Search

Transition into adulthood is a common issue in many disciplines. However, urology faces additional difficulties due to different models of care and training as well as a wide diversity of pathologies. The goal of this paper is to discuss various aspects of the transition of urological care. This review provides some examples of pathologies that might require special attention of specialists. Most patients with rare diseases must be closely followed up in the long term. However, high-volume conditions may also have a huge impact on the well-being and quality of life in adulthood. Children who are cured due to oncological conditions will probably need additional attention in adulthood. The urological care during childhood is provided by a pediatric urologist, a pediatric surgeon or a urologist, depending on the local regulations and the organization of care. All patients are subsequently referred to a general urologist. Nowadays, a multidisciplinary approach is recommended in many cases, with a pediatric urologist as one of the team members. The patient, caregivers and healthcare professionals must be fully involved and focused on close cooperation to make the transition process smooth and successful.

Purpose: To describe experience with partial nephrectomy combined with brachytherapy as part of the local management of bilateral Wilms tumor (WT) including a review of the available literature.Results (methods and case description): Between 2011 and 2014, three highly selected patients (age nine months, 16 months, and 4 years) with bilateral WT (two synchronous and one metachronous) underwent enucleation and perioperative brachytherapy to the tumor bed. With a minimum follow-up of 5 years, all three patients are in continuous complete remission with preserved kidney function.Conclusions: Although nephron sparing surgery aiming at tumor free-margins remains the gold standard for bilateral WT, tumor enucleation followed by brachytherapy may be considered in carefully selected patients at high risk for end-stage kidney failure. Given the rarity and complexity of the procedure, concentration of care of such patients is mandatory.

Background. Distal penile hypospadias account for about 70% of all cases of hypospadias. There is a variety of operative techniques that could be performed when foreskin reconstruction is an option. The urethral stent is left in the urethra to prevent complications. Objectives. To determine whether the duration of stenting influences the healing of foreskin after distal hypospadias repair. Material and methods. Data from 2 institutions was retrospectively analyzed. Inclusion criteria were as follows: 1) a modified meatal advancement glanuloplasty without tubularization of the urethral plate, 2) foreskin reconstruction and 3) follow-up - 12 months. All other types of reconstruction and re-do procedures were excluded. The period of urethral stenting was determined intraoperatively depending on the surgeon's preferences. Mean age at operation was 23.3 months. The cohort was divided into 3 groups. In Group I (G-I), no catheter was left or it was removed the next day after surgery. In Group II, the catheter was left for more than 5 days. In those 2 groups, the surgery was done by different surgeons. Group III consisted of 35 patients who had a stent for

Summary Introduction Congenital Adrenal Hyperplasia (CAH) is the most common reason for undifferentiated genital appearance in new-borns. Psychosexual outcome in women with CAH has been rarely evaluated, but it seems to be one of the most important factors determining the indications for the surgical treatment of CAH. Objective This is to assess sexual function and the health status (HS) in adult females with CAH who had feminizing genitoplasty in childhood. Material and method The protocol was approved by the Ethical Committee, and the hospital database was searched for patients with CAH who had genitoplasty between 1975 and 2000. 57 adult patients were identified, and 9 (18%) patients agreed to participate in the study. Mean age at operation was 5.4 years, and mean follow-up duration was 10.9 years. The Female Sexual Function Index (FSFI) was used to evaluate sexual function, and the 36-item Short Form Health Survey (SF-36) was used to evaluate their health status (HS). A FSFI score Results All patients in the CAH group had female gender identity. One was homosexual, and one reported not having any sexual activity. In the control group, all patients had female gender identity. All were heterosexual and one reported not having any sexual activity. The sexual function in five domains and total score were similar in both groups. More pain was reported in the CAH group as compared with the control group, and it was statistically significant. In the CAH group, 5/9 patients had FSD. In the control group, 4/10 patients had FSD. The difference was statistically insignificant (p = 0.66). Mean SF-36 score in the CAH group was 47.1 points, while it was 46.7 points in the control group. The testosterone level in all CAH patients was within the normal range (0.13–1.1 ng/ml). The 17-OH progesterone level was above normal range in 5/9 (55.6%) patients with CAH. All women in the CAH group were hormonally treated. In the control group, all patients had a normal testosterone level (0.15–0.68 ng/ml); the 17-OH progesterone level was in normal range in this group. Discussion We compared our results with the literature data, which used the same questionnaires as in our study. Conclusions Health status and sexual function in the traceable CAH patients didn't differ from the control group. Summary Table . FSFI score comparison. FSFI domain Our study Fagerholm et al. Seyam et al. Lesma et al. Desire 4.2 4.0 3.2 4.2 Arousal 4.8 5.1 3.4 3.7 Lubrication 5.1 5,6 3.0 4.0 Orgasm 5.2 4.2 3.8 3.6 Satisfaction 5.2 4.9 2.2 3.7 Pain 4.0 4.7 3.2 4.4 Total FSFI score 27.2 28.7 18.6 23.3

