Complications of voiding cystourethrography in the evaluation of infants with prenatally detected hydronephrosis.

PURPOSE: We determined complications in infants undergoing voiding cystourethrography as part of the evaluation for prenatally detected hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed the records of infants referred to our institution for the evaluation of prenatal hydronephrosis from 1992 to 1997. Infants with a prenatal history of bilateral hydronephrosis, bladder distention and oligohydramnios, oligohydramnios only or a prenatal abnormality involving any other organ system were excluded from study. Of 206 patients 129 male and 49 female infants underwent postnatal voiding cystourethrography at our institution. Chart review and a telephone interview with the parents were done to assess lower urinary tract infection, pyelonephritis, hospital admission for urosepsis, gross hematuria, urinary retention or skin rash. RESULTS: Postnatal voiding cystourethrography was normal in 138 patients but it diagnosed bilateral vesicoureteral reflux in 15, unilateral vesicoureteral reflux in 20, ureterocele in 4 and refluxing megaureter in 1. Of the 129 male infants evaluated 101 had undergone circumcision as a newborn, 14 were uncircumcised and the circumcision status of 14 was unknown. At voiding cystourethrography suppressive antibiotics were administered to 166 infants, 7 were not on suppressive antibiotics and antibiotic status was unknown in 5. No patient had a lower urinary tract infection, pyelonephritis or urosepsis. In addition, there were no episodes of urinary retention, gross hematuria or skin rash. CONCLUSIONS: While the reported rate of new or recurrent infection associated with voiding cystourethrography is as high as 6%, we did not identify any infectious or other complications in infants undergoing voiding cystourethrography for prenatal hydronephrosis. When properly performed, we believe that voiding cystourethrography is safe and presents little risk in these patients.

Antegrade pyelography before pyeloplasty via dorsal lumbar incision.

PURPOSE: The need for contrast imaging of the ureter before routine pediatric pyeloplasty is controversial. We evaluated the use of antegrade pyelography for upper tract imaging before pyeloplasty via dorsal lumbar incision. MATERIALS AND METHODS: The records of all patients who underwent pyeloplasty from April 1994 through April 1998 at our institution were reviewed. The findings and outcome of patients with presumed ureteropelvic junction obstruction in whom antegrade pyelography was performed under the same anesthetic were assessed, and those in whom this procedure changed the planned operative approach were identified. RESULTS: Antegrade pyelography was performed without complication in 72 patients before planned pyeloplasty and 2 attempts were unsuccessful. In 10 cases (14%) plans for dorsal lumbar incision were abandoned based on findings of renal malrotation in 3, ureteral stricture in 2, ureterovesical junction obstruction in 2, unusually low or high position of the ureteropelvic junction in 1 each, and concurrent ureteropelvic and ureterovesical junction obstruction in 1. The study was misinterpreted in 1 case of renal malrotation and 1 case of horseshoe kidney, and the dorsal approach was used. In 1 of these cases conversion to an anterior approach was required. A nonobstructing ureterovesical junction was seen in 2 other patients who had ureteropelvic junction obstruction with mild ureteral dilatation on ultrasound. CONCLUSIONS: The dorsal lumbar incision may provide inadequate exposure in certain patients with upper tract obstruction. Antegrade pyelography is a simple, safe and useful technique to visualize the collecting system before planned pyeloplasty via dorsal lumbar incision, allowing the surgeon to choose a more suitable operative approach or procedure when warranted.

Functional, social and psychosexual adjustment after vaginal reconstruction.

PURPOSE: We assessed the long-term functional, social and psychosexual outcome in children who underwent vaginal reconstruction. MATERIALS AND METHODS: We interviewed and assessed the psychological development of 16 women 17 to 28 years old (mean age 22) who underwent vaginal reconstruction only or in combination with other urogenital reconstructive procedures at ages 11 months to 18 years (mean 8.8). Psychological measures included the Beck Depression Inventory, Draw-a-Person test and Linkowski acceptance of disability scale as well as a standard questionnaire evaluating the sexual adjustment, social adjustment and ability for self-support of these women. RESULTS: Mean Beck Depression Inventory was 8.5 with less than 9 defined as minimal depression. Mean acceptance of disability score was 83.9 (range 54 to 94), indicating that patients were well adjusted with respect to the disability. Functionally 10 women were satisfied with the appearance of the vagina, 4 were neutral and 2 were dissatisfied. A total of 12 patients had no doubts about their female identity but 2 had occasional, 1 had significant and 1 had chronic doubts. Of the 16 patients 12 have completed high school, 3 are still in high school and 1 has withdrawn from high school. Of the 12 women who have completed high school 9 are currently in college and 3 have completed college. Socially all 16 participants rated family relationships as good and 13 were at least satisfied with their social life. Of the 16 women 12 have had a sexual encounter, including 1 who did not achieve orgasm. Six women are involved in long-term relationships, of whom 1 is married. In regard to the future all patients believe that they will be independent and financially stable with a fulfilling career. CONCLUSIONS: While women who have undergone vaginal reconstruction may be at risk for avoiding interpersonal relationships and sexual intimacy, we did not note this finding in our series. The majority of these patients were well adjusted to their physical condition, and had a high level of education and a stable family life.

