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Purpose: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to the transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCTs) who underwent EP-RPLND at a single institution., Materials and Methods: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. Surgical, perioperative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included 2-year recurrence-free survival (RFS) and recurrence patterns, which were analyzed according to pathology., Results: Overall, 237 patients underwent EP-RPLND, of which 72% were administered in the postchemotherapy (PC) setting. Median follow-up was 16.7 months (interquartile range [IQR] 3.9-39.6). Median size of retroperitoneal disease was 2.8 cm (IQR 1.8-5.4), of which 16 cases were ≥ 10 cm. There were no cases of postoperative ileus or readmission due to small-bowel obstruction. Median hospital stay was 2 days (IQR 1-3). From 2020 to 2021, 73% of patients were discharged on postoperative day 1 and 89% by postoperative day 2. Thirty-one complications occurred, including 4% grade III to IV complications. In the primary setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00), respectively. In the PC setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95), respectively. Overall, only 7 patients had in-field recurrence., Conclusions: Midline EP-RPLND is safe and associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and PC settings, with low rates of in-field relapse.

Introduction: To evaluate the possible impact of patients' sacral ratios (SRs) on response to biofeedback (BF) therapy in pediatric patients with lower urinary tract dysfunction (LUTD)., Materials and Methods: In this retrospective cohort conducted from 2016 to 2018 in our tertiary medical center, we included the medical records of all pediatric patients with LUTD who were nominated for BF due to having abnormal uroflowmetry patterns and simultaneous increase in electromyography (EMG) activity. Ten sessions of weekly animated BF were performed for each patient. All patients underwent a complete urological evaluation, uroflowmetry with simultaneous EMG and post-void residual measurement before and after treatment. SRs were calculated based on plain anteroposterior lumbosacral radiographs. Patients were then divided into normal SR (≥0.74) and low SR (<0.74) and outcomes were compared between them., Results: Of the total 86 patients included in our study, 48 (55.8%) had a normal SR (≥0.74), while 38 (44.2%) had a low SR (<0.74). Our data revealed that BF therapy significantly improved maximum and average urinary flow rates, urine volume, daytime urinary incontinence, enuresis, urinary urgency and constipation; irrespective of the patients' SRs (all P < 0.001). Our between-groups analyses showed that after the completion of BF, the SR ≥ 0.74 group had significantly higher maximum urinary flow rate (mean difference [95%CI]: 7.7 [5.4, 10.0], P < 0.001) (Figure) and urine volume (mean difference [95%CI]: 49.9 [19.5, 80.4], P = 0.002) and significantly lower diurnal urinary incontinence (4.2% vs. 21.1%, P = 0.020), enuresis (4.2% vs. 18.4%, P = 0.040) and constipation (2.1% vs. 23.7%, P = 0.004) compared to the SR < 0.74 group., Discussion: SR has been proposed as a reliable indicator of bony pelvis growth and subsequent lumbosacral neurodevelopment. Additionally, larger SR values are associated with better postoperative sphincter function in children with urological and anorectal malformations. Our results demonstrated that after completion of BF, the normal SR group had a significantly better improvement of some of the uroflowmetry indicators and LUTD-associated symptoms compared to the low SR group., Conclusion: Our findings implied that although BF therapy is an efficient treatment for children with LUTD, irrespective of their sacral development; children with enhanced sacral development may benefit from better clinical response, especially in terms of LUTD-associated symptoms., Competing Interests: Conflict of interest None., (Copyright © 2024 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate the association between sacral underdevelopment, as defined by subnormal sacral ratio (SR) measurements, with increased maximum detrusor voiding pressure (P det. Max) in infants., Methods: In this 2007-2015 retrospective cohort study, the medical records of all infants who underwent a pyeloplasty due to congenital ureteropelvic junction obstruction were added. Their P det. Max was evaluated through the suprapubic catheter utilized for urinary drainage intraoperatively, without imposing any additional risk of urethral catheterization on the infant. SR was calculated via the plain kidney, ureter, and bladder (KUB) radiography film obtained during the voiding cystourethrogram (VCUG) evaluation before the surgery. Participants were categorized into SR < 0.74 or SR ≥ 0.74. P det. Max was subsequently compared between these two groups., Results: A total of 45 patients were included in our analysis. Twenty-eight (62.2%) patients had a (SR < 0.74), while 17 (37.8%) had a (SR ≥ 0.74). P det. Max was shown to be significantly higher in the SR < 0.74 compared to the SR ≥ 0.74 group (167.5 ± 60.8 vs. 55.7 ± 17.9 cmH 2 O, p < 0.001). After adjusting for age and sex, SR remained a significant contributor to P det. Max (p < 0.001). Physiologic detrusor sphincter dyscoordination (PDSD) rate was significantly higher in the SR < 0.74 versus SR ≥ 0.74 group (100.0% vs. 70.6%, respectively; p = 0.005)., Conclusion: Lumbosacral underdevelopment, as indicated by subnormal sacral ratios, is associated with sphincter-detrusor dyscoordination, which causes PDSD and can ultimately result in higher P det. Max in infants., (© 2024 Wiley Periodicals LLC.)

Background: Women's sexual health after radical cystectomy is an important but poorly understood aspect of bladder cancer survivorship. Dedicated investigation is needed to elucidate patient perceptions on sexual function and dysfunction in this setting., Aims: In this study we sought to qualitatively examine women's perceptions and experiences of sexual health following radical cystectomy for bladder cancer., Methods: We conducted one-on-one qualitative telephone interviews with 40 women who underwent radical cystectomy in the past 6 months to 5 years and signed a research consent form to be contacted for future studies. We examined women's experiences of engaging in sexual activity after surgery and their attitudes toward sex and body image. We audio recorded, transcribed, and coded the interviews using ATLAS.ti software and applied grounded theory methods for analysis., Outcomes: For data that emerged during the qualitative interviews that was related to lack of knowledge about how physical and psychological sexual health would be affected after surgery, we reviewed and discussed transcripts that enabled coding of the data into emerging topic areas., Results: Our analysis yielded 4 main themes. (1) Women reported receiving little to no information from providers about female sexual dysfunction prior to or after radical cystectomy. Women wished they had been provided more information about female sexual dysfunction from their clinicians, including strategies for postoperative self-pleasure and nonintercourse methods of sexual pleasure with partners. (2) Women shared that they were not sexually active following surgery due to physical and mental barriers. (3) When women did try to engage in sex, they described feeling disappointed that it did not feel the same as prior to surgery. (4) Some women found that physical therapy helped them to physically and mentally recover their strength to engage in sexual activity again., Clinical Implications: Clinicians must directly address sexual health concerns with patients who undergo radical cystectomy., Strengths and Limitations: This study has several key strengths. Investigation into women's sexual function and dysfunction addresses a gap in understanding of this component of women's health-related quality of life after radical cystectomy, which represents an unmet need. The large number of interviews conducted as well as the in-depth information obtained through one-on-one interviews are additional strengths. This study also has limitations, including possible shortcomings of telephone interviews compared with in-person interviews. However, telephone interviews were beneficial because the interviews took place during the COVID-19 pandemic and spared patients from extra visits or from having to travel long distances to the respective medical centers. Other possible limitations were that patients may have been reluctant to share all of their experiences and that patients who underwent urostomies, also termed ileal conduits, were overrepresented in this study compared with women who underwent continent urine diversions, which allow greater control over urine output., Conclusion: Broadening the understanding of sexual health beyond sexual intercourse to encompass sexuality and self-pleasure can provide clinicians, patients, and their families with more effective preparation and strategies to care for an essential aspect of their wellbeing., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The use of blue light cystoscopy (BLC) has been shown to improve bladder tumor detection. However, data demonstrating the efficacy of BLC across different races are limited. Herein, we aim to evaluate heterogeneity in the characteristics of BLC for the detection of malignant lesions among various races. Clinicopathologic information was collected from patients enrolled in the multi-institutional Cysview ® registry (2014-2021) who underwent transurethral resection or biopsy of bladder tumors. Outcome variables included sensitivity and negative and positive predictive values of BLC and white light cystoscopy (WLC) for the detection of malignant lesions among various races. Overall, 2379 separate lesions/tumors were identified from 1292 patients, of whom 1095 (85%) were Caucasian, 96 (7%) were African American, 51 (4%) were Asian, and 50 (4%) were Hispanic. The sensitivity of BLC was higher than that of WLC in the total cohort, as well as in the Caucasian and Asian subgroups. The addition of BLC to WLC increased the detection rate by 10% for any malignant lesion in the total cohort, with the greatest increase in Asian patients (18%). Additionally, the positive predictive value of BLC was highest in Asian patients (94%), while Hispanic patients had the highest negative predictive value (86%). Our study showed that regardless of race, BLC increases the detection of bladder cancer when combined with WLC.

