Six of one, half a dozen of the other: A measure of multidisciplinary inter/intra-rater reliability of the society for fetal urology and urinary tract dilation grading systems for hydronephrosis.

INTRODUCTION: The urinary tract dilation (UTD) classification system was introduced to standardize terminology in the reporting of hydronephrosis (HN), and bridge a gap between pre- and postnatal classification such as the Society for Fetal Urology (SFU) grading system. Herein we compare the intra/inter-rater reliability of both grading systems. MATERIALS AND METHODS: SFU (I-IV) and UTD (I-III) grades were independently assigned by 13 raters (9 pediatric urology staff, 2 nephrologists, 2 radiologists), twice, 3 weeks apart, to 50 sagittal postnatal ultrasonographic views of hydronephrotic kidneys. Data regarding ureteral measurements and bladder abnormalities were included to allow proper UTD categorization. Ten images were repeated to assess intra-rater reliability. Krippendorff's alpha coefficient was used to measure overall and by grade intra/inter-rater reliability. Reliability between specialties and training levels were also analyzed. RESULTS: Overall inter-rater reliability was slightly higher for SFU (α = 0.842, 95% CI 0.812-0.879, in session 1; and α = 0.808, 95% CI 0.775-0.839, in session 2) than for UTD (α = 0.774, 95% CI 0.715-0.827, in session 1; and α = 0.679, 95% CI 0.605-0.750, in session 2). Reliability for intermediate grades (SFU II/III and UTD 2) of HN was poor regardless of the system. Reliabilities for SFU and UTD classifications among Urology, Nephrology, and Radiology, as well as between training levels were not significantly different. DISCUSSION: Despite the introduction of HN grading systems to standardize the interpretation and reporting of renal ultrasound in infants with HN, none have been proven superior in allowing clinicians to distinguish between "moderate" grades. While this study demonstrated high reliability in distinguishing between "mild" (SFU I/II and UTD 1) and "severe" (SFU IV and UTD 3) grades of HN, the overall reliability between specialties was poor. This is in keeping with a previous report of modest inter-rater reliability of the SFU system. This drawback is likely explained by the subjective interpretation required to assign grades, which can be impacted by experience, image quality, and scanning technique. As shown in the figure, which demonstrates SFU II (a) and SFU III (b), as assigned by a radiologist, it is possible to make an argument that either of these images can be classified into both categories that were observed during the grading sessions of this study. CONCLUSION: Although both systems have acceptable reliability, the SFU grading system showed higher overall intra/inter-rater reliability regardless of rater specialty than the UTD classification. Inter-rater reliability for SFU grades II/III and UTD 2 was low, highlighting the limitations of both classifications in regards to properly segregating moderate HN grades.

Bladder Training Video versus Standard Urotherapy for Bladder and Bowel Dysfunction: A Noninferiority Randomized, Controlled Trial.

PURPOSE: We evaluated whether an animated bladder training video was as effective as standard individual urotherapy in improving bladder/bowel symptoms. MATERIALS AND METHODS: Patients 5 to 10 years old who scored greater than 11 on the bladder/bowel Vancouver questionnaire were included in a noninferiority randomized, controlled trial. Children with vesicoureteral reflux, neuropathic bladder, learning disabilities, recent urotherapy or primary nocturnal enuresis were excluded from analysis. Patients were randomly assigned to receive standard urotherapy or watch a bladder training video in clinic using centralized blocked randomization schemes. Bladder/bowel symptoms were evaluated at baseline and 3-month followup by intent to treat analysis. A sample size of 150 patients ensured a 3.5 difference in mean symptomology scores between the groups, which was accepted as the noninferiority margin. RESULTS: Of 539 screened patients 173 (37%) were eligible for study and 150 enrolled. A total of 143 patients (95%) completed the trial, 5 (4%) were lost to followup and 2 (1%) withdrew. Baseline characteristics were similar between the groups. Baseline mean ± SD symptomology scores were 19.9 ± 5.5 for the bladder training video and 19.7 ± 6.0 for standard urotherapy. At 3 months the mean symptomology scores for the bladder training video and standard urotherapy were reduced to 14.4 ± 6.5 and 13.8 ± 6.0, respectively (p = 0.54). The mean difference was 0.6 (95% CI -1.4-2.6). The upper 95% CI limit of 2.6 did not exceed the preset 3.5 noninferiority margin. CONCLUSIONS: The bladder training video was not inferior to standard urotherapy in reducing bladder/bowel symptoms in children 5 to 10 years old. The video allows families to have free access to independently review bladder training concepts as often as necessary.

