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Hypospadias patients presenting to adult urologists do so with a wide range of symptoms and problems, including urethral stricture (45-72%), lower urinary tract symptoms (with or without stricture) (50-82%), urethrocutaneous fistula (16-30%), persisting hypospadias (14-43%), micturition spraying (24%), ventral curvature (14-24%), urinary tract infection (15-25%), or lichen sclerosus (13%; range 8-43). Many of these men have concurrent complications as the result of multiple operations and a variety of techniques. Patients with childhood repairs performed by a pediatric urologist are often lost to followup during adolescence and will reemerge in adulthood after what appeared to be a successful pediatric singlestage repair, stressing the need for long-term followup and transitional care. One of the major challenges in successful transitional care is that patients can feel traumatized with feelings of hopelessness surrounding their defects, leaving them hesitant to seek care. As well, these patients often have little knowledge regarding the type of repair or original location of the meatus. Urethral stricture is the most common presenting complication and could be related to various factors, with the clear etiology still under debate. These strictures can fall under four categories based on length, location, and previous surgeries. To lessen the difficulties in transitioning hypospadias patients from pediatric to adult practitioners, followup throughout childhood and adolescence for physical examination, as well as uroflowmetry, is mandatory. [ABSTRACT FROM AUTHOR]

The article presents updated guidelines by the Canadian Urological Association (CUA) and the Pediatric Urologists of Canada for the investigation and management of antenatal hydronephrosis (AHN). Topics of discussion include diagnosis of AHN, postnatal investigations, including renal-bladder ultrasound (RBUS), and the use of continuous antibiotic prophylaxis (CAP).

The article discusses guidelines by Canadian Urological Association-Pediatric Urologists of Canada (CUA-PUC) for the diagnosis, management, and followup of cryptorchidism. Topics discussed include cryptorchidism epidemiology, goals for cryptorchidism treatment, and risk of testicular cancer which is rare in Canada.

Cryptorchidism is one of the most common congenital anomalies of the male genitalia, occurring in 1% of boys by the age of one year. Even though the etiology of cryptorchidism is multifactorial, management has evolved with the clear recognition that hormonal treatment is not effective and surgery between 6-18 months of age leads to better testicular outcomes. Diagnostic laparoscopy is considered the standard approach for management of non-palpable testes, and can be combined with one or two-stage orchidopexy, with up to 80-90% success rates. This review discusses the natural history of retractile testicles, indications for hormonal treatment and orchidectomy, ultrasound's role as a diagnostic tool, risks of infertility and testicular cancer, and surgical techniques for inguinal and intra-abdominal testes. [ABSTRACT FROM AUTHOR]

The article presents the discussion on term "disorders of sex development" (DSD) being first proposed in a consensus statement in 2006. Topics include increasing the role of patient advocacy and the importance of ethical informed consent adding nuance to the management of the DSD population; and multidisciplinary care by pediatric endocrinology, pediatric urology, pediatric and adolescent gynecology, genetics, and social work.

Introduction: Penile degloving is an important step in orthoplasty. Although its role in correcting mild curvature in distal and midshaft hypospadias has been previously reported, its impact on ventral curvature (VC) correction in proximal defects warrants further investigation. Therefore, we sought to document the effect of degloving and proximal urethral dissection on VC correction in children with proximal hypospadias. Methods: We retrospectively reviewed the records of 137 patients who underwent proximal hypospadias repair between 1998 and 2006. VC, defined as mild (<30%), moderate (30%--45%), and severe (>45%), was recorded before penile degloving and after erection test. Percent improvement in VC and need for further treatment (beyond degloving and proximal dissection) based on preoperative degree of curvature were assessed. ANOVA test was used to compare improvement among the 3 groups. Results: Mean age at repair was 14 months (range: 6-24). Penile degloving associated with proximal urethral dissection when necessary was responsible for the improvement in the degree of curvature in 7 of 9 (77%) patients with mild VC, 23 of 44 (52%) with moderate and 35 of 84 (40%) with severe VC. Additionally, degloving alone was sufficient for VC correction in 7 of 9 (77%) mild cases, 14 of 44 (30%) moderate and only 2 of 84 (2%) severe cases. The difference among these 3 groups was statistically significant (p <0.001). Conclusions: Penile degloving alone can correct VC. The percentage of improvement depends on the preoperative degree of curvature, with severe VC cases showing the least improvement. [ABSTRACT FROM AUTHOR]

The article offers the author's insights about hypospadias and mentions topics including the assessment of the disease through penile degloving, challenges featured on the treatment of disease, and the importance of prospective databases for academic pediatric urologists to address shortcomings.

