Optimum duration of ureteral prestenting dwelling time in children undergoing retrograde intrarenal surgery.

INTRODUCTION AND OBJECTIVES: Ureteral prestenting before retrograde intrarenal surgery (RIRS) causes passive dilatation of the ureter, improves stone-free rate and is associated with shorter operative time. However, the presence of a ureteric stent may increase the risk for septic complications, which accelerates with increased dwelling time duration. The aim of the present study is to explore the impact of ureteral prestenting timing in a group of children undergoing retrograde intrarenal surgery (RIRS) on perioperative outcomes and complication rates and to define the optimum duration of prestenting dwelling time. PATIENTS AND METHODS: A retrospective study on 60 children aged less than 14 years, presented with upper tract urinary stones, who were subdivided into two groups: Group 1 and 2, each included 30 children who had undergone RIRS after ureteric stenting for two weeks and four weeks respectively. Success of ureteroscope introduction, operative time, stone free rate (SFR), intraoperative and postoperative complications and number of retreatment procedures after definitive RIRS were recorded and compared between the two treatment groups. RESULTS: Ureteric access was successfully obtained in all children in both groups. Patients in group 1 and 2 had a SFR of 86.6% and 90%, respectively (p = 0.199). The mean operative time of group 1 and 2 were 56.5 and 52.9 min (p = 0.612). Postoperative UTI rates increased with prolonged dwelling time from 6.7% in group 1 to 30% in group 2. No patient in both groups developed high grade complications. CONCLUSIONS: Increasing prestenting dwelling time from two to four weeks had no statistically significant effect on the successful ureteroscopic access nor the stone free rate in children undergoing RIRS. Reducing the ureteric stent dwelling time minimizes the rate of postoperative UTI without compromising the success of operative outcomes.

Laparoscopic staged management of high intrabdominal testis: A prospective randomized study.

OBJECTIVE: To prospectively compare outcomes and complications of both staged laparoscopic techniques used in management of high intrabdominal testis (IAT). MATERIALS AND METHODS: Forty five patients were included in the study in whom unilateral high IAT were identified and were subjected to two-stage laparoscopic orchiopexy. Patients were prospectively randomized into two groups according to laparoscopic technique in use; either two stage Fowler-Stephens laparoscopic orchiopexy (FSLO) or staged laparoscopic traction orchiopexy (SLTO). Intraoperative evaluation for the distance of the testis from the internal ring, state of the internal ring (closed or open), operative time (min), intraoperative and early postoperative complications were recorded after first stage. Surgical outcomes of both techniques included operative time, intraoperative complications, success rate, final scrotal site position, testicular size and vascularity, and these were recorded within 48h of the second stage procedure and at 6 month follow-up. RESULTS: Staged FSLO was performed on 25 testes. Four cases were lost during follow up. Out of these 21 cases, one child had an atrophic testis before the second stage based on previously recorded operative size. SLTO was done on 20 testes. We had 2 cases of fixation suture slippage rendering a total of 18 patients who underwent second stage operation. No patients converted from laparoscopic to open surgery. At 6 month follow-up visits, 27 testes were found on examination to have a low scrotal position, (14 in the FSLO group and 13 in the SLTO group), 9 testes in high scrotal position (5 in the FSLO group and 4 in the SLTO group). Testicular ascent occurred in one patient in each group. Testicular atrophy was identified in 3 cases among the FS group, while no case of testicular atrophy occurred in the traction group of patients (p = 0.048). CONCLUSIONS: Both staged laparoscopic techniques had comparable success rates as regard final scrotal position for high undescended IAT in children, and were associated with no intra or post operative complications. SLTO had a better outcome as it was not associated with any testicular atrophy compared to FSLO at 6 months follow up.

Staged repair of proximal hypospadias: Reporting outcome of staged tubularized autograft repair (STAG).

