This Month in Pediatric Urology

Article Outline

• AUA Guidelines on Management of Primary Vesicoureteral Reflux in Children
• Clinical Practice Guidelines for Screening for Vesicoureteral Reflux and Prenatal Hydronephrosis
• Is a Routine Renogram Required After Pyeloplasty
• Epidemiological Trends in Pediatric Urolithiasis
• Evaluation of Renal Function After Shock Wave Lithotripsy
• What is the Best Minimally Invasive Modality for Distal Ureteral Calculi?
• Copyright

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AUA Guidelines on Management of Primary Vesicoureteral Reflux in Children 

In the first of 2 reports members of the AUA Vesicoureteral Reflux (VUR) Guidelines Panel describe meta-analysis of data extracted from 131 articles in the literature (page 1134). The purpose of the panel was to determine outcomes related to evaluation and treatment of children older than 1 year with VUR, evaluation and treatment of infants younger than 1 year with VUR, and treatment of children with VUR and bladder/bowel dysfunction (BBD). Risk factors for renal cortical scarring were identified, including the frequency of urinary tract infections (UTIs), increasing grade of VUR and presence of BBD. The efficacy of continuous antibiotic prophylaxis could not be established based on current data nor could the lack of efficacy recently reported in prospective clinical trials due to numerous limitations of these studies. The presence of BBD affected spontaneous VUR resolution rates, risk of febrile UTIs and renal scarring, risk of postoperative UTI and rate of cure following endoscopic therapy. Based on evidence and expert opinion, statements were graded based on the degree of flexibility in application. Guidelines were proposed for initial and followup evaluation, nonoperative and operative management, and long-term followup based on relative risk levels.

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Clinical Practice Guidelines for Screening for Vesicoureteral Reflux and Prenatal Hydronephrosis 

The need for diagnosis and treatment of incidentally detected VUR either from screening siblings of patients with VUR or infants with prenatal hydronephrosis (PNH) remains highly controversial. In the second report from the AUA Vesicoureteral Reflux Guidelines Panel the existing evidence related to screening siblings and offspring of index patients with VUR and infants with PNH is summarized (page 1145). A total of 22 articles (3,201 children) were selected for data extraction on sibling and offspring screening for VUR. Of 43 studies on PNH reported between 1991 and 2008 VUR prevalence among 4,765 patients with PNH was described in 34. However, only 5 studies involving 302 infants provided extractable information on renal function abnormalities and only 8 studies on 616 infants included data on UTIs. The authors conclude that the lack of randomized controlled trials of treated vs untreated patients with VUR detected by sibling screening or prenatal sonography preclude assessment of treatment outcomes such as spontaneous VUR resolution, rates of UTI or renal scarring. Screening guidelines were based on present practice, risk assessment, meta-analysis results and panel consensus.

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Is a Routine Renogram Required After Pyeloplasty 

Postoperative evaluation of the results of pediatric pyeloplasty varies from institution to institution but generally includes ultrasound (US) and/or diuretic renal scintigraphy (RS). Greater anatomical detail is provided on US while greater functional information is provided on RS. With the high success rates of pyeloplasty, some question whether RS is necessary for routine clinical practice. Almodhen et al (page 1128) from Montreal, Canada compared retrospectively the results of preoperative and postoperative US and diuretic RS in 97 patients who underwent 101 pyeloplasties at a median age of 18 months. The initial postoperative US showed subjective “improvement” in 90% of kidneys but actual downgrading in only 46. The initial postoperative RS showed nonobstructed drainage in 94% of cases. Obstruction was not seen on RS in any of the 46 kidneys with downgraded hydronephrosis compared to 9% of those without downgrading (p <0.03). In 2 of 91 kidneys with improvement on initial US obstruction was seen on RS which spontaneously resolved. In contrast, of 10 kidneys with no improvement on initial postoperative US 4 had obstruction on RS (p <0.001). The authors conclude that patients with downgraded hydronephrosis on US after pyeloplasty do not require RS to rule out obstruction. However, functional improvement, primarily seen in those with preoperative differential function less than 45%, can only be determined by RS.

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Epidemiological Trends in Pediatric Urolithiasis 

Although recently it has been suggested in the lay press that the incidence of pediatric urolithiasis is increasing, population based, epidemiological data are lacking. Institutional increase in volume at pediatric hospitals could be the result of a variety of factors such as increased marketing of stone management services, referral patterns to pediatric stone centers and pediatric urological staffing, or acquisition of new technology or equipment. Using the Pediatric Health Information System database, Routh et al (page 1100) from Boston, Massachusetts analyzed the trends in hospital encounters for urolithiasis at participating pediatric hospitals from January 1999 to December 2008. Compared to the total number of patients seen at each hospital, the number of children diagnosed with urolithiasis increased from 18.4 to 57.0/100,000 total patients per year (p <0.0001 for trend), representing an annual increase of 10.6% per year when corrected for hospital volume. The authors conclude that while it is important to recognize that their data are hospital and not population based, there has been a significant increase n the number of children diagnosed with and treated for urolithiasis at pediatric hospitals during the last decade, even after correcting for the increases in total patient volume at these hospitals.

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Evaluation of Renal Function After Shock Wave Lithotripsy 

A concern regarding shock wave lithotripsy (SWL) for stones in children has been the long-term safety of shock waves on the renal parenchyma. Fayad et al (page 1111) from Cairo, Egypt prospectively evaluated the records of 100 children (138 stones) 3 to 14 years old treated with SWL in a 3-year period (total 153 sessions, range 1 to 2 sessions per patient). Dimercapto-succinic acid scintigraphy was performed and estimated glomerular filtration rate was measured using diethylenetetramine pentaacetic acid before and 6 months after the last session of SWL. The overall stone-free rate was 88%. None of the patients showed any degree of renal scarring or a decrease in split kidney function. The authors conclude that SWL is a safe treatment modality for children with kidney stones without significant impact on kidney function or subsequent renal scarring, regardless of the size of the stone or number of SWL sessions.

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What is the Best Minimally Invasive Modality for Distal Ureteral Calculi? 

There is a paucity of prospective, well designed, randomized controlled trials analyzing the relative effectiveness of minimally invasive treatment modalities for ureteral calculi in children. Basiri et al (page 1106) from Tehran, Iran conducted a multicenter randomized controlled trial of 100 consecutive children with distal ureteral calculi treated between February 2007 and October 2009. Patients were randomized to undergo either SWL or standard transureteral lithotripsy (TUL) at 6 endourological centers. Centers were matched for equipment/devices, and patients were matched for age, gender and stone size. The stone-free rate 2 weeks after TUL was 78% vs 56% for SWL (p=0.004). The stone-free rate after SWL increased to 72% after session 2 of SWL. Repeat treatment was required in 18% of the TUL group compared 38% in the SWL group. Although the incidence of minor complications was similar in both groups, ureteral perforations associated with the use of a large 8.5Fr ureteroscope occurred in 2 patients. The authors conclude that TUL has a higher success rate than SWL with comparable safety if small caliber ureteroscopes are used.