Impact of Adjuvant Urinary Diversion versus Valve Ablation Alone on Progression from Chronic to End Stage Renal Disease in Posterior Urethral Valves: A Single Institution 15-Year Time-to-Event Analysis.

PURPOSE: Long-term progression to end stage renal disease of valve ablation alone vs ablation followed by additional urinary diversion were compared among children with stage 3 chronic kidney disease due to posterior urethral valves. MATERIALS AND METHODS: We performed a retrospective study of children with posterior urethral valves and stage 3 chronic kidney disease treated at a single institution between 1986 and 2011. The 3 treatment groups were classified as group 1-valve ablation alone, group 2-ablation plus subsequent vesicostomy and group 3-ablation followed by ureterostomies and/or pyelostomies. Baseline demographic characteristics were analyzed. Statistical analyses compared the incidence of time to end stage renal disease among the intervention groups using the Fisher-Freeman-Halton exact test and Kaplan-Meier analysis with the log rank test. Cox regression was used to determine predictors of end stage renal disease progression. RESULTS: A total of 40 eligible patients were included in the study (group 1-14 patients, group 2-13 patients, group 3-13 patients). Baseline characteristics and post-intervention estimated glomerular filtration rate revealed no significant between-group differences. A statistically significant difference in progression to end stage renal disease was noted within 1 year after diagnosis of stage 3 chronic kidney disease among the treatment groups (log rank test p=0.02). However, cumulative end stage renal disease incidence at 15-year followup showed no statistical difference (log rank test p=0.628). Cox regression analysis determined that bilateral renal dysplasia (HR 2.76, 95% CI 1.21-6.30) and estimated glomerular filtration rate 60 ml/minute/1.73 m2 or greater after intervention (HR 0.23, 95% CI 0.09-0.61) were predictive of the likelihood of progression to end stage renal disease. CONCLUSIONS: Urinary diversion following valve ablation in children with stage 3 chronic kidney disease associated with posterior urethral valves may temporarily delay progression to end stage renal disease. However, no long-term benefit was noted from diversion in the ultimate incidence of end stage renal disease, suggesting that these interventions should be seen as a temporizing measure. Bilateral renal dysplasia and post-intervention estimated glomerular filtration rate are independent variables predicting overall chronic kidney disease progression.

Partial nephrectomy for metastatic renal cell carcinoma: Where do we stand?

Nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) offers comparable oncologic results, but a lower risk of chronic kidney disease, when compared with radical nephrectomy. However, there are limited data in the literature examining the safety of NSS in the setting of metastatic RCC. To evaluate the feasibility of NSS and impact on cancer-specific survival (CSS) in patients with metastatic disease, we performed a systematic review of the literature. There is ample evidence that NSS is feasible in metastatic RCC, with comparable results in terms of CSS compared with radical cytoreductive nephrectomy.

Congenital vesicovaginal fistula: spontaneous or forced? Two cases and literature review.

INTRODUCTION AND HYPOTHESIS: Congenital vesicovaginal fistula is an exceedingly rare entity. There is no consensus regarding the nature and origin of this condition. We report two cases with congenital vesicovaginal fistula and compile previously reported cases in the English literature. Theories behind the genesis of this anomaly will be briefly presented. METHODS: We describe the presentation, diagnostic workup, and management of two patients with congenital vesicovaginal fistula. Previously reported cases were retrieved through an extensive English literature review using Medline and PubMed. Cases are tabulated based on the presence or absence of vaginal menstrual outflow obstruction. RESULTS: Two women, aged 23 and 17, had had cyclic hematuria since puberty that was perceived as normal menstruation. One woman presented with an inability to have sexual intercourse, and the other with severe cyclic pelvic pain. Diagnostic workup unveiled congenital vesicovaginal fistula and distal vaginal agenesis in both. One had abnormal ureteric insertion, while the other had a history of anomalies unrelated to the urogenital system. Successful surgical correction of fistula was undertaken in both. An English literature review revealed 23 reported cases of congenital vesicovaginal fistula. While 74 % had concomitant menstrual outflow obstruction, the remaining had normal menstruation per vagina. CONCLUSION: Congenital vesicovaginal fistula can present as an isolated anomaly, or associated with complex malformations of a wide spectrum. The presenting symptoms as well as the age at diagnosis vary widely. While the term "congenital" implies its genesis before birth, a congenital vesicovaginal fistula can be a manifestation of faulty embryological development, but also the result of outflow obstruction.

