Nonrefluxing colonic conduits: a long-term life-table analysis

We evaluated 25 patients undergoing urinary diversion with a nonrefluxing colonic conduit. Renal scarring developed in 10% of the kidneys during a median followup of 12.7 years. In 11 renal units (22%) deterioration of the ureteroenteric anastomosis occurred due to the development of reflux or stricture. Of these kidneys 45% had scarring; no renal unit in which the anastomosis remained intact had renal scars (p less than 0.001). Of our patients 96% had bacterial colonization of the colonic conduit but this was not associated with renal scarring if the urinary diversion was anatomically intact.

Rhabdomyosarcoma of the prostate in childhood: current challenges

Since 1978, six boys with prostatic rhabdomyosarcoma have been treated at our institution. Three had localized disease and were managed by initial biopsy, vincristine, actinomycin-D, and cyclophosphamide (VAC) chemotherapy, and bladder-sparing surgery with or without irradiation. Further combination chemotherapy ("pulse" VAC, Adriamycin, VP-16, cisplatin, and ifosfamide) was continued for 20 to 22 months following the induction course. Two boys had microscopic residual disease undetected by frozen section and unresponsive to radiotherapy. Subsequent total cystectomy 4 and 7 months later resulted in eradication of disease. In one patient, preservation of the bladder was achieved at the age of 3 months for 8 years. Artificial sphincter inserted to cure his urinary incontinence failed because of ischemia secondary to cuff compression and scar tissue. He is alive today with a modified Koch pouch urinary diversion. Of the 50% who had metastatic disease at presentation, two were dead within 12 months despite aggressive chemotherapy and irradiation. The third is currently on treatment. Although chemotherapy has markedly improved the prognosis, surgery is still necessary in most cases for cure. Bladder salvage is a desirable goal; however, residual microscopic disease, difficulty with frozen-section disease detection, and poor tissue vascularization for subsequent sphincter replacement remain significant obstacles.

99mtechnetium-dimercapto-succinic acid renal scanning and excretory urography in diagnosis of renal scars in children

We compared the ability of excretory urography (without tomography) and 99mtechnetium-dimercapto-succinic acid renal scanning to detect renal scars in 32 children with primary vesicoureteral reflux. These children did not have hydronephrosis, renal failure or urinary tract obstruction. In all cases both studies were conducted within a 10-month period. The findings from both modalities were in agreement for 51 of the 64 renal units evaluated (80 per cent). Evaluation of the excretory urogram indicated 6 cases of diffuse and 2 of focal scarring that were not detected by evaluation of the renal scan. The sensitivity of excretory urography to detect renal scars was 84 per cent and the specificity was 83 per cent. The 99mtechnetium-dimercapto-succinic acid renal scan showed 5 cases of focal renal scarring not detected by excretory urography. The sensitivity of the renal scan to detect renal scars was 77 per cent and the specificity was 75 per cent. We conclude that neither study alone could effectively replace the other for the detection of renal scars, and recommend that both be included in the initial evaluation and followup of patients with renal scars.

Closure of the exstrophic bladder: an evaluation of the factors leading to its success and its importance on urinary continence

To determine what factors could affect the success of initial bladder closure in classical bladder exstrophy, 80 patients who have completed staged bladder reconstruction were reviewed. Evaluations comparing early bladder closure performed with or without bilateral iliac osteotomy versus delayed closure performed with iliac osteotomy revealed no statistical difference among the 3 populations in regard to the development of bladder dehiscence or onset of urinary continence (p greater than 0.5). Individuals undergoing delayed bladder closure without iliac osteotomy had no notable difference in the incidence of bladder dehiscence (p greater than 0.5) but they had a statistically significant difference in the ability to gain urinary continence (p less than 0.01). Bladder prolapse, abdominal distension or loss of urinary drainage catheters was significantly related to bladder dehiscence (p less than 0.02). Urinary continence was obtained in 75 per cent of the patients with successful bladder closure, compared to 30 per cent if the initial closure dehisced (p less than 0.01).

