This Month in Pediatric Urology

Article Outline

• Meatotomy Using Local Anesthesia With and Without Penile Block
• Lower Urinary Tract Conditions of Children With Attention Deficit Hyperactivity Disorder
• Use of Stents During Pediatric Pyeloplasty
• Initial Pre-Scrotal Approach for Palpable Cryptorchid Testis
• Disorders of Sex Differentiation
• Copyright

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Meatotomy Using Local Anesthesia With and Without Penile Block 

Meatal stenosis is common after newborn circumcision. Although the effectiveness of office meatotomy has been reported, the office setting is not suitable for all young children due to patient and parental anxiety. Ben-Meir et al (page 654) from Petach Tikva, Israel performed a prospective randomized study evaluating meatotomy performed by a single urologist using local anesthesia with sedation (group 1), general anesthesia without a penile block (group 2) or general anesthesia with a penile block (group 3). Children younger than 5 years were sedated with midazolam and those older than 5 years were sedated with nitrous oxide. Local anesthesia was administered 1 hour before meatotomy using EMLA cream applied topically to the glans. Complications included bleeding in 2 patients in group 1 and 1 in group 3, and laryngospasm in 1 each in groups 2 and 3. Pain recorded at the time of discharge home was not significantly different among the groups. Improvement in the urinary stream and patient/parental satisfaction were similar in all groups. The authors conclude that conscious sedation when used in combination with EMLA cream provides an acceptable alternative to general anesthesia in the ambulatory setting.

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Lower Urinary Tract Conditions of Children With Attention Deficit Hyperactivity Disorder 

It is often appreciated that attention deficit hyperactivity disorder (ADHD) is a common co-existing factor in children evaluated for lower urinary tract dysfunction. However, objective evidence supporting that conclusion is somewhat limited. Burgu et al (page 663) from Ankara, Turkey compared 62 children with ADHD to 124 healthy controls. All parents completed a revised version of the Conners' Parent Ratings Scale (CPRS-R) for ADHD and a lower urinary tract symptom score (LUTSS) questionnaire. All children were given a 3-day diary to document voiding frequency, daytime urine output, incontinence and nocturnal enuresis, and bowel habits. Objective voiding patterns were evaluated in both groups with uroflowmetry and residual urine volume was documented by bladder scan.

LUTSS was significantly higher in the ADHD group than the control group. This included all subindices of LUTSS with the exception of constipation. Nonbell shaped uroflowmetry curves and residual urine volumes were significantly higher in children with ADHD. Abnormal voiding diaries were reported in 22% of children with ADHD vs 5% of the control group. There was a positive correlation between abnormal LUTSS and CPRS-R in the 6 to 10-year age group of children with ADHD. Boys with ADHD had a significantly higher association of nocturnal enuresis and constipation, and girls with ADHD had significantly higher urgency and holding maneuvers. Overall urgency positively correlated with ADHD up to age 13 years. When specifically evaluating nocturnal enuresis, correlation between LUTSS and CPRS-R was positive, particularly in the 13 to 17-year age group.

The authors note that symptoms scores should not replace a voiding diary, but they can provide a helpful structured quantitative assessment of lower urinary tract dysfunction. Their data support the need to evaluate children with ADHD for comorbid lower urinary tract dysfunction. More importantly a child presenting to a urology clinic with voiding dysfunction should be considered to possibly have coexisting ADHD, and a low threshold is reasonable for referring to the appropriate health care provider for evaluation, diagnosis and treatment.

