This Month in Pediatric Urology

Article Outline

• Urethral Mobilization and Advancement with Distal Triangular Urethral Plate for Hypospadias
• Risk Assessment of Complex Renal Cysts Incidentally Detected
• Late Recurrence of Symptomatic Hydronephrosis after Spontaneous Improvement
• Laparoscopic Lymphatic Sparing Varicocelectomy in Adolescents
• Copyright

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Urethral Mobilization and Advancement with Distal Triangular Urethral Plate for Hypospadias 

The tubularized incised plate hypospadias repair is currently the most popular technique for distal hypospadias. Mollaeian et al (page 290) from Tehran, Iran offer an appealing alternative for distal hypospadias and select cases of midshaft hypospadias. They describe their approach using extensive mobilization and advancement of the urethra combined with a triangular distal urethral plate flap in 251 boys who underwent repair of glanular (62), subglanular (128), midshaft (28) and recurrent (33) hypospadias during a 10-year period. Followup ranged from 6 months to 10 years with a mean followup of 7.4 years. More than 200 boys were followed for greater than 5 years. Reoperations were necessary in 2 patients with midshaft hypospadias for recurrent penile curvature and in 1 to drain a penile hematoma. Excellent cosmetic results were reported. The authors conclude that this technique is useful for all cases of distal hypospadias and select cases of midshaft hypospadias with or without penile curvature. They note that it is particularly appropriate for circumcised patients and some with recurrent hypospadias following a failed repair.

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Risk Assessment of Complex Renal Cysts Incidentally Detected 

Complex renal cysts in children are uncommon and often pose a diagnostic and therapeutic dilemma, particularly with regard to potential malignant or premalignant risk. Wallis et al (page 317) from Toronto, Canada analyzed the records of 39 children with complex renal cysts identified retrospectively from an extensive database search. Using a modified Bosniak classification based on ultrasound rather than computerized tomography (CT) as originally described in the adult population, the renal cysts were classified into 4 categories. Additional contrast imaging with either CT or magnetic resonance imaging (MRI) was obtained in 21 cases (54%). Ultrasound imaging was more sensitive than CT for detection of septations within the cysts. Surgical resection was performed in 5 patients, revealing benign cysts in 3 (modified Bosniak category 2 in 2 and category 3 in 1) and renal cell carcinoma in 2 (modified Bosniak category 4 in 1 and category 3 in 1). All other patients with modified Bosniak category 2 remained unchanged during a mean followup of 26.8 months (range 9 to 70). The authors conclude that the ultrasound based modified Bosniak classification allows safe monitoring of category 2 cysts with ultrasound but that suspected category 3 and 4 cysts warrant further investigation with either CT or MRI. If these findings are confirmed by CT or MRI, surgical resection is recommended.

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Late Recurrence of Symptomatic Hydronephrosis after Spontaneous Improvement 

Prenatal hydronephrosis is usually managed initially without surgery and gradual spontaneous improvement has been reported in the majority of mild and moderate cases. How long to follow cases after spontaneous postnatal improvement is a question that has not been fully answered. Matsui et al (page 322) from Osaka, Japan reviewed their experience with 483 hydronephrotic kidneys detected by prenatal sonography during a 13-year period. All patients were assessed with postnatal sonography in the first week of life followed by voiding cystography and diuretic renography using a standardized protocol. Surgery was performed for associated symptoms, giant hydronephrosis (extending beyond midline), worsening hydronephrosis on sequential ultrasound or a decrease in differential renal function greater than 5%. According to the Society for Fetal Urology criteria 129 renal units had grade 1, 170 grade 2, 65 grade 3 and 119 grade 4 hydronephrosis. Surgery was performed in 89 renal units (18.4%) including 7 kidneys with grade 3 and 82 with grade 4 hydronephrosis. The remaining 394 kidneys were followed nonoperatively. In 4 cases (1%) the hydronephrosis improved spontaneously on serial sonography and then worsened at a mean age of 20 months (range 22 to 66). All 4 patients had symptoms of abdominal pain with associated gross hematuria in 1 and vomiting in 1. The authors conclude that although optimal duration of followup is not yet determined, long-term imaging is not necessary following spontaneous improvement on serial sonography. However, parents need to be made aware that these children should be reevaluated if symptoms of abdominal pain or recurrent vomiting subsequently develop.

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Laparoscopic Lymphatic Sparing Varicocelectomy in Adolescents 

The 2 most common complications of adolescent varicocelectomy are persistence/recurrence and ipsilateral hydrocele formation. It has been reported that lymphatic sparing techniques for open and laparoscopic varicocelectomies reduce the incidence of postoperative hydroceles. Glassberg et al (page 326) from New York, New York retrospectively analyzed their experience with 191 adolescents (mean age 15.2 years) who underwent laparoscopic varicocelectomy and had at least 6 months of followup. A total of 174 procedures using a lymphatic sparing (LS) approach were compared 88 nonlymphatic sparing (NLS) procedures. The incidence of postoperative hydrocele formation was significantly lower in the LS group compared to the NLS group (3.4% vs 11.4%, p=0.025). There was no significant difference in the incidence of persistent/recurrent varicoceles in the LS group compared with the NLS group (92.8% vs 4.5%, p=0.736). The authors conclude that the LS approach to laparoscopic varicocelectomy is as effective as NLS approaches and results in a lower incidence of postoperative hydroceles. The LS approach is also advantageous when performing bilateral varicocelectomy.