Urethral Anomalies Research Articles

A New Case of Fournier's Gangrene Caused by Actinotignum schaalii

Actinotignum schaalii (formerly known as Actinobaculum schaalii) is an anaerobic or facultative anaerobic gram-positive bacillus that can be found commensally in the urogenital region. It can be overlooked because it grows slowly and is difficult to identify with classical microbiology laboratory techniques. Colonies become visible after 48-72 hours of incubation on blood agar in anaerobic or CO₂-rich media. While it typically causes urinary tract infection in older individuals, cases of bacteremia, vertebral osteomyelitis, endocarditis and cellulitis have been reported. Fournier's gangrene caused by A.schaalii has been reported very rarely so far. Fournier's gangrene has been defined as necrotizing fasciitis of the external genitalia, perineal and perianal region. Diabetes, immunosuppression, peripheral vascular disease, urethral anomalies, chronic alcoholism and smoking are important predisposing factors. In addition, approximately 25% of the cases have no known or identifiable etiology. The bacteria causing the infection may originate from skin, urogenital or intestinal microbiota. In this case report, a new case of Fournier's gangrene caused by A.schaalii was presented. A 65-year-old male patient admitted to the emergency department with the complaints of pain, swelling, redness in the left testis and also nausea, vomiting and chills that started three days ago. Physical examination revealed increased diameter of the scrotum, intense hyperemia of the skin and foci of necrosis. It was learned that the patient had no known chronic disease other than benign prostatic hyperplasia. The patient reported smoking of 25 packs of cigarettes per year. Routine laboratory tests revealed leukocyte= 32.41 x 109/L, neutrophil= 89.9%, procalcitonin= 1.62 ug/L, CRP= 265.07 mg/L and the patient was operated with the diagnosis of Fournier's gangrene. Gram staining of the abscess specimen obtained during the operation showed gram-positive bacilli both inside and outside the leukocytes. After 24 hours, grampositive bacilli were detected in the Gram staining of thin, transparent/gray colonies grown on 5% sheep blood and chocolate agar. The isolate was identified as A.schaalii by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) VITEK® MS (bioMérieux, France) microbial identification system. VITEK®2 ID ANC (bioMérieux, France) bacterial identification card was also used for comparison but the bacteria could be identified. As a result of the sequence analysis performed for confirmation, it was shown to be 100% homologous with Actinobaculum schaalii (GenBank accession no: FJ711193.1). For susceptibility tests, 5% sheep blood Schaedler agar was used and incubated in anaerobic environment. According to the minimal inhibitory concentration (MIC) results evaluated after 48 hours, penicillin was found to be 0.032 mg/L, clindamycin 0.125 mg/L, ciprofloxacin 0.19 mg/L, ceftazidime 4 mg/L, and amoxicillin 0.19 mg/L. The primary cause that initiated the infection in the case could not be identified, but it was thought that the presence of prostatic hyperplasia and smoking history may have contributed to the occurence or the progress of the disease. It is noteworthy that the ciprofloxacin MIC result was quite low compared to other studies. In addition, this study revealed the value of MALDI-TOF MS based methods in identification. In conclusion, it is thought that a significant proportion of A.schaalii infections may be overlooked due to the difficulty in growth and identification. Increasing the diagnostic power of clinical microbiology laboratories for poorly identified bacteria and renewing the databases of commercial identification systems are important for the early and accurate diagnosis and treatment of serious infections that may occur with such agents.

H-type recto-urethral fistula presenting with recurrent epididymo-orchitis

Anorectal malformation (ARM) is a congenital malformation that has an incidence of 1 in 5000. Krickenbeck classification separate different types of ARM according to the anatomy, with major clinical groups such as perineal fistula, rectourethral fistula (prostatic or bulbar), rectovesical, vestibular, cloaca, no fistula and anal stenosis. Recto-urethral fistula with a normal anus is a rare variant among all ARM with very few cases reported in previous literature. We hereby report a case with H type recto-urethral fistula with a rare clinical presentation of recurrent epididymo-orchitis, with our workup including micturating cystourethrogram (MCUG) and cystoscopy which revealed the fistula; subsequent surgical management using a modified anterior sagittal transrectal (ASTRA) approach and literature review on similar cases. Recto-urethral fistula with a normal anus is a rare condition and an ASTRA approach provides good early results. Furthermore, MCUG should be considered in boys with recurrent epididymitis to rule out urethral anomalies.

