Method for correcting meatal stenosis after hypospadias repair.

Meatal stenosis is uncommon after hypospadias surgery even when the meatus is placed at the tip of the glans. However, when it occurs, such stenosis can be quite troublesome. A conventional meatotomy done in the presence of inflammation is often attended by recurrent stenosis. In such situations we therefore advocate placing a tourniquet around the base of the penis and raising a V-shaped flap of glans with the point of the V at the dorsum of the meatus. The stenosis is then incised along the back wall of the urethra down into non-inflamed tissues. The tip of the flap is sutured to this point and additional absorbable sutures are used to anchor the flap in place so that healthy tissue crosses the stenotic area. Recurrent stenosis after this maneuver is unusual.

Natural history of fetal and neonatal hydronephrosis.

Since pyelocalicectasis alone is common in fetuses, we reviewed reports of fetal hydronephrosis that resolved spontaneously or at birth. Severe fetal hydronephrosis with calicectasis or parenchymal thinning rarely resolves spontaneously before or after birth. We also reviewed the clinical and experimental literature on renal hypertrophy. After unilateral nephrectomy in neonatal animals or after birth with congenital absence of one kidney in humans, the remaining kidney hypertrophies very quickly. In infants and young animals, the eventual size of the remaining kidney is inversely proportional to the age at which one kidney is lost. This improvement in residual renal function seen after renal loss in infancy, compared with older children, itself constitutes a strong argument for early relief of obstruction. If contralateral renal hypertrophy has occurred, the treated damaged kidney may resume growth in parallel with its hypertrophied mate but does not become as large or recover normal potential for growth. In other words, if correction of a unilateral obstruction is deferred until contralateral hypertrophy occurs, the obstructed kidney then has less potential for recovery of function.

Improved technique of laparoscopic nephrectomy for multicystic dysplastic kidney.

We report removal of a multicystic dysplastic kidney with a laparoscopic technique that uses only three trocar sites. Additionally, we have found placement of a ureteral catheter and full mechanical and antibacterial bowel cleansing unnecessary. The role of this surgery in the management of multicystic dysplastic kidney is discussed.

Hypertension and multicystic kidney.

The optimal management of the asymptomatic patient with a multicystic kidney remains a dilemma. The risk of nephrectomy in a neonate or infant with this lesion is small and the morbidity is minimal. The alternative to elective nephrectomy is life-long follow-up with blood pressure determinations, beginning in infancy. We report herein two infants with multicystic kidney (MCK) in whom hypertension was cured by its removal. Since accurate blood pressure measurements are relatively difficult to obtain in infants and since periodic long-term follow-up is difficult in the best of circumstances, we are concerned that hypertension caused by a retained MCK goes undiagnosed perhaps more frequently than a review of the current literature suggests. Such hypertension may result in contralateral renal damage and arteriosclerosis, so that later removal of the MCK may not have a beneficial effect on the elevated blood pressure.

Nonobstructive dilatation of upper urinary tract may later convert to obstruction.

We report on 5 babies found to have pyelocaliectasis or hydroureteronephrosis antenatally who were evaluated soon after birth because of persistent mild or moderate upper urinary tract dilatation. In each instance, vesicoureteral reflux was absent and the technetium-99m diethylenetriaminepentaacetic acid renal scan revealed good function in the ipsilateral kidney. Renogram curves, after furosemide, did not show an obstructed pattern. Indeed, allowing for the dilatation, the drainage patterns were thought to be normal. In each instance the patient represented or was found on follow-up to have increased dilatation. Renograms were then repeated, using the same radiopharmaceutical and dose of diuretic. An obstructive pattern was seen in each instance. These significant observations demonstrate that nonobstructive hydronephrosis, diagnosed prenatally, may later convert to obstruction at the ureteropelvic junction (UPJ) or in the juxtavesical ureter (UVJ). Thus, careful follow-up, for a period yet to be determined, is desirable in patients in whom the initial postnatal evaluation does not demonstrate obstruction by current criteria.

Quantitative nuclear cystogram. Aid in determining spontaneous resolution of vesicoureteral reflux.

The quantatitative data derived from serial nuclear cystograms over a five-year period in 37 children were compared with the clinical course. A direct correlation (92 per cent) between an increasing bladder volume at which reflux occurs was observed in the clinically stable group. In the clinically unstable group, there was a 75-per cent correlation of an unchanged or decreasing bladder volume at which reflux occurs. The quantitative nuclear cystogram provides an objective as opposed to subjective data base for management of patients with vesicoureteral reflux.

