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Aims: Guidelines regarding voiding cystourethrogram (VCUG) indications following a paediatric kidney abscess are lacking. This study evaluates vesicoureteral reflux (VUR) prevalence and outcome after a first kidney abscess. Methods: This retrospective study included all children presenting to a tertiary paediatric reference centre with de‐novo kidney abscesses from 2011 to 2022, diagnosed through imaging (ultrasonography or computed tomography). VCUG's clinical utility was assessed by exploring outcomes related to interventions. Results: Among the 17 patients (median age 9 months, IQR; 6 months–6 years), VCUG identified VUR in 7 (41%; 95% CI: 18–65%), including two with grade IV–V. Median abscess size was 19 mm (IQR; 14–27). 7/8 (88%) children with DMSA scan presented scars, including 4 with hypofunctioning (20%–44%), and one with a non‐functioning kidney. Scarring on the DMSA scan was similar regardless of identified VUR. Six children had subsequent pyelonephritis. Three of the remaining 11 had grade I–III and two IV–V VUR. Surgery was required in four children overall: three for recurrent pyelonephritis and one for high‐grade VUR and scars. Conclusion: Among initial kidney abscess cases, 41% had VUR, similar to children experiencing their first uncomplicated pyelonephritis. VCUG results guided antibiotic prophylaxis but not surgical decisions. We suggest considering VCUG following recurrent pyelonephritis/kidney abscess and/or kidney scarring. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Conservative nonsurgical therapy ensures that the resolution is nearly 80% for vesicoureteral reflux grades I and II and 30%–50% for vesicoureteral reflux grades III and V within 4–5 years of follow‐up. Open surgical reimplantation of ureters of grades IV and V is a highly successful procedure, with reported correction rates ranging from 95% to 99% regardless of the severity of vesicoureteral reflux. Patients with vesicoureteral reflux present with a wide range of severity. With an incidence of approximately 1%, vesicoureteral reflux is a relatively common urological abnormality in children. Postnatal diagnosis of vesicoureteral reflux is typically made following a diagnosis of a urinary tract infection and less frequently following family screening. Voiding cystourethrograms remain the gold standard for diagnosing vesicoureteral reflux. To preserve the kidney and prevent the need for potential renal replacement therapy, infants with a single kidney require significantly more assessments and prompt decision‐making. Surgical correction is advised for patients with vesicoureteral reflux grades IV and V, while vesicoureteral reflux grades I, II, and III are managed conservatively. [ABSTRACT FROM AUTHOR]

Objective: Primary bladder neck obstruction (PBNO) is a condition primarily affecting young men, characterized by obstruction at the bladder neck, leading to lower urinary tract symptoms. The aim of this study was to identify a correlation between the severity of bladder neck opening impairment and urinary symptoms by means of urodynamic studies. Materials and Methods: A retrospective analysis was conducted in adult males diagnosed with PBNO at a university neurourology department between 2015 and 2022 who underwent voiding cystourethrography (VCUG) and pressure‐flow studies. The cohort was divided into two groups: absence of bladder neck opening on VCUG (Group A) and incomplete bladder neck opening (Group B). Results: Out of the 82 patients with PBNO screened, 53 were included in the analysis. Nocturia was the only symptom more prevalent in Group A (65% in Group A vs. 30% in Group B, p = 0.02) but scores and subscores of the Urinary Symptom Profile questionnaire were not different between groups. In addition, the detrusor pressure at a maximum flow rate (PdetQmax), bladder outlet obstruction index (BOOI), and bladder contractility index (BCI) were higher in Group A than in Group B [PdetQmax (A = 93.7 ± 53.7 cmH2O vs. B = 65.7 ± 26.4 cmH2O; p = 0.01)–BOOI (A = 77 ± 58.3 vs. B = 48 ± 25.7; p = 0.03)–BCI (A = 136 ± 51.3 vs. B = 110 ± 41.7; p = 0.04)]. Conclusion: This study demonstrates a significant association between the extent of bladder neck opening impairment observed on VCUG and obstruction and contraction urodynamic parameters, but no association with the severity of urinary symptoms. Future studies should evaluate the predictive value of treatment response and the occurrence of complications based on clinical and urodynamic parameters. [ABSTRACT FROM AUTHOR]

Key Clinical Message Conservative nonsurgical therapy ensures that the resolution is nearly 80% for vesicoureteral reflux grades I and II and 30%–50% for vesicoureteral reflux grades III and V within 4–5 years of follow‐up. Open surgical reimplantation of ureters of grades IV and V is a highly successful procedure, with reported correction rates ranging from 95% to 99% regardless of the severity of vesicoureteral reflux. Abstract Patients with vesicoureteral reflux present with a wide range of severity. With an incidence of approximately 1%, vesicoureteral reflux is a relatively common urological abnormality in children. Postnatal diagnosis of vesicoureteral reflux is typically made following a diagnosis of a urinary tract infection and less frequently following family screening. Voiding cystourethrograms remain the gold standard for diagnosing vesicoureteral reflux. To preserve the kidney and prevent the need for potential renal replacement therapy, infants with a single kidney require significantly more assessments and prompt decision‐making. Surgical correction is advised for patients with vesicoureteral reflux grades IV and V, while vesicoureteral reflux grades I, II, and III are managed conservatively.

