The natural history of idiopathic urethrorrhagia in boys.

PURPOSE: We describe the presenting symptoms, evaluation and natural history of urethrorrhagia in boys. MATERIALS AND METHODS: The records of 27 consecutive toilet trained boys with idiopathic urethrorrhagia were retrospectively reviewed for information regarding age, symptoms, symptom duration, physical examination, and radiographic, endoscopic and laboratory data. Patient interviews were performed, and the resolution rate, symptom duration and associated urological abnormalities were evaluated. RESULTS: Mean age at presentation was 10.1 years. Symptoms included urethrorrhagia in 100% and dysuria in 29.6% of cases. Radiographic and laboratory evaluations were normal in all patients except for microscopic hematuria in 57%. Cystourethroscopy in 4 patients revealed bulbar urethral inflammation without stricture in 2. A total of 24 patients (89%) were followed an average of 37 months (range 10 to 106). Complete resolution developed in 46% of cases at 6 months, in 71% at 1 year and in 91.7% overall. The average duration of symptoms was 9.9 months (range 2 weeks to 38 months). In 2 boys (8.3%) urethrorrhagia persisted for 22 and 28 months, and in 1 cystoscopy revealed urethral stricture. Self-limiting urethrorrhagia recurred in 2 patients (8.3%) after initial resolution. Treatment consisted of watchful waiting in all patients except 1 with urethral stricture, who underwent urethral dilation. After urethrorrhagia resolved epididymo-orchitis recurred in 1 case. CONCLUSIONS: Routine radiographic, laboratory and endoscopic evaluation is unnecessary for evaluating urethrorrhagia. Watchful waiting is indicated because the condition resolves in 71% and 91.7% of patients at 1 and 2 years, respectively. Evaluation should be considered in patients with prolonged urethrorrhagia because urethral stricture may be identified.

Invasive group A streptococcus infection of the scrotum and streptococcal toxic shock syndrome.

We report a case of invasive group A streptococcus infection of the scrotum that presented as epididymoorchitis and rapidly progressed to streptococcal toxic shock syndrome. The presentation, pathophysiology, and management of invasive group A streptococcus and streptococcal toxic shock syndrome are reviewed. Rapid recognition is necessary to avoid the significant morbidity and mortality associated with these invasive infections.

Comparison of laparoscopic versus open nephrectomy in the pediatric population.

PURPOSE: Laparoscopic renal surgery has become an accepted approach for benign disease in adults. We compare our experience with laparoscopic and open nephrectomy in a pediatric population. MATERIALS AND METHODS: A total of 10 pediatric patients underwent laparoscopic nephrectomy or nephroureterectomy and an additional 10 consecutive children underwent similar open procedures. All patients had benign disease and were treated at a single institution. Medical records were reviewed retrospectively for relevant clinical data. RESULTS: Planned surgery was completed in all cases. There were no conversions to open surgery in the laparoscopic group. Mean operative time was 175.6 versus 120.2 minutes (p = 0.01) and mean hospital stay was 22.5 versus 41.3 hours (p = 0.03) in the laparoscopic and open nephrectomy groups, respectively. Blood loss was not statistically different. Analgesic use was qualitatively less in the laparoscopic nephrectomy group. CONCLUSIONS: Laparoscopic nephrectomy and nephroureterectomy may be performed safely in children. While operative time was somewhat longer in our initial laparoscopic series, postoperative hospital stay was significantly shorter than for open surgery. Further experience with this technique is warranted.

Cystic testicular lesions in the pediatric population.

PURPOSE: We present the etiology, histological evaluation and management of all cystic lesions of the pediatric testis. MATERIALS AND METHODS: Illustrative cases from our experience are reported with a literature review of all possible diagnoses. RESULTS: Included in the differential diagnosis of cystic testis lesions in children are epidermoid cyst, dermoid cyst, prepubertal teratoma, juvenile granulosa cell tumor, cystic dysplasia of the rete testis, testicular cystic lymphangioma, simple cyst and cystic degeneration after torsion. Testis sparing surgery is feasible in many circumstances. CONCLUSIONS: Cystic lesions of the pediatric testis are rare but represent an interesting group of diagnoses. Patient age at presentation, examination features, tumor markers and sonographic appearance may assist in making a presumptive and occasionally definitive diagnosis preoperatively. Based on the likely diagnosis enucleation or partial orchiectomy may be considered when performed with frozen section histological assessment. A thorough understanding of potentially cystic testis lesions in children leads to the best management choices and often to preservation of a substantial portion of the affected testis.

