Direct vesicoureteral scintigraphy: quantifying early outcome predictors in children with primary reflux.

UNLABELLED: This study quantifies some of the outcome predictors in a group of children with primary vesicoureteral reflux who were initially managed medically. METHODS: We studied 133 patients with primary reflux for 7.1 +/- 2.2 yr. Direct vesicoureteral scintigraphy (DVS) was used to prospectively measure the absolute bladder volume at which reflux began and the maximum volume of urine refluxed into the ureters during the filling and voiding phases of their first two DVS studies. Findings were related to outcome as defined by spontaneous resolution or the eventual need for reconstructive surgery. RESULTS: Medical management eventually failed in 35% of this sample. Patients who did not begin to reflux until their bladders had been filled to more than 60% total bladder capacity had a substantially smaller risk of surgery than those who began to reflux at smaller bladder volumes. Patients who refluxed a volume of urine back into their ureters that was less than about 2% of their total bladder capacity had a substantially smaller risk of surgery than those who refluxed more than 2%. The difference between groups was significant for both DVS variables (p < 0.001). CONCLUSION: Quantitative DVS contributes to the assessment of prognosis in children with vesicoureteral reflux who are managed medically.

Renal growth in maternal-fetal axis: clinical and laboratory studies.

A hormone (renotropin) is said to play an important role in compensatory renal growth. The role of renotropin in obligatory growth (normal developmental growth) is unknown. It was observed that contralateral renal size in children with unilateral multicystic kidney was found to be normal at birth but became hypertrophied later. The kidneys of twenty-one-day-old fetal rats were significantly smaller than sham controls in animals whose mothers had uninephrectomies at day 8 (26.5 +/- 1.1 mg. versus 18.5 +/- 1.1 mg.). The mothers' kidneys hypertrophied compared with sham controls (1,065 +/- 23 mg. versus 1,347 +/- 78 mg.). It was concluded that renotropin passes the placenta and modifies so-called obligatory renal growth.

True hermaphroditism and normal male genitalia: an unusual presentation.

True hermaphroditism, the rarest form of intersex, is usually diagnosed during the newborn period in the course of evaluating ambiguous genitalia. As an exception, we present an unusual case of a 15-year-old boy with phenotypically normal male genitalia and bilaterally descended ovotestes, who was seen for evaluation of intermittent scrotal swelling and pain. Although rare, true hermaphroditism should be included in the differential diagnosis of apparently normal males presenting with similar complaints.

Megalourethra.

Megalourethra is a rare congenital disorder involving the formation of the anterior urethra. Both clinical varieties, the scaphoid and fusiform types, involve extensive defects in the formation of the spongiosum urethra. Our experience with 5 patients is discussed with particular reference to associated anomalies, diagnostic procedures, timing of surgical intervention, and definitive reconstructive surgery.

Congenital penile curvature (chordee without hypospadias).

We treated 30 patients aged six months to nine years with congenital penile curvature from 1988 to 1993. Twenty-four patients appeared to have a primary curvature with normal corpus spongiosum. In 12 of these 24 patients dissecting skin and dartos fascia were adequate to straighten the penis. In the other 12 patients, artificial erection demonstrated a varied degree of convexity of the penis after the skin and dartos fascia release, implying a disproportion of the corpora cavernosa bodies. We corrected this deformity using dorsal tumica albuginea plications (TAP). The remaining 6 patients presented with a primary curvature and hypoplastic urethra. In 5 of these patients we divided the hypoplastic midportion of the urethra leaving the meatus naturally on the glans and replaced the midurethral segment using a tubularized island flap. Of these 5 patients 2 required TAP for penile straightening. The final patient with a hypoplastic urethra was managed by preserving the urethral plate and applying an only island flap urethroplasty. Complications were one fistula and two mild ventral penile curvatures, presently not severe enough for reoperation (mean follow-up 2.6 years). We present a systematic approach for the repair of congenital penile curvature using intraoperative artificial erection, TAP, and the island flap urethroplasty when needed.

Phytohemagglutinin lymphocyte stimulation in children with recurrent urinary tract infections.

The delayed hypersensitivity (T cell) response of children with recurrent urinary tract infections, normal children, and children with other bacterial infections was measured by the ability of their lymphocytes to react to vitro to phytohemagglutinin. A comparison among these three groups demonstrated no differences in response. We conclude that the delayed hypersensitivity response is grossly normal in most children with recurrent urinary tract infections.

Renal hypertension secondary to ureteropelvis junction obstruction. Unusual presentation and new therapeutic modality.

We recently have treated an infant with a ureteropelvic junction obstruction believed to be the first reported case of nonrenovascular renal hypertension presenting as a cerebrovascular accident. A new role for the percutaneous nephrostomy as a predictive, diagnostic, and therapeutic tool is illustrated. Pitfalls in the preoperative assessment of ureteropelvic junction obstructions are discussed, and possible mechanisms for reno-prival hypertension are suggested.

