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Objective: To compare the postoperative outcomes including the cosmetic results of robotic-assisted laparoscopic pyeloplasty (RALP) performed with and without assistant port in pediatric population. Methods: 47 patients with ureteropelvic junction obstruction consecutively underwent RALP were stratified as: three-port (Group 1, n = 26) and four-port (Group 2, n = 21). In Group 1, no assistant port was placed and double-J stent was introduced with the aid of an angiocatheter via the percutaneous route. In group 2, an assistant port was placed. The Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale(VSS), Satava, Clavien classification systems, and success rates were compared. Results: We found similar success rates for both groups (group 1:96.2%, group 2:100%). Two groups were similar in terms of improvement in the postoperative anteroposterior diameter of the renal pelvis and parenchymal thickness. There was no difference in terms of perioperative and postoperative complication rates (group 1:19.2%, group 2:9.5%). The total PSAS was significantly lower in Group 1 (p < 0.008). No difference was observed for VSS and OSAS. Conclusions: Using an assistant port does not improve the success or complications of RALP, while the cosmetic outcomes are inferior to three-port RALP in children. We suggest avoiding the use of assistant port during RALP in children.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered. ispartof: JOURNAL OF PEDIATRIC UROLOGY vol:17 issue:6 pages:815-831 ispartof: location:England status: published

BACKGROUND: Testicular tumors in prepubertal boys account for 1-2% of all solid pediatric tumors. They have a lower incidence, a different histologic distribution and are more often benign compared to testicular tumors in the adolescent and adult group. This fundamental difference should also lead to a different approach and treatment.OBJECTIVE: To provide a guideline for diagnosis and treatment options in prepubertal boys with a testicular mass.METHOD: A structured literature search and review for testicular tumors in prepubertal boys was performed. All English abstracts up to the end of 2019 were screened, and relevant papers were obtained to create the guideline.RESULTS: A painless scrotal mass is the most common clinical presentation. For evaluation, high resolution ultrasound has a detection rate of almost 100%, alpha-fetoprotein is a tumor marker, however, is age dependent. Human chorionic gonadotropin (HCG) was not a tumor marker for testis tumors in prepubertal boys.CONCLUSION: Based on a summary of the literature on prepubertal testis tumors, the 2021 EAU guidelines on Pediatric Urology recommend a partial orchiectomy as the primary approach in tumors with a favorable preoperative ultrasound diagnosis.

INTRODUCTION: Dorsal inlay graft urethroplasty (DIGU) has been described as an effective method for hypospadias repair with the proposed advantage of reducing the risk of complications. We aimed to systematically assess whether DIGU has any additional advantages over standard tubularized incised plate urethroplasty (TIPU) repair in children with primary hypospadias.MATERIALS AND METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The a priori protocol is available at the PROSPERO database (CRD42020168305). A literature search was conducted for relevant publications from 1946 until January 10, 2020 in seven different databases. Randomized controlled trials (RCTs), comparative studies (TIPU vs DIGU) and single arm case series (>20 cases) of DIGU were eligible for inclusion. Secondary hypospadias, two-stage repairs, disorders of sex development, significant curvature of >30°, and a mean or median follow-up of less than 12 months were excluded.DISCUSSION: A total of 499 articles were screened and 14 studies (3 RCTs, 5 non-randomized studies (NRSs), and 6 case series) with a total of 1753 children (distal: 1334 (76%) and proximal: 419 (24%)) were found eligible. Mean follow-up of the studies was between 16 and 77 months. DIGU was found superior to TIPU in decreasing meatal/neourethral stenosis (p = 0.02, 95% CI 0.02-0.78). All other parameters were found comparable including overall complications, fistula and glans dehiscence rates. Success rates were similar among the groups ranging between 48% and 96% for DIGU and 43-96% in the TIPU group. The lack of standardization in the definition of complications and success was the major limitation of this study.CONCLUSIONS: Using an inlay graft during primary hypospadias repair decreases the risk of meatal/neourethral stenosis. However, current evidence does not demonstrate superiority of DIGU over TIPU in terms of treatment success and overall complication rates.

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

BACKGROUND: In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia.AIMS: Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC).MATERIAL AND METHODS: After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update.RESULTS: The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment.DISCUSSION AND CONCLUSIONS: The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.

Pediatric urologists are dealing with urogenital anomalies on a daily basis, often involving also the gonads and sometimes being part of very rare or syndromal conditions. Besides performing urogenital reconstructive surgery we aim to provide children a holistic care until adulthood (at least): Aspects of sexuality and fertility therefore must play an integral role in pediatric urology.

Document Information Language:English Accession Number: WOS:000548718100005 PubMed ID: 31435732, Purpose The aim of this randomized controlled trial (RCT) is to compare the outcomes of conventional laparoscopic pyeloplasty (LP) versus robotic-assisted laparoscopic pyeloplasty (RALP) in the treatment of ureteropelvic junction obstruction (UPJO) in children. Methods A total of 53 patients with UPJO were randomized as LP (Group 1,n: 27) and RALP (Group 2,n: 26). Redo cases and patients with anatomical abnormalities were excluded. Urinary ultrasound was performed at postoperative 3, 6 and 12 months; whereas, diuretic renal scintigraphy was performed at 1 year. Failure was defined as progressive hydronephrosis on ultrasound, decline in renal function, or symptom relapse. All parameters were statistically compared. Results The mean age of the patients was 55.53 +/- 57.25 months. There were no statistical differences between the groups in terms of patient gender, body mass index, laterality, preoperative renal function, renal pelvis antero-posterior diameter and presence of crossing vessel. Mean total operative time in LP group was longer than RALP (139 min vs 105 min, respectively,p = 0.001). The hospital stay was similar between the two groups. After a mean follow-up of 12.43 +/- 5.34 months, the complication and success rates were found comparable. Only two patients required re-do pyeloplasty in LP group. The mean total cost of RALP procedure was approximately four times higher than LP. Conclusions This is the first RCT comparing LP and RALP in pediatric population. Both LP and RALP are safe and effective in children with comparable success and complication rates. Operative time was longer for LP; whereas, total cost was higher for RALP.

