The Safety and Efficacy of Fluoxetine for the Treatment of Refractory Primary Monosymptomatic Nocturnal Enuresis in Children: A Randomized Placebo-Controlled Trial.

PURPOSE: We investigated the efficacy and safety of fluoxetine, a selective serotonin reuptake inhibitor, for treating refractory primary monosymptomatic nocturnal enuresis in children. MATERIALS AND METHODS: Children 8-18 years old with severe primary monosymptomatic nocturnal enuresis unresponsive to alarm therapy, desmopressin, and anticholinergics were screened for eligibility. After excluding children with daytime urinary symptoms, constipation, underlying urological, neuropsychiatric, endocrinological, or cardiac conditions, patients were randomly and equally assigned to 10 mg fluoxetine once daily or placebo for 12 weeks. The primary outcome was treatment response according to the International Children's Continence Society terminology. Treatment-related adverse effects and nighttime arousal were secondary outcomes. RESULTS: A total of 150 children were enrolled, of whom 110 (56 in fluoxetine group and 54 in placebo group) with a mean age of 11.8 (SD 2.46) years were finally analyzed. After 4 weeks, 7.1% and 66.1% of the fluoxetine group achieved complete response and partial response (defined as 50%-99% reduction of the number of wet nights), respectively, versus 0% and 16.7% of the placebo group (P < .001). At 12 weeks, complete and partial responses were achieved in 10.7% and 21.4% of the fluoxetine group, respectively (vs 0% and 14.8% of the placebo group, P = .023). Fluoxetine-treated patients had fewer wet nights (4.7 [SD 4.2] fortnightly vs 9.7 [SD 3.5] at 4 weeks, P < .001; 5.7 [SD 4.4] vs 9.9 [SD 3.4] at 8 weeks, P < .001; 7.5 [SD 4.6] vs 9.9 [SD 3.4] at 12 weeks, P = .003). Fluoxetine was associated with improved nighttime arousal (P = .017), and minor and rapidly reversible adverse effects in 5 (8.9%) patients. CONCLUSIONS: Fluoxetine is safe treatment for refractory primary monosymptomatic nocturnal enuresis in children with good initial response that declines at 12 weeks.

Can Concomitant Bladder Neck Incision and Primary Valve Ablation Reduce Early Re-admission Rate and Secondary Intervention?

OBJECTIVE: To assess the effect of bladder neck morphology and its incision (BNI) in patients with posterior urethral valve (PUV) on early reintervention rate. PATIENTS AND METHODS: Infants undergoing PUV ablation (PVA) before 24 months of age and had at least 18 months of follow-up, were categorized into three groups according to the bladder neck appearance on baseline radiological and endoscopic examination: group 1; normal bladder neck underwent PVA, group 2; high bladder neck underwent PVA plus BNI, group 3; high bladder neck underwent PVA only. Early reintervention was defined as the need for check cystoscopy because of persistent renal function deterioration, worsening hydronephrosis and/or unsatisfactory VCUG improvement during the 1st six months post primary PVA. RESULTS: Between 2000 and 2017, a total of 114 patients underwent PVA and met the study criteria with a median follow-up of 58 (18-230) months. For group 1, 16 (22.9%) patients needed readmission. Check cystoscopy was free and no further intervention was performed in 5(7.5%) and re-ablation was performed in 11(15.7%) patients. For group 2, 3(14.3%) patients needed reintervention. Re-ablation and re-ablation plus BNI were performed in 1(4.8%) and 2(9.5%), respectively. For group 3, cystoscopy was free in 1(4.3%), re-ablation and re-ablation plus BNI were performed 2(8.7%) and 1(4.3%), respectively. There were no significant differences in the re-admission and re-intervention rates among the three study groups (p=0.65 and p=0.50, respectively). CONCLUSION: In morphologically high bladder neck associated PUV, concomitant BNI with PVA doesn't reduce early re-intervention rate.

