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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]

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]

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 upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence. Materials and methods Consecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Results There were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet). Conclusions Upper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation. [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]

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]

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]

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]

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]

There are limited published data characterizing pediatric burn patients with genital burns (GB). Assess prevalence of GB in pediatric burn patients and analyze clinical characteristics including predictors of mortality. We queried American Burn Association's National Burn Repository to identify all pediatric burn patients who presented to North American burn centers over a 10-year period. We excluded all patients aged ≥18 years and patients with unknown sex, race, and/or mortality. We also excluded subsequent encounters for patients with multiple visits. Demographic and clinical characteristics were compared between patients with and without GB. Univariable and multivariable logistic regression analyses were performed to identify predictors of mortality. Among 38 211 pediatric burn patients, 1244 (3.3%) suffered from second- or third-degree GB. Patients who suffered from third-degree GB (GB3) were significantly older than patients who suffered from second-degree GB (GB2) or patients without GB. Of the patients, 32.3% were aged 0–2 years. Scalding was the most common mechanism of injury for pediatric GB patients at 73.8%. Compared to non-GB patients, GB patients had significantly higher total body surface area (TBSA) burned (16.5% vs 7.0%), higher rates of associated inhalation injury (4.1% vs 2.6%), longer length of stay (LOS) (14.3 days vs 6.7 days), higher rates of urinary tract infection (UTI) (13.0% vs 2.8%) and sepsis (14.1% vs 2.3%), and higher mortality (3.5% vs 0.7%) (P < 0.0001 for all). The differences were more pronounced for the subset of patients who suffered from GB3 (TBSA 43.5%, associated inhalation injury 19.9%, LOS 42.9 days, 21.3% UTI, 33.3% sepsis, and 19.3% mortality). On multivariable analysis, the presence of GB3, TBSA, non-white ethnicity, and the presence of associated inhalation injury were significant predictors of mortality. Only 4.5% of pediatric GB patients underwent genital surgery, with the majority consisting of excision, reconstruction, or repair of the penis, vulva, or perineum. No patient required orchiectomy or suprapubic catheter placement. This is the largest study to date of pediatric GB patients. A minority of pediatric burn patients present with GB. However, when they occur, GB are associated with significantly worse clinical outcomes. Importantly, the presence of GB3 is an independent predictor of mortality in pediatric burn patients. The presence of GB appears to be a strong marker of severe burn injury. Pediatric GB patients need to be carefully assessed and aggressively managed for additional injuries, complications, surgical needs, and mortality risk. Multivariable analysis of risk factors for mortality in pediatric burn patients. OR 95% CI P value GB3 present 1.88 1.01–3.49 0.0451* Age 1.01 0.99–1.04 0.3674 TBSA 1.05 1.05–1.06 <0.0001* Male sex 1.30 0.97–1.74 0.0823 Non-white ethnicity 1.46 1.08–1.96 0.0134 Inhalation injury 7.64 5.45–10.71 <0.0001* OR = odds ratio; CI = confidence interval. * indicates statistical significance. [ABSTRACT FROM AUTHOR]

