Treatment of colonic anastomotic strictures with 'through the scope' balloon dilators.

Stricture occurs in 1.2-4.2% of colonic anastomoses. Symptomatic strictures have previously been treated by resection and re-anastomosis and more recently by radiographically guided dilatation by a modified Seldinger technique. This paper describes the endoscopic balloon dilatation of five symptomatic cases and three asymptomatic cases. Eight patients underwent balloon dilatation of colonic anastomotic strictures. Four patients had no symptoms post dilatation and the strictures remained patient on follow-up endoscopy. All the remaining patients required re-dilatation at approximately 2 months. One of these patients underwent dilatation but remained symptomatic, the dilatation was repeated and a colonic perforation occurred at this time. Of the other three, two continue to be followed up, and are well and one patient died of disseminated malignancy. Balloon dilatation with 'through the scope' dilators is a simpler technique than radiologically guided dilatation. These early results suggest that endoscopic dilatation may avoid further surgery in some patients with anastomotic stricture.

Urethral strictures and aortic surgery. Suprapubic rather than urethral catheters.

Urethral strictures associated with the use of a urethral catheter may be more common after cardiac and aortic surgery when compared with other surgical procedures. The reasons for this are obscure. Fifty-two aortic procedures in males from 1980-1983 were reviewed with an incidence of urethral stricture of 21%. Forty anterior resections of the rectum in which a urethral catheter was used were also reviewed with an incidence of urethral stricture of only 5%. Since 1985 supra-pubic catheters have been used now in over 200 aortic procedures with no morbidity and no urethral stricture. Bacteriuria has been significantly reduced by the use of supra-pubic catheters and there would appear to be considerable advantages in the use of this technique.

Mercapto-acetyltriglycine (MAG 3) renography and indirect radionuclide cystography in posterior urethral valves.

OBJECTIVE: To assess dynamic isotope renography with 99mTc-labelled mercapto-acetyltriglycine (MAG 3) in conjunction with indirect radionucleide cystography (IRC) in the follow-up of boys with posterior urethral valves. PATIENTS AND METHODS: Fifty-one boys (95 renal units; mean age = 89 months, range 65-118) with previously treated posterior urethral vales underwent MAG 3 renography followed by IRC. Glomerular filtration rate (GFR) was estimated from the plasma clearance of 51Cr-ethylenediamine tetra-acetic acid following single intravenous injection. Renographic parameters noted were renal function based on the quality of renal visualization and background activity as well as renal drainage and the appearance of isotope in ureter and bladder. Following the dynamic 20 min MAG 3 renogram the child was allowed to leave the department and to return when he wished to void. IRC was then performed. Diuretics were not administered. RESULTS: Initial drainage from 30 kidneys was normal, in 36 drainage was delayed and in 25 drainage did not occur during the renogram phase. In four kidneys function was so poor as to preclude assessment. After the IRC, drainage was noted in 17 of 25 units which had not drained during the renogram, six units did not drain and in two drainage was equivocal due to the presence of vesico-ureteric reflux. The quality of the scan was good or very good in 42 patients (mean GFR = 92 ml/min/1.73 m2 SA) and moderate or poor in nine patients (median GFR = 20 ml/min/1.73 m2 SA) (P < 0.001). A residual urine was noted following micturition in 35 boys; this was due to incomplete bladder emptying in 14 and to immediate secondary refilling from dilated upper tracts in the remainder. CONCLUSION: IRC in conjunction with traditional dynamic renography using MAG 3 provides valuable additional information about upper tract drainage. The necessity for diuresis renography is obviated in the majority of patients. IRC also allows an excellent non-invasive, physiological assessment of both upper and lower urinary tract function which is superior to conventional single examination techniques. We recommend the use of MAG 3 with IRC in the routine follow-up of boys with posterior urethral valves.

Persistent polyuria after posterior urethral valves.

