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EAU Guidelines on Paediatric Urology 2017

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EAU Guidelines on Paediatric Urology 2017 EAU Guidelines on Paediatric Urology S. Tekgül (Chair), H.S. Dogan, R. Kocvara, J.M. Nijman (Vice-chair), C. Radmayr, R. Stein Guidelines Associates: M.S. Silay, S. Undre, J. Quaedackers European Society for Paediatric Urology © European Association of Urology 2017 TABLE OF CONTENTS PAGE 1. INTRODUCTION 8 1.1 Aim 8 1.2 Panel composition 8 1.3 Available publications 8 1.4 Publication history 8 1.5 Summary of changes 8 1.5.1 New and changed recommendations 9 2. METHODS 10 2.1 Peer review 10 2.2 Future goals 10 3. THE GUIDELINE 10 3.1 Phimosis 10 3.1.1 Epidemiology, aetiology and pathophysiology 10 3.1.2 Classification systems 10 3.1.3 Diagnostic evaluation 10 3.1.4 Management 10 3.1.5 Follow-up 11 3.1.6 Summary of evidence and recommendations for the management of phimosis 11 3.2 Management of undescended testes 11 3.2.1 Background 11 3.2.2 Classification 12 3.2.2.1 Palpable testes 12 3.2.2.2 Non-palpable testes 13 3.2.3 Diagnostic evaluation 13 3.2.3.1 History 13 3.2.3.2 Physical examination 13 3.2.3.3 Imaging studies 13 3.2.4 Management 13 3.2.4.1 Medical therapy 13 3.2.4.1.1 Medical therapy for testicular descent 14 3.2.4.1.2 Medical therapy for fertility potential 14 3.2.4.2 Surgical therapy 14 3.2.4.2.1 Palpable testes 14 3.2.4.2.1.1 Inguinal orchidopexy 14 3.2.4.2.1.2 Scrotal orchidopexy 15 3.2.4.2.2 Non-palpable testes 15 3.2.4.2.3 Complications of surgical therapy 16 3.2.4.2.4 Surgical therapy for undescended testes after puberty 16 3.2.5 Undescended testes and fertility 16 3.2.6 Undescended testes and malignancy 17 3.2.7 Summary of evidence and recommendations for the management of undescended testes 17 3.3 Hydrocele 17 3.3.1 Epidemiology, aetiology and pathophysiology 17 3.3.2 Diagnostic evaluation 18 3.3.3 Management 18 3.3.4 Summary of evidence and recommendations for the management of hydrocele 18 3.4 Acute scrotum 19 3.4.1 Epidemiology, aetiology and pathophysiology 19 3.4.2 Diagnostic evaluation 19 3.4.3 Management 20 3.4.3.1 Epididymitis 20 3.4.3.2 Testicular torsion 20 3.4.3.3 Surgical treatment 20 3.4.4 Follow-up 20 2 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2017 3.4.4.1 Fertility 20 3.4.4.2 Subfertility 21 3.4.4.3 Androgen levels 21 3.4.4.4 Unanswered questions 21 3.4.5 Summary of evidence and recommendations for the management of acute scrotum in children 21 3.5 Hypospadias 21 3.5.1 Epidemiology, aetiology and pathophysiology 21 3.5.1.1 Epidemiology 21 3.5.2 Risk factors 21 3.5.3 Classification systems 22 3.5.4 Diagnostic evaluation 22 3.5.5 Management 22 3.5.5.1 Indication for reconstruction and therapeutic objectives 22 3.5.5.2 Pre-operative hormonal treatment 23 3.5.5.3 Age at surgery 23 3.5.5.4 Penile curvature 23 3.5.5.5 Urethral reconstruction 23 3.5.5.6 Re-do hypospadias repairs 24 3.5.5.7 Penile reconstruction following formation of the neourethra. 