Long-term outcome of pediatric renal transplantation with donors younger than 6 years

BACKGROUND

Renal transplantation is currently the best treatment option for patients with end-stage renal disease. However, the use of kidneys from donors under 6 years of age as a possibility to increase the organ pool in pediatric recipients remains a controversial matter. We aimed to investigate whether donor age is associated to the long-term functionality of the renal graft. Likewise, we analyzed the adaptation of the graft to the ascending functional requirements in the pediatric patient.

METHODS

Retrospective study of the results obtained in pediatric recipients transplanted with grafts from donors between 3 and 6 years of age, comparing them with those of grafts from donors older than 6 years. Among the variables compared are cumulative graft survival, renal size, need for antiproteinuric therapy, GFR, incidence of rejection, pyelonephritis, renal failure and surgical or tumor complications.

RESULTS

A total of 43 transplants were performed with donors aged 3-6 years, and 42 transplants with donors older than 6 years. Cumulative graft survival at 5 years was 81% for the younger donor group compared to 98% for the older donor group (p < .05). At 8 years, cumulative graft survival for donors <6 years was 74%. As for the mean estimated graft survival, it was 11.52 years for the younger donor group and 14.51 years for older donors. During follow-up, the younger donor group presented greater renal enlargement and need for antiproteinuric therapy. The older donors group had a higher GFR during the first year of follow-up, which then equalized in both groups. There were no statistically significant differences in the incidence of acute or chronic rejection, acute pyelonephritis, acute renal failure or surgical or tumor complications.

CONCLUSIONS

Renal transplants of grafts equal to or less than 6 years old have good short-term and acceptable long-term results in pediatric patients.

Standardization and Implementation of a Surgical Coaching Model for Pediatric Urology

To bridge gaps in proficiency and encourage life-long learning following training, coaching models have been utilized in multiple surgical fields; however, not within pediatric urology. In this review of our methodology, we describe the development of a coaching model at a single institution. In our initial experience, the perceived most beneficial aspect of the program was the goal setting process with logistics around debriefs being the most challenging. With our proposed coaching study, we aim to develop a model based upon prior coaching frameworks,1,2 that is feasible and universally adaptable to allow for further advancement of surgical coaching, particularly within the field of pediatric urology.

Urethral Duplication With Dorsal Chordee: A Case Report and Literature Review

Urethral duplication is a diverse spectrum of disease having multiple anatomic variants. The clinical presentation varies from being asymptomatic to recurrent urinary tract infections. A high level of clinical suspicion and awareness among primary caregivers is needed to make a proper diagnosis. All patients presenting with any sort of penile deformity or abnormality of the urinary stream should be evaluated to rule out this condition. In this case report the patient had presented with the urinary stream being directed towards his abdomen due to abnormal dorsal curvature of the penis which was due to tethering of the accessory urethra.

Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review

Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.

A Single-System Ectopic Ureter in a Child: A Challenge for Early Diagnosis

An ectopic ureter is an uncommon anomaly, usually associated with a duplicated urinary system. Up to 20% of ectopic ureters occur in a single system. In females, only 25% of ectopic ureters insert into the vagina and usually cause urinary incontinence, which can be confused with vaginal discharge. The diagnostic investigation includes urinary tract ultrasound, DMSA, and urethrocystography, which evaluate renal morphology and function, determining factors for surgical treatment decision that aims to preserve renal function, prevent the recurrence of infections, and reestablish urinary continence. The rarity of this anomaly and the delay in recognizing symptoms are factors related to late diagnosis.

Utility of preoperative urine cultures and cystoscopies before ureteral reimplantation in pediatrics

BACKGROUND

Ureteral reimplantation remains the primary surgical method used for patients with vesicoureteral reflux (VUR). Cystoscopy is commonly performed first to visualize anatomy and rule out possible abnormalities. Urine cultures may also be obtained. The objective of this study is to evaluate the prudency of preoperative urine cultures and cystoscopies in pediatric patients undergoing ureteral reimplantation.

METHODS

Pediatric urologists were surveyed regarding collecting urine cultures in asymptomatic patients and cystoscopies before reimplantation. A retrospective review was also conducted of patients who underwent ureteral reimplantation for VUR between March 2018 and April 2021 at Cook Children's Medical Center.

RESULTS

When physicians were asked the frequency they obtain urine cultures before reimplantation on asymptomatic patients, 36% said "never" and 38% said "always." Regarding cystoscopy, 53% said "never" and 32% said "always." Inclusion criteria were met by 101 patients. Cystoscopies were performed in 46 patients and never altered the reimplantation. There were 20 preoperative, 90 intraoperative, and 61 postoperative urine cultures. Complications were associated with positive cultures of urine collected intraoperatively and postoperatively only.

CONCLUSION

Cystoscopies and asymptomatic urine cultures obtained before ureteral reimplantation provide no additional benefit while increasing cost for patients' families. Further research is needed to thoroughly identify the prudency of such practices in ureteral reimplantation for VUR.

Treatment of bilateral encrusted ureteral stents, large volume renal stones, and ureteral stricture in a complex pediatric patient: a surgical video and case review

Myotonic dystrophy is a debilitating genetic disease that carries a predilection for a variety of comorbidities. Kidney stone disease in this population can present a variety of unique challenges related to patient age, comorbidities, and social factors. We present a video review case of a 13-year-old girl with myotonic dystrophy who was treated surgically for large bilateral stone burden, bilateral retained ureteral stents with nephrostomy tubes, and right ureteral stricture. The patient had multiple prior urologic procedures and recurrent admissions for infection prior to presentation. Preoperative planning included non-contrast CT imaging, admission to an intensive care unit, and multidisciplinary discussion of treatment and goals. Through combined antegrade and retrograde approaches, the patient's stone burden was cleared, right ureteral stricture was treated, and all tubes were able to be removed in two major procedures and one minor cystoscopy with stent removal under anesthesia. Early referral to tertiary care centers and involvement of multiple specialist teams may help reduce perioperative risk and minimize the number of surgeries. Additionally, patients at high anesthesia risk may benefit from concurrent percutaneous nephrolithotomy with endopyelotomy.

Identifying Targets for Innovation in Amazon Reviews of Bedwetting Alarms: Thematic Analysis

BACKGROUND

Nocturnal enuresis (NE) is a frequent diagnosis in pediatric and adolescent populations with an estimated prevalence of around 15% at the age of 6 years. NE can have a substantial impact on multiple health domains. Bedwetting alarms, which typically consist of a sensor and moisture-activated alarm, are a common treatment.

