Telemedicine Versus Traditional for Follow-Up Evaluation of Enuresis.

Introduction: Telemedicine allows health care professionals to diagnose and treat patients remotely. Enuresis is one of the most common chronic problems in childhood and specialized care can be limited. Utilization of telemedicine in this setting has not been previously analyzed. Materials and Methods: This study's aim is to evaluate the feasibility and effectiveness of telemedicine follow-up treatment of enuresis compared with traditional follow-up at our institution. A retrospective review of patients treated for nocturnal enuresis with either telemedicine (Group 1) or traditional (Group2) follow-up care was conducted. Patients, aged 5-18 years, treated for enuresis between July 2016 and December 2017 were included. Patients with confounding disease were excluded. Resolution of enuresis was the primary outcome as categorized by the International Children's Continence Society standards. Results: Seventy-seven (n = 77) patients met inclusion criteria with 23 patients in Group 1 and 54 patients in Group 2. Two patients in each group were lost to follow-up and 61.9% in Group 1 and 48.1% in Group 2 responded to treatment. The average age for both groups was 9.2 years. Patients in Group 1 averaged four appointments per patient and patients in Group 2 averaged 3.04 appointments per patient. Telemedicine follow-up patients missed fewer appointments (0.14) than patients with traditional follow-up (0.5) (p-value = 0.016). Thirteen of 21 patients (61.9%) responded to treatment in Group 1 (7 partial and 6 complete responders) as compared with 25 of 52 patients (48.1%) responding to treatment in Group 2 (8 partial and 17 complete responders) (p = 0.22). Of patients in Group 1, 87% reported they would use telemedicine again. Conclusions: Telemedicine follow-up of patients with enuresis demonstrated comparable effectiveness. Most patient families demonstrate a favorable opinion of using telemedicine again for this problem. Further research to understand the efficacy and benefits of telemedicine in this setting is needed.

Urological Emergencies and Diseases in Wilderness Expeditions.

When considering medical emergencies that might affect an expedition, urologic emergencies are typically not included. However, the reality is that manageable and prevalent urologic disease processes can pose significant challenges for the wilderness medicine physician and warrant consideration. The purpose of this review is to identify and discuss the most commonly encountered urologic emergencies and diseases in the wilderness setting and to prepare the expedition medicine physician for management of these urgent conditions. A PubMed and Internet search for urologic emergencies and diseases in wilderness conditions was conducted. We also searched bibliographies for useful supplemental literature and material from leading mountain medicine and wilderness medicine societies as well as population-based studies for common urologic diseases. Urologic emergencies and diseases on expeditions and in wilderness conditions have been reported primarily with retrospective case series and case reports. The most commonly reported urologic emergencies in this setting include urologic trauma, renal calculi, and urinary retention. Parasitic infections in the urinary tract also have been reported to cause urinary symptoms and urinary retention in wilderness conditions. Although urologic diseases in such conditions are uncommon, significant morbidity and even potentially life-threatening sequelae to urologic emergencies were found to occur. Major genitourinary emergencies in expedition medicine are uncommon but involve both potentially manageable urgent conditions and serious life-threatening conditions best treated with urgent stabilization and occasionally medical evacuation. The opportunity exists for increased awareness for management strategies for urologic conditions in the often remote or extreme environments of an expedition.

2-octyl cyanoacrylate hypospadias repair dressing: a retrospective, controlled comparison.

INTRODUCTION: 2-octyl cyanoacrylate (OC) has been shown to be a viable option for usage following standard circumcision but data on its utilization following hypospadias repair is limited. Both OC and a standard waterproof transparent dressing (WD) are used following hypospadias repair at our children's hospital. Our hypothesis is that patients with distal hypospadias repair using OC for surgical dressing have similar outcomes as compared to patients with WD. MATERIALS AND METHODS: A retrospective study was performed evaluating all patients with distal hypospadias repair during a 2 year period. OC was primarily used by one of the three physicians in the practice with the other two primarily used WD for surgical dressing. The primary endpoints evaluated include hematoma requiring surgical drainage, infection, meatal stenosis, urethrocutaneous fistula, dehiscence, and diverticulum. Standard follow up after hypospadias repair includes a 1 week follow up for patients requiring urethral stent removal and reevaluation for all patients 3-4 months after surgery. REDCap was used in order to compile the database used in this study. RESULTS: A total of 280 patients underwent distal hypospadias repair during this interval. One hundred twenty-two patients had OC used with 3 (2.4%) having complications: 2 fistulas and 1 with both meatal stenosis and fistula. One hundred fifty-eight patients were dressed with WD with 5 (3.2%) complications: 4 fistulas and 1 meatal stenosis. No patients had hematoma, wound dehiscence, diverticulum, or infection. CONCLUSION: A low rate of complication was observed following distal hypospadias repair using both 2-octyl cyanoacrylate and a standard waterproof transparent dressing. 2-octyl cyanoacrylate is a safe option for surgical dressing following distal hypospadias repair but its utilization in this setting is surgeon dependent.

