Assessment of lower urinary tract function in pediatrics using ultrasonography.

Ultrasound imaging is a less invasive imaging modality without radiation exposure and is available for repeated tests. It is the gold standard examination for diagnosing and managing disorders of the urinary tract, including lower urinary tract dysfunction (LUTD) in pediatric urology. Ultrasound imaging is effective for screening underlying diseases and determining treatment strategies. Ultrasound examination at the bedside should focus on post-voided residual urine (PVR), bladder wall thickening, renal morphology, and rectal diameter. Since PVR must be tested immediately after voiding, examining infants who cannot complain of the urge to void is difficult. PVR measurement combined with a 4-h voiding observation or alarm system activated by urine is recommended for these infants. Early diagnosis is important because LUTD is associated with the risk of morbid residual urine and high voiding pressure, which can result in renal deterioration, urinary leakage, and febrile urinary tract infection.

Factors affecting testicular volume after orchiopexy for undescended testes.

PURPOSE: Children with undescended testes (UDTs) undergoing orchiopexy at a later age reportedly experience more negative effects on post-orchiopexy testicular volume (TV). This study aimed to investigate the effect of orchiopexy according to the age at operation. METHODS: We included 93 patients (127 testes) who underwent orchiopexy between 2008 and 2020. According to their age at orchiopexy, they were divided into Group 1 (< 24 months; n = 36, median follow-up: 17 [14-39] months) and Group 2 (≥ 24 months; n = 57, median follow-up: 16 [13-34] months). TV was measured with ultrasonography preoperatively and postoperatively. In unilateral UDTs, the testicular volume rates (TVR) were calculated as diseased-side TV/intact-side TV × 100%. A TVR < 50% indicated preoperative testicular atrophy (pre-op TA), whereas volume loss ≥ 50% from baseline indicated postoperative testicular atrophy (post-op TA). RESULTS: Only seven patients experienced pre-op TA. The TV of these 14 atrophic testes improved after orchiopexy (TVR: 100% (7/7) in Group 1 and 85% (6/7) in Group 2). Furthermore, the median TVR significantly improved after orchiectomy, from 27 to 58% (p < 0.01) and from 32 to 61% in Groups 1 and 2 (p < 0.05), respectively. Post-op TA was found in four testes (8%) in Group 1 and three testes (4%) in Group 2. Multivariate analysis showed that only preoperative testicular location predicted post-op TA. CONCLUSION: Post-orchiopexy TA may occur regardless of the patient's age at orchiopexy, and orchiopexy is recommended irrespective of age at diagnosis.

Effectiveness of a voiding evaluation technique using a diaper equipped with a urination-activated alarm system to assess bladder function and voiding patterns in infants.

PURPOSE: Four-hour voiding observation is a conventional method for evaluating bladder function in infants. However, it requires a diaper check every 5 min during the observation period, which creates an unusual environment for the infant, making the evaluation of natural urination difficult. This study aimed to investigate the parameters of urination before mature bladder function using a diaper equipped with a urination-activated alarm system. METHODS: The study participants were 51 infants aged 0-4 years without bladder dysfunction. A urination-activated sensor was used to notify the inspector wirelessly when urination was detected, enabling the immediate assessment of ultrasonically measured residual urine. Bladder capacity was calculated as the sum of both residual urine volume and micturition volume, and the residual urine rate as the residual urine volume divided by bladder capacity. RESULTS: A total of 36 boys and 15 girls were enrolled. The median (interquartile range) residual urine volume, bladder capacity, and residual urine rate were 3.0 mL (1.1-6.6), 53.0 mL (33.9-75.3), and 7.0% (2.1-15.0), respectively. Infants aged 0-1 and 2-4 years were then classified into Group A (N = 27) and Group B (N = 24), respectively. The residual urine rate was significantly higher in Group A (11.0% [5.4-21.2]) than in Group B (4.8% [0.6-8.9]; p < 0.01). CONCLUSIONS: Voiding observation using a urination-activated alarm system allowed less invasive analysis in infants and revealed that the residual urine rate decreased with mature bladder function from about 2 years of age.

Robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction due to aberrant blood vessel with ipsilateral retrocaval ureter.

