Ahmed Hanno

Post-traumatic posterior urethral stricture in children: How to achieve a successful repair

OBJECTIVE Complex post-traumatic posterior urethral strictures in children constitute a major challenge to the pediatric urologist. Surgical repair depends primarily on the length of the urethral obliteration. Resection with end-to-end anastomosis is the usual procedure in the face of a short segment stricture. Transpubic urethroplasty and substitution urethroplasty are currently used to treat extensive and complex urethral strictures. We present our experience of the management of children presenting with post-traumatic posterior urethral stricture. PATIENTS AND METHODS Fifty boys with a mean age of 9 years (6-13) with obliterative urethral stricture were operated on during May 1999 to August 2006. Short posterior urethral stricture was treated by excision and end-to-end anastomotic urethroplasty in 40 boys. Long posterior urethral stricture was managed by combined inferior pubectomy in three, transpubic urethroplasty in four and tubed penile fasciocutaneous flap in three. RESULTS With a mean follow-up of 4.5 years (6 months-7 years), all children who underwent perineal anastomotic urethroplasty were successfully repaired. Transpubic urethroplasty was associated with a re-stricture in one child 6 years following the repair. In the group repaired by tubed fasciocutaneous flap, we encountered a distal anastomotic stricture accompanied by a huge proximal diverticulum which needed revision in one child, and another diverticulum with multiple stones in another who was treated successfully. CONCLUSION Anastomotic urethroplasty in children is feasible with good results. Proper evaluation is needed to choose the best surgical technique for each patient. Tubed fasciocutaneous flap carries the highest complication rate.

Progressive hair coil penile tourniquet syndrome: multicenter experience with 25 cases

OBJECTIVE Penile hair tourniquet syndrome is an uncommon syndrome characterized by progressive penile strangulation by a hair tie. Complications reported include urethrocutaneous fistula, complete urethral transection, penile gangrene, and penile amputation. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion for early diagnosis. PATIENTS AND METHODS Twenty-five children presenting with different degrees of hair coil penile strangulation syndrome have been operated on in the period from 2000 to 2007 in 2 tertiary care centers in the city of Alexandria. Eighteen boys had complete transection of the urethra at the coronal sulcus. Seven boys had partial transection of the ventral wall of the urethra at the coronal sulcus. Repair of the penis was done in all children in a single stage. RESULTS The mean age of boys is 3 years and 9 months (2-5 years). The mean follow-up is 20.7 (6-48) months. Urethral catheter was left for a mean of 5.5 (4-7) days. In the mean follow-up period, we had 4 complications in the form of 2 tiny urethrocutaneous fistulas and 2 anastomotic urethral strictures. The fistulae were closed surgically after the primary surgery by 1 year in the 2 cases, with no recurrence. Urethral strictures were managed by endoscopic visual urethrotomy, with no recurrence. CONCLUSION Penile tourniquet syndrome can cause serious penile complications. Awareness of this rare syndrome can help in preventing such complications. Being familiar with the surgical reconstruction guarantees high success rate.

Augmentation ureterocystoplasty in boys with valve bladder syndrome

OBJECTIVE Children with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome. PATIENTS AND METHODS Eight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound. RESULTS Bladder capacity (as measured during cystometry at 30 cmH(2)O) and compliance were significantly improved in all children following the procedure (P<0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child. CONCLUSION Ureterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.

Early Valve Ablation Can Decrease the Incidence of Bladder Dysfunction in Boys With Posterior Urethral Valves

