Journal of Pediatric Urology

Editorial board

2010-02-01

Editorial

J.D. Frank, P. Mouriquand, A. Caldamone — 2010-02-01

We have the usual number of interesting papers in this issue. It has become an accepted fact by most of us that the incidence of hypospadias is increasing. We presumed, and were told by some scientists, that this was due environmental factors. The paper by Fisch et al. suggests that there is no increase which opens up a whole new area for debate and discussion. We hope there will be some correspondence from our readers on this topic.

Laparoscopic manoeuvre for orchidopexy in high intra-abdominal testes when cremasteric artery is present

2009-11-19

Abstract: Objective: We report a case of high intra-abdominal testes (HIT) associated with the presence of the cremasteric artery (CA). The aim was to correlate the normal anatomy of the CA with the clinical finding in our patient and discuss its surgical implication.Methods: Left primary laparoscopic testicular descent by the Prentiss manoeuvre was performed in a 2 year-old boy with bilateral HIT. Cadaveric dissection was carried out focusing on the anatomical origin of the CA. Data obtained from cadavers and the clinical findings were analyzed.Results: During laparoscopic orchiopexy a left HIT was found in the presence of the CA. Primary tension-free orchiopexy was achieved preserving the CA. Our cadaver study revealed that the CA arose more frequently (68%) from the medial aspect of the inferior epigastric artery.Conclusion: In the presence of HIT, surgeons should be aware of the CA as part of the testicular collateral circulation. Acquaintance with the normal anatomy of the CA is important to determine the most appropriate laparoscopic manoeuvre in orchiopexy when this artery is present. We believe that the Prentiss manoeuvre avoids compression and strangulation of the CA around the epigastric vessels while allowing testicular placement in the scrotum.

Long-term follow-up of male patients after reconstruction of the bladder–exstrophy–epispadias complex: Psychosocial status, continence, renal and genital function

2009-07-13

Abstract: Objective: There is a paucity of knowledge about long-term outcome issues in the bladder–exstrophy–epispadias complex (BEEC). Adult male BEEC patients were investigated in respect of bladder and renal function, fertility, genital function and psychosocial facts.Patients and methods: In a cross-sectional study, 17 adult male BEEC patients (mean age 23.4 years) from a single centre were evaluated with a questionnaire, renal and bladder ultrasound, blood tests, hormonal profile and semen analysis.Results: Phenotypically one patient had complete epispadias and 16 had classical bladder exstrophy. Five patients underwent a one-stage functional reconstruction as a primary and 12 as a redo procedure. After a mean follow-up of 19.4 years, 15 bladders were preserved with 12 voiding per urethram and 3 performing intermittent catheterization; 2 were secondarily diverted. Significant residual urine was present in 10; kidneys were normal in 14 patients. Sixteen patients proved ejaculations, 3 had normospermia, 7 oligoasthenospermia and 6 azospermia. In patients with only one single bladder neck procedure normospermia was statistically significant.Conclusion: After functional BEEC reconstruction, long-term bladder function is preserved with mostly normal renal function. The number of bladder neck attempts has a significant influence on andrologic outcome. Detailed analysis may detect multifactorial pathogenesis from the impaired sperm quality in the BEEC.

Prognostic value of serum creatinine levels in children with posterior urethral valves treated by primary valve ablation

Osama Sarhan, Khaled El-Dahshan, Mohamed Sarhan — 2009-07-08

Abstract: Purpose: We evaluated the prognostic value of serum creatinine level at presentation and nadir creatinine during follow up for future renal function (RF) in children with posterior urethral valves (PUV).Materials and methods: Between 1987 and 2004, 120 cases of PUV were treated initially at our hospital with valve ablation. Initial assessment included serum creatinine measurement, urine analysis and culture, renal ultrasonography and voiding cystourethrography. After valve ablation, renal ultrasound and serum creatinine measurement were repeated and thereafter during visits until the end of follow up.Results: Follow up ranged from 2 to 12 years (mean=4.4). Renal insufficiency (RI) developed at the end of follow up in 44 patients (36.5%). The mean initial and nadir serum creatinine in the RI group was higher than in the normal RF group (P<0.05). With a cut-off value of 1mg/dl for initial and nadir serum creatinine, the incidence of RI was significantly different (P<0.05).Conclusion: Our data confirm the high prognostic value of nadir serum creatinine after relief of valvular obstruction. Further, the serum creatinine level before valve ablation correlates significantly with long-term RF in children with PUV.

