Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children

BACKGROUND AND OBJECTIVE

The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines.

METHODS

A structured literature review was performed for all relevant publications published from the last update up to March 2022.

KEY FINDINGS AND LIMITATIONS

The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children.

ADVANCING PRACTICE

For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution.

PATIENT SUMMARY

We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.

Role of virtual reality in improving the spatial perception of the kidney during flexible ureteroscopy: A feasibility study using virtual reality simulators and 3D models

Background

The aims were to describe a software-based reconstruction of the patient-specific kidney cavity intraluminal appearance via a head-mounted device and to estimate its feasibility for training novices.

Materials and methods

In total, 15 novices were recruited. Each novice was shown a three-dimensional reconstruction of a patient's computed tomography scan, whose kidney was printed. They then joined the surgeon in the operating room and assisted them in detecting the stone during flexible ureteroscopy on the printed model. Then, each participant did a 7-day virtual reality (VR) study followed by virtual navigation of the printed kidney model and came to the operating room to help the surgeon with ureteroscope navigation. The length of the procedure and the number of attempts to find the targeted calyx were compared.

Results

With VR training, the length of the procedure (p = 0.0001) and the number of small calyces that were incorrectly identified as containing stones were significantly reduced (p = 0.0001). All the novices become highly motivated to improve their endourological skills further. Participants noticed minimal values for nausea and for disorientation. However, oculomotor-related side effects were defined as significant. Five specialists noticed a good similarity between the VR kidney cavity representation and the real picture, strengthening the potential for the novice's education via VR training.

Conclusions

Virtual reality simulation allowed for improved spatial orientation within the kidney cavity by the novices and could be a valuable option for future endourological training and curricula.

Endoscopic dilatation/incision of primary obstructive megaureter. A systematic review. On behalf of the EAU paediatric urology guidelines panel

INTRODUCTION

Historically, ureteral reimplantation (UR) has been the gold standard for treatment of primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent urinary tract infections. In infants, open surgery with reimplantation of a grossly dilated ureter into a small bladder, can be technically challenging with significant morbidity. Therefore, less invasive endoscopic management such as dilatation or incision of the ureter-vesical junction, has emerged as an alternative to reimplantation during the last decades.

OBJECTIVE

To systematically evaluate the effectivity, safety, and potential benefits of endoscopic treatment (dilatation with or without balloon or incision) of POM in comparison to UR.

STUDY DESIGN

A systematic review was conducted. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 20 participants and a mean follow-up more than 12 months were eligible for inclusion.

RESULTS

Of 504 articles identified, 8 articles including 338 patients were eligible for inclusion (0 RCTs, 1 NRSs, and 7 case series). Age at time of surgery was minimum 15 days to a maximum of 192 months. Indications for endoscopic treatment (ET) included patients with loss of split renal function (>10%) and worsening of hydroureteronephrosis. The studies analysed reported a success rate ranging from 35% to 97%. Success was defined as stabilization of differential renal function without further procedures. A post-operative complication rate of 23-60% was reported (mostly transient haematuria, urinary tract infections and stent migration or intolerance). In 14% of the cases salvage UR following initial ET, was performed due to relapse of symptomatic POM.

CONCLUSION

Endoscopic treatment for persistent or progressive POM in children is a minimally invasive alternative to UR with a long-term modest success rate. Additionally, it can be performed within a wide age span, with equal success rate and complication rates.

A cross-sectional analysis of paediatric urologists' current practices, opinions and areas of perceived importance in the delivery of adolescent & transitional care

INTRODUCTION

Complex urological anomalies often require continued care as patients reach adulthood. Adequate transition for adolescents with ongoing urological care needs is critical to allow for seamless care in adult hospitals. Studies have shown that this can lead to improved patient and parental satisfaction, and lower utilisation of unplanned inpatient beds and emergency department visits. There is currently no ESPU-EAU consensus on the adequate mechanism and very few individual papers examining the role of urological transition for these patients in a European setting. This study aimed to identify current practice patterns in paediatric urologists providing adolescent/transitional care, to assess their opinions towards formal transition and to look for variations in care. This has implications for long-term patient health and specialist care.

METHODS

An 18-item cross-sectional survey was compiled and pre-approved through the EAU-EWPU and ESPU board offices prior to dissemination to all registered ordinary members affiliated with the ESPU. This was created using a mini-Delphi method through the EWPU research meetings to provide current semi-quantitative data relating to current opinions and attitudes of this cohort.

RESULTS

A total of 172 respondents (55% paediatric general surgery; 45% urology) across 28 countries completed the survey. The majority of respondents were in practice >10 years and spent >80% time in paediatric urology. There was no formal transition process according to 50% respondents and over half of those that did have less than 1/month, with <10% using validated questionnaires. More than two-thirds respondents continued to provide care after transition, as >70% units had no designated corresponding adult service. Furthermore, 93% paediatric believe a formal transition service to be very important, using a multidisciplinary framework. A pareto chart demonstrated 10 specific conditions to be of most interest in transition to adulthood.

CONCLUSION

This is the first study to assess the requirements of paediatric urologists for adequate transitional care, however due to the nature of the survey's distribution, this was a non-scientific poll based on a convenience sample of respondents. It is critical that dual-trained or adult-trained urologists with a specific interest in paediatric urology work with current paediatric urologists in a multidisciplinary fashion to facilitate early transition based on the adolescent's developmental and biopsychosocial requirements. National urological and paediatric surgical societies need to make transitional urology a priority. The ESPU and EAU should collaboratively consider developing transitional urology guidelines to allow a framework by which this can occur.

Assistant port is unnecessary for robotic-assisted laparoscopic pyeloplasty in children: a comparative cohort study

OBJECTIVE

To compare the postoperative outcomes including the cosmetic results of robotic-assisted laparoscopic pyeloplasty (RALP) performed with and without assistant port in pediatric population.

METHODS

47 patients with ureteropelvic junction obstruction consecutively underwent RALP were stratified as: three-port (Group 1, n = 26) and four-port (Group 2, n = 21). In Group 1, no assistant port was placed and double-J stent was introduced with the aid of an angiocatheter via the percutaneous route. In group 2, an assistant port was placed. The Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale(VSS), Satava, Clavien classification systems, and success rates were compared.

