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Background and Objectives : Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods : Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results : Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion : With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.

Introduction: The aim of this experimental study is to assess, in a porcine model, the onset and grades of vesicoureteral reflux associated with ureteral stents., Methods: Twenty-four female porcine models were used. A 4.7-Fr ureteral stent was placed in all right ureters and kept in place for 6 weeks. Follow-ups were performed on weeks 1, 3, 6, and 12. Ultrasonography, cystoscopy, and fluoroscopy were used to analyze grade of hydronephrosis, presence and grade of vesicoureteral reflux, bacteriuria, and macroscopic changes of the ureteral orifices. Vesicoureteral reflux was classified using a modification of the International Reflux Study Committee grades., Results: 91.7% animals present vesicoureteral reflux, 89.5% grade IA, 3.5% grade IB, and 7% grade II. There is a significant increase in reflux during follow-ups at 3 and 6 weeks, whereas 6 weeks after removal, 26.3% of the ureters still present vesicoureteral reflux. Hydronephrosis and macroscopic changes of the ureteral orifice increase significantly with stenting, but there is no significant association between them and vesicoureteral reflux; the relationship between bacteriuria and the presence of vesicoureteral reflux is not significant either., Conclusion: Vesicoureteral reflux caused by ureteral stents in an animal model is mostly low grade and mainly affects the distal ureter., (© 2021 S. Karger AG, Basel.)

Objectives: To evaluate the clinical spectrum and patterns of clinical presentation in congenital anomalies of kidney and urinary tract., Methods: We enrolled 307 consecutively presenting children with congenital anomalies of kidney and urinary tract at the pediatric nephrology clinic. Patients were evaluated clinically, with serum biochemistry, appropriate imaging and radionuclide scans., Results: The most common anomaly was primary vesicoureteric reflux (VUR) (87, 27.3%), followed by pelviureteral junction obstruction (PUJO) (62,20.1%), multicystic dysplastic kidney (51 16.6%), non-obstructive hydronephrosis (32, 10.4%) and posterior urethral valves (PUV) (23, 7.4%). 247 (80.4%) anomalies had been identified during the antenatal period. Another 33 (10.7%) were diagnosed during evaluation of urinary tract infection, and 21 (6.8%) during evaluation for hypertension at presentation. Obstructive anomalies presented earlier than non-obstructive (7 (3, 22.5) vs 10 (4, 24) mo: (P=0.01)). The median (IQR) ages of presentation for children with PUV (n=23), VUR (n=87) and PUJO (n=62) were 4 (2, 14) mo, 10 (5, 27) mo, and 7 (3, 22.5) mo, respectively. Nine (2.9%) children had extrarenal manifestations., Conclusions: The median age at clinical presentation for various subgroups of anomalies indicates delayed referral. We emphasize the need for prompt referral in order to initiate appropriate therapeutic strategies in children with congenital anomalies of kidney and urinary tract.

Background: Due to the questionable clinical role of vesicoureteral reflux (VUR) and the search for noninvasive, radiation-free procedures sufficiently reliable to detect VUR, we compared the correlation between the midline-to-orifice distance (MOD) measured by ultrasonography (US) and echo-enhanced voiding urosonography (VUS) for detecting VUR in children. The aim of the study was to determine whether measuring MOD by US could be a reliable predictor of VUR in children., Methods: A total of 116 children, aged 0.25-84 months, with 232 potentially refluxing units were investigated simultaneously by measuring the MOD and performing VUS. Indications for cystography were urinary tract infection and follow-up of a previously detected VUR. VUS was performed after the MOD measurement. The results were analyzed with VUS as the reference method., Results: The MOD was significantly larger in VUR grade III (10.7 mm; p = 0.003) and VUR grade II (9.9 mm; p = 0.001) refluxing units than in non-refluxing units (7.8 mm), even when controlling for the estimated volume/expected maximal capacity (Vest/Vmax) ratio. A MOD cutoff value of 7.4 mm was chosen as a predictor of either the presence or absence of VUR; the sensitivity and specificity of this cutoff measurement for VUR detection were found to be 89 and 24%, respectively., Conclusions: Despite the statistically significant difference between the MOD of refluxing versus non-refluxing units identified in our study, the MOD measurement needs further evaluation to determine its potential value as a diagnostic tool for the detection of VUR.

Background: This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with a first febrile urinary tract infection (UTI)., Methods: Hospitalized children aged ≤ 2 years with a first febrile UTI were prospectively evaluated using imaging studies, including (99m)Tc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography., Results: Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with Grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for Grades I-V VUR and 68.4% and 87.8%, respectively, for Grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow up of renal function). Nephromegaly on initial US and Grades III-V VUR were risk factors of RS., Conclusion: Abnormal US may carry a higher probability of Grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and Grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after a first febrile UTI and children with normal US may not require voiding cystourethrography., (Copyright © 2016. Published by Elsevier B.V.)

Aim: Congenital anomalies of the kidneys and urinary tract (CAKUT) comprise various entities of structural malformations that result from defects in morphogenesis of the kidney and/or urinary tract. These anomalies are the most commonly diagnosed malformations in the prenatal period and constitute the leading cause of end-+stage renal disease (ESRD) in children, worldwide. This prospective study was performed to report the patterns of clinical presentation and diagnosis of infants and children with such malformations., Methods: Patients with suggestive features of CAKUT, presenting to Cairo University Children Hospital over one year duration were investigated and categorized based on underlying renal structural/functional malformation and associated extra-renal anomalies., Results: One hundred and seven CAKUT children were enrolled in the study. Familial clustering was identified in 14% of the cohort and syndromic CAKUT accounted for 31.8% of cases. Different anomaly entities have been identified; posterior urethral valves (PUV) being the commonest detected abnormality (36.4%). Of note, 9.3% of cohort patients had ESRD at presentation, of which 60% had PUV as their primary renal disease. Obstructive cases were noted to present significantly earlier and attain advanced CKD stages rather than non-obstructive ones., Conclusion: CAKUT is a clinically heterogeneous group of diseases with diverse clinical phenotypes. More efforts should be aimed at improving antenatal detection as well as classification with comprehensive reference to the clinical, genetic and molecular features of the diseases. The high frequency of familial and syndromic CAKUT among studied patients is seemingly a convincing reason to pursue the underlying genetic defect in future studies., (© 2015 Asian Pacific Society of Nephrology.)

