Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party.

INTRODUCTION: Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP). MATERIALS AND METHODS: The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP. RESULTS: A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb. DISCUSSION: This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder. CONCLUSIONS: Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

[Bilateral perinatal torsion of spermatic cord - a case report and literature review]. / Oboustranná perinatální torze semenného provazce - kazuistika a prehled literatury.

INTRODUCTION: Perinatal spermatic cord torsion represents a less common manifestation of spermatic cord torsion. In newborns, normal fixation between testicular coverings and tunica dartos is not yet well established, and abnormal testicular mobility results in extravaginal type of torsion. Salvage rate of testes after detorsion is low. Management of perinatal torsion still remains a controversial issue. Some authors refuse scrotal exploration as useless, their opponents recommend emergent bilateral surgical exploration for the protection of the healthy gonad. CASE STUDY: Authors report a case of a newborn who underwent scrotal exploration for clinical signs of the right-side perinatal torsion. The right completely necrotic testicle was removed. It was decided to fix the contralateral testis to prevent torsion. However, the exploration of the left testicle revealed ischemic damage corresponding to the asynchronous perinatal torsion after its spontaneous detorsion. The testicle was left (preserved) in scrotum and fixed. The follow-up then confirmed the loss of functional testicular tissue. This is the first case of bilateral perinatal torsion described in the Czech and Slovak literature. CONCLUSIONS: Perinatal spermatic cord torsion may result in a severe complication - bilateral testicular atrophy due to asynchronous torsion of the contralateral testicle. The authors demonstrate that in newborns physical examination and ultrasonography may be not sensitive enough for the assessment of the testis condition. In the light of the case study and literature reviewed they strongly recommend early bilateral scrotal exploration with preventive testes fixation to protect the healthy gonad.

Mycobacterium marinum epididymoorchitis: case report and literature review.

Mycobacterium marinum is the most frequent non-tuberculous Mycobacterium in humans. We report the first ever described case of epididymoorchitis resulting from hematogenous spread of M. marinum from hand oligoarthritis. This was initially mistaken for rheumatoid disease and methylprednisolone-induced immunosuppression led to hematogenous spread of infection to the testis and epididymis.

[Microsurgical subinguinal varicocelectomy in children and adolescents]. / Mikrochirurgická subingvinální varikokélektomie u detí a dospívajících.

BACKGROUND: Microsurgical varicocele repair has become the gold standard in adults and only a few reports are available in children and adolescents. We present our experience with this method and concentrate on the technical performance, complications and development of testicular size. METHODS AND RESULTS: 47 patients aged 11 to 18 years (x15.4) underwent microsurgical subinguinal repair for varicocele grade II.-III. Operation was indicated because of hypoplastic testicle (expressed by the atrophy index > 25%), pain, large varicocele or parents preference. The patients were examined clinically, by ultrasound including the Doppler study; hormonal examination was added using the gonadoreline stimulation test. Microscope has been used to identify the internal spermatic artery, to dissect the artery from the complex of small surrounding veins and to identify the lymphatic vessels. We found 3 recurrences in 46 patients (6%) operated for primary varicocele. The atrophy index decreased from x19.7 to 12.7%, without any association with pubertal stage. Atrophy of the testis was not found in any patient. Hydrocele was detected in one patient (2.1%), and left testicular hypertrophy also in one patient (2.1%). CONCLUSIONS: Microsurgical subinguinal varicocelectomy is a safe and efficacious method in children and adolescents; using the microscopic dissection, the internal spermatic artery and accompanying lymphatic vessels are safely spared.

[Long-term results of uretroplastic operations using buccal mucosa in different modifications]. / Dlouhodobé výsledky uretroplastik s pouzitím bukální sliznice v ruzných modifikacích.

