Laparoscopic ureteral reconstruction in infant with congenital mid ureteric valve Congenital mid ureteric valve (MUV) stenosis is a very rare cause of ureteric obstruction and hydronephrosis (HN) in children.1 Most children are initially diagnosed with more common conditions, including pelviureteric junction (PUJ) obstruction and megaureter. 2,3,4 We describe how we manage laparoscopically one case of a patient with congenital MUV.
Timing and outcomes of testicular torsion during the COVID-19 crisis During the COVID-19 crisis, there has been widespread reporting that non-COVID-19-related medical care has been delayed, even for emergent conditions. Testicular torsion is an emergent condition with higher risk of testicular loss with longer ischemic times. We sought to investigate whether patients with testicular torsion had longer time from symptom onset to initial presentation, longer total ischemic time, and higher rate of orchiectomy during the pandemic.
The value of an additional scrotal suture during orchidopexy Undescended testes present in 3 to 5% of male infants at birth. Orchidopexy is indicated to improve fertility and reduce the risk of testicular tumors. Guidelines recommend orchidopexy as early as six months of age, treatment should be finished within the age of 18 months. So far, no unequivocal proof demonstrated the superiority of one of the different surgical techniques.
Children’s experience with daytime and nighttime urinary incontinence – a qualitative exploration Much of our knowledge about the impact of urinary incontinence (UI) on children is derived from surveys. While these studies provide an overview of the UI experience, personal interviews may offer additional nuances and a more detailed perspective of what the experience of UI is for children. Objective To conduct interviews and use qualitative analysis to explore the experiences of children with UI, with a particular focus on (1) the impact of UI on participants’ lives, (2) which coping strategies children with UI use, and (3) the emotional effects of UI.
Editorial Comment Management of failed exstrophy closure remains a challenging endeavor, and efforts continue to find a single strategy to achieve the outcomes of abdominal wall reconstruction, bladder closure, and possible eventual voided continence. Unfortunately, as most surgeons, taking on these complex and difficult repairs realize, the potential variations in anatomy (preexisting, or modified due to prior reconstruction) are only limited by the numbers of patients that are evaluated. Management therefore should be individualized, based on the presenting anatomy and the availability of resources at the particular treating institution.
A novel approach in the intraoperative management of ovotesticular DSD Ovotesticular disorder of sex development (OTD) management remains challenging. In OTD, cautious gonadal evaluation and separation of ovarian and testicular components might be required to avoid virilization of a patient with female identity. Herein we report our minimal invasive approach in this very rare condition. The gonads are externalized under laparoscopic control through trocar openings. Intraoperative ovotesticular ultrasonography (US) is used for clear identification of ovarian and testicular tissue which can then be safely separated.
Urological profile of children with microcephaly and congenital Zika syndrome An outbreak of Zika virus disease, a self-limiting arbovirus infection involving skin rash and fever, occurred in Brazil in 2015 and was followed by an increase in newborns with microcephaly and brain malformations. Although two recent studies reported neurogenic bladder in children with microcephaly and congenital Zika syndrome (CZS), urologic evaluation is not yet routine. Objective: To investigate the urological profile of children with microcephaly and CZS.
Standardized Protocol for Voiding Cystourethrogram: Are Recommendations Being Followed? Background.Voiding cystourethrogram (VCUG) images the urethra and bladder during filling and emptying, as well as ureters and kidneys when vesicoureteral reflux (VUR) is present, providing detailed information about both anatomical and functional status of the urinary tract. Given the importance of information obtained, and the varying quality depending on VCUG technique and radiology reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016.
Intravascular extension of Wilms tumor: Characteristics of tumor thrombus and their impact on outcomes Studies describing intravascular involvement in Wilms tumor have focused on illustrating individual institutional experience and the elements of surgical management. Thrombus characteristics like extent, patterns of regression, and correlation with the surgical findings, intraluminal adhesion, and viable tumor in the thrombus, and patency of the inferior vena cava (IVC) have not been systematically described.
Benefits and barriers to pediatric tele-urology during the COVID-19 pandemic Telemedicine video visits are an under-utilized form of delivering health care. However due to the COVID-19 pandemic, practices are rapidly adapting telemedicine for patient care. We describe our experience in rapidly introducing video visits in a tertiary academic pediatric urology practice, serving primarily rural patients during the COVID-19 pandemic.
Re: Volumetric and acetabular changes in the bony pelvis associated with primary closure of classic bladder exstrophy This manuscript examines a small subset of bladder exstrophy patients and describes pelvic bony anatomy. 18 patients underwent an MRI after closure, between 2 and 188 days after surgery, and 1/3 of these patients had osteotomies. All patients who were included had a successful closure, but there are no selection criteria provided. Fourteen patients had a pre and post closure MRI, and found that pelvic volumes increased, however, the authors admitted that this is likely due to normal patient somatic growth.