INTRODUCTION: Proximal hypospadias (PPH) repair is a challenge. Dilemma exists whether to do it in single or staged repair. Staged repair is our adopted procedure which was recently modified by Snodgrass into staged tubularized autograft repair (STAG), in which attention was given to ventral straightening of the penis together with some other technical details. Herein, we report our experience with STAG in a cohort of primary posterior hypospadias. PATIENTS AND METHODS: In the period from 2011 to 2018 we operated 43 primary posterior hypospadias. Two principal surgeons (HB, MY) and multiple assistants operate children the same way, and data are recorded in a prospectively designed data base. In all children, inner prepuce graft was utilized, when curvature is more than 30 degrees, plate transection with or without ventral corporotomies were adopted. RESULTS: Forty-three children with PPH and ventral curvature more than 30 degrees underwent first stage with median age 12 months (6-132 IQR16). Penile curvature was corrected by plate transection in 27 children (62.8%), ventral corporotomies in 16 children (37.2%). Graft take was successful in 90.7%, 4 children needed revision of fibrotic graft. Second stage was completed in 37 children, success was 56.8%, 21.6% fistula, 24.3% glanular dehiscence. Overall success after third surgery to correct complications was 78.4%. In a mean follow up of 3.2 years, we had recurrence of curvature in 2 children taking success rate to 72.9%. No meatal stenosis, no diverticulum, no stricture, no urethral dehiscence was encountered. Cosmetic appearance was excellent in follow up. CONCLUSION: STAG achieves proper straightening of the penis and allows for reconstruction of a good urethra, yet urethrocutaneous fistula and glanular dehiscence remain the main complications. Follow up is important to address results of ventral corporotomies. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level IV case series with no comparison group.

Congenital adrenal hyperplasia: Does repair after two years of age have a worse outcome?

INTRODUCTION: Congenital Adrenal Hyperplasia (CAH) is the commonest cause of disorders of sex development (DSD) in children. The timing of surgery, early versus late, is a subject of current debate. We hypothesize that surgery for congenital adrenal hyperplasia after age two results in a worse outcome than procedures performed earlier in the neonatal period." PATIENTS AND METHODS: Retrospectively evaluated children underwent feminizing genitoplasty the period from 2003 to 2015. Sixty-one children included in the study. They were divided into two groups; Group I: those repaired before 2 years of age (early repair), Group II: those repaired after 2 years of age (late repair). We compare both groups as regards the timing, stages of the genitoplasty, genital anatomical assessment, overall cosmetic results and further treatment recommendations. RESULTS: Group I: included 35 children with mean age at presentation 1.73 ± 2.27months (3 days-10.0 months) group II: included 26 children with mean age at presentation 18.78 ± 32.25 months (3 days-150.0 months). 88.5% of children were operated in single stage. Overall cosmetic outcome is good in 94.3% in group I versus 19.2% in group II (p < .001), satisfactory in 5.7% in group I versus 53.8% in group II (p < .001), poor in 0% of group I versus 26.9% in group II (p = .002). 94.3% of children in group I needed no further surgeries versus 26.9% of group II (p < .001). DISCUSSION: a current unsolved debate is when to perform the feminizing genitoplasty in children with congenital adrenal hyperplasia (CAH), some are pushing to wait till puberty and others are advocating early reconstruction. To take this debate a further forward, we studied retrospectively our operated children and stratified them according to age into below 2 years and after 2 years of age and we found that earlier (before 2 years of age) is better then late (above 2 years of age) repair. CONCLUSIONS: Better anatomical findings were significantly observed in patients with early surgical intervention (before the age of 2 years).

Prospective evaluation of the management of bowel dysfunction in children with neuropathic lower urinary tract dysfunction and its effect on bladder dynamics.

INTRODUCTION AND AIM: Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics. PATIENTS AND METHODS: In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart. RESULTS: Mean age was 8.3 ±â€¯3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ±â€¯1.54 to 10.17 ±â€¯1.76, p = 0.00), rectal diameter (decreased from 34.83 ±â€¯5.91 to 27.90 ±â€¯5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ±â€¯24.95 to 30 ±â€¯17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ±â€¯45.69 to 155.17 ±â€¯39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively). CONCLUSION: Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.

Laparoscopic re-implantation of refluxing ureter in children: A feasibility study.

