Objective The pyeloureteral anastomosis remains the most challenging part of pyeloplasty. A purpose-built anastomotic device could simplify this step and potentially improve outcomes. The concept of a pyeloureteral magnetic anastomosis device (PUMA) was proven in minipigs, but only in short term. Our aim was to test the PUMA in domestic pigs and achieve a prolonged follow-up period. Methods Five female domestic pigs underwent laparoscopy and ligation of the left ureter. Four weeks later, laparoscopic implantation of the PUMA was planned. Removal of the device and a retrograde contrast study were scheduled after another 4 weeks. The experiment was terminated when the animals could no longer be properly cared for due to their weight. Results Due to unexpected smaller ureteric diameters, a modified PUMA could only be successfully inserted in pig number 3 (49 kg). Four weeks later, the device was found to be dislocated, but the anastomosis remained patent. After modifying the study protocol, the PUMA was successfully implanted in pigs number 4 (96 kg) and 5 (68 kg) 8 weeks after ureteric ligation. Pig 4 developed malignant hyperthermia and died. In pig 5, the magnets were removed 4 weeks later. After an additional 8 weeks, the animal reached 135 kg and was terminated. The anastomosis remained patent and preserved its diameter. Conclusion Despite limitations, our study successfully demonstrated that the PUMA can achieve a patent ureteric anastomosis in domestic pigs. This suggests a potential for minimally invasive ureteric anastomosis in clinical settings. Further research is needed to optimize the technique and validate its effectiveness in humans.

Background: In proximal hypospadias, ventral curvature is invariable and most have penoscrotal transposition, and we observed that the base of the penis (BOP) was located on the inferior aspect of the pubic bones in those, in contrast to the location of the BOP at the anterior end in normal penises. We also observed an unfused bulbospongiosus muscle (BSM) at surgery in those. The aim was to assess the impact of repairing the unfused BSM or transection and straightening of the urethral plate at the first operation on the low BOP. Method: All consecutive proximal hypospadias operations from January 2021 to August 2023 that had a low BOP were retrospectively studied. At the first operation, some had urethral plate transection only, with no BSM repair. Some had BSM repair with or without plate transection. The BOP position was reassessed post-intervention. Results: Thirty-three cases of proximal hypospadias with low BOP were studied. At the first operation, as the key distinguishing step, 18 had BSM repair and 15 urethral plate transections. BOP shifted to the anterior end of the pubic bones in all 18 patients following BSM repair but showed no change in the 15 without BSM repair (p < 0.01). Subsequent BSM repair, during the second stage, normalized BOP in those 15. Normalising the BOP corrected penoscrotal transposition because the anterior end of the scrotum was at the anterior end of the pubic bones. Conclusion: Repairing BSM is essential for normalising the BOP, which results in a normal penoscrotal relationship and normal anterior penile projection. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, andsimilar technologies.

Retroperitoneal pyeloplasty (RP) was thought to be associated with fewer possible complications than the transperitoneal approach (TP); however, TP offers larger working space and an easier anastomosis, anterior to crossing lower pole vessels, when present. In TP, the peritoneum can be easily reconstructed back, and cosmesis is nearly similar. We reviewed our experience with RP and TP in comparison with the classic open extra/retroperitoneal approach (OP). Data from 156 cases who had pyeloplasty were reviewed: TP: 40 consecutive cases (27 over 5 years old, 13 under 5 years old and 3 under 1 year old; youngest - 5 months old), including 3 redo/revision cases; RP: 56 consecutive primary cases, all over 5 years of age; and OP: 60 primary cases (41 over 5 years old, 19 under 5 years old, and 9 under 1 year old; youngest - 3 months old). Operation time, conversion rate, and complications were all compared. Unpaired t-test and chi-square test were used, and p < 0.05 was considered significant. There were no intraperitoneal surgical complications such as organ injury or bowel adhesions with TP. TP was operatively shorter than RP (230.4 ± 29 vs. 249.8 ± 46 min, p = 0.0036). The conversion rate was lower in TP than in RP [1/40 (2.5

