Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves.

INTRODUCTION: A significant proportion of PUV becomes symptomatic after the perinatal period. Voiding cystourethrography (VCUG) often fails to identify PUVs. This study evaluates the relationship between the radiological appearance of the posterior urethra, potential secondary radiological signs and endoscopically documented PUV in boys with febrile UTIs, VUR, refractory symptoms of bladder overactivity or suggestive sonography findings. PATIENTS AND METHODS: Data on VCUG findings and endoscopy from 92 boys (mean age 27 months) who underwent endoscopic PUV incision between 2012 and 2017 following a VCUG were reviewed. 24 boys with endoscopically unsuspicious urethras were included as control group (mean age 27.5 months). Statistical analysis was performed using Fisher's exact test. RESULTS: In patients with PUV, the urethra was suspicious on a preoperative VCUG in 45.7%, whereas it appeared normal in 54.3%. Abortive forms of PUV were more frequently found in patients with a radiologically unsuspicious urethra (30%vs.16.7%, p = 0.15). Bladder neck hypertrophy on VCUG (16.7%vs.60.9%, OR 7.5, p < 0.001), a trabeculated bladder on VCUG (72%vs.37.5%, OR 4.3, p < 0.001) and a hypertrophied musculus interuretericus (38%vs.4.2%, OR 11.7, p < 0.001) were more common in patients with PUV and urethras appearing normal on VCUG as compared to controls. CONCLUSION: Unsuspicious findings of the urethra on VCUG cannot exclude a relevant PUV and implicate a risk of disregarding abortive forms. The presence of secondary radiologic signs of infravesical obstruction on a VCUG despite an unsuspicious posterior urethra in boys with recurrent UTI's as well as refractory symptoms of bladder overactivity or suggestive signs on sonography must be further clarified endoscopically.

Testicular-sparing surgery in the pediatric population: multicenter review of practice with review of the literature.

PURPOSE OF REVIEW: Pediatric testicular tumors have predominantly favorable histology, which may permit testicular sparing surgery (TSS). Limited guidance exists for TSS in adults and is absent in pediatric practice.The international survey and retrospective case series evaluated the current use of TSS in pediatric testicular tumors. Alongside the complementary literature review, the aim of this work was to provide evidence that could be used to produce a guideline document. RECENT FINDINGS: Published evidence advocates small mass size as an indicator for TSS, this was not supported in the pediatric literature. Frozen section examination at TSS was not always performed by surgeons and yet the literature reports close to 100% specificity. Tumor markers and ultrasound findings are also used as indicators for TSS, a finding reflected in our survey results. SUMMARY: Multiple case series are reported but no large data series exists, which will require international collaboration rather than a drive to publish the results of individual centers. Common indicators for TSS use; such as tumor markers and imaging are known but further work needs to evaluate the role of on-table histology and the risks of this not being available.

Langerhans cells in hypospadias: an analysis of Langerin (CD207) and HLA-DR on epidermal sheets and full thickness skin sections.

BACKGROUND: Hypospadias are among the most common genital malformations. Langerhans Cells (LCs) play a pivotal role in HIV and HPV infection. The migration of LC precursors to skin coincides with the embryonic period of hypospadias development and genetic alterations leading to the formation of hypospadias impact the development of ectodermally derived tissues. We hypothesized that this might be associated with a difference in frequency or morphology of epidermal and dermal LCs in hypospadias patients. METHODS: A total of 43 patients from two centers were prospectively included into this study after parental consent and ethics approval. Epidermal and dermal sheets were prepared from skin samples of 26 patients with hypospadias, 13 patients without penile malformations and 4 patients with penile malformations other than hypospadias. Immunofluorescence staining of sheets was performed with anti-HLA-DR-FITC and anti-CD207/Langerin-A594 antibodies. Skin sections from 11 patients without penile malformation and 11 patients with hypospadias were stained for Langerin. Frequencies as well as morphology and distribution of epidermal and dermal LCs on sheets and sections were microscopically evaluated. Cell counts were compared by unpaired t-tests. RESULTS: There was no difference in frequency of epidermal LCs, Neither on sheets (873 ± 61 vs. 940 ± 84LCs/mm2, p = 0.522) nor on sections (32 ± 3 vs. 30 ± 2LCs/mm2, p = 0.697). Likewise, the frequency of dermal LCs (5,9 ± 0,9 vs. 7.5 ± 1.3LCs/mm2, p = 0.329) was comparable between patients with hypospadias and without penile malformation. No differences became apparent in subgroup analyses, comparing distal to proximal hypospadias (p = 0.949), younger and older boys (p = 0.818) or considering topical dihydrotestosterone treatment prior to surgery (p = 0.08). The morphology of the LCs was not different comparing hypospadias patients with boys without penile malformations. CONCLUSIONS: LCs are present in similar frequencies and with a comparable morphology and distribution in patients with hypospadias as compared to children without penile malformations. This suggests that patients with hypospadias are not different from patients with normal penile development considering this particular compartment of their skin immunity.

