Foreskin preputioplasty and intralesional triamcinolone: a valid alternative to circumcision for balanitis xerotica obliterans.

BACKGROUND: We previously reported our short-term experience of foreskin preputioplasty as an alternative to circumcision for the treatment of foreskin balanitis xerotica obliterans (BXO). In this study, we aimed to compare this technique with circumcision over a longer period. METHODS: Between 2002 and 2007, boys requiring surgery for BXO were offered either foreskin preputioplasty or primary circumcision. The preputioplasty technique involved triradiate preputial incisions and injection of triamcinolone intralesionally. Retrospective case-note analysis was performed to identify patient demographics, symptoms, and outcomes. RESULTS: One hundred thirty-six boys underwent primary surgery for histologically confirmed BXO. One hundred four boys opted for foreskin preputioplasty, and 32, for circumcision. At a median follow-up of 14 months (interquartile range, 2.5-17.8), 84 (81%) of 104 in the preputioplasty group had a fully retractile and no macroscopic evidence of BXO. Of 104, 14 (13%) developed recurrent symptoms/BXO requiring circumcision or repeat foreskin preputioplasty. In the circumcision group, 23 (72%) of 32 had no macroscopic evidence of BXO. The incidence of meatal stenosis was significantly less in the foreskin preputioplasty group, 6 (6%) of 104 vs 6 (19%) of 32 (P = .034). CONCLUSION: Our results show a good outcome for most boys undergoing foreskin preputioplasty and intralesional triamcinolone for BXO. There is a small risk of recurrent BXO, but rates of meatal stenosis may be reduced.

Is intravenous urography necessary in the assessment of renal duplex system in children?

OBJECTIVE: Partial or complete duplication of the renal tract may be an incidental finding or may be associated with significant pathology. Accurate assessment is not always easy. This retrospective review was undertaken to determine whether intravenous urography (IVU) in combination with a DMSA renal scan provides significant additional information. PATIENTS AND METHODS: Eighteen patients referred to our imaging department with a provisional diagnosis on ultrasound of renal tract duplication during a three year period were identified by searching the radiological computer files. The presenting features were urinary infection (13), abdominal pain (3) and abnormal antenatal sonography (2). RESULTS: Four patients were found not to have renal duplication. There was concordance between the IVU and DMSA scan in seven. Additional clinically relevant information was obtained in three cases. A false negative result from the DMSA scan was found in four children and a false positive result in three. CONCLUSION: In a significant number of cases of possible renal tract duplication, additional relevant information can be obtained from an IVU. Patient distress is minimised by combining the IVU and DMSA in one single episode of venous access. Review of the radiological images during the investigation allows minimisation of radiation dosage.

The appendix as ureteral substitute: a report of 10 cases.

BACKGROUND: Ureteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter. METHODS: A retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix. RESULTS: Ten patients were identified, operated in 2002-2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n=1), congenital ureteric stenosis (n=5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n=3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n=1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16months (1-72 months), all the patients were well except one whose kidney function had deteriorated. CONCLUSIONS: Total or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.

Axial fixation of testes for prevention of recurrent testicular torsion.

Testicular torsion is a surgical emergency that requires prompt exploration in order to maintain testicular viability. All testicular fixation techniques, so far in use, are not entirely reliable in preventing recurrences. Although recurrent testicular torsion after previous fixation is rare, in cases that it occurs, it is associated with atrophy of the testis or gangrene leading to loss of the testes. The most common cause for recurrence is improper or inadequate fixation. We describe a simple and effective method using a four point fixation, which is likely to prevent testicular torsion recurrences.

The undescended testis.

Testicular development is determined by the influence of the SRY gene on the Y chromosome of the fetus. This influences the germ cells to produce testosterone and Mullerian inhibiting substance which control descent of the testis. Maldescent of the testis occurs in 0.8% of boys. Current best advice is to perform orchidopexy before the age of two years, therefore a programme for examination by skilled healthcare workers should be established in the first year of life. Indications for surgery include a possible beneficial effect on fertility, malignant potential particularly if intra-abdominal, torsion or trauma and social considerations. Hormonal treatment in the first three months of life is recommended by some. Laparoscopy is the optimum method for evaluating and managing the intra-abdominal testis.

Home-dilatation of the urethral meatus in boys.

OBJECTIVES: To evaluate the efficacy of dilatation of the stenotic urethral meatus in boys at home. PATIENTS AND METHODS: Eighteen boys aged 3-15 years, or their parents, were taught to dilate the urethral meatus at home. The cause of the stricture was balanitis xerotica obliterans (BXO) in five and consequent upon hypospadias surgery in 12, of whom two were complicated by BXO, and one after circumcision for cultural reasons. One boy was re-referred after an interval of 3 years because of apparent deterioration of the stream of urine. Meatal dilatation was taught in the home by one of the authors (J.M.S.). RESULTS: Nine patients were cured by the first course of dilatation, four relapsed early after initial success but responded to further treatment, and three proceeded to meatoplasty because they had no response. Two relapsed late and one responded to further dilatation but the other required surgery. CONCLUSION: Dilatation of the urethral meatus can be taught successfully to boys or their families at home, thus avoiding repeated hospital attendance and often general anaesthesia.

