Pediatric Urology

It is sometimes argued that the non-therapeutic, non-consensual alteration of children’s genitals should be discussed in two separate ethical discourses: one for girls (in which such alterations should be termed ‘female genital mutilation’ or FGM), and one for boys (in which such alterations should be termed ‘male circumcision’). In this article, I call into question the moral and empirical basis for such a distinction, and argue that all children—whether female, male, or intersex—should be free from having parts of their genitals removed unless there is a pressing medical indication.

Bilateral obstructive nephrolithiasis is a rare cause of acute kidney injury (AKI) in early childhood. As soon as the identification of AKI secondary to ureteral stone is made, it will necessitate an emergency treatment. Patients: We report three infants with AKI caused by bilateral obstructive ureteral cystine stones. They were diagnosed with acute post-renal injury due to obstructive bilateral ureteral stones based on ultrasound scan findings. Immediately, bilateral ureteral stents were inserted for urinary drainage. Once renal function recovered to normal, each patient underwent ureteroscopy and percutaneous nephrolithotomy at the same session. Cystinuria was diagnosed by stone analysis and increased urinary excretion of cystine. Patients were advised to maintain a high fluid intake and were treated with potassium citrate in addition to tiopronin. Conclusions: With these three cases we would like to emphasize the importance of urolithiasis in the differential diagnosis of acute renal failure in young children, since urolithiasis may only cause nonspecific symptoms in this population. An early diagnosis with prompt treatment and a close follow-up are the key for achieving the best long-term outcome in cystinuria.

The primary non-refluxing megaureter (MGU) is one of the common causes of hydronephrosis in children. The aim of this study was to introduce ultrasonography (US) prior to and after 3-hour free bladder drainage as a simple method to distinguish primary obstructive, non-refluxing MGU from secondary non-obstructive, nonrefluxing MGU.

Objective: To analyze the spectrum of testicular tumors in children in an unselected population-based series, as well as the results of testis-preserving surgery. Patients and methods: Our hospital database was analyzed for operations for testicular tumors from 1981 to 2006. The clinical data and findings during follow up (4.7 years) were recorded. Results: Thirty-four patients were operated on because of testicular tumors. In 23 (68%) the tumor was benign: benign teratoma (16), Leydig-cell tumor (2), epidermoid cyst (2), Sertolicell tumor (1), cystic dyplasia (1), intratesticular focal fibrosis (1). Eleven patients (32%) had a malignant tumor: yolk-sac tumor (6), embryonal carcinoma (5). Twenty out of the 26 (77%) prepubertal boys had a benign tumor in contrast to only three of the eight (38%) adolescent males (P Z 0.079). Testis-preserving surgery was performed in 10 patients. In eight, the tumor was curatively excised and remaining testis preserved. Two patients with benign teratoma had a recurrence due to incomplete primary resection. In one patient who underwent orchiectomy for benign teratoma, two metachronous teratomas were detected in the contralateral testis 6 years after primary surgery. Conclusions: In children, most testicular tumors are benign, especially before puberty. If testis-preserving surgery is contemplated, complete excision of the tumor should be ascertained. The possibility of metachronous bilateral tumors should be considered in the follow up of testicular teratomas.

Male circumcision, is practised for religious, social, cultural and medical reasons, it is one of the oldest and most common surgical procedure performed globally. It is estimated that one-third of males worldwide are circumcised, 2/3rd of whom are Muslim. The procedure is most commonly practiced in the Muslim world, Israel (where it is near-universal for religious reasons), the United States, and parts of Southeast Asia and Africa. It is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia. Circumcision is performed approximately 1.2 million times each year in the United States.
The most important argument against circumcision is the permanent change of anatomy, histology and function of the penis, with potential complications, with a rates reported to be low in developed countries, whereas it may be up to 85% when circumcision is carried out by traditional circumcisers, rather than by medically trained professionals in developing countries. In some studies reporting the complications of circumcision, primary haemorrhage was the most common (52%), whereas infection, meatal stenosis, incomplete circumcision, penile oedema, glanular injury, penile adhesions, iatrogenic hypospadias and urethral injuries were also detected at different rates.

Objective: To develop a simple, objective and reproducible quantitative measurement to assess success of posterior urethral valve ablation. Method: In 30 patients with posterior urethral valves the diagnosis was confirmed by voiding cystourethrogram (VCUG). Our protocol was to perform valve ablation, and repeat VCUG at 12 weeks postoperatively. Urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. Thirty males undergoing VCUG for urinary tract infections were evaluated as normative controls. Results: Median age of controls was 12 months (2 dayse6 years) and of study group was 13 months (1 daye11 years). Mean urethral ratio in pre-fulguration group was 4.94 (AE2.97) and in post-fulguration group was 2.134 (AE1.19) (P < 0.001). The mean urethral ratio in the control group of 1.73 (AE0.577) was significantly different from the pre-fulguration group result (P < 0.001), but not significantly different in comparison to the post-fulguration group (P Z 0.104). Conclusion: Calculation of urethral ratio on VCUG as a method of assessment of outcome of fulguration is objective, reproducible, and allows preoperative and postoperative VCUG from different facilities to be compared. A post-fulguration urethral ratio of 2.5e3 represents an acceptable result postoperatively.