INTRODUCTION: Ureteropelvic junction obstruction is a common congenital anomaly that causes hydronephrosis but rarely accompanies ipsilateral retrocaval ureter. CASE PRESENTATION: A 39-year-old woman, who visited to our hospital complaining of worsened right low back pain and fever, was diagnosed with right hydronephrosis due to ureteropelvic junction obstruction by contrast-enhanced computed tomography. Intraoperatively before the planned robot-assisted laparoscopic pyeloplasty, retrograde pyelography was performed to reveal concomitant ipsilateral retrocaval ureter. Laparoscopically, ureteropelvic junction obstruction due to aberrant blood vessel and coexisting retrocaval ureter was confirmed. Transposition of the ureter from posterior to anterior of the inferior vena cava and following dismembered pyeloplasty was performed. Two years after surgery, her right hydronephrosis improved and she had no complain of any symptom. CONCLUSION: Retrocaval ureter is a rare abnormality; however, combination of preoperative retrograde pyelography and laparoscopic evaluation was important for management of this concomitant abnormality.

Guidelines for the medical management of pediatric vesicoureteral reflux.

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow-up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long-term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

Magnetic resonance imaging-guided targeted prostate biopsy: Comparison between computer-software-based fusion versus cognitive fusion technique in biopsy-naïve patients.

OBJECTIVE: To compare magnetic resonance imaging-guided cognitive fusion-targeted biopsies versus computer-software-based fusion-targeted biopsies in prostate biopsy-naïve patients. METHODS: This was a retrospective review of 298 consecutive patients, in which suspected clinically significant prostate cancer lesions were detected on pre-biopsy magnetic resonance imaging, and cognitive fusion-targeted biopsies or software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies was carried out. The positivity rates of any cancer and clinically significant prostate cancer, Gleason score, and maximum cancer core length were compared between the cognitive fusion-targeted biopsies and software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies groups. RESULTS: The any-cancer positivity rate was 79.6% (90/113 patients) in the cognitive fusion-targeted biopsies group and 84.8% (157/185 patients) in the software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies group (P = 0.516), and the clinically significant prostate cancer positivity rate was 72.5% (82/113 patients) in the cognitive fusion-targeted biopsies group and 75.7% (140/185 patients) in the software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies group (P = 0.498). Among the patients in which the largest lesion diameter on magnetic resonance imaging was ≤5.0 mm, the clinically significant prostate cancer positivity rate was 39.2% (11/28 patients) in the cognitive fusion-targeted biopsies group and 66.6% (24/36 patients) in the software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies group (P = 0.043). The median maximum cancer core length was 7.5 mm (0.25-16 mm) in the cognitive fusion-targeted biopsies group and 8 mm (0.2-19 mm) in the software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies group (P = 0.040). CONCLUSIONS: Software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies offers a greater detection rate for smaller targeted lesions and also superior ability to sample greater cancer core length compared with cognitive fusion-targeted biopsies. The present results suggest that software-guided magnetic resonance imaging-ultrasound fusion-targeted biopsies might improve biopsy outcomes compared with cognitive fusion-targeted biopsies.

Laparoendoscopic single-site surgeries: A multicenter experience of 469 cases in Japan.

OBJECTIVE: To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan. METHODS: Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates. RESULTS: Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series. CONCLUSIONS: Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

Neoadjuvant Treatment With Cyclooxygenase-2 Inhibitor and Prednisolone Allows Conservative Surgery for Inflammatory Myofibroblastic Tumor of the Bladder.

Inflammatory myofibroblastic tumor (IMT), which expresses cyclooxygenase-2 (COX-2), can be effectively treated with COX-2 inhibitor. Here, we report a case of urinary bladder IMT in a 13-year-old boy. Although total cystectomy was initially planned for complete resection of the tumor, neoadjuvant treatment with COX-2 inhibitor and prednisolone reduced the size of the tumor and enabled complete resection of the tumor by partial cystectomy. Neoadjuvant treatment with COX-2 inhibitor and prednisolone for IMT of the bladder allowed a more conservative surgical procedure that preserved bladder function.

Transvesical laparoscopic surgery for double renal pelvis and ureter with or without ureterocele.

OBJECTIVE: To evaluate the performance of transvesical laparoscopic surgery for patients with complete double pelvis and ureter. METHODS: A total of 10 patients were included in the present study: five had complete double pelvis and ureter with ureterocele (group A), and five did not have ureterocele (group B). Three small incisions of 5 mm were used, without incision in the lower abdomen. In group A patients, the ureterocele wall was resected, and two ureters were sufficiently detached as a combined ureteral complex. Ureterocele on the side of the bladder wall was sutured to the bladder neck, and the bladder wall was strengthened. According to the cross-trigonal technique, ureterocystoneostomy was carried out in two ureters as a combined ureteral complex. In group B patients, two ureters were sufficiently detached, and ureterocystoneostomy was carried out as in group A. RESULTS: In group A, the mean age was 13.4 years (range 2-34 years). The mean operation time was 304.6 min (242-346 min). In group B, the mean age was 16.6 years (range 2-48 years). The mean operation time was 207.8 min (150-249 min). There were no intraoperative and postoperative complications in both study groups. CONCLUSIONS: Transvesical laparoscopic surgery can be safely and effectively used in patients with double pelvis and ureter.

