European Society For Paediatric Urology Research Articles

European Paediatric Surgeons' Association Survey on the Adherence to EAU/ESPU Guidelines in the Management of Undescended Testes.

The aim of this study was to assess the adherence to the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU) 2016 guidelines in the management of undescended testes (UDT). An online questionnaire was sent in 2023 to members of the European Paediatric Surgeons' Association (EUPSA). Among 157 members, 46 and 44% perform orchidopexy before 12 and 18 months, respectively. In total, 92% recommend conservative management of retractile testes and 58% offer close follow-up. In case of nonpalpable testes, 78% favor laparoscopy and 18% ultrasonography. If a peeping testicle is identified at laparoscopy, 76% perform a single-stage orchidopexy. In case of a high testicle, a staged procedure is preferred (84%). Management of blind-ending spermatic vessel is heterogenous with a majority ending the operation, followed by exploration of the inguinal canal and removal of the testicular nubbin with optional fixation of the contralateral testis. Only a minority recommends hormonal therapy to improve fertility potential in bilateral UDT. A majority (59%) discuss testis removal in UDT in postpubertal boys. In addition, 77% declare following the EAU/ESPU guidelines. Unawareness of guidelines was the most common reason cited for nonadherence. International guidelines were found to have the greatest influence on clinical practice; however, personal experience and institutional practice seem to play an important role. Most recommendations of the EAU/ESPU guidelines are being followed by EUPSA members; however, personal and institutional practice impact decision making. Hormonal therapy in bilateral UDT, management of vanishing testes, and UDT in postpubertal boys could be improved.

Primum Non Discernere: Glass Ceilings and Female Representation at the European Association of Urology and European Society for Paediatric Urology Annual Meetings, 2012–2022

BackgroundThe term glass ceiling coined by Loden in 1978 is commonly used to describe difficulties faced by minorities and women when trying to move into senior roles. ObjectiveTo analyse trends and patterns for female representation at the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) annual general meetings over the past decade. Design, setting, and participantsWe used objective data on female representation in the roles of chairs, moderators, and lecture speakers at the EAU and ESPU meetings from 2012 to 2022. Outcome measurements and statistical analysisWe evaluated gender based representation in paediatric urology sessions at the EAU and ESPU meetings, collecting data on the overall number of sessions, lectures, symposiums, abstract/poster sessions, and courses, and analysed the male/female ratio. Data were derived from printed and digital programmes for the relevant meetings. Results and limitationsDuring the period from 2012 to 2022, the percentage female representation varied from 0% (2012) to a maximum of 35% (2022) at EUA paediatric urology sessions, and from 13.5% (2014) to a maximum of 32% (2022) at ESPU meetings. Both associations show clear progression towards equality. ConclusionsFemale representation at EAU and ESPU meetings has risen over the years, reaching 35% and 32%, respectively, in 2022, which is in line with the number of female members. We hope that this motivates a move towards the equality objectives for 2030. A clear and fundamental societal change is needed, with fair and more consistent institutional policies and framework commitments in the areas of science, medicine, and global health. Gender equality and diversity taskforces are essential to achieve these goals. Patient summaryWe analysed the male/female ratio for participants in annual meetings held by the European Association of Urology and the European Society for Paediatric Urology. From a low level in 2012, the ratio increased to over 30% in 2022, in line with the female membership of the societies. Focus on fair and consistent policies is needed to ensure that women are well represented in medicine.

A multinational survey on the management of the urinary tract in newborns with spina bifida: Are we following current EAU/ESPU guidelines?

