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.

Penoscrotal transposition: Long-term outcome in 29 patients.

OBJECTIVE: Penoscrotal transposition (PST) is a rare anomaly of the external genitalia characterized by malposition of the penis in relation to the scrotum. This transposition may be partial or complete and may be associated with hypospadias, chordee, and other anomalies. We have reviewed our experience with the surgical repair of PST utilizing a modified Glenn-Anderson technique. MATERIALS AND METHODS: Twenty-nine patients with a median age of 5.6 years (8 months -15 years) underwent surgical repair of PST at our institution between 2004-2022. Of those, 20 (69%) had complete PST, while 9 (31%) had partial PST. All children were divided into three groups. In the first group of 8 (28%) children, repair of PST was an integral part of one-stage male genitoplasty; in the second group of 18 (62%) children, repair of PST was an isolated last stage of the staged hypospadias repair and the remaining 3 (10%) children underwent PST repair without the presence of hypospadias. All patients underwent modification of the Glenn-Anderson technique involving utilization of bilateral rotational advancement scrotal flap, complete de-tethering of the testis from the internal part of the scrotum when indicated, and relocation of the scrotal compartment in a normal dependent position. The follow-up ranged from 6 months to 18 years. RESULTS: In the first group, five children (62%) underwent Onlay Prepucial Island Pedicle Flap (OIF) hypospadias repair, and three (38%) underwent Long Tubularized Incised Plate Repair (TIP). In the second group, 8 (44%) underwent OIF hypospadias repair, 2 (12%) had Long TIP repair, and the remaining 8 (44%) underwent staged hypospadias repair. Post-operative Clavien Dindo grade III presented among three patients in group I and only one patient in group II. In the third group, no postoperative complications were observed. CONCLUSION: Our data show that penoscrotal transposition correction utilizing the Glenn-Anderson technique is a reliable and durable surgery in the pediatric population. These children require careful monitoring till adolescence to ensure that no re-operation is needed.

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.

Ultrasound-guided percutaneous nephrolithotomy (PCNL) success rates in patients with elevated body mass index: a comparative study.

Percutaneous nephrolithotomy (PCNL) is considered gold standard treatment of renal stones larger than 20 mm. Several studies have shown that ultrasound guidance during this procedure is more effective and safer than fluoroscopy. A higher body mass index (BMI) can make ultrasound-guided renal access more difficult and unsuccessful. We present a prospective analysis and comparison of ultrasound-guided PCNL in patients with normal and increased body mass index. We performed a prospective comparison of patients who underwent ultrasound-guided PCNL to remove renal stones by a single surgeon between 2020 and 2022. Patients with BMIs greater than 30 (mean 33.87-obese) were compared to those with BMIs less than 30 (mean 25.69-non-obese). Demographic, perioperative, and follow-up data were collected, analyzed, and included in this study. Total of 98 consecutive patients, with 49 patients in each group were analyzed. No statistically significant differences were observed in terms of stone volume (P = 0.085), stone density (P = 0.5590), location of renal access (P = 0.108), surgery duration (P = 0.38), blood loss (P = 0.54), or laboratory changes after surgery (P = 0.60). 87.76% of obese patients were stone free per CT scan at follow-up, compared to 73.47% of normal-weight patients (P = 0.1238). According to Clavien-Dindo classification, six patients in the non-obese group experienced grade II (10%) and grade III (2%) complications, as opposed to six patients in the obese group with grade I (2%), grade II (6%), and grade III (2%) complications. There was no significant correlation between body mass index and the success or safety of ultrasound-guided PCNL. Although more challenging, a higher BMI should not be an impediment to performing this approach. This method is safe, with no increased incidence of postoperative complications or compromise in stone-free status postoperatively and can diminish or avoid both patient's and medical team's exposure to ionizing radiation.

The effect of ureteropelvic junction obstruction and pyeloplasty on somatic growth during infancy.

