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Summary Introduction Technetium-99m dimercaptosuccinic acid (DMSA) renal scans are used in the diagnosis of renal scarring. In the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial that randomized 607 children, DMSA renal scans were used for evaluating the presence and the severity of renal scarring. Objective The aim was to determine interobserver variability in reporting of DMSA renal scans in the RIVUR trial. Study design We compared DMSA renal scan reports for renal scarring and acute pyelonephritis from all non-reference local radiologists (ALRs) at study sites with adjudicated as well as non-adjudicated reports from two reference radiologists (RRs) of the RIVUR trial. Two-way comparisons of concordant and discrepant responses were analyzed using an unweighted kappa statistic between the ALR and the adjudicated RR interpretations. All analyses were performed using SAS v 9.4 (SAS institute 2015) and significance was determined at the 0.05 level. Results Of the 2872 kidneys evaluated, adjudicated RR reports had 119 (4%) kidneys with renal scarring compared with 212 (7%) by the ALRs. For 79% kidneys the grading for scarring reported by ALRs was either upgraded (24%) or downgraded (55%) by RRs. For acute pyelonephritis (n = 2924), adjudicated RR reports had 85 (3%) kidneys with pyelonephritis compared with 151 (5%) by the ALRs. For 85% kidneys, the grading for pyelonephritis reported by the ALRs was either upgraded (28%) or downgraded (57%) by the RRs. A three-way comparison revealed that all three (RR1, RR2, and ALR) agreed over presence of renal scarring in 19% cases and two of the three agreed in 80% cases. The respective numbers for pyelonephritis were 13% and 84%. The agreement rate for all DMSA scan reports between the RRs and the ALRs was 93%. Discussion The study revealed significant interobserver variability in the reporting of abnormal DMSA renal scans compared with the previously published studies. A noteworthy limitation was a lack of uniformity in local reporting of the scans. Conclusions Our study highlights the need for optimizing the clinical yield of DMSA renal scans by more specific guidelines, particularly for standardized and uniform interpretation.

On the basis of strong evidence, although primary monosymptomatic nocturnal enuresis (PMNE) is common and most children will outgrow the condition spontaneously, the psychological effect to the child can be significant and represents the main reason for treatment of these children. On the basis of international consensus panels, treatment of PMNE should be targeted toward the specific type of bedwetting patterns the child has, using bladder diary, sleep history, and daytime elimination concerns as a guide (Table 3). On the basis of international consensus panels, it is important for the primary care physician to be able to differentiate children with PMNE from children with nonmonosymptomatic nocturnal enuresis (NMNE) and secondary nocturnal enuresis. On the basis of international consensus panels, children with NMNE should have their underlying voiding or stool problem addressed before initiation of therapy for the nocturnal enuresis. On the basis of strong evidence, both the bedwetting alarm and desmopressin are considered first-line therapy for children with PMNE.

Objective To evaluate the long-term urinary tract infection (UTI) rates after endoscopic correction of vesicoureteral reflux and the possible risk factors for urinary infection. Materials and Methods A retrospective study of patients who underwent endoscopic management of vesicoureteral reflux at a single institution from 2001 to 2011 was performed. Patients were followed up for a minimum of 1 year. Voiding cystourethrograms were completed 3 months postoperatively. UTI questionnaire pertaining to the patient's UTI history before and after the surgery was mailed to each patient. Data were first evaluated looking only at culture-confirmed UTIs, and a second analysis included all patient-reported and culture-confirmed urinary infections. Factors considered in the analysis included sex, age, preoperative dimercaptosuccinic acid (DMSA) scan, reflux on postoperative voiding cystourethrogram, voiding dysfunction, and preoperative reflux grade. Results Data on 175 patients for a minimum of 1 year were collected. There were 34 of 175 confirmed UTIs after endoscopic management, and 11 confirmed febrile UTIs. There were no significant predictors of febrile or afebrile UTIs in this group. Fifty-three of 175 patients (30%) experienced any UTI, 19 of which were febrile (10%). In this group, recurrent reflux was the only significant predictor of UTI ( P = .03) and febrile UTIs ( P = .04). Patients with more UTIs preoperatively were more likely to have a postoperative febrile UTI. Conclusion Rates of UTI and febrile UTI in endoscopic management are similar and no better than those for open ureteral reimplantation. Longer follow-up suggests an association of recurrent reflux and preoperative UTI rates as predictors of postoperative febrile UTIs. These patients benefit from closer postoperative observation.

Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection by subureteric transurethral injection (STING) or hydrodistention implantation technique (HIT) for treatment of vesicoureteral reflux (VUR) has variable results with HIT reporting better outcomes. We determined outcomes with each technique comparing reflux resolution rates and evaluating predictors of treatment success and failure.Univariate and multivariate analysis compared 163 patients (246 ureters) who underwent a single endoscopic Dx/HA injection from December 2001 to April 2010. Data on pre, peri, and post-operative variables were prospectively collected. Resolution was defined as no reflux on voiding cystourethrogram (VCUG) at 3 month follow up. Calculated ellipsoid volume (CEV) of Dx/HA mounds was defined as (4/3π(height/2) × (length/2) × (width/2)) based on post-operative ultrasound dimensions.Ureter resolution was 79.75% and 80.84% for STING and HIT, respectively (p = 0.86). Patient resolution was 70.0% and 74.3% for STING and HIT, respectively (p = 0.57). Multivariate ureter analysis revealed lower pre-operative grade (p = 0.004) and injected Dx/HA volume 0.80-1.00 mL (p = 0.039) as predictors of success. CEV0.20 mL (p = 0.002) and CEV/injected-volume25% (p = 0.006) were predictors of failure. Volcano morphology (p = 0.004) and lower pre-op grade (p = 0.015) were predictors of success for STING and HIT, respectively.We found no differences in ureter or patient resolution between endoscopic Dx/HA injection techniques STING or HIT. Lower pre-operative grade and moderated Dx/HA volume were predictors of success regardless of technique.

Considering that there are few absolute indications for the timing and type of surgical correction of vesicoureteral reflux, we objectively measured parental choice in how the child's vesicoureteral reflux should be managed.We prospectively identified patients 0 to 18 years old with any grade of newly diagnosed vesicoureteral reflux. All races and genders were included, and non-English speakers were excluded from analysis. Parents were shown a video presented by a professional actor that objectively described vesicoureteral reflux and the 3 treatment modalities of antibiotic prophylaxis, open ureteral reimplantation and endoscopic treatment. Then they completed a questionnaire regarding their preference for initial management, and at hypothetical followup points of 18, 36 and 54 months. Consultation followed with the pediatric urologist who was blinded to the questionnaire results.A total of 86 girls and 15 boys (150 refluxing units) were enrolled in the study. Mean patient age was 2.6 years old. Preferences for initial treatment were antibiotic prophylaxis in 36, endoscopic surgery in 26, open surgery in 11, unsure in 26 and no response in 2. Among those initially selecting antibiotic prophylaxis, after 18 months the preference was for endoscopic treatment, but after 36 and 54 months preferences trended toward open surgery. After consultation with the pediatric urologist 68 parents chose antibiotic prophylaxis.Our data show that antibiotic prophylaxis is preferred as the initial therapy for vesicoureteral reflux by 35.6% of parents. However, given persistent vesicoureteral reflux, preferences shifted toward surgery. With time the preference for open surgery increased and the preference for endoscopic surgery decreased.

Objective In the US, there has been an evolution in the practice of pediatric urology from a primary academic sub-specialty focused on reconstruction of major congenital genitorurinary abnormalities to a mixed academic and private practice that serves as the primary care giver for all pediatric urologic concerns. The estimated manpower needs were unable to be resolved, due to our inability to determine the impact of sub-specialty certification on referral patterns, along with the failure to embrace the use of physician extenders. Here, we review a series of surveys performed in 2006–2010 regarding the sub-specialty of pediatric urology. Materials and Methods The four surveys focused on workforce needs, appraised the financial impact of educational debt on the pediatric urology community, and evaluated concerns of the current fellows in training. Results The median financial income for a pediatric urologist, the resident’s educational debt load, and a desire of the fellows to have an open dialog with the urologic community regarding the merits of the research year are revealed. Conclusion We have identified that the ability to recruit fellows into our field is dependent upon a combination of factors: interest in the field, job availability in relationship to geographic locations, mentoring, concerns regarding financial/familial hardships encountered during a 2-year fellowship, and the lack of increased financial reimbursement for the extra training required.

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0–21%, new renal damage in 9–12%, and recurrent reflux in 17–47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.

The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.

