Journal of Pediatric Urology

Editorial Board

2012-06-01

Editorial

J.D. Frank, P. Mouriquand, A. Caldamone, P.S. Malone — 2012-06-01

We are delighted to have received 273 replies from reviewers specifying their subspecialty interests. This helps us editors enormously as it enables us to refer a paper to the correct reviewers and with Annette Fowler's help makes it possible for us to see how many papers a reviewer has reviewed, when they were carried out, how long it took, and with the new marking system, how good the reviews were. This obviously not only helps us but helps to ensure that an author's hard work is rewarded with a rapid and well constructed review. There are still a number of reviewers who have not sent us their replies yet but we will be sending out further reminders.

Frank Douglas Stephens (1913–2011)

Anthony A. Caldamone — 2012-06-01

F. Douglas Stephens AO, DSO passed away on December 10, 2011, at the age of 98. He had distinguished career as a pediatric surgeon, pediatric urologist, and scientist. He will probably be best remembered for his studies and teachings into the patho-embryology of developmental processes in congenital abnormalities. These primarily focused on the areas of the urinary, genital, and ano-rectal systems. A culmination of this work appeared in a great textbook published in 1983 entitled, “Congenital Malformations of the Urinary Tract”. In fact, three months before his passing in Caulfield, Australia, he was preparing a supplement for his monumental text.

Benign cystic lesions in the testis of children

B. Liniger, A. Fleischmann, Z. Zachariou — 2011-07-11

Abstract: Cystic lesions in the testis of children are rare and in most cases benign tumors. However, a preoperative diagnostic work-up could contribute to planning the surgical procedure: orchiectomy in the case of potential malignancy or otherwise a testis-sparing approach. In this study we reviewed our recent cases of benign cystic testicular tumors and the corresponding literature. The different entities are presented with details of the diagnostic work-up, pathology and treatment of these lesions. In all presented cases, organ-preserving treatment was performed. This practice is to be recommended in the case of all prepubertal cystic testicular lesions.

Post-traumatic urethral strictures in children: What have we learned over the years?

2011-07-18

Abstract: Background: Urethral stricture presents an uncommon but difficult urological problem in the pediatric population. Treatment protocols are different from in adults due to anatomical considerations.Material and methods: A thorough manual and Medline search was conducted to review the existing literature on post-traumatic pediatric urethral strictures, with key words: stricture, children, post-traumatic, urethroplasty, pediatric.Results: Opinion early on was that, due to the confined perineum, high incidence of supramembranous injury resulting in less predictable distraction defects of the posterior urethra and a high incidence of prostatic displacement, transperineal urethroplasty is technically more difficult than in adults and thus the transpubic approach is more feasible. Recent reports revealed that both approaches resulted in almost the same clinical outcomes for children with post-traumatic posterior urethral strictures.Conclusion: The ideal reconstruction for the treatment of post-traumatic posterior urethral strictures in children is bulboprostatic anastomosis. This procedure should be initially attempted through the perineum in every case. A transpubic procedure should be done only when tension-free anastomosis cannot be accomplished through the perineum.Highlights: ► The review focuses upon how is a child’s stricture different from adult. ► It details the anatomical differences while dealing with pediatric strictures. ► It analyses how the surgical approach is different in children. ► It details the results of urethroplasty in children.

Paediatric sutureless circumcision and modified circumcision: Video demonstration

Neil C. Featherstone, Feilim L. Murphy — 2012-03-02

Abstract: Objective: Circumcision is undertaken using a variety of surgical methods. Modified circumcision for the hooded prepuce or mild glanular hypospadias mandates an excellent cosmetic result. Tissue glue is an alternative to sutures for circumcision in children and has significant advantages in terms of cosmesis and postoperative pain. We present two detailed videos demonstrating our technique for sutureless circumcision and modified circumcision.Method: The incisions were marked on the outer and inner preputial skin. Incisions were made with a scalpel. Complete haemostasis was ensured. Tissue adhesive was placed onto the wound using a 32-gauge needle to allow controlled application. It is important to ensure that the coronal sulcus is free of glue at the end of the procedure. Once the circumcision is complete the penis can be cleaned and temporarily dressed.Results: Between November 2008 and September 2011, we have used this technique for 57 circumcisions and 30 modified circumcisions. No complications occurred. All were followed up for a minimum of 3–6 months.Conclusion: The technique allows reproducible excellent cosmetic results, can be easily taught to junior surgical staff and should be considered as an alternative to a standard sutured circumcision.

