Laparoscopic ligation of ectopic ureter in pediatric patients: a safe surgical option for the management of urinary incontinence due to ectopic ureters.

BACKGROUND: Ureteric ectopia is a pediatric urinary incontinence cause in girls. It is traditionally managed through hemi-nephrectomy or uretero-ureterostomy, which have the potential for complications including anastomotic stricture, leak, bleeding, and de-vascularization of the functioning renal moiety. Laparoscopic ureteric clipping has been shown to be a good alternative but has not been widely adopted yet. We provide our experience with this technique. METHODS: We retrospectively reviewed the data of 6 patients who underwent laparoscopic clipping of ectopic ureter between 2014 and 2019. We collected the following information: clinical presentation, preoperative and postoperative imaging, age at presentation, age at surgery, operative time, complications, length of stay, length of follow-up, as well as continence outcomes. RESULTS: Five patients were diagnosed with a duplex system associated with an ectopic upper pole ureter. One patient was noted to have a non-functional kidney associated with an ectopic ureter. Median age at presentation was 5 years (6 weeks-9 years), while at surgery was 8 years (2-13 years). Four patients were referred for incontinence, 1 was referred for antenatal hydronephrosis, 1 presented with urosepsis. The preoperative renal pelvis anteroposterior diameter (APD) was 8.60 cm (median) (6.80-8.70 cm). At the post-operative follow-up, the APD increased to median 9.1 cm (6.80-11.50 cm). Median operative time was 91 min (42-60 min). Complications were seen in only one patient who developed an immediate postoperative urinary tract infection (UTI). Five patients were discharged home the same day of the surgery, while the patient who developed UTI went home on post-operative day 3. Median follow-up was 33 months (22-72 months). Currently, all patients have achieved daytime urinary continence. No patient had UTI during the follow-up period. CONCLUSION: Laparoscopic ureteric clipping of the ectopic ureter appears to be a valid alternative to extirpative or reconstructive procedures. Follow-up shows an increase in hydronephrosis without any consequence for the patients. Further studies are necessary to reinforce these observations.

Randomized Crossover Trial of Single Use Hydrophilic Coated vs Multiple Use Polyvinylchloride Catheters for Intermittent Catheterization to Determine Incidence of Urinary Infection.

PURPOSE: Urinary tract infection is a key issue for long-term intermittent catheterization users. Various catheter designs and methods have evolved to decrease the risk but the evidence remains unclear regarding whether product type improves outcomes. We determined whether single use hydrophilic coated catheters reduced urinary tract infections compared to multiple use polyvinylchloride catheters for children with neurogenic bladder due to spina bifida. MATERIALS AND METHODS: This was a randomized crossover 4-center trial with 2 treatment periods of 24 weeks each, consisting of single use hydrophilic coated catheter and multiple use polyvinylchloride catheter (washed with soap and water, and air dried after each use). Each week participants recorded symptoms and urine results (Multistix® 8SG reagent strip). Primary outcome was person-weeks of urinary tract infection, defined as positive leukocytes plus fever, flank pain, increased incontinence, malaise, or cloudy or odorous urine requiring antibiotic treatment. Individuals were included if they were a child or young adult with spina bifida and used intermittent catheterization as the primary method of bladder emptying. RESULTS: Calculated sample size was 97. More than 120 patients were screened, of whom 66 were randomized and 45 completed both trial arms. Mean age was 10.6 years. Of the patients 21 were male and 24 were female. Mean ± SD person-weeks of urinary tract infection was 3.42 ± 4.67 in the single use hydrophilic coated catheter group and 2.20 ± 3.23 in the multiple use polyvinylchloride catheter group (p <0.001). There were no statistical differences in weeks of febrile urinary tract infection or antibiotic use. CONCLUSIONS: Results are consistent with the Cochrane Review in that single use hydrophilic coated catheters may not decrease the incidence of symptomatic urinary tract infection in community dwelling chronic intermittent catheterization users when compared to clean multiple use polyvinylchloride catheters.

Endoscopic ablation of longitudinal vaginal septa in prepubertal girls: a minimally invasive alternative to open resection.

INTRODUCTION: Vaginal septation is a congenital defect seen in patients with persistent cloaca, urogenital sinus and disorders of Müllerian duct aplasia. Rarely, these patients present with symptoms in infancy and childhood with the exception of hydrocolpos. Treatment traditionally consists of surgical excision of the vaginal septum. We present our experience with minimally invasive endoscopic ablation of vaginal septa. MATERIALS AND METHODS: We reviewed retrospectively the management of four patients with vaginal septae: Herlyn-Werner-Wunderlich syndrome (1), cloacal malformations (2), and urogenital sinus (1). All were prepubertal (aged 2-9 years). The first patient presented with hydrocolpos. The others were asymptomatic and identified during definitive reconstruction. All four underwent endoscopic ablation in ≤30 min, using a pediatric resectoscope. RESULTS: One of the cloacal patients developed a postoperative perineal/vestibular infection leading to urethral stenosis and currently requires intermittent catheterization. There were no other complications. Endoscopic examination under anesthesia at 6 months in all patients revealed no septal scarring or vaginal stenosis. CONCLUSION: The advantage of endoscopic ablation over traditional open repair is that it is minimally invasive and can be easily performed as an outpatient procedure or at the time of definitive reconstruction. Our results suggest that endoscopic ablation should be considered as the primary approach for correction of vaginal septa.

Use of mobile extracorporeal shock wave lithotripter: experience in a pediatric institution.

OBJECTIVES: To present our results of the past 3 years using a mobile lithotripter in a pediatric institution. The low incidence of pediatric urinary calculi, along with the high cost of lithotripsy units, has limited the use of extracorporeal shock wave lithotripsy in pediatric institutions. METHODS: A retrospective cohort study was performed of all children who had undergone extracorporeal shock wave lithotripsy at two institutions from 1999 to 2003. All patients were treated with a Dornier Compact Delta mobile lithotriptor with a universal urologic table. RESULTS: A total of 88 patients (38 males and 50 females) underwent a total of 119 outpatient treatments. The mean patient age was 12 years, and the mean follow-up was 20 months. The mean stone size was 6 mm. An average of 1600 shocks per procedure was performed. Overall, 68% were stone free after one treatment, and 74% were stone free after one or two treatments. Of the patients with a solitary stone, 72% were stone free after one treatment and 78% were after one or two treatments. Fifteen patients had multiple stones treated simultaneously on the same side. Of these, 47% were stone free after one treatment and 53% after one or two treatments. Two patients subsequently required ureteroscopy and laser lithotripsy for obstructing ureteral calculi. CONCLUSIONS: The results of our study have shown that the new-generation mobile lithotripter is safe and effective in treating pediatric nephrolithiasis. The success rate was greater for solitary stones than for multiple stones treated at the same setting. Additional endoscopic procedures can be performed simultaneously on the same table.