Journal of Pediatric Urology - Articles in Press

Enuretic children with obstructive sleep apnea syndrome: Should they see otolaryngology first? - Corrected Proof

2012-01-30

Abstract: Objectives: To study: (1) the prevalence of diurnal urinary incontinence (DI) and nocturnal enuresis (NE) in children with obstructive sleep apnea syndrome (OSAS) who underwent surgery for their upper airway symptoms, (2) the postoperative rate of enuresis resolution, and (3) factors that may predict lack of improvement post surgery.Patients and Methods: An observational, pilot study of children 5–18 years of age with OSAS and NE who underwent tonsillectomy and/or adenoidectomy (T&A) between 2008 and 2010 was performed. Study consisted of a phone interview and chart review. Severity of NE and DI, frequency, arousal and sleeping disturbances were assessed pre and post T&A. Factors associated with failure to respond were analyzed using a logistic regression model.Results: Among the 417 children who underwent T&A, 101 (24%) had NE (61 males, mean age 7.8 ± 2.5 years), and of these 24 had associated DI (6%). Mean postoperative follow-up was 11.7 months. Of the 49 whose NE responded to T&A (49%), 30 resolved within 1 month postoperatively. DI resolved in 4 children (17%). There was a statistically significant difference between responders and non-responders regarding the presence of prematurity, obesity, family history of NE, type of enuresis, enuresis severity, and ability to be easily aroused.Conclusion: NE was present in about one fourth of children with OSAS undergoing surgery, and resolved in about half. Lower response rate was associated with prematurity, obesity, family history of NE, presence of non-monosymptomatic NE, severe NE preoperatively, and arousal difficulties.

Clinical and gonadal features and early surgical management of 45,X/46,XY and 45,X/47,XYY chromosomal mosaicism presenting with genital anomalies - Corrected Proof

M.K. Farrugia, N.J. Sebire, J.C. Achermann, A. Eisawi, P.G. Duffy, I. Mushtaq — 2012-01-27

Abstract: Objective: The 45,X/46,XY and 45,X/47,XYY group of patients includes some of those previously diagnosed with ‘mixed gonadal dysgenesis’. Our aim was to establish the clinical and gonadal spectrum, and early surgical management, of patients with chromosomal mosaicism presenting with genital anomalies.Patients and methods: We performed a retrospective review of patients with 45,X/46,XY or 45,X/47,XYY mosaicism presenting with genital ambiguity between 1988 and 2009. At least one gonadal biopsy or gonadectomy specimen was available for each patient. Gonadal histology was re-evaluated by a paediatric pathologist.Results: Of 31 patients with 45,X/46,XY (n = 28) or 45,X/47,XYY (n = 3) mosaicism and genital anomalies, 19 (61%) were raised male. Histology of 46 gonads was available from patients who had undergone a gonadectomy or gonadal biopsy, at a median age of 9.5 months. 18 gonads were palpable at presentation, including 5 (28%) histologically unremarkable testes, 2 streak gonads, and 1 dysgenetic gonad with distinct areas of testicular and ovarian stroma but no oocytes. All intra-abdominal gonads were found to be dysgenetic testes (of which 2 were noted to have pre-malignant changes) or streaks, apart from 1 histologically unremarkable testis. 15 (48%) patients had other anomalies, most commonly cardiac and renal; 4 (13%) had a Turner phenotype.Conclusion: The anatomy and gonadal histology of 45,X/46,XY and 45,X/47,XYY individuals with genital ambiguity do not conform to a set pattern, and hence management of each patient should be individualized according to detailed anatomical and histological assessment.

Evaluating the quality of Internet health resources in pediatric urology - Corrected Proof

Angela M. Fast, Christopher M. Deibert, Gregory W. Hruby, Kenneth I. Glassberg — 2012-01-27

Abstract: Purpose: Many patients and their parents utilize the Internet for health-related information, but quality is largely uncontrolled and unregulated. The Health on the Net Foundation Code (HONcode) and DISCERN Plus were used to evaluate the pediatric urological search terms ‘circumcision,’ ‘vesicoureteral reflux’ and ‘posterior urethral valves’.Materials and methods: A google.com search was performed to identify the top 20 websites for each term. The HONcode toolbar was utilized to determine whether each website was HONcode accredited and report the overall frequency of accreditation for each term. The DISCERN Plus instrument was used to score each website in accordance with the DISCERN Handbook. High and low scoring criteria were then compared.Results: A total of 60 websites were identified. For the search terms ‘circumcision’, ‘posterior urethral valves’ and ‘vesicoureteral reflux’, 25–30% of the websites were HONcode certified. Out of the maximum score of 80, the average DISCERN Plus score was 60 (SD = 12, range 38–78), 40 (SD = 12, range 22–69) and 45 (SD = 19, range 16–78), respectively. The lowest scoring DISCERN criteria included: ‘Does it describe how the treatment choices affect overall quality of life?’, ‘Does it describe the risks of each treatment?’ and ‘Does it provide details of additional sources of support and information?’ (1.35, 1.83 and 1.95 out of 5, respectively).Conclusions: These findings demonstrate the poor quality of information that patients and their parents may use in decision-making and treatment choices. The two lowest scoring DISCERN Plus criteria involved education on quality of life issues and risks of treatment. Physicians should know how to best use these tools to help guide patients and their parents to websites with valid information.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: Surgical considerations - Corrected Proof

Raimund Stein, Annette Schröder, Joachim W. Thüroff — 2012-01-24

Abstract: In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal. After failure of conservative treatment (clean intermittent catheterisation and pharmacotherapy) urinary diversion should be considered. In this review, the surgical options with their advantages and disadvantages are discussed.In patients with a hyper-reflexive, small-capacity and/or low-compliance bladder with normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. To those who are unable to perform clean intermittent catheterisation via urethra, a continent cutaneous stoma can be offered. In patients with irreparable sphincter defects a continent cutaneous diversion is an option. For patients who are not suitable for a continent diversion (incompliant±chronic renal failure), a colonic conduit for incontinent diversion is preferred.Surgical complications specific to urinary diversion include: ureterointestinal stenosis, stomal stenosis, stone formation, bladder perforation, and shunt infection and obstruction. Surgical revision is required in around one third of patients. Careful lifelong follow-up of these patients is necessary, as some of these complications can occur late.

