Better evaluation of the contribution of the main diseases, injuries, and risk factors for mortality and life expectancy is crucial for more efficient policy making at the national and subnational levels in Iran. The aim of this study is to assess the effect of emerging causes of mortality on health, specifically COVID-19, which can help policy makers implement preventive measures in similar situations. In this systematic analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we present estimates of cause-specific mortality at the national and subnational levels in Iran from 1990 to 2023. New to this iteration of GBD, we present a decomposition analysis of the contribution of specific causes of death to net gain or loss in life expectancy across 31 provinces of Iran. We used an array of data sources including censuses, vital registration, and surveys for national and subnational estimates. The two leading causes of death in Iran were ischaemic heart disease and stroke in both 1990 and 2019. However, in 2020 and 2021, the COVID-19 pandemic displaced the leading causes of death, ranking first with age-standardised mortality rates of 286·2 deaths (95% uncertainty interval 267·9-310·5) per 100 000 in 2020 and 250·0 deaths (233·2-272·5) per 100 000 in 2021. COVID-19 ranked second and tenth in 2022 and 2023, respectively. Life expectancy at birth for both sexes combined declined from 78·0 years (77·7-78·1) in 2019 to 74·3 years (74·0-74·4) in 2020. It steadily recovered to 78·8 years (78·5-79·2) in 2023. COVID-19 was the main cause of loss in life expectancy, by 4·19 years, between 2019 and 2020. There was a net gain of 12·4 years in life expectancy in Iran from 1990 to 2023. The net gain at the national level can be mostly attributed to reduced mortality from ischaemic heart disease (2·61 years), stroke (1·63 years), neonatal disorders (1·26 years), transport injuries (0·88 years), and neoplasms (0·64 years). The decline in mortality rates of major causes continued to 2023 despite the pandemic. An exception was Alzheimer's disease, which showed a 4·0% increase in rate between 2019 and 2023 and led to a net loss of 0·04 years in life expectancy since 1990. Diabetes led to a net loss of 0·09 years since 1990. There were variations between provinces in terms of age-standardised rates and the net change in life expectancy before and after the COVID-19 pandemic. The COVID-19 pandemic disrupted the rising trend of life expectancy in Iran, varying across provinces. Findings show that the health-care infrastructure and policies in Iran were not efficient in controlling the pandemic in 2020 and 2021, mainly due to inadequate vaccination coverage and timeliness, specifically for vulnerable subgroups. Sanctions may have aggravated the effect of COVID-19 on loss in life expectancy of Iranians. Despite the pandemic, the declining trend in age-standardised rates for top causes of mortality has continued to 2023, leading to a full recovery of life expectancy and underscoring the ultimate resilience of Iran's health system. Gates Foundation.
In this study, we aimed to present the management and treatment processes of patients with splenic trauma, discuss nonoperative treatment approaches, and share our institutional experience. A total of 244 patients hospitalized for splenic trauma between January 2010 and January 2020 were retrospectively analyzed. Splenic injury was present in 22% of trauma patients who presented to the emergency department and were consulted by pediatric surgery. The most common cause of splenic injury was falls (60%). Forty-three percent of patients were of school age. Ninety percent of patients had Grade I-III splenic injuries. The mean age at presentation was 7.90 years. The mean hematocrit level was 32% and the mean hemoglobin level was 10.90. Blood transfusion was administered to 29% of patients. Additional injuries were present in 45.9% of cases, with the lung being the most frequently affected organ. The mean length of hospital stay was 6.03 days. Mortality occurred in five patients, and morbidity was observed in five patients. There was a statistically significant correlation between blood pressure, urine output, and mortality. A statistically significant association was also found between platelet-to-lymphocyte ratio, blood transfusion, hemoglobin level, Glasgow Coma Scale (GCS) score, and mortality (p<0.001). Furthermore, significant correlations were identified between GCS score, length of hospital stay, neutrophil count, and the presence of additional injuries (p<0.001). A strong negative correlation was observed between lactate levels and blood transfusion (r=-0.610), as well as between lactate levels and GCS score (r=-0.645). In the ROC analysis evaluating lactate as a predictor of additional