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Introduction We evaluated current practice patterns in the management and screening of cryptorchidism among pediatric urologists and compared them to the 2014 AUA (American Urological Association) guidelines on cryptorchidism. Methods A 14-question survey was disseminated to members of the SPU (Society for Pediatric Urology) to assess their current practice patterns. Results There were 187 responses (38.4% response rate) with a notable bimodal distribution in respondent practice years, with 39.3% in practice for 10 years or less and 41.4% in practice for more than 20 years. Despite guideline recommendations against the use of ultrasound, the majority of respondents will use it in cases of obesity or bilateral nonpalpable testes (greater than 50%). In the evaluation for bilateral nonpalpable testes most respondents (greater than 80%) perform an endocrine workup. Nevertheless, 55.1% will proceed with surgical exploration even if the workup indicates absence of testicular tissue. Subgroup analysis revealed those in practice for 10 years or less vs greater than 20 years were more likely to perform 2-stage Fowler-Stephens in cases of short vessels (80.8% vs 58.1%) and to perform transscrotal orchiopexy in cases amenable to that approach (79.5% vs 52%). If examination under anesthesia reveals the testicle in the scrotum, 46.5% still perform orchiopexy, citing concerns the testicle will ascend or parental concerns about the diagnosis. Conclusions Based on the responses some discordance exists between practice patterns and guideline recommendations. Although surgery may be avoided with endocrine evaluation for suspected anorchia, many respondents will still perform exploration. The evaluation, management and surgical approach in cryptorchidism may be influenced by years in practice.

Purpose Eosinophilic cystitis is a rarely seen condition in the pediatric population with indistinct symptomatology and non-standardized treatment protocols. We review our experience of treating patients with this condition. Materials and methods We retrospectively reviewed the records of four patients from a single institution who have been diagnosed and treated for eosinophilic cystitis. In addition, the literature was reviewed for cases of pediatric eosinophilic cystitis. Our patients were added and compared to this cohort. Results Our patients included 3 females and 1 male who range in age from 5 days to 18 years (5 days, 1 month, 7 years, 18 years). Both of the infants presented with a suprapubic mass and bilateral hydroureteronephrosis. The two older patients both had dysuria while the 18 yo also complained of fatigue, flank pain, and hematuria. Only 2 of the 4 patients were found to have significant peripheral eosinophilia and only one patient had eosinophiluria. All of the patients were diagnosed via cystourethroscopy with biopsy. Treatment in each case consisted of a combination of steroids, antihistamines, and antibiotics. Conclusions The presentation of eosinophilic cystitis is varied and diagnosis requires a high index of suspicion. Cystourethroscopy with biopsy is essential to establish the diagnosis as there is no typical appearance of the lesions or presenting signs/symptoms. Most cases of eosinophilic cystitis are responsive to medical therapy although in some cases recurrence may be noted.

To evaluate long-term urologic outcomes of patients with pelvic neuroblastoma (NB) presenting with urinary retention.Five cases of pelvic NB presenting with urinary retention were identified between 1971 and 2011. Clinical presentation, treatment, survival and long-term voiding outcomes were analyzed.All five patients presented with acute urinary retention and pelvic outlet dysfunction including bladder perforation (20%), constipation (40%), or fecal incontinence (20%). The presenting age ranged from 7 days to 4 years with female to male ratio of 3:2. Two patients presented with bilateral hydronephrosis and three patients were stage 4 at presentation. All required debulking surgery, four patients required combined anterior and posterior approaches for tumor resection, with two patients requiring concurrent laminectomy. Adjuvant or neoadjuvant chemoradiation was used in four of five cases. Follow-up ranged from 2 to 41 years. Although the long-term oncological outcome is favorable, urologic outcomes of these patients ranged from normal bladder function to the need significant reconstructive procedures.Urologic outcomes are related to pelvic nerve and organ preservation during resection more than the severity of urinary symptoms at presentation.

Ureteroscopy (URS) is considered a safe and effective treatment modality for ureteral stones in the pediatric population. Patients with scoliosis or spinal hardware, however, may have anatomic variability that makes URS challenging because of ureteral deviation or tortuosity. We reviewed 130 ureteroscopic procedures at our institution to determine if presence of spinal hardware or severe spinal deformities was associated with increased complications or worsened treatment efficacy.A retrospective chart review was performed on 130 ureteroscopic procedures in 102 patients. Patients were divided into two groups: Those with normal spinal anatomy and those with spinal abnormalities including spinal hardware or moderate to severe scoliosis. Parameters evaluated included patient demographics, stone burden, intraoperative complications (including urinary extravasation, bleeding, or need to abort procedure), and stone-free status.Of 130 ureteroscopic procedures between 2002 and 2010, 25 URS were performed for purposes other than stone disease (gross hematuria, filling defects, or encrusted ureteral stents). The remainder of URS (105) were performed for stone disease. Nine patients had spinal hardware or significant spinal deformities including moderate to severe scoliosis. When comparing both the intraoperative complications as well as stone-free status, there was a difference between those patients with spinal abnormalities and those without. Of 90 URS performed for stones in normal anatomy patients, the stone-free rate was 61%, compared with 35.7% in patients with spinal deformities. There were 13 total complications (Satava grade I or II): 40% in spinal deformity patients compared with 6.1% in normal anatomy patients.Spinal hardware and spinal deformities contribute to increased complications and worsened stone-free rates during pediatric URS compared with pediatric patients with normal anatomy. Our experience with URS in patients with spinal deformities suggests it may not be as safe or efficacious as in the general pediatric population but it can still be used as a primary modality.

