Best of the 2017 Society for Pediatric Urology Fall Congress

Meeting Review Best of the 2017 Society for Pediatric Urology Fall Congress Highlights From the 2017 Society for Pediatric Urology Fall Congress, September 8-10, 2017, Montreal, Quebec, Canada [Rev Urol. 2018;20(1):28–30 doi: 10.3909/riu0788] ® © 2018 MedReviews , LLC KEY WORDS Hypospadias • Urinary tract infection/vesicoureteral reflux (UTI/VUR) • Enuresis • Varicocele • Disorders of sexual development (DSD) • Bladder exstrophy • Bladder augmentation and diversion • Clean intermittent catheterization • Ureteropelvic junction (UPJ) obstruction • Bladder and bowel dysfunction T he 5th Pediatric Urology Fall Congress was held on September 8-10, 2017, in Montreal and was well attended by pediatric urology specialists. The scientific program covered the latest developments in the field of pediatric urology including hypospadias, urinary tract infection/vesicoureteral reflux (UTI/VUR), enuresis, varicocele, Disorders of sexual development (DSD), and tumor, stones, and nephrology. Highlights of the program included the American Association of Pediatric Urologists (AAPU) Lecture, “How Do You Know Your Clinical Results Are Valid? 30 Years of Reconstructive Surgery at Indiana University,” presented by Richard Rink, MD; the Society of Fetal Urology (SFU) panel entitled, “Prenatal Intervention in Spina Bifida”; a panel discussion by senior surgeons entitled, “My Worst Complication and What It Has Taught Me”; and “Non-CAH DSD: What to Do With These Gonads?” Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Urology, NYU Langone Medical Center, New York, NY The American Academy of Pediatrics (AAP) Lattimer Lecture, “Disorders/Differences of Sex Development (DSD): A World of Uncertainty,” was presented by Eric Vilain, MD, PhD. The Society for Pediatric Urology (SPU) Lecture, “Cloaca,” was given by Marc Levitt, MD, and on the following day, there was a panel discussion entitled, “Cloacal Exstrophy: Complex Problem With No Easy Solution.” The 2017 AAP Urology Medal was presented by Bernard Churchill to Gordon McLorie (May 2, 1945-February 2, 2015). Dr. McLorie was Professor of Urology in the Division of Urology at the Children’s Hospital of Orange County at the University of California, Irvine. He graduated from the University of Toronto Medical School and completed his residency in urology at that institution in 1976. He completed fellowship training in oncology and transplantation at the University of California, Los Angeles, and then returned to Ontario in 1977. Several years later, he was a fellow with Dr. Hardy Hendren in Boston and joined Dr. Churchill at Toronto Sick Kids to create a very strong pediatric 28 • Vol. 20 No. 1 • 2018 • Reviews in Urology 4170018_06_RIU0788_V1_rev03.indd 28 4/20/18 10:23 PM Pediatric Urology Fall Congress urology team for many, many years. Gord, as he was fondly known to his friends and colleagues, trained 50 fellows in reconstructive surgery and renal transplantation and had a significantly positive influence on students and residents who were fortunate to experience his mentorship and “Gordiesms.” Dr. McLorie published more than 200 peer-reviewed articles and was active as a member or held an elected position in all the major pediatric urology societies. He was the President of the Canadian Urological Association in 2001. Dr. McLorie was promoted to Professor of Urology at the University of Toronto in 2003 before moving to Wayne State University, Detroit, as Director of Pediatric Urology at the Children’s Hospital of Michigan. In 2006, he joined the group at Wake Forest University, and he subsequently joined Dr. Antoine Khoury at the University of California, Irvine in 2012. Dr. McLorie was an early proponent of discontinuing antibiotics for reflux in a select population and of needle biopsy followed by chemotherapy for Wilms tumor (WT). He will be dearly missed by family, friends, and colleagues, but his influence will be everlasting. Clinical Research This year’s First Prize for Clinical Research was awarded to Konrad Szymanski and the Pediatric Urology Midwest Alliance group for their 36-year retrospective cohort study on bladder augmentation, diversion, and clean intermittent catheterization in classical bladder exstrophy. The objective was to provide insight into the need for bladder augmentation and diversion (RAD) after primary closure or clean intermittent catheterization (CIC) in a multi-institutional patient group; most of the literature reports on single-institution experiences. The retrospective cohort involved children born between 1980 and 2016 with classic bladder exstrophy with more than 1 year of follow-up. The primary outcome was RAD following primary bladder closure. A subgroup analysis included RAD after bladder neck surgery. A secondary outcome evaluated individuals on CIC at their last follow-up. There were 210 patients, of which 62.9% were boys and median follow-up was 13.9 years. Only 4 (1.9%) patients underwent primary diversion, whereas the remainder underwent primary bladder closure, most commonly (71.4%) within the first week of life. Of those undergoing primary closure, 104 (50.5%) were augmented and 11 (5.3%) were diverted (continent diversions, ureterosignmoidostomies, conduits). Bladder neck procedures (BNP) were performed on 67%; of those, 26.1% were also augmented at the same surgery. The probability of undergoing RAD after primary closure was 14.9% at age 5 years, 52.0% by 10 years, and 72.1% by 18 years. The probability of RAD varied significantly by institution but was not related to birth decade. At 5 years following BNP, the probability of RAD was 43.1%. At the most recent follow-up, 65.7% of patients perform CIC; this is not related to age, and almost all patients with an augmentation perform CIC, mostly via a catheterizable channel. Of those 91 patients with an intact native bladder, 29% perform CIC, most commonly through a channel (73.1%). One hundred four augmented patients with available follow-up perform CIC, primarily through a catheterizable channel (87.1%). Of the 71 adults