Urological Survey Pediatric Urology Re: Diagnostic and Management Approaches to Pediatric and Adolescent Varicocele: A Survey of Pediatric Urologists A. W. Pastuszak, V. Kumar, A. Shah and D. R. Roth Scott Department of Urology and Center for Reproductive Medicine, Baylor College of Medicine and Division of Urology, Texas Children’s Hospital, Houston, Texas Urology 2014; 84: 450e455.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.032 available at http://jurology.com/ Editorial Comment: Of all the conditions routinely managed by pediatric urologists pediatric and adolescent varicocele may create the greatest degree of confusion. The authors polled 242 members of the Society for Pediatric Urology and received 131 responses (54%). All respondents were pediatric urologists, of whom 70% indicated an academic affiliation, 27% were in private practice and 4% were employed by a health maintenance organization. Most, but not all, operate for decreased ipsilateral testis size, and some operate for varicocele size alone. Some follow patients, while others (3%) operate routinely on all varicoceles at diagnosis. Of the clinicians 89% were unaware of the fertility status of the patients they operated on. For varicocele repair 28% of our colleagues operate microsurgically (with 40% using an operating microscope and the remainder using loupes) and 38% operate laparoscopically. The clear message here is that few of us agree on which cases to manage surgically and how to operate on varicoceles. There is poor long-term followup and poor consensus on who needs surgery. We need to work harder to try to achieve consensus for the large number of boys with this common adolescent diagnosis. Douglas A. Canning, MD
Re: Inguinal Approach for the Management of Unilateral Non-Palpable Testis: Is Diagnostic Laparoscopy Necessary? K. H. Bae, J. S. Park, H. J. Jung and H. S. Shin Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea J Pediatr Urol 2014; 10: 233e236.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.033 available at http://jurology.com/ Editorial Comment: The authors used an inguinal approach in 21 unilateral nonpalpable testes and 3 bilateral nonpalpable testes from a series of 183 cases of undescended testes seen at their center between 2003 and 2012. Of the unilateral testes absence was confirmed in 7 patients, with a scrotal nubbin in 6 and blind ending vas and vessels at the external ring in 1. These testes were removed through the inguinal incision. Of the remaining 14 cases of sizable testes 12 were intra-abdominal peeping testes and 2 were seen in the distal inguinal canal. Each of the intra-abdominal peeping testes was mobilized and successfully brought to the scrotum with cranial mobilization of the spermatic vessel with or without the Prentiss maneuver and with a mild extension of the skin incision.
0022-5347/15/1933-0989/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.12.032 Vol. 193, 989-990, March 2015 Printed in U.S.A.
www.jurology.com
j
989
PEDIATRIC UROLOGY
990
One patient underwent Fowler-Stephens orchiopexy. None of the testes atrophied. Patient age ranged from 11 to 144 months (mean 23). This article confirms what many of us suspect, namely that inguinal incision is as effective as (and may be considerably cheaper than) laparoscopic exploration and orchiopexy for boys with unilateral impalpable testes. Douglas A. Canning, MD
Re: Underuse of 24-Hour Urine Collection among Children with Incident Urinary Stones: A Quality-of-Care Concern? J. S. Ellison, S. R. Kaufman, K. H. Kraft, J. S. Wolf, Jr., B. K. Hollenbeck and J. M. Hollingsworth Divisions of Endourology and Pediatric Urology, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan Urology 2014; 84: 457e461.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.034 available at http://jurology.com/ Editorial Comment: The authors used data from the MarketScan Commercial Claims and Encounters database (2002 to 2006) and observed relative infrequency of 24-hour urine sampling following an index stone episode. Of 1,848 children with an incident of upper tract stone only 12% were referred for 24-hour urine collection. Testing was more common in younger children and those who visited urologists or nephrologists. But in this series only 46% of patients saw a urologist and a shocking 4% saw a nephrologist. We need to work harder to identify these children in our emergency departments and outpatient clinics to ensure an appropriate metabolic evaluation for them. Douglas A. Canning, MD
Re: Obesity and a Febrile Urinary Tract Infection: Dual Burden for Young Children? T. H. Yang, H. E. Yim and K. H. Yoo Department of Pediatrics, Korea University Ansan Hospital, Gyeonggi-do, Korea Urology 2014; 84: 445e449.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.035 available at http://jurology.com/ Editorial Comment: The authors report a correlation between obesity and urinary tract infection and acute pyelonephritis in a series of 465 patients with urinary tract infections and 812 controls. Compared to lean children, obese children showed a longer duration of fever and higher frequency of acute pyelonephritis. This study was a retrospective review of all medical records of children younger than 3 years presenting with a first febrile urinary tract infection. For the control group the authors used the National Health Screening Program for infants and children during the same period. In their comment the authors cite 2 plausible explanations. First, impaired immune response in obese hosts may result in increased predisposition to infection.1e3 Additionally the authors note potential excessive production of proinflammatory cytokines, leptins and tumor necrosis factor, which are known to occur with adipose tissue.4 If subsequent studies substantiate these observations, we will have another reason to support efforts to reduce overweight in children. Douglas A. Canning, MD 1. Arslan E, Atilgan H and Yavas¸oglu I: The prevalence of Helicobacter pylori in obese subjects. Eur J Intern Med 2009; 20: 695. 2. Uberos J, Molina-Carballo A, Fernandez-Puentes V et al: Overweight and obesity as risk factors for the asymptomatic carrier state of Neisseria meningitidis among a paediatric population. Eur J Clin Microbiol Infect Dis 2010; 29: 333. 