Treatment of the Enlarged Clitoris

Management of the enlarged clitoris, because of its import for sexual function, has been and remains one of the most controversial topics in pediatric urology. Early controversy surrounding clitoroplasty resulted from many factors including an incomplete understanding of clitoral anatomy and incorrect assumptions of the role of the clitoris in sexual function. With a better understanding of anatomy and function, procedures have evolved to preserve clitoral tissue, especially with respect to the neurovascular bundles. These changes have been made in an effort to preserve clitoral sensation and preserve orgasmic potential. It is the goal of this manuscript to describe the different procedures that have been developed for the surgical management of clitoromegally, with emphasis on the risks and benefits of each. Equally important to any discussion of such a sensitive topic is an understanding of long-term patient outcomes. As we will see, despite its importance, there has been a dearth of data in this regard. Future work in the arena of patient satisfaction will undoubtedly play a major role in directing our surgical approach.

Treatment of contralateral hydrocele in neonatal testicular torsion: Is less more?

OBJECTIVE

Treatment of neonatal testicular torsion has two objectives: salvage of the involved testicle (which is rarely achieved) and preservation of the contralateral gonad. The second goal universally involves contralateral testicular scrotal fixation to prevent the future occurrence of contralateral torsion. However, there is controversy with regards to management of a synchronous contralateral hydrocele. It has been our policy not to address the contralateral hydrocele through an inguinal incision to minimize potential injury to the spermatic cord. Our objective in this study was to determine whether the decision to manage a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal approach is safe and effective.

PATIENTS AND METHOD

We reviewed all cases of neonatal testicular torsion occurring at our institution between the years 1999 and 2006. Age at presentation, physical examination, ultrasonographic and intraoperative findings were recorded. Patients were followed after initial surgical intervention to determine the likelihood of developing a subsequent hydrocele or hernia.

RESULTS

Thirty-seven patients were identified as presenting with neonatal torsion. Age of presentation averaged 3.5 days (range 1-14 days). Left-sided pathology was seen more commonly than the right, with a 25:12 distribution. All torsed testicles were nonviable. Twenty-two patients were noted to have a contralateral hydrocele at presentation. All hydroceles were opened through a scrotal approach at the time of contralateral scrotal fixation. No patient underwent an inguinal exploration to examine for a patent process vaginalis. None of the patients who presented with a hydrocele have developed a clinical hydrocele or hernia after an average 7.5 years (range 4.3-11.2) follow-up.

CONCLUSION

We have demonstrated that approaching a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal incision is safe and effective. Inguinal exploration was not performed in our study and our long-term results demonstrate that such an approach would have brought no additional benefit. In avoiding an inguinal approach we did not subject our patients to unnecessary risk of testicular or vasal injury. Contralateral hydrocele is commonly seen in cases of neonatal testicular torsion. In our experience this is a condition of minimal clinical significance and does not warrant formal inguinal exploration for treatment. This conservative management strategy minimizes the potential of contralateral spermatic cord injury in the neonate. The aims of the study were met.

Does endoscopy of difficult to catheterize channels spare some patients from formal open revision?

INTRODUCTION

Patients with continent catheterizable channels (CCC) may develop difficulty catheterizing postoperatively. In complex cases, endoscopic evaluation with indwelling catheter placement may be indicated, but the risk factors for subsequent formal channel revision are not well defined. The purpose of this study was to determine the risk factors for formal channel revision after attempted endoscopic management of difficulty catheterizing.

MATERIALS AND METHODS

We performed an IRB-approved retrospective review of pediatric (<21 years old) patients undergoing CCC construction at our institution from 1999 to 2014 to identify patients who underwent endoscopy for difficulty catheterizing. Fisher's Exact test was used for categorical data and Mann-Whitney U test for continuous variables to examine the association between endoscopic intervention and subsequent formal revision.

