Yaser El-Hout

Potential Complications With the Prescrotal Approach for the Palpable Undescended Testis? A Comparison of Single Prescrotal Incision to the Traditional Inguinal Approach

PURPOSE Prescrotal orchiopexy is emerging as an alternative surgical approach to undescended testicles. We compare operative times, success rates and complications of single incision prescrotal orchiopexy and the traditional inguinal approach. MATERIALS AND METHODS During a 3-year period all patients who underwent prescrotal orchiopexy were retrospectively reviewed and compared to age matched controls operated on via the traditional inguinal approach. Data collected included preoperative and postoperative testicular positioning, operative time and complications, including testicular atrophy and ascent. Exclusion criteria were retractile or ectopic testis, incomplete data, including lack of followup, and a concurrent procedure at the time of orchiopexy. RESULTS A total of 63 orchiopexies were performed using the prescrotal approach (mean patient age 4.6 years) and the inguinal approach (4.7 years). Average surgical times for the prescrotal and inguinal groups were 34 and 64 minutes, respectively (p = 0.002). Followup ranged from 6 to 42 months. Complication rates between the groups were similar. However, 2 hernias (3%) occurred in the prescrotal group, of which 1 was incarcerated and associated with Meckels diverticulum, and 1 was a late recurrence. CONCLUSIONS With the paucity of literature on prescrotal orchiopexy potential complications may be underreported. Despite the limitations of sample size, prescrotal orchiopexy may be associated with a 3% risk of postoperative hernia. A single incision prescrotal orchiopexy is still a viable approach for patients with primary palpable undescended testicles. Advantages include shorter operative time, a cosmetically appealing single incision and possibly less pain.

Ureteral Duplication With Lower Pole Ureteropelvic Junction Obstruction: Laparoscopic Pyeloureterostomy as Alternative to Open Approach in Children

OBJECTIVES Despite the widespread introduction of laparoscopy in pediatric urology, many reconstructive procedures, such as ureterostomy and pyeloureterostomy, are still performed in an open fashion because of the perceived intricacy and demanding nature. As we continue to introduce advanced laparoscopic skills into the care of children, we describe our laparoscopic pyeloureterostomy technique for correction of lower pole ureteropelvic junction obstruction in a pediatric patient with duplication anomaly. METHODS The pyeloureterostomy was performed laparoscopically, using three 5-mm trocars. We placed a double-J ureteral stent into the upper pole ureter to facilitate its identification and dissection from adjacent tissues. The anastomosis between the lower pole renal pelvis and the upper pole ureter was performed in a continuous fashion, using 5-0 polyglactin suture. A Penrose drain was left in place at the anastomosis area. RESULTS The child had no postoperative complications. During follow-up, his vesicoureteral reflux continued to be managed conservatively with no antibiotics. At his last follow-up visit, ultrasound examination showed improvement of both upper and lower pole hydronephrosis. CONCLUSIONS Laparoscopic pyeloureterostomy seems to be an effective and minimally invasive option to correct ureteropelvic junction obstruction associated with ipsilateral vesicoureteral reflux in complete ureteral duplication cases. It can be safely performed in children and represents a feasible alternative to open surgery.

Distal hypospadias repair with or without foreskin reconstruction: A single-surgeon experience

OBJECTIVE Dartos flap coverage is routinely used as a protective layer during tubularized incised plate urethroplasty (TIPU) except when an associated foreskin reconstruction (FSR) precludes its use. In this study we compare the outcome of distal hypospadias repair with and without foreskin reconstruction by the same surgeon. MATERIALS AND METHODS Between September 2002 and June 2007, 215 children with distal hypospadias underwent stented TIPU by a single surgeon. Of these, 25 (glanular 8, coronal 17) underwent a two-layer FSR without dartos flap coverage. An age- and time-matched group of 49 patients (glanular 10, coronal 39) who underwent TIPU with dartos flap coverage without foreskin reconstruction (NoFSR) were selected for comparison. Operative time and complications were recorded. RESULTS There was no significant difference in severity of hypospadias and follow-up duration (mean 17 vs 19 months, P=0.57) between the two groups. Operative time ranged between 30 and 86min (mean 57) in the FSR group and 35 and 113min (mean 75) in the NoFSR group (P</=0.01). Initial retraction of the foreskin by the surgeon at 6-8 weeks was successful in 15; five of the six who failed initial retraction responded to steroid cream. Four (16%) children underwent redo surgery in the FSR group (urethrocutaneous fistula in three, circumcision for recalcitrant phimosis in one). In the NoFSR group, six (12.2%) underwent redo surgery (urethrocutaneous fistula in four, removal of redundant skin in two). There was no significant difference in the need for redo surgery (P=0.45) or incidence of fistula (P=0.43) between the groups. CONCLUSIONS There was no statistical difference in outcome between the two techniques, particularly regarding fistula complication. The complication particular to FSR, namely initial failure of foreskin retraction, responds adequately to steroid cream application. Foreskin reconstruction is a surgical alternative in selected patients, particularly those with distal hypospadias and a personal preference of no circumcision. Larger prospective studies are needed to ascertain similarity in outcome between FSR urethroplasty and the conventional urethroplasty with dartos coverage.

