Opioid prescribing patterns, storage, handling and disposal in post-operative pediatric urology patients Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures.
Commentary to '"Mini" Extravesical Reimplant with "Mini" Tapering for Infants Younger than 6 Months of Age' The authors present an extravesical technique in a small series of young infants who underwent ureteral reimplantation for uretero-vesical obstruction or ectopic ureter. Others have shown that ureteral reimplantation with well described intravesical techniques in infants has been successful, with rates of success ranging from 86 to 97%--meaning no residual vesicoureteral reflux or ureteral obstruction. [1,2] Notably, in this series only unilateral procedures were performed. Bilateral extravesical techniques have rarely been associated with urinary retention, and so it might not be prudent to consider extravesical reimplantation if needed bilaterally in this age group.
Mid to long term outcomes of the "anatomical approach" to congenital mega-prepuce repair The understanding of the aetio-pathogenesis and the long-term outcomes ofcorrectional repair of congenital megaprepuce (CMP) remains unestablished. Different techniques have been described, however optimum results have been difficult to achieve. The aim of our study was to review our experience of the “anatomical approach” to the correction of CMP.
Predatory publishing or a lack of peer-review transparency? - A contemporary analysis of indexed open and non-open access papers in paediatric urology and Objective: The advent of open access publishing has allowed for unrestricted, and rapid knowledge dissemination, and can generate higher citation levels. However, the establishment of predatory journals exploits this model and may lead to publication of non-peer reviewed work. The objective of this study was to compare the characteristics and trends of indexed publications in paediatric urology. The primary outcomes were to compare open access vs non-open access publishing. The secondary outcome was to assess whether any open access publications in this cohort could be classified as predatory based on journal data basing and external peer review policies.
”Night-time diuresis pattern in children with and without primary monosymptomatic nocturnal enuresis” Night-time polyuria as the dominating pathophysiological mechanism for PMNE has been put in question with nocturnal detrusor-overactivity and high arousal thresholds as alternatives. Our finding of night-time polyuria in 12 % of healthy non-enuretic schoolchildren underscores that excessive night-time diuresis per se is unlikely as the major cause of PMNE.
Pathological changes in uretero vesical and uretero pelvic junction obstruction explained by fetal ureter histology The etiology of uretero vesical junction obstruction (UVJO) and uretero pelvic junction obstruction (UPJO) is obscure with an adynamic narrow segment causing the obstruction. In this study we have compared interstitial cells of Cajal (ICC), and collagen/muscle ratio (CM ratio) between UVJO, UPJO and fetal ureters to investigate whether a maturational arrest of fetal ureter could explain both clinical pathologies.
Commentary on “external stent in laparoscopic pyeloplasty: the k-wire technique” We were most interested to read about Upasani et al.’s use of a K-wire technique in laparoscopic pyeloplasty [1]. Indeed, we have been performing laparoscopic pyeloplasty in children since 2013, and have notably improved our technique through the prescription of pelvic training, mastery of the suturing technique, and a number of other tips and tricks. The main difficulty remains accurate placement of the internal double J (JJ) stent. However, we have never encountered severe complications; most complications are minor and related to poor urinary drainage.
Hypoxic changes to the urothelium as a bystander of end-stage bladder disease Urothelial cells harvested from benign diseased bladders have a compromised capacity to propagate or differentiate in vitro, potentially limiting their application in autologous tissue engineering approaches. The causative pathways behind this altered phenotype are unknown.Our hypothesis is that hypoxic damage to the urothelium occurs as a bystander to chronic or recurrent episodes of infection and inflammation. The aim of this study was to assess immunohistochemically-detected nuclear hypoxia-inducible factor 1 alpha (HIF-1α) and vascular endothelial growth factor (VEGF) in the urothelium markers of hypoxia exposure.
Hydronephrosis severity score in management of ureteropelvic junction obstruction in children We read with great interest the article written by Babu R, Venkatachalapathy E and Sai E [1]. In their study, Authors developed an original new hydronephrosis severity score combining three parameters, differential renal function, drainage curve pattern, and ultrasonographic evaluation of pelvic dilatation. Since the main aim in the management of asymptomatic uretopelvic junction obstruction (UPJO) is to preserve the renal function, being aware of the possible clinical scenario of spontaneous improvement of hydronephrosis [2], the strain of the clinical research should be pointed out on the identification of predictor factors of future impairment of the renal function.
Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned? Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.
Decreasing Operating Room Costs via Reduction of Surgical Instruments Rising costs in health care demand waste reduction and improved efficiency throughout the hospital. Surgeons have an important role in regards to amount of instruments utilized in procedures. Previous studies demonstrate instrument maintenance and sterilization to cost approximately $0.51 to $0.77 per instrument and found that only 13-21.9% of instruments opened are used.
Prognostic values of shear wave elastography in adolescent boys with varicocele Shear wave elastography is an ultrasound technique for non-invasive quantification of tissue stiffness. It was used in assessing testis elasticity in some scrotal abnormalities, such as undescended pediatric testes or adult varicocele testes. In this study, its usefulness in adolescent patients with varicocele was examined.
Those who cannot remember the past are condemned to repeat it Many famous people, including Winston Churchill, have paraphrased this quote by Santayana. Medicine has a very rich history, filled with success, failures, and misadventures. Recently I was sent a copy of King of Hearts, a book by G. Wayne Miller. This book chronicles the history of open heart surgery with a look into the character of one of the pioneers, C. Walton Lillehei. Lillehei performed the first successful open-heart surgery using cardio-respiratory bypass on an 18-month old boy with a VSD.
‘Mini’ extravesical reimplant with ‘mini’ tapering for infants younger than 6 months Some infants with obstructed megaureters or ectopic ureters requiring surgery undergo a cutaneous ureterostomy followed by definitive repair after 12 months of age. Since 2013, a ‘mini’ extravesical reimplant with or without ‘mini’ tapering (MER) was performed instead of cutaneous ureterostomy in such infants.
Thermal cautery-assisted circumcision and principles of its use to decrease complication rates Circumcision is one of the most frequently applied surgical procedures all over the world and a number of techniques and devices have been described concerning its method. Especially in developing countries where circumcision has been performed intensively under local anaesthesia, the thermocautery device developed to perform circumcisions in a short time and safely has found a widespread application.
Staged Repair of Redo and Crippled Hypospadias: Analysis of Outcome and Complications residual curvature, scarred or absent urethral plate, shortage of skin, paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts. Herein, we present analysis of outcome and complications following repair of cohort of children with redo and cripple hypospadias operated by single surgeon, data are retrieved from prospectively designed database.
Expert opinion: subcutaneous endoscopic assisted ligation to repair pediatric inguinal hernia Training of residents and fellows continues to evolve as technology has improved surgical procedures and platforms to learn. Computer-enhanced visual learning (CEVL) can facilitate training by detailing operations as they will be performed in the operating room. This includes visualization of key steps of the procedure, providing conceptual understanding of steps that may be unclear by description alone.
The clinical significance of an incidentally detected open internal inguinal ring An open internal inguinal ring (IIR) may be discovered incidentally either in the context of correcting pathology involving the contralateral side or at the time of surgical exploration for reasons unrelated to a patent processus vaginalis (PPV). The aim of this study is to determine the evolution of an incidentally encountered open IIR in patients undergoing laparoscopy for reasons not associated with unilateral inguinal hernia or cryptorchidism.
Population-based trend analysis of voiding cystourethrogram ordering practices in a single-payer healthcare system before and after the release of evaluation guidelines While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis.
Commentary to ‘The use of postoperative prophylactic antibiotics in stented distal hypospadias repair: a systematic review and meta-analysis’ The advent of antibiotics made it possible to treat many infectious diseases. Their widespread use, no doubt, has saved many lives or prevented many debilitating consequences. The utility of antibiotics in a postoperative role is less clear; are they helpful? Does their use prevent meaningful complications? Should we continue to use them and risk accelerating drug resistance? Chua et al. look at this question as it applies to stented distal hypospadias repair [1]. They performed a systematic literature review and used a standard meta-analytic approach.
Functional, histological and molecular characteristics of human exstrophy detrusor Bladder exstrophy is a congenital anomaly involving foetal exposure and protrusion of the open bladder through an incomplete lower abdominal wall. Techniques to surgically correct exstrophy after birth have greatly improved, but it still presents a major challenge to achieve continence and a good quality of life for patients and their families as the pathophysiology of bladder dysfunction is unknown.
