Use of non-invasive uroflowmetry with simultaneous electromyography to monitor patient response to treatment for lower urinary tract conditions.

OBJECTIVE: Non-invasive uroflowmetry with simultaneous electromyography (uroflow/EMG) has previously been reported as effective in triaging patients into four specific non-neurogenic lower urinary tract (LUT) conditions for targeted treatment. In this study we sought to determine if the same parameters would be useful for measuring response to treatment. MATERIAL AND METHODS: We reviewed our database of normal children with LUT dysfunction, screened with uroflow/EMG, and diagnosed with a LUT condition: (1) dysfunctional voiding (DV); (2) idiopathic detrusor overactivity disorder (IDOD); (3) detrusor underutilization disorder (DUD); (4) primary bladder neck dysfunction (PBND). Pre- and on-treatment (minimum 3 months) uroflow/EMG parameters and subjective improvements were compared. RESULTS: Of 159 children (71 boys, 88 girls; median age 7.0 years, range 3.5-18.0 years), median follow up was 13.1 months (range 3-43 months). On targeted treatment, DV patients showed relaxation of pelvic floor during voiding and significant decrease in PVR on biofeedback; IDOD patients had normalization of short lag time and increased capacity on antimuscarinics; DUD patients had a decrease in capacity on timed voiding; PBND patients on alpha-blocker therapy showed improved uroflow rates and a decrease in mean EMG lag time (all p < 0.05). CONCLUSION: Non-invasive uroflow/EMG is useful not only for diagnosing specific LUT conditions, but also in objectively monitoring treatment efficacy. Subjective improvement on targeted therapy correlates well with objective improvements in uroflow/EMG parameters lending validation to this simplified approach to diagnosis.

Adolescent varicocelectomy: does artery sparing influence recurrence rate and/or catch-up growth?

The prevalence of varicocoeles is 15% in the general adolescent and adult male population and in 35-40% of men evaluated for infertility. While varicocelectomy can be performed using various methods and techniques, the laparoscopic approach allows for clear visualization of the testicular artery and lymphatics. Amongst urologists, particularly paediatric urologists, and andrologists there is much debate regarding the significance of testicular artery sparing when performing a varicocelectomy, with some believing that ligating the testicular artery impairs catch-up growth and future fertility. On the other hand, several studies have reported higher failure rates with artery preservation. To help resolve the debate regarding the significance of artery sparing, we sought to compare varicocoele recurrence rate and catch-up growth in patients who underwent artery sparing laparoscopic varicocelectomy compared with those who had the artery sacrificed. We identified 524 laparoscopic varicocelectomies in 425 patients from our adolescent varicocoele database. Only patients who had ultrasound determined testicular volume measurements pre-operatively and at least 6 months post-operatively were included. Post-operative persistence/recurrence of varicocoele, testicular atrophy and repeat varicocelectomy were noted. Catch-up growth was compared between procedures in those with significant pre-operative asymmetry. Four hundred and forty primary laparoscopic varicocelectomies were performed in 355 patients (mean age: 15.5 years, range 9.3-20.6; mean follow-up: 32.9 months, range 6.0-128.9) who had both pre- and post-varicocelectomy scrotal Duplex Doppler ultrasound performed. The testicular artery was preserved in 54 varicocoeles (41 patients) and ligated in 384 varicocoeles (312 patients). We observed an increased rate of persistent/recurrent varicocoele in the artery-sparing vs. artery ligating patients (12.2% vs. 5.4%, p = 0.09). In addition, there was no difference in catch-up growth and no instance of testicular atrophy. As artery sparing varicocelectomy offered no advantage in regards to catch-up growth and was associated with a higher incidence of recurrent varicocoele, preservation of the artery does not appear to be routinely necessary in adolescent varicocelectomy.

The valve bladder syndrome: 20 years later.

