A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux

INTRODUCTION

Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported.

OBJECTIVE

In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV + V) VUR in children.

STUDY DESIGN

A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared.

RESULTS

Overall, 135 children who underwent either OUR (n = 68), or RALUR (n = 67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p < 0.01); the open cohort had a weight of 11 kg (IQR 9.9-16.6 kg) while the RALUR group had 19 kg (IQR 13-25 kg) (p < 0.01). No significant differences were found for intraoperative (1.5 % vs 7.5 %, p = 0.09) or for postoperative complication rates (7.4 % vs 9 %, p = 0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p < 0.01). The success rate was 94.0 % and 98.5 % in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively.

DISCUSSION

This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported.

CONCLUSION

RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.

Elevating pediatric urology care: The crucial role of nursing research in quality improvement

This educational article highlights the critical role of pediatric urology nursing research in improving the care of children with urological conditions. It discusses the multifaceted nature of pediatric urology nursing, addresses challenges such as limited nurse scientists and resource constraints, and highlights the need to overcome barriers to increase research involvement. The authors emphasize the importance of prioritizing research areas, the promotion of collaboration, and the provision of adequate funding and academic time for pediatric nurses to contribute to evidence-based practice, to improve patient outcomes. Furthermore, it highlights the importance of research in advancing nursing practice, shaping protocols, and advocating for the rights and needs of children with urological conditions and their families.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Pathways to paediatric urology subspecialisation: a study of casemix, incumbent attitudes and opinions

OBJECTIVE

To identify any self-reported differences or attitudes towards certification, publication, or practice patterns between adult urology and paediatric general surgery-trained paediatric urology providers. There are no known published differences in clinical/operative/research outcomes in either group.

METHODS

An 18-item cross-sectional survey was compiled through the EAU Young Academic Urologists (YAU) office and disseminated to a trans-Atlantic convenience sample of current practising paediatric urologists. This was created using a mini-Delphi method to provide current semi-quantitative data relating to current opinions and attitudes of this cohort.

RESULTS

A total of 228 respondents completed the survey, with female respondents representing 37% and 34% for urology and paediatric general surgery, respectively. Nearly 90% overall respondents felt that a full 2-year paediatric fellowship program was very important and 94% endorsed a collaborative dedicated paediatric urology on call service, with 92% supporting the joint development of transitional care. Urology managed higher numbers of bedwetting (p = 0.04), bladder bowel dysfunction (p = 0.02), endourological procedures (p = 0.04), and robotics (p = 0.04). Paediatric general surgery managed higher numbers of laparoscopic reconstruction (p = 0.03), and posterior urethral valve ablation (p = 0.002).

CONCLUSION

This study represents the first time that a cross-sectional cohort of paediatric urologists from different training backgrounds were compared to assess their productivity, practice patterns and attitudes. Paediatric urology is in a unique position to have two contributing specialities, with the ability to provide optimal transitional and lifelong care. We believe that there should be a strong emphasis on collaboration and to remove any historically-created barriers under policies of equity, diversity and inclusivity.

Primum Non Discernere: Glass Ceilings and Female Representation at the European Association of Urology and European Society for Paediatric Urology Annual Meetings, 2012-2022

Background

The term glass ceiling coined by Loden in 1978 is commonly used to describe difficulties faced by minorities and women when trying to move into senior roles.

Objective

To analyse trends and patterns for female representation at the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) annual general meetings over the past decade.

Design setting and participants

We used objective data on female representation in the roles of chairs, moderators, and lecture speakers at the EAU and ESPU meetings from 2012 to 2022.

Outcome measurements and statistical analysis

We evaluated gender based representation in paediatric urology sessions at the EAU and ESPU meetings, collecting data on the overall number of sessions, lectures, symposiums, abstract/poster sessions, and courses, and analysed the male/female ratio. Data were derived from printed and digital programmes for the relevant meetings.

Results and limitations

During the period from 2012 to 2022, the percentage female representation varied from 0% (2012) to a maximum of 35% (2022) at EUA paediatric urology sessions, and from 13.5% (2014) to a maximum of 32% (2022) at ESPU meetings. Both associations show clear progression towards equality.

Conclusions

Female representation at EAU and ESPU meetings has risen over the years, reaching 35% and 32%, respectively, in 2022, which is in line with the number of female members. We hope that this motivates a move towards the equality objectives for 2030. A clear and fundamental societal change is needed, with fair and more consistent institutional policies and framework commitments in the areas of science, medicine, and global health. Gender equality and diversity taskforces are essential to achieve these goals.

Patient summary

We analysed the male/female ratio for participants in annual meetings held by the European Association of Urology and the European Society for Paediatric Urology. From a low level in 2012, the ratio increased to over 30% in 2022, in line with the female membership of the societies. Focus on fair and consistent policies is needed to ensure that women are well represented in medicine.

