Postnatal Calyceal-to-Parenchymal Ratio: A Promising Predictor for Surgical Correction of Ureteropelvic Junction Obstruction in Newborns.

OBJECTIVE: This study aims to explore a new parameter, the calyceal-to-parenchymal ratio (CPR) of postnatal renal ultrasonography (RUS) as a predictor of surgery in newborns with possible ureteropelvic junction obstruction (UPJO). Although UPJO remains the main surgical category of antenatally detected hydronephrosis, there is a lack of a gold-standard test that predicts the need for pyeloplasty. SUBJECTS AND METHODS: We retrospectively reviewed infants with a positive antenatal history of hydronephrosis who were confirmed to have grade 3 or 4 hydronephrosis on postnatal RUS between 2010 and 2020. We compared postnatal CPR between surgical and control groups and tested the correlation between postnatal CPR and diuretic renogram. RESULTS: A total of 79 and 136 kidneys were included in the surgical and control groups, respectively. Kidneys that were managed with pyeloplasty between January 2010 and July 2020 were included in the surgical group, while kidneys from patients with comparable traits who were managed conservatively comprised the control group. At a mean age of 18.9 weeks at presentation and a mean follow-up period of 48.99 months, the median postnatal CPR was significantly greater in the surgical group (3.62 vs. 0.98, p<0.001). A postnatal CPR of 1.68 had a sensitivity and specificity of 96.2% and 84.8%, respectively, in predicting the need for future pyeloplasty (area under the curve (AUC)=0.966). There was a positive and significant correlation between postnatal CPR and the half-life of the renogram (p=0.018) but not significant with the differential function (p=0.090). CONCLUSION: Diuretic renography has little capability for predicting future pyeloplasty. Current RUS grading systems do not offer an objective measure of renal parenchyma. Numerous other RUS parameters are less frequently utilized in clinical practice, and many are challenging to assess and require sophisticated software or equipment. Postnatal CPR is a promising tool for predicting the need for pyeloplasty in newborns with UPJO. Further prospective studies are needed to standardize and assess the reproducibility of this parameter.

Toward a Financially Sustainable Healthcare System in Saudi Arabia.

BACKGROUND: This study aimed to find out the application of a sustainability model framework to test the financial sustainability of the healthcare system in Saudi Arabia and to suggest some reforms required to maintain a sustainable healthcare system in the country. METHODS: To test the financial sustainability of the publicly funded healthcare system in Saudi Arabia, we applied analytical techniques using a sustainability model framework based on the framework indicators proposed previously by the Office of Sustainable Development, Bureau for Africa, U.S. Agency for International Development. An empirical time-trend analysis was also used to judge the financial sustainability of the healthcare system of Saudi Arabia in the future. RESULTS: The results showed significant threats to the financial sustainability of the healthcare system. Saudi Arabia's revenues, gross domestic product (GDP), government budget, and Ministry of Health (MOH) budget were all directly influenced by the oil prices. CONCLUSION: The healthcare system in Saudi Arabia seems to be financially unsustainable, and the need for change is inevitable. Saudi's ambitious program of development "Vision 2030" will surmount the challenges faced by the country and will lead to substantial enhancements in the health sector in Saudi Arabia, and other opportunities for improvement do exist.

Vaginoscopic Incision of Vaginal Septum With Preservation of the Hymen in a Child With Obstructed Hemi-Vagina Ipsilateral Renal Agenesis (OHVIRA) Syndrome.

Obstructed hemi-vagina ipsilateral renal agenesis (OHVIRA) syndrome, also known as Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian duct anomalies that usually presents after menarche. Although there is increasing awareness about OHVIRA syndrome, high suspicion is needed for the diagnosis. Awareness of the syndrome is crucial for the management and to prevent serious complications. Surgical techniques and age at the surgery are still debatable but, minimally invasive vaginoscopic resection of the vaginal septum should be considered when feasible as it not only allows division of septum with preservation of hymen, but it provides excellent visualization, is less traumatic, and has promising postoperative outcomes. Hymenal integrity is of great concern in specific populations with cultural values. In this report, we present the case of a 24-month-old girl diagnosed with OHVIRA syndrome during a routine follow-up for renal agenesis and was managed with vaginoscopic incision of the vaginal septum using a pediatric cystoscope while maintaining the hymenal integrity.