Analysis of preoperative antibiotic prophylaxis in stented, distal hypospadias repair.

INTRODUCTION: Surgical site infection [SSI] is a risk for any surgical procedure, including hypospadias repair. Prophylactic antibiotic therapy for patients having surgery is often effective in preventing SSIs, but with increasing rates of antibiotic resistance, this practice has been questioned. The objectives of this study are 1) to assess the incidence of SSIs in patients following stented, distal hypospadias repair and 2) to observe for any potential difference in the incidence of SSIs for patients with and without preoperative antibiotic utilization in this setting. MATERIALS AND METHODS: We retrospectively reviewed consecutive patients treated with stented, distal hypospadias repair from 2011 to 2014 by three surgeons and compared two groups: patients who received preoperative antibiotics and patients who did not. Patients with a history of previous hypospadias repair were excluded from the study. RESULTS: Two hundred twenty-four subjects were identified. Group 1 (135) received preoperative antibiotic and Group 2 (89) did not receive preoperative antibiotics. There was no statistically significant difference in SSI prevalence with 0 patients in Group 1 and 1 patient in Group 2 having a SSI. CONCLUSION: Although prophylactic antibiotics prior to hypospadias repair are most often used by pediatric urologists, this study demonstrates further evidence that antibiotics prior to this procedure do not appear to lower the rate of SSI. This study is limited by its retrospective nature and disparate mean follow up in the two cohorts. Surgical site infection does not appear to be decreased by prophylactic antibiotic therapy before distal hypospadias repair.

Shortened operative time for pediatric robotic versus laparoscopic dismembered pyeloplasty.

INTRODUCTION: Robotic-assisted laparoscopic pyeloplasty (RALP) is increasingly becoming the standard procedure for management of ureteropelvic junction obstruction (UPJO) in the pediatric population, but few studies have shown a clear advantage over the more technically demanding laparoscopic pyeloplasty (LP) in children. The objective was to study the patients treated with RALP or LP at our institution and the associated outcomes for each minimally invasive approach for the correction of UPJO. MATERIALS AND METHODS: Our laparoscopic and robotic database was queried to identify all patients with a history of primary robotic-assisted or laparoscopic dismembered pyeloplasty for the correction of UPJO performed at our institution from January 2010 through November 2013 and were retrospectively reviewed. We analyzed age, surgical time, blood loss, hospital stay length, postoperative complications, and success rate. RESULTS: Seventy-three total patients were identified as having RALP or LP during this time period with five patients excluded from the analysis. We identified 55 patients with RALP and 13 patients with LP. No differences in success rate or postoperative complications were found for the two cohorts. The length of procedure was significantly shorter for the RALP group compared to the LP group.

Hypospadias prevalence by severity and associated risk factors: A population-based active surveillance analysis.

INTRODUCTION: Hypospadias is one of the most common congenital anomalies. Trends of hypospadias prevalence by severity are not well reported. Most prevalence studies consist of pooled data from different countries or states suffer from low data quality due to inconsistent methodologies, limited variables, and lack of categorization of hypospadias severity. OBJECTIVE: The objective of this study is to examine the prevalence of hypospadias by degrees of severity and associated risk factors using combined data sources from a stable and well-defined population. STUDY DESIGN: The study population includes infants born with hypospadias to mothers residing in Arkansas from 1997 to 2016. Cases were identified from an active population-based surveillance program of birth defects. Identified hypospadias cases from surveillance data were linked to birth certificate and to a clinical database. These two data sources provide more details on the location of the defect and maternal and infant characteristics. The prevalence and 95% confidence intervals were calculated using total male live births as denominator. Chi-square test was used to assess the association of nominal variables. Logistic regression was used to calculate adjusted odds ratio. RESULTS: A total 3230 hypospadias cases were identified from 1997 to 2016. The overall prevalence is 83.0 per 10,000 male births. A majority of cases (56.7%) were classified as first degree with the others having second degree (22.8%), third degree (4.7%) or not otherwise specified (15.6%). The highest prevalence of hypospadias was observed among Non-Hispanic whites. Higher prevalence also was observed among mothers in the older age group with no prenatal care in the first trimester and with gestational hypertension or diabetes. Premature or small for gestational age infants tend to have higher prevalence across all levels of severity. The number of hypospadias cases increased over time. After maternal age, race and education were adjusted, higher risk persisted for infants of restricted fetal growth, mothers with gestational hypertension or diabetes and the cohort of 2013-2016. CONCLUSION: There is an increase of hypospadias cases in Arkansas. Several maternal and infant characteristics associated with higher prevalence for all levels of severity are worth further investigation.