The clinical utility and safety of the endoscopic treatment of vesicoureteral reflux in patients with duplex ureters

T.W. Hensle, E.A. Reiley, C. Ritch, A. Murphy — 2009-07-22

Abstract: Objective: A systemic review of published literature on the use of bulking agents in the treatment of vesicoureteral reflux (VUR) in patients with duplex systems was performed in order to evaluate the diagnostic challenges; determine success rates, and compare with use in single systems; and evaluate safety, in particular of Deflux.Methods: A PubMed/Medline search was conducted for index articles discussing duplex ureters published in 1963–2007. All types of publications were included. A multiple linear regression analysis was performed.Results: Overall, 28 different treatment arms originating in 17 separate studies (19 publications) satisfied the inclusion criteria for linear regression efficacy analysis. Data were available on 2879 patients: 2400 with single and 479 with duplex systems. Ten publications provided information on the frequency of failure to diagnose duplex systems using specific techniques. An overall 18% failure rate to detect duplex systems was reported for combined techniques. For patients in whom favorable anatomic location of ureters allowed successful endoscopic injection of a bulking agent, correction of VUR was achieved in 53–100% of cases. A univariant analysis showed no difference in success rate between single and duplex systems with the use of Deflux, or other bulking agent. The predicted probability of success in a single system was 68% and in a duplex system 64%.Conclusions: There is significant potential for failing to detect duplex systems prior to preparing an individual for either open or endoscopic treatment. From the studies available, endoscopic injection of bulking agents is highly successful in correcting mild-to-moderate VUR in duplex systems, with no reports of serious or clinically significant adverse effects. At a minimum, duplex systems would not seem to be a contraindication to the use of Deflux or any other bulking agent.

Penile injuries from proximal migration of the Plastibell circumcision ring

C.O. Bode, S. Ikhisemojie, A.O. Ademuyiwa — 2009-07-01

Abstract: Background: Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators.Patients and method: This was a prospective study of penile injuries resulting from proximal migration of the Plastibell device in neonate boys referred to the Lagos University Teaching Hospital, Lagos, Nigeria. The parameters measured were patients' biodata, presentation, management and treatment outcome.Results: Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%). These complications resulted from the use of wrong-sized Plastibell kits, lack of follow-up by the medical staff, and inadequate maternal knowledge of ring fall-out time.Conclusion: Proximal migration of the Plastibell ring can result from employment of an inappropriate size, causing grievous penile injury. Adequate information should be provided to mothers of circumcised babies about possible complications of the Plastibell kit when employed. There is a need to redesign the Plastibell kit to eliminate its migration up the penile shaft.

Plastibell circumcision: A minor surgical procedure of major importance

Abdul Samad, Tariq Wahab Khanzada, Basant Kumar — 2009-06-15

Abstract: Objective: To determine the number of days taken by the Plastibell to fall off after circumcision and the Plastibell impaction rate in various age groups.Methods: This was a prospective cohort study of male babies who underwent circumcision using the Plastibell technique. Patients were followed up 1 week postoperatively as well as soon after the Plastibell had fallen off.Results: Mean age was 14.3 months and mean weight 8.2kg at time of surgery. The average time taken for the Plastibell to fall off after circumcision for babies under 3 months was 8.7 days; this period gradually increased to 16.8 days for children over 5 years of age. The overall complication rate was 7.4%. Plastibell impaction was the commonest complication, encountered after 6.1% of procedures, and was managed by cutting the Plastibell. The impaction rate was only 2.3% for babies under 3 months, but gradually increased to 26.9% for children over 5 years.Conclusion: The time taken by the Plastibell to fall off spontaneously as well as the Plastibell impaction rate increases gradually with age. In view of the overall safety, comfort and absence of any long-term complication, this procedure justifies recommendation in all children aged under 1 year, but its use is debatable in older children.

Urethral ratio on voiding cystourethrogram: A comparative method to assess success of posterior urethral valve ablation

2009-06-29

Abstract: Objective: To develop a simple, objective and reproducible quantitative measurement to assess success of posterior urethral valve ablation.Method: In 30 patients with posterior urethral valves the diagnosis was confirmed by voiding cystourethrogram (VCUG). Our protocol was to perform valve ablation, and repeat VCUG at 12 weeks postoperatively. Urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. Thirty males undergoing VCUG for urinary tract infections were evaluated as normative controls.Results: Median age of controls was 12 months (2 days–6 years) and of study group was 13 months (1 day–11 years). Mean urethral ratio in pre-fulguration group was 4.94 (±2.97) and in post-fulguration group was 2.134 (±1.19) (P<0.001). The mean urethral ratio in the control group of 1.73 (±0.577) was significantly different from the pre-fulguration group result (P<0.001), but not significantly different in comparison to the post-fulguration group (P=0.104).Conclusion: Calculation of urethral ratio on VCUG as a method of assessment of outcome of fulguration is objective, reproducible, and allows preoperative and postoperative VCUG from different facilities to be compared. A post-fulguration urethral ratio of 2.5–3 represents an acceptable result postoperatively.

