Increased prevalence of non-E. coli bacteria-caused urinary infection in neonates delivered by cesarian section.

OBJECTIVES: to assess the association between delivery mode and causative pathogens of infants with urinary tract infections. MATERIALS AND METHODS: We conducted a retrospective analysis of the medical records of neonates delivered in a tertiary academic pediatric hospital and diagnosed with urinary tract infections between January 1,2013 and December 31,2017. Excluded were newborns with urinary tract infections post-urological procedures or neurogenic bladders. The retrieved data included demographic characteristics, clinical presentations, laboratory findings, urine cultures, and renal imaging results. Multivariable logistic regressions were employed to identify associations. RESULTS: 95 of the 131 neonates' (72.5%) cultures were positive for Escherichia coli. Neonates born via cesarean section (C/S) had a significantly higher prevalence (12/25, 48%) of non-Escherichia coli infections (p = 0.01). The mode of delivery was the only variable associated with non-Escherichia coli infections (odds ratio = 3.1, p = 0.014). Two of the 12 neonates (17%) with non-Escherichia coli cultures in the C/S group were diagnosed as having dilating vesicoureteral reflux. DISCUSSION: While the impact of mode of delivery on microbiome composition and UTI risk in the pediatric population is well documented, to the best of our knowledge, our study is the first to evaluate and report on the clinical connection between mode of delivery and neonatal UTIs. Most noteworthy was our finding of an elevated prevalence of non-E. coli cultures in the C/S group (p = 0.014, OR 3.1). This bears important clinical implications, particularly in the setting of congenital anomaly of kidney and urinary tract (CAKUT) screening. CONCLUSIONS: Our analyses in this study reveal a significant link between delivery by cesarean section and neonatal urinary tract infections with non- Escherichia coli urine cultures. These findings carry implications for vesicoureteral reflux screening in neonates by raising the level of awareness of the association between the 2 factors. Additional prospective studies on larger cohorts are warranted to further elucidate this relationship and refine clinical decision-making in neonatal care.

Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair.

BACKGROUND: Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias. OBJECTIVE: In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision. STUDY DESIGN: Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias. RESULTS: In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53 % vs. 28 %, respectively, p = 0.002). The reoperation rate was comparable for the two groups (32 % vs. 27 %, p = 0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p = 0.02), and a higher grade of hypospadias (odds ratio 3.3, p = 0.03 for meatal location lower than the coronal sulcus) in the non-MIP group. DISCUSSION: The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias. CONCLUSIONS: Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

Complete Blood Count Markers and C-Reactive Protein as Predictors of Testicular Viability in the Event of Testicular Torsion in Adults.

INTRODUCTION: The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT. METHODS: Fifty men, ≥18 years of age, operated for TT between the years 2015-2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage. RESULTS: Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p < 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p < 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009). CONCLUSIONS: We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome.

Preoperative Bladder Capacity Predicts Social Continence following Bladder Neck Reconstruction in Children Born with Exstrophy-Epispadias Complex.

INTRODUCTION: The aim of the study is to review the continence and volitional voiding rate in a single center cohort of exstrophy-epispadias patients following Young-Dees-Leadbetter bladder neck reconstruction and to explore factors which predict continence. MATERIALS AND METHODS: Children who underwent Young-Dees-Leadbetter bladder neck reconstruction as a final stage of repair in a large single low-volume center in a small-population country between 1997 and 2019 were included. Demographic and clinical details were extracted from the patients' charts. The primary end point was continence and volitional voiding. Patients were categorized as incontinent, socially continent (daytime dry intervals > 3 hours, wet nights) and fully continent (daytime dry intervals > 3 hours, dry nights). RESULTS: The study cohort included 27 patients whose median age at reconstruction was 5 years, and median follow-up was 7.8 years (interquartile range [IQR] 6-11.2). The cohort included 24 classic exstrophy patients (89%, 17 males and 7 females) and 3 isolated complete epispadias patients (11%, 1 male and 2 females). Nine (33%) patients achieved full continence and social continence was achieved by nine (33%) patients, for an overall social continence rate of 67%. Preoperative bladder capacity of 110 mL or more was associated with achieving social continence (odds ratio = 6.4, p = 0.047). The overall volitional voiding rate was 67%. CONCLUSION: Young-Dees-Leadbetter bladder neck reconstruction yielded rates of 33% for full continence and 67% for social continence and volitional voiding. These rates are comparable to those of large high-volume centers. A preoperative capacity of 110 mL or more was the sole predictor of social continence.

