Detection of vesico-ureteric reflux in children by color-flow doppler ultrasonography

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mend further studies of the health benefits of circumcision to justify the current expenditure on the procedure by the national insurer.—A.J.A. Holland Use of Parenteral Testosterone Before Hypospadias Surgery. CC Luo, JN Lin, CH Chiu, et al. Pediatr Surg Int 19:82-84, (April), 2003. Surgical repair of hypospadias is more difficult in boys with a microphallus. The local application of testosteron cream showed only temporary enlargement with inconsistent results. The study evaluated the use of parenteral testosterone before hypospadias correction. Twenty-five boys within 9 to 12 month of age with penile, penoscrotal or perineal hypospadia received 25 mg testosterone intramuscularly once per month for 3 months. Penile length and glans circumference were measured before and after therapy. All corrections were done by onlay island flap. Penile length (23.8 v 19.8 mm) and glans circumference (37.4 v 27.4 mm) increased significantly in 23 boys compared with initial measurement. Two children didn’t respond. Four patients showed the maximal effect already after one dose; 6 after the second. These 10 boys did not receive further hormones. The authors found no sexual precocity and no delay in bone age, but the second aspect was analyzed in only 2 children with x-rays of the hand. They focused on the fact that cosmetic glans configuration is easier to get if hormonal stimulation took place. Parenteral hormone therapy for microphallus enlargement before hypospadias correction seems to be effective, but the study lacks dosage evaluation especially because nearly 50% of responding boys showed good results after 1 or 2 doses. Therefore less testosterone or fewer injections may be sufficient. The effect on bone age cannot be predicted on the data of 2 children only within a short time course. For this aspect, further data are necessary.—Peter Schmittenbecher Neonatal Scrotal Haematoma: Mimicker of Neonatal Testicular Torsion. D.A. Diamond, J.G. Borer, C.A. Peters et al. Br J Urol Int 91:675-7, (May) 2003. This is a retrospective study of 5 neonates presenting with unilateral scrotal hematoma within the first 48 hours of life over a 5-year period. In the first case, the diagnosis was made at operation, but in the other 4, the diagnosis was made by color Doppler ultrasonography, and surgery was avoided. Patients were followed up for a mean of 31 (range, 6 to 72) months. In each there was complete resolution of the hematoma and testicular volume, and perfusion remained symmetrical. Four of the five children had risk factors associated with neonatal scrotal hematoma, including bleeding diathesis, birth trauma, and high birth weight. The authors conclude that modem Doppler ultrasound equipment generally is capable of making an accurate diagnosis, sparing some children surgical exploration.—M.N. de la Hunt Infertility Despite Surgery for Cryptorchidism in Childhood Can be Classified by Patients With Normal or Elevated Follicle-Stimulating Hormone and Identified at Orchidopexy. D. Cortes, J. Thorup, S. Lindenberg, et al. Br J Urol Int 91:670-4, (May), 2003. The study included patients with cryptorchidism (70 bilateral and 65 unilateral) who had a simultaneous biopsy taken at orchidopexy in childhood, and in adulthood had analyses of semen and folliclestimulating hormone (FSH). In adulthood, 42 formerly bilateral cryptorchid boys had repeat testicular biopsy specimens taken. Based on sperm analysis, infertility was suspected in 38 of 70 (45%) bilateral and 6 of 65 (9%) unilateral cryptorchid patients. High FSH values were expected in these patients, but in 45% (20 of 44) the FSH values were normal. At orchidopexy, these patients were identified to be bilaterally cryptorchid with few germ cells, and those unilaterally cryptorchid had