PURPOSE: Just more than 20 years ago a group of associated findings was identified in patients with posterior urethral valves and persistent upper tract dilatation following valve ablation, including a noncompliant thick walled bladder, incontinence and nephrogenic diabetes insipidus. Subsequently the pseudonym "valve bladder syndrome" became associated with this phenomenon. The history of the valve bladder syndrome concept, continuing debate regarding the etiology and management of the valve bladder, and 20 years of urodynamic and histological investigations are reviewed. MATERIALS AND METHODS: Outcome studies, histological findings, animal model experimentation and urodynamic investigations reported in the literature more than the last 20 years were reviewed and compared. RESULTS: Varying degrees of bladder compliance loss are seen in the majority of patients following valve ablation. Severe loss of compliance can lead to persistent upper tract dilatation and later urinary incontinence. A large urine output, secondary to a loss of renal concentrating ability, contributes to the persistent dilatation and incontinence. Correcting bladder compliance loss helps to lessen the dilatation and incontinence. A literature review revealed little to support the belief that previous temporary diversion is the major cause of severe compliance loss. In fact, instances of severe compliance loss were seen following any mode of therapy, including valve ablation alone, and likely represents a persistent finding secondary to the degree of damage incurred in utero. That there are more patients requiring augmentation after temporary diversion should not imply that diversion caused the poor compliance but that an initially poorly compliant bladder lead to diversion as the choice of treatment. Some investigators have found that many temporarily diverted cases have a bladder equal to or even better in function and capacity than those treated with valve ablation alone. Others have made a case but less substantially to conclude that diversion is the most significant cause of a small, poorly compliant bladder. CONCLUSIONS: Valve ablation alone without urodynamic followup is inappropriate. Proactive management must have a significant role. The vast majority of temporarily diverted cases do not result in a fibrotic, noncompliant bladder. Surgeons who strongly favor diversion should be comfortable with such an approach, although in most cases if diversion is considered, those same patients often can be treated just as adequately with proactive urodynamics and anticholinergic therapy without the required surgery for undiversion. With great anticipation, we look forward to studies that will determine if growth factor inhibitors or angiotensin converting enzyme inhibitors will have a role in preventing or reversing the histological changes of the valve bladder.

The adolescent varicocele. II: the incidence of hydrocele and delayed recurrent varicocele after varicocelectomy in a long-term follow-up.

OBJECTIVE: To determine, in adolescent boys after varicocelectomy, the incidence of hydroceles, when they develop and whether the development is procedure-related. PATIENTS AND METHODS: The records were retrospectively reviewed of 77 boys who underwent 95 varicocelectomies and had an examination at > or = 6 months after surgery. Fifty-six patients underwent a standard Palomo procedure (45 left and 11 bilateral) and 21 a modified Ivanissevich repair (14 left and seven bilateral). The mean (range) age of the patients at surgery was 14.1 (10-22) years and the mean follow-up 25.5 (6-84) months. RESULTS: Of the 67 Palomo varicocelectomies 19 (24%) were complicated by hydroceles after surgery, compared with four of 28 (14%) Ivanissevich procedures (P = 0.034). Of the Ivanissevich repairs, none of the 14 unilateral repairs developed hydroceles. Three hydroceles (one bilateral and one left) developed in two of seven patients after bilateral varicocelectomy. Of the Palomo repairs, 12 of 45 unilateral repairs were complicated by hydroceles, and seven developed in five of 11 patients after bilateral varicocelectomy. Although more hydroceles developed after bilateral varicocelectomy, there was no significant difference from the unilateral group. However, patients who developed hydroceles after bilateral varicocelectomy were more likely to require hydrocelectomy (P = 0.013, Fisher's exact test), implying that hydroceles developing after bilateral repair tend to be larger. Of the hydroceles, two were detected in the first 6 months after surgery, nine at 6-12 months, three at 13-18 months, five at 19-24 months and four at > 2 years after surgery. Three patients had late varicocele recurrence, i.e. 15, 37 and 76 months after surgery; these patients had not had varicoceles on palpation after surgery at 3, 14 and 63 months, respectively. CONCLUSION: Hydroceles are detected infrequently within 6 months of varicocelectomy, with most occurring after 6 months and even appearing after 3 years. They occur significantly more often after a Palomo repair. More hydroceles develop after bilateral repair regardless of the technique used, but not significantly so. Because hydroceles often develop, a lymphatic-sparing procedure should be used, especially for bilateral repair. Recurrent varicoceles may appear as late as 76 months after varicocelectomy in patients where none had been detected at a mean of 27 months after surgery.