Shock wave lithotripsy versus endoscopic cystolitholapaxy in the management of patients presenting with calcular acute urinary retention: a randomised controlled trial.

PURPOSE: Shock wave lithotripsy (SWL) in treatment of bladder and urethral stones was not precisely determined. The objective of this study is to compare the efficacy and safety of SWL versus visual cystolitholapaxy in the management of calcular acute urine retention. METHODS: From March 2015 to February 2017, a randomised controlled study was conducted on 100 patients for whom urethral catheter fixed for acute retention of urine due to urethral or vesical radio-opaque stone(s) ≤ 2 cm. Patients were randomised to either SWL group (n = 50) or visual cystolitholapaxy (endoscopy group) (n = 50). RESULTS: No statistically significant differences between the pre-operative parameters of both groups were found. The mean stone diameter was 12.2 ± 3 mm and 12.2 ± 3.2 mm in SWL and endoscopy groups, respectively (p value = 0.4). The overall success rates of SWL group were 94% (47 of 50 patients) and endoscopy group were 98% (49 of 50 patients). SWL failed in 3 patients (6%); these 3 patients underwent cystolitholapaxy and were rendered free of stones. Intra-operative and post-operative complications were comparable between both groups (p value = 0.5 and 1, respectively). One patient had bladder perforation in the endoscopy group and was managed conservatively. CONCLUSIONS: SWL mono-therapy is safe, non-invasive and as effective as visual cystolitholapaxy in management of patients presenting with acute urine retention by vesical or urethral stones 2 cm or less and could be useful for patients unwilling/unfit for general anaesthesia.

Retropubic bulbourethral sling in incontinence post-exstrophy repair: 2-year minimal follow up of a salvage procedure.

AIMS: Post-exstrophy incontinence is a challenge because continence is difficult to achieve and more difficult to maintain. Feasibility and outcomes of a bulbourethral sling to treat post-exstrophy incontinence is shown in this report. METHODS: A retropubic bulbourethral sling was applied to male patients with incontinence post-exstrophy-epispadius repair. The study included children with total (continuous) incontinence who underwent multiple previous anti-incontinence procedures, ranging from bladder neck injection to bladder neck reconstruction. Preoperative assessment includes urinalysis, renal US, VCUG, 1-hr pad test and urodynamics. The bulbourethral sling applied is made of polypropylene and is suspended by 4 pairs of nylon sutures, to support the bulbar urethra within its covering muscles with the sutures tied on the rectus muscles. Continence was evaluated as well as adverse events. RESULTS: Seventeen children, (median age 8.7 years) completed 24-month of follow up. All had CPRE. Five children (29.27%) were dry. Four micturated through the urethra and one by catheterizing his cutaneous stoma every 3-4 hr. In none, PVR exceeded 10% of expected capacity. Four children underwent re-tightening 1-4 weeks after removal of urethral catheter. Perineal wound dehiscence occurred in one, perineal/suprapubic pain in seven and epididymo-orchitis in one child. CONCLUSION: The current technique is promising for difficult cases of incontinence after CPRE. It is safe, as no serious adverse events occurred during follow up period. It is economic and re-tightening is easy to perform. Neurourol. Urodynam. 35:497-502, 2016. © 2015 Wiley Periodicals, Inc.

Bricker Conduit for Pediatric Urinary Diversion--Should we Still Offer It?

