Congenital Urological Anomalies Research Articles

Anterior Sagittal Epispadias Urethral Duplicity: A Case Report

Urethral duplication is a rare congenital urological anomaly that can be detected incidentally or due to urinary symptoms in young patients. Symptoms may include recurrent urinary tract infections, dysuria, bifurcated urinary stream, urinary incontinence, and purulent discharge from the accessory meatus. The pathophysiology remains poorly understood, with various embryological theories proposed. Treatment typically involves surgical excision of the accessory urethra, especially in symptomatic cases. Urethral duplication is often associated with other malformations, and Effman's classification system categorizes it into three types based on the location of the accessory urethra. We present the case of a 4 years old boy with anterior sagittal epispadias urethral duplicity.

A machine learning algorithm predicting risk of dilating VUR among infants with hydronephrosis using UTD classification

Urinary Tract Dilation (UTD) classification has been designed to be a more objective grading system to evaluate antenatal and post-natal UTD. Due to unclear association between UTD classifications to specific anomalies such as vesico-ureteral reflux (VUR), management recommendations tend to be subjective. We sought to develop a model to reliably predict VUR from early post-natal ultrasound. Radiology records from single institution were reviewed to identify infants aged 0-90 days undergoing early ultrasound for antenatal UTD. Medical records were reviewed to confirm diagnosis of VUR. Primary outcome defined as dilating (≥Gr3) VUR. Exclusion criteria include major congenital urologic anomalies (bilateral renal agenesis, horseshoe kidney, cross fused ectopia, exstrophy) as well as patients without VCUG. Data were split into training/testing sets by 4:1 ratio. Machine learning (ML) algorithm hyperparameters were tuned by the validation set. In total, 280 patients (540 renal units) were included in the study (73% male). Median (IQR) age at ultrasound was 27 (18-38) days. 66 renal units were found to have≥grade 3 VUR. The final model included gender, ureteral dilation, parenchymal appearance, parenchymal thickness, central calyceal dilation. The model predicted VUR with AUC at 0.81(0.73-0.88) on out-of-sample testing data. Model is shown in the figure. We developed a ML model that can predict dilating VUR among patients with hydronephrosis in early ultrasound. The study is limited by the retrospective and single institutional nature of data source. This is one of the first studies demonstrating high performance for future diagnosis prediction in early hydronephrosis cohort. By predicting dilating VUR, our predictive model using machine learning algorithm provides promising performance to facilitate individualized management of children with prenatal hydronephrosis, and identify those most likely to benefit from VCUG. This would allow more selective use of this test, increasing the yield while also minimizing overutilization.

Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux

Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury. This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR. Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated. Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143min for unilateral VUR and 194min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases. Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view. Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

Association between Genitourinary and Congenital Heart Defects: A 52-year Case-Control Study of the Latin American Collaborative Study of Congenital Malformations (ECLAMC)

Abstract Background Congenital urological anomalies are present in 4.3/10 thousand newborns, and their association with other anomalies may increase the overall mortality and disability. The present study establishes the risk of having congenital urological anomalies presenting associated cardiopathies. Methods We conducted a retrospective case-control study using the Latin American Collaborative Study of Congenital Malformations (Estudio Colaborativo Latino Americano de Malformaciones Congénitas, ECLAMC, in Spanish). The analysis included all registered cases of congenital urological malformation from 1967 to 2019. Patients with or without associated heart defects were included for the statistical analysis. Odds ratios (ORs) were calculated using a 95% confidence interval (95% CI). We compared the variables with the Chi-squared test and analysis of variance (ANOVA). The statistical analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, United States) software, version 27.0. Values of p < 0.05 were considered statistically significant. Results A total of 7,767,161 newborns were evaluated, and 17,834 genital and upper urinary tract malformations were identified. Of these, 64.2% were genital anomalies, and 35.8% were abnormalities of the upper urinary tract. Genitourinary malformations and concomitant congenital heart defects (GU + C) were observed in 3.5% of the cases. Subjects with GU + C had a higher number of malformations (4.59 ± 2.3) than patients without heart defects (1.53 ± 1.58) (p < 0.000). The OR was of 3.61 (range: 1.86–7.00) for cloacal exstrophy, of 4.01 (range: 3.14–5.12) for imperforate anus, of 5.52 (range: 3.92–7.78) for horseshoe kidney, and of 13.7 (range: 6.65–28.22) for trisomy 21 (Down syndrome) with malformations of the upper urinary tract. Conclusion The association of congenital heart defects with urological anomalies is higher for complex congenital anomalies such as imperforate anus, cloacal exstrophy, and horseshoe kidney. Patients with urological abnormalities and Down syndrome have the highest likelihood.