The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to screening of siblings and offspring of index patients with vesicoureteral reflux and infants with prenatal hydronephrosis. From this evidence clinical practice guidelines are developed to manage the clinical scenarios insofar as the data permit.The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children, clearly stating the number of children undergoing screening for vesicoureteral reflux. Vesicoureteral reflux should have been diagnosed with a cystogram and renal outcomes assessed by nuclear scintigraphy. The screening articles were extracted into data tables developed to evaluate epidemiological factors, patient and renal outcomes, and results of treatment. The reporting of meta-analysis of observational studies elaborated by the MOOSE group was followed. The extracted data were analyzed and formulated into evidence-based recommendations regarding the screening of siblings and offspring in index cases with vesicoureteral reflux and infants with prenatal hydronephrosis.In screened populations the prevalence of vesicoureteral reflux is 27.4% in siblings and 35.7% in offspring. Prevalence decreases at a rate of 1 screened person every 3 months of age. The prevalence is the same in males and females. Bilateral reflux prevalence is similar to unilateral reflux. Grade I-II reflux is estimated to be present in 16.7% and grade III-V reflux in 9.8% of screened patients. The estimate for renal cortical abnormalities overall is 19.3%, with 27.8% having renal damage in cohorts of symptomatic and asymptomatic children combined. In asymptomatic siblings only the rate of renal damage is 14.4%. There are presently no randomized, controlled trials of treated vs untreated screened siblings with vesicoureteral reflux to evaluate health outcomes as spontaneous resolution, decreased rates of urinary infection, pyelonephritis or renal scarring. In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence. A diameter of 4 mm is associated with a 10% to 20% prevalence of vesicoureteral reflux. The prevalence of reflux is statistically significantly greater in females (23%) than males (16%) (p=0.022). Reflux grade distribution is approximately a third each for grades I-II, III and IV-V. The estimate of renal damage in screened infants without infection is 21.8%. When stratified by reflux grade renal damage was estimated to be present in 6.2% grade I-III and 47.9% grade IV-V (p0.0001). The risk of urinary tract infection in patients with and without prenatal hydronephrosis and vesicoureteral reflux could not be determined. The incidence of reported urinary tract infection in patients with reflux was 4.2%.The meta-analysis provided meaningful information regarding screening for vesicoureteral reflux. However, the lack of randomized clinical trials for screened patients to assess clinical health outcomes has made evidence-based guideline recommendations difficult. Consequently, screening guidelines are based on present practice, risk assessment, meta-analysis results and Panel consensus.

Objectives To review, prospectively, our experience with endoscopic Deflux injection and evaluate the volume injected, grade, endoscopic appearance after injection, and presence or absence of voiding dysfunction as predictors of success. Subureteral injection of dextranomer/hyaluronic acid copolymer (Deflux) has become an effective treatment of vesicoureteral reflux. Methods A total of 52 patients (50 females and 2 males; 80 ureters) were treated with a single subureteral injection of Deflux. The mean patient age was 7.6 years (range 14 months to 22 years). The presence or absence of voiding dysfunction was evaluated with a preoperative questionnaire and patient history. The volume of Deflux injected in each ureter was recorded. The endoscopic appearance after injection was recorded as “volcano” or “other.” Success was defined as no reflux on postoperative voiding cystourethrography. Results The success rate by grade of reflux in individual ureters was 82%, 84%, 78%, and 73% for grade 1, 2, 3, and 4 vesicoureteral reflux, respectively. No statistically significant difference was found in the cure rate by grade ( P = 0.76). The overall cure rate by ureter was 80% and by patient was 71%. New contralateral reflux developed in 12.5% of patients. No statistically significant difference was found in the cure rate with respect to the volume injected or the presence or absence of voiding dysfunction. The ureteral cure rate with volcano and alternate morphology was 87% and 53%, respectively ( P = 0.004). Conclusions Mound morphology was the only statistically significant predictor of a successful outcome, with an associated cure rate of 87%. Concomitant voiding dysfunction did not have an adverse effect on the cure rate. In our experience, no statistically significant difference was found in the cure rate for grades 1 through 4 vesicoureteral reflux after a single injection of Deflux.

Background Children with febrile urinary tract infection commonly have vesicoureteral reflux. Because trial results have been limited and inconsistent, the use of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial. Methods In this 2-year, multisite, randomized, placebo-controlled trial involving 607 children with vesicoureteral reflux that was diagnosed after a first or second febrile or symptomatic urinary tract infection, we evaluated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome). Secondary outcomes were renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance. Results Recurrent urinary tract infection developed in 39 of 302 children who received prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38 to 0.78). Prophylaxis reduced the risk of recurrences by 50% (hazard ratio, 0.50; 95% CI, 0.34 to 0.74) and was particularly effective in children whose index infection was febrile (hazard ratio, 0.41; 95% CI, 0.26 to 0.64) and in those with baseline bladder and bowel dysfunction (hazard ratio, 0.21; 95% CI, 0.08 to 0.58). The occurrence of renal scarring did not differ significantly between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). Among 87 children with a first recurrence caused by Escherichia coli, the proportion of isolates that were resistant to trimethoprim-sulfamethoxazole was 63% in the prophylaxis group and 19% in the placebo group. Conclusions Among children with vesicoureteral reflux after urinary tract infection, antimicrobial prophylaxis was associated with a substantially reduced risk of recurrence but not of renal scarring. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; RIVUR ClinicalTrials.gov number, NCT00405704.).

A comparison of the electron-donating abilities of the hydridotris(pyrazolyl)borate ligand and cyclopentadienyl ligand toward transition metals is presented. These data demonstrate that there is no definitive trend in donor ability across the periodic table, and consequently generalizations about the relative donating abilities of the two ligands should be discouraged.

