Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis.

INTRODUCTION: Undescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam. METHODS: A retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging. RESULTS: From 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5-180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6-171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%. CONCLUSION: The majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6-12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.

Re-evaluating the role of Doppler ultrasonography in patients presenting with scrotal pain.

AIM: To describe our experience of all patients presenting to a tertiary referral centre over a 5-year time period with acute scrotum and to investigate the role of Doppler ultrasonography (DUS) for investigating this group of patients. METHOD: A retrospective analysis was performed on all patients presenting to the emergency department (ED) of a level 1 trauma centre with acute scrotum from 2009 to 2014 inclusive. Inclusion criteria included all patients who underwent an investigatory DUS and/or emergency scrotal exploration. Recorded patient demographics included age, presenting symptoms, duration of symptoms and relevant examination findings. RESULT: Three-hundred and twelve patients were included with a mean age of 15 years (range 1 day-40 years). In total, 106 patients underwent immediate scrotal exploration, and testicular torsion (TT) was found in 30 % (n = 32/106). Two-hundred and twenty-two patients were initially investigated with DUS and 16 (7.2 %) proceeded to scrotal exploration. Of this sub-group, 2/16 presented with a history <24 h and exploration was negative for TT. In comparison, 14/16 presented with a history >24 h, and DUS findings were consistent with TT. No patients with a normal DUS represented to the ED after discharge. CONCLUSION: DUS may prevent unnecessary scrotal exploration in patients presenting with acute scrotal pain and is useful for diagnosing TT in patients presenting with symptoms >24 h.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

OBJECTIVES: To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. METHODS: A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. RESULTS: Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. CONCLUSION: Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort.

MAGPI hypospadias repair: factors that determine outcome.

BACKGROUND: This is a review of our experience with the meatal advancement and glanuloplasty incorporated (MAGPI) hypospadias repair, and we point to some of the factors that determine outcome. METHODS: We identified all patients who underwent MAGPI repair by a single surgeon over an 8-year period. We performed a retrospective chart review followed by telephone interview to assess parent satisfaction and also functional and cosmetic outcome. Decision to undergo this type of repair was intra-operative, depending on position and mobility of the meatus and the quality of peri-urethral tissue. RESULTS: We identified 48 patients, with a median age of 19 months (8 months-13 years). Position of meatus was glanular (40) or coronal (eight cases). Chordee required correction in 40 % (12/30). Urethral stenting was required in one case. There was no case of fistula, meatal regression, stenosis, or second procedure. A single case of mucosal prolapse was encountered. The majority (47/48) were performed as a day-case. Forty parents agreed to telephone interview. Cosmetic outcome was deemed satisfactory in 95 % (38/40). With regard to unsatisfactory cosmetic outcome, one had a megameatus and the other was aged 13 years and developed a mucosal prolapse. CONCLUSION: In selected cases, the MAGPI hypospadias repair provide excellent functional and cosmetic outcomes with minimal complications, and it can safely be performed as a day-case procedure.

Regional variations in testicular cancer rates in Ireland.

BACKGROUND: Traditionally, the incidence of testicular cancer (TCa) has shown a remarkable geographical variation. AIMS: To examine whether the rates of TCa varied within Ireland itself and to find possible explanations for any observations made. METHODS: We observed the incidence of TCa in counties in Ireland between January 1994 and December 2007. The rate of cryptorchidism over the same time was calculated. Incidence of TCa by socio-economic status was reviewed. The role of environmental pollutants was explored. We analysed teenage obesity data as a risk factor for the development of TCa in adulthood. RESULTS: Cork had a significantly higher rate of TCa than any other county in Ireland. Cork also had high rates of cryptorchidism, but interestingly not the highest nationwide. In Cork County specifically, least deprived areas had significantly higher rates of TCa. Organic pollutants previously linked to the development of TCa have been identified in large industries located only in Cork. Teenage obesity rates in Cork were not higher than elsewhere. CONCLUSIONS: There is a higher incidence rate of TCa in Cork than any other county. High rates of cryptorchidism alone cannot explain this. There appears to be a link with higher socio-economic status and possibly industrial pollutants. The association between sedentary lifestyle and the development of TCa is unproven.

Lessons learned using Snodgrass hypospadias repair.

