Friday, October 5, 2012

What's New in Pediatric Urology


INFECTIONS

The presence of even a single episode of epididymitis in children has been considered an indication for evaluation to detect a renal or ureteral anomaly as its etiology. A study from Paris challenges this assumption with data from evaluation of 38 children seen over an 8-year period (Cappele et al., 2000.) They found that only 18% of evaluated children had renal anomalies such as reflux or renal malrotation, and only one child required surgery (for ureterocele.) The frequency of anomalies was lower than expected.

BLADDER ANOMALIES

A prospective placebo-controlled study of ultrasound therapy to the bladder was applied to 35 patients with primary nocturnal enuresis. Delivery of 0.8 W/cm2 was applied to the bladder 8 minutes a day for 10 days. Overall, 82% of children benefited from treatment and responses persisted for 12 months after therapy. There were no responses in placebo-treated controls (Kosar et al., 2000.) Further information on this treatment is needed in a larger trial. The role of bladder dysfunction in failure after renal transplantation was evaluated in a study from Paris in 66 boys with posterior urethral valves (Salomon et al., 2000.) In boys with symptomatic voiding dysfunction, mean serum creatinine increased after five years of followup. Closer followup of boys with symptomatic voiding problems after transplantation is warranted. A consensus survey of the Society for Fetal Urology members was reported on management of antenatally detected urological abnormalities. Only rare conditions were recommended for intervention. These may include oligohydramnios with suspected favorable renal function and the absence of life-threatening congenital anomalies. The presence of normal amniotic fluid was a contraindication to intervention regardless of the detected abnormality. However, early delivery of fetuses with severe genitourinary abnormalities, normal amniotic fluid and confirmed lung maturity is more commonly advocated now (Hernodon et al., 2000.) The group from Hopkins reported on long term outcome of epispadias repair in 93 males with epispadias alone or classic bladder exstrophy. A downward or horizontally-directed penis was obtained for 93% of boys. Early fistulas occurred for 23% of patients with 19% at 3 months. Urethral stricture occurred for 7 boys. These results were considered to be functionally and cosmetically excellent (Surer et al., 2000.) The voiding pattern of healthy preterm neonates was shown to involve a high frequency of interrupted voiding, suggesting the presence of immature detrusor-sphincter coordination. A high number of voids during sleep also indicated a more immature pattern than that seen in full term newborns (Sillen et al., 2000.) The group from Children's Hospital in Boston reported on 25 newborns with normal neurourological evaluation after surgical repair of myelodysplasia. Subsequent neurourological deterioration occurred for 32% of infants secondary to spinal cord tethering, especially during the first 6 years of life. Close followup and intervention of these children was recommended (Tarcan et al., 2001.)

REFLUX

A survey of American Association of Pediatrics, Section on Urology members on standard management of vesicoureteral reflux (Herndon et al., 2001.) Urine culture is routinely performed by 64-71% of respondents and yearly VCUG or radionuclide scan for followup by 99% of respondents with ultrasound by 77%. After reflux surgery, 91% of respondents perform VCUG and ultrasound. The overwhelming majority of practitioners agree on the timing and type of radiographic studies to be used to follow children with reflux. A low incidence (2%) of renal scars in children after ureteral reimplantation was noted in a prospective study from Australia (Webster et al., 2000.) These findings suggest that surgical correction of reflux may protect kidneys better than previously believed.

TESTICULAR CONDITIONS

Men who had previously undergone prepubertal orchiopexy were studied with ultrasound as adults. Of 22 men, tunica albugineal calcification was seen in 32%, consistent with reaction from suture or persistence of a chromic suture, which is typically not absorbed in the region of the tunics. A subtunical hypoechoic area was seen in 14% of patients and only 54% had normal ultrasound studies (Ward et al., 2000.) Cystic testicular lesions are rare but may have multiple possible etiologies. Management with partial orchiectomy and frozen section histologic analysis is the recommended management, but a complete overview is available in this reference (Garrett et al., 2000.) Comparison of boys pretreated with hCG or GnRH prior to orchiopexy versus those who received no pretreatment was provided in a study from Denmark (Cortes et al., 2000.) They found a higher number of spermatogonia per tubule in the untreated patients, suggesting a possible detrimental effect of prior hormonal therapy. The use of orchidometer for assessment of testicular volume was provided in a study from Boston Children's (Diamond et al., 2000.) They found a strong linear relationship between orchidometer and ultrasound measurements, but they felt that orchidometer was not sufficiently accurate to determine growth impairment with sequential evaluations. Yearly ultrasound assessment was recommended for sequential analysis of relative testicular volume. A study from CHOP showed that in 723 patients, germ cell counts correlated with testicular volume. However, prediction of the cut point of <0.2 or >0.2 germ cells per tubule was not possible based on testicular volume measurements alone (Noh et al., 2000.)

TUMORS

The management of synchronous bilateral Wilms tumor was reported from CHOP (Cooper et al., 2000.) Preoperative chemotherapy followed by nephron-sparing surgery was recommended. Brachytherapy was recommended for treating local disease involving chemoresistant tumors. Those patients with diffuse anaplasia are not recommended to have nephron sparing surgery.

HYPOSPADIAS REPAIR

The complication rate of flaps and grafts for repair of proximal hypospadias was reported in a retrospective review of 142 patients from San Diego (Powell et al., 2000.) A higher complication rate occurred after free tubed grafts. Two-thirds of complications presented more than 1 year after surgery. Use of the dorsal inlay graft for 32 patients with coronal to penoscrotal hypospadias after chordee release was reported from Baylor (Kolon & Gonzales, 2000.) Glanuloplasty and in situ tubularization of the urethral plate was reported by Kass from Michigan for distal and midshaft hypospadias repair in 308 patients. They reported excellent overall cosmetic results with a complication rate of 9.7%, most of which occurred in mid shaft lesions (Kass & Chung, 2000.)

RECONSTRUCTION

The use of urinary diversion or stenting after dismembered pyeloplasty was evaluated by Austin et al.(2000) in a review of 137 pyeloplasties. They found that drainage with nephrostomy tube alone resulted in few complications and an open anastomosis in 100% of cases. Use of gastrocystoplasty for bladder reconstruction was reported by Leonard from Winnipeg in a series of 23 patients in a tertiary pediatric urology practice. They found that stomach may be used for augmentation in patients with cloacal exstrophy and/or metabolic acidosis. Histamine blockers and proton pump inhibitors are commonly required for hematuria-dysuria. The symptoms of this syndrome was disabling and resulted in another form of urinary reconstruction for 3 patients (Leonard et al., 2000.) The group from Hopkins reported decreased linear growth in 82% of exstrophy patients managed with intestinal bladder augmentation, compared to 33% of controls. Close followup of patients for subtle evidence of metabolic alterations was recommended (Gros et al., 2000)

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