This Month in Pediatric Urology

Article Outline

• Caliceal Diverticula
• Appearance of Dextranomer/Hyaluronic Acid Copolymer Implants
• Stress and Coping of Parents of Children With Bladder Exstrophy
• Copyright

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Caliceal Diverticula 

Caliceal diverticula are rare in children and the knowledge base regarding their natural history is limited. Estrada et al (page 1306) from Boston, Massachusetts reviewed their 23-year experience with 22 children with caliceal diverticula to better understand the clinical presentation, natural history and outcomes of management. All children were evaluated with a contrast study (excretory urography or computerized tomography [CT]) to differentiate the diverticulum from a simple cyst. Observation was the initial management in all cases. The most frequent presenting diagnoses were febrile urinary tract infection in 10 (45%) and gross hematuria in 2 (9%) patients, while 8 (36%) were diagnosed incidentally during evaluation of other conditions. All caliceal diverticula were polar in location and associated with a minor calix. Vesicoureteral reflux was found in 3 (14%) patients which was ipsilateral in 2. Ten children (43%) ultimately required intervention at a mean of 27 months from the time of diagnosis. Indications included symptomatic enlargement in 5 (27%) cases, symptomatic calculi in 3 (14%), complicated abscess in 1 (5%) and urosepsis in 1 (5%). Treatment consisted of percutaneous ablation in 6 cases, open marsupialization in 1, laparoscopic marsupialization in 2 and partial nephrectomy in 1. The authors conclude that while caliceal diverticula are rare in children, they do warrant long-term clinical and sonographic surveillance, and significant sequelae are not uncommon.

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Appearance of Dextranomer/Hyaluronic Acid Copolymer Implants 

Dextranomer/hyaluronic acid copolymer (Dx/HA) is the only material currently approved by the Food and Drug Administration for subureteral implantation in the United States and is the most commonly used implant material worldwide for endoscopic treatment of vesicoureteral reflux (VUR). In a growing number of cases imaging studies for reasons unrelated to VUR have shown these implants, often leading to diagnostic dilemmas for radiologists, emergency room physicians and even urologists who may be unfamiliar with this technique. From their database of 893 patients who underwent endoscopic treatment for VUR from July 2001 through November 2007, Cerwinka et al (page 1324) from Atlanta, Georgia describe the CT findings in 17. A total of 33 implants appearing as calcifications were designated as high (36%) or low (64%) density based on median values of 193 HU (range 126 to 367) or 22 HU (15 to 27), respectively. As a control, these findings were compared with the CT findings in 30 consecutive patients with ureterovesical junction (UVJ) stones. Fifteen stones were radiolucent on plain x-ray of the kidneys, ureters and bladder with a median of 247 HU (range 180 to 307), and 15 were radiopaque with a median of 618 HU (364 to 1,335). Of the 30 patients with stones urinalysis was performed at CT in 19 and 18 (95%) had microhematuria, while urinalysis was performed at CT in only 2 of the 10 (20%) patients with Dx/HA implants. Hydronephrosis was noted in 24 (80%) patients with stones vs 0 in the Dx/HA implant group. The authors conclude that parents of children undergoing endoscopic treatment of VUR with Dx/HA implants should be counseled that microcalcifications can develop in 30% to 40% and that these may be misdiagnosed as UVJ stones on CT. A history of VUR, absence of hydronephrosis, absence of microhematuria, negative plain film of the kidneys, ureters and bladder, and attenuation less than 400 HU on CT should help to differentiate patients with high density Dx/HA implants from those with UVJ stones.

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Stress and Coping of Parents of Children With Bladder Exstrophy 

Bladder exstrophy is one of the most complex congenital genitourinary anomalies that pediatric urologists manage. While not life threatening, significant hurdles related to management and the need for multiple reconstructive procedures can take a toll on the well-being of the caretakers. Mednick et al (page 1312) from Boston, Massachusetts evaluated stress and coping factors of caretakers of young children with bladder exstrophy. They retrospectively identified children with bladder exstrophy younger than 10 years and contacted their parents regarding their interest in completing a written, telephone or in-person questionnaire related to their stress level (Pediatric Inventory for Parents) and coping ability (The Ways of Coping Questionnaire). Of the 33 parents contacted 20 (65%) participated in the survey. The degree of difficulty for stress in this population was similar to that of parents with a child diagnosed with diabetes. Coping skills reflected “planful” problem solving in 18% of parents, seeking social support in 16% and positive reappraisal in 14%. However, maladaptive coping mechanisms of distancing and escape/avoidance occurred in 10% and 9% of parents, respectively. The authors note the importance of recognizing that while children with bladder exstrophy are generally healthy, the congenital defect results in parental stressors similar to parents of a child suffering from a chronic illness. They conclude that the parents of children with bladder exstrophy have increased stress and diminished use of adaptive coping. Knowing this can facilitate development of specific formal intervention to provide parents a better opportunity to adapt.