Ultrasonographical features of perinatal testicular torsion: an assessment of interobserver variability among radiologists and pediatric urologists.

PURPOSE: To retrospectively compare interpretations of Doppler ultrasound (US) in newborns with confirmed perinatal testicular torsion (PTT) by an experienced faculty (staff) pediatric radiologist (SPR), pediatric radiology fellow (PRF), pediatric urology fellow (PUF) and staff pediatric urologist (SPU). METHODS: US images of 27 consecutive males with PTT between May 2000 and July 2020 were retrieved. The testicles were classified as affected or non-affected by PTT. We performed a blinded comparison of interpretation by four assessors (SPR, PRF, PUF, SPU), with respect to the US features of PTT. Paired inter-rater agreement was calculated using Cohen's Kappa (κ) and overall agreement was assessed using Fleiss' kappa. RESULTS: Overall comparison using Fleiss' kappa found fair agreement for most features except testicular echogenicity and echogenic foci at interface for which there was poor agreement. Paired comparisons revealed better agreement between the SPR and PRF compared to the remaining two pairs, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents. CONCLUSION: This study highlights the need for focused training program for pediatric urologists to attain similar agreement as the radiologists, suggesting a need for the pediatric urologists (PUF and SPU) to acquaint themselves with testicular ultrasonography as this may have an impact on patient risk stratification and the quality of information given to parents.

Varicocoele in adolescence and testicular cancer in young adulthood.

BACKGROUND: Elevated intrascrotal temperature has been suggested as a risk factor for testicular cancer, which is the most common neoplasm among young men. Varicocoele was linked to increased intrascrotal temperature, but whether it is associated with testicular cancer is unclear. OBJECTIVE: To explore the possible association between varicocoele at adolescence and the incidence of testicular cancer at adulthood. DESIGN, SETTING, AND PARTICIPANTS: This nationwide, population-based, historical cohort study includes 1,521,661 Israeli male adolescents (mean age 17.5 ± 0.4 years), who were screened for varicocoele during the years 1967-2012, as part of their medical assessment prior to compulsory military service. The mean follow-up was 18 ± 4.2 years. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The diagnosis of testicular cancer was ascertained from linkage of records to the the Israeli National Cancer Registry. Survival analysis was applied. RESULTS: In total, 53,210 adolescents were diagnosed with varicocoele stages 2 and 3 prior to military service. Of 1988 (0.13% of the total cohort) men who were diagnosed with testicular cancer during follow-up, 54 (0.1%) had varicocoele prior to military service, while 1934 (99.9%) did not; p = 0.213. The age at cancer diagnosis and the distribution of seminomas versus non-seminomas did not differ significantly between those with and without varicocoele in adolescence. In a multivariable analysis controlling for sociodemographic factors, varicocoele was not associated with testicular cancer; odds ratio = 0.816 (CI: 0.615-1.083). CONCLUSIONS: Varicocoele in adolescents was not found to be associated with testicular cancer in young adults. PATIENT SUMMARY: In light of the theoretical association between varicocoele and testicular cancer, we conducted this large population study. We found no association between varicocoele in young adulthood and testicular cancer later in life.

Changing Trends in Surgical Management of Nephrolithiasis among Young Adults: A 15-Year Population-Based Study.

