Management of the refractory nocturnal enuresis patient to desmopressin in a pediatric population: Desmopressin + oxybutynin vs. desmopressin + imipramine.

INTRODUCTION AND OBJECTIVE: Desmopressin is well accepted as first-line medical therapy for enuresis. If ineffective, combination therapy of desmopressin + oxybutynin or desmopressin + imipramine has been used. This study assessed the efficacy of adjunct therapy with either imipramine or oxybutynin in the management of enuresis patients who failed desmopressin treatment. STUDY DESIGN: A retrospective chart review of our database for patients with enuresis was performed. Patients who were prescribed desmopressin, oxybutynin, and imipramine over 14 years for enuresis were included. Two cohorts of patients were examined; group OXY was treated with desmopressin and oxybutynin, and group IMP received desmopressin and imipramine. Pretreatment measurement of Vancouver Symptom Scores (VSS) were used to compare groups using the VSS question "I wet my bed at night" where 4: every night, 3: 4-5 nights per week, 2: 1-2 nights per week, 1: 3-4 nights per month, and 0: never. International Children's Continence Society (ICCS) criteria for continence success was utilized to determine outcomes. RESULTS: 2521 patients prescribed one of the 3 medications were identified. Among them, 81 patients (mean age: 10.5 ± 2.8 years) received combination therapy. Of which, 55 were male and 26 female. Specifically, 58 were prescribed both desmopressin and imipramine (group IMP), 23 desmopressin and oxybutynin (group OXY), and 4 transitioned from OXY to IMP. Mean pretreatment VSS showed no difference between groups. Both groups experienced minimal drops in wet nights with desmopressin alone. A comparison revealed that group IMP reduced wet nights significantly more than group OXY (VSS wet night score 0.7 ± 1.2 vs. 2.3 ± 1.1 respectively, p < 0.0001). Non-intent-to-treat complete response rate was 68% vs 5% (OR = 42.5, p < 0.001) (IMP vs. OXY respectively). Intent-to-treat response rates were 58%. DISCUSSION: Although first-line desmopressin treatment for enuresis is effective, it does not work for all patients, and many parents and children desire nighttime dryness. Clinicians have combined desmopressin with oxybutynin or imipramine for improved results, but research comparing these modalities is scarce. Our study suggests that the desmopressin and imipramine combination is superior at reducing nights wet compared to desmopressin and oxybutynin, attributed to imipramine's probable central mechanism rather than its secondary anticholinergic properties. Limitations include a modest sample size, retrospective design, and subjective responses to the Vancouver questionnaire. CONCLUSION: A combination of desmopressin and imipramine was more effective in reducing wet nights and had a complete response rate that was 42.5 times greater than desmopressin and oxybutynin.

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.

Congenital Anterior Urethral Diverticulum in Identical Twins.

Congenital anterior urethral diverticulum (CAUD) is an uncommon abnormality of the male urethra. In the literature, cases of CAUD affecting both children within a set of identical twins or presenting concomitantly with another urethral condition are exceedingly rare. We describe 2 cases of CAUD in identical twins: a pair of newborns in which Twin 1A and Twin 1B both present with CAUD, and a second pair of newborns in which only Twin 2A presents with CAUD along with a partial collateral urethral duplication. In doing so, we aim to add to the incomplete literature on the embryological development of CAUD.

Pediatric Bladder Tumors: A Ten-Year Retrospective Analysis.

OBJECTIVE: To present our experience in a single pediatric urology practice over a 10-year period with bladder tumors in the pediatric population in an effort to add to the relatively small amount of existing data. We hope to expand the community's knowledge of presentations, management and natural history of pediatric bladder tumors. METHODS: We retrospectively queried our electronic medical records for International Classification of Diseases, Tenth Revision (ICD-10) and Current Procedural Terminology (CPT) codes relevant for bladder tumors. Patients with underlying bladder pathology, such as neurogenic bladder, history of bladder exstrophy, and history of bladder augmentation, were excluded. RESULTS: We identified 30 patients with bladder tumors from 2011 to 2021. There were 21 males and 9 females. Age at diagnosis ranged from 16 months to 19 years. Tumors identified were: 11 of various inflammatory subtypes; 4 papillomas; 4 rhabdomyosarcomas; 3 papillary urothelial neoplasms of low malignant potential and 8 of other types. Treatment included transurethral resection of bladder tumor, chemoradiation and laparoscopic partial cystectomy. Twenty nine patients had disease limited to the bladder and 1 had disease outside the bladder. Follow-up ranged from 2 weeks to 13 years (median 19 months). All patients had no evidence of disease at most recent follow-up. CONCLUSION: Pediatric bladder tumors range from aggressive rhabdomyosarcomas to more benign urothelial lesions. Fortunately, the latter type of tumor is the more prevalent lesion. Knowledge of the treatment options and natural history of these tumors will hopefully be of benefit to clinicians and parents alike.

Finding the Next Resident Physicians in the COVID-19 Global Pandemic: An Applicant Survey on the 2020 Virtual Urology Residency Match.

