Comparing the efficacy of extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy in the treatment of proximal ureteral stones in children: A retrospective study.

OBJECTIVES: Ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy methods are commonly used in the treatment of proximal ureteral stones. There are no adequate studies showing which method is more effective in children. In our study, we aimed to evaluate and compare the efficacy of two treatment methods, commonly used for proximal ureteral stones in children. METHODS: A total of 78 patients who underwent ureteroscopic lithotripsy (n = 38) and extracorporeal shock wave lithotripsy (n = 40) due to stones located in the proximal ureter between 2010 and 2021 were included in the study. Demographic data, clinical characteristics, and treatment outcomes were retrospectively analyzed. Kolmogorov-Smirnov, Chi-square, and Mann-Whitney U tests were used for statistical analysis. RESULTS: There was no statistical difference between the demographic characteristics of the groups, except for the mean age values (p = 0.008). A statistically significant difference was found in favor of the extracorporeal shock wave lithotripsy group in terms of stone-free rates after the first intervention, complication rates requiring intervention, re-intervention rates, and the average number of anesthesia sessions per patient until stone-free status (p = 0.043, p = 0.009, p = 0.017, and p < 0.001, respectively). CONCLUSIONS: The results of this retrospective study suggest that extracorporeal shock wave lithotripsy is the primary treatment option for single, non-complicated proximal ureteral stones.

Acquired Penile Epidermoid Cysts in Children.

Background In this study, we aim to present the experience of a tertiary center regarding penile epidermoid cysts over 15 years. Methodology Patient files of those who underwent surgical excision for penile epidermoid cysts between 2005 and 2019 were reviewed retrospectively. The demographics, clinical characteristics, etiological factors, cyst features, surgical techniques, complications, and follow-up data were analyzed. Results In total, 24 penile epidermoid cysts were excised in 21 boys. The median age at the time of surgery was 52 (15-204) months. The median duration between previous surgery and cyst excision was 40 (1-180) months. In total, 11 cases had a history of circumcision, and 10 had undergone hypospadias surgery. There was no significant difference between these two etiologic groups (p > 0.05). The main symptom was an asymptomatic penile mass. The average cyst size was 9.4 ± 6.7 mm. All cysts were completely excised with incisions made over old scars, except one. No complications were observed during a median follow-up period of 50 (12-120) months, and only one recurrence was noted. Conclusions Acquired penile epidermoid cysts may present as an early or late complication after penile surgery. Complete excision with an incision along the existing scars seems to be an effective solution for preventing new scars.

A pilot study assessing average detrusor pressure garnered from area under a urodynamic curve: Evaluation of clinical outcomes.

INTRODUCTION: The management of neurogenic bladder mostly relies on urodynamic studies; however, several studies have shown low interobserver reproducibility. The aim of this study was to evaluate if a new objective cystometric parameter was superior to other cystometric measures. PATIENTS AND METHODS: A new parameter (pressure adjusted area under curve ratio, PAUC) was formulated from the ratio of area under the cystometry curve to a DLPP-adjusted total area (AT). AT was figured from a rectangle designed on the cystometrogram curve with a fixed height of 200 cmH2O and a width defined by the filling phase (figure). Two different estimated pressure measures derived from this (upper mean static pressure, UMSP and theoretical end filling pressure TEFP) were then calculated. Medical records of myelomeningocele patients with ultrasonography and renal scintigraphy performed at the time of urodynamics (with an interval of >5 years) were reviewed. Hydronephrosis and new scars in scintigraphy were used as the outcome measures. RESULTS: The study group consisted of 115 subjects with a median age of 4 (0-23) years at the time of the first urodynamic study. The median follow-up was 6 (5-14) years. PAUC and its derivatives (UMSP and TEFP) had the best discriminative power in predicting high grade hydronephrosis (0.830, 95% CI:0.732-0.927, p < 0.001), worsening in hydronephrosis (0.827, 95% CI:0.723-0.931, p < 0.001), and new scar formation (0.704, 95% CI: 0.576-0.832, p = 0.002). PAUC>0.1 significantly correlated with urinary tract dilatation (p < 0.001) and new scar formation (p = 0.002). In the multivariate analysis, our three parameters and having scars at admission were the only independent risk factors for new scars (p = 0.001 and p = 0.002, respectively) and worsening in hydronephrosis (p < 0.001 and p = 0.001, respectively). DISCUSSION: Our results show that our three parameters derived from area under the urodynamic curve are more reliable than other urodynamic measures. Their major theoretical advantage is to incorporate all the pressure during filling phase giving a more accurate picture of what the intravesical pressure milleu is. Using these measures, we demonstrated their superiority in predicting clinical outcomes. Major limitations of this study are the retrospectively collected data and lack of longitudinal follow-up starting from infancy in each patient. CONCLUSION: Our new parameters (PAUC, UMSP and TEFP) which incorporate the impact of entire filling phase pressure changes in the analysis, may be useful tools to identify those patients who are under the risk of kidney damage with neurogenic lower urinary tract dysfunction.

