Radiographic gapometry score: A simple predictor for surgical approach in pediatric traumatic posterior urethral strictures.

BACKGROUND: Post-traumatic posterior urethral injuries in children are rare events. Their management algorithms are extrapolations from adult literature and they continue to pose a difficult challenge for pediatric urologists. Not much data for age-related feasibility of an end-to-end urethroplasty are available. OBJECTIVE: This study was designed to validate a simple preoperative radiographic score to predict the type of surgical repair for traumatic posterior urethral strictures in children. MATERIALS AND METHODS: This retrospective study was conducted in a tertiary care center in northern India between 2000 and 2015. All patients under 15 years with traumatic bulboprostatic stricture disease were included. Preoperative voiding cystourethrogam (VCUG) and retrograde urethrogram (RGU) films were used to calculate the gapometry index (G/U index), defined as the length of urethral gap divided by the bulbar urethral length. This index was then analyzed for two patient groups based on the anatomical approach employed for achieving an end-to-end urethroplasty: group 1, who underwent a simple perineal approach, and group 2, who needed a more elaborate procedure. Statistical analysis was performed with the two-tailed t-test with SPSS version 18. RESULTS: A total of 38 patients met the inclusion criteria. The age distribution and G/U index for both groups are detailed in the table. The difference in mean length of the urethral gap for both groups was statistically significant (2.1 cm in group 1 vs. 3.6 cm in group 2). There was a direct correlation between the complexity of surgical procedure required to bridge the urethral gap and the G/U index. The overall success for urethroplasty in either group was between 92.3% and 94.6%. DISCUSSION: Urethral extensibility is more suitable for younger children. This challenges the traditional viewpoint that the transpubic approach for urethroplasty is more favorable in children. No previous study has been cited in literature correlating the gapometry index with the surgical approach for posterior urethral defects. Our results reflect that a preoperative G/U index of 0.44 correlate with a simple perineal repair, whereas an index of above 0.87 indicates the likelihood of needing a more elaborate transpubic approach. CONCLUSIONS: Preoperative assessment of G/U index in children with traumatic posterior urethral injuries can successfully predict the operative approach and may therefore aid in better management of these patients.

Standardized Grading of Shock Wave Lithotripsy Complications with Modified Clavien System.

INTRODUCTION: Definitive consensus on grading of complications of shock wave lithotripsy (SWL) does not exist. The objective of this study was to grade complications of SWL in relation to different stone and shock wave parameters, according to the modified Clavien system. MATERIALS AND METHODS: Complications observed in 2,648 patients who underwent SWL between January 2003 and May 2014 were evaluated statistically and stratified into 5 grades by the modified Clavien system focusing on stone and shock wave parameters. RESULTS: Statistically significant association (p ≤ 0.05) was found between SWL outcome, Clavien grade of complications and stone and shock wave parameters. According to the modified Clavien system, grades I, II, IIIa, IIIb, IV and V complications were observed in 1,811 (68.39%), 619 (23.37%), 183 (6.91%), 34 (1.28%), nil (0.00%) and 1 (0.03%) patients, respectively. The overall success rate at 3 months was 87.72%. CONCLUSIONS: The modified Clavien system provides a standardized grading of SWL complications and can be used to standardize procedural errors and maintain quality, thereby preventing associated complications and improving the overall management and hence outcome of SWL.

Nephron-sparing surgery in bilateral Wilms' tumor: A report of two cases.

Nephron-sparing surgery (NSS) has been proposed by many as an alternative to bilateral nephrectomies and renal replacement therapy in bilateral Wilms' tumor (BWT). NSS is not without significant recurrence, morbidity, and mortality. Long-term follow-up, especially with regard to the renal function, remains lacking. Preoperative computed tomography angiogram can help prepare a roadmap for NSS but can underestimate the salvageable parenchyma due to compression of normal adjacent parenchyma. Intraoperative ultrasound can delineate the boundary of surgical margin and help achieve negative margins. We present two cases of BWT, aged 7 and 13 months, managed with neoadjuvant chemotherapy followed by bilateral NSS and adjuvant chemotherapy and report the follow-up of the same. We also explore the role of preoperative imaging and intraoperative ultrasound in the management. Both patients are alive without recurrence at a follow-up of 12 and 8 months.