Journal of Pediatric Urology最新文献

Introduction and study objective: Hysterosalpingography (HSG) is the standard imaging modality for diagnosing Müllerian structural abnormalities. However, its utility is limited in cases of complete obstruction of the Müllerian ducts. Ultrasonography and MRI often fall short in pinpointing the obstruction's location and extent, which can be critical for surgical planning. This report introduces antegrade genitography as a novel diagnostic approach for congenital obstructive Müllerian malformations, highlighting its potential to enhance diagnostic accuracy and guide patient management.

Methods: This retrospective case series describes three patients with Müllerian obstructive malformations. Using laparoscopic guidance, fluoroscopy, and ultrasound, we performed percutaneous puncture of the uterine cavity and contrast injection into it, followed by X-ray imaging to assess the obstruction's characteristics and location.

Results: Two adolescents (17 and 19 years) with primary amenorrhea and a newborn with oligohydramnios and urinary retention were included. In the two adolescent patients, antegrade genitography confirmed cervical agenesis by showing no contrast progression from the uterus to the cervical canal or vagina. The newborn was diagnosed with a high urogenital sinus and obstructed stenotic distal vaginal insertion into the bladder trigone.

Conclusions: antegrade genitography proves to be a valuable diagnostic tool for patients with complete Müllerian obstructive malformations. We advocate its integration into clinical practice, emphasizing collaboration among urologists, gynecologists, and radiologists to optimize the management of patients with complex Müllerian malformations.

Introduction: Cryptorchidism, occurring in 2-4 % of male newborns, necessitates orchidopexy to mitigate associated risks, preferably between ages 3-12 months. While unilateral cases are common, bilateral intra-abdominal testes (BIAT) present unique challenges. This study reviews outcomes following bilateral Fowler-Stephens orchidopexy (FSO) at a paediatric surgical tertiary centre, aiming to enhance preoperative counselling and contribute to management consensus.

Methods: A retrospective analysis was conducted at a tertiary paediatric centre, identifying BIAT cases between 2005 and 2021. Clinical records of patients undergoing bilateral staged orchidopexy were reviewed. Primary endpoints included testicular size and position, with secondary outcomes examining staged versus non-staged procedures.

Results: We identified thirty patients who underwent Fowler-Stephens orchidopexy (FSO) for bilateral intra-abdominal testes (BIATs) between 2005 and 2021. The procedures were performed using both open surgery (n = 6) and laparoscopic techniques (n = 24), based on consultant preference. Among these patients, three underwent single-stage procedures, with 2 out of 3 having both sides operated on the same day. For the remaining twenty-seven patients, staged procedures were performed. In 22 out of 27 cases, the first stages were conducted bilaterally during the same operation. The second stages were performed synchronously in 3 out of 27 patients and on a metachronous basis in 24 out of 27 patients. The mean age at the time of the first procedure was 1.7 years, ranging from 3 months to 10 years. Outcomes revealed a success rate of 82 %, with 14 % atrophy and 3.5 % ascent rates. Comorbidities were noted in 50 % of patients, and only eight boys underwent endocrine evaluation.

Conclusion: Management of BIATs requires tailored approaches, with staged FSO offering favourable outcomes. Further research is needed to establish consensus guidelines for optimal management strategies.

Introduction: Uroflowmetry is useful in the evaluation of patients with suspected lower urinary tract dysfunction (LUTD). The pattern may serve as a guide to a specific condition, so it is critical to interpret it accurately and consistently. There are various definitions for staccato patterns, but they are primarily descriptive and result in low inter-observer reliability. Some authors stated that a staccato pattern must include a specific amount of "deep drops," "notches," "peaks," and "fluctuations." However, our observations show that these features are common even in uroflowmetry curves of healthy individuals.

Objective: To propose comprehensive criteria for defining "deep drop (DD)", assess the incidence of DD in uroflowmetry curves of healthy children and adolescents, and to evaluate the inter-rater agreement for this new definition.

Materials and methods: This study defines DD as a "sudden decrease of flow ≥√Qmax followed by a rebound of flow ≥2 ml/s". 1787 participants, aged 5-18 years, took 3158 uroflowmetry measurements. Uroflowmetry with artefacts (n = 466) as illustrated in the Supplementary Figure and low voided volume (VV) (n = 1425) were excluded.

Results: Of the 1267 uroflowmetry curves included in the analysis, 16.0 %, 7.4 % and 7.3 % had one, two, and ≥three DDs, respectively. The incidence of any DD increased from 26.1 % at VV 50-75 ml of estimated bladder capacity (EBC) to 51.2 % at VV >150 % of EBC (see Supplementary Table). Excluding uroflowmetry with large voided volume (LVV), the incidence of deep drops decreased to 15.7 %, 6.7 %, and 5.2 % for one, two, and three deep drops, respectively. Among 261 participants with two uroflowmetry measurements, 53.3 % had no DD on both occasions, while 4.6 % and 1.5 % had ≥ two and ≥three DDs on both occasions, respectively.

