Current challenges with proximal hypospadias: we have a long way to go While major advances have been made in hypospadias surgery, most of these have come in the management of distal hypospadias. There is significant variance in approaches to proximal hypospadias repair. This is to some degree because many of us have realized that the ideal procedure to repair proximal hypospadias has not yet been determined. This article reviews the history of proximal hypospadias surgery, comparing single-stage and two-stage surgical approaches, and the authors’ current technique for proximal hypospadias repair is presented.
Commentary to 'Current Challenges with Proximal Hypospadias: We have a Long Way to Go' The authors of this review, like many of us, strived to understand the variables that impact the outcomes following proximal hypospadias repair with varying degrees of ventral curvature, and offered a review of existing knowledge and their own observations on the challenges of successful repair . Clearly there are many ways to perform hypospadias repair, and the lack of consensus suggests that we have yet to achieve sufficient understanding of each nuance of the procedure and postoperative management such as to confidently achieve success: a sentiment that was echoed by each of the four reviewers of this manuscript.
Response to Editorial comments We appreciate your comments and suggestions. Our manuscript summarized the discussion that we had about fetal lower urinary tract obstruction (LUTO) at the SFU 2016 Fall Congress in Dallas . The manuscript reviewed prenatal therapy for LUTO, including fetal cystoscopy and vesicoamniotic shunting (VAS) placement. In addition, we presented a classification of LUTO according to the degree of renal injury at the time of evaluation . Previous studies have suggested that fetal cystoscopy is the only method that allows prenatal diagnosis of the cause of LUTO .
Extracorporeal shock wave lithotripsy (ESWL) monotherapy in children: predictors of successful outcome and objectives: Although extracorporeal shock wave lithotripsy (ESWL) is the first choice for pediatric renal calculi <2 cm, the success rate after the first session is low. This is in contrast to other minimally invasive procedures like percutanous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS), which have higher rates of success. Therefore, the present study sought to identify predictors of success after one session of ESWL.
Clinical heterogeneity in children with gonadal dysgenesis associated with non-mosaic 46,XY karyotype Gonadal dysgenesis is unique in disorders of sex development (DSD), in that it can be associated with 46,XX, 46,XY or mosaic 45,X/46,XY karyotypes. Gonadal dysgenesis can be partial or complete. Gonadal dysgenesis associated with the Y-chromosome has increased risk of gonadal germ cell neoplasms. Most of the literature focus on 45,X/46,XY gonadal dysgenesis, while there are scanty data on the condition when the karyotype is non-mosaic 46,XY.
A potpourri of pediatric urology Pioneer of MRI dies. Sir Peter Mansfield the pioneer of MRI died earlier on this year. He not only led the team that developed the technology, but was also the first human to lie inside the prototype scanner. Sir Peter's life is a lesson to us all and specifically those who judge the academic abilities of children at 11. He failed the examinations to get into grammar school at this age, so went to a non-academic secondary modern school. He left at 15 to become a printer's assistant but eventually managed to study enough in the evenings to get a place at Queen Mary's College London studying physics.
Obesity and lower urinary tract dysfunction in children and adolescents: Further research into new relationships Lower urinary tract dysfunction (LUTD) involves faults in the filling and emptying phases of bladder function in toilet-trained children with no previous infection or any other obvious pathology. Lower urinary tract dysfunction is associated with conditions such as vesicoureteral reflux, recurrent urinary infection, behavioral alterations and decreased quality of life. The literature suggests an association between LUTD and obesity; however, the association between each individual symptom and obesity has yet to be evaluated.
Contralateral metachronous undescended testis: Is it predictable? Metachronous undescended testis (mcUDT), an acquired UDT after contralateral orchiopexy, can occur in some boys. If one were able to predict its occurrence, one might consider a proactive approach or at least one would be able to counsel the parents accordingly. Our hypothesis was there may be characteristics evident at the time of initial orchiopexy which could predict the development of contralateral mcUDT.
Which size of amplatz sheath should be used for pediatric percutaneous nephrolithotomy cases? We have read the study conducted by Gamal et al. with great interest . The authors reported their supine pediatric percutaneous nephrolithotomy (PNL) experiences with 27 pediatric patients. In the literature, there are very limited data about supine PNL in the pediatric age group. In this context, the present study is very attractive and valuable. In the study, the mean age of patients was 6.8 years (range 2.5–12) and the mean stone size was 32 mm (range 20–47). The tract was created by using a 22-F amplatz dilator, in cases with nondilated pelvicaliceal system (PCS) (21 patients), or a 26-F amplatz dilator, in cases with dilated PCS (six patients).
Predictors of upper tract damage in pediatric neurogenic bladder Upper tract damage (UTD) is a life-threatening complication of neurogenic bladder (NB). Early identification of risk factors for UTD and institution of remedial measures may probably prevent UTD. The aim was to study the predictors of UTD in children 2 years or older with NB.