RESULTS

Sixty-three of 434 patients (14.5%) underwent at least one endoscopy for reported difficulty catheterizing their CCC, with 77.8% of these requiring additional intervention during endoscopy (catheter placement, dilation, etc.). Of these, almost half with functioning channels (43.5%, 27/62) were managed successfully with endoscopy without formal revision; six (22.2%) of whom underwent more than one endoscopy. These 27 patients continued to catheterize well at a median follow-up of 3.2 years (interquartile range 2.0-6.0). Patients requiring revision had a median of 1.7 years between CCC creation and first endoscopy, versus 1.6 years in those who were not revised (p = 0.60). There was no statistically significant difference between revised and non-revised channels in terms of patient age at CCC creation, underlying patient diagnosis, status of bladder neck, stomal location, or channel type (p ≥ 0.05) (see Table).

CONCLUSION

Approximately half of our patients did not require a formal channel revision after endoscopic management. We did not identify any specific risk factors for subsequent formal revision of a CCC. We recommend performing at least one endoscopic evaluation for those with difficulty catheterizing prior to proceeding with formal open revision.

Effect of baseline obesity and postoperative weight gain on the risk of channel revision following continent catheterizable urinary channel surgery

OBJECTIVE

Prior studies suggest that obese patients are at increased risk for complications following continent catheterizable urinary (CCU) channel surgery. We hypothesized that postoperative weight gain increases the risk of channel angulation, difficulty catheterizing, and possible channel perforation requiring subfascial revision. The purpose of this study was to evaluate whether baseline obesity or becoming overweight/obese postoperatively was associated with a greater risk of subfascial revision.

METHOD

We reviewed retrospectively an institutional database of patients who underwent CCU channel surgery between the ages of ≥2 and <20 years from January 1990 to May 2013, excluding those with continent urinary reservoirs, continent vesicostomies, and those without body mass index (BMI) data. We collected data on patient/procedure characteristics, baseline/most recent BMI, and subfascial revision(s). We used Cox proportional hazard multivariable regression to assess the association of being overweight/obese at baseline (≥85% BMI) with time to first subfascial revision, and Fisher's exact test to compare rates of subfascial revision between those who became overweight/obese and those who did not.

RESULTS

Of the patients, 328/501 (65.5%) had baseline and post-baseline BMI data available: 53.4% male, 90.6% white, median age 7.4 years; median follow-up 76.4 months. Of the 328 patients, 38 (11.6%) had subfascial revisions. Baseline BMI data were available for 378 patients, and, of these, 130 (34.4%) were overweight/obese at baseline. Overweight/obese patients were more likely to undergo umbilical Monti (10% vs. 8.1%), non-umbilical spiral Monti (33.8% vs. 13.7%), and spiral umbilical Monti channels (13.8% vs. 7.3%) versus normal/underweight patients (p < 0.0001). From a multivariable Cox proportional hazard model controlling for age, BMI category, diagnosis, and ambulatory status, the hazard of subfascial revision for spiral umbilical Monti channels was 2.1× that of other channels (hazard ratio (HR) 2.1 [95% CI 1.2-3.8], p = 0.01). Fifty-one out of 328 patients (15.6%) became overweight/obese postoperatively, with 7.8% having a subfascial revision vs. 12.3% of those whose weight category decreased or remained stable (p = 0.3) (Table 1).

CONCLUSIONS

Patients who were overweight/obese at baseline were more likely to have channels constructed that are at the highest risk of subfascial revision. Patients who became overweight/obese postoperatively were not at greater risk of subfascial revision. Limitations include potential bias because of differential follow-up and inaccuracy of BMI percentile as a measurement of obesity.

Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?

Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.

Bladder stones after bladder augmentation are not what they seem

INTRODUCTION

Bladder and renal calculi after bladder augmentation are thought to be primarily infectious, yet few studies have reported stone composition.

OBJECTIVE

The primary aim was to assess bladder stone composition after augmentation, and renal stone composition in those with subsequent nephrolithiasis. The exploratory secondary aim was to screen for possible risk factors for developing infectious stones.