Endourological and percutaneous approaches are the standard of care for treatment of pediatric urolithiasis. However, in certain situations, an endoscopic-assisted robotic pyelolithotomy (EARP) can be an acceptable alternative. Limited data exist on pediatric EARP; thus, the authors describe their experience. Patient selection: The authors retrospectively analyzed the records of all robotic procedures performed at five institutions from 7/09–10/17 to identify patients who underwent EARP. The authors collected demographics data, indications, operative time, and postoperative complications. Stone composition was reported as the majority composition (≥50%), unless any uric acid or struvite was noted, and those stones were classified as such. Through a traditional or hidden incision endoscopic surgery (HIdES) robot pyeloplasty approach, the authors are able to easily pass a flexible endoscope through a robotic trocar and into the renal collecting system to perform pyeloscopy or ureteroscopy. Stones were primarily retrieved via the pyelolotomy and, if indicated, treated with laser lithotripsy. The authors identified 26 patients who underwent EARP in 27 renal units. Median patient age was 12.2 years (interquartile range [IQR] 6.1–14.5 years), and body mass index was 17.5 kg/m2 (IQR 16.5–25.4 kg/m2). The median pre-operative dimension of the largest stone was 9.0 mm (IQR 5.8 mm–15.0 mm). Reasons for EARP: 21 (77.8%) concomitant pyeloplasty, four (14.8%) altered anatomy precluding other techniques, and two (7.4%) multiple large stones. Multiple stones were present in 20 renal units (74.1%). Stones were located in the renal pelvis in nine (33.3%), lower pole in 10 (37.0%), ureter in one (3.7%), and multiple locations in seven (25.9%). Hidden incision endoscopic surgery approach was used in 14 (51.9%), and the median operative time was 237.5 min (IQR 189.8–357.8 min) with a median length of stay 1.0 day (IQR 1.0–2.0 days). Stone composition included calcium oxalate in 14 (51.9%), calcium phosphate in five (18.5%), cysteine in two (7.4%), struvite in two (7.4%), and unknown in four (14.8%). Overall stone free status was 19 (70.4%); of the eight (29.6%) renal units with residual stones, four underwent ureteroscopy, two extracorporeal shockwave lithotripsy (ESWL), one spontaneously passed, and one underwent percutaneous nephrolithotomy (PCNL). After secondary treatment, final stone free rate was 96.3%. Complications included stent migration and admission for urosepsis. At a median follow-up of 12 months (IQR 6.2–19.2 months), five (18.5%) had stone recurrence. Endoscopic-assisted robotic pyelolithotomy is a reasonable treatment option for select pediatric patients with concomitant ureteropelvic junction obstruction and nephrolithiasis or pediatric patients with stones inaccessible by standard methods. Summary Figure Extrarenal view of the operative field from the laparoscopic camera depicting the flexible nephroscope in the renal pelvis performing nephroscopy. Summary Figure [ABSTRACT FROM AUTHOR]

Summary Background Robotic techniques are increasingly being used for reconstructive procedures in the pediatric population. Objective The present study reported the functional and perioperative outcomes of a multi-institutional cohort of pediatric patients who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA). Study design Pediatric patients who underwent RALMA at five different centers were included. Positioning is shown ( Summary Figure ). Demographics were gathered, and intraoperative parameters included concomitant procedures, detrusor tunnel length, estimated blood loss (EBL) and operative time. Perioperative outcomes included length of hospital stay (LOS), morphine use and 30-day complications. Outcomes were reported in terms of stomal continence and surgical revisions. Results Eighty-eight patients with a mean age of 10.4 ± 4.0 years were included in the analysis. Median follow-up was 29.5 months (IQR 11.8–45.0). Bladder augmentation was performed concomitantly in 15 (17%) patients, and bladder neck procedures in 34 (39%). Mean detrusor tunnel length was 3.9 ± 1.0 cm, EBL was 54 ± 70 ml, and operative time was 424 ± 120 min. Postoperatively, mean LOS was 5.2 ± 2.8 days. Patients who underwent concomitant augmentation had higher EBL and operative times (both P < 0.05). At 90 days, complications occurred in 26 patients (29.5%) with six Clavien grade ≥3 (6.8%). During follow-up, 11 (12.5%) patients required appendicovesicostomy revision. Regarding functional outcomes, 75 (85.2%) patients were initially continent. After additional procedures, 81 (92.0%) patients were continent at last follow-up. Discussion Compared to previous open series, initial stomal continence rates with RALMA were acceptable, with a minority of patients requiring subsequent procedures to manage complications and achieve continence. Conclusion RALMA is safe and effective in a pediatric population with regard to perioperative complications and stomal continence. Summary Figure Adapted from Chang et al. with permission [1] . [ABSTRACT FROM AUTHOR]

Summary Introduction Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention. Materials and methods A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain. Results One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect ( P = 0.040) ( Fig. A) and lacked ureteral opacification ( P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5–2.5), additional operative interventions occurred from day 4–16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission ( Fig. B). Conclusions Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised. Figure A. Axial CT image demonstrating left renal pelvis extravasation and collecting system filling defect (blue arrow). B. Coronal CT image demonstrating dual arterial supply of right kidney with lower pole accessory artery (*) and well-perfused upper and lower pole fragments. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.) [ABSTRACT FROM AUTHOR]

