Posterior Cloaca: A Urogenital Rather Than Anorectal Anomaly ‘Persistent Cloaca’ refers to one of the major groups of anorectal anomalies in the female when a single perineal orifice is located at the normal site of the urethra draining both urogenital and alimentary tracts. However, ‘posterior cloaca’ is a new term developed by Pena to describe a unique defect in females in which a common urogenital sinus is deviated posteriorly to open into normally located anorectum (type A) or in the perineum slightly anterior to the anus (type B).
Laparoscopic hidden incision endoscopic surgery (hides) nephrectomy VS. Traditional laparoscopic nephrectomy: Non-inferior surgical outcomes and better cosmetic results The benefits of laparoscopic total nephrectomy in pediatric patients are well established. Traditional Ports placement (TPP) still follows Clayman's classic description: except for the umbilical scar, the other laparoscopic scars are exposed in the abdomen. Advances in robotic surgery permitted the development of HidES (hidden incision endoscopic surgery) technique, to obtain a better final cosmetic aspect with the scars located intraumbilically and in the hypogastric region, in an area easily hidden by underwear.
A guide to evaluating survey research methodology in pediatric urology Surveys are one of the most common study designs in healthcare research. They are easy to undertake, have minimal cost and aim to obtain reliable and unbiased information from a population of interest. Surveys in pediatric surgery/urology are an effective tool for gathering information on clinical practices for rare and complex conditions that highlight information on their behavior, institutional disparities, and healthcare paradigms.This education article consists of using a published survey by one of the authors as an example to demonstrate both positive and negative aspects, including limitations, of survey design studies with the purpose of helping pediatric urologists develop a framework to create and critically appraise survey methodology.
A POTPOURRI OF PEDIATRIC UROLOGY I began writing this on December 9, which is the 344th day of this calendar year (though I’m certain that many of us may feel differently). On December 9, 1979, the World Health Organization announced that naturally occurring smallpox had been completely eradicated (one of only two diseases for which this has been accomplished, the other being rinderpest). In the 1700s, variolation with a less-intense variant of the virus (variola minor) was routinely used to protect people against contracting the disease.
The learning curve in proximal hypospadias repair Although the learning curve in various surgical procedures is increasingly discussed, there have been only a few reports about the learning curve especially in proximal hypospadias repair.
Evaluation of Educational Value of YouTube Videos addressing Robotic Pyeloplasty in Children Ureteropelvic junction obstruction (UPJO) is the most frequent obstructive uropathy of the upper urinary tract in children. Video-sharing platforms have become a significant source of visual information for health care providers. Among these platforms, YouTube®, (www.youtube.com), contains a high number of videos free of charge and represents one of the most important and known websites of video-sharing. YouTube® is a widely used open-access video sharing website that allows us to watch an unlimited number of video content, and to upload an infinitive number of videos.
Standardization of penile angle estimation with a semi-automated algorithm Penile curvature (PC) refers to an abnormal bending of the main longitudinal axis of the penis. It is frequently associated to hypospadias. To date, accurate and objective evaluation of PC is not easily reproducible amongst surgeons and there are no stablished protocols on how to measure PC in a standard way and in real-time to guide intraoperative decision making. For this reason, we want to present the results of creating a semi-automated algorithm to establish a reproducible and objective assessment of PC and propose it as a standard protocol for clinical applicability using inanimate 3-D penile models.
The Additive Impact of the Distal Ureteral Diameter Ratio in Predicting Early Breakthrough Urinary Tract Infections in Children with Vesicoureteral Reflux Many factors influence patient and provider decisions to surgically correct vesicoureteral reflux (VUR), including risk of breakthrough febrile urinary tract infections and likelihood of spontaneous resolution. Ureteral diameter ratio has been shown in several studies to be more predictive than reflux grade with regard to breakthrough urinary tract infection (UTI). We developed and investigated the accuracy of a computational model for predicating febrile breakthrough urinary tract infection within 13 months of starting prophylactic antibiotics in children with VUR.
Calyx to Parenchymal Ratio (CPR): An unexplored tool and its utility in the follow-up of pyeloplasty Antero-posterior trans pelvic diameter (APD) and renal scintigraphy play a significant role in the diagnosis of pelvi-ureteric junction (PUJ) obstruction and postoperative follow-up following pyeloplasty. However, the APD varies irrespective of improvement, deterioration, or preserved function in a hydronephrotic kidney is not a reliable parameter due to various factors (hydration status, compliance, and reduction pyeloplasty). Calyx to Parenchymal Ratio (CPR) is the ratio of the depth of the calyx and parenchymal thickness measured on ultrasound (USG) in coronal image.
