Redo Laparoscopic Pyeloplasty in Infants and Children: Feasible and Effective.

Purpose: To determine the feasibility and effectiveness of redo laparoscopic pyeloplasty among patients with failed previous pyeloplasty, specifically examining rates of success and complications. Materials and Methods: We retrospectively reviewed the charts of all patients, who underwent redo laparoscopic pyeloplasty from 2006 to 2017. This included patients who underwent primary pyeloplasty at our institution and those referred for failures. Analysis included demographics, operative time, complications, length of hospital stay, complications, and success. Success was defined as improvement of symptoms and hydronephrosis and/or improvement in drainage demonstrated by diuretic renogram, especially in those with persistent hydronephrosis. Descriptive statistics are presented. Results: We identified 22 patients who underwent redo laparoscopic pyeloplasty. All had Anderson-Hynes technique except two cases in which ureterocalicostomy was performed. Median (IQR) follow-up was 29 (2-120) months, median time between primary pyeloplasty and redo laparoscopic pyeloplasty was 12 (7-49) months. The median operative time was 200 (50-250) min, and median length of hospital stay was 3 (2-10) days. The procedure was feasible in all cases without conversion. During follow-up, all but two patients demonstrated an improvement in the symptoms and the degree of hydronephrosis. Ninety-one percent of patients experienced success and no major complications were noted. Conclusions: Redo laparoscopic pyeloplasty is feasible and effective with a high success rate and low complication rate.

The effect of the body mass index on the types of urinary tract stones.

OBJECTIVES: Urinary tract stones are a common public health problem worldwide. In addition, identifying the composition of stones is important for the further metabolic evaluation of patients. We conducted this study to further correlate the relationship between body mass index (BMI) and different compositions of urinary tract stones. MATERIALS AND METHODS: A retrospective study of 433 patients who underwent urinary tract stone analysis via Fourier-transform infrared spectroscopy at King Khalid University Hospital in Riyadh from May 2015 to June 2017 was performed. Their BMI at the time of stone analysis was recorded. RESULTS: A total of 433 stones were analyzed by the statistical data analysis software. The BMI was classified according to the WHO classification. We divided our patients into seven age groups. Most patients were between the age group of 35 and 44 years and were overweight. The incidence of calcium oxalate, carbonate apatite, and uric acid stones was higher in patients with a BMI above thirty than in patients with a lower BMI. However, cystine stones were more common in normal-weight patients. CONCLUSIONS: In this study, we found that the incidence of certain types of stones, such as calcium oxalate, cystine, and uric acid stones, in Saudi Arabia can be predicted by BMI measurement.

Role of duration of catheterization and length of hospital stay on the rate of catheter-related hospital-acquired urinary tract infections.

OBJECTIVE: Our aim is to prove that duration of catheterization and length of hospital stay (LOS) are associated with the rate of hospital-acquired urinary tract infections (UTI), while taking into account type of urinary catheter used, the most common organisms found, patient diagnosis on admission, associated comorbidities, age, sex, precautions that should be taken to avoid UTI, and comparison with other studies. METHODS: The study was done in a university teaching hospital with a 920-bed capacity; this hospital is a tertiary care center in Riyadh, Saudi Arabia. The study was done on 250 selected patients during the year 2010 as a retrospective descriptive study. Patients were selected as purposive sample, all of them having been exposed to urinary catheterization; hospital-acquired UTI were found in 100 patients. Data were abstracted from the archived patients' files in the medical record department using the annual infection control logbook prepared by the infection control department. The data collected were demographic information about the patients, clinical condition (diagnosis and the LOS), and possible risk factors for infection such as duration of catheterization, exposure to invasive devices or surgical procedures, and medical condition. RESULTS: There was a statistically significant association between the rate of UTI and duration of catheterization: seven patients had UTI out of 46 catheterized patients (15%) at 3 days of catheterization, while 30 patients had UTI out of 44 catheterized patients (68%) at 8 days of catheterization (median 8 days in infected patients versus 3 days in noninfected patients; P-value <0.05), which means that the longer the duration of catheterization, the higher the UTI rate. There was a statistically significant association between the rate of UTI and LOS: three patients had UTI out of 37 catheterized patients (8%) at 10 days LOS, while 42 patients had UTI out of 49 catheterized patients (85.7%) at 18 days LOS. The longer the LOS, the higher the UTI rate: LOS for each patient (median 18 days for infected patients versus 10 days for noninfected patients; P-value <0.05), and number of hospital-acquired catheter-related UTI (100 patients had UTI out of 250 catheterized patients, P=0.04). CONCLUSION: Reduction of the duration of catheterization and LOS of the patient have a positive impact in reduction of catheter-related UTI.

