Cumulative re-operation rates during follow-up after hypospadias repair.

OBJECTIVE: To assess the cumulative rates of re-operations after hypospadias repair and evaluate long-term surgical outcomes at a tertiary paediatric urology centre. PATIENTS AND METHODS: Retrospective analysis of 293 boys born between 1991 and 2003 undergoing hypospadias surgery was conducted. The study included 274 patients: 165 with distal, 34 with midshaft, and 75 with proximal hypospadias. Kaplan-Meier methods were used to evaluate the re-operation data. RESULTS: The median age at primary surgery was 1.3 years, with a median follow-up of 14.4 years. The overall re-operation rate was 48.2%, with approximately half of the problems detected within the first 3 months after surgery. The risk of re-operation was correlated with hypospadias severity, with 5- and 15-year re-operation risks at 39.3% and 51.8%, respectively. Limitations of the study include its retrospective nature and variations in surgical techniques from current standards. CONCLUSION: There is a significant risk of unplanned re-operations following hypospadias repair, increasing with the severity of the original condition. This underscores the need for extended follow-up and effective communication with patients and their families about the likelihood of requiring multiple surgeries for optimal outcomes.

Surgical treatment of cryptorchidism: current insights and future directions.

Cryptorchidism presents with an incidence of 1-5% with potential long-term implications on future fertility and overall health. This review focuses on surgical treatment modalities, their impact on testicular development, and function while addressing the Nordic consensus statement as well as current European Association of Urology (EAU) and American Urological Association (AUA) guidelines. Congenital and acquired cryptorchidism present distinctive challenges in surgical management, with different implications for fertility. While congenital cryptorchidism entails a risk to fertility and warrants early intervention, both retractile testes and acquired cryptorchidism also pose risks to fertility potential, underscoring the importance of evaluating treatment options. Testicular location and the child's age form the basis of a practical classification system for undescended testicles. Early diagnosis by clinical examination enables timely treatment. Imaging is reserved for selected cases only. Following guidelines, orchidopexy is recommended between 6-12 months of age for congenital cryptorchidism. Evidence increasingly suggests the benefits of early surgery for promoting testicular health and fertility potential. Current surgical options range from open to laparoscopic techniques, with the choice largely determined by the location and accessibility of the undescended testicle. The advancement in laparoscopic approaches for non-palpable testes underscores the evolving landscape of surgical treatment. Sequential surgeries may be required depending on the mobility of the undescended testes. More research is needed to explore both the potential and limitations of hormonal therapy, which is secondary to surgical treatment and can selectively have a role as adjunct to surgery. Long-term follow-up is imperative to evaluate fertility outcomes, risk of testicular malignancy, and psychological impact. By integrating current guidelines with the latest evidence, this review intends to facilitate a comprehensive understanding of cryptorchidism, thereby optimizing patient management and outcomes.

Urological Outcomes in Post-Pubertal Patients With Myelomeningocele: A Single-Center Retrospective Study.

BACKGROUND: Recent decades have seen changes in the urological treatment of myelomeningocele (MMC). We aimed to evaluate the urological outcomes in post-pubertal patients and to clarify associations with walking status, hydrocephalus, and sex. METHODS: A retrospective study of 103 MMC patients at their final pediatric urological control. Urological procedures, the necessity for Clean Intermittent Catheterization (CIC) and anticholinergic medication, the state of continence, renal ultrasound findings, and serum creatinine values were assessed. RESULTS: The median age of the patients was 18 years (IQR 16.7-19.6), with 51 (49.5%) being female. Renal function was preserved in all but of one, who presented with mild hydronephrosis. 38 patients walked without assistance, 46 used wheelchairs. Most patients (93%) utilized CIC, and 83% had interventions for overactive or poorly compliant bladder, including anticholinergic medication (47%), Botox treatments (35%), or bladder augmentation (36%). Nearly half (45%) had undergone bladder neck procedures. Continence status revealed 55% fully continent, 18% were rarely incontinent, and 26% were incontinent daily, with most episodes limited to droplet leakage. Incontinence was not associated with the ambulatory status, hydrocephalus, or sex (p = 0.08, >0.99, and 0.07 respectively). CONCLUSIONS: Renal function was effectively maintained with our treatment strategy; however, daily incontinence episodes occurred in one out of four patients, with an additional 18% experiencing occasional rare incontinence episodes. Incontinence, when present, was mostly mild. We found no association between patient characteristics, treatment approach, and continence. Emphasizing incontinence treatment becomes a mainstay in future studies. LEVEL OF EVIDENCE: IV.