PURPOSE Valve bladder syndrome represents the worst end of the posterior urethral valve spectrum. Recent data suggest that early valve ablation can provide the chance for the bladder to heal and improve dynamics. We tested the hypothesis that early valve ablation can decrease the incidence of bladder dysfunction in these boys. MATERIALS AND METHODS A total of 16 full-term males with prenatally diagnosed hydronephrosis and a full bladder proved postnatally to have posterior urethral valve were studied. Valve ablation was performed during the neonatal period (group 1). The records of 16 boys with posterior urethral valves who underwent valve ablation after age 1 year were obtained (group 2). Ultrasound was performed every month and urodynamics were performed every 6 months. At age 3 years voiding diary and toilet training results were obtained. The incidence of bladder dysfunction in the 2 groups was recorded according to clinical, ultrasound, voiding cystourethrogram and urodynamic parameters. RESULTS Mean followup was 3 years. Post-void residual urine, measured as more than 30% of expected bladder capacity for age, improved in 14 patients (87.5%) in group 1 and in 10 (62.5%) in group 2. Excluding cases of vesicoureteral reflux-renal dysplasia syndrome, vesicoureteral reflux was present in 20 renal units initially in group 1 and showed resolution or improvement in 16. In group 2 vesicoureteral reflux was present in 26 units and improved in 14. At last followup mean cystometric bladder capacity, measured at 30 cc H(2)O, in group 1 was 145 +/- 22 ml which was comparable to age matched normal bladder capacity. In group 2 mean +/- SD cystometric bladder capacity was 130 +/- 30 ml, which was significantly lower than age matched normal bladder capacity. Hypocompliance and instability were significantly lower in group 1. Toilet training was easier and yielded better results for dryness in group 1. Overall bladder dysfunction was present in 2 boys (12.5%) in group 1 and in 8 (50%) in group 2. CONCLUSIONS Neonatal valve ablation would protect the bladder and allow normal cycling, which helps in bladder healing. This underscores the importance of routine prenatal screening and early intervention at a specialized center.

Transperitoneal versus retroperitoneal laparoscopic pyeloplasty in children: Randomized clinical trial

INTRODUCTION Laparoscopic pyeloplasty achieves good cosmetic and functional outcomes. Both transperitoneal and retroperitoneal approaches are used. No single study to date has compared the two approaches in a prospective randomized design. OBJECTIVE We present a prospective randomized comparison between both approaches in children in a trial to define which technique is better with regard to multiple factors including operative time, hospital stay, recovery of bowel movement, analgesic requirement and complication rate. STUDY DESIGN In the period from June 2010 to September 2012, 38 children (25 boys and 13 girls) were operated laparoscopically. Children were randomized into Group I (19 children) operated by the transperitoneal approach, and Group II (19 children) operated by the retroperitoneal approach. Both groups were compared as regards to the operative time, anesthetic changes, and postoperative recovery. A minimum sample size required was calculated to be 19 for each arm based on previous studies of laparoscopic pyeloplasty, using a mean difference in operative time = 40 min, effect size = 0.95, an alpha of 0.05 and power 80% and an online sample size calculator. Statistical analysis was performed using SPSS software using the Fischer exact test, chi square test and Mann-Whitney U test. The operative time was the primary endpoint for comparison between both approaches. RESULTS DISCUSSION Our series is the first in the literature that compares in a prospective randomized design the transperitoneal and retroperitoneal laparoscopic pyeloplasty in children. Shouma et al. is the only prospective randomized study to compare both techniques in adult pyeloplasty. They had a significantly shorter operative time in the transperitoneal group however, the author in the discussion mentioned that he was at the start of the learning curve for retroperitonoscopic pyeloplasty when he conducted his study, which affected the result of the operative time. Hence, as mentioned above, we stressed the importance of a single surgeon with adequate equal experience in both techniques. The recovery of the intestinal motility and start of oral feeding were significantly faster in the retroperitoneal group compared to the transperitoneal group. In our opinion this can be explained by the absence of intraperitoneal manipulations and urine leakage in the peritoneal space. In their series of retroperitoneal pyeloplasty, El Ghoneimi et al. reported feeding after a mean of 1.4 days, however, in our series there was even earlier oral feeding. Shouma et al. reported no significant difference in the start of oral feeding in their adult series. The limitations of our study are: the choice of the 40 min difference created a statistically significant difference in operative time between the groups which might not be considered a truly clinically important difference. In addition, the single author operating for both approaches, which might create a bias, however the author has sufficient experience in both approaches. Moreover, although there were significant differences in hospital stay and intestinal movement between the two groups, it is not clear if these were of clinical significance. CONCLUSION Both transperitoneal and retroperitoneal approaches have high success rate. The shorter operative time, shorter hospital stay, rapid recovery of intestinal movement and early resumption of oral feeding are in favor with the retroperitoneal approach.