STUDY DESIGN

Patients treated for bladder stones after bladder augmentation at the present institution between 1981 and 2012 were retrospectively reviewed. Data were collected on demographics, surgeries and stone composition. Patients without stone analysis were excluded. Stones containing struvite, carbonate apatite or ammonium acid ureate were classified as infectious. The following variables were analyzed for a possible association with infectious bladder stone composition: gender, history of cloacal exstrophy, ambulatory status, nephrolithiasis, recurrent urea-splitting urinary tract infections, first vs recurrent stones, timing of presentation with a calculus, history of bladder neck procedures, catheterizable channel and vesicoureteral reflux. Fisher's exact test was used for analysis.

RESULTS

Of the 107 patients with bladder stones after bladder augmentation, 85 met inclusion criteria. Median age at augmentation was 8.0 years (follow-up 10.8 years). Forty-four patients (51.8%) recurred (14 multiple recurrences, 143 bladder stones). Renal calculi developed in 19 (22.4%) patients with a bladder stone, and 10 (52.6%) recurred (30 renal stones). Overall, 30.8% of bladder stones were non-infectious (Table). Among patients recurring after an infectious bladder stone, 30.4% recurred with a non-infectious one. Among patients recurring after a non-infectious stone, 84.6% recurred with a non-infectious one (P = 0.005). Compared with bladder stones, renal stones were more likely to be non-infectious (60.0%, P = 0.003). Of patients with recurrent renal calculi after an infectious stone, 40.0% recurred with a non-infectious one. No clinical variables were significantly associated with infectious stone composition on univariate (≥0.28) or bivariate analysis (≥0.36).

DISCUSSION

This study had several limitations: it was not possible to accurately assess adherence with bladder irrigations, and routine metabolic evaluations were not performed. The findings may not apply to patients in all clinical settings. While stone analysis was available for 3/4 of the stones, similar rates of incomplete stone analyses have been reported in other series.

CONCLUSIONS

In patients with bladder augmentation, 1/3 of bladder stones and >1/2 of renal stones were non-infectious. Furthermore, an infectious stone does not imply an infectious recurrent stone and no known clinical variables appear to be associated with stone composition, suggesting that there is a possible metabolic component in stone formation after bladder augmentation.

Is renal scintigraphy necessary after heminephrectomy in children?

INTRODUCTION

Heminephrectomy remains an excellent option for a poorly functioning moiety in a duplicated collecting system. A primary concern during heminephrectomy is the potential for a significant functional loss in the remaining ipsilateral moiety. As the gold standard for the assessment of differential renal function, renal scintigraphy is often used in the postoperative evaluation of children undergoing heminephrectomy. However, this imaging modality is costly, invasive, and associated with exposure to radiation. Doppler renal ultrasound (RUS) avoids these concerns and is able to evaluate for structural and functional abnormalities.

OBJECTIVE

The present study sought to compare Doppler RUS to renal scintigraphy in determining the viability of the remaining ipsilateral moiety in children who underwent heminephrectomy for a poorly functioning moiety in a duplicated collecting system.

MATERIALS AND METHODS

The institutional database of children who underwent open heminephrectomy for a poorly functioning moiety in a duplicated collecting system between 2006 and 2013 was reviewed. Only children who underwent both a postoperative Doppler RUS and renal scan were included. A blinded pediatric radiologist independently reviewed all Doppler RUS. Vascular flow on Doppler RUS was correlated with the preservation of renal function in the remaining ipsilateral moiety on renal scintigraphy.

RESULTS

A total of 29 children were identified for inclusion. Demographic and operative data are provided in Table. The average pre-operative and postoperative differential renal function in the ipsilateral kidney was 41.6% and 38% on renal scintigraphy, respectively, for an average decrease of 3.6% (-18% to +12%). Doppler RUS demonstrated the presence of vascular flow to the remaining ipsilateral moieties of all children after heminephrectomy. Renal scintigraphy confirmed the viability of these moieties in all children.

