Journal of Pediatric Urology

Editorial board

2008-12-01

Editorial

David Frank, Pierre Mouriquand, Tony Caldamone — 2008-12-01

Welcome to this edition of the journal. We hope that you have had as interesting and fulfilling a year as we have had as editors and we wish you all a very Happy Christmas and a prosperous New Year. Your papers should have been sent in by now to the ESPU for presentation at the 2009 meeting in Amsterdam. We trust that yours was accepted and you will submit the finished manuscript to the Journal for consideration for subsequent publication. If you are submitting a video we hope to have sorted out our website by then to enable you to have it visible by journal subscribers but Mark Woodward will be giving you more details in a subsequent editorial.

Jean Cendron: The birth of pediatric urology in France

Marc Cendron — 2008-12-01

A career in Pediatric Urology rarely starts with a trip to the South Pole. In 1950, while finishing his training in general surgery and having found an interest in Urology, Jean Cendron was asked to participate as a surgeon and biologist in the second French expedition to the South Pole. However, having requested permission of his mentor at the time, Professor Couvelaire was quite opposed to the project and stated clearly that one “could not do exploration and urology”. The opportunity to participate in the second French expedition to Terre Adelie (the French sector of Antarctica) was, in the mind of a young surgeon the experience of a life-time. He had volunteered for this expedition in his capacity as physician, biologist, veterinarian and erstwhile dentist. The year of living under very difficult and, at times, extreme conditions was rich and challenging. When queried about it he would describe the experience in a very modest manner, always downplaying his role, but it was clear that it had been an extraordinary one.

Reflux nephropathy

Marc Cendron — 2008-12-01

Abstract: Vesicoureteral reflux may be associated with abnormalities of the renal parenchyma. The purpose of this review is to define what the parenchymal abnormalities are histologically, what their etiologies may be, how they are identified and what their long-term clinical impact may be. Two categories are recognized, renal dysplasia and post-infection, chronic pyelonephritis. The diagnostic gold standard is microscopic evaluation of biopsy specimens but renal scintigraphy can be used in the diagnosis of renal dysplasia versus chronic pyelonephritis. Potential long-term sequelae of reflux nephropathy include hypertension and renal insufficiency although these may occur infrequently. A review of the current literature is provided.

Inter-observer and intra-observer agreement on interpretation of uroflowmetry curves of kindergarten children

Shang-Jen Chang, Stephen S.D. Yang — 2008-12-01

Abstract: Purpose: To evaluate the inter-observer and intra-observer agreement on the interpretation of uroflowmetry curves of children.Materials and methods: Healthy kindergarten children were enrolled for evaluation of uroflowmetry. Uroflowmetry curves were classified as bell-shaped, tower, plateau, staccato and interrupted. Only the bell-shaped curves were regarded as normal. Two urodynamists evaluated the curves independently after reviewing the definitions of the different types of uroflowmetry curve. The senior urodynamist evaluated the curves twice 3months apart. The final conclusion was made when consensus was reached. Agreement among observers was analyzed using kappa statistics.Results: Of 190 uroflowmetry curves eligible for analysis, the intra-observer agreement in interpreting each type of curve and interpreting normalcy vs abnormality was good (kappa=0.71 and 0.68, respectively). Very good inter-observer agreement (kappa=0.81) on normalcy and good inter-observer agreement (kappa=0.73) on types of uroflowmetry were observed. Poor inter-observer agreement existed on the classification of specific types of abnormal uroflowmetry curves (kappa=0.07).Conclusions: Uroflowmetry is a good screening tool for normalcy of kindergarten children, while not a good tool to define the specific types of abnormal uroflowmetry.

Long-term efficacy and safety of tolterodine in children with neurogenic detrusor overactivity

Pramod P. Reddy, Niels G. Borgstein, Rien J.M. Nijman, Pamela I. Ellsworth — 2008-12-01

Abstract: Objective: We evaluated long-term (≥12months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.Subjects and methods: Subjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4months–4years, tolterodine oral solution 0.2–2mg twice daily; 5–10years, tolterodine oral solution 0.5–4mg twice daily; 11–16years, tolterodine extended-release capsules 2, 4, or 6mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.Results: Thirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40cm H2O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10cm H2O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24h decreased in all subjects, as did the number of catheterizations per 24h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.Conclusions: Both tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.