Obituary for Dr. Bernardo Ochoa (1926–2016) It is with deep regret that the Iberoamerican Society of Pediatric Urology (Sociedad Iberoamericana de Urologia Pediatrica) announces the passing of its first President, Dr. Bernardo Ochoa, on 01 January 2017. Those who had the opportunity to meet him remember him as a man with clear and precise concepts in pediatric urology, a man who was very proud of his eloquent Spanish, and a man who always put his patients' interests first.
Obituary – John Atwell John David Atwell who died in December 2016 aged 87, played an influential role in the development of Paediatric Urology in the United Kingdom. Like his contemporaries Joe Cohen and John Scott, John Atwell made his important contributions to the specialty from a background in Paediatric Surgery.
Supporting and caring for transgender and gender nonconforming youth in the urology practice As the number of visible transgender and gender nonconforming (TGN) children, adolescents and young adults increases, pediatric urologists, due to the care they provide, are likely to see more of them. In order to provide culturally competent medical care to TGN patients and their caregivers, this article reviewed common transgender terminology, prevalence and epidemiology. Additionally, it summarized common health concerns and treatment options for these patients, so that providers could provide accurate and appropriate information.
Re. “How do they get here: Does the method of transportation impact salvage for patients with testicular torsion?” We read Weiss et al.'s retrospective review on transportation of patients with testicular torsion  with interest as it is an area we are investigating at our institution. The authors chose not to dichotomize outcomes for surgical treatment of testicular torsion by duration of symptoms. This is a methodological concern. Duration of ischemia is the primary determinant of testicular viability. By considering all presentation durations of testicular torsion together, the authors may have predisposed the results toward no effect.
The method of urine sampling is not a valid predictor for vesicoureteral reflux in children after febrile urinary tract infections The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children logically should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques.
In pursuit of the perfect penis: Hypospadias repair outcomes Hypospadias is commonly assessed and repaired by pediatric urologists. Mild, distal hypospadias is generally more a cosmetic problem than a functional one and is more frequently encountered than severe, proximal hypospadias. Outcomes following repair, especially of mild phenotypes, are important to understand, but range widely in timing and measurability. Surgical complications, postoperative satisfaction of parents, patients, surgeons and even lay observers, urinary function, sexual function, and quality of life all may be considered as relevant outcomes of hypospadias repair.
Clinic meatotomy under topical anesthesia Almost 20 years after Cartwright et al. (1996) demonstrated the feasibility and effectiveness of clinic meatotomy (CM) under topical lidocaine and prilocaine (EMLA) anesthesia, 50% of meatotomies are still performed under general anesthesia (GA) (Godley et al., 2015). The cost of a meatotomy under GA is approximately 10 times the cost of CM in the present practice. This study presented the outcomes for CM under topical anesthesia, in consecutive patients who presented with meatal stenosis secondary to circumcision.
Frequency of gonadal tumours in complete androgen insensitivity syndrome (CAIS): A retrospective case-series analysis Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive disorder of sex development (DSD) where affected individuals are phenotypically female, but have an XY karyotype and testes. The risk of gonadal tumour development in CAIS may increase with age; incidence rates have been reported to be 0.8–22% in patients who have retained their gonads into adulthood. Consequently, gonadectomy has been recommended either during childhood or after puberty is complete, although there is no consensus on the optimal timing for this procedure.
Long-term follow-up after traditional versus modified perineal approach in the management of female epispadias Isolated female epispadias (IFE) is a rare congenital anomaly. The defect extends to the bladder neck, which is usually incompetent. The traditional surgical approach includes urethral and genital reconstruction in the first year, followed by bladder neck reconstruction (Young-Dees-Leadbetter cervicoplasty (YDL)) at the age of social continence. An alternative single-stage technique includes urethral, bladder neck and clitoris repair by a perineal approach. The aim of the present study was to describe long-term follow-up of patients who underwent the traditional vs alternative approach.
Swedish infant VUR trial High-grade vesicoureteral reflux in the infant has long challenged the pediatric urologist. Resolution rates are low, there seems to be a higher risk of infection threatening kidneys that may already be compromised, and surgical repair is not for the timid. The authors continue a long tradition of detailed clinical studies in pediatric infection and reflux; the study was partially concomitant with the larger Swedish reflux trial published in 2011.
The incidence of isolated penile torsion in North India: A study of 5,018 male neonates Congenital penile torsion is a three-dimensional deformity with helical rotation of the distal corporal bodies with the penile crurae remaining fixed to the pubic rami. The first case of congenital penile torsion (hypospadias) was described in 1857. Isolated penile torsion is an under-reported anomaly. The reported incidence of isolated penile torsion is 1.7–27% and severe torsion is 0.7%. There are no studies available from Indian subcontinent on the incidence of isolated penile torque. The objective of this study was to determine the overall incidence of isolated penile torque in a north Indian population.
