This Month in Pediatric Urology

Article Outline

• Detrusor Compliance Changes After Bladder Neck Sling Without Augmentation
• Safety of Shock Wave Lithotripsy for Pediatric Urolithiasis
• Urinary Diversion in Childhood and Alcohol Abuse in Adulthood
• Implications of Ionizing Radiation in the Pediatric Urology Patient
• Is Suppression of the Hypothalamic-Pituitary-Adrenal Axis Significant During Clinical Treatment of Phimosis?
• Copyright

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Detrusor Compliance Changes After Bladder Neck Sling Without Augmentation 

Children with neurogenic bladder dysfunction and associated incontinence benefit from bladder neck sling without augmentation. Snodgrass et al (page 2361) from Dallas, Texas reassess the long-term outcome of a group of children to determine if further bladder deterioration occurs over time. They identified 39 consecutive children who had undergone a bladder neck sling without augmentation. Of the patients 13 were excluded from the final assessment for various reasons. Of the remaining 26 patients available for outcome assessment 16 were dry, 7 were improved and 3 were wet. Anticholinergic medication had been used preoperatively in 23 patients and was required postoperatively in all 26. No patient showed increased bladder pressure or new onset of overactive contractions at the last study (mean 39 months) that had not been present on the initial postoperative study. No patient had postoperative hydronephrosis, bladder trabeculation or vesicoureteral reflux. Acknowledging the limitations of the lack of long-term urodynamic findings in 13 patients, a universal definition of continence and difficulty in relating bladder compliance to clinical practice, the authors remain confident that this patient cohort has not suffered progressive bladder deterioration due to bladder neck sling without augmentation. They believe that the adverse changes noted at the time of the first postoperative urodynamic test can be managed with anticholinergic therapy. These findings continue to challenge dogma stating simultaneous augmentation cystoplasty is needed to improve continence and prevent upper tract deterioration when undertaking a bladder neck sling.

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Safety of Shock Wave Lithotripsy for Pediatric Urolithiasis 

Shock wave lithotripsy (SWL), while effective at breaking renal stones, has been recognized to cause proximal tubular dysfunction, cellular destruction and renal vascular injury. Small vessels in an immature kidney may be at greater long-term risk than those in an adult kidney. Recognizing these issues, Griffin et al (page 2332) from Paris, France evaluate the late effects of SWL in 182 children 9 months to 19.8 years old, treated from 1988 to 2008. Patients underwent 1 to 4 SWL sessions, and the average delivered shock per session was 3,000. Complications occurred in 2% of the patients, and included steinstrasse and pyelonephritis. A total of 94 children were stone-free on posttreatment dimercaptosuccinic acid renal scan (DMSA). Of these 94 patients 66 had normal renal function with no evidence of scarring on DMSA scans before and after SWL, 18 had decreased renal function of the affected kidney on DMSA scans before and after SWL, function of the treated kidney was transiently impaired in 2 and permanently impaired in 1, and improved function was noted on the postoperative DMSA scan in 7. No patient had hypertension after SWL. The authors conclude that SWL is an effective mode of treatment for renal calculi in children. While theoretically the pediatric kidney is at greater risk, their study supports that secondary damage and changes are reversible and most are resolved 6 months following treatment. The authors recommend long-term assessment of blood pressure. While the use of ureteroscopy and laser lithotripsy is gaining popularity, this report provides an important benchmark of outcome for SWL.