Ultrasound evaluation of scrotum in pediatrics.

Scrotal abnormalities are difficult to assess using clinical criteria alone. Ultrasound provides an accurate means of demonstrating the scrotal contents so that appropriate therapy may be instituted. In a retrospective study, 119 ultrasound examinations of 96 patients (aged 4 days to 23 years) have been compared with the clinical diagnosis, surgical/pathologic findings, and other imaging modalities. The gamut of disease identified included congenital anomalies, neoplasm, trauma, torsion, varicocele, hydrocele, epididymo-orchitis, epididymal cyst/spermatocele, and post-radiation fibrosis. The ultrasound findings correlated well in 93/96 patients. In inconclusive cases, sequential imaging helps differentiate traumatic and inflammatory lesions from neoplastic processes.

Skin flap closure by dermal laser soldering: a wound healing model for sutureless hypospadias repair.

OBJECTIVES: Laser tissue soldering (LTS) with the diode laser and human albumin-hyaluronate-indocyanine green solder is a safe and effective method of providing an immediate leak-free closure during hypospadias repair. In this report, we compare the physiology, histology, and immunohistochemistry of wound healing following LTS and suturing in a rat skin flap model. METHODS: A 4 x 5-cm skin flap was raised and bisected (4 cm) on the dorsum of 48 Sprague-Dawley rats. The central wound was either closed from a dermal approach by suturing or LTS or left open, and studied at 0, 3, 5, 7, 10, 14, and 21 days postoperatively. An intraoperative comparison was made between suturing and LTS with respect to operative time. Postoperatively, flaps were excised for tensiometric analysis, and sections were stained with hematoxylin-eosin to define wound architecture. Resting skin temperature, laser exposed temperature without solder, and maximum temperature with solder (one drop) were measured at the level of the deep dermis, superficial striated muscle layer, and within the solder. Mean peak temperatures were recorded during a 1-minute laser activation time. RESULTS: Mean continuous suturing time (4.9 +/- 1.1 minutes) was significantly (P < 0.001) faster than either LTS (7.7 +/- 0.77 minutes) or discontinuous suturing (8.2 +/- 0.62 minutes). Two seromas (sutured) and two instances of partial wound dehiscence (1 sutured, 1 LTS) were noted. Tensile strength was increased significantly (P < 0.001) for up to 5 days in the LTS group, but was equal to suturing at 7 and 10 days. Immediate tensile strength after LTS was equivalent to a 7-day healed wound. At 14 days, wounds initially left open and those closed by LTS were stronger than sutured wounds (P < 0.05). There was no evidence of thermal injury or foreign body reaction in the LTS group. Solder was incorporated within the dermis in all wounds at 21 days. Laser activation of solder resulted in significant increases in temperature at all three tissue levels: 65.0 +/- 5.2 and 69.9 +/- 6.8 degrees C in the deep and superficial skin (no significant difference between the two), and 101 +/- 15.6 degrees C within the solder (P < 0.001 versus superficial and deep skin). CONCLUSIONS: Our results indicate that sutureless dermal LTS of skin flaps provides increased tensile strength for up to 7 days, with relatively greater tensile strength provided within the first 3 days. Our laser technique does not appear to alter the normal wound healing process. Rather, solder-tissue interaction initially, and extracellular matrix infiltration of solder later, provide the basis for improved wound strength. For hypospadias repair using skin flaps, these wound attributes may permit sutureless surgery.

Nonoperative management of blunt pediatric major renal trauma.

Although algorithms exist for the management of renal trauma in adults, guidelines have not been established in children. Of 1,175 patients entered into our Trauma Registry between 1987 and 1991, 61 (5.2%) presented with gross or microscopic hematuria. Eight of the 58 patients (13.8%) who had blunt abdominal trauma had major renal injuries. Gross hematuria (n = 10) was a significant predictor of major renal injury (n = 5) (p < 0.001). All 3 patients with microscopic hematuria and a major renal injury also had evidence of multisystem trauma. Admission blood pressure, hemoglobin, and trauma score were not predictors of major renal trauma. All cases were managed nonoperatively except for 1 patient who required a partial nephrectomy for continued hemorrhage. These data suggest that hematuria of any degree should be evaluated in the pediatric population, since major injuries can occur with even microscopic hematuria or in the absence of shock. Nonoperative management in this series resulted in no morbidity or delayed complications and suggests that surgical exploration be reserved for ongoing bleeding.

Transverse preputial island flap technique for repair of severe hypospadias.

The glans channel technique combined with the use of a transverse preputial island flap to create a neourethra is outlined for one-stage repair of severe hypospadias.

MAGPI (meatoplasty and glanuloplasty): a procedure for subcoronal hypospadias.

