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One. Yes. Uh now you can start sharing your screen so long. Um mhm. Now can you hear me one? Hold on. Yeah the I like to do that. The hello Neha. Can you hear me? Yes, I can hear you now. I'm OK. Good. Yeah um you can start sharing your screen so long. I'll do that. Mm OK. You can go to your first line. I just want to choose uh what I'm only gonna share because I figured this out not to show my note. OK. Now take your time. Yeah. OK. Prof are you just seeing my slides and not seeing in my notes? Uh just go to your 2nd and 3rd slide? OK. That's fine. No, no just see see a slide. Uh Pro Lazarus is going to be a bit delayed. We will just wait for another 34 maximum five minutes and we'll start late latest by five past five once other consult have joined. That's fine. Pro OK. OK. No. Right. Um Yeah. Yeah that's the one way to do. That is a bye. So I don't know um one for you, you something whatsapp or Facebook I meeting in past meeting in? Ok. Mm. May I have Doctor Mala joining in a minute? So as soon as he joins, we will start. Ok. Yeah. No one one. Ok, Neha, it's uh almost seven minutes past five. Doctor Mola joined. So, so we need to start. Uh So uh good afternoon everyone. Um today Doctor Neha Gautam, our registrar is going to talk about urinary tract infections and vaso reflux. And uh Professor John Lazarus uh from uh from University of Cape Town and Red Cross Children's Hospital in hospital will give his expert comments, but he will uh only be able to join in a short while. So I think due to a lack of time, we will just start with uh doctor Gather's presentation. OK? Neha go I see the now just a second. I see John Nazar joining. Let me just introduce him. Just give me one second one. Hello John. Hello John. Hello John. Can you hear me work? Yeah, they told me 11. I saw John Lazarus joining maybe just he's having connectivity issues. I will introduce to him before he starts giving these comments. I think may have probably it's time for you to start start it 10 to 10 past five. Ok. Go ahead. So good evening everybody. So my talk on today is on Pyle uric reflux and urine tract infections. The contents of this talk will be about the basics about urary tract infections as well as I've been covering important topics on the embryology, antireflux mechanisms and approach as well as well as medical and surgical management. So, to introduce a few basics about urine tract infections, the definition is any infection of the urine tract and it extends from the bladder and up to the kidneys. Causes are usually related to any type of bacteria originating from the large bowel or the stool. Improper hygiene techniques contribute to developing a uti also any residual bladder volume where there is poor emptying of the bladder can result in a medium for bacteria to grow and multiply any structure or function abnormalities of the urea tract also contribute to developing a uti. The risk factors associated with uti development are usually abnormalities in the urinary tract in a the party training period where there's incomplete voiding or incomplete emptying of the bladder and infrequent urination contributes to developing a uti and un um circumcised penis, any catheterization, previous uti as well as anatomical anomalies. So, the way the um spectrum of Children uh from neonate to old child present can present with the neonate in a very nonspecific matter where they may present with failure to thrive jaundice or even um symptoms without fever. As the child becomes older towards toddlerhood or an older child above two years of age, they then present with specific symptoms. These being fever, frequent voiding, dysuria, suprapubic, abdominal or lumbar pain that can be dictated on examination, the investigations or the approach to a uti is to look at the history. So a clear medical history needs to be taken questioning about the, is it the first episode of a UTI or the second episode of UTI? Were there any possible malformations of urary tracts in the pre and postnatal ultrasound screening? Were there any previous operations, a family history of reflux or reflux with the parents? Or are there any hi history or symptoms suggestive of constipation or the presence of bladder bowel uh dysfunction that I'll come later on and explain in the talk. The physical examination should be focused and should focus on uh palpa palpating a painful kidney, a palpable bladder. Is there any flank pain? Are there any stigmata of spinal bifida or sacro agenesis? And to have a careful look at the genitalia, looking for features of formosa adhesions, vulva or epidermatitis. And then you need to collect the urine. So in the neonate or the infant, that's not p not toilet trained, there are three ways of collecting urine. This is by means of a plastic bag on a on the clean genitalia. You can perform a bladder catheterization. The conta contamination rate is about 14%. And then ideally, the best form of collection of urine is a super pubic cathe catheter. This is the most sensitive method to obtain an uncontaminated urine sample in this age group and it uses a diagnostic field of almost 97%. And in the toilet trained group or the older child that's able to listen to instructions, you would want a urine midstream sample. So the way this is done is by cleaning the genitalia twice with soapy water retract the foreskin or the labia majora and minora and um ask the child to pass urine and you want to collect the midstream sample of the urine. And this way or technique reduces contamination to up to 8% and then you want to analysis the urine. So the way this can be done is by dipsticks and then microscopy where actually the urine undergoes certification. And you want to um review through high power magnification on how many white blood cells are present. Um Flow analysis looks at the particles in the urine and then culture looks at the exact organism that grows and its sensitivity to antibiotics. And then finally your um exam or investigations where you want to inv investigate any abnormalities in the bladder, the ureter or the kidneys, which we can find in about 37% of patients. And if present, we would proceed to doing a cystourethrogram, which is a VC VCG. The complications related to um uti S are abscess formation, acute kidney injury, generalized sepsis, even reoccurrence and then the management. So your choice of IV antibiotics or peri enteral antibiotics depends on the suspicion of urosepsis, especially in the neonate or the illness severity. Your choice of antibiotics are usually your first generation antibiotics. Usually we use ampicillin and gentamicin. You should base your choice of antibiotics on the strains and the environment you are in and change it as per your urine culture and culture results and sensitivity. Ideally, the duration of the antibiotics should be between seven and 10 days. It's been shown that if you use the antibiotics for longer duration, it reduces your chance of developing renal scarring chemoprophylaxis. So this is quite a controversial topic that I'll discuss later in this presentation. So the long term use of antibacterial prophylaxis can be considered in those that are high risk of developing a uti or those that are high risk of developing damage. As there are some published randomized controlled trials that have come through and they do not support the efficacy of antibacterial prophylaxis. And as I said, I'll discuss the controversies with regards to this last is the monitoring. So you, you, you should ree um expect a response in the 1st 24 to 48 hours if there's any delay, consider complications, obstructions collections or any resistant organisms. So this comes to the important invest uh question that why to