Although the diagnosis of vesicoureteral reflux and of reflux nephropathy is a well-established and shared procedure, its treatment nowadays is still very controversial. New developments on the knowledge of pathophysiology of renal damage associated to reflux opened the way towards a different diagnostic work-up and different therapeutic approaches. Recently, the "top-down" diagnostic approach has gained wider interest, versus the "down-top" protocol. The attention has recently focused on the renal parenchyma damage and less interest has been given to the presence and the radiological degree of vesicoureteral reflux. The review criteria were based on an in-depth search of references conducted on PubMed, using the terms "vesicoureteral reflux", "children", "incidence", "etiology", "diagnosis", "treatment" and "outcomes". The selection of the papers cited in this review was influenced by the content and the relevance to the points focused in the article.Conservative approaches include no treatment option with watchful waiting, long-term antibiotic prophylaxis and bladder rehabilitation. The operative treatment consists of endoscopic, open, laparoscopic and robotic procedures to stop the refluxing ureter.No final consensus has been achieved in literature yet, and further studies are necessary in order to better define the subset of children at risk of developing progression of renal damage.This review aims to clarify the diagnostic management and the urological-nephrological treatment of reflux in pediatric age, on the basis of a review of the best-published evidence.

Despite several recent studies, the advisability of antimicrobial prophylaxis and certain imaging studies for urinary tract infections (UTIs) remains controversial. The role of vesicoureteral reflux (VUR) on the severity and re-infection rates for UTIs is also difficult to assess. Registries and repositories of data and biomaterials from clinical studies in children with VUR are valuable. Disease registries are collections of secondary data related to patients with a specific diagnosis, condition or procedure. Registries differ from indices in that they contain more extensive data. A research repository is an entity that receives, stores, processes and/or disseminates specimens (or other materials) as needed. It encompasses the physical location as well as the full range of activities associated with its operation. It may also be referred to as a biorepository. This report provides information about some current registries and repositories that include data and samples from children with VUR. It also describes the heterogeneous nature of the subjects, as some registries and repositories include only data or samples from patients with primary reflux while others also include those from patients with syndromic or secondary reflux., (Copyright © 2012 Journal of Pediatric Urology Company. All rights reserved.)

Purpose: The International Reflux Committee proposed a grading system for vesicoureteral reflux in 1985 which has been used extensively in everyday practice and research studies. Despite widespread use, based mainly on face validity, the interrater and intrarater reliability of this tool are not known. A tool cannot be considered valid unless it is reliable. Therefore, we estimated the interrater and intrarater reliability of the international grading system for vesicoureteral reflux., Materials and Methods: A series of 28 voiding cystourethrogram studies were selected. The images were assembled in an electronic presentation in random fashion. Four pediatric radiologists, 5 pediatric urologists and 4 senior urology residents graded the studies. The images were then shuffled in a random fashion and re-rated after 7 days (total 728 observations). Cohen weighted kappa statistics were used to determine interrater and intrarater reliability. Subgroup analysis was then performed comparing the variability among the 3 groups of raters and different grades., Results: The average interrater reliability was 0.53 (95% CI 0.52-0.55, p <0.0001). Agreement in subgroups was 0.61 for urologists, 0.59 for residents and 0.56 for radiologists. The lowest agreement was shown in grade III (0.36) and the highest in grade I (0.98). The intrarater reliability was 0.86 (95% CI 0.77-0.95, p <0.001)., Conclusions: The international grading system for vesicoureteral reflux shows low interrater reliability for moderate degrees of vesicoureteral reflux whereas the intrarater reliability is high. Modification of this system may improve its reproducibility., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: In recent years the endoscopic injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis and the surgical management of vesicoureteral reflux. We determined the safety and effectiveness of the endoscopic injection of dextranomer/hyaluronic acid as first line treatment for high grade vesicoureteral reflux., Materials and Methods: Between 2001 and 2010, 1,551 children (496 male, 1,055 female, median age 1.6 years) underwent endoscopic correction of intermediate and high grade vesicoureteral reflux using dextranomer/hyaluronic acid soon after the diagnosis of vesicoureteral reflux on initial voiding cystourethrogram. Vesicoureteral reflux was unilateral in 761 children and bilateral in 790. Renal scarring was detected in 369 (26.7%) of the 1,384 patients who underwent dimercapto-succinic acid imaging. Reflux grade in the 2,341 ureters was II in 98 (4.2%), III in 1,340 (57.3%), IV in 818 (34.9%) and V in 85 (3.6%). Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure, and renal ultrasound was performed annually thereafter. Patients were followed for 3 months to 10 years (median 5.6 years)., Results: Vesicoureteral reflux resolved after the first, second and third endoscopic injection of dextranomer/hyaluronic acid in 2,039 (87.1%), 264 (11.3%) and 38 (1.6%) ureters, respectively. Febrile urinary tract infections developed during followup in 69 (4.6%) patients. None of the patients in the series needed reimplantation of ureters or experienced any significant complications., Conclusions: Our results confirm the safety and efficacy of the endoscopic injection of dextranomer/hyaluronic acid in the eradication of high grade vesicoureteral reflux. We recommend this 15-minute outpatient procedure as the first line of treatment for high grade vesicoureteral reflux., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. 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.)