A cross-sectional analysis of paediatric urologists' current practices, opinions and areas of perceived importance in the delivery of adolescent & transitional care

INTRODUCTION

Complex urological anomalies often require continued care as patients reach adulthood. Adequate transition for adolescents with ongoing urological care needs is critical to allow for seamless care in adult hospitals. Studies have shown that this can lead to improved patient and parental satisfaction, and lower utilisation of unplanned inpatient beds and emergency department visits. There is currently no ESPU-EAU consensus on the adequate mechanism and very few individual papers examining the role of urological transition for these patients in a European setting. This study aimed to identify current practice patterns in paediatric urologists providing adolescent/transitional care, to assess their opinions towards formal transition and to look for variations in care. This has implications for long-term patient health and specialist care.

METHODS

An 18-item cross-sectional survey was compiled and pre-approved through the EAU-EWPU and ESPU board offices prior to dissemination to all registered ordinary members affiliated with the ESPU. This was created using a mini-Delphi method through the EWPU research meetings to provide current semi-quantitative data relating to current opinions and attitudes of this cohort.

RESULTS

A total of 172 respondents (55% paediatric general surgery; 45% urology) across 28 countries completed the survey. The majority of respondents were in practice >10 years and spent >80% time in paediatric urology. There was no formal transition process according to 50% respondents and over half of those that did have less than 1/month, with <10% using validated questionnaires. More than two-thirds respondents continued to provide care after transition, as >70% units had no designated corresponding adult service. Furthermore, 93% paediatric believe a formal transition service to be very important, using a multidisciplinary framework. A pareto chart demonstrated 10 specific conditions to be of most interest in transition to adulthood.

CONCLUSION

This is the first study to assess the requirements of paediatric urologists for adequate transitional care, however due to the nature of the survey's distribution, this was a non-scientific poll based on a convenience sample of respondents. It is critical that dual-trained or adult-trained urologists with a specific interest in paediatric urology work with current paediatric urologists in a multidisciplinary fashion to facilitate early transition based on the adolescent's developmental and biopsychosocial requirements. National urological and paediatric surgical societies need to make transitional urology a priority. The ESPU and EAU should collaboratively consider developing transitional urology guidelines to allow a framework by which this can occur.

Being born small for gestational age (SGA) might be associated with a higher reoperation rate in proximal hypospadias

PURPOSE

Being born small for gestational age (SGA) is associated with a higher frequency and more severe forms of hypospadias as well as with potential developmental differences. This study aims to characterize operative outcomes in SGA boys compared to boys born with normal weight and length for gestational age (appropriate/large for gestational age, AGA/LGA).

METHODS

Demographic data, hypospadias characteristics, associated pathologies and operative outcomes of boys who underwent hypospadias repair at a single center (10/2012-10/2019) were evaluated. Boys were categorized into SGA and non-SGA, which were then compared using unpaired t-tests and chi square tests. To examine the effect of SGA on reoperative risk, a logistic regression model was applied integrating surgical technique, meatal localization and complex hypospadias (narrow glans/plate, curvature, micropenis, bilateral cryptorchidism).

RESULTS

SGA boys accounted for 13.7% (n = 80) of the total cohort (n = 584) and 33% of all proximal hypospadias (n = 99, SGA vs. non-SGA 41.3% vs. 13%, p < 0.001). After a mean follow-up of 18.6 months the reoperation rate for all hypospadias was 17.9% (n = 105). In distal hypospadias there was no difference in reoperation rate between SGA and AGA/LGA boys (p = 0.548, multivariate regression model). For each meatal localization in proximal hypospadias SGA was a significant, independent factor predicting higher reoperation rates (p = 0.019, OR 3.21) in a logistic regression model (Figure ROC).

DISCUSSION

Hypospadias surgery carries a substantial risk for unplanned reinterventions. Apart from meatal localization, there are only a few factors (urethral plate quality, glandular diameter, curvature) reported in literature to be associated with reoperative risk. Intrauterine growth retardation associated with SGA might lead to not only a higher probability of proximal hypospadias but also contribute to a higher risk for complications mediated by developmental differences. Whether these findings could help to tailor surgical strategies or adjuvant measures, as for example the application of preoperative hormonal stimulation remains to be determined in future studies. This study is limited by being a single-center series with limited follow-up resulting in some complications probably not yet detected - however, in the same extent in both groups.

CONCLUSION

Based on this study, 33% of all proximal hypospadias cases occur in boys born SGA. While the reoperation rate in boys with distal hypospadias was not influenced by SGA status, SGA proved to be an independent predictor of a higher risk of reoperation in those with proximal hypospadias. After validation of these findings in other centers, this could be integrated into counseling and risk-stratification.

Detection of bladder trabeculation by voiding cystourethrography and sonography: observations in boys with posterior urethral valves

Background

As trabeculated bladder wall is often referred to as a sign of chronically increased intravesical pressure, we investigated whether voiding cystourethrography (VCUG) or sonography reliably predicts bladder trabeculation on later urethrocystoscopy.

Methods

A total of 76 consecutive patients (2012–2017) with cystoscopically confirmed posterior urethral valves (PUV) and pre-endoscopy VCUG were included. Sonography data were available for 68 of these patients. Radiological findings were reassessed and compared with endoscopic findings using Fisher’s exact test and Spearman’s rank assessment.

