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Re: Analysis of 3,776 Pediatric Inguinal Hernia and Hydrocele Cases in a Tertiary Center
Urological Survey Pediatric Urology Re: Postpubertal Examination after Hypospadias Repair is Necessary to Evaluate the Success of the Primary Reconstruction € rnsson and E. Hansson A. N. Ekmark, H. Svensson, E. Arnbjo Department of Clinical Sciences Malmo, Ska˚ne University Hospital, Lund, Sweden Eur J Pediatr Surg 2013; 23: 304e311.
Abstract available at http://jurology.com/ Editorial Comment: The authors used the HOSE1 protocol to assess boys with hypospadias at ages 7, 10, 13 and 16 years. Of 114 boys undergoing reconstruction between 1989 and 2009 with varying degrees of hypospadias 6 demonstrated progressive curvature between ages 13 and 16. At age 16 years 86% of patients had an excellent result based on the total HOSE score. Patients underwent Mathieu or Scuderi 1-stage operation or modified Byars 2-stage reconstruction. Those with more proximal hypospadias and some with distal or even glanular hypospadias underwent 2-stage repairs, which may explain why there were relatively few patients with additional curvature at puberty. Among cases reconstructed in stages 8 required intermediate operations, including additional release of chordee and different types of correction of the skin or flaps before urethral reconstruction. Complication rates only worsen with time. For years I followed patients only into mid childhood after hypospadias repair. As I have aged in this job, I am learning that more patients than I would like to admit return with complications at or after puberty. This study reminds us of the importance of longer followup in these boys. Douglas A. Canning, MD 1. Holland AJ, Smith GH, Ross FI et al: HOSE: an objective scoring system for evaluating the results of hypospadias surgery. BJU Int 2001; 88: 255.
Re: Analysis of 3,776 Pediatric Inguinal Hernia and Hydrocele Cases in a Tertiary Center an, I. Karaman, M. K. Aslan, A. Karaman and Y. H. Cavus¸og lu D. Erdog Pediatric Surgery Department, Dr. Sami Ulus Maternity and Children’s Research and Training Hospital, Ankara, Turkey J Pediatr Surg 2013; 48: 1767e1772.
Abstract available at http://jurology.com/ Editorial Comment: Parents and patients often ask for statistics. The authors reviewed children operated on between 2005 and 2009 for inguinal hernia, cord hydrocele and hydrocele. There were 2,959 males (78%) and 817 females (22%), for a ratio of 3.6 to 1. The hernia was on the right side in 61% of patients and bilateral in 9.5%. Age at presentation was younger in males than in females. Reoperation was needed because of wound infection in 0.6% of patients, recurrence in 0.4% and
0022-5347/15/1931-0299/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.10.033 Vol. 193, 299-301, January 2015 Printed in U.S.A.
www.jurology.com
j
299
PEDIATRIC UROLOGY
300
hematoma in 0.1%. Testicular atrophy developed in 1 boy postoperatively, which necessitated subsequent surgery for undescended testis. In boys with no evidence of associated hernia the operation for hydrocele was postponed until age 1 year, which is similar to what we do in the United States. Of the entire group only 2.2% required urgent surgery because manual reduction was unsuccessful. Associated pathological conditions included umbilical hernia in 8% of patients, prematurity in 6%, hypospadias in 1.8% and heart defect in 1.7%. Contralateral hernia subsequently developed in 2% of patients, with fewer instances in females than in males. Douglas A. Canning, MD
Re: Age at Orchidopexy as an Indicator of the Quality of Regional Child Health Services C. J. Bruijnen, H. D. Vogels and S. W. Beasley Department of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand J Paediatr Child Health 2012; 48: 556e559.
Abstract available at http://jurology.com/ Editorial Comment: The authors compare the age distribution of boys who underwent orchiopexy for undescended testis between 1997 and 2006 in the South Island of New Zealand and in the state of Victoria, Australia. If one presumes that the incidence of ascending testes is the same in each group, the authors propose that late referral and surgery for children with primarily undescended testes in Victoria resulted in a higher proportion of orchiopexies at ages 9 to 18 in Victoria compared to the South Island. Conversely lower rates of early diagnosis in Victoria resulted in a smaller proportion of boys undergoing orchiopexy between ages 0 and 4 years. The authors suggest that age at orchiopexy may be a surrogate indicator of the relative availability and quality of surgical care in a particular region. Douglas A. Canning, MD
Re: Ultrasound as a Screening Test for Genitourinary Anomalies in Children with UTI C. P. Nelson, E. K. Johnson, T. Logvinenko and J. S. Chow Department of Urology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts Pediatrics 2014; 133: e394ee403.
