Ureteral reimplantation in infancy: evaluation of long-term voiding function

PURPOSE

The advisability of early ureteral reimplantation in neonates and infants is controversial and to our knowledge long-term results are not available. We evaluated long-term voiding function after ureteral reimplantation in infancy.

MATERIALS AND METHODS

Between 1984 and 1993, 32 children underwent ureteral reimplantation in year 1 of life at our institution. Long-term results were evaluated in regard to surgical outcome, voiding function, urinary tract infection and the need for prophylaxis. Analysis of voiding function included family interviews, uroflowmetry and post-void residual urine measurement.

RESULTS

Complete long-term data were available in 14 girls and 7 boys. The diagnosis was primary bilateral and unilateral vesicoureteral reflux, and ureterovesical junction obstruction in 11, 4 and 6 cases, respectively. Of the 26 refluxing renal units overall disease was grade II in 3, III in 6 and IV to V in 17. Patient age at surgery was 0.6 to 12 months (mean 5.4) and followup was 5 to 13 years (mean 9.5). Tapered reimplantation was performed in 8 renal units using excisional or infolding in 5 and 3, respectively. There were no complications in 19 patients (94%), while 2 had postoperative reflux for which 1 underwent reoperation. In 13 patients voiding habits were normal, while 8 reported infrequent voiding (3 or fewer voids daily). In 19 of the 20 patients tested voided volume was appropriate, and the flow rate of 10.8 to 52.7 cc per second (mean 20.9) and post-void residual urine volume of 0 to 40 cc (mean 11) were considered normal. One patient with normal uroflowmetry had incomplete vesical emptying.

CONCLUSIONS

Early reimplantation may result in a high technical success rate and low postoperative morbidity in infants. After long-term followup infrequent voiding was common but noninvasive assessment of bladder function revealed no significant abnormality in the majority of patients.

Long-term outcome based on the initial surgical approach to ureterocele

PURPOSE

The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele.

MATERIALS AND METHODS

We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery.

RESULTS

Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months).

CONCLUSIONS

Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.

Ureteral reimplantation in infancy: evaluation of long-term voiding function

PURPOSE

The advisability of early ureteral reimplantation in neonates and infants is controversial and to our knowledge long-term results are not available. We evaluated long-term voiding function after ureteral reimplantation in infancy.

MATERIALS AND METHODS

Between 1984 and 1993, 32 children underwent ureteral reimplantation in year 1 of life at our institution. Long-term results were evaluated in regard to surgical outcome, voiding function, urinary tract infection and the need for prophylaxis. Analysis of voiding function included family interviews, uroflowmetry and post-void residual urine measurement.

RESULTS

Complete long-term data were available in 14 girls and 7 boys. The diagnosis was primary bilateral and unilateral vesicoureteral reflux, and ureterovesical junction obstruction in 11, 4 and 6 cases, respectively. Of the 26 refluxing renal units overall disease was grade II in 3, III in 6 and IV to V in 17. Patient age at surgery was 0.6 to 12 months (mean 5.4) and followup was 5 to 13 years (mean 9.5). Tapered reimplantation was performed in 8 renal units using excisional or infolding in 5 and 3, respectively. There were no complications in 19 patients (94%), while 2 had postoperative reflux for which 1 underwent reoperation. In 13 patients voiding habits were normal, while 8 reported infrequent voiding (3 or fewer voids daily). In 19 of the 20 patients tested voided volume was appropriate, and the flow rate of 10.8 to 52.7 cc per second (mean 20.9) and post-void residual urine volume of 0 to 40 cc (mean 11) were considered normal. One patient with normal uroflowmetry had incomplete vesical emptying.

CONCLUSIONS

Early reimplantation may result in a high technical success rate and low postoperative morbidity in infants. After long-term followup infrequent voiding was common but noninvasive assessment of bladder function revealed no significant abnormality in the majority of patients.

Lack of morbidity from urodynamic studies in children with asymptomatic bacteriuria

OBJECTIVES

Patients on clean intermittent catheterization (CIC) have a high rate of asymptomatic bacteriuria. Although prophylactic antibiotics for routine surgical procedures in patients with bacteriuria is common practice, the role of prophylaxis for invasive diagnostic procedures remains unclear. The aim of this study was to investigate the morbidity associated with urodynamic evaluation in patients with asymptomatic bacteriuria.

METHODS

Routine urodynamic evaluation was performed in 69 pediatric patients (mean age 10 years). Ninety-six percent had a neurogenic bladder, and most were on CIC. Routine urine cultures were obtained at the time of the cystometrogram. Forty-six patients had positive urine cultures, and 23 patients with sterile urine served as a comparison. Patients were evaluated subjectively for symptoms of a urinary tract infection (UTI) within 1 week of the procedure. The results of the cystometrograms were compared between the patients with and without bacteriuria.

RESULTS

No patient developed symptomatic UTI after the urodynamic studies. Overall, 65% of the patients with and 52% of the patients without bacteriuria had adequate capacity and compliance, and there was no difference in the urodynamic findings between the patients with and without bacteriuria (P = 0.4).