Objectives: High-grade vesicoureteral reflux (VUR, grade IV or V) is a risk factor for renal scarring, impaired renal function, and arterial hypertension. Voiding cystourethrography is the gold standard for detecting the severity of VUR. High-grade VUR is present in the minority of children with urinary tract infection (UTI), thus exposing the majority to invasive diagnostics that have no surgical consequence. We therefore aimed at establishing a noninvasive test to identify children with high-grade VUR., Methods: In a case-control study, a specific urinary proteome pattern was established by capillary electrophoresis coupled to mass spectrometry in 18 patients with primary VUR grade IV or V, distinguishing these from 19 patients without VUR after UTI. This proteome pattern was independently validated in a blinded cohort of 17 patients with VUR grade IV or V and 19 patients without VUR., Results: Sensitivity in detecting VUR grade IV or V in the blinded study was 88%, specificity was 79%. The test's accuracy was independent of age, gender, and grade of VUR in the contralateral kidney. The odds ratio of suffering from VUR grade IV or V when tested positive was 28 (95% confidence interval: 4.5 to 176.0)., Conclusions: This noninvasive test is ready for prospective validation in large cohorts with the aim of identifying those children with UTI and hydronephrosis in need of further invasive diagnostics, such as voiding cystourethrography, thus sparing most children without pathologic urinary proteome patterns from additional diagnostics.

Objective: Published success rates of dextranomer/hyaluronic acid (Dx/HA) injection for pediatric vesicoureteral reflux (VUR) vary widely. Our objective of this study was to assess whether underlying patient or study factors could explain the heterogeneity in reported Dx/HA success rates., Methods: We searched the Cochrane Controlled Trials Register and Medline, Embase, and Scopus databases from 1990 to 2008 for reports in any language, along with a hand search of included study bibliographies. Articles were assessed and data abstracted in duplicate, and differences were resolved by consensus. Conflict of interest (COI) was determined by published disclosure. Meta-regression was performed to adjust for patient as well as study-level factors., Results: We identified 1157 reports, 89 of which were reviewed in full with 47 included in the pooled analysis. Of 7303 ureters that were injected with Dx/HA, 5633 (77%) were successfully treated according to the authors' definition. Injection success seemed to vary primarily on the basis of the preoperative reflux grade. After adjustment for VUR grade, other factors, such as the presence or absence of COI disclosure, were not significant. Studies were markedly heterogeneous overall., Conclusions: The overall per-ureter Dx/HA success rate was 77% after 3 months, although success rates varied widely among studies. Increased VUR grade negatively affected success rates, whereas COI, patient age, and injected Dx/HA volume were not significantly associated with treatment outcome after adjustment for VUR grade. There is a significant need for improved reporting of VUR treatments, including comparative studies of Dx/HA and other VUR treatments.

Background: A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present the long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux) for VUR grade I-IV in children., Patients and Methods: Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux in 30 ureters as an outpatient procedure. Twelve children had a unilateral reflux (two duplicated systems) and nine had a bilateral reflux. The median age was 5 years (6 months to 14.9 years). Six weeks postoperatively a voiding cystourethrogram (VCUG) was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) as well as the quality of life (parents' questionnaire) during long-term follow-up., Results: No intra- and postoperative complications were noticed. In 25 ureters (83%) VCUG showed no VUR 6 weeks postoperatively. In three children a second injection was done (two were successful). After a median follow-up of 2.5 years 27 ureters in 17 children (90%) had no UTI and VUR. The results of the questionnaire regarding quality of life were very good in the successfully treated children and the parents would choose the same treatment option again., Conclusion: Subureteral injection of Deflux for children with VUR is an effective treatment option for VUR with a low complication rate.

Purpose: When children are initially diagnosed with vesicoureteral reflux most undergo a period of antibiotic prophylaxis followed by serial imaging. Although improvement in reflux grade through time presumably predicts eventual resolution, the significance of changing grade through time is unknown. We examined whether improvement in reflux on serial imaging predicts resolution., Materials and Methods: We retrospectively reviewed 1,761 children diagnosed with vesicoureteral reflux, of whom 965 had a minimum of 2 years of followup. We examined initial reflux grade and grade on serial imaging up to 5 years after the original diagnosis. For each child it was determined whether reflux was resolved, eventually resolved or never resolved. Groups were further stratified by clinical characteristics., Results: Multivariate analysis revealed that male gender (HR 1.33, p = 0.05), age younger than 1 year at diagnosis (HR 1.35, p = 0.004), lower grade at presentation (grade I HR 2.2, grade II HR 1.96, grade III HR 1.33; p <0.001) and unilateral reflux (HR 1.39, p = 0.001) were all independent predictors of reflux resolution. Multivariate analysis also showed that reflux improvement on imaging 1 year after diagnosis (HR 3.14, p <0.0001) and improvement from the previous year at any point during followup (HR 1.8, p = 0.009) were independent predictors of reflux resolution., Conclusions: Consistent with previous findings, male gender, lower reflux grade at presentation, age less than 1 year at presentation and unilateral reflux were all predictive of reflux resolution. Our analysis also demonstrated that improvement in reflux grade on imaging study 1 year after diagnosis was predictive of resolution, and that reflux improvement from the previous year at any point during followup was an independent predictor of resolution. This information will prove valuable in clinical counseling and therapeutic decision making., (Copyright 2010 American Urological Association. Published by Elsevier Inc. All rights reserved.)

Background: Antibiotics are widely administered to children with the intention of preventing urinary tract infection, but adequately powered, placebo-controlled trials regarding efficacy are lacking. This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy prevents urinary tract infection in predisposed children., Methods: We randomly assigned children under the age of 18 years who had had one or more microbiologically proven urinary tract infections to receive either daily trimethoprim-sulfamethoxazole suspension (as 2 mg of trimethoprim plus 10 mg of sulfamethoxazole per kilogram of body weight) or placebo for 12 months. The primary outcome was microbiologically confirmed symptomatic urinary tract infection. Intention-to-treat analyses were performed with the use of time-to-event data., Results: From December 1998 to March 2007, a total of 576 children (of 780 planned) underwent randomization. The median age at entry was 14 months; 64% of the patients were girls, 42% had known vesicoureteral reflux (at least grade III in 53% of these patients), and 71% were enrolled after the first diagnosis of urinary tract infection. During the study, urinary tract infection developed in 36 of 288 patients (13%) in the group receiving trimethoprim-sulfamethoxazole (antibiotic group) and in 55 of 288 patients (19%) in the placebo group (hazard ratio in the antibiotic group, 0.61; 95% confidence interval, 0.40 to 0.93; P = 0.02 by the log-rank test). In the antibiotic group, the reduction in the absolute risk of urinary tract infection (6 percentage points) appeared to be consistent across all subgroups of patients (P > or = 0.20 for all interactions)., Conclusions: Long-term, low-dose trimethoprim-sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups. (Australian New Zealand Clinical Trials Registry number, ACTRN12608000470392.), (2009 Massachusetts Medical Society)

