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El escritor búlgaro Tzvetan Todorov publicó en 1982, La conquista de América, la cuestión del otro, lo que despertó gran interés y muchos comentarios. Se sostiene que América le dio al mundo el concepto del «otro» y que quien supo descubrirlo a profundidad fue Vasco de Quiroga. Todorov, al analizar la actuación de Quiroga, afirma que en relación al otro fue un conquistador que obligó a los naturales a asimilar un ideal o proyecto no personal sino de otros, en especial de Tomás Moro. Al hacer uso de la misma metodología de Todorov, se intenta probar que Tata Vasco de Quiroga no sólo fue el descubridor del otro, sino que se hizo otro y contribuyó notablemente para lograr un mestizaje originario muy característico de la identidad mexicana. Abstract The Bulgarian writer Tzvetan Todorov published in 1982 The Conquest of America, the Question of the Other, which aroused great interest and many comments. We maintain that America gave the world the concept of the "other" and that Vasco de Quiroga was the one who knew how to discover it in depth. Todorov, in analyzing Quiroga's actions, affirms that in relation to the other, he was a conqueror who forced the natives to assimilate an ideal or project not of himself but of others, especially Thomas More. Making use of the same methodology of Todorov, we try to prove that Tata Vasco de Quiroga was not only the discoverer of the other, but that he became another and contributed notably to achieve an original mestizaje very characteristic of the Mexican identity. Keywords: Todorov, Vasco de Quiroga, conquest, discovery, the other, utopia, Thomas More.

Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques.Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution.Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation.Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.

Background and Purpose Horseshoe kidney is an uncommon renal anomaly often associated with ureteropelvic junction (UPJ) obstruction. Advanced minimally invasive surgical (MIS) reconstructive techniques including laparoscopic and robotic surgery are now being utilized in this population. However, fewer than 30 cases of MIS UPJ reconstruction in horseshoe kidneys have been reported. We herein report our experience with these techniques in the largest series to date. Materials and Methods We performed a retrospective chart review of nine patients with UPJ obstruction in horseshoe kidneys who underwent MIS repair at our institution between March 2000 and January 2012. Four underwent laparoscopic, two robotic, and one laparoendoscopic single-site (LESS) dismembered pyeloplasty. An additional two pediatric patients underwent robotic Hellstrom repair. Perioperative outcomes and treatment success were evaluated. Results Median patient age was 18 years (range 2.5-62 years). Median operative time was 136 minutes (range 109-230 min.) and there were no perioperative complications. After a median follow-up of 11 months, clinical (symptomatic) success was 100%, while radiographic success based on MAG-3 renogram was 78%. The two failures were defined by prolonged t1/2 drainage, but neither patient has required salvage therapy as they remain asymptomatic with stable differential renal function. Conclusions MIS repair of UPJ obstruction in horseshoe kidneys is feasible and safe. Although excellent short-term clinical success is achieved, radiographic success may be lower than MIS pyeloplasty in heterotopic kidneys, possibly due to inherent differences in anatomy. Larger studies are needed to evaluate MIS pyeloplasty in this population.

PURPOSE: To evaluate the efficacy of needle biopsy for diagnosing Wilmstumor (WT) before chemotherapy. MATERIALS AND METHODS:We reviewed our institutional experience with Tru-Cut biopsy of pediatric renal masses in patients who subsequently underwent nephrectomy. We compared biopsy pathology with nephrectomy specimens to determine if biopsy accurately predicted final pathology. RESULTS: Seven children underwent Tru-Cut renal mass biopsy followed by surgical resection. In 4 patients, the final biopsy pathology was definitively read as WT and in 3 subjects, the pathology was read as WT versus hyperplastic nephrogenic rest. In all 7 patients, the nephrectomy pathology confirmed a diagnosis of WT. There were no complications after biopsy, and no patients have had local or regional recurrence.CONCLUSION: In our experience, pre-therapy Tru-Cut biopsy safely provides an adequate specimen for pathologic review in diagnosing WT.

An index was created for the spatial classification of oyster cultivation areas in terms of their potential productivity in Falsa Bay, San Quintín (Baja California, Mexico). The index included two main variables crucial for oyster development: food availability and depth. Food availability was based on the final distribution of particulate organic material; it is a passive variable that is transported by tidal currents. A balance was obtained between the volume incorporated into the bay by tidal inflow and its consumption by the organisms distributed in the cultivated areas, which are characterized by the percentage of cultivated areas within the bay. The distribution area of depth was obtained from a five-interval classification scale that allowed the identification of the highest and least exposure of the cultivation area to the proposed food availability. Both criteria were combined into one value in order to divide the bay region into zones in relative terms and determine which are the best suited for oyster cultivation. Given the characteristics of the area and production volume, food availability did not appear to be a limiting factor, and culture depth was the main factor controlling the zonal quality. A comparison of the index values and cultivated oyster growth rates showed that the higher index values corresponded to faster growth rates and vice versa.

The global prevalence of pediatric nephrolithiasis continues to rise amidst increased sodium and animal protein intake. Plant-based meat alternatives (PBMAs) have recently gained popularity due to health benefits, environmental sustainability, and increased retail availability. PBMAs have the potential to reduce the adverse metabolic impact of animal protein on kidney stone formation. We analyzed PBMAs targeted to children to characterize potential lithogenic risk vs animal protein. We performed a dietary assessment using a sample of PBMAs marketed to or commonly consumed by children and commercially available at national retailers. Nutrient profiles for PBMAs were compiled from US Department of Agriculture databases and compared to animal protein sources using standardized serving sizes. We also analyzed nutrient profiles for plant-based infant formulas against typical dairy protein-based formulas. Primary protein sources were identified using verified ingredient lists. Oxalate content was extrapolated from dietary data sources. A total of 41 PBMAs were analyzed: chicken (N = 18), hot dogs (N = 3), meatballs (N = 5), fish (N = 10), and infant formula (N = 5). Most products (76%) contained a high-oxalate ingredient as the primary protein source (soy, wheat, or almond). Average oxalate content per serving was substantially higher in these products (soy 11.6 mg, wheat 3.8 mg, almond 10.2 mg) vs animal protein (negligible oxalate). PBMAs containing pea protein (24%) had lower average oxalate (0.11 mg). Most PBMAs averaged up to six times more calcium and three times more sodium per serving compared to their respective animal proteins. Protein content was similar for most categories. Three-quarters of the examined plant-based meat products for children and infants contain high-oxalate protein sources. Coupled with higher per-serving sodium and calcium amounts, our findings raise questions about possible lithogenic risk in some PBMAs, and further studies are needed to assess the relationship between PBMAs and nephrolithiasis. [ABSTRACT FROM AUTHOR]