Circumcision remains as one of the most controversial topics in current medical practice. The most important argument against circumcision is the permanent change of anatomy, histology and function of the penis, with potential complications, which were reported to be low in developed countries, whereas the rate of complication may be up to 45% when circumcision is carried out by traditional circumcisers rather than by medically trained professionals in developing countries. In some studies reporting the complications of circumcision, primary haemorrhage was the most common (52%) complica- tion, whereas infection, meatal stenosis, incomplete circumcision, penile oedema, glanular injury, penile adhesions, iatrogenic hypospadias and urethral injuries were also detected at different rates.
There are minor complications after circumcision that cannot be avoided even when the procedure is undertaken by specialized paediatric surgeons or urologists in properly equipped centres, especially if the child or his penis is congenitally abnormal, for example, circumcising a child with excessive suprapubic fat or a child with webbed penis or microphallus.

Objective: To evaluate outcomes of desmopressin treatment in monosymptomatic enuresis (ME) and nonmonosymptomatic enuresis (NME). Materials and methods: PubMed was searched for all studies investigating enuresis, up to July 2009, in which desmopressin was administered alone or combined with other treatments. Each study was graded according to its respective level of evidence. Results: Altogether, 99 studies enrolling 7422 patients were identified as fulfilling the inclusion criteria. In 76 studies, desmopressin was administered as monotherapy; in 29 it was combined with other treatments such as antimuscarinics and enuresis alarm. Conclusion: Studies incorporating a minor invasive versus a non-invasive diagnostic approach seem to achieve superior long-term success rates. Primary efficacy outcomes following desmopressin treatment are more favourable in ME than NME. Desmopressin administered with adjunct measures achieves superior outcomes compared to monotherapy, especially in NME. Compared to sudden withdrawal, the structured withdrawal programs show better long-term success and lower relapse rates. So far, no superiority has been shown for either time-or dose-dependent structured withdrawal programs. Most studies incorporated only small case series; only 25 studies with level of evidence 1 or 2 have been conducted. The broad range of mono-and adjunct treatments were evaluated according to the evidence based criteria recommended by the European Association of Urology.

A stark contrast exists between the physiologic importance of the umbilicus during development and after birth. During development, the umbilical cord functions as a channel allowing blood flow between the placenta and fetus, it also serves an important role in the development of the intestine and the urinary system. After birth, once the umbilical cord falls off, no evidence of these connections should be present, except the umbilical scar, as landmark of the previously exist cord. Nevertheless, umbilical disorders are frequently encountered in pediatric surgery. It has been estimated that 30% of births have some type of umbilical cord finding. These disorders range from the very common umbilical hernia to infections such as omphalitis, which can be life threatening, and from simple straightforward anatomy like granuloma, to a complicated and sophisticated malformations; like vitellointestinal and urachal anomalies. Most patients with umbilical problems present with a mass or drainage from the umbilicus. An understanding of the anatomy and embryology of the abdominal wall and umbilicus is important to identify and properly treat common as well rare complicated conditions.

Ureteropelvic junction obstruction with concomitant ureterovesical junction obstruction is a rare condition whose treatment remains challenging [1e3]. Renal ultrasonography and diuretic renogram are universally utilized to assess a patient prior to pyeloplasty; however, the role of retrograde pyelography at the time of pyeloplasty is still debatable [5e7]. Herein, we describe two cases where the use of retrograde pyelography preoperatively helped to avoid pyeloplasty failure by allowing the surgeon to visualize a concurrent ureterovesical junction obstruction, which would not have been visible in the surgical field had the procedure been carried out without intraoperative imaging.

Objective: We report additional technical modifications and extended application of proximal TIP hypospadias repair in consecutive patients operated by a single surgeon. Materials: During a 39-month period, 36 patients underwent primary proximal hypospadias surgery, with 26 undergoing TIP and 10 two-stage repair for a thin urethral plate (UP) (1) or ventral penile curvature (VC) requiring UP transection (9). Of the TIP repairs, 16 had UP elevation from the corpora cavernosa to facilitate VC straightening while maintaining the UP for urethroplasty. All TIP patients underwent two-layer urethroplasty with tunica vaginalis coverage over the neourethra. Results: With mean follow up of 12 months (2e38) in 24 TIP patients, 16 had calibration and 11 urethroscopy 6e12 months postoperatively. Complications occurred in three (13%), glans dehiscence (2) and neourethral stricture (1), which represents a significant reduction versus our prior reports. Non-randomized preoperative testosterone in 8/24 with follow up did not influence complication rates. TIP incision of the elevated UP did not divide it into separate strips, or impair vascularity. Conclusions: Dissection of the UP from the corpora facilitates correction of VC while preserving the plate, without increasing TIP urethroplasty complications. Overall, complication rates for TIP have significantly diminished with technical modifications and experience. The role for neoadjuvant hormonal therapy remains unclear. Despite straightening VC preserving the UP, intraoperative assessment deemed it unsuitable for TIP in one case (4%).

We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all patients who underwent circumcision while hospitalized during the first 30 days of life from 2001-2010 using the National Inpatient Sample (NIS). Over 10 years, 200 early deaths were recorded among 9,833,110 subjects (1 death per 49,166 circumcisions). Note: this figure should not be interpreted as causal but correlational: it may include both under-counting and over-counting of deaths attributable to circumcision. Compared to survivors, subjects who died following newborn circumcision were more likely to have associated co-morbid conditions, such as cardiac disease (OR: 697.8 [378.5-1286.6] p<0.001), coagulopathy (OR: 159.6 [95.6-266.2] p<0.001), fluid and electrolyte disorders (OR: 68.2 [49.1-94.6] p<0.001), or pulmonary circulatory disorders (OR: 169.5 [69.7-412.5] p<0.001). Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.

