Zero-echo time MRI: an alternative method for the diagnosis of urinary stones in children.

OBJECTIVES: To evaluate the potential of zero-echo time-magnetic resonance imaging (ZTE-MRI) in the assessment of urolithiasis and compare ZTE-MRI with computed tomography (CT) in pediatric patients. MATERIALS AND METHODS: This was a single-center, prospective cross-sectional study conducted between April 2023 and December 2023. 23 patients (12 girls, 11 boys; mean age: 12.3, range 1-18) with urinary tract stones detected on non-enhanced abdominal CT were enrolled. The images were evaluated independently by two radiologists for the presence, and number of stones in the kidneys, ureters, and bladder. In the second session, two radiologists evaluated whether urinary tract stones could be detected by MRI compared to CT, and the maximum diameter of the stones was measured. The CT and MRI results were compared with the Wilcoxon test. The agreement between the results of the observers was examined using Spearman's rho correlation coefficient and the intraclass correlation coefficient. RESULTS: A total of 58 urinary tract stones were detected by CT and 39 of these were detected by MRI. Most of the stones that MRI could not detect were < 5 mm and the detection sensitivity of MRI increased in correlation with stone size (p < 0.001). There was poor intermodality agreement for stones < 5 mm, substantial agreement for stones 5-10 mm, and almost perfect agreement for stones > 10 mm. Interobserver agreement for stone detection on MRI was almost perfect for stones > 10 mm and 5-10 mm and was substantial for stones < 5 mm. CONCLUSION: ZTE-MRI is a promising modality for detecting urinary stones without radiation exposure in children. CLINICAL RELEVANCE STATEMENT: Zero-echo time-magnetic resonance imaging is a potential method for identifying urinary stones in children and other populations who are particularly sensitive to radiation. KEY POINTS: Urinary system stone disease in children is increasing and imaging is needed for managing urolithiasis. Zero-echo time-magnetic resonance imaging (ZTE-MRI) had an accuracy of 81.8% and 93.7% for stones larger than 5 mm and 10 mm, respectively. ZTE-MRI is a potential non-irradiating method for the diagnosis and management of urolithiasis.

Discontinuing absorbent pants in children with bedwetting: a randomized controlled trial.

The objective of this study is to examine the effect of discontinuing wearing protective garments (absorbent pyjama pants - APP) in children with severe childhood nocturnal enuresis (NE). The study employs a multicenter, parallel, randomized controlled trial. Following a 4-week run-in period, participants were randomly allocated in a 2:1 group allocation to discontinue or continue using APP. The research was conducted across seven European pediatric incontinence centers. The study included treatment-naïve children aged 4-8 years with severe (7/7 wet nights per week) mono-symptomatic NE, who had used nighttime protection for at least 6 months prior to the study. The study consisted of a 4-week run-in period (± 7 days), where all children slept wearing APP (DryNites®). At week 4 (± 7 days), if meeting randomization criteria (7/7 wet nights during the last week of run-in), participants were randomized to continue to sleep in APP or to discontinue their use for a further 4 weeks, with the option of another 4 weeks in the extension period. The primary outcome was the difference between groups of wet nights during the last week of intervention. Quality of life (QoL) and sleep were secondary endpoints. In total, 105 children (43 girls and 62 boys, mean age 5.6 years [SD 1.13]) were randomized (no-pants group n = 70, pants group n = 35). Fifteen children (21%) in the no-pants group discontinued early due to stress related to the intervention. Children in the no-pants group experienced fewer wet nights compared to the pants group during the last week (difference 2.3 nights, 95% CI 1.54-3.08; p < 0.0001). In the no-pants group, 20% responded to the intervention, of whom 13% had a full response. Clinical improvement was detected within 2 weeks. Sleep and QoL were reported as negatively affected by APP discontinuation in the extension period but not in the core period.    Conclusion: A ~ 10% complete resolution rate was associated with discontinuing APP. While statistically significant, the clinical relevance is debatable, and the intervention should be tried only if the family is motivated. Response was detectable within 2 weeks. Discontinuing APP for 4-8 weeks was reported to negatively affect QoL and sleep quality. No severe side effects were seen.Trial registration: Clinicaltrials.gov Identifier: NCT04620356; date registered: September 23, 2020. Registered under the name: "Effect of Use of DryNites Absorbent Pyjama Pants on the Rate of Spontaneous Resolution of Paediatric Nocturnal Enuresis (NE)."