injury, a sensitivity of 58% and specificity of 83% were identified at a cutoff value of 1.9. We recommend nonoperative management for patients with splenic injury, as it reduces mortality, morbidity, and healthcare costs. Treatment protocols for these patients should be scientifically standardized. Dalak travmalı hastaların yönetim ve tedavi süreçlerini sunmayı, nonoperatif tedavi yönetimini tartışmayı ve deneyimlerimizi paylaşmayı amaçlıyoruz. Ocak 2010 ile Aralık 2019 tarihleri arasında dalak travması nedeniyle hastaneye yatırılan 244 hasta çalışmaya dahil edildi ve retrospektif olarak analiz edildi. Acil servise başvuran ve çocuk cerrahisi ile konsülte edilen travma hastalarının %22'sinde dalak yaralanması mevcuttu. Dalak yaralanmasının en sık nedeni düşme (%60) idi. Hastaların %43'ü okul çağındaydı. Hastaların %90'ında evre 1-2-3 dalak yaralanması vardı. Başvuru anında ortalama yaş 7.90, ortalama hematokrit 32, ortalama hemoglobin 10,90 idi. Hastaların %29'una transfüzyon yapıldı. Hastaların %45.9'unda ek yaralanma vardı ve en sık yaralanan organ akciğerdi. Ortalama hastanede kalış süresi 6,03 gündü. 5 hastada mortalite, 5 hastada ise morbidite görüldü. Kan basıncı ve idrar çıkışı ile mortalite arasında istatistiksel olarak anlamlı bir ilişki vardı. (p<0.05) Trombosit/lenfosit oranı, kan transfüzyonu, hemoglobin ve GCS ile mortalite arasında istatistiksel olarak anlamlı bir ilişki bulundu. (p<0.001) GCS, hastanede kalış süresi, nötrofil sayısı ve ek yaralanma arasında istatistiksel olarak anlamlı ilişki bulundu. (p<0.001) Laktat ve kan transfüzyonu ile GKS arasında yüksek düzeyde negatif korelasyon olduğu görüldü. (sırasıyla r=-0,610 ve r=-0,645) Laktat ile ek yaralanma için yapılan ROC analizinde laktat cut off değeri 1,9'da duyarlılık %58, özgüllük %83 olarak belirlendi. Dalak yaralanmalı hastalara ameliyatsız tedaviyi hem mortaliteyi, hem morbiditeyi hem de maliyeti azalttığı için öneriyoruz. Hastaların tedavi yönetimi bilimsel olarak standardize edilmelidir.
Pediatric kidney stone disease is a health problem that may require invasive surgical interventions during childhood and can impose a substantial psychological burden on both the child and the family. Uncertainty regarding anesthesia, perioperative safety, postoperative pain, and early recovery/stone clearance may increase both parental and child anxiety. This study assessed perioperative anxiety in children undergoing kidney stone surgery and their parents, and identified demographic and clinical factors associated with anxiety. This prospective observational study was conducted at a tertiary academic urology center between January and July 2025. The study population consisted of 100 children aged 3-18 years scheduled to undergo ureterorenoscopy (URS) for kidney stones, along with their parents. Anxiety levels of the children were assessed using the Facial Image Scale (FIS), whereas parental anxiety was assessed using the State-Trait Anxiety Inventory, including state (STAI-S) and trait (STAI-T) components. The scales were administered before surgery and at postoperative 1., 2., and 6. h. Data were analyzed using descriptive statistics, analysis of variance, and linear regression methods. The median age of the children included in the study was 7.5 years, and the mean duration of surgery was 44.39 ± 14.60 min. There was no difference between the STAI-S and STAI-T scores of mothers and fathers during the preoperative period. However, in the postoperative 1. h, anxiety levels increased significantly in both parents (p = 0.001) and then gradually decreased. All mothers, and the parents of the children aged 4-<10 years had significantly higher anxiety levels at all preoperative and postoperative time points (p < 0.001). Anxiety scores were higher in mothers in the American Society of Anesthesiologists (ASA) III group, and anxiety levels were also significantly increased in parents with a history of previous major surgery (p < 0.05). In contrast, increasing experience with stone surgery had a reducing effect on parental anxiety (p < 0.01). FIS scores increased significantly during the transfer of the patients from the waiting room to the operating room (p < 0.001). Although FIS scores decreased somewhat in the inpatient unit, they still remained above their preoperative levels. Parental anxiety during pediatric stone surgery increases significantly, especially in the early postoperative period, and is influenced by factors such as the child's age, ASA score, and prior surgical history. The results indicate that the psychological state of the parents is closely related to the emotional and clinical recovery processes of their children. Children's anxiety rose during transfer to the operating room and remained above baseline postoperatively.
