Is Routine Intravenous Urography Indicated in Patients With Hypospadias?

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630 PEDIATRICS Vol. 59 No. 4 April 1977 that children with short stature due to

hypothy-roidism deviate from this generalization. Despite

a marked reduction in height, such children often

have normimal or even increased head size. This

effect may be magnified by early appearing

thyroid disease of relatively long duration, since

our three youngest patients (Table I) had bone

ages which were 2 years or less-a time period

during which 67% of skull growth is

com-pleted-and yet had head circumferences above

the mean for age.

The differences which we note between

hypo-thyroid children and isolated growth hormone

deficient patients appear to hold true for

individ-uals with multiple pituitary tropic hormone loss.

According to the data of Goodman et al.,’ the

head circumference was less retarded in a group

of patients most of whom had TSH deficiency as

compared to 16 individuals with isolated growth hormone deficiency.

A bony abmiornialitv of the skull which has been

observed in patients with primary

hpoth-roidisni is etilargenient of the sella turcica,

presumiiabl the result of hperplasia of the

pitui-tary thvrotroph. Such sella enlargemiiemit has been

an occasional cause for concern regarding

possible pituitary tumors in such patients,

although elevated TSH levels actually mitigate

against such origins. Nevertheless, the presence of

increased head circumiiference may provide

fur-ther concern regarding the existence of

intra-cramiial pathology in hypothyroid children. The

finding in this study of relative megalocephaly in

some patients should serve to reassure the

physi-cian regardimig the improbability that intracranial

miiass lesiomis are preseiit in such patients with

priniarv thyroxin deficiency.

Since submission of the manuscript, we have

seen three additional children who qualify for

inclusion iii the hypothyroid group. At ages 1#{189},

5#{189},and 10, their heights were -2.5 S.D., -4.5

S.D., and -3.5 S.D., respectively, below the

meami. The head circumference for each child was

+ 1.5 S.D., + 1.5 S.D., and + 2 S.D., respectively,

above the normal mean.

LESLIE BURT, M.D.

HOWARD E. KULIN, M.D.

Department of Pediatrics,

Milton S. Hershey Medical

Center,

Pennsylvania State University Hers/met,, Pen nsi,luania

ADDRESS FOR REPRINTS: (H. E. K.) Division of Endo-crinologv. Departmient of Pediatrics, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania 17033.

REFERENCES

1. Goodman HG, Grumbach MM, Kaplan SL: Growth and growth hormone. N Engl J Nied 278:57, 1968. 2. De,ners LM, Abt \VJ, Krieg AF: A new combimied

thyroid hormone index 1)ased on thvroxin, truodo-thyromiine amid resin uptake. Am J Cliii Pathol 65:356, 1976.

3. Patel Y, Busger 11. 1-ludson B: Radioi,n,,ium,oassav of serumil thvrotropimi: Se,isitiitv and specificity.

J Clin Endocrimiol Metal) 3:3:768, 1971.

4. Greulich \\‘W’, Pyle SI: Radiographic Atlas of Skeletal Development of the I-land and \Vrist. ed 2. Stan-ford, California, Stanford University Press, 1959. 5. Nellhaus G: Head circumifere,ice froii birth to eighteemi

years. Pediatrics 41:106. 1967.

6. Tanner JM, \Vhitehouse RH, Takaishi \l: Standards froni birth to maturity for heights, weight, height velocity and weight British children, 1965, Part II. Arch Dis Child 41:613, 1966.

7. Steel R, Torrie J: Principles and Procedures of Statistics. New York, McGraw-Hill, 1960.

8. Macfarlane DW, Boyd RD. Dodrill CB, Tufts E:

Intrau-terine rubella, head size, and i,itellect. Pediatrics

55:797, 1975.

9. Yamada T, Tsukui T, Ikejiri K. Yuki,iiura Y: Vohmmiie of sella turcica ill miorinal subjects and in patiemits vitli primnar\ hypothyroidism amid hvperthvroidismn.

J Climi E,idocrinol \Ietab 42:817. 1976.

ACKNOWLEDGMENT

The authors wish to thank Dr. Selmia Kaplan for providing the clinical data on the growth hormone deficient Pttie1its and Dr. Robert Vaminucci for reviewing the manuscript.