BACKGROUND: This is a review of our experience with the Snodgrass technique for distal hypospadias repair and we point to lessons learned in improving results. METHODS: We reviewed all patients who underwent Snodgrass hypospadias repair for distal hypospadias over a four-year period by a single surgeon. Chart review followed by parental telephone interview was used to determine voiding function, cosmesis and complication rate. RESULTS: Thirty children and three adults were identified. Age at surgery ranged from seven months to 39 years. The urinary stream was straight in 94%, and 97% reported a good or satisfactory final cosmetic outcome. One patient (3.3%) developed a urethral fistula and 21% developed meatal stenosis which required general anaesthetic. CONCLUSION: The Snodgrass urethroplasty provides satisfactory cosmetic and functional results. High rates of meatal stenosis initially encountered have improved with modifications to technique which include modified meatoplasty and routine meatal dilatation by the parents.

The spectrum of urological disease in patients with spina bifida.

BACKGROUND: [corrected] Urological complications are the major cause of ill health during childhood and adult life of patients with spina bifida but the significance of urinary tract disease on the individual and the healthcare services is underemphasised. AIM: To assess the effects of spina bifida on the individual and the healthcare services. METHODS: A retrospective review was performed to assess the frequency and significance of urological conditions requiring hospital attendance in patients with spina bifida currently attending a specialised multidisciplinary clinic over a period of six months. RESULTS: Urinary sepsis accounted for the majority of admissions (62%), while 38 of 62 patients required 60 surgical procedures. Targeting the primary urological abnormality (the dysfunctional and usually poorly compliant bladder) allows implementation of effective treatments, including regular intermittent bladder catherisation (52%) in order to preserve upper renal tract function. Associated postural abnormalities complicated both conservative and interventional therapies. CONCLUSION: This study highlights the surgical commitment for units caring for patients with spina bifida, the important considerations for the future healthcare services, and the range and severity of urological diseases encountered by these patients.

Ischaemia-reperfusion injury in the rat kidney: the effect of preconditioning.

OBJECTIVES: To design and establish a model to examine whether brief periods of renal artery occlusion (ischaemic preconditioning, IP) confers protection from the effects of a subsequent period of ischaemia and reperfusion of the rat kidney. MATERIALS AND METHODS: Ninety rats were randomized into six groups, i.e. sham-operated controls; IP alone; a 20 or 40 min period of left renal ischaemia (RI) alone; and IP followed by a 20 or 40 min period of RI. Preconditioning involved the sequential clamping of the left renal artery for 4 min and its release for 11 min, a total of four times, a 'critical interval' of 30 min before the ischaemic insult. Left renal tissue integrity was determined by dimercapto-succinic acid (DMSA) radionuclide imaging on a gamma-camera both immediately (day 0) and 2 and 9 days later. Acute tubular necrosis was also assessed histologically. RESULTS: RI for 20 min resulted in a significant decrease in left renal tissue integrity on day 2 only (P < 0.001), whereas RI for 40 min caused significant left renal dysfunction on day 0, day 2 and day 9 (P < or = 0.01). For a given duration of ischaemia, there was no significant difference between results from (IP + RI) rats compared with RI-only rats at any of the three times. There was no significant alteration in renal tissue integrity in the IP-only rats compared with sham-operated controls. Histological findings paralleled the data obtained from DMSA uptake. CONCLUSIONS: The IP regimen and 30 min 'critical interval' confers no protection to the kidney from a 20 or 40 min ischaemic episode. The IP regimen itself appears to have no effect, confirming the validity of our experimental model.

Single ectopic ureterocele associated with ipsilateral renal dysplasia and undescended testis.

Ureterocele involving an ectopic ureter is often associated with complete duplex renal units. This report describes the rare association between an ectopic ureterocele with renal dysplasia and testicular maldescent.

Endoscopic laser ablation of the prostate (ELAP): changes in magnetic resonance imaging and clinical outcome at 1 year.

