Half-life of serum alpha-fetoprotein in prepubertal testicular yolk sac tumors: an index significantly associated with prognosis.

PURPOSE: To evaluate the association between serum alpha-fetoprotein (AFP) half-life (HL) and prognosis in prepubertal children with elevated AFP values 3 to 4 weeks after surgery for testicular yolk sac tumors (YST). METHODS: Prepubertal patients with testicular YST treated with radical orchiectomy between January 2016 and December 2022 were retrospectively reviewed. Negative outcomes were defined as relapse, metastasis or death. Univariate and multivariate logistic regression analyses were conducted to select risk factors for negative outcomes. RESULTS: A total of 42 patients were eventually enrolled into the study. Patients were divided into non-negative and negative outcomes groups, consisting of 35 and 7 patients, respectively. Thirty-five patients were stage I, two cases were stage II, and five cases were stage IV, according to the Children's Oncology Group staging system. The overall survival (OS) rate was 100%. Average AFP values significantly decreased after resection (P < 0.001). A significant positive correlation was shown between pre- and postoperative AFP values (r = 0.60, P < 0.001). Long AFP HL was considered as an independent risk factor for negative outcomes in YST patients underwent radical orchiectomy (P = 0.04). The cut-off value for AFP HL was 5.78 days, regardless of age division. CONCLUSION: Testicular YST is a relatively rare disease in children with an OS of 100%, and salvage chemotherapy is effective even in grade IV patients. The postoperative AFP HL was significantly associated with prognosis in prepubertal patients with testicular YST. The cut-off value for AFP HL is 5.78 days regardless of the effect of physiological AFP elevation.

Failure in Double-J stent inserting in laparoscopic pyeloplasty of ureteropelvic junction obstruction: the clinical features and outcomes.

BACKGROUND: Double-J (DJ) stent placement is an important procedure during laparoscopic pyeloplasty (LP). Failing to insert the DJ stent may indicate the patient was also complicated with uretero-vesical junction obstruction (UVJO), and surgeons have to change to another alternative drainage method. In the present study, we analyzed the risk factors of failure of DJ stent placement during the LP and reviewed the clinical outcomes of these challenging pyeloplasties. METHODS: We retrospectively analyzed the clinical data of patients with ureteropelvic junction obstruction (UPJO) who underwent LP in our department from January 2016 to September 2020. For patients who developed a difficult process of inserting the DJ stent, the externalized uretero-pyelostomy (EUP) stent was indwelled. Patients were finally divided into two groups: DJ group and EUP group. The primary outcomes were recurrent UPJO, postoperative uretero-vesical junction obstruction (UVJO) and complications. RESULTS: A total of 535 patients were included in the study, of which 37 patients (6.9%) failed to insert the DJ stent. Age was younger, and weight was lower (P < 0.05) in the EUP group. Within follow-up, recurrent UPJO occurred in ten (1.87%) patients, nine in the DJ group and one in the EUP group (P > 0.05). The incidence of postoperative UVJO in the EUP group was significantly higher than in the DJ group (10.8% vs. 0.2%, P < 0.01). 74 patients (13.8%) developed complications after surgery, 12 patients (32.4%) in the EUP group, significantly higher than that in the DJ group (32.4% vs. 12.4%, P < 0.01). Compared with the DJ group, the larger APD were observed in the EUP group at three months postoperatively (3.50 [3.02;4.58] vs. 2.20 [1.50;2.88], P < 0.05), but the difference vanished in further follow-up. CONCLUSION: The failure of DJ stent placement tends to occur in patients with younger age, lower weight, and larger preoperative APD. Failure may not increase the recurrent UPJO rate, but may indicate a higher probability of postoperative UVJO and may develop more postoperative complications and slower recovery.

Effectiveness of penile ventral curvature correction and the trend of hypospadias repair: a prospective study of the national center in China.

BACKGROUND: Hypospadias repair is a complex surgical procedure that involves correcting penile ventral curvature (VC) and performing urethroplasty. This study aims to evaluate the effectiveness of different strategies for VC correction and analyse the trends in hypospadias repair at a national centre in China. METHODS: Prospective data collection was conducted from 2019 to 2020 for patients undergoing hypospadias repair. The effectiveness of VC correction was assessed based on the degree of VC change with different strategies. Furthermore, the choice of surgical techniques for different types of hypospadias repair was analysed. RESULTS: A total of 434 patients were included, with a median preoperative VC degree of 50° (35°, 70°). All patients achieved a straight penis postoperatively, with 15.2% undergoing degloving, 28.6% undergoing degloving and dorsal plication (DP), 13.1% undergoing degloving and urethral plate transection (UPT), and 43.1% undergoing degloving, UPT and DP. Degloving alone was effective in correcting VC in 57.6% of patients with VC less than 30°. In our analysis, DP after UPT resulted in a higher degree of correction (25°) compared with DP after degloving alone (20°) (p<0.001). The study identified the current trends in hypospadias repair, with tubularised incised plate urethroplasty (TIP) being the most common technique used in distal hypospadias repair (70.6% of patients) and transverse preputial island flap urethroplasty (TPIFU) being preferred for proximal hypospadias repair (63.0%). CONCLUSIONS: Degloving alone is effective for correcting VC less than 30°. The majority of patients in our centre underwent UPT, and DP after UPT yielded better results compared with DP after degloving alone. Distal hypospadias repair commonly used TIP, while TPIFU was favoured for proximal hypospadias repair. TRIAL REGISTRATION NUMBER: ChiCTR1900023055.

