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Purpose We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution. Materials and Methods We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram. Results We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A—short focal recurrence, which may be salvaged with an endoscopic procedure, and type B—the long graft length type, which is less likely to be salvaged with endoscopy. Conclusions Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment. [ABSTRACT FROM AUTHOR]

Purpose The Third International Consensus Definitions for Sepsis and Septic Shock Task Force proposed a new definition of sepsis based on the SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score and introduced a novel scoring system, quickSOFA, to screen patients at high risk for sepsis. However, the clinical usefulness of these systems is unclear. Therefore, we investigated predictive performance for mortality in patients with acute pyelonephritis associated with upper urinary tract calculi. Materials and Methods This retrospective study included 141 consecutive patients who were clinically diagnosed with acute pyelonephritis associated with upper urinary tract calculi outside the intensive care unit. We evaluated the performance of the quickSOFA, SOFA and SIRS (systemic inflammatory response syndrome) scores to predict in-hospital mortality and intensive care unit admission using the AUC of the ROC curve, net reclassification, integrated discrimination improvements and decision curve analysis. Results A total of 11 patients (8%) died in the hospital and 26 (18%) were admitted to the intensive care unit. The AUC of quickSOFA to predict in-hospital mortality and intensive care unit admission was significantly greater than that of SIRS (each p <0.001) and comparable to that of SOFA (p = 0.47 and 0.57, respectively). When incorporated into the baseline model consisting of patient age, gender and the Charlson Comorbidity Index, quickSOFA and SOFA provided a greater change in AUC, and in net classification and integrated discrimination improvements than SIRS for each outcome. Decision curve analyses revealed that the quickSOFA and SOFA incorporated models showed a superior net benefit compared to the SIRS incorporated model for most examined probabilities of the 2 outcomes. The in-hospital mortality rate of patients with a quickSOFA score of 2 or greater and a SOFA score of 7 or greater, which were the optimal cutoffs determined by the Youden index, was 18% and 28%, respectively. Conclusions SOFA and quickSOFA are more clinically useful scoring systems than SIRS to predict mortality in patients with acute pyelonephritis associated with upper urinary tract calculi. [ABSTRACT FROM AUTHOR]

Purpose Distal ureteral diameter ratio is an objective measure that is prognostic of spontaneous resolution of vesicoureteral reflux. Along with likelihood of resolution, improved identification of children at risk for recurrent febrile urinary tract infections may impact management decisions. We evaluated the usefulness of ureteral diameter ratio as a predictive factor for breakthrough febrile urinary tract infections. Materials and Methods Children with primary vesicoureteral reflux and detailed voiding cystourethrogram were identified. Ureteral diameter ratio was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between L1 and L3 vertebral bodies. Demographics, vesicoureteral reflux grade, laterality, presence/absence of bladder-bowel dysfunction, and ureteral diameter ratio were tested in univariate and multivariable analyses. Primary outcome was breakthrough febrile urinary tract infections. Results We analyzed 112 girls and 28 boys with a mean ± SD age of 2.5 ± 2.3 years at diagnosis. Vesicoureteral reflux was grade 1 to 2 in 64 patients (45.7%), grade 3 in 50 (35.7%), grade 4 in 16 (11.4%) and grade 5 in 10 (7.2%). Mean ± SD followup was 3.2 ± 2.7 years. A total of 40 children (28.6%) experienced breakthrough febrile urinary tract infections. Ureteral diameter ratio was significantly greater in children with (0.36) vs without (0.25) breakthrough febrile infections (p = 0.004). Controlling for vesicoureteral reflux grade, every 0.1 U increase in ureteral diameter ratio resulted in 1.7 times increased odds of breakthrough infection (95% CI 1.24 to 2.26, p <0.0001). Conclusions Children with increased distal ureteral diameter ratio are at greater risk for breakthrough febrile urinary tract infections independent of reflux grade. Ureteral diameter ratio provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making. [ABSTRACT FROM AUTHOR]

Purpose Improved bladder and renal management benefit patients with congenital uropathy and congenital pediatric kidney disease. This may translate to delayed initial renal transplantation in these patients, and improved graft and patient survival. Our primary study purpose was to determine whether patients with congenital uropathy and congenital pediatric kidney disease have demonstrated later time to first transplantation and/or graft survival. Materials and Methods SRTR (Scientific Registry of Transplant Recipients) was analyzed for first renal transplant and survival data in patients with congenital uropathy and congenital pediatric kidney disease from 1996 to 2012. Congenital uropathy included chronic pyelonephritis/reflux, prune belly syndrome and congenital obstructive uropathy. Congenital pediatric kidney disease included polycystic kidney disease, hypoplasia, dysplasia, dysgenesis, agenesis and familial nephropathy. Results A total of 7,088 patients with congenital uropathy and 24,315 with congenital pediatric kidney disease received a first renal transplant from 1996 to 2012. A significant shift was seen in both groups toward older age at initial renal transplantation in those 18 through 64 years old. In the congenital uropathy group this effect was most facilitated by decreased renal transplantion in patients between 18 and 35 years old (38% in 1996 vs 26% in 2012). The congenital pediatric kidney disease group showed a substantial decrease in patients who were 35 to 49 years old (from 39% to 29%). At 10-year followup the congenital uropathy group showed better graft and patient survival than the congenital pediatric kidney disease group. However, aged matched comparison revealed comparable survival rates in the 2 groups. Conclusions Analysis of trends in the last 14 years demonstrated that patients with both lower and upper tract congenital anomalies experienced delayed time to the first renal transplant. Furthermore, patients had similar age matched graft and patient survival whether the primary source of renal demise was the congenital lower or upper tract. These findings may indicate that improved urological and nephrological care are promoting renal preservation in both groups. [ABSTRACT FROM AUTHOR]

Purpose Improved identification of children with vesicoureteral reflux at risk for recurrent febrile urinary tract infection may impact management decisions. We hypothesized that reflux occurring earlier during bladder filling increases the duration of exposure of the kidneys to bacteria, and, therefore, increases the risk of pyelonephritis. Materials and Methods Children with vesicoureteral reflux and detailed voiding cystourethrogram data were identified. Bladder volume at onset of reflux was normalized for age. Demographics, reflux grade, laterality, presence/absence of bladder-bowel dysfunction and breakthrough febrile urinary tract infections were assessed. Median followup was 24 months (IQR 12 to 52). Results A total of 208 girls and 47 boys were analyzed with a mean ± SD age at diagnosis of 3.1 ± 2.6 years. On univariate analysis history of febrile urinary tract infection (HR 2.17, 95% CI 1.33–2.85, p = 0.01), dilating vesicoureteral reflux (HR 1.6, 95% CI 1.05–2.42, p = 0.03) and bladder-bowel dysfunction (HR 1.66, 95% CI 0.99–2.75, p = 0.05) were associated with an increased risk of breakthrough febrile urinary tract infection. Median bladder volume at onset of reflux in children with breakthrough febrile urinary tract infection was significantly less (33.1%) than in those without infection (49.5%, p = 0.003). Reflux onset at 35% predicted bladder capacity or less was associated with a significantly increased risk of breakthrough febrile urinary tract infection on multivariate analysis (HR 1.58, 95% CI 1.05–2.38, p = 0.03). Conclusions Children with early filling vesicoureteral reflux are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. Bladder volume at onset of reflux should be recorded during cystograms since it provides additional prognostic information about the risk of pyelonephritis and resolution, and may assist with counseling and clinical decision making. [ABSTRACT FROM AUTHOR]

