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Capillary hemangioma is a rare benign lesion in the testicle, particularly in pediatrics. It can mimic malignancy, leading to radical orchiectomy. We present a case of a testicular hemangioma in a child, and review the literature on testicular hemangiomas in this age group. A hypervascular testicular lesion without elevated tumor markers may warrant intraoperative biopsy to direct surgical management, which may include testis-sparing surgery if amenable. [ABSTRACT FROM AUTHOR]

Purpose We evaluated the clinical course of patients prenatally diagnosed and enrolled early with congenital solitary functioning kidney, and identified the risk factors for renal injury. Materials and Methods We retrospectively evaluated 322 patients with congenital solitary functioning kidney according to the inclusion criteria of 1) prenatal diagnosis of solitary kidney; 2) first evaluation at 1 to 3 months of life with confirmation of congenital solitary functioning kidney, and evaluation of possible associated congenital anomalies of the kidney and urinary tract by abdominal ultrasound, renal scintigraphy and cystography; and 3) absence of any condition potentially affecting renal function in the neonatal period as well as absence of renal injury at enrollment (1 to 3 months of life) confirmed by a normal estimated glomerular filtration rate, lack of proteinuria and hypertension. Followup of 306 patients was evaluated. Results Median followup was 7.2 years (range 1 to 23) and 1 or more signs of renal injury were found in 12 of 306 patients (3.9%). Considering the entire population the cumulative proportion of patients free from renal injury at 17 years old was 93.7%, vs 81.3% and 95.9% for subjects with and those without congenital anomalies of the kidney and urinary tract of congenital solitary functioning kidney (p <0.001), respectively. Of congenital anomalies of the kidney and urinary tract, congenital solitary functioning kidney resulted in significant risk factors for renal injury (HR 8.75, 95% CI 2.77–27.65). Conclusions In an evaluation of a large cohort of patients enrolled early with congenital solitary functioning kidney with a prenatal diagnosis, excluding those with neonatal onset of renal damage, the prevalence of renal damage was 3.9%. Among congenital anomalies of the kidney and urinary tract, congenital solitary functioning kidney represented the major risk factor. [ABSTRACT FROM AUTHOR]

Objective: To characterize contemporary resource utilization and medical outcomes for infants with antenatal hydronephrosis and their mothers from a national claims database. We hypothesize that management of isolated hydronephrosis (IHN) varies widely, with decreased imaging following the 2010 Society for Fetal Urology Consensus Statement.Materials and Methods: Using MarketScan claims from 2007 to 2013, we identified infants 0-12 months of age with hydronephrosis and linked mothers. Those with urologic diagnoses more specific than hydronephrosis, additional urologic comorbidities, or postnatal surgeries were excluded. Resource utilization including prenatal and postnatal imaging, laboratory studies, hospital admissions, and medical outcomes within the first year was captured. Demographics, maternal characteristics, utilization measures, and outcomes were compared across imaging intensity groups based on number of postnatal ultrasounds received using bivariate analysis.Results: Among 801,919 mother-child pairs, 8610 infants (1.1%) had hydronephrosis or a related diagnosis. A total of 5876 (68.2%) met inclusion criteria for IHN. Patients underwent a mean 5.3 ± 3.5 prenatal and 2.1 ± 1.3 postnatal ultrasounds before age 1. Imaging practices were unchanged following the Society for Fetal Urology consensus statement.Conclusion: Antenatal hydronephrosis prevalence in an insured population is consistent with published ranges. Prenatal imaging in IHN is variable and potentially excessive. Future study into the efficacy of evidence-based pathways in reducing excess utilization is warranted. [ABSTRACT FROM AUTHOR]

Abstract: Hypospadias repair is one of the more common operations in pediatric urology centers, with an incidence of 1 in 200 to 1 in 300. This review provides an overview of the prevalence, epidemiology, etiology, and treatment of this condition. Indications for hypospadias repair and preoperative hormonal treatment are discussed. The principles of the different operations and their countless modifications are explained. Hypospadias repair has a long and flat learning curve and requires patience, experience, and great enthusiasm to achieve acceptable results. The results published on the various operative techniques need to be repeated and validated by other surgeons, and long-term results (up to adulthood) are essential to justify operative methods and identify late complications. [Copyright &y& Elsevier]