Genitourinary involvement and management in children with Stevens–Johnson syndrome and toxic epidermal necrolysis Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are devastating hypersensitivity disorders that cause epidermal cell death and can affect all epidermal surfaces, including the urethra, vagina, labial and scrotal skin. Despite the well-described ocular and orofacial manifestations of SJS/TEN, there is a paucity of reports on the genitourinary (GU) symptoms and their management. Specifically, consulting services often ask the pediatric urology team if it is safe to place a urethral catheter, but there is no data in the literature to help guide management.
Utility of a routine urinalysis in children who require clean intermittent catheterization Children who require clean intermittent catheterization (CIC) frequently have positive urine cultures. However, diagnosing a urinary tract infection (UTI) can be difficult, as there are no standardized criteria. Routine urinalysis (UA) has good predictive accuracy for UTI in the general pediatric population, but data are limited on the utility of routine UA in the population of children who require CIC.
New device for intermittent emptying of the bladder in female children and adolescents: A pilot study Urinary incontinence (UI) is a challenging problem for the urological community. Clean intermittent catheterization (CIC) is the most commonly used method to restore bladder emptying to the state close to the physiological condition. This procedure can cause negative aspects such as pain and possible urethral injury. In addition, there is a negative impact on self-image and decline in quality of patient's life. The aim of the present study was to evaluate the safety and efficacy of a new intraurethral self-retaining device (ISRD), in female children and adolescents, as an attractive alternative to CIC.
Coming full circle with vesicoureteral reflux: From Hutch to bladder and bowel dysfunction A comprehensive understanding of any disease process is inherently dependent on a thorough grasp of the historical events that have previously unfolded and the perspectives of key leaders in the field, which have ultimately led us to where we are today. This is particularly true for VUR, a condition that has served as a cornerstone of pediatric urology, and is largely responsible for establishing the field as a sub-specialty. Despite the relatively recent developments in the field over the past few decades, anatomical evidence for the condition dates back as early as the fifth century, as described by Galen, and into the fifteenth century, as depicted by the anatomical sketches of Leonardo da Vinci .
Commentary to ‘Proximal hypospadias repair with bladder mucosal graft: Our 10 years experience’ When I was in training, I remember reading about various methods of hypospadias repair, including techniques that are no longer in vogue. The use of bladder mucosa for proximal hypospadias repair [1,2] is one of those techniques that I thought had been relegated to the category of historical interest only, at least until reading this article. Because of the additional morbidity of an open cystotomy to harvest bladder tissue and requirement for a suprapubic catheter for an extended period, compared to the relative ease, availability, and demonstrated success of other tissue such as buccal mucosa , it would seem that bladder mucosa would no longer be practical as a first-line procedure for these kinds of complex repairs.
Urology Mythbusters: Introducing a new feature of the journal When we were on our surgical rotations as medical students, we were told by our attendings that the square knot was the strongest way to secure a running suture. It sounded plausible, and everyone else seemed to accept this as fact, so we never bothered to question the veracity of the statement. As students, we simply assumed that what was being taught to us was demonstrably correct, and that someone, at some time, had actually demonstrated the correctness of these teachings. Since the advent and evolution of evidence-based medicine, however, we have learned that many assumptions in medicine are not supported by solid evidence.
Leydig cell hyperplasia in children: Case series and review Leydig cell hyperplasia (LCH) and Leydig cell tumours (LCTs) in children are rare, typically presenting with precocious puberty. Previously, orchidectomy was the routine management; however, more recently, testis-sparing surgery has been performed with good results. We present a series of unusual presentations of LCH, raising new management questions, and a review of the literature regarding LCH and LCT in children.
The Swedish infant high-grade reflux trial: UTI and renal damage High-grade vesicoureteral reflux (VUR) in children is associated with recurrent urinary tract infection (UTI) and renal damage. Breakthrough UTI despite continuous antibiotic prophylaxis (CAP) during the first years of life is a matter of concern and evokes early intervention. We investigated whether early endoscopic treatment (ET) of VUR grade 4–5 can reduce the risk of UTI recurrence and renal scarring.
Why we need a higher suspicion index of urolithiasis in children Most children with symptoms of urolithiasis and urinary solute excretion abnormalities leading to stone formation have no calculi revealed by ultrasound or X-ray plain film (“occult urolithiasis”). This covers a large group of children presenting with common symptoms such as abdominal pain, hematuria, and dysuria, often faced by general practitioners and pediatricians. However, half or more of children with urolithiasis could present with abdominal/flank pain without specific urinary symptoms.
Antegrade sclerotherapy in adolescent varicocele patients In the 1970s, Tauber described the antegrade sclerotherapy technique to treat varicoceles, and reported a 10% recurrence rate. The present study aimed to evaluate paediatric success rates and the effect of modifications to the surgical technique.
