Luitzen Albert Groen

Hypospadias Repair at a Tertiary Care Center: Long-Term Followup is Mandatory to Determine the Real Complication Rate

PURPOSE The field of reconstructive surgery for hypospadias is lacking standard techniques and followup. Most published series include complication rates after a short followup. We report and analyze the long-term outcome of primary hypospadias repair at a single tertiary care center. MATERIALS AND METHODS We reviewed 1,061 operations performed at our institution between 1997 and 2010 and registered as hypospadias repair. The operations were performed in 543 patients born between June 1997 and June 2005. A retrospective database was created with information about hypospadias characteristics, surgery and followup. RESULTS A total of 474 primary repairs were selected, excluding incomplete/incorrect files. Distal penile hypospadias was reported in 366 patients (77.2%), mid penile hypospadias in 54 (11.4%) and proximal hypospadias in 54 (11.4%). Initial repair technique was based on incised plate in 189 patients (39.9%), meatal advancement in 171 (36%), onlay flap in 82 (17.3%) and other or combined techniques in 25 (5.3%). Insufficient information was reported for 7 patients (1.5%). Mean age at first operation was 22.6 months (range 4 to 134) and mean followup after first operation was 34.0 months (0 to 145). Of the children 360 (75.9%) had a good long-term outcome and required only 1 procedure. Reoperation was needed in 114 patients (24.1%), of whom 54 (47.4%) underwent reoperation in the first year of followup. CONCLUSIONS Overall a good long-term outcome without further complication was achieved in 75.9% of our cases. Of the 24.1% of patients who needed reoperation only 47.4% presented within the first year postoperatively, indicating the need for long-term followup when reporting outcomes of hypospadias repair.

Sacral Neuromodulation with an Implantable Pulse Generator in Children with Lower Urinary Tract Symptoms: 15-Year Experience

PURPOSE Sacral nerve modulation with an implantable pulse generator is not an established treatment in children. This therapy has been described for dysfunctional elimination syndrome and neurogenic bladder. We report 2 new indications for this approach in children, ie bladder overactivity and Fowler syndrome. The aim of this study was to improve the results of future treatment for sacral neuromodulation in children by describing factors favorable for good outcomes with this method. MATERIALS AND METHODS A total of 18 children 9 to 17 years old were studied. Mean ± SD followup was 28.8 ± 43.8 months. Of the patients 16 underwent S3 sacral neuromodulation and 7 underwent pudendal stimulation (5 as a revision, 2 from the beginning). RESULTS Initial full response was achieved in 9 of 18 patients (50%) and partial response in 5 (28%). In patients presenting with incontinence mean ± SD number of incontinence episodes weekly improved significantly from 23.2 ± 12.4 to 1.3 ± 2.63 (p <0.05). In patients requiring clean intermittent catheterization there was a significant decrease in mean ± SD daily frequency of catheterization from 5.2 ± 1.6 to 2.0 ± 1.9 (p <0.05). At the end of the study 6 of 15 patients (40%) had a full response and 5 (33%) had a partial response, while 4 implantable pulse generator devices (27%) were explanted because of failure. CONCLUSIONS Sacral neuromodulation is feasible in the pediatric population, with good short-term (78% full or partial response) and satisfactory long-term results (73%). Sacral neuromodulation can offer good results for overactive bladder, dysfunctional elimination syndrome and Fowler syndrome. Pudendal nerve stimulation is a feasible salvage treatment that can be useful in cases when S3 implantation is impossible or unsuccessful.

The AdVance male sling as a minimally invasive treatment for intrinsic sphincter deficiency in patients with neurogenic bladder sphincter dysfunction: A pilot study†‡

The aim of the study was to evaluate feasibility, efficacy, and safety of the AdVance male sling in neuropathic male patients with intrinsic sphincter deficiency.