Laparoscopic management of ventriculoperitoneal shunt extrusion through urethra in an infant: Case report and review of literature.

Ventriculoperitoneal (VP) shunting is a well-established procedure for the management of hydrocephalus. Its complications might include distal migration of the shunt and organ perforation. However, bladder perforation and subsequent extrusion of the shunt per the urethra is a rare complication. In this report, we present this exceptional event with a minimally invasive approach of management in a 7-months-old girl.

The Utility of Double Opposing Transposition Flaps in the Management of Inguinal Ectopic Scrotum: Surgical Experience and Literature Review.

An ectopic scrotum (ES) represents a rare developmental anomaly of the male genitalia. The condition usually represents a part of a wide spectrum pathology associated with other anomalies. The different locations in which an ectopic scrotum is found include inguinal, suprainguinal, infrainguinal, and/or perineum. There are several surgical techniques described in the literature related to the management of ES, but none of them showed superior results. We present a rare case of ectopic hemiscrotum managed as part of a multidisciplinary team approach, showing the utility of double opposing transposition z-plasty flaps in managing such a case.

A rare case of Ewing's sarcoma of the kidney.

We report the case of a 15-year-old girl presenting with distended abdomen, left flank pain, and a history of weight loss. Computed tomography showed a large tumor involving the left kidney that was initially diagnosed as renal cell carcinoma. She underwent exploratory open laparotomy and left radical nephrectomy followed by chemotherapy and showed good response. Histology of the resected tumor revealed features of Ewing's sarcoma of the kidney which was confirmed by molecular studies. This disease is rare, particularly in the pediatric population, and this report will help better understand the potential disease course and response to treatment.

Minimally invasive surgical approach to treat posterior urethral diverticulum.

Urethral diverticulum is a localized saccular or fusiform out-pouching of the urethra. It may occur at any point along the urethra in both male and females. Male urethral diverticulum is rare, and could be either congenital or acquired, anterior or posterior. The mainstay treatment of posterior urethral diverticulum (PUD) is the open surgical approach. Here we discuss our minimally invasive surgical approach (MIS) in managing posterior urethral diverticulum.

Protective role of hypothermia on ischemia of prepubertal rodent testicle.

OBJECTIVES: To assess the role of hypothermia in testicular ischemic injury in a prepubertal rat model. METHODS: The study included 24 male, prepubertal Sprague-Dawley rats. Of the 24 rats, 20 were subjected to right testicular ischemia with and without hypothermia for 30 and 60 minutes, 5 in each group. The remaining 4 rats underwent sham operation and were used as controls. A vascular clamp was used to clamp the spermatic cord for the specified time. Hypothermic treatment consisted of placing the testicle in ice slush. At 8 weeks postoperatively, both testicles were harvested. The left testicle was used as the control. A pathologist, who was unaware of the groups, examined all the slides. The mean seminiferous tubular diameter (STD) and mean number of germinal cell layers (GCLs) were obtained. RESULTS: When the contralateral testicle was used as the control, the mean GCL and STD in the ipsilateral operated sides were significantly worse in all ischemic groups. When the sham-operated testicles were used as the control, no significant differences were found between the cold ischemia groups and the sham group. In the warm ischemia groups, the mean GCL and STD were significantly worse than those in the sham group. We compared the operated sides among the groups. At 30 minutes, the mean GCL and STD showed a trend toward preservation with cold ischemia, although the difference was insignificant. At 60 minutes, the mean GCL and STD were significantly worse with warm than with cold ischemia. CONCLUSIONS: The results of our study have shown that permanent ipsilateral ischemic testicular damage occurred as early as 30 minutes in prepubertal rats. The damage might be reduced with hypothermia.

Is routine renography required after pyeloplasty?

