[Trampolining-induced gross hematuria : Unmasking the nutcracker syndrome]. / Trampolinspringen-induzierte Makrohämaturie : Das demaskierte Nussknackersyndrom.

The case of a 12-year-old boy with sports-induced recurrent macrohematuria and left-sided flank pain is reported. After extensive laboratory and imaging diagnostics, the diagnosis of nutcracker syndrome is made based on the characteristic clinical manifestation. Under a conservative approach and abstention from the triggering sport, a clinical as well as image-morphologically confirmed maturation occurred.

[Lichen sclerosus in children]. / Lichen sclerosus im Kindesalter.

Lichen sclerosus (LS) is a chronic inflammatory disease of the skin. It mainly affects the anogenital area. More knowledge of the disease is needed to avoid delay in diagnosis as early treatment may cure the disease in some and reduce or prevent scarring. Initial treatment for girls and boys comprises the daily application of a potent cortisone ointment for 3 months. After remission the treatment should be continued long-term intermittently. If there is no complete remission in boys complete circumcision is recommended. LS usually cannot be healed but only well suppressed, and also after circumcision recurrences may occur years later. Therefore, patients have to be well informed and should be followed up long-term.

[Acute idiopathic scrotal edema-an underestimated differential diagnosis of acute scrotum]. / Das idiopathische Skrotalödem ­ eine unterschätzte Differentialdiagnose des akuten Skrotums.

Considering that Quist et al. first described the acute idiopathic scrotal edema (AISE) already in 1956, there are not many studies published in literature concerning the etiology, the development, and the progress of the disease since then. According to the literature the incidence of AISE is about 20%. Although it is an important differential diagnosis for acute scrotum, it remains extensively unknown. Therefore, AISE should be kept in mind by urologists, pediatric surgeons and pediatricians to avoid needless surgery or antibiotic therapy.

[Pediatric urological challenges in refugee children]. / Kinderurologische Herausforderungen bei Flüchtlingskindern.

In recent years, the number of refugees to Germany has risen dramatically. Nearly half of the refugees are under 18, and a large percentage of them have acute or chronic medical problems. This situation poses a unique challenge to pediatric hospitals. Interprofessional teams in pediatric urology departments must care for an increasing number of patients with genetic abnormalities and diseases, unusual urogenital trauma, as well as frequent multiresistent organisms. In addition, communication problems due to language barriers and intercultural differences abound. Successful urological care for these patients requires not only high technical skills, dedication and empathy, but also the ability to reflect on and adapt to different cultural perspectives.

[Special urological traumatology in children and adolescents]. / Spezielle urologische Traumatologie bei Kindern und Jugendlichen.

Isolated injuries of the genitourinary tract are rare, with the kidney being the most frequently affected organ, especially in situations of polytrauma. Overall, the genitourinary tract is involved in approximately 3 % of all children suffering polytrauma accidents. The literature and international guidelines provide clear therapeutic concepts with a consensus on the diagnosis and treatment of renal trauma, both for the treatment of adults and for children and adolescents. However, the most common injuries to the external genitalia in children and adolescents are caused by blunt trauma, abrasion, bruising, and piling. For these forms of injuries there are no general recommendations in literature and guidelines regarding diagnostic or therapeutic procedures, which may be due to the wide variety of origins of the injuries. Consequently, as shown in our sequence of case reports, each type of injury to the external genitourinary system requires an individual evaluation and therapeutic approach.

[Rare diseases with clinical relevance-the Silver-Russell syndrome]. / Seltene Erkrankungen mit klinischer Relevanz ­ das Silver-Russell-Syndrom.

The Silver-Russell syndrome (SRS) is a rare imprinting disease associated with pre- and postnatal growth retardation, craniofacial features, and asymmetry. Genitourinary abnormalities are seen in up to 20% of affected individuals. Apart from structural renal anomalies, cryptorchidism and hypospadias occur frequently in boys, while girls often have anomalies similar to those in Mayer-Rokitansky-Küster-Hauser syndrome with congenital hypoplasia or aplasia of the uterus and upper part of the vagina. Frequently hypospadias repair and orchiopexy are difficult because of lack of buccal mucosa due to facial dysmorphism and intraabdominal position of the testicles, respectively. Anesthetic problems with SRS children can be profound and mostly concern a difficult airway due to facial dysmorphism. Especially the young, very thin SRS patients are prone to hypoglycemia and hypothermia and require close perioperative monitoring. Children with SRS and their families face challenges from birth to adulthood. In case of urogenital abnormalities, they should receive multidisciplinary care by pediatric urologists/surgeons and pediatric anesthesiologists in a center of expertise in rare diseases.