Conclusion: DDs are common in the uroflowmetry of healthy subjects, but ≥2 DDs are uncommon. Based on these findings, the occurrence of ≥2 DDs on uroflowmetry, particularly if observed repeatedly, may warrant further evaluation for possible LUTD. Further research is needed to determine the validity of the DD definition and number of DD required to define the staccato pattern by correlating the urodynamic findings of patients with DD.

Introduction: A catheterisable continent channel (CCC) is indicated in the treatment of neurogenic bladder. The most performed CCC is the Mitrofanoff's appendicovesicostomy. In case of unavailable cecal appendix, a Monti's ileovesicostomy, consisting in a tubularised ileal conduit, could be performed. This intervention benefits from the ergonomic advantages of robot-assisted laparoscopy.

Objective: We describe a case of a 25-year woman affected by neurogenic bladder consequent to a spina bifida.

Materials: A previous Mitrofanoff CCC failed due to ischemia of the conduit. The bladder voiding was managed by urethral self-catheterization and button cystostomy for several years. A spiral Monti CCC was planned. The intervention was performed by robot-assisted laparoscopic approach. Four robotic 8-mm robotic trocars and one 5-mm trocar were inserted in the umbilic, in both flanks and left hypochondrium respectively. A bowel segment was isolated and spirally shaped to obtain a sufficient length for the CCC.

Results: The length of surgery was 360 min, including docking time. The patient was discharged after two days. At 9-month follow-up, the channel is continent and catheterisable by a 16 Fr tube. No further episodes of UTIs or other complications were reported.

Conclusion: A complete intracorporeal approach was achieved thanks to the robotic platform.

Background: Hypospadias is one of the most common congenital anomalies observed in childhood and treated surgically. This study was designed to compare the postoperative analgesic efficacy of caudal block with sacral ESP block in children following hypospadias surgery.

Methods: This study was designed as a single-center, prospective, randomized, controlled, double-blinded study. A total of 68 male patients were included in the study, and they were divided into two groups: one with sacral ESP (Group ESP) and the other with caudal block (Group C), each group consisting of 34 patients. FLACC (Face, Legs, Activity, Cry, Consolability) scores of all patients were observed and recorded during the first 24 h postoperatively. FLACC scores were recorded at 5 min, 30 min, and 1, 2, 4, 6, 12, and 24 h postoperatively.

Results: The duration of analgesia in Group C (9.7 ± 2.8 h) was statistically significantly longer than in Group ESP (6.3 ± 1.6 h) (p < 0.001). FLACC scores in Group C (2.2 ± 0.5, 2.6 ± 0.6, 3.5 ± 1.5) were statistically significantly lower at 4 and 6 h and statistically significantly higher at 12 h postoperatively than those of Group ESP (2.7 ± 0.7, 4.1 ± 2, 2.7 ± 0.9) (p < 0.001). Group ESP (2.2 ± 0.4) mean FLACC value was found to be statistically significantly higher than that of Group C (1.9 ± 0.3) (p = 0.001). Patient relatives' satisfaction rate in Group C was statistically significantly higher than in Group ESP (p = 0.001).

Conclusion: In the present study, we found that caudal block resulted in a longer duration of postoperative analgesia and lower FLACC scores than ESP block in pediatric patients who underwent hypospadias surgery.

Background: Use of living donors for kidney transplantation in pediatric recipients provides optimal long-term graft and patient survival; however, it accounts for only 28.5 % of transplants performed in the United States in 2021. Robotic-assisted living donor nephrectomy is shown to be a safe and feasible option, offering enhanced visualization and improved surgical dexterity, allowing for a potential increase in the living donor pool for pediatric kidney transplant recipients, even in cases of grafts with anatomical variants.

Methods: We reviewed all pediatric patients (≤18 years of age) that received an open kidney transplant with a robotically procured living donor graft at our institution between October 2022 and July 2023. Recipient and living donor demographics, peri- and post-operative data, and graft characteristics were obtained and analyzed.

Results: Eight pediatric recipients were evaluated. Mean recipient age was 11 years, and seven recipients were male. Four kidney grafts required back-table reconstruction: three underwent vascular reconstruction (two requiring deceased donor vascular grafts as extensions of renal veins; one requiring conjoining of two renal arteries), and one underwent cyst removal. Mean cold and warm ischemia time were 73 and 29 min, respectively. There were no cases of delayed graft function or post-operative vascular or urological complications. Mean serum creatinine value at 1, 3, 6, and 12 months post-transplant was 0.785 mg/dL (N = 8), 0.808 mg/dL (N = 8), 0.818 mg/dL (N = 8) and 0.9 mg/dL (N = 3), respectively.

Conclusion: Our study shows that robotically procured living donor kidney grafts, even with anatomical variants, are a safe and feasible source for pediatric kidney transplantation. Utilization of grafts with vascular abnormalities for transplantation after vascular reconstruction does not appear to increase the risk of developing complications and therefore, can increase the donor pool for pediatric transplant candidates.