PURPOSE: We sought to evaluate long-term outcomes of the Bricker conduit urinary diversion in children. MATERIALS AND METHODS: We retrospectively reviewed the database of a single tertiary center for children who had undergone ileal conduit between 1981 and 2011. Patients followed for less than 1 year were excluded. Patient files were reviewed for demographics, diversion indication, preoperative imaging, surgical details, hospital readmissions and followup data. Renal function at baseline and last followup was assessed by estimated glomerular filtration rate, calculated using the modified Schwartz or MDRD (Modified Diet in Renal Disease) formula. Growth charts elucidated patient growth patterns, while an internally designed quality of life questionnaire demonstrated patient and family satisfaction with the procedure. RESULTS: We evaluated 29 children who underwent Bricker conduit at a median age of 10 years (range 2 to 18) and were followed for a median of 91 months (16 to 389). Neuropathic bladder was the underlying diagnosis in 72.4% of cases. Hydronephrosis improved or remained stable in 39 of 55 studied renal units (70.9%). Although no statistically significant difference was observed between mean ± SD baseline (64.5 ± 46 ml/minute/1.73 m(2)) and last followup estimated glomerular filtration rate (54.1 ± 44.9 ml/minute/1.73 m(2)), chronic kidney disease stage had worsened in 13 patients (44.8%), end-stage kidney disease had developed in 11 patients and 9 patients had died. Six patients underwent undiversion after stabilization of renal function. Linear growth was negatively affected in 12 patients (41.4%), and 85% reported poor quality of life. A total of 19 hospital readmissions were required in 14 patients to treat diversion related complications. CONCLUSIONS: The Bricker conduit does not seem to halt renal deterioration in children. Negative impact on growth and quality of life, and the anticipated rate of complications are significant limitations of the procedure in the pediatric population.

Can computerized tomography accurately stage childhood renal tumors?

PURPOSE: Staging of childhood renal tumors is crucial for treatment planning and outcome prediction. We sought to identify whether computerized tomography could accurately predict the local stage of childhood renal tumors. MATERIALS AND METHODS: We retrospectively reviewed our database for patients diagnosed with childhood renal tumors and treated surgically between 1990 and 2013. Inability to retrieve preoperative computerized tomography, intraoperative tumor spillage and nonWilms childhood renal tumors were exclusion criteria. Local computerized tomography stage was assigned by a single experienced pediatric radiologist blinded to the pathological stage, using a consensus similar to the Children's Oncology Group Wilms tumor staging system. Tumors were stratified into up-front surgery and preoperative chemotherapy groups. The radiological stage of each tumor was compared to the pathological stage. RESULTS: A total of 189 tumors in 179 patients met inclusion criteria. Computerized tomography staging matched pathological staging in 68% of up-front surgery (70 of 103), 31.8% of pre-chemotherapy (21 of 66) and 48.8% of post-chemotherapy scans (42 of 86). Computerized tomography over staged 21.4%, 65.2% and 46.5% of tumors in the up-front surgery, pre-chemotherapy and post-chemotherapy scans, respectively, and under staged 10.7%, 3% and 4.7%. Computerized tomography staging was more accurate in tumors managed by up-front surgery (p <0.001) and those without extracapsular extension (p <0.001). CONCLUSIONS: The validity of computerized tomography staging of childhood renal tumors remains doubtful. This staging is more accurate for tumors treated with up-front surgery and those without extracapsular extension. Preoperative computerized tomography can help to exclude capsular breach. Treatment strategy should be based on surgical and pathological staging to avoid the hazards of inaccurate staging.

Can renal ultrasonography predict early success after pyeloplasty in children? A prospective study.

OBJECTIVE: To study the predictive value of 6 ultrasonographic (USG) parameters for early detection of children at risk of recurrent obstruction. PATIENTS AND METHODS: A prospective nonrandomized study included all patients who underwent pyeloplasty between 2010 and 2012. All of the patients had completed at least 6 months of follow-up and preoperative and postoperative USG imaging data were available. The primary outcome was the correlation between USG and diuretic scintigraphic parameters. The secondary outcome was the predictive ability of the pelvicalyceal system parameters, measured by USG, of parenchymal growth after surgery. RESULTS: Sixty-eight patients were evaluated. The mean age was 3.6 years (range 0.1-12). The mean (± standard deviation) differential renal function improved from 37.4 ± 11 ml/min to 37.7 ± 14 ml/min, which was a difference of no statistical significance. On the other hand, the mean (± SD) half-time (T1/2) significantly improved. After constructing a linear regression model of the 4 USG parameters and the parenchymal growth, the model explained 57.2% of the variance in parenchymal growth after pyeloplasty. The calyx-to-parenchyma ratio change was the largest unique contribution for explaining the variance in parenchymal growth, followed by anteroposterior diameter and calyceal dilatation. CONCLUSION: We proved that calyx-to-parenchyma ratio, anteroposterior diameter and calyceal dilatation are independent predictors of early success after pyeloplasty.

