Comparison of laparoscopic pyeloplasty vs. robot-assisted pyeloplasty for the management of ureteropelvic junction obstruction in children.

Background: Ureteropelvic junction obstruction (UPJO) is a commonly observed abnormality in pediatric urology. Minimally invasive approaches have gained popularity in recent years. Studies have demonstrated excellent results with both laparoscopic pyeloplasty (LAP) and robot-assisted pyeloplasty (RAP). Few studies have compared the experience of both procedures performed in a single institution. Our objective is to compare laparoscopic pyeloplasty and robot-assisted pyeloplasty in the Puerto Rican pediatric population. Methods: We conducted a retrospective cohort study using our clinic's database on patients with UPJO that were operated by the same surgeon (MPB) from 2008 to 2019. Statistical analysis was conducted of demographics, preoperative studies, perioperative data and complications of both procedures. This study was approved by our local IRB committee. Results: A total of 86 patients that underwent pyeloplasty with at least 3 years of follow up were recorded for this study. Laparoscopic pyeloplasty and robot-assisted pyeloplasty were performed in 44 (51.1%) and 42 (48.8%) patients, respectively. Patient age ranged between 4 months and 17 years (LAP group - mean age of 6.19 years/RAP group - mean age of 7.07 years). Success rates was high in this series (LAP - 100% and RAP -95%). Using Wilcoxon signed rank test and Mann whitney sum test, significant differences between preoperative and postoperative hydronephrosis grading were observed in both LAP and RAP groups. However, no significant difference was seen regarding reduction of hydronephrosis grading when comparing both groups. No intraoperative complications were seen on either group. Conclusion: Both LAP and RAP are safe and effective procedures that can properly manage UPJO. Our study shows that, under experienced hands, pure laparoscopic pyeloplasty achieves comparable results to robotic assisted laparoscopic pyeloplasty. Pediatric urologists should be comfortable offering either of these approaches as they demonstrate high success rates in our pediatric population. Selection of LAP vs. RAP approach depends on the Surgeon's preference or experience, and on institutional availability. Minimally invasive therapies will continue to gain popularity with future advances in laparoscopic and robotic technology.

New frontiers on the molecular underpinnings of hypospadias according to severity.

Hypospadias, which is characterised by the displacement of the urethral meatus from its typical anatomical location in males, shows various degrees of severity. In this systematic review, we surveyed our current understanding of the genetics of isolated hypospadias in humans according to the severity of the condition. We found that sequencing and genotyping approaches were the preferred methods of study and that single nucleotide polymorphisms were the most common finding associated with hypospadias. Most genes fell into four gene-pathway categories related to androgens, oestrogens, growth factors, or transcription factors. Few hypospadias studies classify their findings by severity. Taken together, we argue that it is advantageous to take into consideration the severity of the condition in search of novel candidates in the aetiology of hypospadias. Abbreviations: AR: androgen receptor; ATF3: activating transcription factor 3; BMP4: bone morphogenetic protein 4; BMP7: bone morphogenetic protein 7; CYP17: steroid 17-alpha-hydroxylase/17,20 lyase; CYP1A1: cytochrome P450 1A1; CYP3A4: cytochrome P450 3A4; CNVs: copy number variants; DGKK: diacylglycerol kinase kappa; ESR1: oestrogen receptor 1; ESR2: oestrogen receptor 2; FGF8: fibroblast growth factor 8; FGF10: fibroblast growth factor 10; FGFR2: fibroblast growth factor receptor 2; HOXA4: homeobox protein Hox-A4; HOXB6: homeobox protein Hox-B6; HSD17B3: hydroxysteroid 17-beta dehydrogenase 3; MAMLD1: mastermind-like domain-containing protein 1; SF-1: splicing factor 1; SHH: sonic hedgehog; SNPs: single nucleotide polymorphisms; SOX9: SRY-box 9; SRD5A2: steroid 5 alpha-reductase 2; SRY: sex-determining region Y protein; STAR: steroidogenic acute regulatory protein; STARD3: StAR-related lipid transfer protein 3; STS: steryl-sulfatase; WT1: Wilms tumour protein; ZEB1: zinc finger oestrogen-box binding homeobox 1.

