Magnetic resonance imaging of the dysplastic renal moiety and ectopic ureter.

PURPOSE: We determined the role of magnetic resonance imaging (MRI) in symptomatic children with clinically suspected and radiologically occult dysplastic renal moieties and ectopic ureters. MATERIALS AND METHODS: We reviewed clinical, imaging, cystoscopic, surgical and histological findings in 6 symptomatic children 1 to 15 years old with dysplastic renal moieties. RESULTS: After multiple conventional imaging studies failed to delineate urinary tract anatomy MRI provided detailed multiplanar images of dysplastic renal moieties that were diagnostic and predictive of subsequent intraoperative findings. Dysplastic upper pole moieties identified in 4 children were associated with ectopic ureters inserting into the vagina, prostatic urethra, bladder neck and bladder neck ureterocele in each. A solitary kidney with contralateral blind-ending ectopic ureters inserted into the bladder base in 2 cases. Pelvic cystic structures visualized by ultrasound in 3 patients were tortuous distal ureters on MRI. MRI specifically identified ureteral insertion sites that were not evident in 3 of the 5 patients who underwent cystoscopy. CONCLUSIONS: MRI may facilitate diagnosis, guide cystoscopy and aid in preoperative planning in children with poorly functioning renal moieties and ectopic ureters.

Modified technique of antegrade continence enema using a stapling device.

PURPOSE: We present a stapling technique for constructing an antegrade continence enema (ACE) conduit that is helpful in cases of insufficient appendiceal luminal length or when a concomitant appendiceal Mitrofanoff stoma is required. MATERIALS AND METHODS: In 6 patients with a mean age of 9.5 years who required an ACE procedure the cecum was tubularized in continuation with the orthotopic appendix at its base, using a stapling device to construct an ACE conduit. The tubularized segment was imbricated with permanent suture material. In 3 cases appendiceal length after tubularization was sufficient to allow splitting for the concomitant creation of an appendiceal Mitrofanoff stoma. RESULTS: Patients have been followed an average of 16.5 months. Stomal continence was achieved in all cases as well as reliable catheterization of the appendiceal cecostomy in 6 and the Mitrofanoff conduit in 3. CONCLUSIONS: This modification of the ACE procedure with cecal tubularization in continuation with the appendix using a stapling device is an excellent approach in cases of inadequate appendiceal length. It successfully creates a catheterizable stoma with a reliable flap valve continence mechanism. The complex reconstructive procedure is simplified by eliminating the need to use tapered small intestine, while allowing the creation of a concomitant appendiceal Mitrofanoff stoma as necessary.

Mathieu hypospadias repair: experience in 202 patients.

PURPOSE: The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years. MATERIALS AND METHODS: We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months. RESULTS: There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup. CONCLUSIONS: The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

Unusual anatomic presentation of ectopic ureteroceles.

The authors describe four patients with unusual anatomic presentation of ectopic ureteroceles and their surgical treatment. Over a 3-year period, four cases of unusual ectopic ureteroceles were encountered. A 6-month-old girl had a complex cloacal anomaly with an ectopic ureterocele within the cloaca. A 10-year-old boy had two large diverticuli within an ectopic ureterocele combined with a blind-ending ipsilateral ureter. A 3-year-old girl had an ectopic ureterocele combined with a periureteral diverticulum and a completely duplicated ipsilateral kidney. A 4-year-old girl was found to have a vaginal ectopic ureterocele. Despite thorough radiological investigation in all patients, a correct assessment of the anatomic defect was achieved only by surgical exploration or endoscopic evaluation. If preoperative radiological evaluation is equivocal, a high index of suspicion and intraoperative recognition of an unusual anatomic presentation of the ectopic ureterocele are essential for appropriate management and a successful outcome.

Voiding dysfunction after bilateral extravesical detrusorrhaphy.

