Epididymitis in patients with anorectal malformations: a cause for urologic concern.

INTRODUCTION: Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. MATERIALS AND METHODS: We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. RESULTS: Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. CONCLUSION: Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration.

Epididymitis in Patients with Anorectal Malformations: A Cause for Urologic Concern

Introduction Epididymitis in patients with anorectal malformation (ARM) represents a unique problem because unlike the general population, an underlying urinary tract problem is frequently identified. We review our experience with epididymitis in ARM population with an emphasis on examining urologic outcomes. Materials and Methods We performed a retrospective review of male patients with ARM cared for from 1980 to 2010. Clinical and pathologic variables recorded included age at presentation, recurrence, associated urologic anomalies, incidence of ureteral fusion with mesonephric ductal structures, glomerular filtration rate and urodynamic parameters. Results Twenty-six patients were identified with documented episodes of epididymitis. Renal injury was noted in five patients (19%), all of whom were diagnosed with neurogenic bladder (NGB) several years after anorectoplasty. NGB was found in ten patients (38%) in our series. Ectopic insertion of ureter into a mesonephric ductal structure was discovered in five patients (19%). Twelve patients (46%) had recurrent episodes of epididymitis, with seven of these patients (58%) being diagnosed with NGB. Two patients in the pubertal group presented with a history of epididymitis and complained of ejaculatory pain. Conclusion Epididymitis in a patient with ARM warrants a comprehensive urologic investigation, particularly in recurrent episodes. Attempts at surgical intervention (e.g. vasectomy) should be avoided until functional assessment of the urinary tract has occurred. Failure to recognize this association may lead to potentially avoidable complications and morbidity. Long term urological follow up of these patients is warranted to identify at risk patients and minimize renal deterioration .

The posterior sagittal approach for recurrent genitourinary pathology.

PURPOSE: The posterior sagittal transanorectal approach offers the surgeon excellent exposure to the lower genitourinary system. The approach has been successfully used for revisional surgery involving the urinary tract and rectum. We have used this approach to treat müllerian remnants, acquired or congenital fistulas and acquired urethral strictures. In the setting of revisional surgery abdominal or perineal approaches may not provide the same level of exposure to the lower urinary tract. MATERIALS AND METHODS: Of 911 males who underwent a posterior sagittal approach 12 were identified in whom this approach was used to manage lower urinary tract problems without associated anorectal malformation (group 1). An additional 58 patients with associated anorectal malformations were included in analysis (group 2). RESULTS: All cases were approached with a posterior sagittal incision to facilitate exposure after failed prior surgical attempts to treat traumatic strictures of the proximal urethra in 4 and müllerian remnants in 8 (group 1). In group 2 there were 19 urethral diverticula, 8 strictures and 31 persistent rectourethral fistulas. Followup was 6 months to 15 years. There were no recurrences identified in group 1. In group 2 there were 5 postoperative urethrocutaneous fistulas. Data on potency were available on 4 patients in group 1 and 14 in group 2. All 14 patients in group 2 reported intact potency after surgery. One patient in group 1 was impotent before and after surgery. CONCLUSIONS: The posterior sagittal approach is helpful for addressing lower urinary tract pathology when exposure is inadequate from a perineal or abdominal approach. We propose that better exposure with this approach may limit inadvertent injury to nerves and result in more complete treatment of the presenting pathological condition. This approach provides an alternative that warrants careful consideration when dealing with the lower genitourinary tract in pediatric patients, especially in the setting of revisional surgery.

Incontinence following bladder neck reconstruction--is there a role for endoscopic management?

PURPOSE: Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty. MATERIALS AND METHODS: A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours. RESULTS: A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved). CONCLUSIONS: Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck reconstruction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment.

The role of ureteroscopy in pediatric urology.

PURPOSE OF REVIEW: Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract using rigid or flexible endoscopes is now readily feasible and has been shown to be safe and efficacious even in the smallest children. RECENT FINDINGS: Reduction in the size of the endoscopes, improvements in electronic imaging systems, proliferation of ancillary equipment, and improvement in endourologic skills among pediatric urologists make endoscopic treatment of pediatric urolithiasis the treatment of choice. The safety and efficacy of holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Successful outcomes can be obtained for ureteral and renal calculi that are similar to the adult population. Endoscopic treatment can be effective in highly selected children with intraluminal ureteral obstruction in the hands of a very experienced endoscopic pediatric urologist. These conditions include renal hemangiomas or arteriovenous malformations, ureteropelvic junction obstruction, ureteral strictures, or ureteral polyps. SUMMARY: Pediatric ureteroscopic procedures are similar to their adult counterparts, in that basic endoscopic principles should be observed. Nevertheless, children pose specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. Future improvements in ureteroscopy will rely on the continued application of the new technology.

