Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study.

PURPOSE: We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country. MATERIALS AND METHODS: The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR." RESULTS: In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076). CONCLUSION: Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.

Renal stone composition does not affect the outcome of percutaneous nephrolithotomy in children.

PURPOSE: We sought to investigate the association between renal stone composition and percutaneous nephrolithotomy outcomes in pediatric patients and define the characterization of the stone composition. METHODS: The data of 1157 children who underwent percutaneous nephrolithotomy between 1991 and 2012 were retrieved from the multicenter database of the Turkish Pediatric Urology Society. The study population comprised 359 children (160 girls, 199 boys) with stone analyses. Patients were divided into five groups according to the stone composition [group 1: calcium oxalate; group 2: calcium phosphate; group 3: infection stones (magnesium ammonium phosphate, ammonium urate); group 4: cystine; group 5: uric acid, xanthine stones]. RESULTS: Patient characteristics, perioperative, postoperative, and stone characteristics were compared considering the stone composition. There were no significant differences between the groups concerning age, sex, side involved, preoperative hematocrit levels, and solitary renal unit. Patients with cystine stones were more likely to have a history of stone treatment. Groups 2 and 5 had mostly solitary stones. However, group 3 had staghorn stone more often, and group 4 frequently had multiple stones. Overall stone-free rate (79.4%) was similar among the groups. Although stone composition was related to blood transfusion and prolonged operative and fluoroscopy screening times on univariate analysis, it was not a significant predictor of them on multivariate analysis. CONCLUSIONS: Stone composition was not a predictor of outcomes of pediatric percutaneous nephrolithotomy. However, cystine and infection stones, which are larger and filled multiple calyxes due to the nature of stone forming, were more challenging cases that need multiple tracts.

Ultrastructural and immunohistopathological evaluation of intravesical ureters via electron and light microscopy in children with vesicoureteral reflux.

PURPOSE: We used immunohistochemical methods and transmission electron microscopy to investigate the cytokine profiles and ultrastructural changes in the ureterovesical junction of children with primary vesicoureteral reflux. MATERIALS AND METHODS: A total of 39 distal intravesical ureters were obtained from 23 children who underwent ureteroneocystostomy for primary vesicoureteral reflux. Ureteral wall smooth muscle organization and transforming growth factor-ß1, vascular endothelial growth factor and CD34 were evaluated immunohistochemically and compared to controls, which consisted of 10 age matched autopsy specimens. Ultrastructural evaluations and morphological descriptions were performed semiquantitatively and compared to the published data. RESULTS: Of the patients 6 (26%) were male and 17 (74%) were female, and mean ± SD age was 73.2 ± 34.3 months (range 12 to 168). There was no correlation between reflux grade and age (p = 0.39). Smooth muscle disorganization score differed significantly between patients with intravesical ureters and controls (p = 0.01). Transforming growth factor-ß1 levels were significantly higher (p = 0.001) and vascular endothelial growth factor levels and microvessel densities were significantly lower in the patients with reflux compared to controls (both p <0.001). Vascular endothelial growth factor, CD34 and transforming growth factor-ß1 levels did not correlate with reflux grades (p = 0.84, p = 0.76 and p = 0.10, respectively). Urothelium, lamina propria and tunica adventitia appeared normal in the specimens for all grades of vesicoureteral reflux using transmission electron microscopy. Damage was observed in the muscular layers of the ureterovesical junction, especially in patients with grade IV or V reflux. CONCLUSIONS: Primary refluxing ureters exhibit immunohistopathological abnormalities compared to normal ureters irrespective of reflux grade, and ultrastructural changes are especially severe in cases of high grade reflux. These abnormalities can hinder the normal ureteral valve mechanism, and may lead to reflux due to smooth muscle dysfunction and microvascular alterations.

Factors affecting complication rates of percutaneous nephrolithotomy in children: results of a multi-institutional retrospective analysis by the Turkish pediatric urology society.

PURPOSE: We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS: We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS: Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Predictors of reflux persistence after endoscopic dextranomer/hyaluronic Acid copolymer injection in pediatric patients with Vesicoureteral reflux: short-term results.