Background Crossing vessels (CVs) are common in older children and adults with hydronephrosis but no gold standard exists on how to treat this condition. The final decision is made intraoperatively by the surgeon. Objectives To assess the outcome of the laparoscopic dismembered pyeloplasty with translocation of the CVs in children and adults. Material and methods Prospectively collected data from 3 departments was reviewed. Inclusion criteria were: 1) a transperitoneal laparoscopic approach; 2) dismembered pyeloplasty; and 3) the same operating pediatric urologist (RC) or urologist (TS). In the case of CVs, pyeloplasty with vessel transposition (children) or with cephalad translocation (adults) was performed. Forty-eight children and 41 adults met these criteria. Patients were divided into 4 groups: children with (group 1A) and without (group 1B) CVs, and adults with (group 2A) and without (group 2B) CVs. Any surgical reintervention at the uretero-pelvic junction (UPJ) was deemed a failure. Results The overall reintervention rate was 3/48 (6.25%) in children and 2/41 (4.9%) in adults (p > 0.05), and involved the following: 4 endopyelotomies and 1 redo pyeloplasty. Crossing vessels were identified in 28/48 (58%) children and 12/41 (29%) adults. The mean operation time was 152 min in group 1A and 161 min in group 2A (p > 0.5). Reintervention was needed in 2/28 patients in group 1A and in 1/12 patients in group 2A (p > 0.05). There was no difference in the failure rate between group 1A and group 1B, nor between group 2A and group 2B (p > 0.05). Conclusions Crossing vessels should be meticulously looked for during pyeloplasty in older children and adults. Dismembered laparoscopic pyeloplasty (LP) with dorsal transposition or cephalad translocation are comparable methods in terms of success rate for the treatment of UPJ obstruction in these patients.

The incidence of newborns with spinal dysraphism is diminishing worldwide, although survival of individuals with this condition into adulthood continues to improve. The number of adults with spinal dysraphism will, therefore, increase in the coming years, which will pose new challenges in patient management. Urological manifestations of spinal dysraphism can include increased risks of urinary incontinence, urinary tract infection, urinary calculi, sexual dysfunction, end-stage renal disease and iatrogenic metabolic disturbances; however, the severity and incidence of these symptoms varies substantially between patients. Owing to the presence of multiple comorbidities, treatment and follow-up protocols often have to be adapted to best suit the needs of specific patients. Authors describe bladder and kidney function and long-term complications of treatments initiated in childhood, as well as the potential for improvements in quality of life through better follow-up schedules and future developments.

Lower urinary tract symptoms (LUTS) in children is a frequent occurring problem, together with astma the most frequent disease at pediatric age. For many children LUTS is a chronic condition with a major impact on the quality of life. Adequate treatment is needed and useful to enhance quality of life, prevent LUTS at later age and protect the upper urinary tracts in case of co-existing vesico-ureteric reflux. The advice to wait and see is outdated This manuscript tries to give an overview of the current management of LUTS in children.

We explored possible associations between long-term antimuscarinic use and behavioral problems in children with spinal dysraphism and neurogenic bladder. Children with open and closed spinal dysraphism were recruited from 2 pediatric hospitals, 1 in Amsterdam and 1 in Utrecht, The Netherlands. At the Amsterdam facility antimuscarinics were prescribed in selected patients with detrusor overactivity. At the Utrecht facility antimuscarinics were prescribed from birth onward in patients with spinal dysraphism beginning in the early 1990s. Parents of study participants were asked to fill out a Child Behavior Checklist. Demographics, data on level and type(s) of lesion, and presence of hydrocephalus with a drain (and, if applicable, number of drain revisions) were retrieved for each patient. Cases and controls (8 boys and 8 girls per group) were matched on a 1-to-1 basis. Data on 32 children were analyzed. Median age was 10.6 years in cases and 10.5 years in controls (p=0.877). In each group 9 of 16 patients had hydrocephalus with a drain. No significant difference in Child Behavior Checklist scores for total problems was found between cases and controls (median 52.0 vs 59.5, p=0.39). No differences were found between the groups on any subdomain of the Child Behavior Checklist. No significant differences in behavior were found between children with spinal dysraphism with and without long-term use of antimuscarinics

Background Prevalence of lower urinary tract dysfunction (LUTD) in children is between 6 and 9% with urinary incontinence (UI) being one of the most common symptom. Various aspects of lower urinary tract symptoms (LUTS) Anatomical anomalies of the urinary tract as well as neurogenic underlying pathology can results in LUTS. Comorbidities and long-term consequences of the LUTD for the female patients as well as genetic issues are also briefly discussed. The role of the bladder neck Thanks to urodynamics, we have learnt a lot about the lower urinary tract function, but the role of the bladder neck in the pathophysiology of LUTS in children is not clear. Secondary bladder neck hypertrophy is a well-described pathology, but there is no standardized treatment for this phenomenon. Primary bladder neck dysfunction has already been defined by the International Children’s Continence Society. Refractory UI in girls Uniform diagnostic protocols are used in these girls with UI. Treatment consists of standard urotherapy, additional interventions, and pharmacotherapy in selected cases. Those with refractory UI require careful reassessment to look for the unrecognized disorders. Invasive urodynamics should be done in those patients. Ultrasound of the bladder neck region and the pelvic floor can be helpful, but its interpretation is very subjective. In a small group bladder neck insufficiency can be found and those might benefit from a surgical intervention. Future perspective Strict criteria of the bladder neck insufficiency in children must be defined. Early surgical intervention in girls with bladder neck insufficiency might reduce the long period of intensive conservative treatment.