Results

VCUG showed a sensitivity of 83.3% and a specificity of 30% in predicting trabeculation on a later urethrocystoscopy, with no significant difference in determining mild or severe forms (p=0.51). Sonography proved a sensitivity of 27.6% and a specificity of 70%, with no correlation between sonographic signs and trabeculation on cystoscopy (r=0.1311). In addition, vesicoureteral reflux had no significant influence as a possible pressure pop-off mechanism on the development of trabeculation in our group.

Conclusions

While VCUG predicts bladder trabeculation in children with PUV with limited reliability, sonography mostly fails to detect trabeculation. Therefore, such findings should only be used with utmost caution in relation to clinical decision-making.

Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit

Background: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. Methods: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). Results: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111–0.423). Conclusion: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool

OBJECTIVES

Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG).

METHODS

Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients.

RESULTS

Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p < 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%.

CONCLUSIONS

The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.

Low-dose antibiotic prophylaxis has no significant impact on the stability of the intestinal microbiome in children with urogenital tract malformations under 1 year of age

INTRODUCTION

Accumulating data point at potentially lasting effects of early childhood therapeutic antibiotic exposure on the intestinal microbial. Little is known on the impact of low-dose longterm antibiotic prophylaxis on the developing intestinal microbiota in children during their first year of life.

OBJECTIVE

To investigate compositional changes of the intestinal microbiota by next generation sequencing based microbiome analysis and bacterial metabolites in longitudinally collected fecal samples.

STUDY DESIGN

Twelve patients were analyzed in this prospective, longitudinal pilot study during a period of 70 days (sampling on days 0,7,14,30,70). Only transvaginally and term born babies, breastfed with no prior antibiotic exposure with urogenital malformation (vesicoureteral reflux and/or upper urinary tract dilatation) were included into the study. Seven patients received antibiotic longterm prophylaxis with a second-generation cephalosporin and five did not. Sequencing of bacterial 16 S rRNA allowed for an analysis of the microbiome composition. The Principal coordinate analysis was performed for the evaluation of compositional profile. Furthermore, quantitative measurement of short chain fatty acids served as a proxy for the metabolic activity of the individual microbiome over the study time.

RESULTS

Analysis of observed species, Shannon Index and weighted Unifrac distances between timepoints revealed neither significant difference comparing the prophylaxis group versus the control group over the study period, nor significant changes within the groups over time. Principal coordinate analysis (PCoA) was performed for the evaluation of compositional profile. Also, no differences regarding the fecal SCFA content were found between the two groups (>0.05 at each tested point, Mann-Whitney Test).

DISCUSSION

Although there were interindividual compositional differences of the microbiome (cluster of bacterial composition) at the beginning of the observation, we did not observe significant longitudinal changes regarding both bacterial diversity and SCFAs in neither group. Over the study period, the patient's microbiome remained stable and resilient to the antibiotic exposure in terms of bacterial abundance and metabolism. Limitations to the study are the low number of patients included and the use of one single antibiotic (cefaclor).

CONCLUSION

This is the first pilot study to demonstrate that long term low-dose antibiotic administration in children under one year of age does neither seem to influence the composition of the intestinal microbiota nor the quantities of bacterial fermentation products compared to untreated controls.

Torsion of an undescended testis - A surgical pediatric emergency

BACKGROUND/PURPOSE

Torsion of an undescended testis is a surgical emergency whose frequency may be underestimated in the pediatric population. We describe this entity and focus on diagnostic challenges and optimal treatment of torsion of an undescended testis.

METHODS

We present a two-center retrospective chart review of patients with torsion of an undescended testis treated between 2013 and 2018. Two instructive cases are used to depict characteristics of this rare entity.

RESULTS

We identified 11 patients with previously diagnosed cryptorchidism undergoing surgery for torsion of an undescended testis, accounting for 9.7% (11/107) of all testicular torsions in the period. Mean age at diagnosis was 9.4 months (1-22 months). Mean duration from onset of symptoms to presentation was 19.3 h (8-48 h). At admission to hospital 10 patients presented with groin lump (10/11, 90.9%) with or without pain leading to a suspected diagnosis of inguinal testicular torsion (5/11, 45.5%), incarcerated inguinal hernia (4/11, 36.4%) and epididymitis (1/11, 9.1%). Ten patients had an ultrasound examination before surgery leading to the correct diagnosis in six patients. Ultrasound findings were misinterpreted as incarcerated inguinal hernia in three patients. In eight patients the testis had to be removed at time of surgery; one of the three salvaged testes atrophied, resulting in a salvage rate of 18%.

CONCLUSION

Torsion of an inguinal testis is not as rare as it might be presumed. Presentation of these patients is often deferred owing to equivocal signs and symptoms. In addition age at presentation differs from typical testicular torsion. As this might negatively influence testicular salvage rate, we advocate for special attention to this differential diagnosis in children with groin pathologies. Even if the child is not in pain, a tender groin in boys with undescended testes must prompt a quick and thorough examination to rule out torsion of an undescended testis. Ultrasound examination is of limited value and must not delay acute surgical treatment.

LEVEL OF EVIDENCE

IV.

