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)
