Shock Wave Lithotripsy in Pediatric Stone Disease: A 15-Year Single-Center Experience with 2 Types of Lithotripters.

INTRODUCTION AND OBJECTIVES: We report our experience with pediatric shock wave lithotripsy (SWL) using two types of lithotripters: Dornier HM3 (HM3) and Dornier Lithotripter SII (DLS). STUDY DESIGN: We retrospectively reviewed the charts of children who underwent SWL between 2002 and 2016. Patients were divided into two groups based on the type of the lithotripter: during 2002-2009, we used the electrohydraulic HM3 lithotripter which was replaced in 2009 with the DLS electromagnetic lithotripter. Clinical and perioperative parameters were compared. RESULTS: Our cohort included 107 children who underwent SWL. Average age was 11.5 ± 5.1 years. Average stone size was 10.6 ± 4.9 mm. HM3 was used in 38% of children and DLS2 in 62% (n = 41 and 66, respectively). There were no significant differences in age, gender, stone size, or location between the groups. The total SFR did not differ statistically between HM3 and DLS (83% vs. 74%, p = 0.35). SFR after one SWL was higher with the HM3 (78% vs. 62%, p = 0.093). Re-treatment rate was 22% and 17% (HM3 vs. DLS, p = 0.61). Complication rates were low, with renal colic being the most common (HM3 10%, DLS 20%, NS). CONCLUSIONS: SWL in the pediatric population using the DLS showed good results with low complication rates that are equivalent to the gold standard HM3.

Long-term Results of Ventral Penile Curvature Repair in Childhood.

OBJECTIVE: To assess the postpubertal outcome of ventral penile curvature repaired in infancy in terms of recurrence and aesthetics. MATERIALS AND METHODS: Postpubertal patients treated for hypospadias and ventral penile curvature in infancy at a tertiary medical center were invited to undergo assessment of the quality of the repair. Findings were compared between patients with a straight penis after skin release and patients who required dorsal plication. RESULTS: The cohort included 27 patients of mean age 16.5 years who were reported with straight penis after surgery. Postpubertal curvature was found in 6 of 14 patients (43%) successfully treated by skin release and 10 of 13 patients (77%) who underwent dorsal plication (P = .087). Significant curvature (≥30 degrees) was found in 1 of 14 patients in the skin-release group and 4 of 13 in the dorsal plication group (P = .16). Rates of redo urethroplasty were 2 of 14 (14%) and 5 of 10 (50%), respectively. Patient satisfaction with the appearance of the penis did not differ significantly. CONCLUSION: Ventral penile curvature repaired in infancy often recurs after puberty. The need for dorsal plication has a trend-level association with recurrence of penile curvature in puberty. It might also be related to the degree of postpubertal penile curvature and the need for redo urethroplasty. Procedure type does not affect patient satisfaction with the postpubertal appearance of the penis.

Pyogenic Granuloma: Possible Cause for Macroscopic Hematuria in Children.

Pyogenic granuloma (PG) is a benign, vascular tumor that is rarely reported in the urinary tract of pediatric population. Herein we present a case of a child followed up for recurrent painless macroscopic hematuria. We performed ureteroscopy, and a whitish lesion was discovered in the upper calyx of the right kidney. The lesion resected endoscopically, and microscopic examination of the lesion was consistent with PG. It is important for pediatricians and urologists to properly recognize PG as a possible source of hematuria in the pediatric population.

Percutaneous nephrolithotomy for infection stones: what is the risk for postoperative sepsis? A retrospective cohort study.

