Marcus Riccabona

Optimizing the Operative Treatment of Boys with Varicocele: Sequential Comparison of 4 Techniques

PURPOSE We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation. MATERIALS AND METHODS In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months. RESULTS In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient. CONCLUSIONS Comparison of all 4 groups revealed significant differences in varicocele recurrence (p = 0.038) and hydrocele formation (p = 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p = 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age.

Voiding Cystourethrography Using the Suprapubic Versus Transurethral Route in Infants and Children: Results of a Prospective Pain Scale Oriented Study

PURPOSE We determined the advantages and disadvantages of different types of contrast medium injection into the bladder for imaging children during evaluation for urinary tract infection in regard to child behavior and distress during urethral catheterization or suprapubic puncture. MATERIALS AND METHODS From December 2000 to September 2001 we prospectively compared transurethral catheter and suprapubic voiding cystourethrography in children with a history of urinary tract infection. A total of 65 children with a mean age of 33.8 months were entered into the study, of whom 32 underwent transurethral catheterization and 33 underwent suprapubic puncture with topical anesthesia. Each child was evaluated, particularly in regard to discomfort and pain using an objective pain score that measures stress and pain during a medical procedure. RESULTS Objective pain score recording showed a mean pain score plus or minus SD of 4.25 +/- 1.3 in the transurethral catheterization and 3.03 +/- 1.21 in the suprapubic puncture groups. Correlation studies of age in the 2 groups also showed a significant impact of age on the objective pain score. In the transurethral group the score increased with age (p <0.001), whereas in the suprapubic group it decreased with age (p <0.001). CONCLUSIONS The current study shows that the suprapubic puncture technique with topical anesthesia was well tolerated and associated with a low pain score independent of patient age. Transurethral catheterization was also tolerated but it was associated with a low pain score only in the younger age group. Thus, we recommend that voiding cystourethrography in children older than 24 months should be done via the suprapubic route.

Amplitude coded-colour Doppler sonography in paediatric renal disease.

Abstract The aim of our study was to assess the ability of amplitude coded-colour Doppler sonography (ACDS) to depict altered perfusion in paediatric renal disease in a prospective study. Colour Doppler sonography (CDS) and ACDS examinations were performed in 180 renal units (90 patients; age range newborn to 16 years) with unilateral or bilateral renal disease (e. g. reflux nephropathy, renal scars, end-stage renal disease, ureteropelvic junction obstruction, urinary tract infection, renal failure, haemolytic uraemic syndrome, nephrotic syndrome, systemic lupus erythematosus (LE), renal biopsy, congenital dysplasia, tumour/infiltration). The ACDS results were compared with scintigraphy or CT as well as to clinical findings. Amplitude colour-coded Doppler sonography accurately demonstrated normal vasculature in 49 of 51 healthy kidneys ( = 96 %); 3 healthy kidneys could not be evaluated due to motion/artefacts. In 39 of 43 kidneys with focally altered perfusion ACDS could be performed and correctly depicted focally impaired vasculature/perfusion in 35 kidneys ( = 89.7 %). Seventy-three of 83 kidneys with diffusely impaired perfusion could be evaluated by ACDS and altered pattern was correctly depicted in 58 kidneys ( = 79.4 %), with an overall percentage of agreement of 87.1 %. Amplitude CDS appears to be useful in infants and children. Compared with CDS it improves visualisation of especially focally impaired vasculature/perfusion and should be considered a valuable adjunct to conventional investigations.

Comprehensive Analysis of Six Years Experience in Tubularised Incised Plate Urethroplasty and its Extended Application in Primary and Secondary Hypospadias Repair

OBJECTIVE We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results. METHODS In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure. RESULTS The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002. CONCLUSION In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair--irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.