CONCLUSIONS

Urodynamic studies were performed safely in the presence of asymptomatic bacteriuria in the present study. Therefore, routine use of urine cultures or prophylactic antibiotics before urodynamic studies in pediatric patients with a neurogenic bladder does not appear to be indicated.

Outcome of palliative urinary diversion in the treatment of advanced malignancies

BACKGROUND

It is unclear whether palliative endourologic or percutaneous urinary diversion in the treatment of advanced cancer provides significant improvement in quality or duration of life. The purpose of this study was to evaluate survival and performance status after endourologic palliative urinary diversion in patients with advanced malignancy and to compare the results for different malignancies.

METHODS

One hundred three patients with advanced malignancies underwent palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninety-two patients and 11 patients had bilateral and unilateral obstruction, respectively. Indications, complications, performance status after diversion, and survival for patients with different malignancies were identified and compared. A modified Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0-4 was used: 0) hospitalized until death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal.

RESULTS

The mean age of patients was 68 years. The mean pre- and postoperative creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P < 0.0001). The median survival and days of hospitalization were 112 and 45, respectively. The median postdiversion KPS score was 2 (range, 0-4), and 15% of patients never left the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4% had complications (minor, 63%; major, 5.4%).

CONCLUSIONS

Most patients with advanced cancers had poor performance status and survival after diversion. Eighty six percent had cancer-related symptoms despite the diversion. The average survival was 5 months, 50% of which was spent in the hospital. Primary endourologic procedures had a high failure rate, and additional procedures were required.

Outcome of palliative urinary diversion in the treatment of advanced malignancies

BACKGROUND

It is unclear whether palliative endourologic or percutaneous urinary diversion in the treatment of advanced cancer provides significant improvement in quality or duration of life. The purpose of this study was to evaluate survival and performance status after endourologic palliative urinary diversion in patients with advanced malignancy and to compare the results for different malignancies.

METHODS

One hundred three patients with advanced malignancies underwent palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninety-two patients and 11 patients had bilateral and unilateral obstruction, respectively. Indications, complications, performance status after diversion, and survival for patients with different malignancies were identified and compared. A modified Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0-4 was used: 0) hospitalized until death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal.

RESULTS

The mean age of patients was 68 years. The mean pre- and postoperative creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P < 0.0001). The median survival and days of hospitalization were 112 and 45, respectively. The median postdiversion KPS score was 2 (range, 0-4), and 15% of patients never left the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4% had complications (minor, 63%; major, 5.4%).

CONCLUSIONS

Most patients with advanced cancers had poor performance status and survival after diversion. Eighty six percent had cancer-related symptoms despite the diversion. The average survival was 5 months, 50% of which was spent in the hospital. Primary endourologic procedures had a high failure rate, and additional procedures were required.

Inguinal hernia as a rare cause of penile prosthesis malfunction . A report of two cases

Penile prosthesis malfunction is associated with mechanical failure as well as with infection requiring removal of the prosthesis. We report on the 2 first cases in the literature of inflatable penile prostheses in the presence of inguinal hernia. We advocate early hernia repair in patients with inflatable penile prostheses to avoid malfunction related to hernia.

Penile implant for intractable priapism associated with sickle cell disease

Intractable, therapy-resistant priapism in a patient with sickle cell disease is presented. The patient was managed with insertion of an inflatable penile prosthesis. He consequently maintained potency and remains free of priapitic episodes. To our knowledge, immediate penile prosthesis insertion for management of priapism has not been reported. We discuss the indications and advantages of this approach and review the current literature.

Priapism associated with sickle cell hemoglobinopathy in children: long-term effects on potency

PURPOSE

Children with sickle cell priapism have traditionally been treated conservatively with surgery done as a last resort. Only sparse subjective data are available on the long-term assessment of potency in these patients.

MATERIALS AND METHODS

We retrospectively reviewed the charts of all pediatric patients with sickle cell priapism who presented to Children's Hospital of Michigan between 1972 and 1992, and subsequently assessed erectile capabilities subjectively by questionnaire and objectively by RigiScan.

RESULTS

Of the 15 patients interviewed 5 had undergone shunt procedures. The return of potency tended to vary inversely with patient age at onset and duration of priapism.

CONCLUSIONS

Shunts performed within 48 hours, especially in postpubertal children, seemed more likely to preserve potency.

