Malone antegrade continence enema: is cecal imbrication essential? The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation.
Laparoscopic excision of complete bladder duplication in a 1-year-old male Complete bladder duplication is a male predominant rare congenital malformation usually diagnosed at birth. Owing to the rarity of this anomaly, only few reports have discussed the surgical approach for this condition, with the open approach for excision being the most common. We hereby present a video of a laparoscopic resection of complete bladder and urethral duplication in a 1-year-old male.
Spiral Nesbit plication: A simple method for simultaneous correction of penile torsion and chordee (“spiral chordee”) Penile torsion and chordee may be corrected by a variety of techniques; however, when corporal body disproportion is involved plication may be necessary. Herein we describe a technique of placing oblique plication sutures to simultaneously correct both conditions, which we term "spiral chordee". The spiral Nesbit plication (SNP) has been performed on 21 boys at our institution. Median preoperative penile torsion and chordee were 49° (range 30–90°) and 35° (range 15–60°) respectively. Surgical success was 84.6% with two patients exhibiting mild residual chordee (15°) requiring no further treatment.
Re: “Paediatric cystolitholapaxy through the Mitrofanoff/Monti channel” We read with interest the recent publication by Thomas et al. [1] detailing the first series of 13 cases of paediatric cystolitholapaxy via either the Mitrofanoff or the Monti channel. Specific to this series no complications were reported and holmium laser fragmentation was used in one case only but the time range under anaesthesia is not reported. The authors allude to the paucity of data regarding the procedure and highlight the two reported cases in adult literature [2,3], one of which involved a spinal injury patient [3].
Commentary to ‘pediatric and young adult ureteroscopy’ In this article Kokorowski et al. investigated whether control of fluoroscope activation by the surgeon or technologist was associated with fluoroscopy time during endourologic procedures performed on patients age 5–26 years. They studied this via a randomized, controlled trial with five surgeons. Given the rising incidence of nephrolithiasis among children, and the potential long-term risks of the radiation they are exposed to as stone patients, both diagnostically and therapeutically, this is a very important topic.
Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of “genital autonomy” has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties.
Ischemic priapism in pediatric patients: spontaneous detumescence with ketamine sedation Priapism results from either a mechanical or neurologic dysregulation to penile blood flow. Pharmacologic treatment for ischemic priapism targets pathologic cavernosal blood stasis and thrombosis [1]. Priapism presents rarely in pediatric urology and initial conservative measures often do not restore penile blood flow to achieve detumescence. If invasive corporal irrigation is warranted, sedation is usually necessary in this population. This report describes a case series of observed corporal detumescence with administration of IV ketamine for procedural sedation, thereby avoiding corporal irrigation.
Outcome of end cutaneous ureterostomy (ECU) as a non conservative option in the management of primary obstructive megaureters (POM) Primary obstructive megaureters (POM) can be treated with one of the following options: conservative management with antibiotic chemoprophylaxis and active observation of the hydroureteronephrosis (HUN) until suspicion of renal deterioration; refluxing/non-refluxing ureteric reimplantation with antibiotic suppression; temporary double-J stenting; endoscopic balloon dilatation; endoureterotomy; and end cutaneous ureterostomy (ECU).
Commentary to “Who, where, and why are patients lost to follow up? A 20-year study of bladder exstrophy patients at a single institution” The authors [1] report on a series of complex patients with bladder and cloacal exstrophy. This is a large series for these rare diagnoses, and in this group 24% were lost to follow-up. The study identifies that the complexity of primary diagnosis and the number of operations are associated with follow-up. Interestingly, insurance and distance to the hospital were not associated with compliance. More troubling was the fact that there were patients with bladder augmentations who had not been seen in over 2 years.
Robotic-assisted laparoscopic ureteral re-implant (RALUR): can post-operative urinary retention be predicted? Urinary retention following robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) is proposed to be due to traction or injury of the pelvic parasympathetic nerve plexus during distal ureteral dissection. Nerve-sparing techniques have been employed to avoid injury to the pelvic plexus, either directly or indirectly. This single-center study assessed postoperative urinary retention rates after extravesical RALUR and investigated whether demographic or operative factors could predict this occurrence.
Salvaging the dehisced glans penis The glans penis may show a deep groove (surgically favorable), or may appear flat with an absent sulcus (unfavorable). Glans dehiscence following hypospadias repair, especially after multiple surgeries, frequently results in a scarred, obliterated, or absent urethral plate. The glans penis appears to be flat and grooveless. This study reported on the outcome of a two-stage salvage repair for glans dehiscence in 49 consecutive patients.
Back to the future: The Cecil-Culp technique for salvage penile reconstructive procedures Re-operative penile reconstruction is challenging and requires tension-free skin closure. The repair popularized by Cecil and Culp in the 1940s, using the scrotum to provide a temporary vascularized bed for complex hypospadias repairs, fell out of favor due to temporal trends towards single-stage repairs and concern for utilizing hair-bearing skin on the penile shaft.
Response to authors' reply Recently, we had correspondence with the authors of the article ‘Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party’ [1]. My aim is not to maintain a boring and useless discussion on minimally invasive surgery (MIS); however, I feel that I could not clarify my point sufficiently. While ‘decreased pain, better cosmetics, and decreased hospital stay’ are discussed, laparoscopic surgery-specific physiologic changes are not mentioned in detail.
Follow-up imaging after acute evaluations for pediatric nephrolithiasis: Trends from a National database Overuse of computed tomography (CT) in the initial evaluation of children with upper urinary tract calculi (UUTC) has been well documented. Follow-up imaging patterns, however, remain undefined. Sequential imaging following an acute episode of UUTC represents additional opportunity for enacting good imaging stewardship, with the optimal goal to reduce unnecessary radiation exposure and cost while ensuring appropriate follow-up.
Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery.
Effectiveness of caudal epidural block on interaoperative blood loss during hypospadias repair: A randomized clinical trial Intraoperative blood loss is considered to be an important issue in hypospadias surgery. Some studies have demonstrated the utility of caudal epidural block (CEB) in this regard among pediatric patients with hypospadias. Though there is evidence in favor of the use of CEB as the only anesthetic method for pediatric surgeries, it is usually used in combination with general anesthesia. In this form of use, it could have more favorable outcomes for both intra- and postoperative periods. There are few studies regarding the effectiveness of CEB on intraoperative blood loss.
Practice variation on use of antibiotics: An international survey among pediatric urologists Although there is abundance in literature focusing on the use of prophylactic antibiotics for adult urological procedures, the evidence for using antibiotics following common pediatric urological procedures is limited with no specific guidelines for use. Consequently, current practices on antibiotic usage for common interventions may be variable among practicing pediatric urologists, lacking evidence-based support.
Re. “Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes” We write to comment on the recent paper by Bush and Snodgrass [1]. We are not in the custom of writing letters to the editor; however, this paper gives an alarming message to many surgeons around the world who may apply the technique on children with narrow hypoplastic plates. Those children will eventually come back later circumcised, with serious complications, and the only option left is buccal mucosa graft which is not simple and can be associated with considerable complications. One-third of our practice is handling such patients with tubularized incised plate (TIP) complications (persistent fistula, stenosis, and inability to pass urine) referred from other centers and other countries, sometimes with supra-pubic catheters.
Commentary to “Ischemic priapism in pediatric patients: spontaneous detumescence with ketamine sedation” The article gives is a short communication regarding the use of ketamine for the treatment of priapism in four children in the pediatric emergency department, with erections lasting at least 8 h. While the authors were expecting to have to proceed with corporal irrigation, they documented that after sedation with ketamine, the penis detumesced in three, and the fourth required irrigation. It is interesting that the ketamine worked, even though the boys had sickle cell disease as the presumed cause of priapism.
Response to “Re. Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes” The clear message of our study is that pre-incision width of the urethral plate does not impact TIP urethroplasty results. This observation, made in consecutive boys undergoing hypospadias repair, is important for two main reasons. First, 86% of these patients had pre-incision widths <8 mm, which others have described as a narrow plate. If this was truly a contraindication to TIP, then only a minority of boys could have the procedure. Second, the fact that urethral plate width did not predict complications adds to our earlier report that neither does plate characterization as “flat” or “deeply grooved” (reference 5 in article).
Laparoscopic sigmoid vaginoplasty Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHs) is a congenital anomaly of the female genital tract that may require vaginal reconstruction. Laparoscopic sigmoid vaginoplasty allows adequate anatomic and physiologic functions that are essential for sexual-wellbeing. The goal of laparoscopic sigmoid vaginoplasty is a to create a functional self-lubricating vagina via minimally invasive procedure.
Hyaluronidase to reduce a prolapsed incontinent ischemic ileovesicostomy Stomal prolapse is a known late complication of urinary diversions commonly used in urology. While rare, it can lead to ischemia, necrosis, and obstruction of the stoma, requiring urgent reduction before formal revision can be undertaken. Several measures can be attempted to reduce the prolapse including manual pressure and topical osmotic agents. One method that has not been reported in the urologic literature is the use of hyaluronidase. Herein, we report the first case in the literature of hyaluronidase usage to assist in reduction of an ischemic and obstructed prolapsed incontinent ileovesicostomy after manual compression failed.
Influence of BMI in nephrolithiasis in an Appalachian pediatric population: A single-center experience The prevalence of pediatric nephrolithiasis has increased significantly in the past 20 years. Metabolic abnormalities predisposing adults to nephrolithiasis in obese patients include increased urinary sodium and uric acid excretion as well as low urine pH; however, limited data are available in the pediatric population.
The inadequate bladder template: Its effect on outcomes in classic bladder exstrophy Newborns with classic bladder exstrophy (CBE) may present with a bladder template that is inadequate for closure in the neonatal period (figure). In these cases, a delayed primary closure (DPC) is conducted to permit growth of the bladder template. This study reports the surgical and long-term urinary continence outcomes of poor template CBE patients undergoing DPC and compares them to patients who underwent DPC for reasons unrelated to bladder quality (i.e., prematurity, comorbidities, or a late referral).
A novel technique to construct a neo-scrotum out of preputial skin for agenesis and underdeveloped scrotum Congenital scrotal agenesis (CSA) is an extremely rare condition with fewer than 10 cases reported in the literature. These patients are often further complicated by undescended testicles as well as systemic developmental disorders. Herein, we report our experience and an innovative surgical technique for creation of a neo-scrotum in three children.
The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis The prevalence of primary monosymptomatic nocturnal enuresis (PMNE) has a range of 1.6–5.3% in adolescents and 7.5–12.4% in children of 5–10 years. Alarm intervention has been well known for more than 30 years. This method is a reliable and safe means of treating primary monosymptomatic nocturnal enuresis, being effective in 60–80% of cases.
Obituary – Sami Arap The laudation of the dead is a form of prayer for them(Machado de Assis, Brazilian writer)
Macedo procedure: A continent catheterizable ileum-based reservoir. Step-by-step video This video provides a case report of a 16-year-old male patient who underwent bladder enlargement with a catheterized conduit under Macedo's technique. This technique involves the use of a segment of the distal ileum with a flap that is used for confection of the conduit. Key points include: 1) skin incision planning; 2) bladder release to allow a tension-free anastomosis; 3) reservoir and a conduit creation with a distal ileum; and 4) creation of a continence mechanism.
Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide ‘pneumovesicum’.
External stent in laparoscopic pyeloplasty: The K-wire technique The majority of surgeons leave internal stents following laparoscopic pyeloplasty, which necessitates a second anaesthetic for removal. A novel technique of placing external nephro-ureteric stents, thus obviating a second procedure for retrieval, is shown in this video bank. As demonstrated in the video, a Kirschner wire (K-wire) is used to thread the stent in place. Although, there are few reports of using externalised stents in laparoscopic pyeloplasty, it is believed that this technique has not been previously described.
Re. “Diffusion weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study” The ideal evaluation for febrile urinary tract infection (UTI) in children remains a point of debate. The traditional approach - sonography and contrast voiding cystography - has fallen out of favor as, in this era of prenatal screening, patients now rarely demonstrate abnormalities on sonogram, as well as that fewer children presenting with febrile UTI have vesicoureteral reflux (VUR) than do not (approximately 40%). Various guidelines have parsed the available data on UTI and VUR by age, gender, presentation, and response to treatment in an effort to determine the ideal combination of tests for given clinical scenarios.
Feminizing genitoplasties: Where are we now? Feminizing genitoplasties (FG) are controversial, because of possible adverse effects on sex life. Some have suggested limiting surgery to children presenting health problems related to their genital abnormality and patients who may give their informed consent. This paper analyzes research data about late results of FG, to substantiate the choice of whether to operate on children or to limit surgery to adults/adolescents.
Historical bibliometric analysis of the top cited articles on vesicoureteral reflux 1950–2016, and incorporation of a novel impact index Vesicoureteral reflux (VUR) has been one of the defining conditions unique to pediatric urology since its inception. The clinical implications of this disease process depend on intrinsic patient factors such as age, genetics, epigenetics, voiding habits, anatomic anomalies, and extrinsic factors such as the pathogenicity of infectious agents. Knowledge about its natural history, the implications of conservative and surgical management, and their associated outcomes have evolved dramatically over time.
Hemorrhagic cystitis after hematopoietic stem cell transplantation: A challenge for the pediatric urologist Hemorrhagic cystitis (HC) is a serious event that can occur after hematopoietic stem cell transplantation (HSCT). Treatment goals are primarily to preserve life, and then the functionality of the bladder. There is no standard therapeutic approach for HC. Described treatment options provide low success rates and are related to potential life-threatening side effects. The aim of this study was to describe our experience in treatment of HC following HSCT.
Predominant bacteria and patterns of antibiotic susceptibility in urinary tract infection in children with spina bifida Urinary tract infection is more common in children with spina bifida (SB) than neurologically intact children, and Escherichia coli is the most common urinary pathogen in the general pediatric population. Less is known of the pathogens responsible for urinary tract infections (UTI) in the pediatric SB population or their evolving antimicrobial resistance patterns. The goal of this study is to determine the epidemiology and antimicrobial resistance patterns of SB-associated urinary pathogens.
A potpourri of pediatric urology The phrase “potpourri” is derived from an “early 17th century stew made of different kinds of meat, and literally translates to ‘rotten pot’” Nothing to lose, then.
Modified Heitz–Boyer–Hovelacque rectal bladder in children: Reassuring histology after median follow-up of 10.5 years The surgical management of urinary bladder exstrophy is still challenging for the scientific community of pediatric surgeons. There are many surgical procedures available: primary closure, delayed closure (staged procedure), or urinary diversion (internal or external) [1–3]. At our center, a cohort of patients with residual or recurrent urinary incontinence following unoperated or failed bladder exstrophy surgery was managed with the Heitz–Boyer–Hovelacque rectal bladder technique. This is an unusual choice because patients are exposed to possible complications due to admixture of feces and urine that is considered a possible cause of neoplastic change and electrolyte disturbances.
Paediatric cystolitholapaxy through the Mitrofanoff/Monti channel Bladder calculi are a known complication of bladder augmentation. Open cystolithotomy remains the preferred option for treating large or multiple stones. Increasingly, however, minimal access techniques have been used. Reports of Mitrofanoff cystolitholapaxy are rare and have been limited to adults. This study presented a two centre series of children treated by cystolitholapaxy via the Mitrofanoff/Monti channel.
Bladder scan accuracy in pediatric patients: Does patient position matter? Despite its widespread use in pediatric urology clinics, portable bladder scanning is an insufficiently studied tool that lacks standardized protocols. Workflow at the present clinic can be impeded by scanning in the supine position, due to multiple trips to the restroom and back to the exam room.
Urinary antimicrobial peptides: Potential novel biomarkers of obstructive uropathy Antimicrobial peptides (AMPs) have historically been evaluated for their role in protecting against uropathogens. However, there is mounting evidence to support their expression in noninfectious injury, with unclear meaning as to their function. It is possible that AMPs represent urothelial injury. Urinary tract obstruction is known to alter the urothelium; however, AMPs have not been evaluated for expression in this noninfectious injury.
Predictive ability of Guy's stone score in pediatric patients undergoing percutaneous nephrolithotomy Several authors have evaluated, in a number of external validation and predominantly adult studies, Guy's stone score (GSS) as a predictive tool for the assessment of stone clearance after percutaneous nephrolithotomy (PCNL). However, there are limited and conflicting data investigating whether GSS could be a potential independent factor associated with residual stone rates and complications of PCNL for children.
How to close classic bladder exstrophy: Are subspecialty training and technique important? Successful primary closure is one of the main factors for achieving continence in a classic bladder exstrophy (CBE) patient. Even with contemporary management, patients still have failed primary closures. We sought to understand the role of training, surgical technique, and their impacts on outcomes of CBE closure.