Music as an adjunct to combination analgesia for neonatal circumcision: A randomized controlled trial.

INTRODUCTION: Neonatal circumcision is one of the most frequently performed procedures in male infants; it is also particularly painful. In a previous trial, we showed that the combination of Eutectic Mixture of Local Anesthetics (EMLA) + Sucrose + Ring Block (RB) was significantly effective in reducing pain during circumcision. OBJECTIVE: In this study, we added music as an adjunct aiming to further reduce the pain scores. STUDY DESIGN: This was a double-blinded randomized controlled trial comparing EMLA + Sucrose + RB (Control) to EMLA + Sucrose + RB + Music (Intervention). The trial setting was the normal nursery of a university teaching hospital. One hundred and three healthy newborn males were randomized to each of the intervention and control groups. Babies were videotaped (face and torso) during the procedure for assessment of pain by two blinded and independent reviewers. The primary outcome measure was the NIPS score; secondary outcomes included heart rate, oxygen saturation and crying time. RESULTS: The NIPS score of the intervention group (EMLA + Sucrose + RB + Music [2.6 ± 1.6]) was significantly higher than that of the control group (EMLA + sucrose + RB [1.4 ± 0.9]) (p = 0.00). Inter-rater reliability was high (κ .89). The intervention group registered significantly higher mean heart rate (142 bpm) and increased mean crying time (5.44 s) compared to the control group (135 bpm and 1.63s, respectively) (p = 0.01) and (p = 0.00). No adverse events were noted. Delivery music medicine by playing it from an iPad in the procedure room did not reduce pain during circumcision. DISCUSSION: There is overwhelming evidence in the literature describing the effectiveness of music on pain management especially in the NICU. However, our results did not align with the general trend; not only did music medicine fail to enhance analgesia but it might have had the opposite effect, further agitating the infants, as indicated by the significantly increased heart rate, crying time and NIPS scores of the participants in the intervention group. Limitations of our study include the fact that this is a single center study and the method of delivering music via iPads instead of noise-canceling headphone. CONCLUSION: Our results showed that music, delivered in this manner, may have increased agitation. We affirm the fact that the combination of EMLA + Sucrose + RB is highly effective for managing pain during circumcision and further reduction of already low scores might not be possible. CLINICAL TRIAL REGISTRATION: Registry Name: ClinicalTrials.gov; Registration number: NCT04252313; link: https://clinicaltrials.gov/ct2/show/NCT04252313.

Physiological changes in transperitoneal versus retroperitoneal laparoscopy in children: a prospective analysis.