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

INTRODUCTION/BACKGROUND: Urinary tract infections (UTIs) are common in children and require appropriate diagnostic evaluation, management and follow-up. OBJECTIVE: To provide a summary of the updated European Association of Urology (EAU) guidelines on Pediatric Urology, which were first published in 2015 in European Urology. STUDY DESIGN: A structured literature review was performed of new publications between 2015 and 2020 for UTIs in children. The guideline was updated accordingly with relevant new literature. RESULTS: The occurrence of a UTI can be the first indication of anatomical abnormalities in the urinary tract, especially in patients with a febrile UTI. The basic diagnostic evaluation should include sufficient investigations to exclude urinary tract abnormalities, but should also be as minimally invasive as possible. In recent years, more risk factors have been identified to predict the presence of these anatomical anomalies, such as a non-E. Coli infection, high grade fever and ultrasound abnormalities. When these risk factors are factored into the diagnostic work-up, some invasive investigations can be omitted in a larger group of children. In addition to the treatment of active UTIs, it is also essential to prevent recurrent UTIs and consequent renal scarring. With the increase of antimicrobial resistance good antibiotic stewardship is needed. In addition, alternative preventative measures such as dietary supplements, bladder and bowel management and antibiotic prophylaxis could decrease the incidence of recurrent UTI. CONCLUSION: This paper is a summary of the updated 2021 EAU guidelines on Pediatric Urology. It provides practical considerations and flowcharts for the management and diagnostic evaluation of UTIs in children. ispartof: JOURNAL OF PEDIATRIC UROLOGY vol:17 issue:2 pages:200-207 ispartof: location:England status: published

Summary Introduction The COVID-19 pandemic has led to an unprecedented need to re-organise and re-align priorities for all surgical specialties. Despite the current declining numbers globally, the direct effects of the pandemic on institutional practices and on personal stress and coping mechanisms remains unknown. The aims of this study were to assess the effect of the pandemic on daily scheduling and work balances, its effects on stress, and to determine compliance with guidelines and to assess whether quarantining has led to other areas of increased productivity. Methods A trans-Atlantic convenience sample of paediatric urologists was created in which panellists (Zoom) discussed the direct effects of the COVID-19 pandemic on individual units, as well as creating a questionnaire using a mini-Delphi method to provide current semi-quantitative data regarding practice, and adherence levels to recently published risk stratification guidelines. They also filled out a Perceived Stress Scale (PSS) questionnaire to assess contemporary pandemic stress levels. Results There was an 86% response rate from paediatric urologists. The majority of respondents reported near complete disruption to planned operations (70%), and trainee education (70%). They were also worried about the effects of altered home-lives on productivity (≤90%), as well as a lack of personal protective equipment (57%). The baseline stress rate was measured at a very high level (PSS) during the pandemic. Adherence to recent operative guidelines for urgent cases was 100%. Conclusion This study represents a panel discussion of a number of practical implications for paediatric urologists, and is one of the few papers to assess more pragmatic effects and combines opinions from both sides of the Atlantic. The impact of the pandemic has been very significant for paediatric urologists and includes a decrease in the number of patients seen and operated on, decreased salary, increased self-reported stress levels, substantially increased telemedicine usage, increased free time for various activities, and good compliance with guidelines and hospital management decisions. Download : Download high-res image (368KB) Download : Download full-size image Summary Figure . Geographic heatmap demonstrating Transatlantic international discussion of the effects of the COVID-19 pandemic on paediatric urological practice.

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

BACKGROUND: Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor. MATERIAL & METHODS: After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS: In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option. CONCLUSION: In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early. ispartof: NEUROUROLOGY AND URODYNAMICS vol:39 issue:2 pages:498-506 ispartof: location:United States status: published

Re-do pyeloplasty after failed open or laparoscopic ureteropelvic junction (UPJ) obstruction correction can be a challenging procedure because of scar formation at the previous anastomosis site and decreased vascularity of the ureter. This study compared the perioperative parameters for pediatric robot-assisted laparoscopic (RAL) primary and re-do pyeloplasties with an emphasis on the intra-operative parameters.We compared the perioperative parameters of pediatric RAL procedures performed by a single surgeon at a tertiary care children's hospital for both primary ureteropelvic junction obstruction (UPJO) and recurrent UPJO after a previous open or laparoscopic procedure over 2013-2015. The operative time was subdivided as total operative time, console time, port placement time, dissection time to UPJ, and anastomosis time.A total of 65 pediatric RAL pyeloplasty procedures for UPJO were performed (55 primary and 10 re-do pyeloplasties) during the study period. The console times were 43.3% longer for re-do pyeloplasties than for primary pyeloplasties (133.0 ± 30.7 versus 92.8 ± 24.0 minutes, respectively, P .01). The re-do cases had longer operative times, especially for UPJ exposure (52.2 ± 21.0 versus 28.0 ± 14.0 minutes, P .01). There were no conversions to open surgery or significant perioperative complications. There was no difference in hospital pain medication usage and hospital length of stay between the 2 groups. The treatment success rates were 98.2% (54/55) and 100% (10/10), respectively.RAL re-do pyeloplasty is associated with significantly longer operative times as compared with primary pyeloplasties, especially during the exposure of the UPJ, but it is overall a safe and effective surgical modality for persistent/recurrent UPJO in children. As surgeons are increasingly asked for more accurate predictions of operative time lengths when scheduling cases, this information can be helpful for surgeons when scheduling these cases and with counseling families.

