MEETING REvIEw
Best of the 2014 Pediatric Urology Fall Congress Highlights From the 2014 Pediatric Urology Fall Congress, October 24-26, 2014, Miami, FL [ Rev Urol. 2015;17(1):35-37 doi: 10.3909/riu0662]
®
© 2015 MedReviews , LLC
KEY WORDS Vesicoureteral reflex • Renal ultrasound • Urinary tract infection • Appendicovesicostomy • Monti ileovesicostomy • Antiobiotic prophylaxis
T
he 2nd Annual Pediatric Urology Fall Congress was held October 24-26, 2014, in Miami, Florida, and was attended by 550 pediatric urology specialists. The scientific program covered the latest developments in the field of pediatric urology. Highlights of the program included the American Association of Pediatric Urologists lecture entitled, “Update on the AAP UTI Guidelines 2 Years Old,” by Dr. Kenneth Roberts, and the American Academy of Pediatrics (AAP) Latimer Lecture entitled, “The Role of Antibiotic Prophylaxis Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Urology, NYU Langone Medical Center, New York, NY.
with VUR—Results of the RIVUR Trial,” given by Dr. Saul Greenfield. The 2014 AAP Urology Medal was awarded to Selwyn B. Levitt, MD. He earned his medical degree at the University of the Witwatersrand in Johannesburg, South Africa, and completed his pediatric urology fellowship at the Great Ormond Street Hospital in London, United Kingdom. Dr. Levitt was clinical professor of urology at New York Medical College (Valhalla, NY). Dr. Levitt is considered not only an expert in pediatric urology but also in the field of pediatric renal transplantation. His knowledge of abnormal bladder function has led to our current understanding of the importance of evaluating and treating the pediatric bladder prior to transplantation. In addition, he is Vol. 17 No. 1 • 2015 • Reviews in Urology • 35
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Best of the 2014 Pediatric Urology Fall Congress continued credited with the development of innovative nerve- and glans-sparing clitoroplasty. Dr. Levitt has had a special interest in the impalpable testis and his thoughts and recommendations resulted in the use of laparoscopy for the treatment of the undescended testis. He was also the lead surgical coordinator of the First International Reflux Study Group in the early 1980s. This year’s First Prize for Clinical Research was awarded to the Boston Children’s Hospital (Boston, MA) group for their work on the predictive value of specific ultrasound findings for vesicoureteral reflux (VUR) on voiding cystourethrogram (VCUG).1 Renal and bladder ultrasound (RBUS) is not thought to be sensitive or specific for findings on VCUG. The objective of the study was to determine if renal, ureteral, and bladder findings on RBUS are associated with abnormal VCUG findings, and to determine if predictive models can accurately identify patients at high risk for reflux or other abnormalities diagnosed on VCUG. Between January 1, 2006 and December 31, 2010, 3995 patients (age 0-60 mo) underwent VCUG and RBUS on the same day. None had prenatal hydronephrosis or prior postnatal genitourinary imaging. Both multivariate logistic models and a neural network machine learning algorithm were developed to evaluate the predictive power of RBUS for VCUG abnormalities. Sensitivity, specificity, predictive values, and area under receiving operating curves (AUROCs) of RBUS for VCUG abnormalities were determined. Of 2259 patients with urinary tract infection (UTI), 75% of the RBUS findings were reported as normal. VCUG identified any grade of VUR in 41.7%, VUR grade II in 20.9%, and VUR grade III in 2.8%. Many individual RBUS findings were
significantly associated with VUR on VCUG, including hydronephrosis (any grade VUR [odds ratio {OR} 1.36; P .0086], grade II [OR 2.32; P .0001], and VUR grade III [OR 4.67; P .0001]); and ureteral dilation (any grade of VUR [OR 1.43; P .0967], VUR grade II [OR 2.97; P .0001], and VUR grade III [OR 7.41; P .0001]). Parenchymal abnormalities, including dysplasia, duplication, atrophy, and urothelial thickening, were associated with VUR (any grade of VUR [OR 1.61; P .0005], VUR grade II [OR 2.10; P .0001], and VUR grade III [OR 2.75; P .0001]). Renal cysts, agenesis, and stones were not significant predictors. Bladder abnormalities including trabeculation, wall thickening, debris, and ureterocele were also strongly associated with any grade of VUR (OR 1.99; P .0089), VUR grade II (OR 1.98; P .0110), and VUR grade III (OR 5.43; P .0001). Although there were strong univariate associations, multivariate modeling did not provide a highly predictive model. Multivariate logistic regression had an AUROC of 0.57, a sensitivity of 86%, and a specificity of 25% for any VUR; an AUROC of 0.60, a sensitivity of 5%, and a specificity of 99% for grade II; and an AUROC of 0.67, a sensitivity of 6%, and a specificity of 99% for grade III. The best predictive model constructed via neural networks had an AUROC of 0.69, a sensitivity of 64%, and a specificity of 60% for any VUR; an AUROC of 0.67, a sensitivity of 18%, and a specificity of 98% for grade II; and an AUROC of 0.79, a sensitivity of 32%, and a specificity of 100% for grade III. The authors concluded that RBUS is a poor screening test for reflux. These tests should be used together because they provide different, complementary information.
