New Insights in Pediatric Urology

Meeting Review

RIU0381_03-14.qxd 3/15/08 3:02 AM Page 73 MEETING REVIEW New Insights in Pediatric Urology Highlights of the American Academy of Pediatrics Section on Urology Meeting, October 27-30, 2007, San Francisco, CA [Rev Urol. 2008;10(1):73-75] © 2008 MedReviews, LLC Key words: Vesicoureteral reflux • Voiding dysfunction • Hydrocele/hernia • Prenatal hydronephrosis he American Academy of Pediatrics Section on Urology’s Annual Meeting was held in San Francisco, California, October 27-30, 2007. Papers and posters were presented on a wide range of topics, including cryptorchidism, varicocele, exstrophy, sexual differentiation, reflux, hypospadias, neurogenic bladder, hydronephrosis, valves, and voiding dysfunction. A Sunday morning seminar was held on various topics, such as recalcitrant urinary tract infections (UTIs) in augmented bladders, the use of botulinum toxin in pediatric urology, and emerging therapies for voiding dysfunction. Highlights from the meeting are reviewed below. T Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Urology, New York University School of Medicine, New York, NY. Dr. George Kaplan received the prestigious 2007 Pediatric Urology Medal from the Section on Urology. Dr. Kaplan is the chairman of the Department of Surgery and chief of Urology at Rady Children’s Hospital, San Diego, California. He is also clinical professor of pediatrics and surgery/ urology at the University of California San Diego (UCSD) School of Medicine. He was acting chair of the Division of Urology at UCSD 1975-1976 and was chief of Pediatric Urology at UCSD from 1971-1997. Dr. Kaplan is a former trustee of the American Board of Urology. Dr. Kaplan has co-authored one of the gold standard textbooks of pediatric urology, Clinical Pediatric Urology, and has authored over 200 articles and book chapters. He has served as the president for the Society of Pediatric Urology and the chairman of the section on urology of the American Academy of Pediatrics. He is best known for his contributions in reconstructive surgery of the genitourinary tract. Vesicoureteral Reflux Rice and colleagues1 from the Children’s National Medical Center in Washington, DC, reported on patients who had undergone endoscopic injection with Deflux® (Q-Med Scandinavia, Inc., Princeton, NJ) who had a follow-up voiding cystourethrogram (VCUG) at 2-4 months showing no reflux and subsequently developed febrile infections despite an earlier negative study. Forty-five patients had undergone endoscopic therapy (excluding patients with spina bifida and renal transplant), and within 18 months, 12 (27%) developed a febrile urinary tract infection. Nine (75%) of these patients had a VCUG following antibiotic treatment, and 8 (89%) of those demonstrated recurrent reflux, VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY 73 RIU0381_03-14.qxd 3/15/08 3:02 AM Page 74 New Insights in Pediatric Urology continued whereas only 1 patient had a negative study. The authors recommend a VCUG at 1 year following treatment to confirm resolution of reflux following endoscopic therapy with Deflux. Estrada and coworkers2 from Boston Children’s Hospital examined outcomes in children who presented with urinary tract infection versus antenatal diagnoses or sibling screening. They followed 2593 children with vesicoureteral reflux who had had at least 2 serial studies performed at least 1 year apart. They found that patients with prenatal hydronephrosis showed resolution of reflux at a faster rate than those evaluated for urinary tract infection. They conclude that the mode of presentation is important and may help tailor management of reflux. excluded, and 108 patients (74 males, 44 females) were found to have pure urgency/frequency syndrome. These patients were treated not only with a bowel regimen but also with anticholinergics and alpha blockers if needed. There were 25 nonresponders to the regimen. Fourteen of the patients had a neuropsychiatric disorder or had a first order family member with such a disorder. In the therapeutic responder group, only 9 of 83 patients had a neuropsychiatric disorder. They conclude that 56% of the patients who are refractory to more aggressive treatments most likely have some form of neuropsychiatric disorder involving the child or the parent. This should be taken into consideration when dealing with this refractory group of patients. Voiding Dysfunction Hydrocele/Hernia Austin and