Expanded PTFE bladder neck slings for incontinence in children: the long-term outcome.

OBJECTIVE: To assess the long-term outcome of circumferential expanded PTFE (Gore-tex, WL Gore Associates, Scotland) bladder neck slings for achieving urethral continence in children with a neuropathic bladder. PATIENTS AND METHODS: The records were reviewed of 19 children undergoing bladder reconstruction (most with a neuropathic bladder) who had a Gore-tex sling placed circumferentially at the bladder neck, over a 5-year period. Of these, seven had spina bifida; two each spinal dysraphism, surgery for anorectal anomalies and an idiopathic neuropathic bladder; five who developed a neuropathic bladder from other causes, and one born with bladder exstrophy. All children had an uncompliant bladder with a low urethral leak-point pressure on preoperative urodynamics. In all children conventional clean intermittent catheterization and pharmacotherapy had failed. Four had had previous augmentation surgery while 15 had concomitant bladder augmentation and formation of a Mitrofanoff stoma. The main outcome measure was achieving dryness. The original intention of the procedure was also to maintain urethral catheterization. RESULTS: Full details of the follow-up were available in 17 patients. Despite initial good short-term results, at a median follow up of 7 years, in 14 patients the sling had to be removed because of erosion, often with transient urethral leakage before the bladder neck subsequently closed. A bladder calculus was associated with each case of erosion except one. CONCLUSION: Although in the short term this technique had favourable results, it was not a useful technique in the long term.

Hyperammonemia with complex urinary tract anomaly: a case report.

Hyperammonemia has been reported rarely in the pediatric age group in systemically ill patients. All cases resulted from infections with urea splitting organisms, which are more common among patients who have undergone surgical procedures on the urinary tract. The authors report for the first time in the pediatric literature, one patient who presented with hyperammonemic encephalopathy that resulted from urinary tract infection with Staphylococcus epidermidis and Corynebacterium sp.

Laparoscopic excision of a prostatic utricle in a child.

Prostatic utricle cysts result from incomplete regression of Mullerian duct structures and occur most frequently in males with perineal or peno-scrotal hypospadias. Utricular cysts may present with various signs and symptoms including urinary tract infection, pain and post-void incontinence, a palpable abdominal mass or recurrent epididymitis. Treatment is reserved for symptomatic cysts and various techniques have been described including transurethral deroofing, endoscopic incision or surgical excision by suprapubic, posterior and midline transvesical approaches. We present a successful minimally invasive approach for excision of a prostatic utricle cyst in a child. Laparoscopic excision is a safe and viable alternative to open procedures in the surgical treatment of symptomatic utricle cysts in childhood. The presence of a cystoscope within the utricle orifice aids identification and safe dissection of the utricular remnant.

Endourethral injection of bulking agents for urinary incontinence in children.

OBJECTIVE: To assess the early and late outcome of endourethral injection with bulking agents in children with urinary incontinence (a neuropathic bladder or exstrophy-epispadias complex), by reviewing our experience over a 5-year period. PATIENTS AND METHODS: The records of 15 children (10 boys) were reviewed retrospectively; 10 had spina bifida and a neurogenic bladder, four had a neurogenic bladder from other causes and one had epispadias. All children had a stable low-pressure detrusor and a compliant bladder with sphincteric weakness on preoperative urodynamic testing. Four children had undergone previous enterocystoplasty with a Mitrofanoff stoma, with concomitant urethral lengthening in two and a Goretex trade mark bladder neck sling in two. Three children voided spontaneously while 12 depended on intermittent catheterization. The agent was injected under general anaesthesia in all patients but one, with an endourethral submucosal injection of the bulking agent into four or more points at the junction of the bladder neck and proximal urethra, aiming to obtain visual occlusion of the urethra. The median (range) number of injections was 2 (1-3); five children had one injection, seven had two and three had three. There were no procedure-related complications and most were day-case procedures. Initially PTFE paste was used as the bulking agent, being replaced by bovine collagen or polydimethylsiloxane in the latter half of the series. RESULTS: At a median (range) follow-up of 28 (11-65) months three children were completely dry after a single injection; there was no change in four and a short-term improvement (median 25 months, range 4 days to 37 months) in eight. After this period all children deteriorated to their original incontinence grade; hence the overall cure rate was three of 15. CONCLUSION: This experience with a long-term follow-up differs from previously reported high success rates for the endourethral injection of bulking agents for urinary incontinence in children. Despite a short-term benefit, in the long-term this technique was unreliable and often ineffective. Patients and their carers should be given a realistic and guarded prognosis.

Long-term outcome in bladder detrusorectomy augmentation.

