The learning curve for robotic-assisted pyeloplasty in children: Our initial experience from a single center.

BACKGROUND: Robotic-assisted pyeloplasty surgery has become the preferred approach of ureteropelvic junction obstruction (UPJO) in pediatrics. However, to our knowledge, there is limited data on the learning curve for robotic-assisted pyeloplasty in children and no similar study from Saudi Arabia. AIMS: The objective of the study was to evaluate the progression of the surgical team performing robotic-assisted laparoscopic pyeloplasty (RALP) and to assess the feasibility of the RALP in children, since it is having been recently started in the Kingdom. SETTINGS AND DESIGN: Retrospective charts and surgical videos review at the tertiary care centre. SUBJECTS AND METHODS: After approval from the internal review board (IRB), we reviewed the surgical video recording of the RALP procedure of 15 patients presented with UPJO from January 2016 to October 2017. Statistical analysis was done for the variables includes dissection time, pyelotomy, anastomosis on both sides, and total surgery time and calculated in minutes. Renal ultrasound reviewed to assess any change in grade. RESULTS: Fifteen patients with UPJO underwent RALP. Of 15 cases, nine were primary and six cases as secondary UPJO. The median age was 8 (3-15) years. Out of 15 cases, 13 and 2 patients diagnosed as Society for Fetal Urology grades of 4 and 3, respectively. Total operative time was prolonged in secondary group as compared to primary pyeloplasty group (mean [standard deviation (SD)]: 166.3 [35.1], range: 125-223, P = 0.0028 versus mean (SD): 149.17 (30.4), range: (114-207), P = 0.0008). The success rate was 100% in primary and 84% in secondary cases. The median length of follow-up was 12.0 (7.0-18.0) and 10.0 (8.0-12.5) months in primary and secondary cases, respectively. The overall complication rate was 13% (2/15) (Clavien grade: 1-2). CONCLUSIONS: The evaluation of the learning curve of RALP for this group of patients concluded that total operative time for RALP, performed by the pediatric urology team, steadily decreased with collective surgical experience.

Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation.

INTRODUCTION: Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR). MATERIALS AND METHODS: We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test. RESULTS: Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5-2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively. CONCLUSION: SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.

Laparoscopic retroperitoneal approach for retrocaval ureter in children.

PURPOSE: Retrocaval ureter (RCU) is a rare congenital anomaly and published data on pediatric laparoscopic management are poor. The aim of this study was to report our experience of retroperitoneal laparoscopic approach for management of RCU in children. METHODS: A retrospective review of data from patients treated for RCU between 2002 and 2018 in our institution was performed. All patients were positioned in a flank position and underwent a three-port (5-mm optical trocar and two 3-mm trocars) laparoscopic retroperitoneal ureteroureterostomy. Anastomosis was made by 6/0 absorbable sutures. A JJ stent was always inserted. RESULTS: Five patients with a median age of 94 months (5-152) were operated on and followed up for a median time of 103 months (46-201). Median operating time was 200 min (160-270). No conversion and no transfusion occurred. Median hospital stay was 2 days (1-4). Ureteral stent was removed after 52 days (47-82). Complications included pyelonephretis (N = 1). In all cases, hydronephrosis decreased postoperatively. CONCLUSIONS: Retroperitoneal laparoscopic approach for RCU is safe and effective in children. Our video demonstrates different patients with specific surgical details to show how to manage these children. The global vision of the upper tract by laparoscopy leads to optimal management of these children even if the anomaly was not detected preoperatively.

Parents' awareness and knowledge of testicular torsion: A cross-sectional study.