OBJECTIVE

This study aimed to determine areas of satisfaction versus dissatisfaction reported by the parents and caregivers of children using current bedwetting alarms.

METHODS

Using the search term "bedwetting alarms" on the Amazon marketplace, products with >300 reviews were included. For each product, the 5 reviews ranked the "most helpful" for each star category were selected for analysis. Meaning extraction method was applied to identify major themes and subthemes. A percent skew was calculated by summing the total number of mentions of each subtheme,+1 for a positive mention, 0 for a neutral mention, and -1 for a negative mention, and dividing this total by the number of reviews in which that particular subtheme was observed. Subanalyses were performed for age and gender.

RESULTS

Of 136 products identified, 10 were evaluated based on the selection criteria. The main themes identified across products were long-term concerns, marketing, alarm systems, and device mechanics and features. The subthemes identified as future targets for innovation included alarm accuracy, volume variability, durability, user-friendliness, and adaptability to girls. In general, durability, alarm accuracy, and comfort were the most negatively skewed subthemes (with a negative skew of -23.6%, -20.0%, and -12.4% respectively), which are indicative of potential areas for improvement. Effectiveness was the only substantially positively skewed subtheme (16.8%). Alarm sound and device features were positively skewed for older children, whereas ease of use had a negative skew for younger children. Girls and their caretakers reported negative experiences with devices that featured cords, arm bands, and sensor pads.

CONCLUSIONS

This analysis provides an innovation roadmap for future device design to improve patient and caregiver satisfaction and compliance with bedwetting alarms. Our results highlight the need for additional options in alarm sound features, as children of different ages have divergent preferences in this domain. Additionally, girls and their parents and caretakers provided more negative overall reviews regarding the range of current device features compared to boys, indicating a potential focus area for future development. The percent skew showed that subthemes were often more negatively skewed toward girls, with the ease of use being -10.7% skewed for boys versus -20.5% for girls, and comfort being -7.1% skewed for boys versus -29.4% for girls. Put together, this review highlights multiple device features that are targets for innovation to ensure translational efficacy regardless of age, gender, or specific family needs.

Renal-Protective Urinoma Formation in a Newborn Boy With Posterior Urethral Valves

Posterior urethral valves (PUV) are an uncommon urologic congenital anomaly in males often discovered antenatally and more rarely after birth. PUV can lead to obstructive nephropathy and voiding dysfunction, putting patients at increased risk for irreversible renal damage and subsequent progression to end-stage renal disease. Much of the renal damage caused by PUV is proportional to the amount of time that the kidney has been experiencing retrograde pressure. Although much debate exists within the field, spontaneous decompression within the collecting system (e.g., "pop-off" valve) such as urinoma formation or spontaneous ascites has been found to relieve pressure on and thus protect the kidney, decreasing the risk of progression to advanced stages of chronic kidney disease. Despite the significant mass effect on the renal parenchyma, the pressure-relieving function of urinoma formation is a net protective factor allowing renal function to be preserved. We report a unique case of antenatal detection of PUV in a male with postnatal complicated urinoma formation secondary to forniceal rupture. Remarkably, despite significant external compression of the kidney and the development of urosepsis from infection of the urinoma with a multidrug-resistant organism that required percutaneous drainage, renal function was preserved throughout the disease course. After ablation of the PUV and drainage of the septic urinoma, the patient recovered rapidly after intervention and was ultimately discharged in stable condition.

Reasons Behind Patients Defaulting from Elective Pediatric Urology Procedures at a Tertiary Private Teaching Hospital in South India

Aim

The aims of the study are to audit the default rate of the provisional date of elective surgery in pediatric urology private practice and to study the factors involved in the postponement of elective operation dates by patients.

Patients and Methods

The audit involved analysis of reasons behind patients defaulting from elective pediatric urology procedures between January 2019 and December 2019 at a tertiary private teaching hospital in South India. The details were obtained from the outpatient register kept for elective booking. The details of actual procedures performed were obtained from OT records. From the defaulters, the reasons for postponement were obtained through personal/telephonic interview.

Results

A total of 289 patients were given dates for elective procedures. Among this, 72 (24.9%) defaulted, leaving 217 patients who underwent elective surgery. Among those who underwent surgery, 90 (41%) were elective day case (DC) procedures, whereas 127 (59%) were inpatient (IP) procedures. The default rate was 26/116 (22.4%) for DC procedures, whereas 46/173 (26.6%) for IP procedures, with no significant difference between them (P = 0.64). Among the 72 defaulters, the reasons for cancellation were as follows: financial factors (FFs) 22 (30.6%), lack of family support 19 (26.4%), function/grievance in house 10 (13.9%), respiratory illness 14 (19.4%), and treatment at a different center 7 (9.7%). FF (insurance denial) was significantly higher (P = 0.001) in crucial IP procedures at 19/46 (41%) compared to DC procedures at 3/26 (12%). The various diagnoses denied insurance were UPJO (7), VUR (6), hypospadias (4), UDT (3), and PUV (2).

Conclusions

FFs were mainly responsible for parents postponing their children's elective pediatric urology procedures in India. Universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations.

Onabotulinum Toxin A Intradetrusor Injections in Children with Neurogenic Lower Urinary Tract Dysfunction: Long-Term Histological Effects on the Bladder Wall

BACKGROUND

In the last twenty-five years, Onabotulinum Toxin A (BTX-A) has gained increasing popularity for neurogenic lower urinary tract dysfunction (NLUTD) treatment. To maintain its efficacy, repeated BTX-A intradetrusor injections are required over time, with unknown effects on the bladder wall in children. The aim of this paper is to report long-term effects on the bladder wall in children treated with BTX-A.

METHODS

Children with NLUTD not responsive to anticholinergics were treated with BTX-A, according to our protocol, with bladder wall control using endoscopic cold-cup biopsy. Specimens were evaluated considering edema, chronic inflammation, and fibrosis.

RESULTS

Of the 230 patients treated from 1997 to 2022, we considered only specimens obtained in patients who had received ≥5 treatments (36 children), considered as the threshold to evaluate clinical effectiveness on long-term treatment with BTX-A. Most of them had congenital NLUTD (25 patients) and detrusor overactivity (27 patients). In all, increased edema and chronic inflammation with reduced fibrosis over time was reported; these data were not statistically significant. No difference was observed between patients with congenital and acquired diseases.

CONCLUSIONS

Repeated intradetrusor BTX-A injections are not related to significant histological alterations in children, similarly with adults, and repeated injections could be considered safe.