Urological Impact of Epididymo-orchitis in Patients with Anorectal Malformation: An ARM-Net Consortium Study

To investigate the current experience of the ARM-Net Consortium in the management of epididymo-orchitis (EO) in patients with anorectal malformations (ARMs), and to identify specific risk factors and the need for urological care involvement. We retrospectively collected data of EO in patients with ARM between 2015 and 2019. Data on urological aspects, ARM type, surgical approach, associated anomalies, diagnosis, and treatment of EO were collected and analyzed. Twenty-nine patients were reported by 12 centers. Twenty-six patients with EO (90%) had ARM with a rectourinary fistula. Median age at first EO was 2 years (range: 15 days-27 years). Twenty patients (69%) experienced multiple EO, and 60% of recurrences were ipsilateral. Associated urological anomalies included vesicoureteral reflux (48%), urethral anomalies (41%), neurogenic bladder (41%), and ectopic vas (10%). A positive urine culture during EO was present in 69%. EO was treated with antibiotics (90%), limiting surgical exploration to 14%. Prevention of recurrences included surgery (bulking agents 15%, vasectomy 15%, and orchiectomy 5%) and antibiotic prophylaxis (20%). Urologists may encounter patients with EO in ARM patients, frequently with positive urine culture. An appropriate urologic work-up for most ARM patients is necessary to identify and treat underlying risk factors. A practical scheme for the work-up is suggested for a close collaboration between pediatric surgeons and urologists.

Congenital anterior urethral diverticula with posterior urethral valve: rare combination in a neonate: a case report

Congenital Anterior Urethral Diverticulum (CAUD) is defined as a cystic dilatation of the anterior urethra and is one of the rare causes of bladder outlet obstruction. The association of this urethral anomaly with the posterior urethral valve is extremely rare. In this case, we found the association of congenital urethral diverticulum and posterior urethral valve and we aimed to present it.

Congenital anterior urethral diverticula with posterior urethral valve: rare combination in a neonate: a case report

Congenital Anterior Urethral Diverticulum (CAUD) is defined as a cystic dilatation of the anterior urethra and is one of the rare causes of bladder outlet obstruction. The association of this urethral anomaly with the posterior urethral valve is extremely rare. In this case, we found the association of congenital urethral diverticulum and posterior urethral valve and we aimed to present it.

Exon skip-inducing variants in FLNA in an attenuated form of frontometaphyseal dysplasia.

Pathogenic variation in the X-linked gene FLNA causes a wide range of human developmental phenotypes. Loss-of-function is usually male embryonic-lethal, and most commonly results in a neuronal migration disorder in affected females. Gain-of-function variants cause a spectrum of skeletal dysplasias that present with variable additional, often distinctive, soft-tissue anomalies in males and females. Here we present two, unrelated, male individuals with novel, intronic variants in FLNA that are predicted to be pathogenic. Their phenotypes are reminiscent of the gain-of-function spectrum without the skeletal manifestations. Most strikingly, they manifest urethral anomalies, cardiac malformations, and keloid scarring, all commonly encountered features of frontometaphyseal dysplasia. Both variants prevent inclusion of exon 40 into the FLNA transcript, predicting the in-frame deletion of 42 amino acids, however the abundance of FLNA protein was equivalent to that observed in healthy individuals. Loss of these 42 amino acids removes sites that mediate key FLNA functions, including binding of some ligands and phosphorylation. This phenotype further expands the spectrum of the FLNA filaminopathies.