What to do if cystoscopic graspers are not available? Polypropylene loop as an alternative for double J stent extraction, the ‘cowboy way’

A. Ovalle, P.J. López, F. Reed, D. Reyes, N. Letelier, R. Zubieta — 2011-08-03

Double J stent extraction is a very common procedure in urologic services. The best known technique for extraction during a cystoscopy requires the use of a pair of cystoscopic graspers , to grab the stent and drag it out of the ureter into the bladder and out through the urethra. This is a simple procedure that has very few complications. The problem arises when graspers are not available, either because they are broken, lost, unsterilized or have broken during the procedure.

Female epispadias managed by bladder neck plication via a perineal approach

John Lazarus, Andries van den Heever, Bettina Kortekaas, Angus Alexander — 2011-07-18

Abstract: Female epispadias is a rare genitourinary anomaly characterized by urinary incontinence and typical appearance of the external genitalia. Traditional surgical approaches have involved a staged genitoplasty and interval bladder neck reconstruction. We describe further experience of a promising single-stage technique using a cystoscopically guided bladder neck plication via a perineal approach with combined genitoplasty.Highlights: ► Female epispadias is a rare and often missed cause of urinary incontinence. ► Traditionally suprapubic bladder neck reconstruction is performed using the Young–Dees–Leadbetter technique. ► We describe 2 cases managed by bladder neck plication via a perineal approach.

The impact of federal warnings on publically funded desmopressin utilization among children in Ontario

2011-07-18

Abstract: Objective: To determine whether safety warnings issued by health regulatory agencies regarding desmopressin treatment influenced treatment rates among children.Patient population and methods: We conducted a time-series analysis using health administrative data from Ontario, Canada, between January 1, 2003 and March 31, 2010. We examined desmopressin prescribing rates among children (<13 years) and investigated the impact of a United States Food and Drug Administration warning (December 2007) and a subsequent Health Canada warning (July 2008) on these rates. A secondary analysis stratified rates according to route of administration.Results: On average, quarterly desmopressin treatment rates were 29.8% lower following the two warnings (4.7 per 1000 population) compared with the period prior to warnings being issued (6.7 per 1000 population). Structural break analyses identified a significant decrease in overall desmopressin prescribing rates in Q3 2008, with the 95% confidence interval (CI) spanning both safety warnings (Q4 2007 to Q1 2009). A secondary analysis of prescribing rates for oral formulations found consistent results (structural break Q4 2008, 95% CI Q2 2007 to Q2 2009). The average quarterly prescribing rate of intranasal formulations declined by 73.1% following the warnings compared with the period preceding the warnings.Conclusion: Safety warnings issued by regulatory agencies dramatically influenced desmopressin use among Ontario’s children.Highlights: ► Desmopressin use can lead to serious adverse events, including hyponatremia. ► This study investigates the impact of safety warnings on desmopressin use. ► Safety warnings led to a reduction in desmopressin prescribing in children. ► Warnings from regulatory agencies can influence physician prescribing behavior.

Acute pain crisis as a presentation of primary megaureter in children

2011-06-23

Abstract: Purpose: Congenital ureteropelvic junction obstruction may present with flank pain, commonly referred to as a Dietl’s crisis. We report on a similar presentation of primary megaureter.Methods and Materials: We identified all patients with any diagnosis of megaureter treated at our institution between 1993 and 2009 (n = 465). We included 103 patients with primary megaureter and, of these, identified patients presenting with pain. All patients with secondary megaureter were excluded.Results: Seventeen patients (20 megaureters) presented with pain and 10 (13 megaureters) presented with an acute pain crisis. Median age at presentation was 77 months. Seven children initially presented to the emergency department for evaluation and two of them required urgent stent placement for intractable pain. Obstruction was diagnosed in 8 patients. Six patients underwent ureteral reimplantation. Four patients were initially observed: one failed observation at 12 months due to worsening hydronephrosis and required surgery, one was lost to follow up, and two are still successfully being followed. All patients who underwent surgery had pain resolution.Conclusion: In this contemporary cohort, approximately 17% of patients with primary megaureter presented with pain and 10% presented with an acute pain crisis. Most presenting in acute pain required surgery, which resolved presenting symptoms.

