Yusuf Atakan Baltrak

Objective: To compare unsafe storage‐pressure urodynamic findings in children with radiological suspicion or confirmation of tethered spinal cord and in clinically referred children without radiological tethering. Materials and Methods: This single‐center retrospective comparative study included children aged 2–18 years who underwent urodynamic testing between October 2024 and December 2025 and had available spinal magnetic resonance imaging. Of 172 children assessed, 52 were excluded because spinal MRI was unavailable. The final cohort included 120 children: 60 with radiological tethering and 60 without tethering. The primary outcome was an unsafe storage‐pressure urodynamic pattern. Post‐void residual urine was excluded from the primary composite outcome and analyzed separately. Results: Age and sex were comparable between groups. Unsafe storage‐pressure urodynamics were more frequent in the radiological tethered cord group than in the non‐tethered comparison group (48.3% vs. 21.7%, p = 0.003). Low compliance, elevated end‐filling pressure, high‐pressure detrusor overactivity, detrusor‐sphincter dyssynergia, and increased post‐void residual urine were also more common. MRI and urodynamic risk were not fully concordant: 51.7% of children with radiological tethering had safe storage‐pressure urodynamics, whereas 21.7% without tethering had unsafe findings. Radiological tethering alone demonstrated a sensitivity of 69.0%, specificity of 60.3%, positive predictive value of 48.3%, and negative predictive value of 78.3% for unsafe storage‐pressure urodynamics. In multivariable analysis, radiological tethering, increased post‐void residual urine, and hydronephrosis were independently associated with unsafe storage‐pressure urodynamics. Conclusions: Radiological tethering was associated with unsafe storage‐pressure urodynamic findings, but MRI alone did not define functional bladder safety. Increased post‐void residual urine and hydronephrosis may identify children at higher risk; however, these findings are hypothesis‐generating and do not establish a validated pathway for safely withholding urodynamic testing.

Background/Objectives: Pediatric uroflowmetry is volume dependent, and low-volume voids can yield recordings that require repetition or cannot be interpreted confidently. To evaluate whether documented bladder volume-guided timing was associated with first-attempt pediatric uroflowmetry process adequacy in children undergoing evaluation for suspected non-neurogenic lower urinary tract dysfunction. Methods: This single-center retrospective workflow cohort included 110 toilet-trained children aged 5–12 years who underwent uroflowmetry for suspected non-neurogenic lower urinary tract dysfunction. The exposure was classified from contemporaneous pre-test documentation as bladder volume-guided timing (n = 55) or standard urge-based timing (n = 55). Expected bladder capacity (EBC) was calculated as (age + 1) × 30 mL. The primary process outcome was first-attempt voided volume ≥ 50% EBC. Repetition after an inadequate first attempt was treated as a deterministic workflow consequence rather than an independent endpoint. Analyses were observational and effect estimates were interpreted as associations. Results: Adequate first-attempt voided volume was documented in 50/55 children (90.9%) with bladder volume-guided timing and 39/55 (70.9%) with standard urge-based timing (unadjusted risk ratio 1.28, 95% confidence interval [CI] 1.06–1.55; Newcombe risk difference 20.0 percentage points, 95% CI 5.3–34.0). After adjustment for age, baseline urgency score, and time since last void, the association remained (adjusted risk ratio 1.27, 95% CI 1.06–1.53; p = 0.011), and the model converged without numerical warnings. Using the age-specific lowest acceptable voided volume, adequacy occurred in 53/55 children (96.4%) versus 46/55 (83.6%) (adjusted risk ratio 1.15, 95% CI 1.01–1.31; p = 0.040). Repetition after an inadequate first attempt occurred in 9.1% versus 29.1% and was treated as a direct consequence of primary-threshold failure; it was not tested independently. Workflow-time measures were exploratory. Conclusions: Documented bladder volume-guided timing was associated with greater first-attempt process adequacy. Adjustment for age, baseline urgency score, and time since last void did not materially change the estimate. The association was attenuated but remained directionally consistent when the age-specific lowest acceptable voided volume was used. Because the timing rule deliberately targeted the same volume construct as the primary outcome, this finding does not establish improved diagnostic accuracy, clinical decision making, or patient outcomes. Retrospective exposure classification and routine documentation further preclude causal interpretation. Documented bladder volume-guided timing was associated with higher first-attempt achievement of a prespecified voided-volume threshold than standard urge-based timing. Because the pathway targeted the same volume construct used to define the primary outcome and was non-randomized, these findings are interpreted as hypothesis-generating workflow data rather than evidence of improved diagnostic accuracy or downstream clinical benefit.

