Urology Mythbusters: Should hydronephrosis grade be used to decide which newborns should undergo voiding cystourethrogram? In this episode of Mythbusters we critically examine 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. We conclude that severity of dilation is not strongly associated with risk of VUR 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 uretero pelvic junction obstruction (UPJO) is to differentiate the one that is likely to resolve from the pathological one. In this study we have developed a new hydronephrosis severity score (HSS) combining ultrasonographic and renographic parameters. HSS was analyzed with regards to: 1. its usefulness in assessing the severity of UPJO, 2. post operative resolution and 3. inter-observer 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 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 MCDK. The secondary outcome is to determine the malignancy risk associated with 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. 78 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.
Remote Ischemic Conditioning (RIC) 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.
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. Focusing 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 transscrotally. 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.
Does a serious game increase intrinsic motivation in children receiving urotherapy? Urotherapy is considered the treatment of choice for children suffering day time 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. We hypothesize 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.
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.
Robotic-assisted laparoscopic excision of prostatic utricle in a 3 year old Prostatic utricles have traditionally been excised via the open approach or laparoscopically. Recently the robotic-assisted laparoscopic approach has been described in a 19 year old male. We present the case of a 3 year old male with a disorder of sexual development (mosaic 45X/46 XY), with multiple associated anomalies, who presented with recurrent UTI. Renal/bladder ultrasound revealed normal bilateral kidneys, and a 4.3x2.8x3.3 cm cystic mass in the midline posterior to the bladder. Voiding cystourethrogram demonstrated a large cystic mass behind the bladder concerning for large prostatic utricle.
Perineal hypospadias: back to the future Chordee Excision & Distal Urethroplasty Perineal hypospadias correction has swung from two-stage repair in the 1960s to one-stage repair in the 1980s and back to two-stage repair in the 2000s. The author's experience with a technique in which Chordee Excision and Distal Urethroplasty (CEDU) was performed at the first operation leaving a 1-cm segment as perineal urethrotomy to be reconstructed at the second operation is presented.
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.
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.
The ability of a limited metabolic assessment to identify pediatric stone formers with metabolic abnormalities American Urological Association guidelines recommend a urinary metabolic evaluation after the first stone event in all pediatric stone patients. Prior studies identified hypercalciuria and urine hypovolemia as the most common abnormalities in children with urolithiasis. Recent data suggest that hypocitraturia is most prevalent. It was hypothesized that a limited evaluation would detect the majority of clinically significant metabolic abnormalities in pediatric stone formers.
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 .
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.
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.
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.
How the ESPU grades clinical abstracts The ability to consistently review abstracts in an unbiased and objective fashion is a skill that most academics hope to master. However, robust standardized rating systems are sparse, with most scientific boards leaving the task of rating abstracts poorly defined and at the whim of the reviewer. In an effort to bring consistency to this process, in 2013, the ESPU board adopted an abstract rating system that has been previously used in the field of plastic surgery and orthopedics. (van der Steen et al., 2004; Poolman et al., 2007).
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.
Frontiers in pediatric testicular torsion: An integrated review of prevailing trends and management outcomes Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology.
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 . 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.
Laparoscopic ureterocalicostomy in children: The technique and feasibility Ureterocalicostomy is a salvage technique commonly used for failed pyeloplasties; it has also been reported as a primary procedure in ureteropelvic junction obstruction (UPJO). This video describes the technique of laparoscopic ureterocalicostomy for primary UPJO in a child with a malrotated kidney and parenchymal thinning.A 13-year-old girl with symptomatic UPJO was found to have a malrotated kidney with a high posterior insertion of the ureter. A laparoscopic dependent ureterocalicostomy over a double-J stent was performed.
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.
Obituary: A tribute to Prof. Dr. Alfred Sigel On September 25, 2017, Dr. Alfred F. Sigel, the eminent long-standing Professor of Urology at the University Hospital of Erlangen and great pioneer of German Paediatric Urology, died at the wonderful age of 96 (see Fig. 1).