There is no consensus on the ideal follow-up testing after pyeloplasty for ureteropelvic junction obstruction (UPJO) in children. Although diuretic renogram (DR) is considered the gold standard to define successful pyeloplasty, percent reduction in antero-posterior diameter (PR-APD) on post-operative ultrasound (USG) has been reported to be useful to identify successful pyeloplasty. We sought to further explore PR-APD ranges in the first post-operative USG that would have high specificity to identify successful and failed pyeloplasty. From a 10-year database of pediatric pyeloplasties performed in 4 centers, cases with follow-up USG at 3 months post-pyeloplasty and follow-up DR were selected for analysis. On the basis of drainage on follow-up DR, the patients were divided into group 1 (successful) and group 2 (failures). PR-APD was compared between the two groups, and receiver operating curve (ROC) analysis was performed to assess the cutoff value of PR-APD that had the best discriminative ability to predict success. Further, within group 2, PR-APD was compared between early (2a) and late (2b) failures. Three hundred and fifty-nine children (323 group 1, 36 group 2) who underwent primary dismembered pyeloplasty for unilateral UPJO were included. Both groups were comparable for demographic parameters and mean pre-operative APD. On the 3-months post-operative USG, group 1 had significantly lower post-operative APD (p = 0.0001) and higher PR-APD (62.8% vs 24.6%, p < 0.001) than group 2. On ROC analysis, PR-APD of 42% had 91% sensitivity and 100% specificity for predicting success of pyeloplasty. PR-APD <15% predicted early failures with 100% specificity, while PR-APD between 16 and 42% was associated with 45% risk of late pyeloplasty failure. We identified the cut-off values of PR-APD that could predict success and early failure of pyeloplasty with high specificity. While earlier reports had limited number of failed cases, our data was unique that we had a sizable number of failed pyeloplasty cases, thus enabling meaningful comparison of PR-APD between successes and failures. In addition, we identified a subgroup at risk of late failure. These findings might be useful to avoid routine post-operative DR studies after pyeloplasty, detect early failures and identify the few patients who benefit from long-term follow-up. On the 3-month post-operative USG after pyeloplasty, PR-APD 42% or more predicted success with 100% specificity, while PR-APD <15% was 100% specific in predicting early failures. Those with PR-APD 16-42% may be at risk for late failures and may benefit from long-term follow-up.
Dr. Israel Franco is Adjunct Professor of Clinical Urology at Yale School of Medicine. Previously he was Professor of Urology at New York Medical College and Yale School of Medicine. He has held multiple leadership positions in the International Children's Continence Society (ICCS) and on September 5, 2025, he delivered the Kelm Hjalmas lecture at the ICCS meeting in Vienna, Austria. He has long advocated for improved understanding of pediatric urinary continence by looking at the central control of the bladder and urethral sphincter. We took this opportunity to further discuss how this view affects his clinical approach and where he thinks this will lead us in our treatment of pediatric urinary incontinence.
This study aimed to develop and validate a nomogram for predicting the risk of postoperative fever in pediatric patients undergoing percutaneous nephrolithotomy (PCNL) for upper urinary tract stones, to provide a basis for the early identification of high-risk patients and intervention. This retrospective study analyzed the clinical data of 219 pediatric patients with upper urinary tract stones who underwent PCNL performed by the same surgeon at two medical centers between October 2019 and October 2024: Hospital A (150 Uyghur patients) and Hospital B (69 Han patients). Univariate and multivariate logistic regression analyses were used to identify independent risk factors for postoperative fever, which were then used to construct a nomogram. The model's performance, accuracy, and clinical utility were comprehensively evaluated using the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). Multivariate logistic regression analysis identified four independent risk factors: lower preoperative hemoglobin (OR = 0.96, 95%CI: 0.94-0.99, P = 0.003), positive urine culture (OR = 2.26, 95%CI: 1.21-4.22, P = 0.011), multiple stones (OR = 2.01, 95%CI: 1.06-3.81, P = 0.034), and longer operative time (OR = 1.01, 95%CI: 1.01-1.02, P = 0.018). The nomogram based on these factors demonstrated good discrimination, with an area under the ROC curve (AUC) of 0.748. The calibration curve indicated excellent agreement between the predicted risk and actual fever incidence. Decision curve analysis (DCA) showed that using this model for clinical decision-making yielded a higher net benefit than alternative strategies within a threshold probability range of approximately 15%-65%. In support of our initial hypothesis, we conclude that lower preoperative hemoglobin, a positive preoperative urine culture, increasing operative time, and the presence of multiple stones are independently associated with postoperative fever in pediatric patients undergoing PCNL. Based on these results, we successfully created a predictive nomogram and internally validated its predictive ability. However, as this currently represents a proof-of-concept model, external validation and direct linkage to hard clinical outcomes remain critical next steps before it can be adopted for routine clinical decision-making. Not applicable.
