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Children with vesicoureteral reflux (VUR) are at an increased risk of recurrent urinary tract infections (UTIs) and renal scarring. Gut microbiota are associated with disease phenotypes, but there has been no study that associates urinary microbiota (uMB) and metabolic profiles with VUR pathology. To identify dominant uMB genera and metabolites associated with UTIs in VUR, urine samples collected under sterile conditions underwent 16S ribosomal RNA sequencing (n = 49) and metabolomic analysis by mass spectrometry (n = 96). Alterations in uMB and metabolomic profiles in VUR patients suggest remodeling of urinary bacterial communities after UTIs: Dorea- and Escherichia-dominant uMB profiles were more frequently identified in participants with VUR. Prevotella- and Lactobacillus-dominant uMB profiles were more prevalent in controls (p 0.001). Microbial composition varied based on recurrent febrile UTI status (p = 0.001). A total of 243 urinary metabolites involved in energy, amino acid, nucleotide, and lipid metabolism were altered in VUR patients with UTIs (p 0.05). Importantly, VUR specimens revealed changes in the bacteria-associated metabolic pathways such as glutamate degradation, methyl-citrate cycle, and bile acid metabolism. PATIENT SUMMARY: Differences in urinary commensal bacteria and metabolites exist between children with and without vesicoureteral reflux (VUR). These changes may be utilized to identify patients at risk of VUR-associated kidney damage.

We performed a retrospective, single-institution study to characterize the pathological findings of testis tissue specimens from older boys and adolescents with cryptorchidism.With institutional review board approval, pathology reports were obtained for testicular specimens from patients age 10 years or older at a pediatric hospital from 1994 to 2016. Reports were excluded if they lacked clinical records, lacked testicular parenchyma, were from a descended testis or were from a patient with differences of sexual development. Variables of interest included age, testis location, procedure and pathological findings. Presence of malignancy among intra-abdominal versus extra-abdominal undescended testes was compared using Fisher's Exact Test.Seventy-one patients met inclusion criteria. The median age was 15.3 years (range 10.1-27.7). None had a history of testicular malignancy. Forty-five unilateral orchiectomies, 22 unilateral orchiopexies with biopsy and 4 bilateral procedures were performed. Seventeen testes (22.7%) were intra-abdominal, 42 (56.0%) were in the inguinal canal, 9 (12.0%) were at the external inguinal ring, 3 (4.0%) were in the superficial inguinal pouch and 4 (5.3%) were in the scrotum. Malignancy was detected in 2/71 patients (2.8%). By location, 2/16 patients (12.5%) with intra-abdominal testis and 0/55 patients (0%) with extra-abdominal testis demonstrated malignancy (p=0.048).Among males with cryptorchidism ages 10 years and older without differences of sexual development, 2/16 patients with intra-abdominal testis and 0/55 patients with extra-abdominal testis demonstrated malignancy. In older boys and adolescents, orchiectomy or biopsy is indicated for intra-abdominal testes but may not be necessary for extra-abdominal undescended testes.

To examine trends in the number of cases of primary vesicoureteral reflux managed by ureteral reimplantation nationally over the last decade. Substantial changes have occurred in management of vesicoureteral reflux (VUR) over time, but trends in use of ureteral reimplantation have yet to be investigated on a national scale with annualized data.Using the Premier Healthcare Database, we extracted hospital discharge data for pediatric patients (age ≤ 18 years) with a procedure code for ureteroneocystostomy (International Classification of Diseases, Ninth Revision, 56.74) between January 1, 2003 and December 31, 2013. We excluded patients with secondary VUR. The presence of a temporal trend in reimplantation was examined via regression using generalized estimating equations.In 4301 cases of primary VUR (23,602 weighted), there was a substantial decrease in the number of reimplantations performed, with an estimated decline in the rate of 0.239 cases per attending per year (P = .006). Average patient age declined 1.2 months in each year (P .0001) due largely to a decline in reimplantation in those over age 2, which fell by 0.15 reimplantations per attending per year (P = .026). There was no difference between rates of decline in reimplantation for children with and without reflux nephropathy (P = .21) CONCLUSION: Nationally there has been a marked decrease in the incidence of ureteral reimplantation among children with primary VUR. The potential factors contributing to this are broad, including changes in diagnostic patterns, treatment recommendations, and the rise of endoscopic intervention.

