Bladder Neck Surgery is not Routinely Needed to Achieve Urinary Continence in Patients with Primary Epispadias.

BACKGROUND: This study aims at investigating the continence outcome in primary epispadias patients treated at a tertiary center. The authors hypothesized that additional continence procedures following primary epispadias repair is not routinely needed. METHODS: Patients treated for primary epispadias at the authors' institution between 2007 and 2019 and toilet trained, were identified from a prospective maintained database. Males underwent chordee correction, urethroplasty and glanuloplasty. Females underwent genitoplasty with reduction urethroplasty. If continence was not achieved by 4-5 years of age, pelvic floor muscle (PFM) biofeedback therapy was performed. Other continent procedures were discussed with family/patient if still incontinent. PRIMARY OUTCOME: urinary continence. SECONDARY OUTCOMES: PFM biofeedback therapy, continence surgery, hydronephrosis. Type of epispadias, age at repair and follow-up presented as median was also reported. RESULTS: Thirty-three patients (29 males) were included. Twelve had penopubic epispadias, 13 glanular/penile, 4 duplicated urethra, 4 females. Median age at repair: 2 years (IQR 1-3), at follow-up: 8 years (IQR 6-10). Daytime continence: 100 % in penile/glanular; 33 % in penopubic and 75 % in duplicated urethra. Nighttime continence: respectively 92 %, 50 % and 100 %. 24 % of males were intermittently incontinent. All patients except one voided urethrally. One patient underwent bladder neck closure, ileocystoplasty and Mitrofanoff. One girl achieved daytime continence, 2 were intermittently incontinent, one continuously incontinent. All were enuretic. 38 % of boys and 100 % of girls had biofeedback therapy. None had hydronephrosis/renal impairment. CONCLUSIONS: Most children with primary epispadias can achieve social urinary continence spontaneously or with the support of PFM biofeedback therapy. Other continence procedures should be reserved for patients who do not attain satisfactory continence. LEVEL OF EVIDENCE: Treatment study - level IV.

Robot-assisted reconstructive surgery of lower urinary tract in children: a narrative review on technical aspects and current literature.

Background and Objective: Robotic approach is used widely for paediatric upper tract urinary reconstruction. This is a narrative review looking at the current status of robotic approach in lower urinary tract reconstruction. The aim of this article is to highlight the important technical aspects of commonly performed robotic lower urinary tract reconstructive surgeries and review the current literature. Methods: MEDLINE database search was conducted using MeSH terms and Boolean operators from Jan 2000 to Jun 2022. Abstracts were screened to exclude those in languages other than English as also articles pertaining to (I) upper urinary tract surgery, (II) only laparoscopic surgery (not robot-assisted) and (III) non-urological topics. Selected articles were then reviewed and search expanded to include their references with a focus on advanced lower urinary tract reconstruction. Key Content and Findings: The technical aspects of robotic ureteric reimplantation, continent catheterisable channel and autoaugmentation are discussed in detail. The early outcomes are comparable to open surgery. The true advantage of robotic approach becomes apparent when performing lower urinary tract reconstruction, where space in the pelvis is limited and access is challenging. Only a few centres are currently performing bladder neck surgery and bladder augmentation. Conclusions: Robotic lower urinary tract reconstruction in children is feasible and safe. Robotic approach offers better access, especially in the limited space within the pelvis. It reduces blood loss and post-operative pain allowing early recovery and discharge. Long-term follow-up with increasing experience could further validate these early observations.

Urethral Plate Grafting for Deficient Urethral Plate in Exstrophy: An Alternative Method to Augment Urethral Plate.

