A novel therapy for idiopathic urethritis in children: Local steroid injection.

Idiopathic urethritis (IU) is difficult to manage and there is no standarized therapy. The technique of local steroid injection (LSI) for the treatment of IU in children and the results of the patients undergoing LSI from 2020 to 2021 in a single center are presented. Seven patients with IU underwent LSI. An internal urethrotomy was also performed in two patients with stricture. Complete resolution of symptoms and signs occurred in six patients. The remaining patient did not achieve total remission but did substantially improve symptoms. LSI seems to be an effective alternative for treatment of IU in children.

Long-term outcome of randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR).

OBJECTIVE: The aim of our study is to compare long-term outcome of endoscopic treatment of VUR using PPC or Dx/HA. PATIENTS AND METHODS: From October 2014 to April 2017 patients with VUR grades from 3 to 5 that needed endoscopic treatment were eligible for this RCT. Patients were randomized in two groups: PPC and Dx/HA. A VCUG was performed at 6 months; if VUR > 3 was still present a second ET was performed. We included for this long-term follow-up study those patients that were successfully treated at short-term follow-up. At 36 months postoperative VCUG was performed to assess outcome. Success was considered if postoperative VUR grade was 0 at 36 months, and there was no ureteral obstruction. RESULTS: In the previous study, 60/73 ureters were successfully treated in 36/44 patients, and then we have analyzed 60 ureters in 36 patients. Three patients were lost in long-term follow-up, and then we analyzed 57 ureters in 33 patients divided. PPC group 18 patients (28 ureters); and Dx/HA group 15 patients (29 ureters). After 3 years of follow-up the VCUG showed a success rate of 26/28 of RU in PPC and 26/29 of DX/HA. Two RU in PPC group had ureteral obstruction, and then the successful rate for PPC group dropped to 24/28. The overall successful rate at long-term was 72.7% of the RU in PPC group and 70.3% in Dx/HA group. CONCLUSION: PPC and Dx/HA has similar long-term outcome in VUR resolution, but ureteral obstruction could be present at long-term follow-up in PPC group.

Are weight or age limits for pediatric laparoscopic pyeloplasty? Results of a multicentric study.

INTRODUCTION: Anderson-Hynes pyeloplasty is the technique of choice for the treatment of pyeloureteral junction obstruction (PUJO) with an excellent success rate. Minimally invasive surgery has become the standard of care for the management of PUJO in children. Although it has been comparable to the open approach at all levels, its diffusion or employment in younger children has not been widely adopted. Our aim is to evaluate laparoscopic pyeloplasty outcomes from international academic centers in children under 1 year of age, focusing on feasibility and outcomes including possible complications. MATERIALS AND METHODS: This is review of consecutive infants under 1 year of age who underwent laparoscopic pyeloplasty between 2009 and 2018 with more than 12 months of follow-up. Seven different training centers with different backgrounds participated in this study. Evaluation was carried out with ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications, and results are described and analyzed. RESULTS: Over 9 years, 124 transperitoneal laparoscopic Anderson-Hynes pyeloplasties were performed on 123 children under 1 year of age; 88 males and 35 females, with 1 case of bilateral PUJO. Of the 124 renal units, 86 were left-sided. Mean age at surgery was 6.6 months (1 week-12 months), with 56% (n = 70) done before 6 months of age. Mean weight at surgery was 6.8 kg (3-12 kg), with 59% (n = 73) weighing less than 8 kg. Mean operative time (skin-to-skin) was 150 min (75-330 min). After a mean follow-up of 46 months (12-84 months), 12 (9%) patients developed complications, with only 1 needing a redo pyeloplasty also done laparoscopically. One child, with deterioration in renal function, underwent nephrectomy. CONCLUSION: Laparoscopic pyeloplasty under 1 year of age and/or less than 12 kilos is feasible with lower complication rate. Furthermore, age younger than 6 months and weight less than 8 kg are no longer limiting factors for a successful pyeloplasty as shown by this multicentre study.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children.

PURPOSE: The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. MATERIALS AND METHODS: A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. RESULTS: Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). CONCLUSION: We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Cuerpo extraño intravesical / Intravesical foreign body

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Imposibilidad para el sondaje vesical: siringocele de Cowper / Impossibility for bladder catheterization: Cowper's syringocele

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Comparison between mini-laparoscopy, conventional laparoscopy and open approach for ureteropelvic junction obstruction treatment in children.

