Management of prepubertal varicoceles-results of a questionnaire study among pediatric urologists and urologists with infertility training.

OBJECTIVES: Varicoceles are a common condition affecting male fertility seen by urologists. However, prepubertal varicoceles are much less common and their management is controversial. We designed a questionnaire to assess the practice patterns among urologists (pediatric urologists/urologists with infertility training) with regard to prepubertal varicocele management. METHODS: A 15-point questionnaire pertaining to management issues of prepubertal varicoceles was sent to 150 pediatric urologists and 150 urologists with infertility training. Two clinical scenarios referring to treatment algorithms of prepubertal varicoceles were included. RESULTS: Of the 300 questionnaires mailed, 174 urologists (58%) responded. Seventy-five of the respondents were urologists with an interest in infertility, and 99 were pediatric urologists. Of the 174 respondents, 86.2% treated prepubertal varicoceles and 13.8% referred patients to interventional radiologists for embolization. The ratio of varicocelectomy to expectant management was about equal between urologists with infertility training and pediatric urologists (46% versus 54%). A difference in testicular size was the most common indication for varicocelectomy (80.5%), followed by pain (51.1%) and potential fertility problems (24.7%). About one third of all urologists would perform varicocelectomy on patients of any age and seven (4%) would not operate before puberty. In 136 responses (78.2%), follow-up information was not available. Among the 35 respondents with follow-up information (21.8%), 21 reported infertility occurring after varicocelectomy and 16 after expectant management. If varicocelectomy was performed, most urologists (47.2%) used magnification loupes, 29.3% used microscopes, and 29% used no magnification. The preferred approach was inguinal (Ivanissevich) in 35.6% followed by subinguinal in 30%; 21% performed retroperitoneal varicocelectomy (Palomo) and 9.8% used a laparoscopic approach. Of the 300 complications reported, postoperative hydroceles were the most common (40.4%), followed by recurrence (20.8%) and hematomas (17.4%). CONCLUSIONS: The management of prepubertal varicoceles is controversial among different urologic subspecialties (pediatric urology/infertility). Differences include indications, timing, and techniques used for varicocelectomy. Accurate follow-up information for children with prepubertal varicoceles is rare. A prospective randomized study comparing varicocelectomy versus expectant management of prepubertal varicoceles is needed to assess the outcomes and define uniform treatment criteria.

Septic arthritis secondary to vesicoureteral reflux into single ectopic ureter.

A 3-week-old male infant, born full term without complication, developed septic arthritis of his left shoulder. His joint fluid, blood, and bone marrow were all positive for Escherichia coli. Urinalysis demonstrated pyuria. Urine culture obtained after one dose of ceftriaxone and several doses of nafcillin was negative. Work-up revealed a refluxing, right single ectopic ureter with severe hydroureteronephrosis and a non-functioning ipsilateral kidney. After appropriate management of the musculoskeletal infection, he underwent a right nephroureterectomy. Coliform septic arthritis is exceedingly rare in children, with only a few cases reported. We report the first case of septic arthritis with anomalous genitourinary tract development as the source of bacterial seeding. This report re-emphasizes the need to screen the urinary tract in all cases of pediatric gram-negative sepsis.

Ureteroneocystostomy: to drain or not to drain.

PURPOSE: Indications for the use of external abdominal drains after ureteral reimplantation are not well defined. We determine the nature of the drainage fluid as well as the current use of drains by pediatric urologists. MATERIALS AND METHODS: We prospectively evaluated 15 consecutive patients 7 months to 19 years old who underwent unilateral or bilateral intravesical ureteroneocystostomy for primary vesicoureteral reflux. All patients were treated with a urethral Foley catheter and closed suction Jackson-Pratt abdominal drain. Fluid from the Jackson-Pratt drain and Foley catheter was analyzed for urea and creatinine on postoperative day 1, and compared to serum values. The Foley catheter was removed after the urine became clear, and the Jackson-Pratt drain was removed after drainage was 5 ml. or less for 12 hours. In addition, a questionnaire was distributed to 268 pediatric urologists to determine current practice regarding the use of routine postoperative drains. RESULTS: Urea and creatinine from the Jackson-Pratt drains in all 15 patients were consistent with serum values. The Foley catheter and Jackson-Pratt drain were removed an average of 3 and 4 days postoperatively, respectively. There were 186 responses from the 268 questionnaires distributed (69.4%). Of the pediatric urologists surveyed 70.4% performed intravesical ureteral reimplantation exclusively, 5.9% extravesical reimplantation exclusively and 23.7% both techniques. Of the group surveyed 73.1% placed external abdominal Jackson-Pratt or Penrose drains, although 26.5% of those who routinely used external drains believed that they were probably unnecessary. Of the physicians who placed drains 53.7% believed that the drainage fluid had some component of urine. CONCLUSIONS: In our small prospective study group we demonstrated that external abdominal drainage fluid is consistent with serum despite the popular belief that it may have some component of urine. The gynecological literature has shown repeatedly that there is no increase in morbidity after radical hysterectomy and pelvic lymph node dissection when no external abdominal drains are used. Although to our knowledge there are no previous reports of drain use after ureteral reimplantation, 26.9% of pediatric urologists currently do not place external abdominal drains with no apparent increase in morbidity. Larger prospective cohorts with long-term followup are needed to address adequately the issue of whether drains are needed after uncomplicated ureteral reimplantation.