This book provides all pediatric surgery trainees and other professionals involved in the care of childhood surgical disease a hands-on guide to the management of typical common clinical pathologies, as well all possible rare anomalies affecting the prepuce.
This book presents more than 300 full-color illustrations, covering the whole spectrum of congenital and acquired diseases affect the human prepuce, allowing the reader to apply their knowledge to real-life situations and assess their level of expertise.
As the prepuce discarded along the mankind history, and still sacrificed in some communities, it wasn’t either demonstrable, repeatable for elaborated studies, little data are available about its normal structure, or the natural deviations affecting it as a congenital anomalies or as an acquired diseases.
Aiming to settle down the argument about genital cutting; this book emerge as an attempt to review the progress made in the understanding of some interesting anatomy, embryology and pathology of this freestanding unique organ; “The Prepuce” in male and female.
There is no point in looking for new ideas in old stuff, but this book review our accumulated old knowledge about prepuce, with a plural of newly detectable variations, anomalies and diseases cumulated to the author after dealing with thousands of the prepuces along 40 years of practice.
This illustrative book discusses the normal embryology, anatomy, functions, normal variations and diseases affecting the prepuce. It also explores other rare anomalies and diseases of the prepuce as well as many unreported cases. In addition to the male prepuce, the book also discusses the female prepuce (hood) in order to elucidate some lights in normal and abnormal prepuce.  A separate section covers the frenulum and its anomalies.

Objective: This study addresses mothers' experiences with potty training in a Vietnamese population. Subjects and methods: Forty-seven mothers were interviewed and followed from the time that their children were newborns until they were 24-months old. The interviews were analyzed using qualitative content analysis. Results: According to tradition, diapers were used only rarely. The mothers used a whistling sound at certain times to remind their children to eliminate and frequently checked for signs of need. With this process, all children used the potty by the age of 9 months. At the age of 24 months the potty training was completed, and most of the children managed the whole process independent of help. Conclusion: This study shows that it is possible to start potty training with good outcomes very early in life. The process described can be achieved through an ongoing communication between parent and child.

In 2012 the American Academy of Pediatrics (AAP) released a policy statement and technical report stating that the health benefits of newborn male circumcision outweigh the risks. In response, a group of mostly European doctors suggested that this conclusion may have been due to cultural bias among the AAP Task Force on Circumcision, since their conclusion differed from that of international peer organizations despite relying on a similar evidence base. In this article, we evaluate the charge of cultural bias as well as the response to it by the AAP Task Force. Along the way, we discuss ongoing disagreements about the ethical status of nontherapeutic infant male circumcision, and draw some more general lessons about the problem of cultural bias in medicine.

Whatever this part of the body will be kept and cared, or it will be removed and discard, we have to confess that the prepuce is exquisitely designed, highly vascularised and innervated with a complex of specialised erogenous structures that are vital to natural and normal sexual function. Anatomy of the prepuce is unique from many aspects; firstly, as the prepuce removed early from a majorities of infants in many communities, so its anatomy is not well known among many physicians. Secondly, the prepuce after delivery is in continuous development till puberty, so its anatomy is diverse at different stages of life, and lastly preputial skin and muscles had no underneath attachments, the prepuce have to contract, retract and return back to cover the glans through a sequence of sloping muscle fibers. It is astounding that the complex nature of the prepuce (or the fact that it is not a simple fold of skin) was not described until 1991 and that this did not appear in the mainstream medical media until 1996. Genital autonomy is a recent issue emerged to refers to a person's being left to make their own informed decision about whether or not to have his intact or "natural" genital, and this mainly concerned with the importance of prepuce. There is no previous distinctive description of the different sections of the prepuce as an unrivalled organ. Herein we will describe separately, and in details, five parts of the prepuce; outer skin (with its three parts: base, body and tip), preputial meatus, inner mucosa, frenulum and balanopreputial sac. Preputial surface anatomy and morphology Balanopreputial Seperation (Preputial sac) Preputial Musculature Preputial blood supply Preputial nerve supply Normal preputial variations Most of the textbooks or research papers describing prepuce are not inclusive, and usually deal with the prepuce from the point of either its removal along circumcision or preservation to compete against this deeply rooted procedure. Steve Scott indicated that most physicians were ignorant of the anatomy and physiology of the genital structures they were routinely removing from infants and children 1. The prepuce is remarkably thin, dark, and loosely connected to the rest of penile skin. It has features of true skin but is devoid of subcutaneous adipose tissue, without associated hair follicles and few sweat glands are present in the superficial dermis.

Background: Penile length-for-age nomograms in prepubertal boys may aid in early recognition of endocrine and genetic disorders associated with abnormal phallic size. There are scarce data on the penile length measurements in children beyond the neonatal period and there is a lack of such a nomogram for Asian Indians. Materials and methods: Of the boys who were admitted in our ward or seen in the outpatient setting for genitalia-unrelated surgical problems, 20 consecutive boys were included in each of the following ten age slots (total of 200 subjects): 0e1, 1e2, 2e3, 3e4, 4e5, 5e6, 6e7, 7e8, 8 e9, and 9e10 years. Their stretched penile length (SPL) measurements were used to establish the normal range (mean AE 2 SD) of penile length-for-age in prepubertal Indian boys. Mean AE 2.5 SD was also calculated to define the cut-offs for micropenis and macropenis, respectively, in each age group. Results: A rapid increase is seen in penile length up to 4 years of age. A much slower increase is implied thereafter. Conclusion: This study provides reference values of penile lengths for Asian Indian boys aged 0 e10 years.