PURPOSE: Extravesical detrusorrhaphy has been successful for correcting unilateral vesicoureteral reflux, although its use in bilateral ureteral reimplantation has been questioned because of a reportedly high incidence of significant postoperative voiding dysfunction. We reviewed the incidence of voiding dysfunction after bilateral extravesical detrusorrhaphy during the last 5 years. MATERIALS AND METHODS: From 1990 to 1995, 123 patients with a mean age of 5.8 years (231 refluxing renal units) underwent bilateral extravesical detrusorrhaphy. Patients requiring anticholinergic therapy or intermittent catheterization at surgery were excluded from study, although in 6 who were included voiding dysfunction had previously resolved. RESULTS: Grades I and II vesicoureteral reflux persisted in 1 and 3 renal units, respectively, representing a 98.3% success rate. There was no postoperative upper urinary tract obstruction. Postoperatively voiding dysfunction developed in 8 patients (6.5%), including 2 with a history of voiding dysfunction. In 3 cases (2.5%) irritative voiding symptoms controlled with oxybutynin chloride resolved 2, 4 and 24 months postoperatively, respectively. In 5 patients (4%) temporary incomplete bladder emptying and/or urinary retention required outpatient Foley catheter drainage or intermittent catheterization for 2 to 21 days. CONCLUSIONS: Bilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of significant voiding dysfunction. Should this condition develop, in our experience it is transient and of minimal morbidity. We found an increased rate of postoperative voiding dysfunction in younger patients as well as in those with a history of resolved voiding dysfunction.

Incidence of contralateral vesicoureteral reflux following unilateral extravesical detrusorrhaphy (ureteroneocystostomy).

PURPOSE: The development of contralateral vesicoureteral reflux following different types of unilateral antireflux surgery has been reported to be as high as 22%. We review our recent experience with unilateral extravesical detrusorrhaphy in regard to the incidence of postoperative contralateral vesicoureteral reflux. MATERIALS AND METHODS: Between 1990 and 1995, 72 children underwent unilateral extravesical detrusorrhaphy. Of 73 refluxing renal moieties (1 patient had reflux in both moieties of a completely duplicated kidney) reflux grade was II in 35 (48%), III in 25 (34%), IV in 11 (15%) and V in 2 (3%). Common sheath reimplantation for complete ipsilateral duplication was performed in 16 patients. RESULTS: One patient had grade I postoperative ipsilateral vesicoureteral reflux resulting in a success rate of 98.6%. In 4 patients (5.6%) contralateral vesicoureteral reflux developed, and was grade II in 3 and grade I in 1. In all patients contralateral reflux resolved at 16, 17, 18 and 31 months of followup. No additional surgery was required in any patient. There was no association between the incidence of contralateral vesicoureteral reflux, and patient age, gender, preoperative ipsilateral reflux grade and presence of ipsilateral duplication. CONCLUSIONS: Unilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of postoperative contralateral vesicoureteral reflux. Should reflux develop, it is of low grade with a significant rate of spontaneous resolution.

Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results.

PURPOSE: In large series of adults microsurgical varicocelectomy has been associated with extremely high success rates, combined with minimal incidence of postoperative hydrocele. We report our initial experience of inguinal varicocelectomy using an intraoperative microscope in adolescents. MATERIALS AND METHODS: From 1994 to 1996, 32 adolescents (mean age 15.3 years) underwent inguinal microsurgical varicocelectomy. An operative microscope and Doppler probe were used during spermatic cord dissection to identify and preserve the testicular artery and lymphatics. RESULTS: All patients were available for followup, which ranged from 2 to 35 months (mean 20). There were no intraoperative complications. A temporary reactive hydrocele, which subsequently completely resolved, was observed in 1 patient. There were no palpable recurrent varicoceles. CONCLUSIONS: The operative microscope permits reliable identification of the testicular artery and lymphatics, as well as venous channels in adolescents. As a result, the postoperative development of hydrocele or recurrence of the varicocele may be prevented.

Role of the antegrade continence enema in the management of the most debilitating childhood recto-urogenital anomalies.

PURPOSE: We evaluated the antegrade continence enema for managing the most severely compromised fecal continence mechanisms and the efficacy of nonappendiceal conduits in children when appendix is unavailable. MATERIALS AND METHODS: Ten patients 3 to 25 years old underwent continent cecostomy for the purpose of the antegrade continence enema. Diagnoses included the VATER association in 4 cases, myelomeningocele in 3, cloacal anomaly in 2 and isolated imperforate anus in 1. Eight patients received a tubularized ileal conduit, 2 received an appendiceal conduit and 2 underwent concomitant fecal undiversion. RESULTS: Followup ranged from 4 to 28 months (mean 17.6). All patients have achieved excellent fecal continence and no significant stomal soilage or difficulty with catheterization has been noted. Patients reported a high degree of satisfaction. CONCLUSIONS: Continent cecostomy for the antegrade continence enema is highly effective even in the presence of severe structural anorectal disease. The tapered ileal conduit is an excellent alternative to the appendiceal conduit.

