Ahmed I. Shoukry

Outcome of complete primary bladder exstrophy repair: Single-center experience

OBJECTIVE Reconstruction of bladder exstrophy remains a challenge. We evaluated our experience with complete primary repair in classic bladder exstrophy. METHODS A retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. Fifty-one patients (21 females and 30 males) with classic bladder exstrophy were included. Age of presentation ranged from 24h to 14 months. Mean follow up was 3 years (1 month-7 years). Patients were evaluated for continence, upper tract dilatation and cosmetic result. RESULTS Eight patients (15.6%) had failed closures and six (11.7%) had fistulae. Evaluation of continence excluded 16 patients not followed up at our center. Thirty-seven percent were continent on clean intermittent catheterization after the age of 5 years. Patients became dry only after augmentation cystoplasty. Upper tract changes were mild during our study with all patients having normal serum creatinine. CONCLUSION Patients may require more than one procedure for reconstruction. In our series, augmentation was required to achieve acceptable dryness. Early promising results with dry intervals in young patients did not translate to continence in older patients.

A new option for splenic preservation in normal sized spleen based on preserved histology and phagocytic function of the upper pole using upper short gastric vessels

Despite the recognized desirability of splenic salvage, forced splenectomy remains the rule in many operative situations, including trauma and pancreatic cancer. An anatomic study was conducted to assess whether the upper short gastric arteries provide sufficient collateral circulation to the spleen that the upper pole could remain viable even when the hilum is resected and the splenic artery and vein no longer intact. The anatomy of the upper short gastric vessels was studied in 59 human spleens and 18 albino rat spleens. Fifty-four human specimens (92%) and 18 (100%) of the rat spleens showed at least 1 upper short gastric artery and 1 vein connecting the fundus of the stomach with the interior of the upper pole of the spleen with no connection to the major hilar vessels. Lower two-thirds splenectomy, which included excision of the hilum of the spleen after ligation of both the splenic artery and vein, was performed on 14 of the 18 rats. The remaining 4 rats served as control animals. The upper pole of the spleen was preserved solely on the upper short gastric vessels that pass directly between the stomach and the interior of the spleen. Structure and macrophage function in the residual splenic tissue was shown to be preserved at 1 hour and 2 weeks postoperatively, based on results of the India ink technique for demonstrating phagocytic function and on results of regular histologic examination. Preservation was attributed to the fact that blood supply for the residual splenic tissue after splenic mass reduction remained adequate through the upper short gastric vessels. Splenic mass reduction is essential to improve perfusion to the residual splenic tissue if excision of the splenic hilum or ligation of the main splenic vessels becomes an operative necessity.

Outcome of Mini-percutaneous Nephrolithotomy for Renal Stones in Infants and Preschool Children: A Prospective Study

OBJECTIVE To assess the safety and efficacy of Miniperc for renal stones in preschool-age patients. To the best of our knowledge, this may be the first prospective study on this subject. Reports on Miniperc are still few and mostly retrospective using a sheath size of ≥ 18Fr, which is still relatively large for young children. PATIENTS AND METHODS From January 2012 to May 2013, Miniperc was performed for 26 children (≤ 6 years old) with renal calculi <5 cm through 14Fr sheath using a 9.5Fr semirigid ureteroscope with Holmium:yttrium-aluminum-garnet laser lithotripsy. Effects of different factors on operative time, complications, and stone-free rate (SFR) were compared using chi-square, Fischer exact, or Mann-Whitney tests as appropriate using SPSS v15.0. RESULTS Primary SFR, SFR after retreatment, and SFR after auxiliary extracorporeal shock wave lithotripsy (ESWL) were 77%, 85%, and 92%, respectively. Retreatment rate was 8%. Auxiliary ESWL was done in 11%. Complications were bleeding (8%), hematuria and blood transfusion (4%), renal pelvis perforation (4%), leakage (8%), and fever (15%). Operative time was significantly prolonged in multiple (>2) stones (P = .006), calyceal stones (P = .002), or stone size ≥ 30 mm (P = .022). SFR was significantly lower in children with >2 stones (P = .028) and increased stone size ≥ 30 mm (P = .014). CONCLUSION Miniperc is a safe and effective minimally invasive procedure for pediatric renal stones using 14Fr access sheath. SFR was significantly lower in children with >2 stones or increased stone size ≥ 30 mm. This was overcome by retreatment and auxiliary ESWL.

Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less

OBJECTIVES To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing ≤ 20 kg, because the number of this challenging group of children is increasing. PATIENTS AND METHODS Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. RESULTS The mean weight was 16.46 ± 2.61 kg. Mean cold ischemia time was 53.85 ± 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 ± 7.4 months. CONCLUSION Excellent PSR and GSR can be achieved in low weight (<20 kg) recipients. Even in very low weight patients, the EPA was used. No cases were reported with primary graft non-function due to use of living donors, increasing pre-Tx body weight to at least 10 kg and maintaining adequate filling pressure before graft reperfusion. The presence of related donors and use of induction therapy and tacrolimus decreased the rate of ARE while the presence of pre-Tx lower urinary tract surgical interventions increased the rate of ureteric complications, but this was statistically insignificant.