Injury of the ileum during percutaneous nephrolithotomy in a pediatric patient

Ileum injury during percutaneous nephrolithotomy (PCNL) is an extremely rare complication. We describe the successful management of an inadvertently injured ileum during subcostal PCNL in a 12-year-old boy. Mechanism of injury, presentation and management will be discussed.

Safety and feasibility of laparoscopic appendicovesicostomy in children

INTRODUCTION Mitrofanoff appendicovesicostomy is needed for securing a conduit for clean intermittent catheterization in children with myelomeningocele, posterior urethral valves and non-neuropathic neuropathic bladder. An open technique is widely used; herein we report our initial experience with minimally invasive laparoscopic appendicovesicostomy in children. PATIENTS AND METHODS During 2007-2011 we operated on 4 male children with a mean age of 6 years (3-9) suffering from posterior urethral valves (1), myelomeningocele (2), and non-neuropathic neuropathic bladder (1). A posterior Mitrofanoff trough was used in one child while in the remaining children we used the anterior Mitrofanoff trough. RESULTS The mean operative time was 3.5 h (3-5). The mean hospital stay was 3.7 days (2-5). The mean follow up was 12.5 months (5-30). All are continent; one child was converted to open because of failure to pass the catheter at the end of the procedure. Cosmetic aspect is perfect. No difficulty in catheterization was encountered. CONCLUSION Laparoscopic Mitrofanoff is a feasible, safe and effective technique associated with low morbidity.

Single-stage repair of bladder exstrophy in older children and children with failed previous repair.

AIM Evaluation of cosmetic and functional outcome of single-stage exstrophy-epispadias complex repair in older children and those with previously failed repair. MATERIALS AND METHODS This study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2-24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell-Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children. RESULTS One child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm(3) (range 110-160 cm(3)) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1-3 years). CONCLUSIONS Single-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.

Retroperitonoscopic Nephrectomy and Nephrouretrectomy in Children and Adolescents: Analysis of a Single-Center Experience

INTRODUCTION AND OBJECTIVES Retroperitonoscopic nephrectomy in children was considered by some authors to be the final gold standard in children. Hence, we reviewed our data focusing on the safety and efficacy of the procedure. MATERIALS AND METHODS In the period from November 2005 till February 2010, 35 patients were operated by a single surgeon (the first author); patients comprised 18 boys and 17 girls, with a mean age of 7.5 years (range: 1-19 years). In all patients, the retroperitonoscopic approach was used with the use of only three trocars, one 10-mm optic trocar and two 5-mm trocars. The retroperitoneal space was established either by direct insufflation into the Gerota fascia, which is grasped and opened under vision, or using a balloon dilator to widen the space and then incising the Gerota fascia under control of the optic trocar, then control of the pedicle is performed, and the specimen is extracted from the same optic trocar. RESULTS The mean operative time is 75 minutes (range: 45-120 minutes). Nineteen nephrectomies and 16 nephrouretrectomies were performed. Blood loss was minimal, blood transfusion was not given, and conversion to open surgery was not needed. There were no intraoperative complications, and only one postoperative hematoma resolved spontaneously. The mean hospital stay was 2 days (1-3 days). CONCLUSION Retroperitonoscopic nephrectomy in children is safe and feasible. Blood loss is minimal, hospital stay is very short, and complications are minimal. It has excellent cosmetic outcome.

Upper tract low-grade papillary carcinoma in a 20-months-old boy: A rare case report

Urothelial tumors in children are rare pathology. A 20-months-old male patient presented with upper ureteric papillary tumor in a setting of ureteroscopy after multiple procedures for cystine stones former. Biopsy revealed low-grade papillary carcinoma.