Long-term urology outcomes of anorectal malformation

Urological problems are a recognised feature of anorectal malformation (ARM). Previous assumptions of favourable long-term urinary outcomes are being challenged. We hypothesised that urinary tract problems are common in ARM and frequently persist into adulthood. We retrospectively reviewed long-term renal and bladder outcomes in ARM patients. Patients with ARM born between 1984-2005 were identified from electronic hospital databases. Their case notes were reviewed. Renal outcomes included serum creatinine and the need for renal replacement therapy. Bladder outcomes included symptom review, bladder medication, need for intermittent catheterisation, videourodynamics and whether the patient had undergone augmentation cystoplasty. RESULT (TABLE 1): The case notes of 50 patients were reviewed. The median age at last follow up was 18 years (range 12-34 years). The level of fistula was noted to be high in 17 patients, intermediate in eight, and low in 10. Four had cloaca. Congenital urological abnormalities were present in 25 (50%). An abnormal spinal cord was present in 22 (44%) patients. VACTERL association occurred in 27 (54%). Chronic kidney disease stage II or above was found in 14 (28%) patients, of whom four required a renal transplant. Abnormal bladder outcomes were found in 39 (78%) patients. Augmentation cystoplasty with Mitrofanoff had been performed in 12. Of those who had not undergone cystoplasty, 17 had urinary symptoms, including urinary incontinence in 12. Of the 39 patients with abnormal bladder outcome, 19 (49%) did not have a spinal cord abnormality. There was no significant statistical association between level of ARM and abnormal renal outcome or presence of bladder abnormality. Adverse renal and bladder outcomes are common in our cohort of young people with ARM with a significantly higher incidence compared with current literature. We did not demonstrate an association between level of ARM or presence of spinal cord anomaly with persistent bladder problems. Congenital urological anomalies are more common in those who later have an abnormal renal outcome. Although this difference is statistically significant, one fifth of patients born with anatomically normal upper tracts develop reduced renal function, implying an important acquired component. Bladder problems and reduced renal function affect a significant proportion of young adults with ARM. Neither adverse outcome is reliably predicted from ARM level, congenital urological anomaly or spinal cord anomaly. We advise continued long-term bladder and kidney follow-up for all patients with ARM.

FACTORS ASSOCIATED WITH HAEMATURIA IN CHILDREN IN AGE GROUP OF 1 TO 14 YEARS

BACKGROUND: Haematuria is the most common urinary finding that bring children to the attention of the paediatric nephrologists. It can be caused by glomerular & non-glomerular diseases. The main causes of Haematuria are urinary tract infections, trauma to abdomen, acute post streptococcal glomerulonephritis and congenital hydronephrosis.
 OBJECTIVE: The objective of this study was to identify the distribution of factors in children with haematuria in age group of 1 to 14 years
 METHODS: A total of 84 admitted patients of haematuria, who fulfill the inclusive criteria,were enrolled in this study after consent from their parents. Each patient was evaluated through history, examination and investigated. Urine sample of each patient was analyzed for a microscopic examination. Investigations / imaging were performed in clinical laboratory of LGH / PGMI, Lahore. The collected information was entered into SPSS version 20, and analyzed.
 RESULTS: There were 47(44.05%) male and 37(55.95%) female patients in this study. The mean age of patients was 8.69 ± 3.63 years.We found 14 patients (16.66%) has urological anomalies,6 boys have posterior urethral valves.2 girls and one boy has vesicoureteral reflux.One boy and one girl has ureterovesical junction obstruction,one boy has hypospadias and 2 girls , ureteropelvic junction obstruction.History of recent bladder catheterization was seen in 5(5.59%), urinary tract infection 17(20.23%) and 14 patients has urological anomalies(16.66%).
 CONCLUSION: According to this study ,most common factors causing haematuria was urinary tract infection 17(20.23%) , acute poststreptococcal glomerulonephritis 16(19.04%) and congenital urological anomalies 14(16.66%).Renal stones were found in 10(11.90%).