To assess the results of endoscopic bladder neck procedure on the anterior bladder wall in children. Surgery is done in the lithotomy position using three 5-mm ports. The bladder is insufflated with CO2. A U-shaped incision is made around the bladder neck. A mucosal strip is tabularized around a 12 French catheter and covered with the second layer of mucosa. Twenty procedures were performed on 18 patients (mean age, 9.8 years), and the follow-up period was >1 year (mean, 34 months). Mean operation time was 149 minutes. Twelve patients had neurogenic lower urinary tract dysfunction. Fifteen patients failed earlier bladder neck surgery, predominantly fascia sling suspension. Preoperatively, all patients had low detrusor leak point pressure. Clean intermittent catheterization (CIC) was resumed through the urethra in 11 patients and through a stoma in 6 patients. Two patients needed conversion because of CO2 leakage. Six patients were dry, and 4 improved in the short term (3-6 months). After 1 year of follow-up, 2 patients were dry, and 6 improved. In the long term, 1 (9%) out of 11 patients who were catheterized through the urethra was dry, and 3 of the 11 patients (27%) improved. Of the 6 patients with a CIC stoma, 1 (17%) was dry, and 3 (50%) improved. Endoscopic bladder neck surgery is, for most patients, a minor operation, but the long-term results are disappointing. The construction of a continent channel for CIC can improve the outcome when anterior bladder neck plasty is performed

Objective To gain insight into the efficacy and safety of urethral de-obstruction in boys with overactive bladder (OAB) complaints refractory to conservative treatment. Materials and methods All boys, older than 5 years, referred in 2009 for OAB complaints were included, n = 180. Nine had abdominal or penile pain as predominant complaint. 82% were tertiary referrals after unsuccessful conservative treatment with antimuscarinic medication and/or urotherapy for OAB. In 121, urethral obstruction was urodynamically proven or seriously suspected, and they underwent urethrocystoscopy with relief of obstruction, when present. Average duration of unsuccessful conservative pre-treatment in this group of patients was 1.2 years. Postoperative results, in terms of relief of complaints, were analyzed. Safety was assessed by analyzing those patients who had a secondary transurethral procedure in the same year, or in the 3 years after primary treatment. Results Of 106 boys with OAB, urge incontinence or therapy-resistant bedwetting, after de-obstruction 33 became free of complaints and 39 showed significant improvement, totaling 72 (68%); dry after additional urotherapy 11 (10%); no change 21 (20%). Nine boys had de-obstruction because of penile or abdominal pain, with 5 completely cured after the procedure. Follow-up treatment was cognitive training in 39, temporary anticholinergic treatment in 26 and CIC in 2 cases. Recurrence of obstruction was seen in 10% during the 3-year follow-up period. Conclusion After failure of conservative therapy, one should actively look for any urethral obstruction as underlying cause of OAB. For such patients, urethral de-obstruction is highly effective, with only a few minor late complications resulting in recurrence of obstruction.

OBJECTIVE To investigate whether children with lower urinary tract (LUT) anomalies are at greater risk for postoperative complications after laparoscopic pyeloplasty stented with a double-J catheter (JJC). MATERIALS AND METHODS Prospectively collected data of laparoscopic pyeloplasty (LP) performed between 2006 and 2015 were analyzed. Inclusion criteria are (1) toilet-trained child and (2) unilateral dismembered pyeloplasty stented with a JJC done by the same surgeon. Our pyeloplasty protocol includes cystoscopy and retrograde pyelography. JJC is left in for 3weeks. Asymptomatic patients with infravesical LUT anomalies (a-LUTA) and those with history of LUT symptoms (LUTS) were identified. Any short-term complication was classified according to Clavien-Dindo. Fisher's exact test was used for statistical analysis. RESULTS Fifty-four children (mean 9.8 years) were included. Ten of 54 patients had LUTS. In 4 of those 10, anatomical infravesical anomaly was found during cystoscopy. Accidental urethral anomaly was found in 11 patients (a-LUTA). The control group (CG) consisted of 33 patients. Postoperative hospital stay ranged from 1 to 8 days (mean 2 days). Overall complication rate was 8 of 54 (14%). Grade 1 complications occurred in 3 patients in the CG. Five patients had grade 3 complications (2 needed replacement of bladder catheter, and 3 had diversion of the upper tract). Those problems occurred in 1 of 10 patients with LUTS and 3 of 11 patients with a-LUTA compared to 1 of 33 in the CG. This difference was statistically significant (P

