Outcomes and considerations for retrograde intrarenal surgery (RIRS) in the setting of multiple and large renal stones (>15 mm) in children: Findings from multicentre and real-world setting.

Purpose: The aim of this study is to evaluate the outcomes of retrograde intra renal surgery (RIRS) in the setting of large or multiple stones in children (<18 years). Materials and Methods: Retrospective analysis was performed of paediatric RIRS cases at nine centres worldwide over a 6-year period. Patients were divided into two groups: Group 1 had a single stone <15 mm. Group 2 had either multiple stones, maximum stone diameter of >15 mm, or both. Outcomes included stone free rate (SFR) and complications within 30 days. Results: In total, 344 patients were included with 197 and 147 in Groups 1 and 2, respectively. Ureteric access sheaths were more frequently used in Group 2 (39.5% vs. 56.8%, p = 0.021). The operation time was significantly longer in Group 2 (p < 0.001). SFR after a single procedure was 84.7% in Group 1 and 63.7% in Group 2. Overall complication rates in Groups 1 and 2 were 7.6% and 33.3%, respectively. The most frequently reported complication in both groups was post-operative fever (4.4% vs. 14%, p = 0.004). The rate of Clavien I/II complications in groups 1 and 2 was 6% and 25.1%, respectively (p < 0.05). The rate of Clavien ≥ III complications in groups 1 and 2 was 1.6% and 8.1%, respectively (p < 0.05). On multivariate analysis, total operation time, stone size and multiplicity were significant predictors of residual fragments. Conclusions: RIRS can be performed in paediatric cases with large and multiple stone burdens, but the complication rate is significantly higher when compared to smaller stones.

Mini Endoscopic Combined Intra-Renal Surgery (MiniECIRS) with endoview puncture in A 12 month boy. A safe but challenging procedure.

INTRODUCTION: Associating minipercutaneous nephrolithotomy and retrograde flexible ureteroscopy (fURS) is called Mini Endoscopic Combined Intra-Renal Surgery (miniECIRS). It's a safe and efficient technique, also in children. MATERIAL AND METHODS: The video describes miniECIRS in a 12 month-old boy with an infectious pelvic left stone (16 mm) and multiple caliceal stones. The UAS used was a 10FR and the percutaneous access was a 14Fr with Clear-Petra® sheath. RESULTS: The operative time was 180 min and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 5th day. After 1 month, double J was removed having a stone free status. CONCLUSIONS: MiniECIRS with endoview puncture is a safe and efficient technique when performed by experienced hands. Therefore, it is an alternative to consider for the treatment of complex lithiasis in the pediatric population.

The Utility and Safety of Ureteral Access Sheath During Retrograde Intrarenal Surgery in Children.

OBJECTIVE: To compare retrograde intrarenal surgery (RIRS) with and without ureteral access sheath (UAS) in different pediatric age groups. METHODS: The data of RIRS for kidney stone in children were obtained from 9 institutions. Demographic characteristics of patients and stones, intraoperative and postoperative results were recorded. While analyzing the data, patients who underwent RIRS without UAS (group 1) (n = 195) and RIRS with UAS (group 2) (n = 194) were compared. RESULTS: Group 1 was found to be young, thin, and short (P <.001, P = .021, P <.001), but there was no gender difference and similar symptoms were present except hematuria, which was predominant in group 2 (10.6% vs 17.3%, P <.001). Group 1 had smaller stone diameter (9.91 ± 4.46 vs 11.59 ± 4.85 mm, P = .001), shorter operation time (P = .040), less stenting (35.7% vs 72.7%, P = .003). Re-intervention rates and stone-free rates (SFR) were similar between groups (P = .5 and P = .374). However, group 1 had significantly high re-RIRS (P = .009). SFR had a positive correlation with smaller stone size and thulium fiber laser usage compared to holmium fiber laser (HFL) (P <.001 and P = .020), but multivariate analysis revealed only large stone size as a risk factor for residual fragments (P = .001). CONCLUSION: RIRS can be performed safely in children with and without UAS. In children of smaller size or younger age (<5 years), limited use of UAS was observed. UAS may be of greater utility in stones larger than 1 cm, regardless of the age, and using smaller diameter UAS and ureteroscopes can decrease the complications.