Summary Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology. [ABSTRACT FROM AUTHOR]

In the past two decades, technology has advanced to augment an already minimally-invasive approach in laparoscopic surgery. Robotic-assisted laparoscopic platforms have now evolved to its 4th-generation product: a single-port system, first cleared through the FDA for urologic procedures last year. A single, 2.5 cm incision allows for placement of a port that admits a fully-wristed camera as well as three fully-wristed instruments, all controlled by the surgeon at the console. We sought to document the feasibility of the single-port (SP) robotic platform in the first clinical series of pediatric patients, reporting use of this system for dismembered pyeloplasty and Mitrofanoff. Secondary aims were to report intraoperative details and perioperative outcomes. Seven patients underwent surgery using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). Six patients, two girls and 4 boys, were diagnosed with ureteropelvic junction obstruction and underwent SP robotic-assisted dismembered pyeloplasty while one male patient with neurogenic bladder underwent SP robotic-assisted Mitrofanoff procedure. Patient's ages ranged from 22 months to 14 years. A 2.5-cm incision was made within the Pfannenstiel line in HIdES fashion for the pyeloplasties, while the previous gastrostomy tube site was used for the Mitrofanoff. Through this incision a 25-mm multichannel port was placed. The 12 × 10-mm articulating robotic camera and two 6-mm articulating robotic instruments were utilized. All surgeries were completed successfully through the single port without intraoperative complications, need for separate ports, or conversion. Median operative time was 120 min, and all patients were dismissed in less than 24 h, taking only acetaminophen and ibuprofen for pain control. There was no issue with instrumentation in older patients; however, shorter working distance in the 22-month-old pyeloplasty limited wristing of the instruments. We report the first cases utilizing the SP robotic platform in children. Despite their smaller size and limited workspace, we had no issues with instrument clashing or triangulation in older patients, completing the procedures in a similar timeframe as multiport robotic platforms. Use of the SP platform is not recommended if working distance will be < 10 cm from the end of the port as instrument movement is prohibitive. The HIdES approach of placing the port in the Pfannenstiel line gave additional working distance and kept the incision below the swimsuit line for excellent cosmesis (Figure 1). Further study with additional cases will compare this approach with standard multiport robotics to analyze and compare operative data and outcomes. [ABSTRACT FROM AUTHOR]

Assessment and management of congenital penile curvature (PC) can be variable. Methods for correction of PC usually are dependent on degree of PC which is reliant on how degree is assessed. We sought to assess the confidence and accuracy of measuring PC and hence management using case-based examples. A survey was emailed to members of the Societies for Pediatric Urology. Demographic information, management strategies for PC, and self-reported confidence in measuring PC were assessed. A Likert scale measured self-confidence. Case scenarios were used to assess ability to measure PC and methods of correction. The cases consisted of three computer-generated penis model images with arc-type ventral curvature and one image of lateral curvature in an infant. The response rate was 30% (108/355). The mean confidence score was 3.6 ± 0.8 (3-fairly confident; 4-very confident). In clinic, 89% of urologists used eyeball estimates to assess PC; 5% used both eyeball and goniometer. In the operating room, 71% used eyeball estimates, 8% used goniometer, and 16% used both. If sole decision-maker, urologists recommend surgical correction of PC over observation at median 30° (IQR 21–30°). At a median of 45°, there was a shift in corrective surgical preference from dorsal plication (DP) (IQR 30–54°) to ventral lengthening (IQR 34–60°). Urologists underestimated PC degree for all cases (summary table). For all cases, there was no association between years in practice or confidence level on estimated PC degree. In case 1, only 24% of urologists would correct a mean estimate of 23° PC; those who would correct had a higher mean PC estimate vs those who would not (28° vs 21°, p < 0.001). Case 2 and 4 had similar estimations and correction methods. In case 2, those who chose VL had a higher mean PC estimate vs those who did not (43° vs 37°, p < 0.01), but no estimate difference was seen for DP (p = 0.52). In case 4 with lateral PC, those who chose DP had a higher mean PC estimate vs those who did not (41° vs 33°, p = 0.049). Yet in case 3, there was no difference in PC estimate in urologists who chose VL vs not (57° vs 53°, p = 0.16). A uniform underestimation of PC existed despite self-reported confidence in the ability to measure PC. An increasing willingness to perform surgical correction was demonstrated with a shift towards VL for ventral curvature and less so for lateral curvature as PC worsens. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Care of children with spina bifida has significantly advanced in the last half century, resulting in gains in longevity and quality of life for affected children and caregivers. Bladder dysfunction is the norm in patients with spina bifida and may result in infection, renal scarring and chronic kidney disease. However, the optimal urological management for spina bifida related bladder dysfunction is unknown. Materials and Methods In 2012 the Centers for Disease Control and Prevention convened a working group composed of pediatric urologists, nephrologists, epidemiologists, methodologists, community advocates and Centers for Disease Control and Prevention personnel to develop a protocol to optimize urological care of children with spina bifida from the newborn period through age 5 years. Results An iterative quality improvement protocol was selected. In this model participating institutions agree to prospectively treat all newborns with spina bifida using a single consensus based protocol. During the 5-year study period outcomes will be routinely assessed and the protocol adjusted as needed to optimize patient and process outcomes. Primary study outcomes include urinary tract infections, renal scarring, renal function and bladder characteristics. The protocol specifies the timing and use of testing (eg ultrasonography, urodynamics) and interventions (eg intermittent catheterization, prophylactic antibiotics, antimuscarinic medications). Starting in 2014 the Centers for Disease Control and Prevention began funding 9 study sites to implement and evaluate the protocol. Conclusions The Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida began accruing patients in 2015. Assessment in the first 5 years will focus on urinary tract infections, renal function, renal scarring and clinical process improvements. [ABSTRACT FROM AUTHOR]

