Journal of Pediatric Urology - Articles in Press

Early insertion of trans-scrotal port during laparoscopic orchidopexy: A new concept - Corrected Proof

Ahmed Khairi, Nour El-Kholi, Sameh Shehata — 2010-09-01

Abstract: Laparoscopic orchidopexy has become the routine tool in managing abdominal testes. Many techniques have been used to deliver the dissected testis to the scrotal position; a trans-scrotal port is one of them. We present a technique in which the trans-scrotal port is inserted early on, and used not only for testis delivery but also to aid the testicular dissection. We used the technique for 15 abdominal testes in 13 boys and it was safe, and very helpful in dissecting the vascular pedicle to higher levels in an ergonomically easier plane. In addition, it helped in establishing the tract and eventually guiding the dissected testis to the desired scrotal position (12 low and 3 mid-scrotal).

Response to 10-00179 - Corrected Proof

Christopher S. Cooper — 2010-08-27

All children with low-grade reflux are not created equal. Our study evaluating initial ultrasound findings was an attempt to evaluate whether these findings provided incremental prognostic information relative to the resolution of vesicoureteral reflux. We previously identified 10 variables in our model available at www.urocomp.net , and our approach to personalized risk assessment is based on the concept that multiple clinical factors may provide useful prognostic information even if not an independent predictor on multivariable analysis. Our goal is for this data to be utilized in counseling parents about realistic expectations of reflux resolution, and is not an endorsement for immediate operative treatment.

Metastatic transitional cell carcinoma of the bladder arising in a patient with bladder autoaugmentation - Corrected Proof

2010-08-26

Abstract: We report a case of a metastatic transitional cell carcinoma of the bladder in a 20-year-old patient who had previously undergone resection of posterior urethral valves, clean intermittent catheterization, bladder autoaugmentation, and later renal transplantation. To our knowledge, this is the first report of transitional cell carcinoma following bladder autoaugmentation. We also review the literature on bladder autoaugmentation and transitional cell carcinoma.

Adolescent girls with disorders of sex development: A needs analysis of transitional care - Corrected Proof

Lih-Mei Liao, Erasmo Tacconelli, Dan Wood, Gerard Conway, Sarah M. Creighton — 2010-08-19

Abstract: Objective: To collect information on clinical concerns relating to adolescent girls with disorders of sex development (DSD) during the process of transition from paediatric-to-adult clinical services.Subjects and methods: This was a prospective audit of the clinical indications for referral and on-going clinical needs for all girls aged 12–20 years seen in a specialist DSD clinic over a 6-month period. Clinical needs were classified according to level of urgency using a simple ‘traffic light’ classification: green for low, amber for moderate, and red for high.Results: Fifty girls were seen during the study period and all were referred from paediatric services. Patients may have had one or more indication(s) for referral to the adult clinic and these were: urology/gynaecology (70%), endocrinology (42%) and psychology (14%). The most common indication for on-going clinical input was psychology, with 46% of patients requiring monitoring and intervention. Of the 14 patients (28%) classified red suggesting they had an urgent clinical need, psychology was a major factor in all but one patient.Conclusion: Clinicians working with adolescents with DSD need to develop a co-ordinated programme for transitional care that recognises the importance of psychological input within the multi-disciplinary team.

Editorial comment–Spica casts - Corrected Proof

Paul D. Sponseller, John P. Gearhart — 2010-08-19

The authors of this treatise try to convince us that, in a small series with a significant failure rate, a spica cast is safe and comparable to pelvic immobilization with an external fixation device and modified Buck’s traction. In these reviewers’ extensive experience with both primary and failed exstrophies, we do not find this to be the case at all. By quoting some of the older literature, they try to bring the use of spica casts up to the level of success of external fixation. Much more recent references show that the rate of nerve palsy and of superficial pin-site infection are 2% and 3%, respectively .

A biomechanical, histological and biochemical study in an experimental rabbit hypospadias repair model using scanning acoustic microscopy - Corrected Proof

2010-08-19

Abstract: Objective: To investigate the biomechanical, histological and biochemical properties of rabbit urethra at long-term follow up after hypospadias simulation and acute repair.Materials and methods: Thirty-eight white New Zealand male rabbits underwent experimental creation of a hypospadias-like defect and acute repair (mobilization and advancement, tubularized incised posterior urethral plate (TIP), modified TIP) and sham operation. After 23 weeks all groups + controls underwent biomechanical, histological and biochemical assessments.Results: The mobilization and advancement group showed a higher stiffness compared to the TIP groups (P < 0.05) in the posterior urethra, whereas the TIP group was stiffer compared to the other two operative groups (P < 0.001) in the ventral urethra. In the dorsal urethra, the mobilization and advancement group and the modified TIP group had a higher collagen content compared to shams (P < 0.05). No differences in collagen content were found between groups in the ventral urethra. A correlation between acoustic and histological layers was found, partially related to collagen content.Conclusion: The urethras had different microelastic properties in different layers of the dorsal and ventral urethra, with higher stiffness in the connective tissue layers surrounding and within the urethra. The repaired urethras had partially recovered their elasticity at micrometer resolution at long-term follow up. Scanning acoustic microscopy elucidated structure–function relationships at microscopic level in normal and operated urethra.

Complete androgen insensitivity syndrome: An anatomic evaluation and sexual function questionnaire pilot study - Corrected Proof

2010-08-18

Abstract: Purpose: To further characterize the anatomy and sexual function of women with CAIS compared to normal females, and assess the utility of magnetic resonance imaging (MRI) to distinguish anatomical differences.Materials and methods: In a prospective cohort pilot study, five individuals with androgen insensitivity syndrome and six, normal, nulliparous women underwent an interview, physical examination, questionnaire completion and MRI of the pelvis. Statistical analysis was performed with emphasis on determining significant differences in anatomical findings and sexual satisfaction.Results: MRI demonstrated statistically significant differences in vaginal depth and size that were not confirmed on physical exam. MRI and physical exam demonstrated a non-significant difference in average phallic thickness between the two groups, although the CAIS group clitoral width tended to be smaller. Physical exam demonstrated a higher average erect height and longer arm span in the CAIS patients but this was not statistically significant. No significant differences were noted in categories designed to assess satisfaction with ability to achieve orgasm, vaginal appearance and frequency of sexual intercourse between the two groups.Conclusions: The women with CAIS were as satisfied with sexual function as were the women within the control group. Physical exam and MRI did not find any statistically significant clinically relevant differences between the two groups.

The prognostic impact of an abnormal initial renal ultrasound on early reflux resolution - Corrected Proof

Kenneth G. Nepple, Angela M. Arlen, J. Christopher Austin, Christopher S. Cooper — 2010-08-16

Abstract: Objective: In a group of children diagnosed with vesicoureteral reflux (VUR) we evaluated renal ultrasound findings, associated findings on renal scan, and prognostic impact on VUR resolution.Methods: Medical records were reviewed for children with primary reflux and no history of antenatal hydronephrosis who underwent an initial renal ultrasound. Abnormal renal ultrasound was defined as hydronephrosis or relative difference in renal size ≥1 cm. Reflux resolution was evaluated at 2 years post diagnosis.Results: In 129 children with VUR (111 girls, 18 boys), 39 (30%) had an abnormal renal ultrasound. Two-year VUR resolution in the abnormal renal ultrasound group was 21% versus 46% in the group with normal renal ultrasound (P = 0.01). Combining grade II and III reflux, an abnormal ultrasound was associated with a statistically significantly lower resolution rate (grade II–III 23% vs 47%, P = 0.049). For children with moderate hydronephrosis, 8/9 (89%) had abnormal initial renal scans and all failed to achieve resolution of reflux at 2 years.Conclusions: In this cohort of children with VUR, 30% had abnormalities on renal ultrasound. The presence of moderate hydronephrosis on ultrasound may indicate a high likelihood of abnormality on renal scan and failure to achieve early resolution of VUR.

