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BACKGROUND: Micturating cystourethrograms (MCUG) are the gold standard for evaluating vesicoureteric reflux (VUR). There is a growing consensus for increasing the threshold for performing MCUGs following urinary tract infections (UTI) in children. There are several varying guidelines. It is important to detect high-grade reflux in the setting of an UTI because of potential long-term complications. OBJECTIVE: This audit aimed to retrospectively: (1) identify the conformance rate of local guidelines at the Women's and Children's Hospital (WCH); (2) assess predictors for an abnormal MCUG; and (3) compare local guidelines against the Royal Children's Hospital, Melbourne (RCH), National Institute for Healthcare and Excellence (NICE), and American Academy of Pediatrics (AAP) guidelines for selectively detecting high-grade reflux. METHOD: The number of MCUGs performed from 2008 to 2012 at the WCH radiology department was collected. Patients undergoing MCUG during the 2012 calendar year were identified. Only children having an initial MCUG as part of an UTI investigation with prerequisite imaging as per guidelines were included. Each child's age, sex, referral source, reason, renal ultrasound (RUS) prior to the MCUG, MCUG result and VUR grade were recorded. The WCH guidelines were applied to determine conformance, to evaluate predictors for an abnormal MCUG, and compared against other retrospectively applied guidelines (RCH, NICE, AAP). RESULTS/DISCUSSION: There was complete data for 168 children who underwent MCUG as part of an UTI investigation (median age 0.79 years, range 0.12-8.74, male:female 67:101). There were 67/168 abnormal MCUGs (62 children with VUR, five bladder diverticulum), and 97 refluxing renal units (43 high-grade VUR units). No posterior urethral valves (PUV) were identified as part of the UTI investigation. A total of 143/168 patients had prior RUS (normal:abnormal 67:76). The WCH guidelines had 82% conformance. There was no statistically significant association between an abnormal MCUG and age, sex, referral source, reason, or prior RUS result. The WCH guidelines may have missed five children with high-grade VUR (four children had surgery), compared with RCH, APP and NICE, with 8, 15, and 17 children, respectively, having high-grade VUR (two, five, and five children had surgery, respectively) show in the Summary Table. The retrospective study had limitations and possible selection bias (children with UTI without a MCUG). There were no standard treatment approaches for VUR; hence establishing a MCUG guideline is difficult. An alternative is the top-down approach. CONCLUSION: Current institutional guidelines for considering MCUG following UTI in children vary considerably. The MCUG guidelines at any institution must take into account the local management guidelines for high-grade VUR.

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We describe a case of synchronous torsion of testicular appendages, a previously unreported cause of bilateral scrotal pain. Exploration and excision was curative.

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Thirty-six Australian Aboriginal children with urolithiasis were reviewed. Males dominated the series. The age distribution ranged from 8 months to 12 years and nearly 70% were 2 years or younger. Thirty-five patients had upper tract stones. Ultrasound was diagnostic in 35 patients and was falsely negative in one. Dietary factors, dehydration and recurrent diarrhoea are incriminated in the aetiology, because ammonium urate and oxalate were the main constituents of the stones. Malformations of the urinary tract were rare and known metabolic disorders were not seen. Chemical dissolution of the stones was found to be a safe and effective adjuvant in the management of urate stones.

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Xanthogranulomatous pyelonephritis (XGP) is an unusual chronic inflammatory condition which most often affects women in their 5th to 7th decades and is rare in infants. Predisposing factors include infection, calculi and obstructive uropathy. We have reviewed the surgical files of 4 cases seen over a 28 yr period from 1964-91. All of the 3 partial and one total nephrectomy specimens demonstrated typical features of XGP with renal parenchyma effaced by a mixed acute and chronic inflammatory infiltrate which included prominent aggregates of foamy histiocytes containing eosinophilic inclusions. No Michaelis-Gutmann bodies were seen. This study shows the association of XGP with chronic infection, anatomical malformation and reflux in infancy, and raises the possibility of a temporary altered immune response in its pathogenesis.

