Male pediatric, adolescent, and young adult reproductive survivorship

As pediatric, adolescent, and young adult cancer survival rates increase, emphasis is placed on reducing late effects, including reproductive complications and potential impact to fertility. Male survivors are at risk of abnormalities in sperm, hormone deficiencies, and sexual dysfunction. This can impact one's progression into puberty and ability to have a biological child and impacts quality of life following treatment. Access to reproductive care is important and requires patient assessment and appropriate referral to reproductive specialists. This review addresses reproductive complications associated with therapy, standard-of-care testing, and therapeutic interventions. The psychologic impact on psychosexual functioning is also addressed.

White paper: Onco-fertility in pediatric patients with Wilms tumor

The survival of childhood Wilms tumor is currently around 90%, with many survivors reaching reproductive age. Chemotherapy and radiotherapy are established risk factors for gonadal damage and are used in both COG and SIOP Wilms tumor treatment protocols. The risk of infertility in Wilms tumor patients is low but increases with intensification of treatment including the use of alkylating agents, whole abdominal radiation or radiotherapy to the pelvis. Both COG and SIOP protocols aim to limit the use of gonadotoxic treatment, but unfortunately this cannot be avoided in all patients. Infertility is considered one of the most important late effects of childhood cancer treatment by patients and their families. Thus, timely discussion of gonadal damage risk and fertility preservation options is important. Additionally, irrespective of the choice for preservation, consultation with a fertility preservation (FP) team is associated with decreased patient and family regret and better quality of life. Current guidelines recommend early discussion of the impact of therapy on potential fertility. Since most patients with Wilms tumors are prepubertal, potential FP methods for this group are still considered experimental. There are no proven methods for FP for prepubertal males (testicular biopsy for cryopreservation is experimental), and there is just a single option for prepubertal females (ovarian tissue cryopreservation), posing both technical and ethical challenges. Identification of genetic markers of susceptibility to gonadotoxic therapy may help to stratify patient risk of gonadal damage and identify patients most likely to benefit from FP methods.

Prenatal tobacco exposure and psychiatric outcomes in adolescence: is the effect mediated through birth weight?

OBJECTIVE

This study aims to examine the associations between prenatal exposure to maternal smoking, birth weight and persistent offspring psychiatric symptoms. Additionally, we aim to examine whether the relationship between prenatal maternal smoking and persistent offspring psychiatric symptoms is mediated by offspring birth weight.

METHODS

This study used the Growing Up in Ireland (GUI) longitudinal cohort. The GUI is a nationally representative longitudinal study of children which consisted of three data collection waves, at ages 9, 13, and 17 years. Logistic regression analysis was used to examine associations between prenatal tobacco exposure, and offspring psychiatric symptoms. Linear regression was used to examine associations between prenatal tobacco exposure and offspring birth weight. We conducted a mediation analysis examining potential etiological pathways linking maternal smoking during pregnancy, offspring birth weight, and later offspring psychiatric symptoms. All analyses were adjusted for confounders including household income, maternal level of education, and family psychiatric history. Additionally, examination of birth weight and subsequent psychiatric symptoms also was controlled for prematurity.

RESULTS

We found that the association between prenatal tobacco exposure and later psychiatric symptoms is mediated by birth weight.

CONCLUSIONS

This work provides further evidence that maternal smoking during pregnancy is an important modifiable lifestyle factor that has an impact not just on the physical health of offspring but also their mental wellbeing. Supporting women with structured smoking cessation programs at the earliest stages of pregnancy should be a public health priority.

The association between subjective maternal stress during pregnancy and offspring clinically diagnosed psychiatric disorders

OBJECTIVE

Exposure to prenatal stress is a ubiquitous and non-specific risk factor for adverse outcomes in adulthood. In this study, we examined associations between exposure to subjective maternal stress during pregnancy and subsequent diagnosis of psychiatric disorders in offspring.

METHOD

This study used the Helsinki Longitudinal Temperament Cohort, a prospective birth cohort of individuals born between 1 July 1975 and 30 June 1976 in Helsinki, Finland. The sample for this study comprised 3626 infants whose mothers had completed health and well-being assessments during pregnancy which included a measure of self-reported stress. We ran logistic regressions to assess potential associations between prenatal stress and offspring psychiatric disorder in adulthood, identified through the Finnish Hospital Discharge Register.

RESULTS

Individuals whose mothers reported stress during pregnancy had significantly greater odds of developing a psychiatric disorder (OR = 1.41, 95% CI = 1.10-1.81) particularly a mood disorder (OR = 1.67, 95% CI = 1.10-2.54). These associations remained after adjusting for parental psychiatric history, and other prenatal factors.

CONCLUSIONS

Individuals exposed to prenatal stress had significantly increased risk of developing psychiatric disorders later in life. This finding highlights the importance of supporting the mental health and emotional well-being of women during pregnancy.

Management of Recurrent Pelvic Fluid Collections in Adult Male Bladder Exstrophy Patients With Maintenance of Erectile Function

OBJECTIVE

"To describe management options for pelvic fluid collections in adult patients with classic bladder exstrophy."

