Shorter androgen receptor CAG repeat lengths associated with cryptorchidism risk among Hispanic white boys.

CONTEXT: Cryptorchidism is the most frequent congenital malformation among males, the major established risk factor for testicular germ cell tumors, and a presumed infertility risk factor. Androgens are essential for testicular descent, and functional genetic polymorphisms in the androgen receptor gene (AR) are postulated to influence cryptorchidism risk. OBJECTIVE: The aim of the study was to investigate whether the CAG repeat length polymorphism in exon 1 of the AR is associated with cryptorchidism risk. DESIGN AND SETTING: We conducted a family-based genotype-risk association study employing the transmission disequilibrium test for genotypic variants transmitted on the X-chromosome at a university-affiliated regional children's hospital. PARTICIPANTS: We studied 127 Hispanic boys with persistent cryptorchidism and comorbidities described in detail and their biological mothers. INTERVENTION: Genotypes defined by number of CAG repeats were measured for each member of participating son-mother pairs. MAIN OUTCOME MEASURE: Associations between CAG tract length genotype and cryptorchidism risk were estimated using matched-pairs logistic regression. RESULTS: Cryptorchidism risk was significantly associated with shorter CAG repeats [CAG≤19 vs. CAG≥20, odds ratio (OR)=0.44; 95% confidence interval (CI), 0.23-0.88]. This association was restricted to cryptorchidism with accompanying comorbidities, which was primarily hernia [CAG≤19 vs. CAG≥20, OR=0.35 (95% CI, 0.16-0.78)], and was strongest for bilateral cryptorchidism [CAG≤19 vs. CAG≥20, OR=0.09 (95% CI, 0.010-0.78)]. CONCLUSIONS: Androgen receptor genotypes encoding moderate functional variation may influence cryptorchidism risk, particularly among boys with bilateral nondescent or congenital hernia, and may explain in part the elevated risk of testicular seminoma experienced by ex-cryptorchid boys. Mechanistic research is warranted to examine both classical and nonclassical mechanisms through which androgens may influence risk of cryptorchidism and related conditions.

Early comparison of nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery).

OBJECTIVE: To compare the perioperative parameters of paediatric patients who underwent nephrectomy via laparo-endoscopic single site (LESS) surgery (also known as single incision laparoscopic surgery or SILS) with those who underwent nephrectomy via conventional laparoscopy (LAP), robotic-assisted laparoscopy (RALN), and open surgery (OPEN). PATIENTS AND METHODS: The medical records of 69 paediatric patients at a single institution who underwent nephrectomies for non-functioning kidneys in 72 renal units (39 OPEN, 11 LAP, 11 RALN and 11 LESS) were reviewed for patient demographics and perioperative clinical parameters. RESULTS: The minimally invasive modalities in children, including LESS nephrectomy, were associated with shorter lengths of hospital stay (P < 0.001) and decreased postoperative pain medication usage (P < 0.001) than with open surgery. Similar surgical times were noted with LESS and the other minimally invasive modalities (LAP and RALN) (P= 0.056). However, the minimally invasive modalities (LESS, LAP and RALN) were associated with slightly longer surgical times when compared with open surgery (P < 0.001), which may, in part, be secondary to learning curve factors. No differences were noted among the minimally invasive modalities for postoperative pain medication usage (P= 0.354) and length of hospital stay (P= 0.86). CONCLUSIONS: The minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are associated with shorter lengths of hospital stay and decreased postoperative pain medication use when compared with open surgery. LESS nephrectomy in children is associated with similar surgical times, lengths of hospital stay and postoperative pain medication use as the other minimally invasive modalities (LAP and RALN). Slightly longer surgical times are noted with the minimally invasive modalities, including LESS nephrectomy, when compared with open surgery, which may, in part, be secondary to learning curve factors.

Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty.

PURPOSE: Robotic assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in children for ureteropelvic junction obstruction. The procedure is associated with smaller incisions and shorter hospital stays. To our knowledge previous outcome analyses have not included human capital calculations, especially regarding loss of parental workdays. We compared perioperative factors in patients who underwent robotic assisted laparoscopic and open pyeloplasty at a single institution, especially in regard to human capital changes, in an institutional cost analysis. MATERIALS AND METHODS: A total of 44 patients 2 years old or older from a single institution underwent robotic assisted (37) or open (7) pyeloplasty from 2008 to 2010. We retrospectively reviewed the charts to collect demographic and perioperative data. The human capital approach was used to calculate parental productivity losses. RESULTS: Patients who underwent robotic assisted laparoscopic pyeloplasty had a significantly shorter average hospital length of stay (1.6 vs 2.8 days, p <0.05). This correlated with an average savings of lost parental wages of $90.01 and hospitalization expenses of $612.80 per patient when excluding amortized robot costs. However, cost savings were not achieved by varying length of stay when amortized costs were included. CONCLUSIONS: Robotic assisted laparoscopic pyeloplasty in children is associated with human capital gains, eg decreased lost parental wages, and lower hospitalization expenses. Future comparative outcome analyses in children should include financial factors such as human capital loss, which can be especially important for families with young children.