Epidemiological assessment of hypospadias by degree of severity.

PURPOSE: Hypospadias is one of the most common congenital malformations, with reportedly increasing rates of prevalence but poorly defined etiological factors for the disease and the varying degrees of manifestation. We characterize the prevalence of hypospadias in Arkansas with consideration of the degree of hypospadias. MATERIALS AND METHODS: Data from the Arkansas State Birth Defects Surveillance Program of the Arkansas Reproductive Health Monitoring System were used to identify hypospadias cases and all male births by women residing in Arkansas between 1998 and 2007. Categorization of hypospadias severity into first, second or third degree was determined by a common 6-digit birth defect coding system used by surveillance programs across the country. Prevalence rates were computed for maternal and infant characteristics, birth year and birth residence. RESULTS: The prevalence of hypospadias in Arkansas for births between 1998 and 2007 was 74.2 cases per 10,000 live births. Degrees of hypospadias were graded as first (coronal/distal) in 60.7% of cases, second (mid penile/subcoronal) in 18.8%, third (perineal/proximal penile) in 4.6% and hypospadias not otherwise specified in 16%. The prevalence of hypospadias increased during the surveillance period, with 66.9 per 10,000 live births between 1998 and 2002, and 81.0 per 10,000 live births between 2003 and 2007 (p = 0.0003). While the prevalence rates for every degree of hypospadias also increased, the prevalence of hypospadias not otherwise specified decreased from 14.8 to 9.0 during these periods. CONCLUSIONS: Hypospadias prevalence in Arkansas is increasing. Improvement in recognition and categorization of degrees of hypospadias may have an impact on the reported prevalence rates.

Alternative approaches to expanding pediatric urology services and productivity.

PURPOSE: We critically assessed the outcomes of a new model of pediatric urology delivery using alternative approaches to expand care without increasing the number of pediatric urologists. The approaches included the use of advanced practice nurse practitioners, pediatric physician specialists, part-time contract pediatric urologists from neighboring institutions and part-time contract adult urologists from our university. MATERIALS AND METHODS: Data were collected from the Division of Pediatric Urology at Arkansas Children's Hospital during 2009 and 2010. The only pediatric urologist at our institution retired in December 2009 with an immediate transition to a new pediatric urologist in January 2010. Comparisons were made in the numbers of clinic visits, inpatient admissions/consultations, surgical volume and patient satisfaction scores. RESULTS: Average clinic monthly visits in 2009 and 2010 were 153 and 271, respectively (p <0.0001). Inpatient admissions increased from 43 in 2009 to 162 in 2010. Inpatient initial consultations and followup consultations increased by 115 and 112, respectively, from 2009 to 2010. Surgical volume increased 26.7% in 2010 (p = 0.0832) and Press Ganey® scores were comparable or improved from 2009 to 2010. CONCLUSIONS: The use of advance practice nurse practitioners, part-time contract adult and pediatric urologists, and pediatric physician specialists can effectively increase the number of patients treated without adding full-time pediatric urology staff. The assignment of patient and disease populations to each team member has been an ongoing process of critically defining and updating responsibilities in an attempt to expand care, increase productivity and maximize the quality of delivery of these services.

Prevalence and Clustering of Congenital Heart Defects Among Boys With Hypospadias.

