Theodore Barber

Pediatric Testicular Torsion: Demographics of National Orchiopexy Versus Orchiectomy Rates

PURPOSE While the timely diagnosis and management of pediatric torsion can lead to testicular salvage, limited data exist on rates of orchiopexy vs orchiectomy and associated factors. Thus, we examined the Pediatric Health Information System database for torsion outcomes and demographics at American pediatric hospitals. MATERIALS AND METHODS Using the Pediatric Health Information System database we performed a 7-year retrospective cohort study in children 1 to 17 years old with a primary ICD-9 diagnosis of torsion, assessing CPT codes for orchiopexy and orchiectomy. Data were analyzed with SPSS®, version 17.0. RESULTS Of 2,876 patients who underwent surgery for an ICD-9 diagnosis code of testicular torsion 918 (31.9%) underwent orchiectomy at a mean age of 10.7 years and 1,958 (68.1%) underwent orchiopexy at a mean age of 12.6 years (p <0.0001). In the age groups 1 to 9, 10 to 13 and 14 years or greater 274 (49.9%), 311 (29.4%) and 333 patients (26.2%), respectively, underwent orchiectomy. A higher orchiectomy rate was seen at age 1 to 9 vs 10 years or greater. Torsion and orchiectomy rates did not vary by season or geographic region. A higher orchiectomy rate was seen in black vs white children (37.6% vs 28.1%) and in patients without vs with private insurance (36.7% vs 27.0%). Multivariate analysis revealed an association of age (p <0.0001), race (p <0.0001) and insurance status (p <0.001) with orchiectomy. CONCLUSIONS Nationally an average of 32% of the 411 pediatric torsion cases explored annually result in orchiectomy. Identified factors increasing the orchiectomy risk included age 1 to 9 years, black race and lack of private insurance. Efforts should continue to identify modifiable variables that can increase testicular salvage in patients with testicular torsion.

Detrusor Compliance Changes After Bladder Neck Sling Without Augmentation in Children With Neurogenic Urinary Incontinence

PURPOSE We reviewed preoperative, and initial and final postoperative urodynamic testing in consecutive children undergoing bladder neck sling without augmentation for neurogenic urinary incontinence to determine if progressive loss of compliance occurs. MATERIALS AND METHODS We assessed consecutive patients with neurogenic outlet incompetence who underwent 360-degree tight fascial wrap around the bladder neck with appendicovesicostomy but no augmentation. This population comprised all patients undergoing outlet surgery between 2002 and 2007. Inclusion criteria were initial urodynamic test within 1 year postoperatively and final urodynamic test at least 18 months postoperatively. RESULTS A total of 26 patients met inclusion criteria. Most patients (73%) had an acontractile bladder with detrusor pressures less than 25 cm H(2)O preoperatively. Initial postoperative urodynamic test at a mean of 7 months was most predictive of subsequent urodynamic findings. Eight patients (31%) had increased detrusor pressures and/or uninhibited contractions postoperatively. Six patients increased anticholinergic therapy dose. At a mean of 39 months urodynamic patterns were either stable or improved in all patients. CONCLUSIONS Progressive compliance loss was not observed after bladder neck sling without augmentation. Postoperative increases in detrusor pressure and/or uninhibited contractions within 1 year postoperatively should prompt review of anticholinergic therapy rather than enterocystoplasty.

Comparison of Bladder Outlet Procedures Without Augmentation in Children With Neurogenic Incontinence

PURPOSE We compared continence results of the bladder neck sling vs the Leadbetter-Mitchell bladder neck procedure plus fascial sling in children with neurogenic urinary incontinence. MATERIALS AND METHODS We compared consecutive patients who received a 360-degree tight bladder neck sling to subsequent, similar patients who underwent a Leadbetter-Mitchell bladder neck procedure plus fascial sling involving a 50% reduction in bladder neck and proximal urethral diameter before a 360-degree tight sling. All patients underwent simultaneous appendicovesicostomy and none had undergone prior or simultaneous augmentation. All patients followed similar preoperative and postoperative protocols for urodynamic evaluation and anticholinergic therapy with data maintained prospectively. RESULTS After surgery 46% of 35 sling cases did not require pads vs 82% of 17 Leadbetter-Mitchell cases with a sling (p = 0.02). Mean followup was 28 months in sling and 13 months in Leadbetter-Mitchell cases. Initial urodynamics done approximately 6 months postoperatively were similar in the 2 cohorts and no patient had hydronephrosis. Transient low grade reflux occurred in 2 Leadbetter-Mitchell cases, of which 1 with increased intravesical pressures early after surgery that caused trabeculation received increased medical management. Augmentation was not done in any patient except 1 previously reported on after a sling. CONCLUSIONS Patients undergoing Leadbetter-Mitchell procedure plus fascial sling were significantly less likely to require pads postoperatively than those with a sling alone. Adverse bladder changes have not required augmentation to date.

