Evidence Based Medicine III; Level of evidence The present article is the third installment in a five part series related to evidence based medicine (EBM) provided by the European society for pediatric urology (ESPU) research committee. It will present the different levels of evidence (i.e. systematic review, randomized controlled trial, cohort study) available to clinicians and researchers and describe the strengths of each study type. While EBM provides a valuable construct to aid in medical decision-making, it remains imperative that this information be interpreted and applied in the clinical context with a good dose of common sense.
Embracing Change—The Time for Pediatric ERAS is Now The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues and has culminated in a new standard of care for a variety of surgical procedures.[1] To date however, the concepts of ERAS have been embraced more slowly in the pediatric surgical subspecialties. On November 30th, 2018 at Virginia Commonwealth University in Richmond, Virginia, the first World Congress for Pediatric Enhanced Recovery After Surgery (ERAS) was held, bringing together experts from across the globe.
Anterior approach retroperitoneal laparoscopic renal surgery in children Retroperitoneoscopic renal surgery is performed by lateral or posterior approaches. Iterative modification led to development of an alternative “anterior” approach. We report our experience with this novel approach in a prospective series of 69 children that includes 17 infants. Mean operating time was 225 minutes for reduction pyeloplasty. Peritoneal tear is not uncommon (22%) but often doesn’t require conversion. In our early experience, the conversion rate was 17% and postoperative complications 2.9%.
Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion To determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room (ER) throughput, and distance travelled) affect orchiectomy rates in minors with testicular torsion (TT) using a National database.
The Learning Curve of Contrast-Enhanced “Microbubble” Urosonography – A Validation Study Vesicoureteric reflux (VUR) is a common pediatric urologic condition associated with urinary tract infection and pyelonephritis. It can be diagnosed via fluoroscopic voiding cystourethrogram (VCUG) and, more recently, contrast-enhanced voiding ultrasonography (ceVUS), which does not expose the patient to ionizing radiation. CeVUS contrast agents for the diagnosis of VUR have been widely available in Europe but were only FDA-approved for use in the United States in 2016.
Mental Health Status Of Individuals With Sexual Development Disorders: A Review Health care recommendations for people with Disorders of Sex Development (DSD) include mental health attention and active participation of psychiatrists and psychologists in dedicated multidisciplinary teams. Thereby, it seems crucial for them to improve knowledges about specific difficulties and needs of these patients. The aim of this paper is to report in a synthesising manner the recent works evaluating the mental health and psychological status of individuals with DSD. After research conducted using PUBMED and SCIENCEDIRECT, 18 studies were inventoried and qualitatively analyzed in response to three main questions: do individuals with DSD suffer more frequently and/or more severely from psychological conditions or mental disorders? From what kind of disorder do they suffer? What are the determinant factors involved in their development? Our work highlights an increased risk of affective disorders in individuals with DSD, particularly anxiety and depressive disorders and interpersonal difficulties.
Sens-U: Clinical Evaluation Of A Full Bladder Notification – A Pilot Study Urinary incontinence is one of the most commonly treated disorders in children at school-age. Recently, a new, wearable bladder sensor became available, the SENS-U® Bladder Sensor. The SENS-U is a small, wireless ultrasonic sensor, which continuously monitors the bladder filling and provides a personalized notification when it is time to go to the toilet. In this study, the aim is to examine the performance of the SENS-U as a full-bladder-based notification system in children during daily life activities.
Suprapubic Grasper assisted Transvesical Endoscopic Ureterocele Puncture (SATUP): A Novel Technical Innovation Although endoscopic drainage remains treatment of choice for ureterocele in pediatric age group but often urologist especially during learning phase and difficult anatomy feel limitation due inability to do intra-vesical manipulation. This can be attributed to absence of second working channel in pediatric cystoscope owing to size limitation. Here in, we describe novel technique for safe introduction of grasper which acts as second surgical arm for endoscopist and simultaneously facilitates both intravesical manipulation and drainage of ureterocele at optimal location with minimal complications.
The Effect of Intraurethral Dexpanthenol in Hypospadias Repair:Experimental Rabbit Study In our study we aimed to research the histopathologic effects of intraurethral use of dexpanthenol for hypospadias repair. Dexpanthenol is a derivative of pantothenic acid, a B complex vitamin. Pantothenic acid is a molecule taking part in the structure of coenzyme A. It decreases the release of myeloperoxidase from granulocytes and inhibits formation of free oxygen radicals, and it exhibits an anti-inflammatory effect by increasing mitotic activity.
Semen analysis in adolescents with familial mediterranean fever Little is known about sperm health in male patients with FMF. In this study we aimed to search the frequency of sperm abnormalities of adolescent boys with FMF and also to investigate whether disease activity or colchicine treatment have negative effects on sperm parameters.
More Anxious or More Shy? Examining the social anxiety levels of adolescents with PEN: A controlled Study Enuresis Nocturna (EN) is very common worldwide, and psychiatric disorders are 1.3–4.5 times higher in children with EN. When we focus on symptoms of individuals with EN, we figured out that they were impaired in social and emotional skills because of the dramatic consequences of EN. We presume that, in spite, a lack of psychiatric comorbidity, Primer Enurezis Nocturna (PEN) itself and its consequences may increase adolescents' social anxiety (SA) leading to adulthood mental diseases.
Factors associated with delay in undescended testis referral Undescended testis (UDT) is one of the most common congenital disorders and is associated with infertility and testicular cancer. Multiple guidelines internationally have recommended orchiopexy by 18 months. Multiple large retrospective studies published in the last decade have found persistent delay in timing of orchiopexy.
