Pediatric Annals

EDITORIAL 

Urologic Problems - Prenatal and Postnatal

Milton I Levine, MD

Abstract

Abnormalities in the urologie system of infants and children are not uncommon findings in the practice of pediatrics. All of us, 1 am sure, have seen among our patients cases of cryptorchidism, and most of us have had cases of hypospadias, many with severe chordee. Other serious problems relate to such conditions as oligohydramnios and hydronephrosis.

To organize the discussion related to Pediatric Urology and introduce the papers, we have turned to Dr. Chester M. Edelmann, Jr. as Guest Editor. Dr. Edelmann, a national authority on the subject, is Professor of Pediatrics, and Associate Dean of the Albert Einstein College of Medicine, Bronx, New York.

In this interesting group of articles, new techniques in diagnosis and treatment are described for fetal problems as well as problems during the postnatal period. Although the use of ultrasonography in medicine was first reported in the 1950s, its full use was not developed until the 1970s. Then, with the knowledge that its use was entirely safe, came amazing and exciting advances in pediatrics. Of primary importance was our new ability to visualize the infant prenatally and observe the fetus for long periods without fear of damaging the sensitive fetal tissue. Prior to that time conditions such as hydronephrosis were almost always discovered postnatally when often much damage had already occurred. The back pressure on the kidneys prenatally destroyed much of the tissue and damaged function severely.

Now with ultrasonography one is not only able to visualize the defect in the fetal body but at times even use corrective surgery. I was very much impressed a year ago by a report of a fetus diagnosed as having congenital hydronephrosis. Under ultrasound visualization, a balloon-tipped catheter was placed into the distended fetal bladder, releasing urine into the amniotic sac.

This new development and its use in detecting genitourinary anomalies is beautifully described in the first article of this issue of Pediatric: Annals. It has been written by Dr. Jack S. Elder, Associate Professor of Surgery (Urology) at the Rainbow Babies and Children's Hospital, Case Western University, Cleveland, and Dr. John W. Duckett, Director, Pediatric Urology, Children's Hospital of Philadelphia.

The authors begin by noting the number of differing lesions that may be detected by modern ultrasonography. They state, however, that recognition of a structural anomaly by prenatal ultrasound depends on the skill and experience of the sonographer. The article contains a great deal of important and valuable information of special concern in diagnosing genitourinary pathology. When does urine first form and at what age is nearly all the amniotic fluid composed of voided urine? This is of almost vital importance since oligohydramnios usually signifies an obstruction to the normal fetal flow of urine, and a prolonged oligohydramnios may result in fetal pulmonary hypoplasia.

Doctors Elder and Duckett emphasize that the amount of amniotic fluid should remain normal, and if there is an insufficiency it must be quickly and carefully studied and the etiology determined. Fetal surgery is discussed with the warning that it should be considered only in rare cases. The article concludes with a discussion of the management of the newborn with suspected obstructive uropathy.

The second paper on "Current Views on Posterior Urethral Valves" is an important supplement to the previous article. It has been written by Dr. William C. Hulbert, Head, Section of Pediatric Urology, Arkansas Children's Hospital, Little Rock, and Dr. John W. Duckett, Children's Hospital of Philadelphia.

It is emphasized at the outset that the posterior urethral valves are the most common cause of bladder outlet obstruction in children. Whereas previously this diagnosis was almost always made postnatally, today the diagnosis…

Abnormalities in the urologie system of infants and children are not uncommon findings in the practice of pediatrics. All of us, 1 am sure, have seen among our patients cases of cryptorchidism, and most of us have had cases of hypospadias, many with severe chordee. Other serious problems relate to such conditions as oligohydramnios and hydronephrosis.

To organize the discussion related to Pediatric Urology and introduce the papers, we have turned to Dr. Chester M. Edelmann, Jr. as Guest Editor. Dr. Edelmann, a national authority on the subject, is Professor of Pediatrics, and Associate Dean of the Albert Einstein College of Medicine, Bronx, New York.

In this interesting group of articles, new techniques in diagnosis and treatment are described for fetal problems as well as problems during the postnatal period. Although the use of ultrasonography in medicine was first reported in the 1950s, its full use was not developed until the 1970s. Then, with the knowledge that its use was entirely safe, came amazing and exciting advances in pediatrics. Of primary importance was our new ability to visualize the infant prenatally and observe the fetus for long periods without fear of damaging the sensitive fetal tissue. Prior to that time conditions such as hydronephrosis were almost always discovered postnatally when often much damage had already occurred. The back pressure on the kidneys prenatally destroyed much of the tissue and damaged function severely.

Now with ultrasonography one is not only able to visualize the defect in the fetal body but at times even use corrective surgery. I was very much impressed a year ago by a report of a fetus diagnosed as having congenital hydronephrosis. Under ultrasound visualization, a balloon-tipped catheter was placed into the distended fetal bladder, releasing urine into the amniotic sac.

This new development and its use in detecting genitourinary anomalies is beautifully described in the first article of this issue of Pediatric: Annals. It has been written by Dr. Jack S. Elder, Associate Professor of Surgery (Urology) at the Rainbow Babies and Children's Hospital, Case Western University, Cleveland, and Dr. John W. Duckett, Director, Pediatric Urology, Children's Hospital of Philadelphia.

The authors begin by noting the number of differing lesions that may be detected by modern ultrasonography. They state, however, that recognition of a structural anomaly by prenatal ultrasound depends on the skill and experience of the sonographer. The article contains a great deal of important and valuable information of special concern in diagnosing genitourinary pathology. When does urine first form and at what age is nearly all the amniotic fluid composed of voided urine? This is of almost vital importance since oligohydramnios usually signifies an obstruction to the normal fetal flow of urine, and a prolonged oligohydramnios may result in fetal pulmonary hypoplasia.