Correspondence to “the usefulness of ultrasound examination in detecting testicular nubbin in Japanese boys with non-palpable testes” The authors report the usefulness of ultrasound (US) examination in detecting testicular nubbin (TN) in boys with non-palpable testis. They used US in detecting the testicular nubbin and choice was offered to the patients to either opt for follow-up or testicular nubbin excision. None of these patients underwent diagnostic laparoscopy to look for intra-abdominal testis. This approach deviates from the standard practice of diagnostic laparoscopy in all cases of impalpable testis. The American Urological Association and European Society for Pediatric Urology also do not recommend any radiological imaging for impalpable undescended testis (UDT).
Laparoscopic ureteroplasty with gonadal vein graft for long ureteral stenosis: A step by step video Strictures of the ureter may occur from iatrogenic injury or impacted kidney stones. Complications from ureteroscopy may result in ureteral stricture in 0,5–2% of patients. New techniques are being described in order to minimize the morbidity associated with classic approaches. This is a step-by-step video of this novel technique: a successful laparoscopic ureteroplasty with gonadal vein graft for a iatrogenic long ureteral stenosis.A 16 year old female patient, with multiple previous ureteroscopies for ureteral stones, presented with severe left lumbar pain.
Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA).
Meeting report on the NIDDK/AUA Workshop on Congenital Anomalies of External Genitalia: challenges and opportunities for translational research Congenital anomalies of the external genitalia (CAEG) are a prevalent and serious public health concern with lifelong impacts on the urinary function, sexual health, fertility, tumor development, and psychosocial wellbeing of affected individuals. Complications of treatment are frequent, and data reflecting long-term outcomes in adulthood are limited. To identify a path forward to improve treatments and realize the possibility of preventing CAEG, the National Institute of Diabetes and Digestive and Kidney Diseases and the American Urological Association convened researchers from a range of disciplines to coordinate research efforts to fully understand the different etiologies of these common conditions, subsequent variation in clinical phenotypes, and best practices for long term surgical success.
Evaluation of parental sociocultural background and education level in response to pediatric testis torsion Acute scrotal pain (ASP) remains one of the most common male urologic emergencies in the pediatric age group. The most concerning outcome of testicular torsion (TT) is the need for orchiectomy, which has a negative impact on the child's development in general and on sexual development and psychology in particular. Time is the most important factor in the treatment of TT. Parental awareness of ASP indicating the possibility of TT is a significant factor in children's hospital admission time. Sociocultural background may be an indicator in parental awareness.
Response to letter re ‘Congenital adrenal hyperplasia: Does repair after two years of age have a worse outcome?’ Although sufficient evidence is present to support early feminizing genitoplasty, we still have deficient evidence that deferred treatment after age of consent is associated with the best outcome. We still lack evidence concerning many perspectives including the psychological aspect to parents and growing child, outcome of deferred surgery, its complications and its outcome and whether satisfaction of patients with such deferred surgery will be obtained or not.
BSPU live, challenging the crisis The world has changed, 2020 will forever be remembered as the COVID-19 year. When the year started, we had amazing opportunities looking forward to exchange experiences in Pediatric Urology. Everyone was excited about the AUA, the ESPU, and we, in Latin America, the SIUP meeting which was to be held in Ecuador. In addition, who reading this letter was not excited with the joint meeting in Lisbon? The Brazilian School of Pediatric Urology (BSPU), a joint group of urologists and pediatric surgeons in Brazil with more than 200 members, was prepared to be part of the joint ESPU meeting in Portugal as supporting members, as Portugal is our mother country., Unfortunately, our world fell apart in March when the Health World Organization announced the pandemic status, from 1 min to another our small and globalized world past.
Measurement accuracy of 3-Dimensional mapping technologies versus standard goniometry for angle assessment A specific aspect of the hypospadias phenotype that may contribute to long-term outcomes is the presence of ventral penile curvature and the adequacy of its surgical correction. The current gold standard to assess this angle is intraoperative goniometry of an erect penis. 3-dimensional (3D) mapping technologies may overcome the limitations of these traditional methods through their combination of digital image and geometric replication to produce consistent 3D digital forms of a physical structure.
How geneticists think about Differences/Disorders of Sexual Development (DSD): A conversation A multidisciplinary DSD clinic offers the opportunity for different specialties to learn from each other, as each provides their own perspective and expertise to the management of these complex patients, leading to collaborative care. For the patient, a multi-disciplinary clinic can improve access to care and decrease stress, as patients see all of the specialists on one day. For urologists seeing patients with DSD within a multi-disciplinary DSD clinic as well as independently, understanding what other specialists provide can help facilitate care and referral.
