I Thought I Saw a Retrocaval Ureter; Don't Bite the Fish-Hook Sign So Easily.

Background: During the management of patients with hydronephrosis, a possibility of retrocaval ureter (RCU) may emerge indicated by a fish-hook sign or its mimickers. Owing to infrequent incidence, the proper way to diagnose or exclude an RCU is challenging and has not been discussed previously. Methods: The aim of this study was to retrospectively evaluate the children who were suspected to have an RCU during management for urinary tract dilation. An RCU may be missed or misdiagnosed owing to rare incidence. Results: The children with urinary tract dilation in whom RCU was considered are enrolled in the study (n = 13). The demographics of the patients, findings suggesting RCU, evaluation process, management, and final diagnosis are retrospectively evaluated. The final diagnosis of the patients was RCU (n = 4), ureteropelvic junction obstruction (UPJO) (n = 7), and duplicated collecting system (n = 2). An RCU was confirmed or excluded by ultrasonography (US) while there was a stent in the ureter in 6 patients and by laparoscopic exploration in the other 7 patients. Four underwent correction for RCU, 7 for UPJO, 1 for reflux, and 1 ureterocele puncture. Conclusion: The fish-hook sign is a rare conflicting radiological finding that can be encountered in imaging studies. This uncommon finding needs confirmation or exclusion of a possible RCU as missed cases manifested after failed pyeloplasty or ureteroneocystostomy were reported. Radiological evaluation (by US or cross-sectional studies) while there is a stent in the ureter is the most satisfactory radiological technique to confirm or exclude an RCU. Alternatively, being aware of a possible RCU and performing a more extensive dissection may be necessary during surgery to confirm or exclude it. If available, laparoscopy may provide this goal in a minimally invasive manner with superior visualization.

Low-Grade Injury following Testicular Torsion: A Multicenter Study Confirming a Disturbing Possibility.

INTRODUCTION: There is an ongoing debate whether to perform orchiectomy or orchidopexy following testicular torsion (TT) in cases where the testis seems non-viable. The main problem is lack of objective criteria defining testicular viability. The aim of this study was to investigate the grade of injury in orchiectomy specimens obtained from cases of TT and its association with clinical findings. METHODS: This multicenter retrospective study involved double-blinded reassessment of the patient files and the pathological specimens using Mikuz classification to analyze the relation between clinical and pathological findings. RESULTS: A total of 289 patient charts from 14 centers were reviewed and 228 were included in this study. Twenty (8.8%) patients had grade 1 injury which refers to reversible injury. The clinical findings of these 20 patients were compared to 208 patients with higher grades of injury. As expected, there was statistically significant difference regarding duration of symptoms (p < 0.001); however, range was wide in both groups (as long as 96 h for grade 1 and as short as 7 h for higher grades). There was no statistically significant difference in any other variable including age (median 14 for both, p = 0.531), symptoms (pain: 19/20 vs. 189/202, p = 0.801; swelling: 13/19 vs. 168/197, p = 0.094), absence of blood flow in Doppler US (15/19 vs. 164/197, p = 0.635), or degree of torsion (median 720° for both, p = 0.172). CONCLUSION: Our study revealed necessity for better criteria to define viability of testis following TT. Histopathological injury appeared to be reversible even in some patients with more severe perioperative findings, late admission, or high degree of twisting. Our findings support the tendency for testicular fixation instead of orchiectomy as none of the clinical or perioperative findings could be attributed to high-grade injury.

Non-hormonal Clitoromegaly due to Clitoral Priapism Caused by Appendicitis/Appendectomy

Clitoromegaly usually develops due to hyperandrogenism. There are a few cases of clitoromegaly described without clinical and biochemical hyperandrogenism. Clitoromegaly due to clitoral priapism and clitoral priapism after appendectomy have not been reported previously. A 7-year-old girl was referred for enlargement of the clitoris. She reported having a mild, pulsating clitoral pain starting three days after an appendectomy operation. Subsequently, painful swelling and an increase in the size of the clitoris was observed. Her growth and physical examination were otherwise normal. Causes of the clitoromegaly due to androgen excess were excluded after a comprehensive work-up. Color Doppler ultrasound revealed a high peak systolic velocity and resistance in the cavernosal artery, consistent with clitoral priapism. The clitoromegaly and associated symptoms improved significantly with oral pseudoephedrine and intracavernosal aspiration. This unique case illustrates that clitoral priapism is a rare, non-hormonal cause of clitoromegaly and may occur after appendectomy. Pseudoephedrine treatment is helpful in alleviating the symptoms.

Do preoperative leukocyte and neutrophil levels have a predictive value on the complications of hypospadias repair in children?

