Pediatric Urology: Evidence for Optimal Patient Management PDF
Preview Pediatric Urology: Evidence for Optimal Patient Management
Warren 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 © Springer Science+Business Media New York 2013 This work is subject to copyright. 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Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) 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
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