Background: Increases in obesity and diabetes rates among all ages have led to a greater prevalence of nephrolithiasis worldwide. We aimed to explore the changing trends in surgical management of nephrolithiasis in young adults over a 15 year period. Methods: We reviewed medical records of military personnel for information on the diagnosis and care of nephrolithiasis before and during active service between 2007−2021, divided into three 5 year periods: 2007−2011, 2012−2016, and 2017−2021. Demographic, clinical, radiological, and surgical data were retrieved for the analysis of changing trends. Results: The records of 1,117,692 recruits yielded 7383 (0.66%) with stone-related surgeries, of whom 1885 were operated during military service. Their median age was 19.6 years (interquartile range [IQR] 16.8−21.2), 829 (70%) were males, and the cohort's median body mass index was 23.6 (IQR 17.3−26.1). There was a dramatic decline in shock wave lithotripsy (SWL) prevalence (35.1%, 10.4%, and 4.4%, respectively) with a continually increasing prevalence of ureteroscopy (URS)/retrograde intrarenal surgery (RIRS) (62.7%, 88.5%, and 94.6%, p = 0.01). Percutaneous nephrolithotomy (PCNL) procedures have become nearly extinct over time (0.8% in 2017−2021). The number of median-sized stones treated by URS/RIRS increased (7.5 mm, 8.2 mm, and 9.7 mm, p = 0.044), but not those treated by SWL/PCNL. The median length of medical leave for URS/RIRS and PCNL decreased significantly (7 vs. 4 days, p = 0.05 and 10 vs. 6 days, p = 0.036, respectively), with no comparable change for SWL. There was a substantial decline in ancillary procedures in the URS/RIRS groups (9%, 6.8%, and 3.1%, p < 0.01), but not in the SWL/PCNL groups. Conclusions: Advancements in technology and surgical training are leading to the extinction of SWL and the adoption of URS/RIRS as the new standard of care for nephrolithiasis among young adults.

Perinatal testicular torsion: The clear cut, the controversial, and the "quiet" scenarios.

BACKGROUND: Perinatal testicular torsion (PTT) is a catastrophic event that occurs in utero or up to 30 days postnatally, with testicular loss being the most common outcome. OBJECTIVE: To assess clinical evaluation, surgical management and clinical outcomes in patients with PTT in a quaternary referral pediatric center, to determine testicular salvageability and propose future management options. METHODS: We retrospectively reviewed a cohort of males born outside the quaternary center with a diagnosis of PTT, from May 2000 to July 2020. Data collection included mode of delivery, gestational age, birth weight, testicular examination at birth, clinical presentation, ultrasound results at diagnosis, surgical management and findings, perioperative complications, and follow-up. RESULTS: 62 patients, including 2 patients with bilateral asynchronous PTT, were identified. Median (IQR) gestational age and birth weight were 39 (38-39.4) weeks and 3.4 (3.1-3.72) kg, respectively. Abnormal testicular examination at birth was found in 69% (Table 1). Doppler ultrasound was performed in all but 1 patient. 59 patients underwent surgery, 21 within 4 h, with bilateral exploration in 44 cases. Affected and non-affected testicles were explored in 76% and 98% of cases, respectively. 3 "nubbins" were found, of which 2 were excised. 3 nonsurgical complications were identified. During a median (IQR) follow-up of 3 (3-3) months, 63 testicles were removed or found to be non-functional, with compensatory hypertrophy in 38% of patients. CONCLUSION: Given that 3% of our patients presented with asynchronous bilateral PTT, as well as the safety of general anesthesia in a referral pediatric hospital, early bilateral scrotal exploration of PTT is recommended. LEVEL OF EVIDENCE: IV.

Congenital Anomalies of the Kidney and Urinary Tract and Adulthood risk of Urinary Tract Cancer.

INTRODUCTION: Congenital anomalies of the kidney and urinary tract (CAKUT) are the most common kidney diseases in childhood. Alterations in genes governing nephrogenesis may cause CAKUT, and in some cases may contribute to development of urinary tract (UT) tumors later in life. We aimed to assess the association between CAKUT and UT cancer in adulthood. METHODS: We conducted a population-based historical cohort study encompassing 1,510,042 recruits to the Israeli army between 1967 and 1997. CAKUT exposure was determined by army medical coding of CAKUT in childhood. Incidence of UT cancer (kidney, ureter, or bladder) was available through record linkage with the Israeli Cancer Registry. Recruits were followed from the prerecruitment assessment until cancer diagnosis, death, or study termination, in 2012. Cox proportional hazards models were constructed to estimate the hazard ratios (HRs) for UT cancer in participants with vs. without CAKUT. RESULTS: During a mean follow-up of 30.4 years, 2959 participants (2573 men and 386 women) developed UT cancer. Men with CAKUT exhibited an increased risk of UT cancer compared with men without CAKUT, yielding an adjusted HR of 1.98 (95% confidence interval [CI] 1.03-3.82). Among women CAKUT was associated with a HR of 5.88 (95% CI 2.19-15.76). Notably, upon stratification according to age of cancer diagnosis, the association between CAKUT and UT cancer was statistically significant only before 45 years of age in women and only after 45 years of age in men. CONCLUSION: CAKUT is associated with a significantly increased risk of UT cancer, although the incidence and absolute risk remained quite low.

