Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society.

BACKGROUND: The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. METHODS: We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. RESULTS: we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9 ± 4.7 years (mean ± SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1 ± 8.2 years (mean ± SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3ß-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. CONCLUSIONS: Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients.

OBJECTIVE: To evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot-assisted approaches. MATERIALS AND METHODS: Retrospective review of all pediatric laparoscopic and robot-assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR, LVCUR, LDECUR, RALUR, and RADECUR. RESULTS: One thousand three hundred forty-three patients (490 boys and 853 girls) with a median age of 30 months (IQR 12-63) were treated at 13 centers. Nine hundred and eight patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). Four hundred thirty-five (32%) had a surgery due to ureterovesical junction (UVJ) obstruction. Mean length of follow-up was 14 months (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (P = .45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. Six patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent voiding cystourethrography postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm, respectively. Grade 3 complications occurred in 17 (1.2%) and 8 (0.5%) in both arms, respectively. Surgical success was achieved in 96% of patients. CONCLUSION: Laparoscopic and robot-assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot-assisted approach is beneficial in terms of operative time, intracorporeal suturing, and lower complications rate.

Robotic-Assisted Laparoscopic Pyeloplasty in Challenging Cases of Ureteropelvic Junction Obstruction in the Pediatric Population: A Multicenter Review.

Purpose: To report a multi-institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes. Materials and Methods: Retrospective chart review of all pediatric patients who underwent robotic-assisted laparoscopic pyeloplasty (RALP) for UPJO in challenging cases between 2013 and 2021 was included. Demographics, perioperative surgical data, complications, and results are described. Challenging cases were defined as bilateral UPJO, failure of previous open pyeloplasty (thus re-do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis, and low-weight infants (<6 kg). Results: Over an 8-year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. Fifteen patients underwent RALP for recurrent UPJO; among them, 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing <6 kg, 3 cases of huge hydronephrosis, and 2 cases of bilateral UPJO. The median age and weight were 36 months (interquartile range [IQR] 14-84) and 12 kg (IQR 10-20.5), respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90-135). The mean length of hospital stay was 2.6 days. Four patients (17%) had postoperative complications-1 ileus (Clavien-Dindo grade [CDG] I) and 3 urinary tract infections (CDG II). No CDG III or higher complication was encountered. At a median follow-up of 36 months, the success rate was 95% with 1 patient requiring another re-do procedure due to recurrent obstruction. Conclusions: Our data suggest that RALP is safe and effective even for challenging cases of UPJO in children.

Long term results of non-refluxing ureteral reimplantation in the pediatric population.

PURPOSE: To evaluate the long-term results of UR and to determine the difference between patients with VUR and OMU in terms of re-obstruction rate, complications associated with pregnancy, and de novo reflux. METHODS: Two-site retrospective study with 69 patients (36 females and 33 males) with a mean age of 5 ± 3.4 years. Fifty-nine (85.5%) underwent UR due to VUR and 10 (14.5%) due to OMU. Mean length of surgery and hospitalization was 90 ± 29.2 min and 9 ± 2.4 days, respectively. RESULTS: Eight (13.5%) patients with VUR suffered from febrile UTI with a mean of 2.1 ± 1.3 events. In the OMU group, 1 (10%) patient suffered from febrile UTI. None of the patients showed recurrence, obstruction or de novo VUR. Two patients (20%) with OMU suffered from CKD. In the VUR group, 3 (5.1%) patients suffered from CKD. Three women suffered from UTIs during pregnancy. Mean follow-up was 17.5 ± 4.6 years. CONCLUSIONS: Successful UR is associated with a decreased rate of febrile UTI in patients with VUR. Patients with OMU maintained and improved renal function in the long term. None demonstrated technical failures in the long term. Patients who presented with bilateral VUR are more prone to developing major complications.

Medical clowns versus sedation for paediatric urinary catheter insertion-A randomised pilot study.

AIM: To investigate the potential benefits of medical clowns (MCs) in reducing anxiety and pain during paediatric urinary catheter insertion. METHODS: In this prospective pilot study, 51 children who required urinary catheter insertion were randomised into two groups; the first group (n = 29) underwent the procedure in the presence of a MCs, and the second control group (n = 22) underwent the procedure using sedation. Pain and anxiety levels as well as procedural duration were recorded. All procedures were filmed and evaluated for anxiety level by a paediatric psychiatrist. General satisfaction questionnaires were filled by the medical team and parents in the clown group. RESULTS: There were no differences in pain scores or anxiety levels between the two groups. Procedure duration and total hospital stay were significantly shorter in the MC group (p < 0.001). One hundred percent of the parents and the medical team were in favour of incorporating MCs during urinary catheter insertion. CONCLUSION: MCs are as good as sedation in lowering anxiety and pain levels in children undergoing urinary catheter insertion. In addition, MCs reduce the duration of the procedure and elicit a high degree of overall satisfaction from the parents and medical team.