[The value of DMSA scintigraphy in the diagnostic evaluation of vesicoureteric reflux]

In terms of treatment planning, the radiologic phenomenon of vesicoureteric reflux has become less important than its inherent risk of further urinary tract infections and loss of renal function. Whilst radiologic and sonographic voiding cystourethrography continues to be the gold standard in the mere detection of vesicoureteric reflux, dimercaptosuccinic acid scanning is important for risk stratification. Also it serves to confirm renal involvement in uncertain situations with urinary tract infection and fever. In older children, it is the standard in primary diagnostics. Furthermore, it enables the diagnosis of occult reflux in many cases. Therefore, dimercaptosuccinic acid scanning is an indispensable tool in the diagnostic evaluation of vesicoureteric reflux.

Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves

INTRODUCTION

A significant proportion of PUV becomes symptomatic after the perinatal period. Voiding cystourethrography (VCUG) often fails to identify PUVs. This study evaluates the relationship between the radiological appearance of the posterior urethra, potential secondary radiological signs and endoscopically documented PUV in boys with febrile UTIs, VUR, refractory symptoms of bladder overactivity or suggestive sonography findings.

PATIENTS AND METHODS

Data on VCUG findings and endoscopy from 92 boys (mean age 27 months) who underwent endoscopic PUV incision between 2012 and 2017 following a VCUG were reviewed. 24 boys with endoscopically unsuspicious urethras were included as control group (mean age 27.5 months). Statistical analysis was performed using Fisher's exact test.

RESULTS

In patients with PUV, the urethra was suspicious on a preoperative VCUG in 45.7%, whereas it appeared normal in 54.3%. Abortive forms of PUV were more frequently found in patients with a radiologically unsuspicious urethra (30%vs.16.7%, p = 0.15). Bladder neck hypertrophy on VCUG (16.7%vs.60.9%, OR 7.5, p < 0.001), a trabeculated bladder on VCUG (72%vs.37.5%, OR 4.3, p < 0.001) and a hypertrophied musculus interuretericus (38%vs.4.2%, OR 11.7, p < 0.001) were more common in patients with PUV and urethras appearing normal on VCUG as compared to controls.

CONCLUSION

Unsuspicious findings of the urethra on VCUG cannot exclude a relevant PUV and implicate a risk of disregarding abortive forms. The presence of secondary radiologic signs of infravesical obstruction on a VCUG despite an unsuspicious posterior urethra in boys with recurrent UTI's as well as refractory symptoms of bladder overactivity or suggestive signs on sonography must be further clarified endoscopically.

Androgen receptor expression in preputial dartos tissue correlates with physiological androgen exposure in congenital malformations of the penis and in controls

INTRODUCTION

The androgen receptor (AR) plays an important role in the development of male genitalia, and impaired androgen signalling has been hypothesised to underlie congenital penile malformations (CPM) such as hypospadias. Previous studies exploring the role of AR expression in the development of CPM have yielded conflicting results.

OBJECTIVES

To assess AR expression in human foreskin of boys/men born with hypospadias, buried penis versus controls.

STUDY DESIGN

Foreskin samples of 428 boys and men undergoing primary penile surgery (198 controls, 197 hypospadias, and 33 buried penis) were collected between October 2013 and July 2018. AR staining was performed in all samples and semi-quantitatively scored by two researchers independently, using a modified quick score (mQuicks) that assesses the proportion and intensity of AR staining in smooth muscle fibres.

RESULTS

The interobserver variability of the mQuicks had a high level of agreement for the total score, as well as for the subscores. Two phases of high AR expression were observed in all groups, the first following the postnatal gonadotropin surge (i.e., mini-puberty) and the second in (pre-) puberty. No differences in AR expression were found in hypospadias or buried penis cases as compared to controls matched for age at time of surgery.

DISCUSSION

This study describes the physiological evolution in AR expression in the human foreskin of boys with CPM and explains the cause of the previously reported, conflicting results. Despite the very large cohort, the limitations of this study are the low number of cases younger than six months at the time of surgery and the lack of Tanner stages to correlate with the mQuicks in adolescents.

CONCLUSIONS

The mQuicks is a straightforward and informative tool to semi-quantitatively assess AR expression in the dartos tissue. In this study, AR expression in human foreskin shows a bimodal distribution in boys with CMP and controls, following physiological androgen exposure. No statistically significant difference in AR expression could be found between both groups. Whether other local mechanisms are affected by these physiological changes is currently unclear. However, strict age-matching should be considered when exploring the mechanisms underlying disturbed penile and urethral development in CMP.

Ureteroureterostomy in patients with duplex malformations: does a large diameter of the donor ureter affect the outcome?

INTRODUCTION

Ureteroureterostomy is a commonly adopted, minimally invasive approach in the management of duplex anomalies requiring diversion, e.g., ectopic upper pole ureters.

OBJECTIVE

The authors hypothesized that a large diameter of the donor ureter could affect the outcome of this procedure.

STUDY DESIGN

Forty-two patients from two centers were retrospectively reviewed. To compare patients with small (group 1) vs large donor ureters (group 2), they were split at the median of the sonographically measured diameter at the level of the future anastomosis (n = 20 < 1.2 cm, mean 0.71 cm vs n = 22 ≥ 1.2 cm, mean 1.75 cm; P < 0.001) Figure. Ureteroureterostomy was performed in an end-to-side fashion with the donor ureter being tapered if required.