Purpose Delivering the recommended care is an important quality measure that has been insufficiently studied in urology. Obstructive pyelonephritis is a suitable case study for this focus because many patients do not receive such care, although guidelines advocate decompression. We determined the influence of hospital factors, particularly familiarity with urolithiasis, on the likelihood of decompression in such patients. Materials and Methods We used the NIS from 2002 to 2011 to retrospectively identify patients admitted to community hospitals with severe infection and ureteral calculi. Hospital familiarity with nephrolithiasis was estimated by calculating hospital stone volume (divided into quartiles) and hospital treatment intensity (the decompression rate in patients with ureteral calculi and no infection). After calculating national estimates we performed logistic regression to determine the association between the receipt of decompression and hospital stone volume, controlling for treatment intensity and other covariates thought to be associated with receiving recommended care. Results Of an estimated 107,848 patients with obstructive pyelonephritis 27.4% failed to undergo decompression. Discrepancies were greatest between hospitals with the highest and lowest stone volumes (76% vs 25%, OR 2.77, 95% CI 1.94–3.96, p <0.01) as well as high and low treatment intensity (78% vs 37%, p <0.01). Conclusions High hospital stone volume and treatment intensity were associated with an increased likelihood of receiving decompression. Such findings might be useful to identify hospitals and regions where access to quality urological care should be augmented. [ABSTRACT FROM AUTHOR]

Purpose We investigated the efficacy of recombinant human interferon-γ in experimental pyelonephritis due to Escherichia coli. Materials and Methods Pyelonephritis was induced by intrapelvic inoculation of bacteria after ureteral ligation in 38 rabbits assigned to 1 of 3 groups, including group 1--16 controls, group 2--14 rabbits treated with intravenous recombinant human interferon-γ and group 3--8 rabbits treated with intravenous recombinant human interferon-γ plus amikacin. Bacterial counts, cytokines and malondialdehyde were measured in blood. Peripheral blood mononuclear cells were isolated to measure TNFα transcripts, cytokine stimulation and apoptosis. Survival was recorded, and the tissue bacterial load and myeloperoxidase activity were measured after sacrifice. Results The mortality rate in groups 1, 2 and 3 was 66.7%, 25% and 12.5%, respectively. The circulating bacterial count and tissue bacterial load were less in group 2 than in group 1. Circulating malondialdehyde negatively correlated with the bacterial load of the spleen. Although the number of TNFα transcripts in circulating peripheral blood mononuclear cells did not differ, peripheral blood mononuclear cells isolated from group 2 at 48 hours produced much greater concentrations of tumor necrosis factor-α after stimulation with Pam3Cys. In parallel, the apoptosis rate of circulating monocytes was increased in group 2 at 48 hours. Lung myeloperoxidase activity at 24 hours, serving as indirect evidence of neutrophil infiltration, was decreased in group 2. Conclusions Recombinant human interferon-γ administration prolonged survival in rabbits with experimental E. coli urosepsis. Its action was probably related to increased bacterial phagocytosis after modulation of oxidant status and reversal of monocyte immunoparalysis. [ABSTRACT FROM AUTHOR]

Purpose: Dilating vesicoureteral reflux provokes concern for physicians and parents that often leads to corrective surgery in young children. Since there are limited data describing the natural history of dilating vesicoureteral reflux in infants, we identified factors predictive of resolution/improvement in infants initially treated nonoperatively. Materials and Methods: We reviewed the medical records of 90 infants 6 months old or younger from 2004 to 2010 who were referred for prenatal hydronephrosis or initial febrile urinary tract infection and found to have dilating vesicoureteral reflux (grade 3 or greater). Variables of interest included presentation, dimercapto-succinic acid results, sex, breakthrough febrile urinary tract infections, reflux grade and bilateral reflux. Cox regression analysis was performed to determine predictors of spontaneous resolution and/or improvement to reflux grade less than 3 as well as predictors of surgical intervention. Results: Included in final analysis were 80 infants (113 renal units). Of the patients 51 (64%) experienced spontaneous resolution/improvement with a mean followup of 29 months before resolution, discharge home and/or end of followup. Only 20 patients (25%) underwent surgery. Cox regression analysis revealed that a normal initial dimercapto-succinic acid scan, initial reflux grade less than 5 and absent breakthrough febrile urinary tract infections were predictive of reflux resolution/improvement (p <0.05). Dimercapto-succinic acid scan abnormalities, prenatal hydronephrosis and breakthrough febrile urinary tract infections were significant predictors of surgery (p <0.05). Conclusions: Dilating vesicoureteral reflux in infancy often resolves/improves spontaneously. Therefore, surgery should be directed toward patients unlikely to experience resolution, ie those with an abnormal initial dimercapto-succinic acid scan, grade 5 vesicoureteral reflux and breakthrough febrile urinary tract infections. [Copyright &y& Elsevier]

Purpose: The AAP (American Academy of Pediatrics) no longer recommends voiding cystourethrogram in children 2 to 24 months old who present with a first urinary tract infection if renal-bladder ultrasound is normal. We identified factors associated with abnormal imaging and recurrent pyelonephritis in this population. Materials and Methods: We retrospectively evaluated children diagnosed with a first episode of pyelonephritis at age 2 to 24 months using de-identified electronic medical record data from an institutional database. Data included age at first urinary tract infection, gender, race/ethnicity, need for hospitalization, intravenous antibiotic use, history of abnormal prenatal ultrasound, renal-bladder ultrasound and voiding cystourethrogram results, urinary tract infection recurrence and surgical intervention. Risk factors for abnormal imaging and urinary tract infection recurrence were analyzed by univariate logistic regression, the chi-square test and survival analysis. Results: We identified 174 patients. Of the 154 renal-bladder ultrasounds performed 59 (38%) were abnormal. Abnormal prenatal ultrasound (p = 0.01) and the need for hospitalization (p = 0.02) predicted abnormal renal-bladder ultrasound. Of the 95 patients with normal renal-bladder ultrasound 84 underwent voiding cystourethrogram. Vesicoureteral reflux was more likely in patients who were white (p = 0.003), female (p = 0.02) and older (p = 0.04). Despite normal renal-bladder ultrasound, 23 of 84 patients (24%) had dilating vesicoureteral reflux. Of the 95 patients with normal renal-bladder ultrasound 14 (15%) had recurrent pyelonephritis and 7 (7%) went on to surgical intervention. Conclusions: Despite normal renal-bladder ultrasound after a first pyelonephritis episode, a child may still have vesicoureteral reflux, recurrent pyelonephritis and the need for surgical intervention. If voiding cystourethrogram is deferred, parents should be counseled on these risks. [ABSTRACT FROM AUTHOR]

Purpose: Nephrostomy tube placement is often necessary to avert acute renal failure in patients with cancer with obstructive uropathy or in patients with ureteral leak. However, there have been limited published studies on the rate and risk of nephrostomy tube related pyelonephritis in patients with cancer. Therefore, in this study we determined rates of nephrostomy tube related pyelonephritis and predisposing risk factors in patients with cancer. Materials and Methods: We retrospectively reviewed patients who underwent nephrostomy tube placement between September 1, 2009 and September 16, 2010 at MD Anderson Cancer Center. Patients were followed for 90 days. The primary outcome assessed was the development of nephrostomy tube related pyelonephritis and the secondary outcome was the development of asymptomatic bacteriuria. We also determined risk factors associated with pyelonephritis. Results: Of the 200 patients analyzed 38 (19%) had pyelonephritis and 15 (7.5%) had asymptomatic bacteriuria. Of the nephrostomy tube related infections 34 cases (89%) were with the primary nephrostomy tube. Subsequently 4 of the patients who underwent nephrostomy tube exchange had an episode of pyelonephritis. Pyelonephritis developed within the first month in 19 (10%) patients. Prior urinary tract infection and neutropenia were found to be significant risk factors for pyelonephritis (p = 0.047 and 0.03, respectively). Conclusions: The placement of nephrostomy tubes in patients with cancer is associated with a significant rate of pyelonephritis. Neutropenia and history of urinary tract infection were significant risk factors for pyelonephritis. This finding warrants further investigation into preventive strategies to reduce the infection rate. [ABSTRACT FROM AUTHOR]