fellow investigators3 from Washington University and St. Louis Children’s Hospital in Missouri compared the effect of adding desmopressin with a long-acting anticholinergic therapy in patients who are refractory to desmopressin alone. They studied 34 patients who had no success when desmopressin was used alone. Those who were treated with desmopressin and an anticholinergic agent showed a significantly decreased risk of wet episodes (66%) when compared with the placebo group. Franco and coworkers4 from New York Medical College in Valhalla, NY, examined the urinary frequency syndrome to determine if certain patients were more likely to respond to conventional treatment than others. They identified 326 patients with the diagnosis of frequency and urgency. Of these, 126 patients were seen more than once, which provided adequate follow-up. The majority responded to a bowel regimen and timed voiding with behavioral modification. Eighteen patients who had infections were Wilson and associates5 from the University of California San Francisco examined the best approach for managing hydroceles in pediatric patients depending upon age. They attempted to identify an age above which a significant percentage of children had noncommunicating hydroceles. They examined 94 patients with a total of 103 hydroceles, ranging in age from 0.1 to 19.9 years. Five children had bilateral hydroceles and 3 had recurrence of hydrocele in the contralateral side. The majority (84%) of hydroceles in children older than 10 years had findings at the time of surgery consistent with a noncommunicating hydrocele, and almost 90% of the hydroceles in children older than 12 were noncommunicating. These findings were statistically significant when using age 10 as a cutoff age with a 16% chance of needing high ligation of a patent processus vaginalis. When using age 12 as the cutoff for an inguinal approach, there was a 10% chance of finding a communicating hydrocele. Both commu- 74 VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY nicating hydroceles (suspected preoperatively) in the 12 or older age group were confirmed at surgery. They conclude that in children over 12 years of age, hydroceles can be approached through a scrotal incision with little to no chance of finding a patent processus vaginalis unless the history suggests a communication. When the age was lowered to 10, there was a 16% chance of finding a communication. They suggest that children below the age of 10 should undergo inguinal exploration for repair of hydrocele. Prenatal Hydronephrosis Thomas and colleagues6 from St. James’ University Hospital in the United Kingdom evaluated the impact of prenatal diagnosis on the long-term prognosis for renal function in patients with posterior urethral valves (PUV). They compared published long-term outcome data reported by Parkhouse in 1988 with 26 patients diagnosed with PUV who had been followed for 10 to 22 years (mean age, 18.5 years). They identified 37 patients born between 1984 and 1994 with 26 presenting prenatally and 11 postnatally. They evaluated the incidence of end-stage renal failure (ESRF), age at transplantation, and most recent plasma creatinine in nontransplanted patients. In the 26 prenatally detected patients, there were 3 deaths. Of the 4 shunted in utero, 3 died or developed early onset renal failure. In 24 prenatally detected patients surviving the neonatal period, 5 underwent renal transplant at a mean age of 7.4 years, and 5 of the 11 postnatally presenting patients were transplanted at a mean age of 12.4 years. In nontransplanted patients, almost 70% who were prenatally detected had a normal plasma creatinine at 10 to 22 years compared with 10% in the clinically presenting group. They conclude that prenatal diagnosis had RIU0381_03-14.qxd 3/15/08 3:02 AM Page 75 New Insights in Pediatric Urology little impact on mortality or ESRF in the first 10 years of life. However, the incidence of late onset ESRF and renal impairment was significantly lower in patients with prenatally detected valves compared with those with clinical presentation. Only 8.3% of patients with prenatal PUV developed ESRF between 10 to 22 years compared with 32% in Parkhouse’s 1988 study. Snodgrass and fellow investigators7 from the University of Texas Southwestern Medical Center and Children’s Medical Center in Dallas examined the outcomes of patients with SFU Grades 3 and 4 initially managed conservatively. The objective of this