Uncharted territory: navigating the pediatric urology job market There is not a structured algorithm, timeline, or resource on how, when, and which programs are looking for a new staff pediatric urologist. We hypothesized that current and future pediatric urology fellows could benefit from the experiences of recently graduated fellows on navigating the urology job market.
Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution? Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution.
Constipation in nocturnal enuresis may interfere desmopressin management success Previous studies indicated that the prevalence of constipation in enuretic patients is higher than that in the general population. Several studies have revealed that successful treatment of constipation may be helpful in resolving enuresis. However, constipation affecting the efficacy of desmopressin in treating enuresis remains to be clarified.
Response to commentary to ‘The search for the definition and effective diagnosis of upper urinary tract obstruction: the Whitaker test then and now’ Your reviewer is generous with his/her comments and very eloquently describes the effect of compensatory compliance, an enormously important factor that I admit I was slow to appreciate in the early days. Indeed, it was my very good friend and colleague Stephen Koff who finally convinced me of its importance. I have pleasure in acknowledging his very significant contribution to the investigation of obstruction. Your reviewer makes it adequately clear that it was not so much the development of tests to diagnose obstruction that was the breakthrough but the change in perception by urologists that obstruction is not an all-or-nothing phenomenon.
Retroperitoneoscopic lower pole heminephrectomy Retroperitoneoscopic heminephrectomy is a challenging procedure but with advantages over open and transperitoneal laparoscopic approaches. Lower pole heminephrectomy is less commonly undertaken compared with the upper pole.s
Posterior urethral valves: comparison of clinical outcomes between postnatal and antenatal cohorts Posterior urethral valves (PUVs) constitute the most common infravesical urinary obstruction in boys and are often accompanied by severe consequences to the lower and upper urinary tract. Currently, about two-thirds of diagnosis of PUVs has been suspected by prenatal ultrasonography findings. The aim of this study was to compare long-term clinical outcomes in two groups of patients with PUVs, with antenatal vs. postnatal diagnosis.
Evidence-based medicine I background The Research Committee of the European Society of Pediatric Urology will present a series of short educational communications related to evidence-based medicine. The aim of the series is to emphasize the importance of grading evidence, thereby determining the best clinical practice for patients. The goal of this series is to guide the clinician in using tools for setting up a clinical question, finding appropriate information, searching appropriate databases, and evaluating the results in relation to the patient in mind.
Videolaparoscopic lower pole heminephrectomy for treatment of a duplex kidney In a duplicated renal collecting system, or duplex kidney, the most frequent pathology presenting at the lower pole is the vesicoureteral reflux (VUR), which could lead to urinary tract infections (UTI) or even renal dysplasia. Under some circumstances, such as recurrent UTIs or impaired kidney function, heminephrectomy of the pathologic moiety is indicated. However, there are only few academic videos of laparoscopic lower pole heminephrectomy in the pediatric population available in literature.
Surgical validation of functional magnetic resonance urography in the study of ureteropelvic junction obstruction in a pediatric cohort Ureteropelvic junction obstruction (UPJO) is one of the most common urological diseases in children. The etiology can be intrinsic, extrinsic (crossing vessel [CV] or adhesions), or mixed. To date, ultrasonography and scintigraphy are considered gold-standard imaging techniques for the study of UPJO. Functional magnetic resonance urography (fMRU) combines anatomical and functional information and has been recently evaluated for the detection of CVs in UPJO.
The evaluation of vesicoureteral reflux among children using contrast-enhanced ultrasound: a literature review Voiding cystourethrogram (VCUG) with fluoroscopy remains the gold standard for detection and evaluation of vesicoureteral reflux (VUR) among children. However, the ionizing radiation exposure remains a concern for this diagnostic modality. Recent studies have proposed using contrast-enhanced ultrasound as an alternative option for VUR screening and follow-up in children. The aim of the study was to review the literature of comparative studies that assessed the diagnostic accuracy of contrast-enhanced ultrasound compared with VCUG.
Variations of sex development: The first German interdisciplinary consensus paper The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly ‘feminizing’ elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female.
