Updates in Pediatric Urology

MEETING REVIEW Updates in Pediatric Urology Highlights of the American Academy of Pediatrics Section on Urology Annual Meeting, October 8-11, 2004, San Francisco, CA [Rev Urol. 2005;7(2):100-104] © 2005 MedReviews, LLC Key words: Pediatric urology • Wilms tumor • Orchiopexy • Varicocelectomy • Torsion • Circumcision • Reflux • Urinary tract infection • Paraureteral diverticulum he American Academy of Pediatrics Section on Urology Annual Meeting was held in San Francisco on October 8-11, 2004. One hundred sixteen papers and posters were presented on a wide range of topics, including cryptorchidism, genitourinary tumors, varicocele, exstrophy, sexual differentiation, reflux, hypospadias, neurogenic bladder, hydronephrosis, valves, and voiding dysfunction. Rudolf Hohenfellner, MD, was chosen to receive the Pediatric Urology Medal. Hohenfellner is best known for his contributions to pediatric and reconstructive urology. He is also recognized for popularizing the Lich-Gregoir technique for the treatment of vesicoureteral reflux, T Reviewed by Ellen Shapiro, MD, FACS, FAAP, Department of Neurology, New York University School of Medicine, New York, NY 100 VOL. 7 NO. 2 2005 ureterosigmoidostomy, and the Mainz II pouch for children. The meeting was well attended by pediatric urologists from North America, South America, Europe, and Asia. Clinical research abstracts of note are highlighted below. Genitourinary Oncology Bilateral Wilms Tumor Missed on Preoperative Imaging Ritchey and colleagues,1 from the National Wilms Tumor Study Group (NWTSG), reported on the fate of bilateral lesions found to be Wilms tumor but missed on preoperative imaging. The study reexamined the question of contralateral renal exploration in children undergoing nephrectomy for Wilms tumor. Of 3335 patients, 188 (5.6%) had bilateral Wilms tumor. The 11 patients for whom the diagnosis of bilateral Wilms tumor was made only at surgical exploration comprised REVIEWS IN UROLOGY 5.9% of the bilateral tumor patients but only 0.3% of all patients enrolled in the fourth National Wilms Tumor Study. Two patients were not included because they had not undergone preoperative imaging studies. Missed lesions were less than 1 cm (6) and 1 to 2 cm (3) and were managed by enucleation (2), biopsy (6), and no surgery (1). Five children received doxorubicin, dactinomycin, and vincristine, and 3 received dactinomycin and vincristine alone. Pathology studies in 8 patients revealed nephrogenic rest (1), Wilms tumor (4), and tissue indistinguishable between Wilms tumor and nephrogenic rest (3). Follow-up ranged from 1 to 12 years (median 9 years), with no recurrences in any of the kidneys with the missed lesion. All 9 patients were disease free at their last examination. Because the outcomes in “missed lesions” are uniformly excellent, contralateral tumor exploration will no AAP Section on Urology longer be recommended for patients undergoing nephrectomy for radiographic evidence of a unilateral renal tumor. Surgical Complications After Nephrectomy for Wilms Tumor Ritchey and colleagues,2 from the NWTSG and the International Society of Pediatric Oncology (SIOP), reported on surgical complications after nephrectomy for Wilms tumor. Two groups of patients were evaluated in Testis Intermittent Testicular Torsion Eaton and coworkers,3 from Children’s Hospital Boston (Boston, MA), examined the features of intermittent testicular torsion and the indications for elective transscrotal orchiopexy. These investigators reviewed patients aged 1 to 18 years who presented with acute scrotal pain and spontaneous resolution and who underwent bilateral testicular transscrotal orchiopexy. The study included 51 patients, with a The patients for whom the diagnosis of bilateral Wilms tumor was made only at surgical exploration comprised only 0.3% of all patients enrolled in the fourth National Wilms Tumor Study. this study: 326 in the NWTSG and 360 from the SIOP. The complication rates of the 2 groups were not statistically significantly different: 9.8% for the NWTSG and 6.8% for the SIOP. The most common problems were hemorrhage, bowel obstruction, and tumor spillage. Bowel obstruction was significantly increased in the NWTSG (4.5% vs 0.8% in SIOP). Intraoperative tumor spill was also significantly greater in the NWTSG (15.3% vs 2.2%), and stage III tumors were more common in the NWTSG (40% vs 14.2%). Resection of organs