[Foreskin transplantation between monozygotic twins discordant for hypospadias].

This is a case report of monozygotic twins discordant for hypospadias, where the afflicted twin, a 33-year-old male, needed extensive redo urethral reconstruction. A two-stage reconstruction was planned by using the twin brother's prepuce. The scarred urethra was replaced by the isograft, and one year later the second stage was completed. At five-year follow-up, there was good cosmesis, and the index patient reported excellent voiding and no fistulae or stenosis. Despite its rarity, foreskin transplantation between discordant monozygotic twins is possible and offers a unique and durable management opportunity.

Antenatal biological models in the characterization and research of congenital lower urinary tract disorders.

Congenital lower urinary tract disorders are a family of diseases affecting both urinary storage and voiding as well as upstream kidney function. Current treatments include surgical reconstruction but many children still fail to achieve urethral continence or progress to chronic kidney disease. New therapies can only be achieved through undertaking research studies to enhance our understanding of congenital lower urinary tract disorders. Animal models form a critical component of this research, a corner of the triangle composed of human in-vitro studies and clinical research. We describe the current animal models for two rare congenital bladder disorders, posterior urethral valves (PUV) and bladder exstrophy (BE). We highlight important areas for researchers to consider when deciding which animal model to use to address particular research questions and outline the strengths and weaknesses of current models available for PUV and BE. Finally, we present ideas for refining animal models for PUV and BE in the future to stimulate future researchers and help them formulate their thinking when working in this field.

Robotic versus laparoscopic urological surgery: incidence of reoperation and complications.

Objective: To report the introduction of minimum invasive surgery in Denmark with focus on the reoperation and complication rates. Materials and methods: Data were prospectively collected at the national UroLap database. The database was established in 2003 in Denmark to register all laparoscopic urological procedures as well as their peri- and post-operative outcomes. In the period from 2009-2014, 10,843 patients were registered with the database, of which 10,546 (97%) had a complete Clavien-Dindo score within the first 30 postoperative days. Results: The mean age of patients was 60.5 years (S.D. = 16.2), and 415 patients (4%) were under the age of 17 years. The male-to-female ratio was 4:1. At the end of 2010, 25% of surgeries used the robotic technique, but the frequency of robotic surgeries increased to 56% in 2014. No complications were reported in 74.6% of the urological procedures. The mortality rate was reported at only 0.27% of all patients. Patients who underwent a urological procedure performed by consultant urologists had a lower rate of complication compared to procedures performed by trainees (p = 0.03) but not staff doctors (p = 0.9). There were no significant differences in complication rates between staff doctors and trainee (p = 0.2). Conclusion: Robotic and laparoscopic urological procedures are associated with low serious complication rates. Postoperative complications were more common among surgeries performed by trainees. The robotic approach is associated with a shorter L.O.S. compared to the laparoscopic approach and linked to lower reoperation rates.

Exposure to Perfluoroalkyl Substances during Fetal Life and Pubertal Development in Boys and Girls from the Danish National Birth Cohort.

BACKGROUND: It remains unsettled whether prenatal exposure to perfluoroalkyl substances (PFASs) affects human reproductive health through potential endocrine disruption. OBJECTIVES: We aimed to explore the associations between prenatal exposure to several PFASs and various aspects of pubertal development in boys and girls. METHODS: We studied two samples ([Formula: see text] and 445) from the Puberty Cohort, nested within the Danish National Birth Cohort (DNBC), measuring PFAS in maternal plasma from early gestation. Data on pubertal development were collected biannually from the age of 11 y until full maturation, using web-based questionnaires. Outcomes were age at menarche, voice break, first ejaculation, and Tanner stages 2 to 5 for pubic hair, breast, genital development, and a combined puberty indicator. A regression model for censored data was used to estimate mean difference (months) in age at achieving the pubertal outcomes across tertiles of PFAS concentrations and with a doubling of PFAS concentrations (continuous). For perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS), a meta-analysis was used to provide a weighted average of the point estimates from samples 1 and 2. RESULTS: Overall, prenatal exposure to PFOS, perfluorohexane sulfonate (PFHxS), perfluoroheptane sulfonate (PFHpS), perfluorononanoic acid (PFNA), and perfluorodecanoic acid (PDFA) (girls) and PFHxS and PFHpS (boys) was associated with lower mean age at puberty marker onset. PFDA and PFNA exposure was associated with higher mean age at onset of puberty in boys. Nonmonotonic associations in girls (PFOS, PFHpS, PFDA) and boys (PFDA, PFNA) were observed, showing larger mean age differences for the combined puberty indicator in the middle tertile [girls: PFOS: [Formula: see text] mo, 95% confidence interval (CI): [Formula: see text], [Formula: see text]; PFHpS: [Formula: see text] mo, 95% CI: [Formula: see text], 1.85; PFDA: [Formula: see text] mo, 95% CI: [Formula: see text], 1.83; and boys: PFNA: 4.45 mo, 95% CI: [Formula: see text], 10.21; PFDA: 4.59 mo, 95% CI: [Formula: see text], 10.11] than in the highest tertile with the lowest as reference. CONCLUSIONS: Our population-based cohort study suggests sex-specific associations of altered pubertal development with prenatal exposure to PFASs. These findings are novel, and replication is needed. https://doi.org/10.1289/EHP3567.