Expert opinion: art of endoscopic injection therapy for primary pediatric vesicoureteral reflux Volume of exposure, rather than specifically designed curricula, had been the previous hallmark of adequate surgical training. As opportunities for learning through work with ‘real’ patients have diminished, interest in laboratories with formal curriculum, specifically designed to teach surgical skills, has increased dramatically. This decrease in real-life resident exposure, along with the known impact of a given surgeon's volume and experience on patient outcomes, makes it challenging for a junior faculty to turn over a case to a resident.
Expert opinion: art of endoscopic injection therapy for primary pediatric vesicoureteral reflux The diagnosis and management of vesicoureteral reflux (VUR) continues to evolve. Injection techniques for the treatment of VUR gained prominence because of the presumed simplicity of the technique and the intended benefit of a minimally invasive method as an outpatient procedure. Importantly, Kirsch and his Atlanta colleagues have consistently modified injection techniques so that reflux resolution and success rates, in their hands, have paralleled the results reported with open techniques. The advent of describing ureteral H1-H3 ureters, popularizing the HIT and double hydrodistention implantation technique (HIT) techniques, along with experience revealing that more volume of Deflux might be necessary in some cases to have a successful outcome, has led to our better understanding of their approach.
Urinary metabolic abnormalities in children with idiopathic hematuria Hematuria, either macroscopic or microscopic, is an incidental finding of multiple nephrologic or urologic disorders. Disturbances of urine inhibitors or promotors have been suggested as the potential causes of isolated idiopathic hematuria in children and its recurrence. Meanwhile, appropriate treatment of these risk factors might improve secondary asymptomatic or macroscopic hematuria.
Response to editorial commentary: predatory publishing or a lack of peer-review transparency?—a contemporary analysis of indexed open and non-open access articles in paediatric urology The advent of open access publishing as a model has indeed led to a more accessible and egalitarian approach to digital manuscript archiving. This model has not only been shown in some studies to increase citation count but also provides a means to those countries that do not have the funds to access these archives through standard subscriptions, as well as to those that simply may not be affiliated to institutions/universities with this access any more, such as retired academics who wish to keep up to date or continue to contribute with a vast level of knowledge and experience.
Prevalence of urinary incontinence and other lower urinary tract symptoms in children in the Netherlands The International Children's Continence Society (ICCS) defines urinary incontinence (UI) as ‘involuntary leakage of urine’ [1], a condition that can have a negative impact on a child's life. Although UI is common among children, the reported prevalences worldwide vary. Regarding children in the Netherlands, only a few studies report on the prevalence of UI and other lower urinary tract symptoms (LUTSs).
Authors’ reply to commentary JPUROL-D-18-00309 refers to JPUROL_2018_56 “The authors greatly appreciate the reviewer's commentary and concur with the insights on the intricacies of systematic reviews and conclusions drawn from such analysis. We also strongly advocate poor-quality studies to be considered low-level evidence and rarely, if ever, generate any meaningful or clinically applicable recommendations. However, when inconsistencies of the outcome report were noted in the literature, we felt compelled to highlight the importance of performing good quality systematic review and meta-analysis on the topic.
Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shifts and require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects.
Response to letter re 'Pneumovesical ureteric reimplantation using T-fastener: a modification for bladder wall anchorage' We would like to thank you for the opportunity to respond to the issues concerning methods of cystopexy. Indeed, the conventional approach of bladder wall anchoring used in our centre also applied the same ‘U stitch’ principle as described by the authors, but a loop was used to catch the suture instead of an ureteroscopic forceps [1]. The main reason for our switch over to the new modification is that passing the suture relies on a paradoxical vesicoscopic view, which may be time-consuming. The authors did not mention the time needed to complete the cystopexy, but after all, their technique still needs to work under a paradoxical environment using two parallel ports.
Robot-assisted resection of ectopic kidney in children: An anatomical illustration Failure of kidney migration during embryonic life results in an ectopic kidney, with an incidence varying from 1 in 500 to 1 in 1200. Pelvic kidney can be a rare cause of recurrent urinary tract infection (UTI), warranting nephrectomy in some cases.