Objectives To assess the results of secondary endopyelotomies (SEP) that were performed in our center in children who had earlier failed pyeloplasty. Methods Eleven secondary endopyelotomies were done between 2005 and 2010 in 10 patients (5 boys and 5 girls, mean age 6.8 years), with a follow-up time of >6 months. The primary procedure was an open/laparoscopic pyeloplasty (n = 10) or a ureterocalicostomy (n = 1). In all cases, endopyelotomy was done by means of a monopolar electrocautery hook using the standard pediatric resectoscope. In 10 patients, SEP was done percutaneously, and in 1 patient it was done in a retrograde fashion. The mean operation time was 69 minutes. Results After a mean follow-up of 20 months, 70% of patients were free of complaints (n = 7), which was defined as a resolution of complaints, resolution of hydronephrosis, and improvement of renal wash-out curve and function. In 4 renal units, reintervention had to be considered; in one of these, a re-pyeloplasty has already been performed. The mean postoperative hospital stay was 2.8 days. No intraoperative complications occurred. In 1 patient, postoperative leakage around the nephrostomy drain occurred but resolved spontaneously. Conclusions SEP is a fairly safe method to treat recurrent ureteropelvic junction–stenosis after failed pyeloplasty in children. However, because it seems to be less affective than the open redo pyeloplasty, it cannot be considered as a gold standard procedure and as such should be thoroughly discussed with the patient and parents.

To assess the outcomes of nondismembered pyeloplasty for ureteropelvic junction obstruction in a pediatric population of children and adolescents. Between 2005 and 2009, a total of 129 pyeloplasties were performed at our institution. In all, 34 (24%) renal units underwent primary nondismembered Fenger-type plasty, 22 open (OPEN) and 12 laparoscopic (LAP). Gender distribution, left to right ratio, follow-up period, grade of kidney dilatation and split renal function were similar in both groups. The decision to perform a nondismembered procedure was made by the surgeon intraoperatively. The mean age at surgery was 4.5 years for the OPEN group and 14.2 years for the LAP group. Mean follow-up was 30 months (range 12-70 months). The overall success rate was 91% (95.5% the OPEN group and 83.5% in the LAP group). Secondary surgery was required for 3 renal units. Other complications included pyelonephritis in 3 patients (2 in OPEN and 1 in LAP), ileus in 1 patient (OPEN), and prolonged postoperative pain in 1 patient (LAP). The mean operation time was significantly shorter for open surgery (95 minutes for OPEN vs 179 minutes for LAP; P < .05). There was no significant difference in the length of the postoperative hospital stay (2.5 days for OPEN vs 3 days for LAP). Nondismembered pyeloplasty is an effective procedure for curing ureteropelvic junction obstruction in the pediatric population, and can be considered as an option in well selected cases

PURPOSE: We evaluated the effectiveness of bladder neck injection as a supplementary treatment for persistent low pressure incontinence after unsatisfactory fascial sling procedures in patients with neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS: A total of 89 patients with neurogenic lower urinary tract dysfunction underwent fascial sling procedures between 1992 and 2005. Because of unsatisfactory results, 27 patients received endoscopic injection of a bulking agent. All patients included in the study underwent urodynamic examination after the sling procedure, which revealed persistent low pressure transurethral leakage of urine. We retrospectively analyzed the endoscopic approach used to administer the bladder neck injection, method of postoperative catheterization and number of injections given. Efficacy of bladder neck injection was graded by the patient and the urologist. RESULTS: After a median followup of 8 years (range 2.5 to 14) only 2 patients (7%) were continent after having received a single injection of bulking agent. A total of 12 patients (44%) were given a second injection and 8 (30%) were given a third injection but these subsequent injections did not result in continence. Of the patients 16 (59%) eventually underwent bladder neck surgery, 2 (7%) were dry and 8 (30%) accepted the inconvenience. Two patients underwent ileocystoplasty and 1 patient underwent botulinum A toxin (Botox(R)) injection due to decreased bladder capacity and poor bladder compliance. Neither the endoscopic approach nor the method of postoperative catheterization affected the success rate. CONCLUSIONS: Bladder neck injection after failure of primary sling procedures has limited value in patients with neurogenic lower urinary tract dysfunction. Repeat bladder neck injection yields no additional benefits

Surgery for urinary incontinence in childhood is in the process of an ongoing search for better results because a procedure that guarantees dryness still does not exist. This study has been conducted to assess the overall results of the fascia sling procedure for incontinence in children. Eighty-nine patients with neurogenic lower urinary tract dysfunction and follow-up of more than 2 years have been included in the study (46 boys and 43 girls aged 2-17 years). All patients underwent U-type sling suspension of the bladder neck. In 59 patients detrusorectomy and in 11 patients bladder augmentation was performed. Sphincter incompetence was defined as low-pressure (

