Mohammed Dawaba

Doxazosin versus tizanidine for treatment of dysfunctional voiding in children: a prospective randomized open-labeled trial.

OBJECTIVE To examine the efficacy and tolerability of tizanidine for the treatment of dysfunctional voiding in children compared with those of doxazosin. METHODS A total of 40 children with dysfunctional voiding were enrolled in a prospective, randomized, 2-parallel group, flexible-dose study. The evaluations were performed in accordance with the International Childrens Continence Society guidelines. The children were followed up after 1 week and then monthly for 6 months for the clinical, urine culture, and urodynamic parameters. The degree of improvement was assessed using a satisfaction scale that ranged from 0 (no improvement at all) to 10 (total improvement). RESULTS A total of 40 patients with a mean±SD age of 7±2.6 years were enrolled. The clinical and urodynamic parameters were comparable between both groups. At the last follow-up visit, both groups had had similar improvement in the severity of symptoms, satisfaction scale, and noninvasive flowmetry parameters. In the doxazosin group, urge episodes was the only symptom that showed a significant reduction compared with the baseline values (P=.028). However, the incidence of nocturnal enuresis, urgency attacks, and daytime incontinence were significantly reduced compared with baseline in the tizanidine group (P=.003, P=.008, and P=.017, respectively). Adverse effects were recorded in 6 patients (15%). Epigasteric pain was reported in 2 children (10%) who received doxazosin. In the tizanidine group, a loss of appetite was noted in 2 children (10%), epigastric pain in 1 (5%), and headache in 1 (5%). CONCLUSION Tizanidine could be a safe and effective treatment of children with dysfunctional voiding due to pelvic floor/skeletal sphincter dysfunction. More placebo-controlled trails with larger sample sizes are needed.

Critical Analysis of Outcome After Open Dismembered Pyeloplasty in Ectopic Pelvic Kidneys in a Pediatric Cohort

OBJECTIVE To evaluate the functional and morphologic outcome after open pyeloplasty for ureteropelvic junction obstruction (UPJO) in ectopic pelvic kidneys. MATERIALS AND METHODS A retrospective review of all patients who underwent open pyeloplasty in ectopic pelvic kidneys was conducted. Records were evaluated with respect to age at presentation, preoperative imaging, surgical details, and postoperative course. Patients were followed up regularly for functional and morphologic outcome. Success was defined as symptomatic relief and radiographic improvement of obstruction at the last follow-up. RESULTS Between 1995 and 2010, 680 patients with primary UPJO underwent open dismembered pyeloplasty at our center. Of these patients, 43 (6.3%) had UPJO in ectopic pelvic kidneys. No perioperative complications were encountered in the study group. Mean follow-up was 42 months (range, 18-90 months), and 5 patients were lost to follow-up. The overall success rate was 82.6%. Postoperative hydronephrosis was improved in 20 (52.6%), stable in 11 (29%), and worsened in 7 (18.4%). Postoperative renal function was improved in 12 (31.6%), stable in 19 (50%), and deteriorated in 7 (18.4%). Redo pyeloplasty was required in 4 patients and secondary nephrectomy in 3. Preoperative differential renal function and surgeon experience were statistically significant predictors of improvement in renal function after pyeloplasty. CONCLUSION Open pyeloplasty for UPJO in ectopic pelvic kidneys is feasible, but varying degrees of hydronephrosis and radiologic obstruction persist after pyeloplasty that could be attributed to anatomy-related pelvocaliectasis, and so regular follow-up is warranted in this subpopulation.

Can Renal Ultrasonography Predict Early Success after Pyeloplasty in Children? A Prospective Study

Objective: To study the predictive value of 6 ultrasonographic (USG) parameters for early detection of children at risk of recurrent obstruction. Patients and Methods: A prospective nonrandomized study included all patients who underwent pyeloplasty between 2010 and 2012. All of the patients had completed at least 6 months of follow-up and preoperative and postoperative USG imaging data were available. The primary outcome was the correlation between USG and diuretic scintigraphic parameters. The secondary outcome was the predictive ability of the pelvicalyceal system parameters, measured by USG, of parenchymal growth after surgery. Results: Sixty-eight patients were evaluated. The mean age was 3.6 years (range 0.1-12). The mean (± standard deviation) differential renal function improved from 37.4 ± 11 ml/min to 37.7 ± 14 ml/min, which was a difference of no statistical significance. On the other hand, the mean (± SD) half-time (T1/2) significantly improved. After constructing a linear regression model of the 4 USG parameters and the parenchymal growth, the model explained 57.2% of the variance in parenchymal growth after pyeloplasty. The calyx-to-parenchyma ratio change was the largest unique contribution for explaining the variance in parenchymal growth, followed by anteroposterior diameter and calyceal dilatation. Conclusion: We proved that calyx-to-parenchyma ratio, anteroposterior diameter and calyceal dilatation are independent predictors of early success after pyeloplasty.