occurred more frequently in the NWTSG (15% vs 7%). In the SIOP, 51% of surgeons had performed more than 6 nephrectomies in the past 2 years, compared with only 24% of the NWTSG surgeons. When the tumor stage was primarily I or II, there was less frequent removal of other organs and less tumor spillage. This was more commonly seen in the SIOP group, because they commonly administer preoperative chemotherapy. This study also demonstrated that patients treated by surgeons who perform more nephrectomies annually have fewer complications. mean age of 12 years. The mean number of episodes of pain before surgery was 4.3. All patients had had severe pain. Most had a rapid onset as well as a rapid resolution of the pain. Approximately 25% had nausea and vomiting or were awakened from sleep. Only 14% had pain associated with activity, and 7% had abdominal pain. Half the patients presented with a horizontal lie of testis when there was no pain. During pain, 33% had a horizontal lie of testis, half had scrotal swelling, and another third had elevation of the deformity, comprising 30 of 50 surgical reports. Six had a small scarred appendix testis, and 2 had an inflamed epididymis. Of the patients undergoing exploration, 92% had resolution of their pain, and 8% had a recurrence in the affected testis at 3, 12, and 13 months postoperatively. None of these episodes were torsion. The investigators conclude that bilateral transscrotal orchiopexy is effective in almost all patients (92%) who develop scrotal pain that is rapid in onset and rapid in resolution. Hydrocele After Laparoscopic Varicocelectomy Hassan and colleagues,4 from Vanderbilt Children’s Hospital (Nashville, TN), examined whether hydrocele occurs more frequently after a laparoscopic technique of varicocelectomy. They evaluated 63 patients who had varicoceles treated by laparoscopic ligation of the internal spermatic vessels. Patients were seen at 1 and 12 months postoperatively. The mean follow-up was 7.6 months. Almost 25% of the patients developed a hydrocele, 4 of whom required surgical intervention. In 28 patients with more than 6 months’ follow-up, 40% were found to have developed a hydrocele on physical examination. The investi- Hydrocele formation after varicocelectomy might be underreported in the literature because follow-up intervals are often short. testis. Only 20% had an absent cremasteric reflex. Ultrasound findings when pain was absent showed a hydrocele in one third of patients; only 8% had altered echogenicity, and only 4% showed decreased or no blood flow. When pain was present, almost 50% had decreased or no blood flow, one third had altered echogenicity, and 23% had a hydrocele. At surgery, 77% were found to have a bell clapper gators also found that approximately 30% of patients who underwent both ligation and division of the spermatic vessels (29.3%) instead of ligation alone (13.3%) developed a hydrocele, although this was not statistically significant. This study shows a high rate of hydrocele formation, especially when patients are followed up beyond 6 months. It is thought that hydrocele formation might be underreported in VOL. 7 NO. 2 2005 REVIEWS IN UROLOGY 101 AAP Section on Urology continued the literature because follow-up intervals are often short. The investigators propose that the laparoscopic varicocelectomy might not be the best method for vessel ligation, owing to the high rate of hydrocele formation. Perinatal Torsion Yerkes and colleagues,5 from Riley Hospital for Children (Indianapolis, IN) and Wilford Hall Medical Center (San Antonio, TX), reported on the management of perinatal torsion, a subject that remains controversial. Although there is rare salvage of the gonad that has undergone torsion, it is becoming increasingly common to explore neonates as soon as a problem is suspected, obviating the devastating consequences of asynchronous neonatal torsion, which almost every pediatric urologist has observed. There No anesthetic-related complications occurred. These investigators concluded that bilateral asynchronous torsion, although uncommon, is devastating. Contralateral torsion was not suspected before exploration. Large hydroceles do not permit adequate assessment of a contralateral testis. Bilateral asynchronous torsion has consistently poor outcomes. Aggressive management of the unilateral suspected perinatal torsion is recommended. Recently, a neonate at our institution was noted