Severity-Dependent Profile of the Metabolome in Hypospadias.

Background & Objective: Hypospadias, characterized by the displacement of the opening of the urethra at any point in the medial-ventral side of the penis, is classified upon severity as mild (Type I) and severe (Type II and Type III) hypospadias. Hypospadias' etiology is idiopathic in the majority of cases, and underlying causes seem of multifactorial origin. Studies regarding genetic variants support this notion. It is unknown whether downstream gene products fit this profile. This study evaluated the metabolome of hypospadias by using the emerging technology of metabolomics in the search for distinct cellular processes associated with hypospadias' etiology according to the severity of this congenital urogenital condition. Methods: Foreskin samples were collected during urethroplasty from boys with Type I, II, and III hypospadias or undergoing elective circumcision (N = 28) between 5 and 28 months of age. Samples were processed and submitted to gas chromatography-mass spectrometry (GC/MS). MetaboloAnalyst (http://www.metaboanalyst.ca/) online platform was used for bioinformatic analyses. Results: Thirty-five metabolites across experimental groups were identified by GC/MS. Principal component analysis (PCA) and partial least squares-discriminant analysis (PLS-DA) showed that the metabolome of Type II and Type III hypospadias patients differs from the metabolome of Type I hypospadias and control patients. Of those 35, 10 amino acids were found in significantly low concentrations in severe hypospadias: aspartate, glutamate, glycine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, and tyrosine. A high concentration of the amino acid lysine was detected in mild hypospadias. Conclusions: The observed downregulation of specific amino acids in severe hypospadias provides alternative routes for future research aiming to identify disrupted networks and pathways while considering the severity of hypospadias.

A Proteomics Signature of Mild Hypospadias: A Pilot Study.

Background and Objective: Mild hypospadias is a birth congenital condition characterized by the relocation of the male urethral meatus from its typical anatomical position near the tip of the glans penis, to a lower ventral position up to the brim of the glans corona, which can also be accompanied by foreskin ventral deficiency. For the most part, a limited number of cases have known etiology. We have followed a high-throughput proteomics approach to study the proteome in mild hypospadias patients. Methods: Foreskin samples from patients with mild hypospadias were collected during urethroplasty, while control samples were collected during elective circumcision (n = 5/group). A high-throughput, quantitative proteomics approach based on multiplexed peptide stable isotope labeling (SIL) and liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis was used to ascertain protein abundance changes in hypospadias patients when compared to control samples. Results: A total of 4,815 proteins were quantitated (2,522 with at least two unique peptides). One hundred and thirty-three proteins from patients with mild hypospadias showed significant abundance changes with respect to control samples, where 38 proteins were increased, and 95 proteins were decreased. Unbiased functional biological analysis revealed that both mitochondrial energy production and apoptotic signaling pathways were enriched in mild hypospadias. Conclusions: This first comprehensive proteomics characterization of mild hypospadias shows molecular changes associated with essential cellular processes related to energy production and apoptosis. Further evaluation of the proteome may expand the search of novel candidates in the etiology of mild hypospadias and could also lead to the identification of biomarkers for this congenital urogenital condition.

Current Concepts in Pediatric Robotic Assisted Pyeloplasty.

Robotic surgery in pediatric urology has been gaining popularity since its introduction almost two decades ago. Robotic assisted pyeloplasty is the most common robotic procedure performed in pediatric urology. Advances in robotic technology, instrumentation, patient care and surgical expertise have allowed the correction of ureteropelvic junction (UPJ) obstruction in most patients using this minimally invasive technique. The excellent experience with robotic assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction. In this review, we will describe the technique as it relates to the different robotic platforms, review the surgical experience and compare its results to other surgical approaches. Also, we will discuss patient and parent satisfaction, cost and financial considerations, along with evaluating the future of robotic surgery in the treatment of UPJ obstruction.

Evaluation and Management of the Undescended Testis in Puerto Rico: A Single Surgeon's 10 Years of Experience.