Objectives To test the agreement among pediatric urologists regarding endoscopic findings concerning posterior urethral valves. Methods A total of 25 experienced pediatric urologic surgeons observed 11 video fragments of cystourethroscopy in boys. For most of these boys, a strong suspicion of urethral obstruction had been present; however, some were controls. The video fragments stopped when an incision seemed about to be made using the endoscopic hook on, or behind, 17 folds/valves. The pediatric urologic surgeons were then asked whether they would have incised these folds/valves. The only additional clinical information given was that a suspicion of obstruction was present for most cases and that a few control cases had been included. They could only answer “yes” or “no.” Results Agreement of ≥80% was observed for 12 of the 17 questions. Of the 17 cases, 5 yielded agreement of 50%-75%. Only in 1 case, was 100% agreement reached. Most surgeons did not regard a flap valve at the 12-o'clock position as an obstruction. The voiding cystourethrograms of several cases with good positive agreement regarding posterior urethral valve obstruction displayed no radiologic suspicion of posterior urethral valves. Conclusions When judging cystoscopy results, we found fair to good agreement among pediatric urologists regarding whether a urethral obstruction is present. If a urethra appears normal on voiding cystourethrography, this does not exclude the possibility of a urethral obstruction. A true reference standard for urethral obstruction in boys does not seem to exist, and clinical data and additional diagnostic procedures are needed for diagnosis in most cases.

Objectives To assess outcomes in hypospadias repair at our institution, as compared with the literature, with repair technique and surgeon considered as risk factors. Methods The results of 299 primary hypospadias corrections were analyzed. All procedures were performed by three experienced pediatric urologists. Mean patient age at operation was 16.3 months. Follow-up was between 6 months and 5.5 years. Distal hypospadias repair was carried out in 242 patients, with tubularized incised plate reconstruction in 100 patients, advancement in 128, and the Mathieu technique in 14. Results During follow-up, complications occurred overall in 93 patients (31%). For distal hypospadias complications occurred in 59 patients (24%). The most common findings for distal hypospadias were urethral fistulas (14.4%). The complication rate depended on the severity of the anomaly (0 glanular, 28% pericoronal, and 63% proximal) and the chosen technique (16% advancement technique versus 60% tubular techniques). We found statistically significant differences in complication rates between operating surgeons. Conclusions Complications after hypospadias surgery are frequent. They are multifactorial and depend mainly on the type of the anomaly, the chosen technique, and the experience of the surgeon. More studies are needed to obtain an internationally accepted quality indicator for the outcome of hypospadias repair.

Background Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. Objective To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). Study design The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Results Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. Discussion There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Conclusion Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

Minimal invasive surgery (MIS) has developed tremendously during the last 20 years. Nowadays, a wide spectrum of ablative and reconstructive procedures in urology can be done in adults as well as in children. MIS has been proven to be a safe and effective technique regardless of the age of a patient, provided it is done by a well prepared team. MIS has its disadvantages and limitations. In this article the differences between adults and children in different aspects of MIS are described. The current status of MIS in paediatric urology is provided. The authors show their own experience in laparoscopic surgery for the treatment of congenital and acquired anomalies of the urogenital tract. The future of MIS in paediatric urology is briefly discussed. Proper training is crucial to reduce the complication rate and to improve the results. The numbers of laparoscopic procedures in childhood are relatively low. Therefore, there is a need for concentration of the MIS care to ensure surgeons’ exposition to higher volumes, which can improve the quality of care.

To present the primary results of laparoscopic, Burch-type colposuspension (LBC) in children. LBC was performed in eight children (mean age, 14 years) with urinary incontinence after failed extensive urotherapy program. In all patients, bladder neck (BN) incompetence was proven by clinical observation, perineal ultrasound (US), and video-urodynamic study (V-UDS). The LBC was performed with patients in the lithotomy position by means of three 5-mm ports. The anterior wall of the vagina, lateral to the BN, was mobilized, and the vaginal wall was bilaterally lifted and sutured to Cooper's ligament, resulting in elevation and fixation of the BN. A catheter was left for 4 days. The mean operation time was 101 minutes (range, 56-150 minutes), and the follow-up time was >6 months. The postoperative period was uneventful for all patients. Shortly after the procedure, 5 patients (62.5%) were dry, and 1 patient improved (12.5%). After 6 months, 3 patients (37.5%) were dry, and 2 (25%) improved. In 3 wet patients, control US and V-UDS focused on the BN revealed hypermobility and persistent flat vesicourethral angle (VUA) in 1 patient, hypermobility with a good restoration of the VUA in 1 patient, and good fixation with good restoration of the VUA in 1 patient. LBC is a challenging procedure in children because of the small operation field. This procedure can be considered to cure refractory stress urinary incontinence in children with BN insufficiency when noninvasive methods have failed

To present an overview of the clinical presentation and pathological anatomy, and the results of surgical correction of 7 cases of epispadias with intact prepuce; a rare condition that has only occasionally been reported in literature. A retrospective search was performed in the surgical and diagnoses database between 1991 and 2011. Seven cases of epispadias with intact prepuce were identified. Five presented as a webbed and buried penis, 1 as phimosis and 1 with suspicion for congenital anomaly of the genitalia. In 3 of 7 cases, epispadias was suspected or diagnosed at first presentation and could be surgically corrected in the first intervention. In the other 4 cases, epispadias was discovered during surgery, requiring an additional intervention to perform epispadias repair in 3 cases. One boy was diagnosed with glandular, 3 with coronal, 1 with shaft and 2 with penopubic epispadias. Epispadias repair was successful with regard to cosmesis and erectile function. Five patients developed normal continence after surgery, 1 after intensive urotherapy. An under average penile length was the main reported problem during follow-up. In the diagnostic process for a concealed penis, the possibility of epispadias should be considered. If epispadias is suspected or confirmed, epispadias repair can occur in the first intervention, reducing the number of additional interventions. Epispadias with intact prepuce appears to have a better prognosis concerning urinary continence compared to classical epispadias