Acquired cryptorchidism: More harm than thought?

INTRODUCTION: Acquired cryptorchidism (AC) has been recognized as a subgroup of undescended testes (UDT). There is growing evidence that the compromising effect equals that of congenital UDT (cUDT). This prospective study included an extensive histological examination of biopsies taken from AC patients. PATIENTS AND METHODS: From August 2013 to December 2014, 21 boys (3-12 years of age) underwent testicular biopsy during orchiopexy for AC. Patient and family histories were taken. The amount of germ cells (GC) per tubule (T) and the amount of adult dark spermatogonia (Ad-S) per T were determined by resin semi-thin sections examination. The samples were also scanned for signs of malformation. Immunohistochemical stains were performed as markers for atypical germ cells. RESULTS: Four (19%) boys were born prematurely, two (9.5%) were small for gestational age (SGA), and nine (43%) had a positive family history of UDT. The median of GC/T was 1.06 in boys <9 years, and 0.60 in boys ≥9 years. The median of Ad-S/T was 0.02 in boys <9 years and 0.01 in boys ≥9 years. There were no signs for malformation and no atypical cells. The immunohistochemical stains were negative in all specimens. CONCLUSIONS: Prematurity, SGA, and a positive family history appeared to be predictors for AC. Extensive histopathological examination of AC revealed a significant reduction of germ cell count and fertility markers, comparable with that in cUDT. The alterations were more severe in boys aged ≥9 years. It is unclear as to whether or not this was possibly caused by a longer duration of inguinal position, but this finding suggests that routine checks of testicular position throughout childhood are needed, and that there is a cause for continued efforts in educating parents and primary care physicians regarding AC. Current data support the notion of surgical correction once the diagnosis is made.

[Bladder exstrophy: Quality of primary care and long-term prognosis]. / Blasenekstrophie : Qualität der Primärversorgung und Langzeitprognose.

BACKGROUND: It is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome. Due to a number of reasons, including a lack of comparable multicenter studies, there are numerous concepts for initial exstrophy closure. DISCUSSION: Therefore, we describe our concept of delayed, staged reconstruction without osteotomy in classical bladder exstrophy, while taking into considerion the available literature on long-term follow-up as well as on own clinical and research data. CONCLUSION: Most notably there are multiple medical but also psychological advantages of a delayed procedure. Primary closure without osteotomy is feasible and has no disadvantages in the long-term follow-up when compared to the invasive procedure of osteotomy. Due to high intravesical pressure, initial bladder neck surgery might have negative effects on bladder development and on the upper urinary tract.

[Scrotal ultrasound examinations in infants and toddlers]. / Sonographie des Skrotalinhalts bei Säuglingen und Kleinkindern.

BACKGROUND: Besides physical examination, ultrasonography is the most valuable diagnostic tool to assess the scrotum and testes in the case of an acute scrotum or scrotal pathology. PROBLEMS: In infants and toddlers the examination can be challenging. Due to the limited patient compliance, the small testicular size (< 0.5 ml), and low blood flow velocity (< 3 cm/s), it can be difficult to achieve a proper flow curve when assessing blood flow. CONCLUSION: The examiner's skills are as important as adequate equipment (i. e., linear ultrasound probe, 12-14 MHz) and optimal program settings (Doppler scale < 3 cm/s, gate 1 mm). However, if there is doubt, surgical exploration is unavoidable.

[Circumcision and orchiopexy: management of complications]. / Zirkumzision und Orchidopexie: Komplikationsmanagement.