Response to commentary to ‘Gonadal dysgenesis in disorders of sex development (DSD): Diagnosis and surgical management’ We acknowledge that gonadal management of DSD patients, like many other DSD-related issues, is controversial. Bilateral gonadectomy in children with DSD conditions with known high germ cell cancer (GCC) risk is indeed a safe option, but at a significant price in terms of need for puberty induction and subsequent hormone replacement therapy, and definite loss of fertility. For patient and parent counseling procedures it is regrettable that reliable figures on gonadal GCC risk in many DSD conditions are either lacking or at best roughly known.
Glans duplication: In-depth review and proposal of a new classification Diphallia is a very uncommon malformation, and glans duplication (GD) is its rarest form. In this last group, patients normally present with esthetic/sexual complaints or obstructed voiding late in life after pubertal genital development. Associated malformations are uncommon and relatively mild in those cases.
Re. “Comparison of variables affecting surgical outcomes of tubularized incised plate urethroplasty in adult and pediatric hypospadias” The title of the article by Bhat et al.  promises a review of variables that impact TIP results. The primary goal was to compare these in boys versus adults, and the main conclusion was that men had more complications than did boys undergoing similar repair. However, three different, widely available, online chi-square calculators finding reported complications in 10/60 (16.7%) men versus 4/60 (6.7%) boys is not significantly different (p=0.1533, and not the 0.08 found in Table 2); nor was the difference significant considering only distal repairs, 4/43 (9.3%) men versus 0/41 boys (p=0.1164, and not the 0.045 in Table 2).
Neo-yoke repair for severe hypospadias: A simple modification for better outcome Although staged repair for reconstructing severe hypospadias is more popular, various one-stage repairs have been attempted. Koyanagi repair (parameatal-based and fully extended circumferential foreskin flap urethroplasty) has enabled correction of severe hypospadias in one stage. However, its un-acceptably high incidence of complications has initiated a series of technical modifications, including the “yoke” repair.
Commentary to: Does maternal exposure during pregnancy to higher ambient temperature increase the risk of hypospadias? The authors presented a retrospective review of patients with hypospadias, and correlated the historic database temperatures during critical gestational weeks and compared them with controls. The presented results lead to the conclusion that high environmental temperatures are associated with the risk of hypospadias. Multiples studies have shown increases in prevalence rates of hypospadias during the last decades. Geographical distribution of different trends worldwide has also been clearly described [1–4].
Splenogonadal fusion in an 18-month-old Splenogonadal fusion is rare abnormal congenital connection of splenic tissue and gonad. It commonly presents with either cryptorchidism or as a palpable mass. As a benign anomaly, orchiectomy is often unnecessary. Removal of the splenic component may be accomplished with preservation of the testicle.
Mobility, hydrocephalus and quality of erections in men with spina bifida Little is known about erectile dysfunction (ED) among men with spina bifida (SB). The goal of this study was to determine quality of erections and possible factors affecting erections in this population. It was hypothesized that men who ambulate and do not have a ventriculoperitoneal shunt (VPS) are more likely to have erections sufficient for intercourse.
Outcome of urethroplasty after parenteral testosterone in children with distal hypospadias Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias.
High GMS score hypospadias: Outcomes after one- and two-stage operations Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other.
Robotic appendicovesicostomy revision in a pediatric neobladder patient Robot-assisted surgical techniques are being applied to increasingly complex procedures. However, re-operative surgeries for reconstruction are conventionally performed open, owing to the potential for intra-abdominal adhesions. In this video, we present a robot-assisted laparoscopic revision of an appendicovesicostomy channel on a patient with a neobladder.
Repair of stenosed neourethra using the proximal neourethral diverticulum – A technique in redo hypospadias surgery Neourethral diverticulum secondary to distal neourethral stenosis is not uncommon after proximal hypospadias repair. We describe a technique using the neo urethral diverticular roof and overlying skin as a composite flap to reconstruct the urethral stenosis distal to the diverticulum. The composite flap is advanced distally for reconstruction of the stenosed urethra either as a tube or as an onlay. Urethra at the diverticular bed is tubularized to reduce its caliber. This technique has yielded excellent results in three children.
Changes in levels of parental distress after their child with atypical genitalia undergoes genitoplasty The birth of a child with a disorder of sex development (DSD) and atypical genitalia can be traumatizing and isolating for families. Parents of children with DSD are at risk for increased levels of psychological distress, including depression, anxiety, illness uncertainty (IU), post-traumatic stress symptoms (PTSS), and impairments in quality of life (QOL). Our previous report indicated that although the majority of parents of children with atypical genitalia were coping well prior to the child's genitoplasty, approximately 25% of them reported experiencing some type of psychological distress.
Commentary to “Urinary continence outcome following vaginoplasty in patients with congenital adrenal hyperplasia” Stites et al.’s  report on long-term urinary continence following specific surgical approaches to vaginoplasty in the CAH population is of particular importance. The authors document a 20% incidence of continuous urinary leakage following total urogenital sinus mobilization (TUM, as described by Pena ), whereas patients undergoing partial urogenital sinus mobilization (PUM, as described by Rink ) or pull through procedures (or a combination of the two) experienced no urinary incontinence.