Relation between blood levels of heavy metals and some markers of oxidative stress among boys with neuropathic bladder and posterior urethral valve.

BACKGROUND: The status of heavy metals in children with lower urinary tract pathology that may harm the upper tract, e.g., neuropathic bladder and posterior urethral valve and its relationship with oxidative stress has not been adequately investigated. Therefore, the object of the current work was to evaluate the concentrations of copper, zinc, cadmium and lead and their relations with levels of catalase (CAT), malondialdehyde (MDA) and glutathione (GSH) in boys with neuropathic bladder and posterior urethral valve. METHODS: Thirty-six children with neuropathic bladder, 35 children with posterior urethral valve and 33 health controls were included in the study. In addition to routine laboratory tests, blood samples were collected from patients and controls to assess levels of Cu, Zn, Cd and Pb in addition to plasma concentrations of CAT, MDA and GSH. RESULTS: Significantly elevated levels of Cu, Pb, CAT, MDA and GSH and significantly lower concentration of blood Zn were found in the studied groups compared to the controls. In the posterior urethral valve group, blood level of Cu was positively correlated with GSH while a significantly negative relation was observed between blood Zn and CAT activity among the neuropathic bladder patients. CONCLUSION: Neuropathic bladder and posterior urethral valve may lead to abnormalities in the blood levels of heavy metals (i.e. Cu, Pb and Zn) and markers of oxidative stress (CAT, MDA and GSH). Therefore, the levels of theses metal ions should be monitored during the treatment course of neuropathic bladder and posterior urethral valve patients to prevent or minimize long-term oxidative injury.

Does immunohistochemical staining of P53, Ki 67 and cyclin A accurately predict Wilms tumor recurrence and survival?

Objective: To evaluate whether p53, cyclin A and ki67 immunohistochemical (IHC) assay can be used as predictors for Wilms' tumor (WT) unfavorable outcomes. Methods: It is a non-concurrent cohort study including patients who underwent nephrectomy for WT from January 2000 to December 2015 in a tertiary referral center. Over a 5- year follow-up, unfavorable events, including relapse and cancer-specific mortality (CSM), were recorded. P53, cyclin A, and ki67 IHC assay were carried out for formalin-fixed paraffin-embedded WT samples. Results: After excluding those who did not meet the inclusion criteria, 75 patients were enrolled. Of the patients, 15/75 (20%) experienced WT relapse while 11/75 (14.6%) died of WT over five years. Unfavorable histology (UFH), including prominent blastemal components and anaplasia, was found in 15/75 (20%) children.Cyclin A immunopositivity was associated with high rates of relapse and CSM. P53 and ki67 positive IHC assay did not show any statistically significant association with unfavorable outcomes. Other risk factors e.g. advanced staging, UFH, extracapsular extension, tumor rupture, lymphadenopathy, and venous thrombosis were not associated with poor prognosis. However, the presence of residual tumors was accompanied by lower survival rates. Conclusion: Cyclin A IHC assay can be used as a predictor of WT recurrence and CSM. Further studies with prospective patterns and a larger sample size are needed.Abbreviations: WT: Wilms' tumor, UFH: unfavorable histology, IHC: immunohistochemical, PI: proliferation index, RFS: relapse-free survival, CSS: cancer-specific survival, FH: favorable histology, CSM: cancer-specific mortality, CDK: cyclin-dependent kinase.

Reoperation for Channel Complications in Children With Continent Cutaneous Catheterizable Channels: The Test of Time.

