The sequence of intervention determines the risk of early postoperative acute kidney injury in infants with bilateral ureteropelvic junction obstruction.

INTRODUCTION AND OBJECTIVES: The management of bilateral ureteropelvic junction obstruction (UPJO) is greatly debated. We aim to identify the risk of early postoperative acute kidney injury (AKI) in relation to the sequence of intervention in children with bilateral UPJO managed in a sequential manner. METHODS: A single center database was retrospectively reviewed for children ≤2 years who underwent bilateral pyeloplasty. According to the differential renal function on the preoperative renograms, patients were categorized into group A: pyeloplasty on the poorer functioning kidney first and group B: pyeloplasty on the better functioning side first. Serum creatinine and eGFR, using the modified Schwartz formula, were evaluated at four time points (I): before the first intervention (II): within 48 h of the first intervention (III): before the second intervention and (IV): within 48 h of the second intervention. Preoperative and postoperative values were compared. The incidence of early postoperative AKI in both groups was defined according to the Acute Kidney Injury Network (AKIN) criteria. RESULTS: The study comprised 46 children treated by staged pyeloplasty, 28 of them underwent pyeloplasty on the poorer functioning side first. Baseline serum creatinine and eGFR were not significantly different between both groups. Patients who underwent pyeloplasty on the poorer functioning side first, had a significant decline of eGFR after the first intervention (p = 0.006). Conversely, no significant eGFR changes were observed after the first or second interventions in the other group (figure). Overall, 64.3% and 33.3% of patients developed some degrees of AKI when intervention was started on the poorer and better functioning renal units, respectively (p = 0.04). DISCUSSION: Bilaterality is seen in approximately » of patients with UPJO. Oftentimes, both renal units are asymmetrically affected with little data to guide surgeons on the optimal sequence of intervention. Following pyeloplasty, 52.2% of the evaluated children with bilateral UPJO had early postoperative AKI, mostly of low stage. Our data suggest that intervening first on the better functioning side allows for better recovery of the renal functional reserve and lowers the risk of postoperative AKI. CONCLUSION: In children with bilateral UPJO, starting intervention on the poorer functioning kidney is associated with increased risk of postoperative AKI. Long-term prospective studies are needed to confirm our findings.

Reoperation for Channel Complications in Children With Continent Cutaneous Catheterizable Channels: The Test of Time.

OBJECTIVES: To examine the durability of continent cutaneous catheterizable urinary channels (CCCC) in children and assess whether channel complications continue to arise with extended follow-up. Previous studies demonstrated that complications of CCCC cluster in the early years following surgery. METHODS: The database of a tertiary center was queried for patients≤21 years who underwent CCCC. Patients with <6 years of follow-up were excluded. Patients were invited for follow-up to assess continence. Clinic visits and hospital admissions were reviewed for channel complications requiring reoperation. Complications were analyzed against patient and channel characteristics and time since initial surgery. RESULTS: Between 1993 and 2012, a total of 120 patients underwent CCCC at a median age of 6.8(0.4-21) years and a median follow-up of 11.4(6.6-27) years. CCCC were created using the appendix, Monti channels and tapered ileal segments in 74(61.7%), 33(27.5%) and 13(10.8%), respectively. Continence relied on the extra-mural serous lined principle in 85.8% and the stoma was anastomosed to the umbilicus in 90%. Dryness with catheterization intervals of 3 hours or longer was eventually achieved in 90.8% with similar rates among different channel types (P=.149). 26(21.7%) required 42 interventions to treat channel complications with 32.5% occurring >5 years following initial surgery irrespective of the channel type (P=.978). On multivariate analysis, ileal channels had 3.372 higher odds of needing reoperation compared to appendicovesicostomy (95%CI=1.240-9.166; P = .037). CONCLUSION: A high reoperation rate is anticipated throughout the lifetime of CCCC. Appendicovesicostomy has a low complication risk relative to ileal channels.

Optimization of shockwave lithotripsy use for single medium sized hard renal stone with stone density ≥ 1000 HU. A prospective study.