A rare case of horseshoe kidney with unilateral chronic pyelonephritis in a cadaver

Horseshoe kidney is one of the most common congenital urologic anomalies, with an incidence of 1 in 400 live births. The presence of this type of fusion anomaly of kidneys with resultant progression to renal pathology sometimes may remain obscured or dormant, due to the person being asymptomatic for years, only to be incidentally encountered during an autopsy, or during a cadaveric dissection. Similarly, during routine cadaveric dissection, we came across with a list of variations along with congenital anomalous horseshoe kidney. In this case report, we discuss about anatomical variation and pathological findings of horseshoe kidney.

Evaluation of Ventral Dartos Fascia Flap as a Covering Layer in TIP (Tubularized Incised Plate) Repair for Distal Hypospadias Patients [Snodgrass Technique

Hypospadias is one of the most frequent congenital urological anomalies. Reports have suggested that the prevalence of hypospadias varies across different races, being highest among Caucasians, less in Hispanics, and least in blacks usually it occurring in 1–3 per 1,000 live births .The different degrees of hypospadias require different technique; which carry different complication rates and different prognoses. The aim of this study is to evaluate the outcome and efficiency of Ventral Dartos Fascia Flap as a covering layer in TIP [Tubularized Incised Plate] Repair for Distal Hypospadias Patients. Twenty-three patients with distal hypospadias was involved in this study. The Snodgrass technique was done to them using ventral Dartos fascia flap as a covering layer in this surgery.the risk of the fistula is about 4.3 %, and the cosmetic appearance was so acceptable in 22 patient out of 23 which is very convincing result from this simple technique. Glans dehiscence hadn’t occur, Meatal stenosis hadn’t occur, Skin infection occurred in one patient because he neglect the post-operative follow up visits and bad hygiene so the wound was moisture and infected, Edema , Inflammation and Encrustations. Urethral Stricture wasn’t reported in this study. Twisting of the penis is not reported in this study. TIP repair is a good procedure with no more complications than other procedures used in hypospadias surgery which can achieve both results, restore good function and normal appearance to the penis.

Hafif ve Orta Dereceli İzole Antenatal Hidronefrozlu Süt Çocuklarının Postnatal İzlem Sonuçlarının Değerlendirilmesi

A ntenatal hydronephrosis is one of the most common congenital urological anomalies identified on prenatal ultrasound. There are controversial results in the postnatal management of mild-moderate isolated antenatal hydronephrosis . The purpose of this study was to investigate the clinica l outcome and the frequency of urinary tract infection in infants with mild-moderate isolated antenatal hydronephrosis during the first year of life. The patients with mild-moderate hydronephrosis on the first renal ultrasonography done between seven days and two weeks of age were included in this study. The patients with other kidney abnormalities other than hydronephrosis, ureteral dilatation or bladder abnormalities were not included in the study. Hydronephrosis was classified as mild (5-9.9 mm), moderate (10-14.9 mm) by anterior-posterior pelvic diameters. 140 patients [96 boys (68.6%), 44 girls (31.4%)] were included in the study. Sixty (42.9%) patients had mild hydronephrosis and 80 (57.1%) patients had moderate hydronephrosis. The rate of spontan resolution was higher in patients with mild hydronephrosis than other group [n=58 (96.6%), n=48 (60%), respectively, p<0.01]. The median regression time was shorter in patients with mild hydronephrosis [median regression time; 4 (3-5.25); 6 (5-7) months, respectively, p<0.01]. The frequency of urinary tract infection did not differ between the patients with mild and moderate hydronephrosis patients (p>0.05). There was no evidence of acute pyelonephritis and obstructive or progressive hydronephrosis. Mild and moderate isolated antenatal hydronephrosis is often a self-limited condition. Children with mild and moderate isolated antenatal hydronephrosis might be followed without antibiotic prophylaxis.