The purpose of this study was to compare the postoperative course of patients with positive stone culture (SC) to patients with sterile SC, and to analyze the predictors for post percutaneous nephrolithotomy (PCNL) sepsis; and to describe the type and resistance patterns of bacteria responsible for post PCNL sepsis. From a cohort of 206 consecutive patients undergoing PCNL, we identified 45 patients with a positive SC (group A) and compared them to patients with a sterile SC (group B). Association between different groups was assessed using Chi square, two-tailed Student's t test and Mann-Whitney U test, as appropriate. Twenty-three patients had postoperative sepsis and regression analysis was performed to identify clinical variables associated with sepsis. Demographics, stone load and hospitalization time were similar in both groups. Postoperative sepsis developed in 31.1% of patients in group A compared to 5.9% in group B. In multivariate analysis, only positive SC was an independent risk factor for postoperative sepsis (OR 6.894, 95% CI 2.31-20.59, P = 0.001). All patients responded well to treatment with no septic complications. Enterococci were the prevalent organism (29.4%) in patients with a positive SC. Quinolone resistance was high in both gram negative and gram positive bacteria. Patients with an infected stone are at high risk to develop postoperative sepsis despite standard preoperative antibiotic preparation. SC is important to direct further treatment as almost half of patients with positive SC have a discordant or sterile urine culture. Determining the prevalent bacteria and resistance patterns in SC can aid the selection of empiric antibiotic therapy in high-risk patients.

Urinary retention in children.

OBJECTIVE: To describe the causes and outcome of urinary retention in children and assess its prevalence by gender and age. METHODS: The medical records of all children (aged <18 years) who presented to the emergency room with acute urinary retention from 2000 to 2012 were reviewed. Patients with postoperative urinary retention, a known neurologic disorder, and neonates were excluded. Data were collected on patient demographics and cause, treatment, and outcome of the urinary retention. Findings were evaluated and compared by age and gender. RESULTS: The study group comprised 42 boys (75%) and 14 girls (25%). Median follow-up time was 25 months. Causes of urinary retention were mechanical obstruction in 14 patients (25%), infection or inflammation in 10 (18%), fecal impaction in 7 (13%), neurologic disorders in 6 (11%), gynecologic disorders in 4 (7%), and behavioral processes in 3 patients (5%); 12 patients (21%) were idiopathic. All patients with mechanical obstruction were boys, of whom 5 had a pelvic tumor. Age distribution was bimodal: 29% of the events occurred between ages 3 and 5 years, and 32%, between ages 10 and 13 years. Fifteen children underwent surgery. Three children required continuous catheterization during follow-up. CONCLUSION: Urinary retention in children is characterized by a variable etiology and bimodal age distribution. The high rate of severe underlying disease is noteworthy and should alert physicians to the importance of a prompt, comprehensive, primary evaluation of this patient population in a hospital setting to initiate appropriate treatment and avoid complications.

Urinary stone composition in Israel: current status and variation with age and sex--a bicenter study.

BACKGROUND AND PURPOSE: The epidemiologic data regarding stone composition in Israel are based on anachronistic methods of stone analysis. Historically, Israel was noted for an unusually high percentage of uric acid stones. The aim of the study was to describe the current stone composition distribution in Israel, using modern techniques of urinary stone analysis. Age and sex correlations were investigated. MATERIALS AND METHODS: In a bicenter study, using infrared spectroscopy and X-ray diffraction, stones from five hundred and thirty eight (538) patients were analyzed and demographic data recorded. RESULTS: The study cohort included 401 men (74.5%) and 137 women (25.5%) with a male to female ratio of 2.9:1 and a median age of 48 years (range 2-85 years). While calcium oxalate monohydrate was the predominant component in both sexes, it was lower in female patients (77.3% vs 65%). The rate of infection stones (struvite+carbonate apatite) was significantly higher in women (35.7% vs 10.2%). Uric acid stones were found in only 14.5% of the patients and increased with age. Conversely, the rate of calcium oxalate dihydrate decreased with age. CONCLUSIONS: Modern techniques of urinary stone analysis showed that the most frequent stone component in Israel is calcium oxalate monohydrate. In contrast to earlier reports and in accordance with reports from other countries, the overall frequency of uric acid is 14.5%. With age, the frequency of uric acid increases reaching 21% in persons >60 years old. A significant sex difference was noted in the distribution of calcium oxalate stones and infection stones. The classic 3:1 ratio was maintained, however.

Testicular torsion in the first year of life--characteristics and treatment outcome.

