Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric patients with chronic and life-limiting conditions and neuropathic bladders.

Introduction: Lower urinary tract dysfunction (LUTD) in cerebral palsy (CP) and other neuromuscular diseases can present with chronic retention that leads to hydronephrosis, recurrent urinary tract infections (UTI), and stone formation. Whenever the conservative treatment of LUTD fails for any reason, it is considered to be complicated LUTD, in which a surgical approach is warranted. Cutaneous vesicostomy (CV) is a simple, well-tolerated, and potentially reversible procedure that protects the upper tracts. We describe our experience using CV for this complex population. Materials and methods: Children with CP and other neuromuscular diseases admitted to pediatric long-term care units for palliative care between 2015 and 2019 were included in the study. They present multi-system involvement, polypharmacy, and Gross Motor Function Classification System levels of 4 or 5. We retrospectively studied this population's indications and results of CV. Results: Of the 52 admitted patients, 18 presented LUTD with UTI (n:18; 100%), stones (n:5; 28%), progressive hydroureteronephrosis (n:3; 17%), or stones (n:2; 11%). Conservative initial management (catheterizations, prophylaxis antibiotics) was effective in half the cases. The remaining nine were defined as complicated LUTD and underwent CV. After a mean follow-up of 11.3 months, the follow-up showed improved hydronephrosis in all nine (100%) patients. Recurrent UTIs were no longer seen in eight of nine patients, although three patients required bladder irrigations; bladder stones did not recur after CV; the kidney stones needed further intervention. Revision of the CV was required in two (11%) cases at 12 and 24 months postoperatively due to stoma stenosis. Conclusion: CV is a relatively simple and effective procedure representing a pragmatic solution for managing complicated LUTD in complex long-term institutionalized pediatric palliative care patients with neuropathic bladders.

An unusual case of ureteric stricture post robotic partial nephrectomy of a renal mass managed by Memokath insertion.

Robotic assisted partial nephrectomy is the gold standard treatment for small renal masses. Ureteric stricture is a rare but serious complication that significantly increase the morbidity and worsens the quality of life for cancer patients. Definitive treatment such as surgical reconstruction or ureteroureterostomy is not always feasible as in patients with significant morbidity or high-risk patients. Other options include ureteric double J stent or nephrostomy tube placement with regular exchange. We present a case of iatrogenic upper ureteric stricture post robotic assisted partial nephrectomy for right renal mass that was discovered on postoperative follow up imaging treated with metallic ureteral stent (Memokath) as reconstructive surgery was difficult due to proximity to the tumor bed. We found that if reconstructive surgery is not feasible, metallic ureteral stents has good durability, better quality of life than ureteric double stents for the management of ureteric stricture.

Early vs delayed insertion of penile prosthesis in patients with refractory priapism: a systematic review and meta-analysis.

INTRODUCTION: Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking. OBJECTIVES: To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED). METHODS: We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model. RESULTS: We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group. CONCLUSION: The results from this study favor an early approach to ED (within 30 days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.

Isolated Trapezoid Fracture in Adolescent Goalkeepers: A Scoping Review of the Literature and a Report of Two Cases.

Purpose: Isolated trapezoid fractures are rare injuries, particularly among adolescents, constituting only 0.4% of all carpal bone fractures. This study aims to present two cases of isolated trapezoid fracture in adolescent goalkeepers and a scoping review of the literature to provide guidelines for the management of this injury. Methods: Following PRISMA-ScR guidelines, a scoping review of reported cases was conducted. Two hundred and twenty articles were found using PubMed and Google Scholar. After full-text review, a total of 30 cases from 22 articles along with our 2 cases were analyzed based on demographics, injury mechanism, method/timing of diagnosis, prognosis, and time to recovery. Results: Thirty-two reported cases of trapezoid fractures with a mean age of 26.7 years (75% male) were found, with pain as the most common presenting symptom. A majority (78%) had initial negative findings on radiography, and the diagnosis was primarily established through computed tomography (59%; n = 19) or magnetic resonance imaging (50%; n = 16). There was a substantial delay in diagnosis (mean 26 days), primarily because computed tomography/magnetic resonance imaging was frequently ordered late. The majority of cases (78%) were managed conservatively, with immobilization periods ranging from 4 to 12 weeks. The average duration for full recovery was 4.5 months, with operative management taking 7.3 months and conservative management taking 3.5 months. Conclusion: Trapezoid fractures, though rare, are often not promptly diagnosed on initial plain radiographs, leading to a potential underreporting of cases. Because of the risk of complications associated with this type of injury, clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents. Further research and guidelines are needed to enhance our understanding and management of this uncommon injury in the future. Type of study/level of evidence: Differential diagnosis/symptom prevalence IIIb.