Blunt pediatric anterior and posterior urethral trauma: 32-year experience and outcomes

Bryan B. Voelzke, Benjamin N. Breyer, Jack W. McAninch — 2011-06-13

Abstract: Objective: To analyze our experience with delayed repair of pediatric urethral trauma.Materials and methods: From 1978 to 2007, 26 boys <18 years old (mean age 15.0) presented for delayed repair of urethral stricture after blunt trauma. Anterior and posterior urethral injuries were separately stratified.Results: There were 8 anterior and 18 posterior urethral strictures. All patients presented in a delayed fashion. Mean follow up of the anterior cohort was 2.9 years. All repairs were performed via a ventral onlay buccal graft or anastomotic approach. The mean follow up of the posterior cohort was 1.1 years, and all posterior urethral injuries were repaired via an anastomotic approach.Overall success for anterior stricture disease was 88.9% and for posterior stricture disease was 89.5%. All three urethroplasty failures responded favorably to internal urethrotomy; however, one failed anterior repair and one of the two failed posterior repairs required two internal urethrotomy operations for success. No secondary urethroplasty operations were required and ultimately all patients were voiding per urethra without need for urethral dilation.Conclusion: Delayed, definitive repair of pediatric urethral trauma via open urethroplasty has a high success rate.

Prepuce preserving versus conventional Mathieu urethroplasty for distal hypospadias – A prospective randomized study

Ehab O. ElGanainy, Diaa A. Hameed, Yaser M. Abdelsalam, Mohamed A. Abdelaziz — 2011-06-06

Abstract: Objectives: To evaluate the impact of prepuce preservation during Mathieu repair for distal hypospadias.Methods: This prospective randomized comparative study, carried out in Assiut University Hospital, between 2006 and 2009, included 200 patients with distal penile or coronal hypospadias. They underwent either Mathieu repair with prepuce preservation (group I, n = 100) or traditional Mathieu repair with circumcision (group II, n = 100). Follow up was at 2 weeks, and 1 and 3 months postoperatively, which only 153 patients completed (I: n = 86 and II: n = 67).Results: The mean operative time was 64.5 min in group I and 121.7 min in group II (p < 0.001). All patients in group I developed postoperative preputial edema. Patients from group I who had a successful operation underwent circumcision at least 3 months later. Urethrocutaneous fistulae developed in 7 and 6 patients in group I and II respectively (p = 0.967). Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success between the two groups. Two cases of glanular dehiscence were detected (one in each group); the patient from group I had a successful onlay island flap repair.Conclusions: Preputial preservation during Mathieu repair is a time-saving procedure with similar complication rate to traditional repair. Valuable local tissue is preserved to deal with complications that may occur.

Robotic-assisted laparoscopic extravesical ureteral reimplantation: An initial experience

David Chalmers, Katherine Herbst, Christina Kim — 2011-06-06

Abstract: Objective: There are many emerging techniques using robotic-assisted laparoscopy (RAL) in pediatrics. We performed a retrospective review of our first patients who underwent RAL extravesical ureteral reimplantation.Materials/Methods: Between October 2007 and May 2010, a single surgeon performed RAL extravesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplantation, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age 6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessed by voiding cystourethrogram.Results: 16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5 months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateral repair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgrading in one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3 days. No patients required postoperative catheterization at discharge.Conclusions: Outcomes for new procedures can be variable and unpredictable as the technique evolves. Given the high success rates of open reimplantation, a minimally invasive technique must show comparable results if it is to play a continuing role. Our initial results are encouraging, but prospective analyses are required to outline the future role of RAL ureteral reimplantation.