Background: This study aims at investigating the continence outcome in primary epispadias patients treated at a tertiary center. The authors hypothesized that additional continence procedures following primary epispadias repair is not routinely needed. Methods: Patients treated for primary epispadias at the authors ' institution between 2007 and 2019 and toilet trained, were identi fied from a prospective maintained database. Males underwent chordee correction, urethroplasty and glanuloplasty. Females underwent genitoplasty with reduction urethroplasty. If continence was not achieved by 4-5 years of age, pelvic floor muscle (PFM) biofeedback therapy was performed. Other continent procedures were discussed with family/patient if still incontinent. Primary outcome: urinary continence. Secondary outcomes: PFM biofeedback therapy, continence surgery, hydronephrosis. Type of epispadias, age at repair and follow-up presented as median was also reported. Results: Thirty-three patients (29 males) were included. Twelve had penopubic epispadias, 13 glanular/ penile, 4 duplicated urethra, 4 females. Median age at repair: 2 years (IQR 1-3), at follow-up: 8 years (IQR 6-10). Daytime continence: 100 % in penile/glanular; 33 % in penopubic and 75 % in duplicated urethra. Nighttime continence: respectively 92 %, 50 % and 100 %. 24 % of males were intermittently incontinent. All patients except one voided urethrally. One patient underwent bladder neck closure, ileocystoplasty and Mitrofanoff. One girl achieved daytime continence, 2 were intermittently incontinent, one continuously incontinent. All were enuretic. 38 % of boys and 100 % of girls had biofeedback therapy. None had hydronephrosis/renal impairment. Conclusions: Most children with primary epispadias can achieve social urinary continence spontaneously or with the support of PFM biofeedback therapy. Other continence procedures should be reserved for patients who do not attain satisfactory continence. Level of Evidence: Treatment study - level IV. Crown Copyright (c) 2023 Published by Elsevier Inc. All rights reserved.

Research studies with porcine acellular bladder matrix (PABM) showed integration of only small sized stamps in recipient bladders, however for clinical use in bladder augmentation significantly larger patches are needed. We hypothesised pre-vascularisation with omentum may be a step towards clinical translation. Eight domestic pigs were operated three times 8–10 weeks apart: 1–Implantation; PABM with recorded dimensions were sutured around a tissue expanding device, wrapped in omentum and sutured to the anterior abdominal wall. 2–Augmentation; hemi-cystectomy and bladder augmentation was performed with the pre-vascularized PABM using non-absorbable suture 3–Sacrifice; The dimensions of the PABMs were measured macroscopically, the in-vivo microcirculation of the PABMs were assessed using laser speckle contrast imaging. HE staining, uroplakin 3 and CK7 immunohistochemistry was performed. In seven animals, the bladder augmentation was successful without complication. One animal was lost in bowel obstruction and in two animals enteric fistula was found after the first intervention. The rectangular shape of the initial tissue expander was subsequently changed. All the seven patches were strong, compliant and had integrated with the surrounding native bladder and were 83

We believe that this Elsevier publication on MRI studies to obtain objective information on assessing the degree of virilization in Congenital Adrenal Hyperplasia and which describes the ‘bifid bulb’ sign, is highly relevant to the readers of JPU [ [1] AbouZeid A.A. Mohammad S.A. Transformation of the female genitalia in congenital adrenal hyperplasia: MRI study. J Pediatr Surg. 2020; 55: 977-984https://doi.org/10.1016/j.jpedsurg.2020.01.002 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ]. 45 years’ experience with early childhood anatomical technique of feminising genitoplasty for 46 XX Congenital Adrenal Hyperplasia –observations of vaginal introital anatomy and its relationship to the perineal bodyJournal of Pediatric UrologyVol. 18Issue 5PreviewIn Manchester, feminising genitoplasty is offered to children with 46XX Congenital Adrenal Hyperplasia (CAH) when there is a single perineal opening and/or enlarged clitoris. Our aims are to describe the anatomical reconstructive technique and present long-term outcomes. Our hypothesis is that ‘the common channel (CC) length and distance to the vagina from perineal skin is mostly due to virilisation and hypertrophy of perineal tissue over the almost normally positioned vaginal introitus (V–I) in relation to the perineal body (PB)’. Full-Text PDF

Background: We designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy.Methods: Synthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students ( n = 10) and surgical trainees ( n = 10) were asked to perform thoracoscopic repair of an "EA" with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3-4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5-3 kg) esophagi ( n = 25 in each test series). BP and PF were measured and compared against each other. Results: Medical students were unable to complete HA, but were successful with the EMAD in 11.1 & PLUSMN; 2.78 min. Surgical trainees completed EMA in 4.6 & PLUSMN; 2.06 min vs. HA 30.8 & PLUSMN; 4.29 min ( p < 0.001). The BP following a HA (14.1 & PLUSMN; 3.32 cmH 2 O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH 2 O), whereas the BP with the EMAD was extremely high ( > 90 cmH 2 O) ( p < 0.001). The PF of an EMA (1.8 & PLUSMN; 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 & PLUSMN; 0.43 N) ( p < 0.0 0 01).Conclusion: The EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation.& COPY; 2022 Elsevier Inc. All rights reserved.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Simulation-based training (SBT) has a significant role in training in complex procedure like laparoscopic pyeloplasty. We propose a new training model for laparoscopic pyeloplasty which has been compared to other models. Trainees (n = 22) evaluated our balloon model (BM) and three other models -glove finger model (GFM), chicken thigh model (ChTM) and chicken crop model (ChCrM)- subjectively, based on a 5-point Likert scale. The face validity mean score of our BM model was 3.58 ± 0.69. Our novel model can be a cost-effective, hygienic, and easy-access alternative to other laparoscopic pyeloplasty models.