Introduction: Pregnancy induced hypertension (PIH) is one of the leading cause of maternal and fetal morbidity and mortality. Oxidative stress is considered as one of the aetiological factor in PIH. The present study was done to study the levels of plasma malondialdehyde (MDA) and serum superox-ide dismutase (SOD) level in pregnancy and their association with PIH. Material and methods: Study was conducted in the MP. 100 antenatal patients were included in the study and they were divided into two groups: normotensive group (50 patients) and pregnancy induced hypertension group (PIH) (50 patients). MDA was estimated as per Jean et al method and SOD by Mishra and Fridovich in all the patients. Results: Mean MDA level in normotensive, mild PIH and severe PIH patients was 4.15±0.35 nmol/ml, 5.11±0.41 nmol/ml and 6.27±0.37 nmol/ml respectively. Mean SOD level in nor-motensive, mild PIH and severe PIH patients was 3.15±0.21 unit/mg/ml, 2.56±0.32 unit/mg/ml and 2.02±0.19 unit/mg/ml respecti...

According to Brian Morris (2013), “Science supports infant circumcision” and “so should skeptics.” It would be more accurate to say that ‘Brian Morris supports infant circumcision,’ and that skeptics can think for themselves. In this paper, we critically assess the arguments and evidence presented by Morris in his recent article, and draw some general lessons for the ongoing debate about the science and ethics of infant male circumcision.

Neuromuscular dysfunction of the bladder (NMDB) – multifaceted dis-ease whose main manifestations is a violation of accumulation and/or evacuation bladder function requires careful diagnosis and long-term comprehensive treat-ment, which is not always quite effective. Particularly noteworthy refractory
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NMDB in children. The most common causes of dysfunction mainly consider congenital malformations (myelodysplasia, extrophy/epispadias etc.). In the US myelodysplasia occurs with a frequency of 1 in 1000 births and in 95% of cases accompanied NMDB [11]. While 30% of children with disorders of voiding in case myelodysplasia to primary surgery had urodynamic disorders and other complications associated with spinal cord defect [8]. The big problem is the condition in those countries where the law prohibits abortion even in the case of antenatal diagnosed anomalies of the spine and spinal cord (e.g., Poland). Each year in the United States for treatment NMDB spent 26.3 billion dollars, indicat-ing that the huge economic importance of this disease [14].
These aspects of the disease, the lack of standardized whole complex (ex-cept conservative therapy) treatments determine the relevance of the search for additional methods of complex treatment NMDB.
Increasingly conduct research activities on urinary incontinence, more common takes neurourology. Searching methods treatment of this disease, which would enable to achieve long-term normalization of voiding that contrib-utes to the physiological and social adaptation patient [5, 10].
The study protocol NMDB children should consist of ultrasound of the kidneys and SM voiding cystography and urodynamic research. Some authors suggest benefits performance uroflowmetry at home that makes it possible to get the best results of the study [6]. If a combination of neurogenic dysfunction of recurrent urinary tract infection should conduct DMSA to determine the degree of kidney damage. Great importance is attached neuroimaging methods of diag-nosis of pelvic floor (CT and MRI).
So, determined that only 37.2% of children with myelodysplasia have re-nal disease, and 78% of those who observed pathology of the upper urinary ways had bladder-ureteral reflux (mostly high degree) [4, 7, 9, 12].
Given the nature NMDB, it should be noted that in 37% of cases – a lack of sphincter apparatus of urine bladder and deficit its capacity, 22% – only lack of sphincter apparatus, 11% – high pressure in bladder background spastic con-traction sphincter, 4% – detrusor overactivity in 26% of patients causes urinary incontinence were mixed. Revealed that 69.4% of patients with urinary inconti-nence myelodysplasia [2, 7]. Other authors emphasize that urodynamic studies indicate that 62% of patients with myelodysplasia with detrusor contraction and discoordination sphincter, and in some cases sufficient to apply permanent cath-eterization and anticholinergic drugs. In 45% of patients observed violations locking properties sphincter [5].
Violations urine bladder innervations leads to severe hypoxic changes its walls that worsens impact of drug use means for correcting the pathology uro-dynamics [5, 9].
Results of treatment of patients with NMDB indicate the need for an inte-grated approach to problem-solving treatment of severe urinary incontinence in children. The most important aspect NMDB treatment – is prevention of kidney
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damage. The effectiveness of neurosurgical treatment of urinary incontinence during myelodysplasia achieved only in 28.6% of cases [3, 9].
Only 22.1% for patients with myelodysplasia social adaptation rather complex conservative treatment, patients need rest various surgical correction (not only urological but neurosurgical) [9]. Others authors [1, 5] argue that the positive effect conservative therapy can achieve in 72% of patients, but this pos-itive effect is regarded as an adequate preoperative preparation. Some authors emphasize that in the absence effect of conservative therapy NMDB children with myelodysplasia for 18 months there is a need in the surgical treatment of defects [7].
By the choice of surgical treatment should be approached strictly individual-ly, taking into account the type of incontinence, a condition wall NMDB and cen-tral nervous system treatments which were applied in individual patients [13].
Thus, for successful treatment NMDB, particularly in myelodysplasia re-quired hard work urologist, and it is very useful collaboration with neurosur-geon. Only when patients and/or their relatives aware of the need, importance and complexity of surgical treatment NMDB then can be a satisfactory outcome.
References:
1. Борисова С.А. Оптимизация лечения нейрогенной дисфункции мочевого пузыря у детей: Автореф. дис. …к. мед. н.– М., 2006.
2. Бурханов В.В. Хирургическая коррекция нижних мочевыводящих путей при недержании мочи у детей: Автореф. дис.…к. мед. н. – СПб, 2009.
3. Бурханов В.В., Осипов И.Б., Лебедев Д.А. Вестник Санкт-петербургского университета. Сер. 11. – Прил. К. – 2008. – Вып. 1.– С. 184-195.
4. Гаджиев Т.В. Урофлоуметрический мониторинг в диагностике нарушений мочеиспускания у детей с хирургическими заболеваниями нижних моче-вых путей: Автореф. …к. мед. н.– М., 2006.
5. Гусева Н.Б. Коррекция нарушений функции мочевого пузыря в консерва-тивном и оперативном лечении детей с недержанием мочи при миелодис-плазии: Автореф. дис. …д. мед. н. – М., 2007.
6. Данилов В.В., Вольных И.Ю. Уродинамические исследования в отборе больных и оценке результатов операции TVT у женщин с недержанием мочи // Pacific Medical Journal. – 2004. – N 1.– Р. 65 –69.
7. Еликбаева Г.М. Система диагностики и дифференцированного хирургиче-ского лечения миелодисплазии у детей: Автореф. дис. …д. мед. н.– СПб, 2009.
8. Николаев С.Н., Меновщикова Л.Б., Шмыров О.С. и др. Принципы хирур-гического лечения детей с миелодисплазией и недержанием мочи в ран-нем возрасте // Детская хирургия. – 2005. – № 4. – С. 4–8.
9. Осипов И.Б., Хачатрян В.А., Сарычев С.А. и др. Диагностика и лечение миелодисплазии у детей с урологическими осложнениями // Педиатрия жэне бала хирургиясы. – 2008. – № 1. – С. 14–17.
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10. Шмыров О.С. Реконструкция сфинктерного аппарата нижних мочевыво-дящих путей у детей с недержанием мочи при миелодисплазии: Автореф. дис. …к. мед. н.– М., 2007.
11. Bauer S.B. Neurogenic bladder dysfunction // Pediatric Clin. North. Am.– 1987.– Vol. 34.– P. 1121–1132.
12. Joao Luiz Pippi Salle Bladder Neck Reconstruction for the Treatment of Refrac-tory Urinary Incontinence in Children // http://ww2.ttmed.com/sinsecc.cfm?Http://ww2.ttmed.com/arg_sida/texto_art_long.cfm?ID_dis=212&ID_Cou=20&ID_Art=1633&comecover=Y&ID_dis=212&ID_cou=20.
13. Schulte–Baukloh H., Michael T., Schobert J. et al. Efficacy of botulinum–a tox-in in children with detrusor hyperreflexia due to myelomeningocele: prelimi-nary results // Urology.– 2002.– Vol. 59 (3).– Vol. 325–327.
14. Wagner T.H., Hu T.W. Economic course of urinary incontinence in 1995 // Urology.– 1998.– Vol. 51.– P. 355.

