Management of Upper Tract Urothelial Carcinoma in a Double Collecting System Kidney.

Upper tract urothelial carcinoma (UTUC) in a duplex collecting system (DCS) is a relatively uncommon presentation with unclear management guidelines. Herein, we retrospectively reviewed all published cases of DCS with UTUC aiming to suggest personalized clinical care options for future cases. We conducted a systematic search for all cases of UTUC in DCS from published literature using the following keywords: UTUC, urothelial carcinoma (UC), collecting duct carcinoma, and DCS. The cases were summarized based on demographics, clinical presentation, predisposing risk factors, tumor location, management, and follow-up. We present an additional case based on our experience with a 69-year-old female with high-grade (HG) UTUC of the upper moiety in complete DCS. The patient underwent a robotic upper pole hemi-nephroureterectomy (hemi-NU) with a common sheath distal ureterectomy and a bladder cuff, followed by lower pole ureteral reimplantation. Overall, 34 patients with 35 renal units of UTUC in DCS were included and analyzed. To conclude, UTUC of DCS is rare and underreported. Hence, it is difficult to define a standard treatment. Although hemi-NU has been previously described, to the best of our knowledge, this is the first case report of robot-assisted hemi-NU for complete DCS with single-moiety UC.

The accuracy of cystography under general anesthesia in children with vesicoureteral reflux.

PURPOSE: To examine the accuracy of cystography under general anesthesia in children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: A prospective study of children who had VUR on cystography without general anesthesia (i.e., the gold-standard), and who are candidates for endoscopic VUR repair surgery. All children subsequently underwent a cystography under general anesthesia before injection using standardized method, which was compared to the gold-standard cystography. χ2 and Mann-Whitney U tests were used to compare proportions and medians between groups. RESULTS: Between 2017 and 2021, 126 renal units in 13 boys and 50 girls were included. Median age was 3.4 years (interquartile range [IQR] 1.5-6.5). Median time from cystography without to cystography with general anesthesia was 3.8 months (IQR 2.7-6). Of the 126 renal units, 96 had VUR on cystography without general anesthesia. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative and positive predictive values of cystography under general anesthesia were 47% (45/96), 87% (26/30), 34% (26/77) and 92% (45/49), respectively. Accuracy was 56.3%; Cohen's Kappa coefficient was 0.22, indicating poor agreement. In subgroup analysis, the sensitivity of cystography under general anesthesia was significantly lower in primary VUR (20% vs. 55% in secondary VUR, p = 0.01) and active VUR (14% vs. 52% in passive VUR, p = 0.008). CONCLUSION: Cystography under general anesthesia was poorly correlated to cystography performed while the child was awake or lightly sedated. Clinical decision relying on this cystography is questionable.

Ectopic Intravesical Ejaculatory Ducts: Case Report of Bulking Agent Injection for Treatment of Recurrent Epididymitis in a Patient With Anorectal Malformation.

As far as we know this is the first report on bulking agent injection into intravesical ectopic ejaculatory orifices reported in the English literature. During a follow-up period of 23 months, the child was free of episodes of epididymo-orchitis. Deflux injection in this rare anomaly of intravesical refluxing ducts had prevented irreversible damage to the testes from recurrent EO. Thus, it may be a better option than vasectomy when antibiotic treatment fails.

Long-term Results of Ventral Penile Curvature Repair in Childhood.

OBJECTIVE: To assess the postpubertal outcome of ventral penile curvature repaired in infancy in terms of recurrence and aesthetics. MATERIALS AND METHODS: Postpubertal patients treated for hypospadias and ventral penile curvature in infancy at a tertiary medical center were invited to undergo assessment of the quality of the repair. Findings were compared between patients with a straight penis after skin release and patients who required dorsal plication. RESULTS: The cohort included 27 patients of mean age 16.5 years who were reported with straight penis after surgery. Postpubertal curvature was found in 6 of 14 patients (43%) successfully treated by skin release and 10 of 13 patients (77%) who underwent dorsal plication (P = .087). Significant curvature (≥30 degrees) was found in 1 of 14 patients in the skin-release group and 4 of 13 in the dorsal plication group (P = .16). Rates of redo urethroplasty were 2 of 14 (14%) and 5 of 10 (50%), respectively. Patient satisfaction with the appearance of the penis did not differ significantly. CONCLUSION: Ventral penile curvature repaired in infancy often recurs after puberty. The need for dorsal plication has a trend-level association with recurrence of penile curvature in puberty. It might also be related to the degree of postpubertal penile curvature and the need for redo urethroplasty. Procedure type does not affect patient satisfaction with the postpubertal appearance of the penis.