RESULTS

We found similar success rates for both groups (group 1:96.2%, group 2:100%). Two groups were similar in terms of improvement in the postoperative anteroposterior diameter of the renal pelvis and parenchymal thickness. There was no difference in terms of perioperative and postoperative complication rates (group 1:19.2%, group 2:9.5%). The total PSAS was significantly lower in Group 1 (p < 0.008). No difference was observed for VSS and OSAS.

CONCLUSIONS

Using an assistant port does not improve the success or complications of RALP, while the cosmetic outcomes are inferior to three-port RALP in children. We suggest avoiding the use of assistant port during RALP in children.

Factors predicting the success of intradetrusor onabotulinum toxin-A treatment in children with neurogenic bladders due to myelomeningocele: The outcomes of a large cohort

OBJECTIVE

This study aimed to determine the effectiveness of intradetrusor injections of onabotulinum toxin-A (BoNT-A) in pediatric patients with neurogenic bladders (NB) due to myelomeningocele (MMC). The factors predicting success were also evaluated.

STUDY DESIGN

We retrospectively identified 62 patients with NB due to MMC who underwent intravesical BoNT-A injection (100-300 U) between May 2013 and December 2018. Indications for BoNT-A injection were according to the European Association of Urology guidelines and included children for whom clean intermittent catheterization (CIC) and anticholinergic therapy had failed. Children who had previous bladder surgery or anti-reflux operations, coagulation disorders, myasthenia gravis, and non-neurogenic bladders were excluded. Twenty-one patients had accompanying vesicoureteral reflux (VUR). Preoperative and postoperative urodynamic parameters, clinical success, and VUR grades for all patients were recorded. Clinical success was defined as 4 h of dryness or bladder control between CICs. Logistic regression analysis was performed to evaluate the factors affecting treatment success.

RESULTS

The mean age of the children was 9 ± 3.36 years. The mean follow-up was 28.5 ± 12.2 months. Clinical success was achieved in 64.5% (n: 40) of the patients. The mean maximal cystometric capacity increased from 172.4 ± 45.6 mL to 236.3 ± 67.2 mL. The mean bladder compliance increased from 14.8 ± 8.1 mL/cm H₂O to 19.3 ± 7.4 mL/cm H₂O, and the mean maximal detrusor pressure decreased from 56.7 ± 18.8 cm H₂O to 36.6 ± 10.1 cm H₂O. Urodynamic parameters did not improve in patients with hypocompliant (fibrotic) bladders. In patients with accompanying VUR, reflux was completely resolved in 53.8% (n: 14) of the ureters, improved in 26.9% (n: 7) of the ureters, and remained unchanged in 19.2% (n: 5) of the ureters after subureteral injection.

CONCLUSION

Intradetrusor BoNT-A injections provide excellent outcomes in children with NB refractory to conservative treatments. Poor responses were observed in patients who had low-compliant bladders without detrusor overactivity.

Are there any benefits of using an inlay graft in the treatment of primary hypospadias in children? A systematic review and metanalysis

INTRODUCTION

Dorsal inlay graft urethroplasty (DIGU) has been described as an effective method for hypospadias repair with the proposed advantage of reducing the risk of complications. We aimed to systematically assess whether DIGU has any additional advantages over standard tubularized incised plate urethroplasty (TIPU) repair in children with primary hypospadias.

MATERIALS AND METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The a priori protocol is available at the PROSPERO database (CRD42020168305). A literature search was conducted for relevant publications from 1946 until January 10, 2020 in seven different databases. Randomized controlled trials (RCTs), comparative studies (TIPU vs DIGU) and single arm case series (>20 cases) of DIGU were eligible for inclusion. Secondary hypospadias, two-stage repairs, disorders of sex development, significant curvature of >30°, and a mean or median follow-up of less than 12 months were excluded.

DISCUSSION

A total of 499 articles were screened and 14 studies (3 RCTs, 5 non-randomized studies (NRSs), and 6 case series) with a total of 1753 children (distal: 1334 (76%) and proximal: 419 (24%)) were found eligible. Mean follow-up of the studies was between 16 and 77 months. DIGU was found superior to TIPU in decreasing meatal/neourethral stenosis (p = 0.02, 95% CI 0.02-0.78). All other parameters were found comparable including overall complications, fistula and glans dehiscence rates. Success rates were similar among the groups ranging between 48% and 96% for DIGU and 43-96% in the TIPU group. The lack of standardization in the definition of complications and success was the major limitation of this study.

CONCLUSIONS

Using an inlay graft during primary hypospadias repair decreases the risk of meatal/neourethral stenosis. However, current evidence does not demonstrate superiority of DIGU over TIPU in terms of treatment success and overall complication rates.

The optimal settings of holmium YAG laser in treatment of pediatric urolithiasis

The aim of this study is to present our experience on the use of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser in pediatric patients for pediatric urolithiasis and describe the optimal settings. A total of 116 children who underwent urolithiasis treatment (percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS), retrograde intrarenal surgery (RIRS)) were included. The mean age of the patients was 8.4 ± 5.2 years (1-18). The mean follow-up was 26 ± 8.8 months (9-45). There was no difference between the mean stone sizes of PNL and RIRS patients (p = 0.816). Operations were performed with 200, 272, and 365-μm fibers. In mini-URS, stone fragmentation was achieved with the energy settings set between 0.5 and 1 J and frequency set to > 8 Hz. In RIRS, fragmentation was achieved with the setting of 0.5-0.8 J at 10-20 Hz. Stone fragmentation was performed with energy settings of 0.8 to 2 J between 5 and 15 Hz for PNL. There was no significant difference between the stone-free rates of the PNL and RIRS (p = 0.150). Four postoperative complications occurred (Clavien II), which included febrile urinary infections in two patients who underwent mini-URS, one patient who underwent PNL, and one patient who underwent RIRS. Our results confirmed that Ho-YAG laser can be effectively used in children for stone treatment by using low-energy high-frequency settings for URS and RIRS and a high energy setting for PNL.

A survey and panel discussion of the effects of the COVID-19 pandemic on paediatric urological productivity, guideline adherence and provider stress

INTRODUCTION

The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity.

METHODS

A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels.

RESULTS

There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%.

CONCLUSION

This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions.

