Vitalii I. Dubrov

Introduction. Obstruction of the pyeloureteral junction (PUJO) of the horseshoe kidney is a very rare disease both in adults and children. This is the reason for the small number of scientific works on the subject of pyeloplasty for this pathology in children. Isthmus crossing and nephropexy followed by dissecting pyeloplasty have been suggested as one of the surgical treatment options. There are no convincing data on the feasibility of this procedure in the literature. The aim of our work was to evaluate 25 years of experience in the treatment of PUJO of horseshoe kidney in children. Materials and Metods. A few small cohort studies have reported the efficacy of pyeloplasty for horseshoe kidney in children, and a limited number of studies have compared different operative treatments. It was these facts that prompted us to perform this work. We retrospectively evaluated the results of 112 pyeloplasties in 105 children from 1999 to 2024. Patients were divided into 3 groups according to the method of surgical intervention: open pyeloplasty with isthmotomy, open pyeloplasty without isthmotomy, laparoscopic pyeloplasty. We also divided the patients into 4 groups according to the method of urinary tract drainage. Resulrs. Clinical data and outcomes were further analyzed. We obtained positive results when performing pyeloplasty in 92.9% of patients. There was no significant difference in pyeloplasty results between the groups. We also found no statistically significant differences in the methods of urinary tract drainage. Conclusion. Today, preference should be given to minimally invasive method of treatment in children, even in such a complex malformation as hydronephrotic transformation of the horseshoe kidney, taking into account comparable results with the open method of treatment and the unconditional advantages of laparoscopic access in the form of early rehabilitation of the child, minimal pain syndrome and cosmeticity of this method.

BACKGROUND: Bladder exstrophy is a rare congenital urological anomaly affecting the bladder, genitalia, pelvic floor, and pelvic bones. Skeletal abnormalities associated with bladder exstrophy include external rotation of the iliac bones, shortening and hypoplasia of the pubic rami, and retroversion of the acetabulum. The main challenge in defect closure is pubic diastasis. AIM: The work aimed to present a novel pelvic osteotomy technique for the treatment of bladder exstrophy. METHODS: The study included 30 patients with classical bladder exstrophy who underwent pelvic osteotomy using the proposed technique. The cohort comprised 24 boys and 6 girls, aged from 1 day to 17 years, operated in various clinics in St. Petersburg (Russia), Tashkent (Uzbekistan), and Minsk (Belarus). RESULTS: After 30 surgical procedures for classical bladder exstrophy with pelvic osteotomy performed according to our technique in children aged from 1 day to 17 years, a complication occurred in only one case—postoperative wound infection—which was treated conservatively using broad-spectrum systemic antibiotics and local therapy. This complication occurred in the group of patients who underwent reoperation after prior surgical bladder repair without pelvic osteotomy. No patient developed an increase in pubic diastasis in the postoperative period. CONCLUSION: The proposed pelvic osteotomy technique is effective for abdominal wall closure and bladder reconstruction. This is confirmed by the low complication rate (3.3%), involving both orthopedic and urological aspects, as well as the absence of postoperative pubic diastasis in all patients. Moreover, this pelvic osteotomy technique is an effective procedure due to its excellent correction of the disrupted pelvic ring and preservation of this correction.

BACKGROUND: Open reimplantation has been considered the gold standard treatment for pathologies of the ureterovesical segment. In 2000, studies that presented results of the use of laparoscopic and vesicoscopic techniques for ureteral reimplantation in children began to emerge. AIM: This study aimed to retrospectively analyze the results and complications of minimally invasive interventions in children with obstructive megaureter using various ureteral reimplantation techniques. MATERIALS AND METHODS: Data from 369 patients (385 ureters) operated on in 12 clinics were included. The median age of the patients was 6 months (4; 7.8), and 39 (10.7%) patients had concomitant pathology of the ureter and bladder. Cohen’s vesicoscopic operation, extravesical transverse reimplantation, Lich–Gregoir dissection, and psoas-hitch reimplantation were conducted on 189, 148, 27, and 21 ureters, respectively, and ureteral diameter remodeling was performed in 23.6% of patients. The Mann–Whitney U-test, Kruskal–Wallis test, Fisher’s exact test, and binary logistic regression model were used to assess the statistical significance of the studied variables. RESULTS: The median operation time was 140 minutes (110; 170). Obstruction was eliminated in 375 of 385 ureters (97.4%), regardless of the type of reimplantation, and vesicoureteral reflux developed in 35 (9.1%) ureters. Intraoperative (3) and postoperative complications (22) were present in 0.8% and 6% of cases, respectively. Reoperations were performed in 31 patients (8%). The statistically significant predictors of reimplantation outcome were tunnel orientation, infant age, and ureteral diameter. CONCLUSIONS: Minimally invasive ureteral reimplantation for obstructive megaureter is safe for children, with efficacy comparable to open surgery, and with few complications.