Retractable Foreskin Reduces Urinary Tract Infections in Infant Boys with Vesicoureteral Reflux Uncircumcised males are at higher risk of urinary tract infection (UTI) in the first year of life and circumcision is recommended as an option for males with vesicoureteral reflux (VUR). Uncircumcised males treated successfully with topical corticosteroid cream have decreased risk of UTI but the role of preputial management has not been explored previously in males with VUR.
Opioid prescribing is excessive and variable after pediatric ambulatory urologic surgery Acute pain after surgery is one of the most frequent indications for opioid prescribing in children. Opioids are often not stored or disposed of safely after their use, placing children and others in the home at risk for accidental ingestion or intentional misuse. We currently lack evidence-based guidelines for post-operative pain management after common ambulatory pediatric urologic procedures. Thus, each surgeon must decide if and how much opioid to prescribe based on his/her own assumptions of perceived post-operative pain.
Remote consultations in paediatric urology–Not just for pandemics? Although some centres have successfully integrated remote clinics into their paediatric urological practice, for many, remote clinics have developed due to the COVID-19 pandemic. One UK-based institution has integrated remote clinics in their practice for over two years and has developed guidelines considering which conditions may be suitable for remote consultations. These guidelines have been appraised by the European Association of Urology Young Academic Urologists paediatric working group. Through practical experience and anticipated difficulties, we have discussed considerations that paediatric urology departments should ponder when integrating remote clinics into their practice as we move forward from the pandemic.
Gender-dependent bladder response to one-day bladder outlet obstruction BackgroundDevelopment of bladder fibrosis, loss of compliance, and voiding dysfunction are among the severe consequences of various lower urinary conditions, for example, bladder outlet obstruction (BOO), neurogenic bladder, and radiotherapy to the pelvic area. The bladder remodelling results in significant changes in bladder function and architecture, and may ultimately be deleterious for kidney function. The molecular signals underlying pathologic bladder remodelling, as well as the impact of gender, remain poorly understood.
Comment to “Identification of risk factors associated with numerous reoperations following primary hypospadias repair” I read with great interest the paper on the identification of risk factors associated with numerous reoperations following hypospadias repair and would like to commend the authors on trying to improve our understanding of outcomes following this type of surgery [1]. Data were collected retrospectively from patients who underwent reoperations for complications following primary hypospadias repair at a single institution from 2008 to 2017.
Treatment of obstructive sleep apnea does not treat primary nocturnal enuresis Primary Nocturnal Enuresis (PNE), obesity, and obstructive sleep apnea (OSA) are suggested to share a complex interaction whereby risk for PNE is increased when obesity and airway obstruction are present. We aimed to evaluate whether surgical or medical management of OSA in the treatment of patients with PNE and improves PNE outcomes.
Surveying unmet pediatric urological needs in low- and middle-income countries Access to pediatric urological surgery is low in low-and-middle income countries (LMICs). Pediatric Urological missions have often been undertaken without best practice guidelines. Many strides have been made in pediatric general surgery and other surgery but little in pediatric urology as a component of global surgery.
Barriers in transitioning urologic patients from pediatric to adult care As the advances in medicine continue to emerge, more children with congenital or pediatric-onset chronic urologic conditions are surviving well into adulthood. This imposes an ever rising there is a need for adequate transition of these patients from pediatric to adult care. Despite position statements from multiple heath care organizations and several models proposed in literature, different issues and gaps in urologic transition continue to exist. Major barriers in this transition are adolescence, a challenging time that is characterized by impulsive behavior and risk taking, and the longstanding relation between both patients and paediatric providers.
Autologous fat grafting with stem cell transplantation in an exstrophic patient. A case Lipofilling has been used in plastic surgery for breast reconstruction and treatment of burns. Carrying out minimally invasive techniques would allow treatment of hypertrophic scars and depressed suprapubic area in exstrophic patients to improve their aesthetic appearance.