Diffusion tensor imaging in anorectal malformations: a pilot study for the evaluation of lumbosacral plexus.

INTRODUCTION: Neurogenic bladder with anorectal malformations (ARM) is a well-known yet understudied topic. Diffusion tensor imaging (DTI) is a special usage of MRI that can evaluate peripheric nerves. The aim of this study is to evaluate the lumbosacral plexuses of patients with ARM using DTI. PATIENTS AND METHODS: Patients with ARM willing to participate were included. Patient files were reviewed, a questionnaire was made, and DTI was performed. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were computed for the right and left lumbosacral plexuses. RESULTS: There were 18 patients and 12 controls. Groups were similar in terms of sex (p = 0.232) and age (p = 0.853). There was a significant difference only for ADC of the left plexus. There was visible asymmetry in tractographies and DTI parameters of two patients with severely deformed pelvises (image 1) but also in another patient with a normal sacrum. In addition, despite asymmetry, FA and ADC were similar to controls also in these patients. CONCLUSION: This is the first study presenting quantitative data about the lumbosacral plexus in ARM. We think the most interesting finding of this study was observing the normal values even in the patients with severely malformed sacrum which is yet to be validated with further studies.

Is the Reference Electrode Location Important for the Electromyography Evaluation of the Pelvic Floor in Urodynamic Studies?

PURPOSE: Perineal electromyography (EMG) is a crucial part of urodynamic studies. Many researchers focused on the standardization of techniques in urodynamics, but no study has yet evaluated the differences with various reference electrode placements. The aim of this study was to determine the optimal placement of the reference electrode for recording pelvic floor activity in urodynamic studies. METHODS: Children over 6 years of age without anatomic or neurological abnormalities were invited to participate in the study. Four reference electrodes were placed on the right kneecap, the inner surface of the right inner thigh, the right anterior iliac spine (AIS), and the skin over the left gluteal muscles for simultaneous recording. The EMG signal formed by pelvic contraction during forceful straining was recorded both in the supine and sitting positions. The root mean square (RMS) value of each muscle contraction signal was calculated. RESULTS: Twenty-one participants (10 boys and 11 girls) were included. The mean age was 10.19±3.20 years. The highest RMS values were obtained with the reference electrode on the thigh in the supine position and the AIS in the sitting position. Significant differences were found between the mean RMS values of the knee and other locations of reference electrodes in the supine position, as well as between mean RMS values in all regions except the thigh and gluteus in the sitting position. The minimum mean RMS values in both positions were obtained with the reference electrode on the knee. CONCLUSION: During urodynamic studies, reference electrodes shall be placed on AIS in the sitting and on the inner thigh in the supine position. The knee is not a suitable option for reference electrode placement. This information may help improve EMG recordings in the evaluation of pelvic floor muscles.

A large cohort of disorders of sex development and their genetic characteristics: 6 novel mutations in known genes.