The overlooked association between lower urinary tract dysfunction and psychiatric disorders: A short screening test for clinical practice. Lower urinary tract dysfunction (LUTD) often presents with other associated comorbidities such as urinary tract infections, constipation, fecal incontinence, and vesicoureteral reflux. However, the psychiatric conditions that can be associated with LUTD tend to go unnoticed. The evaluation, diagnosis, and treatment of children with LUTD and psychiatric disorders is difficult and time-consuming. Moreover, there is currently no accepted consensus on this subject.
Response to commentaries re 'Variations of sex development First German interdisciplinary Consensus Paper' The authors of the consensus paper represent the main medical clinics, institutions and organizations in Germany involved with DSD-patients. With regard to the structure of the consensus paper, there is a distinction between an S2k- and S3-level paper. An S2k-level paper requires the participation of persons who represent those institutions/groups for whom the consensus is written. A formal consensus process has to be guaranteed but a systematic review of the literature is not necessary.
Laparoscopic pediatric pyeloplasty using the Flexdex® articulating needle driver: step-by-step video Ureteropelvic junction (UPJ) stenosis is the most common cause of pathological neonatal hydronephrosis. UPJ obstruction may be treated conservatively in some cases, but surgery is indicated if symptoms occur or renal function deteriorates.Pyeloplasty is the procedure of choice for UPJ stenosis. Pyeloplasty can be done by open laparoscopic or robotic technique. The laparoscopic technique is safe and may be associated with shorter length of hospital stay and reduced complications. Lately, robotic pyeloplasty has been done with similar results adding the benefits of easier suturing maneuverability, but with increased costs.
Commentary to variations of sex development: first German interdisciplinary consensus paper This manuscript, resulting from a German interdisciplinary consensus conference studying management of children with Disorders of Sexual Development (DSDs), presents a series of 38 recommendations with supporting discussion. Not surprisingly, there is considerable agreement with the recommendations of the 2005 Chicago consensus conference, which it emulates. But, there are also crucial differences that deserve heightened attention and examination.
Access for retroperitoneoscopic surgery Retroperitoneoscopic surgery is used for a variety of renal and adrenal procedures in the paediatric population. This can be a challenging procedure but has advantages over open and transperitoneal laparoscopic approaches. This VideoBank article aims to aid the surgeon in gaining safe and efficient access for retroperitoneal surgery by demonstrating key steps including patient positioning and optimal trocar placement.
Reverse pedicle flap as a barrier layer for circumcised patients with megameatus hypospadias Intact prepuce megameatus hypospadias is seen in approximately 5% of all hypospadias cases. Unfortunately, many of these children are inadvertently circumcised at birth, creating a dilemma for obtaining good barrier layer coverage at the time of surgical repair. Hill and Waxman et al. described a novel way to provide coverage in the form of a reverse pedicle flap that is presented in this video. Over the past year, 6 boys with megameatus variant hypospadias presented to the authors' service in a circumcised state.
Robotic Assisted Laparoscopic Mid Ureteral Stricture Repair and Percutaneous Stent Placement in an Infant With the widespread use of ultrasound during pregnancy, 1-3% of fetuses are diagnosed with hydronephrosis1. Commonly congenital obstructing lesions are located at the proximal and distal ends, and congenital mid ureteral strictures are relatively rare, reported as 4-5% of cases of urologic obstruction2. The treatment for an obstructing segment of the ureter is removal and anastomosis of the ureter3. Historically these were performed open, and then laparoscopically, but with the widespread use of robotic assistance for laparoscopic surgery, many pediatric urologists perform pyeloplasties using robotic assistance.
The use of nitrofurantoin for children with acute cystitis caused by extended-spectrum Β-lactamase–producing Escherichia coli Acute cystitis in children caused by extended-spectrum β-lactamase (ESBL)–producing Escherichia coli (E. coli) is on the rise. Treatment of these is usually parenteral treatment. The aim of this study was to investigate the clinical and microbiological efficacy of oral nitrofurantoin treatment in children with lower urinary tract infection (UTI) caused by ESBL-producing E. coli.
Parental home removal of urethral catheters after urological surgery—a prospective benchmarking study Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution.
Outcome of kidney transplantation from young pediatric donors (aged less than 6 years) to young size-matched recipients Pediatric donation is underutilized because of presumed increased risk of vascular thrombosis (VT) and graft loss. Using young pediatric donors (YPDs) for young pediatric recipients (YPRs) is suggested to be even at greater risk and therefore precluded in many centers. The aim of this study was to analyze the outcome of kidney transplantation (KT) from YPD to age-matched YPR.
Real-time kidney graft perfusion monitoring using infrared imaging during pediatric kidney transplantation Ischemia times in kidney transplantation have shown to be predictive for future graft function. Preservation solutions and anticoagulation protocols have improved the management of pediatric kidney transplantation. Nonetheless, there is no current tool for intraoperative graft monitoring. The aim of our project is to present a novel technique for intraoperative real-time assessment of graft perfusion using a non-invasive infrared camera.
Commentary to “Outcome of end cutaneous ureterostomy (ECU) as a non conservative option in the management of primary obstructive megaureters (POM)” Authors present the results of a retrospective case series of patients who underwent end cutaneous ureterostomy (ECU) for obstructive megaureters (OMUs) during a 10-year period. Their results are comparable with those of other series of cases that have been described before [1]. The mean age at the moment of diversion was 7 months. Our position with regard to the potential damage that obstruction can cause to renal units in the early years of life implies to take actions sooner rather than later, and we are pleased to see that authors decided to do diversions at an early age.