Worldwide trends of practice and intervention in paediatric endourology: comparison of European versus Non-European responses.

Introduction: The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise. Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients. Material and methods: The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia. The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM). Results: 221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries). In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice. Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists. 12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists. Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)]. Conclusions: Treatment of paediatric stones can vary according to country and legislations. Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular. In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.

Comparison of Low-Power vs High-Power Holmium Lasers in Pediatric Retrograde Intrarenal Surgery Outcomes.

Objectives: To compare the outcomes of using low-power (up to 30 W) vs high-power (up to 120 W) holmium lasers in retrograde intrarenal surgery (RIRS) in children and to analyze if lasering techniques and the use of access sheath have any influence on the outcomes. Methods: We retrospectively reviewed data from 9 centers of children who underwent RIRS with holmium laser for the treatment of kidney stones between January 2015 and December 2020. Patients were divided into two groups: high-power and low-power holmium laser. Clinical, perioperative variables and complications were analyzed. Outcomes were compared between groups using Student's t-test for continuous variables, and Chi-square and Fisher's exact test for categorical variables. A multivariable logistic regression analysis model was also performed. Results: A total of 314 patients were included. A high-power and low-power holmium laser was used in 97 and 217 patients, respectively. Clinical and demographic variables were comparable between both groups, except for stone size where the low-power group treated larger stones (mean 11.11 vs 9.70 mm, p = 0.018). In the high-power laser group, a reduction in surgical time was found (mean 64.29 vs 75.27 minutes, p = 0.018) with a significantly higher stone-free rate (SFR) (mean 81.4% vs 59%, p < 0.001). We found no statistical differences in complication rates. The multivariate logistic regression model showed lower SFR in the low-power holmium group, especially with larger (p = 0.011) and multiple stones (p < 0.001). Conclusion: Our real-world pediatric multicenter study favors high-power holmium laser and establishes its safety and efficacy in children.

Are weight or age limits for pediatric laparoscopic pyeloplasty? Results of a multicentric study.

INTRODUCTION: Anderson-Hynes pyeloplasty is the technique of choice for the treatment of pyeloureteral junction obstruction (PUJO) with an excellent success rate. Minimally invasive surgery has become the standard of care for the management of PUJO in children. Although it has been comparable to the open approach at all levels, its diffusion or employment in younger children has not been widely adopted. Our aim is to evaluate laparoscopic pyeloplasty outcomes from international academic centers in children under 1 year of age, focusing on feasibility and outcomes including possible complications. MATERIALS AND METHODS: This is review of consecutive infants under 1 year of age who underwent laparoscopic pyeloplasty between 2009 and 2018 with more than 12 months of follow-up. Seven different training centers with different backgrounds participated in this study. Evaluation was carried out with ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications, and results are described and analyzed. RESULTS: Over 9 years, 124 transperitoneal laparoscopic Anderson-Hynes pyeloplasties were performed on 123 children under 1 year of age; 88 males and 35 females, with 1 case of bilateral PUJO. Of the 124 renal units, 86 were left-sided. Mean age at surgery was 6.6 months (1 week-12 months), with 56% (n = 70) done before 6 months of age. Mean weight at surgery was 6.8 kg (3-12 kg), with 59% (n = 73) weighing less than 8 kg. Mean operative time (skin-to-skin) was 150 min (75-330 min). After a mean follow-up of 46 months (12-84 months), 12 (9%) patients developed complications, with only 1 needing a redo pyeloplasty also done laparoscopically. One child, with deterioration in renal function, underwent nephrectomy. CONCLUSION: Laparoscopic pyeloplasty under 1 year of age and/or less than 12 kilos is feasible with lower complication rate. Furthermore, age younger than 6 months and weight less than 8 kg are no longer limiting factors for a successful pyeloplasty as shown by this multicentre study.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children.