Purpose: Various screening approaches have been proposed to identify the subgroup of children with urinary tract infection who have vesicoureteral reflux. However, few studies have compared the sensitivity of screening approaches in a representative population of young children. We compared the sensitivities of the top-down (99mtechnetium dimercaptosuccinic acid renal scan to screen) and biomarker based (C-reactive protein level at presentation) approaches in identifying children with vesicoureteral reflux. Materials and Methods: We calculated the sensitivity of the 2 screening approaches in detecting vesicoureteral reflux and subsequently high grade (III or greater) vesicoureteral reflux in children. Results: The top-down and C-reactive protein based approaches missed 33% and 29% of cases of high grade vesicoureteral reflux, respectively. Conclusions: The sensitivity of the top-down approach for detecting high grade vesicoureteral reflux was lower than previously reported. Further study of novel methods to identify children at risk for renal scarring is warranted. [ABSTRACT FROM AUTHOR]

Purpose: Prophylactic antibiotics are commonly used to prevent urinary tract infections in children with conditions such as vesicoureteral reflux. Patient compliance with antibiotics is salient, given the effects that noncompliance can have on development of antibiotic resistance and outcomes of clinical trials. Prior series have shown variable compliance (17% to 70%). However, no study has used objective methods. We hypothesized that direct measurement of urine antibiotic levels can reveal poor compliance. Materials and Methods: During a pediatric urology clinic visit patients 0 to 18 years old taking trimethoprim prophylaxis for any urological diagnosis were invited to participate in the study. They were unaware of any potential urine testing before the visit. Urine was sent for chromatography to quantify trimethoprim levels. Parents also completed a compliance self-assessment. Results: Of patients invited to participate 97% consented (54 patients). Of the patients 91% were compliant based on urine levels. Factors not associated with compliance included age, gender, self-report of compliance, duration of time on antibiotics, insurance status and history of breakthrough infection, surgery, pyelonephritis or hospitalization. Conclusions: This study demonstrates the highest compliance reported for children taking prophylactic antibiotics to prevent urinary tract infection. We attribute this unexpected result to the discussion by specialists of 1 problem for the duration of an office visit. All education in this study was part of clinical care. Thus, our results should be generalizable to nonstudy environments. Future studies should confirm whether this high level of compliance can be achieved by nephrologists and pediatricians. If such compliance cannot be achieved at nonsurgical clinics, then early referral to a pediatric urologist may be warranted. [ABSTRACT FROM AUTHOR]

Purpose: We prospectively determined the risk factors for renal scar formation after the first episode of acute pyelonephritis as confirmed on dimercapto-succinic acid scintigraphy in children younger than 1 year. Materials and Methods: A total of 213 infants with acute pyelonephritis were enrolled in the study. Infants with urological abnormalities other than vesicoureteral reflux were excluded from analysis. Followup scanning was performed 6 months after acute pyelonephritis and voiding cystourethrography was performed after the acute phase of infection. Possible risk factors were evaluated including gender, peak fever, duration of fever before and after treatment with antibiotics, white blood cell count, C-reactive protein concentration, presence of vesicoureteral reflux and reflux grade. Results: Six months after acute pyelonephritis 37 of 213 (17.4%) infants and 41 of 248 (16.5%) renal units with acute photon defects on initial dimercapto-succinic acid scintigraphy had renal scars. The rates of scar formation were significantly higher in infants with vesicoureteral reflux than in those without (39.4% vs 7.5%, p <0.001, OR 9.433) and in renal units with vesicoureteral reflux than in those without (39.4% vs 8.2%, p <0.001, OR 7.237). Renal scar formation was related to reflux grade (none—8.2%, grade I—20%, grade II—22.7%, grade III—40%, grade IV—70%, grade V—55.6%, p <0.001) but not to any other clinical or laboratory variables. Conclusions: The presence of vesicoureteral reflux was the only independent risk factor for renal scar formation after acute pyelonephritis in infants. The prevalence of renal scarring was significantly correlated with reflux grade. Voiding cystourethrography is necessary in infants after the first acute pyelonephritis episode is confirmed on dimercapto-succinic acid renal scintigraphy. [Copyright &y& Elsevier]

Purpose: We determined whether nephromegaly on ultrasound can be used to identify patients with urinary tract infection at increased risk for renal scarring, and we investigated the effect of vesicoureteral reflux on renal scarring. Materials and Methods: We enrolled hospitalized patients with a first febrile urinary tract infection. All patients underwent renal ultrasound and most patients underwent voiding cystourethrography. Renal scarring was assessed using 99mtechnetium dimercapto-succinic acid renal scintigraphy at least 6 months after treatment. Children with recurrent urinary tract infections before scintigraphy were excluded from the study. Results: A total of 545 children (80 with and 465 without nephromegaly) were enrolled. Infection was more severe in patients with than without nephromegaly. The incidence of renal scarring was significantly higher in patients with nephromegaly (90% vs 32%, p <0.001), in kidneys with nephromegaly (80.5% vs 18.7%, p <0.001) and in kidneys with vesicoureteral reflux (41.5% vs 22.2%, p <0.001). Kidneys with nephromegaly had a greater incidence of reflux. The finding of nephromegaly is associated with a greatly increased likelihood of renal scarring in patients with vesicoureteral reflux. Conclusions: Our results indicate that ultrasound diagnosis of nephromegaly at onset is associated with a high incidence of renal scarring, and identification of nephromegaly at onset and vesicoureteral reflux are significant risk factors for renal scarring in children with a first febrile urinary tract infection. Nephromegaly is associated with an increased frequency of vesicoureteral reflux and increased likelihood of renal scarring in patients with reflux. [ABSTRACT FROM AUTHOR]

Purpose: We assessed the usefulness of procalcitonin as a biological marker in diagnosing acute pyelonephritis and for predicting subsequent renal scarring in young children with a first febrile urinary tract infection. Materials and Methods: Children 2 years old or younger with a first febrile urinary tract infection were prospectively studied. Renal parenchymal involvement was assessed by 99mTc-dimercaptosuccinic acid scan within 5 days of admission and after 6 months. Serum samples from all patients were tested for procalcitonin, C-reactive protein and white blood cell count measurements. Results: The 112 enrolled patients (age range 24 days to 24 months old) were divided into acute pyelonephritis (76) and lower urinary tract infection (36) groups according to the results of 99mTc-dimercaptosuccinic acid scans. Median values of procalcitonin, C-reactive protein and white blood cell count at hospitalization were significantly higher in patients with acute pyelonephritis than in those with lower urinary tract infection. The area under receiver operating characteristic curves showed that procalcitonin was superior to C-reactive protein and white blood cell count as a marker for diagnosing acute pyelonephritis. Initial and post-antibiotic treatment procalcitonin values were significantly higher in children with renal scarring than in those without scarring (p <0.001). Procalcitonin values at hospitalization and after treatment were independent predictors of later renal scarring on logistic regression analysis. Conclusions: Our results indicate the superior diagnostic accuracy of procalcitonin for predicting acute pyelonephritis in children 2 years old or younger. Higher initial and posttreatment procalcitonin values are independent risk factors for later renal scarring. [ABSTRACT FROM AUTHOR]