A needs analysis and guide for interpretation of voiding cystourethrogram for trainees The voiding cystourethrogram (VCUG) is a flagship pediatric urological test which is done to make diagnoses and formulate managements of many common conditions such as urine infection and hydronephrosis, along with monitoring of vesicoureteral reflux (VUR) disease. While detecting abnormalities in a VCUG study is important in diagnosis, the clinical context of why the study was ordered, an understanding of a normal VCUG study, as well as how the study is performed are important in clinical management and decision making.
Commentary to “Hypospadias repair with the glanular frenular collar (GFC) technique” I congratulate the authors for their study. In this study, the authors present their operative technique based on a glanular–frenular collar (GFC). The GFC technique includes approximation of the terminal ends of the diverted corpus spongiosum and the dartos tissue of the mucosal collar at the midline, which results in the formation of a septum and a frenulum between the glans wings, similar to the embryologic development of the glans penis [1]. The authors specified that, in general, GFC is not specifically addressed in urethroplasties.
Incontinence affects health-related quality of life in children and adolescents with spina bifida Despite devoting many resources to managing urinary and fecal incontinence (UI and FI) in children with spina bifida (SB), it remains unclear whether either is associated with lower health-related quality of life (HRQOL). We sought to determine the impact of UI and FI on HRQOL in this population.
Vascular thrombosis in pediatric kidney transplantation: Graft survival is possible with adequate management Vascular thrombosis (VT) in pediatric kidney transplantation (KT) is a dreaded event that leads to graft loss in almost 100% of cases. In recent years, VT has become the most common cause of early graft loss. The aim of this study was to analyze our experience in diagnosis and treatment of VT and the impact of a new management protocol on patient outcome.
Who, where, and why are patients lost to follow-up? A 20-year study of bladder exstrophy patients at a single institution Individuals with bladder and cloacal exstrophy are at increased risk for kidney disease, renal failure, and bladder complications. Given the social implications and sensitive nature of the disease, these patients are also at risk for psychosocial problems. Lack of regular medical follow-up visits may pose serious risks to their long-term health status. The aim of this study is determine what factors place an affected individual at risk for limited long term follow up.
Response to “Re. Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis” We appreciate Dr. Maruf and colleagues' comments as well as their institution's experience and contributions to the literature. The risks of transfusion and other post-operative occurrences should be taken into account when weighing the potential risks and benefits of delaying bladder exstrophy closure. We agree that the findings of this NSQIPP analysis can be useful in counseling families and in setting expectations. While these data add to our knowledge of 30-day events after early and delayed closure, further work is needed to determine whether any approach is superior.
Female epispadias: Single-stage approach – A technique to achieve continence This video provides a case report of a 3 year old girl with epispadia and the highlights of the surgery. A cystoscopic guided bladder neck plication was performed to achieve continence.Key points include: (1) Skin incision planning; (2) Cutaneous flap liberation to create a new urethra; (3) Complete bladder neck release to allow a controlled plication; (4) Use of cystoscopy to achieve the ideal bladder neck closure; (5) Bladder neck manipulation to achieve continence.
Laparoscopic inguinal hernia repair by modified peritoneal leaflet closure: description and initial results in children Inguinal hernias are common in infants and children. While the gold standard for hernia repair in the pediatric period has been via an open inguinal incision with dissection and high ligation of the hernia sac, over the past two decades laparoscopic herniorrhaphy has increased in popularity. The advantages of laparoscopy include decreased post-operative pain, improved cosmetic results, ability to easily assess the contralateral side for an open internal inguinal ring, and decreased risk of metachronous hernias.
Active surveillance for antenatally detected ureteroceles: Predictors of success Historically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles.
Re: “Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis” We would like to congratulate Ahn and colleagues for a very thorough exploration of the timing of bladder exstrophy bladder closure [1]. The authors investigated the NSQIPP database for bladder exstrophy cases between 2012 and 2015. Operative time, anesthesia time, frequency of concurrent pelvic osteotomy, and blood transfusions rates were, on average, higher in delayed closures. In the logistic regression, pelvic osteotomies significantly increased the odds of receiving a blood transfusion.
Cryopreservation of testicular tissue in pre-pubertal and adolescent boys at risk for infertility: A low risk procedure Cryopreservation of testicular tissue (TT) has become an increasingly attractive option for fertility preservation (FP), particularly for pre-pubertal boys at risk for gonadotoxicity from cancer therapy. At our institution, all at-risk families undergo counseling regarding infertility risk and available FP strategies, including this vulnerable patient population. As the technology required to use the acquired tissue is, as yet, unproven, it is paramount to document minimal morbidity and complications from this procedure.
Commentary to ': Non-stented versus stented urethroplasty for distal hypospadias repair: a systematic review and meta-analysis' The authors performed a superb systematic review and meta analysis comparing outcomes of stented repairs versus unstented repairs. Their study included over 1000 patients in each group and showed that short-term and long-term outcomes with or without stents are similar. We can argue about the validity of their results or the types of repairs they evaluated but the most important message of this article is the lack of high-quality hypospadias research. Even the RCTs were at best of moderate methodological quality.
Genitoplasty in newborn females with adrenogenital syndrome: Focus on the reconstruction technique and its outcomes The adrenogenital syndrome is an autosomal recessive disorder in which an enzyme defect in the steroid pathway leads to excessive prenatal exposure of androgens. In the female fetus, masculinization of the external genitalia is observed. Surgery aims for functional and aesthetical reconstruction. Many techniques have been described. A video of our modified pull-through reconstruction technique is hereby presented. A retrospective descriptive database was created with patients who underwent genitoplasty for a CAH-associated genital condition.