Artificial intelligence (AI) is revolutionizing prostate cancer genomics research. By leveraging machine learning and deep learning algorithms, researchers can rapidly analyze vast genomic datasets to identify patterns and correlations that may be missed by traditional methods. These AI-driven insights can lead to the discovery of novel biomarkers, enhance the accuracy of diagnosis, and predict disease progression and treatment response. As such, AI is becoming an indispensable tool in the pursuit of personalized medicine for prostate cancer., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: Live feedback in the operating room is essential in surgical training. Despite the role this feedback plays in developing surgical skills, an accepted methodology to characterize the salient features of feedback has not been defined., Objective: To quantify the intraoperative feedback provided to trainees during live surgical cases and propose a standardized deconstruction for feedback., Design, Setting, and Participants: In this qualitative study using a mixed methods analysis, surgeons at a single academic tertiary care hospital were audio and video recorded in the operating room from April to October 2022. Urological residents, fellows, and faculty attending surgeons involved in robotic teaching cases during which trainees had active control of the robotic console for at least some portion of a surgery were eligible to voluntarily participate. Feedback was time stamped and transcribed verbatim. An iterative coding process was performed using recordings and transcript data until recurring themes emerged., Exposure: Feedback in audiovisual recorded surgery., Main Outcomes and Measures: The primary outcomes were the reliability and generalizability of a feedback classification system in characterizing surgical feedback. Secondary outcomes included assessing the utility of our system., Results: In 29 surgical procedures that were recorded and analyzed, 4 attending surgeons, 6 minimally invasive surgery fellows, and 5 residents (postgraduate years, 3-5) were involved. For the reliability of the system, 3 trained raters achieved moderate to substantial interrater reliability in coding cases using 5 types of triggers, 6 types of feedback, and 9 types of responses (prevalence-adjusted and bias-adjusted κ range: a 0.56 [95% CI, 0.45-0.68] minimum for triggers to a 0.99 [95% CI, 0.97-1.00] maximum for feedback and responses). For the generalizability of the system, 6 types of surgical procedures and 3711 instances of feedback were analyzed and coded with types of triggers, feedback, and responses. Significant differences in triggers, feedback, and responses reflected surgeon experience level and surgical task being performed. For example, as a response, attending surgeons took over for safety concerns more often for fellows than residents (prevalence rate ratio [RR], 3.97 [95% CI, 3.12-4.82]; P = .002), and suturing involved more errors that triggered feedback than dissection (RR, 1.65 [95% CI, 1.03-3.33]; P = .007). For the utility of the system, different combinations of trainer feedback had associations with rates of different trainee responses. For example, technical feedback with a visual component was associated with an increased rate of trainee behavioral change or verbal acknowledgment responses (RR, 1.11 [95% CI, 1.03-1.20]; P = .02)., Conclusions and Relevance: These findings suggest that identifying different types of triggers, feedback, and responses may be a feasible and reliable method for classifying surgical feedback across several robotic procedures. Outcomes suggest that a system that can be generalized across surgical specialties and for trainees of different experience levels may help galvanize novel surgical education strategies.

Background: To compare the effectiveness of pelvic floor interferential (IF) therapy with trans-abdominal IF therapy in children with intractable functional constipation., Methods: Information of 64 children (38 boys, 26 girls; mean age: 6.6 ± 2.2) with functional constipation who had been treated with IF therapy were considered for this retrospective study. Group A (n = 32) underwent pelvic IF electrical stimulation + pelvic floor muscle (PFM) exercises while the group B (n = 32) received transabdominal IF therapy + PFM exercises. A complete bowel habit diary, a constipation score questionnaire and a seeable pain scores had been recorded before, after the ending of treatment courses and six months later for children in both groups. Additionally, children had been assessed with a constipation-related quality of life questionnaire before and six months after treatment., Results: The number of patients who compiled the diagnostic criteria for constipation significantly decreased in both groups after treatment, in which 27/32 (84.3%) of patients in each group had no constipation after the ending of therapy courses (P = 1). Fecal soiling episodes reduced in both groups after treatment, this finding was significantly higher in group A than in group B after the ending of therapy courses (P = 0.05) and six months later (P = 0.01)., Conclusion: Results of this study showed that using IF therapy both pelvic floor and transabdominal significantly boosts the effects of treatment among patients with functional constipation. Pelvic floor IF therapy is more effective in patients who had concomitant fecal soiling., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: We explored the accuracy of a urine-based epigenetic test for detecting upper tract urothelial carcinoma., Materials and Methods: Under an Institutional Review Board-approved protocol, urine samples were prospectively collected from primary upper tract urothelial carcinoma patients before radical nephroureterectomy, ureterectomy, or ureteroscopy between December 2019 and March 2022. Samples were analyzed with Bladder CARE, a urine-based test that measures the methylation levels of 3 cancer biomarkers (TRNA-Cys, SIM2, and NKX1-1) and 2 internal control loci using methylation-sensitive restriction enzymes coupled with quantitative polymerase chain reaction. Results were reported as the Bladder CARE Index score and quantitatively categorized as positive (>5), high risk (2.5-5), or negative (<2.5). The findings were compared with those of 1:1 sex/age-matched cancer-free healthy individuals., Results: Fifty patients (40 radical nephroureterectomy, 7 ureterectomy, and 3 ureteroscopy) with a median (IQR) age of 72 (64-79) years were included. Bladder CARE Index results were positive in 47, high risk in 1, and negative in 2 patients. A significant correlation was found between Bladder CARE Index values and tumor size. Urine cytology was available for 35 patients, of whom 22 (63%) results were false-negative. Upper tract urothelial carcinoma patients had significantly higher Bladder CARE Index values compared to the controls (mean 189.3 vs 1.6, P < .001). The sensitivity, specificity, positive predictive value, and negative predictive value of the Bladder CARE test for detecting upper tract urothelial carcinoma were 96%, 88%, 89%, and 96%, respectively . Conclusions:Bladder CARE is an accurate urine-based epigenetic test for the diagnosis of upper tract urothelial carcinoma, with much higher sensitivity than standard urine cytology.

