Eric A. Jones

Megalourethra and urethral diverticula

Megalourethra and urethral diverticula encompass a diverse group of congenital and acquired urethral defects. The appropriate management of these anomalies relies on a keen appreciation of phallic anatomy and an understanding of urethral embryology. A thorough history and physical examination--including a careful evaluation of the urinary tract--is necessary to identify associated congenital anomalies. Finally, satisfactory surgical management demands meticulous attention to surgical technique.

Factors Associated With Delayed Treatment of Acute Testicular Torsion—Do Demographics or Interhospital Transfer Matter?

PURPOSE Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.

Metanephric Adenoma in a Five-Year-Old Boy Presenting with Chyluria: Case Report and Review of Literature

Metanephric adenoma and chyluria are rare entities, especially in the pediatric population of North America. To date, no report of chyluria associated with metanephric adenoma has been published. The incidental presentation is most common in the fifth decade of age with this tumor; however, when signs and symptoms are present they include hematuria, palpable mass, flank pain, polycythemia, and hypercalcemia. We present the case of a 5-year-old boy who did not demonstrate the common findings listed, but rather he presented with chyluria.

Cross-Sectional Evaluation of Parental Decision Making Factors for Vesicoureteral Reflux Management in Children

PURPOSE Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux. MATERIALS AND METHODS We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Childrens Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery. RESULTS Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important. CONCLUSIONS Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

Bladder injuries during laparoscopic orchiopexy: incidence and lessons learned.

PURPOSE Laparoscopic orchiopexy is a safe operation. However, the bladder can be injured during creation of the transperitoneal tunnel for the cryptorchid testis. We reviewed our experience with this complication. MATERIALS AND METHODS We searched the operative notes of patients who had undergone laparoscopic orchiopexy between August 15, 2002 and October 1, 2008, and identified bladder injuries and their treatment. RESULTS A total of 93 patients underwent laparoscopic orchiopexies for 101 undescended testes during the study interval, with 3 procedures resulting in bladder injuries. The 3 operations varied with regard to whether the injury was recognized intraoperatively or postoperatively, and repaired in an open or laparoscopic fashion. CONCLUSIONS Bladder injury during laparoscopic orchiopexy is a rare but serious complication that can be managed by an open or laparoscopic approach. We recommend placement of a urethral catheter and syringe assisted drainage of all urine from the bladder at the beginning of the operation, careful perivesical dissection particularly in children with prior inguinal surgery, filling and emptying of the bladder during the procedure, and maintaining a high index of suspicion especially when hematuria is observed.

Primer: diagnosis and management of uncomplicated daytime wetting in children

Functional daytime wetting is a common source of pediatric urologic complaints. Evaluation typically begins in the office setting. In contrast to the adult population, where an inability to maintain voiding control is virtually always considered pathologic, the evaluation of urinary incontinence in children must occur within the context of the childs developmental age. Functional incontinence refers to cases of urinary incontinence in which no structural or neurologic abnormality can be identified. The underlying etiologic mechanisms are heterogeneous, and include disorders of both the storage and voiding phases of the bladder cycle. Optimal treatment of functional daytime wetting depends on an accurate determination of the underlying etiology. Therapeutic options include behavior modification, medication, and aggressive treatment of comorbid conditions such as urinary infection and constipation.