OBJECTIVE: To assess interviewing applicant perceptions of a virtual urology residency interview in the setting of changes mandated by COVID-19 and to determine applicant preference for virtual or in person interviews. Applicant perceptions of multiple interview components were queried to identify program specific and interview modality specific strengths or weaknesses in the 2020 to 2021 Urology Match. METHODS: A 12 question multiple choice and free text survey was emailed to 66 virtually interviewed applicants for open residency positions at a metropolitan training program after conclusion of interviews. Items of interest included interview type preference, overall interview impression, and recommendations for improvement. RESULTS: A total of 50 of 66 (76%) applicants completed the survey corresponding to approximately 11% of the 2020 national urology applicant pool. A total of 49 of 50 (96%) respondents assessed faculty interaction and the virtual platform positively. A total of 38 of 50 (76%) was satisfied with their resident interaction and 32 of 50 (64%) applicants stated they were able to satisfactorily evaluate the site and program. Ultimately, 39 of 50 (78%) respondents would have preferred an in person interview to our virtual interview. Respondents cited challenges in assessing program culture and program physical site virtually. CONCLUSION: The majority of survey respondents indicated a preference for in person interviews. A smaller proportion of applicants preferred virtual interviews citing their convenience and lower cost. Efforts to improve the virtual interview experience may focus on improving applicant-resident interaction and remote site assessment.

Botulinum Toxin-A therapy in pediatric urology: indications for the neurogenic and non-neurogenic neurogenic bladder.

Although, the role of Botulinum Toxin-A in the treatment of the neurogenic and non-neurogenic neurogenic bladder is becoming more defined, this is the first review article to characterize the emerging role of Botulinum Toxin-A in the pediatric urologic population. Injection of Botulinum Toxin-A at the level of the bladder works by inhibiting uninhibited bladder contractions and, possibly, by blocking some of the sensory nerve fibers. In children with sphincter dyssynergy, injection at the level of the urethral sphincter works by inhibiting the involuntary guarding reflex and blocking dyssynergic voiding.

Robot-assisted Laparoscopic Urachal Excision in Children.

OBJECTIVE: To report the first exclusively pediatric series of robot-assisted urachal remnant excisions in children. METHODS: We reviewed the medical records of all children who underwent robot-assisted excision of urachal remnants from 2010 to 2016. For the procedure, a 3-port approach was performed in all cases. Excision of the urachus was performed, along with partial cystectomy if there was clear or suspected bladder involvement. Outcomes and complications were reviewed. RESULTS: Sixteen cases of robotic urachal excision were performed during the study period in patients aged 0.8-16.5 years. Complete excision was accomplished in all cases with no conversions. Partial cystectomy was performed in 11 cases, in which a urinary catheter was left for 1 day in all cases (no catheter was left in the absence of partial cystectomy). The only complication was a bladder leak requiring open surgical repair. There were no bowel injuries or hernias. The median operative time was 107 minutes. The length of stay was 2 days with partial cystectomy and 1 day without partial cystectomy. All patients were well at follow-up. CONCLUSION: We report the largest known series of robot-assisted urachal remnant excisions in children, demonstrating this minimally invasive approach to be safe and effective.

Laparoscopic pyeloplasty in the pediatric patient: hand sewn anastomosis versus robotic assisted anastomosis--is there a difference?

PURPOSE: The most difficult portion of laparoscopic pyeloplasty is the intracorporeal suturing involved in the anastomosis. We identified whether there is a difference in outcomes between a laparoscopic hand sewn anastomosis and a robotic assisted anastomosis. MATERIALS AND METHODS: We studied 29 patients who underwent pyeloplasty in the last 30 months, including a robotic assisted procedure in 15, a laparoscopic procedure in 12 and an aborted procedure in 2. RESULTS: Followup was 10 to 122 weeks (average 41). All surgeries except 1 were deemed successful by resolution of hydronephrosis on ultrasound and symptomatic criteria. Intraoperative time for robotic assisted pyeloplasty was 150 to 290 minutes (average +/- SD 223.1 +/- 46.5). Laparoscopic time was 200 to 285 minutes (average 236.5 +/- 24.1). CONCLUSIONS: Robotic assisted and laparoscopic anastomosis produced similar outcomes in pediatric patients who underwent pyeloplasty. Overall operative times did not vary significantly between the 2 procedures. There appeared to be no quantifiable benefits between the 2 procedures.

Endoscopic injection of bulking agents in children with incontinence: dextranomer/hyaluronic acid copolymer versus polytetrafluoroethylene.

PURPOSE: Treating pediatric incontinence can be challenging. Many surgical procedures are available with variable success and complications. Endoscopic injection of bulking agents into an incompetent bladder neck was first described using Teflon and most currently using Deflux. We compared the results of bladder neck injection using Deflux and Teflon to manage urinary incontinence in children. MATERIALS AND METHODS: A retrospective study was performed in children who underwent primary endoscopic injection of Teflon or Deflux to the bladder neck. Patients with prior bladder neck surgery were excluded. Data were collected on underlying anatomical pathology, preoperative bladder capacity, endoscopic approach, quantity of bulking agent and outcome. Dry was defined as 3 hours or greater awake without wetting. Wet was defined as the need for a pad or diaper. RESULTS: A total of 34 patients underwent primary injection of bulking agents, including 32 via a retrograde approach and 2 via a combined antegrade-retrograde approach. A total of 20 children with a mean age of 2.7 years were injected with Teflon and 11 were injected with Deflux. One of the 20 Teflon injected patients was dry more than 6 months. One of the 14 Deflux injected patients was dry at 3 months in the daytime, another 2 improved at 3 months (antegrade/retrograde in 1) but worsened at 6 months and another was dry after a second injection. All 4 improved children had age appropriate bladder capacity. The volume of injected agent was 1 to 10 cc. No complications were seen. Five children per group underwent subsequent open continence surgery. CONCLUSIONS: Bladder neck injection of bulking agents is a generally ineffective therapy for incontinence. While neither the number of injections nor the bulking agent used affected the results, adequate bladder capacity and antegrade injection with Deflux heralded short-term improvement. Patients with exstrophy consistently did poorly.

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.