Stratifying Antenatal Hydronephrosis: Predicting High-Grade VUR Using Ultrasound and Scintigraphy.

(1) Background: Antenatal hydronephrosis (AHN), detected in approximately one percent of prenatal ultrasounds, is caused by vesicoureteral reflux (VUR) in 15-21% of cases, a condition with significant risks such as urinary tract infections and renal scarring. Our study addresses the diagnostic challenges of VUR in AHN. Utilizing renal ultrasonography and scintigraphy, we developed a novel scoring system that accurately predicts high-grade VUR, optimizing diagnostic precision while minimizing the need for more invasive methods like voiding cystourethrogram (VCUG); (2) Methods: This retrospective study re-analyzed renal ultrasonography, scintigraphy, and VCUG images from infants admitted between 2003 and 2013, excluding cases with complex urinary anomalies; (3) Results: Our analysis included 124 patients (75% male), of whom 11% had high-grade VUR. The multivariate analysis identified visible ureter, reduced renal length, and decreased differential renal function (DRF) as primary predictors. Consequently, we established a three-tier risk score, classifying patients into low, intermediate, and high-risk groups for high-grade VUR, with corresponding prevalences of 2.3%, 22.2%, and 75.0%. The scoring system demonstrated 86% sensitivity and 79% specificity; (4) Conclusions: Our scoring system, focusing on objective parameters of the visible ureter, renal length, and DRF, effectively identifies high-grade VUR in AHN patients. This method enhances diagnostics in ANH by reducing reliance on VCUG and facilitating more tailored and less invasive patient care.

Management of sphincter insufficiency in patients with neurogenic bladder and bladder augmentation.

PURPOSE: To investigate the need and efficacy of treatment of bladder neck procedures in patients with neurogenic bladder and augmentation. METHODS: The hospital database was reviewed for patients undergoing enterocystoplasty because of neurogenic bladder during 1990-2019. Diagnoses of patients as well as frequency, type, and efficacy of treatment of sphincter insufficiency were evaluated. RESULTS: Thirty-seven of 87 patients (43%) underwent surgery because of sphincter insufficiency. The median age at bladder augmentation was 11.9 years (IQR 8.5-14.8), and at the last control, 21.8 years (IQR 18.9-31.1). Bladder neck injections (BNI) were performed for 28 patients, fascial sling operation for 14 patients, and bladder neck closure (BNC) was done for five females. Full continence was achieved in 10/28 (36%) patients with one or repeat BNIs and 9/14 (64%) with sling operation. The outcome of BNIs and sling operations was similar in both sexes. All five female patients with BNC became continent. At the end of follow-up, 64 (74%) patients were dry, 19 (22%) had occasional incontinence episodes, and 4 (5%) had daily incontinence episodes necessitating pads. CONCLUSIONS: Treatment of sphincter insufficiency is challenging in patients with bladder augmentation and neurogenic disease. Only 74% of our patients became fully continent despite treatments for sphincter insufficiency.

Additional surgery in patients with bladder augmentation.

