Background/Objectives: Primary non-refluxing megaureters (PM) are common congenital anomalies of the urinary tract. While spontaneous resolution is frequent, reliable non-invasive predictors of outcome are scarce. Ureteral peristalsis is frequently regarded as a sign of functional maturation and favorable prognosis, although supporting clinical evidence is limited. This study aimed to evaluate whether sonographically visible ureteral peristalsis at initial diagnosis predicts spontaneous resolution, pyelonephritis, or the need for surgery in infants with PM. Methods: In this retrospective single-center study, infants diagnosed with primary non-refluxing megaureters before one year of age between 2012 and 2018 were analyzed. Patients with refluxing, secondary, syndromic, or ectopic megaureters were excluded. Sonographic detection of distal ureteral peristalsis at initial examination was recorded. Clinical outcomes included spontaneous resolution, episodes of pyelonephritis (including breakthrough infections under antibiotic prophylaxis), and surgical intervention. Univariate and multivariate logistic regression analyses were performed. Results: Sixty-three infants were included, with a median follow-up of 34 months. Peristalsis was detected in 52.3% at initial ultrasound. Complete spontaneous resolution occurred in 66% of patients, while 20.9% required surgical reimplantation. The presence of peristalsis at diagnosis was not associated with spontaneous resolution, time to resolution, occurrence of pyelonephritis, breakthrough infections, or surgical intervention. Multivariate analysis confirmed that initial peristalsis was not an independent predictor of outcome. Conclusions: Sonographically visible ureteral peristalsis is a transient and inconsistent finding in infants with primary non-refluxing megaureters and does not predict clinical outcome. Peristalsis observed on initial ultrasound should not be used as a decision-making parameter in the management of PM during the first year of life.

Editorial Comment: Evaluation of perfusion and vascularization using Near Infrared Imaging (NIR) and Indocyanine Green (ICG) is increasingly applied, also in pediatric urology with an example recently reported in this journal concerning exstrophy repairs [ [1] Kaefer M. Saad K. Gargollo P. Whittam B. Rink R. Fuchs M. et al. Pediatric Urology Midwest Alliance, PUMA. Intraoperative laser angiography in bladder exstrophy closure: a simple technique to monitor penile perfusion. J Pediatr Urol. 2022; 18: 746.e1-746.e7https://doi.org/10.1016/j.jpurol.2022.10.012 Abstract Full Text Full Text PDF Scopus (0) Google Scholar ]. In some cases of testicular torsion, it remains difficult to decide whether or not to remove a testis with very limited options to further evaluate perfusion and tissue viability. The technique presented herein to evaluate residual perfusion and vascular damage in testicular torsion might help to further refine an individualized approach to preserve only mildly damaged testes after torsion.

INTRODUCTION:Ureteroceles are rare congenital malformations of the urinary tract and challenging in management. Other than localisation (ectopic or orthotopic) and features of the upper tract, there are no well-tested predictive variables. We aimed at evaluating the initial sonographically measured ureterocele diameter (UD) as a predictor for underlying anatomy, success of primary management and long-term complications. PATIENTS AND METHODS:All patients (n = 131, 41m/90f) referred to a single tertiary department with the diagnosis of an ureterocele between 07/1995 and 07/2019 were included. The UD was measured sonographically at the time of initial diagnosis. Most patients (n = 108, 82.4 %) underwent scintigraphy (either MAG3 or DMSA-scan) and voiding cystourethrography. After initial wait-and-see or primary endoscopic intervention, complications and symptomatic or high-grade VUR were indications for further surgical treatment, following an individualised protocol. Beneath data from sonographic exams, occurrence of urinary tract infections and voiding problems, all surgical and endoscopic data was recorded. Variables were examined using univariate and stepwise multivariate statistical methods. RESULTS:With a median age at first presentation of 2 months (IQR 8) the mean follow-up accounted to 6.5 years ± 4.8 years (range 0-20 years, median 5.4 years, IQR 7.3). Information on the initial diameter was available in 123 patients (94 %) with a median of 14 mm (IQR 14, range: 4-40). In a stepwise multivariate analysis, the UD significantly correlated with the localisation (ectopic/orthotopic, p = 0.001, AUC 0.7), successful primary endoscopic intervention (p = 0.02, AUC 0.71) and successful wait-and-see (p = 0.003, AUC 0.82). Female sex showed a significant impact on the probability of successful primary endoscopic intervention (p = 0.002, AUC 0.71) and was besides age the only variable correlating with UTIs prior to treatment (p = 0.01, AUC 0.8) whereas UD was not. Figure. The anatomic localisation (ectopic or orthotopic) showed less significance than UD in all the analyses performed. In a prediction model based on the multivariate analysis a diameter of <10 mm and >26 mm showed a ≥90 % probability of either orthotopic or ectopic localisation. CONCLUSION:In this retrospective cohort sonographically measured ureterocele diameter was an easy and non-invasively detectable feature predicting localisation and proved a stronger predictive variable for the success of primary management strategies, superior to endoscopically verified ureterocele localisation, in a stepwise multivariant analysis. Furthermore, UD was predictive of long-term complications with an AUC of 0.7. Conversely, neither UD nor localisation predicted the frequency of UTIs prior to treatment, underlining the importance of CAP, especially in female patients.