Is the prognosis of congenital single functioning kidney benign? A population-based study.

BACKGROUND: We investigated the risk of kidney injury among adolescents with and without a congenital single functioning kidney (SFK). METHODS: This retrospective study is based on a medical evaluation database of 17-year-old Israeli conscripts, born during 1989-1999. Those with congenital SFK diagnosis, verified by a pediatric nephrologist's review of the original military medical committee classifications, were compared to the rest of the cohort. Kidney injury (KI) was defined as proteinuria, high blood pressure (BP), or estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2 prior to army recruitment. Risk factors for KI were examined using logistic regression. RESULTS: Of 979,630 screened candidates, 353 were diagnosed with SFK. The yearly incidence of SFK gradually increased in the first years of the study, reaching a plateau in 1995 (5.5 ± 1.2/10,000 births/year). The male to female ratio was 2.7:1. Concomitant genital malformations were documented in 5.5% of those with SFK. KI was more prevalent in the SFK than the control group (42.2% vs. 23.5%, p < 0.001). All three components of KI were more common in the SFK than the control group: high BP (31.7% vs. 23.1%, p < 0.001), proteinuria (18.2% vs. 0.4%, p < 0.001), and eGFR <90 ml/min/1.73m2 (12.0% vs 0.1%, p < 0.001). Multivariate analysis of the SFK group revealed associations of higher mean BMI, male sex, and smaller ultrasonographic kidney length with KI. CONCLUSIONS: This large population-based study documents a significant risk for KI among adolescents with SFK. Obesity represents a major modifiable risk factor for KI, implicating the need for closer follow-up in this group during childhood.

The Impact of Dietary Modifications and Medical Management on 24-Hour Urinary Metabolic Profiles and the Status of Renal Stone Disease in Recurrent Stone Formers.

BACKGROUND: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse. OBJECTIVES: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers. METHODS: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6-8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation. RESULTS: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2-70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6-25) years and 5 (3-6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events. CONCLUSIONS: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

Acute pyelonephritis in children and the risk of end-stage kidney disease.

BACKGROUND: Pyelonephritis is the most common serious bacterial infection during childhood. The long-term importance of kidney scarring is unclear. OBJECTIVE: To assess the risk of end-stage kidney disease (ESKD) in adolescents and young adults with history of pyelonephritis. STUDY DESIGN: A nationwide, population-based, historical cohort study, including 1,509,902 persons (62% male) examined for military service between 1967 and 1997. Participants with a history of pyelonephritis were sub-grouped according to presence of kidney scarring and baseline kidney function. Data were linked to the Israeli ESKD registry to identify incident ESKD cases. Cox proportional hazards models were used to estimate the hazard ratio (HR) of treated ESKD (dialysis or kidney transplant). RESULTS: Pyelonephritis was diagnosed in 6979 participants (0.46%). 6479 had normal kidney function and no evidence of kidney scarring, 400 had normal kidney function with evidence of scarring, and 100 demonstrated reduced baseline kidney function. Treated ESKD developed in 2352 individuals (0.2%) without history of pyelonephritis, 58 individuals (0.9%) with normal kidney function, history of pyelonephritis and no kidney scarring, 14 individuals (3.5%) with normal kidney function, history of pyelonephritis and kidney scarring, and 23 individuals (23.0%) with history of pyelonephritis and reduced baseline kidney function, yielding HR of 3.3, 34.8 and 43.2, respectively, controlling for age, gender, paternal origin, enrollment year, body mass index, and blood pressure, and accounting for death as a competing risk. CONCLUSION: History of pyelonephritis was associated with significantly increased risk of treated ESKD, particularly when associated with kidney scarring or reduced baseline kidney function.