Evaluation of terminology used to describe disorders of sex development - Corrected Proof

J.H. Davies, E.J. Knight, A. Savage, J. Brown, P.S. Malone — 2010-08-16

Abstract: Objective: The terminology used to describe abnormalities of sex determination and sex differentiation was revised in 2006. It was anticipated that new terms, such as ‘disorders of sex development’ (DSD), would improve communication between health professionals, aid parental understanding and be acceptable to affected individuals. The purpose of this study was to evaluate the success of the new terminology.Subjects and methods: Using a questionnaire, we evaluated the acceptance of these new terms by parents of children with a DSD (n = 19), health professionals (n = 15) and parents of unaffected children (n = 25).Results: Comparing the term ‘DSD’ to ‘intersex’, overall 86.4% of participants preferred the term ‘DSD’, and parents of a child with a DSD had an even higher preference (94.7%). Parents of an affected child considered the new term to improve their understanding of their child’s condition (83.3%), and to aid explanation by parent to affected child (82.4%) and to wider family and friends (84.2%). Health professionals preferred the genotype-based terms, whereas parents considered these terms confusing. Overall, 59.3% of participants agreed DSD was an acceptable new term.Conclusions: There was broad support for the new terminology by parents and health professionals. The description ‘disorder of sex development’ may be helpful to parents at the time when it is not possible to assign gender, after which aetiologically based diagnoses should be used where possible.

Response to commentary JPUROL-D-10-00172 - Corrected Proof

J. Christopher Austin — 2010-08-16

While I cannot be certain, but based on the tone of their comments, the description of our series as a ‘treatise’ may be referring to our work as obsolete or a tale rather than a systematic exposition. I am pleased that Drs Gearhart and Sponseller also refer to the reference by Meldrum et al., since it was published by their institution, and was the motivation for me to review our series. The ‘abysmal’ results (17% success rate) with spica casting were based on the Hopkins’ database of patients, an institution that doesn’t ever use the spica cast for immobilization. Despite that, they felt compelled to push their own agenda by publishing this misleading paper with its flawed methodology and data to conclude that spica casts result in inferior success rates.

Management of recurrent epididymitis in children: Application of neurovascular sparing vas clipping in refractory cases - Corrected Proof

Abdol-Mohammad Kajbafzadeh, Mehdi Shirazi, SeyedSaeid Dianat, Mehrzad Mehdizadeh — 2010-08-02

Abstract: Purpose: To investigate the efficacy of therapeutic methods for recurrent epididymitis and neurovascular sparing vas clipping in refractory cases.Materials and Methods: Fifteen boys with recurrent epididymitis were enrolled: the first group (9) with primary structural anomalies and the second group (6) with voiding dysfunction without structural anomalies. Median age was 4 (29 months to 7 years) and 4.5 (6 months to 11 years) years, respectively. Mean follow up was 7.5 (2–11) and 5.2 (3.5–8) years, respectively.Results: Urethrovasal reflux was detected in all patients of the first group except one. Endoscopic injection of bulking agent was successfully applied in three patients with no recurrent epididymitis. No further episodes of epididymitis were reported after valve ablation or clean intermittent catheterization. In four non-responders, vas clipping was successfully undertaken. Voiding dysfunction was the possible etiology of epididymitis but with no obvious urethrovasal reflux in the second group. No further episodes of epididymitis occurred using bladder retraining and medications for detrusor and sphincter relaxation.Conclusions: The results suggest that neurovascular sparing vas clipping can be used effectively in children with structural anomalies and urethrovasal reflux who have developed intractable epididymitis.

Clinical experience of the VQZ plasty for catheterizable urinary stomas - Corrected Proof

Toshihiko Itesako, Keigo Nara, Futoshi Matsui, Fumi Matsumoto, Kenji Shimada — 2010-07-21

Abstract: Objective: To evaluate the effectiveness of VQZ plasty, we analyzed our experience with continent catheterizable urinary stomas using VQZ plasty and V-flap techniques.Patients and Methods: We retrospectively reviewed the records of 25 patients who underwent Mitrofanoff procedures in 2000–2009. All stomas were created in the lower quadrant. There were 10 patients who underwent VQZ plasty and 15 in whom the V-flap technique was used. The stomal complications of these two groups were compared.Results: Two patients (20%) with VQZ plasty and five (33.3%) with V-flap required surgical revision. Hypertrophic mucosae that excreted mucus and blood periodically were resected in two patients (13.3%) with V-flap. One patient (10%) with VQZ plasty had a surgical site infection. Although the stomal complication rate was lower in patients with VQZ plasty compared to those with V-flap, this difference was not statistically significant (P = 0.4).Conclusions: Our results show a tendency towards decreased stomal complications rates in patients with VQZ plasty, suggesting its superiority over the V-flap technique because of good cosmesis. To successfully construct VQZ stomas, surgeons should work to preserve the blood supply of skin flaps and reduce the subcutaneous dead space, and thus reduce the risk of surgical site infection.

A review of the urologic manifestations of Beckwith–Wiedemann syndrome - Corrected Proof

Charlene A. Wong, Scott Cuda, Andrew Kirsch — 2010-07-20

Abstract: Objective: Beckwith–Wiedemann syndrome (BWS) is a constellation of congenital anomalies that classically presents with macroglossia, abdominal wall defects and gigantism. Although renal and adrenal pathology are the most commonly associated urologic findings of BWS, we report a case of a girl with BWS and symptomatic clitoromegaly, recurrent urinary tract infections and vesicoureteral reflux, followed by a review of the literature regarding urologic manifestations of BWS.Materials and methods: A comprehensive review of the literature for renal and non-renal urologic manifestations of BWS was conducted using a computer-based (PubMed) search. The reported renal and non-renal urologic findings are summarized.Results: In addition to well-described renal manifestations, a variety of non-renal urologic findings have been reported in patients with BWS.Conclusions: Healthcare providers should carefully evaluate both patients and their family members for urologic manifestations of BWS. Early diagnosis and thorough evaluation allows for potential improved management and prognosis of BWS urologic sequelae, including tumors, cryptorchidism and urinary tract abnormalities.