A new class of group 4 complexes bearing the tropidinyl (Trop) ligand were synthesized. This novel anionic ligand, easily derived from the natural product tropine, is regarded as an analogue of the well-studied Cp ligand (Cp = cyclopentadienyl) and features a bicyclic ring system in which an allyl function donates 4π electrons and an amine function donates 2σ electrons to the metal center. The synthesis of the group 4 complexes involved transmetalation of a stannylated allyl functionality with a group 4 metal halide with concomitant elimination of Me3SnCl. Reaction of endo-stannylated tropidine (1) and ZrCl4, CpZrCl3, or CpTiCl3 afforded the complexes (Trop)2ZrCl2 (2), (Cp)(Trop)ZrCl2 (3), and (Cp)(Trop)TiCl2 (4), respectively. These dihalide complexes were alkylated using methyllithium to generate (Trop)2ZrMe2 (5), (Cp)(Trop)ZrMe2 (6), (Cp)(Trop)TiMe2 (7), or benzylmagnesium chloride to give (Trop)2ZrBn2 (8) and (Cp)(Trop)ZrBn2 (9). Complexes 2, 3, 5, and 8 were characterized by X-ray crystallography. Co...

Juvenile granulosa cell tumor is a rare benign neoplasm of the testicular stroma that accounts for 1-5% of all prepubertal testis tumors [Metcalfe PD, Farivar-Mohseni H, Farhat W, McLorie G, Khoury A, Bagli DJ. Pediatric testicular tumors: contemporary incidence and efficacy of testicular preserving surgery. J Urol 2003;170:2412-2416; Ross JH, Rybicki L, Kay R. Clinical behavior and a contemporary management algorithm for prepubertal testis tumors: a summary of the prepubertal testis tumor registry. J Urol 2002;168:1675-1679]. A prior case series retrospectively identified a cystic testis tumor on prenatal ultrasound images which was subsequently diagnosed as a juvenile granulosa cell tumor [Bryan DE, Cain MP, Casale AJ. Juvenile granulosa-theca cell (sex cord-stromal) tumor of the infant testis. J Urol 2003;169:1497-1498]. We report a case of a prenatally diagnosed testis tumor which was subsequently diagnosed as a juvenile granulosa cell tumor.

The structure of Ru(dppe)(CO)3 was characterized by single crystal X-ray diffraction [monoclinic crystal system, space group P21/n, a=12.2353(2) A, b=16.0803(3) A, c=14.2451(3) A, β=111.109(1)°, V=2614.62(9) A3, Z=4] and found to be intermediate between trigonal bipyramidal and square pyramidal. One electron oxidation of Ru(dppe)(CO)3 using [(η5-C5H5)2Fe][PF6] produced [Ru2(dppe)2(CO)6][PF6]2. The dicationic complex was fully characterized by solution spectroscopic methods and by single crystal X-ray diffraction [trigonal crystal system, space group P3121, a=20.566(2) A, c=13.871(2) A, V=5080.7(8) A3, Z=3] and found to have a dimeric structure with two octahedral units sharing a common apex via a Ru(I)–Ru(I) single bond. One octahedral unit is rotated approximately 45° relative to the other, and the chelating phosphine ligand occupies sites cis and trans to the Ru(I)–Ru(I) bond. All of the carbonyl ligands were found to be terminal. The dimer was fluxional in solution and line-shape analysis of the 31P{1H} and 13C{1H} variable-temperature NMR spectra was used to investigate the exchange mechanism and evaluate the rate constants. The mechanism involved an intramolecular, two-site exchange involving pairwise bridging carbonyls and had activation parameters of 11.8±0.15 kcal mol−1 and −6.7±0.6 eu for ΔH‡ and ΔS‡ respectively. The dimer exhibited similar thermal and photochemical reactivity patterns; disproportionation occurred in CH3CN and halogen atom abstraction occurred in halogenated solvents.

Kinetic and mechanistic studies on the deoxygenation of nitroarenes by Ru(dppe)(CO)3, where dppe = 1,2-bis(diphenylphosphino)ethane, are described. The products of the reaction included 1 equiv of carbon dioxide and an η2-nitrosoarene ruthenium complex (Ru(dppe)(CO)2[ON(Ar)] for Ar = 4-chloro-2-trifluoromethylphenyl), which was isolated and fully characterized by solution spectroscopic methods and by single crystal X-ray diffraction [monoclinic crystal system, space group P21/c (#14), a = 14.556 (8) A, b = 12.903 (6) A, c = 20.10 (1) A, β = 105.60 (6)°, V = 3636 (8) A3, Z = 4]. The deoxygenation reaction was determined to be first-order with respect to both Ru(dppe)(CO)3 and nitroarene. Electron withdrawing substituents on the nitroarene and polar solvents accelerated the rate, and a substituent study provided a ρ of +3.45 indicating negative charge buildup on the nitroarene in the rate determining step of the reaction. Activation enthalpies for 2-CF3, 4-Cl, 4-H, and 4-CH3 substituted nitroarenes were 9.3...