OBJECTIVE: To review the characteristics and treatment outcome of testicular torsion in infants, aged 1 month to 1 year, and compare them with those seen in neonates. METHODS: The study group included 30 patients aged younger than 1 year who were treated for testicular torsion at a tertiary pediatric medical center between 1993 and 2012. Medical records were retrospectively reviewed for clinical characteristics and treatment outcome. Findings were compared between patients who presented before age 1 month (neonate group, n = 17) or later (infant group, n = 13). RESULTS: The common clinical presentation in the neonate group was a solid, nontender scrotal mass apparent in 13 of 17 patients (76%). In the infant group, 11 of 13 patients (85%) presented with restlessness and 12 of 13 (92%) with a tender scrotal or inguinal mass. Torsion of an undescended testis was significantly more prevalent in infants, 7 of 13 (54%), than neonates, 1 of 17 (6%; P = .009). Although extravaginal torsion was documented in 5 of 6 neonates (83%), 8 of 9 infants (89%) had an intravaginal torsion (P = .011). Orchiectomy was performed in 14 of 17 neonates (82%) and 6 of 13 infants (46%; P = .056). Of the 29 patients with follow-up data, testicular salvage was documented in 1 of 17 neonates (6%) and 2 of 12 infants (17%), at a minimum follow-up of 5 months (P = .55). CONCLUSION: Testicular torsion in the first year of life is a diverse condition. Although neonatal torsions were predominantly extravaginal, infantile torsions were mostly intravaginal, involving undescendent testes in more than half of the cases. Despite fewer orchiectomies performed on the infant group, testicular salvage rates in both groups were similarly low.

The impact of retrograde intrarenal surgery for asymptomatic renal stones in patients undergoing ureteroscopy for a symptomatic ureteral stone.

BACKGROUND AND PURPOSE: In the era of rigid ureteroscopy (URS) for ureteral stones, asymptomatic renal stones were often left in place. With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Data are scarce regarding the impact of retrograde intrarenal surgery (RIRS) performed at the time of URS for a symptomatic ureteral stone in comparison with ureteral stone removal alone. The purpose of the study was to compare the outcomes of URS combined with RIRS with URS alone. PATIENTS AND METHODS: A comparison between patients who underwent URS and RIRS (group A, n=47) and a matched control group of patients undergoing URS alone (group B, n=47) was performed. Matching was based on ureteral stone size and location, and preprocedural Double-J stent placement. RESULTS: The median size of the largest ureteral stone in both groups was 8 mm with a mean total stone burden of 52.9 mm(2) (28.9) and 47 mm(2) (21.1) in groups A and B, respectively. Median renal stone size was 9 mm with a mean total stone burden of 84.1 mm(2) (40.3). Mean surgery time in groups A and B was 68 minutes (19.61) and 39 minutes (15.96), respectively (P<0.001). Median hospital stay was 1 day for both groups. The success rate for ureteral stone removal was 98% and 100% in groups A and B, respectively. Success rate for RIRS was 85% (40/47 cases). Hospitalization length and complications, mainly postoperative fever, did not differ significantly between the groups. CONCLUSIONS: Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates. This combined approach reduces the need for future procedures and is probably more cost effective.

Histology proved malpositioning of dextranomer/hyaluronic acid in submucosal ureter in patients after failed endoscopic treatment of vesicoureteral reflux.

PURPOSE: We histologically investigated the cause of failed endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. MATERIALS AND METHODS: A total of 192 children underwent dextranomer/hyaluronic acid injection at our institution between January 2008 and September 2010. The study population consisted of 13 children (22 ureters) with vesicoureteral reflux who underwent ureteroneocystostomy following failed endoscopic injections (1 to 2) of dextranomer/hyaluronic acid. In all cases the dextranomer/hyaluronic acid was implanted in the mucosa of the mid to distal ureteral tunnel following hydrodistention of the ureter. The medical records were reviewed, and specimens of the archived distal ureters removed during surgery were examined histologically. RESULTS: Mean patient age was 4.1 years. Mean dose of dextranomer/hyaluronic acid was 0.9 ml (both treatments) and mean lag between treatments was 13.4 months. Indications for open surgery were recurrent urinary tract infections and/or residual or aggravated reflux grade IV or higher. Histological study revealed that the dextranomer/hyaluronic acid was malpositioned in 21 of 22 ureters, residing in the muscle fibers in 2, adventitia in 14 and periureteral space in 5. CONCLUSIONS: This is the first known study to provide a histologically proved cause of failure of endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. Malpositioning of the material outside the submucosal ureter was identified in a high percentage of cases. Larger studies are needed to corroborate these findings.

Retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant kidneys after failed antegrade balloon dilation.

OBJECTIVE: To evaluate the long-term outcomes and complications of retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant patients after percutaneous balloon dilation failure. METHODS: From January 2000 to May 2010, 26 (2.6%) of 1004 renal transplant patients developed ureterovesical anastomotic stricture after surgery. Seven of these patients and five additional referred patients with similar characteristics were treated with retrograde endoureterotomy after ≥1 previous unsuccessful attempt at percutaneous balloon dilation. All strictures treated were <1 cm in length. The clinical characteristics and outcomes were analyzed. Success was defined as the absence of symptoms and the resolution of obstruction on imaging after the procedure. RESULTS: The median interval from initial treatment to endoureterotomy was 2.9 months (range 1.3-62.1). Before endoscopic treatment, 8 patients (67%) were treated with a single trial of balloon dilation and 4 (33%) with multiple trials. Endoureterotomy was performed using cold knife, holmium:yttrium-aluminum-garnet laser, and Bugbee electrode in 9, 2, and 1 patients, respectively. The median follow-up period was 44.4 months (range 2.4-68.6). Recurrent stricture developed in 2 patients during a mean follow-up of 4.7 months. Thus, the overall success rate was 83%. Postoperative complications appeared in 3 patients (25%) with culture-positive urinary tract infection. One graft failure occurred but was not related to a recurrent stricture. CONCLUSION: After failure of antegrade percutaneous balloon dilation, retrograde endoureterotomy is an effective salvage procedure for well-selected cases of renal transplant patients with a short ureterovesical anastomotic stricture.

Meatotomy using local anesthesia and sedation or general anesthesia with or without penile block in children: a prospective randomized study.

PURPOSE: Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. MATERIALS AND METHODS: A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. RESULTS: There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). CONCLUSIONS: Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.

Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair - clinical characteristics and oncological outcomes.

OBJECTIVE: • To examine the clinical characteristics and long-term outcomes of patients with bladder perforation requiring open surgical repair as a complication of transurethral resection of bladder tumour (TURBT). PATIENT AND METHODS: • A search of our institutional database yielded 4144 patients who underwent TURBT from 1996 to 2008, of whom 15 (0.36%) required open surgical intervention to repair a large bladder perforation. • In all cases, a filling cystogram was performed before laparotomy. Clinical, pathological and follow-up data were reviewed, and the incidence and time of extravesical tumour recurrence were recorded. RESULTS: • Median patient age was 77 years. Intraperitoneal perforation was diagnosed in 12 patients, generally involving the posterior wall. Concomitant bowel injury was identified in two patients and managed by primary repair. Two patients in whom the diagnosis and intervention were delayed died within 1 week of surgery. • Metastatic progression was observed in two patients shortly after the perforation (median interval, 4.8 months), and local pelvic recurrence was noted in one of them. • None of the patients with stage Ta tumours had evidence of extravesical progression. Actuarial estimates of disease-free survival at 1, 3 and 5 years after the perforation were 83%, 71% and 41%, respectively. CONCLUSIONS: • A significant bladder perforation during TURBT requiring open surgical repair is more likely to occur in elderly patients with large posterior wall tumours and heavily pretreated bladders. • Despite its potential for considerable morbidity, this adverse event does not seem to substantially increase the risk of extravesical tumour seeding. Prompt diagnosis, immediate intervention and meticulous bladder and bowel inspection during laparotomy are imperative.

Continuous epidural versus nonepidural analgesia for post-pyeloplasty pain in children.