INTRODUCTION: Short urethral plate remains a challenge in exstrophy management. We report our experience with urethral plate grafting in cases of exstrophy with deficient urethral plate. METHODS: Among the exstrophy patients treated at the authors' institutions (2018-2022), those with a short urethral plate were prospectively included. A short urethral plate was defined as a distance between the verumontanum and the base of the glans of less than 10 mm. Urethral plate grafting was performed electively before the exstrophy closure. The urethral plate was divided just distal to verumontanum, and a thin inner preputial or para-exstrophy skin graft was harvested and deployed to cover the defect. Exstrophy closure was subsequently performed. The following parameters were recorded: age at grafting, type of graft and age at exstrophy closure. Reported outcomes include success of closure, complications, and follow up. RESULTS: Six male patients were included in the study: 3 classic bladder exstrophy (CBE) and 3 cloacal exstrophy (CE). Median age at grafting was 9 (3-18) months. Inner preputial grafts were utilized in the 3 CBE patients, and para-exstrophy skin grafts were used for the 3 CE patients. There was no graft loss, and longer and wide urethral plate was seen in all cases. Median time to bladder exstrophy closure was 3 (3-13) months after grafting. CONCLUSION: Pre-closure urethral plate grafting represents a safe and effective option for exstrophy patients with a short or inadequate urethral plate.

Bladder salvage in children with congenital lower urinary tract malformations undergoing renal transplant.

INTRODUCTION: Patients with Congenital Lower Urinary Tract Malformations (CLUTM) have increased risk of post-transplant complications if bladder dysfunction is not addressed. Pretransplant assessment may be difficult if urinary diversion has been previously applied. In case of low capacity and/or low compliance and/or high-pressure overactive bladder, transplantation into a diverted or augmented system may be required. We hypothesised that a bladder optimization pathway may help identify potentially salvageable bladders and prevent unnecessary bladder diversion or augmentation. We propose a structured bladder optimisation and assessment programme for safe transplant and native bladder salvage. MATERIAL AND METHODS: Data of 130 children who underwent renal transplant between 2007 and 2018 were retrospectively collected and analysed. All patients with CLUTM were assessed by urodynamic study. Bladder optimisation: Low compliance bladders were managed with anticholinergics and/or Botulinum toxin A (BtA) injections. Those who had urinary diversion for their pathology underwent a structured assessment and optimisation process with undiversion/anticholinergics/BtA/bladder cycling/Clean Intermittent Catheterisation (CIC)/Suprapubic catheter (SPC) as indicated. Details of medical and surgical management were collected (Figure 1). RESULTS: Between 2007 and 2018, 130 renal transplants were done. Of these, 35 (27%) had associated CLUTM (PUV in 15, neurogenic bladder dysfunction in 16, other pathology in 4) which was managed in our centre. Ten patients needed initial diversion in the form of vesicostomy (2) or ureterostomy (8) to manage primary bladder dysfunction. The median age at transplant was 7.8 years (range 2.5-19.6). After bladder assessment and optimisation, a safe bladder was demonstrated in 5 of 10 with initial diversion leading to transplant into native bladder (without augmentation). Overall, of the 35 patients, 20 (57%) had transplant into native bladder, 11 patients had ileal conduits and 4 had bladder augmentation. Eight required help with drainage: three with CIC, four with Mitrofanoff, and one had reduction cystoplasty. CONCLUSION: With a structured bladder optimisation and assessment programme, safe transplant and 57% native bladder salvage is achievable in children with CLUTM.

45 years' experience with early childhood anatomical technique of feminising genitoplasty for 46 XX Congenital Adrenal Hyperplasia -observations of vaginal introital anatomy and its relationship to the perineal body.