Balanitis xerotica obliterans in children and its incidence under the age of 5 years

S. Jayakumar, B. Antao, O. Bevington, P. Furness, G.K. Ninan — 2011-06-27

Abstract: Objective: To analyse the incidence of BXO among paediatric circumcisions for preputial pathology, in particular in children under the age of 5 years.Methods: Retrospective review revealed 1769 paediatric circumcisions performed between 1997 and 2008 at our institution. Data were collected on patient’s age, date when sample received by pathology department and histological findings for all the foreskin samples received and examined during the study period. Epidemiological data were obtained from the Office for National Statistics, UK.Results: A total of 346 foreskin samples were received and BXO was found in 182 (52.6%). There were 31 children under the age of 5 years circumcised for preputial pathology. BXO was reported in 6 (19.3%) and chronic inflammation in 16 (51.6%) of these patients. The foreskin was reported normal in 2 (6.5%) and the remaining 7 (22.6%) patients had preputial cysts or other pathology. Epidemiological population data analysis revealed the incidence of BXO per year to be 3.01 cases/1000 boys under 15 years of age and 0.322 cases/1000 boys under 5 years.Conclusion: The incidence of BXO in boys noted in our study is higher than previously reported. BXO can result in significant complications and should be considered in children even under 5 years.

Transition from open to robotic-assisted pediatric pyeloplasty: A feasibility and outcome study

Sean T. O’Brien, Aseem R. Shukla — 2011-05-27

Abstract: Purpose: Laparoscopic reconstructive procedures in the pediatric patient are associated with a steep learning curve. Outcomes from robotic-assisted pediatric urology have been reported by surgeons with known facility in laparoscopic surgery. We describe the experience of a single surgeon in transitioning from open to robotic-assisted laparoscopic pyeloplasty (RALP) without previous training in traditional laparoscopic pyeloplasty or intracorporeal suturing.Materials and Methods: We reviewed our experience with 20 (mean age 7.4 years) consecutive children undergoing RALP for ureteropelvic junction obstruction at our institution over 36 months. Additionally, a literature search was conducted to identify age-similar patient groups who underwent open and laparoscopic pyeloplasty.Results: Length of hospitalization and postoperative analgesia requirement were greater in the age-similar open pyeloplasty group compared to the other two groups. Intraoperative times were greater in the laparoscopic and RALP groups compared to the open pyeloplasty group.Conclusions: Our experience confirms the feasibility of transitioning from open to robotic-assisted laparoscopic pediatric pyeloplasty without previous experience in conventional laparoscopy. Outcomes, analgesic requirement and hospitalization for the patients from our institution are comparable to the laparoscopy patient group and improved compared to open pyeloplasty patients from the literature

Surgical technique for antegrade dissection of the preputial vascular pedicle during hypospadias repair

Hrair-George O. Mesrobian, Douglas A. Canning — 2011-05-19

Abstract: Objective: Both layers of the prepuce can be used as vascularized flaps in hypospadias repair. The aim of this communication is to describe an antegrade approach to the harvesting of the vascular pedicle.Surgical technique: The vascular pedicle is isolated at the level of the penopubic junction where it is most robust. Dissection then proceeds distally towards the prepuce fanning laterally.Results: Of 306 boys presenting for hypospadias repair in 2002–2008, this approach was utilized in 235 (77%). The vascularized flap was used as 1) a classic single or double faced onlay flap in 95, 2) a vascularized layer to cover a tubularized incised plate urethroplasty in 68, 3) a tube-onlay in 39, 4) a tubularized urethroplasty in 23, 5) for ventral skin coverage alone in 7, and 6) for a planned first stage repair in 3. Age at repair averaged 12 months (range 2–160) and follow up 36 months (range 2–68).Conclusions: Antegrade dissection of the vascular pedicle is a simple, expeditious and reliable way of isolating the prepuce on its blood supply. The versatility of the resulting flaps allows the repair to be adapted to the individual anatomic conditions as opposed to one type of repair being used for all variants.

Reduced anti-diuretic response to desmopressin during wet nights in patients with monosymptomatic nocturnal enuresis

2011-04-25

Abstract: Objective: To investigate why not all children with monosymptomatic nocturnal enuresis (MNE) treated with desmopressin give an adequate response.Materials and methods: We included 114 children with MNE aged 5–15 years (9.8 ± 0.2 years) who experienced at least 1 wet night and more than 2 dry nights during desmopressin treatment. The patients made home recordings for 2 weeks as baseline and for 2–4 weeks of desmopressin titration. Nocturnal urine production during wet and dry nights, and maximum voided volumes (MVVs) were documented in all patients.Results: Sixty-four patients were desmopressin non-responders, 29 were either partial responders or responders, while 21 patients were full responders. Desmopressin reduced nocturnal urine production dramatically during dry nights compared with pre-treatment wet nights. Nocturnal urine production during desmopressin treatment was significantly greater during wet nights compared to dry nights (243 ± 9.32 vs 176 ± 5.31 ml, P < 0.001). There was a highly significant correlation between individual nocturnal urine output and MVV, and dry nights were characterized by nocturnal urine output/MVV ratios well below 1.0.Conclusion: The anti-enuretic response to desmopressin seems to be dependent upon the degree of reduction in nocturnal urine production. Research on desmopressin bioavailability in children is needed.