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision.

PURPOSE: To present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success. METHODS: Records of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation. RESULTS: A total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression). CONCLUSION: Hypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision. LEVEL OF EVIDENCE: Treatment study, level IV.

Parental Regret Following Decision to Revise Circumcision.

Purpose: Revision surgery for the removal of excess foreskin after circumcision is a common procedure. The decision regret scale (DRS) is a validated questionnaire which assesses regret after medical decision making. The aim was to evaluate parental regret by means of the DRS and querying about factors associated with regret about deciding to revise their child's circumcision. Patients and Methods: Included were all pediatric patients who underwent revision of neonatal circumcision in a single center between 2010 and 2016. Excluded were children who underwent revision for reasons other than excess foreskin, those who underwent additional surgical procedures during the same anesthetic session, and those who had undergone previous penile surgery other than circumcision. Response to the DRS questionnaire was by a telephone call with the patient's parent. Regret was classified as none (a score of 0), mild (1-25), or moderate-to-strong (26-100). Surgical and baseline demographic data were obtained from the departmental database and compared between the no regret and regret groups. Results: Of the 115 revisions of circumcisions performed during the study period, 52 fulfilled the inclusion criteria, and the parents of 40 (77%) completed the DRS questionnaire. Regret was reported by 11/40 [28%: nine as mild (23%) and two as moderate-to-strong (5%)]. The average age of the child in the regret group was 17 months compared to 18 months in the no regret group (p = 0.27). The median weight percentile was 43% in both groups. Surgical variables, including anesthesia type (caudal vs. no block, p = 0.65), suture type (polyglactin vs. poliglecaprone, p = 0.29), operation time (28 vs. 25 min, p = 0.59), and anesthesia time (55 vs. 54 min, p = 0.57) were not significantly different between the groups. Conclusions: Regret for deciding upon revision surgery for removal of excess foreskin post-circumcision was reported by 27.5% of parents of children who underwent revision. No clinical, surgical, or demographic characteristics predicted parental decisional regret.

Concomitant Repair of Meatal Stenosis and Urethral Fistula Does Not Increase the Risk of Fistula Recurrence Post Hypospadias Surgery.

OBJECTIVE: To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure. METHODS: A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006 and 2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence. RESULTS: In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17 per 81 (21%) for the fistula only group and 5 per 25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5 of 81 in the former group vs 3 of 25 patients in the latter group. CONCLUSION: The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair.

Asymptomatic bacteriuria and antibiotic resistance profile in children with neurogenic bladder who require clean intermittent catheterization.

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To document the prevalence of asymptomatic bacteriuria and to characterize the resistance patterns to antibiotics among children with neurogenic bladder who require clean intermittent catheterization, with an emphasis on multidrug resistance. SETTING: A national referral pediatric and adolescent rehabilitation facility in Jerusalem, Israel. METHODS: Routine urine cultures were collected before urodynamic studies in suitable individuals during 2010-2018. None of them had symptoms of urinary tract infection at the time of specimen collection. Cultures were defined as being positive if a single bacterial species was isolated together with a growth of over 105 colony-forming units/ml. Resistance patterns were defined as extended-spectrum beta-lactamase (ESBL) and resistant to 3 antimicrobial groups (multi-drug resistant, MDR). RESULTS: In total, 281 urine cultures were available for 186 participants (median age 7 years, range 0.5-18). Etiologies for CIC included myelomeningocele (n = 137, 74%), spinal cord injury (n = 16, 9%) and caudal regression syndrome (n = 9, 5%). Vesicoureteral reflux was diagnosed in 36 participants (19%), 14 of whom were treated with prophylactic antibiotics. Asymptomatic bacteriuria was present in 217 specimens (77%, 95%CI [0.72-0.82]). The bacteria species were E. coli (71%), Klebsiella (13%), and Proteus (10%). ESBL was found in 11% of the positive cultures and MDR in 9%, yielding a total of 34 (16% of positive cultures) positive for ESBL and/or MDR bacteria. CONCLUSIONS: Asymptomatic bacteriuria and resistance to antimicrobials are common in pediatric individuals who require CIC.