OBJECTIVE: To assess the ability of magnetic resonance imaging (MRI) to detect tissue changes immediately after laser ablation of the prostate and to correlate these changes with clinical outcome by detecting changes that may improve the outcome by allowing the laser dosimetry to be adjusted during therapy by monitoring effects on gland morphology. PATIENTS AND METHODS: Eight men with proven bladder outlet obstruction had a standard four-quadrant laser ablation of the prostate with a side-firing non-contact fibre. MRI scans were performed before, during and immediately after treatment and again after one week, 3 months and one year. RESULTS: The clinical outcome was a decrease in the American Urological Association (AUA)-7 symptom score from a pre-operative mean of 21.3-12.0 1 year after treatment and a corresponding increase in peak urinary flow rates from a mean of 8.9 mL/s to 12.3 mL/s. Immediately after treatment, MRI showed marked swelling of the gland (mean increase in volume 34%, range 12-75) with the loss of internal architecture. A low-signal thin periurethral band was present in six of the eight patients after 1 week and was replaced by a wider periurethral ring at 3 months in four of the six patients. No patient had evidence of prostatic cavitation after treatment or a significant reduction in prostate volume at 1 year. CONCLUSION: MRI can detect tissue changes after laser ablation of the prostate. The marked swelling seen on MRI immediately after laser prostatectomy may explain the delayed improvement in symptoms. The periurethral ring may indicate the depth to which laser energy has an effect on the tissue and could delineate an area of necrosis. The lack of cavitation at one year questions the durability of the effect of laser treatment delivered in this way.

Maternal serum human chorionic gonadotrophin during early pregnancy resulting in boys with hypospadias or cryptorchidism.

OBJECTIVE: To compare maternal serum human chorionic gonadotrophin (hCG) samples before 18 weeks gestation in mothers of boys with cryptorchidism or hypospadias with that in mothers of normal boys. The effect of season on maternal hCG was also assessed. SUBJECTS AND METHODS: Stored serum samples from mothers of singleton male fetuses born between January 1988 and December 1992 were assayed for total hCG, using a Delfia assay. There were 153 eligible samples from 96 mothers of normal boys, 31 of those with cryptorchidism, and 26 of those with hypospadias. RESULTS: The data from mothers of normal boys were used to construct a time-specific reference range for hCG. Plotting the hCG levels of the other groups and superimposing the reference range showed no significant difference between them (P = 0.09). Maternal hCG was not significantly different between cryptorchid boys requiring orchidopexy and those experiencing early spontaneous descent. An analysis of covariance allowing for gestational age showed that maternal hCG is significantly higher during the peak summer than peak winter months (P = 0.046). CONCLUSION: While a seasonal effect on maternal hCG was demonstrated our data does not suggest this to be the sole cause for cryptorchidism or hypospadias or to account for the observation that both have a seasonal frequency.

Endoscopic laser ablation of the prostate: MR appearances during and after treatment and their relation to clinical outcome.

OBJECTIVE: Endoscopic laser ablation is a new treatment for benign prostatic hypertrophy. The objectives of this study were to determine the appearances of the prostate on MR images obtained during, 1 week after, and 3 months after this procedure and to determine if a correlation exists between the MR findings and the clinical outcome. Such appearances could then be used to guide the application of laser energy during the procedure in order to optimize the clinical result. SUBJECTS AND METHODS: Eight consecutive men 58-74 years old with symptoms of bladder outflow obstruction caused by benign prostatic hypertrophy underwent endoscopic laser ablation of the prostate under spinal or epidural anaesthesia. Imaging was done on a 0.5-T Picker Asset system with an endorectal receiver coil and conventional T1-weighted spin-echo, T2-weighted spin-echo, and gradient-recalled-echo sequences. T1-weighted magnetization transfer images were obtained in three patients. Images were obtained preoperatively, after ablation of the left-sided quadrants, immediately after completion of the procedure, and 1 week and 3 months later. Preoperative and 3-month postoperative symptom scores, peak urine flow rates, and bladder residual volumes were studied. Images were visually assessed for signal-intensity changes and the presence of cavitation by three radiologists in conference. The results were quantitatively analyzed by measuring prostatic volumes on the gradient-recalled-echo images and by measuring the width and area of regions of signal-intensity change on the T2-weighted images. RESULTS: MR images made immediately after treatment showed an increase in the volume of the prostate (mean, 34%) and a poorly defined, low-signal-intensity region around the urethra on the T2-weighted images in six patients. This probably represented coagulative necrosis. The prostate was smaller on MR images made 1 week after treatment, and after 3 months the prostate returned to its preoperative size. After 1 week, the low-signal-intensity periurethral region on the T2-weighted images was less obvious, and at 3 months it was replaced in four patients by a well-demarcated low-signal-intensity ring on the T2-weighted and gradient-recalled-echo images. No evidence of cavity formation in the prostate was seen on MR images in any patient. Symptom scores and peak urinary flow rates improved after 3 months, with a significant difference between the mean increase in symptom scores in the patients with and without the periurethral changes seen immediately after treatment. However, we found no significant difference between the mean increase in peak urinary flow rates in the patients with and without periurethral changes seen either immediately or at 3 months after treatment. No statistically significant correlation was found between the amount of prostatic swelling and the improvement in symptom scores or peak urine flow rates. CONCLUSION: In patients who have had laser prostatectomy, MR imaging shows significant immediate glandular swelling, which may account for the delayed improvement in symptoms reported with this technique. The presence of the periurethral changes immediately after treatment was correlated with a subsequent improvement in symptom scores. After 3 months, no cavity could be seen in the prostate. This may account for the poorer long-term clinical outcome reported with endoscopic laser ablation of the prostate compared with transurethral prostatectomy.