In Manchester, feminising genitoplasty is offered to children with 46XX Congenital Adrenal Hyperplasia (CAH) when there is a single perineal opening and/or enlarged clitoris. Our aims are to describe the anatomical reconstructive technique and present long-term outcomes. Our hypothesis is that 'the common channel (CC) length and distance to the vagina from perineal skin is mostly due to virilisation and hypertrophy of perineal tissue over the almost normally positioned vaginal introitus (V-I) in relation to the perineal body (PB)'. METHOD AND RESULTS: This is a retrospective notes review of all consecutive 46XX CAH operations from 1976 to December 2021. 99 patients, who had feminising genitoplasty and being followed-up, were included. 15 patients who were lost to follow up were excluded. Median age at surgery was 15 months. In 91, midline division of the labia majora, spongiosum, bulbo-spongiosus muscle (BSM) and CC down to PB was performed. This was sufficient to expose the V-I at the same level or within 5 mm depth of PB in 88. In 78 V-I was adequate taking 10/12fr dilator (Type 1). In 10, CC resembled a male urethra and V-I was narrow (Type 2), requiring widening by 5-10 mm incision at 6 o'clock position. Dartos of labia majora was attached to BSM to reduce the distance to V-I from perineal skin and the gap was lined with inner foreskin to create a vestibule. Out of 70 who were post-pubertal, 75% (53/70) had adequate calibre vaginal openings. 5 had introitoplasty and 2 had dilatation under anaesthesia. 10 needed self dilators only. 29 patients, of one of the three surgeons, had measurements of clitoris, CC, urethra and vagina. A hymen was found in 86% (25/29). There was significant strong, inverse correlation between the CC length and the urethral length (r = -0.708, p < 0.001, n = 27) but not between CC and vaginal lengths. After adjusting for age, the urethral length of Type 2 patients was 3.825 mm shorter than those of Type 1 (p = 0.017). CONCLUSION: Our data show that 'high' confluence is mostly due to virilisation of genitalia; and the anatomical technique of reversing the fusion of the urethral folds, spongiosum and bulbo-spongiosus muscle could be performed with all degrees of virilisation with success in early childhood with no need of local flaps or mobilisation of the urethro-vaginal complex. About 10% require surgery to treat narrowing of vaginal opening post puberty.

Risk factors of positive surgical margins after robot-assisted radical prostatectomy in high-volume center: results in 732 cases.

The aim of the study was to evaluate clinical, pathological and peri-operative factors associated with the risk of positive surgical margins (PSM) after robot-assisted radical prostatectomy (RARP) in a high-volume center. The study is a retrospective analysis of prospectively collected data. We excluded cases who were under androgen deprivation or had prior treatments. The population included negative cases (control group) and PSM subjects (study groups). The logistic regression model assessed the independent association of factors with the risk of PSM. From January 2013 to December 2017, 732 patients underwent RARP. Extended pelvic lymph node dissection was performed in 342 cases (46.7%). Overall, 192 cases (26.3%) had PSM. Independent factors associated with the risk of focal PSM were body mass index (odds ratio, OR = 0.936; p = 0.021), percentage of biopsy-positive cores (BPC; OR = 1.012; p = 0.004), pathological extracapsular extension (OR = 2.702; p < 0.0001), seminal vesicle invasion (OR = 2.889; p < 0.0001) and high-volume surgeon (OR = 0.607; p = 0.006). In high-volume centers, features related to host, tumor biology and surgeon are independent factors associated with the risk of PSM after RARP, which are decreased by the high-volume surgeon. The inverse association between BMI and PSM risk needs further clinical research. These issues should be discussed when counseling patients.

Prostate volume index and prostatic chronic inflammation predicted low tumor load in 945 patients at baseline prostate biopsy.

PURPOSE: To assess associations of prostate volume index (PVI), defined as the ratio of the volume of the central transition zone to the volume of the peripheral zone of the prostate and prostatic chronic inflammation (PCI) as predictors of tumor load by number of positive cores (PC) in patients undergoing baseline random biopsies. METHODS: Parameters evaluated included age, PSA, total prostate volume, PSA density, digital rectal exam, PVI, and PCI. All patients underwent standard transperineal random biopsies. Tumor load was evaluated as absent (no PC), limited (1-3 PC), and extensive (more than 3 PC). The association of factors with the risk of tumor load was evaluated by the multinomial logistic regression model. RESULTS: The study evaluated 945 patients. Cancer PC were detected in 477 (507%) cases of whom 207 (43.4%) had limited tumor load and 270 (56.6%) had extensive tumor load. Among other factors, comparing patients with limited tumor load with negative cases, PVI [odds ratio, OR = 0.521, 95% confidence interval (CI) 0.330-0.824; p < 0.005] and PCI (OR = 0.289, 95% CI 0.180-0.466; p < 0.0001) were inversely associated with the PCA risk. Comparing patients with extensive tumor load with negative patients, PVI (OR = 0.579, 95% CI 0.356-0.944; p = 0.028), and PCI (OR = 0.150, 95% CI 0.085-0.265; p < 0.0001), predicted PCA risk. Comparing extensive tumor load with limited tumor load patients, PVI and PCI did not show any association with the tumor load. CONCLUSIONS: Increased PVI and the presence of PCI decreased the risk of increased tumor load and associated with less aggressive prostate cancer biology in patients at baseline random biopsies.

