Examining trends in the treatment of ureterocele yields no definitive solution.

INTRODUCTION: The surgical management of ureteroceles is extremely variable. Some have hypothesized that if these patients were treated with 'definitive' staged surgical intervention, the need for further revision surgery would be eliminated. OBJECTIVE: The present study sought to determine if the rate of revision surgery differed among patients who have undergone different surgical approaches for the ureterocele complex. STUDY DESIGN: A large retrospective chart review was conducted, identifying all patients having undergone ureterocele surgery at a single institution over the past 41 years. The cohort was divided into four groups based on surgical approach: upper tract approach (UTA), lower tract reconstruction (LTR), simultaneous upper and lower tract approach (ULTA), and staged lower tract reconstruction (SLTR). Demographics, the presence of preoperative/postoperative VUR, postoperative morbidity and the need for revision surgery were compared using the Chi- squared test, Fisher's exact test, Kruskal-Wallis test, Mann-Whitney U test (Bonferroni correction), logistic regression modeling and survival analyses (Kaplan-Meier and Cox proportional Hazards regression with unplanned revision operation as the outcome event). RESULTS: Between 1969 and 2010, 180 patients were identified as having undergone surgical management of ureteroceles, of which 120 had complete demographic data available for analysis. The median age at the time of initial surgical intervention was 5.8 months and the majority of patients (83.3%) were female. The median follow-up was 33.1 months. Surgical management was as follows: 18 (15.0%) patients underwent UTA, 47 (39.2%) underwent LTR, 23 (19.2%) underwent ULTA, and 32 (26.6%) underwent SLTR. Among these groups, the only difference in median age was between the LTR and SLTR groups (6.3 months vs 3.7 months, P=0.012). Additional revision surgery was required in: nine (50.0%) of UTA, ten (21.3%) of LTR, four (17.4%) of ULTA, and three (9.4%) of SLTR. The only statistically significant difference in unplanned revision surgery was noted in the UTA group versus each of the other groups with VUR as the predominant indication (88.9%). The likelihood of requiring revision surgery in comparison to the SLTR group was significantly increased in the UTA group (OR 9.67, CI 2.15-43.56), but not in the LTR (OR 2.61, CI 0.66-10.37) or the ULTA group (OR 2.04, CI 0.41-10.13). Obstruction, recurring UTIs and VUR were the main indications for revision surgery overall. DISCUSSION: There is a large body of literature examining the surgical management of ureteroceles. It most recently primarily focuses on an endoscopic approach to the lower tract. The present retrospective review examined the need for re-operative intervention by comparing four different surgical approaches, and found that there is no panacea. Although heminephrectomy (UTA) was a definitive procedure in some patients without reflux at presentation, many who underwent heminephrectomy, went on to require later bladder surgery for either recurrent UTI or persistent reflux. The present study has multiple limitations. Although VUR was an indication for revision surgery in the early part of the series, the current treatment of VUR is not necessarily as stringent. In addition, no distinction was made between an orthotopic or ectopic ureterocele, although some authors have reported differing outcomes in these two groups. However, it is felt that given the large data set of a relatively uncommon condition, the lack of superiority of one approach is apparent. CONCLUSION: There is no definitive surgical repair for the ureterocele complex. All groups except UTA had statistically similar rates of revision surgery. The widespread variability in current management echoes the lack of one superior approach found in this comprehensive series.

Pediatric urolithiases: a ten-year review.

Sixty-one children who presented with urinary calculi between 1967 and 1977 were reviewed. The overall incidence of calculus disease in our patients was higher than reported previously from other centers in this country. Because presenting symptoms varied, a high index of suspicion was often required for diagnosis. Stones of infection were the most common type identified. Inasmuch as the revurrence rate of calculi in children was low (6.5%), careful consideration of time and cost is warrented before extensive evaluation for metabolic causes of stone formation is undertaken. Immobilization was an important factor in the etiology of stone disease. Most stones less than 5 mm in size passed without surgery.

Incidence of renal anomalies in children prenatally exposed to ethanol.

OBJECTIVE: Based on a number of studies involving animals as well as human case reports indicating an association between prenatal ethanol exposure and renal malformations, it has been suggested that children with fetal alcohol syndrome (FAS) should be screened for renal anomalies. The purpose of this study was to evaluate a group of children prenatally exposed to alcohol to determine the incidence of renal anomalies and to evaluate the need for such a screening procedure. METHODS: Renal ultrasounds were performed on a total of 84 patients (68 children, 13 adolescents, and three adults). In addition to screening for malformations, renal size was studied. Data were analyzed using both chronologic and height-age as determinants of kidney size. PATIENTS: Of these 84 patients, 51 (61%) had FAS, and 33 (39%) had a history of prenatal ethanol exposure but did not have FAS. RESULTS: Three (3.6%) patients (one with FAS, two with prenatal ethanol exposure who did not have FAS) had significant renal abnormalities. This incidence was not significantly different from that found in ultrasound screening of newborns. The kidneys of children with both FAS and prenatal ethanol exposure who did not have FAS were significantly smaller than normal for both chronologic and height-age. When children were compared across chronologic ages, those with FAS had significantly smaller kidneys than those who had no evidence of FAS. After adjusting for height, the difference between these two groups was no longer significant. CONCLUSIONS: Based on these data, children prenatally exposed to ethanol do not need to be screened for renal anomalies.