Self-assessment of pubertal development in a puberty cohort.

Background We evaluated the inter-rater agreement between self-assessed Tanner staging and clinical examination and the intra-individual agreement of self-assessed information on various puberty markers in late adolescents from the longitudinal nationwide Puberty Cohort, a sub-cohort of the Danish National Birth Cohort (DNBC). Methods We invited 715 children from the ongoing Puberty Cohort between June 2016 and January 2017. In total, 366 children (51%) returned an add-on questionnaire identical to the questionnaire used to collect information on puberty markers, including Tanner staging, in the Puberty Cohort. Of these, 197 (54%) also participated in a clinical examination with Tanner staging. We used percentage agreement and weighted kappa statistics to evaluate the inter-rater and intra-individual agreement. Results Due to late entry, more than 75% of children were Tanner stage 4 or above at clinical examination. In girls, the inter-rater agreement for pubic hair and breast staging was 54% and 52%, respectively, yielding weighted kappas of fair strength. In boys, pubic hair and genital staging agreed in 55% and 33%, respectively, corresponding to weighted kappas of fair to moderate strength. Boys tended to underestimate genitalia staging consistently. The intra-individual agreement on Tanner staging was 75-77% in girls and 69% in boys, whereas the intra-individual agreement on axillary hair and acne was above 92%. Conclusions Self-assessment of late stages of pubertal development may be misclassified, leading to random errors in studies of puberty timing. However, self-assessment continues to serve as an important time- and cost-saving tool in large prospective puberty cohorts.

Laparoscopic cryoablation of angiomyolipomas in adolescents and young adults: A report of four cases associated with tuberous sclerosis and 1 case of sporadic origin.

INTRODUCTION: Renal angiomyolipomas (AMLs) can be of sporadic origin or associated with tuberous sclerosis (TS). TS-associated AMLs often present in childhood, tend to be bilateral and multiple, and often exhibit a faster growth rate with an increased risk of hemorrhage. Renal cryoablation is well described in adults, whereas experiences with adolescents and young adults are limited. We present here for the first time a series of renal AMLs within adolescents and young adults treated with laparoscopic assisted cryoablation (LCA). OBJECTIVE: The aim was to evaluate whether LCA of AMLs in adolescents and young adults is a safe and feasible treatment modality. STUDY DESIGN: From October 2009 to September 2013 a total of five patients at our institution were diagnosed with AMLs requiring treatment. Four patients had TS and one had AML of sporadic origin, all five patients underwent LCA. Data were retrospectively collected by a systematic review of patient material and reassessment of renal imaging. RESULTS: The median age was 16 years (range 13-27 years). Eight AMLs with a median size of 3.9 cm (range 2.1-7.7 cm) were treated in five patients because of tumor size and rapid growth. Follow-up was a median 37 months (range 20-62 months), and all tumors showed a reduction in tumor size, and no regrowth was recognized (see summary table). The procedure was well tolerated, with only few perioperative complications and no postoperative complications. DISCUSSION: When considering the indication for treating AMLs, the origin (sporadic or TS associated) and size of the tumor are the decisive factors. To preserve renal function and prevent spontaneous hemorrhage caution should be intensified when tumors reach 4 cm, particularly if TS is present. After the diagnosis is established, patients should be monitored with renal imaging at regular intervals to identify rapid-growing tumors. As an alternative to current treatment modalities such as partial nephrectomy and super selective angioembolization, cryoablation is an emerging approach, although experience with pediatric patients is limited. For patients not requiring immediate surgery, pharmacological treatment with mTOR inhibitors is now being evaluated as an alternative treatment option or as neo-adjuvant therapy to ablative techniques. CONCLUSION: Prophylactic treatment of large or rapid growing AMLs with LCA appears to be a safe and feasible nephron-sparing approach in adolescents and young adults. The low perioperative complication rate and promising effect on outcome might allow treatment of subclinical AMLs in order to minimize the risk of potentially life-threatening complications and preserve renal function.