The article presents Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants. Topics discussed include normal foreskin care in early childhood, pathological phimosis and history of recurrent urinary tract infections (UTIs), and role of topical steroids and preputial stretching in resolving physiological phimosis.

The article presents Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants. Topics include natural history of the foreskin like collection of smegma separating the prepuce from the glans, pathological phimosis and history of recurrent urinary tract infections (UTIs), and role of topical steroids and preputial stretching in resolving physiological phimosis.

Continuous antibiotic prophylaxis (CAP) has traditionally been offered for children with recurrent urinary tract infections (UTIs) or those at risk, including children diagnosed with prenatal hydronephrosis (HN) and vesicoureteral reflux (VUR). However, indications for antibiotic prophylaxis are controversial, data on who should benefit from this therapy is conflicting and, thus, guidelines are unable to provide conclusive recommendations. In the setting of prenatal HN, although randomized trials are currently underway, most evidence is derived from low- to moderate-quality observational studies. Although there is no benefit in those with low-grade HN, a systematic review of the available studies showed that highgrade HN patients on prophylaxis experienced fewer infections with an estimated number needed to treat of 7. On the other hand, there are eight randomized trials that have investigated the use of antibiotic prophylaxis in the setting of VUR. Although four of the studies have demonstrated some value of prophylaxis and the other four have not, meta-analysis has shown an overall benefit of antibiotic prophylaxis in preventing infections. The observed differences are likely due to different inclusion criteria and study heterogeneity. Although generalizing results of meta-analyses to all children is tempting, an individualized approach, by determining which patients best behave like those of the included studies, is recommended. [ABSTRACT FROM AUTHOR]

Introduction: While continuous antibiotic prophylaxis (CAP) is currently recommended to prevent urinary tract infections (UTIs) in infants with prenatal hydronephrosis (HN), this recommendation is not evidence-based. The objective of this study was to systematically determine whether CAP reduces UTIs in the HN population. Methods: Applicable trials were identified through an electronic search of MEDLINE (1946-2015), EMBASE (1980-2016), CINAHL (1982-2016), and CENTRAL (1993-2016) and through a hand search of American Urological Association (AUA) (2012-2015) and European Society for Pediatric Urology (ESPU) (2012-2015) abstracts, as well as reference lists of included trials. The search strategy was not limited by language or year of publication. Eligible studies compared CAP to no CAP in patients with antenatal HN, <2 years of age, and reported development of UTI and HN grades. Two independent reviewers performed title and abstract screening, full-text review, and quality appraisal. Results: Of 1518 citations screened, 11 were included, contributing 3909 patients for final analysis. Of these, four (36%) were considered high-quality when assessed by the Newcastle Ottawa Scale. Meta-analysis of the non-randomized trials (n=10) provided similar pooled UTI rates, regardless of CAP use: 9.9% (95% confidence interval [CI] 8.4-11.4%) for CAP and 7.5% (95% CI 6.4-8.6%) for no CAP. Conclusions: This systematic review and meta-analysis suggests there may be value in providing CAP to infants with high-grade HN; however, due to the very low-quality data from non-randomized studies, important clinical variables, such as circumcision status, were unable to be assessed. [ABSTRACT FROM AUTHOR]

Introduction: Upon inquiring with medical students and urologists across Canada, it is evident that urology is perceived as a maledominant specialty, among other stereotypes. These misperceptions may hamper the recruitment of the best and brightest trainees. With that in mind, we surveyed medical students at our institution to obtain an objective assessment of their perception of urology and to determine the cause for misperceptions. Methods: A 25-factor, validated, anonymous, cross-sectional, selfreported, electronic survey was sent to all medical students at McMaster University to assess their perception of urology. The survey was piloted among students and educational leaders to optimize face and content validity, and minimize measurement bias. Six variables (years in training, role model, a family member or friend in urology, gender, and exposure) were selected a priori and entered into a logistic regression model to determine factors associated with a positive impression of the specialty. Results: The overall response rate was 70%. Of the respondents, 66% had no exposure to urology and 61% found the amount of exposure to be inadequate. Urology staff and resident involvement in education was considered to be poor by over 30% of medical students. Over 70% perceived urology to be a specialty with a great gender imbalance. On multivariate analysis, exposure to urology was the most important factor (p<0.001) associated with students' positive perception of the specialty, in addition to male gender, earlier years in training, and positive role models. Conclusions: Concerns regarding inadequate urology exposure and poor staff and resident involvement in undergraduate education were seen as potential causes for misperceptions of the specialty. Increasing exposure to urology, encouraging female students, constant effort to approach senior students, and providing mentorship are found to be important factors in establishing a positive perception of urology. [ABSTRACT FROM AUTHOR]