Priapism in boys. Management with cavernosaphenous shunt.

Two children with priapism are presented; one case was secondary to trauma and the other was idiopathic in nature. Both boys were effectively treated by bilateral corporosaphenous shunts. The mechanism of normal erection and the pathophysiology of priapism are discussed.

Multiple simultaneous urologic procedures in pediatric patient. Evaluation of risk and cost-effectiveness.

We report on several pediatric patients in whom multiple surgical procedures were performed under the same anesthesia. The hospital cost is compared with the estimated cost if the procedures were performed separately. The savings were considerable, and there was no increase in morbidity and no lessening of the quality of results.

Urinary undiversion in patients with myelodysplasia and neurogenic bladder dysfunction. Report of a workshop.

This workshop was conducted in an attempt to analyze critically the role of reconstruction of the myelodysplastic patient who had undergone urinary diversion and to develop guidelines for selecting those patients in whom urinary undiversion might be undertaken safely. The collective experience initially seems to be acceptable; however, the authors emphasize the gravity of the decision and the complexity of the evaluation which must be undertaken prior to embarking on such reconstructive surgery. Contrary to some reports, we believe that the defunctionalized bladder frequently can be evaluated. Further, many of the contraindications to urinary undiversion have been identified and several of the hazards involved therein can be avoided. We believe that the neurogenic bladder is no longer an absolute contraindication to undiversion. Our experience suggests that undiversion is a reasonable surgical treatment in select patient with neurogenic bladder dysfunction. But, the decision to remove a satisfactorily functioning conduit must not be undertaken lightly. Patients should be selected only after a thorough, detailed, and properly conducted evaluation. A protocol has been developed which will hopefully assist in this evaluation. Perhaps additional shared experience will further refine and delineate the circumstances appropriate for reconstruction of these patients.

Hydronephrosis. When is obstruction not obstruction?

It once was relatively simple for most urologists to diagnose ureteropelvic junction obstruction, and it was previously axiomatic that obstruction required repair to preserve and maximize renal function. Modern imaging studies have cast doubt on previously held concepts, leaving the clinician with an enigma. Prolonged follow-up of some non-operated cases has demonstrated late deterioration of function, further compounding the diagnostic uncertainty.

Bladder substitution in children.

In spite of all the difficulties, cystoplasty, particularly with the ileocecal segment, has proved rewarding. Undiversion is easily accomplished in this way. Most patients are outwardly well and happy. Reflux usually does no harm in the near term, especially if infection can be prevented, and bladder pressures are not elevated. However, we believe that we are close to being able to prevent reflux in a reliable manner. If this is the case, the ileocecal segment or hemi-Kock pouch may clearly become the optimal choice for bladder substitution in patients with reflux or ureteral obstruction, as well as those with short ureters or very small bladders, or as a standard method of undiversion. We have also employed the intussuscepted ileum as the antireflux mechanism in patients undergoing bladder substitution using a patch of small bowel as in the hemi-Kock. This technique allows one to leave the cecum and ileocecal valve in situ, reducing the risk of chronic postoperative diarrhea. In addition, small bowel is proving to be more compliant on the average than large bowel segments when used in bladder reconstruction. Whether the ileocecal segment or the hemi-Kock cystoplasty has a permanent place in undiversion and in the treatment of chronic or pharmacoresistant noncompliant bladder, neuropathic or otherwise, the techniques learned are making total replacement of the bladder with bowel segments a more attractive and feasible undertaking. The pool of patients susceptible to such maneuvers is a large one.

Torsion of the testis: techniques of assessment.

Results of treatment of torsion of the testicle can be measured only by determining the rate of testicular salvage, which has been low but has improved in recent years. The Doppler instruments and the technique of scrotal imaging with the gamma camera provide noninvasive and rapid diagnostic aids with a high degree of accuracy. There is evidence that these techniques will aid in the differential diagnosis of equivocal cases, and thus lower the incidence of delay in the diagnosis of torsion, a cause of lower than optimal salvage rates in the past. Fluorescein staining can also be used in the operating room if there is a question of testicular viability. The availability of these new modalities, however, is no substitute for early evaluation. Quick referral from primary physicians and a high awareness of torsion as a cause of acute scrotal pain and swelling are extremely important. Reviews clearly indicate that improved salvage rates are achieved with early evaluation and treatment. Therefore the urologist has a continuing responsibility to educate pediatricians, family practitioners, and emergency room physicians in the urgency of diagnosis and treatment in cases of testicular torsion. Although new diagnostic aids are useful, only early surgical exploration can save a torsive testis.