Social and Clinical Impact of Congenital Urological Malformations in a Developing Country: The Need for a Transdisciplinary Way of Treatment

Introduction The prognosis of congenital anomalies (CAs) can be improved if detected and treated accurately. Given the complexity of some anomalies, it is almost always necessary to approach them with an interdisciplinary team. Our objective was to contact patients with congenital urological anomalies (CUAs) and follow them up during their first years of life and evaluate their clinical status, as well as their social and health care limitations. Method Based on the Bogota Congenital Malformations Surveillance Program (BCMSP), we have contacted by phone all the patients with CUAs and evaluated their follow-up. We have included all the registered patients from 2006 until 2015. A standardized questionnaire was applied by a trained staff. The questions assessed on each call included: evaluation of the clinical status of the patient, the clinical treatments and evaluations performed by clinical and surgical subspecialties, health care limitations, and social barriers. The first call was made at the 2nd month, then every 3 months during the 1st year and every 6 months thereafter. Results A total of 277 patients were contacted, 97.3% of whom have an increased risk of mortality or significant disability. The malformation related mortality was of 38.1%. Only 38.7% of the patients were evaluated by a specialist, while 57.4% where still waiting to be seen by a specialist. Ninety eight percent of the limitations related to the health care system were the long waiting lists to be seen by a specialist. Conclusion Many of the pathologies that we have found belong to the group that has a significant reduction in mortality when treated accurately and promptly. However, we have a profound problem in our health care system, in that many of the patients have not been seen by a specialist, which results in a worse prognosis and recovery rate.

Molecular genetics of inherited kidney disease in Saudi Arabia

Human kidneys serve important physiological functions in the body. There is an increasing evidence suggesting that the majority of renal diseases have an underlying genetic component. At least 40 genes have been shown to be involved in kidney development and many more genes are expressed within the kidney and regulate renal physiology. It is observed that genetic and congenital disorders are more common in Arab countries than in industrialized countries. Saudi Arabia is the largest Arab country and estimation of patients with end-stage kidney failure is 136 for each million yearly. Preliminary observations indicate that children in Saudi Arabia probably have a higher incidence of polycystic kidney disease, familial juvenile nephronophthisis, congenital urological anomalies, and familial nephrotic syndrome. Molecular diagnosis would help enormously in prevention and introduce early management which could ensure a better outcome. This is a review article of molecular studies conducted in the Kingdom of Saudi Arabia from 1990 till present time to elucidate disease-causing genes of inherited kidney disease.

Laparoscopic heminephrureterectomy for duplex kidney in children

Duplication of the upper urinary tract is one of the most common congenital urological anomalies. In patients with critically decreased or lost function of one of the renal segments, heminephrureterectomy is usually the treatment of choice. Until recently, this was an open surgery; in cases of complete removal of the ureter, an additional incision in the iliac region was required. Currently, heminephrureterectomy is increasingly performed laparoscopically. We report the experience in laparoscopic heminephrureterectomy (LHNUE) in 10 clinics in Russia and Belarus. Some of them have already used this technique for 10 years. The study aimed to to improve the treatment results in children with urodynamic dysfunction due to duplicated upper urinary tract. We retrospectively analyzed medical records of 111 children treated from 2007 to 2016. There were 26 (23.4%) boys and 85 (76.6%) girls with mean age 44.6 months (from 2 to 170) at the time of surgery. All children included in the study had complete duplex kidneys, including 51 (45.9%) right-sided and 60 (54.1%) left-sided. All the children underwent LHNUE for a critical decrease or absence of function of the upper or lower segment of the duplex kidney caused by the following pathology: obstruction of the ureterovesical junction with the development of the megaureter of the upper ureteral segment in 57 (51.4%) patients; ureterocele in 28 (25.2%); extra-vesical ectopic ureter with urinary incontinence in 10 (9.0%) girls; high-grade UVR in 16 (14.4%) patients. There were no conversions in this series of patients. The mean operative time was 135 minutes (60-240 min.). All children included in the study were followed for 1 to 9 years after surgery. Complications occurred in 17 (15.3%) patients, of whom 12 (10.8%) required repeat surgery. In one patient with the loss of lower pole function, the treatment result was considered unsatisfactory. LHNUE for duplex kidney is performed by a few clinics and is still at the stage of development and accumulation of experience. Nevertheless, LHNUE, though an effective treatment modality, carries the risk of reducing or losing the function of the retained segment.

Crossed ectopic kidney: prenatal diagnosis and postnatal follow-up.

