Journal of Pediatric Urology最新文献

Introduction: Catheter-associated urinary tract infections (CAUTIs) cause significant morbidity and financial strain in the pediatric intensive care unit (PICU). There is a significant incentive to reduce the rate of CAUTIs through multimodal quality improvement initiatives; however, these initiatives are often costly to implement.

Objective: This article examines the cost-savings associated with a novel "two-part, two-person" catheter insertion protocol implemented at a pediatric quaternary care center PICU which replaced costly pre-packaged, closed system urinary catheter kits with their individually packaged components, along with its impact on CAUTI rates and nursing satisfaction.

Study design: The "two-part, two-person" insertion protocol involved two nurses placing an appropriate size indwelling catheter using an individually packaged sterile insertion kit, urine meter bag, and Foley catheter. All patients with Foley catheters placed in the PICU between April 2021 and March 2022 were included in this study. Endpoints included the cost of each insertion, CAUTI rates per 1000 Foley days, and nursing satisfaction.

Results: The "two-part, two-person" insertion protocol resulted in a projected 12-month cost savings of $38 521 while CAUTI rates over this period (3.8 per 1000 Foley days) did not significantly deviate from the 6 months prior to program initiation (5.65 per 1000 Foley days, p = 0.06). This protocol garnered an approval rating of 87 % by PICU nurses.

Conclusions: Catheter expenditures can be reduced and quality standards can be maintained by eliminating costly pre-packaged, closed system urinary catheter kits in favor of their individual components. This protocol demonstrates an acceptable and sustainable intervention to improve value of care within the PICU.

Objectives: This review aims to (a) provide a concise overview of early clinical trials in bladder tissue engineering and the associated challenges, (b) evaluate significant advancements over the past 15 years in addressing key limitations in angiogenesis, scaffolding, cell sourcing, and immunomodulation, and (c) explore the individual and synergistic contributions of each domain toward the development of a viable engineered solution.

Materials and methods: Relevant papers for this narrative review were selected through a PubMed search for "bladder tissue engineering" studies published between 01/01/2009 and 12/31/2024, as well as earlier clinical trials that predate this period.

Results: Along with reviewing four major clinical trials, this review highlights nearly 20 distinct studies that showcase progress in the critical domains of angiogenesis, scaffolding, cell sourcing, and immunomodulation.

Conclusions: Are we close to developing an off-the-shelf bladder substitute? Not yet. Current efforts are focused on addressing two major knowledge gaps: (a) the lack of testing in clinically relevant disease models and (b) the need for a more comprehensive understanding of engineered tissue physiology.

Introduction: The Mirabegron-anticholinergic (MAC) combination has proven effective as a step-up strategy in managing paediatric neurogenic bladder following anticholinergic medication and botulinum toxin (BTX) therapy. This study assesses the long-term efficacy of MAC in children with neurogenic bladder.

Patients and methods: A retrospective chart review was conducted from 2015 to 2023, including consecutive paediatric patients receiving Mirabegron (25/50 mg) with an anticholinergic agent (solifenacin 16, tolterodine 7, oxybutynin 7, trospium 1). MAC was started where previous therapy had failed to control bladder pressures. The study cohort had a minimum of 2 years of videourodynamics (VUD) follow-up (2-7 years) and 3.5 years of symptomatic follow-up (2-7 years). All patients used CIC. Efficacy was determined from VUD data, symptom reports, and adverse events (AEs) with upper tract status. Statistical analysis used median values, Friedman's two-way analysis of variance by ranks and Chi-squared testing (p < 0.05).

Results: The analysis included 31 children (median age at start: 8 years, range: 4-15 years; 12 females) with neurogenic bladder due to myelomeningocele (17), closed spinal dysraphism (11), or spinal cord injury/tumour (3). A minimum of 8 weeks post-MAC therapy, significant improvements were observed in VUD parameters of: bladder capacity, compliance, and maximum detrusor pressure. These improvements were sustained at final VUD follow-up (median 33 months) in 21 patients (Summary Table). However, 9 patients who showed initial VUD improvement at median 5 months lost the effect by median 27 months, with 4 non-adherent patients and 5 with lower initial bladder compliance. Initial symptom improvement occurred in 25 patients, sustained for a median of 43 months (range: 23-85) in 19 patients. Adverse events were minimal (constipation, fatigue, and UTI reported in one patient each). No significant changes in blood pressure or upper tract status were observed.