Sexual function and dysfunction in men with spina bifida Spina bifida is the most common neural tube defect, which can lead to multiple urologic problems stemming from neurogenic bladder including need for lifelong renal monitoring and urinary continence. However, as males with SB age, it is clear that many also start to care about their sexuality, which may also be affected by the disease process.After reviewing the literature, the authors summarize the available information regarding sexual function and sexual dysfunction in adult males with spina bifida, specifically focusing on sexuality education, relationship status/sexual activity, continence, penile rigidity, penile sensation, ability to orgasm, ability to ejaculate, quality of ejaculation and non-genital sexual contact.
Pyeloplasty is a safe and effective surgical approach for low functioning kidneys with ureteropelvic junction obstruction Indications for treatment of ureteropelvic junction obstruction (UPJO) include symptomatic obstruction, urinary tract infections, presence of an obstructive pattern on functional renal scan and/or worsening differential renal function (DRF). This paper aims to determine the relationship between preoperative DRF and surgical outcomes after pyeloplasty. We hypothesized that low preoperative DRF is not an independent predictor of pyeloplasty failure.
Ascending testis: A congenital predetermined condition About 0.8% of boys have undescended testes at 1 year of age. However, the overall rate of orchidopexy is 2.5 times that expected. While studies have shown ascending testes accounting for a proportion of such discrepancy, the aetiology of this ascent remains controversial. In this study, intra-operative findings of patients underwent orchidopexy for ascending testes are evaluated to infer aetiology.
Transparenchymal testicular suture: A systematic review and meta-analysis highlighting the impact of additional fixation suture during routine orchiopexy Orchiopexy for cryptorchidism is one of the common day-care surgeries performed by pediatric surgeons across the globe. Although majority of the surgeons reposition the testis into a sub-dartos pouch, the practice of taking an additional transparenchymal anchoring suture is often debated. The potential risks include impaired spermatogenesis and sub-fertility. Also, a consensus statement regarding the superiority of suture fixation over no suture fixation, in terms of prevention of recurrence of cryptorchidism, is lacking.
Check cystoscopy in the management of anterior urethral valves in a cohort of pediatric patients Anterior urethral valves (AUV) are a rare cause of lower urinary tract obstruction which could progress to renal damage, Clinical presentation varies according with patient’s age and severity of obstruction, but, in most cases, diagnosis is based on voiding cysto-urethrogram (VCUG). To date, the treatment of choice is endoscopic ablation even if approved guidelines about the overall management of AUVs, including the recognition and treatment of residual valves, are not available.
Response to commentary re ‘Majority of females with a life-long experience of CAH and parents do not consider females with CAH to be intersex' Two subpopulations appear to exist among women with CAH born with atypical genitalia. The majority and minority groups differ greatly in their viewpoints regarding identifying as intersex, being legally designated as intersex, and (as a soon to be published subsequent report from this study indicates) legislation banning early surgery. This provides only further support that these challenging decisions should be made thoughtfully and in a supportive multidisciplinary environment, not legislated with a “one size fits all” approach.
Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars’ flaps.
Self- and proxy-reported outcomes after surgery in people with disorders/differences of sex development (DSD) in Europe (dsd-LIFE) Surgery is performed in many individuals with disorders/differences of sex development (DSD). Irreversibility of some surgical procedures, lack of information about the procedures, and lack of follow-up care for physical and psychological outcomes, lead to wish for more knowledge from both surgeons and patients. After the consensus conference in 2006, multidisciplinary care is provided to a higher degree with psychological support and more restricted surgical procedures. Outcome studies after genital surgery often lack of patient's perspective.
Letter to the Editor: “Protective effect of hydrogen sulfide on experimental testicular ischemia reperfusion in rats” Gains and troubles of an experimental study I have just read a previously published article in Journal of Pediatric Urology with great interest which is corresponded by Bozkurt et al. [1]. In this study, the authors investigated protective effect of hydrogen sulfide on testicular ischemia-reperfusion (I/R) with an experimental animal model. The study is well designed and I would like to congratulate the authors. While reading the mentioned article, I have identified some limitations and troubles that may lead misunderstood at the readers. Therefore, I would like to make some contributions in order to make this study more valuable and to reveal the issues that need more attention at future for experimental studies.
Editorial comment for: Extracorporeal shock wave lithotripsy in Indian children: Predictors of outcome and validation of pre-treatment nomograms, J Pediatr Urol., 2020 We know that SWL is facing a loss in popularity compared to other minimally invasive endourological methods. However, we should always keep in mind that nowadays, SWL (shock wave lithotripsy) is the only non-invasive first-line treatment method for kidney stones smaller than 2 cm. The success rate depends on the patient and the stone-related factors [1], and the patient selection is one of the most critical factors to achieve high success rates in SWL treatment. It is wise to define the patients who will benefit the most from the SWL treatment, and nomograms have been developed for this purpose.