This study aims to investigate the factors effective in predicting the persistence of reflux after the first subureteric transurethral injection (STING) of dextranomer/hyaluronic acid copolymer in pediatric patients with vesicoureteral reflux. The data of patients without a previous history of surgery to treat vesicoureteral reflux and who underwent STING for the first time between September 2011 and November 2020 were investigated retrospectively. After considering exclusion criteria, of 199 patients, 127 patients and 180 renal units were suitable for inclusion. A renal unit-based evaluation was made. Age < 61 months (univariate: p = 0.001, multivariate: p = 0.015, HR: 2.352 (1.181-4.686), OR (95% CI)), moderate reflux level (grade 3) (univariate: p < 0.001, multivariate: p = 0.019, HR: 2.703 (1.177-6.209), OR (95% CI)), DRF (differential renal function) < 45 (univariate: p = 0.020, multivariate: p = 0.047, HR: 1.992 (1.009-3.935), OR (95% CI)), and UDR (ureteral diameter ratio) > 0.15 (univariate: p < 0.001, multivariate: p = 0.005, HR: 2.786 (1.368-5.672), OR (95% CI)) were found predictors of reflux persistence after STING surgery both univariate and multivariate analysis. High reflux level (grade 4-5) was statistically significant in univariate analysis (p < 0.001) but not statistically significant in multivariate analysis (p = 0.215). In our study, UDR and DRF were found to be factors affecting reflux persistence. UDR and DRF should be considered in order to predict reflux resolution in patients who will undergo STING.

Is percutaneous nephrolithotomy effective and safe in infants younger than 2 Years old? Comparison of mini standard percutaneous nephrolithotomy.

BACKGROUND: In this study, we aimed to compare the operative outcomes, postoperative outcomes, stone-free status and complications of SPCNL and MPCNL in infants younger than two years of age. METHODS: We retrospectively analyzed 163 patients younger than two years of age who underwent percutaneous nephrolithotomy (PCNL) in our institution between September 1999 and March 2022. The patients were divided into two groups depending on the tract size. The MPCNL group consisted of 73 patients with a tract of 22 Fr or less, and the SPCNL consisted of 90 patients with a tract greater than 22 Fr. RESULTS: The median age of 163 patients included in the study was 17.3 (range 7-24) months. Although the median stone size was lower in the SPCNL group, no statistically significant difference was found between the two groups in terms of stone size (p = 0.073). The median operative time was 74.8 min in the MPCNL group and 62.8 min in the SPCNL group, with a statistically significant difference (p = 0.002). Stone free rates (SFR) were 89 % and 90.8 % in the MPCNL and SPCNL groups, and the clinically insignificant residual fragments (CIRF) rates were 11 % and 4.6 %, respectively (p = 0.064). The fluoroscopy time, nephrostomy withdrawal time, and hospitalization stay were similar in the two PCNL groups (p = 0.535, p = 0.253, and p = 0.143, respectively). Postoperative fever was similar in MPCNL and SPCNL groups (p = 0.504). Although bleeding (6.7%-2.7 %) and blood transfusion (3.3%-1.4 %) rates were higher in the SPCNL group, there was no statistically significant difference (p = 0.248 and p = 0.420, respectively). Prolonged urinary leakage occurred in 6 (8.2 %) patients in the MPCNL group and 1 (1.1 %) patient in the SPCNL group, with a statistically significant difference (p = 0.026). CONCLUSIONS: With the development of MPCNL, the use of SPCNL in infants has decreased considerably. However, SPCNL continues to be an effective and reliable method when needed in suitable patients. Although PCNL in infants shows some differences from adults, it is an effective and safe method for suitable patients. LEVEL OF EVIDENCE: Although we created our study by retrospectively examining the pediatric urology data that we created prospectively, our study is of a retrospective nature. Therefore the Level of Evidence is 3.

Epidemiological characteristics of Fournier's gangrene: a report of 71 patients.