Laparoendoscopic Single-Site Surgery for Pediatric Urologic Disease.

BACKGROUND: Laparoendoscopic single-site surgery (LESS) was performed for 31 cases of pediatric urologic disease in our department. OBJECTIVE: A retrospective chart review was performed on pediatric patients who underwent LESS. DESIGN, SETTING, AND PARTICIPANTS: Procedures included pyeloplasty (21), nephrectomy (4), varicocele ligation (3), orchiectomy (1), orchiopexy (1), and removal of female genitalia (1). In all 31 cases, an incision of 15 to 20 mm was made in the umbilical region, and a port for LESS was put in place. A 5-mm flexible scope and 5-mm forceps with a bending tip and regular laparoscopic forceps (3, 5 mm) were used. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Intraoperative and postoperative outcomes were evaluated. RESULTS AND LIMITATIONS: For the 21 patients with pyeloplasty, the mean operation time was 240 minutes. Postoperative renal pelvis dilatation was relieved in all patients. For the 4 patients with nephrectomy, the mean operation time was 128 minutes. Postoperative urinary incontinence disappeared in all patients. The mean operation time of varicocele ligation was 73 minutes. Postoperation, varicocele disappeared and there was no testicular atrophy. The operation times of orchidectomy, bilateral orchidopexy, and removal of female genitalia mutilation were 60, 170, and 189 minutes, respectively. In all cases, there were no intraoperative or postoperative complications. CONCLUSIONS: The advantages of LESS include superior aesthetics with a smaller scar and less pain. LESS is considered as a less burdensome surgery for pediatric patients.

The efficacy of radio-frequency ablation for metastatic lung or liver tumors of male germ cell tumors as an alternative minimally invasive therapy after salvage chemotherapy.

BACKGROUND: The aim of this study was to assess the efficacy of radio-frequency ablation (RFA) for metastatic lung or liver tumors of germ cell tumors (GCTs) after chemotherapy. METHODS: RFA with computed tomography guidance and monitoring was performed in 24 patients with 48 metastatic lung or liver tumors of GCTs. Group A consisted of 9 patients with tumor marker normalization after salvage chemotherapy and group B consisted of 15 patients without tumor marker normalization in spite ofintensive treatment. RESULTS: Out of 48 tumors, 41 tumors in 21 patients were evaluated for the efficacy of the RFA treatment. Of the 41 tumors, successful ablation was achieved in 34 (82.9 %). The patients in group A had significantly better survival than the patients in group B (p = 0.0003). In group A, all 9 patients are still alive with no evidence of disease (NED). Patients with a solitary tumor had significantly better survival than those with multiple tumors (p = 0.0247). In group B, 2 patients are alive with NED, 1 patient is alive with disease, and the remaining 12 patients have died a tumor-related death. Three cases of pneumothorax requiring intubation were observed. CONCLUSIONS: RFA is less invasive than surgery and is an effective treatment option for curative and palliative therapy as an alternative to invasive salvage surgery for post-chemotherapeutic metastatic lung or liver lesions from GCT.

Permanent prostate brachytherapy and short-term androgen deprivation for intermediate-risk prostate cancer in Japanese men: outcome and toxicity.