Fetal Urology - Corrected Proof

C.D. Anthony Herndon — 2012-01-24

In this special fetal section of the Journal of Pediatric Urology, four manuscripts are presented that range from epidemiology, to outcomes analyses to an observational study that addresses the challenges faced with the prenatal detection of rare conditions.

Commentary to ‘Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux’ - Corrected Proof

Jonathan C. Routh — 2012-01-20

Dr Cerwinka and colleagues have presented an interesting case series of 339 children with unilateral VUR undergoing endoscopic injection. During the initial portion of their series, 267 patients underwent ipsilateral injection only; during the latter portion, contralateral ureters were also injected if significant hydrodistention was present (defined by the authors as Grade H2 or H3). In the initial group, 30 patients (11%) developed de novo contralateral VUR (NCVUR) in the previously non-refluxing ureter. In the injected group, no patients developed NCVUR. Based on these results, the authors recommend injection of the contralateral non-refluxing ureter if significant hydrodistention is present.

Long-term incidence of urinary tract infection after ureteral reimplantation for primary vesicoureteral reflux - Corrected Proof

2012-01-19

Abstract: Objective: To determine the incidence of urinary tract infection (UTI) after ureteral reimplantation (UR) for primary vesicoureteral reflux (VUR).Materials and methods: In this retrospective review, the pyelonephritis-free survival of patients with primary VUR who underwent open UR from January 1990 to December 2002 was assessed using a Cox proportional hazards analysis.Results: 1076 patients underwent open UR for primary VUR. 73.0% were female; median age was 4.7 years. 80.1% presented with UTI. Clinical success rate for non-tapered UR was 96.5%. Median follow-up was 2.9 years. 21.8% had at least one postoperative UTI. 6.5% had postoperative pyelonephritis (POP) at a median of 21 months postoperatively. On multivariate survival analysis female gender (OR 9.97, 95% CI 3.07–32.34), preoperative VUR grade ≥3 (2.14, 1.25–3.69), breakthrough preoperative UTI (2.00, 1.22–3.25), and preoperative renal scarring (1.86, 1.15–2.99) were associated with POP.Conclusion: POP is rare on long-term follow-up, suggesting that UR is effective in reducing pyelonephritis in this population.

Delayed onset ureteral obstruction following Deflux® injection for vesicoureteral reflux - Corrected Proof

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.

Urinary incontinence and quality of life in children - Corrected Proof

Betty Ann Thibodeau, Peter Metcalfe, Priscilla Koop, Katherine Moore — 2012-01-11

Abstract: Objective: Urinary incontinence (UI) negatively affects children’s quality of life (QOL). It is not known if parents are reliable informants on impact and QOL nor if lower urinary tract symptoms (LUTS) are related to QOL. We wished to determine the association between LUTS measured by the Dysfunctional Voiding Symptom Score (DVSS) and QOL measured by the Pediatric Urinary Incontinence QOL tool (PIN-Q), and to test the relationship between parent and patient’s responses.Subjects and method: Forty children (10 males, 30 females), aged 5–11 years with non-neurogenic daytime wetting, and their parents completed DVSS and PIN-Q as well as responding to open-ended questions about the effect of incontinence.Results: Child DVSS: mean 12.6 (3 (very mild) to 21 (severe)); parent DVSS: mean 12.8 (3–20). Child PIN-Q: mean 37.6 (8 (no effect) to 70 (severe effect)); parent PIN-Q: mean 38.7 (15–61). Parents indicated a major effect of UI on family function and dynamics, as well as on the child.Conclusions: UI has a major effect on the child and the family. The PIN-Q and DVSS are complementary and provide a clinically appropriate picture of LUTS and impact on QOL. Parents understood the effect of incontinence and could act as proxy for the child.

Distal ureteral diameter measurement objectively predicts vesicoureteral reflux outcome - Corrected Proof

2012-01-11

Abstract: Objective: Vesicoureteral reflux (VUR) grading may be difficult when discrepancies exist between the degree of dilation of the pyelocalyceal system and the ureter. Resolution may be more accurately predicted by the appearance of the distal ureter. We analyzed a novel, objective method of evaluating VUR based on the diameter of the distal ureter.Methods: Seventy-nine voiding cystourethrograms were reviewed (18 boys; 61 girls; aged 1 month to 7.5 years). The largest ureteral diameter within the false pelvis was measured and normalized by dividing by the distance from the L1-L3 vertebral body to give the distal ureteral diameter: L1-L3 ratio (UDR). Clinical outcome was defined as spontaneous resolution or surgical correction.Results: A significant association between grade and UDR existed (p < 0.0001). Mean UDR was significantly greater in those who underwent surgical correction (0.34 ± 0.02 vs 0.18 ± 0.02; p < 0.0001). Logistic regression analysis demonstrated a significant association of UDR with outcome controlling for grade (p = 0.001). Grade effect on outcome when controlling for UDR was not significant (p = 0.76). Odds ratio for surgical correction corresponding to a 0.1 increase in UDR equaled 2.25 (95% CI: 1.39, 3.64).Conclusion: UDR provides an objective measurement of VUR and appears more predictive of clinical outcome than grade in this series.

Polyps in continent catheterizable bladder channels - Corrected Proof

Travis W. Groth, Michael E. Mitchell, Anthony H. Balcom — 2012-01-09

Abstract: Objective: We describe our experience with polyps encountered in bladder continent catheterizable channels.Material and methods: An IRB-approved retrospective study was conducted on all patients at Children's Hospital of Wisconsin with continent catheterizable channels managed by a single physician over a 16-year time period.Results: Fifty-five patients were identified with bladder channels. During a median follow-up of 7 years (range 3–16 years), 20% (11/55) of bladder channels developed polyps. The time to diagnosis of a polyp in bladder channels from initial surgery ranged from 3 months to 8 years (median of 29 months). Fifty-five percent (6/11) of patients who developed bladder polyps were symptomatic. All patients' symptoms resolved after treatment by endoscopic resection. Forty-five percent (5/11) of polyps recurred after resection. The time of recurrence ranged from 4 months to 7 years (median of 19 months). Polyps were universally benign inflammatory granulomatous tissue.Conclusion: This is the first series reporting the incidence of polyps in bladder catheterizable channels. Patients with continent catheterizable bladder channels can develop symptomatic polyps in their channels, of unknown long-term significance and risk.

