Journal of Pediatric Urology最新文献

Introduction: Functional constipation (FC) is the most prevalent digestive complaint in children and adolescents, significantly impacting quality of life and often associated with fecal incontinence, emotional disturbances, and urinary symptoms. Although its diagnosis is primarily clinical and based on the Rome IV criteria, the lack of objective severity parameters and reliance on self-reported symptoms can hinder early identification. In this context, the present study aimed to evaluate the diagnostic accuracy of commonly used auxiliary tools - the pediatric-adapted Cleveland Clinic Constipation Score (CCS), the Bristol Stool Scale, the Dysfunctional Voiding Symptom Score (DVSS), and rectal diameter (RD) - using the Rome IV criteria as the gold standard.

Methods: This cross-sectional study included 106 patients aged 4-17 years, evaluated in general pediatric and specialized lower urinary tract dysfunction outpatient clinics. Each assessment tool was compared against the Rome IV criteria in terms of sensitivity, specificity, and overall accuracy.

Results: The CCS demonstrated the highest diagnostic accuracy (92.1 %), with a sensitivity of 89.5 % and specificity of 80.0 %, establishing it as an effective tool not only for diagnosing FC but also for grading its severity. Item 4 of the DVSS, which assesses the perception of effort during defecation, showed an accuracy of 72.5 % and should be valued by healthcare professionals as a relevant marker of FC. In contrast, the Bristol Stool Scale (types 1 and 2), RD measurement, and DVSS item 3 (bowel movement frequency) presented low accuracy levels (<60 %).

Conclusion: With its high accuracy, the CCS has proven to be a valid and reliable tool that supports the diagnosis of functional constipation and may also assist in determining its severity. Additionally, DVSS item 4 proves useful in clinical evaluation, while other instruments should be considered auxiliary tools, applied selectively based on individual patient needs.

Purpose: Urothelial cell carcinoma of the bladder (UCCB) is a common malignancy in adults but is rarely seen in children. Due to its rarity in the pediatric population, we utilized a national database to compare demographics, tumor characteristics, staging, and outcomes among pediatric patients, young adults (YA), and older adults (OA).

Materials and methods: We performed a retrospective cohort study using the National Cancer Database (NCDB) to identify patients diagnosed with UCCB (ICD-O-3 histology codes 8120-8131) from 2004 to 2020. Patients were grouped as Pediatric (≤21 years), Young Adult (22-50 years), and Older Adult (>50 years). Cases with missing survival data were excluded. We analyzed demographic data, tumor stage, treatment, and overall survival using chi-square tests, Kaplan-Meier survival estimates, and Cox regression models.

Results: We identified 235 pediatric (0.1 %), 22,034 YA (4.3 %), and 488,182 OA (95.6 %) cases. Among pediatric cases, 64 % were male, and most were non-Hispanic white. Non-muscle-invasive bladder cancer (NMIBC; Stage Ta, Tis, T1) was present in 96.2 % of pediatric cases, compared to 3.8 % having muscle-invasive disease (MIBC; Stage T2-T4). Pediatric patients had superior 1-, 2-, 5-, and 10-year survival rates compared to older cohorts. Across all age groups, invasive disease was associated with worse outcomes. Surgery was the primary treatment for 98.3 % of pediatric patients, with 19.6 % receiving intraoperative or adjuvant chemotherapy, compared to 31.7 % in the YA group and 33.1 % in the OA group. Treatment approaches depend largely on muscle-invasive status and have evolved over time.

Conclusions: This is the most extensive study to date on pediatric UCCB, revealing a predominance of NMIBC and improved survival rates in children compared to adults. Pediatric patients were less likely to receive chemotherapy despite high surgical rates. These findings underscore the need for further research to inform the development of standardized treatment for pediatric UCCB.

Objective: This study evaluates the growth potential of the affected testis and its influencing factors in patients undergoing redo orchiopexy (RO).

Material and methods: Between 2014 and 2024, 53 patients (4.6 %) with 57 testes who underwent RO among 1130 inguinal orchiopexies were analyzed retrospectively. Changes in testicular volume (TV), testicular growth percentage (TGP), and testicular atrophy index (TAI) after failed orchiopexy (FO) and redo orchiopexy were assessed using Doppler ultrasonography. Age, testis location, laterality, surgical approach, fixation, and the interval between operations were obtained from patient data.

