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Y. Ak ın et al.
32.3.1.2 Bladder Augmentation
Neuropathic bladder (NB) is a heterogeneous
clinical entity that can result from a variety of
conditions affecting the central or peripheral nervous systems. Myelodysplasia, specically spina
bida, remains the most common cause of NB in
the paediatric population [36]. The management
of NB aims to preserve the native bladder to store
urine at low pressure and to allow efcient emptying of the bladder. Additionally, to keep quality
of life is another target of clinicians during the
management of NB. Early management is usually focused on preventing irreversible injury to
either the upper or lower urinary tract. Evaluation
of NB is not the topic of this chapter. Over
29 years, clinicians have been routinely using
clean intermittent catheterization (CIC) at the
rst step of NB management [37].
Medical management includes using anticholinergic/beta3 mimetic [38], and endoscopic
interventions might be used in the case of not
responding to medical treatment [39]. Botulinum
A is used in endoscopic management of NB [40].
Surgical treatment as augmentation cystoplasty
seems optimal when medical and endoscopic
interventions are not sufcient for NB [41]. The
surgical technique is used as Szymanski et al.
(2015) described [42]. This surgical modality
leads to keep a high quality of life as possible
[43]. Additionally, to protect the upper urinary
tract is very important to make augmentation cystoplasty for delayed or absent kidney failure as
much as possible. However, bladder augmentation is the reference standard surgical procedure
used to increase bladder capacity and reduce
storage pressures; it has some serious risks for
long-term. [44]. Bladder calculi, possible metabolic derangements, vitamin B12 deciency and
in long-term, some malignancies might occur
[45]. On the other hand, in patients who have
physical or cognitive barriers to compliance with
CIC, vesicostomy has come into question as a
surgical treatment of NB [46]. Furthermore,
some incontinent diversions might also be performed [47]. Despite there are some complications in long term, signicant advantages of
bladder augmentation cystoplasty are performed
to preserve bladder and upper urinary tract.
Therefore, if there is no contraindication, such as
inammatory and congenital bowel disease, augmentation cystoplasty should be done before the
patient develops kidney failure. When ESRD
occurs, the management of the disease will be
complicated. Besides, performing simultaneously kidney transplant and bladder augmentation is still a subject of debate. However, Capizzi
etal. (2004) have reported kidney transplantation
in children with reconstructed bladder [48]. This
is a well-known truth that wound and tissue
healing would be delayed in patients with renal
failure [49]. Thus, performing both procedures
simultaneously are reasonable. Additionally,
decreased risk of infection of the allograft, two
anaesthetics, difcult dissection and the possibility of damaging the arterial supply of the augment may be avoided.
32.4 Prostate Surgery
32.4.1 Chronic Prostatitis
Chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS) is a condition of chronic pelvic pain
among the men and accounts for 80–95% of all
symptomatic prostatitis cases [50]. The aetiology
and pathogenesis are still not clear. Thus, the
optimal treatment of CP/CPPS is a subject of
debate. Infections, chemical irritation, trauma,
genetics, and psychological stress that result in
some subsequent neurological changes, such as
brain microstructural changes, central sensitization, and pelvic oor spasms, have been claimed
for trigger factors [51]. A combination of alterations to the nervous system with endocrine, psychosocial, or immunological abnormalities leads
to the chronic state of CP/CPPS [52]. Chronic
bacterial prostatitis and chronic pelvic pain syndrome are common diagnoses in urology and
represent a relevant health problem [53].
Sometimes, medical and minimally invasive
treatment options cannot be enough to heal the
symptoms [54]. The main goal of this chapter is
to discuss surgical treatment options for chronic
prostatitis, notably to face prophylactic
modalities.