Dysfunctional voiding in children secondary to internal sphincter dyssynergia: treatment with phenoxybenzamine.

Through the use of urodynamic evaluation, the authors have been able to define and categorize internal sphincter dyssynergia as a clinical, obstructive, dysfunctional voiding disorder in children. Treatment with the alpha-adrenergic sympatholytic agent, phenoxybenzamine, was successful in their series of patients.

Pituitary hormone response to head injury.

Measurements of the serum levels of pituitary hormones were made in six patients with uncomplicated head injury. Samples were obtained at 4-hour intervals for 72 hours to evaluate diurnal rhythms. Three of the six patients revealed elevations of serum growth hormone (GH) and prolactin, but no trends could be established. Likewise, three patients had marked elevations of luteinizing hormone and lesser elevations of follicle-stimulating hormone, but no pattern was discernible. The level of thyroid-stimulating hormone was stable and remained in the normal range throughout. GH was measured after intravenous glucose loading. A paradoxical rise reverted to normal at the late follow-up evaluation. It is suggested that the abnormal levels were related to abnormal hypothalamic function rather than to pituitary damage.

Tolerance to oxotremorine's effects on schedule-controlled behavior in physostigmine-tolerant rats.

Tolerance to the effects of physostigmine and oxotremorine in rats was evaluated using a multiple fixed-ratio 10, extinction schedule of food presentation. Physostigmine was administered either once daily or three times daily for 18 consecutive days. Tolerance to physostigmine's response decreasing effects was observed under both administration regimens. Cumulative dose-effect functions for oxotremorine (0.0056-0.562 mg/kg) were determined before and after chronic physostigmine administration. Oxotremorine's potency to produce response rate suppression decreased in rats receiving physostigmine three times daily but did not substantially change in rats receiving single daily injections. These results demonstrate that the dose or duration of action of physostigmine can determine whether tolerance to physostigmine's effects is accompanied by cross-tolerance to oxotremorine's effects.

Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis.

A hundred patients with RCAV fistulas we compared with 100 patients with expanded PTFE fistulas created during the same time period. The fistulas were analyzed to compare early and late thrombosis, life table patency, infection rate, venous hypertension, and vascular steal. There was a significantly greater incidence of early thrombosis in the RCAV fistula group. Late thrombosis was seen with equal frequency in both groups. Thirty month patency by life table analysis favored the RCAV group to a significant degree, whereas infections, pseudoaneurysms, venous hypertension, and vascular steal were all more common in the expanded PTFE group. The RCAV fistula remains the ideal form of access but it is less frequently available for women and patients with peripheral vascular disease. Utilization of the expanded PTFE loop fistula requires closer observation and maintenance to keep it functional. Improved methods of patient selection for RCAV fistula using ultrasonographic imaging may allow for increased use of this form of access. Improvement in early patency in RCAV fistulas will magnify the superiority of RCAV fistulas in comparison to expanded PTFE fistulas, however, a prolonged period of venous maturation may be necessary to improve early function.

Use of the expanded thoracoepigastric myocutaneous flap in the closure of cloacal exstrophy.

We describe the first reported use of an expanded thoracoepigastric myocutaneous flap in the closure of cloacal exstrophy. This approach offers several distinct advantages. The expander increases the available cutaneous surface area of the thoracoepigastric region, improves vascularity, induces a fibrous capsule that augments the abdominal wall, permits primary closure, and avoids prosthetic adjuncts that increase scarring and hinder delayed urinary tract reconstruction. Osteotomy and spica casting may be obviated by using this flap, but mesh may be required eventually. We anticipate its use in all future cases in which the abdomen cannot be closed safely at the primary procedure at this institution. This technique also should be considered for classic bladder exstrophy or any other large congenital or acquired defect of the lower abdomen.

Ectopia of the vas deferens.

Ectopic location of the vas deferens is a rare congenital abnormality that has a spectrum of presentations. Such cases have been associated with anorectal anomalies. Knowledge of distal Wolffian duct embryology may help to explain the developmental steps involved in these anomalies, as well as provide theories for the variations that may be encountered. Vas deferens development is reviewed, and two cases of vas ectopia are presented to illustrate and lend support to current theories of normal and abnormal vasal embryology.