Hypospadias is a relatively common genital condition in which the urethral opening forms on the underside of the penis, as opposed to at the tip of the glans. Patients with hypospadias are typically referred for surgery during infancy or early childhood. Recent evidence, however, indicates that many individuals with hypospadias do not experience the functional or psychosocial difficulties that are commonly attributed to the condition, and that surgical intervention for hypospadias carries substantial risk of adverse outcomes. In this article, we review published outcomes data and conduct an in-depth analysis of the typical rationales for hypospadias surgery, taking into consideration both the potential benefits and harms of the procedure, as well as the existence of non-surgical alternatives. We argue, firstly, that most childhood surgeries for hypospadias are performed for anticipated future problems concerning function and cosmesis, rather than extant problems that serve to undermine the child’s well-being. Secondly, we contend that the surgery can be safely performed after an age of consent without increasing the absolute risk of surgical complications to an ethically meaningful degree. We conclude that surgery for hypospadias should typically be performed only if requested by the affected individual, under conditions of informed consent.

• Excellent guide to rare congenital genitourinary anomalies
• Offers simplicity on a complex subject
• Includes numerous informative illustrations
• Will serve as an excellent reference
Patients with rare diseases, affecting less than 1 in 2000 persons, frequently experience delays or errors in diagnosis, sometimes with tragic consequences. Even after the diagnosis has been established, the quality of health care delivered is often poor. This book, which is both textbook and atlas, covers the full range of rare congenital genitourinary anomalies encountered in males and females, many of which have previously been described only in sporadic case reports. In the case of the more established anomalies, variants are presented. For each anomaly, information is provided on incidence, similar cases, clinical presentation, diagnosis, possible management and outcome. Informative supporting illustrations are presented for each anomaly, and the book will serve as an excellent reference for all pediatricians, urologists and surgeons who are responsible for the care of such patients.
Content Level » Professional/practitioner
http://www.amazon.com/Rare-Congenital-Genitourinary-Anomalies-Illustrated/dp/3662436795/ref=sr_1_1?ie=UTF8&qid=1422885583&sr=8-1&keywords=rare+genitourinary+anomalies&pebp=1422885592799&peasin=3662436795

Four members of the Dawoodi Bohra sect of Islam living in Detroit, Michigan have recently been indicted on charges of female genital mutilation (FGM). This is the first time the US government has prosecuted an “FGM” case since a federal law was passed in 1996. The world is watching to see how the case turns out. A lot is at stake here. Multiculturalism, religious freedom, the limits of tolerance; the scope of children’s—and minority group—rights; the credibility of scientific research; even the very concept of “harm.” To see how these pieces fit together, I need to describe the alleged crime.