OBJECTIVE: Cryptorchidism is an abnormality of the male genitourinary tract in which one or both testes fail to descend into the scrotum. The American Urological Association (AUA) clinical guidelines for the evaluation and treatment of cryptorchidism were recently published. We reviewed our experience with the evaluation and management of our patients and examined our findings with respect to the AUA and European Association of Urology (EAU) guidelines. METHODS: Data were obtained from pediatric patients who underwent a surgical intervention for an undescended testis from 2007 through 2017 at HIMA Hospital and the University Pediatric Hospital (both in Puerto Rico); all the surgeries were performed by the same surgeon. A total of 754 patients were identified; 142 patients were excluded due to lack of follow-up data (N = 612). The data obtained included age, testes locations, radiologic and surgical findings, and postoperative results. RESULTS: At their initial evaluations, a large proportion of the patients (46.4%) came accompanied with radiographic imaging. These findings were consistent with those of the physical examination in 58.5% of the patients and with the surgical findings in 63.1% (sensitivity 77.9%, specificity 45.8%). Our data showed that the median referral age was 24 months, which suggests that there was a significant delay in diagnosis. At the time of surgery, the average age of the patients who required an orchiectomy was 3.93 years, while those who underwent an orchiopexy had an average age of 3.28 years. CONCLUSION: Our data reveal that, despite its lack of usefulness, radiologic imaging continues to be included in the diagnostic workups of children newly identified with cryptorchidism in Puerto Rico. In addition, and contrary to the guidelines, there tends to be a significant delay in treatment with surgical intervention. It is important to continue to educate our referring physicians on the AUA and EUA guidelines in order to create awareness and encourage the proper diagnostic and treatment approach for cryptorchidism.

Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery?

BACKGROUND: Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations. OBJECTIVE: The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block. STUDY DESIGN: A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis). RESULTS: Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure). DISCUSSION: Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias. CONCLUSION: The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.

Age of the mother as a risk factor and timing of hypospadias repair according to severity.

BACKGROUND & OBJECTIVES: Hypospadias is characterized by a displacement of the urethral opening in males that can change from the typical position within the glans penis to a subcoronal position (Type I), to anywhere along the ventral shaft (Type II), to penoscrotal, scrotal, or perineal positions (Type III). We and others have previously reported that age of the mother (≥ 40 years old) is a risk factor for having a child with hypospadias, but there is a scarcity of reports on whether such risk is higher for having a child with the mild (Type I) or the more severe forms (Types II and III). In addition, we aimed to assess the timing of hypospadias repair according to severity. METHODS: Parents of children with hypospadias were interviewed by using a series of questionnaires (n = 128 cases). Severity was confirmed in the clinic and age of the mother was self-reported. Number of surgeries, age of child by the first and the last intervention was also assessed. Ordered logistic regression and the Brant test were employed to calculate risk between mild (Type I) and severe cases (Types II and III), and the assumption of proportional odds, respectively. The Mann-Whitney U Test was used to compare number of surgeries and age by the last repair between mild and severe cases. One-way ANOVA was employed to compare age of the child at the time of first surgery across severities (Types I - III). RESULTS: Women ≥ 40 years of age are 3.89 times [95% CI: 1.20-12.64] at a higher risk for having a child with the more severe forms of the condition than younger women. Repair of Type I was accomplished with 1 intervention whereas more severe cases required 1 - 4 (2 ± 0.5) surgical interventions. The timing for hypospadias repair of Type I cases occurred at an average age of 16.2 ± 4.88 months, of Type II cases occurred at an average age of 20.3 ± 8.15 months whereas the average age of the first hypospadias repair among Type III cases was 12.68 ± 2.52 months. Number of surgeries according to severity (p ≤ 0.0018, z-ratio = 2.91) and age difference for the timing of last repair (p ≤ 0.045, z-ratio = 1.69) were statistically different, but not the age difference for the first repair. CONCLUSIONS: Increased maternal age is associated with the most severe forms of hypospadias. There is room for improvement for the timing of hypospadias repair according to severity.

Concordance of Expert and Parental Opinion about Hypospadias Surgical Outcome Is Severity Dependent.