Intravesical Agents in the Treatment of Bladder Clots in Children

Bladder blood clots represent an infrequent urinary condition in children. They usually result from hematuria with many underlying causes, such as urinary tract infections and urethral/bladder traumas. Treatment options for clot removal include trans-urethral or suprapubic bladder irrigation and, if unsuccessful, endoscopic management under general anesthesia with a resectoscope. In younger male children, however, the repeated passage of a trans-urethral resectoscope may be challenging and traumatic, due to the small lumen diameter. Eventually, an open surgical approach can be required in many patients. Few anecdotal non-surgical approaches have been proposed for the management of bladder blood clots in children. This review aims to summarize the conservative techniques described in the literature with the instillation of intravesical agents, analyzing the different strategies and their advantages.

Defining the Infant Male Urobiome and Moving Towards Mechanisms in Urobiome Research

The urinary bladder harbors a community of microbes termed the urobiome, which remains understudied. In this study, we present the urobiome of healthy infant males from samples collected by transurethral catheterization. Using a combination of extended culture and amplicon sequencing, we identify several common bacterial genera that can be further investigated for their effects on urinary health across the lifespan. Many genera were shared between all samples suggesting a consistent urobiome composition among this cohort. We note that, for this cohort, early life exposures including mode of birth (vaginal vs. Caesarean section), or prior antibiotic exposure did not influence urobiome composition. In addition, we report the isolation of culturable bacteria from the bladders of these infant males, including Actinotignum schaalii, a bacterial species that has been associated with urinary tract infection in older male adults. Herein, we isolate and sequence 9 distinct strains of A. schaalii enhancing the genomic knowledge surrounding this species and opening avenues for delineating the microbiology of this urobiome constituent. Furthermore, we present a framework for using the combination of culture-dependent and sequencing methodologies for uncovering mechanisms in the urobiome.

Pediatric cystine stone successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy

Introduction

Cystinuria is often diagnosed by large renal stone for pediatric patients. The patients suffer from recurrence of stone disease, develop the chronic kidney disease and fall into end-stage renal failure. Total removal of stone at the first intervention and prevention of recurrence are essential. Although, it is difficult to treat the pediatric stone patients for their anatomical feature.

Case presentation

We report three cases of pediatric cystine stone patients (two 4-year-old boys and a 9-year-old girl) successfully treated by mini-percutaneous nephrolithotripsy and antegrade ureteroscopy. We could remove stones completely in all three cases, and the patients did not suffer from major complications.

Conclusion

It is essential to select the surgical approach, the endourological device, and the patient's position which is suitable for the age, the body size, and the condition of stones at the initial intervention of pediatric cystine stone.

Differences in Clinical Characteristics Between Prepubescent and Postpubescent Males With Testicular Torsion

Testicular torsion represents a pediatric surgical emergency. In this 6-year study with 140 patients, prepubescent (<13 years) and postpubescent (≥13 years) males with testicular torsion were identified. Prepubescent boys had a longer symptom duration (P = .016) and underwent more orchiectomies (P = .005) compared with postpubescent boys. The risk of orchiectomy decreased by 15% per 1-year increase in age (P = .002). Boys who underwent an orchiectomy had a longer symptom duration (P < .001), were younger (P = .002), had scrotal swelling (P = .001), scrotal erythema (P < .001), higher degrees of torsion (P = .036), and more left-sided surgeries (P = .014) compared with those who had an orchiopexy. Postpubescent boys were 63% less likely to receive an orchiectomy versus an orchiopexy compared with prepubescent boys. Pediatricians should be cognizant of the age discrepancies between prepubescent and postpubescent males with testicular torsion and educate parents about the importance of urgent evaluation in the Emergency Department to reduce the likelihood of an orchiectomy.

Medical clowns versus sedation for paediatric urinary catheter insertion-A randomised pilot study

AIM

To investigate the potential benefits of medical clowns (MCs) in reducing anxiety and pain during paediatric urinary catheter insertion.

METHODS

In this prospective pilot study, 51 children who required urinary catheter insertion were randomised into two groups; the first group (n = 29) underwent the procedure in the presence of a MCs, and the second control group (n = 22) underwent the procedure using sedation. Pain and anxiety levels as well as procedural duration were recorded. All procedures were filmed and evaluated for anxiety level by a paediatric psychiatrist. General satisfaction questionnaires were filled by the medical team and parents in the clown group.

RESULTS

There were no differences in pain scores or anxiety levels between the two groups. Procedure duration and total hospital stay were significantly shorter in the MC group (p < 0.001). One hundred percent of the parents and the medical team were in favour of incorporating MCs during urinary catheter insertion.

CONCLUSION

MCs are as good as sedation in lowering anxiety and pain levels in children undergoing urinary catheter insertion. In addition, MCs reduce the duration of the procedure and elicit a high degree of overall satisfaction from the parents and medical team.

The surgical techniques of transperineal anastomotic urethroplasty for complex posterior urethral stenosis in boys and the long-term follow up outcomes

Objective

To explored the curative effects of various surgical methods used to treat complicated posterior urethral strictures in boys and the long-term complication.

Methods

We retrospectively studied 28 boys under 14 years of age with complicated posterior urethral strictures treated at our hospital from January 2015 to December 2020. Urethral angiography revealed posterior urethral strictures. Twelve had previously failed urethral surgery; four had urethral fistulae. All underwent end-to-end urethral anastomoses via a transperineal, inferior pubic approach. We freed the distal end of the urethra, split the penile cavernous septum, partially resected the lower edge of the pubic symphysis, and rerouted the urethra under a corpus cavernosum to reduce the tension of the urethral anastomosis.

Results

All boys were 2-14 years of age at the time of surgery (mean 6.3 years). The urethral strictures were 3-5.5 cm in length (mean 4.2 cm). Catheters were removed 4 weeks postoperatively. The postoperative follow-up time was 4-72 months (mean 36.8 months). Twenty-four patients exhibited unobstructed urination after a single operation. The maximum urinary flow rate was 15-22 ml/s (average 17.8 ml/s); the success rate was 85.7%. Two patients required second urethral end-to-end anastomoses; urination became normal postoperatively. Two continued to exhibit cystostomies, and two evidenced mild incontinence. Of the six children who have attained puberty, two report erectile dysfunction.

Conclusion

End-to-end urethral anastomosis via a transperineal inferior pubic approach is an ideal treatment for posterior urethral strictures in boys. The complications include incontinence and erectile dysfunction, and require long-term follow-up.