Objective. Determination of fetal sex is an important part of detailed second-trimester ultrasonography. This task can be hindered by the fetal position, a low amniotic fluid volume, and advanced gestational age. Identification of fetal sex is further important in multiple gestations and prior histories of indeterminate-sex pregnancies. The goal of the study was to compare the effectiveness of 2-dimensional ultrasonography (2DUS) versus 3-dimensional ultrasonography (3DUS) at sex identification and to determine how genitalia measurements taken with 3DUS technology compare with measurements taken with 2DUS. Methods. A total of 111 patients at or beyond 16 weeks’ gestation were recruited. Assignments of fetal sex using 2DUS and 3DUS were compared by the test of proportions. The actual neonatal sex was obtained after delivery. Given such small number of misdiagnoses by either 2DUS or 3DUS, the accuracies of the two modalities were not found to be statistically distinguishable from one another (P = .5585). The penile length, scrotal width, and bilabial diameter according to gestational age were measured and compared with previously published 2DUS data by t tests. Results. Sexes were assigned and interpreted in 65 cases. Ranges of genitalia measurements were plotted against gestational age and were found to be comparable with published data. There was a dramatic difference between the bilabial diameter and scrotal width with advancing gestational age that made sex determination much easier in the third trimester. Conclusions. Although 3DUS did not have better prediction of fetal sex when compared with 2DUS, it may be a useful tool in conjunction with traditional imaging techniques in assigning fetal sex. Key words: ambiguous genitalia; fetus; genitalia; sex; ultrasonography.

Objective To evaluate the long-term outcomes of hypospadias repair using an onlay preputial graft. Patients and Methods Patient records from 1989 to 2013 were retrospectively reviewed. One surgeon performed all cases and surgical technique was the same for all patients. Results There were 62 patients in the cohort, with a mean (range) follow-up of 47.4 (1–185) months. The meatal location was separated into distal (one patient), midshaft (19) and proximal (42). In all, 22 (35.5%) patients had complications. There were three main types of complications, including meatal stenosis in three (4.8%), stricture in three (4.8%), and fistula in 21 (33.9%). The mean (range) timing of presentation with a complication after surgery was 24.9 (1–127) months. In all, 54.5% of the patients with complications presented at ≥1 year after the initial surgery and 31.8% presented at ≥3 years. On univariable analysis age at the time of surgery, length of the graft, presence of chordee or meatal location (proximal or midshaft) did not predict a complication. The width of the graft was associated with a complication, with each 1 mm increase in width decreasing the odds of a complication by 56%. On multivariable analysis width remained statistically significant (odds ratio 0.44, 95% confidence interval 0.230–0.840; P = 0.013) for predicting a complication. Conclusion Hypospadias repair with onlay preputial graft is an option for single-stage repair, especially in cases of proximal hypospadias or where the urethral plate width and/or the glanular groove is insufficient for other types of repair. Compared with flaps, the use of grafts may decrease the risk of penile torsion and prevent less bulk around the urethra, improving skin and glans closure.

This study sets to determine the optimal duration of behavioral urotherapy necessary to achieve maximal improvement in the management of pediatric bowel and bladder dysfunction.

Urinary tract polyps occur anywhere from the renal pelvis to the anterior urethra. Lower tract polyps occur less frequently than upper tract polyps and are a rare finding in children. Symptoms include obstruction, dysfunctional voiding, or hematuria. We report the case of a 17-year-old male who presented with persistent leakage of urine following voiding. Ultrasound demonstrated a small cystic lesion in the posterior aspect of the prostate and a voiding cystourethrogram was suggestive of a utricular cyst or polyp. He underwent a cystoscopy that demonstrated a large cystic structure originating from the verumontanum, nearly obstructing the prostatic urethra.

Idiopathic fibrosis of the retroperitoneum is rare in childhood. The authors describe an 11-year-old boy who presented with progressive renal failure, bilateral hydronephrosis, hypertension, and elevated erythrocyte sedimentation rate (ESR) owing to retroperitoneal fibrosis. Ureterolysis was performed with improvement in his creatinine level and blood pressure. The soft tissue mass consisted of dense collagenous fibers consistent with retroperitoneal fibrosis. Postoperatively, he received steroids and azathioprine. Retroperitoneal fibrosis in the pediatric population is rare with only 23 cases reported in the English-language literature. Treatment includes pulsed steroid regimens, ureteral catheterization, and retroperitoneal exploration with ureterolysis. If allowed to progress, renal failure can result and lead to death. The etiology of retroperitoneal fibrosis in the pediatric patient may include autoimmune diseases, infection, and neoplasm, but most cases are idiopathic. Retroperitoneal fibrosis should be considered in patients with an elevated ESR, hypertension, renal failure, and hydronephrosis. Evaluation also should include a search for autoimmune diseases and malignancy.

We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis.Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent.A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter.HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.

Purpose: Inpatient stays of 3 to 5 days are common in the surgical management of vesicoureteral reflux and often include the use of bladder catheters, ureteral stents and perivesical drains. We reviewed our recent experience, in which patients undergoing routine ureteroneocystostomy were often discharged home on postoperative day 1 to determine the safety and efficacy of our management.Materials and Methods: Between July 1998 and March 2001 patients who underwent intravesical ureteroneocystostomy at 2 major tertiary care institutions were identified. Patients who also underwent simultaneous additional operative procedures, bilateral ureteral duplication or ureteral tapering were excluded from study. Data recorded included patient demographics, the procedure, operative and postoperative pain, nausea and bladder spasm management, hospital stay, post-hospital discharge problems and operative success.Results: Of the 113 patients with complete data available for analysis 101 received ketorolac postoperatively,...