Kidney failure risk in type 1 vs. type 2 childhood-onset diabetes mellitus.

BACKGROUND: Diabetic kidney disease (DKD) is becoming increasingly common among children. We aimed to estimate the risk of end-stage renal disease (ESKD) and mortality among adolescents with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) and normal renal function compared with non-diabetics. We hypothesized that childhood onset T1DM vs. T2DM would be associated with a different risk profile for developing ESKD and its complications. METHODS: A nationwide, population-based, retrospective cohort study, including 1,500,522 adolescents examined for military service between 1967 and 1997, which were classified according to the presence and type of diabetes. Data were linked to the Israeli ESKD registry. Cox proportional-hazards models were used to estimate the hazard ratio (HR) for ESKD. RESULTS: At study enrolment, 1183 adolescents had T1DM and 196 had T2DM. ESKD developed in 2386 non-diabetic individuals (0.2%) compared with 72 individuals (6.1%) with T1DM and 8 individuals (4.1%) with T2DM. Participants with T1DM were younger at ESKD onset than participants with T2DM (median age, 36.0 vs. 40.5 years, P < 0.05). In a multivariate model adjusted for age, sex, paternal origin, enrollment year, BMI, and blood pressure, T1DM and T2DM were associated with HR of 36.4 (95% CI 28.3-46.9) and 19.3 (95% CI 9.6-38.8) for ESKD, respectively. Stratification according to sex, ethnicity, immigration, and socioeconomic status did not materially change the HR. During the follow-up period, mortality rates were higher in T2DM as compared with T1DM and controls (8.7 %, 2.2%, and 2.7% respectively). CONCLUSIONS: T1DM and T2DM in adolescents with normal renal function confer a significantly increased risk for ESKD. T1DM is associated with younger age at ESKD onset while T2DM is associated with higher mortality rate.

Childhood Cancer and the Risk of ESKD.

BACKGROUND: Increasing cancer incidence among children alongside improved treatments has resulted in a growing number of pediatric cancer survivors. Despite childhood cancer survivors' exposure to various factors that compromise kidney function, few studies have investigated the association between childhood cancer and future kidney disease. METHODS: To assess the risk of ESKD among childhood cancer survivors, we conducted a nationwide, population-based, retrospective cohort study that encompassed all Israeli adolescents evaluated for mandatory military service from 1967 to 1997. After obtaining detailed histories, we divided the cohort into three groups: participants without a history of tumors, those with a history of a benign tumor (nonmalignant tumor with functional impairment), and those with a history of malignancy (excluding kidney cancer). This database was linked to the Israeli ESKD registry to identify incident ESKD cases. We used Cox proportional hazards models to estimate the hazard ratio (HR) of ESKD. RESULTS: Of the 1,468,600 participants in the cohort, 1,444,345 had no history of tumors, 23,282 had a history of a benign tumor, and 973 had a history of malignancy. During a mean follow-up of 30.3 years, 2416 (0.2%) participants without a history of tumors developed ESKD. Although a history of benign tumors was not associated with an increased ESKD risk, participants with a history of malignancy exhibited a substantially elevated risk for ESKD compared with participants lacking a history of tumors, after controlling for age, sex, enrollment period, and paternal origin (adjusted HR, 3.2; 95% confidence interval, 1.3 to 7.7). CONCLUSIONS: Childhood cancer is associated with an increased risk for ESKD, suggesting the need for tighter and longer nephrological follow-up.

Delaying Urgent Exploration in Neonatal Testicular Torsion May Have Significant Consequences for the Contralateral Testis: A Critical Literature Review.