Percutaneous endoscopic trigonoplasty in children: long-term outcomes and modifications in technique.

PURPOSE: Long-term outcomes of a minimally invasive method of correcting vesicoureteral reflux are presented with a discussion of the modification in our original technique. PATIENTS AND METHODS: A total of 29 children (46 refluxing ureters), 14 months to 18 years old, underwent percutaneous endoscopic trigonoplasty (PET) between December 1994 and June 1996. Follow-up ranged from 19 to 37 months. Reflux was grade 1 in 2, grade 2 in 16, grade 3 in 19, grade 4 in 8, and grade 5 in 1. The technique was a Gil-Vernet method in the first 23 patients and Cohen reimplantation in the last 6 patients. RESULTS: Resolution of reflux was observed to decrease from 63% to 47% with long-term (30-37 months') follow-up using the Gil-Vernet technique. Resolution was greater with unilateral reflux than bilateral reflux (83% v. 27%, respectively). The Cohen technique resulted in resolution of reflux in 83%; however, the operating time nearly doubled when compared with the Gil-Vernet group. In both groups, failure was unrelated to grade of reflux, age, operative sequence, or bladder instability. CONCLUSIONS: Although showing an improvement in resolution of reflux over the Gil-Vernet PET procedure, the Cohen PET reimplant has a lower success rate than traditional open operative reimplants. The PET also requires more operating time and two operating surgeons. Despite some advantages in the promptness of recovery, we do not recommend PET by either technique at this time. Future modifications may make this approach more tenable.

Inflammatory (pseudosarcomatous) myofibroblastic tumor of the urinary bladder causing acute abdominal pain.

Inflammatory myofibroblastic tumor is a reactive proliferation of myofibroblasts that rarely involves the urinary bladder. The cause of inflammatory myofibroblastic tumor is unknown but may represent an initial reactive process to an infectious agent or trauma that transforms into neoplastic growth. Cases reported in children, however, often lack any preexisting bladder pathology. The authors present a case in a young child that presented as acute abdominal pain. In general, these tumors follow a benign clinical course after resection, although close monitoring is essential given the rarity of this bladder lesion.

Apparent unilateral ureteropelvic junction obstruction in the newborn: expectations for resolution.

PURPOSE: We retrospectively reviewed the records of patients with prenatal hydronephrosis to characterize those in whom it was more likely to resolve with conservative management. MATERIALS AND METHODS: We studied 51 patients in a 4-year period who presented with nonspecific unilateral hydronephrosis diagnosed by prenatal and confirmed by postnatal sonography. Patients were followed with sequential nuclear renograms with furosemide washout to evaluate function and drainage. In all cases a nonoperative approach was attempted. Pyeloplasty was performed only for poor or decreasing kidney function and/or drainage. RESULTS: Four of the 51 patients were lost to followup, 21 of the remaining 47 (45%) eventually underwent surgery, and 26 (55%) had complete normalization of renal function and washout pattern without surgery. There was no statistically significant correlation between hydronephrosis grade on initial postnatal sonography and the likelihood of nonsurgical resolution. However, the shape of the washout curve on nuclear renography was informative for predicting outcome, since 86% of the cases with a nonobstructive drainage pattern normalized without surgery, while 62% with indeterminate and only 18% with obstructive curves resolved with conservative management (p <0.01). Notably in 83% of the cases of normalization without surgery resolution occurred before age 18 months. Also, an initial obstructed washout pattern was more likely to be associated with a poor outcome. Of the 6 patients with less than 40% final differential function 5 had an obstructed washout pattern on the initial nuclear renogram. CONCLUSIONS: Patients diagnosed by prenatal ultrasound with apparent unilateral ureteropelvic junction obstruction generally do well with conservative treatment. However, those who present with an obstructed washout pattern are less likely to have resolution without surgery and more likely to have poor final differential function.

Surgery versus observation for managing obstructive grade 3 to 4 unilateral hydronephrosis: a report from the Society for Fetal Urology.

