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Purpose: Posterior urethral valves (PUVs) are the most common cause of congenital bladder obstruction in boys. Our aim was to assess the impact of early diagnosis and fulguration of PUVs on bladder function and compare their functional and urodynamic outcome with children who underwent delayed intervention. Materials and Methods: We retrospectively evaluated 153 patients who underwent primary valve ablation from two tertiary hospitals between 2001 and 2018. Patients have been divided into 2 groups, group 1 included 69 patients who were detected antenatally and underwent early fulguration of PUVs while group 2 included 84 children presented postnatally and underwent delayed valve ablation. The recorded data throughout follow-up in renal function tests, urodynamics and changes in the upper urinary tracts were evaluated and compared. Results: Median age at time of valve ablation was 10 days in group 1 and 7 months in group 2. The median follow-up period was 6.5 and 7 years in group 1 and 2, respectively. Chronic kidney disease (CKD) developed in 15 (22%) boys in group 1 while in group 2 it was observed in 31 (37%), p=0.04. While Q-max, mean bladder capacity and post-void residual (PVR) volumes were comparable in both groups, percent PVR was significantly higher in group 2 (3.27 vs. 1.44, p=0.002). Detrusor overactivity was slightly different in both groups (p = 0.07). Conclusions: Compared to delayed intervention, primary ablation of PUVs during the early neonatal life possibly provides the optimum chance to have optimum renal function without impact on bladder function.

Testicular tumors are not uncommon in children and represent 1%-2% of all pediatric malignancies. Prepubertal testicular yolk sac tumor is the most common childhood testicular cancer, accounting for 70%-80% of all cases. The clinical presentation varies from one patient to another; most common presentation is painless scrotal mass. Herein, we present a case of pediatric patient with a testicular yolk sac tumor who had unusual presentation followed by a local relapse and metastasis and continued to have high markers while he was on chemotherapy, then underwent retroperitoneal lymph node dissection and local recurrence excision.

Objective Vesicoureteral reflux (VUR) is a common finding in the pediatric population with the risk of repeated infections and renal damage. There is little is known about the natural history of primary bilateral high-grade reflux. Herein we present our experience in the management of primary high-grade bilateral VUR and the long-term outcome of renal function in this specific group of patients. Materials and methods We retrospectively evaluated all patients with congenital bilateral VUR between 2006 and 2014. Records were reviewed for patient age at diagnosis, antenatal history, clinical presentation, the grade of VUR on voiding cystourethrogram (VCUG), presence of scars on dimercaptosuccinic acid (DMSA) scan, indications for surgical intervention, and surgical approaches. Clinical and radiological outcomes of this subgroup of patients were assessed. Results A total of 67 patients with bilateral VUR were identified, of whom 31 (20 boys and 11 girls) had primary high-grade (grade IV and V) bilateral VUR. The mean age at diagnosis was seven months. DMSA scans showed renal scars in 19 patients (61%) and eight of them were bilateral. Surgical intervention was necessary for 81% of patients with a success rate of 58% after endoscopic correction and 100% after reimplantation. Chronic kidney disease (CKD) developed in 13 patients (42%) after a mean follow-up of eight years. Conclusions Primary bilateral high-grade VUR carries a high rate of surgical intervention. The endoscopic correction has an acceptable success rate and efficient long-term outcome. Nevertheless, a significant proportion of patients progresses to CKD even after VUR management.

Summary Introduction and objective Ureteropelvic junction obstruction (UPJO) is a common pathology in pediatric urology practice. Indications for intervention are well established while the ideal management of children with UPJO in poorly functioning kidneys is still debatable. We aimed in this study to evaluate the outcome of pyeloplasty in patients with UPJO and low DRF ≤20%. Study design We retrospectively evaluated 218 children with congenital UPJO from two tertiary hospitals between 2008 and 2018. We included only those with primary unilateral UPJO and DRF ≤20% on diuretic renography. Open dismembered pyeloplasty with stenting was carried out in all. Patients with bilateral UPJO, solitary kidney, DRF above 20%, association with other urinary anomalies and patients who underwent previous renal or ureteric surgeries and patients with missed follow-up were excluded. Clinical and radiological outcomes of this subgroup of patients were assessed. Results A total of 21 patients (12 boys, 9 girls) with a median age at surgery of 2 years were included. Preoperative DRF ranged from 8 to 20% with a mean of 15% ± 3.5%. The median follow-up period was 2.5 years. Renal ultrasound showed improved HN in 16 patients (4 had a complete resolution) and stable in the remaining 5. Most of the improvement was noted in the first postoperative ultrasonography 16/21 (76%). Diuretic renography showed improved DRF by 10–15% in 8 patients (38%) while the remaining patients showed stable DRF with a non-obstructive curve with a mean improvement in DRF of 8 ± 5%. No postoperative complications were encountered and none of our patients required reintervention during follow-up. Discussion The ideal management of children with UPJO and poorly functioning kidneys is still arguable. In our study we evaluated the outcome of pyeloplasty in patients with a low DRF ≤ 20% aiming to test the patients’ variables that can affect the improvement of DRF and HN grade after surgical intervention, however, none of these preoperative variables seemed to be a significant predictor. Conclusions Children with unilateral UPJO and DRF ≤ 20% have a favorable outcome after pyeloplasty. Improvement of HN in the first postoperative renal ultrasound is a good indicator for success.

