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It is a common practice to monitor blood tests in patients receiving long-term trimethoprim-sulfamethoxazole (TMP-SMZ) prophylaxis for recurrent urinary tract infections. This multicenter, randomized, placebo-controlled trial enrolled 607 children aged 2 to 71 months with vesicoureteral reflux diagnosed after symptomatic urinary tract infection. Study participants received TMP-SMZ (n = 302) or placebo (n = 305) and were followed for 2 years. Serum electrolytes (n ≥ 370), creatinine (n = 310), and complete blood counts (n ≥ 206) were measured at study entry and at the 24-month study conclusion. We found no significant electrolyte, renal, or hematologic abnormalities when comparing the treatment and placebo groups. We observed changes in several laboratory parameters in both treatment and placebo groups as would normally be expected with physiologic maturation. Changes were within the normal range for age. Long-term use of TMP-SMX had no treatment effect on complete blood count, serum electrolytes, or creatinine. Our findings do not support routine monitoring of these laboratory tests in children receiving long-term TMP-SMZ prophylaxis.

Objective: Antimicrobial prophylaxis for children with vesicoureteral reflux (VUR) reduces recurrences of urinary tract infection (UTI) but requires daily antimicrobials for extended periods. We used a cost-utility model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks and, if so, to investigate whether the benefits and risks vary according to grade of VUR. Methods: We compared the cost per quality-adjusted life-year (QALY) gained in four treatment strategies in children aged <6 years diagnosed with VUR after a first UTI, considering these treatment strategies: (1) prophylaxis for all children with VUR, (2) prophylaxis for children with Grade III or Grade IV VUR, (3) prophylaxis for children with Grade IV VUR, and (4) no prophylaxis. Costs and effectiveness were estimated over the patient's lifetime. We used $100,000/QALY gained as the threshold for considering a treatment strategy cost effective. Results: Based on current data and plausible ranges to account for data uncertainty, prophylaxis of children with Grades IV VUR costs $37,903 per QALY gained. Treating children with Grade III and IV VUR costs an additional $302,024 per QALY gained. Treating children with all grades of VUR costs an additional $339,740 per QALY gained. Conclusions: Treating children with Grades I, II, and III VUR with long-term antimicrobial prophylaxis costs substantially more than interventions typically considered economically reasonable. Prophylaxis in children with Grade IV VUR is cost effective., (Copyright © 2020 Shaikh, Rajakumar, Peterson, Gorski, Ivanova, Gravens Muller, Miyashita, Smith, Mattoo, Pohl, Mathews, Greenfield, Docimo and Hoberman.)

Introduction: Technetium-99m dimercaptosuccinic acid (DMSA) renal scans are used in the diagnosis of renal scarring. In the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial that randomized 607 children, DMSA renal scans were used for evaluating the presence and the severity of renal scarring., Objective: The aim was to determine interobserver variability in reporting of DMSA renal scans in the RIVUR trial., Study Design: We compared DMSA renal scan reports for renal scarring and acute pyelonephritis from all non-reference local radiologists (ALRs) at study sites with adjudicated as well as non-adjudicated reports from two reference radiologists (RRs) of the RIVUR trial. Two-way comparisons of concordant and discrepant responses were analyzed using an unweighted kappa statistic between the ALR and the adjudicated RR interpretations. All analyses were performed using SAS v 9.4 (SAS institute 2015) and significance was determined at the 0.05 level., Results: Of the 2872 kidneys evaluated, adjudicated RR reports had 119 (4%) kidneys with renal scarring compared with 212 (7%) by the ALRs. For 79% kidneys the grading for scarring reported by ALRs was either upgraded (24%) or downgraded (55%) by RRs. For acute pyelonephritis (n = 2924), adjudicated RR reports had 85 (3%) kidneys with pyelonephritis compared with 151 (5%) by the ALRs. For 85% kidneys, the grading for pyelonephritis reported by the ALRs was either upgraded (28%) or downgraded (57%) by the RRs. A three-way comparison revealed that all three (RR1, RR2, and ALR) agreed over presence of renal scarring in 19% cases and two of the three agreed in 80% cases. The respective numbers for pyelonephritis were 13% and 84%. The agreement rate for all DMSA scan reports between the RRs and the ALRs was 93%., Discussion: The study revealed significant interobserver variability in the reporting of abnormal DMSA renal scans compared with the previously published studies. A noteworthy limitation was a lack of uniformity in local reporting of the scans., Conclusions: Our study highlights the need for optimizing the clinical yield of DMSA renal scans by more specific guidelines, particularly for standardized and uniform interpretation., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: To characterize our contemporary clinical experience with cryptorchidism., Materials and Methods: The records of boys referred for cryptorchidism were reviewed from 2001 to 2011. Data regarding the incidence of retractile testes, testicular ascent, surgical approach and outcomes were tabulated. Follow up was both early (< 12 weeks) and late (> 12 weeks)., Results: A total of 1885 patients, or 2593 testes, were identified. Eight hundred and forty-one children (45%) or 1204 testes (46%) were retractile on initial exam-57% bilateral; 187 testes (7%) later 'ascended' on re-examination and underwent surgery--15% bilateral; 1340 (85%) testes were palpable in the inguinal canal and underwent inguinal orchidopexy--98% were successful; 69 (4%) of initially palpable testes were found to be atrophic and removed; 167 (11%) testes were non-palpable and underwent laparoscopy-46 were atrophic and removed; 31 were vanishing; 33 were brought down using an inguinal approach at the same sitting with 97% success; 47 underwent staged Fowler-Stephens orchidopexy (FSO) and 10 underwent non-staged FSO, with 82% and 78% success respectively. All second stages were performed open., Conclusions: Almost half of children referred for cryptorchidism had retractile testes. Surgery for later ascent was required in 16% of testes judged to be retractile at a median age of 8 years, emphasizing the need for repeat examination. High success rates with inguinal orchidopexy were achieved, even in non-palpable testes. Testes requiring FSO were uncommonly encountered-approximately 5 testes/year or 4% of testes undergoing surgery-and success was achieved in approximately 80%.