Cancer screening in the pediatric cancer patient: a focus on genitourinary malignancies, and why does a urologist need to know about this? The long-term survival of a patient with childhood cancer now exceeds 80%. Unfortunately, as survivorship improves, the long-term consequences of the treatments used have become manifest. Specifically, the finding that development of a subsequent malignant neoplasm (SMN) is the leading cause of late mortality is concerning. In cancer survivors who are at high risk for developing an SMN, cancer screening protocols have well-documented survivorship benefits. Regrettably, 50% of these high-risk patients are non-compliant with these protocols, with studies revealing that inadequate patient compliance is in part because of insufficient knowledge of the physician regarding its need.
This is the first edition of this textbook, designed to cover all topics of urology, including inflammation, stones, endo-urology, female urology, reconstructive urology, benign prostatic hypertrophy, urologic oncology, andrology, pediatric urology, renal function, and urologic radiology.
Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication.
Scrotal injuries during neonatal circumcision To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision.
Elevated urinary lipocalin-2, interleukin-6 and monocyte chemoattractant protein-1 levels in children with congenital ureteropelvic junction obstruction In children with congenital ureteropelvic junction obstruction (UPJO), urinary biomarkers could assist in the diagnosis of renal damage or kidneys at risk for damage. Urinary levels of interleukin-6 (IL6), neutrophil gelatinase–associated lipocalin (LCN2), monocyte chemoattractant protein-1 (MCP1), and transforming growth factor-β1 (TGFB1) proteins have been correlated with renal damage in several contexts. Whether they might be useful non-invasive biomarkers of obstructive nephropathy due to unilateral and bilateral congenital UPJO was tested.
Response to the editorial comment We thank the reviewer for the pertinent editorial comments and for the opportunity to clarify the reasons why we changed our approach to maintain the advantages of the complete primary repair of exstrophy (CPRE) while decreasing the potential risk of penile injury, an underreported complication with irreversible consequences. This complication is so devastating that a responsible surgeon should not accept many cases before exploring safer alternative to manage men with bladder exstrophy. This is the basis for reporting our experience; after performing 24 cases using CPRE, we had a case that suffered penile ischemia after pelvic osteotomies and forceful pubic approximation.
Correspondence: the complexities of cystopexy In the surgical management of paediatric urological conditions, the vesicoscopic approach has shown promise in recent years [1]. Fixation of the bladder to the anterior abdominal wall (cystopexy) is a crucial step in this approach [2]. It creates an easier access tract for bladder port insertion, and they allow misplaced ports to be easily resited into the bladder [1].
Urology Mythbusters: should hydronephrosis grade be used to decide which newborns should undergo voiding cystourethrogram? In this episode of Mythbusters the premise that among infants with prenatally identified urinary tract dilation (UTD), voiding cystourethrogram (VCUG) should be performed in those with higher grade UTD but not in those with lower grade UTD is critically examined. It is concluded that severity of dilation is not strongly associated with risk of vesicoureteral reflux or other anomalies diagnosed by VCUG. Therefore, using hydronephrosis grade to decide which infants with UTD should undergo VCUG is not evidence based.
Hydronephrosis severity score: an objective assessment of hydronephrosis severity in children—a preliminary report The main challenge in the management of antenatally diagnosed hydronephrosis and ureteropelvic junction obstruction (UPJO) is to differentiate the one that is likely to resolve from the pathological one. In this study, a new hydronephrosis severity score (HSS), combining ultrasonographic and renographic parameters, has been developed. Hydronephrosis severity score was analyzed with regard to its usefulness in assessing the severity of UPJO, postoperative resolution, and interobserver reliability.
Evidence-based treatment of multicystic dysplastic kidney: a systematic review There is a lack of a standardised protocol for the investigation and non-operative management of paediatric multicystic dysplastic kidney (MCDK). Institutional protocols for non-operative management remain essentially ad hoc. The primary outcome of this systematic review is to establish the incidence of hypertension associated with an MCDK. The secondary outcome is to determine the malignancy risk associated with an MCDK. The tertiary outcome is to assess the rate of MCDK involution. Subsequent to these, an evidence-based algorithm for follow-up is described.
Commentary to ‘A tailored surgical approach to the palpable undescended testis’ This study aims to establish whether it is possible to offer individualized interventions for the palpable undescended testis. It constitutes a retrospective chart review of 259 orchidopexies performed on 181 boys. Seventy-eight underwent bilateral synchronous procedures. A scrotal approach was used in 125 (48%) and inguinal in 134 (52%). It is important to stress that it is not comparing the two methods, but rather outlining the approach.