to have large bilateral hydroceles and impalpable testes. A sonogram was obtained only to document the presence of descended normal-appearing testes. At that time, normal flow was observed on the right and no flow in the left testis. There was slight increased echogenicity on the left compared Bilateral asynchronous torsion, although uncommon, is devastating. have been concerns about the risk of anesthesia in the neonate versus the potential risk of bilateral testicular loss. This study was undertaken in academic centers or in major metropolitan areas where pediatric anesthesia was available and where early exploration for suspected perinatal torsion is routinely practiced. Six cases were identified for review. Bilateral extravaginal torsion was found in 4 patients, and bilaterality was not suspected at the time of presentation or referral from outside facilities. In 2 of these patients, a contralateral hydrocele did not permit examination of the testis. Atrophy occurred in all of the gonads that had undergone torsion, even when salvage was attempted in the testis with better perfusion. Intravaginal torsion and a contralateral bell clapper deformity were noted in 1 patient, and contralateral atrophy was found at the time of exploration in another patient. 102 VOL. 7 NO. 2 2005 with the right. There were no scrotal wall changes. In view of the change in echogenicity and unilateral absent blood flow, exploration was recommended. Intraoperatively, the left testis was found to have undergone extravaginal torsion, and the right testis was entirely normal. In this case, torsion had not been suspected, and it was fortuitous that an ultrasound was obtained for the purpose of identifying impalpable testes. Circumcision Palmer and colleagues,6 from both Rainbow Babies and Children’s Hospital (Cleveland, OH) and Schneider Children’s Hospital (New Hyde Park, NY), reported on their use of betamethasone cream (0.05%) three times daily for 3 weeks in patients who develop a cicatrix over the glans after circumcision. The investigators followed 14 boys who presented REVIEWS IN UROLOGY within 4 weeks of their neonatal circumcision. Each of them had the glans entrapped by a cicatrix of the preputial skin. There were no side effects to the betamethasone. Almost 80% developed softening of the tissue, with easy exposure of the glans. A mild cicatrix requiring a simple incision occurred in 2 patients, and 3 patients required formal circumcision revision. The investigators conclude that betamethasone cream is effective for infants with a trapped penis after neonatal circumcision. Betamethasone might provide complete retractability of the foreskin or obviate the need for complete formal revision of the circumcision. Undescended Testis Renzulli and investigators,7 at Yale University School of Medicine and Brown Medical School, reported their findings on the clinical and histologic significance of the testicular nubbin found on inguinal exploration after diagnostic laparoscopy for a nonpalpable testis. There is controversy as to whether inguinal exploration is necessary if a vas deferens and spermatic vessels exit the internal ring. Previous studies have shown a 10% incidence of viable germ cells in the specimen but did not determine whether a patent processus vaginalis was present. Inguinal exploration was performed after diagnostic laparoscopy in 110 children. There was no patent processus vaginalis in this group. The median age was 33 months. Almost 30% of cases were right-sided; the remainder were left-sided. Viable tissue was found in 7% of the testicular nubbins. These specimens showed calcifications, hemosiderin, and/or fibrosis. This study showed that the incidence of viable germ cell tissue is small when there is a closed internal ring. This supports the investigators’ hypothesis that this scenario is a different pathologic event from that AAP Section on Urology which occurs with a patent processus vaginalis. Nonetheless, they continue to recommend inguinal exploration despite the small number of patients with viable testicular tissue. Reflux and Urinary Tract Infection Congenital Paraureteral Diverticulum Afshar and colleagues,8 from the Hospital for Sick Children in Toronto, posed of patients with reflux alone and no PUD. The results showed that reflux resolved in 43%, persisted in 27%, and required surgery in 30% of renal units associated with PUD. Of 25 patients who underwent surgical