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A potpourri of pediatric urology
Journal of Pediatric Urology (2017) 13, 82e83
A potpourri of pediatric urology Stuart O’Toole
In the News Consultant Pediatric Urologist, Royal Hospital for Children, Glasgow, Scotland, UK [email protected] (S. O’Toole)
“Post Truth”. As a parent, I emphasize the importance of honesty and hard work to my children. In a year dominated by politics, lies and distortions this is proving a difficult sell. It is no surprise that the Oxford English Dictionaries word of the year 2016 is “post truth”, it is defined as an adjective used where objective facts are less influential in shaping opinion than emotional appeals. Medicine has its own “post truth” scenario with the scare around childhood vaccinations. It is ironic that the incoming US President has appointed Robert Kennedy Jr (a vaccination conspiracy theory supporter) to chair a new group on vaccine safety. The independent January 2017 and BBC NEWS November 2016 Parkinson’s disease and the gut. “Paradigm shift” is a phrase that is thrown around a lot in medicine; however, it may be appropriate for our emerging understanding of Parkinson’s disease. Over recent years it has become apparent that there is a role for gut bacteria in the development of the disease. A group from California designed a very elegant experiment utilizing a genetically modified mouse that over expressed a-synuclein (aSyn). Mice with the mutation developed the disease, but mice with the mutation and a sterile gut did not. Interestingly mice that had gut micro flora transplanted from patients with Parkinson’s disease had earlier and more severe neurological manifestations of the disease. Sampson et al. Gut Microbiota Regulate Motor Deficits and Neuroinflammation in a Model of Parkinson’s Disease. Cell (2016) vol. 167 (6) pp. 1469e1480.e12 Reply to all! An IT breakdown at work is one of the most infuriating thing we have to deal with, but a recent one in England was quite entertaining. An administrator sent an e-mail message one morning to a colleague and inadvertently copied it to the entire distribution list. Unfortunately the e-mail went to all 840 000 NHS England employees. This temporarily crashed the e-mail server, but the situation
http://dx.doi.org/10.1016/j.jpurol.2017.02.002 1477-5131
was then compounded by angry e-mail users using the reply to all function to complain about the original crash. My own rules on email are: read the distribution list before using the reply to all function, wait 12 hours and read the text again before sending an e-mail to hospital management and if you have more than 4 e-mail replies in a thread phone. BBC NEWS November 2016
In the Journals When do urethral fistula occur? Single surgeon case series are rarely published, but every now and then you find a nugget of information that makes you consider changing your practice. Smith et al looked at the timing an incidence of urethral fistula post hypospadias repair in his own extended personal series. Boys presented with a fistula between 1 month to 13.9 years post-hypospadias surgery. The median time to fistula presentation was 8.5 months which somewhat undermines my own practice of discharging my straightforward hypospadias repairs 6 months post surgery. Liao and Smith. Urethrocutaneous fistulae after hypospadias repair: When do they occur?. J Paediatr Child Health (2016) vol. 52 (5) pp. 556e60 An Islamic perspective of DSD. As we are all aware the management of DSD is a technical and psychosocial challenge. Zainuddin and Mahdy have illustrated the Islamic perspective of gender related issues in the management of a series of patients with a DSD. In a very interesting article they tell us that a DSD is recognized as “Khunsa”. Islam goes on to distinguish two types of Khunsa: wadhih (discernible) and musykil (intractable), which sort of fits with our own pathophysiological category. Apparently there is general agreement in Islamic law on the position of “Khunsa” in prayer congregations but there are differences of opinion on issues related to property inheritance and bathing rituals. In Malaysia a recent fatwa (religious edict) has decreed that it is permissible to have a male-assigned patient surgically
A potpourri of pediatric urology treated and reassigned to female, but at the present time not a female assigned patient converted to male. Zainuddin and Mahdy. The Islamic Perspectives of Gender-Related Issues in the Management of Patients With Disorders of Sex Development. Archives of Sexual Behavior (2016) pp Long-term growth in Cloacal Exstrophy. The experience of most pediatric urologists is that children with cloacal exstrophy grow poorly. The group from Boston Children’s Hospital had 71 children with cloacal exstrophy over a 42-year period. Their growth observations available on 62 patients confirm the consensus view. Their patients with cloacal exstrophy had lower heights and weights for age than the general population but they maintained a reasonable BMI. Short bowel and enterocystoplasty were associated with this reduced growth. Their conclusion was that their data would be a useful benchmark for comparison for us all. Fullerton et al. Growth morbidity in patients with cloacal exstrophy: a 42-year experience. J Pediatr Surg (2016) vol. 51 (6) pp. 1017e21 Predicting reflux in children with UTI. Some Pediatric Urologists are keen to identify every child with vesicoureteric reflux after their first UTI so they can offer treatment. This invariably involves a lot of cystograms, many of which are normal or show only minor reflux. Rianthavorn et al looked at an interesting group of patients presenting with a febrile UTI under the age of 5. They identified a subset of children who had normal ultrasound examinations and looked at the incidence of dilating reflux (grade III and higher). They found dilating reflux in 7%, interestingly the children with the dilating reflux tended to be older and present with non E Coli UTIs. Unfortunately, they were not able to look at at the status of bladder filling in their study. It would be interesting to know how many of the older children with dilating reflux would have had abnormalities visible on our standard pre and post void renal US scans. Rianthavorn and Tangngamsakul. Probabilities of Dilating Vesicoureteral Reflux in Children with First Time Simple Febrile Urinary Tract Infection, and Normal Renal and Bladder Ultrasound. J Urol (2016) vol. 196 (5) pp. 1541e1545