Outcomes and costs analysis of Externalized PyeloUreteral versus internal Double-J ureteral stents after paediatric laparoscopic Anderson-Hynes pyeloplasty The gold standard treatment for Uretero-Pelvic Junction Obstruction (UPJO) is laparoscopic dismembered pyeloplasty according to the Anderson-Hynes technique. The internal Double-J ureteral (DJ) and the Externalized PyeloUreteral (EPU) stents are usually the drainage of choice. Only a few articles have compared the clinical impact of the different drainage techniques on the perioperative morbidity and none presented a cost analysis of the incurred hospital stay.
Correspondence to “Duplex systems: Top-Down or bottom-up approach?” We read with interest the article titled “Duplex systems: Top-down or bottom-up approach?” [1] The authors preferred the upper tract approach for duplex systems during their initial years of practice (2003–2009) but decided to shift the approach to the lower tract approach (after 2009) because they noted that a significant number of patients required bladder level surgery following a top down approach. The authors attempt to compare outcomes following upper tract and lower tract approach in surgical management of duplex systems.
Response to letter to editor ‘The clinical manifestations of intermittent hydronephrosis and their relationship with renal function in pediatric patients’ We are glad that our study attracted attention on the attacks of Dietls' Crisis. I think most pediatric urologists will agree that the convertional term of ‘intermittent hydronephrosis’ does not mean no pelvicaliceal system dilation during the asymptomatic intervals. As Ansell mentioned in their study, none of their cases of intermittent hydronephrosis was truly ‘normal’ between attacks. Their urogram showed minimal squaring of the renal pelvis or slight blunting of the calyxes [1]. However, the term of ‘symptomatic UPJO with Dietl's Crisis' is more precise.
Commentary: The clinical manifestations of intermittent hydronephrosis and their relationship with renal function in pediatric patients I read with great interest the article of Chen et al. in a recent issue of the Journal of Pediatric Urology [1]. The authors conducted a study to characterize the clinical manifestations and imaging results of intermittent hydronephrosis, and also to clarify parameters relating to differential renal function (DRF) loss. Their study demonstrated that children with prenatally detected hydronephrosis could develop Dietl's Crisis at an earlier age than those in whom hydronephrosis was detected after birth.
Preclinical studies of testicular ischemia-reperfusion treatment Testicular torsion occurs annually in appr. 3.8/100.000 under the age of 18 years The condition has a bimodal incidence pattern with peaks in infancy and early adolescence (1). If retorsion is performed within the first few hours, there might be a chance of preservation of testicular function, but when the time period from onset of symptoms exceeds 12 hours, the testicular function is lost. So acute surgery is mandatory, but could it be possible to get a higher success rate with supplementary measures? This is the topic of the preclinical study by ???? (2) where they explore the effect of famotidine, a competitive inhibitor of histamine H2 receptors, normally used to reduce gastric acid, to counteract the reperfusion damages to the testicular tissue?
Metabolic risk factors and the role of prophylaxis in pediatric urolithiasis Suppose that the recurrence in pediatric urolithiasis has a close relationship with metabolic abnormalities and is affected by residual burden and prophylaxis. If so, the recurrence rates could be reduced with effective surgery and appropriate prophylaxis. Here we retrospectively evaluate the metabolic risk factors data of 148 children who were operated on between January 2005 and March 2013 due to kidney stones. All patients underwent percutaneous nephrolithotomy (PCNL), and all were children. Thirteen children had a history of surgery performed to treat urological anomalies.
24-Hour Urine Collection for First Time Pediatric Stone Formers: Is it Worth it? 24-hour urine collections are recommended for motivated first-time stone formers. Given that children have a lifetime potential for recurrences, metabolic work-up has been recommended. 24-hour urine collections can be problematic, especially in children. We sought to study the benefits of 24-hour urine collections in children with stones.