investigate uti. So at least 50% of Children that have presented with a uti have some abnormalities of the urine tract system and of that group, um 35% present with some form of reflux. So this goes to my talk about vesica vesica ureteric reflux. So it's hives incidence is typically in males almost 30% and it's very common in the age groups of less than three months. With regards to the embryology, there's a problem with the U VJ junction. So the um uteric binding starts very early off the meso mesonephric duct. At least 4 to 6 weeks, the ureter gets incorporated into, into the urogenital um system. And then it places itself in its correct anatomical position. And this position is designed in a way that prevents passive reflux and acts as a compressive valve. But if this uteric budding takes place very early, this will result in a uric of orifice to be located very high and laterally with a short intramural um length. And this then um causes reflux. So there are three anti-reflux mechanisms that are identified that prevent reflux. The first is the functional integrity of the ureter, which means that u um urine passes um antegradely and opposes any form of reflux. The other one is the anatomical composition of the UVJ. So first, it's the intramural length which follows the ratio of fives to one. And then the way the ureter is fixed in two points, the extra versal and intravesicle points that acts as a compressive valve. And then also the complex muscle structure within the bladder um forms a deep Trigon that also prevents reflux. And then lastly looking at the functional compliance of the bladder. So the intramural ureter remains passively compressed when the bladder is when the bladder wall um is the intramural uter remains passively compressed by the bladder wall d during bladder filling. So, lastly, there are five grades of uh reflux um to look at that um is a international um grading system. So the first grade looks at reflux only into the non dilated ureter. The second one is reflux in a non dilated ureter pelvis. And the calices grade three is mild dilatation of the ureter, the pelvis and slight blunting of the forni. grade four is more dilatation of the ureter, the renal pelvis, the calices and complete obliteration of the sharp angle fornices but still able to maintain the papillary impression in most of the calices. And the last grade which is the severe form of reflux is gross dilatation and tortura of the ureter, the renal pelvis and the calices with actually no pu um impression present naturally reflux does actually resolve and it typically resolves in those who are less than one year of age, more in females in siblings that present with reflux and your low grade reflux. As I mentioned, the different grades in grade one to grade three. Also those that present with Asma in asymptomatic presentation during the prenatal period where hydronephrosis was diagnosed, they do resolve and also in the high grade. So, meaning grade four and five have a 25% chance of resolving. So, the American Urology Association had looked at 27 different reports and from their reports, what they did find when looking at 2000 Children. So there were factors they identified that where reflux would not resolve or where reflux would resolve. And what they identified that when there's bilateral reflux, there seems to be um slow resolution of reflux. But however, in the grades of grade one and three, reflux does resolve faster than grades three, grades four and five. So looking at the etiology and classification, um reflux can be classified into primary causes. The main reason is the deficiency in the function of the U VJ anti-reflux mechanism that I've described in this talk. And then secondary, it's the overwhelming normal function of the U EJ or there is a presence of congenital, acquired or behavioral in nature that is often the root. Then risk factors related to reflux are the age in gender. Mostly it's boys, any associated conditions like prune belly syndrome, spinal cord, spinal cord problems, neurogenic bladder, ectopic, kidney or renal agenesis. And then this comes to, to the discussion about bladder and bowel dysfunction. So any child that uh screens for sims or signs suggestive of constipation or overactivity of the bladder. It's important to screen these Children in the presence of a uti by treating the constipation and decreasing. Um the overactivity of the bladder. The reoccurrence or association with uti does um decrease. Therefore, um exclusion of any bladder and bowel dysfunction is strongly recommended in any child with febrile and or recurrent uti and it should be treated if there's an evidence if there's evidence of bladder and bowel dysfunction. So, according to the American Urology Association, they have a list of blood and bowel rehab methods um that you can look up what they mean by these um rehab methods. So the presentation in this group, so antenatally, they can present with prenatal hydronephrosis on an ultrasound, postnatally as I discussed, may present with the toddler infant or the older child can present with febrile uti no, no symptoms can present with urgency, urgent continence frequency. The investigations of choice is A VCU G, which is the gold standard. This will define the anatomical details and in deformities. And also you're able to grade the reflux an ultrasound. We'll have to look at the bladder ureter and the kidneys to look at any anatomical or structural abnormalities and then your renal scans. So ideally the A DMSA scan um helps to, you can all screen for acute pyelonephritis. At the same time, it can function as a baseline to look for renal scarring. And then you can follow up with other D MSN S to see how your, your renal scarring worsens or improves. If that's not present in your facility. You can use a max three scan, which is an indirect measurement of reflux. And at the same time, you can look at the split function of the kidney and how the kidney excretes and then urodynamics. This plays an important role in secondary reflux as I've defined in usually in your patients that have some form of spinal cord issues like spinal bifida or neurogenic bladder. The other important parameters think about is the somatic growth of the child ie that you actually take the height of the child and see if they're growing hypertension screen their BP. Make sure that you always have a BP as a baseline and always monitor their BP. Look at their renal function by means of the G fr or the creatinine. And then at the same time, every time you see them, you send off urine for culture and sensitivity. So the complications related to this is that with reflux, you have an accent of microorganisms that actually reflux from the bladder and into the kidneys. And with reflux, this will increase your risk of a febrile uti. And every time you have a um the presence of a uti, this will increase your risk of renal sca scarring. And then this follows the concept about reflex reflux nephropathy, that the chil that 60% of Children will develop hypertension and eventually the end of the disease process is endstage renal disease. So with the management of reflux, unfortunately, we don't really have good scientific evidence available to actually give us clear cut guidelines on the conservative and surgical management. We still lack a lot of prospective randomized controlled trials. So rather we are gonna follow the recommendations based on European and American urology societies. And this is what they have to recommend on the management. So the goals of management are to prevent your recurrent febrile uti S, as I've said, every time you have a febrile uti that increases your chances of renal scarring and hypertension and endstage renal disease. You want