Hypospadias repair with onlay preputial graft: a 25-year experience with long-term follow-up.

OBJECTIVE: To evaluate the long-term outcomes of hypospadias repair using an onlay preputial graft. PATIENTS AND METHODS: Patient records from 1989 to 2013 were retrospectively reviewed. One surgeon performed all cases and surgical technique was the same for all patients. RESULTS: There were 62 patients in the cohort, with a mean (range) follow-up of 47.4 (1-185) months. The meatal location was separated into distal (one patient), midshaft (19) and proximal (42). In all, 22 (35.5%) patients had complications. There were three main types of complications, including meatal stenosis in three (4.8%), stricture in three (4.8%), and fistula in 21 (33.9%). The mean (range) timing of presentation with a complication after surgery was 24.9 (1-127) months. In all, 54.5% of the patients with complications presented at ≥1 year after the initial surgery and 31.8% presented at ≥3 years. On univariable analysis age at the time of surgery, length of the graft, presence of chordee or meatal location (proximal or midshaft) did not predict a complication. The width of the graft was associated with a complication, with each 1 mm increase in width decreasing the odds of a complication by 56%. On multivariable analysis width remained statistically significant (odds ratio 0.44, 95% confidence interval 0.230-0.840; P = 0.013) for predicting a complication. CONCLUSION: Hypospadias repair with onlay preputial graft is an option for single-stage repair, especially in cases of proximal hypospadias or where the urethral plate width and/or the glanular groove is insufficient for other types of repair. Compared with flaps, the use of grafts may decrease the risk of penile torsion and prevent less bulk around the urethra, improving skin and glans closure.

Urethral strictures in children.

PURPOSE OF THE REVIEW: The review is an attempt to present the current literature regarding strictures in children to provide an evidence-based recommendation regarding diagnosis and treatment. RECENT FINDINGS: The level of evidence upon which to base therapy of strictures in children is low and consists mostly of case series from single institutions. Hence most of the information is extrapolated from the adult literature. A consensus committee of the Societe Internationale d'Urologie reviewed the literature, and the committee report (which is as yet unpublished) provides the basis for most of the information herein. SUMMARY: Because there is relatively little information published on this subject, there is a need for prospective studies and multi-institutional series. Additionally, there is a need for basic studies of urethral wound healing to provide a better understanding of the problem.

Does administration of transdermal dihydrotestosterone gel before hypospadias repair improve postoperative outcomes?

In an effort to improve the outcome of hypospadias repair, Kaya et al. performed a prospective, randomized study of transdermal dihydrotestosterone (DHT) gel as a preoperative adjunct to surgery. They found that patients who received DHT gel had fewer complications and better cosmesis than patients who underwent surgery alone. The authors attribute the differences between the two groups to an increased blood flow produced by the gel. The series of patients was small, and a larger sample size might have produced different results. Some of the outcomes measured were subjective, and the methods used to assess these outcomes were not clear. If a larger study confirms the results obtained by Kaya and colleagues, transdermal DHT gel might prove to be a valuable adjunct to hypospadias surgery.

Verumontanum Cyst Associated With Lower Urinary Tract Symptoms in an Adolescent.

Urinary tract polyps occur anywhere from the renal pelvis to the anterior urethra. Lower tract polyps occur less frequently than upper tract polyps and are a rare finding in children. Symptoms include obstruction, dysfunctional voiding, or hematuria. We report the case of a 17-year-old male who presented with persistent leakage of urine following voiding. Ultrasound demonstrated a small cystic lesion in the posterior aspect of the prostate and a voiding cystourethrogram was suggestive of a utricular cyst or polyp. He underwent a cystoscopy that demonstrated a large cystic structure originating from the verumontanum, nearly obstructing the prostatic urethra.

Prepubertal male genitourinary metastatic Crohn's disease: report of a case and review of literature.