PURPOSE: The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. MATERIALS AND METHODS: A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. RESULTS: Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). CONCLUSION: We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Retrorenal colon in pediatric patients with urolithiasis: Is the supine position for PCNL advantageous?

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is one of the main approaches for the treatment of large and complex stones in pediatric patients. The patient position for PCNL has been classically divided into prone or supine and the prone position is more commonly used. One of the most feared complications of this surgical technique is colon injury and the objective of this work is to evaluate the incidence of retrorenal colon (RRC) both supine and prone position, in pediatric patients, through radiological images. MATERIALS AND METHOD: A retrosepctive review was performed of all abdominal CT scans performed in one center, in patients under 18 years since 2017 to 2019. The ideal path for percutaneous puncture was traced in the upper, middle, and lower calyces of both kidneys in the prone and supine positions and contact with the kidney and adjacent organs was evaluated, with a uro-radiologist. Chi-square test and Student's t test were applied. RESULTS: 50 CT-scans were performed on 44 children. Patients had a mean age of 12.6 years and 71.4% were male. Twenty-five scans were performed in the prone and 25 in the supine position. The incidence of RRC for the left kidney (LK) was significantly higher in the lower calyx in prone position than in the supine position, 28% vs 4% (p = 0.049), and the right kidney (RK) presented RRC only in the prone position. The liver was the most frequent retrorenal organ (97.7%) for the RK, with a non-significant difference by position, while for the LK the spleen was the most frequent (61.1%). DISCUSSION: Colon injury is one of the most morbid complication in PCNL and one of the reasons to perform a CT scan before surgery, on which its incidence appears to be <1% in adults. The present study revealed RRC to be present in three (12%) patients in the supine position and seven (28%) patients in the prone position (p=0.15). These results were slightly higher from those reported in adults (supine: 1.7%-10%; prone: 6.8%-20%), but there are no reports in the literature on this issue to allow appropriate comparison. This is the first study to attempt to assess the incidence of RRC in children according to position. CONCLUSION: The incidence of RRC for an ideal puncture was significantly higher in the lower calyx of the left kidney in the prone position than in the supine position, and in the right kidney, the RRC only occurred in the prone position.

Robotic retroperitoneal lymphadenectomy in paratesticular rhabdomyosarcoma.

INTRODUCTION: Paratesticular sarcoma is an aggressive malignant tumor of mesenchymal origin. The rhabdomyosarcoma is the most common among children. Rhabdomyosarcoma treatment consists of surgery, chemotherapy and radiotherapy. Prognosic depends on local recurrence and distant metastasis. MATERIAL AND METHODS: We present the case of a 16-year-old male, who in April 2016 underwent right radical orchiectomy surgery by testicular mass rapidly evolving, with pathological results indicating a paratesticular rhabdomyosarcoma. The extension study showed a precaval adenopathy suggestive of lymph node metastasis, therefore it was a high-grade rhabdomyosarcoma. There was an appropriate response after chemotherapy (Protocol EpSSG RMS2005) and we decided to perform a robotic lymphadenectomy. RESULTS: We performed a transperitoneal approach with 8 mm trocar and 12 mm optica trocar. We accessed the retroperitoneal space through a latero-colic incision. Then we performed a craniocaudal lymph node dissection until the aortic bifurcation. The surgical time was 240 min with a blood loss of 200 ml. There were no complications. The patient was discharged on the fourth day after surgery. Pathology showed metastasis of rhabdomyosarcoma without capsular rupture. After two months, we placed the left testicle into inguinal canal prior to radiotherapy. CONCLUSIONS: Robotic lymph node metastasis lymphadenectomy from paratesticular sarcomas is a feasible treatment with the advantage of minimally invasive surgery and acceptable morbidity.

Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in the pediatric population: the initial experience of two tertiary referral centers.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study was to assess the safety and feasibility of semi-closed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients. METHODS: From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra® (Well Lead Medical Co., Ltd., Guangzhou, China) access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~120-150 cmH2O) by a 200 Ml plastic stone collector. Pre-, intra- and postoperative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments >4 mm with either ultrasound or kidney, ureter, and bladder X-ray. RESULTS: Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Postoperative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €). CONCLUSIONS: The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Ultra-mini Pcnl with clear Petra® suction-evacuation access sheath and warming irrigation fluid system (Rocamed®) for stone treatment in children.

INTRODUCTION: Inadvertent perioperative hypothermia (a drop in core temperature to below 36 °C) occurs because of interference with normal temperature regulation by anaesthetic drugs, skin exposure for prolonged periods and the introduction of large volumes of intravenous and irrigation fluids. If the temperature of these fluids is below core body temperature, they can cause significant heat loss. Warming irrigation fluids might prevent some of this heat loss and subsequent hypothermia and that is the role of warming irrigation fluid systems. MATERIAL AND METHODS: The video describes prone ultra mini PCNL with suction-evacuation access sheath under warming irrigation fluid system in a 15 month-old boy with a 2 cm-600HU staghorn calculi and one stone of 7 mm-500HU in proximal ureter. RESULTS: The surgery was performed without intraoperative complications and perioperative hypothermia was prevented. The patient started the surgery at 35.4 °C and the final temperature was 36.3 °C in 90 min of procedure, in addition to being free of stones. CONCLUSIONS: The warming irrigation fluid system can be helpful in preventing inadvertent perioperative hypothermia in children, improving the safety of ultra mini PCNL with suction-evacuation access sheath and shows promising results with high stone-free rates and low complications.

Sexuality of Female Spina Bifida Patients: Predictors of a Satisfactory Sexual Function.

OBJECTIVE: To assess the sexual function of women with spina bifida (SB), and to verify the factors that influence their sexual function. METHODS: A cross-sectional study in which a validated female-specific questionnaire was applied to 140 SB female patients from four different cities (Porto Alegre, Brazil; and Barcelona, Madrid, and Málaga, Spain) between 2019 and 2020. The questionnaires collected data on the clinical characteristics of SB, and female sexual function was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) validated to Portuguese and Spanish. RESULTS: Half of the patients had had sexual activity at least once in the life, but most (57.1%) did not use any contraception method. Sexual dysfunction was present in most (84.3%) patients, and all sexual function domains were impaired compared those of non-neurogenic women. The presence of urinary and fecal incontinence significantly affected the quality of their sexual activity based on the FSFI-6. CONCLUSION: The specific clinical aspects of the SB patients, such as urinary and fecal incontinence, should be properly addressed by their doctors, since they are associated with reduced sexual activity and lower FSFI-6 scores in the overall or specific domains. There is also a need to improve gynecological care among sexually-active SB patients, since most do not use any contraceptive methods and are at risk of inadvertent pregnancy.

OBJETIVO: Analisar a função sexual de pacientes do sexo feminino com espinha bífida (EB), e avaliar quais fatores influenciam na função sexual. MéTODOS: Uma pesquisa transversal em que um questionário validado para mulheres foi aplicado em 140 pacientes com EB de quatro cidades diferentes (Porto Alegre, Brasil; e Barcelona, Madri e Málaga, Espanha) entre 2019 e 2020. Os questionários coletaram dados sobre características clínicas da espinha bífida, e a função sexual feminina foi avaliada com a versão de seis itens do Índice de Funcionamento Sexual Feminino (IFSF-6) nas versões validadas para português e espanhol. RESULTADOS: Metade das pacientes havia praticado atividade sexual pelo menos uma vez na vida, mas a maioria (57.1%) não utilizava nenhum método contraceptivo. A disfunção sexual estava presente na maioria das pacientes (84.3%), sendo todos os domínios de função sexual prejudicados em comparação com os de mulheres não neurogênicas. A presença de incontinência urinária e fecal afetou significativamente a qualidade da atividade sexual das pacientes. CONCLUSãO: Aspectos clínicos específicos da EB, como incontinência urinária e fecal, devem ser adequadamente abordados pelos médicos assistentes, visto que estão associados à redução na atividade sexual e piores resultados no IFSF-6. Também é necessário melhorar o atendimento ginecológico das pacientes sexualmente ativas, uma vez que a maioria não utiliza métodos contraceptivos e corre o risco de gravidez inadvertida.