Importance: Hypospadias is a common birth defect of the male urinary tract that may be isolated or may co-occur with other structural malformations, including congenital heart defects (CHDs). The risk for co-occurring CHDs among boys with hypospadias remains unknown, which limits screening and genetic testing strategies. Objective: To characterize the risk of major CHDs among boys born with hypospadias. Design, Setting, and Participants: This retrospective cohort study used data from population-based birth defect surveillance programs on all male infants born in 11 US states from January 1, 1995, to December 31, 2014. Statistical analysis was performed from September 2, 2020, to March 25, 2022. Exposure: Hypospadias. Main Outcomes and Measures: Demographic and diagnostic data were obtained from 2 active state-based birth defect surveillance programs for primary analyses, the Texas Birth Defects Registry and the Arkansas Reproductive Health Monitoring System, with validation among 9 additional states in the National Birth Defects Prevention Network (NBDPN). Birth defect diagnoses were identified using the British Pediatric Association coding for hypospadias (exposure) and major CHDs (primary outcomes). Maternal covariates and birth year were also abstracted from the vital records. Poisson regression was used to estimate adjusted prevalence ratios and 95% CIs for major CHDs within Texas and Arkansas and combined using inverse variance-weighted meta-analysis. Findings were validated using the NBDPN. Results: Among 3.7 million pregnancies in Texas and Arkansas, 1485 boys had hypospadias and a co-occurring CHD. Boys with hypospadias were 5.8 times (95% CI, 5.5-6.1) more likely to have a co-occurring CHD compared with boys without hypospadias. Associations were observed for every specific CHD analyzed among boys with hypospadias, occurred outside of chromosomal anomalies, and were validated in the NBDPN. An estimated 7.024% (95% CI, 7.020%-7.028%) of boys with hypospadias in Texas and 5.503% (95% CI, 5.495%-5.511%) of boys with hypospadias in Arkansas have a co-occurring CHD. In addition, hypospadias severity and maternal race and ethnicity were independently associated with the likelihood for hypospadias to co-occur with a CHD; boys in Texas with third-degree (ie, more severe) hypospadias were 2.7 times (95% CI, 2.2-3.4) more likely than boys with first-degree hypospadias to have a co-occurring CHD, with consistent estimates in Arkansas (odds ratio, 2.7; 95% CI, 1.4-5.3), and boys with hypospadias born to Hispanic mothers in Texas were 1.5 times (95% CI, 1.3-1.8) more likely to have a co-occurring CHD than boys with hypospadias born to non-Hispanic White mothers. Conclusions and Relevance: In this cohort study, boys with hypospadias had a higher prevalence of CHDs than boys without hypospadias. These findings support the need for consideration of additional CHD screening programs for boys born with hypospadias.

Results: Survey of pediatric urology electronic medical records-use and perspectives.

PURPOSE: The $19.2 billion Health Information Technology for Economic and Clinical Health Act will have a dramatic effect on the adoption of electronic medical records in the United States by directly reimbursing for the adoption of electronic medical records in the future. We sought to gain an understanding of electronic medical record use in pediatric urology to aid in the transition to electronic medical records. MATERIALS AND METHODS: All Fellows and post-fellowship Fellow Candidates of the American Academy of Pediatrics Section on Urology were recruited to participate in the survey. Electronic and paper versions of this 50-question internal review board approved anonymous survey were sent to potential participants. RESULTS: Of 286 pediatric urologists 165 completed the survey for a 65% response rate. Of the respondents 67.3% were pediatric urologists in academic or hospital based practice while the remaining 32.7% were in private practice. Overall 78.8% of respondents reported using electronic medical records at the hospital while 67.3% used them at the office/clinic. Of the physicians 12.1% reported that they would retire if electronic medical record use was federally mandated. CONCLUSIONS: Pediatric urologists in the United States appear to have embraced the adoption of electronic medical records. A large number of academic/hospital based and private practice pediatric urologists have begun to use electronic medical records. Most respondents were interested in improving electronic medical record use in our field, believed that physicians would be most capable of developing ideal electronic medical records and would be interested in participating in a national cooperative effort to improve electronic medical record use.

Comparative analysis of perioperative prophylactic antibiotics in prevention of surgical site infections in stented, distal hypospadias repair.