Loss of Insl3: A Potential Predisposing Factor for Testicular Torsion

PURPOSE The testicular hormone Insl3 is critical for mouse gubernacular development. Knockout mice exhibit bilateral intra-abdominal cryptorchidism with absent gubernaculum. Prior studies described torsion of the vas deferens in Insl3 mutant mice. We performed a detailed anatomical analysis of the vas deferens and testis in Insl3 mutant mice to characterize associated anomalies further. MATERIALS AND METHODS Insl3 wild-type (Insl3(+/+)), heterozygous (Insl3(+/-)) and knockout (Insl3(-/-)) male mice were examined either prepubertally (postnatal day 23) or in adulthood (postnatal day 90 or later). The macroscopic appearance, characteristics, and mobility of the testes and spermatic cord were recorded. RESULTS We examined 56 prepubertal and 33 adult mice (175 testes, 28 [20:8] Insl3(+/+), 97 [60:37] Insl3(+/-), 50 [32:18] Insl3(-/-)). Unlike normal Insl3(+/+) testes, 94% of Insl3(-/-) testes were located intra-abdominally at all ages. Delayed descent occurred in Insl3((+/-)) testes, since 37% of postnatal day 23 and 8% of P90 or later testes were intra-abdominal. Vas elongation/convolution and spermatic cord twisting were noted in 65% of Insl3(-/-), 27% of Insl3((+/-)) and 0% of Insl3(+/+) testes. While all Insl3(+/+) testes were normal, 5% of Insl3((+/-)) and 32% of Insl3(-/-) testes showed significant testicular pathology, including torsion, atrophy and vanished testis, which statistically increased with age. CONCLUSIONS Poorly formed gubernacula and increased testicular mobility in Insl3 mutant mice result in spermatic cord anomalies, delayed/absent testicular descent and subsequent testicular torsion in a gene dose dependent manner. Prepubertal testicular torsion in the mutant mice predisposes to testicular atrophy and vanishing testes in adulthood. Thus, Insl3 is a candidate signaling molecule in human delayed testicular descent and torsion.

Wilms Tumor: Preoperative Risk Factors Identified for Intraoperative Tumor Spill

PURPOSE We identified preoperative parameters associated with increased risk of intraoperative Wilms tumor spill. MATERIALS AND METHODS We retrospectively reviewed an institutional database of patients diagnosed with Wilms tumor between 2000 and 2008. Inclusion criteria consisted of available abdominal computerized tomogram and pathological stage I to IV disease. Patient characteristics and neoadjuvant chemotherapy use were noted. After blinding, a radiologist reviewed preoperative computerized tomogram parameters, calculating tumor volume and assigning a preoperative radiological stage. RESULTS Of 67 patients diagnosed with Wilms tumor 41 (22 males, 19 females) met inclusion criteria, while 26 had incomplete imaging for analysis. Comparison of patients with and without intraoperative tumor spill demonstrated no significant differences in age (3.8 vs 3.6 years), sex (3 males and 3 females vs 19 males and 16 females), body weight or tumor capsule thickness. Preoperative radiological staging was unable to predict pathological stage I to III disease. Six intraoperative tumor spills (15%) were identified (left in 4, right in 2), of which 3 were stage III disease and 3 stage IV. Without neoadjuvant chemotherapy, patients with tumors greater than 1,000 cc had an increased risk of spill (2 of 2 [100%] vs 4 of 33 [12%], p = 0.03). Of 9 patients with stage IV disease 0% (0 of 4) receiving neoadjuvant chemotherapy experienced tumor spill, while lack of neoadjuvant chemotherapy was associated with a 60% (3 of 5 patients, 1 male and 2 females) risk of stage IV spill (p = 0.17). CONCLUSIONS The sole significant tumor spill risk factor identifiable preoperatively was tumor volume greater than 1,000 cc. However, spill occurred at volumes less than 400 cc. Although not statistically significant, neoadjuvant chemotherapy for stage IV disease trended toward diminishing spill risk. Patients with Wilms tumors greater than 1,000 cc may benefit from neoadjuvant chemotherapy with less tumor spill, while stage IV tumors warrant further study in this regard.

Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms

OBJECTIVE Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children. PATIENTS AND METHODS Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parents perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB. RESULTS Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms. CONCLUSIONS Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.

Nephrectomy for hypertension in pediatric patients with a unilateral poorly functioning kidney: A contemporary cohort

