This Month in Pediatric Urology

Article Outline

• Prepubertal Orchiopexy for Cryptorchidism and Lower Risk of Testicular Cancer
• Laparoscopic Orchiopexy for Intra-Abdominal Testes Near the Internal Ring
• Tubularized Incised Plate Versus Onlay Island Flap Urethroplasty for Hypospadias
• Effect of Obesity on Nocturnal Enuresis and Voiding Dysfunction Treatment
• Radiographic Changes After Excisional Tapering and Reimplantation of Megaureters
• Endoscopic Treatment of Vesicoureteral Reflux Associated With Paraureteral Diverticula
• Postpubertal Urodynamic and Upper Urinary Tract Changes in Children With Myelomeningocele
• Copyright

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Prepubertal Orchiopexy for Cryptorchidism and Lower Risk of Testicular Cancer 

While there is an increased risk of testicular cancer in men with a history of an undescended testis, whether orchiopexy reduces the risk of testicular cancer is controversial. Walsh et al (page 1440) from San Francisco, California performed a systematic review and meta-analysis of literature pertaining to cryptorchidism and testicular cancer. Summary risk measures were calculated using a random effects model, and 4 studies met the study criteria. The authors calculated an increased risk of testicular cancer with an odds ratio from 2.9 to 32 if orchiopexy was delayed until after age 10 to 11 years or never performed. In addition, these men were 5.8 times more likely to have testicular cancer compared to those in whom orchiopexy was performed earlier. The authors conclude that prepubertal orchiopexy may reduce the risk of testicular cancer.

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Laparoscopic Orchiopexy for Intra-Abdominal Testes Near the Internal Ring 

There are multiple surgical options for an abdominal undescended testis, including standard orchiopexy with a Prentiss maneuver, staged orchiopexy, Fowler-Stephens orchiopexy (1 or 2 stage), autotransplantation and orchiectomy. The staged techniques are necessary if the vessels are too short. During laparoscopic orchiopexy it has been proposed that if the testis was within 2 cm of the internal inguinal ring or could be stretched to the contralateral internal ring, then a standard orchiopexy probably would be successful. Yucel et al (page 1447) from Dallas, Texas performed a retrospective review of the records of 46 patients with an abdominal testis to assess whether these parameters were valid. All patients underwent a single stage orchiopexy, either standard or with division of the spermatic cord vessels if the testis did not reach the base of the scrotum. Overall 20 of the 46 testes reached the dependent aspect of the scrotum (group 1) while 26 did not (group 2). Of the latter group 12 were subjected to a Fowler-Stephens orchiopexy, while the remaining testes were left in the upper scrotum. At followup 18 of the 20 testes in group 1 were palpable normal and 2 were atrophic. Of 12 group 2 testes left in the upper scrotum 6 were still in position, 3 had migrated out of the scrotum and secondary orchiopexy was performed, and 3 were atrophic. Of the 10 testes treated with the Fowler-Stephens orchiopexy 7 were in satisfactory position, 2 were too high and 1 became atrophic. All of the testes in this series were within 2 cm of the internal inguinal ring. In addition, 37 of 41 testes reached the contralateral internal ring. These data suggest that neither testis mobility nor preoperative position of an abdominal testis predicts whether it can reach the scrotum without performing a Fowler-Stephens orchiopexy.

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Tubularized Incised Plate Versus Onlay Island Flap Urethroplasty for Hypospadias 

The tubularized incised plate (TIP) and onlay island flap (OIF) urethroplasties are often used to treat proximal hypospadias. Braga et al (pages 1451) from Toronto, Canada retrospectively reviewed their experience with these 2 techniques in boys with penoscrotal hypospadias. Based on surgeon preference 35 boys underwent TIP and 40 underwent OIF repair. At followup the complication rate was 60% for TIP and 45% for OIF. Fistula or wound dehiscence occurred in 51% of the TIP versus 25% of the OIF cases, and a proximal fistula developed more often after TIP. Meatal stenosis occurred in 1 patient in each group. Ventral curvature recurred in 6% of the TIP group and in 13% of the OIF group. A plateau-shaped uroflow curve was noted in 67% of the patients treated with TIP compared with 33% of those treated with OIF. Although the overall complication rate for the 2 repairs was similar, the authors caution that the uroflow curve and fistula position of the TIP cases suggest more outflow resistance than with OIF. Longer followup is necessary for these boys.