Acute urinary retention in children Acute urinary retention is a common emergency in adult patients, foremost in older men. In childhood urinary retention is a rare entity with only sparse literature on the etiology.
Dorsal penile block versus caudal epidural anesthesia effect on complications post-hypospadias repair: Dilemmas, damned dilemmas and statistics The evidence examining the effects of regional blocks on complications posthypospadias repair has been controversial. Nine observational studies have been published thus far, with inconsistent and somewhat contradictory results. In this educational article, we attempt to explain the concepts of study accuracy and precision in the context of the hypospadias literature to shed some light on the reasons behind those controversies. Methodological issues such as selection bias, confounding effect, sample size, confidence interval and study generalizability from studies involving dorsal penile block versus caudal epidural anesthesia in hypospadias repair are discussed.
Adjuvant pharmacological and surgical therapy for testicular torsion: Current state of the art Although the consequences of testicular torsion (TT) have been recognized for centuries, little progress has been made to improve outcomes beyond those seen with timely scrotal exploration. Even with testicular salvage, ischemia/reperfusion injury cause significant atrophy and functional impairment. Recent efforts have sought to identify adjuvant pharmacological or surgical interventions that may attenuate these consequences. In this review, we assess the evidence supporting clinical use of these nascent interventions.
Commentary to ‘in-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement’ Antegrade continence enemas (ACE) revolutionized bowel management for patients with neurogenic bowel, anorectal malformations, Hirschsprung's disease, and chronic constipation. In addition to its high success rate in achieving continence (93% in this manuscript), it can also provide greater patient independence versus transanal enemas which can be difficult to self-administer. The initial report of ACE procedure by Malone  employed the appendix during open bladder reconstructive surgery. Modifications of the ACE procedure include laparoscopic techniques and percutaneous cecostomy tube (CT) developed by Chait at the authors' institution (reference 12).
User-centered development of a hypospadias decision aid prototype Many parents who choose hypospadias repair for their sons experience decisional conflict (DC) and decisional regret (DR). We previously found that parental decision-making about hypospadias surgery is a complex process characterized by cyclic information-seeking to alleviate anxiety and confusion.
Garrahan U-Stitch laparoscopic appendicovesicostomy – Making surgery easier Appendicovesicostomy is an established continent urinary conduit. The development of minimally invasive techniques and the reduction of operative time instigated the search for new techniques. In this video we show the laparoscopic transabdominal technique for appendicovesicostomy using U-stitch technique as proposed by Santiago Weller et al.We present a case of a teenager with neurogenic bladder and intolerance for urethral catheterization. The procedure was performed using a transperitoneal approach.
Fond memories of Howard In the early 1980s I was fortunate to be awarded a three-month travelling fellowship to study Paediatric Urology in the U.S.A. I visited Baltimore, Boston and Philadelphia. When in Philadelphia, Howard and Mimi very kindly let me stay at their house and looked after me. All was well until one night when Mimi was away and Howard and I had a cigar in his study after dinner. We went to bed and then 5 min later there was a loud noise of sirens outside and the fire brigade had arrived. The automatic fire alarm from the cigar smoke had sounded in the fire brigade, hence they had turned up.
Five years' experience of double faced tubularized preputial flap for penoscrotal hypospadias repair in pediatrics The success of techniques for proximal hypospadias repair using vascularized preputial flaps has led to their wide application for the last decade. From these techniques, transverse tubularized preputial flaps are particularly attractive. However, high reported rate of complications, including recurrence and urethro-cutaneous fistulae are still challenging the success of these techniques, probably related to vascular insufficiency for the lengthy neourethra. Therefore, many surgeons trying to improve the outcome by utilizing the unique vascular benefits of double faced preputial flap.
The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously.
Management of ischemic tissues and skin flaps in Re-Operative and complex hypospadias repair using vasodilators and hyperbaric oxygen Repeated and multiple surgeries for hypospadias result in varying degrees of scarring and hypovascularity of penile tissues which may result in poor healing and increasing complication rates with each additional repair. Vasodilator agents such as Nitroglycerine (NTG) can be helpful in the immediate postoperative period to improve flap viability. Hyperbaric oxygen therapy (HBOT) has well-established benefits to promote angiogenesis and wound healing. We hypothesized that NTG and HBOT, methods to promote blood flow and wound healing, would provide better outcomes in redo hypospadias surgeries and reduce complication rates; and, that HBOT and NTG would provide better outcomes compared to NTG alone.