Objective To characterize the spectrum of congenital penile curvature without hypospadias evaluated at our institution, and to assess the efficacy of surgical repair in prepubescent boys. Methods The study group included 82 boys with a diagnosis of congenital penile curvature without hypospadias who elected for surgical repair from 2008 to 2010. We retrospectively reviewed clinical and operative characteristics and recorded surgical outcomes during the length of patients' follow-up at our institution. Results Of the patients electing surgery, 32 of 82 (39%) underwent penile degloving alone for class I (skin) chordee. Ten of 82 patients (12.2%) required further excision of class II (dysgenic fascial) chordee, and 40 of 82 (48.8%) patients required some combination of techniques to correct varying degrees of class III (dysgenic fascial) chordee. A total of 22.2% of patients returning for follow-up with corporal disproportion had persistent penile curvature compared with 14.3% of boys with fascial chordee and 11.5% of boys with skin chordee. Those children treated with tunical plications and incisions alone fared worse than those children treated with some combination of the Nesbit or modified Nesbit procedure. Conclusion Our study shows not only that the proportion of patients with a hyposplastic urethra may be smaller than previously reported but also that corporal disproportion may be more prevalent. Attention should be paid to this later group as plication without the use of Nesbit techniques may not be enough to ensure an appropriate repair.

The diagnosis and treatment of ureteroceles continue to evolve. Not only are the majority of patients diagnosed prenatally, but a significant proportion of cases can be dealt with in a minimally invasive, endoscopic fashion. Although a single treatment strategy for all ureteroceles is an unrealistic expectation, more valuable to the practicing urologist is an understanding of the variable anatomy and presentation of this entity and an appreciation for the breadth of treatment options at his or her disposal. This, the first of our two reviews on ureteroceles, provides the necessary background. This review contains 10 figures, 6 tables and 35 references Key words: bladder trigone, cecoureterocele, ectopic ureterocele, extravesical ureterocele, intravesical ureterocele, lower tract approach, obstructed ureterocele, reflux, transurethral incision, transurethral puncture, upper tract approach, ureterocele, ureterocele algorithm

Summary Background Renal and bladder ultrasound (RBUS) is recommended in evaluation of children after an initial, febrile urinary tract infection. Although it is not uncommon to observe debris within the bladder lumen on sonography, the significance of this finding is uncertain. Debris may be interpreted as an indication of ongoing infection, but there have been no studies to date investigating the association of bladder debris with a positive culture. Objective The aim of this study was to evaluate the association of bladder debris noted at the time of RBUS with positive urine culture results obtained from a catheterized specimen, among patients undergoing RBUS and voiding cystourethrogram (VCUG) on the same day. Study design We performed a retrospective cross-sectional study of 3995 patients who presented for same-day RBUS and VCUG. RBUS reports were reviewed for the presence of bladder debris, and analysis was limited to patients under 60 months of age with a catheterized urine specimen sent for culture at the time of the studies. Those with prior postnatal imaging or a diagnosis of prenatal hydronephrosis or other GU abnormalities were excluded. Thirty-four subjects with bladder debris on RBUS were identified and matched to 155 controls based on age, gender, circumcision status, and presence of vesicoureteral reflux. A positive urine culture was defined as ≥50,000 colony forming units per mL of at least one organism. A conditional logistic regression model was used to evaluate the association between debris on RBUS and positive urine culture results. Results In conditional logistic regression stratifying by matching age, gender, circumcision status, and presence of vesicoureteral reflux, there was a statistically significant association between bladder debris on RBUS and positive urine culture result collected on the same day during VCUG (OR 7.88, 95% CI 1.88–33.04, p = 0.0048). This corresponds to a 688% increase in odds of positive urine culture for patients with debris (Table). Discussion This is the first study to evaluate the association between bladder debris on RBUS and positive urine culture, and it should serve as a starting point for future investigations. The study is limited in its generalizability to the sampled population; further work should evaluate the predictive value of RBUS debris among children without UTI history, with prior imaging or known genitourinary anomalies, or older children. Conclusion Among children younger than 60 months old undergoing initial imaging for history of UTI, there is a significant association between bladder debris and a positive urine culture. Table . Urine culture results for patients with and without bladder debris on renal bladder ultrasound ( p = 0.0048). Bladder debris ( n = 34) No bladder debris ( n = 155) Urine culture Positive 5 (14.7%) E. coli (1) Enterococcus (1) P. mirabilis (2) P. vulgaris (1) 3 (1.9%) E. coli (1) Enterococcus (1) E. cloacae (1) Negative 29 (85.3%) 152 (98.1%)

Errors in urachal obliteration may result in 4 clinical anomalies: patent urachus, urachal cyst, urachal sinus, or vesicourachal diverticulum. Despite the fact that urachal cysts are one of the more common of these anomalies, most go undetected, presenting in the setting of infection. There are reports in the literature of cysts misdiagnosed as other inflammatory processes; however, the converse is reported with less frequency. We present the case of a 3-year-old girl who was admitted to our institution with a suspected urachal cyst. This was subsequently diagnosed as a granulomatous mass caused by the gram negative bacterium Bartonella.

