Does surgical subspecialization in pediatrics provide high-quality, cost-effective patient care?

OBJECTIVE: To determine if pediatric surgical subspecialization provides cost-effective, high-quality pediatric patient care. METHODS: Ureteroneocystostomy inpatients over 4 years were studied. Hospital charges and complications were compared between general urologists and fellowship-trained pediatric urologists. RESULTS: Hospital charges were significantly less ($1095) for patients under the care of a pediatric urologist. Complication rates were also lower. CONCLUSIONS: Pediatric urology subspecialization offers high-quality, cost-effective pediatric patient care.

Transverse corporeal plication for persistent chordee.

A technique is described wherein chordee which persists after resection of all evident fibrous tissue may be corrected. This technique involves a ventral midline incision and transverse dorsal plicating sutures which rotate the corporeal bodies to allow a straight erection.

Megalourethra associated with normal corpus spongiosum and dorsal chordee.

We report a case of scaphoid megalourethra which represents the first reported case of megalourethra with normal corpus spongiosal histology and associated dorsal chordee. Embryologic implications are presented.

Retroperitoneal fibrosis in children (eosinophilic and idiopathic).

Two cases of retroperitoneal fibrosis in children are presented; one was idiopathic while the other was in association with eosinophilic cystitis, heretofore not reported. A literature search of patients under eighteen years of age reviews presentation, treatment, and associated diseases.

Tunica vaginalis urethroplasty.

Tunica vaginalis on a vascular pedicle was tubularized and used as a urethra to repair hypospadias in three difficult cases. This is the first report of tunica vaginalis utilized for a urethral reconstruction in humans. This new surgical technique is described.

Repair of urethral diverticulum by plication.

OBJECTIVES: To develop a new technique to repair congenital and acquired megaurethra without opening the enlarged urethra. METHODS: A urethral plication similar to the Starr ureteral plication was developed, which allows the urethra to be plicated without opening into the lumen. This technique also allows the operation to be done in conjunction with hypospadias repairs. RESULTS: Eight of 10 patients had uneventful recoveries. One had obstruction and infection that resolved with drainage and antibiotics. A coronal margin fistula developed in a patient who had urethral plication as well as urethral advancement. CONCLUSIONS: This new urethral plication eliminates the need for opening the urethra and its associated complications while preserving urethral blood supply and allowing associated hypospadias repairs to be simultaneously performed.

Techniques for outpatient hypospadias surgery.

With careful attention to patient selection and anesthesia, as well as easy-to-manage dressings and urinary diversions, outpatient surgery for all degrees of hypospadias can be performed safely and economically. By using these techniques over an eighteen-month period all hypospadias operations were performed in the outpatient department. This included thirty-four minor operations as well as twenty-five major hypospadias repairs. Seven complications were encountered in the fifty-nine operations.

Testicular tumor in patient with persistent müllerian duct syndrome.

A case of a yolk-sac tumor associated with an intra-abdominal testis in a patient with persistent müllerian duct syndrome is presented.

Color Doppler ultrasound in newborn testis torsion.

OBJECTIVES: To assess the usefulness of color Doppler ultrasound in evaluating the newborn with suspected antenatal testis torsion. METHODS: Nine newborns with 10 antenatally torsed testes were examined using color Doppler and gray-scale ultrasound. RESULTS: Each examination revealed lack of intratesticular blood flow on the affected side and normal flow within the contralateral testis. In addition, gray-scale sonographic architecture of the affected testes appeared to reflect the duration of in utero torsion. CONCLUSIONS: Color Doppler sonography accurately assesses intratesticular blood flow in newborns with antenatal testis torsion and offers interesting details.

Bladder autoaugmentation.

Autoaugmentation has proved effective in many patients in lowering bladder pressures, increasing bladder capacity, and improving their related symptoms. Patients with sever bladder hyperreflexia, uncontrolled with medications, have also benefited greatly from autoaugmentation procedures. Only patients who failed conventional medical management have undergone autoaugmentation at the authors' institution.

Percutaneous endoscopic trigonoplasty in children: long-term outcomes and modifications in technique.

PURPOSE: Long-term outcomes of a minimally invasive method of correcting vesicoureteral reflux are presented with a discussion of the modification in our original technique. PATIENTS AND METHODS: A total of 29 children (46 refluxing ureters), 14 months to 18 years old, underwent percutaneous endoscopic trigonoplasty (PET) between December 1994 and June 1996. Follow-up ranged from 19 to 37 months. Reflux was grade 1 in 2, grade 2 in 16, grade 3 in 19, grade 4 in 8, and grade 5 in 1. The technique was a Gil-Vernet method in the first 23 patients and Cohen reimplantation in the last 6 patients. RESULTS: Resolution of reflux was observed to decrease from 63% to 47% with long-term (30-37 months') follow-up using the Gil-Vernet technique. Resolution was greater with unilateral reflux than bilateral reflux (83% v. 27%, respectively). The Cohen technique resulted in resolution of reflux in 83%; however, the operating time nearly doubled when compared with the Gil-Vernet group. In both groups, failure was unrelated to grade of reflux, age, operative sequence, or bladder instability. CONCLUSIONS: Although showing an improvement in resolution of reflux over the Gil-Vernet PET procedure, the Cohen PET reimplant has a lower success rate than traditional open operative reimplants. The PET also requires more operating time and two operating surgeons. Despite some advantages in the promptness of recovery, we do not recommend PET by either technique at this time. Future modifications may make this approach more tenable.