INTRODUCTION: The aim of the study was to compare 3 mm mini-laparoscopy (mini LP), standard 5 mm laparoscopy (LP) and open surgery for pediatric pyeloplasty in a single center. METHODS: Patients who underwent pyeloplasty from 1997 to 2017 at Hospital Sant Joan de Déu were prospectively collected. Demographic data, clinical, surgical and radiological variables were assessed. A multivariate logistic regression analysis was performed in order to identify risks for surgical complications, urinary leak and need for redo-surgery. RESULTS: 340 pyeloplasties were performed in this period: 197 open, 30 LP and 113 mini LP. Independent risk factors for surgical complications in a multivariate logistic regression model were: LP (vs mini LP, OR = 3.95; 95% CI: 1.13-13.8), higher differential renal function (each point more increases the risk 6%; 95% CI: 1-11%), older children (every year increases the risk 1.11 times; 95% CI: 1.002-1.225). Open surgery, pelvis diameter or the use of different stents were not risk factors. This model had an 80% PPV and a 92% NPV. LP (OR = 4.65; 95% CI: 1.08-19.96) and longer surgical time (OR = 1.014; 95% CI: 1.003-1.025) were independent risk factors for urinary leak. Higher pelvis diameter (OR = 0.93; 95% CI: 0.87-0.99) and the use of external stents were independent protective risk factors for urinary leak (OR = 0.09; 95% CI: 0.01-0.72). We have not found independent risk factors for redo-surgery in a multivariate logistic regression model. CONCLUSION: mini LP can be safely and effectively used to perform pyeloplasty in pediatric patients of all ages.

Incidence and risk factors for calcification after dextranomer/hyaluronic acid (Dx/HA) copolymer injection for vesicoureteral reflux.

INTRODUCTION: Since the first case of dextranomer/hyaluronic acid (Dx/HA) implant calcification in 2008, concern about the long-term sequelae of Dx/HA injection has been growing. According to previous reports, the incidence of Dx/HA calcification 4 years after injection would be around 2%. AIM: The primary aim was to estimate the incidence of Dx/HA implant calcification after endoscopic treatment of vesicoureteral reflux in pediatric patients. Secondary objectives were to establish risk factors and to perform a survival analysis after Dx/HA injection. STUDY DESIGN: Patients undergoing Dx/HA endoscopic injection from 2007 to 2014 were prospectively registered. The database included clinical, surgical and radiological outcomes. Patients that showed Dx/HA implant calcification during follow-up were compared to those who did not. Univariable and survival statistical analyses were performed. RESULTS: 30 implants calcified over 355 ureters endoscopically treated. Age at first treatment was lower in patients with implant calcification (2.4 ± 1.3 years vs 3.6 ± 2.5 years; p < 0.005). The risk of implant calcification was 8.45% (95% CI: 5.96-11.85%). Median follow-up was 7.6 years (IQR: 5.2-9.5). The incidence rate was 12.06 cases per 1000 ureters-year. The period of highest hazard of implant calcification was between 3 and 5 years after injection. The only risk factor related to implant calcification was the age at first injection: relative risk of implant calcification was 4.4 (95% CI: 1.6 to 12.4; p = 0.002) for patients first treated before the age of 3.5 years. DISCUSSION: The risk and the incidence rate of Dx/HA implant calcification were higher than previous data. The period of highest hazard and detection of implant calcification were consistent with previous reports. Patients first treated before the age of 3.5 had shorter survival time without implant calcification. These are the first data about risk factors and survival function of Dx/HA implant calcification. However, our conclusions about the clinical significance of Dx/HA implant calcification were limited because the patients with implant calcification were asymptomatic. Further studies with larger sample and longer follow-up should confirm the clinical significance and life-long tendency of Dx/HA implant calcification. CONCLUSIONS: The risk and the incidence rate of Dx/HA implant calcification were higher than expected. The hazard of calcification was higher between 3 and 5 years after injection. The risk was especially higher in patients treated before the age of 3.5. Caution should be taken not to confuse implant calcifications with ureteric stones. A 5-year follow-up would set a better understanding of the actual incidence and clinical significance of implant calcification.

Value of supranormal function on 99m Tc-mercaptoacetyltriglycine renal scan in paediatric patients with obstructive hydronephrosis.

