Introduction of Pediatric Robot-Assisted Pyeloplasty in A Low-Volume Centre

(1) Background: This study investigated the introduction of pediatric robot-assisted pyeloplasty in a low-volume centre with reference to open pyeloplasty with regards to operative times, length of stay (LOS) and outcomes and cost analysis. (2) Methods: Data from 10 consecutive robot-assisted pyeloplasties was compared retrospectively to an age and weight matched cohort of open pyeloplasties operated on during two previous years. Operative times were analyzed in conjunction with LOS, outcomes and cost-analysis from patient records. (3) Results: Operative times remain longer in robot-assisted pyeloplasties (168 (IQR 68) vs. 141 (IQR 51) min), but patients are discharged from the hospital earlier and may return to daily activities earlier. In our hospital, the difference in LOS levels to some degree the cost difference between operations. (4) Conclusions: Robot-assisted pyeloplasty can be safely and economically introduced and maintained in a low-volume centre.Peer reviewe

Does intraoperative success predict outcome in the treatment of urethral sphincter insufficiency with bulking agent?

Introduction Sphincter insufficiency is mostly associated with neurogenic and some structural abnormalities in the pediatric population. As a mini-invasive treatment, urethral bulking agents have been used to treat this problem. Objective The aim was to evaluate if technical success, defined as intraoperative increase in abdominal leak point pressure (ALPP), predicts the outcome of the treatment of sphincter insufficiency with urethral bulking agent. Study design We reviewed all children treated first time with dextranomer/hyaluronicacid (Dx/HA) copolymer (Deflux) for urethral sphincter insufficiency and who intraoperatively had ALPPs measured during 2004-2014. Patient characteristics, change in urinary continence and the duration of the possible response were evaluated in neurogenic and non-neurogenic cases. Results The median age of the patients was 7.8 years (range 4.1-14.5) at initial treatment and median volume of Dx/HA instilled was 3.5 mL (IQR 2-5). Twelve patients had neurogenic disease and 15 had nonneurogenic disease. Median ALPPs before and after the injections were 19 cmH(2)O (IQR 14-28) and 70 cmH(2)O (IQR 48-80), p <0.001. Increases in ALPPs were similar in both patient groups (p = 0.661) and in 17 patients with any response and 10 patients with no response (p = 0.267). In patients with any response the median duration of the response was only 0.8 years (IQR 0.09-2.0). During a median follow-up of 4.9 years (range 1.7-11.8), 15 patients received one to three repeat injections and eight patients went through sling or bladder neck operation (Summary table). During repeat injections, the preoperative ALPPs had returned injections, the preoperative ALPPs had returned to the original levels. Currently, 20% are continent or almost continent with one or more Dx/HA injections. In half of the patients with neurogenic bladder, compliance or volume deteriorated slightly in follow-up. Five out of 15 patients who reached puberty become continent spontaneously after failed bladder neck injection. Discussion Intraoperative ALPPs increased significantly in most patients during the procedure. However, only 52% of the patients experienced more than 1 month of success after the procedure, and even in those the effect lasted mostly under a year. With one to four injections one-fifth seem to have had a good longterm result. Although the long-term success rate is limited, bulking agent injection allowed the patients with spontaneous voiding to continue it and the injection did not prevent future treatments. Conclusion Intraoperative increased ALPP does not predict a good long-term outcome after Dx/HA injection. At the end, only a fifth of our patients had good result with one or more Dx/HA injections. A change in bladder behavior is possible after treatment.Peer reviewe

Evaluation of effect of preoperative chemotherapy on Wilms' tumor histopathology

Purpose: To evaluate usefulness of cutting needle biopsy (CNB) to recognize pediatric renal tumors and to predict the evolution of histology during preoperative chemotherapy of Wilms tumors. Methods: Ninety pediatric patients were operated for renal tumors at our institution in 1988-2015. We included all 64 patients who had undergone CNB at diagnosis and whose CNB and nephrectomy samples were available for re-evaluation. Results: The CNB was diagnostic in all 59 Wilms tumors but only in two out of live non-Wilms tumors. Anaplasia was missed by CNB in one of three with diffuse anaplasia in nephrectomy specimens. In Wilms tumors the proportions of the blastemal, stromal and epithelial components were 55% (IQR 25-85), 28% (IQR 10-58) and 2% (IQR 0-10) in CNB samples and 5% (IQR 0-64), 15% (IQR 0-50) and 15% (IQR 0-44) in the nephrectomy specimens (p-values 0.002,0.599 and 0.005 respectively). The degree of tumor necrosis was in median 80% (IQR 21-97), after preoperative chemotherapy. The degree of tumor necrosis after chemotherapy had a positive correlation with the proportion of blastemal component (p = 0.008) and a negative correlation with proportion of epithelial component in pre-chemotherapy CNB samples (p <0.001). Conclusions: Wilms tumors are usually recognizable unlike non-Wilms tumors in CNB at diagnosis. In Wilms tumors, high blastemal cell content is associated with significant tumor necrosis during pre-operative chemotherapy. Our results do not support routine use of CNB in diagnosis of renal tumors. Type of study: Retrospective review. (C) 2017 Elsevier Inc. All rights reserved.Peer reviewe

