Age at orchidopexy in the UK: has new evidence changed practice?

INTRODUCTION: Research suggesting progressive deterioration in an undescended testis has led to the reduction in the target age for orchidopexy to 6-12 months of age. This age was selected as normal testicular descent is unlikely after 3 months of age and it is timed to prevent early gonadocyte developmental delay as suggested by Hutson and Hasthorpe. This study aims to determine the current age at orchidopexy in one UK training centre and whether changing targets have altered practice. METHODS: The demographics of orchidopexies performed at a single unit between 1998 and 2011 were reviewed. RESULTS: A total of 1325 orchidopexies were performed over 13 years. The median age at orchidopexy fell between 1998 and 2011. There was an initial drop in the age for orchidopexy in 2000 corresponding with the change in target age to "less than 18 months". However, no subsequent improvement was seen over the following decade. DISCUSSION: Early orchidopexy is not being achieved. We have identified how slowly such advice is implemented locally and recognise the national need to address this. The approach should include earlier primary care referral directly from the routine postnatal check to a centre prepared to undertake surgery in this age group.

British Association of Paediatric Urologists consensus statement on the management of the primary obstructive megaureter.

INTRODUCTION: It is well-known that the majority of congenital megaureters may be managed conservatively, but the indications and surgical options in patients requiring intervention are less well defined. Hence this topic was selected for discussion at the 2012 consensus meeting of the British Association of Paediatric Urologists (BAPU). Our aim was to establish current UK practice and derive a consensus management strategy. METHODS: An evidence-based literature review on a predefined set of questions on the management of the primary congenital megaureter was presented to a panel of 56 Consultant Surgeon members of the British Association of Paediatric Urologists (BAPU), and current opinion and practice established. Each question was discussed, and a show of hands determined whether the panel reached a consensus (two-thirds majority). RESULTS: The BAPU defined a ureteric diameter over 7 mm as abnormal. The recommendation was for newborns with prenatally diagnosed hydroureteronephrosis to receive antibiotic prophylaxis and be investigated with an ultrasound scan and micturating cystourethrogram, followed by a diuretic renogram once VUR and bladder outlet obstruction had been excluded. Initial management of primary megaureters is conservative. Indications for surgical intervention include symptoms such as febrile UTIs or pain, and in the asymptomatic patient, a DRF below 40% associated with massive or progressive hydronephrosis, or a drop in differential function on serial renograms. The BAPU recommended a ureteral reimplantation in patients over 1 year of age but recognized that the procedure may be challenging in infancy. Proposed alternatives were the insertion of a temporary JJ stent or a refluxing reimplantation. CONCLUSION: A peer-reviewed consensus guideline for the management of the primary megaureter has been established. The guideline is based on current evidence and peer practice and the BAPU recognized that new techniques requiring further studies may have a role in future management.

Button vesicostomy: 13 years of experience.

INTRODUCTION: Over recent years the button vesicostomy has become an alternative management option in children with poor bladder emptying, when clean intermittent catheterisation (CIC) cannot be initiated for reasons of age, sensation, or urethral anatomy. This study reviews recent experience of this technique and evaluates its use. METHODS: Retrospective review of patients who had a button vesicostomy to permit bladder drainage between 1998 and 2011. RESULTS: Thirty children underwent button vesicostomy insertion aged between 4 days and 16 years. Indications were neuropathic bladders (n = 15), congenital hypotonic bladders (n = 6), functional bladder disorders (n = 5), and post-obstruction bladders (n = 4). The median length of use was 11 months; however, 7 patients still have the button in situ. Minor complications (n = 12) included transient leakage, wound infection, and overgranulation. Major complications included 2 UTIs, 1 device failure, and 2 significant leaks, requiring revision of the tract and removal of the button. CONCLUSION: The button vesicostomy is a suitable and safe technique for use in the short- and medium-term. The procedure has minimal morbidity and therefore is acceptable to families. It has a wide scope, including patients with a neuropathic bladder as an alternative to CIC and where temporary drainage is required until bladder function can recover.

Cultural bias in the AAP's 2012 Technical Report and Policy Statement on male circumcision.

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report's conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non-US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

What is the evidence for radical surgery in the management of localized embryonal bladder/prostate rhabdomyosarcoma?

As survival outcomes for bladder/prostate rhabdomyosarcoma have improved over the last 40 years, the emphasis has shifted to minimizing treatment related morbidity. We undertook a critical review of the current literature to examine the role of radical pelvic surgery to achieve local control. We illustrate that there appears to be no difference in overall survival or event free survival when comparing differing modalities utilized in local disease control, microscopic disease clearance does not correlate with improved outcomes, and the morbidity associated with radical surgery for BP RMS is significantly greater than for a conservative method of local control.

Long-term functional outcome of sacrococcygeal teratoma in a UK regional center (1993 to 2006).

