Table Of ContentWarren T. Snodgrass
Editor
Pediatric Urology
Evidence for Optimal
Patient Management
123
Pediatric Urology
Warren T. Snodgrass
Editor
Pediatric Urology
Evidence for Optimal Patient
Management
Editor
Warren T. Snodgrass
Department of Pediatric Urology
University of Texas Southwestern Medical Center
and Children’s Medical Center Dallas
Dallas , TX , USA
ISBN 978-1-4614-6909-4 ISBN 978-1-4614-6910-0 (eBook)
DOI 10.1007/978-1-4614-6910-0
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013934223
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Preface
The primary aim of this book is to assemble data needed by clinicians in their
daily decision making.
The format differs from usual textbooks in that it assumes a basic knowl-
edge of pediatric urology and so is focused on pivotal clinical questions. Each
chapter begins with a statement of the primary and secondary aims for the
diagnosis and treatment of the condition, followed by a synopsis of the evi-
dence we found for those aims. Information from the primary sources is sum-
marized so that readers know how studies were done and reported.
To write the book an outline for each chapter was made including ques-
tions frequently encountered in diagnosis and management, and then broad-
based computer searches were done to identify articles potentially answering
them. We followed the general methodology of a guidelines panel to review
materials and results for pertinent information to extract.
We gave greater emphasis to meta-analyses, such as Cochrane Reviews,
RCTs, and prospective studies, as well as to well-done retrospective analyses
with clearly de fi ned objectives and well-described results. In the abse nce of
these, useful information still could be obtained from primary sources that
otherwise would not rate high in current evidence-based standards.
Why do this?
Numerous studies report wide variations in practice among pediatric urol-
ogists, despite the obvious truth that recommendations a patient receives
should not be an accident of geography. One step towards greater consistency
is summarizing the expected fi ndings and outcomes from diagnostic and
management options. Rather than base decisions on surgeon opinion and
preference, this book facilitates rapid review of published data to guide
treatment.
Study of the available evidence for most topics in this book also highlights
need for multicenter cooperation to enroll suf fi cient patients in trials to answer
important clinical questions. Most urologic conditions in children simply do
not affect suf fi cient numbers of patients for single centers to perform high-
quality studies. For example, no RCT proves bene fi t of antibiotic prophylaxis
in children with either prenatally detected hydronephrosis or VUR, and sev-
eral centers would need to pool their patients to power such a trial.
v
vi Preface
Management of various conditions by pediatric urologists has been chal-
lenged by outside specialties for focusing too much on surgical outcomes
rather than bene fi ts to the child. We are experts in correcting re fl ux, or pre-
dicting when it will spontaneously resolve, but pediatricians are asking which
children need this expertise. A common theme throughout this book is that
there is less evidence on health bene fi ts from therapy than on surgical success
rates. To that end, the book may also stimulate new avenues of research.
Writing this book has changed our own practice in many ways. When
questions arise, for example, in preoperative conferences, we no longer ask
each surgeon what he or she would do, but instead review available published
information to narrow the options. Although we each trained in different cen-
ters and bring different perspectives to discussions, this process has reduced
variations in our individual practice, with the additional bene fi ts of simplify-
ing on-call coverage, instructions to nurses, and fellow training. Studying the
sometimes weak evidence on which clinical decision making is based has
stimulated us to design better prospective trials, some in collaboration with
other centers.
Here are three speci fi c examples of changes made in our practices prompted
by this book. We operate much less often on an “undescended” testis in boys
older than 1 year, especially when records from the hospital and initial pri-
mary care provider indicate it was descended at birth, given the evidence
cited in Chap. 5 that even specialists are sometimes fooled by retractile testes
and most of those testes not in the scrotum after a normal newborn exam
return to the scrotum during puberty. We no longer consider baseline renal
function or diuretic washout times indications for pyeloplasty, since repair
most often does not improve differential function and “obstructive” drainage
curves do not predict future function loss. We now use results of semen analy-
sis at age 17 to recommend varicocelectomy, since testicular size discrepancy
does not appear to correlate with fertility potential.
Our work inevitably has similar shortcomings as textbooks. It is not pos-
sible to include every published study in a review, and while we tried to cast
a broad net to identify articles and then extract the best data from them, we
still could have overlooked a pertinent report. To minimize intrusion of our
own opinions we emphasized summaries from the original sources, but it is
dif fi cult to be completely objective.
Nevertheless, we believe this book will be useful to pediatric urologists in
training and at all stages of practice, and hope it helps to improve care for the
children entrusted to us all.
The book is designed for use as a manual, and so studies are sometimes
mentioned in several sections within a chapter. It was written over a 1.5-year
period beginning in March 2011, with fi nal editing completed in October
2012. An outline with speci fi c clinical questions was used as a guide by
authors, who then performed computer searches to identify articles contain-
ing information to answer those questions. After drafts were completed and
edited, we met as a committee, repeating selected computer searches and
reviewing and critiquing each chapter to fi nalize the manuscript.
Preface vii
Two authors have advanced degrees of relevance, one a Master’s in Public
Health and Epidemiology and the other a Master’s in Clinical Studies.
Nevertheless, the Editor bears fi nal responsibility for the reporting in this book.
Dallas, TX, USA Warren T. Snodgrass
Linda A. Baker
Nicol C. Bush
Patricio C. Gargollo
Micah A. Jacobs
Contents
1 Urinary Tract Infection ............................................................... 1
2 Vesicoureteral Reflux ................................................................... 19
3 Bladder and Bowel Dysfunction ................................................. 35
4 Nocturnal Enuresis ...................................................................... 53
5 Undescended Testes ...................................................................... 67
6 Hernias and Hydroceles ............................................................... 81
7 Testicular Torsion ......................................................................... 89
8 Varicocele ...................................................................................... 103
9 Hypospadias.................................................................................. 117
10 Phimosis, Meatal Stenosis, and BXO ......................................... 153
11 Ureteropelvic Junction Obstruction ........................................... 165
12 Multicystic Dysplastic Kidney .................................................... 183
13 Ureteroceles and Ectopic Ureters ............................................... 191
14 Non-refluxing Megaureter ........................................................... 199
15 Posterior Urethral Valves and Ureterovesical
Junction Obstruction ................................................................... 205
16 Neurogenic Bladder ..................................................................... 223
17 Urolithiasis .................................................................................... 259
Index ...................................................................................................... 275
ix
