Predictive value of ultrasound in prenatal diagnosis of hypospadias: hints for accurate diagnosis.

OBJECTIVES: This study aims to assess the diagnostic accuracy of targeted ultrasound examination in prenatal diagnosis of hypospadias and to evaluate the predictive values of defined ultrasonographic findings of hypospadias. METHODS: The cases diagnosed with hypospadias in our fetal medicine center were identified on an electronic database. The ultrasound reports, images and hospital records were reviewed retrospectively. The predictive value of prenatal ultrasound diagnosis and the predictive values of each sonographic finding were assessed according to the postnatal clinical examinations. RESULTS: Thirty-nine cases were diagnosed with hypospadias on ultrasound during the 6 years. Nine fetuses with missing postnatal examination records were excluded. Twentytwo of the remaining fetuses had their prenatal diagnosis of hypospadias confirmed in postnatal examinations, indicating a 73.3 % positive predictive value. Normal external genitalia was detected in postnatal examinations of three fetuses. Five fetuses were diagnosed with other external genital abnormalities, including micropenis (n=2), clitoromegaly (n=2), and buried penis with bifid scrotum (n=1) in postnatal examinations. The positive predictive value of prenatal ultrasound for any external genital abnormality was 90 %. CONCLUSIONS: Although the positive predictive value of ultrasound for genital anomalies is satisfying, it is slightly lower for the specific diagnosis of hypospadias. This reflects overlapping ultrasound findings of different external genitalia anomalies. Standardized, systematic evaluation of the internal and external genital organs, karyotyping and genetic sex determination are essential to achieve a precise prenatal diagnosis of hypospadias.

Maintenance biofeedback therapy for dysfunctional voiding: Does every child need it?

OBJECTIVES: The aim of the present study is to analyze the long-term clinical outcomes in children who were treated with biofeedback therapy (BF) for dysfunctional voiding (DV) and to determine the need for maintenance of BF due to clinical relapse. METHODS: Files of children with DV who underwent BF between 2013 and 2020 were retrospectively reviewed. Patients with neurological or anatomical problems were excluded. A total of 64 patients (52 girls, 12 boys) with a mean age of 8.89 ± 2.48 years who completed the initial BF sessions were included in the study. The demographic and clinical data, dysfunctional voiding symptom scores (DVSS), and uroflowmetry parameters were recorded before and after the initial BF sessions. Clinical success was regarded as the cessation of electromyography activity as well as concurrent resolution of lower urinary tract symptoms and improvement in uroflowmetry parameters. After the initial BF sessions, children who had initial success showed DV relapse at any time during follow-up received the maintenance BF sessions. Therefore, the patients with successful initial BF were divided into two groups: the group that needed maintenance BF, and the group which required no maintenance BF. RESULTS: Clinical success was achieved in 48 (75.0%) of 64 children following a median of 6 sessions (range 2-8). At the follow-up, 10 (20.8%) out of 48 patients showed symptom relapse at a median of 8 months (range 2-24 months). After a median of 3.5 maintenance BF sessions (range 1-6), clinical success was observed in all patients. Both groups showed a significant DVSS decrease after initial BF, however, those who needed maintenance had significantly higher DVSS (6.80 ± 2.53 vs. 3.61 ± 1.12, p < 0.001). At admission, DVSS <17.5 (odds ratio [OR]: 4.31, p = 0.025) and post-voiding residual volume as a percentage of estimated bladder capacity for age <28.9 (OR: 5.00, p = 0.009) were found as the predictive factors for initial BF success. The need for maintenance BF was 2.56-fold higher with a DVSS above 5.5 after initial BF sessions. CONCLUSIONS: Our results show that despite a clinical success rate of 75% after the initial BF, relapse can be seen within 2 years in approximately 20% of the patients. Nevertheless, maintenance of BF may provide clinical success in all patients. Relatively higher DVSS after initial BF can be used as a predictor of the need for maintenance BF.

Urinary HSP70 can predict the indication of surgery in unilateral ureteropelvic junction obstruction.