Malpractice risks for urologists.

OBJECTIVES: To obtain data regarding the frequency of malpractice suits against urologists. METHODS: Those urologists listed in the Best Doctors in America were sent an anonymous survey that requested their personal malpractice history (group A). Additionally, the professional responsibility history of the candidates for recertification by the American Board of Urology in 1996 (group B) was reviewed. RESULTS: One hundred ten urologists in the United States in group A were surveyed. Ninety-one (83%) responded. Seventy (77%) had been sued (average 2.36 claims per physician who had been sued). Forty-four percent of the claims resulted in payment to the plaintiff. Claims frequency of group A was 0.09 claims per physician per year. Urologists in the Northeast, North Central, and Mid-Atlantic Sections of the American Urological Association were less likely to be sued than urologists in the other five sections. There were 246 urologists in group B. One hundred twenty-two (49%) reported a claim against them (average 1.9 claims per physician who had been sued). Twenty-nine percent of the closed claims resulted in payment to the plaintiff. Claims frequency of group B was 0.09 claims per physician per year. CONCLUSIONS: Most urologists can expect to be sued at least twice in their professional careers. The longer one is in practice, the greater the chance of a suit being filed. Where one practices may be a factor in the likelihood of being sued. There does not seem to be a direct or inverse correlation between professional reputation and the incidence of being sued.

Accessory and ectopic scrota.

Two cases of ectopic scrotum are presented, and 12 previously reported cases are reviewed. This anomaly presumably develops secondary to faulty division or abnormal migration of the embryonic labioscrotal swellings.

An unusual case of urinary incontinence, ataxia-telangiectasia, and metastatic dysgerminoma: case report and review of the literature.

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

Ketoconazole for prevention of postoperative penile erection.

OBJECTIVES: To determine if ketoconazole, an inhibitor of testosterone synthesis, can prevent postoperative spontaneous erections in patients undergoing penile surgery. METHODS: Ketoconazole was administered to 8 patients, aged 14 to 42 years, who underwent penile surgery. All patients received ketoconazole 400 mg orally three times daily starting on the day of surgery. Liver function tests were obtained preoperatively and after the completion of treatment. RESULTS: Ketoconazole successfully prevented erections in all patients. None of the patients demonstrated liver function abnormalities. CONCLUSIONS: Ketoconazole is a reliable method to prevent postoperative penile erection. With the proper monitoring of liver function tests and the avoidance of drug interactions, ketoconazole therapy also appears to be safe.

Incidence of the bell-clapper deformity in an autopsy series.

OBJECTIVES: Testicular torsion is seen in all age groups. The bell-clapper deformity (BCD) when present predisposes the patient to torsion. This study was undertaken to determine the incidence of the BCD. METHODS: An autopsy series of 51 males with 101 testes was dissected by the senior author to determine the incidence of the BCD. RESULTS: The manner of testicular investment by the tunica vaginalis was classified as normal, intermediate, or absent (BCD). Seventy-six testes were normal, 13 were intermediate, and 12 were of the bell-clapper type. CONCLUSIONS: The incidence of the BCD in this autopsy series was 12%. Because the incidence of testicular torsion in the general population is far less than 12%, other factors in addition to anatomic predisposition must be involved.

Orchiopexy: experiences at two centers.

The results of two series of patients undergoing orchiopexy procedures at different medical centers using different surgical approaches were analyzed. Satisfactory results were obtained in 89 and 91 per cent of patients, and there was no significant difference between centers in the results obtained. The results were further analyzed with respect to the age of the patient at surgery, prior treatment with human chorionic gonadotropin (HCG), and postoperative hospitalization. These were found to have no significant bearing on the outcome of the procedure. Orchiopexy, if meticulously performed according to recognized surgical principles, continues to be an operation of considerable merit in the treatment of cryptorchism.

Neonatal urinary tract infection with petechiae and thrombocytopenia.

