Update in Pediatric Urology

Annual Meeting of the American Academy of Pediatrics Section on Urology

MEETING REVIEW Update in Pediatric Urology Highlights From the Annual Meeting of the American Academy of Pediatrics Section on Urology November 28-29, 2000, Chicago [Rev Urol. 2001;3(1):10-17] Key words: Cryptorchidism • Enuresis • Hypospadias • Reflux • Torsion • Ureterocele • Urinoma T he well-attended annual scientific session of the American Academy of Pediatrics Section on Urology brought together an international group of pediatric urologists. Highlights of the presentations are discussed below. Undescended Testis/Torsion/ Prosthesis Although the literature suggests that men with a history of unilateral cryptorchidism have about a 90% fertility rate, Lee and colleagues1 examined the relationship between testicular size at orchiopexy and paternity. Of 166 individuals at orchiopexy, 98 had a small testis, 65 had a normal-sized testis, and 3 had a large testis for age. Overall, there was an 89.8% paternity rate, and testicular size was not a predictor of paternity. Of 98 small testes, 19 were atrophic, and all but 1 of the individuals with an atrophic testis reported successful paternity. Testicular size, including atrophic testes, did not adversely affect paternity, even in the subfertile group (defined as longer than 12 months to conception). Age at orchiopexy also had no influence on paternity. In the patients studied, the contralateral testis was normal or larger. Hormonal levels and sperm counts were not different among the groups. Patients with a history of small or normal-sized testes had no Reviewed by Ellen Shapiro, MD, FACS, FAAP, New York University School of Medicine, New York. 10 REVIEWS IN UROLOGY WINTER 2001 testicular volume differences in adulthood, although the previously undescended testis remained smaller than the contralateral testis. Recently, there have been reports that hormonal treatment may suppress the number of germ cells in boys, aged 1 to 3 years, with cryptorchidism.2 Hadziselimovic and coworkers3 determined the rate of apoptosis in testes in 12 infants who had received gonadotropin-releasing hormone and human chorionic gonadotropin and in 12 boys who received no hormones before orchiopexy. Biopsy was obtained 2.3 months after unsuccessful hormonal therapy. Surprisingly, 57% of the hormonally treated group had normal germinal epithelium versus 12.5% of the nontreated group. No apoptosis was observed in either of the groups. In 1976, Rajfer and Walsh4 reported on hypospadias and cryptorchidism. They found an intersex condition in 53% of patients with cryptorchidism and hypospadias who had ambiguous genitalia versus 27% of those patients in whom the genitalia were not ambiguous. More recently, Kaefer and associates5 noted that intersex conditions were more likely when there were severe hypospadias and impalpable testis(es). Fenig and coworkers6 studied differences in testicular histopathology in boys with undescended testis(es) with and without hypospadias. Of 1549 boys undergoing orchiopexy, 69 (4.5%) had hypospadias with unilateral or bilateral undescended testes. Bilateral undescended testes were more commonly associated with proximal hypospadias than was unilateral undescended testis. There were no differences in testicular pathology in the group with unilateral undescended testis, with or without hypospadias. Surprisingly, the contralateral testis volume in males with unilateral undescended testis and proximal hypospadias was significantly smaller when compared with controls. Bilateral undescended testes’ histopathologic changes were significant, regardless of whether proximal hypospadias was present. Therefore, more significant hormonal defects may be present when there is unilateral undescended testis and proximal hypospadias, as reflected in the changes in the contralateral descended testis. In bilateral cryptorchidism, the testicular changes are severe, independent of the hypospadias status. It has been thought that the testis undergoes medial rotation in testicular torsion. Mevorach and colleagues7 reported on 146 patients undergoing scrotal exploration for testicular torsion. Medial rotation occurred in only 100 testes (68%), with lateral rotation occurring in the remaining testes. There was no difference in the percentage of left or right testes involved, and lateral rotation occurred equally on each side. Therefore, one must consider this new information when performing manual detorsion in the emergency room setting, since orchiectomy Pediatric Urology was associated with 540 degrees of torsion and salvage of the testis was associated with 360 degrees of torsion. A multicenter clinical trial has examined a new saline-filled testicular prosthesis (the gel-filled prosthesis is no longer available in the United States).8 Prostheses were implanted in 145 patients, half of whom were younger than 18 years. The prosthesis was placed through either an inguinal or a scrotal incision. The appropriate-size silicone shell of the implant was filled with saline intraoperatively, through an injection port. The volume instilled correlated with the desired size. Complications were uncommon, including scrotal hematoma, keloid formation, scrotal edema, and infection. One