Post-ritual Circumcision Bleeding-Characteristics and Treatment Outcome.

OBJECTIVE: To report the characteristics, treatment, and short-term outcome of neonatal post-circumcision bleeding, and to identify predictors of surgical treatment. MATERIALS AND METHODS: The medical records of 90 consecutive neonates who presented to the emergency room with post-circumcision bleeding between 2009 and 2014 were reviewed. Circumcisions were performed using the traditional Mogen shield device. The study end point was surgical intervention for hemostasis. Predictors of surgical treatment were evaluated. RESULTS: An estimated total of 28,383 circumcisions were performed during the study period; thus, the post-circumcision bleeding rate was 0.32%. Initial treatment included compressive dressing in 15 infants (17%) and hemostatic dressing in 47 infants (52%); 28 infants (31%) did not require treatment upon arrival to the emergency room. Two infants (2%) received blood transfusion. Surgical treatment was required in 11 infants (12%); 10 of 43 infants (23%) with active bleeding on arrival to the emergency room required surgery compared to 1 of 47 infants (2%) without active bleeding (P = .003). Similarly, 3 of 7 infants (43%) referred from other hospitals required surgery compared to 8 of 83 infants (10%) referred from the community (P = .037). Abnormal blood tests at presentation were not associated with surgical treatment. At 1 month of follow-up, 2 infants were admitted for recurrent bleeding. Coagulation abnormalities were found in 4 infants. CONCLUSION: Surgical treatment was required in 12% of infants presenting to the emergency room with post-circumcision bleeding. The rate of surgical intervention was significantly higher in infants with active bleeding at presentation and in those referred from other hospitals. Physicians should consider admitting infants presenting with active post-circumcision bleeding, whereas infants without active bleeding may be observed and discharged.

Epididymitis in patients with anorectal malformations: a cause for urologic concern.

INTRODUCTION: Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. MATERIALS AND METHODS: We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. RESULTS: Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. CONCLUSION: Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration.

Urinary retention in children.

OBJECTIVE: To describe the causes and outcome of urinary retention in children and assess its prevalence by gender and age. METHODS: The medical records of all children (aged <18 years) who presented to the emergency room with acute urinary retention from 2000 to 2012 were reviewed. Patients with postoperative urinary retention, a known neurologic disorder, and neonates were excluded. Data were collected on patient demographics and cause, treatment, and outcome of the urinary retention. Findings were evaluated and compared by age and gender. RESULTS: The study group comprised 42 boys (75%) and 14 girls (25%). Median follow-up time was 25 months. Causes of urinary retention were mechanical obstruction in 14 patients (25%), infection or inflammation in 10 (18%), fecal impaction in 7 (13%), neurologic disorders in 6 (11%), gynecologic disorders in 4 (7%), and behavioral processes in 3 patients (5%); 12 patients (21%) were idiopathic. All patients with mechanical obstruction were boys, of whom 5 had a pelvic tumor. Age distribution was bimodal: 29% of the events occurred between ages 3 and 5 years, and 32%, between ages 10 and 13 years. Fifteen children underwent surgery. Three children required continuous catheterization during follow-up. CONCLUSION: Urinary retention in children is characterized by a variable etiology and bimodal age distribution. The high rate of severe underlying disease is noteworthy and should alert physicians to the importance of a prompt, comprehensive, primary evaluation of this patient population in a hospital setting to initiate appropriate treatment and avoid complications.

Epididymitis in Patients with Anorectal Malformations: A Cause for Urologic Concern

Introduction Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. Materials and Methods We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. Results Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. Conclusion Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration .

Histology proved malpositioning of dextranomer/hyaluronic acid in submucosal ureter in patients after failed endoscopic treatment of vesicoureteral reflux.

PURPOSE: We histologically investigated the cause of failed endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. MATERIALS AND METHODS: A total of 192 children underwent dextranomer/hyaluronic acid injection at our institution between January 2008 and September 2010. The study population consisted of 13 children (22 ureters) with vesicoureteral reflux who underwent ureteroneocystostomy following failed endoscopic injections (1 to 2) of dextranomer/hyaluronic acid. In all cases the dextranomer/hyaluronic acid was implanted in the mucosa of the mid to distal ureteral tunnel following hydrodistention of the ureter. The medical records were reviewed, and specimens of the archived distal ureters removed during surgery were examined histologically. RESULTS: Mean patient age was 4.1 years. Mean dose of dextranomer/hyaluronic acid was 0.9 ml (both treatments) and mean lag between treatments was 13.4 months. Indications for open surgery were recurrent urinary tract infections and/or residual or aggravated reflux grade IV or higher. Histological study revealed that the dextranomer/hyaluronic acid was malpositioned in 21 of 22 ureters, residing in the muscle fibers in 2, adventitia in 14 and periureteral space in 5. CONCLUSIONS: This is the first known study to provide a histologically proved cause of failure of endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. Malpositioning of the material outside the submucosal ureter was identified in a high percentage of cases. Larger studies are needed to corroborate these findings.

High-grade transitional cell carcinoma of the pediatric bladder.

Transitional cell carcinoma of the bladder is extremely rare in the first decade of life. We present the case of a 5-year-old male with gross hematuria found to have high-grade transitional cell carcinoma of the bladder. To our knowledge this is the first such reported case in this age group.

The impact of the alexander technique on improving posture and surgical ergonomics during minimally invasive surgery: pilot study.

PURPOSE: One of the main ergonomic challenges during surgical procedures is surgeon posture. There have been reports of a high number of work related injuries in laparoscopic surgeons. The Alexander technique is a process of psychophysical reeducation of the body to improve postural balance and coordination, permitting movement with minimal strain and maximum ease. We evaluated the efficacy of the Alexander technique in improving posture and surgical ergonomics during minimally invasive surgery. MATERIALS AND METHODS: We performed a prospective cohort study in which subjects served as their own controls. Informed consent was obtained. Before Alexander technique instruction/intervention subjects underwent assessment of postural coordination and basic laparoscopic skills. All subjects were educated about the Alexander technique and underwent post-instruction/intervention assessment of posture and laparoscopic skills. Subjective and objective data obtained before and after instruction/intervention were tabulated and analyzed for statistical significance. RESULTS: All 7 subjects completed the study. Subjects showed improved ergonomics and improved ability to complete FLS™ as well as subjective improvement in overall posture. CONCLUSIONS: The Alexander technique training program resulted in a significant improvement in posture. Improved surgical ergonomics, endurance and posture decrease surgical fatigue and the incidence of repetitive stress injuries to laparoscopic surgeons. Further studies of the influence of the Alexander technique on surgical posture, minimally invasive surgery ergonomics and open surgical techniques are warranted to explore and validate the benefits for surgeons.

Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer.

PURPOSE: Ureteral obstruction due to benign strictures is a significant complication of radical cystectomy and urinary diversion for bladder cancer that can lead to renal function loss and infection related morbidity. Treatment may be performed surgically or with minimally invasive techniques. We describe the 10-year experience at our department with various treatment modalities for post-cystectomy benign strictures. MATERIALS AND METHODS: The study group consisted of 28 patients treated for benign ureteral strictures following radical cystectomy for bladder cancer. Their medical records were reviewed for clinical presentation, diagnostic procedures, treatment and long-term outcome. RESULTS: The study group represented 12.7% of all 221 patients treated at our department with radical cystectomy for bladder cancer in 1994 to 2004. Ureteral strictures were asymptomatic in 71.4% of cases. Median time to diagnosis was 7.0 months and 75% of the patients were diagnosed within year 1 after cystectomy. Treatment consisted of stenting, dilation and open surgical revision with removal of the strictured segment and reanastomosis. Median followup was 62.5 months. The stenting procedures served as the long-term definitive treatment in 45% of cases, whereas balloon dilation uniformly failed. Although open surgical revision was technically challenging, it had a long-term success rate of 93%. CONCLUSIONS: Benign ureteral strictures commonly occur during postoperative year 1 and they are usually asymptomatic. Early diagnosis and prompt drainage are required to prevent consequent renal parenchymal loss and infectious complications. Although minimally invasive procedures are viable treatment alternatives, open surgical revision is still the preferred long-term definitive treatment.