Background Crossed fused renal ectopia (CFRE) is a rare congenital malformation. Renal bladder ultrasound (RBUS) is a good tool for establishing the diagnosis, however, additional imaging with a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid scan (DMSA) might be required. We assessed the need for postnatal evaluation and the long-term consequences in patients with this diagnosis. Methods A retrospective review of the records of all patients diagnosed with CFRE between 2004 and 2014 was done. We included all patients who underwent postnatal evaluation with RBUS, DMSA and VCUG. Long-term radiological and functional outcomes were assessed. Results A total of 29 patients with CFRE were identified. Majority of cases were detected antenatally (79%) and left to right crossed ectopia constituted the majority of cases (65%). RBUS revealed associated hydronephrosis (HN) in 11 patients (38%). DMSA scans confirmed the diagnosis in all patients and showed impaired renal function in 10 ectopic kidneys (34%). Vesicoureteral reflux was detected in 12 patients (41%); one third of them needed surgical intervention. Extra-urinary anomalies were present in 14 patients (48%) mainly of cardiac origin. After a mean follow-up of 4.5 years, 4 patients (14%) with extra-urinary anomalies developed chronic kidney disease and two of them died. Conclusions Crossed fused renal ectopia is commonly associated with both urinary and extraurinary malformations. Postnatal RBUS is usually sufficient for diagnosis, however, additional imaging may aid for confirming the diagnosis and detection of associated urinary anomalies. Presence of extra-urinary malformations with crossed fused ectopia carries a higher risk of morbidity. Type of the Study Retrospective study [diagnostic/prognostic study]. Level of Evidence Level IV.

Background The therapeutic potential of bone marrow-derived mesenchymal stem cells (BM-MSCs) against cisplatin-induced nephrotoxicity has been reported, however, its efficacy in gonadotoxicity still has not been addressed. Herein, we investigated the effect of BM-MSCs in cisplatin-induced testicular toxicity and its underlying mechanism of action. Methods Thirty male Sprague–Dawley rats were divided into a control group: injected with phosphate-buffered saline (PBS) intraperitoneal (ip), a cisplatin group: injected with a single dose of 7 mg/kg cisplatin ip to induce gonadotoxicity and a BM-MSCs group: received cisplatin ip followed by BM-MSCs injection 1 day after cisplatin. In testicular tissues, malondialdehyde (MDA), superoxide dismutase (SOD), and reduced glutathione (GSH) levels were assessed. Additionally, gene expressions of inducible nitric oxide synthase (iNOS), caspase-3, and p38 mitogen-activated protein kinase (MAPK) were measured. The testicular tumor necrosis factor alpha (TNF-α) protein contents and Bcl-2 associated X protein (BAX) expression were determined. Histopathology of testicular tissues was examined. Results Cisplatin injection showed a significant decrease in GSH and SOD testicular levels besides a significant increase of MDA and TNF-α testicular levels and upregulation of testicular gene expressions of iNOS, caspase-3, and p38-MAPK in comparison to the control group. Moreover, a marked increase in BAX protein expression was observed in the cisplatin group when compared with the control one. Histopathological examination exhibited significant seminiferous tubules atrophy in cisplatin-treated rats. Conclusions The BM-MSCs injection significantly repaired the testicular injury and improved both biochemical and histopathological changes. The MSCs mitigated the gonadotoxicity induced by cisplatin through antioxidative, anti-inflammatory, and antiapoptotic mechanisms.

Purpose: The aim is to assess the outcomes of different approaches for the management of renal stones associated with horseshoe kidneys (HSKs) in our institution over a 12-year period. Methods: A retrospective review of 144 patients with HSKs who presented from 2000 to 2012 was performed. Twenty-eight patients (19.4%) were found to have renal stones. Demographic data were collected; the method of treatment and the outcomes of stone management were reviewed. We excluded patients with non-functioning moieties and associated genitourinary anomalies, and those with incomplete data. Results: We included 25 patients, of which 16 males (64%) and 9 females (36%), with a mean age of 37 years. Mean serum creatinine level was 66 mmol/L. Eleven patients with a stone size 2 cm were treated with percutaneous nephrolithotomy. One patient with a 10 mm stone was treated using flexible ureteroscopy. No significant perioperative complications were encountered. Conclusions: Indications, methods of treatment, and outcomes of management of stones associated with HSKs were comparable to those for stones associated with normal kidneys. Tailored approach based on stone size is highly recommended. ESWL accompanied with ureteric stenting is a promising strategy for the management of stones associated with HSKs in selected patients requiring intervention.

Cisplatin (CDDP) is widely used as an effective chemotherapy; nevertheless, its use is associated with male reproductive system damage. Candesartan (Cand) is an angiotensin II receptor blocker which showed a protective effect against CDDP-induced testicular toxicity. This study was implemented to investigate further novel molecular protective effect of Cand. Animals were divided into four groups and treated for 10 days as: Group I (Normal control): received saline, Group II (Cand control): treated with Cand (10 mg/kg/day) orally, Group III (CDDP): injected with a single dose of 10 mg/kg CDDP intraperitoneally (ip), Group IV (Cand + CDDP): treated with Cand (10 mg/kg/day) orally plus a single ip dose of 10 mg/kg CDDP at day 3. Blood and testicular tissue collections were done at the end of the experiment. A marked decrease in testicular, body, and relative body weights in addition to testosterone level was observed in the CDDP group when compared with normal rats. In addition, exposure to CDDP showed a marked upregulation of testicular TNF-α mRNA level and a significant rise in testicular levels of total oxidant status, oxidative stress index (OSI) ratio, pro-apoptotic protein Bax, Bax/Bcl-2 ratio alongside with a marked reduction in testicular levels of total antioxidant status, antiapoptotic protein Bcl-2, and a significant upregulation of the testicular caspase-3 expression in comparison to normal group. Histopathological findings after CDDP injection showed apoptosis and necrosis in testicular tissues. Administration of Cand ameliorated these biochemical and histopathological findings. Cand exhibited a novel protective mechanism against CDDP induced-gonadal damage via antioxidant, anti-inflammatory, and anti-apoptotic activities. Impact statement Cisplatin is a commonly used drug in the treatment of solid tumors and its application is associated with testicular toxicity. The effect of candesartan in cisplatin-induced testicular toxicity and its fundamental mechanism of action were investigated. Candesartan had certainly repaired the testicular injury and ameliorated both biochemical and histopathological changes. Candesartan mitigated the gonadotoxicity induced by cisplatin via antioxidative, anti-inflammatory, and antiapoptotic actions.