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none in the biopsy. No patient had low FSH. The authors conclude that these patients may have relative FSH deficiency. Therefore, after orchidopexy in childhood, additional hormonal treatment, eg, recombinant FSH or buserelin, may be indicated in these patients.—M.N. de la Hunt Vaginoplasty From Peritoneal Tube of Douglas Pouch for Congenital Vaginal Agenesis. N.P. Sheth, M.S. Chainani, and S.N. Sheth. Eur J Pediatr Surg 13:213-214, (June), 2003. Vaginal reconstruction using skin and sigmoid loop has resulted in complications like dryness, stenosis, and hair growth in the graft in the former procedure and mucus discharge in the latter. A case of Douglas’s pouch peritoneal tube vaginoplasty in a 17-year-old girl with absent vagina is reported with satisfactory functional results. The procedure is much less invasive than the currently described methods.—Thomas A. Angerpointner Urogynaecologic and Obstetric Issues in Women With the Exstrophy-Epispadias Complex. R.I. Mathews, M. Gan, and J.P. Gearhart Br J Urol Int 91:845-9, (June), 2003. This is a retrospective review of 83 women (mean age 24 years; range, 13 to 52) with exstrophy-epispadias complex (EEC). Their original medical records were reviewed, and they were mailed a survey, with telephone follow-up, to identify social and sexual concerns. Fifty-six women had classical bladder exstrophy (CBE), 13 had female epispadias (FE), and 14 had cloacal exstrophy (CE). The bladder was closed in 51 patients with CBE and 13 with CE. Urinary calculi developed in 10 patients with CBE, 2 with FE, and 3 with CE. Vaginal and uterine prolapse occurred at an earlier age in patients with EEC. Thirty-four responded to the survey. Eight women had 13 pregnancies 8 of which resulted in normal healthy children, with 1 delivered vaginally. Overall continence was achieved in 85% of the women surveyed. Urinary tract infections remained a frequent problem for women with only 27% of respondents indicating they were infection free. Twenty-four women aged more than 18 years who responded indicated that they had appropriate sexual desire; 16 were sexually active, and the mean age for commencing sexual activity was 19.9 years. Six patients had dyspareunia and 10 indicated that they had orgasms. However, 5 additional patients indicated that they had restricted intercourse, because they were dissatisfied with the cosmesis of their external genitalia. This report includes much interesting detail about treatment outcomes and sexual and gynecologic issues become increasingly important to as the patients mature. Understanding these problems enables better counselling of future parents and patients.— M.N. de la Hunt Detection of Vesico-Ureteric Reflux in Children by ColorFlow Doppler Ultrasonography. A Kos¸ar, A Yes¸ildagˇ, O Oyar, et al. Br J Urol Int 91:856-9, (June), 2003. Thirty-five children (aged 2 to 15 years) were examined for vesicoureteric reflux (VUR) by color-flow Doppler ultrasonography (DUS) and standard voiding cysto-urethrography (VCUG). All patients underwent DUS and VCUG within 48 hours of each other, but the VCUG findings were not revealed to the ultrasonographer. The DUS was done with the bladder moderately full and during micturition looking for retrograde flow into the ureter. Of 70 ureters assessed, 28 were refluxing on DUS and 29 on VCUG. In comparison with VCUG, the DUS was found to be 90% sensitive with a specificity of 93% for detecting VUR. There were 2 false-positive and 3 false-negative results. Four patients had reimplantation during their treatment. DUS findings correlated well with standard VCUG in these patients as a method of follow-up. The authors concluded that DUS can be used as an alternative to standard VCUG for screening and following VUR. It

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avoids ionizing radiation and catheterization but does provide less anatomic detail.—M.N. de la Hunt The Results of 15 Years of Consistent Strategy in Treating Antenatally Suspected Pelvi-Ureteric Junction Obstruction. J. Thorup, R. Jokela, D. Cortes, et al. Br J Urol Int 91:850-2, (June), 2003. One hundred consecutive infants with antenatally detected suspected unilateral pelvi-ureteral junction (PUJ) obstruction and a normal contralateral kidney were studied. Four patients initially had poor function in the hydronephrotic kidney (⬍10%), treated in 3 by nephrectomy. Sixty-one had normal function in the hydronephrotic kidney, of whom, 12 later had surgery between 0.7 and 8 years for infection, pain, or deterioration in function, and 49 were followed up for 1 to 10 years with no change in kidney function or symptoms. Thirty-five had moderately impaired function (10% to 40%). Of these, one kidney was lost at age 3 weeks from severe pyelonephritis, 29 had pyeloplasty at age 4 to 11 months, and 5 were managed conservatively at their parents request. After pyeloplasty, function increased from 32% before to 42% after operation, with 15 kidneys recovering normal function. In the 5 with reduced function managed conservatively, none deteriorated further, and function did increase from 32% to 35% at the 1-year follow-up but significantly less than in the surgical group. Three later had surgery. The surgical complication rate was 4% with 2 requiring revision for stricture. Although the follow-up was intense, there was moderate and irreversible functional kidney deterioration in 5%. After reconstructive surgery, only a few follow-up procedures were needed in most patients.—M.N. de la Hunt