to prevent renal injury and you want to minimize morbidity of treatment and you want to follow up these patients. So the management options are divided into two groups. First thing is conservative where you can actually surveillance these patients and wait and watch. And then as we described and discussed about the bladder and bowel re uh rehab, you want to obviously screen for lower U tract symptoms and treat these patients and then the role of continuous or intimate antibiotic, prophylaxis that I'll discuss shortly and then surgery and your options are endoscopic, open surgery or laparoscopic or robotic surgery. So now when it comes to the controversy with it related to continuous antibody prophylaxis. The reason why it was firstly considered is that the idea is that if you sterile the urine, if you reflux sterile urine, it doesn't cause any renal damage. And it was typically used in the night where there was the longest retention of urine and the highest concentration will be maintained in the bladder. But however, studies have come through and have demonstrated no benefit from this method. Here is a, a table of all the different studies that have been done in the past and the latest study that we still have and still looking at is the review trial. Uh It stands for randomized intervention for Children with a fascial uric reflux study. It's a multicenter double blinded study. And they basically randomized two groups, there were 600 Children who were randomized into those that received prophylaxis and those that didn't receive prophylaxis. And what they found was the group that was given prophylaxis actually showed some benefit in developing a recurrent uti. However, these Children were followed over two years and they looked for signs of renal scarring on a DMS A scan. And what they found was there was actually no benefit in the two groups. So both of them had an incidence of 8% of um renal scarring. So looking at other um different studies, a large meta analysis of Children was done where they almost had collected two hun 2300 Children. And they also said there was no benefit of using continuous antibody prophylaxis. Another liter review had looked at Children very young age, almost two months to two years of age and still showed no benefit. Then I come to the Swedish reflux trial, quite a popular trial where they actually took about 200 Children. They were 100 and 28 girls and they were 75 boys and they basically divided the groups into prophylaxis, endoscopic treatment and surveillance. And then they followed these Children over a 1 to 2 year period and they performed um VCG S, they performed a DMSA scan, they looked at the bladder function. So the results were as such. So you can see the Red Witches girls had obviously the worst outcome of developing febrile UTI S in each of the groups. So if they were surveillance, they had the worst choice chance to developing febrile UTI S. But if you look in the group of prophylaxis and surveillance in the boys, the blue, you can see that it's not really significant. It didn't really show any benefit by giving prophylaxis in the boys group. And as we've said, boys are the ones that have the highest reflux and the um highest incidence of reflux is in that population. So to summarize who actually needs continuous antibody prophylaxis, the rep the recommendations are your high grade reflux 3 to 5, your high risk patients, which we said the girls, those that are young and those who present with your lower, your lower urinary tract symptoms with reflux until they're actually toilet trained. You'd want to consider giving them prophylaxis and then looking at the circumcision status. So according to the American Urology Association in 2016, they actually said that there's a 12 fold increase of develop, developing in an uncircumcised, uncircumcised uh male. So they actually recommend um circumcision in boys less than one year, obviously who are on the higher risk groups. So I want to just stress. It's important to discuss with family, the advantages and disadvantages of continue antibody prophylaxis because it has its benefits in some group of patients and it doesn't have its benefits in all group of patients. And also the um issue about resistance is a problem. And then when I, when would you consider um surgical intervention, there are specific indications. So your breakthrough infections on continuous antibody prophylaxis or noncompliance, your high grade or grade four and grade five with an issue of renal scarring or decreased renal function. If there's failure of renal growth and if there's persistent reflux with puberty, approaching in girls and affects their growth. The options are multiple from endoscopic to inter and extravesicle approaches. So I'll be only um talking about approaches, the surgery interventions. So, endoscopy, what, what's known as a sting um operation or sub uric injection of bulking materials and basically on this picture, um the material is injected below the uric orifice and it acts as a way to actually close that terric orifice and minimize reflux. And the agents that used to be used were teflon paste or PTF E it was re relatively inexpensive but it had problems with migration. So therefore, they abandoned this. The modern day products used today are macroplastique and deflux. So, deflux is commonly used. It's actually preferred as it's a biodegradable product and it's encased with fibroblasts and collagen that in stimulates a inflammatory reaction. The su su success rate is between 50 to 92%. But the problem is that um it's costly. Um, the endoscopic approach is more beneficial in the groups with low grade reflux and doesn't really show any benefit in high grade reflux. And often as much as you repeat it one or two or three times, the reoccurrence does increase. It actually doesn't show any benefit after multiple times of increased using it, then when it comes to open surgery. So the principles of open surgery are to increase your submucosal tunnel length to the ratio of fives to one. And the success rate is a good of more than 98%. So, the different types of um approaches are intravesicle, which just means inside the bladder or extravesicle. And I've listed a few um few operations that can be done through the supra heal and infra heal approach. So, the principles behind a successful ureteral reimplantation are that you want adequate exposure of the ureter and you want to mobilize it, you want to preserve its blood supply. At the same time, you want to create a long submucosal tunnel length um versus the ureter uh diameter ratio that exceeds force to one. And you want to prevent angulation and twisting when you do your anastomosis. So the one I'll be describing is the colon crossed tr Gonal infra vesicle Infra Hyal approach, which means you actually have to enter the bladder. So the first stage is is that you actually intubate. Um the ureter, you can use a small feeding tube. You can use a size 34 or even up to eight, depending on the size of the ureter. You want to actually um immobilize the ureter ph with attachments and preserve its blood supply. And then you want to create a submucosal tunnel as seen over here where you start from the lateral aspect and you bring it across the midline and they cross the two, the each side crosses. And then you want to actually push the, the ureter through the submucosal tunnel. And the you're following the ratio of more than four is to one and complete your ureter. Um anastomosis. You would need to leave a double J stent in these um ureters, you need to drain the bladder and then I think, keep the J just, you keep the stents for about 10 days. And the advantage of the co cross tral um approach is that it's simple, it's relatively safe