Chronic penile swelling in prepubertal boys is an uncommon problem. The differential diagnosis includes primary and secondary lymphedema, trauma, previous penile surgery, and extraintestinal metastatic Crohn's disease. We report a 6-year-old boy who presented with persistent penile edema as an extraintestinal manifestation of Crohn's disease. In this case, the penile edema preceded the overt bowel symptoms associated with Crohn's disease, and a high index of suspicion led to the underlying diagnosis. Few previous reports have reviewed the different treatment options and their associated outcomes for Crohn's disease in prepubertal boys with genital edema.

SIU/ICUD Consultation on Urethral Strictures: Urethral strictures in children.

A literature search was made through PubMed from 1990 to the present for articles on strictures in children. There were 32 articles that provided the data for this review. The studies were rated according to the level of evidence and the grade of recommendation using the International Consultations in Urologic Disease standards.

Perinatal testicular torsion: preoperative radiological findings and the argument for urgent surgical exploration.

Perinatal testicular torsion is an infrequent event, the management of which has been controversial. Occurrence is rare, estimated at 1 in 7500 newborns (Kaplan, G. W., Silber, I.: Neonatal torsion--to pex or not? In: Urologic surgery in neonates and young infants. Edited by King, L.R. Philadelphia: W.B. Saunders Co., 1988; Chapter 20, pp. 386-395). The frequency of bilateral perinatal torsion is up to 22% (J Urol. 2005;174:1579). Here, we describe two cases of bilateral asynchronous perinatal torsion, in which the only presenting abnormality on exam after birth was a unilateral scrotal mass. These cases illustrate that contralateral perinatal torsion may be present even when physical exam findings suggest unilateral involvement.

Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite.

PURPOSE: With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS: A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS: At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS: Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

Congenital mid ureteral strictures.

PURPOSE: Congenital mid ureteral stricture is rare. We report 7 cases, and discuss the differences in preoperative evaluation and surgical management compared to other obstructive entities. MATERIALS AND METHODS: Medical records and imaging studies of 7 children identified with mid ureteral strictures between 1998 and 2002 were reviewed retrospectively. Five newborns presented with prenatal hydronephrosis, and 2 children presented at age 15 years, one in the course of evaluation of blunt trauma, and one due to pain and abdominal mass. Imaging studies included renal ultrasound, voiding cystourethrography, radionuclide renography and computerized tomography. All patients underwent retrograde pyelography. Pathological examination of each specimen was undertaken at the respective institutions. RESULTS: Prenatal hydronephrosis was the most common presentation. There were no urinary tract infections. All patients had significant obstruction on the affected side. No patient had vesicoureteral reflux. After imaging but before surgery the urinary obstruction was believed to be at the ureteropelvic junction in 4 patients and the ureterovesical junction in 2, and secondary to posterior urethral valves in 1. At cystoscopy all of the affected ureters had a normally located and normally configured orifice. Retrograde pyelography led to an accurate diagnosis of mid ureteral narrowing in all patients. Six patients underwent ureteroureterostomy, all of whom had satisfactory outcomes. In 1 of these patients contralateral nephrectomy was performed due to nonfunction of the multicystic dysplastic kidney. The remaining patient underwent nephrectomy for ipsilateral end stage kidney disease and hydronephrosis. In this patient the ureters were stenotic and suggested asymmetry in the thickness of the muscular coat, perhaps secondary to extrinsic compression. CONCLUSIONS: Congenital mid ureteral stricture is rare. Renal ultrasound and radionuclide renography alone do not reliably demonstrate the site of obstruction. Retrograde pyelography at the time of surgical correction of presumed ureteral obstruction is an important adjunct for correctly identifying the site of narrowing in the affected ureteral segment, unless the ureter has been imaged with another modality.

Renal and testis injuries in team sports.