OBJECTIVES: To examine the durability of continent cutaneous catheterizable urinary channels (CCCC) in children and assess whether channel complications continue to arise with extended follow-up. Previous studies demonstrated that complications of CCCC cluster in the early years following surgery. METHODS: The database of a tertiary center was queried for patients≤21 years who underwent CCCC. Patients with <6 years of follow-up were excluded. Patients were invited for follow-up to assess continence. Clinic visits and hospital admissions were reviewed for channel complications requiring reoperation. Complications were analyzed against patient and channel characteristics and time since initial surgery. RESULTS: Between 1993 and 2012, a total of 120 patients underwent CCCC at a median age of 6.8(0.4-21) years and a median follow-up of 11.4(6.6-27) years. CCCC were created using the appendix, Monti channels and tapered ileal segments in 74(61.7%), 33(27.5%) and 13(10.8%), respectively. Continence relied on the extra-mural serous lined principle in 85.8% and the stoma was anastomosed to the umbilicus in 90%. Dryness with catheterization intervals of 3 hours or longer was eventually achieved in 90.8% with similar rates among different channel types (P=.149). 26(21.7%) required 42 interventions to treat channel complications with 32.5% occurring >5 years following initial surgery irrespective of the channel type (P=.978). On multivariate analysis, ileal channels had 3.372 higher odds of needing reoperation compared to appendicovesicostomy (95%CI=1.240-9.166; P = .037). CONCLUSION: A high reoperation rate is anticipated throughout the lifetime of CCCC. Appendicovesicostomy has a low complication risk relative to ileal channels.

Posterior urethral valves: multivariate analysis of factors affecting the final renal outcome.

PURPOSE: Posterior urethral valves represent the most common obstructive uropathy in children with a broad spectrum of clinical severity. We evaluated prognostic variables affecting the outcome of renal function in such children. MATERIALS AND METHODS: Between 1987 and 2004, 120 patients with a mean age of 2 years with posterior urethral valves were treated initially with valve ablation at our center. We studied certain parameters, including age at presentation, serum creatinine (initial and nadir), initial creatinine clearance, renal ultrasound findings (hydronephrosis and renal parenchymal echogenicity), vesicoureteral reflux on initial voiding cystourethrogram, bladder dysfunction and popoff mechanisms such as the syndrome of large vesical diverticulum, urinoma and ascites. Long-term renal outcome was assessed. RESULTS: Followup was 2 to 16 years (median 3.6). Renal insufficiency developed at the end of followup in 44 patients (36.5%). Serum creatinine at hospital admission, nadir serum creatinine, initial creatinine clearance and renal parenchymal echogenicity were significant predictors of the final renal outcome (p < 0.05). Patient age at diagnosis (2 or less vs greater than 2 years), upper tract dilatation, the presence or absence of vesicoureteral reflux, popoff mechanisms and bladder dysfunction had no significant impact on future renal function. On multivariate analysis nadir serum creatinine was the only independent prognostic factor. CONCLUSIONS: Our data confirm the high prognostic value of nadir creatinine after primary valve ablation. Also, initial serum creatinine, creatinine clearance and renal parenchymal echogenicity on initial renal ultrasound correlate significantly with long-term renal function in children with posterior urethral valves.

Durability of oncological outcomes of combination chemotherapy as a monotherapy for a select patient subset with non-metastatic non-alveolar bladder/prostate rhabdomyosarcoma.