Objectives. To report the largest series of pelvic fracture and lower genitourinary tract injury in the pediatric population to further define its incidence. The association between pelvic fractures and lower genitourinary tract injury has been well recognized in the adult population. The incidence of bladder or urethral injury is approximately 10% to 15%. Previous limited pediatric reviews placed its incidence at slightly lower levels. Methods. A retrospective review of 8021 trauma patients presenting between July 1992 and March 1999 to a pediatric trauma center included 212 consecutive patients with pelvic fractures. These records were reviewed to determine the incidence of genitourinary injury in children with pelvic fractures. Thirty-six patients were identified with a genitourinary injury, and their records were analyzed. Results. Thirty-six patients (17%) were identified to have sustained a genitourinary injury out of the study cohort of 212 patients with pelvic fractures when patients with isolated hematuria were included. Hematuria was noted in 30 patients (14.2%). Fourteen (6.6%) had gross hematuria. Only 2 (0.9%) of the 212 patients had a significant lower urinary tract injury (one extraperitoneal bladder rupture and one posterior urethral disruption); both had gross hematuria. Genital injuries were seen in 4 other patients (1.9%). Lower genitourinary injury occurred in a total of 6 (2.8%) of the 212 patients with pelvic fractures. Conclusions. The incidence of significant lower genitourinary injury in pediatric patients with pelvic fractures is lower than that reported in previous adult and pediatric reviews. Significant lower genitourinary injuries were not found in stable patients without gross hematuria or multiple associated injuries and with a normal genitourinary examination.

Background: Bladder reconstruction in the pediatric population is challenging for many reasons, including perioperative complications and readmissions. Objectives: On a national scale, determine readmission rates at 30, 60 and 90 days after bladder reconstruction in a pediatric population over a 7-year period, evaluating the influence of hospital and patient-specific variables. Patients and Methods: Using the Pediatric Health Information System database, we identified patients 0-17 years of age, from 2004-2010, undergoing bladder reconstruction using ICD-9 procedure codes. Descriptive statistics characterized demographics, prevalence of surgeries, and readmission rates. Surgery prevalence over time was examined using linear regression. Readmission rates were compared using the Chi2 test. Regression was used to evaluate the influence of variables on readmission risk. Results: We identified 1,985 patients for inclusion, of which 52.7% were female. Median age was 9 years. There has been no change in the prevalence of bladder reconstruction surgeries (P = 0.327). There was no change in 30-day (P = 0.272), 60-day (P = 0.788) or 90-day readmission rates (P = 0.924). Despite surgical volume adjustment, 90-day readmission rates did not significantly vary among the majority of hospitals. Initial LOS > 7 days (P < 0.001) and complex chronic condition males (P < 0.001) were significantly associated with 90-day readmission. Conclusions: No improvement in readmission rates after pediatric bladder reconstruction was observed during the study period. Nearly all centers have a similar readmission rate despite volume adjustment.

Summary Introduction The surgical management of ureteroceles is extremely variable. Some have hypothesized that if these patients were treated with ‘definitive’ staged surgical intervention, the need for further revision surgery would be eliminated. Objective The present study sought to determine if the rate of revision surgery differed among patients who have undergone different surgical approaches for the ureterocele complex. Study Design A large retrospective chart review was conducted, identifying all patients having undergone ureterocele surgery at a single institution over the past 41 years. The cohort was divided into four groups based on surgical approach: upper tract approach (UTA), lower tract reconstruction (LTR), simultaneous upper and lower tract approach (ULTA), and staged lower tract reconstruction (SLTR). Demographics, the presence of preoperative/postoperative VUR, postoperative morbidity and the need for revision surgery were compared using the Chi- squared test, Fisher’s exact test, Kruskal-Wallis test, Mann-Whitney U test (Bonferroni correction), logistic regression modeling and survival analyses (Kaplan-Meier and Cox proportional Hazards regression with unplanned revision operation as the outcome event). Results Between 1969 and 2010, 180 patients were identified as having undergone surgical management of ureteroceles, of which 120 had complete demographic data available for analysis. The median age at the time of initial surgical intervention was 5.8 months and the majority of patients (83.3%) were female. The median follow-up was 33.1 months. Surgical management was as follows: 18 (15.0%) patients underwent UTA, 47 (39.2%) underwent LTR, 23 (19.2%) underwent ULTA, and 32 (26.6%) underwent SLTR. Among these groups, the only difference in median age was between the LTR and SLTR groups (6.3 months vs 3.7 months, P=0.012). Additional revision surgery was required in: nine (50.0%) of UTA, ten (21.3%) of LTR, four (17.4%) of ULTA, and three (9.4%) of SLTR. The only statistically significant difference in unplanned revision surgery was noted in the UTA group versus each of the other groups with VUR as the predominant indication (88.9%). The likelihood of requiring revision surgery in comparison to the SLTR group was significantly increased in the UTA group (OR 9.67, CI 2.15-43.56), but not in the LTR (OR 2.61, CI 0.66-10.37) or the ULTA group (OR 2.04, CI 0.41-10.13). Obstruction, recurring UTIs and VUR were the main indications for revision surgery overall. Table . Demographics, Interventions, and Revisions. Upper/lower tract (ULTA) (N = 23) Lower tract (LTA) (N = 47) Upper tract (UTA) (N = 18) Staged (SLTR) (N = 32) p-value Median age (IQR), months 5 (2.6–25.8) 6.3 (3.8–16.4) 5.6 (1.3–10.3) 3.7 (1.2–8.1) 0.025 Age group 0.733 12 (52.2%) 22 (46.8%) 10 (55.6%) 19 (59.4%) ≥6 months 11 (47.8%) 25 (53.2%) 8 (44.4%) 13 (40.6%) Female 18 (78.3%) 39 (83%) 13 (72.2%) 30 (93.8%) 0.210 Side 0.235 Left 14 (60.9%) 26 (55.3%) 8 (44.4%) 12 (37.5%) Right 9 (39.1%) 20 (42.6%) 10 (55.6%) 17 (53.1%) Bilateral 0 1 (2.1%) 0 3 (9.4%) Lower tract surgery None 0 0 18 (100%) 0 Marsupialization 17 (73.9%) 35 (77.8%) 0 1 (3.1%) Ureterectomy 4 (17.4%) 8 (17.8%) 0 0 TUI/Incision 1 (4.3%) 1 (2.2%) 0 28 (87.5%) Other 1 (4.3%) 1 (2.2%) 0 3 (9.4%) Upper tract surgery None 0 47 (100%) 0 32 (100%) Heminephrectomy 23 (100%) 0 18 (100%) 0 Revision required 4 (17.4%) 10 (21.3%) 9 (50%) 3 (9.4%) 0.009 1 Revision 2 (8.7%) 7 (14.9%) 8 (44.4%) 2 (6.3%) 2 or greater revisions 2 (8.7%) 3 (6.4%) 1 (5.6%) 1 (3.1%) Discussion There is a large body of literature examining the surgical management of ureteroceles. It most recently primarily focuses on an endoscopic approach to the lower tract. The present retrospective review examined the need for re-operative intervention by comparing four different surgical approaches, and found that there is no panacea. Although heminephrectomy (UTA) was a definitive procedure in some patients without reflux at presentation, many who underwent heminephrectomy, went on to require later bladder surgery for either recurrent UTI or persistent reflux. The present study has multiple limitations. Although VUR was an indication for revision surgery in the early part of the series, the current treatment of VUR is not necessarily as stringent. In addition, no distinction was made between an orthotopic or ectopic ureterocele, although some authors have reported differing outcomes in these two groups. However, it is felt that given the large data set of a relatively uncommon condition, the lack of superiority of one approach is apparent. Conclusion There is no definitive surgical repair for the ureterocele complex. All groups except UTA had statistically similar rates of revision surgery. The widespread variability in current management echoes the lack of one superior approach found in this comprehensive series.

