The Journal of Urology - Articles in Press

Dr. Bernard Churchill - Corrected Proof

Antoine E. Khoury — 2010-08-26

In 1999 Dr. Bob Jeffs was the first Canadian to receive the American Academy of Pediatrics Medal for pediatric urology. Doctor Churchill succeeded Doctor Jeffs as the second chief of pediatric urology at the Hospital for Sick Children in Toronto when Dr. Jeffs moved to Baltimore. Thus, it is indeed fitting that 10 years later Dr. Bernard Churchill is the second Canadian to receive this prestigious medal.

Re: Validation of the Partin Nomogram for Prostate Cancer in a National Sample: J. B. Yu, D. V. Makarov, R. Sharma, R. E. Peschel, A. W. Partin and C. P. GrossJ Urol 2010; 183: 105–111 - Corrected Proof

2010-08-23

In this study the final pathological findings of the removed specimen and lymph nodes were correlated with the Partin nomograms. Lymph node involvement was observed to be highly correlated with the estimates of risk of lymph node involvement derived from the Partin nomograms (AUC for positive lymph node 0.78). Additionally, lymph node involvement was much more common among patients older than 61 years (AUC 0.80 vs 0.74). Therefore, the authors concluded that the Partin nomograms can predict seminal vesicle and lymph node involvement more accurately than extracapsular extension or organ confined disease.

Re: Overactive Bladder Medication Adherence When Medication is Free to Patients: C. L. Sears, C. Lewis, K. Noel, T. S. Albright and J. R. FischerJ Urol 2010; 183: 1077–1081 - Corrected Proof

Cuneyd Ozkurkcugil, Levend Ozkan — 2010-08-23

Patient compliance with antimuscarinic agents in overactive bladder (OAB) treatment is a hot topic in the literature. Side effects and patient treatment expectations seem to be major factors for discontinuing OAB medication. However, there is currently a paucity of data on the reasons for poor adherence. This study gives additional information on this argument with larger sample sizes. According to the authors, in a health care system where patients do not pay for medications most compliance measures were the same or greater compared to a co-pay setting. However, patient treatment expectations may change depending on age, which is an important factor for nonadherence. Besides side effects, polypharmacy in older patients is another factor in discontinuing antimuscarinics. Benner et al showed that only 17% of respondents in a screening survey who discontinued their OAB medication indicated that the cost of medication or amount of co-pay was a contributing factor. In light of the literature and personal experience the reason for nonadherence to antimuscarinics is related to treatment expectations and population age more than other factors such as amount of co-pay and drug selection.

Re: Can Advance Transobturator Sling Suspension Cure Male Urinary Postoperative Stress Incontinence? E. B. Cornel, H. W. Elzevier and H. PutterJ Urol 2010; 183: 1459–1463 - Corrected Proof

Peter Rehder — 2010-08-23

The authors studied 36 patients receiving an AdVance™ male sling system at 2 different centers. They conclude that this procedure is not indicated at this time and further clinical research in a large multicenter trial is warranted. A few questions remain.

Re: Comparative Effectiveness of Prostate Cancer Surgical Treatments: A Population Based Analysis of Postoperative Outcomes: W. T. Lowrance, E. B. Elkin, L. M. Jacks, D. S. Yee, T. L. Jang, V. P. Laudone, B. D. Guillonneau, P. T. Scardino and J. A. EasthamJ Urol 2010; 183: 1366–1372 - Corrected Proof

William A. See — 2010-08-23

Embedded within the data in this article lies a disturbing statistic. Using the population based SEER (Surveillance, Epidemiology and End Results) cancer registry data linked to Medicare claims, the authors found that 29% of men undergoing either open or laparoscopic radical prostatectomy (RP) manifested bladder neck/urethral obstruction within 365 days after the procedure. Although the risk of this complication was inversely related to surgical experience, the overall incidence was quite remarkable.

Re: Decreased Sperm DNA Fragmentation After Surgical Varicocelectomy is Associated With Increased Pregnancy Rate: M. Smit, J. C. Romijn, M. W. Wildhagen, J. L. Veldhoven, R. F. Weber and G. R. Dohle J Urol 2010; 183: 270–274 - Corrected Proof

Rima Dada, Sundararajan Venkatesh, Kishlay Kumar, Monis B. Shamsi — 2010-08-23

Varicocele is the most common surgically reversible cause of infertility. Its etiology is multifactorial but recent studies have documented that oxidative stress and DNA damage are the major factors that lead to decreased semen quality in varicocele. Varicocelectomy helps improve the chances of conception in these patients. Smit et al highlight a significant finding that varicocelectomy results in decreased DNA fragmentation index, which improved spontaneous and assisted conceptions. However, this study could have been even more significant if patients were followed for a longer period than 3 months (as duration of spermatogenic cycle is about 64 days).

Re: Risk Factors for Breakthrough Infection in Children With Primary Vesicoureteral Reflux: K. Shiraishi, K. Yoshino, M. Watanabe, H. Matsuyama and S. TanikazeJ Urol 2010; 183: 1527–1531 - Corrected Proof

Gregory E. Tasian — 2010-08-23

Shiraishi et al report that children with vesicoureteral reflux and an abnormal dimercapto-succinic acid (DMSA) scan after initial urinary tract infection (UTI) were more likely to experience breakthrough infections on antibiotic prophylaxis. An odds ratio of 11.08 with a significant p value of less than 0.0001 is given. However, the 95% CI for this point estimate is listed as 0.76 to 1.72.

Re: Should Patients With Primary Upper Urinary Tract Cancer Receive Prophylactic Intravesical Chemotherapy After Nephroureterectomy? W. J. Wu, H. L. Ke, Y. H. Yang, C. C. Li, Y. H. Chou and C. H. HuangJ Urol 2010; 183: 56–61 - Corrected Proof

Pascal Mouracade — 2010-08-23

This is a prognostic and retrospective study comparing 3 groups of patients, those who received intravesical prophylactic epirubicin after nephroureterectomy, those who received intravesical mitomycin C and those who did not receive adjuvant intravesical therapy. The authors concluded that patients who received adjuvant mitomycin C or epirubicin were at decreased risk for recurrence and had a longer interval until the first recurrence. However, this conclusion is not justified by the results of the study.

Laparoscopy/New Technology - Corrected Proof

Jeffrey Cadeddu — 2010-08-23

B. M. Benway, S. B. Bhayani, C. G. Rogers, J. R. Porter, N. M. Buffi, R. S. Figenshau and A. Mottrie Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri

Geriatrics - Corrected Proof

Tomas L. Griebling — 2010-08-23

T. Y. Chen, D. J. Anderson, T. Chopra, Y. Choi, K. E. Schmader and K. S. Kaye Detroit Medical Center, Wayne State University, Detroit, Michigan

Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors - Corrected Proof

Fray F. Marshall — 2010-08-23

T. E. Hutson, I. D. Davis, J. P. Machiels, P. L. De Souza, S. Rottey, B. F. Hong, R. J. Epstein, K. L. Baker, L. McCann, T. Crofts, L. Pandite and R. A. Figlin Baylor-Sammons/Texas Oncology Physician's Association, Dallas, Texas

Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology - Corrected Proof

James E. Montie — 2010-08-23

S. F. Shariat, M. Milowsky and M. J. Droller Division of Urology, Sidney Kimmel Center for Prostate and Urologic Cancer, Memorial Sloan-Kettering Cancer Center, New York, New York

