Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society

BACKGROUND

The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center.

METHODS

We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years.

RESULTS

we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9 ± 4.7 years (mean ± SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1 ± 8.2 years (mean ± SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3β-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population.

CONCLUSIONS

Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients

OBJECTIVE

To evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot-assisted approaches.

MATERIALS AND METHODS

Retrospective review of all pediatric laparoscopic and robot-assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR, LVCUR, LDECUR, RALUR, and RADECUR.

RESULTS

One thousand three hundred forty-three patients (490 boys and 853 girls) with a median age of 30 months (IQR 12-63) were treated at 13 centers. Nine hundred and eight patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). Four hundred thirty-five (32%) had a surgery due to ureterovesical junction (UVJ) obstruction. Mean length of follow-up was 14 months (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (P = .45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. Six patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent voiding cystourethrography postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm, respectively. Grade 3 complications occurred in 17 (1.2%) and 8 (0.5%) in both arms, respectively. Surgical success was achieved in 96% of patients.

CONCLUSION

Laparoscopic and robot-assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot-assisted approach is beneficial in terms of operative time, intracorporeal suturing, and lower complications rate.

Robotic-Assisted Laparoscopic Pyeloplasty in Challenging Cases of Ureteropelvic Junction Obstruction in the Pediatric Population: A Multicenter Review

Purpose: To report a multi-institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes. Materials and Methods: Retrospective chart review of all pediatric patients who underwent robotic-assisted laparoscopic pyeloplasty (RALP) for UPJO in challenging cases between 2013 and 2021 was included. Demographics, perioperative surgical data, complications, and results are described. Challenging cases were defined as bilateral UPJO, failure of previous open pyeloplasty (thus re-do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis, and low-weight infants (<6 kg). Results: Over an 8-year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. Fifteen patients underwent RALP for recurrent UPJO; among them, 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing <6 kg, 3 cases of huge hydronephrosis, and 2 cases of bilateral UPJO. The median age and weight were 36 months (interquartile range [IQR] 14-84) and 12 kg (IQR 10-20.5), respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90-135). The mean length of hospital stay was 2.6 days. Four patients (17%) had postoperative complications-1 ileus (Clavien-Dindo grade [CDG] I) and 3 urinary tract infections (CDG II). No CDG III or higher complication was encountered. At a median follow-up of 36 months, the success rate was 95% with 1 patient requiring another re-do procedure due to recurrent obstruction. Conclusions: Our data suggest that RALP is safe and effective even for challenging cases of UPJO in children.

Long term results of non-refluxing ureteral reimplantation in the pediatric population

PURPOSE

To evaluate the long-term results of UR and to determine the difference between patients with VUR and OMU in terms of re-obstruction rate, complications associated with pregnancy, and de novo reflux.

METHODS

Two-site retrospective study with 69 patients (36 females and 33 males) with a mean age of 5 ± 3.4 years. Fifty-nine (85.5%) underwent UR due to VUR and 10 (14.5%) due to OMU. Mean length of surgery and hospitalization was 90 ± 29.2 min and 9 ± 2.4 days, respectively.

RESULTS

Eight (13.5%) patients with VUR suffered from febrile UTI with a mean of 2.1 ± 1.3 events. In the OMU group, 1 (10%) patient suffered from febrile UTI. None of the patients showed recurrence, obstruction or de novo VUR. Two patients (20%) with OMU suffered from CKD. In the VUR group, 3 (5.1%) patients suffered from CKD. Three women suffered from UTIs during pregnancy. Mean follow-up was 17.5 ± 4.6 years.

CONCLUSIONS

Successful UR is associated with a decreased rate of febrile UTI in patients with VUR. Patients with OMU maintained and improved renal function in the long term. None demonstrated technical failures in the long term. Patients who presented with bilateral VUR are more prone to developing major complications.

Medical clowns versus sedation for paediatric urinary catheter insertion-A randomised pilot study

AIM

To investigate the potential benefits of medical clowns (MCs) in reducing anxiety and pain during paediatric urinary catheter insertion.

METHODS

In this prospective pilot study, 51 children who required urinary catheter insertion were randomised into two groups; the first group (n = 29) underwent the procedure in the presence of a MCs, and the second control group (n = 22) underwent the procedure using sedation. Pain and anxiety levels as well as procedural duration were recorded. All procedures were filmed and evaluated for anxiety level by a paediatric psychiatrist. General satisfaction questionnaires were filled by the medical team and parents in the clown group.