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Aims: This study aims to evaluate the role of standardized dynamic renal scintigraphy (DRS) in recognizing vesicoureteral reflux (VUR) in patients detected with VUR by voiding cystourethrography (VCUG). Methods: The data of all pediatric patients who underwent both VCUG and DRS [technetium-99m diethylenetriamine pentaacetic acid (Tc-99m DTPA) or technetium-99m mercaptoacetyltriglycine dynamic renal scintigraphy (Tc-99m MAG-3)] in our hospital between 2013 and 2022 were retrospectively reviewed. Tc-99m MAG-3 was used in infants and Tc-99m DTPA radiopharmaceutical in children over one year old. According to VCUG findings, VUR grades were grouped as grade I-II-III low-grade VUR and IV-V high-grade VUR. The role of DRS in detecting VUR in both low and high-VUR-grade groups was evaluated. Results: A total of 56 patients (and 69 renal units), 23 girls (%41.1), and 33 boys (%68.9) were included in this study. The median value of the time elapsed between the DRS and VCUG examinations was nine days. According to VCUG, VUR was grade I in five renal units, grade II in 19 renal units, grade III in six renal units, grade IV in six renal units, and grade V in 33 renal units. DRS detected VUR in two of 30 renal units (%6.7) in the low VUR grade group. On the other hand, VUR was observed with DRS in 27 of 39 renal units (%69.2) in the high VUR grade group. Conclusions: Standardized DRS shows very low sensitivity in recognizing low-grade VUR, and its performance in detecting high-grade VUR is comparatively better. Raising awareness among clinicians that VUR can be observed with standardized DRS will benefit the patient in terms of early detection of accompanying VUR pathologies.

Aims:: To present the ICS Teaching Module on Videourodynamics (VUD) and the information as a best practice report. Methods:: This teaching module was developed by the (International Continence Society) ICS Urodynamics Committee to assist ICS members in their clinical practice. A detailed literature search on studies and guidelines published on the clinical role of VUD as well as expert opinions have been considered. A slideshow on VUD has been developed and will be presented to the members of the ICS Urodynamics Committee and will be made available to the ICS membership on the ICS website. Results:: The scientific evidence on the indications, recommended techniques and interpretation of VUD in patients presenting with lower urinary tract symptoms has been summarised. Troubleshooting and optimisation of the imaging as also been described to minimise the radiation exposure to both patient and healthcare professionals. Conclusions:: The scientific evidence on the clinical role, techniques and the indications for VUD is sparse with varying clinical expert opinion. The ICS Urodynamics Committee recommends its use as a second line diagnostic tool for a thorough visualisation of the lower urinary tract anatomy and real time function. This manuscript summarises the evidence and provides practice recommendations on VUD for teaching purposes in the framework of an ICS teaching module.

Aims: This study aims to evaluate the role of standardized dynamic renal scintigraphy (DRS) in recognizing vesicoureteral reflux (VUR) in patients detected with VUR by voiding cystourethrography (VCUG). Methods: The data of all pediatric patients who underwent both VCUG and DRS [technetium-99m diethylenetriaminepentaacetic acid (Tc-99m DTPA) or technetium-99m mercaptoacetyltriglycine dynamic renal scintigraphy (Tc-99m MAG-3)] in our hospital between 2013 and 2022 were retrospectively reviewed. Tc-99m MAG-3 was used in infants and Tc-99m DTPA radiopharmaceutical in children over one year old. According to VCUG findings, VUR grades were grouped as grade I-II-III low-grade VUR and IV-V high-grade VUR. The role of DRS in detecting VUR in both low and high-VUR-grade groups was evaluated. Results: A total of 56 patients (and 69 renal units), 23 girls (%41.1), and 33 boys (%68.9) were included in this study. The median value of the time elapsed between the DRS and VCUG examinations was nine days. According to VCUG, VUR was grade I in five renal units, grade II in 19 renal units, grade III in six renal units, grade IV in six renal units, and grade V in 33 renal units. DRS detected VUR in two of 30 renal units (%6.7) in the low VUR grade group. On the other hand, VUR was observed with DRS in 27 of 39 renal units (%69.2) in the high VUR grade group. Conclusions: Standardized DRS shows very low sensitivity in recognizing low-grade VUR, and its performance in detecting high-grade VUR is comparatively better. Increasing the awareness of clinicians about the detection of VUR with standardized DRS will benefit patients. [ABSTRACT FROM AUTHOR]

