Post-Ureteroscopy Infections Are Linked to Pre-Operative Stent Dwell Time over Two Months: Outcomes of Three European Endourology Centres

Background: The aim of this study is to investigate outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and stone treatment to identify a time cut-off. Material and Methods: Three tertiary referral centres in Europe retrospectively collected outcomes of ureteroscopy and laser fragmentation (URSL) for all patients with pre-operative indwelling ureteric stents over a period of up to 5 years. Data was collected on patient details, stone demographics, stent dwell time, complications and stone free rate (SFR). Matching for age, sex, operative time, stone size and post-operative stent insertion. To examine for a threshold effect, monthly cut-offs were used to compare post-ureteroscopic febrile UTIs. Binomial logistic regression was used (SPSS v.24) with a significance level set at 0.0036. The risk ratio (RR) with a 95% confidence interval (CI) and the number needed to harm (NNH) are reported. Results: There were 467 patients with a pre-operative stent for analysis. These patients (n = 315) were matched to non-stented controls after excluding 152 patients to achieve adequate matching. There was a significant difference in rates of post-ureteroscopic febrile UTI between stented vs non-stented patients (RR = 2.67, 95% CI: 1.10–6.48, p = 0.03). On adjustment, a dwell time of more than two months was associated with an increased risk of post-ureteroscopic febrile UTI (RR = 3.94, 95% CI: 1.30–12.01, p = 0.02), this increased risk rose with longer dwell time. At stent time longer than four months was associated with a significantly increased risk of post-ureteroscopic febrile UTI (5% vs. 15%, RR = 3.09, 95% CI: 1.56–6.10, p = 0.001), with the number needed to harm at 10. Conclusions: Overall infectious complication rates from URSL are low. The risk of post-operative UTI after four months of dwell time is nearly tripled compared to less than four months.

Association of Electrolyte Changes and Inflammatory Markers with Renal Involvement in Children with Febrile UTI

Background: We need some simpler, cheaper, and less burdensome tools to investigate the severity of renal parenchymal involvement in children with clinical pyelonephritis. Objectives: The present study was designed to investigate the relationship between electrolyte changes with renal involvement as documented by dimercaptosuccinic acid (DMSA) scan in children with febrile urinary tract infection (UTI). Methods: This is a retrospective cohort study, involving 158 children aged two months to 14 years with febrile UTI admitted to Taleghani Hospital in Gorgan from 2018 to 2019. Their documents in hospital were analyzed. They were divided into two groups with positive or negative defects on DMSA scan. Clinical and laboratory data were studied. Statistical analysis was performed using SPSS version 18. Data were analyzed using independent t-test with normal distribution of variables, otherwise chi-square test was used. The statistical significance level of the study was considered 0.05. Results: Among the 158 children, 78 patients (49.4%) had normal DMSA scan results, and 80 patients (50.6%) had an abnormal result. The mean age in month was not different between the two groups. In patients with positive renal cortical defects on DMSA Scintigraphy (group 2), ESR was significantly higher than the first group (P < 0.05). The mean serum Na level in the second group was lower than in the first group; however, it was only slightly significant (P = 0.058). The two groups showed no difference with respect to serum potassium, urine specific gravity (SG), WBC count, and the duration of fever (P > 0.05). The frequency distribution of proteinuria was not different between the two groups (P = 0.836). Conclusions: We suggest that increased ESR, positive CRP, and the presence of reflux can predict renal parenchymal involvement in children with febrile UTI as evidenced by a positive finding on DMSA scan, and the presence of hyponatremia has a little predictive value in this regard.

Clinical Characteristics of Febrile Urinary Tract Infection and Application of Thai Guideline Imaging Recommendations Compared between Children Aged 2 Months to 2 Years and Children Aged 2 to 5 Years

Background: In 2014, the Thai Pediatric Nephrology Association (TPNA) launched a guideline for febrile urinary tract infection (UTI) in children aged two months to five years. Renal and bladder ultrasound (RBUS) is recommended for first febrile UTI, and voiding cystourethrography (VCUG) is recommended in patients with at least one of eight proposed risk factors. Objective: To compare characteristics of febrile urinary tract infection (UTI), compliance with the imaging study recommendation regarding to the TPNA guide, and kidney, ureter, and bladder (KUB) abnormality detections between children aged two months to two years and older than two years to five years. Materials and Methods: The present study was a retrospective study, reviewed children aged two months to five years presenting with first or recurrent episode of febrile UTI between 2014 and 2019 at Siriraj Hospital. Clinical parameters during febrile UTI, indications to perform VCUG, and kidney, ureter, and bladder (KUB) abnormality detections were compared between the younger group and the older group. RBUS and VCUG undergone according to the recommendation were accounted for the compliance. Results: The mean age of 259 younger and of 51 older age children was 8.2±5.6 and 40.0±10.9 months, respectively. Female gender (p=0.01), complaint of constipation (p=0.03), abnormal bladder emptying (p<0.01), and renal impairment (p=0.03) were more frequent in the older than the younger. Overall imaging study compliance was 73.9% and the KUB abnormality detection was 16.5%. High-grade vesicoureteral reflux (VUR) was more common than low-grade VUR. The rates of compliance (p=0.45) and KUB abnormality detections (p=0.54) between the younger and older children were not different. Conclusion: Female gender, and bladder and bowel dysfunction were associated to febrile UTI in older children. The TPNA febrile UTI guideline imaging recommendation was shown to be applicable in both younger and older children. Keywords: Clinical characteristics; Febrile urinary tract infection; Thai guideline imaging recommendations; Renal and bladder ultrasound; Voiding cystourethrography

