Voiding cystourethrogram in the diagnosis of vesicoureteric reflux in children with antenatally diagnosed hydronephrosis.

UNLABELLED: Prenatal ultrasonography has revolutionized the detection and management of many urological abnormalities. Vesicoureteric reflux (VUR) which develops in 10% to 15% of cases of prenatal hydronephrosis, is difficult to predict prenatally. While all children with prenatal hydronephrosis should undergo ultrasonography within the first few weeks of life, there seems to be controversy regarding the role of voiding cystourethrogram (VCUG) in the assessment of these children. MATERIALS AND METHODS: Neonates with antenatally diagnosed unilateral hydronephrosis were prospectively assessed with sonography on day 3-7, and VCUG and isotope imaging at three months. RESULTS: Seven (16.6%) children of the 42 children with Society of Fetal Urology grade 0/I/II hydronephrosis on postnatal sonography had evidence of VUR on VCUG. 44.4% of the refluxing ureters identified involved high grade disease and two (28.5%) children required reimplantation. CONCLUSIONS: Children with fetal reflux may be diagnosed prior to urinary tract infection and in whom further renal injury may be prevented. VCUG when performed properly is safe and presents with little risk of infectious and noninfectious complications. VCUG should be done in children in whom hydronephrosis is detected prenatally to restrict the use of VCUG to diagnose VUR. Two patients had infection.

Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children.

OBJECTIVE: Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels. METHOD: After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port. RESULTS: RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions. CONCLUSION: These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population.

Posterior urethral injury in male children: long-term follow up.

OBJECTIVE: Owing to the immature pelvis and the relative intra-abdominal position of the child's bladder, children with a posterior urethral injury differ from adults. We report our experience in the management of such injuries in male children. PATIENTS AND METHODS: Children with suspected urethral injury underwent retrograde urethrography once their clinical condition was stable. Children with complete urethral injury underwent primary urethral realignment either endoscopically or by open surgical technique. Suprapubic cystostomy was performed in other children who were unfit to undergo primary realignment or in whom the management of other injuries took precedence over that of urethral injury. Children referred from elsewhere for further management of urethral injury and those with initial suprapubic cystostomy underwent delayed urethroplasty. RESULTS: Twenty-two children with mean age of 11.3 years were treated at our centre for urethral injury. Seven children underwent primary endoscopic urethral realignment, five open surgical realignment and 10 initial suprapubic cystostomy followed by delayed urethroplasty. Six of the 12 children undergoing primary urethral realignment required additional endoscopic urethrotomy for managing the stricture, and three of these six children eventually underwent urethroplasty. Of the 10 children undergoing delayed urethroplasty, three required additional sessions of endoscopic urethrotomy and two of these required further correction graft urethroplasty. CONCLUSION: Most male children with posterior urethral injuries need immediate realignment to prevent long-term complications.

Laparoscopic bladder (Boari) flap ureteroneocystostomy.

Iatrogenic ureteric injuries in gynecologic surgery are quite common. The laparoscopic spectra of treatment gives a wide range of application. We present the case of a 40-year-old female who underwent total abdominal hysterectomy with bilateral salpingo-oopherectomy for dysfunctional uterine bleeding. Postoperatively, she had oliguria with raised creatinine and was found to have ureteric narrowing on magnetic resonance urogram. The patient was successfully managed by laparoscopic (Boari flap) ureteroneocystostomy.

Laparoscopic pyeloplasty compared with open pyeloplasty in children.

BACKGROUND AND PURPOSE: Open dismembered pyeloplasty by a retroperitoneal approach remains the reference standard for correcting ureteropelvic junction (UPJ) obstruction in children. We prospectively compared the results of laparoscopic and open pyeloplasty in children with UPJ obstruction. PATIENTS AND METHODS: During the period April 2003 to March 2005, 15 children underwent laparoscopic pyeloplasty and 14 children underwent open pyeloplasty. The two groups were similar in age and mean weight. We prospectively analyzed and compared operative time, postoperative pain and activity, complications, and hospital stay in the two groups. The mean follow-up was 23 and 24 months in the laparoscopy and open surgery group, respectively. RESULTS: The mean operative time was significantly shorter in the open surgery group (159 +/- 21.39 [SD] v 214 +/- 32.26 minutes; P = 5.874 x 10(-6)). Postoperative discomfort/pain on day 7 was significantly less in the laparoscopic group, and the mean hospital stay was significantly shorter (P = 0.018019). CONCLUSIONS: The benefits of laparoscopic pyeloplasty include a high reproducible success rate comparable to the results achieved by open pyeloplasty. Our results indicate minimal morbidity such as pain and a quick return to normal activities. The hospital stay is significantly reduced, although the operative times are long compared with open pyeloplasty.

Severe hypospadias with micropenis, case of confused sex, psychosocial changes and treatment.

Disorders such as severe hypospadias presenting as ambiguous genitalia have serious and potentially life-long consequences for affected individuals and, depending on the underlying cause, are likely to entail surgery in childhood and in later life, psychosocial and psychosexual support, and possible fertility treatment including assisted conception. Genetic males with severe hypospadias who were wrongly brought up as females formed the study group. They were reassigned as males and underwent surgery for correction of hypospadias. Three children with severe hypospadias were reassigned to male gender. Psychosocial changes were made and psychosexual counseling was done. All three have adjusted to their new environment and gender. It is preferable to reassign these children who are genetic males but wrongly assigned as females at birth. Repair of hypospadias, psychosocial changes, and psychosexual counseling will help these children to reorient themselves.

Finasteride to evaluate the efficacy of dutasteride in the management of patients with lower urinary tract symptoms and enlarged prostate.

Patients with lower urinary tract symptoms and enlarged prostate were randomized to receive, in a double blind fashion, either Finasteride 5 mg/day or Dutasteride 0.5 mg/day for a period of 12 weeks. IPSS score, Qmax, and Quality of Life were assessed at the end of 0 and 12 week periods. Dutasteride significantly improved Qmax, reduced IPSS score, and improved Quality of Life as compared to Finasteride at the end of the 12-week period. Dutasteride with its inhibitory effects on type 1 and 2 5alpha-reductase, produces significantly better results than Finasteride.

Laparoscopic dismembered pyeloplasty in children.

PURPOSE: Ureteropelvic junction obstruction remains the most common obstructive uropathy in children. Although laparoscopic dismembered pyeloplasty was described in a child in 1993, there have been few reports of laparoscopic Anderson-Hynes dismembered pyeloplasty in children. We report on a series of children who underwent laparoscopic Anderson-Hynes dismembered pyeloplasty. MATERIALS AND METHODS: The diagnosis of ureteropelvic junction obstruction was firmly established in all patients based on history, clinical examination, renal sonography and scintigraphy. Laparoscopic Anderson-Hynes pyeloplasty was performed using either 3 or 4 ports. Children were followed for urinary tract infection, and renogram was repeated at 3 months. RESULTS: A total of 16 children 5 months to 11 years old underwent laparoscopic Anderson-Hynes pyeloplasty between July 2002 and December 2003. No major intraoperative or postoperative complications were noted. One child with horseshoe kidney had development of fever and tenderness on the operated side on postoperative day 4. A percutaneous nephrostomy tube was placed and was removed 2 weeks later. CONCLUSIONS: Laparoscopic Anderson-Hynes pyeloplasty in children is too new to assess long-term outcome adequately. However, our study reveals improved outcome in the short term in the form of improved hydronephrosis and improved glomerular filtration rate on renal scan, and resolution of symptoms in all children.