24 3.5.5.8 Urine drainage and wound dressing 24 3.5.5.9 Outcome 25 3.5.6 Follow-up 25 3.5.7 Summary of evidence and recommendations for the management of hypospadias 26 3.6 Congenital penile curvature 26 3.6.1 Epidemiology, aetiology and pathophysiology 26 3.6.2 Diagnostic evaluation 26 3.6.3 Management 26 3.6.4 Summary of evidence and recommendations for the management of congenital penile curvature 27 3.7 Varicocele in children and adolescents 27 3.7.1 Classification systems 27 3.7.2 Diagnostic evaluation 28 3.7.3 Management 28 3.7.4 Summary of evidence and recommendations for the management of varicocele 29 3.8 Urinary tract infections in children 29 3.8.1 Epidemiology, aetiology and pathophysiology 29 3.8.2 Classification systems 29 3.8.2.1 Classification according to site 29 3.8.2.2 Classification according to episode 30 3.8.2.3 Classification according to severity 30 3.8.2.4 Classification according to symptoms 30 3.8.2.5 Classification according to complicating factors 30 3.8.3 Diagnostic evaluation 30 3.8.3.1 Medical history 30 3.8.3.2 Clinical signs and symptoms 30 3.8.3.3 Physical examination 31 3.8.3.4 Urine sampling, analysis and culture 31 3.8.3.4.1 Urine sampling 31 3.8.3.4.2 Urinalysis 32 3.8.3.4.3 Urine culture 32 3.8.3.5 Imaging 32 3.8.3.5.1 Ultrasound 32 3.8.3.5.2 Radionuclide scanning 33 3.8.3.5.3 Voiding cystourethrography 33 3.8.3.6 Bladder and bowel dysfunction 33 3.8.4 Management 33 3.8.4.1 Administration route 33 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2017 3 3.8.4.2 Duration of therapy 33 3.8.4.3 Antimicrobial agents 34 3.8.4.4 Chemoprophylaxis 36 3.8.4.5 Monitoring of UTI 37 3.8.5 Summary of evidence and recommendations for the management of UTI in children 37 3.9 Day-time lower urinary tract conditions 38 3.9.1 Epidemiology, aetiology and pathophysiology 38 3.9.2 Classification systems 38 3.9.2.1 Filling-phase dysfunctions 39 3.9.2.2 Voiding-phase (emptying) dysfunctions 39 3.9.3 Diagnostic evaluation 39 3.9.4 Management 39 3.9.4.1 Standard therapy 39 3.9.4.2 Specific interventions 40 3.9.5 Summary of evidence and recommendations for the management of day-time lower urinary tract conditions 40 3.10 Monosymptomatic enuresis 40 3.10.1 Epidemiology, aetiology and pathophysiology 40 3.10.2 Classification systems 41 3.10.3 Diagnostic evaluation 41 3.10.4 Management 41 3.10.4.1 Supportive treatment measures 41 3.10.4.2 Alarm treatment 41 3.10.4.3 Medication 41 3.10.5 Summary of evidence and recommendations for the management of monosymptomatic enuresis 42 3.11 Management of neurogenic bladder 43 3.11.1 Epidemiology, aetiology and pathophysiology 43 3.11.2 Classification systems 43 3.11.3 Diagnostic evaluation 44 3.11.3.1 Urodynamic studies 44 3.11.3.1.1 Method of urodynamic study 44 3.11.3.1.2 Uroflowmetry 44 3.11.3.2 Cystometry 44 3.11.4 Management 45 3.11.4.1 Investigations 46 3.11.4.2 Early management with intermittent catheterisation 46 3.11.4.3 Medical therapy 47 3.11.4.4 Management of bowel incontinence 47 3.11.4.5 Urinary tract infection 47 3.11.4.6 Sexuality 48 3.11.4.7 Bladder augmentation 48 3.11.4.8 Bladder outlet procedures 48 3.11.4.9 Continent stoma 48 3.11.4.10 Total bladder replacement 48 3.11.5 Follow-up 49 3.11.6 Summary of evidence and recommendations for the management of neurogenic bladder 49 3.12 Dilatation of the upper urinary tract (UPJ and UVJ obstruction) 49 3.12.1 Epidemiology, aetiology and pathophysiology 49 3.12.2 Diagnostic evaluation 50 3.12.2.1 Antenatal ultrasound 50 3.12.2.2 Postnatal ultrasound 50 3.12.2.3 Voiding cystourethrogram 