Laparoscopic ligation of ectopic ureter in pediatric patients: a safe surgical option for the management of urinary incontinence due to ectopic ureters.

BACKGROUND: Ureteric ectopia is a pediatric urinary incontinence cause in girls. It is traditionally managed through hemi-nephrectomy or uretero-ureterostomy, which have the potential for complications including anastomotic stricture, leak, bleeding, and de-vascularization of the functioning renal moiety. Laparoscopic ureteric clipping has been shown to be a good alternative but has not been widely adopted yet. We provide our experience with this technique. METHODS: We retrospectively reviewed the data of 6 patients who underwent laparoscopic clipping of ectopic ureter between 2014 and 2019. We collected the following information: clinical presentation, preoperative and postoperative imaging, age at presentation, age at surgery, operative time, complications, length of stay, length of follow-up, as well as continence outcomes. RESULTS: Five patients were diagnosed with a duplex system associated with an ectopic upper pole ureter. One patient was noted to have a non-functional kidney associated with an ectopic ureter. Median age at presentation was 5 years (6 weeks-9 years), while at surgery was 8 years (2-13 years). Four patients were referred for incontinence, 1 was referred for antenatal hydronephrosis, 1 presented with urosepsis. The preoperative renal pelvis anteroposterior diameter (APD) was 8.60 cm (median) (6.80-8.70 cm). At the post-operative follow-up, the APD increased to median 9.1 cm (6.80-11.50 cm). Median operative time was 91 min (42-60 min). Complications were seen in only one patient who developed an immediate postoperative urinary tract infection (UTI). Five patients were discharged home the same day of the surgery, while the patient who developed UTI went home on post-operative day 3. Median follow-up was 33 months (22-72 months). Currently, all patients have achieved daytime urinary continence. No patient had UTI during the follow-up period. CONCLUSION: Laparoscopic ureteric clipping of the ectopic ureter appears to be a valid alternative to extirpative or reconstructive procedures. Follow-up shows an increase in hydronephrosis without any consequence for the patients. Further studies are necessary to reinforce these observations.

Vaginal entrapment of bathwater: a source of extra-urethral incontinence.

This report presents 2 cases of females (a prepubertal and a pre-menopausal female) with dribbling "incontinence" caused by vaginal entrapment of bathwater. In the first case, an 8-year-old girl presented with a history of bothersome wetness of her underwear, noted mainly in the morning. History revealed that she bathed almost nightly. She was instructed to shower or bath only, each for one week. The wetting occurred only after bathing. In the second case, a 39-year-old female, G2P2 with normal genitalia noted occasional, yet significant, dribbling into her underwear only after baths. She concluded this to be bathwater accumulating in her vagina, which she evacuates digitally. The differential diagnosis of dribbling incontinence in females of any age should include the extra-urethral cause of entrapped fluids of immersion. Although this condition may be rare, it is simple to rule out on history based on its temporal association with fluid immersion. Once diagnosed, the management is behavioural.

Endoscopic ablation of longitudinal vaginal septa in prepubertal girls: a minimally invasive alternative to open resection.

INTRODUCTION: Vaginal septation is a congenital defect seen in patients with persistent cloaca, urogenital sinus and disorders of Müllerian duct aplasia. Rarely, these patients present with symptoms in infancy and childhood with the exception of hydrocolpos. Treatment traditionally consists of surgical excision of the vaginal septum. We present our experience with minimally invasive endoscopic ablation of vaginal septa. MATERIALS AND METHODS: We reviewed retrospectively the management of four patients with vaginal septae: Herlyn-Werner-Wunderlich syndrome (1), cloacal malformations (2), and urogenital sinus (1). All were prepubertal (aged 2-9 years). The first patient presented with hydrocolpos. The others were asymptomatic and identified during definitive reconstruction. All four underwent endoscopic ablation in ≤30 min, using a pediatric resectoscope. RESULTS: One of the cloacal patients developed a postoperative perineal/vestibular infection leading to urethral stenosis and currently requires intermittent catheterization. There were no other complications. Endoscopic examination under anesthesia at 6 months in all patients revealed no septal scarring or vaginal stenosis. CONCLUSION: The advantage of endoscopic ablation over traditional open repair is that it is minimally invasive and can be easily performed as an outpatient procedure or at the time of definitive reconstruction. Our results suggest that endoscopic ablation should be considered as the primary approach for correction of vaginal septa.