Introduction: Voiding cystourethrogram (VCUG) provides a wealth of data on urinary tract function and anatomy, but few standards exist for reporting VCUG findings., Objective: We aimed to assess variability in VCUG reports and to test our hypothesis that VCUG reports from pediatric facilities and pediatric radiologists are more complete than those performed at other facilities or by non-pediatric radiologists., Study Design: We analyzed original VCUG reports from children enrolled in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial. A 23-item checklist was created and used to evaluate reporting of technical (e.g. catheter size), anatomic (e.g. vesicoureteral reflux (VUR) presence and grade, bladder shape), and functional information (e.g. bladder emptying). Radiologists were classified as pediatric or non-pediatric radiologists. Facilities were categorized as to whether they were a free-standing pediatric hospital (FSPH), a pediatric "hospital within a hospital" (PHWH), a non-pediatric hospital (NPH), or an outpatient radiology facility (ORF). Multivariate linear regression was used to analyze factors associated with the completeness of the VCUG reports (percent of items reported from the 23-item checklist)., Results: Six-hundred and two VCUGs were performed at 90 institutions. Of those, 76% were read by a pediatric radiologist, and 49% were performed at a FSPH (Table). On average, less than half of the 23 items in our standardized assessment tool were included in VCUG reports (mean 48%, SD 12). The completeness of reports varied by facility type: 51% complete at FSPH (SD 11), 50% at PHWH (SD 10), 36% at NPH (SD 11), and 43% at ORF (SD 8) (p < 0.0001). In multivariate analysis, VCUG reports generated at NPH or ORF had 8% fewer items included (95% CI 3.0-12.8, p < 0.01), and those generated at PHWH did not differ from those generated at FSPH. Reports read by a non-pediatric radiologist had 6% fewer items included (95% CI 3-9.7; p < 0.01) compared with those read by a pediatric radiologist., Discussion: There is substantial underreporting of findings in VCUG reports when assessing a widely represented sample of routine, community-generated reports using an idealized standard. Although VUR was often reported, other crucial anatomic and functional findings of the VCUG were consistently underreported across all facility types., Conclusion: Although pediatric radiologist and pediatric hospitals generated more complete VCUG reports compared with those having non-pediatric origins, the differences are small when considering the substantial underreporting of VCUG findings in general. This underscores the opportunities for improvement in reporting of VCUG findings., (Copyright © 2016. Published by Elsevier Ltd.)

Introduction: Voiding cystourethrography (VCUG) is the modality of choice to diagnose vesicoureteral reflux (VUR). Although grading of VUR is essential for prognosis and clinical decision-making, the inter-observer reliability for grading has been shown to vary substantially. The Randomized Intervention for Children with VesicoUreteral Reflux (RIVUR) trial provides a large cohort of children with VUR to better understand the reliability of VCUG findings., Objective: To determine the inter-observer consistency of the grade of VUR and other VCUG findings in a large cohort of children with VUR., Study Design: The RIVUR trial is a randomized controlled trial of antimicrobial prophylaxis in children with VUR diagnosed after UTI. Each enrollment VCUG was read by a local clinical (i.e. non-reference) radiologist, and independently by two blinded RIVUR reference radiologists. Reference radiologists' disagreements were adjudicated for trial purposes. The grade of VUR and other VCUG findings were extracted from the local clinical radiologist's report. The unit of analysis included individual ureters and individual participants. We compared the three interpretations for grading of VUR and other VCUG findings to determine the inter-observer reliability., Results: Six-hundred and two non-reference radiology reports from 90 institutions were reviewed and yielded the grade of VUR for 560 left and 524 right ureters. All three radiologists agreed on VUR grade in only 59% of ureters; two of three agreed on 39% of ureters; and all three disagreed on 2% of ureters (Table). Agreement was better (≥92%) for other VCUG findings (e.g. bladder shape "normal"). The non-reference radiologists' grade of VUR differed from the reference radiologists' adjudicated grade by exactly one grade level in 19% of ureters, and by two or more grade levels in 2.2% of ureters. When the participant was the unit of analysis, all three radiologists agreed on the grade of VUR in both ureters in just 43% of cases., Discussion: Our study shows considerable and clinically relevant variability in grading VUR by VCUG. This variability was consistent when comparing non-reference to the adjudicated reference radiologists' assessment and the reference radiologists to each other. This study was limited to children with a history of UTI and grade I-IV VUR and may not be generalizable to all children who have a VCUG., Conclusion: The considerable inter-observer variability in VUR grading has both research and clinical implications, as study design, risk stratification, and clinical decision-making rely heavily on grades of VUR., (Copyright © 2016 Journal of Pediatric Urology Company. All rights reserved.)

