Journal of Pediatric Urology最新文献

Background: The standard technique of endoscopic fulguration of posterior urethral valves (PUV) involves fulguration at 5,7 and 12o'clock, with urethral stricture being a major complication. Since the anterior portion of the valve is the point of maximal obstruction, hence we modified the technique by fulgurating only the anterior part of the valve between 10 and 2 o'clock positions. We present the results of the standard and modified techniques of PUV fulguration. We hypothesised that the modified technique might reduce the risk of urethral strictures, while achieving adequate valve ablation.

Methods: All PUV undergoing cystoscopic fulguration in our unit over a 6-year period were divided into 2 groups (group 1: standard 3-point fulguration; group 2: modified anterior fulguration). For valve fulguration, a 3F bugbee or hook electrode was used with appropriate sized compact cystoscope in all cases (6F in infants and 8/9.8F in older children). The two groups were compared for the adequacy of fulguration and urethral stricture formation during follow-up.

Results: Fifty-nine cases were included (22 group 1, 37 group 2). The mean age at fulguration was comparable between both groups. Follow-up voiding cystourethrogram and check cystoscopy revealed urethral stricture in 3 and residual valves in 4 children. The incidence of urethral stricture was significantly higher (p=0.047) in group 1 (3/22, 13.6 %) compared to group 2 (0/37, 0 %); there was no difference in the incidence of residual valves between both the groups (0/19, 0 % group 1 vs 4/37, 10.8 % group 2, p=0.288).

Discussion: We adopted a modified technique of PUV fulguration limiting diathermy application to the anterior part of PUV. There is no consensus on the best method of PUV ablation; commonly used techniques are cold knife and diathermy ablation. Incision with cold knife may cause bleeding, and may have a higher incidence of residual valves. Diathermy may predispose to more urethral strictures, especially when applied at 3 points circumferentially inside the small urethra, as in the standard technique of fulguration. Several autopsy and videocystoscopic studies, including our own observations, have documented that the valve is, in reality, a membrane with a posterior opening, the anterior part of the membrane being the major obstructing component. The results of the present study seem to be in agreement with this morphology of PUV.

Conclusions: The modified technique of only anterior PUV fulguration resulted in significantly reduced incidence of urethral strictures with no increase in residual valves compared to the standard technique.

Introduction: Urotherapy remains the first-line conservative treatment of pediatric bowel and bladder dysfunction (BBD), however, some patients show limited or no response. Early identification of patients likely to fail urotherapy alone could influence early management and outcomes. This study aimed to develop predictive models to identify pediatric patients unlikely to respond to urotherapy alone (Summary Figure).

Methods: A retrospective cohort of 123 pediatric patients aged 5-10 years diagnosed with BBD who completed a validated 18-question BBD symptomology questionnaire at their initial and follow-up visit was analyzed. Patients underwent urotherapy as the primary intervention and symptom improvement was assessed at 6 months or less through a standardized scoring system. Machine learning (ML) models, including multivariable logistic regression and random Forest classifiers, were developed to identify predictors of non-response to urotherapy. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC).

Results: 123 patients met inclusion criteria with 92 (75 %) females, and the median age was 6 years (IQR 5, 8). The median time from the initial to the next follow-up visit was 3 months (IQR 1, 4). Overall, 26 (21 %) patients had complete improvement, 28 (23 %) had moderate improvement, 23 (19 %) patients had minimal improvement (19 %), and 46 (38 %) had no improvement. Older age (OR 1.45, 95 % CI 1.09, 1.98; p = 0.01) and presence of dysuria (OR 1.54, 95 % CI 1.06, 2.37; p = 0.03) at initial visit were associated with an increased likelihood of response to urotherapy, whereas the presence of daytime incontinence (OR 0.67, 95 % CI 0.46, 0.97; p = 0.04) was associated with a lower likelihood of response. The logistic regression model achieved an AUROC of 0.67, while the random Forest model slightly outperformed it with an AUROC of 0.71.

Conclusion: ML models using demographic and standardized questionnaire data predicted non-response to urotherapy in pediatric BBD patients. Age, dysuria, and daytime incontinence were identified as significant predictors. Early identification of potential non-responders could permit clinicians to implement additional therapeutic strategies sooner, improving overall patient care and outcomes.

Introduction and objective: Lower urinary tract symptoms (LUTS) are common in children with cerebral palsy (CP). Increased severity of functional impairment and impairments in trunk-related structures may be associated with increased severity of LUTS. The aim of our study was to examine the distribution of LUTS in children with mild to moderate spastic type CP and to investigate the relationship between LUTS severity and functional level, trunk control, trunk muscle strength and endurance, respiratory functions and rib cage mobility.