Purpose: We evaluated the usefulness and interobserver concordance of a novel grading system for dynamic ureteral hydrodistention., Materials and Methods: Between May 1, 2002 and July 1, 2008 the hydrodistention grade in 697 ureters was prospectively assigned and recorded, including H0-no hydrodistention, H1-ureteral orifice open but tunnel not evident, H2-tunnel seen only and H3-extravesical ureter visualized. Specifically 489 refluxing ureters (vesicoureteral reflux group) were compared to 100 normal control ureters (normal control group). Additionally, the posttreatment hydrodistention grade in 56 ureters in which surgery for reflux failed was compared to that in 52 ureters with successful surgery. Hydrodistention grades assigned to an additional 77 ureters by 3 blinded observers were compared to assess the interobserver concordance of this system., Results: Vesicoureteral reflux and hydrodistention grades correlated significantly (p <0.001). Ureters with a higher reflux grade also showed a higher hydrodistention grade. The normal control group (mean +/- SEM hydrodistention grade 0.62 +/- 0.07) showed a statistically lower hydrodistention grade than the reflux groups (overall mean hydrodistention grade 2.26 +/- 0.01). Mean posttreatment hydrodistention grade in the failed reflux surgery group was statistically higher than that in the mean successful reflux surgery group (2.03 +/- 0.09 vs 1.33 +/- 0.08). By defining the degree of hydrodistention as normal (H0-H1) and abnormal (H2-H3) the concordance between observers was 95% and 96%., Conclusions: The dynamic hydrodistention classification is a reliable method of evaluating the presence or absence of vesicoureteral reflux as it correlates significantly with radiographic reflux grade. It has high interobserver concordance.

Objectives: The objective of this monograph is to familiarize the reader with dynamic hydrodistention classification of the ureter and Hydrodistention Implantation Technique (HIT) methodology for the endoscopic correction of vesicoureteral reflux (VUR). The indications, current success rates, complications, and potential future applications of these methods are reviewed., Methods: Hydrodistention (HD) of the ureteral orifice and distal ureter permits visualization of the intraureteral submucosal injection site and assessment of the degree of ureteral coaptation. We have designated 4 levels of HD. HO denotes absence of ureteral dilation, H1 indicates dilation of the ureteral orifice only. H2 allows visualization of the intramural ureter, and H3 allows visualization of the extramural ureter. The Double HIT method is a systematic technique that utilizes HD to both classify the ureter and gauge the degree of ureteral coaptation secondary to bulking during endoscopic injection. The needle is inserted at the mid ureteral tunnel at the 6 o'clock position. The first injection coapts the detrusor tunnel (until H1 or H0 is achieved), while a second implant within the most distal intramural tunnel leads to complete coaptation of the ureteral orifice (H0)., Results: HD grade correlated significantly with VUR grade. Normal ureters rarely hydrodistended. While non-refluxing contralateral ureters demonstrated low HD grades, all contralateral ureters that subsequently developed VUR showed H2 or H3. The HIT method has not only been employed for primary VUR (90% cure), but also for repeat endoscopic injections (90%), VUR associated with paraureteral diverticula (81%), complex cases such as post-reimplantation (88%), neurogenic bladders (78%), duplication anomalies (80%), and in adults (88%). Furthermore, injection of contralateral VUR-negative but hydrodistending ureters may be treated to prevent new contralateral VUR. While decreasing success was seen with increasing VUR grade with the STING method, superior success rates have been realized with the HIT method., Conclusions: The dynamic hydrodistention classification reflects the competency of the ureterovesical junction. The HIT and Double HIT methods achieve superior cure rates and are likely to become the method of choice for the treatment of primary as well as complex cases of VUR.

Objectives: Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritis and high grade (G) Vesicoureteral Reflux (VUR)., Inclusion Criteria: infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibiotic prophylaxis (AP). N = 27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: G II (control without AP); Persistence: III-V Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings., Results: 34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6%), Improved 1, OS 3 (33.3%). Overall results: Solved: 24 U (70.58%), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery., Conclusions: ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.

Objectives: To update the classification of vesicoureteral reflux in children., Methods: Videourodynamics., Results: We categorize the different types of vesicoureteral reflux in children., Conclusions: The usefulness of the classification is demonstrated, with the introduction of some modifications necessary for its continuous updating.

Vesicoureteral reflux (VUR) refers to the retrograde flow of urine from the bladder into the ureter and renal pelvis. It generally results from congenital maldevelopment of the ureterovesical junction, although VUR may develop in individuals with abnormally high detrusor pressure. VUR increases a child's susceptibility to pyelonephritis and renal scarring. Treatment goals include the prevention of pyelonephritis, reflux nephropathy, and other complications of reflux. Treatment alternatives include antibiotic prophylaxis, urotherapy (correction of voiding dysfunction), and surgical correction (open, injection therapy, or laparoscopic). Recent studies have challenged the presumed benefit of prophylaxis in children with VUR, while long-term retrospective studies have documented a high rate of hypertension in adults with reflux nephropathy. In addition, the risk of persistent VUR in adulthood is unresolved. These reports have stimulated a reevaluation of the role of various treatment options in children with VUR.

