Bernhard Haid

Enhanced Recovery after Surgery Protocol for Pediatric Urological Augmentation and Diversion Surgery Using Small Bowel

Purpose Enhanced recovery after surgery protocols aim to improve recovery following urological augmentation and diversion surgery. Based on the positive experiences in adult patients, we evaluated safety and outcomes after implementation of an enhanced recovery after surgery protocol in children undergoing urological augmentation and diversion using small bowel. Materials and Methods Complications, time to stool, time to flatus and total hospital stay of 15 consecutive patients (group 2) were recorded and compared to the data of 15 consecutive patients before the changes in protocol were effective (group 1). The groups were comparable in age (mean 10.93 vs 9.267 years, p = 0.33), gender (p = 0.71) and operative times (387.9 vs 336.5 minutes, p = 0.19). Results Compared to the previous protocol involving a mean ± SD of 7.9 ± 1.38 enhanced recovery after surgery items per patient, 15.9 ± 0.26 items per patient were implemented in the new protocol. In group 2 mild bowel related complications were less frequent (1 vs 5, p = 0.168). Time to stool was significantly shorter in group 2 (3.33 vs 5.53 days, p = 0.002), as was time to flatus (2.8 vs 4.73 days, p = 0.002). Total hospital stay in group 2 was 11.93 days, compared to 19.87 days in group 1 (p <0.001), mainly due to more rapid convalescence, although influenced by associated changes in the postoperative protocol as well. Conclusions In pediatric augmentation and diversion surgery using small bowel the implementation of an enhanced recovery after surgery protocol is safe and effective, reinforcing faster bowel recovery. We did not observe complications or problems after introducing the new protocol.

Congenital Urinary Tract Dilatation and Obstructive Uropathy

The reported incidence of upper urinary tract dilatation (UTD) is 1–5.4 % of all pregnancies, dependent on the diagnostic criteria that are being applied, accounting to 60–120,000 children being diagnosed per year in the USA (Mallik and Watson 2008). Of these, around 25 % are persistent throughout birth (Barbosa et al. 2012). Sonographically detected intrauterine UTD can be observed in varying degrees in the 18th to 20th week of gestation. A prognostic cutoff level of prenatally diagnosed UTD on the basis of many studies has been determined; the risk of a significant UTDs after birth was linked to its prenatal manifestation (Nguyen et al. 2010): Whereas children with an anteroposterior renal pelvis diameter of ≥15 mm have a risk of 75 % of persistence after birth, in children with an anteroposterior renal pelvis diameter of ≤9 mm, it amounts to only 10 % (Benfield et al. 2003). The risk for later surgery is connected also with the grade of the prenatal urinary tract dilatation (Fig. 1).

Undescended testes: Diagnostic Algorithm and Treatment

Undescended testis persistently present at the 6th month of life in a term born boy should be treated, with the aim of bringing them to a scrotal position until the 12th month of life. Acquired undescended testes has to be looked for actively and treated at the earliest possible after diagnosis, that might be deferred due to a lack of attention and less access to a regular physical exam in older boys as opposed to infants.

Impact of Long-term Antibiotic Prophylaxis on Intestinal Microbiome Stability in Children

The intestinal microbiome is an ecosystem of bacterial microorganisms that is linked to metabolic and immune-related diseases. Our trial is analyzing 16S RNA sequencing data for the intestinal microbiome in children with urogenital malformations who do or do not receive antibiotic prophylaxis as part of their treatment.

Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment

CONTEXT Enuresis is a common and possibly underestimated condition. While 5-10% of school-aged children suffer from the condition, a lack of background knowledge may impede timely child-adapted and successful therapy. OBJECTIVE To provide a comprehensive overview of the pathophysiology, diagnosis, and treatment of enuresis. EVIDENCE ACQUISITION Guideline and position papers from the European Society of Pediatric Urology, the European Association of Urology, and the International Childrens Continence Society were acquired. PubMed was searched for literature on enuresis, and all papers published in the last 5 yr were considered. The most relevant information from the papers with the highest level of evidence was extracted and incorporated into the review. EVIDENCE SYNTHESIS An altered antidiuretic hormone profile, arousal failure, and delayed bladder maturation are the main pathophysiological factors in primary enuresis. Coexisting constipation, obstructive airway disease, attention deficit hyperactivity disorder, obesity, and genetic preconditions influence its prevalence. Diagnosis relies on history-taking and simple noninvasive examinations to differentiate monosymptomatic enuresis and patients with daytime symptoms. It is essential to exclude daytime voiding symptoms, overactive bladder, dysfunctional voiding, and urinary tract infections. Further imaging is indicated in complex cases with a suspicion of underlying congenital malformations or systemic or endocrine diseases and in children refractory to initial therapy. In secondary enuresis, psychological causes should also be taken into consideration. While desmopressin melt tablets and alarm systems constitute the mainstays of treatment in monosymptomatic enuresis, anticholinergics and urotherapy play an additional role in nonmonosymptomatic enuresis. For therapy-refractory cases, after a thorough re-investigation to identify any missed comorbidities and anatomical or functional causes of enuresis, combination therapy and stationary urotherapy might be promising options. CONCLUSIONS While enuresis seems to be an often underestimated condition in terms of the suffering that children and their families, there are efficacious therapy options once a correct and full diagnosis is made. PATIENT SUMMARY This article reviews primary and secondary nocturnal enuresis, which is the medical term for the condition whereby children wet their beds regularly after their first birthday. We describe the background of enuresis,including its complex underlying mechanisms, as well as diagnosis and treatment in the light of current scientific publications. We conclude that while enuresis seems to be an often underestimated condition in terms of the suffering that children and their families may undergo, there are efficacious therapy options once a correct and full diagnosis is made.

Embryologie des Urogenitalsystems

Der Genitaltrakt stammt primar vom intermediaren Mesoderm der Genitalleiste ab. In der Genitalleiste entwickeln sich die Vorniere (Pronephros), die Urniere (Mesonephros) sowie die Nachniere (Metanephros). Vor dem Mesonephros entsteht durch die sich entwickelnden Gonaden der Urnierengang (Wolff-Gang) oder Ductus mesonephricus. Nach dem Beginn der Degeneration der Vorniere entsteht in der 4. Gestationswoche (GW) die Urniere, welche sich wiederum ab der 7.–8. GW zuruckbildet. Am Ende des Wolff-Ganges, kurz vor Erreichen der Kloake, entsteht durch metanephrogene Stimulation die Ureterknospe, welche wiederum das metanephrogene Mesoderm zur Proliferation und Differenzierung anregt. Wahrend der Teilung der Kloake in einen vorderen (Sinus urogenitalis) und hinteren (Hinterdarm – Hindgut) Anteil implantiert sich der distale Anteil des mesonephritischen Ganges in den dorsalen Anteil des Sinus urogenitalis. Dabei positionieren sich die Ureteroffnungen im lateral dorsalen Wandbereich und begrenzen das zu diesem Zeitpunkt entstehende Trigonum vesicae. Die primordialen Keimzellen entwickeln sich extraembryonal in der Dottersackwand, zwischen der 3. und 5. Woche migrieren sie uber das dorsale Gekrose in die Gonadenanlage medial der Urniere. In der Folge stimulieren sie die Differenzierung der sich entwickelnden Gonade in ein Ovar oder einen Hoden. Voraussetzung fur die Entwicklung eines Hodens ist das Vorhandensein eines XY-Chromosoms bzw. die Aktivierung des SRY-Gens.

Imaging for Vesicoureteral Reflux and Ureteropelvic Junction Obstruction

CONTEXT Although the imaging techniques used for diagnosing vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) are well determined, there is a need to decrease the numbers of unnecessary imaging and radiation exposure as most of the target population is children. Newer imaging techniques are promising and could be eventually used for follow up in the near future. OBJECTIVE To review the contemporary literature regarding the imaging techniques used for VUR and UPJO. EVIDENCE ACQUISITION We conducted a nonsystematic review of the literature. A comprehensive search was performed through PubMed database between 1980 (where maternal ultrasound [US] was first popularized) and 2015 focusing on the last decade. EVIDENCE SYNTHESIS Conventional US cannot replace voiding cystourethrography in the detection of VUR. Contrast enhanced voiding sonography and direct radionuclide cystography suggest acceptable detection rates of VUR with sensitivity of 71-100% and specificity of 67-100%. Renal US and diuretic radioisotope renography with choice of technetium99m mercaptocetyltriglycine are invaluable imaging modalities for the detection of UPJO. CONCLUSIONS Despite the concerns about the invasiveness and radiation exposure of conventional voiding cystourethrography, it is still the gold standard technique in the detection of VUR and is superior to the other options in depiction of anatomical details. US and mercaptocetyltriglycine scintigraphy are also the gold standards and will continue to be so in the diagnosis of UPJO. PATIENT SUMMARY New imaging modalities such as contrast enhanced voiding sonography and direct radionuclide cystography are promising in the detection of vesicoureteral reflux. Major effort in literature is given to decrease the radiation dose of the available imaging techniques.