The aim of this work was to present a new vesicoscopic technique for treatment of sphincter insufficiency and to evaluate the short-term results. Eight children (mean age, 11.7 years), 4 with non-neurologic and 4 with neurologic sphincter incontinence, were operated on. All had previously failed open surgery. In all, leak-point pressure was below 30 cm H(2)O. Mean follow-up was 5.2 months. In the supine position, three ports were inserted into the bladder under direct visual control. A U-shaped incision was made in the mucosa around the bladder neck, leaving a strip of mucosa on the anterior bladder wall that was tubularized. One lateral mucosal flap was used to cover the tube. A transurethral catheter was left in for 3 weeks. One conversion to open procedure was necessary because of leakage. Mean operation time was 161 minutes (range, 150-194). Postoperative hospital stay was between 2 and 4 days (mean, 2.7). Transurethral clean intermittent catheterization has been resumed in 4 children without complications. Four patients are dry, 2 are sporadically wet but satisfied with the result, and 2 patients are wet. Vesicoscopic U-bladder neck plasty is a promising procedure. A major advantage of the technique is the fact that it is a relatively minor surgery with excellent cosmetic outcome and quick recovery

INTRODUCTION: Varicocele occurs in about 15% of adolescents, but it is hardly ever noticed in children under 10 years old. Surgical treatment in adolescents is still controversial. Objectives: The aim of this work was to assess the outcome of laparoscopic varicoelectomy by using electrocoagulation versus clips. MATERIALS AND METHODS: In the Pediatric Surgery and Urology Departments of the Medical University of Wroclaw, 139 boys with varicocele were operated on by using laparoscopy between 1995 and 2007. In total, 68 (49%) patients appeared for the control ultrasound after the surgery, and only those patients were included in this study. The spermatic vessels (both the artery and the vein) were trans-sected by monopolar diatermy (38 patients; 55.8%) or clips (29 patients; 42%). The spermatic Artery was saved in 5 cases, which have been operated on by using diatermy and in 3 by using clips. The follow-up was from 0.5 to 7 years (mean, 2.7 years). RESULTS: Among 68 patients from the control group of persistent varicocele with grade II and grade III (Dubin-Amelaar classification) were recognized in 5 (7.3%) boys. In the group of boys, who have been operated on by using diatermy, persistent varicocele was noticed in 10.5% (4), while in those who have been operated on by using clips, the persistent varicocele was recognized only in 3.4% (1). Varicocele with grade I, not demanding a second operation, was recognized in 9 boys (14.7%). The most often found complication was hydrocele. It was recognized in 23.7% (9) boys operated on by using diatermy and in 13.8% (4) boys operated on by using clips. CONCLUSIONS: Varicocelectomy using clips gives much less complications then the electrocoagulation and should be firstly chosen

Purpose To investigate systematically the length of the urethra in girls with lower urinary tract symptoms. Materials and methods In a group of 121 consecutive girls presented at a tertiary referral clinic for urinary incontinence or recurrent urinary tract infections, urethral length was measured by perineal ultrasound. The urethra was measured with the patient in supine position without anesthesia. Mean age of the patients was 7.8 (0–15) years. Results Average urethral length was 26 mm. Minimum length was 12 mm, measured in a 5-year-old girl with dribbling incontinence. Maximum measured length was 40 mm in a 15-year-old girl. In four girls (3.3%), aged 1–10 years (mean 6.3), a short urethra was detected, with measured lengths of 12 and 14 mm. All four had normal genitalia, and were referred with therapy-resistant urinary incontinence or urinary tract infections. A gradual increase in average urethral length was measured from 23 mm at birth to 32 mm at 15 years. Conclusion Urethral length can be measured accurately by ultrasound. Although a short urethral length is rarely detected by ultrasound in girls with incontinence, it may be associated with therapy-resistant incontinence. In such cases, different treatment options are available.

OBJECTIVES To describe the use of colonic washout enemas for persistent constipation in children treated for dysfunctional voiding by cognitive and biofeedback training. METHODS We treated 50 children, who had dysfunctional voiding and persistent dilatation of the rectum notwithstanding adequate oral laxatives, with colonic washout enemas. We performed retrograde filling of the rectum with 20 mL/kg water, starting once daily for 2 weeks, then 3 times per week for 6 to 12 months. RESULTS During the 6-month follow-up, 30 children were free from urinary tract infections. In 20 children we observed partial relief of complaints. On ultrasound all children showed a normalized diameter of the rectum. In 33 patients washout treatment could be stopped with continuing success. Relapse of a distended rectum triggered the need for chronic intermittent enema therapy in 17 patients. A few patients reported pain during enema treatment; otherwise, we noted no counter-effect. CONCLUSIONS Dysfunctional voiding combined with constipation in children can be cured by washout enemas if oral laxatives fail.