INTRODUCTION AND OBJECTIVES: We aim to assess the long-term oncological outcomes of children with bladder/prostate rhabdomyosarcoma (B/P RMS) treated with multiagent chemotherapy as a monotherapy. We hypothesize that a highly select patient subset can be treated with multiagent chemotherapy as a monotherapy and spared the morbidity of local treatment with similar oncological outcomes. METHODS: Patients (≤21-year-old) treated for non-metastatic non-alveolar B/P RMS at a tertiary center and followed for>one year, were retrospectively reviewed. After pathological confirmation, patients received 12 weeks of induction VAC chemotherapy (IC) followed by second-look biopsies. Between 1996 and 2006 (group A), patients with>50% tumor size reduction and negative second-look biopsies following IC were spared local treatment and followed-up closely. Between 2007 and 2020 (group B), local treatment was routinely given at 12 weeks according to the COG protocols, irrespective of IC response. For all patients, consolidation chemotherapy was administered for additional 12-18 months. RESULTS: Between 1996 and 2020, 27 patients (10 stage II, 17 stage III) with a median age of 3(1-21) years were included. Median follow-up was 87.5(15.3-247.1) months. Among 15 patients in group A, 3 were ineligible for the monotherapy protocol and received local treatment. The remaining 12 patients [9 complete (CR) and 3 incomplete response (IR) to IC] were treated exclusively with chemotherapy, of whom 9 were alive free of relapse at last follow-up. Two patients with IR to IC had disease relapse: one had pulmonary relapse at 8.2 months and one had local relapse at 35 months. The 5-year OS and EFS of group A were 86.7% and 80%, respectively. Analyzing survival according to IC response, CR to IC was achieved in 10 patients (9 group A and one group B) and was associated with significantly better OS and EFS than IR(p = 0.026 and 0.004, respectively) (Summary figure). All patients with CR to IC were alive free of relapse at last follow-up. DISCUSSION: Treatment of RMS is traditionally multimodal. Local treatment of B/P RMS is associated with significant patient morbidity. In this study, CR to IC predicted better OS and EFS. Patients who achieved CR (radiological and pathological) to IC remained alive free of relapse irrespective of local treatment. CONCLUSIONS: Our results suggest that patients with non-metastatic non-alveolar B/P RMS who achieve CR to IC can be treated with combination chemotherapy as a monotherapy and spared the morbidity of local treatment with durable survival outcomes. Prospective validation in a larger patient cohort is needed to support our hypothesis.

Chemically modified rice husk as an effective adsorbent for removal of palladium ions.

Bio-matrix of rice husk and Mobil Composition of Matter No. 41 (MCM-41) was modified with alizarin red S for preconcentration of Pd2+ prior flame atomic absorption spectrometric determination. The prepared bio-matrix (RH@MCM-41@ARS) was characterized by Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), transmission electron microscope (TEM), scanning electron microscope, energy dispersive X-ray spectrometer (SEM/EDX) and surface area studies. The impact of different parameters (solution pH, amount of sorbent, contact time, sample volume, initial Pd2+ concentration and diverse ions) on the uptake of Pd2+ were evaluated. The maximum adsorption capacity of Pd2+ onto RH@MCM-41@ARS was 198.2 mg g-1 at optimum conditions. Applying the optimized procedure as a preconcentration step led to limit of detection of 0.13 µg L-1 and dynamic analytical range up to 500 µg L-1. The sorbent was regenerated by 0.5 mol L-1 thiourea for at least 10 cycles without significant reduction of adsorption capacity. The method was applied for preconcentration of Pd2+ from real samples.

Management of bladder exstrophy epispadias complex in adults: is abdominal closure possible without osteotomy?

PURPOSE: Presentation of bladder exstrophy epispadias complex (BEEC) during adulthood is rare. A major surgical challenge encountered in adults with BEEC is the closure of the anterior abdominal wall defect. In this case series we report our experience with the abdominal closure without osteotomy. MATERIALS AND METHODS: Five adult male patients with BEEC were managed at our center. None of the patients had any prior attempts of surgical correction. A right renal tumor was incidentally discovered in one patient and a right partial nephrectomy was performed. All patients underwent urinary diversion and abdominal wall closure at the same operative setting except one. Cystectomy was performed in two patients while the vesical plate muscular coat was utilized for providing support to the anterior abdominal wall in the other three patients. One patient underwent an ileal conduit, while the other patients underwent continent cutaneous diversion. None of our patients underwent osteotomy. RESULTS: Follow-up ranged from 6 to 52 months (mean = 31). Patients who underwent continent cutaneous diversion were continent by day and night. One patient had wound infection and partial disruption and secondary sutures were performed. One patient developed stomal stenosis and was managed by stomal dilatation. All patients showed marked satisfaction with their body image following surgery. CONCLUSION: Management of BEEC in adults is challenging. Utilization of the vesical plate muscular coat for supporting the anterior abdominal wall is a reliable method for abdominal reconstruction. Urinary diversion and abdominal wall closure in one surgical procedure without osteotomy is feasible.