Laparoscopic retroperitoneoscopic nephrectomy and partial nephrectomy in children.

OBJECTIVES: The aim was to evaluate our experience in the retroperitoneal laparoscopic approach in total and partial nephrectomies in children. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients who underwent retroperitoneal laparoscopic total or partial nephrectomies performed in our center from 2004 to 2012. We looked at the demographic data, age at surgery, indication, operative time, surgical complications, conversion to open surgery and operative complications. RESULTS: Thirty-five total and six partial nephrectomies (upper pole) were performed. The mean age was 84 months (7-175). Vesicoureteric reflux, pelviureteric junction obstruction, and multicystic dysplastic kidney disease were the main underlying pathologies. The mean operative time was 158 min (60-280). There were no intraoperative complications (surgical and anesthetic), and no significant blood loss was observed. Conversion to open surgery was necessary in two cases caused by failure to progress due to difficult anatomy during the partial nephrectomies. No major postoperative complications were noted. The mean hospital stay was 2.5 days (1-5). A drain was used in 12 cases and was removed after a mean of 2 days. CONCLUSIONS: Laparoscopic retroperitoneoscopic renal surgery can be carried out safely and effectively in children. Still, this procedure is more challenging and requires an excellent image of the retroperitoneal space, especially when partial nephrectomies are concerned.

Hospital acquired blood stream infection as an adverse outcome for patients admitted to hospital with other principle diagnosis.

BACKGROUND: Hospital acquired infections (HAI) have emerged as an important public health problem and are a leading cause of morbidity and mortality worldwide. They affect both developed and resource-poor countries and constitute a significant burden both for the patient and for the health care system. Specific objectives in this study are assessment of HAI rate among patients admitted with other principle diagnosis, to identifying the causative agents of hospital acquired infections and to identify some possible risk factors associated with each type of infection, both health related and non-health related. PATIENTS AND METHODS: The study was done on selected diagnosis groups during year 2010. The infections were found among 250 patients (43.6% males) have been exposed to episodes of infections. Median age of patients was 56. Data were abstracted from the archived patients' files in medical record department using the annually infection control log-book prepared by the infection control department. The Data collected were demographic information about the patients (age and sex), clinical condition (diagnosis and the length of hospital stay) and possible risk factors for infection as smoking, diabetes mellitus, hypertension and exposure to invasive devices or exposure to surgical procedures. RESULTS: Liver diseases 22.8%, cardiac diseases 22.8%, Gastro-Intestinal System diseases 20%, urinary system diseases 13.6%, and endocrinal disorder 13.6% Prostate gland diseases 7.2%. Episodes of infections caused by 9 types of organisms divided into 47.2% for blood stream infection and 52.8% for other types. 66% acquired blood stream infection were exposed to central venous line. CONCLUSION: Most common type of HAIs was blood stream infections. Liver, cardiac diseases and gastro-intestinal diseased patients show more proportion of HAIs while urinary system and prostate disease patients show less proportion of HAIs. Gram negative bacilli were the most common organisms found in our study (60%).

Percutaneous nephrolithotomy in children: A preliminary report.

OBJECTIVES: The recurrence of pediatric nephrolithiasis, the morbidity of repeated open surgical treatment as well as our experience in percutaneous nephrolithotomy (PNL) in adult patients, all derived us to shift to PNL for managing renal stones >1.5 cm in pediatric patients. Our aim of this study is to evaluate the safety and efficacy of PNL in pediatric patients. MATERIALS AND METHODS: During the period of the month between May 2011 and April 2013, 38 children (47 renal units) underwent PNL for renal stones 1.5-5 cm in length. Patient demographics, stone characteristics, and clinical outcome were prospectively studied. Data of those who underwent conventional and tubeless PNL were compared. Median follow-up period was 12 months (range: 6-24). RESULTS: The median age at presentation was 8-year (range: 3-12). The operative time ranged from 30 to 120 min (median 90). Overall stone clearance rate was 91.5% after single PNL. The median hospital stay was 3 days. Auxiliary procedures were successful for the remaining 4 patients (nephroscopic clearance in one and shockwave lithotripsy in 3). Tubeless PNL was performed in 17 renal units with a comparable outcome to conventional ones. The perioperative complications were noted in 5/47 (10.6%) of all procedures (Clavien Grade II in 4 and Clavien Grade IIIa in 1) and were managed conservatively. CONCLUSIONS: Percutaneous nephrolithotomy for renal stones in pediatric patients is safe and feasible if performed by a well-experienced endourologist. Tubeless PNL is a better choice for children.