Learning Curves in Pediatric Robot-Assisted Pyeloplasty: A Systematic Review

Background: Robot-assisted surgery demands a specific skillset of surgical knowledge, skills, and attitudes from the robotic surgeon to function as part of the robotic team and for maximal utility of the assistive surgical robot. Subsequently, the learning process of robot-assisted surgery entails new modes of learning. We sought to systematically summarize the published data on pediatric robot-assisted pyeloplasty (pRALP) to decipher the learning process by analyzing learning curves. Methods: This review followed the PRISMA guidelines. PubMed, EMBASE, Web of Science, and Scopus databases were systematically searched for ‘learning curve’ AND ‘pediatric pyeloplasty’. All studies presenting outcomes of learning curves (LC) in the context of pRALP in patients < 18 years of age were included. Studies comparing LC in pRALP versus open and/or laparoscopic pyeloplasty were also included; however, those solely focusing on LC in non-robotic approaches were excluded. The methodological quality was assessed using the Newcastle and Ottawa scale. Results: Competency was non-uniformly defined in all fifteen studies addressing learning curves in pRALP. pRALP was considered safe at all stages. Proficiency in pRALP was reached after 18 cases, while competency was estimated to demand 31 operated cases with operative duration as outcome variable. Conclusions: Pediatric RALP is safe during the learning process and ‘learning by doing’ improves efficiency. Competencies with broader implications than time must be defined for future studies.

Fluorescence-Guided Surgery and Novel Innovative Technologies for Improved Visualization in Pediatric Urology

Fluorescence-guided surgery (FGS), three-dimensional (3D) imaging technologies, and other innovative devices are rapidly revolutionizing the field of urology, providing surgeons with powerful tools for a more complete understanding of patient-specific anatomy. Today, several new intraoperative imaging technologies and cutting-edge devices are available in adult urology to assist surgeons in delivering personalized interventions. Their applications are also gradually growing in general pediatric surgery, where the detailed visualization of normal and pathological structures has the potential to significantly minimize perioperative complications and improve surgical outcomes. In the field of pediatric urology, FGS, 3D reconstructions and printing technologies, augmented reality (AR) devices, contrast-enhanced ultrasound (CEUS), and intraoperative magnetic resonance imaging (iMRI) have been increasingly adopted for a more realistic understanding of the normal and abnormal anatomy, providing a valuable insight to deliver customized treatments in real time. This narrative review aims to illustrate the main applications of these new technologies and imaging devices in the clinical setting of pediatric urology by selecting, with a strict methodology, the most promising articles published in the international scientific literature on this topic. The purpose is to favor early adoption and stimulate more research on this topic for the benefit of children.

[The use of "Fast-Track" in pediatric urology]

BACKGROUND

Current trends in the anesthesiology require a change in the perioperative management of patients, with a consideration of new approaches to anesthesia and the introduction of methods that reduce the stress response to surgery.

AIM

To introduce the "fast-track" concept with the analysis of systemic hemodynamics and stress markers at the perioperative stage in children with urological diseases.

MATERIALS AND METHODS

A prospective and retrospective analysis of the results of 42 children with urological disorders treated from 09.2016 to 04.2021 under spinal anesthesia (SA) was carried out. In each case, perioperative parameters were evaluated, including central hemodynamics and biochemical markers of stress response.

RESULTS

Hemodynamic stability under SA in young children has an evidence base and a physiological explanation. Changes in stress response markers in various anesthesia methods revealed a more pronounced stress-protective effect in SA than in general anesthesia.

CONCLUSIONS

Our data have shown that combined SA for urological procedures in children allows to more effectively and reliably prevent and block the manifestations of stress-induced reactions of hemodynamics and metabolism than general anesthesia. The introduction of fast-track approach in pediatric urology resulted in the faster postoperative recovery and shorter length of stay.

Understanding why caregivers call after ambulatory pediatric urologic surgery

INTRODUCTION

To uncover factors associated with an increased likelihood of a postoperative triage phone call from caregivers after pediatric ambulatory urologic surgery with a focus on social determinants of health.

MATERIALS AND METHODS

This was a retrospective cohort study from July 2014-January 2020. Patients undergoing ambulatory urologic surgery by three different pediatric urologists were included. The primary outcome was the number of patient families that called within 30 days after surgery. Univariable tests and multivariable logistic regression analysis were used to identify factors associated with the increased likelihood of a postoperative phone call.

RESULTS

The families of 460 patients out of 1618 patients called at least once within 30 days of surgery (28%). There were 665 total calls, an average number of 1.5 (SD+/-0.8) phone calls per family. Families who live further away (OR 0.66, 95%CI 0.46-0.93), who do not speak English as a primary language (OR 0.61, 95%CI 0.38-1.00), and who were Native American/Alaskan Native (OR 0.33, 95%CI 0.11-0.99) were less likely to call after surgery. Those with commercial insurance (OR 1.42, 95%CI 1.09-1.85), recovering from non-hypospadias penile surgery (OR 3.20, 95%CI 2.46-4.32), or from hypospadias repair (OR 5.14, 95%CI 3.28-8.18) were more likely to call after surgery.

CONCLUSIONS

Nearly 1 in 3 families call the hospital triage line after ambulatory urologic surgery with postoperative concerns. Families with children who undergo penile surgery are 3-5 times more likely to call after surgery. Social determinants of health may have a role in postoperative phone call rates as medically underserved patients are less likely to call.

Tissue Engineering and Regenerative Medicine in Pediatric Urology: Urethral and Urinary Bladder Reconstruction

In the case of pediatric urology there are several congenital conditions, such as hypospadias and neurogenic bladder, which affect, respectively, the urethra and the urinary bladder. In fact, the gold standard consists of a urethroplasty procedure in the case of urethral malformations and enterocystoplasty in the case of urinary bladder disorders. However, both surgical procedures are associated with severe complications, such as fistulas, urethral strictures, and dehiscence of the repair or recurrence of chordee in the case of urethroplasty, and metabolic disturbances, stone formation, urine leakage, and chronic infections in the case of enterocystoplasty. With the aim of overcoming the issue related to the lack of sufficient and appropriate autologous tissue, increasing attention has been focused on tissue engineering. In this review, both the urethral and the urinary bladder reconstruction strategies were summarized, focusing on pediatric applications and evaluating all the biomaterials tested in both animal models and patients. Particular attention was paid to the capability for tissue regeneration in dependence on the eventual presence of seeded cell and growth factor combinations in several types of scaffolds. Moreover, the main critical features needed for urinary tissue engineering have been highlighted and specifically focused on for pediatric application.

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.

Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience

Objective

Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot‐assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why.

Methods

Retrospective analysis identified patients who underwent open or robot‐assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach.