Introduction. The first description of ureteral appendicoplasty was provided by the Italian surgeon Giannettasio in 1901, followed by two German surgeons, Franke and Rydygier. Their work was later included in a review by Melnikoff in 1912. However, it is Melnikoff who is often erroneously credited with performing the first appendicoplasty in the literature. The first ureteral appendicoplasty operation on a 1.5-year-old child in Russia was performed by Soloviev in 1976.Objective. To report the results of performing operations on replacement of ureteral defects by ureteral appendicoplasty in children.Materials & Methods. Between 2009 and 2023, a total of 11 surgeries were conducted to replace extended ureteral defects using the appendix technique in four clinics in Russia and the Republic of Belarus. The follow-up included six boys and five girls with an average age of 79 months (ranging from 18 months to 16 years). Six operations were performed by laparoscopic access (mean operative time 356 minutes). Five operations were performed by open access (mean operative time 257 minutes).Results. Long-term results were assessed between 18 and 192 months in all patients. Urinary tract patency was evaluated based on the results of micturition cystography (in one case, vesicoureteral reflux was recorded) and intravenous urography (one case of stenosis of the distal anastomosis, which was corrected by endoscopic dissection of the stricture site using a fiberoureteroscope). In patients who underwent renoscintigraphy, no progression of renal function decline was observed. In all patients, long-term follow-up showed satisfactory urine passage.Conclusion. The results of the surgical interventions performed by us are assessed as good. In all 11 cases, the replacement of the extended ureteral stricture using an appendix allowed for the restoration of urinary flow. Furthermore, any complications that arose did not necessitate repeated reconstruction of the urinary tract. Nevertheless, it is important to note that, in our opinion, this technique cannot be considered the method of choice. Rather, it represents a last resort for patients who have undergone multiple previous operations due to severe trauma or oncological diseases. In cases involving ureteral strictures, priority should always be given to an operation involving anastomosis with sufficient ureteral length and minimal tissue tension. We firmly believe that this approach offers the best chance for a successful outcome.

Introduction. Until recently, open ureteral reimplantation was considered the gold standard for the surgical treatment of ureterovesical junction (UVJ) pathologies. The introduction of minimally invasive ureteral reimplantation (MIUR) for the treatment of vesicoureteral reflux (VUR) and primary obstructive megaureter (POM) in children started in the 1990s. However, studies describing national trends in the use of minimally invasive and open approaches in the surgical treatment of UVJ pathology in children are limited.Objective. To describe changes in the use of MIUR and open ureteral reimplantation (OUR) between 2007 and 2022 in some regions of the Russian Federation and the Republic of Belarus and compare the results and complication rates of the two surgical approaches. Materials & methods. The study includes 1273 patients (1793 ureters), operated on for UVJ pathology in the period from 2007 to 2022. MIR was performed in 1356 (75.6%) ureters (913 for VUR and 443 for POM). The studied parameters included an annual amount of reimplantation, the age of patients, the frequency of intra- and postoperative complications, as well as the medium-term results of operations.Results. The use of MIUR techniques has increased significantly over time, and in 2022, seventy-five percent of surgeries were performed using MIUR. Analysis of the rate of adoption of MIUR by clinics showed that those that began using it first experienced a significant increase in frequency of use after 4 to 6 years, while those that started later took 2 to 3 years to achieve a significant positive trend. There were 5 (0.4%) intraoperative complications in the MIUR group. All these complications were classified as grade I according to the Satava grading system. There was no significant difference between MIUR and OUR in terms of postoperative complication rates (6.6% vs. 7.6%, p = 0.8). The efficiency of reimplantation was 96.6% in the MIUR group compared to 95.9% in the OUR group for POM and 96.2% in the MIR group compared to 94.6% in the OUR for VUR.Conclusion. In the regions of Russia involved in the study, there has been a trend towards completely replacing open surgery with minimally invasive techniques. Regarding complication rates and efficacy, MIUR is not significantly different from OUR.