Purpose: President Woodrow Wilson was never able to gain ratification of the Treaty of Versailles, the peace accord to end World War I. Before he could convince the American people of the importance of ratification, Wilson suffered a stroke followed by life threatening urinary sepsis due to urinary retention, and was treated by the father of modern urology, Hugh Hampton Young. The effects of these health problems are examined in the context of their implications on international affairs. Materials and Methods: Biographical sources and primary documentation of Wilson''s physicians were reviewed to determine the effect of Wilson''s stroke on his voiding habits. Hugh Hampton Young''s evaluation and decision making is examined in depth. Results: In the fall of 1919 President Wilson was recovering from a stroke. Shortly after the stroke his preexisting voiding dysfunction progressed to urinary retention from which urinary sepsis developed. Hugh Hampton Young advised on Wilson''s case and counseled patience over surgery. The President began voiding spontaneously and recovered from sepsis. The illness left him severely weakened and unable to mount an aggressive campaign to persuade the U.S. Senate of the importance of ratifying the Treaty of Versailles. His personal physician, Admiral Cary T. Grayson, stated that the President was mentally never the same after the sepsis. Conclusions: Wilson''s voiding dysfunction contributed to his inability to win approval for the Treaty of Versailles and the League of Nations. As a result, the United States returned to a policy of isolationism and Europe plunged into 2 decades of upheaval, leading to World War II. [Copyright &y& Elsevier]

Purpose: We examined trends in pediatric hospitalization for pyelonephritis from 1985 to 2006 and identified factors associated with admission. Materials and Methods: We performed a population based analysis of hospital discharges using the Office of Statewide Health Planning and Development database to evaluate trends in California regarding pediatric hospitalizations for pyelonephritis from 1985 to 2006. Multivariable logistic regression was performed to identify factors associated with admission for pyelonephritis. Results: A total of 46,300 children were hospitalized for pyelonephritis in California from 1985 to 2006. The overall rate of hospitalization for pyelonephritis increased by greater than 80%, from 17 per 100,000 children in the California population in 1985 to 31 per 100,000 in 2005. This change was primarily due to the nearly ninefold increase in pyelonephritis hospitalizations observed in children younger than 1 year, from 28 per 100,000 in 1985 to 238 per 100,000 in 2005. Among children younger than 1 year males without private insurance and of nonwhite race had increased odds of hospitalization, while females with private insurance and of Asian race had increased odds of hospitalization, compared with nonprivate insurance and white race, respectively. Conclusions: A significant increase in hospital admissions for pyelonephritis, primarily in children younger than 1 year, occurred in California between 1985 and 2006. Further studies are needed to establish the cause of this striking increase and to determine why certain pediatric populations are at increased risk for hospitalization. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the influence of patient factors and virulence factors of uropathogenic Escherichia coli on the occurrence of acute pyelonephritis and subsequent renal parenchymal scarring. Materials and Methods: We evaluated 80 boys and 45 girls 1 to 180 months old with febrile urinary tract infections who underwent renal scan to diagnose acute pyelonephritis and followup dimercapto-succinic acid scintigraphy at least 6 months later. Urinalysis, white blood cell count, uropathogenic E. coli genotype and vesicoureteral reflux were measured. Voiding cystourethrogram was investigated after acute pyelonephritis was confirmed by renal scan and acute inflammation subsided, about 2 to 4 weeks later. Results: Acute pyelonephritis was significantly more likely to develop in children with urinary tract infections and persistent fever before and after hospitalization, elevated C-reactive protein or positive renal ultrasound findings. E. coli strains with the papG II and iha genes were significantly more likely to occur in patients with acute pyelonephritis. Patients with a fever for more than 3 days and C-reactive protein levels greater than 90.8 mg/l were significantly more likely to have renal scarring. Age was not an independent predictor of acute pyelonephritis, but modified the effect of virulence factors on the development of acute pyelonephritis. Conclusions: Bacterial virulence factors and host factors are associated with the occurrence of acute pyelonephritis. Host factors such as patient age and vesicoureteral reflux severity modify the influence of virulence factors, although only host factors are associated with the occurrence of renal scarring. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation in children after febrile urinary tract infection involves voiding cystourethrogram, which emphasizes urinary reflux rather than renal risk. We believe that early dimercapto-succinic acid renal scan after febrile urinary tract infection predicts clinically significant reflux and which children should undergo voiding cystourethrogram. The criticism of this approach is that some reflux and preventable renal damage would be missed. This study validates the use of initial dimercapto-succinic scan and presents 5-year renal outcomes. Materials and Methods: We prospectively studied children with febrile urinary tract infection using initial dimercapto-succinic acid renal scan, voiding cystourethrogram and renal/bladder ultrasound. Children with anatomical or neurological genitourinary abnormality and protocol failures were excluded from analysis. Dimercapto-succinic acid scan was repeated at 6 months if initially abnormal. Followup was done every 6 months in all children for at least 5 years. Results: A total of 121 children fit study inclusion criteria and completed the 5-year study. Overall 88 initial dimercapto-succinic acid scans (73%) were abnormal and 78 children (64%) had urinary reflux. The OR of having clinically significant reflux predicted by abnormal initial scan was 35.4. Abnormal followup scan did not predict clinically significant reflux. Overall subsequent urinary tract infection developed in 32 patients (26.5%) and 27 (85%) had an abnormal initial scan. No child with a normal initial scan had clinically significant reflux. Conclusions: Dimercapto-succinic acid scan can predict clinically significant reflux and children at greatest renal risk. Initial dimercapto-succinic acid scan should be done in all children after febrile urinary tract infection while voiding cystourethrogram should be reserved for those with an abnormal initial dimercapto-succinic acid scan. [Copyright &y& Elsevier]

Purpose: The use of antibiotic prophylaxis for preventing urinary tract infections has recently been called into question. Some studies support discontinuation of antibiotic prophylaxis in selected groups of children with vesicoureteral reflux. We report on the outcome of this practice in a cohort of patients assembled based on initial presentation with a febrile urinary tract infection. Materials and Methods: We retrospectively reviewed records of patients with persistent vesicoureteral reflux without symptoms suggestive of dysfunctional elimination who discontinued antibiotic prophylaxis after being toilet trained. Exclusion criteria consisted of secondary reflux and previous surgery for vesicoureteral reflux. End points included development of febrile urinary tract infections, renal abnormalities on followup ultrasound and need for further interventions. Infection-free survival was analyzed using the Kaplan-Meier method and compared using the log rank and Cox''s tests. Results: We evaluated 84 girls and 26 boys with a mean age of 5.4 years. Febrile urinary tract infections developed in 10 girls and 1 boy at an average of 17.2 months after discontinuation of antibiotic prophylaxis. In a time to event analysis group comparison showed no significant differences when patients were stratified by gender (p = 0.22), age at antibiotic prophylaxis discontinuation (p = 0.14) or disease laterality (p = 0.23). However, a significant difference was found in number of patients with high grade vesicoureteral reflux (III to V, p = 0.05) and development of symptoms suggestive of bladder/bowel dysfunction (p <0.01). Conclusions: Our data support antibiotic prophylaxis discontinuation in the majority of patients with persistent vesicoureteral reflux who initially present with a febrile urinary tract infection, once their elimination habits have been optimized. Those with high grade reflux appear to be at increased risk for recurrent urinary tract infections. Development of dysfunctional elimination symptoms appears to be a risk factor amenable to treatment. [Copyright &y& Elsevier]