We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study. We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with <1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (<10 years), older children (10 to <18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs. >2000). A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p < 0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p = 0.31) or based on birthyear (p = 0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p = 0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55–91%, p = 0.001), but not birth year (p = 0.85). We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness. In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients. Summary Table Urinary and bowel management stratified by age. Summary Table Younger children (0–9.9 years old, n = 57) Older children (10.0–17.9 years old, n = 35) Adults (≥18 years old, n = 68) p-value Overall (n = 160) Urinary management Clear intermittent catheterizations (CIC) 18 (32%) 29 (83%) 46 (68%) <0.001 93 (58%) Per channel 16 (89%) 28 (97%) 39 (85%) 83 (89%) Per urethra 2 (11%) 1 (3%) 7 (15%) 10 (11%) Augmentation 12 (67%) 25 (86%) 45 (98%) 82 (88%) Incontinent diversion 15 (26%) 3 (9%) 19 (28%) 37 (23%) Incontinent into diaper 24 (42%) 3 (9%) 2 (3%) 29 (18%) Empties per urethra with Valsalva maneuver 0 (0.0%) 0 (0%) 1 (1%) 1 (0.6%) Overall: empties urine via urethra (CIC, incontinent, Valsalva) 26 (46%) 4 (11%) 10 (15%) <0.001 40 (25%) Bowel management Intestinal diversion 45 (79%) 27 (77%) 54 (79%) 0.99 126 (79%) Pull-through without a MACE 7 (12%) 4 (11%) 7 (10%) 18 (11%) Pull-through with a MACE 5 (9%) 4 (11%) 7 (10%) 16 (10%) [ABSTRACT FROM AUTHOR]

The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach. We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure. Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1 mg per 10 kg body weight. Measurements were taken at 80 s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure. Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up. This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality. [Display omitted] [ABSTRACT FROM AUTHOR]

Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60 min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60 min. To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60 min. We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60 min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected. Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60 min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169 min (for the last <10 min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5–7) months, and median procedure length was 95 (IQR 75–120) minutes. Following initial preoperative intranasal dexmedetomidine ± fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60–120) minutes into surgery. Following closure, patients exited the OR after a median 10 (IQR 8–12) minutes and subsequently discharged after spending a median of 73 (IQR 61–96) minutes in recovery. We describe pediatric urologic surgical cases lasting ≥60 min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60 min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia. A single-injection bupivacaine-only spinal anesthesia approach for urologic surgery lasting over an hour and up to 3 h is safe and effective in infants. Selecting appropriate candidates for SA should be a joint decision between the surgeon and the anesthesiologist. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder. Materials and Methods We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups. Results A total of 45 patients underwent bladder neck reconstruction (open in 26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5). Conclusions Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes. [ABSTRACT FROM AUTHOR]

Purpose Bladder outlet procedures without augmentation cystoplasty remain controversial. We hypothesized that bladder outlet procedures without augmentation cystoplasty may lead to unfavorable bladder dynamics, upper tract changes and/or continued incontinence. We reviewed long-term urodynamic, upper tract and continence outcomes following bladder outlet procedures without augmentation cystoplasty. Materials and Methods We retrospectively reviewed all patients who underwent bladder neck reconstruction/closure/sling without augmentation cystoplasty between 2000 and 2014. Because of variation in length of followup, we calculated the cumulative incidence and proportion of cases of upper tract and urodynamic changes, augmentation cystoplasty and subsequent continence procedures. Preoperative factors were compared between patients with and without adverse outcomes. Results A total of 109 patients underwent bladder outlet procedures without augmentation cystoplasty at a mean age of 8.5 years. At a mean of 4.9 years of followup 59 patients (54%) had undergone additional continence surgery, 20 (18%) had undergone augmentation cystoplasty, 50 (46%) manifested vesicoureteral reflux or hydronephrosis and 23 (21%) had newly diagnosed or worsening renal scarring. At augmentation cystoplasty 13 of 18 patients (72%) had upper tract changes, 15 (83%) had continued incontinence and 11 (61%) had an end fill pressure of greater than 40 cm H 2 O. All patients had resolution of these changes after augmentation cystoplasty. Patients who had previously undergone vesicostomy or surgery for vesicoureteral reflux were significantly more likely to undergo a subsequent augmentation cystoplasty or to show upper tract changes. Conclusions Following bladder outlet procedures without augmentation cystoplasty the estimated 10-year cumulative incidence of augmentation cystoplasty is 30%, continence procedures 70%, upper tract changes greater than 50% and chronic kidney disease 20%. Because of these risks, careful patient selection and close followup are essential if considering a bladder outlet procedure without augmentation cystoplasty. [ABSTRACT FROM AUTHOR]

Purpose Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution. Materials and Methods We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables. Results A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346). Conclusions Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups. [ABSTRACT FROM AUTHOR]

Purpose Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications. Materials and Methods We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed. Results A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01). Conclusions The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported. [ABSTRACT FROM AUTHOR]

Pediatric surgery began with single-incision flank surgery and has evolved to multi-port laparoscopic and robotic approaches. Recent technological advances with the single-port (SP) robot have allowed for transition back to single-incision surgery. A 14-year-old paraplegic male with T2 spinal injury presented with neurogenic bladder and increasing difficulty performing clean intermittent catheterization thus the decision was made to perform the first SP robotic Mitrofanoff procedure in a pediatric patient. The SP platform has one 2.5 cm, 4-channel port, a 12 × 10 mm articulating camera, and 6 mm multi-wristed instruments. The SP robotic Mitrofanoff was completed successfully without issues with space, triangulation or articulation. There is, however, loss of insufflation with use of laparoscopic instruments as the seal on the port is difficult to maintain. The single-port robot has been successfully utilized in seven patients: six underwent dismembered pyeloplasty and one underwent Mitrofanoff with a median operative time of 120 min and estimated blood loss of <25 cc. Postoperatively, no patients required opioid pain medications, and all were discharged in <24 h without complications. Single-port robotic surgery is feasible in pediatric patients, but patient selection is key. Future development of the platform is needed to widen application to smaller patients. [ABSTRACT FROM AUTHOR]