Response to commentary to ‘Bleeding after circumcision is more likely in children with Lichen Sclerosus (Balanitis Xerotica Obliterans)’ We thank the commentators for their review and acknowledge that there are weaknesses in the data that we analysed. The commentary suggests that 11 out of the 14 patients requiring additional surgery for bleeding had histologically proven lichen sclerosus (LS), which would clearly affect the statistical analysis of the presented data. However, this was not the case, as only six of the 14 had histologically proven LS - there was no histology sample sent in six of the 14 (presumably due to a very low likelihood of LS) and chronic inflammation of the foreskin was identified on histology in the remaining two.
Bleeding after circumcision is more likely in children with lichen sclerosus (balanitis xerotica obliterans) Over 27,000 circumcisions were performed in England in 2012–13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis xerotica obliterans, more correctly termed Lichen Sclerosus et atrophicus (LS), is one of the commonest indications for medical circumcision. To test the hypothesis that children undergoing circumcision for LS have a higher rate of postoperative bleeding than those undergoing the procedure for other reasons, we retrospectively reviewed records for patients undergoing circumcision.
Inter-rater reliability of distal ureteral diameter ratio compared to grade of VUR Management of vesicoureteral reflux (VUR) remains controversial, and reflux grade constitutes an important prognostic factor. Recent work has suggested that distal ureteral diameter ratio (UDR) is a predictive factor relative to clinical outcome independent of grade. Previous studies have noted significant inter-rater variability with grading of VUR. The present study compared inter-rater reliability of reflux grade and UDR in children with primary VUR.
The Swedish Infant High-grade Reflux Trial – Bladder function It has been suggested that infants with high-grade vesicoureteral reflux (VUR) have lower urinary tract dysfunction (LUTD) that is characterised by large bladder capacity (BC) and increased post-void residual (PVR). However, most of these infants have normal or small BC in early infancy and develop large capacity during the first year of life.
Commentary to “Prospective assessment of cosmesis before and after genital surgery” Cosmesis refers to the preservation, restoration, or bestowing of bodily beauty, whereas in a medical context it is generally defined as surgical correction of a disfiguring defect. The adjective, cosmetic, conjures a slightly different relationship of affecting only the appearance of something rather than its substance (aka function).
Mucosectomy impairs ileal microcirculation and results in flap contraction after experimental ileocystoplasty Bladder augmentation with demucosalized ileal flap is a promising alternative approach for mucus free bladder augmentation; however, the contraction of the flap is still a major concern. It has been hypothesized that mucosectomy causes ischemic damage, but no direct histological evidence has been found and attention is now focused on the urothelium cover to prevent the exposure of the denuded surface to urine or the use of balloons to keep the flaps distended.
Commentary to “Prospective assessment of cosmesis before and after genital surgery” Nokoff et al.  studied the delicate subject of cosmetic evaluation in children with atypical genital development (AGD). The authors attempt to systematize the cosmetic evaluation of AGD using measurable parameters; however, the results remain subjective and dependent on multiple variables which should be mentioned. The methodology of assessment of the genital phenotype should be challenged as it would benefit from more details. The Prader classification originally described for CAH patients erroneously correlates the degree of virilization of external genitalia with the level of vagino-urethral confluence.
Response to commentary by Goedele M.A. Beckers We thank the commentator for their kind comments on our paper on fetal megacystis, which we believe to be the first systematic review of this topic. The inclusion of case reports in systematic reviews is contentious. Some systematic reviews have by necessity had to include case reports because these represent the only available data, but single case reports tend not to be included in systematic reviews that can incorporate case series or higher levels of evidence [1,2]. In our study design, we followed the advice of systematic review experts who suggest first asking the question “Will case reports provide valid and useful information to address the key questions in our study?” We considered that bias from inclusion of single case reports would skew our data, and therefore conclusions .
Commentary to “Fetal megacystis: A systematic review” The authors of this article  are to be congratulated for their summary on the ultrasound criteria for diagnosis of fetal megacystis. As prenatal ultrasound, although evident in modern medicine, is a relatively young and evolving tool in antenatal medicine; a lack of consensus on sonographic criteria for megacystis and the description of features as bladder wall thickness, trabeculation, or the presence/absence of a keyhole sign, still exists.
Effectiveness of ureteroscopy among the youngest patients: One centre's experience in an endemic region in Turkey In recent years, the incidence of urinary stone disease reportedly has been increasing. The use of shockwave lithotripsy has seen low success rates, the inefficacy of a single session, and the need for general anaesthesia in children; additionally, children are exposed to radiation. These suboptimal treatment conditions have all led to ureteroscopy (URS) becoming the treatment method of choice for paediatric ureter stones. The aim of this study is to examine the effectiveness of 4.5-Fr URS when used on children younger than 1 year of age.
