The practice of urethral dilation for voiding dysfunction among fellows of the Section on Urology of the American Academy of Pediatrics

PURPOSE

Review of the literature reveals little scientific evidence to prove or disprove the efficacy of urethral dilation for children with dysfunctional voiding and recurrent urinary tract infections. We ascertain the current practice of urethral dilation among pediatric urologists.

MATERIALS AND METHODS

An anonymous questionnaire regarding the practice of urethral dilation was mailed to all fellows in the Section on Urology of the American Academy of Pediatrics. The questionnaire contained 14 questions and included biographical information.

RESULTS

The questionnaire response rate was 64%. When asked how one would treat a typical female child with classic voiding dysfunction, 87% responded with timed voiding and relaxation techniques with or without anticholinergics. Only 2.5% would proceed directly to cytoscopy and urethral dilation. For patients who did not respond to initial treatment, 67% would proceed with either urodynamics or biofeedback and only 10% would then perform urethral dilation. Of responders 61% do not practice urethral dilation under any circumstance, 36% will use it when all other means of therapy have failed, while only 2% use urethral dilation regularly and 2% find it helpful and will occasionally use it. Among physicians who perform urethral dilation 63% believed that less than half of the patients experienced long-term improvement. Overall, there was no consensus as to mechanism of action of urethral dilation.

CONCLUSIONS

Urethral dilation is rarely used as primary treatment for pediatric voiding dysfunction, is usually reserved until all other treatments have failed and appears to have long-term efficacy in less than 50% of patients. To define better the need for this treatment modality and its efficacy, a randomized prospective trial is mandatory.

[Pre- and postpartum ultrasound examinations for diagnosis of urogenital abnormalities]

BACKGROUND

The aim of the study was to evaluate prenatal and postpartal sonographic investigations to diagnose congenital uropathies.

PATIENTS/METHODS

The Mainz birth defect monitoring system, the "Mainzer Model", was launched in 1990. Over a period of five years (1/90 to 1/95) 19,028 newborns underwent postpartal sonographic examination. Anamnestic data including prepartal sonographic examination were collected. According to a defined ultrasound criteria list, ultrasound findings were considered normal in 94.8% of the neonates, 4.4% were defined as requiring a follow-up examination and 0.8% were pathological. In the current study we analyzed patients with pathological findings with their pre- and postpartal sonographic investigations as well as their clinical data (urinary tract infections, operative procedures).

RESULTS

In the study group prenatal ultrasonography showed evidence of severe anomalies only in 51 fetuses (32.9%). Surgical correction was required in 39 cases. 20 (51%) have been diagnosed prenatally. 28 patients presented with urinary tract infections. Out of this group only 11 patients have been detected by prenatal ultrasound.

CONCLUSION

In conclusion, postnatal ultrasound is more effective to diagnose anomalies of the urinary tract. To prevent complications i.e. urinary tract infections a neonatal screening program would be valuable.

[Evaluation of bacteriological research data and laboratory symptoms of infection in the diagnosis of congenital and acquired infections]

The predisposition of the newborns to contract infections diseases is dependent upon the limited efficiency of their immune mechanisms. Congenital infections amount to 5.7% in the research material, and the acquired infections 1.15%. The isolation of the microorganism is the basis for treating infections-the profiles of the pathogenic bacterial in flora were subjected to analysis. Im generalised infections Stafphylococcus epidermidis makes 56.6% and E. Coli accounts for 87.5 of the infections of the urinary system. In our research the late sepsis and pneumonia are more frequently the result of the hospital infection (14.2%) in the cases of congenital infections-pneumonia and the infection of the urinary system (72%). Hematologic indicators such as: leucopenia, thormbocytopenia, I/T are distinct infection markers (those were found in 31% of the cases). The CRP protein shows the lowest values in congenital infections, still monitoring its level is useful for assessing the effectiveness of the undertaken antybacterial treatment. The newborns of male sex (58%) more often prone to infection. Pneumonia is the manifestation pertaining to an organ in 70% of congenital infections, the infection of urinary system amounts to 17.1%.

Ectopic ureter with complete ureteric duplication: conservative surgical management

To assess the outcome of conservative procedures, the authors reviewed their experience in the management of 31 ectopic ureters with complete ureteric duplication. Twenty-eight girls and three boys (aged 19 days to 10 years; mean, 30 months) were operated on between 1968 and 1994. Twenty-four of the children presented for evaluation of dribbling urinary incontinence and/or febrile urinary tract infections; seven presented after prenatal ultrasonographic diagnosis of hydronephrosis. The location of the ectopic orifice was identified in 25 children: bladder neck (6), posterior urethra (6), vagina (7), and vestibule (6). Upper pole nephroureterectomy was performed in 16 children who had nonfunctioning renal segments. Ureterovesical reimplantation was performed in 10 children who had functioning segments. In five borderline cases, temporary cutaneous ureterostomy was performed, followed by ureteropyelostomy (2), ureterovesical reimplantation (2), and upper pole nephrectomy (1). Histological examination of the polar nephrectomy specimens showed lesions of dysplasia in only four cases (24%). The follow-up period ranged from 6 months to 20 years (mean, 66 months). All children who presented with incontinence became continent after polar nephrectomy or conservative surgery. One child required surgical revision of the ureteropyelostomy anastomosis. Of the 12 children who had ureterovesical reimplantation, none needed further procedures. Ectopic ureters in duplex systems with functioning renal segments should be conserved.

Neonatal hydronephrosis: 146 cases

Recognition and precise etiologic diagnosis of neonatal hydronephrosis is worthwhile since, although often severe, it is usually treatable with at least partial success. This relatively favorable prognosis, despite dilatation that may be marked, suggests a greater regenerative capacity at this age, or may be due to the relative infrequency or short duration of the infection.