Cause and Effect versus Confounding-Is There a True Association between Caudal Blocks and Tubularized Incised Plate Repair Complications?

PURPOSE: We studied the impact of caudal block vs dorsal penile block on the rate of urethrocutaneous fistula and glans dehiscence in children who underwent hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the records of 849 consecutive patients who underwent tubularized incised plate repair between 2004 and 2015. A total of 331 cases with incomplete medical records, other techniques and redo repair were excluded. The preference for caudal block was based on anesthesiologist discretion. Age at surgery, meatal location, preoperative testosterone stimulation, type of regional anesthesia (caudal block vs dorsal penile block), degree of ventral curvature, surgeon expertise and complications (urethrocutaneous fistula/glans dehiscence) were captured. Univariate and multivariable analyses were done of risk factors for complications. RESULTS: Median age at surgery was 18 months and median followup was 6 months. Of 518 patients 405 (78%) had distal and 113 (22%) had mid shaft/proximal defects. Complications developed in 37 cases (7%), including urethrocutaneous fistula in 21 (19 with a caudal block and 2 with a dorsal penile block) and glans dehiscence in 16 (13 with a caudal block and 3 with a dorsal penile block). On univariate analysis preoperative testosterone stimulation vs no preoperative testosterone stimulation (13.0% vs 6.2% of cases, p = 0.04), mid shaft/proximal vs distal defects (15.9% vs 4.7%, p <0.01) and caudal block (8.7% vs 3.3%, p = 0.03) were significantly associated with more complications. However, on multivariable analysis the associations of preoperative testosterone stimulation (OR 1.2, 95% CI 0.4-3.7) and caudal block (OR 2.4, 95% CI 0.9-6.4) with complications did not hold. Only the combination of meatal location/ventral curvature remained as an independent risk factor for urethrocutaneous fistula/glans dehiscence (OR 2.4, 95% CI 1.1-5.7, p = 0.04). CONCLUSIONS: Our data indicate that hypospadias severity and not the type of regional anesthesia was the only risk factor significantly associated with postoperative complications. To confirm these findings and provide strong and definitive evidence on this topic a well powered, randomized, controlled trial is clearly required.

Comparative Outcome Analysis of Children Who Underwent Pyeloplasty for Ureteropelvic Junction Obstruction Associated With or Without Supranormal Differential Renal Function.

OBJECTIVE: To compare pyeloplasty outcomes in children with and without "supra-normal" differential renal function (SNDRF) defined as >55% differential renal function (DRF) in children with ureteropelvic junction obstruction. METHODS: Our prospectively collected pyeloplasty database (2008-2015) was reviewed (n = 151). A total of 140/151 (93%) patients had preoperative renograms and 26/140 (19%) were found to have SNDRF (DRF ≥ 55%). Of 151 patients, 51 (34%) had pre- and postoperative renograms allowing determination of change ≥5% in function. After excluding 2 patients with solitary kidneys, a total of 49 patients defined the study group. RESULTS: Of 49 patients, 12 had SNDRF and 37 did not. Baseline characteristics were similar including mean age at surgery (47.3 months vs 45.4 months) and time to surgery (8.7 months vs 9.8 months). Mean preoperative anteroposterior diameter was significantly different between groups (23.2 mm vs 31.0 mm; P = .04), but postoperative was similar (9.0 mm vs 12.1 mm; P = .14). Mean preoperative DRF was 60.2% in the SNDRF group vs 44.3% in the non-SNDRF. Mean postoperative DRF was 52.4% and 45.3%, respectively (P = .04). There were 9/12 (75%) SNDRF patients who experienced ≥5% loss in function compared to 2/37 (5%) in the non-SNDRF group (P < .01). CONCLUSION: Three-quarters of SNDRF patients demonstrated a decline of ≥5%DRF postoperatively when compared to non-SNDRF. This finding may not reflect true elevated renal function, but rather hyperfiltration in the setting of obstruction, which-if unrecognized as such-could result in postponing an otherwise beneficial surgical intervention.