PURPOSE: The Society for Fetal Urology has undertaken the first multicenter prospective randomized study of high grade obstructive unilateral hydronephrosis to evaluate the natural history of untreated obstruction and compare it to the benefits of pyeloplasty. MATERIALS AND METHODS: Since 1991, infants with isolated unilateral Society for Fetal Urology grade 3 hydronephrosis and ipsilateral obstruction with greater than 40% differential renal function on well tempered renography were studied. Patients were randomly assigned to observation or pyeloplasty groups. Renal ultrasound and well tempered renography were performed biannually for 1 year and yearly thereafter. Crossover criteria for surgery included concurrent worsening of isotope washout and increasing grade of hydronephrosis or a greater than 10% point loss in percent differential renal function that was noted between studies. The end point of the study was the 3-year anniversary of randomization. RESULTS: A total of 32 infants from 10 centers were randomized equally to 2 groups. The starting grade of hydronephrosis and percent differential renal function were similar between the 2 groups. At 6 months and 1 year the grade of hydronephrosis was significantly reduced (p < 0.02) and well tempered renography was significantly more likely to demonstrate no obstruction (p < 0.03) in the surgical group compared with the observation group. The mean percent differential renal function remained stable and similar in both groups. Reduced hydronephrosis and resolution of obstruction in the surgery group persisted as a trend at the 2 and 3-year anniversaries. In the observation group 4 patients (25%) showed enough renal deterioration to qualify for crossover to surgery. CONCLUSIONS: Infant pyeloplasty significantly improved the grade of hydronephrosis and drainage pattern at 6 months and 1 year postoperatively, when compared with observation. Renal function stabilization was similar for either management approach. However, 25% of the patients satisfied objective criteria of status deterioration requiring pyeloplasty.

Common office problems in pediatric urology and gynecology.

The number of genital problems that pediatricians encounter is substantial. The most common ones have been reviewed in this article. Perhaps the most important point to reinforce is the appropriateness of nonintervention in uncircumcised boys whose foreskins have not become retractile during early school years. Without infections or pathologic phimosis, these boys do well, and most foreskins become retractile as they approach puberty. Abnormalities beyond those discussed or those not fitting the anticipated pattern probably warrant specialty referral.

Percutaneous endoscopic trigonoplasty: a minimally invasive approach to correct vesicoureteral reflux.

PURPOSE: A procedure was designed to correct vesicoureteral reflux with minimally invasive technology. MATERIALS AND METHODS: A total of 22 children 14 months to 18 years old underwent percutaneous endoscopic trigonoplasty between January and June 1995. Followup ranges from 4 to 11 months. In 32 ureters reflux was grade 2 in 13, grade 3 in 13, grade 4 in 5 and grade 5 in 1. RESULTS: All patients had normal sonography of the kidneys after surgery. On followup voiding cystourethrography at 2 or 6 months there was resolution of reflux in 20 of the 32 ureters (62.5%). The probability of resolution was unrelated to patient age, laterality of reflux, initial grade, operative sequence or preoperative bladder instability. The 3 major complications were vesicovaginal fistula, hyponatremia and perivesical fluid collection. CONCLUSIONS: Percutaneous endoscopic trigonoplasty is technically feasible but it involves a distinct learning curve. It offers significant advantages related to more rapid recovery with less discomfort. The success rate is modest at present. If it were to be improved with technical modifications, percutaneous endoscopic trigonoplasty may change the basic approach to treating children with vesicoureteral reflux.

Urethral meatotomy in the office using topical EMLA cream for anesthesia.

PURPOSE: We determined the effectiveness of lidocaine and prilocaine (EMLA) topical cream for anesthesia during urethral meatotomy performed in an office setting. MATERIALS AND METHODS: Meatotomy was performed in 58 patients 1 hour after topical application of EMLA cream to the glans. RESULTS: Of the 58 patients 55 had no pain, while early in our experience 3 had limited discomfort because EMLA cream was applied in too small a volume or it became dislodged. Results have been good in 57 patients, while partial restenosis developed in 1. CONCLUSIONS: Urethral meatotomy in an office setting with EMLA cream for anesthesia is generally painless, well tolerated, successful and cost-effective versus operative meatotomy.

Unilateral hydronephrosis in infants: are measurements of contralateral renal length useful?