OBJECTIVE: To assess urinary concentrating ability, urine production and glomerular filtration rates in a cohort of boys with previously treated posterior urethral valves. PATIENTS AND METHODS: Urinary concentrating capacity was assessed in 51 boys aged 5.4-9.9 years with previously treated posterior urethral valves. They all completed urinary frequency/volume charts, permitting calculation of 24 h urine volumes. The osmolality of an overnight urine collection was measured and, if < 800 mOsm/kg (n = 40), an intramuscular injection of desamino-cys-1-8-D-arginine vasopressin was given to determine the maximum concentrating ability. The glomerular filtration rate (GFR) was estimated from the plasma clearance of 51Cr-ethylenediamine tetra-acetic acid following a single intravenous injection. RESULTS: The mean 24 h urine volume was 1025 +/- 448 (SD) mL. The mean overnight urine flow rate was 28.4 +/- 17.9 mL/h. Urinary concentrating capacity was impaired (< 800 mOsm/kg) in 30 (59%) of the boys and < 300 mOsm/kg in eight (16%). The mean GFR was 81 +/- 38 mL/min/1.73 m2SA. Significant correlations were noted between the GFR, the maximum urine concentration and the 24 h urine volume. CONCLUSION: Persistent polyuria after valve ablation occurs in boys with posterior urethral valves. This has implications both in terms of urinary continence and on-going renal impairment.

Pedicle patch urethroplasty.

The pedicle patch urethroplasty provides an alternative single-stage vascularised graft procedure for the repair of moderately severe hypospadias. Over a 7-year period, 38 primary hypospadias repairs were performed employing this technique. The fistula rate was 18% in the 34 patients reviewed, but there were few other significant complications. The operation is recommended when the urethral plate can be preserved and the penis straightened in boys who are unsuitable for a meatal-based flap.

Hypospadias: Duckett pedicle tube urethroplasty.

The Duckett transverse tube pedicle urethroplasty was used to repair the primary hypospadias of 190 boys over an 11-year period. The fistula rate was 34.4%. The majority of boys have obtained a satisfactory cosmetic and functional result with a single operation.

Controlled trial of polyglycolic acid versus catgut and nylon for appendicectomy wound closure.

Six hundred and fifty patients undergoing appendicectomy were included in a prospective randomized controlled trial. At operation patients were allocated to control (chromic catgut ligatures and muscle closure, nylon skin closure) or study (polyglycolic acid ligatures and muscle and skin closure) groups. Wounds were examined by an independent observer daily in hospital and 1 month after operation. Wound infection was defined as discharge of serous or purulent material, or a grossly inflamed wound without discharging pus, or any evidence of intra-abdominal sepsis. Of the 650 patients (335 men, 315 women, age 5-80 years, median 18 years), 615 have completed follow-up. Groups were well matched for age, sex, degree of sepsis at operation, histological diagnosis and surgeon. Infection was significantly reduced in the study (polyglycolic acid) group (12.0 per cent) compared with the control (chromic catgut/nylon) group (21.2 per cent) (chi 2 = 9.3, P = 0.002). Infection was significantly reduced in the polyglycolic acid group regardless of whether the appendix was inflamed or normal. These results indicate that suture material can influence the incidence of wound infection and that this is less frequent when polyglycolic acid sutures are used.

Antenatal diagnosis of posterior urethral valves.

The antenatal histories of 42 patients with posterior urethral valves diagnosed between June 1987 and September 1990 were reviewed. The mothers of all patients had at least one ultrasound scan during pregnancy. Despite this, fetal uropathy was diagnosed in only 19 cases. The remaining 23 undiagnosed children presented acutely, all within the first 6 months of life. In 33 of 36 pregnancies scanned before 24 weeks' gestation, fetal urological pathology was undetected. Mean plasma creatinine (pCr) at presentation in the group antenatally diagnosed was 139 mumol/l and in those presenting acutely was 238 mumol/l. All pCr analysed were taken after at least 48 h of life. Renal function as measured by follow-up pCr was better in the antenatally diagnosed group during the first year of life. It would appear that a routine second ultrasound scan at 26 weeks' gestation or later would reveal more cases of posterior urethral valves and this information may improve the outcome in terms of renal function.

