Testicular Microlithiasis in Patients With Congenital and Acquired Ascending Testes

Testicular microlithiasis continues to attract interest particularly due to its association with testicular germ cell tumors. The incidence of a testicular germ cell tumor developing in an undescended testis is 3% to 5% vs 0.3% to 0.7% in a normal testis. Testicular microlithiasis also occurs in a higher percentage of boys with an undescended testicle, thus predisposing them to testicular germ cell tumor. Goede et al (page 1539) from Alkmaar, the Netherlands prospectively evaluated the records of boys with congenital (181 boys, 199 testes) and acquired (320 boys, 350 testes)  undescended testes specifically noting the presence of testicular microlithiasis.

Patients with congenital undescended testes were examined only once while those with acquired undescended testes were followed prospectively. Overall testicular microlithiasis was identified in 5 boys with congenital undescended testes and 9 with acquired undescended testes, all of whom were Caucasian.

The presence of microlithiasis was not dependent on patient age, side of the undescended testicle, or whether the testicular descent was congenital or acquired. In 13 boys the testicular microlithiasis was diffusely involved throughout the testicular parenchyma. No testicular tumors were detected in any patient during the study.

The overall rate of 2.8%  for testicular microlithiasis in this study is slightly lower than the 4.2% reported in the asymptomatic population. The authors acknowledge the limitation of performing only a single ultrasound in boys with a congenital undescended testis and, while multiple imaging studies have been obtained in boys with an acquired undescended testis, further assessment in both groups may show an increased incidence of testicular microlithiasis in later life.
The clinical impact of testicular microlithiasis in children remains in question.

Fentanyl Sparing Effects of the Combined Use of Ketoralac and Acetaminophen

Postoperative pain management is a significant factor of any operative procedure and is particularly important in the recovery of children.

While it is appreciated that most pediatric patients respond well to traditional postoperative management, it is beneficial to critique other treatment options to determine their usefulness.  Hong et al (page 1551) from Seoul, Korea prospectively assessed the effectiveness of the combined use of ketoralac and paracetamol for controlling pain, and decreasing secondary effects of sedation and vomiting. The authors randomized 60 children, 1 to 5 years old, who were undergoing elective unilateral inguinal hernia repair into group 1—1 mg/kg ketoralac and 20 mg/kg paracetamol intravenously, and group 2—controls given an equal volume of intravenous saline.  All other factors of the operative procedure were similar and regional anesthesia was not administered.

Postoperative pain was assessed by the Wong and Baker scale (FACES),  and patient satisfaction was reported by the parents using a 4-point Likert questionnaire. Pain in the control group was reported to be significantly higher than that of the treatment group upon arrival to the post-anesthesia care unit.

The initial pain assessment resulted in further treatment and from that time there was no significant difference in postoperative pain between the groups. Vomiting and sedation occurred more frequently in the control group. Overall the single administration of ketoralac and paracetamol reduced the need for postoperative fentanyl rescue, and decreased postoperative pain and vomiting.

The authors conclude that the combination of ketoralac and paracetamol provides effective postoperative pain control. This treatment may effectively control pain when regional blocks are refused by parents or caudal nerve blocks are otherwise contraindicated.

Melamine Related Bilateral Renal Calculi in Children

Wen et al (page 1533) from Zhengzhou, Henan Province, China introduce us to bilateral renal melamine calculi in infants, a condition with significant short-term ramifications and hopefully a self-limited occurrence. Knowledge of melamine stones in Chinese children is important particularly with the number of adoptions that have occurred from this region.

Infant formula that was tainted with melamine to spuriously increase protein content was found to have a significant adverse medical impact. Therefore, medical clinics were established in China to assess all infants and children exposed to the tainted formula.  In a 2-month period more than 3,000 children were screened with renal sonography and 165 were identified to have melamine stones, seen most often in boys. Bilateral renal calculi were noted in 50 cases and there were 11 cases of renal failure due to obstruction, 8 of which required hemodialysis and 1 required ureteral stenting.

