Up and Away: Five Decades of Urologic Investigation in Microgravity

A renewed global interest in manned space exploration has emerged, propelled by the challenge of reaching a new frontier: travel to the Red Planet, Mars. As the physiological changes induced by microgravity bear direct relevance to the safety and viability of these goals, we provide a historical narrative of the urologic investigations in space. We review the significant contributions to the understanding of the urologic consequences associated with exposure to microgravity, considerations for prolonged missions, and forward-looking efforts to manage emergent conditions remotely. Historical insights gleaned are poised to inform interplanetary travel, where urologic pathology will remain an important practical consideration.

The Current State of Urological Education for Medical Students

INTRODUCTION

Providing medical students with a basic urological education is important as the geriatric population expands and the need for urological care increases. In the last decades there have been considerable changes to medical school curricula and graduation requirements that may impact medical student exposure to urology. We reviewed the literature pertaining to urological education for medical students in the United States.

METHODS

We searched the PubMed® and Medline® databases to identify articles pertaining to medical student education in urology. We summarized these articles according to 4 themes, including 1) medical student electives in urology, 2) medical student career interest in urology, 3) new interventions in urology education and 4) the urology match.

RESULTS

We identified 25 articles, which showed that 1) medical student exposure to urology has markedly declined, 2) medical students remain highly interested in pursuing a career in urology, 3) the AUA (American Urological Association) medical student curriculum has provided a key resource for medical school urological education and 4) applying for urology residency may be expensive and challenging.

CONCLUSIONS

Medical school urological education has changed in the last decades. Although it appears that fewer medical students are required to rotate through urology, new materials are available to educate medical students in urology and many students are highly interested in pursing a career in the field.

Challenges Facing Program Directors in the Urology Match

INTRODUCTION

We investigate urology residency program directors' perspectives on the current residency matching system.

METHODS

A survey was emailed to Society of Urology Chairpersons and Program Directors members. The survey queried respondents' perspectives on the current residency matching system, with special attention to the recent surge in application volume and the usefulness of the Medical Student Performance Evaluation. Participants were also asked about their perspective on a possible application limit for students applying to urology residencies.

RESULTS

A total of 70 members of the Society of Urology Chairpersons and Program Directors responded to the survey. The majority of respondents received more than 200 applications for their program's residency positions (77.1%) and used a Step 1 cutoff score to screen applications (81.4%). Approximately half of the respondents (51.4%) were in favor of imposing a limit to the number of applications that applicants are permitted to submit. The Medical Student Performance Evaluation was considered important or very important by 20% and 94.3% favored including an applicant's class rank in the evaluation. An applicant's projected likelihood of attending a respondent's program was considered by 76%, and 60% had previously not offered superior candidates interviews because they estimated the applicants were not truly interested in the program.

CONCLUSIONS

Urology program directors exclude a large number of applications based on board scores and applicants' perceived levels of interest in the programs. A significant number of program directors favored an application limit as well as including class rank in the Medical Student Performance Evaluation.

The Current State of Urological Residency Education

INTRODUCTION

We reviewed literature pertaining to the current state of urological education for residents in the United States.

METHODS

A literature review was performed to identify relevant manuscripts using a key word search of the PubMed® and MEDLINE® databases. Central themes of the literature were identified and summarized for the purpose of this review.

RESULTS

A literature search identified 23 articles related to urological residency education. Key themes identified in the available literature included surgical simulation, decreasing open experience, and improving the efficiency and quality of resident education and evaluation. With increasing limitations in available resident training hours as well as increasing utilization of minimally invasive approaches in the field of urology it is important to critically assess how urological residents are trained.

CONCLUSIONS

As the scope and complexity of medical knowledge and surgical approaches evolve in the field of urology it is imperative to critically evaluate how urological residents are trained to ensure that graduating residents are prepared to provide outstanding patient care as independent surgeons.

Fluid Management in Pediatric Urology: A Review of the Literature and Call for a Change in Practice

INTRODUCTION

We investigate the intravenous fluid ordering practices of pediatric urologists. We also provide evidence for the use of isotonic fluids and, thus, establish a new standard for the field.