Cryptorchid testis histopathology in myelomeningocele patients

2008-12-01

Abstract: Purpose: Cryptorchidism occurs in 25% of boys with myelomeningocele (MMC) compared to 3% of the general population. Testicular biopsy histopathology correlates with future sperm counts. We studied testicular histology in boys with cryptorchidism and MMC to investigate if the MMC influences histological findings.Materials and methods: The study group consisted of six patients with MMC and undescended testis (UDT) who underwent orchiopexy and bilateral testis biopsy. Twelve testicular biopsies from six patients were compared to 40 biopsies from 20 UDT-only controls. Total germ cell count per tubule (TGC/T) and the percentage of adult dark spermatogonia (%Ad) in undescended and contralateral descended testes from the patients were compared with controls.Results: In the study group, two had total absence of germ cells (TGC/T=0) and three had severely reduced germ cells (TGC/T<0.2). Four had total absence of Ad spermatogonia and the remaining two had severely reduced Ad spermatogonia (%Ad=5). The mean TGC/T and %Ad in patients with UDT and MMC were conspicuously lower than controls. The differences did not reach statistical significance (P=0.09–0.29).Conclusion: These results suggest that patients with both MMC and UDT have a more severe reduction in total number and more severely delayed maturation of germ cells than do patients with UDT alone. With only six patients in this study, there was not the power to detect statistical significance. In addition to the reproductive problems due to erection and ejaculatory dysfunction in patients with MMC, this severe testicular histopathology may increase the risk of subfertility.

One-stage repair of severe hypospadias using modified tubularized transverse preputial island flap with V-incision suture

2008-12-01

Abstract: Purpose: Although hypospadias repair for preserving the urethral plate is popular among pediatric urologists, applying this procedure to severe hypospadias is controversial. We report the outcome of applying additional modifications to the modified tubularized transverse preputial island flap (TPIF) procedure reported previously [Patel RP, Shukla AR, Austin JC and Canning DA. Modified tubularized transverse preputial island flap repair for severe proximal hypospadias. BJU Int 2005;95:901–4] for repairing severe hypospadias.Materials and methods: We retrospectively evaluated our series of 22 patients (mean age 17.5months) who underwent the modified TPIF with an additional simple modification of meatoplasty with V-incision suture. Patients were followed for a mean period of 18months.Results: After releasing the chordee, the hypospadiac orifice was retracted to become penile in five patients (22.7%), penoscrotal in six (27.3%), scrotal in nine (40.9%), and perineal in two (9.1%). The median length of the neourethra was 46mm. One-stage repair was successful in 19 patients (86.4%) without any complications.Conclusion: Our modified TPIF procedure yielded favorable outcomes functionally and cosmetically with a low postoperative morbidity rate. Such a procedure can be considered useful for repairing severe hypospadias when the urethral plate cannot be preserved.

Long-term (>5 years) donor site outcome after mandibular labial mucosa graft harvesting for urethral reconstruction in children

2008-12-01

Abstract: Objective: To report long-term donor site outcome after mandibular labial mucosa graft (LMG) harvesting in children.Material and methods: Donor site outcome was evaluated after a follow-up of at least 5 years in 30 patients ≤14 years of age at surgery undergoing mandibular LMG harvesting for urethral reconstruction. Outcome domains considered included intra-oral donor site scarring, alteration in salivary flow, peri-oral numbness and tightness of the mouth.Results: After a median follow-up of 8 years (range 6–11.8 years), at a median age at evaluation of 13.4 years (range 9–22.2 years), 16 (53%) of the patients reported to feel a thickening at the harvesting site, none reported alterations in the salivary flow, and one patient each reported tightness of the mouth and peri-oral numbness. None of the patients reported symptoms to be bothersome enough to seek treatment.Conclusion: LMG harvest is safe in children and associated with minimal long-term intra-oral symptoms.