Immune expression in children with Wilms tumor: a pilot study Given improvements in multimodality therapy, survival among children with Wilms tumor (WT) exceeds 90%. However, 15% of children with favorable histology and 50% of children with anaplastic WT experience recurrence or progression. Of patients with advanced disease, only 50% survive to adulthood. In adult malignancies (including renal tumors), patient survival has improved with the advent of immunotherapy. However, little is known about the immune microenvironment of WT, making the potential role of immunotherapy unclear.
BDNF and NGF gene polymorphisms and urine BDNF–NGF levels in children with primary monosymptomatic nocturnal enuresis The pathophysiology and genetic influences in nocturnal enuresis have not been fully elucidated. Delayed neuronal maturation has been suggested as a pathogenetic mechanism in primary monosymptomatic nocturnal enuresis (PMNE). Brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) are neurotrophins affecting maturation of the nervous system.
The role of renal biomarkers to predict the need of surgery in congenital urinary tract obstruction in infants The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage.
Road to pediatric urology subcertification: a 25-year journey Subcertification in pediatric urology was not an overnight success story. In fact, it was a 25-year process in which critical elements were put into place which eventually culminated in a change in philosophy and attitude toward subspecialization in urology. Most importantly, it required unanimity of all the subgroups and leadership in pediatric urology to come together with a single voice in pursuit of a common goal. At each step, a new bar was established in the road to subcertification.
Robert Martin Weiss 34th recipient of the American Academy of Pediatrics Medal in Urology Dr. Robert Martin Weiss chose his parents well. He was born in New York to a power couple. His father was a general surgeon and a Major in the US army and served in WWII in New Guinea, while his mother raised him and his younger brother. He spent his formative years in Queens, where even from an early age he surrounded himself with future leaders: he was the captain of the Forest Hills High School math team, where he competed alongside Lubert Stryer (author of ‘Biochemistry’ first published in 1975.)
EBM II: How to perform a literature search The present article is a second part related to evidence based medicine (EBM) in a series of five by the European society for paediatric urology (ESPU) research committee. It will present the different databases/search engines available to clinicians and researchers and describe strategies to focus the search to one's particular needs. Indeed, databases/search engines used and search strategy should vary according to the goal of the research. If the aim is to address a clinical problem, the search should allow to identify a small number of most pertinent articles (high specificity); if the search is for research purposes, instead, it should ensure no meaningful articles are overlooked (high sensitivity).
A holistic approach in children with DSD Krege et al. [1] presented an abridged report about a German consensus process on diagnosis and management of children with disorders of sex development (DSD), carried out by 23 participants: 19 professional experts and 4 representatives of patient advocacy groups. The method used was a mix of the Delphi and nominal group technique and included a single plenary consensus meeting. The project was successfully concluded with a high degree of consensus.
Pupillometric assessment of dysautonomia in pediatric bowel and bladder dysfunction: a pilot study Bowel and bladder dysfunction (BBD) refers to a heterogeneous group of voiding disorders, accounting for an estimated 40% of pediatric urology visits. Symptoms of BBD include enuresis, urgency, and urinary retention, often accompanied by constipation. The aim of this pilot study was to explore whether a pupillary response can be characterized for BBD, by examining the pupillary light reflex (PLR) before and after voiding among patients with BBD. A total of 28 patients aged from 7 to 21 years were recruited from the Wetting, Infections, and Stooling Help clinic at Children's National Medical Center.
Response to letter to the editor regarding 'Externalised stenting in laparoscopic pyeloplasty: The K-wire technique' Thank you for your thoughtful comments and working through the pros and cons of a variety of stenting techniques previously described for laparoscopic pyeloplasty. We were relieved to have come to this position of being able to offer a safe and reliable technique similar to what we used to do for open surgery. This has stood the test of time in addition to not requiring an additional procedure for stent removal. It must be reiterated that we do not offer this to all our patients and indications including difficult pyeloplasty, malrotated kidney, long pelvi-ureteric junction obstruction (PUJ), severe hydronephrosis, redo pyeloplasty, intrarenal hydronephrosis, and ureterocalycostomy for internal JJ stenting remain the same.
Laparoscopic posterior appendix Mitrofanoff using the modified Shanfield anastomosis Laparoscopic transperitoneal technique for appendicovesicostomy was performed in a 5-year-old boy with a non-neurogenic neuropathic bladder using a transumbilical 5-mm port, two 3-mm working ports and a modified Shanfield anastomosis. Posterior extramucosal detrusorotomy and submucosal dissection was performed. The proximal appendix was spatulated and advanced into the bladder through a mucosal window using a U-stitch and fixed. The detrusor was then approximated creating an antirefluxing extramucosal tunnel.
Spinal anesthesia in children: most pediatric urologists are not on board In 2016, the Food and Drug Administration issued a warning on general anesthetic medications used for lengthy procedures (>3 h) in children younger than 3 years. Spinal anesthesia can be a safe alternative to general anesthesia for many pediatric urology procedures. It can shorten total operating room (OR) time, provide excellent pain control, and allow parents to reunite with their child immediately after surgery. However, use of spinal anesthesia can also directly affect the operating surgeon (awake patient, time constraints of spinal, and prolonged preoperative time).
Long-term growth in children with posterior urethral valves Posterior urethral valves (PUVs) are one of the leading causes of pediatric chronic kidney disease (CKD). Growth impairment is prevalent in pediatric CKD, and children with PUVs are at high risk for growth retardation.
Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature – where do we stand? Randomized controlled trials (RCTs) are considered the "gold standard" methodology for examining the effects of clinical interventions, yet only 1% of urology literature employs this design. The Consolidated Standards of Reporting Trials (CONSORT) statement contains a standardized checklist of 37 items to be included when reporting RCTs to ensure transparency and completeness of information [2]. Despite the robust design of RCTs, the number of events can greatly change the significance of the results, which can be represented by the fragility index (FI).
Outcome of feminizing genital reconstruction in female sex assigned disorder of sex development in a low-income country In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist.
Response to commentary to ‘"Mini" Extravesical Reimplant with "Mini" Tapering for Infants Younger than 6 Months of Age’ Because of the good clinical outcome of the first 7 cases, the last 2 patients were not recommended to have a 3-month postoperative VCUG – it was believed to be clinically unnecessary in the face of improved hydronephrosis and no UTIs. The patient with postoperative VUR who was lost to follow-up eventually came back 4 years later for evaluation; his ultrasound showed no hydronephrosis, and he had remained infection free for 4 years, the reason why I did not repeat a VCUG. I try to avoid ordering studies if they are unlikely to change what I do.
The fallow mitrofanoff Treatment of severe congenital dysfunctional bladders often requires bladder drainage to maintain low bladder pressure, thus preserving renal function. Although clean intermittent catheterization is the ideal choice, this can be especially challenging in the younger pediatric population or in children with neurological impairment. Alternatives such as incontinent vesicostomy, long-term suprapubic catheterization, or button cystostomy exist, but these are rarely very long-term options.
Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients Emerging research on surgeons and the opioid epidemic have focused on the adult population. Consequently, little is known regarding opioid-prescribing practices in the pediatric population. The goal of this study is to examine postoperative opioid-prescribing and consumption patterns, as well as storage and disposal trends for specific pediatric urologic procedures.
Commentary to ‘“Mini” Extravesical Reimplant with “Mini” Tapering for Infants Younger than 6 Months of Age’ The authors present an extravesical technique in a small series of young infants who underwent ureteral re-implantation for ureterovesical obstruction or ectopic ureter. Others have shown that ureteral re-implantation with well-described intravesical techniques in infants has been successful, with rates of success ranging from 86 to 97% – meaning no residual vesicoureteral reflux or ureteral obstruction [1,2]. Notably, in this series, only unilateral procedures were performed. Bilateral extravesical techniques have rarely been associated with urinary retention, and so it might not be prudent to consider extravesical re-implantation if needed bilaterally in this age group.
Night-time diuresis pattern in children with and without primary monosymptomatic nocturnal enuresis Night-time polyuria as the dominating pathophysiological mechanism for primary monosymptomatic nocturnal enuresis (PMNE) has been put in question with nocturnal detrusor overactivity and high arousal thresholds as alternatives. An earlier finding of night-time polyuria in 12% of healthy non-enuretic schoolchildren underscores that excessive night-time diuresis per se is unlikely the major cause of PMNE.
Pathological changes in ureterovesical and ureteropelvic junction obstruction explained by fetal ureter histology The etiology of ureterovesical junction obstruction (UVJO) and ureteropelvic junction obstruction (UPJO) is obscure with an adynamic narrow segment causing the obstruction. In this study, the authors compared interstitial cells of Cajal (ICC) and collagen-to-muscle ratio (CM ratio) between UVJO, UPJO, and fetal ureters to investigate whether a maturational arrest of the fetal ureter could explain both clinical pathologies.
Commentary on ‘External stent in laparoscopic pyeloplasty: The K-wire technique’ We were most interested to read about Upasani et al.'s [1] use of a K-wire technique in laparoscopic pyeloplasty. Indeed, we have been performing laparoscopic pyeloplasty in children since 2013 and have notably improved our technique through the prescription of pelvic training, mastery of the suturing technique, and a number of other tips and tricks. The main difficulty remains in accurate placement of the internal double J (JJ) stent. However, we have never encountered severe complications; most complications are minor and related to poor urinary drainage.
Hypoxic changes to the urothelium as a bystander of end-stage bladder disease Urothelial cells harvested from benign diseased bladders have a compromised capacity to propagate or differentiate in vitro, potentially limiting their application in autologous tissue engineering approaches. The causative pathways behind this altered phenotype are unknown.The hypothesis is that hypoxic damage to the urothelium occurs as a bystander to chronic or recurrent episodes of infection and inflammation.
Hydronephrosis severity score in management of ureteropelvic junction obstruction in children We read with great interest the article written by Babu R, Venkatachalapathy E and Sai E [1]. In their study, Authors developed an original new hydronephrosis severity score combining three parameters, differential renal function, drainage curve pattern, and ultrasonographic evaluation of pelvic dilatation. Since the main aim in the management of asymptomatic uretopelvic junction obstruction (UPJO) is to preserve the renal function, being aware of the possible clinical scenario of spontaneous improvement of hydronephrosis [2], the strain of the clinical research should be pointed out on the identification of predictor factors of future impairment of the renal function.
Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned? Diuresis renography (DR) is widely used in the evaluation of hydronephrosis and hydroureter in infants and children. The goal of this provocative nuclear imaging examination should be to detect the hydronephrotic kidneys at risk for loss of function and development of pain, hematuria, and urinary tract infection. The reliability of DR is dependent on the acquisition and processing of the data as well as interpretation and utilization of the results. In this review, the key concepts of standardized DR and pitfalls to avoid are highlighted.
