Urinary tract infections (UTIs) are common in children and require appropriate diagnostic evaluation, management and follow-up. To provide a summary of the updated European Association of Urology (EAU) guidelines on Pediatric Urology, which were first published in 2015 in European Urology. A structured literature review was performed of new publications between 2015 and 2020 for UTIs in children. The guideline was updated accordingly with relevant new literature. The occurrence of a UTI can be the first indication of anatomical abnormalities in the urinary tract, especially in patients with a febrile UTI. The basic diagnostic evaluation should include sufficient investigations to exclude urinary tract abnormalities, but should also be as minimally invasive as possible. In recent years, more risk factors have been identified to predict the presence of these anatomical anomalies, such as a non-E. Coli infection, high grade fever and ultrasound abnormalities. When these risk factors are factored into the diagnostic work-up, some invasive investigations can be omitted in a larger group of children. In addition to the treatment of active UTIs, it is also essential to prevent recurrent UTIs and consequent renal scarring. With the increase of antimicrobial resistance good antibiotic stewardship is needed. In addition, alternative preventative measures such as dietary supplements, bladder and bowel management and antibiotic prophylaxis could decrease the incidence of recurrent UTI. This paper is a summary of the updated 2021 EAU guidelines on Pediatric Urology. It provides practical considerations and flowcharts for the management and diagnostic evaluation of UTIs in children.

Historically, ureteral reimplantation (UR) has been the gold standard for treatment of primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent urinary tract infections. In infants, open surgery with reimplantation of a grossly dilated ureter into a small bladder, can be technically challenging with significant morbidity. Therefore, less invasive endoscopic management such as dilatation or incision of the ureter-vesical junction, has emerged as an alternative to reimplantation during the last decades. To systematically evaluate the effectivity, safety, and potential benefits of endoscopic treatment (dilatation with or without balloon or incision) of POM in comparison to UR. A systematic review was conducted. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 20 participants and a mean follow-up more than 12 months were eligible for inclusion. Of 504 articles identified, 8 articles including 338 patients were eligible for inclusion (0 RCTs, 1 NRSs, and 7 case series). Age at time of surgery was minimum 15 days to a maximum of 192 months. Indications for endoscopic treatment (ET) included patients with loss of split renal function (>10%) and worsening of hydroureteronephrosis. The studies analysed reported a success rate ranging from 35% to 97%. Success was defined as stabilization of differential renal function without further procedures. A post-operative complication rate of 23-60% was reported (mostly transient haematuria, urinary tract infections and stent migration or intolerance). In 14% of the cases salvage UR following initial ET, was performed due to relapse of symptomatic POM. Endoscopic treatment for persistent or progressive POM in children is a minimally invasive alternative to UR with a long-term modest success rate. Additionally, it can be performed within a wide age span, with equal success rate and complication rates.

We evaluated the long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction. Data were compiled from the records of 25 children with a median age of 9.3 years (range 0.9 to 14.2) who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end filling pressures, and were unresponsive to clean intermittent catheterization and anticholinergics. Median followup was 6.8 years (range 0.1 to 15.6). Median postoperative bladder capacity was unchanged or decreased to 95 ml (range 25 to 274) during the first 3 months compared to a median preoperative capacity of 103 ml (14 to 250). At 5 months postoperatively median bladder capacity increased significantly to 176 ml (range 70 to 420, p<0.01). This increase remained significant during the rest of followup. Median bladder compliance doubled after 1 year to 10 ml/cm H2O (range 1 to 31, p<0.05) compared to the preoperative level, and further increased to 17 ml/cm H2O (5 to 55) at 5 years (p<0.05). Median maximal detrusor pressure was 43 cm H2O (range 8 to 140) preoperatively. This value decreased significantly postoperatively (p<0.01) and at final followup it was 26 cm H2O (range 6 to 97). Kidney function developed normally in all patients except 1 with persistent uremia. Reflux was alleviated in 7 of 9 cases. Of the patients 18 became continent on clean intermittent catheterization. Bladder autoaugmentation in children with neurogenic bladder dysfunction offers, after a transient decrease in bladder capacity, a long lasting increase in capacity and compliance, while the end filling pressure decreases.

The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

The aim of this study was to assess the diagnostic prevalence, incidence, diagnostic age, and surgical volume of hypospadias in Denmark. Males with a hypospadias diagnosis in the Danish National Patient Registry (n = 10,276) were identified (1977-2019). A diagnostic algorithm, validated by medical file review (n = 1710), confirmed diagnoses and severity (distal/proximal). The yearly prevalence (live-born hypospadias boys/100,000 newborn boys) and incidence (first hypospadias registration in the Danish National Patient Registry/100,000 boys in background population) were calculated. Age at diagnosis and number of health care contacts were calculated. Poisson regression was used to analyze temporal trends. Hypospadias was verified in 9189 males (89.4%; distal 8404 [91.5%]; proximal 785 [8.5%]). From 1977 to 2006, the prevalence rose significantly to a mean of 503 (95% CI: 440-565) and peaked at 847 (distal 768, proximal 79) in 2007. From 2008 to 2018, the prevalence stabilized (mean 774, 95% CI: 738-810). A significant rise in incidence was observed. Age at diagnosis decreased from 1977 to 2019. Proximal hypospadias was diagnosed earlier (median 0 years, IQR, 0-0.5) than distal (median 0.2 years, IQR, 0-1.9) and had more (P < 10^-4) nonsurgical hospital contacts (median = 5, IQR, 3-7 vs median = 2, IQR, 1-3). At least 1 surgical admission was recorded for 4550 (58.4%). Boys without surgical admissions (n = 3244, 41.6%) were primarily distal cases (97.7%). Since 1977, the prevalence of diagnosed hypospadias cases significantly increased and peaked around 800 per 100,000 live boys in 2007. The diagnostic age decreased, proximal cases were diagnosed earlier, and there were more surgical admissions than distal cases. A significant proportion were never operated.