Undescended testis: A roundtable discussion based on clinical scenarios - Part 1.

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Could urinary nerve growth factor and bladder wall thickness predict the treatment outcome of children with overactive bladder?

ABSTRACT Objective: Bladder wall thickness (BWTh) measurements and Nerve Growth Factor (NGF) /creatinine (Cr) values, as noninvasive tools, were found to predict daytime voiding problems in children with overactive bladder (OAB). The goal of this research was to examine if bladder wall thickness together with urine NGF/Cr could be a clinical utility in treatment outcome of OAB in children. Patients and Methods: A total of 60 children with OAB, (Group 1; n=40) and healthy normal controls (Group 2; n=20), aged 6-14 years old were involved in this prospective study. Children were evaluated with detailed history and physical examination, including neurologic examination, and were asked to complete a self-reported questionnaire and a 3-day bladder diary with the aid of their parents. Uroflowmetry was performed in all cases. Urinary nerve growth factor levels were measured by the ELISA and BWTh was measured trans-abdominally by one uro-radiologist specialized in pediatric ultrasonography. Urinary NGF levels were normalized by urinary creatinine levels and compared among all subgroups. Children with OAB received urotherapy as first line treatment at least for three months. 18 children refractory to urotherapy received anticholinergic therapy defined as group 3. Results: The median age of the study group was 10 (range 6 to 16). After urotherapy, 22 children had similar BWTh and NGF/Cr values compared to controls. (2.75 ± 1.15; 2.40 ± 1.00 mm; p=0.86 and 1.02 ± 0.10; 0.78 ± 0.15; p=0.12, respectively). After anticholinergic treatment, BWTh levels (2.25 ± 0.90; 2.40 ± 1.00 mm; p=0.94) and NGF/Cr values (0.95 ± 0.10; 0.78 ± 0.15; p=0.42, respectively) had no significantly difference compared to controls (Group 2). In receiver operating characteristic analysis, bladder wall thickness was found to have sensitivity of 85% and specificity of 84.2% (3,20 AUC, 913; 95 %) and NGF/Cr had sensitivity of 90% and specificity of 92.1% (1,595; AUC, 947; 95 %) in predicting treatment outcome in children with OAB. Conclusions: Bladder wall thickness measurements and NGF/Cr values, as noninvasive tools, could guide outcomes in the treatment of children with overactive bladder.

Could urinary nerve growth factor and bladder wall thickness predict the treatment outcome of children with overactive bladder?

OBJECTIVE: Bladder wall thickness (BWTh) measurements and Nerve Growth Factor (NGF) /creatinine (Cr) values, as noninvasive tools, were found to predict daytime voiding problems in children with overactive bladder (OAB). The goal of this research was to examine if bladder wall thickness together with urine NGF/Cr could be a clinical utility in treatment outcome of OAB in children. PATIENTS AND METHODS: A total of 60 children with OAB, (Group 1; n=40) and healthy normal controls (Group 2; n=20), aged 6-14 years old were involved in this prospective study. Children were evaluated with detailed history and physical examination, including neurologic examination, and were asked to complete a self-reported questionnaire and a 3-day bladder diary with the aid of their parents. Uroflowmetry was performed in all cases. Urinary nerve growth factor levels were measured by the ELISA and BWTh was measured trans-abdominally by one uro-radiologist specialized in pediatric ultrasonography. Urinary NGF levels were normalized by urinary creatinine levels and compared among all subgroups. Children with OAB received urotherapy as first line treatment at least for three months. 18 children refractory to urotherapy received anticholinergic therapy defined as group 3. RESULTS: The median age of the study group was 10 (range 6 to 16). After urotherapy, 22 children had similar BWTh and NGF/Cr values compared to controls. (2.75 ± 1.15; 2.40 ± 1.00 mm; p=0.86 and 1.02 ± 0.10; 0.78 ± 0.15; p=0.12, respectively). After anticholinergic treatment, BWTh levels (2.25 ± 0.90; 2.40 ± 1.00 mm; p=0.94) and NGF/Cr values (0.95 ± 0.10; 0.78 ± 0.15; p=0.42, respectively) had no significantly difference compared to controls (Group 2). In receiver operating characteristic analysis, bladder wall thickness was found to have sensitivity of 85% and specificity of 84.2% (3,20 AUC ,913; 95 %) and NGF/Cr had sensitivity of 90% and specificity of 92.1% (1,595; AUC ,947; 95 %) in predicting treatment outcome in children with OAB. CONCLUSIONS: Bladder wall thickness measurements and NGF/Cr values, as noninvasive tools, could guide outcomes in the treatment of children with overactive bladder.