Objective: To evaluate perioperative and functional outcomes of radical cystectomy (RC) and urinary diversion (UD) in patients with a single kidney (SK) vs. double kidneys (DK)., Methods: We reviewed records of patients who underwent RC for bladder cancer with a history of prior or concurrent nephrectomy at USC between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with DK using 2:1 matching with respect to age, sex, preop GFR, and tumor stage., Results: We included 186 patients (SK = 62 and DK = 124). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar. In patients with continent diversion, SK vs. DK showed similar 90-day complications (71% vs. 69%, P = 1.0). SK patients had significantly lower GFRs at discharge, 3-, and 12-month following RC compared to the DK group. Postoperative GFRs of the SK patients with continent vs. incontinent UD were statistically similar. On multivariable analysis, UD (i.e. continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-month following RC., Conclusions: Perioperative outcomes of radical cystectomy patients with single kidney are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney is as safe as double kidney patients., Competing Interests: Conflicts of interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To examine the oncological outcomes and recurrence patterns in patients with no residual disease at the time of radical cystectomy (RC)., Methods: A retrospective review of our IRB-approved bladder cancer database identified patients who underwent RC between 2000 and 2019 and were found to have no residual disease (pT0N0), either following neoadjuvant chemotherapy (NAC) or transurethral resection (TURBT) alone. The primary outcome was recurrence-free survival (RFS). Regression models assessed factors influencing recurrence, and a detailed description of recurrence patterns was compiled., Results: From a total of 2222 patients, 234 (10.5%) were included with a median age of 67 years. NAC was used in 89 (38%) patients and 145 (62%) cases were rendered pT0 following TURBT alone. At a median follow-up of 44 months, there were 16 (6.8%) recurrences, 10 (63%) of which occurred in the ypT0 group. None of the patients with clinical Ta/Tis disease had a recurrence after RC. The median time to recurrence was 9 months. Ninety-one percent (10/11) of recurrences in the ypT0 group were within 2 years of cystectomy, while half of the recurrences in the pT0 group occurred after 2 years. Patients with ypT0 had worse 2- and 5-year RFS compared to the pT0 group (85% and 84% vs. 99% and 95%, respectively; P = 0.003). Variant histology was noted in 49 (21%) patients; the recurrence rate was higher in this subgroup compared to those with pure urothelial carcinoma (12.2% vs. 5.4%, P = 0.02). Lung metastasis and involvement of distant organs, while rare, were noted at similar rates in both groups., Conclusion: Patients with pT0N0 pathology at the time of cystectomy should prudently undergo long-term surveillance as recurrence and metastasis can still develop up to 4 years after surgery. Patients achieving ypT0 after NAC exhibit worse prognosis and shorter times to recurrence, closer follow-up may be considered., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To evaluate whether a restaging transurethral resection of bladder tumor (TURBT) is necessary in high-risk nonmuscle invasive bladder cancer (NMIBC) if the initial TURBT was performed using blue light (BL) technology., Methods and Materials: Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, BL vs. white light (WL), and compared to determine rates of residual disease and upstaging. Univariate analysis was performed using Mann-Whitney U and chi-square tests, with P < 0.05 considered significant., Results: Overall, 115 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. Patients who underwent BL compared to WL for their initial TURBT had higher rates of benign pathology on restaging TURBT, although this was not statistically significant (47% vs. 30%; P = 0.08). Of patients with residual tumors on restaging TURBT, there were no differences in rates of Ta (22% vs. 26.5%; P = 0.62), T1 (22% vs. 26.5%; P = 0.62), or CIS (5.5% vs. 13%; P = 0.49) when the initial TURBT was done using BL compared to WL. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using BL compared to WL (3% vs. 4%; P = 0.78)., Conclusions: TURBT using BL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in Ta or T1 disease. Thus, a restaging TURBT is still necessary even if initial TURBT was performed using BL., Competing Interests: Conflict of interest Siamak Daneshmand is a paid consultant for Photocure. Yair Lotan is a paid consultant for Photocure and does research with Storz. Sima Porten is a paid consultant for Photocure. Brian Willard has research funding from and on speakers bureau for Photocure. Additional research funding with Jansseen, Myriad, and Coloplast. Gary D. Steinberg is a paid consultant for Photocure. Also, he is a member of Clinical Trial Protocol Committees for Photocure., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aims: To compare the effects of functional electrical stimulation (FES) with conventional therapy and conventional therapy alone on improvement of faecal incontinence (FI) symptoms in a number of children with functional non-retentive FI., Methods: Data of 28 children with FI were accepted for this retrospective study. The case group (n = 14) underwent FES + conventional therapy and the control group (n = 14) received conventional therapy only. Data of children with faecal retention, inflammatory, anatomic, metabolic and neurological disorders were excluded. Children were assessed with a paediatric FI score questionnaire, and a bowel habit diary both before treatment sessions, after they ended, and after 6 months. A FI quality of life questionnaire was completed before and after treatment for all children., Results: Full response to the treatment (100% reduction in FI episodes) was significantly observed in 8/14 (57.1%) of children in the case group compared to 2/14 (14.2%) of children in the control group after the ending of treatment sessions (P = 0.005). The baseline mean ± SD of FI episodes per week was 3.7 ± 2.1 among both groups which significantly decreased after the ending of treatment sessions in the case group compared to the control group (1.4 ± 2.1 vs 3 ± 2.7; P = 0.05). Mean ± SD of FI score was significantly reduced in the case group compared to the controls after the ending of treatment sessions (3.9 ± 4.5 vs 8 ± 4.7; P = 0.02) and maintained after 6 months (P = 0.05)., Conclusions: Functional electrical stimulation is a safe, effective, non-invasive, inexpensive, reproducible and easy-to-use modality for treatment of functional non-retentive faecal incintinence in children., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Many patients with anorectal malformations (ARM) experience a long-lasting problem with faecal incontinence (FI). We assessed the effectiveness of a pelvic floor rehabilitation program including transcutaneous functional electrical stimulation (TFES) in combination with pelvic floor muscle (PFM) exercises on post-surgical FI in children with ARM., Methods: Data of 40 children at the age of 4 years or older who had undergone surgical correction for ARM and suffered from persistent FI referring for pelvic floor rehabilitation were analysed respectively. Patients underwent TFES and PFM exercises for 20 sessions. TFES was applied for 20-min during each session, two times a week. A paediatric FI score questionnaire and a bowel habit diary were completed both before and after the treatment for all children. We completed a FI quality of life questionnaire before the therapy and again after treatment for all patients., Results: Twenty-two out of 40 (55%) patients responded completely to the treatment (100% reduction in FI episodes) after the completion of treatment sessions, sustained in 19/40 (47.5%) patients after 6 months. Mean ± SD of FI score was 4.9 ± 3.6 at baseline that significantly reduced to 2.4 ± 1.3 and 2.4 ± 1.8 after completion of treatment sessions and 6 months later, respectively (P < 0.05)., Conclusions: Our results show that TFES and PFM exercises have a considerable beneficial impact on post-surgical FI in children with ARM., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Objectives: To evaluate the role of blue-light cystoscopy (BLC) in detecting invasive tumours that were not visible on white-light cystoscopy (WLC)., Patients and Methods: Using the multi-institutional Cysview registry database, patients who had at least one white-light negative (WL-)/blue-light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL-/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected., Results: Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL-/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL-/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL-/BL+ lesion who underwent radical cystectomy (RC), high-risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node-positive disease., Conclusions: A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach., (© 2021 The Authors BJU International © 2021 BJU International.)

