Outcome analysis of staged preputial graft technique for primary proximal hypospadias with and without post-operative vacuum physiotherapy.

PURPOSE: Management of proximal hypospadias remains challenging. We assessed the results of staged preputial graft repairs (SPG) for proximal hypospadias and hypothesize that post-operative vacuum physiotherapy (VP) improves graft suppleness and overall outcomes. MATERIALS AND METHODS: Retrospective analysis of n = 71 patients with proximal hypospadias and severe ventral penile curvature (PC) of ≥50° after degloving. PC was corrected using ventral transverse incisions of the tunica albuginea (VTITA) without applying a tourniquet, taking care to avoid injuring the underlying erectile tissue. The ventral raw area at the penile shaft, including VTITA, were covered with either divided and partially mobilized urethral plate, or with the inner preputial graft itself. During the second stage, a tunica vaginalis flap was often used to cover the tubularized neourethra. Outcomes and post-op complications were assessed after each stage, comparing patients who received vacuum physiotherapy (VP+, n = 49) with those who did not (VP-, n = 22). RESULTS: Mean PC was 66°, average follow-up duration was 13.01 months, and overall complication rate was 22.5%. Only 6 of 49 VP + patients experienced complications (12.24%; 4 fistulas; 2 urethral strictures) and no recurrence of PC after second stage was observed in this group. VP- patients displayed a significantly higher rate of complications, with 10 of 22 cases (45.45%) exhibiting fistula development (n = 5) and glans dehiscence (n = 5). Recurrence of mild PC after first-stage repair was comparable between patient groups (12% VP+, 18% VP-) and easily corrected by simple graft tubularization or dorsal plication during second-stage repair. CONCLUSIONS: Staged repair using VTITA is effective for correcting proximal hypospadias with severe chordee. VP appears to promote and expedite graft suppleness and significantly improves patient outcomes.

Functional recoverability post-pyeloplasty in children with ureteropelvic junction obstruction and poorly functioning kidneys: Systematic review.

BACKGROUND: The management of poorly functioning kidneys (PFK) associated with ureteropelvic junction obstruction (UPJO) is controversial. There is contradictory information about how to best manage these cases: pyeloplasty or nephrectomy? OBJECTIVE: To systematically summarize the available evidence concerning the effects of pyeloplasty on the differential renal function of PFK in children with unilateral UPJO, highlighting the ongoing challenges in their definition, management, and long-term follow-up. In addition, we aim to verify potential predictors of renal functional recoverability that could help clinicians choose candidates for pyeloplasty. METHODS: We searched several databases including PubMed, Embase, and Cochrane Library CENTRAL until August 20, 2021, according to the PRISMA guidelines. The following concepts were searched: pediatric, ureteropelvic junction obstruction, UPJO, pyeloplasty, recovery, split renal function, and differential renal function. We enrolled studies where the PFK was defined as preoperative differential renal function (DRF) ≤30% by renal scintigraphy. Potential predictors of renal functional recoverability were assessed and compared among studies. The quality of the included studies was evaluated using a modified version of the Newcastle-Ottawa scale (NOS). RESULTS: 1499 citations perceived as relevant to screening were retrieved. After screening, 20 studies were included, comprising a total of 625 cases. The number of patients in each study varied between 5 and 84, while the average post-surgical follow-up duration ranged between 3 months and 180 months. The most significant preoperative predictive factor for postoperative functional recoverability was the baseline DRF, especially when antenatally diagnosed. The quality was considered average in a significant portion of included studies. CONCLUSION: A significant proportion of PFK showed an increase of DRF post-pyeloplasty. However, no consistent predictive factors for functional recoverability have yet been determined apart from preoperative DRF. Until further evidence appears, pyeloplasty should be considered a valid option in the armamentarium of UPJO management in PFK.

Postoperative pain and analgesia administration in children after urological outpatient procedures.

INTRODUCTION: There are limited data about pain patterns, analgesic requirements and factors predicting opioid requirements of children undergoing outpatient urologic surgery. This prospective study aimed to assess recovery profiles and pain medication requirements. METHODS: Patients between 6 months and 12 years of age were recruited prospectively between December 2013 and June 2014. Demographic and operative characteristics were collected. Following discharge home, the parents were asked to administer both acetaminophen and ibuprofen Q6H at a weight-adjusted dose, based on a schedule, until the end of postoperative day 2, and to administer the medication as required on postoperative day 3. Pain severity was recorded using validated pain scores (Face, Legs, Activity, Cry, Consolability/Parents' Postoperative Pain Measurement). A morphine prescription was provided for breakthrough pain. A Likert scale was used to assess parent's satisfaction with the pain management. RESULTS: A total of 249 patients were recruited, 111 patients (45%) returned appropriately completed surveys and were included in the final analysis. Mean age was 44.1 months (SD = 37.3). The performed procedures were orchidopexy (31), hypospadias repair (26), hernia/hydrocele repair (15), Fowler-Stephens procedure (13), meatoplasty (7), phalloplasty (4), scrotoplasty (1), circumcision (7), and diagnostic laparoscopy (5). After discharge home 17 patients (15.3%) received morphine. Mean utilization of non-opioid analgesia was 79% on postoperative day 1, 67% on day 2, 36% on day 3, and 2% on day 4. Parental satisfaction was high (92.0% satisfied/very satisfied). No patient, anaesthetic or surgical factors were associated with opioid use or prolonged need for postoperative analgesia. CONCLUSION: The combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. There were no specific patient, anesthetic or surgical factors that predicted postoperative opioid requirements.