The incidence of intersex states has been reported to be 27% to 100% in patients with hypospadias and cryptorchidism, and routinely determining karyotypes has been recommended. This incidence seems much higher than in our experience. We reviewed the records of patients with hypospadias and/or chordee plus cryptorchidism as well as those referred with ambiguous genitalia to determine whether these findings were associated with a high incidence of chromosomal abnormalities and whether they warrant routine karyotype screening.We reviewed the records of patients with undescended testis plus hypospadias and/or chordee, and those with ambiguous genitalia who presented between 1986 and 1999. Patients without karyotype determination, and those with iatrogenic cryptorchidism, retractile testes, congenital adrenal hyperplasia or female-appearing external genitalia were excluded from study. Meatus and testis locations at surgery, and associated Müllerian structures and medical conditions were documented. Fisher's exact test was done to determine statistical significance.Of the 113 patients whose records matched study inclusion criteria only 48 had complete anatomical, karyotypic, pathological and radiographic information available. Eight patients (16.7%) had chromosomal abnormalities, including 2 (4.2%) with karyotypic intersex disorder and 6 (12.5%) with autosomal chromosomal abnormalities. There were persistent Müllerian structures in 2 patients (4.2%) with a normal 46 XY karyotype. As described by a staff pediatric urologist, 20 patients (41.7%) had ambiguous genitalia and 8 of the 48 (16.7%) had nonpalpable cryptorchidism. Ambiguous genitalia were associated with chromosomal abnormalities, in 4 of the 20 cases, including 2 karyotypic intersex cases. Only 3 patients with ambiguous genitalia had nonpalpable gonads and 1 with karyotypic intersex disorder had a nonpalpable gonad that involved the testicular elements only. The incidence of autosomal chromosomal abnormalities was not significant (2-tailed Fisher's exact test p==0.05) and the incidence of karyotypic (autosomal or sex) abnormalities was not significant compared with hypospadias (p = 0.3), genital ambiguity (p = 0.7) or cryptorchidism (p = 0.69), including nonpalpable testis (p = 1). When patients had karyotypic abnormalities, they were more likely to have proximal hypospadias (57.2%), palpable cryptorchidism (62.5%) and ambiguous genitalia (50%).Most patients who present for the evaluation of hypospadias, chordee and undescended testis have a normal karyotype. Routine karyotype investigation of all patients with hypospadias, chordee and cryptorchidism does not seem warranted. If karyotypic intersex abnormalities are identified, those patients are more likely to have ambiguous genitalia, especially those with perineal hypospadias and cryptorchidism.

Purpose: We analyzed the complication rate in patients who underwent proximal hypospadias repair using preputial skin as a flap or free graft. Materials and Methods: We retrospectively reviewed the records of 142 patients who underwent proximal hypospadias repair. Repairs were subdivided into tubed and onlay repairs within the flap and free graft groups. We analyzed postoperative complications, including fistulas, proximal strictures, diverticula and meatal stenosis. Results: Median patient age at followup was 11.3 months and median followup was 9.4 months. Two-thirds of the repairs were performed with free grafts. A proximal stricture developed in 8 and 0 patients who underwent free tubed graft and free onlay repair, respectively (p = 0.047). Otherwise there was no significant difference in the complication rate of the various types of repair. Of the 43 patients who had stricture, fistula or meatal stenosis 29 (67%) presented more than 1 year after surgery. Conclusions: In repairs performed with free grafts there is a significantly higher proximal stricture rate when a tube rather than an onlay is used. Otherwise we noted no significant difference in the complication rates of flaps and grafts used to repair proximal hypospadias. A significant number of complications presented more than 1 year postoperatively and they may even present as late as 4 years. This finding suggests that longer followup may be necessary to assess completely the outcome of proximal hypospadias surgery.

