Joana Dos Santos

Recommendations for the Management of Bladder Bowel Dysfunction in Children

Bladder Bowel dysfunction (BBD) represents a broad term used to describe a multitude of conditions associated with incontinence or Urinary Tract Infections (UTI) that commonly is seen in primary Family and/or Pediatrics care. The BBD spectrum includes lower urinary tract conditions such as overactive bladder and urge incontinence, voiding postponement, underactive bladder, and voiding dysfunction, and, importantly, also includes bowel issues, as constipation and encopresis. BBD is often not recognised by family or child or even the referring professional, but it is the secondary symptoms of wetting or UTI, that prompts the child to be evaluated by a consultant. The goal of this review is to provide a practical guideline for diagnosis and management of BBD in children, common problem in daily pediatric practice. Most importantly, considering that most of these issues are functional, is that the majority of these children are best evaluated and treatment instituted by the primary provider, with referral to a specialist, only in exceptional cases.

Bladder and bowel dysfunction in children: An update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem

Bladder and bowel dysfunction (BBD) describes a spectrum of lower urinary symptoms (LUTS) accompanied by fecal elimination issues that manifest primarily by constipation and/or encopresis. This increasingly common entity is a potential cause of significant physical and psychosocial burden for children and families. BBD is commonly associated with vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs), which at its extreme may lead to renal scarring and kidney failure. Additionally, BBD is frequently seen in children diagnosed with behavioural and neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Patients with concomitant BBD and neuropsychiatric disorders have less favourable treatment outcomes. Early diagnosis and treatment of BBD are critical to avoid secondary comorbidities that can adversely impact childrens kidney and bladder function, and psychosocial well-being. The majority of patients will improve with urotherapy, adequate fluid intake, and constipation treatment. Pharmacological treatment must only be considered if no improvement occurs after intensive adherence to at least six months of urotherapy ± biofeedback and constipation treatment. Anticholinergics remain the mainstay of medical treatment. Selective alpha-blockers appear to be effective for improving bladder emptying in children with non-neurogenic detrusor overactivity (DO), incontinence, recurrent UTIs, and increased post-void residual (PVR) urine volumes. Alpha-1 blockers can also be used in combination with anticholinergics when overactive bladder (OAB) coexists with functional bladder outlet obstruction. Minimally invasive treatment with onabotulinumtoxinA bladder injections, and recently neurostimulation, are promising alternatives for the management of BBD refractory to behavioural and pharmacological treatment. In this review, we discuss clinical presentation, diagnostic approach, and indications for behavioural, pharmacological, and surgical treatment of BBD in children based on a thorough literature review. Expert opinion will be used when scientific evidence is unavailable.

A New Grading System for the Management of Antenatal Hydronephrosis

BACKGROUND AND OBJECTIVES Standard clinical assessments do not predict surgical intervention in patients with a moderate degree of upper tract hydronephrosis. This study investigated whether combined measures of renal calyceal dilation and anteroposterior diameter (APD) of the renal pelvis at the first postnatal ultrasound better predict surgical intervention beyond standard assessments of the APD or Society of Fetal Urology (SFU) grading system. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort of 348 children with antenatal hydronephrosis followed from 2003 to 2013 were studied. Using Cox regression, the risk for surgery by APD, SFU, and combined grading on the basis of the first postnatal ultrasound was calculated. The predictive capability of each grading system for surgery was determined by calculating the positive likelihood ratio (LR+). RESULTS The combination of APD≥6-9 mm and diffuse caliectasis had a hazard ratio (HR) of 19.5 (95% confidence interval [95% CI], 3.94 to 96.9) versus 0.59 (95% CI, 0.05 to 6.53) for APD≥6-9 mm alone and a similar risk of 8.9 for SFU grade 3 (95% CI, 3.84 to 20.9). The combination of APD≥9-15 mm and diffuse caliectasis had an HR of 18.7 (95% CI, 4.36 to 80.4) versus 1.75 (95% CI, 0.29 to 10.5) for APD≥9-15 mm alone. The LR+ for surgery for diffuse caliectasis and APD≥6-9 mm was higher than for APD≥6-9 mm alone (HR=2.62; 95% CI, 0.87 to 7.94 versus HR=0.04; 95% CI, 0.01 to 0.32) and was higher for APD≥9-15 mm and diffuse caliectasis than APD≥9-15 mm alone (HR=2.0; 95% CI, 1.15 to 3.45 versus HR=0.14; 95% CI, 0.04 to 0.43). Both combined groups of moderate hydronephrosis (APD≥6-9 mm or ≥9-15 mm with diffuse caliectasis) had only slightly higher LR+ than SFU grade 3 (HR=1.89; 95% CI, 1.17 to 3.05). CONCLUSIONS These results suggest a grading system combining APD and diffuse caliectasis distinguishes those children with moderate degrees of upper tract hydronephrosis that are at higher risk of surgery.