Cystine stones are a rare yet challenging cause of pediatric nephrolithiasis, marked by high recurrence and repeated surgical needs. Although endourological advances have improved the safety of percutaneous nephrolithotomy (PCNL), long-term renal outcomes remain strongly influenced by adherence to medical therapy. To evaluate the efficacy, safety, recurrence patterns, and long-term renal outcomes of PCNL for cystine stones in children across a 25-year institutional experience. This retrospective review included pediatric patients with cystine stones who underwent PCNL between 2000 and 2024 at a tertiary referral center. Surgical success was defined as stone-free status. Complications were graded using the modified SATAVA and Clavien-Dindo systems. All patients received urine alkalization and thiol therapy, with adherence assessed by the Medication Possession Ratio. Long-term renal function and blood pressure were evaluated during follow-up. A total of 127 PCNLs were performed in 94 renal units of 78 patients (median age at first PCNL 6 years [IQR 2-14]; 56% male, 44% female), with a median follow-up of 216 months (IQR 141-287). The overall stone-free rate was 64%, increasing to 81% when combined with simultaneous endoscopic procedures. Repeat PCNL for recurrence occurred in 42.5% of renal units (n = 40/94), and regrowth in 11.7% of the renal units (n = 11/94). Only nine (11.5%) of patients were fully adherent to medical therapy. Kaplan-Meier analysis showed a significantly shorter time to repeat PCNL in non-adherent renal units (log-rank p = 0.016); among those that experienced an event, the median time to first repeat PCNL was 15 months, whereas no repeat PCNL events were observed in adherent renal units. During follow-up, 18 patients (23%) developed hypertension and eight (10.3%) developed renal function decline, all confined to the non-adherent group. Although PCNL provided high clearance with good procedural safety, long-term success was limited by poor adherence. Recurrence and renal deterioration rates were comparable to those reported in previous series. Major limitations include the retrospective, single-center design and incomplete metabolic data. PCNL is a safe and effective option for pediatric cystine stones, but sustained medical adherence is essential to prevent recurrence and preserve renal function, ensuring durable long-term outcomes.
Prune Belly Syndrome extends beyond the classical triad of deficient abdominal wall musculature, urinary tract anomalies, and cryptorchidism. Urological abnormalities may be severe enough to require renal transplantation during their lifetime. The RUBACE score is currently the most comprehensive tool for categorising the multisystem manifestations of the syndrome. We hypothesized that higher RUBACE scores would be associated with poorer post renal transplantation outcomes. We conducted a retrospective review of 500 paediatric renal transplantations performed between April 2008 and October 2021, identifying all patients with Prune Belly Syndrome undergoing their first transplant. Demographic variables were collected, and RUBACE scores were assigned based on clinical assessment and physical examination prior to renal transplantation. Descriptive analyses were performed using the software R 4.4.3. Qualitative variables were expressed as percentages, and numeric variables as medians and interquartile (IQR 25-75). Associations between RUBACE scores graft loss or mortality were evaluated using a permutation test with 100.000 simulations, adopting a level of significance of 5%. In the period of the study, 22 patients with Prune Belly Syndrome underwent their first renal transplantation. During follow-up, 11 patients (50%) experienced at least one febrile urinary tract infection, 3 (14%) had graft loss, and 2 (9%) died. Those with graft loss had higher RUBACE scores than those without, although this difference was not statistically significant (p = 0.16). RUBACE scores were higher among patients who died (p = 0.03). Intestinal, osteoarticular, neurologic, pulmonary and cardiac manifestations impact the quality of life and survival of patients with Prune Belly Syndrome and should be considered in multidisciplinary care when preparing these patients for renal transplantation. Many of the patients in the present study needed procedures to allow adequate bladder emptying and to reduce complications such as recurrent urinary tract infections. Until now, no previous study has evaluated RUBACE score with renal outcomes in paediatric Prune Belly patients that received renal transplantation. Renal transplantation in children with Prune Belly Syndrome presents unique clinical challenges. RUBACE score may assist in risk stratification, helping to identify patients at higher risk of graft loss and mortality after transplantation.
This study aimed to investigate the feasibility and advantages of enlisting an external drainage tube in pneumovesicoscopic ureteral reimplantation using the Politano-Leadbetter technique (PVUR-PL) in children. A retrospective analysis was conducted on the clinical data of 90 pediatric patients who had undergone PVUR-PL at our institution from March 2024 to September 2025. Based on the stent placement method, the patients were divided into Group A (external drainage) or Group B (internal drainage). The two groups were compared in terms of postoperative parameters, including the incidence of leukocyturia, hematuria, febrile urinary tract infection (fUTI), and positive urine culture; hospitalization costs; duration of stent indwelling; and length of hospital stay. Statistically significant differences (p < 0.05) were observed between Groups A and B in terms of the incidence of postoperative leukocyturia, fUTI, and positive urine culture; hospitalization costs; duration of stent indwelling; and length of hospital stay. The application of external stent drainage in PVUR-PL is reliable and effective. Compared with internal drainage, it may offer potential benefits in terms of reducing the need for additional anesthesia, hospital stay, and costs. Furthermore, shortening the duration of stent indwelling may reduce the incidence of urinary tract infections. This method possesses significant potential for clinical application.