PURPOSE: We assessed whether renography should be performed routinely following pyeloplasty. MATERIALS AND METHODS: We identified the records of all patients undergoing pyeloplasty at our hospital between 1989 and 2005. Patients were eligible for the study if they had undergone preoperative ultrasound and renal scan, and postoperative ultrasound and renal scan within 3 months and 1 year postoperatively, respectively. Patients were excluded if they had associated anomalies or high grade reflux. Postoperative downgrading or decompression of the pelvicaliceal dilatation within the same grade was recorded as "improved," while unchanged or worsening hydronephrosis was recorded as "no improvement." All information was obtained from the official radiologist reports rather than from the postoperative surgeon notes. Data obtained from the postoperative renal scan included the presence or absence of obstruction as well as split renal function. We compared postoperative ultrasound and renal scan, as well as changes between preoperative and postoperative split renal function in patients with a normal contralateral kidney. Fisher's exact test was used for comparison. RESULTS: A total of 97 patients who underwent 101 pyeloplasties at a median age of 18 months were eligible for review. Mean +/- SD followup was 4.5 +/- 2 years. Of the 91 kidneys with improvement on postoperative ultrasound 2 (2%) had an obstructive postoperative renal scan, which spontaneously resolved during followup. In contrast, of the 10 kidneys with postoperative ultrasound showing no improvement 4 (40%) had an obstructive renal scan, of which 2 (50%) required a second procedure (p <0.001). Of the 46 kidneys with downgraded hydronephrosis none had an obstructive postoperative renal scan, compared to 6 of 55 (11%) without downgrading (p <0.03). Of the 49 patients with preoperative split renal function greater than 45% none demonstrated changes of more than 5% postoperatively, compared to 15 of 35 (43%) with split renal function less than 45% (p <0.001). CONCLUSIONS: Patients in whom postoperative ultrasound reveals downgrading may not require postoperative renal scan to rule out obstruction. However, those with preoperative function less than 45% may exhibit functional changes greater than 5% that can be determined by postoperative renal scan.

The role of bladder urine transforming growth factor-beta1 concentrations in diagnosis and management of unilateral prenatal hydronephrosis.

PURPOSE: We evaluated the relationship between bladder urine transforming growth factor-beta1 concentration and severity of hydronephrosis in newborns with unilateral prenatal hydronephrosis. MATERIALS AND METHODS: We prospectively studied all newborns presenting with unilateral prenatal hydronephrosis between January 2005 and 2007. Patients with associated anomalies, vesicoureteral reflux, contralateral pathology or ipsilateral ureteral dilatation were excluded from study. Postnatal evaluation included voiding cystourethrography, renal ultrasonography and determination of bladder urine transforming growth factor-beta1 concentration. Diuretic renal scans were performed in patients with initial grade 3 or 4 hydronephrosis or increasing hydronephrosis during followup. Pyeloplasty was performed when a well tempered renogram showed an obstructive drainage curve with a half-time greater than 20 minutes and/or an obstructive washout curve pattern during the diuretic phase. Patients were analyzed in observational and surgical groups. We studied the longitudinal changes in bladder urine transforming growth factor-beta1 in each group and compared concentration levels in the first 3 months of life in both groups. RESULTS: A total of 42 newborns were included. The observational group consisted of 31 patients followed for a mean of 14 +/- 6 months. During the first 3 months, from 3 to 12 months and in the second year of life mean ultrasound grade and bladder urine transforming growth factor-beta1 decreased from 2.3 to 1.7 to 1.2 (p <0.05) and from 11.5 to 8.6 to 6.1 pg/mmol creatinine (p <0.05), respectively. Pyeloplasty was performed in 11 patients at a mean age of 6 +/- 5 months. Mean followup was 7 +/- 5 months. In the first 3 months, preoperatively and at 3 to 12 months postoperatively mean ultrasound grade and bladder urine transforming growth factor-beta1 were 3.5, 4 and 3 (p >0.05), and 23, 29 (p >0.05) and 8 pg/mmol creatinine (p <0.003), respectively. Mean bladder urine transforming growth factor-beta1 levels in the first 3 months of life were 23 +/- 14 and 11.5 +/- 8 pg/mmol creatinine in the surgical and observational groups, respectively (p <0.001). Limiting comparison to the 23 patients with initial grades 3 and 4 hydronephrosis revealed levels of 23 +/- 14 and 13 +/- 9 pg/mmol creatinine in the surgical and observational groups, respectively (p <0.02). At a cutoff of 17 pg/mmol creatinine bladder urine transforming growth factor-beta1 in the first 3 months of life was 82% sensitive and 86% specific in predicting surgery. CONCLUSIONS: Bladder urine transforming growth factor-beta1 changes through time are associated with similar changes in hydronephrosis grade. Bladder urine transforming growth factor-beta1 in the first 3 months of life can predict the need for surgery in newborns with prenatal hydronephrosis.

Nonstented tubularized incised plate urethroplasty with Y-to-I spongioplasty in non-toilet trained children.

