Does renal transplant in children with LUTD improve their bladder function?

Much is still unknown about LUT function after receiving renal graft. Graft function was the main focus of different studies discussing the same issue. However, these studies ignored the effects of the graft on lower tract function and more demand for bladder cycling and growth of the child. Therefore, we aimed at evaluating the LUT function after RT into patients with LUTD. We enrolled a retrospective cohort of 83 live renal transplant children with LUTD. The 44 patients in Group (A) had a defunctionalized bladder, and the 39 patients in Group (B) had underlying LUT pathology. All patients had clinical and urodynamic evaluation of LUT functions at least 1 year after RT. We found that the improvement in patients with impaired bladder compliance was 73% in Group (A) and 60% in Group (B), with no statistically significant difference between the study groups. In Group (B), there was statistically significant worsening of MFP (8.4%) and mean PVR (79.9%) after RT. In Group (A), mild but stable significant improvement of all clinical and urodynamic parameters was observed. Serum creatinine was significantly worse in patients with pathological LUTD compared with those with defunctionalized bladder but without significant effect on graft survival. All LUT variables seemed to have no adverse effect on graft survival except for use of CIC and augmented bladder. Incident UTI independent of LUT variables accounted for 20% of graft creatinine change.

Trifecta in flexible ureteroscopy for treatment of renal and upper ureteral calculi: A multicenter study.

Purpose: To determine predictors for missing trifecta in patients who underwent flexible ureteroscopy (FURS) for treatment of renal and upper ureteric calculi. Patients and Methods: The data of adult patients with renal or upper ureteral stones who underwent FURS from June 2021 through December 2022 were retrospectively reviewed. Stone-free status (no residual stones > 3 mm) was evaluated after 3 months with non-contrast CT. Modified Clavien classification was used to grade complications. A stone-free status after a single intervention of FURS without complications was defined as trifecta. Patients were divided into two groups (trifecta and non-trifecta). Risk factors for missing trifecta were compared between both groups using univariate and multivariate analyses. Results: Three hundred twenty-three patients with mean age 48.9 ± 13 years and mean stone length 16 ± 5.9 mm were included. The trifecta criteria were applicable for 250 patients (71%). On multivariate analysis, risk factors for missing trifecta were stone multiplicity (OR: 3.326, 95%CI: 1.933-5.725) and non-experienced surgeons (OR: 1.819, 95%CI: 1.027-3.220). Conclusions: Multiple stones and performance of FURS by non-experienced surgeons are the independent risk factors for missing trifecta of FURS.

Ultrasound Diagnosis and Active Ureteroscopy for Obstructive Ureteral Calculi During Pregnancy: Multicenter Experience.

Objectives: To evaluate the safety and efficacy of ultrasound (US) and primary ureteroscopy (URS) in the management of symptomatic obstructive ureteric stones during pregnancy. Patients and Methods: A prospective multicenter study was performed between June 2013 and December 2019, including all consecutive pregnant patients admitted to three urology centers with intractable renal colic with obstructed ureter secondary to obstructive ureteral calculi. Color Doppler ultrasound was used to evaluate renal Resistive Index (RI) and ureter jet. Primary URS was performed to remove the blocking stones. The safety and effectiveness of the procedures were assessed, as well as the stone-free rate (SFR) and the condition of the upper tract after delivery. Results: A total of 111 pregnant patients were included with a mean age of 27.4 ± 4.4 years and a mean renal RI of 0.78 ± 0.02. US diagnosed stones in 46.8% of patients, while 100 (90%) patients had altered lower ureter urinary jet, including 86.5% who had URS-confirmed ureteric stones; SFR was 95.8% with no serious urologic, fetal, or obstetric complications. Nine percent of patients had premature delivery, which was significantly correlated with postoperative urinary tract infection and premature uterine contraction (p ˂ 0.0001). In the third-month follow-up of US, all patients showed no residual hydronephrosis. Postoperative follow-up procedures were required in 15.3% of patients. Conclusion: Obstructive ureteral stones during pregnancy can be detected safely and appropriately with a combined elevated renal RI and absent ureteral jet detected by Doppler US. Definitive URS is an efficient and safe alternative option for those who fail in conservative management.