INTRODUCTION: To identify the predisposing factors, etiological and clinical characteristics as well as the Fournier's gangrene (FG) severity index (FGSI) in the outcomes of patients with FG. MATERIALS AND METHODS: The data from 71 patients diagnosed with FG in a period of 17 years were retrospectively reviewed for the age of the patient, their history, predisposing factors, etiology, prodromal symptoms, FGSI, culture results, hospitalization period, surgical interventions, responses to the therapy and complications. RESULTS: All of the patients were Caucasian males, and the mean age was 61.3 (range 36-92) years. The mean duration from the onset of symptoms to surgery was 7.5 days. The mean hospitalization time was 27.4 days and the most common etiological factor for FG was a perineal abscess. The overall mortality rate was 29.6%. The relationship between the number of predisposing factors and mortality rates in patients with FG was the most statistically significant parameter (p = 0.001). CONCLUSIONS: Multiple predisposing factors predict a poor prognosis and correlate significantly with mortality. Extension of the disease and the FGSI score were not predictive of outcome. The most essential intervention for stopping the rapidly progressing infectious process of FG consists of early recognition of the disease, proper management of the predisposing factors and aggressive surgical debridement. Such an intervention can improve clinical outcomes.

Factors affecting complication rates of ureteroscopic lithotripsy in children: results of multi-institutional retrospective analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society.

PURPOSE: We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS: We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate. CONCLUSIONS: Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Determination of the etiology of pediatric urinary stone disease by multigene panel and metabolic screening evaluation.

INTRODUCTION: Urinary tract stone disease (UTSD) is seen with increasing frequency in children, and genetic, metabolic and environmental factors are known to play a role in its etiology. Since it is a genetically heterogeneous disease, we investigated the multigene panel and metabolic evaluation together. MATERIAL AND METHOD: Forty-eight pediatric patients that underwent surgery for UTSD and were followed up in the Department of Urology of Çukurova University Faculty of Medicine between March 2016 and July 2019 were included in the study. Children with known metabolic diseases were excluded.A detailed history was taken from each patient, and presence of a positive family history was questioned. Blood and urine samples were obtained, and metabolic evaluation was performed. In addition, 2 cc peripheral blood samples were collected from selected patients to perform DNA isolation at Çukurova University Adana Genetic Diseases Diagnosis and Treatment Center. The analysis of the obtained sequence data was performed. RESULTS: Of the 48 children included in the study, 29 (60.4%) were male and 19 (39.6%) were female. The mean age was 60 ± 50 (12-192) months. It was observed that 28 (58.3%) of the patients included in the study had a positive family history.As a result of the next-generation sequencing studies conducted with the multigene panel, a total of 21 clinically significant variants in eight different genes were identified with the bioinformatics analysis on the data on which quality control was performed. The weighted distribution of the 21 variants according to the genes was as follows: five variants (23.8%) in the SLC3A1 gene, four (19%) in SLC6A20, and three (14.3%) in SLC7A9 and SLC26A1. The clinical reporting of the disease etiology and/or variants with prognostic significance determined as a result of the performed analyses was completed by field experts in accordance with international standards. The visuals of the detected variants are presented in Summary figure. CONCLUSION: In pediatric cases with UTSD, it is important to determine the underlying metabolic and genetic risk factors in order to prevent recurrence and apply the most effective treatment.

Which factors affect the success of pediatric PCNL? Single center experience over 20 years.

OBJECTIVE: We aimed to investigate the impact of surgeons' experience on pediatric percutaneous nephrolithotomy (PCNL) outcomes. MATERIALS AND METHODS: Between June 1997 and June 2018, 573 pediatric patients with 654 renal units underwent PCNL for renal stone disease by senior surgeons. Data were divided into two groups, group-1 (n = 267), first ten years period, group-2 (n = 387); second ten years period. RESULTS: Mean ± SD age of patients was 7.6 ± 4.9 (1-17) years. The stone-free rates (SFR) assessed after 4 weeks were 74.9% vs. 83.4% in group-1 vs. group-2, respectively (p = 0.03). The mean operation time, fluoroscopy time, and the number of patients requiring blood transfusion significantly decreased in group 2 (100.4 ± 57.5 vs. 63.63 ± 36.3, 12.1 ± 8.3 vs. 8.3 ± 5.4, and 24.3% vs. 2.9%; p < 0.001, p < 0.001, and p = 0.002 in group-1 versus group-2, respectively). On multivariate analysis, increasing stone size increased operation time (p < 0.001), fluoroscopy time (p < 0.001), intraoperative and postoperative blood transfusion rates (p = 0.006 and p = 0.018, respectively), and hospital stay (p = 0.002) but was not associated with change of glomerular filtration rate (GFR) (p = 0.71). Sheath size also correlated with increased fluoroscopy time (p < 0.001), operation time (p < 0.001), intraoperative blood transfusion (p < 0.001) and hospital stay, but sheath size did not affect postoperative blood transfusion (p = 0.614) or GFR change (p = 0.994). CONCLUSIONS: The percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure and is well accepted because of its lower complication rate and high efficiency for pediatric patients. Stone and sheath size are predictive factors for blood loss and hospital stay. During 20 years, our fluoroscopy time, operation time, blood loss, and complication rates decreased, and stone-free rate increased.