Abstract available at http://jurology.com/ Editorial Comment: The recent American Academy of Pediatrics urinary tract infection (UTI) guideline recommends renal and bladder ultrasound (RBUS) instead of voiding cystourethrography (VCUG) after the first urinary tract infection. The authors show by analyzing a large institutional series of children with UTI in whom VCUG and RBUS were performed that RBUS is not a good screening test for vesicoureteral reflux. The accompanying editorial concurs but indicates that the screening tool is the second UTI, not the RBUS.1 The reasoning includes the observation that 90% of children will never have a second UTI, and, therefore, will be spared the discomfort, expense and radiation associated with VCUG. I believe that “the ship has sailed” regarding pulling back on the American Academy of Pediatrics recommendations. Our efforts should now be directed to ensure that every child with symptoms of
Abstract available at http://jurology.com/ Editorial Comment: The authors used the HOSE1 protocol to assess boys with hypospadias at ages 7, 10, 13 and 16 years. Of 114 boys undergoing reconstruction between 1989 and 2009 with varying degrees of hypospadias 6 demonstrated progressive curvature between ages 13 and 16. At age 16 years 86% of patients had an excellent result based on the total HOSE score. Patients underwent Mathieu or Scuderi 1-stage operation or modified Byars 2-stage reconstruction. Those with more proximal hypospadias and some with distal or even glanular hypospadias underwent 2-stage repairs, which may explain why there were relatively few patients with additional curvature at puberty. Among cases reconstructed in stages 8 required intermediate operations, including additional release of chordee and different types of correction of the skin or flaps before urethral reconstruction. Complication rates only worsen with time. For years I followed patients only into mid childhood after hypospadias repair. As I have aged in this job, I am learning that more patients than I would like to admit return with complications at or after puberty. This study reminds us of the importance of longer followup in these boys. Douglas A. Canning, MD 1. Holland AJ, Smith GH, Ross FI et al: HOSE: an objective scoring system for evaluating the results of hypospadias surgery. BJU Int 2001; 88: 255.
Re: Analysis of 3,776 Pediatric Inguinal Hernia and Hydrocele Cases in a Tertiary Center an, I. Karaman, M. K. Aslan, A. Karaman and Y. H. Cavus¸og lu D. Erdog Pediatric Surgery Department, Dr. Sami Ulus Maternity and Children’s Research and Training Hospital, Ankara, Turkey J Pediatr Surg 2013; 48: 1767e1772.
Abstract available at http://jurology.com/ Editorial Comment: Parents and patients often ask for statistics. The authors reviewed children operated on between 2005 and 2009 for inguinal hernia, cord hydrocele and hydrocele. There were 2,959 males (78%) and 817 females (22%), for a ratio of 3.6 to 1. The hernia was on the right side in 61% of patients and bilateral in 9.5%. Age at presentation was younger in males than in females. Reoperation was needed because of wound infection in 0.6% of patients, recurrence in 0.4% and
0022-5347/15/1931-0299/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.10.033 Vol. 193, 299-301, January 2015 Printed in U.S.A.
www.jurology.com
j
299
PEDIATRIC UROLOGY
300
hematoma in 0.1%. Testicular atrophy developed in 1 boy postoperatively, which necessitated subsequent surgery for undescended testis. In boys with no evidence of associated hernia the operation for hydrocele was postponed until age 1 year, which is similar to what we do in the United States. Of the entire group only 2.2% required urgent surgery because manual reduction was unsuccessful. Associated pathological conditions included umbilical hernia in 8% of patients, prematurity in 6%, hypospadias in 1.8% and heart defect in 1.7%. Contralateral hernia subsequently developed in 2% of patients, with fewer instances in females than in males. Douglas A. Canning, MD
Re: Age at Orchidopexy as an Indicator of the Quality of Regional Child Health Services C. J. Bruijnen, H. D. Vogels and S. W. Beasley Department of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand J Paediatr Child Health 2012; 48: 556e559.
Abstract available at http://jurology.com/ Editorial Comment: The authors compare the age distribution of boys who underwent orchiopexy for undescended testis between 1997 and 2006 in the South Island of New Zealand and in the state of Victoria, Australia. If one presumes that the incidence of ascending testes is the same in each group, the authors propose that late referral and surgery for children with primarily undescended testes in Victoria resulted in a higher proportion of orchiopexies at ages 9 to 18 in Victoria compared to the South Island. Conversely lower rates of early diagnosis in Victoria resulted in a smaller proportion of boys undergoing orchiopexy between ages 0 and 4 years. The authors suggest that age at orchiopexy may be a surrogate indicator of the relative availability and quality of surgical care in a particular region. Douglas A. Canning, MD
Re: Ultrasound as a Screening Test for Genitourinary Anomalies in Children with UTI C. P. Nelson, E. K. Johnson, T. Logvinenko and J. S. Chow Department of Urology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts Pediatrics 2014; 133: e394ee403.
Abstract available at http://jurology.com/ Editorial Comment: The recent American Academy of Pediatrics urinary tract infection (UTI) guideline recommends renal and bladder ultrasound (RBUS) instead of voiding cystourethrography (VCUG) after the first urinary tract infection. The authors show by analyzing a large institutional series of children with UTI in whom VCUG and RBUS were performed that RBUS is not a good screening test for vesicoureteral reflux. The accompanying editorial concurs but indicates that the screening tool is the second UTI, not the RBUS.1 The reasoning includes the observation that 90% of children will never have a second UTI, and, therefore, will be spared the discomfort, expense and radiation associated with VCUG. I believe that “the ship has sailed” regarding pulling back on the American Academy of Pediatrics recommendations. Our efforts should now be directed to ensure that every child with symptoms of