The value of an additional scrotal suture during orchidopexy.

INTRODUCTION: Undescended testes present in 3-5% of male infants at birth. Orchidopexy is indicated to improve fertility and reduce the risk of testicular tumors. Guidelines recommend orchidopexy as early as six months of age, treatment should be finished within the age of 18 months. So far, no unequivocal proof demonstrated the superiority of one of the different surgical techniques. OBJECTIVE: To evaluate the value of an additional scrotal suture between the tunica albuginea and the dartos fascia during orchidopexy in an outpatient setting. It is yet unclear, whether the suture influences the incidence of secondary cryptorchidism or recurrence. STUDY DESIGN: This is a retrospective cohort study. Between 2010 and 2018 two experienced surgeons performed 561 inguinal orchidopexy-procedures in an open technique (375 boys). In group 1 (2010-2014) they managed 234 IOP (156 boys) without an additional scrotal suture. Since 2014, in group 2 an additional suture has been performed in 327 IOP (219 boys). Statistically, we compared both groups over a period of consecutive 4 years after the model of a life table analysis (Logrank). RESULTS: The numbers of boys with complete follow-up were 118 of 156 in group 1 and 154 of 219 in group 2, demonstrating 7 (5.9%) and 7 (4.5%) recurrences, respectively. There was no statistically significant difference in recurrences between group 1 and group 2 (Logrank-Test, p = 0.97). Orchidopexie failure was detected between 0.9 and 23.1 months after the IOP in group 1 and between 3.2 and 17.7 months in group 2. Mean age in months at the operation in both groups was significantly higher than the recommended 6-18 months in the EAU/AUA-guidelines. Both groups showed similar rates of postoperative complications. DISCUSSION: Orchidopexy is a safe procedure in an outpatient setting. So far there is no evidence that performing an additional scrotal suture decreases the operative failure rate in inguinal standard orchidopexy procedures.

[Hypospadias : Insights and challenges]. / Hypospadie : Erkenntnisse und Herausforderungen.

Disorders of the ventral tubularization of the urethra, such as the hypospadias, are among the second most frequent congenital childhood malformations. An increasing incidence has been observed suggesting a doubling in the US, which could not be documented for the European area. The underlying causes of this congenital defect remain unidentified. Genetic risk constellations or environmental influences, in particular by so-called endocrine disrupting chemicals (EDCs), are discussed as triggering factors. Boys after in vitro fertilization are more likely to have hypospadias than in nonreproductive-assisted pregnancies. Animal models (especially mice) elicited causal relationships between prenatal hormonal exposure (estrogens, progesterone) and antiandrogens such as flutamide, finasteride, antiandrogenic fungicides (vinclozolin) and phthalates and the formation of hypospadias. An aesthetic and/or functional deficit are indications for surgical correction. The indications and the complications of hypospadias surgery must be in detail and realistically discussed with the parents and patients. Recent publications demonstrated that the risk of complications increases with the increase of the follow-up time. High-volume centers with extensive experience have a positive effect on the complication rate. Competent follow-up to adult age should be ensured.

[Cryptorchidism and fertility]. / Hodenhochstand und Fertilität.

BACKGROUND: Through the completion of the first year of life, cryptorchidism is the most common genital malformation in pediatric urology; unilateral cryptorchidism is detected in about 1% of full-term male infants and a fifth (20%) of children are bilaterally affected. DISCUSSION: It must be understood that azoospemia affects about 10% of men with unilateral and about 32% of men with bilateral cryptorchidism and that approximately 10-20% of men, in whom infertility has been diagnosed, have a history of orchiopexy. AIM: What factors influencing the fate of postpubertal spermatogenesis are dependent on the first year of life? The purpose of this article is to answer questions and summarize the current knowledge about this complex topic.

[Distal hypospadias: Current therapeutic approach and various aspects of follow-up]. / Die distale Hypospadie : Aktuelles therapeutisches Vorgehen bei unterschiedlichen Aspekten der Nachbeobachtung.

BACKGROUND: Hypospadias is the second most common birth anomaly in male newborns. Most have a distal variant with the urethral opening on or near the glans, which is called distal hypospadia. METHODS: Surgical repair is recommended around the first birthday of the child in distal hypospadias mostly due to cosmetic and psychosexual reasons to establish a normal body image. RESULTS: Recently published long-term follow-up studies revealed a complication rate of around 20%, which means that for every fifth child undergoing surgery for distal hyspoapdia, more than one operation is needed in the long term. Parents of patients who have undergone distal hypospadia repair suffer from decisional regret in around 50% of cases, especially when complications occurred. CONCLUSION: Surgeon's experience and patient's age have a direct impact on complication rates. Thus, urological counseling of parents and patients should take these issues into account.