Cognitive developmental disorders (CDD) including intellectual disability (ID), cerebral palsy (CP), Down's syndrome (DS), and autism spectrum disorder (ASD) are often associated with lower urinary tract dysfunction. This study aimed to characterize urodynamic (UD) patterns in pediatric patients with CDD and analyze their relationship with clinical variables and treatment outcomes. A retrospective observational study was conducted including 79 pediatric patients (ages 4-17) with confirmed CDD who underwent comprehensive video urodynamic evaluations between 2009 and 2024 at a tertiary pediatric center. Data analyzed included age, sex, diagnosis, urodynamic parameters (detrusor overactivity, bladder compliance, detrusor-sphincter dyssynergia, bladder sensation), vesicoureteral reflux (VUR), and treatment modalities. Statistical associations between CDD type and UD parameters were examined using chi-square tests (p < 0.05). The mean age was 9.2 years, with male predominance (70.9%). Diagnoses included CP (38.0%), ID (32.9%), ASD (24.1%), and DS (5.1%). Dysfunctional voiding was the most frequent diagnosis (32.9%), particularly in CP (43.3%) and ASD (36.8%). Detrusor overactivity was common in ID (57.7%) and CP (40.0%) but rare in ASD (5.3%). Detrusor-sphincter dyssynergia was seen in 56.7% of CP and 26.9% of ID patients and absent in ASD. Decreased bladder compliance (<20 ml/cmH2O) occurred in 90.0% of ID and 57.7% of CP patients but was preserved in ASD. Absent urgency sensation was found in 50.0% of CP and 19.2% of ID patients. VUR was present in 10.5% of ASD and 6.7% of CP patients. Clinical management was most frequent in ID (96.2%) and ASD (94.7%) patients. Clean intermittent catheterization was required in 43.3% of CP and 12.5% of ID cases. Surgical intervention was necessary in 12.7% of patients, mainly in CP (20.0%). Distinct urodynamic patterns were observed across cognitive developmental disorders. CP patients showed predominantly neurogenic patterns with high rates of detrusor-sphincter dyssynergia and need for invasive management. ID patients exhibited storage-phase dysfunction responsive to medical therapy, while ASD patients showed preserved motor coordination and compliance, suggesting primarily behavioral or sensory dysfunction. Urodynamic studies are crucial for individualized diagnosis and management in children with cognitive developmental disorders.
To evaluate whether nighttime centralization of pediatric acute scrotum management improves timeliness of care and surgical outcomes in a rural regional network. We conducted a retrospective cohort study of 215 pediatric acute scrotum cases managed between 2003 and 2024 in Yamanashi Prefecture, Japan. Nighttime centralization was implemented in October 2018, designating a single receiving institution during off-hours. Outcomes before (2003-2017) and after (2018-2024) centralization were compared. Time intervals were analyzed when complete timestamps were available and restricted to ≤1440 min. Continuous variables were compared using the Mann-Whitney U test. A total of 215 cases were included (Before n = 103; After n = 112). Baseline characteristics, including age distribution and proportion of confirmed torsion among surgical cases, were comparable between periods. Following centralization, annual case volume increased, while surgical and salvage proportions remained stable. Of the total cohort, 195 cases were included in the onset-to-consultation analysis, and 68 cases were included in the consultation-to-surgery analysis after exclusion of intervals >24 h. Median onset-to-consultation time did not differ between eras (300 vs 296 min, p = 0.708). Among surgically treated cases, median consultation-to-surgery time showed no significant difference (133 vs 143 min, p = 0.107). Among cases with complete onset and surgery timestamps (n = 52), orchiectomy was associated with longer onset-to-surgery intervals compared with salvaged testes (630 vs 416 min, p = 0.068). Nighttime centralization increased case capture without worsening in-hospital delay or compromising testicular salvage. Pre-hospital delay remained unchanged. These findings suggest that nighttime centralization functions as a capacity-preserving system reorganization, maintaining in-hospital timeliness despite increased case volume, rather than directly reducing pre-hospital delays.
Hypospadias is a common congenital anomaly seen in newborn males. The phenotypic spectrum is wide, and complication rates are high, particularly in severe cases. Multi-stage approaches to surgical management have gained traction over recent years. However, a comprehensive understanding of national practice patterns is limited. To perform a contemporary analysis of hypospadias repair patterns and complication rates in the United States, with a focus on surgical staging. The Pediatric Health Information System (PHIS) database was queried to create a cohort of pediatric patients under 5 years of age who underwent single- or multi-stage hypospadias repair between January 1, 2016 and June 30, 2025. ICD-10 and CPT codes were used for cohort creation. Patients with inconsistent coding were excluded. Patient demographics and features of hypospadias phenotype were explored. Comparisons between single- and multi-stage patients, longitudinal trends in staging, and factors impacting complication rates were analyzed. We identified 25,989 patients at 45 children's hospitals. Overall, 96.5% of patients underwent single-stage repair at a median age of 9.3 months, while 3.5% underwent multi-stage repair, starting at 15.4 months. For proximal cases, 35.5% were managed in a multi-stage fashion. On longitudinal analysis, rates of multi-stage repair for proximal hypospadias have significantly increased over time (p = 0.003). Compared to single-stage patients, multi-stage patients were more likely to be non-White, receive care in the Northeast or Midwest, have a proximal meatus and associated chordee, and undergo grafting or complex scrotoplasty. On multivariate analysis of multi-stage patients, increasing age was a significant predictor of complications (p < 0.0001), while Midwest region (p = 0.003) and non-Hispanic Black (p = 0.02) and Hispanic race-ethnicity (p = 0.01) were protective. Meatal location was not a significant factor impacting complications after multi-stage repair (p = 0.28); however, in single-stage patients, complication rates did increase with a more proximal meatus (p < 0.0001). Use of multi-stage repairs for proximal hypospadias has increased over the past decade in the United States. Single- and multi-stage patients differ in terms of hypospadias phenotype, demographics, and factors associated with complication rates.