32 Prophylactic Surgery forUrologic Pathologies
383
Transurethral resection of the prostate (TURP)
is advocated for CP/CPPS based on a few anecdotal
experiences, but there are absolutely no reliable
data or experiences to substantiate a treatment
effect [55]. Patient with signicant lower urinary
tract symptoms with a background of CP/CPPS
may benet from this therapy [56]. Especially, the
optimal therapy for category 2 and 3 prostatitis is
still not clear, and surgical options might prove to
be a viable alternative. In the systemic review by
Schoeb etal. (2017), 110 TURP cases and 21 radical prostatectomies for CP/CPSS were evaluated
[54]. At this point, we have to emphasize that per-
forming radical prostatectomy for these patients is
controversial. Additionally, ethical aspects have
come into mind. All these patients had CP/CPPS
type 2 and 3 patients. TURP for CP/CPPS patients
should be evaluated in clinical council and radical
prostatectomy, and of course, it should not be the
rst surgical choice. If the surgery is preferred,
complete removal of inamed or infected prostate
tissue should be performed. Therefore, holmium
laser enucleation seems a plausible option that can
easily remove all prostate tissue [57]. To perform
surgical treatment for CP/CPSS, as TURP at the
rst step, is not mentioned in the guidelines. This
is because most of the CP/CPSS patients are
young, male and complications of the TURP, such
as retrograde ejaculation [58, 59]. More clinical
trials are needed to nd out optimal surgical interventions for CP/CPSS.However, prophylactic surgical treatment for CP/CPSS can be dened in the
future.
32.4.2 High-Bladder Neck Elevation
Bladder neck elevation (BNE), which indirectly
reects prostatic urethral angle (PUA), can be a
cause of bladder outlet obstruction (BOO) and
BOO-related symptoms [60]. We know the starting age of BOO due to benign prostatic hyperplasia (BPH); however, BNE can cause to BOO in
younger ages. Medical management options are
similar to BPH [61, 62]. In the lack of response to
medical management, surgical options come into
question. Because of the side effects of TURP,
clinicians would not perform at the rst step in
the management of BNE [63]. However, ejaculation preserving endoscopic surgical techniques
were described during TURP [64]. Nonetheless,
patient selection is very important for this indication. Thus, preoperative cystoscopy can be performed to dene BNE and to measure bladder
neck angle. If the angle is >35°, surgical treatment options might be more benecial [65]. To
perform endoscopic prostate incision and/or
TURP is dependent according to prostate size
and grade of obstruction [66]. In the name of prophylactic surgery, TURP/prostate incision should
be considered in patients with BNE.However, as
it is mentioned above, it depends on patient complaints, prostate volume and bladder neck angle.
32.5 Penile Surgery
However, male circumcision is usually practised
for routine and religious reasons; this is one of
the most suitable surgeries for the denition of
prophylactic surgery. Besides, circumcision is
mostly performed on the penis without any
pathology.
32.5.1 Circumcision
Circumcision has a long history, dating back to
4000BC [67]. Besides Jewish communities have
traditionally practised circumcision on the eighth
day of life since 1800BC, the age of circumcision widely change in the Muslim community
[68]. Additionally, circumcision is performed in
some of the African communities and certain
Australian indigenous tribes since ancient times
[69, 70]. Circumcision is also one of the most
frequently performed surgery worldwide [71].
Morris etal. (2016) revealed that nearly 33–37%
of the males are estimated to be circumcised
[72]. There are many surgical techniques for circumcision [73].
For the purposes of this book and chapter, circumcision can prevent the development of UTI
and penile cancer and help to reduce the human
immunodeciency virus (HIV) transmission.
Shapiro et al. (1999) concluded that UTI is more
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Y. Ak ın et al.
frequent in uncircumcised men. This might be
related to bacterial colonization in foreskin [74].
Moreover, circumcision may play an essential
role to prevent VUR in boys. UTI and renal scar
due to VUR can be avoided by circumcision [75].
Mukherjee etal. (2009) commented that the positive effect of circumcision is to prevent UTI in
boys with posterior urethral valve [76].
Furthermore, Morris etal. (2013) published lowered risk of UTI in a lifetime in circumcised man
[77]. Nonetheless, UTIs can be managed conservatively with antibiotics without renal tissue loss
[78]. More studies are needed to prove this issue.
There is no doubt that circumcision was historically quoted as a preventative measure for
the future development of penile carcinoma.
Invasive penile cancer is strongly associated
with phimosis, that is, of course, the risk can
easily be removed by circumcision [79]. In a
study that makes this situation contradictory,
Sewell et al. (2015) reported the incidence of
penile cancer in the USA is similar to that in
Australia even though circumcision rates in the
USA are signicantly higher [80]. Except for
prepuce and related diseases, there are some
factors that can predispose penile cancer, such
as genital hygiene, tobacco usage and other sexual transmitting diseases [81]. It is obviously
clear that circumcision may not stop penile cancer but can reduce the risk.
Studies from Africa proved that male circumcision can protect against acquiring HIV among
heterosexual men [82]. The exact mechanism is
based on removing parts of the foreskin that are
most susceptible to infection by the virus [83].