Impact of surgical intervention on progression to end-stage renal disease in patients with posterior urethral valve

Background Posterior urethral valve patients present with varied presentations at any age of life and have significant associated morbidity and require long-term follow-up and care. Methods This was a single-center ambispective cohort study carried out over a period of 2 years. Patient data regarding the symptoms, investigations, interventions, secondary complications were recorded and were followed up regularly during the study till either normalization of their creatinine level which was maintained up to one-year post-fulguration (non-CKD) or progression to end-stage renal disease (ESRD) requiring renal transplant. Various clinical factors were then compared between these groups. Results The age of presentation varies from 6 months antenatal period to a maximum of 34 years. Most common symptom was of lower urinary tract obstruction, followed by recurrent febrile UTI. The interval between disease presentation detection and PU valve fulguration ranged from 6 days to more than 5 years, median duration being 1 month. 85.7% patients had hydroureteronephrosis on initial USG. In VCUG, there was no significant difference found between the presence of reflux and poor renal outcome. Age of presentation greater than 2 years was seen in 52% of patients with CKD compared to only 10% patients in non-CKD group (significant, p value 0.02). Among patients who developed CKD, 60% of patients had PU valve fulguration after one month of disease presentation, while in contrast, among the non-CKD group, 80% of patients had it done within one month of disease presentation. (significant, p value 0.03). Conclusions Late age of presentation, delayed fulguration with high initial creatinine, and failure of serum creatinine to return to normal after one-month post-fulguration are important risk factors in the progression of the disease to ESRD. Symptomatic improvement after interventions does not correlate with progression to ESRD. The number of interventions also does not predict progression to ESRD. Interventions should be chosen wisely on case to restore near-normal physiology and delay progression to ESRD.

Egyptian pediatric clinical practice guidelines for urinary tract infections in infants and children (evidence based)

Background National evidence-based recommendations for diagnosis, treatment, imaging, and follow-up in urinary tract infection are crucial being a major health problem in pediatrics. Every region should follow international recommendations with respect to the disease local profile and available facilities for that area. Methods Based on AGREE II (the assessment tool of practice guidelines), Egyptian CGLs used *American Academy Pediatrics, *European Association Urology, European Society Pediatric Urology, and *Asian Association Urinary tract infections as its evidence-based references. Health questions were listed for evidence base answers adopted from selected CGLs after their permission. Key statements were approved by all members and further approved by the Egyptian Pediatric Guidelines Committee after local and international external peer reviewing. Results (1) Diagnosis recommendations: Urine culture with diagnostic colony counts is essential for diagnosis. Catheter samples are important for critical cases and non-toilet-trained cases especially when they show significant bacteriuria and pyuria. (2) Treatment plan included areas of debate as choice of antibiotic, oral versus intravenous, duration, antibiotic prophylaxis considering age, disease severity, recurrence, + risk factors, and imaging reports. (3) Imaging recommendations were tailored to suit our community. Renal bladder ultrasound is important for children with febrile UTI, due to the high prevalence of congenital anomalies of the kidney and urinary tract, paucity of prenatal ultrasound, and lack of medical documentation to reflect previously diagnosed UTI or US reports. We recommend renal isotopic scan and voiding cystography for serious presentation, high-risk factors, recurrence, and abnormal US. (4) Urological consultation is recommended: in urosepsis or obstruction, male infants < 6 months. Acute basal DMSA is recommended in congenital renal hypodysplasia. Six months post-infection, US and DMSA are recommended in severe pyelonephritis and vesico-ureteric reflux, where those with abnormal US or DMSA or both should have voiding cystography. (5) Follow-up recommendations include family orientation with hazards of noncompliance and monitoring at pregnancy. Conclusion Diagnosis and treatment show strong recommendations. Imaging depends on patient assessment. Referral to a pediatric nephrologist and urologist in complicated cases is crucial. Follow-up after the age of 16 years in adult clinics is important.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Patients with preoperative asymptomatic pyuria are not prone to develop febrile urinary tract infection after ureteroscopic lithotripsy

