This Month in Pediatric Urology

Article Outline

• Training Residents in Hypospadias Repair
• Community Associated Methicillin Resistant Staphylococcal Infections
• Intraoperative Cystography After Injection of Dextranomer/Hyaluronic Acid Copolymer
• Outcome Analysis of Isolated Male Epispadias
• Copyright

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Training Residents in Hypospadias Repair 

Hypospadias repair is a challenging reconstructive procedure in pediatric urology. Improved techniques and dedicated “hypospadiologists” have contributed to the advances which have all but eliminated the “hypospadias cripple” of the past. DeLair et al (page 1102) from Sacramento, California report the results of an electronic survey inquiring about the level of resident participation in each step of hypospadias repair and the necessity of pediatric fellowship training for this procedure. The survey was sent to 518 urology residents and 168 practicing pediatric urologists with response rates of 53% and 40%, respectively. In contrast to Accreditation Council for Graduate Medical Education self-reported data, approximately 70% of residents and attendings reported that residents perform less than 50% of the overall procedure. There was general agreement on the perceived amount of resident participation for all steps except glanular mobilization. Regarding the need for pediatric urology fellowship training to perform hypospadias surgery, 71% of residents and 86% of attendings believed that specialized training was a necessity. The authors conclude that current performance data and practice trends suggest that mandated pediatric urological educational requirements for general urology residents need to be updated. At the same time, the role of resident exposure to hypospadias repair should not be questioned.

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Community Associated Methicillin Resistant Staphylococcal Infections 

A major cause of serious nosocomial infection in recent years has been the emergence of methicillin resistant Staphylococcus aureus (MRSA). Growing concern regarding community associated MRSA has been expressed in the infectious disease community but has received little attention in the urological literature. In a provocative article Koski et al (page 1098) from Nashville, Tennessee report their experience with 12 patients who presented with skin/soft tissue infections between October 2004 and August 2006. Abscess location was inguinal in 4 cases (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). Infections were spontaneous in 11 cases and presented as a wound infection in 1. Ten (83%) cultures revealed MRSA. All patients eventually required surgical drainage in addition to antibiotic therapy. The authors encourage increased awareness of the growing incidence of community associated MRSA urological soft tissue infections.

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Intraoperative Cystography After Injection of Dextranomer/Hyaluronic Acid Copolymer 

Increasing use of endoscopic treatment for vesicoureteral reflux (VUR) has evolved since the Food and Drug Administration approved dextranomer/hyaluronic acid for subureteral injection. At most centers the success rates are lower than those observed following open ureteral reimplantation, necessitating continuation of antibiotic prophylaxis at least until postoperative voiding cystourethrography (VCUG) 3 to 4 months after the procedure demonstrates successful correction of VUR. Palmer (page 1118) from Long Island, New York prospectively evaluated his experience with the use of post-injection intraoperative cystography to improve the success rate of injection and to determine if a negative intraoperative cystogram could obviate the need for the 3 to 4-month postoperative VCUG. A total of 41 patients (64 ureters) were evaluated with intraoperative and 3 to 4-month followup cystograms after subureteral injection of dextranomer/hyaluronic acid for vesicoureteral reflux. Three patients required additional injection of the bulking agent based on the initial intraoperative cystogram showing persistent VUR, and none had persistent VUR 3 to 4 months later. Of 52 ureters (32 patients) evaluated with intraoperative post-injection cystography and postoperative VCUG at 3 to 4 months 2 (3.8%) demonstrated persistent VUR immediately after cystoscopic injection compared to 12 (23%) with persistent VUR at the time of the followup VCUG. The authors conclude that whereas intraoperative cystography may help determine immediate success, it cannot replace the 3 to 4-month postoperative VCUG.

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Outcome Analysis of Isolated Male Epispadias 

Epispadias and exstrophy repair represent some of the most complex reconstructive cases in pediatric urology. Braga et al (page 1107) from Toronto, Canada retrospectively reviewed their experience with 33 patients with isolated epispadias (glanular 3, penile 9, penopubic 21) between 1994 and 2005. They specifically compared their outcomes with the Cantwell-Ransley (CR) repair (14 cases) and the Mitchell-Bagli (MB) repair (7 cases) in regard to continence status and postoperative complications. Mean patient age in the CR group was 16.8 months (range 12 to 24) compared with 19.3 (9 to 42) in the MB group. In the MB group continence following the primary repair was achieved in 4 of 6 (66.7%) patients compared to 0 of 13 in the CR group (p <0.01). A subsequent bladder neck procedure (BNR) for continence was performed in 11 of 13 patients in the CR group and 6 achieved continence. Subsequently, of the 5 cases of BNR failure continence was achieved in 3 after a second BNR combined with augmentation cystoplasty. In contrast, the 2 boys who were incontinent following the MB repair were treated successfully with endoscopic injection of a bulking agent. At last followup 13 of 17 patients (76.5%) patients with penopubic epispadias were completely dry or had dry intervals greater than 4 hours. Complications developed in 8 of 14 patients (57.1%) after the CR repair and in 2 of 7 (28.5%) after the MB repair.