according to treatment method, presence of UTI before treatment and age at diagnosis was not statistically significant; however, the difference in distribution for initial serum creatinine (P<0.001), mode of clinical presentation (0.016), presence of HUN (0.019) and state of VUR (0.037) before treatment was statistically significant. CONCLUSION Final outcome with regard to renal function in PUV patients is affected by bilateral VUR and most significantly by serum creatinine levels higher than ASCR.