PURPOSE: The choice of minimally invasive surgical approaches in pediatric urology is largely influenced by surgeon preference and experience. Little is known about the differences in physiological variables that might objectively influence the choice of surgical approach. We compared the cerebral and systemic hemodynamic effects of transperitoneal vs retroperitoneal CO(2) insufflation in children. MATERIALS AND METHODS: After receiving ethical review board approval and written parental consent 36 pediatric patients undergoing transperitoneal (18) or retroperitoneal (18) laparoscopic surgery were enrolled in this study. A standardized anesthetic technique of isoflurane 1 MAC and remifentanil 0.2 mcg/kg per minute was used. Measured parameters included end tidal CO(2), middle cerebral artery blood flow velocity, heart rate and noninvasive mean arterial blood pressure. Transcranial Doppler ultrasound was used to measure middle cerebral artery blood flow velocity. Data were collected before, during and after CO(2) insufflation to 12 mm Hg pneumoperitoneum at regular intervals, including every minute for 10 minutes and every 2 minutes thereafter. Within group analysis was done using repeated measures ANOVA. Nonlinear regression analysis was used to determine the best fit and the relationship of each variable with time with p <0.05 considered significant. RESULTS: Patient age and weight were comparable in the 2 groups. Transperitoneal CO(2) insufflation resulted in a rapid parallel increase in middle cerebral artery blood flow velocity, mean arterial pressure and end tidal CO(2) during the first 8 minutes of pneumoperitoneum (p <0.05). Despite a continued increase in end tidal CO(2) thereafter middle cerebral artery blood flow velocity and mean arterial pressure attained a plateau within the first 8 minutes (p <0.05). In contrast, middle cerebral artery blood flow velocity and end tidal CO(2) increased progressively throughout the retroperitoneal CO(2) insufflation period (p <0.01). CONCLUSIONS: Cerebral blood flow velocity and end tidal CO(2) seem to increase progressively and gradually during retroperitoneal laparoscopy, in contrast to the more rapid increase and plateau effect during transperitoneal laparoscopy. Presumably the smaller absorptive surface in the retroperitoneal space explains this physiological difference.

Comparative histological and functional controlled analysis of tubularized incised plate urethroplasty with and without dorsal inlay graft: a preliminary experimental study in rabbits.

PURPOSE: We analyzed the histological and functional characteristics of the tubularized incised plate vs dorsal inlay graft urethroplasty in an experimental rabbit model. MATERIALS AND METHODS: A total of 24 New Zealand male rabbits were randomly allocated into 4 groups, including sham operation, urethroplasty, tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised and the dorsal aspect was tubularized. In the tubularized incised plate group the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group the defect created by the dorsal incision was covered with an inner preputial graft. The animals were sacrificed at 4 and 8 weeks, respectively. The penis was immediately harvested for standardized passive flowmetry and subsequently fixed for histological staining. RESULTS: The grafts took in all animals. The tubularized incised plate defect was bridged by urothelium while in the dorsal inlay graft group the preputial graft kept its original histological characteristics. There was a significant decrease in average flow in the urethroplasty group (1.6 ml per second) compared to that in the sham operated group (3.4 ml per second) and to the other groups (p <0.05). However, no significant difference in average flow was found for the tubularized incised plate and dorsal inlay graft groups (2.4 and 2.2 ml per second, respectively, p = 0.7). CONCLUSIONS: In this short-term rabbit model dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to significantly decreased flow. Incision of the reduced plate with or without grafting improved the average flow. Findings in this experimental model do not support the superiority of dorsal inlay graft urethroplasty over tubularized incised plate urethroplasty in terms of urethral flow dynamics.

Hypertension in children with poorly functioning unilateral kidneys: predictors of resolution after nephrectomy.

OBJECTIVE: To identify the outcome of nephrectomy and predictors of hypertension (HTN) resolution in children with poorly functioning unilateral kidneys (differential renal function, DRF of < 15%), as concurrent HTN is often an indication for nephrectomy. PATIENTS AND METHODS: Over a 7.5-year period, a single centre retrospective analysis of 89 children with unilateral nonfunctioning/poorly functioning kidney who underwent nephrectomy was conducted. Preoperative HTN was present in 18 children (20.2%). The childrens' characteristics (age, sex, body mass index, pathology, side), cause of nonfunction, diagnostics including preoperative proteinuria (dipstick) and DRF (nuclear scan), pathological features of specimen and follow-up were recorded. RESULTS: The mean (median; range) age at nephrectomy was 6.8 (5; 0.333-14) years with a mean (median; range) follow-up of 2.4 (3; 0.083-5.5) years. The mean (median; range) DRF was 6.5 (1; 0-15)%. Twelve of 18 children (67%) resolved their HTN. Age at nephrectomy, sex, side of nonfunctioning kidney and surgical approach (78% laparoscopic nephrectomy) did not correlate with HTN resolution. Persistence of HTN seemed to correlate with residual function of more than a DRF threshold of 5% (P = 0.05), the presence of preoperative qualitative proteinuria by dipstick (P = 0.03) and inflammation on pathology. CONCLUSIONS: HTN resolved after nephrectomy for poorly functioning unilateral kidney in most of the children. Persistence of HTN is probably multifactorial. Ipsilateral residual function before nephrectomy, preoperative proteinuria and pathological features of nephrectomy specimen may serve as clinically useful markers for outcome prediction.