Perinatal testicular torsion is an infrequent event, the management of which has been controversial. Occurrence is rare, estimated at 1 in 7500 newborns (Kaplan, G. W., Silber, I.: Neonatal torsion--to pex or not? In: Urologic surgery in neonates and young infants. Edited by King, L.R. Philadelphia: W.B. Saunders Co., 1988; Chapter 20, pp. 386-395). The frequency of bilateral perinatal torsion is up to 22% (J Urol. 2005;174:1579). Here, we describe two cases of bilateral asynchronous perinatal torsion, in which the only presenting abnormality on exam after birth was a unilateral scrotal mass. These cases illustrate that contralateral perinatal torsion may be present even when physical exam findings suggest unilateral involvement.

Purpose: The use of refined microscopic urinalysis for the presence of dysmorphic red blood cells (RBCs) has been evaluated in children and adults with a known source of hematuria. We examined the clinical usefulness of this study in a pediatric population with an unknown source of hematuria.Materials and Methods: Children 12 years old or younger referred for evaluation of asymptomatic microscopic hematuria exhibiting 4 or more RBCs per high power field were enrolled in this study. Patients provided a first morning urine sample subjected to refined urinalysis for RBC morphology. Standard evaluation of patients was performed until a final diagnosis of the hematuria source was identified.Results: A total of 44 patients completed the study. Refined urinalysis revealed pure dysmorphic RBCs in 22 patients, pure isomorphic RBCs in 8 and mixed isomorphic/dysmorphic RBCs in 14. The presence of dysmorphic RBCs correctly predicted a glomerulotubular source of hematuria in 29 of 36 patients (sensitivity 83%,...

Though the reported frequency of infant hydrocele has varied, the frequency of hydrocele in the fetus has not been studied. Our purpose was to determine the frequency of fetal hydrocele in the third trimester and subsequent outcome. Of the 123 fetuses studied, 19 fetuses had hydroceles. Of these, 14 babies were normal at follow-up, one baby had a persistent hydrocele, and four babies were lost to follow-up. Our study suggests that hydrocele is a relatively common finding in the third trimester in utero. Moreover, it suggests that parents can be reassured that, in the absence of other abnormalities, a hydrocele is usually a physiologic finding which resolves spontaneously.

Chronic penile swelling in prepubertal boys is an uncommon problem. The differential diagnosis includes primary and secondary lymphedema, trauma, previous penile surgery, and extraintestinal metastatic Crohn's disease. We report a 6-year-old boy who presented with persistent penile edema as an extraintestinal manifestation of Crohn's disease. In this case, the penile edema preceded the overt bowel symptoms associated with Crohn's disease, and a high index of suspicion led to the underlying diagnosis. Few previous reports have reviewed the different treatment options and their associated outcomes for Crohn's disease in prepubertal boys with genital edema.

A literature search was made through PubMed from 1990 to the present for articles on strictures in children. There were 32 articles that provided the data for this review. The studies were rated according to the level of evidence and the grade of recommendation using the International Consultations in Urologic Disease standards.

An animal study was performed to evaluate the effect of posterior sagittal pararectal mobilization on anorectal sphincter function.We initially divided 11 juvenile pigs into 3 groups: group 1-anesthesia alone (3), group 2-posterior sagittal incision alone (4) and group 3-posterior sagittal incision with unilateral pararectal dissection (4). Two animals in group 1 subsequently underwent posterior sagittal incision with circumferential pararectal dissection (group 4). The anal canal was preserved intact in all animals. Anorectal sphincter manometry was performed preoperatively, and 2, 4, 8 and 12 weeks postoperatively. Electromyography was performed 12 weeks postoperatively. Anorectal sphincter muscle complexes were harvested for histological examination.All animals had postoperative bowel continence. Postoperatively manometry revealed no difference from preoperative measurements in all study groups (p = 0.90). Electromyography and histological examination of the anorectal sphincters were normal in all but 2 animals. Denervation injury and histological atrophy were detected after repair of inadvertent enterotomy in 1 animal following unilateral pararectal dissection, and polyphasic motor unit potentials implying reinnervation were detected in another after circumferential pararectal mobilization.These results indicate that posterior sagittal incision and unilateral pararectal mobilization cause no permanent injury to the anorectal sphincter. However circumferential pararectal dissection or repair of a rectal injury may cause measurable changes in sphincter function.

Extracorporeal membrane oxygenation (ECMO) is an effective treatment modality for the newborn with refractory hypoxemia. Oligohydramnios can be associated with congenital renal disease (CRD) and can result in respiratory insufficiency from pulmonary hypoplasia, delayed lung maturation, and persistent pulmonary hypertension of the newborn. In this retrospective study, the authors reviewed the outcome of four children with CRD who required ECMO in the neonatal period. Between October 1987 and December 1995, ECMO was used in four newborns with CRD and pulmonary hypoplasia unresponsive to maximal medical management. The causes of CRD were urinary obstruction (2), renal dysplasia (1), and vesicoureteral reflux (1). Neonatal survivors of ECMO with CRD had regular follow-up with a nephrologist, urologist, and pediatrician. Developmental history, assessment of renal function, and a nutritional evaluation were recorded on each visit. The follow-up period ranged from 6 months to 5 years. All patients with CRD were successfully weaned from ECMO. One child died, at 1 month of age, because of renal failure. The estimated glomerular filtration rates in the three survivors were 20, 24, and 60 mL/min/1.73 m2. Growth and development have been delayed in two patients. Based on the author's experience, ECMO may improve the survival of neonates with pulmonary hypoplasia and CRD. Factors associated with successful long-term outcome include (1) renal disease amenable to surgical correction, (2) aggressive nutritional support, and (3) a reliable social support system.

We report on 226 male patients with cryptorchidism 6 months to 16 years old who underwent open testis biopsy at orchiopexy or orchiectomy at Children's Hospital and Health Center from 1986 to 1990. A total of 355 specimens was obtained. Tissues were preserved in Bouin's solution and examined on light microscopy for fertility index measurements. Several biopsies prepared using Bouin's preserved paraffinized tissue and glutaraldehyde preserved semi-thin cut tissue were found to have comparable fertility index measurements. Of 184 patients with unilateral undescended testes 87 also underwent biopsy on the contralateral descended testis. A total of 42 patients had bilateral undescended testes. Age matched comparisons were made between fertility index measurements of the undescended testes and those previously reported of normal testes. Additional case matched comparisons of fertility indexes were made in those children who underwent biopsy of the undescended testis and its descended mate. Statistical ...