Purpose: Published cohorts of children with vesicoureteral reflux placed on antibiotic prophylaxis differ in baseline characteristics and methodology. These data have been combined in meta-analyses to derive treatment recommendations. We analyzed these cohorts in an attempt to understand the disparate outcomes reported., Materials and Methods: A total of 18 studies were identified from 1987 to 2013. These series retrospectively or prospectively evaluated children with vesicoureteral reflux who were on long-term antibiotic prophylaxis. Presenting demographic data, criteria and methods of evaluation were tabulated. Outcomes were compared, specifically recurrent urinary infections and renal scarring., Results: Significant differences identified in baseline characteristics included gender, circumcision status and reflux grade, and differences in methodology included evaluation of bowel and bladder dysfunction, method of urine collection, definition of urinary infection, measurement of compliance and means of identifying renal scarring. Cohorts with larger numbers of uncircumcised boys had more breakthrough urinary infections. Infection and renal scarring rates were higher in series with higher grades of reflux. Bagged urine specimens were allowed in 6 series, rendering the data suspect. Children with bowel and bladder dysfunction were excluded from 3 cohorts, and bowel and bladder dysfunction was correlated with outcome in only 1 cohort. Compliance was monitored in only 6 studies., Conclusions: Subpopulations and methodologies vary significantly in published series of children with vesicoureteral reflux on antibiotic prophylaxis. It is inappropriate to combine outcomes data from these series in a meta-analysis, which would serve to blur distinctions between these subpopulations. Broad recommendations or guidelines based on meta-analyses should be viewed with caution., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial found that recurrent urinary tract infections (rUTI) with resistant organisms were more common in the trimethoprim-sulfamethoxazole prophylaxis (TSP) arm. We describe factors associated with trimethoprim-sulfamethoxazole (TMP-SMX) resistance of rUTIs in RIVUR., Methods: Children aged 2 to 71 months with first or second UTI (index UTI) and grade I to IV vesicoureteral reflux (VUR) were randomized to TSP or placebo and followed for 2 years. Factors associated with TMP-SMX-resistant rUTI were evaluated., Results: Among 571 included children, 48% were <12 months old, 43% had grade II VUR, and 38% had grade III VUR. Recurrent UTI occurred in 34 of 278 children receiving TSP versus 67 of 293 children receiving placebo. Among those with rUTI, 76% (26/34) of subjects receiving TSP had TMP-SMX-resistant organisms versus 28% (19/67) of subjects receiving placebo (P < .001). The proportion of TMP-SMX-resistant rUTI decreased over time: in the TSP arm, 96% were resistant during the initial 6 months versus 38% resistant during the final 6 months; corresponding proportions for the placebo arm were 32% and 11%. Among children receiving TSP, 7 (13%) of 55 with TMP-SMX-resistant index UTI had rUTI, whereas 27 (12%) of 223 with TMP-SMX-susceptible index UTI had rUTI (adjusted hazard ratio 1.38, 95% confidence interval 0.54-3.56). Corresponding proportions in placebo arm were 17 (26%) of 65 and 50 (22%) of 228 (adjusted hazard ratio 1.33, 95% confidence interval 0.74-2.38)., Conclusions: Although TMP-SMX resistance is more common among children treated with TSP versus placebo, resistance decreased over time. Among children treated with TSP, there was no significant difference in UTI recurrence between those with TMP-SMX-resistant index UTI versus TMP-SMX-susceptible UTI., (Copyright © 2016 by the American Academy of Pediatrics.)

Background and Objectives: The main objectives of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial were to evaluate the role of antimicrobial prophylaxis in the prevention of recurrent urinary tract infection (UTI) and renal scarring in children with vesicoureteral reflux (VUR). We present a comprehensive evaluation of renal scarring outcomes in RIVUR trial participants., Design, Setting, Participants, & Measurements: This multicenter, randomized, placebo-controlled trial enrolled 607 children aged 2-71 months with grade 1-4 VUR diagnosed after a first or second febrile or symptomatic UTI. Study participants received trimethoprim-sulfamethoxazole or placebo and were followed for 2 years. Renal scarring was evaluated by baseline and follow-up (99m)technetium dimercaptosuccinic acid (DMSA) renal scans that were reviewed independently by two blinded reference radiologists., Results: At the end of the study, 58 (10%) of 599 children and 63 (5%) of 1197 renal units had renal scarring. New renal scarring did not differ between the prophylaxis and placebo groups (6% versus 7%, respectively). Children with renal scarring were significantly older (median age, 26 versus 11 months; P=0.01), had a second UTI before enrollment (odds ratio [OR], 2.85; 95% confidence interval [95% CI], 1.38 to 5.92), were more likely to be Hispanic (OR, 2.22; 95% CI, 1.13 to 4.34), and had higher grades of VUR (OR, 2.79; 95% CI, 1.56 to 5.0). The proportion of new scars in renal units with grade 4 VUR was significantly higher than in units with no VUR (OR, 24.2; 95% CI, 6.4 to 91.2)., Conclusions: Significantly more renal scarring was seen in relatively older children and in those with a second episode of febrile or symptomatic UTI before randomization. Preexisting and new renal scars occurred significantly more in renal units with grade 4 VUR than in those with low-grade or no VUR. Antimicrobial prophylaxis did not decrease the risk of renal scarring., (Copyright © 2016 by the American Society of Nephrology.)

