How the 99mTc-DMSA scintigraphy findings are reflected in the adopted treatment of primary vesicoureteral reflux: One centre experience.

BACKGROUND: Renal changes may have long-term sequalae and prevention is a main goal of management of primary vesicoureteral reflux (VUR). AIM: This study aims to reveal how much 99mTc-DMSA scintigraphy findings are reflected in the adopted surgical or non-surgical treatment in children with diagnosed primary VUR and to give the clinicians information regarding their final therapeutic decision. PATIENTS AND METHODS: A total 207 children with primary VUR who underwent non-acute 99mTc-DMSA scan were retrospectively evaluated. The presence of renal changes, their grading, differential function asymmetry (<45%) and grade of VUR were compared with subsequent choice of therapy. RESULTS: Altogether 92 (44%) children had asymmetric differential function, 122 (59%) showed presence of renal changes, 79 (38%) had high-grade VUR (IV-V). Patients with renal changes had lower differential function (41%vs.48%) and higher grade of VUR. The incidence of high-grade changes (G3+G4B) afflicting more than one third of the kidney was significantly different between grade I-II, III and IV-V VUR (9%, 27%, 48%, respectively). Renal changes were detected in 76% of surgically and 48% of non-surgically treated patients, high-grade 99mTc-DMSA changes in 69% and 31%, respectively. In children with no scars/dysplasia (G0+G4A), non-surgical treatment prevailed in 77%. The independent predictors for surgical intervention were presence of renal changes and higher grade of VUR, but not functional asymmetry. DISCUSSION: Over the last 20 years, there has been a shift toward more non-surgical management of VUR. The long-term outcome of this approach should be thoroughly studied. This is the first study analysing renal status in VUR patients using 99mTc-DMSA scan and its grading regarding the adopted treatment. Renal changes in almost half of non-surgically treated children with VUR should be an indicator for earlier diagnosis and effective treatment of acute pyelonephritis and VUR. We recommend distinguishing grade III VUR, as a moderate-grade VUR, because it is linked to higher incidence of high-grade 99mTc-DMSA changes (G3+G4B); our findings of 65% of grade III VURs treated non-surgically should be cautionary. Grade III VUR does not mean a low-risk condition and should alert the clinician to evaluate the extent of renal changes and unmask high-risk cases. CONCLUSIONS: Our data strengthens the need to investigate the extent of renal changes in VUR patients regarding treatment decision. Performing 99mTc-DMSA scan individualizes the treatment of VUR patients; its grading can distinguish grade III-VUR as a separate risk entity because it differs significantly in terms of incidence of high-grade renal changes and chosen therapy.

Myointimoma (angiocentric myofibroblastic tumor) of the glans penis in an adolescent: a case report and review of the literature.

BACKGROUND: Soft tumors of the penis are extremely rare in childhood and adolescence. Because there are no guidelines, each such case raises embarrassment over the extent and degree of aggressiveness of the diagnostic and therapeutic procedures. Herein, we describe a case of a teenager with a penile myointimoma along with a review of the literature. So far, only 10 cases have been reported in this age group. CASE PRESENTATION: The 15-year-old boy presented with a 6-months history of a slowly growing, palpable firm nodule in glans penis. Physical examination revealed a palpable, well circumscribed, firm, whitish painless mass, around 1 cm in diameter within the glans. Ultrasound revealed hypoechogenic, hypoperfused poorly defined area inside the glans. MRI did not confirm any other pathologic mass inside the glans and corpora cavernosa. An excisional biopsy was performed; its immunohistological features indicated myointimoma. DISCUSSION AND CONCLUSION: Given the rarity of this benign entity, the main importance is to distinguish myointioma from more clinically aggressive neoplasms. The key to a correct diagnosis is a careful histological examination, including immunohistochemistry. Local excision is safe and effective treatment modality.

The safety of neoadjuvant hormonal treatment in infants with cryptorchidism.