Dorsal penile curvature and megameatus intact prepuce hypospadias: A common association in a rare variant of hypospadias.

BACKGROUND: Megameatus intact prepuce (MIP) is a rare variant of hypospadias. Unlike the hooded ventrally absent prepuce in non-MIP hypospadias, the prepuce in MIP hypospadias is fully circumferential and intact. The distal urethra remains wide with a deep glanular groove. While ventral curvature is a common finding in non-MIP hypospadias, neither ventral nor dorsal penile curvature has been reported in MIP hypospadias. OBJECTIVE: To assess the association of the MIP hypospadias variant with penile curvature. STUDY DESIGN: We retrospectively reviewed the medical records of all children who underwent hypospadias repair and identified those who were documented as having the MIP variant of hypospadias and operated in our center from January 1998 to June 2020. The patients were considered as having MIP hypospadias if no hypospadias had been evident before circumcision, if a circumferential circumcision scar was present (instead of the inverted V-shaped scar in the ventral aspect of the penis following circumcision of the hooded prepuce associated with non-MIP hypospadias), and if there was a wide meatus. Penile curvature was diagnosed intraoperatively by an artificial erection test that uses saline solution for injection. Patients were considered surgical candidates if the degree of curvature was equal to or greater than 30°. RESULTS: The study cohort consisted of 118 male children who were identified as having the MIP hypospadias variant according to the inclusion criteria. The median age at repair was 1.1 years (interquartile range 8 months to 1.6 years). Penile curvature was found in 29 children (24%), of whom 23 had dorsal curvatures (19%) and 6 had ventral curvatures (5%). DISCUSSION: MIP hypospadias is associated with penile curvature, and more frequently with dorsal than ventral curvature. This study is retrospective and does now identify specific features of MIP associated with penile curvature. We encourage pediatric urologists to perform an artificial erection test intraoperatively in children with the MIP variant and repair associated curvatures. CONCLUSIONS: A dorsal curvature was found in 19% of patients with a MIP variant of hypospadias, and most of them (86%) required ventral plication due to the severity of the curvature.

Comparison of Caudal Block vs. Penile Block vs. Intravenous Fentanyl Only in Children Undergoing Penile Surgery: A Prospective, Randomized, Double Blind Study.

Objectives: Penile surgery is commonly performed in pediatric surgical centers. There is no consensus regarding which analgesic method is most effective in controlling pain in these children. Methods: Consecutive children between 4 months and 16 years of age who underwent elective penile surgery were recruited. After inhaled induction of anesthesia, children were randomized to one of three methods of intraoperative analgesia: caudal block, IV fentanyl titrated to surgical response and spontaneous respiration, or dorsal penile nerve block (DPNB). All patients were given inhaled agents; fentanyl was added if either block was insufficient. Demographic data, analgesic use and pain scores were recorded by a blinded investigator in the PACU and ward. Pain scores, analgesic requirement, and recovery parameters of returning to normal activity level, eating, and voiding post-operatively for up to 4 days, were compared. Results: 116 children were recruited. Pain scores in the post anesthesia care unit were significantly lower in the DPNB and caudal block groups compared to the fentanyl group for the first 30 postoperative min. Pain scores and analgesic use were subsequently similar among the three groups for the rest of the study period. There was no statistical difference in time to eat, return to normal activity or in parental satisfaction scores among the groups. There was a trend toward earliest time to void in the DPNB group. Conclusions: Regional blocks most effectively controlled pain for 30 min after surgery. The choice of intra-operative analgesia protocol had no effect on later pain and recovery parameters.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair.