In August 2019, the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) published updated guidelines on the management of neurogenic bladder in children and adolescents. Our study aimed to establish whether members of the ESPU are adhering to these guidelines. We designed a survey comprising 26 questions using SurveyMonkey®. Respondents were asked about management of neurogenic bladder at birth in newborns with spina bifida (SB), urological investigations, as well as short and long-term follow-up in their institutions. There were 103 respondents to the survey (754 recipients, giving a response rate of 14%) spanning 36 countries. 100% of respondents carry out a renal/bladder ultrasound at birth. Only 53% routinely commence clean intermittent catheterization soon after birth as recommended by the guidelines. Only 56% recommend anticholinergic medications after abnormal videourodynamics (VUDs). The guidelines recommend the use of continued antibiotic prophylaxis if there is evidence of vesicoureteral reflux and hostile bladder/non-conclusive results on VUDs which is followed by only 30% of providers. 63% of respondents carry out baseline VUDs at the recommended time. Seeing larger volumes of SB patients, having a formal SB protocol, having formal SB multidisciplinary clinics and working in a tertiary referral center did not make respondents more likely to adhere to guidelines. Our survey demonstrated that large variations from the EAU/ESPU guidelines exist in practice. The study confirms that further work is required across institutions and countries to implement these evidence-based recommendations for standardized practice.

EBM II: How to perform a literature search

The present article is a second part related to evidence based medicine (EBM) in a series of five by the European society for paediatric urology (ESPU) research committee. It will present the different databases/search engines available to clinicians and researchersand describe strategies to focus the search to one's particular needs. Indeed, databases/search engines used and search strategy should vary according to the goal of the research. If the aim is to address a clinical problem, the search should allow to identify a small number of most pertinent articles (high specificity); if the search is for research purposes, instead, it should ensure no meaningful articles are overlooked (high sensitivity).

Surgical outcome of patients with vesicoureteral reflux from a single institution in reference to the ESPU guidelines: a retrospective analysis

Vesicoureteral reflux (VUR) is an anatomic or functional disorder, and it is a condition associated with renal scarring, hypertension, and end-stage renal disease. Renal damage can be prevented by appropriate medical and surgical intervention for selected patients. The objective of this study was to retrospectively analyze the surgically treated patient group of this study in reference to the risk analysis criteria used in European Association of Urology (EAU), European Society for Paediatric Urology (ESPU) guidelines to see the outcome of the study management protocol within the last 15 years in respect to this risk analysis. A total of 686 patients who were operated upon in a single institution for VUR between 1997 and 2016 were retrospectively analyzed. According to the criteria in EAU/ESPU guidelines, the patients were classified into three groups: low, medium, and high risk. Risk factors were compared between the groups. The patient numbers for low, medium, and high risk were 92 (13.4%), 485 (70.7%), and 109 (15.9%), respectively. In the high-risk group, surgeons tended to do more ureteroneocystostomy (UNC) (82.6%), whereas in the low-risk group, surgeons tended to do more subureteric injection (STING) (76.1%). The success rates for STING and UNC were found to be 75% and 93%, respectively. Although there was a difference in success rates among patients treated with STING or UNC, this difference was not statistically significant in success rates regarding risk groups for patients treated with STING or UNC. The most recent guideline was that which was published by the EAU/ESPU organization in 2012. This guideline is established based on the risk analysis. The analysis revealed that patients in the low-risk group tended to undergo endoscopic surgery treatment method, whereas patients in the high-risk group tended to undergo open surgery. Therefore, the study management over the last 10 years has been mainly in line with the current recommendations. The analysis shows that when the patients are classified according to the EAU/ESPU risk classification, surgeons tended to perform more endoscopic and more open surgery for the low- and high-risk groups, respectively. Although each surgical modality had similar success rates in each group, open surgical results were overall much higher than those of endoscopic surgery in each group. This was a specifically important finding in high-risk group where the endoscopically treated group of patients was small in number, and the need for a definitive correction is essential in this group because of increased risk of renal injury.

Reply by Authors

No AccessJournal of UrologyPediatric Urology1 Dec 2018Reply by Authors View All Author Informationhttps://doi.org/10.1016/j.juro.2018.06.093AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Reply by Authors." The Journal of Urology, 200(6), p. 1361 References 1 Di Carlo H, Tekes A and Gearhart JP: Intraoperative 3D MRI guided pelvic dissection in the closure of classic bladder exstrophy: a novel approach. Presented at annual meeting of European Society for Paediatric Urology, Prague, Czechoslovakia, October 14-17, 2015. Google Scholar 2 Kasprenski M, Maruf M, Jayman J et al: Penile disassembly in exstrophy: time to reevaluate? J Urol, suppl., 2018; 199: e326, abstract MP25-02. Google Scholar © 2018 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 200Issue 6December 2018Page: 1361 Advertisement Copyright & Permissions© 2018 by American Urological Association Education and Research, Inc.MetricsAuthor Information Expand All Advertisement PDF downloadLoading ...

