Multi-institutional experience with PIC cystography--incidence of occult vesicoureteral reflux in children with febrile urinary tract infections.

OBJECTIVES: It has been reported that all children with febrile urinary tract infections (FUTIs) and normal voiding cystourethrogram (VCUG) findings show occult reflux (vesicoureteral reflux [VUR]) when examined by cystography performed with positioning of the instillation of contrast at the ureteral orifice (PIC cystography). In this study, we evaluated the reproducibility of this finding using a prospective multi-institutional collaborative examination to determine whether PIC-VUR is as common in such cases as previously shown. METHODS: From March 2002 to October 2003, four institutions performed PIC cystography consecutively and prospectively in pediatric cases of FUTI (greater than 101 degrees F) who had not shown VUR by conventional VCUG. We correlated the ureteral orifice (UO) configuration and position with the status of PIC-VUR. RESULTS: PIC cystography was performed in 39 children (31 girls and 8 boys; 75 FUTIs). We identified PIC-VUR in 32 (82%) of 39 children, involving 58 (74%) of 78 ureters. The likelihood of demonstrating PIC-VUR was increased 37-fold if the UO showed a patulous configuration and was increased 9-fold if the UO showed a lateral configuration. PIC-VUR was noted uniformly in UOs showing hydrodistension. CONCLUSIONS: This multi-institutional registry showed that the incidence of PIC-VUR (82%) in children with FUTI and normal standard VCUG findings is similar to that previously reported. We consider that PIC-VUR likely accounts for the FUTIs.

Results of 265 consecutive proximal hypospadias repairs using the Thiersch-Duplay principle.

PURPOSE: We review the evolution of the concept of tubularization of the urethral plate and our results in the repair of proximal hypospadias. MATERIALS AND METHODS: A total of 281 children born with proximal hypospadias underwent Thiersch-Duplay urethroplasty with or without a midline incision of the urethral plate between 1989 and 1998. Followup data were available in 265 children. RESULTS: Excellent functional and cosmetic results were achieved in 88.7% of the patients. The use of either a dartos or tunica vaginalis flap to waterproof the urethral suture line resulted in a decrease in the fistula rate from 17% to 1.8%. CONCLUSIONS: The principles of Thiersch-Duplay urethroplasty represent the basic foundation for surgical techniques that use the urethral plate to construct a urethral tube. The use of this principle in the repair of proximal hypospadias compares favorably with other methods.

Single layered small intestinal submucosa in the repair of severe chordee and complicated hypospadias.

PURPOSE: Severe ventral chordee often accompanies proximal hypospadias. We describe our experience with single layered small intestinal submucosa (SIS), a commercially available, acellular, collagen based biomaterial, in the repair of severe chordee as part of a multistage approach to the repair of proximal hypospadias. MATERIALS AND METHODS: Between 2001 and 2002, 9 boys with proximal hypospadias (penoscrotal to perineal) and severe ventral chordee (greater than 40 degrees) underwent SIS grafting to correct the curvature. In each case the urethral plate was transected at the point of maximal curvature, the defect in the corporal bodies was measured, and the SIS graft was cut 2 mm wider around the perimeter of the defect and sutured into place. Skin resurfacing of the ventral penis was performed in standard fashion using Byars flaps. Recurrence of chordee was assessed by an artificial penile erection test at the time of stage 2 reconstruction. RESULTS: Of the 9 boys 8 underwent a planned 2-stage repair with subsequent urethroplasty 6 to 12 months after the initial stage 1 chordee repair. Median age at stage 1 repair of the 8 boys was 9 months. Native meatus location was penoscrotal in 6 boys, mid scrotal in 1 and perineal in 1. A 14 month-old boy underwent 1-stage chordee correction with SIS and a transverse preputial island tube graft urethroplasty for penoscrotal hypospadias. There were no perioperative medical or surgical complications related to use of SIS for chordee repair. Median age of the 8 boys at stage 2 repair was 18 months. At stage 2 the graft site was supple and smooth without significant scarring. All chordee correction has remained durable with followup ranging from 16 to 21 months. Postoperative complications occurred in 3 cases, including meatal stenosis requiring meatoplasty, subcoronal fistula requiring repair and complete breakdown of the neourethra in the single stage repair case. CONCLUSIONS: Although this study includes a small population of patients and has limited followup, our favorable experience with single layer SIS suggests that it is a safe and effective, commercially available material for corporal body grafting to correct severe chordee as part of a multistage surgical approach to repair complex hypospadias. A larger series of patients with longer followup is necessary to determine if the chordee correction remains durable. Our experience is insufficient to judge its efficacy in single stage repairs.

Chylous ascites following surgical treatment for wilms tumor.

PURPOSE: Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor. MATERIALS AND METHODS: We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic. RESULTS: Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt. CONCLUSIONS: Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

Percutaneous hepatolithotomy: the Northwestern University experience.

Obstruction of intrahepatic ducts by calculi can lead to abdominal pain, cholestasis, abscesses, and cholangitis. Patients with stones recalcitrant to extraction using endoscopic retrograde cholangiopancreatography (ERCP) have traditionally been referred to a general surgeon for open stone extraction or hepatic lobectomy despite its great potential morbidity. Borrowing techniques, instrumentation, and experience in performing percutaneous nephrolithotomy, we describe our experience with percutaneous hepatolithotomy (PHL), a minimally invasive, safe, and effective alternative to open surgery for recalcitrant biliary stones.