[Cryptorchidism: the point of view of a pediatric urologist]

Cryptorchidism is a very common anomaly of testicular migration, different from ectopy, anorchidy or retractile testis. Physiopathology of cryptorchidism is now well known. Hypogonadotrophic hypogonadism during pregnancy is mostly admitted. Recent epidemiologic studies show a significant increase due to toxic environmental factors, in particular pesticide. Cryptorchidism is most often isolated but polymalformatives entities must be eliminated, requiring sometimes hormonal or genetic investigations. Diagnosis is firstly clinical but coelioscopy adds accuracy and fiability. Infertility and cancer are the two majors risks of cryptorchidism, but their physiopathological mechanisms are still debated. It is not yet clear, in particular as far as the risk of infertility is concerned, if the testicular damage is primitive or (and) deteriorates with age. Medical and surgical treatments are now rather well codified. If, so far, there is no consensus about the age of management of cryptorchidism, many data of the literature lead pediatric urologists to manage these boys as soon as they are two or three.

ULTRASONOGRAPHY OF THE SPERMATIC CORD IN CHILDREN WITH TESTICULAR TORSION: IMPACT ON THE SURGICAL STRATEGY

PURPOSE

Many surgeons advocate systematic exploration for acute scrotum rather than risking a misdiagnosis of testicular torsion. Study of testicular vascularization with color Doppler sonography (CDS) can be inaccurate, leading to dangerous false-negative results. We determine whether direct visualization of the twisted cord during emergency high resolution ultrasonography (HRUS) is a reliable sign to diagnose the torsion and whether its absence can dispense with unnecessary surgery.

MATERIALS AND METHODS

From 1993 to 2002 an average of 35 patients per year presented with acute scrotum, and 44 patients had spermatic cord torsion. CDS and HRUS were performed in all cases. Transversal and longitudinal scans on both sides of the scrotum permitted comparison of testicular echogenicity, size and vascularization. The spermatic cord was studied along its complete length to detect spiral twist. The surgical findings were correlated with the preoperative results.

RESULTS

Spermatic cord torsion at surgery was confirmed in all 44 cases. The time lost by the examination was never more than 30 minutes. Intratesticular blood flow was absent in the affected testis in 31 cases, and CDS was unreliable in the others. In all cases, regardless of CDS findings, HRUS succeeded in detecting the twist as a snail shell-shaped mass measuring 11 to 33 mm.

CONCLUSIONS

The finding of a twisted spermatic cord is a highly reliable sign for the diagnosis of testicular torsion. Whereas normal intratesticular perfusion does not dispense with emergency exploratory surgery, direct and complete visualization of a nontwisted spermatic cord strongly indicates that surgery is unnecessary. Strict conditions are required, including time spent on HRUS should not exceed 30 minutes, which generally can only be achieved by a senior pediatric radiologist.

[Lower pole pedicle in a series of 84 pyelo-ureteral junction syndromes surgically treated in children]

OBJECTIVE

To evaluate the involvement and consequences of the lower pole pedicle (LPP) associated with ureteropelvic junction syndrome.

MATERIAL AND METHOD

Retrospective study in 81 children presenting a total of 84 ureteropelvic junction syndromes operated consecutively between 1994 and 1998. Urinary tract ultrasound and cystography were systematically performed. Renal scintigraphy (DTPA or MAG 3) was performed in 80 children. Preoperative intravenous urography was performed in 60 children. LPP was considered to be present when its participation in the obstruction was confirmed intraoperatively (Anderson Hynes technique with uncrossing of the vascular pedicle).

RESULTS

Group I: a LPP was revealed in 24 kidneys (28.5% of cases), 17 left kidneys and 7 right kidneys, in 14 boys and 10 girls, with a mean age of 4 years (range: 2 months-14 years). Group II: 60 kidneys without LPP (71.5% of cases), 32 left kidneys and 28 right kidneys, in 40 boys and 17 girls, with a mean age of 2 years (range: 1 month-15 years). The most frequent presenting complaint was recurrent low back pain in 58% of cases in group I (14/24) and 5% of cases in group II (3/60). The mean age at diagnosis was 6 years. Hydronephrosis was detected by antenatal ultrasound in 33% of cases in group I (8/24) and in 72% of cases in group II (43/60). Kidney function in group I was greater than 40% in 19 patients, between 20 and 39% in 2 patients and less than 20% in 2 patients. These results were not influenced by age at diagnosis and were not significantly different from those observed in group II. Renal malrotation was observed in 2 cases in group I and in 12 cases in group II. Histology of the junction revealed nonspecific fibrosis in the same percentage of cases (91%) in the two groups. The mean follow-up was 15 months (range: 2 months-5 years). No surgical failure was observed.

