Pediatric Urology
CONGENITAL DEFECTS
1-5% have antenatal hydro (5). 1 in 500-1000 have UPJO. Indications for pyeloplasty include worsening differential renal function, worsening hydronephrosis especially with development of thinning parenchyma, urinary tract infections, pain, or nephrolithiasis.
Megaureter in about 1/2500 live birthday, defined as > 7 mm. If the split function is equal, there is a high likelihood that the megaureter will improve or resolve with time. Risk of iatrogenic upper pole reflux after incision of ectopic ureterocele is >50%. VUR is seen in around 30% of infants and young children with a febrile UTI. (1)
Megaureter in about 1/2500 live birthday, defined as > 7 mm. If the split function is equal, there is a high likelihood that the megaureter will improve or resolve with time. Risk of iatrogenic upper pole reflux after incision of ectopic ureterocele is >50%. VUR is seen in around 30% of infants and young children with a febrile UTI. (1)
HYPOSPADIAS
20% of patients having an affected relative. The vast majority of boys with hypospadias have no other health problem. Undescended testes are associated with hypospadias.(4) The incidence increases with severity of hypospadias. (2,3) Disorder of sexual development (DSD) should be considered when one testis is non-palpable and the other is inguinal or both testes are non-palpable, in which case a karyotype should be considered. Recommended surgery between 6-12 months b/c reduced anesthetic risk. Repairing @1yr vs 5 is better. Each additional year of patient age at distal repair was associated with a 15% increased risk of requiring secondary cystoscopy and a 21% increased risk of requiring urethral dilation/incision. Preop bHCG may decrease complications but is controversial.(4)
HYDRONEPHROSIS
Antenatal hydronephrosis is a common finding. 1-5% have antenatal hydro (5). SFU Grading of hydronephrosis helps determine treatment. This can be due to reflux, megaureter or UPJO. 1 in 500-1000 have UPJO. Indications for pyeloplasty include worsening differential renal function, worsening hydronephrosis especially with development of thinning parenchyma, urinary tract infections, pain, or nephrolithiasis. (1) A study of 401 patients showed the 3yr resolution rate of hydronephrosis SFU grade I was 98%, grade II 87%, grade III 76% , grade IV 57%. By 5 years, resolution rate was 98% for grade II, 91% for grade III and 91% for grade IV. (6) A 1994 study of 104 patients with unilateral hydronephrosis suggestive of UPJO, 7% ultimately required surgery due to decreased function on DTPA renography or worsening hydronephrosis. That means 93% did not need intervention. (7)
UNDESCENDED TESTIS
Undescended testicles should be fixed to decrease risk of malignancy and infertility. The risk of cancer is estimated to be increased 2-8 times and 5-10% of all men with testicular cancer have h/o cryptoorchadism. (11,12) Earlier fixation is better generally starting at 6mo of age (<6mo of age has increased anesthesia risks). A large study there is a 6% increase risk in testicular cancer for every 6mo delay in orchidopexy. This Western Australian retrospective study of all patients born from 1970-1999 covered more than 350,000 boys and showed 0.7% rate of hypospadias and 2.1% undescended testicles. Undescended testes has hazard ratio of 2.43 and for every 6mo delay in orchidopexy there is a 6% increase in risk of testicular cancer and 1% reduction in paternity. (9) Another Swedish study from 1964-1999 of 16,983 men treated for undescended testis showing a 2.23 RR of testicular cancer if treated at <13yrs and RR of 5.4 if treated at >13 ages at a mean follow up of 12.4yrs. This data supports that the older orchidopexy occurs, the higher the risk of malignancy. The authors calculated that 69 boys would need to be treated before age 13 to avoid one case of testicular cancer before age 55. (10)
UPJO
1-5% have antenatal hydro (5). 1 in 500-1000 have UPJO. Indications for pyeloplasty include worsening differential renal function, worsening hydronephrosis especially with development of thinning parenchyma, urinary tract infections, pain, or nephrolithiasis. (1) A 1994 study of 104 patients with unilateral hydronephrosis suggestive of UPJO, 7% ultimately required surgery due to decreased function on DTPA renography or worsening hydronephrosis. (13)
- AUA Core Curriculum, Urinary Tract Anomalies. Accessed 9/04/2018
- Kaefer M, Diamond D, Hendren WH, et al. The incidence of intersexuality in children with cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. The Journal of urology 1999;162:1003-6; discussion 6-7.
- Rajfer J, Walsh PC. The incidence of intersexuality in patients with hypospadias and cryptorchidism. The Journal of urology 1976;116:769-70.
- AUA Core Curriculum, Hypospadias. Accessed 9/05/2018
- Woodward, M., and D. Frank. "Postnatal management of antenatal hydronephrosis." BJU international 89.2 (2002): 149-156.
- Woodward, M., and D. Frank. "Postnatal management of antenatal hydronephrosis." BJU international 89.2 (2002): 149-156.
- Braga, Luis H., et al. "Society for Fetal Urology classification vs Urinary Tract Dilation grading system for prognostication in prenatal hydronephrosis: a time to resolution analysis." The Journal of urology 199.6 (2018): 1615-1621.
- Koff, Stephen A., and Kevin D. Campbell. "The nonoperative management of unilateral neonatal hydronephrosis: natural history of poorly functioning kidneys." The Journal of urology 152.2 (1994): 593-595.
- Schneuer, Francisco J., et al. "Association between male genital anomalies and adult male reproductive disorders: a population-based data linkage study spanning more than 40 years." The Lancet Child & Adolescent Health (2018).
- Pettersson, Andreas, et al. "Age at surgery for undescended testis and risk of testicular cancer." New England Journal of Medicine 356.18 (2007): 1835-1841.
- Toppari, Jorma, and Marko Kaleva. "Maldescendus testis." Hormone Research in Paediatrics 51.6 (1999): 261-269.
- Dieckmann, K-P., and U. Pichlmeier. "Clinical epidemiology of testicular germ cell tumors." World journal of urology 22.1 (2004): 2-14.
- Koff, Stephen A., and Kevin D. Campbell. "The nonoperative management of unilateral neonatal hydronephrosis: natural history of poorly functioning kidneys." The Journal of urology 152.2 (1994): 593-595.