Association between organic dietary choice during pregnancy and hypospadias in offspring: a study of mothers of 306 boys operated on for hypospadias.

PURPOSE: The etiology of hypospadias is poorly understood. Exposure to pesticides has been considered a risk factor, although findings are inconsistent. Diet constitutes a significant exposure route for pesticides, and pesticide residues are more frequently reported in conventional than organic food products. We examined the association between organic dietary choice during pregnancy and presence of hypospadias in the offspring. MATERIALS AND METHODS: Mothers of 306 boys operated on for hypospadias were frequency matched for geography and child birth year to 306 mothers of healthy boys in a case-control study. Telephone interviews were conducted regarding demographic and lifestyle factors, including intake and organic choice of selected food items (milk, dairy products, egg, fruit, vegetables and meat). Logistic regression models were constructed for dietary variables, and odds ratios were calculated controlling for maternal age, body mass index and alcohol consumption. RESULTS: Overall organic choice of food items during pregnancy was not associated with hypospadias in the offspring. However, frequent current consumption of high fat dairy products (milk, butter) while rarely or never choosing the organic alternative to these products during pregnancy was associated with increased odds of hypospadias (adjusted OR 2.18, 95% CI 1.09-4.36). CONCLUSIONS: This large case-control study of boys operated on for hypospadias suggests an association between hypospadias in the offspring and the mother not choosing the organic alternative, and having a high current intake of nonorganic butter and cheese. This finding could be due to chemical contamination of high fat dairy products. However, general lifestyle and health behavior related to choosing organic alternatives may also explain the finding.

Urinary proteome analysis in congenital bilateral hydronephrosis.

OBJECTIVE: A proteomics strategy was applied to map protein changes in urine after relief of congenital bilateral hydronephrosis to identify proteins correlated with the pathophysiological processes in congenital obstructive nephropathy as potential urinary biomarkers. MATERIAL AND METHODS: Urine samples from 10 infants with bilateral abnormal drainage from the kidneys were collected at the time of relief from obstruction, and after 2 and 4 weeks. Proteomics techniques were used on samples from three patients for identification of protein changes between the three time-points, and enzyme-linked immunosorbent assay (ELISA) was used on samples from all 10 patients for validation of five selected proteins. RESULTS: Mass spectrometry quantified 315 protein hits, out of which 33 proteins showed significantly changed urinary excretion between the time-points. Validation by ELISA showed high urinary excretion of fibrinogen, plasminogen, transthyretin and transferrin at the time of relief from obstruction, followed by a significant reduction. In contrast, Tamm-Horsfall protein exhibited the reverse pattern. CONCLUSION: Using a mass spectrometry-based proteomics approach, this study identified 33 proteins related to congenital bilateral hydronephrosis, and pinpointed a panel of five proteins consistently linked to this congenital kidney disorder as potential urinary biomarkers.

Epidermal growth factor and monocyte chemotactic peptide-1: potential biomarkers of urinary tract obstruction in children with hydronephrosis.

OBJECTIVE: Hydronephrosis is diagnosed in 0.5% of all newborns, and ureteropelvic junction obstruction (UPJO) is a common cause. The aim of this study was to test whether specific urinary cytokines can be used as UPJO biomarkers in children with hydronephrosis. MATERIALS AND METHODS: Twenty-eight children referred for pyeloplasty due to UPJO and 13 controls were included in this prospective study. Kidney function was assessed and urine samples collected pre-, peri-, and post-operatively. Urine levels of epidermal growth factor (EGF), monocyte chemotactic peptide-1 (MCP-1), macrophage inflammatory protein-1α (MIP-1α), interferon-γ-inducible protein-10 (IP-10), and RANTES were measured simultaneously by using a bead-based multiplex sandwich immunoassay. RESULTS: In hydronephrotic children, preoperative urine levels were significantly increased for EGF (median 7.4 [1.2-60.2] vs. median 4.0 [1.2-13.8] ng/mg creatinine) and MCP-1 (median 136.9 [47.7-545.5] vs. median 80.1 [28.8-149.9] pg/mg creatinine) compared to those of controls. Urine levels of EGF and MCP-1 were identical to controls at the postoperative 1-year follow-up exam. CONCLUSION: Urine levels of EGF and MCP-1 were preoperatively increased and postoperatively normalized. This study demonstrates that urine-excreted kidney cytokines may be potential biomarkers of obstruction in children with hydronephrosis.