with either an augmentation or native bladder, 86% perform CIC, 100% of those with an augmentation and 29%, with a native bladder. In total, 15 patients were diverted. The authors show that RAD increased with age with 50% of patients being augmented or diverted by age 10 years and the majority by adulthood. About 29% of patients with a closed native bladder require CIC. Only 14% of all adults did not require CIC. The Second Prize for Clinical Research was awarded to The Cohen Children’s Medical Center for their work on the effects of ureteropelvic junction (UPJ) obstruction on the contralateral kidney using sonographic heterogeneity. This technique has been previously reported by this group. Using a heterogenicity index (HI), the study evaluated the use as the patient’s normal kidney as an internal control versus the pyeloplasty renal unit versus two normal controls. Pre- and post-pyeloplasty measurements (116) were taken in 58 patients who were age matched to 2 normal controls (except for 2; therefore, 114 normal controls). Pre-operative HI in the contralateral kidney was significantly higher than post-operative HI, either mean 50 days prior to stent removal or mean 131 days following surgery, in the contralateral kidney. When compared with normal controls, HI was higher in pre- and post-surgery contralateral renal units. In the pyeloplasty with stent, the HI normalizes to the contralateral kidney but not to normal controls. Therefore, the contralateral kidney may have an intrinsic physiological change or hyperfiltrating and should not be considered a “normal” control. Although the HI is interesting, our group uses improved resistive index and end-diastolic flow on the arterial spectral waveform in the previously obstructed kidney as an internal measure of improvement for the short- and long-term follow-up Vol. 20 No. 1 • 2018 • Reviews in Urology • 29 4170018_06_RIU0788_V1_rev03.indd 29 4/20/18 10:23 PM Pediatric Urology Fall Congress continued sonograms of our patients undergoing pyeloplasty. The Third Prize for Clinical Research was awarded to the University of California, San Francisco (UCSF) group who reported on risk factors in patients with VUR for the development of bladder and bowel dysfunction (BBD). Using the Randomized Intervention for Children With VUR (RIVUR) and the Careful Urinary Tract Infection Evaluation (CUTIE) trials, secondary analysis was performed and patients with existing BBD or with an unknown status of BBD were excluded, as well as those not potty-trained at the end of the trials. The outcome of interest was the development of BBD. Independent effects of sex, body mass index (BMI) at baseline, cohort status (RIVUR vs CUTIE trial), continuous antibiotic preventative, and reflux status (dilating vs nondilating) on the development of BBD during 2 years of follow-up. Inclusion criteria was met by 317 patients, most of whom (94%) were girls with a median baseline age of 21 months (range, 11-35 months) and 75% of whom were not potty-trained at the start of the study. Other characteristics of the group included a mean BMI of 64, dilating reflux (almost 50%), and inclusion in the RIVUR trial (75%). BBD developed in 111 (35%) and were more likely to be girls. Baseline BMI and antibiotic prophylaxis were not related to the development of BBD and patients with dilating reflux were 2.2 times more likely to develop BBD. This study emphasizes the importance of educating parents not only about VUR, but also about ways to optimize bowel habits of their child prior to potty-training, and voiding habits at potty-training to possibly minimize the number of children who develop BBD. An important retrospective cohort study from UCSF evaluated whether contralateral hypertrophy (CH) compensates for renal loss in patients with solitary kidneys due to a multicystic dysplastic kidney (MCDK) or WT. In addition, these investigators asked if CH persists overtime. Only patients with more than 7 years of followup with MCDK and those following nephrectomies for WT were included to determine the natural history of CH. CH was noted when there were 1 to 2 standard deviations above normal mean kidney lengths. A sub-analysis was performed on patients in the UCSF medical records who had a creatinine level and a renal length in their record. Of 85 patients, 56% had WT and 44% had MCDK with mean followup of 7.5 years. About 50% of the WT patients had CH at the time of surgery and 24% of the MCDK patients had CH at diagnosis. Long-term follow-up demonstrated CH in ,50% of WT and MCDK patients at about 1 year post-operatively and 3 years following diagnosis, respectively. Sub-analysis in 70 patients showed that as renal length increases by 1 cm, creatinine clearance increased by 8.2 after adjusting for age. The authors conclude that CH, once it occurs, is permanent with no evidence of hyperfiltration during the cohort study period, but should be monitored into adulthood. In addition, renal length directly correlates with creatinine level. References 1. 2. 3. 4. Szymanski KM, Fuchs M, Mcleod D, et al. Bladder augmentation, diversion and clean intermittent catheterization in classical bladder exstrophy: a 36year multi-institutional retrospective cohort study. Presented at Annual Pediatric Urology Fall Congress; Montreal, Quebec, Canada; September 9, 2017. Morganstern BA, Wu W, Vasudevan V, et al. Ureteropelvic junction obstruction affects the contralateral kidney: a novel investigation of sonographic heterogeneity. Presented at Annual Pediatric Urology Fall Congress; Montreal, Quebec, Canada; September 9, 2017. Gaither T, Cooper C, Komberg Z, et al. Risk factors for the development of bladder and bowel dysfunction. Presented at Annual Pediatric Urology Fall Congress; Montreal, Quebec, Canada; September 9, 2017. Gaither T, Wang MK, Baskin LS. Does contralateral hypertrophy compensate for renal loss in patients with solitary kidneys? Presented at Annual Pediatric Urology Fall Congress; Montreal, Quebec, Canada; September 9, 2017. 30 • Vol. 20 No. 1 • 2018 • Reviews in Urology 4170018_06_RIU0788_V1_rev03.indd 30 4/20/18 10:23 PM