Phallic reconstruction in cloacal exstrophy

During the last 25 years 8 genotypic male subjects with cloacal exstrophy have undergone phallic reconstruction. All 8 patients had phallic inadequacy after completion of the reconstruction with penile lengths at or below 2 standard deviations below the mean. Of the patients 4 have reached puberty and 2 have documented physiological impotence by nocturnal penile tumescence testing. Three patients have required intensive psychiatric counseling, ranging from 18 months to 3 years because of feelings of sexual inadequacy. Of 2 patients who have attempted sexual relations 1 is unable to penetrate the vagina because of phallic size and 1 is presently engaged in successful vaginal intercourse. As a consequence of phallic inadequacy and its associated psychological trauma in these individuals we strongly recommend sexual conversion as part of the initial management plan.

Urethral replacement with tunica vaginalis: a pilot study

A vascularized tube flap of tunica vaginalis was used to replace the penile urethra in 12 rabbits. Ten flaps were available for assessment, 2 flaps became necrotic as a result of compression of the vascular pedicle and 1 rabbit had a proximal anastomotic stricture. The healing process was satisfactory clinically and histologically in the remaining 7 flaps.

A comparative study of intravenous urograms and radionuclide renal scans in diagnosis of renal trauma

We analyzed 31 patients who underwent intravenous urograms (IVU) and radionuclide renal scans (RNRS) in the investigation of blunt abdominal trauma, and compared the IVU to the RNRS in the definition of blunt renal injuries, and their correlation with patients' symptoms and signs. Thirteen patients had abnormal IVU and 12 had abnormal RNRS (42% of the 31 patients). In 8 patients findings on IVU correlated with those on RNRS (62%), and in 5 patients findings were different (38%). Only 2 patients (6.5%) had significant differences which may have influenced further treatment. Only 1 patient required operative management. Follow-up IVUs were performed on 6 of the 13 patients who had abnormal radiologic studies. The radionuclide renal scan was shown to be as accurate as the intravenous urogram in defining renal trauma. Patients who undergo liver-spleen scans for investigation of blunt abdominal trauma, and who may have renal trauma, may well undergo RNRS at the same time and obviate the need for an IVU, without any diagnostic compromise.

Accuracy of bladder volume determinations in children using a suprapubic ultrasonic bi-planar technique

Accurate residual urine determination is an important measurement in children. We developed a suprapubic ultrasonic method using a bi-planar volume estimation technique to obtain this information in a noninvasive manner. Our data confirm that this method accurately detects an empty bladder in children and can provide reliable estimates of bladder volume.

Fibrous hamartoma of infancy

We report a case of recurrent fibrous hamartoma of infancy in the inguinal region. To our knowledge this is the first such case reported, and it illustrates the benign nature and recurrent potential of the tumor.

Management of the hindgut in cloacal exstrophy: terminal ileostomy versus colostomy

In the management of cloacal exstrophy, controversy exists regarding use of the rudimentary hindgut as a terminal colostomy v salvage of the hindgut for urinary or genital tract reconstruction. Over the past 26 years, 19 patients with cloacal exstrophy have undergone surgical reconstruction at our institution. Ten were managed by terminal ileostomy with an average follow-up of 9 years; nine were managed by permanent colostomy with an average follow-up of 8 years. The number of in-hospital days required due to gastrointestinal (GI) complications and the number of days required for supplemental parenteral hyperalimentation were significantly higher in patients managed by terminal ileostomy than by colostomy (P less than .05 and P less than .03, respectively). All patients have had continued long-term follow-up evaluations in regard to their weight and growth velocities. There is essentially no difference in regard to these characteristics within the two patient population groups. In summary, patients with terminal ileostomies require more frequent hospitalization and prolonged intravenous nutrition during their initial management phase. However, as the child matures and adaptation of the intestine develops, it appears that there are no substantial differences between the growth characteristics of the two patient populations.