Response to commentaries on The American Academy of Pediatrics Workforce Survey for the Section on Urology 2015 The survey provides many important insights into to the practice of pediatric urology through the eyes of the practicing pediatric urologists. The editorial comment astutely extrapolates information gleaned from the survey to address: important issues related to appropriate complex reconstructive case volumes to maintain surgical proficiency; whether trainees will find positions that meet geographic expectations; and the impact of physician extenders on practice satisfaction. The fact the editorial comment stimulated a conversation of these issues justifies the effort put forth to develop the survey, review the data, and prepare the manuscript.
Commentary to “The American Academy of Pediatrics Workforce Survey for the Section on Urology 2015” The use of surveys to assess medical-workforce needs are of benefit in giving us a ‘snapshot’ regarding physicians opinions relating to the state of practice; however, the foundations of their viewpoints, in most cases, lack supporting data. Indeed, information obtained from surveys may at times be incongruent; for example, 75% of respondents reported no change in clinical volume and operative case complexity, however, 50% reported an increase in minor cases, and 40% reported a decrease in the number of open cases.
Single stage urethroplasty for perineal hypospadias in a horse: A case report Within the veterinary world, data regarding the surgical management of hypospadias is lacking. Reports within equines have documented resective phallectomy procedures rather than urethral reconstruction. This case report documents the first ever urethroplasty for an equine hypospadias, performed by a consultant paediatric surgeon. The urethroplasty was achieved by applying the same surgical principles mastered from paediatric urology to a horse. The indication for surgery was contact dermatitis of the hind-leg, which impaired the thoroughbred foal's racing potential.
Adenotonsillectomy can decrease enuresis and sympathetic nervous activity in children with obstructive sleep apnea syndrome The nocturnal intermittent hypoxia caused by obstructive sleep apnea syndrome (OSAS) can provoke the sympathetic nervous activity (SNA). Salivary alpha-amylase (sAA) is a sensitive, non-invasive biomarker for reflecting the SNA, and a useful marker for pediatric OSAS subjects. Adenotonsillar hypertrophy (ATH) is the most commonly identified risk factor in OSAS childhood, therefore, several studies showed that the adenotonsillectomy (T&A) may alleviate nocturnal enuresis (NE) in children with OSAS.
Editorial comment to: The American Academy of Pediatrics Workforce Survey for the Section on Urology 2015 Shapiro et al. detail the results of the American Academy of Pediatrics Workforce Survey for the section on Urology. We read their findings with great interest, particularly within the context of ongoing conversations about whether our specialty is training too many pediatric urologists. The authors conclude: ‘The consensus is that the number of new trainees is appropriate for the workforce needs.’ We respectfully suggest that an alternate conclusion may also be drawn, based on several key data points presented in the paper.
Lower urinary tract symptoms in children and adolescents with Williams-Beuren syndrome Williams-Beuren syndrome (WBS) is a genetic condition caused by a microscopic deletion in the chromosome band 7q11.23. Individuals with WBS may present with congenital cardiovascular defects, neurodevelopmental disturbances and structural abnormalities of the urinary tract. Lower urinary tract symptoms (LUTS) seem to be frequent in this population, but studies on this topic are scarce and based on small case series.
Hypospadias repair with the glanular-frenular collar (GFC) technique In the normal human penis, the glans wings merge in the midline ventrally, but are separated by the ‘septum glandis’ in conjunction with the frenulum. The frenulum is also included in the formation of the distal (glanular and subcoronal) urethra, which has a special part known as the ‘fossa navicularis’. This has inspired a hypospadias repair technique that simulates the development of the glanular and subcoronal urethra, which can be incorporated into the repair of all cases of hypospadias.
Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry? The main indications for adolescent varicocelectomy are testicular hypotrophy or pain. However, we have previously shown that both serial total testicular volume and volume differential are weakly associated with semen quality. The ultimate patient goal is paternity, but semen analysis is critical to appropriate management of varicocele. We hypothesize that varicocelectomy improves total motile count (TMC) among patients who only have abnormal semen analysis (SA) parameters, but not among those with potential hormonal dysfunction such as Klinefelter syndrome or cryptorchidism.
Assessment of serum level of corticotropin-releasing factor in primary nocturnal enuresis Primary nocturnal enuresis is one of the sleep related phenomena characterized by disruption in the relationship between arousal and urination. Corticotropin-releasing factor (CRF) is a neurohormone released from the paraventricular nucleus of the hypothalamus into the median eminence to elicit release of adrenocorticotrophin from the anterior pituitary. It may act to modulate autonomic function and behavior in concert with the endocrine effects. Conflicting animal studies about the role of CRF in micturition, either facilitating or inhibiting, have been raised.