The importance of accurate diagnosis and early close followup in patients with suspected multicystic dysplastic kidney.

PURPOSE: Conservative management of children who have unequivocal multicystic dysplastic kidney with a stable or regressive pattern of disease during close followup is well established. However, a clear diagnosis may prove difficult. We report 3 cases in which the diagnosis was particularly difficult to increase awareness of the importance of applying strict criteria for the diagnosis of multicystic dysplastic kidney. MATERIALS AND METHODS: Three children in whom a diagnosis of multicystic dysplastic kidney was suspected underwent surgical exploration. One patient who did not comply with followup presented with a large retroperitoneal mass suspicious for neuroblastoma 8 months later. In another patient a growing renal cystic mass was suspicious for a multilocular cyst at 3 months of followup. At 2 months of followup a cystic nephroma was suspected in the remaining patient. RESULTS: All patients underwent surgical exploration. The patient with suspected neuroblastoma had extensive stage 3 Wilms tumor. In the child with a suspected multilocular cyst segmental multicystic dysplastic kidney of the lower pole of an ipsilateral duplicated system was found. In the patient in whom cystic nephroma was suspected mesoblastic nephroma was confirmed by the National Wilms Tumor Study Pathology Center. CONCLUSIONS: An unequivocal diagnosis of multicystic dysplastic kidney should be made early in life. The urologist should have an active role in making the initial radiological diagnosis and close followup with renal ultrasound every 3 to 4 months is essential during year 1 of life. Surgical exploration is indicated if the diagnosis becomes equivocal at any point or should concerns exist regarding compliance with followup.

The infected urachal cyst: primary excision versus a staged approach.

PURPOSE: We compared outcomes following single or 2-stage repair of infected urachal cysts in the pediatric population. MATERIALS AND METHODS: We reviewed the records of 17 patients 1 day to 14 years old (median age 22 months) with a urachal cyst. Immediate cyst excision was performed in 6 patients without infection, while those with an abscess underwent single or 2-stage repair. RESULTS: Median postoperative hospital stay for the urachal abscess group was 14 and 11.5 days for single and 2-stage procedures, respectively. After immediate excision postoperative complications developed in each case, although none occurred with a 2-stage approach. CONCLUSIONS: In the absence of infection, urachal cyst excision affords the most benign postoperative course. However, when infection is present, perioperative drainage with subsequent total excision, including a cuff of bladder, may offer the most effective surgical option.

A peel away sheath endoscopic technique for difficult pediatric urethral intubation problems.

PURPOSE: We describe a useful technique for overcoming difficult pediatric urethral intubation problems. MATERIALS AND METHODS: An 8F pediatric urethroscope is passed through a peel away sheath, advanced through the urethra into the bladder and removed. An 8F urethral catheter is passed, the balloon is inflated and the peel away sheath is removed. RESULTS: This procedure has been performed in 6 children with difficult urethral problems without complication and with universal success. CONCLUSIONS: The peel away sheath technique offers a more reliable and less traumatic mechanism for difficult infant urethral intubation.

Pediatric ureteroscopy: technique and preliminary results.

Ureteroscopic management of ureteral obstruction in children presents a challenge to the urologist because of the use of relatively large instruments in smaller anatomy. The authors present our initial experience and describe the technique and equipment found to be most useful. Eleven ureteroscopic procedures were performed in ten patients, either for stone extraction or diagnostic evaluation of ureteral obstruction. Six of seven patients with ureteral stones became stone free, and the stone load was reduced to 25% in the remaining patient. Diagnostic ureteroscopy for ureteral obstruction was successfully performed in four patients. There were no intraoperative ureteral injuries and no postoperative complications. Pediatric ureteroscopy appears to be safe and effective for the diagnosis and treatment of distal ureteral obstruction. Further studies and longer follow-up are necessary to determine whether this technique will prove as successful in children as it has been in the adult population.

Unilateral vesicoureteral reflux: association with protected renal function in patients with posterior urethral valves.