Summary Objective This study aimed to determine the effectiveness of intradetrusor injections of onabotulinum toxin-A (BoNT-A) in pediatric patients with neurogenic bladders (NB) due to myelomeningocele (MMC). The factors predicting success were also evaluated. Study design We retrospectively identified 62 patients with NB due to MMC who underwent intravesical BoNT-A injection (100–300 U) between May 2013 and December 2018. Indications for BoNT-A injection were according to the European Association of Urology guidelines and included children for whom clean intermittent catheterization (CIC) and anticholinergic therapy had failed. Children who had previous bladder surgery or anti-reflux operations, coagulation disorders, myasthenia gravis, and non-neurogenic bladders were excluded. Twenty-one patients had accompanying vesicoureteral reflux (VUR). Preoperative and postoperative urodynamic parameters, clinical success, and VUR grades for all patients were recorded. Clinical success was defined as 4 h of dryness or bladder control between CICs. Logistic regression analysis was performed to evaluate the factors affecting treatment success. Results The mean age of the children was 9 ± 3.36 years. The mean follow-up was 28.5 ± 12.2 months. Clinical success was achieved in 64.5% (n: 40) of the patients. The mean maximal cystometric capacity increased from 172.4 ± 45.6 mL to 236.3 ± 67.2 mL. The mean bladder compliance increased from 14.8 ± 8.1 mL/cm H2O to 19.3 ± 7.4 mL/cm H2O, and the mean maximal detrusor pressure decreased from 56.7 ± 18.8 cm H2O to 36.6 ± 10.1 cm H2O. Urodynamic parameters did not improve in patients with hypocompliant (fibrotic) bladders. In patients with accompanying VUR, reflux was completely resolved in 53.8% (n: 14) of the ureters, improved in 26.9% (n: 7) of the ureters, and remained unchanged in 19.2% (n: 5) of the ureters after subureteral injection. Conclusion Intradetrusor BoNT-A injections provide excellent outcomes in children with NB refractory to conservative treatments. Poor responses were observed in patients who had low-compliant bladders without detrusor overactivity.

Summary Background The benefits and harms of continuous antibiotic prophylaxis (CAP) versus observation in patients with antenatal hydronephrosis (ANH) are controversial. Objective The aim was to determine the effectiveness of CAP for ANH, and if beneficial to determine the best type and regimen of antibiotic and the most harmful to provide guidance for clinical practice. Methods A systematic literature search was performed in databases including Medline, Embase, and Cochrane in June 2015. The protocol was prospectively registered to PROSPERO (CRD42015024775). The search started from 1980, when maternal ultrasound was first introduced into clinical practice. Eligible studies were critically evaluated for risk of bias using Revman software. The outcomes included reduction in urinary tract infections (UTI), drug-related adverse events and kidney functions. Results Of 797 articles identified, 57 full text articles and six abstracts were eligible for inclusion (2 randomized controlled trials, 11 non-randomized comparative studies, and 50 case series). It remains unclear whether CAP is superior to observation in decreasing UTIs. No conclusion could be drawn for drug-related adverse events and kidney function because of lack of data. Children who were not circumcised, with ureteral dilatation, and high-grade hydronephrosis may be more likely to develop UTI, and CAP may be warranted for these subgroups of patients. A majority of the studies had low-to-moderate quality of evidence and with high risk of bias. Conclusions The benefits of CAP in a heterogeneous group of children with ANH involving different etiologies remains unproven. However, the evidence in the form of prospective and retrospective observational studies has shown that it reduces febrile UTI in particular subgroups.

Miniaturized instrumentation used for endoscopic treatment of urinary stone disease in children has been readily adopted in clinical practice. However, there is a need to optimize and individualize the surgical approach according to the patient's age, body habitus, and stone characteristics. Promising novel equipment and techniques will continue to advance the surgical care of these children.To review the literature regarding surgical and shockwave lithotripsy (SWL) treatment of urinary stone disease in children and provide an overview on future treatment innovations.We conducted a nonsystematic review of the literature using the PubMed database. The search focused on the most recent two decades to provide a contemporary overview of surgical outcomes.Although SWL use has proportionally decreased over time, it remains an important treatment option for kidney stones2cm and upper ureteral calculi, with success rates between 49% and 97%. Rigid/semirigid ureteroscopy is the first-line therapy for distal ureteral stones and has success rates comparable to SWL for upper ureteral stones. Success rates between 80% and 100% are achieved with retrograde intrarenal surgery (RIRS) for kidney stones2cm but may require pre-stenting in smaller children. Mini percutaneous nephrolithotomy (PNL) is the most efficient technique for treating kidney stones in children. Micro-PNL and ultramini-PNL are valuable alternatives, especially for smaller renal stones.Modern endoscopic treatment options together with SWL allow personalized management of stone disease in the pediatric population. Future technical improvements on the horizon offer the promise of increasing the efficiency of current procedures while minimizing complications.Miniaturization of the instruments used for treatment of stone disease in children provides a variety of options for clinical practice. Rather than routinely using a single technique, personalized treatment is recommended to increase the success of each procedure.

Item does not contain fulltext Trainee-led collaboratives offer exciting new perspectives and approaches to urological research. They provide a central network of expertise in methodology, mentoring, and knowledge of research processes that allows the conduct of large multicentre studies that can recruit quickly. This provides the consultant workforce of tomorrow with the skills required to deliver practice-changing clinical studies in urology.

WOS: 000462681000013, PubMed ID: 30900625, Objective: We investigate the protective and therapeutic effects of ozone therapy (OT) in radiotherapy (RT)-induced testicular damage. Methods: Thirty healthy adult male Wistar rats divided into five groups consisting of six animals each as follows: (1) Control (C), (2) RT, (3) OT, (4) OT + RT, and (5) RT + OT group. Histopathological findings, Johnsen scores, thiobarbituric acid-reactive substances (TBARS), glutathione (GSH), superoxide dismutase (SOD), catalase, and glutathione peroxidase (GPx) levels were evaluated. Results: RT caused a significant decrease in testicular weight and Johnsen score compared to the control group. In addition, TBARS level was significantly higher, whereas GSH, SOD, catalase, and GPx levels were significantly lower in the RT group when compared to the control group. Pre and postRT OT significantly increased GSH, SOD, catalase, and GPx levels and decreased TBARS level. Furthermore, testicular weight and Johnsen score were increased with OT. Conclusions: The present study showed that OT is protective and therapeutic in radiation-induced testicular damage. OT may be beneficial to the patients who underwent RT.