Scientific basis of testicular descent and management implications for cryptorchidism.

Cryptorchidism occurs in about 1% of boys, but has a raised incidence in those with deficiencies of androgen function. Greater knowledge of fetal-maternal endocrinology and related experimental work has provided evidence that fetal testicular endocrine function is vital in descent of the gonad. The therapeutic use of hCG has, however, been disappointing, and its role is confined to helping to distinguish the retractile from the undescended testis. Cryptorchidism is commonly associated with congenital pathological defects such as ductal abnormalities, and others (including interstitial fibrosis and a reduction in germ cells) develop after 1-2 years, while later these patients are at greater risk of carcinoma in situ and germ cell cancer. The demonstration of the early pathological changes has recently dictated much earlier surgical correction, but long-term follow-up is needed to prove clinical benefit from this practice.

Acute and chronic bioeffects of single and multiple doses of piezoelectric shockwaves (EDAP LT.01).

Piezoelectric second generation lithotriptors are an established means of administering extracorporeal shockwave lithotripsy (ESWL) enabling treatment to be performed without anaesthesia or analgesia, but higher shockwave doses and multiple or staged treatment are frequently required. The bioeffects of this modality of ESWL, therefore, require further assessment. Seven experimental groups of adult male rabbits were treated using the EDAP LT.01 in order to determine the acute and chronic bioeffects of clinical dose, excess dose, divided excess dose, high frequency and multiple treatment (X10) piezoelectric shockwaves (PSW). Renal function was measured before and after treatment using mercaptoacetyltriglycine (MAG 3) scans. Gross and histological morphological changes were assessed at one and 30 days following application of PSW. Application of single clinical dose PSW was not associated with any significant functional or morphological renal injury. Excess dose PSW caused transient gross renal contusion, which resolved in the majority of animals with no persistent microscopic abnormality. Divided excess dose PSW resulted in no gross or microscopic damage. High frequency PSW was associated with mild histological abnormality. Multiple PSW treatments caused small discrete fibrotic lesions in all cases, without any change in renal function.

Ultrasonic imaging for extracorporeal shockwave lithotripsy: analysis of factors in successful treatment.

The emergence of real-time ultrasonic imaging for extracorporeal shockwave lithotripsy poses questions regarding the factors and techniques which facilitate stone imaging for clinicians with no previous practical experience in ultrasonography. The ability of these clinicians to assess when stone disintegration has been achieved also needs to be confirmed. A wide range of data was recorded from each of 2688 lithotripsy treatments performed over a 2-year period using the EDAP LT.01 ultrasound-imaged piezoelectric lithotriptor. An analysis of these data was performed using a comprehensive microcomputer-based statistics package. The mean time taken for stone imaging and positioning was reduced from 11.2 to 7.5 min over the 2-year period. Obese patients and those with renal pelvic stones were best imaged in a lateral position. Overall there was no difference in percentage stone disintegration or clearance between treatments in the supine or lateral positions, but a significant reduction in the clearance of small caliceal stones resulted when the lateral position was used. Factors associated with a significantly greater percentage of stone disintegration and clearance included pain experienced by the patient during fine adjustment of the processing head during treatment, acoustic focus attenuation and widening and acoustic shadow widening as detected by the urologist at the end of treatment. Among the factors not associated with significant alterations in the percentage of stone disintegration or clearance were the lithotriptor operator, the side or site of the calculus, obesity and shockwave frequency or power. This study confirmed the ability of urologists to develop expertise in ultrasonography for renal stone imaging and to interpret successfully the subtle signs of stone disintegration.