Evaluation of the Intravesical Ureters after Failed Endoscopic Treatment of Vesicoureteral Reflux with Dextranomer/hyaluronic Acid in Children via Light and Transmission Electron Microscopic Analysis. A Matched Case-Control Study.

INTRODUCTION: The cytokine profile and the ultrastructural changes of refluxing ureterovesical junctions(UVJs) of children treated with failed dextranomer/hyaluronic-acid (Dx/HA) injections were investigated using immunohis-tochemical methods and transmission electron microscopy(TEM). PATIENTS AND METHODS: Eighteen children who had undergone injection for reflux were included the study. The smooth muscle arrangement of the ureteral wall, transforming growth factor-? (TGF-?1),vascular-endotheli-al-growth factor (VEGF) and CD34 were evaluated immunohistochemically, and the results were compared with 10 age-matched autopsy specimens as controls. The ultrastructural evaluation and morphological description was made semi-quantitatively and compared with published data. RESULT: Four of the patients (22%) were male, and 14 (78%) were female. The mean age of the patients was 105.4 ± 44.5(48-184) months. There was no correlation between the vesicoureteral reflux (VUR) grade and age (P = 0.85). The mean VEGF and CD34 scores were 16.2 ± 9.6 (0-90) cells per HPF and 10.2 ± 3.5 (4-16) vessels per HPF in ureters with reflux; these values were 60.6±16.4 (32-84) cells per HPF and 17.8 ± 4.1 (12-24) vessels per HPF in the control group. The amount of VEGF and CD34 were significantly decreased in patients compared with the control group (P < 0.001, P < 0.001).The TGF-?1 levels were significantly higher in patients with VUR compared with the control group (34.2 ± 19.9 vs 5.0±1.9; P=0.001).The amount of VEGF, CD34, and TGF-?1 were not correlated with the grade of reflux (P = 0.26, P = 0.94, and P = 0.42, respectively). Ultrastructural changes in the muscle cells were observed in all the VUR specimens (Grade II-IV). CONCLUSION: Refluxing ureters exhibited immune-histopathological abnormalities and ultrastructural changes of the muscle cells in all VUR specimens in the ureterovesical junctions of children treated with failed Dx/HA injec-tions for reflux.

Factors predicting postoperative febrile urinary tract infection following percutaneous nephrolithotomy in prepubertal children.