Anomalies in the enumeration of starved bacteria on culture media containing nalidic acid and tetracycline

Culturable counts of antibiotic resistant, genetically engineeredPseudomonas fluorescens were determined on antibiotic-containing plate count agar during starvation in water. Prior to starvation, colony counts obtained on all media separated into two groups. The mean of the colony counts on plate count agar with or without tetracycline (4.9 × 10(6) ml(-1)) was significantly higher than the mean colony counts on plate count agar containing either nalidixic acid or nalidixic acid plus tetraclycline (2.5×10(6) ml(-1)). After 20 days of starvation the highest mean colony counts continued to be obtained on plate count agar (7.2 × 10(6) ml(-1)) with slightly, but significantly, lower counts obtained on plate count agar containing either nalidixic acid (5.6 × 10(6) ml(-1)) or tetraclycline (1.5×10(6) ml(-1)). A combination of nalidixic acid and tetracycline in plate count agar, however, dramatically reduced colony counts (8.3 × 10(2) ml(-1)) after this starvation period. The addition of catalase to plate count agar containing nalidixic acid and tetracycline negated the effect caused by this combination of antibiotics. When colony counts obtained over the entire 20 day incubation were considered, the addition of MgSO4 to plate count agar containing nalidixic acid and tetracycline resulted in a significant increase in colony counts. Other combinations of antibiotics, nalidixic acid+carbenicillin, nalidixic acid+kanamycin, streptomycin+tetracycline, streptomycin+carbenicillin, rifampicin+tetracycline, rifampicin+carbenicillin, and rifampicin+kanamycin, did not inhibit colony formation of starved cells. Antibiotic resistant strains ofP. putida andEscherichia coli also displayed sensitivity to the combination of nalidixic acid and tetracycline in plate count agar after starvation.

Radiation survival of bacterial spores in neutral and acid ice

Spores of C. botulinum 33A were irradiated at pH 2, 3, 4, 5, 6, and 7 to 0.6, 0.7, and 0.9 Mrad cobalt-60. Temperatures were controlled at −196 °C to 0 °C in distinct intervals. The survival data presented a complex wave-like pattern which appeared to be influenced by pH, temperature, and dose of radiation. Three typical survival patterns could be recognized. Pattern A (at −190 °C) showed peaks of high survival at pH 4 and 7 and low survival at pH 2 and 6. Pattern B (at −50, −40, and −30 °C) showed peaks of high survival at pH 3 and 6 and low survival at pH 2, 4–5, and 7.0. Pattern C (at 0 °C) was similar to pattern A but had generally higher peaks and deeper troughs. Between the temperatures showing typical A, B, and C patterns, the survival profiles indicated various degrees of transition from A to B or from B to C.The effect of pH appears to be related to its influence on yield of radicals in water such as, for example, ∙OH, which may result in highly lethal conditions within the region of low spore survival, and extinction of ∙OH by reaction with H∙ at the peaks of spore survival.

Radiation survival of bacterial spores in neutral and alkaline ice

The effect of pH values ranging from 6 to 12 on spores of Clostridium botulinum 33A exposed to 0.6–0.9 Mrad Co-60 resulted in a complex wavelike pattern of survival which was influenced by pH, temperature, and dose of radiation. Within the experimental pH range three typical survival patterns could be recognized. Pattern A (at −190 °C) showed peaks of high survival at pH 7 and 9.5 and troughs of low survival at pH 8 and 10–11. Pattern B (at −50 °C) showed a single broad peak of high survival at pH 8.5 to 9 and troughs of low survival at pH 7 and 10. Pattern C (at 0 °C) showed peaks of high survival at pH 7.5 and 10 and troughs of low survival at pH 6,9, and 11. Between the temperatures showing typical A, B, and C patterns the survival profiles indicated various degrees of transition from A to B and from B to C.These results can be tentatively explained in terms of indirect effects, viz. maximum activity of radicals such as ∙OH in the troughs and extinction of ∙OH by reaction with eaq− or H∙ at the peaks.

EFFECT OF TEMPERATURE ON RADIATION RESISTANCE OF SPORES OF CLOSTRIDIUM BOTULINUM 33A

Spores of Clostridium botulinum 33A in two suspending media, phosphate buffer and pork pea broth, were gamma irradiated at radiation temperatures from +20 °C to −196 °C. The liquid–solid transition around 0 °C introduced a one-step plateaulike change in radiation sensitivity of spores. The spores were considerably more resistant in the solidly frozen medium than in the liquid medium. The solid state reduced indirect effects of radiation by physical blocking of secondary radicals. The one-step transition was much smaller in pork pea broth than in buffer. This indicated that scavenging of secondary radicals by pork pea broth caused a considerable reduction of indirect effects of radiation, but did not completely eliminate them.Freezing alone did not eliminate all indirect effects. This was evident from the gradual reduction in radiation sensitivity of spores in the solidly frozen phosphate buffer betweeen −25 °C and −196 °C. Furthermore, even at −196 °C indirect effects of radiation remained active since (a) spore survival did not level off with respect to temperature and (b) the lethal efficiency of radiation was still appreciably greater in phosphate buffer than in pork pea broth at −196 °C.In frozen pork pea broth at −25 °C to −196 °C temperature had no effect on radiation sensitivity of spores. This indicated that spores were killed by direct hits; apparently physical blocking by the solidly frozen medium, plus radical scavenging by pork pea broth eliminated all indirect effects of radiation.