Surgical Treatment of Meatal Stenosis: Lessons Learned from the Pediatric Urology Practice.

OBJECTIVE: To evaluate the indications for surgery and outcome of meatotomy and meatoplasty in a big cohort of children. METHODS: We retrospectively evaluated 2211 children who underwent either meatotomy or meatoplasty between 2009 and 2020 utilizing the same operative setup. For continuous data, we performed t-test and Mann-Whitney U test. For categorical data, chi-squared test or Fisher's exact test was used. A binary logistic regression model was used to compare the indications for surgery between the groups. RESULTS: Of 2211 children, 1906 underwent meatotomy and 305 meatoplasty. The mean age was 5 years (range: 1m-15y) and there was no age difference between the groups. There was no difference between duration of surgery, recovery time, or complication rates between the groups. Deviated stream was the most frequent indication for treatment 1477 (67%). On Univariate logistic regression children with the following indications: dysuria, meatitis, and urinary retention had increased odds toward meatoplasty, while the indication of deviated stream had increased odds toward meatotomy. On Multivariate Logistic regression only deviated stream (Odd-ratios 1.47, P: .005) and urinary retention (Odds-ratio 4.5, P: .027) remained significant for meatotomy and meatoplasty respectively. Eleven (0.58%) children who underwent meatotomy developed recurrent Urethral Meatal Stenosis and underwent another surgery. Sixty-nine children (3.6%) after meatotomy required manual opening of the meatus on the first post-operative visit. None of the children, who underwent meatoplasty needed reoperation. CONCLUSION: Meatotomy had a higher reoperation rate and frequently required manual meatal spreading in early postoperative period. We believe meatoplasty is a preferable surgery for pediatric UMS.

Current management of the urachal anomalies (UA). Lessons learned from the clinical practice.

PURPOSE: It has been suggested that symptomatic UA requires surgical excision. However, the management of asymptomatic urachus is still controversial. We aimed to evaluate the clinical presentation, the efficacy of current modalities used, and postoperative pathology in patients with UA. MATERIALS AND METHODS: We have performed a retrospective review of all patients diagnosed with UA and treated surgically or conservatively over 18 years. Demographic data, clinical presentation, imaging modalities, pathology, treatment, and postoperative complications were analyzed. RESULTS: Twenty-five symptomatic patients (18 males and seven females) with a median age of 13 years (1 month to 37 years) were identified. 15 (60%) were diagnosed with a urachal cyst, 4 (16%) with sinus, 3 (12%) with urachal diverticulum, and the remaining 3 (12%) with patent urachus. Of those, 20 (80%) underwent surgical repair, and the remaining five (20%) patients were managed conservatively. 4 (20%) underwent laparotomy, 7 (35%) laparoscopic incision, and the remaining 9 (45%) laparoscopic robotic-assisted surgery. Nine patients required bladder cuff excision. The median operative time was 75 min (42-140 min). One patient developed Clavien-Dindo grade IIIA complication resulting in infected hematoma, which resolved after drainage. Another patient with a complication of grade IIIB needed reoperation as a result of recurrent events of an abscess. 13 (65%) demonstrated epithelium lining of the urachus on postoperative pathology. CONCLUSIONS: Our data show that most of the patients with UA presented with epithelial lining, which might lead to the later malignant transformation. It might cause a shift from the conservative management of asymptomatic patients to surgical intervention. Robotic-assisted surgery appears beneficial in these patients, especially when the bladder cuff excision is required.

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE: To review our experience with quadratus lumborum block (QLB) in pediatric urology. MATERIALS AND METHODS: This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry. RESULTS: There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction. CONCLUSION: Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience.

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

Does Renal Function Remain Stable after Puberty in Children who underwent Ureteral Reimplantation due to Ureterovesical Junction Obstruction?