Adolescent testicular microlithiasis: A case-based, multinational survey of clinical management practices

Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up. European Society for Paediatric Urology (ESPU) and Society for Pediatric Urology (SPU) members were invited to complete an online case-based survey of clinical management practices of TM. Eight cases had a single variable changed each time (classic versus limited TM, unilateral versus bilateral, prior cryptorchidism versus no cryptorchidism) to ascertain the provider's perception of risk. The respondents completed multiple choice questions on initial management, follow-up plan, length and interval of follow-up. Multivariate logistic regression was performed to determine factors associated with decisions on management and follow-up. There were 265 respondents to the survey from 35 countries (Table). Median time in practice was 13 years. Factors that were significantly associated with more aggressive initial management (more than counseling on self-examination) included: not yet in independent practice, low volume TM cases per year, those practicing pediatric and adult urology, classic appearance of TM and cryptorchidism. Factors that were significantly associated with urologist follow-up and active investigation included: European practitioners, low TM case volume per year, those practicing both pediatric urology and pediatric surgery, classic TM appearance and a case history of cryptorchidism. Interval and length of follow-up was wide-ranging, with most respondents favoring annual follow-up. Management of TM varies and a mix of surgeon and case factors significantly influences management strategies. This baseline understanding of the lack of systematic management suggests the need for the development of consensus guidelines and prospective study.

Enuresis: practical guidelines for primary care.

Although the evidence is relatively weak, expert opinion recommends accurate diagnosis of enuresis and the use of enuresis alarms and desmopressin, in addition to behavioural approaches Worldwide, around 10% of 6–7-year-olds suffer from enuresis. Enuresis is therefore highly prevalent, but its impact is often underestimated. Training for family doctors rarely includes specific guidance on enuresis, and the default approach is often to wait for spontaneous resolution. Despite comprehensive enuresis guidelines in specialist journals for secondary and tertiary care, versions for use in primary care are scarce (for example, https://pathways.nice.org.uk/pathways/bedwetting-in-children-and-young-people), and often confusing because of outdated terminology. This article provides practical guidelines and tools to manage enuresis in primary care in children of ≥5 years based on the guidelines of the International Children’s Continence Society (ICCS), following the new ICCS standardisation and subtyping of patients.1–3 The document was developed by the steering committee of World Bedwetting Day 2017 representing the American Academy of Pediatrics (AAP), the North American Paediatric Urology Societies, the European Society for Paediatric Nephrology (ESPN), the European Society for Paediatric Urology (ESPU), the Asia Pacific Association of Paediatric Urology (APAPU), the Sociedad Iberoamericana de Urologia Paediatrica (SIUP), the International Pediatric Nephrology Association (IPNA), and the ICCS. It should be highlighted that this guideline differs to some extent from previous guidelines, based on historical studies, in which there was no differentiation between NMNE and MNE, contrary to current understanding. …