Uronephrological outcomes of patients with neural tube defects. Does a spina bifida clinic make a difference?

OBJECTIVE: To review the uronephrological outcomes of myelomeningocele (MMC) patients attending a Spina Bifida Clinic. METHODS: We retrospectively reviewed the medical records of all patients from the combined Spina Bifida Clinic, at King Khalid University Hospital, Riyadh, Saudi Arabia between 1999 and 2009 who had at least one year of follow-up with us. We examined their demographic data, uronephrological status at presentation, most recent follow-up, and the rate of surgical intervention. RESULTS: During the 10-year period, 188 patients were actively followed-up. The mean age at presentation was 5.3 years +/- 3.6 SD. At their last follow-up, 109 patients (58%) were using clean intermittent catheterization, 44 (23%) had received Botox injections, and 26 (14%) had undergone bladder reconstruction. Most (66%) patients were older than 3 years when they presented to us; this group had a significantly higher rate of surgical intervention (Botox or reconstruction) compared with those who came to us earlier (p=0.003 for patients receiving Botox injections, and p=0.025 for patients undergoing bladder reconstruction). CONCLUSION: Our multidisciplinary Spina Bifida Clinic is an integral part of MCC management to reach a safe urological outcome. Early presentations to our clinic resulted in a lesser need for surgical intercession compared with those who presented at more than 3 years old.

Outcome of prenatally detected bilateral higher urinary tract obstruction or megacystis: sex-related study on a series of 709 cases.

OBJECTIVE: To compare the sex specific outcome of fetuses with prenatally detected urinary tract dilatation, with the exclusion of pyelectasia. METHOD: Included in the study were 709 cases of major dilatation of the fetal urinary tract, diagnosed at routine ultrasound scan. For each sex group, cases were divided into two subgroups depending on the level of dilatation. Final diagnosis was based on postnatal evaluation or on fetal autopsy. Postnatal renal function was evaluated using serum creatinine at two years of age. RESULTS: Bilateral higher urinary tract dilatation was prenatally observed in 148 (20.8%) and lower urinary tract obstruction or bladder dilatation in 561 (79.1%) of the 709 cases (121 female and 588 male fetuses) (P <0.001). Bladder dilatation was less frequent in female fetuses (62%) than in males (82.6%) (P <0.001). At final diagnosis, associated malformations were observed in 53.7% of female fetuses versus 11% in males (P <0.001). The survival rate was 42.7%. Postnatal renal function, evaluated in 289/303 live infants, was impaired in 29.7% of cases and depended on the level of obstruction, but not on the sex. CONCLUSION: Prenatally detected urinary tract dilatation has a poor prognosis both in male and female fetuses. Associated malformations are observed more frequently in female than in male fetuses.

Laparoscopic orchidopexy: the easy way to go.

BACKGROUND/PURPOSE: Intraabdominal testes represent less than 10% of cryptorchid testicles, and yet, they are the most challenging to correct. In the last 15 years, the two-stage Fowler-Stephens orchidopexy has gained popularity. The traditional approach includes laparoscopic or open clipping of the testicular vessels (first stage) and open inguinal orchidopexy (second stage). We present our experience with 2-stage orchidopexy with both stages done through a laparoscopic approach. MATERIALS AND METHODS: Over a recent 5-year period, we reviewed patients operated for intraabdominal testis using a two-stage laparoscopic orchidopexy with a minimum of 1-year follow-up. In this study, success is defined as a nonatrophic, intrascrotal testis. Fifteen patients met the inclusion criteria, and none were lost to follow-up. RESULTS: In the 15 patients, 11 had a unilateral intraabdominal testis, and 4 had bilateral cryptorchidism, with one of the 2 testes intraabdominal. The first stage was done at a mean age of 32 months, and the average time between the two stages was 9.7 months. All procedures (31) were done on an outpatient basis. Only 2 complications occurred, one scrotal hematoma and one redo first stage because of unsuccessful clipping noted at the time of planned second stage. The success rate is 93.3% (14/15). All testicles are intrascrotal, and all but 1 have maintained preoperative volume. CONCLUSION: Two-stage laparoscopic orchidopexy is a fairly easy surgical procedure with minimum morbidity and high short term success rate. A larger cohort of patients with long-term follow-up is needed to substantiate these findings.

