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Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Summary Introduction Non-refluxing ureteral reimplantation is favored in pediatric renal transplantation to prevent complications, such as vesicoureteral reflux (VUR) in the transplant ureter. VUR resulting in febrile urinary tract infections remains a problem in this population, leading to repeated hospitalizations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR. Objective The authors reviewed their experience of the management of VUR in the transplant ureter, comparing outcomes of various modalities. Study design With Institutional Review Board approval, a retrospective chart review of all renal transplant patients from January 2002 to January 2017 was conducted. All patients with VUR on voiding cystourethrogram (VCUG) after surgery were identified. Indications for end-stage renal disease, urologic comorbidities, pretransplant VCUG, and operative details were recorded. After transplantation, febrile urinary tract infections, ultrasound findings, and any further interventions—surveillance, subureteral endoscopic injection of Deflux, or ureteral reimplantation—were documented along with their outcomes. Results Overall, VUR was identified in 35/285 (12.3%) transplant patients after a non-refluxing ureteroneocystostomy. VUR was managed with surveillance in 17/35 (49%), intravesical Deflux injection in 11/35 (31%), and immediate redo ureteral reimplantation in 7/35 (20%). Ten out of 11 patients undergoing Deflux injection had a postoperative VCUG. All patients developed VUR recurrence; the majority showed immediate failure and only 1/10 showed late recurrence. Of the immediate failures, 3/9 patients were maintained on prophylactic antibiotics, and 6/9 patients underwent ureteral reimplantation. In these six patients undergoing reimplantation after failed Deflux, 3/6 (50%) patients required additional surgeries: One patient developed recurrence of reflux and two patients developed ureterovesical junction obstruction. In contrast, no complications were seen in patients undergoing primary ureteral reimplantation. Discussion The study is limited by low numbers and a retrospective design. However, the results of this study differ significantly from the published Deflux series showing a success rate of more than 50% in the treatment of transplant kidney VUR. In fact, post-Deflux redo ureteral reimplantation was associated with an increased risk of postoperative complication. Conclusion The use of Deflux in the post-transplant setting has poor results. In the study series, 11/11 patients demonstrated clinical and radiographic failure. Therefore, as an institution the authors do not recommend Deflux as first-line treatment of VUR in the transplant patient. Download : Download high-res image (298KB) Download : Download full-size image Extended Summary Figure . Treatment flowchart for transplant kidney vesicoureteral reflux (VUR).

Posterior urethral valves (PUV) are the most common cause of lower urinary tract obstruction in male infants. Due to improved technique and availability of prenatal imaging, diagnosis is typically suspected prenatally and confirmed postnatally. Prenatal intervention is performed in select centers with vesicoamniotic shunting or with fetal cystoscopy and antegrade ablation of the PUV when detected. Prenatal intervention has been associated with an improvement in neonatal survival; however, evidence that renal function is indeed improved remains scant. The mainstay of treatment remains early diagnosis with early establishment of drainage and subsequent management of bladder dysfunction with behavioral therapy, medication, clean intermittent catheterization, and occasionally with bladder augmentation. Other measures such as nephrectomy can be implemented to manage polyuria. Ultimately, 30 % of patients born with PUV develop end-stage renal disease and require renal transplantation.

Introduction A great need currently exists for medical devices designed specifically for children. This gap is most likely a result of economic, clinical and regulatory challenges as well as a lack of established mechanisms for joining pediatric device ideas with qualified individuals/programs and industry partners. We describe our experience with forming a pediatric medical device consortium that originated from the pediatric urology division and the technology transfer office of a university affiliated children’s hospital. Methods We reviewed the developmental history of a pediatric medical device consortium at a university affiliated children’s hospital from March 2011 to June 2013 with emphasis on the organizational aspects of the consortium. Results A pediatric medical device consortium was formed with the assistance of university seed funding to encourage faculty collaboration across multiple campuses. The consortium continued its progress as a resource for pediatric device projects to become a Food and Drug Administration supported pediatric device consortium in 2013. This allows the consortium to expand its activities through the P50 PDC Grant Program. Conclusions Pediatric urologists can have a major role in organizing pediatric device consortia. Consortia can combine academic centers with the local business, investment, higher education and philanthropic communities to rapidly advance pediatric medical device projects. Novel approaches are necessary for pediatric device projects to overcome current barriers to commercialization, including an extended stay in the academic setting.

The da Vinci robot is being used for an increasing variety of reconstructive procedures. Robotic-assisted laparoscopic ureteral reconstruction is now performed routinely, and has been shown to have similar efficacy and safety profiles to open surgery in various studies. In this article, we focus on use of the robot to aid in distal ureteral reconstruction in the adult and pediatric population. Indications reviewed will include benign and malignant conditions. The appropriate pre-operative evaluation, the set-up of the operating room and patient positioning, the described techniques for ureteral reimplantation, and the appropriate post-operative care and follow-up will all be discussed. Literature for the past 10 years has been reviewed, and emphasis given to most recent publications and those describing novel approaches to using the robot for distal ureteral reconstruction.

The bladder can lose the ability to store and empty effectively as a result of numerous conditions. When conservative methods to maximize patient safety and quality of life fail, surgical reconstruction of the bladder is usually considered. Augmentation cystoplasty can be performed with the use of the small bowel, large bowel, or less often, stomach. An alternative approach, tissue engineering, identifies the body's own potential for regeneration and supports this propensity with appropriate raw materials and growth factors so that the body's original structure and function may be restored. Tissue engineering can involve the use of a scaffold or matrix alone or of cell-seeded matrices. Harvesting cells and culturing them has become an important tool in tissue engineering. Multiple possibilities for sources of cells have been investigated, including stem cells and differentiated cells from organs other than the bladder; however, to date, autologous bladder cells remain the gold standard for culture and seeding.

Objective To determine if this trend toward calcium phosphate stone formation exists in children. Methods This is a retrospective study of medical records of 179 children managed at our medical center from 1992-2010 for whom stone analysis and other pertinent laboratory data were available. A comparison of patients managed from 1992-2000 (P1) and 2001-2010 (P2) was undertaken. Statistical analysis included nonparametric tests. Results There were no significant differences in the mean age of the 2 cohorts. During both periods, boys comprised a significantly higher proportion during the first decade of life, whereas girls comprised a significantly higher proportion during the second decade. A higher percentage of patients had calcium oxalate (CaOx) stones in P1 compared to P2 (60% vs 47%, P = .0019). There was a significant increase in the percentage of patients having calcium phosphate stones in P2 compared to P1 (27% vs 18.5%, P = .008). Twenty-seven patients had recurrent stones. A comparison of the compositions of the first and last stones of patients within this group demonstrated an increasing proportion of brushite stones (3.7% vs 11.1%, P = .04). Twenty-four hour urine testing results were similar for those with CaOx and calcium phosphate stones. Conclusion An increasing proportion of children have calcium phosphate calculi. Brushite stones are more prevalent in children with recurrent stone events. The impetus of these shifts is not readily apparent.

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. Download : Download high-res image (175KB) Download : Download full-size image 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.)