Purpose: Desmopressin nasal spray has proved to be efficacious treatment of primary nocturnal enuresis. Oral desmopressin tablets would be a more easily used, convenient vehicle for our patients and their parents. We evaluated the effectiveness of oral desmopressin in decreasing the number of wet nights in patients with primary nocturnal enuresis.Materials and Methods: We performed a double-blind, placebo controlled, parallel group trial of oral desmopressin in 141 children 5 to 17 years old with documented primary nocturnal enuresis at 14 sites. Patients were screened for number of wet nights for 2 weeks before study entry. A minimum of 3 wet nights weekly for 2 consecutive weeks was required for study entry. Patients were randomized to receive 200, 400 or 600 mcg. desmopressin or placebo before bedtime. Fluids were restricted 2 hours before bedtime based on body weight. The primary efficacy variable was mean decrease in the number of wet nights recorded during the last 2-week treatment period. T...

Accumulating evidence from animal and human studies has demonstrated that varicoceles are associated with a time-dependent decline in testicular function.1-4 As a result, the finding of dilated scrotal veins, a varicocele, in an adolescent presents the practicing physician with a number of problems: When should one surgically intervene in the adolescent? Although infertility is not a presenting complaint, should prophylactic varicocele repair be performed to prevent future infertility and possible testosterone deficiency? These questions can only be answered when we have a better understanding of the pathophysiology of the varicocele. The purpose of this review is to present the most current information on the adolescent varicocele, provide guidelines on managing this perplexing problem in the asymptomatic adolescent male, and stimulate future research about the enigmatic relationship between the varicocele and its effects on testicular growth and function. Approximately 15% of all adult males have a varicocele.5 One-third of all males evaluated for infertility have a varicocele, demonstrating the negative impact of varicoceles on testicular function.6 However, only 15% to 20% of males with a varicocele seek treatment for infertility, suggesting that most males with a varicocele are fertile or do not seek treatment. Although varicoceles have been reported in the preadolescent male, they are rare in this age group.7,8 In a survey by Oster9 (1971) of 1072 school boys in Denmark, there were no varicoceles found in 188 boys who were between the ages of 6 to 9 years. The incidence of varicoceles in the older child, (ages 10 to 25), varies between 9% to 25.8% with a weighted average of 16.3% (Table 1).9-14 This is similar to the incidence of varicoceles in the adult population and suggests that the physiologic changes associated with puberty, such as an increase in testicular …

Purpose: Surgical management of steroid unresponsive testicular tumors of the adrenogenital syndrome has been orchiectomy. Magnetic resonance imaging (MRI) of these tumors accurately delineates the extent of disease. Testis sparing surgery is an important consideration, since male individuals with congenital adrenal hyperplasia are potentially fertile. We present our results of surgical management of this tumor based on MRI findings.Materials and Methods: Four boys with steroid unresponsive testicular tumors of the adrenogenital syndrome were evaluated with MRI, testicular ultrasound and color flow Doppler examinations preoperatively and postoperatively. Three patients had 21-hydroxylase deficiency and 1 had 3-beta-hydroxysteroid dehydrogenase deficiency. Contralateral testicular abnormalities included a vanished testis, testicular atrophy due to trauma and bilateral tumors in 1 boy each. Bilateral orchiectomy and surgical enucleation were performed in 1 and 3 patients, respectively. Followup rang...

Anomalies of the scrotum are uncommon. The most frequent malformations include bifid scrotum, scrotal ectopia and penile scrotal transposition. Congenital scrotal agenesis (CSA) is an extremely rare phenomenon, with only 3 cases reported in the worldwide literature. We report a case of CSA in an infant and review the current literature to identify possible congenital associations, diagnostic approaches and surgical reconstructive options. A MEDLINE search was performed for the period January 1965 to December 2003 using the National Center for Biotechnology Information PubMed Internet site.