New instructions for authors specific to survey studies submitted to JPU Survey research can provide valuable insights into the practices and perspectives of patients, providers, and others. Indeed, measurement of patient-reported outcomes has come to be seen as an essential component of high-quality clinical research. However, certain principles must be followed when conducting survey research to avoid results that are biased or misleading. We have observed a significant increase in the number of these papers being submitted in recent years, and in particular, an increase in papers that consist of surveys of groups of physicians or other health professionals.
Editorial “We are all in the same storm. But we are not all in the same boats”Canadian Health Official, Dr. Bonnie Henry quoted in the New York Times, (Week: June 26, 2020, Volume:20, Issue: 981, Page: 17)
Comment on “The GUD technique: Glandular urethral disassembly for distal hypospadias repair” I read the article (in press) and watched the video with great interest in the Journal of Pediatric Urology, entitled ‘The GUD technique: Glandular urethral disassembly for distal hypospadias repair’ . The authors describe the mobilization of the urethra, the incision of the glans in the midline and enclose the mobilized urethra in the glans penis. The authors use the definition of “aggressive glans deconstruction” for the urethral and glanular disassembly and propose that its refurbishment creates a much more conical and better cosmesis.
High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI.
Response to letter to the Editor re ‘Posterior urethral valves are more common in boys with hypospadias’ We thank the authors for their discussion points and agree that voiding dysfunction and atypical cystoscopic appearances are not uncommon post hypospadias repair. The patients described in the study were cystoscoped on the basis of voiding dysfunction, UTI or as part of the assessment to ensure that there was no surgical complication. Cystoscopy was performed or directly supervised by the consultant urologist involved. In the patients reported as valves the findings were of leaflets extending distally from the verumontanum which were more prominent with antegrade flow in keeping with the expected appearance of classical valves although the size was variable.
Key anatomic findings on fetal ultrasound and MRI in the prenatal diagnosis of bladder and cloacal exstrophy Prenatal determination of bladder exstrophy (BE) or cloacal exstrophy (CE), known also as the omphalocele-exstrophy-imperforate anus-spinal anomaly complex (OEIS), is challenging. Distinguishing between BE and CE is important because children with CE have many more challenges initially and during their lifetime. An accurate diagnosis is critical when counselling expectant parents. We hypothesized that there are key imaging features that can distinguish BE from CE, and that there are areas of diagnostic concordance and discordance between fetal ultrasound (fUS) and fetal MRI (fMRI) among these entities.
In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases.The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution.
Idiopathic hemorrhagic urethritis of childhood idiopathic hemorrhagic urethritis of childhood (IHU) is uncommon. Data about the disease are limited. There are no available protocols for diagnosis, treatment, or follow-up and prognostic factors are unknown.
“Functional outcome in pediatric grade IV renal injuries following blunt abdominal trauma salvaged with minimally invasive interventions” Non-operative management of higher-grade renal injuries has gradually become accepted in pediatric circles following multiple studies over the past decade which showed good renal salvage rates. However, some children do fail this conservative approach and need interventions which are mostly minimally invasive. There is still paucity of studies on the functional outcomes in this unique subgroup of patients. In this study, we review our management and functional outcome of children with grade IV renal injury due to blunt trauma of abdomen managed with minimally invasive interventions (MII) in a tertiary referral center.
Are anogenital distance and external female genitalia development changed in neural tube defects? Study in human fetuses Anogenital distance (AGD), the distance from the anus to the genitals, is a marker of normal genital development. AGD and other biometric parameters of external female genitalia are important as ultrasonographic markers that can determine fetal gender in the first trimester. Neural tube defects are one of the commonest congenital malformations of the central nervous system, with anencephaly being the most severe defect. Female genitalia development and their association with anencephaly have not been previously described.
A simulated model for fluid and tissue heating during pediatric laser lithotripsy Laser lithotripsy (LL) is a common modality for treatment of children and adolescents with nephrolithiasis. Recent introduction of higher-powered lasers may result in more efficacious “dusting” of urinary calculi. However, in vivo animal studies and computational simulations have demonstrated rapid and sustained rise of fluid temperatures with LL, possibly resulting in irreversible tissue damage. How fluid and tissue heating during LL vary with pediatric urinary tract development, however, is unknown.
Fluoroscopic imaging optimization in children during percutaneous nephrolithotrispy Radiation protection management recommends radiation exposures that are as low as reasonably achievable (ALARA), while still maintaining image quality. The aim of the study is to compare radiation exposure during pediatric percutaneous nephrolithotomy (PCNL) before and after implementation of strategy for optimization of fluoroscopic imaging by measuring the Dose Area Product (DAP) and the Fluoroscopy time (FT) and study its effect on surgical outcomes.