Insurability of children with congenital urological anomalies.

PURPOSE: We sought to determine life insurance underwriting practices for children diagnosed with multicystic dysplastic kidney or unilateral neonatal hydronephrosis, and evaluate whether management options (observation versus operative intervention) have an influence on such practices. MATERIALS AND METHODS: A questionnaire and history of 1 child with multicystic dysplastic kidney and 1 with unilateral neonatal hydronephrosis were distributed to 348 insurance companies licensed to issue life insurance policies in New Jersey. The medical director of each insurance company was requested to indicate the current underwriting practices for life insurance policies based on these 2 case scenarios, and asked whether observation or operative intervention influenced such decisions. RESULTS: Of the 348 insurance companies licensed to issue life insurance 130 (37.4%) responded, including 5 (3.8%) that did not choose to participate in the study, 56 (43.1%) that did not issue life insurance to children and 69 (53.1%) that completed the questionnaire based on current life insurance underwriting practices. For a child with multicystic dysplastic kidney 10 companies (14.5%) would issue life insurance if treatment involved observation only, while 49 (71%) would do so after nephrectomy. For a child with unilateral neonatal hydronephrosis 19 (27.5%) companies would issue life insurance if treatment involved observation only, while 46 (66.7%) would do so after pyeloplasty. CONCLUSIONS: Despite limited long-term data on and uncertainty about the natural course of multicystic dysplastic kidney and unilateral neonatal hydronephrosis, treatment options offered a child with a congenital urological anomaly may have a significant impact on the ability to obtain life insurance. Children with multicystic dysplastic kidney and unilateral neonatal hydronephrosis can usually obtain life insurance after early operative intervention (nephrectomy and pyeloplasty, respectively), although sometimes at higher cost.

Relationships between the structure and function of lipopolysaccharide chemotypes with regard to their effects on the human polymorphonuclear neutrophil.

Polymorphonuclear neutrophils (PMN), harvested from healthy volunteers, were challenged with endotoxins from Salmonella minnesota smooth-strain and rough-strain mutants (Ra, Rb2, RcP-, Rd1P- and Re) as well as with lipid A in an effort to determine the relationship between lipopolysaccharide (LPS) structure and its ability to affect PMN chemotaxis (CT), random migration (RM) and luminol-dependent chemiluminescence (CL). In the presence of untreated autologous serum (UAS), as has been previously demonstrated for CL, CT in a modified Boyden chamber is stimulated but no significant differences among the chemotypes were observed. In the presence of heat inactivated autologous serum (IAS), significant variations among the LPS chemotypes occurred. Also noteworthy was the observation that, although the total number of cells migrating across the membrane was similar for both UAS and IAS, UAS promoted PMN migration beyond the membrane into the chamber, as opposed to IAS which caused the cells to remain adherent to the distal face of the membrane. In the absence of serum, RM was inhibited in a dose-dependent fashion by LPS from lipid A and the rough-strain mutants, with the degree of inhibition being progressively greater with increasing molecular complexity of the chemotype LPS. The smooth-strain LPS exerted an intermediate effect. In the case of CL, lipid A was the most potent stimulus, with the response decreasing as molecular complexity increased up to RcP-; the remaining core mutant LPS provided slightly greater responses. The LPS from the smooth-strain promoted a response similar to the response to Ra LPS. Based on these data, it is concluded that there are qualitative as well as quantitative effects of the carbohydrate moieties of LPS. These data also suggest that while LPS may provoke active migration in the circulation during endotoxemia, infection localized in tissue might bring about an inhibition of PMN migration while allowing the PMN to mount an oxidative response.