Pediatric urology training: performance-based assessment using the fundamentals of laparoscopic surgery.

BACKGROUND: Despite the proven utility of laparoscopy in pediatric urology, widespread adoption of the surgical approach has been limited. The Fundamentals of Laparoscopic Surgery (FLS) is a reliable teaching mode for surgeons. Our study objective was to evaluate the effectiveness of a laparoscopic training course via a performance based assessment of participants' technical skills on the FLS module. MATERIALS AND METHODS: The laparoscopic pediatric urology course, administered to 18 fellows, consisted of a 6-h didactic session and a full d practice on a live porcine model. FLS skills were practiced prior to and immediately following the course, and included peg transfer, precision pattern cutting, securing a ligating loop, and intracorporeal suturing. Written exams were used to evaluate participants' cognitive knowledge about laparoscopic procedures. Pretest and post-test performances were compared using paired t-tests. Previous laparoscopic caseload was addressed as a potential predictor of performance using two separate Pearson correlations between total caseload and performance scores. RESULTS: Participation in the course led to significant improvements in FLS and written exam scores. Laparoscopic caseload was correlated with pretest performance (R = 0.53, P < 0.05) though this correlation was not significant at post-test (R = 0.41, P > 0.05). However, the improvement from pretest to post-test (i.e., difference score) was significantly related to the participants' pediatric laparoscopic caseload (R = -0.47, P < 0.05). CONCLUSIONS: Operative experience is instrumental in attaining laparoscopic skills. However, intensive simulation-based training improves technical performance and cognitive knowledge competence, especially for novice trainees. Long-term assessment of trainees is required to ascertain the effectiveness of this approach to laparoscopic training.

Burnout of residents: Overview from various medical institutions - A suggested model for improvement.

BACKGROUND: Burnout is a common issue among residents across the globe. Although several attempts were made to propose better working hours for residents, burnout is still prevalent as depicted by several studies. OBJECTIVES: The aim of the paper is to review several worldwide studies related to burnout in residents and propose potential suggestions. METHODS: The following paper summarizes studies pertinent to burnout in residents from different countries categorized into three main regions: North and South America, Europe, and Middle East. The studies were collected from February 2018 to March 2019. RESULTS: Numerous studies across the world have revealed high rates of burnout in residents during the last decades. CONCLUSIONS: Various awareness and wellness programs, as well as professional counseling sessions, are proposed to help residents overcome burnout.

Practice patterns in ordering a voiding cystourethrogram for pediatric patients among different specialties in a Middle Eastern tertiary care center.

INTRODUCTION: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. METHODS: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. RESULTS: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. CONCLUSION: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.

Potential complications with the prescrotal approach for the palpable undescended testis? A comparison of single prescrotal incision to the traditional inguinal approach.