MP66-14 TESTICULAR MICROLITHIASIS: A CASE-BASED, MULTINATIONAL SURVEY OF CLINICAL MANAGEMENT PRACTICES

INTRODUCTION Testicular microlithiasis (TM) is a condition characterized by calcium deposits within the testis, usually detected incidentally during ultrasonography of the scrotum. TM has been associated with the presence of, and possibly the development of, testicular malignancy. Our aim was to document international clinical management practices for TM and to analyze what factors and perception of risk influence conservative versus active management and follow-up. METHODS European Society for Paediatric Urology (ESPU) and Society for Pediatric Urology (SPU) members were invited to complete an online case-based survey of clinical management practices of TM. Eight cases had a single variable changed each time (classic versus limited TM, unilateral versus bilateral, prior cryptorchidism versus no cryptorchidism) to ascertain the provider's perception of risk. The respondents completed multiple choice questions on initial management, follow-up plan, length and interval of follow-up. Multivariate logistic regression was performed to determine factors associated with decisions on management and follow-up. RESULTS There were 265 respondents to the survey from 35 countries (Table). Median time in practice was 13 years. Factors that were significantly associated with more aggressive initial management (more than counseling on self-examination) included: not yet in independent practice, low volume TM cases per year, those practicing pediatric and adult urology, classic appearance of TM and cryptorchidism. Factors that were significantly associated with urologist follow-up and active investigation included: European practitioners, low TM case volume per year, those practicing both pediatric urology and pediatric surgery, classic TM appearance and a case history of cryptorchidism. Interval and length of follow-up was wide-ranging, with most respondents favoring annual follow-up. CONCLUSION Management of TM varies and a mix of surgeon and case factors significantly influences management strategies. This baseline understanding of the lack of systematic management suggests the need for the development of consensus guidelines and prospective study.

Antibiotic prophylaxis for prevention of urinary tract infections in prenatal hydronephrosis: An updated systematic review.

While continuous antibiotic prophylaxis (CAP) is currently recommended to prevent urinary tract infections (UTIs) in infants with prenatal hydronephrosis (HN), this recommendation is not evidence-based. The objective of this study was to systematically determine whether CAP reduces UTIs in the HN population. Applicable trials were identified through an electronic search of MEDLINE (1946-2015), EMBASE (1980-2016), CINAHL (1982-2016), and CENTRAL (1993-2016) and through a hand search of American Urological Association (AUA) (2012-2015) and European Society for Pediatric Urology (ESPU) (2012-2015) abstracts, as well as reference lists of included trials. The search strategy was not limited by language or year of publication. Eligible studies compared CAP to no CAP in patients with antenatal HN, <2 years of age, and reported development of UTI and HN grades. Two independent reviewers performed title and abstract screening, full-text review, and quality appraisal. Of 1518 citations screened, 11 were included, contributing 3909 patients for final analysis. Of these, four (36%) were considered high-quality when assessed by the Newcastle Ottawa Scale. Meta-analysis of the non-randomized trials (n=10) provided similar pooled UTI rates, regardless of CAP use: 9.9% (95% confidence interval [CI] 8.4-11.4%) for CAP and 7.5% (95% CI 6.4-8.6%) for no CAP. This systematic review and meta-analysis suggests there may be value in providing CAP to infants with high-grade HN; however, due to the very low-quality data from non-randomized studies, important clinical variables, such as circumcision status, were unable to be assessed.

Retrospective clinical studies

Patient-based retrospective studies are most often based on one unique patient cohort from one particular institution. At best, they can give rise to observations leading to future prospective studies and new hypotheses. The study by Pamela Ellsworth et al. [1] is one such study: the patient cohort consisted of a mixture of monosymptomatic and former nonmonosymptomatic bedwetters, some of which were still in treatment, which were then considered to be one category. This kind of approach is not confined to this study; others have also used this approach (e.g. Herzeele [2]). The definition of enuresis, according to the International Children’s Continence Society [3] is: enuresis is both a symptom and a condition of intermittent incontinence that occurs during periods of sleep. According to the European Society for Paediatric Urology/ European Association of Urology, a history is sufficient for the diagnosis. Therefore, successful treatment of daytime symptoms, even with ongoing medication and persistent enuresis, is allowed to be labelled monosymptomatic bedwetting. It could be questioned whether that is acceptable. Is a wellcontrolled diabetic who is receiving medication a non-diabetic? There seems to be a need for a more strict definition, as well as a consensus between scientific societies, about what is meant, in this case, by monosymptomatic and non-monosymptomatic bedwetting. As with many other retrospective studies from particular institutions, the present study cannot be claimed to globalise conclusions. The foundations for the title, conclusion and

Undescended testis: current treatment guidelines

Cryptorchidism is the most common genital malformation in male newborns. In recent years, guidelines concerning diagnosis and therapy have undergone considerable evolution with the implementation of recent knowledge in pathophysiology, diagnosis, and therapy. The aim of this publication is to provide an overview of the current national and international guideline recommendations concerning diagnosis and treatment of cryptorchidism. Critical points are discussed in light of current scientific literature. The current guidelines of the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU), the American Association of Urology (AUA), the pediatric urologic task force of the Austrian Society of Urology (ÖGU), the international consultation on urological disease (ICUD) and the German Society of Urology (DGU)/German Association of Pediatric Surgery (DGKCh) have been analyzed concerning the most important aspects of treatment and diagnosis. There is broad consensus concerning most steps and decisions for the treatment of cryptorchidism. However, some aspects of diagnostic imaging, the use of hormonal therapy, and surgical access in nonpalpable testis warrant further discussion and are the fields of considerable changes.