PURPOSE: Children with a solitary testis or kidney are generally advised against contact team sport participation to protect the solitary organ. We performed a review of renal and testis injury cases to ascertain if there was an increased likelihood of significant renal or testis injury in team sports. MATERIALS AND METHODS: We retrospectively reviewed charts on patients evaluated and/or admitted to the trauma service with renal or testis injuries. Severity, outcome and external cause of injury were evaluated as well as patient demographics. Patients were excluded from study if there was no radiographic or physical (postmortem or surgical) evidence of injury. Trauma admission/registry data from all patients enrolled were used for comparison. RESULTS: Of 14,763 patients enrolled in the trauma registry from July 1984 until December 2000, 450 (3%) were given a renal or testis injury diagnosis by the registry but only 209 patients (1.4%) met the review criteria for documentation of injury. There were 193 renal injuries (92.3%) and 16 testis injuries (7.7%). A total of 113 injuries were sustained during a recreational or team sport activity (54.1%) and only 10 renal (6) or testis (4) injuries recorded were sustained in team sports (4.8%). Overall team sports injuries recorded in the trauma registry for the study period was 3.4%. No team sports injured patient had a solitary testis or kidney and 1 patient had congenital ureteropelvic junction obstruction. There were only 3 associated injuries (spleen 2, skeletal 1) in the 10 patients. Surgical exploration was performed in all 4 testis injury cases, acute repair of renal injury was done in 1 and delayed pyeloplasty was performed for congenital ureteropelvic junction obstruction. No organs were lost and all patients recovered uneventfully. CONCLUSIONS: Renal and testis injuries occur with team sports, although at a much lower rate than from other external causes of injury. Most patients ultimately do well without loss of the injured organ. Recommendations against team sport participation may not be necessary in patients with a solitary kidney or testis.

Congenital urinary tract anomalies in pediatric renal trauma patients.

PURPOSE: Congenital genitourinary tract anomalies occur commonly in the general population. Anomalous kidneys are thought to be more frequently injured by trauma than normal kidneys. We reviewed patients with renal injuries to determine the etiology, severity, associated injuries and associated congenital genitourinary abnormalities. MATERIALS AND METHODS: A retrospective review of renal injuries was performed on patients evaluated and/or admitted to the trauma service. Severity, outcome, external cause of injury and patient demographics were evaluated. Patients were excluded from study if there was no radiographic or physical (postmortem or surgical) evidence of injury. Findings on urinalysis alone did not confirm a renal injury without other evidence. Trauma registry data from all enrolled patients were used for comparison. RESULTS: A total of 14,763 patients were enrolled in the trauma registry from July 1984 to December 2000, of whom 384 (2.6%) were given a diagnosis of renal injury but only 193 (1.3%) with radiographic or other physical evidence of renal injury were included in this review. Of the 16 renal injury patients (8.3%) 15 boys (93.8%) and 1 girl (6.2%) had congenital genitourinary abnormalities. Of the 193 patients 136 boys (70.5%) and 57 girls (29.5%) sustained renal injuries. A total of 20 patients (10.4%) died of injuries but none had a genitourinary anomaly. The genitourinary anomaly group had 6, and the entire renal injury group had 298 associated injuries. Only 6 patients with congenital genitourinary anomalies required surgical procedures primarily for elective repair of ureteropelvic junction obstruction. The most common external sources of injury, primarily falls, recreational or motor vehicle accidents, were similar for all patients, all renal injury patients and those renal injury patients with congenital genitourinary abnormalities. CONCLUSIONS: Renal injuries occur in about 1.3% of trauma patients (193 of 14,763) and 8.3% of the renal injury patients had congenital abnormalities (16 of 193). Most injuries occurred with falls or recreational activities. This population is small but the injuries were nonlife threatening and renal salvage was likely with or without surgery. Congenital genitourinary anomalies may not increase risk of morbidity.

Staghorn calculus endotoxin expression in sepsis.

Staghorn calculi are infrequent and generally are infected stones. Struvite or apatite calculi are embedded with gram-negative bacteria, which can produce endotoxin. Sepsis syndrome may occur after surgical therapy or endoscopic manipulation of infected or staghorn calculi. Sepsis, which can occur despite perioperative antibiotic use, may be due to bacteremia or endotoxemia. We present a child with an infected staghorn calculus who developed overwhelming sepsis and died after percutaneous stone manipulation. Endotoxin assay of stone fragments demonstrated an extremely high level of endotoxin despite low colony bacterial culture growth. This is the first reported case in which endotoxin was demonstrated in stone fragments from a child who died of severe sepsis syndrome after percutaneous staghorn stone manipulation.