This Month in Pediatric Urology

Abstract

You have accessJournal of UrologyThis Month in Pediatric Urology1 Sep 2022This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002822AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Awake Intravesical Botulinum Toxin in Pediatric Neurogenic Bladder Many pharmacological agents are derived from natural products. What started out as reports of poison-tipped arrows and blowgun darts led to interest about the paralytic properties of curare. The medical benefits of paralysis led to research into the mechanism of action and commercially available sources with reliable dosages and effects.1 One of the earliest motivations was to try to limit the effects on severe muscle contractions during electroconvulsive therapy. These efforts led to its role in general anesthesia as the paralytic agent tubocurarine.2 While other agents such as pancuronium have become more commonly used,3 the precedent was set. Botulinum toxin (Botox®) is the neurotoxin produced by Clostridium botulinum bacteria. It affects the acetylcholine receptors at the neuromuscular junction, leading to flaccid paralysis. It is a potent lethal naturally occurring toxin and has led to medical interest in much the same fashion as curare was developed into a therapeutic.4 Commercial botulinum toxin has been shown to help with muscle spasticity and to improve storage pressures in neurogenic bladder patients when injected intravesically. These treatments are usually carried out under general anesthesia. Overland et al (page 702) from San Francisco, California discuss the use of botulinum neurotoxin in an awake setting.5 They note that physiatrists have been injecting intramuscular botulinum toxin without general anesthesia or sedation in their cerebral palsy and spasticity patients. They present a small series of patients (sensate and nonsensate) who received bladder botulinum toxin injection without general anesthesia but with support standing by if needed. They had good results, with only 2 patients requiring conversion to general anesthesia or sedation, and mitigating factors such general anxiety and communication issues were present. Because botulinum toxin effects are limited and repeat injections are often necessary, performing the procedure without repeated general anesthesia not only is economical and conserves operating room time, but also helps limit anesthesia exposure. Do New Complications Develop during Puberty after Hypospadias Repair? We are currently in a period of reassessment of hypospadias methods and the reporting of complications and reoperations.6 An experienced pediatric urologist once noted that “everyone’s repair looks good at the time of surgery; tell me what it looks like at 1 year.”7 This concern about late-presenting issues has led many to advocate long-term followup through puberty. While logical, given the many anecdotal reports of late-presenting fistulas, or perhaps more accurately, late-reported fistulas, more is needed to be known about late effects, particularly in those patients who had more complex procedures. Do the growth of the penis during puberty, erections and onset of sexual activity risk greater complications later in life, when many of these patients may be transitioning out of pediatric urology care? Snodgrass and Bush (page 696) from Dallas, Texas report on their experience with patients who presented with late complications.8 All were peripubertal or postpubertal. They found in their retrospective review that 86% recalled complications occurring before puberty. They noted a bimodal presentation, with most being reported before puberty and a few developing later into adulthood, usually related to obstruction and stenosis. Selection and recall bias clearly can affect these findings, because one can only report on patients who are unhappy enough to present, and recall of exact onset can be difficult in some to pin down. Adolescents and young men who might not have relished recurrent operations on their penis as a child may not have the most reliable recall of exact onset of complications. This bimodal presentation supports the finding of Barbagli et al.9 An initial group will have issues attributed to evaluation, surgical technique and approach, and postoperative care. The later group are those older men who have had good early results but who develop late strictures and stenosis; this is believed due to neourethras created out of skin and lack of a natural corporal spongiosum support. Followup through puberty seems warranted, and patients who present later in life with a prior history of hypospadias repair deserve further investigation despite making it through adolescence doing well.