These do not mean that circumcision is denitely
avoiding HIV transmission. Thus, safe sex comes
into question [84]. Nevertheless, circumcision is
not enough to stop HIV transmission, but it can
reduce. More strategies are needed to stop HIV
transmission both for men and women before and
during sexual intercourse.
Balci et al. (2015) revealed the risk of 9%
oncogenic human papillomavirus (HPV) in the
foreskin in pre-pubertal boys [85]. This is another
benet of circumcision that possible reducing
HPV in the pre-pubertal boys and their future
partners.
In the light of all above, it is seen that circumcision might be also accepted as one of the prophylactic procedures that can prevent UTI in
boys, reduce penile cancer and HIV transmission
in heterosexual men.
32.5.2 Urethral Surgery
32.5.2.1 Urethral Valves
Posterior urethral valve (PUV) occurs in 1:4000
to 1:25,000 of live births, and clinical presentation of PUV considerably varies [86]. PUVs are
the most common causes of bladder outlet
obstruction in children. Despite medical management, PUV may lead to serious inabilities,
such as renal insufciency and incontinence
[87]. Rapid diagnosis and treatment are essential. Endoscopic resection, which has been
accepted as a denitive surgical treatment, is still
maintaining its importance in the treatment of
PUV [87].
Follow-up methods may still be a subject of
debate after PUV resection. However, a strict
follow-up schedule would be better for preserving bladder and kidney functions. Additionally,
the serum creatinine may be an indicator of better
outcomes in long-term follow-up. Routine cystoscopy and voiding cystourethrography are the
preferred ones. Furthermore, routine uroowmetry can be another tool during follow-up.
Nevertheless, PUV should be operated as soon
as it is diagnosed. Thus, bladder and kidney dysfunctions (notably ESRD) caused by PUV can be
prevented.
32.6 Testicular Surgery
Undescended testis (UDT) is common in paediatric ages. Because of UDT being the most common genital disorder identied at birth, the
diagnosis can be performed very easily and rapidly [88]. The position of UDT might vary and be
located in the abdominal cavity, inguinal canal or
subcutaneous cavity, which could determine the
extent of the associated phenotype. The main reasons for treatment of this remain reducing the
32 Prophylactic Surgery forUrologic Pathologies
385
risks of impairment of fertility potential, testicular malignancy, torsion and/or associated inguinal hernia. Therefore, orchiopexy is the most
successful therapy to relocate the testis into the
scrotum without any additional hormonal therapy
(that is also not recommended) [88]. Therefore, it
should be operated in childhood to prevent all
pathologies, previously addressed as orchiopexy,
and is recommended for testes that remain undescended after 6months of age [89].
32.6.1 Orchiectomy forUndescended
Testis intheAdult
The risk of developing testicular cancer due to
UDT is increased to 5–10 times that of the general male population. This increased risk for a
UDT or previously cryptorchid individual is
indicative of long-term damage, despite early
orchiopexy in many cases [90]. The association
between UDT and testicular germ cell tumour
has been well documented since the 1940s.
UDT is an accepted risk factor with a relative
risk of 3.7–7.5 times higher than the scrotal testis population [91]. If UDT is bilateral naturally,
the risk of testicular cancer is higher than unilateral one. Moreover, Peterson et al. published
that if the UDT is corrected after 13years old,
there is two times more the risk of cancer occurring than in patients underwent surgery before
13 years old [92]. Nevertheless, there is
increased risk of testicular cancer in UDT
patients [93].
However, diagnosis of UDT is often delayed
for reasons, including patient unawareness or
denial of abnormal ndings in the testis [94].
Moreover, the UDT loses its function by the
time [95].
Patients with a single testis or bilateral postpubertal UDT, preservative treatment might be
considered, although such treatment requires
careful follow-up [96]. Additionally, careful
observation may be considered in patients over
50 years of age with palpable UDT. Lifelong,
regular self-examinations are needed for patients
with UDT, even though they had been operated.
In view of all these, orchiectomy should be per-
formed for UDT after puberty with some exceptions. Another point of view, prophylactic
orchiectomy is needed with patients with UDT
after puberty.
Last but not least, taking a biopsy from the
contralateral testis might be needed to rule out
germ cell neoplasia in situ and either take the pertinent prophylactic treatment, as it is a pre-cancer
lesion, or to inform the patient about the risk.