OBJECTIVE: To assess the optimal management strategy for boys with neonatal testicular torsion (NTT) in the first 30 days of life, and to stratify outcomes for prenatal, postnatal, unilateral, synchronous, and asynchronous events METHODS: All articles including case reports published between 1946 and 2020 in Embase/Scopus/Medline/Pubmed and Web of Science that had a defined diagnosis of NTT within the first 30 days of life were reviewed. Data and outcomes were analyzed individually, and together as pooled data, using a random effect model. RESULTS: There was a total of 152 studies representing 1336 patients. Outcome data was available on 974 patients (1121 testes). NTT was unilateral in 829 cases, synchronous bilateral in 80 cases, and asynchronous in 66 cases. There were a total of 1107 orchiectomies, and 229 salvage orchiopexies. A total of 2.5% synchronous NTT underwent successful salvage. A total of 95.7% of prenatal unilateral torsions underwent orchiectomy, compared with 92% postnatal torsions. 11.8% of all NTT events were asynchronous with a median time to second torsion of 1 day (Range 1-8). The contralateral orchiectomy rate in this group was 31.8%, with a 40% atrophy rate following orchiopexy. The number needed to treat to avoid bilateral orchiectomy was 1.6, and the number needed to treat to avoid solitary atrophy was 2.6. CONCLUSION: NTT is an important condition carrying a significant risk for testicular loss and endocrine insufficiency. Given the potential catastrophic risk of asynchronous extravaginal torsion, we recommend urgent, safe, surgical intervention with both unilateral and bilateral NTT.

Management of Pancreatic Injuries Following Nephrectomy.

BACKGROUND: Pancreatic injuries during nephrectomy are rare, despite the relatively close anatomic relation between the kidneys and the pancreas. The data regarding the incidence and outcome of pancreatic injuries are scarce. OBJECTIVES: To assess the frequency and the clinical significance of pancreatic injuries during nephrectomy. METHODS: A retrospective analysis was conducted of all patients who underwent nephrectomy over a period of 30 years (1987-2016) in a large tertiary medical center. Demographic, clinical, and surgical data were collected and analyzed. RESULTS: A total of 1674 patients underwent nephrectomy during the study period. Of those, 553 (33%) and 294 patients (17.5%) underwent left nephrectomy and radical left nephrectomy, respectively. Among those, four patients (0.2% of the total group, 0.7% of the left nephrectomy group, and 1.36% of the radical left nephrectomy) experienced iatrogenic injuries to the pancreas. None of the injuries were recognized intraoperatively. All patients were treated with drains in an attempt to control the pancreatic leak and one patient required additional surgical interventions. Average length of stay was 65 days (range 15-190 days). Mean follow-up was 23.3 months (range 7.7-115 months). CONCLUSIONS: Pancreatic injuries during nephrectomy are rare and carry a significant risk for postoperative morbidity.

Renal trauma: the current best practice.

The kidneys are the most vulnerable genitourinary organ in trauma, as they are involved in up to 3.25% of trauma patients. The most common mechanism for renal injury is blunt trauma (predominantly by motor vehicle accidents and falls), while penetrating trauma (mainly caused by firearms and stab wound) comprise the rest. High-velocity weapons impose specifically problematic damage because of the high energy and collateral effect. The mainstay of renal trauma diagnosis is based on contrast-enhanced computed tomography (CT), which is indicated in all stable patients with gross hematuria and in patients presenting with microscopic hematuria and hypotension. Additionally, CT should be performed when the mechanism of injury or physical examination findings are suggestive of renal injury (e.g. rapid deceleration, rib fractures, flank ecchymosis, and every penetrating injury of the abdomen, flank or lower chest). Renal trauma management has evolved during the last decades, with a distinct evolution toward a nonoperative approach. The lion's share of renal trauma patients are managed nonoperatively with careful monitoring, reimaging when there is any deterioration, and the use of minimally invasive procedures. These procedures include angioembolization in cases of active bleeding and endourological stenting in cases of urine extravasation.

Secondary enuresis and urological manifestations in children with ataxia telangiectasia.