Background: We compared the effects of transcutaneous functional electrical stimulation (TFES) and biofeedback therapy with TFES alone in a cohort of children with functional non-retentive fecal incontinence (FNRFI)., Methods: This prospective, single-center randomized clinical trial was performed on 40 children with FNRFI. Patients were randomly allocated into two equal treatment groups. Group A (n = 20) underwent TFES + biofeedback therapy, and group B (n = 20) received TFES alone. All patients were assessed with a pediatric fecal incontinence (FI) score questionnaire, a visual pain score, and a bowel habit diary both before and at the end of treatment sessions and also at 6 months of follow-up. In addition, a FI quality-of-life (QoL) questionnaire was recorded for all patients before and 6 months after the treatment., Results: FI significantly improved in 13/20 (65%) patients in group A and 11/20 (55%) patients in group B (P < 0.05). A significant reduction in FI score was seen in each group at the end of treatment sessions and maintained at 6 months of follow-up (P < 0.05). A significant improvement in FI-QoL scores was seen in both groups at 6 months of follow-up in which there was no significant difference in terms of FI-QoL scores improvement between both groups after treatment., Conclusions: The use of electrical stimulation in combination with other treatment methods improves symptoms in patients with FNRFI who are refractory to conventional treatment., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: To evaluate the relationships between physical activity, both work and recreational, and urinary incontinence among women., Methods: We assessed women aged 20 years and older in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles who answered self-reported urinary incontinence and physical activity questions. Weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking., Results: A total of 30,213 women were included in analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively)., Conclusions: Moderate physical activity and greater time spent participating in moderate physical activity are associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. We hypothesize that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients., Methods: An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported., Results: A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively)., Conclusions: Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion., (© 2021 The Japanese Urological Association.)

Objectives: To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors., Patients and Methods: Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention., Results: Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m 2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention., Conclusion: In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m 2 are at significantly increased risk of retention and need for self-catheterisation., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Background: Lower urinary tract dysfunction (LUTD) is the most common problem of the referral children to the pediatric urology clinics. If this condition does not treat early in life, it will be a lifelong problem. During recent decades, electrical stimulation therapy has been expanded and extensively used for the treatment of LUTD in both adults and children. The aim of this review is to suggest clinicians an updated understanding of effects of interferential (IF) electrical stimulation therapy in management of LUTD in children., Materials and Methods: The search was performed in databases of Medline, PubMed, Google Scholar, ,and Scopus for information about  IF electrical stimulation and its application using search words such as " IF electrical stimulation", "transcutaneous IF electrical stimulation" ,  "IF therapy " , " electrical stimulation", "voiding dysfunction" , " LUTD", " urinary incontinence" and " children". As this review focuses on the answer of this question "Does transcutaneous IF electrical stimulation has effect on management of LUTD in children?" we included the reference list of articles identified by this search strategy and selected those we judged relevant according to our keywords. Clinical trial studies that publishing in English were included. Categorical data were reported as frequencies and percentages., Results: Eleven studies were included in this review. The success rate of IF therapy in these studies has been reported from 61% to 90% of children with LUTD and urinary incontinence., Conclusion: IF electrical stimulation is an effective, safe and reproducible option to manage LUTD and urinary incontinence in children.

By driving the ongoing pandemic of coronavirus disease 2019 (COVID-19), coronaviruses have become a significant change in twenty-first-century medicine, healthcare systems, education, and the global economy. This chapter rapidly reviews the origin, immunopathogenesis, epidemiology, diagnosis, clinical manifestations, and potential therapeutics of COVID-19. It would also explore the effects of the introduction of a single virus, the so-called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), on the public health preparedness planning.

Introduction: Children with refractory constipation might not respond to conventional medical treatments. In this study, we assessed the effectiveness of intrarectal botulinum toxin type A/electromotive drug administration (BoNTA/EMDA) on constipation in these children and compared its efficacy with routine intrasphincteric BoNTA injection., Methods: From 2017 to 2019, 60 children aged 5-13 years who fulfilled Rome III criteria for intractable constipation were enrolled and randomly assigned into 2 treatment groups. EMDA group (n = 30) underwent BoNTA/EMDA, whereas the control group (n = 30) received injection of BoNTA into the internal anal sphincter. A complete bowel habit diary (with data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before treatment and at 1 month and 6 months after treatment. In addition, children in both groups were assessed with a constipation-related quality of life questionnaire., Results: After 1-month follow-up, treatment reduced the number of patients fulfilling the diagnostic criteria in both EMDA (24/30, 80%) and injection (25/30, 83.3%) groups (P < 0.001). The stool form was normalized in 73.3% (22/30) in EMDA group and 80% (24/30) in injection group after treatment. The median of constipation score and pain score decreased significantly in both groups after treatment (P < 0.001 and P < 0.001, respectively)., Discussion: BoNTA/EMDA seems to be as effective as intrasphincteric BoNTA injection for treatment of intractable constipation. In addition, this technique is associated with less comorbidity, is less costly, and can be performed in an office-based setting without general anesthesia.

We assessed efficacy of biofeedback therapy and home pelvic floor muscle exercises in children with dysfunctional voiding (DV) associated with mild to moderate hydronephrosis. This prospective study comprised fifty seven children (21 boys, 36 girls; mean age 8.9 ± 2.6) with DV and mild to moderate hydronephrosis. Children were randomly allocated into two treatment groups including control group who underwent standard urotherapy and case group who received biofeedback therapy in addition to standard urotherapy. A 99mTc diethylenetriamine pentaacetic acid (99mDTPA) scan, voiding cystoureterography, kidney and bladder ultrasounds, voiding diary and uroflowmetry with electromyography (EMG) were performed in all study participants at the baseline. Children with evidence of complete obstruction in DTPA scan and vesicoureteral reflux were excluded from enrollment. A complete voiding diary, kidney and bladder ultrasounds and uroflowmetry/EMG were also performed 6 months and 1 year after completion of the treatment. We noted a more significant decline in anteroposterior pelvic diameter in case group compared to control group (P < 0.05). The mean maximal urine flow rate prior to treatment was 16.5 ± 2.6 and 16.1 ± 3 ml/s in case and control groups, respectively. This finding increased significantly 1 year after the treatment in case group compared to controls (25 ± 7.2 ml/s vs. 18.4 ± 5.9 ml/s, respectively; P < 0.001). Improvement of various parameters in voiding diary was also more significant in the case group. Biofeedback therapy can effectively resolve non-refluxing and non-obstructive hydronephrosis in children with DV.