and safe and it has a success rate of more than 95% with minimal invasive surgery, laparoscopic and robotic approaches have been tried. They should actually be considered to be successful and quite easy to do and also have less morbidity. But the problem with your minimal invasive surgery that in, in when it comes to ureteric implantation is that the procedures are very long. There's a steep learning curve and there are a lot of technical challenges. The procedures that have been attempted are the extravesicle reimplantation. This is the Gilbert procedure. So to conclude my discussion, I decided to look at a full um conclude, uh look at a summary of what I've described of the management and the approach of reflux. And I've divided into two groups. So in the group of less than one year of age, you would have anti anti diagnosed hydronephrosis, you would opt to do an ultrasound after 48 hours in the postnatal period, document your AP diameter and later on produ pro perform a BCG, then you need to grade the reflux. So in the low grades, these are the group that you can follow at 36 and nine months with the higher grades obviously require regular follow up. And this is the group you would choose to give continuous a uh continuous antibiotic, prophylaxis. And then those that present with dura sepsis like the neonate you would admit to with IV antibiotics, perform an MCU uh perform AMC unit and actually send it off for um culture and also estimate the G fr. And at the same setting, you want to do an ultrasound to look for any abnormalities as well as hydronephrosis. Later on, you perform a VCG, you grade your reflux and then consider doing either if a DMA scan is available in your facility or a mag three scan to check the function as well as the excretion of the kidneys. If you have a, a patient that has repeated UTI S consider secondary reflux and then consider urodynamics in this group and then in the child over 1 to 5 years of age. So they, technically they, they typically present with febrile uti S. You want to do a clear history and examination? Sorry, I don't, I don't know what happened. Yes. Yes. Sorry. Ok. Yeah, no problem. Start. Yeah. Start where you were there. Ok. So, um I'll go back to the group of 1 to 5 years of age. Yeah. So they present with febrile UTIs. You want to examine, take a history, send off your urine, check their BP, the GFR and the renal function and treat with IV antibiotics. The imaging would be an ultrasound to look for features of hydro nephrosis or any structural abnormalities. I don't know why. Ok, there we go. You want to grade your, um, your reflux by performing a BCG. So your low grades, grades 123. These are the asymptomatic group. If they present, you want to wait and watch and follow up these patients even annually. But those with high grade reflux, more than four, you'd want to follow them up every six months and consider giving them continuous antibiotic prophylaxis. Lastly, if the grades are more than 4 to 5 and present with a breakthrough, the indications that I described it a breakthrough. Um Febrile uti you were gonna consider um surgery in this group and then once again, if they present with multiple UTI S consider again secondary um causes of reflux and therefore urodynamic studies come into play. Thank you. And this is, are my, these are my references. OK. Neha. Uh Thank you very much that, that was quite um an elaborate talk uh on a, on a very complex uh subject. And, and you had collected a lot of information and you tried to compress it in, in the 30 minutes which you were allocated to you. So um now I will actually formally welcome Professor John Lazarus, who uh is uh a professor of uh Urology and Head of Division of Urology at University of Cape Town and uh S Hospital at Red Cross Hospital as well. And he is the in charge pediatric urologist at Red Cross uh Children's Hospital in Cape Town. And uh Professor John uh has a strong uh personal and professional connection to East London. He has also worked in our department for a short while many years ago and he has always been um um guiding us and helping us with complicated cases which we have been sending to him uh over these years. So John, I formally welcome you and uh and request you to give your expert comments about uh about uh uh the topic uh in addition to your comments on presentation. But I think your, your valuable thoughts about this uh this complex topic of UTI and where you are uh Professor Chit. Thank you very much for that, very generous introduction. Uh um It's a very strong team you've got there, my goodness. Uh uh And uh congratulations uh to Doctor Gautam for a very good uh overview, very sound solid and uh well put together. Um I can make a few comments but uh I'm sure there might be some questions from some of the other colleagues who have some questions for Doctor Gautam. Yes, please, please. I'm sure Doctor Majola has got something to ask. Uh I see him there on the list. Yes. Uh He, he is there. Uh We have decided that you will go first for the comments. Then Professor Colin Lazarus will go after you and then Doctor Moola. OK. Very good. Um II think that uh uh firstly to say that it is a topic that has evolved quite dramatically over the years is the psych ureteric reflux. And um many of the things that one presents now are slightly outdated and some of the things that one report were cutting edge very soon uh have become outdated. And I always tell my colleagues it's a bit like prostate cancer and maybe that doesn't mean too much to pediatric surgeons, but prostate cancer has got a bit of a bad rap because urologists have been very good at diagnosing it. And we have as a result overtreated uh prostate cancer. And my conclusion and much of the reading uh to do with uh primary vasu reflux is that it's a condition that we have, uh, tended to overdiagnose and tended to overtreat and I don't want to sound nihilistic about it that we shouldn't be doing that. But I think that uh many of, uh, the stats that we took from the earlier studies, uh, the famous pediatric urologist from Great Ormond Street is Philip Ransley and he's kind of the father of, um, reflux research and he was able to show that reflux on its own in the pig kidney was a little consequence. But reflux plus infection resulted in chronic pyelonephritis hypertension and renal failure. And that panicked us as doctors. We thought my goodness, this is awful. One or two parts of infection, you're going to end up in renal failure. And another famous pediatric surgeon from England uh called Patrick Malone from Southampton. He had the Malone continence enema. He was able to show that um the number of patients in a, in a million Children who actually end up in renal failure. And I haven't got the exact number to hand, but it's actually a tiny number. And it tells us the story that perhaps uh only a small number of patients really going to suffer terrible consequences uh from uh the reflux added to. That is a lot of medical uncertainty. We don't know if that original work from Philip Ransley is correct because it's been shown for example, that there are uh Children in utero who already have scars from reflux. So it's not only reflux plus infection. But reflux per se through a water hammer effect may in fact, uh cause trouble with the kidneys. And so there's a lot of basic signs of what you said, Doctor Goutam. The first is that collecting urine is not quite as easy as you suggested. Uh getting the child to go and give a midstream urine, that's fine for an adult. But obviously, most of these Children presenting are toddlers and they are going to need to have a bag put on rather than being asked to give him a stream urine. So we like a bag. It's a very simple thing and uh if