Aim: The presence and clinical importance of vesicoureteric reflux in patients with a double collecting system are being questioned. Therefore, the role of voiding cystourethrography in the management of patients with ureterocele is unclear. This study aimed to evaluate patients with a ureterocele in terms of urinary tract infection (UTI) and vesicoureteral reflux (VUR). Material Methods: The cases who were admitted to the Pediatric Nephrology Clinic of Health Sciences University Tepecik Training and Research Hospital between 2012 and 2022 and were diagnosed with ureterocele were evaluated retrospectively. Demographic, clinical, and laboratory data were obtained from file records. Results: All patients diagnosed with ureterocele and voiding cystourethrography (VCUG) were evaluated. A total of 24 (female 13 (54.2%)) children were included. The reasons for admission were antenatal hydronephrosis in 13 (54.2%) patients, UTI in 9 (37.5%) patients, and incidentally diagnosed ureterocele in 2 (8.3%) patients. Urinary tract infection was observed in 20 patients at admission, recurrent UTI in 21 patients at follow-up, preoperative pyelonephritis in 12 patients. VUR was found in 11 patients, and severe VUR (≥stage 3) was found in 9 patients. Ten patients had ipsilateral hydronephrosis, and 14 patients had a double collecting system. The presence of VUR was found to be associated with female gender, UTI at admission, and recurrent UTI at follow-up (p < 0.05). However, there was no difference between groups with or without VUR in terms of ipsilateral hydronephrosis, scar formation, and the need for surgery (p > 0.05). Conclusions: We could not demonstrate any criteria to select patients to receive VCUG; on the other hand, VUR did not cause more kidney damage. Our study supports the need for more scientific data to determine management in patients with ureterocele.

Objective: To determine the incidence of culture-positive urinary tract infection (UTI) after micturating cystourethrogram (MCUG). We further wanted to identify risk factors for developing a culture-positive UTI following MCUG. Methods: A retrospective review of the available medical records of 500 paediatric patients who underwent MCUG in Perth, Western Australia was performed. Results: Seven (1.4%) patients comprised of four females and three males developed a febrile, culture-positive UTI within 14 days following MCUG. Significant association was found for female patients, patients with neurogenic bladder, and patients with previous culture-positive UTI as developing a culture-positive UTI following MCUG. Multivariate logistic regression determined that patients were more likely to develop culture-positive UTI within 14 days following MCUG if they had a known history of UTI (odds ratio: 5.0, 95% confidence interval: 1.5–17.3, p=0.010) or had a neurogenic bladder (odds ratio: 4.2, 95% confidence interval: 1.0–17.9, p=0.049). Conclusion: The incidence of patients who developed a febrile, culture-positive UTI following MCUG was low at 1.4%. Statistically significant and independent associations for the development of culture positive UTI were found in patients with neurogenic bladder and patients with previous culture-positive UTI. Further prospective studies are necessary to determine necessity of prophylactic antibiotics for high-risk patients, e.g., patients with neurogenic bladder or previous culture-positive UTI.

Introduction: Prostatic utricles (PUs) are the remnants of Mullerian ducts found in the male posterior urethra. Enlarged symptomatic utricles are known to be associated with hypospadias. There is a dearth of literature defining an enlarged utricle and also its clinical significance. Aims: The aim of this study was to describe anatomical difference of PUs of cases with severe hypospadias and also to find their clinical significance if any. Materials and Methods: A prospective study was carried out, and all patients with proximal hypospadias were enrolled. Cystoscopy was performed in all cases. Symptomatology, size, and location of PU were recorded. PU of >0.5 cm was considered enlarged. Results: In the present series, a total of 70 cases were included over a period of 2 years. Enlarged utricle was found in 47/70 (67.14%) on cystoscopy. They were wide-mouthed and negotiated 9 Fr/11 Fr cystoscope with ease. Recurrent epididymo-orchitis, recurrent urinary tract infection, and obstructive features were the most common complications requiring intervention. Conclusions: PUs in boys with hypospadias are enlarged as well as wide-mouthed. Most of these remain asymptomatic, but few of them carry the potential of complications. Cystoscopy helps in direct visualization of utricular anatomy, so it should be a preferred investigating modality for investigating a PU.

Aim: The presence and clinical importance of vesicoureteric reflux in patients with a double collecting system are being questioned. Therefore, the role of voiding cystourethrography in the management of patients with ureterocele is unclear. This study aimed to evaluate patients with a ureterocele in terms of urinary tract infection (UTI) and vesicoureteral reflux (VUR). Material Methods: The cases who were admitted to the Pediatric Nephrology Clinic of Health Sciences University Tepecik Training and Research Hospital between 2012 and 2022 and were diagnosed with ureterocele were evaluated retrospectively. Demographic, clinical, and laboratory data were obtained from file records. Results: All patients diagnosed with ureterocele and voiding cystourethrography (VCUG) were evaluated. A total of 24 (female 13 (54.2%)) children were included. The reasons for admission were antenatal hydronephrosis in 13 (54.2%) patients, UTI in 9 (37.5%) patients, and incidentally diagnosed ureterocele in 2 (8.3%) patients. Urinary tract infection was observed in 20 patients at admission, recurrent UTI in 21 patients at follow-up, preoperative pyelonephritis in 12 patients. VUR was found in 11 patients, and severe VUR (≥stage 3) was found in 9 patients. Ten patients had ipsilateral hydronephrosis, and 14 patients had a double collecting system. The presence of VUR was found to be associated with female gender, UTI at admission, and recurrent UTI at follow-up (p < 0.05). However, there was no difference between groups with or without VUR in terms of ipsilateral hydronephrosis, scar formation, and the need for surgery (p > 0.05). Conclusions: We could not demonstrate any criteria to select patients to receive VCUG; on the other hand, VUR did not cause more kidney damage. Our study supports the need for more scientific data to determine management in patients with ureterocele. [ABSTRACT FROM AUTHOR]