METHODS

An online questionnaire was distributed via the listserve of the American Academy of Pediatrics Section on Urology. For 3 patient scenarios the respondents were asked to select which intravenous fluid they would prescribe and which infusion rate they would choose. Fluid choices were listed as lactated Ringer solution, normal saline, 0.45% normal saline, 5% dextrose in lactated Ringer solution, 5% dextrose in 0.45% normal saline, none and other (with write-in option). Infusion rate choices were listed as maintenance (defined according to the Holliday-Segar 4-2-1 nomogram), ½x maintenance, 1.5x maintenance, 2x maintenance and other (with write-in option). A final question probed physician reason(s) for selections.

RESULTS

The survey had a 35% response rate. The majority of respondents use 5% dextrose in 0.45% normal saline, and the most common infusion rate is 1.5x maintenance. Additionally, choices for fluid use and infusion rate were based on a combination of physician training and personal experience. Only 13% of respondents stated that they routinely avoid isotonic fluids. A PubMed® literature search demonstrated that the general pediatric and surgical specialty literature discourages hypotonic fluids and favors the judicious use of isotonic hydration and dextrose.

CONCLUSIONS

A change in pediatric urology needs to occur such that isotonic fluids at maintenance rate become the standard, with the addition of dextrose and/or increasing of rate only for carefully selected patients.

Relationship Between the Number of Residency Applications and the Yearly Match Rate: Time to Start Thinking About an Application Limit?

BACKGROUND

There has been an increase in the number of applications medical students have submitted for the National Residency Matching Program (NRMP). These additional applications are associated with significant costs and may contribute to match inefficiency.

OBJECTIVE

We explored if match rates improved in years when an increased number of applications were submitted.

METHODS

We analyzed yearly published data from the NRMP and the Electronic Residency Application Service for 13 specialties. A generalized linear model was used to assess the relationship between the annual match rate and the mean number of applications submitted per applicant, while controlling for the number of positions available and the number of applicants in the given year.

RESULTS

Over the last 13 years there has been an increase in the mean number of applications submitted per applicant (P < .001). For the 13 assessed medical specialties, there was no statistically significant relationship between the mean number of applications per applicant per year submitted to the NRMP, and the annual match rate (odds ratios near 1.00 and nonsignificant, P values > .05).

CONCLUSIONS

There was no improvement in the match rate in years when medical students submitted an increased number of applications. Therefore, it would appear that the applicants do not benefit from the larger number of applications submitted. Further study is required to assess the cost and benefit of these additional applications.

Circumcision of privately insured males aged 0 to 18 years in the United States

BACKGROUND

Male circumcision confers protection against HIV, sexually transmitted infections, and urinary tract infections. Compared with circumcision of postneonates (>28 days), circumcision of neonates is associated with fewer complications and usually performed with local rather than general anesthesia. We assessed circumcision of commercially insured males during the neonatal or postneonatal period.

METHODS

We analyzed 2010 MarketScan claims data from commercial health plans, using procedural codes to identify circumcisions performed on males aged 0 to 18 years, and diagnostic codes to assess clinical indications for the procedure. Among circumcisions performed in the first year of life, we estimated rates for neonates and postneonates. We estimated the percentage of circumcisions by age among males who had circumcisions in 2010, and the mean payment for neonatal and postneonatal procedures.

RESULTS

We found that 156,247 circumcisions were performed, with 146,213 (93.6%) in neonates and 10,034 (6.4%) in postneonates. The neonatal circumcision rate was 65.7%, and 6.1% of uncircumcised neonates were circumcised by their first birthday. Among postneonatal circumcisions, 46.6% were performed in males younger than 1 year and 25.1% were for nonmedical indications. The mean payment was $285 for a neonatal and $1885 for a postneonatal circumcision.

CONCLUSIONS

The large number of nonmedical postneonatal circumcisions suggests that neonatal circumcision might be a missed opportunity for these boys. Delay of nonmedical circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child.

Pediatrician noncompliance with the American Academy of Pediatrics guidelines for the workup of UTI in infants

BACKGROUND

The American Academy of Pediatrics (AAP) guidelines on the workup for urinary tract infections (UTIs) in infants discourages the use of bagged urine specimens for urine culture. We report the results of a survey to assess urine collection preferences and adherence to AAP guidelines in clinical practice.

