Cumulative summation (CUSUM) charts in the monitoring of hypospadias outcomes: a tool for quality improvement initiative.

OBJECTIVE: Cumulative summation (CUSUM) charting is a statistical tool that allows an individual surgeon or surgical department to monitor any binary outcome and rapidly detect when complications are outside the acceptable limits. We applied CUSUM statistical analysis to hypospadias repair to utilize the results in our own quality Improvement process. MATERIALS AND METHODS: An institutional review board-approved retrospective review of all patients who underwent hypospadias repair by a single fellowship trained pediatric urologist at a single institution between September 2004 to July 2009 was performed. To graphically represent the complication rates and to assess for unacceptable rates, the use of CUSUM control charting was employed. RESULTS: In our retrospective review, there were a total of 184 patients who underwent a total of 203 surgeries. Using CUSUM analysis, our incidence of major complications was within acceptable limits until approximately the first 150 operations had been performed, at which time the complication rate fell below the lower limit, indicating performance exceeded expectations. CONCLUSION: CUSUM statistical charting was successfully applied to the retrospective monitoring of hypospadias outcomes at our institution. This is the first known publication in which CUSUM charts were used to evaluate complications of hypospadias repair.

Buccal mucosal graft for hypospadias repairs.

Buccal mucosal grafts are being utilized increasingly in urethral reconstruction for hypospadias and urethral stricture disease. We describe our technique for harvesting and utilizing buccal mucosal grafts in cases of severe proximal hypospadias anomalies or failed prior hypospadias repair.

Colonic duplication: an unusual cause of enterovesical fistula.

Intestinal duplications are rare, occurring in 1 in 4000 births. Even rarer are tubular hindgut duplications, with less than 75 cases reported in the literature to date. We report an uncommon case of an enterovesical fistula caused by a duplication of the sigmoid colon. This is the first reported case of a tubular colonic duplication presenting as a colovesical fistula in an adult. We discuss the presentation and shortcomings in the diagnosis and treatment of enterovesical fistulas and colonic duplications.

Pseudoureterocele: potential for misdiagnosis of an ectopic ureter as a ureterocele.

OBJECTIVE: To present several case reports of children with 'pseudoureteroceles'. Familiarization with this entity should help to avoid an error in diagnosis and possible improper therapy. PATIENTS AND METHODS: Three girls with ectopic ureters entering mesonephric duct cysts are presented for review. RESULTS: Misdiagnosis of the pseudoureterocele as an ectopic ureter was made in two children. The 'pseudoureterocele' may lie dormant for many years and often presents with acute urinary incontinence and/or onset of urinary tract infections. Resection of the dysplastic kidney and ipsilateral ureter, marsupialization of the cyst into the vagina, and closure of the vesical fistula is the preferred treatment. CONCLUSION: An ectopic ureter draining into a Gartner's duct cyst can be confused with an ectopic ureterocele. Correct diagnosis is vital to ensure proper treatment.

Reconstruction of the umbilicus in exstrophy.

Reconstruction of the umbilicus has cosmetic and functional value in the surgical treatment of the child with bladder exstrophy. We report on 12 patients who underwent creation of a neoumbilicus as part of genitourinary reconstruction.

Gastrocystoplasty in children.

The use of stomach for bladder reconstruction is an important tool for the urologic surgeon. Just as one would not perform hypospadias repair knowing only one technique, one should not consider bladder reconstruction with only one option for augmentation available. The advantages, disadvantages and a brief overview of our operative technique are presented. We have been very pleased with our experience with the use of stomach in the appropriate clinical situation.

The Mitrofanoff principle in urinary reconstruction.

We report the use of the Mitrofanoff principle to achieve urinary continence in 47 patients. A catheterizable channel can be used as the primary continence mechanism, or as an adjunct to ensure complete bladder emptying if urethral catheterization or voiding is inadequate. Appendico-vesicostomy was performed in 25 of 47 patients (55%). Satisfactory continence was achieved in 45 patients (96%). Bladder emptying by clean intermittent catheterization was performed in all patients. Early complications included peristomal abscess (1 patient) and small bowel obstruction (1). Late complications included difficulty with catheterization (5 patients), stomal stenosis (9) and persistent incontinence (2). Our results support use of the appendix as the catheterizable segment of choice. We describe the technique and discuss the management of complications.

Aggressive surgical and medical management of autosomal recessive polycystic kidney disease.

The treatment of autosomal recessive polycystic kidney disease (ARPKD) is evolving. Overall prognosis is difficult to determine, but most neonates without severe pulmonary hypoplasia will survive. It is difficult to predict which neonates with ARPKD requiring immediate ventilatory support have pulmonary hypoplasia incompatible with survival. Massively enlarged kidneys restricting diaphragmatic excursion can cause respiratory distress in addition to pulmonary hypoplasia. Three infants with ARPKD underwent bilateral nephrectomies and institution of peritoneal dialysis in an attempt to improve ventilatory status and assess long-term pulmonary function. Two children are alive at twelve and thirty months postoperatively and awaiting renal transplantation. One infant died of acute cardiorespiratory complications.

The use of the AMS800 artificial urinary sphincter in combination with the gastric tube for continence in the canine model.

An experimental canine model was designed to examine the potential use of the artificial urinary sphincter around a gastric tube. The artificial urinary sphincter was placed around a tubularized gastric flap as part of a continent gastric reservoir in 4 dogs and in 2 additional dogs the gastric tube was anastomosed to the native bladder. Two dogs underwent placement of the artificial urinary sphincter around the gastric tube 4 weeks postoperatively and the remainder had the sphincter placed simultaneously with creation of the gastric tube. All dogs with the gastric reservoir underwent urodynamics before and after activation of the sphincter. Only 61 to 70 cm. water pressure balloons were used. All dogs were continent postoperatively on clean intermittent catheterization every 8 hours. There were no erosions or problems with catheterization. Urodynamics confirmed a complaint system and an average increase of capacity of 410% after artificial urinary sphincter activation (4 dogs). There was no leakage at capacity. Histology of the artificial urinary sphincter and neighboring (control) regions, and of the reservoir at 1 (2 dogs), 3 (3 dogs) and 6 months (1 dog) was obtained. Microscopic examination of the cuff site showed mild serosal hyperplasia and fibrosis, a well preserved muscularis and mild to moderate focal mucosal atrophy. These changes were slightly more evident at 6 months. Mucosal folds were well preserved with normal submucosa and lamina propria. In the control region histology was well preserved and similar to native stomach. We conclude that the artificial urinary sphincter around a gastric tube can provide urinary continence. The minimal changes in histology under the cuff are encouraging and support the potential for use of the gastric tube with the artificial urinary sphincter, although longer term effects are unknown.

Histopathology of the internal anal sphincter in chronic anal fissure.

A prospective study of 18 consecutive patients undergoing unilateral, partial-thickness, distal, internal sphincterotomy for the treatment of chronic anal fissure was performed. Biopsies were taken from the base of the fissure and from the lateral muscle before division. Normal specimens were taken from the internal anal sphincter of patients undergoing abdominoperineal resection. Specimens confirmed the presence of fibrosis throughout the internal anal sphincter in patients with anal fissures, but none in controls.