Introduction: Prostatic utricles (PUs) are the remnants of Mullerian ducts found in the male posterior urethra. Enlarged symptomatic utricles are known to be associated with hypospadias. There is a dearth of literature defining an enlarged utricle and also its clinical significance. Aims: The aim of this study was to describe anatomical difference of PUs of cases with severe hypospadias and also to find their clinical significance if any. Materials and Methods: A prospective study was carried out, and all patients with proximal hypospadias were enrolled. Cystoscopy was performed in all cases. Symptomatology, size, and location of PU were recorded. PU of >0.5 cm was considered enlarged. Results: In the present series, a total of 70 cases were included over a period of 2 years. Enlarged utricle was found in 47/70 (67.14%) on cystoscopy. They were wide-mouthed and negotiated 9 Fr/11 Fr cystoscope with ease. Recurrent epididymo-orchitis, recurrent urinary tract infection, and obstructive features were the most common complications requiring intervention. Conclusions: PUs in boys with hypospadias are enlarged as well as wide-mouthed. Most of these remain asymptomatic, but few of them carry the potential of complications. Cystoscopy helps in direct visualization of utricular anatomy, so it should be a preferred investigating modality for investigating a PU. [ABSTRACT FROM AUTHOR]

Abstract Background Surgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics. Methods Ethical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001–2020. Results The 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other. Conclusions Ostomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60–70%.

Children with spina bifida (SB) undergo a videourodynamic study (VUDS) or urodynamic study and voiding cystourethrogram (VCUG). A standardized protocol for imaging during a pediatric VUDS has not been established. Our aim is to quantify radiation exposure and establish a baseline for children with spina bifida (SB) undergoing VUDS in current practice at our institution. This is a retrospective study from 2013 to 2020 of consecutive pediatric SB patients undergoing VUDS by a single provider. Patients were categorized into three groups based on age; group 1 (0-2 YR), group 2 (2-10 YR), group 3 (>10 YR). Radiation data was reported as mean air kerma (AK), dose area product (DAP) and exposure time (seconds). Effective dose (ED) was calculated based on radiation quantity (Air Kerma, AK) and organ sensitivity. The lifetime attributable risk (LAR) was calculated based on AK and a risk coefficient. Data points calculated for patients undergoing VUDS were then compared to age matched institutional VCUG data in the same age groups. 398 patients undergoing VUDS met inclusion criteria and 262 independent patients underwent VCUG. ED increased with age in both VUDS and VCUG. All VCUG groups were found to have a higher ED than VUDS. The LAR for VUDS groups 1–3 was 0.001, 0.002, and 0.006, respectively. Reported in percentages, there is a 0.1%, 0.2%, and 0.6% chance, respectively, of age groups 1, 2 and 3 developing cancer as a result of the radiation exposure from a VUDS. Our study found that ED was low across all age groups for VUDS, comparing favorably to the VCUG groups. VCUG was selected as a benchmark comparison for its diagnostic similarities and, at times, overlapping indications. Few studies have described ED with respect to VUDS or extrapolate the ED of VUDS into LAR in the pediatric population. We recognize that we have not determined the true ED of the gonads and bladder, rather we have overestimated, as the data is based on an international reference point proximal to the exposed individual. However, LAR was calculated for each age group and revealed that patients are at a negligible increased risk of developing malignancy secondary to exposure compared to the general population. Our current practice for pediatric VUDS has exhibited consistently low radiation exposure amongst all age groups. Moving forward, we have the foundation and flexibility to create an imaging protocol for pediatric VUDS, while taking more calculated steps toward incorporating ALARA, as low as reasonably achievable, principles. A protocol adhering to the ALARA principle could provide consistency across institutions and aid in multi-institutional studies. [ABSTRACT FROM AUTHOR]

