This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Mar 2021This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001583AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The evaluation of a patient’s health can be direct or indirect. We directly measure parameters such as weight, height and temperature. We directly measure voided urine and post-void residual. We directly measure grip strength, visual fields and acuity. Many of our other important tests are indirect. We measure something that is strongly linked or correlated with our area of interest because of practical limitations and concerns. We measure serum creatinine, for example, as a marker of renal function rather than a more precise measurement such as inulin clearance. It is relatively simple to perform, accurate enough for most clinical applications, and inexpensive enough to accept the limitations due to muscle mass and catabolism. Total Motile Sperm Count in Adolescent Boys with Varicocele is Associated with Hormone Levels and Total Testicular Volume Unlike adults, adolescents with varicoceles are not usually actively interested in paternity, but have a concern over future fertility. This has led urologists to use testicular volume as an indirect measure. While this approach is useful, it can be affected by normal variations in relative testicular volume growth during puberty. Van Batavia et al (page 888) from Philadelphia, Pennsylvania note that a semen analysis would be ideal but, due to personal, familial and religious reasons, is often unavailable.1 They reviewed their Tanner 5 patients with palpable left varicoceles who had a semen analysis along with basic hormone levels (luteinizing hormone, follicle-stimulating hormone, inhibin B, anti-müllerian hormone) and total testicular volume. They found that the total motile sperm count was inversely associated with follicle-stimulating hormone levels, and directly correlated with inhibin B levels and total testicular volumes. These measurements along with proposed cutoff values may serve as surrogate markers for total motile sperm count. This approach, combining testicular volumes and hormone assays, may help in situations where a semen analysis is not a practical option. It also suggests a greater role for hormone evaluations when observing adolescents with varicoceles. Randomized Controlled Trial of Scrotal versus Inguinal Orchiopexy It has long been understood that undescended testicles need to be brought down into the scrotum to mitigate the risks of infertility and testicular cancer. Historically, surgeons were skillful enough to bring a cryptorchid testis down, although the dangers of wound infection and subsequent systemic fatal peritonitis and erysipelas limited interest in the operation until the development antiseptic technique.2 Coupled with advances in pediatric anesthesia, the ability to safely perform the operation led to interest as to whether the approach could be optimized to reduce postoperative pain and discomfort. In addition to the older inguinal approach, a newer scrotal approach has found many adherents who have noted equivalent success and postoperative complication rates. Attempts to compare the procedures were hampered by varying definitions of success, surgical indications, age of patients and locations of the testicles, making any meta-analysis impractical. McGrath et al (page 895) from Canada present an effort to assess the differences between these methods.3 Using a superiority randomized controlled trial design, 173 boys (age 10–95 months) with palpable undescended testicles were enrolled, with 161 completing the study. The authors found 24% of the scrotal approach testicles had to be converted to an inguinal approach to allow for adequate exposure to perform a high ligation of a patent processus vaginalis. They conclude that a scrotal approach may not be well suited for a cryptorchid testis near the internal inguinal ring or in an older patient (over age 5 years) due to age related variations in the inguinal canal. No differences were seen between the 2 groups in terms of postoperative pain and analgesic use. These results suggest that for low lying cryptorchid testes in younger children, a scrotal approach is no worse than the traditional inguinal method. Pedicled Anterolateral Thigh and Radial Forearm Free Flap Phalloplasty for Penile Reconstruction in Patients With Bladder Exstrophy Bladder exstrophy epispadias complex and cloacal exstrophy patients are among the most challenging for pediatric urologists. If the fundamental issue were simply one of reassembling pieces that were scattered like some great biological jigsaw puzzle, the task would still be difficult but would be something that could be systematically analyzed in a series of iterative steps.4 Unfortunately, these patients can have underdeveloped or missing pieces. For adolescent and adult patients, a congenital short phallus is often a significant concern. Attempts to use groin and genital tissue have not proven to be an effective solution. Harris et al (page 880) from Baltimore, Maryland share their experience performing phalloplasty using either a pedicled anterolateral thigh flap or a radial forearm free flap.5 They report good results using these techniques, which can be effective with an experienced team. These very complicated procedures whose end goal is adequate replication of normal phallus function (sufficient for intercourse) will require longer followup. Many procedures may appear sufficient in the short term but over several years prove to have issues, as pediatric urologists have learned from their experience with proximal hypospadias. Due to the sensitive and personal nature of the surgery, patient involvement in operative decision making, detailed counselling and patient reported outcomes should be part of this whole process. References 1. : Total motile sperm count in adolescent boys with varicocele is associated with hormone levels and total testicular volume. J Urol 2021; 205: 888. Link, Google Scholar 2. : Thomas Annandale and the first report of successful orchiopexy. J Urol 2005; 174: 37. Link, Google Scholar 3. : Randomized controlled trial of scrotal versus inguinal orchiopexy on postoperative pain. J Urol 2021; 205: 895. Link, Google Scholar 4. : Solving jigsaw puzzles by computer. Ann Oper Res 1988; 12: 51. Google Scholar 5. : Pedicled anterolateral thigh and radial forearm free flap phalloplasty for penile reconstruction in patients with bladder exstrophy. J Urol 2021; 205: 880. Link, Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 205Issue 3March 2021Page: 649-650 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Julian Wan More articles by this author Expand All Advertisement Advertisement Loading ...

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