Decreasing operating room costs via reduction of surgical instruments Rising costs in health care demand waste reduction and improved efficiency throughout the hospital. Surgeons have an important role in regard to the number of instruments used in procedures. Previous studies have demonstrated instrument maintenance and sterilization cost approximately $0.51–$0.77 per instrument and found that only 13–21.9% of instruments opened are used.
Prognostic values of shear wave elastography in adolescent boys with varicocele Shear wave elastography is an ultrasound technique for non-invasive quantification of tissue stiffness. It was used in assessing testis elasticity in some scrotal abnormalities, such as undescended pediatric testes or adult varicocele testes. In this study, its usefulness in adolescent patients with varicocele was examined.
“Those who cannot remember the past are condemned to repeat it”
‘Mini’ extravesical reimplant with ‘mini’ tapering for infants younger than 6 months Some infants with obstructed megaureters or ectopic ureters requiring surgery undergo a cutaneous ureterostomy followed by definitive repair after 12 months of age. Since 2013, a ‘mini’ extravesical reimplant with or without ‘mini’ tapering (MER) was performed instead of cutaneous ureterostomy in such infants.
Thermal cautery-assisted circumcision and principles of its use to decrease complication rates Circumcision is one of the most frequently applied surgical procedures all over the world and a number of techniques and devices have been described concerning its method. Especially in developing countries where circumcision has been performed intensively under local anaesthesia, the thermocautery device developed to perform circumcisions in a short time and safely has found a widespread application.
Staged repair of redo and crippled hypospadias: analysis of outcomes and complications Residual curvature, scarred or absent urethral plate, shortage of skin, and paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts.
Expert opinion: subcutaneous endoscopic assisted ligation to repair pediatric inguinal hernia Training of residents and fellows continues to evolve as technology has improved surgical procedures and platforms to learn. Computer-enhanced visual learning (CEVL) can facilitate training by detailing operations as they will be performed in the operating room. This includes visualization of key steps of the procedure, providing conceptual understanding of steps that may be unclear by description alone.
The clinical significance of an incidentally detected open internal inguinal ring An open internal inguinal ring (IIR) may be discovered incidentally either in the context of correcting pathology involving the contralateral side or at the time of surgical exploration for reasons unrelated to a patent processus vaginalis (PPV). The aim of this study is to determine the evolution of an incidentally encountered open IIR in patients undergoing laparoscopy for reasons not associated with unilateral inguinal hernia or cryptorchidism.
Population-based trend analysis of voiding cystourethrogram ordering practices in a single-payer healthcare system before and after the release of evaluation guidelines While voiding cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis.
Commentary to ‘The use of postoperative prophylactic antibiotics in stented distal hypospadias repair: a systematic review and meta-analysis’ The advent of antibiotics made it possible to treat many infectious diseases. Their widespread use, no doubt, has saved many lives or prevented many debilitating consequences. The utility of antibiotics in a postoperative role is less clear; are they helpful? Does their use prevent meaningful complications? Should we continue to use them and risk accelerating drug resistance? Chua et al. look at this question as it applies to stented distal hypospadias repair [1]. They performed a systematic literature review and used a standard meta-analytic approach.
Functional, histological and molecular characteristics of human exstrophy detrusor Bladder exstrophy is a congenital anomaly involving foetal exposure and protrusion of the open bladder through an incomplete lower abdominal wall. Techniques to surgically correct exstrophy after birth have greatly improved, but it still presents a major challenge to achieve continence and a good quality of life for patients and their families as the pathophysiology of bladder dysfunction is unknown.
Uncharted territory: navigating the pediatric urology job market There is not a structured algorithm, timeline, or resource on how, when, and which programs are looking for a new staff pediatric urologist. We hypothesized that current and future pediatric urology fellows could benefit from the experiences of recently graduated fellows on navigating the urology job market.
Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution? Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution.
Constipation in nocturnal enuresis may interfere desmopressin management success Previous studies indicated that the prevalence of constipation in enuretic patients is higher than that in the general population. Several studies have revealed that successful treatment of constipation may be helpful in resolving enuresis. However, constipation affecting the efficacy of desmopressin in treating enuresis remains to be clarified.
Response to commentary to ‘The search for the definition and effective diagnosis of upper urinary tract obstruction: the Whitaker test then and now’ Your reviewer is generous with his/her comments and very eloquently describes the effect of compensatory compliance, an enormously important factor that I admit I was slow to appreciate in the early days. Indeed, it was my very good friend and colleague Stephen Koff who finally convinced me of its importance. I have pleasure in acknowledging his very significant contribution to the investigation of obstruction. Your reviewer makes it adequately clear that it was not so much the development of tests to diagnose obstruction that was the breakthrough but the change in perception by urologists that obstruction is not an all-or-nothing phenomenon.
Retroperitoneoscopic lower pole heminephrectomy Retroperitoneoscopic heminephrectomy is a challenging procedure but with advantages over open and transperitoneal laparoscopic approaches. Lower pole heminephrectomy is less commonly undertaken compared with the upper pole.s
Posterior urethral valves: comparison of clinical outcomes between postnatal and antenatal cohorts Posterior urethral valves (PUVs) constitute the most common infravesical urinary obstruction in boys and are often accompanied by severe consequences to the lower and upper urinary tract. Currently, about two-thirds of diagnosis of PUVs has been suspected by prenatal ultrasonography findings. The aim of this study was to compare long-term clinical outcomes in two groups of patients with PUVs, with antenatal vs. postnatal diagnosis.