METHODS

A single institution retrospective chart review was performed of patients who presented between 1998 and 2016 with a history of bladder exstrophy and pelvic fluid collections and 3 patients were identified. Patients had been followed for a mean of 9.0 years (1-23).

RESULTS

All 3 patients required urinary diversions at various intervals following their exstrophy repair as newborns. All initially presented with symptomatic fluid collections located inferior to the bladder visualized by cross-sectional imaging. Mean age at presentation was 32.3 years (26-38 years). Two patients underwent drainage and sclerosing of cystic fluid collections with durable symptomatic relief for 1 patient. The other had recurrence of the fluid collections so he underwent marsupialization of the fluid collection which failed to sufficiently alleviate his symptoms. Ultimately, he along with the last patient, underwent open excision of the presumed hypoplastic prostate leading to resolution of pain symptoms, though the last patient did have some persistence of the fluid collection. All patients maintained their erectile function subsequent to these interventions.

CONCLUSION

Adult patients with bladder exstrophy can present with painful cystic fluid collections potentially due to secretions from presumed hypoplastic prostate tissue. Sclerosing of the cyst can be successful in a subset of these patients, though some may require removal of the presumed prostatic tissue, which is curative and can be achieved with preservation of erectile function.

Incorporating fertility preservation into the care of young oncology patients

As the number of cancer survivors continues to increase, oncologists are faced with the challenge of providing cancer therapy to patients who may 1 day want to have children. Yet, gonadotoxic cancer treatments can compromise future fertility, either temporarily or permanently. There are established means of preserving fertility before cancer treatment; specifically, sperm cryopreservation for men and in vitro fertilization and embryo cryopreservation for women. Several innovative techniques are being actively investigated, including oocyte and ovarian follicle cryopreservation, ovarian tissue transplantation, and in vitro follicle maturation, which may expand the number of fertility preservation choices for young cancer patients. Fertility preservation may also require some modification of cancer therapy; thus, patients' wishes regarding future fertility and available fertility preservation alternatives should be discussed before initiation of therapy. This commentary provides an overview of the range of fertility preservation options currently available and under development, using case-based discussions to illustrate ways in which fertility preservation can be incorporated into oncology care. Cases involving breast cancer, testicular cancer, and rectal cancer are described to illustrate fertility issues experienced by male and female patients, as well as to provide examples of strategies for modifying surgical, medical, and radiation therapy to spare fertility. Current guidelines in oncology and reproductive medicine are also reviewed to underscore the importance of communicating fertility preservation options to young patients with cancer.

Nine critical elements of promising violence prevention programs

To identify approaches to school-based violence prevention that are most promising and those that may not be effective, a review of the literature was conducted. In addition, telephone interviews were conducted with 15 experts on topics related to school-based violence prevention. Nine critical ingredients of promising approaches to violence prevention were identified. Specifically, the approaches are comprehensive and multifaceted; begin in the primary grades and are reinforced across grade level; are developmentally tailored: and cover appropriate content area. Appropriate content areas include information; anger management; social perspective taking; decision making and social problem solving; peer negotiation and conflict management; social resistance skills; active listening and effective communication; and material on prejudice, sexism, racism and male-female relationship. In addition, promising programs use interactive teaching techniques, are culturally sensitive, and provide teacher training. They promote a positive school climate and foster norms against violence. Six violence prevention activities that appear not to be effective are also discussed. The authors conclude with a discussion of the need for more rigorous evaluation of violence prevention programs.

Microanatomy and morphometry of the hydronephrotic "obstructed" renal pelvis in asymptomatic infants

There has been limited histological study of the obstructed ureteropelvic junction in patients less than 1 year old. We present our prospective studies on the histomorphometry of the ureteropelvic junction complexes of 35 infants, of whom 23 underwent pyeloplasty for obstruction and 12 were age matched autopsy normals. Qualitatively, the major abnormalities of the pelvic microanatomy in the hydronephrotic obstructed kidneys included a lamina muscularis that was significantly thicker than normal and the presence of collagen fibers between muscle fascicles. Additionally, variable amounts of elastin were present in the adventitia and lamina muscularis. At the ureteropelvic junction the abnormalities were an increase in the number of inner longitudinal muscle bundles, collagen between muscle bundles (p less than 0.016) and elastin in the adventitia. Quantitatively, for the pelvis the lamina muscularis was significantly thicker in 18 obstructed kidneys compared to 7 controls (1,075 +/- 79 mu. versus 420 +/- 63 mu., mean +/- standard error of mean, p less than 0.001). The percentage area density of smooth muscle in the obstructed versus normals was increased (45.1% versus 35.2%, p less than 0.039). The percentage area density of collagen in the obstructed specimens versus normal showed an upward trend (38.6% versus 27.6%), which was not significant. In conclusion, the obstructed ureteropelvic junction complexes of kidneys in asymptomatic infants show significant qualitative and quantitative differences from normal.