Trauma is the leading cause of death in children in the United States, and blunt trauma is responsible in most cases. The kidney is the urogenital organ most frequently injured. Renal injuries are classified on a scale of I to V. Only grades IV and V injuries need operative intervention. CT is the preferred diagnostic imaging modality in most instances. Cystography and urethrography are necessary to diagnose bladder and ureteral injuries. Genital injuries sometimes are produced by sexual abuse, and the clinician must be alert to this possibility.

Many imaging modalities are available to study children with urologic disorders. Ultrasonography, renal scintigraphy, and voiding cystourethrography are best for study of patients with infection and antenatal hydronephrosis; intravenous urography, for hematuria and wetting; ultrasonography and CT, for tumor; and CT, for trauma.

This article includes facts and figures useful in the management of pediatric urologic patients. A formulary of commonly used drugs as well as modified doses for use in renal insufficiency is provided. In addition, data on bowel preparations, vital signs, hypertension, creatinine clearance, Tanner stages, and stretched penile length are provided.

The investigation of hematuria in children should never be allowed to pose a greater risk to the child's health than does the problem itself. For this reason, angiography and cystoscopy are rarely employed in the evaluation. The evaluation of the child should proceed methodically and rest firmly on a well-taken history and results of physical examination. The microscopic examination of the urinary sediment is the cornerstone of the evaluation process and can itself suggest the origin of the hematuria. Red cell casts, if present, indicate glomerulonephritis and obviate further urologic evaluation. Genitourinary imaging should be tailored to each clinical situation.

The review is an attempt to present the current literature regarding strictures in children to provide an evidence-based recommendation regarding diagnosis and treatment.The level of evidence upon which to base therapy of strictures in children is low and consists mostly of case series from single institutions. Hence most of the information is extrapolated from the adult literature. A consensus committee of the Societe Internationale d'Urologie reviewed the literature, and the committee report (which is as yet unpublished) provides the basis for most of the information herein.Because there is relatively little information published on this subject, there is a need for prospective studies and multi-institutional series. Additionally, there is a need for basic studies of urethral wound healing to provide a better understanding of the problem.

omiasis comprises a group of chronic dised by blood flukes. Three species of schisre clinically important: Schistosoma man~onicum, and S. haematobium. S. mansoni )nicum colonize the portal circulation and estinal schistosomiasis. S. haematobium the veins of the bladder and distal ureter :s urinary schistosomiasis (bilharziasis). 1 estimated that 200 to 300 million people :d with schistosomiasis worldwide. Eighty lion people are infected by S. haemato: vast majority of these cases are found in Memic regions, s. haematobium is found through~t the African continent, including the islands of i~dagascar and Mauritius. In southwest Asia, it is ~nd in Yemen, Saudi Arabia, Lebanon, Syria, rkey, Iraq, and Iran. ~ S. haematobium is not transited in the United States because the appropriate itermediate host snail necessary for asexual repro~ tion of the parasite is absent. However, the ret increase in immigrant populations from enicrnic countries has introduced into the United ;ates a population of patients infected with S. iematobium Urologists in the United States are !~reasingt_y diagnosing and treating patients with :rtnary schistosomiasis. Between December 1991 ndJanuary 1994 we have diagnosed and treated 7 Nldren with schistosomiasis at Children's Hospital !d Health Center, San Diego. The age at presenta!~n was 6 to 12 years of age. All patients presented !th a his tory of gross hematur ia . Urinalysis bowed 15 to 20 red blood cells (RBC) per high~ower field in all patients and ova with, terminal ipines in all but 1 patient (Fig. 1). This patient reiuired a. bladder biopsy to detect ova (Fig. 2). U1~sonography demonstrated bladder wall thicken}ng (Fig. 3) in 5 c h i l d r e n and mi ld r igh t hydronephrosis in 1 child. All patients were treated :~th praziquante140 mg/kg and showed resolution "fhematuria and absence of ova from their urine at { month follow-up. The main focus of this review NIl be on S. haematobium infection in childhood. HISTORY Schistosomiasis is one of the oldest known diseases. Calcified S. haematobium ova have been discovered in Egyptian mummies from the 20th dynasty, 1200 to 1090 BC. Many of Napoleon's troops, "the menstruating men," during the Egyptian invasion are believed to have been infected with S. haematobium. In 1851, Theodore Bilharz first identified S. haematobium as the agent responsible for Egyptian endemic hematuria. In 1921 Cristol described the cystoscopic findings of schistosomiasis. McDonough introduced the first effective chemotherapy, tartar emetic (antimony potassium tartrate) in 1918. 2,3 Recent advances in the control and treatment of schistosomiasis have been based on a better understanding of the life cycle of S. haematobium.

We have adopted an approach to the management of myelodysplasia patients which is contrary to that most commonly supported by the existing literature. We screen patients shortly after birth with ultrasound, urine culture and serum creatinine, and then follow patients at 3 to 6-month intervals with similar studies. Cystography and urodynamics are done only as required clinically or by a change in the sonogram. Clean intermittent catheterization is indicated for continence or medical reasons. With this approach of aggressive observation and prompt intervention, we observed a rate of renal deterioration (diminished function on renal scan or parenchymal loss on imaging studies) of 5%. Renal deterioration was associated statistically with urinary tract infections and reflux. Patients started on clean intermittent catheterization for medical indications had greater risk for renal deterioration than those started on it for continence. Renal deterioration occurred with equal frequency between patients with abnormal and normal urodynamic studies, that is urodynamics did not predict renal deterioration. Our data show a rate of renal deterioration similar to other reports. We believe that aggressive observation with prompt intervention for problems once identified represents a reasonable alternative to managing patients with myelodysplasia.

