The Kelly technique of bladder exstrophy repair: continence, cosmesis and pelvic organ prolapse outcomes.

PURPOSE: The Kelly technique of radical soft tissue mobilization, an alternative to osteotomy and modern staged repair, has been used extensively at our tertiary referral center for bladder exstrophy in the last 2 decades. We present what is to our knowledge the first long-term followup of the Kelly technique in 31 patients treated at our institution. MATERIALS AND METHODS: Patients admitted for bladder exstrophy at our institution since 1980 were identified and the medical charts were reviewed. Continence questionnaires were completed during followup appointments or by mail. Continence was defined as complete-dry greater than 3 hours during the day and night with 2 or fewer night wets per month and partial-dry 2 hours or more during the day and 3 or greater night wets per month, and/or stress incontinence. The degree of pelvic organ prolapse was assessed in females older than 12 years. RESULTS: Data were available on 31 Kelly patients, including 14 females, 4 to 25 years old and 13 patients, including 4 females, 2 to 29 years old treated with another staged technique. Of 30 Kelly patients without urinary diversion 21 (70%) were completely or partially continent. Of the 30 patients 17 voided spontaneously without clean intermittent catheterization or augmentation, of whom 12 (71%) were continent. Lower abdominal appearance was graded as abnormal in 11 of 12 male Kelly patients vs in 2 of 7 nonKelly males with pubic approximation (p = 0.01). Of the 12 females assessed none of 9 Kelly patients had prolapse, whereas 2 of 3 nonKelly patients had prolapse (p <0.05). CONCLUSIONS: The continence rate after the Kelly operation compares favorably with that in recent series. The abnormal appearance of the lower abdomen and bony pelvis in Kelly males may result from a lack of pubic approximation. Importantly pelvic organ prolapse may be decreased in women after the Kelly technique.

The management of renal transplant artery stenosis in children by percutaneous transluminal angioplasty.

Between 1967 and 1989 in this unit 262 children (age at transplantation 9 months to 17 years, mean 9.6 years) had 345 renal transplants performed. Transplant artery stenosis (TAS) was found in 30 (8.7%) as demonstrated by arteriography, performed only when there was unexplained deterioration in transplant function, hypertension that was difficult to control, or in the presence of a vascular bruit. All patients with TAS except one had received a cadaveric allograft. From 1980 onward, percutaneous transluminal angioplasty (PTA) has been available for TAS, and this was attempted on 21 occasions in 16 patients. Nine patients demonstrated angiographic improvement following the procedure, and 7 showed immediate clinical improvement. On one occasion angioplasty precipitated graft loss. Five patients underwent planned corrective surgery, 4 after unsuccessful angioplasties. Our experience suggests that PTA should be the first method of intervention for TAS. Moderate success, both in angiographic and clinical terms, can be achieved, negating the need for surgery, while failure of PTA does not preclude surgical attempts at correction.

The influence of HLA matching on renal allograft survival at a single pediatric center.

Between January 1, 1969, and February 2, 1988, 331 pediatric renal transplants were performed at a single pediatric center. Of these 225 were first cadaveric allografts. Graft allocation was independent of the outcome of human lymphocyte antigen (HLA) matching. The results of class I antigen matching were analyzed in 224 transplants, and actuarial graft survivals were calculated. Class II antigen matching was analyzed in 80 patients from January 1, 1982, and submitted to the same analysis. HLA matching could not be demonstrated to be beneficial. It is proposed that any matching benefit is small and obscured in our series by the dominance of other factors.

Selective use of splenectomy after liver transplantation in children.

In a series of 106 pediatric liver transplantations, five patients were identified with recurrent rejection who could not tolerate the addition of azathioprine (Aza) to their immunosuppressive therapy because of leukopenia. Splenectomy was performed posttransplantation to allow the use of Aza. The number and severity of rejection episodes were compared before and after splenectomy in these patients. In addition, presplenectomy and postsplenectomy rejection frequencies were compared with rejection frequencies in 35 patients who did not require splenectomy and had at least 1 1/2 years of follow-up. Mild, moderate, and severe rejection episodes were defined by the treatment (mild, steroid bolus only; moderate, steroid recycle; and severe, monoclonal antibodies or Minnesota antilymphocyte globulin) required to produce complete resolution. There was a mean of 342 +/- 111 days from transplantation to splenectomy and a mean of 674 +/- 109 days of follow-up after splenectomy. Follow-up in the control group was 934 +/- 44 days. After splenectomy, the average platelet count increased from 78 +/- 15 to 514 +/- 113 (P = .020) and white blood cell count increased from 3.2 +/- 0.6 to 16.7 +/- 2.7 (P = .010). Splenectomy permitted the implementation of Aza therapy in one patient who previously was not a candidate because of hypersplenism and allowed uncomplicated Aza therapy in four patients who became severely leukopenic during previous Aza trials. All five patients who underwent splenectomy demonstrated a statistically significant (P less than .05) decrease in the total number of rejection episodes. Rejection frequency after splenectomy was no different from the rejection frequency in patients who did not require splenectomy (P = .682).(ABSTRACT TRUNCATED AT 250 WORDS)

The negative influence of delayed renal allograft function on longer-term graft survival in a pediatric population.