To compare the surgical and functional outcomes of PSARVUP and TUM in a contemporary cohort of patients with cloacal malformations, with particular emphasis on urological results and the influence of individual patient anatomy on these outcomes. A retrospective cohort study of patients with cloacal malformations who underwent definitive repair between 2020 and 2023. Inclusion criteria were confirmed cloacal malformation with prior colostomy and definitive repair by PSARVUP or TUM, whilst cases with complex sacral and spinal anomalies were excluded. Preoperative workup included cystoscopy, pelvic and spinal MRI, renal ultrasound, and voiding cystourethrography. Outcome measures included postoperative complications, ability to void spontaneously, requirements for clean intermittent catheterization (CIC), status of urinary continence, incidence of febrile urinary tract infections (UTIs), and urodynamic findings. A total of 27 patients with confirmed cloacal malformations were included. Of these, 16 patients (59.3%) underwent PSARVUP and 11 patients (40.7%) underwent TUM. Within the PSARVUP cohort, wound dehiscence represented the most frequent complication compared to vaginal stenosis in TUM group. As regards recurrent frequent UTIs, the overall incidence of infection was lower in PSARVUP as compared to TUM. Overall, approximately two-thirds of all evaluated patients demonstrated abnormal findings on urodynamic assessment with neurogenic bladder patterns were the most common. PSARVUP and TUM are effective techniques for repairing long common channel cloaca, each with distinct advantages and limitations. TUM offers an improved cosmetic outcome but can result in long-term urological complications. On the other hand, PSARVUP yields an improved functional outcome despite a more complex operative course and higher rates of vesicourethral fistulas. Longer follow-up and multicenter studies are required to refine surgical planning and optimize outcomes.
To evaluate the long-term incidence of urethral stricture intervention following hypospadias repair, a procedure for a common urogenital birth defect in which the urethral meatus is repositioned to the penile tip, as long-term outcomes are not well studied. A retrospective, population-based cohort study of males born in Ontario, Canada from April 1994-March 2023, was conducted using healthcare administrative databases. Cases undergoing hypospadias repair were matched to four controls by birthdate. Primary outcome was urethral stricture requiring intervention, assessed using Cox proportional hazards models. Secondary exposure was hypospadias location (distal vs proximal). Models were adjusted for baseline and secondary covariates. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated. A total of 9130 cases and 36,520 controls were analyzed. The mean and median age at surgery was 26.9 months and 19 months, respectively. Distal hypospadias accounted for 68.9% of cases, 9% required multi-stage repair, and 7% had post-operative complications. Urethral stricture requiring intervention developed in 169 cases (1.85%), versus 24 controls (0.06%). The risk of stricture was significantly higher in cases compared to controls (HR 26.80, 95% CI 17.43-41.20). Proximal repairs carried higher risk than distal repairs (HR 3.20, 95% CI 1.60-6.41). Mean follow-up was 13.5 years. Although absolute risk is low, patients with hypospadias repair are more likely to develop urethral strictures that require intervention compared with controls, particularly following proximal repair. These findings suggest that clinicians should maintain a high index of suspicion for urethral strictures in this population, even many years after the initial surgery.