Native nephrectomy in pediatric transplantation – Less is more! - Corrected Proof

Nia Fraser, P.C. Lyon, A.R. Williams, M.T. Christian, M.U. Shenoy — 2012-01-09

Abstract: Objective: Indications for pre-transplantation native nephrectomy (PTNN) include chronic renal parenchymal infection, proteinuria, intractable hypertension, polycystic kidneys and malignancy. Our aim was to establish the frequency and reasons for PTNN in children undergoing renal transplant at our center.Materials and methods: Children listed for renal transplant between 1998 and 2010 who underwent PTNN were analyzed. Etiology of established renal failure, indication for nephrectomy, stage of chronic kidney disease, laterality, complications, and timing of subsequent transplant were determined. Outcome of children, and that of preserved native kidneys following transplant, was reviewed.Results: 21/203 children listed for transplant (10.3%) underwent PTNN (32 nephrectomies). Indications were drug-resistant proteinuria (6 children), recurrent upper tract urosepsis (6), refractory hypertension (4), malignancy/malignant predisposition (4), concomitant procedure during ureterocystoplasty (1). Median age at nephrectomy was 3.3 years; 86% had impaired renal function at time of (first) nephrectomy. Median time until transplantation following bilateral nephrectomy was 1.7 years. 19/21 children have been transplanted; 17 reached stable graft function. Only 2 children who did not undergo PTNN required nephrectomy post-transplant.Conclusion: When malignancies were excluded, PTNN was performed in a minority (8.4%) of children, mainly for proteinuria. This adds great advantage by reducing morbidity. Resulting graft function seems favorable.

Long-term results of endoscopic treatment of vesicoureteral reflux in children: Comparison of different bulking agents - Corrected Proof

Regina Johanna Franziska Stredele, Hans-Georg Dietz, Maximilian Stehr — 2012-01-04

Abstract: Objective: To determine the long-term effect in children of endoscopic treatment of vesicoureteral reflux (VUR) using different bulking agents. VUR status, recurrence of urinary tract infection (UTI), and recurrence of febrile UTI were evaluated as endpoints.Methods: From 1993 to 2005, we injected 229 refluxive ureters (VUR grade II–IV) in 135 children. Mean age of the children was 55.7 months. We used collagen in 98 (years 1993–2000), polydimethylsiloxane in 32 (years 1999–2000), and dextranomer/hyaluronic acid copolymer (Dx/HA) in 99 ureters (years 2000–2005). Of the 135 children, 127 underwent a voiding cystourethrogram (VCUG) (radiologic or nuclid) 3 months after the first injection, and 88 children a second VCUG (nuclid) after 37 months (mean) postoperatively. Clinically, patients were monitored for non-febrile or febrile UTI. Data were collected and analyzed retrospectively by chart review.Results: After first injection with collagen, polydimethysiloxane and Dx/HA, 52%, 55% and 81.5% of the children were without VUR, respectively. Repeated injections were successful in only 21% (collagen) to 42% (Dx/HA). Of the 88 with a second VCUG, 48.5% of the initially reflux-free children developed relapse VUR after collagen, 45.5% after polydimethylsiloxane and 21.5% after Dx/HA injection. Clinically, there was a significant difference in postoperative UTI occurrence in favor of the Dx/HA group.Conclusions: Clinically and radiologically, Dx/HA exhibited the best results, giving better protection against UTIs and a better VUR cure rate. There was still a risk of VUR recurrence in successfully treated children after 3 years of follow up.

Urinary schistosomiasis in children in the United Kingdom - Corrected Proof

Abid Qazi, Jens Stahlschmidt, Ramnath Subramaniam — 2012-01-03

Abstract: We report on two patients with urinary schistosomiasis, who both presented within a fortnight to our hospital with similar symptoms of persistent painless haematuria. Ultrasound, cystoscopic biopsies and histology were used to confirm diagnosis. Treatment with praziquantel was given. Symptoms of urinary schistosomiasis can easily be missed in non-endemic areas and possibly confused with a more sinister pathology. A thorough history and awareness of disease can avoid interventional investigations.

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

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.

Posterior urethral injuries associated with motorcycle accidents and pelvic trauma in adolescents: Analysis of urethral lesions occurring prior to a bony fracture using a computerized finite-element model - Corrected Proof

2011-12-29

Abstract: Adolescent males involved in motorcycle accidents are particularly at risk for pelvic injury, which may provoke a posterior urethral injury. The aim of this study was to develop a model to analyze the association between injuries and fractures of the pelvic ring and the risk of posterior urethral injury.Method: Based on experience with traffic accident modeling, a computerized finite-element model was extrapolated from a computerized tomography scan of a 15-year-old boy. The anatomic structures concerned in urethral and pelvic ring trauma were isolated, rendered in 3D and given biomechanical properties. The model was verified according to available experiments on pelvic ring trauma.Results: To apply the model, we recreated three impact mechanisms on the pelvic ring: lateral impact, antero-posterior impact and a real car‒motorcycle accident situation (postero-lateral impact).In all three situations, stretching of the posterior urethra was identified prior to bony fracture visualization.Conclusion: Application of this model allowed us to analyze precisely the link between trauma of the pelvic ring and lesions of the posterior urethra. The results should help to establish guidelines for urethral catheterization in male adolescents in cases of pelvic trauma, even when no bony fracture is present, in order to prevent iatrogenic worsening of a misdiagnosed posterior urethral trauma.

A multi-center study of pediatric uroflowmetry data using patterning software - Corrected Proof

2011-12-26

Abstract: Objective: We created software for patterning uroflowmetry (UFM) curves, and validated its utility.Patients and Methods: The software patterns a given UFM curve upon four parameters: sex, voided volume, maximal flow rate, and amplitude of fluctuation. Using the software, 6 urologists from 4 institutes assessed 30 test curves. Further, 329 UFM curves obtained from children presenting to 3 institutes for daytime and/or nighttime wetting were assessed. Clinical presentation was divided into 3 groups: group A, daytime incontinence; group B, non-monosymptomatic nocturnal enuresis without daytime wetting; and group C, monosymptomatic nocturnal enuresis.Results: Using the software, inter-rater agreement ranged from 0.85 to 1.00 (mean, 0.93 ± 0.04). It could pattern 310 out of 329 clinical curves. In each institute, the tower pattern was prevalent according to severity of daytime symptoms, although not significantly. The merged data showed that the percent tower pattern significantly correlated with presence of daytime symptoms (groups A, B, and C, 29.7%, 27.0%, and 16.3%, respectively; p < 0.05). No correlation with daytime symptoms was noted for fluctuated (staccato and interrupted) and plateau patterns.Conclusion: The software creates a common platform for evaluating pediatric UFM, enabling extraction of common and biased features of different cohorts, and their integration into one single cohort.

