Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?

INTRODUCTION: Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution. To the knowledge of the authors, no study has yet explored the time delays and outcomes associated with these repeat ultrasounds. OBJECTIVE: The objective was to investigate the impact of repeat ultrasound imaging on time to treatment and patient outcomes in patients with testicular torsion. STUDY DESIGN: A retrospective chart review of 133 patients, aged 0-20 years, treated at the authors' institution for testicular torsion was conducted. Neonate patients and patients who did not receive ultrasound were excluded. Demographic and clinical variables were collected from the electronic medical record. Pearson Chi-squared and t-tests were used for univariate comparisons, and multivariate logistic regression analysis was performed to measure the relationships between variables. RESULTS: Forty-nine percent of patients were primary patients, and 51% were transfer patients. Fifty-two percent of transfer patients received repeat ultrasounds. In comparison to salvaged patients, those who underwent orchiectomy experienced a greater delay between presentation at the institution and surgical intervention (229 min vs 177 min, p = 0.048). The transfer status does not appear to be related to the outcome, i.e. orchiectomy versus salvage. Patients who underwent orchiectomy were more likely than salvaged patients to have received repeat ultrasounds (p = 0.008). Repeat ultrasound patients had three times the likelihood of orchiectomy of single ultrasound patients. In a subset analysis of transfer patients, repeat ultrasound patients were more likely than single ultrasound patients to receive an orchiectomy (p = 0.03). DISCUSSION: In agreement with previous studies, patients who underwent orchiectomy were found to experience greater treatment delays and trend toward transfer. Specifically, repeat ultrasound and time between presentation and intervention appear to influence patient outcomes. The effect of repeat ultrasound on outcomes appears to be independent of the transfer status. The study was limited by its retrospective nature and small sample size. CONCLUSION: The analysis suggests that efforts to prevent repeat ultrasounds and minimize the time between presentation and intervention would improve patient outcomes. It is proposed that standardized clinical decision-making procedures, such as the TWIST scoring system, be incorporated into hospital protocols.

Angiotensin induces the urinary peristaltic machinery during the perinatal period.

The embryonic development of mammalian kidneys is completed during the perinatal period with a dramatic increase in urine production, as the burden of eliminating nitrogenous metabolic waste shifts from the placenta to the kidney. This urine is normally removed by peristaltic contraction of the renal pelvis, a smooth muscle structure unique to placental mammals. Mutant mice completely lacking angiotensin type 1 receptor genes do not develop a renal pelvis, resulting in the buildup of urine and progressive kidney damage. In mutants the ureteral smooth muscle layer is hypoplastic and lacks peristaltic movements. We show that angiotensin can induce the ureteral smooth muscles in organ cultures of wild-type, but not mutant, ureteral tissues and that, in wild-type mice, expression of both renal angiotensin and the receptor are transiently upregulated at the renal outlet at birth. These results reveal a new role for angiotensin in the unique cellular adaptations of the mammalian kidney to the physiological stresses of postnatal life.

Interdisciplinary pain management is beneficial for refractory orchialgia in children.