Predicting ESWL success by determination of Hounsfield unit on non-contrast CT is clinically irrelevant in children.

The necessity of determining stone density by non-contrast computerized tomography (NCCT) before extracorporeal shock wave lithotripsy (ESWL) is a controversial topic due to the radiation exposure. We aimed to investigate whether stone density is helpful in predicting the success of ESWL in pediatric patients or not. In this retrospective study, database of a single center was used to identify 232 children aged between 2 and 16 years. Patients with abnormal renal anatomy, distal obstruction, a known cystine stone disease, a previous history of an intervention regarding stone, and an insufficient follow-up period (< 3 months) were excluded from the study. A total of 209 patients were included in the study (94 with NCCT, 115 without NCCT). Groups were compared in terms of stone size, stone location, and stone-free rate at 3 months after a single ESWL session. The mean age was 6.17 ± 3.27 years and 120 (57.4%) of the patients were male and 89 (42.6%) were female. Mean stone size was 11.7 mm in NCCT group and 12.3 mm in non-NCCT group (p 0.128). The complete stone clearance rate in NCCT and non-NCCT group at 3 months after ESWL was 57.4% (54/94) and 54.7% (63/115), respectively, and there was no statistically significant difference (p 0.316). In conclusion, unnecessary NCCT use should be avoided before ESWL considering the similar success rates after ESWL and the risk of exposure to radiation.

Can lockdown and homeschooling change the outcome of urotherapy for lower urinary tract dysfunction in children?

OBJECTIVE: Lower urinary tract dysfunction (LUTD) are still important for both children and pediatric urologists. Urotherapy is recommended in LUTD treatment management. In our country, all citizens under the age of 20 were banned from going out of their homes due to Covid-19 and the homeschooling system has been adopted The aim of this study is to investigate the effect of lockdown and homeschooling on the effectiveness of urotherapy used for LUTD treatment. METHODS: 83 patients were included in the study group. Besides 306 patients were determined as the control group (pre-Covid). The patients in the study group and the control group were compared in terms of improvement in Dysfunctional voiding and incontinence scoring system (DVISS), quality of life scores, bladder diary, Bristol stool scale, and treatment responses at 3rd and 6th months. RESULTS: The study group and control group were compared in terms of DVISS, voiding frequency and incontinence in the voiding diary, quality of life score, and Bristol stool scale at admission visit and the group characteristics were similar. During the 6th month visit, the mean DVISS of the study group was found to be significantly lower (7.12 ± 3.48; 8.58 ± 4.06 respectively (p 0.002)). Daily voiding frequency was similar in the study group and the control group during the 2nd and 3rd visit. The study group's mean number of daily incontinence was significantly lower at visit 3 (0.57 ± 0.9; 0.94 ± 0.27, respectively (p 0.02).After six months of treatment, 13.3% of the study group patients had a complete response, 44.6% had a partial response, whereas 42.2% non-responders. In the control group, the response rates were as 5.9%, 39.2% and 54.9% respectively (p 0.02). CONCLUSIONS: LUTD is still very common in pediatric urology. Standard urotherapy is widely used in treatment management. According to our results, the success of standard urotherapy increases with lockdown and homeschooling. We have shown that the success of standard urotherapy can be improved by regulating environmental conditions. In terms of LUTD management, environmental conditions can be regulated to provide a better quality of life and a better cure in a more economical way.

Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study.

PURPOSE: We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country. MATERIALS AND METHODS: The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR." RESULTS: In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076). CONCLUSION: Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.

The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels.