patient had extrusion of the prosthesis following trauma, and none of the patients had migration or deflation of the prosthesis. Diversion/Augmentation Cystoplasty Drs Van Savage and Yepuri9 described a catheterizable transverse retubularized sigmoidovesicostomy to the umbilicus, which was performed in 4 patients with spina bifida. The mean length of this sigmoidovesicostomy (equal circumference of the sigmoid before retubularization) was 13 cm. All segments reached to the umbilicus and were easily catheterizable. Urinary continence was satisfactory. This technique is similar to the Monti procedure, which utilizes ileum, and should be added to our surgical reconstructive armamentarium for the creation of a continent urinary diversion. The long conduit obviates the need for the double Monti procedure in obese patients. Roth and colleagues10 reviewed the Children’s Hospital (Boston) experience with gastrocystoplasty and GI composite bladder augmentations during the past 10 years. Urodynamic findings were correlated with urinary continence, reflux, hydronephrosis, urinary tract infection (UTI), and the hematuria-dysuria syndrome. The age range of patients was 17 months to 23.3 Main Points • In patients with unilateral cryptorchidism, age and testicular size at orchiopexy have no influence on paternity. • Both medial and lateral rotation occur in testicular torsion. • Delayed open surgery for ureteroceles does not lead to increased morbidity. • Initial percutaneous catheter placement for kidney drainage in patients with urinoma may obviate the need for open surgery. • A pelvic floor muscle retraining program may help decrease surgical intervention in patients with reflux. • Scarring is lower in children with high-grade reflux detected by screening versus presentation with urinary tract infection. • Long-term use of desmopressin for nocturnal enuresis is safe and may be efficacious. years; the mean follow-up was 4.7 years. Although bladder capacity was significantly increased (at least 3-fold) after gastrocystoplasty, there was a 60% (26 of 43) incidence of day and/or nocturnal incontinence. Hypertonicity occurred initially in 32 patients (74%) and persisted in 20 (47%) after the first year. Hypertonicity was associated with incontinence (16), reflux (4), the hematuria-dysuria syndrome (4), and febrile UTI (4) in a significant percentage of these patients. Therefore, one should consider using other GI segments in bladder reconstruction. Ureterocele/Ectopic Ureter Treatment of ureteroceles remains controversial. Most children with nonfunctioning upper-pole moieties are given antibiotic prophylaxis and undergo partial nephrectomy at age 3 to 6 months. It has been thought that delayed intervention results in increased morbidity. A study compared the UTI rate and incidence of bladder neck obstruction with antibiotic alone and delayed open surgery versus primary endoscopic therapy and antibiotics.11 Of 72 patients, 40 were randomized to antibiotics alone versus 32 who underwent endoscopic therapy and antibiotic prophylaxis. Complications developed in 5 patients (13%) in the antibiotic-only group: 3 (8%) had UTI and 2 (5%) had an increase in the size of the ureterocele with subsequent increase in hydronephrosis from bladder neck obstruc- tion. Complications developed in 4 patients (13%) in the primary endoscopic group. There was a 9% incidence of UTI, and 3% developed increased hydronephrosis because of incomplete puncture of the ureterocele. These data show that delayed open surgery does not lead to greater morbidity in these patients. There is continued interest in determining the best treatment for reflux or obstruction associated with complete ureteral duplication. Lashley and colleagues12 reported their experience with ureteroureterostomy with or without a lower-pole ureteral reimplantation. Most of the 100 ureteroureterostomies were performed for reflux or for an obstructed upper-pole moiety associated with a ureterocele or an ectopic ureter. Ureteroureterostomy can be technically challenging when there is a significant size discrepancy (defined as 2 times the diameter of the recipient ureter). Ureteroureterostomy with and without ureteral reimplantation was successfully performed in almost all patients, with only 6 failures. A significant ureteral size discrepancy was noted in 69 kidneys; 4 of the 6 unsuccessful cases were in this group. Although there were 21 complications in 19 patients, all of these patients had successful outcomes long-term. The study shows that ureteroureterostomy can be used for problems associated with duplicate ureters despite significant ureteral size discrepancy. continued WINTER 2001 REVIEWS IN UROLOGY 15 Pediatric Urology continued Trauma Although major renal trauma is managed conservatively, there is no consensus on the treatment of patients with significant renal injury involving a laceration extending into the collecting system, with urinary extravasation. In a study involving 15 patients who sustained this degree of blunt trauma, 9 received no intervention and 1 underwent nephrectomy for bleeding and hypertension.13 Of the 5 patients in whom a urinoma developed, all underwent percutaneous catheter drainage of the kidney. Two required subsequent stent placement