Commentary to ‘Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature’ The authors have done an outstanding job at presenting the available bladder and bowel dysfunction (BBD) symptomatology questionnaires and further identifying the perceived strengths and weaknesses of each tool. Generating such a list allows clinicians to critically appraise each instrument in a comprehensive manner and to choose the most appropriate tool for clinical use and assessment of their patients' needs [1].
Commentary on ‘Effect of vitamin D and omega-3 on nocturnal enuresis of 7–15-year-old children’ We read with great interest the recent contribution by Dr. Rahmani et al. [1]. They showed the beneficial effect of vitamin D on nocturnal enuresis (NE) but did not suggest the possible mechanisms in the discussion. We would like to add some considerations on the possible mechanisms of the effects of vitamin D on NE.
Remote ischemic conditioning in a rat model of testicular torsion: does it offer testicular protection? Testicular torsion is a surgical emergency mainly affecting adolescent boys, with a relatively high rate of missed torsion and testicular loss secondary to delay in prompt diagnosis and surgical intervention. With ischemic reperfusion injury as its underlying culprit, testicular torsion may respond favorably to remote ischemic conditioning (RIC) where a non-privileged site (e.g. limb) is concurrently rendered ischemic to divert the cascade of reperfusion injury from the privileged organ (e.g. testicle), thus offering a protective effect in improving salvage.
Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy Penile ischemic injury is a reported catastrophic complication after complete primary repair of exstrophy (CPRE). Aiming to improve the bladder exstrophy-epispadias repair outcomes, the study institution adopted a modified staged exstrophy repair to incorporate the advantages of CPRE by avoiding concurrent epispadias repair and adding bilateral ureteral re-implantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral re-implantation [SRBE-BUR]) at the initial repair.
Commentary to ‘One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results’ The authors present data from a retrospective review of 27 bladder exstrophy patients operated in a modified technique of the radical soft tissue mobilization (RSTM). According to their concept, they combined delayed bladder closure and RSTM as a single-stage procedure. Focussing on the safety of this modified concept, the main outcome criterion was the rate of bladder dehiscence. Secondary outcome criteria were UTI, urethral stenosis urethrocutaneous fistula and parietal hernia. Important technical details are keenly described and complemented by coherent drawings and video clips.
A tailored surgical approach to the palpable undescended testis Orchiopexy for a palpable undescended testis can be approached through a traditional inguinal incision or trans-scrotally. Despite the possible advantages of the scrotal approach, including reduced postoperative pain and shorter recovery, it is not consistently advocated.
Sexual orientation of 46, XX patients with congenital adrenal hyperplasia: a descriptive review Congenital adrenal hyperplasia (CAH) consists of a group of diseases characterized by an enzyme deficiency, particularly 21-hydroxylase deficiency. The condition may present in the simple virilizing form or in the salt-wasting form, with varying degrees of genital ambiguity. The non-heterosexual orientation is used in gender studies fields and includes bisexual, homosexual, Lesbians, gays, bissexuals, transgender, intersex, and others.
The biomechanical properties of the urethra in boys with hypospadias: a preliminary study The ventral aspect of the penis in boys with hypospadias is composed of dysplastic tissue of the skin and the urethra.The aim of this study was to assess the pre-operative size and biomechanical properties of urethrae in boys with and without hypospadias using a more objective catheter-based system.
Does a serious game increase intrinsic motivation in children receiving urotherapy? Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding.
Tubulocystic anomalies of the mesonephric duct associated with ipsilateral renal dysgenesis Renal agenesis and multicystic dysplastic kidney (MCDK) are usually associated with either an absent or atretic ureter. Occasionally, these renal anomalies may be associated with a dilated tortuous ureter, ureterocele or other cystic malformation of mesonephric duct (MND) remnants.
Long-term follow-up of bladder outlet procedures in children with neurogenic urinary incontinence Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions.
Long-term results using a transanal irrigation system (Peristeen®) for treatment of stool incontinence in children with myelomeningocele Faecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families' quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications.Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents.
Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided.
Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter? Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes.