Urological Oncology: Testis Cancer - Corrected Proof

Jerome P. RichieM.D. — 2010-08-23

C. Kollmannsberger, S. Daneshmand, A. So, K. N. Chi, N. Murray, C. Moore, B. Hayes-Lattin and C. Nichols Division of Medical Oncology, British Columbia Cancer Agency–Vancouver Cancer Centre, Vancouver, British Columbia, Canada

Imaging - Corrected Proof

Cary Siegel — 2010-08-23

D. H. Jin, G. R. Lamberton, D. R. Broome, H. P. Saaty, S. Bhattacharya, T. U. Lindler and D. D. Baldwin Department of Urology, Loma Linda University School of Medicine, Loma Linda, California

Corrected Proof

2010-08-23

We appreciate the interest and thoughtful insights of Ozcan et al. They correctly note that only 8.6% of our cohort of selected patients from 2004 to 2005 in the National Cancer Institute SEER (Surveillance, Epidemiology and End Results) database had a PSA of 2.6 to 4.0 ng/ml. They also state that most physicians will recommend a biopsy for patients with a PSA of 2.6 ng/ml or greater. As they indicate, there are better pathological outcomes and a lower risk of PSA failure in patients who undergo surgery for prostate cancer detected when PSA is 2.6 to 4.0 ng/ml vs 4.1 to 6.0 ng/ml. Therefore, there may be a reduction of advanced pathology in patients with a higher proportion of prostate cancers removed for a PSA of 2.6 to 4.0 ng/ml. However, having a small proportion of patients in our cohort with a PSA of 2.6 to 4.0 ng/ml reflects current United States (US) practice. For example the American Cancer Society continues to use the traditional PSA level of 4.0 ng/ml to recommend biopsy for men with average risk. Also, until recently the American Urological Association recommended biopsy in patients with a PSA of 4.0 ng/ml or greater. Currently the association does not have a threshold for biopsy but recommends that the decision to proceed to prostate biopsy should be individualized to each patient (although still based primarily on PSA and digital rectal examination). Therefore, our most recent practice experience has been that biopsy for a PSA of 2.6 to 4.0 ng/ml is more often recommended for younger men, and the selection of patients for such a biopsy is based on a discussion with the patient and a recognition of the possibility of detecting disease that may not cause appreciable morbidity for many years. Indeed, the SEER database during the years investigated evaluated more than 26% of the US population, and so is relatively representative of practice patterns within the US as a whole.

Corrected Proof

2010-08-23

We thank Dada et al for their interest in our article, in which we reported a significant decrease in sperm DNA fragmentation following varicocelectomy in 49 infertile patients with a palpable varicocele and oligospermia. In our pilot study followup was limited to 1 postoperative semen sample at 3 months. Because a 6-month postoperative semen sample was available in only 28 patients, results from the second postoperative semen sample were not included in the study. In this unpublished data set we observed a durable decrease in sperm DNA damage. This finding is in agreement with the improvement in sperm DNA integrity 6 months after varicocelectomy described by Dada et al, as well as a recent report by Zini et al, which showed sperm DNA damage improvement at 4 months and sustained nonsignificant improvement at 6 months after varicocelectomy in 19 patients.

Corrected Proof

2010-08-23

The following odds ratios and confidence intervals should have been included in the article—for table 2 OR 11.08, 95% CI 7.6 to 17.2, and for table 3 OR 2.03, 95% CI 1.1 to 16.7; OR 8.31, 95% CI 5.2 to 17.1; and OR 21.46, 95% CI 6.5 to 30.2. We apologize for the oversight. Our conclusion that an abnormal renal scan is an independent risk factor for breakthrough infection is correct, and there should be no hesitation in applying these data to clinical practice.

Corrected Proof

2010-08-23

When comparing any postoperative complication rates huge variations are seen across series according to how the complication is defined, and depending on the intensity and duration of clinical followup. As a result, it is important to understand how we defined the bladder neck/urethral obstruction complication in our analysis. A total of 79 unique billing codes were included in our definition of bladder neck/urethral obstruction. These codes ranged from “slow urinary stream” to “revision of bladder neck,” ensuring that we cast a broad net and captured all claims relating to obstructive problems after RP. Importantly our definition included procedure and diagnostic codes. In most other reports bladder neck contractures are defined as those necessitating a procedure, either catheter placement or transurethral resection. Our followup was the 365 days immediately after RP.

Computer Enhanced Visual Learning Method to Train Urology Residents in Pediatric Orchiopexy Provided a Consistent Learning Experience in a Multi-Institutional Trial - Corrected Proof

2010-08-20

Purpose: Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial.Materials and Methods: We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution.Results: The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant).Conclusions: The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

Factors Associated With Delayed Treatment of Acute Testicular Torsion—Do Demographics or Interhospital Transfer Matter? - Corrected Proof

2010-08-20

Purpose: Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition.Materials and Methods: We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability.Results: We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy.Conclusions: Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.

Sonourethrogram to Manage Adolescent Anterior Urethral Stricture - Corrected Proof

Edward M. Gong, Claudia Martinez Rios Arellano, Jeanne S. Chow, Richard S. Lee — 2010-08-20

Purpose: Accurate measurement of anterior urethral stricture length is critical to determine the appropriate surgical approach. Retrograde urethrogram is often used to determine stricture location and length. However, the adult literature shows that retrograde urethrogram may underestimate stricture length. We investigated the role of sonographic urethrogram in the preoperative evaluation of adolescent urethral stricture disease.Materials and Methods: Between June 2008 and February 2009 we retrospectively evaluated 12 pediatric patients with urethral stricture disease using retrograde and sonographic urethrogram. Stricture length was categorized by 2 radiologists as I—less than 1, II—1 to 3 and III—greater than 3 cm. On sonographic urethrogram stricture length was measured as the longest extent of the urethral abnormality.Results: Mean patient age was 16.9 years (range 9.5 to 20.8). Retrograde urethrogram classified 7 cases as category I, 4 as category II and none as category III stricture, and 1 with no evidence of stricture. Sonographic urethrogram revealed strictures greater than 1 cm in all 7 category I cases and 2 of the 4 category II cases had strictures longer than 3 cm. One patient in whom retrograde urethrogram showed a category II stricture was stricture-free on sonographic urethrogram. One patient with a negative retrograde urethrogram had a stricture on sonographic urethrogram. Sonographic urethrogram upgraded stricture length in 10 of the 12 patients and outperformed retrograde urethrogram in 11.Conclusions: Sonographic urethrogram is effective for evaluating adolescent urethral stricture disease. It may provide more accurate measurement of stricture length and improve preoperative planning.

Validity of the International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms: A Screening Questionnaire for Children - Corrected Proof

2010-08-20

Purpose: Lower urinary tract symptoms are common in pediatric patients. To our knowledge no validated instruments properly designed to screen lower urinary tract symptoms in the pediatric population have been published to date. In the International Consultation on Incontinence Questionnaire Committee the psychometric properties of a screening questionnaire for pediatric lower urinary tract symptoms were assessed.Materials and Methods: The 12-item International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms was developed in child and parent self-administered versions, and produced in English, Italian and German using a standard cross-cultural adaptation process. The questionnaire was self-administered to children 5 to 18 years old and their parents presenting for lower urinary tract symptoms (cases) or to pediatric/urological clinics for other reasons (controls). A case report form included history, urinalysis, bladder diary, flowmetry/post-void residual urine volume and clinician judgment on whether each child did or did not have lower urinary tract symptoms. Questionnaire psychometric properties were evaluated and data were stratified into 3 age groups, including 5 to 9, 10 to 13 and 14 to 18 years.Results: A total of 345 questionnaires were completed, of which 147 were negative and 198 were positive for lower urinary tract symptoms. A mean of 1.67% and 2.10% of items were missing in the child and parent versions, respectively. Reliability (Cronbach's α) was unacceptable in only the 5 to 9-year-old group. The high ICC of 0.847 suggested fair child/parent equivalence. Sensitivity and specificity were 89% and 76% in the child version, and 91% and 73.5% in the parent version, respectively.Conclusions: The questionnaire is an acceptable, reliable tool with high sensitivity and specificity to screen for lower urinary tract symptoms in pediatric practice. Problems related to literacy suggest use of the child versions for patients older than 9 years. In research this questionnaire could be used to recalibrate the prevalence of lower urinary tract symptoms in children.