PURPOSE: There is limited evidence that prophylactic antibiotics prevent surgical site infection in stented, distal hypospadias repair. Our hypothesis is that the use of prophylactic antibiotics does not affect the rate of surgical site infection in this setting. METHODS: We conducted a retrospective study of consecutive patients over a 6-year period with distal penile hypospadias treated with urethral stenting. Variables analyzed include age, type of repair, usage of preoperative and/or postoperative antibiotics, and length of follow-up. Patients with a history of proximal or re-operative hypospadias repair were excluded. Surgical site infection was defined by the presence of postoperative penile erythema and/or purulent drainage treated with therapeutic antibiotics. Secondary outcome analysis included the presence of other hypospadias complications. RESULTS: 441 consecutive subjects met our inclusion criteria with a mean age of 13.3 months. Patients were categorized into groups: Group 1 - Preoperative antibiotics (n = 64), Group 2 - Both Preoperative & Postoperative antibiotics (n = 159), Group 3 - Postoperative antibiotics (n = 122), Group 4 - No Preoperative or Postoperative antibiotics (n = 96). Two surgical site infections were reported out of the 441 patients: 1 in Group 3 and 1 in Group 4 (p = 0.513). There was no significant difference in the total patients with a hypospadias complication between groups. In the table below, Groups 1-3 were combined (345 patients) for comparison to Group 4 (No antibiotics, 96 patients) for further analysis with no difference in SSIs (p = 0.388) or respective hypospadias complications. CONCLUSIONS: The use of perioperative prophylactic antibiotics, both before and after surgery for distal, stented hypospadias repair, have not been shown to reduce the rate of surgical site infections nor hypospadias complications. Consequently, the benefit of prophylactic antibiotics in this setting is unclear.

Hydronephrosis and Hydroureter Improvement Rates in Robotic-Assisted Laparoscopic Uretero-Ureterostomies: Does Anastomotic Site Matter?

OBJECTIVE: To compare improvement/change of hydronephrosis and hydroureter in patients with complete ureteral duplications that underwent upper and lower robotic-assisted laparoscopic uretero-ureterostomies. The hypothesis being that improvement of hydronephrosis and hydroureter between the two groups was similar. METHODS: 35 subjects met inclusion criteria and were reviewed retrospectively. 'Upper' anastomoses were defined as those being done below the lower pole of the kidney (Group 1), while 'lower' anastomoses were those done below the iliac vessels (Group 2). Primary variables analyzed were antero-posterior and diameter measurements of the renal pelvis and ureter, respectively, before and after surgery. Secondary variables included operative time, length of hospital stay, and complication rates. RESULTS: Group 1 consisted of 20 subjects while Group 2 consisted of 15 subjects. Presenting diagnoses were hydronephrosis in 31 subjects and incontinence in 4 subjects. Group 1 mean AP renal diameters decreased by 62.9% (P<.05), while Group 2 decreased by 65.4% (P<.05). Group 1 mean hydroureter diameter measurements decreased by 80.3% (P<.05), while Group 2 decreased by 83% (P<.05). The improvement in hydronephrosis and hydroureter between the two groups was not statistically different. Group 1 median operative time (271 minutes) was longer than Group 2 (201 minutes) (P<.05). There was no significant difference in hospital stay between the groups and there were no significant complications within the cohort. CONCLUSION: The improvement rate of hydronephrosis and hydroureter is similar in upper versus lower RAL UU. Operative time was significantly shorter in the lower anastomosis group.

Effect of rectal distention on lower urinary tract function in children.

PURPOSE: We investigated the effect of rectal distention on lower urinary tract function. MATERIALS AND METHODS: Children were assigned to a constipation and lower urinary tract symptoms group or to a lower urinary tract symptoms only group. The definition of constipation was based on pediatric Rome III criteria. Standard urodynamics were done initially and repeated during simultaneous barostat pressure controlled rectal balloon distention and after balloon deflation. We evaluated the effects of rectal balloon inflation and deflation on urodynamic parameters. Colonic transit time measurement, anorectal manometry and the Parenting Rating Scale of child behavior were also used. RESULTS: We studied 7 boys and 13 girls with a median age of 7.5 years who had constipation and lower urinary tract symptoms, and 3 boys and 3 girls with a median age of 7.5 years who had lower urinary tract symptoms only. Urodynamic patterns of response to rectal distention were inhibitory in 6 children and stimulatory in 12, and did not change in 8. In 54% of the cases balloon deflation reversed balloon inflation changes while in 46% balloon inflation changes persisted or progressed. No significant differences were noted in children with vs without constipation and no clinical symptom or diagnostic study predicted the occurrence, direction or degree of bladder responses. CONCLUSIONS: In almost 70% of children with lower urinary tract symptoms rectal distention significantly but unpredictably affected bladder capacity, sensation and overactivity regardless of whether the children had constipation, and independent of clinical features and baseline urodynamic findings. Urodynamics and management protocols for lower urinary tract symptoms that fail to recognize the effects of rectal distention may lead to unpredictable outcomes.