study was to determine the likelihood of significant improvement or resolution of hydronephrosis in this group of patients without surgical intervention. All patients underwent a postnatal ultrasound, VCUG, and MAG-3 renal scan. Surgery was performed for increased hydronephrosis, decreased renal function, urinary tract infection, failure to resolve the hydronephrosis, and in some, parent preference. Of the 35 patients, 22 (63%) underwent pyeloplasty. Increased hydronephrosis was noted in 16, urinary tract infection in 1, and pain in 1. Parent preference was noted in 2 patients with persistent grade III hydronephrosis at almost 2 years and in 2 with grade IV hydronephrosis at 8 months. Resolution was noted in 3 patients (9%). When the MAG-3 renal scan was repeated preoperatively, increased hydronephrosis was demonstrated in 7 and decreased function in 3. Of the grade IV hydronephrosis, none re- solved and 80% had surgery, whereas in grade III, 33% resolved or improved and 50% had surgery. The authors conclude that although their intent was to follow patients conservatively, 63% underwent pyeloplasty usually for increased hydronephrosis. They further conclude that prolonged observation for grade IV is most likely not indicated. The objective of the study by Coplen and coworkers8 from Washington University was to examine whether the degree of fetal renal pelvic dilation (RPD) could be correlated with reflux. RPD is a manifestation of reflux in about 10% to 25% of infants. The threshold for study inclusion was renal pelvic dilation 4 mm or larger before 33 weeks or 7 mm or larger after 33 weeks. They found that of 215 neonates, 46 (21%) had reflux, which was grade III or higher in 26 (12%). The reflux was present on the ipsilateral side of dilation in 75%. The mean RPD was 11.8 mm in 169 with a normal VCUG, and the mean RPD of 14.4 mm was demonstrated in 46 with reflux, but there was no statistical difference between the 2 groups. Therefore, they found that an RPD cutoff of 14 mm predicted only 50% of reflux and had a specificity of 63%. However, reflux was identified in a greater number of neonates with caliectasis (24%) versus those with just isolated renal pelvic dilation (3%). The authors conclude that one cannot predict the presence of reflux based on fetal RPD, but if there is postnatal caliectasis in children with RPD then this may serve as a more important predictor of reflux. They suggest that if there is caliectasis or a renal pelvic dilation greater than 10 mm in a newborn, a VCUG may be warranted. References 1. 2. 3. 4. 5. 6. 7. 8. Rice DC, Sedberry-Ross S, Pohl HG, et al. Febrile urinary tract infections in children with an early negative post-treatment voiding cystourethrogram after treatment of vesicoureteral reflux with Deflux® (abstract 875). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Estrada CR, Passerotti CC, Graham D, et al. The mode of presentation predicts the resolution of vesicoureteral reflux in children (abstract 1007). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Austin PF, Ferguson G, Yan Y, et al. Combination therapy in nonresponders to Desmopressin for monosymptomatic nocturnal enuresis: a randomized, double-blind, placebo-controlled trial (abstract 188). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Franco I, Cagliostro S, Collett T, Reda EF. Refractory pediatric urgency frequency syndrome: Are there characteristics that separate responders from nonresponders? (abstract 401). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Wilson JM, Aaronson D, Baskin LS. Hydroceles in the pediatric patient: inguinal or scrotal approach? (abstract 28). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Thomas D, Kousidis G, Morgan H, et al. Does prenatal diagnosis improve the long term prognosis of posterior urethral valves? A 10-22 year followup study (abstract 110). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Snodgrass W, Yie J, Ziada A. Does prenatally detected SFU Grades 3 and 4 hydronephrosis from presumed UPJ anomalies spontaneously resolve? (abstract 205). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. Coplen DE, Austin PF, Dicke JM, Yan Y. Correlation of prenatal and postnatal ultrasound findings with the incidence of vesicoureteral reflux in children with fetal renal pelvic dilation (abstract 316). Presented at: American Academy of Pediatrics Section on Urology; October 27-30, 2007; San Francisco, CA. VOL. 10 NO. 1 2008 REVIEWS IN UROLOGY 75