Introduction: Pediatric uroflowmetry is volume dependent, and low-volume voids can yield recordings that require repetition or cannot be interpreted confidently. Objective: To evaluate the association between documented bladder scan-guided test timing and first-attempt uroflowmetry adequacy in children. Study design: This single-center retrospective workflow cohort included 110 toilet-trained children aged 5-12 years who underwent uroflowmetry for suspected non-neurogenic lower urinary tract dysfunction. The exposure was defined from contemporaneous pre-test documentation as bladder scan-guided timing (n=55) or standard urge-based timing (n=55). Expected bladder capacity (EBC) was calculated as (age + 1) × 30 mL. The primary outcome was first-attempt voided volume ≥50% EBC. Key secondary outcomes were repetition because of inadequate volume and workflow time. Analyses were observational and effect estimates were interpreted as associations. Results: Adequate first-attempt voided volume was documented in 50/55 children (90.9%) in the scan-guided cohort and 39/55 (70.9%) in the standard cohort (unadjusted risk ratio 1.28, 95% confidence interval [CI] 1.06-1.55; risk difference 20.0 percentage points, 95% CI 5.8-34.2). Repetition because of inadequate volume, the direct workflow consequence of primary-outcome failure, occurred in 9.1% versus 29.1%. Scan-guided timing was also associated with a higher voided volume/EBC ratio (mean difference 15.1 percentage points, 95% CI 7.2-23.0), shorter total completion time (-8.8 min, 95% CI -14.9 to -2.7), and shorter documented active staff time (-3.8 min, 95% CI -5.6 to -2.0). Discussion: Objective bladder-volume information was associated with greater first-attempt volume adequacy and shorter workflow times. However, the retrospective exposure definition, uncertain workflow-selection mechanism, unadjusted primary analysis, and reliance on routine documentation prevent causal interpretation. Conclusion: Documented bladder scan-guided timing was associated with greater first-attempt pediatric uroflowmetry adequacy than standard urge-based preparation. The findings should be considered hypothesis-generating pending adjusted patient-level analyses and prospective validation.

Hypospadias-associated ventral penile curvature, commonly referred to as chordee, is a key intraoperative finding that can influence the choice of straightening technique and the need for urethral plate preservation or transection. In routine surgery, curvature is usually estimated visually during artificial erection testing, but this approach is subjective and may vary according to surgeon experience, viewing angle, erection quality, penile rotation, and image perspective. Artificial intelligence and computer vision methods may provide a more objective and reproducible way to measure curvature from standardized operative images. Early studies have used object detection, segmentation, landmark detection, Hough-transform methods, circle fitting, and geometric angle calculation. Reported technical performance is promising, particularly in controlled model-based datasets, but the clinical evidence remains limited because real intraoperative images are heterogeneous and because reference standards vary across studies. This Review summarizes the current evidence for artificial intelligence-based penile curvature measurement in hypospadias surgery and proposes a practical validation framework for future clinical studies. The most important next step is not simply improving model accuracy, but testing locked models on standardized real intraoperative images using patient-level data separation, blinded expert-panel measurements, threshold-focused analysis around 30 degrees, and direct comparison with the operating surgeon's live estimate. At present, artificial intelligence should be considered a measurement aid for documentation, quality improvement, and decision support, not a replacement for expert surgical judgment.

Background: Failures of testicular descent may result in the condition known as an undescended testis (UDT). While mechanical and hormonal causes have been researched quite extensively, not much is known about the underlying genetics. Developmental processes dependent on ciliary function may involve outer dynein arm heavy chain genes. Its role in testicular descent has never been explored. This study attempts to investigate the potential role of Outer Dynein Arm Heavy Chain (ODNAH) genes in UDT. Methods: 24 male juvenile UDT patients and 24 age-matched controls undergoing circumcision were included. Tissue samples from the preputial tissue and processus vaginalis were collected during orchiopexy and circumcision, respectively. RNA was extracted, converted to cDNA, and subjected to quantitative real-time PCR analysis for five ODNAH genes: DNAH5 , DNAH8 , DNAH9 , DNAH11 , and DNAH17 with GAPDH as a reference gene. The relative expression was computed using the 2 ^–∆∆Ct method. Results: The mean age of the control group was 21.9 ± 19.4 months, while that of the UDT patient group was 24.5 ± 12.3 months. There was no significant difference in age between the groups ( p = 0.06). DNAH9 expression was significantly higher when comparing UDT tissues to controls ( p = 0.0021), with a 2.52-fold increase associated with its upregulation (Log2FC = 1.33). Only small, insignificant expression changes were evident for DNAH5 , DNAH8 , DNAH11 , and DNAH17 . Most patients shared a similar expression pattern for DNAH9, suggesting that it may play a role in the pathophysiology of UDT. Conclusion: These results suggest that DNAH9 may play a role in the molecular mechanisms underlying testicular descent. The finding of DNAH9 as a potential marker for disturbed germ cell development in cryptorchidism may represent an adaptive response to the aberrant microenvironment of UDT. These findings need to be verified by further studies, including expanded cohorts and functional analyses, to understand possible clinical relevance.