BACKGROUND: Evaluation of long-term results of uretroplastic using buckle mucosa indicated in long and multiple strictures or after reconstruction of hypospadies is presented. METHODS AND RESULTS: 49 cases of uretroplastic with buccal mucosa graft were performed. 28 patients had complicated strictures after multiple endoscopic or reconstructive operations. Onlay uretroplastic was performed in 35 cases, including ventral graft placing in first 8 patients, afterwards dorsal grafts were performed in 27 patients. In 6 cases whole circumference of urethra was replaced in two steps. The length of buccal graft varied between 30 and 80 mm, aprox. 63 mm, duplex graft was used in 3 cases in max. length of 140 mm. In follow-up on an average 45 months (3-140 months) it has occurred 6 recurrences of stricture; the need of open reoperation was in 3 patients (12.3%), 2 relative restrictures were solved by optic urethrotomy (4%). The reoccurrences appeared after ventral onlay in 2 cases (25%), after the dorsal onlay also in two cases (7.4%), after two-steps uretroplastic there was 20% (2 cases) of the reoccurrence rate. Duplex graft uretrolastics were in all cases without complications. Fistula has not occurred. All stricture recurrences were detected in period of 15 months. CONCLUSIONS: Buccal mucosa graft uretroplastic is long-lasting effectiveness method with low complication rate, especially in dorsal graft placing. Complication rate does not cohere with the length of graft, uretroplastic extent, nor stricture localization.

[Endoscopic and conservative treatment of vesicoureteric reflux]. / Endoskopická a konzervativní lécba vezikoureterálního refluxu.

BACKGROUND: The aim of study is to evaluate the results of endoscopic treatment of vesicoureteric reflux (VUR) comparing with conservative mode. METHODS AND RESULTS: In the years 2003-2006 there were forty for children in prospective randomised study enrolled and divided into two groups. Twenty two children 1-40 months old (22.9 months) were operated. Dx/Ha (Deflux) was instilled for VUR grade 3-5. The results of treatment were compared with outcome of twenty two conservatively treated randomly assigned children aged 1-32 months (mean age 13.5 months) Postoperative videourodynamic study was used to evaluate for the presence of VUR and function of the bladder and ultrasound investigation was performed too (exclusion of obstructive megaureter in operated group). There were 22 children controled after instillation. The children were followed 11-24 months. VUR was cured in 12 cases (54.5%) and improved (grade 1-2) in 5 children (66.7%). All children absolved treatment without any complications, excluding one case with obstructive megaureter after pyelonephritis diagnosed. There were 22 children evaluated in conservative group. Five children were cured (22.7%) and VUR was improved (grade 1-2) in four (18.2%) CONCLUSIONS: Endoscopic miniinvasive instillation of dextranomer is safe and effective treatment of VUR in all age groups with good therapeutical outcome and minimum of adverse effects.

[Comprehensive long-term analysis of hypospadias repair using vascularized flaps and tubularized incized plates--report on 588 cases]. / Dlouhodobé výsledky rekonstrukce hypospadie pomocí vaskularizovaných laloku a tubulizace incidované ploténky--588 prípadu.

BACKGROUND: The article presents a comprehensive long-term analysis of the modem hypospadias repair based on preservation and use of the urethral plate. METHODS AND RESULTS: In years 1987 to 2004, 476 patients (aged 8 months to 45 years) were operated using a praeputial (mostly) flap. 81% were indicated for reconstruction of a proximal form of hypospadias, mostly penile. In years 1986 to 1991, a tubularized flap was performed in 31 patients. Since 1992, an onlay island flap in 394 patients, inlay-onlay flap in 43 patients and onlay-tube-onlay flap in 8 patients have been used. In years 2000 to 2004, 112 patients (aged 13 months do 17 years) were operated using tubularized incised plate (TIP) repair, mostly because of distal form of hypospadias. To cover the neourethra, a dartos flap was used in 72 and spongioplasty in 37 patients. We achieved the primary healing in 89% and 91%, resp., of patients after onlay and onlay-inlay island flap repairs with an average follow-up of 6,7 and 5,7 years, respectively. The most frequent complications were fistula or dehiscence of the glans. After the TIP repair combined with a dartos flap, 89% of the first operated patients healed without complications with an average follow-up of 2.3 years. A higher complication rate (40%) was found after a spongioplasty with foreskin preservation. Secondary repairs were also associated with more complications. CONCLUSIONS: Using onlay and inlay-onlay one-stage repairs, or using TIP one-stage repair combined with a dartos flap, a successful primary hypospadias repair was achieved in 90% of patients. The definite repair should be completed during early childhood.

[Effect of biofeedback in the treatment of voiding dysfunction]. / Efekt biofeedbacku v lécbe nonneurogenních dysfunkcí dolních mocových cest u detí.

