Transient minimal hydronephrosis on contralateral kidney in infants with unilateral hydronephrosis: Is it an early sign of worsening of the affected kidney?

Background/aim: The criteria for surgical management of ureteropelvic junction obstruction are not well-defined, and there is a risk for loss of renal function before the operation. In this context, certain changes in contralateral kidney had been investigated in order to increase the sensitivity of diagnosis. In this study, we aimed to investigate whether contralateral transient minimal hydronephrosis (CTMH) can be considered as an "early alarm" sign for worsening of the affected kidney in infants with hydronephrosis. Materials and methods: A total of 182 infants (92 surgically treated and 90 conservatively followed-up) with unilateral hydronephrosis were retrospectively analyzed. Ultrasonography and renal scan findings were evaluated. Correlation between the appearance of CTMH, contralateral compensatory hypertrophy (CCH) on ultrasonography, and prognosis of the affected kidney were evaluated. Results: Among the surgically treated patients, 18 (19.6%) patients developed CTMH on average 7 months (0­13 months) before surgery. Among these 18 patients with CTMH, 12 patients (66.6%) had loss of renal function preoperatively, while this ratio was 29.7% on their counterparts (p = 0049). CCH was observed in 31 (33.7%) individuals in surgically treated patient group including all 18 patients with CTMH, while none of the conservatively followed-up patients developed CCH and/or CTMH. In the multiple logistic regression analysis, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and of the poor prognosis (p = 0.011 and p = 0.0004, respectively). Conclusion: In our study, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and poor prognosis in infants followed-up with isolated unilateral hydronephrosis. Additionally, CTMH can be considered as an "early alarm" sign for worsening of the affected kidney and the need for surgical intervention.

Transition to adulthood with a bladder augmentation: histopathologic concerns

ABSTRACT Aim: To investigate the histopathologic changes in native bladder and gastrointestinal segment, the relation between histopathologic changes, type of operation and the period passed over operation in patients with bladder augmentation. Materials and methods: Twenty consecutive patients were enrolled in this study. Histopathologic evaluation of the cystoscopic mucosal biopsies from native bladder and enteric augment was performed in all patients. Results: Active or chronic non-specific inflammation of various degrees was found in all specimens except two. Metaplastic changes were detected in 3 patients. Two patients had squamous metaplasia (one focal, one extensive) and one patient had intestinal metaplasia. All metaplastic changes were found in native bladder specimens. The type of augmentation in patients with metaplastic changes were ileocystoplasty and sigmoidocystoplasty. No signs of malignancy were detected in any patient. Conclusion: The complexity of the disorders requiring bladder augmentation does not let the surgeons to draw a clear line between different groups of complications including malignancy formation. However, due to challenging course of the augmentation procedure itself, surgeons should be well aware of the possibility of malignancy development.

Transition to adulthood with a bladder augmentation: histopathologic concerns.

AIM: To investigate the histopathologic changes in native bladder and gastrointestinal segment, the relation between histopathologic changes, type of operation and the period passed over operation in patients with bladder augmentation. MATERIALS AND METHODS: Twenty consecutive patients were enrolled in this study. Histopathologic evaluation of the cystoscopic mucosal biopsies from native bladder and enteric augment was performed in all patients. RESULTS: Active or chronic non-specific inflammation of various degrees was found in all specimens except two. Metaplastic changes were detected in 3 patients. Two patients had squamous metaplasia (one focal, one extensive) and one patient had intestinal metaplasia. All metaplastic changes were found in native bladder specimens. The type of augmentation in patients with metaplastic changes were ileocystoplasty and sigmoidocystoplasty. No signs of malignancy were detected in any patient. CONCLUSION: The complexity of the disorders requiring bladder augmentation does not let the surgeons to draw a clear line between different groups of complications including malignancy formation. However, due to challenging course of the augmentation procedure itself, surgeons should be well aware of the possibility of malignancy development.

Testis sparing surgery for Leydig cell pathologies in children.