Circumcision and orchidopexy are among the most frequently performed pediatric urological procedures. Although they may be classified as surgical interventions suitable for junior surgeons, either procedure can lead to serious consequences including the loss of the respective organ. In this paper, the general aspects of pediatric urological surgery (e.g., distinctive features of informing underage patients, the handling of children in the operating room, and relevant pediatric anesthesiological aspects) are described first. Then, the most important sources of error will be highlighted and potential complications and their management during all stages of the procedure will be illustrated. Apart from the so-called freehand circumcision, this paper also deals with potential complications when using the Plastibell® device. In regard to orchidopexy, laparoscopic procedure shall be discussed in addition to the standard procedure.

[Intrascrotal lipoblastoma in childhood: diagnostic strategies and therapy planning]. / Intraskrotales Lipoblastom im Kindesalter : Diagnostische Strategien und Therapieplanung.

Based on a case report of an intrascrotal lipoblastoma in childhood, we present the preoperative diagnostic algorithm and the main differential diagnoses in testicular and paratesticular tumors as well as their surgical management. An 8-week-old infant was admitted with a scrotal tumor known since birth. MRI showed a pinnate vessel supply, originating in the left internal iliac artery. The tumor was exposed operatively and could be completely removed. Intrascrotal lipoblastoma are rare. Like most testicular and paratesticular tumors in childhood lipoblastomas are benign. Today ultrasound and Doppler sonography are basic tools for diagnosis and surgical planning in testicular and scrotal tumors in childhood. In some cases MRI can provide additional important information for surgical planning. In contrast to adults testis sparing surgery is favoured in children.

[Urinary bladder function disorders in childhood]. / Harnblasenfunktionsstörungen im Kindesalter.

Bladder dysfunction in children is a very common and heterogeneous problem. There can be disturbances either in bladder storage or during voiding phases. First of all it is important to distinguish between non-neurogenic and neuropathic bladder dysfuction. In this article the most common causes, the basic diagnostic evaluation and therapeutic interventions are summarized.

[Tumour registry and reality: differential diagnosis of testicular tumours in childhood: survey and personal experience]. / Tumorregister und Realität - Differenzialdiagnose von Hodentumoren im Kindesalter - Übersicht mit eigenem Patientengut.

Painless scrotal swelling must always be considered as a potential malignant testicular tumour until proven otherwise. Prepubertal testicular tumours are seldom entities, for their differential diagnosis testicular sonography is gaining increasing importance. Although, according to national and international tumour registries, most patients tend to have malignant tumours, some clinical series from paediatric centres confirm that prepubertal testicular tumours are mainly benign lesions, especially up to the age of 12 years. Testis-sparing procedures are favoured when AFP is in a normal range and testicular parenchyma is detected sonographically. Oncological principles should be applied to paediatric patients consequently, staging examinations should be requested when a definite histology is proven. Cases should be reported to national tumour registries and, in addition to close surveillance, in some cases adjuvant therapy is necessary. In addition to the clinical guidelines from the tumour registries, differential diagnosis, testis-sparing surgery and the presence of TIN in the paediatric population should be discussed.

[Vesicoureteral reflux: diagnostics and therapy]. / Vesikoureterale Refluxerkrankung : Diagnostik und Therapie.

The current management of vesicoureteral reflux (VUR) remains controversial. Recent well thought-out randomized studies on VUR in children have led to a debate on diagnostic and therapeutic algorithms. Individual parameters, such as age, gender, clinical course, renal function and scars, dysfunctional elimination syndrome and last but not least the compliance of the parents have gained in importance. Regarding recent data this article gives a summary of diagnostic steps and therapeutic management of VUR.

[Analysis of laparoscopic orchidopexy in intra-abdominal testis]. / Ergebnisse der laparoskopischen Orchidopexie beim nicht palpablen Hoden.