Outcome Analysis of Asymptomatic Lower Pole Stones in Children

PURPOSE Lower pole renal stones in children usually present incidentally. To our knowledge frequency and need for intervention are unknown. We evaluated the outcomes of asymptomatic, incidentally found lower pole renal stones in children. MATERIALS AND METHODS We retrospectively reviewed the charts and renal ultrasounds of children with lower pole stones seen during a period of 14 years. The unpaired t-test was used to determine factors that might predict the need for stone intervention, including size, growth rate, type of stone and underlying metabolic disease. The success rate of nonoperative management, defined by spontaneous passage or lack of growth in the absence of symptoms, was calculated. RESULTS A total of 224 children were found to have lower pole stones. Mean ± SD age at presentation was 95.2 ± 65.3 months. Of the patients 120 (53.6%) spontaneously passed stones. Of the stones 25% remained asymptomatic and did not grow with time. Intervention was performed in 48 children (21.4%). Stones originally managed conservatively that later required intervention were significantly larger at baseline than stones that did not require intervention through the end of followup (median 7 vs 5 mm, p <0.001) and those that grew with time (median stone size 8 mm at surgical intervention, p = 0.01). CONCLUSIONS Our data suggest that asymptomatic lower pole renal stones can be followed conservatively. Of the calculi 78.6% passed spontaneously or remained asymptomatic and did not grow. Median initial size greater than 7 mm and stone growth with time were significant risk factors that predicted the need for intervention.

Clinical Outcomes of the Upper Urinary Tract after Ureteral Clipping for Treatment of Low Functioning or Nonfunctioning Renal Moieties

Purpose: A growing body of evidence suggests that it is safe to ligate the ureter of poorly functioning renal moieties during renal transplantation. We present clinical outcomes and data on hydronephrosis progression in pediatric cases associated with ectopic ureters and obstructive ureteroceles. Materials and Methods: We prospectively collected data for 35 consecutive patients (23 females and 12 males) who underwent ureteral clipping between February 2011 and August 2016. Patients were divided into 4 groups consisting of 1) duplex system with ectopic ureter (45.7%), 2) duplex system with a large ureterocele (11.4%), 3) other duplex system (8.6%) and 4) single system kidneys (34.3%). Patients were followed for clinical outcomes and hydronephrosis trends. Comparisons included preoperative and postoperative anteroposterior diameter, maximal ureteral diameter and ureterocele size. Results: Median age at surgery was 59 months (IQR 11 to 120, range 5 to 216). Median ± SD operative time was 108.9 ± 31.1 minutes (range 20 to 180) and median length of stay was 7.5 hours (IQR 6 to 19, range 5 to 336). Immediate resolution of urinary incontinence was observed in all 16 ectopic ureter cases. After a median ± SD followup of 20.8 ± 13.8 months (IQR 8.5 to 30, range 6 to 50) 97.2% of the patients remained asymptomatic. No significant differences were observed between initial and last anteroposterior diameter measurements except in group 1 (p = 0.001). All ureteroceles demonstrated a significant decrease in median ± SD size after clipping (from 2.7 ± 0.41 to 0.53 ± 0.92 cm, p = 0.003). Pyonephrosis developed in 1 patient, who underwent laparoscopic nephrectomy. Conclusions: Ureteral clipping appears to be a reasonable, safe and effective option for pediatric patients in the reported settings, with the potential to be simpler and quicker than extirpative or reconstructive procedures.