Effect of Wilms tumor histology on response to neoadjuvant chemotherapy

Purpose: To evaluate the association between Wilms tumor histology at diagnosis and the change in Wilms' tumor volume during preoperative chemotherapy. Methods: We included all the 52 patients operated for Wilms tumor at 1988-2015, who had both pathology samples and either CT or MRI-images before and after preoperative chemotherapy, available for reevaluation. Results: The median tumor volume was 586 ml (IQR 323-903) at diagnosis. The median change in tumor volume was -68% (IQR -85 to -40, p <0.001) and the proportion of tumor necrosis 85% (IQR 24-97), after preoperative chemotherapy. There was a correlation between blastemal cell content in prechemotherapy cutting needle biopsy (CNB) sample and the reduction in tumor volume (Rho = -0.452, p = 0.002). High stromal and epithelial cell contents in CNB samples were associated with the lesser change in tumor volume (Rho = 0.279, p = 0.053 and Rho = 0.300, p = 0.038 respectively). Reduction of tumor volume and the proportion of tumor necrosis after chemotherapy were associated (Rho = -0.502, p <0.001). The actual viable tumor volume decreased in median by 97% (IQR 65-100), and the decrease could be seen in all cellular components. In three patients, the tumor volume increased more than 10% during the preoperative chemotherapy. Two of them had anaplastic tumor in the nephrectomy specimen. Conclusion: Wilms tumor total and viable tumor volumes were reduced by 68% and 97% with preoperative chemotherapy, respectively. High proportion of blastemal cells in CNB was associated with greatest decrease in Wilms tumor volume. Increase in tumor volume during preoperative chemotherapy may indicate anaplastic tumor and prolonging of preoperative therapy should be avoided. Type of study: Retrospective review. (C) 2018 Elsevier Inc. All rights reserved.Peer reviewe

Incidence of urinary tract infections in infants with antenatally diagnosed hydronephrosis-A retrospective single center study

Objective: To evaluate the incidence of urinary tract infections (UTIs) in infants with antenatal hydronephrosis (AHN). Materials and Methods: A cohort of AHN patients admitted to our institution between 2003 and 2013 were identified. Altogether 192 patients with nonrefluxing hydronephrosis (HN, n = 135), nonrefluxing hydroureteronephrosis (HUN, n = 21), or vesicoureteral reflux (VUR, n = 36) were identified. Patients with complex anomalies or neonatal decompression of the urinary tract were excluded. Information about UTIs diagnosed among the AHN patients was collected and compared with data from 58 controls. Results: During the median follow-up time of 2.6 (0.3-11.2) years, 24 (13%) patients (15 (10%) males and 9 (19%) females) and 2 (3%) controls experienced at least one UTI (p = 0.033). Eighteen (69%) UTIs were febrile. The males had the first UTI at significantly younger age than the females (0.3, 0.0-1.7 years vs. 1.0, 0.4-4.8 years, p = 0.010). UTI was detected in 15 (63%) patients with grade 4-5 VUR, in 8 (6%) patients with HN, and in one (5%) patient with HUN (p-values 0.999 against the controls). None of the patients with grade = 3 VUR had UTI. Fifty-eight percent of the patients with UTI were on antimicrobial prophylaxis. In five (12%) cases UTI appeared within one week after voiding cystourethrography (VCUG). Conclusions: Infants with AHN and grade 4-5 VUR had the highest risk of UTI. UTIs tented to be more common in females than in males; however, males experienced UTI at younger age than females. VCUG caused UTI in 2.3% in our material. (C) 2017 Elsevier Inc. All rights reserved.Peer reviewe

Prenatal complicated duplex collecting system and ureterocele-Important risk factors for urinary tract infection