Ischaemia-reperfusion injury in the rat kidney: the effect of preconditioning.

OBJECTIVES: To design and establish a model to examine whether brief periods of renal artery occlusion (ischaemic preconditioning, IP) confers protection from the effects of a subsequent period of ischaemia and reperfusion of the rat kidney. MATERIALS AND METHODS: Ninety rats were randomized into six groups, i.e. sham-operated controls; IP alone; a 20 or 40 min period of left renal ischaemia (RI) alone; and IP followed by a 20 or 40 min period of RI. Preconditioning involved the sequential clamping of the left renal artery for 4 min and its release for 11 min, a total of four times, a 'critical interval' of 30 min before the ischaemic insult. Left renal tissue integrity was determined by dimercapto-succinic acid (DMSA) radionuclide imaging on a gamma-camera both immediately (day 0) and 2 and 9 days later. Acute tubular necrosis was also assessed histologically. RESULTS: RI for 20 min resulted in a significant decrease in left renal tissue integrity on day 2 only (P < 0.001), whereas RI for 40 min caused significant left renal dysfunction on day 0, day 2 and day 9 (P < or = 0.01). For a given duration of ischaemia, there was no significant difference between results from (IP + RI) rats compared with RI-only rats at any of the three times. There was no significant alteration in renal tissue integrity in the IP-only rats compared with sham-operated controls. Histological findings paralleled the data obtained from DMSA uptake. CONCLUSIONS: The IP regimen and 30 min 'critical interval' confers no protection to the kidney from a 20 or 40 min ischaemic episode. The IP regimen itself appears to have no effect, confirming the validity of our experimental model.

Long-term renal function in the posterior urethral valves, unilateral reflux and renal dysplasia syndrome.

PURPOSE: The syndrome of posterior urethral valves, persistent unilateral reflux and renal dysplasia (VURD) is said to be protective of the contralateral nonrefluxing kidney and the outcome for renal function is reported to be excellent. We tested this hypothesis in our patients by replicating previous studies but with longer followup and glomerular filtration rate data. MATERIALS AND METHODS: We retrospectively reviewed the records of 183 boys presenting with posterior urethral valves between 1980 and 1989, including 12 who underwent nephrectomy for ipsilateral nonfunction and fulfilled all criteria for the VURD syndrome. Mean age at the most recent followup was 8.5 years. Serial serum creatinine levels and glomerular filtration rates were analyzed and compared to age matched normal values. RESULTS: Histological evaluation revealed dysplasia in all kidneys, confirming the VURD syndrome. Followup plasma creatinine was normal 67% of the patients during year 2 of life, 50% between ages 4 and 5 years, and only 30% between ages 8 and 10 years. Glomerular filtration rate was within the normal range in 25% of boys tested in year 2 of life, and between ages 5 and 8 years. CONCLUSIONS: Our data do not support the protective effect of the VURD syndrome on long-term renal function. All patients with posterior urethral valves require diligent long-term followup.

Renal transplantation in young boys with posterior urethral valves: preliminary report.

Seven boys (mean age 38 months) with posterior urethral valves underwent renal transplantation between June 1988 and August 1991. Urodynamic studies were performed before transplantation in 6/7 patients. In 4 the investigation indicated bladders of capacity and compliance which were deemed suitable for transplantation. Two patients had poorly compliant bladders; one of these underwent bladder augmentation before engraftment and the other proceeded to transplantation without bladder surgery. Six patients have functioning renal allografts with a mean follow-up of 1.3 years and a mean plasma creatinine of 51.6 mumol/l. Mean glomerular filtration rate (ml/min/1.73 m2 SA) 6 months after transplantation was 76.8 and at 1 year it was 84.5. In one patient early rejection was followed by transplant nephrectomy. Careful pre-operative evaluation is mandatory for a successful outcome of renal transplantation in young boys with posterior urethral valves.