Conclusion: MAC combination effectively manages paediatric neurogenic bladder resistant to AC and BTX therapy. The VUD benefits (present in 77.8 %) and symptom benefits (present in 61 %) are maintained and ongoing for a significant period (median 33 and 43 months respectively) when commenced before significant loss of compliance. MAC presents a promising long-term treatment option for the paediatric neurogenic bladder.

Introduction: The guidelines lack clarity on how to follow the patients after endoscopic treatment for vesicoureteral reflux (VUR). The most discussed question is the need for voiding cystourethrogram (VCUG). Risk-based approaches that consider patient characteristics, disease severity, or factors related to the surgery itself could reduce its use, but a satisfactory predictive model has not yet been established. We hypothesized surgeons can predict the treatment success evaluating the procedure and risk factors and analyzed the assessments of five experts on the subject.

Materials and methods: Clinical data of 50 patients (75 renal units) from 2015 to 2021 were analyzed. Detailed medical history (including DMSA, USG, VCUG reports, voiding symptoms, presence of febrile UTI, etc.) and video records of the procedure were evaluated blindly by five expert surgeons. Experts evaluated the injection volume, needle placement site, and mound appearance using a 5-point Likert scale. Based on these assessments, they predicted the likelihood of surgical success and if there was a high risk for obstruction (yes/no).

Results: Consistent responses among evaluators were observed for needle placement site (p < 0.001), but not for injection volume and mound appearance (p = 0.055, p = 0.077, respectively). The scores provided by all evaluators for needle placement site, injection volume, and mound appearance were consistent with their predictions for success (p < 0.001 for all). However, none of the scores given by the evaluators for the three parameters were consistent with actual success (p > 0.05 for all) and predictability for success or obstruction was low for all evaluators (p > 0.05 for all).

Conclusion: The assessment of the operation videos even accompanied with a comprehensive medical history including all known risk factors does not aid in predicting outcomes for endoscopic VUR treatment. Our study highlights the need for better criteria to recommend individualized management strategies and the insecurity of categorizing surgeries as "high-risk" or "safe" based solely on the intraoperative satisfaction.

Introduction: Bladder stones (BS) in children are a rare condition and represent 1-5 % of all urinary tract stones. With advances in miniaturized endoscopes and intracorporeal lithotripters, percutaneous cystolithotomy has been demonstrated to be an effective, safe and quick technique, despite the longer operative time. This limitation may be overcome by a semi-closed-circuit vacuum-assisted technology (vamPCL), characterized by a continuous inflow and a suction-controlled outflow (ClearPetra®).

Objectives: To assess the safety and efficacy of a vamPCL characterized by continuous inflow and suction-controlled outflow to treat bladder stones in pediatric patients with native or augmented bladder.

Study design: From January 2021 up to December 2023, we prospectively collected variables on consecutive vamPCL procedures (Fig.) The stone-free rate (SFR) was defined as absence of stones or residual fragment <5 mm diagnosed with ultrasound.

Results: Six patients with a median age of 139 months (55-212) were recruited for the study. Three patients (50 %) with the initial diagnosis of extrophy-epispadia complex had an augmented bladder, whereas of the remaining three (50 %) with an initial diagnosis of anorectal malformation two had an augmented bladder. All patients had a Mitrofanoff conduit opening on the right flank, except for one (16 %) with umbilical access. The mean cumulative stone size was 24 mm ± 14,2. The mean operating time was 78,3 min ± 14,7. One procedure was interrupted after 90 min due to the overall size (>50 mm). Stone removal was achieved only via suction in all cases. All vamPCL procedures were completed without intraoperative complications. Fever for 24 h (1/6; 16 %) was the only post-operative complication. The mean stay of the suprapubic catheter was 3.4 days ± 1,5 and of the trans-Mitrofanoff catheter was 9.3 days ± 4,5. The SFR was confirmed in all the cases with US performed after 2 months. Only one male patient (16 %) had recurrent stones after 8 months and he is waiting for second surgery. Mean follow-up was 7.2 months ± 9,4.