PURPOSE: We compared the effectiveness of post-pyeloplasty epidural and nonepidural analgesia in children. MATERIAL AND METHODS: After flank dismembered open pyeloplasty 45 children were randomly allocated to group 1-continuous epidural analgesia with a loading dose of 0.25% bupivacaine or 0.2% ropivacaine, followed by continuous drip 0.2% ropivacaine (26) and group 2-nonepidural analgesia with intraoperative morphine intravenously and postoperative oxycodone or tramadol by age plus ibuprofen or paracetamol for 48 hours. The same rescue regimen was used in each group. Pain was scored separately by parents and the ward nurse using the Face, Legs, Activity, Cry and Consolability Scale or a visual analog scale. RESULTS: In groups 1 and 2 mean age was 2.8 and 4.7 years, respectively. There was no significant between group difference in pain degree as scored by the nurse (none in 53.8% vs 36.8% of patients, mild in 26.9% vs 21.1% and moderate in 19.2% vs 42.1%) and parents (none in 40% vs 23%, mild in 20% vs 11.8% and moderate in 40% vs 65.2%) (p >0.05). Rescue treatment 48 to 72 hours after surgery was received by 80% of group 1 and 76% of group 2 for mild pain and by 4% and 30% for moderate pain (p >0.05 and 0.02, respectively). Mean time to mobilization in the 2 groups was 25 and 17 hours, and mean time to discharge home was 4.9 and 4.1 days (p = 0.05 and >0.05, respectively). CONCLUSIONS: Nonepidural analgesia is as effective as continuous epidural analgesia to control post-pyeloplasty pain in children. A noninvasive analgesic regimen is recommended when there is a relative contraindication to line insertion, a less experienced anesthetist is available or parents prefer it.

Predictors of nocturia quality of life before and shortly after prostatectomy.

OBJECTIVES: To evaluate the predictors of nocturia-related quality of life and to assess the early effect of prostatectomy on these parameters in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. METHODS: The study group included 56 consecutive patients scheduled for prostatectomy to treat medical treatment-refractory lower urinary tract symptoms. Nocturia severity was assessed preoperatively and 2 to 3 months after prostatectomy by the number of nocturia events, time from falling sleep to first awakening to void (hours of undisturbed sleep [HUS]), longest sleep interval between voids, and score on the nocturia quality-of-life (N-QOL) questionnaire (range 0 to 48). RESULTS: The mean age of the study group was 69 +/- 9 years. The preoperative N-QOL score correlated strongly with the number of nocturia events, HUS, and longest sleep interval between voids (r = -0.69, r = 0.67, and r = 0.69, respectively, and P <0.001). Of the 56 patients, 36 (65%) underwent transurethral prostatectomy and 20 (35%) underwent open prostatectomy. Significant improvement (P <0.001) was noted in all factors after treatment. The number of nocturia events decreased from 3.4 +/- 1.2 to 2.6 +/- 0.99; the HUS increased from 1.83 +/- 0.55 to 2.74 +/- 0.64 hours; the longest sleep interval between voids increased from 2.36 +/- 0.64 to 2.91 +/- 0.6 hours; and the N-QOL score increased from 24.1 +/- 7 to 34.4 +/- 7.5. On multivariate stepwise regression analysis, the factors predicting for improvement in the N-QOL score after prostatectomy were the number of nocturia events and HUS. CONCLUSIONS: Prostatectomy is associated with an early postoperative improvement in nocturia indexes. The increases in the interval to first void and decrease in even less than one nocturia event were associated with significant improvement in nocturia quality of life.

Expanding use of ureteral access sheath for stones larger than access sheath's internal diameter.

The internal diameter of the ureteral access sheath limits the size of stones that can be removed during flexible ureteroscopy. We describe a technique that allows removal of larger stones, which are entrapped and removed en bloc with the access sheath. This new technique was shown to be efficient and safe.

Continuous positive airway pressure reduces nocturia in patients with obstructive sleep apnea.

