Journal of Pediatric Urology最新文献

Introduction: Ureteroscopy (URS) for urolithiasis in pediatric patients may be particularly challenging for patients with co-morbidities that increase the risk for stone formation and recurrence. Patients with neurogenic bladders (NGB) and/or patients that are non-ambulatory are reported to have higher rates of additional comorbidities and a particularly increased risk of developing urolithiasis, and higher rates of infections and post-operative complications.

Objective: To report outcomes of URS for stone disease in pediatric patients with NGB and/or non-ambulatory status and compare these outcomes to patients without these co-morbidities.

Methods: An IRB-approved prospective single institutional registry was used to retrospectively identify all patients under 18 years of age who underwent URS for stone disease between July 2012 and July 2021, excluding bladder stones. Patients were categorized in two groups: patient with NGB with or without non-ambulatory status versus all other patients (control). Baseline demographics, pre-operative radiologic imaging, intra-operative details, and post-operative outcomes including 30-day complications were aggregated and compared between the two groups.

Results: 275 URS in 198 patients were performed during the study period, and 49 (18 %) of these were performed on patients with NGB. Pre-operative imaging showed significantly higher number of stones (3 vs 2, p = 0.003) and larger total stone burden in patients with NGB than those without NGB (15 mm vs 9 mm, p = 0.009). Patients with NGB had a significantly longer length of procedure (86 vs 60 min, p = 0.002), increased need for staged procedures, increased length of stay (1 vs 0 days, p < 0.001), and increased use of an extended duration of antibiotics prior to the procedure (<0.001). There was no difference in need for passive dilation, stent placement, or other intra-operative parameters. There was no statistical difference in the incidence of 30-day complications between the two groups post-operatively. However, there was a higher incidence of febrile UTIs (8.2 % vs 1.3 %, p = 0.021) in patients with NGB and a lower incidence of pain related complications (0 % vs 9.3 %, p = 0.032). Patients with NGB had a higher incidence of requiring ipsilateral URS for recurrent stone disease within a year of surgery (34.6 % vs 18.9 %, p = 0.01).

Conclusion: The results show that URS for urolithiasis can be done safely and effectively in pediatric patients with neurogenic bladders. The increased risk of infectious complications within 30 days of surgery warrants careful pre- and post-operative antibiotic care plan for this patient population.

Introduction: No report has been published regarding the recommended surgical treatment in patients presenting with symptomatic primary asymmetrical vesicoureteral reflux (VUR): high grade on one side and low grade on the contralateral side. The aim of this study was to evaluate the effectiveness and outcome of combined Lich-Gregoir extravesical reimplantation and subureteric Deflux® injection, of high grade and low grade VUR respectively. Non-inferiority to bilateral cross-trigonal reimplantation was investigated in terms of surgical complications, number of post-operative fUTIs and need for re-intervention.

Patients and methods: A monocentric retrospective study was undertaken of all consecutive children with primary asymmetrical VUR on MCUG treated over an 18-year period (2004-2022). Surgery was indicated following an episode of febrile urinary tract infection despite appropriate non-operative management. Demographic and clinical such as length of hospital stay for pain management, use of urinary Foley catheter and complications were analyzed.

Results: A total of 80 children met the study criteria: 40 patients underwent bilateral cross-trigonal re-implantation (Group 1) and 40 patients the combined Lich-Gregoir extra vesical reimplantation and Deflux® sub ureteric injection (Group 2). Complication and success rates were comparable in the two groups. The median hospital stay was significantly shorter for Group 2, with 50 % of patients who were discharged on day 1. Moreover, the data showed a significant lesser need in number and length of bladder catheter and ureteral stents in Group 2.

Discussion: The technique proposed overcome the inconveniences of the other procedures that are commonly used in bilateral RVU: difficulty in retrograde catheterization or ureteroscopy after bilateral cross-trigonal reimplantation, the risk of transient bladder dysfunction after bilateral extravesical reimplantation and the low rate of success for high grade reflux of the sub ureteric Deflux® injection. The main limitation of the study lies in its retrospective nature and in the relatively short median follow-up.

Conclusion: The combined Lich-Gregoir extra-vesical ureteral reimplantation and sub-ureteric Deflux® injection for the treatment of primary asymmetrical VUR is an effective alternative to the gold standard cross-trigonal ureteral reimplantation. Moreover, the position of the ureteric orifice is not modified in the eventuality of endourological procedures into adulthood.