Methods: Fifty-three children with spastic CP with Gross Motor Functional Classification System (GMFCS) levels I-II and III were included in the study. LUTS was assessed using Dysfunctional Voiding and Incontinence Scoring System (DVISS); functional levels were assessed using GMFCS; and trunk control was assessed using Trunk Control Measurement Scale (TCMS). Transversus Abdominis (TrA) muscle strength was measured with Stabilizer Compression Biofeedback Unit; trunk muscle strength was measured with Sit-ups and Modified Push-up test; trunk muscle endurance was measured with McGill's trunk flexion, trunk extension, lateral bridge tests and prone bridge test. Pulmonary function was assessed by Contec SP10 Spirometer and chest mobility was assessed by chest circumference measurement.

Results: There was statistically significant difference between GMFCS level I and level III mean DVISS scores (p = 0.002). There was moderate negative correlation between DVISS and TCMS score (p = 0.002; r = -0.416), moderate positive correlation between TrA muscle strength (p = 0.001; r = 0.482), modified push-up test (p = 0.025; r = -0.308), trunk extension test (p = 0.021; r = -0.316), prone bridge test (p = 0.008; r = -0.362), FEV1/FVC (p = 0.020; r = -0.320), FEV1 (p = 0.005; r = -0.384), PEF (p = 0.007; r = -0.367).

Conclusion: This study shows that LUTS is common in children with mild to moderate spastic CP and that the severity of these symptoms increases significantly as the severity of functional impairment increases. In addition, it was determined that the decrease in trunk control, trunk muscle strength and endurance, respiratory functions and chest mobility were associated with an increase in LUTS. These findings suggest that isolated pelvic floor training alone may not be sufficient to improve lower urinary tract health in children with CP, but instead, a holistic rehabilitation approach that supports motor function, trunk stability and respiratory capacity should be adopted.

Introduction: Prenatal bladder rupture is a rare condition. The lack of data and coverage in textbooks presents significant challenges for its diagnosis and management.

Objective: This study aims to offer recommendations to assist clinicians dealing with this condition.

Study design: A systematic review was conducted by searching PubMed, Embase, and Science Direct databases, following PRISMA guidelines and using the JBI checklist. Search terms included "prenatal" or "fetal" "bladder rupture," "prenatal" or "fetal" "urinary ascites" as well as "bladder rupture and opioids". The search identified 2156 publications, which were screened; 27 were eligible for inclusion, allowing for a total of 28 cases to be analyzed.

Discussion: Although the data quality and reporting were heterogeneous, several key findings emerged: Prenatal bladder rupture is associated with lower urinary tract obstruction and has also been reported in cases involving maternal opioid use. Defects vary significantly and may resolve prenatally. At birth, some infants required extensive life support and immediate ascites drainage while others are asymptomatic. Postnatally, conservative management with drainage of the bladder, preferably via a transurethral catheter, and ascites management will likely lead to a spontaneous closure of the defect. If conservative management fails, surgical closure may be achieved via laparotomy or laparoscopy. Outcomes were generally reported to be favorable, though follow-up data were often insufficient.

Conclusion: The review highlights the variability in management of prenatal bladder rupture, emphasizing the need for multidisciplinary decision-making and further research to establish evidence-based guidelines.

Purpose: Historically, gonadectomy was uniformly recommended for patients with Androgen Insensitivity Syndrome (AIS) due to the perceived malignancy risk. However, this practice has been questioned given the benefits of hormone production, low prepubertal tumor risk, and unclear long-term malignancy risk. An ideal screening strategy would detect premalignant/malignant changes at an early stage and improve the safety of leaving gonads in situ. This review summarizes existing screening protocols and the evidence supporting their effectiveness.

Methods: A systematic review was conducted per PRISMA-P guidelines to examine malignancy screening in AIS. We searched PubMed, CINAHL, Web of Science, Cochrane, Scopus, Google Scholar, BioRxiv, and MedRxiv using terms related to AIS, gonadal tumors, and screening. We abstracted data from included studies focusing on three major questions: 1. What modality/frequency for screening recommendations are mentioned for AIS patients, 2. What evidence is there for the sensitivity and/or specificity of imaging, and 3. What evidence is there for the effectiveness of any screening protocol to detect neoplasia?

Results: After reviewing 538 studies, 28 met the inclusion criteria. Most recommendations were based on expert opinion. Modalities included biopsy (recommended in 14 studies), physical exams (8 studies), serum tumor markers (4 studies), ultrasound (14 studies), and MRI (6 studies). Biopsy and ultrasound were the most frequently cited, though protocols varied. Only 3 studies had indirect data regarding screening modality effectiveness, and imaging prior to gonadectomy showed limitations in identifying pre-malignant lesions. Three cohort studies included screening protocols but lacked consistency or strong evidence supporting specific strategies.

Conclusions: There is a lack of standardized screening strategies for detecting malignancy in patients with Androgen Insensitivity Syndrome. Current screening methods have limitations and are mostly based on expert opinion rather than clinical evidence. No method has proven effective, and the variability in protocols reflects the uncertainty. Patients retaining their gonads should be informed of the potential risks, as there is limited evidence supporting existing screening strategies.