Is Routine Intravenous

Urography

Indicated

in Patients

With Hypospadias?

For mans’ years intravenous urograph has

been standard in the evaluation of patients with hpospadias. Previous reports have cited a signif-icant incidence of associated urologic anomalies.

Moreover, mimior degrees of hvpospadias are

reportedly associated with anomalies as

frequemit-ly as more severe degrees.’ Because of a clinical imiipressiomi that this routine evaluation yielded a

tiegligible numiiber of “clinically sigmiificamit” or

surgically correctable lesions, we undertook this

retrospective study.

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TABLE I TABLE II

EXPERIENCE

AND

REASON

631

ABNORMALITIES ON UR0GRASIS IN 87 ASYMPTOMATIC MALES

WITH HYPOSPADIAS

Abnormalities Vo.

Ijreterml or pelvic duplication 11#{176}

\Ialrotation 1

Horseshoe kidney 1

Ureteral ectasia 2’

Ureteropelvicjunction ol)structiomi 1

‘One with refiuix.

MATERIAL AND METHODS

A total of 121 patients underwent hypospadias

repair between January 1969 and December

1974. Eighty-seven of these patients had

intrave-nous urography, at which time they ranged in age

fromii 6 weeks to 22 years. In all of these cases,

hvpospadias was the sole indication for the study.

All patients were mm#{176}

RESULTS

Review of the 87 intravenous urograms

revealed 16 “abnormalities,” an apparent

mci-demice of 18% (Table I). However, miiany of these

aI)nornlalities might best be considered anatomic

variants with little or n#{248}clinical significance. Bifid pelves and incomplete ureteral duplications

are of dubious importance. Neither the single

iiialrotated kidney nor the single horseshoe

kidney was obstructed or dilated. The two chil-dren with reflux were unimifected and

asmpto-niatic. The ureteropelvic junction obstruction

was the only anomaly that required surgical

intervemition (1.1% of the total patients

under-going urography).

DISCUSSION

Review of the literature reveals the incidence

of genitourinar tract anomalies associated with

-

hvpospadias to range from 9% to 28%.’ Table II

lists the studies reported, including the present

one. However, these figures are clearly deceptive

iii that (1) visible abnormalities such as

micro-phallus, crvptorchidisni, bifid scrotuni, amid

ambiguous genitalia are included2; (2) coexistence

‘Not included iii these statistics was a l)O\ with distal penile

hvpospadias. recurrent mirinarv tract imifections. and bilateral hvdromiephrosis vitli grade IV vesicoureteral reflux.

PATIENTS WITH HYPOSPADIAS UNDERGOING UROGRAPHIC EVALUATION

Literature Son rees

No. of Patients

“Abnormalities”

(%)

Neyman & Schermer’ 37 24.5

489 28.0

Felton 45 9.0

Willis et a!. ‘ 96 18.0

Smyth & Forsyth& 60 15.0

McArdle & Lebowitz’ 200 3.0

Present study 87 18.0

Total 1,014

of infection is usually not mentioned and this is

relevant to the clinical significance of reflux; (3)

potentially significant and merely interesting

variants are accorded equal consideration; (4)

bladder mieck obstruction is frequently alluded to,

but the criteria for diagnosing this entity remain

controversial and imprecisely defined2-; and (5)

symptomatic and asymptomatic patients are

included in the statistics.

It is generally assumed that the more severe

degrees of hpospadias are associated with a

greater incidence of tipper urinary tract

anoma-lies. However, Neymnan and Schermer found an

equal incidence of abnormalities in all grades of

lwpospadias.’ Our study confirms the lack of

relationship between the degree of hypospadias amid the likelihood of a urinary tract anomaly (Table III), although the low frequency of

signifi-cant abnormalities found in any type is

impres-sive.

In 1975, McArdle and Lebowitz’ reported their

experience in examining 200 hypospadiac males.

Six (2%) had tipper urinary tract anomalies, but none required surgical intervention. They implied

that routimie evaluation by intravenous urography

was unnecessary.