Augmentation cystoplasty (AC) remains the standard reconstructive option for children with refractory lower urinary tract dysfunction (LUTD) and high-risk urodynamic patterns threatening renal function. However, postoperative morbidity and long-term renal outcomes remain clinically relevant concerns. To characterize postoperative complications following AC, evaluate functional and renal outcomes, and identify risk factors associated with intermediate and late adverse events. Retrospective cohort study including patients ≤18 years with neurogenic or congenital bladder dysfunction refractory to optimized medical and endoscopic therapy, who underwent AC between 2003 and 2017 at a tertiary pediatric center. Minimum follow-up was 12 months. Pre- and postoperative assessment included standardized urodynamics, renal ultrasound, DMSA scintigraphy, and estimated glomerular filtration rate (eGFR). Complications were categorized by timing (early <30 days; intermediate 1-12 months; late >12 months) and by type (surgical or clinical). Kaplan-Meier analysis was performed for lithiasis-free survival. A total of 128 patients (mean age 11 years) were included; myelomeningocele and anorectal malformations were the predominant etiologies. Preoperatively, approximately 50% presented with urinary incontinence, recurrent urinary tract infections (UTIs), hydronephrosis, and elevated detrusor leak point pressure (>40 cmH2O). Sigmoid colon was used in 78% of augmentations. At one year, mean maximum cystometric capacity increased by 142%, and mean end-detrusor pressure decreased to 23 cmH2O. Early surgical complications occurred in 12.5% of cases. During follow-up, UTIs were the most frequent clinical event. Bladder lithiasis developed in 20%, with a cumulative incidence of 20% at 70 months, and was significantly associated with constipation, irregular bladder irrigation, wheelchair dependence, and recurrent UTIs. At five years, renal function remained stable in 70.7%, improved in 11.1%, and worsened in 18.2%, without significant overall decline. Despite functional improvements post-AC, intermediate-term postoperative morbidity remains considerable and is influenced by modifiable clinical factors. Interpretation of long-term renal and metabolic outcomes is limited by the retrospective design and heterogeneous follow-up duration. Augmentation cystoplasty provides substantial and sustained improvements in bladder dynamics in children with severe LUTD. Nevertheless, intermediate-term morbidity-particularly UTIs and bladder lithiasis-remains frequent and is strongly influenced by modifiable postoperative management factors. Structured long-term follow-up focused on adherence to catheterization and irrigation protocols is essential to optimize urinary tract preservation.
Posterior urethral valves (PUV) remain an important contributor to childhood chronic kidney disease. After endoscopic valve ablation, residual valves may perpetuate obstruction and worsen renal and bladder outcomes. The posterior: anterior urethral ratio (PAR) on postoperative micturating cystourethrogram (MCUG) is a simple quantitative measure that may help detect residual valves, but reported thresholds and accuracies vary widely. We aimed to evaluate the diagnostic performance of PAR on postoperative MCUG for detecting residual PUV, using cystoscopy as the reference standard. This review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline extension for diagnostic test accuracy reviews and a protocol was a priori registered in PROSPERO (CRD420251010994). PubMed, Scopus, EMBASE and Web of Science were searched on 23 June 2025 for English-language studies in which PAR on postoperative MCUG was used to diagnose residual valves after ablation, with check cystoscopy as reference standard. The risk of bias among the included studies was assessed using QUADAS-2 tool. Two reviewers independently performed data extraction and constructed 2 × 2 tables for each study. Pooled sensitivity and specificity were estimated, and a summary receiver operating characteristic (sROC) curve was constructed using a bivariate random-effects model (Stata 'midas'). Seven studies (n = 565; 398 PUV, 167 controls) met the inclusion criteria for the systematic review; six were included in the meta-analysis. Reported PAR cut-offs for residual valves ranged from 1.2 to 3.5. Pooled sensitivity was 0.77 (95% credible interval [CrI] 0.54-0.90), pooled specificity was 0.95 (95% CrI 0.78-0.99), and the sROC area under the curve was 0.91 (95% CrI 0.88-0.93), with high specificity but only moderate sensitivity. Among the included studies, the majority had low risk of bias for the index test (six out of seven studies) and reference standard (all seven studies), but two studies had high risk in the patient selection and three studies had high risk in flow/timing domains. Also, the risk of applicability was low for all studies in most of the domains. Postoperative PAR on MCUG demonstrates a specificity of 95% and a sensitivity of 77% for detecting residual PUV. Given the wide variation in PAR thresholds and heterogeneity among the included studies, the pooled estimates are promising, yet hypothesis-generating. Interpretation of these results should be cautious and cannot be construed as prescriptive. Further high-quality multicentric studies are needed to validate these results.
Achieving urinary continence is an important objective of surgical reconstruction for bladder exstrophy-epispadias complex (BEEC). Despite its importance to postoperative quality of life, there remains no universally accepted definition of continence in this patient population, with existing evidence suggesting highly inconsistent definitions across studies. We aimed to determine whether a standardized definition of continence exists following intervention for BEEC and to characterize inconsistencies in reporting through a comprehensive systematic review. Following PRISMA guidelines, a systematic search of PubMed, Embase, and Scopus databases was conducted to identify studies that defined/described post-intervention continence in pediatric and young adult populations (≤30 years old) with BEEC. Of 1565 studies identified, 89 were included (n = 4057 subjects; 68% males). Classic bladder exstrophy was the primary condition in 49 studies (n = 2366), epispadias in 7 studies (n = 179), and cloacal exstrophy in 5 studies (n = 184). Twenty-eight studies assessed >1 condition, forming the "BEEC" subgroup (n = 1328). The most commonly utilized definition was "≥3-h dry interval in between voiding/catheterization" (50 studies; 56%). However, reporting was inconsistent regarding pad use, nighttime leakage, catheterization, and continence-promoting drug usage. Continence data were obtained from the patient/parent in 21 studies, while 66 did not specify whether continence was clinician- or patient-assessed. Use of the 3-h definition did not differ significantly by primary diagnosis (p = 0.69), study setting (single-vs. multicenter; p = 0.46), publication date (≥2012; p = 0.28), or country (p = 0.10). Definitions of continence in BEEC remain highly variable. The most frequently used definition of continence included 3-h dry intervals in between voiding/catheterization. However, there were omissions in key factors such as pad use, nighttime leakage, and catheterization. Establishing a standardized definition of continence is essential for measuring success in this critical outcome and ultimately improving patient care.