Plate Objective Scoring Tool (POST) in distal hypospadias: Correlation with post-repair complications.

OBJECTIVES: The Plate Objective Scoring Tool (POST) accurately reflects configuration of the urethral plate in distal hypospadias. Here we assessed whether POST score also correlates with patient risk of complications after surgical repair. METHODS: Data were obtained prospectively from pre-pubertal boys who underwent primary hypospadias repair between January 2020 and February 2023. Both POST and Glans-Urethral Meatus-Shaft (GMS) scores were determined in triplicate by three independent reviewers before evaluating correlation with complications after surgery. RESULTS: POST ratios were strongly correlated with incidence of post-repair complications in n = 121 patients. Mean POST score was 1.10 (range 0.5-1.62) and average GMS value was 5.29 ± 1.36 (median G = 2, M = 2, S = 1). Bivariate correlation analysis indicated that POST score can accurately predict risk of complications after surgery (Pearson correlation coefficient r = 0.821 [0.724-0.918], 95 % CI). A POST threshold of 1.2 provided the highest specificity for risk of post-operative complications, which occurred in 4.4 % of patients with POST score ≥1.2 (2/45 cases), compared with 25 % among patients with POST score <1.2 (19/76 cases). CONCLUSIONS: This study confirms that POST index can be used as a surrogate marker of urethral plate quality and accurately predicts the outcome of distal hypospadias repair. Objective scoring of POST revealed that low ratios were significantly associated with high risk of postoperative complications. In future, this approach could be used to stratify patients and better identify cases that require close follow-up care.

Urolithiasis-related ureteric intussusception: A rare case report.

Ureteral intussusception is a rare condition that historically occurs as a complication of ureteral neoplasms or iatrogenic endoscopic procedures. Although the exact mechanism of ureteral intussusception is unclear, most reported cases are due to leading points as malignant or benign masses. Urolithiasis related is rarely reported and can be challenging in stone management as it might decrease the spontaneous stone passage rate. In addition, it will increase the complexity of the endoscopic stone management. We present the second reported case of urolithiasis-related ureteric intussusception presented with urosepsis due to obstructive uropathy, successfully managed by an endourological approach.

Bilateral large cell calcifying Sertoli cell tumours: A testicular preservation approach in a young male.

Testicular Large cell calcifying Sertoli cell tumours (LCCSTs) are extremely rare. The primary challenge in benign LCCSTs, which are typically multifocal and bilateral tumours affecting young males, is to confirm the diagnosis to avoid radical intervention and preserve fertility potential. Patient clinical presentation, laboratory results, diagnostic radiological tests along with confirmatory histopathological studies, are the cornerstones in such cases, nevertheless genetic testing is warranted, as LCCSTs can be part of genetic syndrome such Carney complex. We present a case of bilateral benign LCCSTs in young male managed with testicular preservation approach with characteristic clinical, radiological and histopathological features.

Migrated Hem-o-lok clip in the bladder: A rare cause of bladder stone for cystolitholapaxy.

The bladder is the most common site of foreign bodies in the urinary tract. Most foreign bodies are self-inserted via the urethra due to exotic impulses, psychometric problems, or sexual curiosity. Here we present a rare case of bladder stones due to the migration of the Heme-o-lok clip. We present a case of a 76-year-old male with hematuria for 4 days. An abdominal computed tomography (CT) scan showed a 15 mm calculus noted in the urinary bladder. The patient underwent cystolitholapaxy which was successful. Foreign bodies inserted in the bladder pose a significant challenge and require timely intervention.