BACKGROUND: Predictive tables and scoring systems can predict stone clearance. However, there is a paucity of evidence regarding the prediction of complications during percutaneous nephrolithotomy (PCNL), particularly in children, which remains under-researched. To our knowledge, no studies have evaluated the risk factors for febrile urinary tract infection (FUTI) after pediatric PCNL. OBJECTIVES: To assess the predictive factors of FUTI in prepubertal children after PCNL and determine whether any prophylactic cephalosporins are superior for decreasing the FUTI rate. STUDY DESIGN: Data from 1157 children who underwent PCNL between 1991 and 2012 were retrieved from the multicenter database of the Turkish Pediatric Urology Society. Children >12 years of age were excluded, leaving 830 children (364 girls, 466 boys). Data were analyzed according to the presence of FUTI and compared between the FUTI and non-FUTI groups. RESULTS: Mean age was 6.46 ± 3.38 years. Twenty-nine (3.5%) children had FUTI which was confirmed by urine culture. FUTI occurred more frequently in young children (5.5%) than school-age children (2.4%). In univariate analysis, there were significant differences between the FUTI and non-FUTI groups regarding age, cephalosporin subgroup (first, second and third generation cephalosporin), side of PCNL, staghorn stones, tract size, operative time, postoperative ureteral catheter usage, perioperative complications (SATAVA), and blood transfusion. Multivariate analysis revealed that age, side of PCNL, staghorn stones, tract size, operative time, and blood transfusion were independent predictors of FUTI. DISCUSSION: The smaller tract size could cause FUTI with poor fluid drainage that may lead to elevate renal pelvic pressure and trigger bacteremia-causing pyelovenous backflow. Filling the calyx and renal pelvis by a staghorn stone and the resulting obstruction of fluid drainage may elevate intrarenal pelvis pressure. Longer operative time is likely to increase renal pelvic pressure over longer periods, which may account for FUTI after pediatric PCNL. CONCLUSIONS: Younger age, right-sided PCNL, staghorn stones, mini-PCNL, longer operative time, and blood transfusion are risk factors for FUTI. First-, second-, and third-generation cephalosporins are equally effective for prophylaxis in prepubertal children undergoing PCNL.

Percutaneous nephrolithotomy in the management of pediatric renal calculi.

BACKGROUND AND PURPOSES: In the era of extracorporeal shockwave lithotripsy (SWL), there are still some patients who will require percutaneous nephrolithotomy (PCNL). Our experience with this procedure is reviewed and discussed. PATIENTS AND METHODS: Fifty five patients with a mean age of 7.9 years (10 months-14 years) underwent 67 PCNL procedures on 62 renal units between September 1997 and April 2001. Of the patients, 13 had previous open renal surgery, 4 had a solitary kidney, 4 were SWL failures, 2 had osteogenesis imperfecta, one had anuria secondary to bilateral calculi, 2 had poorly functioning kidneys, and 1 had cystinuria (complete staghorn calculus). One disabled patient with neurologic disorders who had multiple stones underwent PCNL in order to decrease the stone burden and to improve the kidney function. Operations were performed under the guidance of monoplane fluoroscopy. Pneumatic or ultrasonic lithotripsy and forceps extraction were used with a rigid nephroscope or ureteroscope (as an alternative instrument in small-caliber tracts). RESULTS: Excluding the patient with neurologic disorders, 53 of the renal units (86.9%) were stone free at the time of discharge, and the success rate was 96.7%, with six patients having insignificant residual fragments after the procedure. In one patient, open surgery was required, and the other patient was sent for SWL treatment. There was no contiguous organ injury, but in 16 procedures (23.9%), intraoperative hemorrhage was seen, and blood transfusions were required. CONCLUSION: Pediatric urolithiasis is usually a result of metabolic abnormalities and urinary tract infection, and there is always a risk of recurrence that may necessitate multiple additional intervention. Therefore, PCNL must be considered in selected cases by urologists who are experienced in adult percutaneous procedures.

Metabolic risk factors and the effect of metaphylaxis in pediatric stone disease with hypocitraturia.

To describe the metabolic risk factors and investigate the effect of prophylaxis based on these factors on long-term recurrence of urolithiasis in pediatric patients with hypocitraturia. One-hundred and twenty-nine pediatric patients who underwent percutaneous nephrolithotomy between January 2008 and June 2011 were evaluated for metabolic risk factors. The patients with hypocitraturia were enrolled in this study and the data were analyzed using statistical methods for a mean period of 2 years for metabolic abnormalities, stone type, and the effect of potassium citrate prophylaxis on stone recurrence. A 24-h urine metabolite analysis revealed one or more metabolic risk factors in 115 (89.2 %) of the patients, whereas 14 (10.8 %) of the patients had no metabolic abnormalities. Eighty-two (63.5 %) of 129 patients had hypocitraturia. Of them, 43 (52 %) were male and 39 (48 %) were female, with a mean age of 9.7 ± 4.9 and 6.7 ± 4.4 (1-16) years, respectively(p = 0.102). Thirty-five (42.7 %) had pure hypocitraturia, and 47 (57.3 %) had two or more metabolic abnormalities. The most common dual metabolic abnormality was hypocitraturia and hypomagnesuria. Seventy-one patients (87 %) with hypocitraturia received medical prophylaxis and continued regularly, whereas 11 (13 %) patients did not receive medical prophylaxis despite being advised to do so. After a mean follow-up of 26.5 ± 9.4 months, the rate of recurrence was 1.4 % in the patients with hypocitraturia who continued prophylaxis and occurred in all of the patients who did not receive prophylaxis (p < 0.001). Calcium oxalate stones (95.2 %) were the most commonly found stones in the stone analysis. Detailed clinical and laboratory evaluations should be performed in children with urolithiasis. Appropriate prophylactic treatment as potassium citrate, should be given to prevent reformation of stones in patient with hypocitraturia.

