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Introduction: The radiographic grading of voiding cystourethrogram (VCUG) images is often used to determine the clinical course and appropriate treatment in patients with vesicoureteral reflux (VUR). However, image-based evaluation of VUR remains highly subjective, so we developed a supervised machine learning model to automatically and objectively grade VCUG data., Study Design: A total of 113 VCUG images were gathered from public sources to compile the dataset for this study. For each image, VUR severity was graded by four pediatric radiologists and three pediatric urologists (low severity scored 1-3; high severity 4-5). Ground truth for each image was assigned based on the grade diagnosed by a majority of the expert assessors. Nine features were extracted from each VCUG image, then six machine learning models were trained, validated, and tested using 'leave-one-out' cross-validation. All features were compared and contrasted, with the highest-ranked then being used to train the final models., Results: F1-score is a metric that is often used to indicate performance accuracy of machine learning models. When using the highest-ranked VCUG image features, F1-scores for the support vector machine (SVM) and multi-layer perceptron (MLP) classifiers were 90.27 % and 91.14 %, respectively, indicating a high level of accuracy. When using all features combined, F1 scores were 89.37 % for SVM and 90.27 % for MLP., Discussion: These findings indicate that a distorted pattern of renal calyces is an accurate predictor of high-grade VUR. Machine learning protocols can be enhanced in future to improve objective grading of VUR., Competing Interests: Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity., Methods: An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity., Results: A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019 at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p = 0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p = 0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p = 0.016)., Discussion: After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation., Conclusion: BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient., (Copyright © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group., Materials and Methods: A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life., Results: No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status., Conclusions: Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We studied the clinical evolution of vesicoureteral reflux after endoscopic puncture of ureterocele in pediatric duplex systems., Materials and Methods: We retrospectively reviewed charts of children with duplex system ureteroceles treated between 1992 and 2007. We analyzed patient age, prenatal diagnosis, urinary tract infection at presentation, differential renal function and preoperative vesicoureteral reflux. The fate of associated vesicoureteral reflux after endoscopic puncture of ureterocele was specifically addressed., Results: We analyzed 60 patients with a mean age of 12 months, of whom 32 (52%) were diagnosed prenatally and 40 (66%) presented with a urinary tract infection. The majority of ureteroceles were ectopic, and pre-puncture vesicoureteral reflux was seen in 40 patients (67%). Postoperative voiding cystourethrogram was performed in 50 cases. New onset of vesicoureteral reflux occurred postoperatively in 24 patients (40%), mainly ipsilateral to the lower pole or contralaterally. Spontaneous vesicoureteral reflux resolution or improvement occurred in 16 of 22 patients (72%) observed after primary endoscopic puncture of ureterocele. Surgical intervention after endoscopic puncture of ureterocele was performed in 25 patients (42%), of whom 9 underwent more than 1 reparative procedure., Conclusions: Vesicoureteral reflux after endoscopic puncture of ureterocele may occur in the ipsilateral upper or lower poles, or in the contralateral renal segments. Therefore, the reflux is not necessarily related to the puncture itself. Vesicoureteral reflux after endoscopic puncture of ureterocele can resolve spontaneously in a significant number of patients. Therefore, initial management by close surveillance is warranted. Considering the simplicity of the procedure, our findings support that endoscopic puncture of ureterocele is an attractive alternative for the initial management of pediatric duplex system ureteroceles., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Conflicting reports exist regarding the parameters guiding successful correction of vesicoureteral reflux using dextranomer/hyaluronic acid copolymer. We performed logistic regression analysis to evaluate the effect of injected volume while adjusting for other factors potentially associated with success following dextranomer/hyaluronic acid copolymer injection., Materials and Methods: Between July 2003 and June 2006, 126 consecutive patients (34 boys and 92 girls) with a mean +/- SD age of 6.5 +/- 3.7 years with primary vesicoureteral reflux (196 refluxing ureters) underwent injection for febrile urinary tract infections. Success was defined as complete reflux resolution. Age, gender, laterality, preoperative vesicoureteral reflux grade, surgeon experience, dextranomer/hyaluronic acid copolymer volume, time to surgery from initial presentation and preoperative treatment for lower urinary tract symptoms were analyzed., Results: Vesicoureteral reflux grade was I to V in 7 (3.5%), 53 (27%), 91 (46.4%), 30 (15.3%) and 15 renal units (7.6%), respectively. The success rate after 1 injection was 50% by patient and 59.2% by ureter. Mean injected volume was 0.9 +/- 0.27 ml in those who had a successful injection vs 0.67 +/- 0.24 ml in those in whom injection failed (p <0.001). The success rate after 1 injection was 78.9% using 0.8 ml or greater dextranomer/hyaluronic acid copolymer compared to 31.7% with less than 0.8 ml. Multivariate analysis confirmed that higher dextranomer/hyaluronic acid copolymer volume (p = 0.001), lower preoperative grade (p = 0.013), surgeon experience (p = 0.025) and treatment for lower urinary tract symptoms (p = 0.009) were associated with successful correction of vesicoureteral reflux., Conclusions: Our analysis strengthens the previously reported association of surgeon experience and vesicoureteral reflux grade with successful endoscopic vesicoureteral reflux correction. The data also revealed an association between injected volume and vesicoureteral reflux correction even while controlling for other variables, highlighting its importance as a true success modifier.

