Pediatric Mini-Percutaneous Nephrolithotomy Using Self-Retained Screwed Amplatz Sheath vs Ordinary Sheath.

Objective: To evaluate the use of a new 16F mini-screwed sheath in pediatrics in comparison to a 16F ordinary Amplatz sheath. Methods: Sixty-seven patients <18 years with renal calculi between 1 and 2 cm who was a candidate for mini-percutaneous nephrolithotomy (mini-perc) between January 2019 and September 2021 were randomized by closed envelope in group A (34 patients) using new mini-screwed sheath and group B (33 patients) with ordinary mini-sheath. Patients with contraindications for percutaneous nephrolithotomy were excluded. Results: No significant difference was present between both groups according to patients and stone demographics. There was no significant difference between both groups regarding puncture site and number. The mean operative time was 51.25 ± 2.15 minutes and 52.35 ± 3.45 minutes in groups A and B, respectively. The fluoroscopy time was significantly lower in group A (2.1 ± 0.85 minutes) than in group B (2.9 ± 1.05 minutes). Tract loss was 18.2% in group B while 0% in group A. Although bleeding was less in group A, it was nonsignificant. The stone-free rate was (94.11%) and (90.9%) in group A and group B, respectively. Conclusion: Screwed sheath enables the urologist to have a stable track during pediatric mini-perc surgery despite the thin abdominal wall in the pediatric. The screw sheath provides significantly lower fluoroscopy time and decreases the need for nephrostomy tube insertion when compared with ordinary sheath in mini-perc renal surgery.

Ultra-Mini-Percutaneous Nephrolithotomy in Flank-Free Modified Supine Position vs Prone Position in Treatment of Pediatric Renal Pelvic and Lower Caliceal Stones.

Objectives: To report the safety and efficacy of ultra-mini-percutaneous nephrolithotomy (UMPCNL) in flank-free modified supine (FFMS) and prone positions in management of pediatric renal calculi. Patients and Methods: This prospective randomized study included 55 pediatric patients with symptomatic renal stones and suitable for UMPCNL. They were randomized into two groups. Group A included 28 patients who were treated by UMPCNL in FFMS position (with a pad below the ipsilateral shoulder and buttocks, putting ipsilateral upper limb over the chest, and crossing the extended ipsilateral lower limb over the flexed contralateral one) and Group B included 27 patients treated by UMPCNL in the prone position. In both groups dilatation was done to 13F sheath allowing the introduction of 6/7.5F semirigid ureteroscope and fragmentation of stones by Holmium: yttrium-aluminum-garnet laser with a 550-µm fiber laser lithotripter. Results: The operation time in FFMS position UMPCNL group was significantly shorter than prone position UMPCNL group (84.3 ± 9.87 vs 99.3 ± 8.75 minutes) with p = 0.022. There was no significant difference between both groups in terms of stone-free rate (89.3% vs 88.9%), overall complication rate (including transient fever; 21.4% vs 18.5%), postoperative pain (visual analog scale score; 3.4 ± 0.8 vs 3.3 ± 0.9), or hospital stay (3.53 ± 0.8 vs 4.1 ± 1.1 days). Conclusion: Both UMPCNL in FFMs and prone positions are feasible, safe, and effective in treatment of pediatric renal stones with relatively shorter operative time in FFMS position.

Single versus multiple instillation of povidone iodine and urographin in the treatment of chyluria: A prospective randomised study.

OBJECTIVE: To compare the safety, efficacy and complications of single vs multiple instillations of povidone iodine (PI) and urographin as a sclerosing agent in the treatment of chyluria. PATIENTS AND METHODS: The study included 58 patients diagnosed with chyluria between March 2006 and January 2013. The inclusion criteria were either severe attacks of chyluria or patients with mild-to-moderate chyluria who had failed conservative treatment. The patients were randomly allocated to one of two groups: those in Group A had a single instillation of a combination of PI 0.2% plus the contrast-agent urographin 76%, while those in Group B had multiple instillations of the same combination twice daily for 3 successive days. RESULTS: The mean (SD) age of the patients in Groups A and B was 38.22 (10.67) and 37.9 (10.86) years, respectively. Chyluria was severe in eight patients (14.8%), moderate in 25 (46.3%) and mild in 21 (38.9%). The success rate in Group A (single instillation) was 85.2% and in Group B (multiple instillation) was 88.9%. The recurrence rate in Group A was 14.8% with a disease-free duration (DFD) of 4-15 weeks, while in group B it was 11.1% with a DFD of 6-18 weeks. CONCLUSION: There was no significant difference between a single instillation of a combination of PI 0.2% and urographin 76% as a sclerosing agent in the treatment of chyluria and multiple instillations. However, the single instillation protocol is more cost effective with a shorter hospital stay.