Safety and efficacy of spica casts for immobilization following initial bladder closure in classic bladder exstrophy - Corrected Proof

Angela M. Arlen, Christopher S. Cooper, Jose Morcuende, J. Christopher Austin — 2010-07-20

Abstract: Objectives: Pelvic immobilization constitutes a necessary component of successful bladder exstrophy closure. The efficacy of spica cast immobilization has been reported as markedly inferior to external fixation, with success rates below 25%. We reviewed our experience with spica cast immobilization following bladder closure.Patients and methods: We retrospectively reviewed classic bladder exstrophy patients undergoing bladder closure with spica cast immobilization. Success of bladder closure and complications related to immobilization were noted, as were age, type of closure, use of osteotomy, duration of immobilization, and number of cast changes.Results: Fifteen patients underwent bladder closure (10 staged, 5 complete repair) at a median age of 4 days (range 1–6) and 14 were immobilized with spica casts. Initial closures were successful in 11 (73%). Success rates were higher in patients undergoing osteotomies (6/7, 86%) compared to those without osteotomies (5/8, 63%). No patients immobilized with spica casts developed serious complications related to their immobilization. Minor skin breakdown occurred in 3/14 patients (21%). Median time of immobilization was 39 days (range 22–48).Conclusions: Spica casts are a safe, effective method of postoperative immobilization and are associated with a low risk of cast-related complications.

Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs - Corrected Proof

2010-07-16

Abstract: Purpose: To evaluate the efficacy of fibrin sealant for repair of urethrocutaneous fistula after multiple failed hypospadias and epispadias surgeries.Materials and methods: The study population comprised 11 boys (mean age 12.18 years) with history of hypospadias or epispadias and at least two failed fistula repair operations leading to recurrent urethrocutaneous fistula. During the operation, single-donor fibrin glue, either from the patient (7) or a parent (4), was applied over the suture lines and beneath the skin. A urethral catheter was kept in place for 7–10 days. Follow up ranged from 6 to 24 months (mean 12.63 months).Results: Nine patients had an uneventful postoperative course. In one patient with a large fistula, partial wound dehiscence occurred. In another patient with complete hypospadias, hematoma formation caused skin dehiscence but the urethra remained intact. Both cases recovered after 6 months with no further intervention. No fistula recurrence was reported during follow up.Conclusion: Single-donor fibrin glue could be a useful adjunct to surgical management of patients after multiple failed attempts at hypospadias or epispadias fistula repair. Moreover, this product improves the safety margin regarding the risk of disease transmission.

Hypospadias repair with tubularized incised plate: Does the obstructive flow pattern resolve spontaneously? - Corrected Proof

2010-07-14

Abstract: Objective: The aim of this prospective study was to evaluate whether urinary flow improves with time after tubularized incised plate (TIP) repair.Patients and method: Between 1999 and 2003, primary TIP was performed in 126 boys. In patients old enough (48 boys, mean age at surgery 46 months, range 18–103), uroflowmetry was performed 1 year and 7 (median, range 3–10) years post surgery. Miskolc nomograms were used to compare results from the two follow ups (Qmax in relation to voided volume and age).Results: Eleven boys had symptoms of obstruction resulting in intervention. For the other 37 boys, the mean Qmax was 13.6 ± 5.6 ml/s 1 year postoperatively (mean voided volume 107 ± 43 ml) and 49% had flows below the 5th percentile. Seven years postoperatively the mean Qmax was 19.0 ± 8.1 ml/s (mean voided volume 235 ± 112 ml) and 32% had flows below the 5th percentile. In the group with flows below the 5th percentile at 1 year, all improved and 28% improved to above the 25th percentile. Proximal hypospadias was more often associated with obstructive flow than distal (75%/75% compared to 43%/21% 1/7 years postoperatively).Conclusion: We found spontaneous improvement (P = 0.00022) 7 years after TIP repair, although many boys still had a Qmax in the low normal or obstructive range.

Sexual function in teenagers after multimodal treatment of pelvic rhabdomyosarcoma: A preliminary report - Corrected Proof

2010-07-09

Abstract: Objective: The multimodal approach to treatment of genitourinary rhabdomyosarcoma (RMS) has improved survival rates, but there is now a focus on the effect on quality of life. Our aim was to evaluate erectile function in children with rhabdomyosarcoma (RMS) who underwent chemotherapy, radiotherapy, cystectomy and continent urinary diversion.Material and methods: We evaluated four eligible patients (age > 14 years) from our genitourinary RMS database. In two patients the reservoir was constructed at the same time of the cystectomy and in two after undiversion of an ileal conduit. All patients were treated with chemotherapy and radiation therapy before cystectomy. We used a questionnaire to estimate erectile function in adolescents and young adults. There were four questions, each one to be scored 1–5, assessing capability to masturbate.Results: Mean follow up after cystectomy was 9.75 years. We considered that two patients had erections of good quality (scores 18 and 20) and two of moderate quality (scores 8 and 10). One patient had a good response to sildenafil administration.Conclusion: Our data demonstrate that it is possible to keep erectile function during masturbation in children with RMS who have undergone chemotherapy, radiotherapy, cystectomy and continent urinary diversion.

Laparoscopic nephrectomy of a cross-fused ectopic kidney in a child with hypertension - Corrected Proof

T. Negre, M. Haddad, F. Garaix, C. Fernandez, J.M. Guys, P. de Lagausie — 2010-07-02

Abstract: Objective: We report a case of laparoscopic nephrectomy of a cross-fused ectopic kidney in a 4-year-old girl with renal hypertension and Fanconi anemia.Materials and methods: We performed a transperitoneal laparoscopy. Ectopic kidney resection was done after dissection of the pathological kidney and after clamping vessels, using an ultrasonic device. Hospitalization time was 4 days.Results: At 6 months, blood pressure was normalized and the patient showed an adequate growth curve.Conclusion: The transperitoneal route is very effective when a nephrectomy is necessary. It offers perfect exposure with limited risk of complications.

Tubularized incised plate proximal hypospadias repair: Continued evolution and extended applications - Corrected Proof

Warren Snodgrass, Nicol Bush — 2010-07-02

Abstract: Objective: We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon.Materials: During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra.Results: With mean follow up of 12 months (2–38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6–12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity.Conclusions: Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).

Urinary flow patterns in infants with distal hypospadias - Corrected Proof

L. Henning Olsen, Ingrid Grothe, Yazan F. Rawashdeh, Troels Munch Jørgensen — 2010-07-02

Abstract: Objective: To investigate preoperative urinary flow patterns in hypospadic infants and compare them to those from normal infant boys.Patients and Methods: Twenty-one boys (median age 14.0, range 12.8–21.6 months) referred for distal hypospadias surgery were compared to 19 healthy boys (median age 12.0, 9.2–19.8 months). In both groups a 14-mm transit-time ultrasound flow probe mounted around the base of the penis continuously registered uroflow.Results: Median maximum flow rate (Qmax) was significantly lower in hypospadics (2.4 vs 4.4 ml/s, P < 0.01) while there was no difference in the voided volume per micturition (19.0 vs 21.0 ml, P 0.33). Flow curve pattern analysis revealed plateau-shaped curves in 31% of hypospadics compared to none in normal infant boys. Interestingly, dyscoordinated flow curves (interrupted, staccato, spike–dome) were less common in the hypospadics (36% vs 64%, P < 0.01). Meatal size did not correlate to Qmax (rho = 0.26, P = 0.26).Conclusions: Infants with hypospadias void with a lower Qmax and a lesser degree of dyscoordination as compared to normal infant boys. It can be speculated that decreased urethral compliance may contribute to the lower Qmax and may act as a silencer for dyscoordination.