Purpose: The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR)., Materials and Methods: After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis., Results: The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection)., Conclusions: We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

Objectives: Vesicoureteral reflux (VUR) is detected in 30-50% of pediatric patients diagnosed of urinary tract infection (UTI). Multiple clinical trials have compared the results of conservative management against surgical therapy. The introduction of a third alternative in 1984 (endoscopic approach) has dramatically modified the management of VUR. The objective of our work is to analyze the factors influencing the favourable outcome of the endoscopic treatment of VUR., Methods: Retrospective and prospective cohort study analyzing 90 patients with grades III and IV VUR treated endoscopically over the last eight years. 184 patients undergoing endoscopic management were selected from a group of 550 patients (735 VUR renal units) with the diagnosis of VUR over the study period. All patients underwent VCUG or galactose-based sonocystography to obtain the diagnosis. DMSA scintigram was used to evaluate renal damage. Data about gender, age, UTI, bilateralism, renal damage, voiding dysfunction, outcomes, complications, and recurrences were registered. A new factor was defined: ureteral dilation independent from the international classification. This factor was evaluated by a single pediatric urologist blinded for the international classification results. Data analysis was performed using the chi square test and Fischer exact test; a multiple logistic regression analysis was also performed. Statistical significance was established at p < 0.05. SPSS 11.0 software was employed for data analysis., Results: Boys/girls ratio was 2.91. Bilateral VUR appeared in 44.4% of the cases. UTI was the presenting diagnosis in 64 cases; the diagnosis was prenatal in 21 cases (with a male predominance 5.2:1). We found a strong correlation between renal scarring at the time of diagnosis and voiding dysfunction (p< 0.01). Cure rate after first injection was 64%. Although univariate analysis showed a strong correlation between cure and first injection, biloterality, voiding dysfunction, initial nephropathy, and ureteral dilation grade, on multivariate logistic regression the only significant factor to predict treatment response was the existence of severe ureteral dilation in comparison with mild dilation (p < 0.001; odds ratio 0.045, 95% confidence interval 0.01-0.16). Renal damage progression was specially detected in those patients with voiding dysfunction (p = 0.053), bilaterality (p = 0.034) and severe ureteral dilation (p < 0.001)., Conclusions: A direct relation between cure rate after endoscopic treatment of grade III and IV reflux and severity of ureteral dilation was demonstrated. Other relevant factors implied in the endoscopic resolution of VUR include the existence of voiding dysfunction, bilateral reflux and renal damage determined by DMSA at the time of initial diagnosis. Gender, age, and number of infections during follow up have no influence in the probability of cure of grade III and IV VU reflux treated with subureteral injection of biocompatible substances.

Unlabelled: The aim of the study was to assess the rate of development of voiding dysfunction (VD) in patients with reflux nephropathy. We investigated 150 pts with vesicoureteral reflux (VUR): 33 boys and 117 girls in mean age 9 +/- 3.3 years with normal renal function. In all pts we performed renal scintigraphy (DMSA) and ABPM. Renal scarring by DMSA scan was categorized into grades 1-4. In all pts we assessed high and laterality of VUR, renal function (clearance creatinine--Ccr) and occurency of hypertension (HT)., Results: Of 150 pts, 80 (53.3%) developed VD (54.5% boys and 52% girls). DMSA grade: 1--27 pts, 2--85 pts; 3--31 pts; 4--7 pts. No statistically significant difference was found depends of: sex, age, laterality of renal damage in DMSA, unilateral and bilateral reflux for the development of VD. The incidence 3-4 grade in DMSA scan was significantly higher in pts with IV-V grade of VUR in comparison to pts with lower grade of VUR in group with and without voiding dysfunction. IV-V grades of VUR were observed more frequently in pts with bladder/sphincter dysfunction. The occurency of HT in group with VD and without VD was 12 pts (15%) and 8 (11.4%) respectively (ns). Pts with VD have lower Ccr in comparison with pts without VD (129.1 vs 136.3 ml/min/1.73 m2; p<0.05)., Conclusions: Approximately 50% of patients with VUR demonstrated VD. VD occurred independent of age. IV-V degrees VUR and more severe changes in DMSA scan were seen in pts with bladder/sphincter dysfunction.

Background and Purpose: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR). Several injectable materials have been tried for this purpose. In this study, we tried to determine the efficacy of dextranomer/hyaluronic acid copolymer (Dx/HA) injection for the treatment of VUR in renal-transplant candidates., Patients and Methods: A total of 21 transplant candidates (29 ureteral units; 13 females, 8 males) with a mean age of 20.2 years (range 14-26 years) underwent endoscopic correction of VUR with Dx/HA. Diagnosis of VUR was made by voiding cystourethrography. The efficacy of the treatment was assessed with voiding cystourethrography at 3 months and 1 year postoperatively. Renal transplantation with living related donor organs was performed in 11 of the 21 patients., Results: Endoscopic treatment was performed without complication in all cases. Higher success rates were obtained in patients with low-grade reflux, the overall success rate in the series being 82.7%. The mean follow- up after renal transplantation was 21.8 months (range 5-45 months). In one patient, reflux recurred after renal transplantation and was treated successfully by a repeat Dx/HA injection. The urine cultures of all patients remained sterile., Conclusion: Transplant candidates with VUR can be treated with Dx/HA, which cured the majority of our patients after one or two treatments with few low side effects. Endoscopic subureteral injection of Dx/HA has become an alternative treatment for VUR in transplant candidates. Long-term results are needed before making a final statement about its value.

Aim: To evaluate the management and outcome of children with dilating vesico-ureteric reflux diagnosed before 2 y of age., Methods: This retrospective, multicentre study was part of a programme for quality assurance in Sweden. A total of 2309 unselected children, aged 0-2 y, were investigated after the first urinary tract infection. Voiding cystourethrography was performed in a total of 1953 children, of whom 584 had reflux. Of these children, 303 (119 boys and 184 girls) had reflux with dilatation (grade 3-5)., Results: Follow-up after 4-6 y was reported in 272 of the 303 children. Spontaneous regression of dilating reflux occurred in more than half of the patients and was significantly more frequent in boys than in girls (p = 0.047). In children with grade 3 reflux and grade 4-5 reflux, there were pyelonephritic recurrences in 18% and 45% of the boys and 28% and 70% of the girls, respectively (p < 0.001). One hundred and eighty-one children (65%) were managed conservatively, 58 (21%) were treated with subureteric injection and 33 (12%) with ureteric reimplantation. There were considerable differences in treatment strategies between centres., Conclusion: This study of an unselected cohort of children with urinary tract infection and dilating reflux showed spontaneous resolution of dilating reflux in more than half of the subjects and more often in boys than in girls. Pyelonephritic recurrences were more common in girls than in boys, and more frequent in grade 4-5 reflux than in grade 3. The results indicate important differences between the sexes and that boys and girls should be assessed separately when treatment strategies are studied.