Evaluating quality of patient-reported outcome measures in patients with hypospadias There is growing recognition of the importance of patient-reported outcomes (PROs) in pediatric hypospadias. We have previously presented a conceptual framework for Hypospadias-Specific Health-Related Quality of Life (HRQoL), which posited 5 domains of HRQoL in this population. The framework components (domains) included penile appearance, voiding function, social function, psychological/behavioral function, and pubertal/sexual health. In this work, we investigated the established validity and relevance of PROs within each of these domains for patients with hypospadias.
Emergency scrotal exploration in children: Is it time for a change in mindset in the UK? Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK.
Dr Jean McIldowie Smellie Image 1Dr Jean Smellie who died at the age of 93 was a paediatrician who specialised in the management of children with urinary infection. Her meticulous research was enormously important in developing our current understanding of the condition and significantly reducing the number of investigations and operations to which children were subjected.
Recurrent ventral curvature after proximal TIP hypospadias repair Most boys with proximal hypospadias have ventral curvature (VC) which must be straightened while preserving the urethral plate to use TIP repair. That is usually done by dorsal plication (DP). However, we reported recurrent VC was commonly found after DP in boys with proximal urethroplasty complications, and have diagnosed VC in patients similarly straightened by WS. We reviewed our proximal TIP patients and now report their recurrent VC.
Nerve-sparing circumcision: Myth or reality? Circumcision is a common procedure. Recently, tissue-sparing approaches have become a matter of interest, and a nerve-sparing approach is described in adults. Although circumcision is common in the practice, the nerve-sparing approach has not been evaluated in the pediatric age group.
Clinical outcomes after increasing bladder outlet resistance without augmentation cystoplasty in neurogenic bladder Patients with neurogenic bladder (NGB) and urinary incontinence (UI) due to low bladder outlet resistance may require bladder neck procedures (BNPs) to achieve continence. These patients may also have reduced bladder capacity and or elevated detrusor storage pressures that require augmentation cystoplasty (AC). AC is not without complications that include risks for bladder rupture, urolithiasis, urinary tract infections and metabolic issues. Avoidance of AC would be helpful in patients with neurogenic urinary incontinence that have safe bladder parameters in the setting of low bladder outlet resistance.
Narrow urethral plate augmentation in anterior and middle hypospadias repair: Onlay flap VS. Inlay graft. A prospective randomized comparative study The measurement of the urethral plate width (as an objective parameter) and its effect of this width on the results of tubularized incised plate urethroplasty (TIPU) have been reported in two series and both authors reported that a urethral plate width < 8 mm is associated with higher complication rates.The augmentation of the urethral plate either by dorsal inlay graft urethroplasty (DIGU) or Onlay flap has been compared with the original TIPU in different degrees of hypospadias with better surgical results in augmented cases.
Timing of inguinal hernia following complete primary repair of bladder exstrophy Introduction/background: Bladder exstrophy patients have a high prevalence of inguinal hernia that often become clinically evident following bladder closure. Understanding when the bladder exstrophy patient is under greatest risk of developing an inguinal hernia following bladder closure is important, since incarceration resulting in strangulation of intra-abdominal contents can lead to significant morbidity if not addressed in a timely fashion. Although the incidence and risk factors of inguinal hernia have been reported, the timing of occurrence is not well understood.
Structural and Chemical Heterogeneities of Primary Hyperoxaluria Kidney Stones from Pediatric Patients Calcium oxalate stones are the most common type among stone-forming patients and, in some cases result from predisposed genetic conditions. In this work, we examined the differences in structure and chemical composition between oxalate stones from patients from three groups: 1) pediatric patients that were genetically predisposed (primary hyperoxaluria) to form stones (PPH); 2) control pediatric patients that did not have such genetic predisposition (PN-PH); 3) adult patients that formed oxalate stones without the genetic predisposition (A-CaOx).
Additional VCUG-related parameters for predicting the success of endoscopic injection in children with primary vesicoureteral reflux Prediction of vesicoureteral reflux (VUR) prognosis and decision for treatment are usually made according to the reflux grading classification. But the management of VUR is still controversial since there are difficulties in distinguishing reflux grade due to inter- and intra-observer variations. Previous studies have demonstrated that the distal ureteral diameter ratio (UDR) on voiding cystourethrography (VCUG) may be more predictive for clinical prognosis than reflux grade. We aimed to predict the success of endoscopic injection in primary VUR by creating new models that include other additional parameters (timing of reflux, delayed post-voiding contrast drainage of the upper urinary tract) as well as UDR.
Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.