Results

Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35–1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot‐assisted laparoscopic learning curve.

Conclusions

Optimal procedure approach was determined by case complexity and surgeon's robot‐assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

The obstructive index in antenatal unilateral pelviureteric junction obstruction: A novel predictor of the failure of conservative management

BACKGROUND

To find the impact of the obstructive index (OI) as a predictor of management in antenatal pelviureteric junction obstruction.

METHODS

Records of 135 cases of antenatally detected unilateral pelviureteric junction obstruction, selected for initial observation were retrospectively analyzed. All patients who underwent pyeloplasty on follow up were assigned to Group A. Those patients who were still on conservative management were assigned to Group B. The pelvic anteroposterior diameters of the affected (PAPD[A]) and normal kidney (PAPD[N]) of the same patient, along with the cortical thickness of the affected kidneys (CT[A]) and normal kidneys (CT[N]) on postnatal ultrasound scan, the T1/2 of the affected (T1/2 [A]) and normal kidneys (T1/2 [N]), the differential renal function (DRF), and the shape of the curve on a diuretic renogram were noted for each patient at 6 weeks. The OI was defined as (PAPD[A] × T1/2 [A]) / (PAPD[N] × T1/2 [N]).

RESULTS

The median duration of follow up was 55 months (36-110). Median age at surgery was 12 months (4-80). Group A had 30 patients with 105 in Group B. On multivariate analysis, OI and shape of curve predicted need for surgery with statistical significance. Median OI in Group A was 18.9 compared to 4.82 in Group B (P < 0.001, Mann-Whitney). Using receiver operating characteristic analysis, the area under curve for the OI was 0.95. A level of 12.2 could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%.

CONCLUSIONS

The OI can reliably predict the need for surgery at a very early stage, thus avoiding repeated tests and saving time.

Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation

PURPOSE

To analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported.

MATERIALS AND METHODS

Between years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation.

RESULTS

Mean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months.

CONCLUSIONS

ERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.

Robotic surgery in pediatric urology

Robotic surgery revolutionized minimally invasive surgery. Urology is the widest surgical field in implementing robotic technology. Pediatric urology followed the footsteps of adult urology in utilizing da Vinci™ surgical system for urinary tract reconstruction. Indeed, day after day robotics is gaining more applications and popularity in pediatric urology due to the need for less invasive approach to reconstruct the urinary tract in pediatric population. In this manuscript, we reviewed in this article the steps of evolution of robotic pediatric urology.

Transition from Childhood Nocturnal Enuresis to Adult Nocturia: A Systematic Review and Meta-Analysis

Purpose

Current literature has suggested a relationship between nocturnal enuresis (NE) in childhood and the development of nocturia later in life as both disorders have similar underlying etiologies, comorbidities, and treatments. The objective was to synthesize the available evidence on the association between childhood NE and later presentation of nocturia.

Methods

PubMed, CINAHL, Scopus, and Google Scholar were searched for peer-reviewed studies published between January 1980 and April 2021. Case–control and cohort studies that reported on childhood NE and current nocturia were included. The PRISMA protocol was followed (PROSPERO ID: CRD42021256255). A random-effects model was applied to calculate the pooled odds ratio (OR) and 95% confidence interval (CI). Risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria and with a funnel plot.

Results

Of the 278 articles identified, 8 studies met inclusion criteria. The 6 case–control and 2 prospective cohort studies resulted in a total sample size of 26,070 participants. In a random-effect pooled analysis, childhood NE was significantly associated with the development of nocturia (OR: 1.75, 95% CI: 1.11–2.40). Significant heterogeneity (I² = 92.7%, p < 0.01) was identified among the included studies, which was reflected in an asymmetrical funnel plot. NE and nocturia have similar underlying etiologies of hormonal abnormalities, sleep disorders, physiological disorders, and psychological disorders.

Conclusion

The history of childhood NE is significantly associated with nocturia later in life. The data in this meta-analysis support this transition and identify potential similarities between the two disorders. The sparse number of articles relevant to this topic is a strong indicator of the need for more work on this transition from childhood to maturity. More studies are warranted to further explore the association between NE and nocturia.

Pediatric urology surgical practice in the time of COVID-19: Results from tertiary Saudi Arabia hospitals

Purpose:

Our study aimed to evaluate the effect of COVID-19 on pediatric urology practice in the Kingdom of Saudi Arabia (KSA).

Methods:

Data of 10 tertiary hospitals in KSA were retrospectively analyzed. Data of outpatient department (OPD) visits and pediatric urology surgical procedures from January 1, 2019, to April 30, 2019, and from January 1, 2020, to April 30, 2020, were extracted. The primary outcome was to compare OPD visits and pediatric urology workload in the first third of 2020 versus 2019, where there was no curfew. The secondary outcome was to compare the same variables during the full curfew time, i.e., April 2020 versus April 2019.

Results:

The number of OPD visits was lower in the first third of 2020 (7390 vs. 10,379 in 2019 P < 0.001). OPD visits in April 2020 were 78.6% lower than in April 2019, and teleclinics represented 850 (94.3%). Elective procedures in the first third of 2020 were 688, with a reduction rate of 34.3% compared to the same period of 2019 (P < 0.001). In April 2020, there were 18 elective surgeries, with a 91.4% decrease than in April 2019. Ureteric reimplantation, hypospadias, cryptorchidism, and circumcision stopped, while pyeloplasty (n = 14) and urolithiasis (n = 4) procedures had declined by 50% and 76.5%, respectively. Most of the procedures (71.8%) were day surgery. Emergency procedures were similar in the first third of 2020 (65 vs. 64 in 2019, P = 0.994) and declined in April 2020 by 6.7% versus April 2019. During the full curfew, the most common emergency intervention were cases with obstructive uropathy (42.8%), followed by torsion testis (28.6%), posterior urethral valve (14.3%), and urological trauma (14.3%).

Conclusions:

In KSA, the number of elective pediatric surgical procedures were reduced by >90%, while the number of emergency pediatric surgical procdures were similar during COVID-19 pandemic compared with non-COVID-19 time. Ureteric reimplantation, hypospadias repair, cryptorchidism, and circumcision procedures were postponed. Pyeloplasty and urolithiasis-related procedures were performed to prevent irreversible disease progression or organ damage. There was an increase in rate of teleclinic and day surgery to reduce the risk of COVID-19 infection.

Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics

Background: The most narrow-spectrum antibiotic possible should be used for empiric and definitive treatment of pediatric urinary tract infections (UTIs). Objectives: The objectives of this study were to determine an appropriate narrow-spectrum antibiotic for empiric UTI treatment, factors differentiating empiric first-generation cephalosporin (FGC) versus third-generation cephalosporin (TGC) coverage, and factors associated with unnecessarily broad-spectrum definitive antibiotic treatment. Methods: This was a retrospective chart review of children admitted from 2013 to 2015 who were diagnosed with a UTI and received treatment. Multivariable logistic regression assessed independent factors associated with our outcomes. Results: Of 568 diagnosed UTIs, 88.6% received empiric TGC treatment. Empiric coverage among cultured organisms was only 5.4% lower in FGC versus TGC. Adolescent age group (odds ratio [OR] = 8.83, 95% confidence interval [CI] = 1.47-53.11), uncircumcised males (OR = 4.52, 95% CI = 1.27-16.08), Hispanic ethnicity (OR = 4.37, 95% CI = 1.14-16.82), and hospitalization within the preceding 3 months (OR = 4.73, 95% CI = 1.38-16.23) were associated with FGC nonsusceptibility among TGC susceptible Enterobacteriaceae pathogens. De-escalation occurred in 55.8% of diagnosed UTIs eligible for de-escalation at discharge. Urine white blood cell (WBC) count >5 (OR = 2.89, 95% CI = 1.14-7.21), serum WBC count (OR = 1.04, 95% CI = 1.01-1.07), and having only one narrow-spectrum treatment option (OR = 5.1, 95% CI = 2.43-10.66) were associated with unnecessarily broad-spectrum definitive treatment. Conclusion and Relevance: FGC would be an appropriate narrow-spectrum empiric agent for UTIs at our institution. The factors associated with FGC nonsusceptibility can further stratify empiric treatment decisions. The factors associated with unnecessarily broad-spectrum definitive treatment illustrate areas for educational efforts and future research regarding UTI treatment.

Survey of COVID-19 impact on pediatric urology services

INTRODUCTION

To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning.

MATERIALS AND METHODS

A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020.

RESULTS

The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable.

CONCLUSIONS

Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.

Risk of occult spinal dysraphism based on lumbosacral cutaneous manifestations

Objectives:

Occult spinal dysraphism is a congenital failure of fusion of the posterior vertebral arches with intact skin overlying the defect. Lumbosacral cutaneous manifestations are associated with a variable risk of occult spinal dysraphism. Tethered cord syndrome is a type of occult spinal dysraphism that puts abnormal traction on the spinal cord. This study analyzed neonates and infants who were referred to our pediatric urology practice and had evidence of lumbosacral cutaneous manifestation on physical examination.

Methods:

We reviewed the presence of lumbosacral cutaneous manifestations in neonates and infants evaluated in our pediatric urology clinic at our Institution over a 6-year period (1 March, 2015–28 February, 2021) with no prior diagnosis of lumbosacral cutaneous manifestation. All patients underwent a spinal ultrasound.

Results:

The most common lumbosacral cutaneous manifestations were bifurcated/duplicated gluteal folds (33%), gluteal asymmetry (19%), and sacral dimples (14%). A total of 34 (24%) patients had an abnormal spinal ultrasound; 15 (44%) of these infants underwent a lumbar magnetic resonance imaging. A coccygeal pit was statistically marginally higher in abnormal versus normal spinal ultrasound (p = 0.07). Patients with only one lumbosacral cutaneous manifestation (N = 121) were significantly more likely to have a normal spinal ultrasound compared to those with two or more lumbosacral cutaneous manifestation (N = 17) (79% vs 53%, p = 0.03).

Conclusion:

Due to the varying risk of certain lumbosacral cutaneous manifestations with occult spinal dysraphism, all patients with a lumbosacral cutaneous manifestation should undergo spinal ultrasound. This study also highlights the importance of urodynamic studies when there are abnormal cutaneous findings. Routine physical examinations of the lumbar region for cutaneous manifestations of occult spinal dysraphism are vital to ensure prompt management of tethered cord syndrome and avoid potentially devastating consequences.

Fragility Index of Recently Published Meta-Analyses in Pediatric Urology: A Striking Observation

Background and objective

Fragility Index (FI) of meta-analyses determines their stability in terms of the level of confidence and strength behind the results depicted by them. The present study was conducted to estimate the FI of recently published meta-analyses in the Journal of Pediatric Urology (JPUrol).

Method

Twenty recently published articles on meta-analyses were screened to identify the eligible ones. The baseline data of each meta-analysis including the details of the author, number of included studies, total sample size, the total number of events, the status of the overall outcome (significant or non-significant), type of effect measure, type of method used for pooling the estimates, and type of effects model were recorded. FI was calculated by doing each single status modification. The 95% CI of the treatment effect was re-calculated until the statistical significance of the meta-analysis was reversed.

Results

A total of seven articles incorporating 22 meta-analyses were included. Seven (32%) of them had a statistically significant outcome prior to FI estimation. The risk ratio (17/22; 77%) was the most commonly used effect measure. The random-effects model (15/22; 68%) and the Mantel-Haenszel method (20/22; 91%) of pooling the estimates were utilized in the majority of meta-analyses. The median (Q1-Q3; range) FI of statistically significant, non-significant, and total meta-analyses were 5 (3-19.5; 2-39), 5 (3.5-6; 1-17), and 5 (3-13; 1-39) respectively. FI of ≤5 was noticed in four out of seven (57%), 9/15 (60%), and 13/22 (59%) of these meta-analyses respectively.

Conclusion

Based on our findings, the majority of the recently published meta-analyses in the field of pediatric urology are fragile and depend upon the event status of ≤5 participants.

Survey on what COVID-19 pandemic changed in pediatric urology

OBJECTIVE

We aimed to conduct a survey to see how the patient management of pediatric urologists has changed during the COVID-19 pandemic in daily practice and its compliance with the guidelines that aim to minimize the harm to the patient and healthcare professionals.

MATERIAL AND METHODS

A questionnaire was prepared to be asked to physicians via Microsoft Forms dealing with pediatric urology for this purpose, and a link was shared in social media groups of doctors managing pediatric urology patients.

RESULTS

A total of 58 (46 males and 12 females) doctors participated in the survey. Participants stated that they made a very high rate of change in their clinical routine; the most preferred approach for the prevention in the operating room was reducing the number of the working staff, and the second most frequent was performing a preoperative COVID-19 screening. Elective surgeries (ie, inguinoscrotal pathologies) were delayed by the majority. However, the majority of the surgeons did not delay surgeries for ureteropelvic junction obstruction or urinary stones. Ninety-five percent of the participants stated that the number of patients was decreased in the outpatient clinics, which was mainly due to the hospital and government policies. The most used method to communicate with patients during the pandemic was phone calls, and there was a 52% increase in the WhatsApp messenger application before the pandemic.