Purpose: To evaluate the result of Y-V preputioplasty and to compare this with an earlier technique of prepuce-sparing phimosis treatment. Materials and methods: A total of 65 boys were treated surgically for phimosis without removing the foreskin. Indications were the failure of conservative ointment treatment, congenital uropathies (to prevent infections and to make proper cleaning of the glans and the inner preputium possible to ensure clean urine sampling), recurrent balanitis or painful ballooning of the prepuce, and/or the need for urethral instrumentation. Forty-seven patients were treated with one or two Y-V plasties to widen the narrow preputial ring; 18 were treated using transverse closure of longitudinal incisions of the narrow preputial ring. Results: Of the 47 Y-V plasties, two patients had recurring complaints and needed further treatment (4.3%), and of the 18 patients treated by transversely closed longitudinal incisions, two patients had recurring complaints (11%). Recurrences occurred regardless of age and premedication with topical therapy. Cosmesis was considered to be excellent in all cases of Y-V plasty. Few patients complained about skin tags after longitudinal incisions. Conclusion: Y-V plasty of the preputial skin as an alternative to circumcision in the treatment of phimosis has good functional and cosmetic results. It is a minor operation with less impact on the penis than partial or total circumcision. The cosmetic results are superior to those after transversely closed longitudinal incisions.

Aim: To compare urethral and skin complications between consecutive patients undergoing distal TIP (tubularized incised plate) hypospadias repair with prepucioplasty versus circumcision. Methods: Prospective case-cohort study comparing urethroplasty and skin complications between consecutive patients undergoing distal TIP with prepucioplasty versus circumcision. Those with <1 month follow-up or prior circumcision were excluded. Decision for prepucioplasty or circumcision was made exclusively by caregivers. Operative technique was the same except skin closure. Postoperative foreskin retraction was deferred 6 weeks after prepucioplasty. Results: Of 343 circumcision and 85 prepucioplasty cases, median age and follow-up were 8 (3e420) and 7 (1.5e97.5) months, respectively. Urethroplasty complications occurred in 30 (8.7%) circumcision patients [16 fistulas, 13 glans dehiscences, 1 meatal stenosis due to balanitis xerotic obliterans (BXO) 5 years postoperatively], versus 7 (8.0%) after prepucioplasty [4 fistulas, 2 glans dehiscences, 1 urethral stricture], p Z 1.0. Skin complications resulting in reoperation occurred in 7 (2.0%) circumcision patients and 2 (2.3%) prepucioplasty patients, including an unsightly dorsal whorl in 1 and BXO 66 months postoperatively in another, p Z 1.0. Conclusion: Prepucioplasty does not increase urethroplasty or skin complications after distal TIP hypospadias repair. We found no contraindication for prepucioplasty among consecutive patients, indicating hypospadiologists can manage the foreskin in distal repairs according to caregiver preference.

Introduction: It has been suggested that penile length is negatively correlated to the degree of hypospadias; however, there are no studies in the literature actually comparing penile length in normal patients and patients with hypospadias. Material and method: Between January and May 2011, we measured penile length in two groups of children aged up to 5 years. The first group comprised all boys admitted for hypospadias (40 patients; 25 distal and 15 proximal hypospadias). The control group comprised 100 boys seen for other surgical procedures excluding those with endocrine disorders. We measured the length of the dorsal aspect of the penis in the flaccid state, without stretching. We then established, using our control group, a range of 'normal' values for penile length in our population and determined whether children with hypospadias were within this 'normal' range. Results: Mean penile length in the control group was 4.07 AE 0.92 cm, mean penile length in the hypospadias group was 4.36 AE 0.9 cm (4.48 AE 0.89 cm for distal hypospadias and 4.21 AE 0.79 cm for proximal hypospadias). There was no difference in penile length between the hypospadias group and the control group regardless of degree of hypospadias. Conclusion: This study indicates that penile length in children with hypospadias whether proximal or distal is within the normal range.

A recent study (Bossio, Pukall, & Steele, 2016) reported that neonatal circumcision is not associated with changes in adult penile sensitivity, leading to viral coverage in both traditional and online media. In this commentary the author questions the conclusions drawn from the study and explores the relationship between objective assessments of penile sensitivity and subjective sexual experience and satisfaction. The author concludes with suggestions for improving future research.