Flank-free Modified Supine Percutaneous Nephrolithotomy in Pediatric Age Group.

OBJECTIVE: To evaluate the safety and efficacy of pediatric percutaneous nephrolithotomy (PCNL) in the flank-free modified supine position (FFMSP). PCNL in the supine position is increasingly and successfully used in pediatric age group. Different modifications of supine positions have been described; however, the best supine position is not well established and remains a matter of debate. PATIENTS AND METHODS: This prospective study included 22 children presenting with single renal pelvis stone (2-3 cm) in the period between May 2012 and April 2014. Diagnosis was set by plain x-ray and computed tomography in all patients. PCNL was performed with the patients placed in the FFMSP. The operative time and hospital stay were estimated. The outcome and any perioperative complications or conflicts were recorded. RESULTS: The study included 22 children (15 boys and 7 girls) with a solitary renal pelvis stone. Mean ± standard deviation age of the patients was 9.5 ± 3.2 years (range, 3-15.5 years). Stone length, operative time, and hospital stay had mean ± standard deviation of 2.4 ± 0.23 cm, 65.1 ± 18.7 minutes, and 4.4 ± 0.9 days. Stone-free rate was 90.9% after 1 session of PCNL. One patient (4.5%) needed a second-look PCNL. Shock wave lithotripsy was performed for another patient. Postoperative fever occurred in 4 patients (18.2%). One patient received postoperative blood transfusion. Postoperative transient urinoma occurred in 2 patients (9.1%). CONCLUSION: PCNL in pediatric age group via FFMSP was proved to be safe and effective in management of renal pelvis stones of size 2-3 cm. It provides stone clearance rate comparable with that reported of conventional PCNL in the prone position.

Predictors of severity and treatment response in children with monosymptomatic nocturnal enuresis receiving behavioral therapy.

OBJECTIVE: To evaluate the role of bladder volume and bladder wall thickness measurement by ultrasound in assessing severity and predicting response to behavioral therapy in children with monosymptomatic nocturnal enuresis. METHODS: 122 children (68 boys and 54 girls) aged 5-9 years underwent ultrasound evaluation of bladder volume and bladder wall thickness, followed by calculation of the bladder volume wall thickness index (BVWI). They were treated using first-line management (behavioral therapy) for 4 months. Correlation of severity and treatment response to ultrasound bladder measurements was investigated. RESULTS: Only 74 children completed the study: 16 showed complete response to treatment, 25 good response, 18 partial response, and 15 children showed no response. Age, gender and location of residence did not correlate to severity or to treatment response. Ultrasound measured bladder volume also did not correlate to either severity or response. Bladder wall thickness showed a strong correlation to both severity and response to treatment, as did BVWI. CONCLUSION: Ultrasound measured bladder wall thickness and BVWI are strongly associated with the severity of nocturnal enuresis and are highly predictive of treatment response to behavioral therapy. It is recommended that any child with monosymptomatic nocturnal enuresis should undergo an abdominal ultrasound examination before starting treatment.

Evaluation of distally folded onlay flap in repair of distal penile hypospadias.

OBJECTIVE: To evaluate the results of using a distally folded onlay flap in the repair of distal penile hypospadias, with regard to meatal stenosis, urethrocutaneous fistula and esthetic outcome. PATIENTS AND METHODS: This prospective study involved 36 patients with mean age 3.2 years (range 1-4); 18 had a shallow urethral plate, 10 a small glans, and 8 had undergone a previous operation but still had available preputial skin. All underwent the elective technique of distally folded onlay flap, which was carried out under general anesthesia using a 4× magnifying loupe. Starting with penile degloving and then harvesting the transverse island preputial flap provides a flap about 1 cm longer than the urethral plate. Two lateral incisions are made along the urethral plate with no need for dissection deep into the glanular wings. The flap is sutured to the urethral plate, leaving 1 cm distal to the tip of the glans, which is folded back to be sutured to the edges of the glanular wings. RESULTS: There were no cases of meatal stenosis or requirement for urethral dilatation. Two patients had a urethrocutaneous fistula; one closed spontaneously while the other needed surgical repair 6 months later. Regarding esthetic appearance, 32 were scored good and 4 satisfactory. CONCLUSION: This versatile technique offers satisfactory results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

Interposition of dartos flaps to prevent fistula after tubularized incised-plate repair of hypospadias.

