Adolescent varicocele: limited indications for treatment during puberty and adolescence.

A varicocele is defined as an abnormal dilatation of the pampiniform plexus of veins of the testis. The vast majority of children and adolescents with varicoceles have no subjective symptoms. The complete work-up of patient diagnosed with a varicocele involves a physical exam in supine and prone position with and without Valsalva, and the use of ultrasound to measure testicular volume and blood flow. Because of growth issues occurring during puberty and adolescence, serial follow-ups may be done to determine any detrimental change in testicular size and symptomatology. The main difference of an adolescent varicocele is the fact that semen parameters are unavailable and do not count for treatment strategy. In this review, the focus is made on a recent study that has evaluated the ultimate endpoint: paternity. It appears that screening and treatment of a varicocele in the adolescent period does not influence the ultimate chance of paternity.

Vesicoureteral reflux: current trends in diagnosis, screening, and treatment.

CONTEXT: Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. OBJECTIVE: Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. EVIDENCE ACQUISITION: A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organizations. EVIDENCE SYNTHESIS: We objectively assessed and summarized the published data, focusing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. CONCLUSIONS: The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments.

Does preoperative chemotherapy ease the surgical procedure for Wilms tumor?

PURPOSE: A conclusion of Société Internationale d'Oncologie Pédiatrique in 2001 after protocol 2, 5, 6, 9 and 93-01 was that "preoperative chemotherapy would make nephrectomy easier and furthermore, metastases may disappear or become resectable and vascular extension may regress and partial nephrectomy may become possible." We changed our strategy from preoperative chemotherapy in select cases only to standard 4 to 6-week preoperative chemotherapy in all. However, it appears dubious whether surgical ease or perioperative complications consistently improved after preoperative chemotherapy. We investigated volume changes after chemotherapy and compared all possible variables at a single center using the same surgical team. MATERIALS AND METHODS: A total of 32 children with Wilms tumor between 1998 and 2007 were included in a retrospective analysis, including 15 without preoperative chemotherapy according to the National Wilms' Tumor Study Group protocol before 2001 and 17 with preoperative chemotherapy according to the Société Internationale d'Oncologie Pédiatrique 2001 protocol. We studied the change in tumor volume using picture archive and communication systems volume measurement after chemotherapy, surgical procedure parameters (child body mass index, length and type of incision, blood loss, operative time, hospital stay, pain medication and complications) and outcome (histology and staging). Statistical analysis was performed using the t, Fisher and chi-square tests. RESULTS: The 2 groups were comparable in gender, age (mean 5.4 and 3.9 years, respectively) and staging at diagnosis. At diagnosis mean +/- SD Wilms tumor volume was 408.93 +/- 387.39 and 454.58 +/- 236.71 cm(3) in the nonchemotherapy and chemotherapy groups, respectively. In the chemotherapy group 12 of 17 tumors decreased a mean of 60.9% +/- 24.6% and 5 of 17 increased 42.8% +/- 31.3%. No analyzed parameters were different in the 2 groups. CONCLUSIONS: Our single center analysis with the same surgical team before and after the preoperative chemotherapy era show that it remains unpredictable whether surgery in a child with Wilms tumor is safer and easier after preoperative chemotherapy.

Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys.

OBJECTIVES: To evaluate the long-term efficacy of topical application of a potent corticoid cream and skin stretching in the treatment of unretractable foreskin, pinpoint phimosis, balanopreputial adhesions and lichen sclerosus in prepubertal boys. METHODS: 462 prepubertal boys (mean age 4.7 years) with unretractable foreskin applied a topical potent corticoid cream together with skin stretching twice daily for 6 weeks. Follow-up interview of all patients was performed to evaluate long-term results (median 22 months). Short- and long-term results were compared and evaluated. RESULTS: 400/462 boys (86%) had a retractable prepuce after 6 weeks of treatment. 62/462 boys had no or only a partial response. After a median follow-up of 22 months, the treatment continued to be successful in 383/462 boys (83%). In 76/462 boys the foreskin was unretractable, of which 35 preferred surgical treatment. 12/462 boys presented with lichen sclerosus and the non-surgical treatment appeared efficient in 9/12 (67%). CONCLUSIONS: This study has shown that local application of a potent corticoid cream and skin stretching is a safe, simple and effective long-term treatment for all types of unretractable foreskin in prepubertal boys. The efficiency of the treatment was not related to the age of the patient or the type of unretractable foreskin.

Testicular histology in boys with Prader-Willi syndrome: fertile or infertile?