Summary Introduction and Objective Anderson–Hynes dismembered pyeloplasty is considered the standard surgical treatment for ureteropelvic junction obstruction (UPJO). After pyeloplasty, stent drainage remains controversial. The commonly used stents are either an internal double-J (DJ) or an externalized pyeloureteral (PU) stents. We evaluated the outcome of using DJ versus PU stents following open pyeloplasty for UPJO in children. Study design We retrospectively evaluated 175 patients who underwent primary open pyeloplasty in two tertiary hospitals. A total of 110 patients underwent internal DJ stent insertion (63%) while 65 patients (37%) underwent placement of external PU stent. The type of stent used at the time of surgery was according to surgeon preference and experience. Operative time, postoperative hospital stay, overall complications and success rates were compared between the two groups. Results The mean age was 3.8 years, and the mean follow-up was 4 years. Mean operative time was similar in the two groups (145 min). Mean hospital stay was 3.7 and 4.2 days in DJ and PU stent, respectively (p = 0.003) Summary Table . Postoperative complication developed in 9 out of 110 patients with DJ stent (8%), while complications developed in 6 out of 65 patients with PU stent (9%) (p = 0.81). Success rate of pyeloplasty was 95.5% for DJ group versus 97% for PU group (p = 0.63). Discussion Dismembered pyeloplasty remains the standard treatment of choice as a surgical management for UPJO. A debate is still there in respect to the method of PU anastomotic stenting and which stent can be used. The major advantage for external PU stents is that it can be removed safely in the outpatient clinic without any sedation preventing the risk of repeated exposure to general anesthesia. Internal DJ stent provides a shorter hospital stay and comparable complication and success rates compared with PU stent. If we manage to overcome the longer DJ stent duration and facilitate early removal by an easy mode, that does not require another anesthesia at that moment we can find the optimal stent for all pyeloplasty cases. Conclusions The two types of stents are comparable as regard overall complication and success rates after pyeloplasty. Although internal DJ stent insertion provides a relatively shorter hospital stay, a second operating room visit and anesthesia for removal remains unavoidable.

Summary Introduction and objective Laparoscopic nephrectomy (LN) is an established technique for the management of benign non-functioning kidneys in children. It can be performed either by the transperitoneal (TP) or retroperitoneal (RP) approach. The aim of this study was to compare safety and efficacy of TP with RP approach for LN in children. Study design Between 2007 and 2019, 79 consecutive pediatric patients with benign non-functioning kidneys underwent laparoscopic nephrectomy by a single surgeon. Patients were categorized into two groups according to the approach; Group 1 included 41 patients who underwent transperitoneal laparoscopic nephrectomy (TPLN), while Group 2 included 38 patients who underwent retroperitoneal laparoscopic nephrectomy (RPLN). Comparison was done between the two groups regarding the mean operative time, complications, time to resume oral intake, need for postoperative analgesia and postoperative hospital stay. Results Laparoscopic nephrectomy was successfully completed in 75 of the 79 cases. Four cases were converted to open surgery: 3 from the TPLN group and one from the RPLN group (p = 0.34). There was statistically significant difference between the two groups in terms of estimated blood loss (p = 0.013), time to resume oral intake (p = 0.001) and postoperative hospital stay (p = 0.024). Overall, there was no statistically significant difference as regard mean operative time, overall complication rate, and postoperative analgesia need. Discussion LN is now an established technique in children and surgeon experience is a limiting factor. This experience should be gained progressively with respect to both TP and RP approaches to deal with different indications by optimal approach. Both TP and RP approaches are excellent approaches and it is up to individual surgeons, based on their experience, which approach they select. In this study, a comparative study was made between both TP and RP approaches for pediatric LN. There was no statistically significant difference between the two approaches as regard success rate, mean operative time, need for postoperative analgesia and overall complication rate. In the meantime, RPLN had the advantage of lower intraoperative blood loss, shorter time to resume oral intake and shorter hospital stay. Conclusions Laparoscopic nephrectomy in children may be performed by transperitoneal or retroperitoneal approaches, obtaining equal safety and efficacy. The retroperitoneal approach seems to be advantageous in terms of lower intraoperative blood loss, time to resume oral intake and shorter postoperative hospital stay.

Objective: To investigate the relationship between low birth weight (LBW

Hemorrhagic cystitis is one of the devastating complications seen after receiving cyclophosphamide chemotherapy. Oleuropein is the most important phenolic compound of olive leaves that mediates most of its beneficial pharmacological properties. Herein, we investigated the possible uroprotective effect of oleuropein against cyclophosphamide induced hemorrhagic cystitis in a rat model. For this purpose, we measured bladder nitric oxide, reduced glutathione, catalase, tumor necrosis factor-alpha and vascular endothelial growth factor levels in addition to the bladder gene expression of intercellular adhesion molecule-1 after induction of hemorrhagic cystitis in the presence or absence of oleuropein. Histopathological examination of bladder tissues was also performed. After cyclophosphamide injection, we demonstrated a significant decrease in bladder reduced glutathione (39%) and catalase (55.4%) levels and a significant increase of nitric oxide (5.6 folds), tumor necrosis factor-alpha (3.3 folds), vascular endothelial growth factor (2 folds) and intercellular adhesion molecule-1 (8 folds) bladder contents when compared to those in normal control rats. Administration of oleuropein induced a marked elevation in bladder reduced glutathione (37.8%), catalase (100.4%) with a prominent reduction of bladder nitric oxide (40%), tumor necrosis factor-alpha (35.9%) and vascular endothelial growth factor (56.2%) levels along with downregulation of intercellular adhesion molecule-1 bladder expression (73.1%) in comparison to cyclophosphamide treated rats levels. Our data demonstrated that oleuropein counteracts the harmful effects of cyclophosphamide on the bladder through its antioxidant and anti-inflammatory activities. Oleuropein exerts a definite uroprotective effect against cyclophosphamide induced hemorrhagic cystitis in rats.