Results of two-stage transverse preputial island flap urethroplasty for proximal hypospadias with chordee that mandate division of the urethral plate.

INTRODUCTION: Reconstruction of proximal hypospadias with chordee remains a difficult task. Our work aims to evaluate the role of two-stage transverse preputial island flap urethroplasty for repair of proximal hypospadias with chordee. MATERIAL AND METHODS: This is a retrospective study including 57 children who underwent two-stage transverse preputial island flap urethroplasty. Glans meatus shaft (GMS) score was applied to 24 cases. Patient's characteristics, operative details and complications were assessed. Hypospadias objective scoring evaluation was used for postoperative assessment. RESULTS: The mean age at the first stage operation was 23.6 months (9-84); the mean time interval between the first and second stage operations was 8.1 months (6-12) and the mean follow-up duration was 52.1 months (24-96). Urethral meatus was proximal penile in 18 patients, penoscrotal in 24 and scrotal in 15. The mean degree of ventral curvature (VC) was 51.5° (30-90). After the second stage operation, postoperative complications occurred in 16 (28.1%) patients with urethrocutaneous fistula in 6 (10.5%) cases, diverticulum in 3 (5.3%), glans dehiscence in 5 (8.8%) and meatal stenosis in 2 (3.5%). All cases of glans dehiscence occurred in severe hypospadias and small glans. Moderate GMS score was present in 10 (41.7%) cases and severe GMS in 14 (58.3%). Complications occurred in 7 (29.1%) patients with 5 (20.8%) with a severe GMS score and 2 (8.3%) with a moderate GMS score. The hypospadias objective scoring evaluation showed satisfactory results, with 39 (68.4%) patients achieving a score of 16 points. CONCLUSIONS: Two-stage transverse preputial flap is a good choice for repair of proximal hypospadias with an acceptable complication rate of 28.1%.

Prevention of stone retropulsion during ureteroscopy: Limitations in resources invites revival of old techniques.

OBJECTIVE: To compare a modified technique using the Dormia basket vs Stone Cone for stone entrapment to avoid proximal stone migration during ureteroscopic pneumatic lithotripsy of ureteric stones. PATIENTS AND METHODS: Our study included all patients with ureteric stones of <15 mm who underwent ureteroscopic pneumatic lithotripsy from January 2015 to September 2018. The study had two arms that were conducted over two consecutive periods; the first included 72 patients in whom we used the Stone Cone (Group 1) and the second included 86 patients in whom we started to use a Dormia basket with a modification (Group 2) to guard against proximal stone migration. RESULTS: Both groups were comparable for gender, age, and stone characteristics. Lower ureteric stones were the most prevalent as they represented 62.5% and 60.5% in groups 1 and 2, respectively; while upper ureteric stones were respectively found in 16.7% and 17.4%. Chemical stone analysis revealed that calcium oxalate stones were most predominant accounting for 51.3% and 51.1% in groups 1 and 2, respectively. Most of the stones were radio-opaque stones representing 57% and 58.1% in groups 1 and 2, respectively. There was a significant difference in operative time, with a mean (SD) operative time was 50.9 (11.2) in Group 1 vs 58.3 (12.4) min in Group 2 (P < 0.001). The success rate, defined as no retropulsion of stone fragments, was 97.7% in Group 2 vs 91.7% in Group 1 (P < 0.01). Complications were minor and comparable between the groups. There was no difference in hospital stay between the groups, but the cost assessment favoured Group 2. CONCLUSION: We found that our modified-basket stone entrapment technique compared favourably with the Stone Cone to guard against stone retropulsion during ureteroscopic pneumatic lithotripsy. Our modification to the basket was found to be feasible, efficient, safe, reproducible and cost-effective in preventing proximal stone migration. This procedure is particularly suitable in cost-limited environments.

Management of intravesical self-inflicted sharp objects in children: 10-year single-center experience.

