Management of Urethral Strictures After Hypospadias Repair.

Strictures of the neourethra after hypospadias surgery are more common after skin flap repairs than urethral plate or neo-plate tubularizations. The diagnosis of stricture after hypospadias repair is suspected based on symptoms of stranguria, urinary retention, and/or urinary tract infection. It is confirmed by urethroscopy during anticipated repair, without preoperative urethrography. The most common repairs for neourethra stricture after hypospadias surgery are single-stage dorsal inlay graft and 2-stage labial mucosa replacement urethroplasty.

Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair.

INTRODUCTION: We previously described urethral plate (UP) dissection and urethral mobilization from the corpora cavernosa to achieve or facilitate straightening ventral curvature while preserving the UP for TIP in boys with proximal hypospadias. The original patients had similar complications to those undergoing proximal TIP without UP elevation. Subsequently an increased occurrence of neourethra strictures in those with UP elevation and urethral mobilization was recognized, and is now reported. MATERIALS: Information on consecutive patients with proximal TIP repair with and without UP elevation and urethral mobilization by a single surgeon was reviewed in a database with pre-determined data points entered on the day of service. RESULTS: There were 76 proximal TIP patients with follow up, 29 with and 47 without UP elevation and urethral mobilization, with strictures developing in 5 (17%) and 0, respectively, p = 0.01. All strictures were symptomatic (UTI, urinary retention), 0.1-1.0 cm long, and diagnosed at ≤1.5 years after surgery. CONCLUSIONS: UP elevation and urethral mobilization with TIP resulted in focal devascularization of the neourethra with symptomatic stricture development. Although most patients with these straightening maneuvers did not have stricture, we no longer recommend UP elevation and urethral mobilization with proximal TIP repair.

Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR: a cross-sectional observational study of 565 consecutive patients.

PURPOSE: To determine prevalence and risk factors for renal scar in children referred for urologic assessment of febrile UTI and/or VUR. METHODS: Pre-determined risk factors for renal scar were prospectively recorded in consecutive patients referred for UTI/VUR. Age, gender, VUR grade, and reported number of febrile and non-febrile UTIs were analyzed with logistic regression to determine risk for focal cortical defects on non-acute DMSA. RESULTS: Of 565 consecutive children, 24 (4%) had congenital renal dysplasia and 84 (15.5%) had focal defect(s). VUR, especially grades IV-V, recurrent febrile UTI, and older age increased risk. For any age child with the same number of UTIs, VUR increased odds of renal defect 5.4-fold (OR = 5.4, 95% CI = 2.7-10.6, AUC = 0.759). CONCLUSIONS: Focal DMSA defects were present in 15.5% of 565 consecutive children referred for febrile UTI and/or VUR; 4% had presumed congenital reflux nephropathy without cortical defect. All VUR grades increased risk for these defects, as did recurrent febrile UTIs and older age. However, 43% with grades IV-V VUR and 76% with recurrent UTI had normal DMSA.

Vesicoureteral reflux: current trends in diagnosis, screening, and treatment.

CONTEXT: Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. OBJECTIVE: Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. EVIDENCE ACQUISITION: A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organizations. EVIDENCE SYNTHESIS: We objectively assessed and summarized the published data, focusing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. CONCLUSIONS: The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments.

Parental preferences in the management of vesicoureteral reflux.

PURPOSE: Considering that there are few absolute indications for the timing and type of surgical correction of vesicoureteral reflux, we objectively measured parental choice in how the child's vesicoureteral reflux should be managed. MATERIALS AND METHODS: We prospectively identified patients 0 to 18 years old with any grade of newly diagnosed vesicoureteral reflux. All races and genders were included, and non-English speakers were excluded from analysis. Parents were shown a video presented by a professional actor that objectively described vesicoureteral reflux and the 3 treatment modalities of antibiotic prophylaxis, open ureteral reimplantation and endoscopic treatment. Then they completed a questionnaire regarding their preference for initial management, and at hypothetical followup points of 18, 36 and 54 months. Consultation followed with the pediatric urologist who was blinded to the questionnaire results. RESULTS: A total of 86 girls and 15 boys (150 refluxing units) were enrolled in the study. Mean patient age was 2.6 years old. Preferences for initial treatment were antibiotic prophylaxis in 36, endoscopic surgery in 26, open surgery in 11, unsure in 26 and no response in 2. Among those initially selecting antibiotic prophylaxis, after 18 months the preference was for endoscopic treatment, but after 36 and 54 months preferences trended toward open surgery. After consultation with the pediatric urologist 68 parents chose antibiotic prophylaxis. CONCLUSIONS: Our data show that antibiotic prophylaxis is preferred as the initial therapy for vesicoureteral reflux by 35.6% of parents. However, given persistent vesicoureteral reflux, preferences shifted toward surgery. With time the preference for open surgery increased and the preference for endoscopic surgery decreased.

Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation.

The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.

Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report: Clinical Practice Guidelines for Screening Siblings of Children With Vesicoureteral Reflux and Neonates/Infants With Prenatal Hydronephrosis.

PURPOSE: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to screening of siblings and offspring of index patients with vesicoureteral reflux and infants with prenatal hydronephrosis. From this evidence clinical practice guidelines are developed to manage the clinical scenarios insofar as the data permit. MATERIALS AND METHODS: The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children, clearly stating the number of children undergoing screening for vesicoureteral reflux. Vesicoureteral reflux should have been diagnosed with a cystogram and renal outcomes assessed by nuclear scintigraphy. The screening articles were extracted into data tables developed to evaluate epidemiological factors, patient and renal outcomes, and results of treatment. The reporting of meta-analysis of observational studies elaborated by the MOOSE group was followed. The extracted data were analyzed and formulated into evidence-based recommendations regarding the screening of siblings and offspring in index cases with vesicoureteral reflux and infants with prenatal hydronephrosis. RESULTS: In screened populations the prevalence of vesicoureteral reflux is 27.4% in siblings and 35.7% in offspring. Prevalence decreases at a rate of 1 screened person every 3 months of age. The prevalence is the same in males and females. Bilateral reflux prevalence is similar to unilateral reflux. Grade I-II reflux is estimated to be present in 16.7% and grade III-V reflux in 9.8% of screened patients. The estimate for renal cortical abnormalities overall is 19.3%, with 27.8% having renal damage in cohorts of symptomatic and asymptomatic children combined. In asymptomatic siblings only the rate of renal damage is 14.4%. There are presently no randomized, controlled trials of treated vs untreated screened siblings with vesicoureteral reflux to evaluate health outcomes as spontaneous resolution, decreased rates of urinary infection, pyelonephritis or renal scarring. In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence. A diameter of 4 mm is associated with a 10% to 20% prevalence of vesicoureteral reflux. The prevalence of reflux is statistically significantly greater in females (23%) than males (16%) (p=0.022). Reflux grade distribution is approximately a third each for grades I-II, III and IV-V. The estimate of renal damage in screened infants without infection is 21.8%. When stratified by reflux grade renal damage was estimated to be present in 6.2% grade I-III and 47.9% grade IV-V (p <0.0001). The risk of urinary tract infection in patients with and without prenatal hydronephrosis and vesicoureteral reflux could not be determined. The incidence of reported urinary tract infection in patients with reflux was 4.2%. CONCLUSIONS: The meta-analysis provided meaningful information regarding screening for vesicoureteral reflux. However, the lack of randomized clinical trials for screened patients to assess clinical health outcomes has made evidence-based guideline recommendations difficult. Consequently, screening guidelines are based on present practice, risk assessment, meta-analysis results and Panel consensus.

Urologic care of the neurogenic bladder in children.

Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.

Hernia after pediatric urological laparoscopy.

PURPOSE: The incidence of port site hernia following adult laparoscopy is 0.1% to 3.0%. There are no known published reports concerning hernia incidence or related factors after pediatric urological laparoscopic interventions. We present our experience with port site incisional hernias following pediatric urological laparoscopy. MATERIALS AND METHODS: We reviewed all pediatric urological laparoscopic procedures performed at Children's Medical Center Dallas from 2000 to 2008. A total of 261 cases were identified with followup available in 218 (83.5%). In 187 cases there were sufficient data to evaluate outcomes for each port site separately, and compare the size, location and fascial closure status to hernia development. RESULTS: Median patient age was 6.1 years (range 0.4 to 18.8). A total of 218 patients had a median followup of 5.7 months (range 0.2 to 83.4). Seven hernias (3.2%) were diagnosed at a median of 1.2 months (range 0.1 to 15.1) postoperatively. Patients with hernia were younger than those without hernia, at 1.1 years (range 0.5 to 3.9) vs 6.2 years (0.4 to 18.8, p = 0.04). We analyzed 571 port sites in 187 cases. In 385 ports (67.4%) the fascia was closed. Hernia developed in 4 of 385 ports (1.0%) that were closed and in 3 of 186 (1.6%) that were not closed. No significant relationship was observed between hernia development and port size or location. CONCLUSIONS: The incidence of port site hernia after pediatric urological laparoscopy was 3.2%, similar to the reported incidence in adults. While development of hernia after pediatric urological laparoscopy is rare, it is more likely to occur in infants. Due to the low incidence of this complication, it is difficult to draw conclusions regarding contributing factors.