RESULTS

There was no significant difference in operation time (127 vs 121 min; P = 0.59) or duration of hospital stay (4.15 vs 4.09 days; P = 0.89) or number of postoperative complications (3 febrile urinary tract infections [fUTIs] in group 1 and one fUTI in group 2, P = 0.33). Reoperations during follow-up (1 stump resection and 2 endoscopic vesicoureteral reflux procedures) occurred exclusively in group 1 (P = 0.22). The mean pre-operative hydronephrosis grade of the affected moiety was higher in group 2 compared with group 1 (mean 2.73 Society for Fetal Urology classification [SFU] vs 1.65, P < 0.001). During follow-up, the mean hydronephrosis grade in group 2 improved from 2.73 to 1.36 SFU (P = 0.0011). In patients from group 1, the mean hydronephrosis grade remained relatively unchanged, from 1.65 to 1.35 SFU (P = 0.4).

DISCUSSION

After its first description in 1928, it took almost 40 years for ipsilateral ureteroureterostomy to become a widely adopted technique in the management of duplex malformations, especially for obstructive or ectopic upper pole moieties. Whereas it has been recently shown that the upper pole function does not seem to matter, there are still only narrative reports about the influence of the donor ureter diameter contributing to potential complications such as a de novo hydronephrosis of the receiving ureter with potential damage of the healthy moiety or the persistence of a pre-operatively marked hydronephrosis. While the study data are retrospective, the authors could demonstrate that a ureteral diameter of ≥1.2 cm is not factoring adversely into the occurrence of postoperative complications.

CONCLUSION

A donor ureter diameter ≥1.2 cm in ureteroureterostomy was not associated with a higher complication rate or worse outcome considering further fUTIs or reoperations. The postoperative reduction in hydronephrosis grade was more pronounced in patients with large donor ureters with disappearance of the pre-operative significant difference between the two groups.

Langerhans cells in hypospadias: an analysis of Langerin (CD207) and HLA-DR on epidermal sheets and full thickness skin sections

BACKGROUND

Hypospadias are among the most common genital malformations. Langerhans Cells (LCs) play a pivotal role in HIV and HPV infection. The migration of LC precursors to skin coincides with the embryonic period of hypospadias development and genetic alterations leading to the formation of hypospadias impact the development of ectodermally derived tissues. We hypothesized that this might be associated with a difference in frequency or morphology of epidermal and dermal LCs in hypospadias patients.

METHODS

A total of 43 patients from two centers were prospectively included into this study after parental consent and ethics approval. Epidermal and dermal sheets were prepared from skin samples of 26 patients with hypospadias, 13 patients without penile malformations and 4 patients with penile malformations other than hypospadias. Immunofluorescence staining of sheets was performed with anti-HLA-DR-FITC and anti-CD207/Langerin-A594 antibodies. Skin sections from 11 patients without penile malformation and 11 patients with hypospadias were stained for Langerin. Frequencies as well as morphology and distribution of epidermal and dermal LCs on sheets and sections were microscopically evaluated. Cell counts were compared by unpaired t-tests.

RESULTS

There was no difference in frequency of epidermal LCs, Neither on sheets (873 ± 61 vs. 940 ± 84LCs/mm², p = 0.522) nor on sections (32 ± 3 vs. 30 ± 2LCs/mm², p = 0.697). Likewise, the frequency of dermal LCs (5,9 ± 0,9 vs. 7.5 ± 1.3LCs/mm², p = 0.329) was comparable between patients with hypospadias and without penile malformation. No differences became apparent in subgroup analyses, comparing distal to proximal hypospadias (p = 0.949), younger and older boys (p = 0.818) or considering topical dihydrotestosterone treatment prior to surgery (p = 0.08). The morphology of the LCs was not different comparing hypospadias patients with boys without penile malformations.

CONCLUSIONS

LCs are present in similar frequencies and with a comparable morphology and distribution in patients with hypospadias as compared to children without penile malformations. This suggests that patients with hypospadias are not different from patients with normal penile development considering this particular compartment of their skin immunity.

Testicular-sparing surgery in the pediatric population: multicenter review of practice with review of the literature

PURPOSE OF REVIEW

Pediatric testicular tumors have predominantly favorable histology, which may permit testicular sparing surgery (TSS). Limited guidance exists for TSS in adults and is absent in pediatric practice.The international survey and retrospective case series evaluated the current use of TSS in pediatric testicular tumors. Alongside the complementary literature review, the aim of this work was to provide evidence that could be used to produce a guideline document.

RECENT FINDINGS

Published evidence advocates small mass size as an indicator for TSS, this was not supported in the pediatric literature. Frozen section examination at TSS was not always performed by surgeons and yet the literature reports close to 100% specificity. Tumor markers and ultrasound findings are also used as indicators for TSS, a finding reflected in our survey results.

SUMMARY

Multiple case series are reported but no large data series exists, which will require international collaboration rather than a drive to publish the results of individual centers. Common indicators for TSS use; such as tumor markers and imaging are known but further work needs to evaluate the role of on-table histology and the risks of this not being available.

Management of ureteropelvic junction obstruction in children-a roundtable discussion

The investigation, management and follow-up of paediatric ureteropelvic junction obstruction is not standardized. The Young Pediatric Urology Committee of the European Society of Pediatric Urology interviewed five experts in the field on various aspects of management and compared this with published literature.