INTRODUCTION: Disorders of sex development (DSD) constitutes a group of congenital conditions that affect urogenital differentiation and are associated with chromosomal, gonadal and phenotypic sex abnormalities. OBJECTIVE: To evaluate the clinical and genetic features of childhood DSD cases. MATERIALS AND METHODS: DSD patients followed up between the years of 2002-2018 were evaluated in terms of their complaints, demographic, clinical features and genetic diagnoses. RESULTS: Out of 289 patients, 143(49.5%) were classified as 46XY DSD, 62(21.5%) as 46XX DSD and 84(29%) as sex chromosomal DSD. Genetic diagnosis was achieved in 150 patients (51.9%). The distribution of the molecular diagnosis of the 46XY DSD patients were; 12 (26.6%) SRD5A2, 10 (22.2%) AR, 7 (15.5%) HSD17B3, 3 (6.6%) WT-1, 2 (4.4%) AMHR2, 2 (4.4%) AMH, 2 (4.4%) LHCGR, 2 (4.4%) HSD3B2, 1 (2.2%) NR5A1, 1 (2.2%) CYP17A1 and 1 (2.2%) SRY mutation. Fifty (80.6%) of the 46XX DSD patients received a diagnosis with clinical and laboratory findings. Twenty-four (38.7%) of them were 21-hydroxylase deficiency, 9(14.5%) Rokitansky-Küster-Hauser Syndrome, 4 (6.5%) 11-ß hydroxylase deficiency, 3 (4.8%) gonadal dysgenesis and 2 (3.2%) aromatase deficiency. In 46XX group pathogenic mutations were detected in 21(33.8%) of the patients. Eighty-four (29%) patients were diagnosed as sex chromosomal disorder. Of these 66 (78.5%) were Turner Syndrome, 6 (7.2%) Klinefelter Syndrome and 10 (11.9%) mix gonadal dysgenesis. Gender re-assignment was decided in 11 patients. Malignant and pre-invasive lesions was diagnosed in 8 (2.7%) patients. CONCLUSION: Many of DSD's are clinically similar and etiology of numerous of them still cannot be established. A multi-disciplinary approach and new rapid genetic diagnostic methods are needed in the process from diagnosis to gender assignment and follow-up.

Quality of Life and Psychological Well-being in Children and Adolescents with Disorders of Sex Development

Objective: The aim of this study was to assess the quality of life (QoL) and psychological well-being in child and adolescent with disorders of sex development (DSD). Methods: Sixty-two cases, aged 2-18 years, who were followed by a multidisciplinary DSD team were included. All participants and their parents were requested the complete the Pediatric Quality Of Life Inventory (PedsQL) and the Strengths and Difficulties Questionnaire. The psychiatric diagnoses of the patients were evaluated according to Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Turkish Version. Results: There was no significant difference between the 46,XX DSD and 46,XY DSD groups for both child and parent in Total PedsQL score. In the subscale scores, the PedsQL Physical Functionality Score reported by children was significantly lower for the 46,XX DSD group than for the 46,XY DSD group (p=0.01). There was a psychiatric diagnosis in 25.8% of cases. The PedsQL School Functionality Score reported by children in the group with psychiatric diagnosis was significantly lower than the group without psychiatric diagnosis (p=0.018). In the group with psychiatric diagnosis, the PedsQL Total Score and the subscale scores (Emotional Functionality Score, Social Functionality Score, School Functionality) reported by parents were significantly lower than in parents of the group without psychiatric diagnosis. Conclusion: This study emphasized that psychiatric disorders in DSD patients negatively affect the QoL. Psychiatric support and counseling from a multidisciplinary team are very important for families affected by DSD.

Survey on what COVID-19 pandemic changed in pediatric urology.