INTRODUCTION:Vesicoureteral reflux (VUR) may have long lasting effects on affected individuals, especially in females. Its intertwined relationship with urinary tract infection (UTI) has been well documented and there is a further risk during pregnancy where UTIs are more problematic. OBJECTIVE:To analyze existing data within the literature to identify factors associated with pregnancy-related complications in women with a history of VUR in childhood. METHODS:PubMed, MEDLINE, Embase, and the Cochrane Library databases were searched to identify all published reports of pregnancy outcomes in women with a history of VUR in childhood up to January 2024 (PROSPERO Registration ID: CRD42024550470). Selection criteria included all English-language original articles reporting pregnancy outcomes (maternal and fetal morbidities) in pregnant patients with a history of VUR in childhood. After screening and eligibility assessment, 17 articles met the PICO inclusion criteria. RESULTS:The search yielded 1060 papers, of which 17 remained after exclusions, and assessed 2349 women with a history of VUR in childhood,1167 pregnant women and a total of 2206 pregnancies. Compared with the general obstetric population, the results showed an increased rate of pregnancy-related complications (particularly febrile urinary tract infection, gestational hypertension, pre-eclampsia) in the presence of renal scarring, even if the women had undergone anti-reflux surgery in childhood, but not persistent low-grade VUR. CONCLUSION:Despite the lack of larger prospective randomized controlled trials with long-term follow-up, based on the findings of this systematic review, we conclude that close monitoring during pregnancy should be recommended in the presence of persistent high-grade VUR or in women with renal scarring, even if VUR has resolved.

PURPOSE:There is no universally accepted definition of obstruction in the use of dynamic renography for the evaluation of high-grade hydronephrosis. Prolonged, but insignificant pelvicalyceal tracer retention is often difficult to differentiate from significant obstruction in cases with neither clear obstruction nor unimpaired outflow. We hypothesized that an additional measurement of the residual activity 120 mins after tracer application might reduce the probability of equivocal findings. METHODS:In 37 consecutive MAG3 scans performed for the evaluation of isolated unilateral highgrade hydronephroses ≥SFU III in 28 patients a late static image after 120 mins was additionally acquired in the case of a high residual activity of >30% after 45 mins. Nine board-certified specialists (6 in nuclear medicine, 3 in pediatric urology) independently reviewed all examinations with and without the information on the additional late imaging 120 mins post injection (p.i.) using a predefined ordinal scale from 1 (=normal) to 5 (= obstructive). We measured the extent of change in reporting associated with the addition of late imaging and controlled for the level of interobserver agreement. After follow-up the impact on surgical indications was reviewed. Ranks were compared using Wilcoxon-Mann tests, interobserver agreement was calculated via evaluation of individual findings with ANOVA. P-values <0.05 were considered significant. RESULTS:The addition of a late image resulted in a "less obstructive" interpretation (decreased rank, -0.31, p = 0.000048) compared to standard protocol and led to a reduction of equivocal findings (39 % vs. 28%, p=0.003). There was a low variation in the assessments with no significant differences in rank distribution (p = 0.137) and no difference between nuclear medicine specialists and pediatric urologists. After a median 66 months of follow-up, 25/28 (89 %) patients were eligible for reevaluation, of whom 18/25 (72 %) proceeded to pyeloplasty. Of those with a significantly less obstructive assessment due to late imaging, 6/9 underwent pyeloplasty. CONCLUSION:In preselected patients with high residual activity after 45 mins, measurement of the residual activity 120 min after tracer application influenced interpretation of the diuretic renography towards a less frequent diagnosis of obstruction and reduced the number of equivocal assessments. In this study, the clinical impact of the additional late imaging proved small and relevant only for few patients. Until further studies have found different results, the acquisition of additional late imaging should remain a very individual decision.