Laparoscopic partial upper pole nephrectomy in infants and children.

OBJECTIVE: To retrospectively review 5 years' experience of transperitoneal laparoscopic partial nephrectomy (LPN) in infants and children. PATIENTS AND METHODS: Between January 1995 and December 1999, 14 upper-pole partial nephrectomies (seven right and seven left) were undertaken in 13 children (mean age 3.8 years, range 0.4-14). One patient underwent bilateral upper-pole LPN. No children required a lower-pole partial nephrectomy during the study period. Evaluation included renal ultrasonography, voiding cystourethrography, renal scintigraphy and contrast-enhanced computed tomography in some cases. Three ports (10, 5 and 5 mm) were used in all except two patients, who required an additional 2 mm port for liver retraction. The diseased parenchyma was transected with electrocautery or harmonic scalpel. The distal ureter was simply transected in the absence of reflux, but tied adjacent to the bladder if reflux was present. RESULTS: The mean operative duration for LPN was 100 min, with an estimated blood loss of < 30 mL. A liquid diet was tolerated on the first morning after surgery and age-appropriate regular diet that evening in all except one patient. The mean hospital stay was 2.6 days. One patient had a significant decrease in haematocrit, which was managed conservatively, not requiring transfusion. Follow-up telephone interviews with the patients' parents showed that all were satisfied with the medical and cosmetic outcome. CONCLUSION: Transperitoneal LPN is preferable to open partial nephrectomy because: (i) The magnification provided by laparoscopy provides excellent vision for the precise dissection of the parenchyma and distal ureter, avoiding injury to the healthy tissue; (ii) There is minimal blood loss, fast recovery and less surgical scarring, and when upper-pole partial nephrectomy is required, LPN is less damaging to the lower-pole. Unlike total nephrectomy, where debate remains about open vs laparoscopic methods, the specific advantages of LPN make it clearly preferable.

The adolescent varicocele I: left testicular hypertrophy following varicocelectomy.

PURPOSE: Ipsilateral testicular catch-up growth has been reported to occur in approximately 80% of adolescents with varicoceles following unilateral varicocelectomy. We have been observing not only catch-up growth, but hypertrophy (left at least 10% larger than right testicular volume) in some adolescents postoperatively. To our knowledge this phenomenon has not been previously described. We assess the incidence of left testicular hypertrophy following ipsilateral varicocele ligation and whether it is related to age at operation and/or procedure performed. MATERIALS AND METHODS: We reviewed the records of 42 patients who underwent unilateral left varicocelectomy for asymptomatic varicoceles. Testicular volume was determined before and after surgery, and all patients were followed for a minimum of 6 months. Indication for surgery was ipsilateral left testicular hypotrophy in 23 cases, grade 2 to 3 varicocele with palpably softer ipsilateral left testicle in 5, grade 3+ varicoceles in 12, an exaggerated response to gonadotropin-releasing hormone stimulation test in 1 and persistent pain in 1. Average patient age at operation was 14.7 years (range 9 to 22) and average followup was 22 months (range 6 to 84). Patients were stratified according to Palomo versus modified Ivanissevich technique and age at operation. Testes were measured using the Takihara ring orchidometer with relative volume of the left testis expressed as a percentage of the right testis. Results were compared in different age groups as well as by procedure performed to correct the varicocele using chi-square analysis. RESULTS: Left testicular hypertrophy developed in 13 of 32 patients (43.8%) who underwent a Palomo repair and in 3 of the 10 (30%) who underwent a modified Ivanissevich repair. When compared by age at operation, 8 of 20 patients (40%) 14.7 years old or younger had left testicular hypertrophy compared to 8 of 22 (36.4%) older than 14.7 years. Differences between these groups were not statistically significant. CONCLUSIONS: Ipsilateral testicular hypertrophy occurs in a substantial number of adolescents following varicocele ligation. This phenomenon does not seem to be dependent on age at surgery or type of varicocele repair.

