Antibiotic prophylaxis for surgical procedures on children.

The aim of this study was to evaluate adherence to current local antimicrobial prophylaxis guidelines for children requiring different surgical procedures. One hundred and fifty consecutive surgical procedures on children were included in this retrospective study of adherence. The indication, choice of antibiotic, timing, dose, duration and dosing interval were evaluated and found to be concordant with present local guidelines in 97.3%, 83.3%, 66%, 92%, 40.7% and 94.1% of cases, respectively. Adherence to all parameters was achieved in only 25.3% of cases. Although the overall adherence to antibiotic prophylaxis guidelines was relatively low, the majority of children (84.6%) received an appropriate antibiotic (90.6%) at the appropriate dose (92%) and at appropriate intervals (94.1%). The most discordant duration of prophylaxis was due to controversies in urological prophylaxis guidelines.

Sclerosing inflammatory pseudotumor of the urinary bladder in a child.

A case of inflammatory pseudotumor of the urinary bladder in a 2-year-old child is presented. It was characterized by nodular intravesical growth and massive infiltration of the bladder wall. Microscopically, the lesion showed in its largest part a relatively paucicellular spindle cell growth and a sclerotic appearance with a thin superficial cellular zone resembling granulation tissue. Another morphological characteristic was a marked capillary proliferation revealed by immunohistochemical reactions to factor VIII-associated protein, laminin, and collagen IV. The last feature appears to be an integral part of the process, which most closely resembled fibromatosis of the adult type, a rare pattern of growth in inflammatory pseudotumor.

Recurrent adrenocortical carcinoma in a child.

An 8-month-old girl presented with clitoromegaly, cushingoid features and a large abdominal tumour. Ultrasonography (US) and computed tomography (CT) of the abdomen revealed a tumour of the left suprarenal gland, 12x11x7 cm in size. Serum levels of cortisol, testosterone and DHEA-S, and urinary extretion of 17-ketosteroids and 17-hydroxycorticoids were increased. Complete removal of the tumour was accomplished through a transabdominal approach. The diagnosis of adrenocortical carcinoma was confirmed histologically. Three months after the first operation, a recurrent tumour of the left renal hilus, 23x15 mm in size, was identified by US and verified by aspiration biopsy. The tumour was removed by the transabdominal route. In this report, we discuss the diagnosis and the treatment of this rare disease.

Maximal electrical stimulation in children with unstable bladder and nocturnal enuresis and/or daytime incontinence: a controlled study.

The aim of this study was to investigate clinical and urodynamic effects of anal MES in children with unstable bladder and micturition problems (nocturnal enuresis and/or daytime incontinence). Seventy-three girls, aged 5 to 17 years, mean age 9.7 years, with cystometrically proved idiopathic detrusor instability and nocturnal enuresis and/or daytime incontinence, were treated by maximal electrical stimulation (MES) for 1 to 2 months. Twenty-one girls, aged 6 to 14 years, mean age 9.3 years, with unstable bladder and micturition problems used only the anal plug without a battery for 1 month and served as the control group. Four and a half months (1-36 months) after the end of treatment, 75% of the stimulated patients were cured or improved by 50% or more. In the control group, 86% of the girls remained unchanged (P < 0.01). One month after the completion of anal MES the average number of monthly nocturnal enuretic episodes fell from 14 to 6.5 (P < 0.001) and the number of daytime incontinence episodes diminished from 3 to 0 (P < 0.001). On an average of 14.5 months after the end of anal MES, enuresis recurred in 20% of cases. Post-MES cystometry showed intensified first desire to void (P < 0.05), as well as an increase in maximum cystometric capacity (P < 0.0001), bladder compliance (P < 0.0001), and volume of the first detrusor contraction (P < 0.01). A statistically significant decline in the number of uninhibited contractions was also noticed (P < 0.001). In the control group, the anal plug did not produce any significant cystometrical changes. Anal MES can be recommended as an effective method for treating nocturnal enuresis and/or daytime incontinence and unstable bladder in children.

Possible causes of unsuccessful endoscopic collagen treatment of vesicoureteric reflux in children.