INTRODUCTION: Bladder augmentation is an option to protect kidneys and treat incontinence in frequent neurogenic and congenital non-neurogenic disorders. However, patients may need also other procedures to treat incontinence or to aid catheterizations. In addition, the patients are prone to complications. OBJECTIVE: To evaluate complications or additional surgeries in augmentation cystoplasty according to the etiology of the bladder dysfunction. STUDY DESIGN: Data on additional surgical procedures related to bladder augmentation were collected from 128 patients who had undergone enterocystoplasty between 1990 and 2019, with a median age of 10.1 years (IQR 7.2-12.8) and a follow-up time of 11.8 years (IQR 5.7-18.6) after augmentation. RESULTS: Eighty-three patients had a neurogenic disease, and 45 patients had a non-neurogenic disease. Bladder neck operations were performed either at the time of or after augmentation for 62 patients (48.4%), more commonly in the non-neurogenic than neurogenic group <0.01. In addition, continent stoma operations in 56 (36.8%) patients were more common in the non-neurogenic group (p < 0.01). Ten patients received kidney transplantation (four in the neurogenic, six in the non-neurogenic group); seven of these patients originally had dysplastic kidneys, two developed nephrological kidney disease, and one had hydronephrosis and renal insufficiency at the time of diagnosis of neurogenic bladder. Surgical problems resulting from bladder augmentation were treated in 28 patients (21.8%). The risk for surgical treatment because of complications was 4%, 17%, 24%, 27% and 27% at 1, 5, 10, 15 and 20 years follow up respectively. Complications were more common in patients in non-neurogenic than in patients with neurogenic group (p < 0.01). However, the greater proportion of continent stomas in non-neurogenic group explained the difference (Fig.). The most frequent complication requiring surgery during follow-up was bladder stones, which occurred in 24 (18.8%) patients. The first stone was treated at a median of 3.3 years (range 0.3-14.2) after augmentation. Stones were more common in patients with a continent stoma than without (p < 0.01). Other indications for surgical treatment were as follows: obstructive ileus in five patients, reduced bladder capacity in three patients, bladder perforation in two patients and lobulated bladder with infections in one patient. CONCLUSIONS: The risk for surgical treatment was about 27% in 20-year follow-up after bladder augmentation, because of augmentation related complications. The most prevalent complication was bladder stone, that was mainly associated with continent stomas. Continent stomas were most prevalent in patients with non-neurogenic diagnosis.

Posterior urethral valves and the risk of neurodevelopmental disorders in two FINNISH cohorts.

BACKGROUND: The Posterior Urethral Valve (PUV) is a persistent membrane of the urethra, which causes obstruction in the urogenital tract in boys. To our knowledge, no comprehensive reports have been published on whether PUV is associated to neurodevelopmental disorders. Here, we analyzed a cohort of PUV patients for neurodevelopmental disorders and verified findings in an older cohort. METHODS: In a register based study, we reviewed the hospital registries for patients treated for PUV during 1992-2013 to identify those with neurodevelopmental disorders. Primary outcome measure was any neurodevelopmental diagnosis. Secondary outcome measures were specific disorders: ASD; ADHD, intellectual disability, learning disabilities. Birth weight and gestational age were recorded, serum creatinine levels at specific timepoints were noted. We then investigated these variables to see any correlations to neurodevelopmental disorders. We replicated the strategy for verification in an older cohort of PUV-patients, who had been treated in our institute during 1970-1991. RESULTS: We identified 87 patients treated for PUV of which thirteen (15%) had a verified diagnosis of a neurodevelopmental disorder. 2.3% of PUV patients fulfilled criteria of mild intellectual disability (F70.0/F79.0), 9% had ADHD/ADD-spectrum diagnoses (F90.0/F90.9) and 2.3% had learning disabilities (F83/F81.3). 5.7% of patients presented with difficulties in social interactions (F93.89, F94.8). Five patients presented with more than one neurodevelopmental diagnosis. We confirmed these findings in the older cohort of patients, where a verified neurodevelopmental diagnosis was detected in 14% of patients. We identified no statistically significant associations to gestational age, birth weight or creatinine levels of PUV-patients with neurodevelopmental diagnoses as compared to the PUV-patients not diagnosed for neurodevelopmental disorders. Intellectual disability/mental retardation was more prevalent in our material and this association was statistically significant. DISCUSSION: We show, that the prevalence of intellectual disability among PUV patients exceeds the cumulative prevalence in Finland in both cohorts analyzed here. 15% of PUV-patients presented with a diagnosis of a neurodevelopmental disorder. To our knowledge, this is the first study attempting to outline neurodevelopmental disorders among boys with PUV. This study has limitations. It is register based and only diagnoses made at an institute within our hospital district are considered. The PUV-patients may be under closer surveillance than age-matched healthy children, which may lead to an overrepresentation of cases. The patient number is small and the small subsets of patients within each cohort hamper any further statistical analysis. The neurodevelopmental impacts of pediatric general anesthesia remain elusive and may have corollaries which must be kept in mind when interpretating our results. Patients with PUV require close follow-up in a multi-disciplinary manner, not forgetting neurodevelopmental aspects. Attention to intellectual disability is mandatory. Any suspicion of a developmental delay in a patient with PUV warrants further investigation and corresponding interventions.