OBJECTIVES: To examine whether treatment with continuous positive airway pressure (CPAP) reduces nocturia in patients with obstructive sleep apnea (OSA). METHODS: This prospective clinical study recruited patients referred to the Rambam Sleep Laboratory with suspected OSA. After polysomnography, those found to have no OSA were excluded from the study, and the remainder were treated with CPAP. Nocturia was assessed at four time points: baseline (average number of awakenings to urinate per night during 1 week at home before polysomnography); diagnostic night in the laboratory; CPAP titration in the laboratory; and after 1 to 3 months of stable CPAP treatment at home (average number of awakenings to urinate per night for 1 week). RESULTS: Ninety-seven patients (75 men and 22 women) completed the study. The mean +/- SD age was 55 +/- 12 years, body mass index was 33 +/- 7 kg/m2, and respiratory disturbance index was 34 +/- 24/hr. The mean number of awakenings to void at home before CPAP was 2.5 +/- 2.4 times/night; during CPAP, it was 0.7 +/- 0.6 time/night (P < 0.001). A total of 73 patients reported improvement in nocturia. The mean number of awakenings to void in the laboratory was 1.1 +/- 0.9 before CPAP, with a decrease to 0.5 +/- 0.6 during CPAP (P < 0.001). Weak, but significant, correlations were found in the number of awakenings to void before treatment with the respiratory disturbance index (r = 0.25, P = 0.01) and with minimal oxygen saturation (r = -0.23, P = 0.02). CONCLUSIONS: CPAP appears to be an effective treatment for nocturia associated with OSA.

[The treatment options for localized prostate cancer].

Prostate cancer is a very common tumor in men. Today the disease is very often diagnosed early because of an elevated PSA without symptoms and the disease is localized to the prostate. Patients with prostate cancer can be divided into 3 subgroups for the carcinoma: favorable, moderate, and poorly. The grouping depends mainly on the Gleason score of the prostate biopsy. According to the Gleason score, favorable cancer is up to score 6 (3 + 3), moderate score 7, and poor--Gleason score 8-10. The other favorable clinical factors are PSA < 10 ng/ml, and clinical stage by DRE of T1C or T2 (no nodule or palpable nodule not extending beyond the prostatic capsule). The treatment options for cure when the prostate cancer is localized are either radical prostatectomy or radiotherapy (external or brachytherapy or combination). Each of these therapies has side effects and each has advantages and disadvantages. Sometimes the treatment choice is not for cure and the options are hormonal treatment or watchful waiting. Twenty to 30% of the patients treated for cure may fail the treatment and have elevation of PSA without any clinical symptoms, or signs of local recurrence or distant spread. Some of these patients with biochemical failure may be cured by salvage treatment: radiotherapy after radical prostatectomy and salvage radical prostatectomy or cryotherapy following failure of radiotherapy.

Percutaneous nephrolithotomy in patients who previously underwent open nephrolithotomy.

BACKGROUND AND PURPOSE: Open stone surgery nowdays is rare. However, some patients who are treated today have in the past undergone open nephrolithotomy. The aim of this study was to determine the possible impact of open nephrolithotomy on the efficacy and morbidity of subsequent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: We reviewed the files of all 167 patients undergoing PCNL at our institution between December 2000 and December 2003. The same surgeon performed all of the procedures. We compared 21 patients undergoing PCNL after open nephrolithotomy to the same kidney with all other patients undergoing PCNL. The groups did not differ in terms of age or stone burden (mean size, number of stones, percentage with staghorn calculi). The outcomes measured were operating time, necessity for secondary procedures, stonefree rate, and intraoperative and postoperative complications. RESULTS: The operating time (203+/-92 v 177+/-52 minutes) and percentage of secondary procedures (29% v 12%) were significantly higher in patients who had previously undergone open stone surgery. However, the stone-free rate (95% v 93%), intraoperative complication rate (10% v 9%), and postoperative complication rate (10% v 11%) did not differ significantly. CONCLUSIONS: A PCNL in a patient with a history of open nephrolithotomy may take longer and lead to a higher percentage of auxiliary procedures, probably because of scar tissue and anatomic changes in the kidney. However, the morbidity and efficacy of PCNL appear to remain the same in these patients.