OBJECTIVE: The purpose of this prospective study was to identify possible causes of unsuccessful treatment of vesicoureteric reflux (VUR) in children by endoscopic collagen injection. PATIENTS AND METHODS: Between February 1994 and September 1996, 130 primary VURs in 94 children aged 3-16 years were treated by endoscopic injection of collagen. Grade 2 VUR was found in 46 ureteric units, grade 3 in 55, and grade 4 in 11 ureteric units. Seventy-seven children had normal micturition, and 17 showed signs of an unstable bladder. The collagen injection was performed under general anaesthesia. All children had a follow-up assessment on average 5.1 months after the first injection of collagen. They were evaluated by micturition cystography and ultrasound examination of the urinary tract. RESULTS: A single injection of collagen eliminated VUR in 74 (56.9%) cases. There was a statistically significant correlation between the grade of VUR and the success rate of collagen therapy (p < 0.01). The average amount of collagen used in cured and in noncured children was 0.55 and 0.76 ml, respectively (p < 0.01). Children with normal appearance of the ureteric orifice had significantly better results as compared with other children (p < 0.01). There was no statistically significant correlation between the success rate of treatment and the place of collagen injection or the shape of ureteric orifice following the injection. A statistically significant association, however, was found between the function of the lower urinary tract and the results of endoscopic collagen treatment for VUR (p < 0.05). Ultrasound showed no obstruction of the upper urinary tract. CONCLUSION: High-grade VUR, incorrect technique of injection, and voiding dysfunction seem to be some of the possible causes of an unsuccessful endoscopic collagen treatment of VUR in children.

Neurophysiological study of primary nocturnal enuresis.

The purpose of this study was to investigate nervous system involvement in primary nocturnal enuresis by using electrophysiological techniques. Nineteen boys with primary nocturnal enuresis and 25 boys without uroneurological abnormalities were included. Data about their psychomotor development, micturition, and defecation were obtained by interviewing the boys and their parents. The penile sensory threshold for electrical stimuli was determined. Single and averaged bulbocavernosus reflex (BCR), and averaged pudendal somatosensory evoked potentials (PSEP) to electrical stimulation, were recorded. The only statistically significant difference found in enuretic children was longer latencies of averaged BCR to single electrical stimulation (P = 0.03). No significant BCR latency differences to stimulation with double electrical pulses and no PSEP latency differences were found. By using electrophysiological techniques, differences between the enuretic and control group of boys were demonstrated. Our results can be interpreted as indicating hypoexcitability of sphincter nuclei. Along with the reported hyperexcitability of bladder motor nuclei, a minor dysfunction in the neurocontrol of the lower urinary tract, in at least a subgroup of enuretic children, can be postulated.

Mechanically evoked bulbocavernosus reflex and pudendal somatosensory responses in children.

Electrophysiological investigations of sacral functions are unpleasant and as such rarely performed in children. A novel approach is presented: bulbocavernosus reflex and pudendal cortical somatosensory evoked potentials were studied on mechanical stimulation of the penis and compared with their electrically evoked counterparts in 21 (5-14 years old) boys. An electromechanical hammer was used and only surface electrodes applied. Children preferred mechanical stimulation which also evoked reliable responses in more boys. Reflex responses on mechanical stimulation were found to be of longer latency, however no latency differences between cortical evoked responses to either stimulation were found. We suggest the use of mechanical stimulation in uroneurophysiological testing of children.

A method of uroneurophysiological investigation in children.

Characteristics and reproducibility of bulbocavernosus reflex (BCR) and pudendal somatosensory evoked potentials (PSEP) elicited by mechanical stimulation in children were tested. Twenty-five male children aged 5-14 years without uroneurological complaints were enrolled in the study. In addition to electrical stimulation, a specially constructed electromechanical hammer triggered by an oscilloscope was used for mechanical stimulation of distal penis. All responses were detected by surface electrodes. The latencies and amplitudes of averaged as well as latencies of single BCR on single and double electrical stimuli were determined. Mechanical stimulation was described as much less unpleasant than electrical stimulation. Both mechanical/electrical stimulation elicited consistent and reproducible responses in high percentages of children (BCR: average, 80%/71%, single, 94%/100%; PSEP: 96%/96%, respectively). BCR latencies were significantly longer and PSEP amplitudes were significantly higher on mechanical stimulation. The compliance with mechanical was much better than with the electrical stimulation and the former can be recommended for clinical use. The effective mechanical stimulus delivered by a particular mechanical stimulator has a characteristic 'delay' (as to the actual point of triggering the oscilloscope ray) which influences the latency reading of responses; appropriate control data are therefore necessary.