Table IV lists all abnormalities reported

(in-cluding our own) that would not have been

detected except by routine intravenous

urogra-phy. It is assumed that reflux must be

accompa-nied by ureteral ectasia in order for the diagnosis

to be made on intravenous pyelogram (this

diag-nosis was undoubtedly made at

cystourethrog-raph in most cases and therefore only cases with

ectasia of the ureters have been included). Smyth

and Forsythe’s symptomatic patients are not

included since they would presumably have had

urologic and urographic work-imps for their

symp-toms, even in the absence of hypospadias.

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632 EXPERIENCE AND REASON

TABLE III

RELATIONSHIP OF SEVERITY OF HYPOSPADIAS TO INCIDENCE OF URINARY TRACT “ABNORMALITIES”

Data Degree of Hypospadias#{176}

First Second Third

No. of patients (total = 87) 42 32 13

Al)normrlalities No. (total = 16) (1/a (rneami = 18%)

9 21 4 12 3 23

-Type of abmiormalitv Duplications Mairotation 7 1 3 0 1 0 Horseshoe kidney Ureteral dilatation 1 0 0 1 0 1 Ureteropelvic jumiction

obstruction 0 0 1

‘First-degree = glandular and coronal; second-de-gree = penile shaft; third-degree = peiioscrotal to

pen-neal.

TABLE IV

URO(;RAPHICALLY DEMONSTRABLE ANOMALIES IN MALES WITH HYPO5PADIAS

Anomalies No.

Duplication 21

Calyceal diverticulumii 1

Bladder diverticulum 1

Urachus 1

Nlalrotatiomi 3

Horseshoe 5

Ectopia 7

Aplasia, dsplasia, hpoplasia 7

Polvcystic, multicystic 3

Ureteral ectasia and/or reflux 18

Hdronephrosis 12

Total 79 of 1,014 = 7.8%

TABLE V

OCCURRENCE OF VARIOUS ANOMALIES

Anoma!i, Occurrence (%)

General Population Present Series

Duplication 0.6-4.0” 2.1

Renal ectopia 0.12’ 0.7

Horseshoe kidney 0. 1-0.3’ ‘ 0.5

In discussing the merits of imitravenous urog-raphy in the study of crptorchid males, Donohue et al.7 established criteria for a clinically impor-tant abnormality as one “resulting in significant

loss of renal substance or requiring surgical

correction for conservation of remial substance.”

Interpreting their criteria strictly, we can

certainly exclude the 21 duplications (Table IV). Moreover, duplications max’ occur in one of every 25 normal subjects (Table V). Diverticuli,

malro-tation, ectopia, and horseshoe kidney, which

together occurred in 1.4% of patients with

hpo-spadias and constituted 23% of the reported

anomalies (Table IV), do not require medical or

surgical treatnient in and of themselves. They

may, however, predispose to future obstructive or

infectious problems, and, therefore, prior

knowl-edge of their presence could be construed as

useful information. Ectopia and horseshoe kidmiey do appear to be more comiimomi in hpospadiacs

than in the general population (Table V). If we

include omily the 40 cases of obstruction,

dilata-tion, renal dsplasia, hpoplasia, aplasia, and

cystic disease (Table IV), the incidemice of signifi-cant congenital anomalies detected by urography

in hypospadiac males totals 3.9%. This exceeds

the incidence of major anomiialies found in the

general population. Existing studies indicate that

the overall prevalence of significant tipper tract

anomalies in the asvmiiptomatic general

popula-tion is less than 2%.1 Felton reviewed 152

consecutive complete autopsies on boys between

ages 2 amid 14 years at New York Hospital amid

found two unsuspected niajor amiomiialies. Learv et

a!.” found one congenital ureteropelvic junction

obstruction on intravenous pvelograni in 558

asvmnptomatic adults screened for hypertension.

Moreover, partial or even total unilateral remial

nonfunctiomi on the basis of aplasia, hpoplasia,

dsplasia, or cystic abnormality, which account for 13% of the anomalies reported in association

with hpospadias, is of no consequence to the

patiemit umiless by chance a catastrophe befalls the

other kidney. Ureteral ectasia and/or reflux amid

hdronephrosis are the omily conditions that might

require surgical imitervention. Together they

accoumit for 30% of the reported abnormalities

and occur in 3% of patients with hvpospadias

(Table IV). It is therefore apparent that the

diagnostic yield of clinically correctable

abmior-nialities on routine uroradiographv in

asvmpto-niatic males with uncomplicated hvpospadias is

quite low, though significantly higher than imi the

gemieral population.