BACKGROUND: Testicular torsion (TT) is one of the most common emergencies in pediatric urology. Family awareness of this condition could lead to early diagnosis and intervention and salvage of the effected testicle. The purpose of this study is to assess parental awareness about TT and their source of knowledge. We also evaluated the response of the parents to their children's scrotal pain. METHODS: A quantitative, observational, cross-sectional study was conducted from March 2017 to September 2017 at our institution. The study target were parents attending the pediatric urology clinic and the comparison group included parents attending the general pediatric clinic in the same period. We distributed a questionnaire and then compared the results in both groups. RESULTS: A total of 200 parents participated in this study (100 parents from each clinic). Nineteen percent of pediatric urology clinic parents were aware and 14% of general pediatric clinic parents were aware about TT with no statistically significant difference observed (P = 0.341). The parents in urology clinic choose doctor as their main source of knowledge (42.1%), while in general pediatric clinic, doctor and through a friend as the main source of knowledge had the same percentage (28.6%). Response of the parents to their children's scrotal pain during working hours in urology and general pediatric clinics was to drive their children to the emergency room immediately with 85% and 82%, respectively. The response of the parents after working hours in both clinics did not show difference, with 83% of parents in pediatric urology clinic and 85% in general pediatric clinic driving their children immediately to the emergency room. CONCLUSION: TT in boys is a common problem we face as pediatric urologists and it may lead to testicular loss if not diagnosed and treated early. We found that the awareness of TT in children is low in our community and it is our responsibility to raise it to improve our children's well-being.

Biofeedback as single first-line treatment for non-neuropathic dysfunctional voiding children with diurnal enuresis.

INTRODUCTION: Non-neurogenic dysfunctional voiding (NDV) accounts for a significant portion of pediatric urology outpatient clinic visits. Biofeedback (BF) is a promising, non-invasive modality for treating children with DV and daytime wetting. Our objective was to investigate BF's efficacy as a single first-line treatment for children with NDV and diurnal enuresis. METHODS: A retrospective cohort study was conducted with a total of 61 consecutive patient records from January 2009 to March 2016. All children with NDV who had BF as first-line treatment were included. Full urological histories, physical examinations, dysfunctional voiding symptom score (DVSS), urine analysis, ultrasound (US), and uroflowmetry (UFM), and electromyogram (EMG) were performed and recorded for all patients before and after finishing the last BF cycle. The patient's satisfaction scale was also obtained. RESULTS: The mean age was 10±2.6 years. Most patients (80.3%) were females. The presenting symptoms were diurnal enuresis, urinary tract infections, and voiding discomfort in 52 (85.2%), 16 (26.2%), and 38 (62.3%) patients, respectively. Six months after the last BF cycle, there was a statistically significant objective improvement in US and UFM+EMG findings with the disappearance of EMG signals in 40 of 61 (65.5%) patients. There was also a significant subjective symptomatic improvement, as the mean DVSS had decreased from 14 to 7.9 (p=0.003). Forty-seven patients (77%) were satisfied, while only eight (13.1%) were not. CONCLUSIONS: BF is considered a potentially effective, single first-line treatment modality for children with DV and diurnal enuresis. Long-term outcome assessments are needed to assess the children's compliance and symptom recurrence.

Redo laparoscopic pyeloplasty among children: A systematic review and meta-analysis.

Laparoscopic pyeloplasty (LP) is more beneficial than open procedures. However, studies on laparoscopic management of cases with secondary ureteropelvic junction obstruction (SUPJO) after previous failed pyeloplasty in the pediatric population are lacking. This meta-analysis aimed to assess the difference between redo LP (RLP) and redo open pyeloplasty (ROP) for children with SUPJO, focusing on certain criteria. All recent studies on RLP and ROP in children with SUPJO were searched. Search engines such as Medline, PubMed, and The Cochrane Library of Systematic Reviews were used. Sixty citations were specified. Two reviewers extracted data independently, screened the titles, and assessed the quality of each citation. Continuous data reported as a weighted mean difference (WMD) (95% confidence interval) and dichotomous data reported as relative risk were used. We measured the length of hospital stay (LOS) and operative time using weighted mean and success and complication rates using risk difference and odds ratio (OR). A random effects model was used to pool OR that was tested for heterogeneity. We specified six publications that minutely met our eligibility standards. Meta-analysis of given data resulted in the following: ROP showed reduction in operative time by 12 min (WMD: 12.7 min; P = 0.14). RLP had shorter LOS than ROP (WMD: 0.6 days; P < 0.01). No difference was observed in complication and success rates (OR: 0.8; P = 0.50 and OR: 1.2; P = 0.51, respectively). In conclusion, RLP seems to be better than ROP in terms of LOS reduction; however, both are comparable with respect to success and complication rates, especially postoperative urine leakage.