Complications of circumcision in Israel: a one year multicenter survey.

BACKGROUND: In Israel, virtually all children undergo circumcision in the neonatal period. Traditionally, it is commonly performed by a "Mohel" (ritual circumciser) but lately there is an increasing tendency among the educated secular population to prefer a medical procedure performed by a physician and with local anesthetic injection. OBJECTIVES: To evaluate the outcome of this procedure and to compare the complication rate following circumcisions performed by ritual circumcisers and by physicians. METHODS: In 2001, of the 19,478 males born in four major medical centers in Israel 66 had circumcision-related complications. All the children were circumcised in non-medical settings within the community. The patients were medically evaluated either urgently due to immediate complications or electively in outpatient clinics later on. Upon the initial assessment a detailed questionnaire was filled to obtain data regarding the procedure, the performer, and the subsequent complications. RESULTS: All the circumcisions were performed during the early neonatal period, usually on day 8 of life (according to Jewish law). in 55 cases (83%) it was part of a ritual ceremony conducted by a ritual circumciser (Mohel), while in 11 babies (17%) physicians were involved. Acute bleeding after circumcision was encountered in 16 cases (24%), which required suturing in 8. In addition, we found two cases of wound infection and one case of partial amputation of glans penis in which the circumcision was performed by a ritual circumciser. Among the late complications, the most common was excess of skin in 38 cases (57%); 5 children (7.5%) had penile torsion and 4 children (6%) had shortages of skin, phimosis and inclusion cyst. The overall estimated complication rate of circumcision was 0.34%. CONCLUSIONS: Complications of circumcision are rare in Israel and in most cases are mild and correctable. There appears to be no significant difference in the type of complications between medical and ritual circumcisions.

Assessment of vesicoureteral reflux in patients with self-retaining ureteral stents: implications for upper urinary tract instillation.

PURPOSE: Conservative treatment of upper urinary tract tumors has been popularized during the last decade. Like in bladder cancer management, localized adjuvant therapy has been advocated to reduce the risk of disease recurrence or progression. In this study we tested the feasibility of creating vesicoureteral reflux (VUR) using a Double-J stent (Medical Engineering Corp., New York, New York) as a measure of efficacy for intravesical adjuvant treatment of the ureter and renal collecting system. MATERIALS AND METHODS: The cohort included 100 consecutive patients in whom a Double-J stent was inserted for renal obstruction. All the patients underwent cystography in the supine position by retrograde filling of the bladder with a 50% dilute solution of 300 mgI/ml iopromide in serial increments of 50 ml up to a maximum of 350 ml. A total of 41 patients underwent cystography immediately following stent insertion (early group) and 59 patients with indwelling stents underwent cystography before further endourological intervention (late group). The presence of VUR and the level along the ureter and renal collecting system were assessed fluoroscopically. RESULTS: Overall VUR was detected in 56 patients (56%), specifically 11 of the 41 (27%) in the early group and 45 of the 59 (76%) in the late group (p <0.001). There was no correlation between stent diameter or length and VUR, or between patient sex, age or particular side and the likelihood of reflux. Mean minimal intravesical volume required to obtain reflux was 171 +/- 11 ml, which was significantly higher in the early (255 +/- 21 ml) than in the late (146 +/- 11 ml) cystogram group. In 24 of the 56 patients (43%) with VUR, there was complete visualization of the entire ureter and renal collecting system. However, 15 patients (26%) had opacified renal pelves and calices without concomitant visualization of the ureters, whereas 7 patients (31%) had reflux to the ureter without opacification of the renal pelvis. CONCLUSIONS: VUR is not a guaranteed consequence of Double-J stent placement. Therefore, when upper urinary tract instillation with the Double-J technique is considered, a cystogram should be performed first to confirm the occurrence of reflux, determine the intravesical volume required to induce reflux and ascertain that the pertinent section of the ureter or pelvicaliceal system from which the tumor was initially removed is opacified during study. An interval that remains to be defined should be allowed between stent insertion and VUR assessment.