Background: Orchidopexy is a procedure of securing the testis inside the scrotum in patients with cryptorchidism. In the literature, various dissection techniques have been described to lengthen the spermatic cord to ensure a tension-free fixation of the testis to the lowest point of the scrotum. Objectives: The aim of this study is to determine if incorrect measurement of the spermatic cord’s length during open inguinal orchidopexy had led surgeons to over dissect the cord in a way that may pose an increased risk of testes, vas deferens and spermatic vessels. Materials and Methods: We prospectively studied the results of 40 orchidopexies performed in 40 patients with peeping or canalicular undescended testis , which was done at the Jordan university hospital in Amman from April 2018 to March 2019 , We compared the position of the testis before and after tunneling inside the inguinal canal. The difference in length is measured and analyzed. Conclusion: Failure to account for the subcutaneous fat layer thickness during orchidopexy increases the likelihood of over dissecting the spermatic cord which increases the risk of vas and vessels injury In this study we found that there is a difference between the cord length outside and inside the canal with excess length after passing the cord inside the canal ranges from 1-3 cm . This means that we do not need to dissect the cord to make the testis reaches the scrotum from outside. This decreases the risk of harming the cord and its contents.

Highlights • The absence of nasal columella has functional and esthetic consequences. • The etiology of isolated congenital absence of nasal columella is still unknown. • Reconstruction of absent columella is challenging due to its complex anatomy., Introduction The nasal columella is an important aesthetic and functional entity of the midface. Congenital absence of the nasal columella as an isolated anomaly is extremely rare. Presentation of case We present a case of total congenital aplasia of the nasal columella in a 3-month-old female infant. The deformity was not associated with any other anomalies and with no obvious underlying cause. Discussion Isolated congenital absence of the nasal columella is an extremely rare anomaly and its etiology is still unknown. Surgical reconstruction of absent nasal columella is challenging as a result of its complex anatomy, and different surgical techniques have been described in the literature to reconstruct the nasal columella with varying advantages and disadvantages. Conclusion The variety in available surgical techniques for the reconstruction of nasal columella necessitates a thorough preoperative evaluation in order to choose the most suitable surgical technique and achieve the best outcome, both functionally and esthetically.

Cysts involving the female external genitalia are rare. These cysts are either congenital or acquired. Iatrogenic epidermoid cysts have been reported after female genital mutilation, which is common in some parts of Africa and the Middle East. We report a case of acquired epidermoid inclusion cyst of the clitoris following female circumcision in a 5-year-old girl. The cyst was surgically excised and histopathologic evaluation revealed an epidermal-type inclusion cyst. Keywords : complication, epidermal inclusion cyst, female circumcision

Purpose We report our experience in the management of ureteropelvic junction obstruction in children with congenital upper urinary tract anomalies.Materials and methods A retrospective review was performed for all children with primary ureteropelvic junction obstruction associated with upper urinary tract anomalies between 1999 and 2011 at our hospital. Medical records were reviewed for patient age, sex, type of urinary tract anomalies, affected side, indication of surgery, and operative details. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at final follow-up.Results There were 12 children (10 boys and two girls) with mean age of 5.3 years (range 1–13 years). Anomalies included ectopic pelvic kidney in six patients, crossed fused ectopia in two, a horseshoe kidney in two, and duplex renal units in two. The left kidney was affected in seven and the right kidney in five children. All patients were managed by open dismembered pyeloplasty. No significant perioperative complications were encountered in the study group. The mean follow-up was 30 months (range 15–45 months). Overall success rate was 84%. Relief of obstruction was evident in 10 patients as documented by intravenous urography or diuretic renography. Secondary nephrectomy was necessitated in two patients; one had severely impaired ipsilateral renal function and the other had recurrent pyelonephritis without radiological improvement.Conclusion Despite the anomalous renal anatomy and the challenging surgical exposure, dismembered pyeloplasty in children with upper urinary tract anomalies has a high success rate with excellent functional results.Keywords: crossed ectopic, horseshoe kidney, obstruction, pyeloplasty, ureter

Introduction: Fetal hydronephrosis (HN) occurs in around 5% of pregnancies and its prognosis depends mainly on the grade of the dilation.We attempted to determine the fate of isolated, unilateral, high-grade HN in children with antenatal diagnosis, emphasizing the risk factors for progression.Methods: We retrospectively evaluated 424 children (690 kidney units) with antenatal HN in the period between 2010 and 2014. We included only those patients with isolated high-grade HN (Society for Fetal Urology [SFU] Grade 3 or 4). Patients with bilateral HN or unilateral HN associated with dilated ureter or reflux and patients with missed followup were excluded. The prognosis of HN (whether improved, stabilized, or progressed) and the need for surgical intervention in this subset of patients was evaluated.Results: A total of 44 children (34 boys and 10 girls) were identified. Ultrasounds showed SFU Grade 3 HN in 24 (54%) and SFU Grade 4 HN in 20 (46%). After a mean followup of three years (range 1‒5), 10 children (23%) needed surgical intervention; four Grade 3 HN (16%) and six Grade 4 HN (30%). The majority of children with differential renal function (DRF) ≥40% (69.5%) were stable or improved. Five girls (50%) and five boys (17%) progressed and required surgical intervention. No patient with a renal pelvis anteroposterior diameter (APD)