Vesicoureteral reflux (VUR) grade has been used as a primary factor in assessing a child's risk of clinical outcomes. Unfortunately, grade has poor inter-observer reliability. We hypothesized that more objective and reliable VCUG parameters including the distal ureteral diameter ratio (UDR) and volume at onset of VUR (Vol) may either augment or replace the current grading system to provide more reliable prediction of clinical outcomes. Multivariate clinical outcome models were analyzed to assess the impact on predictive accuracy by the addition of voiding cystourethrogram (VCUG) data including grade, UDR, and Vol, alone or in combinations. Clinical variables from retrospective review of 841 children's records included age, gender, presentation, VUR laterality, bowel and bladder dysfunction, history of febrile urinary tract infection (UTI), and number of UTIs. The primary outcomes assessed included VUR resolution or persistence and need for operative intervention. Grade, UDR, and Vol were independent predictors of resolution and operative intervention. Vol increased predictive accuracy in resolution models with grade or UDR alone; however, no significant difference occurred in models with the substitution of grade with UDR. A more reliable classification system for VUR, with improved predictive accuracy regarding clinical outcomes, may be developed incorporating UDR and Vol. Whether VUR grade can be completely replaced by Vol and UDR measurements requires further evaluation with larger number of patients. Summary table Summary of impact of grade, Vol, and UDR alone or in combination on predictive accuracy of multivariate models relative to clinical outcomes. Summary table Clinical outcome Significance of GR, Vol,UDR on predictive accuracy Impact of combination of GR, Vol,UDR on predictive accuracy Spontaneous Resolution GR, Vol, UDR each significant GR + Vol > GR or Vol alone UDR + Vol > Vol alone GR = UDR = GR + UDR a Vol + UDR = Vol + GR = GR + UDR a Operative Intervention GR, Vol, UDR each significant Not assessed due to a small number of patients with UDR measurements undergoing operative intervention GR = grade. Vol = bladder volume at onset of VUR as a percent of age predicted bladder capacity. UDR = ureteral diameter ratio. a No significant difference demonstrated in these three models. [ABSTRACT FROM AUTHOR]

Voiding cystourethrogram (VCUG) images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when vesicoureteral reflux (VUR) is present. Given the variation in VCUG technique and reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016, which included the recommendation of at least 2 voiding cycles to identify intermittent VUR and/or ureteral ectopia. VCUG were assessed for adherence to performance of cyclic study. Children who underwent cyclic evaluation were compared to those who underwent a single cycle VCUG. Radiation dosage was also analyzed. Studies performed on patients >18 years of age and those obtained as part of a trauma evaluation were excluded from study. Two hundred and eighty-four VCUGs were analyzed, 97 (34.2%) were positive for VUR on the initial cycle. Of the remaining 187 studies, 116 (62%) had multiple filling-voiding cycles while in 71 (38%) only a single cycle was performed. One hundred and sixty-one (86.1%) were negative for vesicoureteral reflux. Twenty-six (13.9%) children were diagnosed with VUR after the initial filling-voiding cycle: 6 were diagnosed with grade I, 2 grade II, 11 grade III, 2 grade IV and 5 grade V. Of the 123 total children found to have VUR, 26 (21.2%) were diagnosed after an initial negative cycle. Younger children were significantly more likely to have a cyclic study performed; mean age of patients undergoing a cyclic study was 1.09 ± 2.16 years versus 3.86 ± 4.5 years (p ≤ 0.0001). Categorically, 74.1% of children less than 1 year of age underwent a cyclic study compared to 6.9% of children older than 5 years of age (p ≤ 0.0001). There was no difference based on sex with 49.1% of males and 50.9% of females (p = 0.667) undergoing cyclic evaluation. Children undergoing a cyclic study had lower median radiation dose 2.15 microGy m2 (range 0.09–111) compared to 4.41 (range 1.3–104) [p = 0.01]. Vesicoureteral reflux may occur intermittently and cyclic VCUG is thought to enhance the ability to detect reflux. In our cohort, 26 children (9.2%) were only diagnosed after an additional cycle – ie 21.1% of reflux would have been missed had a cyclic study not been performed. The majority of these patients (69.2%, 18 of 26) were found to have dilating, and thus perhaps more clinically significant, reflux. Our study highlights the importance of obtaining as much information as possible and adhering to the standardized VCUG protocol. Younger children are more likely to undergo cyclic VCUG. While most reflux is detected with the initial filling-voiding cycle, 26 (21.2%) patients were diagnosed after an initial negative cycle with the majority being dilating VUR. Summary Table Patient age by performance of cyclic study Summary Table Not done (n = 71) Done (n = 116) Overall (n = 187) P value Age (yrs) Mean (SD) 3.86 (4.50) 1.09 (2.16) 2.14 (3.51) <0.0001 Median [Min, Max] 2.33 [0.004, 17.0] 0.250 [0.004, 15.5] 0.500 [0.004, 17.0] Age group (yrs) <0.0001 <1 26 (36.6%) 86 (74.1%) 112 (59.9%) 1–<3 16 (22.5%) 19 (16.4%) 35 (18.7%) 3–5 9 (12.7%) 3 (2.6%) 12 (6.4%) >5 20 (28.2%) 8 (6.9%) 28 (15.0%) [ABSTRACT FROM AUTHOR]

Purpose of Review: This goal of this review is to summarize the current literature on the diagnosis and evaluation of female urethral stricture. Recent Findings: Female urethral stricture is a rare condition, which can present with a wide variety of symptoms, including both obstructive and irritative voiding symptoms, pain, or infection. Initial evaluation with post-void residual and uroflowmetry are good screening tests but are unable to diagnose stricture. Diagnosis often requires more than one modality, most commonly cystoscopy and voiding cystourethrogram, with or without urodynamics. Ultrasound is a newer diagnostic tool that can aid in diagnosis and surgical planning. Summary: Female urethral stricture is a rare pathology and requires a high-clinical suspicion for accurate diagnosis. While there is a lack of consensus on clear diagnostic criteria, multiple modalities are often used to establish a diagnosis. [ABSTRACT FROM AUTHOR]

