Feasibility of Awake Intravesical Botulinum Toxin Injection in Pediatric Neurogenic Bladder.

PURPOSE: Cystoscopic injection of botulinum neurotoxin (BoNT) is typically performed under general anesthesia in pediatric patients with neurogenic bladder, accumulating anesthetic exposures and operating room costs. As most of these patients already tolerate clean intermittent catheterization (CIC), it has become our practice to offer a trial of awake injection. We report our initial experience here. We hypothesized that higher sensory level, female sex and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times. MATERIALS AND METHODS: Surgical records from 2 academic hospitals from 2018-2020 were reviewed. Generalized linear models were fit to determine predictors of success and procedural length. RESULTS: Trial of awake injection was offered to 22 patients. Eighteen patients (8 female, 10 male, 4-20 years old) elected to proceed. All 18 patients were managed with CIC at baseline, 14 had anxiety or behavioral issues, 10 had cognitive delay and 7 had sensory level below S2. Two patients (11%) required conversion to general anesthesia and one of these subsequently opted for a repeat awake injection trial. Fifteen of the 18 patients (83%) had or planned subsequent injections awake. Of the remaining, 1 proceeded to bladder augment, 1 is considering ileovesicostomy and 1 requested subsequent injections under anesthesia. No intraoperative complications occurred. CONCLUSIONS: Awake BoNT injection is feasible in pediatric patients with neurogenic bladder managed with CIC, even in the setting of intact sensation, well-managed mental health issues or cognitive delay, thereby increasing the viability of BoNT as an early tool in the management of neurogenic bladder.

Digital photographic measurement in hypospadias: validation and comparison to intraoperative measurement.

BACKGROUND: We propose a standardized method of photographing the hypospadias penis to capture penile dimensions that may be relevant for surgery. We also validate the use of digital imaging software for calculating penile dimensions as a substitute for intraoperative caliper-based measurements. METHODS: Photographs were taken of hypospadias penises in four different views after placement of a traction stitch and retraction of the preputial hood. Intraoperative measurements were obtained with a caliper. Digital measurements were taken of the same parameters postoperatively. All measurements were obtained in triplicate by multiple participants, and averages were tested for equivalency by determining the correlation coefficient for each parameter. Inter-observer correlation was also calculated for each parameter. RESULTS: 180 intraoperative and 180 digital measurements were taken from 60 dimensions on 10 hypospadiac penises. Strong correlation existed between most digital and intraoperative measurements. Average inter-observer correlations ranged from 0.91 to 0.99 for each of the intraoperative measurements, and 0.90 to 1.00 for each of the digital measurements. CONCLUSIONS: Standardized imaging is effective in capturing penile dimensions and measurements during hypospadias surgery. When compared with intraoperative measurements, digital measurements are reliable and precise; digital photography has the potential to both aid in surgical planning and improve documentation.

Prospective blinded laboratory assessment of prophylactic antibiotic compliance in a pediatric outpatient setting.

PURPOSE: Prophylactic antibiotics are commonly used to prevent urinary tract infections in children with conditions such as vesicoureteral reflux. Patient compliance with antibiotics is salient, given the effects that noncompliance can have on development of antibiotic resistance and outcomes of clinical trials. Prior series have shown variable compliance (17% to 70%). However, no study has used objective methods. We hypothesized that direct measurement of urine antibiotic levels can reveal poor compliance. MATERIALS AND METHODS: During a pediatric urology clinic visit patients 0 to 18 years old taking trimethoprim prophylaxis for any urological diagnosis were invited to participate in the study. They were unaware of any potential urine testing before the visit. Urine was sent for chromatography to quantify trimethoprim levels. Parents also completed a compliance self-assessment. RESULTS: Of patients invited to participate 97% consented (54 patients). Of the patients 91% were compliant based on urine levels. Factors not associated with compliance included age, gender, self-report of compliance, duration of time on antibiotics, insurance status and history of breakthrough infection, surgery, pyelonephritis or hospitalization. CONCLUSIONS: This study demonstrates the highest compliance reported for children taking prophylactic antibiotics to prevent urinary tract infection. We attribute this unexpected result to the discussion by specialists of 1 problem for the duration of an office visit. All education in this study was part of clinical care. Thus, our results should be generalizable to nonstudy environments. Future studies should confirm whether this high level of compliance can be achieved by nephrologists and pediatricians. If such compliance cannot be achieved at nonsurgical clinics, then early referral to a pediatric urologist may be warranted.

Age at orchiopexy and testis palpability predict germ and Leydig cell loss: clinical predictors of adverse histological features of cryptorchidism.

PURPOSE: We determined the relationship between clinical variables and testicular histopathological changes associated with decreased fertility potential in children with cryptorchidism. MATERIALS AND METHODS: Testis biopsies of 274 children who underwent orchiopexy and concurrent testicular biopsy between 1991 and 2001 were analyzed for germ and Leydig cell loss, and testicular fibrosis. Multivariable logistic regression was used to determine if age at orchiopexy (analyzed as continuous and ordinal variables), preoperative testis palpability, unilateral vs bilateral disease and/or side of undescended testis was predictive of these pathological outcomes. RESULTS: Age at orchiopexy was associated with germ and Leydig cell depletion. Each month of testis undescent was associated with development of moderate/severe germ cell depletion (OR 1.02 for each month of age, p <0.005) and Leydig cell loss (OR 1.01 for each month of age, p <0.02). Nonpalpable testes were associated with severe germ cell depletion. Children with palpable testes had lower odds of germ cell depletion than those with nonpalpable testes (OR 0.46, p <0.005). This finding corresponds to a significant 2% risk per month of severe germ cell loss and 1% risk per month of Leydig cell depletion for each month a testis remains undescended, and a 50% greater risk of germ cell depletion in nonpalpable relative to palpable cryptorchid testes. CONCLUSIONS: Testes that remain undescended are associated with progressive loss of germ and Leydig cells, and nonpalpable testes predict severe germ cell loss.

