Pediatric Stone Surgery: What Is Hot and What Is Not.

PURPOSE OF REVIEW: We aim to highlight recent advances in technology and techniques for surgical management of urinary tract calculi in pediatric patients. RECENT FINDINGS: Percutaneous nephrolithotomy (PCNL) is classically performed in the prone position. The supine PCNL was first attempted to overcome the shortcomings of difficult airway access, patient and surgeon discomfort. The supine PCNL, and subsequent modifications, has been successfully described in the pediatric population. Classically, PCNL has also been classically concluded with obligate placement of a nephrostomy tube and bladder catheter. Recently, tubeless and totally tubeless PCNL reduces pain and duration of hospitalization with satisfactory surgical outcomes in children. Finally, we describe the use of thulium laser technology, which offers improved efficacy in stone treatment and may supplant the current dominant technologies in coming years. Recent advances in pediatric stone surgery include supine PCNL, miniaturized PCNL instrumentation, tubeless procedures, and thulium laser technology.

Onabotulinumtoxin A (Botox): A reasonable alternative for refractory neurogenic bladder dysfunction in children and young adults.

AIMS: We aimed to describe the effectiveness of Onabotulinumtoxin A (Botox) in children with neurogenic bladder (NGB) unresponsive to medical therapy to determine urodynamic parameters predictive of success. METHODS: Children receiving Botox for refractory NGB, between 2008 and 2019, from a single academic center, were included in this study. Botox success was defined as improvement of incontinence and/or urodynamic parameters. RESULTS: Of 34 patients who received Botox, 13 (38.2%) had a positive response from their first injection, with improvement in capacity by a median of 35% of expected capacity for age compared to only a 9% increase in those who did not respond clinically. When patients were divided into groups by baseline urodynamic parameters, high-pressure (Pdetmax > 20 cm H2 O) patients had significantly greater improvement in compliance compared with low-pressure patients (p = 0.017). Low compliance patients (<10 ml/cm H2 O) had a dramatic improvement of 3.08 ml/cm H2 O in their compliance compared with minimal change in the high compliance group (p = 0.003). Finally, low-capacity (<50% of expected CC) patients had significant improvement in capacity and compliance when compared with high-capacity patients (p = 0.004 and p = 0.036, respectively). Improvement in detrusor overactivity (DO) was noted in both the clinical responders and non-responders. CONCLUSION: In our series, 38% had clinical success with intradetrusor Botox injections for refractory neurogenic bladder. When successful, improvement in capacity and compliance, DO, and/or incontinence was consistent with prior literature. While we could not determine which parameters predicted success, subdividing patients into categories based on baseline urodynamic parameters identified who would benefit from Botox treatment based on differential improvements in capacity and compliance. At least 1 injection of Botox should be considered for a subset of children with refractory NGB, before undertaking more invasive treatments.

Advanced sperm testing.

PURPOSE OF REVIEW: The sensitivity of semen analysis for detection of infertility remains low. Many factors not measured in traditional semen analysis may contribute to male factor infertility. DNA fragmentation, oxidative stress, and sperm aneuploidy are three factors that may contribute further information to the evaluation when semen analysis is inconclusive. RECENT FINDINGS: DNA fragmentation measures the destruction of and failure to repair damage to DNA. Increased DNA fragmentation has been used as a marker for oxidative stress as well as toxic exposure. The oxidative stress adduct measures DNA aberrations, which sperm cannot repair and has been used to support use of antioxidants. Lastly, the aneuploid sperm frequency is a quantitative measure of deviation from the normal chromosomal complement. Although elevated sperm aneuploid frequency has been associated with recurrent pregnancy loss and implantation failures, barriers remain to its routine use. SUMMARY: We identified these three adjunctive tests, which have the potential to alter either management or counseling of patients with regards to male factor infertility. Elevated DNA fragmentation or significant sperm aneuploidy may suggest the need for further investigation or further preimplantation genetic testing prior to IVF. The oxidative stress adduct may lend further explanation and improved counseling of the infertile patient.

Total knee arthroplasty and fractures of the tibial plateau.

Tibial plateau fractures are common injuries that occur in a bimodal age distribution. While there are various treatment options for displaced tibial plateau fractures, the standard of care is open reduction and internal fixation (ORIF). In physiologically young patients with higher demand and better bone quality, ORIF is the preferred method of treating these fractures. However, future total knee arthroplasty (TKA) is a consideration in these patients as post-traumatic osteoarthritis is a common long-term complication of tibial plateau fractures. In older, lower demand patients, ORIF is potentially less favorable for a variety of reasons, namely fixation failure and the need for delayed weight bearing. In some of these patients, TKA can be considered as primary mode of treatment. This paper will review the literature surrounding TKA as both primary treatment and as a salvage measure in patients with fractures of the tibial plateau. The outcomes, complications, techniques and surgical challenges are also discussed.