INTRODUCTION: Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously. OBJECTIVE: To the best of our knowledge, we have not found a study evaluating the effects of primary or recurrent pediatric urological operations on parental anxiety. Our main aim was to compare the effects of primary and repetitive pediatric urological surgeries on the anxiety levels of both mothers and fathers. We also aimed to investigate the effects of other factors related to parents and children on parental anxiety. DESIGN: A total of 163 patients under 14 years old who had undergone primary or recurrent pediatric urological operations and also their parents were included in a prospective, cross-sectional study. Demographic and clinical data of the patients and their parents were recorded. Before the surgeries, the Children's Fear Scale was applied to all patients over 3 years old and the State-Trait Anxiety Inventory was applied to all parents. The participants were divided into two main groups: primary surgery group (n:84) and recurrent surgery group (n:79). A subgroup analysis was performed according to surgery type (day surgery, minor surgery and major surgery). RESULTS: We found that repetitive surgeries, higher fear scores of children, parents' being younger, having low education level, not having enough information about the surgeries and presence of someone in the immediate vicinity who previously experienced the same surgery increased parental anxiety levels. Day surgeries did not affect fathers' state anxiety levels as much as minor and major surgeries, whereas mothers' state anxiety levels were higher than fathers' regardless of the surgery type. Children's fear level was not affected by child age, gender, surgery type or previous history of surgery. DISCUSSION: The majority of studies in the literature show no significant difference in terms of pain and fear levels in pediatric patients undergoing repeated diagnostic interventions but there are contradictory results about parental anxiety levels. There is also a lack of studies on the effects of recurrent surgeries. CONCLUSION: According to our findings, repetitive surgeries and presence of someone who previously experienced the same surgery are the most significant predictive factors increasing parental anxiety levels.

Concealed Penis after Circumcision: Is It Beneficial in Lowering Uropathogenic Colonization in Penile Skin and Preventing Recurrence of Febrile Urinary Tract Infections?

PURPOSE: To  discuss  whether  concealed  penis  after  circumcision  lowers  perimeatal  urethral  and  glanular  sulcus  uropathogenic  bacterial  colonization  in  healthy  boys  with  no  urinary  tract  problems  and  prevents  attacks  of  febrile  urinary  tract  infections  in  non-healthy  boys  with  defined  urinary  tract  abnormalities.  Materials and Methods:  This  case-control  study  was  conducted  in  Ibn-i  Sina  Hospital  and  retrospectively  collected  data  of   471 boys  were  analyzed.  All  patients  were  scanned  for  any  urinary  tract  abnormality  and  those  with  any  defined  abnormalities  were  classified  as  non-healthy  group. (123 patients)  Non-healthy  patients  were  divided  into  two  subgroups  as  concealed  (n:31)  and  non-concealed  (n:92)  penis  after  circumcision.  Healthy  patients  with  no  urinary  problems  were  divided  into  three  groups  as  circumcised  without  concealed  penis  (n:144),  with  concealed  penis  after  circumcision  (n:104)  and  uncircumcised  control  group  (n:100).  Bacterial  cultures  were  obtained  from  both  periurethral  meatal  and  glanular  sulcus  areas  by  adhering  strictly  to  the  rules  of  obtaining  bacterial  culture  to  avoid  false-positive  or  negative  culture  results.  Also  only  uropathogenic  bacterias  were  evaluated,  irrelevant  results  were  excluded.     Results:  Mean  age  was  similar  in  healthy  population.  Comparison  of  three  groups  showed  that  there  was  a  significant  difference  in  both  cultures.(P = .026 for periurethral meatal region, P = .039 for glanular sulcus region)  In  post  hoc  analysis,  non-concealed  group  had  a  lower  rate  of  culture  positivity  in  both  areas  compared  to  other  groups.    Mean  age  was  also  similar  in  non-healthy  population.  Mean  follow-up  period  was  18.2  months.  Patients  with  concealed  penis  after  circumcision  had  a  significantly  higher  number  of  febrile  UTI  attacks  (20 attacks in 8 patients vs 7 attacks in 5 patients)  compared  to  non-concealed  group. (P = .019)  All  febrile  UTI  attacks  except  one  in  this  group  occurred  below  the  age  of  12  months. A  total  of  10 patients  in  both  healthy  and  non-healthy  groups  had  postoperative  hemorrhage  after  circumcision  and  only  1  patient  had  a  wound  infection.          Conclusion:  Concealed  penis  after  circumcision  does  not  lower  perimeatal  urethral  and  glanular  sulcus  uropathogenic  bacterial  colonization  in  healthy  patients  and does not  protect  unhealthy  patients  from  febrile  urinary  tract  infection  attacks.  If  circumcision  is  planned,  concealed  penis  should  be  avoided  and  also  parents  should  be  informed  about  the  possible  risks  due  to  concealed  penis  before  the  procedure,  particularly  in  patients  with  urinary  tract  abnormalities.