Reflections on the 25th congress of the European society for pediatric urology part 1.

The 25th annual meeting of the European Society for Pediatric Urology (ESPU) took place in Innsbruck, Austria from the 7th to 10th of May 2014. The Specialty Chief Editor and nine Associate editors of Frontiers in Pediatrics, Pediatric Urology were in attendance. Each was asked to select the two presentations that they considered most significant. Here, we highlight some of the papers that we found of particular interest and that may impact our practices. This report reflects personal preferences of the authors and does not pretend to be comprehensive or to rank the quality of the presentations. We are aware that some important presentations may not be included. Our selections are presented in the approximate chronological order of presentation at the meeting.

Commentary to ‘Long-term fate of the bladder after isolated bladder neck procedure’

sphincter in children and young adults. J Urol 2003;169: 650e4. [11] Hidas G, Ortiz-Vanderdys G, Braga LH, Khoury AE. Are bladder and renal function at risk after a procedure to increase bladder outlet resistance? A systematic review and metaanalysis. In: European Society for Pediatric Urology meeting; 2013. Genoa, Italy. [12] Kryger JV, Gonzalez R, Barthold JS. Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol 2000;163:256e63.

Abstracts presented at the European Society for Pediatric Urology (ESPU) meetings (2003–2010): Characteristics and outcome

ObjectiveTo determine the characteristics and outcome of abstracts presented to the meetings of the European Society for Pediatric Urology (ESPU). Material and methodsAbstract books from 2003 to 2010 were reviewed and subsequent publication of presented abstracts determined by MEDLINE/PubMed search. ResultsOf 1194 abstracts, 50–78% per year originated from 15 to 20 European countries and 50–22% from 8 to 13 non-European countries; 233 (19%) were basic science and 961 (81%) clinical. Clinical abstracts included 135 (14%) multicenter/prospective/randomized trials. These figures did not change significantly over time. A total of 564 (47%) abstracts were subsequently published, 65% within 1 year of the meeting, mostly in the Journal of Urology (33%) and the Journal of Pediatric Urology (21%). Multicenter/prospective/randomized trials studies (OR 2.03; 95% CI 1.37–2.96) and abstracts originating from outside Europe (OR 1.61; 95% CI 1.26–2.05) were significantly more likely to be subsequently published in full. ConclusionThe ESPU meetings are a true occasion for international exchange of scientific endeavors. Almost half of the abstracts are subsequently published. The Journal of Urology and the Journal of Pediatric Urology are consistently the two major target journals for publication. Non-European countries, irrespective of whether English-speaking or not, seem significantly more likely to publish their abstracts.

Delayed Primary Repair of Bladder Exstrophy: Ultimate Effect on Growth

Late referrals or unsuitable bladder templates often require delayed primary repair of bladder exstrophy. We investigated longitudinal bladder growth rates and eventual outcomes following this approach. After institutional review board approval, we reviewed the medical records of patients with classic bladder exstrophy who underwent neonatal or delayed (more than 30 days) primary closure at our institution between 1970 and 2006. Clinical characteristics and annual cystographic bladder capacity before the continence procedure were compared. Failed primary exstrophy repairs were excluded. A total of 33 patients with available bladder capacity measurements underwent delayed exstrophy closure due to small bladder template in 18 (88% male) and late referral in 15 (80% male) at respective median ages of 305 days (range 86 to 981) and 172 days (31 to 676). They were compared to 82 patients (71% male) undergoing neonatal closure at a median of 2 days of life (range 0 to 27). Pelvic osteotomy was performed in 32 of 33 delayed closures. Longitudinal analysis of the bladder capacities demonstrated that, compared to neonatally closed cases, bladder capacities were on average 36 ml smaller in those with delayed repair due to small templates (p = 0.01) and 29 ml smaller in those with late referrals (p = 0.13). However, the rate of bladder growth did not differ significantly among the 3 groups. Delayed primary repair of exstrophy does not compromise the rate of bladder growth. However, children born with smaller templates will have overall smaller capacities and are less likely to undergo bladder neck reconstruction.