BACKGROUND: Biofeedback represents a treatment option for children with voiding dysfunction characterised with poor pelvic floor relaxation. METHODS AND RESULTS: Thirty nine children with symptoms of voiding dysfunction were treated in BFB program. Average number of sessions to achieve good response was three. Follow up was 12 to 24 months. Very good clinical response was obtained in 55, 7% of patients, who were characterised by cessation or resolution of incontinence in 66, 7%, dyscoordination in 57, 6% and urinary tract infection in 41, 1% of children. CONCLUSIONS: Biofeedback therapy is an effective method for treating poor pelvic floor relaxation. It helps to improve coordination of the detrusor and external sphincter function and it accelerates voiding reflex maturation.

The expression of PAX5, p53 immunohistochemistry and p53 mutation analysis in superficial bladder carcinoma tissue. Correlation with pathological findings and clinical outcome.

OBJECTIVES: The expression pattern of PAX5 in the tissue of superficial bladder transitional cell carcinoma (TCC), its prognostic value and its correlation with p53 immunohistochemistry and p53 mutation analysis were evaluated. METHODS: Study comprised 61 patients with histologically confirmed superficial bladder TCC. Expression level of PAX5 mRNA was investigated using reverse transcriptase-polymerase chain reaction (RT-PCR) and determined semiquantitatively. The presence of p53 mutations was determined by SSCP and confirmed by direct sequencing. The p53 immunohistochemistry was performed with DO1 antibody and semiquantitatively evaluated using HSCORE (HS) method. As the control group for the evaluation of the PAX5 expression served 8 men with benign prostatic hyperplasia. RESULTS: PAX5 expression was found in 50 patients with bladder TCC but in no patient from the control group. Its quantity however correlated neither with the stage nor with the grade of the tumor. P53 mutation was confirmed only in 1 patient with pTaG2 tumor in exon 5 (deletion of proline 128). On the contrary, positive immunohistochemical staining of p53 was detected in most patients. Using the cutoff value of HS 200, 56.9% of patients showed p53 overexpression. Quantity of p53 immunochistochemical positivity did not correlate with the quantity of PAX5 expression. Using the cutoff values of HS 200 for p53 and of 0.2 for PAX5, 7 of 8 patients with future progression had p53 and 4 had PAX5 overexpression respectively. CONCLUSION: The expression of gene PAX5 is a frequent event in superficial TCC of the bladder.

[Metaphylaxis in the first occurrence of urolithiasis]. / Metafylaxe primourolitiázy.

BACKGROUND: Urolithiasis is a socially important disease with a high tendency to recurrences. By specific medicamentous metaphylaxis it is possible to achieve an as high as tenfold reduction of recurrences, however, regular check-ups focussed on possible side-effects are required. The objective of the project was to assess prospectively the effectiveness of non-medicamentous metaphylaxis in patients with the first kidney stone. In 113 patients, a fluid and specific dietary regimen were recommended based on a comprehensive diagnosis of metabolic disorders (Table 1) and the regimen was modified with regard to results of metabolic check-up examinations after 6, 18, and 36 months (group 1). Ninety-four patients were recommended a fluid and non-specific dietary regimen after a limited metabolic evaluation with a subsequent check-up after 36 months (group 2). The two groups were clinically comparable. A stone recurrence developed in 7 (6%) patients of the group 1 and in 18 (19%) of the group 2 (p < 0.01). The difference was even greater after including the growth of the concrement (7% and 23%). The patients with a recurrence or growth of a stone had more frequently weddellite in the concrement and had also more frequently a bilateral residual or conservatively managed urolithiasis (p < 0.0001). Half the recurrencies were asymptomatic. The development of metabolic disorders in the group 1 indicated a gradual decrease of uric acid in serum and urine (p < 0.01) although it was not yet significant after 6 months. There was also a significant increase of calciuria (p < 0.01), most probably in conjunction with a regular calcium intake. CONCLUSION: Specific non-medicamentous metaphylaxis with an adequate calcium intake leads to a lower incidence of stone recurrences than a non-specific fluid and dietary regimen. It is justified to introduce the specific metaphylaxis in all patients after the first diagnosis of a kidney stone. It ensures subsequent adjustment of the individual diet which the patient is more likely to adhere to than to general non-specific instructions.

A prospective study of nonmedical prophylaxis after a first kidney stone.