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Effect of Obesity on Nocturnal Enuresis and Voiding Dysfunction Treatment 

Previous studies have suggested a high rate of obesity in children with dysfunctional voiding, particularly those with nocturnal enuresis. Guven et al (page 1458) from Albany, New York retrospectively reviewed the records of 250 consecutive children with nocturnal enuresis and voiding dysfunction to determine whether those with a body mass index (BMI) greater than the 85th percentile responded to treatment as well as those with a normal BMI. Treatment was not standardized. However, bladder behavioral therapy including increasing early daytime fluids, timed voiding, reduction of evening fluid intake and aggressive therapy of constipation were initial measures. Subsequently, individualized treatment modalities including anticholinergic medication, alarm therapy and desmopressin were used. Mean patient age was 11 years in those with nocturnal enuresis and 9.3 years in those with dysfunctional voiding. Approximately 50% of both groups had a BMI greater than the 85th percentile. Of patients of normal weight the number of enuretic episodes reduced from 5.6 to 1.3 per week, whereas in obese patients the rate decreased from 5.9 to 5.2. In addition, 85% of children of normal weight with dysfunctional voiding had a complete or partial response to therapy compared to 53% of obese patients. Furthermore, overweight patients were less likely to complete voiding diaries. The authors conclude that obesity correlates with a lower rate of voiding diary completion and lower efficacy of treatment in children with nocturnal enuresis or dysfunctional voiding.

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Radiographic Changes After Excisional Tapering and Reimplantation of Megaureters 

There have been few long-term reports of radiological changes after excisional tapering for megaureter. Link et al (page 1474) from Oklahoma City, Oklahoma retrospectively analyzed the records of 39 children who underwent megaureter repair with tapering and reimplantation. The Society for Fetal Urology scale was used to grade hydronephrosis. Mean patient age at surgery was approximately 4 years. The etiology of the megaureter was variable, and included orthotopic refluxing, obstructed nonrefluxing, ectopic or orthotopic ureterocele, ectopic ureter and megaureter associated with posterior urethral valves or bladder exstrophy. Mean followup was 3.9 years. Less severe hydronephrosis was most likely to resolve postoperatively. Of patients with grade 4 hydronephrosis pelvocaliectasis improved in 38%, resolved in 10% and remained unchanged in 52%. However, no patient demonstrated postoperative obstruction on renography. Postoperative reflux was noted in 6% of cases. The authors conclude that despite functional improvement on postoperative renography, hydroureteronephrosis may persist following megaureter repair.

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Endoscopic Treatment of Vesicoureteral Reflux Associated With Paraureteral Diverticula 

A paraureteral diverticulum has been a relative contraindication to endoscopic treatment of vesicoureteral reflux. Cerwinka et al (page 1469) from Atlanta, Georgia retrospectively reviewed their experience with 17 patients with reflux and a paraureteral diverticulum. The hydrodistention implantation technique was used and dextranomer/hyaluronic acid was the injected bulking agent. Reflux grade ranged from I to III in 18 of the 20 ureters (90%). A mean of 1.2 ml bulking agent was injected per ureter. Success was 100% for grades I and II, and 63% for grade III reflux. Large diverticulum size and high bulking agent volume were associated with treatment failure. The authors conclude that there is a significant likelihood of success with endoscopic treatment in the presence of a paraureteral diverticulum.

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Postpubertal Urodynamic and Upper Urinary Tract Changes in Children With Myelomeningocele 

Some have speculated that continence improves at puberty because of prostatic growth in children with myelomeningocele. Almodhen et al (page 1479) from Montreal, Canada retrospectively analyzed 37 patients with myelomeningocele treated exclusively with intermittent catheterization and/or anticholinergics at their institution. Clinical evaluation including upper urinary tract imaging and urodynamics was performed every 6 to 12 months. Prepubertal and postpubertal continence status was compared. In the prepubertal age group 26 patients were incontinent but after puberty 12 (46%) spontaneously became continent. Hydronephrosis was stable in 4 patients, improved in 3 and developed in 3. Vesicoureteral reflux resolved in 4 of 5 patients. Mean cystometric bladder capacity increased from 277 to 487 ml, and mean detrusor pressure and detrusor leak point pressure increased significantly after puberty. The authors speculate that the increase in bladder capacity resulted from prostate gland enlargement in males and estrogen in females.