Background: Children with febrile urinary tract infection commonly have vesicoureteral reflux. Because trial results have been limited and inconsistent, the use of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial., Methods: In this 2-year, multisite, randomized, placebo-controlled trial involving 607 children with vesicoureteral reflux that was diagnosed after a first or second febrile or symptomatic urinary tract infection, we evaluated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome). Secondary outcomes were renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance., Results: Recurrent urinary tract infection developed in 39 of 302 children who received prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38 to 0.78). Prophylaxis reduced the risk of recurrences by 50% (hazard ratio, 0.50; 95% CI, 0.34 to 0.74) and was particularly effective in children whose index infection was febrile (hazard ratio, 0.41; 95% CI, 0.26 to 0.64) and in those with baseline bladder and bowel dysfunction (hazard ratio, 0.21; 95% CI, 0.08 to 0.58). The occurrence of renal scarring did not differ significantly between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). Among 87 children with a first recurrence caused by Escherichia coli, the proportion of isolates that were resistant to trimethoprim-sulfamethoxazole was 63% in the prophylaxis group and 19% in the placebo group., Conclusions: Among children with vesicoureteral reflux after urinary tract infection, antimicrobial prophylaxis was associated with a substantially reduced risk of recurrence but not of renal scarring. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; RIVUR ClinicalTrials.gov number, NCT00405704.).

Objectives: Our primary objective was to develop and evaluate an intervention to increase recruitment in a multicenter pediatric randomized clinical trial (RCT). Our secondary objective was to assess the impact beyond 120 days., Methods: The study was conducted at 17 academic centers participating in a pediatric RCT. The intervention consisted of utilizing a recruitment assessment tool at a site visit or teleconference with key site personnel., Results: We found a significant increase in the number of individuals enrolled for all 17 sites at 120 days postintervention (mean = 1.12 per site; median = 1 per site; 95% confidence interval = 1-2; P = .04). No significant differences were apparent beyond the first 120 days postintervention., Conclusions: Successful recruitment in RCTs is essential to the quality, generalizability, and cost-effectiveness of clinical research. Implementation of this recruitment intervention may effectively increase recruitment in RCTs. Beyond the first 120 days postintervention, repeated interventions may be required. What is new? Despite general and pediatric-specific challenges to recruitment in RCTs, a paucity of evidence exists on effective recruitment strategies or assessment tools to reliably enhance recruitment. We developed a recruitment intervention for use in RCTs that enables clinical researchers to enhance recruitment.

Intra-abdominal prenatally detected testicular neoplasms are rare; however, increased use of prenatal ultrasonography has led to the discovery of these uncommon neoplasms. We report the fifth case of a prenatally detected intra-abdominal testicular teratoma, which, in this instance, was detected early in pregnancy as a cystic mass within the fetal abdomen that subsequently underwent torsion later in pregnancy before delivery., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: Controversy exists regarding the benefit of open anti-reflux surgery (OS) in reducing the incidence of urinary tract infection (UTI). We, therefore, reviewed our short and long term data in children who have undergone OS., Methods: 153 children (131F, 22M; ages 2-16 yrs, mean 8 yrs) underwent OS from 1990 to 2008. Reasons for presentation were UTI-131; sibling survey-19; prenatal hydronephrosis-3. Major reasons for OS were: breakthrough UTI-74 (48%), high grade (IV or V)-49 (32%), poor compliance with prophylaxis-15 (10%). Of 153 pre-operative DMSA scans, 60 (39%) had defects. Post-operative studies were performed 6 months after surgery and 151 (99%) had negative voiding cystourethrograms (VCUG's). All underwent urine cultures 6 months post-op and prophylaxis was stopped. 56 (37%) were later contacted at an average 7 yrs post-op (range: 2-13 yrs)., Results: 23 (15% of 153 followed short term, 40% of 56 followed long term)-20F, 3M-had non-febrile UTI's (nfUTI's) and one girl (0.6%) had a febrile UTI (fUTI). Of those who had nfUTI's 7 (30%) had high grade reflux and 16 (70%) had pre-op breakthrough UTI's. 11 (48%) had DMSA scans with defects. 2 had UTI's within 1 year after a negative VCUG and 21 had UTI's later (1-8 yrs). 1 girl had a fUTI 1 month after a negative VCUG., Conclusions: Successful OS effectively eliminates fUTI. Families should be counseled that nfUTI may occur many years after surgery, especially in girls with a history of breakthrough UTI and renal scarring., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background and Objective: Vesicoureteral reflux (VUR) is diagnosed in ∼30% to 40% of children who have imaging studies after urinary tract infections (UTIs). Our goal is to characterize children enrolled in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial and to compare our study cohort with those from previously published studies., Methods: RIVUR investigators from 19 pediatric sites in the United States recruited 607 children with grade I through IV VUR. Children were enrolled after a first or second UTI. This cross-sectional report of baseline data includes extensive clinical, parental report, and imaging study results., Results: RIVUR recruited 607 children (558 girls, 49 boys) with grade I (11%), II (42%), III (38%), or IV (8%) reflux. The median age was 12 months, and most children (91%) were enrolled after their first UTI. The UTI leading to enrollment was both febrile and symptomatic for 323 children, febrile only in 197 children, and symptomatic only in 86. Renal involvement at baseline as documented by a (99m)Tc dimercaptosuccinic acid scan was uncommon with cortical defects identified in 89 (15%) children. Bladder and bowel dysfunction was identified in 71 (56%) of 126 toilet-trained subjects assessed., Conclusions: RIVUR is the largest prospective, randomized trial for children with primary VUR to date, comparing prophylaxis with placebo. The study sample comprises patients from 19 pediatric clinical sites in the United States, whose demographic and clinical characteristics may differ from those of children enrolled in previous trials from other countries.