Immunohistochemical and electron microscopic examination of Cajal cells in ureteropelvic junction obstruction.

OBJECTIVE: We examine the ultrastructural configurations of Cajal cells by electron microscopy, as well as the quantitative changes occurring in Cajal cells by light microscopy. METHODS: In total, 35 patients with ureteropelvic junction (UPJ) obstruction and 7 patients without obstruction were compared immunohistochemically with c-kit (CD117) to quantify the number of cells. On electron microscopic examination, 7 patients with UPJ obstruction and 3 patients without obstruction were compared to evaluate the changes which occurred in the ultrastructural configuration of the Cajal cells. RESULTS: On light microscopic examination, it was determined that the Cajal cells, which demonstrate c-kit (CD117) immunoreactive character, were located near the circular muscle layer and parallel to the muscle cells. The number of Cajal cells in the control group was significantly increased compared to the number of cells in patients with UPJ obstruction (p < 0.001). On electron microscopic examination, the number of interstitial cells was also higher in the control group. A decrease in the number of the caveolae in these cells was seen in the group with UPJ obstruction compared to the control group. CONCLUSION: In UPJ obstruction, a decrease in the number of Cajal cells, as well as the changes in the morphologic structure of the Cajal cells, indicates that these cells have a role in the pacemaker system and are associated with ureteral peristalsis.

The effect of prophylactic treatment with Shohl's solution in children with cystinuria.

OBJECTIVE: To investigate the effect of prophylactic treatment with Shohl's solution on the rates of stone recurrence in paediatric patients with cystinuria. PATIENTS AND METHODS: Between June 2007 and October 2011, 185 patients aged 16 years and younger whose stones had been completely removed by percutaneous nephrolithotomy (PCNL) were assessed for metabolic risk factors. Seventeen (9%) patients with positive cyanide-nitroprusside tests (CNT) and cystine stones enrolled in this study, and a Shohl's solution was used for alkalinisation. The patients were followed up for a mean period of two years for stone recurrence. RESULTS: Of the patients, 10 (59%) were male, and 7 (41%) were female (p = 0.13). Twelve patients (70.5%) continued to receive medical prophylaxis regularly, whereas 5 (29.5%) patients did not. The mean pre-treatment and post-treatment urinary pH values were 5.8 ± 0.5 (5-7) and 7.5 ± 0.4 (6.5-8), respectively (p < 0.001). The pre-treatment and post-treatment specific gravities of the urine were 1021.5 ± 5.4 (1010-1030) and 1006 ± 2.3 (1004-1015), respectively (p < 0.001). The rates of recurrence were 16.6% among those who continued prophylaxis and 100% among those who did not receive prophylaxis (p = 0.001). The most common combination of metabolic anomalies was cystinuria and hypocitraturia (p < 0.001). CONCLUSIONS: This study demonstrated that detailed clinical and laboratory evaluations should be performed for all children with cystine stone disease, and, appropriate prophylactic treatment should be recommended to prevent the reformation of stones.

Retroperitoneoscopic nephroureterectomy via three trocars in pediatric patients with end-stage reflux nephropathy.