Serum inhibin B levels and the response to gonadotropin stimulation test in pubertal boys with varicocele.

PURPOSE: The impact of varicoceles on gonadal function in adolescents has been evaluated using several parameters, including size of testes, hormonal levels and provocative endocrine testing. Inhibin B has been demonstrated to be decreased in men with testicular damage from conditions other than varicocele. We determine whether inhibin B levels are low in adolescent boys with varicocele, and if there is a relationship between inhibin B and an exaggerated response to gonadotropin-releasing hormone (Gn-RH) stimulation testing, testicular hypertrophy and/or varicocele bilaterality. MATERIALS AND METHODS: We studied 9 boys at Tanner stages III to V of pubertal development who had either left or bilateral varicoceles. Basal inhibin B, follicle-stimulating hormone, luteinizing hormone and testosterone were measured. Each patient underwent Gn-RH stimulation testing. RESULTS: All patients had essentially normal inhibin B levels for Tanner stage. Of the 9 boys 4 had an exaggerated response to Gn-RH stimulating testing. Inhibin B levels did not vary significantly either with the presence of bilateral or unilateral varicoceles or asymmetric testis. CONCLUSIONS: The lack of correlation between inhibin B levels and the aforementioned parameters failed to suggest that inhibin B has a significant role in the clinical assessment of testicular function in adolescents with varicocele. Further studies of larger populations may further elucidate the value of inhibin B levels and varicoceles.

Vesicoureteral reflux in infants with prenatal hydronephrosis confirmed at birth: racial differences.

PURPOSE: We compared the incidence of vesicoureteral reflux in black and nonblack patients in whom prenatal hydronephrosis was confirmed postnatally. MATERIALS AND METHODS: We reviewed the records of 58 black and 51 nonblack patients with confirmed hydronephrosis who underwent voiding cystourethrography. RESULTS: Reflux was present in 9 cases (8.3%). The prevalence of reflux in black and nonblack patients was 0 and 17.6%, respectively. CONCLUSIONS: The absence of vesicoureteral reflux in black infants with prenatal hydronephrosis and the 17.6% incidence in nonblack infants suggest that voiding cystourethrography should not be routinely performed in the black population, although it should continue to be done on a routine basis in the nonblack population.

The Koyanagi-Nonomura 1-stage bucket repair of severe hypospadias with and without penoscrotal transposition.

PURPOSE: We report our experience with 1-stage Koyanagi-Nonomura hypospadias repair, which may be performed even when penoscrotal transposition is present. Repair involves bilateral parameatal skin flaps based on the meatus and urethral plate. MATERIALS AND METHODS: A total of 14 boys 10 to 20 months old underwent 1-stage Koyanagi-Nonomura repair for severe hypospadias. The meatus was proximal to the penoscrotal junction in all patients, and in 8 penoscrotal transposition was corrected during the same operation. RESULTS: In 7 of the 14 boys 1 or more fistulas developed that were subsequently repaired. In all cases the fistula was on the proximal shaft and/or penoscrotal junction. In no case was there stenosis or breakdown of the distal neourethra. CONCLUSIONS: The Koyanagi-Nonomura 1-stage repair provides excellent cosmetic results in severe hypospadias while preserving the available urethral plate tissue. It is particularly suitable when there is associated penoscrotal transposition. Most if not all 1-stage repairs are inappropriate in patients with severe hypospadias and penoscrotal transposition. In other repairs vascular supply to Byar's flaps and the neourethra may be compromised by mobilization of the anteriorly transposed scrotal tissue. We expect that the fistula rate will decrease with experience but now it is acceptable, considering the severity of hypospadias.