Analysis of duplicate presentations accepted at two top international pediatric urology meetings

S. Kim, L.H.P. Braga, J. Pemberton, J. DeMaria, A.J. Lorenzo — 2011-03-25

Abstract: Objective: Meetings of the European Society for Pediatric Urology (ESPU) and American Academy of Pediatrics (AAP) are held annually to promote dissemination of new research findings among practitioners. We conducted an observational study determining the rate of duplicate research presentations at the two meetings.Methods: A systematic, in-year, cross reference analysis of all clinical and basic research presentations at the ESPU and AAP meetings, for the years 2006–2009, was conducted. The search strategy included abstract title, authorship, country of origin, institution, study design, significance, and sample size. Three reviewers independently abstracted all data. Discrepancies were resolved by consensus.Results: In total, 566 abstracts were presented at the four ESPU meetings. Of these, 23 (4.1%) were also presented at an AAP meeting: 2 of 137 (1.5%) were represented in 2006, 6 of 139 (4.3%) in 2007, 6 of 126 (4.8%) in 2008, and 9 of 164 (5.5%) in 2009. Duplicate presentations were altered by changing the title (57%), adding or removing authors (48%), or changing authorship order (63%) or sample size (22%). Agreement between reviewers was above 90% (kappa = 0.913).Conclusions: Although there was only a 4% duplicate presentation rate between the studied ESPU and AAP meetings, our results suggest a trend toward increasing duplication over the past 4 years.

Commentary to ‘Analysis of duplicate presentations accepted at two top international pediatric urology meetings’

Steven J. Skoog — 2011-03-30

Dr. Braga and associates have written a thought-provoking article on ‘duplicate presentations’ at the annual ESPU and then AAP meeting. Both organizations require upon submission of your presentation that ‘it has not been presented elsewhere’. The frequency of this occurrence has increased from 1.5% of the AAP presentations in 2006 to 5.5% in 2009. The authors comment that we are not as bad as other specialties, where this behavior has been noted for 15–20% of the presentations.

Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: Defining measures of success

2011-05-05

Abstract: Objective: Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up.Methods: We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1–21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12–36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions.Results: In 2004–2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as ‘radiographic cure and no clinical evidence of FUTIs’ it was 82% (275/336).Conclusions: It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.

Commentary to ‘Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: Defining measures of success’

Prem Puri — 2011-03-25

Treatment of vesicoureteral reflux (VUR) remains controversial. During the last decade, endoscopic treatment of reflux using dextranomer/hyaluronic acid (Dx/HA) has become an established alternative to continuous antibiotic prophylaxis and reimplantation of ureters. The reportedly low morbidity of Dx/HA endoscopic injection has encouraged us to recommend this as first-line treatment in the management of high-grade VUR . Most centres perform follow-up voiding cystourethrography (VCUG) to determine success of the endoscopic treatment .

Response to commentary by Puri

Arun Srinivasan, Andrew Kirsch — 2011-04-20

Professor Puri raises the issue of the treatment of low-grade ureters in our series. It is important to point out that only a small percentage of patients (not ureters) had isolated low-grade VUR and none of the patients had grade 5 reflux. In fact, only 3 (0.08%) out of 336 patients had isolated grade 1 reflux. In all the other patients, low-grade reflux was present contralateral to a ureter with a higher reflux grade. The mean maximal VUR grade for patients was 2.9 and the majority (55%) of ureters had moderate to severe VUR. It is our practice to treat all low-grade contralateral refluxing ureters.