METHODS

A 29-question survey was e-mailed to pediatrician AAP members to determine their preferred method of urine collection in hypothetical infant patients.

RESULTS

Data from 155 respondents were analyzed. In febrile, circumcised boys, up to 18% preferred bagged specimens for urine culture, against AAP recommendations. In febrile girls, 13% of respondents preferred bagged specimens. There was no significant relationship between adherence to AAP guidelines and respondent's age, gender, years in practice, fellowship training, academic affiliation, or other demographic factors.

CONCLUSIONS

Up to 18% of practitioners prefer bagged specimens over more sterile ones in the workup of febrile UTIs in infants, against AAP guidelines.

Variations in the management of asymptomatic adolescent grade 2 or 3 left varicoceles: a survey of practitioners

OBJECTIVE

Our study aims to evaluate variations in management of asymptomatic adolescent grade 2 and 3 varicoceles by pediatric urologists.

SUBJECTS AND METHODS

Electronic survey of all 267 current members of AAP Urology with 74 (28%) responding.

RESULTS

When managing patients with positive examination findings, 49% of surveyed practitioners use scrotal sonography as initial screening, while 38% use only manual orchidometry and 11% observation with serial examinations. If significant testicular size discrepancy is identified, 32% immediately intervene surgically, while 59% repeat measurements in 6-12 months. When no discrepancy is identified, 36.6% of practitioners discharge their patients with no follow-up, 22.5% refer to an infertility specialist, and 31% evaluate with semen analysis. Fifty-seven percent of practitioners have never sent patients for semen analysis; only 4% send >50% of patients. Of these, 52% and 27% analyzed semen at 17-18 years and 19-20 years, respectively, and 10% send for semen analysis at <17 years.

CONCLUSIONS

Our survey demonstrates that there does not appear to be a consensus among pediatric urologists managing asymptomatic grade 2 and 3 varicoceles. Better understanding of which adolescent patients with varicoceles will go on to develop male infertility is necessary to identify pediatric patients who could benefit from early intervention.

Practice patterns among pediatric urologists in the use of Deflux® for vesicoureteral reflux: a survey

OBJECTIVES

This study aims to assess pediatric urology practice patterns and factors which influence the use of Deflux(®) in the management of vesicoureteral reflux among pediatric urologists.

METHODS

A 11-question survey was sent out to 476 pediatric urologists who are members of the Society for Pediatric Urology.

RESULTS

23.7% of pediatric urologists use Deflux(®) as first line therapy for Grade III reflux or higher. The presence of renal scarring is not a deterrent to the use of Deflux(®). 17.7% would use Deflux(®) before a trial of observation with or without chemoprophylaxis. In children who are on observation, 20.3% would perform Deflux(®) when they are at an age considered appropriate for surgery as opposed to continued observation. The majority of pediatric urologists cite Deflux(®) success rates of >70% to >80% for Grades II-III and >50% to >60% for Grades IV-V. 23.3% of respondents indicated that new evidence citing low long-term success rates at one year decreased their use of Deflux(®). 59.8% of respondents indicated they would perform a second injection after an initial failure. Ultrasound and VCUG are used as follow-up in 86.9% and 65.4% respectively after Deflux(®); the majority are performed within the first 3 months, rarely at one year.

CONCLUSION

The use of Deflux(®) is growing and whether it surpasses open reimplantation and chemoprophylaxis as first-line therapy remains to be seen. With new literature showing lower success rates, long-term follow-up with repeat imaging may be required.

Vesico-ureteric reflux (VUR) management and screening patterns: are paediatric urologists following the 2010 American Urological Association (AUA) guidelines?

OBJECTIVE

To evaluate the current practice patterns of vesico-ureteric reflux (VUR) management and screening among paediatric urologists and their relationship with the current American Urological Association (AUA) guidelines in managing and treating VUR.

SUBJECTS AND METHODS

A 17-question survey was sent out to 476 paediatric urologists who are members of the Society for Pediatric Urology (SPU). In all, 133 respondents answered the survey and results were included for all questions.