BACKGROUND: Distinguishing hydronephrosis that requires surgical intervention is a clinical challenge. The aim of this study is to determine the level of urinary heat shock protein 70 (HSP70) in children who required surgery for ureteropelvic junction obstruction and its potential use as a biomarker for prediction of surgery in children with isolated unilateral hydronephrosis. METHODS: The data of 43 children with ureteropelvic junction obstruction who underwent pyeloplasty, 25 patients with non-obstructive dilation (NOD) and 30 healthy children (control group) were collected prospectively for this study. Preoperative and postoperative urinary HSP70/Cr levels were also analyzed in 30 children in the pyeloplasty group who had available follow-up information. HSP70 levels were assessed using ELISA. RESULTS: The median age of the pyeloplasty group was 13 months (IQR 7-36 months), NOD group was 42.5 months (IQR 16-73) and it was 36 months (IQR 24-47.5) in the control group. The mean preoperative urinary HSP70/Cr was significantly higher in the pyeloplasty group when compared to controls as well as the NOD group (150.6 pg/mgCr vs. 65.0 pg/mgCr and vs. 64.7 pg/mgCr, p < 0.001 and p < 0.001, respectively). The urinary HSP70 levels significantly decreased in the postoperative period (151.5 vs 79.5, p < 0.001). Using the cutoff value of 94.7 pg/mgCr, the sensitivity and specificity of urinary HSP70 for predicting the risk of surgical intervention were 69.7% and 68%, respectively (AUC = 0.689). CONCLUSION: Urinary HSP70 may be used as an adjunct tool to clinical parameters to identify patients that would require surgery due to ureteropelvic junction obstruction.

Prenatal diagnosis and outcome of unilateral multicystic kidney.

We reviewed the records of 144 patients. The mean gestational age at first US diagnosis was 27.5 ± 4.3 weeks. An anomaly of the contralateral kidney was detected in 25% of cases. An extrarenal anomaly was detected in 13.8%. Karyotype analysis was performed in 16.6% of cases and revealed trisomy 18 in 2 cases with extrarenal defects. Karyotype analysis was normal in all the patients who had isolated multicystic dysplastic kidney (MCDK). The diagnostic accuracy of prenatal ultrasound was 92.2%. Contralateral kidney anomaly was detected 33.9% of patients, and half of these were vesicoureteral reflux. Antihypertensive therapy was required in 2.6% of cases. Nephrectomy was performed in 8%, and partial or total involution of MCDK was achieved in 33.9% of patients. MCDK can be accurately diagnosed by prenatal sonography, and prognosis depends on extrarenal and contralateral renal abnormalities. In isolated cases, require of surgery is rare, and serial follow-up is suggested to determine involution.Impact statementWhat is already known on this subject? Multicystic dysplastic kidney (MCDK) is one of the most renal anomalies and is associated with numerous renal and extrarenal abnormalities. It can lead to severe consequences in the neonatal period.What do the results of this study add? The accuracy of prenatal ultrasonography is excellent for detecting MCDK. In isolated unilateral cases, chromosomal aberrations are low, and the majority of them involute spontaneously. A periodic follow-up of the contralateral kidney is mandatory due to an increased risk of an anomaly. Genital anomaly risk is increased in males.What are the implications of these findings for clinical practice and/or further research? Detailed evaluation and follow-up of the contralateral kidney are crucial for counselling in isolated cases. Karyotype analysis in isolated unilateral MCDK is debateable. Postnatal prognosis is encountering, and the majority of patients have no requirement of surgery.

An unanswered question in pediatric urology: the post pubertal persistence of prepubertal congenital penile curvature correction by tunical plication.