Medical management in all children included intravenous hydration, alkalization and antispasmodic pharmacal therapy to facilitate calculi passage. Urinary pH was monitored closely and maintained between 6.0 and 6.5. Upon discharge home sodium bicarbonate and antispasmodic medications were continued at least until the first followup.

Analysis of stones from 6 cases revealed uric acid and melamine in a 2:1 ratio. Average hospital stay was 8 days with resolution of clinical symptoms in all patients and no new stones were noted at followup. The authors report an excellent outcome to a unique problem related to an experience that hopefully will not occur again.

Use of Rectus Abdominis Muscle Flap

Bladder neck closure is the procedure of last resort to achieve continence in children with a neurogenic bladder after other reconstructive measures have failed. While definitive, it has the potential for persistent leakage due to fistula formation. To achieve continence, positioning well vascularized tissue between the bladder neck and urethra is desirable. In most situations interposing a peritoneal flap would be ideal. However, many of these children have undergone several reconstructive procedures and a suitable amount of peritoneum is not available.
Therefore,  alternative tissue must be considered.

Smith et al (page 1556) from Atlanta, Georgia outline the use of the rectus abdominis muscle in 6 children when the peritoneum was not available.

They go into great detail regarding the technique used for harvesting the muscle and subsequent closure of the rectus fascia. Highlights of the technique include exposing the rectus abdominis muscle from the medial to lateral border and elevating the anterior rectus sheath from the body of the muscle. The inferior epigastric vessel enters posteriorly between the symphysis and arcuate line.

The rectus abdominis is transected below the umbilicus and because of the investment of the inferior epigastric vessel the muscle needs to be taken in bulk. The muscle can easily be rotated into the deep pelvis without tension. At the completion of the procedure the anterior rectus fascia is reapproximated. The authors did not encounter a postoperative ventral abdominal hernia.  Hopefully,  this procedure will be used infrequently but it is well worth reviewing and adding to your surgical armamentarium, especially when confronted with your next bladder neck closure.

Management of Dysfunctional Voiding in Children

The International Children’s Continence Society (ICCS)  presents another article in their series to further define our understanding of abnormal voiding, and assist with standardizing management and treatment of children with dysfunctional voiding.

Chase et al (page 1296) lead a panel of experts from multiple institutions representing the ICCS.  It is acknowledged that evaluation and treatment of dysfunctional voiding are currently supported by expert opinion rather than evidence-based medicine which is limited. The authors stress the importance of using appropriate terminology and accurately defining the problem.

The term dysfunctional voiding should be used to describe an abnormality that occurs during voiding and contraction of the urethral sphincter. While dysfunctional voiding may be associated with other bladder storage problems, the term itself represents a problem during the voiding phase. The authors note that the etiology of dysfunctional voiding is multifactorial, and includes learned behavior, perpetuation of infantile voiding patterns and maturational delay. Dysfunctional voiding often leads to incomplete bladder emptying and subsequent urinary infections. The relationship between bladder and bowel dysfunction is detailed. When therapy is directed to improving bowel dysfunction, concomitant improvement in bladder emptying can also occur. 

A conservative assessment of dysfunctional voiding using uroflowmetry with or without electromyography assessment of perineal muscles is recommended. Treatment begins with education, hydration, timed voiding and bowel management, and may include biofeedback and neuromodulation depending on resources available at local centers.

The authors report that a conservative approach can result with improvement in 20% of children. The remaining children will require escalation to other forms of management including pharmacological treatment. Previous guidelines from the ICCS have been directed to the primary care practitioner, while this article will be most useful to physicians who have a strong interest in pediatric dysfunctional voiding.  It is important for those practitioners to become familiar with these ICCS recommendations.

David B. Joseph
Assistant Editor

0022-5347/10/1834-1272/0
Vol. 183, 1272-1273, April 2010
THE JOURNAL OF UROLOGY®
by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
DOI:10.1016/j.juro.2010.01.052
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