Febrile urinary tract infection after Double-J stent removal is associated with restenosis after laparoscopic pyeloplasty: A propensity score matched analysis of 503 children.

OBJECTIVE: To analyze the association between the febrile urinary tract infection (fUTI) after Double-J (DJ) stents removal and restenosis after laparoscopic pyeloplasty (LP). STUDY DESIGN: We retrospectively reviewed the clinical data of patients who were treated with transperitoneal LP for ureteropelvic junction obstruction from 2016 to 2020. Patients were divided into two groups according to whether they developed fUTI after DJ stent removal within 48 h. The 1:3 Propensity Score Matched (PSM) method was used to balance confounding variables. RESULTS: 503 patients were included in the study. 28 (5.57%) patients developed fUTI after DJ stent removal. Compared with the non-fUTI group, age was younger, and weight was lower (P < 0.05) in the fUTI group. Restenosis occurred in 11 (2.2%) patients, of which six patients developed fUTI after DJ stent removal. The revision surgery rate in the fUTI group was significantly higher than in the non-fUTI group (21.4% vs. 1.1%, P < 0.01). After PSM, the results remained consistent. For 492 patients without restenosis, 22 patients developed fUTI. Compared with the non-fUTI group, the larger anteroposterior diameter (APD) and higher APD/cortical thickness (P/C) ratio were observed in the fUTI group at three months and six months postoperatively (P < 0.05), but the difference vanished at 12 months and 24 months after surgery (Figure). DISCUSSION: FUTI after DJ stent removal is not uncommon after LP, and surgeons are often concerned about the possibility of restenosis. In the present study, although our results demonstrated a significant association between them, restenosis patients comprise only about 20% of fUTI patients. Based on our clinical observations, fUTI is often developed in children from 1 to 6 years of age, and the younger patients may be afraid of voiding because of the postoperative pain after DJ stent removal. Besides, intraoperative manipulation of DJ stent removal may lead to transient edema in the anastomotic site, causing the fUTI. For patients who develop fUTI after DJ stent removal but without persistent symptoms, the transient worsening of hydronephrosis during the early postoperative period may not impact long-term outcomes (As shown in Figure). Additional follow-up is needed to prevent the deterioration of renal function. CONCLUSIONS: Our result demonstrated that fUTI after DJ stent removal is associated with restenosis after LP. For fUTI patients without restenosis, APD and P/C ratio exhibited transient worsening at three months and six months postoperatively, decreasing gradually during follow-up. Patients who develop fUTI after DJ stent removal should be monitored.

Redo laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction: Propensity score matched analyses of a high-volume center.

Purpose: Review the experience of redo laparoscopic pyeloplasty (RLP) in patients with recurrent ureteropelvic junction obstruction (UPJO) in comparison to primary laparoscopic pyeloplasty (PLP) and redo open pyeloplasty (ROP), and determine the feasibility and effectiveness of RLP for recurrent UPJO in children. Methods: We retrospectively reviewed the clinical data of patients treated with transperitoneal PLP, RLP, and ROP for UPJO from December 2015 to December 2022. The Propensity score matching (PSM) was used to balance confounding variables. RLP patients were 1:4 matched with PLP and 1:3 matched with ROP. The primary outcomes were failure and post-operative complications. Complications were classified according to the Clavien-Dindo grading system. Results: The study included ten patients who underwent RLP, 43 patients who underwent ROP, and 412 patients who underwent PLP. The follow-up time ranged from 6 to 36 months in the RLP group, 12 to 60 months in the PLP group, and 24 to 54 months in the ROP group. In the RLP group, no failure but three post-operative complications (Clavien grade II) were observed during the follow-up. Compared with the PLP group, the older age, higher weight, larger pre-operative anteroposterior diameter (APD) and APD/cortical thickness (P/C ratio), longer operation time, and post-operative length of stay (LOS) in the RLP group (P < 0.05). After PSM, longer operation time and post-operative LOS were observed in the RLP group (P < 0.05). Compared with the ROP group, the older age, higher weight, and longer post-operative LOS in the RLP group (P < 0.05). After PSM, longer post-operative LOS was observed in the ROP group (P < 0.05). The failure and complication rates were comparable between RLP and PLP or RLP and ROP (P > 0.05). Conclusions: Our result demonstrated that RLP performed as well as PLP except for a longer operation time. Compared with ROP, RLP has the advantages of a clearer surgical view, sufficient exposure, clearer anatomical landmark position, and minor trauma with a comparable clinical outcome. On experienced hands, RLP for recurrent UPJO after is a safe and effective procedure and should be considered an excellent alternative to the more commonly recommended ROP in select patients.

