Minimally invasive techniques often appropriate in pediatric urology cases

August 15, 2007

Presentations in pediatric urology at the 2007 AUA annual meeting signaled changes in practice, increasing momentum in current trends, and some surprising findings on hot-button topics.

The findings included evidence that minimally invasive surgery is appropriate for children, that conservative treatment for trauma is best, that indications for dextranomer/hyaluronic acid injectable gel (Deflux) are expanding, that reduction clitoroplasty does not damage adult sexuality, and that environmental endocrine disruptors may play a role in hypospadias. For Howard M. Snyder, III, MD, professor of urology in surgery at the University of Pennsylvania School of Medicine, Philadelphia, these were among the most clinically relevant take-home messages from this year's meeting.

Adult urologists, who are often called on to treat urologic trauma in pediatric patients, should know that growing evidence supports more conservative treatment.

In grade IV blunt renal trauma, computed tomograms point the way. In one study, the size and location of leaks did not predict whether intervention was needed. Rather, early stenting was needed when CTs showed multiple sites of extravasation or lack of contrast in the ipsilateral ureter.

With conservative therapy for shattered kidney, "it's amazing how well children do," Dr. Snyder said. Infrequently, patients need nephrectomies, mostly those with major vascular injuries. The initial management strategy was bed rest, close observation and monitoring of vital signs, and serial hematocrit studies. Indications for intervention included progressive urinoma or persistent bleeding with hemodynamic instability.

Just as in adults, minimally invasive surgical (and non-surgical) approaches are being used with good results in children.

Adult urologists who have experience in these techniques can usually handle pediatric cases, Dr. Snyder said.

For kidney stones in children, studies from four different institutions showed high success rates and low complication rates with ureteroscopy and laser lithotripsy. Even a minimally invasive percutaneous procedure showed good results for staghorn stones in children. Stone clearance rates were high, similar to those in adults, but the complication rates were lower and operative times and hospital stays were shorter.

The conservative treatment trend also has expanded the use of biofeedback for dysfunctional voiding beyond physically and emotionally normal children to those who have developmental, behavioral, or neurologic disorders, albeit with a little ingenuity and patience on the therapist's part.

A laparoscopic approach is as safe as, if not safer than, open partial nephrectomy for duplication anomalies. Laparoscopic heminephroureterectomy for duplication anomalies has minimal morbidity with good cosmetic results, even in infants.

One drawback of laparoscopic heminephroureterectomy is that this surgery should be done only by surgeons at specialized centers who have experience in the techniques.

Indications for the use of dextranomer/hyaluronic acid injections to correct vesicoureteral reflux are expanding.

Increasingly, pediatric urologists are using dextranomer/hyaluronic acid to treat vesicoureteral reflux. Now the technique has shown success even in patients with refluxing renal transplant ureteroneocystostomies and in those who have bladder and ureteral anomalies, such as neurogenic bladder, dysfunctional voiding, previous ureteroneocystostomy, duplicated ureters, or periureteral diverticula, according to Dr. Snyder.

Infant boys with hypospadias have reduced anogenital and anoscrotal distances, suggesting that environmental endocrine disrupters play a role in this anomaly.

Adult urologists have long been concerned about the possible effects of environmental endocrine disrupters on male fertility and, recently, about the potential relationship with prostate cancer, but the relationships have been speculative. Now a study of an anomaly of genital development in boys shows that, compared with normal infant boys or those with cryptorchidism, infant boys with hypospadias have reduced anogenital and anoscrotal distances. Re-duced anogenital distance has been associated with endocrine disrupters in animals.

"This is important because this is one of the first extensions to humans of the concept that endocrine-disrupting manmade chemicals in the environment may be affecting genital development," said Dr. Snyder.

Patients with congenital adrenal hyperplasia who undergo reduction clitoroplasty tend to have good sexual and family relationships as adults.

One of the most controversial topics in pediatric urology is surgical management of infants and children with ambiguous genitalia. In the most common condition, masculinized genitals in XX infants with congenital adrenal hyperplasia, reduction clitoroplasty has long been practiced-and criticized.

But now, pediatric urologists are accruing data on children at sexual maturity who have had the surgery within the last 20 years using more modern approaches. Researchers are finding that the girls have good genital sensitivity and sexual function, and good sexual and familial relationships as adults. In addition, one study showed that postponing surgery would be difficult because most parents see early genital surgery as a necessary step toward a normal life.