Outcome of circumcision for newborns with penoscrotal web: oblique skin incision followed by penis shaft skin physical therapy shows success.

SHORT INTRODUCTION/BACKGROUND: and objectives: Although it is widely agreed that newborn circumcision complications are low when the penile anatomy is normal, outcomes are uncertain when a web of skin attaches the penis to the scrotum. This anomaly, called a penoscrotal web or webbed penis, often leads to surgical reconstruction instead of newborn circumcision. OBJECTIVE: With this study, the authors compare the circumcision success rate for webbed penis circumcisions using a new, alternate method vs that using the traditional method. STUDY DESIGN: Data from circumcision patients presenting to the Division of Urology's circumcision clinic from January 2014 to April 2018 were reviewed. All patients who met the checklist criteria for suitability to circumcise were enrolled in the study. They were grouped into the 'normal' group if they had no penile anomalies or the 'web' group if they had a web with a straight penis. Cases with penile anomalies were excluded. The new circumcision method includes altering the circumcision site planned to be oblique, slant up, to compensate for the web, retaining slightly more ventral than dorsal shaft skin, and including home care skin physical therapy as 'push down' the shaft skin. Postcircumcision evaluation was completed within 2 weeks after circumcision, and families were followed up as needed over the study period, six months after circumcision. Circumcision success was defined as the penis shaft no longer attached to the scrotum and circumcision line below the glans corona. RESULTS: Of 828 boys who presented for circumcision, 652 (79%) were enrolled as they were suitable for circumcision: 355 (43%) in the normal group and 297 (36%) in the web group. The remaining 176 (21%) were excluded because they presented with a penile anomaly: buried penis (125), chordee (40), and hypospadias (11). Follow-up was carried out for 6 months. In the web group, follow-up data were obtained for 263 of 297 (89%) cases, with 261 of 263 (99%) showing success, and in the normal group, follow-up data were obtained for 327 of 355 (92%) cases, with all 327 (100%) showing success. The two web group cases (0.7%) who failed had surgical reconstruction. DISCUSSION: It is believed the high success rate for penoscrotal web circumcisions with oblique incision followed by penis shaft skin physical therapy establishes that surgical reconstruction is not required in most of these cases. CONCLUSION: It was found that newborns with a penoscrotal web and straight shaft show 99% success for circumcision, which is not different from boys without any penile anomalies (p = not significant). The authors believe the adoption of these new, alternate circumcision methods will enable boys with a web to avoid surgical reconstruction.

Improving surgical training by identifying the most common feedback trainees receive for index cases.

BACKGROUND: To make surgical training more effective, a proven method is needed to provide feedback to residents on their surgeries. Residency programs may make up for limited training time in the operating room by improving feedback that trainees receive about cases. OBJECTIVE: The goals of this study were (1) to determine if an online tool to communicate feedback for attendings and trainees shows face validity and (2) to use an online tool to identify the most common feedback trainees receive after performing orchiopexy and hypospadias repair by survey. METHODS: In 2016, determining whether an online tool to provide pediatric urology trainees feedback after surgery shows face validity begun. The tool was launched at the authors' institutions. Then, attendings, fellows, and postgraduate year 4-5 trainees of 65 resident training programs were surveyed for their observations on preparing for and performing orchiopexy and hypospadias repair using the study tool to identify common feedback. RESULTS: The results of using the tool to provide feedback shows face validity are as follows: feedback was exchanged between attendings and trainees on orchiopexy (n = 28) and hypospadias (n = 22). Anecdotally, the tool was easy to use. The results of using the tool to identify the most common feedback trainees receive by survey are as follows: from a pool of 65 institutions, 37 attendings and 28 trainees were enrolled who made 219 observations. Most trainees prepare using undocumented online resources (17/28, 67%) instead of speaking with their attendings or cotrainees (11/28, 33%). For orchiopexy, most respondents reported that trainees need to improve skills for hernia ligation (observations: attending = 28/45, 62%; and trainee = 17/26, 65%) and strategies for hernia exposure (observations: attending = 17/27, 62%; and trainee = 7/12, 58%). For hypospadias, most respondents reported that trainees need to improve skills for neourethroplasty (observations: attending = 31/53, 58%; and trainee = 10/16, 62%) and strategies for repair choice (observations: attending = 15/22, 68%; and trainee = 12/18, 67%) (chi-squared, all P = NS). DISCUSSION: It was shown that both trainees and attendings agree on the areas of surgical strategy and execution which require improvement. With this study, it is also shown that the online feedback tool developed shows face validity in allowing attendings and trainees to communicate before and after surgery. CONCLUSIONS: The most common feedback pediatric urology trainees receive for routine pediatric urology surgery is identified. Online tools that emphasize remediations to address a trainee's specific feedback needs are to be built, so that they will be able to improve their skills at their next case.