OBJECTIVE: The aim of this study is to analyze post pubertal results of pre pubertal tunica albuginea plication with non-absorbable sutures in the correction of CPC. MATERIALS AND METHODS: The files of patients who underwent tunica albuginea plication without incision (dorsal/lateral) were retrospectively reviewed. Patients younger than 13 years of age at the time of operation and older than 14 years of age in November 2015 were included. Patients with a penile curvature of less than 30 degrees & more than 45 degrees and penile/urethral anomalies were excluded. All of the patients underwent surgery followed by circumcision. RESULTS: The mean age of patients at the time of the operation was 9.7 years (range, 6-13 years). The mean degree of ventral penile curvature measured during the operation was 39 degrees while it was 41 degrees in the lateral curvatures. All of the patients were curvature-free at the end of the operation. At the time of the follow-up examination, the mean age was 16.7 years (range, 14-25 years). Six patients had a straight (0-10 degrees) penis during erection and seven patients had recurrent penile curvatures ranging from 30 to 50 degrees. CONCLUSION: Pre pubertal tunica albuginea plication of congenital penile curvature (30-45 degrees) with non-absorbable sutures performed without incision is a minimal invasive method especially when performed during circumcision. However, recurrence might be observed in half of the patients after puberty.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years.

AIM: To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications. MATERIALS AND METHODS: Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications. RESULTS: A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS. CONCLUSION: Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Does structured withdrawal of desmopressin improve relapse rates in patients with monosymptomatic enuresis?

PURPOSE: Relapse after cessation of desmopressin is an important problem in treating patients with enuresis. Structured withdrawal of desmopressin tablets has been shown to decrease relapse rates. However, scientific data are lacking on the structured withdrawal of the fast melting oral formulation of desmopressin. We compared relapse rates of structured withdrawal using placebo and direct cessation in a population of patients with enuresis who were desmopressin responders. MATERIALS AND METHODS: Patients diagnosed with enuresis and responding to desmopressin from 13 different centers were involved in the study. Patients were randomized into 4 groups. Two different structured withdrawal strategies were compared to placebo and direct withdrawal. Sample size was estimated as 240 (60 patients in each group), with a power of 0.80 and an effect size of 30%. Randomization was performed using NCSS statistical software (NCSS, Kaysville, Utah) from a single center. The relapse rates of the groups were compared using chi-square testing. Logistic regression analysis was performed to define the independent factors having an effect on relapse rates. RESULTS: Desmopressin treatment was initiated in 421 patients, and 259 patients were eligible for randomization. Relapse rates were 39 (1%) and 42 (4%) for the structured withdrawal groups, which were significantly less than for direct withdrawal (55, 3%) and placebo (53, 1%). Logistic regression analysis revealed that initial effective dose of 240 µcg, greater number of wet nights before treatment and nonstructured withdrawal were associated with higher relapse rates. CONCLUSIONS: We found that structured withdrawal with the fast melting oral formulation of desmopressin results in decreased relapse rates. Application of a structured withdrawal program was also an independent factor associated with reduced relapse rates, together with lower initial effective dose and number of wet nights per week. Relapse after cessation of desmopressin is an important problem, and in this study structured withdrawal was observed to be associated with decreased relapse rates compared to placebo and direct withdrawal.

Urotherapy and biofeedback resistant dysfunctional voiding: How to deal with?

OBJECTIVES: To analyze the management strategies in the children who had treatment-resistant dysfunctional voiding (DV). METHODS: Among 75 children with DV who underwent pelvic floor biofeedback therapy (BF) between 2013 and 2020, 16 patients (14 girls, 87.5%) with a mean age of 9.81 ± 2.53 years that showed incomplete clinical response following urotherapy and initial BF sessions were retrospectively reviewed. The demographic and clinical characteristics, DVSS, and uroflowmetry parameters were recorded before and after the initial BF sessions. Subsequent treatments after initial BF and clinical responses of patients were noted. RESULTS: Clinical success was observed in one patient by addition of an anticholinergic and in three patients with combination of salvage BF sessions and anticholinergics, whom had predominant overactive bladder (OAB) symptoms. The success rate of TENS alone and in combination with other treatment modalities was 88.8% (8/9 patients). In addition, salvage BF sessions (range 2 to 3) enabled clinical success in five (50%) of 10 cases as a combination with anticholinergics or TENS. In case of incomplete emptying without OAB, adequate clinical response to Botulinum-A was observed during an average follow-up of 29 months in two boys who did not respond to alpha-blockers, even though one required repeat injection after 10 months. The total clinical success rate was 87.5% (14/16 patients) after a median follow-up of 24 months. VV-EBC and Qmax increased by a mean of 30.89% and 7.13 mL/min, respectively, whereas DVSS decreased by a mean of 8.88 points and PVR-EBC decreased by a median of 19.04%. CONCLUSIONS: Our findings showed that clinical success in resistant DV was achieved by various combination treatments in the majority of children. However, a small group may still have persistent, bothersome symptoms despite multiple treatment modalities.