Surgeon volume and body mass index influence positive surgical margin risk after robot-assisted radical prostatectomy: Results in 732 cases.

Objectives: To evaluate clinicopathological and perioperative factors associated with the risk of focal and non-focal positive surgical margins (PSMs) after robot-assisted radical prostatectomy (RARP). Patients and methods: The study was retrospective and excluded patients who were under androgen-deprivation therapy or had prior treatments. The population included: negative SM cases (control group), focal and non-focal PSM cases (study groups). PSMs were classified as focal when the linear extent of cancer invasion was ≤1 mm and non-focal when >1 mm. The independent association of factors with the risk of focal and non-focal PSMs was assessed by multinomial logistic regression. Results: In all, 732 patients underwent RARP, from January 2013 to December 2017. An extended pelvic lymph node dissection was performed in 342 cases (46.7%). In all, 192 cases (26.3%) had PSMs, which were focal in 133 (18.2%) and non-focal in 59 (8.1%). Independent factors associated with the risk of focal PSMs were body mass index (odds ratio [OR] 0.914; P = 0.006), percentage of biopsy positive cores (BPC; OR 1.011; P = 0.015), pathological extracapsular extension (pathological tumour stage [pT]3a; OR 2.064; P = 0.016), and seminal vesicle invasion (pT3b; OR 2.150; P = 0.010). High surgeon volume was a protective factor in having focal PSM (OR 0.574; P = 0.006). Independent predictors of non-focal PSMs were BPC (OR 1,013; P = 0,044), pT3a (OR 4,832; P < 0.001), and pT3b (OR 5,153; P = 0.001). Conclusions: In high-volume centres features related to host, tumour and surgeon volume are factors that predict the risk of focal and non-focal PSMs after RARP. Abbreviations: AJCC: American joint committee on cancer; AS: active surveillance; ASA: American society of anesthesiologists; BCR: biochemical recurrence; BMI: body mass index; BPC: percentage of biopsy positive cores; ePLND: extended lymph node dissection; H&E: haematoxylin and eosin; IQR, interquartile range; ISUP: international society of urologic pathology; LNI: lymph node invasion; LOS: length of hospital stay; mpMRI: multiparametric MRI; (c)(p)N: (clinical) (pathological) nodal stage; OR: odds ratio; OT: operating time; PSA-DT: PSA-doubling time; (P)SM: (positive) surgical margin; (NS)(RA)RP: (nerve-sparing) (robot-assisted) radical prostatectomy; RT: radiation therapy; (c)(p)T: (clinical) (pathological) tumour stage.

Multiple stones in neobladder: Case report and literature review.

INTRODUCTION: Neobladder urolithiasis is a rare but important long-term complication of orthotopic urinary diversion. It may be asymptomatic and can be discovered as an incidental finding on a radiological investigation. However, when symptoms occur, they may include lower abdominal pain, dysuria, hematuria, and lower urinary tract symptoms. CASE DESCRIPTION: We report the case of a 63-year-old male patient with irritative lower urinary tract symptoms, lower abdominal fullness, urinary incontinence, fecaluria, and urinary loss from the left inguinal fold 12 years after a radical cystoprostatectomy with a orthotopic neobladder. Computed tomography scan and urethrocystography showed a distended pouch with multiple large stones, an enterovesical fistula, and neovesicocutaneous fistula. The fistulae were successfully managed conservatively with the placement of a Foley catheter. After 3 months, open cystolithotomy was performed and approximately 50 stones with dimensions varying from 5 mm to 5 cm, with a total weight of 890 g, were removed. After a 1-year follow-up, the patient did not report pain, urinary tract infections, or symptoms suggestive of fistula and imaging evaluation confirmed no recurrence of neobladder stones. CONCLUSION: Neobladder stones may present with various symptoms. Our patient had irritative lower urinary tract symptoms, lower abdominal fullness, urinary incontinence, fecaluria, and urinary loss from the left inguinal fold 12 years after a radical cystoprostatectomy with a orthotopic neobladder. Our experience demonstrates that open cystolithotomy is an effective intervention for the removal of large stones in neobladder.