Seromuscular colocystoplasty lined with urothelium protects dogs from acidosis during ammonium chloride loading.

PURPOSE: We compared the metabolism of intravesical ammonium chloride in dogs in which the bladder had been enlarged by seromuscular colocystoplasty lined with urothelium, dogs that had undergone conventional colocystoplasty and control dogs. MATERIALS AND METHODS: Eight adult female mongrel dogs were divided into control (2), colocystoplasty (3) and seromuscular colocystoplasty (3) groups. Serum creatinine, bicarbonate, sodium, chloride, and potassium levels were measured every 2 weeks during the 6-week recovery period. Six weeks after augmentation the dogs were placed under general anesthesia, the bladder was instilled with a hyperosmolar solution of 400 mmol/l. ammonium chloride, the femoral artery and portal vein were cannulated to obtain blood samples and the ureters were divided with the proximal ends diverted to allow serial urine measurements. Blood and urine electrolyte analysis was performed at 0, 60, 120, 180 and 240 minutes after the intravesical instillation of ammonium chloride. RESULTS: During acid loading dogs that had undergone conventional colocystoplasty had a progressive decrease in serum carbon dioxide and arterial pH as well as increased levels of serum chloride and a significant increase in plasma ammonia concentration in the portal vein compared to controls and dogs that had undergone seromuscular colocystoplasty. In contrast, there were no differences in seromuscular colocystoplasty compared to control animals. CONCLUSIONS: Increased ammonia in the portal vein and hyperchloremic acidosis in dogs that underwent conventional colocystoplasty suggest intravesical absorption of ammonium chloride. Dogs that underwent augmentation with seromuscular colocystoplasty lined with urothelium seemed to respond to acute intravesical ammonium in a way similar to that of control dogs and they are protected from these metabolic anomalies.

Methods to enhance in vivo urothelial growth on seromuscular colonic segments in the dog.

PURPOSE: We demonstrated survival and expansion in vivo of urothelial free autografts on demucosalized seromuscular segments. MATERIALS AND METHODS: Four methods of in vivo urothelial expansion were investigated on demucosalized colonic segments in the canine model. Group 1 underwent colonic mucosal removal by manual stripping, group 2 underwent removal of colonic mucosa and submucosa, and group 3 underwent manual stripping of the colonic mucosa followed by treatment with protamine sulfate and urea. In the 3 groups urothelial autografts were then placed on the seromuscular segment and tubularized over a balloon splint. In group 4 the colonic mucosa was removed but the grafts were not tubularized. Instead the colonic segment was sutured to the parietal peritoneum. RESULTS: Group 4 grafts had no epithelial growth and shrinkage of the bowel segment. Group 1 grafts had minimal growth with no expansion and colonic mucosal regrowth. Group 2 grafts demonstrated growth and expansion, although these colonic segments had a significant inflammatory response and fibrosis. Group 3 grafts had the best growth and expansion with the least inflammatory response, and 1 colonic segment was almost completely covered with urothelium. CONCLUSIONS: We demonstrated in vivo expansion of urothelial autografts grown on seromuscular colonic segments. Preservation of the submucosa is essential to prevent fibrosis of the seromuscular colonic segment and a balloon stent is crucial to prevent graft contraction. Treatment of the demucosalized segment with protamine sulfate and urea results in better urothelial expansion and less colonic mucosal regrowth.

An alternative to the Penrose drain in children at risk for latex allergy.

We describe a simple and inexpensive technique to construct a nonlatex Penrose drain substitute using a latex-free surgeon's glove. We have found this to be a safe option for children who are at risk for a latex reaction.

Results of the Mitrofanoff procedure in urinary tract reconstruction in children.