OBJECTIVE: To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair. STUDY DESIGN: We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair. RESULTS: Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs. CONCLUSION: Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

Formulation and validation of meatal stenosis grading system.

INTRODUCTION: Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague. OBJECTIVE: We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding. STUDY DESIGN: Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated. RESULTS: Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05]). CONCLUSION: We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms.

Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter?

BACKGROUND: There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery. STUDY QUESTION: We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes. DATA SOURCES: Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied. STUDY DESIGN: Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded. RESULTS: Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02). CONCLUSIONS: None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.

Results of Epispadias Repair Using the Modified Cantwell-Ransley Technique.

OBJECTIVE: To evaluate our results of epispadias repair with a modified Cantwell-Ransley (MCR) technique. METHODS: A retrospective Institutional Review Board-approved chart review of all patients who underwent an MCR epispadias repair was conducted between 1998 and 2015. Procedures were performed at birth or after the age of 8 months as part of the modern staged repair of exstrophy-epispadias complex (EEC) in patients with bladder exstrophy treated since birth, at presentation for older patients, and after the age of 6 months in isolated epispadias patients. Twenty-two children underwent MCR epispadias repair in our institute during the study period. Sixteen of them had EEC and 6 had isolated epispadias. Four patients underwent exstrophy and epispadias repair at the same session. Twelve children underwent epispadias repair as a second stage of modern staged repair at a mean age of 21 months (range 8-60). The procedures involved dissection of the corporeal bodies and urethral plate from the penile base to the tip of the penile glans. RESULTS: After a mean follow-up of 6.9 years (range 0.5-18), there were no complications in the isolated epispadias group and 4 complications in the bladder exstrophy group: urethrocutaneous fistula (n = 1), residual dorsal curvature (n = 1), and excess of penile skin (n = 2). The meatal location was orthotopic in all cases. All of the complications were successfully addressed in a single subsequent surgical session. CONCLUSION: MCR technique continues to be a reliable, reproducible option for epispadias repair in EEC patients and in cases of isolated epispadias.

Kelly procedure for exstrophy or epispadias patients: Anatomical description of the pudendal neurovasculature.

INTRODUCTION: Adequate penile length in males with bladder exstrophy or epispadias is a major challenge. Kelly previously described a surgical technique of a single stage reconstruction for patients with exstrophy or epispadias that potentially achieves significant penile lengthening by completely detaching the insertion of the corpora cavernosa from the ischiopubic rami. However, because of the possibility of damage to the pudendal neurovascular supply that may lead to partial or complete penile loss, this technique has not gained popularity. The aim of this study is to describe the surgical anatomic relationship of the pudendal neurovascular bundle (NVB) to the ischiopubic rami and to determine a safer approach to dissection during the Kelly procedure. METHODS: We performed meticulous dissection in three formalin-fixed and one fresh adult male cadavers to demonstrate the anatomical relationships between the pudendal neurovascular supply of the penis and the cavernosal insertion to the ischiopubic ramus. RESULTS AND DISCUSSION: We demonstrated the relationships and distance between the NVB and the area of separation between the crus and the ischiopubic ramus at the level of the periosteum. The insertion of the crus to the ischiopubic ramus is inferior lateral, whereas the NVB lies at a superior medial position. This anatomical relationship is best visualized when the dissection is carried out starting from the distal portion of the NVB and proceeding proximally. This area of the periosteum is avascular and the NVB can be preserved safely as long as the dissection is conducted at that subperiosteal level. Based on this cadaver dissection study, we suppose that detaching the corporal cavernosa from the pubic bones at the subperiosteal level allows for a safe distance to be maintained from the pudendal nerve at all times. We believe that if a surgeon performs the dissection inferiorly and laterally, the corpora cavernosa can be safely detached from the ischiopubic ramus and injury to the pudendal vessels and nerve can be avoided. However, it must be noted that there are limitations to applying the results from this study of normal, adult cadavers to the anatomy of children and adolescents with exstrophy or epispadias, who form the largest proportion of patients who are candidates for this procedure. CONCLUSION: This anatomical study demonstrates the relationship between the pudendal NVB, the crus, and the ischiopubic ramus. We demonstrated how the separation of the crus from the ischiopubic periosteum might be performed more safely.