Toward a dry tomorrow: Novel technologies in the treatment of nocturnal enuresis In their highly innovative article, Kwinten et al. characterize the feasibility of a novel wearable ultrasonic bladder sensor for the home-based evaluation and treatment of nocturnal enuresis . As the authors appropriately describe, the SENS-U confers several advantages over traditional alarm therapy, and joins other recent notable technological advancements which may expand the clinician's toolkit in the management of nocturnal enuresis. We suggest that the SENS-U may also be useful in facilitating a more patient-centered treatment algorithm for nocturnal polyuria in tandem with other emerging technologies.
Reply to editorial comment on urinary biomarkers related to UPJO We thank the editors and reviewers for the opportunity to publish our results in JPU. While conceptually simple, finding a biomarker that reliably informs of obstruction has been frustrating. In a recent literature review of this subject, Paraboschi et al.  cited the numerous reasons for the variability of prior findings in this field, including but limited to; heterogeneity of study population and inclusion criteria, study design differences, age variation and sex. In this study we have attempted to address these by starting with a tightly defined and controlled group at the extremes (obstructed or not) by conventional criteria.
A potpourri of pediatric urology It has been a long time since I “penned” a potpouri and as I sit down to compose this we have been in “Lockdown” in Scotland for 13 weeks. I have seen all of our junior surgeons transferred to elderly care and have done my stint in general surgery. I have taken a “selfie” of myself in full PPE to show I was on the front line, but I yearn to get back to normal life. I have abandoned wearing PPE as I cannot really see what I am doing, and nobody can hear what I am saying. In fact, the risk of me succumbing to Covid is significantly less than being involved in a fatal RTA travelling to the High Court to answer for a case I have botched due to the PPE.
Molecular genetic analysis of AKR1C2-4 and HSD17B6 genes in subjects 46,XY with hypospadias The formation of the male urethra depends to enzyme-mediated testosterone (T) conversion into 5α-dihydrotestosterone (DHT). Two metabolic pathways could be operating in the fetal testis to synthesize androgens: 1) the “classic” route (T→DHT) mediated by SRD5A2 and 2) a “backdoor” pathway in which DHT is synthesized by aldo-keto reductase family 1, member C2 (AKR1C2), AKR1C3, and AKR1C4 enzymes without formation of a T intermediate.
The impact of COVID-19 on research Coronavirus disease 2019 (COVID-19) has swept across the globe causing hundreds of thousands of deaths, shutting down economies, closing borders and wreaking havoc on an unprecedented scale. It has strained healthcare services and personnel to the brink in many regions and will certainly deeply mark medical research both in the short and long-term.
Kidney injury molecule-1/creatinine as a urinary biomarker of acute kidney injury in critically ill neonates Acute kidney injury (AKI) is a complex disorder, means acute deterioration of renal function generally occurring over hours to days. Serum creatinine (SCr) is a suboptimal biomarker in neonates as the creatinine concentration reflects the maternal level for up to 72 h after birth, to improve the ability for early prediction of AKI and improve clinical outcomes, there has been a significant amount of research to identify novel biomarkers of damage to allow for the earlier identification of neonates with AKI.
Abdominoscrotal hydrocele: excision of sac may not be necessary Abdominoscrotal hydroceles (ASH) are uncommon occurrences in boys and usually treated similarly to a hernia with the assumption that there is an associated patent processus vaginalis. Treatment in this manner may be challenging due to sac size, extension and adherence to the spermatic cord. Due to the rarity of ASH, the literature is mostly limited to small, single-institution case studies.
Sutureless versus interrupted sutures techniques for neonatal circumcision; a randomized clinical trial and objective: Male circumcision is a common procedure all over the world; in Saudi Arabia, circumcision is the most frequent elective surgical procedure performed on males. The use of sutures for neonatal circumcision may decrease bleeding; however, it may lead to skin sinus formation. The objective of this study was to compare the sutureless to the interrupted sutures technique for neonatal circumcision with Gamco clamp.
Four-hour voiding observation with provocation test reveals significant abnormalities of bladder function in newborns with spinal dysraphism Four-hour voiding observation with provocation test (VOP) using a scale, a damp detector and ultrasound for determination of residuals, is an easily performed non-invasive method for the evaluation of bladder function in newborns. Neonatal bladder function evaluated with VOP has been described for healthy newborns (HN) but not for children with spinal dysraphism (SD), for whom early bladder evaluation is essential for decisions regarding Clean Intermittent Catheterization and follow-up. The aim of the present study was to describe voiding observation with provocation test in newborns with spinal dysraphism and compare with corresponding data for healthy newborns.