Objective We report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence. Materials Consecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study. Results Of 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection. Conclusions Despite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation. [ABSTRACT FROM AUTHOR]

Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited. To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts. Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored. 99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47). The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions. Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification. Summary Table Modified Bosniak class and pathologic correlation. Summary Table mBosniak class Benign Intermediate Malignant p-value 1 24 1 0 <0.001 2 9 6 0 3 4 11 0 4 2 5 37 1/2 33 7 0 <0.001 3/4 6 16 37 [ABSTRACT FROM AUTHOR]

Purpose: Anecdotal evidence suggests that complex congenital genitourinary anomalies are occurring less frequently. However, few epidemiological studies are available to confirm or refute this suggestion. Materials and Methods: The Kids' Inpatient Database (KID) is a national, all payer database of several million inpatient pediatric hospitalizations per year, including complicated and uncomplicated in-hospital births. We reviewed the 1997 to 2009 KID to determine the birth prevalence of spina bifida, posterior urethral valves, bladder exstrophy, epispadias, prune belly syndrome, ambiguous genitalia and imperforate anus. For posterior urethral valves and prune belly syndrome we limited our search to newborn males only. Results: During the study period, there was a diagnosis of spina bifida in 3,413 neonates, bladder exstrophy in 214, epispadias in 1,127, ambiguous genitalia in 726, prune belly syndrome in 180, posterior urethral valves in 578 and imperforate anus in 4,040. We identified no significant change in the birth prevalence of spina bifida (from 33.9 new spina bifida births of 100,000 uncomplicated births to 29.0/100,000, p = 0.08), posterior urethral valves (from 10.4/100,000 to 11.0/100,000, p = 0.51), prune belly syndrome (from 4.8/100,000 to 3.3/100,000, p = 0.44) or ambiguous genitalia (from 5.82/100,000 to 5.87/100,000, p = 0.38). There was a significant decrease in the birth prevalence of bladder exstrophy (from 2.4/100,000 to 1.6/100,000 uncomplicated births, p = 0.01) and a significant increase in epispadias (from 8.0/100,000 to 11.6/100,000) and imperforate anus (from 33.6/100,000 to 35.0/100,000, each p = 0.04) during the study period. Conclusions: The birth prevalence of spina bifida, posterior urethral valves and prune belly syndrome appears to have been stable in the last 12 years. Epispadias, ambiguous genitalia and imperforate anus diagnoses in newborns became more common in the same period, while bladder exstrophy diagnoses became less common. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To present our initial experience with “mini” percutaneous cystolithotomy performed as an outpatient procedure in patients with neurogenic bladders. Materials & methods: Over the last 6 years, patients with neurogenic bladders and bladder calculi were managed with outpatient percutaneous cystolithotomy. All but 1 had previously undergone appendicovesicostomy (APV) creation. The procedure was performed by first passing a pediatric cystoscope per APV. Once the calculi were visualized, and following bladder distention, additional bladder access was obtained by passage of either a 16F Peel-Away introducer using the Seldinger technique or a 5 mm laparoscopic trocar under direct vision. An ultrasonic lithotripter was then advanced through the percutaneous access site and stone fragmentation completed. Following procedure completion, a catheter was placed for 24 h for bladder decompression. All procedures were performed on an outpatient basis. Results: 12 patients underwent 18 successful operations. In 1 patient, percutaneous access was unsuccessful. Mean age at surgery was 12.3 years. Mean operative time was 72 min 8 patients had undergone previous ileocystoplasty. The remainder was rendered stone free at the completion of surgery. One patient had persistent bleeding from the intravesical trocar site necessitating fulguration and an overnight stay for observation. The remainder were sent home the same day. There were no cases of urine extravasation. Conclusions: “Mini” percutaneous cystolithotomy is a safe, effective technique for the outpatient management of bladder calculi. [Copyright &y& Elsevier]

Abstract: Purpose: We report outcomes after dextranomer/hyaluronic acid (Dx/HA) bladder neck injection for persistent outlet incompetency despite prior sling or Leadbetter/Mitchell bladder neck revision plus sling (LMS) in children with neurogenic urinary incontinence. Methods: Consecutive patients with outlet incompetency after sling (n = 17) or LMS (n = 9) underwent a maximum of 2 Dx/HA injections. Antegrade and/or retrograde endoscopy was used to access the bladder outlet, and injection done in quadrants to achieve visual mucosal coaptation. Outcomes were described as either “dry”, not requiring pads, or “wet”. Results: There were 24 children with follow-up after injection, of which 9 (38%) were initially dry and 15 (62%) remained wet. Of the 9 dry patients, 4 had recurrent incontinence at a mean of 16 months while 5 remained dry at a mean of 27 months. Second injections were done in a total of 14 children, with 1 dry at 39 months. Of all 24 children, up to 2 injections resulted in 6 (25%) dry patients, while the remainder was wet at last follow-up. Gender, initial outlet surgery, pre-injection pad use, injection technique, and volume injected did not predict outcomes. Conclusions: Dx/HA bladder neck injection resulted in dryness in 25% of patients in this series after failed sling or LMS. Second injections after either initial failure or success achieved dryness in only 7%, and are no longer recommended. [Copyright &y& Elsevier]