PURPOSE: Prader-Willi syndrome is associated with hypogonadism. Cryptorchidism is found in 93% of cases and considered a phenotypic criterion. Men with Prader-Willi syndrome are thought to be infertile. To study the fertility probability in boys with Prader-Willi syndrome we analyzed testicular histology in 8 prepubertal boys and 1 man. MATERIALS AND METHODS: Eight boys 16 months to 14 years old with a proven molecular diagnosis of Prader-Willi syndrome, including 6 with a deletion on chromosome 15 and 2 with uniparental maternal disomy of chromosome 15, underwent orchiopexy and the man underwent unilateral orchiectomy. Prepubertal testes were classified into 4 Nistal categories according to mean tubular diameter, the tubular fertility index (average percent of tubules containing spermatogonia) and the Sertoli's cell index. RESULTS: Two of 8 prepubertal boys showed a favorable Nistal score of I, 1 showed a Nistal score of II and 5 showed a Nistal score of III. The testis in the man showed diffuse tubular atrophy with tubular hyalinization, a Sertoli's cell nodule, vacuolized Leydig cells, peritubular hyalinization and small tubuli. CONCLUSIONS: Prader-Willi syndrome appears to be a heterogenic disorder with respect to testicular histology. Although most boys showed absent spermatogonia, 2 of 8 had normal testicular histology. Therefore, it is suggested that it is uncertain what the fertility outcome is in boys with Prader-Willi syndrome.

Prenatal magnetic resonance imaging demonstrates linear growth of the human fetal kidneys during gestation.

PURPOSE: Although fetal kidneys have only 10% of their postnatal blood flow, fetal renal development is essential for normal postnatal function. In addition, to our knowledge it is unknown whether human fetal kidney development follows a linear or exponential evolution. We created normative magnetic resonance imaging curves for the kidney prenatal growth pattern in relation to gestational age. MATERIALS AND METHODS: A total of 142 human fetuses at between 20 and 36 weeks of gestation underwent prenatal magnetic resonance imaging for nonurological pathology (pulmonary, cerebral or maternal abnormalities). Twins, urinary tract abnormalities, oligohydramnios or anhydramnios were excluded. T2-weighted images (single shot turbo spin-echo) were used to measure kidney variables. Bipolar and anteroposterior diameters of the 2 kidneys were measured and correlated with gestational age using linear regression analysis. RESULTS: A linear relationship of the bipolar and anteroposterior diameters was found according to gestational age in weeks (p <0.0001). No substantial differences between growth of the left and right fetal kidneys was identified. Bipolar length of the human fetal kidney increases at an average rate of 1.24 mm per week of gestation, while anteroposterior diameter increases at 0.57 mm per week of gestation between weeks 20 and 36. This indicates that bipolar diameter increases twice as rapidly as anteroposterior diameter. Regression analysis curves showed a good fit to the measured data points (anteroposterior and bipolar measurements R2 = 0.36 and 0.58, respectively). The CIs of function variables were small, enabling their use as normative curves. CONCLUSIONS: This prenatal magnetic resonance imaging study demonstrates linear growth of the bipolar and anteroposterior diameters of human fetal kidneys in relation to gestational age. In addition, it is clear that bipolar diameter grows twice as rapidly as anteroposterior diameter and there is less variability for bipolar diameter. These normative curves may allow us to detect abnormal fetal evolution.

A new fast-melting oral formulation of desmopressin: a pharmacodynamic study in children with primary nocturnal enuresis.

OBJECTIVE: To determine the pharmacodynamic properties of a new oral lyophilisate formulation of desmopressin (in single doses of 30, 60, 120, 240, 360 or 480 microg) in children with known primary nocturnal enuresis (PNE) and thus identify those dosages that could provide a duration of action corresponding to a typical length of night-time sleep in children with PNE; additional objectives were to determine the safety and tolerability of desmopressin in this population. PATIENTS AND METHODS: Children with PNE (mean three or more wet nights/week), aged 6-12 years, were randomized into a double-blind, placebo-controlled study. An overhydration technique was used before dosing to suppress endogenous vasopressin production and thereby ensure that any antidiuresis could be attributed to treatment. Dosing with desmopressin or placebo occurred when urinary production was >0.13 mL/min/kg. Urinary volume, osmolality and duration of urinary-concentrating action (above three threshold levels: 125, 200 and 400 mOsm/kg) were determined as endpoints. RESULTS: All 72 participants receiving desmopressin had a pharmacodynamic response to the drug, while there was no change in urinary output in the 12 placebo-treated patients. There was a clear relationship between desmopressin dose and duration of action and osmolality during action, although the three highest-dose groups had similar results. The mean duration of action of desmopressin at the lowest osmolality threshold level was 3.6-10.6 h, according to dose; for the highest threshold, the values were 1.3-8.6 h. CONCLUSION: Desmopressin, as the oral lyophilisate, causes a marked decrease in urinary output in hydrated children with PNE. A small dose range (120-240 microg) is likely to control diuresis for a period corresponding to a night's sleep (7-11 h) in most children with PNE. However, some patients might require a higher dose to obtain antidiuresis for the complete night.