Importance: A child's health, positive perceptions of the research team and consent process, and altruistic motives play significant roles in the decision-making process for parents who consent for their child to enroll in clinical research. This study identified that nonconsenting parents were better educated, had private insurance, showed lower levels of altruism, and less understanding of study design., Objective: To determine the factors associated with parental consent for their child's participation in a randomized, placebo-controlled trial., Design: Cross-sectional survey conducted from July 2008 to May 2011. The survey was an ancillary study to the Randomized Intervention for Children with VesicoUreteral Reflux Study., Setting: Seven children's hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux., Participants: Parents asked to provide consent for their child's participation in the randomized trial were invited to complete an anonymous online survey about factors influencing their decision. A total of 120 of the 271 (44%) invited completed the survey; 58 of 125 (46%) who had provided consent and 62 of 144 (43%) who had declined consent completed the survey., Main Outcomes and Measures: A 60-question survey examining child, parent, and study characteristics; parental perception of the study; understanding of the design; external influences; and decision-making process. RESULTS Having graduated from college and private health insurance were associated with a lower likelihood of providing consent. Parents who perceived the trial as having a low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care, or exhibiting potential for enhanced care, or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of the randomization process, blinding, and right to withdraw were significantly positively associated with consent to participate. CONCLUSIONS AND RELEVANCE Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision, and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. Consideration of the factors included in the conceptual model should enhance the quality of the informed consent process and improve participation in pediatric clinical trials.

Purpose: Two reference radiologists independently review voiding cystourethrograms for the National Institutes of Health sponsored RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial for children with vesicoureteral reflux. A pilot study was required from all clinical centers before enrolling patients., Materials and Methods: Digital images were reviewed. Responses were compared and discrepancies adjudicated by teleconference to a final assessment., Results: A total of 75 studies from 19 sites were reviewed. Discrepancies in vesicoureteral reflux grade level were noted on the left and right side in 11 (15%, kappa 0.85) and 12 (16%, kappa 0.83) ureters, respectively. Other areas of disagreement were the presence of paraureteral diverticulum (left 11%, kappa 0.31; right 9%, kappa 0.34), urethral anatomy (15%, kappa 0.33), whether the child voided (8%, kappa 0.21), the presence of ureteral duplication (left 7%, kappa 0.64; right 3%, kappa 0.78) and the presence of bladder trabeculation (5%, kappa 0.32). Of 83 ureters in which reflux was seen there was grade disagreement about 23 (28%). Of 61 ureters initially assessed as grade II or III reflux by both readers, there was disagreement on 9 (15%). Of these 9 discrepancies 7 (78%) were adjudicated to the higher grade (grade III)., Conclusions: Discrepancies in the assessment of intermediate grade vesicoureteral reflux were noteworthy. Recommendations for patients with grade II or III reflux advanced by studies which rely on a single reading, which categorize only grade III or higher reflux as significant, may not be valid., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

This article discusses the use of antibiotic prophylaxis in the treatment of three common conditions encountered by the pediatric urologist: 1) children with urinary infection and structurally and neurologically normal urinary tracts; 2) children with vesicoureteral reflux (VUR); and 3) children with prenatally diagnosed ureteropelvic and ureterovesical obstruction. The literature remains unclear and contradictory. Additional significant risk factors for recurrent infection are age, circumcision status in boys, and toileting function. The evidence for the use of prophylaxis is best in those with VUR, although not everyone with VUR must be on medication. In the absence of definitive evidence, the clinician must individualize the treatment of each patient and family.

Objectives: To identify the factors that might predict which individuals ultimately fail to resolve voiding symptoms by analyzing their presenting symptoms and video-urodynamic findings. Older children with intractable voiding dysfunction and no evidence of neurologic abnormality, who are recalcitrant to medical treatment, pose a management challenge., Methods: The charts of neurologically normal children with intractable voiding dysfunction, who had fluorourodynamic studies and normal lumbosacral magnetic resonance imaging, were reviewed. A database was created that included the urodynamics, presenting urinary symptoms, presence of soiling or constipation, age at onset of symptoms, cystogram and bladder ultrasound findings, and treatments given. Long-term follow-up was determined from chart review (all patients) or by a mailed survey (15 patients). Patients without symptoms and off medication were defined as normal., Results: A total of 50 children met the criteria mentioned earlier in the text, presented at a mean age of 9.4 years (range, 3.8-17.3) and were followed up for a mean of 4 years (range, 1-11) from their initial urodynamic evaluation. Of them, 33 (66%) remained symptomatic and 1 (34%) normalized. A total of 31 were found to have uninhibited bladder contractions (UBCs) with daytime wetting, of which 24 (77.4%) failed to normalize (P = .037). All 9 with UBCs and detrusor-sphincter dyssynergia remained symptomatic (P = .02)., Conclusions: The majority failed to resolve their voiding symptoms. Children who presented with daytime wetting, UBC, and detrusor-sphincter dyssynergia were the most likely to remain symptomatic. Patients with these characteristics might be considered for more aggressive alternative therapies, after a period of medical management., (2010 Elsevier Inc. All rights reserved.)