Decision making among different treatment options for neurologically impaired boys with undescended testis: A multinational pediatric survey - Corrected Proof

2011-12-23

Abstract: Objective: To determine the attitude of referring pediatricians towards the decision of treatment modalities for undescended testis (UDT) in neurologic impaired boys (NIB).Methods and materials: An online questionnaire was offered to registered pediatricians in Austria and Germany for online completion.Results: 221 male (61.6%) and 138 female (38.4%) pediatricians completed the survey; 326 (90.8%) believe that UDT should be treated according to national guidelines; 31 (8.6%) believe that UDT should be treated according to the parental wish, whereas only 2 (0.6%) tend to no treatment at all. Tumor prophylaxis, further sexual life, legal concerns, risks of anesthesia, and the choice of the parents have major impact on the perception of UDT. Moreover, fertility and limited life expectancy seem to be of minor importance only. In general, Pearson χ2 test could not identify age and sex of pediatricians as significant predictor of how the importance of the treatment of UDT is appraised.Conclusion: From the pediatric point of view UDT in NIB is an important issue and should be treated according to guidelines. Nevertheless, this study indicates the problems in decision-making and choosing the best management for UDT in NIB. Undoubtedly, further ethical discussion is needed to optimize treatment of UDT in NIB.

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

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.

Commentary to ‘Prenatal vitamin use and congenital abnormalities of the genitourinary tract in a developing country’ - Corrected Proof

Adam Benjamin Hittelman — 2011-12-19

Fernández et al. have performed a retrospective case-controlled study to address the association of prenatal vitamin use and the incidence of congenital urologic anomalies in a developing country. They have corroborated prior prospective randomized controlled trials, which have demonstrated the protective effect of multivitamin use on the development of congenital anomalies .

Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux - Corrected Proof

2011-12-16

Abstract: Objective: The objective of this study was to evaluate risk factors for new contralateral vesicoureteral reflux (NCVUR) and to investigate whether assessment of the non-refluxing contralateral ureter (NRCU) by hydrodistention and selective treatment can reduce the incidence of NCVUR.Materials and methods: From 2001 to 2007, 339 of 841 patients (40%) were treated for unilateral VUR by endoscopic injection. While in the first 267 patients the NRCU was only assessed by hydrodistention but not injected (observation group), NRCUs of the subsequent 72 patients were prophylactically treated if deemed at high risk for NCVUR (H2 or H3) (prophylaxis group).Results: NCVUR occurred in 30 of 267 patients (11.2%) whose NRCUs were observed. No statistically significant risk factors for NCVUR were found in this group. In the subsequent 72 patients, whose H2 and H3 ureters were selectively injected (N = 56), no cases of NCVUR were seen.Conclusions: Prophylactic endoscopic treatment of NRCU H2 and H3 ureters successfully prevented the occurrence of NCVUR.

Colovaginoplasty using the Yang-Monti modification - Corrected Proof

Duong Tu, Gina Badalato, Elizabeth A. Reiley, Terry W. Hensle — 2011-12-12

Abstract: Objective: Bowel vaginoplasty is particularly difficult in patients who are extremely obese or those with an android pelvis. This report evaluates the use of the Yang-Monti principle as a viable alternative in the reconstruction of these patients.Methods: Upon retrospective chart review of patients who underwent bowel replacement vaginoplasty between 1980 and 2008, 4/60 were identified who underwent the Yang-Monti modification. The neovagina was created with an 8‒10-cm segment of descending colon which was detubularized and then retubularized using the Yang-Monti principle. This was sewn in place in the perineum. Outcome was evaluated by physical examination data and clinical information on postoperative sexual function.Results: Three of the four patients had an XY karyotype and an android pelvis, and of these two were failures of previous ileovaginoplasties and one was a failed colovaginoplasty. The fourth was a case of primary mullerian failure (XX) in a morbidly obese individual. All four were discharged without complication following surgery. With a median follow-up of 6 years (range 4–9), none showed evidence of introital stenosis or required dilation. Two were engaged in vaginal intercourse at last consultation, and they reported vaginal length was adequate. No further procedures were required in any of the patients at the end of the follow-up period.Conclusion: The Yang-Monti modification, when used as an adjunct to colovaginoplasty, can be an effective reconstructive technique in this subset of patients. It allows for lengthening of the neovagina, without perpetuating tension on the vascular pedicle.

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

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.

Long-term bladder function, fertility and sexual function in patients with posterior urethral valves treated in infancy - Corrected Proof

2011-12-09

Abstract: Objective: To address the issue of sexual function and fertility in PUV patients.Patients and methods: Of 47 patients (age > 18 years) treated for PUV in infancy 28 were contactable. They were sent a standard questionnaire requesting details on voiding dysfunction symptoms, and experience of erection, orgasm and ejaculation.Results: Of the 28, 16 (mean age 24 years) returned the questionnaire. Voiding frequency ranged from 3 to 10 times per day (mean = 5). Two patients had occasional mild diurnal incontinence but none had symptoms of overactivity. Three patients had a weak urinary stream. Renal function was normal in 9, 4 had a glomerular filtration rate <80 ml/min/1.73 m2, and 3 had undergone renal transplant. Erections and orgasm were experienced by the 15 patients who responded to these questions, with 4 reporting mild or medium erectile dysfunction and 1, on dialysis, reporting slow ejaculation. Post-masturbation samples of semen and urine were collected from 6 patients. One had an alkaline pH, high percentage of immotile sperm and low sperm count. Another had a high concentration of abnormal forms, and seminal fluid was present in the urine of 3 patients.Conclusions: In long-term follow-up, 44% of PUV patients develop chronic renal failure or end-stage renal disease, but bladder dysfunction symptoms are infrequent. Sexual function is mostly normal. Total semen counts and motility are compatible with paternity in most patients.