Objective: To assess efficacy of combined pelvic floor interferential (IF) electrical stimulation and muscle exercises on bladder bowel dysfunction (BBD) in children., Materials and Methods: A total of 34 children with BBD (6 boys, 28 girls; mean age 7.4 ± 2.2) were included in this study. Children were evaluated with kidney and bladder ultrasounds, uroflowmetry + electromyography (EMG), and a complete voiding and bowel habit diary before treatment. Exclusion criteria were neuropathic disease, anatomical defects, and mental retardation. Participants were randomly allocated into 2 treatment groups including group A (n = 17) who underwent IF electrical stimulation in addition to pelvic floor muscle (PFM) exercises and group B (n = 17) who received PFM exercises alone. All children were re-evaluated by kidney and bladder ultrasounds, uroflowmetry + EMG and a voiding and bowel habit diary at the end of treatment sessions and 6 months later., Results: Constipation improved in 14 of 17(82%) and 8 of 17(47%) children in group A and B respectively at the end of treatment sessions (P = .03). Daytime incontinence improved in all children in group A and 2 of 8(25%) children in group B after the treatment (P = .007). Urinary tract infection improved in 8 of 10(80%) and 5 of 13(38.4%) children in group A and B respectively, 6 months after the treatment (P = .02). No significant difference was observed in uroflowmetry measures between 2 groups after the treatment., Conclusion: Combination of IF electrical stimulation and PFM exercises is an effective and safe modality for treatment of BBD in children., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Early and prompt diagnosis of pyelonephritis is of great importance in children. The aim of this study is to evaluate the diagnostic accuracy of urinary carbohydrate antigen 19-9 (CA19-9) levels for predicting acute pyelonephritis (APN) in children with urinary tract infection (UTI). Patients were allocated into two groups of APN and acute cystitis according to their diagnosis. Urine samples of all patients were collected. Also, complete history was taken, and physical examination, kidney and bladder ultrasonography, 99m Tc-dimercaptosuccinic acid renal cortical scintigraphy, and urine analysis and culture were performed. Urinary CA19-9 was measured by an electrochemiluminescence enzyme immunometric kit. In addition, CA19-9 levels were measured in the APN group 2 weeks and 3 months later. A total of 100 children were included in this study (mean age 46 ± 31 months, 16 males and 84 females). CA19-9 levels were significantly greater in the APN group than acute cystitis group (510 ± 328 vs. 18.7 ± 18.6 U/ml, P < 0.001). During follow-up periods of the APN group, CA19-9 levels decreased to 180 ± 124 U/ml after 2 weeks (P < 0.001) and 30 ± 23 U/ml after 3 months (P < 0.001). Urinary CA-19-9 had 95.3% sensitivity and 80% specificity for the diagnosis of APN. The area under the curve value of CA19-9 was 0.904 (95% CI 0.831-0.977).Conclusion: Urinary CA19-9 level can be used as a reliable biomarker for early detection of APN prior to urine culture confirmation in children with UTI. What is known: • Early and prompt diagnosis of pyelonephritis is necessary in children to prevent renal damage. • Acute pyelonephritis can present with vague and nonspecific symptoms in infants and children. What is new: • Urinary carbohydrate antigen 19-9 is a reliable biomarker for early detection of acute pyelonephritis prior to urine culture confirmation. • Urinary carbohydrate antigen 19-9 has 95.3% sensitivity and 80% specificity for diagnosis of acute pyelonephritis.