Urinary NGAL, cystatin C, ß2-microglobulin, and osteopontin significance in hydronephrotic children.

BACKGROUND: Ureteropelvic junction obstruction (UPJO) accounts for 35 % of all congenital hydronephrosis cases. The challenge in managing childhood hydronephrosis is to distinguish obstructive from nonobstructive cases and, thereby, identify patients requiring surgical intervention. This study aimed to examine four urinary proteins as potential biomarkers of obstruction in hydronephrosis. METHODS: Urine samples from 24 children with UPJO were collected pre-, peri-, and postoperatively, together with urine samples from healthy children. Neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CyC), ß2-microglobulin (ß2-M), and osteopontin (OPN) in the samples were measured simultaneously using multiplex sandwich immunoassay technology. RESULTS: Compared with controls, NGAL and ß2-M were significantly increased in urine from patients with obstructed kidneys at the time of surgery. This increase was followed by a decrease and stabilization to the same level as that of the controls. Furthermore, age was negatively correlated with preoperative urinary concentrations of CyC, ß2-M, and OPN. CONCLUSIONS: This study confirms increased concentrations of NGAL and ß2-M in urine from obstructed kidneys and should be tested in larger studies to ascertain their ability to identify obstruction and to determine the importance of age-adjusted reference values.

Age at cryptorchidism diagnosis and orchiopexy in Denmark: a population based study of 508,964 boys born from 1995 to 2009.

PURPOSE: Early treatment for cryptorchidism may be necessary to preserve fertility. International guidelines now recommend that congenital cryptorchidism be treated with orchiopexy before age 1 year. Acquired cryptorchidism should be treated at presentation. To our knowledge the rate of adherence to these guidelines in recent years is unknown. Thus, we present data on age at cryptorchidism diagnosis and orchiopexy in recent Danish birth cohorts. MATERIALS AND METHODS: A population of 508,964 Danish boys born alive from January 1, 1995 to December 31, 2009 was identified using the Danish Civil Registration System. Five birth cohorts were defined, including 1995 to 1997, 1998 to 2000, 2001 to 2003, 2004 to 2006 and 2007 to 2009. The boys were followed in the Danish National Patient Registry for a diagnosis of cryptorchidism and for an orchiopexy procedure. Data were analyzed using the Kaplan-Meier estimator and Cox regression models. RESULTS: During followup 10,094 boys were diagnosed with cryptorchidism, of whom 5,473 underwent orchiopexy. Mean age at diagnosis in boys followed at least 6 years was 3.3 years (95% CI 3.3-3.4) in the 1995 to 1997 cohort, 3.1 (95% CI 3.1-3.2) in the 1998 to 2000 cohort and 2.9 (95% CI 2.8-2.9) in the 2001 to 2003 cohort while mean age at orchiopexy was 3.8 (3.7-3.9), 3.6 (3.5-3.7) and 3.3 years (3.2-3.4), respectively. CONCLUSIONS: In the more recent birth cohorts of 1995 to 2009 we observed a shift toward younger age at cryptorchidism diagnosis and orchiopexy.

In vivo biomechanical assessment of anterior rabbit urethra after repair of surgically created hypospadias.