Obesity does not decrease the accuracy of testicular examination in anesthetized boys with cryptorchidism.

PURPOSE: Given that the prevalence of childhood obesity is increasing in the United States, we tested the timely hypothesis that obesity hinders physical examination based localization of the cryptorchid testis. MATERIALS AND METHODS: Body mass index and percentiles of weight for height and body mass index for age were calculated for boys undergoing surgery for cryptorchidism at the University of California San Francisco Children's Hospital and Children's Hospital of Oakland. Two definitions of obesity were examined, ie greater than 85% or greater than 95% for either percentile. Patients were examined in the office and under general anesthesia before the skin incision. Intraoperative testicular location was recorded for each patient. The numbers of correct and incorrect preoperative determinations of testicular location were stratified by weight classification. Results were analyzed using contingency tables and Fisher's exact test. RESULTS: A total of 161 boys were recruited, accounting for 171 testes. The predictive value of palpating a suspected testis preoperatively with patients under anesthesia was greater than 95% for all weight classifications (p <0.0001). The predictive value of not palpating a testis preoperatively under anesthesia was greater than 56% for obese boys and greater than 42% for nonobese boys (p <0.0001). The concordance rates between examinations in the office and those performed under anesthesia were 90.9% and 82.7% for obese and nonobese boys, respectively (p = 0.51). The predictive value of not palpating a suspected cryptorchid testis in the office was higher in nonobese boys than in obese boys (81% vs 22%, p <0.0001). CONCLUSIONS: In our series childhood obesity did not make preoperative testicular examinations under anesthesia less accurate. However, office examinations may be more accurate in nonobese boys.

New concepts in feminizing genitoplasty--is the Fortunoff flap obsolete?

PURPOSE: We retrospectively evaluated the results of an original technique that combines mobilization of the urogenital sinus with the creation of urogenital flaps to enlarge the vaginal introitus for 1-stage feminizing genitoplasty in children with urogenital sinus anomalies, thus, avoiding the use of posteriorly based perineal flaps. MATERIALS AND METHODS: A total of 11 patients with urogenital sinus anomalies have undergone a modified Fortunoff technique combining total urogenital mobilization with the creation of urogenital sinus flaps by a single surgeon (RG) since 1998. Patient age at surgery ranged from 3 months to 13 years (mean 3.8 years). Diagnoses included congenital adrenal hyperplasia in 7 patients, cloacal malformation in 2 and urogenital sinus malformation in 2. Eight patients underwent a perineal approach and 3 underwent a posterior sagittal approach. RESULTS: Followup ranged from 3 months to 5 years (mean 2.5 years). The cosmetic appearance was considered superior to that achieved with previous techniques. The vagina had a more physiological position in all patients except 1, and no patient had development of vaginal stenosis. One patient had development of a mild mid urethral stricture that required a single dilation using anesthesia. In this patient cystourethroscopy performed 3 years later was normal. CONCLUSIONS: We believe that the redundant urogenital sinus tissue must not be discarded, but rather incorporated into the reconstruction of the posterior vaginal wall, thus, avoiding the use of perineal skin flaps. This modification allows placement of the vaginal opening in a more physiological position with a better cosmetic appearance than previous techniques.

Outcomes of continent catheterizable stomas for urinary and fecal incontinence: comparison among different tissue options.

OBJECTIVE: To retrospectively review the outcome of appendix, transverse tubularized intestine segments, caecal flap, gastric tube and others tissue options used as a continent stoma for urinary and fecal incontinence. PATIENTS AND METHODS: Between January 1993 and January 2003 we created 179 continent stomas to treat urinary and fecal incontinence in 135 patients (81 females and 54 males; mean age at surgery 13 years, 118, 87%, aged <17 years). We used either appendix (112), a short segment of bowel following the Yang-Monti technique (49), gastric augment single pedicle tube (eight), caecal flap (seven), Casale continent vesicostomy (two) and Meckel's diverticulum (one). Thirty-six patients had both urinary and fecal continent stomas created. RESULTS: The mean follow-up for the appendix group was 46 months for the urinary stoma and 23 months for the Malone antegrade continent enema (MACE) stoma. Stoma-related complications occurred in 24 of 112 (21%) patients; there was complete channel fibrosis in five (4%). The mean follow-up for the Yang-Monti group was 38 months for the urinary and 59.2 months for the MACE stoma. There were stoma-related problems in 11 of 49 (22%) patients, with complete channel fibrosis in three (6%). Overall, in the long-term follow-up, there were stoma-related complications in 42 of 179 (23.5%) procedures. CONCLUSIONS: Continent catheterizable stomas are a feasible and reliable method for treating urinary and fecal incontinence. Long-term success can be accomplished with appendix, transverse tubularized intestinal segments and caecal flaps, with similar complication rates in all groups. Surgeon preference and individual patient status should determine the surgical technique to be used.