Sleep fragmentation and periodic limb movements in children with monosymptomatic nocturnal enuresis and polyuria

BackgroundChildren with nocturnal enuresis (NE) have been found to have sleep fragmentation and a high incidence of periodic limb movements in sleep (PLMS). This study explored the association of monosymptomatic NE and polyuria in relation to fluid intake, bladder volume, number of wet nights, and number of nights with polyuria to the frequency of PLMS and cortical arousals during sleep.Materials and methodsThirty children with monosymptomatic NE and polyuria were enrolled in the study. Enuretic parameters were determined by diaries, forced drinking, uroflow, and ultrasound examination. All subjects participated in one polysomnographic study. The number of cortical arousals and PLMS were compared with those recorded in a former pilot study which included only children with refractory NE.ResultsOf the 30 children who participated in the study, the mean age was 10.43 ± 3.08 (range 6–16) years, and 23 were boys. The PLMS index was positively associated with the arousal index and the awakening index (p < 0.001). No significant association between the sleep and the enuretic parameters was found. Children with refractory NE showed a significantly higher PLMS index (p < 0.001).ConclusionsWe found that PLMS and cortical arousals in sleep were increased in children with monosymptomatic NE and polyuria, without a significant association with the enuretic parameters. These observations suggest the presence of a comorbid mechanism driven by a common, independent pacemaker. We hypothesize the autonomic system, its sympathetic branch, and the dopaminergic system as candidates for this pacemaker.

Grade of hypospadias is the only factor predicting for re-intervention after primary hypospadias repair: A multivariate analysis from a cohort of 474 patients

BACKGROUND There is an ongoing quest on how to minimize complications in hypospadias surgery. There is however a lack of high-quality data on the following parameters that might influence the outcome of primary hypospadias repair: age at initial surgery, the type of suture material, the initial technique, and the type of hypospadias. OBJECTIVES The objective of this study was to identify independent predictors for re-intervention in primary hypospadias repair. STUDY DESIGN We retrospectively analyzed our database of 474 children undergoing primary hypospadias surgery. Univariate and multivariate logistic regression was performed to identify variables associated with re-intervention. A p-value <0.05 was considered statistically significant and therefore considered as a prognostic factor for re-intervention. RESULTS Distal penile hypospadias was reported in 77.2% (n = 366), midpenile in 11.4% (n = 54) and proximal in 11.4% (n = 54) of children. Initial repair was based on an incised plate technique in 39.9% (n = 189), meatal advancement in 36.0% (n = 171), an onlay flap in 17.3% (n = 82) and other or combined techniques in 5.3% (n = 25). In 114 patients (24.1%) re-intervention was required (n = 114) of which 54 re-interventions (47.4%) were performed within the first year post-surgery, 17 (14.9%) in the second year and 43 (37.7%) later than 2 years after initial surgery. The reason for the first re-intervention was fistula in 52 patients (46.4%), meatal stenosis in 32 (28.6%), cosmesis in 35 (31.3%) and other in 14 (12.5%). The median time for re-intervention was 14 months after surgery [range 0-114]. Significant predictors for re-intervention on univariate logistic regression (polyglactin suture material versus poliglecaprone, proximal hypospadias, lower age at operation and other than meatal advancement repair) were put in a multivariate logistic regression model. Of all significant variables, only proximal hypospadias remained an independent predictor for re-intervention (OR 3.27; p = 0.012). DISCUSSION The grade of hypospadias remains according to our retrospective analysis the only objective independent predicting factor for re-intervention in hypospadias surgery. This finding is rather obvious for everyone operating hypospadias. Curiously midpenile hypospadias cases were doing slightly better than distal hypospadias in terms of re-intervention rates. Our study however has also some shortcomings. First of all, data was gathered retrospectively and follow-up time was ill-balanced for several variables. We tried to correct this by applying sensitivity analysis, but possible associations between some variables and re-intervention might still be obscured by this. Standard questionnaires to analyze surgical outcome were not available. Therefore, we focused our analysis on re-intervention rate as this is a hard and clinically relevant end point. CONCLUSIONS This retrospective analysis of a large hypospadias database with long-term follow-up indicates that the long-lasting debate about factors influencing the reoperation rate in hypospadias surgery might be futile: in experienced hands, the only variable that independently predicts for re-intervention is the severity of hypospadias, the only factor we cannot modify. This retrospective multivariate analysis of a large hypospadias database with long-term follow-up suggests that the only significant independent predictive factor for re-intervention is proximal hypospadias. In our series, technique did not influence the re-intervention rate.