Residency Training in Neonatal Circumcision: A Pilot Study and Needs Assessment - Corrected Proof

2010-08-20

Purpose: Routine neonatal circumcision is one of the most commonly performed procedures in a neonate. Residents are expected to acquire the skills to properly evaluate the neonate and gain proficiency in performing circumcision despite significant variability in training. We performed a needs assessment to evaluate obstetric-gynecology residency training in neonatal circumcision.Materials and Methods: We performed an online self-assessment survey of obstetric-gynecology residents at Prentice Hospital, Chicago, from November 2008 to February 2009. Using images of uncircumcised penises residents were asked to identify which patients were candidates for routine neonatal circumcision.Results: Of 36 obstetric-gynecology residents 27 responded to the survey. Most respondents planned to perform neonatal circumcision when in practice, 44% had no formal training in circumcision and most were comfortable performing routine neonatal circumcision. Overall respondents were less comfortable evaluating whether the a newborn penis could undergo circumcision safely. When presented with 10 pictures of penises and asked to determine whether the neonate should undergo circumcision, 0% of respondents correctly identified all contraindications to neonatal circumcision with an average of 42% of contraindications identified correctly. Of the respondents 77% listed practical experience as the first choice to learn a procedure with an online module preferred by 55% as the second choice.Conclusions: Although most residents feel competent to technically perform the procedure, they are not confident in their ability to judge the appropriate contraindications to neonatal circumcision. This needs assessment highlights the necessity for further curriculum development and formalized training in this domain.

Sexuality and Psychosocial Functioning in Young Women After Colovaginoplasty - Corrected Proof

2010-08-20

Purpose: We examined sexuality and psychosocial functioning in patients with Mayer-Rokitansky-Kuster-Hauser syndrome who underwent colovaginoplasty.Materials and Methods: Patients who underwent colovaginoplasty for Mayer-Rokitansky-Kuster-Hauser syndrome in Italy and Bangladesh were required to meet certain criteria, including age greater than 18 years, college degree/high socioeconomic status, procedure done by the same surgical team and a minimum 6-year followup. Outcomes were evaluated by a retrospective chart review and an English version of the female sexual function index. Psychosocial functioning was measured by an English version of a 36-item survey, including the Rosenberg Self-Esteem Scale, Beck Depression Index and Cohen Test for Life Management ability with results compared to those in 30 healthy control subjects.Results: Of 40 patients who answered the female sexual function index 37% were married and 12% had adopted children while 40% were sexually active, 100% were attracted to males and 7% were on self-dilation. None required pads and 80% used a home douche. Of the patients 92% reported sexual desire and 87% reported sexual arousal. Sexual confidence and satisfaction were reported by approximately 90% of the patients and partner satisfaction was considered adequate by 93%. Most patients reported satisfactory orgasm. Of the women 89% reported adequate lubrication and none reported dyspareunia. Psychosocial functioning was not statistically different between patients and controls.Conclusions: Based on the scoring system outcome colovaginoplasty seems to be an excellent choice to manage vaginal agenesis and ensure good quality of general and sexual life.

Morphology of Mouse External Genitalia: Implications for a Role of Estrogen in Sexual Dimorphism of the Mouse Genital Tubercle - Corrected Proof

2010-08-20

Purpose: We examined the role of androgens and estrogens in mammalian sexual differentiation by morphological characterization of adult wt and mutant mouse external genitalia. We tested the hypothesis that external genitalia development depends on androgen and estrogen action.Materials and Methods: We studied serial sections of the external genitalia of the CD-1 and C57BL6 wt strains of adult mice (Charles River Laboratories, Wilmington, Massachusetts). We recorded linear measurements of key structures in each specimen, including the urethra, erectile tissue, bone and cartilage. We used similar methodology to analyze mice mutant for estrogen receptor α (αERKO) and androgen receptor (XTfm/Y) (Jackson Laboratory, Bar Harbor, Maine).Results: Morphology in XTfm/Y adult murine external genitalia was remarkably similar to that in wt females. Bone and clitoral length was similar in wt females and XTfm/Y mice. Conversely the αERKO clitoris was 59% longer and bone length in αERKO females was many-fold longer than that in female wt mice or XTfm/Y mutants. The αERKO clitoris contained cartilage, which is typical of the wt penis but never observed in the wt clitoris. Serum testosterone was not increased in female αERKO mice 10 days postnatally when sex differentiation occurs, suggesting that masculinization of the αERKO clitoris is not a function of androgen.Conclusions: Masculinization of the αERKO clitoris suggests a role for estrogen in the development of female external genitalia. We propose that normal external genital development requires androgen and estrogen action.

Improved Continence in Patients With Neurogenic Sphincteric Incompetence With Combination Tubularized Posterior Urethroplasty and Fascial Wrap: The Lengthening, Narrowing and Tightening Procedure - Corrected Proof

Bernard M. Churchill, Jonathan Bergman, Blaine Kristo, John L. Gore — 2010-08-20

Purpose: We evaluated the outcome in 19 patients who underwent bladder neck reconstruction by lengthening, narrowing and tightening the bladder neck with a combined tubularized posterior urethroplasty and circumferential fascial wrap.Materials and Methods: We reviewed the records of all patients who underwent bladder neck lengthening, narrowing and tightening between April 1996 and November 2002. Preoperative urodynamic and radiographic data were available on all patients. The surgical technique involved retroperitoneal exposure of the bladder neck with a tubularized posterior urethroplasty over a urethral catheter. The reconstructed urethra was then circumferentially wrapped with a fitted piece of cadaveric fascia.Results: Of the 19 patients 15 remain completely continent at a mean ± SD followup of 35.5 ± 29.1 months. Three patients underwent secondary reconstruction, including bladder neck ligation in all 3 and secondary enterocystoplasty in 2. No patient experienced difficult intermittent catheterization via the urethra postoperatively.Conclusions: Bladder neck lengthening, narrowing and tightening is effective for managing neurogenic sphincteric incontinence. Outcomes are comparable with those of other reconstructive procedures.

