Updates in Pediatric Urology

Highlights from the American Academy of Pediatrics Section on Urology Annual Meeting

MEETING REVIEW Updates in Pediatric Urology Highlights from the American Academy of Pediatrics Section on Urology Annual Meeting, October 18–21, 2002, Boston, MA [Rev Urol. 2003;5(3):186–190] © 2003 MedReviews, LLC Key words: Pediatric urology • Kidney and testis injury • Vesicoureteral reflux • Deflux • Ileocystoplasty • Robotically assisted laparoscopic surgery • Voiding dysfunction • Tolterodine tartrate • Miralax he Annual Meeting of the American Academy of Pediatrics Section on Urology was held in Boston, Massachusetts, on October 18–21, 2002. A total of 137 papers and posters were presented on a wide range of topics that included cryptorchidism, tumors, varicocele, exstrophy, sexual differentiation, reflux, hypospadias, neurogenic bladder, hydronephrosis, valves, and voiding dysfunction. Terry D. Allen, MD, former professor and chief of pediatric urology at the University of Texas T Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Urology, New York University School of Medicine, New York, NY 186 VOL. 5 NO. 3 2003 Southwestern Medical Center at Dallas, was awarded the Pediatric Urology Medal. Dr Allen received accolades for his many contributions that have shaped our understanding of voiding dysfunction, neurogenic bladder, intersex, and endocrine disorders. The meeting was well attended by pediatric urologists from the United States, Canada, and abroad. Highlights of the meeting are presented below. Trauma Corvino and colleagues1 reviewed the National Pediatric Trauma Registry from 1999 to 2000 to define the risk of kidney or testis injury in children who REVIEWS IN UROLOGY play contact sports. Three age groups were examined: 5 to 11 years, 12 to 14 years, and 15 to 18 years. The pediatric trauma centers saw 81,923 patients, and 5439 (6.64%) had sustained trauma while playing sports. Abdominal trauma occurred in 459 (0.56%) of the patients—almost half during contact sports and most during team sports. Injuries occurred most commonly during football (44%), but also during hockey (19%), baseball (15%), soccer (12%), and basketball (6%). Injuries by age group were 16% for 5 to 11 years, 42% for 12 to 14 years, and 42% for 15 to 18 years. Splenic injury was most common, occurring in 50% of Pediatric Urology Updates the patients, whereas renal injury occurred in 22%, most of whom were older teenagers. No testis injuries were reported. Football was associated with the most kidney injuries (62%), followed by baseball (14%), basketball (12%), hockey (7%), and soccer (5%). As a scan was performed at about 20 months of age and was normal in 74% of the patients in the 19 studies of the siblings, compared with 18% of the 35 examinations of index patients. When screening occurred in patients older than 2 years, there was a higher incidence of renal damage Football was associated with the most kidney injuries (62%), followed by baseball (14%), basketball (12%), hockey (7%), and soccer (5%). percentage of all organ injuries, the kidney was most commonly injured in basketball (45%) and football (32%) and less frequently injured in baseball (22%), hockey (19%), and soccer (9%). No nephrectomies occurred in this group. The authors concluded that abdominal injuries do not often occur during team and individual contact sports. During basketball and football, the kidney is at most risk for injury. Splenic injury is most common overall, and the kidney and spleen are at similar risk during basketball. on DMSA. The authors concluded that early screening appears to be useful because antibiotic therapy can be instituted in asymptomatic patients before the development of pyelonephritis and renal scarring. Puri and colleagues,3 from Dublin, Ireland, reported their experience with Deflux, a biodegradable injectable material (dextranomer/hyaluronic acid copolymer), for the endoscopic correction of reflux. They examined 113 children, with a median age of 1 year (range, 3 months to 10 years), with primary vesicoureteral reflux. able alternative to surgery in some patients with vesicoureteral reflux. Läckgren and coworkers,4 from the University Children’s Hospital in Uppsala, Sweden, reported on endoscopic treatment using Deflux injections for reflux associated with either double ureters or a small kidney. Of the 296 patients older than 1 year, 68% had duplicated ureters and 42% had a small kidney that contributed less than 35% to total renal function. Postoperative voiding cystourethrograms were obtained at 3 and 12 months. Some patients required a repeat injection. An excellent response was either no reflux or grade I reflux. Of 83 duplicated renal units treated, 43% had grade IV or V reflux and 64% showed resolution following the