PURPOSE: Prescrotal orchiopexy is emerging as an alternative surgical approach to undescended testicles. We compare operative times, success rates and complications of single incision prescrotal orchiopexy and the traditional inguinal approach. MATERIALS AND METHODS: During a 3-year period all patients who underwent prescrotal orchiopexy were retrospectively reviewed and compared to age matched controls operated on via the traditional inguinal approach. Data collected included preoperative and postoperative testicular positioning, operative time and complications, including testicular atrophy and ascent. Exclusion criteria were retractile or ectopic testis, incomplete data, including lack of followup, and a concurrent procedure at the time of orchiopexy. RESULTS: A total of 63 orchiopexies were performed using the prescrotal approach (mean patient age 4.6 years) and the inguinal approach (4.7 years). Average surgical times for the prescrotal and inguinal groups were 34 and 64 minutes, respectively (p = 0.002). Followup ranged from 6 to 42 months. Complication rates between the groups were similar. However, 2 hernias (3%) occurred in the prescrotal group, of which 1 was incarcerated and associated with Meckel's diverticulum, and 1 was a late recurrence. CONCLUSIONS: With the paucity of literature on prescrotal orchiopexy potential complications may be underreported. Despite the limitations of sample size, prescrotal orchiopexy may be associated with a 3% risk of postoperative hernia. A single incision prescrotal orchiopexy is still a viable approach for patients with primary palpable undescended testicles. Advantages include shorter operative time, a cosmetically appealing single incision and possibly less pain.

Secondary adenocarcinoma of the urinary bladder from a primary gastric cancer.

Primary bladder tumor is a frequent urological malignancy, whereas the incidence of secondary bladder tumor from a distant organ is quite rare. Secondary bladder neoplasms represent no more than 3% of all malignant bladder tumors in surgical specimens, of which distant metastases from stomach account for about 4%. The signs of bladder neoplasm in a patient with malignancy elsewhere should alarm the clinician for a possible metastatic origin. We present a patient with primary adenocarcinoma of the stomach, who underwent total gastrectomy and received adjuvant chemotherapy, and was diagnosed with metastasis to the urinary bladder 15 months later. We review the epidemiology of secondary adenocarcinoma of the bladder, mechanisms of metastasis, associated common primaries with focus on gastric malignancies, radiological findings, and role of immunohistochemical staining.

Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial.

OBJECTIVES: There is no consensus on the most effective pain management for neonatal circumcision. We sought to compare different modalities. METHODS: This is a double-blinded randomized controlled trial comparing 3 combination analgesics used during circumcision (EMLA + sucrose; EMLA + sucrose + dorsal penile nerve block [DPNB]; EMLA + sucrose + ring block [RB]) with the traditional topical analgesic cream EMLA alone. The trial was set in the normal nursery of a teaching hospital. The sample included 70 healthy male newborns, randomly assigned to intervention and control groups at a 2:1 ratio. Infants were videotaped (face and torso) during the procedure for assessment of pain by 2 blinded, independent reviewers. The primary outcome measure is the Neonatal Infant Pain Scale score. Secondary outcomes include heart rate, oxygen saturation, and crying time. RESULTS: Neonatal Infant Pain Scale scores were significantly lower in the intervention groups (EMLA + sucrose, mean [SD]: 3.1 [1.33]; EMLA + sucrose + DPNB: 3 [1.33]; EMLA + sucrose + RB: 2.45 [1.27]) compared with the control (5.5 [0.53]). Between-group analyses showed RB + EMLA + sucrose to be significantly more effective than EMLA + sucrose; EMLA + sucrose + DPNB (P = .009 and P = .002, respectively). Interrater reliability was κ = 0.843. Significant increase in heart rate (139.27 [9.63] to 163 [13.23] beats per minute) and crying time (5.78 [6.4] to 45.37 [12.39] seconds) were noted in the EMLA group. CONCLUSIONS: During neonatal circumcision in boys, the most effective analgesia is RB combined with oral sucrose and EMLA cream.

Functioning metastatic paraganglioma of the urinary bladder in a 10-year-old child.