OBJECTIVE: The aim was to analyze testis-sparing surgical procedures in boys with Leydig cell pathologies. STUDY DESIGN: The hospital records of four boys with Leydig cell hyperplasia who underwent testis-sparing surgery for testicular masses between 2000 and 2012 were analyzed retrospectively. Tumor markers were evaluated and all boys underwent scrotal ultrasonography preoperatively. The hormonal profile was also analyzed for symptoms of precocious puberty. The testis was delivered through a high transverse inguinal incision and the tumor was excised by enucleation. After confirming the benign nature of the tumor with frozen-section examination, the testis was reinserted and fixed into the scrotum with absorbable sutures. All cases were followed-up with physical examination, scrotal ultrasonography, and measurement of ß-human chorionic gonadotropin (HCG), α-fetoprotein, and hormone levels. RESULTS: The mean age of the patients was 9.4 years (1.5-15 years). Testicular mass and scrotal asymmetry were detected in all cases. Ultrasonography was the main initial diagnostic modality for detecting testicular masses (Table). ß-HCG and α-fetoprotein levels were normal. Three cases had Leydig cell hyperplasia and one patient was diagnosed to have a Leydig cell tumor. Signs of precocious puberty were detected in the four patients. The mean follow-up period was 4.8 years (2-8 years). Neither recurrence nor testicular atrophy developed in the follow-up. Findings of precocious puberty continued in one patient with Leydig cell hyperplasia, in whom a 2-mm contralateral metachronous lesion was detected and enucleated successfully. DISCUSSION: Testis-sparing surgery with its potential long-term psychological, cosmetic, and functional advantages should be used in pediatric patients in whom a benign Leydig cell pathology is confirmed histopathologically. CONCLUSION: This intervention with good long-term results can easily be applied through a proper dissection plane in the testicle. Since testicular Leydig cell tumors in childhood have small rates of recurrence, this choice of treatment is efficient in patients with salvageable testicular tissues and normal levels of tumor markers.

Results of a Two-stage Technique for Treatment of Proximal Hypospadias with Severe Curvature: Creation of a Urethral Plate Using a Vascularized Preputial Island Flap.

PURPOSE: To present the results of a two-stage technique used for the treatment of proximal hypospadias with severe curvature. MATERIALS AND METHODS: The medical records of children with proximal hypospadias and severe curvature were retrospectively analyzed. A 2-stage procedure was performed in 30 children. In the first stage, the release of chordee was performed, and a well-vascularized preputial island flap was created. The vascularized island flap was brought anteriorly and sutured over the ventral surface of the glans and degloved penile shaft. The second stage was performed 6-8 months later. A neourethra was reconstructed by the tubularization of the preputial-urethral plate utilizing the principles of Duplay technique. All surgical procedures were performed between 2005 and 2011. RESULTS: The mean age of the patients was 4.4 years (1-17 years). The mean duration of urethral catheterization was 6 days after the first stage and 10 days following the second stage. The flaps were viable in all of the children. There was no residual chordee. Following the second stage (n = 30), complications developed in 11 children (36%), namely, a fistula in 7, a pinpoint fistula in 3, and a diverticulum formation in 1. The cosmetic outcome was satisfactory. Uroflowmetry measurements were evaluated, and only one patient had a diverticulum formation at the late follow-up. CONCLUSION: Vascularized preputial island flap is an alternative to free grafts for the reconstruction of the urethra. The main advantage of this flap technique is the creation of a thick, healthy and well-vascularized urethral plate. The advantages of this technique include better aesthetic appearance, an acceptable complication rate, and a very low rate of diverticula formation.

Transvesicoscopic cross-trigonal ureteroneocystostomy in children: a single-center experience.