Clinical and surgical consequences of the COVID-19 pandemic for patients with pediatric urological problems: Statement of the EAU guidelines panel for paediatric urology, March 30 2020

The COVID-19-pandemic forces hospitals to reorganize into a dual patient flow system. Healthcare professionals are forced to make decisions in patient prioritization throughout specialties. Most pediatric urology pathologies do not require immediate or urgent care, however, delay may compromise future renal function or fertility. Contact with patients and parents, either physical in safe conditions or by (video)telephone must continue. The Paediatric-Urology-Guidelines-panel of the EAU proposes recommendations on prioritization of care. Pediatric-Urology program directors must ensure education, safety and attention for mental health of staff. Upon resumption of care, adequate prioritization must ensure minimal impact on outcome.

Laparoscopy versus robotic-assisted pyeloplasty in children: preliminary results of a pilot prospective randomized controlled trial

PURPOSE

The aim of this randomized controlled trial (RCT) is to compare the outcomes of conventional laparoscopic pyeloplasty (LP) versus robotic-assisted laparoscopic pyeloplasty (RALP) in the treatment of ureteropelvic junction obstruction (UPJO) in children.

METHODS

A total of 53 patients with UPJO were randomized as LP (Group 1, n: 27) and RALP (Group 2, n: 26). Redo cases and patients with anatomical abnormalities were excluded. Urinary ultrasound was performed at postoperative 3, 6 and 12 months; whereas, diuretic renal scintigraphy was performed at 1 year. Failure was defined as progressive hydronephrosis on ultrasound, decline in renal function, or symptom relapse. All parameters were statistically compared.

RESULTS

The mean age of the patients was 55.53 ± 57.25 months. There were no statistical differences between the groups in terms of patient gender, body mass index, laterality, preoperative renal function, renal pelvis antero-posterior diameter and presence of crossing vessel. Mean total operative time in LP group was longer than RALP (139 min vs 105 min, respectively, p = 0.001). The hospital stay was similar between the two groups. After a mean follow-up of 12.43 ± 5.34 months, the complication and success rates were found comparable. Only two patients required re-do pyeloplasty in LP group. The mean total cost of RALP procedure was approximately four times higher than LP.

CONCLUSIONS

This is the first RCT comparing LP and RALP in pediatric population. Both LP and RALP are safe and effective in children with comparable success and complication rates. Operative time was longer for LP; whereas, total cost was higher for RALP.

Does ozone administration have a protective or therapeutic effect against radiotherapy-induced testicular injury?

Objective

We investigate the protective and therapeutic effects of ozone therapy (OT) in radiotherapy (RT)-induced testicular damage.

Methods

Thirty healthy adult male Wistar rats divided into five groups consisting of six animals each as follows: (1) Control (C), (2) RT, (3) OT, (4) OT + RT, and (5) RT + OT group. Histopathological findings, Johnsen scores, thiobarbituric acid-reactive substances (TBARS), glutathione (GSH), superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx) levels were evaluated.

Results

RT caused a significant decrease in testicular weight and Johnsen score compared to the control group. In addition, TBARS level was significantly higher, whereas GSH, SOD, catalase, and GPx levels were significantly lower in the RT group when compared to the control group. Pre and postRT OT significantly increased GSH, SOD, catalase, and GPx levels and decreased TBARS level. Furthermore, testicular weight and Johnsen score were increased with OT.

Conclusions

The present study showed that OT is protective and therapeutic in radiation-induced testicular damage. OT may be beneficial to the patients who underwent RT.

Late ascended testes: is non-orthotopic gubernacular insertion a confirmation of an alternative embryological etiology?

INTRODUCTION

Re-ascended testes account for a proportion of all undescended testes (UDTs); one main hypothesis relating to their etiology relates to a patent processus vaginalis peritonei. The aim was to investigate gubernacular insertion points in boys with late ascended testis as a possible guide to an alternative embryological etiology.

PATIENTS AND METHODS

Patients with proven ascended testes were recruited from four different pediatric urology centers between May 2016 and September 2017. All patients were evaluated regarding their gubernacular insertion during orchidopexy. The presence of accompanying patent processus vaginalis and the association between the epididymis and testis were also documented.

RESULTS

Seventy-seven children (mean age = 73.1 ± 41.2 months [range 18-176]) were enrolled into the study. A non-orthotopic gubernacular insertion point was found in 96.1% (n = 74); 34.2% (n = 26) of these were located in the groin and 63.2% (n = 48), high within the scrotum. Figure A. An open processus vaginalis peritonei was found in 35.1%. Twelve patients (15.6%) had small, dysplastic appearing testis with testis-epididymis dissociation. Boys with a higher insertion of the non-orthotopic gubernaculum (n = 48, groin) were operated earlier (mean age at surgery, 62.3 months) compared with those with a gubernacular insertion at a high scrotal site (mean age at surgery, 90.5 months; p = 0.004). Figure B.

DISCUSSION

This study revealed that non-orthotopic gubernacular insertion is found in the vast majority of the ascending testis cases. Patent processus vaginalis was accompanying only 35.1% of all children and might be the cause of the ascending testis in this small subgroup of patients in line with the earlier reports [1]. In boys with ascending testes, in this population, the gubernaculum was very likely to insert non-orthotopically. In concordance with previous reports [2] and regarding the finding of a an earlier age at surgery in boys with higher inserting gubernacula, this could provide a logical explanation as to how these testes are initially palpable in the scrotum and then, during body growth are retracted to the groin.

CONCLUSION

In 96.1% of the patients, a non-orthotopic gubernacular insertion was found. This points to embryologic etiology, complying well with earlier reports and further underlining the critical importance of timely diagnosis and treatment for this group of patients.

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel

CONTEXT

The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial.

OBJECTIVE

To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion.

EVIDENCE SYNTHESIS

Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates.

CONCLUSIONS

Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown.

PATIENT SUMMARY

In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

Transperitoneal laparoscopic heminephroureterectomy in pediatric population: A single-centre experience using a sealing device

INTRODUCTION

We sought to report the outcomes of transperitoneal laparoscopic heminephroureterectomy (LHNU) in pediatric population and to describe the technical details of this minimally invasive surgery.

METHODS

Seventeen pediatric patients (18 renal units), who had consecutive transperitoneal LHNU in our department between January 2012 and July 2017 were included in the study. In all patients, diagnostic cystoscopy and retrograde pyelography were carried out immediately before the operation. A catheter was inserted in the unaffected ureter and fixed. LHNU with a transperitoneal approach was carried out in all patients with the aid of LigaSure^®. After removal of the specimen, the intervention was finalized with the insertion of a drain. All intraoperative and postoperative data of the patients were recorded prospectively.