Objectives: To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC)., Materials and Methods: A total of 26 children with MMC (11 boys, 15 girls) who had urinary incontinence secondary to NDO were retrospectively enrolled in the study. Patients in EMDA group (n = 14), using an electrode-catheter, 10 IU/kg of BoNTA were inserted into the bladder for EMDA without anesthesia and on an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and 2 dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. Patients in injection group (n = 12) were received interavesical injection of 10 IU/kg of BoNTA via rigid cystoscope on an inpatient basis. All patients had been evaluated by a voiding diary, urodynamic study, renal, and bladder ultrasounds before, 6 months and 1 year after the treatment., Results: Six months after the treatment, 12 of 14 (85.7 %) and 8 of 12 (66.6%) patients in EMDA and injection groups respectively became completely dry between 2 consecutive clean intermittent catheterizations, which maintained in 11 of 14 (78.5%) of patients in EMDA group compared to 6 of 12 (50%) of patients in injection group, 1 year after the treatment., Conclusion: Patients in both groups improved after the treatment; however improvement in EMDA group was more prominent with better sustained effects. BoNTA/EMDA is a feasible, reproducible, cost benefit, and pain free method as an outpatient basis and no need for anesthesia., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the role of atopy (i.e. atopic dermatitis, allergic rhinitis, asthma, and food allergies) and its consequences on developing meatal stenosis in boys., Methods: After obtaining ethics approval from institutional review board, a retrospective chart review was conducted to gather records of patients with meatal stenosis (Group A) presented to our pediatric urology center between August 2012 and May 2016. History of any allergic reactions including allergic rhinitis, asthma, skin, food and drug allergies was considered as positive history of atopy. A control group of children referring to our center due to other etiologies were considered as control group (Group B). Data were analyzed using student t-test and Chi-square test., Results: During the study period, a total of 206 boys (mean age 41.01 months) were assigned to group A and 221 (mean age 35.56 months) to group B. 126 (61.16%) boys had history of allergic reactions in group A compared to 29 (13.12%) in the control arm (group B). Patients with meatal stenosis have a significantly higher (P-value <0.001) likelihood of suffering from allergic reactions., Conclusions: The pathophysiology of meatal stenosis remains not fully understood yet. This study reveals a significant relation between hypersensitivity reactions and meatal stenosis in boys. Persistent inflammation in meatal area could potentially lead to scarring and stenosis. However, more investigation is required to elucidate this pathophysiology., Type of Study: Case-control study., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Several studies have revealed that electrical stimulation is an effective modality for treatment of lower urinary tract (LUT) dysfunction via raising the capacity or compliance of the bladder or maybe by pelvic floor relaxation and reducing detrusor pressure as well., Objective: This study aimed to assess the efficacy of transcutaneous interferential (IF) electrical stimulation on LUT symptoms as well as urine flow parameters in children with primary bladder neck dysfunction (PBND)., Study Design: We reviewed the charts of all children with persistent LUT symptoms who underwent IF electrical stimulation between 2010 and 2017. Twenty-three neurologically and anatomically normal children (mean age: 7.7 years, range: 5-13) with LUT symptoms were included in this study. Children had different LUT symptoms such as hesitancy, straining, urinary incontinence and constipation with no sufficient response to medical treatment (α -blocker) for at least 6 months. IF electrical stimulation was performed for 15 sessions, two times per week. All children were symptomatic and had abnormal urine flow pattern with an electromyographic (EMG) lag time of more than 6 s on uroflowmetry with EMG. A voiding chart, uroflowmetry with EMG and kidney and bladder ultrasounds were performed before and after the treatment for all children. Maximum and average urine flow rates, EMG lag time and postvoid residual volume were analyzed. In addition, alpha blocker therapy was continued during IF therapy., Results: Mean maximum and average urine flow rates improved from 14.1 to 7.6-19.7 ml/s and 9.5 ml/s, respectively, while mean EMG lag time decreased from 11.7 to 5.2 s after the treatment (all P < 0.05). Also postvoid residual volume decreased significantly from 35.6 to 7.6 ml at the end of treatment courses., Discussion: Pelvic floor EMG lag time, a documented parameter on uroflowmetry with EMG, defined as the time from the start of pelvic floor relaxation during a volitional voiding effort (the first stage of normal voiding) to the start of urine flow. Results showed that IF therapy decreased pelvic floor EMG lag time in children with PBND. In addition, increase in mean maximum and average urine flow rates in our patients indicated that pelvic IF therapy and behavioral modification improved voiding dysfunction in most of the patients and probably decreased bladder neck activity during voiding. Future studies with larger sample size are needed to support this finding., Conclusion: IF therapy appears safe, effective and reproducible in improvement of PBND in children., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown., Methods: A cross-sectional survey was developed by the International Federation of Medical Students' Associations (IFMSA)'s Global Surgery Working Group assessing medical students' desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students' perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata., Results: 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students' decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053]., Conclusion: Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student's decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Objective: Electromotive drug administration (EMDA) presents a minimally invasive method of intravesical instillation of therapeutic agents without the need for general anesthesia. 1 It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between 2 electrodes. 2 This video shows feasibility of botulinum toxin type A (BoNTA) EMDA in myelomeningocele children with urinary incontinence secondary to neuropathic detrusor overactivity., Methods: In this technique (Video 1), catheterization was performed with a 10-Fr (CE-DAS, UROGENICS/Ag 9900 (pediatric), Mirandola, Italy) catheter electrode, after providing a local transurethral anesthesia with 2% lidocaine gel. The cuff of the catheter was filled by 2 cc saline solution. The bladder was then drained and irrigated with 0.9% saline solution until the catheter outflow became clear. The bladder was subsequently filled with sterile water to its maximal capacity. BoNTA (Dysport) at a dose of 10 IU/kg was added to the intravesical solution. Negative electrode as 2 dispersive electrodes was placed on the abdomen. Positive electrode was connected to the intravesical catheter. A pulsed current generator (Physionizer 30, Physion srl, Mirandola, Italy), delivered a current with frequency of 2,800 Hz, interval of 50 µs and amplitude of 10-20 mA for 20 minutes. At the end of the procedure, the bladder was emptied., Results: For the first time, BoNTA/EMDA was performed on myelomeningocele patients with urinary incontinence in our center. 3 According to our prior reports, urinary incontinence improved in 75% of the patients between 2 consecutive clean intermittent catheterizations at 1-year follow-up. 4 Mean maximal cystometric capacity significantly increased from 148 ± 62 mL at baseline to 239 ± 73 mL 1 year after the treatment. 4 CONCLUSION: This technique is a feasible, safe, reproducible, cost effective, long lasting, and pain free method, on an outpatient basis with long-term duration of effects and without anesthesia or cystoscopy procedure., (Copyright © 2019. Published by Elsevier Inc.)