OBJECTIVE: To assess, in a multicentre prospective randomized study, the effectiveness of specific nonmedical prophylaxis and nonspecific dietary prophylaxis in patients treated after experiencing their first idiopathic calcium-containing kidney stone. PATIENTS AND METHODS: From 1991 to 1994, 242 patients with idiopathic calcium urinary stones from three urological centres were randomly assigned into two groups. In group 1 (intervention, 113 patients), a specific dietary regimen was recommended and thereafter corrected according to a comprehensive metabolic evaluation. Group 2 (control, 94 patients) underwent only minimal metabolic screening and used general dietary measures, with no regular follow-up. An increased fluid intake was recommended in both groups. After 3 years, the effectiveness of the prophylactic and dietary regimens was evaluated in 207 patients. RESULTS: At entry, the clinical characteristics were comparable in the two groups, with only extracorporeal lithotripsy being more frequent in group 2. Almost 80% of patients reported a high intake of meat and a low intake of dairy products. In group 1 and 2, a recurrent stone was encountered in seven (6%) and 18 (19%) patients, respectively; recurrent and growing stones were found in eight (8%) and 22 (23%) patients, respectively (P<0. 01). There was a higher incidence of bilateral residual (or untreated) stones, and Weddellite stones (P<0.001) among patients with a recurrent or growing stone. An analysis of the dynamics of the metabolic variables indicated the significance of repeated dietary counselling. CONCLUSION: Specific dietary therapy, adjusted according to a metabolic evaluation, is more effective than nonspecific general dietary recommendations in preventing the formation of a second urinary stone.

[Onlay island flap urethroplasty in the treatment of urethral strictures]. / Uretroplastika stopkatým lalokem onlay v lécbe striktury uretry.

UNLABELLED: A skin island flap was used to create a neourethra in 65 patients aged 2 to 66 years with prolonged or multiple stricture of the anterior urethra. Before, all patients were treated repeatedly and unsuccessfully by open or endoscopic surgery. The principle of the used onlay technique was to supplement the missing lumen of the urethra by an island, usually preputial flap. In case of as missing segment of the urethra the original inlay-onlay technique was applied. After a mean follow-up period of 27 months 12 complications (18.4%) were recorded, six strictures of the proximal anastomosis, three fistulas and three dehiscences of the glans. CONCLUSION: The onlay island flap urethroplasty makes it possible to cure prolonged and multiple strictures of the urethra in one stage and with a relatively low complication rate.

Inlay-onlay flap urethroplasty for hypospadias and urethral stricture repair.

PURPOSE: The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or scarred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates. MATERIAL AND METHODS: In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used. RESULTS: The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1). CONCLUSIONS: Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.

[An artificial urinary bladder sphincter for men]. / Umelý sverac mocové trubice u muzu.

Urinary incontinence is a condition with involuntary escape of urine and causes not only medical but also social and hygienic problems. One of the causes of incontinence is insufficiency of the urethral closure mechanism which in men is usually caused by previous prostatectomy or neurogenic dysfunction of the lower urinary pathways. The method of choice is the application of an artificial sphincter (model AMS 800) to the bulbar urethra or cervix. The authors applied an artificial sphincter in 1993-1996 to one boy and 14 men aged 11-72 years. The basic components of the artificial sphincter of the urethra-AMS 800 is a cuff, balloon and pump. The whole system is filled with isotonic solution Omnipaque 300, the cuff which is 45-80 mm long is placed either round the bulbar urethra from a perineal approach or round the cervix by a retropubic approach. The pump is placed beneath the skin of the scrotum and the balloon is in a perivesical position. All parts of the AMS are connected by tubes. Because of infectious complications the authors had to explant the sphincter in two patients. In one patient it was necessary to add another cuff. The perineal approach is simpler, but is associated with a higher risk of erosion of the urethra. Patients with a neurogenic bladder had more complications than those after prostatectomy. Despite the fact that the method and aid is expensive, the treatment is very effective and makes the patients independent on other aids for incontinent patients.

[Surgical correction of hypospadias using a vascularized onlay flap]. / Chirurgická úprava hypospadie ziveným lalokem onlay.