Ginkgo biloba leaf extract (GIN) is a popular Chinese herbal medicine. It has a nephroprotective effect against the nephrotoxicity induced by the chemotherapeutic agent methotrexate (MTX). This work was designed to explore the testicular protective role of GIN on MTX-induced testicular injury in a rat model. The experimental protocol lasted for 10 days for the 4 studied groups. First group: received saline (normal control, NC group). The second group was administered GIN (100 mg/kg/day) orally for 10 days (GIN C). Third group: injected with MTX (20 mg/kg ip) only on the fifth day (MTX group). Fourth group: administered GIN for 10 days with MTX injection on the fifth day (GIN+MTX group). MTX induced testicular injury as evident by a marked rise in the malondialdehyde (MDA) content, interleukin-6 (IL-6) and IL-1β protein levels, nuclear factor kappa-B (NF-κB) protein expression, bcl-2 associated × protein (Bax) mRNA expression, p53 mRNA and protein expressions, and miRNA29-a expression along with a marked decline in the serum level of testosterone and superoxide dismutase (SOD) content in testicular tissue in relation to the NC group. Moreover, histopathological testicular damage with a notable decrease in the Johnsen score together with a significant elevation in the testicular injury score was observed in the MTX group in comparison to the NC group. The administration of GIN ameliorated the biochemical changes as well as the testicular histopathological findings and scores. GIN could protect against MTX-induced gonadotoxicity by its antioxidant, anti-inflammatory, antiapoptotic activities plus the regulation of the miRNA-29a testicular expression.

In the present study, the effect of arjunolic acid on testicular damage induced by intraperitoneal injection of rats with 7 mg/kg cisplatin was studied. Cisplatin induced a significant reduction in testicular weights, plasma testosterone, and testicular reduced glutathione levels in addition to a significant elevation of testicular malondialdehyde levels and testicular gene expressions of inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α), and p38 mitogen-activated protein kinase (MAPK) when compared with the control group (p < 0.05). Lower tubular diameters and depletion of germ cells and irregular small seminiferous tubules with Sertoli cells only were observed in the cisplatin group. Arjunolic acid administration significantly corrected the changes in both biochemical and histopathological parameters. Arjunolic acid plays a significant protective role against cisplatin-induced testicular injury by attenuating oxidative stress parameters along with downregulation of iNOS, TNF-α, and p38-MAPK testicular expressions.

Objective To evaluate the impact of imaging modalities on the evaluation and prognosis of children with multicystic dysplastic kidney (MCDK) disease. Patients and methods A retrospective analysis of all children with MCDK diagnosed from 2004 until 2012 was performed. The study included 63 patients for whom all postnatal imaging modalities were available: renal bladder ultrasound (RBUS), dimercaptosuccinic acid scan (DMSA) and voiding cystourethrogram (VCUG). Cases with major congenital abnormalities or incomplete data were excluded. Abnormalities in the contralateral kidney and the fate of MCDK were also addressed. Results At diagnosis, the average age was four-and-a-half months. The majority of cases were detected antenatally (87%). Postnatal RBUS and DMSA scans established the diagnosis of MCDK in 92% and 98% of patients, respectively. DMSA showed photopenic areas in the contralateral kidneys in 10% of patients; all of them had hydronephrosis and were confirmed to have vesicoureteral reflux (VUR). Contralateral VUR was detected in 16 patients; 63% of them had hydronephrosis. After a mean follow-up of three-and-a-half years, involution occurred in 62% of patients and the involution rate was inversely proportional to the initial size. Conclusions The classical appearance of MCDK on RBUS was sufficient to establish the diagnosis in most patients. DMSA scan was more accurate in confirming the diagnosis and evaluating the contralateral kidney. Selective screening for VUR in patients with contralateral hydronephrotic kidney should be considered.

Objective To evaluate the long-term outcomes of perineal anastomotic urethroplasty for post-traumatic pediatric posterior urethral strictures. Methods We retrospectively reviewed the medical records of 65 boys who had a perineal anastomotic urethroplasty for post-traumatic posterior urethral strictures between 1991 and 2010. Patients were followed up for a mean (range) of 78 (13-210) months by a history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Regression analysis was done to assess the predictors of success after urethroplasty. Results The mean (range) age of the patients was 9.3 (3-16) years. The estimated radiographic stricture length before surgery was 2.4 (1-5) cm. All patients presented with a suprapubic cystostomy tube and scheduled for delayed or repeated correction of a urethral stricture. Twenty boys (30%) had failed previous attempts of repair elsewhere. Mean interval between the original trauma and repair in new cases, and since the last repair in recurrent cases, was 7 months. The perineal anastomotic repair was successful in 58 of 65 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in 5 patients and by repeat perineal anastomotic repair in the remaining 2. All boys are continent. There was no chordee or urethral diverticula during the follow-up. Conclusion One-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is feasible with minimal morbidity. Denovo cases and surgeon experience are the predictors of success after urethroplasty.

Background: Organ donation gives thousands of patients a renewed chance at living full and active lives. Unfortunately, the need for organs does not match their availability. This study aims to analyze the effect of demographic factors on the knowledge and awareness of the Jordanian society towards organ donation. Methods: This cross-sectional study was conducted using a self-administered online questionnaire. We included 1041 adult Jordanians from all the governorates of the Hashemite Kingdom of Jordan. Results: Of the 1041 participants, only 124 (11.9%) had previously singed organ donation card. Overall, 827 (79.4%) were fully accepting organ donation. Among 782 participants in the medical field, 639 (81.7%) fully accepted organ donation, compared to 188 out of 259 (72.6%) in the non-medical field (p= 0.002), with no significant effect of any demographic factor on the willingness to sign organ donation card. There was significant difference in the acceptance of donation from brain dead donors (p< 0.001), with participants from medical field and male participants having higher acceptance rates when compared with non-medical and female participants, respectively. The main barrier for organ donation was found to be the desire to be buried as a whole (58.2%), followed by traditional beliefs (47.4%), and family refusal (42.2%). Conclusions: In conclusion, an educational strategy can improve organ donation awareness from an early age by spreading actionable information through social media and conducting nationwide public campaigns.