Assessment of urethral plate appearance through digital photography: Do pediatric urologists agree in their visual impressions of the urethral plate in children with hypospadias?

OBJECTIVE There is a paucity of literature on a definition or set criteria evaluating urethral plate (UP) quality. We sought to determine whether pediatric urologists are in agreement in their assessment of UP quality. MATERIALS AND METHODS A cohort of 21 pediatric urologists attending a national annual meeting were surveyed with a questionnaire inquiring about practice patterns and perceived impressions of UP quality. Nineteen sequentially projected, standardized, digital photographs, depicting plates with variable meatal locations, were presented. Intra- and inter-rater agreement among pediatric urologists was estimated by calculating the Kappa statistic (kappa). RESULTS Thirty percent of respondents had more than 15years of practice and one-third repair 10 or more hypospadias per month. Measurement of level of agreement in the impression of UP quality of the 18 projected photographs revealed poor inter-rater agreement (kappa=0.06, P=0.0003), which was not improved by focusing on particular meatal locations or surgeon experience. CONCLUSIONS Despite the inherent shortcomings of digital photography, this study highlights the potential subjectivity and lack of agreement on UP quality. Disagreement seems to be present irrespective of level of the defect or surgeon experience. Setting standards and improving agreement is likely to enhance reporting and interpretation of data in hypospadias studies.

Comparative Histological and Functional Controlled Analysis of Tubularized Incised Plate Urethroplasty With and Without Dorsal Inlay Graft: A Preliminary Experimental Study in Rabbits

PURPOSE We analyzed the histological and functional characteristics of the tubularized incised plate vs dorsal inlay graft urethroplasty in an experimental rabbit model. MATERIALS AND METHODS A total of 24 New Zealand male rabbits were randomly allocated into 4 groups, including sham operation, urethroplasty, tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised and the dorsal aspect was tubularized. In the tubularized incised plate group the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group the defect created by the dorsal incision was covered with an inner preputial graft. The animals were sacrificed at 4 and 8 weeks, respectively. The penis was immediately harvested for standardized passive flowmetry and subsequently fixed for histological staining. RESULTS The grafts took in all animals. The tubularized incised plate defect was bridged by urothelium while in the dorsal inlay graft group the preputial graft kept its original histological characteristics. There was a significant decrease in average flow in the urethroplasty group (1.6 ml per second) compared to that in the sham operated group (3.4 ml per second) and to the other groups (p <0.05). However, no significant difference in average flow was found for the tubularized incised plate and dorsal inlay graft groups (2.4 and 2.2 ml per second, respectively, p = 0.7). CONCLUSIONS In this short-term rabbit model dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to significantly decreased flow. Incision of the reduced plate with or without grafting improved the average flow. Findings in this experimental model do not support the superiority of dorsal inlay graft urethroplasty over tubularized incised plate urethroplasty in terms of urethral flow dynamics.

Physiological Changes in Transperitoneal Versus Retroperitoneal Laparoscopy in Children: A Prospective Analysis