Rising hypospadias rates: Disproving a myth

Harry Fisch, Grace Hyun, Terry W. Hensle — 2009-12-21

Abstract: Hypospadias is one of the most common congenital abnormalities occurring in males. In recent years, the prevalence of hypospadias and whether that prevalence is rising or stable has become part of a larger debate over the potential effects of so-called ‘endocrine disruptors’, such as phthalates and bisphenol-A, on male reproductive health.This commentary critically examines allegations suggesting a worldwide increase in hypospadias rates. Despite the lack of scientific support for this hypothesis and for related claims that the disorders of male reproductive health are related to endocrine disruptors, these constructs remain firmly entrenched in popular literature, and are being used in part to justify litigation banning suspected endocrine disruptors such as phthalates and bisphenol-A.A review of the epidemiologic data on this issue amassed to date clearly demonstrates that the bulk of evidence refutes claims for an increase in hypospadias rates. This suggests that two of the three components of alleged testicular dysfunction syndrome, i.e. decline in sperm counts and rise in urogenital anomalies, lack clinical support. It further suggests that extrapolations from data derived in laboratory animal studies about alleged occult risks to humans of various candidate compounds are unwarranted at this time.

Dysplastic kidneys in children – Do they grow?

Nia Fraser, Anu Paul, A.R. Williams, N. Broderick, M.U. Shenoy — 2009-07-02

Abstract: Objectives: Dysplastic kidneys (DK) are a common cause of chronic kidney disease (CKD). Little is known about their growth or how their sonographic appearance changes. This study aimed to test the hypothesis that DK gain little length, and to identify radiologic trends predictive of CKD.Methods: Ultrasound scans of children with DK born in 1980–2005 and referred to a single tertiary centre were analysed by a pediatric radiologist. Renal lengths were plotted on standard nomograms and the degree of dysplastic appearance noted. Factors related to DK – bladder outlet obstruction, vesico-ureteric reflux and renal impairment – were noted.Results: Fifty-three children were studied (83 kidneys), of whom 41 were boys; 289 scans were analysed. In 33 children there was associated bladder outlet obstruction or vesico-ureteric reflux. Forty-four DK were noted to fall off their renal length ‘centile’. This correlated well with the development of CKD and is statistically significant. Deterioration occurred in 53% of DK; primarily progressive reduction in corticomedullary differentiation. This also correlated well with development of CKD.Conclusion: More than half of the DK showed poor growth velocity. This, together with the degree of sonographic abnormality, carries a high predictive value for development of CKD. We recommend diligent serial sonography to follow renal growth and dysplastic appearance in children with DK.

Outcome of proximal hypospadias repair using three different techniques

Essam E. Moursy — 2009-06-11

Abstract: Objective: To evaluate the outcome of proximal hypospadias repair using three different techniques.Patients and methods: The study involved 194 boys with primary proximal hypospadias. The meatus was proximal penile, penoscrotal, scrotal and perineal in 98, 64, 30 and 2 patients, respectively. Tubularized incised plate (TIP) urethroplasty, onlay island flap (OIF) urethroplasty and two-stage repair were used in 96, 57 and 41 patients, respectively. Preoperative anatomical description and postoperative complications were recorded with evaluation of the final functional and cosmetic outcomes for each technique.Results: Mean age at presentation was 14.43 months (range 6–31). Mean follow-up after second stage was 32.9 months (range 11–54). Complications were encountered in 27 cases (13.9%) with no statistically significant differences between techniques; however, a significantly higher complication rate was found among patients with scrotal and perineal hypospadias and in patients with associated scrotal lesions. Urethrocutaneous fistula was the most common complication, being encountered in 7.7% of patients with a significantly higher rate among patients with scrotal hypospadias (16.7%).Conclusions: Single-stage repair of proximal hypospadias can be successfully performed when plate preservation is possible, while two-stage repair is applicable when plate transection is necessary. Functional and cosmetic outcomes are satisfactory, with no statistically significant advantage with any technique.