INTRODUCTION: Idiopathic testicular/groin pain can be a difficult entity for children, their families, and caregivers. The role of interdisciplinary pain management has previously been demonstrated in treating chronic orchialgia at the present pediatric pain clinic. OBJECTIVE: To evaluate the role of interdisciplinary pain management in managing refractory orchialgia. It was hypothesized that children with refractory orchialgia might respond well. Interdisciplinary care was defined as that which crosses two medical disciplines such as a surgical specialty and specialist in analgesia. SUBJECTS AND METHODS: Pediatric patients were identified who were: ≥ 10 years old; evaluated in the pediatric urology clinic between 2002 and 2012; were diagnosed wtih ICD code 608.9 or had the diagnosis of male genital disorder NOS. Children were included if they presented with orchialgia without an identifiable cause and failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids). Patient electronic medical records were reviewed retrospectively. RESULTS: Twenty-two children met inclusion criteria. Mean age was 13.7 years (range 10-17). Nearly half (45%) of the children had chronic medical conditions such as asthma, allergies, and obesity. Twenty-one of the 22 children were referred to the pediatric pain clinic; 15 were evaluated, and one refused treatment. All children evaluated in the pediatric pain clinic were initially offered an empiric anti-neuropathic anti-convulsant (i.e. gabapentin) and/or an anti-depressant (i.e. amitriptyline) before being offered a nerve block. Of the 14 children accepting treatment in the pediatric pain clinic, six were treated solely with an empiric anti-neuropathic anti-convulsant and/or anti-depressant; eight received medications followed by nerve block (seven ilioinguinal-iliohypogastric blocks, one spinal and ilioinguinal-iliohypogastric block) (see Fig. 1). A total of eight of the 14 children (57%) treated by the pain clinic had resolution of pain, with 50% of those treated with medications alone (three out of six children) responding (two responding to gabapentin and a tricyclic antidepressant, one to gabapentin alone); and five out of eight (63%) treated with medications and then nerve block (ilioinguinal-iliohypogastric block) responding. Of the eight children undergoing nerve block, five required more than one block. The time between each block ranged from 4 to 22.6 weeks. Response to nerve block required an average of 1.4 procedures (range 1-2); mean follow-up after nerve block was 2.4 months (range 0.1-4.8). DISCUSSION: Children with refractory orchialgia often have comorbidities that suggest a multidisciplinary approach would be useful for treating them. The present study found that the majority of children with refractory orchialgia treated in the pediatric pain clinic responded to management. Major limitations, however, included small cohort size and short follow-up, particularly in those children undergoing nerve block. There was also no objective assessment of pain improvement or improvement in quality of life, which could be rectified with a prospective study. CONCLUSION: Collaboration and early referral for interdisciplinary pain management as one of these multidisciplinary approaches may help to coordinate care and ease patient suffering.

Evaluation of renal resistive index, maximum velocity, and mean arterial flow velocity in a hydronephrotic partially obstructed pig model.

RATIONALE AND OBJECTIVES: The authors investigate, in a controlled pig model, the usefulness of Doppler sonographic measurements of resistive index (RI), maximum velocity (Vmax), and mean velocity (Vmean) in diagnostic evaluation of the partially obstructed kidney. METHODS: Seven female pigs underwent surgical partial unilateral renal obstruction at the ureteropelvic junction. Doppler parameters of RI, Vmax, and Vmean were measured preoperatively and postoperatively in obstructed and contralateral nonobstructed kidneys. The General Linear Model multivariate analysis of variance was used for statistical analysis of data. RESULTS: There was no significant difference in the preoperative control values of RI (P = 0.71), Vmax (P = 0.27), and Vmean (P = 0.12). There was a statistically significant decrease in the Vmax and Vmean after postoperative day 5 in the obstructed kidney compared with the contralateral nonobstructed kidney (P = 0.01 and 0.03, respectively). There was no statistically significant difference in RI during the study. CONCLUSIONS: In this study, RI was not a reliable indicator of partial renal obstruction. Measurements of maximal and mean blood flow velocities reached discriminatory significance only after the fifth postobstructive day, proving insensitive in the immediate postobstructive period. Vmax and Vmean demonstrated a decrease in the partially obstructed renal collecting system after 5 days of obstruction and may serve as useful parameters in the evaluation of obstruction after the immediate acute period, when compared with a nonobstructed contralateral system.

Renal cell carcinoma in patients with end-stage renal disease: a comparison of clinical significance in patients receiving hemodialysis and those with renal transplants.

OBJECTIVES: This review was undertaken to determine the clinical significance of renal cell carcinoma in the populations undergoing renal transplantation and those undergoing chronic dialysis. METHODS: We reviewed all medical records of patients with renal cell carcinoma treated at our institutions over the last 10 years. From this review we identified 20 patients with end-stage renal disease and renal cell carcinoma. Patients' charts were reviewed to determine presenting features, tumor histologic type, and clinical outcome. RESULTS: Seven patients had functioning renal transplants and 13 patients were on chronic maintenance hemodialysis. Ninety-two percent of the dialysis group had no metastatic disease and there were no deaths from renal cancer. In contrast, 53% of the transplant group did have metastatic disease and 2 patients died of renal cancer. Despite similar pathologic appearances of the tumors in these 2 groups, patients with renal cell carcinoma and renal transplant presented with higher-stage disease and had less favorable clinical courses. CONCLUSIONS: Considering the morbidity of hemodialysis as well as the other comorbidities of this patient population, the clinical significance of renal cell carcinoma in patients undergoing chronic dialysis must be questioned. In contrast, renal cancer in the transplant population behaves aggressively and warrants careful attention both before and after renal transplantation.

Intrapelvic pressure monitoring in the partially obstructed porcine kidney.