PURPOSE The choice of minimally invasive surgical approaches in pediatric urology is largely influenced by surgeon preference and experience. Little is known about the differences in physiological variables that might objectively influence the choice of surgical approach. We compared the cerebral and systemic hemodynamic effects of transperitoneal vs retroperitoneal CO(2) insufflation in children. MATERIALS AND METHODS After receiving ethical review board approval and written parental consent 36 pediatric patients undergoing transperitoneal (18) or retroperitoneal (18) laparoscopic surgery were enrolled in this study. A standardized anesthetic technique of isoflurane 1 MAC and remifentanil 0.2 mcg/kg per minute was used. Measured parameters included end tidal CO(2), middle cerebral artery blood flow velocity, heart rate and noninvasive mean arterial blood pressure. Transcranial Doppler ultrasound was used to measure middle cerebral artery blood flow velocity. Data were collected before, during and after CO(2) insufflation to 12 mm Hg pneumoperitoneum at regular intervals, including every minute for 10 minutes and every 2 minutes thereafter. Within group analysis was done using repeated measures ANOVA. Nonlinear regression analysis was used to determine the best fit and the relationship of each variable with time with p <0.05 considered significant. RESULTS Patient age and weight were comparable in the 2 groups. Transperitoneal CO(2) insufflation resulted in a rapid parallel increase in middle cerebral artery blood flow velocity, mean arterial pressure and end tidal CO(2) during the first 8 minutes of pneumoperitoneum (p <0.05). Despite a continued increase in end tidal CO(2) thereafter middle cerebral artery blood flow velocity and mean arterial pressure attained a plateau within the first 8 minutes (p <0.05). In contrast, middle cerebral artery blood flow velocity and end tidal CO(2) increased progressively throughout the retroperitoneal CO(2) insufflation period (p <0.01). CONCLUSIONS Cerebral blood flow velocity and end tidal CO(2) seem to increase progressively and gradually during retroperitoneal laparoscopy, in contrast to the more rapid increase and plateau effect during transperitoneal laparoscopy. Presumably the smaller absorptive surface in the retroperitoneal space explains this physiological difference.

Do patients with classic bladder exstrophy have fecal incontinence? A web-based study.

OBJECTIVES To explore the occurrence of fecal incontinence in patients with classic bladder exstrophy (CBE) by administering a web-based pilot study. METHODS A questionnaire assessing fecal continence status was devised. Questions included demographics, age to achieve toilet training for bowels, and the patient perception of the degree of fecal soiling during day and night, if present. The CBE contact list of our institutions social worker was addressed (324 patients) and directed to fill the survey posted at the website http://www.SurveyMonkey.com. RESULTS There were 94 responders (29%) to the survey. They were analyzed as 2 groups: pediatric (age up to 18 years, n = 69, 9 excluded for not achieving toilet training) and adult (age >18 years, n = 25). In the pediatric group, fecal incontinence was reported in 57% of patients during the day and 32% during night. In the adult group, fecal incontinence was reported in 44% of patients during the day and 40% during night. Seven patients reported having undergone ureterosigmoidostomy (US) diversion. Stratifying patients based on US diversion showed fecal incontinence of 100% vs 22% during the day (P <.001), and 86% vs 22% during the night (P <.01), for the US vs non-US subgroups, respectively. CONCLUSIONS Our preliminary survey suggests that fecal incontinence in CBE may be a significant overlooked issue that may persist into adulthood of CBE patients. With the potential functional and psychological burden, clinical awareness and management of this issue is crucial. Further exploration of this issue, with detailed attention to surgical procedure(s) involved and degree of quality of life impairment, needs to be initiated.

Current status of retrograde intrarenal surgery for management of nephrolithiasis in children

Purpose To review the current status of retrograde intrarenal surgery (RIRS) for renal stones in children focusing on its indications, outcomes and success in the management of nephrolithiasis. Materials and Methods Between 1988 and 2009, a comprehensive PubMed/MEDLINE literature review on RIRS was conducted. Results The available literature is limited and heterogeneous, skewed by favorable results on ureteral stone outcomes. However, recent case series report outcomes comparable to time-honored modalities: percutaneous nephrolithotomy and shock wave lithotripsy. Concerns about urinary tract damage are not substantiated by the yet available intermediate-term follow-up. Conclusions RIRS seems to be an effective modality in pediatric nephrolithiasis management. However, long-term outcomes and comparative prospective randomized studies are awaited.

Hypertension in children with poorly functioning unilateral kidneys: predictors of resolution after nephrectomy

Study Type – Prognosis (case series)
Level of Evidence 4

IMPACT OF FUNDAMENTALS OF LAPAROSCOPIC SKILLS BASED TRAINING ON POSTGRADUATE PEDIATRIC UROLOGY TRAINEES

and benign prostatic disease) as well as a preference for case-based learning. In response, a series of lectures and case-based sessions was designed to enhance didactic learning. Provision of learning tools included web-based and pocket-card resources for geriatric urology, and a PDA version of a geriatric medicine reference guide. Trainee experiences in the Geriatric Continence and the Urology Voiding Dysfunction Clinics enhanced clinical collaborative learning. Finally, co-operative research projects complemented education in the URGE model. Evaluation components include knowledge of geriatric urology, geriatric hospital care, and multiple program assessment tools to modify and improve content and experiences. CONCLUSIONS: Care of the geriatric patient is an increasingly important aspect of urology. URGE provides a multi-dimensional model