DISCUSSION

The first study comparing Doppler RUS to renal scintigraphy was performed to determine the viability of the remaining ipsilateral moiety after heminephrectomy. While no cases of complete functional loss were observed, an average decrease of 3.6% in the ipsilateral renal function favorably compared with other series of children undergoing open heminephrectomy. The limitations of the study included its retrospective design at a single institution. The interpretation of Doppler RUS by an individual pediatric radiologist may also have lead to interobserver variability and impacted the reproducibility of the study, while the absence of any cases of complete functional loss may have impacted its generalizability.

CONCLUSIONS

Doppler RUS is an accurate imaging modality for determining the viability of the remaining ipsilateral moiety after heminephrectomy and may obviate the need for renal scintigraphy.

Vitamin B12 deficiency in patients after enterocystoplasty

INTRODUCTION

Serum B12 deficiency is a known sequlae of enterocystoplasty. The complications of B12 deficiency include megaloblastic anemia, neuropsychiatric disease, and demyelinating diseases such as peripheral neuropathy. Some studies have suggested that underlying disease states may be more important than enteric absorptive capacity in predicting acquired B12 deficiency. A 38% incidence of low or low-normal serum B12 in patients who have undergone enterocystoplasty has previously been reported, and oral B12 supplementation has been demonstrated to be an effective short-term therapy; however, the long-term results remain unclear.

AIMS

This study hypothesized that oral vitamin B12 supplementation in patients with B12 deficiency following enterocystoplasty is an effective long-term treatment. Additionally, it sought to determine if underlying disease state predicts B12 deficiency following enterocystoplasty.

DESIGN

Children who underwent enterocystoplasty at the present institution prior to August 2007 were reviewed. Patients with non-ileal augment, insufficient follow-up or hematologic disorders were excluded. Patients with low or low-normal B12 levels were included. Treatment consisted of daily oral therapy of 250 mcg or monthly parenteral therapy of 1000 mcg IM. Separately, the institutional database of 898 patients who underwent enterocystoplasty was searched and patients with at least one post-operative B12 level were highlighted. The indication for enterocystoplasty was classified as neuropathic or non-neuropathic.

RESULTS

Twenty-three patients met inclusion criteria. The mean follow-up was 49 months (range 5-85) following initial abnormal B12 level. On the last follow-up, 4/23 (17%) patients had normal serum B12 levels. No patients reported sequelae of long-term B12 deficiency. In the secondary investigation, 113 patients met inclusion criteria. A total of 101 had neuropathic indications for enterocystoplasty, and 12 had non-neuropathic indications. At any time during follow-up, 48/101 (47.5%) neuropathic patients had low or low-normal B12 levels, and 4/12 (33.3%) non-neuropathic patients had low or low-normal B12 levels during follow-up (P = 0.54) (Figure).

DISCUSSION

The initial success of oral B12 deficiency treatment following enterocystoplasty does not persist over time. This contradicts previous results with short duration follow-up. Underlying disease as the indication for enterocystoplasty did not predict B12 deficiency risk. The study was limited by the small number of patients with B12 deficiency who were started on treatment, as well as by the small number of patients with non-neuropathic indications for enterocystoplasty.

CONCLUSION

The aims of the study were met. Further investigation is required to assess predictors of B12 deficiency following enterocystoplasty.

Is CT cystography an accurate study in the evaluation of spontaneous perforation of augmented bladder in children and adolescents?

BACKGROUND

Spontaneous bladder perforation (SBP) is a potentially fatal complication of augmented bladder. Imaging is often used for diagnosis. In this study we present our experience with CT cystography (CTC) in the diagnosis of SBP.

OBJECTIVE

To determine CTC accuracy in the evaluation of SBP in children with an augmented bladder.

STUDY DESIGN

The institutional review board approved this HIPAA-compliant study; informed consent was waived. All patients under 20 years old, who underwent CTC for SBP evaluation from 2003 to 2013, were identified. Two radiologists independently reviewed CTC studies for contrast extravasation, ascites, and pneumoperitoneum. Ascites was graded: small - confined to the rectovesical pouch (RVP); moderate - beyond the RVP; large - beyond the pelvis.