The Swedish infant high-grade reflux trial: Study presentation and vesicoureteral reflux outcome High-grade vesicoureteral reflux (VUR) in infants is associated with congenital renal abnormalities, recurrent UTI, and bladder dysfunction. Endoscopic treatment (ET) is a well-established method in children with low to moderate reflux grades, but there is a lack of randomised controlled trials regarding the use of ET versus continuous antibiotic prophylaxis in infants with high-grade VUR.
Does perception of catheterization limit its use in pediatric UTI? Urinary tract infections (UTIs) affect 3–8% of febrile children annually, but correctly diagnosing UTI in young children can present a challenge. Diagnosis requires a non-contaminated urine sample, which requires catheterization or suprapubic aspiration in infants and young children that have not completed toilet training. To improve adherence to these guidelines, it is critical to understand the barriers to urine testing and catheterization.
Childhood incontinence and pelvic floor muscle function: Can we learn from adult research? Little research has been undertaken regarding pelvic floor muscle function and dysfunction in children. Apart from dysfunctional voiding, whether specific dysfunction of these muscles contributes to different types of childhood incontinence is not documented. The two areas of practice, that is adult and paediatric incontinence, are quite different; nevertheless, there may be lessons to be learned from the extensive work done in pelvic floor dysfunction and rehabilitation in adults. In this paper key points regarding pelvic floor muscle function and dysfunction in adults, and lessons that can be learned from how studies are reported and how muscle function is measured are presented.
Response to Letter to the Editor re ‘TIP hypospadias repair: A pediatric urology indicator operation’ The goal of hypospadias repair is to reconstruct as normal a penis as possible. This includes glansplasty to enclose the urethra within the glans, which is performed by approximating glans wings over the neourethra. The normal glans encloses the urethra for a distance from meatus to corona that averages 4.7 mm (SD 1.2) . We recently reported our glans dissection and re-approximation method, which is similar to both the TIP and two-stage graft repairs and achieves this goal with an average distance of 4.5 mm .
Fetal megacystis: A systematic review Fetal megacystis is variably defined and understood. The literature on fetal megacystis was systematically reviewed, focusing on prenatal diagnosis, associations and outcomes. This yielded a total of 18 primary references and eight secondary references.Fetal megacystis has an estimated first-trimester prevalence of between 1:330 and 1:1670, with a male to female ratio of 8:1. In the first trimester, megacystis is most commonly defined as a longitudinal bladder dimension of ≥7 mm. Later in pregnancy, a sagittal dimension (in mm) greater than gestational age (in weeks) + 12 is often accepted.
Response to ‘Re. Prevalence of nocturnal enuresis and its influence on quality of life in school-aged children’ We thank colleagues for the commentary on our manuscript on the prevalence of nocturnal enuresis and its influence on quality of life in school-aged children . As correctly pointed out, prevalence of daytime incontinence in our study was 18% (34/189) of children with enuresis that can be related with study population. However, the study reported that 1.7% of children had both daytime incontinence and nocturnal enuresis, similar to results from previous studies performed in Finland, England, and Turkey which indicated 1.6%, 3.3%, and 1.9% of children had combined NE and daytime incontinence [2–4].
Preputial reconstruction in hypospadias repair In principle, the prepuce can be reconstructed during hypospadias repair, but the procedure has not gained wide acceptance and preputial reconstruction (PR) is surrounded by several controversies.
Blood pressure and urolithiasis in children Urolithiasis is a condition that is most commonly found in adults, but is becoming increasingly prevalent in children. Little is known about the relationship between blood pressure (BP) and urolithiasis in children.
Utility of retrograde ureterocelogram in management of complex ureterocele Symptomatic pediatric ureterocele has diverse manifestations, making evidence-based management impractical. Thus, detailed visualization of ureterocele anatomy prior to first surgical incision is invaluable. Retrograde ureterocelogram (RUC) is a simple, underutilized radiologic technique that can be performed during cystoscopy. This study sought to determine whether RUC changes surgical management by more accurately depicting the complex ureteral and ureterocele anatomy, compared with renal ultrasound (US) and voiding cystourethrography (VCUG).
Qualitative questionnaire on the psychosocial wellbeing of mothers of children with BEEC The bladder exstrophy–epispadias complex (BEEC) represents a spectrum of malformations that affect the anatomical and functional structure of the urogenital system. The parents of patients affected by this condition are subject to particularly stressful situations, such as worrying about their child's health, long hospital stays, concerns about the health and constant need for personal care for their children, that can profoundly compromise the quality of family life.
Consequences of extensive glanular dissection I read with interest the article entitled “TIP hypospadias repair: A pediatric urology indicator operation” by Snodgrass and Bush . The authors state that the increase in glans size does not reduce the likelihood for glans dehiscence, and it is the extent of dissection into the glans wings that effectively reduces dehiscence. A logical extension of this statement is that glans dehiscence is avoided at the expense of a reduced diameter of the glanular urethra, inevitably leading to stenosis. In their unpublished data, the authors do not specifically give the results for urethral stenosis in patients with “extensive” dissection to avoid glans dehiscence.