Pediatric fibrous pseudotumor of the tunica vaginalis testis.

We describe a 16-year-old male with ultrasound evidence of a 1.3 cm right paratesticular nodule, which was managed by intraoperative frozen section and excisional biopsy. The pathologic findings were consistent with benign fibrous pseudotumor of the tunica vaginalis testis, which is a very rare lesion in the pediatric population. Consideration of fibrous pseudotumor in the differential diagnosis of pediatric paratesticular masses may help prevent unnecessarily aggressive therapy.

A pilot randomized controlled trial evaluating the effectiveness of group vs individual urotherapy in decreasing symptoms associated with bladder-bowel dysfunction.

PURPOSE: We determined the feasibility of a definitive trial comparing the effectiveness of group vs individual urotherapy for children with bladder-bowel dysfunction. MATERIALS AND METHODS: Children 6 to 10 years old with bladder-bowel dysfunction were recruited during the course of 1 year. Feasibility data on screening, eligibility, recruitment and protocol compliance rates were collected. Patients with high grade hydronephrosis, vesicoureteral reflux or learning disabilities and those who had previously undergone urotherapy were excluded. Patients were randomized to 1-hour group urotherapy or 15-minute individual urotherapy. Symptoms and quality of life were measured using the Vancouver Nonneurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire and the Pediatric Incontinence Questionnaire at baseline and at 3 to 6 months of followup. Within/between group comparisons were conducted using t-tests. RESULTS: Of 455 screened children 79 were eligible and 60 were recruited to participate. A total of 24 patients randomized to group urotherapy and 25 randomized to individual urotherapy completed the pilot trial (6 undergoing group and 5 undergoing individual urotherapy withdrew from the study). Symptomology scores between group and individual urotherapy were not different at followup (mean ± SD 14.7 ± 7.9 vs 13.4 ± 6.3, p = 0.54, 95% CI -5.4-2.8). Quality of life scores between patients undergoing group and individual urotherapy at baseline differed (mean ± SD 21.1 ± 10.8 vs 31.0 ± 14.3, p < 0.01, 95% CI 2.7-7.3) but became similar at followup (21.0 ± 14.2 vs 20.1 ± 15.3, p = 0.84, 95% CI -9.4-7.6). Within group analyses demonstrated improvement in symptomology from baseline to followup in patients undergoing group (mean ± SD 3.6 ± 7.6, p = 0.03, 95% CI 0.4-6.8) and individual urotherapy (6.0 ± 5.4, p < 0.01, 95% CI 3.8-8.3). Within group quality of life analyses revealed improvement in Pediatric Incontinence Questionnaire scores from baseline to followup in patients undergoing individual urotherapy (p < 0.01, 95% CI 5.0-16.9) only. CONCLUSIONS: Urotherapy, regardless of modality, effectively improved bladder-bowel dysfunction symptoms. A definitive randomized controlled trial is feasible, considering that a high recruitment rate (76%) for this population has been established.

Misuse of ultrasound for palpable undescended testis by primary care providers: A prospective study.