RESULTS

The average age of the patients was 55.9±35.8 months (range 8-121). The average duration of the operations was 121.7±24.0 minutes (range 100-200). The average hospitalization time was 1.6±0.4 days (range 1-2). No intraoperative complication occurred in our patients. The average followup period was 29.1±13.4 months (range 4-48). During the followup period, no complications were observed except one patient who had pyelonephritis within the first month of surgery.

CONCLUSIONS

Transperitoneal LHNU is a minimally invasive method that can be used safely in pediatric patients. Using a standardized technique during the procedure is critical to increase the success and decrease the complication rates.

Quantifying the Additional Difficulty of Pediatric Robot-Assisted Laparoscopic Re-Do Pyeloplasty: A Comparison of Primary and Re-Do Procedures

BACKGROUND

Re-do pyeloplasty after failed open or laparoscopic ureteropelvic junction (UPJ) obstruction correction can be a challenging procedure because of scar formation at the previous anastomosis site and decreased vascularity of the ureter. This study compared the perioperative parameters for pediatric robot-assisted laparoscopic (RAL) primary and re-do pyeloplasties with an emphasis on the intra-operative parameters.

MATERIALS AND METHODS

We compared the perioperative parameters of pediatric RAL procedures performed by a single surgeon at a tertiary care children's hospital for both primary ureteropelvic junction obstruction (UPJO) and recurrent UPJO after a previous open or laparoscopic procedure over 2013-2015. The operative time was subdivided as total operative time, console time, port placement time, dissection time to UPJ, and anastomosis time.

RESULTS

A total of 65 pediatric RAL pyeloplasty procedures for UPJO were performed (55 primary and 10 re-do pyeloplasties) during the study period. The console times were 43.3% longer for re-do pyeloplasties than for primary pyeloplasties (133.0 ± 30.7 versus 92.8 ± 24.0 minutes, respectively, P < .01). The re-do cases had longer operative times, especially for UPJ exposure (52.2 ± 21.0 versus 28.0 ± 14.0 minutes, P < .01). There were no conversions to open surgery or significant perioperative complications. There was no difference in hospital pain medication usage and hospital length of stay between the 2 groups. The treatment success rates were 98.2% (54/55) and 100% (10/10), respectively.

CONCLUSIONS

RAL re-do pyeloplasty is associated with significantly longer operative times as compared with primary pyeloplasties, especially during the exposure of the UPJ, but it is overall a safe and effective surgical modality for persistent/recurrent UPJO in children. As surgeons are increasingly asked for more accurate predictions of operative time lengths when scheduling cases, this information can be helpful for surgeons when scheduling these cases and with counseling families.

Comparison of intravesical (Cohen) and extravesical (Lich-Gregoir) ureteroneocystostomy in the treatment of unilateral primary vesicoureteric reflux in children

INTRODUCTION

Various intravesical and extravesical techniques have been described for the surgical correction of vesicoureteral reflux (VUR). Among those techniques Cohen (intra-vesical) and Lich-Gregoir (extra-vesical) are the most commonly used ones. However, there are limited studies that compare those two surgical techniques in the literature.

OBJECTIVE

In this study, we aim to compare the outcomes of the open intravesical and extravesical procedures for unilateral primary VUR in children.

METHODS

We analyzed the records of 118 consecutive children with primary VUR who underwent open ureteral reimplantation surgery by single surgeon from January 2011 to October 2015 at our institution. Among them, intravesical reimplantation was group A, and extravesical reimplantation procedure was group B. We retrospectively analyzed the clinical data of both groups, including age, sex, preoperative reflux grade, presence of lower urinary tract symptoms (LUTS), operative time, postoperative complications and hospitalization period. Success of surgery was defined as the resolution of the VUR as determined by voiding cystourethrography 6 -12 months after surgery. All the parameters were statistically compared.

RESULTS

A total of 58 patients were found eligible for the study. In 23 cases intravesical (group A) and in 35 cases extravesical (group B) procedure were performed. The operative time in group A was significantly higher than group B (110.3±16.9 and 87±29.8 min, respectively, p = 0.002). The mean hospital stay was also longer in group A (2.8±0.8 and 1.2±0.6 days, respectively, p = 0.007). The ureteral catheterization periods were 14.1±6.1 days for group A and there was no ureteral catheter placement in group B. The success rate of the two groups were comparable (100% vs 94.9%, p = 0.513). No intraoperative complications were detected in either group. The number of febrile urinary tract infections were similar between the groups after a mean follow up of 18.2 months (p = 0.746).

DISCUSSION

Our results confirmed that both Cohen and Lich-Gregoir procedures had equivalent success and complication rates. Lich-Gregoir technique was found superior to Cohen technique in terms of hospital stay and operative time. Moreover, it avoids the necessity of urethral and ureteral stenting which probably might increase the comfort of the patients postoperatively. The main limitations of our study are unrecorded pain scores and amount of analgesics taken the after surgery and retrospective analysis of the data.

CONCLUSION

Both the open intravesical and extravesical ureteroneocystostomy procedures are equally effective in the treatment of primary unilateral VUR. Any of the techniques can be opted by the surgeons depending on their surgical experience.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party

INTRODUCTION

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).

MATERIALS AND METHODS

The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.

RESULTS

A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.

DISCUSSION

This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.

CONCLUSIONS

Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

A Modified Antegrade Stenting Technique for Laparoscopic Pyeloplasty in Infants and Children

OBJECTIVE

There are 2 critical steps of stent placement during laparoscopic pyeloplasty (LP) in children. Introduction to the ureteropelvic junction and passing through the ureterovesical junction. We aimed at overcoming those 2 steps by creating a modified technique.

METHODS

Consecutive 27 children undergoing transperitoneal laparoscopic dismembered pyeloplasty by a single surgeon were prospectively enrolled into this study. The modifications of our technique are using an Amplatz dilator and a closed tip stent.

RESULTS

The mean age of the children was 6.7 (range 4 months-17 years). The mean time of stent insertion was 2.7 ± 2.0 (2-6) min and the operative time was 128.3 ± 17.6 (90-180) min. The mean number of days of hospital stay was 2.0 ± 0.4 (1-3). After a mean follow-up period of 20.3 ± 4.2 (14-30) months, no operative failure was detected.

CONCLUSION

Our modified technique is a completion of the current armamentarium for stent placement during LP in infants and children.