Aims: The Paediatric Urology Guidelines Panel reports initial experience with patient involvement in spina bifida patient groups to gather information on their awareness of the guidelines and reflection of guideline recommendations. Methods: The survey was delivered to spina bifida patients/parents via the national society groups in Turkey, Germany, and The Netherlands. Questions included demographic features, medical status, awareness, and agreement on the recommendations given in the guidelines and future expectations. Results: A total of 291 patients from 3 countries responded to the survey. Mean age was 13.9 ± 12.2 years, male/female ratio 138/151, 75% of all surveys were completed by the caregivers. The medication was taken by 78% of patients (64% anticholinergics). Complete dryness rates for urine and stool were 24% and 47%, respectively. The agreement rates on the recommendations regarding urodynamics, intermittent catheterization, anticholinergics drug use, bowel management, and life‐long follow‐up were 97%, 82%, 91%, 77%, and 98%, respectively. Only 8% of responders were aware of the European Association of Urology/ European Society for Pediatric Urology guidelines. The priorities of patients for future expectations were as the following: quality of life (QoL), surgical techniques, development of new medications and sexuality/fertility issues. Male spina bifida patients preferred new medications and sex/fertility issues more, whereas females favored QoL issues improvement more. Conclusions: Although the native language of the involved patients was different from English, awareness of guidelines was 8%. The general approval of the recommendations given in the guidelines is quite high. The national society groups showed a great interest to get involved in the creation of the guidelines to improve health care for spina bifida patients.

CONTEXT: The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. OBJECTIVE: To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents. EVIDENCE ACQUISITION: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion. EVIDENCE SYNTHESIS: Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates. CONCLUSIONS: Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown. PATIENT SUMMARY: In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear. ispartof: EUROPEAN UROLOGY vol:75 issue:3 pages:448-461 ispartof: location:Switzerland status: published

Summary Introduction Re-ascended testes account for a proportion of all undescended testes (UDTs); one main hypothesis relating to their etiology relates to a patent processus vaginalis peritonei. The aim was to investigate gubernacular insertion points in boys with late ascended testis as a possible guide to an alternative embryological etiology. Patients and methods Patients with proven ascended testes were recruited from four different pediatric urology centers between May 2016 and September 2017. All patients were evaluated regarding their gubernacular insertion during orchidopexy. The presence of accompanying patent processus vaginalis and the association between the epididymis and testis were also documented. Results Seventy-seven children (mean age = 73.1 ± 41.2 months [range 18–176]) were enrolled into the study. A non-orthotopic gubernacular insertion point was found in 96.1% (n = 74); 34.2% (n = 26) of these were located in the groin and 63.2% (n = 48), high within the scrotum. Figure A. An open processus vaginalis peritonei was found in 35.1%. Twelve patients (15.6%) had small, dysplastic appearing testis with testis–epididymis dissociation. Boys with a higher insertion of the non-orthotopic gubernaculum (n = 48, groin) were operated earlier (mean age at surgery, 62.3 months) compared with those with a gubernacular insertion at a high scrotal site (mean age at surgery, 90.5 months; p = 0.004). Figure B. Discussion This study revealed that non-orthotopic gubernacular insertion is found in the vast majority of the ascending testis cases. Patent processus vaginalis was accompanying only 35.1% of all children and might be the cause of the ascending testis in this small subgroup of patients in line with the earlier reports [1]. In boys with ascending testes, in this population, the gubernaculum was very likely to insert non-orthotopically. In concordance with previous reports [2] and regarding the finding of a an earlier age at surgery in boys with higher inserting gubernacula, this could provide a logical explanation as to how these testes are initially palpable in the scrotum and then, during body growth are retracted to the groin. Conclusion In 96.1% of the patients, a non-orthotopic gubernacular insertion was found. This points to embryologic etiology, complying well with earlier reports and further underlining the critical importance of timely diagnosis and treatment for this group of patients. Download : Download high-res image (112KB) Download : Download full-size image Summary Fig. 1 . (A) Sites of gubernacular insertion in 77 patients with acquired undescended testis. (B) A dot-plot showing the geometric mean with 95% confidence interval of age in months at the time of surgery comparing boys with a high scrotal gubernacular insertion with those with a gubernacular insertion site in the groin.

Our objective was to elucidate the discussion points of circumcision on social media (SoMe) by looking at the Twitter activity. Twitter searched for #circumcision hashtag via www.tweetarchivist.com , www.twitonomy.com , www.symplur.com . Total tweet numbers, most influencers, top users were documented. Tweets including female circumcision were excluded. The contents of the tweets were classified into four subgroups (medical, religious, social, and political) by two independent reviewers. All kinds of tweet activities were statistically analyzed. A total of 9795 users generated 15,989 tweets about circumcision in a 1 month period. Mean daily tweet activity was 532 for #circumcision. The content analysis revealed that 2224 (15.8%) medical, 1133 (8.0%) religious, 323 (2.2%) social and 10,470 (74.0%) political tweets have been sent out by the users. Contributors originated from 174 countries from 6 continents. Media organizations were accounted for 52% of the top 25 influencers in circumcision hashtag. The most common hashtags accompanying #circumcision were #HIV (4.9%), #babiesgotherpes (3.3%), #muslim (1.8%), #malegenitalmutilation (1.6%) respectively. There is an increasing discussion about circumcision through SoMe . Our results provided that the discussion points are mostly driven by the media and the activists. The political tweets have been found to be the center of the discussion. SoMe usage should be increased by medical professionals for true information of the public.