[Neurogenic bladder function disorders in patients with meningomyelocele: S2k guidelines on diagnostics and therapy]. / Neurogene Blasenfunktionsstörungen bei Patienten mit Meningomyelozele : S2k-Leitlinie zu Diagnostik und Therapie.

The treatment of children and adolescents with meningomyelocele has experienced a clear change in the last 30 years. The establishment of pharmacotherapy, clean intermittent catheterization (CIC) and infection prophylaxis have improved the prognosis for patients and have led to new therapeutic strategies. The interdisciplinary cooperation between neonatologists, neurosurgeons, pediatric neurologists, pediatric urologists, pediatric nephrologists, pediatric orthopedists and pediatric surgeons leads to optimization of individualized therapy. These guidelines present definitions and classifications, investigations and timing which are described in detail. The conservative and operative therapy options for neurogenic bladder function disorders are described and discussed with reference to the current literature. The brief overview provides in each case assistance for the treating physician in the care of this patient group and facilitates the interdisciplinary cooperation.

[Aspects of sexuality in adolescents with spinal bifida]. / Aspekte der Sexualität bei Adoleszenten mit einer Spina bifida.

In the last few decades, the life expectancy of patients with meningomyelocele has increased through improved medical care. Problems associated with adulthood like sexuality, friendship, and fertility are now more important for these young persons. Physical and cognitive impairment can alter the complex process of sexual maturation, but nevertheless patients of today are well-informed and show a strong interest in sexual fulfillment.

[Testicular adrenal rest tumors in adolescents]. / Testikuläre adrenale Resttumoren im Hoden bei Adoleszenten.

BACKGROUND: Testicular adrenal rest tumors (TART) frequently occur in patients with congenital adrenal hyperplasia (CAH) and can be detected and treated in childhood as well as in adolescence. Due to the intricate dilimitation to other testicular masses the correct diagnosis of TART can be problematic. An extensive endocrinologic evaluation and ultrasound examination are mandatory. Even though TART are benign lesions a high-dose therapy with glucocorticoid and/or mineralocorticoid suppletion is necessary for protecion or regain of fertility. METHODS: A surgical approach can be considered, depending on stage of disease and response on drug therapy. Consequent treatment and constant therapy monitoring might significantly improve long-term outcome. RESULTS: Currently there is no validated standard therapy concept, which can be explained by the heterogenity of disease patterns progression and the limited data available, respectively. Therefore treatment should be subject to specialized centres.

[Childhood ureteropelvic junction obstruction in a regional treatment center: spectrum and therapy]. / Kindliche Ureterabgangsstenose in einem Zuweisungszentrum : Spektrum und Therapie.

BACKGROUND: Ureteropelvic junction obstruction is the most frequent malformation of the upper urinary tract and treatment with conservative or operative management remains controversial. In this study we present the retrospective analysis of 129 children with ureteropelvic junction obstruction who underwent conservative or operative management. MATERIAL AND METHODS: A total of 129 children with ureteropelvic junction obstruction, who were treated in the department of pediatric nephrology at the University of Essen from 1998-2005, were included into the analysis. Clinical charts were reviewed for the parameters urinary tract infections (total number, severity, bacteriology), antibiotics, ultrasound, Tc-99 diuresis renography, and management (conservative or operative). Statistical analysis was performed using the SPSS software (Version 11.0) RESULTS: A total of 89 urinary tract infections was observed in 52 children. The mean width of renal pelvis was 3.04 ± 1.33 cm in the operative group and 1.98 ± 1.2 cm in the conservative group (p=0.001, ANOVA test). Tc-99 diuresis renography was performed in 70 children of which 46 children received primarily conservative management and 24 children were operated. In the conservative group 6 children underwent pyeloplasty later on due to aggravation of renal function. In 59 out of 129 cases diuresis nephrography was not performed due to only mild ectasia. CONCLUSIONS: This study demonstrates that conservative management is safe in children with ureteropelvic junction obstruction with no or only little constricted renal function, if a close-meshed surveillance protocol is followed and parental compliance is given.

[Pedicled prepuce flap plasty: results in patients with hypospadias or urethral sticture]. / Die gestielte Vorhautlappenplastik: Ergebnisse bei Patienten mit Hypospadie oder Harnröhrenstriktur.