Paragangliomas of the urinary bladder are very rare tumours representing less than 1% of bladder tumours. Preoperative diagnosis is essential to avoid perioperative complications related to catecholamine release. A high index of suspicion should be maintained when the classical symptoms of voiding-related paroxysms of headache, palpitation and dizziness are present. We present a rare case of malignant paraganglioma of the urinary bladder in a 10-year-old boy. The patient had the classic presentation. We review the radiological diagnostic tools and findings of this rare entity.

The workup of microscopic and gross hematuria.

Based on the American Urological Association best practice policy statement, the workup of microscopic hematuria is summarized in the above algorithm (Fig. 1). The presence of gross hematuria is always an indication for prompt full investigation.

TGF-ß1 induces EMT reprogramming of porcine bladder urothelial cells into collagen producing fibroblasts-like cells in a Smad2/Smad3-dependent manner.

Activation of fibroblasts and their differentiation into myofibroblasts, excessive collagen production and fibrosis occurs in a number of bladder diseases. Similarly, conversion of epithelial cells into mesenchymal cells (EMT) has been shown to increase fibroblasts like cells. TGF-ß1 can induce the EMT and the role of TGF-ß1-induced EMT during bladder injury leading to fibrosis and possible organ failure is gaining increasing interest. Here we show that EMT and fibrosis in porcine bladder urothelial (UC) cells are Smad dependent. Fresh normal porcine bladder urothelial cells were grown in culture with or without TGF-ß1 and EMT markers were assessed. TGF-ß1 treatment induced changes in cellular morphology as depicted by a significant decrease in the expression of E-cadherin and corresponding increase in N-cadherin and α-SMA. We knocked down Smad2 and Smad3 by Smad specific siRNA. Downregulation of E-cadherin expression by TGF-ß1 was Smad3-dependent, whereas N-cadherin and α-SMA were dependent on both Smad2 and Smad3. Connective tissue growth factor (CTGF/CCN2), matrix metalloproteinase-2 and -9 (MMP-2, MMP-9) has been shown to play important roles in the pathogenesis of fibrosis. Induction of these genes by TGF-ß1 was found to be time dependent. Upregulation of CTGF/CCN2 by TGF-ß1 was Smad3 dependent; whereas MMP-2 was Smad2 dependent. Smad2 and Smad3 both participated in MMP-9 expression. TGF-ß1 reprogrammed mesenchymal fibroblast like cells robustly expressed collagen I and III and these was inhibited by SB-431542, a TGF-ß receptor inhibitor. Our results indicate that EMT of porcine bladder UC cells is TGF-ß1 dependent and is mediated through Smad2 and Smad3. TGF-ß1 may be an important factor in the development of bladder fibrosis via an EMT mechanism. This identifies a potential amenable therapeutic target.

Current status of retrograde intrarenal surgery for management of nephrolithiasis in children.

PURPOSE: To review the current status of retrograde intrarenal surgery (RIRS) for renal stones in children focusing on its indications, outcomes and success in the management of nephrolithiasis. MATERIALS AND METHODS: Between 1988 and 2009, a comprehensive PubMed/MEDLINE literature review on RIRS was conducted. RESULTS: The available literature is limited and heterogeneous, skewed by favorable results on ureteral stone outcomes. However, recent case series report outcomes comparable to time-honored modalities: percutaneous nephrolithotomy and shock wave lithotripsy. Concerns about urinary tract damage are not substantiated by the yet available intermediate-term follow-up. CONCLUSIONS: RIRS seems to be an effective modality in pediatric nephrolithiasis management. However, long-term outcomes and comparative prospective randomized studies are awaited.

Assessment of urethral plate appearance through digital photography: do pediatric urologists agree in their visual impressions of the urethral plate in children with hypospadias?

