Change of Urodynamic Pattern in Infants With Dilating Reflux
It has been reported that infants with high grade vesicoureteral reflux often have voiding dysfunction. However, more recently urodynamic studies have revealed similar characteristics such as low bladder capacity, dyscoordination of voiding and high pressure voiding in healthy infants. In a prospective, longitudinal, observation study of 114 infants with dilating vesicoureteral reflux (grades III to V) Sjöström et al (page 2446) from Gothenburg, Sweden videocystometry using a highly standardized protocol was performed at mean ages of 6, 20 and 40 months. Bladder capacity (and volume of refluxing urine) increased more than expected from normal for age (twice the expected median capacity at age 20 months in males and greater than normal at all 3 intervals in females). Post-void residual urine increased a median of 54 ml from ages 6 to 20 months. Voiding pressures did not change significantly in females during followup but were higher in males at infancy and then decreased at followup. Overactive bladder contractions during filling were noted in infancy with no difference between boys and girls, and the proportion of children with instability remained constant during followup. Electromyography activity during voiding was increased in infancy but decreased significantly (by 50%) by age 40 months.
At the 20-month examination dilated bladder dysfunction (defined as high bladder capacity, high residual urine with or without pronounced detrusor overactivity), high bladder capacity with incomplete bladder emptying or overactive bladder was documented in 42% of the patients, normal bladder function in 31% and uncertain bladder dysfunction characterized by either high capacity bladder or high residual urine but without pronounced detrusor overactivity in 27%. Recurrent urinary tract infection was the strongest predictor of all bladder dysfunction, whereas increased residual urine at the 6-month examination also predicted bladder dysfunction. For isolated overactive bladder, low bladder capacity at age 6 months was a significant predictor. The authors conclude that urodynamic patterns change between the first and second years of life in children with dilating vesicoureteral reflux from an immature pattern with high pressure voiding to a high capacity bladder with incomplete emptying.
Open Vs Laparoscopic Staged Fowler Stephens Orchiopexy
Many centers have adopted a 2-stage approach to the Fowler-Stephens technique for the management of intra-abdominal undescended testes. Dave et al (page 2435) from Toronto, Canada analyzed whether the presence of a long looping vas deferens (LLV) impacts the outcome of stage 2 when performed laparoscopically vs an open approach. Following an initial laparoscopic stage 1 testicular vessel ligation during which an LLV was noted, a stage 2 Fowler-Stephens orchiopexy was performed in 73 cases (laparoscopic 61, open 12). A scrotal position was achieved in all cases and mean postoperative followup was 13.5 months. Atrophy occurred in 5 of 6 testes (83%) with a LLV treated with the laparoscopic stage 2 procedure vs none treated with the open approach (p=0.03). Analyzing the laparoscopic cases alone, a LLV was significantly associated with the risk of atrophy (p <0.01). The authors conclude that, in addition to this increased risk, an open stage 2 procedure may be preferable in these cases as it allows for better preservation of the main deferential and collateral circulation.
Bladder Function After Urogenital Mobilization for Persistent Cloaca
Although surgical management of persistent cloaca has significantly improved using the technique of total urogenital sinus mobilization (TUM), there is a paucity of data regarding bladder function and associated urological outcomes for this rare anomaly. Matsui et al (page 2455) from Osaka, Japan describe their experience with 11 patients who underwent reconstruction of the cloaca using the TUM method. Postoperatively urinary and fecal continence was assessed by urodynamic studies in 7 patients older than 4 years. Urinary continence was achieved in 6 patients (3 voided spontaneously, 3 required intermittent catheterization), while 1 remained incontinent. The rate of continence was higher in patients with a short common channel (66.7%) compared with those who had a long common channel (25.7%). Urodynamic evaluation revealed detrusor overactivity during filling in 5 of the 7 patients. Bladder compliance was normal in 6 patients and all patients had normal bladder capacity. Detrusor overactivity was noted in 5 patients, and the continence rate was higher in those without it. The authors conclude that most patients with persistent cloaca can achieve urinary continence after TUM.
Polyorchidism
Due to the rarity of the condition, polyorchidism is an interesting but poorly characterized anomaly usually described in isolated case reports. Bergholz and Wenke (page 2422) from Hamburg, Germany report their findings from an exhaustive literature search and meta-analysis of 178 reports of polyorchidism including 191 cases. A new modification of an existing classification of polyorchidism was used to categorize the results. Of the supernumerary testes 65% were on the left side and 4% were bilateral, with the majority (66.4%) in the scrotal region (inguinal 22.9%, intra-abdominal 8.6%). Most of the evaluable reports described the location of the supernumerary testis as superior to the suspected “normal” testis. Histology consistent with age related testicular tissue and spermatogenesis was noted in 52% of the testes, reduced spermatogenesis in 10.7% and absent spermatogenesis in 25.7%. Malignant neoplasms were found in 8 of 140 (5.7%) supernumerary testes at a median patient age of 19 years, 7 of which were maldescended representing 9% of all inguinal and 25% of all intra-abdominal supernumerary testes. The authors conclude that management of the supernumerary testis should be predicated on whether it is attached to a vas deferens and the significantly increased risk of malignancy in the nonscrotal supernumerary testis.
FULL TEXT