Sutureless and Scalpel-Free Circumcision—More Rapid, Less Expensive and Better? - Corrected Proof

2010-08-20

Purpose: We previously reported our success with sutureless circumcision using 2-octyl cyanoacrylate in 267 patients. We have since modified our technique by making incisions with electrocautery. We report our results with this novel technique. We also performed a cost analysis.Materials and Methods: We compiled data on all patients 6 months to 12 years old who underwent primary circumcision and circumcision revision in a 39-month period, as done by 3 surgeons. Study exclusion criteria were complexity beyond phimosis and Gomco clamp use. The technique included 1) a circumferential inner incision using electrocautery on cutting current, 2) a circumferential outer incision using electrocautery, 3) foreskin removal, 4) hemostasis with electrocautery, 5) skin edge approximation with 2-octyl cyanoacrylate or 6-zero suture and 6) antibiotic ointment application. We also determined the cost of all procedures based on anesthesia and operating room facility fees, and material costs.Results: Between July 1, 2006 and October 1, 2009 we performed 493 primary circumcisions and 248 revisions using 2-octyl cyanoacrylate, and 152 primary circumcisions and 115 revisions using 6-zero sutures. Mean operative time for primary circumcision and revision using 2-octyl cyanoacrylate was 8 minutes (range 6 to 18), and for sutured primary circumcision and revision it was 27 minutes (range 18 to 48). At a mean 18-month followup (range 1 to 39) 3 patients treated with 2-octyl cyanoacrylate and 2 treated with sutures were rehospitalized for bleeding. When done with electrocautery, the cost of the 2-octyl cyanoacrylate technique was $743.55 less than the sutured technique as long as the 2-octyl cyanoacrylate procedures required less than 15 minutes and the sutured procedures required more than 15 minutes.Conclusions: Combined electrocautery and 2-octyl cyanoacrylate for circumcision is a safe, efficient, financially beneficial, cosmetically appealing alternative to traditional circumcision done with scalpel and sutures.

Progression of Renal Insufficiency in Children and Adolescents With Neuropathic Bladder is Not Accelerated by Lower Urinary Tract Reconstruction - Corrected Proof

2010-08-20

Purpose: Children with chronic renal insufficiency and neuropathic bladder resistant to medical management may require lower urinary tract reconstruction before renal transplantation. A low pressure urinary reservoir optimizes the chance of graft survival and may slow native kidney death. We evaluated whether the renal deterioration rate is affected by augmentation cystoplasty.Materials and Methods: We performed a retrospective cohort study in children who presented to our institution with chronic renal insufficiency and neuropathic bladders from 2005 to 2009. Chronic renal insufficiency was defined as a glomerular filtration rate of less than 60 ml per minute. As a surrogate for renal function change, we used the inverse creatinine trend with respect to time to determine the progression rate of renal insufficiency before and after augmentation.Results: A total of 11 patients with a mean glomerular filtration rate of 34 ml per minute per 1.73 m2, mean bladder capacity 168 ml and mean compliance 3.5 ml/cm H2O met study inclusion criteria. Bladder augmentation or replacement was done at a mean age of 9.7 years with a resultant mean capacity of 486 ml and compliance of 14.7 ml/cm H2O. Mean followup was 4 years before and 1.9 years after augmentation. There was no statistically significant difference between the preoperative and postoperative slopes of inverse creatinine in 8 of 11 patients (73%). Two of the 3 patients (18%) with different preoperative and postoperative slopes had improving renal function after surgery. There was no statistically significant difference in slopes across all patients.Conclusions: In our series bladder augmentation did not appear to hasten progression to end stage renal disease in patients with severe chronic renal insufficiency and neuropathic bladder.

Cross-Sectional Evaluation of Parental Decision Making Factors for Vesicoureteral Reflux Management in Children - Corrected Proof

2010-08-20

Purpose: Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux.Materials and Methods: We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Children's Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery.Results: Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important.Conclusions: Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

Neuro-Orthopedic Manifestations of the Omphalocele Exstrophy Imperforate Anus Spinal Defects Complex - Corrected Proof

2010-08-20

Purpose: The omphalocele-exstrophy-imperforate anus-spinal defects complex is a severe multisystem congenital defect. To comprehensively care for these patients one must appreciate the neurological and orthopedic impact on the overall health of the child.Materials and Methods: We retrospectively reviewed the medical records of 73 children with omphalocele-exstrophy-imperforate anus-spinal defects who were treated at our institution, identifying neurological and orthopedic anomalies, ambulatory ability and voiding status.Results: No neurological data were available on 5 patients. Of the remaining 68 patients 9 had no spinal anomaly, 57 had spina bifida, 1 had hemivertebrae and 1 had coccygeal hypoplasia. We further classified the 47 spina bifida cases as spina bifida occulta in 6, meningocele/lipomeningocele in 12, myelomeningocele/lipomyelomeningocele in 24 and sacral agenesis in 6. Of the patients with spina bifida 35 had cord tethering. Commonly identified orthopedic anomalies were vertebral malformation in 59 patients, scoliosis in 25, clubfoot in 14 and limb length discrepancy in 8. Ambulatory status in 62 patients of walking age revealed that 37 ambulated fully, 15 ambulated with devices, 2 ambulated minimally with devices and 8 were wheelchair bound. Continence data were available on 61 closed cases. Of these patients 26 were incontinent, including 3 with conduit diversion, 1 with ureterostomy and 1 with vesicostomy. A total of 35 patients were socially continent, of whom 30 catheterized via a continent abdominal stoma and 5 voided/catheterized via the urethra.Conclusions: Early evaluation for neurosurgical and orthopedic anomalies is vital in these children. Despite the high incidence of spinal pathology most patients ambulate without assistance. Few children with omphalocele-exstrophy-imperforate anus-spinal defects achieve continence via the urethra. Vigilant followup is necessary to identify potentially correctable conditions.

Pediatric Urolithiasis—Does Body Mass Index Influence Stone Presentation and Treatment? - Corrected Proof

2010-08-20

Purpose: Pediatric obesity is a major public health concern in the United States. We investigated the association of body mass index with presentation and outcome in children with urolithiasis.Materials and Methods: We identified all patients 2 to 18 years old at our institution with a radiographically confirmed first renal or ureteral stone between January 2003 and June 2008. Data abstracted included demographics, stone characteristics, treatment and metabolic evaluation. Patients were stratified into 3 body mass index categories, including lower (10th percentile or less for age), normal (10th to 85th percentile) and upper (85th percentile or greater) percentile body weight.Results: Of the children 62 boys (55.4%) and 50 girls (44.6%) were evaluable. Mean age at diagnosis was 11.8 years. Body mass index stratification showed lower percentile body weight in 11 patients (9.8%), normal percentile body weight in 55 (49.1%) and upper percentile body weight in 46 (41.1%). Mean stone diameter was 5.0 mm. Of the stones 31 (27.7%) were in the kidney or ureteropelvic junction and 81 (72.3%) were in the ureter. Surgery was done in 87 patients (78.9%) and stone clearance was accomplished by 1 (69.0%) or 2 (31.0%) procedures in all. Lower percentile body weight patients presented earlier than normal and upper percentile body weight patients (9.0 vs 12.2 and 12.0 years, respectively, p = 0.04). Neither stone size nor the number of procedures required for stone clearance differed significantly by body mass index.Conclusions: Upper percentile body weight was not associated with earlier stone development, larger stones or the need for multiple surgical procedures. In lower percentile body weight patients symptomatic renal stones developed significantly earlier than in normal or upper percentile body weight patients. Stone size and the surgical intervention rate were similar regardless of body mass index. Further research may identify potential factors predisposing children with lower percentile body weight to early stone development.

Preoperative Stone Attenuation Value Predicts Success After Shock Wave Lithotripsy in Children - Corrected Proof

2010-08-20

Purpose: We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date.Materials and Methods: We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures.Results: After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003).Conclusions: Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.