Response to Letter to Editor regarding: Abdulhannan P, Stahlschmidt J, Subramaniam R. Multicystic dysplastic kidney disease and hypertension: clinical and pathological correlation. J Pediatr Urol 2011;7: 566–588 - Corrected Proof

Ramnath Subramaniam — 2011-12-05

Re: Letter to the Editor regarding: Abdulhannan P, Stahlschmidt J, Subramaniam R. Multicystic dysplastic kidney disease and hypertension: clinical and pathological correlation. J Pediatr Urol 2011;7: 566–588.

Gabapentin: A novel drug as add-on therapy in cases of refractory overactive bladder in children - Corrected Proof

2011-12-02

Abstract: Objective: To determine the effectiveness of gabapentin as an add-on therapy in children presenting with overactive bladder (OAB) not responding to conventional anticholinergics.Materials and methods: Children with refractory OAB were included prospectively from March 2009 to February 2010. The inclusion criterion was persistence of symptoms while on conventional anticholinergics for 6 months. Gabapentin was prescribed as an add-on therapy. The patients were followed 4 weekly with bladder diary and urodynamic study was repeated at 3 months.Results: There were 31 children, 26 of neurogenic OAB and 5 of non-neurogenic origin. Mean±SD age was 8.5±5.3 years. Data were analyzed in 30 patients as treatment was terminated in 1 due to adverse effects. Continence improved in 16 (53.3%) patients. Voiding volume improved from 175±90 to 320±110ml (p<0.03). Objective assessment of OAB symptom relief showed marked improvement (p<0.05). Mean maximum cystometric bladder capacity improved from 210±94 to 360±110ml (p<0.02). The maximal detrusor contraction decreased from 75±35 to 25±15cmH2O (p<0.02). Fourteen patients (46.7%) failed to respond to gabapentin therapy. These patients had baseline maximum cystometric bladder capacity <60% for age and maximum detrusor contractions >50cm of water (p<0.03).Conclusions: Gabapentin gives moderate results in children with OAB refractory to conventional anticholinergics. In general, the drug is well tolerated with fewer adverse effects.

Dye-assisted lymphatic-sparing laparoscopic varicocelectomy in children - Corrected Proof

2011-12-02

Abstract: Introduction: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques.Materials and methods: Twenty-five consecutive LSLVs were performed on children with a mean age of 15 years over a 4-year period. Varicocele grade was 3 in 21 cases and grade 2 in 4. Indications for intervention were hypotrophy in 12, pain in 11 cases and family preference in 2. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided.Results: Lymphatic sparing was accomplished in all cases. Operative time varied from 30 to 140min (mean 85±26). No perioperative complications were noted. On average follow-up of 13 months a residual varicocele was noted in 2 cases, with no hydrocele and resolution of pain. Mean testicular volume difference diminished from 33% pre to 18% postoperatively.Conclusion: This multi-surgeon experience demonstrates that dye-assisted LSLV is easily accomplished with promising results. It appears that preservation of a single spermatic lymphatic vessel is sufficient, although in some cases a second dye injection is required to visualize the lymphatics.

Renal and urological abnormalities occurring with Mullerian anomalies - Corrected Proof

Margaret A. Hall-Craggs, Alex Kirkham, Sarah M. Creighton — 2011-11-30

Abstract: Objective: To describe the spectrum and frequency of renal and urological abnormalities in a cohort of patients with uterine anomalies.Material and methods: We conducted an ethics committee approved review of 164 women referred to the imaging department from a specialist gynaecological anomaly clinic. Imaging acquired over 8 years was assessed and this was sufficient for assessment of the morphology of the gynaecological and renal tracts in 113 patients.Results: Absent unilateral kidney was the most common abnormality (31.8%), most frequent in Type 3 uterine anomalies. Absent kidneys occurred in other anomaly types at lower frequency.Pelvic ureteric remnants were found in 9 of 36 patients with absent kidneys; these inserted ectopically, most commonly into the vagina. Urological abnormalities were found in 11 patients with two kidneys, including ectopic ureters, scarred kidneys and dysplastic kidney. Obstructed hemivaginas were associated commonly but not invariably with an absent kidney.Conclusion: Previously unreported renal and urological abnormalities have been described in patients with congenital uterine anomalies. These have significant clinical impact. Ectopic ureters can cause incontinence, and potentially cause pain and become infected. Knowledge of the ureteric course, including ureteric remnants, is essential before complex laparoscopic and vaginal surgery.

Bracka’s staged repair of proximal hypospadias - revisiting a versatile technique - Corrected Proof

2011-11-28

Abstract: Objective: Proximal hypospadias is associated with poorly defined urethral plate and often with chordee. A two-staged Bracka’s repair is reproducible and has been used routinely in our practice. We present the key steps of this technique on a 13-month-old boy.Patient and method: This boy presented with proximal penile hypospadias, hooded foreskin and mild chordee. He underwent stage one Bracka’s repair. The steps included: 1) Artificial erection test to define extent of chordee; 2) inner preputial graft harvest and preparation; 3) glans and urethral plate incision down to corpora cavernosa; 4) partial release of chordee by division of aberrant corpus spongiosum, without degloving of penile skin; 5) laying of preputial graft; 6) dressing.Result: The patient had catheter removed on second, and dressing removed on seventh, post-operative days, without complication. The patient is planned for second stage repair in 6 months. Our standard approach includes either removal of catheter on the second or seventh post-operative day, according to surgeon preference. The three senior surgeons have used this method in 54 patients without significant complication. The graft has taken in 100% of cases.Conclusion: The Bracka’s staged repair of proximal hypospadias is a versatile technique that gives reproducible and sound results.

Hydronephrosis following ureteral reimplantation: When is it concerning? - Corrected Proof

2011-11-28

Abstract: Objectives: Hydronephrosis without obstruction is common prior to ureteral reimplant, especially in patients with high-grade VUR. Consequently, when hydronephrosis is present post-operatively, it is unclear when it should be concerning. We evaluated the finding of hydronephrosis in children undergoing reimplantation and its evolution following surgery.Methods: After obtaining IRB approval, we identified 938 children who underwent reimplantation at our institution from 1998 to 2006. Their pre- and post-operative US and clinical course were analyzed.Results: Hydronephrosis was observed in 24% pre-operatively and 21% post-operatively. 52% with pre-operative hydronephrosis had it post-operatively, while 12% without pre-operative hydronephrosis had it post-operatively. 71% of post-operative hydronephrosis resolved on average in 1.36 years. 19% didn’t resolve and 0.1% had ureteral obstruction. Risk factors for post-operative hydronephrosis included increasing severity of VUR, and high degree of pre-operative hydronephrosis.Conclusion: Hydronephrosis following ureteral reimplantation is not rare, and correlated to pre-operative evaluations. Post-operative hydronephrosis is frequently transient and benign, and usually resolves within the first 2 years. These patients do not require follow-up ultrasounds or further imaging, and can be followed clinically. Patients with high-grade VUR and hydronephrosis pre-operatively, however, are at risk for developing worsened hydronephrosis and should be followed with a 3-month post-operative ultrasound.