What happens to asymptomatic lower pole kidney stones smaller than 10 mm in children during watchful waiting?

BACKGROUND: The optimal management of lower pole kidney (LPK) stones in children is controversial. The aim of this study was to determine the outcomes of children with asymptomatic isolated LPK stones smaller than 10 mm during follow-up. METHODS: A total of 242 patients with 284 stones presenting at our institution between June 2004 and December 2014 with an asymptomatic, single LPK stone with a diameter of <10 mm were enrolled in the study. All children were assigned to receive first-line therapy and then categorized according to the need for medical intervention. Age, gender, stone laterality, stone size and type, associated urinary tract problems, and uncontrolled metabolic status were assessed as predictive factors of medical treatment for small (<10 mm) asymptomatic LPK stones. Stone-free rates were compared between interventions. RESULTS: The mean age and mean stone size were 9.4 ± 1.9 years and 7.4 ± 0.6 mm at admission, respectively. Stone progression rate was 61.2%, and the mean time for intervention was 19.2 ± 4.6 months. Flexible ureterorenoscopy (n = 68) or micro-percutaneous nephrolithotomy (n = 4) were performed for 72 stones (25.4%; group 1), and extracorporeal shock wave lithotripsy was performed for 102 stones (35.9%; group 2). The stone-free rates were 81.8 and 79.3% in group 1 and 2, respectively (p > 0.05). The remaining asymptomatic stones (110, 38.8%; group 3) were managed by continued observation, and at the end of the observation time (mean 40.8 ± 20.8 months) the spontaneous passage rate was 9.1% in this group. In the multivariate analysis, stone size of >7 mm, concurrent renal anomalies, and stones composed of magnesium ammonium phosphate (struvite) and cystine were statistically significant predictors of the need for intervention. CONCLUSIONS: Children with stones larger than 7 mm, renal anomalies, or stones composed of metabolically active cystine or struvite are more likely to require intervention, and those with asymptomatic LPK stones smaller than 10 mm can be managed by continued observation.

Response to Anastrozole Treatment in a Case with Peutz-Jeghers Syndrome and a Large Cell Calcifying Sertoli Cell Tumor.

Peutz-Jeghers syndrome (PJS) is inherited as an autosomal dominant trait characterized by multiple gastrointestinal hamartomatous polyps, mucocutaneous pigmentation, and an increased risk of neoplasm. Large-cell calcifying Sertoli cell tumor (LCCSCT) is a kind of sex cord-stromal tumor which may co-exist with PJS and which is characterized radiologically by calcification foci within the testes. Surgical treatment options for this tumor range from testis-preserving surgery to radical orchiectomy. Not with standing this invasive approach, recently, there are some case reports demonstrating the efficacy of aromatase inhibitors in avoiding orchiectomy and its associated complications. In this paper, we have presented a LCCSCT case diagnosed in a boy with PJS and his response to anastrozole treatment.

Preoperative Risk Factors Predicting Complication Rates of Augmentation Cystoplasty Using the Modified Clavien Classification System in Pediatric Population.

OBJECTIVE: To evaluate preoperative predictive factors for postoperative complications of augmentation cystoplasty in children by using the modified Clavien classification system (MCCS). PATIENTS AND METHODS: A retrospective review of medical records between 1994 and 2014 identified 117 children (64 males and 53 females) who underwent augmentation cystoplasty. Complications were evaluated according to the MCCS. Univariate and multivariate analyses were used to determine predictive factors affecting complication rates. RESULTS: The mean (SD) age was 9.3 (1.9) years and the mean (SD) hospitalization time was 9.7 (3.6) days. Patients with an adverse or unexpected event within 30 days of surgery were identified. Complications occurred in 29 (24.7%) children; 13 (11.1%) were MCCS grade I, 8 (5.1%) were grade II, 5 (4.2%) were grade III, and 3 (2.5%) were grade IV. Antireflux surgery, outlet resistance increasing procedures, Society of Fetal Urology (SFU) grades 3-4 hydronephrosis, posterior urethral valves, scoliosis, and serum creatinine greater than 1.0 mg/dL were statistically significant predictors of complications on univariate analysis. In the multivariate analysis, SFU grades 3-4 hydronephrosis, bladder neck reconstruction, and serum creatinine greater than 1.0 mg/dL were statistically significant independent predictors of complications. CONCLUSION: Augmentation cystoplasty remains a valid method of treating severe bladder dysfunction in children. SFU grades 3-4 hydronephrosis, outlet resistance increasing procedures, and serum creatinine greater than 1.0 mg/dL were the main predictive factors for postoperative complications. Use of a standardized complication grading system, such as the MCCS, should be encouraged to allow the valid comparison of complication rates between series.

