An Analysis of Major Causes of Surgical Failure Using Bähren System in Intraoperative Venography During Varicocelectomy.

PURPOSE: In young patients with varicocele, preservation of the internal spermatic artery may be advantageous for catch-up growth, but it may also increase the likelihood of treatment failure. Intraoperative venography reduces the likelihood that unsealed veins will remain after varicocelectomy. We analyzed the characteristics of remnant veins visualized through intraoperative venography to investigate the cause of surgical failure in artery-sparing varicocelectomy (ASV). MATERIALS AND METHODS: We retrospectively analyzed clinical characteristics and outcomes of patients aged 18 years or younger who underwent varicocelectomy with intraoperative venography from January 2005 to December 2017. During varicocelectomy, intraoperative venography was performed to distinguish veins from other structures. Any unsealed veins that were discovered were ligated and classified using the Bahren system. RESULTS: One hundred and sixty-two patients underwent intraoperative venography: 153 cases (94.4%) were for primary varicocelectomy, and 9 cases (5.6%) were for repeat varicocelectomy. Open varicocelectomy was performed in 105 cases (64.8%), and laparoscopic varicocelectomy was performed in 57 cases (35.2%). Venography revealed remnant veins after the first ligation in 51 cases (31.2%), 46 (90.2%) and 5 (9.8%) of which were Bähren types 3 and 4, respectively. Five patients (3.1%) experienced varicocele recurrence, classified as persistence in 1 patient (0.6%) and relapse in 4 patients (2.5%). CONCLUSION: Remnant collateral veins of the internal spermatic vein (ISV) (Bahren type 3) are the most common cause of failure in ASV. In a few patients, an external spermatic vein merges with the ISV at a higher level (Bahren type 4) and is unidentifiable without venography.

Transurethral incision as initial option in treatment guidelines for ectopic ureteroceles associated with duplex systems.

PURPOSE: Treatment strategies for children with ectopic ureteroceles (EUs) and duplex collecting systems or vesicoureteral reflux are controversial. Transurethral incision (TUI) of EUs associated with duplex systems has been considered only as a temporizing technique. This study aimed to evaluate whether primary TUIs could be considered as an initial treatment option in EUs with duplex systems. MATERIALS AND METHODS: Forty-seven children with EUs associated with duplex systems underwent primary TUIs at our institution between November 2007 and October 2017. We retrospectively analyzed patient characteristics such as age, sex, upper tract status, ureterocele location, differential renal function, and preoperative vesicoureteral reflux with regard to postoperative complications requiring additional surgery, postoperative incontinence, and renal function. RESULTS: The mean age at operation was 4.8 ± 4.7 months. Of the 47 patients, 26 (55.3%) underwent primary TUIs only, 3 (6.4%) underwent secondary TUIs, and 18 (38.3%) underwent other secondary procedures such as common-sheath reimplantation (CSR) and ureterocelectomy. Secondary surgeries in 21/47 (44.7%) patients occurred during a mean follow-up of 47.7 ± 23.3 months, and the most common type of secondary surgery was CSR. The most common reason for secondary surgery was febrile urinary tract infection (14/21 patients [66.7%]). There were three cases (3/26 [11.5%]) of voiding problems after primary TUI and two cases (2/15 [13.4%]) after secondary CSR. CONCLUSIONS: Primary TUIs should be considered as initial treatment options for EUs in duplex systems and not just a temporizing technique.

Efficacy and safety of mirabegron, a ß3-adrenoceptor agonist, for treating neurogenic bladder in pediatric patients with spina bifida: a retrospective pilot study.