Retroperitoneoscopic heminephrectomy Retroperitoneoscopic heminephrectomy has multiple potential benefits in both infants and children. This article reviewed technical aspects of the procedure, and provided illustrations and an operative video demonstration. The vital first step is a ‘critical view’ of the collecting system/vascular supply of both upper/lower moieties. Dividing the lateral renal attachments later in the dissection allows passive retraction of the hilum, facilitating this dissection.
Urology mythbusters: Radiation and radiophobia In this episode of Mythbusters we critically examine the premise that there is strong biological and epidemiologic evidence that radiation exposure at levels associated with modern genitourinary diagnostic imaging increases the risk of subsequent malignancy, especially in children.
A brief description of study design Study design can make or break a study. Design choice depends on your research question, yet must also be feasible given time, ethical considerations, access to populations, and funding. Three elements are taken into account when discussing study design: 1) start of the study, 2) exposure, and 3) outcome(s). Start of the study determines whether a study is retrospective or prospective. Retrospective studies look backward in time for exposures or outcomes that have already happened. Prospective studies follow people forward in time before exposures or outcomes have occurred.
Simulation in paediatric urology and surgery. Part 1: An overview of educational theory Surgical training has changed radically in the last few decades. The traditional Halstedian model of time-bound apprenticeship has been replaced with competency-based training. Advanced understanding of mastery learning principles has vastly altered educational methodology in surgical training, in terms of instructional design, delivery of educational content, assessment of learning, and programmatic evaluation. As part of this educational revolution, fundamentals of simulation-based education have been adopted into all levels and aspects of surgical training, requiring an understanding of concepts of fidelity and realism and the impact they have on learning.
Staged laparoscopic traction orchiopexy for intra-abdominal testis: Is it always feasible? Laparoscopic orchiopexy for intra-abdominal testis is a well-known and commonly practiced technique. The traction technique is based on elongation of the testicular vessels without cutting them, in contrast with the two-stage Fowler-Stephens technique in which the testicular vessels are divided. The current study evaluated the feasibility of the traction technique according to the type of intra-abdominal testis.
Caring for urologic transition patients: Current practice patterns and opinions Congenitalism is an emerging field that recognizes the complex needs of adult patients with congenital urologic issues. Despite the onset of transitional care clinics, these patients remain difficult to care for due to resource availability, insurance coverage, and multi-disciplinary needs.
Non-stented versus stented urethroplasty for distal hypospadias repair: A systematic review and meta-analysis The authors sincerely appreciate the kind comments on our paper. Stents are a double-edged sword: we do agree that the discomfort related to the absence or indeed the presence of a urethral stent such as difficulty voiding, parental anxiety, pre-mature stent fall-out or kinking/breaking, and post-operative calls are some of the important post-operative outcomes we need to assess. In our preregistered protocol in PROSPERO (CRD42016047563), these were the variables we intended to evaluate as our secondary outcomes.
The evaluation of three comorbidity indices in predicting postoperative complications and readmissions in pediatric urology The surgical comorbidity assessment is important for patient risk stratification, counseling, and research. In adults, risk assessment indices, such as the Charlson Co-morbidity Score (CCS) or Van Walraven Index (VWI), are well established. In pediatrics, however, risk assessment indices are scarce. Recently, a pediatric-specific risk assessment index, the Rhee index, was developed to discriminate mortality for pediatric general surgery patients. Currently, there is no validated risk assessment tool in pediatric urology.
Commentary on “Extraordinary daytime only urinary frequency in childhood: Prevalence, diagnosis, and management” I read with much interest Marzuillo et al.'s article on extraordinary daytime only urinary frequency (EDOUF) [1]. The authors deserve much credit for having been very careful in the clinical diagnosis of EDOUF and for using the definition of the International Children's Continence Society (ICCS) [2]. In addition, they should be congratulated for their systematization in their follow-up of EDOUF in the sense of providing the largest amount of literature on the subject to the present time.
Response to “Re. A simple technique for small diameter urethrocutaneous fistula repair: Ligation” Thank you for your valuable comments. As we mentioned in our Discussion, covering the fistula with de-epithelialized tissue such as a vascularized dartos flap is one of the principles of successful uretrocutaneous fistula repair and must be performed in all cases managed with either classical or double ligation techniques. Therefore, we think that a comparison of classical repair and double ligation technique is more appropriate than a comparison of two groups in respect of a vascularized dartos flap coverage.
Urinary incontinence among adolescent female athletes A collection of studies have demonstrated that approximately one-third of female nulliparous athletes experience urinary incontinence during their athletic activities. Contributing factors of incontinence that have thus far been the focus of study include type of sport, duration and intensity of athletic activity, use of hormonal contraception, and weight. There has, as yet, been a notable underemphasis on several other factors which influence incontinence, including bowel pattern, urinary habits, and menstrual status.
Re: Urinary tract infection in children: Diagnosis, treatment, imaging – Comparison of current guidelines I would like to commend the authors on their article comparing current guidelines on the management of UTI in children [1]. The authors attempt to reconcile these guidelines but stumble across conflicting data and varying recommendations, reminding us that when it comes to managing UTI, it takes considerable knowledge to realize the extent of our own ignorance.
Is surgical antibiotic prophylaxis necessary for pediatric orchiopexy? Surgeons frequently use surgical antibiotic prophylaxis (SAP), despite limited evidence to support its efficacy. Potential adverse events associated with antibiotic use include allergic reaction (including anaphylaxis), Clostridium difficile infection, and selecting for resistant bacteria. Surgical site infections (SSI) are very rare in patients undergoing clean pediatric urologic procedures. Current guidelines are unclear about the efficacy of surgical antibiotic prophylaxis for prevention of SSI in the pediatric population.