Voiding cystourethrography (VCUG) is a widely accepted radiographic imaging technique that has been traditionally used for identifying vesicoureteral reflux in children. Given the simultaneous evaluation of the lower urinary tract that is afforded by VCUG, many common and uncommon abnormalities of the ureters, bladder and urethra can also be elucidated. Knowledge of the appearance of these urological entities may facilitate their proper identification. [ABSTRACT FROM AUTHOR]

Objective. While international guidelines necessitate Voiding Cystourethrogram (VCUG) for pediatric patients, it is unnecessary for the evaluation of adult patients without urological disorders as renal transplant candidates. The objective of this study was to evaluate the results of adult candidates who underwent VCUG before transplantation and to demonstrate the necessity for this imaging. Methods. A retrospective study of the data of 1265 adult candidates who underwent VCUG before transplantation at our center, was undertaken. VUR, the presence of Postvoiding residual urine (PVR) (>100 ml), Low bladder capacity (LBC) (

Objective: The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF). Patients and Methods: We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day–18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere. Results: The mean duration of follow-up was 7.8 years (range 3–14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%). Conclusions: Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

Objective. International Commission on Radiological Protection (ICRP) Task Group 113 is developing reference values of organ and effective dose coefficients (DCs) for radiography, fluoroscopy, and computed tomography imaging exams. In support of these efforts, our focus is on pediatric diagnostic fluoroscopy. Contrast agents used during clinical examinations are an important consideration of the work undertaken by the Task Group. This work demonstrates the importance of including organ contrast volume concentrations for the calculation of reference organ DCs in the voiding cystourethrogram (VCUG). Approach. The ICRP newborn and 15 year female reference phantoms were utilized within the Particle and Heavy Ion Transport code system for the calculation of organ DCs. A pediatric radiologist with over 30 years of clinical experience defined the imaging fields for a VCUG examination consistent with clinical practice. Of these, four imaging fields were selected for investigation. The transport simulations modeled an iodinated contrast solution similar to Bracco Group's 18% weight per volume, cystografin diatrizoate meglumine and typical bladder content was supplemented to make up the remainder volume. Iodinated contrast volumes of 0%, 25%, 50%, 75%, and 100% concentration by volume were modeled and associated DCs for in-field organs were computed. Main results. Organ DCs were calculated for the urinary bladder wall, colon wall, ovaries, and uterus for both female phantoms under irradiation geometries representative of a VCUG examination. Some organ DCs increased with iodine volume in the bladder and other organ DCs decreased as the iodine contrast volume completely filled the bladder (100%). Significance. The study results demonstrate for the newborn phantom percent differences in organ DCs varied between 0%-10% for the organs of interest, while they varied between 0%-22% in the 15 year phantom suggesting the importance of including contrast media in Monte Carlo radiation transport simulations of the VCUG examination., (© 2024 Institute of Physics and Engineering in Medicine. All rights, including for text and data mining, AI training, and similar technologies, are reserved.)

Bladder prolapse through a patent urachus is rare. We present a newborn with an unusual exophytic, erythematous umbilical mass. Voiding cystography readily demonstrated continuity of the bladder dome with the umbilical mass, confirming bladder prolapse through a patent urachus. The diagnosis of bladder prolapse was rapidly made in a second newborn with similar imaging and clinical findings and confirmed by cystography. We discuss the embryology of this condition including the association with a vesico-allantoic cyst in utero. Pre- and postnatal images are presented. The use of cystography in diagnosis is emphasized. [ABSTRACT FROM AUTHOR]

Background: A portable radiographic system capable of fluoroscopic imaging in the neonatal intensive care unit (NICU) potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite. Objective: To evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite. Materials and methods: In phase A, 20 patients <3 years of age and scheduled to undergo upper gastrointestinal series (upper GI) or voiding cystourethrograms (VCUG) in the radiology fluoroscopy suite were recruited to evaluate a portable fluoroscopic unit. A modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1–4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected. In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to the 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated. Results: In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast. In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system. Conclusion: The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room system for neonates with minimal risks to the staff and other patients in the NICU. [ABSTRACT FROM AUTHOR]

Purpose: The presence and degree of hydronephrosis is very important in the management of many diseases of the urinary tract. In this study, we aim to compare the sensitivity and specificity of 2 classification systems that are used for hydronephrosis grading in ultrasound, for reflux and scar detection. The classification systems were the Society of Fetal Urology (SFU) and Urinary Tract Dilatation (UTD). Material and methods: Ultrasounds and dimercaptosuccinic acid scintigraphies (DMSA) of all patients who underwent voiding cystourethrogram (VCUG) due to urinary tract infection were examined retrospectively. DMSA was accepted for scar detection and VCUG for reflux detection as reference methods. SFU classification was used for hydronephrosis in ultrasound reports, and UTD classification was made over the reports. Sensitivity, specificity, and positive and negative predictive values of UTD and SFU classification systems for reflux and scar detection were calculated, and these 2 systems were compared. Results: 103 (39%) of the patients were male and 162 (61%) were female. Pathologies were detected in 192 (35%) of 530 kidneys in ultrasound. In 110 (42%) of the children, reflux was detected in VCUG. Scars in DMSA were detected in only 16% (44) of 266 kidneys. Sensitivity, positive and negative predictive values of the UTD classification system were statistically significantly higher than the SFU system for scar and reflux detection (p < 0.01). Conclusions: If we use the UTD system in ultrasounds of patients with urinary tract infections, children reported as UTD 0 may not need VCUG, which reduces radiation exposure to children and the cost of the diagnostic interventions. [ABSTRACT FROM AUTHOR]