A Comparison of 2 Percutaneous Nephrolithotomy Techniques for the Treatment of Pediatric Kidney Stones of Sizes 10-20 mm: Microperc vs Miniperc

OBJECTIVE

To compare outcomes of micro-percutaneous nephrolithotomy (PNL; microperc) with mini-PNL (miniperc) in the treatment of pediatric renal stones of sizes 10-20 mm.

MATERIALS AND METHODS

Patients aged <18 years who underwent PNL for renal stones of sizes 10-20 mm between August 2011 and March 2014 in 3 referral centers were reviewed retrospectively. Patients were evaluated in the following 2 groups: microperc (group 1) and miniperc (group 2). Demographics and perioperative parameters (fluoroscopy and operation time, hemoglobin drop, and stone-free and complication rates) were retrospectively analyzed.

RESULTS

A total of 119 patients were evaluated, including group 1 (n = 56) for microperc and group 2 (n = 63) for miniperc. We found mean stone sizes as 13.4 ± 3.4 and 14.8 ± 3.7 mm in the groups, respectively (P = .046). Mean operation and fluoroscopy times were 57.1 ± 31.2 minutes and 132.4 ± 92.5 seconds in the microperc group and 68.9 ± 36.7 minutes and 226.2 ± 166.2 seconds in the miniperc group, respectively (P = .110 and P <.001). Stone-free rates were similar in both groups (82.1% vs 87.3%; P = .433 and 92.8% vs 93.6%; P = 0673) on postoperative day 1 and at first-month follow-up. The mean hemoglobin drop in group 2 differed from that in group 1 significantly (P <.001). The difference of average hospitalization times was statistically significant (43.0 ± 15.4 vs 68.5 ± 31.7 hours; P <.001).

CONCLUSION

Our outcomes show that microperc may be preferred as an alternative to mini-PNL for the treatment of pediatric kidney stones of sizes 10-20 mm with comparable success and complication rates, as well as shorter hospitalization and fluoroscopy times.

Management of the bladder and calyceal diverticulum: options in the age of minimally invasive surgery

Bladder and calyceal diverticula are rare clinical entities in the pediatric population. Most of these diverticula are asymptomatic, incidentally detected, and may not require surgical intervention. However, if surgery is indicated, there are minimally invasive treatment options available that have success rates comparable with those of traditional open surgery. In addition, they offer several advantages including reduced morbidity, decreased hospital length of stay, improved cosmesis, and reduced pain medication requirements. In this review, the minimally invasive surgical techniques in the management of bladder and calyceal diverticula are discussed.

Urinary tract effects of HPSE2 mutations

Urofacial syndrome (UFS) is an autosomal recessive congenital disease featuring grimacing and incomplete bladder emptying. Mutations of HPSE2, encoding heparanase 2, a heparanase 1 inhibitor, occur in UFS, but knowledge about the HPSE2 mutation spectrum is limited. Here, seven UFS kindreds with HPSE2 mutations are presented, including one with deleted asparagine 254, suggesting a role for this amino acid, which is conserved in vertebrate orthologs. HPSE2 mutations were absent in 23 non-neurogenic neurogenic bladder probands and, of 439 families with nonsyndromic vesicoureteric reflux, only one carried a putative pathogenic HPSE2 variant. Homozygous Hpse2 mutant mouse bladders contained urine more often than did wild-type organs, phenocopying human UFS. Pelvic ganglia neural cell bodies contained heparanase 1, heparanase 2, and leucine-rich repeats and immunoglobulin-like domains-2 (LRIG2), which is mutated in certain UFS families. In conclusion, heparanase 2 is an autonomic neural protein implicated in bladder emptying, but HPSE2 variants are uncommon in urinary diseases resembling UFS.

Rare cause of macroscopic hematuria in a pediatric patient: nephrogenic adenoma of the bladder

Pediatric nephrogenic adenoma (NA) is an uncommon benign metaplastic lesion occurring in the urothelium. Herein we report a case of NA of the urinary bladder in a 14-year-old boy. The patient presented with macroscopic hematuria and had a history of ureteral surgery and long-term smoking. NA should be considered in the differential diagnosis of any urinary tract tumor in the pediatric population.

Extraordinary cause of complete colonic obstruction in children: urinary retention

Complete colonic obstruction in children may occur secondary to congenital, and acquired factors related to the gastrointestinal system. Herein, we report an extraordinary presentation of complete colonic obstruction due to extensive urinary retention in a 3-year-old boy. The possible underlying mechanism was detected as urinary infection in a child with horseshoe kidney. The treatment of the bladder symptoms and urinary infection relieved the obstruction of the colon. To our knowledge, especially in children, colonic obstruction due to urinary retention has not been reported in the literature.

Comparison of intrarenal pelvic pressure during micro-percutaneous nephrolithotomy and conventional percutaneous nephrolithotomy

The micro-percutaneous nephrolithotomy (microperc) is a recently introduced percutaneous nephrolithotomy (PNL) technique that is performed through a 4.8 Fr all-seeing needle. We aimed to measure the intrarenal pelvic pressure (IPP) during microperc and compare it with the levels of conventional PNL. A total of 20 patients with 1- to 3-cm renal calculi resistant to shock wave lithotripsy were treated either with microperc (Group-1, n: 10) or conventional PNL (Group-2, n: 10) by the same surgical team. The IPP was measured during different stages (entrance into the collecting system, stone fragmentation, and before termination) of the procedures by an urodynamic machine using the 6 Fr ureteral catheter. All the variables were statistically compared between the two groups. The demographic values of the patients were similar. The operation time and duration of hospitalization were significantly prolonged in conventional PNL group (p = 0.034, p = 0.01, respectively). The mean drop in hematocrit levels was significantly lower in microperc group (3.5 ± 1.5 vs. 1.8 ± 0.8; p = 0.004). The IPP was significantly higher in microperc group during all steps of the procedure. The highest level of the IPP was measured as 30.3 ± 3.9 and 20.1 ± 3.1 mmHg in Group 1 and Group 2, respectively (p < 0.0001). However, the complication and success rates were found comparable. In conclusion, we demonstrate that the level of IPP is significantly increased during microperc compared to conventional PNL. Microperc should be used cautiously in cases with impaired drainage of the collecting system.