Doctors Elder and Duckett emphasize that the amount of amniotic fluid should remain normal, and if there is an insufficiency it must be quickly and carefully studied and the etiology determined. Fetal surgery is discussed with the warning that it should be considered only in rare cases. The article concludes with a discussion of the management of the newborn with suspected obstructive uropathy.

The second paper on "Current Views on Posterior Urethral Valves" is an important supplement to the previous article. It has been written by Dr. William C. Hulbert, Head, Section of Pediatric Urology, Arkansas Children's Hospital, Little Rock, and Dr. John W. Duckett, Children's Hospital of Philadelphia.

It is emphasized at the outset that the posterior urethral valves are the most common cause of bladder outlet obstruction in children. Whereas previously this diagnosis was almost always made postnatally, today the diagnosis can frequently be made prenatally by ultrasonography. However, although fetal surgery may temporarily relieve the obstruction, the most important treatment is reserved for the newborn.

First, the authors state, before any surgical therapy is undertaken, any infection should be treated and the electrolytes normalized. Usually the valves are treated transurethrally. The final result, of course, depends on what amount of damage to the kidneys has already occurred. Next, the problem of vesicoureteral reflux is considered, since this abnormality occurs in 50% of children suffering from posterior urethral valves. How often is antireflux surgery required after valvular treatment? This question as well as several other problems often associated with posterior urethral valves are presented and discussed. An optimistic note reports that with modern methods of therapy the early mortality rate from lack of adequate renal function has dropped significantly in the last 10 to 15 years.

The final two articles in this issue devoted to urology cover subjects which not infrequently confront all practicing pediatricians - undescended testes and hypospadias.

The paper on "The Undescended Testis" comes from the UCLA School of Medicine in Los Angeles, and has been contributed by Dr. Martin A. Koyle, Assistant Professor of Surgery/Urology; Dr. Jacob Rajfer, Associate Professor of Surgery/Urology; and Dr. Richard M. Ehrlich, Professor of Surgery/ Urology.

This article brings the reader up to date on our present knowledge of cryptorchidism - its etiology, pathophysiology, complications, and methods of treatment. The frequency of maldescent among premature and low birth weight infants is noted, with the knowledge that most testes will descend spontaneously by one year of age. The approach to treating cryptorchidism presents the pediatrician with numerous important problems - locating the undescended testes and assuring that they are not simply retractile; instituting hormonal efforts to bring about descent; and deciding on a surgical approach if other efforts to encourage descent have failed.

Every pediatrician realizes the necessity for correction of this defect, not only to avoid future emotional problems, but more importantly to avoid the possibility of malignancy and the potential for infertility. The authors advise when, in their opinion, is the optimal time to surgically place the undescended testes in the scrotal sac. The article concludes with a short discussion of the complications of cryptorchidism. Besides the tendency to form neoplasia and the development of infertility already mentioned, there is also the increased risk of undescended testes to undergo torsion. This excellent article emphasizes the importance of early diagnosis and correction at the optimal time.

The final contribution discusses one of the most common genital anomalies - "Hypospadias." It is written by Dr. Selwyn B. Levitt, Attending Pediatric Urologist at the Albert Einstein College Hospital, Montefiore Hospital and Medical Center, and the Bronx Municipal Hospital, and Clinical Professor of Pediatrics at the Albert Einstein College of Medicine; and Dr. Edward F. Reda, Assistant Professor of Urology at the New York Medical College, Valhalla, and Director of Pediatric Urology at the Lincoln Hospital, Bronx, New York City.

The authors note, at the outset of their article, the interest in genital abnormalities recorded many centuries ago. I have seen a good many of the illustrations from those years and was especially amused and impressed by several interesting examples of hermaphroditism. One was a picture of a child with double sex organs - a penis on one side and a vulva on the other. There is another picture of Siamese twins, from the writings of the famous French surgeon Ambroise Paré. Both of the twins portrayed also show the double sex organs side by side.

The paper by Doctors Levitt and Reda is clear and well organized. First, the different gradations in classifying this defect are presented including the most recent classification where the hypospadias is described relative to the position of the neonatal site after correction of the associated chordee. But what are the etiologic factors known to be associated with the hypospadial abnormality? Most of us have realized the importance of prematurity, but what about such factors as maternal age, blood incompatibility, exposure of pregnant mother to drugs or radiation, paternal tendency, and the administration of progesterone during the first trimester? These are among the possibilities questioned and discussed by the authors.

An important section of the article is given to the number of associated genitourinary abnormalities which may accompany hypospadias. The authors carefully review the literature and, on the basis of this review and their own experience, state that "asymptomatic, abacteremic boys with isolated hypospadias and/or cryptorchidism should be evaluated with renal and bladder ultrasonography." All pediatricians who care for children with this abnormality are always impressed with the difficult problems facing these children both physically and emotionally. The difficulty of urinating in a standing position is minor compared with the necessity of operative procedures and the psychological problems the growing child must endure. These latter important considerations and the timing of surgery are carefully presented, with emphasis on avoiding separation from parents during the period of hospitalization.

The final section of the article deals with treatment of this abnormality. First, the early attempts at correction are described with the notation that the first successful reconstructive repair was accomplished in 1842. Many procedures have been used since. However, today using modern techniques one can expect consistently outstanding functional and cosmetic results."

10.3928/0090-4481-19880101-04

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