Efficacy of transcutaneous posterior tibial nerve stimulation in children with functional voiding disorders.

AIMS: To assess the efficacy of transcutaneous posterior tibial nerve stimulation (TPTNS) on functional voiding disorder (FVD) and investigate the utility of urine biomarkers (UBs: nerve growth factor, transforming growth factor-beta 1, and tissue inhibitor of metalloproteinases 2) in diagnosis and follow-up. METHODS: A total of 44 children were included to this randomized controlled trial prospectively. After randomization, 20 of 30 children with storage phase dysfunction those were unresponsive or noncompliant to medical treatment received TPTNS treatment (test group) and 10 children underwent TPTNS with no current (sham group) for 12 weeks. Fourteen healthy children constituted the nonsymptomatic group. UB levels, dysfunctional voiding and incontinence scoring system (DVISS), voiding diary, and quality of life (QoL) scores were assessed before and after treatment in the treatment groups. RESULTS: QoL scores, overall and day-time DVISS scores were significantly decreased in both sham and test groups (p < 0.05). In addition to these findings, the frequency of incontinence and urgency episodes were also significantly reduced (p < 0.05) in the TPTNS treatment group. This effect in the test group was still valid 2 years after intervention. There was no significant difference in UBs measurements between treatment and nonsymptomatic groups and between pretreatment and posttreatment measurements of test and sham groups. CONCLUSIONS: TPTNS is an efficient minimally invasive treatment in children with FVD who do not respond to medical treatment. TPTNS provides a significant improvement on episodes of frequency, episodes of incontinence, overall and day-time DVISS scores, and QoL scores. The effectiveness of treatment continues even at the end of the second year of intervention. UBs were not found to be predictive in terms of diagnosis and evaluating the treatment response.

Factors associated with the stone-free status after retrograde intrarenal surgery in children.

INTRODUCTION: Paediatric urolithiasis has a recurrent nature because it is frequently associated with metabolic or anatomical disorders or infectious conditions. The rising incidence of the disease with its recurrent nature emphasises the need for minimally invasive therapeutic options. In this study, we aimed to evaluate efficacy and factors affecting the success of retrograde intrarenal surgery (RIRS) in children. MATERIALS AND METHODS: Patients who underwent RIRS were evaluated retrospectively. Two different flexible ureteroscopes (F-URS) were used (7.5F F-URS and 7.95F with a 4.9F bullet-shaped tip). Irrespective of size, all residual fragments were considered as failure. Age, stone size, stone localisation, Hounsfield Unit (HU), stone-free rate (SFR) and complications were evaluated. RESULTS: Forty-six patients (29 boys and 17 girls) with a median age of 70.5 months (6-214 months) were treated with RIRS between August 2014 and November 2019. The median operative time was 60 minutes (45-120 minutes). The median follow-up was 26 months (3-65 months). Fourteen patients had lower pole and 10 patients had multiple stones. Ureteral access sheath (UAS) was used in 16 (35%) patients. SFR was 61%. The median number of general anaesthesia was 2 (min 1, max 5). Auxiliary semirigid URS, PCNL and repeat RIRS were required in 4, 6 and 5 patients, respectively. Two patients had postoperative febrile urinary tract infection (UTI) as a complication. Age was associated with post-operative febrile UTI. Presence of stones with HU lower than 700, being operated 4.9F F-URS and without UAS were associated with better SFR. CONCLUSIONS: RIRS is a minimally invasive method with low complication rates in the treatment of childhood stone disease. Higher stone-free rates are obtained in low HU stones and cases in which we used 4.9 F tip F-URS.

Changes in percutaneous approach to kidney stones in children: A single institute experience over 500 cases.

