Urology

Background/Aim: Approximately 20% of undescended testes (UDT) are bilateral. It is unclear whether bilateral orchidopexy (BO) should be undertaken synchronously (SBO) or metachronously (MBO). Our aim was to investigate current UK practice and the complications of SBO vs MBO.

Materials & Methods: Following approval of BAPS and BAPU ethics committee, a survey was circulated to UK Consultant paediatric surgeons and paediatric urologists regarding practice. A departmental retrospective review was additionally carried out for patients undergoing BO between 2005 and 2017.

Results: Forty-three Consultant surgeons from 20 centres completed the survey. Overall, SBO was preferred by 70% for bilateral palpable UDT versus 30% for bilateral impalpable UDT. When one side was palpable and the other impalpable, 70% preferred SBO. Paediatric urologists were significantly more likely to undertake SBO than paediatric general surgeons.

188 patients (376 testicular units) were identified who had undergone BO with a median follow up of 9 months. 144/188 (76.6%) underwent SBO while 44 had MBO. SBO was financially advantageous by comparison to MBO as a 2^nd operation was avoided, and treatment was completed 6 months more quickly. There was no statistical difference in the complication rate between the two groups (7.6% in SBO vs 9.1% in MBO).

Conclusions: The majority of UK surgeons, in particular paediatric urologists, favour SBO. In addition, SBO offers a reduction in cost, more rapid completion of treatment and is not associated with additional complications by comparison to MBO. We recommend SBO to be standard practice for bilateral UDT whenever possible.

Aim of the Study

Our previous data showed most boys with UDT are referred later than best practice guidelines consider optimal, mainly from delay in referral, resulting in orchidopexy being later than ideal. It was hoped that improvements in primary care education and easily-used referral processes could decrease the age of referral.

An online resource for GPs and allied professionals was initiated in 2008 (CHP). The UDT guideline advises referral to paediatric surgery if testes do not sit spontaneously in the scrotum at 3 months corrected age. We aimed to seek evidence of any reduction in age of referral, and orchidopexy.

Methods

Data were collected prospectively for boys referred with UDT over a 5-year period during which time agreed GP guidelines for referral were introduced. Trends in the age at referral, age at surgery and outcomes were analysed.

Main Results

Complete data were obtained for 164 boys.  Referral before age 6 months increased from 12% in 2012 to 38% in 2016; and before 12 months from 38% in 2012 to 67% in 2016. Orchidopexy by 12 months was achieved in 10% in 2012 and 33% in 2016; and by 18 months in 44% in 2012 up to 68% in 2016. Median age at orchidopexy for this 2012-2016 cohort was 16.6 months compared with 31.1 months from 1997-2007.

Conclusion

These data demonstrate earlier referral of boys with UDT and earlier orchidopexy is occurring. This corresponds to the introduction of the GP website “Community health pathways”. A similar resource available in other regions or countries might be expected to reduce the age of referral from primary care providers.

Aim of the Study

We are a large unit performing predominantly retroperitoneoscopic procedures.   We aim to review our outcomes and analyse the data to elucidate predictors of intra-operative complications and need for further surgery.

Methods

We performed a single centre retrospective review of children undergoing retroperitoneoscopic laparoscopic nephrectomy (RLPN) and retroperitoneoscopic laparoscopic partial nephrectomy (RLN) between 2005 and 2015.  Demographic, diagnostic and surgical variables were analysed for correlation with outcomes using chi², t-test and spearman’s correlation.

Main Results

We performed 173 laparoscopic cases, 119 RLN and 54 RLPN.  Median age and weight: 5 years (6 months – 18 years) and 24.9kg (7.7 to 85kg), median operation time 2:27 hours. There were 4 conversions and 6 intraoperative complications.  26 children required further surgery which included 8 completion stumpectomy (2 with reimplant) and 2 completion nephrectomies.  