OBJECTIVES: The diagnosis of urinary obstruction in newborns and infants remains difficult because the diagnostic studies available at present are fraught with many problems. It is our premise that precise measurement of renal pelvic pressures under physiologic conditions in patients with urinary tract dilation will allow diagnosis of obstruction and prediction of further renal damage. This study evaluates an intrapelvic pressure monitoring system. METHODS: Four porcine subjects had partial ureteropelvic junction obstruction created surgically; two subjects were used as controls. Doppler ultrasound and MAG-3 furosemide renography were performed preoperatively and each week pressures were measured with a Millar 5 F solid-state pressure transducer and the analog signals were converted on line to digital information to allow signal processing and later data analysis. Antegrade nephrostograms were obtained at the same sitting and showed that the model remained stable over time. Measurements were obtained at physiologic flow rates as well as at the standard Whitaker infusion rate of 10 cc/min. RESULTS: Thirteen pressure studies were performed on 9 kidneys. Each study was classified as normal (4), partial obstruction (8), or total obstruction (1), based on ultrasound and nephrostogram criteria. The normal units had baseline pressures of 4.12 +/- 0.94 cm water (H2O), which increased to 9.12 +/- 1.38 cm H2O with infusion. In the partially obstructed group, baseline was 16.4 +/- 3.83 cm H2O and increased to 35.3 +/- 15.9 cm H2O with infusion. The kidney with total obstruction showed a baseline pressure of 27 cm H2O, which increased to 68 cm H2O with infusion. These pressure measurements were also compared to furosemide renography. CONCLUSIONS: Intrapelvic pressures correlated well with conventional ultrasound and nephrostogram in the evaluation of partial obstruction. However, the results of furosemide renography and the Whitaker test were quite variable and did not accurately define partial obstruction or correlate with intrapelvic pressure. The Millar solid-state transducer monitoring system is an accurate method of evaluating the intrapelvic pressure and could possibly become a standard for diagnosing significant urinary obstruction against which other studies can be evaluated.

Penile orthoplasty using dermal grafts in the outpatient setting.

OBJECTIVES: To review and evaluate our extensive outpatient experience in the use of dermal grafts for the correction of significant residual chordee in patients requiring penile orthoplasty. METHODS: The medical records of all patients requiring surgical correction for severe penile curvature over the past 5 years were reviewed. Among these, 51 patients were identified in whom dermal grafts were used to correct severe residual chordee. Of these patients, 41 had severe hypospadias, 9 had epispadias, and 1 had urethral atresia. Graft harvest and placement technique, any resulting complications, and parental satisfaction with cosmetic and functional results were all evaluated. RESULTS: The dermal grafts were harvested from the hairless skin of the inguinal area, using one of two techniques. All were used to fill a tunical defect created by incising the tunica at the point of maximal penile curvature. No complications or postoperative hospitalizations resulted from any of the orthoplasty procedures. At a mean follow-up of 27 months, all patients had excellent cosmetic and functional results. CONCLUSIONS: In patients with significant residual chordee, a dermal graft is our preferred method of penile orthoplasty. This technique provides a straight phallus with a very minimal complication rate, it can easily and successfully be performed as an outpatient procedure, and it has assured an excellent cosmetic and functional result.

Diagnosis and management of major vascular injuries: a review of 200 operative cases.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.

Nitric oxide stabilizes the Mo(V) oxidation state of dimethyl sulfoxide reductase from Rhodobacter sphaeroides without inhibiting enzyme activity.

Dimethyl sulfoxide reductase from Rhodobacter sphaeroides is isolated in an oxidized, Mo(VI) containing form. Both nitric oxide and reduced ascorbate carried out a one electron reduction of the enzyme with formation of stoichiometric amounts of EPR active Mo(V). Nitric oxide also caused a one electron oxidation of reduced, Mo(IV) enzyme. Mo(V) formation was accompanied by appearance of absorbance peaks at 387 and 528 nm. Neither nitric oxide nor ascorbate inhibited the enzyme nor did either compound support enzyme turnover. Both nitrite plus ascorbate and nitroxyl anion (NO-) induced a previously reported rhombic EPR signal (g1 = 1.994, g2 = 1.982, g3 = 1.966) which exhibited superhyperfine coupling to an exchangeable proton (A1 = 1.25 mT, A2 = 0.85 mT, and A3 = 1.0 mT). On the other hand, NO(g) induced an axial signal with g perpendicular = 1.982 and g parallel = 1.961 in which there is no evidence of superhyperfine coupling. Thus, ascorbate, nitric oxide, and nitric oxide donors induce and stabilize Mo(V) formation in dimethyl sulfoxide reductase without inhibiting enzyme activity. The resemblance between NO and the natural N-oxide substrates of this enzyme suggest that the Mo(V)-NO complex may be a transition state analog of the enzyme-substrate complex.