OBJECTIVES: To evaluate the interim outcomes of low-dose-rate permanent brachytherapy (PB) combined with short-term androgen deprivation therapy (ADT) in Japanese men with intermediate-risk prostate cancer excluding those with a Gleason score of 4+3. METHODS: The Protocol-intermediate-risk group (Protocol-IRG) was defined as clinical stage T1c-T2c, Gleason score of 3+4, or lower and prostatic-specific antigen (PSA) level lower than 20 ng/mL. A total of 308 patients underwent brachytherapy in the protocol-IRG group (n=152) or in the low-risk group (n=156). Patients in Protocol-IRG had received at least 6 months of ADT before and after PB. Supplemental external beam radiotherapy was not used. Planned followup by PSA was carried out every 3 months for the first 2 years and every 6 months thereafter. The PSA failure was defined as nadir+2 ng/mL. Patients' Expanded Prostate Cancer Index Composite was recorded before and 3 years after treatment. RESULTS: The median followup was 68 and 68 months for the protocol-IRG and the low-risk groups, respectively. The 5-year biological disease-free survival rates in the low-risk and protocol-IRG groups were 94.8 and 94.6%, respectively. As far as survival rates were concerned, there were no significant differences between the two groups. Overall satisfaction and sexual function at 3 years after PB had significantly improved compared with pretreatment (p=0.01 and p=0.01, respectively). CONCLUSIONS: In intermediate-risk prostate patients, excluding those with a biopsy Gleason score of 4+3, brachytherapy with short-term ADT can be an effective treatment option for Japanese men.

Percutaneous nephrolithotripsy and antegrade ureterolithotripsy in a 10-month-old infant with urinary stones in both kidney and ureter.

The prevalence of urinary tract stones in the pediatric population is lower than that in adults. Although methods of surgery and medical equipment have developed, medical treatments for urinary tract stones are limited for pediatric cases. We report the case of a 10-month-old male infant with urinary stones in the left kidney and ureter who underwent percutaneous nephrolithotripsy and ureterolithotripsy using antegrade insertion of a ureteroscope through the same nephrostomy tract.

CDK1 and CDK2 activity is a strong predictor of renal cell carcinoma recurrence.

BACKGROUND: In renal cell carcinoma (RCC), the prediction of metastasis via tumor prognostic markers remains a major problem. The objective of our study was to evaluate the efficacy of cyclin-dependent kinase (CDK)1 and CDK2 activity as a prognostic marker in human RCC. METHODS: Surgical specimens were obtained from 125 patients with RCC without metastasis. Protein expression and kinase activity of CDKs were analyzed using a newly developed assay system named C2P (Sysmex, Kobe, Japan). We then examined the specific activities (SAs) of CDK1 and CDK2 and calculated CDK2SA-CDK1SA ratio in RCC. Also, risk score (RS) was examined. RESULTS: A total of 125 cases were tested, though 34 cases were excluded because of low sample quality (25 cases) and assay failure (9 cases). In total, 91 cases were analyzed. They included 68 male and 23 female patients, ranging in age from 19 to 83 years. At a median follow-up of 36 months (1-109M), tumor with low CDK2SA-CDK1SA ratio showed significantly better 5-year recurrence-free survival than those with high CDK2SA-CDK1SA ratio (88.7% vs. 54.7%, P = 0.00141). Also, RS enabled the classification of RCCs into high-risk and low-risk groups, and patients with tumors classified as low RS showed better recurrence-free survival than patients with tumors with high RS (88.7% vs. 54.7%, P = 0.0141). CONCLUSION: CDK1SA of tumors and the CDK2SA are both associated with recurrence and prognosis. IMPACT: CDK-based risk demonstrated is strongly associated with clinical outcome. CDK-based risk should be an accurate system for predicting recurrence and survival for planning follow-up.

Experience of laparoscopic partial nephrectomy using a kidney grasper in selective cases.

OBJECTIVE: To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney. MATERIALS AND METHODS: The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper. RESULTS: Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23-25 minutes), and the mean blood loss was 110 mL (range, 20-260 mL). CONCLUSIONS: This procedure may be a useful option in ischemia for partial nephrectomy.

Complete response of sunitinib therapy for renal cell cancer recurrence in the native kidney after renal transplantation: a case report.

BACKGROUND: No case report has yet shown that sunitinib therapy for the postoperative recurrence of renal cancer in a native kidney after renal transplantation can achieve complete response (CR). CASE PRESENTATION: A tumor was detected in the right native kidney of a 35-year-old Japanese male 10 years after renal transplantation. A tumor thrombus that reached the atrium was detected, which suggested cT3cN0M0. Because of the risk of perioperative complications, preoperative therapy with sunitinib was selected and 8 courses were administered. The size of the primary tumor was reduced by 33%, while that of the tumor thrombus was decreased by 39.5%. Right nephrectomy and removal of the tumor thrombus were then performed. Contrast-enhanced computed tomography (CT) four months after surgery suggested local relapse. Sunitinib was administered for 9 months, which led to complete response (CR). CONCLUSIONS: This study presented the case of sunitinib therapy for renal cancer in the native kidney after renal transplantation. The therapeutic efficacy and safety for such cases should be discussed.