Deflux injection. The authors found the following success rates: grade II reflux, 100%; grade III, 70%; grade IV, 52%; and grade V, 75%. Sixty patients with a small kidney and grade IV or V reflux showed a 71% reflux resolution rate after 1 injection. A second injection was successful in 29% of the remaining group. Vesicoureteral Reflux Houle and associates,2 from Montreal, Canada, examined whether screening of siblings helps detect clinically significant vesicoureteral reflux (VUR). Of the 95 families surveyed, 123 patients were screened. VUR was found in 44 (36%) of the children (20 males, 24 females), with a median age of 9 months, in 40 (42%) of the 95 families. VUR was unilateral in 52% and bilateral in 48% of the children. Of those patients with unilateral reflux, 61% had grade II or lower and 39% had grade III or higher; of those with bilateral reflux, 52% had grade II or lower and 48% had grade III or higher. A normal ultrasound did not predict the severity of reflux: ultrasound was normal in 32% of the children with grade III reflux or higher. A dimercaptosuccinic acid (DMSA) Deflux is a reasonable alternative to surgery in some patients with vesicoureteral reflux. Endoscopic therapy was performed on 166 ureters; 58 of the patients had unilateral reflux and 54 had bilateral reflux. Of these patients, 7 (4.2%) had grade II VUR, 91 (54.8%) had grade III, 63 (38.0%) had grade IV, and 5 (3.0%) had grade V. Follow-up ranged from 3 months to 1 year. Correction of reflux occurred in 143 (86.0%) of the 166 ureters after 1 injection. An additional 22 patients showed resolution of reflux after 2 injections, and only 1 patient had resolution after a third injection. The experience with Deflux continues to be favorable, and Deflux is a reason- This study demonstrates that an endoscopic correction of reflux using Deflux for duplex ureters or reflux associated with small kidneys has resolution rates similar to single systems, even when patients have high grades of reflux. Metabolic Complications of Urologic Reconstruction Hafez and associates,5 from the Hospital for Sick Children in Toronto, Ontario, Canada, examined the longterm effect of ileocystoplasty on serum electrolytes, acid base profile, and bone mineral density (BMD) in VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY 187 Pediatric Urology Updates continued neurologically intact patients. Between 1988 and 1997, 25 patients underwent ileocystoplasty, at a mean age of 6 years, for diagnoses including exstrophy, bladder outlet obstruction, and rhabdomyosarcoma. None of the patients had a neurogenic bladder, and none was receiving alkalinization therapy. All patients had serial electrolytes, arterial blood gases, and BMD measured using dual-energy x-ray absorptiometry (DXA) scan- extravesical ureteral reimplant, nephroureterectomy, and renal cyst marsupialization, using transperitoneal laparoscopic access and the da VinciTM surgical robotics system. The age range of patients was 1.5 to 18 years. No complications occurred, and all patients were discharged within 72 hours. The authors noted that the robotics system was helpful in the detailed movement of suturing. In addition, the system allowed The robotics system was helpful in the detailed movement of suturing. ning. During the follow-up duration of 3 to 13 years (mean, 6.9 years), creatinine was normal in 20 (80%) of the 25 patients. The mean for age/sex-corrected BMD was 89%. There was a normal BMD in 17 (68%) of the 25 patients, and a mild reduction in BMD in 3 patients (12%); marked osteopenia was noted in 5 (20%) of the 25 patients. Of the 5 subjects with marked osteopenia, 2 had an elevated creatinine level, 1 had prior radiation for rhabdomyosarcoma, and 2 had short gut syndrome associated with cloacal exstrophy. The authors concluded that, if renal function was normal in this group of patients undergoing ileocystoplasty, then normal or only minimally reduced BMD would occur and electrolytes and arterial blood gases should remain normal. In patients who developed severe osteopenia, cofactors were usually responsible. Laparoscopy and Robotics Initial experiences with robotically assisted laparoscopic surgery (RALS) were presented from Children’s Hospital Boston and New York Medical College, Valhalla, NY.6,7 Peters and colleagues,6 from Children’s Hospital, performed procedures that included pyeloplasty, 188 VOL. 5 NO. 3 2003 the surgeon true 3-dimensional imaging, eliminated all tremor, and provided articulating instruments with 6 degrees of motion and scaling of movement. A similarly favorable experience was reported by Samadi and Franco,7 from New York Medical College, who performed surgeries similar to those done by Peters and colleagues, including varicocelectomy. All of their renal cases were discharged