Pediatric urolithiasis.

Urolithiasis in childhood is of diverse etiology requiring carefully planned individualized diagnostic and management protocols. The efficiency in diagnosis and management of urolithiasis in childhood follows a learning curve, especially when using the more recent technical innovations for management of urinary calculi. With current technical sophistication of transurethral and percutaneous techniques and ESWL, management of urolithiasis during childhood should be relatively straightforward as monotherapy using a single modality or as a combined approach with one or more techniques, saving open surgical intervention for situations where the new technology is either unavailable or inappropriate, or when surgical reconstruction of the urinary tract is necessary to forestall recurrent calculus formation. Postoperative morbidity after management of urinary calculi during childhood appears insignificant; calculus recurrence is uncommon. Long-term postoperative follow-up is mandatory, especially after using the newer technical innovations for urinary calculus management during childhood.

Collagen injections for treatment of urinary incontinence secondary to intrinsic sphincter deficiency.

The injection of glutaraldehyde cross-linked collagen (Contigen) is a recently approved method for treating patients with urinary incontinence secondary to intrinsic sphincter deficiency (ISD). Forty-five patients with ISD, 33 males and 12 females, with a mean age of 60 years (range 5-87 years) have been treated with collagen at our institution since its Food and Drug Administration approval. The etiology of incontinence was radical retropubic prostatectomy (RP) in 22, neurogenic bladder (NB) in 11, and Type III female stress urinary incontinence (FISD) in 12 individuals. The whole group underwent an average of 1.76 treatment sessions (range 1-4), and a mean collagen injection volume of 12.26 cc (range 5-27.5 cc) was delivered per session. There were no postoperative complications. Six patients achieved total continence, 28 were still incontinent but improved, 9 experienced no change, while 2 developed worsening incontinence. Further analysis indicated that male patients with ISD as a result of RP may achieve some degree of improvement, but the chances for eradicating incontinence are minimal, whereas female patients with FISD and individuals with ISD secondary to NB significantly benefit from collagen injection therapy. Longer follow-up is needed to determine the durability of these encouraging results.

Varicocele related testicular atrophy and its predictive effect upon fertility.

Varicoceles are the most common reversible cause of male factor infertility, yet approximately 80% of men with varicoceles are fertile. Therefore, it is unclear whether all adolescents should undergo prophylactic varicocelectomy to prevent future infertility or whether a subgroup of patients who are at increased risk for future infertility can be identified and treated. Testicular size discrepancy or hypotrophy of the testis associated with a unilateral varicocele has been suggested as an indication for prophylactic varicocelectomy in adolescents. We examined 946 men attending a urological clinic for complaints other than infertility to determine whether testis size discrepancy was predictive of infertility in men with left varicoceles. A left varicocele was detected on physical examination in 211 men, of whom 173 (82%) had been able to father children and 38 (18%) had never fathered children. A group of 630 men without palpable varicoceles served as controls, including 528 (84%) with a history of fertility. Testicular size was measured using an orchidometer and the average testicular volume difference was obtained by subtracting left from right testicular volume. The mean testicular volume difference for the fertile men without varicoceles (1.6 +/- 0.3 ml.) was significantly lower than the fertile men with varicoceles (3.1 +/- 0.4 ml.) (p < 0.05) and infertile men with varicoceles (2.5 +/- 0.6 ml.) (p < 0.05). There was no significant difference between fertile and infertile men with varicoceles. This study confirms prior reports that the majority of men with left varicoceles are able to father children and that varicoceles cause significant ipsilateral testicular atrophy/hypotrophy. However, we were unable to demonstrate a correlation between loss of testicular volume and fertility status in men with left varicoceles. Further study is needed to identify the clinical parameters predictive of future infertility in adolescents with varicoceles.

Isolated ureterosigmoidostomy and isolated vesicorectal anastomosis. The rectal bladder.

Our experience documents that an isolated internal urinary diversion and the requisite diverting colostomy offer an acceptable long-term method for establishing sphincteric urinary continence while preserving renal function and upper-tract morphology. This procedure has been widely accepted by those patients undergoing it.

Intraoperative renal ultrasonography: a useful adjunct to partial nephrectomy.

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.

45,X/47,XYY mosaicism: clinical discrepancy between prenatally and postnatally diagnosed cases.

45,X/47,XYY mosaicism is a rare chromosomal disorder with clinical information limited to 11 postnatal cases in the literature and with uncertainty regarding prenatal prediction of phenotype and prognosis. We report on 7 new cases of 45,X/47,XYY mosaicism, three detected prenatally and 4 diagnosed postnatally. A clinical comparison of the cases of 45,X/47,XYY mosaicism is presented together with a literature review.

The effect of back closure on detrusor function in neonates with myelomeningocele.