Renal damage and renal failure are among the most severe complications of spina bifida. Over the past decades, a comprehensive treatment strategy has been applied that results in minimal renal scaring. In addition, the majority of patients can be dry for urine by the time they go to primary school. To obtain such results, it is mandatory to treat detrusor overactivity from birth onward, as upper urinary tract changes predominantly start in the first months of life. This means that new patients with spina bifida should be treated from birth by clean intermittent catheterization and pharmacological suppression of detrusor overactivity. Urinary tract infections, when present, need aggressive treatment, and in many patients, permanent prophylaxis is indicated. Later in life, therapy can be tailored to urodynamic findings. Children with paralyzed pelvic floor and hence urinary incontinence are routinely offered surgery around the age of 5 years to become dry. Rectus abdominis sling suspension of the bladder neck is the first-choice procedure, with good to excellent results in both male and female patients. In children with detrusor hyperactivity, detrusorectomy can be performed as an alternative for ileocystoplasty provided there is adequate bladder capacity. Wheelchair-bound patients can manage their bladder more easily with a continent catheterizable stoma on top of the bladder. This stoma provides them extra privacy and diminishes parental burden. Bowel management is done by retrograde or antegrade enema therapy. Concerning sexuality, special attention is needed to address expectations of adolescent patients. Sensibility of the glans penis can be restored by surgery in the majority of patients. Electronic supplementary material The online version of this article (doi:10.1007/s00467-008-0780-7) contains supplementary material, which is available to authorized users.

Kaefer et al. [1] advocate, in case an indication exists for surgical intervention, to turn an obstructive megaureter into a refluxing one as a temporary solution to avoid reimplant surgery in infants. They do this based on a concern that reimplant surgery should be avoided under the age of 12 months. No scientific proof exists to support this concern that for some people in pediatric urology is a dogma that they strictly adhere to. In contrast, ample scientific proof exists that infant recalibration and reimplantation can be done safely with good results and without any risk for the urodynamic properties of the bladder [2e5]. In this current series, the children are brought into a compromised situation twice because of the need for extra definitive reconstructive surgery at a later age. Therefore, in our opinion, the message should be: if one is not confident to do a major reconstruction in a neonate, refer the patient to a center where, regardless of age, the patient can be treated adequately in one step, instead of bringing the patient at risk by creating a refluxing megaureter. An obstructive megaureter is not an indication for any temporary measures except for a nefrostomy tube in case of a pus-filled system in a septic child or a cutaneous ureterostomy when severe doubts exist on the viability of the kidney, to observe whether

The gold standard of treatment in the case of fecal peritonitis in association with traumatic rectal perforation is closure of the perforation in combination with a diverting colostomy. In this paper, we report the successful laparoscopic management of such a trauma without colostomy 24 hours after the incident.

Purpose To evaluate the effectiveness of bulking agent injection (BAI) in the bladder neck as supplementary treatment of persistent low-pressure incontinence after primary fascial sling procedure. Material and methods Between 1992 and 2005 eighty nine patients with neurogenic lower urinary tract dysfunction underwent fascial sling procedure. Because of unsatisfactory results in 27 children endoscopic injection of a bulking agent was applied. In all patients urodynamic study after the sling procedure showed low-pressure leakage. Endoscopic approach (retrograde, antegrade or both), way of postoperative catheterization and number of sessions were retrospectively analysed. Results of BAI were graded by the patient and the urologist. Results At median (range) follow-up of 8 (2,5-14) years only two were continent after one injection (7%). Thirteen (48%) were given a second and a third bulking agent and four even a fourth one, but these did not result in dryness. The first BAI was given at a median of 13, the second after 20, the third after 31,5 months after the sling operation. Finally 16 patients (59%) had bladder neck surgery. In three patients (11%) ileocystoplasty was done because of decrease in BC and poor compliance. The endoscopic approach and technique of postoperative catheterization did not affect success rate. Conclusions There is no place for repeated BAI in patients with neurogenic sphincter dysfunction after failure of primary sling procedure.

PURPOSE To investigate systematically the length of the urethra in girls presenting with LUTS and to determine changes of length during growth. MATERIAL AND METHODS A group of 122 consecutive girls presenting at a tertiary referral clinic for pediatric urinary incontinence or recurrent urinary tract infections had their urethral length measured by perineal ultrasound. The urethra was measured with the patient in supine position without anesthesia. RESULTS Mean age of the patients was 7, 79 years (0-15). Average urethral length was 25,68 mm. Minimal length in this group was a length of 9 mm, measured in a 5 year old girl with epispadias. Maximum measured length was 40 mm in a 15 year old girl. Five girls, (4.09%) aged 1-10 years (mean age 6 years) had extremely short urethras with measured length resp. 9, 12 (twice) and 14(twice) mms. One of these had epispadias, 4 had normal genitalia. Four had therapy resistant urinary incontinence, 1 was too young to evaluate continence. A gradual increase in average urethral length for age was measured from 23 mms at birth to 32 at age 15 years. CONCLUSIONS Urethral length in girls can be measured accurately by ultrasound and the average length is approximately 25 mm's. Girls with extremely short urethras causing therapy resistant incontinence can easily be detected by ultrasound and selected for different treatment options. Mean urethral length in girls increases from 23 mm at birth to 32 mm at puberty.