Nutcracker syndrome with urolithiasis - Corrected Proof

2010-07-02

Abstract: The nutcracker syndrome, caused by compression of the left renal vein between the superior mesenteric artery and the aorta, usually manifests with hematuria, flank pain and proteinuria. We report on a 9-year-old boy who was previously diagnosed with urolithiasis but had significant proteinuria, not explained by this diagnosis. On further investigation by renal Doppler ultrasonography it was found that he had nutcracker syndrome. We would like to emphasize that this syndrome should be considered where there is no obvious cause of proteinuria and hematuria.

Bilateral simultaneous laparoscopic adrenalectomy for congenital adrenal hyperplasia: Initial experience - Corrected Proof

2010-06-28

Abstract: Objective: Congenital adrenal hyperplasia (CAH) is an uncommon syndrome which represents a therapeutic challenge. We analyzed the role of bilateral simultaneous laparoscopic adrenalectomy in the management of CAH.Material and methods:: Between October 2004 and September 2006, three female patients underwent bilateral simultaneous laparoscopic adrenalectomy for CAH. Data were retrospectively collected. Variables analyzed were persistence of CAH clinical signs, variations in 17 OH progesterone level and corticoid medication, operative time, median blood loss, postoperative pain, hospital stay, and body image perception after surgery.Results: Median age was 16.3 years. Complete regression of virilization signs, acne and hyperpigmentation was achieved in one case. The other two cases showed partial regression of signs. Levels of 17 OH progesterone reached normal parameters in all cases. Steroids doses were lowered and given only for replacement purposes. Mean operative time was 125, 65 and 60min for whole, right and left procedure, respectively. Median blood loss remained under 50ml in all cases and there were no complications. Median postoperative pain level was 5 according to visual analog pain scale. Median hospital stay was 4 days.Conclusion: Bilateral simultaneous laparoscopic adrenalectomy shows all the advantages of minimally invasive surgery, and appears a viable alternative to medical management, which is not exempt from complications.

Urethral Ratio on VCUG - Response to the comment by V.S. Chandrasekharam Vemuri - Corrected Proof

Rahul K. Gupta, Sandesh V. Parelkar — 2010-06-25

We read with interest all the comments made on our paper on the use of urethral ratio as a tool to assess the adequacy of valve ablation in PUV. Our response to these comments is as follows:

Desmopressin treatment regimens in monosymptomatic and nonmonosymptomatic enuresis: A review from a clinical perspective - Corrected Proof

2010-06-25

Abstract: Objective: To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME).Materials and methods: PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence.Results: Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm.Conclusion: Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time- or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono- and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.

Randomized comparison of long-term desmopressin and alarm treatment for bedwetting - Corrected Proof

2010-06-25

Abstract: Objective: To compare the efficacy of long-term primary nocturnal enuresis (PNE) treatment using desmopressin versus enuresis alarm.Materials and methods: A 6-month randomized trial was performed with patients from 29 enuresis clinics: 251 patients ≥5 years in age with severe PNE (mean 5.5–5.6 wet nights/week) were randomized to desmopressin (0.2–0.4 mg daily) or alarm. Efficacy was assessed by percentage reduction in mean number of wet nights/week; patients achieving dryness, mean initial duration of sleep and compliance were evaluated. Efficacy analyses were performed using the intent-to-treat population (all patients) and excluding patients who withdrew; 12-month follow-up data were collected.Results: Data could not be evaluated for the 32% of alarm patients and 7% of desmopressin patients who withdrew early. In intent-to-treat analyses, a similar proportion of patients across groups showed a ≥50% reduction in wet nights/week (desmopressin: 37.5%, alarm: 32.2%) and achieved dryness (desmopressin: 32%, alarm: 37%). Compliance was higher with desmopressin: 95–98% of patients took >75% of tablets; 50–78% used alarm >75% of nights. Initial sleep duration was 1.02 h longer at the end of treatment with desmopressin (95% CI: 0.045, 1.99).Conclusion: Desmopressin and alarm demonstrated comparable efficacy in the treatment of PNE. Withdrawal from the alarm group was high, indicating the importance of considering family motivation before selecting treatment, for optimal outcome.

Presence of dextranomer-hyaluronic acid (DxHA) mound on postoperative ultrasound does not predict resolution of vesicoureteral reflux - Corrected Proof

Pamela I. Ellsworth, Jennifer K. Yates, Anthony A. Caldamone — 2010-06-18

Abstract: Objective: Dextranomer–hyaluronic acid (DxHA) injection is an accepted treatment for vesicoureteral reflux (VUR), with success rates as high as 85–90% in selected patients. The DxHA mound can often be seen on postoperative ultrasound. We sought to determine whether the presence or absence of this mound on ultrasound can predict resolution of VUR on voiding cystourethrogram (VCUG).Materials and methods: A retrospective study evaluating patients who underwent cystoscopy and injection of DxHA from 2003 to the present was performed. Demographic variables, laterality and grade of VUR, postoperative ultrasound findings, and presence of VUR on postoperative VCUG were recorded.Results: Fifty-one patients (95 ureters) underwent DxHA injection and had a postoperative ultrasound and VCUG for review. Five patients with persistent voiding dysfunction were excluded, leaving 46 patients and 86 ureters for review. The mean age at time of injection was 5.2 years (range 0.75–11 years) and mean grade of VUR was 2.5 (range 1–5). After DxHA injection, 75% of the ureters showed resolution of VUR, while 25% demonstrated persistent VUR. No correlation was made between the presence of DxHA mound and resolution of VUR on VCUG.Conclusion: In this series, the presence of a DxHA mound on initial postoperative ultrasound does not predict resolution of VUR. A larger prospective study is needed to evaluate additional parameters.

Urotherapy in children: Quantitative measurements of daytime urinary incontinence before and after treatment: According to the new definitions of the International Children’s Continence Society - Corrected Proof

2010-06-14

Abstract: Objective: To assess the effectiveness of urotherapy in children with lower urinary tract dysfunction, according to the new definitions of the International Children’s Continence Society.Material and methods: We performed a retrospective review of 122 children (aged 8.8±2.0 years) treated in an outpatient program for lower urinary tract dysfunction. Exclusion criteria included all neurologic abnormalities. In 98 children (80%) daytime urinary incontinence was a predominant symptom. Therapy consisted of an individually adapted drinking and voiding schedule, pelvic floor relaxation, instructions on toilet behavior, biofeedback uroflowmetry and if necessary recommendations for regulation of defecation. Before and at the end of training, patients were evaluated for number and severity of daytime wet accidents per week, using a scoring system to grade the severity of incontinence. Secondary measurements of accompanying voiding symptoms were performed.Results: Of the 90 children with daytime urinary incontinence for whom sufficient objective data were collected, 42% became completely dry during the daytime and 36% showed a 50% or greater level of response. Secondary measurements showed a significant reduction in daily voiding frequency (mean 7.0±1.3, P<0.0001) and mean post-void residual (P<0.003), and an improvement in flow pattern (P<0.05).Conclusions: Urotherapy is successful for the treatment of daytime urinary incontinence in children. Additional benefit was evident in improvement of accompanying voiding symptoms. A combination of the definitions of the International Children’s Continence Society and a scoring system to grade severity improved the evaluation method. Further research into long-term efficacy will be performed.

