Outcomes of ureteroscopy for management of stone disease in early and late childhood over a 15-year period.

Background: Although paediatric ureteroscopy is widely performed, there is still a lack of data and outcomes in early childhood. In this two-centre study, we compared the outcomes of ureteroscopy for stone disease management in early and late childhood and provide outcomes for the same. Methods: Data was retrospectively collected on consecutive patients from two tertiary paediatric endo-urology European centres over a 15-year period (2006-2021). Patients were split into two groups, namely, early childhood (age ⩽ 9 years) and late childhood (age 9 to ⩽16 years). Outcomes including stone-free rate (SFR) and complications were compared between these two groups. Results: A total of 148 patients underwent 184 procedures (1.2 procedure/patient) during the study period (66 in early childhood and 82 in late childhood). The mean age in early and late childhood groups were 5.6 and 13.3 years, and a male: female ratio of 1.6:1 and 1.1:1, respectively. The SFR and complications in early and late childhood groups were 87.8% and 90.2% (p = 0.64) and 5.7% and 4.1%, respectively. Conclusion: Paediatric ureteroscopy and laser stone fragmentation achieves good results in both early and late childhood with comparable SFRs, although the complications and need for second procedure were marginally higher in the early childhood group. Our study would set up a new benchmark for patient counselling in future, and perhaps this needs to be reflected in the paediatric urolithiasis guidelines.

Role of Pediatric Ureteral Access Sheath and Outcomes Related to Flexible Ureteroscopy and Laser Stone Fragmentation: A Systematic Review of Literature.

Context: Flexible ureteroscopy and laser lithotripsy (FURSL) represent a good treatment option for pediatric urolithiasis. Scarce evidence is available about the safety and efficacy of the concomitant use of a ureteral access sheath (UAS) in the setting of pediatric ureteroscopy (URS). Objective: To acquire all the available evidence on UAS usage in pediatric FURSL, focusing on intra- and postoperative complications and stone-free rates (SFRs). Evidence acquisition: We performed a systematic literature research using PubMed/MEDLINE, Embase, and Scopus databases. The inclusion criteria were cohorts of pediatric patients <18 yr old, submitted to URS for FURSL, reporting on more than ten cases of UAS placement. The primary outcomes were prestenting rates, operating time, ureteric stent placement rates after surgery, rates and grades of complications, ureteral injuries, and overall SFR. A total of 22 articles were selected. Evidence synthesis: In total, 26 intraoperative and 130 postoperative complications following URS with UAS placement were reported (1.8% and 9.18% of the overall procedures, respectively). According to the Clavien-Dindo classification, 32 were classified as Clavien I, 29 as Clavien II, 43 as Clavien I or II, six as Clavien III, and one as Clavien IV. Twenty-one cases of ureteral injuries (1.59%) were noted in the whole cohort; most of them were ureteral perforation or extravasation, and were treated with a temporary indwelling ureteric stent. The overall SFR after a single URS procedure was 76.92%; after at least a second procedure, it was 84.9%. Conclusions: FURSL is a safe and effective treatment option for pediatric urolithiasis. UAS use was associated with a low rate of ureteric injuries, mostly treated and resolved with a temporary indwelling ureteric stent. Patient summary: We performed a systematic literature research on the utilization of a UAS during ureteroscopy for stone treatment in pediatric patients. We assessed the outcomes related to the rates of intra- and postoperative complications and the rates of efficacy of the procedure in the clearance of stones. The evidence shows a low rate and grade of complications associated with UAS placement and good stone-free outcomes. A ureteric injury may occur in 1.6% of cases, but it is usually managed and resolved with a temporary indwelling ureteric stent.

Retrograde Intrarenal Surgery in Children: Evolution, Current Status, and Future Trends.