83 Oral morbidity from repeated buccal graft harvesting. As a Pediatric Urologist we are forced into harvesting buccal mucosa and I always wonder about the long-term morbidity of this site. Rosenbaum et al looked at their results of repeated buccal mucosa graft urethroplasty for urethral stricture disease. They took all of their grafts from the inner cheek and then close the defect. Their results for the repeat urethroplasty were similar to the primary procedure. The main oral complication they encountered was paraesthesia. This occurred in less than 10% of their patients, which was comparable to the primary surgery. However, the donor site used for the second graft was the opposite cheek to the primary surgery and still a virgin site. The question is where do you take the graft for the next urethroplasty? Rosenbaum et al. Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes. BJU Int (2016) vol. 118 (5) pp. 797e803 Low calorie diets reduce bladder aging (in rats at least). I always and try and discipline myself to look at a few basic science papers just in case there is something on the horizon that I am not aware of. Ito et al looked at the effect of calorie restriction on the bladders of older rats. Essentially they had three groups of rats: one young group, one old group who could eat all they want and one old group who had their diet restricted. Essentially as rats age their bladders become less compliant, show more nonvoiding contractions and they get post void residuals (I know how they feel). This is associated with an increase in the markers of oxidative stress and increased expression of genes associated with inflammation in the bladder and dorsal root ganglia. Restricting the calorie intake of the rats prevents these changes from occurring. I do not think that we are at the stage of restricting the calorie intake of our patients, but this sort of work confirms my prejudice that a highly processed diet is not good for the bladder. Ito et al. Preventive Effects of Long-Term Caloric Restriction on Aging Related In Vivo Bladder Dysfunction and Molecular Biological Changes in the Bladder and Dorsal Root Ganglia in Rats. J Urol (2016) vol. 196 (5) pp. 1575e1583
A potpourri of pediatric urology Stuart O’Toole
In the News Consultant Pediatric Urologist, Royal Hospital for Children, Glasgow, Scotland, UK [email protected] (S. O’Toole)
“Post Truth”. As a parent, I emphasize the importance of honesty and hard work to my children. In a year dominated by politics, lies and distortions this is proving a difficult sell. It is no surprise that the Oxford English Dictionaries word of the year 2016 is “post truth”, it is defined as an adjective used where objective facts are less influential in shaping opinion than emotional appeals. Medicine has its own “post truth” scenario with the scare around childhood vaccinations. It is ironic that the incoming US President has appointed Robert Kennedy Jr (a vaccination conspiracy theory supporter) to chair a new group on vaccine safety. The independent January 2017 and BBC NEWS November 2016 Parkinson’s disease and the gut. “Paradigm shift” is a phrase that is thrown around a lot in medicine; however, it may be appropriate for our emerging understanding of Parkinson’s disease. Over recent years it has become apparent that there is a role for gut bacteria in the development of the disease. A group from California designed a very elegant experiment utilizing a genetically modified mouse that over expressed a-synuclein (aSyn). Mice with the mutation developed the disease, but mice with the mutation and a sterile gut did not. Interestingly mice that had gut micro flora transplanted from patients with Parkinson’s disease had earlier and more severe neurological manifestations of the disease. Sampson et al. Gut Microbiota Regulate Motor Deficits and Neuroinflammation in a Model of Parkinson’s Disease. Cell (2016) vol. 167 (6) pp. 1469e1480.e12 Reply to all! An IT breakdown at work is one of the most infuriating thing we have to deal with, but a recent one in England was quite entertaining. An administrator sent an e-mail message one morning to a colleague and inadvertently copied it to the entire distribution list. Unfortunately the e-mail went to all 840 000 NHS England employees. This temporarily crashed the e-mail server, but the situation
http://dx.doi.org/10.1016/j.jpurol.2017.02.002 1477-5131
was then compounded by angry e-mail users using the reply to all function to complain about the original crash. My own rules on email are: read the distribution list before using the reply to all function, wait 12 hours and read the text again before sending an e-mail to hospital management and if you have more than 4 e-mail replies in a thread phone. BBC NEWS November 2016