Solitary urethrocutaneous fistula managed by the PATIO repair - Corrected Proof

2010-06-14

Abstract: Objective: A novel technique has been described for repairing penile urethrocutaneous fistula: the PATIO (‘preserve the tract and turn it inside out’) repair. We report our experience with this technique in managing solitary urethrocutaneous fistula following primary hypospadias repair.Methods: Children with fistulae underwent the PATIO technique of repair. The inclusion criterion was solitary fistula of <4mm widest diameter.Results: Ten children underwent the procedure. The mean operating time was 22min. In four of these children a healthy vascularized tunica vaginalis flap was interposed between the urethra and skin. No recurrence of fistula was noted.Conclusion: The PATIO repair is simple and easy to perform, with low morbidity, and is reliable in treating solitary urethrocutaneous fistula <4mm in size.

Re: Harry Fisch et al.: Rising hypospadia rates: Disproving a myth. (Journal of Pediatric Urology 2010; 6: 37–39) - Corrected Proof

Siddalingeshwar Neeli, Rajendra Nerli — 2010-06-11

We read with interest the report by Fisch, Hyun and Hensle in the January issue of the Journal of Pediatric Urology . The authors have reviewed the data from the birth registries of New York State, California, Washington, Scotland, and the European registries, and have concluded that the prevalence of hypospadias did not rise significantly during 1982–83 to 2002–05. In addition, based on this data, they have refuted the hypothesis suggesting an increase in the incidence of hypospadias due to the potential effects of ‘endocrine disruptors’ such as phthalates and bisphenol-A on male reproductive health.

Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms - Corrected Proof

2010-06-11

Abstract: Objective: Partial or complete penile loss following bladder exstrophy and/or epispadias repair has been reported in the literature progressively more frequently.Patients and methods: The authors report new cases of penile injury following bladder exstrophy and/or epispadias repair referred to their centers and not previously published. They review the literature on this subject and offer an explanation as to the likely mechanism for the penile injury and recommendations to avoid this complication.Results: Seven new cases of partial or complete penile loss following bladder exstrophy or epispadias repair have been recently referred to the authors’ institutions. Twenty-one patients have previously been reported in the literature. Altogether, 24 cases occurred after bladder exstrophy closure: 23 after complete primary repair of exstrophy (Mitchell repair) and one after first-stage radical soft-tissue mobilization (Kelly repair). Nineteen of 24 patients did not have a pelvic osteotomy at the time of primary closure. Four cases occurred after epispadias repair: two following the second-stage radical soft-tissue mobilization (Kelly repair) and two following penile disassembly epispadias repair (Mitchell repair).Conclusion: Exstrophy closure combined with epispadias repair can be followed by ischemic penile injury, particularly when osteotomy is not performed. Compression of the pudendal vessels after pubic apposition and/or direct injury to the pudendal vessels play an important role in the pathogenesis of this complication.

Laparoscopic orchiopexy for non-palpable testes: outcome of two techniques - Corrected Proof

Essam E. Moursy, Wael Gamal, Mohammad M. Hussein — 2010-06-11

Abstract{AQ1}: Objective: To assess the outcome of laparoscopic orchiopexy and the two-stage Fowler Stephens technique for managing patients with impalpable testis in terms of safety, feasibility and efficacy.Patients and methods: This study included 78 patients who presented with 88 non-palpable testes to the outpatient clinic of Sohag university hospital in 2005–2009, and underwent laparoscopy by the same surgeon. Intra-abdominal testes were managed by laparoscopic orchiopexy if low, two-stage Fowler–Stephens technique if high, and orchiectomy if atrophic. Children were evaluated postoperatively to check the location and size of the testicle and to exclude any other complication.Results: Median age at presentation was 16 months (range 11–42 months). Four testes were absent while inguinal exploration was necessary for six testes with the vas entering the internal ring. Of the 78 intra-abdominal testes, 45 were identified as high (Fowler–Stephens in 43; orchiectomy in two atrophic testes) and 33 as low (orchiopexy). Follow up was 3–55 months (mean 34 months). Twelve patients (12 testes) were lost to follow up (7 Fowler–Stephens; 5 orchiopexy). On follow up, the testes were normal sized and well positioned in the scrotum in 28/28 and 32/36 testes in the orchiopexy and Fowler–Stephens groups with an overall success rate of 100% and 88.8%, respectively. Two testes showed testicular displacement and two showed testicular atrophy in patients of the Fowler–Stephens group.Conclusion: Laparoscopy provides a safe and accurate modality for diagnosing and managing patients with non-palpable testes, with excellent outcomes.

Urethroplasty for failed hypospadias repair: A matched cohort analysis - Corrected Proof

2010-06-07

Abstract: Objective: To determine the outcome of urethroplasty for failed hypospadias repair and to compare this with a matched cohort of patients treated with urethroplasty for other reasons.Patients and methods: Between January 2000 and August 2007, 25 patients with a failed hypospadias repair were treated with urethroplasty (A). This cohort of patients was matched with a cohort of 25 patients who underwent urethroplasty for other reasons (B). The patients were matched for stricture location, stricture length, duration of follow up and type of urethroplasty. The outcomes were analysed and compared. A P-value < 0.05 was considered statistically significant.Results: There were no significant differences between the two cohorts in stricture location, stricture length, follow up and previous interventions. Patients in cohort A however were significantly younger. The surgical technique used was exactly the same in A and B. Failure was observed in 7 patients (28%) in A compared to 4 patients (16%) in B (P = 0.45).Conclusions: Although a higher failure rate was observed after failed hypospadias repair, this is not proof of a worse outcome for urethroplasty after failed hypospadias repair due to the lack of statistical significance.

Ureteropelvic junction obstruction and calyceal diverticulum in a child with Turner syndrome and horseshoe kidney - Corrected Proof

Florian Obermayr, Philipp Szavay, Jürgen Schäfer, Jörg Fuchs — 2010-06-07

Abstract: Laparoscopic dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction is considered to be a routine procedure in many pediatric surgical centers. UPJ obstruction is known to be associated with horseshoe kidney and several reports on successful laparoscopic repair in such cases exist.The case of a 9-month-old girl with Turner syndrome is reported. A horseshoe kidney with grade 4 hydronephrosis on the left side was diagnosed by ultrasound during the neonatal period. MAG3 diuretic renography and dynamic magnetic resonance imaging nephrography revealed a differential renal function of 31% and 69% on the left and right side, respectively. No drainage from the left renal pelvis could be demonstrated.Laparoscopy showed a combined UPJ obstruction and a calyceal diverticulum with a narrow infundibulum of the upper pole calices on the left side of the horseshoe kidney. Laparoscopic dismembered pyeloplasty and an additional infundibulopelvic anastomosis was performed. No intraoperative complications occurred. The immediate postoperative course was uneventful. Unobstructed drainage and stable differential renal function on the left side could be demonstrated on MAG3 diuretic renography 6 weeks postoperatively.In conclusion, laparoscopic repair of complex malformations of the upper urinary tract is feasible and leads to good functional outcome in selected cases.