Risk factors for postobstructive diuresis in pediatric patients with ureteropelvic junction obstruction, following open pyeloplasty in three high complexity institutions Postobstructive diuresis (POD) is a polyuric state in which large quantities of salt and water are eliminated after solving a urinary tract obstruction. These patients are at increased risk of severe dehydration, electrolytic disturbances, hypovolemic shock, and death. Ureteropelvic junction obstruction (UPJO) is the most common etiology of collecting system dilatation in the fetal kidney, and a significant number of patients require pyeloplasty. There are limited data regarding prognostic risk factors for POD in this scenario.
Re. “A simple technique for small diameter urethrocutaneous fistula repair: Ligation” We congratulate Karakus et al. for their study [1]. Repair of urethrocutaneous fistula after urethral surgery in both pediatric and adult patients is really challenging for surgeons. In the described technique, to repair a small urethrocutaneous fistula, the fistula is twisted on itself and a tension-free double ligation is performed from radix of the fistula using 6/0 polyglactin sutures. As Karakus et al. mention, it is well-known that complete excision of the fistula tract, waterproof urethral repair inverting both epithelial edges, avoidance of suture line tension, overlaying the fistula closure with a vascularized and deepithelialized tissue, and skin closure avoiding overlapping sutures with the underlying urethral repair are the main principles for repair of the fistula [1].
Laparoscopic nephrectomy for Wilms' tumor: Can we expand on the current SIOP criteria? Wilms' tumor now has a good overall prognosis with open radical nephrectomy having been the mainstay of surgical treatment. Recently laparoscopic nephrectomy (LN) has been growing in popularity. The aim of our study was to review our indications and outcomes for laparoscopic resections for Wilms' tumor and compare indications with International Society of Paediatric Oncology (SIOP) criteria for LN.
Characteristics of testicular tumors in prepubertal children (age 5–12 years) Testicular tumors in children have two peaks with different types of tumors; in the first 4 years of life a third to half are benign with increased risk of malignancy during puberty. The pathology of testicular tumors between these peaks, at the age of 5–12 years, is not known. We hypothesized that because of the low level of testosterone at this time, the incidence of malignant tumors is very low.
Ethical issues in research: Human and animal experimentation Ethics in research is a set of principles and values that must underline all aspects of the research process. This article focuses on the ethics of human and animal experimentation.
Non-stented versus stented urethroplasty for distal hypospadias repair: A systematic review and meta-analysis Studies have shown that non-stented distal hypospadias repair eliminates stent-related bladder spasm and stent removal discomfort without increasing complications; however, results are inconsistent. We performed a systematic review to assess the complication rates of non-stented compared to the stented distal hypospadias repair.
Extraordinary daytime only urinary frequency in childhood: Prevalence, diagnosis, and management Since standardization of the ICCS terminology, only two small case series of children with extraordinary daytime only urinary frequency (EDOUF) have been published. The aims of the present study were i) to describe a large cohort of children affected by EDOUF, to evaluate its rate among the main micturition pediatric disturbances, and to determine if there is different EDOUF onset among seasons; ii) to investigate possible associations with urodynamic abnormalities by non-invasive techniques; iii) to evaluate whether postponing micturition exercise (PME) can objectively verify the anamnestic data hinting at the EDOUF diagnosis; and iv) to determine the effect of postponing micturition at home.
The Double Dutch technique: A new way of creating an ileocystoplasty with a lengthy catheterizable ileal tube A tubularized conduit from an open 2-cm vascularized ileal segment is a frequently used technique to create a continent catheterizable channel in cases of an inappropriate or absent appendix. In the long term, many patients experience catheterization problems with the classic ileal segment tube, and even more with spiral or double-segment tubes.
Long-term urinary symptoms in adolescent and adult women with congenital adrenal hyperplasia Congenital adrenal hyperplasia (CAH) is an autosomal recessive condition resulting in excess androgen production. Females are typically born with ambiguous genitalia and often undergo feminising genitoplasty in infancy or childhood. Recently, there has been considerable international debate as to whether distressing urinary symptoms in CAH patients are truly present and, if so, whether these urinary problems are a consequence of the feminising genitoplasty.
Ureteral tunnel length versus ureteral orifice configuration in the determination of ureterovesical junction competence: A computer simulation model The long-held belief that a ureteral re-implant tunnel should be five times the diameter of the ureter, as proposed by Paquin in 1959, ignores the effect of the orifice on the occurrence of reflux. In 1969, Lyon proposed that the shape of the ureteral orifice (UO) is more important than the intravesical tunnel. However, both theories missed quantitative evidence from principles of physics. The goal of the current study was to test Lyon's theory through numerical models (i.e. to quantify the sensitivity of ureterovesical junction (UVJ) competence to intravesical tunnel length and to the UO).
Adolescent testicular microlithiasis: A case-based, multinational survey of clinical management practices Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up.
Re. “Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes” I write to comment on the paper by Bush and Snodgrass [1]. The authors describe “an urethral plate incision made deeply up to the corpora” on the glans penis, instead of having a wide (>8 mm) urethral plate, to avoid urethroplasty complications. Although the authors' definition of the ventral glanular surface as “urethral plate” is the subject of another discussion, I would like to refer the readers to the normal anatomy of the penis, in particular the “fossa navicularis.” The male urethra is NOT a tubular structure with uniform configuration and diameter, and has distinct attachments in glans penis with the “fossa navicularis.” The glans wings merge in the midline ventrally, but are separated by the “septum glandis” in conjunction with the “frenulum.” The frenulum is also included in the formation of the distal (glanular and subcoronal) urethra [2–4].