RESULTS

There were no differences in pain scores or anxiety levels between the two groups. Procedure duration and total hospital stay were significantly shorter in the MC group (p < 0.001). One hundred percent of the parents and the medical team were in favour of incorporating MCs during urinary catheter insertion.

CONCLUSION

MCs are as good as sedation in lowering anxiety and pain levels in children undergoing urinary catheter insertion. In addition, MCs reduce the duration of the procedure and elicit a high degree of overall satisfaction from the parents and medical team.

Surgical Treatment of Meatal Stenosis: Lessons Learned from the Pediatric Urology Practice

OBJECTIVE

To evaluate the indications for surgery and outcome of meatotomy and meatoplasty in a big cohort of children.

METHODS

We retrospectively evaluated 2211 children who underwent either meatotomy or meatoplasty between 2009 and 2020 utilizing the same operative setup. For continuous data, we performed t-test and Mann-Whitney U test. For categorical data, chi-squared test or Fisher's exact test was used. A binary logistic regression model was used to compare the indications for surgery between the groups.

RESULTS

Of 2211 children, 1906 underwent meatotomy and 305 meatoplasty. The mean age was 5 years (range: 1m-15y) and there was no age difference between the groups. There was no difference between duration of surgery, recovery time, or complication rates between the groups. Deviated stream was the most frequent indication for treatment 1477 (67%). On Univariate logistic regression children with the following indications: dysuria, meatitis, and urinary retention had increased odds toward meatoplasty, while the indication of deviated stream had increased odds toward meatotomy. On Multivariate Logistic regression only deviated stream (Odd-ratios 1.47, P: .005) and urinary retention (Odds-ratio 4.5, P: .027) remained significant for meatotomy and meatoplasty respectively. Eleven (0.58%) children who underwent meatotomy developed recurrent Urethral Meatal Stenosis and underwent another surgery. Sixty-nine children (3.6%) after meatotomy required manual opening of the meatus on the first post-operative visit. None of the children, who underwent meatoplasty needed reoperation.

CONCLUSION

Meatotomy had a higher reoperation rate and frequently required manual meatal spreading in early postoperative period. We believe meatoplasty is a preferable surgery for pediatric UMS.

Current management of the urachal anomalies (UA). Lessons learned from the clinical practice

PURPOSE

It has been suggested that symptomatic UA requires surgical excision. However, the management of asymptomatic urachus is still controversial. We aimed to evaluate the clinical presentation, the efficacy of current modalities used, and postoperative pathology in patients with UA.

MATERIALS AND METHODS

We have performed a retrospective review of all patients diagnosed with UA and treated surgically or conservatively over 18 years. Demographic data, clinical presentation, imaging modalities, pathology, treatment, and postoperative complications were analyzed.

RESULTS

Twenty-five symptomatic patients (18 males and seven females) with a median age of 13 years (1 month to 37 years) were identified. 15 (60%) were diagnosed with a urachal cyst, 4 (16%) with sinus, 3 (12%) with urachal diverticulum, and the remaining 3 (12%) with patent urachus. Of those, 20 (80%) underwent surgical repair, and the remaining five (20%) patients were managed conservatively. 4 (20%) underwent laparotomy, 7 (35%) laparoscopic incision, and the remaining 9 (45%) laparoscopic robotic-assisted surgery. Nine patients required bladder cuff excision. The median operative time was 75 min (42-140 min). One patient developed Clavien-Dindo grade IIIA complication resulting in infected hematoma, which resolved after drainage. Another patient with a complication of grade IIIB needed reoperation as a result of recurrent events of an abscess. 13 (65%) demonstrated epithelium lining of the urachus on postoperative pathology.

CONCLUSIONS

Our data show that most of the patients with UA presented with epithelial lining, which might lead to the later malignant transformation. It might cause a shift from the conservative management of asymptomatic patients to surgical intervention. Robotic-assisted surgery appears beneficial in these patients, especially when the bladder cuff excision is required.

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE

 To review our experience with quadratus lumborum block (QLB) in pediatric urology.

MATERIALS AND METHODS

 This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry.

RESULTS

 There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction.

CONCLUSION

 Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

Does Renal Function Remain Stable after Puberty in Children who underwent Ureteral Reimplantation due to Ureterovesical Junction Obstruction?