The objective of this study is to investigate prenatal diagnosis and postnatal outcome of fetuses with crossed ectopic kidney. Cases referred for an empty renal fossa and diagnosed with crossed ectopic kidney confirmed postnatally were analyzed retrospectively over a period of 10years. Prenatal diagnosis was established following the detection of one kidney in a normal position and a second ipsilateral kidney fed by abnormal blood vessels on Doppler flow RESULTS: Between 2005 and 2015, 185 fetuses were referred for an empty renal fossa. Crossed ectopic kidney was diagnosed in 10 of them. Associated congenital urological anomalies included two cases of double collecting system and bilateral hydronephrosis in one. Associated extra renal findings were single umbilical artery (4/10), ventricular septal defects (1/10), and persistent left superior vena cava (1/10). On postnatal follow-up, bilateral vesicoureteral reflux was diagnosed in a case who presented prenatally with bilateral hydronephrosis and two cases of mild hydronephrosis. All cases were managed conservatively. Crossed ectopic kidney should be suspected in cases presenting with an empty renal fossa and a normal positioned kidney. Thorough anatomical scan should be performed as well as periodic follow-up throughout pregnancy. Postnatal nephrological follow-up is recommended. © 2017 John Wiley & Sons, Ltd.

Leading contributors to success of transitional urology units.

There is increasing recognition of the need for life-long care in patients who have congenital urological anomalies. This study looks at the factors surrounding transition and suggests those, which may improve the success. One of the most challenging phases in this care is adolescence. There are the physical and psychological changes that all adolescents go through. Patients need medical surveillance through this time in order to ensure good care and patient safety. For affected patients there are other major challenges - first the relationship of their underlying condition, its treatment and the effect that either of these will have on their relationship with normality. The second big challenge is that in the midst of these changes our patients have to move from a paediatric to an adult centred environment.Transition is the term used to define the gradual shift of healthcare responsibility from the parents to the patient and all the factors above will affect this important time in life and care. Transition can be a challenge to both patients and the healthcare team. The key to success is a strong multidisciplinary team to try and maintain patient engagement.

Genetics of Vesicoureteral Reflux.

Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder to the upper urinary tract. It is the most common congenital urological anomaly affecting 1-2% of children and 30-40% of patients with urinary tract infections. VUR is a major risk factor for pyelonephritic scarring and chronic renal failure in children. It is the result of a shortened intravesical ureter with an enlarged or malpositioned ureteric orifice. An ectopic embryonal ureteric budding development is implicated in the pathogenesis of VUR, which is a complex genetic developmental disorder. Many genes are involved in the ureteric budding formation and subsequently in the urinary tract and kidney development. Previous studies demonstrate an heterogeneous genetic pattern of VUR. In fact no single major locus or gene for primary VUR has been identified. It is likely that different forms of VUR with different genetic determinantes are present. Moreover genetic studies of syndromes with associated VUR have revealed several possible candidate genes involved in the pathogenesis of VUR and related urinary tract malformations. Mutations in genes essential for urinary tract morphogenesis are linked to numerous congenital syndromes, and in most of those VUR is a feature. The Authors provide an overview of the developmental processes leading to the VUR. The different genes and signaling pathways controlling the embryonal urinary tract development are analyzed. A better understanding of VUR genetic bases could improve the management of this condition in children.

377 Role of static and dynamic magnetic resonance urography in evaluating congenital urological anomalies in children

377 Role of static and dynamic magnetic resonance urography in evaluating congenital urological anomalies in children

Adolescent urology: developing lifelong care for congenital anomalies

Complex congenital urological anomalies often necessitate ongoing clinical and surgical management as patients reach adulthood and beyond. However, adolescent and lifelong care of such conditions is a relatively new urological specialty, and approaches to transitional health care require further development. Thus, although literature relating to the use of such approaches in urology are lacking, we are able to draw upon experience of models from other specialties. Urological anomalies might complicate an individual's development, particularly during adolescence, which represents a time of rapid and considerable change in most aspects of life. During this period, increased independence and responsibility, necessitating a shift from parent-driven to patient-driven care, and the desire to develop important and intimate social relationships can affect a patient's ability to cope with, and manage, disease. These factors also influence the ability of health-care providers to deliver adequate treatment. In particular, consideration of the effect of a condition or its treatment on the patient's capacity to live a normal life is important. A multidisciplinary approach is essential to overcoming these issues. Furthermore, diagnostic and treatment registries, as well as an increase in the number of adult-focused urologists willing to participate in the transition of patients from paediatric to adult care, are needed to enable provision of optimal patient care for the future.