Adulthood cosmetic and sexual outcomes of the patients who underwent hypospadias repair in childhood.

This study aimed to assess the cosmetic and sexual outcomes of childhood hypospadias repair after puberty. Among 672 patients who underwent hypospadias repair between 2001 and 2017, 243 sexually active patients were included in the study. At their last visit, cosmetic and sexual evaluation were done through the Penile Perception Score, the Hypospadias Objective Scoring Evaluation, IIEF, MSHQ-EjD. The levels of erectile dysfunction(ED) severity were determined according to erectile function domain of IIEF. The median follow-up after the last surgery was 16 [IQR (13-18)] years, and median patient age at the time of study was 19.67 [IQR(18-22)] years. Patients were divided into two subgroups as follows: Group I; Repairs using grafts (n = 120, 49.4%) and Group II; Graft-free repairs (n = 123, 50.6%). The rate of dissatisfaction with penile appearance was higher in Group I (16.7% vs. 4.9%, p = 0.003). Mild ED was more frequent in Group I (14.2% vs. 3.3%, p = 0.007); while none of the patients had either moderate or severe ED. Other domains of sexual function were observed to be similar in both groups. The need for unwanted interventions due to complications, and surgeries requiring grafts were found to be risk factors for ED development and dissatisfaction with penile appearance in adulthood. Those who underwent graft-free hypospadias repair experience better cosmetic and sexual outcomes when compared to grafted repairs, yet, satisfactory results were achieved in almost 90% of the grafted repairs.

Voiding Cystourethrogram Before Pyeloplasty: To Do or Not To Do?

OBJECTIVE: To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction (UPJO) and to identify factors that predict VUR. METHODS: Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed. A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study. Demographic parameters, preoperative hydronephrosis grade, renal pelvis anteroposterior diameter (APD), renal parenchymal thickness (PT), split renal functions on MAG-3 scan and VUR status were noted. The patients were divided into two groups: those with concomitant VUR (group I, n: 24, 8.9%) and those without VUR (group II, n: 246, 91.1%). RESULTS: Among 270 patients (205 boys, 75.9%) with a median age of 4 months (2-98), 197 (72.9%) had antenatal hydronephrosis. Median follow-up was 11 years (5-22). Among 24 patients with concurrent VUR, 6 (25%) had grade II VUR, whereas grade III-V VUR was detected in 18 (75%). Of these, 12 (50%) had ipsilateral VUR, 3 (12.5%) had contralateral, and 9 (37.5%) had bilateral VUR. In a median 137-month follow-up, spontaneous VUR resolution was observed in 6 (25%) patients, whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3 (12.5%) patients ureteroneocystostomy, respectively. Preoperative APD [35.5, (Inter Quantile Range) IQR (27.6-36.0) vs 26.5 IQR (25.0-35.0), P = .004] were significantly higher in group I, whereas group I had significantly lower PT [3.7, IQR (3.4-6.4) vs 5.8 IQR (4.4-6.1), P = .026]. Predictive factors for concomitant VUR were presentation with febrile UTI (odds ratio (OR): 2.769, P = .048), PT <3.95 mm (OR: 1.367, P = .043), and APD >28.8 mm (OR: 1.035, P = .001). CONCLUSION: Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty, while some type of surgical intervention for VUR was required in 75% of these patients. Thus, voiding cystourethrogram prior to pyeloplasty may be limited in those presenting with febrile urinary tract infection, having higher APD and lower PT on preoperative urinary ultrasonography.