CONCLUSION

Ureteropelvic junction syndrome associated with a LPP appears to present later with recurrent low back pain in older children. It does not worsen the functional prognosis of the affected kidney. LPP can be visualized by duplex ultrasound. It may act as an inducer of obstruction by aggravating a pre-existing abnormality of the ureteropelvic junction. When LPP is associated with isolated dilatation of the pyelocaliceal cavities, the risk of subsequent decompensation requires closer ultrasound surveillance, until puberty.

[Diabetes and urination disorders]

Diabetic neuropathy of can induce multi-organ dysfunction. The diabetes simultaneously has profound repercussions on gastrointestinal, sexual and erectile functions. One of the main sequelae of diabetic neuropathy is autonomic neuropathy affecting the vesicosphincteric control. The objective of this study was to review the epidemiological, clinical, laboratory and therapeutic data concerning voiding disorders observed in diabetes. Although the therapeutic management of an isolated voiding disorder in diabetics still remains symptomatic, it raises aetiological problems due to the comorbidity, particularly prostatic obstructive syndromes in men, pelvic dysfunction in women and ageing. Diabetic patients in renal failure also present specific vesicosphincteric disorders which are reviewed. Diabetic patients should be more systematically screened for the development of diabetic bladder disease, especially for associated factors which participate in its clinical expression. This implies extreme caution in the management of benign prostatic hyperplasia in the case of comorbidity, to avoid deteriorating a sometimes fragile detrusor-sphincter equilibrium. Diabetic detrusor hyperactivity must be better known in order to be more effectively detected. Pharmacological treatment of this condition raises problems related to detrusor hypocontractility also related to diabetic bladder disease. Clinical examination should be able to select those patients requiring further urodynamic studies in order to assess the individual detrusor-sphincter equilibrium. These investigations are required when surgical treatment of an associated urological or gynaecological disorder is considered.

[Prenatal diagnosis of bilateral polycystic kidney disease in a twin pregnancy]

Polycystic renal dysplasia is a lethal malformation when it is bilateral. The authors report a rare case of polycystic dysplasia observed in both foetuses of a twin pregnancy, one of whom survived despite bilateral polycystic kidney disease. These biamniotic monoplacental twins were delivered prematurely at 33 weeks of amenorrhoea. The diagnosis was made by antenatal ultrasound. The first twin presented bilateral renal lesions: right polycystic kidney, segmental polycystic dysplasia of the superior pole of the left kidney on a completely duplicated system. The second twin presented a right polycystic kidney. In the light of this case report, the authors describe the various antenatal presentations of polycystic kidney and the associated urological malformations. Involvement of both foetuses of a twin pregnancy raises a discussion of the aetiopathogenesis of polycystic renal dysplasia.

[Pressure-flow urologic analysis in children: reflections after 20 years of practice]

Pressure-flow analysis in children allows optimal definition of the main urodynamic parameters of micturition and clarifies certain aspects of physiology and functional disorders. This examination has allowed urologists to establish reliable relationships between the findings of the clinical interview and clinical examination and the reality of urodynamic parameters, so that, after being widely used for more than 20 years, its indications have now become exceptional, limited to the detection of detrusor-sphincter pathophysiology and a few rare voiding disorders, poorly defined by clinical findings or imaging.

[Varicocele in adolescents. Treatment by sclerotherapy and percutaneous embolization: reflections on the method. Apropos of 23 cases]

OBJECTIVE

The authors report their experience of the treatment of varicocele in adolescents. As a result of progress in interventional radiology and embolization techniques, they have used a technique combining sclerotherapy and percutaneous embolization since 1993.

MATERIAL AND METHODS

Since 1993, twenty three adolescents between the ages of 11 and and 17 years (mean = 14.5 years) were treated percutaneously for grade II and II left varicocele. The operation was performed under local anaesthesia and/or neuroleptanalgesia. Phlebography by selective catheterization of the left spermatic vein was performed for anatomical assessment (ostial incontinence, collateral vessels). Embolization was then performed under fluoroscopic control by injection of a sclerosing liquid, sodium tetradecyl sulphate (Trombovar), and systematically completed by insertion of endovascular occlusive metal coils.

RESULTS

The follow-up ranged from 6 to 48 months (mean = 30 months). The follow-up clinical and ultrasound examination showed complete disappearance of the varicocele in 22 cases (95% of cases), with a persistent grade I asymptomatic left varicocele in 1 case. No complications were observed. The mean hospital stay was 48 hours.