Outcomes in distal hypospadias: A systematic review of the Mathieu and tubularized incised plate repairs

David J. Wilkinson, Paul Farrelly, Simon E. Kenny — 2010-12-15

Abstract: Aim: To compare complication rates after distal hypospadias surgery using the tubularized incised plate (TIP) and Mathieu techniques.Methods: For this meta-analysis, the Medline (1990–2009), Embase (1990–2009) and Cochrane databases were searched using the keyword ‘hypospadias’. Inclusion criteria were: i) primary repairs; ii) distal hypospadias; iii) paediatric case series; iv) standard Mathieu and TIP techniques; v) complication data obtainable from the paper. Cases were only included in the denominator for each complication if explicitly identified in the paper. Fisher’s exact was used for statistical analysis, with P < 0.05 considered significant.Main results: 129 papers were selected for full analysis; 23 papers met the inclusion criteria comprising 1872 TIP repairs and 1496 Mathieu repairs. We identified an increased incidence of urethral fistulae with the Mathieu technique (3.8% vs 5.3%, P = 0.028); however, this is lost on subgroup analysis. An increased incidence of meatal stenosis was identified in the TIP group (3.1% vs 0.7%, P < 0.001).Conclusions: There is no clear consensus on the ideal method of repair for distal hypospadias. Both the Mathieu and TIP techniques have been shown to have low rates of postoperative complications. Comparison between series is difficult because of a lack of consistency in reporting complications and follow up. We advocate uniform standards for reporting outcomes of hypospadias.

Commentary to ‘Outcomes in distal hypospadias: A systematic review of the Mathieu and tubularized incised plate repairs’

Iñigo Tuduri — 2011-04-11

I have read this article with great interest, finding very interesting on the systematic review and the conclusions about the low scientific quality of the articles on hypospadias, but I would like to add some comments about the statistics used.

A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder

Ronak A. Gor, Jamie Fuhrer, Justine M. Schober — 2010-12-06

Abstract: Introduction: Children with attention deficit hyperactivity disorder (ADHD) show an increased prevalence of enuresis and other daytime voiding symptoms (DVS). There is also some evidence toward an increased prevalence of enuresis among children with autism spectrum disorder (ASD), but with no data available with respect to DVS or response to medical treatment. The aim of this study was to assess enuresis and DVS, along with treatment outcomes, in children with ASD, to aid urological management.Methods: A retrospective observational study on the incidence of enuresis and other DVS in 671 children with/without ADHD/ASD was performed. Symptomatic improvement ≥50% was required to be considered positive. Complete resolution of symptoms for 3 months after cessation of treatment was considered cure.Results: Symptomatic improvement with desmopressin or anticholinergic treatment was seen in 76% of patients without ADHD/ASD, 85% of patients with ADHD, and 100% of patients with ASD. Cure was seen in 61% of patients without ADHD/ASD, 48% of patients with ADHD, and 50% patients with ASD. Mean time to cure was 9 months in those without ADHD/ASD (N = 319), 10 months in those with ADHD (N = 62), and 8 months in those with ASD (N = 10) (P = 0.69).Conclusion: Despite the small sample size of patients with ASD, our data show a favorable trend toward efficacy of desmopressin and anticholinergic therapy in these children with enuresis and DVS.

Commentary to ‘A retrospective observational study of enuresis, daytime voiding symptoms, and response to medical therapy in children with attention deficit hyperactivity disorder and autism spectrum disorder’

Simona Nappo — 2010-11-22

The authors report their experience with children affected by enuresis and a psychiatric condition such as attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). The group with ADHD is numerically significant, 130 children, and makes the paper interesting. The prevalence of children with ADHD among enuretics is high (19%) and, although within expected ranges for tertiary care settings, stresses once more the importance of adequate psychiatric assessment of children referred for enuresis and/or voiding symptoms. Unfortunately, given the retrospective design of the study, voiding dysfunction was only investigated on clinical grounds, and no validated questionnaires or any further diagnostic investigations (uroflowmetry, residual urine) were used. This is a significant limit of the study that the authors themselves recognize. That being said, the paper confirms previous studies and underlines once more the high rate of daytime voiding symptoms (DVS) in children with ADHD referred for enuresis. There is increasing speculation that, in children with ADHD, voiding symptoms are not only related to inattention behavior but to more complex mechanisms, involving neuropharmacological pathways in the central nervous system (serotoninergic, adrenergic). Interestingly, the response to urological pharmacological therapy (oxybutynin and desmopressin), which also acts at the central nervous system level, was particularly high in this group, in contrast to previous reports . Furthermore, all patients with ADHD were treated with stimulant medications; interference of such drugs with lower urinary tract function is yet to be elucidated (increased voiding dysfunction due to peripheral alpha-adrenergic action? Or, on the contrary, improvement of symptoms due to improvement of attention?).