OBJECTIVE: There is a paucity of literature on a definition or set criteria evaluating urethral plate (UP) quality. We sought to determine whether pediatric urologists are in agreement in their assessment of UP quality. MATERIALS AND METHODS: A cohort of 21 pediatric urologists attending a national annual meeting were surveyed with a questionnaire inquiring about practice patterns and perceived impressions of UP quality. Nineteen sequentially projected, standardized, digital photographs, depicting plates with variable meatal locations, were presented. Intra- and inter-rater agreement among pediatric urologists was estimated by calculating the Kappa statistic (kappa). RESULTS: Thirty percent of respondents had more than 15years of practice and one-third repair 10 or more hypospadias per month. Measurement of level of agreement in the impression of UP quality of the 18 projected photographs revealed poor inter-rater agreement (kappa=0.06, P=0.0003), which was not improved by focusing on particular meatal locations or surgeon experience. CONCLUSIONS: Despite the inherent shortcomings of digital photography, this study highlights the potential subjectivity and lack of agreement on UP quality. Disagreement seems to be present irrespective of level of the defect or surgeon experience. Setting standards and improving agreement is likely to enhance reporting and interpretation of data in hypospadias studies.

Do patients with classic bladder exstrophy have fecal incontinence? A web-based study.

OBJECTIVES: To explore the occurrence of fecal incontinence in patients with classic bladder exstrophy (CBE) by administering a web-based pilot study. METHODS: A questionnaire assessing fecal continence status was devised. Questions included demographics, age to achieve toilet training for bowels, and the patient perception of the degree of fecal soiling during day and night, if present. The CBE contact list of our institution's social worker was addressed (324 patients) and directed to fill the survey posted at the website http://www.SurveyMonkey.com. RESULTS: There were 94 responders (29%) to the survey. They were analyzed as 2 groups: pediatric (age up to 18 years, n = 69, 9 excluded for not achieving toilet training) and adult (age >18 years, n = 25). In the pediatric group, fecal incontinence was reported in 57% of patients during the day and 32% during night. In the adult group, fecal incontinence was reported in 44% of patients during the day and 40% during night. Seven patients reported having undergone ureterosigmoidostomy (US) diversion. Stratifying patients based on US diversion showed fecal incontinence of 100% vs 22% during the day (P <.001), and 86% vs 22% during the night (P <.01), for the US vs non-US subgroups, respectively. CONCLUSIONS: Our preliminary survey suggests that fecal incontinence in CBE may be a significant overlooked issue that may persist into adulthood of CBE patients. With the potential functional and psychological burden, clinical awareness and management of this issue is crucial. Further exploration of this issue, with detailed attention to surgical procedure(s) involved and degree of quality of life impairment, needs to be initiated.

Ureteral duplication with lower pole ureteropelvic junction obstruction: laparoscopic pyeloureterostomy as alternative to open approach in children.

OBJECTIVES: Despite the widespread introduction of laparoscopy in pediatric urology, many reconstructive procedures, such as ureterostomy and pyeloureterostomy, are still performed in an open fashion because of the perceived intricacy and demanding nature. As we continue to introduce advanced laparoscopic skills into the care of children, we describe our laparoscopic pyeloureterostomy technique for correction of lower pole ureteropelvic junction obstruction in a pediatric patient with duplication anomaly. METHODS: The pyeloureterostomy was performed laparoscopically, using three 5-mm trocars. We placed a double-J ureteral stent into the upper pole ureter to facilitate its identification and dissection from adjacent tissues. The anastomosis between the lower pole renal pelvis and the upper pole ureter was performed in a continuous fashion, using 5-0 polyglactin suture. A Penrose drain was left in place at the anastomosis area. RESULTS: The child had no postoperative complications. During follow-up, his vesicoureteral reflux continued to be managed conservatively with no antibiotics. At his last follow-up visit, ultrasound examination showed improvement of both upper and lower pole hydronephrosis. CONCLUSIONS: Laparoscopic pyeloureterostomy seems to be an effective and minimally invasive option to correct ureteropelvic junction obstruction associated with ipsilateral vesicoureteral reflux in complete ureteral duplication cases. It can be safely performed in children and represents a feasible alternative to open surgery.