OBJECTIVES: To study related factors and clinical significance of supranormal function in paediatric patients with pelvi-ureteric junction obstruction, and to predict which factors cause renal function overestimation. PATIENTS AND METHODS: Patients who underwent pyeloplasty from 2012 to 2017 were prospectively collected. Variables were compared between patients with and without supranormal function on 99m Tc-mercaptoacetyltriglycine renal scan (supranormal defined as differential renal function [DRF] ≥55%). Univariate, multivariate logistic and linear regressions analyses were performed. RESULTS: Of 100 patients, 18 were excluded because of comorbidities. Nine patients (11.5%) showed preoperative supranormal function. The preoperative anteroposterior pelvic diameter (APD; 24 mm vs 35 mm, P = 0.026) and the ratio between preoperative pelvic and kidney volumes (0.2 vs 0.6, P = 0.003) were higher in supranormal kidneys. For each unit increase in the preoperative ratio between pelvic and kidney volumes, the risk of supranormal function rose 3.23-times (95% confidence interval [CI] 1.051-9.955). A preoperative APD ≥30 mm was a reliable predictor of supranormal function (area under the curve 0.804, 95% CI 0.707-0.902), with 88.9% sensitivity. Patients with either preoperative supranormal function or preoperative APD ≥30 mm had a greater reduction in renal function after pyeloplasty. CONCLUSION: Supranormal function is related to large hydronephrosis where geometrical features are modified. A preoperative APD ≥30 mm is a reliable predictive factor of supranormal function. Preoperative renal function is overestimated either in supranormal patients or severe hydronephrotic kidneys. DRF should be interpreted with caution in kidneys with large hydronephrosis with or without supranormal function. Surgical indication should not entirely rely upon DRF.

Postoperative vesicoureteral reflux after high-pressure balloon dilation of the ureterovesical junction in primary obstructive megaureter. Incidence, management and predisposing factors.

OBJECTIVE: To describe the incidence, predisposing factors and management of postoperative vesicoureteral reflux (VUR) after high-pressure balloon dilation to treat primary obstructive megaureter (POM). MATERIALS AND METHODS: We have reviewed patients that underwent endoscopic treatment for POM from May 2008 to November 2013. All patients were evaluated with renal ultrasound, voiding cystourethrography and diuretic renogram. Endoscopic treatment was done with high-pressure balloon dilation of the ureterovesical junction under general anesthesia; a double-J stenting was done in all patients. Follow-up was performed with ultrasonography, voiding cystourethrography and a diuretic renogram in all patients. RESULTS: Fifteen boys and five girls with a mean age of 14.18 months (3-103) were reviewed. A total of 22 ureters underwent HPBD to treat POM. Ureterohydronephrosis improves in 19 ureters. After endoscopic treatment, six ureters developed VUR. Four ureters were managed surgically, and in the other two, VUR disappeared in a second cystogram. The presence of parameatal diverticulum in the preoperative cystography and those patients with bilateral POM are factors related to postoperative VUR (p < 0.05). Urinary tract infection after HPBD was observed in four patients, but only one of them was affected with VUR.

Anderson-hynes pyeloplasty in patients less than 12 months old. Is the laparoscopic approach safe and feasible?

PURPOSE: The aim of our study is to compare the outcomes of open and laparoscopic pyeloplasty in children less than 12 months of age. PATIENTS AND METHODS: We reviewed all medical charts of patients less than 12 months old who underwent pyeloplasty from January 2007 to February 2013. We divided them in two groups: Open pyeloplasty (OP) and laparoscopic pyeloplasty (LP). The following data were analyzed: age, sex, weight, US measurements, operative time, hospital stay, complications, and success rate. Quantitative data were analyzed with the Student t test or Mann-Whitney U test, and chi-square test or Fisher test for qualitative data. RESULTS: Fifty-eight patients (46 boys and 12 girls) with a mean age of 4.66 months (±3.05) were included. Mean age was 4.25 months and 5.15 months in OP and LP group respectively. Mean weight was 6.78 kg and 7.02 kg in OP and LP groups. There were no statistical differences in age, weight, and sex between OP and LP groups. There were no statistical differences in preoperative ultrasonography measurements. Mean posterior-anterior (PA) pelvis diameter was 28.57 mm and 23.94 mm in OP and LP groups, respectively. Mean calices diameter were 10.86 mm and 10.96 mm in OP and LP groups, respectively. Mean operative time was 129.53 minutes in the OP group and 151.92 minutes in the LP group with statistical differences (P=0.018). Mean hospital stay was 6.34 days in the OP group and 3.46 in the LP group with statistical differences (P<0.05). No intraoperative and postoperative complications were found in either group. Hydronephrosis improved in all patients, and no patient needed a repeated pyeloplasty. CONCLUSION: The laparoscopic approach of Anderson-Hynes pyeloplasty in patients less than 12 months old is a safe procedure with the same outcomes as the open approach.

Transitional cell carcinoma of the bladder in children and adolescents: six-case series and review of the literature.