Neonatal circumcision reduces the incidence of asymptomatic urinary tract infection: A large prospective study with long-term follow up using Plastibell

2010-11-09

Abstract: Objective: To evaluate the preventive effect of neonatal circumcision on urinary tract infection and the incidence of complications following neonatal circumcision using Plastibell.Materials and methods: A prospective study was carried out between 2004 and 2008. During this period, there were 3000 neonatal circumcisions. All of the cases were examined for any complications 1 week later, and occurrence of meatal stenosis was followed up to 15 months of age. In this group, urine analysis and culture was successfully performed four times for 2000 circumcised infants at 1.5, 3, 9 and 15 months. In the control group of 3000 uncircumcised infants, 1000 cases accomplished urine analysis and culture at the same designated intervals.Results: A positive urine culture was observed in none of the circumcised cases and in 20 (2%) uncircumcised cases after obtaining a suprapubic bladder aspiration sample. The latter 20 infants were circumcised and follow-up cultures were negative in 17 cases. The overall complication rate in the circumcised group was 1.6%. The difference in frequency of urinary tract infection between the two groups was statistically significant (P<0.0001).Conclusion: Neonatal circumcision has few complications and reduces the incidence of asymptomatic urinary infection. It may be considered as a preventative health measure.

Faculty of 1000 evaluations

2012-06-01

Long-term psychological and sexual outcomes of severe penile hypospadias repair Kiss A, Sulya B, Szász AM, Romics I, Kelemen Z, Tóth J, Merksz M, Kemény S, Nyírády P

A potpourri of pediatric urology

Stuart O'Toole — 2012-06-01

Stem cell therapy for rejection? There are some treatments that you think may be effective, but you just cannot contemplate ever being brave enough to try them out. Our UK press reported that renal transplant surgeons in the United States were able to take away the possibility of renal graft rejection in live donors transplants using “stem cell therapy”. In effect the recipients had pre transplant marrow ablation and a simultaneous marrow and renal transplant. Five out of eight patients are now off anti rejection medication at a year. I personally find live donor renal transplantation quite stressful enough, but will be following the work with interest.

Percutaneous retrieval of coiled double-J stent from renal pelvis after Anderson–Hynes pyeloplasty: Report of two cases

2012-02-10

Abstract: Double-J (DJ) ureteral stents are routinely placed for internal urinary diversion post renal pyeloplasty. Malfunction of the stent may occur due to migration, necessitating removal. Upward migration of a DJ stent is rarely encountered in urologic practice when a ureteroscope is used to retrieve the stent. However, retrieval of upwardly migrated stents through ureteroscopy may be challenging in the pediatric population, especially in postoperative cases. We report two pediatric cases of post Anderson–Hynes pyeloplasty in whom the DJ stents were found coiled up in the renal pelvis and were retrieved successfully through percutaneous nephrostomy using semirigid bronchoscopic forceps.

Delayed onset ureteral obstruction following Deflux® injection for vesicoureteral reflux

R.P. Zemple, A.M. Potretzke, J.V. Kryger — 2012-01-18

Abstract: Endoscopic injection treatment of vesicoureteral reflux is an increasingly common and successful option. Obstruction is an infrequent postoperative complication, occurring in 1% of patients; delayed onset of obstruction is even rarer. There is a paucity of literature describing possible treatments. We present a novel approach by excision of the implanted material.

Asymptomatic chronic partial obstruction of a normal ureter following dextranomer/hyaluronic acid copolymer (Deflux®) injection for grade I vesicoureteral reflux

Angela M. Arlen, Brittany L. Pakalniskis, Christopher S. Cooper — 2012-01-03

Abstract: Endoscopic management of vesicoureteral reflux with dextranomer/hyaluronic copolymer (Deflux®, Oceana Therapeutics, Inc., Edison, NJ, USA) has gained widespread acceptance with increasing success rates and minimal morbidity. Formation of a pseudocapsule and calcification are known histologic changes at the injection site. Postoperative ureteral obstruction has been reported in cases of severe voiding dysfunction, neurogenic bladder and abnormal ureteral anatomy. We present a case of chronic asymptomatic obstruction in a normal ureter following injection of 0.7 ml Deflux.