RESULTS

Paediatric urologists who were surveyed were consistent with the 2010 AUA guidelines in the initial evaluation of children with VUR, continuous antibiotic prophylaxis for the child aged < or >1 year, and follow-up evaluation in children with VUR. Most paediatric urologists do not obtain a serum creatinine on initial screening of children with VUR. The new guidelines address screening of siblings of patients with VUR and most paediatric urologists were consistent with these recommendations. Almost one third of responders screened all neonates diagnosed with prenatal hydronephrosis regardless of clinical history or findings on imaging despite the recommendations of the new guidelines.

CONCLUSION

We conclude that based on our present sample, most paediatric urologists follow the 2010 AUA guidelines on VUR management.

Cystine nephrolithiasis

Cystinuria is a rare etiology of nephroliathiasis but must be considered in the pediatric population and in those patients with recurrent nephrolithiasis. We describe a patient with an unusually large cystine stone burden and our successful multimodality therapy.

Simple, age-based formula for predicting renal length in children

OBJECTIVE

To determine a simple, age based formula for predicting ideal renal length in children. Renal size is a valuable marker in the evaluation of children with urological disorders. Although many authors have described complex nomograms and multivariate formulas for determining renal size, we propose a simple and accurate formula.

MATERIAL AND METHODS

All renal ultrasound (US) studies performed over a 9-year period in patients <18 years of age were retrospectively evaluated, excluding patients with a history of urinary tract disease or with abnormal renal US findings.

RESULTS

Ultrasounds were performed in 778 children <18 years who met inclusion criteria. Sixty-one percent of the patient population was ≥1 year of age at the time of the US. Forty-four percent of the children were male. In children 1 year of age or older, the formula was length (cm) = age (years) × 0.3 + 6, R(2) = .81. In infants younger than 1 year, renal length was poorly estimated by a simple age-based formula.

CONCLUSION

Our proposed formula can be used to predict renal length in children older than 1 year.

Long-term follow-up and late complications following treatment of pediatric urologic disorders

Many pediatric urologic disorders have sequelae that may affect patients well into adulthood. Despite adequate treatment, many patients are at risk for progressive urologic deterioration years after surgical reconstruction. While many pediatric urologists follow their patients years after surgery, screening for late complications is a shared responsibility with primary care providers. This article discusses potential late complications and appropriate follow-up for patients who have a history of ureteral reimplantation, pyeloplasty, hypospadias repair, posterior urethral valve ablation, and intestinal interposition.

Esthetic Outcomes of Genitoplasty in Males Born With Bladder Exstrophy and Epispadias

PURPOSE

Male children born with bladder exstrophy-epispadias complex may have poor self-image because the esthetic aspects of the genitalia acquire greater significance with age. We reviewed our long-term outcomes of genitoplasty in males born with exstrophy-epispadias complex with emphasis on the esthetic results.

MATERIALS AND METHODS

A total of 70 male patients with exstrophy-epispadias complex were the basis of this retrospective review. Primary and secondary genitoplasty was performed in 44 and 26 patients, respectively. Various surgical methods were implemented for genitoplasty, including Cantwell Ransley technique with or without paraexstrophy flaps in 36 cases, partial corporeal mobilization with or without dermal graft in 16, subperiosteal corporeal mobilization from the pubic rami in 7 and complete penile disassembly in 6. The parent and when appropriate the patient determined satisfaction with the cosmetic appearance. The incidence of postoperative complications and need for surgical revision were noted.

RESULTS

Long-term followup was available in 65 of 70 patients. Esthetic satisfaction was present in 60 of 65 patients (92%). A total of 19 revisions (29%) were required with 4 patients undergoing multiple revisions. These revisions included fistula repair, repair of urethral stricture, glanular contouring and recurrent chordee release.

CONCLUSIONS

The penile malformations observed in exstrophy-epispadias complex may be due to a short urethral strip, corporeal disproportion and/or iatrogenic scarring. The optimal method to correct corporeal disproportion includes placement of a dermal graft. In select cases careful and partial mobilization of the crura from the pubic rami allows penile lengthening. In secondary reconstructive efforts subperiosteal dissection provides a virgin surgical field, while protecting neurovascular and erectile structures.

Aesthetic Aspects of Bladder Exstrophy: Results of Puboplasty

PURPOSE

At times children born with bladder exstrophy-epispadias complex must undergo several operations and the resultant scar tissue on the abdomen can be quite disfiguring. Long-term followup in these patients reveals that many have a poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. We present our retrospective case series of the experience of 1 surgeon during 27 years.

