This Month in Pediatric Urology

Pubertal Screening and

Treatment of Varicocele Does Not
Improve Future Adult Chance of Paternity
The timing and role of surgical intervention for adolescent varicocele continue to be debated, as early
surgical intervention is often recommended to prevent future fertility problems. However, long-term
outcome data on adolescent varicocele are limited.
Bogaert et al (page 2298) from Belgium report on
661 boys between 12 and 17 years old with varicocele, of whom 372 had undergone antegrade sclerotherapy and 289 were followed conservatively.1
They obtained followup data on 361 patients using
written surveys and identified 158 men who had
fathered a child. They identified no difference in
paternity between those treated for the varicocele vs
those who were observed (85% vs 79%, p 0.05). The
authors further analyzed patients with a smaller
left testis preoperatively and found no difference in
paternity rates (82% in the treated group vs 90% in
the conservative group, p 1.0). This study is provocative but is limited by its retrospective nature.
The authors conclude that prepubertal screening
and treatment have no beneficial effect on subsequent paternity. Although there are some patients
who could benefit from early intervention, it is not
yet clear how those patients would be identified with
just physical examination or imaging findings alone.

Outcomes Following Fecal

Continence Procedures in Patients
with Neurogenic Bowel Dysfunction
Many pediatric urologists manage fecal incontinence in patients with combined neurogenic bowel
and bladder. Hoy et al (page 2293) from Canada
performed an antegrade continent enema (MACE)
procedure in 26 patients and a tube cecostomy in 23
for the management of neuropathic bowel and fecal
incontinence.2 They assessed both groups in terms
of continence which was defined as the ability to
wear underwear with no accidents. Patients had to
have a minimum of 1-year followup after surgery.
The continence rates were 84.6% for the MACE and
91.3% for tube cecostomy (p 0.48). Conversion
from cecostomy to MACE was done in 8.7% of patients while 11.5% switched to a cecostomy from an
original MACE. The primary complications for the
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MACE procedure were difficulty with catheterization of the stoma and stomal pain each occurring in
about 20% of patients. The most common complication of tube cecostomy was difficulty flushing, occurring in 1 in 4 patients. The authors did not perform
any quality of life assessment to determine if there
were differences between the groups. Some patients
had persistent fecal incontinence that the authors
suspect was related to compliance with irrigation
protocols. As this was a retrospective study, there
could be some selection bias on the part of the surgeon for choosing the different procedures but the
data suggest that good results, in terms of fecal
continence, can be obtained with both methods.

A Novel Noninvasive Approach to

Document Detrusor Overactivity in Children
with Lower Urinary Tract Symptoms
Detrusor overactivity is a common finding in children and adults with lower urinary tract symptoms,
particularly those with urgency and urge incontinence, and the diagnosis cannot always be made on
clinical presentation or urodynamic evaluation. The
role of uroflow combined with electromyography
(EMG) to diagnose detrusor overactivity is described
by Combs et al (page 2282) from New York, New
York.3 They identified 50 patients with an EMG lag
time (interval between the start of pelvic floor relaxation and the start of urine flow during volitional
voiding) of 0 seconds or less and a quiet pelvic floor
during voiding who subsequently underwent urodynamic studies to assess for detrusor overactivity
(group 1). A second cohort of 50 children, previously
documented to have detrusor overactivity on urodynamic studies, was subsequently studied with uroflow/EMG studies to assess for a short EMG lag time
(group 2). Detrusor overactivity was confirmed on
urodynamic evaluation in all group 1 children. The
median EMG lag time in group 2 was 0 seconds on
uroflow/EMG, and 35 patients had a short EMG lag
time of 0 seconds or less. Overall, EMG lag time was
less than 1 second in 80% of the patients and less
than 2 seconds in 88%. The study is limited by its
retrospective nature but may represent a noninvasive method of confirming a diagnosis of detrusor
overactivity. The authors suggest that the short
EMG lag time has 100% specificity for the diagnosis
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THIS MONTH IN PEDIATRIC UROLOGY

of detrusor overactivity. They do state that a normal

EMG lag time does not exclude detrusor overactivity
but that it just may not have been occurring at the
time the particular flow study was performed.

Long-Term Followup for

Hypospadias is Mandatory to
Detect Real Complication Rates
Many reports on hypospadias repair focus on the
short-term surgical complication rate but it is now
apparent that with time many patients require subsequent surgical procedures for a variety of reasons.
Spinoit et al (page 2276) from Belgium describe a
single center experience with 474 children undergoing hypospadias surgery between 1997 and 2005.4
They created a database to follow the patients and
determine how many needed subsequent surgical
procedures. Of 280 patients with followup greater
than 1 year after their initial operation 2 or more
operations were required in 24%, including 47% undergoing reoperation within the first year of followup. The most common reasons for reoperation
were fistula, meatal stenosis and cosmetic reasons.
The time to reoperation for each of these complica-

tions varied considerably with some patients undergoing surgery more than 9 years after the initial
operation. The authors did not report the time to
diagnosis of these complications and, therefore, we
do not know if surgical procedures were delayed due
to a delay in diagnosis of the complications or if they
were diagnosed earlier and surgical repair was deferred. It would have been of interest to have data on
complication rates for individual procedures. The
type of hypospadias repair performed may have a
significant impact on complication rate.
Michael L. Ritchey
Section Editor
1. Bogaert GA, Orye C and De Win G: Pubertal screening and treatment for
varicocele do not improve chance of paternity as adult. J Urol 2013; 189: 2298.
2. Hoy NY, Metcalfe P and Kiddoo DA: Outcomes following fecal continence
procedures in patients with neurogenic bowel dysfunction. J Urol 2013; 189:
2293.
3. Combs AJ, Van Batavia JP, Horowitz M et al: Short pelvic floor electromyographic lag time: a novel noninvasive approach to document detrusor overactivity in children with lower urinary tract symptoms. J Urol 2013; 189: 2282.
4. Spinoit A-F, Poelaert F, Groen L-A et al: Hypospadias repair at a tertiary care
center: long-term followup is mandatory to determine the real complication
rate. J Urol 2013; 189: 2276.