The morphology of the bladder and posterior urethra on initial voiding cystourethrogram (VCUG) in posterior urethral valve (PUV) has been proposed as a meaningful early metric for short- and long-term kidney outcomes. Here, we seek to externally validate the proposed association and assess the reliability of PUV morphology characteristics. We reviewed our institutional database for patients managed for PUV between 2000 and 2022 and included those treated with primary ablation with at least 1 year of follow-up for kidney function. Each VCUG was evaluated by three independent raters for the height-width ratio of the bladder (HW–B), height-width ratio of the posterior urethra (HW-PU), and posterior-anterior urethral ratio (PA-UR), and trabeculation (none, fine, or coarse). We assessed the reliability in these with intra-class coefficient and Fleiss kappa for continuous and categorical data, respectively. We performed univariate analysis with nadir creatinine and five-year follow-up glomerular filtration rate (GFR). In total, 98 patients met inclusion criteria. The median age at diagnosis and ablation was 10 and 21 days, respectively. Patients with nadir creatinine <0.8 mg/dL had higher follow-up GFR (101 vs. 20 ml/min/1.73 m2, p = 0.04), and lower risk of CKD (odds ratio 14.7, p = 0.002). The median value for HW-B was 1.4, median HW-PU was 2.1, and median PA-U was 4.7, There was significant inter-class agreement between all three measures of 0.80, 0.51, and 0.70 (p < 0.001). The inter-rater agreement for bladder trabeculation was fair (Fleiss K = 0.40, p < 0.001). There was no statistically significant correlation between HW-B, HW-PU, PU-A with nadir creatinine (p = 0.07, 0.33, 0.91) or 5-year GFR (0.27, 0.45, 0.62), respectively. There is significant interest in determining prognostic factors and metrics in PUV. The morphological characteristics on VCUG are reliable and is available information for all boys diagnosed with PUV, resulting in an attractive metric. While we do not demonstrate correlation with kidney outcomes, VCUG features warrant further attention as prognostic factors in PUV. PUV morphology on initial VCUG is a reliable metric of lower urinary tract deformity but is not associated with 5-year kidney outcomes. [ABSTRACT FROM AUTHOR]

Background: Surgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics.Methods: Ethical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001-2020.Results: The 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other.Conclusions: Ostomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60-70%. [ABSTRACT FROM AUTHOR]

To investigate the perceptions, attitudes, and treatment selection of Chinese pediatric urologists and pediatric surgeons regarding a “watch and wait” strategy for multicystic dysplastic kidney (MCDK). We used a cross-sectional survey in this study. We sent the questionnaire to pediatric urologists and pediatric surgeons to capture their views via the “Questionnaire Star” online survey platform between November and December 2019. The questionnaire contained the basic information and surgical experiences of the respondent, respondents' awareness regarding the counseling of prenatally-diagnosed MCDK and the treatment of MCDK, and respondents' knowledge regarding the imaging modalities, frequency, and duration of follow-up. Of the 200 questionnaires we sent, we received 151 responses. Of those 151 complete responses, most respondents were women (n = 104, 68.9%), pediatric urologists (n = 78, 51.6%), and practicing with at least 5 years of surgical experience (n = 112, 74.2%); 11.9% reported >20 years' experience. Eighty-two surgeons (54.3%) provided positive counseling for prenatally-diagnosed MCDK. Ninety-nine surgeons (65.6%) advocated conservative management for MCDK, and only 14.8% of respondents suggested limiting the use of radiographic evaluation for MCDK. Surgeons working in academic teaching facilities and those from East China were more likely to select a “watch and wait” strategy. Chinese pediatric urologists and pediatric surgeons have inadequate knowledge of the “watch and wait” strategy for MCDK. An expert consensus on the strategy of “watch and wait” for MCDK in China is urgently needed to promote the application of this non-surgical treatment mode in clinical practice. A larger sample size is required to fully identify the current opinion of Chinese pediatric urologists and pediatric surgeons regarding the management of MCDK.

