Journal of Pediatric Urology最新文献

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.

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.