INTRODUCTION: Ureteric reimplantation due to ureterovesical junction (UVJ) obstruction enjoys high success in the short term. However, renal function after reimplantation must accommodate the numerous changes in the pediatric urinary tract that occur along with child development that may theoretically cause an occult loss of renal function. The purpose of this study was to evaluate whether improved renal function after ureter reimplantation for antenatal diagnosed UVJ obstruction remains stable after puberty. MATERIALS AND METHODS: Twenty-one children who underwent open reimplantation using Politano-Leadbetter technique were followed until they completed puberty. Mean age at surgery was 14.3 months (range: 3-60 months). Five (23.8%) of 21 children had right hydronephrosis, 13 (61.9%) had left hydronephrosis, and 3 (14.3%) had bilateral hydronephrosis. The Society for Fetal Urology (SFU) level of the hydronephrosis was 3 (47.6%) in 10 children and 4 (52.4%) in remaining 11. Fourteen (66.6%) patients had poor renal function upon surgery and the remaining seven (33.4%) patients had moderate renal function. The mean renal function upon operation was 28 ± 4.3 (mean ± standard deviation [SD]). RESULTS: Reimplantation led to the increase in the RRF in the short-term period from 28 ± 4.3% prior to the surgery to 36.4 ± 5% (p < 0.001) in all patients and remains stable 35 ± 5% after puberty in all the reviewed patients. CONCLUSION: Our data demonstrate for the first time that successful ureteral reimplantation following antenatal diagnosis of UVJ obstruction is associated with an improvement in renal function, not only during short- and midterm follow-up but also allows preserving the renal function throughout the puberty period.

Learning curve of robotic-assisted laparoscopic pyeloplasty (RALP) in children: how to reach a level of excellence?

It has been suggested that up to 40 cases of RALP are required to reach the operative results equal to open surgery. We have hypothesized that previous experience in open and laparoscopic surgeries might shorten the learning curve of robotic surgery. We have retrospectively evaluated the data of all children who underwent pyeloplasty in our institute by a single surgeon since 2003. The children were divided into three groups: open pyeloplasty (OP) of 72 children, laparoscopic pyeloplasty (LAP) of 22, and RALP of 33 patients subsequently. The data included: demographics, duration of surgery, length of stay, success of surgery, and complication rate according to the Clavien-Dindo score. The groups were ordered chronologically by the operation date and each group was divided into two different phases: early and late. A comparison was made between the data of the early and the late phase. There was no difference in the demographic data between the groups; however, the patients who underwent laparoscopic surgery were significantly older compared with the patients from the other groups. The median duration of surgery in the RALP group was significantly shorter than the OP group (65 min vs 72.5 min P < 0.01), while the first RALP case was already shorter than the median duration of surgery in OP group. There was no significant decrease in the duration of surgery of the RALP group over the study period, though there was a significant trend of decreasing operative time in the OP and LAP groups. There was no difference in the length of stay in the early vs late phases in the RALP group. There was no difference in the complication and success rate between the RALP and OP group, as well as the early and late phases of the RALP group. Our data show that previous experience in OP and LAP surgery may contribute to a shorter learning curve of robotic surgery required for the surgeon to achieve a similar outcome to that of OP.

Glans injury during ritual circumcision.

BACKGROUND: Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences. OBJECTIVE: In this study we describe the experience of two medical centers with the management and follow up of glans injury after ritual circumcision. METHODS: We have retrospectively reviewed the medical files of all pediatric patients who presented to the ER with glans injury, following ritual circumcision, over a 17-year period from two medical centers. RESULTS: A total of 8 patients were identified, who underwent ritual circumcision between 7 and 9 days of age. On presentation, 1 infant had complete glans amputation, the others presented with partial amputation of the glans. 6 of the 8 patients had a simultaneous urethral injury. All patients underwent surgical correction for their injury; Patients with isolated glans injury, underwent primary glans anastomosis. Of the 6 cases with simultaneous urethral injury: 3 underwent end-to-end urethral anastomosis following anastomosis of the amputated glans, one patient with complete glans amputation underwent a similar procedure, with initial end-to-end urethral anastomosis followed by glans anastomosis to the corpora cavernosa and 2 were managed by urethrostomy together with anastomosis of the amputated glans tissue to the remaining glans. Both patients with urethral injury, in whom end to end urethral anastomosis has not been performed, were found to have hypospadias on follow up. The rest had good functional and cosmetic results. DISCUSSION: There is no single method for managing glans injury following circumcision. Some authors describe healing by secondary intention with delayed formal repair, while others advocate for primary anastomosis of the amputated glans, together with distal urethra-urethrostomy, in cases with simultaneous urethral injury. In this study, both patients without urethral anastomosis, developed secondary hypospadias due to meatal regression and required additional surgery, while the others showed good results. The limitations of our study are its retrospective nature and the small number of cases, preventing us to come to a definitive conclusion regarding the best way to treat such a rare injury. CONCLUSION: Prompt surgical correction by glanular replantation with urethro-urethrostomy, in case of concomitant urethral injury, give good cosmetic and functional results.