Introduction: Incidence of urolithiasis in children has increased in recent years and with technological advancements and miniaturization of surgical instruments, pediatric urologists have acquired an impressive arsenal for their treatment. Retrograde intrarenal surgery (RIRS) has gained widespread popularity as it is a natural extension of semirigid ureteroscopy and can be done through natural orifice minimizing the morbidity of percutaneous access. The aim of this narrative review is to describe how RIRS has evolved over the decades in children and if the age-related anatomical difference impacts reported outcomes especially stone-free rate (SFR) and complications. Materials and Methods: An electronic literature search from inception to October 15, 2021 was performed using Medical Subject Heading terms in several combinations on PubMed, EMBASE, and Web of Science without language restrictions. A total of 2022 articles were founded and 165 articles were full-text screening. Finally, 2 pediatric urologists included 51 articles that summarize the available literature regarding the development and use of RIRS in children. Results: RIRS as of today is well established as a superior modality for all stones in all locations compared with extracorporeal shockwave lithotripsy both in children and adults. The passive dilation has decreased the need of active ureteral dilation, but the need to perform prestenting is not defined yet. Regarding the use of the ureteral access sheath, the literature tends to lean toward its placement in most cases, but we do not know its long-term effects over the growth of children. Finally, the SFR has increased as the experience of pediatric urologists increases, as well as the number of complications has decreased. Conclusion: RIRS in pediatrics has crossed many milestones, yet many areas need further research and larger data are required to make RIRS the procedure of choice for renal stone management in children across all age groups.

Can cystinuria decrease the effectiveness of RIRS with high-power ho:yag laser in children? Outcomes from a tertiary endourology referral center.

Cystinuria, which is the cause of cystine urolithiasis, accounts for 2-6% of all urinary stones in children, has a low prevalence with a high recurrence rate, making this metabolic disorder a therapeutic challenge in pediatric population. The aim of this work is evaluate the efficacy and safety of retrograde intra-renal surgery (RIRS) in pediatric patients with cystinuria and kidney stones smaller than 2 cm. Prospective study of 64 stones treated in 22 retrograde intra-renal surgeries (RIRS) in cystinuric pediatric patients with renal or proximal ureteral stones less than 2 cm. Average age of 9.5 years. The following data were analyzed: demographics, stone characteristics and surgical data with intra- and postoperative complications. Location of the stones was 68.7% in the calyces, 20.3% in the renal pelvis, and 9.3% in the ureteropelvic junction; 41% of cases had multiple locations. The average cystinuria level before the procedure was 825 mg/dL. The anatomy of 73% of the interventions increased the difficulty of flexible ureteroscopy and decreased stone free rates, because distorted renal anatomy was present: sclerosis of the pelvis or infundibulum, abnormal calyceal dilations, or excluded calyces. Intraoperative complications occurred in 18.2% of the procedures. Reno-vesical ultrasound was performed in all patients in the first postoperative month, with an SFR of 59%. Cystinuric patients are a challenge for pediatric urologists, decreasing the effectiveness of RIRS. However, it could be better treatment than SWL and with fewer complications than PCNL in the pediatric population with this disease.

Clinical utility of genetic testing in early-onset kidney disease: seven genes are the main players.

BACKGROUND: Inherited kidney diseases are one of the leading causes of chronic kidney disease (CKD) that manifests before the age of 30 years. Precise clinical diagnosis of early-onset CKD is complicated due to the high phenotypic overlap, but genetic testing is a powerful diagnostic tool. We aimed to develop a genetic testing strategy to maximize the diagnostic yield for patients presenting with early-onset CKD and to determine the prevalence of the main causative genes. METHODS: We performed genetic testing of 460 patients with early-onset CKD of suspected monogenic cause using next-generation sequencing of a custom-designed kidney disease gene panel in addition to targeted screening for c.428dupC MUC1. RESULTS: We achieved a global diagnostic yield of 65% (300/460), which varied depending on the clinical diagnostic group: 77% in cystic kidney diseases, 76% in tubulopathies, 67% in autosomal dominant tubulointerstitial kidney disease, 61% in glomerulopathies and 38% in congenital anomalies of the kidney and urinary tract. Among the 300 genetically diagnosed patients, the clinical diagnosis was confirmed in 77%, a specific diagnosis within a clinical diagnostic group was identified in 15%, and 7% of cases were reclassified. Of the 64 causative genes identified in our cohort, 7 (COL4A3, COL4A4, COL4A5, HNF1B, PKD1, PKD2 and PKHD1) accounted for 66% (198/300) of the genetically diagnosed patients. CONCLUSIONS: Two-thirds of patients with early-onset CKD in this cohort had a genetic cause. Just seven genes were responsible for the majority of diagnoses. Establishing a genetic diagnosis is crucial to define the precise aetiology of CKD, which allows accurate genetic counselling and improved patient management.