Timing of Orchidopexy for Undescended Testis in Israel: A Quality of Care Study.

BACKGROUND: Strong evidence suggests that in order to prevent irreversible testicular damage surgical correction (orchidopexy) for undescended testis (UDT) should be performed before the age of 1 year. OBJECTIVES: To evaluate whether orchidopexy is delayed in our medical system, and if so, to explore the pattern of referral for orchidopexy as a possible contributing factor in such delays. METHODS: We conducted a retrospective chart review of all children who underwent orchidopexy for UDT between 2003 and 2013 in our institution. We collected data on the age at surgery and the child's health insurance plan. We also surveyed pediatricians from around the country regarding their pattern of UDT patient referral to a pediatric urologist or surgeon for surgical correction. RESULTS: A total of 813 children underwent orchidopexy in our institute during the study period. The median age at surgery was 1.49 years (range 0.5-13). Only 11% of the children underwent surgery under the age of 1 year, and 53% between the ages of 1 and 2 years. These findings were consistent throughout the years, with no difference between the four health insurance plans. Sixty-three pediatricians who participated in the survey reported that they referred children to surgery at a median age of 1 year (range 0.5-3 years). CONCLUSIONS: Our results demonstrate delayed orchidopexy in our medical system. There is a need to improve awareness for early specialist consultation in order to facilitate earlier surgery and better care.

Role of routine cystoscopy and cystography in exstrophy-epispadias complex.

OBJECTIVE: Our institutional protocol for the treatment of exstrophy-epispadias complex includes routine endoscopic and cystographic evaluation of the bladder with the child under general anesthesia. The protocols briefly described in the literature include a cystographic evaluation and the measurement of bladder capacity, but there are no reports on concurrent endoscopic findings and the value of examinations in this setting. Our objective is to evaluate the role and necessity of our management protocol by reviewing the findings in our patients' medical charts. STUDY DESIGN: Cystoscopies are performed in children with exstrophy-epispadias complex during the second year of life and then every 18 months until a capacity of 90 mL has been reached and bladder neck reconstruction, the last stage of modern staged repair, is performed. Patients referred from other institutions are evaluated on presentation. The examinations are performed by means of a pediatric cystoscope with the child under general anesthesia. Cystography is performed under a pressure of 30 cm/H2O. The contribution of the findings of these periodic evaluations vis-à-vis the surgical findings were studied. RESULTS: The medical charts of 49 patients who had been surgically treated for exstrophy-epispadias complex in our institution between 2000 and 2014 were reviewed. Thirty patients underwent at least one evaluation. Eighteen underwent serial examinations: four underwent two procedures, eleven underwent three procedures, and three underwent four procedures. The findings in eight cases were significant and they were treated on detection: bladder neck stricture (n = 5), bladder scar bridge (n = 2), and bladder stone (n = 1). Vesicoureteral reflux was present in all 30 patients, and high-grade reflux was present in 10 patients, of whom four had a bladder neck stricture. Fourteen of the 30 patients had a bladder capacity of 90 mL on the first evaluation, as did an additional eight children during later evaluations. Bladder capacity decreased below 90 mL in one child. Seven children did not reach the target capacity (Figure). CONCLUSION: Cystoscopic and cystometrographic evaluation of an exstrophic bladder allows early diagnosis of treatable bladder pathologies and monitoring of bladder capacity. It is a valuable tool in the follow-up period preceding bladder neck reconstruction.

Can Classic Bladder Exstrophy be Safely and Successfully Reconstructed at a Low Volume Center?

