Infant spinal anesthesia: a safe, efficient, and worthwhile collaboration I read with interest Dr. Rehfuss and colleague’s work regarding her survey of pediatric urologists’ opinions on use of spinal anesthesia as opposed to general anesthesia in young children.(1) This is an important exploration of a misunderstood topic. However, several important benefits of spinal anesthesia in infants were unfortunately omitted from her manuscript. Notably, spinal anesthesia allows for avoidance of intubation and subsequent risk of hypoxia associated with airway manipulation, as well as improved hemodynamic stability, with minimal risk of hypotension and bradycardia.
Spinal Anesthesia in Children: Most Pediatric Urologists Are Not On Board Thank you for this thoughtful comment. Several of the authors are in agreement with your points and are advocates for the use of spinal anesthesia in selective infants undergoing urological surgery. We need to emphasize though that the goal of our study was not to espouse our views of the state of the science in this area, but rather to report on the current opinions of pediatric urologists regarding the use of spinal anesthesia in their cases. Whether their patients might be better served by using more spinal anesthesia is a different question, but we did find that general anesthesia remains the preferred option and that it is used by the majority of respondents.
The Role of Anatomic Pelvic Dissection in the Successful Closure of Bladder Exstrophy: An Aid to Success Classic bladder exstrophy is one of the rarest congenital anomalies compatible with life. Surgical treatment of bladder exstrophy has progressed but the goal of surgery remains a successful primary bladder closure. Several factors have been identified to decrease the risk of failed closure, including appropriate use of osteotomy, and adequate postoperative immobilization and analgesia. However, the role of the radical anatomic pelvic dissection, including dissection of the urogenital diaphragm fibers, in a successful closure has not yet been extensively explored.
Parent Perceptions of Psychosocial Care for Children with Differences of Sex Development Children affected by differences/disorders of sex development (DSD) and their families are vulnerable to significant risks across developmental stages that threaten quality of life and psychosocial functioning. Accordingly, both experts in DSD treatment and patient advocacy groups have endorsed the incorporation of psychosocial care into interdisciplinary management of DSD conditions.
Totally fluoroless retrograde intrarenal surgery technique in pre-stented patients - tips and tricks Treatment of urolithiasis has evolved greatly as retrograde intrarenal surgery (RIRS) has gained popularity being nowadays a gold-standard therapy for renal stones up to 2cm. Endourological procedures are traditionally fluoroscopic guided, thus an increasing concern is the harm of radiation exposure, especially in the pediatric population. Therefore, performing fluoroless RIRS should be a feasible option for pediatric urologists. Herein we describe the technique of totally fluoroless RIRS in presented patients and the tips to avoid radiation use at most.
Biomarkers and their future use in clinical diagnostics and treatment Biomarkers can be used to, at least partly, explain underlying mechanisms of a symptom or condition as in the article by Girisgen et al where both non-mono and mono-symptomatic bedwetting is the topic of investigation. During the last 3-4 decades there have been several studies showing that in the normal prepubertal child, the lowering of the nighttime diuresis is accompanied by a nightly increase in plasma arginine-vasopressin (AVP) with a peak in the first third of the night (2). Children with the polyuric type of bedwetting lack this increase on wet nights albeit if they have a dry night they may also display a nightly AVP increase.
Neurogenic bladder and congenital Zika syndrome We read the publication on ‘Neurogenic bladder in the settings of congenital Zika syndrome: a confirmed and unknown condition for urologists’  with great interest . Costa Monteiro et al.  concluded that ‘Neurogenic bladder (NB) is a common condition among our patients with congenital Zika syndrome (CZS) and microcephaly.’ We would like to share ideas and view from our setting in tropical Indochina. In our setting, although the infection is not uncommon  and there are many silent immunoreactive cases , most cases are asymptomatic .
Crossed fused renal ectopia in children: a review of clinical profile, surgical challenges, and outcome Crossed fused renal ectopia is a rare congenital malformation, wherein both kidneys are present unilaterally, with the ureter of the crossed kidney opening into the bladder on the contralateral side. It has varied presentation from incidental detection to renal impairment. In this largest series of crossed fused renal ectopia, the authors assessed the clinical profile of these children and also attempted to shed light on the challenges in the surgical management.
A clinical pathway to minimize computed tomography for suspected nephrolithiasis in children Ultrasound (US) imaging is preferred in the initial evaluation for children with suspected nephrolithiasis; however, computed tomography (CT) continues to be used in this setting with resultant unnecessary ionizing radiation exposure. The study institution implemented a standardized clinical pathway to reduce rates of CT utilization for children with nephrolithiasis.
Computed tomograpy evaluation of ureteral length in children Although ureteral length (UL) is highly variable in children, reliable data on this topic are scarce. During urinary tract surgery, the use of an inappropriately dimensioned ureteral stent is associated with adverse effects. This study aimed to evaluate UL as a function of the child's age, using contrast-enhanced computed tomography (CT) of the abdomen and pelvis, and to calculate a new equation for predicting UL (and thus the optimal length of ureteral stents) in children.