PURPOSE: To evaluate the safety and efficacy of transvesicoscopic ureteric reimplantation in children. PATIENTS AND METHODS: Seventeen ureteric units in 11 patients underwent a transvesicoscopic 'Cohen' ureteroneocystostomy in 2003-2007 and the results were retrospectively analyzed. There were four boys and seven girls. All patients had vesicoureteric reflux (VUR), except for one with paraostial diverticula. Six patients underwent bilateral and five unilateral transvesicoscopic reimplantation (a total of 17 units). RESULTS: The procedure was successfully completed in all patients. Mean operation time was 217 min in unilateral cases and 306 min in bilateral cases without perioperative complications, except for pneumoperitoneum development in two cases. In the early postoperative period, two patients developed macroscopic hematuria. Mean hospital stay was 3.8 days (3-5 days), except for one patient who suffered from urinary tract infection and needed longer hospitalization. Mean follow-up period was 4.5 years (3-7 years). One patient with bilateral VUR had passive unilateral grade I VUR on postoperative cystogram, giving a success rate of 91% (94% of ureters). This patient was followed conservatively. One patient had recurrent urinary tract infections without reflux. CONCLUSION: Transvesicoscopic cross-trigonal ureteroneocystostomy can be safely performed with a high success rate in children.

Histological evaluation of the testicular nubbins in patients with nonpalpable testis: assessment of etiology and surgical approach.

There is a controversy in the literature whether testicular nubbins carry malignancy risk and excision of the nubbin is necessary in patients with nonpalpable testis. It is also controversial whether vanishing testis has the same etiopathogenesis and risk with true undescended testis. The aim of this study is to investigate the histological findings of testicular nubbins in patients with nonpalpable testis and to question etiology and surgical indications for vanishing testis. We reviewed the histopathological results of 44 testicular nubbins in 40 patients (mean age: 4.1 years, range 1-13 years) with nonpalpable testis between 1992 and 2004, retrospectively. Exploration revealed 5 intraabdominal and 39 inguinal testicular nubbins. Of 44 specimens only 5 (11.3%) from inquinal testicular nubbins were found to have seminiferous tubules. Two of the five had seminiferous tubule structures with viable germ cells showing maturation correlating with age. The other two with scarce seminiferous tubules were seen on only a single area and one had Sertoli cells only. None of the excised tissue had malignant degeneration. The vas deferens was identified in 23 (52.2%), vessels in 26 (59%), calcification in 14 (31.8%) and hemosiderin in 12 (27.2%) of excised tissue. Presence of calcification in one-third of the nubbins supports vascular accident thesis in the etiopathogenesis of vanishing testis. The possibility for the presence of seminiferous tubules and viable germ cells in the testicular nubbin is low. These facts decrease theoritical risk of malingnancy. Therefore, an inguinal exploration for testicular nubbin in patients with vas deferens and vessels entering into the inquinal canal diagnosed at laparoscopy can be postponed untill testicular prosthesis implantation and the nubbin can be removed at this operation.

A therapeutic method for failed bladder augmentation in children: re-augmentation.

OBJECTIVE: To investigate the causes leading to the deterioration of previously successful bladder augmentation and to evaluate the efficacy of re-augmentation. PATIENTS AND METHODS: Between 1988 and 2004, 136 bladder augmentations were performed in two paediatric urological units in Hungary and Turkey. Re-augmentation was necessary in two patients after colocystoplasty and in three after gastrocystoplasty. A secondary augmentation was not required in any patients after ileocystoplasty. The clinical data of these five patients were evaluated. RESULTS: On the basis of the clinical signs and urodynamic studies, re-augmentation was performed 2-7 years after the initial augmentation cystoplasties. Anticholinergic therapy given before re-augmentation did not improve bladder capacity, intravesical pressure and/or bladder compliance. An ileal or sigmoid segment was used for the secondary augmentation. After re-augmentation, all five patients became continent, and showed marked improvement in their urodynamic parameters at a mean (range) follow-up of 6.8 (2-10) years. CONCLUSION: A decreased bladder capacity and/or compliance and increased bladder pressure after successful augmentation cystoplasty might be the result of: (i) impairment of the blood supply to the large bowel or gastric segment used for augmentation; or (ii) bowel mass contractions. Ileocystoplasty seems to be the "first-line" of choice for primary augmentation. Re-augmentation with a bowel segment is a suitable treatment if conservative treatment fails. Regular urodynamic investigations are needed for early detection of malfunction of the augmented bladder, and advising therapy.

Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations.

BACKGROUND: Anorectal malformations (ARM) are common congenital anomalies seen throughout the world. Comparison of outcome data has been hindered because of confusion related to classification and assessment systems. METHODS: The goals of the Krinkenbeck Conference on ARM was to develop standards for an International Classification of ARM based on a modification of fistula type and adding rare and regional variants, and design a system for comparable follow up studies. RESULTS: Lesions were classified into major clinical groups based on the fistula location (perineal, recto-urethral, recto-vesical, vestibular), cloacal lesions, those with no fistula and anal stenosis. Rare and regional variants included pouch colon, rectal atresia or stenosis, rectovaginal fistula, H-fistula and others. Groups would be analyzed according to the type of procedure performed stratified for confounding associated conditions such as sacral anomalies and tethered cord. A standard method for postoperative assessment of continence was determined. CONCLUSIONS: A new International diagnostic classification system, operative groupings and a method of postoperative assessment of continence was developed by consensus of a large contingent of participants experienced in the management of patients with ARM. These methods should allow for a common standardization of diagnosis and comparing postoperative results.

Emotional effects of hypospadias surgery on Turkish boys.

PURPOSE: The aim of this study is to investigate in Turkish boys the emotional effects of hypospadias repair before and after the optimal age for repair. MATERIALS AND METHODS: Forty hypospadias patients treated in our department were included in this study. Group 1 consisted of 13 patients operated on at less than 30 months of age. Group 2 consisted of 27 patients operated on at over 30 months of age. Age at time of study, severity of hypospadias, age at repair and number of operations were evaluated for both groups retrospectively. Socio-economic and socio-demographic characteristics of these patients including place of residence, educational level of their parents and parental occupations were determined. The Turkish versions of the Children's Depression Inventory and the State-Trait Anxiety Inventory for Children A-State scale were used to evaluate the emotional effects of hypospadias surgery. For statistical analysis, the Mann-Whitney U test, Student's t test and Chi-squared test were used. RESULTS: There was a significant difference in the age at repair between Groups 1 and 2. No significant differences existed in severity of hypospadias and number of operations between the two groups. All 40 patients had the same socio-economic and socio-demographic characteristics. Group 1 did not significantly differ from Group 2 in regard to the educational level of their parents and parental occupations. Age at repair, which was the only difference between the two groups, did not affect the level of depression and anxiety-state symptoms. CONCLUSIONS: There is a close relationship between emotional effect of hypospadias surgery and age at repair. Possibility of depression and anxiety, which were dominating emotional symptoms among boys operated on for hypospadias, was found not to be high after the recommended age. It is concluded that, as hypospadias surgery creates a circumcised penis, the degree of emotional trauma is lower in Turkish boys than in other nationalities.

Quo vadis? Ureteric reimplantation or ignoring reflux during augmentation cystoplasty.

OBJECTIVE: To decide whether antireflux surgery should be used in the presence of vesico-ureteric reflux (VUR) in children, in whom an augmentation procedure is needed, because secondary VUR in children with a neurogenic bladder, infravesical obstruction and primary VUR in the exstrophy-epispadias complex is expected to resolve after augmentation, which decreases the intravesical pressure and increases capacity. PATIENTS AND METHODS: Between 1987 and 2001, the bladder was augmented in 38 children, using no antireflux surgery in group 1 (15 patients) and antireflux surgery in group 2 (23 patients). RESULTS: VUR was detected in all patients on cysto-urethrography before surgery; reflux resolved after augmentation cystoplasty in 97% and 93% of refluxing units in groups 1 and 2, respectively. The increase in the expected bladder capacity was from 35% to 86% in group 1 and from 38% to 90% in group 2. No patient had any deterioration in renal function. CONCLUSIONS: We recommend using only augmentation in patients with low- or high-grade VUR and a neurogenic bladder, infravesical obstruction and exstrophy-epispadias. Combining antireflux surgery with cystoplasty has no significant effect on either the resolution of VUR or renal function.