The Second Prize for Clinical Research was awarded to the Indiana group for their study on long-term outcomes of channel type: appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) catheterizable channels.2 A retrospective review was performed of the Indiana patients age 21 years undergoing an APV or Monti procedure from 1990 to 2013. The researchers studied the demographics, channel type, stomal location, and channel continence, in addition to stomal and subfascial revisions. Kaplan-Meier survival and Cox proportional hazards analysis were used. Of those patients included (510), 214 patients underwent APV and 296 underwent the Monti procedure, half of which were spiral Monti. Median age at surgery was 7.4 years for those who had APV and 8.7 years for those who had a Monti procedure. Median followup was 5.7 years for those who had APV and 7.7 years for those who had the Monti procedure. Stomal stenosis and channel continence for APV versus Monti technique were similar (7.5% vs 7.4%; P .99; and 98.1% vs 96.6%; P .41, respectively). Fewer APVs (14; 6.5%) had subfascial revision compared with Monti procedures (49; 16.6%; P .001). The probability at 10 years for a subfascial revision for the APV was 8.6%, for Monti channels excluding spiral umbilical Monti technique was 15.5%, and for spiral umbilical Monti procedures was 32.3% (P .0001). Multivariate regression showed that the Monti technique was 2.12 times more likely than APV to require revision overall (P .03). The spiral Monti to the umbilicus was 4.66 times more likely than the APV to require revision (P .03). Factors including sex, age at surgery, date of surgery, and diagnosis of meningomyelocele were not predictive of subfascial revision; the
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Best of the 2014 Pediatric Urology Fall Congress stomal location was significant, but only for the spiral Monti procedure (P .17). The authors show longterm outcomes using the APV and Monti techniques in a large cohort. The risk of channel complication is more than twice as high with Monti procedures as with APV, and continues over the channel’s lifetime. Dr. Saul Greenfield spearheaded the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) trial and presented an excellent review of the findings in his AAP Latimer Lecture entitled “The Role of Antibiotic Prophylaxis with VUR - Results of the RIVUR Trial.”3 The 2-year, multisite, randomized, placebo-controlled trial investigated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome) in 607 children with VUR diagnosed after a first or
second febrile or symptomatic UTI. Secondary outcomes included renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance. The study shows that recurrent UTI developed in 39 of 302 children on prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38-0.78). Prophylaxis was shown to reduce the risk of recurrence by 50% (hazard ratio [HR], 0.50; 95% CI, 0.34-0.74) and was most effective in children with a history of febrile UTI (HR, 0.41; 95% CI, 0.26-0.64) and in children with known bladder and bowel dysfunction (HR, 0.21; 95% CI, 0.08-0.58). No significant difference was seen in the occurrence of renal scarring between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). In the 87 children
with a first recurrence caused by Escherichia coli, the isolates that were resistant to trimethoprimsulfamethoxazole were 63% in the prophylaxis group and 19% in the placebo group. The investigators concluded that antimicrobial preventative significantly reduced the risk of recurrent UTI, especially in those children who had previous febrile UTI. Antibiotic prophylaxis did not affect the development of renal scarring. References 1.
2.
3.
Logvinenko T, Chow JS, Nelson C. Predictive value of specific ultrasound findings for vesicoureteral reflux on voiding cystourethrogram. Presented at: Pediatric Urology Fall Congress; October 24-26, 2014; Miami, FL. Szymanski KM, Whittam B, Misseri R, et al. Does channel type and stomal location affect long-term outcomes of catheterizable continent urinary channels? Presented at: Pediatric Urology Fall Congress; October 24-26, 2014; Miami, FL. Hoberman A, Greenfield SP, Mattoo TK, et al; RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370:2367-2376.