Introduction of Pediatric Robot-Assisted Pyeloplasty in A Low-Volume Centre.

(1) Background: This study investigated the introduction of pediatric robot-assisted pyeloplasty in a low-volume centre with reference to open pyeloplasty with regards to operative times, length of stay (LOS) and outcomes and cost analysis. (2) Methods: Data from 10 consecutive robot-assisted pyeloplasties was compared retrospectively to an age and weight matched cohort of open pyeloplasties operated on during two previous years. Operative times were analyzed in conjunction with LOS, outcomes and cost-analysis from patient records. (3) Results: Operative times remain longer in robot-assisted pyeloplasties (168 (IQR 68) vs. 141 (IQR 51) min), but patients are discharged from the hospital earlier and may return to daily activities earlier. In our hospital, the difference in LOS levels to some degree the cost difference between operations. (4) Conclusions: Robot-assisted pyeloplasty can be safely and economically introduced and maintained in a low-volume centre.

Association of Renal Glomerular and Tubular Function With Renal Outcome in Patients With Posterior Urethral Valves.

OBJECTIVE: To analyze renal glomerular and tubular function and their association in patients operated for posterior urethral valves and to prognosticate the risk for end-stage kidney disease (ESKD) METHODS: Sixty-three previously treated patients were evaluated for renal function during 1987-1991. The patients' age at evaluation was 11 years (range 2-24). Glomerular function was assessed by measuring glomerular filtration rate (GFR) and urine albumin excretion. Tubular function was determined by measuring urine concentration capacity and excretion of electrolytes (Na, K, Cl, Ca, P, Mg) and ß-2-microglobulin. Additionally, the prevalence of hypertension and serum parathyroid hormone and aldosterone values were registered. Tubular function was compared with GFR and the risk of developing ESKD before November 2018. RESULTS: Twenty of the study patients (32%) had decreased GFR. In addition, 19% had proteinuria and 56% were hypertensive. Those without proteinuria or hypertension had better GFR values (P < .01 for both). There was a significant correlation between GFR and all the tubular function (P < .05) variables (except excretion of chloride) measured. Compared to the patients with favorable renal outcome, the patients (n = 10) who later developed ESKD had significantly (P < .01) lower GFR and reduced urinary excretion of all measured electrolytes except calcium. Consistently, urine ß-2 microglobulin and serum parathyroid hormone and aldosterone values were significantly higher in the patients who developed ESKD (P ≤ .01). CONCLUSION: Both glomerular and tubular function decline was common and several parameters were likely to predict ESKD in posterior urethral valves patients.

Development of Late Continence in Bladder Exstrophy and Epispadias Patients.

OBJECTIVE: To evaluate to what extend urinary continence develops during puberty in patients with classic bladder exstrophy (CBE) and epispadias. METHODS: The operative database was reviewed for surgical procedures and urinary continence in all 65 CBE and epispadias patients born in 1976-2005. Excluded were 2 patients who had insufficient data for evaluation. RESULTS: Thirty-five patients with volitional voiding were incontinent at the age of 10 years, 27 had daily incontinence, and 8 had rare incontinence. Sixteen patients (46%) became later fully continent without any major surgery (except Deflux injections in 3 patients) or CIC treatment. Among these 16 fully continent patients there were 7/8 with rare incontinence, 9/23 with daily incontinence (P = .04); 3/9 males with CBE, 10/13 males with epispadias, 3/5 females with CBE, and 0/4 females with epispadias (P = .25 between sex and P = .48 between diagnosis). Of the 15 patients remaining incontinent, 10 had daily and 5 had rare incontinence episodes. The latest control was at the median age of 19 years (interquartile range 17-21 years). Twenty-five patients (40% of the whole material) were fully continent (11/38 (29%) with CBE and 14/25 (56%) with epispadias, P = .04) and 8 (13%) had rare incontinence with volitional voiding (1/38 [3%] with CBE and 7/25 [28%] with epispadias). CONCLUSION: Almost half of the incontinent CBE and epispadias patients with volitional voiding achieved continence after the age of 10 without major surgery. Prognosis for pubertal development of continence was best in patients with rare incontinence and in males with epispadias.