Management of vesicoureteral reflux without indwelling catheter and drain, using trigonoplasty technique

Nasser Simforoosh, Homa Hariri — 2008-12-01

Abstract: Purpose: Gil-Vernet trigonoplasty is a simple, fast and effective technique for treating primary VUR, and is the only technique used to manage unilateral reflux that does not result in contralateral new reflux, due to its inherent bilateral nature. We have tried to further simplify postoperative management of the procedure by eliminating the use of an indwelling urethral catheter and drain.Patients and methods: In a prospective study during a 15-month period, 65 children with 103 refluxing units (56 girls, nine boys), aged 1–15 years, underwent the designed surgery.Results: Preoperative voiding cystourethrogram revealed bilateral reflux in 38 and unilateral reflux in 27 children. Of 130 renal units, 103 were associated with reflux grade I, II, III, IV and V in 8.73%, 24.27%, 35.92%, 30.9% and 0.9% units, respectively. Of 103 refluxing units, 97 units had stopped refluxing on cystogram 3 months after surgery, giving the overall success rate of 94.1% for all grades of reflux included in the study. Only 7.6% of the children needed urethral catheterization after surgery. No ureteral obstruction occurred. Two patients developed urinary extravasation, both managed conservatively. No patient needed reoperation. The procedure was done on an outpatient basis in 40% of cases, while 60% of the children were hospitalized with a mean admission time of 3.4 days.Conclusion: The Gil-Vernet trigonoplasty technique is simple, safe and effective. Our study further simplified postoperative management by avoiding an indwelling catheter and drain. Also, we have shown that this can be done as an outpatient procedure.

Neonatal circumcision in Maryland: A comparison of hospital discharge and maternal postpartum survey data

Diana Cheng, Lee Hurt, Isabelle L. Horon — 2008-12-01

Abstract: Objective: To study circumcision rates in Maryland using hospital discharge and maternal survey data in order to provide healthcare providers, parents and policy makers with more accurate and comprehensive information about this common yet controversial procedure.Methods: Secondary data analyses were performed using Maryland hospital discharge data files containing records of 96,457 male newborns, and postpartum survey data collected from 4273 mothers through the Maryland Pregnancy Risk Assessment Monitoring System.Results: Hospital discharge data showed that 75.3% of male infants were circumcised, and survey data showed that 82.3% of male infants were circumcised. The circumcision rate among infants weighing <1500g at birth was 38.9% using hospital discharge data and 74.5% using maternal survey data. Both sources revealed lower circumcision rates among Asian and Hispanic infants than among non-Hispanic white and non-Hispanic black infants.Conclusions: Despite reports of decreasing circumcision rates nationally, rates remain high in Maryland. In addition to providing for the inclusion of circumcision procedures that may not have been coded properly in hospital discharge records and procedures that were performed after hospital discharge, maternal survey data provide more comprehensive information than hospital discharge data about parental characteristics and factors relevant to the circumcision decision-making process.

High odds for freedom from early complications after tubularized incised-plate urethroplasty in 1-year-old versus 5-year-old boys

Christian Korvald, Kjetil Stubberud — 2008-12-01

Abstract: Objective: We present two parallel case series on outcome after tubularized incised-plate urethroplasty (TIP repair) for hypospadias in 1-year-old versus 5-year-old boys.Patients and methods: Over a 2-year period two groups (1year old, n=57 and 5years old, n=65) of boys were operated in parallel using the TIP repair. Main endpoints were set as incidence of fistula, meatal stenosis and foreskin dehiscence/phimosis. A logistic regression model was used to predict the odds for freedom from either ‘any complication’ or fistula in 1-year-old boys versus 5-year-old boys.Results: Five-year-old boys had a significantly higher incidence of fistula (26% vs. 7%, P<0.01) and ‘any complication’ (50% vs. 18%, P<0.001) than the 1-year-old boys. The odds ratio for freedom from ‘any complication’ and fistula was 4.8:1 (P<0.001) and 4.7:1 (P=0.009), respectively, in favor of the 1-year-old group. Avoiding foreskin reconstruction gave increased odds for freedom of “any complicaton” (4.2:1, P=0.034), but was an insignificant factor concerning freedom from fistula.Conclusion: These data substantiate why boys with hypospadias should be corrected early. Foreskin reconstruction increases postoperative problems but does not increase the rate of postoperative fistulae.