BACKGROUND/PURPOSE: The standard treatment for boys with non-syndromic cryptorchidism is an early orchidopexy. It is unclear if surgical intervention alone is enough for future fertility. Recent studies show benefit of neoadjuvant or adjuvant hormonal treatment with gonadorelin (GnRH) for spermatogonia maturation based on testicular biopsy. The aim of this prospective study was to assess the safety of this treatment in infants with undescended testis at the recommended timing of early gonadorelin administration and timing of orchidopexy. METHODS: Unilateral cryptorchid full term boys were initially examined (including hormonal, physical and ultrasound examination) at the age of 2.5-3.5 months. At 6 months of age, cryptorchidism was confirmed. Those with non-syndromic cryptorchidism and palpable or sonographically detected testis were randomly assigned into two groups: with and without intranasal gonadorelin treatment. Inclusion criteria were met by 36 boys (21 in GNRH and 15 in the control groups). The following orchidopexy was performed before 12 months of age with repeated examination at time of surgery. Penile size and testicular volume (using ultrasound) and basal serum levels of LH, FSH, testosterone, Inhibin B and AMH were recorded at age of 3.0 (mean) months and 11.0 (mean) months (date of surgery). The stimulation hormonal levels were checked during GnRH administration. RESULTS: Between minipuberty (mean 3 months) and time of orchidopexy (mean 11 months of age) the penile size increased significantly and similarly in both groups. There was no significant difference in the change of the volume of descended testis between the groups nor of the volume of undescended testis. In addition, we did not find any significant difference in the change (drop) of hormonal levels of LH, FSH, Testosterone, Inhibin B and AMH (Table 1a) CONCLUSION: The neoadjuvant gonadorelin stimulation in infants with unilateral undescended testis has not shown any specific effect on the development of penile size, testicular volume and hormonal levels at time of orchidopexy in comparison with boys without stimulation, and in the mid-term, this treatment can be considered safe. Further follow-up is necessary to evaluate the long-term effect of this early treatment.

Laparoscopic lymphatic and artery sparing microsurgical varicocelectomy - technique, results and long-term outcomes.

INTRODUCTION AND OBJECTIVE: It is generally considered that artery sparing suprainguinal varicocelectomy is associated with a higher risk of persistence in comparison with the non-sparing (Palomo) procedure. Artery sparing is desirable in specific conditions. Based on our 21-year long experience, this study aims to describe technical details and standard steps of the procedure, leading to a comparatively low recurrence rate. MATERIAL AND METHOD: 336 patients, prospectively collected, who underwent laparoscopic lymphatic and artery-sparing microsurgical varicocelectomy as a primary operation between March 1999 and February 2020, were retrospectively evaluated. Patient age was 7-21.5 years (mean 15.4). The left side was involved in 313 (93.2%), both sides in 23 (6.8%) patients. In total 359 varicoceles were repaired, in which 281 cases were grade III, 65 grade II and 13 cases were grade I. The most common indications for surgery were left testicle hypotrophy, demonstrated in 167 (49.7%) patients, an abnormal spermiogram in 48 (14.2%), pain in 28 (8.3%) and bilateral involvement in 23 (6.8%) of patients. The technique has been standardized into four steps: early artery identification; peeling the network of small veins off the artery; peeling the lymphatic vessels off medium and large size veins and division of all veins; check of residual vascular bundle containing the artery and lymphatics only (video - Appendix A). Mean postoperative followup was 27.1 (range 0.5-174) months. Complications were recorded. Persistent varicocele was defined as clinically significant varicocele accompanied by renotesticular reflux on Doppler ultrasound. Ultrasound was used to rule out hydrocele formation and testicular atrophy. RESULTS: Persistent varicocele was recorded in 15 of 359 (4.2%) cases; secondary hydrocele was detected in 1 case (0.3%). Testicular atrophy was not detected in any of the operated patients. Most complications were recorded in the first 3 years after the introduction of the method; 5 recurrences of 290 (1.7%) cases were detected over the last 18 years (Table). DISCUSSION: The method meets all requirements of subinguinal microscopic repair. The artery preservation is desirable in previous (and for future) inguinal and subinguinal surgery cases where collaterals could be compromised. Artery sparing allows for a future vasectomy. Boys with a varicocele on a solitary testicle may be good candidates for this procedure as well. We consider the method as alternative for experienced laparoscopic surgeons. CONLUSION: The laparoscopic lymphatic and artery sparing microsurgical varicocelectomy is safe and effective method with a low recurrence rate like the non-sparing suprainguinal repairs.

EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children.

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting.

BACKGROUND AND AIMS: The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist. MATERIAL AND METHODS: Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members. RESULTS: The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors. CONCLUSION: Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management.

BACKGROUND: Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor. MATERIAL & METHODS: After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS: In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option. CONCLUSION: In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment.

BACKGROUND: In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia. AIMS: Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC). MATERIAL AND METHODS: After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS: The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment. DISCUSSION AND CONCLUSIONS: The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.

Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel.

CONTEXT: The benefits and harms of intervention (surgical or radiological) versus observation in children and adolescents with varicocele are controversial. OBJECTIVE: To systematically evaluate the evidence regarding the short- and long-term outcomes of varicocele treatment in children and adolescents. EVIDENCE ACQUISITION: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A priori protocol was registered to PROSPERO (CRD42018084871), and a literature search was performed for all relevant publications published from January 1980 until June 2017. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 50 participants were eligible for inclusion. EVIDENCE SYNTHESIS: Of 1550 articles identified, 98 articles including 16 130 patients (7-21 yr old) were eligible for inclusion (12 RCTs, 47 NRSs, and 39 case series). Varicocele treatment improved testicular volume (mean difference 1.52ml, 95% confidence interval [CI] 0.73-2.31) and increased total sperm concentration (mean difference 25.54, 95% CI 12.84-38.25) when compared with observation. Open surgery and laparoscopy may have similar treatment success. A significant decrease in hydrocele formation was observed in lymphatic sparing versus non-lymphatic sparing surgery (p=0.02). Our findings are limited by the heterogeneity of the published data, and a lack of long-term outcomes demonstrating sperm parameters and paternity rates. CONCLUSIONS: Moderate evidence exists on the benefits of varicocele treatment in children and adolescents in terms of testicular volume and sperm concentration. Current evidence does not demonstrate superiority of any of the surgical/interventional techniques regarding treatment success. Long-term outcomes including paternity and fertility still remain unknown. PATIENT SUMMARY: In this paper, we review benefits and harms of varicocele treatment in children and adolescents. We found moderate evidence that varicocele treatment results in improvement of testicular volume and sperm concentration. Lymphatic sparing surgery decreases hydrocele formation. Paternity and fertility outcomes are not clear.

Diffusion-weighted magnetic resonance imaging is more sensitive than dimercaptosuccinic acid scintigraphy in detecting parenchymal lesions in children with acute pyelonephritis: A prospective study.

INTRODUCTION: Static renal scintigraphy is the gold standard for detection of inflammatory changes in the renal parenchyma in acute pyelonephritis. Our aim was to determine whether diffusion-weighted magnetic resonance imaging (DW-MRI) was comparable with static renal scintigraphy (DMSA-SRS) to demonstrate acute renal parenchymal lesions. OBJECTIVE: To compare 99mTc-dimercaptosuccinic acid static renal scintigraphy (DMSA-SRS) with diffusion-weighted magnetic resonance imaging (DW-MRI) for detecting acute inflammatory changes in the renal parenchyma in children with febrile urinary tract infection. METHODS: Thirty-one children (30 girls) aged 3-18 years with a first episode of febrile UTI without a previously detected congenital malformation of the urinary tract, were prospectively included. DMSA-SRS and DW-MRI were performed within 5 days of diagnosis to detect renal inflammatory lesions. The DW-MRI examination was performed without contrast agent and without general anesthesia. Late examinations were performed after 6 months using both methods to detect late lesions. RESULTS: DW-MRI confirmed acute inflammatory changes of the renal parenchyma in all 31 patients (100%), mostly unilateral. DMSA-SRS detected inflammatory lesions in 22 children (71%; p = 0.002). The lesions were multiple in 26/31 children (84%) on DW-MRI and in 9/22 (40%) on DMSA-SRS. At the control examination, scarring of the renal parenchyma was found equally by DW-MRI and DMSA-SRS in five patients (16%), three of whom were the same patients. The overall concordance of positive and negative late findings occurred in 87% of patients. There was correspondence in the anatomical location of acute and late lesions. DISCUSSION: The clinical significance of acute and late parenchymal findings on DWI-MR is yet to be determined. A limitation of our study is the age of the patients (older than 3 years) who are less sensitive to scar development; therefore, a smaller number of patients with scars could be analyzed during control examination. Further studies using the DW-MRI should confirm its reliability to detect acute and late lesions in younger children and infants and determine the clinical consequences. CONCLUSION: DW-MRI has higher sensitivity for detecting acute renal inflammatory lesions and multifocal lesions than DMSA-SRS. The incidence of scars was low and corresponded with the anatomical location of acute and late lesions.

