Duncan T. Wilcox

The Yang–Monti ileovesicostomy: a problematic channel?

Objective To compare the differences in the quality of Mitrofanoff channels created using appendix and re‐tubularized small bowel (the Yang–Monti ileovesicostomy).

Management of fetal hydronephrosis

Prenatally detected hydronephrosis has become a common diagnosis for both pediatric nephrologists and urologists. Hydronephrosis is most commonly assessed by the Society for Fetal Urology grading system or anterior–posterior diameter of the renal pelvis in the transverse plane. Some cases of bilateral obstruction, most commonly from posterior urethral valves, can be life-threatening and require close monitoring or, occasionally, fetal intervention. The majority are unilateral and of no threat to the growing fetus. The crux of postnatal management is the separation of the minority of patients whose renal function is at risk from the majority who will suffer no renal consequences. This management involves a regimen of ultrasounds, voiding cystourethrograms, and nuclear renograms for diagnosis and surveillance. Recent literature has been aimed at the timing and necessity of these studies in order to minimize extraneous studies without compromising renal function.

Upper pole heminephrectomy: is complete ureterectomy necessary?

Objective To determine the re‐operation rate on the distal ureter after upper pole heminephrectomy with incomplete ureterectomy.

Vesicoureteral Reflux: Current Trends in Diagnosis, Screening, and Treatment

CONTEXT Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. OBJECTIVE Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. EVIDENCE ACQUISITION A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organizations. EVIDENCE SYNTHESIS We objectively assessed and summarized the published data, focusing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. CONCLUSIONS The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments.

Pediatric hemorrhagic cystitis

PURPOSE To review the current literature as it pertains to hemorrhagic cystitis (HC) in the pediatric bone-marrow transplant (BMT) population. By reviewing the pathophysiology of the disease, preventive methods, and therapeutic options, urologists may be better equipped to manage this challenging clinical scenario. MATERIALS AND METHODS The HC literature was reviewed using a MEDLINE/PubMed literature search, specifically focusing on the pediatric BMT population as it pertains to the incidence, pathophysiology, prevention, and treatment of HC. RESULTS Conservative estimates of HC incidence in recent retrospective studies of pediatric BMT populations still approach 10-20%. Several high-volume pediatric BMT centers have reported contemporary data on their experience with HC providing increased insight into incidence and pathophysiology. Accumulating evidence linking BK virus to HC is a significant development warranting further investigation. Other contributing agents/risk factors need identification in the likely multifactorial etiology of HC. Preventive and therapeutic strategies have made modest advances, but certainly need further validation with prospective randomized studies. CONCLUSIONS Pediatric BMT patients are susceptible for HC development despite preventive measures and improved insight into the pathophysiology. Unfortunately, there are no evidence-based treatment guidelines for this difficult clinical issue that frequently requires prolonged care and multiple treatment modalities necessitating judicious patience in the application of more aggressive interventions.

Y-type urethral duplication in the male

To present a single series of Y‐type duplication with an analysis of the presenting features, the management and outcome, as complete Y‐type urethral duplication in the male is a rare congenital anomaly that presents many challenges.

Tubularized incised-plate urethroplasty for distal and proximal hypospadias.

To describe the tubularized incised‐plate (TIP) urethroplasty for distal and proximal hypospadias.

Laparoscopic transposition of lower pole vessels – the ‘vascular hitch’: An alternative to dismembered pyeloplasty for pelvi-ureteric junction obstruction in children

OBJECTIVE Dismembered pyeloplasty is the traditional technique in the management of ureterovascular pelvi-ureteric junction obstruction (PUJO) in children. Controversy remains regarding the role of lower pole vessels as the sole aetiology for PUJO. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our technique of laparoscopic transposition of lower pole vessels in children with PUJO, leaving the PUJ intact. PATIENTS AND METHODS Thirteen patients (seven boys and six girls) with a mean age of 10.2 years (range 7-16 years) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of intermittent pain and ultrasound/MAG3 appearance of obstruction with or without reduced function. The technique involved laparoscopic transperitoneal mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and transposing them superiorly onto the anterior wall of the pelvis. The main outcome measures were relief of pain and improvement in ultrasound appearance or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks of surgery. RESULTS Median operating time was 92 min. All patients were discharged within 36 h of surgery. All patients remain pain free at a median of 6 months (range 3-18 months). Twelve patients showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One patient had recurrent symptoms requiring insertion of a JJ stent. She has undergone further laparoscopic exploration. The vessels were in their transposed position and there was a kink at the PUJ which was released. She had a vertical pyelotomy and transverse closure over the JJ stent with good results. CONCLUSION This technique is simple and requires less operating time. No anastomosis or temporary JJ stent is required. Our early results are very encouraging with no serious complications.

Long-term outcomes of anorectal malformations

Anorectal malformations (ARMs) and cloacal anomalies are rare and complex malformations of the lower gastrointestinal and genitourinary tracts. They affect approximately 1 in 3,500 live births. The treatment of these patients has traditionally focused on achieving urinary and faecal continence, with preservation of renal function. With improved surgical techniques and paediatric intensive care facilities, these patients now live relatively normal lives, with a near-normal life expectancy. Comparing results reported by different surgeons is difficult because a wide range of terminology is employed to describe the anomalies encountered. This paper attempts to simplify some of the reported outcomes of bowel function to allow a more direct comparison between groups. Urinary outcomes were not so easily comparable due to the disparity in assessing patient outcomes. Therefore, before a global analysis of all groups can take place, a standardised terminology will be necessary. At present there is a gap in the published literature of comprehensive follow-up in this group of patients, particularly regarding reproductive and sexual functioning. More detailed information on long-term outcomes is needed in these patients to facilitate informed decision-making by the primary physician (usually the paediatric surgeon) and the parents on behalf of their child.

The buried penis – an anatomical approach

Surgical correction of the buried penis is a dif®cult challenge. Many different procedures have been described but the results have generally been disappointing. Re-evaluation of the anatomy of this condition suggests that it results from a failure of separation of the migrational planes in the developing male external genitalia. During the sixth week of development, the scrotal swellings start to appear on either side of the urethral folds. At the cranial tip of the urethral folds is the genital tubercle; this rapidly elongates into the phallus, pulling the urethral folds forward. The urethral folds fuse over the urethral plate to form the penile urethra. Meanwhile, the scrotal swellings, which are initially found in the inguinal region, migrate caudally, where they unite across the scrotal septum [1]. If these developmental planes fail to separate, the penile corpora are tethered to the deep fascia, while the scrotum remains high up in the groin. Herein we describe a new technique to correct the buried penis, based on these anatomical principles, whereby the penis gains the normal circumcised appearance.