Long-term urological follow-up of multicystic dysplastic kidneys: Is it still indicated in 2007?

OBJECTIVE: To determine whether the current indications for the long-term urological follow-up of children with multicystic dysplastic kidneys (MCDKs) are supported by the literature. METHODS: The membership of the Pediatric Urologists of Canada was surveyed to determine if long-term urological follow-up was being performed, and if so, for what indications. A literature search using PubMed, EMBASE and a Conference Papers Index was performed to determine whether the indications listed were supported by the literature. RESULTS: A response rate of 72% was achieved for the survey, with most respondents following children with MCDK long-term. The main indications for long-term follow-up were the increased risk of Wilms' tumour (54%) and hypertension (32%), observation of the contralateral kidney (43%) and involution of the MCDK (36%). The literature search did not support long-term urological follow-up for any of these indications, provided unilateral MCDK was an isolated genitourinary abnormality. Although it is rare, a primary care physician could monitor for hypertension. CONCLUSION: Long-term urological follow-up of children with "simple MCDK" is not supported by the literature, provided the diagnosis has been confirmed with a follow-up renal ultrasound at 12-24 months. Blood pressure monitoring by a primary care physician is recommended.

Sports and the solitary kidney: how to counsel parents.

OBJECTIVE: To determine how to counsel parents of young children with a solitary kidney in a manner compliant with the recommendations of the American Academy of Pediatrics (AAP). METHODS: As per the AAP recommendations, the relevant information required to provide a Qualified Yes to involvement in contact/collision sports was obtained through a PubMed search and local inquiries. Questions specifically addressed were: . Available published information on risks of participation . Availability of effective protective equipment that is acceptable to the athlete . Whether the sport can be modified to allow safer participation. RESULTS: Pediatric renal trauma can result from sporting injuries, however more renal injuries are caused by motor vehicle accidents. Those sports associated with a higher risk of significant renal injury carry a five-fold higher risk of head injury. Tolerable protective equipment is available, but whether it decreases risk of renal trauma is unknown. Participation in high-risk sports can be modified to allow safer participation. CONCLUSIONS: Parents need to be counseled on the consequences of an injury to the solitary kidney, and potential ways to decrease such risks without being unnecessarily restrictive with respect to sports participation. Specific information to convey to parents in a concise manner is provided.

Canadian guidelines for the management of benign prostatic hyperplasia.

OBJECTIVE: To develop the first Canadian guidelines for the management of lower urinary tract symptoms in men with benign prostatic hyperplasia (BPH). METHODS: These guidelines, developed under a mandate provided by the Canadian Urological Association (CUA), were a collaborative effort between the CUA guidelines committee and the Canadian Prostate Health Council. BPH guidelines developed by the American Urological Association, the European Association of Urology, the World Health Organization International Consultation on BPH, and similar committees from Germany, Sweden and Australia were reviewed. The committee further reviewed a systematic literature search, updated to May 2004, and systematically derived Canadian urological opinion data. RESULTS: The subsequent Canadian BPH guidelines were developed as an evidence based consensus among the committee members. Mandatory evaluation includes history, physical examination and urinalysis, while a symptom inventory and PSA in selected patients are recommended. Serum creatinine, uroflow, voiding diary, post void residual and sexual function questionnaire are optional. Unless there is an indication, other related tests are not recommended. Treatment choices should be governed by the severity of the symptoms, bother and patient preference. Guidelines for medical, surgical and minimally invasive treatment as well as special considerations are described in terms of guideline, option and recommendation. CONCLUSIONS: Diagnostic and treatment guidelines for BPH reflect the Canadian social priorities, economics, socialized medical practice, manpower issues, and medicolegal considerations.