Retrograde intrarenal surgery for nephrolithiasis in a 2-year-old boy with type 1 glycogen storage disease: A case report

2011-12-19

Abstract: Treatment for renal stone in a 2-year-old boy with glycogen storage disease type 1 (GSD-1) is reported. To our knowledge, this is the first published report of a child with GSD-1 treated by retrograde intrarenal surgery.

Urethral atresia and anhydramnios at 18 weeks of gestation can result in normal development

Katharina Stalberg, Ricardo González — 2011-12-12

Abstract: Introduction: Second-trimester anhydramnios is incompatible with survival unless amniotic fluid volume is restored. We describe the long-term outcome of a child with documented anhydramnios at 17 weeks.Case report: A 28-year-old gravida II had anhydramnios at 17 weeks. At 19 weeks, the bladder measured 12 cm, and karyotype was XY. At 21 weeks, a fistula between the bladder and the amniotic space developed. At 36 weeks, a 2800 g boy with prune belly phenotype was delivered. The urachus was patent and drained urine. There was a completely obstructing membrane below the veru montanum and a hypoplastic urethra distal to it. The right kidney had no function and the left had grade V reflux. A P.A.D.U.A. (progressive augmentation by dilatating the urethra anterior) procedure was performed and the urachal fistula closed. At 6 months of age abdominoplasty, bilateral orchidopexy, right nephrectomy and left to right transuretero-ureterostomy were performed. At age 30 months he was toilet trained, with creatinine 0.5 mg/dl and normal growth. At 10 years of age he continues to be continent, with serum creatinine 0.9 mg/dl.Conclusion: Resolution of anhydramnios at 21 weeks of gestation can result in normal pulmonary function and acceptable renal and bladder function in childhood. Efforts to develop effective methods of fetal bladder decompression should continue.

High-grade transitional cell carcinoma of the pediatric bladder

Garrett S. Korrect, Eugene A. Minevich, Bezalel Sivan — 2011-11-21

Abstract: Transitional cell carcinoma of the bladder is extremely rare in the first decade of life. We present the case of a 5-year-old male with gross hematuria found to have high-grade transitional cell carcinoma of the bladder. To our knowledge this is the first such reported case in this age group.

Re: Thom M, Campigotto M, Vemulakonda V, Coplen D, Austin PF. Management of lower urinary tract dysfunction: A stepwise approach. J Pediatr Urol 2011;8:20–24.

Ilker Akyol, Hasan Soydan — 2012-02-20

We read with interest this article by Thom et al., which aims to provide an insight for the practitioners in the topic area. For a long time, surgeons have been blamed for ignoring the medical aspects of both diagnostic and therapeutic issues, and shortcutting towards surgical solutions; albeit, it is not true anymore, at least for pediatric urologists. It is amazing to see how urologists began to approach matters from an internist’s viewpoint today. However, ignoring the surgical aspects of medical conditions would be another big mistake.

Re: Simforoosh et al.

Robert S. Van Howe, Michelle R. Storms — 2011-03-18

We read the study by Simforoosh et al. with interest and concern. First, the potential sampling bias that results from using a bag specimen to screen for bacteria in the urine is not eliminated in this study. Three times as many genitally intact boys had colony counts greater than 103 using bagged specimens; consequently, they were more likely to undergo a suprapubic aspiration. To eliminate sampling bias, the investigators would need to perform suprapubic aspiration or bladder catheterization on all the infants in the study. Furthermore, intact males with bacteriuria may have had more manipulation of their foreskins (retractions, etc.). This needed to be accounted for.

Response to Letter to the Editor

N. Simforoosh — 2011-03-02

The important criteria for choosing a screening test are acceptable sensitivity and minimal adverse effect. So, it would not seem rational to catheterize thousands of healthy boys for screening purposes and risk introducing urethral bacteria into the bladder that might start a new infection. Therefore, we used the urine bag as a screening test. We re-checked positive cultures and then confirmed by suprapubic bladder aspiration, which provides the most accurate assessment of bladder urine .