Results: The mean age at FO and RO was 3.18 years and 5.08 years, respectively. The mean interval between FO and RO was 22.8 months(range 6-117 months). Among 39 unilateral undescended testes, TAI increased in 22(56 %) and regressed in 4(10 %) after FO. Following RO, TAI decreased by over 10 % in 21 cases(53 %), while an increase was observed in 11(28 %). Mean TAI values were 30.9 at baseline, 41.65 after FO, and 27.47 after RO(p = 0.068, p = 0.625). Older age at surgery correlated with TAI increase (p = 0.011). In 57 testes, mean TGP significantly increased from 29.8 to 134.68 after RO(p = 0.02). Early RO(≤1 year, n = 29) showed a higher TGP(169 %) compared to late RO(>1 year, n = 23,%101), though the difference was not statistically significant(p = 0.224).

Conclusions: Testicular asymmetry increases less in patients undergoing surgery at a younger age. Redo orchiopexy within the first year helps restore the growth potential of the affected testis more effectively, mitigating the adverse effects of failed orchiopexy.

Introduction: Children with neurogenic bladder (NB) exhibit increased bladder-wall stiffness, yet non-invasive tools to quantify this remain limited. In this study, we assessed whether shear-wave elastography (SWE) distinguishes NB from healthy bladder and explored its relationship with routine upper- and lower-tract investigations.

Methods: In this prospective single-centre study, children with NB and age-matched controls underwent bladder SWE. Young's modulus of elasticity (YME, kPa) was measured in the anterior bladder wall at two filling states: full bladder (100 % estimated capacity) and post-void. Median YME measurements were compared between patients and controls. Inter- and intra-group within-child change, i.e., ΔYME = (full - post-void), was calculated. Also, the YME values (at both states) were compared between binary patient sub-groups divided based on parameters of routine upper and lower urinary tract investigations including ultrasound, scintigraphy studies, micturating cystourethrogram and urodynamic study. Mixed-effects models with a random intercept for patient ID verified all comparisons while accounting for paired measurements.

Results: A total of 44 patients and 42 healthy controls were enrolled in the study. Median YME was higher in NB than controls at both bladder states: full bladder: 9.95 kPa vs 7.50 kPa (p = 0.0006); and, post-void: 9.30 kPa vs 6.80 kPa (p = 0.023). The within-child change, ΔYME, was small and highly variable (median + 0.68 kPa in NB vs + 0.15 kPa in controls; p = 0.27), indicating no systematic stiffening or relaxation after voiding. Both classical statistics and mixed effects modelling showed no significant differences in YME (full-bladder or post-void state) values across NB patient sub-groups stratified by variables including hydroureteronephrosis, vesicoureteral reflux, renal scarring, reduced GFR, bladder capacity, pressure, compliance, hostility, or detrusor overactivity.

Conclusion: Median YME values are higher in NB than in controls at both bladder states, yet the paired change (ΔYME) showed no meaningful inter-group or intra-group variation. Both classical statistics and mixed-effects models likewise detected no association between YME and the various clinical sub-groups. Therefore, until multicentric data confirm diagnostic thresholds, longitudinal reproducibility, and predictive value for upper-tract risk, SWE should be viewed only as a complementary research tool rather than a substitute for current gold standard investigations.

Introduction: Retroperitoneal lymph node dissection (RPLND) is a critical surgical procedure for staging and managing paratesticular rhabdomyosarcoma (RMS) in pediatric patients. While minimally invasive surgical (MIS) approaches, including laparoscopic (LP) and robot-assisted (RA) techniques, are well-documented in adult populations, their utilization in pediatric patients remains limited. This multi-institutional study evaluates perioperative and long-term outcomes of MIS RPLND compared to open RPLND in children with PT-RMS.

Methods: A retrospective analysis was conducted on pediatric patients who underwent RPLND for paratesticular RMS between 2012 and 2024. Data collected included demographics, tumor characteristics, neoadjuvant chemotherapy, operative details, and postoperative outcomes. Descriptive statistics were used to analyze the data.