Body image and sexuality in adolescents after hypospadias surgery

2009-05-28

Abstract: Objective: Patients operated on for hypospadias often display a range of emotional and functional postoperative problems at an early age. This study explores the social, psychosocial and sexual development of adolescent boys operated on for hypospadias at an early age.Patients and method: Ten boys between the ages of 11 and 18 years and an age-matched reference group of 10 boys completed three mailed questionnaires: the Child Behavior Checklist/4–18, the Youth Self Report, and the Self-Perception Profile for Adolescents. Data on body image and genital perception, and on social, psychosocial and sexual development were gathered by interview and standardized questionnaire.Results: Internalizing or externalizing problems were not reported to be increased. Boys operated on for hypospadias had a significantly lower score on the Self-Perception Profile for Adolescents, Social Acceptance subscale. Fewer boys in the clinical group considered their penis to be normal or judged their penis as similar to that of friends. No difficulties were found regarding psychosocial or sexual development; there was however a tendency towards a more negative genital appraisal.Conclusion: Boys operated on for hypospadias appear to experience normal social, psychosocial and sexual development.

Hypospadias repair in a resource-poor region: Coping with the challenges in 5 years

O. David Osifo, Andrew O. Mene — 2009-06-18

Abstract: Objective: To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria.Patients and methods: This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003–2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results.Result: A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years±2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded.Conclusion: Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.

Laparoscopic management and outcomes in non-functioning moieties of duplex kidneys in children

Rashmi R. Singh, Silke Wagener, Harish Chandran — 2009-05-12

Abstract: Aims: Retroperitoneal laparoscopic hemi-nephrectomy (RLHN) is a well tolerated, minimally invasive, although technically demanding, procedure for children with a non-functioning moiety in a duplex kidney. There is very little published data on the long-term follow up of such patients. We collected data to assess outcomes from our experience.Methods: Data were retrospectively gathered on all patients who underwent RLHN at our institution between February 2003 and July 2008. Follow-up ultrasounds were obtained in all patients.Results: RLHN was performed in 42 patients. All had a non-functioning moiety of a duplex kidney and in addition recurrent urinary tract infections (n=36), incontinence (n=5) or vesico-ureteric reflux (n=1). Median age at surgery was 3 years, 7 months (4 months–13 years, 10 months). One patient required conversion to open procedure due to low (pelvic) kidney. The median operating time was 90min (45–150min). Urine leak developed postoperatively in one patient and loss of function of the remaining moiety occurred in another patient. They were followed up for a median period of 11 months (1–51 months).Conclusion: RLHN is a feasible and safe technique for the experienced paediatric laparoscopic urologist. Results compare very favourably with open heminephrectomy in terms of operating time and outcomes. Long-term follow up is mandatory.

Female hypospadias with vaginal stones: A rare congenital anomaly

Amilal Bhat, Ruchi Saxena, Madhu P. Bhat, Manohar Dawan, Gajendra Saxena — 2009-04-27

Abstract: Objective: To highlight the unusual and late presentation of the rare congenital urethral anomaly of female hypospadias and its management.Patients and methods: We report on four cases (aged 18–65 years; mean 34 years and 3 months) of female hypospadias; two presented with urinary incontinence, recurrent UTI since birth and dyspareunia, and two were diagnosed during catheterization following retention of urine. One of the younger patients had vaginal stones. We reached the diagnosis by catheterization, voiding cysto-urethrogram and panendoscopy. A periurethral vaginal flap urethroplasty was performed in three layers with excellent results in three cases, and one patient was managed conservatively.Results: Results were excellent in the three cases treated surgically. Patients were continent after urethroplasty and were happy to pass urine in a stream with complete emptying of the bladder for the first time in their life. Two of them had fertility problems due to urogenital septal defects and are undergoing appropriate treatment.Conclusions: Vaginal voiding leads to urinary stagnation in the vagina causing urinary pseudo-incontinence and vaginal stones. Early diagnosis requires a high index of suspicion.

Faculty of 1000 Evaluations

2010-02-01

The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: a randomized controlled trial van Dommelen P., Kamphuis M., …, Campagne A.E., Verkerk P.H.

A potpourri of paediatric urology

Piet Hoebeke — 2010-02-01

This editions potpourri has been written by Professor Dr. Piet Hoebeke who is a professor in Pediaitric and Reconstructive Urology at the University of Ghent in Belgium (Universitair Ziekenhuis Gent). He gives us the European view of the last few months in Paediatric Urology.