RLPN was not associated with higher rate of cumulative complication than RLN (27 vs 23% p=0.76) or increased LOS (mean 2 days p=0.62).  Predictors of intraoperative complication were hand tie or electrocautery vessel sealing.  Associations with need for reoperation included: diagnosis, degree of CKD, contralateral disease, bladder dysfunction, presence of PD catheter and need for concomitant procedure.   

Conclusion

Our conversion rate (2.3%) and intraoperative complication rates are favourable to the literature.  We have demonstrated that there is no association of heminephrectomy and intraoperative complications (OR 0.96 p=0.42) nor cumulative complication rate.  Need for reoperation is often associated with the underlying diagnosis and the natural sequelae of the disease process, rather than aspects of surgical technique.

Introduction: Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence

Methods: A retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night.

Results:  In total, 140 CE and CE variant patients have been managed at the authors’ institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2-10). This included 1 bladder closure (range 1-3), 2 urinary continence procedures (range 1-4), and 1 (range 0-4) “other” genitourinary procedures. The median time to urinary continence was 11.0 years (95%CI [9.2-14.2]).

Conclusions: A majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11.

Bilateral intra-abdominal testes (BIATs) are rare. There is no consensus regarding optimum management. Fowler-Stephens Orchidopexy (FSO) carries a failure rate of 15-35%, and when bilateral, there is a risk of iatrogenic anorchia. Options in the setting of unilateral testicular atrophy include delaying procedures on the second testis to promote natural puberty.

Aim of the Study

We aimed to evaluate management strategy and cosmetic testicular outcome in boys undergoing FSO for BIATs.

Methods 

We performed retrospective case note review of boys with BIATs (2005-2017). Primary outcome was testicular atrophy based on clinical assessment after at least 4 months. Secondary outcomes included requirement for testosterone replacement in those approaching puberty.

Main Results 

Twenty-nine boys with BIATs were identified. 22/29 have completed bilateral surgery. Median age at first procedure was 1.7 years. 18/29 completed treatment with two normal sized testes in their scrotum. 4/29 patients have completed treatment with either unilateral (n=3) or bilateral (n=1) testicular atrophy. 3/29 patients had unsuccessful surgery on the first side (2 atrophy, 1 excision intra-abdominal remnant), and then remaining testis left within the abdomen, rather than risk pre-pubertal anorchia. 4/29 boys have had successful surgery on one side and await contralateral procedure. 51/58 testes were operated with an atrophy rate of 14% (Median followup 64 weeks; range 16-610 weeks).

8/29 boys underwent endocrine evaluation. Of 2 post-pubertal boys, one required testosterone treatment despite normal appearing testes. 2/6 prepubertal boys had abnormal endocrine function biochemically. One prepubertal boy with a single IAT had normal biochemical function.

Conclusion

We describe the treatment course and cosmetic outcome for 29 boys with BIATs, the largest series reported. Failure rate of FSO is in keeping with previous literature. Cosmetic outcome may not predict normal endocrine function. We recommend endocrine evaluation of all boys with BIATs.

Aim of Study

Paediatric services were recently centralised to a single unit within our multi-site configuration - 17 miles from the Urology Centre. We analysed the subsequent impact on assessment and outcomes for all patients presenting with suspected testicular torsion.

Methods

Using a comprehensive electronic database we conducted a comparative service evaluation on suspected testicular torsion outcomes over two 12-month periods, pre- and post-paediatric centralisation (2015 and 2017). 

Main Results

Total number of scrotal explorations reduced from 41 to 21 - of which 28 and 12 respectively were within the paediatric population. Median age of patients was 15 (range 4-51) vs 16 (range 4-46).  

Where applicable, median time from admission to assessment by the Emergency Department (ED) was 32mins (range 7 – 131) vs 37mins in 2017 (range 9-198).

Time to specialist assessment for the paediatric population was lower in 2017 at median 50mins (range 0-120) vs 55mins (range 0-345), however this was not significant, p=0.87. Where applicable, time for patient transfer in 2015 (n=7) was median 103mins (range 72- 363) vs 139mins (range 129-213) in 2017 (n=4). There was no significant difference in time from presentation to ‘knife-to-skin’ overall: 195mins vs 227mins, p=0.20, or in the paediatric population: 211mins vs 210mins, p=0.95.