Enhanced Recovery after Surgery Protocol for Pediatric Urological Augmentation and Diversion Surgery Using Small Bowel.

PURPOSE: Enhanced recovery after surgery protocols aim to improve recovery following urological augmentation and diversion surgery. Based on the positive experiences in adult patients, we evaluated safety and outcomes after implementation of an enhanced recovery after surgery protocol in children undergoing urological augmentation and diversion using small bowel. MATERIALS AND METHODS: Complications, time to stool, time to flatus and total hospital stay of 15 consecutive patients (group 2) were recorded and compared to the data of 15 consecutive patients before the changes in protocol were effective (group 1). The groups were comparable in age (mean 10.93 vs 9.267 years, p = 0.33), gender (p = 0.71) and operative times (387.9 vs 336.5 minutes, p = 0.19). RESULTS: Compared to the previous protocol involving a mean ± SD of 7.9 ± 1.38 enhanced recovery after surgery items per patient, 15.9 ± 0.26 items per patient were implemented in the new protocol. In group 2 mild bowel related complications were less frequent (1 vs 5, p = 0.168). Time to stool was significantly shorter in group 2 (3.33 vs 5.53 days, p = 0.002), as was time to flatus (2.8 vs 4.73 days, p = 0.002). Total hospital stay in group 2 was 11.93 days, compared to 19.87 days in group 1 (p <0.001), mainly due to more rapid convalescence, although influenced by associated changes in the postoperative protocol as well. CONCLUSIONS: In pediatric augmentation and diversion surgery using small bowel the implementation of an enhanced recovery after surgery protocol is safe and effective, reinforcing faster bowel recovery. We did not observe complications or problems after introducing the new protocol.

Is real-time PCR the correct method to evaluate the incidence of human papillomavirus in prepuces of asymptomatic boys and men?

OBJECTIVE: To investigate the prevalence of human papillomavirus (HPV) in prepuces of asymptomatic boys and men, the present study was designed. METHODS: Two hundred and fifty male prepuce specimens who underwent circumcision due to phimosis were collected. Samples were subdivided into groups regarding their age: children (group I, 0-10 years), adolescents (group II, 11-20 years) and adults (group III, >20 years). HPV High Screen Real-TM Quant 2x kit detecting HPV 6 and 11 (low risk) as well as another kit for identification of HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59 (high risk) were used. Additionally, a Taq Man assay has been designed targeting the L1 gene of HPV 6, 11, 16 and 18. RESULTS: Evaluating the number of low-risk HPV subtypes, we found HPV 6 and 11 in 5.3 % of samples (n = 12/226). Concerning high-risk HPV, we found a positivity in 4 % of samples (n = 9/224). In contrast to low-risk data where no age distribution was observed, we found an age-specific accumulation of high-risk HPV subtypes in the children group (n = 6/9). A second independent assay (Taq Man PCR assay) measuring HPV 6, 11, 16 and 18 of all positive samples confirmed only the high-risk HPV subtypes of the Real-TM Quant 2x assay. CONCLUSIONS: Our study provides evidence that qPCR estimation for HPV infection obviously underestimates the incidence rate of infected prepuces in boys and men with phimosis. Contrary, an overestimation of the HPV infection rate with the in situ hybridization method of phimotic prepuces cannot be excluded.