Additional to caudal bupivacaine preemptive oral ibuprofen does not improve postoperative pain, nausea or vomiting, and resumption of normal activities in children after ambulatory pediatric urologic surgery.

OBJECTIVES: To investigate the possible advantage of administration of preemptive oral ibuprofen in children after ambulatory pediatric urologic surgery such as penile surgery (circumcision and hypospadias repair) and inguinal surgery (communicating hydrocele and orchidopexy), a study was performed on the experience of postoperative pain, nausea or vomiting, and resumption of normal activities such as normal sleep and play activity. In addition, this study has validated a method of measurement of pain and resumption of normal activities in children. MATERIAL AND METHODS: In a prospective, randomized, double-blind study, 66 prepubertal boys (0-12 years) underwent an ambulatory pediatric urological intervention. One hour prior to surgery, the experimental group received 10 mg/kg oral ibuprofen along with their usual premedication (<8 years midazolam 0.5 mg/kg PO or rectal; >8 years or >30 kg alprazolam 0.5 mg, 0.25-0.5 mg PO), whereas the children of the control group received only the usual premedication. Anesthesia was achieved with Sevorane (Sevoflurane) inhalation induction (Sevoflurane 8% in 50% N(2)O/50% O(2)) and a locoregional caudal block (0.5-1.0 ml/kg levobupivacaine 0.25% with a maximum of 30 ml). Immediate postoperative pain was assessed by the child, the parents and a single observer using the Faces Pain Scale and the CHEOPS behavioral scale (Children's Hospital of Eastern Ontario Pain Scale). Vomiting and nausea were also assessed. On the first and second postoperative day the same variables were evaluated by the child and the parents, as well as quality of sleep and play, and need for pain medication. RESULTS: No difference in the experience of pain was found at any point after the operation between the experimental and control groups; moreover, the consumption of pain medication postoperatively did not differ between the two groups. There was also no difference in the incidence of vomiting and nausea in the hospital or at home (p>0.05). The method for measuring pain and normal activities was validated as the assessments of the parents, children and the investigators were concordant throughout the study. CONCLUSIONS: Children who received preoperative oral ibuprofen (10 mg/kg) did not experience less pain or less nausea and vomiting, and did not show a better pattern of sleep and play up to 2 days after ambulatory pediatric urologic surgery than children who did not receive this medication.

The physical and antimicrobial effects of microwave heating and alcohol immersion on catheters that are reused for clean intermittent catheterisation.

INTRODUCTION: Due to worldwide different health insurance policies, patients are often forced to reuse the catheters when performing Clean Intermittent Catheterisation (CIC). We have compared the physical qualities and the antimicrobial effects of two methods of reusing catheters: microwave heating and storage of the catheters in a 70% alcohol solution. The studies were performed during different lengths of time. MATERIALS AND METHODS: Three types of catheters (a standard polyvinylchloride catheter, a special polyvinylchloride catheter with flexible Ergothan tip and a prelubrified catheter), normally intended for single use, were submitted to the effect of a microwave oven (Multitech 215 High Grade and Whirlpool M220 750 W and 1000 W with rotating plate) or preservation in a 70% alcohol solution. To study the effects of microwave heating, a recipient of water was placed in the oven to spread the microwaves and to absorb the heat. The catheters were placed in a resealable plastic bag (Ziploc. To study the effects of preservation in a 70% alcohol solution, the catheters were immerged in the solution for different lengths of time. Thereafter were the physical qualities of the catheters evaluated by using the technique of Differential Scanning Calorimetry (DSC). The antimicrobial effect of the method was evaluated after grafting the catheters with pathogenic E. coli, P. aeruginosa or S. aureus strains. RESULTS: Microwave heating up to 12 minutes at 750 W caused only minimal changes in the physical qualities of all the catheters. However, there was only an antimicrobial effect of the microwave heating on E. coli and not on P. aeruginosa or S. aureus. If the catheter remained longer than 45 minutes in a 70% alcohol solution, the physical qualities of the catheter changed either minimal in the special polyvinylchloride catheter with flexible Ergothan top but changed significantly in the prelubrified catheter). However, already after 5 minutes of immersion in the 70% alcohol solution there was a complete antimicrobial effect on E. coli, P. aeruginosa and S. aureus in all catheters. CONCLUSIONS: It should be recommended to patients on CIC to use a sterile packed and not previously used catheter. In this study we have shown that immersing the catheters in a 70% alcohol solution during 5 minutes can effectively disinfect the catheter without jeopardising the physical qualities. Thereafter, the catheters could be placed in a resealable (e.g. Ziploc bag without being rinsed under water, in order that the few drops of alcohol cause alcohol vapours within the closed plastic bag and maintain the antimicrobial effect.