First stage approximation of the exstrophic bladder in patients with cloacal exstrophy--should this be the initial surgical approach in all patients?

PURPOSE: Cloacal exstrophy is rare and it represents a reconstructive challenge. Options for managing the urinary tract include primary closure or approximation of the bladder halves in the midline with later closure. We present our observations and evolving thoughts concerning optimal treatment in these patients. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with cloacal exstrophy seen in the last 5 years. Initial management was examined, including complete primary closure vs a staged approach. We noted midline defects, spinal cord abnormalities or other anatomical reasons that precluded primary closure. RESULTS: Seven patients, including 5 females and 2 males, were identified. An omphalocele noted in all 7 patients was closed in 5 at initial operation. All underwent preservation of the hindgut in the fecal stream. Spinal cord tethering was noted in 7 of 7 cases. Complete primary bladder closure was performed in 3 of the 7 patients, while the size of the bladder plates or a large abdominal wall defect precluded closure in the remainder. Continence was not achieved in the 3 cases closed primarily. All patients achieving urinary continence underwent bladder neck closure and augmentation cystoplasty with a continent catheterizable channel. CONCLUSIONS: Patients with cloacal exstrophy have anatomical issues that can prevent complete primary bladder closure or preclude the achievement of urinary continence. The high incidence of tethered cord places these patients at risk for upper tract changes and bladder decompensation during followup. Despite successful primary closure in 3 of 7 patients all have a tiny bladder and require secondary procedures to become continent. Extensive dissection during the first operation can contribute to more difficult dissection with potential increased morbidity during subsequent surgeries. Therefore, the best initial approach for the typical patient may be closure of the abdominal wall and approximation of the exstrophied bladder halves in the midline. Secondary closure with continent diversion and reconstruction of the external genitalia can be performed at ages 18 to 24 months.

Continent catheterizable channels and the timing of their complications.

PURPOSE: We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. MATERIALS AND METHODS: A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. RESULTS: Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. CONCLUSIONS: Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

Management of the failed pyeloplasty: a contemporary review.

PURPOSE: We reviewed our experience with open dismembered pyeloplasty, with specific focus on the presentation and management of failed pyeloplasty in the pediatric population. MATERIALS AND METHODS: We performed a retrospective review of patients who had undergone open dismembered pyeloplasty between 1998 and 2003. All patients with less than 6 months of followup were excluded from analysis. The patients were followed postoperatively with serial ultrasounds, with renograms reserved for those patients with prolonged, persistent or worsening hydronephrosis, or recurrent symptoms during followup. RESULTS: A total of 105 pyeloplasties were performed in 103 patients (71 males and 32 females) 1 to 204 months old (mean 60), with an overall success rate of 93.3%. Followup ranged from 6 to 69 months (mean 23). The 7 patients with treatment failure were males 1 to 204 months old (mean 125), who presented most commonly with pain within 3 to 38 months (mean 13.1) after initial surgery. Subsequent ultrasound revealed worsening hydronephrosis, and renography in these patients showed a pattern consistent with obstruction. Five patients underwent initial balloon dilation, in which 1 was successful. In addition, 1 of these patients underwent an unsuccessful antegrade laser endopyelotomy. Six patients (86%) underwent open surgery, consisting of ureterocalicostomy in 3 and reoperative dismembered pyeloplasty in 3. Dense scarring was seen in all patients, 2 patients had a redundant pelvis causing kinking and 2 patients had unrecognized crossing vessels. Overall salvage rate was 100% with continued followup of 3 to 50 months (mean 18). CONCLUSIONS: Dismembered pyeloplasty was successful in the vast majority of patients. In our series failures occurred as late as 3 years postoperatively, although most presented within 12 months of followup. Excluding routine postoperative nuclear renography did not seem to affect our ability to identify these cases. Although anatomical features such as renal pelvic size may have a role, failure is most likely secondary to technical issues, including missed crossing vessels and dependency of the anastomosis. In this series failed pyeloplasties did not respond well to balloon dilation, likely due to scar formation. Our current practice is to manage failures by open surgery, although endoscopic management by an incision may be an option.

