Posterior urethral valves: multivariate analysis of factors affecting the final renal outcome.

PURPOSE: Posterior urethral valves represent the most common obstructive uropathy in children with a broad spectrum of clinical severity. We evaluated prognostic variables affecting the outcome of renal function in such children. MATERIALS AND METHODS: Between 1987 and 2004, 120 patients with a mean age of 2 years with posterior urethral valves were treated initially with valve ablation at our center. We studied certain parameters, including age at presentation, serum creatinine (initial and nadir), initial creatinine clearance, renal ultrasound findings (hydronephrosis and renal parenchymal echogenicity), vesicoureteral reflux on initial voiding cystourethrogram, bladder dysfunction and popoff mechanisms such as the syndrome of large vesical diverticulum, urinoma and ascites. Long-term renal outcome was assessed. RESULTS: Followup was 2 to 16 years (median 3.6). Renal insufficiency developed at the end of followup in 44 patients (36.5%). Serum creatinine at hospital admission, nadir serum creatinine, initial creatinine clearance and renal parenchymal echogenicity were significant predictors of the final renal outcome (p < 0.05). Patient age at diagnosis (2 or less vs greater than 2 years), upper tract dilatation, the presence or absence of vesicoureteral reflux, popoff mechanisms and bladder dysfunction had no significant impact on future renal function. On multivariate analysis nadir serum creatinine was the only independent prognostic factor. CONCLUSIONS: Our data confirm the high prognostic value of nadir creatinine after primary valve ablation. Also, initial serum creatinine, creatinine clearance and renal parenchymal echogenicity on initial renal ultrasound correlate significantly with long-term renal function in children with posterior urethral valves.

Management of bladder exstrophy epispadias complex in adults: is abdominal closure possible without osteotomy?

PURPOSE: Presentation of bladder exstrophy epispadias complex (BEEC) during adulthood is rare. A major surgical challenge encountered in adults with BEEC is the closure of the anterior abdominal wall defect. In this case series we report our experience with the abdominal closure without osteotomy. MATERIALS AND METHODS: Five adult male patients with BEEC were managed at our center. None of the patients had any prior attempts of surgical correction. A right renal tumor was incidentally discovered in one patient and a right partial nephrectomy was performed. All patients underwent urinary diversion and abdominal wall closure at the same operative setting except one. Cystectomy was performed in two patients while the vesical plate muscular coat was utilized for providing support to the anterior abdominal wall in the other three patients. One patient underwent an ileal conduit, while the other patients underwent continent cutaneous diversion. None of our patients underwent osteotomy. RESULTS: Follow-up ranged from 6 to 52 months (mean = 31). Patients who underwent continent cutaneous diversion were continent by day and night. One patient had wound infection and partial disruption and secondary sutures were performed. One patient developed stomal stenosis and was managed by stomal dilatation. All patients showed marked satisfaction with their body image following surgery. CONCLUSION: Management of BEEC in adults is challenging. Utilization of the vesical plate muscular coat for supporting the anterior abdominal wall is a reliable method for abdominal reconstruction. Urinary diversion and abdominal wall closure in one surgical procedure without osteotomy is feasible.

Factors affecting outcome of tubularized incised plate (TIP) urethroplasty: single-center experience with 500 cases.

PURPOSE: To review our experience of tubularized incised plate (TIP) urethroplasty in children with hypospadias defects. METHODS: Of 500 children (mean age 6 years) who received a TIP urethroplasty, 439 (87.8%) had primary hypospadias and 61 had one failed previous repair. The hypospadias defects were coronal in 110 (22%), distal penile in 261 (52.2%), midpenile in 78 (15.6%) and proximal in 51 (10.2%). Chordee was present in 98 (19.6%) patients. Presence of complications requiring re-operation and overall general appearance was recorded. RESULTS: The mean (SD, range) follow-up was 34 (18, 7-77) months. Overall success rate was 81.4%. Re-operation was required in 93 patients (18.6%); for urethrocutaneous fistula in 47 (9.4%), complete disruption of the repair in 32 (6.4%) and meatal stenosis in 14 (2.8%). In univariate analysis, complications were significantly higher in stented repairs, posterior hypospadias, those with no neourethral coverage (spongioplasty), and repairs early in the study. The last three factors were the only significant independent risk factors in multivariate analysis. CONCLUSIONS: TIP is a reliable method for treating both distal and proximal hypospadias and is suitable for both primary and re-operative cases with a low rate of complications. A significantly better outcome is achieved with distal hypospadias, covering the neourethra with the mobilized corpus spongiosum (spongioplasty) or a flap, and experience. Stenting of the repair, patient age, or previous failed repair has no statistically significant impact on outcome.

Ureterocalyceal anastomosis in children: is it still indicated?

OBJECTIVE: We report our experience with ureterocalyceal anastomosis in children regarding indications and outcome. MATERIALS AND METHODS: A retrospective review was performed of all cases that underwent open ureterocalyceal anastomosis at our center between 2000 and 2006. Records were reviewed for patient age, history, affected side, indication of surgery and operative details. Clinical and radiological outcome was assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. RESULTS: There were 10 cases (six males, four females) with a mean age of 6.5 years (range 3-13 years). Follow up ranged from 6 to 46 months (mean 18). The indications for surgery were failed pyeloplasty in six patients and iatrogenic injury of the ureteropelvic junction or the upper ureter in four. No significant perioperative complications were encountered in the study group. Overall success rate was 80%. Relief of obstruction was evident in eight patients as documented by intravenous urography or nuclear renography, while secondary nephrectomy was necessitated in two patients with severely impaired ipsilateral renal function and normal contralateral kidney. In patients with preserved renal units, the differential function on the involved side was stable on comparing the preoperative and postoperative renographic clearance (26 vs 24 ml/min). CONCLUSION: Ureterocalyceal anastomosis in children is still indicated in some difficult situations. Excellent functional results can be achieved in properly selected cases. Nephrectomy may be indicated in cases with impaired renal function and inability to perform salvage procedure.

Surgical management of failed pyeloplasty in children: single-center experience.

PURPOSE: To evaluate the outcome of secondary surgical procedures for the management of failed pyeloplasty in children. MATERIALS AND METHODS: Between 1996 and 2007, 590 cases of primary ureteropelvic junction (UPJ) obstruction underwent open dismembered pyeloplasty at our center. Of these patients, 18 (3%) with recurrent UPJ obstruction (14 males, 4 females; age range: 2-15 years) have undergone management of failed pyeloplasty. Secondary intervention was by open operative procedure in all cases. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. RESULTS: Follow up ranged from 8 to 41 months (mean 28). The overall salvage rate was 89%. Secondary reoperative surgery was successful in 16 patients: dismembered pyeloplasty in 14 patients (78%) and ureterocalyceal anastomosis in 2 (11%). Nephrectomy was necessitated in 2 patients (11%). No perioperative complications were encountered. All patients showed stability of renal function on radiological follow up without evidence of obstruction and with no further symptoms. CONCLUSION: Persistent UPJ obstruction after pyeloplasty is an uncommon complication. Secondary procedures have a very high success rate with excellent functional results. Nephrectomy is indicated in rare cases of severely deteriorated renal function.