Endoscopic insertion of cystostomy button for bladder drainage in children

Nadeem Haider, Ramnath Subramaniam — 2008-12-01

Abstract: Aim: The aim of this study is to describe a safe and simple minimally invasive technique for insertion of cystostomy buttons for bladder drainage and cycling in children.Material and methods: This is part of an ongoing prospective study since 2002 looking at our experience with insertion of cystostomy buttons in children. We recently published the results of the use of cystostomy buttons in 17 children inserted by an open technique reporting minor complications of urinary leakage and wound infection. We have modified our practice in the last 2 years to a percutaneous endoscopic approach.Results: Twelve children (four girls, eight boys) with a mean age of 7.1 years underwent endoscopic insertion of a cystostomy button. Mean follow up was 11 months (3–24 months). There were no complications such as leakage in the endoscopically inserted buttons.Conclusions: Button cystostomy is a safe and effective form of bladder drainage and gives children a less restricted quality of life. Endoscopic technique allows insertion of buttons under vision with good snug fit and no leakage.

Complications of surgical reconstruction of the exstrophy–epispadias complex

David J. Hernandez, Todd Purves, John P. Gearhart — 2008-12-01

Abstract: This review of the complications of all methods of modern treatment of bladder exstrophy emphasizes the complexity of reconstruction of the bladder exstrophy spectrum. The main complications of any method of primary bladder exstrophy closure are complete wound dehiscence, bladder prolapse and urethral outlet obstruction; others include bladder and renal calculi. These complications as well as methods to avoid them are discussed here. Evidence supporting the management strategy is presented where possible.

A potpourri of pediatric urology

Stuart O'Toole — 2008-12-01

Most teenage boys have episodes of poor behaviour, but a small number has such severe and prolonged periods of antisocial behaviour that they arouse the interest of psychologists and psychiatrists. A study by a team from Cambridge University found that boys with severe antisocial behaviour did not have a normal cortisol response to stressful situations. This work raises some interesting questions; is the lack of cortisol a cause of the poor behaviour or did the stress situation that the researchers come up with seem quite tame for the hard core wayward adolescent.

Giant urethral calculus in a 6-year-old girl

F. Rivilla, A. Luis, D. Llanos, A. Ruiz — 2008-12-01

Abstract: Urinary stones are rarely seen in the urethra and are usually encountered in men with urethral stricture or diverticulum. Primary urethral calculi are extremely infrequent in females. We describe a case of a giant urethral stone impacted in a 6-year-old girl.

Prenatal diagnosis of juvenile granulosa cell tumor of the testis

Chad Peterson, Steven Skoog — 2008-12-01

Abstract: Juvenile granulosa cell tumor is a rare benign neoplasm of the testicular stroma that accounts for 1–5% of all prepubertal testis tumors [Metcalfe PD, Farivar-Mohseni H, Farhat W, McLorie G, Khoury A, Bagli DJ. Pediatric testicular tumors: contemporary incidence and efficacy of testicular preserving surgery. J Urol 2003;170:2412–2416; Ross JH, Rybicki L, Kay R. Clinical behavior and a contemporary management algorithm for prepubertal testis tumors: a summary of the prepubertal testis tumor registry. J Urol 2002;168:1675–1679]. A prior case series retrospectively identified a cystic testis tumor on prenatal ultrasound images which was subsequently diagnosed as a juvenile granulosa cell tumor [Bryan DE, Cain MP, Casale AJ. Juvenile granulosa–theca cell (sex cord–stromal) tumor of the infant testis. J Urol 2003;169:1497–1498]. We report a case of a prenatally diagnosed testis tumor which was subsequently diagnosed as a juvenile granulosa cell tumor.