Early orchiopexy restores fertility in the Hoxa 11 gene knockout mouse.

PURPOSE: We investigated whether infertility could be reversed in cryptorchid mice (with disrupted expression of the homeobox gene Hoxa 11) by orchiopexy and mating such animals with females of proven fertility. MATERIALS AND METHODS: Hoxa 11 mutant and WT male mice were genotyped by polymerase chain reaction. Surgery (orchiopexy or sham operation) was performed at age 18 days and fertility was assessed at ages 6 to 8 weeks. Animals were sacrificed at ages 6 to 9 months and computer assisted semen analysis was performed on fluid obtained by epididymal puncture. RESULTS: Five of 28 mutant mice proved fertile following orchiopexy versus 0 of 22 after sham operation (p <0.05). Values in WT mice were 18 of 35 and 25 of 33, respectively (p <0.01). Mean spermatozoa counts +/- SEM were 21.7 +/- 5.9 x 106/ml in 8 mutant mice with orchiopexy, 2.78 +/- 1.59 x 106/ml in 8 sham operated mutant mice (p <0.002), 15.6 +/- 4.9 x 106/ml in 7 WT mice with orchiopexy and 36.3 +/- 10.5 x 106/ml in 9 sham operated WT mice (p <0.02). CONCLUSIONS: Testicular position following orchiopexy is important to achieve fertility but the surgical procedure was associated with a degree of damage. Since mutant animals did not attain the fertility rates observed in WT animals following orchiopexy, other factors (possibly vaso-epididymal) may be necessary for normal spermatogenesis. Further studies of this model may allow the identification of such factors.

The high intra-abdominal testis: technique and long-term success of laparoscopic testicular autotransplantation.

BACKGROUND AND PURPOSE: Treatment of the high intra-abdominal testis is often a challenging problem. We present our technique of and results with laparoscopically assisted testicular autotransplantation (LATA) for treatment of the high intra-abdominal testis. PATIENTS AND METHODS: We reviewed the medical records of 15 patients with a high intra-abdominal testis who underwent procedures between 1993 and 1999 in which intra-abdominal dissection and testicular mobilization was performed laparoscopically. The LATA technique is described. RESULTS: The 15 patients underwent 17 LATA procedures. Age at surgery ranged from 6 months to 13 years (mean 3.6 years; median 2.5 years). Two of these patients had undergone failed contralateral orchidopexy for an intra-abdominal testis, and two patients underwent metachronous bilateral procedures. The laparoscopic dissection and microvascular anastomoses were successful in all patients. There were no postoperative complications. The involved testis remained viable with adequate growth in 15 of 17 procedures (88%) during a median 42-month (range 7-70 months) follow-up. Successful procedures included those in the two patients with contralateral atrophic testes and the two who underwent bilateral procedures. CONCLUSIONS: The LATA demonstrated a good long-term surgical outcome and may be the technique of choice in patients with bilateral intra-abdominal testes or patients who have contralateral testis atrophy following unsuccessful orchidopexy.

Extravesical common sheath detrusorrhaphy (ureteroneocystotomy) and reflux in duplicated collecting systems.

PURPOSE: Various surgical approaches have been used for treatment of vesicoureteral reflux in uncomplicated duplicated collecting systems. We retrospectively evaluated our success with extravesical common sheath detrusorrhaphy in such a setting. MATERIALS AND METHODS: Between 1990 and 1997, unilateral and bilateral extravesical nondismembered detrusorrhaphy was performed in 24 and 19 patients, respectively, with 51 duplicated collecting systems, including 8 bilateral, for management of vesicoureteral reflux. Vesicoureteral reflux was present in the moieties of ipsilateral duplicated kidney in 2 patients, and bilateral reimplantation was performed in 2 who had a history of contralateral vesicoureteral reflux that resolved. Patient age ranged from 1 to 16 years (median 3.67). Followup ranged from 36 to 114 months (median 86), and included cystourethrography and renal ultrasound. RESULTS: Vesicoureteral reflux resolved in all but 1 duplicated renal moiety, which was a success rate of 98%. In this patient the persistent reflux resolved by 16 months postoperatively on conservative treatment. There were no intraoperative complications and all patients resumed spontaneous voiding before discharge home. No postoperative obstruction of the involved kidney or de novo contralateral reflux developed in any patient. CONCLUSIONS: Common sheath ureteral reimplantation with extravesical detrusorrhaphy can be successfully used to treat vesicoureteral reflux in uncomplicated duplicated collecting systems. This approach demonstrates excellent long-term surgical outcome with minimal perioperative morbidity.