Background: Evidence regarding the impact of perinatal ureteropelvic junction obstruction (UPJO) and surgical correction during infancy, on somatic growth are scarce. Understanding these impacts could help advise parents and aid in treatment decision making. Objectives: To assess the impact of unilateral UPJO and surgical correction on somatic growth in infants diagnosed antenatally and treated during infancy. Design: A retrospective bi-institutional analysis of somatic growth in patients under 2 years who underwent dismembered pyeloplasty for the treatment of UPJO was conducted. Methods: We evaluated patients who were diagnosed with unilateral hydronephrosis during pre-natal ultrasound screening for detection of fetal anomalies between May 2015 and October 2020. The height and weight of patients who were diagnosed with UPJO were recorded at the age of 1 month, time of surgery, and 6 months after surgery. Standard deviation scores (SDSs) for height and weight were calculated and compared. Results: Forty-eight patients under the age of 2 years were included in the analysis. Median age and weight at pyeloplasty were 6.9 months and 7.5 kg. At 1 month, the median SDS for weight in the entire cohort was -0.30 [interquartile range (IQR): -1.0 to 0.63] and the median SDS for height was -0.26 (IQR: -1.08 to 0.52). In 22.9% of patients (11/48), weight and height were below -1 age-appropriate standard deviations, and 6.3% (3/48) were below -2 standard deviations, suggesting growth restriction. When comparing SDS for the entire cohort, there was no significant difference corelated to measurement time or effect of surgery. In the growth restricted cohort, we found a significant improvement in linear growth for height, which was demonstrated between birth and surgery as well as after surgery. Conclusion: Infants with unilateral UPJO diagnosed antenatally as a single anomaly may be at an increased risk of somatic growth restriction in comparison with the general population. In children with growth restriction at time of birth, height seems to improve regardless of surgical treatment. Pyeloplasty during infancy does not seem to negatively affect somatic growth. These findings can be used to counsel parents regarding the potential effects of UPJO and pyeloplasty.

Open Label, Pilot Evaluation of the Safety and Efficacy of Intravesical Sustained Release System of Lidocaine and Oxybutynin (TRG-100) for Patients With Interstitial Cystitis/Bladder Pain Syndrome, Overactive Bladder and Patients With Retained Ureteral Stents Following Endourological Interventions.

BACKGROUND: Intravesical instillation of analgesic and anticholinergic drugs have shown efficacy in the treatment of pain and voiding symptoms. Unfortunately, drug loss with urination and dilution in the bladder limit their durability and clinical usefulness. We have recently developed and tested in vitro, a sustained delivery system (TRG-100) of fixed-dose combination of lidocaine and oxybutynin designed to allow for a longer exposure of the urinary bladder to the drugs. OBJECTIVE: To asses the safety and efficacy of TRG-100 in Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), overactive bladder (OAB), and endourological intervention stented (EUI) patients in an open-label, prospective study. METHODS: Thirty-six patients were enrolled: 10 IC/BPS, 10 OAB, and 16 EUI. EUI patients received a once-weekly installation until stent removal, OAB and IC/BPS patient received weekly installations for 4 consecutive weeks. Treatment effect was assessed by visual analog scale (VAS) score for the EUI group, voiding diaries for OAB group and VAS score, voiding diaries and O'Leary Sant Questionnaires for the IC/BPS group. RESULTS: The EUI group showed a mean 4-point improvement in their VAS score. The OAB group showed 33.54% reduction in frequency of urination and IC/PBS group showed a mean of 3.2-point improvement in their VAS score, 25.43% reduction in frequency of urination, and a mean 8.1-point reduction in O'Leary Sant Questionnaires score. All changes were statistically significant. CONCLUSION: Intravesical instillation of TRG-100 was found to be safe and efficient in reducing pain and irritative bladder symptoms in our study population. TRG-100 efficacy and safety should be further assessed in a large, randomized control trial.