Impact of urinary tract infection on inpatient healthcare for congenital obstructive uropathy - Corrected Proof

2011-11-28

Abstract: Purpose: Congenital obstructive uropathy (COU) is a leading cause of pediatric chronic kidney disease (CKD). Urinary tract infections (UTIs) pose a risk for ascending infections and CKD in patients with COU. We evaluated the impact of comorbid UTIs on hospital charges and length of stay (LOS) for pediatric COU discharges.Materials and methods: The study sample (n = 2832) was drawn from the 2003 and 2006 US Healthcare Cost and Utilization Project Kids’ Inpatient Database. Data were analyzed using logistic and linear regression.Results: Comorbid UTIs complicated 6.7% of COU discharges, and were most common in patients with posterior urethral valves (15.7% of discharges). Comorbid UTIs increased mean charges by $7910 (95% confidence interval (CI) $4770–$11,040; p < 0.001) and prolonged mean LOS by 2.66 days (95% CI 2.03–3.29; p < 0.001) compared to COU discharges without UTI. After controlling for LOS, charges for COU with a secondary diagnosis of UTI were no longer significantly higher. Mean charges in inflation-adjusted dollars increased by $2710, a 15.8% increase unexplained by covariate diagnoses and procedures.Conclusions: Comorbid UTIs contribute significantly to inpatient charges for COU, by prolonging LOS.

Evolution of the management of acquired neurogenic bladder in children using intradetrusor botulinum toxin type A injections: 5-year experience and perspectives - Corrected Proof

R. Le Nué, L. Harper, M. De Sèze, C. Bouteiller, D. Goossens, E. Dobremez — 2011-11-24

Abstract: Objective: To report the clinical and urodynamic results of repeated intradetrusor botulinum toxin type A injections in children with an acquired neurogenic bladder.Patients and method: We reviewed the data of 8 patients presenting an acquired neurogenic bladder treated between 2005 and 2010. Their mean age was 12.4 years old (range: 5–18). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. They received between 2 and 6 injections at a dose of 12 botulinum toxin units (BU)/kg (maximum 300 BU). Cystometry was performed 4–8 weeks after treatment.Results: Five patients became completely dry, 2 were only rarely wet, and data are lacking for 1 patient. Febrile urinary tract infections ceased after 1 or 2 injections. The mean maximal detrusor pressure decreased below 40 cmH2O after 1, 2 and 3 injections. The normalized safe capacity rose significantly after 1, 2 and 3 injections. The normalized maximal bladder capacity rose similarly after 1, 2 and 3 injections although not always significantly.Conclusion: Intradetrusor botulinum toxin-A injections significantly reduce detrusor pressure and can be repeated with efficacy. They have their place in between anticholinergic treatment and surgery. The procedure could be simplified and the dosage reduced.

Pyocele of the scrotum in the pediatric patient - Corrected Proof

Kate H. Kraft, Sarah M. Lambert, Howard M. Snyder, Douglas A. Canning — 2011-11-23

Abstract: Pyocele of the scrotum has been reported but is not well described in the pediatric population. The majority of published cases have been treated definitively with surgical drainage, and the severity of some cases has led to orchiectomy. We report a cases series of four boys with idiopathic pyocele, two of whom were managed successfully without operative intervention. Of these, one case was likely due to hematogenous spread of infection, and one case was secondary to spread of abdominal contamination via a patent processus vaginalis. To our knowledge, this is the first case series reporting non-surgical management of infant pyocele. Although rare, this clinical entity should be considered in the differential diagnosis of acute scrotum in the pediatric patient.

Bony abnormalities in classic bladder exstrophy: The urologist’s perspective - Corrected Proof

Kristina D. Suson, Paul D. Sponseller, John P. Gearhart — 2011-11-21

Abstract: Introduction: As the primary practitioner managing patients with classic bladder exstrophy (CBE), it is incumbent upon the pediatric urologist to understand the associated orthopedic anomalies and their management.Methods: A Pubmed search was performed with the keyword exstrophy. Resulting literature pertaining to orthopedics and published references were reviewed.Results: Anatomic changes to the bony pelvis include outward rotation, acetabular retroversion with compensatory femoral anteversion, anterior pubic shortening, and pubic diastasis. Imaging options have improved, which impacts surgical planning. Surgical approach, including type of osteotomy and method of pubic approximation, is evolving. Most centers employ immobilization after surgery, with external fixation, Bryant’s traction, Buck’s traction, and spica casting being the most common methods. Orthopedic complications range from minor pin-site infections to neurologic and vascular compromise. Most experts agree osteotomy aids bladder closure beyond 72 h of life, but effect on continence remains controversial. Although no significant orthopedic benefit has been expounded, it may be too early to appreciate improvement in frequency or severity of osteoarthritis or hip dysplasia.Conclusion: While orthopedic surgeons remain vital to managing exstrophy patients, knowledge of the anatomy, imaging, surgical approaches, and immobilization enable effective communication with parents and other physicians, improving care for these complicated patients.

Commentary to ‘The modern staged repair of classic bladder exstrophy: A detailed postoperative management strategy for primary bladder closure’ - Corrected Proof

Joseph Borer — 2011-11-21

The authors provide a comprehensive description of their postoperative management of the patient with bladder exstrophy following initial closure via modern staged repair. There may be limited benefit of epidural catheter for pain management in light of the mean of 3.1 days of ventilation. Granted, a portion of this total ventilator time is a weaning component. However, it would seem that a minority of patients might benefit from the epidural component beyond the sedation and medication necessary for intubation and ventilation.