OBJECTIVE: Surgeons observed that the outcomes after the same repair technique in the same type of hypospadias performed by the same surgeon may be different. There may be some indeterminate factors that influence the results such as subclinical inflammation. Our study evaluated the predictor values of inflammatory hematologic parameters on the complications after hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the data of patients who underwent hypospadias repair between January 2016 and January 2019 in our clinic. Age at surgery, hypospadias type, repair technique, complications were recorded. Patients who underwent Snodgrass repair by a single surgeon were included in the study while patients who underwent different techniques or procedures that were performed by other surgeons were excluded. The levels of white blood cell, neutrophil, lymphocyte, platelet and monocyte, the mean platelet volumes were recorded from blood test that were performed one day before surgery. Neutrophil-lymphocyte ratio (NLR), plateletlymphocyte ratio (PLR), and other parameters were analyzed to determine their relationship with complications after hypospadias surgery. RESULTS: WBC and neutrophil levels were statistically higher in patients with complications (p = 0.006 and 0.017 respectively). Other hematological parameters were not different between patients with or without complications. To predict the complications, the WBC cutoff was 9500/mm3, the neutrophil cutoff was 3000/mm3. CONCLUSIONS: WBC and neutrophil values were statistically significant in predicting the complications after Snodgrass repair in patients with hypospadias. Our result determined no relation between complications and NLR, PLR.

Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair

Background: The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon's experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial. Aims: To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias. Study Design: Retrospective cross-sectional study. Methods: Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups. Results: The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group. Conclusion: This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.

Rare emergency in children: Priapism and stepwise treatment approach.

BACKGROUND: Priapism is a rare condition in children and the treatment algorithm is controversial in this age group. Herein, we report eight cases with low-flow priapism and our stepwise treatment approach in light of literature. METHODS: We present a simple stepwise treatment for low-flow priapism including five steps. Step 1: Cold compress and analgesia while evaluation the priapism and its etiology. Step 2: Corporal aspiration and adrenaline infusion in the ward. Step 3: Modified Winter shunt in the same place. Step 4: Ketamine application and caudal block in the operating room. Step 5: Sapheno-cavernous (Grayhack) shunt. Eight cases with low-flow priapism were reviewed retrospectively. Symptoms, duration of tumescence, the interventions, and step that provide detumescence were recorded. RESULTS: The mean age of patients was 8.5 years (1-17 y). The median time of the priapism before admission was 15 h (4-165 h). The etiological factors were sickle cell disease, hemodialysis due to chronic renal failure, and factor V Leiden mutation in three patients. Detumescence was achieved in one patient at Step 2, in two patients at Steps 3, 4, and 5, respectively. Rigidity of cavernous body was observed in one patient in long-term follow-up. CONCLUSION: Low-flow priapism is a urological emergency that may cause erectile dysfunction. Treatment options should be selected according to a protocol that prevents time loss and avoids more invasive treatment in unnecessary situations. Our algorithm with simple nature and its steps from less invasive to more invasive procedures may be an alternative for the treatment of low-flow priapism.

Complete Penile Duplication with Structurally Normal Penises: A Case Report

BACKGROUND: Diphallia is a very rare anomaly and seen once in every 5.5 million live births. True diphallia with normal penile structures is extremely rare. Surgical management for patients with complete penile duplication without any penile or urethral pathology is challenging. CASE REPORT: A 4-year-old boy presented with diphallia. Initial physical examination revealed first physical examination revealed complete penile duplication, urine flow from both penises, meconium flow from right urethra, and anal atresia. Further evaluations showed double colon and rectum, double bladder, and large recto-vesical fistula. Two cavernous bodies and one spongious body were detected in each penile body. Surgical treatment plan consisted of right total penectomy and end-to-side urethra-urethrostomy. No postoperative complications and no voiding dysfunction were detected during the 18 months follow-up. CONCLUSION: Penile duplication is a rare anomaly, which presents differently in each patient. Because of this, the treatment should be individualized and end-to-side urethra-urethrostomy may be an alternative to removing posterior urethra. This approach eliminates the risk of damaging prostate gland and sphincter.

Upper pole access is safe and effective for pediatric percutaneous nephrolithotomy.

INTRODUCTION: Upper pole access in percutaneous nephrolithotomy (PCNL) provides a straight tract to the ureter, resulting in easier placement of a guidewire to the ureter, good exposure of the pelvis, calices, and upper ureter, and comfortable manipulations. However, despite these benefits, upper pole access is usually avoided because of the risk of chest complications in both pediatric and adult patients. OBJECTIVE: We aimed to evaluate the safety and morbidity of single upper pole access in pediatric patients undergoing PCNL. STUDY DESIGN: We retrospectively reviewed patients aged ≤17 years with renal stones who underwent PCNL with a single access between August 2004 and February 2016. The patients were separated into two groups: the single upper pole access group (SUPAG) and the single other pole access group (SOPAG). We compared the SUPAG and SOPAG in terms of the demographic features of the patients, stone burden and location, operative data, and postoperative outcomes. Complications were classified according to the modified Clavien system. RESULTS: During the study period, 101 PCNL procedures were performed, 77 of which were managed with only one access. The median age of the 77 patients managed with a single access was 12 years (range 3-17 years). The number of cases in the SUPAG and SOPAG was 10 and 67, respectively. There were no statistically significant differences between the SUPAG and SOPAG in terms of age, sex, stone location, hydronephrosis status, stone area, side of kidney, and previous stone treatment or renal surgery. Furthermoret, there were no significant differences between the groups in terms of the operative parameters. Although the difference was insignificant, the median operation times in the SUPAG and SOPAG were 37 and 45 min, respectively. There was no chest complication or bleeding that required transfusion in the SUPAG. Two cases required transfusion, and one case was managed with a double pigtail catheter (double-J) placement because of prolonged extravasation in the SOPAG. The stone-free ratios were 100% and 82.1% in the SUPAG and SOPAG, respectively. CONCLUSION: Upper pole access provides similar outcomes to other (middle and lower) pole accesses, and may be performed without serious complications. These results indicate that this is a safe and effective approach of PCNL, and it presents a good alternative for removal of renal stones in pediatric patients.