Positive Association between Preoperative Total Testosterone Levels and Risk of Positive Surgical Margins by Prostate Cancer: Results in 476 Consecutive Patients Treated Only by Radical Prostatectomy.

OBJECTIVE: To evaluate preoperative total testosterone (TT) as a predictor of positive surgical margins (PSM) in prostate cancer (PCA). PATIENTS AND METHODS: During the period from November 2014 to July 2017, preoperative TT was measured in 476 PCA patients undergoing only radical prostatectomy (RP) and including all risk classes. Surgical margins were stated negative, focal positive (single and less than 1 mL), and multifocal positive (more than 1). The risk of TT and clinical factors associated with the risk of PSM (focal or multifocal versus negative) was evaluated by the multinomial logistic regression model. RESULTS: Overall, PSM were detected in 149 cases (31.3%), which included 99 patients with focal cancer invasion (20.8%) and 50 subjects with multifocal cancer invasion (10.5%). In univariate analysis, PSM associated with higher median levels of TT and prostate-specific antigen than controls. Multifocal PSM associated with higher rates of high-risk PCA (42%) than focal (22.2%) or control cases (18.3%). In multivariate analysis, TT was the only independent factor positively associated with the risk of focal PSM when compared to controls (OR 1.002; p = 0.035). TT (OR 1.003; p = 0.002) and high-risk PCA (OR 1.002; p = 0.047) were independent factors, which positively associated with the risk of multifocal PSM when compared to controls. Risk models were computed. CONCLUSIONS: In a large and contemporary cohort of patients elected to primary RP, TT was an -independent positive factor associated with the risk of focal and multifocal PSM. TT associated with aggressive PCA biology.

Inverse Association of Prostatic Chronic Inflammation among Prostate Cancer Tumor Grade Groups: Retrospective Study of 738 Consecutive Cases Elected to a First Random Biopsy Set.

OBJECTIVES: The study aimed to evaluate associations of prostatic chronic inflammation (PCI) with prostate cancer (PCA) grade groups by the International Society of Urological Pathology (ISUP). METHODS: The study evaluated retrospectively 738 cases. The patient population was sampled into 3 groups collecting cases without and with PCA including subjects with lSUP grade group 1 and grade groups 2-5. RESULTS: PCI was assessed in 185 patients (25.1%) and PCA in 361 patients (48.9%) of whom 188 (25.5%) had ISUP grade and 173 (23.4%) had ISUP groups 2-5 tumors. PCI inversely related to ISUP groups (p < 0.0001). In multivariate analysis, the risk of ISUP grade group 1 PCA compared to negative cases associated positively with age (OR 1.042; p = 0.001) but inversely with total prostate volume (TPV; OR 0.965; p < 0.0001) and PCI (OR 0.314; p < 0.0001). Intermediate-high grade tumors associated positively with age (OR 1.065; p < 0.0001), prostate specific antigen (OR 1.167; p < 0.0001), and abnormal digital rectal examination (OR 2.251; p < 0.0001) but inversely with TPV (OR 0.921; p < 0.0001) and PCI (OR 0.106; p < 0.0001). CONCLUSIONS: PCI decreased the risk of PCA among ISUP tumor grade groups.

Wandering spleen with a ten-time twisted vascular pedicle.

Torsion of a wandering spleen is a rare cause of acute abdomen in children, usually diagnosed with color-Doppler ultrasonography and enhanced computed tomography. We report a pediatric case of torsion of wandering spleen.