The article presents a case study of a male neonate with bladder wall thickening and decreased bladder capacity i.e. anuria and acute renal failure. It is noted that diagnosis of posterior urethral valves revealed by voiding cystourethrogram (VCUG), which demonstrated bladder wall trabeculation, small bladder capacity. The article discusses that patient developed the disorder immediately following endoscopic valveablation and Foley catheter insertion.

The article focuses on the urology education in the time of COVID-19. Topics include the emergence of COVID-19 and its rapid spread throughout the world has propelled the medical community into a time has accelerated innovation and change, the necessary focus has been on disease containment and delivery of care, and the pandemic has had a profound impact on medical education at both the undergraduate and postgraduate levels.

The article offers information on navigating urology's new normal and mitigating the effects of a second wave of COVID-19. Topics include the initial wave of the COVID-19 crisis has forced immediate and seismic changes on urological practice, patient care, and education collateral damage to the upending of societal and global economic norms, and the lockdowns and limitations has curtailed access to the physical spaces of the clinic and operating room, and slashed remuneration secondarily.

The article discusses about Pediatric urological surgery readiness condition (PedsUROCON). Topics include delivering the optimal care despite this pervasive and fast-evolving event, how healthcare managers must address and adjust four main domains in order to reach optimal surge capacity; and maximizing use of hospital structure, increase staff capacity, prioritize use of equipment and supplies, and develop an efficient communication system between hospitals.

The article focuses on the prioritization and management recommendations of pediatric urology conditions during the COVID-19 pandemic. Topics inlcude the declaration of a worldwide pandemic related to the novel coronavirus (Sars-CoV-2) by the World Health Organization on March 11, 20201, the spread of COVID-19 restrictions on public gatherings have been implemented, and the widespread public adoption of social distancing regulations has alleviated some of the burden on the healthcare system.

Introduction: Although previous evidence has shown that ultrasound is unreliable to diagnose undescended testis, many primary care providers (PCP) continue to misuse it. We assessed the performance of ultrasound as a diagnostic tool for palpable undescended testis, as well as the diagnostic agreement between PCP and pediatric urologists. Methods: We performed a prospective observational cohort study between 2011 and 2013 for consecutive boys referred with a diagnosis of undescended testis to our tertiary pediatric hospital. Patients referred without an ultrasound and those with non-palpable testes were excluded. Data on referring diagnosis, pediatric urology examination and ultrasound reports were analyzed. Results: Our study consisted of 339 boys. Of these, patients without an ultrasound (n = 132) and those with non-palpable testes (n = 38) were excluded. In the end, there were 169 pateints in this study. Ultrasound was performed in 50% of referred boys showing 256 undescended testis. The mean age at time of referral was 45 months. When ultrasound was compared to physical examination by the pediatric urologist, agreement was only 34%. The performance of ultrasound for palpable undescended testis was: sensitivity = 100%; specificity = 16%; positive predictive value = 34%; negative predictive value = 1 00%; positive likelihood ratio = 1.2; and negative likelihood ratio = 0. Diagnosis of undescended testis by PCP was confirmed by physical examination in 30% of cases, with 70% re-diagnosed with normal or retractile testes. Conclusion: Ultrasound performed poorly to assess for palpable undescended testis in boys and should not be used. Although the study has important limitations, there is an increasing need for education and evidence-based guidelines for PCP in the management of undescended testis. [ABSTRACT FROM AUTHOR]

Introduction: Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this pro-cedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of know-ledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision. Methods: A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey partici-pants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants' daily practice. From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urolo-gists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the partici-pants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindica-ted. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons ver-sus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01 ). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24). Conclusions: Our survey findings indicate that most physicians per-forming neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnes-sed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues. [ABSTRACT FROM AUTHOR]