Urethrorectal fistula repair in children: urologic perspective.

OBJECTIVES: We report our experience in the management of urethrorectal fistulae in children with emphasis on the complexity of this rare disease. PATIENTS AND METHODS: A retrospective review was performed in cases that underwent repair of urethrorectal fistula at our center between 1997 and 2007. Records were reviewed for age, history, presentation, radiologic data, operative data, and condition at last follow-up. RESULTS: Five children were managed for urethrorectal fistula. Their mean age was 6.8 years (range, 2 months-12 years). One case had congenital urethrorectal fistula and four had acquired fistulas including two after abdomino-perineal pull through for imperforate anus, one case post perineal urethroplasty, and another post repair of posttraumatic rectal tear. All patients presented with history of passing urine both through the rectum and the urethral meatus. We have three urinary diverted cases: one case in whom urinary and fecal diversions were performed and the remaining case was operated without diversion. Perineal approach was adopted in four procedures and abdomino-perineal approach in one. One patient required optical internal urethrotomy for anastomotic stricture at 6 months follow-up. CONCLUSIONS: Urethrorectal fistula is a rare complication whether congenital or iatrogenic. Perineal repair is challenging, necessities meticulous dissection, adequate vascularity of the edges, and interposition of vascularized flaps and is potentially successful.

Ileal Neobladder With A Continent Cutaneous Catheterizable Channel Using the Extramural Serous Lined (Mansoura) Technique in A Bladder Exstrophy Patient.

INTRODUCTION AND OBJECTIVE: Continent cutaneous diversion is an appealing option when orthotopic diversion is not feasible and continence preservation is desired. We describe the surgical technique of creating an ileal w-neobladder with a continent catheterizable channel using the extramural serous lined (Mansoura) principle in a bladder exstrophy patient. MATERIALS AND METHODS: A 9-year-old boy born with classic bladder exstrophy, underwent cystectomy and a sigma rectosigmoid pouch after multiple unsuccessful attempts of exstrophy reconstruction. Colonic diversion was complicated by refractory metabolic acidosis, ureteral obstruction and recurrent pyelonephritis. Ileal neobladder with a continent stoma was recommended after family counseling. RESULTS: A 50-cm segment of the terminal ileum is isolated. The proximal 7 cm of the isolated segment are partly tailored and used as an afferent limb. The appendix is used for creating the catheterizable channel. The remainder of the ileal segment is fashioned in a w-configuration. Extramural serous-lined tunnels are created between the lateral limbs of the pouch. The appendix and afferent ileal segment are embedded in the serous lined tunnels to achieve continence and antireflux mechanisms, respectively. The ureters are, thereafter, anastomosed to the afferent ileal segment in an end-to-side fashion. Umbilicoplasty was done using the VQZ-plasty technique. CONCLUSION: Conversion to an ileal neobladder is an option in patients who suffer the complications of colonic diversion. The extramural serous-lined technique is a versatile technique that can be used for creating antireflux and continence mechanisms.

Does intraoperative penile tourniquet application during hypospadias repair affect the patients and surgeons reported outcomes? A randomized controlled trial.