BACKGROUND AND PURPOSE: In children with end-stage reflux nephropathy, nephroureterectomy can be performed either open or laparoscopically. It is not common to use a three-trocar retroperitoneal approach for nephroureterectomy with complete ureteral excision in the pediatric age group. We report the results of pediatric retroperitoneoscopic nephroureterectomies by using three trocars only. PATIENTS AND METHODS: Between August 2003 and November 2009, 13 children-seven boys and six girls-with end-stage reflux nephropathy underwent retroperitoneoscopic nephroureterectomy. The operations were performed by using three trocars with the patient in a flank position under general anesthesia. Renal blood vessels were individually dissected and divided followed by the transection of the ureter at the level of the ureterovesical junction. RESULTS: The mean age of the patients was 6.5 ± 4.4 years (15 months-14 years). Eight of the operations were performed on the left and five on the right side. Mean operative time was 137 ± 47 minutes (75-230 min). Estimated blood losses were minimal. Mean hospitalization time was 2.2 ± 0.9 days (2-5 d). No major intraoperative complication was seen. Overall postoperative analgesic requirement was minimal. Cosmetic results were excellent at the initial postoperative visit. CONCLUSION: Retroperitoneoscopic nephroureterectomy by using three trocars is feasible and safe with excellent outcomes in pediatric patients with end-stage reflux nephropathy.

Pediatric transumbilical laparoendoscopic single-site nephroureterectomy: initial report.

OBJECTIVE: To present a case of laparoendoscopic single-site surgery (LESS) nephroureterectomy (NUx), a type of embroyonic natural orifice translumenal endoscopic surgery, which is one of the recent innovations in the era of laparoscopy, in a child. METHODS: A 10-year-old girl underwent left nephroureterectomy by LESS due to end-stage reflux nephropathy on December 25, 2008. The surgery is performed transperitoneally, through a 2-cm semicircular incision in the left inner curve of the umbilicus using three 5-mm trocars. NUx with LESS was performed duplicating standard laparoscopic steps with the help of flexible and straight laparoscopic instruments. RESULTS: Operation time was 140 minutes and the blood loss was minimal. There was no intraoperative or postoperative complication. The patient was discharged at the 24th postoperative hour. The postoperative cosmetic result was excellent as the incision scar was hidden inside the belly button. CONCLUSIONS: NUx with LESS is a feasible technique with the advantages of less pain, shortened convalescence, improved cosmesis, and absence of wound complications in children. However, clear indications of LESS in children remain to be clarified.

The effects of ureteral obstruction on Cajal-like cells in rats.

OBJECTIVE: To determine the changes in number and morphology of interstitial cells of Cajal (ICC)-like cells (ICC-LC) at the ureteropelvic junction (UPJ) of rats after experimental distal ureteral obstruction. MATERIALS AND METHODS: Of a total of 109 rats, 20 served as controls (C), 20 underwent sham-operations (SH) and 69 were in the study (S) groups. The UPJs were extracted initially in the C and SH groups, and 7, 14, 30, 60 and 90 days after ligation of the distal ureter in the study groups (S1, S2, S3, S4 and S5, respectively). The sections stained by c-kit anticore were studied under a light microscope. RESULTS: The mean number of ICC-LC was 4.55+/-2.21 in C, 5.15+/-3.51 in SH, 7.40+/-6.88 in S1, 21.16+/-19.03 in S2, 12.63+/-8.16 in S3, 10.40+/-5.09 in S4, and 10.9+/-6.33 in S5. There was a statistically significant increase in ICC-LC in the study groups, except S1, compared to the C and SH groups. No significant difference was detected in Cajal cell morphology and distribution pattern between groups. CONCLUSIONS: Based on the changes in number of ICC-LC at the UPJ after obstruction of the distal ureter compared with the limited data available in the literature, we suggest that ICC-LC have a close relationship with motility of the ureter.

An unusual cause of pleural effusion, urinothorax in a child with urinary stone disease.

The association of obstructive uropathy with ascites has been known since 1863 and with pleural effusion since 1954. Urinothorax is a rare complication of blunt renal trauma, ureteral instrumentation or ureteral surgery. Leakage from the urinary tract may cause urinoma, retroperitoneal collection of fluid, which can lead to urinothorax. This case report describes a child with a massive right-sided pleural effusion that was caused by same-sided renal calculi. The effusion disappeared within a few days after adequate urinary drainage had been established.