Determinants of hydronephrosis and renal injury in patients with myelomeningocele

Renal injury is a major potential complication of patients with neurogenic bladder impairment. There are many clinical, radiological and urodynamic factors that are widely available and that may aid in predicting which patients are at risk of renal injury. This study aims at achieving an objective statistical analysis of these multiple risk factors. We have applied this statistical analysis in a prospective manner to 215 patients with myelodysplasia and neurogenic bladder impairment. Potential risk factors in the lower urinary tract include bladder capacity, contractility and dyssynergia. Each of these factors was assigned a numerical score of 0 to 3, which was correlated with the presence of vesicoureteral reflux. The upper urinary tracts in these patients were assigned a numerical score according to the degree of radiological changes observed. These results then were tested with a stepwise regression analysis using p equals 0.05 as the significance level. In this analysis significant determinants of vesicoureteral reflux included a change in bladder shape, the presence of uninhibited contractions and the presence of dyssynergia. Renal deterioration was noted, and it was predicted by the presence of vesicoureteral reflux, a high ureteral pressure profile and dyssynergia. We conclude from this clinical study that risk of renal injury is present in these children. We also conclude that the risk can be predicted by urodynamic and radiological criteria and that these data can be correlated and analyzed using statistical methodologies.

A comparison of renal function in the exstrophy patient treated with staged reconstruction versus urinary diversion

To assess the preservation of renal function in bladder exstrophy 91 patients with classical bladder exstrophy managed with either staged reconstruction or urinary diversion were reviewed. Renal damage was defined as the development of a renal scar or a persistent elevation in serum creatinine. Of the patients 72 have completed the bladder reconstruction; 51 (71 per cent) are continent and renal damage occurred in 10 (13 per cent) of the reconstructed patients. Median followup was 12.7 years. In a comparable group of 23 exstrophy patients managed by urinary diversion the occurrence of renal damage was notably higher: 82 per cent for ileal conduits, 22 per cent for nonrefluxing colonic conduits and 33 per cent for ureterosigmoidostomy. Based on these results we believe that staged reconstruction of the patient with classical bladder exstrophy offers a low risk for renal injury, an excellent chance for urinary continence and a more acceptable cosmetic appearance.

Factors influencing patient and graft survival in 300 cadaveric pediatric renal transplants

We reviewed the results of 300 cadaveric pediatric renal transplantations performed at our institution. The procedures provided significant survival and improvement of the quality of life in the majority of children. Recipient and graft survival was better in patients more than 5 years old than in younger children. Early nontechnical thrombosis was a major specific problem in young recipients. The original disease did affect graft survival. Uncorrected congenital bladder storage and micturition inefficiency adversely affected graft survival.

The genitourinary system in patients with imperforate anus

The incidence and significance of associated genitourinary abnormalities was reviewed in a series of 484 infants with imperforate anus encountered over a 17-year period. Fourteen percent of the entire series had significant bilateral upper tract urinary abnormalities (either asymmetric or symmetric). Of 67 such patients only 14 had combinations of renal agenesis and hypoplasia-dysplasia representing uncorrectable renal pathology. A high incidence of vesicoureteral reflex and neurovesical dysfunction represent additional important sources of preventable renal deterioration.

Renal transplantation in children

The application of the principles underlying successful renal transplantation in children has led us to increasing success in achieving our goals, which involve more than simple renal function replacement and include effective growth in stature, skeletal and central nervous system development, as well as social development. To succeed in these diverse areas, all modalities of therapy for ESRD may be needed at various times in some patients. Pretransplant therapy must be judiciously selected, and post-transplant protocols often modified to reflect individualized needs.

The artificial urinary sphincter

Urinary incontinence has many etiologies and a similarly varied and wide-ranging spectrum of therapeutic alternatives. The AMS artificial sphincter represents one of these options that has a distinct, albeit limited, place in certain patients. The authors outline the mechanical details of these devices and present their own clinical experience in a large pediatric population.

Ureteral duplication, ectopy and ureteroceles

These entities pose some of the most challenging diagnostic and therapeutic objectives involving the urinary system. The clinical presentations are varied, and involve children from prenatal to adolescent age groups. The diagnostic and therapeutic alternatives are presented, along with a classification for the more complex clinical settings.

Biological response of bladders rendered continent by insertion of artificial sphincter

Artificial sphincters were inserted in 44 children for intractable urinary incontinence. Of the patients 70 per cent achieved satisfactory continence (minimum followup 18 months) with no revisions, and 10 per cent were rendered continent with 1 revision and 10 per cent with multiple revisions. The procedure failed in 10 per cent of the patients primarily because of infection. Extensive urodynamic studies were performed at reoperation and postoperatively. Long-term urodynamic followup was available in 36 continent children. Hydronephrosis occurred in 2 per cent of the upper tracts assessed and 18 per cent of the patients had significant residual urine. Mean bladder capacity tended to increase progressively postoperatively. Mean bladder compliance also was well maintained.