BACKGROUND: Hemostasis aimed to maintain the bloodless surgical field for better exposure for the surgeon. There are no trials regarding the impact of hemostasis techniques for hypospadias surgery on surgeon satisfaction and patients' reported outcomes. Application of penile tourniquet is a common practice in hypospadias surgery that aims at reducing blood loss and improving visualization. Yet, scarce data exist on the effect of penile tourniquet on hypospadias repair outcomes. PURPOSE: To evaluate the safety and efficacy of restraining penile perfusion using a tourniquet in hypospadias repair on the surgical outcome, also surgeons and patients reported outcomes. To evaluate the effect of penile tourniquet application on hypospadias repair outcome and surgeon's satisfaction with intraoperative hemostasis. STUDY DESIGN: In this single-blinded randomized controlled trial, a total of 110 children with distal hypospadias amenable for TIP repair were assigned to hypospadias repair with or without intraoperative application of a penile tourniquet. Surgeries were performed by a junior (2-5 years of experience in TIP repair) or a senior pediatric urologist (with >5 years of experience). Intraoperative blood loss, the number of times bipolar diathermy was used, hemoglobin deficit, and operative time were compared. Surgeon's satisfaction with intraoperative hemostasis was evaluated using a 4-tiered questionnaire. Patients were followed up for a minimum of one year. Complications and readmission rates were compared. The patient-reported outcome of hypospadias repair was assessed using the hypospadias objective scoring evaluation (HOSE). RESULTS: Baseline patient demographics and hypospadias characteristics were comparable between the study groups. Bipolar diathermy was more often used in the non-tourniquet group (mean ± SD = 5.7 ± 1.8 times vs. 6.7 ± 1.9 for the tourniquet group; p = 0.007). Also, the operative time was longer in non-tourniquet group [mean = 54.7 ± 14.9 vs. 60.8 ± 12.5 min (p = 0.028)]. Junior surgeons were more likely to be satisfied with hemostasis when a tourniquet was used (97.4% vs. 79.5%, p = 0.02). Postoperative complications, readmission rates, and patient-reported outcomes were similar between both groups. CONCLUSION: The application of penile tourniquet during hypospadias repair can reduce operative time and the need for diathermy use; and also improves junior surgeon's satisfaction with intraoperative hemostasis without adversely affecting success rates or patient-reported outcomes.

Are Prophylactic Measures Necessary to Prevent Recurrence of Penile Keloids?

Keloid scars result from excess collagen deposition in the dermis or subcutaneous tissue in response to surgery or tissue trauma. The penis is a rare site for keloid formation, even in predisposed individuals. Only few cases of penile keloids have been reported so far. In this report, we present penile keloids complicating neonatal circumcision in twin brothers. Risk of recurrence in previous reports and measures to guard against its occurrence are also discussed.

Does grafted tubularized incided plate improve the outcome after repair of primary distal hypospadias: A prospective randomized study?

OBJECTIVE: To detect whether grafting the incised plate during Snodgrass repair would improve outcome. MATERIALS AND METHODS: Sixty patients with primary distal hypospadias were included. Patients were equally randomized using closed envelop method to either Snodgrass or grafted tubularized incised plate repair (GTIP). All operations were performed by a single surgeon. All intaroperative data were recorded. All patients were followed up for 1 year. Success was defined as slit shaped meatus at the tip of the glans with no stenosis, fistula or diverticulum. RESULTS: All 60 patients were evaluated at 1 year of follow-up. Mean age at surgery was 40±15months. Both groups were comparable as regard to patients' age, meatus location, length and width and depth of urethral plate and glans width. Success was documented in 29/30 patients (96.7%) in the Snodgrass group. The only complication was meatal stenosis in one patient, whereas success was documented in 28/30 patients (93.3%) in the GTIP group. The two failures were secondary to partial glans dehiscence. Success rate was not statistically different. Flow rate data at 1 year showed insignificant difference between both groups as regards Q-max and voiding time. The only statistically significant difference between both groups was a longer operative time 106±12min in the GTIP group compared to only 77±9 for the Snodgrass group (p = 0.005). CONCLUSIONS: Snodgrass and GTIP techniques for primary distal hypospadias repair have similar outcome. With a significantly shorter operative time, Snodgrass repair remains the first choice for primary distal hypospadias repair. TYPE OF THE STUDY: Prospective randomized study. LEVEL OF EVIDENCE: Level I.