Ejaculatory duct obstruction is an infrequent cause of obstructive azoospermia, occurring in up to 5 % of such patients. However, it is potentially correctable and warrants consideration in the differential diagnosis of the patient presenting for infertility evaluation. This review provides an overview of ejaculatory duct obstruction: its various etiologies, presentation, and associated clinical assessment. It includes a description of diagnostic imaging and interventional studies available to the practicing urologist and concludes with a discussion of current endoscopic management.

Purpose of review The increased risk of infertility in men with varicocele is well established. Varicocelectomy has been shown to improve semen parameters and increase pregnancy rates. Yet varicocele pathophysiology is poorly understood and potential implications for testosterone production are less clear. Evidence suggests that varicocele may result in lower serum testosterone levels and that varicocelectomy may, in turn, correct this deficit. Recent findings Several studies published in the past 18 months have assessed the effect of varicocele and varicocelectomy on serum testosterone levels. These include data gathered from two rat models of varicocele induction and outcomes after repair. Of additional interest is a study of serum testosterone levels in men after varicocelectomy, the first of its kind to stratify data by patient age and to address whether varicocele repair is effective in improving testosterone levels in older men. Summary Definitive statements regarding varicocele, varicocelectomy, and testosterone are difficult to make given the frequent absence of control groups and lack of sample group consistency. Despite this, recent well done animal and human studies suggest an adverse effect of varicocele on testosterone and a potential benefit of varicocele repair. Further controlled studies examining testosterone as a primary data point are required.

OBJECTIVE. In this article, we review the standard of care for imaging of nephrolithiasis as well as new technology and radiation concerns from the perspective of the urologic surgeon. CONCLUSION. Nephrolithiasis is a common cause of morbidity with a lifetime prevalence of 5–10% worldwide. Increasingly, diagnostic evaluation and planning for medical or surgical intervention have become reliant on imaging.

INTRODUCTION AND OBJECTIVES: Freezing low concentrations of sperm from severely oligospermic patients while maintaining adequate post-thaw motility remains a challenge. We previously reported the feasibility of ultra-rapid vitrification using a microcapillary system. In an attempt to improve these results, several modifications were introduced including a larger capillary system and lower concentrations of non-toxic cryoprotectants: trehalose and propanediol. METHODS: Using an IRB-approved protocol, 27 fresh ejaculate samples from healthy men were obtained and prepared via a swim-up protocol in human tubal fluid (HTF). 15 samples with an average concentration of 77 million/mL and pre-thaw total motility of 86% were included in our modified protocol. These samples were diluted in a dropwise, 1:1 fashion with HTF media containing trehalose (0.05M) and propanediol (PrOH, 0.75M). After loading the samples into a series of 200mm capillaries with heat-sealed ends, they were divided into two equal groups: 1) Control, from which the samples were immediately expelled, washed, then assessed via computer-assisted semen analysis, and 2) Experimental, which was vitrified in a super-cooled, liquid nitrogen bath, stored for up to 24hours, then thawed,washed, andanalyzed.A subset of specimens from the experimental group was used for viability staining. RESULTS: Consistent post-thaw motility was achieved using this protocol. While a total motility of 48.6% was recorded in the control, the experimental group demonstrated an overall post-thaw motility of 10.5%. Subset analysis allowed stratification of samples based upon their ability to withstand this process. Of the highest-performing specimens, defined as those with a post-thaw motility >15%, we were able to conserve 22% of the sham control motility in our vitrified samples. CONCLUSIONS: Building upon our prior experience, we sought to enhance sperm survival and improve post-thaw motility. Modifications included use of a larger capillary to reduce shear stress, conversion to a less viscous and less toxic media, and incorporation of a wash prior to final analysis. Gains were achieved in post-thaw motility and confirmed the feasibility of this system. However, it is clear from viability stains and subset analysis that there are yet undiscovered intrinsic and extrinsic variables affecting optimal recovery of specimens with this process. We will continue efforts to optimize this system for use in severely oligoospermic patients.

Androgens play an essential role in the development of male reproductive organs, the maintenance of male fertility, and the preservation of secondary male sexual characteristics. The production of testosterone, the dominant circulating androgen, is a finely balanced process with many points of potential regulation, starting with the translocation of cholesterol across the mitochondrial membrane and ending with the negative feedback of testosterone at level of the hypothalamus and the pituitary gland. This chapter explores the physiology of testosterone production, beginning with its intracellular synthesis and steroidogenic conversion, and then follows testosterone’s transport across the cell membrane and into circulation. Regulation of this system via the hypothalamic–pituitary–testis axis is reviewed. Finally, this discussion concludes with two increasingly prevalent clinical circumstances in which testosterone physiology is altered: the metabolic syndrome and the aging male.