Retroaortic Variant of Reverse Horseshoe Kidney With Butterfly Vertebrae Presenting as Neurogenic Bladder.

Horseshoe kidney is a relatively common congenital anomaly. In 95% of the cases, lower poles are connected to each other. In a small subset, an isthmus connects both upper poles (reverse horseshoe kidney). Almost always, the fusion of kidney poles occurs anterior to the aorta and vena cava. The fusion of renal poles posterior to both aorta and vena cava is extremely rare. Herein, we present a case with multiple rare congenital anomalies-retroaortic variant of reverse horseshoe kidney, retroaortic left renal vein, and butterfly vertebrae.

Can the success of structured therapy for giggle incontinence be predicted?

INTRODUCTION: To evaluate possible factors that can guide the clinician to predict potential cases refractoriness to medical treatment for giggle incontinence (GI) and to examine the effectiveness of different treatment modalities. MATERIAL AND METHODS: The data of 48 children referred to pediatric urology outpatient clinic between 2000 and 2013 diagnosed as GI were reviewed. Mean age, follow-up, GI frequency, associated symptoms, medical and family history were noted. Incontinence frequency differed between several per day to less than once weekly. Children were evaluated with uroflowmetry-electromyography and post-void residual urine. Clinical success was characterized as a full or partial response, or nonresponse as defined by the International Children's Continence Society. Univariate analysis was used to find potential factors including age, sex, familial history, GI frequency, treatment modality and dysfunctional voiding to predict children who would possibly not respond to treatment. RESULTS: Mean age of the patients was 8.4 years (range 5 to 16). Mean follow-up time and mean duration of asymptomatic period were noted as 6.7±1.4 years and 14.2±2.3 months respectively. While 12 patients were treated with only behavioral urotherapy (Group-1), 11 patients were treated with alpha-adrenergic blockers and behavioral urotherapy (Group-2) and 18 patients with methylphenidate and behavioral urotherapy (Group-3). Giggle incontinence was refractory to eight children in-group 1; six children in-group 2 and eight children in-group 3. Daily GI frequency and dysfunctional voiding diagnosed on uroflowmetry-EMG were found as outstanding predictive factors for resistance to treatment modalities. CONCLUSIONS: A variety of therapies for GI have more than 50% failure rate and a standard treatment for GI has not been established. The use of medications to treat these patients would not be recommended, as they appear to add no benefit to symptoms and may introduce severe adverse effects.

Effect of Prestenting on Success and Complication Rates of Ureterorenoscopy in Pediatric Population.

INTRODUCTION: In this study, we aimed to investigate the effect of prestenting on success and complication rates of pediatric ureterorenoscopy (URS) procedures. PATIENTS AND METHODS: We retrospectively analyzed the data of 251 pediatric URS cases. Forty-seven of the patients were prestented. Success and complication rates of the prestented and nonprestented groups were compared and further analysis was performed with respect to stone location (renal vs ureteral) and size (7-mm cutoff). Multivariate analysis was performed to define factors associated with success rates. RESULTS: Mean age of the population was 8.9 years. Success rate of the entire population was 80.5% and significant difference between prestented and nonprestented groups was detected (91.5% vs 77.9%, p = 0.04). Higher success rates of the prestented group were also observed in ureteral stones (94.1% vs 79.5%, p = 0.04) and stones >7 mm (84.6% vs 74.1%, p = 0.72). Prestented group showed higher success rates in kidney stones, but the difference was insignificant (84.6% vs 74.1%, p = 0.72). Prestenting was also identified as an independent predictor of success in multivariate analysis. Complication rate in the prestented group was also lower, but the difference was not significant (8.5% vs 14.7%, p = 0.347). CONCLUSIONS: Prestenting was found to increase the success rate of URS in cases of larger stones and ureteral stones in pediatric population. Prestenting also provides lower, but insignificant, complication rates. However, this procedure also has significant disadvantages. Based on the results of current study, we cannot recommend routine prestenting in pediatric cases. Instead, we recommend an attempt to treat the stone in the first session and place a stent in case of failed procedure to utilize potential benefits of prestenting while avoiding disadvantages.