Sexual function and voiding status following one stage feminizing genitoplasty.

BACKGROUND: The data on long-term outcome of feminizing genitoplasty (FG) with regard to the sexual function and voiding status is limited and nearly always retrospective, reviewing only small numbers of patients. Furthermore, most articles only looked at the success as an adequately open vagina with a feminized appearance. Success should include normal erotic sensation, lubrication, sexual satisfaction, orgasm, and intercourse without discomfort. These latter factors are just beginning to be studied OBJECTIVE: To investigate sexual function and voiding status in women who underwent vaginal reconstruction in childhood. MATERIAL AND METHODS: We retrospectively reviewed medical files of patients who underwent FG at our center from 1988 to 2000. In addition, patients were asked to complete the following standardized questionnaires: Female Genital Self-Image Scale (FGSIS), dysfunctional voiding and incontinence symptoms score (DVISS), and Female Sexual Function Questionnaire (FSFI). RESULTS: patients underwent one-stage FG; of those, 36 with median age of 21 years (range 18-30 years) who completed the puberty period were included into this study. Of the participants, 15 (41.6%) lived in a committed partnership, and 12 (80%) had sexual intercourse on a regular basis. Total FSFI was 22.2 + 3.1 (mean + SE). Domain scores were 3.9, 4.3, 4.5, 4.3, 4.9, and 4.7 for desire, arousal, lubrication, orgasm, satisfaction, and pain, respectively (Summary Figure). None of the patients reported on daytime incontinence or enuresis. Female genital self-image was found to be positive in all patients and related positively to women's sexual function. DISCUSSION: The general rate of the sexual activity of our studied population was similar to that published in the literature 80% in our study vs 60-87% published in the literature. The overall FSFI was 22, showing some evidence of the female sexual dysfunction. However, only one patient regarding pain during vaginal penetration demonstrated mild dyspareunia. At the same time, we have not found any desire, arousal, lubrication, orgasm, satisfaction problems. Furthermore none of our patients complained on lower urinary tract symptoms during questioning, while three girls with congenital adrenal hyperplasia presented during follow-up with dribbling incontinence, which resolved with introitoplasty and creation of the wide vaginal opening. CONCLUSIONS: Our data demonstrate that one -tage FG in childhood is a long-term effective surgical procedure that does not cause voiding dysfunction. If a secondary intervention is required prior to the sexual life, simple introitoplasty usually solves the problem. The FSFI score showed overall acceptable sexual function, whereas mild dyspareunia was a major complain.

Pediatric robotic-assisted laparoscopic pyeloplasty (RALP): does weight matter?

PURPOSE: RALP is rapidly becoming the new gold standard treatment for UPJO in children, who suffer from uretero-pelvic obstruction (UPJO). However, presently there is a lack of data regarding the outcomes of RALP in young infants and smaller children. This study aims to compare the outcomes of RALP in children weighing less than 10 kg and matched with an analogous cohort who underwent open pyeloplasty (OP). METHODS: We prospectively compared patients who underwent RALP to a matched cohort of patients who underwent OP from our retrospectively acquired data registry. Comparative outcomes included: Demographics, success rate, complications, and length of hospital stay, postoperative pain score and failure rate. Failure was defined as the need for a secondary intervention for UPJO, or worsening hydronephrosis during follow-up. RESULTS: A total of 15 patients with a median age of 8 months (range 5-11 months) and median weight 7 kg (range 5.6-9.8 kg) underwent RALP between 2016 and 2018, a matched cohort of 15 children who underwent OP similar in terms of age, weight, gender and affected side between 2014 and 2016. All children had prenatal diagnosis of hydronephrosis and underwent surgery utilizing combined general and regional (Caudal MO) anesthesia. Intrinsic obstruction was present in 13 of RALP group (86.7%) and in 14 in OP group (93.3%). Mean operative time was 67.8 + 13.4 min in RALP group, while 66.5 + 9.5 min in OP group. (p = 0.76) All but two patients in RALP group had stent inserted and required subsequent anesthesia for stent removal, while all OP children had a Salle Pyeloplasty stent inserted during the procedure and underwent removal in an ambulatory setting without the need for anesthesia. There were no failures recorded in the RALP group, while one patient in OP required a secondary intervention. Mean hospital stay was 1 day (1-2 days) for RALP and 2 days (2-3 days) for OP. There was no difference in FLACC Pain Scale in both groups. Clavien-Dindo grade I-II complications occurred in one patient from each group. Two patients from RALP underwent subsequent ureteral reimplantation due to accompanying uretero-vescical junction obstruction. CONCLUSIONS: Our data suggest that RALP can be performed safely in pediatric patients weighing less than 10 kg. with similar outcomes when compared to patients undergoing an open procedure for the same pathology.