Sexuality of Female Spina Bifida Patients: Predictors of a Satisfactory Sexual Function / Sexualidade feminina em pacientes com espinha bífida: preditores de uma função sexual satisfatória

Abstract Objective To assess the sexual function of women with spina bifida (SB), and to verify the factors that influence their sexual function. Methods A cross-sectional study in which a validated female-specific questionnaire was applied to 140 SB female patients from four different cities (Porto Alegre, Brazil; and Barcelona, Madrid, and Málaga, Spain) between 2019 and 2020. The questionnaires collected data on the clinical characteristics of SB, and female sexual function was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) validated to Portuguese and Spanish. Results Half of the patients had had sexual activity at least once in the life, but most (57.1%) did not use any contraception method. Sexual dysfunction was present in most (84.3%) patients, and all sexual function domains were impaired compared those of non-neurogenic women. The presence of urinary and fecal incontinence significantly affected the quality of their sexual activity based on the FSFI-6. Conclusion The specific clinical aspects of the SB patients, such as urinary and fecal incontinence, should be properly addressed by their doctors, since they are associated with reduced sexual activity and lower FSFI-6 scores in the overall or specific domains. There is also a need to improve gynecological care among sexually-active SB patients, since most do not use any contraceptive methods and are at risk of inadvertent pregnancy.

Resumo Objetivo Analisar a função sexual de pacientes do sexo feminino com espinha bífida (EB), e avaliar quais fatores influenciam na função sexual. Métodos Uma pesquisa transversal em que um questionário validado para mulheres foi aplicado em 140 pacientes com EB de quatro cidades diferentes (Porto Alegre, Brasil; e Barcelona, Madri e Málaga, Espanha) entre 2019 e 2020. Os questionários coletaram dados sobre características clínicas da espinha bífida, e a função sexual feminina foi avaliada com a versão de seis itens do Índice de Funcionamento Sexual Feminino (IFSF-6) nas versões validadas para português e espanhol. Resultados Metade das pacientes havia praticado atividade sexual pelo menos uma vez na vida, mas a maioria (57.1%) não utilizava nenhum método contraceptivo. A disfunção sexual estava presente na maioria das pacientes (84.3%), sendo todos os domínios de função sexual prejudicados em comparação com os de mulheres não neurogênicas. A presença de incontinência urinária e fecal afetou significativamente a qualidade da atividade sexual das pacientes. Conclusão Aspectos clínicos específicos da EB, como incontinência urinária e fecal, devem ser adequadamente abordados pelos médicos assistentes, visto que estão associados à redução na atividade sexual e piores resultados no IFSF-6. Também é necessário melhorar o atendimento ginecológico das pacientes sexualmente ativas, uma vez que a maioria não utiliza métodos contraceptivos e corre o risco de gravidez inadvertida.

Pregnancy in Pateints With Exstrophy-Epispadias Complex: Are Higher Rates of Complications and Spontaneous Abortion Inevitable?