intervention, 5 developed breakthrough infection or new renal scarring. The remainder of the operative group had undergone surgery before 1997. The incidence of breakthrough infection and new renal Shaikh and colleagues concluded that residual urine volume on postvoid ultrasound examination is a risk factor for the development of recurrent urinary tract infections. reviewed their findings on resolution rates of reflux in patients with congenital paraureteral diverticulum (PUD). It has always been thought that children with PUD have lower resolution rates of their reflux. In a group of 84 patients with PUD and reflux, the median age was 2 years, and 70% were male. Four patients had bilateral reflux. The grades of reflux were I to II in 39%, III in 35%, and IV to V in 26%. Follow-up ranged from 3 to 168 months, with a median of 47 months. The control group was com- scarring was similar to that of controls. Resolution rates in children with reflux associated with PUD were not statistically different from control resolution rates. Those with PUD had a 60% resolution rate for grades I to II, 39% for grade III, and 22% for grades IV to V, which is similar to the resolution rates in the control group (52%, 28%, and 33%, respectively). The investigators concluded that management of reflux in patients with PUD should be similar to that in patients with no PUD. Ultrasound Prediction of Recurrent Urinary Tract Infection Shaikh and colleagues,9 at the Children’s Hospital of Pittsburgh, studied whether ultrasound or uroflowmetry can predict which children with voiding dysfunction will develop recurrent urinary tract infections. They examined 114 patients who had a history of recurrent urinary tract infections. Residual urine samples were obtained, and then divided by the expected bladder volumes for age. Uroflowmetry was performed on select patients and categorized as either normal (bell-shaped curve) or abnormal (spiked, sawtooth, or plateau-type curve). The results showed that almost 20% of the patients who had postvoid bladder ultrasound examinations had considerable postvoid residual volumes. Eighty percent of the patients undergoing uroflowmetry had abnormal flow curves. The volume of residual urine corrected for age was positively correlated with the number of infections occurring after the initial visit. This relationship was significant even after controlling for gender, constipation, and reflux status. The investigators concluded that residual urine volume on postvoid ultrasound Main Points • Contralateral tumor exploration is unnecessary in patients undergoing nephrectomy for radiographic evidence of a unilateral renal tumor, because the outcomes in “missed lesions” are uniformly excellent. • Bilateral transscrotal orchiopexy is effective for almost all patients who develop scrotal pain that is presumed to be intermittent torsion. • Laparoscopic varicocelectomy might not be the best method for vessel ligation, owing to the high rate of hydrocele formation. • Bilateral asynchronous torsion, although uncommon, is devastating, with consistently poor outcomes; aggressive management of suspected perinatal torsion is recommended. • In infants with a trapped penis after neonatal circumcision, betamethasone cream might provide complete retractability of the foreskin or obviate the need for complete formal revision of the circumcision. • Management of reflux in patients with congenital paraureteral diverticulum (PUD) should be similar to that in patients with no PUD. • In asymptomatic siblings of children with vesicoureteral reflux, ultrasound screening identified siblings with significant reflux. VOL. 7 NO. 2 2005 REVIEWS IN UROLOGY 103 AAP Section on Urology continued examination is a risk factor for the development of recurrent urinary tract infections. Uroflowmetry was not useful in predicting infection recurrence in children with dysfunctional voiding. Ultrasound Screening for Reflux in Asymptomatic Siblings Giel and coworkers,10 from the University of Tennessee, reported on their use of ultrasound screening of asymptomatic siblings of children with vesicoureteral reflux. Noe and colleagues have shown that there is a significant increase in reflux in siblings. Although a voiding cystourethrogram (VCUG) has been recommended for siblings younger than 5 years, ultrasound screening Ultrasound screening identified siblings with significant reflux. New Reflux After Deflux Implantation Perez-Brayfield and colleagues,11 from Emory University, reexamined the question of new contralateral reflux after endoscopic implantation of dextranomer/hyaluronic acid copolymer (Deflux™; Q-Med AB, Uppsala, Sweden), because this occurs in up to 20% of patients. They studied 15 of 95 children with 3 months’ follow-up and a mean age of 4.4 years (new contralateral vesicoureteral reflux). Each of these patients’ development had been assessed with 2 or more VCUGs preoperatively. The mean maximal de- 3. 