for persistent leakage. There were no sequelae seen in 13 of 15 patients, and only 1 patient who was treated with a percutaneous catheter developed hypertension requiring a partial nephrectomy. These investigators recommend that all patients who develop a urinoma undergo initial percutaneous catheter placement, which in most cases obviates the need for open surgery. Dysfunctional Voiding/Reflux/ Urinary Tract Infection There is increasing awareness of the relationship between dysfunctional voiding, constipation, and reflux. Herndon and McKenna14 employed a pelvic floor muscle retraining (PFMR) program to improve voiding. Of 51 patients with reflux and dysfunctional voiding, 37 were females. There were 47 renal units with low-grade reflux and 24 with high-grade reflux. The average age was 8.7 years, and the patients underwent, on average, 5 sessions. Only 6% of these patients had breakthrough infections. There was resolution of reflux in 24 of 71 renal units, 17 with low-grade reflux and 7 with high-grade reflux. The mean age for reflux resolution was 9 years. Reflux improved in 11 patients. Almost 90% of those with high-grade reflux had high postvoid residuals. The authors cautioned against the use of anticholinergic therapy in these patients and concluded that the finding 16 REVIEWS IN UROLOGY WINTER 2001 of postvoid residuals is important. During the past 21 months, the overall surgery rate has been decreased by 95% in their institution, and the authors attribute their improved resolution rate and decreased breakthrough infection rate to the PFMR program. There has been an increasing trend to discontinue use of prophylactic antibiotics for select patients with vesicoureteral reflux (VUR). Recently, investigators at Children’s Hospital of Philadelphia reported on the cessation of antibiotic prophylaxis in select older patients with VUR who had no current history of dysfunctional voiding patterns.15 Thompson and associates16 studied 196 patients with primary VUR (less than grade 3 to 5) who were followed off antibiotic prophylaxis. Four patients with high grades of reflux discontinued antibiotics against medical advice. The patients were followed on and off antibiotics for a similar period (approximately 3 years), and a similar number of patients (122 and 124) were infection-free on and off antibiotic prophylaxis. The infection rate on and off antibiotics was almost identical: 0.29 and 0.24 UTI/patient year. Almost all patients had baseline dimercaptosuccinic acid (DMSA) scans, and 41% (72 of 176) had scarring or decreased differential function. There was no difference in the number of new scars seen on or off antibiotic prophylaxis. The authors concluded that stopping antibiotic prophylaxis before resolution of reflux can be safe in select patients. Noe17 reported that the incidence of reflux in asymptomatic siblings is 34%. The Vanderbilt group found that 51% of 78 siblings had reflux on screening voiding cystourethrography. None had evidence of scarring by ultrasonography.18 All but 1 patient had less than grade 3 to 5 VUR, and two thirds of patients had bilateral VUR. Reflux resolution occurred in 65%, with a mean time to resolution of 16.6 months. Although 18 (69%) of 26 had grade 1 or 2 reflux, the remainder had grade 3 or 4. This study reiterates the high incidence of reflux in siblings. Sibling reflux appears to resolve at a faster rate, and there is a lower incidence of scarring and UTI. This may be due to prompt medical management before the development of symptoms. Sweeney and colleagues19 studied the incidence of reflux nephropathy in patients with high-grade reflux with and without infections. Of 127 infants (194 refluxing units) undergoing surgery for grade 4 or 5 VUR, 76% (97 patients, or 148 refluxing units) presented with UTI. All patients had DMSA scans, and most were followed for at least 3 years. Renal scars were present in 38% of 106 grade 4 refluxing units and in 67% of 42 grade 5 refluxing units. Of those remaining 30 of 127 with 46 refluxing units presenting without a UTI, 6 (29%) of 21 grade 4 refluxing units and 9 (38%) of 24 grade 5 refluxing units had evidence of scarring. Therefore, scarring is lower in children with highgrade reflux detected by screening versus UTI presentation. Frequently, parents ask about the long-term effects of prophylactic antibiotic use. The Stanford University investigators examined antibiotic resistance in bacteria causing UTI in children given trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin prophylactically.20 Of the 47 children (aged 3 months to 16 years) with UTI, 25 and 22 UTIs occurred in patients receiving TMP-SMX and nitrofurantoin, respectively. The organisms were resistant to TMP-SMX (84%) more frequently than to nitrofurantoin (55%) prophylaxis. The most common infecting organism was Escherichia coli. This study shows that children on prophylactic antibiotics are at higher risk for UTI with an organism that is resistant to their current antibiotic. This resistance is more commonly seen when the agent is TMP-SMX. Although resistance may be caused by various factors that are not known at this time, these data should be considered in the initial choice of antibiotic for prophylactic use. Pediatric Urology Nocturnal Enuresis