Utilization of scrotal orchidopexy for palpable undescended testes among surgeons.

INTRODUCTION: Scrotal orchidopexy for palpable undescended testicle (UDT) has received attention in the last decade due to its lower morbidity. This study was conducted to determine the frequency and factors related to the use of the scrotal approach in the surgical treatment of palpable UDT among surgeons. METHODS: An observational cross-sectional study was carried out using an online survey, which was sent to different pediatric urologists, pediatric surgeons, and urologists groups. The survey consisted of questions on demographics as well as surgeons opinions and experience toward scrotal orchidopexy. RESULTS: Of 163 respondents, 57 (35.0%) were pediatric surgeons, 98 (60.1%) were pediatric urologists, and 8 (4.9%) were urologists. There were 86 respondents (52.8%) who used the scrotal orchidopexy approach for UDT at any time in their practice. Pediatric urologists tended to use the scrotal orchidopexy approach for UDT more significantly than others (P < 0.001). There were significantly more scrotal orchidopexies for UDT performed by the pediatric urologists throughout their practice and per year compared to others, respectively (P < 0.001). Fifty-two respondents (31.9%) claimed that scrotal orchidopexy is not a good option for their patients, while seven respondents (4.3%) claimed that the procedure was hard to perform. DISCUSSION: Based on the results of this study, we believe that there is a discrepancy in the reported advantages and success rate of scrotal orchidopexy in the published literature and the utilization of such an approach among surgeons managing palpable UDT in children. CONCLUSION: Scrotal orchidopexy is an underutilized approach in the management of palpable UDT in children. Only 52.8% of our respondents used it for UDT. One of the main reasons why scrotal orchidopexy is underutilized is due to the surgeons' perception that scrotal orchidopexy is not the procedure of choice for their patients and their unfamiliarity with the procedure.

Congenital mid-ureteral stricture: a case report of two patients.

BACKGROUND: Congenital hydronephrosis is a common foetal anomaly. There are numerous causes of hydronephrosis. The diagnosis of ureteral anomalies remains challenging. Congenital mid-ureteral stricture (CMS) is less common than proximal and distal strictures. In most cases involving CMS, this condition is diagnosed intra-operatively. The gold standard treatment is resection of the stenosed segment and ureteroureterostomy. CASE PRESENTATION: We report two patients with CMS which presented as antenatal hydronephrosis with postnatal workup showed a picture of pelviuretric junction obstruction which required surgical correction. Intraoperative retrograde pyelography (RGP) confirmed the diagnosis of mid ureteral stricture which make us to change the planned surgical intervention from pyeloplasty to excision of the ureteral stricture and ureteroureterostomy as definitive management. CONCLUSION: CMS should be considered whenever proximal mega-ureter is an associated finding. Despite advanced radiological modalities, RGP remains the mainstay approach for diagnosing ureteral anomalies.

Timing of orchidopexy at a tertiary center in Saudi Arabia: reasons for late surgery.