3. Jain S and Chaves SS: Obesity and influenza. Clin Infect Dis 2011; 53: 422. 4. Fantuzzi G: Adipose tissue, adipokines, and inflammation. J Allergy Clin Immunol 2005; 115: 911.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.032 available at http://jurology.com/ Editorial Comment: Of all the conditions routinely managed by pediatric urologists pediatric and adolescent varicocele may create the greatest degree of confusion. The authors polled 242 members of the Society for Pediatric Urology and received 131 responses (54%). All respondents were pediatric urologists, of whom 70% indicated an academic affiliation, 27% were in private practice and 4% were employed by a health maintenance organization. Most, but not all, operate for decreased ipsilateral testis size, and some operate for varicocele size alone. Some follow patients, while others (3%) operate routinely on all varicoceles at diagnosis. Of the clinicians 89% were unaware of the fertility status of the patients they operated on. For varicocele repair 28% of our colleagues operate microsurgically (with 40% using an operating microscope and the remainder using loupes) and 38% operate laparoscopically. The clear message here is that few of us agree on which cases to manage surgically and how to operate on varicoceles. There is poor long-term followup and poor consensus on who needs surgery. We need to work harder to try to achieve consensus for the large number of boys with this common adolescent diagnosis. Douglas A. Canning, MD
Re: Inguinal Approach for the Management of Unilateral Non-Palpable Testis: Is Diagnostic Laparoscopy Necessary? K. H. Bae, J. S. Park, H. J. Jung and H. S. Shin Department of Urology, Daegu Catholic University Medical Center, Daegu, Republic of Korea J Pediatr Urol 2014; 10: 233e236.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.033 available at http://jurology.com/ Editorial Comment: The authors used an inguinal approach in 21 unilateral nonpalpable testes and 3 bilateral nonpalpable testes from a series of 183 cases of undescended testes seen at their center between 2003 and 2012. Of the unilateral testes absence was confirmed in 7 patients, with a scrotal nubbin in 6 and blind ending vas and vessels at the external ring in 1. These testes were removed through the inguinal incision. Of the remaining 14 cases of sizable testes 12 were intra-abdominal peeping testes and 2 were seen in the distal inguinal canal. Each of the intra-abdominal peeping testes was mobilized and successfully brought to the scrotum with cranial mobilization of the spermatic vessel with or without the Prentiss maneuver and with a mild extension of the skin incision.
0022-5347/15/1933-0989/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.12.032 Vol. 193, 989-990, March 2015 Printed in U.S.A.
www.jurology.com
j
989
PEDIATRIC UROLOGY
990
One patient underwent Fowler-Stephens orchiopexy. None of the testes atrophied. Patient age ranged from 11 to 144 months (mean 23). This article confirms what many of us suspect, namely that inguinal incision is as effective as (and may be considerably cheaper than) laparoscopic exploration and orchiopexy for boys with unilateral impalpable testes. Douglas A. Canning, MD
Re: Underuse of 24-Hour Urine Collection among Children with Incident Urinary Stones: A Quality-of-Care Concern? J. S. Ellison, S. R. Kaufman, K. H. Kraft, J. S. Wolf, Jr., B. K. Hollenbeck and J. M. Hollingsworth Divisions of Endourology and Pediatric Urology, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan Urology 2014; 84: 457e461.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.034 available at http://jurology.com/ Editorial Comment: The authors used data from the MarketScan Commercial Claims and Encounters database (2002 to 2006) and observed relative infrequency of 24-hour urine sampling following an index stone episode. Of 1,848 children with an incident of upper tract stone only 12% were referred for 24-hour urine collection. Testing was more common in younger children and those who visited urologists or nephrologists. But in this series only 46% of patients saw a urologist and a shocking 4% saw a nephrologist. We need to work harder to identify these children in our emergency departments and outpatient clinics to ensure an appropriate metabolic evaluation for them. Douglas A. Canning, MD
Re: Obesity and a Febrile Urinary Tract Infection: Dual Burden for Young Children? T. H. Yang, H. E. Yim and K. H. Yoo Department of Pediatrics, Korea University Ansan Hospital, Gyeonggi-do, Korea Urology 2014; 84: 445e449.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2014.12.035 available at http://jurology.com/ Editorial Comment: The authors report a correlation between obesity and urinary tract infection and acute pyelonephritis in a series of 465 patients with urinary tract infections and 812 controls. Compared to lean children, obese children showed a longer duration of fever and higher frequency of acute pyelonephritis. This study was a retrospective review of all medical records of children younger than 3 years presenting with a first febrile urinary tract infection. For the control group the authors used the National Health Screening Program for infants and children during the same period. In their comment the authors cite 2 plausible explanations. First, impaired immune response in obese hosts may result in increased predisposition to infection.1e3 Additionally the authors note potential excessive production of proinflammatory cytokines, leptins and tumor necrosis factor, which are known to occur with adipose tissue.4 If subsequent studies substantiate these observations, we will have another reason to support efforts to reduce overweight in children. Douglas A. Canning, MD 1. Arslan E, Atilgan H and Yavas¸oglu I: The prevalence of Helicobacter pylori in obese subjects. Eur J Intern Med 2009; 20: 695. 2. Uberos J, Molina-Carballo A, Fernandez-Puentes V et al: Overweight and obesity as risk factors for the asymptomatic carrier state of Neisseria meningitidis among a paediatric population. Eur J Clin Microbiol Infect Dis 2010; 29: 333. 3. Jain S and Chaves SS: Obesity and influenza. Clin Infect Dis 2011; 53: 422. 4. Fantuzzi G: Adipose tissue, adipokines, and inflammation. J Allergy Clin Immunol 2005; 115: 911.