OBJECTIVE:To investigate the potential influence of vesicoureteral reflux (VUR) on stone formation in children. STUDY DESIGN:A retrospective analysis was conducted on consecutive patients admitted between 2010 and 2023 for either (1) stone treatment (via ESWL or PCNL) or (2) vesicoureteral reflux (VUR). The evaluation included demographic data and, if applicable, the timing and results of voiding cystourethrograms (VCUG). In patients diagnosed with both VUR and stones, a further assessment was performed to analyze potential causality, defined as temporal and spatial co-occurrence, history of UTIs and infection associated stone types (struvite, apatite). RESULTS:In Group 1 (73 stone patients, mean age 8.8 ± 5.2 years), VUR was diagnosed in 8/31 VCUGs (26 %), primarily low-grade and observed in children under three years of age. Only 2/31 patients (6 %) had VUR coinciding with simultaneous ipsilateral infection stones. In Group 2, among 1758 VUR patients (mean age 3.6 ± 4.0 years), stones were identified in 9 cases (0.5 %), with a likely causal association in 6 of them, corresponding to 1 stone in 300 VUR diagnoses. Additionally, 3 of the 6 children had other risk factors for stone formation or infection. CONCLUSION:The association between VUR and stone formation appears to be incidental rather than causal. Consequently, the mere presence of a stone should not broaden the indications for a VCUG.

Undescended testis (UDT, cryptorchidism) is the most frequent genital anomaly in boys. However, its treatment varies widely throughout the world. This second part of our roundtable discussion aims to continue to ask global experts to express their attitudes towards several case scenarios of UDT in order to explore the rationale for their clinical decisions. As the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we believe that this roundtable series will facilitate colleagues all over the world to reflect and improve their practices regarding the treatment of UDT.

We aimed to investigate controversial pediatric urolithiasis issues systematically, integrating expert consensus and comprehensive guidelines reviews. Two semi-structured online focus group meetings were conducted to discuss the study’s need and content, review current literature, and prepare the initial survey. Data were collected through surveys and focus group discussions. Existing guidelines were reviewed, and a second survey was conducted using the Delphi method to validate findings and facilitate consensus. The primary outcome measures investigated controversial issues, integrating expert consensus and guideline reviews. Experts from 15 countries participated, including 20 with 16+ years of experience, 2 with 11–15 years, and 4 with 6–10 years. The initial survey identified nine main themes, emphasizing the need for standardized diagnostic and treatment protocols and tailored treatments. Inter-rater reliability was high, with controversies in treatment approaches (score 4.6, 92

Purpose To investigate the potential influence of vesicoureteral reflux (VUR) on stone formation in children by evaluating causality in terms of temporal coincidence, corresponding laterality, presence of UTI and stone composition. Methods Retrospective data analysis was conducted on pediatric patients with stones (group 1) and those diagnosed with VUR (group 2). Data comprises demographics, voiding cysto-urethrograms (VCUGs) stone characteristics, and UTI history. Results In Group 1 (73 stone patients, mean age 8.8 years), VUR was diagnosed in 26% of VCUGs (8/31), predominantly in children under 3 years. Only in a minority of 6%, VUR may be causally linked to infection-stones (2/31). In Group 2 (1758 VUR patients, mean age 3.6 years), 0.5% were found to have stones (9/1758), with VUR potentially contributing to stone formation in 0.34% of cases. VUR in stone patients was low grade, except one child with neurogenic bladder and bilateral grade 4 VUR. Conclusion An association between VUR and stone formation occurs in very young children and appears incidental rather than causal. Metabolic factors play a more significant role for stone formation. Children with stones need not routinely be subjected to a VCUG.

Randomized controlled trials (RCTs) are at the top of the pyramid of evidence as they offer the best answer on the efficacy of a new treatment. RCTs are true experiments in which participants are randomly allocated to receive a certain intervention (experimental group) or a different intervention (comparison group), or no treatment at all (control or placebo group). Randomization, along with other methodological features such as blinding and allocation concealment, safeguard against biases. This review will focus on parallel group RCT design as it is the most common design in the field of Pediatric Urology. RCTs can be designed using a superiority, equivalency, or non-inferiority hypothesis, and are usually preceded by a pilot, where the trial protocol is implemented in a small number of patients, mimicking the larger, definitive study. Even though regarded as the best available option to bring out scientific data, RCTs might be prone to mislead. If RCTs are small and underpowered, a difference of even one single event between groups, may completely change the trial results. To safeguard against RCTs weakness, a fragility concept of statistical significance was developed and called the Fragility Index (FI). RCTs may not be appropriate, ethical, or feasible for all surgical interventions. They may have limitations such as prohibitive cost and unrealistic large sample sizes. Nearly 60% of surgical research questions cannot be answered by RCTs. Therefore, clinical practice should be based on the best available evidence on a given topic, regardless of the study design. However, even in these situations, conclusions drawn from observational studies must be interpreted with caution.

This educational article highlights the critical role of pediatric urology nursing research in improving the care of children with urological conditions. It discusses the multifaceted nature of pediatric urology nursing, addresses challenges such as limited nurse scientists and resource constraints, and highlights the need to overcome barriers to increase research involvement. The authors emphasize the importance of prioritizing research areas, the promotion of collaboration, and the provision of adequate funding and academic time for pediatric nurses to contribute to evidence-based practice, to improve patient outcomes. Furthermore, it highlights the importance of research in advancing nursing practice, shaping protocols, and advocating for the rights and needs of children with urological conditions and their families.