Methemoglobinemia due to application of prilocaine during circumcision and the effect of ascorbic acid

Perran Boran, Gulnur Tokuc, Zeliha Yegin — 2008-12-01

Abstract: Local anesthesia with prilocaine has become a routine part of ambulatory circumcision procedures. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics.We report the case of a 42-day-old boy who presented with cyanosis after receiving local anesthesia with prilocaine. Methemoglobin level revealed severe methemoglobinemia (methemoglobin=44.5%). His cyanosis promptly resolved after intravenous administration of ascorbic acid.Cases of local anesthetic-induced methemoglobinemia in urology are under recognized. Although the association between prilocaine use and methemoglobinemia has generally restricted prilocaine use in infants, it is still widely used in ambulatory procedures, especially during circumcision in the neonatal period. Prilocaine should not be used in infants less than 3 months of age because of the risk of methemoglobinemia and alternative local analgesics should be considered among this age group. We also discuss the use of ascorbic acid during treatment in light of the literature.

Laparoscopic treatment of unilocular renal hydatid cyst mimicking a simple cyst in a child

Bulent Onal, Oktay Demirkesen, Sinharib Citgez, Burak Argun, Armagan Oner — 2008-12-01

Abstract: A 110×70×60-mm hydatid cyst in the right kidney of a 5-year-old boy was treated using a laparoscopic approach. The renal hydatid cyst was not identified before the operation. There were no complications related to surgery and therapy. The child was under follow-up for 12 months and there was no evidence of recurrence on ultrasonography and computed tomography during this period. To our knowledge, this is the first case of renal hydatid cyst treated by laparoscopic approach in a child.

Open letter to all professors of paediatric urology

Shriram S. Joshi — 2008-12-01

Endoscopic injection (with Deflux) for VUR is now an accepted minimally invasive treatment, used even for higher grade reflux like Grade 4 and Grade 5. ‘HIT’ and ‘Double HIT’ techniques have been popularized by Kirsch et al. from Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA. These are based on ‘mucosal coaptation’ of intramural ureter for reconstituting a flap valve to prevent VUR.

Comment on: Lymphatic preservation using methylene blue dye during varicocele surgery: A single-center retrospective study, by A. D'Alessio, E. Piro, F. Beretta, M. Brugnoni, F. Marinoni, L. Abati. J Pediatr Urol 2008;4:138–40.

Josef Oswald — 2008-12-01

Varicocele surgery in adolescents has been one of the most controversial issues of pediatric urology. The authors' efforts to describe a lymphatic preservation method to avoid postoperative hydrocele are appreciated. In this paper a series is presented of 46 patients who received intraparenchymal injection of 0.25ml of vital dye with a 30-G needle. The originally described method using vital dyes consists of a paratesticular injection in which the point of the needle lies parallel and lateral to the tunica vaginalis of the testis; an intravaginal injection between the two layers of tunica vaginalis is perfectly feasible . I would advise against an intratesticular injection: whatever kind is done, severe damage specifically to the testicular tissue is a possible consequence. To find pathologic changes in testes which were treated with injected liquids is not very new . A close correlation between the frequency of acellular tubules and the dose of injected material had already been described . Furthermore, it is well known that not only the injection itself but the substance used causes specific toxic effects right up to a chemosterilization for example . Additionally, it is apparent from the case of a constant-volume organ with minimal potential for extension that every volume enhancement leads to tissue damage . This was recently confirmed by an article by Makari et al. who found, in an animal experiment, necrosis of seminiferous tubules, interstitial fibrosis and hyalinization and intratubular dystrophic calcification after intratesticular injection of a vital dye . Therefore, intratesticular injection of vital dyes for the visualization of testicular lymphatics in children or adolescents should be avoided.

Akanksha Mehta, Anthony A. Caldamone — 2008-12-01

Essentials of Paediatric Urology Second Edition, is a comprehensive and detailed review of urologic disorders most commonly encountered in childhood. Well-organized and superbly illustrated, this text covers basic urologic knowledge as well as advances made more recently in the field of pediatric urology, such as laparoscopic and robotic-assisted surgical techniques. The stated goal of this publication is that it is a source of easy reference for pediatricians, pediatric nephrologists, radiologists, and nurse specialists. Indeed it is our opinion that the goals are very well achieved.

Acknowledgement of Reviewers 2008

2008-12-01

Research journals could not exist without the generous support from scientists willing to be peer reviewers. Journal of Pediatric Urology gratefully acknowledges the time and effort contributed by the following experts, for refereeing the work of their fellow researchers during the past year.