Effect of Pediatric Testicular Torsion on Testicular Function in the Short Term.

PURPOSE: To evaluate short-term testicular outcome after torsion in children. METHODS: Fifty-four children and adolescents were evaluated after 6 months of the operation for testicular torsion. Testicular volume was measured and circulating Inhibin B, FSH, LH and testosterone levels were checked. RESULTS: Delay from the onset of symptoms to surgery was shorter in the orchidopexy group (n = 47), than in the orchiectomy group (n = 7, p = 0.001). In the orchidopexy group, the median volume of the affected testis was 83% (IQR 43-104) of the contralateral testis (p = 0.002). The plasma hormone levels in orchidopexy and orchiectomy groups were: 148 ng/l (IQR 108-208) vs. 129 ng/l (IQR, 123-138, p = 0.269) for Inhibin B; 4.5 IU/L (IQR2.6-6.9) vs. 11.7 IU/L (IQR 4.3-12.8, p = 0.037) for FSH; 2.9 IU/L (IQR 1.3-3.7) vs. 4.8 (IQR 3.0-5.6, p = 0.066) for LH; and 13.6 nM (IQR 6.5-18.0) vs. 14.5 nM (IQR 6.7-15.9, p = 0.834) for testosterone. The association between FSH, LH as well as testosterone levels was most clear with the volume of the contralateral testis (Rho = 0.574, p < 0.001, Rho = 0.621, p = 0.001 and Rho 0.718, p < 0.001 respectively). CONCLUSIONS: Testicular function is mainly dependent on the volume of contralateral testicle after testicular torsion. However, testis preserving surgery tends to maintain better function than orchiectomy. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: III.

Paternity, erectile function, and health-related quality of life in patients operated for pediatric testicular torsion.

INTRODUCTION: Spermatic cord torsion (SCT) may lead to organ loss and can potentially influence fertility. Long-term effects of SCT are not fully investigated. OBJECTIVE: The purpose was to evaluate paternity rates in adults who have had SCT in childhood and to compare the results to those of a control population. The secondary purposes were to compare paternity rates after testis-preserving surgery with those after orchiectomy and to evaluate erectile function and health-related quality of life (HRQoL). STUDY DESIGN: Questionnaires concerning paternity, erectile function (International Index of Erectile Function [IIEF]-5 questionnaire), and HRQoL (15D questionnaire) were mailed to 74 men who had been treated for SCT and to 92 controls treated for testicular appendage torsion in 1977-1995 and who were currently older than 30 years. RESULTS: Thirty-five of the 74 (47%) patients with SCT and 58 of the 92 (63%) controls responded. A same-aged control was selected for each patient with SCT. The median age at investigation was 41 (interquatile range [IQR]: 36 to 46) years in the SCT group and 41 (IQR: 38 to 46) years in the control group (p = 0.81). The paternity rate was 23 of 35 (66%) in the SCT group and 26 of 34 (76%) in the control group (p = 0.43). Nine percent of patients and controls suffered from infertility. Of the 30- to 50-year-old patients with SCT, 9 of 16 (56%) had children after orchiectomy, and 13 of 16 (81%), after detorsion (p = 0.25). Significant or moderate erectile dysfunction (IIEF-5 total score <12) was observed in 3 of 32 (9%) patients and in 1 of 35 (3%) controls (p = 0.34). Erectile dysfunction was similarly rare in both the orchidopexy and orchiectomy group. Total HRQoL scores were similar in the SCT and control groups (p = 0.69) as well as in patients with orchidopexy and orchiectomy (p = 0.50). DISCUSSION: Paternity, erectile function, or HRQoL was not impaired in the general level in the patients with SCT in comparison with controls. Both the modes of treatment, orchiectomy or detorsion, had no significant impact on the results. However, the results cannot be generalized to the individual level. The limitations were a small sample size and inability to investigate maternal factors to the paternity. However, the results are encouraging for the patients and families. CONCLUSION: Paternity rate and HRQoL were similar in patients with SCT and controls. The type of surgery (orchiectomy vs. detorsion) did not affect paternity rates statistically. Moderate or significant erectile dysfunction was rare in both groups.

Surgically treated ovarian lesions in preadolescent girls.