Neuropsychological functioning related to specific characteristics of nocturnal enuresis

INTRODUCTION/BACKGROUND There is a high comorbidity demonstrated in the literature between nocturnal enuresis and several neuropsychological dysfunctions, with special emphasis on attention deficit hyperactivity disorder (ADHD). However, the majority of the psychological studies did not include full non-invasive screening and failed to differentiate between monosymptomatic nocturnal enuresis (MNE) and non-MNE patients. OBJECTIVE The present study primarily aimed to investigate the association between nocturnal enuresis and (neuro)psychological functioning in a selective homogeneous patient group, namely: children with MNE and associated nocturnal polyuria (NP). Secondly, the study investigated the association between specific characteristics of nocturnal enuresis (maximum voided volume, number of wet nights and number of nights with NP) and ADHD-inattentive symptoms, executive functioning and quality of life. STUDY DESIGN The psychological measurements were multi-informant (parents, children and teachers) and multi-method (questionnaires, clinical interviews and neuropsychological testing). RESULTS Thirty children aged 6-16 years (mean 10.43 years, SD 3.08) were included. Of them, 80% had at least one psychological, motor or neurological difficulty. The comorbid diagnosis of ADHD, especially the predominantly inattentive presentation, was most common. According to the teachers, a low maximum voided volume (corrected for age) was associated with more attention problems, and a high number of nights with NP was associated with more behaviour-regulation problems. No significant correlations were found between specific characteristics of enuresis and quality of life. Details are demonstrated in Table. DISCUSSION The children were recruited from a tertiary referral centre, which resulted in selection bias. Moreover, NP was defined as a urine output exceeding 100% of the expected bladder capacity for age (EBC), and not according to the expert-opinion-based International Childrens Continence Society norm of 130% of EBC. The definition for NP of a urine output exceeding 100% of the EBC is more in line with the recent findings of the Aarhus group. CONCLUSIONS For children with MNE and associated NP, a high comorbidity with the predominantly inattentive presentation of ADHD was demonstrated. Children experienced problems with daytime functioning in relation to their wetting problem at night. According to the teachers, a low maximum voided volume was associated with more attention problems, and a high number of nights with NP was associated with more behaviour-regulation problems. Although comorbidity is still the appropriate word to use, the observation favours a more complex pathogenesis of enuresis with a common pathway in the central nervous system, including: neurotransmitters, influencing neuropsychological functioning as well as sleep, circadian rhythm of diuresis and bladder function control.

Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep

BackgroundThere is a high comorbidity between nocturnal enuresis, sleep disorders and psychological problems. The aim of this study was to investigate whether a decrease in nocturnal diuresis volume not only improves enuresis but also ameliorates disrupted sleep and (neuro)psychological dysfunction, the major comorbidities of this disorder.MethodsIn this open-label, prospective phase IV study, 30 children with monosymptomatic nocturnal enuresis (MNE) underwent standardized video-polysomnographic testing and multi-informant (neuro)psychological testing at baseline and 6 months after the start of desmopressin treatment in the University Hospital Ghent, Belgium. Primary endpoints were the effect on sleep and (neuro)psychological functioning. The secondary endpoint was the change in the first undisturbed sleep period or the time to the first void.ResultsThirty children aged between 6 and 16 (mean 10.43, standard deviation 3.08) years completed the study. The results demonstrated a significant decrease in periodic limb movements during sleep (PLMS) and a prolonged first undisturbed sleep period. Additionally, (neuro)psychological functioning was improved on several domains.ConclusionsThe study demonstrates that the degree of comorbidity symptoms is at least aggravated by enuresis (and/or high nocturnal diuresis rate) since sleep and (neuro)psychological functioning were significantly ameliorated by treatment of enuresis. These results indicate that enuresis is not such a benign condition as has previously been assumed.