OBJECTIVE: Lower urinary tract tumours are uncommon in paediatrics. Transitional cell carcinoma of the bladder (TCCB) is rarely found in the first two decades of life and is exceptional under 10 years of age. The present series aimed to expand the number of reported cases in the literature. PATIENTS AND METHODS: In 1984-2007, six patients (four male, two female), aged 6, 9, 12, 13, 14 and 17 years, were treated at our centre. Clinical presentation was macroscopic haematuria in five and pyelonephritis in one. Physical examination, laboratory analysis, ultrasound and cystoscopy were performed before surgical treatment in all patients. Follow up was by clinical and ultrasound assessment. RESULTS: Neither physical examination nor laboratory analysis revealed any significant abnormalities, but ultrasound showed exophytic intravesical lesions. Surgical resection was performed endoscopically. Histological studies showed grade I TCCB in all cases. The immediate postoperative period was uneventful and long-term follow up did not reveal recurrence. CONCLUSION: Despite its low incidence in children, TCCB must be suspected in the event of macroscopic haematuria. Ultrasound followed by cystoscopy are the ideal diagnostic tools for visualization of these tumours. Endoscopic resection proved effective in all the present cases. Follow up must be clinical with periodic ultrasound evaluation. Urine cytologic examination is ineffective. Periodic cystoscopy is indicated only in cases of clinical or ultrasonographic suspicion of recurrence.

Heminephroureterectomy for duplex kidney: laparoscopy versus open surgery.

OBJECTIVE: To report our experience of laparoscopic heminephroureterectomy (Hnu) in pediatric patients with duplex anomalies, in comparison to open surgery. PATIENTS AND METHODS: Retrospective review of data from patients who underwent Hnu from 2005 to 2008 was performed. The patients were divided into two groups: laparoscopic (LHnu) and open surgery (OHnu). Laparoscopic surgery was performed by transperitoneal approach in majority of cases. Open surgery was performed by retroperitoneal approach in all cases. RESULTS: Group LHnu: nine patients (8 females, 1 male) with median age of 14 months (range 3-205). Transperitoneal approach was performed in eight patients. Mean operative time was 182 min (CI 95% 146-217). No conversion to open surgery was necessary and there were no complications. Mean hospital stay was 2.44 days (CI 95% 1.37-3.52). Group OHnu: eight patients (3 females, 5 males) underwent nine heminephrectomies at median age of 6.9 months (range 1-12). Mean operating time was 152 min (CI 95% 121-183). There were no complications and mean hospital stay was 4.38 (CI 95% 2.59-6.16) days. Statistical analysis showed no statistically significant difference (P>0.05) in operating time between groups while mean hospital stay was significant (P=0.021). CONCLUSION: The laparoscopic approach is feasible, safe, reduces hospital stay, does not increase operating time and has better cosmetic results. We believe this should be the first option for heminephrectomy.

Urinary and gastrointestinal malakoplakia in a 12-year-old girl.

Malakoplakia is a rare chronic inflammatory disease that was originally described in the urinary bladder but can involve many other organs and soft tissues. It is believed to be caused by an alteration in the bacterial phagocytic system. Clinically, it is described as single or multiple tumors that can appear in any part of the body. Histologically, the presence of Michaelis-Gutmann bodies is pathognomonic. Malakoplakia in children is rare. Few pediatric cases in the urinary tract, kidney, or gastrointestinal tract have been published. We present a case of urinary and gastrointestinal malakoplakia in a 12-year-old girl.

Median raphe cysts of the perineum in children.

Median raphe cysts of the perineum are uncommon congenital lesions of the male genitalia. They can be found all the way from the distal penis and scrotum toward the perineum in a midline position. They are considered as congenital alterations in embryologic development. A case of a 6 year-old boy is presented. Review of the literature relevant to children was made regarding the embryologic, diagnostic, and treatment aspects. We believe it is important that adult and pediatric urologists recognize these lesions and their management to provide the appropriate information to the parents.

Bronchial complication of a closed-tube endotracheal suction catheter.

Iatrogenic bronchial complications in intubated premature infants are rare. The authors present one case of rupture of a closed-tube endotracheal suction catheter. Clinical presentation was a persistent pneumothorax that required chest tube placement in several days. A foreign body was confirmed in x-ray and computed tomography (CT) scan. Flexible bronchoscopy showed a piece of catheter in the left bronchus and using a rigid bronchoscope was possible to remove. No perforation was found. There are a few reports in the literature of iatrogenic bronchial complication in premature infants caused by closed-tube endotracheal suctioning catheters. Endobronchial rupture of this catheter has never been reported.