Development of the prediction model for negative outcomes after primary laparoscopic pyeloplasty in children: a retrospective study of 535 patients.

Background: Laparoscopic pyeloplasty (LP) has been widely accepted as an effective method to treat ureteropelvic junction obstruction (UPJO) in pediatric patients. Limited studies focused on the relationship between risk factors and negative outcomes. Our study aimed to seek independent risk factors for negative outcomes and construct a prognostic nomogram to assist clinical decision-making and improve outcomes. Methods: A total of 535 patients with UPJO treated with primary LP between January 2016 and December 2020 were retrospectively reviewed. Negative outcomes were defined as restenosis requiring reoperation and grade III and IV complications based on the Clavien-Dindo grading system. Univariate and multivariate logistic regression analyses were used to select risk factors for negative outcomes after LP and developed the prediction model. The model was internally validated by the parametric bootstrapping method. Results: Among the 535 patients, 33 (6.2%) developed negative outcomes. Ten patients developed ureteropelvic junction (UPJ) restenosis and underwent secondary surgery. UPJ leakage (two cases), difficulty of urinating after the removal of the Double-J (DJ) stent (two cases), and ileus (two cases) were the most common grade IIIa complications, while distal ureteral stricture (five cases), hernia formation (three cases), and delayed wound healing around the fistula (two cases) were the most common grade IIIb complications. After univariate and multivariate logistic analyses, the patient's weight, preoperative anteroposterior pelvic diameter (APD), and difficulty of DJ stent insertion were independent risk factors for negative outcomes, and they were used to fit the prediction model. The Brier score was 0.048. The model was relatively well-calibrated. The area under the receiver operating characteristic curve was 0.831 (95% CI: 0.756-0.906). Decision curve analysis illustrated good clinical utility. Conclusions: Primary LP is a safe and effective method for pediatric patients with UPJO. The patient's weight, preoperative APD, and difficulty of DJ stent insertion were independent risk factors for negative outcomes after LP. We established and validated a predictive model for negative outcomes after LP. With the help of this model, clinicians can make better decisions and improve patient outcomes.

Reoperation frequency after transverse preputial Island flap urethroplasty "Duckett's technique" in treatment of severe hypospadias: A single center study.

Purpose: Transverse Preputial Island Flap Urethroplasty (TPIFU) is one of the most common techniques for treating severe hypospadias. Studies on the reoperation frequency after TPIFU is lacking. In the present study, we reported our clinical outcomes of severe hypospadias treated with one-staged TPIFU and analyzed the operation frequency. Methods: We retrospectively analyzed the clinical data of severe hypospadias patients who underwent one-stage TPIFU from December 2018 to December 2019 in the department of Urology at Beijing Children's Hospital. A stepwise approach was used to manage the curvature. Severe hypospadias was defined as those residual curvature was higher than 30° after degloving. Urethroplasty complications included fistula, urethral stricture, and diverticulum. The short-term cure was identified as no complications occurring for 12 months after the date of last-time surgery. The reoperation rate and operation frequency of TPIFU were analyzed. Results: A total of 136 patients who underwent one-stage TPIFU were included in the study. The follow-up after primary urethroplasty ranged from 22 to 50 months. The median age at primary surgery was 22.5 months (range from 13 to 132 months). After primary TPIFU surgery, 53 (39%) patients underwent additional surgical interventions to treat postoperative complications. Among them, 24 patients (17.6%) developed fistula, 17 patients (12.5%) developed urethral stricture and 11 patients (8.1%) developed diverticulum. After the second surgery, five patients remained fistula, five patients remained urethral stricture, and seven patients remained diverticulum. Overall, 61% (85 patients) met the cured standard after the primary operation, and the two operations cure rate was 87.5% (119 patients). 91.2% (124 patients) were cured in three operations. Conclusions: Although the complication rates after primary TPIFU were relatively high, more than half of patients achieved short-term cured through a single operation, and the cure rate after two or three operations was acceptable.