INTRODUCTION: The purpose of this study was to investigate the epidemiology and characteristics of surgically treated ovarian lesions in preadolescent girls. MATERIAL AND METHODS: This was a retrospective cohort study including all 0- to 11-year-old girls operated at a single center from 1999 to 2016 for ovarian cysts, neoplasms or torsions. Patient charts were reviewed for symptoms, preoperative radiological imaging, operative details and histopathology. RESULTS: We identified 78 girls, resulting in a population-based incidence of 4.2/100 000. Infants (n = 44) presented with benign cysts (42/44, 95%, one bilateral), a benign neoplasm (1/44, 2%) and a torsion without other pathology (1/44, 2%). Torsion was found in 25/29 (86%) ovaries with complex cysts and in 3/15 (21%) ovaries with simple cysts in preoperative imaging (P < 0.001). Most infants were symptomless. Lesions in 1- to 11-year-old girls (n = 34) included benign neoplasms (n = 21/34, 62%), malignant neoplasms (n = 5/34, 15%), a cyst with torsion (n = 1/34, 3%) and torsions without other pathology (n = 7/34, 21%). Torsion was more common in benign (17/21, 81%) than in malignant neoplasms (1/5, 20%) (P < 0.020). Ovarian diameter did not differ between ovaries with or without torsion (P = 0.238) or between benign and malignant neoplasms (P = 0.293). The duration of symptoms in lesions with or without torsion was similar. CONCLUSIONS: The majority of surgically treated ovarian lesions in preadolescent are benign lesions with torsion. Surgery should be ovary-preserving and performed without delay.

No single reason behind adult lower urinary tract symptoms in patients with posterior urethral valves.

Objective: To analyze which factors in the history of a posterior urethral valve (PUV) patient relate to lower urinary tract symptoms (LUTS) in adulthood. This study also aimed to evaluate whether the patients have developed signs of a myogenic failure of detrusor. Materials and methods: LUTS were evaluated with a DAN-PSS questionnaire in 78 adult patients treated for PUV in childhood. Symptom scores (SS) were compared with patient characteristics and types of treatment. The results of uroflowmetry and post-voiding residual (PVR) measurements were collected from their latest visit to Helsinki University Children's Hospital. Results: The median total symptom score (TSS) was 1 (IQR = 0-5, range = 0-18). The patient age during the investigation and SS were associated (R = 0.220, p = 0.032), but the primary creatinine level and SS were not (R = 0.260, p = 0.081). The median age for achieving continence was 6.3 years. The SS and the age when becoming continent were not associated (p = 0.365 and p = 0.679, respectively). In the age group of 39 years or more, 19 patients with a previous bladder neck incision (BNI) had a higher storage-SS than 15 patients without any previous bladder neck incision (1 (IQR = 0-5) vs 0 (IQR = 0-0), p = 0.030). According to symptoms and post-voiding residual measurements, myogenic failure in adults seems to be rare. Conclusions: LUTS are common, but severe symptoms referring to myogenic failure are rare in men treated for PUV in childhood. The specific reasons for LUTS are difficult to indicate and even the sickest children do not necessarily have LUTS in adulthood.

Reduced differential renal function in scintigraphy predicted high-grade vesicoureteral reflux in children with antenatal hydronephrosiss.

AIM: A top-down approach is widely used for detecting vesicoureteral reflux (VUR) in children with febrile urinary tract infections. We evaluated the diagnostic value of renal scintigraphy in predicting VUR in children with antenatal hydronephrosis (AHN). METHODS: The voiding cystourethrogram (VCUG) and renal scintigraphy results of 125 AHN patients (76% male) admitted to the Children's Hospital of Helsinki University, Finland, from 2003 to 2013 were analysed. Of those, 94 had nonrefluxing hydronephrosis, nine had low-grade VUR and 22 had high-grade VUR. RESULTS: Scintigraphy was performed at a median age of 1.4 (0.8-15.6) months. In patients with high-grade VUR, the differential renal function (DRF) of the worse kidney was significantly lower than in patients without VUR, with a median of 35% and interquartile range (IQR) of 20-45 versus 47% (IQR: 44-49), (p < 0.001). There was no difference between patients with low-grade VUR and patients without VUR (p = 0.181). DRFs below 44% showed a sensitivity of 73% and specificity of 79% and predicted significantly high-grade VUR (odds ratio 9.82, 95% confidence interval 3.44-28.05, p < 0.001) in the univariate analysis. CONCLUSION: A DRF below 44% predicted high-grade VUR in patients with AHN and supported the decision to perform VCUG.