OBJECTIVES: To evaluate the success and long-term complications associated with the use of continent catheterizable conduits based on the Mitrofanoff principle in children. PATIENTS AND METHODS: The records of 43 patients (21 female and 22 male) who underwent the construction of a continent catheterizable stoma based on the Mitrofanoff principle between 1987 and 1996 were reviewed retrospectively. The mean age at surgery was 10 years (range 3-21) and the mean follow-up was 3 years (range 0.5-6.5). Twenty-eight of the 43 children underwent augmentation cystoplasty in conjunction with the Mitrofanoff procedure, using ileum in 17, sigmoid in seven, caecum in two and stomach in one; detrusormyectomy was performed in one child. Fifteen patients had only a continent catheterizable stoma formed. The most common type of conduit was appendicovesicostomy (36 of 43 children): other conduits were constructed with ureter (four), tapered ileum (two) and fallopian tube (one). RESULTS: Stomal continence was achieved in 42 of 43 patients (98%). The most common late complication was difficulty in catheterization, which occurred in 14 patients (32%). Stomal prolapse requiring revision occurred in one patient (2%). Conduit dilatation was initially attempted in all patients with difficult catheterization, although it failed in 11 who then required surgical revision. Therefore, the overall revision rate was 28% (12 of 43). The site of stomal placement (umbilical or abdominal) did not significantly influence the risk of difficulty with catheterization. CONCLUSION: The Mitrofanoff procedure can simplify catheterization in children who are dependent upon intermittent catheterization. The vermiform appendix appears to be the best source for constructing the conduit. While stomal continence is excellent, conduit stenosis remains a frequent complication regardless of stomal location.

Urachal adenocarcinoma.

Primary adenocarcinoma of the bladder is a rare neoplasm comprising less than 2% of all bladder tumors. Approximately one-third of primary bladder adenocarcinoma arise in the urachal remnant. Differentiation from vesical adenocarcinoma preoperatively is essential because the surgical approach differs. We herein present a case of urachal adenocarcinoma whose radiographic work-up permitted the correct preoperative diagnosis.

Long-term intravesical oxybutynin chloride therapy in children with myelodysplasia.

PURPOSE: We evaluated the clinical use of long-term intravesical oxybutynin chloride in the treatment of neurogenic bladder dysfunction in children with myelodysplasia who could not tolerate oral anticholinergics. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients recommended for intravesical oxybutynin chloride therapy. A total of 12 girls and 18 boys 1 to 17 years old was recruited for study. Oxybutynin chloride (5 mg.) was instilled 2 times daily and pretreatment cystograms were compared to followup urodynamic studies. Duration of therapy was 2 to 26 months (mean 13, median 12). RESULTS: Mean total capacity plus or minus standard deviation increased from 209 +/- 103 to 282 +/- 148 ml. (p < 0.01), mean safe capacity increased from 157 +/- 105 to 234 +/- 147 ml. (p < 0.01) and mean age adjusted safe capacity increased from 76 +/- 36 to 115 +/- 62%. Of the 29 patients who were incontinent 3 (10%) achieved continence and 19 (65%) reported a decreased use of sanitary pads. None of the patients had systemic side effects related to intravesical treatment. CONCLUSIONS: We believe that intravesical oxybutynin chloride is a viable treatment option for patients with myelodysplasia in whom oral therapy fails.

Is there a best alternative to treating the obstructed upper pole?

PURPOSE: We addressed whether salvage of upper pole renal units in comparison to partial nephrectomy affects differential renal function in patients with a duplicated obstructed upper pole. MATERIALS AND METHODS: We retrospectively reviewed the records of all children who underwent surgery for a unilateral obstructed duplicated kidney at our institution from 1988 to 1995. Patients were evaluated with respect to postoperative complications, reoperation rate and percent change in differential renal function of the obstructed duplicated kidney, as determined by nuclear renography. RESULTS: We identified 46 patients with a unilateral obstructed upper pole of a duplicated kidney who were divided into 2 groups. Group 1 (12 patients) underwent an upper pole salvage procedure, that is ureteropyelostomy or ureteroureterostomy, and group 2 (31 patients) underwent partial nephrectomy. Three reoperations (25%) were performed in group 1 and 1 (4%) was done in group 2. Postoperative symptomatic urinary tract infections were diagnosed in 3 group 1 patients (25%) and in 2 (8%) in group 2. Average change in ipsilateral renal function in the 8 patients who underwent upper pole salvage procedures was 2.25 +/- 2.34% (range -6 to 12). In the 8 patients who underwent upper pole nephrectomy and who also had postoperative renal scans average change in function was -1.25 +/- 4.51% (range -23 to +16). CONCLUSIONS: There was no statistically significant loss of relative renal function in patients treated with partial nephrectomy and no significant gain in relative renal function in those treated with an upper pole salvage procedure. The reoperation rate was higher in the upper pole salvage than in the partial nephrectomy group (25 versus 4%). While not statistically significant, we believe that this rate is clinically important. We think that partial nephrectomy should remain the preferred treatment for most patients with obstructed duplicated kidneys.