Initial experience of micro-percutaneous nephrolithotomy in the treatment of renal calculi in 140 renal units

The aim of this study was to investigate the effectiveness and reliability of the micro-percutaneous nephrolithotomy (PNL) method for the management of kidney stones. We performed a retrospective analysis of 136 patients (140 renal units) who underwent micro-PNL for renal stones between September 2011 and February 2013 in four referral hospitals in Turkey. The selection of treatment modality was primarily based on factors such as stone size and location. In this study, we analyzed patient- and procedure-related factors. The mean age of patients in this study was 28.7 ± 20.6 (1-69) years, and the mean stone size was 15.1 ± 5.15 (6-32) mm. Conversion to mini-PNL was required in 12 patients. All interventions were performed with the patient in the prone position, except for the 3-year-old patient with the pelvic kidney who was placed in the supine position. The mean hospital stay was 1.76 ± 0.65 (1-4) days, and the mean drop in the hemoglobin level was 0.87 ± 0.84 (0-4.1) mg/dL. One of our patients required transfusion. Ureteral J stent was implanted in nine (6.43 %) patients because of residual stones. Seven (6.43 %) patients complained of postoperative renal colic which was managed conservatively. Abdominal distension related to extravasation of the irrigation fluid was observed in three patients (2.19 %). There were no other postoperative complications. An overall success rate of 82.14 % was achieved. Micro-PNL can be effectively and safely used for small and moderate kidney stones resistant to shock wave lithotripsy or as an alternative to other minimally invasive treatment methods.

Comparison of shockwave lithotripsy and microperc for treatment of kidney stones in children

PURPOSE

We aimed to compare the outcomes of microperc and shockwave lithotripsy (SWL) for treatment of kidney stones in children.

PATIENTS AND METHODS

The medical records of 145 patients under the age of 15 years with opaque and single kidney stones treated with either SWL or microperc were retrospectively reviewed. Both groups were compared in terms of fluoroscopy and operative time, re-treatment, complications, success rate, and secondary and total number of procedures.

RESULTS

Microperc and SWL were performed on 37 and 108 pediatric patients, respectively. The mean age of the patients was 5.91±4.03 years (1-15) and 8.43±4.84 (1-15) years in the SWL and microperc groups, respectively (P=0.004). The mean stone size was 11.32±2.84 (5-20) mm in the SWL group and 14.78±5.39 (6-32) mm in the microperc group (P<0.001). In the SWL group, 31 (28.7%) patients underwent a second SWL session and 6 (5%) had a third session. Finally, 95 (88%) patients were stone free at the end of the SWL sessions. In the microperc group, the stone-free rate was 89.2% in a single session (P=0.645). The mean duration of hospitalization was 49.2±12.3 (16-64) hours in the microperc group and 8.4±2.3 (6-10) hours per one session in the SWL group (P<0.001). The fluoroscopy time was significantly longer in the microperc group compared with the SWL group (147.3±95.3 seconds vs 59.6±25.9 seconds, P<0.001). The rate of requirement for an auxiliary procedure was higher in the SWL group than in the microperc group. The overall complication rates for the microperc and SWL groups were 21.6% and 16.7%, respectively (P=0.498).

CONCLUSIONS

The results of our study demonstrate that microperc provides a similar stone-free rate and a lower additional treatment rate compared with SWL in the treatment of kidney stone disease in children.

Preoperative evaluation of pediatric kidney stone prior to percutaneous nephrolithotomy: is computed tomography really necessary?

The objective of the study was to investigate the precise role of computed tomography (CT) in preoperative radiologic evaluation and surgical planning of kidney stone in children prior to percutaneous nephrolithotomy (PNL). A total of 113 pediatric patients (aged ≤18 years) undergoing PNL for renal stone(s) in three referral hospitals between March 2010 and August 2012 were retrospectively evaluated. Depending on the preoperative radiologic evaluation, patients were divided into two groups. Those evaluated with CT were classified as group-1 (n = 50) and the remaining cases undergoing intravenous urography (IVU) examination were classified as group-2 (n = 63). Patient- and procedure-related variables and perioperative measures were compared between the groups. The mean age, stone size and localization were similar in both groups (p = 0.07, p = 0.57, p = 0.6, respectively). Although the postoperative hemoglobin drop was found to be significantly higher in group-2 (1.5 ± 1.3 vs. 0.9 ± 0.6 g/dL, p = 0.005), the mean operation time, fluoroscopic screening time, access number, overall success and complication rates were comparable (p = 0.06, p = 0.94, p = 0.75, p = 041, and p = 0.41, respectively). However, the mean hospitalization time was significantly prolonged in group-2 than in group-1 (p = 0.03). Our findings clearly demonstrate that, despite the key role of preoperative CT in particular patients with anatomically abnormal kidneys, IVU is a valuable alternative imaging modality with comparable radiation doses in children.

Initial report of microperc in the treatment of pediatric nephrolithiasis

BACKGROUND/PURPOSE

To report the first technical feasibility and safety of microperc in the treatment of pediatric nephrolithiasis.

METHODS

A multicenter prospective trial was initiated and microperc was performed in 19 children from four different centers. In all cases, 4.85-Fr all-seeing needle was used to access the collecting system under direct vision. Stone fragmentation was performed using a 200-μm holmium: YAG laser fiber either through the same needle sheath or an 8-Fr microsheath. Patient- and procedure-related factors and perioperative and postoperative parameters were analyzed.

RESULTS

The mean age of the children was 7.5 ± 4.4 years. Mean stone size was 14.8 ± 6.8mm. Conversion to Mini-PNL was required in two patients because of optical default in one and the high stone burden in the other. The mean hospital stay was 1.8 ± 0.8 days and the mean hemoglobin decrease was 0.1 mg/dl. The overall stone-free rate at 1 month was 89.5%. In one patient with obstructed ureteropelvic junction, intravasation of the irrigation fluid has led to abdominal distention and managed with percutaneous drainage intraoperatively. No other postoperative complication was recorded and no ancillary procedure was required.

CONCLUSIONS

Microperc is a safe and effective procedure in the treatment of pediatric kidney stones.

The all-seeing needle instead of the Veress needle in pediatric urologic laparoscopy

PURPOSE

To investigate the feasibility of the all-seeing needle for safe entry and creation of pneumoperitoneum in pediatric urologic laparoscopy.

