VESICOURETERAL REFLUX, URINARY TRACT INFECTION, AND DMSA ABNORMALITIES IN CHILDREN WITH MILD-MODERATE PRENATAL HYDRONEPHROSIS: SHOULD A VCUG AND DMSA SCAN BE PERFORMED?

Carlos R Estrada, Hiep T Nguyen, Alan B Retik, Craig A Peters Urology, Childrens Hospital Boston, Boston, MA

Purpose: The clinical relevance of mild-moderate prenatal hydronephrosis (PNH) is not well defined. We determined the risk of UTI and whether a postnatal VCUG and/or DMSA scan should be performed in patients with mild-moderate PNH.

Methods: From a prospective database of all patients with PNH maintained since 1998, we identified those with Society for Fetal Urology PNH ≤3. This cohort was divided into those who did and did not receive an initial VCUG. The rates of VUR and development of UTI were determined. The presence of DMSA abnormalities was also assessed.

Results: Of 2076 patients, 1514 had PNH≤3.76% had an initial VCUG, and VUR was found in 28%. Of patients without VUR and not on antibiotics, UTI developed in 1.3%. Of the patients with VUR on antibiotics, UTI developed in 1.5% at median age 4 months. In patients who did not have an initial VCUG, we estimated that 98/347 would have VUR and 1/347 would develop a UTI based on the above findings. However, 16 developed a UTI. VCUG performed in these 16 revealed VUR in 12. Thus, of an estimated 98 patients with VUR, 12.2% (p<0.0001) developed a febrile UTI at median age 5.5 months. The degree of PNH, VUR grade, and sex were comparable in both groups. Of the 1514 patients, 140 had an initial VCUG and DMSA scan. Of these, 38% had primary VUR of the following grades: 14% 1-2, 46% 3, and 40% 4-5. Of these 53, 57% had abnormal DMSA scans. All patients with no VUR had normal DMSA scans.

Conclusion: In patients with PNH≤3, identification of VUR and use of prophylactic antibiotics appears to reduce the risk of UTI. In addition, in patients with VUR, DMSA abnormalities are found in a majority, underscoring the value of a baseline renal scan in these patients if future DMSA scans are indicated. Therefore, we recommend that VCUG be performed in patients with PNH≤3 and a DMSA obtained in patients with VUR.

Saturday, October 8, 2005 10:21 AM
Oral Session: Urology - Vesicoureteral Reflux I (10:21 AM-11:00 AM)

AAP5L1_317

PREDICTIVE FACTORS OF SPONTANEOUS VESICOURETERAL REFLUX (VUR) RESOLUTION

Zeb M McMillan, J Christopher Austin, Charles E Hawtrey, Christopher S Cooper Pediatric Urology, Childrens Hospital of Iowa, Iowa City, IA

Purpose: Prognosis for spontaneous resolution of VUR affects treatment. VUR rade is the most commonly used factor to predict spontaneous resolution. We evaluated potential predictive factors aside from the grade of VUR for resolution.

Methods: We reviewed data from 120 children with primary VUR aged 0-7 years from 1990-2000: age, gender, height, weight, UTI history, reflux grade/laterality, bladder volume at onset of reflux relative to predicted bladder capacity, and VUR during filling or voiding for 1st, 2nd and most recent cystogram obtained before spontaneous resolution or operation. Exclusions: ureteral anomalies, functional/structural bladder abnormalities, known voiding dysfunction. Fishers or Chi-square exact tests compared categorical variables, two-sample t-test or Wilcoxon rank-sum test compared continuous and ordinal variables.

Results: Average age at diagnosis was 2.3 yrs.; ave. follow-up was 4.34 yrs. (range = 0.2-14.0). 64% spontaneously resolved, 23% underwent surgery, and 13% are being followed. Ave. time to resolution was 2.2 yrs. (range = 0.5-10.3), vs. 3.6 yrs. (range = 0.2-11.2) to surgery. VUR was bilateral in 53%. There was a significantly higher spontaneous resolution rate for lower grades of VUR at presentation (p=0.0004). Those with initial bladder volume >75% of predicted bladder capacity at onset of reflux were more likely to resolve VUR (p=0.0004, hazard ratio=3.35; 95% CI 1.72, 6.56), independent of grade. Improvement in grade from 1st and 2nd cystogram was also significantly associated with resolution (p=0.0001). Initial/final height and weight percentile, age, gender, and bilateral VUR were not predictors of resolution.

Conclusion: Bladder volume at onset of VUR and improvement between first and second cystogram provides prognostic information regarding VUR resolution. These factors, in addition to grade, should be considered when counseling parents regarding prognosis and treatment.

Saturday, October 8, 2005 10:29 AM
Oral Session: Urology - Vesicoureteral Reflux I (10:21 AM-11:00 AM)

AAP5L1_850

VCUG STUDIES IN CHILDREN: TO SEDATE OR NOT TO SEDATE?

Sean T Corbett, Paul A Merguerian Department of Surgery, Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Purpose: A childs ability to void during voiding cystourethrograms (VCUG) is important in diagnosing vesicoureteral reflux (VUR). At our institution the majority of VCUG studies are performed under sedation. The potential effect sedation has on the childs ability to void may impair our ability to detect VUR. We evaluated all VCUG studies performed over a two year period to assess the impact of sedation on VUR.