Recurrent urinary retention due to seminal vesicle cyst a report of rare entity.

Male pelvic cyst rarely causes symptoms; here, we are presenting a case of a 48-year-old gentleman who presented with acute urinary retention stemming from a pelvic cyst. This presentation has been recurrent despite undergoing repeated TRUS aspiration of the cyst to relieve the symptoms. We performed a robotic pelvic cyst excision with peritoneal window in an attempt to cure the patient. Based on the MRI and histopathology, it was likely a seminal vesicle cyst that is causing these recurrent episodes. On 3 months follow-up, the patient was symptom free without any complaints.

The role of Rezum in the management of refractory urinary retention due to benign prostate hyperplasia: A literature review.

Background: Benign prostatic hyperplasia is the most common cause of urinary retention in men (BPH). The gold standard surgical treatment is transurethral resection of the prostate (TURP). However, due to the morbidity and mortality associated with TURP, more minimally invasive treatments, such as vaporizing the prostate with the Rezum system, have been introduced. We investigated the efficacy of Rezum in the treatment of refractory urinary retention due to BPH in this review. Methodology and materials: To conduct this review, the Cochrane methodology for systematic reviews was used. All studies that used Rezum to treat catheter-dependent patients with enlarged prostates were included. The literature search showed 111 studies, 84 of which were excluded due to non-relevance based on titles and 18 due to lack of relevance based on abstract review. Full manuscripts were reviewed in nine studies, three of which were excluded because they did not meet the inclusion criteria. Results: This review included 301 patients in total. The rate of a successful trial of voiding post Rezum therapy was 85%. The complication rated between 3.8 and 4.3% all of which were mild and self-limited. As there was no major complication of Rezum (clavien dindo >2), the procedure-related morbidity is negligible. Conclusion: In this review, Rezum was found to be an efficacious and safe alternative in the treatment of refractory retention with mild complications and minimal morbidity.

Deep learning based automated quantification of urethral plate characteristics using the plate objective scoring tool (POST).

INTRODUCTION: The plate objective scoring tool (POST) was recently introduced as a reproducible and precise approach to quantifying urethral plate (UP) characteristics and guide to selecting particular surgical techniques. However, defining the landmarks mandatory for the POST score from captured images can potentially leads to variability. Although artificial intelligence (AI) is yet to be wholly accepted and explored in hypospadiology, it has certainly brought new possibilities to light. OBJECTIVES: To explore the capacity of deep learning algorithm to further streamline and optimize UP characteristics appraisal on 2D images using the POST, aiming to increase the objectivity and reproducibility of UP appraisal in hypospadias repair. METHODS: The five key POST landmarks were marked by specialists in a 691-image dataset of prepubertal boys undergoing primary hypospadias repair. This dataset was then used to develop and validate a deep learning-based landmark detection model. The proposed framework begins with glans localization and detection, where the input image is cropped using the predicted bounding box. Next, a deep convolutional neural network (CNN) architecture is used to predict the coordinates of the five POST landmarks. These predicted landmarks are then used to assess UP characteristics in distal hypospadias. RESULTS: The proposed model accurately localized the glans area, with a mean average precision (mAP) of 99.5% and an overall sensitivity of 99.1%. A normalized mean error (NME) of 0.07152 was achieved in predicting the coordinates of the landmarks, with a mean squared error (MSE) of 0.001 and a 2.5% failure rate at a threshold of 0.2 NME. DISCUSSION: Our results support the possibility of further standardizing UP assessment from captured hypospadias images, and the use of machine learning algorithms and image recognition shows that these novel artificial intelligence technologies are useful for scoring hypospadias. External validation can provide valuable information on the generalizability and reliability of deep learning algorithms, which can aid in assessments, decision-making and predictions for surgical outcomes. CONCLUSIONS: This deep learning application shows robustness and high precision in using POST to appraise UP characteristics. Further assessment using international multi-centre image-based databases is ongoing.