Ureteral rupture after blunt abdominal trauma in a child with unknown horseshoe kidney.

More than 90% of renal injuries in children result from blunt abdominal trauma. A 10-year-old female had a blunt abdominal trauma with macro-hematuria. The computed tomography scan revealed the presence of a horseshoe kidney and a 3rd grade renal lesion and contrast leakage from the right ureter. The ureteral rupture was confirmed by cystoscopy and ascendant pyelography and than a double J-stent was implanted. The stent was removed one month later. Non-surgical management has become the standard of care for both ureteral and renal lesions in children. Non-surgical treatment is a safe procedure for renal trauma with ureteral rupture in children.

Mean platelet volume and varicocele: comparison between adolescents and adults.

PURPOSE: To evaluate the association between varicocele and MPV values in pediatric and adult patients. And its association with different clinical parameters. MATERIALS AND METHODS: We retrospectively analyzed the medical charts of patients treated for varicocele at our Institution between December 2010 and December 2014. The study patients were divided into three groups: group 1- patients with varicocele without testicular hypotrophy treated for scrotal discomfort or infertility (percutaneous varicocelecomy-scheloembolization); group 2- (control group) patients without varicocele; group 3- patients with varicocele and testicular hypotrophy (laparoscopic varicocelectomy). The study compared the grade of varicocele and MPV before surgery; age-related MPV and MPV cumulative value between the groups. RESULTS: After revision of the study 145 medical charts (group 1: 47 patients, group 2: 52 patients, group 3: 46 patients), and in compliance with the inclusion and exclusion criteria established, 127 patients were considered for the study; we evaluated 42 patients in group 1, 46 patients in group 2 and 39 patients in group 3. Patients with varicocele had higher MPV value than controls but only in adulthood. Testicular hypotrophy associated with varicocele is not a confusing factor. CONCLUSIONS: Even if MPV is higher in adults with varicocele as reported by other studies, but this result is not thrue in adolescents and its is not correlated with testicular hypotrophy; some confunding factors, i.e. andrological disease or smoking status, could be the reasons of different results present on medical literature.

Laparoscopic resection of a rare gastrointestinal stromal tumor in children.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are uncommon mesenchymal tumors of the gastrointestinal (GI) tract, accounting for 0.1% to 3% of all GI malignancies. Paediatric GIST have an annual incidence of 0.02 per million children, have a female predisposition, are usually located in the stomach (50-60%) and in up to 85% of cases CD117-cKit or PDGFRA mutation is absent, resulting in a decreased efficacy of the target therapy. CASE DESCRIPTION: We report the case of an incidentally diagnosed gastric GIST in a 14-year-old boy with multiple malformations. Genetic tests and Kariotype resulted negative. Recently, an abdominal US visualized an hypoechoic heterogeneous abdominal mass. The common tumor markers resulted negative and the abdominal CT-scan confirmed the presence of a solid round lesion (42×36mm) in contact with the stomach and the pancreas. Laparoscopy allowed the recognition and the removal of the nodular mass at the posterior margin of the stomach. The histopathologic and the molecular biology findings were consistent with a kit-wilde type GIST. Surgical margins were microscopically free of tumor cells. These results justify the decision not to add other surgical or medical therapy. However, for high risk of recurrence and metastasis, a close follow-up was started. DISCUSSION AND EVALUATION: GIST are asymptomatic in 10% to 30% of patients or present nonspecific symptoms and signs. These tumors present usually irregular, lobulated and ulcerated. CT-scan of the abdomen and pelvis or magnetic resonance imaging (MRI) are mandatory in the diagnostic work-up. The final diagnosis is based on histology and immunohistochemistry. Surgery is the first-line treatment in patients with localized disease. CONCLUSION: Guidelines for the management of pediatric GIST are not presently available for the paucity of reports and data. However it is widely accepted that surgery is the first-line treatment and gross resection with negative microscopic margins can be considered therapeutic and lead to full remission of the pathology. Laparoscopy is a safe surgical approach for the exploration of the abdominal cavity, the evaluation of the disease and the complete removal of the tumor.