Summary Introduction Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8 mm instruments for these patients instead of the 5 mm instruments is common because of the shorter wrist lengths. Objective We hypothesized that the use of 5 mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces. Study design We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5 mm camera and 5 mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups. Results A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p > 0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p = 0.08). Discussion We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5 mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided. Conclusions RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5 mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.

Objective The objective of this study is to identify the variables that affect young urologists’ productivity and academic career choice. Patients and Methods We have conducted an internet-based national survey for urologists randomly sampled from the database of Turkish Urological Association and 110 physicians completed this survey. Participants were asked to answer three-page questionnaire including 37 questions, which takes around 5 min to complete. Questionnaire was consisting of four main sections: ‘demography’, ‘education’, ‘working conditions’ and ‘quality of life’. Results Increased dedicated research time, being interested in an academic career, being Fellow of the European Board of Urology (FEBU), having English proficiency, and greater numbers of manuscript publication during residency were associated with increased productivity after residency (p = 0.001, p = 0.028, p = 0.046, pConclusions Our data indicate that increased time spent for research, being interested in an academic career, being an FEBU, having English proficiency, and greater publication during residency were associated with increased numbers of publications and academic career choice.

Relapse after cessation of desmopressin is an important problem in treating patients with enuresis. Structured withdrawal of desmopressin tablets has been shown to decrease relapse rates. However, scientific data are lacking on the structured withdrawal of the fast melting oral formulation of desmopressin. We compared relapse rates of structured withdrawal using placebo and direct cessation in a population of patients with enuresis who were desmopressin responders.Patients diagnosed with enuresis and responding to desmopressin from 13 different centers were involved in the study. Patients were randomized into 4 groups. Two different structured withdrawal strategies were compared to placebo and direct withdrawal. Sample size was estimated as 240 (60 patients in each group), with a power of 0.80 and an effect size of 30%. Randomization was performed using NCSS statistical software (NCSS, Kaysville, Utah) from a single center. The relapse rates of the groups were compared using chi-square testing. Logistic regression analysis was performed to define the independent factors having an effect on relapse rates.Desmopressin treatment was initiated in 421 patients, and 259 patients were eligible for randomization. Relapse rates were 39 (1%) and 42 (4%) for the structured withdrawal groups, which were significantly less than for direct withdrawal (55, 3%) and placebo (53, 1%). Logistic regression analysis revealed that initial effective dose of 240 μcg, greater number of wet nights before treatment and nonstructured withdrawal were associated with higher relapse rates.We found that structured withdrawal with the fast melting oral formulation of desmopressin results in decreased relapse rates. Application of a structured withdrawal program was also an independent factor associated with reduced relapse rates, together with lower initial effective dose and number of wet nights per week. Relapse after cessation of desmopressin is an important problem, and in this study structured withdrawal was observed to be associated with decreased relapse rates compared to placebo and direct withdrawal.

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

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

Objective To investigate whether the child's and the parents' reports about lower urinary tract symptoms (LUTS) are reliable and correlate with each other. Materials and Methods A validated questionnaire, the International Consultation on Incontinence Questionnaire Pediatric Lower Urinary Tract Symptoms, including both children and parent versions, was completed by children (age 5-18 years) with and without LUTS (control) and their parents without assistance. All children were investigated with detailed history, bladder diary, urinalysis, and flowmetry with postvoid residual urine volume measurement. The data were stratified into 3 age groups (5-9, 10-13, and 14-18 years). The reliability of both versions was evaluated using Cronbach's α and ≥0.7 indicated acceptability. The correlation between the children's and parents' reports for each question was evaluated using Spearman correlation coefficients. The receiver operating characteristic curve was used to define the cutoff points, and the sensitivity and specificity were calculated. The principal component analysis method was used to explain the construct validity. Results A total of 272 children (147 with and 125 without LUTS) and their parents completed the questionnaire. The children and parent versions of the questionnaire were both reliable (Cronbach's α 0.709 and 0.710, respectively). The sensitivity and specificity was 82.4% and 80.0% for the children version and 87.8% and 78.4% for the parent version, respectively. The reliability and acceptability of the children's reports were insufficient for the 5-9 year age group, and the parents' answers were unreliable for the 10-13 year age group. The correlation between the parent and children reports was the lowest for the 10-13 year age group. Conclusion The alteration in the reliability in the different age groups suggests that the combination of the parent and children versions is most appropriate for screening children with LUTS.

Background/Purpose To report the first technical feasibility and safety of microperc in the treatment of pediatric nephrolithiasis. Methods A multicenter prospective trial was initiated and microperc was performed in 19 children from four different centers. In all cases, 4.85-Fr all-seeing needle was used to access the collecting system under direct vision. Stone fragmentation was performed using a 200-μm holmium: YAG laser fiber either through the same needle sheath or an 8-Fr microsheath. Patient- and procedure-related factors and perioperative and postoperative parameters were analyzed. Results The mean age of the children was 7.5±4.4years. Mean stone size was 14.8±6.8mm. Conversion to Mini-PNL was required in two patients because of optical default in one and the high stone burden in the other. The mean hospital stay was 1.8±0.8days and the mean hemoglobin decrease was 0.1mg/dl. The overall stone-free rate at 1month was 89.5%. In one patient with obstructed ureteropelvic junction, intravasation of the irrigation fluid has led to abdominal distention and managed with percutaneous drainage intraoperatively. No other postoperative complication was recorded and no ancillary procedure was required. Conclusions Microperc is a safe and effective procedure in the treatment of pediatric kidney stones.