Purpose: Few data have been reported regarding radiation exposure during pediatric endourological procedures, including ureteroscopy. We measured radiation exposure during pediatric ureteroscopy and identify opportunities for exposure reduction. Materials and Methods: We prospectively observed ureteroscopy procedures as part of a quality improvement initiative. Preoperative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Our outcomes were entrance skin dose and midline dose (both mGy). Specific modifiable factors were identified as targets for potential quality improvement. Results: Direct observation was performed in 54 consecutive ureteroscopy procedures. Mean ± SD patient age was 14.8 ± 3.8 years (range 7.4 to 19.2), with 9 children being younger than 12 years. Mean ± SD entrance skin dose was 46.4 ± 48 mGy. Mean ± SD midline dose was 6.2 ± 5.0 mGy. The most important major determinant of radiation dose was total fluoroscopy time (mean ± SD 2.68 ± 1.8 minutes) followed by dose rate setting, child anteroposterior diameter and source to skin distance (all p <0.01). Analysis of factors affecting exposure levels revealed that use of ureteral access sheaths (p = 0.01) and retrograde pyelography (p = 0.04) were significantly associated with fluoroscopy time. We also found that dose rate settings were higher than recommended in up to 43% of cases and ideal C-arm positioning could have reduced exposure by 14% (up to 49% in some cases). Conclusions: Children receive biologically significant radiation doses during ureteroscopy procedures. Several modifiable factors contribute to dose and could be targeted in efforts to implement dose reduction strategies. [ABSTRACT FROM AUTHOR]

Purpose: Voiding cystourethrogram is an invasive test that evokes anxiety. Our primary aim was to determine whether midazolam is beneficial in decreasing anxiety in children who undergo voiding cystourethrogram. Secondary aims were an examination of parent anxiety, health care professional perceptions and post-procedure behavioral outcomes in children after voiding cystourethrogram. Materials and Methods: A total of 44 children were randomized to placebo or oral midazolam before voiding cystourethrogram in double-blind fashion. The Modified Yale Preoperative Anxiety Scale was used to evaluate child behavior before and during voiding cystourethrogram, and the Post Hospitalization Behavior Questionnaire was used to investigate any short-term and intermediate-term behavioral outcomes. The State-Trait Anxiety Inventory was used to evaluate parent personal anxiety during voiding cystourethrogram. A separate questionnaire was administered to radiology staff. Statistical analysis included the 2-sample t and Fisher exact tests. Results: There was no difference in Modified Yale Preoperative Anxiety Scale scores in children randomized to midazolam or placebo. There was also no significant difference in parent anxiety. Radiology care providers identified no reliable benefit when blinded to sedation vs placebo. We did not note any post-procedural behavior issues after voiding cystourethrogram at up to 6 months of followup. Conclusions: Midazolam may not significantly help with child or parent anxiety during voiding cystourethrogram. No reliable benefit was noted according to radiology health care provider perception and there was no significant post-procedural behavior benefit. Midazolam may not provide a significant benefit in decreasing anxiety during voiding cystourethrogram. [ABSTRACT FROM AUTHOR]

Purpose: We prospectively evaluated the precision of ultrasound and computerized tomography to diagnose urinary stones in children and determined whether these differences in radiological findings have any impact on clinical management. Materials and Methods: A total of 50 consecutive patients with suspected urolithiasis underwent computerized tomography and ultrasound. Two radiologists reviewed each study independently in blinded fashion. When a difference in findings was detected, 8 pediatric urologists reviewed the case. Clinical management was based on the results of each radiological test independently. Statistical analysis was performed using Fisher''s exact test. Results: Compared to computerized tomography ultrasound had 76% sensitivity and 100% specificity. In 8 patients stone(s) seen on computerized tomography was not seen on ultrasound. The average size of missed stones was 2.3 mm. In 7 patients computerized tomography showed stones bilaterally but stone was seen on only 1 side on ultrasound. When evaluating the clinical impact, the ultrasound/computerized tomography discrepancy did not result in any significant change in clinical management except in 4 cases. In these cases ultrasound findings suggested that additional imaging was required and, thus, stone(s) in the distal ureter would have been identified on subsequent imaging. Conclusions: Although computerized tomography is more sensitive for detecting urolithiasis than ultrasound, the difference in usefulness between the 2 radiological tests may not be clinically significant. Given concerns for the potentially harmful cumulative long-term effect of radiation, ultrasound should be considered the first imaging test in children with suspected urolithiasis. [Copyright &y& Elsevier]

