Journal of Pediatric Urology最新文献

Objective: Robot-assisted surgery is now established in pediatric urology; however, data on indications and morbidity in children weighing less than 10 kg remain limited. This study evaluates the feasibility and outcomes of robotic surgery in infants.

Study design: A retrospective analysis of prospectively collected multicentric data was performed over nine years (2015-2024) including infants weighing less than 10 kg who underwent robot-assisted urological surgery. Demographic data, perioperative characteristics, and complications were collected from seven university hospitals.

Results: 83 infants were included, with a median age at surgery of 12 months (IQR: 8-16) and a median weight of 9 kg (IQR: 8-10). The main procedures were pyeloplasty (n = 37, 44 %), nephrectomy (upper pole or total, n = 20, 24 %), and adrenalectomy (n = 14, 17 %). Twenty-one procedures (25 %) were performed using a retroperitoneal approach. There were three conversions to open surgery: two during Wilms tumor surgery and one during bilateral adrenalectomy. The median hospital stay was 2 days (IQR: 1-3). Regarding 30-day morbidity, 10 infants (12 %) experienced complications (Grade II Clavien-Dindo), including febrile UTI (5 cases), stent displacement following pyeloplasty (3 cases), and transient urinary retention after bilateral ureteral reimplantation (2 cases). Additional complications observed beyond 30 days included two urinary tract infections (Grade II), one recurrence of hydrocolpos requiring reoperation (Grade IIIb), and one recurrence of ureteropelvic junction obstruction requiring reoperation (Grade IIIb). Median follow-up was 25 months (IQR: 11-66).

Conclusion: This study demonstrates that robot-assisted urological surgery is feasible and safe in infants as young as three months of age. The reduced workspace does not appear to limit this surgical approach, whether via transperitoneal or retroperitoneal approach.

Introduction: Endoscopic treatment (ET) with Dextranomer/Hyaluronic Acid (DxHA) has gained popularity as a minimally invasive option of vesicoureteral reflux (VUR). However, new-onset contralateral VUR (NCVUR) after unilateral ET remains a concern. This systematic review and meta-analysis (SR/MA) aimed to determine the incidence, severity, and clinical significance of NCVUR and explore whether prophylactic treatment of the non-refluxing contralateral ureter is warranted.

Methods: Databases including PubMed were searched for studies (2001-2024) reporting NCVUR after unilateral ET with DxHA. Inclusion criteria encompassed English-language original studies on children undergoing unilateral ET. Studies with other bulking agents, bilateral treatment, or selection bias were excluded. Risk of bias was assessed using ROBVIS 2.0, and a meta-analysis of proportions was performed using MetaXL 5.3.

Results: Seven studies (n = 1479 patients) met inclusion criteria. The pooled incidence of NCVUR was 10 % (95 % CI: 8-12 %). Heterogeneity was low to moderate (I² = 29 %). Among NCVUR cases (n = 148), 62 % were low grade (I-II), 32 % grade III, and only 6 % grade IV; no grade V cases were reported. Only 51 % of NCVUR underwent further ET. Prophylactic contralateral ET based on cystoscopic findings did not consistently reduce NCVUR incidence. Hydrodistention grading and ureteral orifice configuration failed to reliably predict NCVUR risk.

Discussion: NCVUR is a known occurrence following both open surgery and ET for unilateral VUR. While earlier studies raised concerns about the potential morbidity of NCVUR, this meta-analysis suggests that most cases are low grade and clinically insignificant. Importantly, prophylactic injection of the contralateral ureter, based on intraoperative findings, appears to offer limited benefit and may lead to overtreatment. Among patients who received prophylactic DxHA injection, the incidence of NCVUR was similar to those managed conservatively. This analysis also found no consistent preoperative or intraoperative predictors for NCVUR. Given the low clinical impact of most NCVUR and the cost implications of DxHA, routine prophylactic treatment of a non-refluxing contralateral ureter is not justified. Future research should focus on long-term outcomes and patient-centered metrics such as UTI recurrence and need for re-intervention.

Conclusions: This SR/MA found 10 % incidence of NCVUR following ET with DxHA for unilateral VUR. Most cases of NCVUR were low grade VUR. Neither pre-operative factors nor intraoperative cystoscopic assessment of the contralateral UO could predict the risk of future development of NCVUR. Currently there seems to be no role for prophylactic injection of contralateral ureters based on intraoperative cystoscopic assessment.

Background: Patients with spina bifida evaluated for possible urinary tract infection (UTI) often receive antibiotics inappropriately. One possible factor is the diagnostic value placed in a relatively low threshold for "significant" pyuria (typically >10 white blood cells [WBC] per high power field [HPF]), which is relatively common among these patients. Determination of a more optimal WBC/HPF threshold for "significant" pyuria in this population would improve the accuracy of UTI diagnosis for these patients.

Objective: To identify the association between urinary WBC/HPF and the presence symptomatic bacteriuria among children with spina bifida presenting to the emergency department (ED) and identify an optimal WBC/HPF threshold value for this association.