OBJECTIVE: We aimed to conduct a survey to see how the patient management of pediatric urologists has changed during the COVID-19 pandemic in daily practice and its compliance with the guidelines that aim to minimize the harm to the patient and healthcare professionals. MATERIAL AND METHODS: A questionnaire was prepared to be asked to physicians via Microsoft Forms dealing with pediatric urology for this purpose, and a link was shared in social media groups of doctors managing pediatric urology patients. RESULTS: A total of 58 (46 males and 12 females) doctors participated in the survey. Participants stated that they made a very high rate of change in their clinical routine; the most preferred approach for the prevention in the operating room was reducing the number of the working staff, and the second most frequent was performing a preoperative COVID-19 screening. Elective surgeries (ie, inguinoscrotal pathologies) were delayed by the majority. However, the majority of the surgeons did not delay surgeries for ureteropelvic junction obstruction or urinary stones. Ninety-five percent of the participants stated that the number of patients was decreased in the outpatient clinics, which was mainly due to the hospital and government policies. The most used method to communicate with patients during the pandemic was phone calls, and there was a 52% increase in the WhatsApp messenger application before the pandemic. CONCLUSION: Our survey provided us with an opinion about how our colleagues' lives changed during the pandemic and showed us the importance of a well-established telemedicine system.

Psychiatric view for disorders of sex development: a 12-year experience of a multidisciplinary team in a university hospital.

Background Psychiatric consultation is important in the follow-up of disorders of sex development (DSD) patients. In this study, we aimed to present the 12-year psychiatric follow-up data of the patients who were referred by Ege University Medical Faculty DSD Multidisciplinary Team and followed up in Child and Adolescent Psychiatry. Methods Psychiatric data of 118 patients, who were followed by the DSD multidisciplinary team between 2007 and 2019, were reviewed retrospectively. The psychiatric diagnoses of the patients were evaluated according to semi-structured interview form Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Turkish Version. Results The mean age of the 118 cases was 13.21 years (±7.18). Endocrine diagnoses of the cases were 46 XX DSD in 35 (29.6%), 46 XY DSD in 81 (68.7%), and chromosome disorders in 2 (1.7%). There was at least psychiatric diagnosis in 36 (30.5%) cases. The most common psychiatric diagnosis was attention deficit and hyperactivity disorder (ADHD) (n = 18, 15.3%). ADHD was most common in congenital adrenal hyperplasia (n = 4, 22.4%) and androgen synthesis defects (ASD) (n = 4, 22.4%); depression was most common in complete gonadal dysgenesis and ASD (n = 3, 23.1%); and mental retardation was most common in ASD (n = 3, 37.5%). Conclusions In order to provide a healthy perspective for cases with DSD, it is important to make a psychiatric evaluation and to share observations and clinical findings in regular team meetings.

Robotic partial nephrectomy in a child with kidney tumor.

Robotic surgery is gaining wider utility in adults; however, few reports have addressed the applicability of robotic surgery for renal tumors in children. The aim of this report is to share our experience in an 8-year-old child with metanephric stromal tumor. To our knowledge, besides being a rare tumor, this is the youngest case reported in the literature whose kidney tumor has been successfully removed with robotic partial nephrectomy. There is a worldwide tendency to perform minimal invasive surgery for kidney tumors. In the presence of an experienced team and proper conditions, we believe that robotic partial nephrectomy will be the preferred option in future.

Excision of the atrial Wilms` tumor thrombus without sternotomy, atriotomy and cardiovascular By-pass.

Tekin A, Yagmur I, Ergün O, Ayik MF, Atay Y, Ulman I, Avanoglu A. Excision of the atrial Wilms` tumor thrombus without sternotomy, atriotomy and cardiovascular By-pass. Turk J Pediatr 2019; 61: 436-439. The treatment of atrial-extention Wilms` tumor thrombus is surgical excision after chemotherapy. Atriotomy with cardiovascular by-pass is the one of the most common method for this procedure. Herein, we aimed to present a case of Wilms` tumor with a tumor thrombus extending into the right atrium totally excised with retrohepatic cavatomy. A 3.5 year-old girl was admitted with the symptom of dysuria. The examinations revealed a mass consistent with Wilms` tumor in the middle and lower poles of the left kidney. Doppler ultrasound and Echocardiographic examinations showed a tumor thrombus extending into the right atrium and some pulmonary nodules which were interpreted to be metastasis. Wilms` tumor was histopathologically diagnosed by an open biopsy. After three courses of chemotherapy imaging studies revealed that the atrial axtention of the tumor thrombus persisted. The tumor thrombus was found to be fibrotic on the magnetic resonance imaging scan of the patient. Therefore, nephroureterectomy along with the excision of the tumor thrombus from the inferior vena cava was done with intraoperative continuous trans-esophageal echocardiography (TEE). The suprarenal and retrohepatic vena cava were exposed by dissecting and ligating all short hepatic veins and completely mobilizing the right lobe of the liver. The thrombus was dissected out via Vertical cavatomy at the retrohepatic level. TEE confirmed complete removal of the thrombus from the atrium; Vena cava was then repaired. There was no need for a blood transfusion, or cardiovascular by-pass (CPB) during the operation. Total exposure of the retrohepatic and subdiaphragmatic vena cava using transplantation techniques is an effective method for the excision of a tumor thrombus without sternotomy, atriotomy and CPB, avoiding possible intra- and postoperative complications in selected cases of Wilms` tumor with intraatrial thrombus extension. The case emphasises the importance of multidisciplinary communication and collaboration.