RESULTS

Eighty-nine patients (47 males, age 4.2-19.8 years) had 132 CTCs. SBP was diagnosed in 14% (19/132). Both radiologists found contrast extravasation in 74% (14/19) of patients with SBP; two patients had only pneumoperitoneum, and three had only ascites (large = 2, moderate = 1) (Fig.). SBP was found in 1% of CTCs with no ascites or small ascites (1 of 98 and 92; radiologists 1 and 2, respectively). Findings of extraluminal extravasation, unexplained pneumoperitoneum, or large ascites, yielded a detection rate of 95% for SBP by each radiologist. In eight patients, small bowel obstruction was diagnosed.

DISCUSSION

Contrast extravasation was detected in only 74% of patients with SBP. The use of indirect signs of perforation (unexplained pneumoperitoneum and large ascites) in addition to contrast extravasation, increased the detection rate of SBP to 95%. US screening for SBP and selection of patients with moderate or large ascites for CTC, may eliminate the need for most CT scans. In the absence of SBP, other abdominal abnormalities should be evaluated. Bowel obstruction was the most common non-urological emergency detected in this series. The main limitations of the study are: the small number of SBP cases; the diagnosis of SBP not based on surgical findings in three patients; and inability to completely exclude occult SBP in patients not explored surgically.

CONCLUSION

Extraluminal contrast was seen on CTC in most cases of SBP, but some patients with sealed bladder perforation had only pneumoperitoneum or moderate/large ascites. Therefore, SBP should be suspected in any patient with moderate/large volumes of pelvic fluid or unexplained pneumoperitoneum, even when there is no evidence of contrast extravasation. Patients with no ascites, or small volumes, are unlikely to have SBP; therefore, US can be used to screen low risk patients.

Long-term outcomes of catheterizable continent urinary channels: What do you use, where you put it, and does it matter?

INTRODUCTION

Appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) are commonly used catheterizable channels with similar outcomes on short-term follow-up. Their relative long-term results have not been previously published.

OBJECTIVE

Our goal was to assess long-term durability of APV and Monti channels in a large patient cohort.

STUDY DESIGN

In this retrospective cohort study, we retrospectively reviewed consecutive patients ≤21 years old undergoing APV and Monti surgery at our institution (1990-2013). We collected data on demographics, channel type, location, continence and stomal and subfascial revisions. Kaplan-Meier survival and Cox proportional hazards analysis were used.

RESULTS

Of 510 patients meeting inclusion criteria, 214 patients had an APV and 296 had a Monti (50.5% spiral Monti). Median age at surgery was 7.4 years for APV (median follow-up: 5.7 years) and 8.7 years for Monti (follow-up: 7.7 years). Stomal stenosis, overall stomal revisions and channel continence were similar for APV and Monti (p ≥ 0.26). Fourteen APVs (6.5%) had subfascial revisions compared to 49 Montis (16.6%, p = 0.001). On survival analysis, subfascial revision risk at 10 years for APV was 8.6%, Monti channels excluding spiral umbilical Monti: 15.5% and spiral umbilical Monti: 32.3% (p < 0.0001, Figure). On multivariate regression, Monti was 2.09 times more likely than APV to undergo revision (p = 0.03). The spiral Monti to the umbilicus, in particular, was 4.23 times more likely than APV to undergo revision (p < 0.001). Concomitant surgery, gender, age and surgery date were not significant predictors of subfascial revision (p ≥ 0.17). Stomal location was significant only for spiral Montis.

DISCUSSION

Our study has several limitations. Although controlling for surgery date was a limited way of adjusting for changing surgical techniques, residual confounding by surgical technique is unlikely, as channel implantation technique was typically unrelated to channel type. We did not include complications managed conservatively or endoscopically. In addition, while we did not capture patients who were lost to follow-up, we attempted to control for this through survival analysis.