it's positive, however, we would probably want to go on to do a uh a uh suprapubic aspirate or in our catheter to get a specimen, so you speak to the pediatricians. That's probably what they would would do under these circumstances. Um because the bag may be contaminated. So you do want to go and get AAA clean specimen. Uh So me, I hope this is all making sense. I'm happy to carry continued talking. Uh But also we can, I don't want to dominate too much. I think uh John, you have given uh an excellent uh insight or introductory remark. Uh So, so maybe we will have it uh as an interactive session. This is the first time we have invited um uh somebody from outside our department to give expert comments. So we are al also in a learning phase. So I think, let me invite uh Professor Colin Lazarus to give his thoughts and then we will go to Doctor Majola and then we can come back to you if that's OK. So thank you, Melin and th thank you, Naha. Um My contributions can be very brief at this point because firstly, because I missed a lot of the talk through my own incapacity with uh zoom mechanism in a new, on a new computer, which I apologize and I missed a fair amount of the talk. Secondly, because um II have AAA little corner of reflux that I I'd like to discuss, but I'd prefer to do that towards the end of the meeting uh with in relation to an interesting patient. So if I may, I would give the floor or the zoom or whatever we do give to uh Doctor Majola at this moment. Yes, go ahead and ko thank you. Ok. Thank you, Colin. Ok, Doctor Majola, please. Uh Doctor Majola has actually guided Doctor Gautam to uh to prepare the presentation and he is our de facto pediatric urologist in East London. Uh So please uh Doctor Moola give your comments and, and views. Uh Good afternoon everyone. Um Thanks nea for the talk, which we had a bit of a struggle to try and get it to fit the 25 minutes. Um The only things that I would like to just um sort of correct in her talk. So with the DMS A and A mag three scan. The, the, the mechanism or how the scans are done is also quite different. The DSM A is a more of a static scan. So that will only give you the uptake the concentration and the excretion. So you only basically look at renal scarring and um the differential within both the kidneys. The mag three scan as well is, is a scan for the kidneys as well to distinguish the uptake and the excretion. But it also tells you about any uh obstructions within the, the system. So, from the pelvis to the ureter and into the bladder, but it's not a scan to distinguish if there's reflux or not. That is just an afterthought or an aftereffect where, because it's a dynamic scan, you can actually see when the child is starting to pass urine. If there's anything that's coming out cause the scan is a dynamic scan, but it's never used just to see reflux. Then the other thing there that I would just like you to go through, just explain the mechanism of how renal scarring uh occurs in these kids who present with uti. So it's just basically the pathophysiology, I might have missed it or maybe just didn't go through it as we had spoken about during the week. Ok. So um it usually starts from um lower down. So, um from your ureter, it extends to your bladder and then to your kidneys. So every time you develop a febrile uti you can develop um sort of pyelonephritis, um then scarring and then hypertension is OK. So, so basically what? Yeah, so with that, the, the renal scarring itself, as uh prophet said, there's two mechanism, it can, what we call AAA water shot mechanism. So the amount of reflux that goes up to the kidneys can destroy the, the the cortex of the kidney. But in itself, if there's a fever or ut, the only time that you get scarring or damage to the kidneys, if you have a a PLO a pyelonephritis. So if you just have a uti and you are feverish, it doesn't mean that you're gonna get renal scarring. We have to have a confirmed pyelonephritis or infection within the kidney to give you those uh the scarring. Yeah. And then just on the minimal invasive techniques as, as much as it's a new concept. And also people are moving towards the performing certain uh procedures uh minimally invasive. It's a big learning curve and also only high volume centers will be able to uh sort of or who are skilled in laparoscopy to undergo these uh procedures because you need a lot of numbers to be able for a person to just to get sort of uh good comparable quality between an open and a laparoscopic um uh surgery. Yeah, I think that's my comments for now. OK. Thank you. Uh for, shall we say your comments? Uh John um II would like to uh ask you a couple of questions probably will be of use to, to each one of us um uh uh as, as everything in medicine around eighties and nineties, it was hard hit. You see a cancer and you give the maximum treatment you see reflux and you give maximum treatment. Now, the pendulum then later on, slowly shifted to doing minimum. Has the pendulum come to the center? Are we, do you think are we doing the optimum thing or the right thing for the patients who need that particular treatment for Reflux? Mm uh Well, that's an excellent question and perhaps I can come on to it. I just wanted to really highlight three things and I think what the question really relates to the third thing. The first question about Reflux is how do you investigate a uti the second thing would be related to how you interpret the literature, which II think is, is what you're talking about? Yes. So let's start with that first thing. Who, who and how are you going to investigate someone who's had a UTI and perhaps I can share what we do in Cape Town. Um This is from the famous, I don't know if people can see that the famous Red Cross um Red Book. And you will be aware that there is this debate between the top down or the bottom up and in days gone by, we were in favor I hope you can see that. Yes, we can see bottom down, sorry, the bottom down, bottom up was better. Uh The approach which involved an MC GMC G is an invasive thing you speak to radiologists. They don't like doing it. Uh It's a bit traumatic and certainly in older girls, it is certainly uh overly invasive investigation. And the pickup rate in a child who's had a UTI is pretty poor. So it's an investigation that has its place, but we don't do it as a routine. We prefer the top down approach and we rely very heavily on our pediatric radiologist because they are such superb ultrasonographer and they can uh pick up uh most problems very accurately nowadays with ultrasound, of course, ultrasound is a poor modality to look for, for reflux because only the very severe grades are going to be dilating reflux that you pick up on an ultrasound. But you know, if you've had a uti and you've got a normal ultrasound and you've settled. Um and you've got undilated upper tracts, I don't think there's any reason to go on to do mag three or to do an MC. And uh I think the literature would support that. However, if you've had a second uti or an atypical uti, uh then you would probably go on to do the top down approach, which would in our hands be omega three looking for scars. And the debate is whether you do that early or late, we tend to do it late. And in older Children, we will add on an indirect mag three to that. So we rely very heavily on nuclear medicine uh to investigate these Children. So this is quite an important thing because you're going to be sitting in the clinic and you're going to be faced with a child with a UTI and you're going to wonder what you should do. And I think this slide is very helpful to know what to do. Taking one step back if I may for a moment. Me, I think the key is for people sitting in the clinic is to have a classification for