PURPOSE: We studied the in vivo biomechanical properties of the anterior urethra in a rabbit hypospadias simulation model at long-term followup after urethroplasty. MATERIALS AND METHODS: A total of 38, 9-week-old white New Zealand male rabbits were randomized into active treatment and control groups. The active treatment group included hypospadias-like simulation and acute repair (sham, mobilization and advancement, tubularized incised posterior urethral plate). After 23 weeks all groups underwent biomechanical investigation using impedance planimetry. Cross-sectional area pressure measurements during bag distention were conducted at 3 different positions along the urethra, and biomechanical (tension-strain) relations were computed. The biomechanical parameters studied were urethral luminal dimension (cross-sectional area pressure relation) and its deformability to luminal pressure (tension-strain relation). RESULTS: The urethral cross-sectional area was significantly larger in the mobilization and advancement group compared to the tubularized incised plate group (p <0.001), shams and controls at the distal distention site (p <0.05), and other groups at the intermediate distention site (p <0.05). The strain-tension curves were not significantly different between the groups. CONCLUSIONS: All groups showed a nonlinear cross-sectional area pressure and circumferential wall tension-strain relationships in the 3 distention sites. The urethras exhibited a decreasing ability to be distended with increasing pressures, indicating self-protection against damage. At long-term followup no differences in tension-strain relations were found between groups, despite the fact that the mobilization and advancement group had enlarged urethras. Our hypospadias simulation animal model could be useful to test commonly used or new urethroplasty techniques and their functional (biomechanical) long-term results before clinical use.

Urinary flow patterns in premature males.

PURPOSE: We sought to assess urinary flow patterns in premature males using ultrasound flow probes. MATERIALS AND METHODS: Specifically customized ultrasound flow probes connected to a flowmeter were mounted on the penis of 29 premature males (median gestational age 31.3 weeks). Flow data were sampled to a personal computer and flow curves were assessed with regard to configuration, maximum flow rate and voided volume. Examinations were performed at the neonatal unit within the ambient environment of the incubators and under the surveillance of a study nurse for a period of 4 hours. RESULTS: Data from 25 boys (98 voids) were applicable for analysis. Flow curve configuration was bell shaped in 48% of patients, interrupted in 44%, staccato in 6% and plateau in 2%. Overall 59% of flows were dyscoordinated, and no patient with more than 1 assessable void had exclusively coordinated flows. Median voided volume was 3.9 ml (range 0.6 to 25.2), median maximum flow rate was 1.0 ml per second (0.3 to 10.0) and median number of voids per hour was 1.0 (0.2 to 3.6). No correlation was found between flow curve configuration and maximum flow rate (p = 0.32). However, plateau shaped curves were associated with larger voided volumes (p = 0.05). CONCLUSIONS: Urinary flow pattern assessment in preterm males is possible and reveals a high degree of dyscoordination. There is a tendency toward a mixture of coordinated and dyscoordinated flow patterns in the same individual.

Long-term follow-up in spinal dysraphism: outcome of renal function and urinary and faecal continence.

OBJECTIVE: This study evaluated the renal and functional outcome in a cohort of adolescents with congenital spinal malformations followed at this department since birth. All patients went through same follow-up and algorithm of intervention during childhood. None of the patients was treated prophylactically, apart from receiving antibiotics. MATERIAL AND METHODS: Sixty children (31 males, 29 females), born in 1989-1995, were evaluated from June 2006 to May 2007. Ultrasound of the bladder and the upper urinary tract was performed in all patients. Surgical and pharmacological intervention, bowel function, faecal and urinary continence were registered. Renal function was assessed by (51)Cr-EDTA and/or MAG-3 scintigraphy in patients who had previously experienced affected renal function or presented with deteriorated bladder function. RESULTS: Two children died during follow-up. In total, 47 urological procedures were performed in 23 patients. The most frequently conducted procedures were appendicovesicostomy (n = 11) and autoaugmentation (n = 11). Fourteen patients underwent untethering procedures, resulting in improved bladder function in five patients; nine were unaltered. Five patients had a moderate and two a severe decrease in glomerular filtration rate. Eighty-one per cent were performing clean intermittent catheterization, starting at a median age of 3.6 years. Anticholinergics were used in 50%. Sixty-two per cent were totally urine continent, 22% used incontinence pads in case of leakage and 16% were urine incontinent. Two patients had Malone procedures; 29% were using trans-anal irrigation. Eighty-three per cent were totally faecal continent. CONCLUSION: Close follow-up and appropriate intervention have improved renal function in children with congenital spinal malformation, but renal deterioration remains a risk. Total faecal and urinary continence could be achieved in 81% and 62%, respectively.

Urinary flow patterns in first year of life.