Purpose: Guidelines for staging Wilms tumor mandate regional lymph node sampling at nephrectomy. However, the usefulness of preoperative computerized tomography in staging lymph nodes has not been rigorously investigated. Thus, we correlated preoperative computerized tomography and pathological lymph node findings to establish a radiological criterion for pathological lymph node enlargement. Materials and Methods: We reviewed the medical records of children with Wilms tumor at our institution who underwent pre-chemotherapy surgery with lymph node sampling and had preoperative computerized tomography with contrast medium available for interpretation. Computerized tomography was independently reviewed by 2 radiologists blinded to the pathological findings. We collected data on the diameter of the largest regional lymph node identified and this measurement was correlated with the pathological results. Results: A total of 52 children (25 male, 27 female) with a median age of 3.1 years (range 0.4 to 9.6) were identified. The median largest regional lymph node diameter was 6 mm (range 2 to 15). Of the children 10 (19.2%) had metastatic involvement of sampled lymph nodes. A radiological cutoff of 7 mm for lymph node positivity corresponded to a negative predictive value of 89.0%, a sensitivity of 70.0% and a specificity of 57.1%. A ROC curve was constructed with these data describing the prognostic ability of the diameter of the largest regional lymph node on preoperative computerized tomography to determine lymph node positivity in Wilms tumor, which revealed an AUC of 0.67 (95% CI 0.48–0.87, p = 0.09). Conclusions: By defining a radiological size cutoff for suspicious lymph nodes, preoperative computerized tomography for staging lymph nodes in Wilms tumor demonstrates potential clinical usefulness through risk stratification for therapy and future study design. [Copyright &y& Elsevier]

Purpose: Nephron sparing surgery is accepted as standard of care for children with bilateral Wilms tumor or Wilms tumor in a solitary kidney and some study protocols allow nephron sparing surgery in select cases of unilateral Wilms tumor. With the increasing use of nephron sparing surgery in Wilms tumor, we reviewed pathological features from Wilms tumor radical nephrectomy specimens to determine the potential efficacy of a nephron sparing approach. Materials and Methods: Medical records of children undergoing pre-chemotherapy radical nephrectomy for unilateral Wilms tumor at our institution were reviewed. Ideal candidates for nephron sparing surgery were defined as those having a unifocal mass outside the renal hilum, sparing a third or more of the kidney, favorable histology, no signs of renal sinus or segmental vascular invasion, no metastatic lymph nodes or gross regional disease, and a distinct interface on pathological review between tumor and remaining parenchyma. Results: A total of 78 children at a median age of 3.2 years (range 0.3 to 16.2) underwent pre-chemotherapy radical nephrectomy for unilateral Wilms tumor. Median tumor diameter was 11 cm (range 2.5 to 22). Of these children 36 (46.2%) had tumors sparing a third or more of the kidney and 70 (89.7%) had unifocal tumors. There were 73 specimens (94.6%) that showed favorable histology, and 56 (71.8%) of the specimens had a distinct border between tumor and remaining parenchyma. In total, 19 (24.4%) of the patients reviewed met all of our strict pathological criteria as ideal partial nephrectomy candidates. Conclusions: In a post hoc analysis using strict pathological criteria and accepted surgical oncologic principles, as many as 1 in 4 children undergoing pre-chemotherapy surgery for nonmetastatic, unilateral Wilms tumor have post-resection pathological tumor characteristics favorable for nephron sparing surgery. [Copyright &y& Elsevier]

Purpose: A major goal of bladder exstrophy management is urinary continence, often using bladder neck reconstruction. We report our experience with bladder neck reconstruction after complete primary repair of exstrophy. Materials and Methods: Patient history, ultrasound, voiding cystourethrogram, examination using anesthesia and urodynamics were performed during a prospective evaluation. Continence was assessed using the International Children''s Continence Society classification and the dry interval. Bladder capacity was measured by examination using anesthesia, voiding cystourethrogram and/or urodynamics. Urodynamics were also done to assess bladder compliance and detrusor muscle function. Results: From 1994 to 2010 we treated 31 male and 15 female patients with bladder exstrophy after complete primary repair of exstrophy. Of patients 5 years old or older bladder neck reconstruction was performed after complete primary repair in 9 of 21 males (43%) and in 3 of 11 females (27%) at a mean age of 6.3 and 8.1 years, respectively. By the International Children''s Continence Society classification 6 of 12 patients (50%) were continent less than 1.5 years after bladder neck reconstruction and 2 of 9 (23%) were evaluable 1.5 years or greater after reconstruction. Median bladder capacity was 100 ml before, 50 ml less than 1.5 years after and 123 ml 1.5 years or greater after bladder neck reconstruction. Three males and 2 females emptied via an appendicovesicostomy. Two boys underwent augmentation. Conclusions: In our experience most patients with bladder exstrophy require bladder neck reconstruction after complete primary repair of exstrophy. The need for reconstruction is more common in males. Our rates of bladder neck reconstruction after complete primary repair of exstrophy and of continence after bladder neck reconstruction are similar to those in other reports. [Copyright &y& Elsevier]

Purpose: The advantages of minimally invasive surgery over open surgery in pediatrics include smaller incisions, decreased postoperative pain, reduced postoperative narcotic use, faster return to normal activity and decreased length of hospitalization. However, minimally invasive surgery with its traditional port placement leads to visible scars. To eliminate scarring, we have developed HIdESSM, or hidden incision endoscopic surgery. Materials and Methods: For this technique a robotic working port, camera port and 5 mm assistant port are placed below the line of a Pfannenstiel incision. The second working 8 or 5 mm port is placed infraumbilically. The procedure is then carried out depending on the nature of the case. For this study operative times were recorded. Patients who underwent HIdES pyeloplasty or nephrectomy and their parents were asked to compare the cosmetic outcome of the trocar incisions to pictures of patients who had undergone laparoscopic surgery (pyeloplasty or nephrectomy) with traditional port placement and open surgery using validated wound and scar evaluation scales. Results: HIdES was used in 12 cases. No complications were encountered. When comparing all 3 questionnaire results for each technique used, parents and patients were statistically more satisfied with the cosmetic results after HIdES than traditional laparoscopic or open operation. Conclusions: The HIdES technique allows all port sites to be hidden at the level of a Pfannenstiel incision, and thus renders them nonvisible if the patient is wearing a bathing suit. This approach is preferred by patients and parents alike. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique. Methods: All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s). Results: Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P =0.03). Conclusion: Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation. [ABSTRACT FROM AUTHOR]