Psychosocial outcome in adult men born with hypospadias Hypospadias, which is a surgically treated congenital malformation of the male urethra, may have a negative impact on quality of life. This aspect has previously been subject to limited research. This study examined the long-term psychosocial outcome of a large cohort of adult males born with hypospadias.
Reliability of grading of vesicoureteral reflux and other findings on voiding cystourethrography Voiding cystourethrography (VCUG) is the modality of choice to diagnose vesicoureteral reflux (VUR). Although grading of VUR is essential for prognosis and clinical decision-making, the inter-observer reliability for grading has been shown to vary substantially. The Randomized Intervention for Children with VesicoUreteral Reflux (RIVUR) trial provides a large cohort of children with VUR to better understand the reliability of VCUG findings.
Commentary to ‘Perineal ultrasound offers useful information in girls with CAH’ Congenital adrenal hyperplasia (CAH) is the commonest 46,XX Disorders of Sex Development diagnosis that leads to various degrees of genital virilization. Some patients with CAH are eligible for feminizing surgery, which consists of clitoroplasty, vaginoplasty (in which a connection between the vagina and perineum is established), or both – either performed simultaneously or as separate procedures. In functional terms, vaginoplasty is the main indication for surgical intervention, whereas clitoroplasty is optional.
Editorial comment: “Psychiatric dimensions in mothers of children with primary nocturnal enuresis: A controlled study” While much of the literature on nocturnal enuresis has focused on the psychopathology of the affected child, the novelty of this paper is the focus on the psychiatric make-up of their mothers. The authors found that mothers of children with monosymptomatic primary nocturnal enuresis (MPNE) had higher psychopathology, more abusive attitudes towards their children, and were more likely to have suffered childhood trauma than mothers without children with MPNE. They speculated that these factors are contributors to the etiology of enuresis, and concluded that assessment of the mother's psychosocial characteristics should be an integral part of the evaluation and management of enuresis.
Clitoral hoodplasty in females with disorders of sex development The surgical management of girls with masculinized genitalia is gradually changing towards a more conservative approach. Reports on loss of clitoral sensitivity and related impairment of sexual function in women after feminizing genital surgery in childhood have been pivotal in this evolution. An exposed clitoral glans is occasionally seen at follow-up, and while patients may complain of aesthetics, no clitoral discomfort secondary to glans exposure has been reported. A technique has been developed to reconstruct the clitoral hood and the present study reports the preliminary results.
Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA.
Genitourinary and gastrointestinal co-morbidities in children: The role of neural circuits in regulation of visceral function Pediatric lower urinary tract dysfunction (LUTD) is a common problem in childhood. Lower urinary tract symptoms in children include overactive bladder, voiding postponement, stress incontinence, giggle incontinence, and dysfunctional voiding. Gastrointestinal co-morbidities, including constipation or fecal incontinence, are commonly associated with lower urinary tract (LUT) symptoms in children, often reaching 22–34%. This review summarized the potential mechanisms underlying functional lower urinary and gastrointestinal co-morbidities in children.
Psychosexual development management of bladder exstrophy epispadias in complex patients Bladder-exstrophy-epispadias complex (BEEC) represents a spectrum of urogenital step-wise malformations: epispadias, complete exstrophy, and cloacal exstrophy. Psychosexual development in adolescent patients with BEEC may become especially problematic. At present, there are few contributions in the literature investigating the validity of psychosexual treatment in order to tackle this particularly emotional and personal development phase.
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.
Acknowledgement of reviewers 2016 The editors and publisher of Journal of Pediatric Urology would like to thank all of those who have reviewed for the journal over the past year. Their invaluable contribution helps ensure the journal’s continued success.
A potpourri of pediatric urology “Post Truth”. As a parent, I emphasize the importance of honesty and hard work to my children. In a year dominated by politics, lies and distortions this is proving a difficult sell. It is no surprise that the Oxford English Dictionaries word of the year 2016 is “post truth”, it is defined as an adjective used where objective facts are less influential in shaping opinion than emotional appeals. Medicine has its own “post truth” scenario with the scare around childhood vaccinations. It is ironic that the incoming US President has appointed Robert Kennedy Jr (a vaccination conspiracy theory supporter) to chair a new group on vaccine safety.
Introducing the Pediatric Urology Journal Club on Twitter The Journal of Pediatric Urology is excited to announce the Pediatric Urology Journal Club (PUJC). Beginning February 2017, JPU will sponsor monthly discussions on Twitter pertaining to peer-reviewed research articles on topics in pediatric urology. The journal club is the first of its kind in pediatric urology and one of the first in academic medicine.
Editorial “Even if you are on the right track, you will get run over if you just stand there.”Will Rogers, quoted in the Sandusky Ohio Register The Week, May 2, 2016.
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