Purpose: We investigated factors affecting the breakthrough urinary tract infection rate during prophylactic antibiotic treatment in children with primary vesicoureteral reflux. Materials and Methods: Medical charts were retrospectively reviewed in children with primary vesicoureteral reflux diagnosed at age 12 months or less who received prophylactic antibiotics and underwent 99mTc-dimercapto-succinic acid scan. Parameters assessed for their relation to breakthrough urinary tract infection were gender, presenting symptoms, age at presentation, prophylactic antibiotic type, reflux grade at presentation and scan findings. Results: Enrolled in the study were 52 boys and 6 girls with a mean age at presentation of 3.7 months and a mean followup of 42.5 months. Urinary tract infection was a presenting symptom in 46 children. Low reflux grade (1–3) was identified in 18 children and 40 had high grade reflux (4–5). Abnormal 99mTc-dimercapto-succinic acid scan was documented in 36 children (62%). During followup breakthrough vesicoureteral reflux developed in 12 children, including 11 of 36 (31%) with an abnormal scan but only 1 of 22 (5%) with a normal scan (p = 0.021). The breakthrough urinary tract infection-free rate during followup was significantly lower in children with an abnormal scan (p = 0.033). Other factors were not significantly associated with the breakthrough urinary tract infection rate. Conclusions: Abnormal 99mTc-dimercapto-succinic acid scan may be a factor predicting breakthrough urinary tract infection in children with primary vesicoureteral reflux. Prophylactic antibiotics may have a limited treatment role in children with an abnormal scan. [Copyright &y& Elsevier]

Purpose: Studies show that renal volume on magnetic resonance imaging correlates with differential function and is decreased in children with vesicoureteral reflux diagnosed after urinary tract infection. We examined the correlation between ultrasound renal parenchymal area and magnetic resonance imaging volume to determine whether quantitative ultrasound renal parenchymal area might be a reliable, less costly and less invasive substitute for renal magnetic resonance imaging volume. Materials and Methods: To determine the correlation of ultrasound renal parenchymal area with magnetic resonance imaging, we identified 82 children with primary vesicoureteral reflux who underwent renal magnetic resonance imaging and ultrasound. Magnetic resonance imaging volume was compared with ultrasound renal parenchymal area, renal length and calculated ellipsoid volume. To determine the correlation of ultrasound renal parenchymal area with reflux grade, ultrasound renal parenchymal area was examined in 96 children with reflux and urinary tract infection, and in 52 with reflux without urinary tract infection. Linear regression and multivariate analysis were performed to find the relationship between ultrasound renal parenchymal area and reflux grade. Results: The correlation of ultrasound renal parenchymal area with magnetic resonance imaging volume was superior to that of renal length and calculated ellipsoid volume (r2 = 0.90 vs 0.83 and 0.84, respectively). Hydronephrosis did not affect the correlation. On multiple regression analysis in children with reflux and urinary tract infection higher reflux grade correlated with decreased ultrasound renal parenchymal area (p = 0.0016). In children with reflux without urinary tract infection reflux grade did not correlate with decreased ultrasound renal parenchymal area (p = 0.47). Conclusions: Ultrasound renal parenchymal area correlates closely with magnetic resonance imaging derived 3-dimensional renal volume and is capable of detecting progressive renal area loss in patients with reflux and urinary tract infection. More studies are necessary to verify whether data from more invasive tests, such as renal magnetic resonance imaging and dimercapto-succinic acid scan, may be attained from ultrasound renal parenchymal area alone. [Copyright &y& Elsevier]

Objectives: To present the diagnostic results of contrast vaginography to detect a vaginal ectopic ureter, in addition to investigation with ultrasonography, intravenous urography, and technetium-99m-dimercaptosuccinic acid renal scan. A single ectopic ureter is a rare anomaly. Methods: Eighteen girls with a single ectopic ureter were treated at the Children''s Hospital No. 1 from 1995 to August 2008. The diagnostic studies included ultrasonography, intravenous urography, renal scans, and, finally, vaginography with contrast if the renal scans could not detect the poorly functioning kidneys. Results: Intravenous urography showed a poorly functioning kidney in 1 patient. Another 10 poorly functioning kidneys were revealed by technetium-99m-dimercaptosuccinic acid renal scan, but 7 kidneys were not identifiable using contrast, ultrasonography, or radionuclide. Of these 7 patients, 6 vaginal ectopic ureters were detected using contrast vaginography. All 18 dysplastic kidneys were surgically removed. Conclusions: The results of the study have demonstrated the satisfactory diagnostic value of vaginography as an imaging technique to detect the dysplastic kidney draining by a single ectopic ureter. [Copyright &y& Elsevier]