Effect of Wilms tumor histology on response to neoadjuvant chemotherapy.

PURPOSE: To evaluate the association between Wilms tumor histology at diagnosis and the change in Wilms' tumor volume during preoperative chemotherapy. METHODS: We included all the 52 patients operated for Wilms tumor at 1988-2015, who had both pathology samples and either CT or MRI-images before and after preoperative chemotherapy, available for reevaluation. RESULTS: The median tumor volume was 586 ml (IQR 323-903) at diagnosis. The median change in tumor volume was -68% (IQR -85 to -40, p < 0.001) and the proportion of tumor necrosis 85% (IQR 24-97), after preoperative chemotherapy. There was a correlation between blastemal cell content in prechemotherapy cutting needle biopsy (CNB) sample and the reduction in tumor volume (Rho = -0.452, p = 0.002). High stromal and epithelial cell contents in CNB samples were associated with the lesser change in tumor volume (Rho = 0.279, p  =0.053 and Rho = 0.300, p = 0.038 respectively). Reduction of tumor volume and the proportion of tumor necrosis after chemotherapy were associated (Rho = -0.502, p < 0.001). The actual viable tumor volume decreased in median by 97% (IQR 65-100), and the decrease could be seen in all cellular components. In three patients, the tumor volume increased more than 10% during the preoperative chemotherapy. Two of them had anaplastic tumor in the nephrectomy specimen. CONCLUSION: Wilms tumor total and viable tumor volumes were reduced by 68% and 97% with preoperative chemotherapy, respectively. High proportion of blastemal cells in CNB was associated with greatest decrease in Wilms tumor volume. Increase in tumor volume during preoperative chemotherapy may indicate anaplastic tumor and prolonging of preoperative therapy should be avoided. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: Level III.

Correction to: Postnatal imaging of prenatally detected hydronephrosis-when is voiding cystourethrogram necessary?

The original publication contained an erroneous version of Table 3 with incorrect data regarding ureteral visibility. The authors apologize for any inconvenience caused by their mistake and are pleased to present the corrected table here.

Postnatal imaging of prenatally detected hydronephrosis-when is voiding cystourethrogram necessary?

OBJECTIVE: To evaluate whether grade 4-5 vesicoureteral reflux (VUR) can be predicted from renal ultrasound (RUS) findings and perform voiding cystourethrograms (VCUGs) only on high-risk patients. METHODS: The RUS and VCUG images of infants with prenatally detected hydronephrosis admitted to our institution between 2003 and 2013 were re-evaluated. The UTI episodes were collected retrospectively from patient journals. Patients with complex urinary tract anomalies were excluded. RESULTS: One hundred eighty, 44 female and 136 male, patients (352 renal units (RU)), 23 (30 RU) of them having grade 4-5 VUR, were included. The median age of the patients at the time of the RUS was 1.3 (0.1-3.0) months and the median follow-up time was 2.0 (0.1-11.2) years. In multivariate analysis, a visible ureter (OR 12.72; CI 5.33-32.04, p < 0.001) and shorter renal length (OR 2.67; CR 1.50-4.86, p < 0.001) in RUS predicted grade 4-5 VUR while a visible ureter predicted UTIs (OR 5.75; CI 2.59-12.66, p < 0.001). A three-grade risk score for high-grade VUR was developed based on the RUS findings and the patients were categorized into low-, intermediate-, and high-risk groups. The incidence of grade 4-5 VUR was 2.9% in the low-risk, 12.2% in the intermediate-risk, and 52.2% in the high-risk group. The sensitivity and specificity for detecting grade 4-5 VUR were 79 and 82%, respectively. CONCLUSIONS: In patients with antenatally detected hydronephrosis, a visible ureter and reduced renal length in RUS are significant risk factors for high-grade VUR. A RUS-based risk scoring would probably reduce the proportion of unnecessary VCUGs.

Does intraoperative success predict outcome in the treatment of urethral sphincter insufficiency with bulking agent?