BACKGROUND: Orchidopexy should be performed during the first 18 months of life to decrease the risk of infertility and tumor formation. In our center, the timing of surgical correction varies depending on the availability of an operating room. OBJECTIVES: Evaluate whether orchidopexy performed for patients referred to our center is done within the recommended time period and to determine causes for delay. DESIGN: Retrospective descriptive study. SETTING: Pediatric urology department of a tertiary care center. SUBJECTS AND METHODS: We retrospectively reviewed the charts of patients charts who underwent orchidopexy at our center from 2000 to 2010. We assessed referral time and waiting list time, which were subdivided as follows: from referral to first visit and from first visit to surgery. We included patients younger than 14 years and excluded pa.tients with comorbidities that affected the timing of referral and surgi.cal treatment. MAIN OUTCOME MEASURES: Referral time period and waiting list time for surgical correction of patients presented with undescended testis. SAMPLE SIZE: 128 RESULTS: After exclusion of 32 patients because of comorbidities, we describe 128 who underwent surgery for cryptorchidism at our center. The median (interquartile range, minimum-maximum) for age at sur.gery was 46.7 months (24.4-83.4, 3.1-248.6]). The median (IQR) referral occurred at an age of 25.3 months (4.1-65.5). The median (IQR) waiting list time was 15.2 months (8.1-23.3). The median (IQR) waiting time from referral to the first visit was 4.1 months (1.0-8.2). The median wait.ing time from the first visit to surgery was 8.1 months (3.8-17.5). CONCLUSIONS: The age at the time of surgery at our center was far from ideal because of late referrals. A structured program offered by our National Health Service to educate referring physicians is necessary. Community health initiatives must emphasize prompt referral to reduce the impact of delayed surgery. LIMITATIONS: Lack of data on the type of referring physician (i.e., general practitioner, pediatrician, surgeon, urologist). CONFLICT OF INTEREST: None.

Robotic versus open pyeloplasty in pediatric patients: a single center experience in Saudi Arabia.

BACKGROUND: Robotic surgery in pediatric patients is performed in our center since 2013. This study aims to analyze the evolution of robot-assisted laparoscopic pyeloplasty (RALP) in our center to investigate its feasibility and safety compared with open pyeloplasty (OP) technique. METHODS: In this retrospective study, patients aged 2 to 14 years who underwent pyeloplasty procedure for ureteropelvic junction obstruction were divided into two groups according to the type of surgical approach (RALP and OP). The median age, weight, duration of the procedure, length of hospital stays, complication according to the Clavien grading system and success rates were recorded. We determined any trends in RALP activity, the length of hospital stay, and the patients' weight. We also compared the results of two equally divided periods (January 2015 to March 2016 and April 2016 to June 2017). RESULTS: Forty-one pyeloplasty were performed in this study. RALP and OP were performed in 26 (57.8%) and 15 (33.3%) cases, respectively. RALP was more utilized than OP in the second period (19 vs. 7). Comparing the two periods, a reduction in the median weight in the RALP group was observed (P=0.039); in the OP group, the weight remained almost unchanged (15 vs. 18 kg). The median duration of OP was shorter than that of RALP (P<0.04). The length of hospital stays reduced in the RALP group (P=0.013). CONCLUSIONS: RALP is safe and feasible and has a promising potential in pediatric urology. The rapid and favorable evolution in the studied indicators shows encouraging results as the indications for RALP are expanded and the length of hospital stay shortened.

Renal oxalate stones in children with Zellweger spectrum disorders.

Peroxisomal biogenesis disorders due to PEX gene defects are classified into many subgroups, of which Zellweger spectrum disorders (ZSDs) represent the major subgroup. The ZSDs are clinical and biochemical disorders divided into three phenotypes: neonatal, adolescence, or adult. Clinical presentations vary with severity of the condition. Metabolic abnormalities occur due to functional peroxisomal defects that could be detected in blood and urine. No cure or definitive management exists to date; only supportive and palliative measures are applied to prevent worse sequelae. We experienced a case of oxalate renal stones in a patient with ZSD. This patient had hyperoxaluria and hyperglycolic aciduria with clinically associated clues that correlate with urinary oxalate load. Urinary oxalate and glycolate excretion were assessed. Radiological workup revealed renal involvement with urolithiasis and nephrocalcinosis. Urinalysis and ultrasonography for stones and hyperoxaluria should be used to screen patients with ZSD for early intervention to prevent renal damage.