OBJECTIVE: The prognosis in patients with posterior urethral valves (PUV) is related to the degree of renal insufficiency. Urinary ascites or urinoma, congenital bladder diverticula, or severe unilateral vesicoureteral reflux has been associated with protected renal function. We present clinical and imaging findings in eight patients with PUV and unilateral reflux who have preserved renal function. Initial and follow-up sonography, voiding cystourethrography, and nuclear imaging were reviewed and compared with long-term serum creatinine levels. CONCLUSION: All eight patients had normal renal function on long-term follow-up, suggesting that unilateral reflux, which occurs in as many as 35% of boys with PUV, is associated with protected renal function. Although early nephrectomy of the refluxing unit has been advocated for patients with PUV and unilateral reflux into a dysplastic kidney (the vesicoureteral reflux and renal dysplasia syndrome), we found that significant renal function may be present in the refluxing kidney and that function may even increase with time. Most of these patients did well without nephrectomy. Therefore, a sufficient interval should elapse before nephrectomy is considered in these patients.

Laparoscopically assisted testicular autotransplantation for management of the intraabdominal undescended testis.

PURPOSE: The intra-abdominal testis continues to present a considerable urological challenge and the approach to its management continues to evolve. We report our initial experience with laparoscopically assisted testicular autotransplantation. MATERIALS AND METHODS: An intra-abdominal testicle was identified laparoscopically in 5 patients who subsequently underwent testicular autotransplantation. RESULTS: The success rate was 100% and median operative time was 5 hours. All patients were discharged home the day after surgery with no complications and a good result. CONCLUSIONS: Because of success with this technique, this procedure offers significant advantages (decreased hospital stay and lower morbidity) than an open or 2-stage Fowler-Stephens approach.

Relative microbial resistance of gastric, ileal and cecal bladder augmentation in the rat.

PURPOSE: Bladder resistance to bacterial infection after gastrocystoplasty, ileocystoplasty and cecocystoplasty was investigated in the rat. MATERIALS AND METHODS: Bladders were infected with Escherichia coli 6 to 13 months after augmentation and urine culture was obtained weekly for 3 months. RESULTS: No differences were observed in the number of infected animals within each group or electrolyte data among groups. The number of animals infected after surgery but before E. coli challenge was lowest in the gastrocystoplasty group. Bladder stones formed only in ileocystoplasty and cecocystoplasty groups. No group had a change in urinary pH. CONCLUSIONS: Gastrocystoplasty may be associated with a lower incidence of spontaneous infection and stone formation. An aggressive infection protocol may have masked differences in susceptibility to infection. Since urinary pH was unchanged after gastrocystoplasty, use of the rat may not be appropriate for augmentation studies.

Testicular autotransplantation: a 17-year review of an effective approach to the management of the intra-abdominal testis.

PURPOSE: Patients with intra-abdominal testes represent a small but challenging group who require innovative therapy. We report our 17-year experience with testicular autotransplantation. MATERIALS AND METHODS: Testicular autotransplantation was performed in 23 patients with 27 intra-abdominal testes. RESULTS: The success rate was 96% and average operative time was 4.25 hours with 40 to 90 minutes for vascular anastomoses. A contralateral Fowler-Stephens procedure had previously failed in 3 cases. CONCLUSIONS: Since the variability of collateral blood supply in patients with high undescended testes may potentially compromise the Fowler-Stephens procedure, we believe that testicular autotransplantation should be strongly considered in such patients, particularly those with bilateral undescended testicles.

Epididymitis in older boys: dysfunctional voiding as an etiology.

Although male infants and young boys with epididymitis have a high incidence of anatomical pathology, dysfunctional voiding is not a well established cause of epididymitis. In our series 36 boys with epididymitis underwent noninvasive urodynamic studies to determine whether a physiological defect could be assigned as an etiology. The 2 mechanisms proposed are similar to that in children with vesicoureteral reflux associated with dyssynergia or bladder instability and to a cause of recurrent urinary tract infection in children (the infrequent voider syndrome). Urinalysis and urine culture are recommended in all children with epididymitis and urethral swabs are obtained from those who are sexually active. We recommend renal/bladder ultrasound and voiding cystourethrography in all infants and young children with epididymitis. In the older child we advocate detailed questioning regarding voiding symptoms and the performance of noninvasive urodynamic studies.