Distal urethral plate adhesions: New anatomical perspective in hypospadias.

INTRODUCTION: We found midline epithelial adhesions in the glandar urethral plate in patients with hypospadias. After dissolution, a blind epithelized channel becomes visualized inside of the plate pointing to immature embryonic luminization. In addition it reveals that the epithelized surface of the distal urethral plate is larger than previously considered. OBJECTIVE: To determine the incidence and extent of these new anatomical details of urethral plate in hypospadias patients. METHODS: We prospectively assessed the detailed anatomy of the urethral plate in 72 consecutive patients with hypospadias. We recorded the presence of adhesions in the middle of the glandar urethral groove that can be easily dissoluted (dissolution line - D-line). We recorded the plate width before and after D-line dissolution, the presence of the hidden blind channel at continuation of D-line (channel type-A) and of the visible blind channel between D-line and urethral hypospadiac meatus (type-B) (Figure). In 62 patients, where the urethral plate tubularization was considered (Duplay, TIP), septs between channels were opened in the midline and a final width of the plate was measured by rolling the plate around a tube. RESULTS: Midline adhesions (D-line) were found in all 72 patients. Mean length of D-line was 5.13 ± O.17 mm. Mean plate width before dissolution was 5.9 ± 0.15 mm, and after dissolution 7.8 ± 0.16 mm. A blind channel of type A was detected in 22 patients (31%), type B in 24 (33%), type A and B in 16 (22%), and none in 10 patients (14%). Mean final plate width after D-line dissolution and opening of septs between channels in 62 patients with urethral plate tubularization was 8.7 ± 0.15 mm. DISCUSSION: The main contribution of our study is a new perspective of distal urethral plate anatomy that enables enlargement of the epithelized surface of the distal urethral plate by dissolution of the preexisting epithelized groove and opening of epithelized channels within the plate. To the best of our knowledge, this anatomical anomaly has not been described previously. CONCLUSIONS: The distal urethral plate of all hypospadias patients is partially "folded" in the midline by epithelial adhesions of different depth and extent that may be easily dissoluted. In half of the patients (53%) the "folded" part of the plate continues proximally as a blind channel inside the urethral plate (type A channel). Opening of these structures together with the well-known urethral plate pits (type B channel) helps augment the width and the overall epithelized surface of the distal urethral plate.

Role of antibiotic prophylaxis in antenatal hydronephrosis: A systematic review from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel.

BACKGROUND: The benefits and harms of continuous antibiotic prophylaxis (CAP) versus observation in patients with antenatal hydronephrosis (ANH) are controversial. OBJECTIVE: The aim was to determine the effectiveness of CAP for ANH, and if beneficial to determine the best type and regimen of antibiotic and the most harmful to provide guidance for clinical practice. METHODS: A systematic literature search was performed in databases including Medline, Embase, and Cochrane in June 2015. The protocol was prospectively registered to PROSPERO (CRD42015024775). The search started from 1980, when maternal ultrasound was first introduced into clinical practice. Eligible studies were critically evaluated for risk of bias using Revman software. The outcomes included reduction in urinary tract infections (UTI), drug-related adverse events and kidney functions. RESULTS: Of 797 articles identified, 57 full text articles and six abstracts were eligible for inclusion (2 randomized controlled trials, 11 non-randomized comparative studies, and 50 case series). It remains unclear whether CAP is superior to observation in decreasing UTIs. No conclusion could be drawn for drug-related adverse events and kidney function because of lack of data. Children who were not circumcised, with ureteral dilatation, and high-grade hydronephrosis may be more likely to develop UTI, and CAP may be warranted for these subgroups of patients. A majority of the studies had low-to-moderate quality of evidence and with high risk of bias. CONCLUSIONS: The benefits of CAP in a heterogeneous group of children with ANH involving different etiologies remains unproven. However, the evidence in the form of prospective and retrospective observational studies has shown that it reduces febrile UTI in particular subgroups.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines.