INTRODUCTION

 Ureteric reimplantation due to ureterovesical junction (UVJ) obstruction enjoys high success in the short term. However, renal function after reimplantation must accommodate the numerous changes in the pediatric urinary tract that occur along with child development that may theoretically cause an occult loss of renal function. The purpose of this study was to evaluate whether improved renal function after ureter reimplantation for antenatal diagnosed UVJ obstruction remains stable after puberty.

MATERIALS AND METHODS

 Twenty-one children who underwent open reimplantation using Politano-Leadbetter technique were followed until they completed puberty. Mean age at surgery was 14.3 months (range: 3-60 months). Five (23.8%) of 21 children had right hydronephrosis, 13 (61.9%) had left hydronephrosis, and 3 (14.3%) had bilateral hydronephrosis. The Society for Fetal Urology (SFU) level of the hydronephrosis was 3 (47.6%) in 10 children and 4 (52.4%) in remaining 11. Fourteen (66.6%) patients had poor renal function upon surgery and the remaining seven (33.4%) patients had moderate renal function. The mean renal function upon operation was 28 ± 4.3 (mean ± standard deviation [SD]).

RESULTS

 Reimplantation led to the increase in the RRF in the short-term period from 28 ± 4.3% prior to the surgery to 36.4 ± 5% (p < 0.001) in all patients and remains stable 35 ± 5% after puberty in all the reviewed patients.

CONCLUSION

 Our data demonstrate for the first time that successful ureteral reimplantation following antenatal diagnosis of UVJ obstruction is associated with an improvement in renal function, not only during short- and midterm follow-up but also allows preserving the renal function throughout the puberty period.

Glans injury during ritual circumcision

BACKGROUND

Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences.

OBJECTIVE

In this study we describe the experience of two medical centers with the management and follow up of glans injury after ritual circumcision.

METHODS

We have retrospectively reviewed the medical files of all pediatric patients who presented to the ER with glans injury, following ritual circumcision, over a 17-year period from two medical centers.

RESULTS

A total of 8 patients were identified, who underwent ritual circumcision between 7 and 9 days of age. On presentation, 1 infant had complete glans amputation, the others presented with partial amputation of the glans. 6 of the 8 patients had a simultaneous urethral injury. All patients underwent surgical correction for their injury; Patients with isolated glans injury, underwent primary glans anastomosis. Of the 6 cases with simultaneous urethral injury: 3 underwent end-to-end urethral anastomosis following anastomosis of the amputated glans, one patient with complete glans amputation underwent a similar procedure, with initial end-to-end urethral anastomosis followed by glans anastomosis to the corpora cavernosa and 2 were managed by urethrostomy together with anastomosis of the amputated glans tissue to the remaining glans. Both patients with urethral injury, in whom end to end urethral anastomosis has not been performed, were found to have hypospadias on follow up. The rest had good functional and cosmetic results.

DISCUSSION

There is no single method for managing glans injury following circumcision. Some authors describe healing by secondary intention with delayed formal repair, while others advocate for primary anastomosis of the amputated glans, together with distal urethra-urethrostomy, in cases with simultaneous urethral injury. In this study, both patients without urethral anastomosis, developed secondary hypospadias due to meatal regression and required additional surgery, while the others showed good results. The limitations of our study are its retrospective nature and the small number of cases, preventing us to come to a definitive conclusion regarding the best way to treat such a rare injury.

CONCLUSION

Prompt surgical correction by glanular replantation with urethro-urethrostomy, in case of concomitant urethral injury, give good cosmetic and functional results.

Learning curve of robotic-assisted laparoscopic pyeloplasty (RALP) in children: how to reach a level of excellence?