Can the success of structured therapy for giggle incontinence be predicted?

ABSTRACT Introduction: To evaluate possible factors that can guide the clinician to predict potential cases refractoriness to medical treatment for giggle incontinence (GI) and to examine the effectiveness of different treatment modalities. Material and methods: The data of 48 children referred to pediatric urology outpatient clinic between 2000 and 2013 diagnosed as GI were reviewed. Mean age, follow-up, GI frequency, associated symptoms, medical and family history were noted. Incontinence frequency differed between several per day to less than once weekly. Children were evaluated with uroflowmetry-electromyography and post-void residual urine. Clinical success was characterized as a full or partial response, or nonresponse as defined by the International Children's Continence Society. Univariate analysis was used to find potential factors including age, sex, familial history, GI frequency, treatment modality and dysfunctional voiding to predict children who would possibly not respond to treatment. Results: Mean age of the patients was 8.4 years (range 5 to 16). Mean follow-up time and mean duration of asymptomatic period were noted as 6.7±1.4 years and 14.2±2.3 months respectively. While 12 patients were treated with only behavioral urotherapy (Group-1), 11 patients were treated with alpha-adrenergic blockers and behavioral urotherapy (Group-2) and 18 patients with methylphenidate and behavioral urotherapy (Group-3). Giggle incontinence was refractory to eight children in-group 1; six children in-group 2 and eight children in-group 3. Daily GI frequency and dysfunctional voiding diagnosed on uroflowmetry-EMG were found as outstanding predictive factors for resistance to treatment modalities. Conclusions: A variety of therapies for GI have more than 50% failure rate and a standard treatment for GI has not been established. The use of medications to treat these patients would not be recommended, as they appear to add no benefit to symptoms and may introduce severe adverse effects.

Outcomes of Laparoscopic Treatment Modalities for Unilateral Non-palpable Testes.

PURPOSE: To date, laparoscopy has gradually become the gold standard for treatment of non-palpable testicles (NPT) with different success and complication rates. In this study, we aimed to evaluate outcomes of laparoscopic approaches for NPT. MATERIALS AND METHODS: We reviewed data of 82 consecutive patients who underwent laparoscopic treatment for unilateral NPT at two institutions by two high volume surgeons from 2004 January to 2014 December. Laparoscopic-assisted orchidopexy (LAO) and two-stage Fowler-Stephens technique (FST) was performed for 45 and 37 patients, respectively. Age (at surgery), follow-up time, laterality of testes, and postoperative complications were analyzed. Modified Clavien classification system (MCCS) was used for evaluating complications. RESULTS: The median age (at surgery) and median follow-up time were 18 (range: 6-56) and 60 (range: 9-130) months, respectively. Overall success rate for two laparoscopy techniques was 87.8% during the maximal follow-up time. We observed wound infection in two, hematoma in one, testicular atrophy in five, testicular re-ascending in two patients at follow-up period. There was no statistical difference between two laparoscopic techniques for grade I (five vs. two patients, p = 0.14) and grade IIIb MCCS complications (five vs. two patients, p = 0.44). CONCLUSION: Our results have shown that two laparoscopic approaches have low complication rates.

Evaluation of Postoperative Hydronephrosis Following Ureteroscopy in Pediatric Population: Incidence and Predictors.