CONCLUSION

This constitutes a rapid method, which is minimally traumatic for the adolescent. Its efficacy is comparable to that of classical surgical techniques with lasting results. Insertion of coils is the endovascular equivalent of surgical ligation of the pathological vein. The liquid embolus is particularly useful as it diffuses and scleroses collateral veins, responsible for recurrence. The advantage of this method resides in a better understanding of the reflux mechanisms, allowing the procedure to be adapted to the venous anatomy. This technique ensures treatment of complex varicoceles, such as postsurgical recurrences.

[Evaluation of 20 years' experience of enuresis in children]

The clinical and urodynamic approach to enuretic children over a period of more than 20 years has allowed the authors to develop a multifactorial pathophysiological concept of this disorder. The main factors involved are psychological, familial, genetic, vesical, due to bladder immaturity, hormonal, due to a defect of nocturnal ADH secretion, hygiene and dietary habits, etc. The sleep factor is predominant in the majority of cases. Although nocturnal enuresis is apparently isolated in many cases, it is often associated with a state of bladder immaturity, sometimes latent during the day, but occurring at night with episodes of detrusor hyperactivity, occurring during various phases of sleep. In practice, the recognition, in children, of these factors, some of which require specific treatments, implies a management combining several of these therapeutic modalities.

[Fibroepithelial polyps of the ureter and the kidney pelvis. Report of 3 cases]

The authors report 3 cases of fibroepithelial polyps, one of which was an incidental finding and 2 were symptomatic, presenting in the form of macroscopic haematuria and chronic back pain, respectively. These lesions required 2 nephroureterectomies because of their renal repercussions or their multifocal nature, combined with segmental resection of the ureter, including the base of the tumour. In the light of these cases, the authors review the literature and analyse the current management of this rare disease, in particular the indications for endourological techniques which appear to have a major diagnostic contribution as a complement to IVU and retrograde urography, but whose therapeutic value has yet to be defined.

Childhood urolithiasis: urological management of upper tract calculi in the era of extracorporeal shock-wave lithotripsy

OBJECTIVE

To evaluate the management of urolithiasis in children since the development of extracorporeal shock-wave lithotripsy (ESWL).

METHODS

Between 1988 and 1994, 37 children, aged from 2 to 15 years (mean 10), with upper tract urolithiasis were evaluated and treated. Lithogenic metabolic disorders or anomalies of the urinary tract were present in 11 children (30%) Urolithiasis was multiple in 9 cases and bilateral in 2 cases. A total of 47 renal (30) or ureteral (17) stones were managed, of which 5 were partial or complete staghorn calculi. Initial treatment was surgery in 4 cases (1 nephrectomy, partial nephrectomy and 2 pyelolithotomies) and piezoelectric ESWL in 43 cases.

RESULTS

The overall ESWL success rate was 82.2%, with auxillary endoscopic procedures in 3 cases. ESWL failures required surgical stone removal in 5 cases, endoscopic ureterolithotripsy in 1 case and electrohydraulic ESWL in 1 case. Residual fragments after pyelolithotomies were also treated by ESWL.

CONCLUSION

ESWL is the mainstay of treatment of childhood upper tract urolithiasis, but other therapeutic methods retain specific indications. Its application requires great vigilance and its long-term effects are uncertain. It is therefore important to rule out any underlying pathology and where possible to prevent further stone formation.

Urinary calcium oxalate saturation in 'stone formers' and normal subjects: an application of the EQUIL2 program

OBJECTIVE

To produce an index of lithogenic risk which identifies patients at risk of stone recurrence and facilitates the monitoring of prophylactic treatments.

PATIENTS AND METHODS

The EQUIL2 program provides an evaluation of the state of urinary saturation, particularly of calcium oxalate, based on the pH and total concentrations (mmol/l) of sodium, potassium, calcium, magnesium, uric acid, chloride, ammonium, citrate, phosphate, sulphate, oxalate, pyrophosphate and carbon dioxide. The morning urinary calcium oxalate saturation coefficient was thus calculated for 30 stone-formers (Group 1) and 30 normal control subjects (Group 2).

RESULTS

Urine from the majority of individuals was saturated, with no significant difference between the two groups. There appeared to be a correlation between the state of saturation and the urinary calcium oxalate molar product in both stone-formers (r = 0.931) and controls (r = 0.914).