Vol. 17 No. 1 • 2015 • Reviews in Urology • 37
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Best of the 2014 Pediatric Urology Fall Congress Highlights From the 2014 Pediatric Urology Fall Congress, October 24-26, 2014, Miami, FL [ Rev Urol. 2015;17(1):35-37 doi: 10.3909/riu0662]
®
© 2015 MedReviews , LLC
KEY WORDS Vesicoureteral reflex • Renal ultrasound • Urinary tract infection • Appendicovesicostomy • Monti ileovesicostomy • Antiobiotic prophylaxis
T
he 2nd Annual Pediatric Urology Fall Congress was held October 24-26, 2014, in Miami, Florida, and was attended by 550 pediatric urology specialists. The scientific program covered the latest developments in the field of pediatric urology. Highlights of the program included the American Association of Pediatric Urologists lecture entitled, “Update on the AAP UTI Guidelines 2 Years Old,” by Dr. Kenneth Roberts, and the American Academy of Pediatrics (AAP) Latimer Lecture entitled, “The Role of Antibiotic Prophylaxis Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Urology, NYU Langone Medical Center, New York, NY.
with VUR—Results of the RIVUR Trial,” given by Dr. Saul Greenfield. The 2014 AAP Urology Medal was awarded to Selwyn B. Levitt, MD. He earned his medical degree at the University of the Witwatersrand in Johannesburg, South Africa, and completed his pediatric urology fellowship at the Great Ormond Street Hospital in London, United Kingdom. Dr. Levitt was clinical professor of urology at New York Medical College (Valhalla, NY). Dr. Levitt is considered not only an expert in pediatric urology but also in the field of pediatric renal transplantation. His knowledge of abnormal bladder function has led to our current understanding of the importance of evaluating and treating the pediatric bladder prior to transplantation. In addition, he is Vol. 17 No. 1 • 2015 • Reviews in Urology • 35
4004170006_RIU0662.indd 35
23/04/15 1:51 PM
Best of the 2014 Pediatric Urology Fall Congress continued credited with the development of innovative nerve- and glans-sparing clitoroplasty. Dr. Levitt has had a special interest in the impalpable testis and his thoughts and recommendations resulted in the use of laparoscopy for the treatment of the undescended testis. He was also the lead surgical coordinator of the First International Reflux Study Group in the early 1980s. This year’s First Prize for Clinical Research was awarded to the Boston Children’s Hospital (Boston, MA) group for their work on the predictive value of specific ultrasound findings for vesicoureteral reflux (VUR) on voiding cystourethrogram (VCUG).1 Renal and bladder ultrasound (RBUS) is not thought to be sensitive or specific for findings on VCUG. The objective of the study was to determine if renal, ureteral, and bladder findings on RBUS are associated with abnormal VCUG findings, and to determine if predictive models can accurately identify patients at high risk for reflux or other abnormalities diagnosed on VCUG. Between January 1, 2006 and December 31, 2010, 3995 patients (age 0-60 mo) underwent VCUG and RBUS on the same day. None had prenatal hydronephrosis or prior postnatal genitourinary imaging. Both multivariate logistic models and a neural network machine learning algorithm were developed to evaluate the predictive power of RBUS for VCUG abnormalities. Sensitivity, specificity, predictive values, and area under receiving operating curves (AUROCs) of RBUS for VCUG abnormalities were determined. Of 2259 patients with urinary tract infection (UTI), 75% of the RBUS findings were reported as normal. VCUG identified any grade of VUR in 41.7%, VUR grade II in 20.9%, and VUR grade III in 2.8%. Many individual RBUS findings were
significantly associated with VUR on VCUG, including hydronephrosis (any grade VUR [odds ratio {OR} 1.36; P .0086], grade II [OR 2.32; P .0001], and VUR grade III [OR 4.67; P .0001]); and ureteral dilation (any grade of VUR [OR 1.43; P .0967], VUR grade II [OR 2.97; P .0001], and VUR grade III [OR 7.41; P .0001]). Parenchymal abnormalities, including dysplasia, duplication, atrophy, and urothelial thickening, were associated with VUR (any grade of VUR [OR 1.61; P .0005], VUR grade II [OR 2.10; P .0001], and VUR grade III [OR 2.75; P .0001]). Renal cysts, agenesis, and stones were not significant predictors. Bladder abnormalities including trabeculation, wall thickening, debris, and ureterocele were also strongly associated with any grade of VUR (OR 1.99; P .0089), VUR grade II (OR 1.98; P .0110), and VUR grade III (OR 5.43; P .0001). Although there were strong univariate associations, multivariate modeling did not provide a highly predictive model. Multivariate logistic regression had an AUROC of 0.57, a sensitivity of 86%, and a specificity of 25% for any VUR; an AUROC of 0.60, a sensitivity of 5%, and a specificity of 99% for grade II; and an AUROC of 0.67, a sensitivity of 6%, and a specificity of 99% for grade III. The best predictive model constructed via neural networks had an AUROC of 0.69, a sensitivity of 64%, and a specificity of 60% for any VUR; an AUROC of 0.67, a sensitivity of 18%, and a specificity of 98% for grade II; and an AUROC of 0.79, a sensitivity of 32%, and a specificity of 100% for grade III. The authors concluded that RBUS is a poor screening test for reflux. These tests should be used together because they provide different, complementary information.