Does androgen stimulation prior to hypospadias surgery increase the rate of healing complications? – A preliminary report - Corrected Proof

2010-06-07

Abstract: Objective: Androgens have a positive effect on penile growth in children, but they may also have a repressive effect on the healing process. The aim of this prospective study was to compare the outcomes of onlay urethroplasty with and without preoperative androgen stimulation in patients with severe hypospadias.Patients and method: Of 300 severe hypospadias cases treated at a single institution, 126 operated on by the same surgeon had complete follow-up data, and 30 of these received preoperative androgen treatment (human chorionic gonadotrophin and/or systemic testosterone) 1–24 months before surgery.Results: Thirty-five patients presented with a complication (27.7%) of whom 26 (20.6%) had a fistula or dehiscence. Among patients on androgen stimulation there was a 30% healing complication rate (9/30) whereas for those without this was 17.7% (17/96). When androgenic treatment was given > 3 months prior to surgery the healing complication rate was 21.7% (5/23), and when < 3 months prior to surgery the rate reached 57% (4/7). Mean follow up was 41 months (10–97).Conclusion: Although the numbers were too small in this series to reach statistical significance, the tissular interactions of androgens in the healing process reported by dermatologists should alert the hypospadiologists and lead to a further prospective study to define the optimal protocol for stimulation of the penis in specific cases without affecting outcome.

Commentary to “Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms” - Corrected Proof

J.L. Pippi Salle — 2010-06-07

The authors should be commended for this paper, which emphasizes an important yet under-reported pediatric urological issue; namely, penile tissue loss following the surgical treatment of classic bladder exstrophy. They report data from 28 patients who suffered this complication after bladder exstrophy or epispadias repair, and were transferred to their institution, described in the literature or presented in scientific meetings. Understandably some details are missing since the report incorporates cases from other centers, presented at various meetings or collected from limited data provided in the literature. Noticeably, 19 of 20 patients with enough information (as presented in the table) underwent repair in the newborn period and three had the Kelly procedure, which mandates extensive soft-tissue mobilization. The majority of these children did not undergo concurrent pelvic osteotomies, leading the authors to conclude that this is one of the major factors associated with the development of penile tissue loss. Whereas we agree that osteotomies are an important adjuvant procedure to improve wound closure with less tension, other potential factors are equally or perhaps even more relevant. For instance, in cases with large pubic diastasis significant pelvic tension is produced during approximation, generating high pressures in the underlying structures, with or without osteotomies. Additionally, with primary bladder closure and epispadias simultaneous repair (CPRE), extensive penile and pelvic soft-tissue mobilization is carried out. This dissection is likely to induce reflex vasoconstriction and edema, factors that predispose to ischemia, especially when associated with some degree of hypotension. One can imagine the result of such manipulation when performed in the neonate, who is recognized to be more prone to hypothermia and hemodynamic instability. Therefore, it comes with no surprise that the vast majority of patients in this paper were newborns undergoing CPRE. However, there are unquestionable benefits associated with CPRE performed in the neonatal period. Improved bladder capacity and continence have been observed after CPRE and are likely related to the increased urethral resistance generated by the deep pelvic positioning of the proximal urethra during this repair. This has been considered a good reason to perform this extensive repair in the newborn period. However, it carries an increased risk of developing penile tissue loss, as demonstrated in this series. In order to maintain some of the advantages of CPRE we developed an alternative strategy for the primary closure of bladder exstrophy. Aiming to increase urethral resistance, but without concomitant epispadias repair, we have been performing bladder neck tailoring and concurrent bilateral ureteral reimplantations during the primary closure of exstrophy . In this way, urethral resistance and early bladder cycling can be safely achieved, factors that ultimately may be relevant to improving bladder capacity and possibly urinary continence.

The microvessel density of the hypospadiac prepuce in children - Corrected Proof

Mustafa Çaǧrı Savaş, Nilgün Kapucuoǧlu, Kevser Gürsoy, Şirin Başpinar — 2010-06-04

Summary: Objective: The blood supply of the hypospadiac prepuce is crucial for success in surgery. Although the vascular anatomy of the hypospadiac prepuce has been previously documented, data on microvessel density are missing. It was aimed to document the microvessel density of the normal and hypospadiac prepuce.Methods: After ethical approval of the study, prepuces from 24 children with hypospadias undergoing surgical repair and from 9 healthy age-matched controls were stained by immunohistochemical methods using panendothelial cell antigen CD31 in order to assay their microvessel density.Results: The microvessel density was significantly decreased in hypospadiac children when compared to controls (P<0.05). A gradual decrease in microvessel density was observed as the severity of the condition increased, indicating a significant negative correlation (r=−0.585; P<0.05).Conclusion: Our findings should be taken into account when considering preoperative treatments such as topical testosterone application or operative strategies for hypospadias using prepucial flaps, and also during the postoperative course, especially when it is complicated. Further studies are needed to clarify the role of vascularity in the pathogenesis of hypospadias and its consequences for surgical repair.

Corrected Proof

Terry W. Hensle — 2010-06-02

We appreciate the comments concerning our manuscript, Rising hypospadias rates: disproving a myth (J Pediatr Urol 2010;6:37–39). We agree that uniformity, among population study groups, would provide more consistent data. However, the data set analyzed for our study is more than 20 years in length and represents one of the longest databases available. This data accrued over a long study period would appear to be more robust than data collected over a 2-year period by Peirik et al. (A high hypospadias rate in the Netherlands. Hum Reprod 2002;17:1112–1115).

How should we classify intersex disorders? - Corrected Proof

Ieuan Hughes — 2010-06-02

It is a tall order to expect 50 experts on a subject in medicine to reach unanimity when tasked with devising an alternative nomenclature and classification system for a set of conditions that manifest as intersex at birth or at puberty with somatic sex characteristics discordant with sex assignment. Yet, that was attempted in 2005 and realized as what has now become known as the Chicago Consensus on management of intersex disorders . The task was approached using the strategy of consensus decision making, which involves reaching general agreement or an accord amongst a group of individuals. While it is acknowledged that some participants may express divergent views, they are nevertheless willing to accede to the ethos that the sum of the parts is more important than the individual components. This enables a concordat to be reached for which the group as a whole is responsible. When such a consensus document reaches the public domain, it is inevitable that experts in the subject area will exercise their right to dissent over certain elements. Such debate is to be welcomed, for which an opportunity has arisen in this issue of the Journal based on the paper by the Aaronsons .

The predictive value of a repeat micturating cystourethrogram for remnant leaflets after primary endoscopic ablation of posterior urethral valves - Corrected Proof

2010-06-01

Abstract: Objective: We routinely perform a cystourethroscopy 3 months after initial ablation of posterior urethral valves. The aim of this study was to determine the predictive value of the urethral appearance on preoperative micturating cystourethrogram (MCUG) for further valve resection at check cystoscopy.Patients and methods: We retrospectively reviewed 31 consecutive boys (aged 4–18 months) who underwent check cystoscopy and repeat MCUG between 2006 and 2008.Results: Repeat MCUG suggested remnant valves in 10, but no residual leaflets were identified cystoscopically in 4. In 20 boys, the valves appeared completely ablated on MCUG but valve leaflets received further resection in 10. One study was undiagnostic. Residual valves were resected in 83% (5/6) where valves and urethral dilatation were noted on MCUG. Where MCUG suggested either valves or persistent dilatation alone, further resection occurred in 40% (4/10). Remnant leaflets were also present in half of those (7/14) in whom the repeat MCUG had shown complete ablation and resolved/reduced posterior urethral dilatation.Conclusions: The positive predictive value of valve leaflets and/or posterior urethral dilatation on repeat MCUG for subsequent resection of valve remnants was 56%; the negative predictive value was 50%. We found repeat MCUG alone imprecise in excluding residual valve tissue and recommend check cystoscopy in all.