Role of angiotensin in the development of the kidney and urinary tract.

When perfusion pressure to the kidney falls, e.g., as a result of dehydration or mechanical hindrance to the renal arterial blood flow, the release of renin, hence angiotensin (Ang), surges. This feedback regulation is geared to preservation of renal hemodynamic environment by raising systemic blood pressure. We are aware that a surge of renin-angiotensin release also occurs when there is a mechanical hindrance to urine outflow. This phenomenon of ureteral pressure-sensitive activation of renin-angiotensin has been heretofore viewed as an error of nature. We have obtained evidence which challenges this traditional view when we examined strains of mutant mice which are completely devoid of either angiotensin type 1 (AT1) receptor gene (Agtr1-) or angiotensin type 2 (AT2) receptor gene (Agtr2-) as a result of genetic manipulation of these animals. These strains of mice display varying degrees of urinary tract obstruction. In Agtr2- mice obstructions develop during early kidney ontogenesis in ureto, and, in Agtr1- mice, during late ontogenesis ex utero. One may recall that, throughout its normal ontogenesis, the kidney is twice at risk for obstruction of urine outflow. Thus, in utero the ureter is transiently obliterated. This transient obliteration is believed to protect the kidney from the high pressure from the cloaca when urine is not yet formed. During this period, the ureter is surrounded by dense layers of undifferentiated mesenchymal cells. Subsequent expansive growth that the ureter must achieve, therefore, in concert with a timely disappearance of the surrounding mesenchymal cells. The study in Agtr2- embryos indicated that Ang, through the Agtr2 receptor, promotes disappearance of these mesenchymal cells, and that inactivation of this receptor results in congenital obstructive nephropathy. Our additional studies in human specimens indeed indicate that many infants with congenital anomalies of the kidney and urinary tract have a significant mutation within the AT2 gene. Once animals are born, the kidney comes to be of primary importance for preservation of body fluid homeostasis, and urinary output increases dramatically. The large volume of urine predisposes the kidney to obstructive nephropathy due to the high resistance offered to the urine by the downstream ureter. Normally, a special device develops within the urinary tract in a timely fashion, which enables the kidney to collect a bulk of urine, and then to expel it downward periodically without imposing positive pressure upon the renal parenchyma. This special device is the renal pelvis. In the studies on Agtr1 null mutant mice, we learned that Ang, through the AT1 receptor, promotes development of the pelvis shortly after birth, so that inactivation of this receptor in Agtr1- mice leads to absence of development of the pelvis, hence to obstructive nephropathy. Collectively, Agtr1 or Agtr2 null mutant mice suffer from urinary tract obstruction. Given that urinary tract obstruction per se is a potent stimulus for Ang generation, Ang is essential for the kidney to escape from obstructive injury.

Early evolution of bladder emptying after myelomeningocele closure.

OBJECTIVES: To analyze bladder emptying in newborns with spina bifida after closure of the myelomeningocele defect. Manipulation of the spinal cord and nerve roots results in temporary changes in bladder function in many settings. METHODS: We reviewed 62 consecutive newborn patients who underwent closure of a myelomeningocele defect at our institution from January 1990 to December 1997. We examined the catheterized urine volumes obtained before and after closure, radiographic and urodynamic studies, and the subsequent need for intermittent catheterization. Poor bladder emptying was defined as most catheterized urine volumes greater than 10 mL (20% of expected bladder capacity). Adequate follow-up was available for 54 patients for a period of 4 to 96 months (mean 42). One patient with posterior urethral valves was excluded from the study, leaving 53 for evaluation. RESULTS: Of the 53 patients, 4 with high outflow resistance and dyssynergy never emptied the bladder adequately before or after closure. Of the remaining 49 patients, 6 (12%) emptied well immediately after the myelomeningocele repair. In the other 43 (88%), the bladder did not empty as well after closure. The mean volume obtained with catheterization after closure was 20 mL, significantly higher (P <0.001) than the mean volume obtained before repair (6.5 mL) or after resumption of better spontaneous emptying (4 mL). Intermittent catheterization done for poor emptying was required for an average duration of 11 days (range 2 to 42). Of the 43 patients with poor emptying immediately after closure, 32 (74%) required catheterization for 2 weeks or less; the remaining 11 (26%) required catheterization for 2 to 6 weeks. Despite the relatively early resumption of good emptying, numerous patients (19 of 49) required additional intervention (clean intermittent catheterization or vesicostomy) before attempts to toilet train. CONCLUSIONS: A clinical pattern similar to spinal shock does occur in most newborns after closure of a myelomeningocele defect. Resumption of near-complete emptying usually occurs less than 2 weeks after repair but may require up to 6 weeks.