Hydronephrosis Classifications: Has UTD Overtaken APD and SFU? A Worldwide Survey.

Objective: To collect baseline information on the ultrasonographic reporting preferences. Method: A 13-multiple choice questionnaire was designed and distributed worldwide among pediatric urologists, pediatric surgeons, and urologists. The statistical analysis of the survey data consisted of 3 steps: a univariate analysis, a bivariate and a multivariate analysis. Results: Three hundred eighty participants responded from all the continents. The bivariate analysis showed the significant differences in the geographical area, the years of experience and the volume of cases. Most of the physicians prefer the SFU and APD systems because of familiarity and simplicity (37 and 34%, respectively). Respondents noted that their imaging providers most often report findings utilizing the mild-moderate-severe system or the APD measurements (28 and 39%, respectively) except for North America (SFU in 50%). Multivariate analysis did not provide significant differences. Conclusion: Our study evaluates the opinions regarding the various pediatric hydronephrosis classification systems from a large number of specialists and demonstrates that there is no single preferred grading system. The greatest reported shortcoming of all the systems was the lack of universal utilization. The observations taken from this study may serve as basis for the construction of a common worldwide system. As APD and SFU are the preferred systems and the UTD a newer combination of both, it is possible that with time, UTD may become the universal language for reporting hydronephrosis. This time, based on the result of this survey, seems not arrived yet.

[Impact of COVID-19 during de-escalation in pediatric urology.] / El impacto del COVID-19 en la epoca de transición o "desescalada" en la urología pediátrica.

Medical and surgical priorities have changed dramatically following the COVID-19 pandemic declaration. The rapid spread of the virus and the high number of cases has saturated the health system in our country and has forced many hospitals to redistribute resources to care for infected patients. This has led to asignificant reduction in surgical activity, in some cases reaching the point of delaying all elective interventions by performing only urgent interventions. The decrease in the number of infections with the progressive desaturation of hospitals has currently allowed us to enter a new phase of "de-escalation" or transition in order to recover our surgical activity in pediatric urology, which was practically canceled. It is proposed how surgical care activities such as outpatient care should be deal twith, in addition to the different circuits that patients must maintain and, above all, their and professional safety.

Las prioridades médicas y quirúrgicas han cambiado drásticamente tras la declaración de pandemia de COVID-19. La rápida propagación del virus y el elevado número de casos ha saturado el sistema sanitario de nuestro país y obligado a muchos hospitales a redistribuir sus recursos para atender a los pacientes infectados. Esto ha llevado a una reducción significativa de la actividad quirúrgica llegando al extremo de demorar todas las intervenciones electivas, realizándose únicamente las intervenciones urgentes. La disminución del número de contagios con la progresiva desaturación de los hospitales nos ha permitido en la actualidad entrar en una nueva fase de "desescalada" o de transición para poder recuperar nuestra actividad quirúrgica dentro de la urología pediátrica que fue prácticamente cancelada. Se propone cómo se debe afrontar la actividad asistencial quirúrgica así como la actividad de consultas externas, además de establecer los distintos circuitos que deben mantener los pacientes para su seguridad y la de los profesionales que los atienden.

Robot-assisted Radical Prostatectomy Due to a Primary Carcinoid Prostatic Tumor in a Three-Year-Old Child: A Case Report.