OBJECTIVE: To report on the characteristics of pregnancy in female patients with EEC (exstrophy-epispadias complex), determining in particular whether they are at higher risk of spontaneous abortion or complications. MATERIALS AND METHOD: Fifty patients diagnosed with EEC and treated in a reference center for this pathology were reviewed. Those with an incomplete medical history were excluded, leaving a total of 37 women with a median follow-up of 26 years (1-48 years). The outcome measurements were successful pregnancies, miscarriages, urological, gynecological and obstetric complications, impaired renal function, newborn characteristics, and postpartum urogynecological complications. Descriptive statistics was used. RESULTS: Eight patients achieved 17 pregnancies (88.2% spontaneous). Of these pregnancies, 10 (58.8%) were successful, while 7 (41.2%) terminated in miscarriages. Urinary tract infection (UTI) was the most frequent complication (41.6%) and intestinal occlusion was the most severe. A total of 62.5% of the patients presented genital prolapses after pregnancies. A total of 85.7% of patients were dry during the follow-up after their pregnancies. No newborn presented EEC or any other type of malformation. Our study has the limitation of being a retrospective review of a very heterogeneous and small group of patients. CONCLUSION: EEC patients can achieve spontaneous pregnancies but have an increased risk of miscarriage. For this reason, monitoring and control by a specialized and integrated multidisciplinary team is required to minimize complications.

The impact of neurogenic bladder bowel dysfunction in the sexuality of female spina bifida patients.

INTRODUCTION: The sexual life of Spina Bifida (SB) women may be affected by their physical impairments. Data has consistently associated symptoms such as urinary and fecal incontinence with negative effects on social and intimate life. OBJECTIVE: To analyze the female spina bifida patient sexual life and assess which factors - including bladder bowel dysfunction and bladder augmentation - influenced in the sexual function of patients in a multi-center cross-sectional study. STUDY DESIGN: A cross-sectional survey with validated female-specific questionnaire was applied in 140 spina bifida female patients from four different cities (Porto Alegre/Brazil; Barcelona, Madrid and Málaga/Spain) between 2019 and 2020. Questionnaires collected data on spina bifida clinical characteristics and sexuality, which was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) in the Portuguese and Spanish validated versions. Female sexual dysfunction was defined as a FSFI-6 total score ≤19. RESULTS: Sexual dysfunction was present in most (84.3%) patients with a median overall FSFI-6 total score of 14.5 (range 4-26), being all sex domains impaired. Bladder augmentation, type of spina bifida, spinal cord level, hydrocephalus, use of wheelchair and psychological disorder were not statistically associated with differences among rates of sexual activity or female sexual dysfunction. The presence of urinary incontinence (UI) showed both significant lower sexual intercourse and higher dysfunction rates (Summary Table). Urinary and fecal incontinence were significantly associated with worst scores in all domains, except for pain. DISCUSSION: Urinary incontinence status was the most relevant factor since it impaired either female sexual dysfunction and sexual activity rates, as well as the FSFI-6 overall and specific domains. These findings are consistent with previous studies who also observed that desire, arousal and lubrication domains had negative effects from urinary loss on SB patients. Fecal incontinence status did not influenced in sexual activity of female sexual dysfunction rates, nevertheless it promoted lower scores in the overall and specific sexual domains. CONCLUSION: Spina bifida is a complex condition that demands proper care to achieve a satisfactory sexual life, specially regarding neurogenic bladder and bowel dysfunction. Clinical aspects in the SB patient, such as urinary and fecal incontinence, should be properly addressed by pediatric urologists since they are associated with female sexual dysfunction and reduced sexual activity, as well as lower FSFI-6 scores in the overall and specific domains. There is also a need to improve communication about sexuality, because only 18.6% of the patients considered it that had received sufficient sex information from physicians.

Assessment of sexual life in spina bifida patients: A survey among pediatric urologists.