What to Expect on the Long-term Follow-up of Pediatric Pyeloplasty: Critical Time Intervals and Risk Factors.

BACKGROUND: Standard protocol for post-pyeloplasty monitoring in children and natural course of hydronephrosis resolution have not been well defined. We aimed to analyze critical time intervals and risk factors in the long-term clinical outcomes of children who were operated for ureteropelvic junction obstruction. METHODS: Files of patients who underwent open dismembered pyeloplasty between January 2000 and December 2012 and had a ≥10 years follow-up were retrospectively reviewed. Changes in SFU hydronephrosis grade, pelvis anteroposterior diameter (APD), renal parenchymal thickness, split renal functions (SRF) on MAG-3 scan as well as development of hypertension and proteinuria were noted. Complete resolution was defined as SFU grade 0-1 or APD≤10 mm or ≥50 % APD decrease. RESULTS: Overall, 223 patients (161 boys, 72.1 %) with a median age of 9 (range 1-185) months underwent unilateral pyeloplasty, whereas 14 patients (13 boys, 92.8 %) with a median age of 4 (range 2-39) months underwent bilateral pyeloplasty. Median follow-up was 13 (range 10-22) years. Complete resolution was observed in 190 patients (85.2 %). None of the cases required re-do pyeloplasty. Regarding unilateral cases, postoperative changes in hydronephrosis reached a plateau at the 60th month. Also, there was no significant difference regarding SRF between the 12th month and the 60th month (p > 0.05). Hypertension developed after a median period of 12 years in 13 (5.4 %) of the patients, while proteinuria developed in four (1.6 %) patients. Bilateral disease (HR: 2.518, p = 0.034) was found to be a significant determinant for development of hypertension and/or proteinuria. CONCLUSIONS: Our results indicated that ultrasonographic findings stabilized after the 60th month postoperatively, and SRF remained stable between the postoperative 12th and the 60th months. The risk of developing hypertension and/or proteinuria was 2.5 times greater in bilateral cases. LEVEL OF EVIDENCE: Level II.

Can urinary caspase-3 and cytochrome c levels be used as predictive biomarkers in the management of unilateral antenatal hydronephrosis?

PURPOSE: We aimed to investigate the urinary caspase-3 and cytochrome c levels in patients with unilateral antenatal hydronephrosis and to determine whether changes in urinary biomarker levels could be useful for both predicting the need for surgical intervention due to ureteropelvic junction obstruction (UPJO) and postoperative surgical success. METHODS: Sixty-five children with a history of unilateral antenatal hydronephrosis and postnatal anteroposterior diameter ≥ 10 mm were included in this prospective case-control study between January 2013 and December 2021. The obstruction group consisted of 33 patients (28 boys, 84.8%) who underwent open dismembered pyeloplasty due to UPJO. The non-obstructive dilatation (NOD) group consisted of 32 patients (27 boys, 84.4%) with stable or improving hydronephrosis and no significant reduction in ipsilateral split renal function during follow-up, whereas 34 healthy children were enrolled in the study as a control group. Urinary urinary caspase-3 and cytochrome c levels using ELISA were measured. RESULTS: The median preoperative urinary caspase-3 level was significantly higher in the obstruction group when compared to the NOD group (4.82 ng/mgCr vs. 2.61 ng/mgCr, p = 0.013) as well as the control group (4.82 ng/mgCr vs. 1.72 ng/mgCr, p = 0.002). In the postoperative period, urinary caspase-3 levels significantly decreased compared to preoperative measurements (4.82 ng/mgCr vs. 2.51 ng/mgCr, p = 0.006) and became similar to the control group (2.51 ng/mgCr vs. 1.72 ng/mgCr, p = 0.422). On the other hand, no significant differences were observed in urinary cytochrome c levels between the groups. All patients who underwent pyeloplasty achieved postoperative resolution in hydronephrosis and improved drainage on MAG-3, so none of the patients required re-do pyeloplasty. Postoperative decrease in caspase-3 level was found to be compatible with adequate urine drainage on MAG-3 scan. The cut-off value of urinary caspase-3 to predict patients requiring pyeloplasty was found to be 3.31 ng/mg creatinine with 63.6% sensitivity, 62.5% specificity (AUC = 0.679). In the multivariable analysis, urinary caspase-3 level (OR: 1.653, p = 0.019), anteroposterior pelvic diameter (OR: 1.401, p = 0.001), and split renal function on MAG-3 (OR: 1.277, p = 0.011) were found to be independent factors in determining patients who require surgery. CONCLUSION: Based on our preliminary findings, urinary caspase-3 levels could be a useful biomarker not only for predicting the need for surgical intervention but also for determining the postoperative surgical success in children with UPJO.