Congenital anterior urethrocutaneous fistula: Variable clinical features and their management

Anterior congenital urethrocutaneous fistula is a rare urethral anomaly with only a few cases and short case series being reported in the literature. The anomaly can present with variable clinical features and other associated anomalies. It is important to have a good understanding of the anomaly for an optimal outcome. We reviewed our successfully managed three cases of congenital anterior urethrocutaneous fistula with variable presentation requiring different treatment strategies. Level of evidence: Not applicable for this multicentre audit.

Assessment of distal ureteral and ureterovesical junction visualization on contrast-enhanced voiding urosonography.

Contrast-enhanced voiding urosonography (CEVUS) uses intravesically administered microbubble contrast to detect vesicoureteral reflux (VUR) and urethral anomalies with ultrasound. Multiple studies have suggested CEVUS can replace voiding cystourethrogram (VCUG) as a radiation-free alternative. Analysis of the ureterovesical junction and ureters on VCUG documenting the ureterovesical junction position, ureteral duplication, periureteral diverticula and ureteroceles is important as anatomical variations may affect management and surgical approach. Our purpose was to assess distal ureteral and ureterovesical junction region visualization in children with VUR detected on CEVUS. CEVUS studies performed between June 2018 and March 2019 with reported VUR were retrospectively reviewed by two pediatric radiologists to confirm VUR and to qualitatively assess the ureterovesical junction region for each renal moiety using a 3-point scale for clear, limited or absent visualization of the distal ureter, ureterovesical junction, ureteral duplication, periureteral diverticula and ureteroceles. Thirty-four studies with VUR on CEVUS were identified. Sixty-seven renal moieties were evaluated including a solitary kidney in one child. VUR was detected in 52 moieties by reader 1 and in 53 by reader 2. A single moiety with discrepancy between readers regarding VUR was excluded from statistical analysis. No diverticula were detected by either reader and one ureterocele was detected by both readers. Visualization of the ureterovesical junction was described as clear in 5/52, limited in 14/52 and absent in 33/52 refluxing renal moieties by reader 1 and as clear in 12/52, limited in 20/52 and absent in 20/52 by reader 2. The ureterovesical junction was clearly visualized in 5/52 (9.6%) by reader 1 and 12/52 (23.1%) by reader 2. The Kappa value of -0.29 (confidence interval [CI] -0.25, 0.21) reveals a lack of agreement between the readers for clear versus limited or absent ureterovesical junction visualization. Distal ureteral visualization was described as clear in 14/52, limited in 16/52 and absent in 22/52 refluxing renal moieties by reader 1 and as clear in 27/52, limited in 7/52 and absent in 18/52 by reader 2. The distal ureter was clearly visualized in 14/52 (26.9%) by reader 1 and 27/52 (51.9%) by reader 2. The Kappa of 0.43 (CI 0.22, 0.64) reveals moderate agreement between the readers for clear versus limited or absent distal ureteral visualization. Duplication of the renal collecting system was identified in 13/52 refluxing kidneys by reader 1 and 11/52 refluxing kidneys by reader 2. Visualization of ureteral duplication was described as clear in 9, limited in 4 and absent in 39 of 52 refluxing renal moieties by reader 1 and as clear in 9, limited in 2 and absent in 41 by reader 2. Ureteral duplication was clearly visualized in 9/52 (17.3%) by reader 1 and 9/52 (17.3%) by reader 2. Kappa of 0.87 (CI 0.68, 1) reveals high agreement between the readers for clear versus limited or absent identification of ureteral duplication. The distal ureter and ureterovesical junction region frequently are not clearly visualized in refluxing renal moieties on CEVUS. Awareness of this limitation is important as there may be implications when evaluating patients for surgical management of VUR.