INTRODUCTION: Although previous evidence has shown that ultrasound is unreliable to diagnose undescended testis, many primary care providers (PCP) continue to misuse it. We assessed the performance of ultrasound as a diagnostic tool for palpable undescended testis, as well as the diagnostic agreement between PCP and pediatric urologists. METHODS: We performed a prospective observational cohort study between 2011 and 2013 for consecutive boys referred with a diagnosis of undescended testis to our tertiary pediatric hospital. Patients referred without an ultrasound and those with non-palpable testes were excluded. Data on referring diagnosis, pediatric urology examination and ultrasound reports were analyzed. RESULTS: Our study consisted of 339 boys. Of these, patients without an ultrasound (n = 132) and those with non-palpable testes (n = 38) were excluded. In the end, there were 169 pateints in this study. Ultrasound was performed in 50% of referred boys showing 256 undescended testis. The mean age at time of referral was 45 months. When ultrasound was compared to physical examination by the pediatric urologist, agreement was only 34%. The performance of ultrasound for palpable undescended testis was: sensitivity = 100%; specificity = 16%; positive predictive value = 34%; negative predictive value = 100%; positive likelihood ratio = 1.2; and negative likelihood ratio = 0. Diagnosis of undescended testis by PCP was confirmed by physical examination in 30% of cases, with 70% re-diagnosed with normal or retractile testes. CONCLUSION: Ultrasound performed poorly to assess for palpable undescended testis in boys and should not be used. Although the study has important limitations, there is an increasing need for education and evidence-based guidelines for PCP in the management of undescended testis.

Pilot randomized, placebo controlled trial to investigate the effect of antibiotic prophylaxis on the rate of urinary tract infection in infants with prenatal hydronephrosis.

PURPOSE: We determined the feasibility of a clinical trial of continuous antibiotic prophylaxis to prevent urinary tract infections in children with prenatal hydronephrosis. MATERIALS AND METHODS: We piloted a blinded, randomized, placebo controlled study of the urinary tract infection rate in infants with grades III-IV prenatal hydronephrosis at our institution between August 2010 and June 2013. Study exclusion criteria were grades I/II prenatal hydronephrosis, vesicoureteral reflux, duplication anomalies and age at randomization greater than 5 months. Prospectively collected feasibility data were obtained on eligibility, enrollment status, adherence to followup schedule, and medication and protocol compliance. RESULTS: Of 301 screened patients 220 (73.1%) were ineligible for analysis and 2 (1%) missed the randomization window. Of the remaining 81 (26.9%) eligible patients 46 were enrolled (56.8%), 29 refused (39.5%) and consent is pending in 1 (1.2%). Reasons for declining participation included parental preference for or against continuous antibiotic prophylaxis and a lack of interest in participating in clinical research. Of 46 enrolled patients 29 (63%) completed the trial, 12 (26.1%) are still in followup and 5 (10.9%) withdrew. Of the 314 medication logs dispensed 263 were returned for a 95% mean medication compliance rate. CONCLUSIONS: Based on the results of our pilot study a realistic recruitment rate for this group of patients is established, making a definitive trial of this topic feasible. However, due to the low number of eligible patients multicenter collaboration is critical to address the effect of continuous antibiotic prophylaxis on the urinary tract infection rate in this population. After study enrollment high medication and followup compliance can be expected.

Evaluating practice patterns in postnatal management of antenatal hydronephrosis: a national survey of Canadian pediatric urologists and nephrologists.

OBJECTIVE: To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada. METHODS: A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality. RESULTS: A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P = .02); in contrast, 73% of nephrologists and 38.2% of urologists (P = .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P = .02) would obtain this test for patients with unilateral high-grade isolated AHN. CONCLUSION: Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain high-level evidence to develop management protocols for this common condition.

Are physicians performing neonatal circumcisions well-trained?

INTRODUCTION: Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this procedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of knowledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision. METHODS: A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey participants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants' daily practice. RESULTS: In total, we received 54 responses (62% response rate). From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urologists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the participants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindicated. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons versus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24). CONCLUSIONS: Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues.