OBJECTIVE: To report our initial experience in the application of laparoscopy in the management of children with unilateral vesico-ureteric reflux (VUR) using the laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique, and to evaluate the results and benefits of this technique for such patients. PATIENTS AND METHODS: Between February 2013 and August 2014, 17 children [13 girls and four boys, with a median (range) age of 60 (24-120) months] presented with recurrent febrile urinary tract infections and were diagnosed with unilateral VUR. They underwent transperitoneal extravesical laparoscopic ureteric re-implantation following the Lich-Gregoir technique. Postoperatively abdomino-pelvic ultrasonography was done at 1 month after surgery and voiding cystourethrography (VCUG) at 3 months after surgery, and in cases with persistent VUR or de novo contralateral VUR another VCUG was done at 6 months after surgery. RESULTS: The median (range) operative time was 90 (80-120) min and the postoperative hospital stay was 2 (2-5) days. Intraoperative and postoperative complications were minimal. Patients were followed-up for a median (range) of 6 (3-21) months. All the children had complete resolution symptomatically and on VCUG, without further intervention. CONCLUSIONS: The laparoscopic extravesical transperitoneal approach for ureteric re-implantation, following the Lich-Gregoir technique, is feasible and very effective in the management of VUR. Prospective randomised studies are eagerly awaited to define the benefits of this technique to patients, as well as to determine the cost-effectiveness of this approach.

Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience.

OBJECTIVE: To report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole. PATIENTS AND METHODS: Laparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9 years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3 months, with renal scintigraphy at 3 months, to check the remaining function of the lower moiety. RESULTS: Overall, the mean operation time was 152 min (144 min for retroperitoneal and 160 min for transperitoneal). Blood loss was 10-50 mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25) days and 22 (9.83) months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety. CONCLUSION: Laparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.

Transperitoneal versus retroperitoneal laparoscopic pyeloplasty in children: Randomized clinical trial.

INTRODUCTION: Laparoscopic pyeloplasty achieves good cosmetic and functional outcomes. Both transperitoneal and retroperitoneal approaches are used. No single study to date has compared the two approaches in a prospective randomized design. OBJECTIVE: We present a prospective randomized comparison between both approaches in children in a trial to define which technique is better with regard to multiple factors including operative time, hospital stay, recovery of bowel movement, analgesic requirement and complication rate. STUDY DESIGN: In the period from June 2010 to September 2012, 38 children (25 boys and 13 girls) were operated laparoscopically. Children were randomized into Group I (19 children) operated by the transperitoneal approach, and Group II (19 children) operated by the retroperitoneal approach. Both groups were compared as regards to the operative time, anesthetic changes, and postoperative recovery. A minimum sample size required was calculated to be 19 for each arm based on previous studies of laparoscopic pyeloplasty, using a mean difference in operative time = 40 min, effect size = 0.95, an alpha of 0.05 and power 80% and an online sample size calculator. Statistical analysis was performed using SPSS software using the Fischer exact test, chi square test and Mann-Whitney U test. The operative time was the primary endpoint for comparison between both approaches. DISCUSSION: Our series is the first in the literature that compares in a prospective randomized design the transperitoneal and retroperitoneal laparoscopic pyeloplasty in children. Shouma et al. is the only prospective randomized study to compare both techniques in adult pyeloplasty. They had a significantly shorter operative time in the transperitoneal group however, the author in the discussion mentioned that he was at the start of the learning curve for retroperitonoscopic pyeloplasty when he conducted his study, which affected the result of the operative time. Hence, as mentioned above, we stressed the importance of a single surgeon with adequate equal experience in both techniques. The recovery of the intestinal motility and start of oral feeding were significantly faster in the retroperitoneal group compared to the transperitoneal group. In our opinion this can be explained by the absence of intraperitoneal manipulations and urine leakage in the peritoneal space. In their series of retroperitoneal pyeloplasty, El Ghoneimi et al. reported feeding after a mean of 1.4 days, however, in our series there was even earlier oral feeding. Shouma et al. reported no significant difference in the start of oral feeding in their adult series. The limitations of our study are: the choice of the 40 min difference created a statistically significant difference in operative time between the groups which might not be considered a truly clinically important difference. In addition, the single author operating for both approaches, which might create a bias, however the author has sufficient experience in both approaches. Moreover, although there were significant differences in hospital stay and intestinal movement between the two groups, it is not clear if these were of clinical significance. CONCLUSION: Both transperitoneal and retroperitoneal approaches have high success rate. The shorter operative time, shorter hospital stay, rapid recovery of intestinal movement and early resumption of oral feeding are in favor with the retroperitoneal approach.