reflux. This is so crucial. Understand the difference between primary reflux, uh which Doctor Gautam beautifully explained with the tunnel, et cetera, et cetera uh versus secondary reflux, which is reflux where the problem is usually the bladder, either neuropathic or uh following uh posture, valves. And understanding that difference is is key. And I don't believe we see too many cases of primary reflux in South Africa because of the ethnicity issue related to it being a familial thing and it isn't as common as it is described in the books uh for the northern hemisphere. So you want to be very sure that you've got this case to be a primary psychiatric reflux. Uh doctor very well emphasized the importance of excluding bladder bowel dysfunction because if you've got dysfunctional voiding, you're also going to be having a, a degree of um secondary reflux. In which case, managing the reflux isn't the key, managing the dysfunctional voiding is the key with uh uh time voiding uro therapy, et cetera. Probably more important than whatever is happening at the V UJ. So Melinda, I think for the juniors, that's key to understand how important the history in the examination is to exclude uh causes of secondary reflux and to have this kind of schema in your mind. When you think of investigating that if there are no other questions or comments, we could perhaps come on to your question about um where the pendulum is is at the moment. Now, II think, I think that that you e emphasized it it very well John and you clarified um uh to to, to us and basically to the juniors which patients uh they need to be to be worried about and just to add on to your comment. Um uh Doctor Colin Lazarus has always been teaching and telling us uh that our patients don't read Western books. So I'm very glad that you, you um clarified that uh our patients do not have same incidence of reflux because we used to always wonder, are we not missing patients with reflux? Are our GPS and pediatricians not um aware enough to diagnose them? But you have partly answered that question for me. Um So, so I think at this stage, I will uh ask Doctor Gautam if she has any specific questions for Professor John Lazarus or Professor Colin Lazarus because she hasn't had a chance to take their advice. Yeah, I just want to ask in that uh flow diagram, what's an indirect um nuclear medicine scan is? What, what does that mean? Uh So you get the benefit of a cystogram plus you get the benefit of a nuclear medicine study. The nuclear medicine is MAG three which is almost as good as DMS A. Uh because it's able to show you scarring and you're able to get differential function and see that one kidney is affected by scars and has reduced function once that part of the scan is finished and all of the uh radionuclear has moved into the bladder, out of the kidneys into the bladder. You get the child to pass urine under the gamma camera just like a cystogram. And you're able then to determine whether there's reflux or not. So it isn't invasive in the sense of requiring catheterization. And I think that's its, its benefit in older Children. Mm OK. Thank you. Um It sounded like uh Colin had a case and I'm sure that's uh uh excellent uh platform for us to continue uh the discussion. Yes, I will invite him in a second. But uh uh ju ju just uh uh isn't it the principle mainly as minimal invasion, invasion during investigation as necessary? And um endoscopy treatment or surgery only when necessary? Isn't that the concept and the principle now. Yeah. Um, with avoidance of radiation mainly for VC, which is big amount of radiation. Yes. Sorry, a bit. Got confused. Emily, you're talking about treatment or investigations. Certainly, investigation. We want to use the Alara principle to avoid II think. Yeah, let's, let's focus on, uh, on, on the investigation just to emphasize to the juniors that, uh, avoid radiation as far as possible. And, uh, do VC OG in exceptional circumstances is that the correct teaching and the message look, I wouldn't want to be too dogmatic on that. It's certainly true that uh cystogram is far more radiation than a nuclear medicine study. But having said that it's also about what access you have to um facilities. If you don't have a very good nuclear medicine department, I should not be telling you not to be doing MC GS because they are excellent studies. They give you good uh information. OK. OK. I know we are lucky to have uh facilities of nuclear medicine, but uh certainly our radiologist, radiology, doctors and ultrasonographer are are not as experienced as you people have. The the advantage of at this stage. I will uh call back professor Colleague Lazarus to share his case and, and and give his uh advice and insight, please call him. So, thank you Melin. Um My case is from the from the other end of the spectrum. And um so this is a 13 year old twin girl th a 13 month old twin girl, she's thriving. She was born a lot smaller than her sibling and they are both doing well, although she's not quite caught up weightwise with the sibling. Now, at the age of three months, she was admitted to the hospital with a febrile illness. And amongst the things U GI was considered but not confirmed. Uh the urine substance was examined, did not confirm the urinary tract infection. But in the process, she also had an abdominal ultrasound done and surprisingly showed only a single left kidney. She was then investigated further at about the age of six months. And those investigations include and MCU. And that surprisingly showed grade grade five reflux through the dilated ureter into that single left kidney. Now, she had a mag three study done which showed a dilated but not obstructed left kidney. But they wondered on the mag three, whether there was a cortical defect at the upper pole of the kidney. So doesn't see that very clearly on a mag three as far as I'm aware. So subsequently, a few months after that, she in fact had a DMSA scan because one was concerned if that, that cortical defect was real, then the one remaining kidney had already been damaged. The DM SA showed possibly a tiny cortical defect. So she went home or she w she was has been at home the last six months. She's not had a urinary tract infection. She is well and growing and she's not been on antibiotics. She's now 13 months old. So in summary, she's healthy, she may or may not have had a urinary tract infection at an early age, but she has a single left kidney, a single left kidney through with reflux at a grade five level up to that kidney. So, what would be the principles of management? That's my question. Thank you. Thank you, Colin. I think Neha, you are best equipped to answer that question right now. You have done the reading. So um prof so I just to summarize. So she has high grade reflux, she has one kidney and we're not sure if she has renal scarring. So I would like to follow up. Maybe I would follow up in the next six months. I would perform another renal ultrasound. And what I would like to look for in the renal ultrasound is again the growth of the kidney, the quarter me. Um sorry, the, the cortical thickness, the ap diameter and if, if that looks relatively normal, I will still wait and watch if she does develop um features suggestive of hydronephrosis. Um The next investigation I would do is uh I'm more familiar with the mag three scan and I would like to see what's her function. Is there any obstruction? Is there any uh is there uptake and excretion? Is that good in that kidney? If there's nothing found on that investigation, I would still follow up um, regularly with another renal ultrasound. That would be my plan. So I would not intervene yet. I would rather watch and wait and do my investigations, noninvasive investigations. Ok. Uh, just