New Insights in Pediatric Urology

Meeting Review

RiU_Apr2011_p50-52.qxd 4/13/11 10:29 AM Page 50 MEETING REVIEW New Insights in Pediatric Urology Highlights From the American Academy of Pediatrics Section on Urology Meeting, October 2-4, 2010, San Francisco, CA [Rev Urol. 2011;13(1):50-52 doi: 10.3909/riu0517] © 2011 MedReviews®, LLC Key words: Posture and minimally invasive surgery • Alexander technique • Nocturnal enuresis • Obstructive sleep apnea • Adult spina bifida • Reflux he American Academy of Pediatrics (AAP) Section on Urology annual meeting was held in San Francisco, CA, on October 24, 2010. About 70 papers and posters were presented on a wide range of topics including cryptorchidism, genitourinary (GU) tumors, varicocele, exstrophy, sexual differentiation, reflux, hypospadias, neurogenic bladder, hydronephrosis, valves, and voiding dysfunction. There were several panels including Pediatric Trauma, Clinical Research Updates, and an Update on Vesicoureteral Reflux (VUR) that provided an overview of the recently published T Reviewed by Ellen Shapiro, MD, FACS, FAAP, New York University School of Medicine, New York, NY 50 VOL. 13 NO. 1 2011 American Urological Association (AUA) guidelines on VUR. the clinical abstracts are highlighted below. Pediatric Urology Medal Surgical Ergonomics and the Surgeon’s Posture During Minimally Invasive Surgery Dr. Stephen Koff was chosen to receive the Pediatric Urology Medal. He has made innumerable contributions to the field of pediatric urology. Dr. Koff has broadened our understanding of long-term outcomes in prenatally diagnosed hydronephrosis, altered bladder function as seen in children with posterior urethral valves, and voiding and bowel dysfunction and its effects on urinary tract infection (UTI) and VUR. He has also made contributions in the area of bladder neck reconstruction in children with exstrophy. The meeting was extremely well attended by pediatric urologists from North America, South America, Europe, and Asia. Several of REVIEWS IN UROLOGY Reddy and colleagues from Cincinnati assessed the impact of the Alexander Technique (AT) in improving surgical ergonomics during minimally invasive surgery (MIS) and the impact of AT in improving the surgeon’s posture during these procedures.1 A prospective cohort study was performed where the subject served as his or her own control. Seven urologic surgeons underwent certified AT instruction. A pre- and postassessment of laparoscopic skills, coordination, manual dexterity, and posture was performed. The surgeons all reported improvement in their posture and in RiU_Apr2011_p50-52.qxd 4/13/11 10:29 AM Page 51 New Insights in Pediatric Urology the time load test, which assesses postural endurance. They also showed improved post-AT ergonomics and improved post-AT test results in suturing, ring transfer, and intention tremor. In summary, improvement in posture, trunk and shoulder endurance, and surgical ergonomics occurred after the AT training program. By subjective and objective measures, the improvements in posture were noted both at rest and during MIS. These improvements can potentially lead to reduced surgical fatigue and a reduction in fatigue-related surgical errors and repetitive stress injuries. sleep-related breathing disorders in those children presenting with NE. The DVISS scores did not impact the mean OSA-18 score. SDB was more likely present in patients with no daytime element of incontinence. These data suggest that patients with NE have SDB and SDB is greatest in those with no daytime incontinence and normal voiding patterns. The authors recommend that children with NE should be screened for OSA. Future research will focus on treatment of OSA and its impact on the resolution of NE. ready to transition to adult care but about two-thirds (60%) wanted a more gradual transition. Just over half preferred to make more decisions concerning their care. The rating of the pediatric SB clinic was 9.18 and the adult SB clinic 7.35/10. In summary, although trends suggest successful transitioning of patients to adult SB clinics, the adult clinics are rated lower. Barriers and other problems need to be addressed in order for the results of this challenge to be successful. Double HydrodistentionImplantation Technique Endoscopic Treatment of Primary VUR Sleep-Disordered Breathing and Nocturnal Enuresis Transition of Care to an Adult Spina Bifida Clinic: Patient Perspectives and Medical Outcomes Obstructive sleep apnea (OSA) may contribute to nocturnal enuresis (NE).2 Bascom and colleagues from Edmonton, Canada, performed a prospective study to determine the prevalence of OSA in children with monosymptomatic NE (MNE) and diurnal and nighttime enuresis (DNE). They hypothesized that children with MNE had a greater prevalence of OSA than those with DNE. Three surveys were administered including the OSA-18, which assesses quality-of-life parameters in children with sleep-disordered breathing (SDB), the Modified Pediatric Sleep Questionnaire (PSQ-22), which evaluates SDB and behavioral disturbances, and the Dysfunctional Voiding and Incontinence Scoring System (DVISS) to quantify the effects of dysfunctional voiding and bowel problems. Of the 42 children participating in the study, 31 (74%) had a positive DVISS score. The mean baseline of the OSA-18 score