References 21 Zaontz and colleagues studied the long-term efficacy of desmopressin therapy. There were 76 patients studied, and 67 were currently receiving desmopressin. Thirty patients had been taking desmopressin for more than 1 year (mean, 28 months). The researchers found that 42% were completely dry, 19% had more than a 50% reduction in wet nights, and 39% had no response. An 8.9% side-effect rate occurred with use of the nasal spray, including nosebleeds, headache, and rash. Only 2 of the 6 patients with side effects had been receiving the drug for longer than 1 year. Oral desmopressin therapy was started in 23 of the 67 patients. Sixtyfive percent of these patients had no change in their continence status using the oral medication. Seven (30%) of 23 showed improvement, and 3 of these patients were completely dry. One child became incontinent again. Nine patients remained on oral therapy for more than a year and reported no side effects. A disconcerting feature of this study was the lack of durability. On long-term follow-up, 6 (21%) of 29 patients were dry each night, 9 patients had varying success with continence each week, and 14 were incontinent each night. The authors concluded that 60% of patients had excellent/very good response to desmopressin after 7 years of therapy. There is a suggestion that oral therapy may be efficacious and that it does not appear to have any side effects. ■ 1. Lee PA, Coughlin MT, Bellinger MF. No relationship between testicular size at orchiopexy and fertility among formerly unilateral cryptorchid males. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 2. 2. Cortes D, Thorup J, Visfeldt J. Hormonal treatment may harm the germ cells in 1 to 3-year-old boys with cryptorchidism. J Urol. 2000;163:1290-1292. 3. Hadziselimovic F, Lala R, Geneto R, Emmons LR. Questioning the present paradigm: does current hormonal treatment of cryptorchidism affect fertility? Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 3. 4. Rajfer J, Walsh PC. The incidence of intersexuality in patients with hypospadias and cryptorchidism. J Urol. 1976;116:769-770. 5. Kaefer M, Diamond D, Hendren WH, et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J Urol. 1999;162(pt 2):1003-1007. 6. Fenig DM, Hutcheson JC, Canning DA, et al. Testicular histology in patients with proximal hypospadias and undescended testes. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 25. 7. Mevorach RA, Hulbert WC, Goldstein MM, Rabinowitz R. Testicular torsion: direction, degree, duration, and disinformation. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 5. 8. Ortenberg J, Scherz H, Kogan S. Saline-filled testicular prosthesis in children and adolescents. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 6. 9. Van Savage JG, Yepuri JN. Transverse retubularized sigmovesicostomy continent urinary diversion to the umbilicus. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 35. 10. Roth JA, Borer JG, Hendren WH, et al. Is gastric augmentation a good long-term urodynamic solution to the poorly functioning bladder? Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 36. 11. Husmann DA, Strand WE, Ewalt DH, Kramer SA. Is endoscopic decompression of the ectopic ureterocele necessary for prevention of urinary tract infections or bladder neck obstruction? Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 62. 12. Lashley DB, McAleer IM, Kaplan GW. Uretero- 13. 14. 15. 16. 17. 18. 19. 20. 21. ureterostomy for treatment of vesicoureteral reflux or obstruction associated with complete ureteral duplication. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 42. Russell S, Gomelsky A, McMahon D, et al. Management of high-grade blunt renal trauma associated with urinary extravasation in pediatric patients. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 45. Herndon CD, McKenna PH. The treatment of dysfunctional elimination decreases urinary tract infections and surgery in children with vesicoureteral reflux. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 54. Cooper CS, Chung BI, Kirsch AJ, et al. The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol. 2000;163:269-273. Thompson H, Pugach JL, Naseer S, Steinhardt GF. Renal consequences of vesicoureteral reflux for patients off prophylactic antibiotics. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 55. Noe HN. The long-term results of prospective sibling reflux screening. J Urol. 1992;148(pt 2): 1739-1742. Parekh DJ, Adams MC, Pope JC IV, Brock JW III. Outcome of sibling vesicoureteral reflux. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 56. Sweeney B, Velayudham M, Cascio S, Puri P. Reflux nephropathy in infants: a comparison of infants presenting with and without urinary tract infection. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 57. Chen AK, Kennedy WA, Abidari JM, Shortliffe LD. Antibiotic resistance in bacteria causing urinary tract infections (UTI) in children taking urinary antibiotic prophylaxis. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 66. Zaontz MR, Dean GE, Glazier DB, Kesler SS. Long-term experience with desmopressin acetate in children. Paper presented at: American Academy of Pediatrics 2000 Annual Meeting; October 28, 2000; Chicago. Abstract 51. WINTER 2001 REVIEWS IN UROLOGY 17