Hypospadias prevalence in the Emilia Romagna Region registry: Increasing or methodology? Hypospadias is one of the most common congenital anomalies in male infants, defined as incomplete development of the urethra. Despite the wealth of literature, there are conflicting data on the values and trends of prevalence, due to multifactorial origin but often also to methodological differences between studies. The aim of this study was to analyse prevalence, trends and risk factors of hypospadias in the Emilia Romagna Region, Italy.
Anatomic factors predict urinary continence in patient with anorectal malformation It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM.We performed a retrospective review of a large prospectively collected database of children with ARM.
Effect of Puppet Show on Children's anxiety and pain levels during the circumcision operation: A randomized controlled trial Surgical procedures are the most common causes of anxiety and pain in hospitalized children. One of the most common surgical procedures for children is circumcision. Surgical procedures such as circumcision in hospitals are the most common causes of pain, fear, and anxiety in children. Therapeutic play methods as non-pharmacological applications are being developed recently for children who use analgesics in the treatment of pain and anxiety. Nurses can use the game in three areas such as a care strategy for hospitalized children during daily routine practices, surgery, and invasive or painful treatment procedures.
Glans injury during ritual circumcision Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences.
Quality improvement assessment of a bianchi-technique pediatric orchiopexy perioperative pain management pathway Surgical correction of undescended testes is a common surgical procedure which can be performed via a two-incision technique or a single high scrotal incision (Bianchi technique). The Bianchi technique requires less surgical time and may be associated with less pain in the initial postoperative period, however it has been adopted slowly due to a lack of familiarity and perceived technical challenges of the technique. Traditionally postoperative orchiopexy pain is managed with a caudal or ilioinguinal/iliohypogastric nerve block.
The use of Alloderm® for correction of severe chordee in children: An initial experience Correction of chordee remains a prerequisite prior to urethroplasty in children with severe hypospadias. The use of an interposition graft is indicated when significant chordee (>300) persists after division of the urethral plate. The use of free dermis or tunica vaginalis are most often used, but the use of a pre-packaged graft material is attractive with regards to efficiency. The success with small intestine submucosa (SIS) has been variable and experience with Alloderm® has not been published.
Routine circumcision? The role of prepuce in syndactyly repair Circumcisions are among the most commonly performed procedures in the pediatric population, but the value of the preputial skin often goes unrecognized as a potential graft (Ehrlichman et al., 2018). We highlight three patients who underwent coordinated circumcision and use of the excised preputial skin as a graft for syndactyly repair. Syndactyly, a condition where fingers are fused together, is often repaired utilizing skin from the groin region, which can result in unwanted hair growth and subcutaneous fat growth.
Commentary to ‘Continence after BNR in the complete repair of bladder exstrophy (CPRE): A single institution expanded experience' This study reviews continence outcomes among 42 bladder exstrophy patients who underwent a modified Young-Dees Leadbetter bladder neck reconstruction (BNR). These patients had persistent, continuous incontinence following reportedly successful CPREs as infants and were referred to the authors’ institution for further management. Although a quarter of these patients remained continuously incontinent after BNR, more than half achieved day and nighttime continence. The authors observed that a greater number of patients who improved had had osteotomies at initial CPRE and did not have an interval ureteral reimplant before their BNR.
Individualized care for patients with intersex (disorders/differences of sex development): Part 3 The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment.
Inclusion of surgical antibiotic regimens in pediatric urology publications: A systematic review Perioperative antibiotics prevent infections after surgery. Guidelines for antibiotic use allow the surgeon to balance the risks of adverse events and drug resistance with the benefit of reduced infection rates. However, due to a lack of evidence-based guidelines within pediatric urology, antibiotic practices vary widely. We performed a systematic literature review to investigate when and how authors report their antibiotic usage and infectious outcomes. Our aim was to analyze the available data on perioperative antibiotics and infection rates within pediatric urology.
Trolox is more successful than allopurinol to reduce degenerative effects of testicular ischemia/reperfusion injury in rats Reperfusion surgery following testicular ischemia is a reproductive health threatening status and may result with organ dysfunction in men. The high level of reactive oxygen species (ROS) and cease of blood flow to the testis are the most important reasons of this testicular injury. Until today, numerous experimental studies reported that antioxidants might be efficient to alleviate oxidative stress induced organ dysfunction. For this purpose, in this study, we have investigated the protective effects of xanthine oxidase (XO) inhibitor, allopurinol, and ROS scavenger, trolox, in a comparative perspective in testicular ischemia reperfusion injury subjected rats.
Renal artery angiography in pediatric trauma using a national data set With limited pediatric renal trauma management literature, treatment pathways for children have been extrapolated from the adult population. A shift to non-operative management has led to higher renal preservation rates; however, characterization of endovascular intervention in the pediatric trauma population is lacking.