Laparoscopic ureteral ligation (clipping): a novel, simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties.

OBJECTIVE: A simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper. MATERIALS AND METHODS: Prospectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy. RESULTS: Median age was eight years (range 4-17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US. CONCLUSION: Laparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.

Should warm infusion solution be used for urodynamic studies in children? A prospective randomized study.

PURPOSE: We hypothesized that warm infusion solution should be used for urodynamic studies in children because it more closely simulates normal physiology. Thus, we conducted a prospective randomized study comparing consecutive room temperature (RT) and body temperature (BT) cystometrograms (CMG) in the same child. MATERIALS AND METHODS: Subjects underwent identical CMGs using RT and BT saline in random order. Maximum cystometric bladder capacity (CBC), pressure at CBC, uninhibited detrusor contractions, detrusor leak point pressure, maximum flow rate, pressure at maximum flow, maximum voiding pressure, residual urine and pressure specific volumes below 20 and 30 cm water were compared. Data were analyzed using ANOVA, t test, and chi-square. RESULTS: RT and BT CMGs in 44 males and 47 females with a mean age of 8.6 years were compared. Of the children 58 (64%) had spinal dysraphism, 8 (9%) had cerebral palsy, 5 (6%) had posterior urethral valves and 20 (21%) had recurrent urinary tract infection, daytime incontinence or frequency/urgency symptoms. Maximum CBC, pressure at CBC, and pressure specific volumes below 20 and 30 cm water were significantly lower (10% to 15%) during BT cystometry. Maximum flow rate was higher with BT saline. Detrusor leak point pressure, pressure at maximum flow, maximum voiding pressure, and residual urine did not differ. Uninhibited detrusor contractions were more frequent during RT infusions. No gender differences were found. The discrepancies between RT and BT cystometry were most prominent in infants, children with spinal dysraphism and children with large bladders. CONCLUSIONS: There is a difference between cystometries performed using RT and BT saline. Capacity, storage variables and detrusor activity are diminished during BT cystometry. Although statistically significant differences were found between consecutive RT and BT CMGs, the magnitude of the difference may not be clinically relevant to change management. As such, we do not believe it is necessary to use warm infusion solution on a systematic basis for urodynamic studies in children. However, for children younger than 2 years when the magnitude was more relevant, the use of warm solution is recommended.

What is the variability between 2 consecutive cystometries in the same child?

PURPOSE: We compared the results of 2 cystometrograms (CMGs) performed during a single session in the same child to determine the variability between consecutive cystometries. MATERIALS AND METHODS: Subjects underwent 2 consecutive bladder fillings performed at the same rate and position. Maximum cystometric bladder capacity (CBC), pressure at CBC, leak point pressure, maximum flow rate, pressure at maximum flow, maximum voiding pressure, residual urine and pressure specific volumes (PSV) less than 20, 30 and 40 cm water were compared between studies. Uninhibited detrusor contractions (UICs), defined by the previous and new International Children's Continence Society definitions of UIC, were also compared. Data were analyzed using paired t test, chi-square and interclass correlation. RESULTS: CMGs in 32 male and 34 female children were available for analysis. Mean subject age was 7.4 years (range 1 month to 18 years). Of the children 43 (65%) had spinal dysraphism, 4 (6%) had cerebral palsy, 5 (8%) had posterior urethral valves, and 14 (21%) had recurrent urinary tract infection, daytime incontinence and frequency/urgency symptoms. Maximum CBC, pressure at CBC, leak point pressure, maximum flow rate, pressure at maximum flow, maximum voiding pressure and residual urine did not differ between the 2 studies. PSVs less than 20, 30 and 40 cm water were highly correlated between the 2 CMGs (interclass correlation coefficients 0.795, 0.683 and 0.850, respectively). There were more UICs on the first than the second study (p = 0.02 and 0.03) as defined by the previous and new definitions of UIC. UIC threshold volume was less on the first CMG (p = 0.00 and 0.03). UICs were either present or absent on both studies in 56 of the 66 (85%) children by the previous UIC definition and in 51 (77%) by the new UIC definition. CONCLUSIONS: There is no difference in CBC, PSV and pressure flow parameters when performing consecutive urodynamic studies in the same child. However, UICs are more frequent on the first study. We conclude that repeat cystometry is not indicated in the absence of UICs on the first study and suggest that the second consecutive CMG be used for clinical interpretation when repeat studies are performed in the same session.