PURPOSE: The aim of this study is to identify the changes in patient age and stone sizes with technological advancement over time. METHODS: This study was conducted retrospectively with 404 patients (504 renal units) who underwent percutaneous nephrolithotomy (PCNL) between January 1997 and June 2020. Patient characteristics and trends on instrument preferences were investigated. RESULTS: Median age was 7 (1-18) years. Male to female ratio was 1.48:1 (301/203). Median stone burden was 2 cm2 (0.20-25) and median operative time was 90 minutes (20-240). The stone-free rate was 74.6%. Patients were divided into four groups according to the size of the instrument. It was found that the size of sheath used increased significantly with increasing age and stone burden. The micro-PCNL group had the shortest hospitalisation and lowest blood transfusion rate. Chronologically categorised four equal groups were compared to analyse changing patient profiles and trends. Median patient age, stone burden, operation time, sheath size, blood transfusion and complication rates decreased significantly with time. However, the use of tracts smaller than 20F and the number of patients with previous intervention increased significantly. CONCLUSION: Our study demonstrated that the patient's age and stone size at the time of initial diagnosis decrease over time while miniaturisation techniques increase in paediatric urology.

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.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting.

BACKGROUND AND AIMS: The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist. MATERIAL AND METHODS: Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members. RESULTS: The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors. CONCLUSION: Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part II operative management.

BACKGROUND: Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor. MATERIAL & METHODS: After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS: In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option. CONCLUSION: In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early.

EAU/ESPU guidelines on the management of neurogenic bladder in children and adolescent part I diagnostics and conservative treatment.

BACKGROUND: In childhood, the most common reason for a neurogenic bladder is related to spinal dysraphism, mostly myelodysplasia. AIMS: Herein, we present the EAU/ESPU guidelines in respect to the diagnostics, timetable for investigations and conservative management including clean intermittent catheterization (CIC). MATERIAL AND METHODS: After a systematic literature review covering the period 2000 to 2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update. RESULTS: The EAU/ESPU guideline panel advocates a proactive approach. In newborns with spina bifida, CIC should be started as soon as possible after birth. In those with intrauterine closure of the defect, urodynamic studies are recommended be performed before the patient leaves the hospital. In those with closure after birth urodynamics should be done within the next 3 months. Anticholinergic medication (oxybutynin is the only well-investigated drug in this age group-dosage 0.2-0.4 mg/kg weight per day) should be applied, if the urodynamic study confirmed detrusor overactivity. Close follow-up including ultrasound, bladder diary, urinalysis, and urodynamics are necessary within the first 6 years and after that the time intervals can be prolonged, depending on the individual risk and clinical course. In all other children with the suspicion of a neurogenic bladder due to various reasons as tethered cord, inflammation, tumors, trauma, or other reasons as well as those with anorectal malformations, urodynamics-preferable video-urodynamics, should be carried out as soon as there is a suspicion of a neurogenic bladder and conservative treatment should be started soon after confirmation of the diagnosis of neurogenic bladder. With conservative treatment the upper urinary tract is preserved in up to 90%, urinary tract infections are common, but not severe, complications of CIC are quite rare and continence can be achieved at adolescence in up to 80% without further treatment. DISCUSSION AND CONCLUSIONS: The transition into adulthood is a complicated time for both patients, their caregivers and doctors, as the patient wants to become independent from caregivers and treatment compliance is reduced. Also, transition to adult clinics for patients with neurogenic bladders is often not well-established.

EAU-ESPU guidelines recommendations for daytime lower urinary tract conditions in children.

The objective is to review the literature related to lower urinary tract (LUT) conditions in children to conceptualize general practice guidelines for the general practitioner, pediatrician, pediatric urologist, and urologist. PubMed was searched for the last 15-year literature by the committee. All articles in peer-review journal-related LUT conditions (343) have been retrieved and 76 have been reviewed extensively. Prospective trials were few and the level of evidence was low. Most of the recommendations have been done by committee consensus after extensive discussion of literature reports. History taking is an integral part of evaluation assessing day- and nighttime urine and bowel control, urgency, and frequency symptoms. Exclusion of any neurogenic and organic cause is essential. Uroflowmetry and residual urine determination are recommended in all patients to evaluate bladder emptying. Urodynamic studies are reserved for refractory or complicated cases. Urotherapy that aims to educate the child and family about bladder and bowel function and guides them to achieve normal voiding and bowel habits should initially be employed in all cases except those who have urinary tract infections (UTI) and constipation. Specific medical treatment is added in the case of refractory overactive bladder symptoms and recurrent UTIs.Conclusion: Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.What is Known:• Symptoms of the lower urinary tract may have significant social consequences and sometimes clinical morbidities like urinary tract infections and vesicoureteral reflux. In many children, however, there is no such obvious cause for the incontinence, and they are referred to as having functional bladder problems.What is New:• This review aims to construct a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist, and urologist for LUTS in children. Producing recommendations for managing LUTS in children based on high-quality studies is not possible. LUTS in children should be evaluated in a multimodal way by minimal invasive diagnostic procedures. Urotherapy is the mainstay of treatment and specific medical treatment is added in refractory cases.