Effects of insulin-like growth factor-I deficiency and replacement therapy on the hematopoietic system in patients with Laron syndrome (primary growth hormone insensitivity).

BACKGROUND: Primary insulin-like growth factor-I (IGF-I) deficiencies, such as in Laron syndrome (LS), are a unique model in man to study the consequences resulting from defects in growth hormone (GH) signal transmission. OBJECTIVE: To assess retrospectively the effect of IGF-I deficiency and its therapy on the various cells of the hematopoietic system as reflected by peripheral blood counts. PATIENTS AND METHODS: Two groups of patients were studied. The first group consisted of 11 untreated patients with LS, seven males and four females, who were followed from childhood into adult age. Average age at the time of data analysis was 45.4 +/- 9.6 years. The second group included ten children with LS, six males and four females, who received IGF-I replacement therapy for an average period of 6 years, ranging in age from 0.9-11 years. The mean age at initiation of therapy was 6.9 +/- 4.28 years. Only the seven children treated for 5 years or more were included in the analysis. Data on blood counts were collected from the patients' charts. Blood samples were drawn at baseline, weekly during the first month, once a month during the first year, and once every 3 months thereafter. Statistical analysis of the change over time was performed using repeated measures ANOVA. RESULTS: Children with LS had red cell indices in the lower normal range and an elevated monocyte count. A statistically significant rise in red blood cell (RBC) indices was seen in children during IGF-I therapy: RBC rose from 4.66 x 10(6)/ml to 4.93 x 10(6)/ml (p = 0.011); hemoglobin from 11.55 g/dl to 13.01 g/dl (p < 0.001); hematocrit from 34.94% to 38.52% (p = 0.007), and mean corpuscular volume from 72.27 fl to 79.93 fl (p < 0.001). The platelet count diminished significantly during IGF-I therapy from 316 x 10(3)/ml to 219 x 10(3)/ml (p = 0.02), and the monocyte count from 0.74 x 10(3)/ml to 0.49 x 10(3)/ml (p < 0.001). CONCLUSIONS: The present investigation, the first of its kind in this syndrome, confirms that IGF-I has a strong stimulatory effect on erythropoiesis. In addition, IGF-I therapy had a reducing effect on monocytes and platelets, an effect not previously described. The mechanism by which IGF-I mediates these effects needs further elucidation.

Testicular torsion in the pediatric age group: diagnosis and treatment.

PURPOSE: To review and update several aspects of testicular torsion. INCIDENCE: The relative incidence of testicular torsion, torsion of testicular appendix and epididymo-orchitis is variable and depends on mode of diagnosis and patients' age. AGE: Testicular torsion can occur at any age. The peak is in adolescents below the age of 18 years. SYMPTOMS: Classical symptoms are not always present. Range of duration is varied. Nausea and vomiting are positive predictive value for testicular torsion. PHYSICAL EXAMINATION: Main findings predicting testicular torsion are absence of cremasteric reflex and diffuse tenderness. IMAGING: Color Doppler Ultrasound can assess in equivocal and low clinical suspicious conditions for testicular torsion. NEONATAL TORSION: There are two conditions in this age group; the prenatal that urgent exploration is in controversy and postnatal that urgent surgery is required. LATE OUTCOME: Early salvage rate and late atrophy depends on duration and degree of torsion. MEDICOLEGAL: Testicular torsion is an active area of malpractice litigation. Late presentation and atypical presentations do not affect the medicolegal outcome.