The aim of this study was to elucidate whether circumcision during the phallic period (3-to 6-year old) has a negative impact on psychosexual functions in adulthood. Over a 6-month period, healthy and sexually active men between 30 and 40years without any comorbidities were involved. Participants were evaluated with detailed history, physical examination, International Index of Erectile Function (IIEF), Premature Ejaculation Diagnostic Tool (PEDT) and Beck Depression Inventory. Cases were divided into two groups according to the age at circumcision (group-1: phallic period, group-2: nonphallic period). Student-s t-test and Kruskall-Wallis were used for statistical analysis. Of the 321 participants, a total of 302 men were eligible for the study (group-1: n=135, group-2: n=167). No statistical difference was found between the mean total IIEF scores (group-1: 25.1 +/- 4.8, group-2: 25.4 +/- 4.6, P>0.05). The subdomains of IIEF; erectile function, orgasm, sexual desire, intercourse satisfaction, overall satisfaction were also found to be comparable. Additionally, the PEDT scores were similar between the two groups (group-1: 8.2 +/- 4.8, group-2: 8.7 +/- 5.4, P>0.05). Finally, Beck depression scores were also found to be comparable between the groups (group-1: 10.8 +/- 10.4, group-2: 9.8 +/- 8.9, P>0.05). Our results suggest that circumcision during the phallic period does not negatively affect the psychosexual functions in adulthood.

WOS:000315179600010 PubMed: 23313374 Urofacial syndrome (UFS) (or Ochoa syndrome) is an autosomal-recessive disease characterized by congenital urinary bladder dysfunction, associated with a significant risk of kidney failure, and an abnormal facial expression upon smiling, laughing, and crying. We report that a subset of UFS-affected individuals have biallelic mutations in LRIG2, encoding leucine-rich repeats and immunoglobulin-like domains 2, a protein implicated in neural cell signaling and tumorigenesis. Importantly, we have demonstrated that rare variants in LRIG2 might be relevant to nonsyndromic bladder disease. We have previously shown that UFS is also caused by mutations in HPSE2, encoding heparanase-2. LRIG2 and heparanase-2 were immunodetected in nerve fascicles growing between muscle bundles within the human fetal bladder, directly implicating both molecules in neural development in the lower urinary tract.

We present our initial experience with microperc in patients with moderate-size renal calculi.A retrospective analysis of 30 patients (male 14, female 16) with moderate-size (1-3 cm) kidney stones who underwent microperc between August 2011 and July 2012 was performed. The demographic values, perioperative and postoperative measures including age, stone size and location, body mass index, operative and fluoroscopy time, hemoglobin decrease, success and complication rates were prospectively recorded into a patient entry system.The average stone size was 17.9±5.0 mm (10-30 mm). The mean age of the patients was 41.5±18.2 years (range 3-69 years). The duration of the operation was calculated as 63.5±36.8 minutes (range 20-200 min). Mean fluoroscopic screening time was 150.5±90.4 seconds (range 45-360 seconds). The patients were discharged after a mean hospitalization period of 35.5±18.6 hours (range 14-96 hours). An overall success rate of 93% (including 10% of insignificant residual fragment rate) was achieved. In the follow-up, residual stone fragments were detected in two (7%) patients. Conversion to miniperc was necessitated in three (10%) patients. The mean hemoglobin drop was found to be 1.1±0.8 mg/dL (range 0-2.8 mg/dL). Complications were observed in five (13.3%) patients.Our initial results provide that microperc is a feasible, safe, and efficacious treatment modality for moderate-size kidney stones as well as small ones with its minimally invasive nature. Technical refinements are needed to achieve better results and overcome the limitations of technique.

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

The treatment of symptomatic lower pole (LP) calculi poses a challenge because of lower clearance rates. We present our experience with microperc in the treatment of LP renal calculi.We retrospectively evaluated the symptomatic patients with LP renal calculi who underwent microperc between August 2011 and June 2012 from two referral hospitals. Patients were included only in cases of failure after shockwave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS) and according to patient preference. The percutaneous renal access was performed using the 4.8F "all-seeing needle" with C-arm fluoroscopy or ultrasonographic guidance with the patient in the prone position. Stone disintegration was established using a 200 μm holmium:yttrium-aluminum-garnet laser fiber.A total of 21 patients (mean age 37.3 ± 20.1 years) with LP stone underwent microperc. The mean body mass index was 28.6 ± 6.0 kg/m(2), and the mean stone size was 17.8 ± 5.9 (9-29) mm. The duration of surgery and fluoroscopic screening was 62.8 ± 25.2 minutes and 150.5 ± 92.8 seconds, respectively. The patients were discharged after a mean 37.5 ± 14.4 hours of hospitalization time. The mean hemoglobin drop was 0.8 ± 0.6 (0.1-2.3) g/dL. Conversion to miniperc was necessitated in one patient with loss of vision. Stone-free status was achieved in 18 (85.7%) patients. Clinically insignificant residual fragments were observed in only one (4.8%). The procedure failed in two (9.5%) patients. A total of two minor complications (renal colic necessitating stent insertion and urinary tract infection) were observed postoperatively, none severe.Microperc is a feasible and efficient treatment modality for symptomatic LP calculi. Our results provide that microperc might take a part in case of SWL and RIRS failures or as an alternative to percutaneous nephrolithotomy or RIRS in the management of symptomatic LP calculi.

Objective: To evaluate whether renal parenchymal thickness (RPT) has an effect on the outcomes of percutaneous nephrolithotomy (PNL). Methods: We performed a retrospective analysis of 144 patients with lower pole and/or renal pelvic stones who underwent PNL. The relationship between RPT and peri- and postoperative measures was evaluated. Results: The average age was 45.94 ± 14.47 (15-76) years. The mean BMI was calculated as 27.47 ± 4.73 (16.9-44.9) kg/m2. The mean stone burden was 293 ± 126 (150-800 mm2). The mean RPT was measured as 17.33 ± 5.32 (6-35) mm. No correlation was detected between the RPT and the operation or fluoroscopy times or the duration of hospitalization (p = 0.63, 0.52, 0.08, respectively). The mean drop in hemoglobin level was 1.45 ± 1.25 (0-9) g/dl. A negative correlation was detected between hemoglobin drop and RPT (p = 0.01, r = -0.23). However, the RPT was similar in patients who did or did not require a blood transfusion (p = 0.09). The RPT was found to have no impact on success rate (p = 0.4). Conclusion: The postoperative hemoglobin drop increases in parallel with the increase in RPT. However, no relationship was detected between the RPT and blood transfusion, overall success rate or any other perioperative parameters.