Does endoscopic puncture of ureterocele provide not only an initial solution, but also a definitive treatment in all children? Over the 26 years of experience.

PURPOSE: We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status. METHODS: 78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1-26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period. RESULTS: Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p = 0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p = 0.716). CONCLUSIONS: Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.

Voiding patterns of adult patients who underwent hypospadias repair in childhood.

OBJECTIVE: This study aimed at evaluating the voiding patterns of adult patients who underwent hypospadias repair in childhood. METHOD: Following IRB approval 103 (22.7%) of 449 adult patients who underwent hypospadias repair between 1978 and 1993 responded to the following questionnaires: International Prostate Symptom Score (I-PSS) and Short Form 12 questionnaire (SF-12). Uroflowmetry (UF) was performed for all patients. The patients were divided into three groups according to the primary meatus localization. Group I had 63 patients (61.5%) treated for glanular hypospadias, group II had 19 patients (18.4%) treated for distal hypospadias, and group III comprised the remaining 21 patients (20.4%) treated for proximal hypospadias. RESULTS: The mean ± SD I-PSS score for all patients who responded to the questionnaire was 2.3 ± 2.4, and UF was 21.1 ± 4.3 mL/s. The patients from groups I and III had fewer urinary symptoms compared with those of the group II: 1.3 ± 1.5, 5.5 ± 2.4, and 1.6 ± 1.4, respectively (p < 0.0001). With regards to UF, the patients from the groups I and III did better compared with those from the group II: 22.1 ± 4.1 mL/s, 18.91 ± 4.2 mL/s, and 20.11 ± 3.42 mL/s, respectively (p = 0.021) (Figure). The UF was better in patients with normal vs. abnormal IPSS (p = 0.0064). The physical component summary was 49.8 ± 10.3, 51.1 ± 3.6, and 46.4 ± 0.3 in groups I, II, and III, respectively. The mental summary component was 42.64 ± 4.1, 42.2 ± 2.4, and 39.89 ± 2.9 in groups I, II, and III, respectively. CONCLUSIONS: Most of the adult patients who underwent hypospadias repair in childhood had normal or mild voiding disturbance, with no effects on their physical or mental status.

Use of Caudal Analgesia Supplemented with Low Dose of Morphine in Children Who Undergo Renal Surgery.

INTRODUCTION: To test the efficacy and safety of caudal anesthesia (CA) supplemented by low dose morphine in children who undergo renal surgery. MATERIALS AND METHODS: Forty patients aged 2 months-14 years were enrolled and randomly divided into two groups of 20 patients each: Group A (bupivacaine 0.2% with fentanyl); Group B (bupivacaine with morphine). The duration of surgery and hospitalization time were recorded. Postoperative pain score was measured by Face Legs Activity Cry Consolability scale and Wong-Baker Faces scale for those who are older. Overall use of rescue analgesics was calculated. RESULTS: There was no statistical difference in the length of surgery, incidence of pruritus, postoperative nausea, vomiting and urinary retention between the two groups. However the postoperative opioid requirements were significantly higher in Group A 1.03 ± 0.9 mg/kg compared to Group B, in which only one patient required opioid therapy (p < 0.0001). Moreover the need for non-opioid rescue analgesic was higher in Group A, (36 ± 5.7 mg/kg of paracetamol) compared to morphine CA group there only 26 ± 3.6 mg/kg required during first 24 h of the postoperative period (p = 0.0312). The Face Legs Activity Cry Consolability pain score (1, 4, and 24 h after surgery) and Wong-Baker Faces scale were significantly higher in Group A. The hospitalization period was shorter in the CA morphine group, but the difference did not reach statistical significance. None developed hemodynamic instability or respiratory depression. CONCLUSIONS: Our data show that CA supplemented with low dose morphine provides a longer duration of analgesia without significant side-effects in children undergoing renal surgery.