CONCLUSIONS

We demonstrate, durable long-term results with the APV and Monti techniques. The risk of channel complications continues over the channel's lifetime, with no difference in stomal complications between channels. At 10 years after initial surgery, Monti channels were twice as likely to undergo a subfascial revision (1 in 6) than APV (1 in 12). The risk is even higher in for the spiral umbilical Monti (1 in 3).

A comparison of the Monti and spiral Monti procedures: A long-term analysis

INTRODUCTION/BACKGROUND

The Monti ileovesicostomy provides an excellent substitution for an appendicovesicostomy when the appendix is unavailable or suitable for use. The spiral Monti is a useful modification to the traditional Monti as it allows creation of a longer channel when needed. In 2007, the short-term outcomes were reported; they compared traditional and spiral Monti in 188 patients with an average follow-up of 43 months. In the present population, a total of 25 subfasical revisions were performed in 21 patients: nine (8.3%) subfascial revisions in the traditional Monti (TM) patients and 12 (15.2%) subfascial revisions in the spiral Monti (SM) patients. The study found an increased risk of subfascial revisions of either TM or SM when the stoma was located at the umbilicus versus right lower quadrant (16.8% vs 6.3%, P < 0.05). On subgroup analysis, this increased subfascial revision rate appeared to be driven by SM channels to the umbilicus rather than other stomal locations, but this trend was not statistically significant.

OBJECTIVE

It was hypothesized that with longer follow-up, the spiral Monti would require more subfascial revisions due to progressive lengthening of the channel.

STUDY DESIGN

A retrospective chart review was performed for all patients undergoing a traditional Monti (TM) or spiral Monti (SM) procedure at the present institution (1997-2013). Patient demographics, bowel segment used, stomal location, channel or stomal revisions, number of anesthetic endoscopic procedures performed, and indications for revision were reviewed. Kaplan-Meier analysis and Cox proportional hazards modeling was used for analysis.

RESULTS

Of the 296 patients identified, 146 had Monti procedures and 150 had spiral Monti procedures (median follow-up 7.7 years). Median age at surgery was 10.6 years. Myelomeningocele was the most common underlying cause of neuropathic bladder, totaling 169 (57.1%) patients. Stomas were located at the umbilicus (106, 35.8%), right lower quadrant (183, 61.8%) and left lower quadrant (seven, 2.4%). Median follow-up for the entire cohort was 7.7 years (range: 1 month-15.7 years). Stomal stenosis rate was 7.4%, and 96.6% of the channels were continent. A total of 87 revisions were performed in 74 patients (25.0%). Of these, 55 were subfascial revisions in 49 patients (16.6%). The umbilical spiral Monti on univariate and multivariate analysis was found to be over twice as likely to undergo subfascial revision.

DISCUSSION

The majority of patients with a Monti channel had durable results and did not require further channel surgery with long-term follow-up. Spiral Monti channels to the umbilicus were more than twice as likely to undergo subfascial revision compared to all other Monti channels. Overall, one in three umbilical SM channels required a subfascial revision at 10 years after the initial surgery, compared to one in six of all other Monti channels. The study was limited by being a retrospective, single-center series; however, it does represent the largest series of pure SM and TM patients. It focused only on surgical interventions, thus was likely to underestimate the overall risk of complications, as some complications were managed conservatively. As in all studies, some patients were lost to follow-up and inevitably some of these may have had complications. Correction for this was attempted through survival analysis.

CONCLUSION

The present study reported durable and reliable long-term results with Monti and spiral Monti procedures based on a large patient cohort. Spiral Monti to the umbilicus was more than twice as likely to require a subfascial revision.

Ultrasound classification of solitary renal cysts in children

INTRODUCTION

Solitary renal cysts are typically incidentally found in children who have undergone renal ultrasound (US). The main concern is a cystic tumor. There is no US-based grading system for children to guide management.

OBJECTIVE

To evaluate a US-based, modified Bosniak grading system in order to differentiate between simple (grade I or II) and complex (grade II or IV) renal cysts and guide management in children.