Objectives: We compare the cost-utility of laparoscopic radical nephrectomy (LRN), laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in the management of small renal masses (SRMs) when the impact of ensuing chronic kidney disease (CKD) disease is considered. Methods: We designed a Markov decision analysis model with a 10-year time horizon. Estimates of costs, utilities, complication rates and probabilities of developing CKD were derived from the literature. The base case patient was assumed to be a 65-year-old patient with a <4-cm unilateral renal mass, a normal contralateral kidney and a normal preoperative serum creatinine. Univariate and probabilistic sensitivity analyses were conducted to address the uncertainty associated with the study parameters. Results: OPN was the least costly strategy at $25 941 USD and generated 7.161 quality-adjusted life years (QALYs) over 10 years. LPN yielded 0.098 additional QALYs at an additional cost of $888 for an incremental cost-effectiveness ratio of $9057 per QALY, well below a commonly cited willingness-to-pay threshold of $50 000 per QALY. LRN was more costly and yielded fewer QALYs than OPN and LPN. Sensitivity analyses demonstrated our model to be robust to changes to key parameters. Age had no effect on preferred strategy. Conclusions: Partial nephrectomy (PN) is the preferred treatment strategy for SRMs. In centres where LPN is not available, OPN remains considerably more cost-effective than LRN. Furthermore, our study demonstrates that there is no age at which PN is not pre-ferred to LRN. Our study provides additional evidence to advocate PN for the management of all amenable SRMs. [ABSTRACT FROM AUTHOR]

The article highlights lessons to prioritize urological surgeries during epidemics which learned from the Toronto SARS outbreak in 2003. It mentions the need for more efficacious public health policies on restriction of non-urgent clinical activities to increase flow capacity; and also focuses on cancelling elective surgery as a crucial step in creating surge capacity to prioritize hospital resources.

Introduction: We performed a meta-analysis of the current literature to assess the association of caudal block and postoperative complication rates following hypospadias repair., Methods: A Systematic literature search was conducted on October 2017. Five reviewers independently screened, identified, and evaluated comparative studies assessing postoperative outcomes following hypospadias repair with and without caudal block. The incidence of post-surgical complications from each study was extracted for caudal block and control groups to generate the odds ratio (OR) and corresponding 95% confidence intervals (CI). Effect estimates were pooled using inverse-variance method with random-effects model. Subgroup analyses were performed according to study type and hypospadias severity., Results: Nine studies (2096patients) of low- to moderate-quality were included for meta-analysis. Overall pooled effect estimates demonstrated increased occurrence of postoperative complication rates among patients with caudal block (OR 2.32; 95% CI 1.29-4.16). Subgroup analysis according to hypospadias severity revealed that a significant increased OR in complication rate was noted among proximal hypospadias (OR 3.55; 95% CI 1.80-7.01), but not distal hypospadias (OR 1.31; 95% CI 0.59-2.88)., Conclusions: Our meta-analysis of poor-quality evidence may have revealed a significant association between caudal block and postoperative complications following hypospadias repair. However, subgroup analysis demonstrated that hypospadias severity is important in determining complication rates, suggesting that confounding factors and selection bias may play a central role in characterizing the true effect of the anesthesia approach.

Introduction: Penile fractures have classically been thought to require immediate surgical intervention; however, recent series have described acceptable outcomes with delayed repair. In this systematic review, we compared complication rates between immediate and delayed repair of penile fractures., Methods: A systematic search of MEDLINE, Embase, CENTRAL, and Web of Science was performed with predefined search terms between 1974 and 2015. Titles and abstracts were screened prior to full-text review and quality appraisal by two independent investigators. Abstracted outcomes included postoperative erectile dysfunction (ED), tunical scar formation, and penile curvature. Only studies reporting a direct comparison of complications following immediate (<24 hours from injury to presentation/surgery) and delayed (>24 hours) repair of penile fractures were included., Results: A total of 12 studies met inclusion criteria. All were retrospective, observational studies of low or moderate methodological quality. Of the reported 502 patients, 391 underwent immediate repair and 111 delayed repair. In the immediate repair group, the percent of patients with postoperative ED, tunical scars, and curvature were 6.6%, 5.4%, and 1.8%, respectively, while in the delayed group, the rates of ED, tunical scars, and curvature were 4.5% across the board. Rates of ED and tunical scar formation following immediate compared to delayed repair trended towards favouring immediate repair, but did not differ significantly, while rates of curvature significantly favoured immediate repair. However, cases of curvature were typically reported as mild and none affected sexual functioning., Conclusions: In this systematic review, we demonstrated that ED and tunical scar formation rates between immediate and delayed repair of penile fractures were statistically similar, while immediate repair had a lower rate of penile curvature. Although this suggests that a brief delay in repair may be acceptable in select patients, the results should be interpreted with caution, as the included studies were of low or moderate methodological quality. Most importantly, this review highlights the deficiencies in the current penile fracture literature, setting the stage to improve the quality of future studies.