Clinicians should take into account that orchiectomy might be indicated in some cases when the
patient is not suitable for local radiotherapy or
prefers orchiectomy for whatever reason [97].
Additionally, for some congenital syndromes
(e.g. Klinefelter) that are associated with multiple testicular microlithiasis, a testicular biopsy
may be indicated.
32.7 Adrenal Surgery
It is obviously clear that day by day, urologists
are beginning to have a say in adrenal surgery.
The most recent approach in adrenal surgery is
partial adrenalectomy with robotic surgery [98].
On the other hand, when there is insufciency
and/or failure in the treatment of pituitary
Cushing and unlocalized ectopic Cushing’s syndrome (CS), bilateral adrenalectomy may be considered [99]. Pituitary-dependent Cushing’s
disease (CD) is the cause of endogenous CS, and
transsphenoidal resection of a pituitary tumour is
the rst line of treatment option for the patients
of CD.Unfortunately, the operation fails 30% of
the CD cases.
Moreover, in patients of CS with bilateral
adrenal pathology, bilateral adrenalectomy is the
obvious treatment option. Nevertheless, all these
clinical entities could be indications for bilateral
adrenalectomy for preventing severe clinical
symptoms of CS.However, it’s overall morbidity
and mortality is higher than other endocrine
operations [99]. The operation should be discussed with the patient, considering clinical
symptoms and pros and cons. Minimally, invasive approaches should be preferred. If there is a
robot option, it should be considered rst for
adrenal surgery.
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32.8 Conclusions
At rst glance, something does not come to mind
for urological prophylactic surgery; we evaluated
the published literature from point of view of the
urologists. Therefore, bilateral nephrectomy,
endoscopic VUR correction, diverticulectomy,
bladder augmentation, endoscopic prostatectomy
and prostate incision, PUV resection, circumcision, orchiectomy and bilateral adrenalectomy
are evaluated for prophylactic urologic surgeries
in individual indications. Some of the emerging
genetic ndings on the relationship between
BRCA genes and prostate cancer have not been
proven denitely. Thus, we would not want to
discuss these. Prophylactic urological surgeries
may vary with increasing procedures and indications in the future. We hope this section of the
book can help to keep prophylactic surgery in
mind in its indication for clinical practice of
urologists.
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Prophylactic Procedures
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
inPediatric Surgery
GökhanKöylüoğlu andMustafaOnurÖztan
33
33.1 Introduction
Prophylactic surgery, which is done to prevent
diseases that may develop later in a healthy tissue
or organ system, maybe more important in children than in adults because of the long-life expectancy in children. Although the topics are
generally similar to those encountered in adults,
while deciding on prophylactic surgery in children, the age factor, the psychological state of the
patient and his family, the presence of concomitant congenital diseases, and the long-life expectancy change the decision-making processes.
Here, we tried to summarize the reasons and age
groups of prophylactic surgical interventions,
which are applied frequently in children today, in
the light of current literature information.
33.2 Prophylactic Surgery
forContralateral Inguinal
Hernia
Inguinal hernia repair is one of the most common
surgical interventions performed among children
and presents in approximately 0.8–4.4% of the
children [1, 2]. Management of a contralateral
groin is still controversial since it has been
G. Köylüoğlu (*) · M. O. Öztan
Department of Pediatric Surgery, School of Medicine,
Izmir Katip Celebi University, Izmir, Turkey
e-mail: gokhan.koyluoglu@ikc.edu.tr;
mustafaonur.oztan@ikc.edu.tr
discovered that all contralateral patent processus
vaginalis (PPV) do not develop an inguinal hernia. A PPV is not a clinical condition, where it
becomes a problem when it is large enough to
allow pass intra-abdominal contents into the sac.
Processus vaginalis (PV) closes in the rst
2 months after birth in 40% of the infants and
60% of the children at age 2 years [3]. The
remaining PPV rate of 40% did not decline signicantly in teenagers [4]. The reported incidence of metachronous contralateral hernia
(MCH) is varying in several reviews between 7
and 10%, which indicates the necessity of carefully patient selecting for intervention to the contralateral side [5–7].