The Cologne pouch procedure for continent anal urinary diversion in children with bladder exstrophy–epispadias complex In children who remain incontinent after reconstruction of bladder exstrophy–epispadias complex (BEEC), continent anal urinary diversion (CAD) is one option to achieve continence. Known problems after CAD are an increased stool frequency and ureterointestinal stenosis. We devised a new surgical technique of CAD that we named the “Cologne pouch procedure” (CPP) that renders the possibility of separate evacuation of urine and feces. Furthermore, we connect the bladder plate to the rectosigmoid pouch instead of performing a ureterosigmoidostomy to reduce the rate of ureterointestinal stenosis.
Combination treatment for cicatrix after neonatal circumcision: An office-based solution to a challenging problem Cicatrix formation, which can form after neonatal circumcision to entrap the glans penis, presents a therapeutic challenge. Previous studies in the literature have described either using a topical steroid cream or stretching of the scar tissue with an instrument but not a combination of both modalities. In our experience, monotherapy has resulted in significant recurrence and/or need for further treatment. We present our successful experience that combines cicatrix stretching with a hemostat using local anesthesia in the office followed by several weeks of topical steroids with a minority of patients needing any additional therapy.
Is distal hypospadias repair mostly a cosmetic operation? The answer is no, for several reasons. First, the American Society of Plastic Surgeons, British Association of Plastic Reconstructive and Aesthetic Surgeons, and the Australian Society of Plastic Surgeons, all define “cosmetic” surgery as procedures done to “enhance and reshape normal body structures to improve appearance and confidence”. But a penis with hypospadias is not a normal penis. Therefore, surgery to correct hypospadias is “reconstructive surgery”, done to “treat body structures affected aesthetically or functionally by congenital defects”.
The effect of surgeon versus technologist control of fluoroscopy on radiation exposure during pediatric ureteroscopy: A randomized trial Fluoroscopy is commonly used during pediatric ureteroscopy (PURS) for urolithiasis, and the most important contributor to overall radiation exposure is fluoroscopy time (FT). One factor that may impact FT is who controls activation of the fluoroscope: the urologist (with a foot pedal) or the radiation technologist (as directed by the urologist). While there are plausible reasons to believe that either approach may lead to reduced FT, there are no systematic investigations of this question. We sought to compare FT with surgeon-control versus technologist control during PURS for urolithiasis.
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.  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 .
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 . 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.
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’ . 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.
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 . 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 (MRKH) syndrome 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 well-being. The goal of laparoscopic sigmoid vaginoplasty is a to create a functional self-lubricating vagina via a 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.
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).
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.
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.
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.
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.
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 . The authors specified that, in general, GFC is not specifically addressed in urethroplasties.
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.
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 . 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.
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.
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.
Response to “Re: 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.
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.
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.
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.
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).
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 . 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.
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.
Adolescent urology In this edition, Zillioux and colleagues explore “transition clinics” and characterize current practice patterns and opinions regarding care for urologic patients with congenital conditions amongst pediatric urologists who responded to an on-line survey. About a third of respondents participated in a formalized clinic for such patients. Over half (55%) of the clinics at the respondent's institutions are staffed solely by a pediatric urologist. Twenty-nine percent have staffing by both adult and pediatric urologists.
A potpourri of pediatric urology As your usual correspondent warms his chilblains after a longer than usual winter, this month's contribution is provided by a guest author from the far North of Scotland. Although spring has officially arrived, snow still tops the hills around his fair city but the fairways and greens are open and ready so all is well.
Aviso para pacientes:
Esta página contiene información urológica dirigida a profesionales de la sanidad.
Si tiene algún problema relacionado con esta patología,
consulte con su urólogo o médico de familia.
Si desea información diseñada para pacientes y público general. puede visitar:
Portal de Información Urológica para Pacientes