MATERIALS AND METHODS

Our database includes 116 patients born with exstrophy-epispadias complex. Primary reconstruction was performed in 62 infants and neonates, while 54 children and young adults underwent initial surgery elsewhere. Secondary puboplasty was performed in 88 of the 116 patients. Various techniques were used, ranging from simple excision and longitudinal closure in 12 cases, Z-plasty and pubic contouring in 23, the use of axial pattern inguinal skin flaps in 50 and tissue expanders in 3, when necessary. Long-term followup data were available on 76 patients. The parent and, when appropriate, the patient determined satisfaction with the cosmetic appearance.

RESULTS

Patient satisfaction with the cosmetic and functional outcomes of surgery was high. Of the 76 patients 73 (96%) were satisfied following puboplasty. Complications included wound infection and keloid formation in 4% and 10% of cases, respectively.

CONCLUSIONS

Achievement of excellent aesthetic results is possible with secondary puboplasty. Simple closure is associated with a higher incidence of keloid formation compared to the Z-plasty closure technique. Axial pattern skin flaps and Z-plasty techniques yield superior cosmetic results for contouring the mons pubis in patients with exstrophy-epispadias complex.

Aesthetic aspects of abdominal wall and external genital reconstructive surgery in bladder exstrophy-epispadias complex

Long-term follow-up of patients born with classical bladder exstrophy-epispadias complex (EEC) reveals that many of them suffer from poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. In this article, we review the aesthetic outcomes in performing puboplasty, umbilicoplasty, and genitoplasty in patients born with EEC. Retrospective review of the cosmetic and functional outcomes in 116 patients born with EEC treated by puboplasty, umbilicoplasty, or genitoplasty was performed. Satisfaction with the cosmetic and functional outcomes of these three reconstructive surgeries was high following initial reconstructive efforts (> 90%). Attention to cosmesis during abdominal wall and genital reconstruction for EEC helps to improve a patient's perception of body image and self-esteem. Our experience with these procedures over the past 25 years demonstrated that the efforts directed toward aesthetics have been well worthwhile.

Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle

PURPOSE

We review the evolution of the concept of tubularization of the urethral plate and our results in the repair of proximal hypospadias.

MATERIALS AND METHODS

A total of 281 children born with proximal hypospadias underwent Thiersch-Duplay urethroplasty with or without a midline incision of the urethral plate between 1989 and 1998. Followup data were available in 265 children.

RESULTS

Excellent functional and cosmetic results were achieved in 88.7% of the patients. The use of either a dartos or tunica vaginalis flap to waterproof the urethral suture line resulted in a decrease in the fistula rate from 17% to 1.8%.

CONCLUSIONS

The principles of Thiersch-Duplay urethroplasty represent the basic foundation for surgical techniques that use the urethral plate to construct a urethral tube. The use of this principle in the repair of proximal hypospadias compares favorably with other methods.

MANAGEMENT AND OUTCOME OF COMPLEX HYPOSPADIAS REPAIRS

PURPOSE

Repeated attempts at surgical repair of hypospadias may leave the penis scarred, hypovascular and shortened. We report on the clinical outcomes of our repaired complex hypospadias cases, often referred to as hypospadias cripples.

MATERIALS AND METHODS

We evaluated the records of 137 children and young adults from January 1980 through December 2002 who were referred to us after multiple unsuccessful hypospadias repairs. The records of 11 patients were inadequate. The ages of the remaining 126 patients ranged from 14 months to 35 years. The number of prior surgical procedures ranged from 2 to 23. Of the 126 cases 98 (78%) were repaired in a single stage (group 1) and 28 (22%) underwent multistage repairs (group 2).

RESULTS

Major complications occurred in 17 cases (17%) in group 1 and in 2 (7%) in group 2. Major complications included repair breakdown, stricture, diverticulum and multiple fistulas. Minor complications occurred in 9 (9%) cases in group 1 and in 4 (14%) in group 2. Minor complications included a single small urethrocutaneous fistula, skin tethering, inclusion cysts and glandular irregularity. Urethral substitution using skin grafts and/or bladder mucosa resulted in a high complication rate of 32% and 37%, respectively, whereas use of buccal mucosa resulted in a 15% complication rate.

