Mohamed A. Eissa

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.

Management of major blunt pediatric renal trauma: Single-center experience

OBJECTIVE To review the impact of major pediatric renal trauma and its management on long-term function and morphology of the injured kidney. METHODS Thirty-six blunt trauma patients (20 males, 16 females) presented in 2004-2007 (age range 2 days to 14 years; mean 6.2 years). Thirty-seven renal units were included: 13 grade III, 14 grade IV, and 10 grade V injuries. Follow up was for 3-38 (mean 14) months. Patients were managed non-operatively unless vitally unstable. The most common causes of trauma were motor vehicle accidents and falls. Fourteen patients had associated non-renal injuries. Four patients had pre-existing renal problems. RESULTS The surgical intervention group (13 patients, 36%) included 9/10 grade V and 4/14 grade IV renal injuries. Surgical repair of lacerations was performed in seven cases, partial nephrectomy in four cases and nephrectomy in two cases. Follow up showed no significant change in renal function, and none developed hypertension. The non-operative group (24 patients, 63.2%) included all grade III injuries, 10 grade IV injuries, and one grade V injury. There was an excellent outcome for 18/24 patients (75%) with kidney preservation, no complications from urinary extravasation and hematoma resolution. The remaining patients had lower polar infarction (1), renal atrophy (1), persistent subcapsular collection (2), recurrent hematuria requiring angioembolization (1), and there was one death related to central nervous system injury. CONCLUSION The outcome of our management of pediatric major renal trauma was favorable overall. Longer follow up is needed with regard to renal function and development of hypertension.

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.

Assessment of recoverability of kidney function in children with obstructive calcular anuria: multicenter study.

OBJECTIVE Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions. MATERIALS AND METHODS This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0-14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed. RESULTS Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [P(cr)] improved 20-50% the eGFR and CC were doubled, and when improved 50-70% eGFR and CC tripled. Beyond 70% improvement in [P(cr)], eGFR and CC improved 7-8 times. Using Spearmans correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively). CONCLUSION Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.

Functional and structural outcomes of ILM peeling in uncomplicated macula-off RRD using microperimetry & en-face OCT

PurposeTo investigate functional and structural outcomes of internal limiting membrane (ILM) peeling during primary vitrectomy for uncomplicated macula-off rhegmatogenous retinal detachment (RRD).MethodsIn this prospective interventional randomized comparative study, 43 eyes (43 patients) were randomly divided into group A (20), and group B (23), with and without ILM peeling respectively. Patients were evaluated clinically, and by spectral-domain optical coherence tomography (SD-OCT) and microperimetry (MP) following silicone oil removal. Main outcome measures were functional—MP (mean and foveal retinal sensitivity; MRS, FRS) and best-corrected visual acuity (BCVA)—and anatomical—en-face image analysis (retinal dimples), and SD-OCT changes [epiretinal membrane (ERM), subretinal fluid (SRF), ellipsoid zone disruption, central subfoveal thickness (CSFT), and foveal contour].ResultsAll eyes achieved complete postoperative attachment with mean BCVA 1.0 ± 0.4 logMAR (6/60) in group A, and 0.4 ± 0.4 logMAR (6/15) in group B (p < 0.001). MRS and FRS were significantly higher in group B (p = 0.037 and 0.036 respectively). En-face OCT showed retinal dimples in all patients in group A (29.17 ± 7.67 dimples), compared to none in group B (p = 0.007). ERM did not develop in any eye in group A, while it developed in 17.4% of eyes in group B (p = 0.05).ConclusionAlthough ILM peeling prevented ERM, it resulted in poorer visual outcome in these uncomplicated RRD cases, and might be better reserved only for complicated cases.

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.

Recipient surgical complications of renal transplantation in children: our initial experience

Objectives The aim of the study was to evaluate the operative and early postoperative surgical complications of renal transplantation in pediatric recipients. Background Renal transplantation is considered the treatment of choice in children with end-stage renal disease; however, it is still associated with several surgical complications. Patients and methods From July 2010 to January 2013, 50 consecutive pediatric kidney transplants were studied. Immediately before transplantation, a thorough history and physical examination with appropriate laboratory and radiological evaluation were performed to search for any medical or surgical problems that contraindicate the transplantation. We removed the kidney from a living donor through an open surgical technique. The kidney graft was placed extraperitoneally in the right iliac fossa. The arterial anastomoses were performed to the lower aorta or right common iliac artery. The venous anastomoses were performed to the lower inferior vena cava or the right common iliac vein. Our ureteral reimplantation technique was an extravesical, Lich-Gregoir technique. A ureteral stent was placed. We evaluated the ischemia time and any intraoperative or postoperative surgical complications. Results Our patients included 36 boys (72%) and 14 girls (28%). Kidneys came from live-related donors in all cases (27 mothers, 19 fathers, two aunts, one uncle, and one brother). At transplantation, the mean recipient age was 9.9 years (range 3-17 years) and mean body weight was 20.9 kg (range 11-45 kg). The graft was placed in an extraperitoneal position in the right iliac fossa in all cases (100%). In cases of single arterial anastomoses (94%), the mean ischemia time was 53.51 ± 11.68 min. In cases of double arterial anastomoses (6%), the mean ischemia time was 68.33 ± 5.77 min. There was significant association between single or double arterial anastomosis and ischemia time, where double arterial anastomosis had longer ischemia time ( P = 0.004). There was no intraoperative surgical complication in most of our patients (98%) except in one case (2%) in which the kidney has been transplanted upside down due to misdirection of the upper pole from the lower pole of the kidney. Postoperatively, there were no surgical complications in most of our patients (92%), but there were three cases with high debit urine leaks (6%), and unfortunately there was a case of graft renal vein thrombosis (2%). The mean serum creatinine at 6 months post-transplant was 0.6 mg/dl (range 0.4-0.9 mg/dl). There were no cases of hyperacute rejection. All donors are alive with a good renal function after first 6 months postoperatively. Conclusion Our initial surgical experience with renal transplantation carried a low (but clinically significant) risk for vascular and urological recipient complications that increased morbidity, but improvements in our surgical techniques and experience decreased these complications.