Nonneuropathic Neuropathic Bladder-Is it Really Nonneuropathic?

PURPOSE: Hinman syndrome is a rare disease with urodynamic findings and a clinical course resembling neuropathic bladder, without a neuropathic etiology. Diffusion tensor imaging is a special technique of magnetic resonance imaging that has recently been used to evaluate the peripheral nerves but has been demonstrated to be applicable for evaluation of the lumbosacral plexus. We examined the lumbosacral plexus using diffusion tensor imaging, which has not previously been reported in patients with Hinman syndrome. MATERIALS AND METHODS: The study included 12 patients who fulfilled criteria for Hinman syndrome, with severe bladder dysfunction on urodynamics, renal scarring on scintigraphy and no pathological findings on magnetic resonance imaging. The 12 subjects serving as controls required pelvic or spinal magnetic resonance imaging for reasons other than spinal abnormalities. Evaluation was performed with a 3.0 Tesla magnetic resonance imaging system and 16-channel body coil. Tractography was done to examine the lumbosacral plexus. Fractional anisotropy and mean diffusivity were computed and compared between groups for the right and left plexuses. RESULTS: Mean fractional anisotropy was 0.24 and 0.35 for the right plexus in patients and controls, respectively, and 0.24 and 0.36 for the left plexus. Mean diffusivity was 1.39 for the right and left plexuses in patients, and 1.28 for the right and left plexuses in controls (p <0.001 for all). CONCLUSIONS: Our study focusing on the lumbosacral plexus as a possible origin of neuropathy revealed abnormal findings in patients with Hinman syndrome resembling nerve injury series. This is the first known study to provide data showing that Hinman syndrome may have a neuropathic etiology.

Changing bulking agent may require change in injection volume for endoscopic treatment of vesicoureteral reflux

ABSTRACT Introduction: Various bulking agents were utilized for endoscopic correction of VUR. A study reviewing multi-institutional data showed that the amount of injection material has increased over time with the purpose of improving success rates, which also resulted in costs. We noticed an opposite trend in our center since we started using a new bulking agent. The aim of this study was to evaluate evolution of our practice with different bulking agents. Patients and Methods: Records of VUR patients who underwent subureteric injection with polyacrylate polyalcohol copolymer (PPC) and dextronomere hyaluronic acide (DxHA) between 2005 and 2014 were reviewed. Variation of different parameters throughout the study period was evaluated along with the success rate. Success was defined as complete resolution of reflux. Results: A total of 260 patients with 384 refluxing units were included. The success rate was higher in PPC group compared to DxHA group. There was no statistically significant difference between years regarding distribution of VUR grade, body weight, patient height, and age in PPC group. Despite significant reduction in injection volume, success rate did not decrease through the years with PPC. Conclusion: Different bulking agents may require different injection volumes to achieve the same success rate in endoscopic treatment of vesicoureteral reflux. Habits gained with previous experience using other materials should be revised while using a new agent.

Changing bulking agent may require change in injection volume for endoscopic treatment of vesicoureteral reflux.