CONCLUSIONS

Preoperative psychological counseling and discussion with other parents or patients were helpful. We no longer use free skin grafts and/or bladder mucosa for urethral substitution. Waterproofing the urethral tube was performed using either a dartos or tunica vaginalis flap. When the quality of the tissues was poor or severely scarred a 2-stage repair was performed. When resurfacing the penis local skin flaps may be insufficient or unreliable, and rotation of scrotal skin flaps or burial of the penis in the scrotum (Cecil-Culp) offers dependable skin coverage.

Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study

OBJECTIVE

To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTIs) in persons with spinal cord injury (SCI).

DESIGN

A prospective, double-blinded, placebo-controlled, crossover study.

PARTICIPANTS

21 individuals with neurogenic bladders secondary to SCI.

MAIN OUTCOME MEASURES

Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts.

METHODS

Individuals with neurogenic bladders due to SCI were recruited and randomly assigned to standardized 400-mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1-week "washout period," participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count > or = 10 per high power field) in centrifuged urine. Participants with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7-day washout period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead's random effect approach.

RESULTS

There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups.

CONCLUSION

Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders. Further long-term studies evaluating specific types of bladder management and UTIs will help to determine whether there is any role for the use of cranberries in individuals with neurogenic bladders.

Bladder Dysfunction After Bilateral Ectopic Ureterocele Repair

PURPOSE

We examined postoperative outcome, with emphasis on bladder function, in pediatric patients who underwent bilateral ectopic ureterocele repair.

MATERIAL AND METHODS

We reviewed the records of 117 patients with orthotopic and ectopic ureteroceles treated between 1977 and 2000. Twelve of these patients had bilateral ectopic ureteroceles. All patients with bilateral ureteroceles were females 1 day to 2 years old at referral. Initial treatment was transureteral puncture in 6 cases, transurethral unroofing in 2 and extravesical bilateral reimplantation in 1. Of the remaining 3 patients the initial treatment was unilateral heminephroureterectomy in 1 and bilateral heminephroureterectomy in 2. Definitive treatment included bilateral upper to lower ureteroureterostomy, ureterocelectomy with trigonal and bladder neck reconstruction, and bilateral ureteroneocystotomy with or without tapering of the recipient ureter. In patients who underwent upper pole partial nephrectomy the distal upper pole ureter was removed in conjunction with trigonal surgery and ureteroneocystotomy.

RESULTS

There was significant morbidity in this group of patients, including voiding dysfunction and poor bladder emptying with residual urine greater than 20% of bladder capacity in 7 of 10 patients studied by serial bladder ultrasonography. Urodynamic evaluation in 3 patients revealed increased bladder compliance and large volume residual urine. Of these 3 patients 2 perform clean intermittent catheterization. Recurrent symptomatic bacteruria was noted in 7 of the 12 patients.

CONCLUSIONS

Patients undergoing bilateral ectopic ureterocele repair are at increased risk for postoperative voiding dysfunction. Whether this risk is present preoperatively or is a result of trigonal surgery is unclear.

20-Year Experience With Iatrogenic Penile Injury

PURPOSE

We review our experience with the management of iatrogenic penile injuries. Apart from circumcision, serious damage to the penis can occur following hypospadias repair, surgery for priapism or total loss of the penis following surgical repair of bladder exstrophy.

MATERIALS AND METHODS

A retrospective analysis of patients with iatrogenic penile amputation referred to us between 1980 and 2000 was undertaken. Causes of injury and choice of management were reviewed.

RESULTS

Of the 13 cases treated during the 20-year period mechanism of primary injury was circumcision in 4, hypospadias repair in 6, priapism in 1, bladder exstrophy repair in 1 and penile carcinoma in 1. A variety of techniques were used for phallic reconstruction. Penile degloving, division of suspensory ligament and rotational skin flaps achieved penile augmentation and enhancement. Reasonable cosmesis and penile length were achieved in all cases. In indicated cases microsurgical phalloplasty was technically feasible. However long-term followup showed various complications including erosions from the use of a penile stiffener.