INTRODUCTION: Hypospadias is a male congenital condition where the opening of the urethral meatus is not located in the typical anatomical position. It has been a challenge for empirical studies to ascertain the level of concordance of opinion among parents and urologists with regard to surgical outcomes according to hypospadias severity. MATERIALS AND METHODS: Parents of children who had undergone hypospadias repair were recruited for this study (n = 104). A set of questionnaires that included some items with Likert scale were created to evaluate postsurgical satisfaction by parents and urologists. SAHLSA-50, a validated instrument for adult Spanish-speaking adults, was used to assess health literacy. Cohen's kappa (κ) coefficient was used to assess interobserver agreement and Chi Square "Goodness of Fit" Test was used to determine probability of satisfaction. FINDINGS: Concordance on the level of satisfaction with surgical outcomes for Type cases I was slight (κ = 0.20; CI 95% 0-0.60), for Type II cases was moderate (κ = 0.54; CI 95% 0.13-0.94), and for Type III cases was substantial (κ = 0.62; CI 95% 0-0.56). However, the probability of satisfaction did not change according to severity (Chi Square "Goodness of Fit" Test; parents, p = 0.84; pediatric urologists, p = 0.92). These results cannot be explained by parental health literacy according to SAHLSA-50 test scores. CONCLUSION: The level of concordance of opinion among parents and urologists with regard to their level of satisfaction with surgical outcomes is related to hypospadias severity, whereby the greatest level of concordance of opinion was achieved among most severe cases. This study underscores the need for longer follow-up to properly assess satisfaction with hypospadias repair, especially for the less severe forms of the condition.

Multi-institutional Experience in Laparoendoscopic Single-site Surgery (LESS): For Major Extirpative and Reconstructive Procedures in Pediatric Urology.

OBJECTIVE: To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. MATERIALS AND METHODS: Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. RESULTS: Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P < .05). CONCLUSION: LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety.

Laparoscopic Single-Site Surgery in Pediatric Urology: Where Do We Stand Today?

Since the first description of the laparoendoscopic single-site surgery (LESS) in the pediatric urology population, various authors have shared their experiences and results. We aim to provide a review of current studies of LESS and share our experience with this modality. The current literature describes the use of LESS for most surgeries performed in the pediatric urology population with similar results to open and standard laparoscopic surgery. The authors have described their experiences with transabdominal and retroperitoneal nephrectomy, nephroureterectomy, pyeloplasty, orchidopexy, varicocelectomy, and renal cyst decortication. In our experience, LESS has taken a role for extirpative surgery since we use other modalities for upper tract reconstruction. The data available has validated LESS as safe and has demonstrated similar results to standard laparoscopic surgery and open surgery with better cosmetic results.

Laparoscopy in the surgical management of the non-palpable testis.

INTRODUCTION: To demonstrate that laparoscopic intervention should be considered as the initial surgical approach in the management of the non-palpable testis (NPT). METHODS: From 2007 to 2011, 100 testicular units underwent same surgeon laparoscopic management for NPT. Diagnostic laparoscopy was performed in all NPT and intra-abdominal testes (IAT) were managed by laparoscopic orchiopexy if low, laparoscopic Fowler-Stephens technique if high, and laparoscopic orchiectomy if atrophic. Percutaneous access to the abdomen was performed in most cases and laparoscopic management was performed with three 5 mm ports. We compared patient's age, race, pre/post-operative exam, pre-operative work up, and IAT location upon laparoscopic intervention with surgical outcome. Fisher's exact test for two independent proportions was used for statistical analysis and reported our results. RESULTS: One hundred testicular units underwent diagnostic laparoscopy for NPT. All patients were from Puerto Rican descent. 55.0% were found to be intra-abdominal and were subdivided into groups according to surgical intervention. Mean post-operative follow-up was 24 months. Patients 24 months of age or younger undergoing diagnostic laparoscopy for NPT had a statistically significant probability of resulting in successful laparoscopic orchiopexy as opposed to laparoscopic orchiectomy due to an atrophied IAT (n = 55 testicular units, p < 0.05). No laparoscopic related complications were reported. CONCLUSION: Our findings support the use of an initial laparoscopic approach in the NPT as the majority of these patients will have IAT, avoiding unnecessary inguinal and scrotal explorations. We also recommend that patients with IAT should undergo laparoscopic orchiopexy prior to 2 years of age to increase probability of successful management. Further studies focusing in patients with NPT are needed in the future to confirm our findings.