PATIENTS AND METHODS

A total of 14 children underwent various transperitoneal urologic laparoscopic procedures. The all-seeing needle, which is 4.85F in diameter, was used for safe entry into the abdominal cavity at the site of the umblicus in all cases. The microoptic was integrated with the light system and connected via a zoom ocular enabling direct visualization of the layers between the skin and the peritoneal cavity. Once the intraperitoneal access was obtained, CO2 pneumoperitoneum was created from one port of the three-way connector attached to the proximal part of the needle. Then the laparoscopic trocars were placed under vision of the microoptical system.

RESULTS

Mean age of the children was 4.5 ± 2.9 years. In all children, the all-seeing needle was safely introduced into the abdominal cavity under direct vision. Then, CO2 pneumoperitoneum was succesfully performed. The mean time for optical puncture was calculated as 1.1 ± 0.8 minutes. No complication was encountered during the introduction of the needle, creation of the pneumoperitoneum, and placement of the trocars.

CONCLUSIONS

The all-seeing needle appears to be beneficial in safe entry and for creating pneumoperitoneum in laparoscopic pediatric urology cases. It eliminates the disadvantages of the Veress needle, which is blunt insertion, and may possibly prevent complications.

Are small residual stone fragments really insignificant in children?

OBJECTIVES

To assess the significance of asymptomatic residual stone fragments of less than 4mm (clinically insignificant residual fragments [CIRFs]) after shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PNL), and retrograde intrarenal surgery (RIRS) in children.

PATIENTS AND METHODS

Eighty-five children were followed up for 6 to 50months (median 22). Outcomes measured were fragment re-growth, stone events (emergency department visits, hospitalization, or additional interventions) and spontaneous fragment passage.

RESULTS

During follow-up, 22 children (25.8%) passed residual fragments spontaneously. Highest spontaneous passage rate was found for renal pelvis stones and the lowest for the lower pole stones (57.1% vs. 16.1%; p<0.001). When the number of the fragments increased, the chance of the spontaneous passage decreased (30% vs 20%; p<0.05). Symptomatic episodes including renal colic, hematuria, or urinary tract infection were documented in 34 (40%) patients, and re-growth of fragments was observed in 18 (21.2%). Stone size had no significant effect on spontaneous passage (p=0.079), stone growth (p=0.528), and symptomatic episodes (p=0.402). Twenty-five patients (29.4%) required secondary intervention for stone re-growth or stone related events and the remaining 20 patients (23.5%) needed medical treatment for bothersome symptoms or complications.

CONCLUSIONS

Our results suggest that 40% of children with CIRFs will become symptomatic and 20% will develop stone re-growth over the following 6months. Only one fifth of the fragments will pass spontaneously without any complications. Therefore, the use of the term "CIRF" is not appropriate for postoperative residual fragments in children.

Comparison of flexible and rigid cystoscopy-assisted ureteral catheter insertion before percutaneous nephrolithotomy: a prospective randomized trial

BACKGROUND AND PURPOSE

To compare the advantages of flexible and rigid cystoscopy-assisted ureteral catheter placement before prone percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

From March to September 2012, a total of 80 patients with kidney stones underwent PCNL by the same surgical team. The patients were randomly assigned into one of the groups according to the technique used for ureteral catheter insertion: Flexible cystoscopy (group 1, n=40) or rigid cystoscopy (group 2, n=40). Patient demographics and operation-related factors were compared. The preparation period included positioning, cystoscopy-assisted stent insertion, and patient repositioning for PCNL. In addition, discomfort scores of the operating room (OR) staff were measured.

RESULTS

The demographic values of the groups in terms of patient sex, age, body mass index, and stone size were comparable. While the mean preparation period was calculated as 9.9±2.3 minutes in the flexible cystoscopy group, it was significantly longer (19.7±2.9 minutes) in the rigid cystoscopy group (P<0.0001). In addition, the discomfort score of the OR staff was found to be significantly higher in the rigid cystoscopy group (1.1±0.9 vs 2.05±0.68, P<0.0001). The rest of the operative and postoperative parameters were similar.

CONCLUSIONS

The insertion of a ureteral catheter with a flexible cystoscope before prone PCNL shortens the preparation period and minimizes the discomfort of OR staff related to patient positioning and transfer.

Parenchymal thickness: does it have an impact on outcomes of percutaneous nephrolithotomy?

OBJECTIVE

To evaluate whether renal parenchymal thickness (RPT) has an effect on the outcomes of percutaneous nephrolithotomy (PNL).

METHODS

We performed a retrospective analysis of 144 patients with lower pole and/or renal pelvic stones who underwent PNL. The relationship between RPT and peri- and postoperative measures was evaluated.

RESULTS

The average age was 45.94 ± 14.47 (15-76) years. The mean BMI was calculated as 27.47 ± 4.73 (16.9-44.9) kg/m(2). The mean stone burden was 293 ± 126 (150-800 mm(2)). The mean RPT was measured as 17.33 ± 5.32 (6-35) mm. No correlation was detected between the RPT and the operation or fluoroscopy times or the duration of hospitalization (p = 0.63, 0.52, 0.08, respectively). The mean drop in hemoglobin level was 1.45 ± 1.25 (0-9) g/dl. A negative correlation was detected between hemoglobin drop and RPT (p = 0.01, r = -0.23). However, the RPT was similar in patients who did or did not require a blood transfusion (p = 0.09). The RPT was found to have no impact on success rate (p = 0.4).

CONCLUSION

The postoperative hemoglobin drop increases in parallel with the increase in RPT. However, no relationship was detected between the RPT and blood transfusion, overall success rate or any other perioperative parameters.

Is the Percutaneous Nephrolithotomy Procedure Complicated in Patients with Anterior Caliceal Stones?

<b><i>Objectives:</i></b> It was the aim of this study to evaluate and compare the outcomes of percutaneous nephrolithotomy (PNL) for the treatment of posterior and anterior caliceal stones. <b><i>Patients and Methods:</i></b> We performed a retrospective analysis of 86 patients with isolated caliceal stones who underwent PNL between 2011 and 2012. The patients were classified into two groups according to the localization of the stone, either in the anterior (group 1, n = 41) or posterior (group 2, n = 45) calyx, on axial plane computed tomography. <b><i>Results:</i></b> The mean age, male/female ratio and stone size and location were similar in both groups. Fluoroscopy, operation time and duration of hospitalization were also similar between groups. Patients in group 1 had a greater postoperative hemoglobin drop than patients in group 2. Blood transfusion was required for 5 patients in group 1 and for 4 patients in group 2. In addition, open conversion was required for 2 patients in group 1 during the early postoperative period because of extensive bleeding. Hemodynamics were stabilized with angioembolization in 2 patients with prolonged hematuria in group 1. The overall success and complication rates were similar in both groups. <b><i>Conclusion:</i></b> Although the postoperative hemoglobin drop did not significantly differ between groups, hemorrhaging was more severe in patients with anterior caliceal stones than in those with posterior caliceal stones.