Is glans penis width a risk factor for complications after hypospadias repair?

INTRODUCTION: Recent studies have suggested that a smaller glans penis size may be associated with a higher likelihood of complications after hypospadias repair. Accurate identification of risk factors other than the well-understood variable of meatal location would allow development of better prognostic models and individualized risk stratification. OBJECTIVE: To test the hypothesis that a smaller width of the glans penis predicts adverse outcomes after hypospadias surgery. METHODS: Prospectively recorded clinical data were reviewed from a single-institution registry of primary hypospadias repairs performed between 2011 and 2014. Follow-up records were examined for occurrence of complications. Urethroplasty complications were defined to include meatal stenosis, dehiscence, urethrocutaneous fistula, urethral stricture, and/or urethral diverticulum. The subset of meatal stenosis and dehiscence were regarded as glanular complications. Regression analyses were performed to determine association between glans width and occurrence of complications. Because pre-operative androgen stimulation is known to increase glans penis size, separate subgroup analyses were included of patients with and without pre-operative use of testosterone cream. RESULTS: A total of 159 patients met criteria for inclusion in the study cohort: 140 patients underwent a single-stage repair, while 19 patients had a two-stage repair. The median glans penis width was 15 mm (range 10-22). Eighty-four patients (53%) received testosterone cream pre-operatively and had a significantly wider glans penis than the 75 patients who did not (median 15.5 vs 14 mm; P < 0.001). Median clinical follow-up was 7 months (IQR 1-12), with a minimum time elapsed since surgery of 10 months at the time of chart review. Twenty-four patients (15%) had one or more urethroplasty complications, including 11 (7%) with glanular complications. Overall, there was no statistically significant association between glans width and urethroplasty complications (P = 0.26) or glanular complications (P = 0.90) (Summary Table). Subgroup analyses of patients with and without pre-operative testosterone also revealed no significant associations between glans width and complications. CONCLUSIONS: Glans penis width was not a risk factor for complications after hypospadias repair. This finding differs from the results of other recent studies and encourages further research into the value of measuring penile parameters in patients undergoing hypospadias repair.

Antidepressants and Antiepileptic Drugs for Chronic Non-Cancer Pain

The development of newer classes of antidepressants and second-generation antiepileptic drugs has created unprecedented opportunities for the treatment of chronic pain. These drugs modulate pain transmission by interacting with specific neurotransmitters and ion channels. The actions of antidepressants and antiepileptic drugs differ in neuropathic and non-neuropathic pain; and agents within each medication class have varying degrees of efficacy. Tricyclic antidepressants (e.g.; amitriptyline; nortriptyline; desipramine) and certain novel antidepressants (i.e.; bupropion; venlafaxine; duloxetine) are effective in the treatment of neuropathic pain. The analgesic effect of these drugs is independent of their antidepressant effect and appears strongest in agents with mixed-receptor or predominantly noradrenergic activity; rather than serotoninergic activity. First-generation antiepileptic drugs (i.e.; carbamazepine; phenytoin) and second-generation antiepileptic drugs (e.g.; gabapentin; pregabalin) are effective in the treatment of neuropathic pain. The efficacy of antidepressants and antiepileptic drugs in the treatment of neuropathic pain is comparable; tolerability also is comparable; but safety and side effect profiles differ. Tricyclic antidepressants are the most cost-effective agents; but second-generation antiepileptic drugs are associated with fewer safety concerns in elderly patients. Tricyclic antidepressants have documented (although limited) efficacy in the treatment of fibromyalgia and chronic low back pain. Recent evidence suggests that duloxetine and pregabalin have modest efficacy in patients with fibromyalgia

Headache evaluation and treatment by primary care physicians in an emergency department in the era of triptans.