Ultrasonograph, which is a mioninvasive

tech-nique and free of complications, is capable of

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PEDIATRICS Vol. 59 No. 4 April 1977 633

accurately detecting abnormalities of size and

position, as well as hydronephrosis.9’#{176} The possible allergic and radiation hazards of

urog-raph can be entirely avoided. Urography can

then be reserved for the hypospadiac boy with

urologic symptomatology, documented urinary

tract infection, or an abnormal screening ultra-sonogram.

CONCLUSION

Hpospadias is associated with an increased

incidence of ‘‘sigmiificant” urologic anomalies as

compared with the general population. Most do

not require imiimiiediate surgical intervention, but

this informriatioii may be important in planning

the long-term management of the boy, including

follow-up amid advice given in regard to contact

sports. Ultrasonograph avoids the possible

hazards of intravenous urography and would

seem to be the ideal screening test for detecting

the urologic anomalies associated with

hypospa-dias. Intravenous urograph should be reserved

for a selected group of children with hypospadias

with abnornial ultrasonograms or urologic

symp-toniatolog.

LET-n’ G. LUTZKER, M.D.

STANLEY

J.

KOGAN, M.D.

SELWYN B. LEVITT, M.B., B.Ch., F.A.C.S.

Divisions of Pediatric Radiology and

Pediatric Urology,

Albert Einstein College of Medicine,

and Montefiore Hospital and Medical

Center

Bronx, L\C1C )ork

ADDRESS FOR REPRINTS: (S.B.L.) 1)irector, Division of

Pediatric Urology, Albert Eimistein College hospital, Room 1 168, 1825 Eastchester Road, Bronx, New York 10461.

REFERENCES

1. Nevmiami \I#{149},Schermer HKA: Urinary tract evaluation in hvpospadias. J Urol 94:439, 1965.

2. Ke,inedv PA: Hpospadias: A twenty-year review of 489 cases. JUrol 85:814, 1961.

:3. Feltoi LNI: Should intravenous )velographv be a routine procedure for children vith crvptorchidismn

or hpospadias? J Urol 81:335, 1959.

4. Willis C, Brenm,an \V, Ochsner M: Hpospadias and associated amomnalies. South Med J 6():969, 1967. 5. Smrivth BT. Forsythe 1W: Hvpospadias amid associated anomalies of the gemitourinary tract. J Urol 82:109,

1959.

6. NicArdle R, Lebowitz R: Umicomplicated hypospadias amid amu)malies of the tipper urinary tract: Need for screening? Urology 5:712, 1975.

7. Donohue RE, Utley WLF, Maling TM: Excretory

urog-raphy in asymptomatic boys with crptorchidism.

J Unol 109:912, 1973.

8. Lear>’ FJ, Myers RP, Greene LF, Hartman GW: The value of excretory urography as a screening test in asmptomnatic patients. J Urol 107:850, 1972. 9. Ha.sch E: Ultrasound in the diagnosis of hydronephrosis

in infants and children. J Clin Ultrasound 2:21, 1974.

10. Hately W, Whitaker RH: How accurate is diagnostic

ultrasound in renal disease? Br J Radiol 45:468, 1973.

11. Dees JE: The clinical importance of congenital anoma-lies of the upper urinary tract. J Urol 46:659, 1941.

12. Reubenstein M, Meyer R, Bernstein J: Congenital abnor-inalities of the urinary system. J Pediatr 58:356, 1961.

13. Canipbell MF, Harrison JH: Urology. Philadelphia, WB Saunders Go, 1970.

14. Hartnian GW, Hodson CJ: The duplex kidney a,id related anomalies. Clin Radiol 20:387, 1969. 15. K#{246}lhCP, Boatman JD, Schmidt JD, Flocles RH:

Horse-shoe kidney: A review of 105 patients. J Urol 107:203, 1972.

Familial Aggregation of Blood Pressures