Hypospadias repair with onlay preputial graft: a 25-year experience with long-term follow-up.

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.

Verumontanum Cyst Associated With Lower Urinary Tract Symptoms in an Adolescent.

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.

Prepubertal male genitourinary metastatic Crohn's disease: report of a case and review of literature.

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.

SIU/ICUD Consultation on Urethral Strictures: Urethral strictures in children.

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.

Urethral strictures in children.

PURPOSE OF THE REVIEW: The review is an attempt to present the current literature regarding strictures in children to provide an evidence-based recommendation regarding diagnosis and treatment. RECENT FINDINGS: 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. SUMMARY: 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.

Does administration of transdermal dihydrotestosterone gel before hypospadias repair improve postoperative outcomes?

In an effort to improve the outcome of hypospadias repair, Kaya et al. performed a prospective, randomized study of transdermal dihydrotestosterone (DHT) gel as a preoperative adjunct to surgery. They found that patients who received DHT gel had fewer complications and better cosmesis than patients who underwent surgery alone. The authors attribute the differences between the two groups to an increased blood flow produced by the gel. The series of patients was small, and a larger sample size might have produced different results. Some of the outcomes measured were subjective, and the methods used to assess these outcomes were not clear. If a larger study confirms the results obtained by Kaya and colleagues, transdermal DHT gel might prove to be a valuable adjunct to hypospadias surgery.

Perinatal testicular torsion: preoperative radiological findings and the argument for urgent surgical exploration.

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.

Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite.

PURPOSE: With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS: A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS: At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS: Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

Congenital mid ureteral strictures.

PURPOSE: Congenital mid ureteral stricture is rare. We report 7 cases, and discuss the differences in preoperative evaluation and surgical management compared to other obstructive entities. MATERIALS AND METHODS: Medical records and imaging studies of 7 children identified with mid ureteral strictures between 1998 and 2002 were reviewed retrospectively. Five newborns presented with prenatal hydronephrosis, and 2 children presented at age 15 years, one in the course of evaluation of blunt trauma, and one due to pain and abdominal mass. Imaging studies included renal ultrasound, voiding cystourethrography, radionuclide renography and computerized tomography. All patients underwent retrograde pyelography. Pathological examination of each specimen was undertaken at the respective institutions. RESULTS: Prenatal hydronephrosis was the most common presentation. There were no urinary tract infections. All patients had significant obstruction on the affected side. No patient had vesicoureteral reflux. After imaging but before surgery the urinary obstruction was believed to be at the ureteropelvic junction in 4 patients and the ureterovesical junction in 2, and secondary to posterior urethral valves in 1. At cystoscopy all of the affected ureters had a normally located and normally configured orifice. Retrograde pyelography led to an accurate diagnosis of mid ureteral narrowing in all patients. Six patients underwent ureteroureterostomy, all of whom had satisfactory outcomes. In 1 of these patients contralateral nephrectomy was performed due to nonfunction of the multicystic dysplastic kidney. The remaining patient underwent nephrectomy for ipsilateral end stage kidney disease and hydronephrosis. In this patient the ureters were stenotic and suggested asymmetry in the thickness of the muscular coat, perhaps secondary to extrinsic compression. CONCLUSIONS: Congenital mid ureteral stricture is rare. Renal ultrasound and radionuclide renography alone do not reliably demonstrate the site of obstruction. Retrograde pyelography at the time of surgical correction of presumed ureteral obstruction is an important adjunct for correctly identifying the site of narrowing in the affected ureteral segment, unless the ureter has been imaged with another modality.

Presentation of idiopathic retroperitoneal fibrosis in the pediatric population.

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.

Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes.

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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 (p <0.001). 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. CONCLUSIONS: 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.