The influence of delayed graft function on renal allograft survival has been studied in a review of 322 renal transplants performed at one pediatric institution. The appearance of the first radionuclide renal scan was used to indicate early function in patients receiving their first cadaveric allograft. Patients whose first radionuclide renal scan showed both good renal perfusion and good function (n = 52) were compared with those whose scans demonstrated good perfusion but no function (n = 32). the actuarial graft survival of those with no function was significantly worse (P < .05). The difference in graft survival was not solely due to grafts lost in the early posttransplant period. Analysis of serial serum creatinine estimations suggests a process of continued inexorable nephron loss in some patients whose grafts showed a delay in achieving function.

Urinary tract reconstruction in children.

The successful introduction of clean intermittent catheterization and increased awareness of urinary tract physiology and urodynamics have been the basis for recent major advances in urinary tract reconstructive surgery. Surgical techniques are now available to manage anatomical and functional deficiencies of any isolated or combined components of the urinary tract. The high incidence of unsatisfactory long-term results with ileal conduit diversion has led to increased popularity in urinary tract undiversion and greater utilization of reconstructive principles. As with any new surgical field of endeavour, new operative techniques are appearing at a rapid rate. In particular, there has been a recent proliferation of surgical procedures that provide a continent, low pressure, catheterizable reservoir for urine storage. Most children with major urinary tract deficiencies can now be offered socially and cosmetically unobtrusive surgical solutions without jeopardizing renal function.

Appendicitis in the first year of life: a rare but predictable cause of intraperitoneal pus in infants.

Appendicitis is the most common antecedent to peritonitis throughout life. Although quite uncommon during the first year of life, appendicitis is a recognizable entity, and beyond the neonatal period, remains the most common cause of peritoneal suppuration. The Royal Children's Hospital in Melbourne has experienced three cases of appendicitis in the first year of life since 1970. Clinical features helpful in diagnosis are presented, and management guidelines are discussed. When pus is suspected or found in an infant's abdomen, the general surgeon would be wise to presume the cause is appendicitis, despite its rarity.

A pitfall with the EEA stapler in vertical banded gastroplasty.

This report details an intraoperative complication with the anvil of the EEA stapler in the course of a Mason vertical banded gastroplasty for morbid obesity. It was unrecognized by the operating team, and resulted in prolongation of the procedure, excessive manipulation of the stomach, and the use of a second EEA stapling instrument.

Renal allograft survival in patients with congenital obstruction of the posterior urethra.

In an attempt to clarify the influence of dysfunctional bladders on renal allograft outcome, graft survival was studied retrospectively in patients with congenital posterior urethral obstruction (posterior urethral valves). Using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), 25 index patients were compared to all other transplant recipients of the same age range. Three instances of abnormal bladder function leading to graft function deterioration were found, therefore we would recommend investigation of bladder function in all boys with congenital urethral obstruction prior to renal transplant, and as part of the work-up of graft failure, where the cause is otherwise not obvious.

The appropriateness evaluation protocol: application in an Australian children's hospital.

OBJECTIVE: The study was undertaken to evaluate the use of the Paediatric Evaluation Protocol (PAEP) in the Princess Margaret Hospital for Children, Western Australia. A random sample of 557 patient records was reviewed using the United States Paediatric Appropriateness Evaluation Protocol (AEP). RESULTS: Thirteen per cent of admissions and 10% of days of stay may have been medically inappropriate in the year of study. The PAEP is a useful tool for utilization review in children's hospitals in Australia and may with benefit be modified.

Post-proctectomy perineal hernia: case report and discussion.

Perineal hernia is a rare complication of pelvic surgery. Women are more commonly affected, and development of the condition is usually gradual. Although the true incidence of this problem is unknown, few cases are severe enough to require operative repair. We report the experience of one of the authors (E.S.R.H.) in post-proctectomy perineal hernia. One case required surgical repair and is presented, with a discussion of the operative management.

Continence in bladder exstrophy: determinants of success.

We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61% were continent based on a significantly higher urethral continence length (25.8 +/- 6.4 mm., mean plus or minus standard error) and a higher urethral closing pressure (69.4 +/- 5.8 cm. water) compared to the incontinent male population (11.4 +/- 3.1 mm. and 43.4 +/- 4.6 cm. water). No significant difference was noted in the bladder capacity of these 2 groups. Of the female population 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 +/- 4.4 mm.) and a higher urethral closing pressure (62.7 +/- 10.2 cm. water) compared to the incontinent female subjects (8.4 +/- 2.5 mm. and 32.7 +/- 6.9 cm. water). Moreover, those who were continent had a significantly higher bladder capacity (201.2 +/- 39.5 ml.) compared to those who were incontinent (84.3 +/- 23.6 ml.). These findings support a multifactorial mechanism in achieving continence but they suggest that of all the factors urethral length may be the most important.