Altered mechanisms of genital development identified through integration of DNA methylation and genomic measures in hypospadias.

Hypospadias is a common birth defect where the urethral opening forms on the ventral side of the penis. We performed integrative methylomic, genomic, and transcriptomic analyses to characterize sites of DNA methylation that influence genital development. In case-control and case-only epigenome-wide association studies (EWAS) of preputial tissue we identified 25 CpGs associated with hypospadias characteristics and used one-sample two stage least squares Mendelian randomization (2SLS MR) to show a causal relationship for 21 of the CpGs. The largest difference was 15.7% lower beta-value at cg14436889 among hypospadias cases than controls (EWAS P = 5.4e-7) and is likely causal (2SLS MR P = 9.8e-15). Integrative annotation using two-sample Mendelian randomization of these methylation regions highlight potentially causal roles of genes involved in germ layer differentiation (WDHD1, DNM1L, TULP3), beta-catenin signaling (PKP2, UBE2R2, TNKS), androgens (CYP4A11, CYP4A22, CYP4B1, CYP4X1, CYP4Z2P, EPHX1, CD33/SIGLEC3, SIGLEC5, SIGLEC7, KLK5, KLK7, KLK10, KLK13, KLK14), and reproductive traits (ACAA1, PLCD1, EFCAB4B, GMCL1, MKRN2, DNM1L, TEAD4, TSPAN9, KLK family). This study identified CpGs that remained differentially methylated after urogenital development and used the most relevant tissue sample available to study hypospadias. We identified multiple methylation sites and candidate genes that can be further evaluated for their roles in regulating urogenital development.

The role of genetic variation in DGKK on moderate and severe hypospadias.

BACKGROUND: Recent genome-wide association studies of hypospadias have implicated the role of genetic variants in or near the diacylglycerol kinase kappa (DGKK) gene. However, these variants are largely identified among samples of mild and moderate hypospadias cases. Therefore, we evaluated previously identified DGKK variants among second- and third-degree hypospadias cases and controls recruited in Arkansas, a state characterized by a high birth prevalence of hypospadias. METHODS: Second- and third-degree hypospadias non-Hispanic white cases (n = 36 and n = 9, respectively) and controls (n = 45) were recruited at Arkansas Children's Hospital. Preputial tissue was collected on cases and controls between 2013 and 2017. Cases and controls were genotyped using the Illumina Infinium Global Screening Array. We used logistic regression models to assess the association of genotyped and imputed genetic variants mapped to the DGKK region with second- and third-degree hypospadias. RESULTS: All families self-reported as non-Hispanic white and genetic principal component analyses did not demonstrate evidence of population stratification. Five DGKK variants previously reported as associated with hypospadias were identified in the genotype data. None of the variants were associated with second- or third-degree hypospadias (range of odds ratios = 0.7-0.9, all p > .05). CONCLUSIONS: In our analyses, genetic variation in DGKK does not play a role in the development of moderate and severe hypospadias. Our findings provide support to the etiologic heterogeneity of hypospadias by all classifications of severity.

Pathophysiology and management of urinary incontinence in case of distal penile epispadias.

PURPOSE: We evaluated boys with distal epispadias and urinary incontinence to determine the cause, and designed a simplified bladder neck reconstruction to restore urinary continence. MATERIALS AND METHODS: Six boys with epispadias of the glans or distal penile shaft whose incontinence persisted after successful single stage epispadias repair were evaluated with cystoscopy and urodynamics after failed attempts at toilet training. Surgical management--simplified bladder neck reconstruction--involved suprapubic excision of an identified deformity of the roof of the bladder neck and posterior urethra, followed by reapproximation of the remaining normal bladder neck and posterior urethral tissues. RESULTS: All boys displayed a characteristic deformity of the roof of the bladder neck and posterior urethra, which extended distally through the membranous urethral sphincter toward the urethral meatus. Five of the 6 boys were treated surgically, and promptly achieved normal continence and urinary control that remained durable through a mean followup of 9.6 years. Histologically, the roof deformity exhibited abnormalities including attenuation and reduction of smooth muscle. CONCLUSIONS: The meatus is not the only site involved in distal epispadias, which presents as a field defect that deforms the roof of the urethra distal to the bladder neck. Incontinence in distal epispadias has a dual etiology, namely anatomical dilatation and distortion of the bladder neck and posterior urethra, and histological abnormality of the roof tissues. These conditions combine to affect adversely coaptive and constrictive functions of the posterior urethra and urinary sphincter. Excision and reapproximation of the roof deformity appears to be proof in principle of the cause of incontinence, and offers an alternative approach to treating incontinence in these patients without the need for more invasive surgical procedures.