Laparoscopy is an established diagnostic procedure but is less frequently used as a therapeutic method for impalpable testes. To compare the results of the classic two-stage orchidopexy described by Fowler-Stephens with a testicular vessel-sparing single-stage approach in the management of intra-abdominal testes we retrospectively analyzed our data.From January 2005 to September 2010, 105 patients (mean age 32 months) underwent laparoscopy for impalpable testes. In cases of intra-abdominal testes, laparoscopic orchidopexy was performed either in a two-stage procedure including initial ligation of the testicular vessels or as a direct single-stage procedure without ligation of the vessels. The results of both approaches were evaluated postoperatively clinically and by ultrasonography. Among the 122 impalpable testes 63 were located intra-abdominally; single-stage orchidopexy was performed in 29 testes whereas a two-stage approach was conducted in 14 testes. Fourteen gonads had to be removed due to atrophy and in six cases no testis was found at all. In the other 59 cases inguinal exploration followed resulting in 22 orchidopexies, 34 removals and 3 blind-ending vessels. During a mean follow-up of 17 months none of the 29 testes treated by single-stage orchidopexy atrophied or reascended. By contrast, two cases of atrophy, one reascent and one subumbilical wound infection occurred after the two-stage procedure. Considering our excellent experiences with single-stage management, we conclude that the single-stage approach is a reliable, safe and efficacious treatment modality of intra-abdominal testes. However, the two-stage procedure including testicular vessel ligation should be restricted to high abdominal testes with very short vessels.

[Perioperative pain management in major reconstructive surgery in pediatric urology: a plea for continuous epidural anesthesia]. / Perioperatives Schmerzmanagement bei großen plastisch-rekonstruktiven Eingriffen in der Kinderurologie: Ein Plädoyer für die Periduralanästhesie.

Regional analgesia is firmly established in modern pediatric anesthetic practice and its popularity continues to grow. In our department continuous epidural anesthesia (CEA) is a frequently used technique of pain management following major reconstructive procedures of the lower urinary tract. The aim of this study was to investigate the efficacy, safety, and potential benefits of CEA over standard analgesics.We retrospectively reviewed the records of 21 infants who underwent single-stage bladder exstrophy repair in our department. In 15 children an epidural catheter was placed preoperatively for CEA; 6 patients treated without CEA served as controls. Total doses of narcotics and analgesics, length of intensive care unit (ICU) stay and ventilatory assistance, time to first bowel activity, anticholinergic requirements, and CEA-related side effects were documented and compared for both groups.Children given epidural anesthesia required six- to tenfold lower doses of morphine intra- and postoperatively compared to those without CEA; ventilatory support upon completion of surgery was remarkably shorter (59 versus 210 min) in the CEA group as well as ICU stay (1.1 versus 1.8 days). The total consumption of anticholinergics was twice as high as in patients without CEA. There were no relevant CEA-related complications.Being a retrospective audit of practice in our institution with a small number of patients, our results are in line with previously published data on CEA in pediatric patients. CEA has been shown to significantly reduce the need for anesthetics and morphine and allows early extubation with all subsequent advantages for a speedy recovery post surgery. Thus, the technique is to be recommended as a safe and efficacious method for pain management following major reconstructive surgery in pediatric urology. Importantly, this type of anesthesia should be performed only by experienced anesthesiologists in institutions where appropriate equipment, staff, and monitoring are available.

[Late diagnosis of cryptorchidism]. / Der spät diagnostizierte Hodenhochstand

Cryptorchidism is a risk factor for testicular cancer and reduced fertility. Failure of critical maturation steps, with the persistence of gonocytes beyond 6 months, results in a decreased number of adult dark (A-dark) spermatogonia, which causes a deficiency of primary spermatocytes at 3 years of age. We evaluated the histological findings in boys older than 4 years who were diagnosed with a testis located in the inguinal channel. From September 2007 to September 2008, 15 boys (mean age 8 years) underwent orchidopexy with a biopsy taken from the undescended testis of one side. Sonograms were performed in all 15 boys. The incidences of spermatogonia, primary spermatocytes, and Leydig cells (semiquantitative) were estimated as well as the exclusion of intratubular carcinoma in situ cells (Department of Pathology, Central EM Lab, University Medical Center Regensburg, Germany). Orchidopexy was performed on the right side in eight boys, the left side in one, and both sides in six. Sonographically, no parenchymal echotexture abnormalities were found. A-dark spermatogonia could be detected in nine biopsies. The Leydig cell score was reduced in 11 boys. No carcinoma in situ cells were detected. Late diagnosis of undescended testis will have a poor prognosis for future fertility.