PURPOSE: We investigated whether measurement of contralateral renal length in newborns with unilateral hydronephrosis may help to assess clinically significant hydronephrosis in the affected kidney. MATERIALS AND METHODS: We reviewed our experience with 53 newborns who had unilateral hydronephrosis presumed secondary to ureteropelvic junction obstruction. We divided the patients according to the presence of mild hydronephrosis and no obstruction on a furosemide renogram, severe hydronephrosis and obstruction on a furosemide renogram or a unilateral multicystic kidney. RESULTS: We found no significant correlation between findings on the affected and opposite normal sides. Contralateral hypertrophy, hypotrophy and normal sized kidneys were frequent findings. CONCLUSIONS: We conclude that measurement of contralateral renal length is not helpful in the evaluation of newborns with unilateral hydronephrosis.

Bladder autoaugmentation.

Autoaugmentation has proved effective in many patients in lowering bladder pressures, increasing bladder capacity, and improving their related symptoms. Patients with sever bladder hyperreflexia, uncontrolled with medications, have also benefited greatly from autoaugmentation procedures. Only patients who failed conventional medical management have undergone autoaugmentation at the authors' institution.

Complications of pregnancy in women after childhood reimplantation for vesicoureteral reflux: an update with 25 years of followup.

Surgery for the correction of vesicoureteral reflux has been performed routinely since the early 1960s. In 1986 a large group of women who underwent childhood ureteral reimplantation surgery was contacted and surveyed concerning infections, pregnancies and other complications. A notably high rate of cystitis and pyelonephritis was found during pregnancy. Because 9 years have passed and many more pregnancies have occurred, we contacted this cohort again as well as a new cohort of historical controls to reassess long-term complications of childhood ureteral reimplantation in children. Of 67 women who underwent reimplantation with an average followup of 25 years 62 were contacted of whom 75% had urinary tract infections after becoming sexually active and 65% had urinary tract infections with pregnancies. Of 141 pregnancies 57 (40%) were complicated by urinary tract infections and 21 (15%) terminated in spontaneous abortion. Of 37 women with primary vesicoureteral reflux and no surgery with an average followup of 25.5 years there was a 15% prevalence of urinary tract infections with pregnancy in 21. Of 75 pregnancies in this group 14 (18%) terminated in spontaneous abortion. Women with urinary tract infections and reflux as children have high rates of cystitis with the onset of sexual activity whether or not they underwent reimplantation as children. Those who underwent reimplantation as children are at significant risk of urinary tract infection in pregnancy but not at a higher risk of miscarriage than the general population. Education, screening and antibiotic prophylaxis during pregnancy should be considered.

Color Doppler ultrasound in newborn testis torsion.

OBJECTIVES: To assess the usefulness of color Doppler ultrasound in evaluating the newborn with suspected antenatal testis torsion. METHODS: Nine newborns with 10 antenatally torsed testes were examined using color Doppler and gray-scale ultrasound. RESULTS: Each examination revealed lack of intratesticular blood flow on the affected side and normal flow within the contralateral testis. In addition, gray-scale sonographic architecture of the affected testes appeared to reflect the duration of in utero torsion. CONCLUSIONS: Color Doppler sonography accurately assesses intratesticular blood flow in newborns with antenatal testis torsion and offers interesting details.

Bilateral testis tumors in an infant: synchronous teratoma and epidermoid cyst.

Teratoma ranks second in frequency to yolk sac carcinoma among testicular germ cell tumors in infants, accounting for 25% of cases. Testicular teratomas are uniformly benign in children younger than 24 months old. Epidermoid cysts are tumor-like lesions of unknown etiology, probably monodermal teratomas, comprising 3% of all pediatric testis tumors. Bilaterality is rare for both tumors. We report a case of a synchronous left testis teratoma and a right testis epidermoid cyst. Appropriate therapy is discussed.

Tunica vaginalis blanket wrap to prevent urethrocutaneous fistula: an 8-year experience.

An 8-year review of hypospadias repair in patients with a meatus proximal to the coronal margin is reported. Fistula rates were compared among 4 groups: 1) loupe magnification, 2) tunica vaginalis blanket wrap tissue interposition with loupe magnification, 3) operating microscope magnification and 4) tunica vaginalis blanket wrap tissue interposition in conjunction with operating microscope magnification. Rate of fistula formation with loupe magnification alone was 20%, microscope magnification alone was 12% and tunica vaginalis blanket wrap interposition with loupes was 9%. When tunica vaginalis blanket wrap tissue interposition was used in conjunction with intraoperative microscopy no fistulas resulted.