Neurostimulation Therapy for Non-neurogenic Overactive Bladder in Children: A Meta-analysis

OBJECTIVE To assess the efficacy and safety of neurostimulation for non-neurogenic overactive bladder in children, we conducted a meta-analysis of randomized controlled trials (RCTs). MATERIALS AND METHODS A systematic literature search was performed on August 2016. RCTs were evaluated according to the Cochrane Collaboration risk of bias assessment. Number of patients with post-treatment partial response (PR) (50%-89%), complete response (CR) (≥90%), and full response (FR) (100%) were extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled using the Mantel-Haenszel method with random effect model if significant inter-study heterogeneity (P <.1) was noted. Subgroup analysis was performed according to each treatment setting (PROSPERO CRD42016043502). RESULTS Five eligible studies (245 patients) were included. Overall effect estimates showed that compared with standard urotherapy, neurostimulation demonstrated significantly better ≥50% (PR + CR + FR) response (RR = 2.8, 95% CI 1.1-7.2), but not ≥90% (CR + FR) response (RR = 8.28, 95% CI 0.65-105.92). Clinic-based neurostimulation had significantly better treatment outcomes for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) responses (RR = 3.24, 95% CI 1.89-5.57; RR = 20.81, 95% CI 2.97-145.59, respectively), whereas a self-administered regimen showed no differences for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) response rates between treatment groups (RR = 2.61, 95% CI 0.48-14.15; RR = 3.55, 95% CI 0.19-67.82, respectively). No serious adverse events were reported. CONCLUSION Neurostimulation therapy may lead to better partial improvement of non-neurogenic overactive bladder; however, it may not render a definitive complete response. Office-based neurostimulation seems more efficacious than self-administered neurostimulation. Further RCTs are needed to compare outcomes of the 2 regimens.

A critical review of recent clinical practice guidelines for pediatric urinary tract infection

INTRODUCTION Concerns regarding the quality, credibility, and applicability of recently published pediatric urinary tract infection (UTI) clinical practice guidelines have been raised due to the inconsistencies of recommendations between them. We aimed to determine the quality of the recent clinical practice guidelines on pediatric UTI by using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument, and summarize the standard of care in diagnosis and management of pediatric UTI from the top three clinical practice guidelines. METHODS A systematic literature search was performed on medical literature electronic databases and international guideline repository websites. English language-based clinical practice guidelines from 2007-2016 endorsed by any international society or government organization providing recommendations for the management of pediatric UTI were considered. Eligible clinical practice guidelines were independently appraised by six reviewers using the AGREE II tool. Clinical practice guidelines were assessed for standardized domains and summarized for overall quality. Inter-rater reliability was assessed using inter-class coefficient (ICC). RESULTS Thirteen clinical practice guidelines were critically reviewed. The Spanish clinical practice guidelines, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence clinical practice guidelines consistently scored high on all AGREE domains (total averaged domain scores 90, 88, and 88, respectively). Among the six reviewers, there was a high degree of inter-rater reliability (average measure ICC 0.938; p<0.0001). There is reasonable consensus among the top three clinical practice guidelines in their major recommendations. CONCLUSIONS The clinical practice guidelines from Spain, American Academy of Pediatrics, and National Institute for Health and Clinical Excellence, with their major recommendations being similar, have scored highly on the AGREE II indicators of quality for the clinical practice guidelines development process.

Impact of smartphone digital photography, email, and media communication on emergency room visits post-hypospadias repair

INTRODUCTION Advances in communication technology are shaping our medical practice. To date, there is no clear evidence that this mode of communication will have any effect on unnecessary postoperative emergency room (ER) visits. We aim to evaluate the effect of email and media communication with application of smartphone digital photography on post-hypospadias repair ER visit rates. METHODS This prospective cohort study included all patients who underwent hypospadias repair performed by a single surgeon from October 2014 to November 2015. Patients were categorized into two groups: Group A consented for smartphone photography and email communication and Group B declined. Reason for ER visits within 30 days postoperatively was assessed by another physician, who was blinded of patient group assignment. The reasons were categorized as: unnecessary ER visit, indicated ER visit, or visit unrelated to hypospadias surgery. Chi-square test and T-test were used for statistical analysis. Relative risk (RR) and corresponding 95% confidence interval (CI) were also calculated. Statistical significance was set at p<0.05. RESULTS Over a 14-month period, 96 patients underwent hypospadias repair (81 in Group A, 15 in Group B 5). No significant difference was noted between groups for overall ER return rate (RR 0.46, 95% CI 0.21, 1.0). However, the number of ER visits for wound check not requiring intervention was significantly lower in Group A than in Group B (RR 0.14, 95% CI 0.035, 0.56); likewise, a higher number of ER visits requiring intervention was noted in Group A compared with Group B, although statistically this was not significant (RR 1.67, 95% CI 0.23, 12.21). CONCLUSIONS Email communication with the use of smartphone digital photography significantly reduced the number of unnecessary ER visits for post-hypospadias wound checks.