PURPOSE: Antimuscarinics are the first pharmacological treatment option for neurogenic bladder in children with spina bifida but side effects limit their use. Mirabegron, a new ß-3 adrenoceptor agonist with a distinct mechanism of action, is a potential agent for the treatment of neurogenic bladder; however, it has yet to be studied in the pediatric population. This study evaluated the efficacy and safety of mirabegron for treating neurogenic bladder in children with spina bifida. MATERIALS AND METHODS: Clinical and urodynamic parameters were retrospectively studied in 66 children (under 18 years of age) with spina bifida who were treated for neurogenic bladder with mirabegron at Severance Children's Hospital between July 2015 and December 2017. Pediatric patients received 50 mg mirabegron daily for at least 6 weeks either in addition to or instead of antimuscarinic therapy. Urodynamic parameters, including compliance, involuntary detrusor contraction, and maximum cystometric capacity, as well as patient-reported efficacy and adverse events, were measured. RESULTS: In both groups post-treatment, incontinence significantly improved. In addition, maximum cystometric capacity and compliance significantly increased post-treatment. Six patients reported side effects (constipation, 4.5%; headache, 3.0%; and hypertension, 1.5%) and three patients discontinued treatment. CONCLUSION: We evaluated the efficacy and safety of mirabegron for treating neurogenic bladder in pediatric patients with spina bifida. All clinical and urodynamic parameters improved with treatment. Prospective, placebo-controlled studies are necessary to confirm these findings.

The risk factors and clinical significance of acute postoperative complications after unstented pediatric pyeloplasty: a single surgeon's experience.

PURPOSE: To analyze the risk factors and clinical significance of postoperative complications after unstented pediatric pyeloplasty. MATERIALS AND METHODS: We analyzed 285 kidney units (KUs) on which unstented pyeloplasty was performed between April 2002 and March 2010. Measures included preoperative factors, postoperative complications, change in postoperative differential renal function (DRF), and failure of pyeloplasty. Risk factors for acute complications requiring additional ureteral stenting and decreased DRF were analyzed. RESULTS: During a median follow-up period of 67.0 months, an additional ureteral stenting was required in 28 KUs (9.8%) due to the development of acute postoperative complications after unstented pyeloplasty. The incidence of complications increased significantly as preoperative DRF increased. DRF of more than 60% was the only independent risk factor for acute complications. Postoperative decrease in DRF was observed in 58 KUs (22.4%) among 259 KUs analyzed. Pyeloplasty failure was observed in 10 KUs (3.5%). The development of acute complications was not a risk factor for a decrease in DRF or pyeloplasty failure. CONCLUSIONS: Urinary diversion during pyeloplasty is not related to a decrease in DRF or pyeloplasty failure. However, in patients with a preoperative DRF of greater than 60%, diversion could be considered due to the high prevalence of complications.

A modified technique for ureteral reimplantation: intravesical detrusorrhaphy.

PURPOSE: To describe the surgical procedure of intravesical detrusorrhaphy, a modified technique of ureteral reimplantation, and report our initial experience. METHODS: From October 2007 to March 2012, 55 children with vesicoureteral reflux (VUR) and 13 children with obstructive megaureter (OM) underwent intravesical detrusorrhaphy. All surgical procedures were performed via an open intravesical approach. The ureter was mobilized, and the bladder mucosa was separated from the detrusor in a cephalad direction. The separated detrusor was incised vertically and repaired underneath the mobilized ureter to create the submucosal tunnel. The ureteral orifice was anastomosed to its orthotopic position. RESULTS: Of 31 patients treated with bilateral intravesical detrusorrhaphy, no patient had postoperative urinary retention. Follow-up voiding cystourethrography was performed in 45 patients with 72 reimplanted ureters. VUR was resolved in 41 patients (91.1%) with 68 ureters (94.4%). Among 13 patients with 14 ureters treated for OM, hydroureteronephorosis improved in 11 patients (84.6%) with 12 ureters (85.7%). CONCLUSIONS: Intravesical detrusorrhaphy is modified technique of ureteral reimplantation, which recreates the neo-ureteric orifice in the orthotopic position and does not produce postoperative urinary retention in bilateral cases. Intravesical detrusorrhaphy is safe and effective in treating patients with VUR or OM.