Purpose: Recurrent urinary tract infections and pyelonephritis have risk factors suggesting genetic sources. Family history variables indicative of genetic risk merit further investigation. We evaluated the risk of recurrent cystitis and pyelonephritis in women with and those without a family history of urinary tract infection. Materials and Methods: We conducted a population based case-control study of 1,261 women 18 to 49 years old enrolled in a Northwest health plan. Participants were cases identified from plan databases with documented recurrent cystitis (431) or pyelonephritis (400). Shared controls (430) were similar age women with no urinary tract infection history. We evaluated the history of urinary tract infection and pyelonephritis in first-degree female relatives (mother, sister[s], daughter[s]) and other covariates, ascertained through questionnaires and computerized databases. Results: Of the cases 70.9% with recurrent cystitis and 75.2% with pyelonephritis, and of the controls 42.4% reported a urinary tract infection history in 1 or more female relative (p <0.001 for each case group vs controls). In both case groups odds ratios were significantly increased for women reporting a urinary tract infection history in their mother, sister(s) or daughter(s). Risk increased with a greater number of affected relatives. In women with 1 vs 2 or more relatives the ORs for recurrent cystitis were 3.1 (95% CI 2.1, 4.7) and 5.0 (3.1, 8.1), and the ORs for pyelonephritis were 3.3 (2.2, 5.0) and 5.5 (3.4, 9.0), respectively. Conclusions: In these community dwelling women a urinary tract infection history in female relatives was strongly and consistently associated with urinary tract infection recurrence and pyelonephritis. Risk estimates increased with stronger family history indices, suggesting a genetic component for increased susceptibility to these infections. [Copyright &y& Elsevier]

Purpose: The pathophysiology, evaluation, description and clinical implications of renal damage associated with vesicoureteral reflux remain controversial. We summarized the current understanding of this important aspect of clinical vesicoureteral reflux. Materials and Methods: We performed a detailed review of the literature on clinical, pathological and experimental data related to congenital vesicoureteral reflux and bladder dynamics. We also reviewed the clinical context and imaging evaluation with underlying experimental data related to post-infectious reflux nephropathy. Results: Congenital reflux nephropathy is a pattern of impaired renal function and development with renal dysplasia as the most severe but not the only form. Mechanisms of developmental disruption are potentially related to vesicoureteral reflux dynamics during gestation and associated bladder dynamics, which may continue into postnatal life. Acquired renal injury associated with infection is related to particular bacterial and host factors that determine infection virulence, host inflammatory response and tissue recovery. As best seen on dimercapto-succinic acid scan, acute changes may resolve but may also persist as permanent renal scarring. Specific risk factors for acute pyelonephritis and renal scarring in patients with vesicoureteral reflux include higher reflux grade, dysfunctional voiding/elimination, recurrent pyelonephritic episodes and delayed initiation of antibiotic therapy. Low pressure sterile reflux is not a cause of reflux nephropathy. Conclusions: Renal damage associated with vesicoureteral reflux may be congenital or acquired and the respective pathophysiological mechanisms are likely different. Congenital damage is often dysplasia, which may be a result of disordered renal development secondary to significant alterations in bladder dynamics. These processes may continue into the newborn period while kidney maturation continues. Recognizing the clinical potential for ongoing effects on renal function and the role of bladder development are important for clinical care. Post-pyelonephritic acquired damage is the result of a complex interaction of host and bacterial factors that leads to acute alterations in renal function, and may lead to permanent renal scarring. Strategies for timely intervention as well as prevention are essential to limit the risk of permanent renal injury, which may predispose to hypertension and renal insufficiency in some patients. [Copyright &y& Elsevier]

Purpose: Renal scarring is a serious complication that often occurs with chronic pyelonephritis in the presence of vesicoureteral reflux. In a previous study we established a rat model of renal scarring in which we found the up-regulation of neutrophil-gelatinase associated lipocalin at the mRNA and protein levels. In this study we evaluated urinary neutrophil-gelatinase associated lipocalin as a potential biomarker for progression of renal scarring in patients with vesicoureteral reflux. Materials and Methods: A total of 34 patients diagnosed with vesicoureteral reflux without evidence of current urinary tract infection and 28 normal healthy children were enrolled in this study. Renal scars were evaluated by 99mtechnetium dimercapto-succinic acid renal scan in 24 of the reflux cases. Urinary neutrophil-gelatinase associated lipocalin levels were monitored by ELISA. Results: In normal subjects urinary neutrophil-gelatinase associated lipocalin was high during infancy, decreased rapidly within the following year and reached a low stable level from age 3 years onward. Urinary neutrophil-gelatinase associated lipocalin levels, normalized to age matched standards, were significantly increased in patients with vesicoureteral reflux compared to controls. These levels did not correlate with reflux grade, but were significantly higher in patients with radiological evidence of renal scarring irrespective of reflux grade. Conclusions: Estimation of urinary neutrophil-gelatinase associated lipocalin may be useful as a noninvasive diagnostic or prognostic biomarker for renal scarring. [Copyright &y& Elsevier]

Purpose: We assessed predictive factors for acute renal cortical scintigraphic lesion and ultimate scar formation in children with a first febrile urinary tract infection. Materials and Methods: A total of 89 girls and 138 boys with a first febrile urinary tract infection were included in the study. We analyzed radiological (ultrasound, dimercapto-succinic acid scintigraphy, voiding cystourethrogram), clinical (age, gender, peak fever, therapeutic delay time) and laboratory (complete blood count with differential count, absolute neutrophil count, blood urea nitrogen, creatinine, urinalysis, Gram''s stain, culture, C-reactive protein, erythrocyte sedimentation rate) variables. Dimercapto-succinic acid scintigraphy was performed within 5 days and at 6 months after diagnosis of urinary tract infection. Voiding cystourethrogram was performed after the acute phase of the urinary tract infection. Predictive factors for acute scintigraphic lesion and ultimate scar formation were assessed using logistic regression analysis. Results: Of 227 patients enrolled 140 had a refluxing and 87 a nonrefluxing urinary tract infection. On logistic regression analysis therapeutic delay time (p = 0.001) and presence of reflux (p = 0.011) were predictive of acute scintigraphic lesion and ultimate scar formation (p = 0.001 and p = 0.0001, respectively) in children with a first febrile urinary tract infection. Conclusions: Since vesicoureteral reflux is the common risk factor for acute scintigraphic lesion and ultimate scar formation, voiding cystourethrogram must be considered as an initial study in patients with acute febrile urinary tract infection. [Copyright &y& Elsevier]

Purpose: Febrile urinary tract infection represents significant morbidity in patients with vesicoureteral reflux, especially following open surgical or endoscopic treatment. The reported incidence of febrile urinary tract infection after ureteroneocystostomy varies from 10% to 24%. We investigated the incidence of febrile urinary tract infection following ureteroneocystostomy in a contemporary, single institution series. Materials and Methods: We retrospectively reviewed medical records of 395 consecutive patients undergoing ureteroneocystostomy for primary vesicoureteral reflux at our institution between 2002 and 2007. We examined demographic, diagnostic and operative data, including presence of postoperative febrile urinary tract infection. A Cox proportional hazards model was performed to assess predictors of febrile urinary tract infection following ureteroneocystostomy. Results: Ureteroneocystostomy was performed in 395 patients (673 ureters) at a mean age of 58 months. The most common reflux grade was III (41%). The incidence of postoperative febrile urinary tract infection was 4.6% at a mean followup of 15 months. Postoperative dysfunctional elimination syndrome was a significant predictor of febrile urinary tract infection (HR 3.8, 95% CI 1.2–12, p = 0.02), and was identified in 58 of 340 toilet trained children (15% overall). Age at diagnosis, initial presentation, age at surgery, indication for surgery, reflux grade, laterality, surgical technique and preoperative dysfunctional elimination syndrome were not predictive of postoperative febrile urinary tract infection. Conclusions: The incidence of febrile urinary tract infection following ureteroneocystostomy may be lower than previously reported. The presence of postoperative dysfunctional elimination syndrome is a significant predictor of postoperative febrile urinary tract infection. [Copyright &y& Elsevier]