Purpose of Review: Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction., Recent Findings: Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Introduction: During the past decade, increased efforts have been made to develop alternative management options instead of dialysis and homograft renal transplantation for end-stage renal disease. State-of-the-art methods employ tissue engineering to produce natural acellular scaffolds that could resolve the concern of allograft rejection and obviate the need for immunosuppressive therapy. Complete decellularization of kidney with intact extracellular matrix is crucial for in vivo compatibility and success of transplantation. Herein, we evaluate the efficacy of two different whole organ decellularization protocols, vasculature integrity, and in vivo transplantation of sheep kidneys., Materials and Methods: Eight sheep kidneys were decellularized by perfusion-based method utilizing two different protocols (Protocol 1: 1% Triton X-100 and 0.5% SDS vs. Protocol 2: 1% SDS). The samples were evaluated by histopathology in terms of decellularization and extracellular matrix preservation. Computerized tomography angiography was performed to evaluate vasculature. Subsequently, both methods were transplanted in four sheep and monitored for vascular integrity and extravasations in short-term., Results: Scaffolds obtained from both protocols were entirely decellularized. However; the extracellular matrix was better preserved in protocol 1 compared to protocol 2. In addition, the vascular integrity was intact in decellularized scaffolds treated with Triton X-100 plus SDS (protocol 1). After transplantation, the samples treated with protocol 2 showed extravasation of fluid in the interstitial space while the samples treated with protocol 1 showed intact extracellular matrix and vasculature., Conclusions: This study demonstrated the efficacy of well-preserved acellular scaffold and vasculature network in post renal transplant outcome in a sheep model. These results have potential to pave the road for further investigations in acellular whole organ transplantation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To assess the efficacy of combined transcutaneous interferential (IF) electrical stimulation and pelvic floor muscle training through biofeedback on non-neuropathic urinary incontinence in children., Methods: This prospective study comprised of 46 anatomically and neurologically normal children (9 boys, 37 girls; mean age of 8.4 ± 2.2 years old) with non-neuropathic urinary incontinence. All children were evaluated by kidney and bladder ultrasounds, uroflowmetry with electromyography (EMG), a complete voiding diary and a dysfunctional voiding scoring questionnaire at the baseline. Children were randomly allocated into two treatment groups including group A (n = 23) who underwent biofeedback therapy in addition to IF electrical stimulation and group B (n = 23) who received only biofeedback therapy. Re-evaluation was performed 6 months and one year after completion of the treatment sessions., Results: Improvement of non-neuropathic urinary incontinence was significantly higher in group A in comparison to group B at two follow ups (P < 0.05). Daytime incontinence was improved in 19/23(82%) and 13/23(56.5%) of children in groups A and B respectively after the treatment (P < 0.01). There was no significant difference in uroflowmetry measures between two groups after the treatment., Conclusions: Combination of biofeedback therapy and transcutaneous IF electrical stimulation is a potential effective modality in treating non-neuropathic urinary incontinence in children., Level of Evidence: Type of study: Treatment study. Level I: Randomized controlled trials with adequate statistical power to detect differences (narrow confidence intervals) and follow up >80%., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To determine the different urine flow patterns and active pelvic floor electromyography (EMG) during voiding in children with vesicoureteral reflux (VUR) as well as presenting the prevalence of lower urinary tract symptoms in these patients., Materials and Methods: We retrospectively reviewed the charts of children diagnosed with VUR after toilet training from Sep 2013 to Jan 2016. 225 anatomically and neurologically normal children were included. The reflux was diagnosed with voiding cystourethrography. The study was comprised an interview by means of a symptom questionnaire, a voiding diary, uroflowmetry with EMG and kidney and bladder ultrasounds. Urine flow patterns were classified as bell shape, staccato, interrupted, tower and plateau based on the current International Children's Continence Society guidelines., Results: Of 225 children with VUR (175 girls, 50 boys), underwent uroflowmetry + EMG, 151 (67.1%) had an abnormal urine flow pattern. An active pelvic floor EMG during voiding was confirmed in 113 (50.2%) children. The flow patterns were staccato in 76 (33.7 %), interrupted in 41 (18.2%), Plateau in 26 (11.5%), tower in 12 (5.3%) and a bell shape or normal pattern in 70 (31.5%). Urinary tract infection, enuresis and constipation respectively, were more frequent symptoms in these patients., Conclusions: Bladder/bowel dysfunction is common in patients with VUR that increases the risk of breakthrough urinary tract infections in children receiving antibiotic prophylaxis and reduces the success rate for endoscopic injection therapy. Therefore investigation of voiding dysfunction with primary assessment tools can be used prior to treating VUR., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objective: To investigate the long-term efficacy and success rate of intravesical electromotive botulinum toxin type A (BoNTA) "Dysport" administration in patients with myelomeningocele who had urinary incontinence due to neuropathic detrusor overactivity (NDO)., Materials and Methods: Twenty-four patients with myelomeningocele (mean age: 9 ± 3.6 years, range: 3-16) were included in the study and followed up for 6 years. Using an electrode bladder catheter, 10 IU/kg of Dysport (BoNTA) was inserted into the bladder for electromotive drug administration (EMDA) without anesthesia on outpatient basis. The EMDA equipment was connected to the electrode of an indwelling catheter and 2 dispersive electrodes, and a pulsed current generator delivered 10 mA for 20 minutes. The preliminary assessments were voiding diary, urodynamic study, kidney and bladder ultrasounds which were also performed annually., Results: Prior to the treatment, all patients had NDO and urinary incontinence. During the follow-up, 18 of 24 (75%), 11 of 24 (45.5%), 9 of 24 (37.5%), 8 of 24 (33%), and 7 of 24 (29.1%) of the patients were completely dry between 2 consecutive clean intermittent catheterizations after once BoNTA-EMDA treatment at 1, 2, 3, 5, and 6 years of follow-up, respectively. The mean maximum detrusor pressure significantly decreased and mean maximal cystometric capacity significantly increased at follow-ups (P <.05)., Conclusion: The results of the present study have shown that BoNTA-EMDA is a feasible, safe, reproducible, cost-effective, long-lasting, and pain free method on an outpatient basis, with long-term duration of effects without anesthesia or cystoscopy procedure. This novel delivery system resulted in considerable improvement in urinary incontinence and urodynamic study parameters in patients with refractory NDO., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Functional constipation is a common condition in children. We assessed the effectiveness of combined interferential (IF) electrical stimulation and pelvic floor muscle (PFM) exercises on functional constipation in children., Methods: We conducted a single-center, double-blind randomized clinical trial study during 2014-2017 in Tehran, Iran. Ninety children, aged 5-13 years, who fulfilled Rome III criteria were enrolled and randomly assigned into two treatment groups. Case group (n=45) underwent IF electrical stimulation and PFM exercises, whereas the control group (n=45) received PFM exercises plus sham stimulation. A complete bowel habit diary (with concerning data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before, after the treatment and 6 months later for all participants. In addition, children in both groups were assessed with a constipation-related quality-of-life questionnaire before, after the end of treatment sessions, and 6 months after the treatment., Results: Treatment success was achieved for 88.4% of children in the case group compared with 43.2% of children in the control group after the treatment (P<0.003). The median constipation score was reduced in both groups, with the cases having significantly lower scores after the treatment (4 vs. 8, P<0.000). Stool form normalized in 75.6% of the cases and 45.5% of the controls after the treatment (P<0.01)., Conclusions: Our results showed that using IF electrical stimulation as an adjuvant therapy to the medical and rehabilitation programs significantly boosts the effects of treatment among these patients.

Introduction: Underactive bladder (UAB) is a common cause of lower urinary tract dysfunction which has an increasing incidence with aging. It is characterized as an incompetent detrusor contraction with reduced strength and/or duration to completely empty the bladder. UAB is observed in both men and women. The exact definition, classification, and pathophysiological mechanism responsible for UAB is still debatable, however neurologic, myogenic, and iatrogenic causes are explained. The symptom complex related to UAB includes hesitancy, diminished sensation of bladder filling, a slow urinary stream, increased post-void residue, and etc. Areas covered: We reviewed the current understanding of UAB with special focus on pharmacological treatments and potential pharmacotherapy options particularly in neurological conditions. Also, the definition, etiology, symptoms, diagnosis and management of UAB were discussed in this review. Expert commentary: The underlying mechanism of UAB is not clear yet. Therefore; the lack of efficient pharmacotherapies is evident in such patients. Prior to any decision for pharmacological or surgical interventions, the underlying causes of UAB and detrusor impairment in each patient should be distinguished. Future researches need to address the exact dynamics of detrusor contraction and the muscular and neurological contributors to UAB.

Purpose: We assessed the effectiveness of transcutaneous interferential (IF) electrical stimulation on constipation in postoperative Hirschsprung's disease (HD) patients., Methods: Thirty HD children (18 boys and 12 girls) with constipation who had no surgical complication were enrolled and then randomly divided into two treatment groups. The control group underwent only behavioral therapy comprising high fiber diet, hydration, toilet training and pelvic floor muscles exercises while; the IF group underwent behavioral therapy plus IF electrical stimulation. Patients underwent anorectal manometry before and 6months after the treatment. In addition, a complete bowel diary with data on the frequency of defecation per week, stool form and the number of fecal soiling episodes, a constipation score and a visual pain score were obtained from all patients before, after treatment and 6months later., Results: Constipation symptoms were improved in 10 (66%) and 4 (26.6%) patients in IF and control groups, respectively at 6months of follow up (P<0.03). Frequency of defecation per week significantly increased after the treatment in the IF group compared with control group at the 6months of follow up (5.4±2.1 vs. 3.3±1.8 per week, respectively; P<0.009). In addition, mean pain score was significantly decreased in IF group compared with controls after treatment (P<0.05)., Conclusion: IF electrical stimulation is an effective adjunct to behavioral therapy to overcome symptoms of constipation in postoperative HD patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To assess the efficacy of transcutaneous interferential electrical stimulation (IFES) and urotherapy in the management of non-neuropathic underactive bladder (UAB) in children with voiding dysfunction., Patients and Methods: In all, 36 children with UAB without neuropathic disease [15 boys, 21 girls; mean (sd) age 8.9 (2.6) years] were enrolled and then randomly allocated to two equal treatment groups comprising IFES and control groups. The control group underwent only standard urotherapy comprising diet, hydration, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation. Children in the IFES group likewise underwent standard urotherapy and also received IFES. Children in both groups underwent a 15-session treatment programme twice a week. A complete voiding and bowel habit diary was completed by parents before, after treatment, and 1 year later. Bladder ultrasound and uroflowmetry/electromyography were performed before, at the end of treatment course, and at the 1-year follow-up., Results: The mean (sd) number of voiding episodes before treatment was 2.6 (1) and 2.7 (0.76) times/day in the IFES and control groups, respectively, which significantly increased after IFES therapy in IFES group, compared with only standard urotherapy in the control group [6.3 (1.4) vs 4.7 (1.3) times/day, P < 0.002). The mean (sd) bladder capacity before treatment was 424 (123) and 463 (121) mL in the control and IFES groups, respectively, which decreased significantly at 1 year after treatment in the IFES group compared with the controls, at 227 (86) vs 344 (127) mL (P < 0.01). Maximum urine flow increased and voiding time decreased significantly in the IFES group compared with controls at the end of treatment sessions and 1 year later (P < 0.05). All the children had abnormal flow curves at the beginning of the study. The flow curve became normal in 14/18 (77%) of the children in the IFES group and six of 18 (33%) in the control group by the end of follow-up (P < 0.007). At the end of the treatment course, night-time wetting was improved in all children who had this symptom before the treatment in the IFES group (P < 0.01)., Conclusion: Combining IFES and urotherapy is a safe and effective therapy in the management of children with UAB., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