one correction there. Uh, you can't say split function because she has got solitary kidney. Uh, so, uh, call in, you can, uh, just, uh, I don't know what, uh, whether you got the answer you expected or you would like to Dalas. Hello Colin calling. I don't know whether Professor Colin Lazarus is still connected or is having, having uh uh internet connectivity problems. Um Maybe because we are str uh struggling to get him in. Uh John. Can you, can you give your input on on Colin's question basically for there and for us. Sorry. One second John, I'm just unmute you. Yeah. Sorry. Yeah. II have admitted you now. Yeah. Yeah. Um perhaps I can take a little bit of a long view of the case before giving what I would say we would need to consider as a plan. You know, the first thing from the juniors point of view is when you hear that the child has been told that they have a single kidney, you can't accept the ultrasound is giving the definitive answer there. And a mag three or DMS a scan would be important because you would suspect that many of these kids are gonna have a pelvic kidney. So that was done and an ectopic kidney was excluded. Uh in this case, the second thing that uh Colin hasn't mentioned, uh is the bladder. In other words, we got to be 100% clear in our minds that this is a case of primary reflux. Uh And the reason why that's so important is because I personally have very been close to doing a co reimplant thinking this is a case of primary reflux. And I hadn't quite focused on the posterior urethra and it was in fact a boy and it was a subtle feature of the post urethral valve and uh that needed to be ablated before one contemplated anything fancy with the ureter. So be very clear in your mind that you're dealing with primary reflux and that there's not a secondary neuropathic or cum related problem. Um The second thing that I think is quite important to do in this sort of case is to get a baseline. GFR creatinine may be helpful if it's just a single kidney. Uh because I think you are wanting to find evidence of this kidney being in further trouble, which would push you towards doing something uh surgically. So baseline G fr would be important. And I must say, although we've spoken against continuous antibiotic, prophylaxis, I think a case like this of high grade reflux single kidney, I think you could make a reasonable case to the parents uh to offer them antibiotic prophylaxis because your argument would be that one further episode of urinary tract infection can potentially cause further scarring. And you'd really want to avoid that at all costs in this vulnerable uh kidney. The last thing I think is worth discussing is an understanding of the natural history of reflux. And if this is primary reflux by about two years of age, you'd expect that the reflux should have resolved. So the natural history of primary reflux is to resolve and it usually takes about two years. So that is also something you need to factor in to your decision making about what you're going to do. Uh With this reflux. I don't know if Collins there and soit hasn't got some pictures to show us because that's her mind uh about what to do. So I've spoken a lot of generalities but perhaps other people have got comments about what they think should be done. Uh No, I think uh I, I'll invite Doctor Majola in a second but uh I'm so glad that repeatedly you are emphasizing uh to all of us to rule out secondary causes of reflux. Even in a girl. I think that is very important message for us to remember before we plan a fancy operation of reimplantation or try and do an endoscopic uh procedure. Uh So that, that I is a very important message which we need to take home. Uh Please make comment about uh uh Doctor KK Lazarus's case. All right, thanks. Uh I was also just gonna say I will a more towards a more conservative uh management in the case of uh this patient um with regular followups, making sure that there's no other anatomical uh abnormalities, making sure that the kidney is functioning well. So that if you see there's any sort of uh problems earlier on, then you can intervene early. So instead of, oh, I'll say our normal in inverted commas follow up of six months or so. I would do it more regularly, maybe on a three monthly basis. And to make sure that the child doesn't develop any uh in urinary infections and also favor uti so always check the urine as well to make sure that it is sterile as well when they do come in. But my question just as a a divergent to prophy Lazarus uh to join if in this case, cause we were uh prophy colon has mentioned that there is some form of something that they see on the upper pole which they're not sure if it is scarring or not a scar. Would you then intervene in uh as to maybe uh endoscopic uh procedure or do a reimplantation just to try and protect the kidney? Let's say it is a scar that they have seen already in the upper pole. Yeah. Uh Do Majola. That's a very good question. And I think you're hinting that this child deserves uh intervention. I wonder if I can ask doctor Goutam to pull up her slide from the Swedish reflux study because I think that is quite helpful in the setting to know what to do. Yeah. I, I'm trying to make is that, can you share your screen again and put that Swedish study slide, please? I'll do that shortly. Yeah. Ok. So that's very helpful. I think the, the point that I want to emphasize with this study is that these were, um, Children who had high, more high grades of reflux, if I'm not mistaken, they weren't just ones and twos. Um And that bar chart shows very nicely the outcomes of those Children who are randomized to surveillance um prophylaxis or a antireflux procedure using uh deflux sting procedure. And what I take from this uh slide and I'm just trying to see what the uh the bar is there. I presume it's um can you tell us what the uh y axis is there? Doctor Gautam? Um I think that was um I think that was percentage of febrile uti versus the three groups. Prophylaxis. Endoscopic and surveillance. Yes. Yeah. Yeah. So look, II think we're offering Collin's child surveillance at the moment and you can see there's a pretty good chance of another uti uti so that perhaps isn't so appropriate. So your choice then comes between giving prophylaxis and um doing something endoscopically. And I would want to argue that doing something endoscopically is a good option. No parent likes giving their child a daily dose of antibiotic. And there are some concerns about long term antibiotics in the pediatric age group that you could look up endoscopic antireflux. Uh sting is a very simple, straightforward, uncomplicated day case with very little sequela uh in terms of complications. And you can see from the Swedish reflux study that it basically solved the problem. And so I'm very much in favor of telling um community urologists to consider offering this uh for Children who uh warrant it can't make the decision about who needs it. But certainly in terms of management, I think it's not a, a bad option for people who are not that familiar with doing coronary implants every single day or laparoscopic um square goi for that matter. Um And I would, the question that obviously comes back in, in Colin's case is, well, is it going to work in a child who's already got a grade five reflux? And there's some reasonable good evidence out there from a guy called Andy Kirsh from Atlanta in the United States. And uh he makes the point that although you may not cure a grade five reflux with a uh a sting procedure or in his case, he talks about the hi procedure which you can look up is slightly different. Uh, he says, although you may not cure the grade five reflux, you certainly reduce the grading. So it goes to a grade one or two after