Long-term Outcomes of Augmentation Cystoplasty in a Pediatric Population With Refractory Bladder Dysfunction: A 12-Year Follow-up Experience at Single Center.

PURPOSE: Augmentation cystoplasty (AC) is a surgical procedure used in adults and children with refractory bladder dysfunction, including a small bladder capacity and inadequate bladder compliance, and in whom conservative and medical treatment has failed. This study was aimed to determine the long-term outcomes of AC in children. METHODS: A retrospective analysis was conducted of 42 patients (31 males; mean age, 14.2±6.2 years) who underwent AC for neurogenic and nonneurogenic bladder dysfunction, with a median 12.0±1.5 years of follow-up. All patients underwent AC using the ileum with or without continent reconstruction. Pre-AC, concurrent, and post-AC procedures and complications were analyzed. Patients who underwent ureterocystoplasty, were lost to follow-up, or had less than 10 years of follow-up were excluded. The primary outcomes were the complication and continence rates, the post-AC linear rate of height and weight gain, and renal function. The Student t-test was used to evaluate between-group differences and the paired t-test was used to evaluate longitudinal changes in measured variables. RESULTS: Renal function was stable or improved in 32 of 42 patients (76.2%), with a post-AC continence rate of 88.1%. Thirty patients (71.4%) required 72 procedures post-AC. There was no statistically significant difference in the mean percentile of height (P=0. 212) or weight (P=0.142) of patients in the pre- and post-AC periods. No cases of bladder perforation or malignancy were detected. CONCLUSION: We consider AC to be a safe and effective procedure that does not negatively affect future physical growth, while achieving a good rate of stable renal function. Patients need long-term follow-up to address long-term complications.

Total endoscopic and anal irrigation management approach to noncompliant neuropathic bladder and bowel in children: A long-term follow-up.

PURPOSE: To evaluate the long-term efficacy and durability of combined intradetrusor botulinum-A toxin (BTX-A), endoscopic treatment of vesicouerteral reflux and anal irrigation for stool incontinence (SI) via a total endoscopic and anal irrigation management (TEAM®) approach in patients with myelomeningocele and neuropathic bladder and bowel who did not respond to conservative measures. MATERIALS AND METHODS: Fourteen myelomeningocele patients with at least 3 years follow-up were included in the study. All patients have urinary and SI not responded to conservative management. All patients received a cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) BTX-A. There was vesicoureteral reflux in 22 ureters, and a Deflux® injection was completed during the same procedure. SI was managed using trans-anal irrigation, either with a fleet enema or Peristeen® system regularly. RESULTS: After at least 3 years of follow-up, mean maximum bladder capacity increased significantly from 78 ± 36 ml to 200 ± 76 ml (P < 0.0001) and the maximum detrusor pressure decreased from 56 ± 12 cm H2O to 29 ± 7 cm H2O (P < 0.001). Twenty-one refluxing ureters (95%) showed complete resolution and one persisted. Ten patients (72%) achieved complete dryness between catheterizations. Four patients (28%) went for augmentation cystoplasty, due to progressive hydronephrosis and/or persistent urinary incontinence. Thirteen patients achieved complete stool continence. CONCLUSIONS: Over long-term follow-up, major reconstruction surgery can be avoidable or delayable; the TEAM® approach is a minimally invasive, safe, simple, and effective way to achieve upper urinary tract protection and provide urinary and stool continence.

Pressure-induced alopecia in pediatric patients following prolonged urological surgeries: The case reports and a review of literature.

Postoperative alopecia has been reported as a rare complication after prolonged immobilization during general anesthesia. The constant pressure on the scalp is causative and may be exacerbated by hypoxemia or hypotension. There is a correlation between the length surgery duration under anesthesia and the development of permanent alopecia. Regular head turning schedules and vigilance for the condition should be used as prophylaxis to prevent permanent alopecia.

Hourglass bladder after ileocystoplasty (case report).