Antenatal biological models in the characterization and research of congenital lower urinary tract disorders Congenital lower urinary tract disorders are a family of diseases affecting both urinary storage and voiding as well as upstream kidney function. Current treatments include surgical reconstruction but many children still fail to achieve urethral continence or progress to chronic kidney disease. New therapies can only be achieved through undertaking research studies to enhance our understanding of congenital lower urinary tract disorders. Animal models form a critical component of this research, a corner of the triangle composed of human in-vitro studies and clinical research.
Response to letter to the editor re ‘Can urinary biomarkers detect obstruction defined by renal functional loss in antenatal hydronephrosis?’ We appreciate our colleagues' interest in our article [1]. There have been some well-defined problems in urinary biomarker studies throughout the 15 years of ongoing research that precluded urinary biomarkers to become a tool in daily practice for children with antenatal hydronephrosis. These difficulties include lack of standardization in studies, timing/type of urine sampling, absence of standardized clinical group definitions, and last but not the least little knowledge on normal biomarker levels by age.
Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced.
Response to letter to the editor Re: Device outcomes in pediatric sacral neuromodulation: A single center series of 187 patients We appreciate the thoughtful comments from the letter writers concerning our study. The primary goal of our study was to address the repeat surgery rate in pediatric SNM, not to address pediatric SNM efficacy. The latter has been previously addressed and supported by multiple studies. Admittedly, ours is a retrospective study over a long period of time (2002–2019) during which the horizon of treatment options for pediatric BBD was expanding. Likewise, guidelines defining the sub-types of LUTD have been under development over the course of our study period.
What the Editors are Reading – Quality improvement and patient safety Covid-19 continues to impact all of us in so many ways. At the time of this writing, Great Britain is now enduring a prolonged lockdown and both Canada and the USA are experiencing unprecedented numbers of patients infected and dying of the virus. It certainly is a time for reflection. There has been much more time afforded to me to scan the literature relating to quality improvement and patient safety (QIPS). Pertinent to QIPS is leadership development and equality, as evidenced in the 4 articles reviewed in this volume of What the Editors Are Reading.
Urodynamics in Posterior Urethral Valve: Pursuit of prognostication or optimisation Detrusor dysfunction is known to persist in several patients of Posterior Urethral Valve (PUV) after successful fulguration leading to progressive deterioration of renal function. Persistent bladder outlet obstruction (BOO) in the form of bladder neck hypertrophy, residual valves or strictures may contribute to progressive detrusor dysfunction. These are assessed radiologically or cystoscopically and are managed variedly by anticholinergics, alpha-adrenergic blockers or even bladder neck incision.
Stretched penile length and anogenital distance in Egyptian boys aged one month to five years In children with isolated unilateral undescended testis mechanical anomalies are commonly implicated and a diagnosis of simple hypospadius implies that the rest of the external genitalia are normal. Patients with disorders of sexual development, by contrast, have other associated genital anomalies including micropenis and should be referred to the endocrinologist for hormonal assessment before surgical correction of undescended testis or hypospadius. Early diagnosis of abnormal penile size is important but proper assessment begins with defining the normal population-specific age-appropriate reference range.
Definitions, indications and practice of urotherapy in children and adolescents: - A standardization document of the International Children's Continence Society (ICCS) Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training.
Assisted reproductive technologies and the risk of congenital urogenital tract malformations: A systematic review and meta-analysis A systematic review was conducted to evaluate the relationship between ART and the risk of urogenital tract malformations, especially hypospadias and cryptorchidism. Thirty-three papers were selected. Meta-analysis showed that ART was correlated with an increased risk of urogenital tract malformation in offspring (odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.41–1.85), hypospadias (OR = 1.87, 95% CI: 1.47–2.40) and cryptorchidism (OR = 1.83, 95% CI: 1.54–2.18). Among offspring conceived by ART, multiple pregnancies appeared to result in a higher risk of urogenital tract malformation than singleton pregnancies (OR = 1.42, 95% CI: 0.99–2.04; P = 0.058).
Resolution of hydronephrosis after pyeloplasty in children There is still a lack of knowledge regarding the natural course of resolution of hydronephrosis after pyeloplasty, and no consensus exists on how resolution of hydronephrosis is defined or when resolution is expected to occur.
Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear.