Comment on “Urethral ratio on voiding cystourethrogram: A comparative method to assess the success of posterior urethral valve ablation” - Corrected Proof

VVS Chandrasekharam — 2010-06-01

We read with interest the paper on the use of urethral ratio as a tool to assess the adequacy of valve ablation in PUV . The authors compared the urethral ratios of children with PUV pre- and post-fulguration, as well as urethral ratios in the control group. They concluded that a post-fulguration urethral ratio of 3 or less indicated adequate fulguration. We offer the following comments:

Surgical antibiotic practices among pediatric urologists in the United States - Corrected Proof

Michael H. Hsieh, Patience Wildenfels, Edmond T. Gonzales — 2010-06-01

Abstract: Purpose: We hypothesized that there are practice variations in the use of surgical antibiotics by pediatric urologists in the United States.Materials and methods: A 31-question online survey was distributed to members of the Society of Pediatric Urology. The questionnaire examined physician preferences for surgical antibiotic use, including indications, antibiotic selection, timing of administration, and duration.Results: 189 pediatric urologists responded to the survey. >85% of responders give antibiotics before open pyeloplasty, after hypospadias repair (when a urethral catheter is left in place), or perioperative or postoperative antibiotics for open neoureterocystostomy or bladder reconstructive surgery. >90% of responders do not give postoperative antibiotics to children who have undergone circumcisions, simple chordee repairs, herniorrhapies, or hydrocelectomies. For all other open, laparoscopic, and endoscopic operations, use of antibiotics varied significantly. Diverse opinions exist regarding antibiotic use, including the importance of costs, potential adverse reactions, reduction in infection risk, and antibiotic resistance. There are major differences in gentamicin dosing and timing of administration of perioperative antibiotics.Conclusions: Perioperative and postoperative antibiotics are widely used by pediatric urologists. However, there is significant practice variation in surgical antibiotic administration with regards to most areas of pediatric urology, in particular laparoscopic, endoscopic and hypospadias surgery.

How should we classify intersex disorders? - Corrected Proof

Ian A. Aaronson, Alistair J. Aaronson — 2010-05-24

Abstract: The term disorders of sex development (DSD) has achieved widespread acceptance as replacement for the term intersex, but how to classify these conditions remains problematic. The LWPES-ESPE (Lawson Wilkins Pediatric Endocrine Society and European Society of Paediatric Endocrinology) Consensus Group proposed using the karyotype as a basis for classification; however, this is but a crude reflection of the genetic makeup, is diagnostically non-specific, and is not in itself relevant to subsequent clinical developments. The historical classification of intersex disorders based on gonadal histology is currently out of favor, being tainted by association with the terms hermaphroditism and pseudohermaphroditism. We believe this is regrettable, for the histology of the gonad remains fundamental to the understanding of normal and aberrant sexual development by medical students and residents in training, as well as being a major determinant of clinical outcome for the patient.We propose a comprehensive classification of those DSD conditions generally regarded as belonging under the heading of intersex, based on gonadal histology. Biopsy will not be required when the diagnosis is clearly established biochemically or by gene studies as the histology can be confidently predicted. It will only be required when an ovotestis or dysgenetic gonad is suspected in order to determine the definitive diagnosis.

The utilization of stents in the management of primary obstructive megaureters requiring intervention before 1 year of age - Corrected Proof

Marie-Klaire Farrugia, Henrik A. Steinbrecher, Padraig S. Malone — 2010-05-24

Abstract: Objective: To analyse the long-term outcome of 16 infants with primary obstructive megaureter managed by (endoscopic or open) stenting over a 10-year period.Methods: A retrospective case-note and imaging review was performed between 1997 and 2007. Data are presented as medians (range) and were compared using the Mann–Whitney test.Results: Sixteen infants with19 obstructed megaureters were stented at a median age of 24 weeks, for a median of 6 months. One-third of stents were inserted endoscopically. Complications (stent migration, stone formation or infection) occurred in 31.6%. One infant was excluded due to a co-existent pelviureteric junction obstruction. Drainage improved in 10 ureters (56%) following stent removal. Of the remaining renal units, 6 were reimplanted, and 2 underwent a nephrectomy due to deterioration in renal function following stent removal. Resolution of the vesicoureteric junction obstruction occurred in 4 of 6 infants following endoscopic stent insertion, and in 6 of 12 infants following open stent insertion (P=0.60). There was no difference in the length of time that ureters were stented in the resolved (7.5 (6–15) months) versus the reimplanted (6.0 (1–18) months) group (P=0.13).Conclusions: Of obstructive megaureters managed by stenting for a median of 6 months, 56% did not require further surgery. However, morbidity occurred in one third of patients, and function deteriorated after removal of stent in two patients who later required a nephrectomy.

A comparative study between continent diversion and bladder neck closure versus continent diversion and bladder neck reconstruction in children - Corrected Proof

Bart De Troyer, Erik Van Laecke, Luitzen A. Groen, Karel Everaert, Piet Hoebeke — 2010-05-20

Abstract: Objective: To assess the long-term outcome of continent diversion in children with structural or neurogenic cause of incontinence, with special interest in differences between closed and open bladder neck procedures.Patients and methods: A cohort of 63 children with intractable incontinence treated with continent diversion between January 1998 and January 2008 were reviewed for underlying disease, type of surgery, complications and outcome.Results: Forty patients had a continent diversion with open bladder neck (group 1) and 23 patients had their bladder neck closed (group 2: 11 primarily closed; 12 secondarily closed). There was no difference between the two groups in terms of patient characteristics, surgical re-interventions and stone formation. The continence rate however was significantly better in group 2 (95.6% vs 77.5%).Conclusion: Bladder neck closure with continent diversion as primary or salvage procedure in children with intractable incontinence does not result in extra morbidity and has a high success rate. Thorough urodynamic evaluation of bladder function is the key to success in therapy planning for these children, to minimize the need for re-intervention.

Non-invasive vesicoureteral reflux imaging - Corrected Proof

Brent W. Snow, Michael B. Taylor — 2010-05-20

Abstract: Objective: To evaluate non-invasive and non-ionizing methods of determining the presence of vesicoureteral reflux (VUR) and to preview upcoming ideas that have the potential of finding VUR non-invasively.Materials and methods: We performed a PubMed search using the terms ‘vesicoureteral reflux/radiography’, ‘vesicoureteral reflux/ultrasonography’ and ‘magnetic resonance imaging/urologic disease’. We also included information from a recent American Academy of Pediatrics meeting and our own research.Results: Voiding ultrasonography is non-radiating and has undergone significant improvements recently. Best results require instillation of contrast through invasive catheter placement, and doubts regarding sensitivity and specificity are significant. Magnetic resonance cystograms are best with catheter-instilled contrast. They are expensive, require anesthesia or sedation, and are impractical. Horizon technologies include magnetic resonance cystogram with gadolinium ‘activation’ within the bladder. Another promising completely non-invasive method includes warming the bladder with microwaves and measuring kidney temperatures before and after warming. Detection of a rise in kidney temperatures would indicate VUR.Conclusions: Voiding cystourethrography remains the gold standard in reflux diagnosis but is invasive and submits the child to ionizing radiation. Developing technologies need improvements and further research before they may have a role in significantly decreasing voiding cystourethrography use or replacing it completely.