Ureterocele is a cystic dilatation of the intravesical submucosal ureter, with an obstructed orifice. Endoscopic treatment is one of the most common option for surgical treatment. In intravesical ureterocele, the punctures must be made just above the junction between the ureterocele and the bladder floor. We commonly use a 8-9.8 Fr cystoscope, with a 5 Fr working channel, a metallic needle for bulking agent injection 3.7 Fr. In selected cases we also use electric or laser probes to decompress the ureterocele. When evidence of decompression is verified and vesicoureteral reflux is excluded, antibiotic prophylaxis is stopped. If, despite decompression, a large ureterocele is subsequently obstructing the bladder neck a surgical excision is necessary. Forty-four patients (92%) were treated endoscopically. Ureterocele puncture was performed with a metallic needle for bulking agent injection in 30 cases (63%), with a laser fiber in 7 cases (15%), with an electrified ureteral catheter in 4 cases (8%), and with Bugbee in 3 cases (6%). A success rate after one procedure was achieved in 40 children (83%). Adequate opening of the ureterocele with complete decompression of the reno-ureteral system is the goal of endoscopic treatment. An overaggressive incision or puncture could result in an increased chance of secondary vesicoureteral reflux.

Introduction: Ureteropelvic Junction Obstruction (UPJO), is a major cause of pathological hydronephrosis in children. Minimally invasive surgery (MIS), including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), has gained popularity due to its known advantages. LP faces technical difficulties and a steep learning curve. RALP has overcome these limitations, making it safer and more effective for children. The study aims to assess the safety and effectiveness of LP and RALP in infants weighing ≤15 kg.

Materials and methods: This is a retrospective analysis (2010-2022). The study included pediatric patients who had a confirmed diagnosis of UPJO and weighed ≤15 kg. The patients were divided into two groups: LP and RALP. The study evaluated preoperative, intraoperative, perioperative, and follow-up data, including complications. Success was defined as no worsening of hydronephrosis on postoperative ultrasound in the first year of follow-up.

Results: The total patients were 94: 42 in the LP group, and 52 in the RALP group. The median age at the intervention was 17.5 months (LAP group) versus 29 months (RALP group) (p = 0.01). The median weight at the time of intervention was 9.5 Kg (LP group), and 11.6 Kg (RALP group) (p = 0.44). The median operative time was significantly longer in the LP group: 245 min versus 125.5 min in the RALP group (p = 0.001). The median length of hospitalization was comparable: 4.3 days (LP group) and 3.5 days (RALP group) (p = 0.42). No intraoperative complications were reported in either group. There were no statistically significant differences regarding postoperative complications. During follow-up, all patients remained asymptomatic, with no episodes of urinary tract infection or abdominal pain, and none of them had a recurrence of UPJ obstruction. Consequently, the two techniques are equally effective and safe in the short term.

Discussion: Both procedures offer excellent outcomes with comparable postoperative complications. LOS was similar for both groups, with no intraoperative complications or conversions, and a non-significant increase in postoperative complications. A notable finding was the significant difference in operation times between the procedures, emphasizing the importance of reduced surgical time in pediatric patients for minimizing anesthetic and intubation durations.

Conclusion: For the absence of intra- and postoperative complications and recurrences, RALP is as effective as LP in pyeloplasty in children weighing 15 kg or less. This finding reinforces the idea that RALP can be safely executed, benefiting from its advanced technology and the learning curve, for patients of any age regarding pyeloplasty for UPJO.

Background: Disorders/Differences of Sex Development (DSD) encompass congenital conditions with atypical development of chromosomal, gonadal, or anatomical sex. Due to the rarity and complexity of these conditions, strong evidence for clinical practices is scarce, leading to controversies in management.

Objective: This study, part of a broader project, examines changes over time in the attitudes and beliefs of DSD healthcare providers, focusing on factors contributing to patients' life satisfaction and the influence of medical specialty, gender, and age.

Methods: Participants included active members of the Pediatric Endocrine Society (PES) and the Societies for Pediatric Urology (SPU) at three time points: 2003-2004 (T1), 2010-2011 (T2), and 2020 (T3). A survey covering predictors of patient life satisfaction, attitudes and beliefs regarding DSD care and outcomes, and participant characteristics was administered. Data were analyzed using descriptive statistics and Generalized Estimating Equations (GEE).

Results: Demographics: Participation rates were 56% (PES) and 64.7% (SPU) at T1, 41.1% (PES) and 52.3% (SPU) at T2, and 25.6% (PES) and 51.2% (SPU) at T3. Most participants were male (T1: 70.6%, T2: 61.7%, T3: 70.6%). Factors Affecting Life Satisfaction: Both endocrinologists and urologists ranked "gender identity consistent with assigned sex" as most important. Over time, the endorsement of some factors, such as performing genital surgery at Centers of Excellence, increased, while others, like the influence of prenatal androgen exposure determining gender identity, varied by specialty and gender. Attitudes and Beliefs: Across 18 statements, responses indicated three clusters with strong agreement, moderate agreement, and strong disagreement. Statements on the importance of family background and avoiding gender discordance were consistently endorsed, while those on delaying hypospadias repair until consent were least endorsed.