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).The perioperative data of 783 pediatric patients (18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Objective: There are 2 critical steps of stent placement during laparoscopic pyeloplasty (LP) in children. Introduction to the ureteropelvic junction and passing through the ureterovesical junction. We aimed at overcoming those 2 steps by creating a modified technique. Methods: Consecutive 27 children undergoing transperitoneal laparoscopic dismembered pyeloplasty by a single surgeon were prospectively enrolled into this study. The modifications of our technique are using an Amplatz dilator and a closed tip stent. Results: The mean age of the children was 6.7 (range 4 months-17 years). The mean time of stent insertion was 2.7 ± 2.0 (2-6) min and the operative time was 128.3 ± 17.6 (90-180) min. The mean number of days of hospital stay was 2.0 ± 0.4 (1-3). After a mean follow-up period of 20.3 ± 4.2 (14-30) months, no operative failure was detected. Conclusion: Our modified technique is a completion of the current armamentarium for stent placement during LP in infants and children.

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair.A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results.At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable.No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

To compare the results of two different ureteroscopes in pediatric ureteroscopy (URS) procedures. Sixty-five consecutive URS procedures in pediatric population (39 males, 26 females) were retrospectively evaluated. The subjects were divided in two groups according to the type of ureteroscope used: Group 1 (n = 32, Wolf 8F) and group 2 (n = 33, ACMI 6.9F). All the procedures performed in both groups were statistically compared regarding patient age, gender, lateralization, complication rates, whether the procedure was diagnostic or therapeutic, and whether a guide-wire was used. Additionally, in cases with ureteral stones, stone clearance rate and the necessity of a stone extractor were also compared between the groups. All data were statistically analyzed using chi-square and t tests, where appropriate. A p value less than 0.05 was considered as significant. Mean age of the groups were comparable (9.44 ± 4.3 and 8.67 ± 3.9, p = 0.456). There was no statistically meaningful difference between the groups regarding patients’ gender, lateralization rates, whether the procedure was diagnostic or therapeutic, the need for a guide-wire use, and complication rates (p > 0.05). In cases with ureteral stones, both groups exhibited statistically comparable results in stone clearance rates and the use of a stone extractor (p > 0.05). Data on this comparison demonstrated that both ureteroscopy devices in pediatric population can be used safely in URS procedures. Neither the diameter nor the rigidity is significantly affecting the outcomes and success rates ≤8F caliber.

Summary Introduction Various intravesical and extravesical techniques have been described for the surgical correction of vesicoureteral reflux (VUR). Among those techniques Cohen (intra-vesical) and Lich-Gregoir (extra-vesical) are the most commonly used ones. However, there are limited studies that compare those two surgical techniques in the literature. Objective In this study, we aim to compare the outcomes of the open intravesical and extravesical procedures for unilateral primary VUR in children. Methods We analyzed the records of 118 consecutive children with primary VUR who underwent open ureteral reimplantation surgery by single surgeon from January 2011 to October 2015 at our institution. Among them, intravesical reimplantation was group A, and extravesical reimplantation procedure was group B. We retrospectively analyzed the clinical data of both groups, including age, sex, preoperative reflux grade, presence of lower urinary tract symptoms (LUTS), operative time, postoperative complications and hospitalization period. Success of surgery was defined as the resolution of the VUR as determined by voiding cystourethrography 6 -12 months after surgery. All the parameters were statistically compared. Results A total of 58 patients were found eligible for the study. In 23 cases intravesical (group A) and in 35 cases extravesical (group B) procedure were performed. The operative time in group A was significantly higher than group B (110.3±16.9 and 87±29.8 min, respectively, p = 0.002). The mean hospital stay was also longer in group A (2.8±0.8 and 1.2±0.6 days, respectively, p = 0.007). The ureteral catheterization periods were 14.1±6.1 days for group A and there was no ureteral catheter placement in group B. The success rate of the two groups were comparable (100% vs 94.9%, p = 0.513). No intraoperative complications were detected in either group. The number of febrile urinary tract infections were similar between the groups after a mean follow up of 18.2 months (p = 0.746). Discussion Our results confirmed that both Cohen and Lich-Gregoir procedures had equivalent success and complication rates. Lich-Gregoir technique was found superior to Cohen technique in terms of hospital stay and operative time. Moreover, it avoids the necessity of urethral and ureteral stenting which probably might increase the comfort of the patients postoperatively. The main limitations of our study are unrecorded pain scores and amount of analgesics taken the after surgery and retrospective analysis of the data. Conclusion Both the open intravesical and extravesical ureteroneocystostomy procedures are equally effective in the treatment of primary unilateral VUR. Any of the techniques can be opted by the surgeons depending on their surgical experience. Table . Patient demographics. Cohen (n = 23) Lich–Gregoir (n = 35) p Age (years) (Mean + SD) (range) 4.6 ± 1.6 (1–7) 7.6 ± 4.2 (3–17) 0.002 M/F ratio 17/6 2/33 Prior endoscopic injection (n) 13/23 19/35 0.866 Reflux grade 3.4 ± 0.6 (3–5) 3.9 ± 0.5 (3–5) 0.870 Split kidney function (%) 41.5 ± 10.8 (32–49) 34.5 ± 10.1 (28–45) 0.242 Anticholinergic usage (%) 6 (26.1%) 16 (45.7%) 0.132