Renal cell carcinoma in children: the Detroit experience.

PURPOSE: We analyzed the presentation, treatment and survival of 6 children with renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the pathological and hospital records of 6 children diagnosed with renal cell carcinoma at Children's Hospital of Michigan (5) and Henry Ford Hospital (1) from 1980 to 1995. RESULTS: The most common presenting complaints were flank pain (50%) and a palpable abdominal mass (50%), while gross hematuria was present in only 1 patient (16%). No patient had the classic triad of flank pain, hematuria and palpable mass. Only 1 patient had localized disease (stage II), while 5 of the 6 presented with stage III or IV disease. While followup is limited, all patients with stage III disease are without evidence of recurrence at a mean 38.5 months and 1 of 2 with stage IV disease is without evidence of disease at 22 months. CONCLUSIONS: Although renal cell carcinoma in childhood often presents at an advanced stage, the prognosis for those with isolated regional lymph node involvement appears to be encouraging.

Malignant fibrous histiocytoma of the spermatic cord.

PURPOSE: We analyzed 26 cases of malignant fibrous histiocytoma and report our conclusions regarding the diagnosis, pathology and treatment of this unusual tumor. MATERIALS AND METHODS: We reviewed 25 previously reported cases of malignant fibrous histiocytoma of the spermatic cord and report 1 additional case. Further data on patient survival and tumor recurrence rates were obtained from some of the previous authors. RESULTS: Of 26 patients 5 are long-term survivors (more than 5 years). Longest reported followup is 14 years. However, malignant fibrous histiocytoma has recurred as late as 6 years after surgery. To date 4 deaths have been reported, including 1 unrelated to the tumor and 3 from metastatic tumor. Disease recurred in 5 patients. In no case was there local lymph node involvement at surgery. CONCLUSIONS: Malignant fibrous histiocytoma presents earlier in the spermatic cord than at other sites and seems to have a more favorable prognosis. Ultrasound may aid in the diagnosis. Definitive treatment is radical orchiectomy but localized radiotherapy may decrease local recurrence rates. Satellite lesions at surgery indicate a poorer prognosis. Metastases may develop late in the lungs or mesentery, and so long-term followup is necessary.

Adenocarcinoma of the rete testis.

Adenocarcinoma of the rete testis is a rare tumor. Histologic diagnosis is difficult, and in the past the tumor may have been incorrectly identified in a number of cases, leading to misleading information on the nature and behavior of this neoplasm. We present the case of a 39-year-old man with a long history of a small left hydrocele, who was lost to follow-up and presented again 2 years later with testicular discomfort. Sonographic findings were consistent with a testicular tumor. Histology confirmed low-grade adenocarcinoma of the rete testis, the first reported tumor of this grade. Previously reported cases of rete testis carcinoma are reviewed.

Benign fibrous testicular pseudotumors in children.

Benign fibrous pseudotumors of the testicular tunics are rare in children. We report 2 cases of benign fibrous pseudotumors that were managed with gonad sparing surgery. We discuss the etiology, evaluation and treatment of benign fibrous pseudotumors of the testis.

Postoperative management of patients undergoing radical cystectomy and urinary diversion.

The management of patients undergoing radical cystectomy and urinary diversion requires an understanding of the various tubes and drains used in reconstructing the urinary tract. The three major types of urinary diversions are presented with particular attention to the nursing skills required for successful postoperative care.

A simple technique for intraoperatively stenting a transected ureter.

We present a simple technique for intraoperative stenting of a transected ureter. This method does not require cystoscopy, or a separate incision in the bladder or skin.

Acute urinary retention in an infant: an unusual presentation of a paraureteral diverticulum.

We present a case of a male infant with no previous urological symptoms who presented in acute urinary retention caused by compression of the posterior urethra by a paraureteral diverticulum. We discuss the etiology, evaluation and management of bladder outlet obstruction secondary to a paraureteral diverticulum in children.