To determine the effect of back closure on the detrusor-external sphincter coordination, we reviewed the medical records of 40 neonates with myelodysplasia studied prospectively with urodynamic assessment and renal ultrasonography before closure of the spinal defect, within 7 days of closure and at 3-month intervals thereafter. Only 31 of the 40 neonates met all criteria for inclusion. All renal sonograms were normal before and after closure. Urodynamic evaluation demonstrated coordinated detrusor-sphincter activity in 18 neonates before and after closure. During prolonged followup 1 patient had detrusor areflexia and 4 had detrusor-sphincter dyssynergia. Of 11 neonates who demonstrated detrusor areflexia and no external sphincter activity before closure 10 were unchanged on initial post-closure evaluation (4 had detrusor-sphincter dyssynergia during followup), while 1 demonstrated detrusor areflexia with external sphincter overactivity and vesicoureteral reflux after closure. The latter patient subsequently had detrusor hyperreflexia, more severe reflux and upper tract deterioration. She was temporized with a cutaneous vesicostomy. One patient demonstrated detrusor-sphincter dyssynergia before closure and detrusor areflexia with no external sphincter activity after closure, the consequence of surgical division of the neural placode during back closure. The remaining patient demonstrated detrusor-sphincter dyssynergia before and after closure. This patient had coordinated detrusor-sphincter activity during followup. Those neonates who presented with or later had detrusor-sphincter dyssynergia were managed initially with neuropharmacological agents and clean intermittent catheterization. An unsuccessful outcome was managed by cutaneous vesicostomy. Our study demonstrates that neonatal closure of the spinal cord defect does not appear to affect detrusor-sphincter coordination adversely, and re-emphasizes the need for careful and regular followup in children with myelodysplasia to detect deterioration of the urinary tract.

Frenular chordee: implications and treatment.

Twenty of 75 male children undergoing elective circumcision demonstrated a ventral glandular chordee produced by an unusually prominent frenulum. Surgical incision of this prominent band of tissue relaxed the glandular traction (chordee), more adequately exposing the ventral inner prepuce, facilitating skin incisions, and permitting an improved cosmetic and functional outcome.

Pediatric urology.

Development of the genital and urinary systems is interwoven. Developmental abnormalities may cause problems in both systems, although the presenting problem may be ambiguous genitalia, hypospadias, undescended testis, or a urinary tract infection. The primary care physician must understand the underlying significance of pediatric urologic problems and seek appropriate consultation in a timely manner.

Selective elevation of urinary enzyme levels after extracorporeal shock wave lithotripsy.

Urinary enzyme testing has been used by many investigators to diagnose and monitor various types of renal injury. Three urinary enzymes, N-acetyl-beta-glucosaminidase, beta-galactosidase and gamma-glutamyl transferase were monitored in 17 patients before and after a single, unilateral extracorporeal shock wave lithotripsy treatment. Stones were in the renal pelvis or calices except for 1 treated in situ in the proximal ureter. Urine specimens were collected before extracorporeal shock wave lithotripsy and at 1, 3, 5, 7, 10, 14, 21 and 28 days after treatment. N-acetyl-beta-glucosaminidase and beta-galactosidase levels increased significantly after treatment (p less than 0.05). Gamma-glutamyl transferase levels increased after treatment but this was not statistically significant. All enzyme levels were highest on days 1 and 3 after lithotripsy and returned to baseline by day 28. Factors associated with post-treatment enzyme elevation included female sex, a lower pre-treatment creatinine clearance and stone size greater than 1 cm. These findings indicate that there is a transient selective increase in urinary enzyme excretion after extracorporeal shock wave lithotripsy.

The role of open stone surgery since extracorporeal shock wave lithotripsy.

Of 893 stone procedures 37 (4.1 per cent) performed during the first 19 months after extracorporeal shock wave lithotripsy was instituted at our medical center were open operations. Procedures included ureterolithotomy in 23 patients (with simultaneous pyelolithotomy in 1), anatrophic nephrolithotomy in 8, pyelolithotomy in 3 (with concomitant pyeloplasty in 2), partial nephrectomy in 2 and nephrolithotomy with a bowel segment inlay in 1. The most common reasons for electing an open operation were unsuccessful endoscopic stone manipulation, presence of anatomical obstruction in the intrarenal collecting system or ureter, morbid obesity and underlying medical problems precluding lengthy repeated endourological procedures. Over-all surgical results were excellent. Our study indicates that patients who presently require an open stone operation have complex calculous disease associated with a variety of anatomical and physiological problems. Despite this finding good results may be attained.

Effects of shock waves on the rat ovary.

The studies reported in this paper were undertaken to investigate the effect of shock waves on ovarian function. In an initial study, five female Wistar rats underwent general anesthesia. One ovary was then exposed to 1500 shock waves at 20 kV using the Dornier XL-1 experimental lithotripter. One week following this treatment, the animals were sacrificed and both ovaries were step sectioned. We counted all follicles that contained both an oocyte and antrum. These follicles in turn were classified further as being healthy or atretic. No statistical difference in these counts was observed between shocked and unshocked ovaries taken from the same animal. In the definitive study, thirty-one adult female Wistar rats underwent unilateral oophorectomy. These rats were then divided into treated, sham-treated and control groups. The eleven treated animals were given general anesthesia and received 1500 shocks at 15 kV directed at their remaining ovary using the Dornier XL-1 lithotripter. The ten sham treated animals received identical anesthesia and duration of waterbath immersion as the treated group. In contrast, however, sham treated animals were positioned outside the path of the focused shock wave. The control group received no treatment. Normal estrus cycle was maintained in all groups following shock wave exposure. Two weeks after this exposure, all three groups of animals were allowed to mate. All animals in each of the three groups became pregnant. There was no statistical difference in litter size or fetal weights at three weeks gestation. No gross teratogenic effects were observed. The rat ovary appears to be structurally and functionally resistant to the shock wave energy levels used in this experiment.