CONCLUSION

Our survey provided us with an opinion about how our colleagues' lives changed during the pandemic and showed us the importance of a well-established telemedicine system.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

Infant With Severe Penoscrotal Hypospadias: A Complex Case of Genital Ambiguity and Mistaken Identity

Individuals with an incongruence of their chromosomal sex and genital appearance are classified as having a disorder of sexual development (DSD), and they often present with ambiguous genitalia. The diagnosis and management of DSD patients are usually challenging and require a multidisciplinary approach. Gender assignment should not be based solely on physical exam and imaging but also on the genotype and hormonal function of the gonads. We present an infant born with ambiguous genitalia; the parents were told they were having a male infant during the prenatal ultrasound but at birth, the infant was found to have female-appearing external genitalia with no palpable gonads. MRI of the abdomen was inconclusive, but further workup, including karyotype, hormonal function, and intraoperative evaluation, was consistent with a male infant. He was, therefore, subsequently assigned to the male sex.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

Artificial Intelligence and Its Impact on Urological Diseases and Management: A Comprehensive Review of the Literature

Recent advances in artificial intelligence (AI) have certainly had a significant impact on the healthcare industry. In urology, AI has been widely adopted to deal with numerous disorders, irrespective of their severity, extending from conditions such as benign prostate hyperplasia to critical illnesses such as urothelial and prostate cancer. In this article, we aim to discuss how algorithms and techniques of artificial intelligence are equipped in the field of urology to detect, treat, and estimate the outcomes of urological diseases. Furthermore, we explain the advantages that come from using AI over any existing traditional methods.

Evaluation of transverse dorsal lumbotomy in management of PUJ obstruction in patients younger than 6 months

OBJECTIVE

The transverse dorsal lumbotomy approach provides excellent exposure to the PUJ and causes minimal tissue damage. In this study, we assess the efficacy of dorsal lumbotomy in PUJ obstruction in children younger than 6 months.

METHODS

All children less than 6 months who were managed with the dorsal lumbotomy approach between 2009 and 2017 were reviewed prospectively. Data included: demographic data, pre/post-operative renal ultrasound scan with SFU grading and RDS, operative time, post-operative complications, and follow up results.

RESULTS

A total of 42 children with a mean age of 4.4 ± 1 months were included. On pre-operative RDS, all patients had an obstructive pattern and a SRF of 30.3 ± 9.3. The mean operative duration was 49 min and analgesia was minimal. Post-operative ultrasound at 6 months showed an improvement in hydronephrosis (p < 0.05) and a mean SRF of 39.3 ± 6.1 (p < 0.001).

CONCLUSION

Transverse dorsal lumbotomy approach is a safe and efficient alternative in patients less than 6 month.

Case Report: Rare Presentation of Mixed Germ Cell Tumor in an Infant

The estimated incidence of pediatric testis tumor is 0.5-2.0 per 100,000 children, accounting for 1-2% of all pediatric tumors. Mixed germ cell tumors (MGCT) in prepubertal males are exceedingly rare, with only one previous case report found in the literature. We report a case of a MGCT in an infant. For prepubertal males, GCTs typically present with a painless scrotal mass, though trauma, testis torsion and hydrocele are also common presentations. Similar to such tumors in postpubertal males, ultrasonography, computed tomography, and tumor markers are integral to determine the best treatment. The patient described in this report presented with a painless scrotal mass. Following orchiectomy, the patient was found to have MGCT that was limited to the testis. With prudent management, these patients tend to have favorable prognoses.

Case Report: Novel Copy Number Variant 16p11.2 Duplication Associated With Prune Belly Syndrome

Prune belly syndrome (PBS) is a rare congenital disease that predominantly occurs in males and is identified by its classic triad of abdominal wall musculature deficiencies, cryptorchidism, and urinary tract abnormalities. However, numerous anomalies involving the kidneys, heart, lungs, and muscles have also been reported. A multitude of chromosomal abnormalities have been implicated in its pathogenesis. PBS can occur in association with trisomy 18 and 21. Gene duplications and deletions have also been reported; however, a definite cause of PBS is still unknown. We report the first PBS patient with a copy number variant in 16p11.2.

Hydronephrosis Classifications: Has UTD Overtaken APD and SFU? A Worldwide Survey

Objective: To collect baseline information on the ultrasonographic reporting preferences. Method: A 13-multiple choice questionnaire was designed and distributed worldwide among pediatric urologists, pediatric surgeons, and urologists. The statistical analysis of the survey data consisted of 3 steps: a univariate analysis, a bivariate and a multivariate analysis. Results: Three hundred eighty participants responded from all the continents. The bivariate analysis showed the significant differences in the geographical area, the years of experience and the volume of cases. Most of the physicians prefer the SFU and APD systems because of familiarity and simplicity (37 and 34%, respectively). Respondents noted that their imaging providers most often report findings utilizing the mild-moderate-severe system or the APD measurements (28 and 39%, respectively) except for North America (SFU in 50%). Multivariate analysis did not provide significant differences. Conclusion: Our study evaluates the opinions regarding the various pediatric hydronephrosis classification systems from a large number of specialists and demonstrates that there is no single preferred grading system. The greatest reported shortcoming of all the systems was the lack of universal utilization. The observations taken from this study may serve as basis for the construction of a common worldwide system. As APD and SFU are the preferred systems and the UTD a newer combination of both, it is possible that with time, UTD may become the universal language for reporting hydronephrosis. This time, based on the result of this survey, seems not arrived yet.

Challenges in the Prenatal Diagnosis of Cloaca

Background:

Cloaca is a common excretory channel for the genital, urinary, and gastrointestinal tracts. It is considered a severe anorectal malformation caused by failed partitioning of the genital, rectal, and urinary tracts.

Methods:

We report 5 infants with cloaca at birth who were identified prenatally by one or more of the following on prenatal ultrasound (US): ambiguous genitalia, a cystic pelvic/abdominal mass, hydronephrosis, ascites, a single umbilical artery, and oligohydramnios.

Results:

A cystic pelvic/abdominal mass and ambiguous genitalia were each observed in 3 cases by prenatal US. Ambiguous genitalia was observed in all 5 neonates at birth. There were 2 twin pregnancies (dichorionic/diamniotic and monochorionic/monoamniotic), with only 1 twin in a set affected with cloaca.