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Three girls with major urethral injuries following motor vehicle accidents are presented. Early diagnosis of this rare condition, which is often associated with vaginal injuries, is imperative and a cystourethrogram, examination under anesthesia and a cystovaginoscopy are usually indicated. Primary repair of these injuries is recommended and long-term follow-up is essential.

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We have previously described 3 types of lower urinary tract dysfunction in the congenital neuropathic bladder--contractile, intermediate and acontractile--accounting for 35, 40 and 25% of patients respectively. Subsequent urodynamic and surgical experience has shown that the intermediate type is commoner and the acontractile type less common than was thought. The contractile group accounts for 31% of patients and rarely requires surgery (a "clam" ileocystoplasty). The acontractile group accounts for only 9% but more commonly requires surgical treatment, usually the implantation of an artificial urinary sphincter (AUS). The intermediate group accounts for 60% of patients and usually requires surgery. If there is no significant sphincter weakness incontinence, a "clam" ileocystoplasty alone is performed; if there is sphincter weakness, a "clam and a cuff" procedure is performed with implantation of the remainder of the AUS at a later date, if required.

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Vesicoureteral reflux is the most common abnormality seen with complete ureteral duplication. The majority of cases require surgical correction. The techniques used in 62 patients with 71 duplicated systems with reflux are reviewed. Reflux into the lower pole was encountered in 51 duplicated systems, both poles in 19 systems and the upper pole in 1. A total of 42 conjoint ureteral reimplantations was performed but in 8 cases only the lower pole ureter with reflux was reimplanted after it was separated from the nonrefluxing ureter. Ipsilateral ureteroureterostomy was performed in 19 cases of lower pole reflux. Two patients underwent lower pole heminephrectomy. Satisfactory results were obtained by all 3 reconstructive techniques. However, for lower pole reflux we recommend ipsilateral ureteroureterostomy unless a contralateral operation also is necessary. Ureteroureterostomy proved to be a simple and safe operation free of complications, with little morbidity and requiring a shorter hospitalization.

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Urinary undiversion was performed in 21 male and 14 female patients with neurogenic bladder and an ileal conduit urinary diversion, 3-17 years after the original operation. Twenty-six patients had surgery for ileal conduit complications but nine had an elective undiversion. In 24 patients, reconstruction was achieved by ureteroureteric anastomoses, in six by ureteroneocystotomy and in five by primary enterocystoplasty. Transureteroureterostomy (TUU) was an essential part of almost all the reconstructive procedures. Secondary operations were necessary in 10 patients, seven of whom had an enterocystoplasty. Improvement or stabilization of the upper urinary tract was eventually achieved in all patients. Twelve male patients void normally with complete urinary control in eleven and incontinence in one. Eight male and all 14 female patients are managed by clean intermittent catheterization (CIC) with complete urinary control in 12, acceptable dampness in eight and incontinence in two. One male patient is managed by an indwelling urethral catheter. All patients showed an improved physical and emotional status and preferred life without a urinary stoma. Urinary undiversion should be considered in all patients with ileal conduit complications and in selected patients with an uncomplicated ileal conduit.

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One hundred and one children over 1 year of age have had surgery for pelviureteric obstruction over an 11 year period. The common clinical features were abdominal pain, urinary infection or haematuria, but a number presented as an incidental finding. Less commonly, the patients presented with an abdominal mass or with hypertension. The diagnosis was usually made on intravenous pyelography (IVP) but in the latter part of the series, renal nuclide scan (RNS) and ultrasonography (US) were preferred. Ninety-three patients had a unilateral pyeloplasty, three had bilateral pyeloplasty and five had nephrectomy or heminephrectomy. Whereas initially nephrostomy drainage was used in the majority of patients after pyeloplasty, a trend away from nephrostomy evolved in the latter part of the series. With experience, the incidence of postoperative complications was also reduced and there was a reduction in the period of hospitalization. Clinical results were consistently satisfactory. Postoperative assessment after pyeloplasty was made by IVP and/or RNS and also US. A review of these investigations showed that RNS provided more factual information of the result when compared with the IVP.

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