Extracorporeal shock wave lithotripsy in Indian children: Predictors of outcome and validation of pre-treatment nomograms Although multiple variables have been shown to affect outcomes in pediatric lithotripsy (ESWL), there is no consensus on the same. Nomograms combine multiple variables and provide an objective prediction of outcomes. Two nomograms have been previously described and validated in two studies from the same geographical area. External validation in multiple settings is needed, as a nomogram's performance may vary with time, geographical area and clinical scenario.
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. We describe how we manage laparoscopically one case of a patient with congenital MUV.We describe a 6-month-old boy born with antenatal left HN, with an anteroposterior diameter (APD) of 1,5 cm. Follow-up renal ultrasound at 3 months of age showed an increase in left kidney HN, approximately 2.5 cm below the PUJ associated with distal stenosis. Renal scintigraphy with DTPA showed an obstructive pattern.
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 3–5% 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.
Effectiveness of ultrasound-guided shockwave lithotripsy and predictors of its success rate in pediatric population: A report from a national reference center Shockwave lithotripsy (SWL) remains a well-established treatment modality for many of the pediatric renal and ureteral stones. Repeated SWL sessions carry limitations due to the use of general anesthesia and X-ray radiation. The objective of our study was to evaluate stone-free rate (SFR) of 1-session of SWL for the management of pediatric renal and ureteral stones less than 2 cm performed exclusively under ultrasound guidance and identify factors influencing its success.
Editorial Comment on “Management and outcome in Dehisced Exstrophy with a simplified bladder re-closure and further reconstruction” 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.
Letter to the editor: Trolox is more successful than allopurinol to reduce degenerative effects of testicular ischemia/reperfusion injury in rats We read with interest the recent manuscript by Seker et al. [1]. The study mentioned above investigated the therapeutic potential of Trolox therapy for preventing ischemia reperfusion injury after testicular torsion in the experimental rat model. This novel set of experiments opens the door to an intriguing possibility: an approved drug can be treatment method against testicular I/R injury. The implications of such a possibility are fascinating because infertility has become increasingly common in society.
Four-hour voiding observations detect neurogenic lower urinary tract dysfunction in neonates with anorectal malformation Neurogenic lower urinary tract dysfunction (LUTD) has been reported in 20–50% of children with anorectal malformations (ARM). As neurogenic LUTD represents an inherent risk of renal deterioration and urinary tract infections, an early diagnosis is important. The gold standard for evaluating neurogenic LUTD involves invasive urodynamic testing but a useful addition should be an easy-to-perform, non-invasive method of screening.
Spermatogenesis in pre-pubertal boys with Leydig cell neoplasms suggests paracrine stimulation by testosterone Pediatric Leydig cell tumors (LCTs) represent approximately 4% of pre-pubertal testicular tumors and are known to cause precocious puberty secondary to testosterone production. While gonadotropins and testosterone are known to initiate spermatogenesis beginning in puberty, it is yet to be determined if a similar phenomenon is triggered by isolated testosterone production in prepubescent boys.
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? 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.
Is hyperbilirubinemia a contraindication for neonatal circumcision? A survey of practice patterns of pediatric urologists and a review of the literature 50–80% of term newborns develop jaundice, or hyperbilirubinemia (HB), in their first week. The vast majority have benign etiologies, including physiologic jaundice of the newborn and breast milk/breastfeeding jaundice, which do not affect the synthetic capacity of the liver, thus conferring a low risk of peri-procedural bleeding. Though uncommon, HB in the setting of sepsis, biliary obstruction, or metabolic disease, may increase procedural bleeding risk. Circumcision of neonates with HB has not been well studied.
Expression of Mafb is down-regulated in the foreskin of children with hypospadias Hypospadias is the second most common congenital malformation in males. Although the aetiology of hypospadias is not clear, it is generally thought to be affected by both genetic and environmental endocrine-disrupting factors that affect the development of the urethra, leading to deformity.
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.
Laparoscopic robotic-assisted “keel” bladder neck construction Robotic technology has gained popularity allowing performance of several complex and difficult reconstructive procedures. This video demonstrates the advantages of the robotic approach for a “keel” bladder neck construction in an obese patient.
Editorial Comment on: 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).
Revisiting testicular torsion scores in an Asian healthcare system Testicular pain is a common presentation amongst young boys. It is important to distinguish between testicular torsion and other testicular pathology as testicular viability is dependent on timely diagnosis and surgical intervention.
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).
Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms.