Discussion: In the present study we demonstrated that vamPCL is safe and feasible in selected cases especially in those with augmented bladder. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones.

Conclusions: To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. The vamPCL seems to be sustainable, safe and feasible for bladder stones treatment in selected children.

Introduction: Vital dyes lymphography during laparoscopic varicocelectomy (LV) has been suggested to allow for lymphatic mapping thereby allowing for lymphatic sparing (LS) and subsequent reduction of hydrocele formation. Intratesticular injection of the dye seems to achieve the best lymphatic visualization, however, the potential toxicity of some agents, is a cause of concern for the risk of testicular pathological changes. We report our experience with LV, to test the hypothesis that Intraoperative lymphography with methylene blue (BL), is safe and reduces the rate of post-operative hydrocelectomy. Secondary aim was to evaluate the effect of intratesticular injection of the dye.

Material and methods: Retrospective review of all consecutive patients undergoing LV < 18 years of age, between 2018 and 2022, and with at least 12-month follow-up. We compared hydrocele rate after LS-LV vs. non-LS-LV and between patients undergoing LS with vs. without BL and according to injection site. Post-operative ultrasounds were reviewed to rule out testicular anomalies in patients undergoing BL. Reoperations for varicocele were also noted.

Results: 116 patients undergoing LV at a median (range) age of 14 (10-17) years were included. Post-operative hydrocelectomy rate was significantly more common (p = 0.033) in patients undergoing non-LS (3/38, 8 %) vs. LS (0/78) LV. No hydrocelectomy was performed in patients undergoing LS-LV with (0/47) or without (0/31) BL. Vital dye injection site was intra-testicular in 21/47 (45 %) cases. Avascular intra-testicular lesions were identified in 4 (19 %) patients and persisted after a median (range) follow-up time of 21 (14-28) months. Two varicoceles were reoperated for recurrence, one in each group.

Discussion: Vital dyes lymphography improves lymphatics visualization during LV. Although, in present study, overall hydrocele rate was not significantly different in patients undergoing LS vs. non-LS procedures, hydrocelectomy was required only after non-LS procedures. In keeping with other 2 recent studies, avascular intratesticular lesions were observed in one fifth of cases undergoing Intratesticular dye injection. These lesions did not change during follow-up, but their clinical significance remains to clarify. Limitations of study include the retrospective design and the small number of patients undergoing intratesticular dye injection, but still this is one of the largest series with long-term follow-up of intratesticular lesions after BL.

Conclusions: LS-LV significantly reduced the risk of hydrocelectomy, irrespective to the use of BL. Intratesticular methylene blue injection was associated with persistent testicular lesions on follow-up ultrasounds in 19 % of cases. More studies are necessary to prove the safety of dye injections into the testis.

Introduction: The incidence of kidney stones in children has steadily increased in recent years. Miniaturized percutaneous nephrolithotomy (PCNL) techniques, such as micro-PCNL(4.85Fr) and ultramini-PCNL(<15Fr), have become increasingly prevalent in pediatric kidney stone treatment due to their high stone clearance rate and low complication rate. This study aimed to compare the efficacy and safety of micro-PCNL and ultramini-PCNL in preschool children with 10-20 mm kidney stones.

Patients and methods: A retrospective analysis was performed on data from patients under 6 years who received micro-PCNL and ultramini-PCNL surgeries in our hospital between January 2020 and January 2024. The inclusion criteria consisted of pediatric patients (<6 years) with unilateral 10-20 mm kidney stones. Patients with urinary tract malformations or comorbidities were excluded from the study. Patient demographics, stone characteristics, and intra- and postoperative parameters were analyzed.

