Stephen Shei-Dei Yang

The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children's Continence Society.

The impact of the original International Childrens Continence Society (ICCS) terminology document on lower urinary tract (LUT) function resulted in the global establishment of uniformity and clarity in the characterization of LUT function and dysfunction in children across multiple healthcare disciplines. The present document serves as a stand‐alone terminology update reflecting refinement and current advancement of knowledge on pediatric LUT function.

Is Ureteral Stenting Necessary After Uncomplicated Ureteroscopic Lithotripsy? A Prospective, Randomized Controlled Trial

PURPOSE We conducted a prospective, randomized controlled study to investigate the advantages and disadvantages of ureteral stenting after ureteroscopic lithotripsy. MATERIALS AND METHODS A total of 60 patients who underwent ureteroscopic lithotripsy were equally randomized into a stented or a nonstented group. The inclusion criteria were stone 6 to 10 mm., absence of polyp or stricture in the ureter and no mucosal injury during ureteroscopy. The operation was performed with a 6Fr rigid ureteroscope without ureteral dilation and stones were fragmented with a 1.9Fr electrohydraulic lithotriptor without extraction. A 7Fr double pigtail stent was placed in the stented group for 3 days after ureteroscopy. Urinalysis, plain x-ray and renosonography were performed before and after lithotripsy in each patient. Subjective symptoms and pain score were recorded on admission to the hospital and 3 days postoperatively. RESULTS The stone-free rate was 100% in each group and preoperative hydronephrosis equally resolved in both groups. Mean pain score plus or minus standard deviation improved significantly in the nonstented (6.33 +/- 1.81 preoperatively to 2.30 +/- 1.93 postoperatively, paired Students t test p <0.0001) and stented (7.10 +/- 1.03 to 2.30 +/- 2.22, p < 0.0001) group. There was no statistical difference in pain reduction between the 2 groups (p = 0.18). The amount of extra parenteral analgesic used was similar in both groups. One patient in the nonstented group visited the emergency room for postoperative renal colic, 25 (83.3%) patients in the stented group complained of at least 1 irritative bladder symptom and only 4 (13.3%) in the nonstented group experienced bladder discomfort. CONCLUSIONS After uncomplicated ureteroscopic electrohydraulic lithotripsy patients without ureteral stenting tend to have similar renal function recovery and satisfactory pain reduction with less irritative symptoms compared to those treated with a ureteral stent. We suggest that it is not necessary to place a ureteral stent routinely after uncomplicated ureteroscopic electrohydraulic lithotripsy for stones smaller than 1 cm.

Diagnostic Evaluation of Children With Daytime Incontinence

PURPOSE This article is one of the standardization documents of the International Childrens Continence Society, and discusses how anatomical/iatrogenic and functional/urodynamic causes of daytime incontinence in children of all ages are to be diagnosed, how neurogenic bladder dysfunction or urinary tract infection is excluded as a cause of the wetting, and how further diagnostic evaluation of children with disturbances such as overactive bladder, voiding postponement and dysfunctional voiding is performed. The roles of history taking (including prenatal and perinatal issues and family history), physical examination, diagnostic bladder diaries, noninvasive urodynamic investigations and radiological imaging are delineated but therapy is not within the scope of this document. MATERIALS AND METHODS This document was designed and written by an international panel of authors with a large experience in assessment of children with incontinence. RESULTS The best evidence was retrieved from the literature and assembled in a standardization document. CONCLUSIONS Assessment of children with daytime symptoms is discussed. A noninvasive approach in these children allows us to select patients who will need a more invasive assessment.

Homemade transumbilical port: an alternative access for laparoendoscopic single-site surgery (LESS).

BackgroundLaparoendoscopic single-site surgery (LESS) is a possible advancement for minimally invasive surgical interventions. However, this technique requires a specialized multichannel port for introducing laparoscope and instruments. We present our preliminary experience of using a homemade transumbilical single-port access for performing LESS.MethodAn Alexis wound retractor® was placed through the umbilical incision, and a pair of sterile surgical gloves was then snapped onto it. Standard laparoscopic trocars were inserted through the gloves after the upper half parts of the gloves were truncated. Using this port and Roticulator™ articulating instruments, we performed 14 urologic LESS procedures on porcine laboratory and cadaveric cases, and we performed 10 transabdominal pre-peritoneal inguinal hernia repairs (TAPP), and 5 laparoscopic varicocelectomies on human cases, respectively. All procedures were performed with instruments inserted through this port without the need for any extraumbilical incisions or conversion to standard laparoscopic surgery.ResultsAll LESS procedures were successfully completed without any complications. The time to achieve the transumbilical port ready for subsequent LESS was short (range, 4–8 (median, 6) minutes). The total operative time was between 60 and 190 minutes. No port-related complications were noted, and the cosmetic results were excellent.ConclusionsThis homemade transumbilical port offers a safe, reliable, flexible, and cost-effective access for LESS procedures. This technique may be an alternative for current specialized port systems.