The principle of the onlay technique is to create a neourethra from the preserved urethral plate to which the vascularized flap of the prepuce is applied. Thus 51 patients were operated 10 months to 27 years old, half of them were under 5 years. By this method hypospadias was treated from coronary to perineal ones. In 16 patients chordectomy was performed, in 6 plications of the cavernous bodies because of their disproportion of the ventral and dorsal side. In three instances it was necessary to transsection the urethral plate and supplement the onlay flap by tubulization of the neourethra. The method was also used in secondary strictures of the urethra after urethroplasty and in occlusions of a fistula. Complications of the neourethra were recorded in 4 (7.8%) patients. Another four patients had a partial necrosis of the skin cover. The onlay method is becoming universal for resolving the proximal variant of hypospadias, it is associated with a considerably smaller number of complications than tubulized plastic operations and makes possible a definite one-stage solution already at an early age.

[The vermiform appendix and its use in urology]. / Appendix vermiformis a jeho vyuzití v urologii.

There are presented new possibilities of using the appendix vermiformis in urology: Mitrofanoff's procedure (continent appendicovesicostomy), continent appendix stoma performed with the MAINZ pouch technique and continent appendicocolostomy. There was operated on 12 pts. for the neuropathic bladder using the Mitrofanoff's procedure. An ischemic occlusion of the appendicostomy was found out postoperatively in one case. All pts. but one practise clean intermittent catheterization through the appendicostomy (four to six times a day) and eight of them (67%) are continent by day and night.

Development of metaphylaxis in calcium urolithiasis: a restriction of conventional drug therapy.

Between 1978 and 1992 (mean 9.2 years), metaphylaxis was introduced to 110 patients originally hospitalized for recurrent urinary calcium stones (mostly bilateral or multiple). Patients with hyperparathyroidism or with sponge kidney were excluded from the study. Until 1984, the condition had been treated mostly using conventional drug metaphylaxis (thiazides and allopurinol in 75% and 57%, respectively). After that year, there was a gradual decrease in the number of patients treated with thiazides (to 15%) and allopurinol (to 10%). This was associated with a steep rise in the proportion of patients treated with inhibitors (magnesium to 36% and citrates to 30%), or exclusively with non-medicamentous therapy (to 31%). These fundamental changes in approach have not reduced the effectiveness of metaphylaxis, and recurrence rates in individual years have not changed significantly either. Metaphylaxis was successful in 105 patients (95%) and the rate of recurrence has declined from 0.9 to 0.08 stones per year. The restriction of conventional drug metaphylaxis has entailed a marked decrease in the incidence of side effects of therapy and, consequently, a reduced need for follow-up tests and outpatient follow-up.

[A single-stage reconstruction in hypospadias using a vascularized preputial flap]. / Jednodobá plastika hypospadie ziveným lalokem z predkozky.

The authors submit an account of their experience with a modern method of reconstruction of hypospadias connected with the chorda. In 31 boys (10 months to 15 years) they used for reconstruction of the urethra a flap from the prepuce with a preserved vascular stalk, as described by Duckett. In the majority they transferred a double flap ("double face") where the outer sheath of the prepuce was used to cover the ventral side of the penis. In three boys the authors performed their own modification of this plastic operation. Complications developed in 12 boys (38.7%): stricture of the proximal anastomosis of the urethra (6), stricture of the meatus (1), necrosis of the skin cover (4), dehiscence (1). An open operation had to be made in the last five patients (16.1%). In all children excellent functional and aesthetic results were achieved. The above plastic operation is indicated in penile and penoscrotal hypospadias with chorda. It is a single stage operation. Due to the use of vascularized tissue and the microsurgical technique it is possible to perform a definite reconstruction of the external genitalia already by the age of one year.

[Detection of metabolic disorders as a cause of urolithiasis in clinical practice]. / Urcení metabolické poruchy jako príciny urolitiázy v klinické praxi.

Metabolic disorders are the most frequent risk factor for the development of urolithiasis. They are manigenic substances or deficiency of inhibitors of crystalgenic substances or deficiency of inhibitors of crystallization and aggregation. The authors use for their diagnosis a modification of Pak's procedure. It involves examination of 24-hour urine with the patient on a low-calcium diet, supplemented by urine examination on fasting and after a 1000 mg calcium load. The procedure includes also examination of serum and bacteriological examination of urine. A total of 93% of patients with calcium lithiasis had a metabolic disorder, 42% suffered from idiopathic hypercalciuria, 32% from hyperuricosuria, 19% from hyperoxaluria, 15% from magnesium deficiency and 38% from hypocitraturia. On the other hand, patients with uric acid lithiasis had a detectable metabolic disorder only in 62%. Active detection of metabolic disorders is essential for the introduction of effective, specific metaphylaxis of urolithiasis.