BACKGROUND AND OBJECTIVES: Bladder augmentation in children can have significant benefits in terms of continence and social function. In an attempt to overcome the problems associated with using foreign mucosa in the urinary tract, techniques to increase to bladder volume and improve compliance by resecting the detrusor muscle alone have been described. Here we describe our experience using an omental-backed detrusorectomy augmentation and examine possible reasons for a poor outcome observed in some patients in the longer term. METHODS: This was a retrospective review covering an eight-year period with a minimum follow-up of 2 years. Pre- and post-operative urodynamics were performed in every case. RESULTS: 11 patients were included in the study. There were 7 male and 4 female patients with a median age of 10 years (range 4 - 16). The underlying pathology in 6 patients was myelodysplasia and in the remaining cases there was one each of ano-rectal malformation with neuropathic bladder, Guillain-Barré syndrome, a myopathy of unknown cause, transverse myelitis and one case of a non-neuropathic neuropathic bladder. Detrusorectomy provided a modest increase in bladder capacity (median 26 %) and decrease in maximum bladder pressure (median 12 %). Long-term follow-up has revealed treatment failure in 6 patients, resulting in revision augmentation surgery in 3 (with surgery planned in a further 2), and one patient developing end-stage renal failure. Notable complications were bladder stone formation in 4 patients and troublesome lower abdominal pain related to bladder drainage in 2. There appeared to be no correlation between initial diagnosis, age at operation, pre-operative urodynamics, peri- or post-operative factors, and long-term outcome. CONCLUSIONS: In our series, omental-backed detrusorectomy for a neuropathic bladder in children resulted in a poor outcome in 55 % of cases. We were unable to identify factors that would allow this result to be predicted pre-operatively.

Day-care ultrasound avoids urodynamics.

BACKGROUND: Post-voiding residual urine is a common problem underlying urinary symptoms in many children often associated with infection. Tertiary referral is often made to exclude a neurological aetiology. This review reports the experience of clinician-performed ultrasound examinations in the Day-Care Unit on 50 children during a 9-month period, with various aetiologies of urinary incontinence avoiding urodynamic studies in 34. METHODS: From March 1999 tertiary referral patients with urinary incontinence with or without infection and secondary referrals not responding to 'standard' management regimes, underwent clinician-performed bladder ultrasound scans in the day-care ward. A standard renal tract ultrasound examination had been reported as normal in 19 patients. In general referral had been made to exclude a neuropathic aetiology. In addition 5 patients were studied who were known to have a neurogenic bladder, 3 with an anorectal anomaly, 3 were post cystoplasty and 2 had undergone surgery for ureteric reflux. RESULTS: In 34 patients it was considered that a urodynamic study had been avoided, while in one results from a urodynamic study were refuted. By means of directly visualising the bladder on real time scanning, 12 children and families achieved a significantly better understanding of the relevance of residual urine in relation to symptoms, or were shown to have normal detrusor function (7), excluding a neuropathic aetiology. The three who had undergone cystoplasty were shown to have adequate bladder volumes in spite of persisting wetness. CONCLUSION: Real-time ultrasound examination of the bladder performed by a clinician in a patient-friendly environment (day-care ward) can provide significant information regarding detrusor function, often avoiding urodynamic studies. The test does not replace formal scanning for anomalies but may provide information that is masked by the more rigid environment of a radiology department, sometimes correcting results from standard urodynamic studies.

Periurethral Goretex sling in lower urinary reconstruction.

Urethral incontinence in patients with neuropathic bladders remains a management problem not only to urologists but also to the primary carers of these patients. It impairs quality of life and encourages social withdrawal, but also leads to perineal soreness and inflammation. A number of surgical techniques have been described to increase bladder outlet resistance in order to render patients with neuropathic bladders perineally dry. We report our experience in achieving dryness with a periurethral Goretex sling in 17 patients.

Overnight shunt pressure monitoring in children.

We audited the value of overnight shunt pressure monitoring in 17 children with symptoms of possible shunt dysfunction but no other supportive evidence. The shunt was accessed by a 25G butterfly connected to a disposable arterial pressure monitor positioned on the ipsilateral shoulder whose output was recorded continuously, while noting posture, sleep state and symptoms. Initially traces were analysed only for the portion spent both asleep and supine or prone. Six showed pressure peaks while asleep: of these four underwent shunt revision with remission of their symptoms and two resolved spontaneously, one with a simultaneous resolution of a peritoneal CSF collection, but the other had a recurrence of symptoms after six months. Two more subsequently shown to have blocked shunts had normal traces while asleep but abnormal pressure peaks when awake and upright. Two showed pressure troughs: one responded to insertion of an antisyphon device and one resolved spontaneously. Five had normal traces while asleep and awake: symptoms resolved in three and persisted in two in whom later prolonged extradural monitoring with a fibre-optic transducer was also normal. Studies failed in two. We conclude that prolonged overnight shunt pressure monitoring with this technique is useful in diagnosing shunt dysfunction and that abnormalities detected while awake and upright are as significant as those detected asleep and supine or prone.