This Month in Pediatric Urology

Article Outline

• Combined Anticholinergic Treatment and Behavioral Modification for Voiding Dysfunction
• Urodynamic Evaluation of Children With Lipomeningocele
• Initial Experience With Laparoscopic Ipsilateral Ureteroureterostomy for Duplication Anomalies of the Urinary Tract
• Laparoscopic Transureteroureterostomy
• Early Results of Robotic Assisted Laparoscopic Lithotomy in Adolescents
• Prenatal Diagnosis and Neonatal Management of Congenital Urethral Diverticulum
• Copyright

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Combined Anticholinergic Treatment and Behavioral Modification for Voiding Dysfunction 

In many children with voiding dysfunction a combination of behavioral therapy and anticholinergic therapy is prescribed. Ayan et al (page 2325) from Sivas, Turkey performed a prospective blinded randomized controlled trial in 72 children (mean patient age 8.6 years) with nonneurogenic and nonanatomical voiding dysfunction. The patients were divided into group 1—1 mg tolterodine twice daily and behavioral modification, group 2—behavioral modification only and group 3—placebo and behavioral modification. At the beginning, at 1 month and at 3 months of treatment a dysfunctional voiding scoring system questionnaire was completed. There was a significant reduction in the questionnaire scores for all 3 groups at 1 and 3 months, and the results were best for the patients who received tolterodine. The authors recommend tolterodine and behavioral modification as first line therapy for children with voiding dysfunction.

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Urodynamic Evaluation of Children With Lipomeningocele 

A lipomeningocele should be suspected when there is a subcutaneous fatty mass over the sacrum or dermatological anomalies such as a hairy tuft or deep sacral pit. Children with lipomeningocele have a variety of urodynamic abnormalities of the bladder. Rendeli et al (page 2319) from Rome, Italy retrospectively reviewed their experience with 64 patients with a lipomeningocele between the ages of 3 and 17 years (mean 8.5) who had undergone surgical repair. Surgical repair was performed in the first year of life in 53% of the cases, between ages 1 and 3 years in 26% and after age 3 years in 20%. At least 1 preoperative and 2 postoperative urodynamic studies a year apart had been performed in all patients. The authors found that the increase in bladder capacity in children undergoing surgery within the first year of life was similar to that of neurologically normal subjects, whereas those undergoing surgical repair after age 1 year had a lower bladder capacity. In addition, the mean detrusor leak point pressure was lowest in the group undergoing early surgical repair. The authors conclude that early surgical repair of lipomeningocele offers the best chance for favorable lower urinary tract function.

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Initial Experience With Laparoscopic Ipsilateral Ureteroureterostomy for Duplication Anomalies of the Urinary Tract 

Ipsilateral ureteroureterostomy is used in select children with ectopic ureter or ureterocele, or those with lower pole vesicoureteral reflux. Gonzalez and Piaggio (page 2315) from Wilmington, Delaware retrospectively reviewed their experience with 6 patients (mean age 51 months) who underwent 8 laparoscopic ipsilateral ureteroureterostomy procedures. Mean operating room time was 211 minutes for unilateral cases and 348 minutes for bilateral cases. Cystoscopy and retrograde stent placement in the recipient ureter were performed, and then the laparoscopic procedure was completed. The anastomosis was performed at the level of the iliac vessels with interrupted or running 6-zero absorbable monofilament suture. No patient experienced an anastomotic leak. Postoperative results were favorable in all cases.

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Laparoscopic Transureteroureterostomy 

Transureteroureterostomy (TUU) is a technique used to bypass a diseased distal ureter and has a high success rate. Piaggio and Gonzalez (page 2311) from Wilmington, Delaware performed laparoscopic TUU in 3 children 18 to 105 months old (mean age 63). The disorders included an obstructed ureter after reimplantation, ureteral injury following bladder diverticulectomy and unilateral refluxing megaureter. A ureteral stent was placed in the recipient ureter at the beginning of the procedure. The abnormal ureter was transected and brought transversely under the rectosigmoid mesentery. The anastomoses were performed with running 6-zero absorbable monofilament sutures. Mean operating room time was 263 minutes, including 21 minutes for cystoscopy and stent placement. One patient had a transient anastomotic leak. Postoperatively none of the 3 patients had hydronephrosis.

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Early Results of Robotic Assisted Laparoscopic Lithotomy in Adolescents 

The management of large stone burdens in children can be challenging, and requires multiple procedures and a combination of therapies. Lee et al (page 2306) from Boston, Massachusetts retrospectively reviewed their experience with robotic assisted laparoscopic lithotomy in 5 patients with a mean age of 16.8 years. Of the patients 4 had a cystine staghorn calculus, and 1 had a calcium oxalate stone and ureteropelvic junction obstruction. After the pyelotomy the calculi were removed by a robotic grasper or by a flexible cystoscope introduced through a robotic port. Operating room time ranged from 165 to 462 minutes (mean 315). One patient required open conversion because of an inability to remove the stone. Of the remaining 4 patients 3 were rendered stone-free and 1 had a residual 6 mm lower pole calculus. Further evaluation of this treatment modality seems warranted.

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Prenatal Diagnosis and Neonatal Management of Congenital Urethral Diverticulum 

One cause of congenital bladder outlet obstruction is congenital urethral diverticulum, also known as anterior urethral valves. Coplen and Austin (page 2330) from St. Louis, Missouri describe 3 cases that were diagnosed prenatally. All 3 neonates had a cystic midline scrotal mass at 18 to 22 weeks of gestation, and in 2 there was progressive enlargement of the scrotal mass associated with bladder distension, bilateral hydroureteronephrosis and oligohydramnios. The newborns were delivered at 32 weeks of gestation and a temporary cutaneous urethrostomy was performed. One patient had normal renal function and 1 had moderate renal insufficiency postoperatively. In the remaining patient the scrotal cystic mass had disappeared at 30 weeks of gestation and the amniotic fluid was preserved. At birth he had a small fistula distal to the urethral diverticulum and a hypoplastic distal urethra for which urethral reconstruction was performed at age 8 months. This study demonstrates that anterior urethral valves can be diagnosed prenatally, which allows for timely and appropriate intervention.