Laparoendoscopic single-site nephrectomy in pediatric patients: initial clinical series of infants to adolescents.

OBJECTIVES: To present our initial clinical series of laparoendoscopic single-site (LESS) nephrectomy using an umbilical incision in children ranging from infants to adolescents. Laparoscopic surgery in pediatric urology is increasingly being performed for many intra-abdominal ablative procedures, such as nephrectomy for poorly functioning kidneys. We have previously reported our initial experience with LESS surgery in the adult population. METHODS: A total of 11 pediatric patients (age range 0.1-16.2 years, mean 5.7) underwent LESS nephrectomy using an umbilical incision. The perioperative clinical parameters were reviewed retrospectively. RESULTS: The 11 LESS pediatric nephrectomies were technically successful without conversion to conventional laparoscopy or open surgery. An accessory port was used in 5 of the cases early in the clinical series. Of the 11 patients, 2 were infants, aged 39 days and 3.5 months. The mean operative time was 139 minutes (range 85-205), and the mean hospital stay was 1.5 days (range 1.0-2.1). Complications included delayed hydrocele formation in 2 male patients. CONCLUSIONS: The results of our study have shown that LESS nephrectomy using a single umbilical incision in pediatric patients is technically feasible with good outcomes. Additional studies are needed to evaluate the expected benefits of this novel technique. Also, miniaturization of currently available equipment is needed to adapt to the small working spaces available in the pediatric patient.

Large renal cavernous hemangioma with renal vein thrombosis: case report and review of literature.

Kidney cavernous hemangiomas are rare. Renal cavernous hemangioma complicated by secondary chronic thrombosis of the renal vein has not been previously reported. A 17-year-old boy was initially diagnosed with a renal mass with tumor thrombosis. Radical nephrectomy was performed, and the pathologic examination revealed a renal cavernous hemangioma with chronic renal vein thrombosis. We also reviewed the previous diagnostic and treatment methods described in previous reports.

Pediatric robot-assisted laparoscopic excision of urachal cyst and bladder cuff.

Urachal cysts are the most common urachal anomaly in the pediatric population. There is an increasing body of literature documenting successful management of urachal cysts using laparoscopic techniques. There may be an advantage, however, with the use of robot-assisted laparoscopy for reconstructive cases. We describe the techniques used for robot-assisted laparoscopic excision of a urachal cyst and bladder cuff with bladder repair in a female child. This approach is a safe and effective option for the minimally invasive management of pediatric urachal cysts.

Giant prostatic utricle associated with proximal hypospadias: repair by mucosa divesting and muscular tunnel obliteration.

PURPOSE: The purpose of this study was to evaluate the effectiveness of a new approach to repair the giant prostatic utricle (pseudovagina) associated with proximal hypospadias. METHODS: Three patients with giant prostatic utricle associated with proximal hypospadias sought medical advice in our department from 1998 to 2003. The giant prostatic utricles were repaired using the novel approach of divesting of utricular mucosa followed by muscular tunnel obliteration through the opening of the pseudovagina in the dorsal lithotomy position. RESULTS: Follow-up ranges from 3 to 8 years. The divesting of the prostatic utricle mucosa was successful, and the pseudovagina muscular tunnel was closed completely in all 3 patients. One patient underwent urethroplasty and another repair of urethrocutaneous fistula at the same setting. The third patient underwent a second-stage urethroplasty separately. On follow-up, both the urethral reconstruction and the pseudovagina repair remained successful in all the patients. CONCLUSIONS: The technique of the divesting of the prostatic utricle mucosa and closure of the muscular wall is an effective alternative approach for repairing giant prostatic utricles. It is safe and simple. The surgical exposure is very good.

Penile torsion repair by suturing tunica albuginea to the pubic periosteum.