50 3.12.2.4 Diuretic renography 50 3.12.3 Management 51 3.12.3.1 Prenatal management 51 3.12.3.1.1 Antibiotic prophylaxis for antenatal hydronephrosis (ANH) 51 3.12.3.2 UPJ obstruction 52 4 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2017 3.12.3.3 Megaureter 52 3.12.3.3.1 Non-operative management 52 3.12.3.3.2 Surgical management 52 3.12.4 Conclusion 52 3.12.5 Summary of evidence and recommendations for the management of UPJ-, UVJ-obstruction 53 3.13 Vesicoureteric reflux 53 3.13.1 Epidemiology, aetiology and pathophysiology 53 3.13.2 Diagnostic evaluation 54 3.13.2.1 Infants presenting because of prenatally diagnosed hydronephrosis 55 3.13.2.2 Siblings and offspring of reflux patients 55 3.13.2.3 Recommendations for paediatric screening of VUR 55 3.13.2.4 Children with febrile urinary tract infections 56 3.13.2.5 Children with lower urinary tract symptoms and vesicoureteric reflux 56 3.13.3 Disease management 56 3.13.3.1 Non-surgical therapy 56 3.13.3.1.1 Follow-up 56 3.13.3.1.2 Continuous antibiotic prophylaxis 56 3.13.3.2 Surgical treatment 57 3.13.3.2.1 Subureteric injection of bulking materials 57 3.13.3.2.2 Open surgical techniques 57 3.13.3.2.3 Laparoscopy and robot-assisted 58 3.13.4 Summary of evidence and recommendations for t he management of vesicoureteric reflux in childhood 58 3.14 Urinary stone disease 60 3.14.1 Epidemiology, aetiology and pathophysiology 60 3.14.2 Classification systems 60 3.14.2.1 Calcium stones 60 3.14.2.2 Uric acid stones 62 3.14.2.3 Cystine stones 62 3.14.2.4 Infection stones (struvite stones) 62 3.14.3 Diagnostic evaluation 62 3.14.3.1 Imaging 63 3.14.3.2 Metabolic evaluation 63 3.14.4 Management 64 3.14.4.1 Extracorporeal shockwave lithotripsy 65 3.14.4.2 Percutaneous nephrolithotomy (PCNL) 66 3.14.4.3 Ureterorenoscopy 66 3.14.4.4 Open or laparoscopic stone surgery 67 3.14.5 Summary of evidence and recommendations for the management of urinary stones 68 3.15 Obstructive pathology of renal duplication: ureterocele and ectopic ureter 69 3.15.1 Epidemiology, aetiology and pathophysiology 69 3.15.1.1 Ureterocele 69 3.15.1.2 Ectopic ureter 69 3.15.2 Classification systems 69 3.15.2.1 Ureterocele 69 3.15.2.1.1 Ectopic (extravesical) ureterocele 69 3.15.2.1.2 Orthotopic (intravesical) ureterocele 69 3.15.2.2 Ectopic ureter 69 3.15.3 Diagnostic evaluation 70 3.15.3.1 Ureterocele 70 3.15.3.2 Ectopic ureter 70 3.15.4 Management 70 3.15.4.1 Ureterocele 70 3.15.4.1.1 Early treatment 70 3.15.4.1.2 Re-evaluation 71 3.15.4.2 Ectopic ureter 71 3.15.5 Summary of evidence and recommendations for the management of obstructive pathology of renal duplication: ureterocele and ectopic ureter 72 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2017 5 3.16 Disorders of sex development 72 3.16.1 Epidemiology, aetiology and pathophysiology 72 3.16.1.1 Micropenis 73 3.16.2 Diagnostic evaluation 73 3.16.2.1 The neonatal emergency 73 3.16.2.1.1 Family history and clinical examination 73 3.16.2.1.2 Choice of laboratory investigations 74 3.16.2.2 Gender assignment 74 3.16.2.3 Role of the paediatric urologist 75 3.16.2.3.1 Clinical examination 75 3.16.2.3.2 Investigations 75 3.16.3 Management 76 3.16.3.1 Feminising surgery 76 3.16.3.2 Masculinising surgery 76 3.16.4
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