Standardization of anal sphincter EMG: technique of needle examination.

The external anal sphincter (EAS) anatomy is complex, and no exact technique of needle electrode insertion into it for electromyography (EMG) has been described. To define optimal positions for needle electrode insertions, EAS muscle topography was studied by concentric needle EMG. Fifteen women without uroneurological disorders were examined. Perpendicular insertions were made superficially (just under the mucosa) at the mucocutaneous junction, 5 and 10 mm more proximally (toward the anus), and at the anal orifice. In addition, at the anal orifice, deeper insertions were made. Superficially, EMG activity was detected at the mucocutaneous junction in 9 (60%) subjects. In the remaining 6, the muscle was found either 5 mm (in 5) or 10 mm (in 1) more centrally. At the anal orifice, superficial EMG activity was present in 67% of women. On deep insertion (15-25 mm) at the anal orifice, muscle was always present. It is suggested that, in further studies, the portions of the EAS muscle examined should be specified.

Chlamydial infection of the urinary tract in children and adolescents with hematuria.

Urogenital infection with Chlamydia trachomatis in adults and adolescents is a common sexually transmitted disease. The purpose of this study was to investigate whether isolated microhematuria in children and adolescents is associated with Chlamydia trachomatis infection of the urinary tract. The study group included 37 children and adolescents with isolated nonglomerular microhematuria. Urethral smears for the isolation of Chlamydia trachomatis in cell culture were taken at the time of cystourethroscopy from all patients. Polymerase chain reaction (PCR) for the detection of chlamydial DNA in urine was carried out in 25 of 37 (68%) patients and direct immunofluorescence (DIF) of urine in 16 of 37 (43%) patients. The control group included 33 children and adolescents without hematuria; PCR and DIF of urine were carried out in all controls. Chlamydia trachomatis infection of the urinary tract was confirmed in 8 of 37 (22%) patients in the study group, and in none in the control group (0 of 33, P<0.001). Further studies of larger groups of patients should be conducted, before recommending testing for Chlamydia trachomatis infection of the urinary tract in children and adolescents with unexplained microhematuria.

Inverse expression of uroplakins and inducible nitric oxide synthase in the urothelium of patients with bladder outlet obstruction.

OBJECTIVE: To assess the expression and distribution of uroplakins, protein subunits of the asymmetric unit membrane (AUM), and inducible nitric-oxide synthase (iNOS) in the urinary bladder urothelium of patients with bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Urinary bladder urothelium samples from 15 men (mean age 69 years) with BOO secondary to BPH were processed for light and electron immunocytochemistry. Uroplakins and iNOS were detected, and areas of apical surface covered with AUM were compared with those of iNOS-positive urothelial cells. RESULTS: Areas of superficial urothelial cells with no AUM were found in all obstructed bladder samples. The immuno-electron microscopy showed that the uroplakin-positive cells had the characteristic appearance of terminally differentiated umbrella cells, whereas cells from the uroplakin-negative regions were undifferentiated, typically showing microvilli on their apical surface. iNOS was not detected in areas with continuous AUM staining, but was readily detected in the uroplakin-negative areas. There was an inverse correlation between the intensity of uroplakin and iNOS staining. CONCLUSIONS: In patients with BOO associated with BPH, some superficial urothelial cells lacked the AUM, suggesting focal compromise of the blood-urine permeability barrier. In such relatively undifferentiated urothelial zones there was an accompanying increase in the expression of iNOS, which marks perturbed urothelial differentiation and may modulate bladder response to the outlet obstruction.