Congenital Methemoglobinemia in a 33-Year-Old Patient: A Case Report on a Rare Presentation and a Review of the Literature.

Cyanosis and dyspnea are common complaints in adults and have broad differential diagnoses, of which rare ones such as congenital methemoglobinemia should always be considered in the differential diagnosis. Methemoglobinemia might be acquired or congenital. Patients' symptoms vary from severe shortness of breath, mental status changes, and cyanosis to none. The diagnosis of congenital methemoglobinemia is challenging and requires high index of suspension, especially in older patients. In addition, when diagnosed the treatment of congenital methemoglobinemia is oral ascorbic acid which is readily available. We present a rare case of a 33-year-old lady, who had a long history of recurrent episodes of cyanosis, headache, and fatigue. After excluding cardiopulmonary causes, methemoglobin levels were measured and found to be high, and the chart review revealed high levels of methemoglobin in all her previous episodes, without exposure to any offending agent. This raised the concern of a late diagnosis of congenital methemoglobinemia. The patient was treated with a high dose of ascorbic acid resulting in resolution of the symptoms. Congenital methemoglobinemia is a rare diagnosis that needs a high index of suspicion, especially in adults. A thorough history, physical examination, and multiple laboratory tests are needed to confirm the diagnosis and rule out other causes.

Memokath for treating ureteric stricture post cryoablation of renal mass: A case report of rare complication and proposed alternative management.

The use of cryoablation in the management of small renal masses is widely acceptable. Although rare but ureteral injury during the procedure with subsequent stricture formation can result in devastating effects on renal function. On the other hand, the management of such strictures requires reconstructive surgery as gold standard. Unfortunately, in some cases the reconstructive surgery might not be feasible, and the treatment usually is ureteral stent insertion that need to be changed regularly. Here we present a case of a 53-year-old gentleman who developed an upper ureteric iatrogenic stricture post cryoablation in which the reconstructive surgery was not feasible due to high procedural risk. We used metallic ureteral stent (Memokath) instead of regular ureteral double J stent. We found that if the reconstructive surgery is not possible the usage of Memokath in treating iatrogenic ureteral strictures is associated with better quality of life, lower costs and a similar functional outcome when compared to ureteral double J stent that needs regular frequent changes.

Synchronous Bilateral Testicular Tumors With Discordant Histopathology: A Rare Case in an Infertile Male.

Testicular cancer, accounting for 1-1.5% of male malignancies, rarely presents bilaterally, with only 2-3% of cases being bilateral and a mere 10% being synchronous, typically sharing histological patterns in both testes. Discordant histological presentation is exceedingly rare, with only a few reported cases. In this report, we detail a case involving a 35-year-old infertile male with bilateral synchronous testicular tumors, each exhibiting different histopathologies. This case highlights the diagnostic intricacies and the necessity for tailored management in the face of such uncommon presentations. The implications of oncological treatment and fertility preservation significantly affect the patient's overall quality of life.

Urology Residents' Perspectives on the In-House On-Call Systems: A Study in an Accredited Academic Center.