PURPOSE: We studied the natural development of urinary flow and lower urinary tract function in healthy male infants. MATERIALS AND METHODS: Custom-made ultrasound flow probes connected to a flowmeter were mounted on the penis in 20 infants who previously had been assessed in the immediate postnatal period. Median subject age was 10.7 months (range 9.2 to 19.8). Flow data were sampled to a personal computer and flow curves were assessed regarding configuration, maximum flow rate and voided volume. Results were analyzed statistically and were compared to those obtained in the neonatal period. Comparison of uroflow parameters was assessed by using analysis of variance, while contingency coefficients and Wilcoxon test were used for comparisons involving nominal and paired data, respectively. A p value of less than 0.05 was considered statistically significant. RESULTS: A total of 19 infants had evaluable data, of whom 15 also had evaluable data from the original neonatal study. Flow curve pattern was bell shaped in 32% of patients, interrupted in 46%, staccato in 15%, tower in 3% and spike-dome in 3%. Dyscoordinated patterns accounted for 46% of all flows, a significant increase compared to the neonatal period, in which only 34% of flows were considered dyscoordinated (p <0.01). While voided volume increased significantly with age, maximum flow rate remained more or less stable. CONCLUSIONS: Contrary to conventional wisdom, infants continue to exhibit urinary flow dyscoordination to an even greater extent than in the neonatal period. Therefore, the anticipated normalization of urinary flow is most likely to occur after the first year of life.

Natural fill urodynamics and conventional cystometrogram in infants with neurogenic bladder.

PURPOSE: We compared findings from natural fill urodynamics and conventional cystometrogram in infants with neurogenic bladder. MATERIALS AND METHODS: We retrospectively analyzed data from 19 infants undergoing 24-hour natural fill urodynamics and cystometrogram. The infants concurrently underwent ultrasound. Voided volume, detrusor overactivity, area under the curve (per minute) and baseline detrusor pressure obtained at natural fill urodynamics were compared to cystometric capacity, detrusor overactivity, leak point pressures and bladder compliance obtained at cystometrogram. RESULTS: Voided volumes during natural fill urodynamics were significantly less than cystometric capacity volumes (p <0.001). Natural fill urodynamics revealed more detrusor overactivity than did cystometrogram. Four infants with leak point pressures greater than 40 cm H2O had detrusor overactivity at natural fill urodynamics. Five patients with leak point pressure less than 40 cm H2O had no detrusor overactivity at natural fill urodynamics or cystometrogram. Four of 5 infants with decreased bladder compliance had baseline detrusor pressure greater than 10 cm H2O and detrusor overactivity. CONCLUSIONS: Urodynamic parameters obtained at natural fill urodynamics may be associated with cornerstone parameters such as leak point pressure and bladder compliance obtained at cystometrogram.

Urinary flow patterns of healthy newborn males.

PURPOSE: We assessed urinary flow patterns in newborn males using ultrasound flow probes. MATERIALS AND METHODS: Specifically customized ultrasound flow probes connected to a flowmeter were mounted on the penis of 30 newborn males. Flow data together with signals from a silent diaper alarm were sampled to a personal computer, and the flow curves were assessed with regard to configuration, maximum flow rate and voided volume. Studies were performed under the surveillance of a nurse, who together with the parents registered episodes of breast-feeding and periods of sleep and arousal, which were rated on a visual analogue scale and converted to percentages with 0% representing quiet sleep and 100% representing the fully awake state. Data were analyzed using the Kruskal-Wallis test and are presented as median (range). A p value of less than 0.05 was considered significant. RESULTS: The data from 23 neonates were applicable for analysis, and a total of 61 flow assessments were completed. Configuration was bell-shaped in 57% of the studies, interrupted in 18%, staccato in 8%, plateau in 5%, tower flow in 3% and "spike-dome" in 8%. Median voided volume was 10.6 ml (range 1.4 to 65.0) and median maximum flow rate was 2.3 ml per second (0.5 to 11.9). During all but 3 voids the neonates exhibited some degree of arousal. We found no significant correlation between curve configuration and voided volume, maximum flow rate or state of arousal. CONCLUSIONS: Urinary flow curves in newborn males consisted of a known repertoire of configurations, in addition to a "spike-dome" shape not previously described. Of the assessments 34% were dyscoordinated. Voiding tended to occur in the awake state.

Pediatric robot assisted retroperitoneoscopic pyeloplasty: a 5-year experience.