Whose side are you on? The diagnostic conundrum of solitary crossed renal ectopia

L.J. Livermore, N. Thiruchelvam — 2009-07-13

Abstract: A 56-year-old man presents with haematuria and through extensive investigation is found to have solitary crossed renal ectopia. This congenital abnormality occurs as a result of a combination of unilateral renal agenesis and renal ectopia. With only 34 cases reported in the worldwide literature, the rarity of solitary crossed renal ectopia makes its diagnosis a challenge.We review the embryological theories behind this congenital anomaly and highlight some of the typical features demonstrated in our case that would lead one to consider a diagnosis of solitary crossed renal ectopia. We also describe features which have not previously been noted in case reports.

Scrotal hernia of the ureter in association with posterior urethral valves

Berk Burgu, Berkan Reşorlu, Evren Süer, Tarkan Soygür — 2009-06-18

Abstract: Posterior urethral valves are a common obstructive uropathy causing severe hydroureteronephrosis. Ureteral herniation is very rare and often misdiagnosed. We report a male infant with posterior urethral valves who had increased persistent hydronephrosis despite prior successful ablation. Further examination revealed a paraperitoneal inguinal ureter herniation to be responsible for the clinical status.

Duplicated rectum as interlabial mass

Arun Chawla, K. Sasidharan, Laxmi Rao, Sreedhar Reddy — 2009-08-05

Abstract: Duplications of the rectum constitute one of the rare congenital anomalies. Presentation as a sequestrated interlabial mass without any associated anomaly has not been reported before. We cannot readily offer any embryological explanation for this congenital distortion. Total extirpation of the lesion was easily achieved ensuring complete cure.

A large extra-abdominal prevesical pseudo-cyst in a newborn with posterior urethral valves

Mathijs Binkhorst, Robert P.E. de Gier — 2009-05-29

Abstract: A male newborn is described, in whom a large extra-abdominal prevesical pseudo-cyst as well as prune-belly features were present, both of which were supposedly secondary to posterior urethral valves. It is postulated that the subvesical obstruction caused pressure build-up in the urinary tract, followed by fetal bladder rupture. The resultant urinoma migrated extra-abdominally. Distension of the urinary tract, bilateral cryptorchidism and abdominal wall laxity contributed to a prune-belly phenotype.

Re The lost testis: Failure of physical examination and diagnostic laparoscopy to identify inguinal undescended testis, P.I. Ellsworth and L. Chenck, Vol 5 (4) 321–323

John M. Hutson — 2009-10-09

I read with interest the paper by Ellsworth and Cheuck, Vol. 5 (4) 321–323, describing the lost testis. The authors describe the fact that the testis was located in the groin of an obese boy after being impalpable clinically, and showing blind-ending vessels laparoscopically. However, a review of the photographs that the authors present shows a normal left-sided closed internal ring with vas and vessels in Fig. 2. In Fig.1, although the testicular vessels are blind-ending, one is clearly able to see the vas with an enlarged collateral supply, with the arteries to the vas enlarged significantly more than normal, consistent with the fact that they are clearly not supplying just the vas itself but must be supplying a viable testis beyond the internal ring.

Commentary to “‘Open’ minimally invasive surgery in pediatric urology” Ought we not (re)define minimally invasive surgery?

Luke Harper — 2009-10-12

I read with interest the article entitled ‘Open’ minimally invasive surgery in pediatric urology. The authors report and discuss their experience with, what they call, open minimally invasive surgery (MIS). Open MIS is defined as a surgical technique which uses small incisions and obviates the use of laparoscopic instruments.

Commentary to “Pediatric hemorrhagic cystitis” by Decker DB, Karam JA, Wilcox DT. J Pediatr Urol 2009;5:254–264: Management of hemorrhagic cystitis in children after hematopoietic stem cell transplantation: Keep it safe

2009-10-22

Hemorrhagic cystitis (HC) in pediatric recipients of hematopoietic stem cell transplantation is one of the post-transplant complications which may be difficult to treat. In the face of significant morbidity (HC often lasts for several weeks and causes considerable discomfort to the patient) the clinician is left with few treatment options for which only anecdotal evidence of efficacy exists.

Commentary to “Pediatric hemorrhagic cystitis” by Decker DB, Karam JA, Wilcox DT. J Pediatr Urol 2009;5:254–64

Sotirios Bogris, Navroop S. Johal, Imran Mushtaq — 2009-10-19

We congratulate the authors on their efforts to identify an evidence-based treatment for haemorrhagic cystitis in the bone marrow transplantation population. Haemorrhagic cystitis is a life-threatening complication of bone marrow transplantation, chemotherapy and radiation therapy, and is a major management challenge. While there are numerous reports of successful treatment in the adult literature, there is a relative paucity of information in the paediatric population.