Purpose: We determine if the incidence and grade of vesicoureteral reflux (VUR) differs in children based on age, race and gender, and if the incidence and severity of VUR are related to race in girls younger than 7 years presenting for evaluation after urinary tract infection (UTI)., Materials and Methods: The records of all children who underwent a voiding cystourethrogram or radionuclide cystogram between 1993 and 2001 were retrospectively reviewed. Age, gender, race, clinical indication and highest grade of VUR were recorded for the first voiding cystourethrogram or radionuclide cystogram. Frequency tables and logistic regression were conducted to correlate demographics to incidence and severity of VUR., Results: A total of 15,504 patients were included in the analysis. Overall, black children were a third as likely as white children (p <0.0001) and females were twice as likely as males (p <0.0001) to have VUR. Compared to children 0 to 2 years old, the occurrence of reflux was 0.5 times as likely in those 3 to 6 years old (p <0.0001), 0.3 times as likely in those 7 to 11 years old (p <0.0001) and 0.15 times as likely in those 12 to 21 years old (p <0.0001). When analyzing children with UTI, results were similar. Of the patients with VUR 65% were younger than 7 years. The incidence of VUR in black girls younger than 7 years with a diagnosis of UTI was less than 10% compared to white girls, and no black girl had high grade reflux. In young children referred for UTI the incidence and severity of VUR in black patients were significantly lower than those of white girls., Conclusions: This study validates previous observations regarding the low incidence of VUR in black children.

Purpose: We correlated the degree of hydronephrosis (HN) to the grade of vesicoureteral reflux (VUR) and assessed the impact of antireflux surgery on the resolution/persistence of HN., Materials and Methods: Between 1997 and 2000, 308 patients (476 units) underwent antireflux surgery for primary or secondary VUR. Surgical procedures included extravesical reimplantation (291 ureters), intravesical reimplantation (48) and endoscopic polydimethylsiloxane injection (137). The degree of HN was categorized as mild (grade 1 to 2) or moderate/severe (grade 3 to 4). VUR was grade I in 44 cases, II in 145, III in 203 and IV to V in 84. Followup renal ultrasound was performed at 3 and 12 months postoperatively. Statistical analysis consisted of a contingency table and chi-square test for independence., Results: Preoperative HN existed in 123 refluxing units, and was mild in 4 (9%), 11 (7.5%), 39 (19%) and 28 (33%), and moderate/severe in 0, 2 (1.4%), 14 (7%) and 25 (30%) of grade I, II, III and IV to V VUR cases, respectively. The degree of preoperative HN correlated with VUR grade (p <0.0001). At 3 months postoperatively HN resolved in 50.4%, improved in 16.3%, persisted in 30% and worsened in 3.3% of units. At 15 months postoperatively HN resolved in 80 units (65%) and persisted in 43 (35%). Patients with preoperative moderate/severe HN constituted 56% of those with persistent HN., Conclusions: Our data indicate that the presence and degree of preoperative hydronephrosis are closely related to VUR grade. Furthermore, antireflux surgery resulted in a high resolution rate of hydronephrosis. Persistent postoperative hydronephrosis did not require any intervention.

Purpose: We evaluated our experience with endoscopic STING (subureteral polytetrafluoroethylene injection) for grades IV and V vesicoureteral reflux., Materials and Methods: We reviewed the records of 221 boys and 305 girls who underwent STING for primary grades IV (430) and V (96) vesicoureteral reflux between 1984 and 2000. Median patient age at STING was 3 years (range 3 months to 14 years). Reflux was unilateral and bilateral in 335 and 191 children, respectively (717 refluxing units). Median followup was 11.6 years (range 1 to 17)., Results: Reflux was corrected in 420 of the 717 refluxing units (58%) after a single injection. Reflux resolved after a second and third injection in 185 ureters (26%). High grade reflux was converted to grades I and II in 112 ureters (15%) and did not require any further treatment. STING failed to correct reflux in 7 units (0.9%), which were managed by ureteral reimplantation (5) and nephrectomy (2) due to poor renal function. Voiding cystourethrography showed recurrent vesicoureteral reflux in 9 units (1.2%), including 2 with low grade reflux for which no treatment was given. Seven ureters required repeat injection due to grades III and IV reflux. No untoward effects were noted in any patients in whom polytetrafluoroethylene was used as the injected material., Conclusions: STING is a simple, safe and effective outpatient procedure for grades IV and V vesicoureteral reflux.

Aim: The objectives of this study were, first, to determine the probability of detecting vesicoureteral reflux (VUR) into the renal collecting system (VUR grade 2 or higher) by follow-up cyclic radionuclide cystography (CRC) in children with VUR 1 on initial examination, and in children without VUR and with the same clinical history; and secondly, to find out whether dividing VUR 1 into three subclasses, including possible reflux into the ureter, reflux into the lower ureter, and reflux into the whole length of the ureter, enhances detection of higher grade reflux in these children., Methods: 275 children with VUR 1 found on initial CRC, and 31 children without reflux and with the same clinical history were studied. In total, 414 renal units with VUR 1 of different subclasses and 198 renal units without reflux were evaluated., Results: Follow-up CRC disclosed reflux into the renal collecting system in 20% of children with VUR 1 on initial investigation, and in 23% of children with no reflux at the time of initial investigation. The probability that follow-up examination would disclose VUR 2 in 3 in renal units with different subclasses of grade 1 reflux was 8-16%, and did not differ significantly from the probability for detecting reflux in kidneys with no reflux on initial examination., Conclusion: In the absence of recurrent urinary tract infection, the management of children with VUR 1 identified by CRC can be the same as in children without reflux. Yet, in children with no reflux or with VUR 1 detected after urinary tract infection, the probability that reflux reaching the pylon was missed should not be underestimated. Dividing VUR 1 into subclasses does not seem to be of diagnostic value.