A New Technique for Computed-Tomography Urethrography in Males: The Clamp Method

The aim of the present study is to describe and evaluate a new technique for performing Computed-Tomography Retrograde Urethrography (CT-RUG). Males with urethral anomalies detected by retrograde urethrography (RUG) and/or retrograde sonourethrography (RSUG) underwent CT-RUG using the clamp method and three radiologists evaluated the anomalies in each technique separately and blindly. CT-RUG was done successfully in all the cases (n = 22), with means of 6 min duration and 95 mL of contrast; no pain was reported by 81% of the patients (VAS: 0) and very mild pain by the rest (VAS: 0.5–1.2). CT-RUG showed better diagnostic efficacy in cases of periurethral fistula (n = 8), urethral stent (n = 3), previous urethroplasty and urethral lithiasis (n = 2), a similar accuracy to RSUG for measuring the length of anterior urethral strictures (n = 9) and greater accuracy than RUG (p = 0.008). Six cases received 2 CT sweeps, with an effective dose of 4.96 mSv, and the remaining 16 had 1 sweep and received 3.456 mSv. To the best of our knowledge, this is the first study to describe the clamp method for CT-RUG, a method that is effective and comfortable for both the patient and the operator (retrograde infusion of contrast).

Radiology reporting of micturating cystourethrograms (MCUGs): What the paediatric urologists want to know

Micturating cystourethrograms (MCUGs) are commonly requested to exclude vesicoureteric reflux (VUR) and bladder outlet obstruction (BOO). Useful additional information including timing and bladder volume at the start of reflux, urethral anomalies and post-void drainage can be obtained from the cystograms, but are not routinely reported by radiologists. The study aim was to retrospectively review MCUG reports against a proposed reporting proforma, and then re-analyse the effect of the proforma on report quality. A retrospective analysis of paediatric MCUG reports was undertaken from two patient cohorts. Cohorts A (41 reports) and B (51 reports) comprised reports written before (2011-12) and following (2016-17) distribution of the standardised reporting proforma, respectively. Reports were assessed with respect to the parameters outlined on the standardised MCUG reporting proforma, including presence, grade and timing of VUR amongst others. Findings from both cohorts were compared and statistically analysed (p<0.05 significant) to establish if the proforma influenced the content of reports. Statistically significant improvements were demonstrated in the reporting of: bladder outline normal/abnormal - reported in 92% after the proforma vs 56% before (p<0.001); urethra normal/abnormal - 87% vs 68% (p=0.033); contrast volume instilled - 84% vs 61% (p=0.011); bladder emptying - 69% vs 17% (p<0.001). In patients with VUR, reporting of VUR timing - 96% vs 33% (p<0.001) and VUR grade - 91% vs 40% (p=0.002) were also significantly improved. Implementation of a standardised MCUG reporting proforma produced substantial improvements in report quality and consistency, with statistically significant improvements noted in six of seven key features.

Update in management of Congenital Penile Curvature complex .

Background:Congenital curvature of the penis results from abnormal efflorescence of the tunica albuginea of the corpora cavernosa and not accompanied with urethral anomaly. Complex Congenital curvature of the penis has two abnormal elements : mal-rotation either clockwise or anti clockwise and curvature of the penis either dorsal or ventral. Aim of the work: To present update in management of congenital curvature complex of the penis. Background: Congenital curvature of the penis results from abnormal efflorescence of the tunica albuginea of the corpora cavernosa and not accompanied with urethral anomaly. Complex Congenital curvature of the penis has two abnormal elements: mal-rotation either clockwise or anti clockwise and curvature of the penis either dorsal or ventral. Aim of the work: To present update in management of congenital curvature complex of the penis. Patients and Methods:This prospective study done at Al-Azhar University Hospital in Damietta. Fifteen patients [15] with congenital curvature complex of the penis were evaluated and corrected from June. 2019 to January 2020, their mean age was 5.1 ± 2.34 years [range 2–10 year]. The direction of torsion was anticlockwise in 12 patients and in 3 patients was clockwise. Four patients had dorsal curvature and Eight patients had ventral curvature, while three patients had lateral curvature. All patients treated at first by modified Nesbit's procedure for correction of curvature, then dorsal flap of dartos layer for correction of penile torsion in one stage. Results: All cases with congenital curvature complex of the penis corrected in one-set surgery, which is simple, familiar and safe procedure with high successful rate. There were only a few transient complications, such as edema, mild bleeding, and penile hematoma resolved spontaneously. No recurrence of mal-rotation or curvature reported. Conclusion: Congenital Penile Curvature Complex can be treated in single-stage surgery with excellent functional and cosmetic outcomes by combination of modified Nesbit's procedure with dorsal flap of dartos layer. Patients and Methods:This prospective study done at Al-Azhar University Hospital in Damietta. Fifteen patients (15) with congenital curvature complex of the penis were evaluated and corrected from June. 2019 to January 2020 ,their mean age was 5.1 ± 2.34 years (range 2–10 y). The direction of torsion was anticlockwise in 12 patients and in 3 patients was clockwise. Four patients had dorsal curvature and Eight patients had ventral curvature, while three patients had lateral curvature. All patients treated at first by modified Nesbit's procedure for correction of curvature, then dorsal flap of dartos layer for correction of penile torsion in one stage.Results:All cases with congenital curvature complex of the penis corrected in one-set surgery, which is simple, familiar and safe procedure with high successful rate.There were only a few transient complications, such as oedema, mild bleeding, and penile hematoma resolved spontaneously. No recurrence of mal-rotation or curvature reported.Conclusion: Congenital Penile Curvature Complex can be treated in single-stage surgery with excellent functional and cosmetic outcomes by combination of modified Nesbit's procedure with dorsal flap of dartos layer.

