Anesthetic induction trismus, more than a closed-mouth problem

Trismus, or masseter hypertonia, that results from the use of succinylcholine during induction of anesthesia is a rare and dangerous phenomenon. It presents to the anesthesiologist the immediate problem of airway management but it also must be recognized by the physician as a harbinger of malignant hyperthermia. We report a case of induction trismus and discuss its association with malignant hyperthermia. The pathophysiology, diagnosis and treatment of malignant hyperthermia are reviewed.

Traumatic amputation of the left lower renal pole in children

Four children between 5 and 10 years old suffered traumatic amputation of the left lower renal pole following flank trauma. All patients were evaluated with excretory urography and isotope renography. The renal scan clearly demonstrated failure of perfusion of the lower renal pole and urinary extravasation, and was believed to be more valuable than the standard excretory urogram as a diagnostic tool. All children were managed similarly: delayed (72 to 96 hours) exploration, simple removal of the amputated segment and insertion of a Penrose drain. They all have done well. The patients were normotensive at followup and had excellent function of the remaining portion of the kidney.

Comparison of the diuretic renogram and the pressure perfusion study in children

We evaluated 42 hydronephrotic kidneys with diuretic renography and pressure perfusion studies to diagnose or exclude the presence of obstruction. Both studies were highly accurate but a small number of false positive and false negative studies were observed with each testing modality. The advantages, disadvantages and potential sources of inaccuracy of each study are discussed, and a protocol for the evaluation of hydronephrosis incorporating both studies is proposed.

Urinary retention secondary to congenital bladder diverticula in infants

Acute urinary retention in infants is uncommon. We present 2 patients in whom enormous bladder diverticula extended posteriorly, compressing the bladder outlet and causing obstruction. In 1 patient the diverticulum was solitary, periureteral and associated with ipsilateral ureteral reflux, while the other had bilateral paraureteral diverticula without reflux. Primary bladder diverticula in infants and children are the congenital result of localized deficient musculature allowing herniation of mucosa to occur at this site, even with normal voiding pressures. Giant bladder diverticula causing outlet obstruction in small children are rare and constitute one of the unusual indications for bladder diverticulectomy in children.

Results of closure of urethrocutaneous fistulas in children

We reviewed 34 patients undergoing repair of urethrocutaneous fistulas. In 85 per cent of the cases fistulas occurred after hypospadias repair. Midshaft fistulas were closed successfully using a multilayered de-epithelialized "pants over vest" technique. Of 19 cases with midshaft fistulas closed by this method there were no recurrences and 13 (68 per cent) were performed as nondiverted outpatient procedures. Eleven coronal fistulas were repaired by a skin advancement technique that was successful in 10. Of these 11 procedures 10 were done on an outpatient basis without diversion. Most urethrocutaneous fistulas can be closed successfully without urinary diversion on an outpatient basis.

Simultaneous idiopathic adrenal hemorrhage and renal vein thrombosis in the newborn

We report the simultaneous occurrence of renal venous thrombosis and idiopathic adrenal hemorrhage in 2 newborns. Definitive diagnosis can be determined with various laboratory and radiographic diagnostic studies, particularly radioisotope renal scanning and ultrasonography. Familiarity with the appropriate studies for evaluation of the newborn with an abdominal mass may avoid unnecessary surgical exploration.

Ureteropelvic junction obstruction in newborns and infants

Of 11 patients less than 1 year old with ureteropelvic junction obstruction 9 presented with an abdominal mass. The ideal method evaluation of such patients with an abdominal mass includes sonography followed by isotope renal scan if the mass is determined to be urinary in origin. Visualization by excretory urography in this age group is often impaired by poor renal concentrating ability and excessive bowel gas. Repair was achieved successfully using a nonintubated, nonstented, dismembered pyeloplasty in 10 of 13 kidneys. The average postoperative hospital stay for this group was 4.8 days. Three kidneys were diverted temporarily by nephrostomy, leading to a complication in 1 that required secondary repair. Average postoperative hospital stay in the diverted group was 15 days. Renal function was excellent following repair in all patients, suggesting that early repair is highly desirable in this age group.

The modified Mustardé hypospadias repair

The results are reviewed of 30 boys with distal shaft hypospadias who underwent a modified Mustardé single stage hypospadias repair. A ventral pedicle flap is rolled into a tube and tunneled between the glans and corpora to produce a meatus at the tip of the glans.

Lactic acid in urine of children with lower and upper urinary tract infection and renal obstruction

Preliminary evidence suggests that the concentration of lactic acid in urine may be a good means of distinguishing lower urinary tract infection (cystitis) from upper urinary tract infection (pyelonephritis) and may be helpful in detecting urinary tract obstruction. To test this hypothesis the lactic acid concentrations in 291 urine samples from 250 children were tested. Sixty-four patients had no bacterial infection and served as the control group. A second group (153 patients) had cystitis, and the third group (24 patients) showed radiologic, clinical, and laboratory evidence of pyelonephritis. A fourth group of nine patients who had prolonged urinary tract retention was also analyzed. Patients in the control group, as well as those with cystitis, showed relatively; low concentrations of urinary lactic acid. All levels were less than 2 mg/dl; (mean, 0.8 mg/dl; range, 0.1-2 mg/dl). Patients who had clinical pyelonephritis had lactic acid concentrations of 3.3 mg/dl (mean, 11.4 mg/dl; range, 3.3 mg/dl-40.5 mg/dl). There was no overlap in lactic acid concentrations between the two groups. Furthermore, lactic acid concentrations in urine from patients who had pyelonephritis gradually declined after the initiation of therapy, attaining a level of less than 1 mg/dl by the end of the treatment. Recurrence of the pyelonephritis was consistently documented by a renewed increase of urinary lactic acid concentration. Lactic acid levels were also elevated in urine samples collected immediately after relief of obstruction in the nine patients who had urethral obstructions, showing a mean concentration of 15.8 mg/dl (range, 4.2-37.2 mg/dl).

Ruptured congenital mesoblastic nephroma: chemotherapy and irradiation as adjuvants to nephrectomy

A neonate underwent nephrectomy for a congenital mesoblastic nephroma which was found to be ruptured at the time of removal. Two years after operation there is no evidence of recurrent tumor. Present evidence is that nephrectomy alone is adequate treatment for mesoblastic nephroma, but close observation is mandatory if rupture has occurred. Recurrence should be countered with adjunctive chemotherapy.

Prepubertal gonorrhea

Two cases of gonococcal urethritis in male children are presented and the records of 45 other children with gonorrhea are reviewed. The presentation, diagnosis and treatment are discussed. Data on the mode of transmission are presented with emphasis on the high incidence of gonorrhea in family members or close contacts of infected children, or a history of sexual abuse.

H-Y antigen and disorders of sexual differentiation

The process of sexual differentiation has been further clarified by the discovery of histocompatibility -Y(H-Y) antigen. A patient with abnormal sexual differentiation whose workup included testing for H-Y antigen is presented. The discovery and clinical applicability of H-Y antigen in intersex patients are presented.

Quantitative nuclear cystogram. Aid in determining spontaneous resolution of vesicoureteral reflux

The quantatitative data derived from serial nuclear cystograms over a five-year period in 37 children were compared with the clinical course. A direct correlation (92 per cent) between an increasing bladder volume at which reflux occurs was observed in the clinically stable group. In the clinically unstable group, there was a 75-per cent correlation of an unchanged or decreasing bladder volume at which reflux occurs. The quantitative nuclear cystogram provides an objective as opposed to subjective data base for management of patients with vesicoureteral reflux.