Methods: Retrospective evaluation was performed on all patients undergoing VCUG studies at our institution from 2002 to 2004. Patient characteristics, presenting symptoms, bladder capacity, emptying ability, and diagnoses were recorded. Children were categorized as receiving sedation versus not receiving sedation. All sedated children received propofol deep sedation. Statistical analyses were performed using the Pearson chi-square test.

Results: 335 patients were reviewed, of which 73.8% were female. Urinary tract infections (50.7%) and previous VUR (25.7%) were the most common factors necessitating a VCUG study. Other factors included a family history of reflux (1.5%) and hydronephrosis on prenatal ultrasound (6.0%). Sedation was administered in 195 patients and 52.3% were able to void to completion. Of the patients that did not receive sedation, 67.9% were able to void to completion (p=0.004).

Conclusion: Children that underwent a VCUG study with sedation were less likely to void to completion. By performing VCUG under sedation, we may not be able to accurately detect VUR in children. Large prospective studies are needed to better assess bladder emptying and sedation when performing VCUG studies.

Saturday, October 8, 2005 10:33 AM
Oral Session: Urology - Vesicoureteral Reflux I (10:21 AM-11:00 AM)

AAP5L1_532

RENAL SCARRING IN FAMILIAL VESICOURETERAL REFLUX: IS PREVENTION POSSIBLE?

Martina Pirker, Eric Colhoun, Prem Puri Childrens Research Centre, Our Ladys Hospital for Sick Children, Dublin, Ireland

Purpose: Whether screening of asymptomatic siblings of children with vesicoureteral reflux (VUR) is beneficial is still controversial. The aim of this study was to evaluate factors influencing renal scarring in familial VUR.

Methods: We reviewed the medical records and DMSA scans of 314 children (132 boys and 182 girls, 494 refluxing units) with familial VUR. Scarring was classified as mild (focal defects,>40% relative radionuclide uptake), moderate (20 to 40% uptake) and severe (shrunken kidney <20% uptake). The influence of urinary tract infections (UTI), grade of reflux and age at diagnosis on renal scarring were evaluated.

Results: The incidence of renal scarring was identical (37%) in index patients (n=145) and siblings presenting with UTI (n=75), but only 12% in screened asymptomatic siblings (n=91, p<0.001). The difference between siblings with and without UTI was only statistically significant for mild scarring (24% vs. 6.6%, p<0.01), but did not reach significance for moderate to severe scarring (13.3 vs. 5.5%). Renal scarring was found in 15% of grade I to III refluxing renal units and in 27% of grade IV to V units (p<0.001). This difference was only significant for moderate/severe renal scarring (5% vs. 16%, p<0.001), but the of mild scarring was similar in both groups. (9% vs. 12%). Scarring incidence was significantly lower in patients identified to have VUR before three years of age (n=213, 23.6%) scars) than in patients diagnosed late (n=101, 41% scars, p<0.005) affecting both mild scarring (12% vs. 20%) and moderate/severe scarring (11% vs. 22%).

Conclusion: The development of mild renal scarring seems to be predominantly dependent on the occurrence of urinary tract infections, while moderate and severe scarring is mainly seen in patients with high grades of reflux. Early detection and treatment of reflux may minimize both factors and result in a significant decrease in the occurrence of all grades of renal scarring.

Saturday, October 8, 2005 10:37 AM
Oral Session: Urology - Vesicoureteral Reflux I (10:21 AM-11:00 AM)

AAP5L1_256

PROGRESSION TO END STAGE RENAL DISEASE IN MALE PATIENTS WITH BILATERAL REFLUX AND INITIAL RENAL FAILURE

Massimo Villa, Antonio Zaccara, Paolo Caione, Mario De Gennaro, Francesco Rulli, Attilio Maria Farinon, Gianfranco Rizzoni Surgery, University of Rome Tor Vergata, Rome, Italy; Nephrology and Urology, Bambino Gesu Childrens Hospital, Rome, Italy

Purpose: It is believed that Prenatal Diagnosis (PD) as well as prompt treatment of Urinary Tract Infections (UTI) may affect progression of male patients with bilateral Vesico-Ureteric Reflux (VUR) and Initial Renal Failure (IRF) to End Stage Renal Disease (ESRD). However, such factors have never been addresses in terms of analysis of survival.

Methods: All male patients with pre or postnatal diagnosis of bilateral RVU and signs of IRF within one year of life underwent an analysis of progression to ESRD by the Kaplan-Meier survival analysis . IRF was defined as Serum Creatinine (SCr) > 1 mg/dl at one year of age. ESRD was defined as necessity of renal replacement therapyDichotomous variables such as Reflux Grade (RG) , Prenatal Diagnosis (PD), urinary infections (UTI) and Surgical Repair (SR) were taken into consideration

Results: Twenty-eight patients with VUR and IRF were considered over a 18 year period. Mean age was 12.6 .4.4 years :follow up ranged from 3 to 18 years (median: 13.1 years) Four patients had grade III, 18 grade IV and 6 grade V VUR. Mean SCr at one year of age was 1.14 mg/dl.

None of the considered variables proved to be significantly associated to progression to ESRD with the exception of SR (mean survival 179 vs. 120 months; Log Rank test= 7, p< 0.05)

Conclusion: Progression to ESRD in male patients with VUR and IRF appears to be independent of PD, RG or UTI and this confirms that severe dysplasia is probably present before birth. SR appears to reduce the speed of such progression but this finding needs to be validated by a larger number of cases..

Saturday, October 8, 2005 10:43 AM
Oral Session: Urology - Vesicoureteral Reflux I (10:21 AM-11:00 AM)

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