after 36 to 48 hours, except for 1 patient who developed a small bowel obstruction at a trocar site. The authors felt that the robotically assisted aspects of the surgery were most useful in the hilar dissection and ureteropelvic anastomosis during pyeloplasty because of the 3-dimensional stereoscopic images. Laparoscopy is often useful in performing some aspect of major urologic reconstructive surgery. Meldrum and coworkers,8 from the University of Pittsburgh, presented a 7-year experience in 27 patients with a mean age of 14 years. The follow-up period was 32 months. Twenty-six patients had at least 1 stoma. The procedures performed laparoscopically included lysis of adhesions, mobilization of the right colon and/or harvesting the appendix for a REVIEWS IN UROLOGY catheterizable stoma for the urinary tract or for an antegrade continence enema procedure, nephrectomy prior to ureteral augmentation, division of the pedicle of a gastrocystoplasty, and harvesting of the omentum for interposition. The procedures performed in these patients included bladder augmentation, bladder neck reconstruction, fascial sling, revision of an epispadias, and/or redo orchidopexy. Median hospital stay was 6 days. The stoma required revision in 8.3% of patients, and only a minor procedure was needed for 8 stomas. Almost all patients’ stomas were continent and easily catheterizable. The authors concluded that laparoscopicassisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated patients, obviating the need for an upper midline incision. Voiding Dysfunction Investigators from the Hospital for Sick Children in Toronto reported on the efficacy and safety of tolterodine tartrate (TT) in patients with a primary diagnosis of voiding dysfunction.9 All 34 patients who were diagnosed with voiding dysfunction were placed on behavioral modification for 6 months. When this was unsuccessful, an anticholinergic agent was added. Of the 20 subjects who underwent urodynamic studies, 19 demonstrated uninhibited detrusor contractions. The remaining 14 patients were empirically placed on oxybutynin chloride (OC) for a median of 6 months (range, 2-84 months). Participants were crossed-over to TT when side effects occurred. The dose of TT was 1 mg twice daily in 12 patients and 2 mg twice daily in 22 patients. No side effects were seen in 60% of the patients after 11.5 months. Six patients developed side effects similar to those seen with OC, but they were tolera- Pediatric Urology Updates ble, and the drug did not need to be discontinued. Eight patients, however, discontinued the medication because of side effects. At 1 year, there was a greater than 90% improvement in incontinent episodes in 23 patients (68%), a greater than 50% reduction in incontinent episodes in 5 patients, and a less than 50% reduction in incontinent episodes in 6 patients, who were considered failures of therapy. In summary, 77% of least 6 months. A history of constipation or hard, painful stools was important; encopresis was another worrisome complaint. The patients were started on a laxative regimen consisting of a daily dose of mineral oil for 5 days followed by daily milk of magnesia for 1 month. Of 85 patients, aged 3 to 12 years (mean, 6.6 years), 68 were females and 17 were males. All of the patients had urinary frequency and Laxative therapy alone improved the urge syndrome in 32% of the patients. the patients who would otherwise have discontinued their anticholinergic medication continued TT therapy. A great deal of emphasis has been placed on the association of bowel and bladder dysfunction. Snodgrass and Baseman,10 from the University of Texas Southwestern Medical School and the Children’s Medical Center in Dallas, reported on empiric laxative therapy in children with an urge syndrome. The urge syndrome was diagnosed by urinary urgency and frequency and by associated “holding" maneuvers and incontinence (day and night) that were present for at urgency. Almost 80% had daytime incontinence, and 65% had nocturnal enuresis; constipation was present by history in 43%. Laxative therapy alone improved the urge syndrome in 32% of the patients. Of 37 children considered to be constipated at the time of diagnosis, 30% resolved their urinary symptoms, compared with 33% of 48 patients who were not thought to be constipated. Therefore, dysfunctional voiding symptoms of urgency, frequency, and incontinence were improved in one third of the children following 1 month of laxative therapy alone. A history of constipation did not predict a patient’s response to the laxatives. The authors recommend behavioral modification and anticholinergic therapy only after laxative therapy has been instituted. Cooper and colleagues,11 from the University of Iowa, reported on the use of Miralax® as a new agent for