Results: There were 33 patients in the micro-PCNL group and 31 patients in the ultramini-PCNL group, with a mean age of 3.1 ± 1.3 years and 3.6 ± 1.8 years (p = 0.208), respectively. The stone size was 15 ± 4 mm in the micro-PCNL group and 16 ± 4 mm in the ultramini-PCNL group (p = 0.326). Micro-PCNL and ultramini-PCNL groups showed comparable stone-free rates (84.8 % vs. 87.1 %, p = 0.796) and procedure times (49 ± 17 min vs. 54 ± 23 min, p = 0.218). However, a significantly shorter hospitalization period was observed in the micro-PCNL group compared with the ultramini-PCNL group (2.3 ± 1.3 days vs. 4.6 ± 2.2 days, p < 0.001). Complications were similar between groups, with 12.4 % in the micro-PCNL group and 16.1 % in the ultramini-PCNL group and no severe hematuria was observed.

Conclusions: In preschool children with 10-20 mm kidney stones, both micro-PCNL and ultramini-PCNL achieve similarly high stone-free rates with minimal complications, showing comparable outcomes in appropriately selected patients with experienced surgeons.

Introduction: Graft fibrosis following the first stage of a free graft staged hypospadias repair is a difficult scenario where the management has traditionally been to excise the graft and replace it with a new graft. However, still the risk of recurrent fibrosis remains making it difficult to proceed to the second stage and tubularising a fibrosed graft practically ensures a breakdown. Herein, we present our way of using parameatal based flip flap urethroplasty as a salvage procedure in this situation.

Patients and methods: This video is a step by step description of the parameatal based flip flap urethroplasty technique used in our center in patients who returned with graft fibrosis following first stage repair with a graft. Operative details and post-operative management in an index case are described.

Results: We have utilized this technique in 5 patients who had developed graft fibrosis after the first stage of a free graft staged repair. One patient had a small urethrocutaneous fistula which was subsequently closed. At a median follow-up of 34 months, all patients are voiding well from the glanular tip.

Conclusions: Our experiences demonstrates that Parameatal based flip flap urethroplasty can be an effective salvage technique for managing graft fibrosis following the first stage of a free graft staged hypospadias repair. This technique leverages available local tissue, even in complex scenarios where previous repairs and grafting have failed. The satisfactory outcomes in these complex cases highlight its potential as a valuable tool for pediatric urologists.

Introduction: Parental refusal of intramuscular (IM) vitamin K in newborns poses challenges, particularly for pediatric urologists assessing the safety of neonatal circumcision. Vitamin K deficiency bleeding (VKDB) is a known risk, with lack of prophylaxis increasing bleeding complications. This study evaluates the safety of neonatal circumcision without IM vitamin K, reviews guidelines, and explores alternative prophylaxis options.

Objective: To assess if neonatal circumcision can be safely performed on infants lacking IM vitamin K and to identify both optimal timing and alternative prophylactic approaches.

Methods: We conducted a literature review using PubMed and Google Scholar to gather data on neonatal circumcision and VKDB in the context of IM vitamin K refusal. Additionally, we searched for relevant guidelines from the American Urological Association (AUA), American Academy of Pediatrics (AAP), and other organizations. Our study included analysis of ten recent cases of neonatal circumcision without IM vitamin K, focusing on safety outcomes and timing.

Results: IM vitamin K is the most effective prophylaxis against VKDB, significantly reducing bleeding risk up to sixfold in neonatal circumcision. Oral vitamin K, sometimes used as an alternative in Europe, shows variable effectiveness and lacks standardization in the U.S. Newborn prothrombin (PT) levels fluctuate significantly in the first week: PT levels are high at birth, drop within 24 h, reach a nadir at 24-72 h, then rebound. Circumcisions performed at 14 days on ten patients without IM vitamin K showed no bleeding complications, suggesting that timing circumcisions after PT stabilization may be safer.

Conclusions: IM vitamin K prophylaxis should remain standard care. In cases of refusal, alternative prophylaxis and timing circumcision after the PT nadir may improve safety. This study underscores the need for updated guidelines from professional organizations, including the AUA, to address the growing trend of IM vitamin K refusal and its implications for neonatal circumcision.