BACKGROUND: Ataxia telangiectasia (AT) is a neurodegenerative cerebellar disorder, caused by mutations in the ATM gene, involved in DNA repair. Radiosensitivity, progressive ataxia, immune deficiency and malignancies, are well known symptoms, but urological manifestations are scarcely described. OBJECTIVE: To characterize urologic manifestations in a large cohort of AT patients. METHODS: Retrospective cross-sectional chart study comprising 52 AT patients followed at a National AT Center. RESULTS: 25% of the cohort (13 patients/8 males) had urologic symptoms, which presented at 11 ± 4.3 years. The most common symptom was secondary enuresis affecting 15% of the patients (8 children/4 males). Incontinence appeared at 8 ± 6.2 years of age, and resolved spontaneously within 15 ± 8.3 months in 6 patients. It preceded loss of ambulatory capacity by 1-2 years in 7 patients. Lumbosacral MRI were normal (4 children) and urine cultures (all) were negative. Urodynamic evaluation that was performed in only one patient revealed overactive bladder. Additional manifestations were macroscopic hematuria due to bladder telangiectasia in a 12-year-old, and renal cell carcinoma in a 22-year-old. Other manifestations unrelated to AT were neprolithiasis, vesico-ureteral reflux and scrotal pain, each in 1 patient. DISCUSSION: Transient secondary enuresis is a frequent finding in AT patients, heralding loss of ambulatory capacity, tough it's pathophysiological mechanism is largely no understood.

Robot assisted laparoscopic radical prostatectomy: assistant's seniority has no influence on perioperative course.

An experienced surgical team, in general, and the surgeon assistant in particular are believed to play a critical role in the operation's safety and success. We sought to explore whether the assistant's seniority influences perioperative course following robot assisted laparoscopic radical prostatectomy (RALP). We reviewed our prospective registry database of RALP cases performed by a single surgeon who during the study period was beyond his learning curve. The following parameters were documented and analyzed: patient's age, body mass index (BMI), associated comorbidities, previous abdominal surgeries, assistant's identity, total and skin-to-skin operative time (tOT, ssOT, respectively), estimated blood loss (EBL), immediate post-operative complications, length of stay (LOS), and prostate weight per final pathology report. Univariate analysis and Spearman's correlation test were used to evaluate whether the assistant's seniority influenced perioperative course. Between the years 2011-2015, 106 consecutive cases were retrieved and analyzed. Prostate weight was found to be associated with longer tOT (Spearman's ρ = 0.34, p < 0.001), ssOT (0.3, p < 0.01) and increased EBL (0.28, p < 0.01). Patient's age, BMI, associated comorbidities, and previous abdominal surgeries were found to have no influence on neither tOT, ssOT nor EBL. Three assistants' subgroups were identified (seniors, PGY 1-3, PGY 4-6). The assistant's seniority was found to have no influence on tOT, ssOT, EBL, immediate post-operative complications and LOS. Same results were obtained following prostate size adjustments. The assistant's seniority has no influence on perioperative course following RALP. Consequently, given a highly experienced primary surgeon, a less experienced assistant can be safely incorporated into this procedure.

Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results.

INTRODUCTION: Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects. METHODS: We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates. RESULTS: Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup. CONCLUSIONS: Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

The relative contribution of urine extravasation to elevate plasma creatinine levels in acute unilateral ureteral obstruction.

INTRODUCTION: Rising levels of plasma creatinine in the setting of acute unilateral ureteral obstruction (AUUO) often reflects acute renal failure, mandating kidney drainage. We hypothesize that re-absorption of peri-renal urine extravasation (PUE), a common result of UUO, contributes significantly to the elevation in plasma creatinine, rendering the latter an inaccurate benchmark for renal function. We explored this hypothesis in a rat model of AUUO and PUE. METHODS: In total, 20 rats were equally divided into 4 groups. Groups 1 and 2 underwent unilateral ligation of the ureter with infiltration of rat's urine (index group) or saline (control) into the peri-renal space. Two additional control groups underwent peri-renal injection of either urine or saline without AUUO. Plasma creatinine levels were determined immediately prior to the procedure (T0), and hourly for 3 hours (T1, T2 and T3). Renal histology was investigated after 3 hours. RESULTS: Rats in the index group had a significantly greater increase in plasma creatinine levels over 3 hours compared to all other groups (p < 0.05). At T3, average plasma creatinine levels for the index group increased by 96% (0.49 ± 0.18 mg/dL) compared to 46% (0.23 ± 0.06 mg/dL increase) in the AUUO and saline group, and less than 15% rise in both the non-obstructed control groups. Our study limitations includes lack of spontaneous PUE and intraperitoneal surgical approach. CONCLUSIONS: Absorption of peri-renal urine in the presence of AUUO is a significant contributor to rising plasma creatinine levels, beyond those attributable to the obstruction alone, and may overestimate the extent of the true renal functional impairment.