Due to the poor prognosis of advanced bladder carcinoma and the insufficient affects of the chemotherapy agents for this disease, the investigation of the novel genetic and pharmacologic agents including anti-angiogenic agents that can target pathway-specific molecules has been the subject of several publications especially for the last 2 years. Although the clinical trials of these agents are still lacking, the experimental and the preliminary studies are giving hope for the future treatment of advanced bladder carcinoma. Sunitinib malate and sorafenib are the novel food and drug administration (FDA) approved anti-angiogenic agents, which have recently been demonstrated to improve the progression-free survival in patients with metastatic renal cell carcinoma. The main mechanism of these two drugs are defined as preventing the tumor growth by the inhibition of angiogenesis and the induction of apoptosis and necrosis via acting on different types of vascular endothelial growth factor (VEGF) such as the several agents which have been demonstrated to be beneficial for bladder carcinoma. According to this knowledge we suggest that these two new agents may also increase the progression-free survival of the patients with advanced bladder carcinoma due to their anti-angiogenic and tumor cell apoptotic effects. We believe that the evaluation of the effects of these agents on bladder cancer population by clinical, prospective and placebo controlled studies may prove our hypothesis and add critical findings to the literature which is still lacking.

To compare outcomes of micro-percutaneous nephrolithotomy (PNL; microperc) with mini-PNL (miniperc) in the treatment of pediatric renal stones of sizes 10-20 mm.Patients aged18 years who underwent PNL for renal stones of sizes 10-20 mm between August 2011 and March 2014 in 3 referral centers were reviewed retrospectively. Patients were evaluated in the following 2 groups: microperc (group 1) and miniperc (group 2). Demographics and perioperative parameters (fluoroscopy and operation time, hemoglobin drop, and stone-free and complication rates) were retrospectively analyzed.A total of 119 patients were evaluated, including group 1 (n = 56) for microperc and group 2 (n = 63) for miniperc. We found mean stone sizes as 13.4 ± 3.4 and 14.8 ± 3.7 mm in the groups, respectively (P = .046). Mean operation and fluoroscopy times were 57.1 ± 31.2 minutes and 132.4 ± 92.5 seconds in the microperc group and 68.9 ± 36.7 minutes and 226.2 ± 166.2 seconds in the miniperc group, respectively (P = .110 and P.001). Stone-free rates were similar in both groups (82.1% vs 87.3%; P = .433 and 92.8% vs 93.6%; P = 0673) on postoperative day 1 and at first-month follow-up. The mean hemoglobin drop in group 2 differed from that in group 1 significantly (P.001). The difference of average hospitalization times was statistically significant (43.0 ± 15.4 vs 68.5 ± 31.7 hours; P.001).Our outcomes show that microperc may be preferred as an alternative to mini-PNL for the treatment of pediatric kidney stones of sizes 10-20 mm with comparable success and complication rates, as well as shorter hospitalization and fluoroscopy times.

Extravesical robotic-assisted laparoscopic ureteral reimplantation in children is a challenging procedure. Our top-down suturing technique facilitates this reconstructive surgery. After mobilization of the ureter without the use of ureteral stent placement, the detrusor muscle is divided. Once adequate muscle flaps are raised, the ureter is placed into its new muscle tunnel. Unlike previously described techniques, the top-down suturing approach involves placement of the first detrusor stitch at the superior aspect. This allows the ureter to be elevated out of harm's way and in a tension-free manner. The rest of the detrusor reapproximation is performed in a top-down approach with interrupted sutures without the need for ureteral elevation or manipulation. This technique facilitates the suturing process and decreases trauma to the ureter with less instrument contact. This helps to prevent potential complications and improve success rates associated with this procedure.

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

WOS: 000326970200011 PubMed ID: 23560687 Purpose: To investigate the feasibility of the all-seeing needle for safe entry and creation of pneumoperitoneum in pediatric urologic laparoscopy. Patients and Methods: A total of 14 children underwent various transperitoneal urologic laparoscopic procedures. The all-seeing needle, which is 4.85F in diameter, was used for safe entry into the abdominal cavity at the site of the umblicus in all cases. The microoptic was integrated with the light system and connected via a zoom ocular enabling direct visualization of the layers between the skin and the peritoneal cavity. Once the intraperitoneal access was obtained, CO2 pneumoperitoneum was created from one port of the three-way connector attached to the proximal part of the needle. Then the laparoscopic trocars were placed under vision of the microoptical system. Results: Mean age of the children was 4.52.9 years. In all children, the all-seeing needle was safely introduced into the abdominal cavity under direct vision. Then, CO2 pneumoperitoneum was succesfully performed. The mean time for optical puncture was calculated as 1.1 +/- 0.8 minutes. No complication was encountered during the introduction of the needle, creation of the pneumoperitoneum, and placement of the trocars. Conclusions: The all-seeing needle appears to be beneficial in safe entry and for creating pneumoperitoneum in laparoscopic pediatric urology cases. It eliminates the disadvantages of the Veress needle, which is blunt insertion, and may possibly prevent complications.

Purpose: We aimed to compare the outcomes of microperc and shockwave lithotripsy (SWL) for treatment of kidney stones in children. Patients and Methods: The medical records of 145 patients under the age of 15 years with opaque and single kidney stones treated with either SWL or microperc were retrospectively reviewed. Both groups were compared in terms of fluoroscopy and operative time, re-treatment, complications, success rate, and secondary and total number of procedures. Results: Microperc and SWL were performed on 37 and 108 pediatric patients, respectively. The mean age of the patients was 5.914.03 years (1-15) and 8.43 +/- 4.84 (1-15) years in the SWL and microperc groups, respectively (P=0.004). The mean stone size was 11.32 +/- 2.84 (5-20) mm in the SWL group and 14.78 +/- 5.39 (6-32) mm in the microperc group (P