First of all, we would like to congratulate the author in achieving excellent results with the ‘back to the future Chordee Excision & Distal Urethroplasty’’ technique [1]. We would also like to commend the author in attempting this technique, which has initially being used over 100 years back to achieve natural diversion of urine from the repair.

IntroductionPatients with Congenital Lower Urinary Tract Malformations (CLUTM) have increased risk of post-transplant complications if bladder dysfunction is not addressed. Pretransplant assessment may be difficult if urinary diversion has been previously applied. In case of low capacity and/or low compliance and/or high-pressure overactive bladder, transplantation into a diverted or augmented system may be required. We hypothesised that a bladder optimization pathway may help identify potentially salvageable bladders and prevent unnecessary bladder diversion or augmentation. We propose a structured bladder optimisation and assessment programme for safe transplant and native bladder salvage.Material and methodsData of 130 children who underwent renal transplant between 2007 and 2018 were retrospectively collected and analysed. All patients with CLUTM were assessed by urodynamic study.Bladder optimisation: Low compliance bladders were managed with anticholinergics and/or Botulinum toxin A (BtA) injections. Those who had urinary diversion for their pathology underwent a structured assessment and optimisation process with undiversion/anticholinergics/BtA/bladder cycling/Clean Intermittent Catheterisation (CIC)/Suprapubic catheter (SPC) as indicated. Details of medical and surgical management were collected (Figure 1).ResultsBetween 2007 and 2018, 130 renal transplants were done. Of these, 35 (27%) had associated CLUTM (PUV in 15, neurogenic bladder dysfunction in 16, other pathology in 4) which was managed in our centre. Ten patients needed initial diversion in the form of vesicostomy (2) or ureterostomy (8) to manage primary bladder dysfunction. The median age at transplant was 7.8 years (range 2.5-19.6). After bladder assessment and optimisation, a safe bladder was demonstrated in 5 of 10 with initial diversion leading to transplant into native bladder (without augmentation). Overall, of the 35 patients, 20 (57%) had transplant into native bladder, 11 patients had ileal conduits and 4 had bladder augmentation. Eight required help with drainage: three with CIC, four with Mitrofanoff, and one had reduction cystoplasty.ConclusionWith a structured bladder optimisation and assessment programme, safe transplant and 57% native bladder salvage is achievable in children with CLUTM.

Introduction and Aim: A large prostatic utricle (PU) is difficult to remove, when symptomatic, thus indicated, because of its proximity and adherence to the vas deferens, on each side and the occasional ectopic vasal opening into the utricle. Inadvertent vasectomy or deliberately transecting the vas deferens, on one or both sides, is often inevitable, leading to infertility. This work offers an insight into the pertinent surgical anatomy and the aforementioned challenges, as well as a modification of technique in children. Clinical Presentation: A case of a then 4-year-old boy, with penoscrotal hypospadias and a large PU, complicated with recurrent urinary tract infections (UTIs), after a staged hypospadias repair is reported. The hypospadias repair was deemed effective, as judged by cystoscopy. During subsequent laparoscopy, we found the vas deferens bilaterally entering a high point into the PU fundus and running along its wall. Surgical Technique: Definitively, a cystoscopy-assisted laparoscopic technique was performed. The PU was bihalved, then a tubular structure was eventually constructed, from the wall of the utricle on each lateral edge, as an extension of the vas deferens, thus preserving it running towards the urethra and connected to the ejaculatory pathways. The bulky central part of the utricle was discarded. Progress: Recovery was uneventful. The patient was discharged on the next morning and remains asymptomatic for >1 year after surgery. Conclusion: This technique allows for preservation of the vas deferens while excising the main bulk of the utricle. Prospects of sperm delivery are thus kept, as the primary goal of preventing UTIs is fulfilled. A spermatogram could be obtained in the future, when age permits, to confirm this, as it is still not possible during childhood. Authors' Contributions: Both authors share authorship and contribution. Both authors shared the surgical care of the reported patient and acquisition, analysis, and interpretation of the data. Both authors contributed to the literature review, drafted and produced the article then responded to the peer reviewers' critique. The article has been read and approved by both authors. The requirements for authorship as stated in the Instructions to the Authors have been met. Each author believes that the article represents honest work. Ethics Declaration and Consent for Publication: This report followed the principles of the Declaration of Helsinki. It was conducted under the auspices of a university/teaching medical center, which operates under directives allowing utilization of nonidentifiable clinical data. Consent for any clinically indicated surgical procedure or medical intervention followed the standard informed and written documentation, which entails parental consent for sharing the data/findings for educational purposes. Availability of Data and Material: The data and material for this study are available and stored confidentially. No competing financial interests exist. Funding: No funding was received for this article. Runtime of video: 5 mins A preliminary abstract/summary related to this study was presented at the European Society of Paediatric Endoscopic Surgeons, Online Conference, on September 18, 2020, ESPES 2020, Xth Annual Meeting, E-congress (Part 2), hosted at IRCAD France. https://www.espes.eu/media/content/2020_09_15_Abstract_booK.pdf and as a poster at the 20th BAPES Annual Scientific Meeting (virtual), on November 5th–6th, hosted in London. https://www.bapes.org.uk/london2020posters