OBJECTIVE: To identify the incidence and associated factors of the postoperative hydronephrosis in pediatric patients who underwent ureterorenoscopy (URS) for renal or ureteral stones. PATIENTS AND METHODS: We evaluated the results of 116 patients who underwent semirigid or flexible URS retrospectively. Primary end points of the study were to determine the incidence of postoperative hydronephrosis and factors associated with the development of postoperative hydronephrosis. Logistic regression analysis was used to define factors associated with the presence of hydronephrosis. RESULTS: Mean age of the population was 9.5 years and mean stone size was 9.4 mm. Hydronephrosis was detected in 32 (27.6%) patients. Stone-free status was achieved in 101 (87%) patients. Univariate analysis revealed history of ipsilateral URS, duration of operation, presence of impacted stone, development of ureteral injury during operation, and presentation with a renal colic episode as the parameter associated with increased risk of hydronephrosis. History of ipsilateral URS (odds ratio: 1.664, P = .027), presence of impacted stones (odds ratio: 1.788, P = .014), and development of ureteral injury during operation (odds ratio: 1.106, P = .039) were found to be the independent markers of developing postoperative hydronephrosis in a multivariate analysis. CONCLUSION: Ipsilateral hydronephrosis following URS develops in a significant portion of patients. In patients with history of ipsilateral procedure and those with an impacted stone and had ureteral injury, the risk of postoperative hydronephrosis is higher; therefore, physicians should keep these parameters in mind in the decision-making process of selective imaging postoperatively.

HPSE2 mutations in urofacial syndrome, non-neurogenic neurogenic bladder and lower urinary tract dysfunction.

BACKGROUND: Urofacial syndrome (UFS) is characterised by congenital bladder dysfunction accompanied by a characteristic abnormal grimace upon smiling and crying. In recent years, biallelic mutations of HPSE2 and LRIG2 have been reported in UFS patients. Non-neurogenic neurogenic bladder (NNNB) has a bladder identical to UFS without typical facial features. The aim of this study was to analyse HPSE2 mutations in patients with UFS and NNNB or severe lower urinary tract dysfunction (LUTD) without abnormal facial expression. METHODS: Patients with UFS, NNNB and severe LUTD were enrolled in the study. We examined a total of 35 patients from 33 families. There were seven UFS patients from five different families, 21 patients with NNNB and seven with LUTD. HPSE2 gene mutation analysis was performed using the polymerase chain reaction protocol followed by Sanger sequencing in these patients. RESULTS: A twin pair with UFS was found to be homozygous for c.457C>T (p.Arg153*) mutation. No other pathogenetic variant was detected. CONCLUSION: HPSE2 mutations were found in one UFS family but not detected in patients with NNNB and severe LUTD. Considering the increasingly recognised cases of NNNB that were diagnosed in early childhood period, genetic factors appear to be responsible. Thus, further genetic studies are needed to discover novel associated gene variants in these bladder anomalies.

What is the best option for 10-20mm renal pelvic stones undergoing ESWL in the pediatric population: stenting, alpha blockers or conservative follow-up?

OBJECTIVE: In this study we aimed to identify the effect of three different modalities (stenting, doxazosin and conservative follow-up) on stone free rates and complication rates for 10-20mm renal pelvic stones in pediatric patients who underwent shock wave lithotripsy. PATIENTS AND METHODS: In this study data from 241 renal units (RUs) of 195 consecutive patients with 10-20mm renal pelvis stones were analyzed retrospectively. There were 3 groups in the study; 56 (23.2%) RUs with ureteral stenting were categorized as group 1, and 39 (16.2%) RUs that received doxazosin were categorized as group 2. The remaining 146 (60.6%) RUs without history of ureteral stenting or alpha-blockers usage were categorized as group 3. Patient demographics, stone characteristics, stone free rates (SFRs), time to stone expulsion and complications were documented and compared in each group. RESULTS: Mean age of the population was 6.6 years and mean stone size was 13.8 ± 2.9 mm. Demographic characteristics of the 3 groups were not significantly different. SFRs of the three groups were 89.2%, 87.1% and 82.1% (p = 0.275). Mean time to stone expulsion for groups 1 and 2 were 17.4 and 21.8 days respectively and significantly lower than that in group 3 (31.3 days). CONCLUSIONS: Ureteral stenting or doxazosin for shockwave lithotripsy (SWL) is not superior to watchful waiting in terms of SFR and complications however both modalities shorten the stone expulsion time for 10-20mm renal pelvis stones in the pediatric population.