Bilateral epididymitis in a child with undiagnosed posterior urethral valves.

Posterior urethral valves are most commonly detected in the early neonatal period, the diagnosis often antenatally suspected from ultrasound findings. Nevertheless, some cases might go undetected and become manifest later in life with lower urinary tract symptoms. We describe the unusual case of a 5-year-old boy with a 2-month history of bladder distension, urinary dribbling, and epididymitis. Cystourethrography revealed posterior urethral valves with reflux into the seminal vesicles, vas deferens, and epididymis, bilaterally. A review of the published data is provided in the context of this unusual presentation pattern.

Antibiotic prophylaxis for urinary tract infections in antenatal hydronephrosis.

BACKGROUND AND OBJECTIVE: Continuous antibiotic prophylaxis (CAP) is recommended to prevent urinary tract infections (UTIs) in newborns with antenatal hydronephrosis (HN). However, there is a paucity of high-level evidence supporting this practice. The goal of this study was to conduct a systematic evaluation to determine the value of CAP in reducing the rate of UTIs in this patient population. METHODS: Pertinent articles and abstracts from 4 electronic databases and gray literature, spanning publication dates between 1990 and 2010, were included. Eligibility criteria included studies of children <2 years old with antenatal HN, receiving either CAP or not, and reporting on development of UTIs, capturing information on voiding cystourethrogram (VCUG) result and HN grade. Full-text screening and quality appraisal were conducted by 2 independent reviewers. RESULTS: Of 1681 citations, 21 were included in the final analysis (N = 3876 infants). Of these, 76% were of moderate or low quality. Pooled UTI rates in patients with low-grade HN were similar regardless of CAP status: 2.2% on prophylaxis versus 2.8% not receiving prophylaxis. In children with high-grade HN, patients receiving CAP had a significantly lower UTI rate versus those not receiving CAP (14.6% [95% confidence interval: 9.3-22.0] vs 28.9% [95% confidence interval: 24.6-33.6], P < .01). The estimated number needed to treat to prevent 1 UTI in patients with high-grade HN was 7. CONCLUSIONS: This systematic review suggests value in offering CAP to infants with high-grade HN, however the impact of important variables (eg, gender, reflux, circumcision status) could not be assessed. The overall level of evidence of available data is unfortunately moderate to low.

Methodological concerns and quality appraisal of contemporary systematic reviews and meta-analyses in pediatric urology.

PURPOSE: The usefulness of systematic reviews and meta-analyses in influencing clinical practice depends on their quality. We sought to analyze the quality of published systematic reviews and meta-analyses in pediatric urology. MATERIALS AND METHODS: We searched PubMed (MEDLINE) and Embase for all systematic reviews and meta-analyses published in the top 5 pediatric urology journals between January 2000 and November 2009. Two reviewers independently selected articles for full text review. Scientific methodological quality was evaluated using the Assessment of Multiple Systematic Reviews 11-item tool. RESULTS: Of 267 initial results 220 articles were excluded because they were surveys, case reports or narrative reviews. Full text evaluation of the remaining 47 articles further excluded 32 series of exclusively adult patients, leaving 15 for final analysis. Seven articles (47%) were published in 2009 (p <0.01). Only 1 review (7%) described a full search strategy and 3 (20%) allowed inclusion of non-English studies. In 8 reviews (53%) selection of studies was performed by 2 reviewers. Five systematic reviews (33%) described some form of quality assessment. Only 5 reviews (33%) described assessment of publication bias, while 8 (53%) checked for heterogeneity among studies. According to AMSTAR criteria, 7 systematic reviews (47%) were considered of less than fair methodological quality, 5 (33%) fair to good quality and 3 (20%) good quality. CONCLUSIONS: Despite a recent increase in the number of systematic reviews and meta-analyses published in pediatric urology journals, almost half of these reviews lack good scientific quality, raising concerns about their role in influencing clinical practice. Efforts should be made to improve the methodological quality of systematic reviews and meta-analyses in the pediatric urology literature.