The relationship of functional bladder capacity as well as other variables to the responsiveness to desmopressin in children with monosymptomatic nocturnal enuresis was investigated.A total of 95 children 8 to 14 years old with monosymptomatic nocturnal enuresis (6 or more of 14 nights wet) were evaluated in a double-blind study followed by open label crossover extension using 20 to 40 mcg. desmopressin. Evaluated predictors of response included patient age, gender, race, family history, number of baseline wet nights, urine osmolality parameters and maximum functional bladder capacity (as a percent of predicted bladder capacity based on the formula, patient age + 2 x 30 = cc). Responders to desmopressin were classified as excellent (2 or less of 14 nights wet) or good (50% or greater decrease but more than 2 of 14 nights wet) and nonresponders were defined by a less than 50% decrease in wet nights.Of the 95 patients 25 (29.5%) achieved an excellent response to desmopressin and 18 (18.9%) had a good response for a cumulative response rate of 45.3%. The remaining 52 patients (54.7%) were nonresponders. There were no significant differences between responders and nonresponders in regard to gender, race, positive family history or baseline urine osmolality parameters. Response to desmopressin was associated with older age, fewer baseline wet nights and larger bladder capacity. Patients with a functional bladder capacity greater than 70% predicted bladder capacity were 2 times more likely to respond to desmopressin.The responsiveness of children with nocturnal enuresis to desmopressin is adversely affected by reduced functional bladder capacity. The results of this study have implications regarding the potential use of combination pharmacotherapy with desmopressin and an anticholinergic for enuretic patients who are nonresponsive to single drug therapy.

Subureteral injection of dextranomer/hyaluronic acid copolymer is a minimally invasive method to treat vesicoureteral reflux. We report short and long-term success in treating secondary vesicoureteral reflux in patients with neurogenic bladder dysfunction or severe voiding dysfunction.We performed a retrospective chart review of all subureteral injection procedures done to identify patients with neurogenic bladder or severe voiding dysfunction. Short (less than 12 months) and long-term vesicoureteral reflux results for patients and ureters were recorded. Preoperative urodynamics and radiographic findings were reviewed. Preoperative factors were evaluated to identify patients with greater chances of success.A total of 12 patients (17 ureters) were identified (10 with neurogenic bladder and 2 with Hinman syndrome). Short-term success (no vesicoureteral reflux) was achieved in 50% of patients and 58% of ureters. At a median followup of 4.5 years (range 1 to 9) success decreased to 35% of ureters. Overall, long-term success was found in 25% of patients who were free of vesicoureteral reflux and required no additional surgery. Of the patients 41% required additional urological surgery for vesicoureteral reflux or related conditions.With long-term followup many patients who had initial improvement in vesicoureteral reflux ultimately experienced treatment failure and recurrence of reflux. At a median of 4.5 years 25% of patients with neurogenic bladder and vesicoureteral reflux were successfully treated with endoscopic injection of dextranomer/hyaluronic acid copolymer.

The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. From this evidence clinical practice guidelines were developed to manage the clinical scenarios insofar as the data permit.The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children with vesicoureteral reflux and a defined care program that permitted identification of cohort specific clinical outcomes. The reporting of meta-analysis of observational studies elaborated by the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) group was followed. The extracted data were analyzed and formulated into evidence-based recommendations.A total of 2,028 articles were reviewed and data were extracted from 131 articles. Data from 17,972 patients were included in this analysis. This systematic meta-analysis identified increasing frequency of urinary tract infection, increasing grade of vesicoureteral reflux and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The Panel then structured guidelines for clinical vesicoureteral reflux management based on the goals of minimizing the risk of acute infection and renal injury, while minimizing the morbidity of testing and management. These guidelines are specific to children based on age as well as the presence of bladder and bowel dysfunction. Recommendations for long-term followup based on risk level are also included.Using a structured, formal meta-analytic technique with rigorous data selection, conditioning and quality assessment, we attempted to structure clinically relevant guidelines for managing vesicoureteral reflux in children. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve.

The Section on Urology of the American Academy of Pediatrics met for 2½ days in conjunction with the 60th annual meeting of the American Academy of Pediatrics in New Orleans, LA, October 26 through 28, 1991. This conference remains the most important meeting in the United States for pediatric urology. The number and quality of papers presented continue to grow and there is a rich, international participation. The meeting was presided over by Chairperson Edward S. Tank, Jr, MD, of the University of Oregon Health Sciences Center, Portland, OR. The papers presented at this meeting that are of interest to the practicing pediatrician are summarized here according to topic. OBSTRUCTION Investigation of structural, biochemical, and functional changes in both the developing bladder and in the upper urinary tract were studied in the fetal lamb model of bladder outlet obstruction by Peters et al from Boston Children's Hospital and by Cendron et al from Johns Hopkins Hospital. Their findings included an increase in bladder weight due to hypertrophy and hyperplasia, increase in the cholinergic receptor density of the smooth muscle cells of the bladder, and alterations in the myosin heavy-chain isomer ratio. Following birth these alterations in growth and differentiation resulted in functional bladder abnormalities as measured by urodynamic studies. These abnormalities included an increase in bladder capacity, an increase in maximal intravesical pressure with filling, and an increase in postvoid residual urine volumes. Further study in this model should allow better understanding of the spectrum of bladder dysfunction resulting from in utero outflow obstruction of the bladder.