Evidence-based medicine 1: Background The Research Committee of the European Society of Pediatric Urology will present a series of short educational communications related to evidence-based medicine. The aim of the series is to emphasize the importance of grading evidence, thereby determining the best clinical practice for patients. The goal of this series is to guide the clinician in using tools for setting up a clinical question, finding appropriate information, searching appropriate databases, and evaluating the results in relation to the patient in mind.
Videolaparoscopic lower pole heminephrectomy for treatment of a duplex kidney In a duplicated renal collecting system, or duplex kidney, the most frequent pathology presenting at the lower pole is the vesicoureteral reflux (VUR), which could lead to urinary tract infections (UTI) or even renal dysplasia. Under some circumstances, such as recurrent UTIs or impaired kidney function, heminephrectomy of the pathologic moiety is indicated. However, there are only few academic videos of laparoscopic lower pole heminephrectomy in the pediatric population available in literature.
Surgical validation of functional magnetic resonance urography in the study of ureteropelvic junction obstruction in a pediatric cohort Ureteropelvic junction obstruction (UPJO) is one of the most common urological diseases in children. The etiology can be intrinsic, extrinsic (crossing vessel [CV] or adhesions), or mixed. To date, ultrasonography and scintigraphy are considered gold-standard imaging techniques for the study of UPJO. Functional magnetic resonance urography (fMRU) combines anatomical and functional information and has been recently evaluated for the detection of CVs in UPJO.
The evaluation of vesicoureteral reflux among children using contrast-enhanced ultrasound: a literature review Voiding cystourethrogram (VCUG) with fluoroscopy remains the gold standard for detection and evaluation of vesicoureteral reflux (VUR) among children. However, the ionizing radiation exposure remains a concern for this diagnostic modality. Recent studies have proposed using contrast-enhanced ultrasound as an alternative option for VUR screening and follow-up in children. The aim of the study was to review the literature of comparative studies that assessed the diagnostic accuracy of contrast-enhanced ultrasound compared with VCUG.
Variations of sex development: The first German interdisciplinary consensus paper The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly ‘feminizing’ elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female.
Urinary metabolic abnormalities in children with idiopathic hematuria Hematuria, either macroscopic or microscopic, is an incidental finding of multiple nephrologic or urologic disorders. Disturbances of urine inhibitors or promotors have been suggested as the potential causes of isolated idiopathic hematuria in children and its recurrence. Meanwhile, appropriate treatment of these risk factors might improve secondary asymptomatic or macroscopic hematuria.
Response to editorial commentary: predatory publishing or a lack of peer-review transparency?—a contemporary analysis of indexed open and non-open access articles in paediatric urology The advent of open access publishing as a model has indeed led to a more accessible and egalitarian approach to digital manuscript archiving. This model has not only been shown in some studies to increase citation count but also provides a means to those countries that do not have the funds to access these archives through standard subscriptions, as well as to those that simply may not be affiliated to institutions/universities with this access any more, such as retired academics who wish to keep up to date or continue to contribute with a vast level of knowledge and experience.
Prevalence of urinary incontinence and other lower urinary tract symptoms in children in the Netherlands The International Children's Continence Society (ICCS) defines urinary incontinence (UI) as ‘involuntary leakage of urine’ [1], a condition that can have a negative impact on a child's life. Although UI is common among children, the reported prevalences worldwide vary. Regarding children in the Netherlands, only a few studies report on the prevalence of UI and other lower urinary tract symptoms (LUTSs).
Authors’ reply to commentary JPUROL-D-18-00309 refers to JPUROL_2018_56 “The authors greatly appreciate the reviewer's commentary and concur with the insights on the intricacies of systematic reviews and conclusions drawn from such analysis. We also strongly advocate poor-quality studies to be considered low-level evidence and rarely, if ever, generate any meaningful or clinically applicable recommendations. However, when inconsistencies of the outcome report were noted in the literature, we felt compelled to highlight the importance of performing good quality systematic review and meta-analysis on the topic.
Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shifts and require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects.
Response to letter re ‘Pneumovesical ureteric reimplantation using T-fastener: a modification for bladder wall anchorage' We would like to thank you for the opportunity to respond to the issues concerning methods of cystopexy. Indeed, the conventional approach of bladder wall anchoring used in our centre also applied the same ‘U stitch’ principle as described by the authors, but a loop was used to catch the suture instead of an ureteroscopic forceps [1]. The main reason for our switch over to the new modification is that passing the suture relies on a paradoxical vesicoscopic view, which may be time-consuming. The authors did not mention the time needed to complete the cystopexy, but after all, their technique still needs to work under a paradoxical environment using two parallel ports.
Robot-assisted resection of ectopic kidney in children: An anatomical illustration Failure of kidney migration during embryonic life results in an ectopic kidney, with an incidence varying from 1 in 500 to 1 in 1200. Pelvic kidney can be a rare cause of recurrent urinary tract infection (UTI), warranting nephrectomy in some cases.
Cancer screening in the pediatric cancer patient: a focus on genitourinary malignancies, and why does a urologist need to know about this? The long-term survival of a patient with childhood cancer now exceeds 80%. Unfortunately, as survivorship improves, the long-term consequences of the treatments used have become manifest. Specifically, the finding that development of a subsequent malignant neoplasm (SMN) is the leading cause of late mortality is concerning. In cancer survivors who are at high risk for developing an SMN, cancer screening protocols have well-documented survivorship benefits. Regrettably, 50% of these high-risk patients are non-compliant with these protocols, with studies revealing that inadequate patient compliance is in part because of insufficient knowledge of the physician regarding its need.