Lower abdominal mass in a 16-year old adolescent: an unusual presentation of posterior urethral valves.

Posterior urethral valves (PUV) are now commonly suspected on antenatal ultrasound, but can present with a broad spectrum of severity postnatally. Rarely, the diagnosis is missed until adolescence or adulthood when the patient usually presents with lower urinary tract symptoms. We describe an even rarer case of PUV in an adolescent who first presented with renal failure and a palpable lower abdominal mass due to urinary retention. We review the literature on presentation, natural history and outcomes of both early and late presenting PUV cases.

Newborn with persistent cloaca presenting with accessory phallic urethra and ambiguous genitalia.

Persistent cloaca is a rare urogenital anomaly that can pose significant challenges for adequate diagnosis and management. We describe the case of an infant girl with a cloacal malformation, having a single perineal orifice and an accessory phallic urethra, who presented with ambiguous genitalia at birth. The distal part of the accessory phallic urethra was used to create a mucosa-lined vestibule as a part of the total urogenital sinus mobilization. This technical maneuver allowed a more natural looking, and possibly functioning, vaginal introitus, improving the final cosmetic result.

Concurrent ureteropelvic and ureterovesical junction obstruction in children: the value of retrograde pyelography.

Ureteropelvic junction obstruction with concomitant ureterovesical junction obstruction is a rare condition whose treatment remains challenging [1-3]. Renal ultrasonography and diuretic renogram are universally utilized to assess a patient prior to pyeloplasty; however, the role of retrograde pyelography at the time of pyeloplasty is still debatable [5-7]. Herein, we describe two cases where the use of retrograde pyelography preoperatively helped to avoid pyeloplasty failure by allowing the surgeon to visualize a concurrent ureterovesical junction obstruction, which would not have been visible in the surgical field had the procedure been carried out without intraoperative imaging.

Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate.

BACKGROUND: Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO). OBJECTIVE: To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate. DESIGN, SETTING, AND PARTICIPANTS: We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement). INTERVENTION: Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity. MEASUREMENTS: We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity. RESULTS: We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: -10.4 min; 95% CI: -24.6-3; p=0.15) and significantly shorter hospital stay compared with CLP (WMD: -0.5 d; 95% CI: -0.6-0.4; p<0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3-1.6; p=0.40) and success (OR: 1.3; 95% CI: 0.5-3.5; p=0.62). CONCLUSIONS: RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.

Laparoscopic pyeloplasty: role of preoperative retrograde pyelography.

Laparoscopic dismembered pyeloplasty is a minimally invasive, safe and effective therapy for pelvi-ureteric junction obstruction with low morbidity, shorter convalescence and excellent outcomes. To maximize an efficacious outcome, minimally invasive treatment of this condition requires preoperative planning with adequate imaging, but the role of retrograde pyelography remains controversial. We present a report in which retrograde pyelography accurately contributed to the perioperative diagnosis of ureteral fibroepithelial polyps, subsequently altering surgical management.

Scrotoschisis associated with meconium periorchitis.

Scrotoschisis is a rare congenital defect in the scrotal wall resulting in testicular exposure or exstrophy. We report the case of a newborn presenting with a large scrotal wall defect exposing both testicles. The tunica vaginalis appeared to be intact on both sides. Although the pathogenesis of scrotoschisis remains unclear, a proposed mechanism for its occurrence and the management in this case are presented in detail.

Persistent Mullerian duct syndrome associated with transverse testicular ectopia.

Persistent Mullerian Duct Syndrome (PMDS) associated with transverse testicular ectopia (TTE) is rare. Ten cases have been reported in the past. Accurate diagnosis with karyotype and histological analysis is crucial. Surgical management should be geared toward preservation of fertility when possible.