Non-inferiority of silodosin to tamsulosin in treating patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH)

Study Type – Therapy (RCT)

Learning curve of full-endoscopic lumbar discectomy

PurposeTo report the learning curve of full-endoscopic lumbar discectomy for a surgeon naive to endoscopic surgery but trained in open microdiscectomy.MethodsFrom July 2006 to July 2009, 57 patients underwent full-endoscopic lumbar discectomy and 66 underwent open microdiscectomy. The clinical results were evaluated with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Spearman’s coefficient of rank correlation (rho) was used to assess the learning curves for the transforaminal and interlaminar procedures of full-endoscopic lumbar discectomy.ResultsAfter full-endoscopic lumbar discectomy, the VAS and ODI results of the patients followed up were comparable with those of open microdiscectomy. A steep learning curve was observed for the transforaminal procedure, but not the interlaminar procedure.ConclusionsThe learning curve of the transforaminal approach was steep and easy to learn, while the learning curve of the interlaminar approach was flat and hard to master.

REOPERATIVE SNODGRASS PROCEDURE

PURPOSE We examine the results of a reoperative Snodgrass procedure for complex hypospadias. MATERIALS AND METHODS A total of 25 patients with hypospadias in whom repair had failed underwent a reoperative Snodgrass procedure. Mean patient age and number of prior repairs were 11.4 years and 2.5, respectively. Before this treatment the meatus was at the distal shaft in 10 cases, mid shaft in 9, proximal shaft in 4 and penoscrotal junction in 2. Preoperatively the associated complications were fistulas in 13 patients, residual chordee in 12 and diverticulum in 1. In 8 cases the fistula was incorporated into the hypospadiac opening and treated as a longer defect. The urethral plates were, subjectively, surgically altered or unaltered in 7 and 18 patients, respectively. In 8 patients (group A) the previous repair(s) did not involve dissection of the urethral plate (unaltered) nor was there a fistula. The remaining 17 patients were classified as group B. The neourethra was then reconstructed as the Snodgrass technique. Followup urethral calibration was performed in 17 patients. RESULTS Mean followup period was 13.7 months. Mean length and size of neourethra were 19.9 mm. and 14Fr, respectively. There were 7 (28%) postoperative fistulas of the neourethra. The incidences of postoperative fistula of the neourethra were 0% and 41.2% in groups A and B, respectively (p <0.01). Statistically the surgically altered urethral plate and the presence of a preoperative fistula were 2 independent factors predicting a higher postoperative fistula rate. The overall postoperative meatal stenosis rate was 13 (52%) with 3 (37.5%) in group A and 10 (58.8%) in group B, respectively (p >0.05). The meatal stenosis was treated with simple dilation in 11 cases and meatoplasty during subsequent fistula repair in 2. Stricture at the anastomostic site between the normal urethra and neourethra was noted in 2 patients. Fistula repair was successfully performed 6 months later in 4 patients. CONCLUSIONS The Snodgrass procedure is a viable option for the treatment of previously failed hypospadias repair. It was highly effective in patients with a surgically unaltered urethral plate and no preoperative fistula.

The Effects of Bladder Over Distention on Voiding Function in Kindergarteners

PURPOSE We report the effects of bladder over distention on pediatric voiding function. MATERIALS AND METHODS We enrolled healthy kindergarten children (mean age 4.5 +/- 1.0 years) for 2 observations of uroflowmetry and post-void residual urine. Additional observations were requested if the voided volume was less than 50% of expected bladder capacity. Post-void residual was assessed within 5 minutes after voiding. A post-void residual of more than 20 ml is regarded as increased. Bladder capacity is defined as voided volume plus post-void residual and shown as percentage of expected bladder capacity. The uroflowmetry curves were categorized as bell-shaped or nonbell-shaped. RESULTS Among 188 children 355 observations of uroflowmetry and post-void residual were eligible for evaluation. Nonbell-shaped uroflowmetry curves and increased post-void residual were noted in 75 (21.1%) and 78 (22%) of 355 voids, respectively. Based on the receiver operating characteristic curve for the nonbell-shaped curves and increased post-void residual, bladder capacity of 115% of expected bladder capacity or more is defined as bladder over distention. There were statistically more increased post-void residuals and more nonbell-shaped uroflowmetry curves in the voids with bladder over distention than in those without over distention (p <0.01). Of the 38 children displaying both types of curves the nonbell-shaped curves usually occurred at a higher bladder capacity than did the bell-shaped curves (133% +/- 46% expected bladder capacity vs 84% +/- 38% expected bladder capacity, p <0.01). Peak uroflow rate increased as bladder capacity increased but decreased at extreme bladder over distention. CONCLUSIONS Optimal bladder capacity is important for assessing pediatric voiding function. Bladder over distention resulted in more nonbell-shaped uroflowmetry curves and more increased post-void residual. At extreme over distention peak flow rate decreased as well.