Re: Abdulhannan P, Stahlschmidt J, Subramaniam R. Multicystic dysplastic kidney disease and hypertension: clinical and pathological correlation. J Pediatr Urol 2011;7: 566–8 - Corrected Proof

P.G. Ransley — 2011-11-21

I read this case report with some interest but also with the greater concern that it may be used uncritically to tip the delicate balance regarding wider surgical intervention for this anomaly. This already rests on an insecure and largely unscientific fulcrum.

High-grade transitional cell carcinoma of the pediatric bladder - Corrected Proof

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.

The modern staged repair of classic bladder exstrophy: A detailed postoperative management strategy for primary bladder closure - Corrected Proof

2011-11-18

Abstract: Purpose: Successful primary bladder closure of classic bladder exstrophy sets the stage for development of adequate bladder capacity and eventual voided continence. The postoperative pathway following primary bladder closure at the authors’ institution is quantitatively and qualitatively detailed.Materials and methods: Sixty-five consecutive newborns (47 male) undergoing primary closure of classic bladder exstrophy were identified and data were extracted relating to immediate postoperative care. Overall success rate was utilized to validate the pathway.Results: Mean age at time of primary closure was 4.6 days and mean hospital stay was 35.8 days. Osteotomy was performed in 19 patients (mean age 8.8 days), and was not required in 39 infants (mean age 2.9 days). All patients were immobilized for 4 weeks. Tunneled epidural analgesia was employed in 61/65 patients. All patients had ureteral catheters and a suprapubic tube, along with a comprehensive antibiotic regimen. Postoperative total parenteral nutrition was commonly administered, and enteral feedings started around day 4.6. Our success rate of primary closure was 95.4%.Conclusions: A detailed and regimented plan for bladder drainage, immobilization, pain control, nutrition, antimicrobial prophylaxis, and adequate healing time is a cornerstone for the postoperative management of the primary closure of bladder exstrophy.

Tamsulosin for the management of distal ureteral stones in children: A prospective randomized study - Corrected Proof

Ibrahim Mokhless, Abdel-Rahman Zahran, Mohamed Youssif, Ahmed Fahmy — 2011-11-18

Abstract: Purpose: Based on efficacy demonstrated in the adult population, tamsulosin was evaluated with regard to facilitating ureteral stone expulsion in children presenting with distal ureteric calculi.Patients and methods: A prospective randomized controlled study involving 61 children with distal ureteric calculi <12 mm was performed. The children were randomly divided into two groups. Group I (study group, n = 33) received tamsulosin and standard analgesia, and Group II (placebo group, n = 28) received standard analgesia and placebo. Patients were offered a closely monitored trial for spontaneous stone passage in the 4-week period prior to definitive therapy. The stone expulsion rate, number and duration of pain episodes, need for analgesia and possible side effects of medications were observed.Results: All patients completed the study and none were excluded due to side effects. No significant differences were found between the groups for age, gender and stone size. Mean patient age was 8.1 ± 6.8 years. There were 25 females and 36 males. The stone-free rate was 87.8% in Group I (29/33), compared with 64.2% (18/28) in Group II. A mean stone expulsion time of 8.2 and 14.5 days was recorded for Group I and II respectively, and this difference was statistically significant (P < 0.001).Conclusions: Medical expulsion therapy for lower ureteric stones is a successful procedure in children. Tamsulosin demonstrated no clinically significant adverse effect, while proving to be a safe and effective treatment option.

Effect of increased intra-abdominal pressure on urinary system development in fetal rabbits - Corrected Proof

İbrahim Karnak, Pergin Atilla, Sevda Müftüoğlu — 2011-11-18

Abstract: Aim: To investigate the effect of increased intra-abdominal pressure (IAP) on the fetal urinary system.Materials and methods: Pregnant rabbits (15-day gestation) were used. Control (n = 5) and experimental (EG, n = 4) groups underwent intraperitoneal catheter placement. The IAP was increased by intraperitoneal air insufflations during the third trimester in the EG. At term, organ weight and organ weight/body weight (BW) ratios were noted, histological examination of the urinary system organs was performed, and the apoptotic indexes were calculated.Results: BW and total renal weight were significantly increased in the EG (38.65 ± 8.34 g vs 49.36 ± 8.81 g, p = 0.008; and 0.406 ± 0.132 g vs 0.531 ± 0.129 g, p = 0.02). Total renal weight/BW ratio did not differ between groups (0.0103 ± 0.001 vs 0.0107 ± 0.001; p = 0.33). Bladder weight and bladder weight/BW ratio was also significantly increased in the EG (0.067 ± 0.014 g vs 0.114 ± 0.026 g, p = 0.00; and 0.00175 ± 0.00026 vs 0.00229 ± 0.00036, p = 0.001). Immature glomeruli and collecting tubules, and a thin and underdeveloped muscular layer in the ureter and bladder were encountered in the EG, and the apoptotic cell index was significantly increased (p < 0.05).Conclusion: Increased IAP has an adverse effect on fetal urinary system development, and may play a role in the pathogenesis of various congenital abnormalities of the urinary system.

Lower urinary tract symptoms after feminizing genitoplasty - Corrected Proof

Riitta Fagerholm, Risto Rintala, Seppo Taskinen — 2011-11-18

Abstract: Objective: To investigate the prevalence of lower urinary tract symptoms (LUTS) in a Finnish cohort of patients who had undergone feminizing genitoplasty in childhood.Patients and methods: Information on LUTS was assessed using the Danish Prostatic Symptom Score questionnaire: 24 out of 45 females (53%) returned the questionnaire; 16 patients with prenatal androgen exposure (congenital adrenal hyperplasia = CAH group) and eight with androgen insensitivity (AIS group).Results: Urge urinary incontinence was reported by 13% of the patients in both the CAH and AIS groups and by 15% of the controls. Stress urinary incontinence was reported by 31% of the patients in the CAH group, 13% of the patients in the AIS group and 22% of the controls. Distressing voiding symptoms were reported by 19% of the patients in the CAH group, 13% of the patients in the AIS group and 28% of the controls, and of these straining and incomplete emptying were the most prevalent.Conclusions: LUTS are as common in female DSD patients with feminizing genitoplasty as they are in controls. Some degree of distressing incontinence occurred in 13%–25% of the young female patients and the controls.