Laparoscopic reconstructive options for obstruction in children with duplex renal anomalies.

OBJECTIVE: To present our initial experience of laparoscopic reconstructive surgery in children with upper urinary tract obstruction associated with duplex anomalies, as although there is much information on ablative procedures such as laparoscopic heminephrectomy, there is little available about minimally invasive reconstructive options for duplex renal anomalies in children. PATIENTS AND METHODS: We retrospectively reviewed four consecutive patients (aged 6-11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at our institution. The port placement and surgical exposure were analogous to that for transperitoneal laparoscopic pyeloplasty. A JJ stent was placed retrogradely into the ureter immediately before each procedure. The procedures performed were pyelo-ureterostomy for incomplete duplication and lower pole pelvi-ureteric junction (PUJ) obstruction, lower pole pyeloplasty for lower pole PUJ obstruction and complete duplication, and ipsilateral uretero-ureterostomy and distal ureterectomy for an obstructed, ectopic upper pole. Foley catheters were left indwelling for 36-48 h and stents were removed at 4-6 weeks. Postoperative imaging included either ultrasonography or intravenous urography. RESULTS: Three children presented with intermittent flank pain due to lower pole PUJ obstruction. The other child presented with pyonephrosis and purulent drainage from her vagina due to an ectopic ureter associated with a functioning upper pole segment. All procedures were successfully completed. The only complication was in the first patient (pyelo-ureterostomy) who had transient urinary extravasation that resolved with bladder decompression for 10 days. With a follow-up of 6-18 months, all had resolution of symptoms with improvement in radiographic variables. CONCLUSIONS: This series shows that children with duplex anomalies and obstruction can undergo successful reconstruction using techniques learned with laparoscopic pyeloplasty.

Prophylactic Antibiotics After Stented, Distal Hypospadias Repair: Randomized Pilot Study.

The usage of prophylactic oral antibiotics following distal hypospadias repair with stenting has been recently challenged. This study evaluated the incidence of symptomatic urinary tract infections (UTIs) following stented, distal hypospadias repair and the impact of prophylactic antibiotic therapy. Subjects 0 to 5 years of age with distal hypospadias were randomized to either Group 1 (antibiotics) or Group 2 (no prophylactic therapy). Urinalysis/urine culture was obtained intraoperatively with no preoperative antibiotics given. Phone interviews at 1 month and 3 months after surgery were done. Forty-eight patients were successfully randomized to either Group 1 (24) or Group 2 (24). The incidence of symptomatic UTI in this pilot study is low, and prophylactic antibiotic therapy does not appear to lower the incidence of symptomatic UTI. A larger, randomized, multicenter trial is needed to determine whether antibiotic prophylaxis reduces the risk of symptomatic UTIs following stented, distal hypospadias repair.

Nocturnal bladder emptying for reversing urinary tract deterioration due to neurogenic bladder.

Although daytime clean intermittent catheterization with urotropic medications is often sufficient therapy to relieve urinary retention and elevated intravesical pressures, neglecting the bladder affected by neuropathy or other significant pathologies during sleeping hours can lead to overdistension of the bladder and its deleterious consequences. The effect of this seemingly inconsequential clean intermittent catheterization interlude for some patients on an ideal daytime-only management protocol can lead to a syndrome of nighttime overdistension of the bladder, which can result in recurrent urinary tract infections, worsened incontinence, decreased bladder compliance and capacity, and progressive hydroureteronephrosis and renal insufficiency. Fortunately, nocturnal bladder emptying has emerged as a specific antidote for the syndrome of nighttime overdistension of the bladder, and because nocturnal bladder emptying can reverse or prevent bladder and upper tract deterioration, it is suggested that conventional therapies performed only during the daytime may have been inadequate for certain subgroups of patients who require a new therapeutic paradigm for their optimal management.