Purpose: As the indications for endoscopic correction of vesicoureteral reflux continue to expand, the emergence of potential predictive variables has been noted. We used univariate and multivariate statistical analyses to find the most significant predictors of correction to improve patient selection., Materials and Methods: A consecutive series of patients treated at a single institution was reviewed. Between August 1998 and August 2004, 232 children endoscopically injected with polydimethylsiloxane were identified, representing 351 refluxing units. A total of 23 variables were subjected to statistical analysis to detect predictors of reflux correction after injection. All identified patients with complete data and followup evaluations were included irrespective of anatomical variations, previous interventions or comorbidities., Results: The overall success rate by patient and renal unit was 65% and 72%, respectively. In patients with a single system low grade (1-3) vesicoureteral reflux who did not previously undergo injection this success rate increased to 80%. Univariate analysis demonstrated that higher physician experience, low preoperative vesicoureteral reflux grade, absent renal scars and no previous injections were statistically significant predictors of vesicoureteral reflux correction (p <0.05). A history of febrile urinary tract infections and a duplex system did not attain significance (p = 0.069 and 0.076, respectively). On multivariate statistical evaluation only physician experience, preoperative vesicoureteral reflux grade and the number of previous injections remained significant., Conclusions: Multivariate analysis of our data showed the most important determinants of vesicoureteral reflux correction after endoscopic injection. Prospective validation will allow us to generate nomograms to better select and counsel patients who would benefit from vesicoureteral reflux treatment.

Purpose: Retroperitoneal laparoscopic heminephrectomy is a relatively new, well tolerated, minimally invasive alternative to open surgery for children with a nonfunctioning moiety in a duplex kidney. We collected data to assess outcomes in our experience with this procedure., Materials and Methods: Data were retrospectively gathered on all patients operated on for retroperitoneal laparoscopic heminephrectomy at our institution between February 2001 and November 2004. Followup ultrasound was performed in all patients, and additional imaging was done only when clinically indicated., Results: Retroperitoneal laparoscopic heminephrectomy was performed in 18 girls and 4 boys (18 upper and 5 lower pole moieties). Indications included ureterocele (12 patients), ectopic ureter (9) and vesicoureteral reflux (5). Mean age at surgery was 5 years (range 4 months to 18 years). Four patients required conversion to an open procedure due to inadequate exposure and were excluded from further review. Urine leaks developed postoperatively in 3 patients and were treated with Foley catheter drainage and/or stent placement. Two patients were noted to have large (more than 5 cm) asymptomatic retroperitoneal fluid collections on followup ultrasound. Functional loss of the remaining ipsilateral moiety was confirmed by DMSA scan in 2 children (ages 6 and 7 months). Doppler studies confirmed normal hilar blood flow in both cases. Clinical presentation for this subgroup included fever on postoperative day 3 in 1 patient and hypertension at 32 months postoperatively in 1. Mean followup was 33 months (range 3 to 56)., Conclusions: Although retroperitoneal laparoscopic renal ablative surgery in children appears to be relatively safe and is associated with low morbidity, serious complications may occur with subtle or even late presentation.

Purpose: The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD., Materials and Methods: We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups., Results: Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution., Conclusions: The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.

Purpose: The management of vesicoureteral reflux (VUR) in a duplicated collecting system (DS) is controversial. Available literature is sparse and it does not assess all co-factors. We compared the outcome of VUR in DS cases with VUR in single system (SS) cases, given similar clinical management in the 2 groups., Materials and Methods: A retrospective cohort study was done to compare the outcome of VUR in 35 children (44 units) with a DS and in 95 (150 units) with an SS. Patients with secondary reflux, incomplete duplication and ureterocele were excluded. Two groups were similar in terms of prognostic factors. Mean followup in the DS and SS groups was 43 and 48 months, respectively. Outcomes of interest were spontaneous resolution or uncomplicated persistence vs surgical correction. The same criteria were used to intervene surgically in the 2 groups., Results: In the DS group 24 of 35 patients (69%) underwent surgery compared with 25 of 95 (25%) in the SS group. Multivariate analysis showed an association between surgery due to complications and the presence of DS (p = 0.0001). Higher grade and female gender were independent predictors (p = 0.02 and 0.0007, respectively). The likelihood of undergoing surgery was the same for low grade VUR (I and II) in the DS and SS groups (p = 0.16). No resolution was seen in the duplex group with severe VUR at a mean followup of 42 months., Conclusions: Low grade VUR in DS cases has an outcome similar to that of VUR in SS cases. Females with moderate or high grade VUR and a DS should be treated differently because they present more often with complications.