INTRODUCTION: This study was designed to evaluate the supportive role of spongioplasty during tubularized incised plate (TIP) urethroplasty repair of hypospadias. METHODS: All non-toilet trained children who underwent TIP repair for primary hypospadias by 1 surgeon over a 30-month period were included in our study. The divergent spongiosa was mobilized off the corpora cavernosa and was rotated toward the midline to wrap the neourethra. A dartos flap was used to cover the neourethra. The neourethra was calibrated immediately after surgery in all patients. A urethral stent was left in place only when difficult calibration was encountered. Complications and cosmetic appearance were documented at last follow-up. RESULTS: Thirty-two consecutive patients with a mean age of 18 (standard deviation [SD] 6) months were included in the study. The defects were distal and mid-shaft in 26 patients (81.3%) and proximal-shaft in 6 (18.8%). No intraoperative catheterization difficulties were encountered and all repairs were nonstented. Antibiotics and anticholinergics were not required. Mean follow-up was 9 (SD 6) months. Urinary extravasation developed in 1 patient (3.1%) on the second postoperative day. A urethral catheter was easily inserted and left indwelling for 5 days. One patient presented 6 days postoperatively with suspected voiding difficulty. Urethral calibration was easily performed excluding any mechanical obstruction. There were no urinary fistulae and reoperation was not required. An excellent cosmetic appearance was achieved in all patients. CONCLUSION: TIP urethroplasty is a versatile operation that can be performed in almost all cases of penile hypospadias. A nonstented technique for hypospadias repair simplifies postoperative care and obviates the need for antibiotics and anticholinergics. We believe that spongioplasty provides good support to the neourethra and the hypoplastic distal urethra that may facilitate catheterization in the immediate and early postoperative periods, if required. Future controlled study is warranted to further evaluate the role of spongioplasty.

Postpubertal urodynamic and upper urinary tract changes in children with conservatively treated myelomeningocele.

PURPOSE: We examined the urodynamic and upper urinary tract changes in children with myelomeningocele treated conservatively through puberty at our institution between 1980 and 2006. MATERIALS AND METHODS: A total of 40 patients were exclusively treated conservatively with or without anticholinergics and/or clean intermittent catheterization through puberty at our institution. The records of 37 patients (17 males and 20 females) were available for review and constituted the subject matter for our study. The neurological lesion was sacral in 4 patients, lumbosacral in 5, thoracic in 12 and lumbar in 16. Clinical evaluations, radiological imaging studies of the upper urinary tract and urodynamic studies were repeated every 6 to 12 months. Data were collected and comparisons were made with respect to prepubertal (age 10 years) and postpubertal (15) continence status, urodynamic parameters and upper urinary tract changes. Children spontaneously achieving urinary continence postpubertally were examined in a similar fashion as a separate subgroup. Continence was defined as a dry interval of 4 hours or more. RESULTS: Of the 26 patients with urinary incontinence before puberty 12 (2 males and 10 females, 45%, p <0.003) achieved continence following puberty. Hydronephrosis remained stable in 4 patients, improved in 3 and was new onset in 3 (p >0.05). Vesicoureteral reflux persisted in 1 patient, resolved in 4 and was new onset in 1 (p >0.05). Total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure all increased significantly after puberty, from 277 +/- 82 to 487 +/- 140 ml, 45 +/- 17 to 54 +/- 20 cm H(2)O and 49 +/- 16 to 59 +/- 21 cm H2O, respectively. In patients achieving urinary continence following puberty total cystometric bladder capacity increased significantly from 284 +/- 58 to 473 +/- 93 ml (p <0.005). Maximum detrusor pressure and detrusor leak point pressure showed insignificant changes after puberty, increasing from 45 +/- 11 to 47 +/- 16 cm H2O and from 46 +/- 11 to 55 +/- 21 cm H2O, respectively. CONCLUSIONS: This study demonstrates that total cystometric bladder capacity, maximum detrusor pressure and detrusor leak point pressure increase significantly in patients with myelomeningocele following puberty. The increase in bladder capacity could be attributed to increasing bladder outlet resistance resulting from prostate gland enlargement in males and estrogenization in females. A significant number of patients spontaneously achieve continence at puberty, and continence becomes more likely when increased total cystometric bladder capacity is not associated with an increase in maximum detrusor pressure. Finally, no significant postpubertal upper urinary tract deterioration was observed in our series.