CONCLUSIONS

The ultimate goal of reconstructive surgery is to have a penis with normal function and appearance. The management of penile injury requires a wide variety of surgical techniques that are tailored to the individual patient. Expedient penile reconstruction is successful and therapeutic delay is associated with complications.

Modified cecal flap neoappendix for the Malone antegrade continence enema procedure: a novel technique

PURPOSE

We report our experience with the creation of a tubularized cecal flap to construct a neoappendix. This flap effectively serves as an alternative means of creating a conduit for antegrade continence enemas in patients who have either an absent or an unusable appendix.

MATERIALS AND METHODS

We reviewed our results from our initial 4 patients in whom we used this technique. A neoappendix is created from a medially based flap of distal cecum that is tubularized over a catheter and then buried in a seromuscular tunnel to create an antireflux mechanism. A skin stoma is then created.

RESULTS

All stomas are continent, functional and without any evidence of stenosis or necrosis of the cecal flap with followup ranging from 3 months to 8 years.

CONCLUSIONS

A medially based cecal flap neoappendix is an easily created and reliable conduit for antegrade enemas. This procedure should be considered within the surgical armamentarium of urologists and pediatric surgeons when the appendix is absent, atretic or fibrotic.

Prospective evaluation of human chorionic gonadotropin in the differentiation of undescended testes from retractile testes

PURPOSE

We prospectively evaluated the efficacy of human chorionic gonadotropin (HCG) in the treatment of undescended testis and sought to determine whether HCG assists in the differentiation of undescended testis from retractile testis.

MATERIALS AND METHODS

Patients with undescended testes were offered HCG. Testis position, laterality and the presence or absence of a hypoplastic scrotum were noted. The same physician (G. W. K.) recorded physical findings prospectively and stated clinical impression of descent.

RESULTS

A total of 67 patients with 90 undescended or retractile testes were treated and evaluated with HCG. Of the 64 undescended testes 13 (20%) descended with HCG therapy, with none requiring subsequent surgery. Of the 26 retractile testes 15 (58%) descended with HCG (p <0.001). Based on physical examination, 100% of retractile testes descended if the testis was in the high scrotal position but only 40% descended if the testis was in the superficial pouch or inguinal area. In the undescended testes group no ectopic or nonpalpable testis descended with HCG. Evaluation of HCG with age demonstrated minimal response (15%) to HCG at less than 24 months, and a peak response between ages 2 and 6 years (75%) with response decreasing thereafter.

CONCLUSIONS

HCG may have a limited role in the evaluation of undescended testis in patients younger than 2 years. HCG can serve as an adjunct in the clinical diagnosis of retractile testis in older children.

The role of partial nephrectomy in the treatment of pediatric renal hypertension

PURPOSE

From 5% to 25% of hypertension in children is renovascular compared with only 1% in adults. Although much attention is given to renovascular disease involving the main renal arteries, renin producing renal disease may also be intrarenal, involving abnormalities of the segmental vessels or renal parenchyma. We present our results of partial nephrectomy in this unique group of pediatric patients with hypertension in whom renin dependent hypertension involved only a segment of the kidney.

MATERIALS AND METHODS

Six patients 10 months to 16 years old were referred for the evaluation of hypertension. Initial evaluations included computerized tomography, ultrasound, voiding cystourethrography and radionuclide renal scan. Renal arteriography with renal vein renin sampling was performed in 5 patients, of whom 4 underwent selective segmental renal vein sampling. Diagnoses included segmental hypoplasia (Ask-Upmark kidney), reflux associated scarring and renal arteriovenous malformation.

RESULTS

In patients who underwent selective segmental renal vein sampling an increased renin level was present in the area of the renal lesion (mean 24.9 ng./ml. per hour, range 9.2 to 40.6) compared to the ipsilateral renal vein (15.6, 114 to 29.8). Three patients had evidence of contralateral suppression of renin secretion. All 6 patients underwent upper, lower or mid segment partial nephrectomy. All patients became immediately normotensive and remained so at a mean 10 years of followup.

CONCLUSIONS

Partial nephrectomy provides an excellent nephron sparing cure for segmental renal hypertension. In the pediatric population selective segmental renal vein renin sampling is invaluable for locating the renin producing lesion. As in adults, contralateral renin suppression is predictive of surgical cure.