Objective To assess the need for postnatal evaluation and the long-term consequences in patients with prenatal diagnosis of unilateral renal agenesis (URA). Materials and Methods A retrospective review of the records of all patients with prenatal diagnosis of URA between 2004 and 2013 was done. We included all patients who underwent postnatal evaluation with renal bladder ultrasound (RBUS), dimercaptosuccinic acid scan, and a voiding cystourethrogram. Long-term follow-up included physical examination and assessment of contralateral renal growth. Results A total of 46 children (24 boys and 22 girls) with URA were identified. Ultrasounds showed associated hydronephrosis in 9 patients (19%). Dimercaptosuccinic acid scans confirmed the diagnosis of URA in all patients and showed renal scars in 2 solitary kidneys (4%). Vesicoureteral reflux was diagnosed in 4 patients (12%); all were of low grade and managed conservatively. After a mean follow up of 4 years, RBUS showed compensatory hypertrophy in 31 patients (67%), 3 patients (6%) developed chronic kidney disease, and 2 patients (4%) developed hypertension. Conclusion Prenatally detected cases of URA should be promptly evaluated. RBUS is found to be sufficient for diagnosis. However, additional imaging may be indicated for confirming the diagnosis and detection of other associated urinary anomalies. Serial assessment of the contralateral solitary kidney growth and serum creatinine measurement will be helpful to assess kidney function on the long term.

Purpose. Bilateral Wilms' tumor (WT) is a challenge. Aggressive surgical resection is needed to prevent recurrence. We revised the clinico-epidemiological criteria of bilateral WT patients in our locality and relation to outcome. Subjects and methods. 462 WT patients were registered in three medical centers at Mansoura, Egypt. Twenty five patients had bilateral WT whose medical records were revised for all clinico-epidemiologic data plus treatment details, toxicity, and outcome. Results. The mean age was 34.5 months; 64% of cases were female. Abdominal mass was the commonest presentation (72%). Congenital anomalies were reported in two cases (one case showed hemihypertrophy and the other showed aniridia). About 60% had favorable pathology. Nineteen cases had synchronous bilateral WT (76%) and the remaining (six cases) had metachronous tumors. For the synchronous cases, the response rate to preoperative chemotherapy was 79% and nephron sparing surgery for the least involved kidney was possible in all. Survival rate was 74%. Metachronous tumor management included nephrectomy followed by chemotherapy for the initially diagnosed tumors. However, nephron sparing surgery of the contralateral tumors following preoperative chemotherapy was possible in two cases and the survival rate was 33%. No renal failure or any therapy-related complications were reported. Conclusions. Bilateral WT is predominantly synchronous with favorable histology, with female predilection and possibly congenital anomalies. Preoperative chemotherapy followed by nephron sparing surgery has a favorable outcome with preserved renal function especially in patients with synchronous WT. Response to preoperative chemotherapy had a statistically significant prognostic impact.

Objective Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions. Materials and Methods This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0–14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed. Results Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [Pcr] improved 20–50% the eGFR and CC were doubled, and when improved 50–70% eGFR and CC tripled. Beyond 70% improvement in [Pcr], eGFR and CC improved 7–8 times. Using Spearman’s correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively). Conclusion Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.

We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents.We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded.A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients).The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Objectives We report our experience in the management of urethrorectal fistulae in children with emphasis on the complexity of this rare disease. Patients and methods A retrospective review was performed in cases that underwent repair of urethrorectal fistula at our center between 1997 and 2007. Records were reviewed for age, history, presentation, radiologic data, operative data, and condition at last follow-up. Results Five children were managed for urethrorectal fistula. Their mean age was 6.8 years (range, 2 months-12 years). One case had congenital urethrorectal fistula and four had acquired fistulas including two after abdomino-perineal pull through for imperforate anus, one case post perineal urethroplasty, and another post repair of posttraumatic rectal tear. All patients presented with history of passing urine both through the rectum and the urethral meatus. We have three urinary diverted cases: one case in whom urinary and fecal diversions were performed and the remaining case was operated without diversion. Perineal approach was adopted in four procedures and abdomino-perineal approach in one. One patient required optical internal urethrotomy for anastomotic stricture at 6 months follow-up. Conclusions Urethrorectal fistula is a rare complication whether congenital or iatrogenic. Perineal repair is challenging, necessities meticulous dissection, adequate vascularity of the edges, and interposition of vascularized flaps and is potentially successful.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE • To evaluate the functional and morphological outcome after open pyeloplasty for ureteropelvic junction obstruction (UPJO) with huge renal pelvis. PATIENTS AND METHODS • A retrospective review of all cases who underwent pyeloplasty for huge renal pelvis was conducted. • Records were evaluated with respect to age at presentation, preoperative imaging, surgical details and postoperative course. Patients were followed up regularly for both functional and morphological outcome. • Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow-up. RESULTS • Between 1998 and 2008, 526 cases of primary UPJO underwent open dismembered pyeloplasty at our centre. • Of these patients, 41 (8%) had UPJO with huge renal pelvis. • No perioperative complications were encountered in the study group. Mean (range) follow-up was 34 (18–84) months and nine patients were lost to follow-up. The overall success rate was 91%. • Two patients underwent redo pyeloplasty, whereas secondary nephrectomy was necessary in one. • Improvement of hydronephrosis was evident in all patients, except in three patients who underwent secondary procedures. • However, persistent obstruction on diuretic renography was seen in most cases (65%). CONCLUSIONS • Open pyeloplasty for huge pelvis UPJO is feasible with a high success rate. • Varying degrees of hydronephrosis and radiological obstruction after pyeloplasty are not uncommon. • Nephrectomy is rarely indicated in cases with severely deteriorated renal function.