Variation in Management of Duplex System Intravesical Ureteroceles: A Survey of Pediatric Urologists - Corrected Proof

2010-08-20

Purpose: Controversy exists in ureterocele management and the literature lacks clear management guidelines. We surveyed pediatric urologists to understand practice patterns and perceptions of managing duplicated system intravesical ureterocele.Materials and Methods: The survey consisted of 3 case scenarios, including upper pole obstruction without reflux, ureterocele without hydronephrosis and reflux after incision. The survey evaluated management at patient age 3 months and used a Likert scale to evaluate management strategies later in life.Results: We analyzed 233 responses. There was agreement in prophylactic antibiotic use and diagnostic evaluation. When managing a duplicated system intravesical ureterocele with poor upper pole function, 50.6% of respondents advocated puncture at age 3 months. However, when followed conservatively for 18 months, the preference changed to surgical management with partial nephrectomy preferred by 61.8% of respondents. When managing the condition without hydronephrosis, watchful waiting was preferred by 47.2% of respondents while 35.6% chose puncture and another 16.3% chose partial nephrectomy. Most respondents advocated ureteral reimplantation to manage reflux to the upper pole after puncture while some preferred endoscopic Deflux® injection. Continued nonoperative management while off prophylaxis was not preferred. Most respondents viewed the risks of surgery and anesthesia as important factors when weighing options in children younger than 3 months. Preventing symptoms and preserving function of the renal units were significant factors guiding surgical intervention.Conclusions: We found significant variation in management of duplicated system intravesical ureterocele. Most pediatric urologists see fewer than 10 cases per year, stressing the need for multi-institutional, randomized, controlled studies to evaluate management and long-term outcomes.

A Conservative Approach to Testicular Rupture in Adolescent Boys - Corrected Proof

Jimena Cubillos, Edward F. Reda, Jordan Gitlin, Paul Zelkovic, Lane S. Palmer — 2010-08-20

Purpose: Management for blunt trauma with breach of the renal capsule or bladder (extraperitoneal) has largely become nonsurgical since a conservative approach proved to be effective and safe. Currently the recommendation for managing testicular rupture is surgical exploration and débridement or orchiectomy. We report outcomes in boys diagnosed with testicular rupture and treated without surgical intervention.Materials and Methods: In the last year we conservatively treated 7 consecutive boys with delayed presentation of testicular rupture after blunt scrotal trauma. Patients were treated with scrotal support, antibiotics to prevent abscess, rest, analgesics and serial ultrasound. We report clinical information and outcomes.Results: The 7 boys were 11 to 14 years old and presented 1 to 5 days after injury. Trauma was to the left testis in 3 cases and to the right testis in 4. Patients presented with mild to moderate pain and similar scrotal swelling. Ultrasound findings consistently revealed hematocele and increased echogenicity. Blood flow was present in the injured portion of the testes in 3 cases and to the remainder of the affected testicle in 6 of the 7 boys. In the remaining boy an adequate waveform was not seen in either testicle, which the radiologist thought was secondary to prepubertal status. Other findings included scrotal edema, irregular contour and seminiferous tubule extrusion. Followup was greater than 6 months in all cases. Five boys were seen at the office and the 2 remaining had telephone followup. In all cases hematocele resolved, testicular size stabilized without atrophy and echogenicity normalized in the 5 patients with followup ultrasound. One patient required surgical repair of hydrocele 4 months after trauma but no other patient needed surgical exploration. No abscess or infection developed.Conclusions: A conservative approach in a select group of adolescent boys with testicular rupture can result in resolution of the fracture and maintenance of testicular architectural integrity.

Variation Among Pediatric Urologists and Across 2 Continents in Antibiotic Prophylaxis and Evaluation for Prenatally Detected Hydronephrosis: A Survey of American and European Pediatric Urologists - Corrected Proof

Paul A. Merguerian, Daniel Herz, Leslie McQuiston, Michael Van Bibber — 2010-08-20

Purpose: No clear practice guidelines exist to evaluate prenatally diagnosed hydronephrosis or recommend antibiotic prophylaxis. We hypothesized that among pediatric urologists there is significant variability in prenatal hydronephrosis evaluation and management.Materials and Methods: We created a survey questionnaire to answer certain questions, including 1) what prenatal parameters trigger postnatal evaluation, 2) how pediatric urologists manage prenatal hydronephrosis and 3) what are their recommendations for antibiotic prophylaxis. Survey questions included demographics and practice patterns, and influences concerning radiographic tests and prophylactic antibiotics. A Web based survey link was sent to members of the Urology Section, American Academy of Pediatrics and the European Society for Pediatric Urology. We received 156 responses. We also compared practices based in Europe in 60 respondents and in the United States in 70.Results: There was significant response variability to all questions answered with no question achieving a consensus of more than 50%. European and American respondents were equally distributed in regard to years in practice and number of patients per month. Radiographic factors influenced the decision to perform further imaging or provide prophylactic antibiotics in around 50% of respondents. There was wide variability in parameters triggering intervention and in prophylactic antibiotics. Pediatric urologists in practice more than 15 years were less likely to prescribe antibiotic prophylaxis at birth than those in practice less than 15 years. Variation also existed by geographic region with American physicians more likely to prescribe antibiotics for any prenatal hydronephrosis compared to their European counterparts (77% vs 40%, p <0.005) and European physicians more likely to be influenced by prenatal pelvic diameter when obtaining postnatal imaging (unilateral 70% vs 47%, p = 0.009 and bilateral 55% vs 36%, p = 0.03, respectively). European pediatric urologists were also more likely to order renal scans than their American counterparts. These differences were less significant for high grade hydronephrosis.Conclusions: Even among pediatric urologists there is considerable variation in radiographic resource and prophylactic antibiotics use when managing prenatal hydronephrosis. Some variation may be explained by regional differences but it is most probably due to absent clear guidelines based on prospective, randomized, controlled trials.

Should Male Gender Assignment be Considered in the Markedly Virilized Patient With 46,XX and Congenital Adrenal Hyperplasia? - Corrected Proof

Peter A. Lee, Christopher P. Houk, Douglas A. Husmann — 2010-08-20

Purpose: We assess the outcome in 46,XX men with congenital adrenal hyperplasia who were born with Prader 4 or 5 genitalia and assigned male gender at birth.Materials and Methods: After receiving institutional review board approval and subject consent we reviewed the medical records of 12 men 35 to 69 years old with 46,XX congenital adrenal hyperplasia, of whom 6 completed social and gender issue questionnaires.Results: All subjects were assigned male gender at birth, were diagnosed with virilizing congenital adrenal hyperplasia at age greater than 3 years and indicated a male gender identity with sexual orientation to females. Ten of the 12 subjects had always lived as male and 2 who were reassigned to female gender in childhood subsequently self-reassigned as male. Nine of the 12 men had long-term female partners, including 7 married 12 years or more. The 3 subjects without a long-term female partner included 1 priest, 1 who was reassigned female gender, married, divorced and self-reassigned as male, and 1 with a girlfriend and sexual activity. All except the priest and the subject who was previously married when female indicated a strong libido and frequent orgasmic sexual activity. Responses to self-esteem, masculinity, body image, social adjustment and symptom questionnaires suggested adjustments related to the extent of familial and social support.Conclusions: Outcome data on severely masculinized 46,XX patients with congenital adrenal hyperplasia who were assigned male gender at birth indicate male gender identity in adulthood with satisfactory male sexual function in those retaining male genitalia. In men who completed questionnaires results were poorer in those lacking familial/social support. Male gender of rearing may be a viable option for parents whose children are born with congenital adrenal hyperplasia, a 46,XX karyotype and male genitalia, although positive parental and other support, and counseling are needed for adjustment.