A Simple, Non - Biological Model for Percutaneous Renal Access Training.

PURPOSE: Percutaneous renal puncture (PRP) is one of the most important and critical step of urology, especially while performing percutaneous nephrostomy and percutaneous nephrolithotomy (PCNL). In the learning period of this procedures, there is a need for validated, effective, economical models for such training. This study describes a simple non - biological model for learning PRP. The aim was to determine the effectivity of this model as a training and assessment tool, and to assess its cost relative to other models. MATERIALS AND METHODS: We designed a training box, made of foam and rubber with two open sides and performed radiopaque pelvicalyceal system maquettes to insert inside it. Experts in PCNL (i.e., > 100 cases) andnovices (i.e., pediatric surgeons and urologists without PCNL experience) performed percutaneous renal puncture. Novices performed a pre -test and a post - test (i.e., after 2 hour training). Data recorded were total procedure time, X - ray exposure time, and number of puncture attempts. Experts who performed PRP successfully were asked torate the model using a questionnaire. RESULTS: Five experts and 21 novices completed the study. Four experts rated the model as an "excellent" (score 5) training and assessment tool; one expert rated these as "very good" (score 4). Comparisons of novices' pre - and post - test median results revealed significant skill acquisition with shorter procedure time, less X - ray exposure, and fewer attempts for successful puncture (all P < .001). CONCLUSION: This new non - biological training model is an effective training tool that helps learners improve skills in PRP. The model is simple to construct, economical, and highly re-useable compared to others. It provides good visibility and imaging, is portable, and could be used widely in training centres.

The Association of Congenital Urethral Duplication and Double Megalourethra.

BACKGROUND: Urethral duplication and megalourethra are rare urethral anomalies. However, the concomitance of urethral duplication and double megalourethra has not been reported previously. CASE REPORT: A newborn was presented with penile swelling during voiding. Physical examination revealed a retractable foreskin and two external meatus of a double urethra. Retrograde urethrography demonstrated two complete megalourethras. Urethro-urethrostomy and urethroplasty were performed when the patient was 10 months old. The patient was followed up for one year without any urinary problems and has good cosmetics and urinary continence. CONCLUSION: The concomitance of these two rare anomalies and more importantly its surgical treatment makes this case report unique and valuable.

Excisional treatment of renal hydatid cyst mimicking renal tumor with diode laser technique: A case report.

PURPOSE: Cystic echinococcosis, which is one of the most important helminthic infestations, is a serious life-threatening health problem in developing countries. Hydatid cyst of the kidney is a rare condition in children that can be treated with medical therapy or surgical treatment in some resistant cases. Here, we present a case of renal hydatid cyst that was treated with laparoscopic excision with diode laser. PATIENTS AND METHODS: A 15-year-old female patient was admitted with abdominal pain. Abdominal ultrasonography revealed a 32 × 23 × 19-mm solid mass with cystic component at lower pole of right kidney. An indirect hemagglutination (IHA) test for echinococcosis granulosus was positive at a 1:320 titer. Other laboratory tests were within normal limits. The patient received albendazole therapy for 3 months. The follow-up magnetic resonance imaging showed a solitary lesion with exophytic extensions that contained large separations. No contrast enhancement could be detected after gadolinium injection. As no regression could be detected radiologically, surgical treatment was planned. Laparoscopic renal lower pole mass cyst excision with diode laser was performed (Figure). The patient was hospitalized for 1 day without any blood transfusion. Histopathological examination was consistent with hydatid cyst of the kidney. CONCLUSION: Diagnosis of hydatid cyst of the kidney is generally made incidentally and can be misdiagnosed as a primary kidney tumor. Radiological studies may be insufficient for accurate diagnosis. In our case, laparoscopic excision of cyst and histopathological examination confirmed the diagnosis of cyst hydatid. At the postoperative second month the ultrasonography of kidneys were normal. For patients from endemic areas, hydatid cyst should always be included in the differential diagnosis. Laparoscopic excision of renal hydatid cysts with diode laser is a feasible and safe technique for resistant cases.