Incidence of new onset metabolic acidosis following enteroplasty for myelomeningocele.

PURPOSE: Extant literature is mixed regarding risk of metabolic acidosis after enteroplasty for myelomeningocele. This study is the first known attempt to describe the pattern of developing metabolic acidosis in a group of children who underwent enteroplasty and served as their own controls. Multiple preoperative and postoperative laboratory measures for each child were obtained for comparison. MATERIALS AND METHODS: This retrospective cohort study allowed participants to serve as their own controls for pre-intervention and post-intervention analysis. The setting was a tertiary, university affiliated, interdisciplinary spina bifida program. All patients followed in the spina bifida program who had undergone ileal or colonic enteroplasty were included for review (total 113). Strict exclusion criteria were preoperatively diagnosed renal insufficiency, preexisting metabolic acidosis consistent with renal tubular acidosis (pH less than 7.35, bicarbonate 20 mmol/l or less) and history of augmentation using gastric or ureteral tissue. Final analysis included 71 children who met inclusion criteria. Children in our spina bifida program periodically undergo routine laboratory evaluation of electrolytes, blood urea nitrogen, creatinine, blood count, and venous blood gases including pH, bicarbonate and partial pressure of carbon dioxide. Primary outcome measures were comparative shifts in blood gases and electrolytes that would confirm the new onset of metabolic acidosis after enteroplasty. Changes in electrolytes and serum creatinine were secondary outcome measures to identify potential markers for postoperative effects. With each child as his/her own control, analysis included paired t tests. RESULTS: No statistically significant differences (p <0.05) were found when comparing laboratory values before and after bladder augmentation, including pH, bicarbonate, partial pressure of carbon dioxide and electrolytes. No child had metabolic acidosis based on the aforementioned criteria. Followup ranged from 1 to 138 months after enteroplasty (mean 46.8). Respiratory compensation was considered in the analysis, and no difference in partial pressure of carbon dioxide following surgery was noted (p = 0.65). CONCLUSIONS: To our knowledge no previous study has examined the matched paired results of before and after development of metabolic acidosis among children (serving as their own controls) with myelomeningocele undergoing ileal or colonic enteroplasty. The negative statistical results in this controlled cohort are clinically significant. If a child with myelomeningocele has metabolic acidosis after enteroplasty, other clinical reasons beyond the effects of surgery warrant careful consideration.

Tubularized incised plate hypospadias repair for distal hypospadias.

PURPOSE: We report surgical technique and outcomes in consecutive patients with primary distal hypospadias. MATERIALS AND METHODS: A prospectively maintained database of all patients operated by WS in 2000-2008 was reviewed for pertinent data in consecutive patients. RESULTS: A total of 551 consecutive patients of mean age 17 months underwent distal tubularized incised plate hypospadias repair by urethral plate tubularization with (459) or without (92) midline incision. Follow up occurred for 426 (77%) at a mean of 8.2 months. Calibration and/or uroflowmetry were obtained in 279 (65%). Complications developed in 19 (4%), including nine fistulas, nine glans dehiscences and one delayed meatal stenosis from balanitis xerotica obliterans. These complications could not be attributed to meatal location, urethral plate configuration or incision, suture materials or methods for urethroplasty and glansplasty, or to use or not of a dartos flap barrier layer. CONCLUSIONS: No contraindication to urethral plate tubularization with or without incision was found in 551 consecutive patients operated for distal hypospadias. Reliability of the procedure was confirmed by the low complication rate and success using varied suture materials and methods.