Prenatal diagnosis and postnatal outcome of anterior urethral anomalies.

Anterior urethral anomalies (AUA) which present as anterior urethral valve, stenosis or atresia, are a rare cause for congenital urinary tract obstruction. We present our AUA prenatal diagnosis case series. Fetuses presenting with prenatal findings suggestive for AUA according to postnatal reported clinical and imaging signs (urinary tract dilatation, dilated bladder, enlarged edematous fetal penis, dilatation of the fetal urethra and diverticula) were followed prospectively. Six fetuses were diagnosed with AUA. Diagnosis was confirmed upon examination of the neonate or the abortus. All cases presented with variable degrees of urinary tract dilatation. Four fetuses who presented with additional congenital anomalies of the kidneys and urinary tract (CAKUT) developed intra-uterine or early postnatal renal failure, while two isolated AUA cases have a normal renal outcome. AUA is a rare diagnosis. However, high index of suspicion and careful sonographic assessment of the male fetal urethra in cases referred for urinary tract dilatation may enable appropriate parent counseling, optimal prenatal surveillance and timed postnatal urological intervention. As in other lower urinary tract obstructions, future renal function seems to correlate with associated CAKUT, therefore close follow up throughout pregnancy and meticulous sonographic assessment is recommended.

Contrast-enhanced voiding urosonography with intravesical administration of ultrasound contrast agent for the diagnosis of pediatric vesicoureteral reflux.

Vesicoureteral reflux (VUR) is one of the most common urinary tract anomalies in children. It has been reported that VUR may be associated with reflux nephropathy. Ultrasound contrast-enhanced voiding urosonography (CeVUS) has become a routine diagnostic method for VUR in a number of European countries; however, it is not widely used in China. The aim of the present study was to analyze the clinical application and evaluate the safety of CeVUS as a diagnostic tool for VUR in children in order to establish a standardized operating procedure for CeVUS in pediatric VUR in China. Between August 2016 and October 2017, 90 children who were susceptible to VUR were admitted into the Pediatric Nephrology Department of Tongji Hospital and underwent CeVUS. The SonoVue second-generation USA contrast agent was administered intravesically via a transurethral bladder catheter at a dose of 1 ml. The occurrence of adverse events was monitored. Urine analysis and culture were performed. A total of 90 children (47 female, 43 male; mean age, 36.6 months) with 178 Pelvi-Ureteral Units (PUUs) underwent CeVUS to screen for VUR. VUR was detected in 44/90 pediatric patients (48.89%) and 65/178 PUUs (36.52%) by CeVUS. The grade distribution of the 65 PUUs with VUS was as follows: Grade I, 3; Grade II, 9; Grade III, 14; Grade IV, 22; and Grade V, 17. The accuracy of CeVUS in the present study were consistent with previous reports. No urethral anomalies were detected and there were no adverse events. CeVUS was demonstrated to be a safe, accurate and reliable imaging technique for detecting VUR in high-risk children, including neonates. Results of the present study indicated that CeVUS can be adopted as the primary screening and follow-up method for pediatric VUR diagnoses in China.