The article discusses the use of standardized imaging techniques to visualize the kidney and urogenital tract (UGT) of infants and identify neonatal UGT conditions. It cites the imaging techniques in pediatric urology, including ultrasonography (US), intravenous urography (IVU) and computed tomography (CT). It notes the importance of identifying the reasons of the investigation, the possible results and right timing. It also mentions the specific imaging algorithms for neonatal UGT conditions.

As enterocystoplasty has become a routine procedure in pediatric urology, long-term complications are emerging in adult patients. Pediatric urologists in general do not follow their patients beyond late adolescence. The sequelae of enterocystoplasty have fallen into the hands of their adult colleagues. Some of the complications of enterocystoplasty, such as reservoir stones, malignancy and perforation, are also seen in older adults following continent diversion. On the other hand, problems with bone growth, pregnancy and reflux nephropathy are unique to children and young adults. A better awareness and understanding of these complications will lead to improved prevention, surveillance and treatment. [ABSTRACT FROM AUTHOR]

Abstract: Purpose of review: Magnetic resonance urography (MRU) has emerged as a powerful diagnostic tool in the evaluation of the pediatric genitourinary tract. The purpose of this review is to familiarize the reader with the basic techniques, strengths and limitations, as well as the current and potential future applications of MRU in pediatric urology. Recent findings: MRU can provide detailed anatomical information and assess renal function and drainage in a single study. MRU does not employ ionizing radiation and may be utilized in patients with iodine-based contrast allergy or impaired renal function. MRU has been most often applied to the evaluation of hydronephrosis and provides valuable insight into a wide range of obstructive uropathies. MRU was shown to be superior to renal scintigraphy for the diagnosis of pyelonephritis and renal scarring. The use of MRU for the assessment of urolithiasis and vesicoureteral reflux is limited and technical refinements are required. Potential future applications include fetal MRU, virtual endoscopy, and MRU-guided procedures. The development of new contrast agents and new image-processing software will further enhance the diagnostic potential of MRU in pediatric urology. Summary: MRU is currently thought of as a problem-solving tool to define anatomy and function when conventional methods fall short. This technique is likely to emerge as the imaging modality of choice for children with complex genitourinary pathology. [Copyright &y& Elsevier]

Aim: To evaluate the outcome of primary vesicoureteral reflux (VUR) using conservative treatment. Methods: Eighty-seven children with primary VUR who had been treated with a conservative medical regimen and monitored through a yearly cystogram were recruited for the study. The study was conducted at the Pediatric Nephrology Clinic in Songklanagarind Hospital, the major tertiary care center in southern Thailand. Statistical analyses using Kaplan–Meier survival curves, chi-squared test, Fisher’s exact test and multivariate analysis with Cox regression were performed. Results: The study group consisted of 41 boys and 46 girls, with a total of 133 VUR. The age of the boys was significantly lower than that of the girls ( P < 0.001). Resolution of the low grades (grades I–III) of VUR was significantly more frequent than that of the high grades (grades IV–V) (68/95, 72% vs 14/38, 37%; P < 0.001). Using the Kaplan–Meier survival analysis and log-rank test, the resolutions of VUR in boys versus girls, and age <1 years versus ≥1 years were not significantly different ( P = 0.2252 and 0.4756, respectively). Low-grade VUR and unilateral VUR had significantly higher probabilities of resolution than high-grade VUR and bilateral VUR, respectively ( P = 0.0041 and 0.0467, respectively). Multivariate Cox regression analysis indicated that among low-grade VUR, boys and unilateral VUR had significantly higher probabilities of resolution. Among the high-grade VUR, neither sex nor laterality had a significant effect on the probabilities of VUR resolution. Conclusion: This study offers more evidence that children with low-grade VUR have a higher chance of reflux resolution if they are boys and have only unilateral VUR. There is still no good guide for resolution of reflux in children with high-grade VUR. [ABSTRACT FROM AUTHOR]

The article focuses on the aid of radiological imaging to differentiate upper and lower urinary tract infection (UTI) among children. It states that paediatric uroradiology is one of the backbones of radiological practice for UTI. It discusses various imaging systems used for UTI such as dimercaptosuccinic acid (DMSA) scintigraphy, ultrasound (US), and voiding cystourethrography (VCUG). It concludes that radiological imaging in UTI remains crucial for children such as radiation exposure.