Purpose: We performed a meta-analysis of published series of laparoscopic and open pyeloplasty. We compared these data to open pyeloplasty at our institution using diuretic renography as the indicator for obstruction and postoperative success., Materials and Methods: Laparoscopic studies included 19 series published between 1995 and 2007 comprising 346 kidneys. Open pyeloplasty studies included 9 series published between 1998 and 2007 comprising 486 kidneys. Data from our institution included records for 213 patients (224 kidneys). We defined reoperative intervention as unplanned placement of a nephrostomy tube or ureteral stent, balloon dilation or redo pyeloplasty., Results: In the laparoscopic studies 171 cases (49%) were evaluated by preoperative and 137 (40%) by postoperative diuretic renography. Of patients undergoing postoperative diuretic renography 10 (7%) underwent reoperative intervention, including redo pyeloplasty (6, 4%), nephrostomy (3, 2%) and balloon dilation (1, 1%). In the open pyeloplasty studies performed elsewhere 165 cases (34%) were evaluated by preoperative and 230 (47%) by postoperative diuretic renography. Of patients undergoing postoperative diuretic renography redo pyeloplasty was required in 3 (1%). Of 224 cases managed by open pyeloplasty at our institution 215 (96%) had preoperative and postoperative diuretic renography data available. Of these patients 7 (3%) underwent reoperative intervention, including redo pyeloplasty (4, 2%), ureteral stent (2, 1%) and nephrostomy (1, 0.4%)., Conclusions: Most publications do not confirm preoperative obstruction or, following laparoscopic or open pyeloplasty, postoperative success via diuretic renography. While not statistically significant, in the minority of studies with postoperative diuretic renography results the reoperative intervention rate and redo pyeloplasty rate following laparoscopy are approximately double those of open pyeloplasty.

We describe a 3-month-old male infant who presented with gross hematuria and was found to have a renal mass and a testicular mass representing these two entities. This is the first case report of these two lesions presenting concomitantly.

Because of the frequency of urinary tract infections in children, off-label use of antimicrobial prophylaxis is often the usual treatment of children with vesicoureteral reflux, and such use is increasingly being called into question; hence, a definitive study to determine the value of antimicrobial prophylaxis with regard to the recurrence of urinary tract infection and the incidence of renal scarring is essential. The currently recommended follow-up procedures (repeated urine cultures, renal and genitourinary imaging, antimicrobial therapy and prophylaxis, as well as other factors including cleanliness, adequate bladder and bowel emptying, and compliance with protocols) are expensive (in terms of time, attention to detail, and cost) and cumbersome. Such recommendations should be evidence-based.

Objective: Definitive treatment of ectopic ureterocele (EU) implies that no further surgery or prophylactic antibiotic is needed. The literature is unclear on which interventions render a child 'treatment free'., Materials and Methods: Thirty (23 female, seven male) patients presented between 1984 and 2000. Follow up ranged from 5 to 15 years (mean: 7). Presenting reasons were: urinary tract infection in 18 (16 females, two males; age: 17<6 months, one 2 years), prenatal ultrasound in 11 (seven females, four males), and renal failure in one (male, aged 3 weeks)., Results: Treatment was as follows. No intervention, three (10%). Single procedure, eight (27%): five hemi-nephrectomy (HN), two transurethral incisions (TUI), one excision and re-implantation (E&R). Two procedures, 14 (47%): first procedure 10 TUI, 4 HN; second procedure 13 E&R, 1 TUI. Three procedures, three (10%): first 2 TUI, 1 HN; second 3 TUI; third 2 E&R, 1 HN. Four procedures, two (7%): first 2 TUI; second 1 HN, 1 TUI; third 2 TUI; fourth 2 E&R. Eight (27%) remained on prophylaxis: two had no intervention, in 4 the ectopic ureterocele was in situ after HN or TUI, and two had reflux after E&R. Twenty two (73%) came off prophylaxis (16 E&R, 4 HN, 1 TUI, 1 observation). Poorly or non-functioning upper pole moieties were left in place in 14/18 who underwent E&R., Conclusion: 'Treatment-free' status most often requires ureterocele excision. HN alone can be definitive, while TUI alone is so rarely. Poor or non-functioning upper pole segments can remain after E&R. Children with collapsed ureteroceles in situ often must remain on antibiotic prophylaxis. A staged approach with initial TUI, followed by E&R, was successful in definitively treating the majority.

Objectives: Gross hematuria in children is uncommon. We reviewed our experience characterizing its clinical presentation and diagnosis., Methods: The charts of all patients who presented for the 10-year period of 1994 through 2003 were reviewed, and 342 patients were identified. Of these 342 patients, 272 were boys (80%) and 70 (20%) were girls. At presentation, 21 patients (6%) were younger than 3 years (17 were boys and 4 were girls); 199 (58%) were 3 to 12 years old (155 were boys and 44 were girls); and 122 (36%) were 13 to 20 years old (100 were boys and 22 were girls)., Results: Of the 272 male patients, 52 (19%) had benign urethrorrhagia; 48 (14%) had trauma; and 48 had a urinary tract infection (14%), and 10 of those also had urologic anomalies. Of the 342 patients, 45 (13%) had one or more congenital urologic anomalies. Of these 45 patients, 20 boys and 2 girls had vesicoureteral reflux, 10 boys had posterior urethral valves, 7 boys and 1 girl had ureteropelvic junction obstruction, 7 boys had proximal hypospadias, 2 boys and 1 girl had ureterovesical junction obstruction, 2 boys and 1 girl had ureterocele, and 1 boy had caliceal diverticulum. Also, 18 patients (5%) had stones; 3 had low-grade bladder transitional cell carcinoma; and 1 had a Wilms tumor. For 118 patients (34%; 95 boys and 23 girls), no etiology was found., Conclusions: Gross hematuria most often had a benign cause in children and adolescents. It was more common in boys for almost all etiologic categories and ages. The extent of the urologic evaluation should depend on the clinical setting. Voiding cystourethrography is useful in those with suspicious ultrasound findings, urinary tract infection, or voiding symptoms. Cystoscopy should be reserved for the minority in whom hematuria persists or those with ambiguous imaging study findings.