Primary vesicoureteral reflux is a polygenic abnormality due to a deficiency of the ureterovesical junction which allows urine in the bladder to ascend into the ureter and kidney. Fifty-one black children with primary vesicoureteral reflux were evaluated and treated at Children's Hospital from 1976 to 1986. The results of the evaluation and treatment were compared with those of 493 white patients with primary vesicoureteral reflux seen during the same time interval. The general approach to management was nonsurgical. There were no radical differences in the mode of presentation, age at presentation, and age at resolution. The distribution of reflux by maximum grade was not affected by race. Overall, 19 (37%) black children experienced spontaneous resolution of reflux. The mean duration of reflux in black children who had spontaneous resolution was 14.6 months. This duration was statistically significantly shorter than that in white patients with spontaneous resolution of vesicoureteral reflux (P < .005). Surgical correction was believed to be required in 8 (16%) patients and 8 (16%) were lost to follow-up. Renal scarring demonstrated by intravenous pyelogram or renal scan was initially present in 12 (23%) black patients compared with 65 (13%) white patients. This was due to a higher percentage of renal scarring in black girls which was not explained by distribution of grades of reflux. There was no progression of scarring in our black patients, whereas 3 (0.6%) white patients had progression of scarring. Although vesicoureteral reflux is rarely seen in black patients (9% of series), it has similar demographic features. Renal scarring is more frequent in black girls, but one can anticipate a faster rate of spontaneous resolution than in the white population.

Abdominoscrotal hydrocele is a poorly understood entity and multiple theories attempt to explain its occurrence. To our knowledge the factors contributing to the formation of abdominoscrotal hydrocele are unknown, as are its cellular, biochemical and hydrostatic properties. We prospectively evaluated abdominoscrotal hydrocele at surgery to define its cause and its effects on the testicle.Six patients (9 abdominoscrotal hydroceles) were prospectively evaluated at surgery. Hydrocele volume was recorded as well as simultaneous hydrocele and bladder pressure. Fluid at surgery was sent for biochemical and cellular analysis. Testicular and epididymal abnormalities were noted and testicular length was measured. All abdominoscrotal hydroceles were exteriorized and excised. Processus vaginalis patency was documented at repair.Mean patient age was 7.17 months (range 5 to 12). The mean volume recorded was 212.78 ml (range 80 to 320). Mean corrected hydrocele pressure was 15.44 cm H(2)O (range 7 to 28). Mean testicular length was 3.6 cm (range 2.2 to 5.5). All patients had epididymal anomalies and 2 of the 3 unilateral abdominoscrotal hydroceles had abnormal contralateral scrotal findings. In no case was a peritoneal communication identified. Fluid analysis revealed a high protein concentration (mean 4.94 gm/dl), low triglyceride concentration (mean 20.29 mg/dl) and lactate dehydrogenase levels comparable to those in normal serum (mean 99.14 U/l). Cytological analysis revealed a sterile, low cellularity fluid with a macrophage predominance (mean 84.71%).Abdominoscrotal hydrocele occurs as a result of increased intraluminal pressure confined in a proximal closed processus vaginalis. Increased hydrocele pressure allows expansion into the retroperitoneal space through the internal inguinal ring. This increased pressure is associated with testicular elongation and epididymal abnormalities. The exudative fluid is of a noninfectious etiology and it suggests an altered filtration process. To our knowledge the effects on future fertility are unknown.

The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.

We evaluated the effectiveness of initial laser transurethral incision of ureterocele for relieving obstruction, prevention of infection and need for subsequent surgery.We reviewed the medical records and imaging studies of 30 children with ureterocele treated between 1995 and 2000. Of 30 children 14 underwent initial transurethral laser incision of the ureterocele. Records and images were evaluated for mode of presentation, ureterocele location, thickness, and decompression, and relief of obstruction. The incidence of urinary tract infection, new onset vesicoureteral reflux, upper segment renal function and need for subsequent surgery after incision was investigated.There were 5 boys and 9 girls in our series. Mean patient age at presentation was 17.5 months. There were 12 patients who had ectopic and 2 orthotopic ureteroceles. Ureterocele was defined as thick if ultrasound measurement was 4 mm. or greater. Thick ureterocele was present in 4 (28%) patients. All patients had ultrasound evidence of decompression of the ureterocele and upper tract with 1 treatment. Urinary infection risk was 0.015 per month of followup after incision. Vesicoureteral reflux was present in 8 of 12 (67%) ectopic systems before incision and 9 of 10 (90%) after. None had resolved reflux during followup. Upper pole renal function was assessed by renal scan and/or renal ultrasound. Upper pole function or increased cortical thickness was documented in 9 of 11 (82%) patients. Endoscopic laser incision was the only treatment required in 4 of 14 (28%) patients, including 2 with orthotopic and 2 ectopic ureteroceles. Of 14 patients 5 (36%) had undergone definitive surgery and 5 were followed.Endoscopic laser incision of ureterocele allows a precise incision and decompression of the ureterocele with 1 treatment. Laser incision of ureterocele should be considered as the initial treatment in most patients.