INTRODUCTION: Sphincter insufficiency is mostly associated with neurogenic and some structural abnormalities in the pediatric population. As a mini-invasive treatment, urethral bulking agents have been used to treat this problem. OBJECTIVE: The aim was to evaluate if technical success, defined as intraoperative increase in abdominal leak point pressure (ALPP), predicts the outcome of the treatment of sphincter insufficiency with urethral bulking agent. STUDY DESIGN: We reviewed all children treated first time with dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux) for urethral sphincter insufficiency and who intraoperatively had ALPPs measured during 2004-2014. Patient characteristics, change in urinary continence and the duration of the possible response were evaluated in neurogenic and non-neurogenic cases. RESULTS: The median age of the patients was 7.8 years (range 4.1-14.5) at initial treatment and median volume of Dx/HA instilled was 3.5 mL (IQR 2-5). Twelve patients had neurogenic disease and 15 had non-neurogenic disease. Median ALPPs before and after the injections were 19 cmH2O (IQR 14-28) and 70 cmH2O (IQR 48-80), p < 0.001. Increases in ALPPs were similar in both patient groups (p = 0.661) and in 17 patients with any response and 10 patients with no response (p = 0.267). In patients with any response the median duration of the response was only 0.8 years (IQR 0.09-2.0). During a median follow-up of 4.9 years (range 1.7-11.8), 15 patients received one to three repeat injections and eight patients went through sling or bladder neck operation (Summary table). During repeat injections, the preoperative ALPPs had returned to the original levels. Currently, 20% are continent or almost continent with one or more Dx/HA injections. In half of the patients with neurogenic bladder, compliance or volume deteriorated slightly in follow-up. Five out of 15 patients who reached puberty become continent spontaneously after failed bladder neck injection. DISCUSSION: Intraoperative ALPPs increased significantly in most patients during the procedure. However, only 52% of the patients experienced more than 1 month of success after the procedure, and even in those the effect lasted mostly under a year. With one to four injections one-fifth seem to have had a good long-term result. Although the long-term success rate is limited, bulking agent injection allowed the patients with spontaneous voiding to continue it and the injection did not prevent future treatments. CONCLUSION: Intraoperative increased ALPP does not predict a good long-term outcome after Dx/HA injection. At the end, only a fifth of our patients had good result with one or more Dx/HA injections. A change in bladder behavior is possible after treatment.

Prenatal complicated duplex collecting system and ureterocele-Important risk factors for urinary tract infection.

PURPOSE: To evaluate the risk of urinary tract infections (UTIs) in infants with prenatally detected complicated duplex collecting system (CDS) or ureterocele. MATERIALS AND METHODS: All patients with prenatally detected CDS (n=34) or single system ureterocele (n=7) who were admitted to our institution between 2003 and 2013 were enrolled in this retrospective analysis. Duplex collecting systems with ureterocele (n=13), vesicoureteral reflux (VUR) (n=20) or nonrefluxing megaureter without ureterocele (n=7) were determined as complicated. Twenty-six (63%) patients were females. The prevalence of UTI was compared to 66 controls. RESULTS: The median follow-up time was 5.5 (1.7-12.2) years. Eighteen (44%) patients and 3 (5%) controls had at least one UTI (p<0.001) at the median age of 0.8 and 0.4years, respectively (p=0.481). Fifty-seven percent of the UTIs were breakthrough infections and 82% of those were non-Escherichia coli infections. UTIs occurred prior to any surgical intervention in 4/13 (31%) patients with ureterocele, in 2/14 (14%) patients with VUR, in 4/7 (57%) patients with both ureterocele and VUR, and in 3/7 (43%) patients with nonrefluxing megaureter without VUR or ureterocele (p-values 0.012, 0.209, 0.001 and 0.010, respectively, compared to controls). Postoperative UTIs were observed in 29% of the girls and in none of the 11 boys (p=0.072). The incidence of UTI after perforation of ureterocele was only 14%. CONCLUSIONS: Children with prenatally detected ureterocele or duplex collecting system associated with nonrefluxing megaureter are at high risk of UTI despite prophylactic antibiotics. In case of prenatally detected ureterocele we suggest to consider early endoscopic perforation. LEVEL OF EVIDENCE: III.