Acceptance and compliance of clean intermittent catheterization among Saudi patients.

OBJECTIVE: To determine the applicability, acceptance, and compliance of the option of clean intermittent catheterization CIC when needed by patients in our society. METHODS: We retrospectively reviewed the files of all patients for whom CIC was conducted at King Khalid University Hospital and Security Forces Hospital, Riyadh, Saudi Arabia, between 1998, and 2006. We considered primary pathology, indication of CIC, age at CIC initiation, and who administered the CIC. We also documented the acceptance and compliance levels of the procedure by the patient over time. RESULTS: We included 280 patients, of which 118 (42%) were female and 162 (58%) were male in this study. The main pathology was myelodysplasia in 196 (70%) patients, posterior urethral valve in 52 (18.6%) patients, and non-neuropathic bladder sphincter dysfunction in 32 (11.4%) patients. The mean age was 6.49 +/- 4.25 years. Two hundred and fifty-seven (91.7%) families and their children accepted the idea of CIC, and 248 (88.6%) continued with the CIC program. Mothers were responsible for carrying out the procedure in 204 (72.9%) patients. However, in 76 (27.1%) cases, the patient was doing the procedure independently and the average age for a child to master the technique was 8 years. During the last 3 years, an urotherapist took over the educational services and performed outpatient education instead of our previous inpatient education. CONCLUSION: Clean intermittent catheterization is an appropriate method of treatment for our group of patients. They showed excellent acceptance of and compliance with the procedure, however, we suggest that for complete success, proper education, teaching, and follow-up should be conducted.

Urofacial syndrome.

The urofacial or Ochoa syndrome is a rare disease. We report on 2 patients of middle-eastern origin, with a review of the current literature to further document the existence of this syndrome, and to increase the general awareness of the classical facial characteristics, which facilitates diagnosis.

Botulinum-A toxin: solo treatment for neuropathic noncompliant bladder.

PURPOSE: We investigated whether botulinum-A toxin is better used alone or in conjunction with oxybutynin chloride in the management of refractory neuropathic bladder. MATERIALS AND METHODS: Between March 2004 and February 2006 a total of 23 children (mean age 5.6 +/- 2.5 years) with neuropathic bladder refractory to medical treatment underwent cystoscopic treatment with botulinum-A toxin. Patients were randomly assigned postoperatively using closed envelopes (blind randomization) into 2 equal groups. Group 1 (12 patients) continued to receive anticholinergics while in group 2 (11 patients) anticholinergics were discontinued. Clinical and urodynamic evaluations were performed before injection, and at 1 and 6-month intervals. Patients were then followed every 6 months with urodynamic study. The outcomes were compared between groups with a paired t test (2-tailed) and a significant p value <0.025. RESULTS: Maximum bladder capacity increased from 96 +/- 67 (range 15 to 277) to 163 +/- 96 ml (range 50 to 500, p <0.001) and 142 +/- 65 ml (range 21 to 250, p <0.006) at 1 and 6 months, respectively. Maximal detrusor pressure decreased from 76 +/- 36 (range 36 to 209) to 50 +/- 22 cm H2O (range 20 to 100, p <0.001) and 51 +/- 21 cm H2O (range 18 to 104, p <0.001) at 1 and 6 months, respectively. From a clinical point of view 9 of the 16 incontinent patients (56.2%) showed complete continence after treatment while 4 (25%) reported mild to moderate improvement and 3 (18.8%) showed no improvement. None of the patients had side effects related to the procedure or the material used. CONCLUSIONS: We confirmed the beneficial use of botulinum-A toxin for the treatment of refractory neuropathic bladder and have not yet found any augmentative effect of oxybutynin chloride in this study group. Accordingly we can use such a modality as sole treatment for noncompliant neuropathic bladder.