PURPOSE: The aim of the study was to evaluate the effectiveness of a new technique to repair penile torsion in children. METHODS: Eighteen boys with penile torsion were evaluated in our department from 1989 to 2003. Eleven had associated hypospadias, 4 had chordee without hypospadias, and 3 had torsion only. The direction of rotation was counterclockwise in 16 cases and clockwise in 2 cases. Torsion was repaired in 6 patients by degloving the penis and reattaching the dartos and the skin (comparative group). In 11 patients (1 with prior repair), the torsion was corrected by suturing the lateral edge of the corpus cavernosum to the pubic periosteum (study group). Two patients were not treated. RESULT: Follow-up ranges from 6 months to 7 years. All of the 11 cases in the study group had satisfactory correction of the penile torsion. All of the urethroplasties for hypospadias were successful. In the comparative group, none of 6 patients had satisfactory correction of the rotation. CONCLUSION: The technique of degloving the penis and reattaching the skin cannot reliably correct penile torsion in our experience. Lateral suturing of tunica albuginea to the pubic periosteum to repair penile torsion appears to be a better technique.

Risk factors for short- and long-term survival of primary cadaveric renal allografts in pediatric recipients: a UNOS analysis.

BACKGROUND: Pediatric kidney graft survival rates have improved in the United States. This study evaluates early and late risk factors for cadaveric graft loss in pediatric recipients. METHODS: From January 1994 to December 2002, 2,597 primary cadaveric kidney-alone transplants (donor age 5-45 years, recipient age 2-20 years) were reported to the United Network for Organ Sharing (UNOS). The analysis includes follow-up information based on OPTN data as of October 14, 2003. Odds ratio of early graft loss and relative risk of late graft loss are estimated using logistic regression and Cox proportional hazards model, respectively. RESULTS: Graft survival rates significantly improved during 1999-2002 (95% and 79% at 1-year and 3-years, respectively) compared with those of 1994-1998 (88% and 76% at 1-year and 3-years, respectively) (log rank P=0.02). After adjusting for other variables, the factors that significantly affected early transplant outcome adversely within 3 months posttransplant were prolonged cold ischemia time (>36 hours, odds ratio [OR]=3.38 vs. 0-36 hours) and young recipient age (2-5 years old, OR=2.02 vs. 6-12 years). Beyond 3 months, significant risk factors were African-American recipients (relative risk [RR]=1.93 vs. others), teenage recipients (13-20 yrs, RR=1.50 vs. 6-12 yrs), and patients with focal glomerulosclerosis (FGS) (RR=1.27 vs. others). CONCLUSIONS: The short-term graft survival rate of pediatric cadaveric kidney transplants has significantly improved, yet the long-term outcome has changed little. The long-term outcomes for teenagers (13-20 yrs), patients with FGS, and African-Americans lag significantly behind other groups. In order to improve long-term graft survival in these high-risk patients, newer preventive or treatment strategies must be developed.

Access to urologic care for children in California: Medicaid versus private insurance.

OBJECTIVES: To compare the access to urologic care for a child with cryptorchidism insured by Medi-Cal versus one insured by private insurance. Medi-Cal (California State Medicaid) is a joint state and federal health insurance program that plays a significant role in providing healthcare coverage to low-income children. METHODS: A total of 54 randomly chosen urology offices throughout California were surveyed by telephone to determine whether the office accepted pediatric patients, accepted Medi-Cal, and when the earliest appointment date would be for a patient with Medi-Cal versus one with private insurance. RESULTS: Of the 46 practices that accepted pediatric patients, 96% offered a new patient appointment to a child with private insurance, but only 41% were willing to offer an appointment to a child with Medi-Cal (P < 0.0001). Of the offices that would not see a child with Medi-Cal, 75% were unable to recommend a urology office that might accept Medi-Cal. CONCLUSIONS: Children insured by Medi-Cal have significantly less access to necessary urologic care compared with children with private insurance.

The management of old urethral injury in young girls: analysis of 44 cases.

BACKGROUND/PURPOSE: Traumatic urethral injury in girls is rare, and there is no consensus on its management. The authors report their 22-year experience. METHODS: Forty girls presented with urethrovaginal fistula. Twenty-six girls presented with cystostomy tube in place, whereas 17 girls presented with complete urinary incontinence. Incision and dilatation of the obliterated urethra was carried out in 7 patients. Vaginal repair of urethrovaginal fistula was performed in 4 patients. Transpubic reconstruction of the urethra using a modified Young-Dees-Leadbetter procedure with simultaneous repair of the urethrovaginal fistula was performed in 35 patients (once in 27, twice in 5, and 3 times in 3 patients). RESULTS: Follow-up in 40 girls averaged 3.5 years. Twenty-nine patients have regained normal urinary control, and 11 patients have mild stress urinary incontinence. Four patients were lost to follow-up. CONCLUSIONS: Simple dilation of the obliterated urethra can reestablish satisfactory urethral patency if the obliterated segment is short. The vaginal approach to urethrovaginal fistula may be successful in patients without concomitant urethral stricture or in those with stricture amenable to simple dilation. The transpubic approach remains the method of choice for repairing complete urethral disruption and severe urethral stricture, especially when associated with urethrovaginal fistula.