The Megameatus, Intact Prepuce Variant of Hypospadias: Use of the Inframeatal Vascularized Flap for Surgical Correction.

The megameatus intact prepuce (MIP) variant of hypospadias is a rare variant of hypospadias that is diagnosed either early at the time of circumcision or later as the foreskin is retracted. The true incidence of the anomaly is difficult to determine precisely as some patient never come to medical attention but is felt to under 5% of all cases of hypospadias. The purposes of this study are to review the embryology and clinical findings of MIP and then, in light of a personal experience, present a series of patients evaluated for MIP who were treated with a modification of the Mathieu technique. A PubMed search of all articles in the MIP variant of hypospadias was carried out followed by an exhaustive review of the literature. The charts of all patients evaluated and treated at Boston Children's Hospital by MC between 2007 and 2017 were reviewed retrospectively. The patients were divided into two groups: those who underwent the standard procedure and those who underwent a repair using a modification of the Mathieu procedure using an inframeatal flap. The embryologic explanation of the MIP variant is not clear but failure of the distal, glanular portion of the urethra to tubularize results in spectrum of abnormality characterized by a deep glanular groove and an abnormal opening of the urethra anywhere from the mid-glans to a subcoronal location. Surgical repair is complicated by a wide distal urethra which may be injured if not properly identified. Overall good outcomes were noted with one patient experiencing a urethra cutaneous fistula in the first group and one patient having a mild glans dehiscence in the second. The MIP variant of hypospadias is a rare variant of hypospadias that presents as a spectrum of urethral anomaly. Surgical repair may not always be necessary but if surgical repair is carried out, the Mathieu technique modification may offer better anatomic delineation of the urethra and will provide an extra layer of tissue to cover the reconstructed urethra. Low complication rates should be expected with adequate functional outcome such as a normal urinary stream. In addition, criteria for selecting patients for surgical repair are provided.

Clinical and urodynamic outcomes in children with anorectal malformation subtype of recto-bladder neck fistula

Patients with anorectal malformations (ARMs) have a high incidence of genitourinary anomalies. Those with a recto-bladder neck fistula may represent a high-risk group, but their long-term urologic outcomes are poorly described. To evaluate the clinical and urodynamic outcomes in a large cohort of patients with an ARM subtype of recto-bladder neck fistula. A retrospective cohort study was performed of patients who had been treated for a recto-bladder neck fistula at the present institution since 2007. The primary outcomes were the ability to achieve urinary continence after 4 years of age, and development of a mildly decreased glomerular filtration rate (GFR) or worse (<89ml/min/1.73m2). Continence was defined as the ability to store urine for 3-4h during the day and 8h overnight without leakage. Demographic and clinical data are provided in the Summary Table. The most recent urodynamic findings included the presence of detrusor overactivity in 30 (75%) patients, median leak point pressure of 56.0cmH2O (range, 14-140), median functional cystometric capacity at 40cmH2O of 125.5% age-expected capacity (range, 36-473%), and median maximum cystometric capacity of 131.0% age-expected capacity (range, 44-473%). A mildly decreased GFR or worse developed in 13 (24%) patients. Of the 52 (78%) patients who were followed by pediatric urology at the present institution with a median follow-up of 30.9 months (range, 0.0-86.8), 35 (67%) were at least 4 years of age and could be assessed for continence. Continence was achieved in five (14%) patients voiding spontaneously and 15 (43%) performing CIC. Recurrent urinary tract infections (UTI) (OR 0.70, P=0.006) were an independent predictor of incontinence, while urethral anomalies (OR 1.40, P=0.03) were an independent predictor of chronic kidney disease (CKD) on multiple logistic regression analysis. The findings favorably compared with other studies, but were more robust due to the size of the cohort and breadth of urologic evaluation. Limitations included the retrospective design at a single institution. Incomplete clinical data and misclassification of continence may have lead to bias. This large cohort of patients with an ARM subtype of recto-bladder neck fistula had a high incidence of genitourinary anomalies. They were rarely able to achieve continence with spontaneous voiding alone and were at risk of developing CKD, both of which were likely multifocal in origin. Long-term urologic follow-up is warranted for patients with a recto-bladder neck fistula.

