Renal dysgenesis and cystic disease of the kidney: a report of the Committee on Terminology, Nomenclature and Classification, Section on Urology, American Academy of Pediatrics

We believe that the confusion regarding abnormal renal development could be reduced by more precise terminology. Therefore, we suggest precise definitions for dysgenesis, hypoplasia, dysplasia, hypodysplasia, aplasia and agenesis of the kidney. We suggest the term reflux nephropathy be a generic label for any instance of abnormal renal morphology (gross or microscopic) associated with vesicoureteral reflux. Hypoplasia and hypodysplasia can be subclassified on the basis of associated urological criteria. There have been many previous attempts to classify cystic disease of the kidney but none has been accepted collectively by pathologists, urologists, nephrologists and radiologists. On the basis of known patterns of inheritance, a classification is outlined in which renal cystic disease is divided into 2 major groups: genetic and nongenetic. Each entity is discussed.

Experiences with bladder reconstruction in children

The results in 56 children (28 with neurogenic bladder dysfunction) undergoing enterocystoplasty between 1981 and 1985 are presented. Ileal, ileocecal, right colon and sigmoid segments were used in tubular and opened configurations. Our experience leads us to recommend opened ileal segment reconstruction in neurogenic bladder patients and those with weak anal sphincters generally, and open ileocecal or open right colon segments in patients with other etiologies. Continence was achieved in 53 patients, although secondary procedures, particularly at the bladder outlet, were required in 13. When ureteral reimplantation was required we achieved excellent success with normal-sized or mildly dilated ureters regardless of the operative technique used. Initial failures to prevent reflux in the face of marked ureterectasis using the ileocecal valve have been resolved by a modified technique of intussusception and fixation. An over-all favorable experience is reported, which we believe permits us to formulate certain rules that will improve the acceptability and success of bladder reconstruction in general.

Percutaneous balloon dilatation of ureteral strictures

Percutaneous balloon dilatation of ureteral strictures has not gained widespread acceptance, despite proven success with the techniques for dilating stenotic blood vessels. Thirty-one ureteral strictures (in 30 patients) that were dilated during a 42-month period were reviewed to assess the results and to determine which patients are most likely to benefit from the procedure. Eighteen (58%) of 31 strictures were successfully dilated and remained patent for at least 6 months. Thirteen (42%) of 31 strictures resulted in failed patency either immediately (two patients) or within 3 months (seven patients), 6 months (three patients), or 21 months (one patient). Fourteen (64%) of 22 strictures less than 7 months of age were successfully dilated. All dilations for strictures more than 7 months of age failed. Four strictures were of unknown age. Nine (69%) of 13 strictures located in the proximal or midureter remained patent, and three (60%) of five dilations at a ureteroileal anastomosis were successful. Neither of two strictures at a ureterocolic anastomosis was treated successfully. We conclude that percutaneous balloon dilatation is an effective treatment of ureteral strictures in some patients, especially when the strictures are less than 7 months of age.

Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis

A hundred patients with RCAV fistulas we compared with 100 patients with expanded PTFE fistulas created during the same time period. The fistulas were analyzed to compare early and late thrombosis, life table patency, infection rate, venous hypertension, and vascular steal. There was a significantly greater incidence of early thrombosis in the RCAV fistula group. Late thrombosis was seen with equal frequency in both groups. Thirty month patency by life table analysis favored the RCAV group to a significant degree, whereas infections, pseudoaneurysms, venous hypertension, and vascular steal were all more common in the expanded PTFE group. The RCAV fistula remains the ideal form of access but it is less frequently available for women and patients with peripheral vascular disease. Utilization of the expanded PTFE loop fistula requires closer observation and maintenance to keep it functional. Improved methods of patient selection for RCAV fistula using ultrasonographic imaging may allow for increased use of this form of access. Improvement in early patency in RCAV fistulas will magnify the superiority of RCAV fistulas in comparison to expanded PTFE fistulas, however, a prolonged period of venous maturation may be necessary to improve early function.

Balloon dilation of upper ureteral strictures in primates

We report the successful creation of ureteral strictures in primates and their successful management by balloon dilation 3 months later without ureteral stenting. This experimental work confirms the sporadic clinical reports of the effectiveness of balloon dilation in the management of ureteral strictures and suggests that ureteral stenting is not necessary for a successful result.

Ileocaecocystoplasty in urinary tract reconstruction in children

Ten children have undergone lower urinary tract reconstruction by ileocaecocystoplasty. Four patients had previously been diverted and the other six were reconstructed because of intractable incontinence or deteriorating renal function. Continence was primarily achieved in eight patients and renal function improved or remained stable in all 10. Reflux was prevented by a plicated ileocaecal valve in five of eight patients. Continued pharmacological manipulation, intermittent self catheterisation and secondary surgical intervention were frequently necessary in these patients who required careful counselling and follow-up.

Bladder substitution in children

In spite of all the difficulties, cystoplasty, particularly with the ileocecal segment, has proved rewarding. Undiversion is easily accomplished in this way. Most patients are outwardly well and happy. Reflux usually does no harm in the near term, especially if infection can be prevented, and bladder pressures are not elevated. However, we believe that we are close to being able to prevent reflux in a reliable manner. If this is the case, the ileocecal segment or hemi-Kock pouch may clearly become the optimal choice for bladder substitution in patients with reflux or ureteral obstruction, as well as those with short ureters or very small bladders, or as a standard method of undiversion. We have also employed the intussuscepted ileum as the antireflux mechanism in patients undergoing bladder substitution using a patch of small bowel as in the hemi-Kock. This technique allows one to leave the cecum and ileocecal valve in situ, reducing the risk of chronic postoperative diarrhea. In addition, small bowel is proving to be more compliant on the average than large bowel segments when used in bladder reconstruction. Whether the ileocecal segment or the hemi-Kock cystoplasty has a permanent place in undiversion and in the treatment of chronic or pharmacoresistant noncompliant bladder, neuropathic or otherwise, the techniques learned are making total replacement of the bladder with bowel segments a more attractive and feasible undertaking. The pool of patients susceptible to such maneuvers is a large one.