Results: A total of 16 patients were included in our study (8 MIS and 8 open). The median age of MIS patients was significantly younger (12.6 vs. 15 years, p = 0.03). MIS cases demonstrated shorter operative times (median 436 vs. 590 min, p = 0.03), lower estimated blood loss (35 vs. 200 mL, p = 0.03), and shorter hospital stays (2.5 vs. 6 days, p = 0.01). Lymph node yield was lower in the MIS group (median 13 vs. 26, p = 0.46), but within the COG-recommended range. Both groups had three patients with positive lymph nodes and comparable complication rates. No recurrences were observed in the MIS group over a significantly longer median follow-up period (71.5 vs. 19 months, p = 0.05). Two patients in the open group experienced relapse, including one mortality.

Conclusion: MIS RPLND is a safe and effective surgical option for managing paratesticular RMS in pediatric patients. Wider adoption and further research with larger cohorts are necessary to validate these findings and optimize surgical techniques.

Objective: Children with neurogenic bladder (NGB) are at increased risk for urinary tract infections (UTIs), but there is a lack of guidelines to assist clinicians in diagnosing and treating these children. Our objective was to describe the presentation and treatment of provider diagnosed UTIs in children with NGB compared to children with vesicoureteral reflux (VUR) and to assess the proportion of children with NGB who met a consortium definition of UTI.

Study design: We included children <18 years old with either VUR or NGB who were diagnosed in the emergency department with a febrile UTI in our multicenter retrospective cohort study. We extracted and compared UTI symptoms and urinalysis results specific to children with NGB to children with VUR. We measured the proportion of UTI diagnoses concordant with the Urologic Management to Preserve Initial Renal Function (UMPIRE) consensus definition of UTI, defined as ≥ 100,000 CFU/mL of 1 or 2 organisms, pyuria, and ≥ two symptoms of UTI.

Results: The most common symptom among all children in the cohort was vomiting (38.8 %). Of the 215 children with NGB, 41.3 % met the UMPIRE definition for UTI. More children with NGB had multidrug resistant organisms (MDROs) cultured from their urine than those with VUR. Children with NGB, both who did and did not require CIC, had increased odds of MDRO in urine culture compared to those with VUR. Children with NGB were more likely to be prescribed broad-spectrum antibiotics than children with VUR.

Conclusions: Most children with NGB diagnosed with febrile UTI in the ED did not meet a commonly recommended definition for UTI. The higher prevalence of MDRO UTIs and broad-spectrum antibiotic use in children with NGB highlights the need for accurate diagnostic approaches for UTI in this population, as well as the difficulty in diagnosing UTI in patients with NGB.

Purpose: To evaluate the effectiveness of external urethral sphincter (EUS) and perineal body BTX-A injections on uroflowmetric factors as well as severity of dysfunctional voiding.

Methods: In a prospective cohort study, patients diagnosed with refractory non-neurogenic voiding dysfunction were included in this study. All cases were evaluated pre-operatively by ultrasonography, uroflowmetric study and electromyography (EMG). Voiding cystourethrography or direct radionuclide cystography and other diagnostic modalities were performed if indicated. Using a rigid pediatric endoscope, the urethra and bladder evaluated for underlying concurrent anomalies. BTX-A injection of the perineal body and EUS, was performed transperineally or/and endoscopically. The uroflowmetric parameters and dysfunctional voiding scoring system (DVSS) were evaluated as therapeutic outcomes. Post-operative voiding satisfaction was assessed using a 7-point Likert-type scale with higher response values reflecting greater symptom improvement.

Results: The study demonstrated significant improvements in DVSS and uroflowmetric parameters in the included cases after a mean follow-up period of 16.14 ± 6.14 months. Among the 82 included cases, 12 patients experienced transient post-injection urinary incontinence, which resolved on average within 0.32 ± 0.91 weeks post-injection. Post-operative voiding satisfaction demonstrated a median score of 7 with an inter-quartile range of 1.25. Several limitations can be addressed including single center cohort study and absence of control group.

Conclusion: This study demonstrates the therapeutic potential of BTX-A injection in refractory non-neurogenic dysfunctional voiding pediatric cases. In addition, the BTX-A injection depicted promising improvements of post-operative voiding satisfaction.

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.