OBJECTIVE: To evaluate the effect of urethral coverage by a single- or double-layered dorsal dartos flap after tubularized incised-plate (TIP) repair of hypospadias on fistula formation. PATIENTS AND METHODS: In this retrospective study we evaluated sequential patients with hypospadias who underwent TIP urethroplasty with a dorsal dartos interpositional flap between April 2008 and December 2009. We reviewed their medical records for the site of hypospadias, previous hypospadias repair, single- or double-layered dartos flap and postoperative complications. The patients were divided into two groups; in group A the urethra was covered by a single layer of dartos fascia, and in group B the urethra was covered by double layers of dartos flap. RESULTS: Of 91 patients who opted for hypospadias repair during the time of the study, 62 had a TIP urethroplasty with a dorsal dartos flap; of these 62, three did not fulfil the requirement of the minimum follow-up, so 59 were eligible for the study (32 in group A and 27 in group B). Preoperative clinical data were comparable in both groups. At a mean of 12.2 months of follow-up, there was no reported fistula in group B, while two patients in group A developed a urethrocutaneous fistula (P = 0.19). Meatal stenosis occurred in two patients in group A and one in group B (P = 0.66). CONCLUSION: There was no significant difference in subsequent urethrocutaneous fistula between a double-layered dorsal dartos flap and single layer for covering the urethra as a part of TIP urethroplasty for repairing hypospadias.

Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique.

OBJECTIVE: To evaluate the results of simple closure using bilateral anterior pubic osteotomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with bladder exstrophy. PATIENTS AND METHODS: A prospective study carried out between 2006 and 2009 included 15 patients (13 boys and 2 girls; age range 3-47 months). Of these patients, three had recurrent exstrophy while 10 were operated primarily. An elective surgical technique was used for all patients, which included dissection of the exstrophic bladder from the abdominal wall, closure of the bladder and reconstruction of the urethra, then dissection of the rectus muscle and sheath lateral to the attachment of muscle to pubic bone, which makes osteotomy of the superior pubic ramus easy, thus facilitating closure. RESULTS: For closure of the bladder and anterior abdominal wall the results were excellent for all patients soon after surgery, but there was soft-tissue infection in two patients. Of all 15 patients, one had incomplete bladder dehiscence and another had a vesico-cutaneous fistula; both needed surgical intervention later. CONCLUSIONS: Simple closure with anterior pubic osteotomy is a feasible and effective means to facilitate both bladder and abdominal closure for patients with bladder exstrophy. It is advantageous in being a rapid procedure, and can be completed by the paediatric urologist.

Obesity and morbid obesity are associated with a greater conversion rate to open surgery for standard but not hand assisted laparoscopic radical nephrectomy.

PURPOSE: We noted that the impact of obesity on renal laparoscopy may vary with the specific surgical approach. MATERIALS AND METHODS: Patients who underwent standard and hand assisted laparoscopic radical nephrectomy at our institution were categorized by body mass index as nonobese--body mass index less than 30, obese--30 to 39.9 and morbidly obese--40 kg/m(2) or greater. We assessed the association of intraoperative and postoperative outcomes with body mass index for standard and hand assisted laparoscopic radical nephrectomy. RESULTS: Of 350 patients who underwent standard (196) or hand assisted (154) laparoscopic radical nephrectomy 36% were obese and 12% were morbidly obese. Patients who underwent hand assisted laparoscopic radical nephrectomy had a greater body mass index, more frequent assignment of American Society of Anesthesiologists score 3 or 4 and larger masses than those who underwent standard laparoscopic radical nephrectomy. Despite this fact conversion to open surgery from hand assisted laparoscopic radical nephrectomy did not occur, while such conversion occurred in the standard laparoscopic radical nephrectomy group in 0.8% of nonobese, 3.0% of obese and 17% of morbidly obese patients (association with body mass index p = 0.003). Operative time, intraoperative and postoperative complications, and hospitalization duration did not vary with body mass index. On multivariate analysis only body mass index and not age, gender, American Society of Anesthesiologists score, prior abdominal surgery or tumor size was associated with an increasing likelihood of conversion to open surgery (p = 0.04), and only in the standard laparoscopic radical nephrectomy group. CONCLUSIONS: Although obesity and morbid obesity are associated with more frequent conversion to open surgery during standard laparoscopic radical nephrectomy, such conversion did not occur during hand assisted laparoscopic radical nephrectomy. This advantage of hand assisted laparoscopic radical nephrectomy should be considered when planning laparoscopic radical nephrectomy in obese and morbidly obese patients.