Our experience on management of failed pediatric pyeloplasty.

PURPOSE: The purpose of the study was to assess the outcomes of salvage procedures after failed pediatric pyeloplasty. Recurrent ureteropelvic junction obstruction treatment is a difficult course. The salvage surgery is more challenging in the pediatric population. We aimed to assess the outcomes of salvage procedures after failed pediatric pyeloplasty to determine the most efficient surgical intervention. METHODS: 40 children with 41 renal units who have been treated for recurrent ureteropelvic junction obstruction after pyeloplasty were analyzed retrospectively. The outcomes of all initial and sequent interventions were assessed including redo pyeloplasty, endopyelotomy and balloon dilatation. RESULTS: Children's mean age at initial intervention for failed pyeloplasty was 45.9 (± 46.4) months. Our mean follow-up time after the initial intervention was 46.9 (± 46.6) months. The success rate of our initial treatment methods was 48.7% (20/41). Although redo pyeloplasty was the most successful intervention (83.3%) than DJS placement (45.5%), endopyelotomy (50%) and balloon dilatation (30.8%), the statistical difference was not significant in the initial operations. The overall success rates of redo pyeloplasty, double-J stent placement, endopyelotomy and balloon dilatation were 78.9%, 46.1%, 38.8% and 29.4%, respectively (p < 0.05). CONCLUSIONS: Redo pyeloplasty provides the best improvement in recurrent ureteropelvic junction obstruction in children. In selected patients, minimal invasive methods such as endopyelotomy and balloon dilatation offer alternative treatment.

Are EAU/ESPU pediatric urology guideline recommendations on neurogenic bladder well received by the patients? Results of a survey on awareness in spina bifida patients and caregivers.

AIMS: The Paediatric Urology Guidelines Panel reports initial experience with patient involvement in spina bifida patient groups to gather information on their awareness of the guidelines and reflection of guideline recommendations. METHODS: The survey was delivered to spina bifida patients/parents via the national society groups in Turkey, Germany, and The Netherlands. Questions included demographic features, medical status, awareness, and agreement on the recommendations given in the guidelines and future expectations. RESULTS: A total of 291 patients from 3 countries responded to the survey. Mean age was 13.9 ± 12.2 years, male/female ratio 138/151, 75% of all surveys were completed by the caregivers. The medication was taken by 78% of patients (64% anticholinergics). Complete dryness rates for urine and stool were 24% and 47%, respectively. The agreement rates on the recommendations regarding urodynamics, intermittent catheterization, anticholinergics drug use, bowel management, and life-long follow-up were 97%, 82%, 91%, 77%, and 98%, respectively. Only 8% of responders were aware of the European Association of Urology/European Society for Pediatric Urology guidelines. The priorities of patients for future expectations were as the following: quality of life (QoL), surgical techniques, development of new medications and sexuality/fertility issues. Male spina bifida patients preferred new medications and sex/fertility issues more, whereas females favored QoL issues improvement more. CONCLUSIONS: Although the native language of the involved patients was different from English, awareness of guidelines was 8%. The general approval of the recommendations given in the guidelines is quite high. The national society groups showed a great interest to get involved in the creation of the guidelines to improve health care for spina bifida patients.

Can we predict vesicoureteral reflux resolution in patients with non-neurogenic lower urinary tract dysfunction?