Tunica albuginea decompression fails to alter the injury of prolonged arterial occlusion during testicular torsion.

PURPOSE: The correlation between intratesticular pressure during torsion/detorsion and subsequent testicular function and viability has been reported in several recent studies. We assessed the impact of tunica albuginea incision with tunica vaginalis flap coverage on intratesticular pressure and future histopathological parameters in a rat testicular torsion model. MATERIALS AND METHODS: A total of 21 rats were divided into 3 groups. Group 1 consisted of 7 controls undergoing a sham operation, group 2 consisted of 7 animals undergoing torsion-detorsion, and group 3 consisted of 7 animals undergoing testicular torsion-detorsion followed by tunica albuginea incision and tunica vaginalis flap coverage. Torsion was created by 720-degree counterclockwise rotation of the left testis for 2 hours. By using a compartment monitor, the intratesticular pressure of the torsed testes was measured before torsion (pre-torsion), immediately before torsion repair (pre-detorsion), 5 minutes after detorsion (post-detorsion), and after tunical incision and tunica vaginalis flap application. The correlations between intratesticular pressure values and testicular weight, modified Johnsen score and mean seminiferous tubule diameter were evaluated 4 weeks postoperatively. RESULTS: Median pre-detorsion intratesticular pressure was significantly decreased after detorsion in group 2 (21 vs 7 mm Hg, p <0.001) and group 3 (23 vs 7 mm Hg, p = 0.001). In addition, median intratesticular pressure after tunica albuginea incision and tunica vaginalis flap coverage in group 3 was significantly less compared to median post-detorsion intratesticular pressure in group 2 (5 vs 7 mm Hg, p = 0.025). Overall no significant difference was detected between groups 2 and 3 regarding median modified Johnsen score, mean seminiferous tubule diameter or median testicular weight. The significant reduction of intratesticular pressure in group 3 did not correlate with testicular weight (r = 0.500, p = 0.391), modified Johnsen score (r = -0.205, p = 0.741) or mean seminiferous tubule diameter (r = -0.200, p = 0.747). CONCLUSIONS: Tunica albuginea decompression with tunica vaginalis flap coverage is an effective technique for decreasing intratesticular pressure in torsed testes. However, this technique failed to alter the injury of prolonged arterial occlusion in testicular torsion.

Manganese superoxide dismutase Ile58Thr, catalase C-262T and myeloperoxidase G-463A gene polymorphisms in patients with prostate cancer: relation to advanced and metastatic disease.