Late ascended testes: is non-orthotopic gubernacular insertion a confirmation of an alternative embryological etiology?

INTRODUCTION

Re-ascended testes account for a proportion of all undescended testes (UDTs); one main hypothesis relating to their etiology relates to a patent processus vaginalis peritonei. The aim was to investigate gubernacular insertion points in boys with late ascended testis as a possible guide to an alternative embryological etiology.

PATIENTS AND METHODS

Patients with proven ascended testes were recruited from four different pediatric urology centers between May 2016 and September 2017. All patients were evaluated regarding their gubernacular insertion during orchidopexy. The presence of accompanying patent processus vaginalis and the association between the epididymis and testis were also documented.

RESULTS

Seventy-seven children (mean age = 73.1 ± 41.2 months [range 18-176]) were enrolled into the study. A non-orthotopic gubernacular insertion point was found in 96.1% (n = 74); 34.2% (n = 26) of these were located in the groin and 63.2% (n = 48), high within the scrotum. Figure A. An open processus vaginalis peritonei was found in 35.1%. Twelve patients (15.6%) had small, dysplastic appearing testis with testis-epididymis dissociation. Boys with a higher insertion of the non-orthotopic gubernaculum (n = 48, groin) were operated earlier (mean age at surgery, 62.3 months) compared with those with a gubernacular insertion at a high scrotal site (mean age at surgery, 90.5 months; p = 0.004). Figure B.

DISCUSSION

This study revealed that non-orthotopic gubernacular insertion is found in the vast majority of the ascending testis cases. Patent processus vaginalis was accompanying only 35.1% of all children and might be the cause of the ascending testis in this small subgroup of patients in line with the earlier reports [1]. In boys with ascending testes, in this population, the gubernaculum was very likely to insert non-orthotopically. In concordance with previous reports [2] and regarding the finding of a an earlier age at surgery in boys with higher inserting gubernacula, this could provide a logical explanation as to how these testes are initially palpable in the scrotum and then, during body growth are retracted to the groin.

CONCLUSION

In 96.1% of the patients, a non-orthotopic gubernacular insertion was found. This points to embryologic etiology, complying well with earlier reports and further underlining the critical importance of timely diagnosis and treatment for this group of patients.

The method of urine sampling is not a valid predictor for vesicoureteral reflux in children after febrile urinary tract infections

INTRODUCTION

The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children logically should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques. We hypothesized that children with possibly contaminated urine samples during the initial diagnosis may show a lower rate of VUR in subsequent VCUGs because of a wrong diagnosis initially compared to children, where accurate urine sampling techniques were used.

PATIENTS

Between 2009 and 2014, a total of 555 patients underwent a primary VCUG at our department indicated because of febrile UTIs. Patients with urine collection methods other than bag urine and catheter/suprapubic aspiration (SPA) were excluded from this study (mid-stream urine, potty urine, n = 149). We evaluated 402 patients (male/female 131/271, mean age 1.91 years), VUR rates and grades were compared between patients where urine was sampled by the use of a urine bag only at the time of diagnosis (n = 296, 73.6%) and those where sterile urine sampling (catheter, suprapubic puncture) was performed (n = 106, 26.3%). 4 patients were excluded due to equivocal data on urine sampling.

RESULTS

VUR rate in children after sterile urine sampling using a catheter or SPA accounted to 31.1%. In those where urine samples acquired by the use of urine bags were used, 33.7% showed VUR on subsequent VCUG (p = 0.718). There were no significant differences as to VUR grades or gender, although VUR was much more commonly diagnosed in female patients (37.0% vs 28.2%, p = 0.227) (Figure).

CONCLUSION

Children diagnosed with their UTI by use of bag urine in our experience carried the same risk of showing a VUR in a subsequent VCUG compared to those, where the initial diagnosis relied - beneath clinical criteria - on urine samples acquired by suprapubic puncture or catheterization. Consequently urine-sampling technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI diagnosis and should not influence the further management after UTI.

Evaluation of Mathisen's technique for ureteral reimplantation in children with primary vesicoureteral reflux

INTRODUCTION

Although cross-trigonal ureteral reimplantation (Cohen) is a commonly used technique in children, it represents a non-physiological transfer of the ureteral orifices and may prove challenging with regard to endoscopic ureteral operations in later life. In 1964, Mathisen described an alternative method of ureteral reimplantation with lateralization of the neohiatus, creating an orthotopic course of the submucosal ureter. We have evaluated success and complication rates of both techniques that were applied sequentially at our departments.

METHODS

Forty-eight consecutive patients (83 ureters, 24 males/24 females) following Mathisen reimplantation were compared with 53 consecutive patients (98 ureters, 30 males/23 females) following Cohen reimplantation. Inclusion criteria were primary vesicoureteral reflux (VUR) and no previous intervention. Reflux grades (Mathisen 58 ureters/69.9% VUR ≥ III; Cohen 66 ureters/66.7% VUR ≥ III) and the occurence of other complicating factors (ureteroceles, megaureters, posterior urethral valves) in both groups were comparable.