Medical clowns reduce pre-operative anxiety, post-operative pain and medical costs in children undergoing outpatient penile surgery: A randomised controlled trial.

AIM: The aim of this paper is to investigate prospectively the potential benefits of the participation of the medical clowns in the outpatient paediatric penile surgery programme. METHODS: Eighty children undergoing meatotomy, age 2 to 16 years, were randomised into two groups (40 each). In the first group, the medical clown was an integral part of the medical team, and in the second group, the treatment was given without participation of the medical clown. The following parameters were measured: the level of pre-operative anxiety, the level of the post-operative pain, the amount of pain medication use in the first 24 h after surgery and the time needed to return to normal activities. The operating room time and hospital costs were calculated. RESULTS: The patients from the first group demonstrated a lower pre-operative anxiety index upon (P = 0.0319) and after surgery (P = 0.0042), required less induction time for anaesthesia (P < 0.001), spent overall less time in the operating room (P < 0.0001) and required less time to recover from the surgery and to be discharged (P = 0.0172). The overall OR time and post-operative unit care savings of 20 and 155 min, respectively, led to the cost savings of $467. CONCLUSION: Our data demonstrated that the use of the medical clown functioning as an integral part of the operating team reduces children pre-operative anxiety and leads to a shortening of the overall time in the hospital thereby reducing the overall medical cost justifying the participation of medical clown as an integral part of the health team in a paediatric urology outpatient surgical unit.

Fenestrated sheet split-thickness skin grafting for reconstruction of penile skin loss in pediatric population.

OBJECTIVES: We aimed to evaluate our experience with fenestrated sheet split-thickness skin grafts (STSGs) in the pediatric population. MATERIALS AND METHODS: We retrospectively studied a cohort of 17 children 2-18years old who underwent skin grafting owing to circumcision injuries (2 patients), traumatic penile injury (1) and after previous multiple hypospadias surgery (14). Fenestrated 0.012in sheet STSGs from thigh area (15 patients) and buttock area (2) were fashioned to resurface the denuded penis following reconstruction. The median follow up was 13years (range 1-19years). RESULTS: There was 94% take of the grafts. One patient required additional grafting following first graft infection. Six patients underwent concomitant surgery at the time of grafting (4 chordee repair and 2 meatoplasty). Two patients had slight chordee at 3 and 6years postoperatively, and 2 with the history of preputial tubularized island flap hypospadias repair had developed a urethral stricture, which required staged repair with buccal mucosa 12 and 14years following primary hypospadias repair. Six sexually active patients reported normal sexual intercourse and sensation following grafting. None of the patients demonstrated shrinkage of the STSGs over the follow up period. CONCLUSIONS: Our data demonstrated that the use of fenestrated sheet STSGs in patients with penile skin loss yields satisfactory functional and cosmetic outcomes. The buttocks might be considered as a preferable donor site in terms of avoiding a visible scar.

Extracorporeal Ureteric Stenting for Pediatric Laparoscopic Pyeloplasty.

INTRODUCTION: We aimed to evaluate a novel technique for ureteric stent insertion during dismembered pediatric laparoscopic pyeloplasty. PATIENTS AND METHODS: Following identification and dissection of the ureteropelvic junction (UPJ) with the proximal part of ureter, the ureter is dismembered just proximal to the UPJ at the level of the renal pelvis, allowing use of the excess pelvic tissue for further manipulation of the ureter. Then the abdomen is desufflated and the ureter delivered to the skin level. The externalized ureter is then spatulated and the stent inserted in an antegrade fashion to the bladder. The first stitch for further laparoscopic anastomosis is applied to the lower part of the spatulated ureteric end and then following insufflations the ureter is returned to the abdomen. The laparoscopic anastomosis is completed in a routine fashion. RESULTS: Over the past 4 years, we have used this technique in 26 children (17 boys and 9 girls) with median age of 4 years (range, 2-18 years). Left pyeloplasty was performed in 16 and right pyeloplasty in the remaining 10 patients. The mean (range) time of insertion was 6 minutes (range, 4-7 minutes). All stents were correctly placed. In one patient, the stent dislodged to distal part of the ureter. No other intraoperative or postoperative complications related to our technique of stent insertion were observed. CONCLUSION: Our data show that extracorporeal antegrade ureteric stent insertion is an easy-to-learn and a safe and reliable technique for pediatric dismembered pyeloplasty. It obviates the problem of having the stent in the pelvis during dissection and the need for patient repositioning.