OBJECTIVE: To analyze factors influencing reflux resolution in patients with the coexistence of non-neurogenic lower urinary tract dysfunction and vesicoureteral reflux. METHODS: The data of 153 children who were diagnosed with vesicoureteral reflux and accompanying non-neurogenic lower urinary tract dysfunction between 2010 and 2015 were retrospectively evaluated. Patients with neurogenic and anatomical malformations, monosymptomatic nocturnal enuresis, previous history of vesicoureteral reflux surgery, irregular and/or incomplete follow-up data were excluded. After exclusion of 55 patients, 98 patients were enrolled in this study. Patients were divided into two groups according to the presence of spontaneous vesicoureteral reflux resolution during the follow-up period. Group 1 consisted of 54 children with spontaneous vesicoureteral reflux resolution, whereas group 2 included 44 children without resolution. Medical history, physical examination, urinalysis, uroflowmetry combined with electromyography, ultrasonography, as well as the Dysfunctional Voiding and Incontinence Symptom Score questionnaire were also evaluated. RESULTS: The mean age at presentation was 7.57 ± 0.23 years (range 5-13 years), and the mean follow-up period was 28.3 months. Significant differences were noted between the two groups in terms of dysfunctional voiding and incontinence symptom score, bladder wall thickness, and the post-void residual urine volumes. In addition, lower urinary tract symptoms, namely frequency, urgency and daytime incontinence, were found to be higher in group 2. In multivariate analysis, post-void residual urine volume and Dysfunctional Voiding and Incontinence Symptom Score were found to affect reflux resolution rates (P = 0.002, P = 0.002, respectively). CONCLUSIONS: The absence of significant post-void residual urine volume, and a low Dysfunctional Voiding and Incontinence Symptom Score increase the likelihood of spontaneous resolution rates of vesicoureteral reflux in children with non-neurogenic lower urinary tract dysfunction.

Renal stone composition does not affect the outcome of percutaneous nephrolithotomy in children.

PURPOSE: We sought to investigate the association between renal stone composition and percutaneous nephrolithotomy outcomes in pediatric patients and define the characterization of the stone composition. METHODS: The data of 1157 children who underwent percutaneous nephrolithotomy between 1991 and 2012 were retrieved from the multicenter database of the Turkish Pediatric Urology Society. The study population comprised 359 children (160 girls, 199 boys) with stone analyses. Patients were divided into five groups according to the stone composition [group 1: calcium oxalate; group 2: calcium phosphate; group 3: infection stones (magnesium ammonium phosphate, ammonium urate); group 4: cystine; group 5: uric acid, xanthine stones]. RESULTS: Patient characteristics, perioperative, postoperative, and stone characteristics were compared considering the stone composition. There were no significant differences between the groups concerning age, sex, side involved, preoperative hematocrit levels, and solitary renal unit. Patients with cystine stones were more likely to have a history of stone treatment. Groups 2 and 5 had mostly solitary stones. However, group 3 had staghorn stone more often, and group 4 frequently had multiple stones. Overall stone-free rate (79.4%) was similar among the groups. Although stone composition was related to blood transfusion and prolonged operative and fluoroscopy screening times on univariate analysis, it was not a significant predictor of them on multivariate analysis. CONCLUSIONS: Stone composition was not a predictor of outcomes of pediatric percutaneous nephrolithotomy. However, cystine and infection stones, which are larger and filled multiple calyxes due to the nature of stone forming, were more challenging cases that need multiple tracts.

Histopathological evaluation of orchiectomy specimens in 51 late postpubertal men with unilateral cryptorchidism.

PURPOSE: We evaluate the histopathological features of uncorrected undescended testis presenting at a late postpubertal age. MATERIALS AND METHODS: The study included 51 men (age 20 to 24 years) diagnosed with inguinal unilateral undescended testis found on routine examination for military recruits. None was evaluated or treated for undescended testis previously. All of the men had a normal contralateral testis and no other observed phenotypic alterations, and all had undergone unilateral orchiectomy. The surgical specimens were first examined histologically, and sections were additionally examined with immunohistochemical methods using antibodies against CD117 and OCT3/4 proteins to verify the presence of intratubular germ cell neoplasia. RESULTS: Histopathology revealed the presence of germ cells at different maturation levels in 26 of 51 (51%) cases. There were 28 cases (55%) with different degrees of basal membrane thickening. A decrease in seminiferous tubule diameter was observed in 23 (45%) patients. Six patients (12%) had dystrophic calcification and 12 (24%) had Leydig cell hyperplasia. Although morphological evaluation did not show intratubular germ cell neoplasia in any patients, 1 with germ cells had positivity for OCT3/4 and CD117 staining. Therefore, 1 case out of 51 had diagnosed intratubular germ cell neoplasia. CONCLUSIONS: There was a wide range of histopathological changes in undescended testis. Nearly half the patients may still have significant germ cell activity at a variety of maturation levels. The incidence of intratubular germ cell neoplasia was 2% in this group. Intratubular germ cell neoplasia may be overlooked with hematoxylin and eosin staining so immunohistochemical study should be added for evaluation.