Five patients exceeded a 6-hour target of ‘knife-to-skin’ time during 2015 compared to one in 2017. There were 6 vs 4 confirmed torsions on exploration - all testes were viable. Orchidectomy was not required in either period.

Conclusion

Although paediatric services have been centralised distant to our Urology Centre, there has not been an increase in time taken for specialist assessment. The number of patients breaching the 6-hour target has reduced. Interestingly, total numbers of referrals have fallen which may indicate a shift of patients to neighbouring units as an unintended consequence of centralisation.

Aim of the study: Disorders of Sex Development is a childhood and infantile anomaly affecting not only the somatic growth; but also leading to stress and anxiety among parents who are seeking optimal treatments. In this study the surgical outcomes in patients with Disorders of Sex Development in Mofid Children’s Hospital from 2001 to 2014 were determined.

Methods: In this case series study 72 children with Disorders of Sex Development in Mofid Children’s Hospital from 2001 to 2014 were enrolled and followed in a regular manner. Data were gathered by existing medical documents and were recorded in prepared checklist. The surgical outcomes were assessed with interview and clinical examination. The success and complication rate were determined by group of surgeons .

Main Results: Seventy two patients; 55 (76.38%) affected by Congenital Adrenal Hyperplasia, thirteen (18.05%) by Testicular Feminization , 2 (2.7%) by OvoTesticular Disorder and two case (2.7%) by Mixed Gonadal Dysgenesis,were enrolled. Most common intervention was Clitroplasty, Genitoplasty and Pullthrough Vaginoplasty (table1). Fifty nine patients (81.9%) had no surgical complications. All patients were discharged uneventfully. Three cases of Testicular Feminization (4.2%) who underwent pulltrough colovaginoplasty were married.

Conclusion: Surgical outcomes in cases of Disorders of Sex Development were relatively satisfactory. However long-term follow-up study is required to determine the final outcomes especially for marital and sexual issues.

Table 1

Aim of the Study
MRU is a modality that provides detailed anatomical and functional information when investigating urological disease. Following evaluation of exisiting Magnetic Resonance Urography (MRU) protocols in our institution, we introduced modified protocols intended to enhance our detection of these anomalies in equivicol diagnostic scenarios and evaluated the impact on the rate of definitive diagnosis of these conditions.  

Methods
Data were collected retrospectively on all infants and children undergoing MRU at a single institution over an eight year period (2010-2018).  MRU performed for non-urological purposes were excluded. Demographic and clinical data were recorded. Data from Phase 1, (pre-existing protocols) and Phase 2, (updated static / dynamic protocols) were compared.

Main Results
Fifty-eight patients (32 male, 26 female) underwent MRU during this period. Median age at MRU was 5.3 years (range 8m – 10 years).

Investigation of suspected pelvi-ureteric junction obstruction (PUJO) was the commonest indication for MRU (33 studies 56%).

During Phase 1 (2010-2014) 10 studies were performed for possible PUJO, 8 were definitive in confirming or excluding diagnosis (80%). During Phase 2 (2014-2018) 23 studies were performed to investigate PUJO, 22 were definitive (96%). For confirmation of ectopic ureter insertion definitive clinical answers were obtained in 66% (2/3) of studies during phase 1 and 83% (4/5) in phase 2. Overall definitive diagnosis was achieved in 67% of cases (18/27) during phase 1 and in 93.8% (30/32) in phase 2.

Conclusion
MRU has been previously shown to be beneficial in diagnosing complex urological pathology. The introduction of modified protocols increased the rate of definitive diagnosis in this institution. This was particularly evident when assessing for PUJO and ectopic ureter insertion where the new protocols enhanced assessment of drainage and structure.  We would encourage other institutions to consider this process in order to assist the diagnosis of aberrant functional anatomy.