Outcome Analysis of Redo Orchiopexy: Scrotal vs Inguinal

PURPOSE Redo orchiopexy after previous surgery is technically challenging and requires skills and care to ensure preservation of cord structures. We report our experience with redo orchiopexy in children. MATERIALS AND METHODS We retrospectively reviewed patients who had undergone redo orchiopexy between January 2004 and May 2015. Variables evaluated included primary procedure, type of redo procedure, operative time, shift of surgical route, operative and postoperative complications, and testicular location at last followup. RESULTS A total of 3,384 orchiopexies were performed during the study period, with 61 children (1.8%) requiring redo orchiopexy. Mean ± SD patient age at redo orchiopexy was 6.4 ± 3.6 years (range 1.5 to 17.1) and average followup was 24.9 months (2.1 to 99.6). The primary surgical procedure preceding redo surgery was inguinal orchiopexy in 45.9% of the patients, scrotal orchiopexy in 13.1% and laparoscopy in 13.1%, and 27.9% of patients were status post inguinal surgery (hernia/hydrocele repair). Redo surgery was performed by inguinal approach in 33 patients, while 28 children underwent a scrotal approach. There was no statistical difference in intraoperative and postoperative complication rates for the 2 approaches (p = 0.52 and p = 0.26, respectively). However, there was a statistically significant difference in overall operative time between approaches (p = 0.003) with scrotal orchiopexy being significantly shorter (53.1 minutes) compared to inguinal orchiopexy (84.6). CONCLUSIONS Scrotal and inguinal orchiopexy appear to be viable in managing secondarily ascending testes, with the scrotal approach offering some advantage in terms of length of procedure.

Clinical implication of renal allograft volume to recipient body surface area ratio in pediatric renal transplant

Our study aims to assess the clinical implication of RAV/rBSA ratio in PRT as a predictor for attained renal function at 1 year post‐transplantation and its association with surgical complications. A retrospective cohort was performed for PRT cases from January 2000 to December 2015 in our institution. Extracted clinical information includes the recipients demographics, donor type, renal allograft characteristics, arterial, venous and ureteral anastomoses, vascular anastomosis time while kidney off ice, overall operative time, and estimated blood loss. The RAV/rBSA was extrapolated and assessed for its association with renal graft function attained in 1 year post‐transplantation and surgical complications within 30‐day post‐transplantation. A total of 324 PRTs cases were analyzed. The cohort consisted of 187 (52.4%) male and 137 (42.3%) female recipients, with 152 (46.9%) living donor and 172 (53.1%) deceased donor renal transplants, and an overall median age of 155.26 months (IQR 76.70‐186.98) at time of renal transplantation. The receiver operating characteristic identified that a RAV/rBSA ratio of 135 was the optimal cutoff in determining the renal graft function outcome. Univariate and multivariate analyses revealed the relative OR for RAV/rBSA ≥ 135 ratio in predicting an eGFR ≥ 90 attained within 1 year post‐transplant was highest among younger pediatric recipients (<142.5 months) of deceased kidney donors (OR = 11.143, 95% CI = 3.156‐39.34). Conversely, Kaplan‐Meier analysis revealed that RAV/rBSA ratio ≥ 135 is associated with lower odds of having eGFR <60 (OR = 0.417, 95% CI = 0.203‐0.856). The RAV/rBSA ratio was not associated nor predictive of transplant‐related surgical complications. Our study determined that the RAV/rBSA ratio is predictive of renal graft function at 1‐year PRT, but not associated with any increased surgical complications.