Does structured withdrawal of desmopressin improve relapse rates in patients with monosymptomatic enuresis?

PURPOSE: Relapse after cessation of desmopressin is an important problem in treating patients with enuresis. Structured withdrawal of desmopressin tablets has been shown to decrease relapse rates. However, scientific data are lacking on the structured withdrawal of the fast melting oral formulation of desmopressin. We compared relapse rates of structured withdrawal using placebo and direct cessation in a population of patients with enuresis who were desmopressin responders. MATERIALS AND METHODS: Patients diagnosed with enuresis and responding to desmopressin from 13 different centers were involved in the study. Patients were randomized into 4 groups. Two different structured withdrawal strategies were compared to placebo and direct withdrawal. Sample size was estimated as 240 (60 patients in each group), with a power of 0.80 and an effect size of 30%. Randomization was performed using NCSS statistical software (NCSS, Kaysville, Utah) from a single center. The relapse rates of the groups were compared using chi-square testing. Logistic regression analysis was performed to define the independent factors having an effect on relapse rates. RESULTS: Desmopressin treatment was initiated in 421 patients, and 259 patients were eligible for randomization. Relapse rates were 39 (1%) and 42 (4%) for the structured withdrawal groups, which were significantly less than for direct withdrawal (55, 3%) and placebo (53, 1%). Logistic regression analysis revealed that initial effective dose of 240 µcg, greater number of wet nights before treatment and nonstructured withdrawal were associated with higher relapse rates. CONCLUSIONS: We found that structured withdrawal with the fast melting oral formulation of desmopressin results in decreased relapse rates. Application of a structured withdrawal program was also an independent factor associated with reduced relapse rates, together with lower initial effective dose and number of wet nights per week. Relapse after cessation of desmopressin is an important problem, and in this study structured withdrawal was observed to be associated with decreased relapse rates compared to placebo and direct withdrawal.

Factors affecting complication rates of percutaneous nephrolithotomy in children: results of a multi-institutional retrospective analysis by the Turkish pediatric urology society.

PURPOSE: We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS: We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS: Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates.

INTRODUCTION: To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR). MATERIALS AND METHODS: Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement. RESULTS: Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients). In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys. CONCLUSIONS: Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.

Laparoscopic correction of vesicoureteral reflux in children: review of the current literature.

Vesicoureteral reflux is one of the most important pediatric urology topics. The correction of this pathology by means of open and endoscopic surgery has been well established. The laparoscopic approaches are evolved with the aim of combining the minimally invasive nature of endoscopic treatments with the high success rates of open surgeries. The first applications of laparoscopic ureteral reimplantation techniques started in mid 1990s. However, it did not gain wide acceptance as the latter endoscopic trigonoplasties could not. With 2000s, case series of transperitoneal extravesical and pneumovesicoscopic intravesical ureteral reimplantations showed the feasibility. Today, both conventional and robotic assisted laparoscopic approaches are shown to have comparable outcomes with open counterparts in terms of successful resolution of reflux, postoperative comfort and improved cosmesis. The only shortcoming of new techniques seem to be the longer operative period which stands as a barrier against the wide acceptance which probably will take some time to be improved.

Ureteritis cystica: A rare entity in children.

Ureteritis cystica (UC) is a benign condition. Although it can often be diagnosed with imaging techniques, we report a case of a child for whom we planned nephrectomy and ureteral augmentation cystoplasty, but abandoned the cystoplasty due to extensive UC in the ureter.