OBJECTIVE: To evaluate the relationship between manganese superoxide dismutase (MnSOD) Ile58Thr, catalase (CAT) C-262T and myeloperoxidase (MPO) G-463A gene polymorphisms and the susceptibility and clinicopathological characteristics of prostate cancer. PATIENTS AND METHODS: In all, 155 patients diagnosed with prostate cancer and 195 controls with negative digital rectal examinations and PSA levels of <4 ng/dL were enrolled in this study. MnSOD, CAT and MPO gene polymorphisms were identified by polymerase chain reaction restriction-fragment length polymorphism methods. RESULTS: The TT genotype in MnSOD Ile58Thr polymorphism, CC genotype in the CAT C-262T polymorphism and the GG genotype in the MPO G-463A polymorphism were the predominant genotypes amongst this Turkish male population. There was no association between MnSOD Ile58Thr polymorphism and prostate cancer. For the CAT C-262T polymorphism, the TT genotype had significantly increased prostate cancer risk compared with the CC genotype. Similarly, the TT genotype had a 1.94- and 3.83-fold increased risk for high-stage disease and metastasis, respectively, when compared with the CC genotype. For the MPO G-463A polymorphism, the GG genotype had 1.78-fold increased risk of prostate cancer compared with the AA genotype. However, no association was found regarding Gleason score, advanced and metastatic prostate cancer risk. CONCLUSIONS: It seems that there is no association of prostate cancer with MnSOD Ile58Thr polymorphism, whereas the TT genotype in the CAT C-262T polymorphism and the GG genotype in the MPO G-463A polymorphism may be associated with increased prostate cancer risk. The TT genotype in the CAT C-262T gene polymorphism may also be a risk factor in tumour progression and metastasis among Turkish men.

Use of a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi.

BACKGROUND: To report our initial experiences using a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi. MATERIALS AND METHODS: Two patients underwent this technique for tumors 11- and 13-cm in diameter. After transection of the renal artery with limited mobilization of the kidney using a retroperitoneoscopic approach, additional ports were placed, and the management of the tumor thrombus was performed in the large working space provided by the transperitoneoscopic approach. RESULTS: The technique was feasible in the present 2 cases. The total operative times were 170 and 200 min, respectively. The estimated blood loss was 450 cc in the first case and 200 cc in the second case. No complications were observed in either of the patients. CONCLUSIONS: Based on the initial clinical experience, we have presented a feasible surgical option for the laparoscopic management of renal cell carcinoma with level I thrombi.

Outcomes of a newly established transitional urology outpatient clinic: a real-world experience.

PURPOSE: To evaluate the demographic and clinical characteristics of patients who visited our transitional urology (TU) outpatient clinic formed by pediatric urologists with urology background within the first year upon its establishment. METHODS: Files of 130 consecutive patients who visited our TU outpatient clinic, which was established in 01 March 2021, between 01 March 2021 and 01 March 2022 were retrospectively collected. Patients were divided into two groups: those with a previous follow-up in our pediatric urology department (Group I, n: 81, 62.3%) and those who were followed up in other clinics during childhood (Group II, n: 49, 37.7%) afterwards. Demographic characteristics, complaints at admission, previous medical history, and management plans at the recent clinical visit were noted. We defined a successful and smooth transition from childhood to adult care as not being without follow-up within the first year after the age of 18 years and not requiring extraordinary medical assistance (e.g., emergency room visits, hospitalization, intensive care unit admissions) from the last urological control to the TU outpatient clinic visits. RESULTS: The most common diagnoses were vesicoureteral reflux (n: 32, 24.6%), neuropathic bladder accompanied by spina bifida (n: 31, 23.8%), obstructive uropathy (n: 25, 19.2%), hypospadias (n: 20, 15.3%), non-neurogenic lower urinary tract dysfunction (n: 19, 14.6%), and bladder exstrophy (n: 8, 6.1%). The distribution of primary diagnosis in the two patient groups was similar. The median time from the last pediatric urology visit to the current TU clinical visit was significantly longer in Group II (12 vs. 60 months, p < 0.001),consequently, the median patient age at admission was significantly higher in Group II (21 vs. 23 years, p = 0.020). The rate of a successful and smooth transition was 86.4% in Group I, whereas Group II had a completely unsuccessful transition period. Upon admission to TU outpatient clinic, the requirement of a surgical intervention was lower in Group I (21% vs. 38.8%, p = 0.028).Also,the need for medical treatment changes was higher in Group II (9.9% vs. 53.1%, p < 0.001). CONCLUSION: Our findings emphasize the importance of patient referral to a TU clinic that deal with lifelong problems of congenital genitourinary diseases. Delays in receiving medical or surgical treatments during transition from childhood to adulthood may be associated with higher need for subsequent surgical interventions in this vulnerable patient population.