Laparoscopic adrenalectomy for adrenal masses in children - Corrected Proof

2010-05-20

Abstract: Objective: The laparoscopic approach to the adrenal gland was first reported in 1992. Since then numerous studies have been published, comprising of adults. Experience with the laparoscopic technique for adrenal disease in children and adolescents has been limited. We have reviewed our experience with laparoscopic adrenal surgery in children.Patients and methods: All children with pathologic adrenal masses undergoing laparoscopic adrenal surgery were included. The primary study outcome measures included operative time, conversion to open surgery, complications, duration of hospital stay and outcome of surgery.Results: Eighteen children underwent laparoscopic adrenalectomy during the period January 2003–July 2009. The mean operating time was 95min, mean blood loss was 30ml and the average postoperative hospital stay was 50h. There were no conversions to open surgery and no major intra- or postoperative complications noted.Conclusions: Laparoscopic adrenalectomy is a safe and feasible procedure with good results. It can be used to safely treat suspected benign and malignant adrenal masses in children with minimal morbidity and a shorter hospital stay.

Total urogenital sinus mobilization in common cloaca: Experience of 25 cases - Corrected Proof

B.K. Lahoti, G. Aggarwal, B. Satsangi, R.K. Mathur — 2010-05-14

Abstract: Objective: Common cloaca is a complex anorectal and genitourinary malformation in which the rectum, vagina and urinary tract are fused to form a single channel. Surgical treatment is complicated especially when the channel is long. Our aim was to emphasize the importance of joint mobilization of the urogenital sinus after separation from the rectum. This maneuver avoids separation of the urinary tract from the genital tract, and reduces operating time by more than 60%. The functional and cosmetic results are also excellent.Patients and methods: We retrospectively reviewed all consecutive cases of persistent cloaca managed by total urogenital mobilization via a posterior sagittal approach during 2005–2009. There were 25 patients, with a median age of 18 months (10 months–3 years). Two patients with a long common channel required additional maneuvers after mobilization to complete the reconstruction. Each patient had a primary covering colostomy. After distal loop colograms, genitograms, renal ultrasound and genitoscopy, patients were planned for definitive surgery at 1–3 years of age.Conclusion: Total urogenital sinus mobilization in cases of common cloaca represents a surgical advance, and is a promising procedure with reasonably good results for this complex anomaly.

Management of recurrent urethral strictures after hypospadias repair: Is there a role for repeat dilation or endoscopic incision? - Corrected Proof

Patricio C. Gargollo, Amanda W. Cai, Joseph G. Borer, Alan B. Retik — 2010-05-12

Abstract: Objective: Urethral strictures are among the most common complications after hypospadias repair. We report our 10-year experience with endoscopic incision or dilation of urethral strictures after hypospadias repair, to determine the best management technique.Methods: All cases of urethral strictures after hypospadias repair treated with direct vision internal urethrotomy (DVIU), dilation or urethroplasty at our institution from 1997 to 2007 were included. Records were reviewed and clinical parameters analyzed. Data were statistically analyzed to identify risk factors for stricture recurrence after initial or subsequent treatment(s).Results: Of 2273 patients, 73 were treated for a postoperative urethral stricture and 15 others were referred for stricture treatment. Of these 88 patients, 39 were treated with initial dilation or DVIU and 49 underwent urethroplasty or reoperative hypospadias repair. Fifteen (38%) of the patients treated with initial DVIU or dilation showed no recurrence. Of the patients that did have a recurrence, a repeat DVIU or dilation had a success rate of 17% with no difference in success between these two groups. Choice of therapy between repeat dilation/DVIU and urethroplasty at the second procedure showed a statistically significant higher success rate in the urethroplasty group (67% vs 17%, P=0.03).Conclusion: Although numbers are small, our data suggest that if there is recurrent stricture after initial DVIU/dilation then a formal urethroplasty has a significantly higher success rate than repeat DVIU/dilation.

The challenge of maintaining dialysis lines in the under twos - Corrected Proof

Anu Paul, Nia Fraser, Sengamalai Manoharan, Alun R. Williams, Manoj U. Shenoy — 2010-04-16

Abstract: Introduction: Hemodialysis (HD) and peritoneal dialysis (PD) are essential adjuncts in the management of children with established renal failure (ERF), but complications are common, particularly in the younger age groups. We reviewed catheter life and catheter-related complications in children who began chronic dialysis before the age of 2 years.Method: From the case notes of the children, born between 1990 and 2008, the data gathered included etiology of ERF, age at first dialysis catheter, complications, catheter life, and number of PD and HD.Results: Ninety lines were inserted (40 PD and 50 HD) in 22 children with ERF. Eleven children were aged <6 months when commencing dialysis, six of whom were neonates. PD, the preferred modality, was offered to all but two children. Four children were managed with PD alone. One child died of overwhelming sepsis secondary to PD peritonitis. Average catheter life for HD was 3 months and PD 9.1 months. Luminal blockage and infection were the commonest reasons for change of HD catheters. Peritonitis was the commonest factor leading to PD removal.Conclusions: Children younger than 2 years can be dialyzed successfully by HD or PD but complications are frequent, leading to >2 catheters in the majority. Chronic dialysis in the very young is achievable and useful, but a high incidence of catheter changes must be anticipated.

Comparison between imipramine and imipramine combined with pseudoephedrine in 5–12-year-old children with uncomplicated enuresis: A double-blind clinical trial - Corrected Proof

Mehdi Abedin Zadeh, Mohammad Kazem Moslemi, Golrasteh Kholaseh Zadeh — 2010-04-16

Abstract: Objective: Monosymptomatic nocturnal enuresis is a common entity, with a prevalence of 10% at the age of 7 years. For its primary treatment, we compared the effect of combination medical therapy (imipramine with pseudoephedrine) with imipramine alone.Materials and methods: In this one-center prospective double-blind clinical trial, 100 school-age children (age range 5–12 years) were enrolled. They were divided into two groups, comparable in terms of age and other demographic factors: (A) adjusted doses of a combination of imipramine with pseudoephedrine, and (B) imipramine with placebo were administered. Improvement was defined as less than 2 wet nights per week.Results: Four weeks after drug withdrawal, the response rate was 74% in group A in comparison to 52% in group B, this difference being statistically significant. There was a recurrence of enuresis in both groups during the 4 weeks after treatment was discontinued (10% increase in group A and 8% increase in group B).Conclusion: The additive pharmacologic effects of imipramine with pseudoephedrine for the treatment of monosymptomatic nocturnal enuresis in children were well tolerated, and gave significantly faster results than single drug therapy using imipramine. The moderate-to-high recurrence rate following discontinuation of medical treatment indicates the need for a longer term study involving more cases.