Введение. Эндоскопическая коррекция декстраномером в сочетании с гиалуроновой кислотой является наиболее часто применяемым методом малоинвазивного хирургического лечения пузырно-мочеточникового рефлюкса у детей. Прогнозирование эффективности процедуры позволяет повысить частоту разрешения рефлюкса. Цель исследования. Выявить независимые факторы и разработать прогностическую модель эффективности эндоскопического лечения пузырно-мочеточникового рефлюкса у детей. Материалы и методы. Исследование базируется на результатах эндоскопической коррекции у 715 пациентов (223 мальчика, 492 девочки) в возрасте от 2 месяцев до 16 лет. Двусторонний рефлюкс диагностирован у 348 (47,8%) пациентов. Общее количество оперированных мочеточников составило 1063, из них рефлюкс I степени имелся в 22 случаях, II - в 154, III - в 610 и IV - в 227. Полное удвоение мочеточников обнаружено в 62 наблюдениях (5,8%). Общая эффективность однократной эндоскопической коррекции составила 53,2%. Для прогнозирования результатов лечения применялась бинарная логистическая регрессия. В качестве предикторов были выбраны возраст и пол пациента, степень рефлюкса, диаметр мочеточника в тазовом отделе, односторонний или двусторонний рефлюкс, наличие удвоения мочеточника и рефлюкс-нефропатии. Результаты. Установлено, что ширина дистального отдела мочеточника является единственным статистически значимым фактором эффективности эндоскопической коррекции. Логистическая регрессия показала хорошую точность предикции (площадь под ROC-кривой составила 0,84, чувствительность и специфичность модели - 81,8% и 82,0% соответственно). Выводы. Результаты исследования показали, что ширина дистального отдела мочеточника является единственным статистически значимым предиктором эндоскопического разрешения пузырно-мочеточникового рефлюкса у детей, разработанная математическая модель обладает высокой надежностью. Introduction. Endoscopic dextranomer/hyaluronic acid injection is the most commonly used minimally invasive method of surgical treatment of vesicoureteral reflux in children. Purpose. To identify independent factors and develop a prognostic model of the effectiveness of endoscopic treatment of vesicoureteral reflux in children. Materials and methods. We used endoscopic dextranomer/hyaluronic acid injection in 715 patients (1063 ureteric units) with reflux grades I-IV (I - 20, II - 133, III - 443, IV - 187), 53 ureters had complete duplication. The total effectiveness of a single endoscopic correction was 53.2%. A binary logistic regression model was created, taking the following as independent variables: grade of reflux, pelvic ureteral diameter, the patient’s age and sex, the ureteral duplication and reflux nephropathy. Results. Diameter of the distal ureter is the only statistically significant factor in the effectiveness of endoscopic correction. Logistic regression showed good predictive accuracy (the area under the ROC curve was 0.84, the sensitivity and specificity of the model were 81.8% and 82.0%, respectively). Conclusion. The results of the study showed that the diameter of the distal ureter is the only statistically significant predictor of endoscopic resolution of vesicoureteral reflux in children, the developed predictive model is highly reliable.

Introduction. Urinary obstructions caused by foreign bodies (FB) represent quite a rare clinical case in practicе of pediatric urologists. However, some recent publications note a tendency towards higher occurrence of FB in urinary tracts in children. Most publications on FB urinary obstructions in children are devoted to the descriptions of individual medical cases. Considering the lack of multicenter research works on the problem, a study based on generalized clinical experience of several hospitals appears relevant. Materials and methods. The study is based on retrospective analysis of treatment results of 44 pediatric cases from 10 clinics of Russia and Belarus during the period from 2000 through 2020. The study population comprised 28 (63.3%) boys and 16 (36.4%) girls. Mean age of the patients was 10.9±3.7 years. The children were subdivided into two groups: group I included 28 (63.3%) cases where FB had been introduced in the urethra or bladder by the child; group II included 16 (36.4%) cases where foreign bodies ended up in urinary tracts as a result of instrumental or surgical procedures. Results. Clinical manifestation of FB was typical among the patients in the group I while in group II the condition more often occurred inapparently. Children often concealed FB introduction in the urinary tracts, and so contacts with a healthcare institution were ordinarily triggered by changes in urine analysis findings. Concealment of FB introduction in the urinary tracts determined help seeking start later than 7 days following the incident in 64.2% cases of group I. More than a half of the FB in children of group I were revealed within the first month after the incident. In group II, FB were revealed accidentally during follow-up examinations in 75% of the children. Transurethral FB extraction succeeded in 50% of the patients in group I. In group II, transurethral FB extraction was performed in 5 (31.3%) children. In 2 cases (12.5%), FB were extracted using flexible ureteroscopy. Percutaneous nephroscopy was used in 2 (12.5%) patients. 5 (31.3%) cases required pyelotomy with laparoscopic access, and in 2 (12.5%) patients a lumbotomy had to be carried out. Discussion. The rarity of FB of the urinary tract in the practice of a pediatric urologist is the reason for the combination ofthe existing experience in providing medical care to children from 11 centers. Delayed demand for medical care was noted if FB were introduced by the child independently. The generalized material shows that in childhood, the same approaches to FB extraction are applicable as in adult patients; endoscopic FB removal is optimal. Conclusions. In most cases of children suffering from foreign bodies in urinary tracts, the FB can be extracted using endoscopy without complications and with favourable outcome.

