Reflujo vesicoureteral en niños.

Indian J Pediatr. 2017 Jul;84(7):540-544. doi: 10.1007/s12098-017-2359-4. Epub 2017 May 6.

Controversies Regarding Management of Vesico-ureteric Reflux.

Babu R1, Chowdhary S2.

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Abstract

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

KEYWORDS:

Children; Fetal ultrasound; Hydronephrosis; Reflux nephropathy; Renal scarring; Urinary tract infection; Vesico-ureteric reflux

Hidronefrosis e infección urinaria

J Pediatr Urol. 2016 Aug;12(4):261.e1-7. doi: 10.1016/j.jpurol.2016.04.024. Epub 2016 May 26.

Urinary tract infections in children with prenatal hydronephrosis: A risk assessment from the Society for Fetal Urology Hydronephrosis Registry.

Zee RS1, Herbst KW2, Kim C3, McKenna PH4, Bentley T4, Cooper CS5, Herndon CD6.

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Abstract

INTRODUCTION:

Risk factors for urinary tract infection (UTI) in children with prenatal hydronephrosis (PNH) are not clearly defined. Our study aim was to describe incidence and identify factors associated with UTI among a cohort of children diagnosed with PNH.

MATERIAL AND METHODS:

Patients with confirmed PNH from four medical centers were prospectively enrolled in the Society for FetalUrology (SFU) hydronephrosis registry between 9/2008 and 10/2015. Exclusion criteria included enrollment because of UTI, associated congenital anomalies, and less than 1-month follow-up. Univariate analysis was performed using Fisher's Exact test or Mann-Whitney U. Probability for UTI was determined by Kaplan-Meier curve.

RESULTS:

Median follow-up was 12 (IQR 4-20) months in 213 patients prenatally diagnosed with hydronephrosis. The majority of the cohort was male (72%), Caucasian (77%), and 26% had high grade (SFU 3 or 4) hydronephrosis. Circumcision was performed in 116/147 (79%) with known status, 19% had vesicoureteral reflux (VUR), and 11% had ureteral dilatation. UTI developed in 8% (n = 18), 89% during their first year of life. Univariate analysis found UTI developed more frequently in females (p < 0.001), uncircumcised males (p < 0.01), and the presence of parenchymal renal cyst (p < 0.05). Logistic regression found renal cyst to no longer be significant, but female gender a significant risk factor for development of UTI (p < 0.001). Regression analysis stratified by gender found neither hydronephrosis grade nor parenchymal renal cyst to be significant risk factors for UTI development among females. However, hydronephrosis grade and circumcision status were significant risk factors for development of UTI among males (p < 0.05 and p < 0.01, respectively).

CONCLUSION:

Identification of factors associated with UTI in patients with PNH is still progressing; however, several observational studies have identified groups that may be at increased risk of UTI. Use of prophylactic antibiotics (PA), degree of kidney dilation, gender, and circumcision status all have been reported to have some degree of impact on UTI. A previous study identified risk factors for UTI as female gender, uncircumcised status, hydroureteronephrosis, and VUR, and reported that prophylaxis provided a protective effect on prevention of UTI. Our data mirror those in some respect, identifying an association of UTI with female gender and, among males, uncircumcised status, and high grade hydronephrosis. However, we were unable to demonstrate an association between UTI and the use of PA, presence of VUR, dilated ureter, or renal duplication in this observational registry.

Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:

Antibiotics; Hydronephrosis; Urinary tract infection

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J Pediatr Urol. 2017 Jun;13(3):306-315. doi: 10.1016/j.jpurol.2017.02.023. Epub 2017 Mar 19.

Role of antibiotic prophylaxis in antenatal hydronephrosis: A systematic review from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel.

Silay MS1, Undre S2, Nambiar AK3, Dogan HS4, Kocvara R5, Nijman RJM6, Stein R7, Tekgul S4, Radmayr C8.

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Abstract

BACKGROUND:

The benefits and harms of continuous antibiotic prophylaxis (CAP) versus observation in patients with antenatal hydronephrosis (ANH) are controversial.

OBJECTIVE:

The aim was to determine the effectiveness of CAP for ANH, and if beneficial to determine the best type and regimen of antibiotic and the most harmful to provide guidance for clinical practice.

METHODS:

A systematic literature search was performed in databases including Medline, Embase, and Cochrane in June 2015. The protocol was prospectively registered to PROSPERO (CRD42015024775). The search started from 1980, when maternal ultrasound was first introduced into clinical practice. Eligible studies were critically evaluated for risk of bias using Revman software. The outcomes included reduction in urinary tract infections (UTI), drug-related adverse events and kidney functions.

RESULTS:

Of 797 articles identified, 57 full text articles and six abstracts were eligible for inclusion (2 randomized controlled trials, 11 non-randomized comparative studies, and 50 case series). It remains unclear whether CAP is superior to observation in decreasing UTIs. No conclusion could be drawn for drug-related adverse events and kidney function because of lack of data. Children who were not circumcised, with ureteral dilatation, and high-grade hydronephrosis may be more likely to develop UTI, and CAP may be warranted for these subgroups of patients. A majority of the studies had low-to-moderate quality of evidence and with high risk of bias.

CONCLUSIONS:

The benefits of CAP in a heterogeneous group of children with ANH involving different etiologies remains unproven. However, the evidence in the form of prospective and retrospective observational studies has shown that it reduces febrile UTI in particular subgroups.

Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:

Antenatal hydronephrosis; Antibiotic prophylaxis; Children; Urinary tract infection

Female gender (pZ0.02),
uncircumcised males (p Z 0.02), lack of CAP (p < 0.01),
HUN (p < 0.01), and VUR (p < 0.01) were found to be the
independent predictors. The subgroup analysis by excluding
patients with VUR revealed that high-grade HN (p Z 0.04)
was also a significant predictor for fUTI.
However, there were some other reports clearly stating
that no benefit of CAP was achieved regarding the UTI rates

even in the high risk groups
The results of the forest plot tables demonstrate five
important findings. First, it is not possible to establish
whether CAP was superior to no CAP in terms of decreasing
UTI (Fig. 3). Second, non-circumcised infants, high-grade
HN, and HUN may be at higher risk of developing UTI
(Figs. 4, 6 and 7). Finally, there was no significant difference

in UTI risk between males and females

we are not able to recommend routine use of CAP
in neonates with ANH. However, infants with ANH constitute
a highly heterogeneous group of patients. Individual
risk stratification is warranted taking patient factors (ureteral
dilatation, circumcision status, high-grade HN) into
account during decision-making. If CAP is favored by the
clinician, no recommendations can be made on the type

and optimal dose of antibiotic regimen.

Obstrucción pieloureteral: OPU

La pieloplastía abierta sigue siendo la técnica más apropiada en los casos de OPU especialmente en los menores de 3 años ya que el tiempo de la operación es acotada ( 1 hora y media), los días de hospitalización no superan los dos días, el resultado estético es bueno ya que se usa una incisión no mayor de 2,5 cm. y los costos son muy inferiores a la laparoscopía o cirugía robótica

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Leer:

Pyeloplasty without intrarenal stent in pediatric patients.

Actas Urol Esp. 2012 Sep;36(8):469-73. Epub 2012 Jun 17.