Thrombocytopenia and petechiae were signs of urinary tract infection in 2 neonates. Both infants had significant anomalies of the urinary tract. In each case antimicrobial therapy eliminated the infection and thrombocytopenia, allowing the surgical correction to be performed when the infants were clinically well. The importance of urine cultures and excretory urography in such cases is emphasized.

Topical testosterone therapy for penile growth.

Three prepubertal males were treated with daily applications to the penis of 5 per cen topical testosterone cream. Penile growth occurred in all 3 patients. Serum testosterone values rose dramatically in 2 of the patients. Topical testosterone probably causes penile growth via its systemic action, not merely through its local effect.

Genitourinary trauma in the pediatric patient.

Trauma is the major source of mortality in the pediatric population. A retrospective review was performed on patients admitted to the Children's Hospital and Health Center Trauma Program, San Diego, California, from August 1984 to May 1990. The purpose of this review was to evaluate pediatric trauma and to determine the best treatment and evaluation for genitourinary injuries. Blunt trauma was responsible for 98 percent of the injuries, with renal injuries being the most common. Bladder (7) and male urethral (2) injuries, and vaginal lacerations (8) also occurred. The most severe renal injuries (70%) and all significant bladder and urethral injuries were associated with gross hematuria. Hypotension was present in 31 percent of patients but rarely required surgical exploration for correction. Eighty-six patients underwent radiographic imaging. Computerized tomography (CT) scans demonstrated the most information about intra-abdominal solid organ injuries but was inaccurate in detecting bladder or urethral injuries. Genitourinary injury is common in children but rarely requires surgical management. CT scan is the best study to determine extent of solid-organ injury but is inferior to cystourethrography to diagnose bladder or urethral injuries.

Serum immunoglobulin E and incidence of allergy in group of enuretic children.

Serum immunoglobulin E levels were determined in 34 enuretic children and 20 age-matched controls. No differences were detected. Additionally, the incidence of allergic disorders in these enuretic children was no different from the general population.

Transitional cell carcinoma of bladder in children.

Transitional cell carcinoma of the bladder occurs rarely during the first two decades of life. The malignancy is usually low grade and noninvasive, with a low recurrence rate. Transurethral resection or fulguration is the treatment of choice, and the prognosis is favorable. We present 4 patients, aged two to eighteen years, with transitional cell carcinoma of the bladder and review the literature.

Fibrous hamartoma of infancy: a report of two cases in the genital region.

OBJECTIVES: Fibrous hamartoma of infancy (FHI) is an uncommon subcutaneous proliferative lesion usually found in the upper portions of the body, particularly in males during the first 2 years of life. We report 2 cases of FHI in the genital region. METHODS: We retrospectively reviewed the charts of children treated at Children's Hospital and Health Center, with FHI located in the genital region. RESULTS: We report 2 cases of FHI in the genital region, 1 involving the scrotum and 1 the labium majus. CONCLUSIONS: FHI should be considered in the differential diagnosis of genital masses in children. The histologic features are characteristic, local excision of the tumor is curative, and the local recurrence rate is low.

Complications of circumcision.

In summary, there are multiple complications that can occur following circumcision, ranging from the insignificant to the tragic. Virtually all of these complications are preventable with only a modicum of care. Unfortunately, most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons. However, it usually will fall to the urologist to consult in the management of these complications and to repair such problems as they arise.

Etiology, diagnosis, and management of urethral strictures in children.

Urethral strictures in children, like those in adults, are problems whose management embodies all that is basic to urology. It is helpful to think of strictures according to etiology: congenital, infectious-inflammatory, and traumatic (iatrogenic and noniatrogenic). The treatment options are diversion (nearly always temporary), manipulation, and repair. The authors also review their research on urethral healing.

The wet child.

Urinary incontinence is one of the most frequent problems seen in pediatric urology. Although there can be serious structural problems that produce wetting, most of the children seen will have nonstructural causes for their incontinence. A systematic approach and persistence with therapy should result in resolution of the problem in most instances.

Gonadal stromal tumors, gonadoblastomas, epidermoid cysts, and secondary tumors of the testis in children.

Gonadal stromal tumors generally are benign and hormonally silent. When hormonally active, they may cause either virilization or feminization, posing an endocrine threat to the prepubertal boy. Accurate diagnosis is essential to differentiate those tumors that require medical management from those best treated by surgical ablation and to distinguish the benign ones from the malignant. Leukemic infiltration is the most common secondary testis tumor; others are neuroblastoma, Wilms' tumor, and gonadoblastoma.

Imaging of common problems in pediatric urology.

Many imaging modalities are available to study children with urologic disorders. Ultrasonography, renal scintigraphy, and voiding cystourethrography are best for study of patients with infection and antenatal hydronephrosis; intravenous urography, for hematuria and wetting; ultrasonography and CT, for tumor; and CT, for trauma.