In this study, a novel technique of irreversible sphincter deficiency by pudendal nerve transection (PNT) using 40 female rats for studying the pathophysiology of stress urinary incontinence associated with childbirth was developed. Of the 40 rats, 10 served as controls and the remaining underwent bilateral PNT at the anastomotic lumbosacral trunk level. Urethral morphological changes following bilateral PNT were assessed with serial hematoxylin and eosin (H&E) and immunohistochemistry (IHC) staining methods at 50, 90, and 130 days post-intervention. Leak point pressure (LPP) measurement was used to determine the effect of pudendal injury on urethral outlet resistance after the transection. H&E and IHC staining showed irreversible loss of striated muscle mass of the sphincter region and increase in collagen deposition compatible with muscle atrophy. LPP measurements also significantly decreased following bilateral PNT. In conclusion, a novel method of irreversible sphincter insufficiency was developed. This model effectively decreased urethral outlet resistance and caused irreversible striated muscle atrophy. It was suggested that this technique can be used to develop a permanent sphincter deficiency model for the preclinical testing of treatment modalities exclusively triggering the pudendal nerve., (© 2015 Wiley Periodicals, Inc.)

Bladder duplication is a rare entity in children. The term encompasses a wide spectrum of anomalies from isolated bladder duplication in coronal or sagittal planes to duplicated bladder exstrophy and associated musculoskeletal and visceral anomalies. Given this wide variability, the treatment of these patients is not standardized. We hereby present a female patient with chief complaint of long-standing urinary incontinence who had complete bladder and urethral duplication and pubic diastasis. The patient was treated with bulking agent injection at the incompetent bladder neck and proximal urethra with resolution of incontinence, obviating the need for extensive surgeries.

Introduction: To report the feasibility, efficacy and safety of decellularized dermal strip as a sling material in the pudendal denervated stress urinary incontinence (SUI) in an animal model., Methods: Thirty female Sprague-Dawley rats were randomly allocated into three equal groups (n = 10). In group 1, rats underwent bilateral pudendal nerve transection (BPNT) with no vaginal sling placement. Group 2 underwent BPNT with homologous decellularized dermal strip placement as vaginal sling 12 weeks later. Group 3 was considered as controls to evaluate baseline leak point pressure (LPP). Leak point pressure was measured 18 weeks after BPNT in group 1 and 6 weeks after sling implantation in group 2. Sling and sphincter samples were prepared for histological and immunohistochemistry (IHC) staining., Results: H&E staining of external urethral sphincter showed decrease in striated muscle layer in group 1 (BPNT) compared to control confirmed by desmin staining (45 % decrease in desmin staining). Sling implantation caused significant increase in mean LPP from 11.6 ± 2.8 cm H2O in group 1 (BPNT) to 27.2 ± 5.4 cm H2O in group 2 (BPNT/sling). There was no significant difference between LPP after the sling placement in group 2 and LPP in group 3 (27.2 ± 5.4 cm H2O vs. 27.6 ± 5.9, P = 0.832). IHC staining was positive for α-SMA and CD34., Conclusions: Based on present results, this dermal strip could be considered as a potential sling material for treatment of SUI in this animal model. This study provides the basis for further investigation of the efficacy of biological decellularized scaffold as suburethral sling material.

Background: Electrical stimulation has been used as an alternative therapy for adult urinary syndromes and for children with constipation. We have evaluated the safety and efficacy of interferential (IF) electrical stimulation in children with nocturnal enuresis (NE)., Methods: This was a randomized clinical trial in which 54 children (23 girls, 31 boys) aged 6-14 years with primary NE were recruited and randomly divided into two groups. Children in the control group underwent standard urotherapy only (hydration, scheduled voiding, toilet training, diet), whereas children in the IF group (cases) were treated with standard urotherapy + 15 sessions of IF electrical stimulation for 20 min twice per week. An improvement score was calculated to identify relative decrease in wet nights after the treatment for each child. All children were followed for 1 year., Results: Overall, 15/27 (55.5%) and 6/27 (22%) of children in the IF and control groups responded to treatment at the 1-year follow-up (P = 0.01). The mean number of wet nights per week in the control and IF groups decreased from 5.4 ± 2 and 5.7 ± 2 to 3.3 ± 3 and 1.1 ± 2, respectively, at first evaluation (P = 0.003). The mean improvement score in the IF group was significantly higher than that of the control group after 1 year (78 vs. 46%, respectively; P = 0.004)., Conclusion: Interferential therapy can be applied as a safe, effective and well-tolerable alternative therapy in the treatment of children with NE.

Unlabelled: We report the clinical results of two types of urotherapy programs in children with dysfunctional voiding (DV). Sixty children with a median age of 8 (range, 5-14) diagnosed with DV were randomly allocated to one of two groups, each made up of 30 patients. Patients in group A underwent behavioral urotherapy (hydration, scheduled voiding, toilet training, and high-fiber diet) combined with pelvic floor muscle (PFM) exercises, whereas group B only received behavioral urotherapy. All parents completed a voiding and bowel habit diary chart. Uroflowmetry with pelvic floor surface electromyography (EMG) and bladder ultrasound were performed on all patients at the beginning and the end of the 1-year study. Abnormal voiding pattern normalized to a bell shape in 21/30 of patients in group A and 8/30 of patients in group B (P < 0.000). EMG activity during voiding disappeared significantly in 23/30 patients in group A compared to 15/30 patients in group B (P < 0.02). Episodes of urgency resolved in 12/14 of patients in group A and 3/11 of patients in group B (P < 0.01). Daytime wetting improved in 15/17 and 4/11 of patients in groups A and B, respectively. In addition, reduction in post-void residue (PVR) was significant in group A (P < 0.003)., Conclusion: Functional PFM exercises with Swiss ball combined with behavioral urotherapy proved as a safe and effective therapeutic modality, reducing the frequency of urinary incontinence, PVR, and the severity of constipation in children with DV.