4. 5. 6. 7. Uroflowmetry was not useful in predicting infection recurrence in children with dysfunctional voiding. has been suggested in older siblings and for those whose parents refuse VCUG for their younger children. This study examined the long-term data on the use of ultrasound in asymptomatic siblings. Follow-up data were available for 85 of 117 (73%) of siblings screened with ultrasound. The average follow-up was 8.3 years. Of 85 siblings, 11 (9.4%) underwent VCUG when abnormal ultrasound results were found (9 asymptomatic siblings and 2 who developed urinary tract infections). It is interesting that the VCUG results were negative for the 2 who developed infections, whereas 5 of the 9 with abnormal ultrasound results were found to have vesicoureteral reflux. This study demonstrates the utility of ultrasound in screening a welldefined population at risk for reflux. 104 VOL. 7 NO. 2 2005 gree of reflux preoperatively was grade 2.3. The ureteral orifice was considered to be normal in all patients. The new reflux grades were I in 7 patients, II in 7 patients, and III in 1 patient. Thirteen patients are being observed, and in 1 the reflux has resolved spontaneously. These investigators recommend examining the nonrefluxing orifice at the time of endoscopy. If it appears abnormal, Deflux injection is recommended. 8. 9. 10. References 1. 2. REVIEWS IN UROLOGY Ritchey ML, Shamberger RC, Hamilton T, et al. Fate of bilateral lesions missed on preoperative imaging: a report from the National Wilms Tumor Study Group. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Podium Session 1, no. 1. Ritchey ML, Godzinski J, Shamberger RC, et al. Surgical complications following nephrectomy for Wilms tumor: a prospective study from the National Wilms Tumor Study Group (NWTSG) and International Society of Pediatric Oncology 11. (SIOP). Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Podium Session 1, no. 5. Eaton SH, Cendron MA, Estrada CR, et al. Intermittent testicular torsion: diagnostic features and surgical outcomes. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Podium Session 2, no. 8. Hassan JM, Pope JC IV, Adams MC, Brock JW III. Is hydrocele a too frequent complication of laparoscopic varicocelectomy? Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 2, no. 27. Yerkes EB, Robertson F, Gitlin J, et al. Management of perinatal torsion: today, tomorrow or never. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 2, no. 31. Palmer JS, Elder JS, Palmer LS. Topical steroids averts the need for reconstruction of the trapped penis in neonates. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 2, no. 29. Renzulli JF II, Caldamone AA, Mangray S. Clinical and histological significance of the testicular nubbin found on inguinal exploration following diagnostic laparoscopy in the absence of a patent processus vaginalis. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 2, no. 32. Afshar K, Malek R, Papanikolaou F, et al. Should the presence of congenital paraureteral diverticulum affect the management of vesico-ureteral reflux? Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Podium Session 6, no. 39. Shaikh N, Abedin S, Wise B, et al. Can ultrasonography or uroflowmetry predict which children with voiding dysfunction will develop recurrent urinary tract infections? Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Podium Session 7, no. 46. Giel DW, Noe HN, Williams M. Ultrasound screening of asymptomatic siblings of children with vesicoureteral reflux: a long-term follow up study. Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 3, no. 49. Perez-Brayfield MR, Kirsch AJ, Snodgrass W, et al. New contralateral vesicoureteral reflux following endoscopic implantation of DX/HA: when is contralateral treatment indicated? Presented at: Annual Meeting of the American Academy of Pediatrics Section on Urology; October 8-11, 2004; San Francisco, CA. Poster Session 7, no. 99.