Comparison of preputioplasty and circumcision in distal hypospadias correction: long-term follow-up A normal penile cosmesis is an important goal in distal hypospadias repair. Depending on cultural standards, repairs are combined with a preputioplasty or circumcision to attain a ‘normal’ penile appearance. Although short-term complication rates of preputioplasty are available, data on long-term outcomes are scarce. Therefore, this study assessed long-term functional and cosmetic outcomes of distal hypospadias repair with either a preputioplasty or a circumcision.
Benefits of spinal anesthesia for urologic surgery in the youngest of patients Increasing concerns regarding potential negative effects of early use of inhalational and intravenous anesthetics on neurocognitive development have led to a growing interest in alternative forms of anesthesia in infants. The study institution's outcomes with spinal anesthesia (SA) for urologic surgery in infants aged less than 90 days are reported and their outcomes with a matched cohort of patients who underwent general anesthesia (GA) are compared.
Urinary continence appears to enhance social participation and intimate relations in adolescents with myelomeningocele The majority of adults with myelomeningocele (MMC) in Western Sweden use incontinence pads. There is an ongoing discussion as to whether continence improves the quality of life (QoL) in individuals with MMC as it has been hard to establish that an increase in QoL measured by generic health-related quality of life (HRQoL) instruments is achieved by continence surgery.
Onabotulinum toxin A in children with refractory idiopathic overactive bladder: medium-term outcomes Botulinum toxin-A (BtA) has been used for refractory idiopathic overactive bladder (IOAB) in children. Data on the optimum dose success rates, duration of effect, complications and medium-term outcomes are limited. This study aims to analyse the authors' experience to provide medium-term results of BtA in symptomatic refractory patients.
The amount of urine voided in bed by children with enuresis Enuretic children wet their beds either because of nocturnal polyuria or nocturnal detrusor overactivity. Polyuric children often respond to desmopressin, whereas children with nocturnal detrusor overactivity are often therapy resistant and may have low daytime voided volumes. It is logical to assume that the enuretic event in children with nocturnal polyuria occurs with a full bladder, i.e. with the enuretic voided volume (EVV) close to the child's expected bladder capacity (EBC) for his/her age.
Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described.
Pediatric penile surgery by a nurse practitioner in the operating room With the growing shortage of pediatric urological surgeons, it was our aim to streamline our system to get patients with less complex penile procedures performed in a timely manner. To do this, an advanced practice provider (APP) was trained to perform minor penile procedures in children in the operating room(OR).
Commentary to “Improving surgical training by identifying the most common feedback trainees require for index cases” The authors present a novel opportunity to capture common feedback themes for trainees performing pediatric urological procedures. As the time we have allocated for teaching surgical technique dwindles because of productivity pressure and duty hour restrictions, we must become more efficient in our educational strategies. To this end, the authors' work to formalize an individual needs assessment could be a valuable addition to any surgical curriculum. Trainees are typically dissatisfied with the amount and quality of postoperative feedback given, in contrast to the faculty perception regarding the appropriateness of the very same feedback sessions [1].
SENS-U: validation of a wearable ultrasonic bladder monitor in children during urodynamic studies Urinary incontinence is a common problem in school-age children. Because many children remain unaware of a full-bladder sensation, the SENS-U™ Bladder Sensor was developed. The SENS-U is a small, wearable ultrasound sensor, which is positioned on the lower abdomen using a skin-friendly adhesive. The sensor continuously estimates the bladder filling status and informs the user when it is time to go to the toilet. In this study, the clinical performance of the SENS-U is evaluated in children during (video) urodynamics.
Behavioral disorders and impairment of quality of life in children and adolescents with lower urinary tract dysfunction Lower urinary tract dysfunction (LUTD) is a broad term describing the full spectrum of disorders in any of the stages of bladder function—storage or voiding LUTD is a clinical condition associated with emotional and behavioral disorders in children. This cross-sectional study aimed to investigate the association of emotional and behavioral symptoms and their impact on the quality of life (QoL) in children and adolescents with LUTD.
Variation among subspecialists in the diagnosis of urinary tract infection in children with neurogenic bladders Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have bacteriuria. However, there is no consensus on what constitutes at urinary tract infection (UTI) in this population. Multiple subspecialists are often involved in the management of these patients, although they are frequently cared for by hospitalists when admission is required.