Discussion: The study highlights variability in beliefs about DSD management over time, influenced by specialty, gender, and age. Despite consensus on some care principles, discrepancies remain, particularly regarding the impact of prenatal androgens and the timing of surgical interventions. These findings underscore the need for regular interdisciplinary communication to align clinical practices with evidence-based guidelines and address subjective beliefs.

Conclusion: The survey illustrates evolving perspectives among DSD healthcare providers, emphasizing the need for continued dialogue and education to bridge gaps between clinical evidence and practice. Collaborative efforts, such as the international I-DSD and the U.S. DSD Translational Research Network, are crucial for advancing patient-centered care in this field.

Introduction/background: Ureteroceles are often diagnosed antenatally and incidentally and treated in a minimally invasive fashion with endoscopic puncture. Recent literature suggests that observation, or non-operative management, is an effective and viable management option in select patients with ureteroceles and certain radiologic findings, however there is no consensus on how to best select patients for non-operative management.

Objective: To 1) determine if pediatric ureteroceles managed non-operatively require less or sooner secondary surgical intervention than those managed with up-front incision, 2) describe characteristics of success and failure in pediatric ureteroceles managed non-operatively, and 3) identify risk factors associated with receiving intervention and time to intervention.

Results: Of 287 ureteroceles, 65 (23%) were managed non-operatively and underwent secondary surgical intervention less frequently (9% vs. 34%, P < 0.01) and later (median age 40 vs. 20 months) than those managed with puncture. Successful non-operative management was associated with fewer comorbidities, smaller ureterocele size, absence of vesicoureteral reflux (VUR) and high-grade VUR, single collecting system, lesser degree of hydronephrosis, ipsilateral MCDK and intravesical location. For all ureteroceles, high-grade VUR, duplex system, and female sex were associated with shorter time to secondary intervention (intervention after initial management).

Discussion: In the largest retrospective review of ureterocele management, smaller ureterocele size, absence of high-grade VUR, single system, ipsilateral MCDK and minimal hydronephrosis were factors that increased the efficacy of non-operative management of select pediatric ureteroceles. Furthermore, time to event analysis showed that non-operative management did not predispose patients to sooner secondary intervention (Figure). Lack of a standardized protocol for ureterocele management is a limitation of this single institution retrospective study as it introduces selection bias to the results, however few patients with low risk characteristics underwent puncture and no high risk patients were observed.

Conclusion: Smaller ureterocele size, absence of high-grade VUR, single system, ipsilateral MCDK and minimal hydronephrosis are factors that may increase the efficacy of non-operative management of select pediatric ureteroceles, which may delay or avoid secondary surgical intervention.

Introduction: Hypospadias is a common disease that affects approximately 1 in every 200 live male births in the United States, and long-term studies of individuals who have undergone repair demonstrate complication rates of 15%-70%. The Hypospadias-Specific Health-related Quality of Life (HRQOL) Conceptual Framework for youth and adults suggests that additional morbidity may be incurred from poor psychological, social, and sexual health. The current study sought to clarify hypospadias-specific HRQOL and care priorities in a pre-pubertal population.

Material and methods: This IRB-approved, semi-structured interview study used rigorous qualitative research methods. Eligible patients were English-speaking 8-12-year-old males with hypospadias and their parents. Families completed a demographic questionnaire and separate youth and parent 30-min telephone interviews. We used hybrid thematic analysis to develop an operational codebook, analyze participant responses, and generate conceptual themes. Mixed methods analysis was used to explore patterns of experiences across groups defined by socioeconomic level.

Results: We interviewed 10 parents and 8 children (Median age 9 years, Range 8-11). We generated three overarching themes: Penile Factors, Psychosocial Concerns, and Expectations of Surgery and the Healthcare Team. These highest-order themes were generated for youth, parent-proxy, and parent self-reported experiences, and there were different sub-themes for each participant type (Figure). Youth were focused on avoidance of disclosure and the psychological impact of self-comparisons and embarrassment, while the parental perspective centered on worries about future fertility, complications, psychological health, and normality. Some youth and parents from disadvantaged neighborhoods or those with public insurance indicated a need for more education on normal penile functions and provision of strategies for long-term self-monitoring and facilitation of long-term follow-up on mixed methods analysis.

Conclusion: These findings add insight into the multifaceted experiences of pre-pubertal youth and families dealing with hypospadias, and underscore the consistent, wide-ranging interplay between medical, psychological, and social concerns. Patterns in themes across socioeconomic status and insurance coverage suggest that access to information and quality care may vary significantly and could contribute to health disparities. Urologists should employ an individualized approach to counseling and care delivery. Future studies will seek to characterize care priorities in pubertal and post-pubertal age groups to design developmentally adjusted support tools for youth and adults with hypospadias and their families.