Analysis of duplicate presentations accepted at two top international pediatric urology meetings

ObjectiveMeetings of the European Society for Pediatric Urology (ESPU) and American Academy of Pediatrics (AAP) are held annually to promote dissemination of new research findings among practitioners. We conducted an observational study determining the rate of duplicate research presentations at the two meetings. MethodsA systematic, in-year, cross reference analysis of all clinical and basic research presentations at the ESPU and AAP meetings, for the years 2006–2009, was conducted. The search strategy included abstract title, authorship, country of origin, institution, study design, significance, and sample size. Three reviewers independently abstracted all data. Discrepancies were resolved by consensus. ResultsIn total, 566 abstracts were presented at the four ESPU meetings. Of these, 23 (4.1%) were also presented at an AAP meeting: 2 of 137 (1.5%) were represented in 2006, 6 of 139 (4.3%) in 2007, 6 of 126 (4.8%) in 2008, and 9 of 164 (5.5%) in 2009. Duplicate presentations were altered by changing the title (57%), adding or removing authors (48%), or changing authorship order (63%) or sample size (22%). Agreement between reviewers was above 90% (kappa = 0.913). ConclusionsAlthough there was only a 4% duplicate presentation rate between the studied ESPU and AAP meetings, our results suggest a trend toward increasing duplication over the past 4 years.

Variation Among Pediatric Urologists and Across 2 Continents in Antibiotic Prophylaxis and Evaluation for Prenatally Detected Hydronephrosis: A Survey of American and European Pediatric Urologists

No clear practice guidelines exist to evaluate prenatally diagnosed hydronephrosis or recommend antibiotic prophylaxis. We hypothesized that among pediatric urologists there is significant variability in prenatal hydronephrosis evaluation and management. We created a survey questionnaire to answer certain questions, including 1) what prenatal parameters trigger postnatal evaluation, 2) how pediatric urologists manage prenatal hydronephrosis and 3) what are their recommendations for antibiotic prophylaxis. Survey questions included demographics and practice patterns, and influences concerning radiographic tests and prophylactic antibiotics. A Web based survey link was sent to members of the Urology Section, American Academy of Pediatrics and the European Society for Pediatric Urology. We received 156 responses. We also compared practices based in Europe in 60 respondents and in the United States in 70. There was significant response variability to all questions answered with no question achieving a consensus of more than 50%. European and American respondents were equally distributed in regard to years in practice and number of patients per month. Radiographic factors influenced the decision to perform further imaging or provide prophylactic antibiotics in around 50% of respondents. There was wide variability in parameters triggering intervention and in prophylactic antibiotics. Pediatric urologists in practice more than 15 years were less likely to prescribe antibiotic prophylaxis at birth than those in practice less than 15 years. Variation also existed by geographic region with American physicians more likely to prescribe antibiotics for any prenatal hydronephrosis compared to their European counterparts (77% vs 40%, p <0.005) and European physicians more likely to be influenced by prenatal pelvic diameter when obtaining postnatal imaging (unilateral 70% vs 47%, p = 0.009 and bilateral 55% vs 36%, p = 0.03, respectively). European pediatric urologists were also more likely to order renal scans than their American counterparts. These differences were less significant for high grade hydronephrosis. Even among pediatric urologists there is considerable variation in radiographic resource and prophylactic antibiotics use when managing prenatal hydronephrosis. Some variation may be explained by regional differences but it is most probably due to absent clear guidelines based on prospective, randomized, controlled trials.