PURPOSE: We report our 5-year experience with retroperitoneoscopic robot assisted pyeloplasty for the treatment of ureteropelvic junction obstruction in children using the da Vinci Surgical System. MATERIALS AND METHODS: A total of 65 children (median age 7.9 years, range 1.7 to 17.1) underwent 67 robot assisted retroperitoneoscopic pyeloplasties with the da Vinci Surgical System between 2002 and 2006. Operative data were sampled prospectively, while outcome data were collected from chart review. Retroperitoneal access was modified from standard retroperitoneoscopic access due to the limits of the camera arm movement. RESULTS: Median operative time was 143 minutes (range 93 to 300). Complications occurred in 12 of the 67 procedures (17.9%), with urinary tract infection observed in 2 cases, transient hematuria in 2, displaced Double-J catheter in 3 and postoperative temporary nephrostomy in 4. One case was converted to open surgery due to lack of space and limits in the movement of the camera arm. Four patients (6%) underwent repeat surgery due to a kinking ureter (2 patients), an overlooked aberrant vessel (1) and decreasing differential function on renography necessitating balloon dilation (1). In all other cases followup was uneventful. CONCLUSIONS: Robot assisted retroperitoneoscopic pyeloplasty gives more direct access to the ureteropelvic junction, allowing shorter operative times with results and complication rates comparable to transperitoneal robot assisted pyeloplasty, and laparoscopic and open procedures in children.

Biomechanical and biochemical assessment of properties of the anterior urethra after hypospadias repair in a rabbit model.

PURPOSE: We created a rabbit model to test hypospadias operations and investigate the biomechanical properties of the urethra at long-term followup using biomechanical and biochemical assessments. MATERIALS AND METHODS: A total of 38 New Zealand White rabbits were randomized into 4 groups, including controls, sham operation and 2 operation groups (experimental creation of a hypospadias-like defect and acute repair, respectively). In operation group 1 the ventral urethral wall and dorsal plate were longitudinally incised, half of the ventral urethral wall was excised (hypospadias-like defect) and the incised urethra was tubularized (tubularized incised posterior plate urethroplasty group). In operation group 2 the urethra was mobilized from the corpora cavernosa, excised in its distal end (hypospadias-like defect) and advanced to the glanular tip (mobilization and advancement group). At 23 weeks postoperatively biochemical and biomechanical assessments were performed. RESULTS: Maximum urethral strength and stiffness, strain at maximum load and the collagen weight fraction were not significantly different among the groups. Urethral diameter was larger and the total amount of collagen was higher in the mobilization and advancement group only (p <0.05). The mechanical quality of urethral collagen was decreased in the 2 operation groups (p <0.05). CONCLUSIONS: This animal model proved to be useful for testing hypospadias operations and urethral mechanical properties. At long-term followup after experimental hypospadias repair biochemical and biomechanical assessments showed no differences among the groups in mechanical strength, strain and stiffness, and no indication of fibrosis. Consequently testing new hypospadias repair techniques and evaluating their biomechanical long-term results could be performed using hypospadiac animal models before clinical use.

Robotics in paediatric urology.

After the emergence of robotically assisted systems in laparoscopic surgery more than 15 years ago, several systems have been on the market. At the time being only one system, the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA), has survived in clinical use with an increasing spread particularly among adult urologists used primarily for radical prostatectomies. However, the reconstructive nature of paediatric urology makes the system interesting for the paediatric urologists, since its strength is laparoscopic suturing and difficult dissection. So far only few reports have been published about its clinical use in paediatric urology. The main advantages are the 3D magnified view, the wrist-like movements of the instruments, and the scaling and precision of instrument movements. The system has been used for upper tract reconstruction like pyeloplasties and heminephrectomies, both for the transperitoneal and, more technical challenging, the retroperitoneal approach. In the pelvic region, anti-reflux surgery (both extra- and intravesically) and surgery for malformations of the internal genitalia like utriculus cysts and gonadal streaks are feasible. More simple procedures like nephrectomies and the management of the intra-abdominal testis are not justified due to the high costs. In addition, no advantage for the patients related to standard laparoscopic procedures has been proofed yet. For the surgeon the minimally challenging invasive procedures become feasible with certainly improved ergonomics. The use of the system is much easier than standard laparoscopic surgery and its widespread will give more patients to access minimal invasive surgery.