Microsurgical anastomosis of renal vasculature in rats: A practical platform for acellular kidney transplantation End-stage renal disease is becoming a contemporary global concern with increasing prevalence. The available treatment strategies are limited to dialysis and renal transplantation. However, limited organ supply and autoimmune rejection are the shortcomings that limit widespread application of transplantation. Favorably, regenerative medicine is able to provide acellular natural scaffolds for renal transplantation. Experimental surgeries in animal models are a fundamental step in transplantation research.
Bladder debris on ultrasound as a predictor for positive urine culture in a pediatric population Debris within the bladder is commonly seen on ultrasound. The etiology of bladder debris is varied and the likelihood that urinary debris represents positive urine culture is under investigation. We hypothesize that bladder debris will increase the likelihood that a urine culture is positive compared to those without bladder debris.
Reviewing scientific manuscripts Peer review is the process that guarantees the scientific quality of published studies. It ensures that published research is newsworthy for the readership, that data presented are original/relevant, that research methods are sound and duplicable, and finally that ethical principles are respected.
Upper pole access is safe and effective for pediatric percutaneous nephrolithotomy Upper pole access in percutaneous nephrolithotomy (PCNL) provides a straight tract to the ureter, resulting in easier placement of a guidewire to the ureter, good exposure of the pelvis, calices, and upper ureter, and comfortable manipulations. However, despite these benefits, upper pole access is usually avoided because of the risk of chest complications in both pediatric and adult patients.
Prevalence of UTI among Iranian infants with prolonged jaundice, and its main causes: A systematic review and meta-analysis study An extremely variable and high prevalence of urinary tract infection (UTI) in infants with prolonged jaundice has been reported in Iran. However, there is no research from the area that has attempted to estimate pooled prevalence of UTI from considerably diverse evidence. Therefore, this systematic review and meta-analysis study aimed to estimate the prevalence of UTI in infants with prolonged jaundice who were admitted into clinics or hospitals in Iran.
Simulation in paediatric urology and surgery, part 2: An overview of simulation modalities and their applications Surgical training has changed radically in the last few decades. The traditional Halstedian model of time-bound apprenticeship has been replaced with competency-based training. In our previous article, we presented an overview of learning theory relevant to clinical teaching; a summary for the busy paediatric surgeon and urologist. We introduced the concepts underpinning current changes in surgical education and training. In this next article, we give an overview of the various modalities of surgical simulation, the educational principles that underlie them, and potential applications in clinical practice.
Commentary to “Does intraoperative success predict outcome in the treatment of urethral sphincter insufficiency with bulking agent?” To publish negative and honest results is important particularly in the extremely difficult field of management of structural incontinence. Regarding the main purpose of the study, the authors clearly demonstrate that the per operative evaluation of the ALPP has no predictive value on the final outcome. This confirms most previous reports in that initial success rate may reach an average of 70% during the first month post treatment which drops to various levels afterwards, generally to less or maximum 50% as an average, after one or several treatment sessions.
Parental decisional regret and views about optimal timing of female genital restoration surgery in congenital adrenal hyperplasia The role of female genital restoration surgery (FGRS) in girls with congenital adrenal hyperplasia (CAH) is controversial, with no long-term parent-reported outcomes available. Decisional regret (DR) affects most parents after their children's treatment of pediatric conditions, including hypospadias. We aimed to assess parental DR after FGRS in infancy or toddlerhood and explore optimal timing for surgery.
Testicular adrenal rest tumor screening and fertility counseling among males with congenital adrenal hyperplasia Reduced fertility is a common potential problem among males with congenital adrenal hyperplasia (CAH), with nearly half experiencing impaired sperm production. The major cause of oligo/azoospermia in CAH is testicular adrenal rest tumors (TARTs). Studies indicate that ultrasound screening for TARTs should begin during childhood, yet it remains unclear whether boys with CAH are routinely screened for TARTs and/or counseled about infertility risk and potential interventions such as fertility testing and/or preservation.
Immediate and delayed effects of atmospheric temperature in the incidence of testicular torsion Ongoing controversy surrounds the role of atmospheric temperature in the incidence of intravaginal testicular torsion (iTT). This debate may be attributed to inadequate research methodology. As environmental risk factors have been successfully investigated with distributed lag non-linear model regression (DLNM), we applied this methodology to investigate the association between daily mean atmospheric temperatures (Tmean) and daily incidences of intravaginal testicular torsion (iTT) in our region.
Ethical issues in research: Human and animal experimentation Ethics are primordial in all aspects of the research process. This includes not only the execution of research, but also its reporting and the reviewing and editorial processes. Sound ethics imply that data and conclusions are honestly obtained and attributed, accurately measured and reported, repeatable, and free from any dishonest manipulation or misinterpretation [1]. Research misconduct is any behavior by a researcher, intentional or not, that fails to scrupulously respect these standards: fabrication, falsification, or plagiarism in performing research, reporting results, or reviewing manuscripts.
The implications of fellowship expansion on future pediatric urologist surgical volumes Over the past 25 years, Pediatric Urology fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) have more than doubled. This increase may lead to a significant decrease in the number of operative cases per surgeon and therefore impact the current practice of pediatric urology.
Xanthogranulomatous pyelonephritis in a paediatric cohort (1963–2016): Outcomes from a large single-center series Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic destructive granulomatous inflammation of the kidney. It was first described in 1916, and is thought to affect 6/1000 cases of pyelonephritis. Its manifestations are varied, and with a limited number of cases in the literature, the optimal diagnosis and management of XGP in the paediatric cohort is still unknown.