Introduction Mucus production by the intestinal segment used in bladder augmentation results in long term concerns especially stones and UTI. Bladder augmentation with demucosalized intestinal flap is a potential promising approach for mucus-free bladder augmentation, however the contraction of the flap remains a major concern. Mucosectomy has been shown to result in abrupt and immediate cessation of microcirculation in the ileum. However, assessment of microcirculation shortly after mucosectomy may miss a gradual recovery of micro-circulation over a longer period of time. Previous studies have not assessed the colon response to mucosectomy. Objective Our aim was to assess the effect of mucosectomy on the microcirculation of the colon and ileum beyond the known warm ischemia time. Study design Ileum and colon segments were detubularised and mucosectomy was performed in (n = 8) anesthetised minipigs. Group A: sero-musculosubmucosal flaps were created with removal of the mucosa and preserving the submucosal layer Group B: sero-muscular flaps were created with the removal of submucosal-mucosal layer. The Microvascular Flow Index (MFI), the velocity of the circulating red blood cells (RBCV) was measured using Intravital Dark Field (IDF) side stream videomicroscopy (Cytoscan Braedius, The Netherlands) after mucosectomy, for up to 180 min. Results Both the MFI and RBCV showed an abrupt reduction of microcirculation, on both surfaces of the remaining intestinal flap, in the ileum as well as in the colon. Slightly better values were seen in Group A of the colon, but even these values remain far below the preoperative (control) results. Some, tendency of recovery of the microcirculation was noted after 60-90 min, but this remained significantly lower than the preoperative control values at 180 min. Conclusion Both the ileal and the colonic flap remains in severe ischemia after mucosectomy beyond the warm ischemia time. Discussion This study shows that surgical mucosectomy compromises vascular integrity of the intestinal flaps used for bladder augmentation. Partial recovery which occurs within the warm ischemia time is not significant enough to avoid fibrosis therefore flap shrinkage may be inevitable with this technique. Limitation The gastrointestinal structure of the porcine model is not the same exactly as the human gastrointestinal system. However, although not an exact match it is the closest, readily available animal model to the human gastrointestinal system.