BACKGROUND: Operative interventions of the urethra remain challenging procedures. The vascular onlay flap of the inner prepuce is a possible technique for short and long segment urethral defects. PATIENTS AND METHODS: A total of 195 patients were surgically treated with a vascular prepuce flap between 1994 and 2010 at the Urology Department of Essen Medical University. Patient data were analyzed retrospectively and a questionnaire was sent to all patients. RESULTS: Of the patients 115 answered the questionnaires and were included in the study. Of these 61 patients were treated in childhood due to hypospadias and 54 patients suffered from acquired urethral stricture. Major complications were postoperative fistulas in 8.2 % and 7.4 % and hematomas in 6.6 % and 11.1 % of cases, respectively. Operative revision had to be performed in 13.1 % and 14.8 % of cases and severe obstructive micturition problems (IPSS score ≥ 20) were observed in only 3.3 % and 11.1% of patients, respectively. Subjective overall satisfaction with the result of the operation was high (67.2 % and 88.9 %, respectively). CONCLUSION: The vascular prepuce flap is a reliable method for correction of short and long segment urethral defects and is associated with high patient satisfaction.

[Phimosis]. / Phimose.

Phimosis is a common condition in which the foreskin cannot be retracted over the glans penis. First appearing at 8 weeks gestation as a ridge of thickened epithelium, the prepuce grows forward over the developing glans. Physiological phimosis is common in male patients up to 3 years of age. Balanoposthitis is an inflammation of the foreskin and glans and occurs in 4-11% of uncircumcised boys. Lack of circumcision has been identified as a risk factor for urinary tract infection in infants as well as several sexually transmitted diseases and penile cancer in adults. Local steroid application showed satisfactory success rates of more than 80% and is recommended as first choice therapy. Male circumcision carried out under the age of 14 years without medical indications is unlawful and classified as bodily harm under German law.

[Non-neurogenic bladder dysfunction and vesicoureteral reflux in children]. / Nicht neurogene Blasenfunktionsstörungen und vesikoureteraler Reflux bei Kindern.

Various types of bladder dysfunction are associated with urinary tract infection, renal damage and vesicoureteral reflux (VUR). In this article the influence of functional bladder disturbances such as detrusor instability (overactive bladder, OAB) and bladder sphincter dyssynergia (dysfunctional voiding), on the resolution of vesicoureteral reflux are reviewed. In summary, it is important to distinguish between children with dysfunctional voiding (increased activity of the pelvic floor during voiding) and those with OAB (detrusor overactivity during filling) because the latter has less effects on VUR.

[Perioperative pain management in major reconstructive surgery in pediatric urology: a plea for continuous epidural anesthesia]. / Perioperatives Schmerzmanagement bei großen plastisch-rekonstruktiven Eingriffen in der Kinderurologie: Ein Plädoyer für die Periduralanästhesie.

Regional analgesia is firmly established in modern pediatric anesthetic practice and its popularity continues to grow. In our department continuous epidural anesthesia (CEA) is a frequently used technique of pain management following major reconstructive procedures of the lower urinary tract. The aim of this study was to investigate the efficacy, safety, and potential benefits of CEA over standard analgesics.We retrospectively reviewed the records of 21 infants who underwent single-stage bladder exstrophy repair in our department. In 15 children an epidural catheter was placed preoperatively for CEA; 6 patients treated without CEA served as controls. Total doses of narcotics and analgesics, length of intensive care unit (ICU) stay and ventilatory assistance, time to first bowel activity, anticholinergic requirements, and CEA-related side effects were documented and compared for both groups.Children given epidural anesthesia required six- to tenfold lower doses of morphine intra- and postoperatively compared to those without CEA; ventilatory support upon completion of surgery was remarkably shorter (59 versus 210 min) in the CEA group as well as ICU stay (1.1 versus 1.8 days). The total consumption of anticholinergics was twice as high as in patients without CEA. There were no relevant CEA-related complications.Being a retrospective audit of practice in our institution with a small number of patients, our results are in line with previously published data on CEA in pediatric patients. CEA has been shown to significantly reduce the need for anesthetics and morphine and allows early extubation with all subsequent advantages for a speedy recovery post surgery. Thus, the technique is to be recommended as a safe and efficacious method for pain management following major reconstructive surgery in pediatric urology. Importantly, this type of anesthesia should be performed only by experienced anesthesiologists in institutions where appropriate equipment, staff, and monitoring are available.