Minilaparoscopic herniorrhaphy with hernia sac transection in children and young adults: a preliminary report

BackgroundWe designed a technique of pure minilaparoscopic hernia sac transaction and ligation to repair primary inguinal hernias in children and young adults.MethodsBetween September 2003 and December 2004, 83 patients with primary inguinal hernia were treated surgically with minilaparoscopic herniorrhaphy. The mean patient age was 6.8 years. Before the operation there were synchronous bilateral hernias in 2 (2.4%) patients, left inguinal hernias in 39 (47%) patients, and right inguinal hernias in 42 (50.6%) patients. The minilaparoscopic herniorrhaphy was carried out with the 3-mm laparoscopic and hand instrument system. Three 3.5-mm trocar ports were used for the telescope and 3-mm instruments. The peritoneum overlying the internal ring was circumferentially incised, then the peritoneal defect was closed with intracorporeal sutures.ResultsOne hundred and fourteen minilaparoscopic herniorrhaphies were performed. The mean followup period was 12.9 months. The mean operation time was 52 min. There was only one recurrence (1.2%) that was detected nine months after primary repair. All patients were able to return to unrestricted activity immediately and were discharged within 24 h after the operation. There was no reported case of testicular atrophy to date.ConclusionsMinilaparoscopic herniorrhaphy with hernia sac transaction is a safe and effective technique in children and young adults with indirect inguinal hernias.

α1-Adrenergic Blockers in Young Men With Primary Bladder Neck Obstruction

PURPOSE We assessed the efficacy and safety of the mid term use of alpha1-adrenergic blockers for treating primary bladder neck obstruction in young and middle-aged men. MATERIALS AND METHODS Between May 1998 and February 2001 primary bladder neck obstruction was diagnosed by videourodynamic study in 28 men younger than 55 years. The degree of obstruction was graded by the Schafer nomogram. Mean patient age and mean symptom duration were 39.3 years and 18.1 months, respectively. The presenting symptom was frequency in 22 cases (78.6%), urgency in 10 (35.7%), weak stream in 9 (32.1%), nocturia greater than 2 times in 7 (25%) and hesitancy in 7 (25%). A dose of 1 to 2 mg. doxazosin was administered at bedtime for at least 3 months. International Prostate Symptom Score (I-PSS), quality of life, uroflowmetry and post-void residual urine were assessed before and 3 months after medication. Improved urine flow was defined as at least a 2.5 ml. per second increase in the maximum flow rate. Improved symptoms was defined as more than a 50% decrease in I-PSS. Successful treatment was defined as improved urine flow and symptoms. RESULTS Followup data were available in 24 patients. The medication period and followup were 7 and 12 months, respectively. Mean I-PSS plus or minus standard deviation decreased from 18.3 +/- 4.6 to 11.6 +/- 5.2 (p <0.01) and mean quality of life decreased from 4.1 +/- 1.1 to 2.6 +/- 1.0 (p <0.01). Mean maximum flow increased from 11.8 +/- 3.2 to 15.9 +/- 3.9 ml. per second (p <0.01). Mean post-void residual urine decreased from 80.2 +/- 17.1 to 48.5 +/- 10.3 ml. (p <0.01). Treatment was successful in 13 patients (54.2%) and 3 (12.5%) were free of medication for at least 6 months. More successful outcomes were noted in patients with high grades III to IV obstruction than in those with low grades 0 to II obstruction (80% versus 35.7%, p = 0.03). Before treatment higher detrusor pressure at maximum flow (70.1 versus 47.8 cm. water, p = 0.01) and lower maximum flow (10.6 versus 13.3 ml. per second, p = 0.02) were observed in patients with successful versus unsuccessful treatment, respectively. Differences in patient age, I-PSS, quality of life, prostate size and post-void residual urine were not statistically significant. No significant adverse effects were noted. CONCLUSIONS alpha1-Blockers were effective and safe for treating young men with primary bladder neck obstruction.