OBJECTIVE: To assess the status of the sexual education approach with spina bifida (SB) patients. MATERIALS AND METHODS: An online survey was sent to 223 pediatric urologists from Latin countries, all contacted using email or mobile messaging software. There were 12 questions about participants' demographic characteristics and SB-specific care topics. Data was collected from January 2019 to January 2020. Checklist for reporting results of internet e-survey (CHERRIES) guidelines were followed to ensure the quality of this study. RESULTS: We received 101 valid answers from participants practicing in seven different countries. Among these, 98.4% confirmed that sexuality in the SB population is considered relevant, nevertheless it is only evaluated by 62.5%. Transitional urologists discuss sexuality more often than those whose practice consists solely of pediatric patients (70% vs. 50%). Basic surgeon training (urologist vs. pediatric surgeon), age, part or full-time pediatric urology practice and country of participants were of no statistically different influence inrates of approach to sexuality. CONCLUSION: Our study demonstrates that pediatric urologists are insufficiently addressing sexuality in SB patients. Those who practise transitional urology show higher rates of approach to sexuality with SB patients, which suggests this is an important model of care.

Autologous fat grafting with stem cell transplantation in an exstrophic patient. A case.

INTRODUCTION: Lipofilling has been used in plastic surgery for breast reconstruction and treatment of burns. Carrying out minimally invasive techniques would allow treatment of hypertrophic scars and depressed suprapubic area in exstrophic patients to improve their aesthetic appearance. MATERIAL AND METHODS: This video presents the case of a female 16 year old patient with bladder exstrophy, who initially had an urinary reconstruction with ureterosigmoidostomy and posteriorly bladder augmentation and Mitrofanoff, with hypertrophic scars and depressed abdominal wall in suprapubic area. We present this procedure for autologous fat grafting with stem cells in the abdominal area. RESULTS: The lipofilling procedure was carried out successfully, without intraoperative complications in 120 min. The liposuction was 250 cc and 80 cc was used for injection, achieving the improvement of the aesthetic appearance of the scars in a short time. The imaging control was follow up with abdominal wall ultrasound, three months later, increasing its thickness by 42%. CONCLUSION: The autologous fat grafting with stem cells is a safe and feasible procedure in the exstrophic population, with excellent aesthetic results, but we need long term follow ups to determine how long the effect of fat grafting remains.

Novel Plicating "Wrap" Technique for Treating Anterior Urethral Ballooning.

OBJECTIVE: To describe an original approach, inspired by the technique proposed by Kalicinsky, which has the advantages of not requiring opening of the urethra, modeling the urethra to a suitable caliber without urethral anastomosis and providing the urethra with a solid and stretchable ventral support. MATERIALS AND METHODS: We operated on 3 cases of anterior urethral ballooning between November 2013 and June 2014. Retrograde and micturition urethrography ruled out any urethral anastomosis and disclosed the ballooning. A 10-F silicone catheter was placed in all 3 cases with the purpose of monitoring the tailoring. Complete dissection of the urethral "sac" was carried out regarding circumference and length, and the result was a normal urethra with respect to both the penoscrotal angle and the glans. Urethral tapering was then undertaken with a continuous 5-0 polyglactin suture, which produced a straight urethra just a little wider than the previously placed monitoring catheter. The remnants of the dilated urethra were wrapped around the urethra with the aid of 2 traction stitches. Urethral tailoring was completed with a longitudinal suture that fixed the wrap. The urethral catheter was left 1 week after. RESULTS: The children urinated without problems and with a good micturition jet that remained unaltered over the ensuing months. CONCLUSION: A novel technique for treating a rather infrequent pathology has been described. The reported technique is simple and reproducible, and our 3 cases had excellent cosmetic and functional results.

Quality of life in female patients with bladder exstrophy-epispadias complex: Long-term follow-up.