being grade five and it can be repeated this thing. Although certainly after the second sting. I think it's advocated that you don't do anything more after that. So I think that would be my answer in general terms uh to this child who is at risk with a single kidney who has very significant dilating reflux presumably. Uh and who has had a possible uti I would be inclined to, to treat if the parents are against. I would still encourage them to take continuous antibody prophylaxis. I think medic legally you would be backed up by the river trial if the child were to run into mischief later on. So that's a long winded answer. I'm sorry, Professor Chit. Uh No, no, maybe discussion, other people might have different opinions. No, no, I think, I think uh uh it's, it's a, it's a conned topic. So I think your answer is according to the topic. So it's not a straightforward road in ac but uh this is almost like Chapman's Big Drive. Um Unfortunately, we lost uh Professor Colin Lazarus, but I see he's back. Uh So Colin um unfortunately, we lost you for a while. But uh would you please give uh sort of your guidance to Neha about what is your approach to your patient and, and what is your basis for your approach, please? Yeah. Thank you, Meland. Uh Yes, II lost. I did not lose you but uh I was lost from you. Um So here we are. Um II, so I want to thank John very much for his comments. Um the need to, to assess uh the G fr and, and uh I think it, I think that's, that is valid and to remember that there may be even in this girl, something wrong with the bladder is also, I think very important that we be sure of that. Um So it happens, I saw this girl today for the first time in six months and um I've not uh had an opportunity really to spend time thinking about the management, but I know she's been free of urinary tract infections for those six months. And um I wonder even if she'd been on prophylaxis, whether she would have, in fact, um being free of, of infections, I think we have to be very careful before we assume that urinary prophylaxis does of necessity make a difference. Um So I will be seeing and talking to the family in the near future. Uh Yes, I do need, we do need a new ultrasound and that's easy to do with regard to see, to seeing that there's no further dilatation uh of the hydronephrosis in that kidney. Um I probably would want in the next few months to repeat uh the nuclear medicine study. Um But I'm not sure about the intervention and whether I would be justified in saying why don't we wait for at least one further urinary tract con one, at least one confirmed urinary tract infection before we do anything further. If we don't see any other deterioration? Yeah, it's just making a case. No doubt we'll talk about this a little more. Thank you. Thank you. Thank you, Colin. Um uh I will uh I invite John to, to just make a brief comment on that, but II don't think there is uh absolute right or absolute wrong if I understand it correctly. I think there can be, there can be uh support for, for uh each argument as long as it is carefully considered. And as John said, we have scientific basis for it and we consult uh and, and uh discuss with the parents. Uh So John, you can uh you can give your opinion on that and we have two questions also. So I think before we close, I would like to ask those questions to you. So maybe first your comment on, on, on uh Collin's plan if you may. Yeah, II think uh it's, it's a balance of um uh probabilities and risks. Undoubtedly. Uh this child would have some features that would prompt one to do something. But having said that the child has a uh undilated system if I understand Colin correctly, uh there'd be no further uti s the story of the initial uti and the scarring is in question and he's got the natural history on his side. The child has made the first year. He only, he has to hopefully get to the second year and things may well settle down. So I think uh U vil would be very helpful here to have educated parents who have dipsticks at home with some urine bags. It can be quite uh active to monitor for urinary tract infections and uh get it treated early before uh it becomes um a nasty pyelonephritis. Ok, John, thank you. Uh There, there are two questions. Uh so one question is from our medical officer, Doctor Pedersen and it's in the chat group. I'll just read it in primary vasic ric reflux. Is there a period where it will worsen first before starting to resolve or is any sign of worsening disease an indication to intervene? John, if you can answer that, please? Yes, I II don't know that, that we regard it as something that, that worsens. I think it's, it's, it's coming back to uh Dr Gautam reasons to intervene and many of those reasons that have traditionally been mentioned uh have in fact been questioned in terms of their validity. Uh For example, uh Children who are approaching uh adulthood who may become pregnant girls. Uh We wanted to intervene even if, if their reflux hadn't resolved. And that hard and fast indication has been called into question. So each of those things that you mentioned doctor and there's a fair bit of body of literature on all of them. Um But in general terms, high, higher grades of reflux Children who are not prepared to be um compliant Children who've got uh some vu J anomaly that might not going to resolve. Uh and uh those with evidence of scarring uh A and kidneys that are not growing would certainly be at much higher risk and push you towards intervening in primary reflux. Thanks Melinda. Any further questions? Mhm. Yes. Yeah. Sorry. Uh Sorry John. There is a question about w what is your opinion on H I hydro distension implantation technique? Yeah. So uh it was originally uh uh prem P, the famous uh Dublin and Barry o'donnell, I think, who devised a Teflon injection and they called it the sting from uh subtrigonal injection I think is what the acronym stands for. Um And the more modern version of that is something called the hip where you use the cystoscopes jet of water to open up the uh ureteric orifice line, the scope in many cases to get inside the ureter and then to inject the uh uh uh bulking agent at um six and 12 o'clock and hopefully coact uh I must say it's not always possible to do that. In which case, the sting is perfectly fine. Uh I haven't read anything in the literature that said one is better than the other. I think it's just uh evolution of the technique and it's about in your hands. What you can feel confidently that you're able to reproducibly get a coaptation of the uh the ureter. Uh John T. Thank you very much. I think uh this was extremely useful and this meeting just went in the way we wanted it to go, uh that we had half an hour of presentation, but uh almost another 45 minutes plus, uh of, of advice, opinion from experts. And we really appreciate you uh spending your time and, uh and sharing your thoughts and, and expertise. And unfortunately, uh we haven't managed to get you uh physically to be with our team uh for so many years, even though we both of us have been planning about it. But with this pandemic, at least we can get you invited into the virtual zoom meetings. So I really thank uh Doctor Gautam for her excellent presentation. Doctor Majola for advise her um all the way through. And uh Professor Colin Lazarus and Professor John Lazarus for their insight and for their uh expert advice and all the uh participants which come from as far as counting, not only in the Eastern Cape. So thank you all and have a good evening. The meeting is being recorded. So I will put the link on the group and anybody who wants to access it can can then access it afterwards. Thank you, John. Thank you everyone. We'll see you next time, John bye-bye. The big spots. Bye.