INTRODUCTION: Medical education and training are crucial in maintaining patients' safety and improving patient care quality. Multiple studies have evaluated the effects of restrictive policies on the resident's quality of life and education. Due to the compiling data and the fact that these trials evaluated programs with a substantial number of residents, it remains uncertain whether these conclusions can be extended to urology programs with a small number of residents. Multiple on-call systems have been adopted in residency programs across the world. This study evaluated the residents' quality of life, clinical experience, and education upon transitioning from 24-hour to 12-hour in-house on-call systems. METHODS AND MATERIALS: In this observational and questionnaire-based study, the effect of the transition from 24-hour to 12-hour in-house on-call systems was compared in terms of the resident's quality of life and education, surgical case volume, and working hours' rules compliance. Quality of life and education: We adopted a validated survey based on a 5-point Likert scale to assess the residents' perception of the transition to a 12-hour on-call system on their quality of life and education. Surgical case volume: We extracted the number of cases the residents operated on from the operating theater database at our institution. Working hours: compliance and violations: The weekly working hours, compliance, and violations per ACGME-I rules were collected from the MedHub platform. RESULTS: Quality of life and education: Residents rated the 12-hour on-call system superior in terms of quality of life, education, and surgical case volume. Surgical case volume: There was a 45% increment in the surgical case volume (p = 0.04) with the 12-hour on-call system. Working hours: compliance and violations There was no significant difference in the mean weekly working hours (p = 0.1). However, the total number of duty hours violations decreased in the 12-hour on-call system. CONCLUSION: The 12-hour system is a better alternative to the 24-hour system in terms of the resident's quality of life, education, surgical case volume, and compliance with duty hour rules.

Metachronous bilateral spontaneous spermatic vein thrombosis: A rare cause of orchialgia.

Scrotal pain and swelling are common presentation, the prompt evaluation and diagnosis is needed due to wide range of causes, uncommon causes of orchialgia should be kept in mind whenever there is no clear diagnosis. Spermatic vein thrombosis usually presents with orchialgia along with episodes of acute exacerbation of pain. The diagnosis is challenging and need high index of suspension and detailed radiological evaluation. We present a case of metachronous bilateral unprovoked spermatic vein thrombosis treated conservatively with anticoagulation with good response and resolution of symptoms.

A Literature Review and Two Case Reports: Is Traumatic Dislocation of the Testes a Surgical Emergency?

Traumatic dislocation of the testes (TDT) is a rare sequela of blunt scrotal and perineal trauma. TDT can easily be overlooked during concomitant trauma due to other injuries, The damage to the testis appears to be not severe in dislocation and may be corrected by repositioning even if it is delayed. However, delayed intervention might be associated with pain and discomfort and may lead to abnormal sperm parameters and possible infertility. The urgency of surgical intervention increases whenever there is associated testicular torsion, rupture, or bilateral testicular TDT. We report two cases of unilateral traumatic testicular dislocation following motorcycle crashes with different presentations and approaches to treatment. We also engage in a review of the relevant literature.

Squamous cell papilloma a rare urinary bladder tumor, case report and operative video.

Bladder noninvasive squamous lesions are usually rare; here, we are presenting a case of 39 years old male patient with a benign squamous cell papilloma. The tumor grossly presented as cauliflower mass mimicking squamous cell carcinoma, while histologically, the tumor showed extensive keratinization at its surface and showed no nuclear atypia or stromal invasion. This tumor is benign and extremely rare. In this manuscript, we summarized a case of Squamous cell papilloma of the bladder with the first operative video for the transurethral resection of squamous cell papilloma with percutaneous management of associated urinary bladder stones.

Replacement Time of Custom Ocular Prosthesis in Children: A Review Article.

The aim and objective of this article is to analyze the published literature on the replacement time of ocular prostheses in children. A systematic search of Indexed English literature up to November 31, 2020, was conducted. Data from PubMed, Scopus, and Cochrane library were searched for relevant manuscripts. Predefined inclusion and exclusion criteria were used by assessors, who inspected 910 manuscripts and selected 7 manuscripts, after analyzing their full texts. Because of the constant growth of the orbital socket in children, the ocular prosthesis has to be replaced till the growth of the orbit is complete. Custom ocular prosthesis requires recurrent relining or replacement, in growing children. The rate of relining or replacement of the prosthesis varies according to the growth of the orbit. Children with ocular prostheses should be appointed biannually or quarterly for routine examination. Yearly replacement or relining of the prosthesis should be conducted. Various factors, like patient comfort, age, signs, and clinical assessment, should be evaluated before relining or replacing the old prosthesis. How to cite this article: Jain S, Idris KIA, Al Omar NEM, et al. Replacement Time of Custom Ocular Prosthesis in Children: A Review Article. Int J Clin Pediatr Dent 2021;14(4):558-561.