New Surgical Technique for the Treatment of Buried Penis: Results and Comparison with a Traditional Technique in 75 Patients

Introduction: Buried penis is a pathology for which several reconstructive techniques are described. We report our technique and its outcome. Patients and Methods: 75 patients underwent repair of buried penis by one surgeon (P.H.) between 1997 and 2011. The first 17 patients (mean age 2.6 years) underwent skin-sparing circumcision. The next 58 patients (47 children, mean age 4.4 years; 11 adults, mean age 38 years) underwent our new technique. Its key point consists in releasing dartos tissue and in anchoring the corpora cavernosa to dartos bundles at the penile base. Outcome was evaluated by reoperation rate, complications and satisfaction according to surgeon/patients/parents. Results: The results of skin-sparing circumcision performed in 17 children at 1 year were reported as good by the surgeon in 62.5% (n = 10) and in 82.4% (n = 14) by patients. Reoperation for recurrence occurred in 29.4% (n = 5) patients. Complications treated conservatively were reported in 35.3% (n = 6) of the children. The new technique was performed in 58 patients (47 children, 11 adults). The results were reported as good by the surgeon in 96.6% (n = 56) and in 91.4% (n = 53) by patients. Reoperation occurred in 4 patients (6.9%). Conclusions: The outcome of the new technique is superior to skin-sparing circumcision regarding complication/reoperation rate and cosmesis according to patients/parents/surgeon.

A comparative study between continent diversion and bladder neck closure versus continent diversion and bladder neck reconstruction in children

OBJECTIVE To assess the long-term outcome of continent diversion in children with structural or neurogenic cause of incontinence, with special interest in differences between closed and open bladder neck procedures. PATIENTS AND METHODS A cohort of 63 children with intractable incontinence treated with continent diversion between January 1998 and January 2008 were reviewed for underlying disease, type of surgery, complications and outcome. RESULTS Forty patients had a continent diversion with open bladder neck (group 1) and 23 patients had their bladder neck closed (group 2: 11 primarily closed; 12 secondarily closed). There was no difference between the two groups in terms of patient characteristics, surgical re-interventions and stone formation. The continence rate however was significantly better in group 2 (95.6% vs 77.5%). CONCLUSION Bladder neck closure with continent diversion as primary or salvage procedure in children with intractable incontinence does not result in extra morbidity and has a high success rate. Thorough urodynamic evaluation of bladder function is the key to success in therapy planning for these children, to minimize the need for re-intervention.

Urodynamic studies in children: Standardized transurethral video-urodynamic evaluation

OBJECTIVE The aim was too demonstrate standardized video-urodynamic study (VUDS) in children using a transurethral catheter and pressure transducers. METHODS Data necessary to obtain urodynamic evaluation of bladder sphincter function were gathered by concomitant measurement of bladder, urethral, and abdominal pressure. A 7F transurethral triple-lumen water-filled catheter was used for measuring the bladder and sphincter pressures and a water-filled 8F catheter connected to a pressure transducer was inserted into the rectum for pressure measurement. Cystometry was combined with fluoroscopy, providing simultaneous voiding cystourethrography information. Detrusor activity, bladder sensation, capacity, and compliance were measured during filling cystometry. Voiding cystometry consisted of recording pressures in the bladder sphincter and abdomen with simultaneous urinary flow measurement. RESULTS Transurethral VUDS was safely and easily performed in a clinical setting adapted to children. CONCLUSIONS A good and reproducible UDS is mandatory for correct therapeutic decisions. A standardized study associated with fluoroscopic assessment is presented in this video.