PURPOSE A unilateral poorly or non-functioning kidney is a cause of hypertension in children. We report the outcomes of pediatric patients with unilateral renal parenchymal disease who underwent nephrectomy for hypertension. MATERIALS AND METHODS Consecutive hypertensive children undergoing nephrectomy with a unilateral poorly or non-functioning kidney were retrospectively reviewed; preoperative and postoperative clinical variables were analyzed. RESULTS From July 2002 to August 2009, 21 patients (8M:13F) with average age 3.5 years and average follow-up 17.8 months were studied. Eleven patients had multicystic dysplastic kidney, 8 had reflux nephropathy, and 2 had ureteropelvic junction obstruction. Fourteen of 21 (67%) had blood pressure normalization after nephrectomy. Seven of 11 with MCDK were normotensive postoperatively compared to 6/8 patients with reflux nephropathy, and 1/2 patients with UPJ obstruction. Of the 14 patients normotensive postoperatively, 7 were on antihypertensives prior to surgery. Four of 7 patients stopped their anti-hypertensive medications postoperatively, 2 decreased from 3 and 4 medications to 1, and 1 remained on an ACE inhibitor. There were 2 patients with contralateral renal scarring, both of which remained hypertensive postoperatively. CONCLUSIONS Nephrectomy in hypertensive pediatric patients with a unilateral poorly functioning or non-functioning kidney yielded hypertension resolution in 67% (14/21), permitting cessation or diminution of antihypertensives in many patients. Given the alternative of lifelong antihypertensives with the risk of medication non-compliance and side-effects, nephrectomy is a logical option of care which can be offered to patients and families with informed knowledge of the potential for cure.

Cold knife valvulotomy for posterior urethral valves using novel optical urethrotome.

OBJECTIVES To present our results after valve ablation using a novel cold knife urethrotome. METHODS Eleven consecutive male patients with posterior urethral valves underwent cold knife valvulotomy using a modified optical pediatric urethrotome. Patients were assessed both pre- and postoperatively using serum creatinine, voiding cystourethrography, and renal/bladder ultrasonography. RESULTS From August 2003 to August 2005, 11 patients underwent cold knife valvulotomy, of whom 7 returned for postoperative follow-up (mean follow-up 17.4 months). At surgery, the patients ranged in age from 5 days to 9 years. At presentation, 5 of the 7 patients had an elevated serum creatinine (mean 2.5 mg/dL, range 0.3-6.5), all had bilateral hydronephrosis of at least grade 3, and 6 of 7 had at least grade 3 reflux on 1 side. Intraoperatively, 1 complication (minor urethral laceration) occurred. Postoperatively, all 6 patients with serum creatinine levels measured showed improvement in renal function (mean creatinine 0.47 mg/dL, range 0.2-0.9). For the 6 patients who underwent postoperative ultrasonography, 4 had either complete resolution or significant improvement in their hydronephrosis, and none showed worsening. Six patients underwent postoperative voiding cystourethrography, with 5 showing either marked improvement or complete resolution of their reflux and 1 showing stable, unilateral reflux. CONCLUSIONS Valvulotomy using our modified urethrotome is a safe and effective technique for valve ablation.

MP61-20 ACUTE URETERAL JET ANGLED MEASURED BY PREOPERATIVE ULTRASOUND CORRELATES WITH RESOLUTION OF VESICOURETERAL REFLUX TREATED WITH ENDOSCOPIC INJECTION OF SUBURETERIC BULKING AGENTS

INTRODUCTION AND OBJECTIVES: We aim to present longterm outcomes of patients with ureterocele, treated by an innovative technique. To date the optimal surgical technique for ureterocele complex remains unclear and treatment options are extremely variable in this regard. These techniques mostly share major drawbacks including de novo vesicoureteral reflux (VUR) into ureterocele moiety and mandatory secondary surgery. A feasible and minimally invasive method for treatment of ureterocele using concomitant ureterocele double puncture and intraureterocele fulguration has been previously introduced (Kajbafzadeh et al. J Urol 2007; 177: 1118-23). Herein, we present long-term outcomes of this technique. METHODS: After obtaining institutional ethical approval, a retrospective chart review was performed to gather records of patients undergone this technique between 1999 and 2014. Patients with history of previous ureterocele surgery or follow up period of less than two years were excluded from the study. In this technique, after maintaining two punctures into the poles of ureterocele using the stylet of a 3Fr ureteral stent and cutting current, a Double-J stent was inserted into the both punctured sites. Afterwards, fulguration of anterior and posterior ureterocele walls at multiple sites was performed under direct vision in order to create anterior and posterior wall surface welding of urine channel. RESULTS: During the study period, 48 patients (51 ureteroceles) underwent this technique. From these, 31 (64.6%) patients were female. Two patients had single system ureteroceles. Three patients (6.2%) underwent bilateral ureterocele double puncture. Mean (range) age at the time of surgery was 2.9 (2 months 13 years) years. The mean follow up period was 6.1 (2-15.2) years. Mode of presentation was febrile UTI (52%). Ureterocele was successfully decompressed in all except two kids (success rate1⁄496%). Secondary ureterocele surgery was performed successfully in two aforementioned patients. De novo VUR was diagnosed in another two patients in upper pole ureter (one grade II, one grade III) which was endoscopically treated with success in both cases. No febrile UTI was encountered postoperatively. CONCLUSIONS: The present study suggests that double puncture ureterocele surgery is highly successful in decompressing ureterocele without incurring major complications, further partial nephroureterectomy or common sheet double ureteric reimplatation. We believe that, this technique could serve as a promising minimally invasive alternative in ureterocele management.