A comparison of 467 uroflowmetry results in repaired hypospadias vs. normal male flows.

INTRODUCTION: There are currently no clinical criteria for obstructed urinary flow after hypospadias repair surgery. Previous studies have utilized adult and pediatric nomograms and flow shapes to define obstruction, however these methods are limited by a lack of standardization and lack of interrater reliability when determining flow shapes, respectively. The idealized voider derived flow indexes offer a way to track uroflowmetry results in a volume and age agnostic manner. OBJECTIVE: We sought to evaluate all our hypospadias patients over a 10-year period and identify patients without complications and those with complications and determine their respective flow parameters. Our secondary objective is to identify which uroflowmetry parameters are the most significant predictors of urethral stricture and meatal stenosis at the time of the uroflowmetry study. STUDY DESIGN: Retrospective chart review was used to compile demographic information, details of hypospadias repair surgeries, and uroflowmetry results from pediatric hypospadias repair patients. Subjects were divided into distal, midshaft, and proximal groups based on the initial location of their urethral meatus. Flows from the hypospadias repair groups were compared to flows from normal age matched controls from a previous study. We compared flows from hypospadias repair patients with no complications present with those who had urethral stricture or meatal stenosis present at the time of uroflowmetry. Binary logistic regression and ROC analysis was used to assess different uroflowmetry parameters' ability to detect the presence of obstructed urine flow. RESULTS: 467 uroflowmetry studies from 200 hypospadias repair patients were included in the database. Compared to controls, the hypospadias repair groups tended to have significantly lower Qmax, Qavg, Qmax FI, Qavg FI, and longer ttQmax. Significant differences in flow parameters were observed when comparing hypospadias repair patients with and without flow obstructing complications at the time of uroflowmetry. Binary logistic regression including various uroflowmetry parameters showed Qmax FI had a significant effect on the odds of observing the absence of a stricture in proximal and distal hypospadias cases. DISCUSSION: Of the uroflowmetry parameters analyzed, binary logistic regression and the likelihood ratio of a positive result all point to Qmax FI as the better parameter to use to detect the presence of complications in patients who have undergone distal or proximal hypospadias repair surgery. CONCLUSION: We have established normal parameters for post-operative hypospadias repair patients which can be used to follow patients over time and allow for the identification of complications by keeping track of flow indexes which are volume and age agnostic.

Size matters: Total testicular volume predicts sperm count in Tanner V varicocele patients.

INTRODUCTION: It is known the prevalence of varicoceles in adolescent men is 14-29% but there is debate surrounding implications on fertility. As obtaining a semen analysis (SA) may be challenging, there is need for objective tests as measures of fecundity. Our aim was to investigate the relationship between testicular volume differential (TVD), varicocele grade, and total testicular volume (TTV) on seminal parameters including total motile sperm count (TMSC). MATERIALS AND METHODS: We conducted a retrospective single-center chart review over 14 years of 486 Tanner V adolescent males. Three hundred and four met inclusion of palpable, non-operated left-sided varicocele who underwent at least one SA and ultrasound. Abnormal TMSC was defined by World Health Organization 2010 criteria for minimal reference ranges. Multivariate logistic regression, receiver operating characteristic analysis with Youden J-statistic and descriptive statistics were performed. RESULTS: Three hundred and four Tanner V adolescents with median age of 18.0 years (18.0-19.0), median TTV of 34.5 cc (28.9, 40.2) and median TMSC of 62.5 million/ejaculate (25.4, 123.4) were evaluated. TTV cutoff of 29.5 cc was found to predict TMSC of <9 million/ejaculate with negative predictive value of 96.2% and odds ratio of 6.08 ([2.13-17.42], p < 0.001). TVD greater than 20% did not reach statistical significance with an odds ratio of 1.66 ([0.41-6.62], p = 0.50). DISCUSSION: In clinical practice, each patient will need to have an individualized plan. Based on our data, for older adolescents (17 or 18 years) with varicocele and an abnormal TTV, clinicians may have a lower threshold for advising SA, and if unable to obtain, surgical intervention and/or closer surveillance should be stressed. Patients should be informed of their six-fold increase in abnormal SA. Patients with normal TTV should be advised they are at lower risk of having abnormal SA. Younger patients with varicocele and an initial TVD>20%, should be followed closely but intervention delayed until 17 or 18 to better assess TTV. The importance of trending patient data should be emphasized as a single measurement has low predictive value for developing adolescents. Limitations of our study include a retrospective design and the lack of uniform correlation between adolescent SA and paternity. CONCLUSIONS: Total testicular volume less than 29.5 cc increased odds of abnormal semen analysis by over six times and had a negative predictive value of 96.2%. Ultrasound results may be useful for risk stratification and counselling on appropriateness of surgical intervention.

The use of botulinum toxin A injection for the management of external sphincter dyssynergia in neurologically normal children.

PURPOSE: Botulinum toxin A has previously been used for neurogenic and nonneurogenic urgency and urge incontinence. We evaluated the effects of sphincteric botulinum toxin A injection in a series of neurologically normal children with evidence of external sphincter dyssynergia with various voiding problems documented by abnormal voiding electromyography as well as voiding cystourethrography to assess its effectiveness for eliminating post-void residual urine. MATERIALS AND METHODS: We retrospectively reviewed the charts of 16 dysfunctional voiders who underwent botulinum toxin A injection to the external sphincter between 2002 and 2006, including 1 to 3 injections in 14, 1 and 1, respectively. Of 19 injections 17 were performed with 300 U to the sphincter, while 2 of 19 were done with 200 U. Two patients also received 100 U injected into the detrusor. Mean patient age at surgery was 9.0 years (range 6 to 16). Preoperative clinical data were recorded, including medications, electromyography, uroflowmetry with post-void residual urine, ultrasound and voiding cystourethrography. Before botulinum toxin A injection medical therapies had failed in all patients, including alpha-blockers in 100%, biofeedback in 100%, oxybutynin in 33% and tricyclics in 3 (20%). One patient was on intermittent catheterization. All patients were refractory to bowel regimens and timed voiding. Postoperative parameters consisted of medications, symptoms and post-void residual urine. In the 3 males the resolution of epididymitis symptoms and prevention of recurrence were evidence of success. RESULTS: Before treatment patients experienced symptoms of urge incontinence (14 of 16), recurrent urinary tract infections (66%), voiding postponement (45%) and epididymitis (3 of 16). All patients had external sphincter dyssynergia, as documented by preoperative electromyography or voiding cystourethrography. Average preoperative post-void residual urine was 107 cc (range 49 to 218). Two patients who underwent preoperative voiding cystourethrography had unilateral grade 1 reflux. Of the 16 children 12 (75%) were dry at the first postoperative visit. The remaining 2 patients had decreased enuresis and 13 of 16 were dry at the second postoperative visit. The last patient became dry after treatment for attention deficit disorder was initiated. Average initial postoperative post-void residual urine volume was 43 cc (range 0 to 141) and the average best postoperative visit post-void residual urine was 8 cc (range 0 to 26). Uroflow data revealed no difference in uroflow before or after injections. Neuropsychiatric problems were present in 9 of the 16 patients, including depression in 4, anxiety in 3 and attention deficit disorder in 2. CONCLUSIONS: Before our study in the pediatric literature doses between 50 and 100 U were used. We used a significantly higher dose with increased efficacy and no increased morbidity. Endoscopic botulinum toxin A injection of the external sphincter appears to be a safe and efficacious way to treat refractory nonneurogenic voiding dysfunction in children with external sphincter dyssynergia. Long-term followup is necessary and repeat endoscopic injections may be required in select patients.