Pain control in neonatal male circumcision: A best evidence review Routine male infant circumcision (RMIC) is a common procedure that inadvertently causes significant but preventable pain. In this best evidence review, we examine the available pain management options and their effectiveness for RMIC.
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.
Radiology reporting of micturating cystourethrograms (MCUGs): What the paediatric urologists want to know Micturating cystourethrograms (MCUGs) are commonly requested to exclude vesicoureteric reflux (VUR) and bladder outlet obstruction (BOO). Useful additional information including timing and bladder volume at the start of reflux, urethral anomalies and post-void drainage can be obtained from the cystograms, but are not routinely reported by radiologists.
Can urinary biomarkers detect obstruction defined by renal functional loss in antenatal hydronephrosis? Diagnosing obstruction and thus, assessment of need for surgery in the management of antenatal hydronephrosis may be challenging. Current diagnostic tests are not capable of indicating which patients are at risk for obstructive nephropathy. Biomarkers may play an important role in distinguishing these patients.
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.
Tumoral and pseusotumoral processes of the vagina in the pediatric population: A 26-YEAR retrospective study Vaginal lesions are rare and of various types in children. Clinical presentation is generally undifferenciated. Histological examination is fundamental to ascertain the nature of the lesion. Regarding tumoral lesions, histological subtypes encountered are radically different from those seen in adults, dominated by stromal benign lesions.
The incidence of epididymal anomalies in the bilateral and unilateral cryptorchidism cases: A comparative study Our study was planned based on the hypothesis that epididymal anomalies may be more incidental and more severe in cases with bilateral undescended testicles compared to unilateral undescended cases. We also aimed to review the classifications of epididymal anomalies in the literature and to establish a simpler and clinically applicable classification in the present study.
“When ablation goes wrong”- urethral strictures after ablation of posterior urethral valves-characteristics, management and outcomes” Post-ablation urethral strictures are a rare but devastating complication following transurethral ablation of posterior urethral valve which can be more difficult to treat than the valve itself. Though with the miniaturization of scopes the incidence of these strictures has decreased, sadly they still continue to occur. Hence, literature on these strictures is also limited due to the rarity of occurrence.
Volumetric and acetabular changes in the bony pelvis associated with primary closure of classic bladder exstrophy Repair of classic bladder exstrophy (CBE) is known to alter dimensions of the bony pelvic ring. Pelvic volume and acetabular configuration are additional metrics which merit analysis in the reconstruction process. Advances in magnetic resonance imaging (MRI) allow for precise elucidation of such anatomy in pediatric patients, providing enhanced knowledge of how primary reconstruction may impact factors in pelvic health.
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.
The management of testicular torsion in the UK: How can we do better? A national quantitative and qualitative analysis of the factors affecting successful testicular salvage We found variability in resource provision across England, as well as the number of explorations, and the number of unviable testicles found at exploration nationally. We received variable and incomplete data on emergency scrotal explorations and subsequent orchidectomies, very low levels of local audit and limited disclosure of incident reports. A mandatory national audit would allow more comprehensive data collection to accurately identify trends and make informed recommendations. To improve outcomes, we recommend continued education of ED and surgical teams, with mandatory testicular examination for young males presenting with abdominal pain.
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.
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.
Side predilection in congenital anomalies of the kidney, urinary and genital tracts There appear to be various patterns of sidedness with relation to the common urogenital malformations observed in pediatric urology. The objective of this statistical review was to synthesize this data and to assess if these patterns are significant.
WITHDRAWN: Introductory editorial – Basic science The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jpurol.2016.01.009. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
The lowest acceptable bladder capacity for interpretation of uroflowmetry tests in children Under- or overdistended bladder is associated with impaired bladder emptying. Therefore, uroflowmerty of low bladder capacity is regarded as irrelevant for interpretation. However, is no general consensus with regard to the lowest acceptable value of bladder capacity (LABC) for interpretation of uroflowmetry in children.
CME credits for reviews The Editorial Board of the Journal of Pediatric Urology is pleased to announce that starting in 2021, reviewers will be able to claim pediatric specific CME credits for manuscript reviews. This is made possible through a generous grant from the Journal of Pediatric Urology Company. The CME accreditation will be done through the Warren Alpert Medical School of Brown University. We would like to thank Maria Sullivan and Andrea Goldstein for their guidance, patience, and expertise in bring this to fruition.
Editorial “There are decades where nothing happens; and there are weeks where decades happen”Vladimir Ilyich Lenin
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