It has been suggested that up to 40 cases of RALP are required to reach the operative results equal to open surgery. We have hypothesized that previous experience in open and laparoscopic surgeries might shorten the learning curve of robotic surgery. We have retrospectively evaluated the data of all children who underwent pyeloplasty in our institute by a single surgeon since 2003. The children were divided into three groups: open pyeloplasty (OP) of 72 children, laparoscopic pyeloplasty (LAP) of 22, and RALP of 33 patients subsequently. The data included: demographics, duration of surgery, length of stay, success of surgery, and complication rate according to the Clavien-Dindo score. The groups were ordered chronologically by the operation date and each group was divided into two different phases: early and late. A comparison was made between the data of the early and the late phase. There was no difference in the demographic data between the groups; however, the patients who underwent laparoscopic surgery were significantly older compared with the patients from the other groups. The median duration of surgery in the RALP group was significantly shorter than the OP group (65 min vs 72.5 min P < 0.01), while the first RALP case was already shorter than the median duration of surgery in OP group. There was no significant decrease in the duration of surgery of the RALP group over the study period, though there was a significant trend of decreasing operative time in the OP and LAP groups. There was no difference in the length of stay in the early vs late phases in the RALP group. There was no difference in the complication and success rate between the RALP and OP group, as well as the early and late phases of the RALP group. Our data show that previous experience in OP and LAP surgery may contribute to a shorter learning curve of robotic surgery required for the surgeon to achieve a similar outcome to that of OP.

Sexual function and voiding status following one stage feminizing genitoplasty

BACKGROUND

The data on long-term outcome of feminizing genitoplasty (FG) with regard to the sexual function and voiding status is limited and nearly always retrospective, reviewing only small numbers of patients. Furthermore, most articles only looked at the success as an adequately open vagina with a feminized appearance. Success should include normal erotic sensation, lubrication, sexual satisfaction, orgasm, and intercourse without discomfort. These latter factors are just beginning to be studied OBJECTIVE: To investigate sexual function and voiding status in women who underwent vaginal reconstruction in childhood.

MATERIAL AND METHODS

We retrospectively reviewed medical files of patients who underwent FG at our center from 1988 to 2000. In addition, patients were asked to complete the following standardized questionnaires: Female Genital Self-Image Scale (FGSIS), dysfunctional voiding and incontinence symptoms score (DVISS), and Female Sexual Function Questionnaire (FSFI).

RESULTS

patients underwent one-stage FG; of those, 36 with median age of 21 years (range 18-30 years) who completed the puberty period were included into this study. Of the participants, 15 (41.6%) lived in a committed partnership, and 12 (80%) had sexual intercourse on a regular basis. Total FSFI was 22.2 + 3.1 (mean + SE). Domain scores were 3.9, 4.3, 4.5, 4.3, 4.9, and 4.7 for desire, arousal, lubrication, orgasm, satisfaction, and pain, respectively (Summary Figure). None of the patients reported on daytime incontinence or enuresis. Female genital self-image was found to be positive in all patients and related positively to women's sexual function.

DISCUSSION

The general rate of the sexual activity of our studied population was similar to that published in the literature 80% in our study vs 60-87% published in the literature. The overall FSFI was 22, showing some evidence of the female sexual dysfunction. However, only one patient regarding pain during vaginal penetration demonstrated mild dyspareunia. At the same time, we have not found any desire, arousal, lubrication, orgasm, satisfaction problems. Furthermore none of our patients complained on lower urinary tract symptoms during questioning, while three girls with congenital adrenal hyperplasia presented during follow-up with dribbling incontinence, which resolved with introitoplasty and creation of the wide vaginal opening.

CONCLUSIONS

Our data demonstrate that one -tage FG in childhood is a long-term effective surgical procedure that does not cause voiding dysfunction. If a secondary intervention is required prior to the sexual life, simple introitoplasty usually solves the problem. The FSFI score showed overall acceptable sexual function, whereas mild dyspareunia was a major complain.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

BACKGROUND

It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction.

OBJECTIVE

This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris^®, and performed clinical and histological review of these patients.

METHODS

The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux^® (1790) and Vantris^® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls.

RESULTS

Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2 ± 0.6 cc (mean ± SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction.

DISCUSSION

This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction.

CONCLUSION

Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

One-Stage Laparoscopic Orchiopexy for the Treatment of Intraabdominal Testis

BACKGROUND

Laparoscopy has gradually become the gold standard for the treatment of non-palpable testicles (NPT), with different success and complication rates.

OBJECTIVES

To evaluate outcomes of the one-stage laparoscopic orchiopexy for NPT in our department.

METHODS

We retrospectively evaluated the medical files of patients who underwent laparoscopic orchidopexy with the identical technique. Only patients with at least one year follow-up were included. At follow-up we assessed the age (at surgery), follow-up time, laterality of testes, postoperative complications, testicular size and testicular localization.