Background This study aimed to evaluate the association of asymptomatic pyuria before ureterorenoscopic lithotripsy (URSL) with postoperative febrile urinary tract infection (UTI). Methods This observational case–control study identified the patients undergoing URSL for ureteral stones between May 2011 and October 2015. The included patients were classified into two groups: the asymptomatic pyuria group (6–50 white blood cells [WBCs]/high-power field [HPF]) and the non-pyuria group (≤ 5 WBCs/HPF). All data were collected by reviewing medical records. Postoperative outcomes were collected in terms of febrile UTI, emergency visits, and stone-free rate. Results A total of 232 patients were included, 101 in the pyuria group, 131 in the non-pyuria group. Two (0.9%) patients developed febrile UTI after URSL and 12 (5.2%) patients visited emergency department for URSL-related symptoms. The overall stone-free rate was 90.9%. There was no significant difference between the pyuria and non-pyuria groups regarding febrile UTI, emergency visits, and stone-free rate. Multivariate analysis revealed that pyuria was neither significantly associated with postoperative febrile UTI (OR = 1.03, 95% CI = 0.06–18.10, P = 0.98), nor with emergency visits (OR = 0.48, 95% CI = 0.13–1.85, P = 0.29). Conclusions Compared to the patients with sterile urine prior to URSL, those with asymptomatic pyuria were not prone to develop febrile UTI after URSL.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

Clinical and laboratory differences between extended-spectrum β-lactamase-positive and extended-spectrum β-lactamase-negative bacteria in febrile urinary tract infection in pediatrics

Introduction: The prevalence of urinary tract infections (UTIs) due to extended-spectrum beta-lactamase (ESBL)-producing bacteria is rising, which needs more potent antibiotics, such as carbapenems. Objectives: To evaluate the clinical and laboratory differences between ESBL-positive and ESBL-negative bacteria in febrile UTI in children between one month to seven years to indicate prognostic parameters for ESBL+ UTI and to suggest appropriate antibiotic treatment. Patients and Methods: This cross-sectional study investigated 282 patients diagnosed with the first febrile UTI. The participants were assigned to ESBL-positive and ESBL-negative UTI groups. The groups were compared based on their clinical and laboratory characteristics and outcomes; the infant group was assessed separately (with the onset age of <3 months). Results: The ESBL UTI was detected in 10.2% of the cases with a history of more frequent hospitalization (P=0.002), longer hospitalization (P=0.04), higher recurrence rate (P=0.003), and more red blood cell count in urine analysis findings (P=0.02). In the antimicrobial susceptibility assay, the ESBL-positive UTI group indicated resistance to third-generation cephalosporins; nevertheless, 93.1% of the cases responded clinically. The infant group showed 13% of the patients with ESBL-positive UTI that was correlated with a history of longer preonset hospital stay (P=0.001), elevated C-reactive protein (CRP) concentration (P=0.002), and elevated recurrence rate (P=0.03), compared to the older group. Conclusion: The ESBL UTI should be further considered due to the resulted recurrence rate. The antimicrobial sensitivity assay indicated resistance to third-generation cephalosporins; however, these drugs are applied as the first choice due to the high response rate. Aminoglycosides are applicable as second choice drugs prior to initiating the use of carbapenems, if third-generation cephalosporins did not indicate bactericidal impacts on ESBL UTI.

Plasma D-Dimer as a Marker of Urinary Tract Infection in Children

Background: Urinary tract infections (UTIs) are very common in children. Several biomarkers have been used for the diagnosis of UTI and prediction of renal parenchymal involvement. Objectives: This study aimed to evaluate plasma D-dimer as a diagnostic marker of UTI in children. Methods: This cross-sectional study included 41 children aged 1 month to 14 years with their first febrile UTI confirmed by positive urine culture referred to Bandar Abbas Children’s Hospital, Iran, from October 1, 2017, to April 1, 2018. Participants’ demographic features, including age and gender were recorded. White blood cell (WBC) count, percentage of neutrophils, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum D-dimer were measured in random blood samples for all the patients. Results: Out of 41 children (mean age: 5.50 ± 4.01 years) evaluated in this study, 6 (14.6%) were male, and 35 (85.4%) were female. The mean plasma D-dimer level was 1496.49 ± 2787.55 µg/L. A significant positive correlation was found between D-dimer with ESR (r = 0.647, P = 0.026) and CRP (r = 0.525, P = 0.001). Plasma D-dimer was not associated with age; however, age was inversely correlated with WBC count (r = -0.327, P = 0.037). No significant relationship was found between plasma D-dimer, ESR, CRP, WBC count, and neutrophil percentage with gender (P > 0.05). Conclusions: According to our results, in children aged 1 month to 14 years with culture-confirmed UTI, plasma D-dimer is positively correlated with ESR and CRP. Nevertheless, D-dimer appears not to be influenced by age or gender. Further studies are required to confirm the utility of D-dimer as a diagnostic marker of UTI in children.