Isolated vesicorectal internal urinary diversion: a 37-year review of the Boyce-Vest procedure.

The challenges that management of exstrophy of the bladder pose the pediatric urological surgeon have resulted in a multitude of ingenious operations and a voluminous literature on exstrophy. Despite this intense interest in an uncommon anomaly, no consistently satisfactory approach to achieve urinary continence in children with exstrophy has evolved. We summarize a 37-year clinical experience with a form of urinary diversion that provides sphincteric urinary continence, and unexcelled long-term preservation of renal function and upper urinary anatomy. From our review it appears that the infant with exstrophy is served best by neonatal closure of the exstrophic bladder with attempts to establish urinary continence later in childhood. When other methods to establish urinary continence are unsuccessful and satisfactory anal continence has been demonstrated, a diverting colostomy combined with anastomosis of the isolated bladder to the isolated rectal stump offers an acceptable long-term alternate form of urinary diversion to produce sphincteric urinary continence with relative freedom from upper urinary deterioration.

Radiologic contribution to the management of patients undergoing extracorporeal shock wave lithotripsy.

Since its first clinical application in 1980, the use of extracorporeal shock wave lithotripsy (ESWL) has dramatically changed the treatment of urinary tract stone disease. More than 80% of patients with urolithiasis will undergo ESWL as a first line therapy. Detection of stones, appropriateness of ESWL treatment, successful stone therapy, termination of the ESWL procedure, and evaluation of treatment complications are all dependent on radiologic input. The application of adjuvant interventional radiologic percutaneous techniques will extend the use of ESWL to an additional 15% of patients and reduce the need for surgical intervention. Additionally, percutaneous techniques can be used to improve success rates in problematic cases and to treat complications related to the ESWL procedure. This article discusses the pre- and postprocedural radiologic evaluation of patients undergoing ESWL. Adjuvant interventional radiologic techniques useful in the management of these patients are also discussed.

Extracorporeal shock wave lithotripsy in childhood.

Extracorporeal shock wave lithotripsy is the treatment of choice for the majority of upper urinary calculi in adults. Technical limitations, including patient size and concerns over post-treatment stone fragment passage, have made the application of extracorporeal shock wave lithotripsy in children less clearly defined. We report the successful application of the Dornier lithotriptor in the management of 18 children (22 kidneys) with upper urinary calculi.

The Boyce-Vest operation for exstrophy of the bladder. 35 years later.

Twenty-four patients with exstrophy of the urinary bladder (23 patients) or epispadias (1 patient) who were treated by the Boyce-Vest operation have been followed for a total of 482 patient-years (range 3 to 34 years, mean 22 years). In all patients upper urinary morphology and renal function have remained normal, and those with preoperative compromise have stabilized or improved. Postoperatively, no patient has developed an electrolyte imbalance or metabolic acidosis requiring treatment, urinary calculi, or malignant change in the vesicorectal reservoir. Although the procedure and the exstrophy-epispadias complex present many unresolved of management. The infant with exstrophy of the urinary bladder appears best served by early neonatal closure of the exstrophic bladder as described by Jeffs, 6,8 with attempts at establishing urinary continence later in childhood. 6,8,11 When other methods to establish urinary continence are unsuccessful and satisfactory anal continence has been demonstrated, the Boyce-Vest procedure offers an acceptable long-term alternative to establish sphincteric urinary continence. Properly managed, the newborn with uncomplicated exstrophy should have a life expectancy equal to that of any other neonate. More importantly, it is within our ability to provide such patients with adult social acceptability and relative freedom from urinary disease.

Urinary tract deterioration associated with the artificial urinary sphincter.

In most recent series of artificial sphincter implantations there has been a reduction in mechanical and surgical complications, with continence rates approaching 90 per cent. Despite initially excellent results in 47 children, with increasing durations of followup we noted a transient hydronephrosis related to incomplete bladder emptying in 5 and a persistent physiological alteration of detrusor dynamics consisting of a rigid, noncompliant bladder in 7. Preoperatively, all patients had had indepth radiological studies and most had a urodynamic evaluation, and were considered to be excellent candidates. The etiology of these alterations is not understood at this time. Bladder and even upper tract deterioration can occur without the appearance of urinary leakage. Therefore, children with an artificial sphincter must be monitored indefinitely with semiannual assessment of the upper tracts and periodic urodynamic evaluation.