Purpose We introduce a modification of ileocystoplasty combined with double Monti tube. This modification prevents the dog ear of the ileum during detuberalisation and also the Monti tube is supported by the surrounding mesenterium of the ileal augment. Material and Methods In 5 patients that needed ileocystoplasty the new technique has been used. Four patients had a small neuropathic bladder, one patient had a small contracted bladder without neurological disorder. The surgical technique is as follows: 30 or 40 cm ileum is isolated and plicated in a U shape and completely divided in the middle. A 16 mm wide strip of ileum is then cut from the top of the right ileal part, and a similar strip is cut from the bottom of the left ileal part. The strips are cut near the mesentery to form the Monti tubes. The small strips are tubelarised and joined in the middle to form a catheterisable tube. The ileal segments are opened antimesenterially. These ileal flaps are closed over the Monti tube in the middle. The lower part of the Monti tube is implanted with a submucosal tunnel in the bladder wall and the ileal patch is then anastomosed with the bladder. The Monti tube is anastomosed to the umbilicus in an ordinary way without any traction. Results All patients have umbilical stoma's without leakage or strictures. Intermittend cathetrisation is very easy. It seems that the Monti tubes are strait and well supported by the surrounding tissues so that kinking is not possible. The augmented bladders show excellent volume and compliance. Conclusions Although we treated only a small number of patients we are convinced that this modification provides advantages during the procedure and produces better results in the future.

PURPOSE Surgery for sphincter incontinence remains challenging. Regardless of the methods the final success rates not usually exceed 70-80%. Short term results of a new vesicoscopic technique for bladder neck reconstruction are presented. MATERIAL AND METHODS Between Nov 2007 and Sept 2008 eight children (mean age 11,7 years), four with non-neurogenic, four with neurogenic sphincter dysfunction were operated. All had failed earlier surgery. All had leak-point pressure below 30 cm H2O. Mean follow up period is 5.8 months. Technique: In supine position, 3 ports are inserted into the bladder under direct visual control. U-shaped incision is done of the mucosa around the bladder neck leaving a strip mucosa on the anterior bladder wall that is tubularised. One lateral mucosal flap is used to cover the tube. A transurethral catheter is left for 3 weeks. RESULTS Mean operation time was 161 min (110 – 198 min). There was one conversion to open procedure. Mean postoperative hospital stay was 2.7 days (2 – 4 days). Transurethral CIC has been resumed in 4 children without any complication. Four patients are dry, two are sporadically wet but satisfied with the result and two patients are wet. CONCLUSIONS Short time results of vescicoscopic U-Bladder neck plasty are encouraging but long follow-up of a large group is necessary to evaluate the efficacy of this technique. Major advantage is the fact that it is a relatively minor surgery with excellent cosmetic results and quick recovery.

Purpose To assess bladder behaviour after detrusorectomy and check whether good short time outcome remains unchanged at long-time follow-up. Material and methods Between 1990 and 2001 forty nine detrusorectomies were done (mean follow up 9,6 years). Urodynamic study (UDS) was done before surgery and at 12 months and 3 to 5 years post-op. Bladder capacity (BC) was considered good when more than 80% of EBC. Compliance was defined as good when less than 20 H2O at 80% of EBC. Twenty patients had good BC and compliance before surgery (group I). Indication for detrusorectomy in this group was: detrusor overactivity and/or complex surgery (fascial sling/reimplantation). Twenty nine patients had poor BC or/and compliance preoperatively (group II). Good BC and compliance postoperatively were considered as good result. Results All had UDS with success rate of 70% (14 pts) in group I and 31% (9 pts) in group II. Long term follow-up (min. 6 years) revealed 28 good bladders (16 group I and 12 in group II). Six patients had only one control UDS. Those patients did clinically very well and did not need 2nd UDS. Overall success rate was 57%. Two bladders deteriorated in function and 3 improved. Nine patients (18%) needed formal bladder augmentation (group I – 3pts; group II – 6pts). In eleven patients anticholinergics could be stopped (group I – 5pts; group II – 6pts) and in 2 patients reduced to once daily. Conclusions Bladder behaviour improves after detrusorectomy and can obviate the need of antimuscarinics in most of succesfull cases. Good short term result remain usually unchanged at long term outcome.

All patients were treated with clean intermittent catheterisation (CIC), antimuscarinic agents, and antibiotic chemoprophylaxis from birth onwards in order to prevent obstructive uropathy and to preserve renal function. To secure low intra-vesical pressure, antimuscarinic agents were administered (oxybutynin, sometimes replaced by tolterodine if necessary). If conservative management failed a sling and (auto) augmentation was offered. Our definition of 'continent' is when a patient can retain urine and can void normally. Our definition of 'dry' is when a patient is on catheterisation without requiring pads.

Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Meeting