RESULTS

Thirty-six consecutive patients, median age 16 months, underwent one-stage laparoscopic orchiopexy. Sixteen patients (44.4%) had peeping testis type, in 13 patients (36.1%) the testicle was located within 2 cm from the internal ring and in the remaining 7 patients (19.4%) it was detected > 2 cm from the internal ring. In six children (16.7%) dividing the spermatic vessels was performed in one stage with laparoscopic orchiopexy. In the remaining 30 patients (83.7%) a laparoscopic one-stage procedure was performed with preservation of the spermatic vessels. Testicular atrophy was observed in 2 cases (5.6%), and 6 patients (16%) had a relatively small testicle compared to the contralateral normal testicle at follow-up. Two patients (5.6%) presented with testicle positioning at the entrance area into the scrotum. None of the patients demonstrated hernia recurrence at follow-up. There was no difference in surgical outcome in children who had surgery with preservation of the spermatic vessels versus those who underwent orchiopexy with division of the spermatic vessels in one stage.

CONCLUSIONS

Laparoscopic transection of the testicular vessels appeared to be safe in boys with high abdominal testes that did not reach the scrotum after laparoscopic high retroperitoneal dissection.

Use of Caudal Analgesia Supplemented with Low Dose of Morphine in Children Who Undergo Renal Surgery

INTRODUCTION

To test the efficacy and safety of caudal anesthesia (CA) supplemented by low dose morphine in children who undergo renal surgery.

MATERIALS AND METHODS

Forty patients aged 2 months-14 years were enrolled and randomly divided into two groups of 20 patients each: Group A (bupivacaine 0.2% with fentanyl); Group B (bupivacaine with morphine). The duration of surgery and hospitalization time were recorded. Postoperative pain score was measured by Face Legs Activity Cry Consolability scale and Wong-Baker Faces scale for those who are older. Overall use of rescue analgesics was calculated.

RESULTS

There was no statistical difference in the length of surgery, incidence of pruritus, postoperative nausea, vomiting and urinary retention between the two groups. However the postoperative opioid requirements were significantly higher in Group A 1.03 ± 0.9 mg/kg compared to Group B, in which only one patient required opioid therapy (p < 0.0001). Moreover the need for non-opioid rescue analgesic was higher in Group A, (36 ± 5.7 mg/kg of paracetamol) compared to morphine CA group there only 26 ± 3.6 mg/kg required during first 24 h of the postoperative period (p = 0.0312). The Face Legs Activity Cry Consolability pain score (1, 4, and 24 h after surgery) and Wong-Baker Faces scale were significantly higher in Group A. The hospitalization period was shorter in the CA morphine group, but the difference did not reach statistical significance. None developed hemodynamic instability or respiratory depression.

CONCLUSIONS

Our data show that CA supplemented with low dose morphine provides a longer duration of analgesia without significant side-effects in children undergoing renal surgery.

Medical clowns reduce pre-operative anxiety, post-operative pain and medical costs in children undergoing outpatient penile surgery: A randomised controlled trial

AIM

The aim of this paper is to investigate prospectively the potential benefits of the participation of the medical clowns in the outpatient paediatric penile surgery programme.

METHODS

Eighty children undergoing meatotomy, age 2 to 16 years, were randomised into two groups (40 each). In the first group, the medical clown was an integral part of the medical team, and in the second group, the treatment was given without participation of the medical clown. The following parameters were measured: the level of pre-operative anxiety, the level of the post-operative pain, the amount of pain medication use in the first 24 h after surgery and the time needed to return to normal activities. The operating room time and hospital costs were calculated.

RESULTS

The patients from the first group demonstrated a lower pre-operative anxiety index upon (P = 0.0319) and after surgery (P = 0.0042), required less induction time for anaesthesia (P < 0.001), spent overall less time in the operating room (P < 0.0001) and required less time to recover from the surgery and to be discharged (P = 0.0172). The overall OR time and post-operative unit care savings of 20 and 155 min, respectively, led to the cost savings of $467.

CONCLUSION

Our data demonstrated that the use of the medical clown functioning as an integral part of the operating team reduces children pre-operative anxiety and leads to a shortening of the overall time in the hospital thereby reducing the overall medical cost justifying the participation of medical clown as an integral part of the health team in a paediatric urology outpatient surgical unit.

Fenestrated sheet split-thickness skin grafting for reconstruction of penile skin loss in pediatric population

OBJECTIVES

We aimed to evaluate our experience with fenestrated sheet split-thickness skin grafts (STSGs) in the pediatric population.