INTRODUCTION: Various bulking agents were utilized for endoscopic correction of VUR. A study reviewing multi-institutional data showed that the amount of injection material has increased over time with the purpose of improving success rates, which also resulted in costs. We noticed an opposite trend in our center since we started using a new bulking agent. The aim of this study was to evaluate evolution of our practice with different bulking agents. PATIENTS AND METHODS: Records of VUR patients who underwent subureteric injection with polyacrylate polyalcohol copolymer (PPC) and dextronomere hyaluronic acide (DxHA) between 2005 and 2014 were reviewed. Variation of different parameters throughout the study period was evaluated along with the success rate. Success was defined as complete resolution of reflux. RESULTS: A total of 260 patients with 384 refluxing units were included. The success rate was higher in PPC group compared to DxHA group. There was no statistically significant difference between years regarding distribution of VUR grade, body weight, patient height, and age in PPC group. Despite significant reduction in injection volume, success rate did not decrease through the years with PPC. CONCLUSION: Different bulking agents may require different injection volumes to achieve the same success rate in endoscopic treatment of vesicoureteral reflux. Habits gained with previous experience using other materials should be revised while using a new agent.

Parental Perception of Terminology of Disorders of Sex Development in Western Turkey

Objective: Disorders of sex development (DSD) is a nomenclature intended to defeat the discomfort of families and patients and has found worldwide usage. The aim of this study was to address the perception and usage of terminology among the parents of DSD patients in a tertiary center in western Turkey. Methods: The records of the DSD council (multidisciplinary team where each patient with DSD is discussed) between years 2008-2015 were reviewed retrospectively. Data including details of the management process, patient characteristics and follow-up details were noted. Then inquiries reflecting parental perception about terminology were implemented during clinical visits. Results: In total, 121 patients were evaluated in monthly meetings of the DSD council and 79 inquiries were completed. Fifty-one percent of the families admitted knowing the terms DSD, ambiguous genitalia, "dubious genitals" and intersex. However, only 2% preferred using DSD, 6% intersex and 14% ambiguous genitalia. Fifty-two percent of the parents used a disease name in Latin (mostly hypospadias) addressing the disorder. The offspring of 69% of the parents who were familiar with the name "dubious genitals" were diagnosed in the neonatal period. The preferred terminology used by parents was strongly associated with the terminology used most commonly in the medical speciality their child most often attended. Conclusion: Each country has its own social norms. We suggest therefore that local committees including medical professionals, patients and families should be employed to develop proper terminology.

Benign prostatic hyperplasia: Case report of a 17-year-old.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is generally common in men older than 50 years of age but is extremely rare in childhood. In the literature to date, fewer than five cases have been reported under 18 years of age. Owing to the limited number of cases, the etiology and management of BPH in the first two decades is not clear. OBJECTIVE: We herein report a 17-year-old boy who presented with acute urinary retention due to BPH and was treated with endoscopic transurethral resection of the prostate (TUR-P). CASE REPORT: A 17-year-old male patient with a history of intermittent hematuria was admitted elsewhere with acute urinary retention. An increase in prostate size was detected on digital rectal examination. Pelvic ultrasound revealed a large mass arising from the prostate and filling the bladder lumen. Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) was performed to exclude malignancy. After the documentation of benign prostate tissue in the histopathological analysis, the patient was referred to our clinic for further evaluation and management. Magnetic resonance (MR) imaging revealed a 48 × 55 × 68 mm mass arising from the middle lobe of prostate and filling the bladder lumen (Figure) with an initial diagnosis of a non-ductal malignant tumor because of his age. Enlarged lymph nodes or any sign of metastasis were not detected. Re-examination of the previous biopsy specimens confirmed the absence of malignancy; therefore he underwent endoscopic treatment with TUR-P. Histopathological examination reported BPH. The postoperative 1-year follow-up was uneventful. DISCUSSION: The patient was extensively evaluated with a suspicion of malignancy, especially rhabdomyosarcoma, which is more expected for this age group. Reviewing juvenile cases with BPH in the literature, two authors explained the possible etiologic factors of their cases as gonadotropin supplement therapy for undescended testes and the mother's utilization of a human chorionic gonadotropin-containing agent during pregnancy to prevent spontaneous abortion. Our case had no history of drug intake, endocrinologic abnormality, or any other possible relevant factor. Owing to the limited number of cases, there is not enough data to understand the etiology and also no consensus on the treatment of BPH in the adolescents. Therefore, experiences gained from adult cases guide the pediatric treatment modalities. CONCLUSION: Despite the fact that BPH is very rare in childhood, one should keep it in mind in the differential diagnosis of acute urinary retention and malignant prostate diseases. The endoscopic method is the treatment of choice in BPH.

Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps.

INTRODUCTION: Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate. AIM: The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification. STUDY DESIGN: Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions. RESULTS: Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure). DISCUSSION: Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication. CONCLUSION: Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Multicenter survey of endoscopic treatment of vesicoureteral reflux using polyacrylate-polyalcohol bulking copolymer (Vantris).

OBJECTIVE: To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS: From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS: Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION: The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.

Involution of multicystic dysplastic kidney: is it predictable?

OBJECTIVE: To evaluate the clinical course of multicystic dysplastic kidney (MCDK) and to reveal any criteria indicating spontaneous involution. MATERIAL METHODS: Hospital records of patients with MCDK followed in two different institutions in 1994-2009 were reviewed and data were analyzed regarding involution. RESULTS: Records of 96 patients were reviewed, of whom 46 were diagnosed antenatally and followed for more than 1 year. Fourteen patients had undergone nephrectomy. There was one case of hypertension which resided with nephrectomy. There was no malignancy. Involution rate was 53.6% (15/28) for right-sided and only 16.7% (3/18) for left-sided kidneys. The initial size of the kidney was found to be another predictive parameter for involution. Initial sizes of 43 (15 involuted and 28 non-involuted) kidneys were documented. Mean standard deviation score for involuting and non-involuting kidneys was -3.19 and 3.12, respectively. The chance of involution for a large kidney on the left was zero; however, involution risk for a small right-sided kidney was 67%. CONCLUSION: Reviewing a 15-year period of our patient records conveyed data supporting current literature mainly encouraging non-operative management of MCDK. Further studies are required; however, our two objective indicators, the initial size and side of dysplastic kidney, may contribute to the management.

Psychiatric approaches for disorders of sex development: experience of a multidisciplinary team.

OBJECTIVE: Disorders of sex development (DSD) are a group of congenital medical conditions that affect life as a whole. In this study, we aimed to reflect the experience of a multidisciplinary team in the clinical/psychiatric follow-up of a group of children and adolescents with DSD. METHODS: The study group consisted of 51 patients diagnosed with DSD. The Kiddie-Schedule for Affective Disorders and Schizophrenia, Wechsler Intelligence Scale for Children-Revised, Draw a Person Test and Children's Apperception Test, and the Clinical Global Impression Scale (CGIS) were used for psychiatric evaluations. RESULTS: The mean age of the patients was 7.8 years (median: 7.8; min: 1.0; max: 18.0). Genetic evaluation showed 46,XX configuration in 15 patients (29.4%) and 46,XY in 35 (68.6%). One patient (2.0%) was diagnosed to have a sex chromosome disorder. Forty patients (78.4%) had no problems with their given gender identity and gender role. Thirty-four (66.7%) patients had normal intellectual capacity. Twenty-eight (54.9%) patients did not have any psychiatric problem. Depression, anxiety disorders, attention deficit/hyperactivity disorder, and adjustment disorders were the common diagnoses. The mean score of symptom severity on CGIS-severity-baseline was 6.15±0.68 and after one year, it was 1.46±0.51 (Z=-3.236 p=0.001). The mean score of CGI-Improvement was 1.23±0.44. CONCLUSION: It is important to identify and treat the psychiatric disorders encountered in patients with DSD. A psychiatrist needs to be included in the professional team following these patients. Examination and observation results need to be shared by holding periodic team meetings to establish a wholesome point of view for every unique child.