INTRODUCTION: Intravesical foreign bodies (FBs) are rare and have interesting pathology for urologists. There has been an increase in reports of intravesical FBs in the last few decades, but they are still considered to be rare in children, especially young girls. Here we present our experience in the assessment and management of intravesical self-inserted sharp objects in children. PATIENTS AND METHODS: We reviewed the records of children with self-introduced intravesical FBs admitted to our hospital during the last 10 years. Twenty-four cases were included in this study (20 girls and 4 boys). The presenting symptoms and methods of diagnosis and treatment were reviewed. RESULTS: The ages of the patients ranged from 4 to 12 years. In all cases, foreign bodies were self-inserted. All patients were subjected to KUB (kidney, ureter, bladder radiograph) and abdominal ultrasonography. Based on the KUB findings, the FBs in girls were found to be metal pins in 12, a hair clip in four, and a wooden pencil in three (Figure). In boys, a coiled electric wire was found in three, with a urinary calculus formed over one of them. There were small metallic objects in two cases (1 boy and 1 girl). Endoscopic removal of FBs was done successfully in 19 cases (18 girls and 1 boy), and open cystostomy was performed in four cases (3 boys and 1 girl). DISCUSSION: Intravesical FBs are important considerations in the differential diagnosis of pathological lower urinary tract symptoms. They represent significant challenges to urologists. Among children, the reasons for self-insertion of FBs might reflect psychiatric disorders. Routine psychiatric evaluations should be offered to all patients with intentional FB insertion to avoid missing any underlying psychiatric disorders. In our study, psychiatric evaluations have been advised for all the affected children and their parents. Self-inserted FBs are commonly seen in adults and are rarely encountered in children. To our knowledge, this is the largest reported series of children with self-inflicted intravesical FBs. In addition, all of the FBs in this study had one or more sharp edges that made their endoscopic extraction more difficult without causing bladder or urethral damage. In children, removal of intravesical FBs represents a great challenge, as the size of the pediatric urethra may hinder safe transurethral removal. Endoscopic handling of intravesical FBs is mostly unsuccessful in boys because of the long and narrow urethra, and open cystostomy might be the treatment of choice to save the urethra. In contrast, the short female urethra renders the endoscopic removal of intravesical FBs more successful. In this study, endoscopic removal of FBs was done successfully in 19 cases (18 girls and 1 boy), and open cystostomy was performed in four cases (3 boys and 1 girl). CONCLUSIONS: Although FBs in the urinary tract of children are very rare, they need to be considered during any evaluation of pathological lower urinary tract symptoms. Endoscopic management is feasible for most of these patients. The size, number, nature of foreign bodies, and any associated urinary calculi determine the treatment modality.

Computed tomography-virtual cystoscopy in the evaluation of a bladder mass: Could it replace standard conventional cystoscopy?

OBJECTIVE: To determine the role of computed tomography-virtual cystoscopy (CT-VC) in the detection and evaluation of bladder cancer, compared to standard conventional cystoscopy (CC). PATIENTS AND METHODS: Twenty-five patients with a clinical presentation of a bladder mass(es) were selected from an outpatient urology clinic between May 2011 and August 2012. All patients were then assessed using multi-slice CT of the bladder, CT-VC and CC. The results were then compared amongst axial CT images, multiplanar reconstruction (MPR) images, CT-VC and CC, and compared with the pathological results. RESULTS: Forty lesions were found at CC in the 25 patients. MPR images had a greater sensitivity for detecting small masses of ⩽5 mm, and for identifying the location of the masses, especially basal (100%), than had axial images. The diagnostic results varied significantly (P = 0.031 and 0.039) between CC and axial images. The difference was slightly significant (P = 0.063) for MPR images and was not significant (P = 0.99) for virtual images. CONCLUSIONS: Compared to CC, CT-VC was much less invasive, but it was not possible to take a biopsy and provide tissue for histopathology, and it could not depict flat lesions or mucosal colour changes. Therefore, CT-VC could be considered for bladder mapping before CC, in the follow-up of patients with superficial transitional cell carcinoma after transurethral resection of the tumour, in combination with urine cytology, and for patients in whom CC is difficult or contraindicated.