PURPOSE: Exstrophy reconstruction is challenging and requires expertise and experience. However, many patients are treated at low volume centers. We evaluated whether classic bladder exstrophy could be safely and successfully reconstructed at a low volume center. MATERIALS AND METHODS: A total of 31 patients with classic bladder exstrophy were primarily treated at our low volume center during a 17-year period. A total of 22 patients underwent primary closure within 5 days of birth and 9 underwent delayed closure with osteotomy. Of the patients 29 underwent planned modern staged repair and 2 underwent attempted complete primary repair. RESULTS: The bladder was successfully closed in all 31 children. All 22 newborns underwent primary bladder closure without osteotomy, including 4 with extremely small bladder plates. Bladder neck obstruction developed in 3 patients (10%), of whom 2 were treated successfully with transurethral dilation and 1 underwent open repair. Epispadias repair was successful in 12 of 15 patients undergoing the Cantwell-Ransley technique and in 2 of 4 undergoing complete primary repair. A total of 16 patients underwent bladder neck reconstruction, of whom 9 are awaiting appropriate age or capacity, 4 were lost to followup, 1 is continent after bladder closure alone and 2 underwent continent diversion (1 after failed bladder neck reconstruction). Of the 15 patients with at least 1 year of followup after bladder neck reconstruction 9 are continent day and night, 2 are continent only during the daytime and 4 are incontinent, for a 73% post-bladder neck reconstruction continence rate (11 of 15 patients). CONCLUSIONS: Successful exstrophy reconstruction is achievable at a low volume center, with results comparable to those of high volume centers.

[General recommendations for the initial management of primary monosymptomatic nocturnal enuresis in children].

Bedwetting is a very common condition affecting about 15% of children 6 years of age, and is considered one of the main reasons for referrals to pediatricians. Bedwetting is a medical situation and should be managed by physicians. A child wetting his bed is distressing and this has a deep impact on the child's behavior and it is also very stressful for the parents. The causes of bedwetting are not fully understood. Bedwetting can be considered to be a symptom that may result from a combination of different factors. This guideline presents recommendations on the assessment and management of bedwetting in children.

Non-contrast computed tomography after percutaneous nephrolithotomy: findings and clinical significance.

OBJECTIVE: To describe the post-percutaneous nephrolithotomy (PNL) non-contrast-enhanced computed tomography (NCCT) findings and assessed their clinical significance. NCCT evaluates stone clearance after PNL and also reveals procedure-related changes. METHODS: One hundred consecutive patients who underwent PNL were evaluated by NCCT one day post-procedure. Two radiologists analyzed the type and severity of the NCCT findings, which were then statistically analyzed in relation to the patient's clinical course. RESULTS: The patients' mean age was 54 years (range 18-82) and the mean maximal stone diameter was 37 mm (range 15-70). The median operative time was 110 minutes for an immediate stone-free rate of 83%, changing to 94% (P = .073) after a second-look PNL in 11 patients. The post-PNL NCCT findings were hydronephrosis (70%), atelectasis (54%), ipsilateral pleural effusion (52%), paracolic gutter fluid (44%), perinephric hematoma (40%), perinephric fluid (32%), ureteronephrosis (31%), renal swelling (23%), contralateral pleural effusion (22%), residual fragments (RFs) (17%), subcapsular hematoma (10%), and flank hematoma (6%). Univariate analysis revealed a significant association with clinical variables for all NCCT findings except for atelectasis, ureteronephrosis, contralateral pleural effusion, RFs, and flank hematoma. In multivariate analysis, only perinephric fluid (P = .007) and ipsilateral pleural effusion (P = .034) were associated with longer hospitalization, and perinephric fluid with longer recovery (P = .004). The complication rate was 12%, but none were linked with the radiological findings. CONCLUSION: This work describes the post-PNL NCCT findings and their clinical significance. Perinephric fluid and ipsilateral pleural effusion were found to independently predict longer hospitalization and recovery time.