Results of Bladder Neck Reconstruction After Newborn Complete Primary Repair of Exstrophy

We describe the results of modified Young-Dees-Leadbetter bladder neck reconstruction to achieve continence in patients who underwent complete primary repair of bladder exstrophy as newborns. Using the Johns Hopkins Exstrophy Database we identified patients who underwent bladder neck reconstruction after having undergone complete primary repair of bladder exstrophy as newborns. We determined patient characteristics and surgical outcomes. A total of 30 males and 3 females were referred after complete primary repair of bladder exstrophy, of whom 26 underwent bladder neck reconstruction. Results of complete primary repair of bladder exstrophy were strongly associated with osteotomy use. Of the patients 19 (58%), including 16 males and 3 females, who underwent complete primary repair of bladder exstrophy without osteotomy had complications (dehiscence and bladder prolapse), while none of 14 male patients who underwent complete primary repair of bladder exstrophy with osteotomy had complications, although none were subsequently continent. Of the 19 patients who had complications after complete primary repair of bladder exstrophy 12 underwent bladder neck reconstruction and total continence was achieved in only 3 (25%). Of the 14 patients with successful complete primary repair of bladder exstrophy 8 (57%) are dry day and night, 4 (28%) are dry during the day and wet at night, and 2 (14%) are completely incontinent. Continent children underwent successful complete primary repair of bladder exstrophy with pelvic osteotomy, all underwent hypospadias repair before age 1 year and none required ureteral reimplantation before bladder neck reconstruction. Many patients who undergo newborn complete primary repair of bladder exstrophy will require bladder neck reconstruction. Bladder neck reconstruction is more successful in those in whom complete primary repair of bladder exstrophy was successful. As in all types of repair, failed initial closure usually results in a bladder that is unsuitable for bladder neck reconstruction. These patients often require bladder augmentation and a continent stoma to be dry.

Correspondence Re: “Garat JM, de la Peña E, Caffaratti J, Villavicencio H. Prevention of Vesicoureteral Reflux at the Time of Complete Primary Repair of the Exstrophy-epispadias Complex. Int Urol Nephrol. 2004; 36: 211–2”.

This letter is in reference to the recently published paper ‘‘Prevention of vesicoureteral reflux at the time of complete primary repair of the exstrophy– epispadias complex’’ [1] to which we would like to add some comments. The paper presents for the second time in a PubMed indexed journal [2] one case of total neonatal exstrophy reconstruction associated to theGil-Vernet antireflux technique [3]. Unfortunately, Garat et al. disregard the fact that the association of the ureteral advancement designed by Gil-Vernet with the one step exstrophy closure, had already been published in the BJU Int [4] after being presented in 2002 at the European Society for Pediatric Urology (ESPU). In that paper, the authors, leaded by De Castro (with a solid reputation and experience in bladder exstrophy), hypothesized that the Gil-Vernet procedure could add a certain antireflux effect. Three exstrophy patients of their series were treated in that fashion and none of them presented vesicoureteral reflux in the follow-up. Furthermore, it seems exceeding to conclude that the procedure is ‘‘very successful’’ when only one patient, in the authors’ hands, underwent the procedure. Besides, we miss in Garat et al. [1] case report a critical appraisal of the possible limitations that the incorporation of this surgical step could imply. No doubt the proposal of adding the Gil-Vernet trigonoplasty to the one-stage complete neonatal exstrophy closure is appealing. However, the text does not mention the differences that this antireflux technique presents in cases of bladder exstrophy as opposed to conventional vesicoureteral refluxing bladders. Anatomical issues such as pubic diastasis, the defect in the bladder floor reinforcement or the existence of an incompetent bladder neck as well as the possible variation in the intramural course of the ureter are some of the subjects that could have been addressed when evaluating the potential effectiveness of this antireflux mechanism in these patients. Moreover, as De Castro et al. [4] state: ‘‘more experience and a longer follow-up is required to assure if this technique will be of interest’’. Finally, Garat el al. [1] report’ missreferences the first report(s) of Grady and Mitchell [5, 6] on the complete one-stage exstrophy closure and instead makes reference to the penile disassembly technique for the epispadias reconstruction developed by Mitchell and Bagli [7]. We believe the authorship of Grady and its’ contribution to this innovative technique should be acknowledged.