Skin langerin+ dendritic cells transport intradermally injected anti-DEC-205 antibodies but are not essential for subsequent cytotoxic CD8+ T cell responses.

Incorporation of Ags by dendritic cells (DCs) increases when Ags are targeted to endocytic receptors by mAbs. We have previously demonstrated in the mouse that mAbs against C-type lectins administered intradermally are taken up by epidermal Langerhans cells (LCs), dermal Langerin(neg) DCs, and dermal Langerin(+) DCs in situ. However, the relative contribution of these skin DC subsets to the induction of immune responses after Ag targeting has not been addressed in vivo. We show in this study that murine epidermal LCs and dermal DCs transport intradermally injected mAbs against the lectin receptor DEC-205/CD205 in vivo. Skin DCs targeted in situ with mAbs migrated through lymphatic vessels in steady state and inflammation. In the skin-draining lymph nodes, targeting mAbs were found in resident CD8α(+) DCs and in migrating skin DCs. More than 70% of targeted DCs expressed Langerin, including dermal Langerin(+) DCs and LCs. Numbers of targeted skin DCs in the nodes increased 2-3-fold when skin was topically inflamed by the TLR7 agonist imiquimod. Complete removal of the site where OVA-coupled anti-DEC-205 had been injected decreased endogenous cytotoxic responses against OVA peptide-loaded target cells by 40-50%. Surprisingly, selective ablation of all Langerin(+) skin DCs in Langerin-DTR knock-in mice did not affect such responses independently of the adjuvant chosen. Thus, in cutaneous immunization strategies where Ag is targeted to DCs, Langerin(+) skin DCs play a major role in transport of anti-DEC-205 mAb, although Langerin(neg) dermal DCs and CD8α(+) DCs are sufficient to subsequent CD8(+) T cell responses.

Elevating pediatric urology care: The crucial role of nursing research in quality improvement.

This educational article highlights the critical role of pediatric urology nursing research in improving the care of children with urological conditions. It discusses the multifaceted nature of pediatric urology nursing, addresses challenges such as limited nurse scientists and resource constraints, and highlights the need to overcome barriers to increase research involvement. The authors emphasize the importance of prioritizing research areas, the promotion of collaboration, and the provision of adequate funding and academic time for pediatric nurses to contribute to evidence-based practice, to improve patient outcomes. Furthermore, it highlights the importance of research in advancing nursing practice, shaping protocols, and advocating for the rights and needs of children with urological conditions and their families.

A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux.

INTRODUCTION: Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. OBJECTIVE: In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV + V) VUR in children. STUDY DESIGN: A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. RESULTS: Overall, 135 children who underwent either OUR (n = 68), or RALUR (n = 67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p < 0.01); the open cohort had a weight of 11 kg (IQR 9.9-16.6 kg) while the RALUR group had 19 kg (IQR 13-25 kg) (p < 0.01). No significant differences were found for intraoperative (1.5 % vs 7.5 %, p = 0.09) or for postoperative complication rates (7.4 % vs 9 %, p = 0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p < 0.01). The success rate was 94.0 % and 98.5 % in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. DISCUSSION: This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. CONCLUSION: RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.

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

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

Primum Non Discernere: Glass Ceilings and Female Representation at the European Association of Urology and European Society for Paediatric Urology Annual Meetings, 2012-2022.

Background: The term glass ceiling coined by Loden in 1978 is commonly used to describe difficulties faced by minorities and women when trying to move into senior roles. Objective: To analyse trends and patterns for female representation at the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) annual general meetings over the past decade. Design setting and participants: We used objective data on female representation in the roles of chairs, moderators, and lecture speakers at the EAU and ESPU meetings from 2012 to 2022. Outcome measurements and statistical analysis: We evaluated gender based representation in paediatric urology sessions at the EAU and ESPU meetings, collecting data on the overall number of sessions, lectures, symposiums, abstract/poster sessions, and courses, and analysed the male/female ratio. Data were derived from printed and digital programmes for the relevant meetings. Results and limitations: During the period from 2012 to 2022, the percentage female representation varied from 0% (2012) to a maximum of 35% (2022) at EUA paediatric urology sessions, and from 13.5% (2014) to a maximum of 32% (2022) at ESPU meetings. Both associations show clear progression towards equality. Conclusions: Female representation at EAU and ESPU meetings has risen over the years, reaching 35% and 32%, respectively, in 2022, which is in line with the number of female members. We hope that this motivates a move towards the equality objectives for 2030. A clear and fundamental societal change is needed, with fair and more consistent institutional policies and framework commitments in the areas of science, medicine, and global health. Gender equality and diversity taskforces are essential to achieve these goals. Patient summary: We analysed the male/female ratio for participants in annual meetings held by the European Association of Urology and the European Society for Paediatric Urology. From a low level in 2012, the ratio increased to over 30% in 2022, in line with the female membership of the societies. Focus on fair and consistent policies is needed to ensure that women are well represented in medicine.