Purpose: Urinary and sexual functions were assessed in post-pubescent boys who had undergone 2-stage hypospadias repair in infancy for severe hypospadias with chordee., Materials and Methods: A total of 44 boys who had undergone 2-stage hypospadias repair from 1985 to 1993 and who were at least 13 years old were contacted. Of the 44 boys 27 (61%) with an average age of 15.4 years (range 13 to 21) responded. Meatal locations were midshaft in 14 cases, penoscrotal in 9 and perineal in 4. Four boys had bifid scrotum and 5 had intersex disorders. Intramuscular testosterone was administered preoperatively to 15 (56%) boys. A Nesbit procedure was performed in 18 boys (67%). Average patient age at stage 2 repair was 2.3 years. Mean followup was 12.7 years (range 10.7 to 17.2). Additional surgery was performed for diverticuli in 5 cases, fistula in 3 and minor strictures in 4. Of the 27 patients 25 presented for examination and 2 responded to questionnaire only., Results: All patients had normal meatal position, normal glanular anatomy, a well-defined coronal sulcus, normal cylindrical shafts without extra skin and well-defined penoscrotal junctions. Ten boys (40%) had minor spraying of stream, all stood to void and 10 (40%) milked the urethra after voiding. None had chordee. Twenty patients were able to ejaculate and 9 (42.9%) had to milk the ejaculate. Two patients (7.7%) had minor pain with erection. All subjects were satisfied with urinary, erectile and ejaculatory functions, and 23 (92%) were pleased with appearance., Conclusions: The 2-stage approach for severe hypospadias results in excellent function, cosmesis and patient satisfaction after puberty, with no chordee. Minor voiding and ejaculatory problems are to be expected. Late complications are rare. The use of extragenital skin to either primarily repair or salvage a "cripple" has not been necessary.

Purpose: The presentation and management of pediatric stone disease have changed due to early identification and treatment of congenital urological conditions, as well as technological advances. Therefore, we reviewed our 12-year experience., Materials and Methods: A total of 123 patients with 158 stones presented from 1991 to 2003. The 46 boys and 77 girls were 8 months to 25 years old, including 5 boys (4%) younger than 3 years, 46 (37%) 4 to 12 years old and 72 (59%) older than 13 years. A 24-hour urine collection was done in 50 patients (41%) and serum chemistry studies were performed in 66 (54%)., Results: The seasons of presentation were fall in 41% of cases, summer in 24%, spring in 22% and winter in 13%. Of the patients 94 (76%) had loin pain, 10 (8%) had urinary tract infections, 13 (11%) had a history urinary tract infection, 18 (15%) had gross hematuria, 14 (11%) had structural urological abnormalities and 7 (6%) had neurogenic bladder. Metabolic abnormalities were uncommon and included hypercalciuria in 12%, hyperoxaluria in 2% and cystinuria in 2%. A total of 57 patients (46%) passed the stones and 34 (28%) underwent extracorporeal shock wave lithotripsy, of whom 24 (71%) became stone-free. Ureteroscopy was performed in 10 patients (8%) 6 to 19 years old, percutaneous nephrostolithotomy was done in 4 (3%) and 4 (3%) underwent open surgery. Stone analysis showed calcium based in 88% of the cases, struvite in 7% and cystine in 5%., Conclusions: The majority of patients had no congenital abnormalities. Early diagnosis of urological abnormalities and urinary infection, and appropriate management of neurogenic bladder may have reduced the incidence in those groups. Most stones are calcium based but occur in the absence of metabolic disturbances. More patients presented in the fall, perhaps reflecting the increased concentration of urine in the summer. Half of the patients passed the stones and shock wave lithotripsy was curative in most others. Ureteroscopy, percutaneous nephrostolithotomy and open surgery were rarely required.

Objectives: To characterize the clinical characteristics of a group of children with neurogenic bladder, high leak point pressures (LPPs), bladder wall changes, and hydronephrosis in whom medical management failed, who then underwent vesicostomy. Medical management can, rarely, fail in children with neurogenic bladder, high LPPs, bladder wall changes, and hydronephrosis. When it does, surgical intervention is necessary., Methods: Between 1988 and 2001, 8 girls with spina bifida (4 with thoracic and 4 with lumbosacral) underwent vesicostomy after medical management. All had undergone neonatal back closure and five had ventriculoperitoneal shunts. The mean follow-up after vesicostomy was 6 years., Results: High-grade reflux was present at birth in 3 patients and developed later in 3 patients at 1 year. Two had undergone ureteral reimplantation before vesicostomy. Four girls had trabeculation at birth and it developed in three at 1 year and one at 3 years. Hydronephrosis was present at birth in 2 patients and developed later in 6. High LPPs were noted at younger than 10 months of age in 6 patients. Oral oxybutynin was begun in 7 patients before 1 year of age and 5 were later given intravesical oxybutynin. Six patients began clean intermittent catheterization in infancy. The indications for vesicostomy were persistently elevated LPPs and hydronephrosis. Six had recurrent urinary tract infections. The mean age at vesicostomy was 3 years. Hydronephrosis resolved in 7 patients, and only 1 had additional febrile urinary tract infections. Two underwent reversal along with bladder augmentation and were continent at last follow-up., Conclusions: A small subset of girls with spina bifida are unresponsive to early and intensive medical therapy. Most have high LPPs and bladder wall and upper tract changes early in infancy. Vesicostomy reverses the clinical course. At an appropriate age, these children can undergo reconstruction with a high likelihood of continence.