CONCLUSION

In future studies on urinary calcium oxalate saturation, it should be possible to supplement the sophisticated coefficient determined by the EQUIL2 program with the molar product, except in cases where monitoring therapies have little or no effect on urinary oxalate or urinary calcium levels.

Plasma levels of oxybutynine chloride in children

Anticholinergic adverse-effects in children treated with conventional doses of oxybutynine led us to measure plasma oxybutynine levels in children. 18 children, aged 5 to 13 y, who required treatment with oxybutynine chloride for daytime incontinence were studied. Plasma concentrations were measured on the fifth day of a course of treatment in which the dose was adapted to the child's body weight; the dose was given twice daily at 12-hour intervals. In 10 children aged between 5 and 8 y, the mean dose was 0.1 mg.kg-1. In 8 children aged between 10 and 13 years, the mean dose was 0.15 mg.kg-1. The highest concentration was usually found between 1 and 2 h after administration. The subsequent fall in concentration was rapid and after 6 h oxybutynine was no longer measurable in 14 of the children. The concentrations found were not different from those seen in adults given equivalent doses. The results show that plasma concentrations in children were not very different from those observed in adults if the dose were adapted to the body weight of the children. No special differences in paediatric use were revealed that might explain the particular adverse-effects. The results of the study argue against the dosage regimen proposed before these adverse events were detected. They strongly favour a dose adapted to the body weight of the child, with a 12-hour interval between doses.

[Urologic manifestation of Waldenström's disease. Apropos of a case with pyelo-ureteral location]

The authors report a case of Waldenström's disease in which the initial staging assessment reveals an isolated tumour of the left upper urinary tract. Combination chemotherapy (6 courses of protocol M2) induced a marked reduction in the monoclonal IgM peak and in the tumour mass. In the light of this atypical case, which emphasises the diversity of the potential sites of Waldenström's macroglobulinaemia, the authors review its potential for progression and the various therapeutic modalities available.

[Ballistic (Lithoclast) and hydro-electric (Riwolith) endo-ureteral lithotripsy. Report of 60 cases]

25 hydroelectric endoureteric lithotripsies (Group 1, Riwolith) and 35 ballistic endoureteric lithotripsies (Group 2, Lithoclast) were analysed. 60 stones were treated, including 18 pelvic stones (Group 1 : 10, Group 2 : 8), 39 iliolumbar stones (Group 1 : 14, Group 2 : 25), and 3 stones of the ureteropelvic junction (Group 1 : 1, Group 2 : 2). The mean maximal diameter was 9.9 mm (Group 1 : 8.2, Group 2 : 11). Complementary Dormia extraction was performed in 24 cases (Group 1 : 8, Group 2 : 16), 55 double J stents were implanted (Group 1 : 24, Group 2 : 31) and 23 immediate ECL sessions were performed (Group 1 : 8, Group 2 : 15). Overall, 57 good results were recorded, but 3 complete failures of fragmentation and 2 severe ureteric lesions were attributed to hydroelectric lithotripsy. The Lithoclast, much less traumatic, had a greater stone fragmentation potential, but its efficacy on very mobile stones is limited due to its more intense stone propulsion effect.

Sleep polygraphic studies using cystomanometry in twenty patients with enuresis

Polygraphic exploration during sleep using cystomanometry was performed in 20 patients aged 7-17 years with primary (17) or secondary (3) enuresis. In this group of patients, 9 presented with isolated nocturnal enuresis while 11 patients had associated diurnal micturition troubles. During this study we documented 24 episodes of enuresis. There was no disturbance in sleep architecture or correlation between the uncontrolled micturition and any particular state or stage of sleep. Most episodes of enuresis occurred in a unique pattern in which a sudden or progressive intravesical increased pressure was associated with an awakening reaction. From a physiopathologic point of view, our findings are in favor of immaturity of the central system of inhibition of micturition reflex during sleep.

[Leiomyosarcoma of the inferior vena cava]

The authors report a case of leiomyosarcoma of the infrarenal inferior vena cava presenting as an abdominal mass. CT and MR imaging and immunotyping led to the diagnosis of retroperitoneal leiomyosarcoma whose origin in the inferior vena cava was only confirmed by histological examination of the resection specimen. Surgical resection was followed by radiotherapy (4,500 rads) with a favourable course after 12 months. The progress in medical imaging and histology has considerably simplified the diagnosis of these rare retroperitoneal tumours. In the absence of any truly effective adjuvant therapy, treatment essentially consists of surgery and the clinical course is characterised by a high incidence of local recurrences.