Urodynamics

Urologic problems constitute a very significant percentage of all clinical problems in pediatrics. Incorporation of urodynamic evaluation and followup is important in achieving optimal results in a significant number of these entities. In terms of cost effectiveness, it is particularly efficient in this age of extremely high-priced technology.

Neoplastic potential in patients with disorders of sexual differentiation

The occurrence of tumors was determined in 157 patients with disorders of sexual differentiation at a major pediatric hospital from 1960 to 1980. Gonadoblastoma developed in 2 of the 4 patients with mixed gonadal dysgenesis (MGD) who had not had bilateral gonadectomy; this indicates the need for early gonadectomy in such cases. Gonadal embryonal carcinoma developed in 1 child with Turner's syndrome (1 of 71). Four cases of nephroblastoma occurred, 1 in a child with MGD (1 of 18) and 3 in male pseudohermaphrodites (3 of 35). The nature of the defect linking male pseudohermaphroditism with Wilms tumor remains to be established.

A broader spectrum of abnormalities in the prune belly syndrome

The clinical course of 25 children with the prune belly syndrome was reviewed retrospectively to assess the over-all morbidity associated with this disorder. There were 3 neonatal deaths of renal or pulmonary disease. Chronic renal insufficiency or end stage renal disease developed in 5 survivors, all of whom had impaired kidney function in early infancy. An additional 17 patients survived with only mild renal insufficiency. Growth retardation, which correlated poorly with renal function, was present in a third of the patients. Clinically significant pulmonary and orthopedic problems were noted in 55 per cent of the survivors. Chronic constipation was another common, although less serious, feature. This report emphasizes the severity of the extrarenal problems associated with the prune belly syndrome.

Assessment of urinary stream after repair of anterior hypospadias by meatoplasty and glanuloplasty

Voiding function was studied after repair of anterior hypospadias in 44 boys using Duckett's technique of meatoplasty and glanuloplasty. Assessment of the urinary stream was done in 2 ways. At least 6 weeks postoperatively a uroflow measurement using a DISA rotating disk machine was done. Peak flow was compared to previously prepared normal values in a large group of normal boys. Then, a high speed picture of the stream was taken using electronic video photography at the time of peak flow. Of the boys 42 had normal flow rates and 40 had acceptable stream patterns. The only complication was meatal stenosis in 2 cases. There were no fistulas. Although the primary indication for correction of anterior hypospadias is cosmetic, it is essential that function not be sacrificed to achieve this end. This study indicates that voiding function is maintained after hypospadias repair with meatoplasty and glanuloplasty.

External genital abnormalities associated with Wilms tumor

The records of 170 patients with unilateral and 18 patients with bilateral Wilms tumor and 6 patients with congenital mesoblastic nephroma were reviewed for abnormalities of the external genitalia. There were 4 patients with cryptorchism, 1 with hypospadias, 1 with mixed gonadal dysgenesis, and 3 with male pseudohermaphroditism. Of the group, these 9 patients had earlier symptoms; 6 of them were under two years old. Five patients (27.7%) with bilateral Wilms tumors had external genital anomalies in contrast to only 4 (2.3%) of those with unilateral tumors. One of the 9 children with genital anomalies had unilateral congenital mesoblastic nephroma; the others had Wilms tumor. In all cases the histologic subtypes were unusual. These observations substantiate the previously reported association between external genital abnormalities and Wilms tumor and also represent a somewhat higher than expected incidence. The children with this association are remarkable for the high frequency of a particular histologic type of tumor and for the high incidence of bilaterality. The high incidence of Wilms tumors in the male pseudohermaphrodite population presented suggests that such patients should be monitored for development of renal tumors.

Familial persistent müllerian duct syndrome

We found persistent müllerian duct structures in 2 phenotypically normal brothers who had undergone an operation for inguinal hernia. The older boy had transverse testicular ectopia and his younger brother had unilateral cryptorchidism. Bilateral orchiopexy was done with excision of the fallopian tubes, uterus and upper vagina. Histological examination showed normal testes in both patients. Since there is a risk of testicular malignancy in such patients, long-term followup is mandatory.