Non-iatrogenic ureteral injuries in children are rare. Only sparse literature reports are available regarding management and outcome. We reviewed our experience in diagnosis and treatment of complex non-iatrogenic ureteral injuries in children. From 2000 to 2010, children who were treated for non-iatrogenic ureteral injuries were reviewed. Patients’ characteristics, mechanism of trauma, affected ureteral segment, time of recognition, associated injuries, presentation, mode of treatment and postoperative complications were studied from the medical records of those patients. Five children (four boys and one girl) with a median age of 10 (range 2–15) were treated at our center. Blunt abdominal trauma was documented in three children, while in another two penetrating trauma was inflicted. Associated hepatic tear was noted in one child and bowel injury in another. The affected segment was UPJ in three and mid-ureter in two. All cases presented with Urinoma. Diagnosis was confirmed after fixation of percutaneous nephrostomy and antegrade pyelography in four children, while reterograde pyelography was done in the remaining child. Surgical interventions included uretero-calyceal anastomosis in two, while nephrectomy was necessitated in another two with poor kidney function. In the child to whom retrograde pyelography was done, a double J stent was fixed for 3 months and the patient did well. Pediatric non-iatrogenic ureteral injuries are rare. A raised index for suspicion should be considered intra-operatively during initial exploration. Missed injuries are more common and may end in dense scarring and up to nephrectomy.

Purpose We evaluated the prognostic value of serum creatinine level at presentation and nadir creatinine during follow up for future renal function (RF) in children with posterior urethral valves (PUV). Materials and methods Between 1987 and 2004, 120 cases of PUV were treated initially at our hospital with valve ablation. Initial assessment included serum creatinine measurement, urine analysis and culture, renal ultrasonography and voiding cystourethrography. After valve ablation, renal ultrasound and serum creatinine measurement were repeated and thereafter during visits until the end of follow up. Results Follow up ranged from 2 to 12 years (mean = 4.4). Renal insufficiency (RI) developed at the end of follow up in 44 patients (36.5%). The mean initial and nadir serum creatinine in the RI group was higher than in the normal RF group (P

Purpose To review our experience of tubularized incised plate (TIP) urethroplasty in children with hypospadias defects. Methods Of 500 children (mean age 6 years) who received a TIP urethroplasty, 439 (87.8%) had primary hypospadias and 61 had one failed previous repair. The hypospadias defects were coronal in 110 (22%), distal penile in 261 (52.2%), midpenile in 78 (15.6%) and proximal in 51 (10.2%). Chordee was present in 98 (19.6%) patients. Presence of complications requiring re-operation and overall general appearance was recorded. Results The mean (SD, range) follow-up was 34 (18, 7–77) months. Overall success rate was 81.4%. Re-operation was required in 93 patients (18.6%); for urethrocutaneous fistula in 47 (9.4%), complete disruption of the repair in 32 (6.4%) and meatal stenosis in 14 (2.8%). In univariate analysis, complications were significantly higher in stented repairs, posterior hypospadias, those with no neourethral coverage (spongioplasty), and repairs early in the study. The last three factors were the only significant independent risk factors in multivariate analysis. Conclusions TIP is a reliable method for treating both distal and proximal hypospadias and is suitable for both primary and re-operative cases with a low rate of complications. A significantly better outcome is achieved with distal hypospadias, covering the neourethra with the mobilized corpus spongiosum (spongioplasty) or a flap, and experience. Stenting of the repair, patient age, or previous failed repair has no statistically significant impact on outcome.

We studied the effect of suturing technique and the impact of urethral plate characteristics on the complication rate following tubularized incised plate urethroplasty.We prospectively studied 80 boys (mean age 4.5 years, range 3 to 7) with primary hypospadias in a randomized fashion between January 2004 and May 2005. Of the patients 64 had anterior and 16 had mid penile hypospadias. Patients were allocated into 2 groups according to suture technique, with continuous sutures used in 40 boys and interrupted sutures in 40. We evaluated urethral plate depth, length and width before and after incision. Correlation between suture technique, plate type, width and length, and complication rate was performed.Mean followup was 3 years. Success rates were 90% and 69% for anterior and mid penile hypospadias, respectively (p = 0.037). Complications developed in 11 patients (13.8%) and consisted of fistula (8), dehiscence (2) and meatal stenosis (3). On univariate analysis the suture technique, depth and length of urethral plate, width after incision and presence of hypoplasia had no impact on complication occurrence. However, urethral plate width before incision was significantly related to complication occurrence (p = 0.048).Suture technique has no influence on the outcome of tubularized incised plate urethroplasty. Urethral plate characteristics do not affect the complication rate except for plate width, which significantly affects the outcome. Adequate urethral plate width (8 mm or greater) is essential for successful tubularized incised plate repair.

Vesical stones are common in children in developing countries. Cystolithotomy is the traditional treatment but a percutaneous approach has been advocated. The aim of this study was to evaluate retrospectively our experience with percutaneous cystolithotomy, cystolitholapaxy and open cystolithotomy in children with bladder stones.A total of 107 children (96 boys and 11 girls) with vesical stones were treated at our center between January 1992 and March 2008. Mean patient age at the time of diagnosis was 5 years (range 2 to 15). The patients were stratified retrospectively into 2 groups according to the procedure of stone removal. Group 1 (53 patients) underwent open cystolithotomy, and group 2 (54) underwent endourological treatment via the transurethral route (27) or the suprapubic approach (27). Stone size ranged from 0.7 to 5 cm (mean 2.8).In all cases the stones were removed successfully. Operative time was comparable in both groups. The hospital stay was significantly shorter after endourological procedures compared to open surgery (2.6 vs 4.8 days, p0.05). In the open surgery group 1 patient had a small intestinal injury that necessitated repair, while in the endourological group 2 patients had urinary extravasation (1 urethral and 1 vesical). There were no early or late complications in group 1. In comparison, 4 patients (7.4%) in group 2 had early complications in the form of persistent urinary leakage from the suprapubic site and 1 patient had a bulbous urethral stricture 1 year after transurethral stone disintegration.Open and endourological management of vesical stones in children is efficient, with a low incidence of complications. Endourological management offers a shorter hospital stay compared to open surgery. However, open cystolithotomy seems to be safer.