BACKGROUND: Despite advances in treatment, patients with migraine have been underdiagnosed and undertreated. METHODS: Documentation of visits by patients with headache to an urgent care department staffed by primary care physicians was reviewed. Patients were also sent a brief headache screen, and those who replied were interviewed by telephone. "Repeaters" (patients who made 3 or more visits in 6 months) were excluded from chart review. RESULTS: Over 6 months, 518 patients made 1004 visits to the emergency department for primary headache complaints: 464 patients (90%) made 1 or 2 visits (total visits, 502). A review of 174 charts documenting a diagnosis of migraine found that (1) the need for prophylaxis was determined in only 40 (31%) of the patients who were not already undergoing prophylaxis and (2) treatment in the emergency department was migraine specific in 46 patients (26%) or otherwise appropriate in 45 (25%). A review of 90 charts documenting nonmigraine diagnoses found that 30 patients (33%) had adequate history documented to exclude migraine as the diagnosis. Eighty-six patients (17%) were interviewed. An emergency department diagnosis of migraine (n = 59) corresponded to a final diagnosis of migraine with (n = 21) or without (n = 18) medication overuse or chronic daily headache and/or transformed migraine with (n = 18) or without (n = 2) medication overuse. Discharge diagnoses that were not migraine (n = 27) had final diagnoses of migraine with (n = 9) or without (n = 9) medication overuse or chronic daily headache/transformed migraine with (n = 7) or without (n = 2) medication overuse. CONCLUSIONS: In this emergency department population, many patients with migraine, chronic daily headache, or medication overuse are not accurately diagnosed. The need for prophylaxis is not usually assessed. Treatment is migraine specific in the minority of patients. Tension-type headache is rarely an accurate diagnosis in this emergency department population.

Lamina muscularis propria thickness of renal pelvis predicts radiological outcome of surgical correction of ureteropelvic junction obstruction.

PURPOSE: We examine if there is a relationship between the histopathology of the renal pelvis and postoperative radiological findings in children with ureteropelvic junction obstruction. MATERIALS AND METHODS: The records of 220 patients who underwent pyeloplasty for isolated ureteropelvic junction obstruction between 1988 and 1996 were retrospectively reviewed, and 41 (42 kidneys) were identified who had adequate histological specimens and postoperative radiographic studies (ultrasonography and/or well tempered renogram) for examination. Histological features of the lamina muscularis propria from the renal pelvis were correlated with the radiographic outcome after pyeloplasty. RESULTS: Lamina muscularis propria thickness of the renal pelvis correlated significantly with radiological improvement. All kidneys with renal pelvic lamina muscularis propria thickness less than 250 microm. showed radiological improvement at 3 to 6 months postoperatively, those with thickness between 250 and 350 microm. had improvement at 9 months and those with lamina thickness greater than 350 microm. had a significantly worse outcome at all observation points. At 3 and 6 months postoperatively 16 of 30 (53%) and 23 of 34 (68%) children with radiological improvement had a mean lamina muscularis propria thickness of 252 +/- 131.5 microm. and 263 +/- 122.8 microm., respectively, while the remaining unimproved 14 and 12 patients had a mean thickness of 374 +/- 64.3 microm. (p <0.01) 372 +/- 66.1 microm. (p <0.05), respectively. CONCLUSIONS: The lamina muscularis propria thickness of the renal pelvic wall can provide insight to the expected time of postoperative improvement on radiological studies in children with ureteropelvic junction obstruction.

The undescended testicle.

The cryptorchid testis is a common pediatric condition, usually diagnosed by the primary physician. The diagnosis, classification, and treatment options of the cryptorchid testis are discussed in hopes of clarifying some of the controversy surrounding this common problem.

Exact mass measurements for confirmation of pesticides and herbicides determined by liquid chromatography/time-of-flight mass spectrometry.

The accuracy and precision of exact mass measurements are determined using positive ions formed in the electrospray of 10 nonvolatile or thermally unstable carbamate, urea, and thiourea pesticides and herbicides. Environmentally significant approximately 7-ng quantities of the analytes were separated with microbore liquid chromatography, and the exact mass measurements were made in real time with a benchtop time-of-flight mass spectrometer. The positive ion electrospray mass spectra of the analytes generally consist of one or a few ions which are usually adducts of the molecule with a proton, a sodium ion, or an ammonium ion. Fragment ions and the rich mass spectra typical of electron ionization (EI) are generally not produced in the soft electrospray ionization process. Confirmation of the identity of a nonvolatile pesticide or herbicide depends largely on the masses of the few ions formed and the retention time, which can vary with chromatography conditions. Identifications of these analytes in environmental or other samples are less certain than identifications of volatile pesticides determinated by gas chromatography and EI mass spectrometry. The benchtop time-of-flight mass spectrometer was equipped with an electrostatic mirror, and resolving powers of 3500-5000 were routinely obtained and used for these exact mass measurements. This type of mass spectrometer is significantly less costly and complex than other types of mass spectrometers with exact mass measurement capabilities. The mean errors from three replicate exact mass measurements of the 10 test analytes were in the range of 0-5.4 parts-per-million. Potential interferences from substances with similar exact masses were evaluated.