Trends in Imaging and Surgical Management of Pediatric Urolithiasis at American Pediatric Hospitals - Corrected Proof

Jonathan C. Routh, Dionne A. Graham, Caleb P. Nelson — 2010-08-20

Purpose: Little is known of current practice patterns for pediatric urolithiasis. We examined recent trends in imaging and surgical management.Materials and Methods: The Pediatric Health Information System database is a national database collected at American pediatric hospitals. We searched the database from 1999 to 2008 to identify children diagnosed with urolithiasis. Inpatient hospital admissions, and emergency department and outpatient medical/surgical short stay visits were included. We examined imaging and surgical management trends during the study period using bivariate and multivariate logistic regression models.Results: We identified 7,921 children diagnosed with urolithiasis during the study period, of whom 1,712 (22%) underwent stone related surgery and 6,318 (80%) underwent stone related diagnostic imaging. The surgery rate remained stable during the study period (p = 0.15), as did the overall imaging rate (p = 0.2). However, computerized tomography use increased (26% to 45%) and plain x-ray of kidneys, ureters and bladder plus excretory urogram use decreased (59% to 38%) during the study period (each p <0.0001). Surgery was associated with older patient age, female gender, white race and private insurance. Computerized tomography use was associated with older patient age, nonwhite race and public insurance. After adjusting for other factors, including hospital region, the treating hospital was most important for predicting surgery or computerized tomography (each p <0.0001).Conclusions: Surgery and imaging for pediatric urolithiasis remained stable at pediatric hospitals in the last decade, although computerized tomography use has increased. The hospital where a patient receives treatment is the single most important feature driving computerized tomography and surgery use. Patient age, race and insurance status have a smaller but significant role.

Rate and Associations of Epididymal Cysts on Pediatric Scrotal Ultrasound - Corrected Proof

2010-08-20

Purpose: We established the baseline occurrence of epididymal cysts, and the correlation between epididymal cysts and testicular size.Materials and Methods: We retrospectively reviewed all pediatric scrotal ultrasounds done at our institution in 8 years. We analyzed the proportion of cysts by patient age and compared testicular size in boys with vs without epididymal cysts.Results: Of all patients 14.4% had epididymal cysts. The cyst incidence increased with age, ie 35.3% of boys older than 15 years had cysts. Boys with epididymal cysts had larger testes than boys without cysts regardless of side or age (p <0.001).Conclusions: Epididymal cysts are more common in older boys. Boys with epididymal cysts had larger testes than boys without cysts.

Predicting Renal Outcomes in Children With Anterior Urethral Valves: A Systematic Review - Corrected Proof

2010-08-20

Purpose: Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death.Materials and Methods: We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest.Results: We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005).Conclusions: Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome.

Effect of Rectal Distention on Lower Urinary Tract Function in Children - Corrected Proof

2010-08-20

Purpose: We investigated the effect of rectal distention on lower urinary tract function.Materials and Methods: Children were assigned to a constipation and lower urinary tract symptoms group or to a lower urinary tract symptoms only group. The definition of constipation was based on pediatric Rome III criteria. Standard urodynamics were done initially and repeated during simultaneous barostat pressure controlled rectal balloon distention and after balloon deflation. We evaluated the effects of rectal balloon inflation and deflation on urodynamic parameters. Colonic transit time measurement, anorectal manometry and the Parenting Rating Scale of child behavior were also used.Results: We studied 7 boys and 13 girls with a median age of 7.5 years who had constipation and lower urinary tract symptoms, and 3 boys and 3 girls with a median age of 7.5 years who had lower urinary tract symptoms only. Urodynamic patterns of response to rectal distention were inhibitory in 6 children and stimulatory in 12, and did not change in 8. In 54% of the cases balloon deflation reversed balloon inflation changes while in 46% balloon inflation changes persisted or progressed. No significant differences were noted in children with vs without constipation and no clinical symptom or diagnostic study predicted the occurrence, direction or degree of bladder responses.Conclusions: In almost 70% of children with lower urinary tract symptoms rectal distention significantly but unpredictably affected bladder capacity, sensation and overactivity regardless of whether the children had constipation, and independent of clinical features and baseline urodynamic findings. Urodynamics and management protocols for lower urinary tract symptoms that fail to recognize the effects of rectal distention may lead to unpredictable outcomes.

Objective Patterning of Uroflowmetry Curves in Children With Daytime and Nighttime Wetting - Corrected Proof

2010-08-20

Purpose: Pediatric uroflowmetry curve interpretation is incompletely standardized. Thus, we propose new, objective patterning.Materials and Methods: Uroflowmetry curves were obtained in 100 children presenting with daytime incontinence or enuresis. Each curve was compared with a standard curve generated from a published nomogram and a new patterning method was formulated. Staccato and interrupted patterns were defined using International Children's Continence Society criteria. The remaining curves were divided by the deviation of the maximal flow rate from the median nomogram value as certain patterns, including tower—greater than 130%, not abnormal—70% to 130% and plateau—less than 70%. The correlation between the presenting symptom and patterns or other uroflowmetry parameters was evaluated. Six pediatric urologists also patterned the same curves subjectively.Results: All curves could be classified as 1 of the defined patterns using this method. Pattern distribution reflected the spectrum of presenting symptoms with more tower, interrupted and staccato patterns in children with daytime wetting than in those with monosymptomatic enuresis. Age adjusted voided volume was also smaller in the former group but post-void residual urine, and maximal and average flow rates did not correlate with presenting symptoms. Subjective patterning showed marked interobserver differences. When patterning applied by the current method was used as a reference, observer sensitivity for abnormal patterns inversely correlated with specificity.Conclusions: Subjective uroflowmetry patterning is liable to personal bias. The proposed method enables objective patterning that complies with International Children's Continence Society standardization and clinical presentation.

Parent Perspectives of Health Related Quality of Life for Adolescents With Bladder Exstrophy-Epispadias as Measured by the Child Health Questionnaire-Parent Form 50™ - Corrected Proof

2010-08-20

Purpose: Few groups have examined health related quality of life for adolescents with bladder exstrophy-epispadias. We studied parent reported health related quality of life for adolescents with bladder exstrophy-epispadias using the Child Health Questionnaire-Parent Form 50.Materials and Methods: We recruited 11 to 17-year-old participants with bladder exstrophy-epispadias and their parents. Parents served as proxy respondents for the adolescents by self-administering a validated generic health related quality of life instrument, the Child Health Questionnaire-Parent Form 50. We collected urinary incontinence, catheterization status, and medical and surgical history data. Mean questionnaire scores were compared to population based norms.Results: Median age of the 55 patients was 14 years, 69% were male and 84% were white. Diagnoses included bladder exstrophy in 48 cases and epispadias in 7. Of the participants 29 (53%) reported urinary incontinence. The median number of lifetime surgeries was 9. Although physical and psychosocial summary measure scores were comparable to norms, the mean general health perception score was significantly worse than that of a population based sample (65.8 points, 95% CI 61.4–70.2 vs 73, 95% CI 71.3–74.7, p = 0.004). Mean family activity and parent emotional impact scores were also significantly worse than in a population based sample (83.6 points, 95% CI 79.3–88.0 vs 89.7, 95% CI 87.9–91.5, p = 0.02 and 67.7, 95% CI 61.9–73.6 vs 80.3, 95% CI 78.4–82.2, p <0.0001, respectively). Comparison of incontinent to continent children revealed a lower mean score on the parent emotional impact scale (62.6 points, 95% CI 55.5–69.8 vs 73.4, 95% CI 63.9–82.9), which approached significance (p = 0.06).Conclusions: Although overall adolescent quality of life was comparable to norms, parents reported significantly impaired adolescent general health and family activity as well as a negative parental emotional impact. Further research is needed to identify interventions that can decrease the adverse impact of bladder exstrophy-epispadias on family activity and parent emotional distress.