In Manchester, feminising genitoplasty is offered to children with 46XX Congenital Adrenal Hyperplasia (CAH) when there is a single perineal opening and/or enlarged clitoris. Our aims are to describe the anatomical reconstructive technique and present long-term outcomes. Our hypothesis is that 'the common channel (CC) length and distance to the vagina from perineal skin is mostly due to virilisation and hypertrophy of perineal tissue over the almost normally positioned vaginal introitus (V-I) in rela-tion to the perineal body (PB)'.Method and results This is a retrospective notes review of all consecu-tive 46XX CAH operations from 1976 to December 2021. 99 patients, who had feminising genitoplasty and being followed-up, were included. 15 patients who were lost to follow up were excluded. Median age at surgery was 15 months. In 91, midline division of the labia majora, spongiosum, bulbo-spongiosus muscle (BSM) and CC down to PB was performed. This was sufficient to expose the V-I at the same level or within 5 mm depth of PB in 88. In 78 V-I was adequate taking 10/12fr dilator (Type 1). In 10, CC resembled a male urethra and V-I was narrow (Type 2), requiring widening by 5-10 mm incision at 6 o'clock position. Dartos of labia majora was attached to BSM to reduce the distance to V-I from perineal skin and the gap was lined with inner foreskin to create a vestibule.Out of 70 who were post-pubertal, 75% (53/70) had adequate calibre vaginal openings. 5 had introitoplasty and 2 had dilatation under anaes-thesia. 10 needed self dilators only.29 patients, of one of the three surgeons, had measurements of clitoris, CC, urethra and vagina. A hymen was found in 86% (25/29). There was signifi-cant strong, inverse correlation between the CC length and the urethral length (r =-0.708, p < 0.001, n = 27) but not between CC and vaginal lengths. After adjusting for age, the urethral length of Type 2 patients was 3.825 mm shorter than those of Type 1 (p = 0.017).Conclusion Our data show that 'high' confluence is mostly due to virilisation of genitalia; and the anatomical technique of reversing the fusion of the urethral folds, spongiosum and bulbo-spongiosus muscle could be performed with all degrees of virilisation with success in early childhood with no need of local flaps or mobilisation of the urethro-vaginal com-plex. About 10% require surgery to treat narrowing of vaginal opening post puberty.

Severe abdominal pain and vomiting are common symptoms in children with pediatric multisystem inflammatory syndrome (PIMS). Mesenteric lymphadenitis and aseptic peritonitis are predominantly reported in cases where acute surgical abdomen was suspected and laparotomy was performed at the early stage of the pandemic. These reports generally discouraged surgeons to perform exploration in COVID-19-related cases and medical management was prioritized. Only a few COVID-19-specific surgical cases with intestinal ischemia were published. Here, we report another case of COVID-19-related intestinal ischemia complicated with Meckel's diverticulitis in a non-immunocompromised child who clearly required surgical intervention. In our case, the combination of COVID-19-related vasculitis and low blood pressure episodes may have contributed to this severe outcome.

Introduction There are various techniques described for repair of penile hypospadias. Objective To present the anatomical repair technique and to discuss the lessons learned from this technique over 18 years. Methods All consecutive patients with penile hypospadias who underwent anatomical repair of urethra, spongiosum, bucks and dartos fascia and foreskin by the 3rd author, with a minimum of 1 year follow up from January 2003 to March 2020 at the Royal Manchester Children's Hospital, United Kingdom, were included in the study. No formal ethics approval taken as this study was done as a service evaluation. Perioperative and follow up data were recorded prospectively in the departmental database. SIPP 21 was used for statistical analysis. Fisher’s Exact Test used for sub-group analysis. Findings were considered statistically significant at p<0.05. Results 368 patients had surgery at a median age of 18 months. 94.6% had no complications, 4.1% had minor and 1.3% had significant complications. 77.5% had a distal ectopic meatus. The mean length of urethroplasty was 8mm. To widen the urethral plate, a meatoplasty (M) was performed in 34% and urethral plate incision (UPI) in 14%. Catheters were used in 71% for a median duration of 7 days, and 40% had a 6F catheter. Regards to meatal stenosis the only statistically significant causative factor was UPI with 6fr catheter. P value=0.02. Conclusions Anatomical repair provides a completely normal penis with minimal complications. Meatoplasty widens the urethral-plate and reduces the risk for meatal stenosis.

Optical balloon ports offer quick, easy and well controlled retroperitoneal access. However, the relatively long tip of the port in small children requires special consideration. We report our 5-year experience with regards to safety, efficacy and advantages with optical balloon ports over conventional ports in retroperitoneal laparoscopic surgery. Forty-two patients who underwent laparoscopic nephrectomy, heminephrectomy, pyeloplasty with a retroperitoneal approach in between June 2015 and July 2020 were selected for the study. These patients were divided in to two groups of 21 each. Patients in Group 1 underwent conventional port placement while patients in Group 2 were subjected to optical balloon port insertion. The time taken for access, gas leak, the need of wound extension for specimen removal, safety and complication rates were compared. Age of the patients ranged from 5 months to 17 years. No complications or conversion to an open approach were recorded. In Group 1, the mean time for access was 9 (5–19) min. Gas leak was recorded in 13 patients, wound extension for specimen removal required in 6 patients and muscle closure all patients. In Group 2 the mean time taken for access was 2.5 (1–7) min (p < 0.05), there was no gas leakage recorded. Among 12 patients wound extension was necessary for specimen removal. Muscle closure was performed only among 12 patients in Group 2. Optical technique provides quick and safe access to the retroperitoneum with no air leak, however, it requires modification of the technique in small children.

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