[Piezoelectric extracorporeal lithotripsy in children: first results and reflections after 18 sessions]

From 1988 to 1990, we treated 13 children between the ages of 2 and 15 years with stones of the upper urinary tract. These stones were treated by means of 18 sessions of piezoelectric extracorporeal lithotripsy: 14 under general anaesthesia and 4 without even any analgesia. We obtained an 84.5% success rate with no particular adverse effects. These results are similar to those reported for hydroelectric or electromagnetic shock wave lithotripsy, which are associated with a higher morbidity. The efficacy of extracorporeal lithotripsy in paediatrics is remarkable, but clinical studies in adults as well as animal experimentations have demonstrated severe renal contusion and do not formally exclude the possibility of delayed complications. At the present time, this technique should therefore be used very cautiously and must be accompanied by systematic prevention of recurrent stones.

[Endo-urologic treatment of ureteral fistulas occurring after pelvic surgery for carcinoma: report of 5 cases]

The authors report 5 cases of ureteric fistula after radical pelvic cancer surgery. Three patients had a recurrent tumour and 3 had received radiotherapy. Endourological methods achieved 4 immediately satisfactory results, but only one complete long-term success. Isolated percutaneous drainage of the pyelocaliceal cavities effectively dried up the urine leak, but carried a high risk of secondary stenosis of the excretory tract in the absence of concomitant intubation of the fistula zone. However, endourological treatment, combined with urinary diversion and catheterisation of the pathological ureter, represented a reliable alternative to conventional surgery.

[Abdominal injuries in children. Diagnosis and treatment of renal lesions. Apropos of 26 cases]

During the past ten years, we have treated 26 children with closed renal injuries. Hematuria appeared in 19 cases, but was not detected in 7 other cases, 6 of which corresponded to severe, especially pedicular, lesions. The diagnostic means for the lesion included IVP in 24 cases, ultrasonography in 23, angiography in 8 and computed tomography in 7. The treatment was medical for 18 children and surgical for 8. Observation revealed 4 cases of renal atrophy, including 1 of general atrophy without residual arterial hypertension. On the basis of this series and of a review of the literature, we study the evolution of the diagnosis and treatment of this condition with the development of new medical imaging techniques, especially of CT.

[Urinary calculi in children. Etiologic survey]

Thirty-three children with urinary calculi were studied. In 12, a metabolic cause of calculi was identified (4 hyperoxaluria, 6 hypercalciuria, 2 cystinuria). In 14 children, lithiasis was associated with a urinary tract infection. No identifiable cause could be found in 7 children. A protocol for metabolic evaluation is proposed.

[Enuresis: the viewpoint of the urologist]

After a description of the bladder-sphincter system physiology and of the different stages in the acquisition of micturition control by children, as revealed by urodynamic explorations, the author presents the bladder immaturity syndrome. This entity includes diurnal disorders of micturition--such as urgencies, pollakiuria, more seldom retention and incontinence--which can readily be identified by questioning. It accounts for many cases of nocturnal enuresis which may benefit from treatment with anticholinergic drugs. Nocturnal enuresis without disorders of micturition in daytime is due to other physiopathological mechanisms. It is preferably treated with tricyclic antidepressants and other non-medicinal therapies. All cases should be investigated for a possible organic pathology. A practical classification of enuresis is given.

[Anterior urethral valve in a five year old boy (author's transl)]

The authors report the case of a valve of the anterior urethra in a five year old boy, which was carefully explored from a radiological, endoscopic and urodynamic standpoint. The lesion was successfully treated by transurethral resection. The features of this type of obstructive problem are discussed in the light of the case, together with the diagnostic value of urodynamic studies and endoscopic photography and, finally, the possibilities of treatment, emphasising the simplicity and effectiveness of transurethral resection.

Voiding pressure in children

A study of voiding pressure (VP) by a suprapubic catheter was performed in 100 children. The children were divided into two groups. Group I (n=96) comprised children with no evidence of clinical, radiological and endoscopic lower urinary tract obstruction. Group II (n=4) consisted of children with a lower urinary tract obstruction. 17 children of group I, judged to be free of uropathy, were considered as the control group. There was no significant difference in the VP of this group when compared with 79 children with uropathy (group IB=47 enuretic, 19 vesicoureteral reflux and 13 urinary tract infection). The VP was studied in each of these groups in relation to sex and age. Males had higher VP than females. There was a significant correlation between age and VP in enuretic children. It was concluded that the VP was only one of the parameters for investigating the urodynamics of the lower urinary tract and should always be accompanied by a measurement of urinary flow.