Purpose: To analyze the efficacy of the different treatments of vesicoureteric reflux (VUR) associated with reflex bladder sphincter dyssynergia (RBSD)., Patients and Methods: The medical records of 33 children (28 girls) aged 4 to 12 years presenting reflex bladder sphincter dyssynergia and vesicoureteric reflux have been reviewed. The most common clinical symptom was urinary tract infection. Voiding dysfunction included: dysuria, urinary leak, enuresia, urgency, constipation. In most cases, vesicoureteric reflux was low grade (grade 1, n=9; grade 2, n=18; grade 3, n=6) and bilateral (n=18). Three types of treatments have been utilized: reimplantation, reeducation, medical treatment (diet, antibio-prophylaxis, anti-cholinergics)., Results: Eleven children (2 with a solitary kidney) underwent early reimplantation which was effective on vesicoureteric reflux but 6 of them had post-operative voiding dysfunction and 5 had a new episode of urinary infection. Six had reeducation first then they underwent reimplantation. Sixteen children had an exclusive medical treatment (13 with reeducation). In 9 children vesicoureteric reflux disappeared (one child still complains of voiding dysfunction). In 7, voiding dysfunction improved but vesicoureteric reflux is still present., Conclusion: The management of vesicoureteric reflux associated with reflex bladder sphincter dyssynergia is complex. Surgery should certainly not be the initial treatment. However, it can remain useful if one wishes to get complete resolution of reflux.

Unlabelled: This study evaluates the accuracy of noninvasive renal ultrasound (US) in the detection of dilative vesicoureteric reflux (VUR) compared to voiding cysturethrography (VCUG), taking both sonographic morphology and kidney length into account. The data and images of 205 paediatric patients who had renal ultrasound and VCUG performed were reviewed. Abnormalities of renal length and kidney morphology were compared with degree of reflux on VCUG for each renal unit. A total of 407 renal units were evaluated. When the sonographic diagnosis of reflux was based solely on morphological criteria and degree of dilatation, correlation with VCUG results was poor. However, the fraction of kidneys of anomalous size increased markedly with grade of reflux, from 10% of non-refluxing renal units to 50% of renal units subjected to grade 4 and 5 VUR. Taking abnormal kidney length into account as well, dilative VUR was diagnosed by ultrasound with a sensitivity of 92% (95% CI 82%-100%) and a sensitivity of 67% (95% CI 63%-72%), P<0.001., Conclusion: the results of this study show that ultrasound cannot accurately diagnose vesicoureteric reflux by morphological changes alone, but requires the consideration of age-adjusted abnormalities in kidney length.

A group of 62 children (age 5-12) with vesicoureteral reflux (VR) in infancy, including those who were under either ambulatory or surgical treatment and also those whose parents didn't undergo treatment, was observed with special attention paid to the following features: evaluation of height, weight, arterial blood pressure, presence of VR, size of kidneys and renal scars in them, creatinine clearance, urine analysis and urine cultures. The analysis of studied parameters proves the necessity of constant nephrological control for many years in spite of disappearance of reflux. The reason is the high risk of recurrent urinary tract infections, arterial hypertension and worse kidney functioning.

Reflux nephropathy is an important cause of chronic renal failure and arterial hypertension in children. While its prognosis is favourably influenced by the early recognition and management of vesicoureteric reflux, there is a real risk of missing the diagnosis of this insidious condition. This article describes the main features of vesicoureteric reflux and associated nephropathy and presents practical recommendations, through a nonexhaustive literature review. As several aspects of this disease remain to be established, any recommendation concerning its management should be constantly reevaluated according to new data.

A number of 411 pediatric patients (636 refluxing renal units) diagnosed as having vesicoureteral reflux (VUR) were evaluated in our Hospital between 1985 and 1997. All the patients were divided in two historic groups based on the therapeutical modalities employed. The children included in group A (between 1985 and 1995) were medically or surgically treated according to the grade of reflux. In the group B (between 1995 and 1997), the endoscopic treatment was added to previous. All cases underwent urine cultures, renal ultrasonography, voiding cystourethrography and isotopic gammagraphy with DMSA scan. In some patients were performed radionuclide renography with DTPA or MAG-3 to assess renal function. We consider that medical management is required in low grade reflux (I and II) but patients with high grade reflux (IV and V) clearly benefit from early ureteral surgical reimplantation (Cohen technique). In our series, patients with reflux grade III are treated endoscopically with Teflon or PDMS (polydimethylsiloxane) with resolution of reflux in 82-92% after first injection.

From June 1985 to December 1998, 173 pediatric renal transplants were carried out in 170 patients at our center. From this pool, 73 patients (34 males and 39 females) with a follow-up of 48 months were examined. In all patients, ureteroneocystostomy was performed according to the Lich-Grégoire procedure. All patients were treated with cyclosporin A (CsA)-based immunosuppression, including prednisone and sometimes azathioprine (AZA). Six months after transplantation, voiding cystography (VCU) was performed in all patients and reflux was classified from Grade I to Grade IV. The patients were divided into two groups: those with reflux (Group A: 25 patients) and those without (Group B: 48 patients). Grade I reflux was found in four patients, Grade II in seven patients, Grade III in seven patients, and Grade IV in seven patients. All the patients with severe reflux (Grade IV) underwent a corrective surgical procedure. Both groups were examined for immunologic and non-immunologic risk factors and no significant differences were found. Analysis of patient and graft survival rates revealed no statistical differences (NS) between Groups A and B. Mean serum creatinine (mg/dL) was 1.06 +/- 0.28 and 1.12 +/- 0.41 at 4 yr in Groups A and B, respectively (NS). Mean calculated creatinine clearance (cCrC; ml/min) was 76.74 +/- 15.92 and 77.96 +/- 15.66 in Groups A and B, respectively (NS). The analysis was further extended by considering the grade of reflux (I to IV). Again, no significant differences in the above parameters emerged between the reflux sub-groups; only in the Grade IV sub-group was a slight decrease in cCrC detected, although this difference was not statistically significant when compared with the other sub-groups. In conclusion, vesico-ureteral reflux (VUR) does not seem to negatively affect graft function. However, as all severe reflux patients (Grade IV) were surgically corrected, no conclusions can be drawn with regard to the influence of Grade IV reflux on long-term graft function.

