This Month in Pediatric Urology

Article Outline

• Female Sexual Function and Pregnancy After Genitourinary Reconstruction
• Transcutaneous Parasacral Electrical Stimulation for Overactive Bladder
• Algorithm for Hypospadias Reoperation
• Effectiveness of Doxazosin for Distal Ureteral Stones
• Copyright

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Female Sexual Function and Pregnancy After Genitourinary Reconstruction 

There is a void in our knowledge regarding the most appropriate management of pregnancy in women who have undergone urinary reconstruction. Recognizing this lack of knowledge, Thomas and Adams (page 2578) from Nashville, Tennessee provide a current review on what is known. The authors make the important point that current management and results are based on reconstructive measures undertaken years ago. Contemporary intervention may or may not have the same outcome as in the past before we knew the significance of the present management options. What is appreciated is that women who have undergone reconstruction wish to be sexually active and look forward to the opportunity of pregnancy.

The authors provide important information that can be used when obtaining informed consent before performing urinary reconstruction in girls and young women. They report that end stage renal failure occurs in 10% of women with preexisting renal insufficiency after reconstruction who become pregnant. Pregnancy may be diagnosed by measuring serum human chorionic gonadotropin due to a high level of false-positive indicators on the urinary pregnancy test. The authors describe the importance of identifying asymptomatic bacteriuria, and determine when treatment and prophylaxis should be considered. They highlight the options for delivery and discuss in-depth when cesarean section should be considered based on factors of augmentation, bladder neck reconstruction and pelvic anomalies that could preclude vaginal transport of the fetus. The unique considerations for those who have undergone reconstruction for bladder exstrophy, spina bifida and urogenital or cloacal anomalies are presented. To my knowledge this article is the most up-to-date resource for the management of pregnancy in women who have undergone urological reconstruction, serving as a guide to the care of this population.

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Transcutaneous Parasacral Electrical Stimulation for Overactive Bladder 

Treatment of the overactive bladder in children primarily centers on improvement of bowel and bladder habits, changes in diet and use of antimuscarinic medications. Direct electrical stimulation to improve voiding dysfunction is limited and has been reported with variable success. Lordelo et al (page 2900) from Bahia, Brazil present the short and long-term results for 36 girls and 13 boys treated with transcutaneous parasacral electrical stimulation to improve overactive bladder function. Therapy consisted of a short course of low frequency parasacral stimulation 3 times a week for 20 minutes. During treatment children complained only of a sensation of “pins and needles” in the sacral area. Initially urgency and incontinence were eliminated in 79% and 76% of the patients, respectively. Of the parents 51% reported 100% improvement and 12% reported 90% to 99% improvement. At 2 years after treatment improvement in daytime incontinence and urgency was maintained in 74% and 84% of patients, respectively. Urinary infections were initially reported in 67% of cases before treatment but recurred in only 6% within the 2-year followup. The authors conclude that transcutaneous parasacral electrical stimulation for the treatment of the overactive bladder appears to be well tolerated and effective. It will be interesting to see if these encouraging results hold true in other series and for the child refractory to traditional treatment.

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Algorithm for Hypospadias Reoperation 

Everyone appreciates the complexity of a primary hypospadias repair, and understands the importance of training and experience to achieve a successful result. As challenging as a primary repair can be, secondary surgery for complications are exceedingly more problematic. Reports assessing hypospadias surgery are often confounded by multiple techniques and multiple surgeons of varying expertise. A simple algorithm for treating hypospadias complications has been developed by Snodgrass et al (page 2885) from Dallas, Texas with assessment based on the results of a single experienced surgeon. The decision algorithm for repair is based on whether the urethral plate is maintained and unscarred tubularized incised plate (69 patients) or replaced with skin tissue without scarring (1-stage inlay of buccal tissue 16), or the presence of ventral scarring and chordee is greater than 30 degrees (2-stage buccal graft urethroplasty 48). The authors describe in detail the specific technique for each procedure, report the complications and discuss further operative intervention. Overall, complications occurred in 19% of tubularized incised plate procedures, 15% of 1-stage inlay buccal procedures and 38% of 2-stage buccal procedures. The authors objectively compare their data to other reports in the literature regarding reoperative procedures, highlight lessons learned during this study and recognize that longer followup may detect additional complications. This article provides important insight for anyone embarking on a reoperative hypospadias repair.

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Effectiveness of Doxazosin for Distal Ureteral Stones 

It has become common practice for an alpha antagonist or channel blocker to be used to promote spontaneous ureteral stone passage in adults, and similar practice in children is gaining enthusiasm. Aydogdu et al (page 2880) from Ankara, Turkey prospectively evaluated 39 patients 2 to 14 years old with a distal ureteral stone smaller than 10 mm who received no treatment (control group) or doxazosin. Doxazosin was selected primarily for its ease of dosing in children and the reported beneficial response in adults. After 3 weeks the stone had passed in 14 of 20 children (70%) in the control group, and 16 of 19 (84%) in the doxazosin group. The mean expulsion time was 6.1 and 5.9 days respectively for the control and Doxazosin group. The difference in stone passage and expulsion time was not statistically different between the groups. There appeared to be subjective benefit of less pain in those children treated with doxazosin but this was not specifically assessed by the authors.

The authors recognize the limitations of their study in regard to the fact that no placebo was given in the control group and the stone had to be smaller than 10 mm. It is possible that doxazosin would have had more of an effect on larger stones. In addition, the authors selected a starting dose of 0.03 mg/kg which may be low to achieve stone passage but they indicate that this dose is considered high in children. They discuss the difficulty of assessing dose range response in a study of such short duration but conclude by questioning doxazosin as an effective agent to enhance stone passage in children.