This is the first edition of this textbook, designed to cover all topics of urology, including inflammation, stones, endo-urology, female urology, reconstructive urology, benign prostatic hypertrophy, urologic oncology, andrology, pediatric urology, renal function, and urologic radiology.
Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication.
Scrotal injuries during neonatal circumcision To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision.
Elevated urinary lipocalin-2, interleukin-6 and monocyte chemoattractant protein-1 levels in children with congenital ureteropelvic junction obstruction In children with congenital ureteropelvic junction obstruction (UPJO), urinary biomarkers could assist in the diagnosis of renal damage or kidneys at risk for damage. Urinary levels of interleukin-6 (IL6), neutrophil gelatinase–associated lipocalin (LCN2), monocyte chemoattractant protein-1 (MCP1), and transforming growth factor-β1 (TGFB1) proteins have been correlated with renal damage in several contexts. Whether they might be useful non-invasive biomarkers of obstructive nephropathy due to unilateral and bilateral congenital UPJO was tested.
Response to the editorial comment We thank the reviewer for the pertinent editorial comments and for the opportunity to clarify the reasons why we changed our approach to maintain the advantages of the complete primary repair of exstrophy (CPRE) while decreasing the potential risk of penile injury, an underreported complication with irreversible consequences. This complication is so devastating that a responsible surgeon should not accept many cases before exploring safer alternative to manage men with bladder exstrophy. This is the basis for reporting our experience; after performing 24 cases using CPRE, we had a case that suffered penile ischemia after pelvic osteotomies and forceful pubic approximation.
Correspondence: the complexities of cystopexy In the surgical management of paediatric urological conditions, the vesicoscopic approach has shown promise in recent years [1]. Fixation of the bladder to the anterior abdominal wall (cystopexy) is a crucial step in this approach [2]. It creates an easier access tract for bladder port insertion, and they allow misplaced ports to be easily resited into the bladder [1].
Urology Mythbusters: should hydronephrosis grade be used to decide which newborns should undergo voiding cystourethrogram? In this episode of Mythbusters the premise that among infants with prenatally identified urinary tract dilation (UTD), voiding cystourethrogram (VCUG) should be performed in those with higher grade UTD but not in those with lower grade UTD is critically examined. It is concluded that severity of dilation is not strongly associated with risk of vesicoureteral reflux or other anomalies diagnosed by VCUG. Therefore, using hydronephrosis grade to decide which infants with UTD should undergo VCUG is not evidence based.
Hydronephrosis severity score: an objective assessment of hydronephrosis severity in children—a preliminary report The main challenge in the management of antenatally diagnosed hydronephrosis and ureteropelvic junction obstruction (UPJO) is to differentiate the one that is likely to resolve from the pathological one. In this study, a new hydronephrosis severity score (HSS), combining ultrasonographic and renographic parameters, has been developed. Hydronephrosis severity score was analyzed with regard to its usefulness in assessing the severity of UPJO, postoperative resolution, and interobserver reliability.
Commentary to ‘A tailored surgical approach to the palpable undescended testis’ This study aims to establish whether it is possible to offer individualized interventions for the palpable undescended testis. It constitutes a retrospective chart review of 259 orchidopexies performed on 181 boys. Seventy-eight underwent bilateral synchronous procedures. A scrotal approach was used in 125 (48%) and inguinal in 134 (52%). It is important to stress that it is not comparing the two methods, but rather outlining the approach.
Commentary on ‘Effect of vitamin D and omega-3 on nocturnal enuresis of 7–15-year-old children’ We read with great interest the recent contribution by Dr. Rahmani et al. [1]. They showed the beneficial effect of vitamin D on nocturnal enuresis (NE) but did not suggest the possible mechanisms in the discussion. We would like to add some considerations on the possible mechanisms of the effects of vitamin D on NE.
Remote ischemic conditioning in a rat model of testicular torsion: does it offer testicular protection? Testicular torsion is a surgical emergency mainly affecting adolescent boys, with a relatively high rate of missed torsion and testicular loss secondary to delay in prompt diagnosis and surgical intervention. With ischemic reperfusion injury as its underlying culprit, testicular torsion may respond favorably to remote ischemic conditioning (RIC) where a non-privileged site (e.g. limb) is concurrently rendered ischemic to divert the cascade of reperfusion injury from the privileged organ (e.g. testicle), thus offering a protective effect in improving salvage.
Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy Penile ischemic injury is a reported catastrophic complication after complete primary repair of exstrophy (CPRE). Aiming to improve the bladder exstrophy-epispadias repair outcomes, the study institution adopted a modified staged exstrophy repair to incorporate the advantages of CPRE by avoiding concurrent epispadias repair and adding bilateral ureteral re-implantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral re-implantation [SRBE-BUR]) at the initial repair.
A tailored surgical approach to the palpable undescended testis Orchiopexy for a palpable undescended testis can be approached through a traditional inguinal incision or trans-scrotally. Despite the possible advantages of the scrotal approach, including reduced postoperative pain and shorter recovery, it is not consistently advocated.
The biomechanical properties of the urethra in boys with hypospadias: a preliminary study The ventral aspect of the penis in boys with hypospadias is composed of dysplastic tissue of the skin and the urethra.The aim of this study was to assess the pre-operative size and biomechanical properties of urethrae in boys with and without hypospadias using a more objective catheter-based system.
Does a serious game increase intrinsic motivation in children receiving urotherapy? Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding.
Tubulocystic anomalies of the mesonephric duct associated with ipsilateral renal dysgenesis Renal agenesis and multicystic dysplastic kidney (MCDK) are usually associated with either an absent or atretic ureter. Occasionally, these renal anomalies may be associated with a dilated tortuous ureter, ureterocele or other cystic malformation of mesonephric duct (MND) remnants.
