This Month in Pediatric Urology

Article Outline

• Ultrasound Bladder Measurements for Nocturnal Enuresis
• Computerized Tomography and Pediatric Renal Trauma
• Ileal Enterocystoplasty and B12 Deficiency
• Nonrefluxing Neonatal Hydronephrosis and Urinary Tract Infection
• Short Stay Pyeloplasty
• Copyright

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Ultrasound Bladder Measurements for Nocturnal Enuresis 

The treatment of children with nocturnal enuresis often involves a gunshot approach resulting in variable success. Sreedhar et al (page 1568) from Hong Kong investigate the use of a bladder volume wall thickness index (BVWI) to determine ultrasonographically the ability to predict successful treatment response. The authors defined 3 BVWI categories of thick, normal and thin. They prospectively recruited 23 boys and 12 girls, and correlated the BVWI with urodynamic bladder assessment. Enuresis treatment was based on a standardized management protocol targeting underlying physiology and bladder dysfunction. BVWI was normal in 8 children including 7 (88%) with a normal urodynamic pattern, thick in 24 children including 23 (95%) with overactive detrusor contractions and thin in 3 all of whom had underactive detrusor contractions. All children with a normal BVWI had either a complete or good response to treatment. Initially only 16 (66%) of those with a thick BVWI had a complete, good or partial response, and 1 of 3 with a thin bladder had a partial response only. At followup urodynamic improvement was noted in 9 (36%) children with an initially thick BVWI, and all subsequently responded to further treatment. The authors suggest that ultrasonographic assessment of the bladder correlates favorably with urodynamic findings and can be an effective noninvasive predictor of primary nocturnal enuresis management.

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Computerized Tomography and Pediatric Renal Trauma 

A conservative approach of observation is considered to be in the best interest of children with variable degrees of renal trauma. However, not all patients can be treated conservatively. Cannon et al (page 1529) from Pittsburgh, Pennsylvania assess whether the initial computerized tomogram can predict who will require operative intervention. The scan was reviewed to determine the location of injury, size and number of sites of extravasation, and the presence of contrast material in the ipsilateral ureter. These data points were compared between conservatively treated children and those requiring intervention. The authors identified 17 patients with grade 4 blunt renal trauma and urinary extravasation, of whom 8 (47%) required delayed intervention. Intervention was based on progressive flank pain, persistent fever or persistent extravasation after 2 weeks of observation. A predictor of unsuccessful conservative management appeared to be lack of contrast material in the ipsilateral ureter. The specific location of extravasation and the size of the hematoma/urinoma did not predict the outcome. The authors conclude that early placement of a ureteral stent may decrease morbidity and length of stay, especially when contrast material is not seen in the ipsilateral ureter. Further investigation is required to determine the clinical significance of widely separated renal fragments, areas of extravasation and need for transfusion.

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Ileal Enterocystoplasty and B12 Deficiency 

B12 deficiency is a well recognized potential complication in any child undergoing urinary reconstruction when using ileum. However, there are few data to support if and when B12 deficiency becomes clinically significant. Rosenbaum et al (page 1544) from Indianapolis, Indiana share their experience reviewing more than 500 records of children who have undergone augmentation cystoplasty at their institution. They selected children younger than 18 years and eliminated from the study those who had received B12 supplementation during the course of evaluation. The authors identified 79 patients for review and found a statistically significant correlation between diminishing levels of serum B12 as followup time increased. An abnormally “low” B12 level was identified in 21% of children 7 years after surgery while an additional 41% had “low-normal” levels. It is predicted that the B12 level in the “low-normal” group will continue to decrease with time. When a deficiency is present, B12 supplementation via either monthly intramuscular injections or intranasal administration is recommended. These data support the theory that B12 deficiency is a significant factor in the majority of children undergoing augmentation cystoplasty. The authors recommend annual serum B12 levels be obtained beginning 5 years postoperatively.

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Nonrefluxing Neonatal Hydronephrosis and Urinary Tract Infection 

Hydronephrosis is reported to occur in 0.5% to 1% of neonates and is the most frequently detected prenatal anomaly. The empiric use of antibiotic prophylaxis in newborns with the diagnosis of prenatal hydronephrosis is recommended due to the presumed increase susceptibility to urinary infection. However, there is limited evidence based data to support the benefit of antibiotic prophylaxis particularly in the absence of vesicoureteral reflux. Lee et al (page 1524) from Seoul, Korea compared the incidence of urinary tract infections during the first year of life in neonates with variable grades of hydronephrosis, a hydroureter and obstruction. Children with vesicoureteral reflux were excluded from the study. A total of 430 children were evaluated, 82% of whom were boys. Urinary tract infection (UTI) developed in 20% of the infants within the first 4 months of life. Of the infants with obstructive uropathy based on a ^99mtechnetium mercaptoacetyltriglycine renal scan 40% had a UTI compared to 11% without obstruction. UTI occurred more frequently in patients with higher grades of hydronephrosis (from 4% for grade I to 40% for grade IV). The presence of a hydroureter also appeared to have a significant impact on increased UTIs. The authors suggest that in the absence of reflux, antibiotic prophylaxis appears to have the greatest benefit in children with obstructive uropathy, severe hydronephrosis or hydroureteronephrosis.

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Short Stay Pyeloplasty 

Minimally invasive standards continually evolve regarding the treatment of ureteropelvic junction (UPJ) obstruction. To place the role of minimally invasive therapy in perspective, appropriate benchmarks for open intervention are required. Chamie et al (page 1549) from Sacramento, California evaluate factors affecting pain and length of stay following open pyeloplasty. They retrospectively reviewed the charts of 51 children younger than 10 years who had undergone either a flank or dorsal open pyeloplasty. Pain control included morphine sulfate, Ketorolac and/or oral acetaminophen with codeine as needed. Age, gender, operative time and the placement of the stent had no correlation with the level of pain recorded based on standardized pediatric pain scales. Children who received parenteral morphine appeared to have higher pain scores and a prolonged length of stay (33 versus 23 hours). The authors noted a higher recorded pain score related to the dorsal lumbotomy but the requirement for pain medication and length of stay were similar compared to the flank approach. The authors admit that subjective pain analysis and physician and family expectations are difficult variables to control, and could easily influence the perception of pain and length of stay. They suggest that a higher pain score and length of stay occur when an “as needed” order for morphine sulfate is written compared to children who are treated with scheduled Ketorolac and supplemental acetaminophen with codeine. The authors conclude that when pain is controlled following an open pyeloplasty, the length of stay can be minimized to less than 23 hours, qualifying the technique as minimally invasive.