MATERIALS AND METHODS

We retrospectively studied a cohort of 17 children 2-18years old who underwent skin grafting owing to circumcision injuries (2 patients), traumatic penile injury (1) and after previous multiple hypospadias surgery (14). Fenestrated 0.012in sheet STSGs from thigh area (15 patients) and buttock area (2) were fashioned to resurface the denuded penis following reconstruction. The median follow up was 13years (range 1-19years).

RESULTS

There was 94% take of the grafts. One patient required additional grafting following first graft infection. Six patients underwent concomitant surgery at the time of grafting (4 chordee repair and 2 meatoplasty). Two patients had slight chordee at 3 and 6years postoperatively, and 2 with the history of preputial tubularized island flap hypospadias repair had developed a urethral stricture, which required staged repair with buccal mucosa 12 and 14years following primary hypospadias repair. Six sexually active patients reported normal sexual intercourse and sensation following grafting. None of the patients demonstrated shrinkage of the STSGs over the follow up period.

CONCLUSIONS

Our data demonstrated that the use of fenestrated sheet STSGs in patients with penile skin loss yields satisfactory functional and cosmetic outcomes. The buttocks might be considered as a preferable donor site in terms of avoiding a visible scar.

Extracorporeal Ureteric Stenting for Pediatric Laparoscopic Pyeloplasty

INTRODUCTION

We aimed to evaluate a novel technique for ureteric stent insertion during dismembered pediatric laparoscopic pyeloplasty.

PATIENTS AND METHODS

Following identification and dissection of the ureteropelvic junction (UPJ) with the proximal part of ureter, the ureter is dismembered just proximal to the UPJ at the level of the renal pelvis, allowing use of the excess pelvic tissue for further manipulation of the ureter. Then the abdomen is desufflated and the ureter delivered to the skin level. The externalized ureter is then spatulated and the stent inserted in an antegrade fashion to the bladder. The first stitch for further laparoscopic anastomosis is applied to the lower part of the spatulated ureteric end and then following insufflations the ureter is returned to the abdomen. The laparoscopic anastomosis is completed in a routine fashion.

RESULTS

Over the past 4 years, we have used this technique in 26 children (17 boys and 9 girls) with median age of 4 years (range, 2-18 years). Left pyeloplasty was performed in 16 and right pyeloplasty in the remaining 10 patients. The mean (range) time of insertion was 6 minutes (range, 4-7 minutes). All stents were correctly placed. In one patient, the stent dislodged to distal part of the ureter. No other intraoperative or postoperative complications related to our technique of stent insertion were observed.

CONCLUSION

Our data show that extracorporeal antegrade ureteric stent insertion is an easy-to-learn and a safe and reliable technique for pediatric dismembered pyeloplasty. It obviates the problem of having the stent in the pelvis during dissection and the need for patient repositioning.

Laparoscopic single site surgery: Experience in pediatric urology

Laparoendoscopic single-site surgery (LESS) has been developed to benefit patients by enabling surgeons to perform scarless surgery. In this review we aimed to summarize and critically analyze the available evidence on the current status and future prospects for LESS in pediatric urology, with special emphasis on our experience with LESS in children. The clinical data available clearly demonstrate that LESS can safely and effectively be performed in a variety of pediatric urology settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low; mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains improved cosmetic outcome. Prospective randomized studies are awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technological advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics may be a driving force in the development of LESS.

Downgrading of high-grade vesicoureteral reflux is a reliable option in the treatment of children with grade IV‒V reflux accompanied by breakthrough infections

PURPOSE

To evaluate incidence of urinary tract infection (UTI) and natural history of downgraded vesicoureteral reflux (VUR) in children with high-grade VUR following endoscopic correction.

MATERIALS AND METHODS

We retrospectively studied 54 children (13 males and 41 females) with a mean age of 1.8 years who underwent endoscopic correction of Grade IV‒V VUR due to breakthrough infections while on antibiotic prophylaxis. Reflux was Grade IV in 40 (74%) and V in 14 (26%) patients comprising 95 renal refluxing units (RRU). Reflux was corrected in 72 (76%) RRU. 18 (34%) patients/23 (24%) RRU demonstrated downgrading of VUR. 21 of the 23 RRU showed Grade II and 2 Grade III VUR, and were taken off antibiotic prophylaxis and allocated to observation. Patients were followed for 2-22 years (median 14 years).