Response to letter to the Editor re ‘electrical stimulation for overactive bladder in children: a pilot study’ I would like to express thanks for the interest shown in our article and this new way of treating lower urinary tract dysfunction in children and adolescents. Perhaps we have not been clear and have been misunderstood regarding our comments about percutaneous electrical nerve stimulation (PENS) being more convenient than transcutaneous electrical nerve stimulation (TENS). In fact, PENS can be performed once per week, and, by coming close to S3 and without the impedance of the skin, the effectiveness may be greater.
Ensuring affirming care for youth with variations of sex development It would behoove physicians like Dr. Diamond (‘Commentary to variations of sex development: first German interdisciplinary consensus paper’ ) to recognize that medicine does not exist in a vacuum that exempts pediatric urologists from the purview of ethics, human rights, and the law. Unfortunately, physicians who wish to continue to perform cosmetic surgeries on infants with variations in their sex characteristics continue, as they have for many years, to ignore the mounting condemnation of the performance of non-emergent medical procedures prior to the ability of an individual to participate in the decision-making process.
Fetal exposure to polybrominated diphenyl ethers and the risk of hypospadias: focus on the congeners involved Polybrominated diphenyl ethers (PBDEs) are widely used flame retardants, and their endocrine-disrupting properties have focused growing attention regarding their teratogenic potential. We have recently documented that mothers of children born with hypospadias had been exposed to statistically higher levels of PBDE during pregnancy than mothers of healthy controls. However, it is not known which congeners of PBDE are associated with this putative teratogenic effect.
Outcome of surgical management of urethral stricture following hypospadias repair Reconstruction of urethral strictures in patients with a history of hypospadias repair is controversial. The authors policy has been that if a residual healthy urethral plate is present, single-stage urethroplasty is recommended. However, if the urethral plate is fibrotic or absent or if lichen sclerosus is present, two-stage repair is utilized.
Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature.
Augmentation vaginoplasty with buccal mucosa for the surgical revision of post-reconstructive vaginal stenosis: a case series Vaginal stenosis is a common consequence of vaginal reconstruction in childhood. . Significant scarring can make dilation ineffective and there maybe a paucity of skin to create perineal skin flaps. Numerous vaginoplasty techniques exist including perineal skin flaps for distal stenosis and intestinal vaginoplasty requiring laparotomy and bowel anastomosis. Buccal mucosa is widely used in urethroplasty and has been reported in neovaginal construction. It is easily accessible with minimal graft site morbidity and provides a close functional replica to vaginal mucosa.
Laparoscopy-assisted ureterostomy— technique Urinary tract anomalies in children at times pose challenges in which immediate urinary diversion is required before definitive reconstruction. Open cutaneous ureterostomy technique is a well-established approach for this scenario. We describe the laparoscopy-assisted alternative.
Evidence Based Medicine IV: how to find an evidence-based answer to a clinical question? Make a critically appraised topic! This manuscript is the fourth in a five part series related to evidence based medicine (EBM) provided by the European society of pediatric urology (ESPU) research committee. It will present a way to come to a quick and critical appraisal of available evidence on a specific topic: a CAT (critically appraised topic). The way how to write a cat is described for interventions to be compared to a control group, and for other, more generalized clinical questions. While systematic reviews provide a throughout overview of all evidence available, a CAT provides a shorter way to come to quick insights based on EBM.
Open vs robotic infant ureteroureterostomy A ureteroureterostomy (UU) is often used to manage some duplication anomalies. The operation is commonly performed through a Pfannenstiel incision, but other minimally invasive approaches have been described. The objective of this study is to compare open vs robotic infant UU with regards to operative time, complications, and operative success.
Pediatric urology in Ibero-America: origin and current status Before the 1960s, pediatric urology in Ibero-America (Latin America, Spain, and Portugal) was a weakly defined subspecialty practiced by those who had interest in the area: general surgeons, adult urologists, and pediatric surgeons. At this same time, pediatric urology was an emerging subspecialty of pediatric surgery or general urology in Europe and the United States. Toward the end of the 1950s and the beginning of the 1960s, a few visionary urologists and pediatric surgeons from Latin America traveled overseas to acquire advanced training in pediatric urology, recognizing that a proper training was needed to master the skills and knowledge of this unique emerging specialty.
Parental Perspectives on Decision-making about Hypospadias Surgery Many parents who choose hypospadias repair for their son experience decisional conflict and regret. The utilization of a shared decision-making process may address the issue of decisional conflict and regret in hypospadias repair by engaging both parents and physicians in decision-making.