Management of bladder exstrophy in adulthood: Report of 5 cases

OBJECTIVE To report our experience in the management of adult classic bladder exstrophy. PATIENTS AND METHODS During 1977-2006 we treated five adult males presenting with classic exstrophy-epispadias complex. Patient age at presentation ranged from 17 to 30 with a mean age of 23 years. Four patients had received no previous treatment and one underwent previous ureterosigmoidostomy. Work-up included evaluation of upper tract and bladder biopsy. Bladder patch condition was variable. Surgery involved bladder preservation in the three patients who underwent primary repair, including bladder closure, bladder neck reconstruction and epispadias repair; two of them also had augmentation ileocystoplasty. The remaining two patients underwent ureterosigmoidostomy, cystectomy and epispadias repair. Abdominal wall closure was by fasciocutaneous M-plasty. Osteotomy was not done in any case. RESULTS In patients with bladder preservation, one patient was continent (>3 h) and voided normally whereas the other two showed day and night continence (2-3 h) with mild stress incontinence. Patients were satisfied with functional outcome. Ultrasound and intravenous pyelography showed preservation of upper tract. Follow-up period ranged from 1 to 8 years. CONCLUSION Patients with bladder exstrophy presenting in adulthood should not be denied the opportunity of primary reconstruction with bladder preservation in the absence of significant histological changes in the bladder mucosa.

Lower calyceal and renal pelvic stones in preschool children: A comparative study of mini-percutaneous nephrolithotomy versus extracorporeal shockwave lithotripsy

To compare outcomes of the mini‐percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy for lower calyceal and renal pelvic stones in preschool children.

Ureteric stents vs percutaneous nephrostomy for initial urinary drainage in children with obstructive anuria and acute renal failure due to ureteric calculi: a prospective, randomised study

To compare percutaneous nephrostomy (PCN) tube vs JJ ureteric stenting as the initial urinary drainage method in children with obstructive calcular anuria (OCA) and post‐renal acute renal failure (ARF) due to bilateral ureteric calculi, to identify the selection criteria for the initial urinary drainage method that will improve urinary drainage, decrease complications and facilitate the subsequent definitive clearance of stones, as this comparison is lacking in the literature.

Use of holmium laser for urethral strictures in pediatrics: A prospective study

INTRODUCTION The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions. OBJECTIVE To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures. PATIENTS AND METHODS From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation. RESULTS The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six. DISCUSSION One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study. CONCLUSION HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.

The role of voiding cystourethrography in asymptomatic unilateral isolated ureteropelvic junction obstruction: A retrospective study

INTRODUCTION The presence of concomitant vesicoureteric reflux (VUR) and ureteropelvic junction obstruction (UPJO) is uncommon. Nevertheless, the reported VUR coexisting with asymptomatic unilateral isolated hydronephrosis (AUIH) requiring pyeloplasty for correction of UPJO was of low grade and mostly resolved during conservative follow-up. Therefore, VCUG may be not indicated in these children except if voiding symptoms, urinary tract infection (UTI), dilated ureters, or bladder and ureteric abnormalities are suspected. OBJECTIVES The aim was to evaluate the need for VCUG in infants <1 year old with AUIH for whom a dismembered pyeloplasty was indicated for correction of UPJO. METHODS Ninety-six children <1 year old with pyeloplasty carried out from January 2012 to March 2014 were retrospectively included. Children with voiding symptoms or dilated ureter, duplex system, fused kidneys, bilateral dilatation, or any bladder abnormality on ultrasound were excluded. Anderson-Hynes pyeloplasty was performed through a flank incision. Preoperative VCUG was analyzed in relation to outcome and any UTI during follow-up. The Student t test, Mann-Whitney U test, or Fisher exact test were used to compare variables. RESULTS Five children had concomitant VUR with UPJO. Most of the children were circumcised during the first postnatal week. The remaining few children were circumcised at the time of pyeloplasty. Side, grade of detected VUR, and complications (18.75%) (postoperative or during follow-up) are presented in the Table. Outcomes in children with and without VUR were not different. Dismembered pyeloplasty was successful in children with VUR and with no complications except for non-febrile UTI in one child only. Ureters were still not dilated at the last follow-up. DISCUSSION The required imaging in infants with AUIH is still a subject of debate. As we expected, there was a low incidence of associated VUR in the present study. They were of low grade without any complications during follow-up and without affecting the outcome. The present study has its limitations, including the retrospective nature and short follow-up. However, as at least 2 years of follow-up were documented without any harm or ureteric dilation, VUR will mostly resolve. The present study is strengthened by inclusion of infants only. CONCLUSIONS Our data suggest that VCUG is not indicated in infants with AUIH requiring pyeloplasty for correction of UPJO. VCUG will not affect the treatment decision, operative outcome, or postoperative complications. VCUG may be indicated in case of suspected voiding symptoms, UTI, dilated ureters, or bladder and ureteric abnormalities.

Risk factors for urological complications following living donor renal transplantation in children

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy‐three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow‐up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.