In the Journals When do urethral fistula occur? Single surgeon case series are rarely published, but every now and then you find a nugget of information that makes you consider changing your practice. Smith et al looked at the timing an incidence of urethral fistula post hypospadias repair in his own extended personal series. Boys presented with a fistula between 1 month to 13.9 years post-hypospadias surgery. The median time to fistula presentation was 8.5 months which somewhat undermines my own practice of discharging my straightforward hypospadias repairs 6 months post surgery. Liao and Smith. Urethrocutaneous fistulae after hypospadias repair: When do they occur?. J Paediatr Child Health (2016) vol. 52 (5) pp. 556e60 An Islamic perspective of DSD. As we are all aware the management of DSD is a technical and psychosocial challenge. Zainuddin and Mahdy have illustrated the Islamic perspective of gender related issues in the management of a series of patients with a DSD. In a very interesting article they tell us that a DSD is recognized as “Khunsa”. Islam goes on to distinguish two types of Khunsa: wadhih (discernible) and musykil (intractable), which sort of fits with our own pathophysiological category. Apparently there is general agreement in Islamic law on the position of “Khunsa” in prayer congregations but there are differences of opinion on issues related to property inheritance and bathing rituals. In Malaysia a recent fatwa (religious edict) has decreed that it is permissible to have a male-assigned patient surgically
A potpourri of pediatric urology treated and reassigned to female, but at the present time not a female assigned patient converted to male. Zainuddin and Mahdy. The Islamic Perspectives of Gender-Related Issues in the Management of Patients With Disorders of Sex Development. Archives of Sexual Behavior (2016) pp Long-term growth in Cloacal Exstrophy. The experience of most pediatric urologists is that children with cloacal exstrophy grow poorly. The group from Boston Children’s Hospital had 71 children with cloacal exstrophy over a 42-year period. Their growth observations available on 62 patients confirm the consensus view. Their patients with cloacal exstrophy had lower heights and weights for age than the general population but they maintained a reasonable BMI. Short bowel and enterocystoplasty were associated with this reduced growth. Their conclusion was that their data would be a useful benchmark for comparison for us all. Fullerton et al. Growth morbidity in patients with cloacal exstrophy: a 42-year experience. J Pediatr Surg (2016) vol. 51 (6) pp. 1017e21 Predicting reflux in children with UTI. Some Pediatric Urologists are keen to identify every child with vesicoureteric reflux after their first UTI so they can offer treatment. This invariably involves a lot of cystograms, many of which are normal or show only minor reflux. Rianthavorn et al looked at an interesting group of patients presenting with a febrile UTI under the age of 5. They identified a subset of children who had normal ultrasound examinations and looked at the incidence of dilating reflux (grade III and higher). They found dilating reflux in 7%, interestingly the children with the dilating reflux tended to be older and present with non E Coli UTIs. Unfortunately, they were not able to look at at the status of bladder filling in their study. It would be interesting to know how many of the older children with dilating reflux would have had abnormalities visible on our standard pre and post void renal US scans. Rianthavorn and Tangngamsakul. Probabilities of Dilating Vesicoureteral Reflux in Children with First Time Simple Febrile Urinary Tract Infection, and Normal Renal and Bladder Ultrasound. J Urol (2016) vol. 196 (5) pp. 1541e1545
83 Oral morbidity from repeated buccal graft harvesting. As a Pediatric Urologist we are forced into harvesting buccal mucosa and I always wonder about the long-term morbidity of this site. Rosenbaum et al looked at their results of repeated buccal mucosa graft urethroplasty for urethral stricture disease. They took all of their grafts from the inner cheek and then close the defect. Their results for the repeat urethroplasty were similar to the primary procedure. The main oral complication they encountered was paraesthesia. This occurred in less than 10% of their patients, which was comparable to the primary surgery. However, the donor site used for the second graft was the opposite cheek to the primary surgery and still a virgin site. The question is where do you take the graft for the next urethroplasty? Rosenbaum et al. Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes. BJU Int (2016) vol. 118 (5) pp. 797e803 Low calorie diets reduce bladder aging (in rats at least). I always and try and discipline myself to look at a few basic science papers just in case there is something on the horizon that I am not aware of. Ito et al looked at the effect of calorie restriction on the bladders of older rats. Essentially they had three groups of rats: one young group, one old group who could eat all they want and one old group who had their diet restricted. Essentially as rats age their bladders become less compliant, show more nonvoiding contractions and they get post void residuals (I know how they feel). This is associated with an increase in the markers of oxidative stress and increased expression of genes associated with inflammation in the bladder and dorsal root ganglia. Restricting the calorie intake of the rats prevents these changes from occurring. I do not think that we are at the stage of restricting the calorie intake of our patients, but this sort of work confirms my prejudice that a highly processed diet is not good for the bladder. Ito et al. Preventive Effects of Long-Term Caloric Restriction on Aging Related In Vivo Bladder Dysfunction and Molecular Biological Changes in the Bladder and Dorsal Root Ganglia in Rats. J Urol (2016) vol. 196 (5) pp. 1575e1583