Seth A. Alpert

Sacral nerve stimulation: a promising therapy for fecal and urinary incontinence and constipation in children

PURPOSE This study describes our series of children with bowel and bladder dysfunction (BDD) treated with sacral nerve stimulation in order to begin to identify characteristics associated with better outcomes and guide future therapies. METHODS Between May 2012 and February 2014, 29 patients were evaluated before and after sacral nerve stimulator (SNS) placement. A prospective data registry was developed that contains clinical information and patient-reported measures: Fecal Incontinence Qualify of Life Scale, Fecal Incontinence Severity Scale, PedsQL Gastrointestinal Symptom Scale, and Vancouver DES Symptom Scale. RESULTS The median age of patients was 12.1 (interquartile range: 9.4, 14.3) years and the median follow-up period was 17.7 (12.9, 36.4) weeks. 93% had GI complaints and 65.5% had urinary symptoms while 7% had urologic symptoms only. The most common etiologies of BBD were idiopathic (66%) and imperforate anus (27%). Five patients required reoperation due to a complication with battery placement. Six of 11 patients (55%) with a pre-SNS cecostomy tube no longer require an antegrade bowel regimen as they now have voluntary bowel movements. Ten of eleven patients (91%) no longer require anticholinergic medications for bladder overactivity after receiving SNS. Significant improvements have been demonstrated in all four patient-reported instruments for the overall cohort. CONCLUSIONS Early results have demonstrated improvements in both GI and urinary function after SNS placement in pediatric patients with bowel and bladder dysfunction.

A Review of Pediatric Glans Malformations: A Handy Clinical Reference

PURPOSE Lesions of the pediatric glans penis are an uncommon but important aspect of pediatric urological care. We reviewed the available literature on this topic and did not identify a comprehensive reference resource. We compiled our multi-institutional experience with such conditions to prepare a handy clinical reference source. MATERIALS AND METHODS The diversity of pediatric glans penis lesions was documented by searching the English and nonEnglish literature as well as the archives at our institutions. Cases were included in the study if the patient(s) identified were younger than 18 years at initial presentation or documented to have first had a glans penis lesion when younger than 18 years. Hypospadiac-epispadiac anomalies of the glans were excluded. RESULTS From our institutions we identified 6 new cases of various pediatric glans lesions. Altogether the literature describes 137 distinct nondiphallia glans lesions and more than 100 cases of diphallia, including glans duplication. The nondiphallia reports consist of a total of 61 cystic lesions (44%), 33 vascular malformations (24%), 20 dermatological lesions (15%), 20 infectious lesions (15%) and 3 neurogenic lesions (2%). We did not identify a compact resource to compare these anomalies. Visual comparison permits structuring a differential diagnosis and determining urological treatment, which is typically excisional biopsy, laser treatment, sclerotherapy or topical steroid administration. CONCLUSIONS We present a visual reference of varied lesions of the pediatric glans penis, including 6 new cases, with urological significance. These lesions are always benign but they typically require surgical excision for a definitive pathological diagnosis.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation

BACKGROUND Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE IV.

The Prenatal Diagnosis of Beckwith-Wiedemann Syndrome Using Ultrasound and Magnetic Resonance Imaging

Beckwith-Wiedemann syndrome is a rare congenital overgrowth syndrome. It carries important connotations for the pediatric urologist because it is associated with an increased risk for developing certain embryonal tumors. Until recently, these patients were not diagnosed until after birth; however, with newer imaging modalities, this syndrome may be diagnosed prenatally. We present a case of Beckwith-Wiedemann syndrome, depicting the prenatal modalities that may be used to diagnose this unusual condition.

Is VCUG Still Indicated Following the First Episode of Urinary Tract Infection in Boys

OBJECTIVES To determine if voiding cystourethrogram (VCUG) following first episode of urinary tract infection (UTI) offers any incremental diagnostic advantage in boys if a comprehensive renal and bladder ultrasonogram (RBUS) revealed no abnormalities. METHODS All boys less than 10 years of age whose first evaluation for UTI included RBUS and VCUG were retrospectively studied over a 10-year period. Those with a disorder of the urinary tract known before imaging were excluded. RBUS and VCUG results were analyzed. RESULTS Of the 77 who met the inclusion criteria, 58 (77%) were <1 year old. 45 (58%) boys had normal RBUS and VCUG. In 16 (21%) both studies were abnormal: 15 had vesicoureteral reflux (VUR) and one had posterior urethral valves. The remaining 16 (21%) had one abnormal study: 10 had pelvicaliectasis on RBUS without VUR; 6 had normal RBUS with VUR. No urethral abnormality was diagnosed on VCUG when RBUS was normal. Of the six who had VUR and normal RBUS, the one who required surgical intervention had recurrent febrile UTI. CONCLUSIONS If a well-performed RBUS is normal in a boy with first UTI, the likelihood of a significant finding in VCUG is low. A VCUG is likewise of no apparent screening benefit for obstructive uropathy. With the uncertainties surrounding the benefit of chemoprophylaxis, omitting a VCUG when a RBUS is normal in boys with a first UTI avoids the morbidity without missing important pathologies or altering evolving management protocols.

