Miklós Merksz

THE RESPONSE OF BALANITIS XEROTICA OBLITERANS TO LOCAL STEROID APPLICATION COMPARED WITH PLACEBO IN CHILDREN

PURPOSE We evaluated the clinical effectiveness of topical steroid application for balanitis xerotica obliterans in children and analyzed the association of any clinical response with histological findings. MATERIALS AND METHODS Our double-blind, placebo controlled, randomized study included 40 boys in whom balanitis xerotica obliterans was diagnosed clinically by cicatricial phimosis. The severity of phimosis was graded into 4 groups. Patients were randomized to receive the topical application of 0.05% mometasone furoate or placebo. After 5 weeks phimosis severity was reevaluated and all patients underwent circumcision. Surgical specimens were histologically typed as an early, intermediate or late form of balanitis xerotica obliterans. RESULTS Seven patients were withdrawn from the study. In the steroid group 7 boys had clinical improvement and 10 had no change. Histological study showed an early, intermediate and late form of balanitis xerotica obliterans in 5, 5 and 7 cases, respectively. Of cases with clinical improvement 5 were the early and 2 the intermediate type. In the placebo group 5 cases worsened clinically and 11 did not change. Histological evaluation revealed an early, intermediate and late form of balanitis xerotica obliterans in 3, 7 and 6 boys, respectively. Of the 5 cases with histological worsening, disease was the early, intermediate and late type in 2, 2 and 1, respectively. CONCLUSIONS Applying a potent topical steroid affects improvement in balanitis xerotica obliterans in the histologically early and intermediate stages of disease, and may inhibit further worsening in the late stage.

Long-term psychological and sexual outcomes of severe penile hypospadias repair

INTRODUCTION Hypospadias is the most common penis malformation, and there exist a variety of surgical approaches used to correct the abnormal position of the meatus. Although the long-term outcomes of surgery are considered important for psychosexual development, only a few attempts have been made to evaluate patient satisfaction. AIM The aim of our study was to evaluate surgical results and psychosocial adaptations in a homogeneous group of subjects with severe penile hypospadias who underwent the same types of surgical repairs during childhood and compare the results to data obtained from age-matched healthy controls. METHODS In this cross-sectional study, 104 men (between 24 and 42 years old) who underwent an uncomplicated two-stage hypospadias repair in their childhood and 63 age-matched healthy men without genital malformations completed the questionnaire. MAIN OUTCOME MEASURES   Difference in self-perception assessed by a 15-item questionnaire regarding psychosexual well-being and penile appearance between subjects with corrected hypospadias and healthy participants. RESULTS On average, subjects with a hypospadias repair were less satisfied with their genital appearance; however, they were more satisfied with their sex lives compared to healthy controls. The meatus distance was approximately 1.5 cm from the tip of the penis after surgical correction. None of the postoperative surgical results correlated with patient satisfaction. Furthermore, the small percentage of patients (11%) who were very unsatisfied with their surgical outcomes had no significant differences in surgical outcomes compared to satisfied patients. However, there was a significant difference between the two groups in almost all psychological outcome measures. CONCLUSIONS In adults who underwent an uncomplicated ventral repair of a severe penile hypospadias 20-30 years earlier, healthy psychosexual development was achieved despite the lack of a glanular meatus. Early identification of unsatisfied patients is important for appropriate long-term follow-up and counseling.

Use of Buccal Mucosa Patch Graft for Recurrent Large Urethrocutaneous Fistula after Hypospadias Repair

Introduction: To assess the effectiveness of buccal mucosa patch graft in the treatment of recurrent large urethrocutaneous fistula after hypospadias repair. Materials and Methods: A free graft of buccal mucosa was used for closure in 7 boys (mean age 4.8 years) with large (>4 mm) urethocutaneous fistula. Four fistulas were in the midshaft, 2 of them penoscrotal and 1 coronal type. All patients had undergone at least two previous unsuccessful fistula repairs, and 3 of them had undergone three attempts for closure. Fistula repairs were similar in all cases. Results: The repair was successful in 6 out of 7 cases, and in these cases the urinary stream was good after the removal of the catheter. The unsuccessful case was the coronal one. Conclusion:Based on our experience it seems that in cases with recurrent large fistula after hypospadias reconstruction, the use of buccal mucosa patch graft for closure is a good treatment choice.

Testicular-epididymal fusion abnormality in undescended testis.

In the course of 1195 operations, performed in children with cryptorchidism, the testes were studied for size, turgor and fusion with the epididymis. Inquiries were made into the reasons of fusion disorders which were conspicuously numerous. Attention is called to this not too familiar condition which seems to play an important role in the emergence of fertility disorders in men with congenital cryptorchidism.