Purpose: Proteus mirabilis is a common cause of urinary tract infection. We determined the role of Tamm-Horsfall protein as a host defense factor against the cystitis and pyelonephritis caused by P. mirabilis. Materials and Methods: We generated Tamm-Horsfall protein gene knockout mice using homologous recombination. We introduced P. mirabilis transurethrally into the bladder of Tamm-Horsfall protein deficient (THP−/−) and genetically similar WT (THP+/+) mice. We cultured urine to quantitate the degree of bacteriuria. We examined bladders and kidneys grossly and histomorphometrically to determine the intensity of inflammation. Results: THP−/− mice had more severe bacteriuria and cystitis than THP+/+ mice. THP−/− mice had more pyelonephritic abscesses than THP+/+ mice. The severity of histological pyelonephritis on semiquantitative histomorphometric analysis appeared to be greater in THP−/− mice. The difference between the 2 groups approached but did not attain statistical significance (p = 0.053). Conclusion: Tamm-Horsfall protein acts as a host defense factor against P. mirabilis induced urinary tract infection. [Copyright &y& Elsevier]

Purpose: We investigated ethnic differences in the risk of post-pyelonephritic renal scarring in infants and children for possible genetic determinants. Materials and Methods: We searched all peer reviewed articles published from 1980 through 2006 in the PubMed®, MEDLINE® (Ovid), Cochrane Central Register of Controlled Trials and EMBASE® databases for the keywords, “renal scarring and pyelonephritis,” “renal fibrosis” and “kidney scarring.” References were included only when they specified acute pyelonephritis defined by a fever, positive urine culture and areas of photopenia in the renal cortex on 99mtechnetium dimercapto-succinic acid renal scans, repeat dimercapto-succinic acid scans obtained at least 3 months after acute pyelonephritis to assess for renal cortical scar formation and absence of recurrent urinary tract infection during followup. When possible data were analyzed according to patients and renal units. Results: Among 23 references the overall rates of renal scarring in terms of patients and renal units were 41.6% and 37.0%, respectively. In terms of patients the incidence of renal scarring following acute pyelonephritis varied by region, from 26.5% (Australia) to 49.0% (Asia). In terms of renal units the incidence of acquired renal cortical scarring varied by region, from 16.7% (Middle East) to 58.4% (Asia). When combined by vesicoureteral reflux status children and renal units with refluxing ureters exhibited an increased risk of renal scarring (odds ratios 2.8 and 3.7, respectively). Conclusions: Although scarring was different across some regions, only scarring in Asian studies comparing patients displayed a statistically significant difference. A regional effect explained the heterogeneity observed in the overall estimate for patients and partly for renal units. The greatest risk of renal scarring may be imparted by the presence of vesicoureteral reflux. [Copyright &y& Elsevier]

Purpose: Acute pyelonephritis is a common condition in children, and can lead to renal scarring. The aim of this study was to analyze the progression of renal scarring with time and its impact on renal growth. Materials and Methods: A total of 50 children who had renal scarring on dimercapto-succinic acid scan 6 months after acute pyelonephritis underwent a repeat scan 3 years later. Lesion changes were evaluated by 3 blinded observers, and were classified as no change, partial resolution or complete disappearance. Renal size at time of acute pyelonephritis and after 3 years was obtained by ultrasound, and renal growth was assessed comparing z-score for age between the 2 measures. Robust linear regression was used to identify determinants of renal growth. Results: At 6 months after acute pyelonephritis 88 scars were observed in 100 renal units. No change was observed in 27%, partial resolution in 63% and complete disappearance in 9% of lesions. Overall, 72% of lesions improved. Increased number of scars was associated with high grade vesicoureteral reflux (p = 0.02). Multivariate analysis showed that the number of scars was the most important parameter leading to decreased renal growth (CI −1.05 to −0.35, p <0.001), and with 3 or more scars this finding was highly significant on univariate analysis (−1.59, CI −2.10 to −1.09, p <0.0001). Conclusions: Even 6 months after acute pyelonephritis 72% of dimercapto-succinic acid defects improved, demonstrating that some of the lesions may be not definitive. The number of scars was significantly associated with loss of renal growth at 3 years. [Copyright &y& Elsevier]

Purpose: There is no current consensus on what constitutes the ideal management of emphysematous pyelonephritis. We review the current management strategies including the role of nephron preserving percutaneous drainage in the treatment of emphysematous pyelonephritis. Materials and Methods: We searched MEDLINE®, PubMed®, EMBASE®, CINAHL® and the Cochrane Library from 1966 to 2006. Abstracts were reviewed including all types of studies from prospective randomized controlled studies to small retrospective series. All relevant English language articles reporting on at least 5 patients were reviewed. Results: Ten retrospective studies on 210 patients with emphysematous pyelonephritis met the inclusion criteria. There were 167 females and 43 males with a mean age of 57 years (range 24 to 83). Of the patients 96% had diabetes mellitus and 29% had urinary tract obstruction. The diagnostic accuracy of computerized tomography was 100%. Escherichia coli and Klebsiella were the most common causative agents. The mortality from medical management alone was 50%, medical management combined with emergency nephrectomy was 25% and medical management combined with percutaneous drainage was 13.5%. Mortality was significantly less in patients undergoing percutaneous drainage compared to other treatments (Pearson chi-square p <0.001). Of the patients who underwent medical treatment with percutaneous drainage a small number (15) underwent elective nephrectomy and mortality was 6.6% (1 of 15). Conclusions: Percutaneous drainage should be part of the initial management strategy for emphysematous pyelonephritis. This strategy is associated with a lower mortality than medical management or emergency nephrectomy. Delayed elective nephrectomy may be required in some patients. [Copyright &y& Elsevier]

Purpose: We performed a case-control study in children diagnosed by the first episode of upper urinary tract infection with or without vesicoureteral reflux to evaluate the association of functional polymorphism of interleukin-8 (−251A>T and +2767A>G), and its receptor CXCR1 (+2607G>C). Materials and Methods: Genomic DNA was obtained from 265 children with a clinical and laboratory diagnosis of urinary tract infection who were recruited in northeast Italy. The children were subdivided as 173 who were dimercapto-succinic acid scan positive with positive static renal scintigraphy in acute conditions, consistent with the diagnosis of acute pyelonephritis, and 92 who were dimercapto-succinic acid scan negative. Genetic analysis for the same polymorphisms was also extended to a control population of 106 umbilical cord DNA samples. Results: Statistical analysis of genotype data showed that 1) the tested populations were in Hardy-Weinberg equilibrium, 2) there were significant differences between the dimercapto-succinic acid scan positive and negative groups (p = 0.049), and the dimercapto-succinic acid scan positive group vs controls (p = 0.032) in terms of interleukin-8 −251A>T polymorphism frequency, 3) there was also a significant difference in the distribution of IL-8 −251A>T and +2767A>G polymorphisms between dimercapto-succinic acid scan positive and negative children in the subgroup without vesicoureteral reflux (p = 0.03 and 0.02, respectively) and 4) no significant differences were found in the frequency of the distribution of CXCR1 +2607G>C polymorphism in all groups. Conclusions: These data suggest that the gene for the proinflammatory chemokine interleukin-8 is involved in susceptibility to acute pyelonephritis during upper urinary tract infection in children with or without vesicoureteral reflux. [Copyright &y& Elsevier]