The Second Prize for Clinical Research was awarded to the Indiana group for their study on long-term outcomes of channel type: appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) catheterizable channels.2 A retrospective review was performed of the Indiana patients age 21 years undergoing an APV or Monti procedure from 1990 to 2013. The researchers studied the demographics, channel type, stomal location, and channel continence, in addition to stomal and subfascial revisions. Kaplan-Meier survival and Cox proportional hazards analysis were used. Of those patients included (510), 214 patients underwent APV and 296 underwent the Monti procedure, half of which were spiral Monti. Median age at surgery was 7.4 years for those who had APV and 8.7 years for those who had a Monti procedure. Median followup was 5.7 years for those who had APV and 7.7 years for those who had the Monti procedure. Stomal stenosis and channel continence for APV versus Monti technique were similar (7.5% vs 7.4%; P .99; and 98.1% vs 96.6%; P .41, respectively). Fewer APVs (14; 6.5%) had subfascial revision compared with Monti procedures (49; 16.6%; P .001). The probability at 10 years for a subfascial revision for the APV was 8.6%, for Monti channels excluding spiral umbilical Monti technique was 15.5%, and for spiral umbilical Monti procedures was 32.3% (P .0001). Multivariate regression showed that the Monti technique was 2.12 times more likely than APV to require revision overall (P .03). The spiral Monti to the umbilicus was 4.66 times more likely than the APV to require revision (P .03). Factors including sex, age at surgery, date of surgery, and diagnosis of meningomyelocele were not predictive of subfascial revision; the
36 • Vol. 17 No. 1 • 2015 • Reviews in Urology
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Best of the 2014 Pediatric Urology Fall Congress stomal location was significant, but only for the spiral Monti procedure (P .17). The authors show longterm outcomes using the APV and Monti techniques in a large cohort. The risk of channel complication is more than twice as high with Monti procedures as with APV, and continues over the channel’s lifetime. Dr. Saul Greenfield spearheaded the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) trial and presented an excellent review of the findings in his AAP Latimer Lecture entitled “The Role of Antibiotic Prophylaxis with VUR - Results of the RIVUR Trial.”3 The 2-year, multisite, randomized, placebo-controlled trial investigated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome) in 607 children with VUR diagnosed after a first or
second febrile or symptomatic UTI. Secondary outcomes included renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance. The study shows that recurrent UTI developed in 39 of 302 children on prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38-0.78). Prophylaxis was shown to reduce the risk of recurrence by 50% (hazard ratio [HR], 0.50; 95% CI, 0.34-0.74) and was most effective in children with a history of febrile UTI (HR, 0.41; 95% CI, 0.26-0.64) and in children with known bladder and bowel dysfunction (HR, 0.21; 95% CI, 0.08-0.58). No significant difference was seen in the occurrence of renal scarring between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). In the 87 children
with a first recurrence caused by Escherichia coli, the isolates that were resistant to trimethoprimsulfamethoxazole were 63% in the prophylaxis group and 19% in the placebo group. The investigators concluded that antimicrobial preventative significantly reduced the risk of recurrent UTI, especially in those children who had previous febrile UTI. Antibiotic prophylaxis did not affect the development of renal scarring. References 1.
2.
3.
Logvinenko T, Chow JS, Nelson C. Predictive value of specific ultrasound findings for vesicoureteral reflux on voiding cystourethrogram. Presented at: Pediatric Urology Fall Congress; October 24-26, 2014; Miami, FL. Szymanski KM, Whittam B, Misseri R, et al. Does channel type and stomal location affect long-term outcomes of catheterizable continent urinary channels? Presented at: Pediatric Urology Fall Congress; October 24-26, 2014; Miami, FL. Hoberman A, Greenfield SP, Mattoo TK, et al; RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370:2367-2376.
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