Purpose: To evaluate the risk of urinary tract infections (UTIs) in infants with prenatally detected complicated duplex collecting system (CDS) or ureterocele. Materials and methods: All patients with prenatally detected CDS (n= 34) or single system ureterocele (n= 7) who were admitted to our institution between 2003 and 2013 were enrolled in this retrospective analysis. Duplex collecting systems with ureterocele (n = 13), vesicoureteral reflux (VUR) (n = 20) or nonrefluxing megaureter without ureterocele (n = 7) were determined as complicated. Twenty-six (63%) patients were females. The prevalence of UTI was compared to 66 controls. Results: The median follow-up time was 5.5 (1.7-12.2) years. Eighteen (44%) patients and 3 (5%) controls had at least one UTI (p <0.001) at themedian age of 0.8 and 0.4 years, respectively (p= 0.481). Fifty-seven percent of the UTIs were breakthrough infections and 82% of those were non-Escherichia coli infections. UTIs occurred prior to any surgical intervention in 4/13 (31%) patients with ureterocele, in 2/14 (14%) patientswith VUR, in 4/7 (57%) patients with both ureterocele and VUR, and in 3/7 (43%) patientswith nonrefluxingmegaureterwithout VUR or ureterocele (p-values 0.012, 0.209, 0.001 and 0.010, respectively, compared to controls). Postoperative UTIswere observed in 29% of the girls and in none of the 11 boys (p = 0.072). The incidence of UTI after perforation of ureterocele was only 14%. Conclusions: Children with prenatally detected ureterocele or duplex collecting system associated with nonrefluxing megaureter are at high risk of UTI despite prophylactic antibiotics. In case of prenatally detected ureterocele we suggest to consider early endoscopic perforation. Level of evidence: III. (c) 2017 Elsevier Inc. All rights reserved.Peer reviewe

Development of Late Continence in Bladder Exstrophy and Epispadias Patients

OBJECTIVE To evaluate to what extend urinary continence develops during puberty in patients with classic bladder exstrophy (CBE) and epispadias. METHODS The operative database was reviewed for surgical procedures and urinary continence in all 65 CBE and epispadias patients born in 1976-2005. Excluded were 2 patients who had insufficient data for evaluation. RESULTS Thirty-five patients with volitional voiding were incontinent at the age of 10 years, 27 had daily incontinence, and 8 had rare incontinence. Sixteen patients (46%) became later fully continent without any major surgery (except Deflux injections in 3 patients) or CIC treatment. Among these 16 fully continent patients there were 7/8 with rare incontinence, 9/23 with daily incontinence (P = .04); 3/9 males with CBE, 10/13 males with epispadias, 3/5 females with CBE, and 0/4 females with epispadias (P = .25 between sex and P =.48 between diagnosis). Of the 15 patients remaining incontinent, 10 had daily and 5 had rare incontinence episodes. The latest control was at the median age of 19 years (interquartile range 17-21 years). Twenty-five patients (40% of the whole material) were fully continent (11/38 (29%) with CBE and 14/25 (56%) with epispadias, P =.04) and 8 (13%) had rare incontinence with volitional voiding (1/38 [3%] with CBE and 7/25 [28%] with epispadias). CONCLUSION Almost half of the incontinent CBE and epispadias patients with volitional voiding achieved continence after the age of 10 without major surgery. Prognosis for pubertal development of continence was best in patients with rare incontinence and in males with epispadias. UROLOGY 144: 194-197, 2020. (c) 2020 Elsevier Inc.Peer reviewe

Effect of Pediatric Testicular Torsion on Testicular Function in the Short Term

Purpose: To evaluate short-term testicular outcome after torsion in children. Methods: Fifty-four children and adolescents were evaluated after 6 months of the operation for testicular torsion. Testicular volume was measured and circulating Inhibin B, FSH, LH and testosterone levels were checked. Results: Delay from the onset of symptoms to surgery was shorter in the orchidopexy group (n = 47), than in the orchiectomy group (n = 7, p = 0.001). In the orchidopexy group, the median volume of the affected testis was 83% (IQR 43-104) of the contralateral testis (p = 0.002). The plasma hormone levels in orchidopexy and orchiectomy groups were: 148 ng/l (IQR 108-208) vs. 129 ng/l (IQR, 123-138, p = 0.269) for Inhibin B; 4.5 IU/L (IQR2.6-6.9) vs. 11.7 IU/L (IQR 4.3-12.8, p = 0.037) for FSH; 2.9 IU/L (IQR 1.3-3.7) vs. 4.8 (IQR 3.0-5.6, p = 0.066) for LH; and 13.6 nM(IQR 6.5-18.0) vs. 14.5 nM(IQR 6.7-15.9, p = 0.834) for testosterone. The association between FSH, LH as well as testosterone levels was most clear with the volume of the contralateral testis (Rho = 0.574, p <0.001, Rho = 0.621, p = 0.001 and Rho 0.718, p <0.001 respectively). Conclusions: Testicular function is mainly dependent on the volume of contralateral testicle after testicular torsion. However, testis preserving surgery tends to maintain better function than orchiectomy. Type of study: Retrospective review. (c) 2019 Elsevier Inc. All rights reserved.Peer reviewe