RESULTS

After Cohen's reimplantation there were no immediate complications requiring intervention; during follow-up (mean 28.2 months) three patients (5.6%) suffered febrile urinary tract infections (UTIs), of which one (1.8%) was diagnosed with a persisting VUR. Persistent hydronephroses (≥II SFU) were recorded in six patients (13.2%). After reimplantation using Mathisen's technique, two patients (4.1%) suffered significant intravesical bleeding; during follow-up (mean 23.06 months) four patients (8.3%) suffered febrile UTIs, and seven patients (14.5%) were diagnosed with persisting VUR after a mean follow-up of 10.8 months. The patients with persistent VUR had more commonly high-grade (IV and V) VUR initially, compared to the whole group. Two patients (4.1%) had persistent hydronephroses (≥II SFU). Mathisen's technique for ureteral reimplantation yielded a significantly (p = 0.0256 patients, p = 0.006 ureterorenal units) lower success rate (85.5% patients, 89.2% ureterorenal units) in comparison with Cohen's technique (98.2% patients, 99% ureterorenal units). Although there was no intervention for obstruction, persistent hydronephrosis was more common in the Cohen group (13.2% vs. 4.1%, n.s.).

CONCLUSIONS

Despite the advantages of an orthotopic ureteral orifice close to the bladder neck, as achieved by Mathisen's reimplantation, cross-trigonal ureteral reimplantation proved more reliable for VUR correction. As regards optimizing the results, patient selection for either technique could prove essential. Nevertheless, as regards the difficulties with ectopic ureteral orifices in the Cohen technique in the long-term follow-up, the concept of anatomic, orthotopic ureteral reimplantation should be pursued and the technique should be further refined.

[Undescended testis: current treatment guidelines]

BACKGROUND

Cryptorchidism is the most common genital malformation in male newborns. In recent years, guidelines concerning diagnosis and therapy have undergone considerable evolution with the implementation of recent knowledge in pathophysiology, diagnosis, and therapy.

OBJECTIVES

The aim of this publication is to provide an overview of the current national and international guideline recommendations concerning diagnosis and treatment of cryptorchidism. Critical points are discussed in light of current scientific literature.

MATERIALS AND METHODS

The current guidelines of the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU), the American Association of Urology (AUA), the pediatric urologic task force of the Austrian Society of Urology (ÖGU), the international consultation on urological disease (ICUD) and the German Society of Urology (DGU)/German Association of Pediatric Surgery (DGKCh) have been analyzed concerning the most important aspects of treatment and diagnosis.

RESULTS

There is broad consensus concerning most steps and decisions for the treatment of cryptorchidism. However, some aspects of diagnostic imaging, the use of hormonal therapy, and surgical access in nonpalpable testis warrant further discussion and are the fields of considerable changes.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party

INTRODUCTION

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).

MATERIALS AND METHODS

The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.

RESULTS

A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.

DISCUSSION

This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.

CONCLUSIONS

Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Measurement of Hydrodynamic Growth near Peak Velocity in an Inertial Confinement Fusion Capsule Implosion using a Self-Radiography Technique

First measurements of hydrodynamic growth near peak implosion velocity in an inertial confinement fusion (ICF) implosion at the National Ignition Facility were obtained using a self-radiographing technique and a preimposed Legendre mode 40, λ=140  μm, sinusoidal perturbation. These are the first measurements of the total growth at the most unstable mode from acceleration Rayleigh-Taylor achieved in any ICF experiment to date, showing growth of the areal density perturbation of ∼7000×. Measurements were made at convergences of ∼5 to ∼10× at both the waist and pole of the capsule, demonstrating simultaneous measurements of the growth factors from both lines of sight. The areal density growth factors are an order of magnitude larger than prior experimental measurements and differed by ∼2× between the waist and the pole, showing asymmetry in the measured growth factors. These new measurements significantly advance our ability to diagnose perturbations detrimental to ICF implosions, uniquely intersecting the change from an accelerating to decelerating shell, with multiple simultaneous angular views.

Persistence and recurrence of vesicoureteric reflux in children after endoscopic therapy - implications of a risk-adapted follow-up

Introduction

There is no well-defined follow-up scheme available to reliably detect persistent or recurrent vesicoureteric reflux (VUR) after endoscopic therapy (ET), but also to reduce postoperative invasive diagnostics in these children.

Our aim was the evaluation of possible predictors of persistence and recurrence of VUR, in order to elaborate and test a risk-adapted follow-up regimen.

Material and methods

92 patients (85/92%f, 7/8%m, age 2.99y) underwent direct isotope cystography (DIC) three months after ET. Persistent or recurrent VUR, scarring on dimercaptosuccinic acid (DMSA) scans and further fUTIs after therapy (follow-up 24.6 m) were documented and analysed.

Results

VUR persistence 3 months after ET was found in 11 (11.9%) patients; recurrent VUR in 4 (4.3%) patients. Scarring on preoperative DMSA and dilating VUR (°III and °IV) were significantly associated with recurrent VUR. If only children with preoperative positive DMSA scan or dilating VUR would have undergone DIC, only 58/92 DICs (64%) would have been necessary. Only 45.5% of otherwise detected VURs would have been identified using this risk-adapted strategy.