STUDY DESIGN

This was a retrospective (2003-2011) study of 212 children (114 females), age range one day to 17 years (mean 8.4 years), with solitary renal cysts diagnosed by US. Two radiologists, who were independent and blinded to clinical information, graded the cysts using the modified Bosniak classification system. In children with more than one year of follow-up US, the change (>10%) in cyst diameter was evaluated. Inter-observer variability (Kappa) was calculated.

RESULTS

Radiologists one and two saw simple renal cysts in 96.2-96.6% (204-205/212) of the children. Ten children had complex renal cysts, as rated by either of the radiologists. There was good inter-observer agreement (kappa = 0.65) for simple versus complex cysts. In 20.2% (18/89) of the children, the cysts increased in size. A definitive diagnosis was obtained in 8.5% (18/212) of the children. A cystic tumor (multilocular cystic nephroma) was found in one child (Figure) with a complex cyst (graded III by both radiologists).

DISCUSSION

The use of a modified Bosniak classification system to grade renal cysts was found to have good inter-observer variability (kappa = 0.65) in differentiating between simple and complex renal cysts. Using this classification, few (<4%) renal cysts were classified as complex. Cystic tumors are rare and the only cystic tumor (multilocular cystic nephroma) was classified as complex renal cysts by the two radiologists. Growth of simple, solitary renal cyst is common (20.2%) and, therefore, if not associated with other imaging findings, is not an indication for a cystic tumor. There were limitations inherent in the retrospective nature of the study and because only one child had a cystic tumor.

CONCLUSION

The modified Bosniak classification system demonstrated good inter-observer agreement, and identified the single tumor as a complex cyst. The vast majority of solitary renal cysts in children are simple and if asymptomatic, they require no other imaging evaluation. Complex renal cysts are uncommon and should be evaluated with a pre-intravenous and postintravenous contrast CT scan to exclude a tumor.

A novel colonoscopic approach for the management of a Malone antegrade continence enema channel, which cannot be catheterized in the immediate postoperative period: a case report

Early Malone antegrade continence enema (MACE) complications are rare, but can be devastating, particularly if they involve loss of the channel. Management of these complications is not well described. We report on a patient who had her MACE channel successfully salvaged in the immediate postoperative period using a colonoscopic retrograde wire and catheter placement after failing antegrade percutaneous endoscopic management. To our knowledge, this is the first report of a novel, colonoscopic, minimally invasive technique of managing select MACE channels, which cannot be otherwise recatheterized. We also review the management of postoperative MACE complications.

Multicystic dysplastic kidney: is an initial voiding cystourethrogram necessary?

INTRODUCTION

Traditionally, a voiding cystourethrogram (VCUG) has been obtained in patients diagnosed with multicystic dysplastic kidney (MCDK) because of published vesicoureteral reflux (VUR) rates between 10%-20%. However, with the diagnosis and treatment of low grade VUR undergoing significant changes, we questioned the utility of obtaining a VCUG in healthy patients with a MCDK. We reviewed our experience to see how many of the patients with documented VUR required surgical intervention.

MATERIALS AND METHODS

We performed a retrospective review of children diagnosed with unilateral MCDK from 2002 to 2012 who also underwent a VCUG.

RESULTS

A total of 133 patients met our inclusion criteria. VUR was identified in 23 (17.3%) children. Four patients underwent ureteral reimplant (3.0%). Indications for surgical therapy included breakthrough urinary tract infections (2 patients), evidence of dysplasia/scarring (1 patient) and non-resolving reflux (1 patient). All patients with a history of VUR who are toilet trained, regardless of the grade or treatment, are currently being followed off antibiotic prophylaxis. To date, none have had a febrile urinary tract infection (UTI) since cessation of prophylactic antibiotics. Hydronephrosis in the contralateral kidney was not predictive of VUR (p = 0.99).