Summary Introduction Open ureteroneocystostomy (UNC) is the gold standard for surgical correction of vesicoureteral reflux (VUR). Beyond single-center reports, there are few published data on outcomes of minimally-invasive (MIS) UNC. Our objective was to compare postoperative outcomes of open and MIS UNC using national, population-level data. Method We reviewed the 1998–2012 Nationwide Inpatient Sample to identify pediatric (≤18 years) VUR patients who underwent either open or MIS UNC. Demographics, National Surgical Quality Improvement Program (NSQIP) complications, length of stay (LOS), and cost data were extracted. Statistical analysis was performed using weighted, hierarchical multivariate logistic regression (complications) and negative binomial regression (LOS, cost). Results We identified 780 MIS and 75,976 open UNC admissions. Compared with patients undergoing open UNC, patients who underwent MIS UNC were likely to be older (6.2 versus 4.8 years, p < 0.001), publically insured (43 versus 26%, p < 0.001), and treated in recent years (90 versus 46% after 2005, p < 0.001). MIS admissions were associated with a significantly shorter length of stay (1.0 versus 1.8 days, p < 0.001) and higher cost ($9230 versus $6,304, p = 0.002). After adjusting for patient-level confounders (age, gender, insurance, treatment year, and comorbidity), and hospital-level factors (region, bedsize, and teaching status), MIS UNC was associated with a significantly higher rate of postoperative urinary complications such as UTIs, urinary retention, and renal injury (OR 3.1, p = 0.02), shorter LOS (RR 0.8, p = 0.02), and higher cost (RR 1.4, p = 0.008). Discussion Strengths of this study are its large cohort size, long time horizon, national estimation, and cost data. Most prior studies are case-series limited to the size of the institutional cohort. Our analysis of 76,756 operative encounters revealed that open UNC continues to be performed at far greater frequency than MIS UNC, outpacing the latter modality by nearly 100:1. Children treated with MIS UNC had three times greater odds of developing postoperative urinary complications, and MIS UNC patients incurred average costs per admission that were nearly 1.5 times higher than those of children who underwent open UNC. These children were also likely to be older, publically insured, and treated in more recent years. On the other hand, patients treated with MIS UNC required substantially shorter postoperative hospitalization, with an average LOS roughly half that of open UNC cases. Limitations include the retrospective nature of the administrative database, lack of detailed patient-level data, and no available long-term postoperative outcomes. Compared with open surgery, MIS UNC was associated with shorter LOS but higher costs and possibly higher urinary complication rates. Table Bivariate/multivariate analysis of postoperative complications for MIS UNC. NSQIP complications a Unadjusted OR (95% CI) Adjusted OR b (95% CI) p value b UTI 1.00 (0.37–2.72) 0.99 (0.40–2.44) 0.98 Urinary complications 2.63 (1.00–6.91) 3.13 (1.17–8.40) 0.02 All complications 1.15 (0.48–2.78) 1.27 (0.57–2.85) 0.56 a Using open UNC as reference. b After adjusting for age, gender, insurance, year, comorbidity, teaching status, hospital region, and hospital size. [ABSTRACT FROM AUTHOR]

