This Month in Pediatric Urology

Article Outline

• Prognostic Calculator for Prediction of Reflux Resolution
• Posterior Urethral Valves, Primary Voiding Pressures and Kidney Function
• Age at Orchiopexy and Testis Palpability Predict Germ and Leydig Cell Loss
• Quality of Life and Self-Esteem for Children With Urinary Incontinence
• Copyright

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Prognostic Calculator for Prediction of Reflux Resolution 

The treatment of vesicoureteral reflux (VUR) in children spans many options including observation, prophylactic antibiotics and open or endoscopic operative intervention. Having the ability to accurately predict the course of VUR could have a positive impact on the choice of management. Recognizing a high likelihood of VUR resolution might favor a conservative approach of observation or prophylactic antibiotics, while a low likelihood of resolution may warrant earlier operative intervention. Shiraishi et al (page 687) from Iowa City, Iowa validate the use of a computational model which includes 9 clinical variables (available on line at www.eurocomp.org) to predict spontaneous resolution of VUR in 82 Japanese children followed for 2 years. The authors accurately predicted reflux would resolve in 33 of 40 patients and would not resolve in 33 of 42, for an accuracy rate of 80.5% with a positive predictive value of 78.6% and a negative predictive value of 82.5%. Of the remaining children for whom reflux resolution could not be predicted the only factor significantly different from those correctly identified was mean age, which was older in the group not correctly identified. If all variables are routinely documented, this prognostic calculator may provide further support when making recommendations regarding long-term treatment of children with primary VUR.

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Posterior Urethral Valves, Primary Voiding Pressures and Kidney Function 

The majority of neonates with obstructive uropathy secondary to a posterior urethral valve are identified in utero, allowing for early assessment and treatment. Even with early treatment, a substantial number of newborns have reduced renal function and progressive renal insufficiency. The decrease in renal function may be due to predetermined embryological factors that result in renal dysplasia or a change in bladder dynamics secondary to the posterior urethral valve causing secondary renal insufficiency. Taskinen et al (page 699) from Helsinki, Finland compared the association of voiding pressure and primary renal function in infants younger than 1 year with and without posterior urethral valves or obstruction. Urodynamic testing was performed within 15 days of valve ablation, and was repeated at a median of 1.7 and 12.6 months following resection. The control group of male infants had been evaluated for a urinary tract infection. Urodynamic parameters of interest included cystometric bladder capacity and peak detrusor pressure during voiding. Aggression analysis was performed to evaluate the association of those urodynamic parameters to the serum creatinine or split renal function.

The cystometric bladder capacity was similar in both groups and there did not appear to be a significant difference before or after valve ablation regardless of the presence of vesicoureteral reflux. The median maximal detrusor pressure during voiding was also equal in both groups. There was no difference in maximal voiding pressure or mean bladder capacity in patients with posterior urethral valves with or without vesicoureteral reflux at first followup. However, at 1 year there was a significant increase in median bladder capacity and decrease in the median maximal voiding pressure in the group with posterior urethral valves. There was no correlation between cystometric bladder capacities and serum creatinine during the first year of life. The authors identified high voiding pressures in infants with posterior urethral valves similar to what they noted in the control group and it was not associated with poor renal function. Voiding pressure was documented to slowly improve the first several months after valve ablation but the pathological impact on the upper tract status remains in question. Improvement in voiding pressure may merely be a reflection of increased urethral caliber secondary to normal growth.

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Age at Orchiopexy and Testis Palpability Predict Germ and Leydig Cell Loss 

It is widely accepted that orchiopexy before age 1 year is prudent to maximize the potential for fertility. Progressive loss of germ and Leydig cells along with testicular fibrosis has been shown to be time dependent. It is reasonable to presume that clinical factors have an important role in predicting which children are at higher risk for histological abnormalities. Tasian et al (page 704) from San Francisco, California compared clinical factors of age at the time of orchiopexy, palpable location of the testis, side of involvement and unilaterally or bilaterally undescended testis to the histological status of a gonadal biopsy. They retrospectively reviewed the records of boys younger than 18 years who had undergone orchiopexy between 1991 and 2001. During that time a testis biopsy was a routine part of standard treatment. The authors identified 274 boys who had complete histological assessment for germ cells, Leydig cells and interstitial fibrosis. Unilateral cryptorchidism occurred in 187 (68%) and the undescended testicle was palpable in 172 (63%) cases. Of the nonpalpable testes 45 were intra-abdominal.

Multivariate logistic regression analysis determined testis descent was associated with the development of moderate to severe germ cell depletion and Leydig cell loss. This risk increased proportionally with age. When adjusting for age, the odds of germ depletion in the palpable testes were lower than those in nonpalpable testes. Overall the authors noted a 2% risk for germ cell depletion and 1% for Leydig cell depletion for each month the testes remained undescended. A 50% greater risk for germ cell depletion was noted in the nonpalpable testes. No correlation was found between pathological outcomes and laterality of the involved testis or presence of a bilateral condition. The authors conclude that severe germ cell loss can be predicted based on time and palpable status, which supports the trend for early orchiopexy. What remains unknown is whether early intervention halts the pathological process.

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Quality of Life and Self-Esteem for Children With Urinary Incontinence 

Management of voiding dysfunction requires a disproportionate amount of outpatient clinic time compared to the management of other complex urological disorders. It is not unusual for some children to respond quickly to basic dietary changes, bowel management and antimuscarinic medication, while others remain unengaged as their parents express endless frustration. Natale et al (page 692) from Homburg, Saarland Germany compared 27 children with voiding dysfunction described as daytime urinary incontinence due to voiding postponement and 22 with urge incontinence to a control group of 30 children with normal voiding habits. There was a similar distribution between gender and IQ. The rate of encopresis was comparable in both incontinent groups but significantly higher compared to controls.

Children with voiding postponement had a greater number of behavioral disorders. Overall incontinent children appeared to have a lower quality of life than controls with the lowest reported in those postponing voiding, as noted by the parents. However, the response given directly by the affected children was no different than that given by the control group. These findings support the complex nature of voiding disorders and may help to enlighten why some children respond poorly to traditional management. Self-esteem perceived by the parents to be poor for children with urinary incontinence in fact was not different between the study and control groups, indicating that the impact of incontinence may not be as great in children as perceived. The authors note that in addition to traditional therapy, the subset of children with urinary incontinence may require and benefit from intensive formal counseling.