Specific computed tomography imaging characteristics of congenital mesoblastic nephroma and correlation with ultrasound and pathology Congenital mesoblastic nephroma (CMN) is a common solid renal tumor in the neonate. Congenital mesoblastic nephroma can be divided into classic, cellular, and mixed types. The prognosis of CMN is very optimistic. But CMN can easily be misdiagnosed as the other malignant renal tumors by radiology. However, no studies have described the computed tomography (CT) imaging appearance of CNM in detail. The objective of this study is retrospective analyses of the multislice CT characteristics of CMN and their corresponding ultrasound findings and pathology.
Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR.
Penile fasciocutaneous flap urethroplasty for the reconstruction of pediatric long anterior urethral stricture Though pediatric urethral stricture is an uncommon urological problem, it is a challenging urological one. The causative factors are iatrogenic, traumatic, and inflammatory. In the current study, the authors report their experience of the treatment of pediatric long anterior urethral stricture using penile circular fasciocutaneous flap.
Comparing treatment modalities for transplant kidney vesicoureteral reflux in the pediatric population Non-refluxing ureteral reimplantation is favored in pediatric renal transplantation to prevent complications, such as vesicoureteral reflux (VUR) in the transplant ureter. VUR resulting in febrile urinary tract infections remains a problem in this population, leading to repeated hospitalizations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR.
Measurement of stretched penile length in prepubertal boys in Egypt Early diagnosis of penile size abnormalities is both medically and psychologically important. It is important in the diagnosis of penile problems. Therefore, a current established reference for penile size in newborns and children is vital for diagnosis and early management of micropenis.
Commentary on “Outcome of end cutaneous ureterostomy (EUC) as a non conservative option in the management of primary obstructive megaureters (POM)” We read with interest the article entitled “Outcome of end cutaneous ureterostomy (EUC) as a non conservative option in the management of primary obstructive megaureters (POM)” [1] recently available online, and soon to be published in the Journal of Pediatric Urology. While interesting, the discussion seems to lack a more in-depth analysis of recent trends in management, which depart from creating a temporary stoma. This paradigm shift is important to acknowledge, and a change that could be of great value to our patients.
Evaluation of applying Kinesio taping in children with urinary incontinence Physiotherapeutic methods, used in patients with urinary incontinence, are recommended and acknowledged treatment methods. They include pelvic floor muscle exercises, electrical stimulation, magnetic field, acupuncture, and biofeedback. However, the influence of Kinesio taping (KT) applications is not known. The aim of this work was to assess the influence of the KT method on the number of incontinence incidents in children. Additionally, children included in the research were given a depression level test to assess their mental state and how it is influenced by incontinence.
Predicting postoperative pain and analgesia in children after urological outpatient procedures: Is it clear? I read with great interest the article by Schröder et al. in a recent issue of the journal [1]. The authors performed a prospective study on 249 patients between 6 months and 12 years of age who underwent outpatient urological procedures and concluded that the combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. The authors should be congratulated for performing a well-designed study on an important topic (e.g.
Thirty-day hospital readmissions after augmentation cystoplasty: A Nationwide readmissions database analysis Reducing hospital readmissions is a growing priority for hospitals and clinicians in their efforts to improve quality of care and curtail costs. Augmentation cystoplasty is among the most complex and high-morbidity operations in pediatric urology, with up to 25% of patients experiencing a postoperative complication. However, there is a paucity of literature addressing the incidence and characteristics of hospital readmissions after these procedures. This information may be useful in tailoring perioperative interventions to reduce rehospitalization in this population.
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.
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.
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).
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.
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.
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).
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.
A potpourri of adolescent urology Unlike the Olympics, the World Cup and a leap year, the potpourri of adolescent urology has lain dormant for four years. Those with a lightning mathematical brain will instantly realize that the previous edition hit the press in 2014. Of course, one would like to talk of revolution or something to lift the whole subject off the page. Revolution would be overstating things, but evolution certainly seems true. We are a burgeoning bunch—with increasing interest and a developing discussion across the world.
Editorial “When we are no longer able to change a situation, we are challenged to change ourselves.”Neurologist and Psychiatrist Viktor Frankl quoted in Forbes.com.The Week 18 (899): Nov 16, 2018.
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