Background: The role of the voiding cystourethrogram (VCUG) in the follow-up of children with posterior urethral valves (PUVs) post-ablation has been considered a standard practice. The urethral ratio and gradient of change have proven to be useful. Objectives: We aimed to review the role of the ‘ideal’ ratio on predicting residual PUV post-ablation. Methods: A systematic review of the PubMed, SCOPUS and Web of Science databases was performed (April 2019). The search terms included ‘Urethral Ratio and Posterior urethral valve ablation’. All cited reference lists were further evaluated for additional inclusive studies. Results: Eleven studies were identified, of which nine were relevant to the topic. Case reports, comments and adult and animal studies were excluded, leaving four studies for critical review. In total, 338 patients were assessed. The control group consisted of 167 age-matched, male children. Study regions included India and Australia. The ages ranged from 15 days to 3.4 years. Ablation methods included the use of a resectoscope with cutting diathermy, cold knife or Bugbee electrode. The mean urethral ratios in the control group ranged from 1.04 to 1.73. The suggested predictive urethral cut-off ratios recommended include 2.2 (p = 0.001), 2.5–3 and 3.5. Conclusion: Although the precise cut-off ratio could not be clearly defined in this review, a urethral ratio less than a range of 2.2–3.5 has proven to be a beneficial predictor of ablation success and should thus be incorporated into standard VCUG reporting templates in the follow-up of PUVs in male children in resource-limited settings.

Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.

Objective: The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF). Patients and Methods: We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day–18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere. Results: The mean duration of follow-up was 7.8 years (range 3–14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%). Conclusions: Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence. [ABSTRACT FROM AUTHOR]

Background: Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis.Objective: We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining voiding cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume.Materials and Methods: Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing.Results: The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36-0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43.Conclusion: Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the value of the voiding cystourethrogram (VCUG) in children with multicystic dysplastic kidney (MCDK) who have a normal versus abnormal contralateral kidney and bladder ultrasound (US), and assess the risk of having vesicoureteral reflux (VUR) or urinary tract infection (UTI) based on the US results.Methods: A retrospective chart review including children with unilateral MCDK with postnatal US and VCUG available at our institution between January 2008 and September 2017 was performed. Analysis was done to find association between abnormal contralateral US and contralateral VUR and UTI.Results: One hundred and fifty-six children were analyzed; 118(75.6%) patients had a normal contralateral kidney US, while 38(24.4%) had abnormal US. The rate of severe contralateral VUR (grade IV and V) was 2 (1.7%) and 5 (13.2%) in children with normal and abnormal contralateral US, respectively. The risk analysis demonstrated a significant association between severe VUR on the contralateral kidney and an abnormal contralateral US (odds ratio = 7.73; 95%CI: 1.43-41.81; P = 0.018) and no significant association with UTI (odds ratio = 1.58; 95%CI: 0.50-4.94; P = 0.435).Conclusion: Our data suggests, the rate of severe contralateral VUR in children with unilateral MCDK and normal contralateral kidney is low. VCUG should be considered for infants with proven MCKD and alterations on the contralateral kidney on US. Following patients with MCDK and normal contralateral kidney without the use of VCUG is a reasonable approach, unless there is development of signs and symptoms of recurrent UTI or deterioration of the renal function. We found that abnormal contralateral kidney US was associated with severe VUR. [ABSTRACT FROM AUTHOR]

Background: The role of the voiding cystourethrogram (VCUG) in the follow-up of children with posterior urethral valves (PUVs) post-ablation has been considered a standard practice. The urethral ratio and gradient of change have proven to be useful. Objectives: We aimed to review the role of the 'ideal' ratio on predicting residual PUV post-ablation. Methods: A systematic review of the PubMed, SCOPUS and Web of Science databases was performed (April 2019). The search terms included 'Urethral Ratio and Posterior urethral valve ablation'. All cited reference lists were further evaluated for additional inclusive studies. Results: Eleven studies were identified, of which nine were relevant to the topic. Case reports, comments and adult and animal studies were excluded, leaving four studies for critical review. In total, 338 patients were assessed. The control group consisted of 167 age-matched, male children. Study regions included India and Australia. The ages ranged from 15 days to 3.4 years. Ablation methods included the use of a resectoscope with cutting diathermy, cold knife or Bugbee electrode. The mean urethral ratios in the control group ranged from 1.04 to 1.73. The suggested predictive urethral cut-off ratios recommended include 2.2 (p = 0.001), 2.5–3 and 3.5. Conclusion: Although the precise cut-off ratio could not be clearly defined in this review, a urethral ratio less than a range of 2.2–3.5 has proven to be a beneficial predictor of ablation success and should thus be incorporated into standard VCUG reporting templates in the follow-up of PUVs in male children in resource-limited settings. [ABSTRACT FROM AUTHOR]

Clinical/methodological Problem: Urinary tract infections are among the most common infectious diseases in childhood. The task of imaging is to detect predisposing factors, such as urinary transport disorders, vesicoureteral reflux, as well as complications such as abscesses or pyonephrosis in addition to possible morphological changes of the kidneys and the draining urinary tract during an infection., Standard Radiological Procedures: The initial diagnostic imaging technique is generally sonography. For the diagnosis of vesicoureteral reflux, voiding urosonography or alternatively radiological voiding cystourethrography are used. Further diagnostic workup may include scintigraphy, magnetic resonance imaging (MRI) or, in exceptional cases, computed tomography (CT)., Recommendation for Practice: In children and adolescents, it is of particular importance to avoid recurrent urinary tract infections and their sequelae. This requires precise imaging diagnostics, which must be performed with special consideration of radiation protection., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)