Is postoperative cystography necessary after ureteral reimplantation?

OBJECTIVES: To evaluate the patients in our practice to determine whether postoperative cystography was useful in monitoring the outcome after ureteroneocystostomy. Surgical repair of vesicoureteral reflux is the treatment of choice after medical therapy failure. Radiographic evaluation by ultrasonography or voiding cystourethrography (VCUG) is commonly used postoperatively to evaluate for urinary tract obstruction or persistent reflux. However, imaging modalities are not without cost, both in monetary terms and in terms of radiation exposure and trauma to the child. METHODS: We reviewed the records of all patients who underwent ureteroneocystostomy without ureteral tapering at our institution between January 1, 1996 and December 31, 1999 for primary vesicoureteral reflux. These records were evaluated with respect to the type of surgical procedure, preoperative and postoperative clinical course, and radiographic studies performed. RESULTS: We performed reimplantation on 267 renal units in 153 patients. The surgical technique was the Cohen cross-trigonal in 120 renal units (45%), Glenn-Anderson ureteral advancement in 92 (35%), and modified Leadbetter-Politano ureteral advancement in 55 (20%). All patients underwent imaging with ultrasonography within 6 weeks of surgery. The follow-up ranged from 4 to 42 months (average 14.2). Between 3 and 8 months postoperatively, 61 patients underwent imaging with VCUG. We identified persistent reflux in six renal units. Four of six had marked improvement in their reflux. All the patients with persistent reflux were asymptomatic, including 2 patients who were no longer receiving antibiotics. Four patients developed febrile urinary tract infections postoperatively. Three of the four underwent imaging with VCUG after treatment; all three had no evidence of reflux. CONCLUSIONS: In our population, the addition of VCUG to the postoperative evaluation did not allow us to identify those patients at risk of febrile urinary tract infections. Patients in whom persistent reflux was identified were all asymptomatic. We continue to monitor patients with ultrasonography, but believe that VCUG often provides little benefit to these children.

Ureterocystoplasty: is it necessary to detubularize the distal ureter?

PURPOSE: The conventional technique for ureterocystoplasty includes complete mobilization and incision of the ureter. We describe a modified procedure in which the distal 3 cm. of ureter are left in place and intact. MATERIALS AND METHODS: This modification has been used in our last 13 cases of ureterocystoplasty. The first 7 patients with followup of more than a year (mean 28 months) are included in this series, and 6 have undergone video urodynamic evaluation before and after reconstruction. RESULTS: Clinical results have been good. Four patients who have been toilet trained are continent. There have been no problems from stagnant urine in the intact ureter with only 1 case of pyelonephritis and no bladder calculi. Mean bladder capacity on cystometrogram has increased from 103 to 236 ml. after reconstruction and reached 137% of expected capacity for age and size (range 110 to 155%). No uninhibited contractions or problems with compliance have been noted. CONCLUSIONS: The distal ureter may be left intact for ureterocystoplasty to protect ureteral blood supply. This modified technique is sound from a physiological standpoint, technically easier and associated with good results.

Augmenting the augmented bladder: treatment of the contractile bowel segment.

PURPOSE: Bowel used for bladder reconstruction regardless of detubularization occasionally retains its contractile properties. Of 323 patients who underwent primary enterocystoplasty we identified 19 who continue to have high pressure bladder contractions and required augmentation of the previously augmented bladder. MATERIALS AND METHODS: Reason for repeat augmentation, upper tract changes, original and secondary bowel segments used, and urodynamic findings were evaluated in all patients. Current status and followup also were noted. RESULTS: After initial augmentation 8 patients had persistent incontinence, 5 bladder perforation, 3 isolated upper tract changes, 2 incontinence and bladder perforation, and 1 incontinence plus intractable pain. Preoperative urodynamics revealed detrusor pressures from 30 to 100 cm. water. All patients had adequate bladder outlet resistance. The original bowel segments used were sigmoid in 12 cases, stomach in 4, ileum in 2 and cecum in 1. Bowel segments for re-augmentation were ileum in 16 cases and sigmoid in 3. Of the 11 patients with incontinence 10 are now dry. All cases of upper tract changes resolved. Mean followup since re-augmentation is 52 months. CONCLUSIONS: If the outcome of bladder augmentation is less than optimal, it is important to reevaluate the bladder dynamics. In rare instances these patients may continue to have high pressure contractions with a functionally small bladder capacity. In such situations reaugmentation with an additional bowel segment is an excellent alternative to a difficult clinical problem and provides good results in the vast majority of cases. This treatment may not totally alleviate the contractions but it does decrease them and increase the volumes at which the contractions occur, making them no longer clinically or functionally significant.