We present an extremely rare case of a 3-year-old child with a primary carcinoid tumor of the prostate. A 3-year-old boy presented with failure to thrive, constipation, recurrent respiratory tract infections, and pain in the genital area. His karyotype was normal and cystic fibrosis and coeliac disease were excluded prior to further investigation. An abdominopelvic computed tomography scan revealed a prostatic mass. Transrectal ultrasound-guided prostate biopsy was therefore performed and pathological examination revealed a carcinoid tumor. A robotic radical prostatectomy was performed. As this is an innovative surgical approach, we describe the surgical technique used.

[Radical prostatectomy in patients with history of transurethral resection of the prostate]. / Prostatectomía radical en pacientes con antecedentes de RTU próstata.

OBJECTIVES: To perform a retrospective evaluation of surgical complications and morbidity in patients undergoing radical retropubic prostatectomy (RRP) as elective treatment for organ-confined prostate cancer in our center with previous transurethral resection of the prostate (TURP). METHODS: Between 1980-2004 we performed 59 radical prostatectomies in patients with previous TURP. We analyze the morbidity and mortality of the RRP, its functional outcomes, and the accordance between clinical and pathological stage. RESULTS: Mean time between TURP and RRP was 16 months. Mean patient age at the time of diagnosis was 63 years. Clinical stage: 16 T1a, 18T1b, 20T1c, 3T2a, 2T2b. Average surgical time was 180 minutes. Intraoperative events: technical difficulties in the dissection of the gland 57%, bladder neck preservation 27%, neuro vascular bundles preservation 3.39%, ureter ligation 1.69%, rectal laceration 1.69, urethrorrhagia 1.69%, urinary leak 5%, and blood transfusions 11.8%. Postoperative complications: urinary tract infection 10.17%, wound infection 10.17%, pelvic hematoma 5.08%, deep vein thrombosis 1.69%, and one sudden death of unknown cause one month after surgery. Pathologic report: 49pT2b, 8 pT3 and 2pT4. Late complications: erectile dysfunction 85.7%, vesicourethral anastomosis stenosis 10.3%, and complete urinary incontinence 3%. CONCLUSIONS: Radical retropubic prostatectomy in patients with previous TURP is technically more difficult and has comparable outcomes to RRP patients without previous TURP.

Acute bacterial prostatitis: two different sub-categories according to a previous manipulation of the lower urinary tract.

Acute bacterial prostatitis (ABP) (NIH Category I), has not undergone any modification in the update of prostatitis classification. ABP was diagnosed in 614 patients in our centre over 9 years (1993-2001). We analyse the clinical pattern of ABP and the role of bladder outlet obstruction in its etiology, as well as whether two different ABP sub-categories could be defined as a function of a history of previous manipulation of the lower urinary tract. The results of the study show that the clinical pattern of a patient suffering from ABP does not differ from the statements of previous publications. On the other hand, patients with ABP have been shown to present with no bladder outlet obstruction. Finally, this study has disclosed the fact that the cases of ABP elicited by previous manipulation of the lower urinary tract (10%) show a different pattern from those cases where no previous manipulation has occurred (90%). The patients with ABP secondary to manipulation are older, have a higher risk of prostate abscess and higher frequency of multiple infections and also infections by pathogens other than Escherichia coli. Due to all of these reasons, it would be advisable to subdivide category I within the classification of prostatitis.

[Penile hematoma secondary to rupture of the superficial dorsal vein of the penis]. / Hematoma peneano secundario a rotura de la vena dorsal superficial del pene.

OBJECTIVES: To report a very unfrequent case of penile hematoma secondary to rupture of the superficial dorsal vein of the penis during intercourse. METHODS: 35-year-old patient presenting at the emergency department with a half moon shape hematoma in the dorsal part of the penis, not much painful, developed when initiating intercourse that we believe was a rupture of the superficial dorsal vein of the penis. RESULTS: In spite of the few cases of rupture of the superficial dorsal vein of the penis described, and after differential diagnosis with other causes of acute penis, conservative attitude with anti-inflammatory drugs and compressive bandage was undertaken. CONCLUSIONS: The rupture of the superficial dorsal vein of the penis is an unfrequent pathology which should be taken into differential diagnosis in a patient consulting with acute penile edema, the attitude is conservative with complete recovery without sequel.