Robot-Assisted Pyeloureterostomy for Lower Pole Ureteropelvic Junction Obstruction in an Incomplete Duplicated System

Introduction: Ureteropelvic junction obstruction (UPJO) and duplicated collecting systems, complete or incomplete, are relatively common congenital urologic anomalies, but rarely occur together. UPJO in incomplete duplicated systems usually involves the lower pole moiety1,2 and patients can present with obstruction-related problems, including flank pain and upper urinary tract infection.3 We present a video-enhanced description of a robot-assisted pyeloureterostomy for a symptomatic right lower pole UPJO in an incomplete duplex system. The video outlines the initial presentation, provides all related radiologic investigations, details the surgical technique, and provides initial outcome data. Methods: A healthy 54-year-old woman presented with a 3-year history of intermittent right flank pain. All preoperative imaging studies confirmed the diagnosis of a right lower pole UPJO in an incomplete duplicated system. Renal scintigraphy revealed 53% right differential function and a furosemide clearance half-time of 145 minutes for the lower pole moiety. One week preoperatively, the patient's right upper pole (UP) moiety was stented to facilitate identification of the collecting system. After appropriate preparation of the patient, pneumoperitoneum was obtained using a Veress needle technique. The da Vinci© robot was docked after placement of all ports: a 12-mm camera, two 8-mm robotic and one 8-mm assistant ports. First, the right colon was mobilized to expose the retroperitoneum. To aid exposure, the overlying perinephric tissue was tacked laterally to the abdominal sidewall using Hem-o-Lok® clips. The bladder was filled with methylene blue-infused normal saline (methyleneNS), which easily refluxed into the UP, but did so very slowly into the lower pole moiety. This permitted easier identification of the dilated lower pole moiety with a narrowed entry point at the level of the bifurcation. We continued dissection to identify, but not devascularize, the common ureter and its bifurcation into the upper and lower pole moieties. Rather than excise the stenotic UPJ and perform an end-to-side anastomosis, a decision was made to perform a side-to-side anastomosis in an effort to minimize scarring of the common ureter. An incision was made on the cephalad aspect of the lower pole pelvis and the caudal aspect of the dilated UP moiety ureter. Using a 3-0 PDS suture, a side-to-side anastomosis was performed in a running fashion. The posterior layer of the pyeloureterostomy was closed first, from lateral to medial, followed by the anterior layer in a similar manner. Before completing the anastomosis, a 6F ureteric stent was inserted antegradely over a hydrophilic-tipped guidewire, next to the existing preoperative UP moiety stent. The anastomosis was then tested using retrograde infusion of methyleneNS. At the end of the procedure, a Jackson-Pratt drain was placed through the lower robotic port. Results: The surgical time was 127 minutes, estimated blood loss was 50 cc, and the patient was discharged on POD 2 with no postoperative complications. Both ureteric stents were removed 4 weeks postoperatively and 6 weeks later, renal scintigraphy demonstrated no evidence of obstruction with a significantly improved furosemide clearance half-time of 6 minutes. The patient remains pain free for 9 months postoperatively. Conclusion: Robot-assisted pyeloureterostomy for lower pole UPJO in an incomplete duplicated system is a safe and feasible option. No competing financial interests exist. Runtime of video: 6 mins 7 secs

Gömülü Penis Şeklinde Ortaya Çıkan Epispadyas

Epispadias is one of the rarest congenital urological anomalies. In epispadias, prepuce is usually a redundant tissue located on the ventral part of penis. Diagnosis is easily made on phys - ical examination. The presence of a complete prepuce associated with epispadias is rare, and diag - nosis can be difficult. A 2.5-year-old male patient was admitted to our center for circumcision. Preputial skin was intact and patient presented with a concealed penis. In this paper, we report an unusual case with epispadias and a concealed penis. The patient was managed with a one-stage re -

562 Radiological Evaluation of Pediatric Congenital Urinary Tract Anomalies

PurposeTo illustrate a wide spectrum of congenital anomalies of the urinary tract in children.Materials and MethodsWe demonstrate radiological evaluation and its clinical significance of congenital anomalies of the urinary tract...