En Ünlü Arap İslam Medikal Kitaplarındaki İnsan Anomalileri

Objective: Congenital anomalies in human is well known since prehistoric man, but it is believed now that these anomalies are continuously increasing in their incidence on one side and in their differences on the other. Aim of the paper: to identify the most important congenital anomalies in human, according to what was written in the most important old Arabic medical books during the Arab Islamic civilization era. Material and Methods: the historical method was followed in this research, by going back to some important old Arabic medical books, mainly al-Hawi and al-Taqseem Waltashjeer books of Rhazes, al-qanun fi al-tibb book of Avicenna, and al-Tasreef book of Albucasis. Then, a comparison study of these anomalies were done with what is currently known in modern medicine. Results: 1- Old Arab physicians knew some congenital anomalies in human, and they talked about in their books. 2- Arab physicians distinguished between two types of hydrocephalus; congenital, which its cause is unknown, and acquired such as resulted from midwifery trauma. 3- Arab physicians talked on the treatment of two types of urethral anomalies. 4- Arab physicians did not mention to some anomalies currently known, such as cleft palate. Conclusion: Old Arab physicians talked in their books on some congenital anomalies in human, and in some cases they determined their treatment either surgical or non-surgical. But they did not mention to some anomalies well know now.

Short-term Complications After Pyeloplasty in Children With Lower Urinary Tract Anomalies

To investigate whether children with lower urinary tract (LUT) anomalies are at greater risk for postoperative complications after laparoscopic pyeloplasty stented with a double-J catheter (JJC). Prospectively collected data of laparoscopic pyeloplasty (LP) performed between 2006 and 2015 were analyzed. Inclusion criteria are (1) toilet-trained child and (2) unilateral dismembered pyeloplasty stented with a JJC done by the same surgeon. Our pyeloplasty protocol includes cystoscopy and retrograde pyelography. JJC is left in for 3weeks. Asymptomatic patients with infravesical LUT anomalies (a-LUTA) and those with history of LUT symptoms (LUTS) were identified. Any short-term complication was classified according to Clavien-Dindo. Fisher's exact test was used for statistical analysis. Fifty-four children (mean 9.8 years) were included. Ten of 54 patients had LUTS. In 4 of those 10, anatomical infravesical anomaly was found during cystoscopy. Accidental urethral anomaly was found in 11 patients (a-LUTA). The control group (CG) consisted of 33 patients. Postoperative hospital stay ranged from 1 to 8 days (mean 2 days). Overall complication rate was 8 of 54 (14%). Grade 1 complications occurred in 3 patients in the CG. Five patients had grade 3 complications (2 needed replacement of bladder catheter, and 3 had diversion of the upper tract). Those problems occurred in 1 of 10 patients with LUTS and 3 of 11 patients with a-LUTA compared to 1 of 33 in the CG. This difference was statistically significant (P < .05). Careful history should be taken in toilet-trained children before pyeloplasty. If any infravesical abnormality is discovered, internal diversion should probably be avoided. Special attention must be paid to bladder function in the postoperative period.

Multiple urethral anomalies: Parameatal urethral cyst, penile curvature, incomplete hypospadiac anterior duplication of the urethra and distal hipospadias.