Purpose: The optimal method for neovagina creation in patients with vaginal agenesis is controversial. Progressive perineal dilation is a minimally invasive method with high success rates. However, the economic merits of progressive perineal dilation compared to surgical vaginoplasty are unknown. Materials and Methods: We performed a Markov based cost-effectiveness analysis of 3 management strategies for vaginal agenesis—progressive perineal dilation with and without subsequent vaginoplasty, and up-front vaginoplasty. Cost data were drawn from the Pediatric Health Information System database (2004 to 2009) for inpatient procedures and from governmental cost data (2009) for outpatient procedures and clinical followup. Other model parameters were derived from a systematic literature review and comparison with other congenital and acquired pediatric and/or adolescent gynecologic conditions. Bounded and probabilistic sensitivity analyses were used to assess model stability. Results: Including all procedures, equipment and physician visits, progressive perineal dilation had a mean cost of $796, while vaginoplasty cost $18,520. Up-front vaginoplasty was strongly dominated at any age, ie was more expensive but no more effective than other options. In cases of progressive perineal dilation failure the incremental cost-effectiveness ratio of progressive perineal dilation with subsequent vaginoplasty was $1,564 per quality adjusted life-year. Only the utility weights of life after treatment impacted model outcomes, while frequency of followup and probability of treatment success did not. Conclusions: Initial progressive perineal dilation followed by vaginoplasty in cases of dilation failure is the most cost-effective management strategy for vaginal agenesis. Initial vaginoplasty was less cost-effective than initial progressive perineal dilation in 99.99% of simulations. [ABSTRACT FROM AUTHOR]

Purpose: An increasing number of parents and practitioners use the Internet for health related purposes, and an increasing number of models are available on the Internet for predicting spontaneous resolution rates for children with vesicoureteral reflux. We sought to determine whether currently available Internet based calculators for vesicoureteral reflux resolution produce systematically different results. Materials and Methods: Following a systematic Internet search we identified 3 Internet based calculators of spontaneous resolution rates for children with vesicoureteral reflux, of which 2 were academic affiliated and 1 was industry affiliated. We generated a random cohort of 100 hypothetical patients with a wide range of clinical characteristics and entered the data on each patient into each calculator. We then compared the results from the calculators in terms of mean predicted resolution probability and number of cases deemed likely to resolve at various cutoff probabilities. Results: Mean predicted resolution probabilities were 41% and 36% (range 31% to 41%) for the 2 academic affiliated calculators and 33% for the industry affiliated calculator (p = 0.02). For some patients the calculators produced markedly different probabilities of spontaneous resolution, in some instances ranging from 24% to 89% for the same patient. At thresholds greater than 5%, 10% and 25% probability of spontaneous resolution the calculators differed significantly regarding whether cases would resolve (all p <0.0001). Conclusions: Predicted probabilities of spontaneous resolution of vesicoureteral reflux differ significantly among Internet based calculators. For certain patients, particularly those with a lower probability of spontaneous resolution, these differences can significantly influence clinical decision making. [Copyright &y& Elsevier]

Purpose: In women with vaginal agenesis progressive perineal dilation provides a minimally invasive method to create a functional vagina without the attendant risks or complications of traditional surgical options. We report our 12-year experience with this technique. Materials and Methods: Patients with vaginal agenesis treated at our institution were analyzed retrospectively and followed prospectively using case report forms and semistructured interviews. Patients diagnosed with vaginal agenesis were counseled on vaginal reconstruction options. Those electing progressive perineal dilation were instructed on the proper use of vaginal dilators by one of us (MRL) and advised to dilate 2 or 3 times daily for 20 minutes. All patients received physician, nursing and social work education and counseling. Parameters reviewed included primary diagnosis, start and end of vaginal dilation, dilation frequency, dilator size, sexual activity and whether the patient experienced pain or bleeding with dilation or sexual activity. Functional success was defined as the ability to achieve sexual intercourse, vaginal acceptance of the largest dilator without discomfort or a vaginal length of 7 cm. Univariate and multivariate analysis was performed to identify factors associated with successful neovaginal creation. Results: From 1996 to 2008 we enrolled 69 females with vaginal agenesis in a progressive perineal dilation program. The primary diagnosis was Mayer-Rokitansky-Küster-Hauser syndrome in 64 patients. Mean age at the start of vaginal dilation was 17.5 years (range 14 to 35) Mean followup was 19 months (range 0 to 100). Four patients (5.7%) were lost to followup. In 7 of the remaining 65 patients (12%) treatment failed due to noncompliance and 50 (88%) achieved functional success at a median of 18.7 months. Patients who dilated frequently (once daily or greater) achieved a functional neovagina at a mean ± SD of 4.3 ± 2.4 months. Functional success correlated positively with frequent (once daily or greater) dilation and the initiation of sexual activity. Complications were minor. Three patients reported infrequent pain and 2 reported a single episode of bleeding with dilation. A total of 18 sexually active patients reported satisfactory intercourse without dyspareunia. Conclusions: Progressive perineal dilation for neovaginal creation is a valuable, minimally invasive therapy to create a functional vagina with a high success rate and a much lower complication rate than that in published surgical series. Given these findings, progressive perineal dilation should be offered as first line therapy in adolescents with a congenitally absent vagina. [Copyright &y& Elsevier]

Abstract: Objective: Clitoroplasty is a procedure usually performed in young children, but its long-term psychosexual importance is controversial. We present two adult women from different cultural backgrounds who desired surgery for clitoromegaly. Methods: A similar clitoroplasty procedure with preservation of the neurovascular bundle was performed on both patients. Preoperative and postoperative interviews were conducted by an independent observer to learn about the effects of the condition and the surgery. Results: The Icelandic patient had bilateral ovarian dysgerminomas and a gonadoblastoma. The Bolivian patient had a 17β-hydroxysteroid oxidoreductase deficiency. Both patients reported normal libido but sexual inactivity because they felt ‘embarrassed’. Postoperatively, our patients reported normal clitoral sensation and that they were sexually active. They differed in their opinion regarding the optimal timing of clitoroplasty – one suggesting surgery soon after birth and the other recommending deferral until informed consent by the patient is possible. Conclusions: Regardless of cultural background patients are affected by clitoromegaly. This is demonstrated in these cases by the reported feelings of discomfort, distress, and sexual inactivity due to embarrassment. The long-term significance of clitoromegaly and the value of clitoroplasty for young patients with disorders of sexual differentiation remain controversial. [Copyright &y& Elsevier]