INTRODUCTION: Bladder exstrophy-epispadias complex (BEEC) is a congenital malformation that requires multiple surgeries during childhood and life-long follow-up. It often presents with conditions that have the potential to impact quality-of-life (QoL) and psychosocial functioning of affected patients, such as incontinence and sexual dysfunction. The aim of this study is to examine the QoL, urinary continence, sexual function, and overall health in a long-term series of female patients with BEEC. METHOD: A retrospective review was performed of female patients with BEEC born between 1964 and 1996. Thirty-three patients were asked to complete four validated questionnaires to evaluate their QoL regarding urinary continence and sexual activity (ICIQ, Potenziani-14, and PISQ-12 questionnaires). Nineteen patients completed and returned the questionnaires. The overall QoL was assessed with the SF-36 questionnaire, and demographics were evaluated. Statistical analysis was performed to compare the general QoL with that of the general population. RESULTS: The median age of the patients was 26 years (range 18-50) (Table). A low to moderate impact of urinary incontinence on QoL was reported by 30% of patients in the ICIQ. Also as a result of urinary incontinence, 84% of patients reported a moderate to severe impact on their sexual lives. Twelve patients got married with eight gestations and five births. SF-36 reported general QoL comparable with that of the general population in five out of eight items. Differences were seen in the mental health, emotional role, and physical functioning items (p < 0.001). The main factors for the differences were poor body image, anxiety, and urinary incontinence. A satisfactory social life was reported by 70% of patients. CONCLUSION: Questionnaire studies on BEEC consistently report a high rate of patients not answering, 43% in the present study. The rarity of the disease determines a small sample size, which diminishes statistical power and could potentially conceal small differences with controls. Despite these limitations, the present findings are consistent with previous studies on BEEC with validated QoL questionnaires: adult women with BEEC suffer psychosocial impact mainly from incontinence, and also from gynecological complications, but their resilience and coping mechanisms allow them to achieve a quasi-normal QoL. Female patients with BEEC reported a normal QoL in five of eight items in the SF-36 questionnaire. Urinary incontinence was the main factor for the moderately decreased QoL according to specific questionnaires.

Mini-percutaneous nephrolithotomy with high-power holmium YAG laser in pediatric patients with staghorn and complex calculi.

INTRODUCTION: Shock wave lithotripsy (SWL) is the treatment of choice for most cases of renal lithiasis in children. Some cases, however, are refractory to SWL and may be associated with anatomic and metabolic changes or a large stone burden. In these circumstances, mini-percutaneous nephrolithotomy (mini-PCNL) is an option. OBJECTIVE: The aim was to assess the safety and efficacy of high-power holmium YAG (Ho:YAG) laser in mini-PCNL for staghorn calculi. PATIENTS AND METHODS: The clinical records relating to 35 mini-PCNLs (Table) performed between January 2008 and December 2012 in 33 patients (27 boys and 6 girls; mean age 7 years, range 2-18 years) were retrospectively reviewed. Twenty-two (66.7%) of the patients had undergone a previous SWL (28.6% three sessions). The mini-PCNL puncture technique used involved fluoroscopic guidance with the C arm at 0-90° in the supine position. An 18F tract was used. Stone fragmentation was performed with a high-power Ho:YAG laser (Lumenis 100 W). RESULTS: Ten of the mini-PCNLs (28.6%) were right sided, and 25 were left sided (71.4%). Stones were located in the lower calyceal group in 64% of patients and in the renal pelvis in 50%. The mean stone size was 4.46 cm(2) (range 3-13.20 cm(2)). The number of stones varied between one and 20, and 83.3% were radiopaque. The laser was set at 70 W (range 50-100 W) (3.5 J/pulse with a frequency of 20 pulses/s). The mean surgical time was 150 min. In 78% of patients, complete stone clearance was achieved, and the overall stone-free rate rose to 85% when residual stones were treated with either SWL or retrograde intrarenal surgery. No perioperative complications were seen. DISCUSSION: There are few reports in the literature concerning the use of a high-power laser for treatment of complex stones and the few that do exist relate to adults have similar results, showing it to be highly effective and safe, with low morbidity. Some limitations of the present study must be acknowledged. It was retrospective and a relatively small number of patients were included. However, randomized prospective studies are required to confirm our findings and conclusions. CONCLUSION: In the pediatric population, mini-PCNL with high-power Ho:YAG laser is feasible and safe and represents the technique of choice for complex renal stones.