Guideline Adherence of Paediatric Urolithiasis: An EAU Members' Survey and Expert Panel Roundtable Discussion.

Background: Paediatric nephrolithiasis has increased globally, requiring standardized recommendations. This study aims to assess the paediatric urolithiasis care between EAU members along with the statements of three experts in this field. Methods: The results of an electronic survey among EAU members comparing the guideline recommendations to their current practice managing paediatric nephrolithiasis in 74 centres are contrasted with insights from an expert-panel. The survey consisted of 20 questions in four main sections: demographics, instrument availability, surgical preferences and follow-up preferences. Experts were asked to give insights on the same topics. Results: A total of 74 responses were received. Computerised Tomography was predominantly used as the main imaging modality over ultrasound. Lack of gonadal protection during operations was identified as an issue. Adult instruments were used frequently instead of paediatric instruments. Stone and metabolic analysis were performed by 83% and 63% of the respondents respectively. Conclusions: Percutaneous Nephrolithotomy is the recommended standard treatment for stones > 20 mm, 12% of respondents were still performing shockwave lithotripsy despite PNL, mini and micro-PNL being available. Children have a high risk for recurrence yet stone and metabolic analysis was not performed in all patients. Expert recommendations may guide clinicians towards best practice.

Being born small for gestational age (SGA) might be associated with a higher reoperation rate in proximal hypospadias.

PURPOSE: Being born small for gestational age (SGA) is associated with a higher frequency and more severe forms of hypospadias as well as with potential developmental differences. This study aims to characterize operative outcomes in SGA boys compared to boys born with normal weight and length for gestational age (appropriate/large for gestational age, AGA/LGA). METHODS: Demographic data, hypospadias characteristics, associated pathologies and operative outcomes of boys who underwent hypospadias repair at a single center (10/2012-10/2019) were evaluated. Boys were categorized into SGA and non-SGA, which were then compared using unpaired t-tests and chi square tests. To examine the effect of SGA on reoperative risk, a logistic regression model was applied integrating surgical technique, meatal localization and complex hypospadias (narrow glans/plate, curvature, micropenis, bilateral cryptorchidism). RESULTS: SGA boys accounted for 13.7% (n = 80) of the total cohort (n = 584) and 33% of all proximal hypospadias (n = 99, SGA vs. non-SGA 41.3% vs. 13%, p < 0.001). After a mean follow-up of 18.6 months the reoperation rate for all hypospadias was 17.9% (n = 105). In distal hypospadias there was no difference in reoperation rate between SGA and AGA/LGA boys (p = 0.548, multivariate regression model). For each meatal localization in proximal hypospadias SGA was a significant, independent factor predicting higher reoperation rates (p = 0.019, OR 3.21) in a logistic regression model (Figure ROC). DISCUSSION: Hypospadias surgery carries a substantial risk for unplanned reinterventions. Apart from meatal localization, there are only a few factors (urethral plate quality, glandular diameter, curvature) reported in literature to be associated with reoperative risk. Intrauterine growth retardation associated with SGA might lead to not only a higher probability of proximal hypospadias but also contribute to a higher risk for complications mediated by developmental differences. Whether these findings could help to tailor surgical strategies or adjuvant measures, as for example the application of preoperative hormonal stimulation remains to be determined in future studies. This study is limited by being a single-center series with limited follow-up resulting in some complications probably not yet detected - however, in the same extent in both groups. CONCLUSION: Based on this study, 33% of all proximal hypospadias cases occur in boys born SGA. While the reoperation rate in boys with distal hypospadias was not influenced by SGA status, SGA proved to be an independent predictor of a higher risk of reoperation in those with proximal hypospadias. After validation of these findings in other centers, this could be integrated into counseling and risk-stratification.