Sacral nerve stimulation for constipation and fecal incontinence in children: Long-term outcomes, patient benefit, and parent satisfaction

To evaluate the long‐term efficacy of sacral nerve stimulation (SNS) in children with constipation and describe patient benefit and parent satisfaction.

Factors Predicting Complications After Sacral Neuromodulation in Children

OBJECTIVE To identify if any preoperative variables are associated with postoperative complications after pediatric sacral neuromodulation (SNM). MATERIALS AND METHODS A review of all patients undergoing SNM with an implantable pulse generator at our institution was performed. Postoperative infection, lead migration, lead breakage, and need for reoperation were recorded in a prospective database. We collected demographic information and indication for the procedure. We defined indication for procedure as either primarily bowel or primarily bladder symptoms. Multivariate analysis was used to determine any associations between preoperative factors and postoperative complications. RESULTS Sixty-three children (34 females, 29 males) underwent SNM from 2012 to 2015. Mean age was 11.5 years, and body mass index (BMI) was 51st percentile for age. SNM was placed for primarily bowel symptoms in 49% and for primarily bladder symptoms in 51%. Follow-up was 1.9 years (0.19-4.3). Reoperation was required in 25%, with mean time to reoperation of 10.9 months (0.9-31.5). Lead migration occurred in 17.4%, and wound infection in 8%. There were no significant associations between patient age, gender, or BMI, and need for reoperation, wound infection, or lead migration. Low BMI had no increased risk of lead complications (P = .115). There was a significant increase in lead migration in the children who underwent SNM for primarily bladder symptoms (P = .0034). CONCLUSION There is no association between age, gender, or BMI and postoperative complications in this large cohort of pediatric SNM. Children with primarily bladder symptoms may have higher rate of lead complications for unclear reasons.

The Relationship Between Obesity and Complications After Neonatal Circumcision

PURPOSE Penile adhesions with hidden penis and penile skin bridges are complications after neonatal circumcision that seem to develop more often in overweight children. They could possibly be avoided if there were neonatal parameters predicting circumcision complications. We hypothesized that penile adhesions with hidden penis and skin bridges may be predicted by the height and weight of a newborn. MATERIALS AND METHODS We performed an institutional review board approved case-control study. Boys younger than 5 years who presented for evaluation of penile adhesions with hidden penis and/or penile skin bridges after newborn circumcision were compared to boys of the same age who were circumcised at birth and did not have penile adhesions with hidden penis and/or skin bridges when evaluated for cryptorchidism or hernia/hydrocele. Weight for length percentiles were compared at birth and at urological evaluation. RESULTS We evaluated 51 patients with penile adhesions and hidden penis after newborn circumcision, and compared them to 33 age matched controls. Boys with hidden penis had a statistically higher weight for length percentile at birth and at urological evaluation. However, in boys with penile skin bridges there was no statistical difference in the weight for length percentile at either time. CONCLUSIONS An increased weight for length percentile in male infants before and after circumcision may be associated with penile adhesions with hidden penis but not penile skin bridges. These parameters should be considered before newborn circumcision when counseling parents, and after circumcision since early recognition of obesity might indicate the need for diligent genital hygiene to try to prevent post-circumcision complications.

Double-V scrotoplasty for repair of congenital penoscrotal webbing: a hidden scar technique.

OBJECTIVE Penoscrotal webbing (PSW) is a common reason for deferral of neonatal circumcision. Reports of successful procedures and outcomes in the literature are sparse. We have performed double-V scrotoplasty (DVS), a modification of a V-Y technique, in 138 patients with excellent results. PATIENTS AND METHODS We retrospectively reviewed the charts of boys who had undergone DVS for PSW since January 2009 by a single surgeon (S.A.A.). The indications, intraoperative findings, concomitant procedures, outcomes, and complications were recorded. RESULTS A total of 138 DVSs were performed. Concomitant genital surgeries included 81 hidden penis repairs and 10 other (hernia, hypospadias, chordee, orchidopexy). The median age at the time of surgery was 9.6 months (6.1 months-9.8 years). Patients were evaluated about 1 month postoperatively. In seven cases (5%), minor skin separation occurred at the penoscrotal junction but all healed completely. Superficial skin infection occurred in one patient. None required reoperation and cosmetic results were subjectively excellent. CONCLUSIONS PSW has been corrected in 138 patients without significant complications and with excellent results. This is the largest known peer-reviewed series evaluating a surgical technique for congenital PSW repair. We believe our technique is simple, reproducible, and, with no diverging suture lines lateral to the median raphe, improves cosmesis.

Results: Survey of Pediatric Urology Electronic Medical Records—Use and Perspectives

PURPOSE The