MUSCULOSKELETAL SYSTEM Orthopedic Injuries Associated With Backyard Trampoline Use in Children. G.B. Black, R. Amadeo. Can J Surg 46:199-201, (June), 2003. In this report, the authors reviewed the backyard trampoline orthopedic injuries in children admitted to the Winnipeg Children’s Hospital. They made up 1.6% of all trauma admissions. The charts, x-rays, and operative reports for 80 children (40 boys and 40 girls), from 2 to 15 years (mean, 9 years, with 18% between 2 and 4 years and 49% in the 5 to 9 years age group) were reviewed, covering January 1996 to October 1997 (21 months). They noted the mechanism, type, severity, and treatment of the orthopedic injury. Fifty-two (65%) children were injured on the trampoline mat, and 24 (30%) were injured when they were ejected from the trampoline. Sixty (75%) children sustained a

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fracture or fracture/dislocation, and 25% reported only soft-tissue injury. Forty-eight (80%) of these orthopedic injuries occurred in the upper extremity. Not surprisingly, most (74%) injuries occurred during the summer months (June to September), and the majority (51%) were at a neighbor’s home. One third said the injury occurred when they were alone on the trampoline, whereas 35% sustained their injury while on the mat with 1 to 5 other children, although the actual incidence may have been underestimated, as reported by others. In only 10% of cases was an adult “supervising” the trampoline use. Nonetheless, the authors speculate that because most children sustained their injury from a simple fall on the mat even with adult supervision, the injury may not have been preventable. A number of children were injured throught imaginative uses of the trampoline (eg, jumping from the roof onto the trampoline). These innovative mechanisms might have been preventable had adult supervision been available. The most common fracture sites were the forearm (45%) followed by the humerus and elbow (35%); supracondylar fractures (81%) and fracture-dislocations of the elbow accounted for the 21 injuries, about and above the elbow. There were no associated vascular injuries and no knee dislocations. The most serious injury was a fracture-dislocation of the cervical spine, with paralysis, in an 8 year old boy, who was ejected from the mat. There were no deaths. The rare deaths that did happen in the 1996 statistics from the Consumer Product Safety Committee in the United States (US) were all secondary to severe head and neck trauma. The Canadian Hospital Injury Reporting and Prevention Program, (a computerized information database) records injuries in children’s hospitals in Canada. In 1996, 1,042 trampoline injuries in children were seen in emergency departments: (36% fractures, 12% involved head and neck, 64% occurred on home trampolines). There were several limitations to this study, according to the authors: (1) It was a retrospective study. (2) They could not obtain information on the number of and overall use of trampolines in Winnipeg; therefore, no conclusion could be made about the relative risk of injury from the backyard trampoline versus other childhood activities. 3. Because histories were obtained from the injured child or witnesses of similar age, a reporting bias may have been present. Finally, the authors suggested the following guidelines for the use of backyard trampolines: (1) Physicians should advise children and their families of the potential dangers of trampoline use, (2) children younger than 6 years should not use the trampoline, (3) children should not use the trampoline without adult supervision, (4) no more than 1 person should be on the trampoline at any time, (5) no flips or other advanced maneuvres should be attempted. In children, a trampoline is a high-risk activity, and the backyard trampoline has the potential for significant orthopedic injury.—Sigmud H. Ein