A genome-wide association study with tissue transcriptomics identifies genetic drivers for classic bladder exstrophy.

Classic bladder exstrophy represents the most severe end of all human congenital anomalies of the kidney and urinary tract and is associated with bladder cancer susceptibility. Previous genetic studies identified one locus to be involved in classic bladder exstrophy, but were limited to a restrict number of cohort. Here we show the largest classic bladder exstrophy genome-wide association analysis to date where we identify eight genome-wide significant loci, seven of which are novel. In these regions reside ten coding and four non-coding genes. Among the coding genes is EFNA1, strongly expressed in mouse embryonic genital tubercle, urethra, and primitive bladder. Re-sequence of EFNA1 in the investigated classic bladder exstrophy cohort of our study displays an enrichment of rare protein altering variants. We show that all coding genes are expressed and/or significantly regulated in both mouse and human embryonic developmental bladder stages. Furthermore, nine of the coding genes residing in the regions of genome-wide significance are differentially expressed in bladder cancers. Our data suggest genetic drivers for classic bladder exstrophy, as well as a possible role for these drivers to relevant bladder cancer susceptibility.

Detection of bladder trabeculation by voiding cystourethrography and sonography: observations in boys with posterior urethral valves.

Background: As trabeculated bladder wall is often referred to as a sign of chronically increased intravesical pressure, we investigated whether voiding cystourethrography (VCUG) or sonography reliably predicts bladder trabeculation on later urethrocystoscopy. Methods: A total of 76 consecutive patients (2012-2017) with cystoscopically confirmed posterior urethral valves (PUV) and pre-endoscopy VCUG were included. Sonography data were available for 68 of these patients. Radiological findings were reassessed and compared with endoscopic findings using Fisher's exact test and Spearman's rank assessment. Results: VCUG showed a sensitivity of 83.3% and a specificity of 30% in predicting trabeculation on a later urethrocystoscopy, with no significant difference in determining mild or severe forms (p=0.51). Sonography proved a sensitivity of 27.6% and a specificity of 70%, with no correlation between sonographic signs and trabeculation on cystoscopy (r=0.1311). In addition, vesicoureteral reflux had no significant influence as a possible pressure pop-off mechanism on the development of trabeculation in our group. Conclusions: While VCUG predicts bladder trabeculation in children with PUV with limited reliability, sonography mostly fails to detect trabeculation. Therefore, such findings should only be used with utmost caution in relation to clinical decision-making.

Sedation Rate Reduction in Paediatric Renal Nuclear Medicine Examinations: Consequences of a Targeted Audit.

BACKGROUND: Nuclear medicine investigations are essential diagnostic tools in paediatric urology. Child-orientated examination techniques and the avoidance of sedation or anaesthesia vary in different institutions. We aimed at evaluating child friendly measures in our department to identify the potential for improvement. Based on these data, we changed the standards regarding the sedation policy and consequently re-evaluated sedation rates. METHODS: Four-hundred thirty-five consecutive investigations were evaluated regarding the need for sedation, outcome and patient satisfaction at our department. After the revision of our department standards, we re-evaluated 159 examinations. Statistical analysis was performed with JUMBO (Java-supported Münsterian biometrical platform). RESULTS: Eighty-six percent (60/70) would agree to perform an investigation under identical conditions again. Seventy-seven percent (17/22) of eligible patients >5 years of age felt good during the investigation. By changing our sedation policy, we could reduce the sedation rate from 27.1% to 7.5% (p < 0.0001; OR 0.219 95% CI 0.111-0.423). CONCLUSION: The evaluation of child friendly examination protocols demonstrated high reliability and patient satisfaction using situational sedation with a relatively high proportion of patients being sedated. Through protocol adaption with clear age limits, individual indication and education of staff, as well as the use of optimized sedatives, the need for sedation could be further reduced whilst maintaining a high patient satisfaction.