Objective. Based on a number of studies involving animals as well as human case reports indicating an association between prenatal ethanol exposure and renal malformations, it has been suggested that children with fetal alcohol syndrome (FAS) should be screened for renal anomalies. The purpose of this study was to evaluate a group of children prenatally exposed to alcohol to determine the incidence of renal anomalies and to evaluate the need for such a screening procedure. Methods. Renal ultrasounds were performed on a total of 84 patients (68 children, 13 adolescents, and three adults). In addition to screening for malformations, renal size was studied. Data were analyzed using both chronologic and height-age as determinants of kidney size. Patients. Of these 84 patients, 51 (61%) had FAS, and 33 (39%) had a history of prenatal ethanol exposure but did not have FAS. Results. Three (3.6%) patients (one with FAS, two with prenatal ethanol exposure who did not have FAS) had significant renal abnormalities. This incidence was not significantly different from that found in ultrasound screening of newborns. The kidneys of children with both FAS and prenatal ethanol exposure who did not have FAS were significantly smaller than normal for both chronologic and height-age. When children were compared across chronologic ages, those with FAS had significantly smaller kidneys than those who had no evidence of FAS. After adjusting for height, the difference between these two groups was no longer significant. Conclusions. Based on these data, children prenatally exposed to ethanol do not need to be screened for renal anomalies.

Purpose: Children with a solitary testis or kidney are generally advised against contact team sport participation to protect the solitary organ. We performed a review of renal and testis injury cases to ascertain if there was an increased likelihood of significant renal or testis injury in team sports.Materials and Methods: We retrospectively reviewed charts on patients evaluated and/or admitted to the trauma service with renal or testis injuries. Severity, outcome and external cause of injury were evaluated as well as patient demographics. Patients were excluded from study if there was no radiographic or physical (postmortem or surgical) evidence of injury. Trauma admission/registry data from all patients enrolled were used for comparison.Results: Of 14,763 patients enrolled in the trauma registry from July 1984 until December 2000, 450 (3%) were given a renal or testis injury diagnosis by the registry but only 209 patients (1.4%) met the review criteria for documentation of injury. There were 19...

Purpose: Congenital genitourinary tract anomalies occur commonly in the general population. Anomalous kidneys are thought to be more frequently injured by trauma than normal kidneys. We reviewed patients with renal injuries to determine the etiology, severity, associated injuries and associated congenital genitourinary abnormalities.Materials and Methods: A retrospective review of renal injuries was performed on patients evaluated and/or admitted to the trauma service. Severity, outcome, external cause of injury and patient demographics were evaluated. Patients were excluded from study if there was no radiographic or physical (postmortem or surgical) evidence of injury. Findings on urinalysis alone did not confirm a renal injury without other evidence. Trauma registry data from all enrolled patients were used for comparison.Results: A total of 14,763 patients were enrolled in the trauma registry from July 1984 to December 2000, of whom 384 (2.6%) were given a diagnosis of renal injury but only 193...

Objectives (1) Determine the number of urologic conditions diagnosed by computed tomography (CT) in children in the emergency department setting. (2) Identify which diagnoses were incidental. (3) Determine how often there was urologic follow-up by a local pediatric urologist. Patients and methods We reviewed the charts and radiologist interpretations of all CT scans of the abdomen and pelvis performed within 2 days of admission via our emergency department from July 2007 to June 2009. Patients were included if the diagnosis was new. If a urologic finding was noted on final read, the CT was re-examined by one of our urologists to verify the finding. Results Among 2991 CT scans (one CT scan per patient), there were 213 (7%) new urologic findings: 124 were incidental; 144 patients (68% of patients with urologic findings) did not receive follow-up. Renal abnormalities were present in 127. The most common finding was renal cyst (69 patients). Ureteral abnormalities were present in 47. The most common ureteral finding was hydroureteronephrosis (40). Other anomalies identified included bladder (7) and scrotal (14) abnormalities, stones (13), and adrenal lesions (5). Conclusion Many urologic diagnoses are revealed during CT scans of the abdomen and pelvis. The majority are cysts, hydroureteronephrosis, and pyelonephritis. Many incidental findings have also been revealed in the emergency department setting.

Gonadal stromal tumors generally are benign and hormonally silent. When hormonally active, they may cause either virilization or feminization, posing an endocrine threat to the prepubertal boy. Accurate diagnosis is essential to differentiate those tumors that require medical management from those best treated by surgical ablation and to distinguish the benign ones from the malignant. Leukemic infiltration is the most common secondary testis tumor; others are neuroblastoma, Wilms' tumor, and gonadoblastoma.

Ureteroneocystostomy after dextranomer/hyaluronic acid injection is reportedly associated with significantly more morbidity, and increased operative time, length of stay and postoperative obstruction. To evaluate our experience, we reviewed results of patients who underwent salvage ureteral reimplantation following failed dextranomer/hyaluronic acid injection.We retrospectively reviewed charts of patients at a single institution who underwent intravesical ureteral reimplantation as salvage treatment following failed dextranomer/hyaluronic acid injection. Data points such as operative time, blood loss and length of stay were compared to those of controls undergoing de novo reimplantation by the same surgeons. Statistical analysis was performed using Student's t test and chi-square test.We identified 18 patients who underwent salvage reimplant. We compared data to an equal number of controls. Mean age (4.28 years in patients vs 3.34 years in controls, p = 0.62) and mean reflux grade at reimplant (3.15 vs 3.40, p = 0.97) were comparable between the groups. Operative time (128 vs 141.9 minutes, p = 0.14), blood loss (12.9 vs 11.9 ml, p = 0.71) and length of hospital stay (1.68 vs 1.3 days, p = 0.25) were not significantly different. No statistically significant differences were found regarding any of the compared variables.Ureteral reimplantation after dextranomer/hyaluronic acid injection is no more difficult than primary ureteral reimplantation regarding operative time, blood loss and length of hospital stay. These results support dextranomer/hyaluronic acid as initial operative treatment of vesicoureteral reflux when deemed appropriate and may further shift the paradigm of treatment away from prolonged medical management.