CONCLUSION

Routine VCUG in healthy children diagnosed with unilateral MCDK may not be warranted given the low incidence of clinically significant VUR. If a more conservative strategy is preferred, routine VCUG may be withheld in those children without normal kidney hydronephrosis and considered in patients with normal kidney hydronephrosis. If a VCUG is not performed the family should be instructed in signs and symptoms of urinary tract infection.

Refluxing ureteral reimplantation: a logical method for managing neonatal UVJ obstruction

OBJECTIVE

An obstructed megaureter can be managed using a number of techniques, with the primary goal being to minimize the potential for further injury to the affected kidney. Classically, these obstructed ureters have been treated using cutaneous ureterostomy. However, this technique has certain limitations including the potential for stenosis. We describe our experience with the refluxing ureteral reimplantation as a novel, yet technically simple, method for temporary internal diversion of the obstructed megaureter.

METHODS

Treatment consists of transecting the ureter proximal to the obstruction and performing an end-to-side anastomosis with the bladder in a freely refluxing fashion. Patients are placed on antibiotic suppression following surgery. Subsequent open definitive surgery is performed through the same incision site once the child is older than 1 year of age.

RESULTS

Sixteen patients identified with severe hydroureteronephrosis were found to have an obstructed megaureter(s) involving 19 ureteral moieties. Patients underwent internal diversion at an average age of 5 months. All patients demonstrated improved drainage of the affected kidney(s) following surgery. Three patients developed a febrile urinary tract infection. Definitive surgical treatment was undertaken in 18 of 19 ureters, and consisted of ureteral reimplantation with tapering or plication (13), ureteral reimplantation without tapering (3), and nephrectomy (2). One patient with multiple other congenital anomalies is not a candidate for further genitourinary reconstruction.

CONCLUSIONS

Refluxing ureteral reimplantation is a safe and easy method of temporary internal urinary diversion. Simple in principle, the concept of creating a refluxing ureteral reimplantation is no different from that of incising an obstructing ureterocele. This technique allows time for the child to mature, while preserving renal function and awaiting definitive repair.

Mortality after bladder augmentation in children with spina bifida

PURPOSE

Renal failure has been a leading cause of death for children with spina bifida. Although improvements in management have increased survival, current data on mortality are sparse. Bladder augmentation, a modern intervention to preserve renal function, carries risks of morbidity and mortality. We determined long-term mortality and causes of death in patients with spina bifida treated with bladder augmentation.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients with spina bifida who underwent bladder augmentation between 1979 and 2013. Those born before 1972 or older than 21 years at augmentation were excluded. Demographic and surgical data were collected. Outcomes were obtained from medical records, death records and the Social Security Death Index. Fisher exact and Wilcoxon rank-sum tests and Kaplan-Meier plots were used for analysis.

RESULTS

Of 888 patients in our bladder reconstruction database 369 with spina bifida met inclusion criteria. Median followup was 10.8 years. A total of 28 deaths (7.6%) occurred. The leading causes of mortality were nonurological infections (ventriculoperitoneal shunt related, decubitus ulcer fasciitis, etc) and pulmonary disease. Two patients (0.5%) died of renal failure. No patient died of malignancy or bladder perforation. Patients with a ventriculoperitoneal shunt had a higher mortality rate than those without a shunt (8.9% vs 1.5%, p = 0.04).

CONCLUSIONS

Previously reported mortality rates of 50% to 60% in patients with spina bifida do not appear to apply in children who have undergone bladder augmentation. On long-term followup leading causes of death in patients with spina bifida after bladder augmentation were nonurological infections rather than complications associated with augmentation or renal failure.

A novel technique for endoscopic management of stones in a continent urinary reservoir

Urinary stones are a well-established complication of lower urinary tract reconstruction in children and can be managed through an open, percutaneous, or transurethral endoscopic approach for their surgical removal. For children with no urethral access, it is not generally advised to pursue an endoscopic approach through a catheterizable channel. In this study, we describe a safe and effective technique for the endoscopic management of stones through a catheterizable channel in a child with a continent urinary reservoir.