Eye injury in the Israeli Defense Force: "an ounce of prevention is worth a pound of cure".

BACKGROUND: The eye occupies 0.1% of the total body surface yet it accounts for 8-13% of battle injuries in modern warfare worldwide. Protective eyewear can prevent over 90% of these eye injuries in both military and civilian settings. This study presents an analysis of a military casualty database and describes the proportion and distribution of eye injuries among Israel Defense Force (IDF) Soldiers. METHODS: All trauma patients recorded in the IDF Trauma Registry (ITR) in whom ocular injury related to combat or to training was documented were reviewed. RESULTS: There were 129 patients with documented eye injury sustained during combat or training between 1997 and 2013: 75% of injuries were related to combat and the remainder occurred during training. Penetrating fragmental injuries accounted for 74% of combat related injuries and 28% of training related injuries. Sixty-six percent (66%) of these casualties were subsequently re-classified as no longer fit for combat duties. Combat related injuries resulted in a higher incidence of severe injuries compared to training related injuries (P<0.05). CONCLUSIONS: Despite optimal medical care, the majority of soldiers who sustain eye injuries during military service suffer from substantial disability and most are no longer fit for combat service. A majority are discharged from military service. Protective eyewear could potentially prevent penetrating fragmental wounds which are the most common cause of injury. Further research on optimal orbital protection is critical for both the military and the civilian sectors.

Preparation of medical personnel for an early response humanitarian mission - lessons learned from the Israeli defense forces field hospital in the Philippines.

INTRODUCTION: Humanitarian aid provision and early medical response missions to areas ravaged by natural disasters are as essential nowadays as in the past, and medical personnel play a pivotal role in these delegations. CASE DESCRIPTION: In November 2013, tropical cyclone Haiyan (Yolanda) slammed the Philippines archipelago, leaving more than an estimated 6000 dead in its wake while demolishing vital infrastructure and affecting the life of an estimated 25 million locals. The Israeli Defense Forces (IDF) rapidly constructed and sent a humanitarian aid delegation which included a field hospital deployment with medical capabilities from diverse specialty fields. DISCUSSION AND EVALUATION: The purpose of this article is to summarize our experience in the preparation process of medical personnel before and during deployment. We offer a simple, practical and structured checklist that will assist the medical specialist in preparation for his mission. CONCLUSION: Preparation of medical personnel for humanitarian aid medical missions is a complex and vital task that might be better accomplished with thorough briefing and structured checklists which begin with addressing of personal safety and other daily needs of the staff.

Physiological and cognitive military related performances after 10-kilometer march.

BACKGROUND: Prior operational activities such as marching in diverse environments, with heavy backloads may cause early fatigue and reduce the unit's readiness. The purpose of this preliminary study was to evaluate the effect of 10-kilometer (km) march on selected, military oriented, physiological and cognitive performances. Eight healthy young males (age 25 ± 3 years) performed a series of cognitive and physiological tests, first without any prior physiological strain and then after a 10 km march in comfort laboratory conditions (24°C, 50%RH) consisting a 5 km/h speed and 2-6% incline with backload weighing 30% of their body weight. RESULTS: We found that the subjects' time to exhaustion (TTE) after the march decreased by 27% with no changes in anaerobic performance. Cognitive performance showed a significant (20%) reduction in accuracy and a tendency to reduce reaction time after the march. CONCLUSIONS: We conclude that a moderate-intensity march under relatively comfort environmental conditions may differently decrease selected military related physical and cognitive abilities. This phenomenon is probably associated with the type and intensity of the pre-mission physical activity and the magnitude of the associated mental fatigue. We suggest that quantifying these effects, as was presented in this preliminary study, by adopting this practical scientific approach would assist in preserving the soldiers' performance and health during training and military operations.