Conclusions

Limiting invasive follow-up diagnostics (VCUG) and, therewith, the radiation burden in a predefined group of patients at risk for persistence or recurrence of VUR is not recommended, due to the significant chance of missing persistent or new onset contralateral VUR. Therefore, we recommend a routine follow-up VCUG after ET. Further prospective scientific efforts to evaluate new, alternative factors influencing persistence and recurrence of VUR, in order to establish an effective follow-up strategy, are warranted.

Lower radiation burden in state of the art fluoroscopic cystography compared to direct isotope cystography in children

INTRODUCTION

Both, fluoroscopic voiding cystourethrography (fVCUG) and direct isotope cystography (DIC) are diagnostic tools commonly used in pediatric urology. Both methods can detect vesicoureteral reflux (VUR) with a high sensitivity. Whilst the possibility to depict anatomical details and important structures as for instance the urethra in boys or the detailed calyceal anatomy are advantages of fVCUG, a lower radiation burden is thought to be the main advantage of DIC. In the last decade, however, a rapid technical evolution has occurred in fluoroscopy by implementing digital grid-controlled, variable rate, pulsed acquisition technique. As documented in literature this led to a substantial decrease in radiation burden conferred during fVCUGs.

OBJECTIVE

To question the common belief that direct isotope cystography confers less radiation burden compared to state of the art fluoroscopic voiding cystography.

STUDY DESIGN

Radiation burden of direct isotope cystography in 92 children and in additional 7 children after an adaption of protocol was compared to radiation burden of fluoroscopic voiding cystourethrography in 51. The examinations were performed according to institutional protocols. For calculation of mean effective radiation dose [mSv] for either method published physical models correcting for age and sex were used. For DIC the model published by Stabin et al., 1998 was applied, for fVCUG two different physical models were used (Schultz et al., 1999, Lee et al., 2009).

RESULTS

The radiation burden conferred by direct isotope cystography was significantly higher as for fluoroscopic voiding cystourethrography. The mean effective radiation dose for direct isotope cystography accounted to 0.23 mSv (± 0.34 m, median 0.085 mSv) compared to 0.015 mSv (± 0.013, median 0.008 mSv, model by Schultz et al.) - 0.024 mSv (± 0.018, median 0.018 mSv, model by Lee et al.) for fluoroscopic voiding cystourethrography. After a protocol adaption to correct for a longer examination time in DIC that was caused by filling until calculated bladder capacity, mean radiation burden accounted to .07 mSv (median 0.07 mSv) and the values were less scattered.

DISCUSSION

As it had to be expected from literature, radiation dose from fVCUG, if modern image acquisition techniques are used, is even less than from DIC. In our protocol, according to nuclear medicine standards, bladders were filled until calculated capacity. This resulted in a longer examination time for the patients with a higher functional capacity, resulting in relatively higher radiation burden. However, also if the protocol is changed or only the patients with relatively fast bladder emptying are considered, radiation burden conferred by DIC is higher (at least × 2.9, comparing the "worst" case for fVCUG with the "best" case for DIC). Absolute radiation burden conferred by either exam is extremely low compared to other medical radiation exposures as well as to environmental radiation. Consequently it is most probably not relevant for the individual childs future risk for cancer or other radiation damage. However, because of repeated investigations with correspondingly higher radiation burden in this patient group the ALARA (as low as reasonably achievable) principle should lead to a optimized use of fVCUG rather than an uncritical use of DIC, given that modern acquisition standards are available and radiation measurement is performed. Also, fVCUG provides more information concerning anatomical details compared to DIC.

CONCLUSION

Contrary to common beliefs, effective radiation dose conferred during fluoroscopic voiding cystourethrography is significantly lower than during direct isotope cystography. The prerequisite for our findings, however, is the use of modern image acquisition tools and an optimized protocol. Both exams confer low radiation doses probably only relevant to children undergoing repeated radiation exposure. Nevertheless, this findings should be considered in indication for either exam in order to reduce the radiation burden to a minimum whilst optimizing the information yield.

Precision shock tuning on the national ignition facility

Ignition implosions on the National Ignition Facility [J. D. Lindl et al., Phys. Plasmas 11, 339 (2004)] are underway with the goal of compressing deuterium-tritium fuel to a sufficiently high areal density (ρR) to sustain a self-propagating burn wave required for fusion power gain greater than unity. These implosions are driven with a very carefully tailored sequence of four shock waves that must be timed to very high precision to keep the fuel entropy and adiabat low and ρR high. The first series of precision tuning experiments on the National Ignition Facility, which use optical diagnostics to directly measure the strength and timing of all four shocks inside a hohlraum-driven, cryogenic liquid-deuterium-filled capsule interior have now been performed. The results of these experiments are presented demonstrating a significant decrease in adiabat over previously untuned implosions. The impact of the improved shock timing is confirmed in related deuterium-tritium layered capsule implosions, which show the highest fuel compression (ρR~1.0 g/cm(2)) measured to date, exceeding the previous record [V. Goncharov et al., Phys. Rev. Lett. 104, 165001 (2010)] by more than a factor of 3. The experiments also clearly reveal an issue with the 4th shock velocity, which is observed to be 20% slower than predictions from numerical simulation.