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Use of Stents During Pediatric Pyeloplasty 

Outcomes assessment is an important aspect of any operative procedure. The goal is to identify a cost-effective technique that results in the greatest success with the least morbidity. Yiee and Baskin (page 673) from San Francisco, California report on a decision tree analysis tool that integrates small differences in outcomes and complications of pediatric pyeloplasty while accounting for a negative impact on emotional distress. They established a comparative model that included 3 branches related to the decision mode of the use of no stent, external stent or an internal stent to determine the cost per quality adjusted life-year of each technique. The authors found that external stents were superior to no stents and internal stents, and no stents were superior to internal stents. They then tried to improve the outcome of the use of the internal stent by decreasing its complication and failure rates with pyeloplasty repair. When decreasing the complication rate of internal stents to 0 and increasing the success rate of a pyeloplasty repair to 100%, an improved outcome could be achieved but it was at excessive cost of quality adjusted life-years. The practical interest of this exercise is that the authors show that what has often been considered a “minor” procedure for removal of internal stents results in significant expense and cost to the quality of adjusted life-years. While seemingly clinically insignificant, the authors conclude that this type of statistical analysis may become more relevant to health policy makers, particularly when making decisions on the most effective use of health care dollars in the United States.

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Initial Pre-Scrotal Approach for Palpable Cryptorchid Testis 

There is increasing interest in a single pre-scrotal incision for exposure and treatment of the undescended testicle which results in a high success rate, minimal morbidity and improved cosmesis. Patient selection is critical for the success of the single scrotal incision and often the palpable, immobile inguinal testis is excluded from assessment due to a presumed poor result. Yucel et al (page 669) from Antalya, Turkey performed a retrospective study of their experience treating all palpable undescended testes using a pre-scrotal inguinal approach regardless of the ability to mobilize the testicle into the scrotum. The study included 72 boys with 88 cryptorchid testes, 74 of which could be manipulated into the scrotum before operation and 14 were palpable but fixed. A pre-scrotal 2 cm semicircular incision was used for exposure and dissection of the testicle, identification of the external ring and high ligation of the patent processus vaginalis, allowing placement of the testicle into the scrotum. All 74 testicles that could be manipulated into the scrotum were successfully brought down through the single pre-scrotal incision. In contrast, only 6 (43%) of the 14 fixed testicles could be transferred effectively into the scrotum through the pre-scrotal approach and 8 (57%) required a secondary inguinal incision and further dissection. Overall, 80 of the 88 (91%) testes were brought down with a single incision. Operative times averaged 21 minutes for the pre-scrotal approach and 54 minutes for the inguinal approach. However, more time was spent attempting to bring the fixed testis down using the scrotal approach than may have been necessary had the testis first been approached by an inguinal incision. At followup there was no testicular atrophy, reascent, hydrocele or hernia. The results of this study support the presumption of others that the pre-scrotal approach is ideally suited for the testis that can be manipulated into the scrotum. The authors confirm that the majority of palpable, fixed testes will require an inguinal approach but still believe it is practical to try a pre-scrotal incision since they were able to bring 40% of fixed nonpalpable testes into the scrotum.

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Disorders of Sex Differentiation 

Any pediatric urologist who cares for a child with atypical genitalia must be familiar with the recommendations made by medical and lay experts in 2005 in what has been called the “Chicago Consensus.” In this review article Barthold (page 393) from Wilmington, Delaware has masterfully summarized the salient points and recommendations put forward by that group. She reviews the genesis of the “Chicago Consensus,” and details their rationale for changing our current terminology and viewpoints on assessment and treatment. She succinctly presents the updated taxonomy based on the primary disease process that reflects the content of the consensus group using specific nomenclature that does not establish or dictate a gender assignment or treatment. The impact of using new nomenclature such as disorder of sex differentiation is discussed along with the benefit and potential disadvantages of adopting this nomenclature. The importance of a multidisciplinary approach for evaluation, establishing gender assignment and treatment is a strong foundation of the “Chicago Consensus.” The timing and ramifications of gender assignment and potential effects on long-term gender dysphoria are reviewed in detail. The appreciation for psychosocial support for not only the child with a disorder of sex differentiation, but the family is critical. Finally the timing of genital surgery and the need for gonadectomy are discussed. While all recommendations of the “Chicago Consensus” may not align with the personal opinion of every pediatric urologist, awareness of the statements put forth by this group is prudent.