Summary Introduction Posterior urethral valves (PUVs) are the most common etiology for congenital urethral obstruction and congenital bilateral renal obstruction. PUVs produce a spectrum of urologic and renal sequelae. Our aims were to assess outcomes of PUV patients, to determine whether vesicoureteral reflux (VUR) is a risk factor for progression to renal failure, and to identify other risk factors for poor outcomes. Materials and methods We conducted a retrospective analysis of PUV patients from 2006 to 2014. Data collected included demographics, initial renal ultrasound (RUS) findings, creatinine at presentation and nadir, pre- and postoperative VUR status, presence or absence of recurrent urinary tract infections (UTIs), and surgical intervention(s). Univariate and multivariate analyses were used to determine risk factors for renal failure. Results Of 104 patients, 42.3% (44/104) were diagnosed prenatally, 31.8% (14/44) of whom underwent prenatal intervention. Postnatally, 90.4% (94/104) initially underwent transurethral resection of PUVs (TUR-PUVs). Vesicostomy was the next most common index surgery (4.8%). Forty-two percent (44/104) required >1 surgery. The predominant second surgery was repeat TUR-PUV in 16 patients. At last follow-up (mean 28.8 months after initial surgery), 20.2% had chronic kidney disease (CKD) of at least stage IIIA, and 8.6% had progressed to end-stage renal disease (ESRD). Antenatal diagnosis, prematurity, abnormal renal cortex, and loss of corticomedullary differentiation (CMD) on initial RUS were associated with CKD and ESRD on univariate analysis, as were elevated creatinine on presentation and at nadir. Presence of pre- or postoperative VUR and recurrent UTIs were associated with the need for multiple surgeries, but not with poor renal outcomes. On multivariate analysis, nadir creatinine was the only independent predictor of final renal function. Conclusions Our finding that creatinine is the only independent risk factor for poor renal outcomes in PUV patients is consistent with the literature. The effect of VUR has been controversial, and our finding that VUR is associated with need for multiple surgeries but not with CKD or ESRD is novel. Limitations include biases inherent to retrospective studies and relatively small sample size. The majority of patients with PUVs (56.7%) required one surgery and maintained renal function with CKD II or better (79.8%) up to 2 years after initial surgery. While multiple factors were associated with poor renal outcomes, nadir creatinine was the only independent predictor. VUR and recurrent UTIs were not associated with poor renal outcomes. Longer follow-up is necessary to identify risk factors for delayed progression of renal disease. Table Summary of results. A. Predictors of ESRD p -value Categorical Prematurity 0.010 Prenatal diagnosis 0.034 Abnormal renal cortex on initial RUS 0.011 Loss of CMD on initial RUS <0.001 Continuous Presenting creatinine: mean non-ESRD pts vs ESRD pts: 1.3 vs 2.9 <0.001 Nadir creatinine: mean non-ESRD pts vs ESRD pts: 0.4 vs 2.7 <0.0001 B. Predictors of CKD p -value Categorical Prematurity 0.038 Prenatal diagnosis 0.014 Abnormal renal cortex on initial RUS <0.001 Loss of CMD on initial RUS <0.001 Continuous Presenting creatinine: mean non-ESRD pts vs ESRD pts: 1.3 vs 2.9 <0.0001 Nadir creatinine: mean non-ESRD pts vs ESRD pts: 0.4 vs 2.7 <0.0001 C. Predictors of >1 surgery p -value Categorical Prematurity 0.028 Prenatal diagnosis 0.027 Symptomatic presentation 0.048 Recurrent UTIs <0.001 Pre-op VUR 0.006 Post-op VUR 0.049 Loss of CMD <0.001 CKD, chronic kidney disease; CMD, corticomedullary differentiation; ESRD, end-stage renal disease; RUS, renal ultrasound; UTIs, urinary tract infections; VUR, vesicoureteral reflux. [ABSTRACT FROM AUTHOR]

Summary Introduction Laparoscopic hernia repair with percutaneous ligation of the patent processes vaginalis is a minimally invasive alternative to open inguinal herniorrhaphy in children. With the camera port concealed at the umbilicus, this technique offers an excellent cosmetic result. It is also faster than the traditional laparoscopic repair with no differences in complication rates or hospital stay. The goal of this study was to describe a series of consecutive patients, emphasizing the impact of suture materials (absorbable vs. non-absorbable) on hernia recurrences. Methods A retrospective review was performed of consecutive transperitoneal laparoscopic subcutaneous ligations of a symptomatic hernia and/or communicating hydrocele by 4 surgeons. Patients > Tanner 2 or with prior hernia repair were excluded. The success of the procedure and number of sutures used was compared between cases performed with absorbable vs. non-absorbable suture. Risk factors for surgical failure (age, weight, number of sutures used, suture type) were assessed with logistic regression. Results 94 patients underwent laparoscopic percutaneous hernia ligation at a mean age of 4.9 years. Outcomes in 85 (90%) patients with 97 hernia repairs at a mean of 8 months after surgery revealed 26% polyglactin vs 4% polyester recurrences ( p = 0.004) which occurred at mean of 3.6 months after surgery, Table 1. Repairs performed with non-absorbable suture required only 1 suture more often than those performed with absorbable suture (76% vs 60%, p = 0.163). Logistic regression revealed suture type was an independent predictor for failure ( p = 0.017). Weight ( p = 0.249), age ( p = 0.055), and number of sutures ( p = 0.469) were not significantly associated with recurrent hernia. Discussion Our review of consecutive hernia repairs using the single port percutaneous ligation revealed a significantly higher recurrent hernia rate with absorbable (26%) versus non-absorbable (4%) suture. This finding remained significant in a logistic regression model irregardless of number of sutures placed, age, and weight. Though the authors acknowledge the drawback of the potential for learning curve to confound our data, we still feel these findings are clinically important as this analysis of outcomes has changed our surgical practice as now all providers involved perform this procedure with exclusively non-absorbable suture. We thus suggest that surgeons who perform this technique, especially those newly adopting it, use non-absorbable suture for optimal patient outcomes. Conclusions Recurrent hernia after laparoscopic percutaneous hernia ligation was significantly lower in repairs performed with non-absorbable suture. Based on this data, we recommend the use of non-absorbable suture during laparoscopic ligation of inguinal hernias in children. [ABSTRACT FROM AUTHOR]