Retroperitonoscopic pyelopexy for pelviureteral junction obstruction with crossing vessel in adolescents: Hellstrom principle revisited.

OBJECTIVE: To present our new approach using a minimally invasive technique for the management of pelviureteral junction (PUJ) obstruction with a crossing vessel. MATERIALS AND METHODS: In December 2009 to December 2011, out of 23 cases of retroperitoneoscopic laparoscopic pyeloplasty, four adolescents presenting with PUJ obstruction due to an aberrant crossing vessel, with intermittent attacks of renal colic and mild dilatation of the renal pelvis and calyces, were operated by retroperitoneoscopic pyelopexy. A retroperitoneoscopic approach was used in all patients using three trocars. After dissection of the PUJ from the anterior crossing vessel, and ensuring good funneling of the PUJ that proved to show mild dilatation, an interrupted 3/0 polyglycolic suture was used to fix the renal pelvis to the psoas muscle away from the crossing vessel (pyelopexy). A retrograde DJ stent was placed at the end of the procedure. RESULTS: The four patients had a mean age of 18.25 years (16-20): 2 males and 2 females, two right sided and two left sided. Average operative time was 46 min (40-55). All patients were discharged on the same day. No intraoperative complications were encountered. The DJ stent was removed 6 weeks postoperatively. After a mean follow up of 2.125 years (6 months-3 years) no recurrences were observed. CONCLUSION: Retroperitoneoscopic pyelopexy is shown to be a reliable, effective, safe and minimally invasive technique for the management of PUJ obstruction with a crossing vessel in selected cases. Long-term follow up is needed to assess any recurrence or development of complications.

Safety and feasibility of laparoscopic appendicovesicostomy in children.

INTRODUCTION: Mitrofanoff appendicovesicostomy is needed for securing a conduit for clean intermittent catheterization in children with myelomeningocele, posterior urethral valves and non-neuropathic neuropathic bladder. An open technique is widely used; herein we report our initial experience with minimally invasive laparoscopic appendicovesicostomy in children. PATIENTS AND METHODS: During 2007-2011 we operated on 4 male children with a mean age of 6 years (3-9) suffering from posterior urethral valves (1), myelomeningocele (2), and non-neuropathic neuropathic bladder (1). A posterior Mitrofanoff trough was used in one child while in the remaining children we used the anterior Mitrofanoff trough. RESULTS: The mean operative time was 3.5 h (3-5). The mean hospital stay was 3.7 days (2-5). The mean follow up was 12.5 months (5-30). All are continent; one child was converted to open because of failure to pass the catheter at the end of the procedure. Cosmetic aspect is perfect. No difficulty in catheterization was encountered. CONCLUSION: Laparoscopic Mitrofanoff is a feasible, safe and effective technique associated with low morbidity.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues.

INTRODUCTION: The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair. METHODS: We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate. RESULTS AND CONCLUSIONS: The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.

Retroperitonoscopic nephrectomy and nephrouretrectomy in children and adolescents: analysis of a single-center experience.

INTRODUCTION AND OBJECTIVES: Retroperitonoscopic nephrectomy in children was considered by some authors to be the final gold standard in children. Hence, we reviewed our data focusing on the safety and efficacy of the procedure. MATERIALS AND METHODS: In the period from November 2005 till February 2010, 35 patients were operated by a single surgeon (the first author); patients comprised 18 boys and 17 girls, with a mean age of 7.5 years (range: 1-19 years). In all patients, the retroperitonoscopic approach was used with the use of only three trocars, one 10-mm optic trocar and two 5-mm trocars. The retroperitoneal space was established either by direct insufflation into the Gerota fascia, which is grasped and opened under vision, or using a balloon dilator to widen the space and then incising the Gerota fascia under control of the optic trocar, then control of the pedicle is performed, and the specimen is extracted from the same optic trocar. RESULTS: The mean operative time is 75 minutes (range: 45-120 minutes). Nineteen nephrectomies and 16 nephrouretrectomies were performed. Blood loss was minimal, blood transfusion was not given, and conversion to open surgery was not needed. There were no intraoperative complications, and only one postoperative hematoma resolved spontaneously. The mean hospital stay was 2 days (1-3 days). CONCLUSION: Retroperitonoscopic nephrectomy in children is safe and feasible. Blood loss is minimal, hospital stay is very short, and complications are minimal. It has excellent cosmetic outcome.

Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases.

OBJECTIVE: Penile hair tourniquet syndrome is an uncommon syndrome characterized by progressive penile strangulation by a hair tie. Complications reported include urethrocutaneous fistula, complete urethral transection, penile gangrene, and penile amputation. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion for early diagnosis. PATIENTS AND METHODS: Twenty-five children presenting with different degrees of hair coil penile strangulation syndrome have been operated on in the period from 2000 to 2007 in 2 tertiary care centers in the city of Alexandria. Eighteen boys had complete transection of the urethra at the coronal sulcus. Seven boys had partial transection of the ventral wall of the urethra at the coronal sulcus. Repair of the penis was done in all children in a single stage. RESULTS: The mean age of boys is 3 years and 9 months (2-5 years). The mean follow-up is 20.7 (6-48) months. Urethral catheter was left for a mean of 5.5 (4-7) days. In the mean follow-up period, we had 4 complications in the form of 2 tiny urethrocutaneous fistulas and 2 anastomotic urethral strictures. The fistulae were closed surgically after the primary surgery by 1 year in the 2 cases, with no recurrence. Urethral strictures were managed by endoscopic visual urethrotomy, with no recurrence. CONCLUSION: Penile tourniquet syndrome can cause serious penile complications. Awareness of this rare syndrome can help in preventing such complications. Being familiar with the surgical reconstruction guarantees high success rate.

Post-traumatic posterior urethral stricture in children: how to achieve a successful repair.

OBJECTIVE: Complex post-traumatic posterior urethral strictures in children constitute a major challenge to the pediatric urologist. Surgical repair depends primarily on the length of the urethral obliteration. Resection with end-to-end anastomosis is the usual procedure in the face of a short segment stricture. Transpubic urethroplasty and substitution urethroplasty are currently used to treat extensive and complex urethral strictures. We present our experience of the management of children presenting with post-traumatic posterior urethral stricture. PATIENTS AND METHODS: Fifty boys with a mean age of 9 years (6-13) with obliterative urethral stricture were operated on during May 1999 to August 2006. Short posterior urethral stricture was treated by excision and end-to-end anastomotic urethroplasty in 40 boys. Long posterior urethral stricture was managed by combined inferior pubectomy in three, transpubic urethroplasty in four and tubed penile fasciocutaneous flap in three. RESULTS: With a mean follow-up of 4.5 years (6 months-7 years), all children who underwent perineal anastomotic urethroplasty were successfully repaired. Transpubic urethroplasty was associated with a re-stricture in one child 6 years following the repair. In the group repaired by tubed fasciocutaneous flap, we encountered a distal anastomotic stricture accompanied by a huge proximal diverticulum which needed revision in one child, and another diverticulum with multiple stones in another who was treated successfully. CONCLUSION: Anastomotic urethroplasty in children is feasible with good results. Proper evaluation is needed to choose the best surgical technique for each patient. Tubed fasciocutaneous flap carries the highest complication rate.

Pneumovesicoscopic diverticulectomy in children and adolescents: is open surgery still indicated?

OBJECTIVES: Surgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy. METHODS: We operated on three boys with a mean age of 11.6 years (10-14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO(2) insufflation at a pressure of 12-15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days. RESULTS: The mean operative time was 133.3 min (100-180 min). Oral intake began after a mean of 5.3h (4-6h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphine. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3-6 months). CONCLUSION: Pneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery.

Single-stage repair of bladder exstrophy in older children and children with failed previous repair.

AIM: Evaluation of cosmetic and functional outcome of single-stage exstrophy-epispadias complex repair in older children and those with previously failed repair. MATERIALS AND METHODS: This study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2-24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell-Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children. RESULTS: One child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm(3) (range 110-160 cm(3)) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1-3 years). CONCLUSIONS: Single-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.

Augmentation ureterocystoplasty in boys with valve bladder syndrome.

OBJECTIVE: Children with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome. PATIENTS AND METHODS: Eight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound. RESULTS: Bladder capacity (as measured during cystometry at 30 cmH(2)O) and compliance were significantly improved in all children following the procedure (P<0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child. CONCLUSION: Ureterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.