Common office problems in pediatric urology and gynecology.

The number of genital problems that pediatricians encounter is substantial. The most common ones have been reviewed in this article. Perhaps the most important point to reinforce is the appropriateness of nonintervention in uncircumcised boys whose foreskins have not become retractile during early school years. Without infections or pathologic phimosis, these boys do well, and most foreskins become retractile as they approach puberty. Abnormalities beyond those discussed or those not fitting the anticipated pattern probably warrant specialty referral.

Yoke hypospadias repair.

A new one-stage operation for correction of the more severe degrees of proximal hypospadias is described. This allows for the correction of chordee and maintains a dual vascular supply to the urethral flap derived from periurethral and pedicle blood vessels. This technique allows for correction of chordee and urethroplasty, and avoids the need for combination or staged repairs.

Deterioration of renal function in a conjoined twin: lack of compensatory renal hypertrophy.

The renal function of conjoined twin girls was evaluated by radioisotopic, radiographic, and laboratory techniques. The smaller of the twins was shown to have severe impairment of renal function, but due to the "auto-dialysis" by her normal twin, she was able to maintain a normal BUN and creatinine. Compensatory hypertrophy was not found in the normal twin, despite renal failure and loss of renal mass in the smaller twin.

Non-invasive vesicoureteral reflux detection: heating risk studies for a new device.

OBJECTIVE: To investigate a novel non-invasive device developed to warm bladder urine and to measure kidney temperature to detect vesicoureteral reflux. MATERIALS AND METHODS: Microwave antennas focused energy within the bladder. Phantom experiments measured the results. The heating protocol was optimized in an in-vivo porcine model, and then tested once, twice and three times consecutively in three pigs followed by pathologic examinations. RESULTS: Computer simulations showed a dual concentric conductor square slot antenna to be the best. Phantom studies revealed that this antenna easily heated a bladder phantom without over heating intervening layers. In-vivo a bladder heating protocol of 3 min with 30 W each to two adjacent antennas 45 s on 15 s off followed by 15 min of 15 s on and 45 s off was sufficient. When pigs were heated once, twice and three times with this heating protocol, pathologic examination of all tissues in the heated area showed no thermal changes. More intensive heating in the animal may have resulted in damage to muscle fibers in the anterior abdominal wall. CONCLUSIONS: Selective warming of bladder urine was successfully demonstrated in phantom and animals. Localized heating for this novel vesicoureteral reflux device requires low-power levels and should be safe for humans.

Use of tunica vaginalis to prevent fistulas in hypospadias surgery.

Tunica vaginalis was used to wrap around the neourethra at the time of hypospadias repair. This tunica vaginalis wrap prevented urethrocutaneous fistulas in 20 patients who underwent hypospadias repair. It also was successful when used in conjunction with urethrocutaneous fistula repair in 2 patients.

The versatility of the posterior lumbotomy approach in infants.

The versatility of the posterior lumbotomy approach to the upper urinary tract in infants is reviewed. A total of 32 procedures in 25 patients was performed. Nine different types of operations were performed ranging from upper pole heminephrectomy to ureterolysis. Surgical techniques and outcome are reviewed.

Massive cystic ureteral diverticula in infancy.

We report 2 cases of massive abdominal distension due to a mid ureteral diverticulum. In a 1-year-old boy the mid ureteral diverticulum was associated with an atrophied chronically scarred kidney. In a female newborn the diverticulum was associated with an upper pole ureter of a completely duplicated system. To our knowledge this type of ureteral diverticulum has not been reported previously.

Bladder autoaugmentation: early clinical experience.

A surgical technique is described in which detrusor muscle over the entire dome of the bladder is excised while leaving the bladder epithelium intact. A large epithelial bulge is created, which functions to augment the storage properties of the bladder without using bowel, and it is referred to as "autoaugmentation". Seven patients have undergone autoaugmentation of whom 5 have excellent clinical results while 1 has modest improvement. The remaining patient was a technical failure. Postoperative urodynamics in 5 patients demonstrated improved bladder capacity in 3 and markedly improved bladder storage pressures in 4 compared to preoperative studies. The technical aspects of the procedure and patient management are discussed. Autoaugmentation offers potential advantages over enterocystoplasty, is simple to perform, does not preclude future enterocystoplasty if needed and may be a reasonable alternative to conventional augmentation in selected patients.