The analysis presents 622 children in the age ranged from 4 months to 14 years, operated on vesicoureteral reflux. The treatment was carried on in Department of Pediatric Surgery in Poznan between 1983 and 1992. All these children were operated on with antireflux Politano-Leadbetter technique, modified by Sarrazin, protecting reimplanted ureters with stenting catheters. Duplicated ureters were reimplanted "en bloc" according to Bettex technique, also with Sarrazin modification. Preoperative parameters included: history, radiological evaluations: voiding cystourethrogram, intravenous pyelogram or ultrasound imaging, endoscopic evaluations--cystourethroscopy (with meatal calibration in girls), laboratory blood and urine results. The reflux degree was estimated according to international classification IRSC. There were 12 (2%) children with II degree, 498 (80%) with III degree, 101 (16%) with IV degree and 11 (2%) patients with V degree reflux. In order to compare the results of operative treatment, all analyzed children were subdivided into groups: 303 (48.7%) patients with primary reflux, 77 (12%) with reflux to duplicated pyelo-ureteral systems, 17 (2.7%) with refluxing megaureters, 66 (10%) with reflux to hypoplastic kidney, 99 (15.9%) with cystic cystitis and 114 (18%) children with urethral meatal stricture. Good recovery with uncomplicated postoperative course was obtained in 606 (97.4%) patients. Early postoperative complications occurred in 16 (2.6%). In outpatient control the results of urinalysis and urine cultures, ultrasound imaging and voiding cystourethrograms were tested. Urine cultures were negative in 501 (80.5%) patients 3-4 weeks after discharge increasing to above 92% of patients 6 months after operation. In postoperative imaging control, 600 (96.5%) patients presented with normal status of upper urinary tract, in 14 (2.2%) transient dilatation of reimplanted ureters was observed and in 8 (1.3%) ureters had to be reimplanted because of secondary dilatation. After 6 months postoperative voiding cystourethrograms showed cessation of reflux in 589 (94.6%) patients, in 33 (5.2%) recurrent reflux was observed, which disappeared in 20 of them in control. In 13 patients urodynamic evaluation showed vesicourethral dysfunction, medically curable.

Unlabelled: Endoscopic subureteral collagen injection (SCIN) was performed in 24 girls and 5 boys (mean/range: 3.2/0.7-12.2 years) with primary grade III vesicoureteral reflux. Clinical outcome was compared to 20 girls and 6 boys treated by antireflux surgery (mean/range: 3.0/0.2-9.4 years). forty-one ureters were treated by endoscopy, 37 by surgery. Patients were followed for 12 months. SCIN was not associated with severe persistent complications. No reflux was detected immediately after SCIN. After 6 months recurrent grade II reflux was present in 1 (4%) surgically treated patient and in 12/29 (41%) patients treated by collagen injection. This corresponded to a recurrence rate of 1/37 (3%) of ureters following surgery and 15/41 (37%) following SCIN. 8/15 refluxing ureters after collagen showed decreased reflux grade (two grade I, six grade II). After 12 months 24/26 (92%) patients with antireflux surgery remained free of urinary tract infections as compared to 25/29 (86%) children following endoscopy. Following SCIN, 4/29 (14%) patients required secondary antireflux surgery because of recurrent urinary tract infections., Conclusion: On the basis of this study endoscopic SCIN appears to be safe in children. It is less effective than surgery with regard to elimination of primary grade II reflux. However, clinical success rate is comparable to surgery with regard to the frequency of recurrent urinary tract infections after the procedure. This may be due to the reduction of refluxing urine volume in those patients who showed recurrence of reflux after collagen injection.

Objectives: To determine, in the particular case of neurogenic bladder, the best criteria for selection and grading of the modalities available for the treatment of vesicoureteric reflux, which is often associated., Methods: 194 patients with congenital neurogenic bladder, including 76 cases with vesicoureteric reflux were retrospectively reviewed. The various treatments applied, their results and their complications were reviewed. Conclusions are drawn and proposals are made for the optimal management of vesicoureteric reflux in the particular context of congenital neurogenic bladder., Results: This series included 8 grade I, 28 grade II, 49 grade III and 23 grade IV and V. In more than 50% of cases, reflux was detected on during routine assessment of congenital neurogenic bladder, demonstrating the value of this assessment (25% of cases of reflux were detected before the age of one year). Management initially consisted of vesical drainage, often by intermittent catheterization, from the age of 2 to 3 years and antibiotic prophylaxis. This treatment was sufficient to correct reflux in 9 cases and to control it in 16 cases (no urinary tract infection, no deterioration of the upper tract). An elective anti-reflux operation was decided in 69 cases of VUR (1 grade I, 15 grade II, 38 grade III, 16 grade IV or V). Cohen's technique was performed in 3 cases and endoscopic injection of PTFE was performed in 3 cases. Most of these refluxing bladders were hypertonic and/or presented an abnormally high closing pressure. The operative criteria were: symptomatic reflux; persistent reflux; renal deterioration; non-compliance with treatment. Several complications were observed and are described., Conclusion: Vesicoureteric reflux in the context of congenital neurogenic bladder plays a major role in the deterioration of renal function. These forms of reflux usually occur in hypertonic bladders. Urodynamic studies appear essential before deciding treatment. Intermittent catheterization is able to control or even correct a certain number of these cases of reflux and should be introduced by the age of 2 or 3 years. When surgery is required, Cohen's operation is the easiest to perform, but is associated with an increased complication rate. Injection of PTFE or macroplastic could constitute a good indication.