Purpose: Tethered cord was classified based on clinical presentation and correlated with urodynamic and uroradiographic findings., Materials and Methods: A total of 54 children underwent cord untethering from 1993 through 2000. Preoperative magnetic resonance imaging, fluorourodynamics and renal ultrasound were performed in all cases, and postoperative (mean 16 months) fluorourodynamics was done in 33. The conus was at L-2 or lower, with or without a thickened filum in 51 patients and 3 older children with voiding dysfunction had normal cords., Results: Children were classified into group 1-19 with orthopedic deformities (scoliosis or lower limb abnormalities, group 2-16 with cutaneous back lesions, group 3-13 with voiding dysfunction (VD) or urinary tract infection without cutaneous lesions and group 4-6 with associated syndromes. In group 1, 3 patients (16%) had preoperative hyperreflexia (HR) which improved postoperatively in 2, HR developed in 1, none had hydronephrosis or reflux (VUR), 5 (26%) had voiding dysfunction (VD) and 4 improved postoperatively. In group 2, 4 patients (25%) had preoperative HR and all improved postoperatively, and 5 (31%) had VUR and 2 improved postoperatively. In group 3, 11 patients (85%) had HR and 2 (15%) were areflexic preoperatively and 6 (areflexic 1, HR 5) improved postoperatively, 3 (23%) had VUR and 2 improved postoperatively, and 7 (54%) had improved VD but 5 (71%) were on anticholinergics. All 3 patients with VD/normal cords had preoperative HR, and 1 improved, 1 had preoperative VUR which resolved and 1 clinically improved but was on anticholinergics. In group 4, 5 patients (83%) had HR and 2 improved, 2 (33%) had VUR and both improved, and 3 (50%) had VD and 1 improved., Conclusions: Older children who present with orthopedic problems have rare neurourological abnormalities many of which resolve after surgery. Similarly, infants who are diagnosed early with a cutaneous back lesion can have urodynamic abnormalities, which also have a high rate of resolution. Older children who present with VD have the highest incidence of urodynamic abnormalities. While many seem improved clinically after surgery, they require anticholinergics. All patients with VATER's syndrome should be evaluated prospectively for tethered cord.

Vesicoureteral reflux has long been recognised as a major child and public health problem. Widespread recognition and screening of at-risk populations has the potential to significantly reduce long-term morbidity in both children and adults. Advances in pharmacotherapy, materials science and surgery, have caused many experts to reassess established dictums of treatment. Concern regarding the overuse of antibiotics and surgery has led to efforts to tailor therapy more narrowly for those who are at the highest risk from recurrent urinary tract infection and pyelonephritis. Children after a certain age, without underlying voiding dysfunction, might not require treatment at all. Newer surgical and anaesthetic techniques have the potential of transforming surgical correction from a painful experience to an ambulatory procedure, with a rapid return to daily activities. Both the promise and pitfalls of these newest advances will be discussed in this review.

Purpose: We define the risk of kidney or testicle injury in children who play contact sports., Materials and Methods: National Pediatric Trauma Registry data from 50 United States pediatric trauma centers for 1990 to 1999 were analyzed. The data were from age groups 5 to 11, 12 to 14 and 15 to 18 years. Major abdominal injuries, injuries due to team and individual contact sports, and the site of injury were examined., Results: Of the 81,923 cases 5,439 were sports related. Abdominal injuries occurred in 459 patients (0.56%), and were due to contact sports in 191. Team sports were involved in 184 cases, including football in 44%, hockey in 19%, baseball in 15%, soccer in 12% and basketball in 6%. Abdominal injury rate by age was 16% for 5 to 11-year olds, 42% for 12 to 14-year-olds and 42% for 15 to 18-year-olds. Most common was splenic injury at 50% of cases, kidney injuries occurred in 22% and no testicle injuries were reported. Football accounted for the most kidney injuries (62%). Kidney injuries were more common among older teenagers. No injuries led to nephrectomy., Conclusions: Abdominal injuries are rare in children who play team and individual contact sports. No testicular injuries were reported. Kidneys are most at risk in football. Splenic injuries are most common overall, although the risk to kidney and spleen is equal in basketball. No kidneys were reported as lost. These data should help families and schools when assessing risk to genitourinary organs during these activities.

Purpose: We estimate the incidence of recreation related pediatric abdominal, testis and kidney injuries., Materials and Methods: Trauma registry data at the regional pediatric trauma center for 1993 to 2000 were analyzed for recreational injuries. The data were divided into the 3 age groups of 5 to 11, 12 to 14 and 15 to 18 years. The recreation, and site and severity of injury were cross referenced. Injury incidence was calculated using United States census data., Results: Of 4,921 children 34 boys and 2 girls (0.73%) had a genitourinary or abdominal injury due to recreation. Kidney injuries were the most common (44.4%), followed by spleen (36.1%) and liver (19.5%). No testicle injuries were reported. Skiing was the most common cause of injury (22.2%). Hockey, football, snowboarding, sledding and bicycling accounted for 83% of all injuries. There were no injuries related to basketball and soccer. The 12 to 14-year-old group had 50% of the injuries. Records were available for 15 kidney injuries, of which 11 were on the left side, 1 was bilateral, 3 required transfusion and 1 required nephrectomy. Injury grades were I in 2 cases, II in 5, III in 4, IV in 3 and V in 1. Kidney and spleen injury incidence due to recreation per year per million children was 6.9 and 5.6, respectively., Conclusions: Kidney injuries were more common than spleen injuries. Skiing, sledding and snowboarding accounted for more injuries than team sports. Testicle injuries were not seen and are rare. Basketball and soccer caused no injuries. Middle school-age children appear to be at greatest risk.