Introduction. Penile agenesis (aphallia) is an extremely rare congenital defect characterized by the complete absence of the penis in a child with a male karyotype 46XY.Material. The analysis of the literature on keywords in the Pubmed and Medline databases was carried out.Results. The incidence of aphallia is estimated 1 out of 10-40 million newborn boys. Aphallia, in spite of its rarity, is a congenital defect which is thoroughly described in the medical literature. The combination of agenesis of the penis with other congenital anomalies often leads to death in such children. Currently, it is believed that these patients should be left with their genetic male sex, therefore, there is a difficult dilemma of choosing the optimal method and age for creating the neophallus and neourethra.Conclusions. The rarity of the aphallia determines the lack of publications covering the long-term results of phalloplasty in both children and adults.

Introduction. Endoscopic dextranomer/hyaluronic acid copolymer (DxHA) injection is the most commonly used minimally invasive method of surgical treatment of vesicoureteral reflux (VUR) in children.Purpose of the study. To estimate the accuracy of logistic prognostic models and artificial neural network for prediction a single endoscopic injection DxHA in VUR.Materials and methods. We used endoscopic DxHA in 582 patients (783 ureteric units) of all grades reflux (I - 20, II - 133, III - 443, IV - 187), 53 ureters had complete duplication. A total effectiveness of surgery was 53.2%. A binary logistic regression model and an artificial neural network (multilayer perceptron) were created, taking the following as independent variables: grade of reflux, the patient's age and sex, the ureteral duplication and ureteral dilatation index.Results. The univariate logistic regression showed that the selected predictors were strongly related to the outcome of the treatment. Binary logistic regression and neural network developed high accuracy of the predictions, area under ROC-curve was 0,7 for logistic regression model (a sensitivity of 70.7%, and a specificity of 66.3%) and 0.74 for artificial neural network (a sensitivity of 85.5%, a specificity of 65.3%). Synaptic neural network weights and logistic regression parameters were used in a scoring model to predict the outcome of a single endoscopic injection of DxHA in 2 independent hospitals. An outcomes analysis using predictive models in independent clinics showed a good quality of prediction both with the use of logistic regression (75% and 90% of the correct prognosis) and using a neural network (89.7% and 77% of the correct prediction).Conclusion. An artificial neural network and a binary logistic regression model are an effective tool to assist urologists in identifying and applying endoscopic treatments for VUR in children.

Objective. To study the results of laparoscopic heminephrureterectomy (LHNE), ureteropyelostomy (LUPS) and ureteroureterostomy (LUUS) in the laparoscopic treatments of megaurete of a duplex system in children. Methods. The records of patients (n=102) who underwent LHNE and LUPS (LUUS) were retrospectively analyzed (26 (25,5%) boys and 76(74,5%) girls). The age of patients was from 3 months to 17 years (median - 17.9 months). Megaureter of the upper pole was observed in 82 (80.4%) patients, of the lower pole - in 20 (19.6%). LHNE was performed in 68 patients (66.7%), LUPA (LUUA) - in 34 (33.3%). Results. Intraoperative complications occurred in 2 patients (2.0%), conversion was required in both cases. Median operative LHNE time was 146,0±46,2 minutes (median - 120 minutes); in LUPS(LUUS) - 160,1±44,7 minutes (median - 150 minutes). One patient after LUUA developed the urinary leakage due to stent obstruction and required nephrostomy (IIIb, Clavien-Dindo classification). The remote results were traced for a period from 10 months to 6 years.The patients after LHNE (n=15) (22.1%) had a significant decrease of kidney function (>5%), including one patient (1.5%) with a complete loss of the function. An inflammatory process after partial ureteral resection was observed in the stump , which required relaparoscopy in 3 children (6.5%). The ipsilateral ureter injury during the total ureterectomy in the lateral position occurred in 2 children (6.9%). Conclusion. LHNE and LUPA (LUUA) are considered to be the effective surgical methods of duplex system megaureter in children. The disadvantage of LHNE is the high risk of significant decrease of kidney function; LUPA (LUUA) are the safer methods. Total ureterectomy in the supine position of a patient can prevent the complications associated with the healthy ureter injury and leaving the ureteral stump. What this paper adds For the first time, it has been proven that laparoscopic heminephrectomy in comparison with laparoscopic ipsilateral ureteropyeloanastomosis or ureteroureteroanastomosis is considered to be an unsafe operation, since this can cause kidney failure. It has been established that total ureterectomy in the supine position of a patient can prevent the complications associated with the healthy ureter injury and leaving the ureteral stump.