Ex vivo intracystic contrast studies of multicystic dysplastic kidneys.

PURPOSE: Classically cysts in multicystic dysplastic kidneys are described as noncommunicating. We determined the accuracy of this hypothesis by performing ex vivo intracystic contrast studies of the typical multicystic kidney and hydronephrotic form of the multicystic kidney. MATERIALS AND METHODS: We evaluated 7 multicystic dysplastic kidneys in patients between 2 weeks and 6 months old using intracystic injection of contrast material, including 4 that were typical and 3 with the hydronephrotic form of multicystic disease. Six and 1 kidneys were evaluated ex vivo and percutaneously, respectively. We obtained images during injection and shortly thereafter. RESULTS: When contrast material was injected into 1 cyst, it was eventually seen in most of the other cysts in all 7 kidneys. In 6 kidneys discrete ducts were clearly visualized between the cysts. In the hydronephrotic form of the disease these ducts connected to a pelvis-like structure. When evaluated grossly and the cysts were unroofed, a small orifice was noted in each cyst that sometimes admitted a 3.5F feeding tube. CONCLUSIONS: It is generally thought that multicystic kidneys represent a condition with noncommunicating cysts. We believe that the cysts in most multicystic kidneys communicate whether or not a renal pelvis is present.

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves.

PURPOSE: There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. MATERIALS AND METHODS: We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. RESULTS: Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. CONCLUSIONS: Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Management of posterior urethral valves on the basis of urodynamic findings.

PURPOSE: Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation. MATERIALS AND METHODS: After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization. RESULTS: Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2. CONCLUSIONS: Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

Periurethral collagen injection for the treatment of urinary incontinence in children.

PURPOSE: We assessed the efficacy and safety of periurethral collagen injection for urinary incontinence in children with neurogenic bladder dysfunction. MATERIALS AND METHODS: We treated 11 children (mean age 10.6 years) who had incontinence and neurogenic bladder dysfunction with periurethral injections of glutaraldehyde cross-linked collagen. All patients were on anticholinergics and all but 1 were on clean intermittent catheterization preoperatively. Four patients had previously undergone augmentation cystoplasty. All patients were assessed before and after injection with a subjective continence scale and multichannel urodynamics. Followup ranged from 4 to 20 months from the last injection. RESULTS: Mean group Valsalva leak point pressure was 34.5 cm. water. Four of the 11 patients had an identifiable detrusor leak point pressure. Overall success rate was 55% with 4 patients dry and 2 improved. Success correlated with a minimum increase in Valsalva leak point pressure of 20 to 25 cm. water to greater than 60 cm. water. Three patients had no demonstrable Valsalva leak point pressure after injection. All 5 patients in whom treatment failed had no change in Valsalva leak point pressure, including 2 with small capacity, poorly compliant bladders preoperatively. Because they had a component of sphincteric insufficiency, they underwent injection in the hope of increasing capacity with increased continence. In 3 patients Valsalva leak point pressure was greater than 50 cm. water. Detrusor leak point pressure developed in 3 patients postoperatively, including 1 with significantly increased Valsalva leak point pressure. One patient with significantly increased Valsalva leak point pressure had urethral hypermobility postoperatively. Of the 3 patients who subsequently underwent augmentation cystoplasty 1 is now dry, 1 is wet and 1 died of complications unrelated to urological disease. Patients underwent 1 to 4 procedures (mean 2.5). CONCLUSIONS: Periurethral collagen injection may be effective for urinary incontinence in patients who have adequate capacity with good compliance and low Valsalva leak point pressure. When there is no response to repeat injections or a transient response, one should consider the possibility of bladder decompensation.

Comparative urodynamic findings after primary valve ablation, vesicostomy or proximal diversion.

PURPOSE: There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy. MATERIALS AND METHODS: Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation. RESULTS: Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months. CONCLUSIONS: Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.