Invited commentary Morin et al.  write a systematic review of pre-malignant and invasive germ cell tumors (GCTs) in patients with differences in sexual differentiation (DSD), reviewing 386 manuscripts over a 67-year period. They found that GCTs were more common when surgery was performed in children aged 15 years of age and older, with survival being worse when GCT was found rather than when gonadoblastoma or germ cell neoplasia in situ was present.
Comment on, hyperbaric oxygen for pediatric hypospadias cripples, evaluating the advantages regarding graft take I read with interest this article where the authors discussed the role of hyperbaric oxygen therapy (HBOT) in hypospadias surgery, but I have several concerns. In compiling the references, the authors appear to have ignored several contributions on the subject, some of them are mine. This may seem trivial, but recently inappropriate accreditation and misquotation appear to be occurring frequently in the literature of hypospadias. Nowhere in the manuscript is any credit given to the classic article by Perrins and Cantab who in 1967 first investigated the use of HBOT for skin grafts in humans .
Hyperbaric oxygen therapy for pediatric “hypospadias cripple” – Evaluating the advantages regarding graft-take It is good that others are also incorporating HBOT into their care of patients who have had unsuccessful hypospadias surgery. Until recently that use was largely anecdotal, and we were not aware of the series Dr Hanna describes, since it is not found by either a Google search or in pubmed. We hope Dr Hanna will not consider this as a slight, and his earlier use of HBOT, as well as that of Perrins and Cantab, and Kara et al., were cited in a prior article by some of us .
Commentary to megaprepuce: Presentation of a modified surgical technique with excellent cosmetic and functional results We read with great interest the article written by Hirsch et al. The study is well written with a precise description of their technical points. We thank the authors for their repeated references to our study published in JPUrol in 2012 about our experience in surgically treating megaprepuce . We considered, as previously postulated by Redman , that one of the anatomical characteristics of the buried penis is rather short penile shaft skin. For that reason, we achieved coverage of the penis by unfurling the inner prepuce after partial reduction .
Calyceal diverticulum of the kidney in pediatric patients – Is it as rare as you might think? Calyceal diverticulum (CD) is rarely diagnosed in children. It mimics other cystic lesions of the kidney and may be very difficult to identify. Displaying the communication of these fluid-filled cavities with the collecting system of the kidney via imaging methods is the key diagnostic method. The purpose of this study is to determine the presence of calyceal diverticulum in pediatric patients followed up due to simple renal cyst and/or parapelvic cyst.
Response to commentary: Practice patterns in classic bladder exstrophy: A global perspective The comment to the editor is well taken. The authors agree there is considerable heterogeneity between surgeons given bladder exstrophy is a rare condition and availability of appropriate resources, e.g. pediatric orthopedic surgeons, expert pain management team, trained cadre of nursing staff, may alter the approach taken for management. In regards to experience, even in the United States, the highest volume centers have single digit number of cases on average per year . Having a global consortium or having dedicated centers of excellence around the world, not just localized in a few geographic regions, would certainly help us answer questions proposed by the commenter.
Significant rate of lower urinary tract dysfunction in patients with sacrococcygeal teratomas Sacrococcygeal teratoma (SCT) is the most commonly occurring presacral tumor and can affect the lower urinary tract by direct mass effect, or as a sequela from surgical resection. Despite the potential impact on urologic function, there is no current standard for urological involvement or follow-up for these patients. The purpose of this study was to evaluate the need for urologic involvement for lower urinary tract dysfunction (LUTD) in patients with SCTs at our institution.
Continence after BNR in the complete repair of bladder exstrophy (CPRE): A single institution expanded experience Several surgical methods have been used for primary repair of bladder exstrophy in the newborn. Complete primary repair of exstrophy (CPRE) aims to prevent the need for surgeries beyond the newborn period. Due to the rarity of bladder exstrophy, it has proven difficult in the past to analyze whether use of this method of closure truly does confer acceptable continence outcomes and hence minimizes the requirement for additional surgeries later in life.
Commentary to “Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imagingˮ The use of a triple-phase CT imaging for the evaluation of blunt abdominal trauma has significantly decreased over the most recent decade . Indeed, newer approaches to the traumatically injured patient with the use of FAST (focal abdominal sonogram for trauma), the use of serial physical evaluations of the patients while in the emergency room and when indicated the use of a split-dose contrast-enhanced single imaging CT scan, is currently the standard of care at most institutions . This methodologic sequence significantly reduces the exposure of the patient to excessive radiation dosage, and has the added benefit of ruling out concurrent intraabdominal injuries.