The role of the Lich–Gregoir procedure in refluxing duplicated collecting systems: Experience from long-term follow up of 45 children

OBJECTIVE The need for surgical correction of vesicoureteral reflux (VUR) is increased in duplicated systems. The aim of this study was to evaluate the outcome of the Lich-Gregoir procedure (LG) with regard to VUR persistence, contralateral de-novo VUR, hydronephrosis, preservation of split renal function, urinary tract infections (UTI) and postoperative side effects. PATIENTS AND METHODS Between 1993 and 2007, 45 children (mean age 3.2 years) underwent a unilateral common sheath LG. A combined number of at least 75 episodes of febrile UTI had occurred in 39 children prior to surgery. VUR grades I to V were present in two, nine, 16, 16 and two children, respectively. Hydronephrosis was present in 18 children. Mean split renal function was 44.03% (range 15-63%). Indications for surgery were febrile breakthrough UTI in 11 children and abscessing pyelonephritis in two. The remainder underwent surgery due to renal scars, reduced split renal function (<45%), VUR persistence and/or parental desire. RESULTS Persistent ipsilateral and de-novo contralateral VUR were detected in three children (ipsilateral in one, contralateral in one, bilateral in one), resulting in a 4.4% rate of persistent ipsilateral VUR. One year post surgery, low-grade hydronephrosis persisted in six patients without impact on split renal function. Mean split renal function remained stable at 44.06% (range 15-68%). During follow up (mean 41 months), six febrile UTIs occurred in five girls (92.4% risk reduction, P<0.00000005). Neither urinary retention nor any other side effect was observed. CONCLUSION Performed unilaterally, common sheath LG is a safe and effective technique to cure VUR, prevent febrile UTI and maintain split renal function in duplicated systems with otherwise uncomplicated anatomy.

Long-term follow-up after botulinum toxin A (BTX-A) injection into the detrusor for treatment of neurogenic detrusor hyperactivity in children.

Purpose To prove the long-term efficacy of BTX-A injection in the management of children with neurogenic detrusor hyperactivity. Materials and methods 28 out of 145 children with neurogenic bladder (15 male and 13 female, mean age 10.7 years) who were treated between 2002 and 2010 and became non-responders to conservative treatment were included into the retrospective study. We injected 10-12 U/kg of BTX-A (Botox®) into the detrusor at 20-30 sites, sparing the trigone. The mean follow-up was 48 months (range 6-84 months). Results Group 1. 14 patients had a single injection of BTX-A. Five of them were successful. Mean bladder reflex volume increased (from 62.9 to 117.5 ml), maximum detrusor pressure decreased (from 59 to 37.5 cm H2O), detrusor compliance increased (from 4.8 to 9.5 ml/cm H2O), and leak-point-pressure decreased (from 46.5 to 24.2 cm H2O). Four patients did not respond and were treated by ileocystoplasty. Another five were lost to follow-up. Group 2. 14 patients had repeated (mean 2.5) injections of BTX-A with a mean interval of 13.7 months. In thirteen patients, urodynamic parameters of the first and last injection were similar to those obtained in Group 1, showing a good response. One patient received an ileocystoplasty. Conclusion BTX-A is a safe alternative in the treatment of detrusor hyperactivity in children with myelomeningocele (MMC). The efficacy lasted a mean of 12 months and urodynamic response was unchanged even after several injections. In our series, 21.7% of children with severe low-compliance bladders were non-responders.

Single- vs. Two-Stage Fowler-Stephens Orchidopexy: Are Two Operations Better than One? A Retrospective, Single-Institution Critical Analysis

Aim: To compare the outcomes of patients with abdominal testes undergoing single-stage Fowler-Stephens (FSI) vs. two-stage (FSII) procedures. Patients and Methods: Between 01/1993 and 06/2009, a total of 41 children (median age 24.5 months) with 50 abdominal testes were treated. Orchidopexy was performed according to the surgeon’s choice, resulting in 33 FSI and 17 FSII open procedures. In this retrospective study the charts of all children followed in our outpatient department at one, three and 12 months postoperatively and afterwards annually by the use of volumetry and color Doppler-sonography were reveiwed. Data regarding testicular position, size (consistency), and atrophy were recorded. Results: In FSI, the overall success rate was 79%: 64% (21/33) were of normal size with a normal scrotal position; 15% (5/33) were not at the deepest scrotal point, and 21% (7/33) developed testicular atrophy. In FSII, the overall success rate was 82%: 76% (13/17) were found to be of normal size and 6% (1/17) were not at the deepest point of the scrotum, and 18% (3/17) developed testicular atrophy. Conclusions: In this consecutive series there were no significant differences observed between the two procedures with regard to size, blood supply, position, or atrophy rate of the testes.