Narrowing of the anastomotic area between the bowel segment and urinary bladder is known as "hourglass bladder." This report describes a rare case of hourglass bladder deformity occurring post-ileocystoplasty in a 14-year-old male. We describe the essential steps that should be taken during bladder augmentation to avoid such a complication, along with a discussion of the relevant literature. This case emphasizes the need to strictly adhere to the steps of augmentation cystoplasty to avoid this technical complication.

Outcomes of a minimally invasive surgical approach to manage persistent high-grade vesicoureteric reflux post successful augmentation cystoplasty of patients with non-compliant bladder.

INTRODUCTION: Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation. OBJECTIVE: Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP. DESIGN: Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value <0.05 was considered statistically significant (Table 1). RESULTS: Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2). DISCUSSION: VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47-57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR. CONCLUSION: ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.

Congenital anterior urethrocutaneous fistula: Two case reports and review of literature.

Congenital anterior urethrocutaneous fistula (CAUF) of the male urethra is a rare anomaly. CAUF can be defined as a urethral fistula in which the urethra and external urethral meatus are intact, typically with intact prepuce and no history of any penile trauma (including surgical trauma).We report 2 cases of CAUF to highlight this pathology with hints of the published similar cases in the literatures and discuss the surgical reconstruction ways for management.

Peristeen anal irrigation as a substitute for the MACE procedure in children who are in need of reconstructive bladder surgery.

INTRODUCTION: We evaluate the efficacy of the Peristeen (Coloplast A/S, Kokkedal, Denmark) transanal irrigation (TAI) system, as a stool cleansing mechanism, to gain stool continence in children who need reconstructive bladder surgery and have fecal incontinence. METHODS: We prospectively evaluated children with neuropathic bladder and bowel dysfunction who were intended for reconstructive bladder surgery and the Malone antegrade continence enema (MACE) procedure. All patients were started on the Peristeen TAI system at least 3 months before surgery to assess their response. Each patient's bowel function, frequency of using the system, satisfaction (and that of their parents) and diaper independency were evaluated before and after reconstructive surgery. RESULTS: We included 18 patients (11 female, 7 male) who were evaluated from April 2006 to the present. The mean age of the group was 7.6 years (range: 4-15). Fifteen patients (83.3%) showed complete dryness from stools. Of the 15 patients, 8 (53.3%) were able to be diaper-free, while 6 continued wearing diapers due to fear of soiling and 1 due to urinary incontinence. The patients underwent reconstructive bladder surgery and continued to use the Peristeen TAI system with the same results postoperatively. The main limitation of this study is the small number of patients included, although this is a very specific patient group. CONCLUSION: Our initial results suggest that the Peristeen TAI system is a successful conservative substitute for the MACE procedure in children who require reconstructive bladder surgery.

Endoscopic correction of vesicoureteral reflux in children with a solitary kidney: the risk of obstruction.

PURPOSE: We aimed to review patients with a solitary kidney and ipsilateral vesicoureteral reflux (VUR) who underwent endoscopic correction of VUR (ECVUR) and to evaluate the prevalence of obstruction in this group of patients. MATERIALS AND METHODS: We retrospectively reviewed the files of all patients who underwent ECVUR at our center between January 2000 and June 2011. Only patients with a solitary kidney and ipsilateral VUR were included. RESULTS: Thirteen patients met our criteria. Two patients (15.38%) developed obstruction post-ECVUR. Both patients developed anuria in the first 24 h after surgery and required intervention. Two patients (15.38%) had increasing hydroureteronephrosis that was discovered on follow-up ultrasound, with no symptoms or signs of obstruction. Both were managed conservatively. CONCLUSION: Our results showed a higher percentage of obstruction post-ECVUR in patients with a solitary kidney (15.38%), who required immediate intervention. Thus, we recommend giving clear instructions to parents of patients with VUR and a solitary kidney post-ECVUR before discharge from the hospital regarding decreased urine output and loin pain. We recommend a follow-up ultrasound to rule out obstruction and detect new-onset hydronephrosis.