Conclusion:

Pediatricians should be alert to the prenatal US findings that may raise suspicion of a persistent cloaca to improve both prenatal counseling and family preparation.

Robot-Assisted Laparoscopic Resection of the Mesonephric Duct Remnant in a Patient with Zinner Syndrome

Introduction: A 17-year-old male with Zinner syndrome, a right seminal vesicle cyst, and a solitary left kidney presented with chronic pelvic pain. Previous surgeons had attempted robot-assisted laparoscopic seminal vesicle cyst aspiration and transurethral resection of the ejaculatory duct. Neither surgery provided sustained symptom relief. Abdominal and pelvic MRI showed a cystic structure lodged between the prostate and bladder. The right seminal vesicle, kidney, and ureter were not observed. Materials and Methods: A robot-assisted laparoscopic seminal vesiculectomy was planned. Dissection distal to the right vas deferens and between the bladder neck and prostate revealed a cystic seminal vesicle-like structure. Attached to this was a tubular structure coursing deep to the vas deferens from the right renal fossa. This was presumed to be a dysplastic ureter. The dysplastic ureter was transected from the seminal vesicle and the seminal vesicle was marsupialized to the deep pelvis. Proximally, the dysplastic ureter was transected and left open. Results: Histologic assessment of the specimen revealed an ∼12.1 cm tubular mesonephric remnant. The postoperative course was uncomplicated. At 6 months follow-up, the patient remains free of symptoms with preserved ejaculatory volume. Conclusions: Mesonephric duct abnormalities and symptoms present on a spectrum. We present a safe and effective resection of a mesonephric duct remnant from a 17-year-old male with Zinner syndrome. A robotic approach localized to the right allowed for excellent observation without compromising left-sided genitourinary anatomy. In males presenting with renal agenesis and pelvic symptoms, clinicians should be suspicious of Zinner syndrome and other mesonephric abnormalities.

Robot-Assisted Laparoscopic Urachal Excision Using Hidden Incision Endoscopic Surgery Technique in Pediatric Patients

Introduction: Although laparoscopic urachal excision in children has been well reported, there are limited data on a robot-assisted surgery (RAS) approach. The hidden incision endoscopic surgery (HIdES) technique is an established method of eliminating visible scars following a number of RAS urologic procedures. We report our experience of using a robotic approach to treat urachal anomalies in children, and we present the first description of utilizing the HIdES port configuration for this procedure. Materials and Methods: We retrospectively reviewed pediatric patients who underwent resection of a urachal remnant at our institution from 2013 to 2018. Surgical techniques were either the traditional open approach (OA) or RAS. HIdES trocar placement configuration was employed in all robotic cases. Patient demographics, perioperative data, pathology reports, and outcomes were abstracted and compared. Results: Twenty-three patients underwent a urachal remnant resection in the study period (RAS: 14 patients vs OA: 9 patients). RAS patients were older (8.5 vs 2.0 years, p = 0.031) and weighed more than OA patients (36.1 vs 13.9 kg, p = 0.063). Median operative time for RAS was longer than OA operative time (136 vs 33 minutes, p < 0.01). Fewer RAS patients were outpatient compared with OA (7.1% vs 66.7%, p < 0.01), but with a median length of stay of 1 day (0-1 day). Two patients (14.3%) in the RAS group experienced postoperative complications within 1 week of the procedure compared with 1 (11.1%) in the OA group. There was no significant difference in blood loss, postoperative narcotic requirements, or duration of follow-up between both groups. Conclusion: RAS is a safe and feasible alternative to open surgery for urachal anomalies. Complete excision can be achieved by using HIdES port configuration, allowing for excellent cosmetic outcomes that are superior to traditional surgical scars without limitation to essential surgical ergonomics.

[Surgical learning curve for top-down two-knot laparoscopic pyeloplasty in congenital hydronephrosis in children]

The aim was to evaluate the surgical learning curve and advantages of top-dow two-knot laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO).

MATERIALS AND METHODS

A retrospective analysis of medical records regarding 98 patients from Speranskij Childrens Municipal Hospital No9, Moscow and Regional Clinical Hospital No7, Volgograd, aged from 3 to 24 months with unilateral hydronephrosis of varying degrees, according to the SFU classification (Society of Fetal Urology) in the Onen modification was carried out. LP in all children was performed in accordance with the Heins-Andersen technique, with minimal resection of the pelvis. In order to compare different techniques for the formation of pyeloureteral anastomosis, patients are divided into two groups: on the first group (n=59) TDTKT was performed, and on the second (n=39) - the standart knotting technique (SKT) was performed. The patients were operated by two surgeons from different clinics. Average time of operation, learning curves, frequency of post-operative complications and post-operative assessments were included as criteria for the comparison of the two groups.

RESULTS

Using TDTKT allowed a reduction in mean time of surgery of 30%. Positive results were obtained in both groups of patients by reducing the degree of hydronephrotic transformation of the kidney during their follow-up year.

CONCLUSION

Using TDTKT not only permits an experienced surgeon to reduce his duration of operation to 67.86 minutes, it also positively affects the surgical learning curve for less experienced surgeons. In this regard, this technique can be recommended to surgeons who do not have much experience in conducting laparoscopic pyeloplasty.

Bilateral aniridia and congenital ureteral valve: Role of genetic testing

Background

Congenital aniridia involves total or partial hypoplasia of the iris and is due to a deficiency in PAX6 gene expression. WAGR syndrome is comprised of Wilms tumor, aniridia, genitourinary abnormalities, and intellectual disability. Numerous genitourinary pathologies may be associated with WAGR syndrome, necessitating an evaluation of the genitourinary anatomy. The WT1 is vital for the development of kidneys, ovaries in females, and testes in males. WT1 gene mutations result in a WT1 protein with a decreased ability to bind to DNA, leading to uncontrolled growth, and cell division in the kidney which permits the development of Wilms tumor. A congenital ureteral valve is an exceedingly rare cause of obstructive uropathy.

Results

A renal and bladder ultrasound demonstrated a renal cyst. A voiding cystourethrogram revealed grade 3 vesicoureteral reflux, and a MAG3 renal scan showed ureteropelvic junction obstruction and hydronephrosis. A ureteral stent was inserted at 3 months of age after which the renal cyst resolved. The patient was urinary tract infection‐free at 27 months of age. Genetic testing confirmed a heterozygous alteration in PAX6 (c.495delG, p.Thr166Leufs*41) and no abnormalities of WT1, excluding WAGR syndrome.

Conclusion

The genitourinary risks potentially associated with aniridia necessitate prompt genetic analysis to evaluate for WAGR syndrome.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.