The use of radiography, urodynamic studies and cystoscopy in the evaluation of voiding dysfunction.

PURPOSE: Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution. MATERIALS AND METHODS: We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively. RESULTS: Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2. CONCLUSIONS: The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

How they begin and how they end: classic and new theories for the development and deterioration of congenital anomalies of the kidney and urinary tract, CAKUT.

CAKUT are problems that often require surgical intervention or, in the worst case, lead to renal failure and the need for dialysis and/or renal transplantation. It is believed that these anomalies share a common genetic cause and to date there has been no good animal model with which to study these abnormalities. Although the abnormal interaction between the ureteral bud and metanephric blastema leads to renal hypodysplasia, vesicoureteral reflux, and ectopic ureters to name a few, the genetic and biochemical modulation of urinary tract development is not understood. Studies using the mouse strain mutant for angiotensin type 2 (AT2) receptors have given new insight into this mystery. The animals show defective apoptosis of undifferentiated mesenchymal cells in the area surrounding the developing kidney and urinary tract. This abnormal apoptosis may well interfere with the normal interaction between the ureteral bud and metanephric blastema resulting in CAKUT. This abnormal interaction would theoretically lead to preexisting intrinsic abnormalities of the kidney, which are programmed and take effect early in embryonic development. In the worst cases, the renal abnormalities would lead to progressive deterioration of renal function. Undoubtedly, there are more genes and biochemical modulators involved in this process other than the RAS and AT2 receptors. Our current animal model gives new and unique possibilities with which to study development of the kidney and urinary tract and ultimately seek ways of preventing an often debilitating disease process.

Does every patient with prenatal hydronephrosis need voiding cystourethrography?

PURPOSE: Prenatal ultrasound has allowed early identification of urinary tract abnormalities that may require urological followup or early intervention. While all children with prenatal hydronephrosis should undergo ultrasound within the first few weeks of life, we believe that there is a subset of postnatal hydronephrosis for which voiding cystourethrography can be avoided if careful observation is continued. MATERIALS AND METHODS: For 5 years 175 infants with a history of prenatal hydronephrosis were evaluated by ultrasound. Of 60 infants with less than Society for Fetal Urology grade II unilateral or bilateral hydronephrosis 44 underwent voiding cystourethrography as part of the early evaluation and 16 were observed without voiding cystourethrography. Four infants for whom we would routinely obtain voiding cystourethrography were excluded from study due to severe prenatal hydronephrosis, renal duplication, hydroureter, ipsilateral small or echogenic kidney and grade II or higher hydronephrosis. RESULTS: Voiding cystourethrography was positive in 6 of the 40 infants (15%) with less than grade II hydronephrosis. Of these cases 3 had grade III or higher vesicoureteral reflux and 1 with high grade reflux required reimplantation. None of the 16 patients followed without voiding cystourethrography has required further evaluation or intervention. In all patients with negative or no voiding cystourethrography parenchyma was preserved and hydronephrosis stabilized or resolved. CONCLUSIONS: Prenatal and postnatal ultrasound in infants should be used to guide further urological evaluation. Among infants with less than grade II hydronephrosis postnatally 15% had reflux on voiding cystourethrography, which is significantly higher than that reported among normal children (approximately 1%). However, none of the 16 infants observed without voiding cystourethrography on short-term antibiotic prophylaxis had deleterious renal events with 6 months to 4.5 years of followup. Therefore, we question the actual significance of the reflux detected in the first cohort of infants. Voiding cystourethrography can provide a definitive answer. However, we also believe that it is not absolutely mandatory based on the outcome in the observed group. With careful counseling and followup most patients with less than grade II hydronephrosis can be observed without urological sequela.