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Tumor in bladder reservoir after gastrocystoplasty.

PURPOSE: To our knowledge the risk of malignancy in patients with previous bladder augmentation with stomach is unknown. We report 3 cases of gastric adenocarcinoma and 1 of transitional cell carcinoma after augmentation cystoplasty with stomach with long-term followup. MATERIALS AND METHODS: Between August 1989 and August 2002, 119 patients underwent augmentation cystoplasty with stomach at our 2 institutions (University of Miami School of Medicine, and Seattle Children's Hospital and Regional Medical Center). Medical records, urodynamic studies, radiographic imaging and laboratory evaluations were reviewed retrospectively and cases of malignancy were analyzed in detail. RESULTS: Four male patients had carcinoma after augmentation gastrocystoplasty. Preoperative diagnosis was neurogenic bladder in 3 patients and posterior urethral valve in 1. Three patients had gastric adenocarcinoma, while the other had poorly differentiated transitional cell carcinoma. Each case progressed to malignancy more than 10 years after augmentation (11, 12, 14 and 14 years, respectively). CONCLUSIONS: Patients who undergo bladder augmentation with a gastric remnant are at increased risk for malignancy, probably similar to that in patients with enterocystoplasty. Therefore, they require close long-term followup. Patients should be followed annually with ultrasound, and cystoscopy should be performed annually starting 10 years after gastrocystoplasty unless they have abnormal ultrasound, hematuria or another cancer risk factor. Any suspicious lesions should be biopsied, especially at the gastrovesical anastomotic site.

Severe congenital midureteral dilatation.

Congenital midureteral stricture is an uncommon cause of prenatal hydronephrosis, and it is generally associated with proximal hydroureteronephrosis . We report a unique case of a congenital severe midureteral dilatation associated with mild proximal ureteral dilatation and normal distal ureteral diameter. The dilated midureter was excised, and an open end-to-end ureteroureterostomy was performed. Follow-up 6 months after surgical correction revealed marked improvement in the left-sided hydronephrosis and complete resolution of the hydroureter.

Salvage extravesical ureteral reimplantation after failed endoscopic surgery for vesicoureteral reflux.

PURPOSE: Open intravesical ureteral reimplantation has been reported to be uncomplicated following dextranomer/hyaluronic acid implantation. However, there are no known reports regarding extravesical ureteral reimplantation following dextranomer/hyaluronic acid failure. We reviewed our experience with extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. MATERIALS AND METHODS: We reviewed the charts of 30 patients who underwent extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. If reflux was initially bilateral and only a unilateral cure was achieved, the cured ureter was not reimplanted. Intraoperative complications, need for stenting or prolonged bladder catheterization, length of hospitalization and radiographic results were noted. RESULTS: At cystoscopy the dextranomer/hyaluronic acid implants were not seen in half of the patients. In the remaining 15 patients the blebs had moved caudally and/or were seen extravesically at the ureteral hiatus or along Waldeyer's sheath. Unilateral extravesical ureteral reimplantation was performed without difficulty in all patients and there were no intraoperative complications. Stents were left indwelling only in those patients who had undergone dismembered ureteral reimplantation. No patient required prolonged bladder drainage. All patients except 2 who had undergone additional procedures were discharged home within 24 hours postoperatively. There was no evidence of obstruction on postoperative renal sonography, and extravesical ureteral reimplantation was confirmed to be successful in all 24 patients with postoperative voiding cystourethrograms. CONCLUSIONS: Extravesical ureteral reimplantation can be performed without difficulty following dextranomer/hyaluronic acid implantation. Since extravesical ureteral reimplantation is less morbid and better tolerated than intravesical reimplantation, it is an excellent treatment option for patients with persistent unilateral vesicoureteral reflux following dextranomer/hyaluronic acid implantation. Furthermore, in cases in which vesicoureteral reflux is initially bilateral our data suggest that reimplantation of the successfully treated contralateral ureter can be avoided.