Ureterocalyceal anastomosis in children: Is it still indicated?

OBJECTIVE We report our experience with ureterocalyceal anastomosis in children regarding indications and outcome. MATERIALS AND METHODS A retrospective review was performed of all cases that underwent open ureterocalyceal anastomosis at our center between 2000 and 2006. Records were reviewed for patient age, history, affected side, indication of surgery and operative details. Clinical and radiological outcome was assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. RESULTS There were 10 cases (six males, four females) with a mean age of 6.5 years (range 3-13 years). Follow up ranged from 6 to 46 months (mean 18). The indications for surgery were failed pyeloplasty in six patients and iatrogenic injury of the ureteropelvic junction or the upper ureter in four. No significant perioperative complications were encountered in the study group. Overall success rate was 80%. Relief of obstruction was evident in eight patients as documented by intravenous urography or nuclear renography, while secondary nephrectomy was necessitated in two patients with severely impaired ipsilateral renal function and normal contralateral kidney. In patients with preserved renal units, the differential function on the involved side was stable on comparing the preoperative and postoperative renographic clearance (26 vs 24 ml/min). CONCLUSION Ureterocalyceal anastomosis in children is still indicated in some difficult situations. Excellent functional results can be achieved in properly selected cases. Nephrectomy may be indicated in cases with impaired renal function and inability to perform salvage procedure.

Perineal anastomotic urethroplasty in a pediatric cohort with posterior urethral strictures: critical analysis of outcomes in a contemporary series.

OBJECTIVE To evaluate the long-term outcomes of perineal anastomotic urethroplasty for post-traumatic pediatric posterior urethral strictures. METHODS We retrospectively reviewed the medical records of 65 boys who had a perineal anastomotic urethroplasty for post-traumatic posterior urethral strictures between 1991 and 2010. Patients were followed up for a mean (range) of 78 (13-210) months by a history, urinary flow rate estimate, retrograde urethrography, and voiding cystourethrography. Regression analysis was done to assess the predictors of success after urethroplasty. RESULTS The mean (range) age of the patients was 9.3 (3-16) years. The estimated radiographic stricture length before surgery was 2.4 (1-5) cm. All patients presented with a suprapubic cystostomy tube and scheduled for delayed or repeated correction of a urethral stricture. Twenty boys (30%) had failed previous attempts of repair elsewhere. Mean interval between the original trauma and repair in new cases, and since the last repair in recurrent cases, was 7 months. The perineal anastomotic repair was successful in 58 of 65 (89%) patients. All treatment failures were at the anastomosis and were within the first year. Failed repairs were successfully managed endoscopically in 5 patients and by repeat perineal anastomotic repair in the remaining 2. All boys are continent. There was no chordee or urethral diverticula during the follow-up. CONCLUSION One-stage perineal anastomotic repair of post-traumatic urethral strictures in boys is feasible with minimal morbidity. Denovo cases and surgeon experience are the predictors of success after urethroplasty.

Non-Iatrogenic Ureteric Injuries in Children: Single Center Experience

Purpose Non-iatrogenic ureteral injuries include those resulting from blunt trauma, stab wounds and gunshot wound. This type of ureteric trauma is extremely rare, occurring in 1% of all genitourinary trauma. We reviewed our experience in diagnosis and treatment of non-iatrogenic ureteric injuries in children over 15 years. Material and Methods From 1990 to 2005, ten children were treated for non-iatrogenic ureteric injuries. Patients characteristics, mechanism of trauma, affected ureteric segment, time of recognition, associated injuries, presentation, mode of treatment and postoperative complications were studied from the medical records of those patients. Results Ten non-iatrogenic ureteral injuries were repaired over 15 years. Five males and 5 females with median age 8 years (range 2-16). Right side was affected in 6 children. Blunt abdominal trauma was accused in 8 children while in two children penetrating trauma was inflicted (stab wound). Associated injuries were documented in 4 children- two of the penetrating trauma and two from the 8 blunt trauma. The affected segment was PUJ in 7 children, mid ureter in 2 and juxtavesical in one child. Urinoma was the presentation in all cases and diagnosis was established by reterograde pyelography in 4 children while PCN and antegrade pyelography in the others. In 4 children to whom retrograde pyelography was done, JJ stent was applied for 3 months in addition to percutaneous drain in 2 while ureterovesical reimplantation and A-H pyeloplasty in the others. In children to whom percutaneous nephrostomy was performed for 3-6 months, three necessitate nephrectomy for non functioning kidneys, two were treated by ureterocalyceal anastomosis and the other child was managed by ureteroureterostomy. Conclusions Pediatric non-iatrogenic ureteral injuries are extremely rare but can be devastating and/or challenging according to the subsequent fibrosis and the state of kidney function and also delay in diagnosis of those patients will increase the risk of complications.