Long-term follow-up of bladder outlet procedures in children with neurogenic urinary incontinence Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions.
Long-term results using a transanal irrigation system (Peristeen®) for treatment of stool incontinence in children with myelomeningocele Faecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families' quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications.Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents.
Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter? Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes.
Comparison of preputioplasty and circumcision in distal hypospadias correction: long-term follow-up A normal penile cosmesis is an important goal in distal hypospadias repair. Depending on cultural standards, repairs are combined with a preputioplasty or circumcision to attain a ‘normal’ penile appearance. Although short-term complication rates of preputioplasty are available, data on long-term outcomes are scarce. Therefore, this study assessed long-term functional and cosmetic outcomes of distal hypospadias repair with either a preputioplasty or a circumcision.
Benefits of spinal anesthesia for urologic surgery in the youngest of patients Increasing concerns regarding potential negative effects of early use of inhalational and intravenous anesthetics on neurocognitive development have led to a growing interest in alternative forms of anesthesia in infants. The study institution's outcomes with spinal anesthesia (SA) for urologic surgery in infants aged less than 90 days are reported and their outcomes with a matched cohort of patients who underwent general anesthesia (GA) are compared.
Urinary continence appears to enhance social participation and intimate relations in adolescents with myelomeningocele The majority of adults with myelomeningocele (MMC) in Western Sweden use incontinence pads. There is an ongoing discussion as to whether continence improves the quality of life (QoL) in individuals with MMC as it has been hard to establish that an increase in QoL measured by generic health-related quality of life (HRQoL) instruments is achieved by continence surgery.
Onabotulinum toxin A in children with refractory idiopathic overactive bladder: medium-term outcomes Botulinum toxin-A (BtA) has been used for refractory idiopathic overactive bladder (IOAB) in children. Data on the optimum dose success rates, duration of effect, complications and medium-term outcomes are limited. This study aims to analyse the authors' experience to provide medium-term results of BtA in symptomatic refractory patients.
The amount of urine voided in bed by children with enuresis Enuretic children wet their beds either because of nocturnal polyuria or nocturnal detrusor overactivity. Polyuric children often respond to desmopressin, whereas children with nocturnal detrusor overactivity are often therapy resistant and may have low daytime voided volumes. It is logical to assume that the enuretic event in children with nocturnal polyuria occurs with a full bladder, i.e. with the enuretic voided volume (EVV) close to the child's expected bladder capacity (EBC) for his/her age.
Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described.
Predicting postoperative pain and analgesia in children after urological outpatient procedures: Is it clear? I read with great interest the article by Schröder et al. in a recent issue of the journal [1]. The authors performed a prospective study on 249 patients between 6 months and 12 years of age who underwent outpatient urological procedures and concluded that the combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. The authors should be congratulated for performing a well-designed study on an important topic (e.g.
Re. “Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes” We write to comment on the recent paper by Bush and Snodgrass [1]. We are not in the custom of writing letters to the editor; however, this paper gives an alarming message to many surgeons around the world who may apply the technique on children with narrow hypoplastic plates. Those children will eventually come back later circumcised, with serious complications, and the only option left is buccal mucosa graft which is not simple and can be associated with considerable complications. One-third of our practice is handling such patients with tubularized incised plate (TIP) complications (persistent fistula, stenosis, and inability to pass urine) referred from other centers and other countries, sometimes with supra-pubic catheters.
Response to “Re. Pre-incision urethral plate width does not impact short-term tubularized incised plate urethroplasty outcomes” The clear message of our study is that pre-incision width of the urethral plate does not impact TIP urethroplasty results. This observation, made in consecutive boys undergoing hypospadias repair, is important for two main reasons. First, 86% of these patients had pre-incision widths <8 mm, which others have described as a narrow plate. If this was truly a contraindication to TIP, then only a minority of boys could have the procedure. Second, the fact that urethral plate width did not predict complications adds to our earlier report that neither does plate characterization as “flat” or “deeply grooved” (reference 5 in article).
WITHDRAWN: Introductory editorial – Basic science The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.jpurol.2016.01.009. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
The lowest acceptable bladder capacity for interpretation of uroflowmetry tests in children Under- or overdistended bladder is associated with impaired bladder emptying. Therefore, uroflowmerty of low bladder capacity is regarded as irrelevant for interpretation. However, is no general consensus with regard to the lowest acceptable value of bladder capacity (LABC) for interpretation of uroflowmetry in children.
Acknowledgement of reviewers 2018 The reviewers are the backbone of any scientific journal. It is through the process of peer review that we are able to improve the quality of scientific publication and in turn improve care for our patients. We on the Editorial Board are indebted to our reviewers for the personal time that they take to provide outstanding constructive reviews. We would like to highlight these top ten reviewers for 2018 as listed below as they have outstanding marks for the quality of their reviews and the number of reviews they completed in 2018.
Editorial Happy New Year to all from the Editorial Board of the Journal of Pediatric Urology. With the new year, the Journal will be initiating a couple of new initiatives that you will see rolled out.
A potpourri of pediatric urology The potpourri of pediatric urology is entering its 14th year, and it is now time for me to pass over the baton of producing this section to Professor Chris Cooper. It is a testament to the success of the Journal that this section has become increasingly difficult to put together in recent years as the majority of the good and relevant articles in pediatric urology are now published in our Journal. It has been a great privilege writing the potpourri, and I wish him every success and hope that he enjoys it as much as I have.
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