Lower Urinary Tract Reconstruction for Ectopic Ureterocele: What Happens in the Long-term Follow-up?

BACKGROUND: We aimed to analyze the long-term clinical and lower urinary tract function outcomes in children with duplex system ectopic ureterocele who underwent ureteroneocystostomy and ureterocelectomy. METHODS: Fifty-one patients (28 females, 23 males) who underwent a series of surgical interventions including lower urinary tract reconstruction in childhood for duplex system ectopic ureterocele in our center between 1998 and 2019, were retrospectively reviewed. The demographic and clinical data, surgical history, and the indication for ureterocelectomy were noted. Lower urinary tract dysfunction (LUTD) status was assessed through dysfunctional voiding symptom scores (DVSS) and uroflowmetry in all patients at the last follow-up. The clinical outcomes, and LUTD were evaluated. RESULTS: At the last visit at a mean follow-up of 117.18 ± 57.87 months after ureterocelectomy, ipsilateral persistent lower pole VUR was detected in 5.6% (3/54 renal units, 2 females and 1 male) of the cases, who were treated using the subureteric injection. Abnormal DVSS (median 11, range 9-15) was detected in 27.4% (14/51 pts) of the patients. Out of these, 57.1% (8/14 pts) had storage symptoms, 35.7% (5/14 pts) had voiding symptoms, and 7.1% (1/14 pts) had both storage and voiding symptoms while 71.4%(10/14 pts) had abnormal uroflowmetry findings (plateau shaped flow curve in 2, staccato shaped curve with sustained EMG activity in 3, tower shaped curve in 2, interrupted shaped curve in 3 patients). Five patients had elevated residual volume. Anticholinergics were administered to six patients who had overactive bladder symptoms. In addition, two girls required open bladder neck reconstruction due to stress incontinence caused by bladder neck insufficiency. CONCLUSIONS: Our findings showed that clinical success was achieved using the lower urinary tract reconstruction with no need for re-operation in 90.2% of patients with duplex system ectopic ureterocele. However, LUTD was present in 27.4% of our patients in the long-term follow-up. Therefore, LUTD should be carefully assessed in the long-term follow-up of these patients.

Impact of the Age at Distal Hypospadias Surgery on Behavioral Problems, Somatic Symptoms and Irritability Levels in Children.

BACKGROUND: To assess the effect of age at hypospadias surgery on emotional and behavioural problems, somatic symptoms, irritability, and penile perception. METHODS: We retrospectively identified the patients who underwent single distal hypospadias surgery and age-matched healthy controls were included. There were two further subgroups according to the age at the time of hypospadias repair (<2 vs. >2 years). The Strengths and Difficulties Questionnaire (SDQ), Revised Children's Anxiety and Depression Scale (RCADS), Affective Reactivity Index (ARI), Level 2 Somatic Symptom Scale, and Penile Perception Score (PPS) scale were used. The groups were compared using multivariate variance analysis (MANOVA). RESULTS: Both groups consisted of 70 patients (mean age 14.0 ± 0.2 years, for both), while there were 34 patients in the hypospadias groups who underwent surgery at <2 years of age. Depressive, panic, separation anxiety, social phobia, and somatic complaint symptom scores of the hypospadias group were lower than those of the control group. Obsessive-compulsive symptom levels were significantly higher in patients who underwent hypospadias surgery at >2 vs. <2 years of age. Additionally, PPSs rated by the surgeon were significantly higher in the former. A multivariate linear regression model indicated that panic disorder symptom scores predicted child PPS in the hypospadias group. Limitations include retrospective design. CONCLUSIONS: Single hypospadias surgery seems not to have a negative impact on emotional and behavioural status. Children who underwent distal hypospadias surgery after 2 years of age had higher levels of obsessive-compulsive symptoms. Following emotional status may help the early diagnosis of future psychopathologies. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: III.