Purpose: Methods of stenting after laparoscopic pyeloplasty have included indwelling Double-J® stents and percutaneous nephrostomy tubes. The disadvantages of these methods are that they necessitate a second surgery for stent removal or require an external drainage bag. To circumvent these issues, the tolerance, safety and outcomes of using a Double-J ureteral stent with a dangler, permitting early office removal, was investigated in a series of pediatric laparoscopic pyeloplasties. Materials and Methods: Medical records from a consecutive series of pediatric patients undergoing transperitoneal laparoscopic pyeloplasties were reviewed. Indications for surgery included ipsilateral flank pain with severe hydronephrosis (12 patients), recurrent pyelonephritis with severe hydronephrosis (2), and hematuria and flank pain (6). All patients were discharged home within 24 to 48 hours of the procedure with prophylactic oral antibiotics. The stent was removed by postoperative day 18 during a followup office visit. Patient tolerance of the indwelling stent, outpatient removal and success of pyeloplasty were assessed. Results: A total of 20 patients underwent transperitoneal laparoscopic pyeloplasty by 1 surgeon (LAB) between 2001 and 2005. All patients underwent cystoscopy and retrograde Double-J ureteral stent placement before pyeloplasty under the same anesthesia. Mean patient age at operation was 11.3 years (median 11.3, range 4.6 to 17.2). Stents were left indwelling for a mean of 10.3 days (median 10, range 7 to 18). All patients tolerated the Double-J stent well, with 2 requiring anticholinergic therapy for mild urgency symptoms and 1 demonstrating urinary tract infection. All patients tolerated outpatient stent removal via the dangler at the office without discomfort. One patient was lost to followup. At a mean followup of 1.04 years (range 0.1 to 2.88) 17 of 19 patients (89%) had resolution of flank pain/urinary tract infections, with sonographic improvement in hydronephrosis with or without endoscopic intervention. Six patients (30%) had flank pain with or without continuous hydronephrosis and required re-stenting, and 3 also required balloon dilation. Of these 6 patients 2 (10%) had recurrent ureteropelvic junction obstruction and required open pyeloplasty. All patients are now clinically and radiologically unobstructed and asymptomatic. Conclusions: Pediatric transperitoneal laparoscopic pyeloplasty with indwelling Double-J ureteral stent with a dangler is successful and the stent is well tolerated. Whether the duration of ureteral stenting affects the surgical success will require further controlled long-term studies. [Copyright &y& Elsevier]

Purpose: Vesicoureteral reflux and pyelonephritis following transplantation may significantly contribute to renal damage and premature graft loss. We report our retrospective experience with redo ureteral reimplantation of refluxing pediatric renal transplants and describe our surgical technique. Materials and Methods: We identified 20 children with a diagnosis of symptomatic post-transplant vesicoureteral reflux, of whom 16 underwent redo ureteral reimplantation. Patient characteristics including etiology of end stage renal disease, presenting symptoms, serum creatinine and postoperative followup were documented. The presence or absence of lower urinary tract dysfunction was documented and values between the 2 groups were analyzed for significance. Results: All 20 patients presented after assessment for a febrile urinary tract infection, and 35% had concurrent lower urinary tract dysfunction. Median interval between transplantation and vesicoureteral reflux diagnosis was 1.3 years, and mean vesicoureteral reflux grade was 3.2. Patients with lower urinary tract dysfunction presented significantly earlier and had a higher postoperative serum creatinine than those without lower urinary tract dysfunction (1.1 vs 1.7 years, p = 0.048). Redo reimplantation was performed in 94% of patients using an extravesical approach with ureteral stent placement. Seven of 16 patients underwent followup voiding cystourethrogram, with 5 demonstrating resolution and 2, both with lower urinary tract dysfunction, exhibiting persistent vesicoureteral reflux. At a mean followup of 3.6 years 25% of patients experienced recurrent pyelonephritis, while 75% were asymptomatic. One instance of anastomotic stricture occurred in a patient with lower urinary tract dysfunction. Conclusions: Effective repair of post-transplantation vesicoureteral reflux can be performed using an extravesical technique, facilitated by preoperative ureteral stent placement. Patients with lower urinary tract dysfunction are likely to present earlier after transplantation than those without lower urinary tract dysfunction, and may have an increased risk of persistent vesicoureteral reflux and renal damage despite surgical correction. [Copyright &y& Elsevier]

PURPOSE:: Surface enhanced laser desorption/ionization mass spectrometry can generate robust information from a small amount of clinical samples such as serum and plasma. In this study we identified novel diagnostic biomarkers of renal cell carcinoma (RCC) by large-scale serum protein profiling using surface enhanced laser desorption/ionization mass spectrometry.MATERIALS AND METHODS:: Proteomic spectra were generated by a time of flight mass spectrometer from a set of training samples (21 patients with RCC and 24 healthy volunteers) and another set of validation samples (19 patients with RCC, 20 healthy volunteers and 5 patients with pyelonephritis). Information on the peaks (intensity and m/z) was extracted from the mass spectra using newly developed algorithms, and the Mann-Whitney’s U test and linear support vector machine were used to identify the peaks distinguishing RCC samples from the controls.RESULTS:: Two peaks with molecular masses of 4,151 and 8,968 m/z were selected as significantly more prominent in RCC samples (p <0.01) among the 3,539 peaks in the range of 3,000 to 30,000 m/z obtained from the training samples. Simultaneous recognition of these 2 biomarkers was shown to have a sensitivity of 89.5% for the diagnosis of RCC and an overall specificity of 80.0% (95% [19 of 20] of healthy volunteers and 20% [1 of 5] of patients with pyelonephritis) in the blinded validation samples, and to allow detection of RCC in stage I (UICC) in 88.9% (16 of 18) of the cases.CONCLUSIONS:: We identified 2 serum biomarkers potentially useful for the early diagnosis of RCC. This finding warrants a further large-scale multi-institutional analysis for clinical evaluation of the diagnostic significance of these biomarkers. [ABSTRACT FROM AUTHOR]

PURPOSE:: At a single center we compared the efficacy of 3 generations of lithotriptors using identical protocol inclusion and followup criteria but with different modes of anesthesia. MATERIALS AND METHODS:: We compared stone disintegration and dilatation of the pyelocaliceal system achieved in a prospective, randomized trial comparing the original HM3 (Dornier Medtech, Kennesaw, Georgia) and Lithostar® Plus (LSP) lithotriptors, and a matched, consecutive series of 107 treatments with the Modulith® SLX. Stone disintegration and dilatation of the pyelocaliceal system were evaluated by abdominal plain x-ray and renal ultrasonography 1 day and 3 months after treatment. RESULTS:: A total of 82 treatments with the HM3, 75 with the LSP and 107 with the SLX were analyzed, matched for stone burden and location within the pyelocaliceal system. On postoperative day 1, 91%, 65% and 48% patients treated with the HM3, LSP and SLX, respectively, were stone-free or had fragments that were 2 mm or less (HM3 vs LSP p <0.001, HM3 vs SLX p <0.001 and LSP vs SLX p = 0.015). Three to 5 mm fragments were found in 7%, 21% and 35% of patients (p = 0.006, <0.001 and 0.06), and fragments 6 mm or greater were found in 1%, 14% and 15% (p = 0.002, <0.001 and 0.1, respectively). The re-treatment rate was 4% in the HM3 group, 13% in the LSP group and 38% in the SLX group (HM3 vs LSP p = 0.05, HM3 vs SLX p <0.001 and LSP vs SLX p <0.001). Obstructive pyelonephritis occurred in 1% of the HM3 group, 8% of the LSP group and 5% of the SLX group (HM3 vs LSP p = 0.02, HM3 vs SLX p = 0.12 and LSP vs SLX p = 0.4). All re-treatments except those in 5 patients were performed with the HM3. Therefore, the 3-month stone-free rate was comparable in all 3 groups (HM3 87%, LSP 80% and SLX 81%). CONCLUSIONS:: This study indicates that the HM3 lithotriptor disintegrates caliceal and renal pelvic stones better than the LSP and SLX machines, resulting in fewer complications and re-treatments. Disintegration with the LSP machine was also superior to that of the SLX with a need for fewer re-treatments. [ABSTRACT FROM AUTHOR]