Trends in surgical management of multicystic dysplastic kidney at USA children's hospitals Multicystic dysplastic kidney (MCDK) is a congenital renal cystic disease often incidentally diagnosed in children. Historically, children with MCDK underwent early nephrectomy because of concerns for the development of hypertension or malignancy. Over the last decade, management recommendations have not supported routine early surgical removal of MCDK. The study authors sought to determine the current trends in the use of nephrectomy for MCDK in US children's hospitals because national practice patterns have not been investigated.
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 Paediatric Urology 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 enhanced recovery after surgery is now The concept of enhanced recovery after surgery (ERAS) has increasingly been embraced by the study authors' adult surgical colleagues and has culminated in a new standard of care for a variety of surgical procedures . 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 on Enhanced Recovery After Surgery in Pediatrics 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. The study authors' experience with this novel approach in a prospective series of 69 children that includes 17 infants is reported. Mean operating time was 225 min for reduction pyeloplasty. Peritoneal tear is not uncommon (22%) but often does not require conversion. In the study authors' early experience, the conversion rate was 17% and postoperative complications 2.9%.
The learning curve of contrast-enhanced ‘microbubble’ voiding urosonography—validation study Vesicoureteral 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. Voiding urosonography contrast agents used for the diagnosis of VUR have been widely available in Europe but were approved by the Food and Drug Administration for use in the United States only in 2016.
Mental health status of individuals with sexual development disorders: A review Healthcare recommendations for people with disorders of sexual development (DSDs) include mental health attention and active participation of psychiatrists and psychologists in dedicated multidisciplinary teams. Therefore, it seems crucial for them to improve knowledge about specific difficulties and needs of these patients. The aim of this article is to report in a synthesizing manner the recent works evaluating the mental health and psychological status of individuals with DSDs. After research conducted using PubMed and ScienceDirect, 18 studies were inventoried and qualitatively analyzed in response to three main questions: Do individuals with DSDs suffer more frequently and/or more severely from psychological conditions or mental disorders? From what kind of disorder do they suffer? and What are the determinant factors involved in their development? This work highlights an increased risk of affective disorders in individuals with DSDs, 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 was 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: a novel technical innovation Although endoscopic drainage remains treatment of choice for ureterocele in pediatric age group, often urologists, especially during the learning phase and difficult anatomy, feel a limitation because of inability to do intravesical manipulation. This can be attributed to absence of the second working channel in pediatric cystoscope owing to size limitation. Herein, we describe a novel technique for safe introduction of a grasper which acts as a second surgical arm for endoscopists and simultaneously facilitates both intravesical manipulation and drainage of ureterocele at an optimal location with minimal complications.
The effect of intraurethral dexpanthenol in hypospadias repair: experimental rabbit study In this study, the authors 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 contributing in the structure of coenzyme A. It decreases the release of myeloperoxidase from granulocytes and inhibits the 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 familial Mediterranean fever (FMF). In this study, the authors 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 primary enuresis nocturna: 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 the authors focus on symptoms of individuals with EN, they figured out that the individuals were impaired in social and emotional skills because of the dramatic consequences of EN. The authors presume that, despite a lack of psychiatric comorbidity, primary enuresis 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.
Response to commentaries on ʻVariations 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 disorders of sexual development (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.
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.
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.
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 intra-operative graft monitoring. The aim of this project is to present a novel technique for intra-operative real-time assessment of graft perfusion using a non-invasive infrared camera.
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.
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).
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).
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 . 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).
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.
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.
Commentary on ‘External stent in laparoscopic pyeloplasty: The K-wire technique’ We were most interested to read about Upasani et al.'s  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.
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.
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.
Expert opinion: open primary, nerve-sparing retroperitoneal lymph node dissection Teaching trainees any surgery can be difficult as it requires ‘hands-on’ experience which can be difficult with actual patients in a clinical environment. That difficulty is only made more so in situations where the surgery in question is rare and/or complex. Retroperitoneal lymph node dissection (RPLND) is just such an example of a rare surgery that is very technically demanding.
A potpourri of pediatric urology It's an honor, but also a challenge, to be invited to contribute to potpourri, after Stuart O'Toole's (and others) amazingly entertaining and educational pieces which have been published over the past decade and a half. I am certain that Chris Cooper will indeed carry that baton and run with it successfully for a similar time period. I thank Stuart for educating me via his columns on the nuances of gin making, in particular flavored varieties. Sloe gin, for instance, a UK Christmastime essential, was introduced in the 17th century as land enclosure became common and sloe bushes became useful as way of ‘natural’ fencing.
This month's review: quality improvement and patient safety The editors of the Journal of Pediatric Urology are introducing a new section to the journal entitled ‘What the Editors are Reading.’ This section will be related to each subsection of our specialty, in which each section editor and selected colleagues will review 2–4 articles from the urological and non-urological literature, which would not likely have passed over your desk and which may be timely and pertinent to our specialty and how we practice. The editor and colleagues will provide their evaluation of the selected article and include an editorial comment as well as a take-home message.
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