Testicular growth arrest is the main criterion for performing varicocele ligation in the adolescent population. Previous assessments concerning significant size discrepancy range from 0.5 to 5cm.3, a 10-fold difference. We prospectively assessed testicular size in 22 male adolescents (ages 9 to 19 years) with varicoceles, and compared testicular volume as measured by ultrasound and Prader orchidometer in 19 of these patients. The accuracy of ultrasound for this purpose was evaluated by blinded ultrasonic measurements of models of known volume and a standard deviation of ± 1.6cm.3 was found. Using a size discrepancy of greater than 2cm.3 as the criterion for growth arrest, 4 of 17 patients (24%) with growth arrest would have been missed with the Prader orchidometer alone. Testicular volumetric assessment by ultrasound accurately measured volumetric differences of greater than 2cm.3 and can be used to determine growth arrest in the male adolescent with a varicocele.

Isolated abdominal bronchogenic cysts are extremely rare. We report the fourth such case in an asymptomatic 4-year-old girl who initially presented for evaluation of urinary tract infection and new-onset urinary incontinence. Ultrasound, computed tomography, and magnetic resonance imaging findings were consistent with an adrenal mass. At exploration, the patient wes found to have a mass in the area of the gastroesophageal junction and a normal left adrenal gland. The final pathology confirmed the diagnosis of a bronchogenic cyst. Abdominal bronchogenic cysts, although rare, should be considered in the diagnosis of a retroperitoneal mass.

The discovery of a scrotal mass by a parent, physician, or young patient can be an emotionally alarming event. The treating physician is confronted with a staggering list of possibilities as to the origin and cause of the mass (Table 1) . In the infant it may be a simple hydrocele, in the adolescent a varicocele or a testicular neoplasm. The key to solving the diagnostic dilemma is a systematic approach based on presence of symptoms, location of the mass, physical findings, and an understanding of the anatomic contents of the spermatic cord and scrotum. The clinical presentation of a painful scrotal mass requires immediate action because torsion of the spermatic cord is a urologic emergency. The clinical dictum that a painful scrotal mass is torsion until proven otherwise should be heeded. Other painful scrotal lesions include orchitis, epididymitis, torsion of appendix testis or appendix epididymis, acute bleeding into a testicular tumor, trauma, and incarcerated hernia. The diagnosis, evaluation, and treatment of painful scrotal masses is covered in detail in the article by Kass and Lundak. The child or adolescent with a painless scrotal mass may have a life-threatening testicular neoplasm. The most important step is to establish the exact location of the lesion (Fig. 1) . An intratesticular lesion should be considered a malignancy unless proven otherwise. When the results of the physical examination, including transillumination, fail to distinguish the exact location of the lesion, then scrotal sonography is of great value, especially when the testis is not palpable and a hydrocele is present. Scrotal sonography localizes the lesion and distinguishes a solid from a cystic mass. 5 It can be extremely helpful in detecting small lesions within the testis, but its findings are not specific and by itself cannot exclude malignancy. 29 Consequently, sonography has not altered the surgical approach to a painless testicular mass in adults or children.

T he development of bilateral testicular masses is an unusual complication of congenital adrenal hyperplasia (CAH) , occurring in patients with poorly controlled adrenal insufficiency (21hydroxylase deficiency and less commonly llbeta-hydroxylase deficiency). The cell of origin of the testis mass and the management of these patients has been a source of controversy.1$2 The images presented are from a 17-year-old male with a history of salt-wasting adrenal insufficiency

A multicenter study was undertaken to study cryptorchidism and the timing of orchidopexy. A total of 329 children underwent surgery at a mean age of 4.2 years; 17% of the surgery was performed between 6 and 12 months of age, 25% between 5 and 10 years of age, and 9% during or after puberty. Only 30% of the pediatricians and 14% of the family practitioners recommended orchidopexy between 6 and 12 months of age, and 17% of these referring physicians recommended waiting until 3 to 10 years of age. Improved education is needed if current recommendations for early orchidopexy are to be achieved. (J P EDIATR 1995;127: 948-51)

Transverse testicular ectopia is a rare but well documented abnormality in which both testes descend through 1 inguinal canal. We report on a 14-month-old boy in whom laparoscopy was diagnostic for this abnormality. Laparoscopic examination of the pelvis is imperative to rule out the presence of mullerian remnants that commonly occur in patients with transverse testicular ectopia. Our case further supports the use of laparoscopy in patients with nonpalpable undescended testes.