was 49.5 out of 126 indicating that sleep apnea had a mild impairment of quality of life. More than half (26) of the patients had a positive score on the PSQ-22, suggesting a high incidence of Cox and colleagues in Halifax, Canada, examined the patient and parent perspectives of transitioning urological and neurosurgical care, and determined the barriers for this to be successful in this population.3 Only 20 of 94 adult spina bifida (SB) patients participated by completing three telephone surveys: the Medical Outcomes 36-Item Short Form Health Survey (SF-36), the Ambulatory Care Experience Survey (ACES), and a Transition of Care Survey. Five of the 20 surveys were completed by parents. Urological and neurosurgical outcomes were correlated with patient and parent perspectives. Almost half of the participants had a postsecondary education and 30% were using their education. Fourteen of the 15 patient responders were wheelchair bound and 12 lived with their parents. Twothirds of the patients described their health as good to very good. Almost 75% felt that they were limited in their work and social activities by their physical health. About 75% of the adult caregivers were felt to listen, have adequate knowledge about the patient’s medications, and provided clear instructions. Many (73%) were The clinical versus radiologic success rate after injection with dextranomer/ hyaluronic acid copolymer is variable, ranging from 90% to 99% and 69% to 90%, respectively.4 This study examined a group of patients undergoing double hydrodistention-implantation technique (HIT) endoscopic treatment with follow-up consisting of an early ultrasound and a voiding cystourethrogram (VCUG) beyond 1 year. If the implants were seen on the ultrasound performed at 4 to 6 weeks, the antibiotic was discontinued and a VCUG was scheduled at 1 year. A negative VCUG defined radiologic success, and no febrile UTIs defined clinical success. Of the 54 patients entering into the study, 91% underwent an ultrasound at 6 weeks but 49% (24) were noncompliant at the 1-year followup. Eighteen of 24 were contacted to assess their clinical status. Only 2 of 28 patients had persistent VUR at 1 year for a radiographic success rate of 93%. One patient had improved VUR, one showed no change, and one showed new contralateral reflux. Despite persistent VUR, the patients had no infections. Clinical status was available for 25 compliant and 18 noncompliant patients. Of VOL. 13 NO. 1 2011 REVIEWS IN UROLOGY 51 RiU_Apr2011_p50-52.qxd 4/13/11 10:29 AM Page 52 New Insights in Pediatric Urology continued these 43 individuals, 3 had a febrile UTI for a clinical success rate of 93%. This long-term study of the double HIT method shows similar success radiographically and clinically, with more favorable outcomes and fewer reoccurrences than previously reported. The authors question the need for radiographic follow-up in asymptomatic patients. References 1. 2. Reddy PP, Reddy T, Roig-Francoli J, et al. The impact of the Alexander technique in improving surgical ergonomics and the surgeon’s posture during minimally invasive surgery. Paper presented at American Academy of Pediatrics Section on Urology Annual Meeting; October 2-4, 2010; San Francisco, CA. Abstract 42. Bascom A, Penney T, Eng B, et al. Sleepdisordered breathing and nocturnal enuresis. Paper presented at American Academy of Pediatrics Section on Urology Annual Meeting; October 2-4, 2010; San Francisco, CA. Abstract 44. 3. Cox AR, Breau LM, Connor L, et al. Transition of care to an adult spina bifida clinic: patient perspectives and medical outcomes. Paper presented at American Academy of Pediatrics Section on Urology Annual Meeting; October 2-4, 2010; San Francisco, CA. Abstract 45. 4. Kalisvaart JF, Scherz HC, Cuda S, et al. Prospective long-term follow-up indicates low risk of recurrence after double HIT endoscopic treatment for primary vesicoureteral reflux (VUR). Paper presented at American Academy of Pediatrics Section on Urology Annual Meeting; October 2-4, 2010; San Francisco, CA. Abstract 37. Main Points • Improvement in posture, trunk and shoulder endurance, and surgical ergonomics occurred after an Alexander Technique training program. By subjective and objective measures, the improvements in posture were noted both at rest and during minimally invasive surgery. These improvements can potentially lead to reduced surgical fatigue and a reduction in fatigue-related surgical errors and repetitive stress injuries. • Data suggest that patients with nocturnal enuresis (NE) have sleep-disordered breathing (SDB) and SDB is greatest in those with no daytime incontinence and normal voiding patterns. The authors recommend that children with NE should be screened for obstructive sleep apnea. • Although trends suggest successful transitioning of patients to adult spinal bifida clinics, the adult clinics are rated lower. Barriers and other problems need to be addressed in order for the results of this challenge to be successful. • A long-term study of the double hydrodistension-implantation technique method shows success radiographically and clinically, with more favorable outcomes and fewer reoccurrences than previously reported. The authors question the need for radiographic follow-up in asymptomatic patients. 52 VOL. 13 NO. 1 2011 REVIEWS IN UROLOGY