Response to commentary letter: Kalisvaart JF, Scherz HC, Cuda S, Kaye JD, Kirsch AJ. Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux. J Pediatr Urol 2011 Aug 3 [Epub ahead of print] - Corrected Proof

Andrew J. Kirsch, Jonathan F. Kallisvaart — 2011-11-14

First, we agree that a 50% radiologic follow-up rate is not ideal but it is a realistic expectation in patients who are clinically well and are reluctant to undergo an invasive study. Importantly, we did do follow-up with all non-compliant patients and noted a high clinical success rate (93%). Our study is unique since we included initially non-compliant patients in order to determine overall clinical success.

A model of delivering multi-disciplinary care to people with 46 XY DSD - Corrected Proof

2011-11-11

Abstract: In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) . A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team’s interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Commentary to: ‘Intermediate-long term follow-up indicates low risk of recurrence after double HIT endoscopic treatment for primary vesicoureteral reflux (VUR)’ - Corrected Proof

Paul H. Noh — 2011-11-10

The authors are to be commended for their ongoing commitment to reporting their extensive experience with endoscopic treatment of VUR using dextranomer-hyaluronic acid copolymer. They continue to set the standard for outcomes regarding endoscopic treatment. This most recent report demonstrates improved outcomes with a refinement in technique and the potential to obviate an invasive postoperative imaging study. If endoscopic treatment is utilized, the authors’ technique should be emulated and reported as well.

Pediatric chronic orchalgia - Corrected Proof

2011-11-07

Abstract: Introduction: Chronic orchalgia, defined as testicular pain lasting > 3 months and interfering with normal activities, is neglected in the pediatric literature. We describe our experience with the evaluation and treatment of pediatric chronic orchalgia patients.Materials and methods: Charts were screened to identify patients meeting the criteria for chronic orchalgia. Charts were further reviewed to record the history and physical exam, diagnostic tests, treatment and outcomes.Results: 65/982 patients met the criteria for chronic orchalgia. Mean age was 13 and mean duration of pain was 8.6 months. Physical exam findings were normal in 46 patients (70%). 59 patients were managed conservatively with resolution (10/59, 17%) or a single visit (36/59, 61%) in 78%. 13/59 (22%) patients showed either minor improvement or no change in symptoms. 5 non-responding patients were managed by the anesthesia pain service; 4 received epidurals with or without additional oral pain medications with 3 experiencing significant pain improvement.Conclusion: Conservative management of chronic orchalgia allowed symptoms to subside in the majority of cases. We recommend patients be treated with conservative measures for 1–2 months. If this fails, early involvement of the anesthesia pain service can offer treatment modalities such as epidural analgesia. Surgical management in the face of a normal physical exam does not seem to have a role.

Cloacal exstrophy variant with intravesical phallus: Further description of anatomy and implications for gender reassignment - Corrected Proof

2011-11-07

Abstract: Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.

Lymphatic preservation in varicocele in the adolescent: Does prior embolization limit spermatic dissection? - Corrected Proof

2011-11-07

Abstract: Objective: One of the complications after complete section of the spermatic pedicle in the treatment of adolescent idiopathic varicocele is the formation of a scrotal lymphocele. This can be avoided by preserving lymphatic vessels using dye, but there is a risk that dissection may be complicated in patients who have previously undergone embolization. The aim of this study was to determine whether prior embolization limits spermatic dissection.Material and Method: We used lymphography with dye (Patent Blue) prior to surgery in order to mark and preserve the lymph vessels during spermatic section. This was done by laparoscopy with a single umbilical port.Results: We treated six patients aged 12.5–15 years (mean 13.12 years), two of whom had grade 2 varicoceles and four grade 3. Prior percutaneous embolization with metallic coils had been undertaken in all cases but had not been curative. Post-surgery controls were undertaken for a mean duration of 5 months without any lymphoceles appearing. No testicles were lost, nor did any other complication arise.Conclusion: The presence of embolization material in the spermatic veins and perivascular fibrosis does not complicate surgery, enabling the single port laparoscopic technique to be undertaken.

Commentary to ‘Ureteral obstruction following injection of dextranomer/hyaluronic acid copolymer: An infrequent but relevant complication’ - Corrected Proof

Peter Metcalfe — 2011-11-07

Although, this publication suffers from many of the common flaws in a surgical review, it raises several significant concerns regarding the endoscopic treatment of reflux. Although considered to be ‘minimally invasive’, the authors clearly demonstrate that it is not without risk. Their complication rate is very high, which is likely contributed to by their low volume and the complexity of the cases. Furthermore, their complications were significant, as none of the reported patients’ obstructions were amenable to being treated conservatively.

Intermediate to long-term follow-up indicates low risk of recurrence after double HIT endoscopic treatment for primary vesico-ureteral reflux - Corrected Proof

Ilker Akyol — 2011-11-07

Endoscopic treatment for VUR has been increasing in popularity, in parallel with the higher success rates associated with the recent technical modifications to the surgery. The current article aims to further support this method of treatment. However, bearing in mind that only 51% of the patients had radiologic follow-up, the article is not devoid of sampling bias. Furthermore, those who are interested in the technique should be cautioned about the possible downside of the double HIT method, since our own experience resulted in some findings contradictory to the article by Kalisvaart et al. .

Prentiss orchiopexy applied in younger age group - Corrected Proof

2011-11-04

Abstract: Purpose: To evaluate the efficacy and safety of the operative technique for the correction of cryptorchidism described by Prentiss in the 1950s, who conducted measurements on patients over 6 years of age, and on cadaveric specimens. We applied the technique in a younger age group.Material and methods: We prospectively studied the results of 50 orchiopexies in children 8–59 months of age (mean 32.3 months), separated into three age groups: 8–18 (N=14), 19–36 (N=18), and 36–59 (N=18) months. The patients were selected for having their undescended testis in the inguinal canal and not reaching the scrotum after adequate inguinal and retroperitoneal dissection. We eliminated the anatomic angulation of the vas deferens and testicular vessels around the internal inguinal ring and inferior epigastric vessels, in order to improve distal scrotal positioning (Prentiss maneuver). We compared the position of the testis before and after the maneuver. We re-examined the children 1 year postoperatively for testicular position and quality.Results: The average gain in scrotal positioning was 6–20mm (mean 13mm). At follow-up, 36 testes (78%) had retained a low scrotal position, 10 (20%) a middle scrotal position, and 4 (8%) presented in an upper scrotal position.Conclusions: The Prentiss maneuver is both safe and efficient when applied to the younger age group, in order to gain adequate intrascrotal cord length and to place the testis in a more distal scrotal position.