Suggested terminology for duplex systems, ectopic ureters and ureteroceles

Recommendations are made for the standardization of nomenclature describing duplex systems, ectopic ureters and ureteroceles. The elimination of some terms and redefinition of others are proposed in the hope to eliminate the ambiguity and confusion that exist currently.

The case for immediate pyeloplasty in the neonate with ureteropelvic junction obstruction

The 99mtechnetium-diethylenetriaminepentaacetic acid renal scan allows differentiation of ureteropelvic junction obstruction from multicystic kidney in most instances. Although renal function usually will improve at least a little after relief of obstruction, the young infant is privileged and more improvement can be expected than occurs usually in older children. Since an operation is as safe and results of pyeloplasty are as good in the neonate as in older infants or children early correction of ureteropelvic junction obstruction is advocated in otherwise healthy infants as soon as the diagnosis is established.

Initial experiences with percutaneous and transurethral ablation of postoperative ureteral strictures in children

A transurethral or percutaneous procedure was used in 11 children and 1 young adult in an attempt to correct obstruction at the site of previous pyeloplasty, ureteroenterostomy or vesicoureteral reimplantation into the bladder. When a guide wire could be passed through the obstructed segment a balloon would always pass over the wire. The balloon could then be inflated to dilate the narrowed area. Five patients in whom the obstruction was detected and treated in this manner within a few months after the initial operation exhibited relief of obstruction and these good results have persisted. The exception to this generalization is a 5-year-old girl who did not experience durable improvement in obstruction when treated 3 months after ureteral implantation. Four additional children with ureteral strictures diagnosed 1 to 4 years postoperatively also were not improved by dilation, even when a post-dilation stent (usually a double-J catheter) was used for 6 to 8 weeks. Two boys with recurrent ureteropelvic junction obstruction after pyeloplasty underwent percutaneous resection of the ureteropelvic junction. In 1 boy the hook electrode and cautery were used and stenosis recurred, apparently due to thermal injury. In the other boy a sharpened hook electrode was used to incise the ureteropelvic junction, which has stayed open for 18 months, and he is our longest followup.

Multiple simultaneous urologic procedures in pediatric patient. Evaluation of risk and cost-effectiveness

We report on several pediatric patients in whom multiple surgical procedures were performed under the same anesthesia. The hospital cost is compared with the estimated cost if the procedures were performed separately. The savings were considerable, and there was no increase in morbidity and no lessening of the quality of results.

Ureteroceles in children. A simplified and successful approach to management

This review documents the success that we have experienced in treating most ureteroceles that present in children by heminephroureterectomy. If excision of the ureterocele is required, or reimplantation of a ureter other than the ureter obstructed by the ureterocele, this is deferred until the degree of hydronephrosis is reduced or bladder thickening and trabeculation have returned toward normal. In instances where there is function in the upper pole segment obstructed by the ureterocele, ureteropyelostomy has enabled us to preserve renal function by removing the obstructed ureter to permit the ureterocele to collapse.

The vesical sphincter electromyogram in children with normal and abnormal voiding patterns

Recording the vesical sphincter electromyogram clarifies abnormal patterns of voiding in children. Since the electromyogram patterns in children with normal voiding patterns have not yet been evaluated, we recorded the sphincter electromyograms during voiding of 39 children with normal voiding patterns. These normal electromyograms were compared to those recorded in 86 children with abnormal voiding patterns. Each of the 39 children with a normal voiding pattern demonstrated synergy of the vesical sphincter during voiding. Of the 86 children with an abnormal voiding pattern 69 per cent demonstrated synergy and 31 per cent demonstrated dyssynergia of the vesical sphincter during voiding. Of the children with dyssynergia 89 per cent were girls and only 11 per cent were boys. Sphincter dyssynergia was demonstrated only by children with an abnormal pattern of voiding and those with a history of a normal pattern of voiding demonstrated only sphincter synergy (p less than 0.005). The electromyographic diagnoses of vesical sphincter synergy and dyssynergia obtained by surface electrode recordings correlated with the clinical voiding patterns of the children.

Cowper's syringocele: a classification of dilatations of Cowper's gland duct based upon clinical characteristics of 8 boys

Lesions of Cowper's gland duct assume various appearances. A system to classify each of these appearances is offered to diagnose these lesions more precisely. The urethrographic and endoscopic characteristics of dilated Cowper's gland ducts noted in 8 boys are grouped as a simple classification. The dilated Cowper's duct is referred to as a syringocele (Greek syringo--tube plus cele--swelling). There are 4 groups of Cowper's syringoceles: 1) simple syringocele--a minimally dilated duct, 2) perforate syringocele--a bulbous duct that drains into the urethra via a patulous ostium and appears as a diverticulum, 3) imperforate syringocele--a bulbous duct that resembles a submucosal cyst and appears as a radiolucent mass, and 4) ruptured syringocele--the fragile membrane that remains in the urethra after a dilated duct ruptures. Marsupialization of the syringoceles cured urine infection and hematuria but voiding symptoms may persist.