PURPOSE: To identify shock wave lithotripsy (SWL) success predictors in hard renal stones (average stone density ≥ 1000 HU). MATERIALS: We prospectively evaluated patients who underwent SWL for hard renal stones between April 2018 and December 2020. Radiological parameters were identified, e.g., stone site, size, the average density in addition to stone core and shell mean density, and renal cortical thickness (RKT). SWL sessions were performed using Doli-S lithotripter till a maximum of 3-4 sessions with 2-4 weeks interval. Initial response to SWL included stone fragmentation and decreased stone size after the first SWL. Treatment success was considered if complete clearance of renal stones occurred or in case of clinically insignificant residual fragments ≤ 4 mm after 12 weeks follow up by NCCT. RESULTS: Out of 1878 patients who underwent SWL, the study included 157 patients with hard renal stones. Treatment overall success was found in 92 patients (58.6%) where 69 patients (43.9%) had complete stone clearance. On multivariate analysis, stone shell density < 901 HU, maximum stone size < 1 cm, RKT > 1.95 cm and initial treatment response were associated with increased the success rate after SWL for hard renal stones (P = 0.0001, 0.009, < 0.0001 and < 0.0001, respectively). CONCLUSION: In hard renal stones, treatment overall success was found in 58.6% where complete stone clearance was found in 43.9%. Stone outer shell fragility, lower stone size, increased RKT and initial response to SWL were associated with a higher success rate at 12-week follow-up.

Critical analysis of pyeloplasty role in adults with late diagnosis of ureteropelvic junction obstruction-a comparative study.

PURPOSE: Due to the data paucity about the functional outcomes post pyeloplasty for patients diagnosed with ureteropelvic junction obstruction (UPJO) with a preoperative age above the age of 45 years and according to the elderly definition (age ≥ 65 years), we conducted this study to clarify the different outcomes in adults presented with late hydronephrosis. METHODS: We included patients who were managed by pyeloplasty with a preoperative age ≥ 45 years. We further subdivided those patients into; group (A) patient's age ≥ 65 years and group (B) patient's age ≥ 45 and < 65 years. Split renal function (SRF) difference was evaluated by the changes between the last follow-up and the baseline renogram, where 5% change was considered a significant change. Functional outcomes and factors predicting the functional recoverability post pyeloplasty were evaluated. RESULTS: A total of 119 patients were included. The mean age was 62.3 ± 16.4 years. Group (A) and group (B) included 47 and 72 patients, respectively. After 24 months, GFR and SRF were increased at the last follow-up (P = 0.32 and 0.57, respectively). No significant functional changes were noted between both groups. Sixty two, 7 and 13 patients showed static, decreased and improved renal function. Lower preoperative SRF was the only predictor for poor functional recoverability in patients with age ≥ 45 years who were managed by pyeloplasty. CONCLUSION: Elderly patients should not be excluded from the corrective surgery for UPJO. Lower preoperative SRF was the only predictor for renal function deterioration post pyeloplasty.

Are Prophylactic Measures Necessary to Prevent Recurrence of Penile Keloids?

Keloid scars result from excess collagen deposition in the dermis or subcutaneous tissue in response to surgery or tissue trauma. The penis is a rare site for keloid formation, even in predisposed individuals. Only few cases of penile keloids have been reported so far. In this report, we present penile keloids complicating neonatal circumcision in twin brothers. Risk of recurrence in previous reports and measures to guard against its occurrence are also discussed.

Holmium Laser En Bloc Resection of Urethral Polyps in Children: A Case Series.

Background: Urethral fibroepithelial polyps (FEPs) are scarce benign mesodermal tumors arising mainly from the posterior urethra in boys. FEPs are rarely reported in girls. There is no consensus regarding their etiology; however, some authors attribute their presence to abnormal mesodermal involution. FEPs have different clinical presentations, including acute urinary retention (AUR), difficult micturition, hematuria, and recurrent urinary tract infection in addition to interlabial mass in girls. Radiologic studies are usually insufficient for diagnosis. Cystourethroscopy and histopathologic examination are considered the diagnostic tool of choice. In this report, we introduce Holmium Laser En Bloc Resection of Urethral Polyp (HoLERUP) as an alternative technique to conventional and en bloc electric resection. Case Presentation: Three boys with benign urethral polyps (UPs) presented with AUR, difficult micturition, and hematuria. The diagnosis of UP was confirmed by means of cystourethroscopy. HoLERUP was carried out for all three of them and histopathologic examination revealed FEP in two cases and an inflammatory polyp in the third. Conclusion: UPs should be considered in the differential diagnosis of children presenting with AUR, difficult micturition, and hematuria. HoLERUP overcomes the limitations of conventional resection and can be performed when en bloc electric resection is not feasible.