Background/Objectives: Vesicoureteral reflux (VUR) is an important pediatric urologic condition in which accurate grading on voiding cystourethrography (VCUG) may influence counseling, surveillance, antimicrobial prophylaxis, and surgical decision-making. Visual grading is partly subjective, particularly around the grade III-IV boundary. This review mapped the available evidence on AI-based pediatric VUR assessment on VCUG, with emphasis on diagnostic performance, clinician comparison, AI-assisted interpretation, and implementation gaps. Methods: A computer-assisted scoping evidence map was conducted using an exported screening dataset containing 500 records and an extraction dataset containing 13 included studies. Studies were classified as direct VCUG-based VUR grading, low/high-grade classification, AI-assisted clinician interpretation, or indirect clinical prediction. Because the exported files did not document independent duplicate screening, full-text verification, or database-specific deduplication, the synthesis was designed as an evidence map rather than a formal diagnostic meta-analysis. Results: Thirteen studies published between 2019 and 2025 were included. Reported AI performance was generally promising but heterogeneous. The strongest externally validated Deep-VCUG study reported external AUC values of 0.944 for unilateral reflux and 0.924 for bilateral reflux. A qVUR model achieved AUC 0.84 and improved grading reliability 3.6-fold. A multicenter VCUG-DAM study showed marked improvement in clinician AUC with AI support. Direct AI-versus-clinician evidence remained limited. Conclusions: AI may support pediatric VCUG interpretation by improving grading consistency and high-grade VUR recognition. However, current evidence does not establish autonomous superiority over radiologists. AI should currently be considered a decision-support tool rather than a replacement for expert clinician interpretation.

Background: Redo orchiopexy is usually evaluated based on the position of the scrotum after surgery, but satisfactory scrotal placement may not necessarily reflect preserved long-term testicular growth. In this study, we evaluated whether the early postoperative testicular volume ratio (TVR) is associated with long-term growth failure after unilateral redo orchiopexy in children. Methods: This retrospective single-center cohort study included children who underwent unilateral redo orchiopexy between January 2013 and January 2023. Early postoperative ultrasonography was performed 6–12 months after surgery, and subsequent follow-up ultrasonography was performed at ≥24 months. TVR was calculated as the operated testicular volume divided by the contralateral testicular volume × 100. Long-term growth failure was defined as long-term TVR p < 0.001). Early TVR showed good apparent discrimination, with an area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.72–0.96). In the exploratory multivariable model, each 10-percentage-point increase in early TVR was associated with a lower odds of growth failure (odds ratio [OR] 0.56; 95% bootstrap CI 0.36–0.84). The apparent model AUC was 0.86, and the optimism-corrected AUC after 1000 bootstrap resamples was 0.81. The exploratory 55% cutoff yielded 82% sensitivity, 78% specificity, 69% positive predictive value, and 88% negative predictive value. Conclusions: Early postoperative TVR is associated with long-term testicular growth failure after unilateral redo orchiopexy. A TVR of approximately 55% may help identify children who require closer ultrasonographic surveillance, but this threshold is hypothesis-generating and requires external validation before clinical implementation. TVR should be interpreted as an imaging-based risk stratification marker rather than a direct measure of endocrine, fertility, or histologic testicular function.

Background: Renal ultrasound is the first-line imaging method for postnatal hydronephrosis, but its severity grading remains partly reader dependent. Although previous studies have applied artificial intelligence (AI) to pediatric hydronephrosis assessment, the clinical feasibility of a simplified two-still-image workflow in a homogeneous infant cohort remains insufficiently defined. Methods: This retrospective single-center proof-of-concept diagnostic accuracy study was conducted among 186 infants younger than 12 months with unilateral hydronephrosis who had one protocol-compatible transverse and one sagittal renal ultrasound image. The AI workflow classified hydronephrosis as mild, moderate, or severe using a two-branch convolutional neural network (CNN). Model performance was assessed using stratified patient-level five-fold internal validation. The reference standard was expert consensus based on the complete ultrasound examination. Study categories were aligned descriptively with accepted Society for Fetal Urology (SFU) and Urinary Tract Dilation (UTD) severity concepts but were not intended to replace these systems. Results: A total of 186 infants were included. Expert consensus classified 79 cases as mild, 62 as moderate, and 45 as severe. The AI-assisted workflow showed exact agreement with expert consensus in 159 of 186 infants, corresponding to 85.5%, with a linear weighted kappa of 0.83. For clinically significant hydronephrosis, defined as moderate or severe disease, the AI workflow showed a sensitivity of 92.5%, a specificity of 86.1%, an accuracy of 89.8%, a positive predictive value of 90.0%, and a negative predictive value of 89.5%. The ordinal-score area under the curve (AUC), which is based on class labels rather than calibrated probability outputs, was 0.92 for clinically significant hydronephrosis and 0.96 for severe hydronephrosis. Because patient-level probability outputs were unavailable, formal calibration, decision curve analysis, threshold adjustment, and individualized risk estimation could not be performed. Conclusions: This single-center proof-of-concept internal validation study suggests that a simplified two-plane AI-assisted workflow could closely match expert consensus grading in selected infants with unilateral hydronephrosis. The workflow should be considered a research-only ordinal class assignment tool. This study does not establish clinical readiness, external generalizability, calibrated risk prediction, or diagnostic superiority over routine reporting. Prospective multicenter validation with preserved probability outputs and formal calibration is needed before any clinical implementation.