CONTEXT: Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood. OBJECTIVE: To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood. EVIDENCE ACQUISITION: Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy. CONCLUSIONS: There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.

Urinary tract infections in children: EAU/ESPU guidelines.

CONTEXT: In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract. OBJECTIVE: To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI. EVIDENCE ACQUISITION: The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low. EVIDENCE SYNTHESIS: UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded. CONCLUSIONS: The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage. PATIENT SUMMARY: In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

Unstented laparoscopic pyeloplasty in young children (1-5 years old): a comparison with a repair using double-J stent or transanastomotic externalized stent.

OBJECTIVE: To evaluate feasibility of unstented laparoscopic pyeloplasty in young children to prevent pyelonephritis and second anaesthesia. PATIENTS AND METHODS: During 2006-2013, 70 children (1-5 years old) underwent laparoscopic pyeloplasty for high grade hydronephrosis. Unstented repair was indicated in 34 children (GroupL1), double-J stent was placed in 21 patients (Group L2) and uretero-pyelostomy stent (Cook) in 15 patients (Group L3). Stenting was preferred in large thin-walled pelvis, thin ureter, kidney malrotation, and unfavourable course of crossing vessels. The outcome was compared with age-matched group of 52 children who had open surgery during 1996-2006 (Groups O1, O3). RESULTS: Operation times were significantly shorter in Groups L1 and L2 than in Group L3; the times were shorter in open repairs. Three patients with crossing vessels from Group L1 had urine leakage and one had obstruction (11.4%). In Group L2, one patient had obstruction, one incorrect placement of the stent, and one girl had serious pyelonephritis (14.3%). In Group L3, displacement of uretero-pyelostomy occurred in one patient (6.7%). There is no statistical difference between laparoscopic groups and between laparoscopic and open groups. CONCLUSION: Unstented laparoscopic pyeloplasty is a safe procedure in selected young children with favourable anatomical conditions preventing additional anaesthesia and stent-related complications.

Torsion of spermatic cord in children: a review.

The current opinion on spermatic cord torsion is discussed in this review, with special attention to natural history, value of diagnostic tools, evidence for surgical management, outcome and management of atypical forms of torsion.

EAU guidelines on vesicoureteral reflux in children.

CONTEXT: Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention. OBJECTIVE: To present a management approach for VUR based on early risk assessment. EVIDENCE ACQUISITION: A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come. EVIDENCE SYNTHESIS: There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques. CONCLUSIONS: While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.

Transmesocolic laparoscopic pyeloplasty in children: a standard approach for the left-side repair.

OBJECTIVE: To compare the transmesocolic approach in the left laparoscopic pyeloplasty with the laterocolic right-side repair in children. PATIENTS AND METHODS: Dismembered pyeloplasty was performed in 77 consecutive children aged 1.2-18.2 years. The transmesocolic approach was used in 49 patients with left hydronephrosis (group I) and the conventional laterocolic approach in 28 patients with right hydronephrosis (group II). Three age groups were defined. RESULTS: The transmesocolic approach was applicable in 48 of 49 patients (98%); the colic vessels were preserved. The operation time was significantly shorter in the transmesocolic group, also when comparing patients with similar age, incidence of crossing vessels and urinary diversion. A shorter operation time was achieved in children without internal urine diversion. Postoperative complications were encountered in 6.3% of group I and 7.1% of group II without any conversion to open repair or recurrence of obstruction within a 2.5-year follow-up period. CONCLUSIONS: The transmesocolic approach offers clear anatomy and provides safe access to the dilated left renal pelvis and crossing vessels. The operative time is shorter due to very limited tissue dissection. The medial reflection of the colon is avoided. This approach allows for microsurgical performance of the left-side pyeloplasty in all paediatric age groups.