Introduction We provide a single-institution comparison of open, conventional laparoscopic (CL) and laparoendoscopic single-site (LESS) nephrectomy in children. Methods We identified all nephrectomy cases occurring at Rady Children's Hospital from July 2007 to March 2010. Exclusion criteria included redo/bilateral operations, malignancy, transplant nephrectomy, or complex urogenital anomalies. We compared patient demographics, total operative times, estimated blood loss (EBL), length of stay (LOS), complication rates, postoperative pain score, narcotic usage, and total hospital costs. Results We identified 7 LESS, 11 CL, and 8 open nephrectomy patients who met our criteria. The mean age of patients was 8.5, 7.3, and 4.2 years for LESS, CL, and open nephrectomy, respectively ( P = .217). Operative times were 192.2, 219.3, and 127.4 minutes for LESS, CL, and open nephrectomy, respectively ( P = .076). EBL was 15, 13.2, and 12.5 mL, respectively, for these groups ( P = .871). There were no complications in any of the groups, although 1 LESS patient required conversion to open nephrectomy for bleeding. Mean LOS was 46.8, 36.9, and 33.8 hours in the LESS, CL, and open nephrectomy groups ( P = .308). Mean pain scores on postoperative day 1 were 2.3, 1.8, and 1.6 in each group, respectively ( P = .518). Hospital costs were comparable between the LESS and CL groups. The mean cost for open nephrectomy was 54.4% the mean cost for CL, however ( P = .001). Conclusions LESS nephrectomy in children is safe and overall comparable with CL. In our experience, no modality confers a distinct advantage except for the decreased cost associated with open surgery.

Purpose: We provide a sonographic description of postpubertal testicles in patients who have undergone prepubertal orchiopexy with placement of a suture through the tunica albuginea. Materials and Methods: Testicular ultrasound was performed in men who had undergone prepubertal testicular fixation for cryptorchidism using a suture passed through the tunica albuginea. Comparison was made to the sonographic appearance of cryptorchid testicles not secured with a fixating suture through the tunica albuginea. The operative report for each patient was reviewed with specific attention to use and type of suture material, and age at orchiopexy. Results: Ultrasonography was performed on 22 men in whom a tunica albuginea fixating suture was placed during orchiopexy for cryptorchidism. Average patient age at orchiopexy was 5.6 years and median time from orchiopexy to this examination was 14.8 years. Right cryptorchidism existed in 64% of the men. No significant difference was noted in size between the 2 testicles in any patient. Ultrasonography did not identify any parenchymal abnormalities. A tunica albuginea calcification with posterior shadowing on the side of fixation was noted in 32% of patients, of whom 3 had calcified areas evident on physical examination. An area of subtunical hypoechogenicity was noted in 14% of patients. All tunical abnormalities were associated with the use of chromic suture. The remaining 12 patients (54%) had normal sonographic and physical examinations. The control group comprised 6 men who underwent orchiopexy without a fixating suture through the tunica albuginea. These men were examined identically and no sonographic abnormalities were noted in the tunica albuginea or testicular parenchyma. At a median of 16 months no patient had been diagnosed with testicular cancer or had a change in testicular self-examination. Conclusions: Tunica albuginea calcifications and hypoechogenic cysts are common ultrasonic findings in men who have undergone orchiopexy using a suture passed through the tunica albuginea. Parenchymal lesions should not be considered secondary to this procedure and must be treated as de novo abnormalities. These changes seem to be induced by the use of a fixating suture through the tunica albuginea.

The combination of a horseshoe kidney and ureterocele is a rare complex with no definite genetic or developmental association. Only two cases have been reported historically. Diagnosis and treatment of such a complex can be varied amongst providers. We performed a partial nephrectomy with lower pole reimplant after marsupialization of the ureterocele. The patient currently has no evidence of reflux and has been infection free.

Approximately 60% of VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula with atresia, renal defects/radial limb dysplasia) patients have renal anomalies that can be associated with chronic kidney disease (CKD). With improved medical care, a large proportion of these patients survive into adulthood. Longitudinal follow-up data regarding the management of kidney disease in these children is lacking. Twelve VACTERL patients with CKD stage 2-5 and 12 age-matched controls with similar urologic anomalies and CKD [mean follow-up period 15.0 +/- 1.4 (SE) and 11.9 +/- 2.1 years, respectively] were identified in a single center. Eight VACTERL patients progressed to end-stage renal disease (ESRD) compared to four controls (66.7 vs. 33.3%, respectively). Six VACTERL patients were dialyzed pre-transplant. Of the four patients on peritoneal dialysis (PD), three had to be switched to hemodialysis due to complications, whereas two of the three controls on PD did not experience significant problems. Seven VACTERL patients underwent renal transplantation compared to four controls. Mean creatinine clearance 2 years post-transplant was 65.8 +/- 6.3 in VACTERL patients vs. 87.8 +/- 7.1 ml/min per 1.73 m(2) in controls (p = 0.03). VACTERL patients had a significantly lower mean height standard deviation score than the controls (-2.34 +/- 0.41 vs. -1.27 +/- 0.24, respectively; p0.05). Based on these results, VACTERL patients with CKD develop ESRD more frequently, experience more complications with dialysis, may have a poorer transplant outcome, and have more severe growth failure than controls.