The male genitourinary system is quite complex. There are numerous known anomalies of the male urethra either as isolated cases or in combination with other disorders. An improved understanding of the embryology and anatomy of the normal male urethral development might help explain the causes of the various urethral abnormalities. We contribute to the etiology of congenital anomalies with this multiple urethral anomalies case.

Imaging after Urinary Tract Infection in Older Children and Adolescents

There are few guidelines and little data on imaging after urinary tract infections in older children. We determined the clinical yield of renal and bladder ultrasound, and voiding cystourethrogram in older children and adolescents after urinary tract infection. We analyzed findings on voiding cystourethrogram, and renal and bladder ultrasound as well as the clinical history of patients who underwent the 2 studies on the same day between January 2006 and December 2010. We selected for study patients 5 to 18 years old who underwent imaging for urinary tract infection. Those with prior postnatal genitourinary imaging or prenatal hydronephrosis were excluded from analysis. We identified a cohort of 153 patients, of whom 74% were 5 to 8 years old, 21% were 8 to 12 years old and 5% were 12 to 18 years old. Of the patients 77% were female, 78% had a febrile urinary tract infection history and 55% had a history of recurrent urinary tract infections. Renal and bladder ultrasound findings revealed hydronephrosis in 7.8% of patients, ureteral dilatation in 3.9%, renal parenchymal findings in 20% and bladder findings in 12%. No patient had moderate or greater hydronephrosis. Voiding cystourethrogram showed vesicoureteral reflux in 34% of cases and bladder or urethral anomalies in 12%. Reflux was grade I, II-III and greater than III in 5.9%, 26% and 2% of patients, respectively. For any voiding cystourethrogram abnormality the sensitivity and specificity of any renal and bladder ultrasound abnormality were 0.49 (95% CI0.37-0.62) and 0.76 (95% CI 0.66-0.84), respectively. Positive and negative predictive values were 0.58 (95% CI 0.44-0.71) and 0.69 (0.59-0.77), respectively. In older children with a history of urinary tract infection the imaging yield is significant. However, imaging revealed high grade hydronephrosis or high grade vesicoureteral reflux in few patients. Renal ultrasound is not reliable for predicting voiding cystourethrogram findings such as vesicoureteral reflux.

Anterior Urethral Valve and Diverticulum in a Neonate with Urinary Tract Infection

Introduction:Anterior urethral valve (AUV) is a rare congenital anomaly that can cause obstructive uropathy. AUV can lead to variable urinary tract symptoms, and if left untreated, it can result in end-stage renal disease. AUV should be immediately evaluated and managed. Herein, we present a neonate with AUV and diverticulum, who was treated by cystoscopy. Case report:A 11-day-old boy was referred to the nephrology department for evaluation of urinary tract infection, which was developed 2 days prior to admission. Pregnancy and routine ultrasound (US) were normal, and urinalysis showed pyuria. Routine investigations included blood urea nitrogen, serum creatinine, electrolyte panel, urine analysis (UA), and urine culture (UC). Abdominal US examination displayed a normal bladder with normal kidneys. A voiding cystourethrogram (VCUG) showed an anterior urethra diverticulum with dilation of the proximal urethra and trabeculated bladder; however, no vesicoureteral reflux was observed. Finally, the patient underwent endoscopy. Discussion: AUV is a congenital mucosal fold, located distally to the membranous urethra. AUV can be located anywhere distal to the membranous urethra and is found in bulbar urethra (40%), penoscrotal junction (30%), pendulous urethra (30%), and occasionally in the fossa navicularis, respectively. The exact etiology of this disease is unclear. AUV with associated diverticulum is a rare congenital urethral anomaly that can lead to penile swelling, urethral obstruction, urinary retention, incontinence, nocturnal enuresis, bladder rupture, and end-stage renal disease. Depending on the severity of anatomical obstruction, this condition may present soon after birth or later during childhood. VCUG is the most important imaging technique for the evaluation of urethral abnormalities. Congenital AUV in children has a generally good prognosis, but may occasionally result in poor renal outcomes such as renal insufficiency, renal failure, and patient‘s death.