This Month in Pediatric Urology

Article Outline

• Bladder Dysfunction and Infantile High Grade Vesicoureteral Reflux
• Ultrasonography of the Spermatic Cord for Acute Scrotum
• Laparoscopic Dismembered Pyeloplasty in Children
• Urodynamic Findings in Children with Myelomeningocele
• Extraperitoneal Laparoscopic Trigonoplasty for Vesicoureteral Reflux
• Endoscopic Management of Incontinence After Bladder Neck Reconstruction
• Long-Term Preservation of Dextranomer/Hyaluronic Acid Copolymer Implants
• Dextranomer/Hyaluronic Acid Copolymer for Persistent Vesicoureteral Reflux
• Copyright

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Bladder Dysfunction and Infantile High Grade Vesicoureteral Reflux 

In infants with high grade vesicoureteral reflux bladder dysfunction is common and spontaneous reflux resolution often occurs. However, urinary tract infection is also common in these patients despite treatment with antibiotic prophylaxis. Sillén et al (page 325) from Goteburg, Sweden studied whether treatment of bladder dysfunction in these children enhanced the spontaneous reflux resolution rate. Of 80 boys and 35 girls with high grade reflux 20 were treated with clean intermittent catheterization every 3 hours because of bladder dysfunction on videourodynamics and recurrent urinary tract infection. These patients were characterized by high bladder capacity and high post-void residual urine volume. At followup the incidence of urinary infection was significantly reduced. However, reflux stopped in only 1 patient and the rest underwent ureteral reimplantation 4 years later. Subsequently, intermittent catheterization was unnecessary. The authors conclude that management of bladder dysfunction in infants with high grade reflux by intermittent catheterization appears to reduce the risk of urinary tract infection but does not improve the rate of spontaneous reflux resolution.

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Ultrasonography of the Spermatic Cord for Acute Scrotum 

In boys with testicular pain color Doppler sonography is often used to assess testicular blood flow. However, false-negative studies can occur if torsion is incomplete. Another method of assessment is high resolution sonography of the testis and spermatic cord in an attempt to visualize the spermatic cord twist. Kalfa et al (page 297) from Montpellier, France and 10 other European hospitals retrospectively reviewed their experience with high resolution sonography in boys younger than 18 years with testicular pain. Of 919 patients who underwent color Doppler sonography and high resolution sonography 208 were found to have spermatic cord torsion on surgical exploration. Of those with torsion absent intratesticular vascularization was noted in 76%. In contrast, the spermatic cord twist was demonstrated in 95% of cases. The radiologist’s level of training was the best predictor of reliability of high resolution sonography. Further study on the reproducibility of this type of evaluation is important.

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Laparoscopic Dismembered Pyeloplasty in Children 

Although laparoscopic pyeloplasty is performed commonly in older children and adolescents, there are few reports in children younger than 2 years. Cascio et al (page 335) from Adelaide, South Australia retrospectively reviewed their experience with 11 children younger than 2 years who underwent transperitoneal laparoscopic pyeloplasty. They used a trans-abdominal hitch stitch, only partially dismembered the ureteropelvic junction to make it easier to orient and spatulate the upper ureter, used 6-zero polydioxanone sutures for the anastomosis and left a trans-anastomotic Double-J® stent. Mean operative time was 100 minutes. Followup studies demonstrated normal drainage in all except 1 patient who had prolonged but improved drainage following redo pyeloplasty.

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Urodynamic Findings in Children with Myelomeningocele 

Following repair of myelomeningocele, there is typically an abnormally low conus medullaris and scarring around the lower spinal cord. Tethered cord is generally diagnosed on the basis of symptoms and urodynamics. Symptoms may include increasing lower extremity weakness, worsening gait, scoliosis, pain, orthopedic deformity and bladder dysfunction. Abrahamsson et al (page 331) from Goteborg, Sweden retrospectively studied 20 children with a tethered spinal cord following closure of myelomeningocele. Indications for surgery were progressive scoliosis in 6 cases and motor symptoms in 13. Mean patient age was 8 years (range 2 to 13). Bladder symptoms were the main indication in 1 child and part of the indication in 5. Bladder function deterioration improved after detethering in 6 patients. Stable bladder function preoperatively deteriorated in 1 case postperatively and remained unchanged in the others. The authors recommend continuous close monitoring of bladder function in children with spina bifida.

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Extraperitoneal Laparoscopic Trigonoplasty for Vesicoureteral Reflux 

Laparoscopic treatment of reflux has been performed as an extravesical and transvesical transtrigonal approach. Simforoosh et al (page 321) from Tehran, Iran describe an extraperitoneal laparoscopic trigonoplasty in 27 children (mean age 8.2 years). Their technique included placement of horizontal mattress sutures through the ureteral wall and Waldeyer’s sheath near the orifices, and the ureters were approximated in the midline. The success rates were 92.7% (ureters) and 89% (patients). Longer followup is needed to assess the durability of this type of repair.

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Endoscopic Management of Incontinence After Bladder Neck Reconstruction 

Bladder neck reconstruction is often performed in children with myelodysplasia and bladder exstrophy. However, persistent incontinence is common. One option is endoscopic injection of the bladder neck using a bulking agent. Kitchens et al (page 302) from Cincinnati, Ohio and Denver, Colorado reviewed their experience with bladder neck injection of dextranomer/hyaluronic acid. The injection was performed retrograde via the native urethral or antegrade via a Mitrofanoff neourethra or suprapubic bladder access. The injections were performed in 4 quadrants. Continence was achieved after 1 or 2 injections in 6 of 14 patients (43%) and 4 (29%) improved. The average injection dose of the bulking agent was 4.5 ml for children who became continent, 3.6 ml for those who improved and 3.0 ml for those who did not improve. Whether the injections are durable in these patients is uncertain.

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Long-Term Preservation of Dextranomer/Hyaluronic Acid Copolymer Implants 

Following subureteral injection of dextranomer/hyaluronic copolymer implants for correction of vesicoureteral reflux, the hyaluronic acid component disappears within several weeks. McMann et al (page 316) from Atlanta, Georgia retrospectively studied volume retention of the implanted material over time with sonography. The implant volume was compared to the injected volume. All children underwent a postoperative voiding cystourethrogram. Of 296 injected ureters available for study 2 weeks after implant (down to 20 ureters at 24 to 36 months) mean percentage of the retained implant was 79% at 2 weeks, 74% at 3 months, 78% at 12 months and 65% at 24 to 36 months. When the measured volume was greater than the injected volume the success rate was 95%. When volumes were lower volume retention did not correlate with cure.

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Dextranomer/Hyaluronic Acid Copolymer for Persistent Vesicoureteral Reflux 

Endoscopic therapy is an option in patients with persistent vesicoureteral reflux after ureteroneocystostomy. Jung et al (page 312) from Nashville, Tennessee evaluated 12 patients with 14 refluxing ureters. Of the ureters 9 had been reimplanted with a Politano-Leadbetter, 2 with a Glenn-Anderson and 1 with a transtrigonal technique. After 1 injection 7 of 10 ureters demonstrated reflux resolution, and 2 of the remaining ureters were rendered reflux-free following a second injection. The authors conclude that endoscopic therapy is an option for children with persistent reflux after ureteral reimplantation.