BACKGROUND: Sacrococcygeal teratoma (SCT) is the commonest neonatal neoplasm. Its long-term effects are important in prenatal counseling and the delivery of an appropriate postoperative plan. AIM: To determine the long-term functional outcome after SCT excision in a UK regional center. STUDY DESIGN: Follow-up data for all patients with a SCT excised at the John Radcliffe Hospital in Oxford was collected retrospectively from notes and prospectively in clinic visits. OUTCOME MEASURES: Clinical evidence of bowel or bladder impairment, mortality. RESULTS: Over a 14-year period, 18 patients had a histologic diagnosis of SCT. Nine patients (50%) were born, 7 (39%) were terminated, and 2 (11%) were stillbirths. Of the 9 patients who had SCT resection, 4 (44%) were antenatally diagnosed. There were no perioperative deaths and alpha-fetoprotein levels normalized by 6 to 12 months after tumor resection. Median follow-up of patients was 30 months (range: 6 to 132 mo) with 1 patient lost to follow-up at 6 months, although he was asymptomatic at the time. Three patients developed urologic complications (2 within 1 year of tumor resection), including 2 patients with neurogenic bladder dysfunction and 1 patient with detrusor sphincter dyssynergia. CONCLUSIONS: Approximately one-third of patients will develop major urologic complications after resection of SCT. Routine ultrasonography in the first postoperative year after tumor resection may help to identify patients with neuropathic bladder at the early stage and predict late complications. Parents need to be aware of this potential long-term complication during prenatal counseling and the need for regular long-term follow-up with the pediatric surgical team.

Button vesicostomy: a continent urinary stoma.

OBJECTIVE: A modified technique of vesicostomy is described using a gastrostomy button, which could be used as a continent urinary stoma in children with incomplete voiding. PATIENTS AND METHODS: From 1998 to 2005, 21 children aged between 4 days and 16 years underwent insertion of button vesicostomy to permit bladder drainage. They had incomplete bladder emptying and clean intermittent urethral catheterization (CIC) could not be established. In six of 23 procedures, the button was placed through a classical vesicostomy (3) or via a suprapubic catheter tract (3). In 17, a standardized technique of button vesicostomy stoma formation was used. The median follow up was 2.5 years (0.75-8 years). RESULTS: Patients were selected on the basis of clinical need. Idiopathic hypotonic bladder was the most common indication (9), followed by anorectal malformation (5), neuropathic bladder and posterior urethral valves (2 each), traumatic rupture of urethra (1), visceral myopathy (1) and posterior urethritis (1). Granuloma formation around vesicostomy button was observed in five patients. Local infection was observed in three patients and urinary tract infection in four. No peri-button leakage occurred in the standardized button stomas but was seen in all three of the buttons placed in classical vesicostomies, and transient leakage occurred in one of the three patients with a button placed via a suprapubic catheter tract. The median duration of use of vesicostomy button was 11 months (2-30 months). In eight patients, bladder function improved and intermittent drainage was no longer required. Three patients are still using the button, four progressed to Mitrofanoff, four started CIC per urethra, and two reverted to continuous drainage. CONCLUSIONS: Button vesicostomy is a useful addition to the options available for a catheterizable continent urinary stoma in children in the short or medium term. The risk of major complications was low although minor complications were common, and the technique was well accepted by patients and parents.

The incidence of complications following primary inguinal herniotomy in babies weighing 5 kg or less.

The aim of this study was to quantify the incidence of complications following inguinal herniotomy in small babies weighing 5 kg or less. This was a retrospective review of inguinal herniotomies performed in our unit between December 1997 and March 2002 on babies weighing 5 kg or less. A total of 154 patients underwent hernia repair, of which 125 patients (221 hernias) were available for review (81%). The median weight at surgery was 3.6 kg (range 1.7-5 kg) and 84 patients (67%) were classified as premature (< 36 weeks gestation). Thirty-three patients presented with an irreducible hernia, in whom all but one were successfully reduced prior to surgery. Patients were reassessed at a clinic following surgery and follow-up data was obtained from the clinic notes after a median follow-up of 3 months (range 1-60 months). Five cases of hernia recurrence occurred in four patients (2.3%) and the incidence of testicular atrophy was 2.7% (six patients). In the testicular atrophy group, four of the six patients presented with an incarcerated hernia and of these, three were noted to have evidence of ischaemia at operation. There were six cases of high testes requiring subsequent orchidopexy (2.7%). Although neonatal inguinal herniotomy is a technically demanding procedure, this series has demonstrated a low complication rate. Testicular atrophy was associated with a history of preoperative incarceration in the majority of cases.

Left-sided gastroschisis and pseudoexstrophy: a rare combination of anomalies.

Pseudoexstrophy is a rare variant of the exstrophy/epispadias complex, comprised of the musculoskeletal defects of classic exstrophy but with an intact bladder and urethra. We present a case of a neonate with left-sided gastroschisis and pseudoexstrophy, the first reported combination of these two anomalies. The anomalies in this case were unusual but highlight the importance of careful clinical evaluation before and during surgery so as to carefully define the anatomy of the abnormalities, which will assist in planning surgery and further postoperative management. Identifying and reporting these unusual cases is essential to further expand our understanding of these conditions and their potential associations.

Use of sarcoma-based chemotherapy in a case of congenital mesoblastic nephroma with liver metastases.

Congenital mesoblastic nephroma was originally considered to be a benign neoplasm. A more aggressive cellular form, however, that has a close relationship to congenital fibrosarcoma, is widely described. Previous reported sites of metastases are the lungs, heart, brain, and bone. We describe a patient with isolated metastasis to liver and review the management, together with evidence that it may be more appropriate to use a vincristine, ifosfamide, doxorubicin, and etoposide (VIDE) regimen rather than Wilm's tumor-based regimens in those cases for which chemotherapy is indicated.