Testosterone secretion in children with undescended testis

Testicular testosterone (T) production was examined in thirty boys with undescended testes (UT) following the administration of 4500 U gonadotropic hormone. Twenty boys had bilateral UT and ten had UT plus hypospadias. As for possible causes of reduced Leydig cell activity it was investigated whether the testis was (1) hypoplastic; (2) abnormally fused with the epididymis; (3) located in the abdomen; (4) or UT was associated with hypospadias. Average T values were significantly lower when the testicle was hypoplastic or its fusion with the epididymis was imperfect; but remained largely undiminished when the testicle was located in the abdomen or when UT was combined with hypospadias. The occurrence of both pathologic and physiologic T reactions in each of the four groups suggests that the population of UT children is heterogeneous, probably due to differences in aetiology and in intrauterine hormonal processes. In the case of UT and hypoplasia the time and method of operation (orchidopexy) must be selected with utmost care, bearing in mind that an originally small testicle with impaired T secretion may become physiologic by the time of puberty.

Intrascrotal and testicular solid masses in childhood

A retrospective study was performed between 1985 and 1994 on paediatric patients operated for asymptomatic intrascrotal or testicular palpable masses. Tumour was suspected in each case and it was surgically explored. Twenty-six children were affected, their age ranging between 9 days and 14 years. In 11 cases testicular torsion, in 4 epididymitis and in another 2 dystrophic calcification were found. Tumours, including rather rare alterations, were observed in only 9 children. The present results draw attention to the tumour-like occurrence of testicular torsions and other benign alterations of the scrotum.

Neurofibromatosis of the bladder

Neurofibromatosis of the urinary tract is estimated to account for 20 per cent of the visceral manifestations of the generalized disease. Among its urological forms involvement of the bladder is the most common. Clinically, neurofibromatosis resembles a tumour, therefore, its early histologic diagnosis is of utmost importance. In the present case a tumour involving the posterior bladder wall was found in a 6 years old boy subjected to examination because of a terminal haematuria. First the tumour was resected, later cystectomy with implantation of the distended ureter into the sigmoid was undertaken because of progression of the tumour. Postoperative hypokalaemia responded to the usual medication. Ureteral distension was reversed by the operation.Though neurofibromatosis (NF) is histologically a benign process, it tends to recur, is invasive, and impairs urinary functions. Therefore, it may endanger life and thus requires cystectomy with surgery for urinary diversion.

Congenital lymphovascular malformations with urological symptoms: a report of two cases and review of the literature

AbstractObjectivesTo collect and review the diagnostic and therapeutic solutions for primary and congenital lymphovascular malformations leading to urological symptoms in childhood and also to find the most efficient therapeutic algorithms managing such conditions.MethodsIn our work, we assemble all the diagnostic and therapeutic tools for lymphovascular malformations with urological–urogenital symptoms and demonstrate the interventional therapeutic algorithms through two of our cases where surgery (laparoscopic intervention and clipping of the lymph vessel) had to be performed to stop lymphoid leakage and restore anatomy. ResultsIn cases, where lymphovascular malformations and urological–urogenital symptoms are both present, therapeutical success is graded by Browse’s scoring system. According to that, our choices of management achieved the best possible outcome in both cases below.ConclusionsAlthough conservative ways of therapy are known and widely used, in more advanced cases surgical help is often needed to reach long-term improvement. In situations where significant mass of chyle has accumulated causing severe complaints, conservative therapy should not to be started. Surgical solutions provide fast and lasting improvement for patients suffering from congenital lymphovascular malformations.

Intermittent hydronephrosis in childhood

INTRODUCTION Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed. AIM The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary. PATIENTS AND METHODS Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed. RESULTS 76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed. CONCLUSIONS Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.

Is premature induced labour justified in case of fetal urinary tract dilatation

UNLABELLED There is a decreasing trend in the number of intrauterine interventions performed due to urinary tract dilatations of the foetus diagnosed ultrasonographically. This is due to the low efficacy of the interventions, the high rate of complications and a better knowledge of the foetal physiology. However, the demand for early corrective surgery is still present. In Hungary pre-term caesarean section is performed in many institutions in order to enable the operation of the neonate, despite the fact that the benefits of this intervention have not been established. AIM In order to test the correctness of this practice, the authors conducted a retrospective analysis of the patients of two large case-volume paediatric institutions. PATIENTS In a period of 5 years, 329 neonates were followed due to intrauterine diagnosis of urinary tract dilatations (197 at the Department of Urology, Heim Pál Childrens Hospital in Budapest, whereas in Miskolc 132), including 13 cases where the urological anomaly was the indication for pre-term induction of labour. RESULTS Of the 13 neonates who had been delivered prematurely, none were operated before the postconceptional age of 40 weeks, and 3 subsequently required no surgical intervention. Two neonates developed life-threatening conditions that presumably could have been avoided without the premature caesarean section. CONCLUSIONS The authors conclude that there are several arguments against pre-term delivery: 1. Prenatal diagnostics does not always yield as accurate information as the diagnostic procedures performed in infancy; 2. Intrauterine urinary tract dilatation often resolve spontaneously, superseding the need for both pre- and post-natal surgical interventions. 3. Scientific observations have confirmed that there is no difference between the efficacy of postnatal and pre-term interventions. Based on the above-mentioned, authors emphasize that this outdated practice can no longer be accepted, and call for good cooperation between the obstetrician, the paediatric urologist and nephrologist, to coordinate the management of the case.