ABSTRACT: Purpose:: We evaluated the health utilization and economic burden on society of urinary tract infections (UTIs) in children using a variety of public and commercial health care databases. Materials and Methods:: Numerous available databases were evaluated for health care utilization, including inpatient hospitalization, and outpatient physician and emergency department visits, by children with a coded diagnosis of urinary tract infection. Utilization was analyzed by age, gender, race, insurance type and geographic location, and trends were assessed during the last decade. Results:: UTIs resulted in more than 1.1 million physician visits annually, accounting for 0.7% of doctor visits and occurring in 2.4% to 2.8% of children. Overall, inpatient hospitalization decreased slightly, although pyelonephritis still accounted for more than 13,000 admissions. Infants were more likely to receive inpatient care for UTIs than children or adolescents, although hospital costs were higher in adolescents. Inpatient hospital costs are estimated to be greater than 180 million dollars per year. Conclusions:: Pediatric UTIs constitute a significant health burden on society. Available data do not allow a full accounting of costs due to a lack of information regarding outpatient expenses, as well as the cost of ancillary evaluation and treatment. However, the magnitude of the burden suggests the importance of further research and data collection of health care utilization in the pediatric population. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: We determined the impact of vesicoureteral reflux (VUR) on the size of renal lesions in children after an episode of acute pyelonephritis. Materials and Methods:: A total of 161 children (mean age 2.44 years) with acute pyelonephritis were studied. All had renal lesions on dimercapto-succinic acid scintigraphy done at admission to the hospital. A second dimercapto-succinic acid scan was performed at 3 months. Voiding cystourethrography was done at 6 weeks and VUR was graded I to V. For each renal unit layouts of renal lesions were drawn, and the damage surface was calculated and reported for the total surface of the kidney. Results:: Mean size of acute lesions and scars increased with severity of reflux (p <0.0001), with an important overlap of individual values. Mean size of renal scars in the group of renal units with acute lesions was 5.8% ± 8.5% in patients without VUR, 9.9% ± 7.3% in those with grade I reflux, 7.7% ± 11.0% in those with grade II reflux, 17.7% ± 14.7% in those with grade III reflux and 17.4% ± 27.7% in those with grade IV reflux (p <0.001). The size of renal lesions decreased significantly with time. The rate of regression of lesions decreased with increasing reflux. When analyzed according to 3 age groups sizes of scars increased significantly with age. Conclusions:: VUR has an impact on the size of renal lesions after an episode of pyelonephritis. Children with a grade III or IV reflux are more likely to have larger renal scars. On the other hand, acute lesions of important size may develop even in the absence of VUR. [Copyright &y& Elsevier]

ABSTRACT: Purpose: We correlated abnormal findings on renal ultrasonography (US) and inflammatory volume (Volume) on 99mtechnetium dimercaptosuccinic acid renal single photon emission computerized tomography (DMSA) in children with acute pyelonephritis (APN) with renal scars. Materials and Methods: A total of 31 males and 14 females (9 days to 9.8 years old) who fulfilled diagnostic criteria for APN and who underwent initial DMSA between January 1995 and July 2002 and followup DMSA at least 6 months later were enrolled in the study. APN was diagnosed by initial DMSA, and placement in the scar or scar-free group was determined by followup DMSA. Photopenic areas on initial DMSA were calculated as Volume, and were compared to US findings. Results: Ultrasound demonstrated 35 abnormal kidneys (38.9%) among these children with APN. Significant differences in age, Volume (11.19 ± 2.52 ml vs 3.02 ± 0.75 ml, p <0.005), C-reactive protein (CRP) and photopenic lesion on initial DMSA were found between children with abnormal and normal US. Of 65 children with initial APN foci 33 (50.8%) recovered, and the others had development of scars. The sensitivity of US for detecting APN (identified by DMSA scan) was 49.2%, and the specificity was 88% (OR 7.1, 95% CI 2.18 to 24.41). The sensitivity of US for predicting renal scarring was 59.4%, and the specificity was 60.6% (OR 2.3, 95% CI 0.82 to 7.65). Patients with abnormal US findings and high serum CRP (greater than 70 mg/l) had a large Volume (10.96 ± 3.05 ml) and a 76.2% chance of being in the scar group. Conclusions: US findings are significantly correlated to Volume in APN. Along with a high level of CRP, US is helpful in predicting development of renal scarring. [Copyright &y& Elsevier]

Purpose: Recent studies have demonstrated trends of decreasing voiding cystourethrogram utilization rates and delayed vesicoureteral reflux diagnosis in some children. It is possible that such delays could lead to more children sustaining repeated episodes of febrile urinary tract infection, and potential kidney injury, prior to diagnosis and treatment., Materials and Methods: Using single institutional, cross-sectional cohorts of patients in 2 time periods (2005 and 2015), we compared clinical presentation and renal outcomes among patients 13 years and younger with history of febrile urinary tract infection presenting for initial voiding cystourethrogram. Outcomes included 1) recurrent urinary tract infection, 2) presence of vesicoureteral reflux, 3) grade of vesicoureteral reflux, and 4) renal scarring. Associations between year of presentation and outcomes of recurrent urinary tract infection and vesicoureteral reflux diagnosis were evaluated using multivariable logistic regression models. For the outcome of renal scarring, a logistic regression model was fitted for propensity score matched cohorts., Results: Compared to children presenting in 2005, those in 2015 had 3 times the odds of recurrent urinary tract infection (OR 3.01, 95% CI 2.18-4.16, p <0.0001). Time period was not associated with the odds of vesicoureteral reflux (OR 0.98, 95% CI 0.77-1.23, p=0.85). Those in 2015 were more likely to present with vesicoureteral reflux grade >3 (OR 2.22, 95% CI 1.13-4.34, p=0.02) but not vesicoureteral reflux grade >2 (OR 1.11, 95% CI 0.74-1.67, p=0.60). Renal scarring was more common among children presenting in 2015 (OR 2.9, 95% CI 1.03-8.20, p=0.04)., Conclusions: Compared to 2005, children presenting in 2015 for post-urinary tract infection voiding cystourethrogram have increased likelihood of recurrent urinary tract infection and renal scarring, despite similar likelihood of vesicoureteral reflux diagnosis.

Purpose: Vesicoureteral reflux is not usually considered a major cofactor in acute pyelonephritis in women. However, there is a subset of individuals in whom reflux must be considered in the evaluation of acute pyelonephritis. We sought to evaluate the effectiveness of endoscopic treatment for vesicoureteral reflux in this subset of patients. Materials and Methods: We retrospectively reviewed the records of 13 female patients presenting with clinical pyelonephritis between 2001 and 2005. All of these patients had either a history of vesicoureteral reflux in childhood or a family history of reflux, or had previously undergone surgery for reflux. All patients underwent voiding cystourethrogram and dimercapto-succinic acid renal scan as part of the evaluation. Results: Of the 13 individuals evaluated 9 had vesicoureteral reflux. Of these patients 5 had been operated on previously for vesicoureteral reflux, 2 had a strong family history of reflux and 2 had reflux as a child with documented resolution. Six of the 9 patients with reflux exhibited renal scarring on dimercapto-succinic acid renal scintigraphy. Endoscopic correction of reflux was done in all 9 patients and was successful in 8, as shown on voiding cystourethrogram at 3 months postoperatively. One patient required a second procedure, which was successful. Only 1 patient has had a subsequent episode of clinical pyelonephritis, and voiding cystourethrogram following treatment again revealed resolution of reflux. Conclusions: There is a subset of women presenting with acute pyelonephritis in whom vesicoureteral reflux is a risk factor. When documented, vesicoureteral reflux can be managed effectively with endoscopic treatment. [Copyright &y& Elsevier]