Management of recurrent urethral fistulas after hypospadias repair

OBJECTIVES

To report on our experience in the management of recurrent urethrocutaneous fistulas in order to understand the etiology and outcome of secondary repair of the failed fistula closure.

METHODS

We reviewed the records of 28 patients between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts. In 17 children, a single large fistula was present, and in 11 children, multiple fistulas were present. The causes of failure were believed to be the awkward fistula site in 12 (coronal fistulas), urethral diverticula in 7, and distal urethral strictures in 4. In 5 children, the cause of fistula formation was unclear.

RESULTS

The 12 coronal fistulas were converted into coronal hypospadias. Thereafter, the urethral plate was tubularized using a wider strip (Thiersch tube) with (n = 3) or without (n = 9) a relaxing midline incision (Reddy-Snodgrass). Of the 12 repairs, 11 were successful; 1 child developed wound separation, resulting in a megameatus that was subsequently corrected. In 7 children, the cause of the fistula was a urethral diverticulum, which was excised and closed in multiple layers. All were successful (voiding well and no stricture or fistula). In 4 children (1 with multiple fistulas), the distal urethra was stenotic, and repair of the fistula included repair of the stricture using an island onlay flap in 2 and a buccal mucosal graft in 2. All 4 patients achieved a successful outcome. Dartos flaps were used to cover the repair in 18 patients, and tunica vaginalis flaps were used in 6 children.

CONCLUSIONS

Recurrent urethral fistula after hypospadias repair may be a manifestation of another problem, such as urethral stricture and/or urethral diverticulum. Intraoperative calibration of the distal urethra and distension of the repaired hypospadias to search for a diverticulum are recommended. Coronal fistulas are best repaired by converting them into coronal hypospadias, followed by tubularization of the urethral plate with or without a dorsal midline relaxing incision. In resurfacing the operative site, the traditional transposition flaps (Y-V and advancement) may be unreliable, because their vascularity may be compromised by previous surgery. The hairless scrotal island or rotation scrotal flap is more reliable for these cases.

A case for 2-stage repair of perineoscrotal hypospadias with severe chordee

PURPOSE

In the majority of children hypospadias can be corrected in a single stage procedure. However, there is a subgroup of patients with perineoscrotal meatus and severe chordee who frequently exhibit some degree of penile scrotal transposition. It is this subgroup of patients in whom a critical review of the long-term results is examined.

MATERIALS AND METHODS

Between 1980 and 1995, 1,934 children underwent repair of hypospadias and chordee. Of these patients 51 had perineoscrotal hypospadias with severe chordee and 40 underwent single stage repair (23), which included either full thickness skin graft urethroplasty (6), a proximal Thiersch procedure with distal free preputial skin graft (7) or an island tubularized flap (10). The chordee were corrected by either Nesbit or tunica albuginea plication. A 2-stage repair was performed in the remaining 11 children. Stage 1 consisted of chordee repair by either dermal (5) or tunica vaginalis (6) grafting of the ventral tunica albuginea surface, while stage 2 urethroplasty was performed 6 months later. These 2 groups were compared in regard to function status and cosmetic results.

RESULTS

Of the patients 34 (61%) were available for a greater than 5-year followup. An excellent outcome (terminal meatal voiding, near normal appearance, no complications) was obtained in only 5 (21%) patients of the single stage repair group, while satisfactory (subterminal meatus, irregularities in meatal, glandular or penile skin) or complicated results were obtained in 4 (17%) and 14 (61%), respectively. The overall complication rate was 61% (14 of 23 patients), including fistula, urethral diverticulum, distal breakdown or stricture formation. Recurrent chordee was noted in 5 (22%) children. Of the 2-stage group excellent results were obtained in 7 (63%), patients, while satisfactory and complicated results was seen in 2 (18%) and 2 (18%), respectively. Overall complication rate was 18%, and included fistula and diverticular formation. However, no recurrence of the initial chordee was noted.

CONCLUSIONS

Our long-term followup suggests that ventral grafting of the corporal wall in patients with severe chordee as a staged procedure is superior to the dorsal plication or Nesbit procedure. The overall functional and cosmetic results are excellent with the 2-stage compared to the single stage repair.