How to more effectively determine what is true: The limits of intuition The plethora of scientific data and explosion of published materials often leave it challenging to develop a clear and concise overview of many scientific topics. A number of factors may contribute to our misunderstanding. It is the focus of this article to describe primary reasons for failure to establish a clear, factual and functional understanding regarding scientific areas of inquiry.
Ventral penile curvature estimation using an app The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a 1 or 2-stage procedure should be done. The objective of this study was to test the accuracy of penile curvature measurements using an App-based method among non-urologists.
Ingrafts in hypospadias surgery: Longer-term outcomes The technique of hypospadias repair with a dorsal inlay graft (ingraft) was initially reserved for boys with an unfavorable glans configuration or in previously failed repairs. Although the ingraft technique has been used for some time, there is scarce literature describing its longer term outcomes. Additionally, there is minimal data comparing inner preputial skin and buccal mucosal graft outcomes in primary and reoperative surgery.
Use of retrograde pyelogram to plan for miniature open incision in pediatric pyeloplasty As robotic-assisted surgery becomes increasingly utilized for pediatric ureteropelvic junction (UPJ) obstruction, open surgeons have countered by using muscle-splitting, miniature (≤2 cm) incisions. To prepare for this type of incision during pyeloplasty, it is necessary to define the exact location of the UPJ. The use of retrograde pyelogram (RPG) at the time of pyeloplasty helps the surgeon to identify the exact location of UPJ, and thus be able to use a muscle-splitting, miniature incision for open pyeloplasty.
Opioid usage after outpatient pediatric urology I read with great interest the article of Bilgutay et al. in a recent issue of the Journal of Pediatric Urology . The authors performed a prospective study on 202 patients undergoing ambulatory urologic surgery and concluded that most pediatric patients used zero to two doses of prescription pain medication after hospital discharge following outpatient urologic surgery representing a small percentage of the total prescribed amount. The authors should be applauded for performing a well-designed study in an important topic (e.g.
Do current scientific reports of hydronephrosis make the grade? In December 2014, Nguyen et al. introduced the Upper Tract Dilation (UTD) classification scheme, hoping to unify multiple disciplines when describing ultrasound imaging of congenital hydronephrosis. We hypothesized that the academic community has been slow to adopt its use in publications.
Anterior urethral valves – A rare but challenging congenital pathology Anterior urethral valves (AUV) and associated anterior urethral diverticula (AUD) are a rare cause of congenital lower urinary tract obstruction. They occur 25–30 times less frequently than posterior urethral valves (PUV) and historically tend to have a less aggressive presentation and outcome. However, due to the low incidence, little is known about management and long-term prognosis.
Practice patterns in classic bladder exstrophy: A global perspective While evaluation and management options for classic bladder exstrophy (CBE) patients are numerous and varied, little is known regarding the relative utilization of these different methods throughout the world. A large group of exstrophy surgeons practicing globally was surveyed, seeking to document their methods of care.
Musings onleadership, quality and safety, and burnout: what goes up must come down Burnout in healthcare has been increasingly recognized over the past few decades and has recently been accepted as a recognized diagnosis by the World Health Organization. By choice, we have sought careers where unfortunately both the stakes and the chances for error are high. When a serious safety event occurs, our patients (and their families) become the first victims. Those of us in healthcare, however, can become traumatized when a poor or unanticipated adverse outcome occurs, leading to morbidity and/or mortality, and where one personally bears the responsibility.
Michael L. Ritchey 35th recipient of the American Academy of Pediatrics medal in Urology The Urology Medal was established by the Section on Urology of the American Academy of Pediatrics in 1984. It confers the highest honor given to a pediatric urologist. The medal represents outstanding contributions to pediatric urology and the care of children. Past medalists have influenced pediatric urology through their innovative minds and investigative research; others have contributed the technical skill of their hands and operative creativity; and many have been recognized for their organizational talents, leadership, and mentorship.
A case series of infants with increased VAMP7 gene dosage at birth and virilization defects Genitourinary disorders are the most frequent congenital defects in newborns; however, little is known about their etiology. Several studies have been carried out to find genetic risk factors in the development of these malformations. The expression of VAMP7 is found in testes, epididymis, seminal vesicles, prostatic tissues, penis, and urethra. Alterations in gene dose of VAMP7 were recently reported in a subset of male patients initially identified clinically by the presence of congenital genitourinary disorders.
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.
Tribute to Howard M. Snyder III Pediatric urology lost a friend on June 4th 2020. Howard McCrum Snyder III (Fig. 1) was a patriot, a consummate surgeon, an engaged teacher, a clear-thinking scholar both in and out of the operating room, and a family man who gave as generously at home as he did at work.
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