Purpose: Endoscopic treatment of vesicoureteral reflux has gained popularity and is frequently used as a first-line therapy. Reports of potential long-term complications from this treatment modality are lacking. We review the development of mound calcification in a cohort of patients undergoing endoscopic treatment of vesicoureteral reflux with autologous chondrocytes. Materials and Methods: All patients who underwent endoscopic treatment of vesicoureteral reflux with autologous chondrocytes at our institution were included in this study. All available renal and bladder ultrasounds, as well as any other imaging studies of the urinary tract, were reviewed by a staff radiologist (HJP) and 2 urologists (PCG, DAD) to assess for the presence of mound calcification. A variety of clinical factors were assessed, including grade and laterality of initial reflux, volume of autologous chondrocytes injected, number of injections, postoperative mound appearance and mode of presentation. Statistical comparison between groups was performed by paired sample t test and Fisher''s exact test. Univariate and multivariate analysis was used to identify potential risk factors for the development of mound calcification. Results: Total median followup was 9 years (range 7 to 11). Mound calcifications developed in 10 of our 27 patients (37%) at a median interval of 2.1 years after injection (range 1 to 5). More females (40%) than males (28%) had calcifications, although the difference was not statistically significant. Of the 10 patients with mound calcifications 7 presented with gross or microscopic hematuria, with or without flank pain. Three of these patients were initially thought to have ureterovesical junction stone(s). The remaining 3 cases were found incidentally. Hydroureteronephrosis was absent in all patients with mound calcifications. Univariate and multivariate analyses revealed no relationship between the presence or absence of calcification when controlled for gender, initial reflux grade, amount of autologous chondrocytes injected, number of injections used or total followup time from initial injection. Conclusions: Mound calcifications have now been reported after endoscopic therapy for vesicoureteral reflux with autologous chondrocytes as well as dextranomer/hyaluronic acid copolymer. The etiology of these calcifications remains unknown, and it is unclear whether mound calcification after endoscopic treatment will have any associated morbidity in long-term followup. Urologists, patients and other health care providers should be aware that mound calcification is a potential risk after endoscopic treatment of vesicoureteral reflux, and that these calcified mounds may mimic ureterovesical junction stones. [Copyright &y& Elsevier]

Purpose: Previous studies have examined the psychological impact that living with bladder exstrophy has on patients. However, little is known about how parents of children diagnosed with this condition are affected. We examine how parents caring for children diagnosed with bladder exstrophy are impacted. An increased understanding of the stressors these parents face may lead to the development of appropriate parenting interventions, which may ultimately affect psychosocial and health outcomes in the child. Materials and Methods: All parents of children 10 years and younger treated for bladder exstrophy at our institution were selected from a centralized database. A total of 20 parents (65% of the eligible population) completed standardized questionnaires assessing pediatric specific parenting stress (Pediatric Inventory for Parents) and coping (Ways of Coping Questionnaire). Results: Parents identified several common stressors (eg worrying about the long-term impact of the illness, helping the child with his/her hygiene needs) and overall reported using adaptive ways of coping (ie planful problem solving, seeking social support, positive reappraisal). However, when they experienced increased stress they reported using more nonadaptive ways of coping (ie escape/avoidance and distancing). Conclusions: Overall the findings of our study suggest that parents of children diagnosed with bladder exstrophy experience a significant amount of stress. In fact, parents in our study indicated experiencing similar frequency and difficulty of stress compared to parents of the same aged children diagnosed with type 1 diabetes. Increased stress can have negative consequences for parents and children. Future directions and implications of these findings are discussed. [Copyright &y& Elsevier]