Segmental multicystic dysplasia and ureteropelvic junction obstruction in a nonduplicated kidney.

A 2-month-old child presented for evaluation of prenatal hydronephrosis. Imaging studies were consistent with a right duplex system with a dysplastic, nonfunctioning upper pole and lower pole ureteropelvic junction obstruction. We proceeded with removal of the upper pole and pyeloplasty and were surprised to find a single collecting system with a cystic, dysplastic upper pole segment and the absence of an upper pole pelvis or ureter. The rare diagnosis of a segmental multicystic dysplastic kidney with ipsilateral ureteropelvic junction obstruction was made. We present a review of the case and of previous literature on this topic.

New contralateral vesicoureteral reflux following dextranomer/hyaluronic Acid implantation: incidence and identification of a high risk group.

PURPOSE: To our knowledge the incidence of NCVUR following the endoscopic treatment of VUR with Dx/HA has not been reported previously. We evaluated the outcomes in a group of patients to determine the incidence, and to attempt to identify risk factors. MATERIALS AND METHODS: A total of 126 children with primary unilateral VUR underwent unilateral Dx/HA implantation at our institutions. The incidence of NCVUR was determined by postoperative VCUG. Indications for surgery, patient age and gender, preoperative grade of VUR and volume of Dx/HA injected were assessed as possible risk factors for NCVUR. RESULTS: Of the patients 96 (76.2%) were female, and mean age was 4.8 years. The principal indications for Dx/HA implantation were persistent reflux in 56 patients (44.4%) and primary therapy in 51 (40.5%). At followup VCUG 17 patients (13.5%) had NCVUR. No variable independently appeared to influence the incidence of NCVUR. Statistical analysis suggests that females younger than 5 years have an increased incidence of NCVUR (13 of 62, or 21% vs 4 of 64, or 6.3% of the remaining patients, p = 0.016). CONCLUSIONS: NCVUR occurred in approximately 13% of our patients. Patients with higher preoperative VUR grade or a lower number of preoperative VCUGs and those undergoing treatment as primary therapy did not have an increased incidence. Girls younger than 5 years had the highest incidence of NCVUR, and initial bilateral injection may be a consideration for this group. Further effort directed at identifying the etiology and risk factors for NCVUR is needed.

The treatment of catheterizable stomal incontinence with endoscopic implantation of dextranomer/hyaluronic acid.

PURPOSE: The creation of a catheterizable stoma has revolutionized the management of complex bladder reconstruction. Unfortunately, urinary incontinence per catheterizable stoma is seen in some patients. We present our experience with the use of submucosal implantation of dextranomer/hyaluronic acid in patients with catheterizable stomas with urinary incontinence. MATERIALS AND METHODS: A total of 14 patients 9 to 49 years old (mean age 17.8) underwent submucosal implantation of dextranomer/hyaluronic acid for incontinence of catheterizable stoma at our institutions between October 2001 and March 2004. RESULTS: There were 9 males and 5 females. Type of bowel for stoma creation included 12 appendixes and 2 small bowels. All patients had significant leak per stoma and were candidates for revision. The dextranomer/hyaluronic acid volume injected ranged from 2 to 6 cc (mean 3.7). A total of 10 patients were dry after 1 injection, 1 was dry after 2 injections and 3 remained incontinent after the procedure. Our success rate was 79%. CONCLUSIONS: Our initial experience with the endoscopic treatment of incontinence of catheterizable stoma is encouraging, with a 79% success rate. We believe that this minimally invasive approach is warranted as an initial step in the management of urinary incontinence of catheterizable stoma before undertaking more challenging procedures.

Adolescent urology.

The area of adolescent urology encompasses a period of development that coincides with puberty. Disorders seen during this time either carry over from childhood (eg, hydronephrosis, enuresis, voiding dysfunction) or are early manifestations of urologic problems seen more commonly in adulthood (eg, urolithiasis, varicoceles). This article focuses on several areas of urology common to the adolescent.