Elevated bladder urine concentration of transforming growth factor-beta1 correlates with upper urinary tract obstruction in children.

PURPOSE: We evaluated urinary transforming growth factor-beta1 (TGF-beta1) concentration in children with upper urinary tract obstruction as a potential tool for supporting the diagnosis of clinically significant obstruction. MATERIALS AND METHODS: Renal pelvic and bladder urine samples were obtained for analysis from 30 patients a median of 5 months old who underwent surgery for obstruction at the ureteropelvic (29) and ureterovesical (1)junctions. Urinary TGF-beta1 concentration was measured using a quantitative sandwich enzyme-linked immunoassay technique. Bladder urine TGF-beta1 in patients with obstruction was compared with that in controls. In addition, we compared renal pelvic and bladder urine TGF-beta1 in patients with obstruction. RESULTS: Mean bladder urine TGF-beta1 plus or minus standard error of mean was 4-fold higher in patients with upper tract obstruction than in controls (195 +/- 29 versus 47 +/- 7 pg./mg. creatinine, p <0.001). In the obstructed group mean TGF-beta1 in the renal pelvic urine was 378 +/-86 pg./mg. creatinine, or twice that of the bladder urine (p = 0.02). CONCLUSIONS: Bladder urine TGF-beta1 in patients with upper urinary tract obstruction is significantly elevated compared with that in controls. To our knowledge our study is the first to identify a bladder urinary marker that correlates with upper urinary tract obstruction with greater than 90% sensitivity. Measuring TGF-beta1 in a voided bladder urine sample may provide an objective and noninvasive test for assisting in the diagnosis of upper urinary tract obstruction.

Single system ureteral ectopia in boys associated with bladder outlet obstruction.

PURPOSE: Ureteral ectopia is frequently associated with dysplasia of the associated renal segment in girls with ureteral duplication. However, single system ureteral ectopia is an uncommon anomaly more frequently noted in boys. We report on 6 boys with single system ureteral ectopia into the prostatic urethra above the verumontanum, who presented with radiological and clinical findings of bladder outlet obstruction. MATERIALS AND METHODS: Antenatal ultrasound in 3 boys demonstrated renal abnormalities and postnatal studies suggested the diagnosis of posterior urethral valve obstruction. Older boys presented with symptoms suggestive of bladder outlet obstruction. RESULTS: An ectopic ureter inserting into the prostatic urethra was noted in all 6 boys. The distal ureter was dilated elevating the bladder neck causing outlet obstruction. Surgical management consisted of nephrectomy and transurethral endoscopic incision of the distal ureter or nephroureterectomy with reconstruction of the prostatic urethra. In 2 younger boys voiding dysfunction with inability to empty developed. CONCLUSIONS: Single system ectopic ureters in boys may present with symptomatic and radiological findings resembling posterior urethral valves. Surgical treatment should include nephroureterectomy with reconstruction of the hypoplastic prostate. Some patients may have later voiding dysfunction.

Intranasal lidocaine to prevent headache following migraine aura.

OBJECTIVE: To report the consistent effect of intranasal lidocaine 4% on preventing headache following aura in one individual. BACKGROUND: A treatment that could prevent the headache which follows an aura would be an important advance in the treatment of migraine. No migraine abortive treatment has been shown to have such an effect. METHODS: A 15-year-old adolescent boy with a history of recurrent headache since aged 2, fulfilling the criteria for migraine with aura, was seen in consultation. Intranasal lidocaine 4% was used during the aura phase to prevent the headaches. RESULTS: Before using intranasal lidocaine, the patient invariably experienced a migraine following a typical visual aura. The episodes occurred approximately weekly, with a stable pattern for several years. When given during the aura, intranasal lidocaine prevented the headache following the aura, and remained successful on all but two occasions over 1 1/2 years of use (approximately 75 episodes). There was no effect on the duration of the aura itself. CONCLUSIONS: Intranasal lidocaine consistently prevented the development of headache symptoms following aura in this individual. Such an effect suggests a role for the sphenopalatine ganglion in the development of migraine pain.