Purpose: The new technique of complete primary repair of bladder exstrophy has offered the promise of improved bladder functional outcomes and yet longitudinal followup in patients with exstrophy who have undergone this form of closure is sparse. We present our median 5-year data on patients who have undergone complete primary repair of bladder exstrophy. Materials and Methods: The records of patients who underwent complete primary repair of bladder exstrophy were analyzed retrospectively. Patients were followed prospectively using case report forms, radiological and clinical data, and semistructured parental and patient interviews. We reviewed parameters including clinical events, scarring on renal scan, vesicoureteral reflux, surgical procedures, urodynamic studies, urinary and fecal continence status, and episodes of urinary tract infection. Results: From 1994 to 2007 complete primary repair of bladder exstrophy was performed in 32 patients. Of these patients 28 underwent closure within 72 hours of life, including 20 males and 8 females, and 4 underwent it after 72 hours at ages 7 days to 12 months. One patient underwent complete primary repair of bladder exstrophy elsewhere. Median followup was 5 years (range 1 to 13). In 32 patients a total of 193 surgical procedures were done, of which 40% were minor endoscopic cases. Six of 23 males (26%) underwent bladder neck reconstruction at a median age of 4.5 years (range 4 to 10). Two boys and 1 girl received Deflux® injection to the bladder neck at ages 3 to 5 years. To date no patient has undergone bladder augmentation. Nine patients (28%) had 1 to 4 episodes of pyelonephritis and 6 had cortical defects on renal scan. A total of 30 patients were voiding or incontinent via the urethra. One patient performed clean intermittent catheterization via the urethra and 1 performed it via appendicovesicostomy. All 4 children who were at least 6 months from bladder neck reconstruction after complete primary repair of bladder exstrophy had urinary continence periods of 2 to 3 hours or greater. Parents did not report any fecal incontinence or soiling in children older than 4 years. Relative to males the females had better urinary continence and a decreased need for bladder neck reconstruction. Conclusions: Complete primary repair of bladder exstrophy has been shown to be safe and efficacious. Prospective followup in this small number of evaluable patients reveals that continence periods of more than 2 hours are possible in patients after bladder neck reconstruction. Long-term followup in patients after complete primary repair of bladder exstrophy continues to be necessary to establish the long-term effects of this procedure. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: Complete primary repair of bladder exstrophy (CPRE) represents a paradigm shift from the staged approach for surgical management. We present early clinical outcomes in our patients following CPRE. Materials and Methods:: From 1996 to 2004 all newborns with bladder exstrophy were treated with CPRE within 48 hours of birth. We reviewed parameters including transfusions (packed red blood cells), urethral meatal position, complications, findings on renal ultrasound and renal scan, and post-CPRE procedures and infections. Results:: A total of 16 boys and 7 girls were treated with CPRE. Followup ranged from 8 to 96 months. Twelve boys (75%) and 2 girls (29%) received packed red blood cells at CPRE (p = 0.066). The tubularized urethral plate could not be brought to the penile tip, resulting in hypospadias in 9 of 11 boys (82%) with the running suture technique and only 1 of 5 boys (20%) with the interrupted technique (p = 0.036). Of the 23 patients 6 had a total of 8 complications after CPRE. Vesicoureteral reflux was present in 17 of 23 patients. After CPRE a total of 93 endoscopic/surgical procedures (median 4, range 0 to 16 per patient) were performed. Five patients had 1 to 4 episodes of pyelonephritis, 16 of 23 had 1 or more episodes of asymptomatic bacteriuria and 5 had cortical defects on renal scan. Conclusions:: We recommend that urethral closure during CPRE be performed with interrupted suture technique to prevent hypospadias. An aggressive approach should be taken toward reflux in the setting of urinary infection. Consideration should be given for repair of all aspects of the defect during CPRE, including bilateral ureteral reimplantation. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: We characterize pelvic soft tissue and bony anatomy of patients before and after complete primary repair of exstrophy (CPRE). Materials and Methods:: We evaluated 15 measurements on pelvic magnetic resonance imaging (MRI) in patients who underwent CPRE without osteotomy at our institution from 1996 to 2004. MRI protocols included axial, sagittal and coronal fast spin echo proton density sequences. Measurements were compared before and after CPRE using a paired t test, and between patients after CPRE, and age and gender matched controls using linear regression adjusting for the matched case-control groups. Patients older than 3 years with continent intervals longer than 3 hours after CPRE were compared to age and gender matched controls using linear regression. Results:: A total of 29 MRIs in 18 patients with exstrophy were available for analysis. Median patient age at postoperative MRI was 25 months (range 4 to 36). The configuration of the post-CPRE pelvis was significantly different from that of controls in all parameters measured including wider symphyseal diastasis (34.5 mm vs less than 1 mm) and more obtuse iliac wing (121° vs 98°), puborectalis (94° vs 49°) and ileococcygeus angles (111° vs 98°). The anatomy of continent patients after CPRE was not significantly different from that of controls in most parameters measured. Conclusions:: Comparison of the pelvic anatomy in patients before and after CPRE suggests that after CPRE patients have parameters that more closely approximate, but are still significantly different, from those of control patients. Patients with greater than 3-hour continent intervals after CPRE have anatomic parameters most similar to those of age matched controls. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: We assessed bladder growth and dynamics following complete primary repair of bladder exstrophy (CPRE) compared to the staged approach. Materials and Methods:: We reviewed the records of 16 boys and 7 girls who underwent CPRE within 3 days of life from 1996 to 2004 and compared them to the records of 8 boys and 6 girls treated with a staged repair from 1979 to 1996. Screening methods included voiding cystourethrogram, radionuclide cystogram and urodynamic study. We estimated growth curves for bladder capacity following repair in each group, and compared percent predicted bladder capacity (PPBC), compliance and detrusor overactivity between the CPRE and staged repair groups following bladder neck reconstruction. Results:: Bladder capacity in the staged repair group was 69.8 ml (95% CI 46.7–104.4) immediately after bladder neck reconstruction and increased by 15.0% per year thereafter (95% CI 6.2–24.5, p = 0.002). In the CPRE group bladder capacity was 29.0 ml (95% CI 21.3–39.5) initially and increased by 28.9% per year thereafter (95% CI 17.4–41.5, p <0.001). PPBC started at 45.6% (95% CI 35.7–55.5) and increased 1.2% per year (95% CI −1.1–3.5, p = 0.29) following repair for all genders and surgery groups. Compliance was 124.4% (95% CI 22.6–310.7, p = 0.01) greater in the CPRE group at all times following repair. Detrusor overactivity was present in 0 of 19 patients in the CPRE group and 6 of 13 (46%) in the staged group (exact p = 0.002). Conclusions:: Within the CPRE group bladder stability was universal, and sphincter electromyography was normal suggesting no neuromuscular compromise of the pelvic floor. At early followup, our results suggest that PPBC is equivalent irrespective of gender or management. Further objective evaluation is needed in both groups. [Copyright &y& Elsevier]

PURPOSE:: Balanitis xerotica obliterans (BXO) is a chronic dermatitis of unknown etiology most often involving the glans and prepuce but sometimes extending into the urethra. We report our 10-year experience with BXO in pediatric patients.MATERIALS AND METHODS:: Our pathology database was queried for all tissue diagnoses of BXO from 1992 to 2002. Available charts were reviewed and patient presentation, clinical and referral history, operative procedure(s) and postoperative course were recorded.RESULTS:: A total of 41 patients had a tissue confirmed diagnosis of BXO. Median patient age was 10.6 years. Of the patients 85% were 8 to 13 years old and all had referrals available for review. The most common referral diagnoses were phimosis (52%), balanitis (13%) and buried penis (10%). No patient had the diagnosis of BXO at referral. Of the patients 19 (46%) underwent curative circumcision or redo circumcision and had no recurrence at a mean followup of 12.5 months (range 1 to 57). A total of 11 patients (27%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. Nine patients (22%) required extensive plastic operation(s) of the penis, including buccal mucosa grafts in 2.CONCLUSIONS:: The incidence of BXO in pediatric patients may be higher than previously reported, with the diagnosis rarely made by pediatricians. Our study demonstrates that older patients, those with BXO involvement of the meatus and those with a history of surgery for BXO tend to have a more severe and morbid clinical course. [ABSTRACT FROM AUTHOR]

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. 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. 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%. 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. Summary Figure Geographic heatmap demonstrating Transatlantic international discussion of the effects of the COVID-19 pandemic on paediatric urological practice. Summary Figure [ABSTRACT FROM AUTHOR]