Bladder exstrophy-epispadias complex (BEEC) involves osseous pelvic defects and a wide pubic diastasis (PD). PD widens over time after the initial closure, but the degree and impact of this increase is not well delineated. Using the transverse distance between posterior inferior iliac spines (dPIIS) as an internal comparison, we aimed to: 1) compare dPIIS, PD, and M-factor (PD/dPIIS) measurements made on radiographs to computed tomography (CT) images and between reviewers; 2) assess the measurements at birth and over time for BEEC and for age- and gender-matched controls; 3) determine how the M-factor compares with the PD over time. This was a single institution, IRB-approved retrospective study of patients with BEEC who underwent a complete primary repair of bladder exstrophy (CPRE) or repair of epispadias or cloacal exstrophy with bilateral osteotomies between 5/1/2013 and 3/1/2020. PD and dPIIS were measured on cases and controls at 4 timepoints: preoperative, intraoperative, early post-operative (6-8 weeks) and late post-operative (greater than 6 months). For statistical analysis intra class correlations were used to assess inter-rater reliability. Mixed model two-way ANOVA was done with subjects as random effect, and group (patient/control), exam time as the two fixed effects. Forty-three cases (33 male) ranging in age from 1 day to 129 months (IQR 15.25 months) during the time points were evaluated. There was excellent agreement for measurements among the 6 raters. Following BEEC repair with osteotomies, PD and the M-factor decreased significantly. In the entire cohort, due to early post-operative spreading of the bones, there was no difference between pre-operative and early post-operative PD (35.2 ± 8.6 mm to 34.1 ± 9.8 mm, p = 0.08), however there was a significant difference in the M-factor between those time points (0.89 ± 0.2 to 0.73 ± 0.2, p < 0.01). With gradual increase in PD over time, there was a significant difference between early and late post-operative PD measurements (35.2 ± 8.6 mm to 39.8 ± 9.9 mm, p < 0.01), but not in the M-factor (0.73 ± 0.2 to 0.75 ± 0.2 (p = 0.45). PD in patients with BEEC changes over time due to surgery as well as growth, while a ratio of PD to an internal reference (dPIIS), does not change. This M-Factor ratio can better determine the initial extent of PD within the context of the size of the child, as well as standardize assessment of changes after surgery and during growth and development.
Urological complications remain a significant cause of morbidity in pediatric kidney transplantation (KT). While ureteroneocystostomy (UNC) according to Lich-Gregoir is the standard technique for urinary reconstruction, pyeloureterostomy (PU) with native ureter ligation has emerged as a potential alternative, though its role as a first-line approach is still debated. We retrospectively reviewed all pediatric KTs performed in two university hospitals between January 2013 and January 2023. Patients with documented vesicoureteral reflux were excluded. Two groups were compared according to the urinary reconstruction technique: PU with native ureter ligation versus UNC. Data collected included patient demographics, perioperative characteristics, postoperative complications, renal function, pain management, and 2-year graft survival. A total of 74 patients were analyzed (26 PU; 48 UNC). Baseline characteristics were comparable between groups. Two-year graft survival was similar (PU: 90% vs. UNC: 89%). Renal function, assessed by glomerular filtration rate (GFR) at follow-up, showed no significant difference. The overall rate of major urological complications requiring surgical revision was comparable (PU: 11% vs. UNC: 10%). PU was associated with a higher incidence of transient graft pelvic dilatation (27% vs. 0%), which spontaneously regressed in most cases, while symptomatic vesicoureteral reflux occurred only in the UNC group (6.2%). Ligation of the native ureter did not result in specific morbidity or increased pain. First-line PU with ligation of the native ureter is a safe and effective alternative to UNC in pediatric KT. It avoids bladder dissection, preserves better vascularization of the donor ureter, and facilitates endourological procedures, without increasing complication rates. Prospective multicenter studies with longer follow-up are warranted to confirm long-term outcomes and better define optimal surgical strategies.
This study presents a novel endoscopic laser internal drainage technique for pediatric endophytic simple renal cysts. Tailored to anatomy using flexible ureteroscopy or needle-perc approaches, it creates a cyst-collecting system fistula via holmium laser for durable decompression. With a high success rate and minimal invasiveness, it offers a safe and effective alternative to traditional methods for problematic pediatric cysts.