Bladder contractility index in posterior urethral valve: A new marker for early prediction of progression to renal failure Posterior urethral valve (PUV) is the most common cause of pediatric end stage renal disease (ESRD), imposing a major health burden on medical community caregivers and adversely affecting the quality of life of patients. Chronic kidney disease (CKD) stage III or estimated GFR of <60 mL/min/1.73 m2 is known to be associated with more adverse renal, cardiovascular, and clinical outcomes. Thus, it is desirable to identify factors predicting the rapid and early progression of disease. In the present study, baseline characteristics and urodynamic study (UDS) parameters of boys with PUV are correlated with CKD progression to IIIB or more.
Endoscopic balloon dilatation in primary obstructive megaureter: Long-term results Open neoureterocystostomy is the traditional surgical treatment for primary obstructive megaureter (POM). Endoscopic balloon dilation is a new minimally invasive alternative. It has been shown to be a safe and effective endoscopic procedure over short-term follow-up; however, few studies have shown its long-term efficacy.
Distal urethral plate adhesions: New anatomical perspective in hypospadias We found midline epithelial adhesions in the glandar urethral plate in patients with hypospadias. After dissolution, a blind epithelized channel becomes visualized inside of the plate pointing to immature embryonic luminization. In addition it reveals that the epithelized surface of the distal urethral plate is larger than previously considered.
Nonpalpable testes: Ultrasound and contralateral testicular hypertrophy predict the surgical access, avoiding unnecessary laparoscopy In up to 20% of patients presenting with undescended testes, one or both are non-palpable. Whereas the most reliable means to exclude an abdominal testis is laparoscopy, there has been a lot of debate about the role of inguinal ultrasound (US) in detecting non-palpable inguinal testis. While we do not aim to add another paper claiming the benefits of US, we wanted to determine the excess capability of US to determine the correct surgical approach – inguinal or laparoscopy. In the light of avoiding unnecessary diagnostic laparoscopies, even the cost-effectiveness raised in many current papers might be called into question.
E-learning teaches attendings “how to” objectively assess pediatric urology trainees' surgery skills for orchiopexy Established methods to train pediatric urology surgery by residency training programs require updating in response to administrative changes such as new, reduced trainee duty hours. Therefore, new objective methods must be developed to teach trainees. We approached this need by creating e-learning to teach attendings objective assessment of trainee skills using the Zwisch scale, an established assessment tool. The aim of this study was to identify whether or not e-learning is an appropriate platform for effective teaching of this assessment tool, by assessing inter-rater correlation of assessments made by the attendings after participation in the e-learning.
Risk association of congenital anomalies in patients with ambiguous genitalia: A 22-year single-center experience Ambiguous genitalia refers to a form of differences of sex development (DSD) wherein the appearance of the external genitalia is atypical. This rare condition presents challenges in decision-making and clinical management. Review of historical data may reveal areas for clinical research to improve care for patients with ambiguous genitalia.
5 years after introduction of a transition protocol: An evaluation of transition care for patients with chronic bladder conditions In recent years, more attention has been given to the transition of adolescents in urological care. In 2010, the current team investigated the needs of children with chronic bladder conditions, in preparation for transfer to adult care. A transition protocol was developed and implemented. The current study evaluated current transition care, in order to further improve the transition process.
Evidence of reduced bladder capacity during nighttime in children with monosymptomatic nocturnal enuresis Bladder capacity in children with nocturnal enuresis is assessed by maximal voided volumes (MVV) obtained through daytime frequency volume (FV) charts. Although a degree of association has been demonstrated, daytime MVV does not consistently correspond with the nocturnal bladder capacity (NBC) in monosymptomatic nocturnal enuresis (MNE). It was hypothesized that isolated reduced NBC is a common phenomenon in children with nocturnal enuresis, despite normal daytime bladder function.
WITHDRAWN: Introductory editorial – Basic science The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jpurol.2016.01.009. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
The lowest acceptable bladder capacity for interpretation of uroflowmetry tests in children Under- or overdistended bladder is associated with impaired bladder emptying. Therefore, uroflowmerty of low bladder capacity is regarded as irrelevant for interpretation. However, is no general consensus with regard to the lowest acceptable value of bladder capacity (LABC) for interpretation of uroflowmetry in children.
Expert opinion: “1 Voice” elements of prenatal urological consultation Lower urinary tract abnormalities are perhaps the most commonly identified findings on prenatal ultrasounds. Challenges in the past have been lack of consensus as to how to classify these findings and then correlate them with long-term outcomes to help with the prenatal counseling about prenatal and postnatal management. Using a web-based Computer Enhance Visual Learning (CEVL) approach to this problem, the authors have created a unique method to learn these skills and enhance our understanding for fetal urologic consultations.
Editorial “To teach is to learn twice.” – Joseph Joubert.
Featuring: Implications of fellowship expansion on future pediatric urologist surgical volumes The February Pediatric Urology Journal Club featured a look at the impact of the current number of pediatric urology fellowship training positions future case volumes [1]. Authors Travis Groth (@groth_travis), Christopher Cooper (@coopeduro) and John Kryger (@johnkryger3) joined the discussion [2].
Featuring: Ultrasound guided ureteroscopy in children: Safety and success In December 2017 the Pediatric Urology Journal Club discussed a report from Children's Hospital of Philadelphia in which the authors describe their initial experience performing ultrasound (US)-guided ureteroscopy (US-URS) in children [1]. Authors Jason Van Batavia (@urojvb), Christopher Long (@clonguro), and Aseem Shukla (@aseemrshukla) joined the discussion [2].
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