Introduction: We evaluate the influence of surgeon experience and other clinical factors on the success of primary hypospadias repair, using the tubularized incised plate urethroplasty (TIPU) technique., Methods: We retrospectively reviewed pediatric cases of primary hypospadias repair performed by a single pediatric urologist (soon after his fellowship training) using TIPU between July 2002 and January 2011. The surgical techniques (including the fact that the procedure was an outpatient one) were the same for each patient. The overall complication rate (CR) was analyzed for the following factors: patient age, use of a stent, meatal position, and surgeon experience. All significant covariates on univariate analysis or with a clinical relevance were entered into a multivariable logistic regression model. A non-linear model was created to estimate the change in the CR over the years., Results: Pediatric patients (median age 1.4 years old) presenting with distal (n = 251), midshaft (n = 22) or proximal (n = 30) hypospadias and with a minimum 6-week follow-up (median 13 months) were included. Most patients (87%) had a urethral stent postoperatively (mean duration 9.8 days). In total, 96 patients had 133 complications: 27 meatal stenosis, 25 meatal coronal migrations, 22 urethrocutaneous fistulas and 59 other complications. Of these, 53 patients underwent a second operation. On multivariate analysis, the only factor increasing the CR was a non-distal meatus. The non-linear model demonstrated a significant learning curve with a decreasing CR over the years. The limitations of this study are its retrospective nature and lack of long-term follow-up., Conclusions: When using TIPU, the CR significantly increases as the meatal position gets more proximal; the learning curve stabilizes after about 50 to 75 cases.

Introduction: Urinary continence after cloacal repair is difficult to achieve and renal outcome in patients with cloacal malformations has been scarcely reported. As a result, we reviewed our experience with cloacal malformations to determine the status of continence and the long-term renal function in these children., Methods: A retrospective chart review from 1990 to 2003 identified 12 patients with cloacal malformation (1 posterior, 4 complex and 7 classical) who underwent surgical reconstruction. The confluence was defined as high (common channel >/= 3 cm) and low (< 3 cm) by cystovaginoscopy. Renal ultrasound, voiding cystouretrogram, renal scan and sacral radiograph were performed in all children. Most patients underwent 1-stage abdominoperineal pull-through, applying the principle of total urogenital sinus mobilization. We collected data regarding hydronephrosis, vesicoureteral reflux and split differential renal function. Renal outcome was evaluated based on glomerular filtration rate and age-adjusted serum creatinine values (mumol/L). Urinary continence was defined as a dry interval > 4 hours., Results: Patients' mean age at surgery was 20 months (range 7-29 mo). Of the 12 children who underwent cloacal repair, 7 (58.3%) had a common channel >/= 3cm. Renal anomalies were identified in 3 of 12 (25%) girls: there were 2 solitary kidneys and 1 pelvic kidney. Lumbar-sacral radiography demonstrated bony abnormalities in 11 of the 12 (91.6%) cases: hemivertebra in 3 cases, sacral agenesis in 4 cases, hypoplastic sacrum in 3 cases and bifid sacrum in 1 case. Total urogenital sinus mobilization through an abdominoperineal approach in a single stage was performed in 8 girls. Follow-up ranged from 4 to 14 years (mean 8.5 yr). Eight (66.6%) children had dry intervals > 4 hours, 5 (62.5%) of them were on clean intermittent catheterization through a Mitrofanoff channel and 1 (12.5%) was through the urethra. The remaining 2 (25%) patients were voiding spontaneously. Three (33.3%) patients were totally incontinent, and 1 (8.3%) patient was awaiting reconstruction. The mean measured glomerular filtration rate was 93.5 mL/min/1.73m(2) (range 34-152 mL/min/1.73m(2)). Four (57.1%) of 7 patients who had a common channel >/= 3 cm ended up needing augmentation cystoplasty, compared with none of the patients with a common channel < 3 cm (57.1% v. 0%, p = 0.038)., Conclusion: Urinary continence can be achieved in most patients with cloacal malformation at the expense of major reconstructive surgery and despite the presence of associated urological abnormalities. However, these children harbour an important risk for renal impairment later in life and should be closely monitored.