Abstract: Purpose: To evaluate the outcome of secondary surgical procedures for the management of failed pyeloplasty in children. Materials and methods: Between 1996 and 2007, 590 cases of primary ureteropelvic junction (UPJ) obstruction underwent open dismembered pyeloplasty at our center. Of these patients, 18 (3%) with recurrent UPJ obstruction (14 males, 4 females; age range: 2–15 years) have undergone management of failed pyeloplasty. Secondary intervention was by open operative procedure in all cases. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. Results: Follow up ranged from 8 to 41 months (mean 28). The overall salvage rate was 89%. Secondary reoperative surgery was successful in 16 patients: dismembered pyeloplasty in 14 patients (78%) and ureterocalyceal anastomosis in 2 (11%). Nephrectomy was necessitated in 2 patients (11%). No perioperative complications were encountered. All patients showed stability of renal function on radiological follow up without evidence of obstruction and with no further symptoms. Conclusion: Persistent UPJ obstruction after pyeloplasty is an uncommon complication. Secondary procedures have a very high success rate with excellent functional results. Nephrectomy is indicated in rare cases of severely deteriorated renal function. [Copyright &y& Elsevier]

To study the surgical treatment and outcome of hydronephrosis secondary to pelviureteric junction obstruction (PUJS) that is so massive that the renal pelvis crosses over the vertebral column [mega-hydronephrosis (MH)]. Of the 40 cases of PUJS we treated over the past 5 years, 6 cases had MH secondary to PUJS (MH-PUJS) in 6 renal units and were reviewed. Incidence of MH was 15.0%. All had Anderson-Hynes dismembered pyeloplasty to treat obstructive renal pattern on technetium-99m diethylenetriaminepentaacetic acid (DTPA) scans in five and gait disturbance due to MH in one. The contralateral kidney was normal in five and dysplastic in one. Three had nephrostomy before pyeloplasty. Preoperative DTPA scans showed good renal function in four and poor in two. Plication of the entire dilated, lax renal parenchyma ("nephroplication") was performed in three to decrease the intra-renal pelvic cavity. Prenatal diagnosis was performed in three cases. Mean age at pyeloplasty was 3.5 years and mean duration of follow-up was 1.5 years. Postoperatively, two of the three who did not have nephroplication had prolonged but not obstructed renal pattern on DTPA scans, and the other case who did not have nephroplication had nephrectomy for non-functioning kidney caused by recurrent pyelonephritis 2 years after pyeloplasty. In the three who had nephroplication, DTPA scans showed acceptable to relatively good passage in all cases. The surgical treatment of MH-PUJS is challenging with no fixed guidelines. However, nephroplication may be useful during pyeloplasty to decrease the size of MH-PUJS. [ABSTRACT FROM AUTHOR]

The article focuses on the need for morbidity grading system for diagnosis of pediatric urology. Topics discussed include surgical complications made by urologists; repeated episodes of anesthesia and increasing radiation exposure with increased risk for developmental delays; and Unplanned Postoperative Morbidity in Children (UPMC) classification system for improving pediatric quality of life.

The article cites a finding which evaluates the relevance of the cremasteric reflex during physical examination in diagnosing the presence of testicular torsion. It notes, however, that some case reports showed a coexistence between the two factors. It also offers several resolutions from the authorities regarding the problem which includes Doppler ultrasound from the European Society for Pediatric Urology (ESPU), and radionuclide scrotal ultrasound (RNSI) from the American College of Radiology.

The article discusses the integration of robotic assisted surgery in several procedures in pediatric urology such as pyeloplasty, nephrectomy and ureteral reimplantation. Topics discussed include how robotic surgery enables pediatric urologists to overcome the limitations of conventional laparoscopy, the increased popularity of robotic assisted laparoscopic surgery in pediatric urology in the last decade and its proven success as open procedures and the better visualization it provides.