Is Adolescent Varicocelectomy Safe After Previous Inguinal Surgery? - Corrected Proof

2010-08-20

Purpose: Varicocelectomy after previous inguinal surgery poses a potential risk of testicular volume loss. To assess the extent to which varicocelectomy can be done without the complication of ipsilateral testis atrophy we present outcomes in adolescent patients with a history of inguinal surgery who underwent ipsilateral varicocelectomy.Materials and Methods: We retrospectively reviewed patient data from a single urologist practice. Testicular volume was recorded preferentially by ultrasound or, when unavailable, by ring orchidometry. Testicular asymmetry was calculated using the formula, [(right testis volume − left testis volume)/right testis volume] × 100. Symmetry was defined as less than 10% asymmetry. Catch-up growth was defined as resolution of asymmetry.Results: We identified 22 adolescent patients who fit study criteria. The patients underwent a total of 25 varicocelectomies since 3 underwent bilateral repair after previous bilateral inguinal surgery. Initial inguinal surgery included inguinal herniorrhaphy, hydrocelectomy and orchiopexy. Varicocelectomy was done laparoscopically in 17 cases and via open technique in 8 with variations in preservation/sacrifice of the lymphatics and artery. Median ± SD followup was 24.2 ± 18.2 months. After varicocelectomy mean testicular asymmetry decreased from 27.6% to 10.5%. There was no incidence of testicular atrophy postoperatively. The incidence of catch-up growth was 43% with no difference between the artery sparing and the nonartery sparing technique.Conclusions: Varicocelectomy with a history of previous inguinal surgery is safe and provides a significant incidence of testicular catch-up growth. Artery sparing vs sacrificing technique did not make a difference in terms of catch-up growth.

Prospective Open Label Study of Solifenacin for Overactive Bladder in Children - Corrected Proof

2010-08-20

Purpose: We evaluated the effect of solifenacin for urinary incontinence in children with overactive/neurogenic bladder refractory to oxybutynin or tolterodine.Materials and Methods: Pediatric patients presenting with refractory overactive bladder with incontinence were offered the opportunity to enter a prospective, open label protocol using adjusted dose regimens of 1.25 to 10 mg solifenacin. Study inclusion criteria were absent correctable neurological anomalies on magnetic resonance imaging, failure of symptoms to improve on intensive behavioral and medical (oxybutynin or tolterodine) therapy, and/or significant side effects of those agents. Followup consisted of a voiding diary, post-void residual urine measurement, urine culture, ultrasound and urodynamics. Families were questioned about continence, side effects, compliance, behavior change and quality of life. The primary end point was efficacy for continence and secondary end points were tolerability and safety.Results: Enrolled in the study were 42 girls and 30 boys. Of the patients 27 with neurogenic bladder, of whom 11 were on clean intermittent catheterization, and 45 with overactive bladder completed a minimum 3-month followup. Patients were on solifenacin a mean of 15.6 months. Mean age at study initiation was 9.0 years. Mean ± SD urodynamic capacity improved from 146 ± 64 to 311 ± 123 ml and uninhibited contractions decreased from 70 ± 29 to 20 ± 19 cm H2O (p <0.01). Continence improved in all patients, including 24 who were dry, and 42 and 6 who were significantly and moderately improved, respectively. Of the patients 50 reported no side effects while 15 had mild and 3 had moderate side effects. Four patients withdrew from the protocol due to intolerable side effects. Four patients had significant post-void residual urine (greater than 20 ml).Conclusions: In children with overactive bladder refractory to oxybutynin or tolterodine solifenacin is an effective alternative to improve symptoms. Tolerability was acceptable and the adjusted dose regimen appeared safe.

Can We Spare Removing the Adrenal Gland at Radical Nephrectomy in Children With Wilms Tumor? - Corrected Proof

2010-08-20

Purpose: In patients with Wilms tumor indications for adrenalectomy are not well-defined. Following the rationale for preserving the adrenal gland in cases of other renal malignancies we determined predictors of adrenal involvement and the impact of adrenalectomy on retroperitoneal recurrence.Materials and Methods: We retrospectively reviewed the record of patients who underwent surgical resection as primary treatment for Wilms tumor between 1990 and 2008 at 2 Canadian pediatric centers. Patient and tumor characteristics were reviewed to determine potential links to adrenal involvement. Recurrence was evaluated as a time dependent variable based on followup duration.Results: Of 180 patients diagnosed with Wilms tumor 95 underwent initial radical nephrectomy. Mean ± SD age at diagnosis was 46 ± 38 months and mean survival followup was 189 ± 8.3 months. Disease was stage 1 to 4 in 28, 34, 23 and 4 patients, respectively. Adrenalectomy was done in 58 patients (61%). Only 1 adrenal gland was reportedly positive for tumor invasion while peri-adrenal fat involvement was noted in 3 patients. No studied patient or tumor characteristics predicted involvement. No statistically significant difference in retroperitoneal recurrence was found between the groups in which the adrenal gland was removed vs preserved.Conclusions: Adrenal involvement in patients with Wilms tumor is rare and difficult to predict. Preserving the adrenal gland was not associated with an increased risk of local recurrence. Thus, it seems prudent to avoid adrenalectomy at radical nephrectomy when technically feasible, instead attempting to otherwise remove all peri-adrenal fat with the specimen.

Comparison of Bladder Outlet Procedures Without Augmentation in Children With Neurogenic Incontinence - Corrected Proof

Warren Snodgrass, Theodore Barber — 2010-08-20

Purpose: We compared continence results of the bladder neck sling vs the Leadbetter-Mitchell bladder neck procedure plus fascial sling in children with neurogenic urinary incontinence.Materials and Methods: We compared consecutive patients who received a 360-degree tight bladder neck sling to subsequent, similar patients who underwent a Leadbetter-Mitchell bladder neck procedure plus fascial sling involving a 50% reduction in bladder neck and proximal urethral diameter before a 360-degree tight sling. All patients underwent simultaneous appendicovesicostomy and none had undergone prior or simultaneous augmentation. All patients followed similar preoperative and postoperative protocols for urodynamic evaluation and anticholinergic therapy with data maintained prospectively.Results: After surgery 46% of 35 sling cases did not require pads vs 82% of 17 Leadbetter-Mitchell cases with a sling (p = 0.02). Mean followup was 28 months in sling and 13 months in Leadbetter-Mitchell cases. Initial urodynamics done approximately 6 months postoperatively were similar in the 2 cohorts and no patient had hydronephrosis. Transient low grade reflux occurred in 2 Leadbetter-Mitchell cases, of which 1 with increased intravesical pressures early after surgery that caused trabeculation received increased medical management. Augmentation was not done in any patient except 1 previously reported on after a sling.Conclusions: Patients undergoing Leadbetter-Mitchell procedure plus fascial sling were significantly less likely to require pads postoperatively than those with a sling alone. Adverse bladder changes have not required augmentation to date.