Laparoscopic-assisted "microperc" of a stone in a pelvic kidney of a 3-year-old girl

Treatment of kidney stones in pelvic ectopic kidneys of children is a challenging procedure for urologists. Herein we report a case of laparoscopy-assisted "microperc" in a 3-year-old girl with a stone in her pelvic ectopic kidney. This micro-optical system is helpful in confirming the percutaneous access and provides the possibility of fragmenting the stone without the necessity of dilating the tract.

Micropercutaneous nephrolithotomy in the treatment of moderate-size renal calculi

PURPOSE

We present our initial experience with microperc in patients with moderate-size renal calculi.

PATIENTS AND METHODS

A retrospective analysis of 30 patients (male 14, female 16) with moderate-size (1-3 cm) kidney stones who underwent microperc between August 2011 and July 2012 was performed. The demographic values, perioperative and postoperative measures including age, stone size and location, body mass index, operative and fluoroscopy time, hemoglobin decrease, success and complication rates were prospectively recorded into a patient entry system.

RESULTS

The average stone size was 17.9±5.0 mm (10-30 mm). The mean age of the patients was 41.5±18.2 years (range 3-69 years). The duration of the operation was calculated as 63.5±36.8 minutes (range 20-200 min). Mean fluoroscopic screening time was 150.5±90.4 seconds (range 45-360 seconds). The patients were discharged after a mean hospitalization period of 35.5±18.6 hours (range 14-96 hours). An overall success rate of 93% (including 10% of insignificant residual fragment rate) was achieved. In the follow-up, residual stone fragments were detected in two (7%) patients. Conversion to miniperc was necessitated in three (10%) patients. The mean hemoglobin drop was found to be 1.1±0.8 mg/dL (range 0-2.8 mg/dL). Complications were observed in five (13.3%) patients.

CONCLUSIONS

Our initial results provide that microperc is a feasible, safe, and efficacious treatment modality for moderate-size kidney stones as well as small ones with its minimally invasive nature. Technical refinements are needed to achieve better results and overcome the limitations of technique.

The role of microperc in the treatment of symptomatic lower pole renal calculi

BACKGROUND AND PURPOSE

The treatment of symptomatic lower pole (LP) calculi poses a challenge because of lower clearance rates. We present our experience with microperc in the treatment of LP renal calculi.

PATIENTS AND METHODS

We retrospectively evaluated the symptomatic patients with LP renal calculi who underwent microperc between August 2011 and June 2012 from two referral hospitals. Patients were included only in cases of failure after shockwave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS) and according to patient preference. The percutaneous renal access was performed using the 4.8F "all-seeing needle" with C-arm fluoroscopy or ultrasonographic guidance with the patient in the prone position. Stone disintegration was established using a 200 μm holmium:yttrium-aluminum-garnet laser fiber.

RESULTS

A total of 21 patients (mean age 37.3 ± 20.1 years) with LP stone underwent microperc. The mean body mass index was 28.6 ± 6.0 kg/m(2), and the mean stone size was 17.8 ± 5.9 (9-29) mm. The duration of surgery and fluoroscopic screening was 62.8 ± 25.2 minutes and 150.5 ± 92.8 seconds, respectively. The patients were discharged after a mean 37.5 ± 14.4 hours of hospitalization time. The mean hemoglobin drop was 0.8 ± 0.6 (0.1-2.3) g/dL. Conversion to miniperc was necessitated in one patient with loss of vision. Stone-free status was achieved in 18 (85.7%) patients. Clinically insignificant residual fragments were observed in only one (4.8%). The procedure failed in two (9.5%) patients. A total of two minor complications (renal colic necessitating stent insertion and urinary tract infection) were observed postoperatively, none severe.

CONCLUSION

Microperc is a feasible and efficient treatment modality for symptomatic LP calculi. Our results provide that microperc might take a part in case of SWL and RIRS failures or as an alternative to percutaneous nephrolithotomy or RIRS in the management of symptomatic LP calculi.

"Snodgraft" technique for the treatment of primary distal hypospadias: pushing the envelope

PURPOSE

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair.

MATERIALS AND METHODS

A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results.

RESULTS

At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable.

CONCLUSIONS

No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

Revisiting the predictive factors for intra-operative complications of rigid ureteroscopy: a 15-year experience

PURPOSE

To revise the predictive factors for intra-operative complications of rigid ureteroscopy in the treatment of ureteral calculi.

MATERIALS AND METHODS

During a 15-year period (1993 to 2008), a total of 1496 consecutive patients who had undergone 1660 ureteroscopy procedures were retrospectively reviewed. After exclusion of the cases for diagnostic purposes, diseases other than ureteral calculi, and repeated ureteroscopy procedures, 1189 patients were left as the study population. Those patients were then divided into two groups based on the presence of the complications: complication-positive (group 1, n = 57) and complication-negative (group 2, n = 1132). Both groups were statistically compared regarding patients' age and gender, stone surface area, lateralization and localization of the stone, impaction of the stone, type of the ureteroscope, necessity of ureteral orifice dilation, and use of a catheter during and after the procedure. Furthermore, the effect of leaving the fragmented stones in situ small enough to pass spontaneously (break'n'leave) on occurring of the complications has been investigated.

RESULTS

The complication rate was recorded as 4.7%. Success rate after a single intervention was 86.3%, whereas increased to 94.1% after ancillary procedures. Stone surface area, lateralization, and type of lithotripter used were comparable between the groups, but impacted stones and the stones located at the upper ureters were associated with significantly increased complication rates. Furthermore, significantly less complication has been observed in cases where we performed break'n'leave. Furthermore, multivariate analysis revealed that stone impaction and failure to adhere to the "break'n'leave" principle were the independent predictors of occurring of the complications.

CONCLUSION

Ureteroscopy is safe and effective in the treatment of ureteral calculi. Careful attention for the patients having a potential for occurrence of the complications and selection of the techniques are of importance for reducing untoward events.