Objective: To determine the number of days taken by the Plastibell to fall off after circumcision and the Plastibell impaction rate in various age groups. Methods: This was a prospective cohort study of male babies who underwent circumcision using the Plastibell technique. Patients were followed up 1 week postoperatively as well as soon after the Plastibell had fallen off. Results: Mean age was 14.3 months and mean weight 8.2 kg at time of surgery. The average time taken for the Plastibell to fall off after circumcision for babies under 3 months was 8.7 days; this period gradually increased to 16.8 days for children over 5 years of age. The overall complication rate was 7.4%. Plastibell impaction was the commonest complication, encountered after 6.1% of procedures, and was managed by cutting the Plastibell. The impaction rate was only 2.3% for babies under 3 months, but gradually increased to 26.9% for children over 5 years. Conclusion: The time taken by the Plastibell to fall off spontaneously as well as the Plastibell impaction rate increases gradually with age. In view of the overall safety, comfort and absence of any long-term complication, this procedure justifies recommendation in all children aged under 1 year, but its use is debatable in older children.

Summary. In patients with miyelodysplazia urination disorders are 95–98%. Found that 62% of patients with miyelodysplazia discoordination detrusor contraction and sphincter (sphincter-detruzo dyssynerhia) and are likely to use adequate permanent catheterization and anticholinergic drugs. In addition, 45% of patients observed a violation of the locking properties sphincter. Botulinum toxin A - neurotoxic protein produced by the bacterium Clostridium botulinum with the presynaptic blocking effect, which provides the selective blockade of the detrusor during its intramuscular injection. It is proved that the BTA blocks muscle M2, M3, and R2H2 R2H3 receptors, which makes it possible to increase the volume of the bladder in children. Also, there is evidence that botulinum toxin A reduces the level of nerve growth factor (nerve growth factor (NGF)). In general, the positive effect of the use of botulinum toxin A is observed in 75% of children with miyelodysplazia. In this paper the clinical example of effective use of botulinum toxin A in a child with neuromuscular dysfunction of the bladder as a result of spinal dyzrafia. Thus, it was found that injection of botulinum toxin A intradetruzor is sufficiently effective and safe alternative in the surgical treatment of resistant forms of neuromuscular bladder dysfunction in children operated on dyzrafia spinal cord. The technique is simple in execution, is well tolerated by patients, the effect occurs in a relatively short time, has a prolonged effect. Intradetruzor injection of botulinum toxin A may be offered to all patients with sphincter-detruzor dyssynerhia and/or cistalgia anywhere in life.

Abstract Purpose: There are no reports of systematically-measured penile dimensions in boys with varying extents of hypospadias. To determine reference values, we prospectively measured maximum glans width in patients undergoing distal and proximal hypospadias repair as well as newborns undergoing elective circumcision. Methods: The maximum glans diameter was measured in consecutive boys aged 0e24 months presenting for newborn circumcision (controls), or repair of distal (distal shaft or glanular) and proximal (proximal shaft to perineal) hypospadias. Patients with proximal hypospadias and glans diameter <14 mm received intramuscular testosterone 2 mg/kg injection once monthly for 2e3 treatments, with measurements recorded prior to the first injection, and again intraoperatively 3e4 weeks after the final injection. Results: Data were obtained in 240 controls, 188 boys with distal hypospadias, and 39 boys with proximal hypospadias. Median ages were 1, 9 and 9 months, respectively. Males undergoing newborn circumcision were younger than both cohorts of hypospadias patients (p < 0.0001), but no difference in age was noted in those with distal and proximal hypospadias (p Z 0.194). Average maximum glans diameters were significantly different: 14.3, 14.8, and 12.9 mm, respectively, for controls, distal and proximal hypospadias (p < 0.0001). Despite mean older age, 46 (24.5%) boys with distal hypospadias and 24 (61.5%) with proximal hypospadias had small glans diameter <14 mm. Increasing age was not correlated with increasing glans size in patients with distal or proximal hypospadias (r Z À0.136, p Z 0.062 and r Z À0.089, p Z 0.580) at 3e24 months of age. Conclusion: Some boys with distal and the majority of those with proximal hypospadias have a glans width less than that of the average normal newborn. Glans size does not correlate with age in patients with hypospadias between 3 and 24 months old, supporting the decision to operate as early as 3 months in some centers. ª

Objective: To present an overview of the clinical presentation and pathological anatomy, and the results of surgical correction of 7 cases of epispadias with intact prepuce; a rare condition that has only occasionally been reported in literature. Patients and methods: A retrospective search was performed in the surgical and diagnoses database between 1991 and 2011. Seven cases of epispadias with intact prepuce were identified. Five presented as a webbed and buried penis, 1 as phimosis and 1 with suspicion for congenital anomaly of the genitalia. Results: In 3 of 7 cases, epispadias was suspected or diagnosed at first presentation and could be surgically corrected in the first intervention. In the other 4 cases, epispadias was discovered during surgery, requiring an additional intervention to perform epispadias repair in 3 cases. One boy was diagnosed with glandular, 3 with coronal, 1 with shaft and 2 with penopubic epispadias. Epispadias repair was successful with regard to cosmesis and erectile function. Five patients developed normal continence after surgery, 1 after intensive urotherapy. An under average penile length was the main reported problem during follow-up. Conclusion: In the diagnostic process for a concealed penis, the possibility of epispadias should be considered. If epispadias is suspected or confirmed, epispadias repair can occur in the first intervention, reducing the number of additional interventions. Epispadias with intact prepuce appears to have a better prognosis concerning urinary continence compared to classical epispadias.