constipation in children with dysfunctional elimination syndromes. Miralax is a nonaddictive, tasteless powder (polyethylene glycol) that can be mixed with any liquid. The study included 30 girls and 10 boys who had dysfunctional elimination for an average duration of approximately 6 months. The average final dose of Miralax was 0.6 mg/kg. Urodynamics and a postvoid residual were performed before and during therapy. Miralax improved the frequency of bowel movements in these children. There were no side effects except for diarrhea in 8 patients. Sixteen of the 40 children developed satisfactory continence, 18 had a diminution in their incontinence, and 5 were unchanged. There was some improvement in voided volumes but, more importantly, the postvoid residual decreased significantly. This study showed the efficacy, compliance, and Main Points • A study on the risk of organ injury in children playing contact sports showed that abdominal injuries do not often occur during either team or individual sports. The kidney is most at risk for injury during basketball and football. Splenic injury is most common overall, and the kidney and spleen are at similar risk during basketball. • A study of children with vesicoureteral reflux (VUR) concluded that, with early screening, asymptomatic children could be started on antibiotics before the development of pyelonephritis and renal scarring; a second study showed that the use of Deflux is a reasonable alternative to surgery in some children with VUR; and a third study found that endoscopic correction of VUR with the use of Deflux in children with duplex ureters or small kidneys had resolution rates similar to single systems. • Three favorable experiences with robotically assisted laparoscopic surgery in children found advantages in the system’s 3-dimensional imaging, elimination of tremor, and scaling of movement, as well as in functional outcomes in major urologic reconstructive surgery. • A study of voiding dysfunction showed that tolterodine tartrate reduced incontinent episodes in children; another study on the urge syndrome concluded that behavioral modification and anticholinergic therapy be started only after laxative therapy has been instituted; a third study found that Miralax improved the frequency of bowel movements in children with dysfunctional elimination syndromes. VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY 189 Pediatric Urology Updates continued lack of side effects of this new agent for the treatment of constipation in children with dysfunctional elimination problems. The authors recommend that, when initial improvement is not seen, an increase in the Miralax dose may be needed. 4. References 1. 2. 3. 190 Corvino, TF, Wan J, Greenfield SP, DiScala C. Contact sports and pediatric kidney and testicle injuries: data from the National Pediatric Trauma Registry. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 13. Houle AM, Rivest MC, Barrieras D, et al. Does screening of siblings help detect clinically significant vesicoureteral reflux? Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 20. Puri P, Chertin B, Velayudham M, et al. VOL. 5 NO. 3 2003 5. 6. 7. REVIEWS IN UROLOGY Treatment of vesicoureteral reflux by endoscopic injections of dextranomer/hyaluronic acid copolymer (DEFLUX): preliminary results. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 22. Läckgren G, Wåhlin N, Sköldenberg E, Stenberg A. Endoscopic treatment is effective in VUR associated with either double ureters or a small kidney. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Poster 52. Hafez AT, McLorie GA, Gilday D, et al. Longterm evaluation of metabolic profile and bone mineral density (BMD) following ileocystoplasty. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 32. Peters CA, Cilento BG, Borer JB, Retik AB. Robotically assisted laparoscopic surgery in pediatric urology. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 34. Samadi A, Franco I. Robotic assisted laparo- 8. 9. 10. 11. scopic surgery in pediatric urologic patients utilizing the da Vinci system. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 35. Meldrum K, Chung S, Docimo SG. Laparoscopic-assisted reconstructive surgery: functional outcomes. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Poster 12. Bolduc S, Upadhyay J, Bagli DJ, et al. Use of tolterodine in children after oxybutynin failure. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 40. Baseman AG, Snodgrass WT. Empiric laxative therapy in children with urge syndrome. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 10. Cooper CS, Erickson BA, Boyt MA. The utility of Miralax® for constipation in children with dysfunctional elimination. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 18-21, 2002; Boston, Mass. Podium 11.