The MAGPI operation for the distal meatus has been a satisfactory operation both functionally and cosmetically. The complication rate is minimal. We therefore believe it is warranted in such cases, particularly to produce the esthetic appearance of a normal penis. We have found it to be a difficult operation to teach others except by demonstration, since we have not been very very successful in producing diagrams or photographs which convey the details of the technique adequately. It is therefore recommended that before this procedure is attempted, one should observe its performance by a surgeon who has mastered the technique.

Use of the Mitrofanoff principle in urinary reconstruction.

The catheterization of a urinary reservoir by way of a narrow conduit such as appendix or ureter has proved a very successful additional technique in urinary reconstruction. The Mitrofanoff principle can be added to our armamentarium in a variety of clinical settings. Closure of the vesical neck, as indicated in previous reports, is not necessarily required.

Neuroblastoma.

Neuroblastoma is the most common solid malignant tumor in children. The prognosis is poor, and despite varying chemotherapy and radiation regimens, its status has not been altered much in the past 20 years. Seventy per cent of the patients have abdominal neuroblastomas, which carry the worst prognosis of all the possible sites for the disease. Seventy per cent of the patients have metastases at the time of diagnosis. Survival is best in children under one year of age and in those patients (8 per cent) who are fortunate enough to have only stage I disease. Stage IV disease has only a 3 per cent survival rate. Surgical removal of the tumor is still the primary therapy; irradiation is of significant benefit in patients with stage III disease. Immunotherapy offers an optimistic modality for future improvement in survival rates.

Outpatient pediatric urologic procedures.

Outpatient pediatric urologic surgery is not a new concept. However, it has recently become extremely popular. The general experience nationwide and particularly the experience at Children's Hospital of Philadelphia and the University of Virginia Hospital indicate that outpatient surgery can be very safe and satisfactory for patients. The outpatient approach requires close cooperation among anesthesiologists, surgeons, and outpatient personnel. Excellent communication with the patient and family is essential. This includes extensive educational printed material and 24-hour availability by telephone. Once the infrastructure is in place, outpatient pediatric urologic surgery results in efficient use of facilities and a more pleasant surgical experience for the patient. The psychological, social, and economic benefits of outpatient surgery make it imperative that a large percentage of pediatric procedures be done on an ambulatory basis. We do not, however, intend to suggest that all minor procedures can be done on an outpatient basis, as certain special situations will mandate hospitalization.

Panel: complications of hypospadias repair.

Complications of hypospadias repair result from errors in the initial evaluation of a patient, the design of the operation, the surgical technique, or the postoperative care. The most commonly encountered complications are discussed, with emphasis both on methods of prevention and of treatment.

Characterization of a fibroblast cell from the urinary bladder wall.

For the first time we report on the growth, culture, and matrix production characteristics of a cell type isolated from the lamina propria of the urinary bladder wall. A fibroblastlike cell was identified as distinct from bladder detrusor smooth muscle cells and urothelium based on morphology, growth characteristics, and immunohistochemical staining. Characterization of extracellular matrix synthesis by this cell type using 35S-methionine metabolic labeling demonstrated that these cells are capable of secreting components of the surrounding connective tissue, including several fibrillar collagens, a basement membrane collagen, and fibronectin.

Hypospadias.

This article outlines the basic etiologic, anatomic, and reconstructive considerations needed for screening, evaluating, counseling, and following patients with hypospadias.

Neuroblastoma masquerading as congenital ureteropelvic junction obstruction.

A case of perirenal neuroblastoma causing intrarenal obstruction of the pelvis of the kidney presented as a small hydronephrosis at 3 days of age. The tumor grew rapidly over the next 48 hr, diagnosis was confirmed by ultrasonography, and the mass was removed surgically.

Urolithiasis in childhood: current management.

During the past 12 years, 62 children with urinary stones have been treated at the Children's Hospital of Philadelphia. The most common presenting symptoms were abdominal or flank pain (45%), recurrent or persistent pyuria (35%), and gross hematuria (21%). Twenty-two patients had associated congenital urologic anomalies. Infection-related struvite stones were most common and were found in 18 children, of whom 15 were found to have anatomic abnormalities. Eighteen of 28 children evaluated for a metabolic cause were found to have an abnormality, most frequently hypercalciuria. No predisposing factors could be found in 16 of the 62 patients. Forty-four (87%) children had upper urinary tract stones. Twelve of 15 bladder stones were in children with a neuropathic bladder and all were related to infection. Treatment was directed to the correction of anatomic and metabolic predisposing causes, as well as to removing the stones. Fifteen patients passed stones ranging in size from 2 to 6 mm. Forty-six surgical procedures were performed in 43 children. Pyelolithotomy and cystolithotomy were the most frequent procedures. There were three residual stones and five recurrences. Of the 29 operations for upper urinary stones reviewed, 17 might today be considered suitable for percutaneous nephrostolithotripsy or extracorporeal shockwave lithotripsy. Possible future stone management will be discussed in light of this analysis.