RESULTS

Technetium 99m dimercaptosuccinic acid renal scan demonstrated preoperative renal scarring in 21 (78%) of the 23 RRU with downgraded VUR. None of the children developed febrile UTI after surgery. 1 RRU showed renal function deterioration. 8 (44%) of the 18 patients underwent follow-up voiding cystourethrogram, and in 7 (88%) there was either spontaneous resolution of VUR or downgrade to Grade I VUR.

CONCLUSIONS

Downgrading of VUR is a reasonable option in patients with high-grade VUR suffering from breakthrough infections while on antibiotic prophylaxis. It leads to the cessation of febrile UTIs, further spontaneous resolution of VUR and may potentially avoid renal damage.

Use of BioGlue Surgical Adhesive in Hypospadias Repair

PURPOSE

To prospectively evaluate the efficacy of albumin glutaraldehyde tissue adhesive (BioGlue) in the surgical treatment of patients with hypospadias.

MATERIALS AND METHODS

Two groups of 20 patients each who underwent hypospadias repair were included in the study. In the first group we utilized BioGlue as an additional protective layer to the suture line of the neo-urethra, while patients in the second group were operated on utilizing a routine surgical technique.

RESULTS

There were no statistical differences between patients from the 2 groups in terms of surgical complications. Urethrocutaneous fistula was revealed in 4 (20%) patients after repair with BioGlue and in 3 (15%) patients from the control group (p = 0.686), suture line breakdown in 4 (20%) and in 1 (5%) patients (p = 0.478), meatal stenosis in 1 (5%) and in 1 (5%) patient (p = 1). Furthermore more patients in the BioGlue group (n = 12, 60%) demonstrated poor cosmetic results compared to the control group where most patients - 19 (95%) had acceptable cosmetic outcomes (p = 0.007).

CONCLUSIONS

Our data showed no benefits of BioGlue use in hypospadias repair.

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood

PURPOSE

We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood.

MATERIALS AND METHODS

After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias.

RESULTS

All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed.

CONCLUSIONS

Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

Preliminary data on endoscopic treatment of vesicoureteric reflux with polyacrylate polyalcohol copolymer (Vantris®): surgical outcome following single injection

PURPOSE

The aim of this study was to evaluate the efficacy of single injection of a new non-biodegradable agent (Vantris(®)) Manufactured by Promedon, Cordoba, Argentina for treatment of vesicoureteric reflux (VUR).

PATIENTS AND METHODS

38 children (11 males and 27 females) with a mean age of 5.3 ± 3.8 years underwent endoscopic treatment of VUR using Vantris. VUR was unilateral in 17 and bilateral in 21 patients, comprising 59 renal refluxing units (RRU). The VUR was primary in 42 RRU and 17 comprised complex cases: 3 duplex systems, 1 with prune belly syndrome, and 13 after failed previous endoscopic correction with Deflux(®). VUR was Grade I in 5, II in 11, III in 23, IV in 15 and V in 5 RRU.

RESULTS

All patients completed 3 months of follow up. The reflux was corrected in 56 (94.9%) of the 59 RRU (35/38 patients) after a single injection. Of the 38 patients, 21 completed 1 year of follow up, at which time ultrasound demonstrated no change compared with 1 month after injection. Eight of these 21 children underwent 1 year radionuclide cystography, and no reflux recurrence was shown.

CONCLUSIONS

Our short-term data show that Vantris injection provides a high level of reflux resolution. Long-term follow up with this tissue-augmenting substance is required.

Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances

OBJECTIVE

To review the current literature regarding the outcome of endoscopic treatment of vesicoureteric reflux (VUR) using different tissue-augmenting substances, with special emphasis on long-term efficacy.

MATERIAL AND METHODS

The current literature, including our own experience, on long-term results after endoscopic treatment was reviewed by MEDLINE/PubMed search.

RESULTS

The short-term results are similar in the majority of series to those of open surgery, but there is a high recurrence rate with use of dextranomer/hyaluronic acid (Deflux) as a tissue-augmenting material.

CONCLUSIONS

There is a significant shortage of evidence-based literature on long-term follow-up after endoscopic correction of VUR utilizing dextranomer/hyaluronic acid. The high recurrence rate that has been reported after Deflux injection highlights a need for close observation beyond routine protocols and appropriate parental counseling upon endoscopic correction, and also the need to search further for alternative tissue-augmenting substances. The algorithm for treating VUR is yet to be finally determined.