Objective We report our experience with ureterocalyceal anastomosis in children regarding indications and outcome. Materials and methods A retrospective review was performed of all cases that underwent open ureterocalyceal anastomosis at our center between 2000 and 2006. Records were reviewed for patient age, history, affected side, indication of surgery and operative details. Clinical and radiological outcome was assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. Results There were 10 cases (six males, four females) with a mean age of 6.5 years (range 3–13 years). Follow up ranged from 6 to 46 months (mean 18). The indications for surgery were failed pyeloplasty in six patients and iatrogenic injury of the ureteropelvic junction or the upper ureter in four. No significant perioperative complications were encountered in the study group. Overall success rate was 80%. Relief of obstruction was evident in eight patients as documented by intravenous urography or nuclear renography, while secondary nephrectomy was necessitated in two patients with severely impaired ipsilateral renal function and normal contralateral kidney. In patients with preserved renal units, the differential function on the involved side was stable on comparing the preoperative and postoperative renographic clearance (26 vs 24 ml/min). Conclusion Ureterocalyceal anastomosis in children is still indicated in some difficult situations. Excellent functional results can be achieved in properly selected cases. Nephrectomy may be indicated in cases with impaired renal function and inability to perform salvage procedure.

Objective This work aims at evaluation of chemotherapy as mono-therapy for treatment of non-metastatic bladder/prostate embryonal rhabdomyosarcoma in children. Patients and methods Between 1996 and 2002, 10 children presented with RMS of the bladder/prostate at a mean age of 6.6 years (range 1.5–18). Four patients had stage 2 disease and 6 had stage 3. The histology was embryonal in 8 and botryoid in 2. All patients received VAC chemotherapy for a mean duration of 14 months (range 12–18). CT or MRI was performed at 8 weeks, every 3 months in the first year and every 6 months thereafter. Results The mean follow-up duration was 48 months (range 12–96). At 8 weeks, 7 children showed more than 50% reduction in tumour size and the remaining 3 showed complete disappearance on CT or MRI. At final follow-up 8 patients are living, disease-free, with functioning bladder. The remaining 2 patients died of metastatic disease at 12 and 14 months from start of treatment. Out of the 8 survivors, 5 had complete disappearance of the tumour at last follow-up while 3 had residual tumour on CT/MRI. Those children underwent transurethral endoscopic resection and the pathology showed no evidence of malignancy in all. The 4-year disease-free survival was 100% for stage 2 and 66% for stage 3. Conclusions Chemotherapy as mono-therapy is effective treatment in children with stage 2 embryonal RMS of the bladder/prostate with the advantage of bladder preservation. Within stage 3, non-survivors had statistically significant larger tumours. Adjuvant therapy or more intensive chemotherapy might be required for those with large stage 3 tumours.

OBJECTIVE To evaluate the long-term results of one-stage perineal anastomotic urethroplasty for post-traumatic paediatric urethral strictures. PATIENTS AND METHODS Thirty-five boys who had a perineal anastomotic urethroplasty for post-traumatic bulbous or posterior urethral strictures between 1991 and 2003 were analysed retrospectively. Patients were followed up for a mean (range) of 46 (6-132) months by a history, urinary flow rate estimate, retrograde urethrography and voiding cysto-urethrography. RESULTS The mean (range) age of the patients was 11.9 (6-18) years. The estimated radiographic stricture length before surgery was 2.6 (1-5) cm. The perineal anastomotic repair was successful in 31 of 35 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in two patients and by repeat perineal anastomotic repair in the remaining two, giving a final success rate of 100%. All boys are continent except two who had early stress incontinence, and that resolved with time. There was no chordee, penile shortening or urethral diverticula during the follow-up. CONCLUSIONS The overall success of a one-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is excellent, with minimal morbidity. Substitution urethroplasty or abdomino-perineal repair should be reserved for the occasional patients with concomitant anterior urethral stricture disease or a complex posterior urethral stricture, respectively.

OBJECTIVES To assess the prognostic factors that could be used to predict tumour recurrence and progression, and to construct and validate a predictive index. PATIENTS AND METHODS Between June 1991 and December 2000, 533 patients (418 men and 115 women; mean age 55.4 years) underwent complete transurethral resection of histologically confirmed pTa and pT1 transitional cell carcinoma of the bladder, after which 377 (test series) were randomized into two subsequent studies, of six groups, to receive adjuvant intravesical sequential bacillus Calmette-Guerin (BCG) and epirubicin, BCG alone, epirubicin (50 or 80 mg), adriamycin 50 mg or no adjuvant therapy. Factors potentially affecting tumour recurrence or progression were assessed using univariate and multivariate analysis, i.e. tumour stage, histological grade, DNA ploidy, history of recurrence, multiplicity, size, tumour configuration, associated carcinoma in situ, recurrence at the first 3-month check cystoscopy and the use of adjuvant therapy. The regression coefficients determined by Cox regression analysis were used to construct a predictive index (PI). The algebraic sum of the regression coefficients of the factors with independent and significant association with disease-free survival for each case represented a proportional hazard score (PHS). The PI was validated in another series of 156 patients (validation series) in whom the same regression coefficients for the same significant factors as the test series were used to categorize it into three risk groups. Kaplan-Meier survival curves were plotted to compare the different risk categories in both test and validation series. RESULTS The mean (sd, range) follow-up in the test and validation series were 58 (19, 5–96) and 28.3 (14.9, 2–94) months, respectively. In the test series, tumour stage, DNA ploidy, multiplicity, history of recurrence, tumour configuration, cystoscopy result and the type of adjuvant therapy had independent significance for recurrence on multivariate analysis. For progression, the cystoscopy result, DNA ploidy and grade were the only independent and significant predictors. The ranges of PHS for the factors affecting recurrence-free and progression-free survival were 0.0–7.14 and 0.0–5.84, respectively, which were divided equally into three risk categories with significant differences on Kaplan-Meier curves and a log-rank test (P