Sexual function in adult patients who have undergone augmentation surgery in childhood: what is really important?

Problems relating to the development of a healthy approach to sex and intimacy during puberty, after augmentation cystoplasty, are scarcely discussed in literature. Therefore, this may suggest that such issues are insufficiently addressed by pediatric urologists. We gathered four experts in the field as well as an experienced leader of a patient group and mother of a girl with spina bifida and asked questions relevant to the following areas of care: (a) diversion, urinary incontinence, and sexual life; (b) impact of a stoma on body image perception and self-esteem; (c) specific female concerns with regard to fertility and recurrent urinary infections; (d) specific male concerns on anejaculation and erectile dysfunction. Their answers are discussed in view of the available literature. All experts and the patient group representative agreed that most of these patients will experience: lack of self-confidence as the most frequent obstacle to starting a relationship and incontinence as a barrier to sexual activity. The cosmesis of the stoma and abdominal scars might influence self-esteem and therefore the sexual activity, however it appears to be a less common concern in males than females. Our results outline the importance and influence that the body image, self-esteem, and confidence present for the individual expectations of the patients related to sex life and sexual activity. Physicians should be encouraged to ask all postpubertal patients about their sexual concerns at every visit. Further studies and exchange of information between clinicians are needed to provide meaningful and analyzable patient-related outcome measures (PROMs).

[The value of DMSA scintigraphy in the diagnostic evaluation of vesicoureteric reflux]. / Refluxdiagnostik − Pro DMSA.

In terms of treatment planning, the radiologic phenomenon of vesicoureteric reflux has become less important than its inherent risk of further urinary tract infections and loss of renal function. Whilst radiologic and sonographic voiding cystourethrography continues to be the gold standard in the mere detection of vesicoureteric reflux, dimercaptosuccinic acid scanning is important for risk stratification. Also it serves to confirm renal involvement in uncertain situations with urinary tract infection and fever. In older children, it is the standard in primary diagnostics. Furthermore, it enables the diagnosis of occult reflux in many cases. Therefore, dimercaptosuccinic acid scanning is an indispensable tool in the diagnostic evaluation of vesicoureteric reflux.

Torsion of an undescended testis - A surgical pediatric emergency.

BACKGROUND/PURPOSE: Torsion of an undescended testis is a surgical emergency whose frequency may be underestimated in the pediatric population. We describe this entity and focus on diagnostic challenges and optimal treatment of torsion of an undescended testis. METHODS: We present a two-center retrospective chart review of patients with torsion of an undescended testis treated between 2013 and 2018. Two instructive cases are used to depict characteristics of this rare entity. RESULTS: We identified 11 patients with previously diagnosed cryptorchidism undergoing surgery for torsion of an undescended testis, accounting for 9.7% (11/107) of all testicular torsions in the period. Mean age at diagnosis was 9.4 months (1-22 months). Mean duration from onset of symptoms to presentation was 19.3 h (8-48 h). At admission to hospital 10 patients presented with groin lump (10/11, 90.9%) with or without pain leading to a suspected diagnosis of inguinal testicular torsion (5/11, 45.5%), incarcerated inguinal hernia (4/11, 36.4%) and epididymitis (1/11, 9.1%). Ten patients had an ultrasound examination before surgery leading to the correct diagnosis in six patients. Ultrasound findings were misinterpreted as incarcerated inguinal hernia in three patients. In eight patients the testis had to be removed at time of surgery; one of the three salvaged testes atrophied, resulting in a salvage rate of 18%. CONCLUSION: Torsion of an inguinal testis is not as rare as it might be presumed. Presentation of these patients is often deferred owing to equivocal signs and symptoms. In addition age at presentation differs from typical testicular torsion. As this might negatively influence testicular salvage rate, we advocate for special attention to this differential diagnosis in children with groin pathologies. Even if the child is not in pain, a tender groin in boys with undescended testes must prompt a quick and thorough examination to rule out torsion of an undescended testis. Ultrasound examination is of limited value and must not delay acute surgical treatment. LEVEL OF EVIDENCE: IV.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool.

OBJECTIVES: Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG). METHODS: Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients. RESULTS: Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p < 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%. CONCLUSIONS: The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.