A comparison of patient and parental experiences and diagnostic quality of suprapubic versus transurethral voiding cystourethrogram in children.

INTRODUCTION: Voiding cystourethrogram (VCUG) used in the radiologic evaluation of the upper and lower urinary tract can be performed by suprapubic puncture (SP) or by transurethral catheterization (TC). Data on which instillation technique is superior are scarce. VCUG tends to be a distressing procedure for both parents and children. METHODS: We evaluated the experience of VCUG analyzing 417 families with focus on contrast medium instillation in groups of single and repeated VCUGs and assessed quality and complication rate. The median age of children who had undergone VCUG was 38.6 months (0 - 159 months). Satisfaction with informed consent (IC), degree of fear and pain in parents and children prior and during VCUG were recorded. VCUG was compared to blood withdrawal and vaccination. RESULTS: Satisfaction with IC was higher for repeated VCUG (p= 0.024) which resulted in a lower degree of fear in parents and children. The fear of children during VCUG was lower when SP was performed rather than TC. This was in contrast to parental fear of SP (all p< 0.05). In repeated VCUGs, children who underwent SP were less afraid. Better diagnostic quality was more commonly reported with SP, yet the complication rate was higher (p=0.035). CONCLUSIONS: Our study highlights the importance of IC as a pivotal necessity before VCUG is conducted. SP might be beneficial over TC in terms of fear and distress in the case of repeated VCUGs. Diagnostic quality is comparable, both methods are safe and complications are low.

Long-term outcome after urinary diversion using the ileocecal segment in children and adolescents: Complications of the efferent segment.

INTRODUCTION: Long-term outcomes are of special concern in children after urinary diversion. In a single institution study we evaluated retrospectively the long-term outcomes of urinary diversion in children, in whom the ileocecal segment had been used, in respect to complications of the efferent segment. METHODS: The Mainz pouch was used in 107 children for continent urinary diversion. Indications were neurogenic bladder (53%, 57/107), exstrophy-epispadias complex (25%, 27/107), malignancy (13%, 14/107), and others (9%, 9/107). Continent cutaneous diversion was performed in 95 patients, and 12 patients received bladder augmentation/substitution with a continent cutaneous stoma. As efferent segment, we used the in situ submucosally embedded appendix in 55/107, and an intussuscepted ileal nipple valve in 45/107 patients, other in seven patients. Complication rates and degree of satisfaction with urinary diversion were evaluated by assessing medical records and using follow-up questionnaires. RESULTS AND DISCUSSION: The median follow-up time was 15.9 years (0.4-27.6 years). There was a significant difference between the stenosis rates of appendical stoma and the intussuscepted ileal nipple valve. In general, 38% of patients (41/107) with a continent cutaneous stoma developed a stoma stenosis at the skin level, with 41% (17/41) of those having recurrent stenoses (2-6×). Of the patients with an appendix stoma, 49% (27/55) developed a stenosis, compared with 20% (9/45) of those with an intussuscepted ileal nipple valve (p < 0.001). In an attempt to reduce the incidence of stenosis, we implemented use of the ACE stopper during the last 2 years, but whether this is successful is subject to further investigations. For surgical treatment of stoma stenosis, reanastomosis of the efferent segment to the skin (n = 37, re-stenosis rate 37%, [14/37]) was superior to endoscopic scar incision (n = 44, re-stenosis rate 59% [26/44], OR 2.4). The overall continence rate was 85% (91/107). At the latest follow-up, 89% (49/55) of patients with an appendix stoma and 82% (37/45) of those with an intussuscepted ileal nipple valve were completely continent. CONCLUSION: The in situ submucosally embedded appendix and the intussuscepted ileal nipple valve are reliable continence mechanisms in the long-term median follow-up of nearly 16 years. The stomal stenosis rate is approximately double for the submucosal appendix, likely because of its smaller diameter in comparison with the ileal valve. Although we encountered a high overall rate of complications, the satisfaction rate with the diversion was high (99% [88/89] satisfied or very satisfied patients).

Glaucoma screening in Western Cameroon.

PURPOSE: To quantify glaucoma-related parameters in a rural African region. MATERIAL AND METHOD: In a population-based investigation, 635 persons in six villages underwent slit-lamp examination including investigation of the optic nerve head with a 90D lens and Goldmann applanation tonometry. The mean age of the persons was 49.4 +/- 19 years, minimum 5, maximum 90, median 52 years. The inferior, superior, nasal and temporal margin width of the optic nerve head (ONH) were estimated as fractions of the total disk diameter, thus allowing the evaluation of the horizontal and vertical cup-disk ratio (CDR), the ratio of the elliptical cup area to the total disk area (area CDR), and violations of the ISNT rule (Inferior>or=Superior>or=Nasal>or=Temporal ONH rim). RESULTS: Area CDR significantly increased with age, on average from 0.1 in the youngest to 0.47 in the oldest person, corresponding to an increase of linear CDR from 0.32 to 0.68. The total fraction of eyes exceeding an area CDR of 0.5 (i.e. linear 0.7) was 13.4%. In addition, the intraocular pressure (IOP) increased on average from 14 mmHg in the youngest to 20 mmHg in the oldest persons, but nevertheless many high CDR values were found in eyes with normal to moderately elevated IOP. Violations of the ISNT rule were found in approximately 25% of the eyes. Application of a combination of glaucoma criteria as commonly used in literature resulted in a total prevalence of 18.7% of the screened persons, corresponding to a prevalence of 8.2% after age correction for the--on average--very young Cameroonian population. CONCLUSION: Compared to Europe, glaucoma prevalence appears to be nearly an order of magnitude higher in this rural African population.