Study design: We retrospectively reviewed the charts of children (age <21 years) with spina bifida who presented to the ED between January 2016 and January 2020. Patients reliant on intermittent catheterization or volitional voiding/permissive incontinence and had both urinalysis and urine culture were included. The primary outcome was symptomatic bacteriuria, defined as having ≥2 urologic symptoms with >100k CFU/mL urine culture, regardless of urinalysis results. The primary exposure was pyuria, defined as >10 WBC/HPF on urinalysis. Sensitivity analysis was performed to identify an optimal threshold value of urinary WBC/HPF to identify symptomatic bacteriuria, defined as one which maximized the area under the classification receiver-operator curve (AUC).

Results: A total of 84 patients across 256 ED encounters were included. The median urinary WBC/HPF value was 40 (range 0-3607) with 68 % of patients having >10 WBC/HPF. Symptomatic bacteriuria was identified in 17 % of patients. Pyuria was associated with symptomatic bacteriuria (p = 0.019), however with poor classification AUC (0.578). On sensitivity analysis, the threshold >45 WBC/HPF maximized the classification AUC for symptomatic bacteriuria (AUC = 0.602), however this did not differ significantly from the prior threshold (p = 0.24) and would still be characterized as a poor classifier. This result was similar when patients were stratified by catheterization status.

Discussion: Limitations of this study include its retrospective nature and the definition of symptomatic UTI that was utilized, which has not been validated. The study's findings contribute to the body of literature highlighting the poor performance of pyuria with respect to UTI diagnosis in the spina bifida population.

Conclusions: Urinary WBC/HPF at any threshold performed poorly at classifying symptomatic bacteriuria among children with spina bifida presenting to the ED. The importance of pyuria for UTI diagnosis for these patients should be rethought.

Background: Ureteropelvic junction obstruction (UPJO) is an anatomical lesion in the renal collecting system and is one of the most common congenital causes of hydronephrosis, occurring in 1-5 % of pregnancies. Surgical predictive scores have been extensively studied as a promising way to assist and optimize management in cases of UPJO.

Objective: Apply the pyeloplasty predictive score and evaluate its effectiveness in patients with UPJO treated at a tertiary care hospital.

Study design: The Pyeloplasty Prediction Score (PPS) was retrospectively applied to patients diagnosed with UPJO and treated at a tertiary care hospital. The PPS is based on the Society for Fetal Urology grading system, the anteroposterior diameter of the pelvis, and the absolute percentage of the difference in renal length. The PPS ranges from 0 to 12 and is calculated by adding each of the scored variables, classifying surgical risk as low, intermediate, and high.

Results: Out of the 48 kidney units studied, 18 did not undergo surgical treatment, and 30 underwent pyeloplasty. The number of units with low, intermediate, and high non-surgical PPS was 8, 8, and 2, respectively, and surgical PPS was 1, 8, and 21. The sensitivity of the PPS was 96.67 %, and the specificity was 44.44 %. The positive predictive value was 74.36 %, and the negative predictive value was 88.89 %.

Discussion: The majority of surgical kidney units had a high score. The only patient operated on with low risk had associated vesicoureteral reflux in the same unit. Half of the non-surgical patients had a low score. The two high-risk non-surgical cases had megacalicosis as the final diagnosis.

Conclusion: PPS may aid the clinical practice of UPJO due to its high sensitivity in high and low scores, necessitating an individualized clinical and radiological assessment in intermediate-risk cases.

Introduction: This study aimed to investigate the role of advanced ultrasonographic techniques-Shear Wave Elastography (SWE) and Superb Microvascular Imaging (SMI)-in evaluating testicular parenchymal damage following surgical detorsion in patients with testicular torsion. Additionally, the study assessed the potential contribution of these modalities to clinical decision-making.

Materials and methods: Seventeen patients who underwent surgical detorsion without orchiectomy for testicular torsion between January 2015 and January 2025 were included in the study. In each case, both the detorsed and contralateral testes were evaluated. Testicular volume, SMI score, and SWE values were measured using a standardized ultrasonography protocol. Between-group comparisons were performed using the Mann-Whitney U test, and correlations between continuous variables were analyzed using Spearman's rank correlation coefficient.

Results: The mean age of the patients included in the study was 13.8 ± 3.6 years. In the majority of cases (76.5 %), the duration of torsion was less than 24 h. There were no statistically significant differences between detorsed and contralateral testes in terms of testicular volume, SWE values, or SMI scores (p > 0.05). However, in the detorsed group, testicular volume showed a strong negative correlation with SWE values (r = -0.6965, p = 0.002) and a positive correlation with SMI scores (r = 0.668, p = 0.003) (Tble 1).

Conclusion: These findings suggest that volume measurements alone may be insufficient to accurately reflect testicular function. Functional ultrasonographic modalities such as SWE and SMI may offer substantial benefits in the postoperative monitoring of detorsed testes and in predicting long-term outcomes. These advanced imaging techniques may also facilitate more objective decision-making regarding testicular preservation versus orchiectomy.