Same Setting Laparoscopic Antegrade Continence Enema and Antegrade Bladder Neck Injection for Constipation and Urinary Incontinence in the Spina Bifida Population - Corrected Proof

2010-08-20

Purpose: Fecal impaction and urinary incontinence and are among the most important problems in patients with spina bifida. We report our preliminary results with a minimally invasive approach to these 2 problems, that is same setting laparoscopic antegrade continence enema and antegrade bladder neck injection.Materials and Methods: We reviewed the charts of all patients who underwent same setting laparoscopic antegrade continence enema and antegrade bladder neck injection between January 1, 2006 and August 1, 2008. Demographic data, surgical indications, operative details and results were recorded. Surgical steps were uniform in all cases. Diagnostic laparoscopy was performed. Two additional 5 mm trocars were placed. The appendix was mobilized to reach skin in the right lower quadrant. The antegrade continence enema channel was matured. A small percutaneous cystotomy was then created via the suprapubic port site. The cystoscope was passed suprapubically and dextranomer/hyaluronic acid was injected in the bladder neck. A suprapubic tube was placed.Results: We performed a total of 10 same setting laparoscopic antegrade continence enemas with antegrade bladder neck injection in 4 males and 6 females with a mean age of 9.4 years (range 6 to 13). All patients had a smooth walled bladder on cystogram, and good capacity, good compliance and low leak point pressure on urodynamics. There were no intraoperative complications and all patients were discharged home within 24 hours. At an average 18-month followup (range 12 to 27) all 10 patients were continent of stool and reported marked improvement in daily care. No patient experienced stool or gas leakage via antegrade bladder neck injection. Seven of 10 patients (70%) were continent of urine and no longer wore diapers.Conclusions: Same setting laparoscopic antegrade continence enema with antegrade bladder neck injection is a safe, efficacious, reasonably simple minimally invasive approach to severe constipation and urinary incontinence in patients with spina bifida.

Is Retroperitoneoscopy the Gold Standard for Endoscopic Nephrectomy in Children on Peritoneal Dialysis? - Corrected Proof

Konrad M. Szymanski, Martin Bitzan, John-Paul Capolicchio — 2010-08-20

Purpose: The literature on minimally invasive nephrectomy in adults and children on peritoneal dialysis is sparse. Case reports suggest that the transperitoneal approach is effective. We present our experience with retroperitoneoscopic nephrectomy in children on peritoneal dialysis.Materials and Methods: At 11 consecutive retroperitoneoscopic nephrectomies a total of 14 kidneys were removed from 10 children with a mean age of 12 years. We used a 3-port lateral retroperitoneoscopic nephrectomy technique with active trainee participation. Preoperative and postoperative biochemistry results within 3 months of surgery were compared with the Wilcoxon signed rank test.Results: Three bilateral synchronous, 1 bilateral staged and 6 unilateral retroperitoneoscopic nephrectomies were done. Mean operative time was 174 minutes for unilateral and 458 minutes for bilateral nephrectomy, including 1 simultaneous peritoneal dialysis insertion and 1 umbilical hernia repair. No open conversion, blood transfusion or postoperative surgical complication was noted. Peritoneal dialysis was initiated at a median of 9 hours postoperatively and dialysate volume was titrated to target within a median of 60 hours. One patient with a small peritoneotomy needed temporary hemodialysis despite intraoperative airtight repair. After surgery median serum albumin increased from 30.0 to 34.3 gm/l.Conclusions: Retroperitoneoscopic nephrectomy for end stage renal disease is a safe, effective technique that preserves peritoneal integrity in children who require immediate postoperative peritoneal dialysis. Avoiding post-nephrectomy hemodialysis decreases patient morbidity, preserving vessels for future vascular access. Compared to the literature on laparoscopy in this setting, retroperitoneoscopic nephrectomy can be considered the ideal approach for minimally invasive nephrectomy in patients on peritoneal dialysis.

Outcome After Discontinuing Prophylactic Antibiotics in Children With Persistent Vesicoureteral Reflux - Corrected Proof

David M. Kitchens, Anthony Herndon, David B. Joseph — 2010-08-20

Purpose: Treatment for vesicoureteral reflux remains controversial. Lacking an evidence-based treatment protocol, we offered the option of terminating prophylactic antibiotics in otherwise healthy patients with persistent vesicoureteral reflux at age 5 years or greater. We report outcomes with respect to the urinary tract infection incidence and to whether surgical intervention was eventually done.Materials and Methods: We obtained institutional review board approval to retrospectively review the records of all children with vesicoureteral reflux from December 1999 to February 2009. Of this group we selected children 5 years old or older who had been taken off prophylactic antibiotics. We assessed children with primary vesicoureteral reflux in detail.Results: The records of 1,217 that we reviewed showed that antibiotics were discontinued in 185 patients, including 160 girls (89%) and 25 boys (11%), at an average age of 6.2 years. Average followup was 2.0 years with recorded followup up to 8 years off prophylaxis. In 50 girls (91%) and 5 boys (9%), urinary tract infection developed after discontinuing prophylaxis. Correction was done in 57 patients, including open repair in 34 and endoscopic injection in 23. Two patients underwent intervention at parent request after an average of 0.7 years of uneventful observation. We identified no parameter predicting patients at risk for urinary tract infection.Conclusions: Urinary tract infection develops in 29% of patients 5 years old or older with persistent vesicoureteral reflux within 2 years after the cessation of prophylaxis. Most of these cases are febrile. Discontinuing antibiotics is reasonable but a prospective, randomized, long-term, multi-institutional trial is required to determine whether this approach is beneficial.

High Grade Primary Vesicoureteral Reflux in Boys: Long-Term Results of a Prospective Cohort Study - Corrected Proof

2010-08-20

Purpose: We evaluated the incidence of new permanent defects in boys with grade 4 or 5 vesicoureteral reflux, identified the risk factors for new permanent defects and reviewed the outcome of different management approaches by assessing the rates of urinary tract infection and new permanent defects.Materials and Methods: This prospective cohort study recruited patients from July 1995 to December 2006. Study inclusion criteria were male gender and grade 4 or 5 primary vesicoureteral reflux. Patients were divided into 2 groups by presentation mode, including group 1—prenatal reflux diagnosis and group 2—reflux diagnosed after investigation for urinary tract infection. All patients underwent initial renal 99mTc-dimercapto-succinic acid scan evaluation. Continuous antibiotic prophylaxis was given in all patients until at least age 2 years. Surgical correction for reflux was done in 28 patients and 76 were circumcised. Followup included renal 99mTc-dimercapto-succinic acid scan with renal ultrasound at age 12 months with repeat 99mTc-dimercapto-succinic acid scan at ages 2 and 4 years.Results: Included in our study were 151 patients (206 high grade refluxing renal units) with a median age at diagnosis of 1.9 months (range 1 day to 8.8 years). Median age at first followup was 14 months (range 3 months to 3 years) and at next followup it was 39 months (range 10 months to 11.3 years). There were 52 boys (34%) in group 1 and 99 (66%) in group 2. Baseline perfusion defects on initial renal 99mTc-dimercapto-succinic acid scan were identified in 41 of 52 boys (78.8%) in group 1 and in 74 of 99 (74.7%) in group 2. During followup new permanent defects developed in 8 of 52 boys (15%) in group 1 and in 10 of 99 (10%) in group 2. In 18 patients a total of 20 renal units showed new permanent defects, including 13 in kidneys with baseline perfusion defects and 7 in previously normal kidneys (p >0.9). In groups 1 and 2 combined infection developed before and after circumcision in 62 of 137 (45.2%) and 5 of 74 cases (6.7%), respectively (p <0.001). New permanent defects were seen in 4 of 76 circumcised (5.2%) and in 14 of 137 uncircumcised boys (10.2%) (p >0.3).Conclusions: Baseline perfusion defects were seen on 99mTc-dimercapto-succinic acid scan at presentation in 115 of our 151 patients (76%) independent of presentation mode. New permanent defects developed in abnormal and previously normal kidneys, and were associated with urinary tract infection. Being circumcised was associated with fewer urinary tract infections and a lower incidence of observed new permanent defects (5.2% vs 10.2%).