The detection of an MCH was done with herniography and pneumoperitoneum in previous
years, but these technics have been abandoned
because of its drawbacks and unreliability [
The examination of the contralateral side may be
done using laparoscopy via a transumbilical port
or a 70-degree laparoscope by passing through
the operated hernia sac with a sensitivity and
specicity over 99% [2]. Also, in a meta-analysis
of Dreuning etal. (2019), they have reported that
preoperative ultrasonography has a high sensitivity (88%) and specicity (93%) for detecting
PPV [9].
The advantages of the repair of the asymptomatic side include avoiding second anesthesia,
reduce patients’ and parents’ anxiety, reduce the
risk of incarceration, and reduced costs. Besides
this, an unnecessary intervention has the risk of
8].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_33
391
392
G. Köylüoğlu and M. O. Öztan
injury to the spermatic cord, wound infection,
hematoma, testicular atrophy, increased pain,
prolonged operation and anesthesia risk, and
increased costs [1].
Since time, there is a decline in the routine
contralateral exploration regarding the large
reviews and meta-analyses. Historically, many
surgeons performed bilateral exploration in the
presence of unilateral hernia according to the age
or gender of the patient or the side of the hernia. It
has been thought that in premature patients, girls,
and left-side hernias, the contralateral exploration
must be carried out because of the high risk of an
MCH. These approaches have been abandoned
because multiple studies revealed that the waitand-see method is reliable with only a 0.5–2%
complication rate, and 10 patients must be operated to cure one MCH [10–13].
Nowadays, contralateral exploration is recommended for children at risk of having MCH more
than healthy patients. In patients who have ventriculoperitoneal shunts or peritoneal dialysis
catheters, there is excess uid and pressure in the
peritoneal cavity, and the hernias are mostly
bilateral. In these patients, the contralateral side
must be explored in the case of clinical unilateral
hernia since it has been documented that incarceration is a great risk, and spontaneously, obliteration of a PPV is not likely [14, 15]. Patients
with connective tissue diseases like HunterHurler, Ehlers-Danlos, Marfan’s or cutis laxa
syndrome, chronic pulmonary disease, or highrisk patients with cardiovascular or neurologic
problems, in whom second anesthesia has to be
avoided, are candidates to the contralateral exploration for an MCH [12, 16].
In conclusion, a contralateral exploration is
not mandatory in all patients with an inguinal
hernia. The risk and advantages of this intervention for each child must be evaluated on a personal basis.
33.3 Prophylactic Resection
forMeckel’s Diverticulum
Meckel’s diverticulum (MD) is the most commonly encountered anomaly of the gastrointestinal tract (GI) and is caused by incomplete
obliteration of the omphalomesenteric duct during gestation. The reported prevalence is between
0.3 and 2.9% of the general population, but the
majority of the patients are asymptomatic for life,
where symptomatic cases are almost in the earliest years of life [17–19]. MD is symptomatic due
to intestinal obstruction, GI bleeding, and diverticulitis with or without perforation. There is no
controversy about to resect every symptomatic
MD in all patients of any age, but an incidentally
discovered asymptomatic MD is still a surgical
dilemma.
Only 4% of the patients with an MD are symptomatic, and more than 50% of patients of the
symptomatic patients are under the age of 10 [20,
21]. In this group, the majority is under age
<1 year, wherein the adolescents and adult
patients, the majority is in 11–30 years of age
[22]. There is also a male predominance among
symptomatic patients with a 2.9:1 male to female
gender ratio. The length and width of MD are
reported with a mean length of 3.05 cm and a
diameter of 1.58cm in a review of Hansen etal.
[23]. In several reports, it has been mentioned
that MD in symptomatic patients tends to be longer with a narrower base [22, 24]. The presence
or absence of ectopic tissue is the most signicant determinant for the need for surgical removal
of MD. Palpation of the thickening of MD is
investigated and demonstrated no association, but
a wider diverticulum base was reported in the
study of Slívová etal. (2018) [25, 26].
Under this knowledge, the question is that,
does it worth resecting an asymptomatic MD and
faces the possible complications of a bowel
resection? Zani et al. (2008) declared in their
review article that postoperative complication
rates after prophylactic resection reach 5.3%,
where 1.3% of children with an MD left in situ
have symptoms with time [20]. In an epidemiologic, population-based study of Cullen et al.
(1994), they stated that the risk did not decrease
with age, so they recommended resection of all
encountered MDs, except in the presence of additional conditions like generalized peritonitis [27].
Also, some authors support resection because of
the life-threatening clinical course in some
patients with MD, where others are against it
after encountering life-threatening complications
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