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Urinary Diversion in Childhood and Alcohol Abuse in Adulthood 

The need to conform to society, particularly the activities of one's peer group, is not limited because of a disability. Young adults with spina bifida encounter pressures similar to those of other teenagers, especially as it relates to alcohol consumption and drug abuse. Impairment from alcohol consumption has obvious ramifications. Fox and Husmann (page 2342) from Rochester, Minnesota show how this impairment can have a significant impact on patients who have undergone augmentation cystoplasty. They retrospectively identified a study group of 203 patients who consumed more than 2 alcoholic beverages a day and a control cohort. Study inclusion criteria were enterocystoplasty before age 16 years and followup at least through age 18 years. Of the 203 patients 24 (12%) had a history of alcohol abuse, including 5 (21%) with 10 bladder ruptures vs 5 of 179 (2.8%) with bladder ruptures in the control group. Of the 5 patients with alcohol related perforations 1 died and 1 required conversion to an ileal conduit. The 12% rate of enterocystoplasty and abused alcohol parallels the lifetime risk of alcohol abuse within the United States population, which underlines the importance of screening for alcohol, and educating patients and families on the potential dangers of alcohol consumption. It is presumed that the 12% rate likely underrepresents the true number of individuals who have undergone reconstructive surgery and drink consistently or have binge episodes. In addition to the obvious significance of bladder rupture, the authors discuss other significant effects related to alcohol abuse and augmentation. They conclude that alcohol abuse must be screened for and discussed at the time of bladder reconstruction and all subsequent patient visits. This information should be included in the medical record at the time of transitioning care from the pediatric to adult urologist.

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Implications of Ionizing Radiation in the Pediatric Urology Patient 

With significant advances in imaging we have a battery of studies available to assist with our diagnosis. However, 2 factors that should temper our enthusiasm for testing are the impact on health care dollars and, more importantly the impact on the health of the child. During the last few years radiology has pushed forth the ALARA (as low as reasonably achievable) philosophy to help guide our imaging decisions and reduce the exposure of unnecessary radiation. Stratton et al (page 2137) from Nashville, Tennessee review the impact of ionizing radiation on the pediatric urology patient. They performed a MEDLINE® search with emphasis on computerized tomography (CT), which revealed an 800% increase in the use of CT imaging since 1980. Although CT imaging represents only 5% of the imaging studies in the pediatric population, it provides greater than 40% of the radiation exposure. The authors describe various calculations regarding the relationship between CT radiation exposure and the potential for carcinogenesis in several pediatric age groups. For example, it has been predicted that 480 cancer related deaths will ultimately occur based on evaluation of all children younger than 15 years who have undergone either head or abdominal CT annually. Other studies equate a lifetime risk of death from cancer at 1% in a 5-year-old child who has undergone an abdominal CT, which compares to a 1 in 5,000 lifetime risk of an adult undergoing abdominal CT. While these calculations may be flawed due to the fact that exposure was calculated at adult levels, they reinforce the importance of critically assessing the need for the imaging study. The authors also review the risks of the voiding cystourethrogram, nuclear medicine applications, ultrasonography and magnetic resonance imaging. They conclude noting the importance the urologist has in the decision making process for imaging and the responsibility the urologist has to protect their patients. Several resources, including the “Image Gently” campaign by the Alliance for Radiation Safety in Pediatric Imaging, are provided that will enhance learning the effects of ionizing radiation. This is a must read review for anyone using imaging technology in the pediatric patient.

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Is Suppression of the Hypothalamic-Pituitary-Adrenal Axis Significant During Clinical Treatment of Phimosis? 

Corticosteroids for the treatment of phimosis have gained recent interest in the United States. While considered safe in children, there is little information related to absorption of the steroid and the effect on the hypothalamic-pituitary-adrenal (HPA) axis. Overexposure to glucocorticoids may cause Cushing's syndrome and suppression of the HPA axis. To determine the effect of glucocorticoids on the HPA axis when treating phimosis, Pileggi et al (page 2327) from Sao Paulo, Brazil evaluated 31 boys 2 to 13 years old who were given twice daily application of 0.05% clobetasol propionate. They assayed the cortisol levels in samples of saliva to assess the cortisol circadian rhythm and, therefore, any change in the HPA axis, and found no significant difference in the levels of cortisol at the beginning or end of sampling. Their results suggest that topical preputial application of clobetasol propionate does not affect the HPA axis as there is no significant absorption of the steroid. They recognize that a major limitation of the study is the variable amount of topical cream applied, which routinely occurs at home.