INTRODUCTION: Postnatal management of prenatally detected hydronephrosis remains controversial. It has been suggested that cortical transit time (CTT) could successfully predict deterioration in children with pelvi-ureteric junction (PUJ) obstruction. We decided to conduct a retrospective study in our hydronephrosis population to evaluate whether initial CTT was significantly correlated with the need for surgery. PATIENTS AND METHOD: We reviewed the charts of all our patients managed for significant PUJ obstruction (&gt;12 mm) between 2007 and 2010 and determined CTT retrospectively, on the first diuretic scan of each of these patients. We then determined the relationship between initial CTT and the need for surgery. RESULTS: We identified 37 patients with hydronephrosis (pelvic size &gt;12 mm) of which 26 were diagnosed prenatally. Out of 22 patients with an initial abnormal CTT, 20 underwent surgery. Out of 15 children with a normal initial CTT, 4 underwent surgery (OR 27.5 (IC95%...

Objective: To report our experience in the management of adult classic bladder exstrophy. Patients and methods: During 1977-2006 we treated five adult males presenting with classic exstrophyeepispadias complex. Patient age at presentation ranged from 17 to 30 with a mean age of 23 years. Four patients had received no previous treatment and one underwent previous ureterosigmoidostomy. Work-up included evaluation of upper tract and bladder biopsy. Bladder patch condition was variable. Surgery involved bladder preservation in the three patients who underwent primary repair, including bladder closure, bladder neck reconstruction and epispadias repair; two of them also had augmentation ileocystoplasty. The remaining two patients underwent ureterosigmoidostomy, cystectomy and epispadias repair. Abdominal wall closure was by fasciocutaneous M-plasty. Osteotomy was not done in any case. Results: In patients with bladder preservation, one patient was continent (>3 h) and voided normally whereas the other two showed day and night continence (2e3 h) with mild stress incontinence. Patients were satisfied with functional outcome. Ultrasound and intravenous pyelography showed preservation of upper tract. Follow-up period ranged from 1 to 8 years. Conclusion: Patients with bladder exstrophy presenting in adulthood should not be denied the opportunity of primary reconstruction with bladder preservation in the absence of significant histological changes in the bladder mucosa.

Purpose To describe a modification in Mathieu (perimeatal-based flap urethroplasty) technique that incorporates glans augmentation into the procedure and is applicable for hypospadias patients with small glans and shallow urethral grooves. Patients and methods Fifty-four children with primary hypospadias and small glans underwent either the new double-faced Mathieu (DF-Mathieu) technique (33 patients) or tubularized incised plate (TIP) procedure (21 patients). DF-Mathieu perimeatal-based skin flap was meant to cover the distance from urethral orifice to the tip of the glans and flip back to fill the gap between glans wings. Patients were followed up for 20 months (12-30). TIP group underwent the conventional procedure. Results The mean age in DF-Mathieu and TIP group was 43.1 and 39.8 months, respectively. Post-operative results in DF-Mathieu group revealed one urethral fistula and no urethral break down or necrosis. In TIP group, there were one glans fistula (4.7%) and one meatal stenosis (4.7%). Overall success rate was 97% in DF-Mathieu and 90.5% in TIP operation. After 6 months, all DF-Mathieu patients had slit-like meatus and their cosmetic results were satisfactory.

Objective: Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up. Methods: We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1e21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12e36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions. Results: In 2004e2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as 'radiographic cure and no clinical evidence of FUTIs' it was 82% (275/336). Conclusions: It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.

Testicular tumors are rare in children. In addition, prepubertal testicular tumors (PTT) are fundamentally different from their postpubertal counterparts. We reviewed our 20-year experience with 40 cases to suggest an algorithm for the appropriate surgical approach for patients with PTT. All tumors ultrasonographically suspected of being benign were confirmed to be benign postoperatively. There was a significant difference between median preoperative a-fetoprotein (AFP) levels of infants with yolk sac tumor and teratoma. The majority of our cases were benign, with the most common histopathological subtype being teratoma, as recently reported. Testis-sparing surgery was carried out in five patients with teratoma and three patients with epidermoid cyst. Other than one patient with teratoma, none of the patients developed recurrence or testicular atrophy after testis-sparing surgery. When testis-sparing surgery is considered , our algorithm based on ultrasonographic findings and preoperative AFP levels might be helpful.

Objective: To report the presentation and treatment outcomes on a series of 12 paediatric bulbar or posterior urethral strictures that were possibly congenital in origin, identified in a 9-year period. Methods: A retrospective case-note review of all cases of urethral strictures thought to be congenital in origin, prospectively collected into the departmental database. Results: The age at presentation had a bimodal distribution with 6/12 presenting in the first year of life of which four had antenatal hydronephrosis and 5/12 presenting after the age of 11 years. All six patients under 1-year old had a successful outcome following urethrotomy and urethral dilatation. Four of five over 11 years of age ultimately required an urethroplasty and one 3-year-old may well require an urethroplasty in the future. Conclusion: This outcome, in conjunction with the bimodal age distribution at presentation, would suggest a different aetiology in older children, and we would urge caution in classifying strictures in ambulant children as genuinely congenital, as this population may represent the long-term manifestation of unrecorded bulbar urethral trauma or asymptomatic inflammation. Optical urethrotomy or dilatation is durable when treated in infancy, but older patients do not experience prolonged resolution and we would recommend treatment along adult lines for these.

HPV infection is the main risk factor for cervical carcinoma in 70 out of 100 cases. The aim of our prospective study was to investigate the epidemiology of human papilloma virus (HPV) and its colonization of the male genital tract in particular the inner layer of the foreskin.