Effectiveness and Cost Analyses of Different Methods of Antirefluxiv Operations in Vur 3

Purpose In order to the cure rates and cost-effectiveness of different antirefluxiv surgeries in children with VUR (vesicorenal reflux) Grade 3. Material and Methods We reviewed retrospectively the medical records of 401 patients (514 renal units (RU) who got admitted to our institution for treatment of primary VUR 3 between 1993 and 2009. Three different therapeutic options (Group 1: intravesical; Group 2: extravesical; Group 3: endoscopic) were offered to parents. The average costs of different surgeries and re-interventions. were calculated according to the hospital stay with operation theatre (OR), ultrasound (US) and standard laboratory examinations (LA). Results Intravesical re-implantation (group 1) were performed in 98 children (n=152 RU). There was no re- intervention necessary. In group 2 132 children (n= 136 RU) underwent an extravesical surgery. In 4% a second intervention was necessary and of these six patients treated, one subsequently required surgery.In group 3 171 patients (n= 226 RU) underwent endoscopic injection (Deflux ® ). After the first injection 157 RU (69%) were cured, 9 RU required a second, 2 RU a third injection and 58 RU required surgical reimplantation. Mean cost/patient in group 1, 2 and 3 were 16,293€, 10,365€ and 5,659 €, respectively. Mean total (surgery + redo surgery) cost/patient in group 1, 2 and 3 after one year were 16.471€, 19.633 € and 17.925€, respectively. Conclusions For each child with VUR grade 3 open ureteral reimplantation (intra- or extravesical) conveys a higher initial success rate than endoscopic correction. The long-term cost-effectiveness is higher in group 1 than in group 3, where initially surgery costs less.

Endoskopische Eingriffe bei Kindern

Beim Erwachsenen gehort die Endoskopie haufig zur allgemeinen urologischen Abklarung. Im Gegensatz dazu ist ein endoskopischer Eingriff bei Kindern in der Regel nur in Narkose moglich, sodass die Indikation enger gestellt wird. Unabhangig davon, ob eine Endoskopie aus diagnostischer oder therapeutischer Sicht durchgefuhrt wird, gehort die Endoskopie bei Kindern in erfahrene Hande, um das Risiko des Eingriffs fur das Kind zu minimieren und eine korrekte Interpretation der erhobenen Befunde zu gewahrleisten. Jede diagnostische Endoskopie bei Kindern sollte hinsichtlich Notwendigkeit und eventueller therapeutischer Konsequenzen mit Sorgfalt hinterfragt werden. Eine suffiziente konservative Diagnostik sollte obligat vorangestellt werden, entsprechend dem Grundsatz „vom wenig Invasiven zum Invasiven“ und um dem Kind ggf. den Narkoseeingriff zu ersparen.

Does a Preoperative Percutaneous Nephrostomy Influence the Outcome of Pyeloplasty in Infants and Children

Introduction: We evaluated the potential and outcome of preoperative percutaneous nephrostomy (PCN) in infants and children with severe hydronephrosis (Society for Fetal Urology grade IV) due to ureteropelvic junction obstruction. We focused on pre- and post-operative renal split function (RSF), histological findings of the renal pelvis and the reop-eration rate. Patients and Methods: The medical records of 249 patients (254 renal units) who underwent pyeloplasty for ureteropelvic junction obstruction between 1992 and 2009 were retrospectively reviewed. In 24 patients (group 1), PCN was performed before the pyeloplasty for various reasons. Renal split function was investigated using diuretic renogra-phy before PCN or pyeloplasty and 1 year after surgery. His-tological findings and reoperation rates were compared in patients with (group 1) and without (group 2) PCN. Results: Of the 254 renal units, 24 patients with a median age of 80 days (1 day to 11 years) received a PCN before pyeloplasty. The initial median RSF was 43% (4–58%) preoperatively and 45% (21–67%) 1 year postoperatively in group 1 and 47% (11–71%) preoperatively and 47% (0–74%) postoperatively in group 2. Histology revealed chronic inflammation of the renal pelvis in 60% of the PCN patients compared to 21% in group 2. The reoperation rate was 12.5% (3/24) in group 1 and 4% (9/230) in group 2. Conclusions: Preoperative PCN in severe hydronephrosis results in little or no improvement in RSF, causes a high percentage of chronic inflammation of the renal pelvis and increases the risk of reoperation.